And so why don't I just jump in and say that this is a joint meeting which we appreciate having between the House Healthcare Committee and the House Commerce and Economic Development Committee. And specifically because we both are concerned about workforce issues and wanting to and have been addressing workforce issues. And so for those who don't know, I'm Bill Lippert, I'm the chair of the House Healthcare Committee and Mike, you wanna introduce yourself as the chair. Thank you, Bill. I really appreciate the invitation that you extended to us for, to meet with you. This is an important topic for us as well as you. And we really appreciate it. So I am Mike Maricott, I'm from Coventry and chair, House Commerce and Economic Development. Great. So given that we have an hour with Ina, as my understanding of other commitments as well, but I'm not sure everyone on your committee will have met Ina Bacchus before. Perhaps I'm wrong on that, but Ina, do you wanna, so we've invited Ina Bacchus who's the director of healthcare reform for the state of Vermont, to present the healthcare strategic workforce, well, she'll get the name right, but it's basically the healthcare workforce strategic plan which she has overseen and facilitated. And I believe there are links, there should be a link to an overview of that report. Do most folks have aware that they have that and I'm guessing that that will be helpful in following the presentation. The overview link is not working for me. Okay, it wasn't working for me earlier, but then it, I think it was taken down and put back up, can you try again and see if it comes through this time? Do other folks able to access it just by nodding heads? I see some nodding heads. Yep. Yep. And so are those who were not able to access it, are you able to get it now? Yeah, I see nodding heads. Okay, so Mike, if it's okay, I'm just gonna ask Ina to go ahead and begin to welcome you and then introduce yourself and give us the opportunity to hear about the healthcare workforce development strategic plan. So I'm turning it over to you. Thank you. Good afternoon. Happy new year. My name is Ina Bacchus. I am the director of health reform at the Agency of Human Services. And in my role, I am responsible for coordinating healthcare reform initiatives between government agencies and departments and also with the Green Mountain Care Board. If it's helpful to the committee, I can share my screen, the committees. And it is very exciting to have the opportunity to meet with both committees together on this important topic. If it is all right with you, I will share my screen to walk through the presentation. Does that work for your committee? We go back and forth. Sometimes we share the screen and sometimes we don't, but I think it might be helpful. Yeah, I think it sounds good. We generally have screen sharing. Okay, go for it, Ina. I'm just working through. I've been, go. I think now you can see the slide. Yes, yeah, full screen, looks good. Thank you again for having me to discuss the healthcare workforce development strategic plan. And I will provide an overview of the plan today and assume that there may be areas where you would want to dig more deeply in the future. I think it's important to provide you with the background and process for this plan, including the primary legislative charge for it, as well as background and context for our current healthcare workforce challenges, which as you're all familiar, are evolving along with the pandemic that we're now multiple years in and are also not different or unusual, given the workforce challenges broadly speaking. And then I want to talk about the healthcare workforce development strategic plan itself and give an overview of the recommendations that are contained within it. The plan was required by Act 155 of 2020, which provided that the director of healthcare reform in the agency of human services maintain a current healthcare workforce development strategic plan and that it consult with an advisory group in maintaining that plan and in updating the plan as well. The advisory group members are represented here and the membership can included representatives of the Green Mountain Care Board's primary care advisory group, the Vermont State Colleges, the area health education centers workforce initiative, federally qualified health centers, Vermont hospitals, physicians, mental health professionals, dentists, naturopathic physicians, home health agencies, long-term care facilities were all the designated representatives in the advisory group. We also had participants in the advisory group, a number of subject matter experts from state government and sometimes beyond, participated in the advisory group and their participation is much appreciated for the subject matter expertise that they brought. We had regular participation from the blueprint for health, the Department of Labor, Division of Vocational Rehabilitation, Green Mountain Care Board, Office of Professional Regulation, Office of Rural Health and Primary Care. Required by Act 155 of 2020 was for the plan to be reviewed and approved by the Green Mountain Care Board that requirement timeline was amended by the big bill in 2021. And so the plan was required to be submitted to the Green Mountain Care Board October 15th, 2021. The plan was presented to the board on October 20th, 2021. I'm sorry for the typo there. And the plan revisions, there were plan revisions as a result of the public presentation, public comment was received, comments from board members were incorporated and the plan was revised and presented back to the board November 10th of 2021. And the board voted unanimously to approve the plan on November 12th. Current context for our workforce challenges and specifically our healthcare workforce challenges. I am sure that you've all been becoming familiar with the term the great resignation. It is a term that is being used to describe the current experience for the American workforce prompted by or disrupted by the global health pandemic in COVID-19. Americans are quitting their jobs and record numbers. The US Chamber of Commerce reports that employers in South Dakota, Nebraska and Vermont are experiencing the greatest challenge as the total jobs available in these states outnumber the total workers to fill them. So we are in a group of states experiencing some of the greatest challenge. We observed headlines just in the last couple of days about the rate of Americans quitting their jobs in November being the highest since that rate has been captured at the federal level. So we continue to see Americans and Vermonters leaving jobs. Unlike past recessions where healthcare sector jobs have stayed strong, if you will, or continue to grow, we now can observe that healthcare sector jobs are falling sharply alongside jobs for other sectors. And the Kaiser Family Foundation reports on this in a recent data briefing. And here they depict the Kaiser Family Foundation using statistics from the Bureau of Labor depict that health and human services employment in all sectors is below what it should be. Here you can see the sectors as depicted. This is the percent difference in November, 2021 for health employment by setting actual versus projected were it not for the pandemic. So we are seeing healthcare employment below what the projections for healthcare employment determine would be the appropriate level of employment. Also over the last decade, Vermont's home care workforce has declined. The home care workforce is defined as combined employment counts for two occupation types, personal care aids and home health aids, personal care aids assist older adults or people of all ages who have disabilities with activities of daily living. While home health aids provide routine individualized healthcare, such as changing bandages and dressing wounds. And you can see that in Vermont, our number of workers in this sub sector of the healthcare workforce has declined. And we are among a group of states, a small group of states where this number has declined. In order to maintain access to healthcare services, Vermont providers are relying on traveling staff. Traveling staff have increased in their use, not only by hospitals, but by other healthcare employers as well. The Vermont Hospital Association reports that for hospital fiscal year 2020 to projected 2021, the use of travelers for hospitals who have reported information has increased 26% from 270 to 341 positions, while hospital costs associated with these services has increased 50% from 50 million to 75 million over the course of the year. Further, here home, excuse me, skilled nursing facilities are also relying on traveling staff in order to offer services and are relying more so on traveling staff in light of the challenges that the healthcare workforce is facing. So here you can see that in 2021 is estimated that the skilled nursing facilities will have spent $37 million for traveling staff to ensure access to their services. With that context, I want to share with you today a number of strategies that the advisory group determined, it would want to recommend to improve our healthcare workforce in Vermont. These strategies include financial incentives, education and training, recruitment and retention, how we can ensure that regulations promote healthcare employment in the state, how we can ensure that the practice of healthcare promotes more employment in the state and recommendations for policy changes or advocacy at the federal level that could promote and foster and strengthen healthcare employment in the state of Vermont, permanent healthcare employment in the state of Vermont. These recommendations are all framed within the report as being organized through interagency and department collaboration. And that collaboration is necessary in order to carry through with these recommendations just as you're meeting in a collaborative way across committees today, that is really the spirit of the framework that we recommend in the report for following through with the various strategies for improving healthcare workforce in Vermont. We also recommend that they are be designated a health data hub where data that describes healthcare employment in Vermont is brought together in a common place, particularly so that that data can be better harnessed for supply and demand modeling, which we don't currently do in the state of Vermont with workforce data, but we would like to see in the state of Vermont for workforce data in the future that supply and demand modeling better preparing us for future need and informing policy decisions regarding the healthcare workforce. So the first grouping of recommendations are financial incentives for healthcare workers to live and work as permanent employees in Vermont. These recommendations include broadening and expanding existing loan repayment programs to more professional types. Based on an evaluation of existing data and potential new sources of data, the advisory group and the strategic plan recommend that the area health education centers should develop a proposal for expanding its service-based loan repayment program so that it can include more health professionals such as mental health and substance use disorder treatment professionals and naturopathic practitioners, for example, and increase its current program offerings on the whole. These recommendations should include the funding necessary to increase existing loan repayment programs as well as the funding necessary for including additional professional types. The next recommendation is to increase scholarship funding created by Act 155 of 2020 and to identify a permanent funding source. And the plan recommends that there be that the interagency task team should recommend whether and how these scholarship and service opportunities be expanded to more healthcare professional types, including nursing faculty, and recommend, along with that, evaluation and ongoing funding source. We also recommend evaluating the effectiveness of existing scholarship programs available to Vermonters who attend dental school, making financial assistance options for healthcare workforce clear and transparent and easy to find, and using VSAC and its resources as a clear wayfinder for this information. So that potential or current health employees can find programs to provide for potential financial assistance. In the category of financial assistance recommendations or financial incentives for healthcare workers to live and work in Vermont, we also propose a number of recommendations that would promote permanent healthcare employment and residency in Vermont. These include revisiting tax incentive proposals looking at how other states have utilized tax incentive proposals to recruit young professionals and healthcare workers to live and work as permanent residents in the state. And in this reconsidering or revisiting of the tax incentive, the plan also proposes that there should be consideration for the exemption of preceptor income in Vermont to participate so that there is a stronger incentive for healthcare professionals to participate in educating new professionals to the field. And also that there should be considerations for those tax incentives that could be offered to employers who are offering housing or other benefits to full-time employees. And generally tax incentives that can strengthen the ability of employers to recruit and retain professionals as permanent employees in the state. We also recommend identifying barriers to recruitment and retention for the non-licensed workforce, identifying the most significant barriers for recruiting non-licensed allied health and direct support professionals to participate in Vermont's workforce. And there should be consideration given here to benefits, cliffs, housing costs, transportation and competition from other industries. The training needs for this sector and career advancement opportunities for this sector of the healthcare workforce. We also recommend that one-time funds be used for healthcare employers to attract permanent employees. And here, this recommendation has been taken and is reflected in the proposal, both for the budget adjustment as well as budget adjustment too. Through that proposal, there's, we are recommending an investment in total of $33 million for healthcare providers to recruit, train and retain staff to be permanent employees. And through this investment, we are offering flexibility for employers to be able to use dollars flexibly to attract and retain staff. Can I interrupt and just say, I'm thinking that many of us will want to know more specifics about that proposal, but perhaps not now as we'll work our way through the broad recommendations, but I know that I have questions and I'm guessing others we've heard about this initiative, but not the detail of it, so. And I would be happy if you wanted to circle back to this in questions and I can, or I can take questions now or we can keep going. Michael, I'm being inclined for us to keep going and circle back because I think we could swallow, get swallowed up by this, but let's keep going. Okay, the final recommendation in this category is to consider a longer-term grant incentive program and hear the advisory group and the report recommends that there be consideration for a longer-term program to entice health professionals to seek permanent employment and residency in Vermont and that such a program could be modeled after or expand upon the remote worker program. And here's another theme that runs throughout the recommendations in this report or runs throughout the report, really utilizing our existing platforms for recruiting workers to Vermont where necessary highlighting specific ways that Vermont is particularly well-suited for health professionals, but certainly capitalizing on our existing tools and resources for attracting workers broadly to Vermont but to include healthcare workers as well. The next set of recommendations regards education and training to strengthen the healthcare workforce. The first recommendation is to increase enrollment in nursing programs and the advisory group recommended that the office of professional regulation should facilitate a working group between the schools of nursing and clinical sites, healthcare organizations and others to establish a preceptor model of clinical training to maximize opportunities for student nurses who need to obtain the required clinical time and that would minimize the need for nursing programs to recruit additional faculty. Further, the report recommends that this work group should consider how preceptorships should consider a model of preceptorships that span the care continuum, including home and community-based settings and the work group also recommended evaluating any gaps in compensation between academic faculty and practitioners, identifying possible solutions and making any further recommendations necessary including funding. This work group as described in the plan should also consider how nurses transitioning to retirement could be incentivized to work as nurse educators and the working group should identify any additional barriers and recommendations for increasing enrollment in nursing programs. The plan also recommends supporting a transition to practice program for professional roles and within the $33 million that has been recommended to strengthen the workforce in terms of immediate need for recruitment, retention and training. This aspect here is represented in that investment, meaning we see a role for transition to practice programs within those dollars that can help strengthen training for new graduate health professionals. We also recommend strengthening incentives for preceptors for all professions. Exploring opportunities to expand family practice residency programs, modifying the curriculum to introduce primary care earlier in medical school. And here we recommend that the University of Vermont College of Medicine modify the curriculum for medical students to put more emphasis on primary care. And as an example, that students would start that primary care rotation early on in their programs and continue into the subsequent years of their education. We also recommend advancing a coordinated approach to promote healthcare careers in K to 12 educational settings. And this approach would leverage existing resources in the state such as the area health education centers, the Vermont State Student Assistance Corporation, BESAC, Vermont After School programs, Vermont Career and Technical Education Centers and Vocational Rehab programs. And through leveraging these resources and working across these programs, clearly document and develop a plan to actively promote healthcare careers in K to 12 educational settings. We also recommend establishing a physician education program that recommendation requires, however, the Vermont State Colleges to study and provide a report to the legislature on the potential to offer a physician assistant program, including an analysis of the employer demand for the program. The study would also include a timeline to implement the program, the financial resources necessary to develop it and to equip staff to operate such a program. And the report would need to include a timeline to obtain accreditation and to launch the first cohort of the program. The workforce development strategic plan also recommends modifying curriculum to prepare students for work and interdisciplinary teams across the continuum of care. In addition, the program would also include the continuum of care. In addition to preparing students to practice in acute care settings, the Vermont State Colleges here and other institutions offering nursing curricula in Vermont should modify curriculum where necessary to prepare students for practice across the continuum of care, including home and community-based settings, long-term care facilities, mental health agencies and public health entities. The strategic plan also recommends developing and identifying strategies to streamline advancement through the nursing career ladder and to up-skill existing staff and specifically to identify best practices and programs to help professionals transition within the career ladder, for example, transitioning from LNA to LPN and identifying more ways to streamline advancement through the career ladder while working in clinical settings. The plan also recommends that there be healthcare education offered to all students before leaving middle school. And the plan recommends that there be advertisement and recruitment for existing apprenticeship opportunities that are already supported by the Department of Labor. The next category of recommendations is about recruiting and retaining health professionals. And the first recommendation is to inventory and highlight state programs that support recruitment and retention of health professionals. In this recommendation, the plan puts forward that working across agencies in the state of Vermont, there should be inventory to promote existing state programs that assist healthcare employers in recruiting and retaining staff. For example, the Department of Labor could clearly advertise its role and ability to assist Vermont organizations that are seeking international staff members. We also, in this category of recommendations, recommend modifying or expanding programs that support working and living in Vermont already. The state working across agencies, the state team here should recommend and identify strategies to support workforce development and employment in Vermont. And key strategies would include increasing available housing and childcare for all professionals and healthcare workers. For example, team members could identify and highlight existing opportunities for healthcare employers such as the Vermont Rental Housing Investment Program and recommend how these programs and others could be modified, expanded, or newly implemented for greater impact. Examples could include fully funding the existing pipeline of housing projects, investing in the successful Vermont Housing Investment Program, investing in a new private home builder program that's focused on creating missing middle housing for moderate income home buyers. We also recommend in this strategic plan capitalizing on existing incentives to live and work in Vermont and promoting new incentives and to do this through work between agencies in the state of Vermont to market Vermont naturally as a place to live and work. And then again, to highlight those aspects of Vermont that are particularly appealing to healthcare workers and potentially to highlight new programming that would be even more appealing to healthcare workers. Some things that are important that we already know can be highlighted include the fast track for healthcare professional licensure where through the office of professional regulation healthcare workers can become licensed to work in Vermont in a streamlined fashion. And Vermont is very competitive in this area in what the fast track program offers from the time that someone applies for licensure and becomes licensed. And I'm sure that's an area you may want to explore further with the office of professional regulation. We also recommend in this section promoting healthcare careers to new Vermonters. And in this recommendation, particularly promoting again the office of professional regulations interim administrative rule for assessing foreign credentials. This administrative rule is also designed to streamline the path to licensure for persons who have foreign credentials looking to work in the state of Vermont. I also want to highlight here that within the $33 million and specifically within the $15 million proposal that we have identified that some dollars be made available for the purpose of assisting employers with costs that result from and that would support employment of international health workers. We also recommend developing a cross system strategy and this language is very particular to a particular section of ARPA, of the American Rescue Plan. I think you're probably more familiar with thinking about this section of ARPA as the home and community based services 10% FMAT bump. You may be familiar with the federal program that provides for strengthening the home and community based services sector by providing for enhanced federal matching dollars. And again, we emphasized in the report that these dollars be used to strengthen the home and community based services system through recruitment and retention programming and these dollars are contributing to that $33 million total investment that is being proposed. We also, the plan recommends supporting organizational wellness and peer support programs and specifically promoting wellness and peer support for healthcare employers and leveraging existing resources for doing so through our Department of Mental Health. And finally, the final recommendation in this category is to reduce administrative burden for healthcare providers so that there's an easing of the burden of practice and here the recommendation is for the legislature to review the results of the reports being submitted pursuing to Act 140 of 2020 and to take further action to implement any recommendations included in these reports that could lead to reducing administrative burden specifically regarding the administrative burden associated with prior authorizations. In the category of regulatory strategies to address the healthcare workforce, you've heard me name this strategy already which is to advertise and promote the fast track for healthcare professional licensure for all OPR regulated professions. And in this regard, again, a theme in this report and in this presentation is to utilize existing platforms for the state of Vermont, such as the Think Vermont program as a way to advertise, promote and elevate Vermont's fast track to licensure for healthcare providers. We also recommend in the report differentiating Canadian healthcare workers from international healthcare workers to create an even more expedited path to licensure for our neighbors and sharing of a border. We also recommend reducing licensing barriers for telehealth practice and taking into account the recommendations that have come forward from the work group that was created by Act 21 of 2021. The plan also recommends further evaluating opportunities to remove barriers to licensure for mental health and substance use disorder treatment professionals specifically. And because of the types of credentials in this field, there are potentially more barriers for licensure for persons in this field who are coming to work in Vermont and the recommendation here would be that within the next five years, the OPR would undertake a systematic review of the licensing process for mental health and substance use disorder treatment professionals and make recommendations to address these barriers to licensure specific in this field. And finally, the final recommendation in the regulatory strategy category is a consideration for temporarily waiving licensure fees for first-time licensed nursing assistants in the interest of reducing as many barriers as possible for people to come into the healthcare workforce. This category of recommendations speaks to modifications to practice that could provide for and or stretch the current workforce to accommodate more need. These recommendations include maximizing Medicare's flexibility and reimbursements. There are a number of ways where through Vermont's particular agreement with the federal government, it may be possible for Medicare reimbursement to be provided for certain services where it is not provided now. And that would mean that there would be more Medicare coverage for those services and those types of healthcare professionals, thereby multiplying the workforce at least from the perspective of what Medicare is reimbursing for. This section also recommends developing commercial reimbursement models for audio-only services, expanding telehealth coverage, making telehealth billing requirements clear and exploring how we could establish a statewide telepsychiatry program in emergency departments similar to one in North Carolina. So that there could be a system to help treat and divert psychiatric patients that are seeking care in emergency departments. And finally, I want, there are within the report a number of other recommendations for federal action, but I wanted to highlight these recommendations for federal action specifically with regard to traveling staffing agencies. Because these agencies, while we have some local traveling staff agencies, we also have the presence of many traveling staffing agencies that work across state lines. So really becomes a federal issue. We recommend supporting strategies that would minimize the increasing trend towards travel staffing. This trend does result in unsustainably high cost increases for healthcare employers. We recommend that these strategies could include anti-poaching provisions that would be directed at travel staffing agencies, price gouging prohibitions directed at these agencies and potentially reforming federal tax incentives that very strongly advantage these traveling staff agencies over employers because the agencies can offer non-taxed housing stipends non-taxed per diem, such as meals and incidentals and non-taxed travel reimbursements. And that's the conclusion of the overview of the report and recommendations. Oh, thank you. And if anyone else isn't kind of tired when thinking about everything that needs to happen and is some of which is underway, we're not alone. So I'm gonna turn to my companion co-chair, Rep. Mark Hot, and I see a lot of hands are going up. Is that the practice in your committee as well to use your electronic hands? So I'm gonna make sure that we all work together on this. Yes. Okay. You know, I'm gonna suggest perhaps that we take down the screen sharing so that we can all see each other. And while we really have some limited time ahead of us, that's Mike, are you okay with just starting to take questions? Yeah, I think that's fine, Bill. Or do you wanna weigh in at this point with any thoughts or comments? No, I think it's probably good to go right to questions. And I think if anyone from commerce has questions, if we don't get to them, I think we will ask Ina to come into our committee for further discussions as we go along with our workforce. Yeah. And I can just say this is the next step. It's not the final step in this process of working together with Health, Healthcare and Commerce and also looking at the budget adjustment proposals, which we're trying to become more familiar with. So let's get right to it. I'm gonna start with, I'm gonna alternate between committees just as kind of a principle of how to proceed. So let's start with Representative Cortis and then Representative Kimball. And then we'll go back to Representative Peterson. Thank you. And thank you Ina for providing us with the recommendations. And I wanna preface what I'm about to say is that this is not my, I am frustrated and I may be blunt at points and it's not directed at you, Director. The great resignation is happening for a reason. It's happening because healthcare providers, healthcare workers, people in the system are burnt out. We've been working overtime and yes, we get paid for working overtime, but that's not sustainable. Where the crisis is well beyond a lot of these initiatives which frankly, we have put into programs and into bills in the past before the pandemic. So yes, tuition reimbursement, making licensing more efficient. All of those things are good things. I don't wanna say they aren't, but they're not gonna fix this problem. And it's a very little about retention of existing workers in this program. And I recognize that the state doesn't have jurisdiction over private employers. So I get that, but I just want it to be clear that before the pandemic, there was a vast gap, inequity between just compensation for workers and the administrative portion of, and I'm thinking of institutions right now. That has further caused injury at this point when the kind of work that we're doing and the intensity of the work that we're doing we're not gonna be able to recruit more people and retain people by offering tax incentives and education, tuition reimbursement. We're just, we're not, as I said, we're well beyond that. And there's a lot more I could say, but I won't. I'll just end by saying the, I know we don't have jurisdiction over the federal, what the federal government does, but to take away, I think we need to be very careful or the federal government needs to be very careful about taking away the, one of the only options that workers have for just compensation, which is by taking away the opportunity to do travel work and get paid what they actually should get paid instead of focusing on keeping people in state and not expecting retirees. I don't know when I'm gonna be able to retire. I'd like to, maybe, I'm just gonna end there. This is, we need to do more than this. And I do appreciate all the work that went into this and I hope that frontline workers if they weren't involved in this planning process that they get invited to be part of the process now. Thank you. I'm just gonna take on the role of moderating the questions at this point and alternate between committees as I indicated. So, Representative Kimball, Representative Peterson. Thank you, Robert. Thank you very much for your presentation. I think you've probably listed every conceivable incentive program that has been discussed over the past. You're too, I guess my question, because we can't certainly do all of them if the advisory committee was looking at prioritizing them and saying what was more effective than others. I think the second question in terms of looking at the fundamentals is, is there anything that Vermont is doing now in the delivery of healthcare that stands out above its peers or could there be that would attract professionals or retain professionals to Vermont that stands out because of the way that we either educate or the way that we deliver healthcare services. Did the committee look at that as a different tactic? So I'll take both of your questions and I'll try to take them in order. So first, the question about the prioritization of strategies, I think that that is a very fair question because this is a very comprehensive contendium, if you will, of strategies. I think the advisory group felt strongly that that these strategies do and are interconnected and rely on one another. We could have a great way, we could have all the slots in the world for persons to be educated, but if we're not kind of fostering that excitement about the healthcare careers in the K through 12 realm, for instance, then we may not have people who want to move into that field as an example. However, in terms of prioritization, the challenges for the workforce seemed very apparent and daunting at the time of this committee's convening. And I think have persisted and even become more acute since the time that this report was written. And so that is why you see, again, a proposal for investing a total of $33 million for healthcare employers to provide in the very near future for recruitment and retention, retention of their existing employees and hopefully recruitment as well. So in that sense, that's certainly a priority in the very near term. When it comes to how the delivery of healthcare stands out in Vermont, different than other places to make it more competitive. I really appreciate Representative Cordes' suggestion for frontline workers to be contributing to this work because I think it's the frontline workers that would be able to identify where Vermont stands out best in terms of how practice looks different. But we also have discussed among those in-across departments as we think about strategies and how Vermont can be competitive in a fiercely competitive environment. One of the things that stands out is Vermont's vaccination rate so that healthcare workers coming to provide care in the state understand that they are coming to provide care in a highly vaccinated environment. I'm going to continue with, so Representative Peterson and Representative Mulvaney-Stanik. Yes. Black and Dickinson. Yes, thank you. And thank you, Director, for a comprehensive presentation. It seems to me, well, let me just ask a question, I guess, before I go into any other things. I think we need to, we need to. I know. You're right. And we'll take our testimony to you later. My question is this, does the state maintain a list of retirees from the healthcare industry that they can then go to and maybe coax some folks out of retirement to maybe work half a day, a couple days a week or a full day, one day a week or assist in any way possible to take the burden off of the healthcare? I didn't see anything in your presentation about that because part of my philosophy on this, on the lack of workforce and people not coming back is a lot of older people working and when the pandemic hit, they were the most vulnerable. They left and found retired life pretty good and they never came back. But all of us that are retired can use three or 400 bucks extra a week. And it seems to me that might be a way too. I wondered if that was considered. I'll leave it at that. Certainly there was consideration for whether or not the retired nurses would want to serve as nurse educators. Whether or not we have a comprehensive listing of those retired individuals, I think that's something I need to follow up on. But there are a number of, and someone can please help me. The name is escaping me, but we did see and have seen many retired health professionals participate in the delivery of vaccines to Vermonters and in testing and in other ways working with their local healthcare providers as ambassadors or in other roles. Representative Mulvaney-Stanik. Thank you Representative Lippert. Hi Anna, it's nice to meet you. I serve on conversations that we've met yet. And I just was wondering to build off a little bit about the existing workforce because I think it's a lot of folks what we heard in the state of state yesterday and even in this plan, the focus is a lot about bringing new people in. And we have a lot of Vermonters here working in healthcare, working in mental health and substance abuse field. And I was, I share Representative Cortes' point a little bit here about, I'm curious if we can learn more about how to retain people in these fields. Because when I see folks working in the healthcare world here in the state, I'm wondering about livability of these jobs in terms of what they're paying and the hours required of folks. I'm wondering about safe and inclusive work environments for folks who especially are new Vermonters where there's language access or other issues that might come up with workplaces not being inclusive and safe issues of racism and other things. I've heard stories from UVM Medical Center near my district. So I'm just curious if the advisory group went into the weeds a little bit to consider these pieces of the existing Vermont workforce and why we're losing people because if we keep recruiting people into a system that's going to lose them in a year or two, that's not solving any sort of problem. The advisory group did have discussion and consideration, perhaps not comprehensively to address all of the factors that you just named, but certainly in acknowledging and recommending that there be strategies specifically to address burnout in the healthcare and the health provider workforce. And so that is where our dialogue was addressing your question and in those recommendations specifically. So again, I'm aware of the time, I'm aware of trying to balance, we've got more questions and I'm sure there are even more. This is a next step. And so I'm gonna be also respectful of our witnesses' commitments which I understand and she is actually going to be testifying in the Appropriations Committee, House Appropriations Committee later this afternoon, our committee is going to go and follow that testimony as well. And so represent Mark, I'm torn, but I'm thinking we probably need to not continue much, continue any longer for that matter, despite the fact that we have many questions in front of us because our witness needs to meet another commitment. So... I agree, Bill. I think it's a beginning, not the end. So as you said, so I would ask my committee members to hold on to their questions and as we meet again, we'll bring those questions to the forefront. Thank you. And while our committee has done a fair amount of work, frankly, on healthcare workforce issues over the past number of years, I think it would be helpful at some point, perhaps for us to benefit from what your committee and House Commerce and Economic Development has learned generally around what you understand to be the most appropriate incentives, et cetera. So let's consider this the beginning and take some further steps together at some point in time as we can figure that out. So I apologize for members who haven't had a chance to pose their questions. I'm sure, you know, it would welcome you to reach out to her directly as well. And unfortunately, I think we need to bring this to a close for the current moment.


Well, thank you all for coming out this morning. It is a great pleasure to share the experience of space flight with those folks that make it happen, if it wasn't for all the efforts of people around the NASA centers and here at JSC that support our missions. None of this could occur. And we're going to show you a film today, followed by some slides. But before we do that, I'd like to introduce the crew members one more time. And one crew member is not here today. It's Pedro Duque. He was selected to become an astronaut candidate in the next NASA class later this summer and he is back in Spain preparing to move here permanently. Down here on the front row we have our other alternate payload specialist, Dr. Luca Rubani from Italy, Luca. And we trained as a crew of nine, and for those not familiar with alternate payload specialist roles, they are prepared to step in and fill the shoes of one of the payload specialists up until the last minute. All the training on all the medical baseline data collection. And then once the mission lifted off, took up roles similar to a CAPCOM at the Paled Operations Center in Marshall. I'd like to begin introducing the crew at the far end of the table here. This is the pilot, Kevin Kriegel. He was on his second mission. Next to Kevin is Dr. Chuck Brady, a former Navy flight surgeon on his first flight. Next to me on my left is Dr. Bob Thurst from the Canadian Space Agency, flying as payload specialist number two. On my right is Lieutenant Colonel Susan Helms. She was mission specialist number two, which is our flight engineer and also our payload commander, a very challenging role. Next to Susan is our PhD in microgravity, Jean-Jacques Fabier from CNES, the Canadian, I'm sorry, the French Space Agency. And this was Jean-Jacques' first flight. His family has been living at Huntsville, so he was very familiar with the Marshall Space Flight Center's role in not only this mission, but other microgravity science missions. And at the end of the table is our first NASA doctor of veterinary medicine to fly in space, and that's Rick Lenahan also on his first flight. Without any further ado, we'd like to go ahead and begin the video if we could bring the lights down and roll the video. And parts of the video we will narrate other portions include some of the intercom that was recorded during ASIN. Here we are, suiting up at the Kennedy Space Center for our launch on June 20th. Again, Kevin Krigel, the pilot waving to his family. Jean-Jacques Fabier from France, very eager to get into space. Susan Helms all pressure checked and ready to begin her third space flight. And the alien here is Dr. Rick Lenahan, our veterinarian. And Dr. Chuck Brady, also eager to get into space for his first time. And from Canada, Dr. Bob Thursk. The launch morning schedule is quite a quick pace. No sooner had we suited up when it was time to head out to the launch pad, and LeVan would take us out there. During this walkout, we were thrilled to see some of our friends and colleagues who had gotten up early that morning to wish us all well as we were heading off on our mission. And waiting for us at the launch pad was our beloved Columbia, and at this point it seemed like it was a living creature, as it hissed and fumed and groaned, and it seemed as eager as we were to get ready for the launch. The crew was greeted at the launch pad on the gantry by the closeout crew who helped us put on our harnesses and our parachutes and check out our equipment before we got inside Columbia. The strapping in procedure is quite a busy choreographed affair, and it's also a bit of an emotional affair as well. And for a first-time flyer such as myself, I found that my thoughts went to friends and family, to the emergency procedures that I was going to have to perform in the event of an emergency.  It was really nice for me to strap in in the middeck the same time that Tom Hendricks, a three-time flyer was strapping in the flight deck. If Tom thought this was a safe thing to do, then I thought it was as well. And these wonderful views you have of the strapping in procedure occur to see a mini- It was just absolutely fantastic to see the avian space and see this great piece of American technology come off the external tank. It was really difficult for Rick and I to focus on getting pictures of this here we saw the earth and land masses and the oceans floating beneath us. But the external tank just did a super job and would perform greatly. A mission that had dual objectives. It was a microgravity mission and a life science mission combined together, but the focus of the very first day right after we got into space was to capture the life science data for documenting the adaption process. So without any further ado, as soon as we desuaded, people were working on experiments, which is probably a first in the shuttle program as quickly as we did. Here you see Bob on one of our life science facilities. It's a dynamometer, and what it's meant to do is help measure both the static and dynamic performance of the musculoskeletal system. We had several PI investigative teams that were part of this major experiment, and here you see some of the activities taking place. Yeah, that's me strapped into the TVD now being electrically stimulated involuntarily by a device which measures muscle contraction. Here's Chuck on the arm lever, and we're measuring torque output and muscle strength and degradation over the 17 days of the flight on the torque velocity dynamometer. And Chuck here is going through the different protocols. You can see the IBM ThinkPad up there on his right hand, and he's following those, and that interfaces with software in the TVD. Jean Jacques is holding a hand grip dynamometer, and he is performing various protocols that he is reading on the ThinkPad screen up there in front of him, and they are anywhere from following torque curves to producing various contractions anywhere from 10% to 100% on the hand grip. And all this will be compared to ground-based data when we get back, when we are back now, actually, and look at changes in muscle physiology. That's me again, and I am on Alfie, the astral lung function experiment, and I'm about to get on there and start blowing into this tube, and it's measuring gaseous exchange in the lungs, and we're comparing pulmonary physiology on orbit to ground-based studies. And right there, I'm interfacing with the keyboard unit and reading the LEDs and following the flow, the flow parameters up there on the screen. And also, we used Alfie with exercise. We did resting PFTs. Here's a picture of Jean Jacques with his many watches on, and the magic mask, and he's just gotten off the ergometer and he's going on to Alfie right now to determine if there are any changes pre- and post-exercise. Here's Chuck with the Olympic torch, and Chuck is hooked up to Alfie and the ergometer right now simultaneously performing the exercises, and it's measuring his pulmonary output. And here's the rest of the crew offering to cheer Chuck on and share in the Olympic moment with the torch. Now, that torch was later taken down by the orbiter crew and walked around the orbiter after we landed. We had another study. It was not relative to the lung function or the musculoskeletal studies that we have already talked about, but we also were looking at the vestibular system, the neurovestibular system. Specifically on this experiment, the goal here is to try to capture what happens to eye and head movements and posture movements when the inner ear becomes confused about what's up and what's down. Without the effect of gravity, your inner ear doesn't really understand which way it's heading relative to the earth, and so when you remove that effect, the question is how does the inner ear then translate to the eyes and head, how to move? And so we had a number of experiments. You can see some of them in progress here, where we were doing very disciplined head and eye movements, and likewise we did eye movements with and without knowledge of what was going on in the immediate environment, and by comparing this relative to what was captured in pre- and post-flight, we hope to better understand how that whole inner ear, eye, postural integrated system works together. And of course, an application for this is, among other things, a study of space motion sickness, because we know that that's got an influence on how people react in space to that effect. The award for the Autist-Looking LMS experiment goes to the torso rotation experiment. This investigation also measures how the vestibular apparatus or inner ear adapts to the weightless environment, and we also hope to come up with a cause for this space motion sickness problem, which afflicts about half of all astronauts during the first two or three days of spaceflight. Here in the mid-deck, Jean-Jacques and I have just donned the equipment, which includes accelerometer packages on the top of our head and also on our back, and we're performing a strange-looking dance, which is very much important to calibrate the equipment. Since it's the only experiment on our flight that comes from Canada, I thought it appropriate on one of the data collection days to wear my team Canada hockey jersey. We hope also that the results of this experiment will help improve treatment programs for people that suffer from motion sickness and settings on the ground. Well, this is the lace and sleepwear here. You're seeing four of us come out of our bunks in the morning. This is a study looking at the circadian rhythms of astronauts who actually had their brainwaves measured at night during six nights on four subjects. You see us coming out of there. We're really a fashion statement here, as you'll see in just a moment, but Tom's getting us all up, and we're going to line up here in just a second with all our sleep equipment on. We think we're going to get really great data from this. We're looking at long-duration spaceflight and hopefully we'll be able to help people rest better and be more efficient, both in space and here on the ground. We're going to simplify the changes in performance. On this flight, we flew a small laptop computer, which we would practice with a few times before flight, during flight, and then post-flight, and we could see the changes in our memory capabilities and in our hand-eye coordination. This mission was a life science mission, but also a microgravity science mission, and we had several fields of investigations, including fluid physics. Here we see the fluid physics experiment called the BDPU for bubble drop and particle unit. Each PI had a special container to be able to load in this optical bunch, and we had to make some critical optimization before getting the hand to the ground and to the PI. These experiments worked very well, except one day we had a little problem that Kevin and myself and Susan are trying to fix, a shortcut in the connector. But when we got that fixed, we were able to get very nice views of boiling in this particular experiment or convection driven by capillary forces like for this bubble in another experiment. And we tried to get the best quiet conditions for these critical phases. Another important experiment was a material science project, a furnace in which we elaborated different kinds of specimens, aluminum alloyed for instance, as well as semiconductors. So we tried to get the best environment, thermal environment to study the kind of structure we can expect to get in space and as you can see here, sometimes it's easier to walk upside down to get accurate positioning of the cartridge inside the furnace. And Susan looks very comfortable doing that. You can see that the Space Lab is very busy with activities and a lot of experiments. We also were doing some experiments on the flight deck. This is the voice command system. It's a voice activated system for the payload bay cameras. And Tom and myself were working on this experiment and just seeing how well it performed on orbit. We also got great views of outside the Earth. We had a full moon and it was setting and as it sets and goes through the atmosphere, it actually turned blue. So we had a blue moon and on orbit, we had a real blue moon, which is a second full moon in a month. We thought it would be fairly clever and we videoed this down to Mission Control Center, but they were on top of us and they had the song to play when we were videoing this down. One of our best passes was early in the morning. We had a nice pass above the Mediterranean Sea, Europe and Spain here. We were able to see our hometowns. This one was Spain and Madrid, a hometown of Petroduke, our alternate. Then we had some of these beautiful islands south of the coast of France that we saw sometimes and it was not so cloudy. And we continued above Italy and Greece and it was a very nice award in the morning to wake up early just to see that. We also had some marvelous passes over the United States. You may recall that during the end of June, it was absolutely clear over most of North America and this is one scene here of us saying goodbye to California, currently over Nevada, New Mexico, there's Lake Mead near Las Vegas, nearly in the center of the picture and one of the current events that happened while we were on orbit were the wildfires in the Grand Canyon area and you can actually see those in the bottom left of the picture at this time coming into the field of view just before we head over into Mexico on this particular pass. As you can see, it was quite impressive from space. Just absolutely fantastic to travel from 39 degrees north to 39 degrees south and this is a view of the Appalachians, the great smoky mountains from Tennessee to North Carolina. Now we're getting ready to come on. I don't think anyone's wanting to come home but this is a view inside of preparing for entry and as a rookie, I can't begin to tell you just what a spectacular light show it was. I'm pretty glad there were three veterans on the flight deck with me because I felt like the whole front end of the orbiter was coming on fire. As you can see, looking out the back there's just awesome light show that's going on and in just a second we'll see the lights reflecting off of Tom and Kevin in front and illuminating fully in a darkened cabin Susan's face here, just an absolutely spectacular show as we reach the entry. You saw videos in the launch, we also had that small camera for videos out the front. We're over the panhandle of Florida if you look in the middle of the picture, it's kind of cloudy but you can actually see the coast of the Fault Walton Beach Pensacola area as we come to land at the Kennedy Space Center. It was an overcast day. We had clouds at about 20,000 feet. We're at the Heading Alignment Cone. Tom's in a right hand turn trying to line up on Kennedy Space Center. Runway 33, we go through the clouds and this is looking out my window. That's what I saw on the entry day. You can see the rivers of the Kennedy Space Center as we make the turn. Coming around the Heading Alignment Cone we're doing about 300 miles per hour and we roll out about six miles from the runway at 12,000 feet, pointing 20 degrees nose low. Fairly steep approach. Tom's lined up right on the numbers for our landing there on that morning several weeks ago. Of course the entry flight control team had gotten us to this point with a great effort by some of the folks here in the room with us today. Here we are at 2,000 feet, beginning the gentle pullout from that steep dive to approach the runway. Using the lights to the left of the runway to achieve a one and a half degree approach, Kevin puts the wheels down about 10 seconds before touchdown and the airspeed is bleeding from about 300 knots down to target of 205 at touchdown and we're intending to touch down about here with the black marks. You can see that's about where we touched down so the numbers worked out well. The pre-planned numbers at 195. Kevin pushes two buttons which deploys the drag chute. I lower the nose to the runway and then we can use the nosewheel steering system on the orbiter much like an airliner to track the centerline which you see here. It also has brakes like an airliner so we're slowing it with the brakes at about 60 knots. Kevin punches another button so it doesn't drape down over the engines after we stop and we continue braking until we come to complete stop and that's the end of the flight portion of the mission but some of the most crucial data still had to be collected as these four payload crew members re-adapted to gravity so we very efficiently with the help of the folks here in Mission Control egressed the vehicle. They began their data takes and I think you can see from this that we were very pleased with the 17-day flight. Let's take a position now to the slides. The STS-78 mission links past with present through a crew patch influenced by Pacific Northwest Native American Art. Central to the design is the space shuttle Columbia whose shape evokes the image of the eagle an icon of power and prestige in the national symbol of the United States. The eagle's feathers representing both peace and friendship symbolize the spirit of international unity on STS-78. An orbit surrounding the mission number recalls a traditional NASA emblem. The Life Sciences and Microgravity Space Lab or LMS is housed in Columbia's payload bay and is depicted in a manner reminiscent of totem art. The pulsating sun, a symbol of life, displays three crystals representing STS-78s three microgravity materials processing facilities. The constellation Delfinas recalls the dolphin friend of sea explorers each star representing one member of STS-78s international crew including our alternate payload specialist Pedro Duque and Luca Urbani. The Olympic colored thrusterings at the base of Columbia signify the five continents of Earth united in global cooperation for the advancement of all humankind. And this is a photo of the ET after separation about a third of the way through the sequence and it's about to re-enter and it has started its tumble already and if you'll look up near the top of the ET you can see kind of a bullseye like Mark Gray and Black and that is the characteristic burn scar of the SRBs. This was taken with a Nikon F4 and a 300 millimeter lens with a doubler on it kind of looked like a small bazooka actually when you got it out there so you can imagine Chuck and I were both up there getting the cameras out with Susan's help and maneuvering ourselves into the back window to take this picture and I think we got some good ones. Well this is the shuttle amateur radio experiment what a delight this was each crew member got a chance to talk with school kids all around the world and these school kids had worked for six months for up to a year even preparing, working in science and mass studying the orbital trajectories of the shuttle getting ready with antennas and so forth to get a chance to talk with us on board the real credit goes to our Sarex team here on site these guys and ladies that worked so hard on this program we got a chance to talk with many people around the world and just the feel of someone being whether it's an internet question or KCA or our shuttle amateur radio experiment gets a chance for people to feel like they're inside the shuttle and this is what this business is all about. There was another experiment that we had on our flight that wasn't seen in the film and that's the plant growth facility I know there are a number of people here interested in how plants grow in space we continue to do research in that area and Jean-Jacques and I were the two people that were designated to monitor and harvest these plants after they had been growing in space for about a week and a half to two weeks what you see here is documentation of the chambers we had five chambers four of which were exposed to the cabinet and one of which was totally self-contained in the next slide you can see one of the chambers that was exposed to the cabinet and the needles are quite sparse two of the plants are bent over on purpose to see if they can grow reactive tissue at the bend while they're in microgravity versus the ones that aren't bent at the middle but when we took out the one that had not been exposed to the cabinet it was like a lush tropical forest in there and when you thought about the fact that this is what it looks like when it's exposed to cabinet it really made all of us pause for a minute wonder what was in our air I'm sure we're interested in hearing the scientific results of this experiment and this is a picture of well we're taking blood from each other and believe it or not throughout this 17-day mission the payload crew all donated about 120 cc's of blood per person Chuck is there with a tourniquet on his arm is he about to place butterfly catheter into his vein to get a morning fasting blood sample and in many in many instances we were actually taking blood samples pre and post TBD exercise you saw that earlier in the slides there and we were measuring hormone levels and other physiologic functions with the blood and to my knowledge between the SLS series of flights this is one of the big successes here was that we managed to get every blood sample and so far from what we've heard from the PIs they've all been very good and they're getting the data they need you saw we recognize folks what they call the KCA equipment and really all it is is a video teleconferencing system we use the KU antenna on the orbiter's capability to uplink video files and we had two-way transmissions Tracy is here with a little camera on the laptop computer we can see the people admission control center they can see that it turned out to really help us out and we did one of the in-flight maintenance works on the bubble experiment having the opportunity to see from the from space his hometown is for each of us very good satisfaction here you have the south part of France with on the left bottom part the beginning of the French Riviera Marseille and going to the Italian border you can see also the Alps these very nice mountains on the middle right some snow on top of the glaciers and just in the middle the Grenoble valley Grenoble is my hometown and is also the capital of the goat cheese another good shot of an important city for us this is Madrid in Spain just in the middle of the Iberian peninsula it's not very easy to see the city because of the colors which match actually the landscape around it but we are sure that Madrid is just in the middle of this picture here and this was an important shot for Peter Duque our alternate everyone recognizes this is the boot of Italy and in particular along the spine of Italy near the east coast or the Apennine mountains on the west coast about halfway down the boot is the city of Rome a little bit further down from that is the famous bay of Naples to the left is the island of Sicily which in this very rare occasion during our mission was cloud covered Italy is very important country a contributor to the international space program I got up every morning to look at this view thinking about Italy being the cradle of western civilization centuries ago and about today it's high tech space program and also Italy is the home of Luca Urbani our alternate payload specialist who is a member of our crew we considered Luca and Pedro as members of our crew because of their training but also of the payload development and procedures development they contributed to our flight and it's very likely that Luca will have his own shuttle flight in the coming years moving on to the United States and the rest of North America this is a picture of the cascade range with the diamonds of the mountains rarely seen from space without cloud cover just to orient you up to the very top of the picture you're basically looking at the south tip of British Columbia including Vancouver Island which is where Bob is from, he's from Victoria the mountain at the very top there is Mount Rainier and Chuck is from the Seattle area just nearby that area just to the south of Mount Rainier to the little bit to the right is Mount Adams and then a little bit further down there is a little white blotch with some brownish gray just to the north that's Mount St. Helens and it looks like it's been had its cap blown off and of course that's exactly what happened in 1980 and then the residue from the volcanic eruption you can still see from space here if you look at the gray area just to the north of that the next mountain down is near my hometown of Portland, Oregon so we've crossed over the Columbia River into the state of Oregon and that's Mount Hood and then further down near the bottom of the picture is Mount Jefferson and at the very bottom are the three sisters which is in Central Oregon and opportunities to take pictures of Denver and Colorado Springs if you look at this picture the green is the Rampart Range south of Denver and the brown that's to the left of the picture near the bottom is Pikes Peak and of course I know you can see very clearly in the center of the picture at the Air Force Academy which is the alma mater of myself Tom and Kevin like the second home so we were surprised how clearly we could see details of unique landmarks and while we were up there we had the opportunity to give a welcome to the incoming class of basic cadets that happened to be planned for graduation in the year 2000 so it was quite a landmark as Jean-Jacques mentioned we all got to view our homes from space this is where my roots are and it's Lake Erie is at the top right hand corner that's the western end of the lake that very corner of the lake is Toledo, Ohio named after Toledo, Spain I grew up in a small town called Woodville just outside there so this was the first out of four flights that I'd been far enough north to see Ohio which you see in the center part of the screen Michigan up in the upper half we also have Detroit in the field of view near the upper right hand corner and then the land mass just across the river is Windsor, Ontario could you tell from my accent this is my hometown this is the longest island in the United States the second one is Woodville Island where Chuck is from very cleverly we named it Long Island this is where I grew up in the south side just north of the beaches in the middle of the picture is my hometown of Amityville Long Island Long Island has about 7 million of this country's people living there this is a picture of Washington D.C. area our nation's capital you can see the coastline on the right side of the view you can see the Potomac River is coming in on the left side the central part of the view and then winds down through Washington D.C. in the very center of the frame and then exits near the bottom left hand corner we had the opportunity of celebrating the independence of three nations of our crew members during or shortly after the flight to Canada Day on the 1st of July we obviously celebrated Independence Day on the 4th of July for the U.S. and then just last weekend we had the pleasure of celebrating the French National Holiday on the 14th of July this is an infrared picture of the same area not directly from the same location this is looking straight down on Washington D.C. with infrared film I'm sorry it shows up red as you can see the river shows up more blue or green as it winds through Washington D.C. and the city itself shows up very gray or white colored and some of the other white blotches you see are the tops of clouds and on the very left hand side of the slide you can see a Dulles Airport very distinctly so infrared photography can make man-made structures very distinct Atlanta, Georgia, home of the 1996 Olympics and just as the athletes are gathering this week from all around the world in the spirit of international goodwill and cooperation and our crew and our mission we're particularly blessed in having representatives from five nations and from four separate space agencies and we feel like that's a great forerunner of the International Space Station in a cooperation and goodwill that that forbodes and as you can tell from this scene we enjoyed our 17 days in space immensely we did not look forward to returning, we were happy to stay on orbit a few more days gathering the data for the folks here on the ground but again as I mentioned at the introduction none of this would be possible without the tremendous efforts that people here at the Johnson Space Center the Kennedy Space Center and in our case the dedicated folks at the Marshall Space Flight Center that directed the science and data gathering during this mission and after the crew we would like to thank each of you for your individual efforts in making STS-78 the success that it was, thank you


So I am going to be speaking next. And I really quibbled with Mark about where I should be, seasoned surgeon or young surgeon. And he said there was no question, which was really depressing. But I am real happy to be here with you. I'm sorry that I wasn't here yesterday. I was on my way back from a surgical congress in Greece. And so if I'm appearing to suffer from jet lag today, I'm sorry. But I'm trying very hard to avoid the presence of jet lag. So I have no disclosures.  So with that being said, I want to talk a little bit about training surgeons and ethics. And this is my outline. We don't have to spend a lot of time because you're going to be here for it. So the stages of surgical education, as I see it, are really four stages. And many people may disagree with this. And perhaps it's not an exact chronological stepwise movement through these stages. But I do think that this is a way to think a little bit about it. The first stage is identification of ethical issues. And this is what I would refer to as the sort of fire spotting. You're sort of looking around. OK, there's an ethical issue. There's another one over there. The second stage is sort of OK in an educational program. We have ethics-focused educational work. So for example, in a surgery department, we're doing surgery now. We're having a surgical conference. And now next week, we're doing ethics. We have an ethics conference next week. And so that's sort of a second stage. And then I would say that is kind of what we do with the surgical ethics case conferences, which we have a couple times a month. A third phase is this integrated ethics discussion. So we integrate ethics discussions into surgical conferences. And the paradigm of that is the surgical ethics M&M discussion. And I don't have to spend a lot of time talking about it, because Karen Devin will be spending more time. And then the fourth phase is what I call mindfulness. Now, many people say, well, mindfulness, what is this mindfulness? We've not seen this described. So let me tell you, it's not a religion. And it's not a hippie thing. And it fortunately does not involve yoga.  So what I would say is this mindfulness, as I think about it, is the complete integration of the ethical dimension into the care of every patient. And so I would say this is what we ultimately want ethics education to be, which is not, I'm a doctor and I'm taking care of patients. And occasionally I think about ethical issues. But rather, that the ethical considerations are completely infused in my care of every patient. And so I see that as sort of the ultimate goal. Now, in terms of these stages, this movement from the second stage to the third and fourth stages, I do believe requires surgeons to be trained in ethics who are comfortable with and able to lead integrated discussions. And so in the first two stages, it's very helpful. And it's been certainly used by many, many departments to bring in outside ethics experts.  We'll have an ethicist come in and participate in a discussion. And that's valuable, helpful, and don't get me wrong. There's no negative about that. But I would say what's even better is if you can integrate it, you need someone who has much more of a basis in surgery to be able to participate in those discussions. So what have we done then with respect to training surgeons and ethics at the University of Chicago? I mentioned the surgical ethics case conferences. We have these a couple times a month during the academic year. We have ethics discussions at our M&M conferences, sort of dedicated time once a month. We have an introduction to surgical ethics at the surgical intern orientation program. And so this is what we call the intern boot camp. So they come in, spend a couple of days, learn how to do important things like answer pages, and log into the computer. And so during that time, as part of that critical information is thinking about how to analyze an ethics case, how to analyze a surgical case from an ethics point of view. We continue to have grand round presentations on ethics. Occasionally a journal club will be focused on an ethics related article. And then a periodic ethics curriculum for surgical residents. This is what I've referred to as the basic surgical ethics curriculum. We did this through a lot of efforts by Melanie Sir who you'll be hearing from shortly. 2015-16, we had 10 sessions. It was an interactive case-based program covering the usual topics that we thought were important.  So we of course have had surgeons participate in the ethics fellowship. And this has really been something that it's not for every surgical resident or fellow, but for fellows residents and even faculty who have a particular interest in gaining that extra depth. The ethics fellowship has been wonderful.  This is just a graph because as a surgeon it's hard to present a talk without at least some graph. Although I don't have P values, but I got a graph for you. So if you look at the graph here, what you'll see is that the red, which maybe doesn't show up well, are the surgeons and the blue are the non-surgeons. So early on there were a surgeon here or there in 2002, 2003 the year, I think I was here, there were two surgeons, but mostly it was one surgeon most years until recently. Prior to 2007, there were 12 surgeons was 5% of the trained ethics fellows. Since 2007, 48 surgeons, 24%, almost a quarter. So why the increasing numbers? Well, I think a few things. I would suggest it's increasing realization of the importance of the topics, role modeling from faculty who have done the fellowship, surgical residents and surgical fellows who have done the ethics fellowship and really are our best recruitment strategy. Other residents see the residents who've done the fellowship and talk about how valuable it was and that's better than anything I could ever say. There's been enthusiastic support from department leadership and surgery and in fact it has now become somewhat of a point of distinction for our residency program and many of our fellowships that during the recruitment process when we either for the residents, when we have students coming in to interview the presentation about the department or for fellowships the presentation about the program is we have an interest in ethics. You have the opportunity to do an ethics fellowship. We have all of these opportunities built into the curriculum. So let me turn just for a second to expand upon some of the things that Ira mentioned with respect to the American College of Surgeons and surgical ethics. So at the American College of Surgeons Clinical Congress so the Clinical Congress is the big meeting every year in the fall. There's been a long-standing ethics colloquium with four cases, a discussion. There's often been a pro and con debate. Many of the surgeons who have been ethics fellows here have participated in those. We have the John Jay Conley Ethics and Philosophy Lecture. This is a long-standing lectureship previously given by Ira Kodner as well as Mark Siegler and increasingly surgical ethics programs elsewhere throughout the conference. We've had town hall meetings on ethics, meet the expert lunches, panel discussions that relate to ethical issues. The scientific forum session, Ira mentioned this research project and looking at the outcomes of the Camongar grants. And in fact, the scientific forum is the opportunity to present empirical research. And now there's a dedicated session on ethics and end-of-life care. We had recently the third year of this dedicated session. There's been an increasing number of abstracts every year. And if you look at the rate of increase in the numbers of abstracts year over year, it's the highest growth of any subject area. Now you could argue that we started low and we're coming on strong. And so I won't show you the actual numbers, but the rate of growth is very high. So you got to focus on the positive. Now, for those of you who are thinking about what empirical research project can I do, keep in mind that the deadline for next year's clinical Congress abstract submission deadline is approximately March 1st. It hasn't actually been announced, but it's always the beginning of March. Well, what about the fellowship? How could we expand that? Well, recently a joint program between the American College of Surgeons and the McLean Center started in 2015. We have a national selection process, partial support for surgeons to come to the McLean Center as ethics fellows from around the country. Peggy Kelly is the second fellow this year who's working with us and has great projects ongoing. And we've received a number of applications already for next year. So we really think that this is an opportunity to expand the reach. There is a surgical ethics interest group. This has now come to be known as the SEAG dinners. It's just a coincidence. So through support of Washington University and the McLean Center, it's been this informal networking dinner for surgeons who are at the clinical Congress who have an interest in these areas. We've had 30 to 50 attendees, each of the last four years. And it's been a discussion of numerous things, either challenging cases, how to do research in ethics. This past few weeks ago, we had a story slam on cases of regret that I found really to be very moving. In addition, the college has a newsletter that our newspaper that goes out monthly to the surgical members. And they've been nice enough to let me write a column a couple times, every couple months. I refer to it as the right choice. There is a question mark there because initially it was just the right choice without a question mark. And I thought that was not exactly the way we want to present this. But what I have found is that although I try to write scholarly articles, these 800 word essays are what people read more than other things. And I write them when the assumption that nobody reads them, but apparently people do because they write me often letters about them. For the 2017 Clinical Congress of the College, we've proposed a postgraduate course in surgical ethics. Gretchen Schwarzie has been nice enough to agree to co-direct it with me. It'll be four additional hours of CME credit. It'll fulfill the ethics requirement in some states. We do have an ACS Surgical Ethics textbook. It's multi-authored, edited by myself, Alberto Ferreros and Eric Singer. We anticipate completion in the fall of 2017 and hope that this will be a valuable reference and resource. What does the future hold? Well, Niels Bohr, winner of the Nobel Prize said in 1922, prediction is very difficult, especially about the future. And, but the beauty of talking, making predictions about the future in any given talk, and I found this to be very effective, nobody can complain that you're wrong when you predict the future. Because first of all, nobody remembers what you said after five minutes, let alone 10 years. And if they do think back 10 years, they won't remember what you said. So it's all my opinion. I do think that practicing surgeons and organized surgery have accepted the importance of surgical ethics. This is a big change from what it was like when I was applying for residency programs and said I was getting a PhD in philosophy, was interested in ethics, and I wanted to combine ethics and surgery, and I applied to probably 20 programs, and one person asked me how I was gonna integrate that. Nobody else even thought that it was relevant to ask. There's clearly increasing national and international interest in ethics. I'm very hardened to see our finishing fellows and residents who have done the ethics fellowship who tell me that it was in fact part of their recruitment was we want you to participate in the ethics program at our institution, and that I think is really a phenomenal thing and speaks to the value of the McLean Fellowship. I think that surgical grand rounds is something that many of us get invited to give grand rounds talks as visiting professors, and I've found that increasingly, if somebody asks me to give a talk, it's not about endocrine surgery, which is what I do clinically, but it's about ethics, and I think that that's a heartening thing, and there have been invitations for international presentations on ethics and surgery in France, Taiwan, China, Hong Kong, Korea, most recently Greece, and it's really interesting because every time if I give a talk that's on surgical ethics, the response is always we've never had a surgeon give a talk on this in a surgical congress, but we're very interested, and so I really do think that that's a valuable thing for the future. So thanks to the support of the McLean Center, I do think that the future of ethics and surgery looks bright, and thank you very much for your attention. So we're gonna move on immediately now to the younger surgeons. This is the group that you've all been waiting for. I know the first person that I'm gonna introduce is Dr. Melanie Sir. I mentioned Melanie a few minutes ago. She's currently assistant professor of surgery at Mount Sinai Health System. Melanie came here as a surgical oncology fellow, and if that wasn't enough, she also did a medical education fellowship and a fellowship in the McLean Center, and she's really done some phenomenal work, and I must say for me there's nothing better than seeing how great the people that I at least had a small part in training have done as they've left the University of Chicago. So Melanie, welcome.