Actually, earlier when there was a conversation about publicly owned utilities versus cooperatively owned energy, I was kind of thinking in my head, is it possible for those to coexist? Because it's really important for the case of uproads, it's like low income people, people of color coming together to cooperatively own their power supply, and to kind of create energy storage systems and actually have the panels in the neighborhood and actually do the outreach kind of in a hub from the community organization that can kind of integrate both the popular education aspect and the energy supply aspect. So did you want to? I agree with that, but I also think regulation and scale are key. We can do these isolated efforts and feel good about them and provide like help or support to these communities, but if you don't have the structure, who's actually closing the gaps, it's going to become like the system that we, you know, like a checkbox. We have like people of color doing this clean energy and that's right, that's problematic.


are we doing such a big video? if you like this video give us a thumbs up and share and subscribe to this channel


Did the narcissist get away with what they did to you? Did they really gain an advantage from dealing with you? Did they really benefit at your expense? It may seem that way initially But it doesn't end how you might expect It just looks that way Because you're looking at it from the outside You might see them go in shopping Maybe they bought a new car Because they got some money out of you So they've got that money in their account Which is what they want They need the money for the thrill And so they can attract attention That's all it's for So they can buy a car to show off to their friends And they can go to all of these places that they would never normally be able to go to But they can do that now After dealing with you So from the outside it may look like they've got this new situation They've taken your money to start something new with someone else And everything looks good in the beginning They're having fun Because a relationship doesn't even begin until after one or two years Before that there's no duty or responsibility They're just having fun So of course it's going to look good But after one or two years That's when things begin to change That's when things start to fall apart If it even lasts that long Because the money goes really quick And whoever their dinner with is usually running a scam on them When people deceive or do harm It will come back to them in some way Because they're running And they run into something that isn't what they thought it was They thought they were going to become more successful But they didn't Because it all fell apart It didn't turn out how they expected it to And they start to feel embarrassed So they've got to avoid humiliation Because they've talked so much about the possibility of some future event occurring But it turned out to be ineffective And maybe they got played too Maybe someone got one over on them So then you won't hear from them But for the first few months Up until one year You shouldn't be concerned about anything you see Although sometimes it may fall apart very quickly But that's just the honeymoon phase You have to wait until they start getting bored Or until their mask comes off Because they haven't really come up They didn't really get one over on you They haven't moved on to a better life They're just surrounded by people who can't get themselves out of it Because they all have problems They may think that they've gotten one over on you But they haven't It doesn't turn out the way that you think it does It's just your imagination You don't know what is really going on They could be fighting every day But they still choose to stay together But you're looking at it from the outside So you assume that they must be doing okay But they're not Most of the time they get in played as well And even if they're not, it's only a matter of time until they do They didn't get over on you They didn't get away with it Everything they did to you will create a negative situation for them in the future People play the game of cheating and deceiving people Of using and mistreating people And trying to get over on them There are consequences that come with behaving in that way And there's no other way around it They will experience the negative effects as well They may think that they've gotten one over on you But it will come back to get them in the game Thank you for watching If you found this video helpful please give it a thumbs up Share your thoughts in the comment section Hit the subscribe button to receive the notifications If you would like to support the channel You can donate at paypal.me-naxviver You can book a one-on-one with me on my website It's naxviver.uk Thank you for watching and I'll talk to you soon


Good afternoon. I'm delighted to welcome you to today's seminar in the professionalism series. We're delighted and honored that Dr. Holly Humphrey is able to join us and speak to us today. Holly and I go back a couple of years to today's where we were both medical students and interns and residents and not at the same time. We were separated by a generation, but it does go back a ways. As you know, Dr. Humphrey is the Dean of Medical Education at the University of Chicago, highly regarded nationally as one of the leading medical educators in the United States. Here at Pritzker, Holly took the lead in developing the Pritzker initiative, the curricula reform for the 21st century, and Holly has also launched the roadmap to professionalism initiative with colleagues. Nationally, when Dr. Humphrey was the head of the program in internal medicine, she also was the president of the program directors in internal medicine. And since then, as she moved from there to the Dean's office, she's become the chair of the American Board of Internal Medicine. So it's hard to think of anybody who has received more acknowledgement and recognition for contributions to the field of medical education than Dr. Humphrey. Today, Holly will talk about case studies in medical professionalism, a view from the front lines. Holly was so glad you're here. Thank you. Thank you, Mark. Thank you very much for that wonderful introduction. I'm glad you clarified that we weren't in the exact same medical school class. In all honesty, Mark was one of my teachers when I was a medical student here. And I have continued to learn from him over the years since I was a student as we all have. I wanted to say at the outset a thank you to Dana Levinson, who helped put this presentation together. There are a number of different angles that I could have taken with the presentation today. But I thought I would try to build on what we have learned as a group, beginning with the fall seminar series that I thought was very elucidating and interesting. And you'll see that some of what I'll present will touch on some of the conversations that we had in the fall. Let's get started. I do intend to address this question of the definitions of professionalism. And then I'd like to share with you what some very important accreditation expectations are in this domain of professionalism. Because I think in many ways the accreditation expectations force a lot of not only the conversation but the behavior that medical schools and residency programs are engaged in today in 2012. And then to try to make the point and drive the point home, I'm going to ask you to engage in some problem solving experiences through a few case studies. And I will conclude those case studies by posing what I believe are some unanswerable questions. However, it's possible that as a group, you will persuade me that there are in fact answers to some of what I'm posing as unanswerable. And then I will conclude by inviting you to think about the impact that mentoring can have in helping us solve some of the questions. And I think that everybody in this room has an opportunity to be engaged in a mentoring relationship on one level or another. I won't go into that topic in great detail given some time constraints. So I think early in this seminar series in the fall, we had an opportunity to think about the major principles of medical ethics that in fact form the foundation for the whole conversation and all of the published literature on medical professionalism. And I know that many of you who are real experts in the field of medical ethics may be content to leave this topic of medical professionalism right there with those four basic principles of medical ethics. You also know, given the presentation that Laney Ross did in the fall, that a more contemporary definition of medical professionalism was done by the American Board of Internal Medicine Foundation and the American College of Physicians through the physician charter. And that charter is based on the three principles which we covered in the fall as well as the professional responsibilities that the charter calls each physician to adhere to. Now, as I have listened to the conversation in the fall and being well familiar in particular with the physician charter, it gave me an opportunity to ask myself the questions of why is it that this topic of medical professionalism creates so much controversy and so many questions and conundrums. And I've certainly had the opportunity to think about that when our own medical students have pushed back on instruction related to medical professionalism. I think that the lofty goals of medical ethics and the lofty goals of the physician charter are in fact aspirational in what they intend to invite us all to aspire to. But I think the real essence of this conundrum gets back to the fundamental definition that we would find in any major dictionary. And that fundamental is that the professionalism is focusing on the conduct or the qualities that characterize or mark a profession or a professional person. And it's in trying to set expectations for conduct that I think we run up against some real dilemmas because I think they can very often stray a long way away from those fundamental high minded ethical principles as well as the principles of the physician charter. I also think that today this concept of professionalism is often applied to groups that would not historically have been thought of as representing a profession such as athletics according to Miriam Webster uses athletics as the example. And if you were to look in the literature you would find that a whole host of groups are using the term professionalism to describe the work that they do and the group that they happen to be a part of whether it's veterinaries or nurses or individual employees at Walmart. Now Herbert Swick published in academic medicine a set of expectations for physicians that he believed incorporated the contemporary definition of professionalism and we've had a chance to talk about these multiple times over the fall what in fact physicians do they subordinate their own interest to the interests of others they adhere to these high ethical and moral standards they respond to societal needs they events core humanistic values they have accountability for themselves and their colleagues they demonstrate continuing commitment to excellence they have a commitment to scholarship and advancing their field they deal with high levels of complexity and uncertainty and they reflect upon their actions and the decisions that they make that's a very long list. So with all of this background one reader who posted his comment on the internet said that that list actually read like a combination of the Boy Scouts code the Ten Commandments the Golden Rule and the Pledge of Allegiance all lovely and legal yet impossible to adhere to and enforce platitudes and pedestals warm the cockles but reality is chilly. I think in many ways we have heard that point of view in this seminar over the course of the fall but now let me show you what in fact physicians say when they have a chance in focus groups to talk about what they think of as professionalism and what I'm showing you is basically a word cloud that was developed by the American Board of Internal Medicine Foundation after doing a series of focus groups with practicing physicians largely in small and mid-sized group practices when they talked about their work as physicians in the community. This is the word cloud and one thing that gives me a great deal of a reassurance is that the very center of the word cloud is the patient. So when physicians talked about their role as professionals it was really their interaction with patients that drove their conversation in the focus groups as well as these qualities of compassion and honesty everything that you see on the word cloud in smaller font and lighter text are things that were mentioned in the focus groups but to a less extent. Okay so with that background let me show you what the accreditors expect medical schools to do. I'm going to talk about the LCME which is the accrediting group for medical schools and then the ACGME which is the accrediting group for residency and fellowship programs. So the LCME has several standards that are going to be very much related to this topic of professionalism. One of those standards is ED23 related to the curriculum. A medical education program must include instruction in medical ethics and human values and require its medical students to exhibit scrupulous ethical principles. They go on to say that the medical education program should ensure that medical students receive instruction in appropriate medical ethics, human values and communication skills and adherence to ethical principles should be observed, assessed, i.e. evaluated and reinforced through formal instructional efforts. Okay that's ED23. The phrase scrupulous ethical principles implies characteristics that include honesty, integrity, maintenance of confidentiality and respect for patients, their families, other students and other health professionals. The next standard is a relatively new standard and it applies to the learning environment. The standard 31. A medical education program must ensure that its learning environment promotes the development of explicit and appropriate professional attributes in its medical students, their attitudes, behaviors and identity. It is expected that a medical education program will define the professional attributes it wishes its medical students to develop as part of their formal training. Medical students should learn the importance of demonstrating the attributes of a professional and understand the balance of privileges and obligations that the public and the profession expect of a physician. Keep this in mind when we get to case study number one. The medical education program should also regularly evaluate the learning environment to identify positive and negative influences on the maintenance of professional standards and conduct and develop appropriate strategies to enhance the positive and to mitigate the negative influence. And then there's a standard related to outcomes. A medical education program must collect and use a variety of outcome data including national norms of accomplishment to demonstrate to the extent to which we meet these objectives and that we should collect that outcome data on medical student performance. The kinds of outcome data that could serve this purpose include assessments by graduates of the school by residency directors of the graduates preparation in areas related to the medical education program objectives including the professional behavior of its of its graduates. Now the Association of American Medical Colleges which is one of the two main parents of that accrediting body the LCME convened about a decade ago a task force to to provide guidance for medical schools on how we should report the performance of our students to the outside world specifically how we should report the performance of our graduates to the residency programs that they're applying to. That report is called an MSPE the medical student performance evaluation and it's the report is about 50 pages long and it has a whole series of recommendations for schools. I'm going to focus on only one of those recommendations right now and that is the recommendation that medical schools should provide a comparative performance of professional attributes of all of our graduates in this MSPE previously known as the dean's letter so no longer a letter of recommendation today a letter of evaluation and the recommendation from the AAMC is that medical students should be reporting on the performance of our graduates as exemplary adequate or below average compared to their peers that's what this arrow means how does this particular student compare to their peers in the domains that were put forward by the AAMC do they treat patients compassionately are they exemplary adequate or below average are they honest do they have integrity again exemplary adequate or below average do they respect others what is their ability to communicate do they advocate for patients do they put others first and let me remind you that we are one of a growing number of schools in the country that is a past fail competency based school so for us this this promotes an extra conundrum and I will tell you that we do not currently adhere to this recommendation okay but keep that in the back of your mind okay now what about the ACGME what about the group that accredits resident season fellowships they also have accreditation standards on this topic and they say that they must integrate the following ACGME competencies into the curriculum and one of those competencies is professionalism residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles residents are expected to demonstrate okay here we are the conduct of the profession compassion integrity and respect for others responsiveness to patient needs that supersedes self interest respect for patient privacy and autonomy accountability to patient society in the profession and sensitivity and responsiveness to a diverse patient population including but not limited to diversity and gender age culture race religion disabilities and sexual orientation so that's the expectation from the ACGME now with that background i want to invite you to come with me to the front lines let me say at the outset that the cases i am about to present are based on real incidents which have occurred in our own medical school and medical center however i have changed some of the details in order to protect the privacy of the faculty and the students who may have been involved in these okay so let me take you to rounds on the general medicine service and a commonly encountered conundrum of the pressure to discharge a patient so the patient is an 85 year old woman with end stage renal disease on parent neal dialysis she had a fall at home and came to our emergency room where it was determined she needed to be hospitalized for placement over the course of the hospitalization the team noted that there were several other diagnoses including high blood pressure diabetes and glaucoma and that she lived alone in a second floor apartment and had no known family members so the team caring for this patient needed to not only evaluate and care for her but then work on this issue of placement and as they tried to do that without family support in place and the need for the patient to be on parent neal dialysis which the patient wished to continue the team began to feel a lot of pressure from the utilization review committee to discharge this patient i'm sure that some of you in the room have found yourself in this situation and i'd be interested to know if you have found yourself in this situation how you have handled that in my experience nine times out of ten you know that it is the case the patient needs to be in the hospital but it's not been documented clearly and so with some easy an easy fix is to just make sure that your team is documenting clearly that the patient needs to be in the hospital according to the guidelines set forth by the utilization review committee i just think that it highlights that actually being able to advocate for your patient is such a key part of professionalism in the sense of knowing the ropes and unfortunately that does mean knowing a lot about coding these days and and the different sort of requirements of managed care that i think maybe none of us like but is a real reality okay excellent point from the oh just from the other side on utilization review they also have a you know sort of an obligation societally and into the institution as a whole as well as sort of to all the patients and i believe a lot of them as vini said are very amenable to negotiations and understanding sort of how to do things so okay great my first question is have we discussed with the 85-year-old that we're talking placement and are we removing her from her home and does she know this and is she consenting to this and how much does she have a say in everything that's going on i understand why it's hard for her to live on a second floor apartment but she's been doing it for weeks and months and years with all of these other comorbidities and what's pushing us and does she really agree to it yeah that's an excellent point and i know that the team was actively engaged with this patient and the patient actually did wish to return home with some extra supports in place if that could be arranged however 48 hours was not enough time to get all that in place okay well what ended up happening is utilization review was literally placing a lot of pressure on this team in fact involving the department chair to move the patient out of the hospital we talked about how the attending physician might manage the patient we didn't necessarily think about the role modeling aspect for residents and students about the highest standard of care however i think the comments that you shared were very much applicable as positive role modeling experiences what happened in this particular patient is that the patient was worked up for a pulmonary embolism there was potentially episode of shortness of breath overnight and while the index of suspicion for a pulmonary embolism did not seem to be very high it wasn't completely unreasonable but i just invite all of us to think about the cost implications when we're ordering tests so the patient got one extra day for being worked up for a pulmonary embolism and then the second thing that happened is after the pulmonary embolism was ruled out once again utilization review had made arrangements for the patient to go home however in the evaluation of the patient the team discovered that the patient was actually severely malnourished and the team was also working this patient up for whether or not there was a swallowing disorder whether or not there were other issues in terms of caloric intake etc and in the end the patient actually had a feeding tube placed which got the patient another additional day in the hospital so this case obviously has a whole host of avenues that we could pursue about patient management about the role modeling for physician for students and residents who are on this team and about really ultimately doing our best to take care of patients ultimately this team was able to find outpatient peritneal dialysis and a home healthcare nurse and the patient was in fact discharged home now I want to invite you to think about how should the attending physician grade the student for professionalism on this rotation because professionalism is one of the the domains that the attending physician is going to need to complete at the end of this rotation now I haven't really shared with you any of the data points for what the students role in the care this patient was but certainly as an observer the student had an awful lot of data points of their own to see what transpires in a hospital when a patient with this condition gets admitted given what you heard transpire during the management of this patient do you think as an attending physician you would be in a position to evaluate the student in the way that the WMC is asking us as medical schools to evaluate our students if you were strongly advocating to get the patient out as quickly as possible and the medical student was coming and telling you that he thought that wasn't a good idea and that the patient's not ready then you would probably give him maybe a higher point for advocates but then maybe a lower point for well the reality of the situation I mean I mean the fact of the matter is it has a lot to do with the attending's own perspective on what would be the ethical approach to doing this and I think a lot of how we end up evaluating medical students is how well they you know how well they fill their role in sort of living up to our expectations of what we think they should do in any given situation which is always going to be different depending on our perspectives about it and so the smartest medical students the best medical students I think are the ones who are able to perceive what it is the attending has in his mind about the best the best way to be and connect that way unfortunately in some ways but I think you know if the if the attending was you know advocating you know was more like Javad and saying we're not going to listen and the medical student you know went along with that you know I think that would be fine if the medical if the attending was saying we got to get this patient out as soon as possible and the medical student really gave them grief about it then I think there may be a problem that if the student begins to ask questions from my perspective they're going to get higher grades on professionalism so if they say ask a question should we be gaming the system is that what advocacy for our patients really means well well then you know honest has integrity becomes something significant and I think that's a real serious professional question raised by this case that hasn't been so far and if a student raised it I'd give them high high points so one thing that you should know is that feedback that the medical school receives from the students is plentiful and very constructive almost all of the time but one of the common themes that is a part of that feedback over many many years is that the students often feel the evaluations in the clinical arena are very subjective and so to the extent that you and I work together to make our evaluation of the student as explicit and known in advance so that they have less a feeling of the subjectivity the better okay let me move on and tackle case number two this particular case involves a student an interaction of a student with a nurse this is a third year student who was in the operating room during the surgery clerkship one of the surgical nurses believed that the student had become contaminated during an operation and asked the student to step out of the OR and to scrub in again the student disagreed and in fact an altercation ensued a verbal altercation ensued between the student and the nurse in fact the student gave the nurse the finger in the OR and at that point the attending physician asked the student to leave the operating room there were a few other factors which came to light multiple other students had actually complained of mistreatment specifically bullying by this same nurse in the past and the student had earlier reported comments made by this nurse regarding the student's religion which was Islam which were felt to be disparaging okay so this is a complicated situation and I'd like to ask you first of all how should the medical school respond to the incident holding the student accountable to the highest standards of professional behavior that might be the first thing we try to tackle here aside from the background issues that may have you know gone on in the past between this student and the nurse I guess my sense is the nurse is the boss in the operating room and if the nurse has the impression that the that the student contaminated herself that's a patient care issue and I think that the student has to abide by that even if she believes that it didn't happen because you know I think that the the nurse in the OR is trained to be on the lookout for these sorts of things and you know it may be that she was wrong or maybe she really does have it in for the student but we don't really know that and I think that that she's the boss and the student has to comply even aside from what background there may have been okay good Jeannie we can't control others behaviors but we can only control our reactions to their behavior and regardless of what the whatever the motivation was for the nurse's behavior clearly the students lack in judgment in the way that he or she responded really is something that is sort of in complete contrast to this professional behavior expectation okay I would just I think echo what others have said I think that one important thing that Dr. Hoffman point out which is that you know you have to know sort of who's the boss of what and although it's a team effort I think that this concept of what's sterile and what's not sterile is largely the nurse's responsibility and I think that it is it's absolutely the case that there may be other issues there may be issues of bullying those are all important things but ultimately everything should go towards benefiting the patient and no matter how upset the student would have been their response in no way benefits the patient and so I think that that to me would make that particularly problematic great so one thing to just keep in the back of your mind in as we think about the next question is to consider the mitigating factors and the impact of the institutional action on this student's future career so I already explained to you that the medical student performance evaluation is this comprehensive assessment composed by the medical school faculty regarding a student's performance it's supposed to compare him or her to their peers in achieving the educational objectives of the school it's neither a letter of recommendation nor our prediction of the student's future performance in a residency program and so one of the things that we are asked to report as a medical school is was the student the recipient of any adverse action by the medical school or its parent institution okay so that's the expectation we complete these these letters for all of our students when they're applying for for their residency program and so I'd like to share with you what the medical school actually did the committee on promotions actually put this student on academic probation for three quarters remember the student was a third year medical student so the student was put on probation for basically the remainder of the third year of medical school and the first quarter of the fourth year of medical school and the when a student is on academic probation the faculty committee on promotions would have an opportunity to discuss any students on probation at each of those meetings so student doesn't just go on probation and then they get forgotten about they go on probation and they get discussed at every meeting with updates on how are they performing have there been any other incidents in any of the other clerkships what what are we hearing from the faculty about their performance the student was actually removed from academic probation at the end of the summer quarter before the MSPE was released on November 1st based on the fact that there were no further incidents of unprofessional behavior I will tell you however that during this time that the student was on academic probation and before the committee took the student off of academic probation there were multiple meetings that the student had with me with lawyers and phone calls and meetings with this student's mother however the committee was independent of all of that activity and made the decision to remove her from academic probation for the reason that I mentioned the one of the deans in the medical school met with the surgery clerkship director to discuss the student's concerns related to the surgical nurse and provided mistreatment report data that we collect from the students in aggregate and that the WMC also collects from our students at the time that they graduate from medical school the surgery clerkship director implemented a mistreatment intervention in the department of surgery for faculty residents and clinical staff and I can now tell you several years later that intervention seems to have been very successful in that we have today much lower reported rates of mistreatment on all of our clerkships including the surgery clerkship one of the closest thing to an analogy happens in the first year what do you do and by that I mean that like here's the third year specific example it's easier to put a handle on in terms of well potentially unprofessional behavior although there were quite significant extenuating circumstances when I look at like the two cases and maybe what you're driving at a lot of us going to come back to those fundamental principles that have been sort of poo-pooed in the beginning and how a few people treat people as individuals but like in the first year they're clearly are going to be times when unprofessional behavior occurs but it's sort of it's somewhat harder to you know pitch and hold and say well okay you know we have a clinical example situation and we can then put this portion on probation but in some ways it's at least if not more important sort of address some of these issues early on and so how do you deal with the analogous situation when there may not be as easily formable structure to deal with it yeah that is an excellent question and in and of itself is a topic for an entire lecture but as a result of trying to find the right balance between these accreditation standards behaviors that we know take place in the classroom and in the clinical environment and trying most of all to promote the care of the patient as the highest priority and the proper professional development as a development in aspiring physicians several years ago with help from our students and faculty we developed a whole system of professionalism reporting and I see Shalini Reddy in the very back of the room Shalini led that task force and Shalini do you want to just stand up and say a word about how we would manage that today if we encounter an incident of unprofessional behavior in the first year or the second year whenever it happens but we are specifically trying to capture it in the first year so I sit in the back in the hopes that no one will call on me but so in the first two years if an incident occurs the clerkship director or the course director has the option to complete a form and on this form the particular individual the faculty member provides a description of what happened and refers to whether it falls in the category of an egregious violation of professional behavior once that form is completed the student meets with the clerkship director or the course director goes through the form provides their input and then that goes on to further reporting in the in the medical school with one of the medical school deans and then what that determines whether there's a pattern of behavior or if this is an isolated incident with the knowledge that people are generally good good people sometimes behave badly and good people sometimes get put in bad situations so what's the proper form for evaluating these kinds of this kind of standard of professional behavior and the question is whether we want to sort of where to find out where students lie in a continuum between you know Dr. Wellby you know and you know some horrible person at the other end or do we want to simply be able to sort out those persons who fail to meet the professional standards and to flag those and to say that either they can be you know rehabilitated if you will that we can help the you know call those people out for special attention and try to get them to realize that their behavior needs to change or to say that that is incorrigible and that they don't meet the standards to be able to practice professionally and isn't that what you know more what we're after than saying you know you've got an A, B, C or D on professionalism on each of these I think that's a serious question for the profession and the evaluation of professionalism Yeah, I think actually that is very well stated and in fact in some ways I think at the root of the conundrum we find ourselves in because I think that the accreditation standards drove evaluation at a point in time when we were not prepared to be properly evaluating people and so I think that there's a lot of angst in the community about how we do this and do it right This was an opportunity for remediation I mean it was it was an outrageous behavior the patient was not taken into account and in fact was put at some risk with all this stuff going on lack of impulse control merely putting such a student on probation for two or three quarters without also offering some intervention in a constructive way even if it weren't done in the operating room but subsequently using all of the resources we've got to teach people about professional behavior I think would have been worthwhile and could be seen here as an opportunity missed that's one point my second point is that if I were the program director receiving this student for whatever residency I gotta tell you that I would like to know that this behavior happened I might not do anything about it and it might as you you fear put the student at some risk of not being selected but by for sure I'd keep an eye on this the student as they started the independence of a residency program yeah so mark those are two great points and let me say even though I didn't have it here on a bullet point on this slide this student had multiple interventions at a very high level oh really okay attempting to put this whole incident in the perspective of the patient on that table in the operating room I think I mean my own assessment is that the student over time did develop some insight I think the mother also helped now was it a perfect intervention I certainly don't say that it was but I can tell you that the student just did not get a letter from the committee on probation at promotions and we let it go there were multiple meetings with multiple people thank you for exactly that intervention the other thing that I want to say is that when we are thinking about the professional behavior of students and residents and faculty we're really looking for patterns of behavior and to the best extent of our ability to collect data and make observations we are after all a pretty small medical schools so we see our students in ways that other schools may not this was a single incident and so to report it to a residency program and I can guarantee you that if if that had been in the MSPE this student would not have matched now this student did not go into surgery in fact I will tell you this student did not go into a direct patient care specialty however this student did match in a non-direct patient care specialty but I know if this had been in the letter the student would not have matched now maybe this student really shouldn't have matched but my hypothesis is as a former residency program director is that the residency period is the period in which the number of data points will increase significantly and so if in fact there is a professional behavior problem it isn't going to go away it will come up again and again and again and the residency program then needs to be prepared to make the observations and intervene now the real issue is because we have this new system that Shalini Reddy described with we may well have students for whom we have a pattern of unprofessional behavior and if and when that happens we will I believe as a medical school need to include it in the MSPE and I think it will have very significant consequences on whether or not there will be a residency in that person's future how do you think about it from the perspective of maybe like an international medical student and because I know a lot of them don't match but I'm just thinking from their perspective they were you know hardworking and didn't have or had zero you know professionalism incidents it just seems a little concerning that maybe our student would get it over them I mean I understand the perspective that we don't want to harm our students career but there it's kind of an idea of a zero some game that there are other people not matching because our student is matching yeah I didn't know if there was any thoughts on that so for example we do share data very freely with a group of 12 other medical schools so we share numbers we share case studies we try to learn from one another so if if I were to get an MSPE from one of the peers with whom I share data and kind of keep an eye on how much our other schools revealing and in fact from time to time I ask our own residency programs if they can de-identify letters from other medical schools and let me look at them so I can keep a sense of what our other schools reporting in the MSPE I certainly don't have that kind of first hand data from the international community so I know what the numbers tell me but I don't know the quality of their evaluations or what would be in their letters of recommendation so I think while I want to keep that global perspective in mind without having the data I don't feel like I'm in a very good position to try to answer that okay I'm going to move past this third case but assure you that we actually have several cases that would be fun to try to ask and answer so what are some of the unanswerable questions what is moral behavior in an immoral system now there's a big one how do you learn to be professional in a broken healthcare system and in frequently in a broken society and what is more important in professional formation what we know or what we experience see or feel and I do think that these three questions would be questions perhaps for more than just one lecture but perhaps a series of conversations so it seems to me that in thinking about at least these two cases there is an intellectual response that we can have and we can base our intellectual response on hopefully some common basic principles there's also an institutional response which we try to follow and in fact do follow accreditation expectations and then there's an individual response and I want to put forward the idea that perhaps an individual response can be framed in this whole concept of memes and mentoring so what are memes well memes are a lot like genes this is a term coined by Richard Dawkins where the memes are the cultural analogues to genes and that they self-replicate and they respond to selective pressures and they are passed on from one mentor to mentee and actually two investigators Shurnoff and Nakamura make the case actually quite compellingly that memes and the cultural analogues are transmitted over generations I think we know about mentoring lineages from our day-to-day enjoyment but the work that's actually been published shows some very powerful mentoring lineages one of the most powerful being in the field of physics where the laboratory of JJ Thompson was the laboratory that first discovered the electron Rutherford the laboratory that first discovered radioactivity and every one of the persons in this mentoring lineage actually ultimately became the recipient of a Nobel Prize over now multiple generations so one of the frameworks that has been proposed by Daylos as a way by which adults learn is this framework of challenge plotted against support and Daylos proposes that when adults are in situations of very high challenge medicine and medical education would probably fit that definition the optimal is to have a support system in place that is also equally high and if that's the case then growth occurs if in fact the challenge is high but the support is low and or punitive stasis occurs if the challenge is high and support is low retreat occurs if the challenge is low and support is high it's confirmation of one's ability and then if the challenge is high and support is growth the most optimal so let's see if we can apply this to our student how should the medical school respond to the student incident in the surgery clerkship so if the challenge was low and the support was low we could blame the student we could ignore the nurses role we could hold the student accountable through academic probation and include everything in the MSPE as we've discussed if the challenge is high and the support is low we could blame the nurse absolve the student no adverse reaction okay retreat not much learning taking place there probably if the challenge is low and the support is high we could confirm address the student's concerns regarding mistreatment in the surgery clerkship and completely ignore the student's behavior or ideally if there's growth we could address the student's concerns regarding mistreatment but hold the student accountable through academic probation providing the student an opportunity to redress the issue now does this same framework work to work for case number one how should the attending explain his or her actions to those for whom he serves as a role model in managing the patient who's been admitted for placement in many ways I feel like this one is really hard and it's the kind of thing that we had a chance to talk about earlier stasis the attending could simply say to the student what can you do it's how the game is played we're gaming the system the attending could say to the student this is why I'm planning to leave academic medicine I'm joining a boutique medicine practice in Hindsdale the attending could say to the student I'm very troubled by the choices we were forced to make I base these decisions on the harm which might have resulted from an early discharge and several of you actually suggested that or we could try for growth and I have left growth as a question mark because I don't think it's obvious how to do the very perfect thing when the system itself is somewhat broken and and society is not all on the same page about how we should fix this system so that gives us opportunity I think for further reflection and further conversation and then we didn't have a chance to to talk about case number three but I wanted to show you that well actually given time I think I'm going to stop right there and see if there are any other questions or comments or areas that you'd like to explore before we wrap this up you make a compelling argument for not reporting this student as a single incident but then I think I heard you saying that in the case of repeated incidents which were not remediable that you would consider including it on the dean's dean's letter and I wonder if that's adequate or whether the school would be prepared to take the stand of saying this person doesn't meet the standards required to graduate from the Pritzker school with a medical degree and what it takes to do that and are we prepared to do that on the basis of professionalism? Yeah so I can actually answer that with two specific examples one example is of a student who had repeated evidence throughout medical school of serious issues of unprofessionalism and that student became very familiar with how serious those issues were and ultimately after six years in medical school was able to clear the hurdle the multiple hurdles for graduation however the details of the unprofessionalism were a big part I believe three paragraphs in the MSPE maybe two but it was definitely in the MSPE the student had an opportunity to see what was in the MSPE and the university lawyers also signed off on that you should know and the student ultimately had a very small number of interviews in what we would consider a less competitive field and at the end of the first year of training the student has done well I don't have the sense from that program director that the student is the star of that program but the student to my knowledge as revealed by the student and by that program director there has not been further evidence of the kind of difficulty that they had during the time that they were our students so that's example one example two is that we had a student get to the summer of the fourth year of medical school actually without any difficulties in the prior three years at least not any difficulties that were on our radar screen and for the radar screen yeah yes and in the summer of their fourth year they basically failed a their very first elective rotation and in digging into why that student had failed the rotation it was actually a combination of things it was a combination of intellectual preparedness as well as professional behavior the school quite honestly was a little bit surprised because they've made it through all the hurdles all the way to the summer of fourth year however failing an elective is a pretty serious issue so the student was given an opportunity to repeat that elective with a different team a different attending physician and the student received a marginal pass the student was then put on academic probation was required to do another series of rotations including a sub internship the student failed the sub internship and the student was dismissed from the medical school well i guess you know i'm going to just ask this group of people a really um pointed question and that question is one of the things that i have learned in um moving from the being the program director for a large residency program and going to the medical school beginning with applicants to the medical school who are between 18 and 22 years old is there is an awful lot of adult development that takes place in four years of medical school and i personally feel a lot more committed to being as far as i can to the right on that support access to support the proper adult development now the LCME says we think the environment in which students learn is so important that we're going to make a standard an accreditation standard about that and so one of the things that i feel and you've heard me say it at prior sessions of this group that i feel a real personal responsibility for is this environment that our 18 to 22 year olds are learning medicine and if you look at the literature on competencies as students are doing things and residents doing things for the very first time the anxiety level are extremely high the stress levels are extremely high and the way a physician develops proficiency and competency is that they practice those things over and over and over and as they practice the stress comes down the anxiety comes down and they're able to be an outstanding professional so i clearly don't want felons in the medical school i don't want people who can't hear feedback and change their behavior but i'm going to if i'm invested in somebody who we've admitted i'm going to do everything possible to help them through that professional development unless they're unteachable unless they're unable to hear that feedback as part of a residency program before i came as a faculty and residency program before i came here we had a student who had made the comment that my patient looks like xyz during a presentation during attending which that attending was very upset about the rest of the attendings might not have thought might have just joked right and not have said anything and there was a big debate of whether we should put that down on their evaluation as an off-service rotation we should say that you know they this was because one of it it was adamantly saying that i can't tolerate this at all but the rest of it like ah well you know he was making a joke you just took it the wrong way you had a bad day and so how far does that go back into what all of my peers are going to say as opposed to what i believe or someone else maybe it was a core ethical yeah that's an excellent point i'm really glad you raised it because we um that mspe is actually a document that stays with the student for life if they go apply for privileges in hospital xyz 20 years from now and they call the medical school for um an evaluation that's the document they get they get that and they get the university of chicago transcript that's it so it's a very summative document what you just described is what i put into the category of formative evaluation and feedback and without formative evaluation and feedback about the fact that that description of a patient was completely inappropriate and unacceptable and here are the reasons why and here's what i expect for tomorrow's presentation the student would would not have the opportunity to learn from their mistakes and to grow into the physicians that we can all be proud of so formative evaluation has a very important place equal to or bigger than the place of a summative evaluation


Hey everyone, welcome back for more EXO Zeroes content. Today's video, we're going to discuss a hero guide for Estelle. But before that, if you want updated EXO Zeroes content, please hit the subscribe button down below. Hey guys, before we start, so I'd like to invite you to join our Discord chat or Discord server. It's actually in the description below, the link. So please check that out. Okay, so what we have here is Estelle. So we're going to focus on Estelle. She's actually a collaboration character or collaboration hero from Tales of Vesperia. So she's the third one that dropped for that collaboration. She dropped I think two days ago to Thursday and let's start with her hero profile. So her number one on this is her nation is Historic Republic. So this actually is actually good because she gives Historic Republic a solid healer. My question is that, will she be able to get a future faith core? Will we be able to summon additional copies from her eventually in the future, aside from this event? So who knows? Okay, so anyway, she is of nature element. She is of support and she is also a magical type hero. Okay, so for Estelle stats, so for her strengths, she only has actually two. It's her HP which is high and her dodge which is average. The rest would be actually on the below average side to the low side. So you have her attack at below average, defense at low, hit at below average, critical hit below average, block is low and also attack speed is low. So we'll start off with her passive skill which is grant, heal of 100% attack to an ally if they take damage and the health falls to 20%. So this is her first A3. Okay, Gainsman I've own health is at 20% or less when triggered and if health is at 70% or more when triggered. Okay, here is her passive Angel's Tear. So she has a self revive at 100% health upon own death and one time per battle. Okay, so this is actually good for her. This gives her more stability in terms of a healer, especially if in PVP because usually we try to get rid of the healer as early as possible. But in her case she can actually revive 200% health which is very, very good. Okay, and her other passive is healing our test. So once every two turns gain mana, five mana from self upon sacred penance. So sacred penance is actually her S2 skill. So I will actually cover this in a bit just to give you an idea of this. After she uses her S2 she gains that five mana. So more or less based on my play testing of her she can actually use this actually triggers on her first use, then also on her first turn then this triggers then on her third turn. So it starts on her first turn actually. Let's actually take a look at her S1. So extreme stars, so required mana is three. So deals 525% damage to one enemy. That's just it. A good S3 just to take out for example, squishy characters as well on the other side and let's go to her S2. So for her S2 this is her sacred penance. This is actually what makes her very, very good. So it's a required mana five. It's a burst skill. But if you take a look closely at the lines that are there it's actually built in with three abilities. So she has heal, all allies by 34% of own maximum health. So you have to bump up her HP for you to maximize this. Okay, so also deals 178% damage to all enemies and also it has a provoke for five thirds. So basically this is all one S2 skill that can be used more or less almost every turn that she has. This actually is actually vital to her kit because this is what makes her great. And her heal which scales up her HP is actually also a burst skill. So burst heal and burst damage as well for this one. And the provoke is actually a very good addition because it takes a lot of heat away from your other heroes and it actually damage is brought upon her. The key is just to make her very tanky in terms of HP and probably increase her defense as well. So for a stealth on each potential you really have to, right now she doesn't have, she doesn't have, it's really hard to get copies of her. Number one she's stuck at level 90, I'm sure. But for those who got extra copies of her, very good. And also we don't have her Fate Core. I'm not sure if she's going to have a Fate Core in the future but right now Anish Potential is her best friend. So you have to basically bump up her defense tree and stamina tree, especially this one. The last portion for her stamina tree which is Anish Potential effect. So overtime effect reduces damage against all allies by 30%. So I'm sure that your other heroes has this but if they don't have Estelle is actually, Estelle actually has one of these damage reduction by 30%. So this is actually good for her. And also for her defense tree status effect community for two turns and for her S1 it's more of deals additional damage of 12% of own maximum health. Again, when the attack hits. So again, scale up her Anish Potential, preferably start with her stamina tree then her defense tree and work your way across up to her attack. Okay, so we're going to test out some of her skills. Let's put this off auto play. So Garf goes first. Let's wait for Estelle's turn. So Estelle actually usually goes last or goes forth but usually with her attack speed of 36 she will be going last. So the only way that you could for example mitigate her attack speed is actually if you want to play FC Shell with her. FC Shell can actually hasten her turn so that you can actually use her S2 and actually bring out provoke. So if you could take a look later her mana would be at around eight. So after we cast her S2 take a look at how many mana does she still have. So we're going to cast S2 heal provoke and damage as well. So this is how our S2 looks. So if you can see there from a six she has gone down to only, sorry from an eight she's gone down to six. So basically for again for her S what do you call this? Her passive, her second passive which gives her five mana it triggers on the first turn. So let's actually move this on so that we could see what happens on her second turn. This is actually good because her passive, her our test passive, I forgot what it is. Let's check it out in a while. So again, so this one healing our test. So again, this is once every two turns gain five mana for self upon using sacred penons. So again, when you saw there on her first turn she actually gained five mana. For this one to start, she has 10 already. So let's see if her mana goes down to one or goes down to zero. So we're going to use it again. So activate provoke. See she's down to two. She used most of it and she gained actually some mana as well. So if you can see, so first turn, second turn none she will use all it up. Then the mana gain will be triggered on her third turn after she uses S2. So it only triggers when she uses her S2, okay? So very good character design in terms of spamming her skill. She is actually further enhanced by shell for this one. It takes a lot of pressure on the other heroes that you have in terms of her provoke in terms of her healing. The only key for her is that if you want her healing to increase you have to scale up her HP. So that's the only way that you can really take advantage of her S2 further. Okay guys, we move on to her recommended garden stones. So basically for Estelle what I would recommend are mainly two. At most three actually. But primarily you should consider awakening her with an all fires or all fireset so that she could be given plus 5,000 HP because that is what she needs. The other sets give her little HP. The others which I would recommend as well would be either nature or machine set but I highly recommend that you put her with fireset effect before you awaken her. Again, to maximize the 5,000 HP that she will be getting. Okay, once you have awakened her with a fireset you can actually use any set that you want after that because more or less you'll be mixing and matching with the other colors because you have to avoid being guard broken. So more or less you could actually mix a little bit of red and sorry fire and machine set once she is already awakened. Okay, so synergy for other heroes actually priority would be given to her nation. So if you have Estorys built up she really, really works well with Estorys Republic heroes. So especially actually FC Shell. Again, you've seen there the turn reset early provoke and as well as the heals as well. You can accelerate heals. You can actually heal two times and provoke two times per round as you've seen there. So basically she gets her turn after FC Shell casts S2, then she takes her own turn as well. Okay, so she is actually the only healer for Estorys Republic. So take advantage of her in terms of that but she can be played with other nations as well. That is what is good about her. Okay, so for overall rating one being the lowest and three, sorry and five being the highest. So for her stats I would give her a three because again, if you can remember her highest stat would be only HP and dodge. HP with high, dodge with average stats. So the rest would be either below average up to low. So that's it for stats. So for a playability content, more or less I would give her a five because number one, she is good in PVP because she can actually dictate the tempo together with FC Shell. It really boils down on how you're going to build her knowing that you won't have enough copies of her and also currently she doesn't have any Fate Core yet. So basically she can be used a bit in the early stages of PVP but not on the higher tiers. Also for PVE, actually for PVE she will shine even with the limited number of transcend that you have on her. So basically she will help you clear the content especially for her, what she gives your team is reduced damage and also heals. And lastly with her synergy with other heroes I would also give her a five because of her flexibility in putting her in any nation. She will obviously excel in historicity public but again, she excels with almost any team comp and but actually FC Shell would be your best friend if you put them together in a team. I assume as well that that composition will have Jenai so almost a historicity public team for them three and the rest can be a mix of other nations as well. Okay, so for my final thoughts so number one, she needs to be core shared. I actually did a core share with Mai Estelle with FC Annie to bump up her stat. Okay, she badly needs good gear and she has to be awakened for her to shine. You cannot, she doesn't have, again she doesn't have the opportunity to have copies. It's really hard for you to summon five copies unless you really wanna spend a lot of zest on her. Hopefully they could open up another banner in the future to get copies of her, okay. So bump up as well her HP for S2 skill. This is where she will shine. So can support, can be a very good support for her team. So again, as damage reduction or she can taunt or provoke her enemies and also heal that much and that frequent, okay. And I actually am looking forward to for her to having her fake core because she has a lot of potential if they just limit us with this banner that just dropped for the collaboration. This is actually going to be useless but if we have the opportunity to get copies of her in the future, she will be very, very good. Also for her fake core, I would suggest that they align their art with XOZeros for her fake core. I don't really mind this art but this is actually an old, I don't know. The design is actually old. Her costume is also pretty much very old in design and concept that it doesn't really reflect the way XOZeros decides their character. So hopefully fake cores would be better design. Anyway guys, if you have any comments below please write them down. I hope this video helps you. I'll see you in future videos. You always take care, stay safe. This is The Warden and I'm out.


I'm very happy to have come to Australia. I think this is where the best universities in the region and some of the best in the world are. I am very happy to study in Australia because it's a beautiful country, very safe country, great nature, great food and very friendly people. The strong in the global research. Quality of education has just been outstanding. I think it's not only about the learning environment but we also have really beautiful places to go to and we have a really vibrant quality of teaching and learning at schools. So I think it's a really good choice. You get the most up-to-date technologies to study with. Happy to live here, happy to study here, happy to experience Australia. Academically it's very proficient and it's an amazing experience you can have in your life.


What is your biggest gripe about Java? I don't like that the JDK doesn't have this integration with Maven. You write it out of the box. Community is so fragmented that the innovation that open source has brought to Java has meant that there are now so many different vendors, which is great, but that there isn't really a cohesive single type of intro point for newbies and, you know, where do you go? What is the place for Java? So, I mean, I opened this project which is a bit bigger. It always takes time. It's an amazing idea to use nowadays. The fact that we are still somewhat burdened by having to provide backers competitive. A lot of developers out there, that's their first contact with Java is a little bit frustrated. Right. So if we can remove that barrier, we can get more people than it's going to be helpful for and awesome for everyone. You know, on the one hand, I love the fact that there are such a wealth of APIs out there. The downside of them is there's a surprising amount of duplication.


What's up everybody, Jason here for jasperjakesrakes.com.  You have a chance to get a little rookie here Zion maybe job Then at the end of the break we'll take the customer names and two out of the 30 customer names top to Get a spot each was a $500 value each thousand dollars in total so you can win a $500 spot for as low as 36 bucks Two out of the 30 customer names will win a spot in the high end random number block And again the second one is down to five left that'll be breaking soon in a separate video And that should unlock the break. That's the last two spots were given away. So let's do break number one first Let's do it. Good luck roll it. This is for the teams and names five and a six eleven times. Good luck one two three four five six seven eight nine ten eleven Steve down to de cons eleven times one two three four five six seven eight nine ten eleven 76ers down to the Dallas Mavericks All right, so quickly guys just 1920 a little filler pack But Tyler you have the Palikins Brian there with the Bulls most notable teams of course bigger teams J with the Grizzlies Heat will be here Lakers down here for Jacob and You have the heat as well Boom just a quick little pack filler. So no trades And I believe it says right here know that common shit, but everything else will so rookies numbered cards potential autographs All that good stuff There you go a little quick fat pack We got a little gold is that what I see I know there's like a certain wave you can get out of here very nice brookalopas green yellow We got a nice bros daikus deandre hunter down your gaffer little Zion rated rookie very nice Doesn't look too bad Master your little And both success very nice so pelicans When entirely a little a Zion rookie in there Very very nice So it seems now And have the new dice roller here's the original list that got in Let's click dice roll And it is a six and a three this time for nine times number top two get in guys. Good luck one two three four five six seven eight and Ninth and final times six and a three boom nine times Remember top two get in top two Jay and Nicholas Wow There you go six and a three nine times congratulations top two get in And again last way to win is right here, but already sold out So if you just missed out unfortunately, there you go Nine times boom. Appreciate you guys. Jasper's case first


I'm Joe Quinney, so I work with Great Liquor Trains of Wales, and I'm the project manager on Wales on Rails, which is RDP funded. Wales on Rails is a project to get people onto public transport as a tourist. So you might want to go and visit somewhere, so jump on a train, jump on a bus, and then ultimately go and see a heritage railway or other amazing attractions that we've got in Wales. And while you're doing that, from public transport, you'll see great scenery and beautiful places. You'll have an amazing journey and a great experience. Mae'r bydd sodiad yn fantaisiol iawn i'r ardal erwydd bod yn helpu busnes efeol gan bod pobl yn cael ei ddynnu ddod i'r ardal. Dim ond yn fyddio'n ni yma'n treul ffyrdd festi nhw'n cyrwri, ond hefyd i'r busnes e ledled Cymru. Mae'n dod ari yn fenn i'r ardal, ond hefyd mae'n allwchlau o strain gan bod na pob o'r lostyn ni'n gobeithio bod yn defnyddio trefnidiau'r cyhoeddi. Felly mae'n gori, a felly mae'n allwchlau o strain ar y llefydd parkio. Dyna byddir manteisio'n fwyaf pwysig o'r project. For anyone that's interested online, the Wales on Rails map is great, so you can have a look where you can go in Wales, but links to that are loads of cards. They're a bit like top trump cards, and they have a great picture and fantastic information. And there's thousands of these cards in the website, which gives you great ideas, inspiration and fantastic places to go, all using public transport throughout Wales. The main benefits have been collaborative working, so we've managed to work with the community rail officers, transport for Wales, Strath Cymru, loads of tourism partners. So coming for a project where there were 12 great little trains of Wales members, we've managed to include all these other people who have become part of the project, and it's grown bigger than the sum of its parts. The long-term legacy of the project is to get people to think differently about being a tourist. So we're hoping that active travel, bike riding, getting out and about will include loads of other projects, and it will just become bigger and change and get better over time.


And today's topic is about extremism and terrorism in Pakistan.  Many analysts would actually trace it to the 2021 Kabul takeover by the Taliban, which has resulted in alpha elements such as the Tariqat Alehman Pakistan killing innocent lives, ensuring that there's damage to critical infrastructure, and threatening peace, stability, and economic prosperity within the country. The spike is quite profound, and it is extremely important to understand the underlying factors which are resulting in this menace of terrorism revisiting Pakistan. That is precisely what we're going to be examining in this show. I have with me security and political analyst Mr. Amir Rana, who's also the director of the Pakistan Institute for Peace Studies. Mr. Amir Rana, thank you so much for joining me on the show. Yeah, thank you, Hamza, for having me in your show. All right, so Mr. Amir Rana, let's speak about the Bajor incident that recently took place. I mean, the Jammet-Ulma Islam puzzle was planning on holding a rally. And then you had this horrendous blast which took place. It, you know, there were massive casualties. It's all over the news, whether it's been on the BBC, on Al Jazeera, or in domestic media outlets as well. But this is not the first time this has happened. What in your view explains this spike of terrorism within Pakistan? Yeah, let's first discuss this latest terrorist attack which happened in Bajor yesterday. So it has a very particular background because there is one group called the Islamic State Horasan is active since many years and targeting the religious community. And mainly the GUI. And few times they also attempted to target the Jammet-Islamic. And the reason is that they believe that these parties are part of the democratic system. And ISK disagree with this notion. Though the TTP also have the similar ideology, but there's a deep-rooted debate in this area, which goes across the border in host and in Kunar as well. And it has a one sectarian dimension, which is the Salafi and Diwbandis. So this debate is going on in this territory since early 1980s. So this is a very particular background this area has. And this was the manifestation of the group. So in that context, a lot of suspicion is going on about the ISK. But we cannot rule out the other groups that can be involved, including the few hardliner TTP factions. They share the similar ideology and they are part of the sectarian divide. And they remain a very active actor in the past. We can't rule out the TTP and al-Qaeda, Indian subcontinent, is also evolving the new operational collaborations. So in that context, this incident is quite significant and it will determine the future course of these terrorist organizations. If it is the ISK, then we can presume that they will continue to take the political activities and be organized by the religious party, JUI and the JIA in this area and may expand their terrorist activities in other parts of the province. If this is to the TTP hardliner groups or al-Qaeda, it may be the warning for these religious parties that do not go and participate in the election. Then it would mean that it may be because the local factors are more involved in these attacks. We may see this in a very different context. So I think this will be the investigations going on and what will be revealed in coming days. It will be very important to assess in which way the things will go. So many analysts would claim that since the 2021 Kabul takeover by the Taliban and the US withdrawal from Afghanistan after decades of military presence over there attributes a spike in terrorist attacks to developments within Afghanistan. And there are certain statistics and you being an expert in this field, you would know for a fact that this is pretty much ever present that terrorist attacks have actually spiked since 2021. Do you think that's the sole factor which is contributing to the rise of terrorism or there are other variables involved? Yeah, I think we have to put all these things in context. Usually the time after the APS attacks describe that it was a peacetime. But even during these three, four years, we have seen the TTP and its breakaway factions launched massive attacks inside Pakistan. So there was no peacetime. It's an ongoing terror campaign in Pakistan. Though in terms of the military operation, we can claim few successes. The operations that were successful to route it out of the terrorist network from North Pakistan. But they had continued the activities across the border. And this was the reason that in 2019 security institutions thought maybe this is a time to negotiate with the TTP because they are weak. And we can talk with them. We can negotiate with them from the position of strength. You may recall that this was quite a popular argument in 2013 to 2014-15. Most of the analysts had argued that we must have to with terrorists from the position of strength when the government was initiating the talks with them. So this was a mindset that was at play in 2019. And the certain strategies were chopped out at what time they will go to have the negotiations. Initially, they had offered the Ministry for those who would surrender. Only few had surrendered and they come back and in these areas then TTP complained that those haven't been treated well. So this is a context. So when after Talban takeover, it was a major contributing factor which the establishment thought that now we have the pro Pakistan regime, they will facilitate this peace process with the TTP. But we ignore that this TTP and Al-Qaeda are ideologically and politically the same. And they also share the tribal bond. So this was in my view, if I may say it was a strategic error at the part of the Pakistan security institutions that they undermined the ideological credentials of this movement. They thought maybe the Talban would be friendly, mainly the Hakanis we were depending that they will facilitate. But the Hakanis were proved very clever player in all these negotiations game. They tried to keep their neutral position. They forced Pakistan's state to get indulged in the negotiations. So it was a major mistake and Pakistan allowed on the behalf of the Taliban the TTP to come back in Pakistan. And Pakistan was hoping the situation has been changed, TTP is weak. So this wasn't the case and many analysts were indicating even at that time this is going to be very counterproductive. But this also I think the security institution and even the government at that time had some other broader political, geoeconomic vision in their mind that the Taliban government will facilitate their many initiative, transnational development initiative in this region. And of course the Indian factor to whom the Pakistan had tried to counter since last four or five decades in Afghanistan. It was considered the major success. But at what cost? And the cost Pakistan is still paying. And we haven't seen any development on mega transnational projects. Even we can see that this small developments happen or our relationship is Central Asia, but not significant will happen. And this is going to be Taliban going to be complete there in two years.  Rather they had made things for Pakistan more complicated. Even when we have seen that they had not only created the security situation, they created dispute over the fence on the borders. And the first year we have seen the many insiders around this fence related disputes for economy and how they have evolved their monetary policy and they control the currency market. It had the direct impact on Pakistan economic crisis, the smuggling. So all the areas from women's marketing to the North Cortex to listen to weapons. In every areas we have seen that Taliban wasn't the one cooperative and rather been assertive compared with the previous regime. So there was a need for Pakistan to revise and review its approach towards Taliban. They had reviewed, but the problem is that they reviewed the approach. And those who are right now are the architect or running this behind the door negotiation with the Taliban. They don't want to bring this process on surface, surface answer. And maybe they're thinking they can convince Taliban because Pakistan had invested the four or five decades in this war. And Pakistan will not go to sacrifice or surrender so easily. It will try to attempt to maximum to convince Taliban and to bring them on their terms. But I don't think the prospects of the success of any backdoor channel unless things will bring on surface. And this can ensure the transparency. It can hold the Taliban, accountable, the commitment they will make. They are very good negotiation behind the doors. But they are very bad making their commitments on public. You may recall that after the August 15, after takeover in 2021, they had made a lot of promises, inclusive government, ensuring the women's rights to the government. Yeah, and we have seen how they had fulfilled their promises. So I think this is the way to bring everything on surface. The people can see the people from Iran, Iran, people from Pakistan, all these terrorist networks, militant networks, they will also, of course, show their reaction. And we will see that which side the Taliban are going. And if the TDP is not happy with the Taliban, then what will be their strategy? So there will be a plenty of advantages if we will bring all this process on surface. Okay, so when we talk about the TTA for the Taliban of Pakistan, who does that? It's almost as if based on your analysis, like they're providing sanctuaries to the TDP, to the ETIM, to the ISKP in provinces such as Helmand. So in a way, the TTA or the Taliban government in Kabul is exercising plausible deniability with regard to providing sanctuaries and claiming internationally that they're not harboring terrorists. Is that a fair argument? Yes, of course, they are doing this, playing the same game as they had attempted in their first regime in the 90s. And they had denied that they have no presence of the terrorist networks. And later we found the multiple kind of terrorist networks who are not sharing in Afghanistan. So the approach is the same. And I think they have their own justification, ideological linkages and access, religious bond, tribal, ethnic. So they have many justification. But most important for them is the moral obligation. They feel that these groups had provided them the support of the war. If they went against them, maybe it will prove counterproductive and create resentment within their ranks and files. So this is the backlash they are scared of. So it's a complicated choice for the Taliban. But one thing they can can ensure, as they had promised China, that they relocate the DIM in the far away from the area. So Chinese are not going to buy this argument to Pakistan, even they haven't offered this. Though this was disclosed in media, the Taliban, for potential sport, we will really get them away from the border. But this is this is not a guarantee that they will stop terrorist attacks inside Pakistan. Rather, it will give more advantage to the TTP, that their families are in the secure places, safe and secure places, and they can continue their campaign. They haven't even a single time, at least in a form, either our NSO was the state minister for foreign affairs with the or the defense minister. Yes, they haven't formally, publicly acknowledged that TTP is not just. So this is a very complicated situation Pakistan has got. Okay, all right. So I mean, what are the policy responses that the government can exercise or maybe the military established to get exercise when there's evidence to suggest that the TTP sanctuaries are across the border? Does Pakistan have the option of pursuing hot pursuit, trying to eradicate these terrorist groups within Afghanistan? What should Pakistan do? I mean, obviously, you've mentioned that diplomacy negotiation for the TPA might be ongoing back channel, but it's not really resulted in a decline in the spike in terrorist activities in the country. What do you think are the policy responses that Pakistan government should exercise? Yeah, Pakistan had tried multiple, both the diplomatic, as I said, it was mostly a backdoor. And even on the operational front, they had given the proper response to these networks who are trying to launch attacks inside Pakistan. They eliminated multiple terrorist cells, but of course, they have their bases in Afghanistan. And Pakistan still got a few operational options, but a few of them are very tricky to use. And if the tariff didn't increase in Pakistan specifically during the election times, so it will build pressure on the security institution to effectively respond to the threat, then the fear is that Pakistan may launch the strikes inside Afghanistan as Pakistan did these strikes in last year, and which had proved somehow counterproductive and make things more worse. Though TTP claimed that the Pakistan intelligence agencies are conducting operations inside Afghanistan, killing their leaders. But these kind of operations continue, but operational response, I think this could be a very counterproductive. This why that we are saying that we have to be bring before we reach at the level of the zero tolerance, we have to at least use all the political and diplomatic options and see that how these will go. If we are not utilizing them, and we are talking only the backdoor, so I think it will put more pressure on the Pakistan security forces to go over for the ultimate choices for counter offensive. And this is going to be a war-like situation, and this war is the groups the state had patronized once, and they still have enjoyed the centuries, they have their network, the properties, businesses in Pakistan. So it will complicate the security challenge for Pakistan, not only for Pakistan, for Afghanistan, of course, but for the regional security. So I don't think the Central Asian state and mainly China even can imagine that the Pakistan will reach at that point, because they think Pakistan would be facilitating pursuing the Taliban for their geopolitical relationship, for forcing them to change their mind. So this challenge will get complex. You see that Pakistan is right now walking on a very tight road. So let's see how intelligently our security solution will deal with this situation. Amir, what about hybrid warfare? We talk about propaganda warfare or the use of social media. I mean, you write extensively, as the columnist for Don, occasionally he also spoken about extremist literature as well. Do you think that extremism and the literature, which is actually disseminated through social media platforms, which often appeal to the youth, which are either disenchanted, they're not employed, they're not disenfranchised, but they're pretty much isolated from society? Do you think that there's a need to nab literature, which is actually promoted to social media platforms and also to nab propaganda warfare, which is being perpetrated by these terrorist outfits? Yeah, I think it has a different context, in a broader context. If you're talking about that, if maybe the external forces are involved creating this hybrid warfare in Pakistan and they are fueling, I think, first we have to look at from where they are getting all the materials. So this is all the timelines we got in our society, in our policies. So when we have somebody is exploiting, so first we have to look at our weaknesses and to be removed from all this because nobody can explain. So this exercise, not extensive level, though very few efforts have been done, but I think we still need to be look at it. We've got the basic attitude towards extremist group, either they are from each sect or another. So this is, I think, make things very complicated and is deep-rooted in the state view of the religion. So they think this is going to create the harmony within the society and they had outsourced this project to religious organization. And time these religious parties, the groups to the establishment relied on, had failed Pakistan. And we still are blaming and these organizations, mainly on social media, consumed this similar argument of externalizing threat, utilizing the same narrative that the state has not shared in the partnership with these religious institutions. And even now, they twist these narratives, the argument against the state and state institutions. And they, it has created a state of denial within the society. Let me give you the example. What do you think, what should be the reaction of the GUI after yesterday's attack? If you go to the social media, you can see that the local GUI leaders saying that neither TTP is our enemy, neither IS is our enemy, and we don't consider them our enemies. So this is the responsibility of the state to provide us the security. So from when this narrative comes, aren't they scared of these groups? Do they, at least it's clearly indicated that they don't trust on Pakistan the state institutions and they are demanding the security. So this is, I think, the kind of the mindset, the mindset of the denial which has created. This is only one example, but if you go to look at the mindset of all religious actors, even the political actors in the country, it's almost the same. Okay, so domestically, I mean, is there, there is this claim that maybe there are sleeper cells within Pakistan which are being tapped into by these nefarious elements. Because to conduct attacks with such brazen frequency, you obviously need the requisite infrastructure and you do need domestic level support. So do you think that countering extremism within Pakistan by tackling these sleeper cells is also a strategy that the government can follow over? Of course, we need to follow our very comprehensive counter-extremism policy. Though we have on papers, but practically, we haven't seen any substantive development. Of course, the sleeper cells, this is very important. This is the one operational aspect and they got the sleeper cells. And you might have noticed that during last few weeks, the TTP is issuing the statement on social media that this group in this area, this area had joined the TTP. Can you imagine that so many militant commanders and groups were operating in several districts Pakistan from South Punjab to Belochistan and North Punjab? No, we haven't heard any of these commanders, the people, the TTP is claiming that they are joining the organization. They are new recruits. They can prove to be their human resource, the facilitator. They can help them to establish the sleeper cells. This is very concerning. And most of these people are announcing their affiliations with the TTP. They come from a religious background or a religious motherhood. So this is, I think, the Pakistan state need to be very vigilant. We see from where the new recruits can come. And so this need a very comprehensive counter extremism policy. Unless we will have this an effective one. On paper, you will see the talk about the counter narrative. They talk about the sermons controls and the loudspeaker control, controlling the religious spaces. But practically, we see very little substantive developments. Even they talk about the militant groups. And we know that despite the ban on several militant groups, they are still in the streets. And ironically, they come up in the support of the state institutions. So this gave a very wrong message that it shows that maybe the state institutions are soft on certain banned militant groups. We have to be a very uniform, zero tolerance space, counter extremism policy. So very briefly, Amir, because I'm actually running out of time. Do you think that there's a need to distinguish between the good Taliban and the bad Taliban on thought of maybe the government of Pakistan or the establishment? Or do you think it's a fallacy to believe that there could actually be a good Taliban? All of them are extremists. All of them have taken up arms. And all of them would actually attack innocent civilians if given a chance. Yeah, this is a fallacy in a political context. In a strategic context, when you want to talk, then it may have little utility. As the US has exploited with the Taliban and apparently they disengaged the Taliban from Al-Qaeda and they agreed on that they will not allow the Al-Qaeda to exploit their side. But in Pakistan's perspective, this is more complicated issue because this is deep rooted in our view about the religious groups. We are still very soft on the extremist group and it goes to the TTP and Taliban as well. For us, this is a fallacy and we shouldn't discriminate between good and bad because they are counterproductive of our society for our strategic, political and economic priorities. After that, the states adopt different approaches while considering the threat at a serious level. At what stage they can be engaged in rehabilitation? How they can be disengaged with the violent activities? So these kind of the models are available all across the world which can be used rather than to go for having distinction between good and bad. Alright, Mr. Amirana, Political and Security Analyst and Director of the Pakistan Institute for Security Studies. Thank you so much for joining me on this. That's all that we have for now on Islamabad today for Think Tech Hawaii. To follow us on social media, you can log on to our updates all across the platforms so that we can actually keep you abreast of all the major happening within Pakistan and all across the world. That's it from me, Hamd Arifat. Until next time, take care. If you like what we do, please click the like and subscribe button on YouTube. You can also follow us on Facebook, Instagram and LinkedIn. Check out our website, thinktechawaii.com. Mahalo.