On the second day of the McLean Conference, we're up to panel number six. Panel number six will be moderated by Peter Angelos, who's the Linda Kohler Anderson Professor of Surgery and is also the Vice Chair in the Department of Surgery for Ethics, Professional Development and Wellness. Peter is also the Chief of Endocrine Surgery here at the University of Chicago. Peter has published more than 200 articles and book chapters on research on improving the outcomes of thyroid and parathyroid surgery, minimally invasive endocrine surgery and the best practices for thyroid cancer treatment. Peter Angelos is also a nationally recognized expert in surgical ethics. Indeed, he's widely regarded as perhaps the national leader in surgical ethics. Peter has written extensively on ethical issues in surgical practice and on how to best teach medical ethics to surgical residents. In addition to moderating today's panel focused on surgical ethics, Dr. Angelos will give the first talk in the panel entitled, quote, surgical ethics and the McLean Center from oxymoron to essential components of surgical ethics, end quote. The other speakers on the surgical ethics panel will include Alex Langerman, Sarah Scarlett, Megan Applewhite, and Juliana Testa. Please join me in giving a warm welcome to the moderator of the panel, Dr. Peter Angelos. Thank you. Thank you, Mark, very much. It is truly an honor for me to be here with you, at least virtually. It is also a little bit daunting to be speaking directly after your outstanding presentation a few minutes ago as you accepted the McLean Center Prize. So that was really an inspiring talk and something that I know many people will be going back to in the years to come to watch. I'm happy to be moderating this session on surgical ethics today. We've got a really wonderful group of speakers, and I will introduce each one of them individually for their presentations. I think that I will begin by first just saying that my presentation this morning is much less of a well thought out view than you heard Dr. Sigler present. Instead, I'm going to present more a few thoughts and considerations about surgical ethics and how I think it has changed and how the world of surgery has changed its view of surgical ethics and the role that the McLean Center has played in that. I do have no disclosures with respect to this presentation. By way of outline, I will give you a little bit of my initial perspective on surgical ethics and I'll talk a little bit about what the literature shows with respect to surgical ethics and how that compares to medical ethics. I will then talk a little bit about surgical ethics in the American College of Surgeons, and Mark mentioned a few minutes ago some of the ways that the McLean Center and the college have collaborated, and so I'll just expand on some of those things. We'll talk a little bit about the McLean Center and the field of surgical ethics in general, and then I'll just conclude by suggesting that perhaps surgical ethics is not new and perhaps we are not seeing a discovery of this importance but a rediscovery, and I will suggest to you a few reasons why I think that that may be the case. Let me begin by just sharing a little bit of personal experience. Many of you have heard me talk about this and for those who have, I apologize, but I will certainly keep it brief. I was an MD-PhD student at Boston University, I was working on my PhD in philosophy, I had taken time out from medical school, and eventually I reached the point where I was applying for residencies and I had decided that I was going to go into surgery and undoubtedly I was significantly influenced by my father who was a general surgeon. So in the winter of 1988 and the spring of 1989, that was the sort of application and interview time, and so I had of course decided to go into surgery and I had written a personal statement about the importance of integrating ethics into academic surgical practice, and I'm not sure I fully understood what academic surgical practice was, but it was something that was appealing to me, and I knew that having spent all that time studying philosophy, I really was hopeful that I would be able to integrate ethics into an academic surgical practice, and I'm not exactly sure what I wrote, but I know I spent a lot of time on it, and then I sent out my applications and I was fortunate enough to get, I think maybe ten interviews, and I was struck by the overwhelming lack of interest by every person that I interviewed with about what I had written about, and in fact, nobody asked me about it. It was as though I had written about how I was going to integrate modern dance into an academic surgical practice. It just seemed like something that nobody could quite get a handle on, except for one person, and that was Dr. David Narwald, who was the chair of surgery at Northwestern University, and Dr. Narwald was in fact very interested, and I'm pretty sure that that's why I was fortunate enough to match in surgery at Northwestern, because without question my board scores weren't good enough, and I don't think I measured up to so many of my resident colleagues. I do feel as though early in my surgical experience, it seemed as though very few surgeons were interested in ethics, and you know it's interesting, John Lantos mentioned how David Cronin would say that he was going to the gym instead of going to have an ethics lecture. I did find that for a lot of the faculty in surgery when I was a resident for many of my colleagues, surgical ethics was something that was referred to frequently as an oxymoron, and that was something that was not an unusual occurrence at that time. Now, I have spent a little bit of time over the years thinking a little bit about the differences and similarities between medical ethics and surgical ethics, and I'm going to share with you a brief content review of medical ethics, and so I did a search in PubMed for medical ethics in the title or abstract, and found that between 1830 and the present day, there were 6431 results, which is really an impressive number, and there's a maximum of 432 references in a single year, and that is most recently in 2020. And if you're interested, the very first sighting that I found was from 1830 Modern Medical Ethics or State Maxims in Medicine, and I just think it's interesting, and I'll just read just a short passage from this brief mention. Medical ethics in the modern sense, again this is 1830, must be considered the most important branch of our professional studies, because it involves the science of life, a knowledge of human nature, and the art of turning that knowledge to the greatest possible advantage. Now it is very remarkable that although this noble science of life, this useful art has been cultivated with great success during the last 20 years, it is now brought to the highest degree of perfection, not a line has been written on the subject, or any code of instructions put on the record for the benefit of the rising or falling generation. Now I just think that that's so well stated, and important for us to occasionally take a look back. Now what does a content review of surgical ethics reveal? So a similar search, I was able to find 49 results, and so it's got much less, or has had much less traction in the years. Now there is a maximum of eight references in a single year so we are certainly behind in surgery when compared to medical ethics. Now Mark Siegler mentioned a little while ago about the American College of Surgeons and Surgical Ethics, and I do want to again just point out some of the changes that I at least have seen in the college, and if we look at the American College of Surgeons, their premier educational activity every year is the annual Clinical Congress, and for many years there was very little attention to ethical issues in surgery at the annual Clinical Congress. Beginning in 1987, however, C. Rollins Hanlon, who is the former Executive Director of the College, pioneered teaching humanism to surgeons with an annual Science and Humanism seminar at the Clinical Congress. In 1991, the very first John J. Conley Ethics and Philosophy lecture was given by Dr. Leon Cass, who many of you will remember from the University of Chicago, and so this annual lecture has been given every year since then, and some of the speakers have included Mark Siegler, Gretchen Schwarz, who you heard give an excellent talk yesterday. I've been honored to be able to give that talk as well. In 1997, the first of an annual Ethics colloquium was given at the Clinical Congress, and the very first one was moderated by Dr. Tom Krizak, who was Chief of Plastic Surgery at the University of Chicago. Many of you remember Tom. Now, if you think back to those individual activities at the Clinical Congress and look at what's happened since then, and I'm going to look back at the Clinical Congress of 2019 since the most recent 2020 Clinical Congress was, as you can imagine, a different affair. It was completely online, and many of the previously scheduled programs were canceled. So let's look back at 2019, which was the last time the Clinical Congress met in person. The John Jay Connolly lecture was given. The Ethics Colloquium was on the schedule. There was a four-hour course entitled Ethical Issues in Geriatric Surgical Care. The Scientific Forum session occurred on ethics with 10 empirical abstracts presenting studies in surgical ethics. There was a Meet the Expert session on an ethics topic, and there were four additional panel sessions on topics ranging from what is futile surgery to surgeons and palliative care. And so I would suggest that this is really evidence of a big change and a shift in the way the American College of Surgeons has viewed ethics, rather than it being some sort of a fringe activity, is really much more mainstream and part of what's necessary to give great care to patients. Now, I do think it's valuable to think a little bit about the impact of the McLean Center on surgical ethics, because I think that the center and Mark in his role as director has played a leading role. This is a graphic representation of the numbers of surgeons who have completed the Ethics Fellowship at the McLean Center. And I do want to acknowledge the work of Chiro Andolfi, a past Ethics Fellow, who, along with the other people noted on this slide, did this study to look at the surgeons who have completed the Ethics Fellowship. And you'll see that the numbers are rising and between 1991 and 2019, which was the period of this study for this graph, 78 surgeons, either surgical residents or fully trained surgeons, have been trained at the McLean Center. And I do want to make note of that one from 1990-91. That was actually when I was an Ethics Fellow at the McLean Center. And I really need to give special thanks to Mark and David Narwald, my chair in surgery for making it possible for me to do the fellowship that year and allow me to join, as John Lantos said, the group of misfits and mongrels that called the McLean Center home. So a few additional thoughts. Mark mentioned the book, Ethical Issues in Surgical Care, co-edited with Dr. Alberto Ferraris and Dr. Eric Singer and me. And 10 of the 21 chapters were authored or co-authored by McLean Fellows. There's a whole book series called Difficult Decisions in Surgery, an evidence-based approach that has had multiple titles, nine current books, including Difficult Decisions in Bariatric Surgery, Difficult Decisions in Thoracic Surgery, Difficult Decisions in Endocrine Surgery. In 2021, Difficult Decisions in Surgical Ethics will be forthcoming with my co-editors, Vaseel and Peggy, who all of us are past ethics fellows, of the 52 plan chapters, 43 are authored or co-authored by former McLean Fellows. And I do have a tremendous optimism for the future of surgical ethics. But I do think that we need to see that perhaps we are seeing more than a realization of the importance of surgical ethics and surgical patient care. But perhaps we're seeing more of a reawakening of this importance. And I just want to share with you an interesting document that I came across. This is a short monograph entitled The Ethics of Operative Surgery. It is from the Dublin Journal of Medical Sciences in 1894. It was an address by Sir William Stokes to medical students at the Dublin Infirmary in October of 1894. Mr. Stokes was a prominent surgeon and his titles include Surgeon in Ordinary to Her Majesty Queen Elizabeth as well as past president of the Royal College of Surgeons and of the Pathological Society of Ireland. And I'll just share with you what I do believe, at least as far as I can tell, is the first use of surgical ethics in the literature. Stokes stated, a creation of surgical ethics that frequently exercises the mind of the operating surgeon is the question of the principles that should guide him in dealing with cancerous growths. The question as to what constitutes justification in dealing with them in an operative way is ever present and surrounded with difficulty. As the result of such interference must end in wheel or woe, satisfaction or regret to the patient as to the operator. Now this same central question remains in the care of every patient with cancer or other surgical problems even today. And that central question is do the risks of the operation outweigh the potential benefits to the patient? As our possible interventions have increased, the question of what is best for each individual patient remains central to surgical decision making. And I do believe that we cannot hope to answer what is best for my patient without attending to the ethical dimensions of surgical care. And those are things such as communicating with patients and understanding their values with respect to the possible interventions. So I just leave you with a few thoughts. I think surgical ethics is not a new idea but is a rediscovery of an absolutely central and fundamental idea to surgical practice. I think that surgeons cannot ignore the ethical dimensions of surgical patient care. And surgical ethics expertise is critical to the contemporary education of surgeons. And I do think that the discipline of surgical ethics owes a debt to Mark Segler for supporting surgeons and surgical scholarship in ethics. And I personally want to thank Mark for the years of his support, mentorship, and guidance. Thank you very much. Well now it is my pleasure to put on the hat of moderator and introduce the next speaker, Alex Langerman, who is the Chief Medical Officer of Explorer Surgical, which specializes in real-time surgical data acquisition. He's also an associate professor in the Department of Otolaryngology at the Vanderbilt Institute for Surgery and Engineering, and a faculty member at the Center for Biomedical Ethics and Society at Vanderbilt University. Dr. Langerman is a practicing head and neck surgeon whose research focuses on the intersections of ethics management and data science in the operating room. I have known Alex since prior to his going to medical school, so it's been a real pleasure for me to follow his many professional successes.  Please join me in giving a warm welcome to Dr. Alex Langerman. Hi everyone. This is Alex Langerman, and what a treat to present. I'm recording this presentation a couple days before the conference. I have equity interests in a company I started. I won't be discussing its products or services. Okay, so, you know, as I mentioned, I'm recording this in advance and I'm following Peter who's talking about, you know, the birth of surgical ethics at the McLean Center. And so I'm not sure what he said, but I want to take an opportunity to just acknowledge Mark's role as a tremendous mentor for those of us surgeons who care about ethics. And I think the cool thing about Mark is that, of the many cool things about Mark, of course, the cool thing about him is that he didn't try to seek shaping surgical ethics in the image of medical ethics, but rather allowed us to evolve as our own a unique branch of ethics and encouraged us in this regard to focus on the special topics and the ways of thinking that most fit practicing surgeons. So thank you, Mark, and I wish I could be seeing you in person. You know, it's hard not to be there. It's coming home to McLean is kind of like coming home for the holidays.  I like those little paired seats in the back. You get to pick your seat partner and get easy access to get out to the bathroom. And you have a great view of the speaker. So I missed the law school. And I like coming home for the holidays.  And I miss the fun. I wish I could wish we could all be there together this year. It's a strange time that we're in. Things are not as normal. Things are different than the way that we conceive they would be. And it's important to reflect upon that feeling in ourselves as we think about patients going through the informed consent process. Patients who have to have a surgical procedure many times are undergoing a major life event. This is not what they expected. This is not how they thought their life was going. And there's all the fear and confusion and uncertainty that's built into that. And we have to recognize that aspect of the surgical informed consent process as we think about how to improve it. That from a patient-centered standpoint, this is an extremely difficult and scary time. And so how can we make the informed consent better for patients going through this? Now, when you think about how to innovate in healthcare, one of the ways that you can do this is through design thinking. Now, design thinking is an established method of innovation that centers around the users. It's really user-centered design in many ways. But design thinking is a process to elicit this. So you want to know who the users are of informed consent. Well, of course, as mentioned, the patients, also the surgeons and nurses, these consents do not occur in a vacuum outside of the people who are actually obtaining the consent from patients. Design thinking process, this is from Stanford's D school, has several steps. It starts with empathy, understanding the users and their needs, and then defining the challenges, the pain points, the particular needs for your thing, which in this case is an informed consent. Then you have ideas, you come up with prototypes, and eventually in a very scientific manner, you test them. Cat Moon, a professor of legal innovation at Vanderbilt Law School, and I undertook a design study looking into the surgical informed consent process, and we published our initial process in this book here, Health Design Thinking, which is a great book for those of you thinking about health innovation by Bon Koo and Alan Lupton. I encourage you to check it out. It's first printing sold out. It's a popular book. So what we did was we started with reviewing the legal underpinnings of informed consent and this included both the statutes and on a hospital level, what inspired a in-house legal team to design a particular set of clauses for their informed consent. Then we evaluated a number of existing consents from around the country. We interviewed patients, surgeons, clinic and periop nurses, patient advocates, IT staff, administrators, and anyone else who might have a hand in the informed consent. Then we did prototyping sessions with students and professional lawyers, physicians, and designers. We were hoping to take this on to testing, but with COVID, many things have been put on hold. Those of you who spoke in McLean conferences before the fellows conference, you're asked to pick your topic a year in advance. I don't think any of us knew that this is what would be going on this year, but I thought I might have a little more to present about our testing or some of our finalized prototypes. However, I think it's still good when I'm presenting because it's going to be the insights that we gained from these first three steps, which really highlights ways we could improve the informed consent process. Maybe all of you listening to this can think about ways that you could do it in your own spheres of improving informed consent. The first question, of course, we started with was, what was surgical consent? Really, there's two parts to it. There's this document, and then there's the conversation, the laying of hands, the decision-making, helping a patient think through their disease and understanding it, and they each have their own elements. The document has a number of important disclosures, including some CYA for the institution. It's also acts as proof, really the only good proof that the consent process took place. The conversation, on the other hand, is more about decision-making, as I mentioned, is more about understanding, but it can be difficult to adequately document that. You don't really see that in the record, and it's not clear how good the document, the paper document, captures what was going on in the conversation. Often, the conversation document are uncoupled, and so the consent just has to be gotten. You get the consent in the pre-upholding area, the resident goes and gets the patient consent, or a nurse gets it in clinic, or that kind of thing. It's very different from the idea of it being a kind of holistic process, which you could imagine if the document and conversation were coupled together. When I reviewed consent forms from around the country, we found that most of them had the name of the procedure, of course, and the permissions, and noted that there would be assistance in the operating room in some kind of vague boilerplate, and talked about the fact that there would be specimens that would be collected and disposed of by the hospital. That was for all of them. Commonly, they also had in spots to fill in the surgical risks for blood consent, and a boilerplate about unanticipated procedures, which is really a huge permission that patients giving, that there may be some procedure that the surgeon didn't talk about, that the patients agreeing that they're willing to let the surgeon do based on their best judgment. Less commonly, but still in many of the consents was a photo or video consent about the taking of pictures in the LR and how it will be used, anesthesia risks, and some statements about pre-critical overlapping surgery, really talking about the possibility that the attending surgeon might be out of the room. Rarely were things like exam under anesthesia permission for medical students to examine a patient, financial conflicts of interest. A couple consents had this. They mentioned that that's possible. The surgeon would have to disclose that. Some consents had built-in research components about biospecimens or data, and then some consents had spots actually fill in the anesthesia risks much more specific than a laundry list of potential risks. In none of the consents that we reviewed in 2018, were there any spots to name the assistants, actually say who would be doing what in your surgery. There were no opioid consents, although I know that that has become more common since more national attention has been paid to that. There's no spots for key contacts or decision makers. These are who you would want to make a decision on your behalf should some decision need to be made while you're asleep under anesthesia. Then there was no format for initial clauses. What I mean by that is you have all these disclosures, but no active acknowledgement that the patient has been told these, versus having them sign next to each disclosure, each clause, something they acknowledge that they're being made aware of that. That was an old style of consent and actually I think it's coming back in some ways, but in the ones that we reviewed that was not present. These are intimidating documents though, and they can be scary for the patients. When we had patients look at them, they had a lot to say about ways that you could make the consent process better. That can set form better rather, they could put in different kind of details that they could explain things better. There could be more active engagement with patients. We took this information and we also looked at the process of how informed consent was obtained. The reality is it was kind of all over the place. First, the patients typically reported not reading the consent form, but not a surprise. It's a scary document. You don't read your mortgage document either from cover to cover most people, so you might not read it. Also, surgeons are very busy. They had trouble going through all of the different clauses necessarily. This is an important clue to what was really being transmitted as part of the document signing. Lastly, there was no standard consent process. We saw that some surgeons got it in clinic, others got it in pre-upholding, or in other times. There wasn't a really straightforward way to intervene on this process. Our key insights from looking over the document and its workflow, it's that there was non-center processes, as I mentioned. Overall, it was intimidating, but that some patients wanted a lot of information and they just found it hard to get it out of the document. Other patients found the document so overwhelming they didn't want, none of that information was stuff they really even wanted to know about. Lastly, there were four key components here. There's the procedure, there's the team and the process, then there's the disclosures, and then there's the special choices which include blood consent. Each of these had sort of unique roles within the document. We took all this information and we did these ideation sessions. These were students and professionals, came up with a number of maquettes, prototype ideas, and ways that you could improve this informed consent document and process. For the document, their enhancements were, first, one of the big ideas came out of many groups was this idea of segmenting the document. What part of this is a record of what's actually going to be done to you and what did we discuss? What part of it is a choice? Are you okay with blood or not okay with blood? Are you okay within a student doing an examiner's seizure or not okay with that? And then one part was a disclosure. For example, we're not going to let patients take their amputated limb home with them. That's not an option. It's a disclosure that we send it away. That's not a choice. Us, if for many academic institutions, the participation of residents in surgery is not a choice. It's not something that we're offering the patients to decide between, but actually say that is part of your care is that residents will be care at this institution. Residents will be involved. For the disclosures, the groups thought that there should be adaptive information, recognizing that some patients wanted no more information and some patients felt intimidated and overwhelmed by the information that was being dumped on them. The ultimately came down to, you know, patients needed to get enough information to know what they don't know. To know that there are certain topics they could have more information about, but that you didn't necessarily have to dump all that information on them. And ways that you could potentially handle this is either through e-forms that allowed you to click for more information or just prompting a discussion by the surgeon to provide more information if this patient wanted it. And this kind of goes back to the shared decision-making continuum. This idea that, you know, the perfect shared decision-making and really, by extension, the perfect consent doesn't have to fall anywhere specifically on this continuum. It really depends on, you know, the physician and most importantly, the patient's needs as to where they need it to be. And this also goes back to the idea of the right to choose and not the duty to choose. We don't have to force patients to go through all these disclosures to a degree that makes us satisfied if they could be satisfied and less intimidated by a more simple discussion. So lastly, the groups felt that there were a number of special components that needed to be included. You know, many of these I mentioned earlier, but a couple I'll highlight. So they felt there should be a component about patients attempting to record their own procedures or taking photos and then what they might do with those. So the patient takes a photo in the recovery room of their wound. Is it okay if they post it on social media and make a and say something about it, you know, and how that they might have to interact with the hospital regarding that? Putting in a spot for named assistance and what they were actually doing, of course, including the examiner anesthesia permission, the financial research conflicts of interest and opioid consent. We also felt like there should be a pace in the medical in the document for patients to identify who they would want the surgeon or surgical team to talk to should there need to be some decision made while the patients asleep. And this might be very specific to that particular procedure, which is why it's important to include that beyond some kind of durable power of attorney document. We felt that all sections should be initialed by the patient to prove that they were told about those sections and that anesthesia should have their own distinct section to allow them to discuss risks and document that discussion. Quickly, we also thought about the consent conversation. And there's a lot more to talk about than what I have here. But in brief, there's some advantages, of course, it's tailored, it's adaptive, it allows for these shared decisions. When a surgeon has a conversation with a patient, it demonstrates their competency in the procedure they're talking about and bolsters trust. But there are some big flaws. There's comparative spills, some surgeons may say one thing and other surgeons may say another. It's potential for manipulation. Some surgeons may avoid certain topics or gloss over them because they find them difficult.  There's also time constraints of the conform consent process. And it can be inconsistently recorded what actually happened in the discussion. And so when we imagine an idealized consent putting these together, we have a document that guides the conversation. So this is a document that has the best practices of establishing trust and reducing anxiety, includes things like goals of care. Gretchen Schwarz's Best Case, Worst Case is a perfect example of how goals of care could be documented in a consent form in some way. And also as a force function for topics. So it makes you talk about certain things that we feel surgeons need to talk about with patients. It also empowers the patient to claim the consent. So there would be supplementary material, it would be available for a pre-surgical and post-surgical review, and it guides the patient through a periopter of journey. And lastly, it becomes a shared record in reference between the patient and physician moving forward. It is about this moment in time between the patient and the physician. So of course, this is a work in progress. And this is a short talk. So thank you for your attention, listening, and I'll be live to answer any questions you have.  Thank you. Thank you, Alex. That was, as always, an outstanding talk. And we'll look forward to your live participation in the question and answer session. And that's a reminder for me to encourage all of you to ask your questions in the chat function. And if you see a good question, click on it to vote it up to the top of the list so that we'll know that people consider that important. So it's time now to move on to our next speaker. And that is Sarah Scarlett. Sarah is a resident physician in general surgery at the University of North Carolina Healthcare. In 2018, she completed the American College of Surgeons McLean Center Surgical Ethics Fellowship and also served as the editor for the May 2018 issue of the AMA Journal of Ethics entitled The Ethics of Trauma Surgery. Sarah's specific areas of interest include moral distress among healthcare providers, the ethics of healthcare for incarcerated patients, and ethics education for surgeon trainees. I have always enjoyed listening to Sarah's presentation as they're always thoughtful and thought-provoking. Sarah, today we'll be speaking on the question should anesthesiologists and surgeons take breaks during cases? Please join me in giving a warm welcome to Dr. Sarah Scarlett. So thank you so much. Just waiting on my slides. Sorry about that. Thank you so much for having me today. I am really excited to talk about this project. I sincerely wish that I was in the auditorium in Chicago with you all, but I'm excited to be here virtually. And this project and question came from a collaboration between myself, my surgeon and anesthesia colleagues, in which we worked on an issue of the AMA Journal of Ethics related to relationships between surgeons and anesthesiologists. And this was just one small piece of that work and I'm excited to share it with you today. I have no financial disclosures. I do have two enthusiastic golden doodles sitting at my feet and I sincerely apologize if they wish to make their opinions known during my talk, but I can make no guarantees about this. Just completed a residency in general surgery and over the past seven years, I have been involved in countless operations. And while the work of surgery can be incredibly rewarding, I can also attest that it can be exhausting. And the physical demands of the work that we do coupled with long case times make for challenging dates. We also face discomforts related to holding specific positions that can cause fatigue, such as in cases, such as in laparoscopic cases and endoscopic cases. And we often use accessories such as headlights and loops that further potentially physical discomfort. And despite this, I can tell you that during my short surgical career, I have taken very few breaks myself. And this practice is rather unique or this practice is not unique, but rather held by many surgeons. And interestingly, across the drapes, our anesthesia colleagues regularly incorporate breaks into their practice. And so this got me thinking about whether or not breaks could enhance surgical practice and what effect they have on the work that we do. The patient safety movement began in the late 90s and it focused on reducing adverse outcomes of promoting safety in medicine. And one function of this movement was to evaluate other industries and look at their safety initiatives and try to recapitulate those in medicine. And one of those industries that has been heavily, the inspiration has been drawn heavily from the airline industry. And in surgery, we all know of the surgical safety checklists, which has revolutionized the work that we do, that came straight from collaborations and study of practices in the air industry. One other element of safety in this industry is something called crew resource management. And this attitude and practice focuses on the effect of fatigue on performance and monitoring fatigue and trying to ameliorate it to reduce adverse events. Things like peer monitoring, debriefings, operating procedures and standards, and also scheduled breaks are part of this. So as we continue to think about patient safety going into the future, incorporating things like breaks may be very important to surgical practice or medical practice as a whole. And I believe looking to other industries and other professions that breaks have the potential to improve attention focus and stamina, which are essential attributes of safe surgeons. However, not all breaks are created equal. Ineffective transitions of care necessitated by breaks can introduce error if key details of operations or patient care are not communicated. Breaks and signouts can create distractions in the operating room. I can tell you that during critical portions of many cases I've been a part of, if a scrub tech takes a break and has a transition of care that requires counting of instruments, this can be very distracting and potentially harmful to the work at hand. The same thing is true of when we notice our anesthesia colleagues taking a break. So breaks that are ill timed can certainly contribute to negative care. And for surgeons who may not be operating in a place where there are many surgeons to relieve them of their duties, taking a break may result in an individual at the bedside who's not capable of continuing an operation such as trainees or surgical scrubs, and that can actually or could potentially prolong operative time. And what we know in surgery is that operative time and increased anesthesia time can be negative for patients. There is some literature on taking breaks in the operating room that I'll share with you. I would say that overall there's only a handful of studies on this topic. The surgical literature on breaks focuses primarily on reducing pain and fatigue of surgery. And while there are studies on taking breaks in the operating room, these studies primarily relate to taking breaks from the operation but not breaking scrub. And what I mean by that is the use of things called micro breaks or targeted stretching breaks, and those have been studied within surgery. These breaks in which surgeons step away from the procedure that they're doing in small studies have been shown to improve physical performance and mental focus. And interestingly, in some studies, they have also been shown to reduce the physical effects of stress on surgeons as measured by things like vital signs and stress hormones without prolonging operative time, suggesting that taking a break may actually promote our efficiency. In the anesthesia literature, studies related to breaks primarily relate to handoffs and whether or not they lead to adverse events or patient safety events. The scant literature that does exist within anesthesia does not show significant relationship between breaks, transitions of care, and harmful patient events. But as I said, this is this minimal literature that needs expansion for a full understanding of the relationships of breaks and patient safety. I think I've conveyed to you that there are differences across the drapes. Anesthesiologists have embraced relief breaks as part of their daily practice, but surgeons take breaks seldomly. There are events in which surgeons may leave an operation in the hands of trainees, topics such as concurrent surgery, which has been discussed at this conference. But there's little mention of surgeon practice to take breaks to honor their own humanity. Tensions can often arise between anesthesiologists and surgeons related to taking breaks in the transitions of care that they necessitate. And I think that this can be explained by a wide variety of issues. One being that the work of surgery in anesthesiology is quite different. Surgeries involve multi-step processes in which progress is tangible and very satisfying. And the nature of our work as surgeons doing these operations is such that it promotes engagement and attention throughout a case which may reduce our need or interest in taking a break. However, for anesthesia care, what is required is a significant amount of vigilance and attention. I'm an ensuring patient homeostasis throughout an operation via constant monitoring of things like vital signs, depth of anesthesia, sedation, and patient pain. And while the beginning and end of an operation from an anesthesia perspective often require a significant amount of procedural care or more rigorous care, the middle of an operation really is a period of monitoring. And in speaking with my anesthesia colleagues on this topic, they note that ongoing vigilance and attentiveness essentially requires taking breaks on their part. But these differing perceptions about breaks held by surgeons and anesthesiologists is not solely explained by the nature of the work that we do. And I think that there's something deeper here. And I believe that it relates to the commitments we have to our patients and our sense of responsibility. One piece of writing that really resonated with me as I explored this topic was that of Miles Little who mentioned that defining principles of surgical ethics include presence and proximity of the individual surgeon and the commitment of that surgeon to personally witness the ordeal and aftermath of surgery itself. And I think that shines through in our interactions with patients. When I consent patients in clinic or when I speak with them about surgery, in addition to questions about the operation itself, there's often questions from patients such as, will you be there with me the whole time? And I think that much of our identity as surgeons is to confirm that and to comfort our patients and give them the sense that yes, we will be with them throughout the entire perioperative experience, including our presence in the OR. The American College of Surgeons actually addresses breaks in their code of professional conduct, noting that in general the patient's primary attending surgeon should be in the operating suite or should be immediately available for the entire surgical procedure, which speaks against taking breaks. They do say that long procedures are valid exceptions, but these require preoperative discussions with patients about any plant absences, which as I've alluded to before, it may be difficult when our commitment to patients is emphasized that we will not be leaving their side during an operation. And I would be very interested to hear from other surgeons if this plays out in their practice. I think that another aspect of surgeon attitudes towards breaks and whether or not we begin to adopt these into our practice more widely relates to who we are as a workforce.  And while these are important skills and many relics of these still exist in the surgeon workforce today, our workforce is changing. And there is a new phase of surgery in which people have more diverse backgrounds, genders, attitudes and needs are part of the workforce. And a really wonderful part of this new phase of surgery is our introspection and considering our own humanity in our practice. And the study of things like moral distress and surgery and burnout and surgery suggest and willingness and interest into looking at how the practice affects us, our ability to care for patients and the longevity of our career. So I think that going forward, this new workforce may adopt breaks and have attitudes towards breaks that are different. Thinking about anesthesia, core notions of their professional duties relate to communication, safe transitions, and team efficacy. In contrast to surgeons, anesthesiologists provide episode of care. They often meet patients on the day of surgery and their care is limited to an operation immediate perioperate or postoperative period. Related to this, anesthesiologists and other clinicians who provide anesthesia care have adopted a systems based care team model in which multiple clinicians care for a single patient. They incorporate dedicated relief time into practice. And this allows for the most experienced or highly skilled individuals to participate in the most critical portions of anesthesia care, sharing in the less rigorous parts of care with more junior colleagues, trainees or other individuals such as nurse anesthetists. And so I think taken together are professional identities, the work that we do and our notions of duty significantly contribute to whether or not we feel comfortable taking breaks and how they're adopted in our practice between anesthesiologists and surgeons. I have several conclusions. Experiences from industry suggest that breaks have the power to reduce fatigue and error. There is scant evidence in the surgical and anesthesia literature related to breaks, suggesting that they reduce physical and mental stress without prolonging operative time or increasing the likelihood of error. But I think much is much still needs to be understood about the influence of breaks on surgical practice. The willingness to incorporate breaks into practice relates to differences in our professional duties, professional identity, but may change based on the changing surgical workforce. And in order to incorporate breaks successfully into surgical practice, we must develop evidence based practice and guideline development. And important questions need to be answered. Who should take breaks and when? How long should a break be? Where should these breaks occur and how do we talk to our patients about them? And I'm excited to think about how to answer those questions in the future. I'd like to thank my collaborators and colleagues on this project, the AMA Journal of Ethics and also the McLean Center for supporting my work. Thank you very much. Thank you, Sarah, for another outstanding presentation. Really appreciate it. It's now my pleasure to introduce the next speaker on this panel and that is Megan Applewhite. Megan is the Director of the Alden March Bioethics Institute at Albany Medical College and the John A. Baylent MD Chair of Medical Ethics. She's also an Associate Professor of Surgery. Dr. Applewhite completed a Fellowship in Clinical Medical Ethics at the McLean Center and also a Fellowship in Endocrine Surgery here at the University of Chicago in 2016. She returned to her alma mater, Albany Medical College, where she has been incredibly successful and is now leading their ethics center. Her research interests include the surgeon-patient relationship, informed consent, and communication in end-of-life care surgical patients and their families. Most recently, aided by Albany Med's contract with the New York State Department of Corrections and Community Supervision to provide care to inmates, Dr. Applewhite has focused her attention on researching surgical outcomes among inmate populations. Please join me in giving a warm welcome to Dr. Megan Applewhite. Hi, thank you. I'll pull my slides up here in just a second. It is my distinct pleasure to be here and there are no number of words of gratitude for Dr. Angelos and Dr. Siegler for your support over the years and for helping to propel my career on this trajectory. I am really excited to talk to you guys today about this topic of surgical residence as quality control agents, which really is an under-recognized and inappropriate role that our trainees have. This topic came to the forefront about a year ago when I was operating with a second-year resident and it was quiet and we were taking out a thyroid and everything was fine and then she said, Dr. Applewhite, can I ask you an ethical question?  So I said, sure. So she said, what should I do if I'm in the operating room and a surgeon asks me to do something that I don't think is safe? And I said, like what? So she said, well, there's a surgeon that's known throughout the residency program to sort of rush through things and sometimes skip steps the way that we perceive it. And then she told me a story about how she was asked to clip a comm induct. We'll just staple across it. I know the clips don't fit, but she said, oh, I'd really prefer to see the critical view for my training in similar circumstances of not seeing the recurrent laryngeal nerve on one side and being asked to go to the other side anyway to take out the other half, which is really not the way to practice necessarily. But she had really hard time with this because although other residents had experienced a similar situation with the surgeon, because of their position in this really intense hierarchy that exists in the surgical profession, she felt like, A, either she was just a resident and she didn't understand that it was safe and it was okay. And B, she was afraid to tell anyone because she knew her place as a resident and she wanted to follow the rules and she wanted to be the appreciative trainee. So this really brought to mind that really the residents are the only ones that see us all operate at academic centers and that we're not really monitored in any way in our technical or cognitive skills. And it got me thinking about the problem and thinking about what we could do about it. So I do have one disclosure that I'm a consultant to the Department of Defense Medical Ethics Center, but this does not have any influence on my talk. So what does it mean to be a surgeon? The general perception of what it means to be a surgeon is beautiful people doing beautiful operations, driving beautiful cars, making lots of money, leaving early to go golfing, and all the while with a really gruff bedside manner. People don't care if their surgeons have a good bedside manner because they just want them to be technically good as if it's sort of a binary choice to make with your surgeon. When their people are going to medical school, the view sort of transitions of what it means to be a surgeon. So when they get to medical school, they get to the operating room, they sort of learn at the feet of the masters effectively and they will never forget the first time they were able to make an incision. They will never forget the first time they held the bovier through a stitch and they work really hard to sort of achieve a residency program position where they will at some point be able to be an attending surgeon. So this takes us to the residency position. So when you become a resident, your view shifts and your job shifts dramatically. So you are constantly at the beck and call of your page or your phone or however you're contacted for consults and floorwork that ranges from really intense and emergent to totally mundane and unnecessary.  You need to not only understand the preoperative workup, but the intraoperative steps and the postoperative care of all of your patients. You learn to medically manage patients. You learn to manage all of their medications, their comorbidities in and around surgery, and so your medical knowledge grows on the job.  And this is maybe the hardest part of a resident's job is knowing all of the surgeon preferences. And so you can have any number of surgeons doing the exact same operation and they do it totally differently. And if you ask any of them, they definitely do it the only right way. So if Dr. Reed tells you that you put the tape twice around the body's belly, you're the patient's belly to fix them to the bed, and you put it three times around, you've done it wrong. And it's going to have to get redone. And then he's going to be angry for the rest of the case. And you don't want it to be angry for the rest of the case, right? Because that's four hours. So I had a little booklet that resembles this mockup that I made that had all of my surgeon's preferences in it so that I could learn them and know them and effectively manage the patient the exact way that they wanted to. So you really are influenced by all of the different surgeons that you train with and you end up being sort of a love child of these surgeons by the time you're done with your training. And you operate, you operate every day with different surgeons and you see the ways to do things are all different. There are different subtleties. There are different approaches. There are different rights and wrongs and you really every day are managing many people, a team of residents, a team of surgeons, and it ends up being a very stressful job that in the end when you graduate, you're exhausted. You've just drunk from the fire hose of training of really, really good, but also really questionable behavior at times. And then you finish and you're very much alone, right? From the moment we step out of training, no one ever watches us operate again, most of the time. We have no evaluation of our technical skills over the course of our career. We are not observed by our peers or superiors in a formal way. We have no management or technical feedback. Our maintenance of certification for evaluation is of medical knowledge only. There are no individual surgeon reported outcomes with the exception of a couple of subspecialties. So how do surgeons know if they're safe? How do patients know if their surgeons are safe? It's this guy, right? Surgeons are only ever seen consistently in academic centers by their residents. And they, the residents are the ones that do cases with every single other surgeon. So if we think about the dissemination of knowledge and technical skills, you can say, all right, we've got five colorectal surgeons in one group. So you have 11 residents. They rotate through the year with these surgeons. So, you know, this one particular resident operates with this surgeon on Monday, this one on Tuesday, this one on Wednesday, this one on Thursday, this one on Friday. And then the other, you know, the second resident comes by and does his or her rotation and does the same thing and learns all of the different approaches, all of the different ways to do things good or bad. And every single resident is able to operate with dozens of different attendings throughout their training and learn dozens of different ways to do things right and wrong. And as such, they know a lot about what happens in the operating room. Sometimes those things are not ideal, like the resident that I talked about at the beginning of my case. But because of this strict hierarchy under which we work and because of their, their role as trainees, recognizing that they don't have the experience that the surgeon has, it's a really difficult position to be in. And really what we could benefit from, we don't have, which is understanding how each other operate and not in an punitive way, but really in an information sharing way in a constructive feedback model. So our technical skills are, are never looked at again unless we call another surgeon in for an interactive console. But in that case, I'm not really asking for my feedback. I'm asking for your help with finding this pair of thyroid gland or getting out of the trouble that I found myself in. So other professions whose responsibilities are with regard to patient, excuse me, the safety of the public are the Federal Aviation Administration, right? So as Dr. Scarla pointed out, we've taken a lot of models from the Federal Aviation Administration because of our direct responsibility for the public safety and theirs as well in a totally different way, but very consistently. For example, pilots who are over 40 years old need to get first class medical certificates renewed every six months. They need a flight review test every two years. And if you're older than 65 years, you can't be a commercial airline pilot anymore. 33 states have mandatory retirement ages for judges. And there are multiple other professions that require separation from the service between the ages of 57 and 65. And this includes air traffic controllers, FBI agents, firefighters, nuclear materials carriers, careers. And all of this is because part of their job is to protect the safety of the public. And don't we fall into that category? So, so what should we do? How should we do this? The American College of Surgeons does recognize that surgeons are not immune to age-related decline in physical and cognitive skills, recommends voluntary and confidential intermittent baseline physical exams, visual testing and overall health assessment, and voluntary assessment of neurocognitive function with online tools. And if these are abnormal, it says we have an obligation to disclose, which which I would agree with. Now more recently that these are unpublished data, which I won't disclose in their entirety, but last year at the ACS Clinical Congress as part of the surgical metrics project, which Carlo Pugh has spearheaded and there are much more data coming with that, we surveyed 189 participants, so surgeons who are at the ACS Clinical Congress and we interviewed 23 of those. So we discussed the areas questions regarding the support of longitudinal databases for outcomes research, surgeon-specific outcomes research. We talked about skills assessment and formalized skills assessment not only near the end of people's careers or as they age, but throughout, right, to compare people to themselves. And then we asked the question of whether or not we have an ethical obligation to the public to report our surgeon-specific outcomes and to make that public knowledge and to have a formal skills assessment throughout the course of our career. So almost everyone who was surveyed did support a longitudinal database and participation in that, as well as surgical skills assessment, although that would come in different flavors and people had different comments about how to do that. Interestingly, only 80% thought that we had an ethical obligation to the public to formally test ourselves along the course of our career. So these are some of the quotations from the interviews that we did. One surgeon said, I do worry about stagnation of my skills. I think comparison of personal metrics is important throughout someone's career to compare them to themselves. So really saying that, yes, we should commit ourselves to technical and cognitive testing, but only in so far as we're compared to ourselves. This is a great idea. So to make sure that from my baseline, I don't decline over the course of my career. And if I do begin to decline, I understand when that's happening and I take the appropriate measures to fix it. Another quotation, I would like to have feedback. Even Tiger Woods has a coach. I would like to know what I could be doing better. And I think there's definitely something to this. I think so many people with high stakes jobs, Tiger Woods, have individual coaches. CEOs of major organizations and industries have personal coaches and technical coaching and cognitive coaching. Just making sure that we're up to snuff on our literature and things like that is, you could argue, it's really important for surgeons. It needs to be done in a totally supportive environment. Some surgeons will likely be resistant to this idea. I do watch my peers operate and I steal their tricks liberally. It is not a bad idea to offer feedback, but it can be tricky depending on the way it's phrased. I also love watching my peers operate. I have told Dr. Angelos that if I could operate with him again and go back to being a fellow for one day, I think I would gain so much at this point in my career. I think that once you're established as a surgeon, the ability to gain sort of technical feedback and to relearn the little tricks that you may have missed the subtleties of long in your training, it could be invaluable. Dr. Dellinger wrote an article for JAMA surgery about the aging physician in the medical profession. In this, they just sort of discussed how all the way from individual physicians, all the way to liability insurers and specialty certifying boards, how can we really talk about holding ourselves accountable? So they recommend voluntary testing at the individual physician level. So yeah, participate, right? They say that healthcare organizations should mandate testing and set up a structure for peer observation and peer assessment. They encourage the local medical societies to promote standards and to provide resources for those solo practitioners who don't necessarily have access to partners or other people to engage in the peer observation and assessment. And they say that liability insurers should reward compliance for those who do undergo the first class medical examinations and rigorous peer evaluations. So in closing, after talking to my resident that day, it sort of made me back up to the bird's eye view to say over five years we go from, hey, I think being a surgeon is a great idea, but I've never seen an appendectomy will try, right? All the way to being an attending surgeon, which is a profoundly lonely place to be, even if you don't wish for it to be lonely because we don't really find ourselves evaluating ourselves or one another or giving feedback in any sense along the way. And I do think that it is our distinct obligation to our patients and frankly, to each other to hold ourselves accountable and to make ourselves as good as we can be. So I think that is one thing that we can definitely work on as a society and as a profession. So I want to thank you for your time and thank Dr. Siegler genuinely for allowing me to present today. Thank you, Megan. That was great. So it is a real pleasure for me to now introduce the last speaker of the panel on surgical ethics, Juliano Testa. Juliano specializes in living donor liver transplantation for both adult and pediatric patients as well as being a pioneer in uterine transplants. Dr. Testa is the surgical director of the living donor liver transplantation program at Baylor University Medical Center. He is world-renowned for his surgical expertise and for years he was a valued colleague in surgery at the University of Chicago and someone who I always look forward to those opportunities to operate with. In 2018, Dr. Testa was named one of Time Magazine's 100 most influential people for his work as principal investigator on the uterus transplant clinical trial. His groundbreaking work resulted in a successful functional uterine transplant and the first baby born via uterus transplant in the U.S. Today, Dr. Testa will give a talk entitled values, personal perspectives, and experiences in uterus transplantation. Please join me in giving a warm welcome to Dr. Juliano Testa. Thank you, Mark. Clearly, as I'm seated this morning, those are readers with times, but I can offer you to notice that in these times the entire yesterday's presentation were dedicated to the COVID pandemic and so many of Mark's pupils and the colleagues have had now a true impact in understanding, in trying to support honest research and to find solutions for this pandemic. So I think this is if it was needed in order of testament to what Mark has done in this field, aside helping people like me to really avoid a lot of this career to use mentorship. So today, I want to talk to you through this job that this work has been started about six years ago here and has now brought us to routinely deliver babies through uterus transplantation. And I can now start this without first acknowledging the fact that the groundwork of what I'm presenting today has been done by NGVOL, my partner and incredible support in understanding these issues. And I want the audience also to, I have no financial disclosure of any kind, I want also the audience to understand my discomfort as a man and also as a father of a beautiful girl who was born quote unquote naturally, in talking about these issues. The uterus transplant is a little bit of methotetic stuff. The indication mainly is absolute tranquility, mainly due to the absence of the uterus congenital. It's a solution for women who are willing to have their own pregnancy. We have alternatives, as we know, are adoptions and surrogacy. And it can be done with a living dog or a disease drug. The process is very straightforward, kind of. There is an individual process, fertiliser embryos that need to be present prior to the shape of the process, there's an evaluation, the transplant occurs, so there's the implantation of the fertilised eggs, and then hopefully there is a pregnancy and at the end there is the birth of a healthy baby. The two ways is the Dallas uterus transplant study, was started in 2015 and that culminated in 2016 with the first baby born in young states and the 11th baby born in the world. It was a, the contribution that we gave was substantial to the field. The techniques related to the procurement of the uterus and disease, donor, would be the first fully robotic donor hysterectomy in a living, of course, person, and also the graft hysterectomy after the delivery because this graft had removed once the baby was born. Those farmed and 20 uterus transplant, you know this, you are coming from living donors to the disease, and we have had 12 beautiful babies, they are born and one of them will be born next week. So this is too far, the largest experience in the world and demonstrated to all of us that it's technically feasible, but most importantly it's reprocessable and that it's safe for both the donor and the receiver. So the fact that we can do it, and going back to Maria Ruz as a siloed McLean is, should we do it? And the corollary to this question is, is the only opinion that we can through this matter, the one that we did as physicians and the most important to this audience, the opinion of the bioethicist. So there are different assumptions from an ethical point of view, that come back when we talk about uterus transplant or say any innovative surgical procedure. Are we violating any of this? The assumptions, the beneficence are we doing good by doing this transplant? Is there a true respect for autonomy since this is an informed percent based on an experimental procedure, at least when we started? Are we really avoiding the program of non-maleficence? And this is very important because in a way or another, as in any international operation, and in this case for an operation that is not needed for the health of the receiver, are we committing non-maleficence? Are we really applying the principle of justice for treating this non-malevoluntary, the need to have an absorptive training of activity? And then is there really a balance between the risk and benefit to providing this procedure? So there are other assumptions that I think are important. Is there a therapeutic misconception? Is this a different experience than in the normal, in parenthesis pregnancy? Is the value of this transplant limited to the pregnancy? And is this just a quality life transplant or something different since it just gives lives or a second from a quality life? So the expanding ethics in uterine transplantation, this is based on same instruction interviews or recipient of uterine transplant and going back to the experience as having uterine infertility and going back to the experience of not being able to have a normal pregnancy. And the response from the public with perceptions. So Angie and the group performed this thematic analysis of the interviewed aspect and we go into very quickly the characteristics. I'm going to go really fast in this, only to say that some of the participants already had children and they were interviewed at different stages of the experience throughout the journey to become mothers.  First of all, this where diagnosed a younger age for most of the participants, 18 out of 20. And what we found out the impact is non-lasting for the rest of their life is now a time in point of the diagnosis that can be solved with the procedure. There is a, sorry, there is an issue regarding isolation is derived by the fact that there is a reality that sinks in and is the one of being different from the peers, the schoolmates and the college mates and everybody else around you. And there is also the impact of self-image. Because in reality, there is the possibility of being less than a woman of the normal because that is the absence of the uterus. And those are very important issues. In terms of the first, I want to read a quote that was recorded. You kind of close yourself off to other girls only from my experience because you couldn't talk about when you got your first period, you weren't the girl with the pattern. In terms of the identity, and in order to have that identity as a woman completely taken away from me was pretty hard. When you told a young age that it's not just an option for you to have your own child, how that cuts into you, like you can't describe that, it feels like part of you is just ripped out and completely taken away. So in general, the effect of absolute Iranian fertility is negative and it starts in a young age, affects multiple stages of life, result in a feeling of isolation and affect the female identity. Then we can look into what were the motivations of participating in the trial in pursuit of transplantation. Well, there was the number one, the desire to participate in a pregnancy. No doubts about that. But also, there was the desire of participating in something that would allow many older women to have a pregnancy. So to participate in the solution to the problem was very important. And lastly, there is also being before to defy the odds. Because of course, you're told that you couldn't do that and then you end up doing it. And I think this may have something to do with the early adopter and the fact that it takes a certain degree of a certain type of personality to participate in a trial like this. Some quotes again, I wanted to be pregnant. I wanted to have the entire experience that all other women in the universe, it seems, are able to have. And even if this doesn't work for me, I wanted to be able to move forward with research for other girls who are coming out behind me, who are 16, 17 years old and getting pregnant. So this is the idea of participating in something that's good for many other people. It wasn't that I'm doing just because it was because I was told I would never be able to do this. So this is defying the odds. And it's really powerful in my opinion. And then there is the, this is developed by the societal level, perception level, the limitation to alternative options. And there can be financial limitations, of course, there will be logistic, legal, religious motivations. And there is a different appeal that uterus transplant has for this woman, in comparison to the other available solution to absurbitant fertility. So this is another quote. And so my partner and I started looking into surrogacy and adoption, and they just did not feel right to us. Surrogacy felt like it was all about the man in adoption. It's very much the word, too. At that point in our lives, adoption wasn't the right fit for us. I think we thought that option just felt like we'll explore this for a while, but it didn't have a making desire to go those routes. But I had a making desire for uterus transplant. This is how I could see my family starting. So why don't you just adopt or do surrogacy? That's really not the question. I presented something about uterus transplant and the machine center fellow conference two years ago. And this was one of the questions. And this is one of my, one of the most profound answers. That really upsets me. I just want to respond to them and ask them why didn't they adopt? Why did they choose to have their own children? Why didn't the adopter do surrogacy? It's because they had the option to have their own child. But women who have a MRK age, which is absurbitant fertility due to congenital absurbitant uterus, but the uterus removed for other reasons. They don't have that option. Well, we do now. So this is really important to me. It's very profound is the possibility of an option to a solution to a problem and not being stuck to one, even society driven idea of taking care of that problem. Being infertile doesn't mean that I have to be the savior of that. It may be harsh, but it's very, very true. Constellation of the alternatives, adoption of surrogacy, an offering of financial justice, cultural barriers. Nutrition from physical sickness fundamentally different option than adoption surrogacy because it was the only one and this is very important that allowed the participant to carry their own pregnancy. We cannot discount this. I tend to say I've been involved in this adventure for the past six years. I hope I understood some of it. It's not a technical transplant only. It's not an unbelievable reality that you can allow somebody to a couple and the woman to have a child, but it's also the fact that this is an experience. You are transplanting an experience, not on the subject of uterus. Participants felt more pressure to defend their decision not to adopt than they felt pressure to pursue the transplantation, which probably is a testament to the way that we build the program and the fact that I just follow all the teachings that I had during Living Down with a Transplant and I gather in two of my careers to work. Mark really pointed out about Living Down with a Transplantation, with Poison, those concepts and the fact that you need to be really clear and honest about the things you don't know when the opportunity of something that nonetheless is experimental. So what is the value of the uterus transplant? I used to feel super different alone having a marked age, but just being accepted, having that option, so uterus transplant, and the mean, what was something that was in itself. And there is now this 16 or 17-year-old finding out. Now she has hope for the future. Now she has an option. So the question is what is worth to your druid in the end space? Yes. When I had the uterus transplant, I started having periods, a family trip to me that I was a woman, whether I had that period or not. Conclusions. So definitely, absolutely to an infertility for those who have any question about this negatively and affect the life of any woman who is affected by it. The primary motivation for uterus transplantation is specific to the pregnancy experience, which is very, very important. I will never discount that. And I learned how to discount that. Alternative options are various and are fundamentally different from BTX. They are there, they are absolutely legit, but at the end of the day, it's a matter of choice. It's a matter of what you are delivering with the solution and what the woman is looking for. And the value of the uterus transplantation is multifactorial and deeply personal. There's no doubts about that. And this is the value of changing minds. I had a doctor that participated in my C-section that actually came into my postpartum room and told me I was against this transplant until I was in the room with you. And so to hear that from a medical professional was completely against this transplant because he thought that there were a waste of money and a waste of time. And then to hear my story and see my baby girl before, people just can put the number on that financially. And they can say it's not worth it unless they are on our shoes and they see what we're going through. This just goes back a little bit in terms of is the opinion of the well-studied and cultural bioethics is the only one that counts. Final thoughts. There's much more work to be done and we're trying to do this. We cannot assume that our outside perception are true. We need to open up a little bit. The next step we're going to seek an experience with pregnancy and graft-fistarectomies. For example, we found that it's not easy to give it up once you give it. Our women don't like the idea of undergoing graft-fistarectomy. And personally, and this is my last quote, I thank the US for this program. I thank them for giving me the opportunity and the understanding of the word that was completely foreign to me. And I think I hope I will become a better person, a better surgeon. Could also to the member of the team, Monica Sol, Elisa Johaneson, Elisa Gordon, and that Christine Wally said that particular and most of all, to engine work. Thank you for the attention. Thank you. That was fantastic, Giuliano. Thank you very much. Well, it is now my pleasure to welcome all of the speakers from the panel on surgical ethics to participate in a short question and answer session. And I think that those of you who have been watching these presentations, many of you have written down questions. And I encourage you, if there are other questions that you have not yet seen asked, go ahead and ask them. If there's a good question that you would like to have answered, please go ahead and vote for that question. And I'm going to try to at least have a question or two about each of the talks that we've heard. And we're going to start. And I apologize when you're seeing me looking left to the side. I've got two computers and multitasking my age is a challenge. So I'm going to do my very best. So let me start by asking a question of Alex about informed consent. And that question was, in informed consent, do you include in documents the literacy of the patient in language or level of education? I think that's a great, I mean, it's a suggestion as much as really a question. And I think it's a great idea. The degree to which, you know, the classic form of this is some kind of teachback, you know, the patient was able to teach me the risks and benefits or something on those lines. But assessing that in a more formal way is an excellent suggestion. I have to admit, although the the need to turn that any documentation was written at a very low literacy level. And that's a pretty standard approach to patient facing documents, if you're doing it right. Of course, was a part of our process. That idea didn't come up. And it's a really good one whoever posed it. And I'm going to steal it. So thank you. It's great idea. Alex, can I can I just follow up and you know, certainly interested in other other of the panelists thoughts on this topic. But it does strike me that the actual written document is perhaps something that it has an underestimated importance. But it seems to me that the actual discussion is so much more important. And in many ways, what's written on the paper is less important than it seems like my interaction with the patient and whether the patient's understanding based on verbal and nonverbal cues, what I'm saying, I completely agree with you 100%. And I think the thing that that was evident from the beginning of this investigation was how the document and conversation were considered so separate, like there are really separate things. And maybe they should be maybe maybe if that's a good idea. But we approached this project to say, could there be a way for those to be more unified and more representative of each other? And I think there's some advantages of having them more unified. So one, although the conversation is so much more important, and it's context aware, it's adaptive, it's, you know, in the most sense where the patient is understanding or upset or how can you help them. But there are times that we forget to talk about certain issues, or there are times that we intentionally choose not to talk about certain issues because they're difficult topics. And having some kind of either electronic or written around the informed consent of the process includes the record of that shouldn't that becomes your document. And so we really tried to kind of throw away all existing conceptions and just start from the end. And what ultimately emerged was my process as the idea that we came up with. But you know, I think it's the ad hoc and word and the, you know, and I think unfortunately the sending, not the residents are amazing and wonderful and elevate and so I'm not down talking residents, but since it's often like an intern, you know, to go get the consent, so to speak, and have a consent document signed, you presume that the conversation has happened in time. But that may not be an accurate presumption in all situations. And so the danger in having the consent document be like the thing that counts in some kind of medical legal way and having the conversation be this lofty ideal that we keep separate and hidden and not really, you know, always guaranteed to be engaged with, if that makes sense. So we saw a unified process. But I love the other panelists thoughts on that. Yeah, I agree. I mean, I think that the idea that we could somehow capture exactly the sort of the tone in the room when we're having the conversation about the informed consent and the surgery and sort of setting realistic expectations postoperatively. And the idea that we can somehow capture that would be, I think, incredible, right, because as Dr. Angelos mentioned, sometimes it's not even the verbal conversation, but it's sort of the nonverbal cues that occur in the room. And it's just sort of the feeling that you get and the comfort that the patient has and the trust that you feel is being transferred. And I hope, Dr. Legerman, that you are able to figure this out because I'm on board. Thank you. I'll say one other thing. I'm sorry. Go ahead. I'll wait. I was just going to say the other future spinning part of this is if you think about autonomous systems listening in on what we do, which is how some primary care offices are starting to document their visits. It's automatically documented by some kind of AI speech recognition. You could ultimately have some kind of automated recognition that a consent was taking place. It was adequately done. Just thinking about not too far in the future, but in the future. Yeah, interesting. You should be, sorry. Go ahead. So there should be an evolution in the way that we perceive also our presence as surgeons when we try to obtain consent. I think that you go from thinking that just a piece of paper to thinking that you're creating some chemistry or some really connection with your patients. And maybe that is an evolution that needs time to mature. For me, it was the fact that I operate on so many healthy people because of living donation that really put a lot of stress on the idea and the will and the wish that I have that they understand it is what I'm going to do. And when I have that feedback, because it's not a unilateral way, it's got to be, it's a surgery, you want to have some feedback. Then I hope that you establish that connection. And the idea of this electronically signed is completely foreign to my profession and I think it's wrong. Thanks, Julian. And Sarah, go ahead. Sure. I really struggle with how to disjoint the conversations that I have with my patients about consent and the relic or that form that I present to them is and I often will go through it with patients and people, some people don't read every point, others do. And it's very interesting when the things that are written on our university consent form come up and they seem so surprising or jarred to patients, which is always a big challenge to me. For instance, it involves things like it addresses the implantation of devices, the harvesting of graphs, videotaping, and all these things that aren't a part of the conversation that I have with my patients because they're not relevant to that specific operation. But it's really a struggle sometimes to make the conversation in that document alive. So I'd love to see a more reflective document of what we're actually doing. Thank you. So let me go on and ask a question for you, Sarah. The question was raised, what happens during a break by a surgeon? Is the operation continued or do things just stop? Yeah, that's a great question. I think it's very practice dependent. I think at an academic medical center where I practice, if an attending surgeon leaves the room, there may be a trainee present or an advanced practice provider who may be able to advance the operation or complete the operation, I think that probably varies widely among surgeons who practice in other environments or who practice were isolated from other colleagues. And I think that based on who's there to cover, that may be their prolonged operative time, which can be harmful or not, which is really important and probably factors in the surgeon's decision to take a break. Now, if I could just ask Giuliano, I think you mentioned that when you're doing these long liver transplants and other long procedures, you often take breaks. So how does it work in your system? Well, it was introduced in the system and now it's mandatory and we just leave the room. We literally leave the room. And I know that we discuss about being present and always close to our patients. This has changed a little bit with robotics surgery, by the way, but even then, we leave it. I think it's extremely safe and it's good for your mind and it's good for the atmosphere in the room. There are so many positive externalities about leaving the field. I cannot even start counting them. Of course, as Sara mentioned, you have to choose the right moments for doing that. And in certain operations, there are moments where you're perfectly capable of doing this without jeopardizing neither safety nor the vital outcome of the operation. Thank you very much. Yeah, go ahead. Sara, I really loved your talk. And one of the things that you mentioned was how do people talk to their patients about it. And I imagine all of us could play wax wheel, soffin about it. But one element that I think is important to mention is that there is this concept of the surgeon as the only person who matters in a room. And that, I'm sure, came up with the thesis of anesthesiologist. Surgeons often act that way. I think there's an opportunity in the consent process to elevate our entire team. And in particular, I'm talking about residents here. And so the idea that I might step out of the room to go to the bathroom and come back and made our case, when I talk to my patients about it, I explain that I'm in charge. I'm not going to be doing every room. And that's true. And in fact, I think we don't say that enough that it's not my hands doing every thing that get done by members of the team who are capable of doing it. And for times when I think it's safe, I may not even be in the room if I'm helping care someone else or I take a break. And I say that to every patient. And so I think that people think of it as like, oh, I'm bad news that I might not be in the room. But rather, I use it as an opportunity to talk about the great team that's taking care of them that I am but a part of, even if I am, you know, kind of. I think that surgeons could take a lot from the systems for the multiple clinicians based care team model the anesthesiologists have really run with. They think that this enhances our practice and makes it easier to discuss things that breaks a transition to care. No. Thank you guys. Megan, let me ask you a question that was raised in the chat. What do you think about using surgical simulation or other type of mechanisms for board recertification to ensure continued competency either over time or as surgeons age? I think it's a great idea. I think that it is certainly one way that we could consistently evaluate each other and ourselves and sort of compare ourselves not only to our peers and the same sort of experience level, but also to ourselves over time and sort of how we're changing. It would also allow for surgeons in sort of rural or more remote hospitals to have the same access to those evaluation tools as surgeons in major academic centers rather than saying, you know, you have to be supervised by, you know, your chairperson who doesn't do this type of operation ever, but is going to watch you do it, or you're going to be supervised by your peer who does the exact same type of operation every day, but kind of feels uncomfortable with, you know, giving you feedback. It is a much more, it is a much more, I guess, standardizable way to evaluate people if we can get such a method to be predictable and validated. Great. Giuliano, if I could raise the question that was asked by Dr. Sigler, how did your 18 living donors do medically and psychologically? So I think Mark is going to ask him about complications or general outcomes of the surgery. Dave, I have to say that the donors have done extremely well. We have, we published about this in the recent thing, Annus of Surgery, and the recipients are really, it's impressive how free of complications have been.  They are in the process of delivering or having the pregnancy started and then we'll be done with this first cohort. The most fascinating things has been the complication rate has been much lower than we expected for a procedure that did not exist before. And secondly, the fact that the take-home baby rate, which is a metric that the American Social Democratic Medicine uses, is phenomenal. It's practically 100% of the five successful in the first 10. And for the time being, it's already 70% in the next 10. So it's higher than any other IDF or infantry treatment available, which speaks a lot for the benefit of this procedure. Thanks, Juliana. There's a question here. This is, I guess, primarily for Megan Applewhite. If we are, depending on residents' quality feedback mechanisms for attendings, what can we do to create a safe place for them to voice their concerns? Such a good question. You know, I think part of what makes surgical training so challenging is the, as I mentioned in the talk, sort of the strict hierarchy of, you know, knowing your place, knowing who you talk to, when, when you talk, what you can say, and how you can say it, right? It's almost militaristic in sort of how regimented it is and how hierarchical it is. And it does, it makes a really uncomfortable environment when somebody feels the need to ask a question, right? A question that could potentially be perceived as that trainee presuming to know more than they do know, or presuming to know better than the attending, which how dare you, right? I think all we can do is foster an environment of safety and of support. I think that one of the really good things that a lot of surgical programs have implemented is mentorship programs, where they have a faculty mentor, either of their own choosing or to whom they've been assigned that they meet with regularly, that they're able to talk to sort of off the books about certain things. I think changing our environment of fear that exists, but doing so in a way that still respects the experience and of the surgeons themselves would be the best way to go. But finding, when the resident asked me, you know, what do I do, right? In this situation, I say, I actually said, you find a mom or a dad, right? Like you tell me, so you find someone that you feel safe with, you find someone who you can trust, and you just say, listen, I could be totally off base with this, but I'm worried. And frankly, we owe it to our patients as residents to be able to see that.  Or I could tell you, all right, we'll take this to the next level, you know, but I think having safety at least in a mentor or to someone that you just know you can talk to off the books is a good step before we are able to make the next step and in a more structured way, evaluate each other in a really very formal process. Thanks, Megan. Alex? No, Megan, I was really intrigued by what you said about the evolution in a certain way of self assessment. Of course, I'm a completely different surgeon than I was 20 years ago. But also I grew in different systems and always under the scrutiny, as you say, of the residents, the fellows and my peers. And I think that we have acknowledged the fact that our reality, the reality of this panel and the reality of the participants of this conference is limited to a very elective academic centers. And it doesn't reflect the reality of most of the surgery performed in the United States. So the question would arise how you continue this growth, this longitudinal growth that we have at least a mirror to look at. If you work doing different kinds of surgeries and you're always your own, you don't have that kind of feedback. So I think we should take that in account when we start thinking about how to implement some of the things that you so elegantly discussed today. Yeah, I agree wholeheartedly. Thanks, Juliano. Alex, we are going to be wrapping up in a minute. I want to give you a chance to weigh in on this question, since I know that you take very seriously your role with respect to the surgical residents. This particular question, I thought you were... Yeah, no, no, no. Yes, yes, I do. Can you hear me? So, yeah, you know, I actually, I love the find a mom or daddy thing. I think it's right. And that happens. And sometimes I think I played that role. And sometimes I wonder if I'm going to be upset.  But I think that one of the struggles that that residents face is, and we saw this in the work that Malani did on residents speaking up, that like there was this dichotomy between residents that felt like they had been taken care of versus, you know, it's the attending patient and I'm just sort of there under their good graces. And the idea of having some thinking of a patient as your patient and being powerless to affect good care on them because of, you know, the patient where you feel like the best care is not being delivered is extremely difficult for residents. And I don't know that there's actually been a good way through it. But I think the way that I would teach you, you know, like I said, you know, that come and let's talk about it and find a way to elevate it appropriately if that's... Because that's the powerlessness of being able to ensure for your patients because you're in a resident not attending. There is one outlet for that, that if there's a real problem or a pattern, the residents are going to be the first ones to see that. And that would be a way to affect change. And in the times that I've been with residents where it's been some signal in the noise that something needs to be done about it, that actually has been the thing that made everyone feel better was knowing that there could be some intervention or opportunity for growth. Yeah, it's such a good point we make about what the trainees are to do in that moment because after I'd spoken with that second year resident, one of the 50 years I talked to said, he said he doesn't know what to do when he's in that moment because when that surgeon is doing something that's not safe, he feels like he should leave and not be a part of it because he can't change it. But he feels like he needs to stay to help protect the patient to do his best from his trainee voice to sort of guide the surgeon in the way that he thinks is the safest. And so he feels really, as you say, powerless and just caught in the situation. This is such an important topic and I'm sorry that we're actually over time. But I do want to ask Sarah Starlett to perhaps make the last comment with respect to the really central question. Sarah, you have been a surgical resident most recently. I the longest of anyone on this panel, it's been the longest. So I hardly even remember what it was like. But so tell us, you know, what do you think is the best way to manage the situation that Megan raised? Yeah, I think that creating a culture in which we can feel empowered to make up is really important. And one aspect of that is promoting diversity in the workforce. I think it's a lot easier when you have a mentor or a surgeon that you can relate to that you can go forward to. I think diversification of the workforce will support that. I think a lot of the experiences alluded to in this talk, in this discussion, are referenced in the moral distress literature among residents. And I think that recognizing those conflicts and creating platforms to talk about them when they exist is really important and is the first step. I think that as we move away from a surgical culture that's very hierarchy based and less diverse than to the one that we have today, I think that it'll be supported by that. But that's a really important topic. Thank you so much for talking about it. Pleasure. Well, thank you all, all of the panelists for a great session. And thanks to all who were listening and asking excellent questions. We're going to take a break for a late lunch and then reconvene at 2.30 for the session Clinical Medical Ethics 2, moderated by Dr. Tracy Cooper. Thank you.