It's a pleasure to welcome you to today's session on professionalism. We're honored that Dr. Jordan Cohn from George Washington University is able to join us. Dr. Cohn and I have known each other since the early to mid-80s when Jordy was the chair of medicine at the Michael Reese Hospital and served as the co-chair of the Department of Medicine here at the university. Those were the halcyon days of the University of Chicago Michael Reese relationship and they were wonderful days indeed. Dr. Cohn has served as president of all of the important medical organizations. He's been chair of the American Board of Internal Medicine, chair of the Accreditation Council of Graduate Medical Education, president of the Association of Program Directors in Internal Medicine and for 10 years served as president of the AAMC, the Association of American Medical Colleges. He's spent his career in academics as a professor and dean of several medical schools. His travels have taken him to Harvard, Brown, Tufts, SUNY and to our own Pritzker. Currently Dr. Cohn is the emeritus president of the AAMC. He serves as the chair of the Arnold Gold Foundation which as you know focuses on medical humanism and has sponsored the white coat ceremony for a very long time since 1993. His background is in internal medicine and nephrology and I am delighted that today Dr. Cohn is going to talk about industry funding of medical education. Can we put the genie back in the bottle? Jordy, welcome. Thank you Mark. It's always a terrific pleasure to come back to the University of Chicago to see so many old friends and to see so many new friends too. I'm really delighted to see so many. I assume these younger people in the audience are students, at least some of them are.  But it's great to see so many of you here and have a chance to pay my respects to Mark and to the Clayne Center and to also congratulate Mark and all of you for this wonderful gift from the Booksbaum family for this incredibly important new initiative that is going to focus I think much needed energy and focus and attention on professionalism to really maintain the values that we have inherited from our forebears. And I'm going to be talking about at least one rather in some small aspect but I think indicative of some of the challenges that we're facing in contemporary medicine today and that's the way industry has over the past several decades managed to make itself extremely, I would say intrusive just to give you my bottom line on the topic but it's certainly very impactful in terms of its influence on medical education and what I want to talk about are three aspects of the way industry does involve itself in medical education. One is with obviously the funding of accredited continuing medical education programs in the country and then the direct interaction that industry has with practicing physicians as well as those in academia and I'm going to spend most of the time talking about the interactions that has developed with academic medical centers in their educational mission. Well, beginning with the funding of CME it's an incredibly lucrative activity. Over $2 billion a year is spent on continuing medical education in this country and at least half and I'll show you some data to support that comes directly from industry just direct subvention of continuing education programs from pharmaceutical industry mostly but increasingly from device industries as well. There's another percentage, it's hard to get a handle around the exact number and I really don't know what its magnitude is but clearly it seems to be growing and that is the support that industry provides through the so-called MEX the medical education and communication companies. These are either for-profit or often not-for-profit organizations that take money from the pharmaceutical industry, launder it would be my word and then pass it through to the continuing education sponsors to support education in that way so that the fingerprints of the industry are not directly traceable on those dollars. Well, here's some data showing you the very rapid increase in the extent to which the industry, pharmaceutical industry particularly supports CME in 1998 the total CME support was less than a billion dollars and again half of it roughly from industry but over the course of the subsequent nine years or so the industry managed to increase its activity and the total of course exceeded now well over $2 billion as I mentioned I'll show you some other data shortly about the timeline. So there's been a rapid expansion of industry support and of CME in general and I think the increase in the CME is probably traceable to the complexity increased complexity, increased need that physicians feel to maintain their skills as medicine has gotten more and more complex. Well, the industry is at least represented by the vice president for Pharma which is the as you know the major national umbrella organization for the pharmaceutical industry does much of the advocacy, lobbying in Washington as well as a lot of other activities in support of the pharmaceutical industry. What Ken Johnson the senior vice president said just a little over a year ago he says there is no evidence that a company's funding of CME or other physician educational activities caveat when provided with inappropriate guidelines creates bias. Well I'm just astounded that that statement given what I'll show you momentarily the evidence that is overwhelming that CME particularly industry supported CME does have an influence on physicians behavior particularly their prescribing behavior. Well what about physicians? What are their attitudes about the industry support for CME? Well in a study just earlier this year was found in a survey that 88% of practicing physicians believe that industry support of CME does introduce bias so they're cognizant of that fact yet less than half report a willingness to support their own continuing education. I'll show you some more data about that as well. This is again an astounding I think indictment of the way we think about these issues where we're mindful of the bias but unwilling to eliminate it by supporting our own CME as it were. Well the Senate Finance Committee as you may know has gotten into this act because of all of the visibility that industry support of education research as well which I'm not going to be talking about but Senator Grassley in the Senate Finance Committee quoted as saying it seems unlikely that this sophisticated industry would spend such large sums on an enterprise but for the expectation that the expenditures will be recouped by increased sales. And again I believe it's axiomatic to conclude that industry that is committed to its shareholders interest is going to pursue interests that are profitable and not those that are not. So this is I think an obvious statement. Well there is a Council for Ethical and Judicial Affairs at the AMA which has for many many years been a very strong voice for ethical principles, ethical values within the medical profession. It is a committee of the AMA, it doesn't speak directly for the AMA and its recommendations need to go through the AMA's apparatus. But now for several years including the current year they have concluded that individual physicians, medical schools, teaching hospitals and professional organizations must not accept industry funding to support professional education activities. Pretty straightforward statement. Medical schools and teaching hospitals must limit again caveat to the greatest extent possible industry marketing and promotional activities on their campuses. Well these are pretty I think strong guidelines coming from this organization but the fact is that these recommendations have been repeatedly rejected by the House of Delegates of the AMA so they are not official AMA policy but they represent simply the views of this subset of the AMA. Well the Macy Foundation had a conference in 2008 on this topic and came up with the following recommendations that credited organizations that provide CMA should not accept commercial support from pharmaceutical or medical device companies whether such support is provided directly or again through these MEK organizations. And secondly that the financial resources to support CMA should derive entirely from individual health professionals, their employers, including academic health centers, health care organizations, group practices or other non-commercial sources. In addition the double AMC I'm happy to say and also in 2008 came up with the recommendation that all medical schools and teaching hospitals should adopt policies that prohibit the involvement of industry in continuing medical education activities. The double AMC in 2008 also weighed in and suggested or recommended that medical schools and teaching hospitals not accept any commercial support for educational activities. And finally the IOM in 2009 and I'll come back to another recommendation from this group later said a new system of funding accredited continuing education should be developed that is free of industry influence, enhances public trust in the integrity of the system and provides high quality education. So these three organizations have essentially come to the same conclusion namely that industry support of continuing education is something we ought to wean ourselves away from. Well what has happened in that time since these recommendations came forward? Well again in keeping with the subtitle of this talk putting the genie back in the bottle the genie is maybe got a toe back in the bottle but not much more I would say. But the data that I showed you earlier were from 2006 which is just about at the apex of the total funding for continuing education in this country and also the height of the industry support which was close to a billion and a half dollars in direct this is direct support and this is advertising at CME activities which is virtually comes almost exclusively from industry as well. So but you can see since that time the direct support from industry has in fact gone down quite substantially still I think in the neighborhood of a billion dollars a year so it's hardly decimal dust but it's certainly an indication that at least there is some recognition on the part of industry that these activities are under greater scrutiny and are under significant criticism and there may be some backing away from these supports but still I would argue that the involvement of industry in these activities is still quite substantial and I think from my point of view worrisome and needs to be monitored closely. Well let me move on then to I'm sorry one other point about this do you guys know Howard Brody? Mark are you familiar with Howard? You must he's the director of the Institute for Medical Humanities at University of Texas Medical Branch in Galveston and he quotes this the CME issue seems to me to strike the very core of medicine's claim to be a profession and to adhere to a professional ethic one of the defining characteristics of a profession is its own collective responsibility to assure the adequate education of its members its rapidly advancing feel like medicine this means that ongoing continuing education is a professional necessity American physicians as a group are wealthy enough to pay for their own continuing education I subscribe to that view and I don't know that I don't think it's a very widespread view yet in the profession because as I'll show you shortly many doctors believe that they are entitled to these kinds of subventions for their education and that's an issue that I think we need to recognize and I think in some ways address well let me turn then to the second major area where industry has an impact on the education of physicians namely the way in which the industry interacts mostly with practitioners who are seeing patients in the real world as it were well the vast majority of the drugs of drug industries $28 billion of promotional activities is in fact directed at physicians as you can see that the total expenditure is $27.7 or $28 billion in 2004 the support for journal professional advertising is down here at the bottom the direct consumer advertising which has been a huge issue and has raised a lot of questions about the appropriateness of the pharmaceutical industry going directly to the public with its promotional activities is sizable but still a rather small investment in comparison to the retail value of the drug samples that are given to physicians in their offices in part as a way of gaining access to physicians' offices by bringing these samples to doctors and also obviously as a way of introducing new medications particularly to patients and influencing the prescribing behavior of doctors in that way and another $7 plus billion is spent on the individuals who do the detailing the drug reps as it were that convey the drug samples and the promotional slash educational materials to practicing physicians well here's an article from the New York Times a few years ago that I thought sort of captured this in a way that cheerleaders prep up drug sales was the headline of this as an ambitious college student and star cheerleader Cassie Napier with all these had all the right moves flips, tumbles and ever flashing America's sweetheart smile to prepare for her job after graduation she became a drug saleswoman she now applies doctors' offices selling the antacid previsit for TAP pharmaceutical go on to quote there's a saying that you'll never meet an ugly drug rep that's I don't know who Thomas Carly is but I think he's correct I've never seen an ugly drug rep so this is again a common form of involvement of the industry in the practicing physicians continuing education on a one-on-one basis or a few-on-one basis directly in their offices now how prevalent are interactions between physicians and industry again some data from a year ago by Eric Campbell 84% of practicing physicians in his survey report that they have some direct interaction with industry gifts 71% I was surprised it's only 64% of them except drug samples I would have thought that might even have been higher 18% claimed to have been supported for travel to meetings and another 14% were directly involved in quote consultation with industry in one fashion or another well here's a simple question I'd like to pose you didn't know you were coming for a test but this is a test ok here's the question why does industry give gifts to physicians it's a multiple choice question first possibility in gratitude for all of the hard work that doctors do it's a possibility right or in the hope of curing favor for its products well what would the man in the street give what answer I have to tell you that in the car I'm here from the hotel this morning the driver asked me what I was going to be talking about I said I'm going to be talking about industry support of medical education he says well they must be wanting to get something back from that don't they he was a man not in the street but he was in the car but it's the same idea well do I mean it's one thing for the industry to apply physicians with gifts but I think we still have to ask the question does it make any difference I mean if they just want to give gifts and it has no impact that would be nice but do these gifts to physicians influence prescribing practices well the answer is overwhelmingly yes there have been multiple studies now that have documented the fact that physicians both in training as well as in practice who are exposed to gifting and other activities of the industry do in fact change their prescribing behavior as a consequence of that here's some of the evidence from some time ago and I want to draw attention particularly to this 2007 symposium where some neurobiologists were convened to give an update about the kind of evidence that they were accumulating from their studies of both animals and humans about the way in which reciprocity is elicited from acts of gifts and other such activities and the influence is really quite remarkable not just on behavior but on the neurological correlates of those behaviors that one can pick up by neuroimaging and the like so the fact that it's not just a question of the big gifts but even small gifts have a predictable influence what social scientists have shown and this is an article from 2003 that when a gift or gesture of any size is bestowed it imposes on the recipient a sense of indebtedness it's just the way we are hard wired as human beings the obligation to directly reciprocate whether or not the recipient is even conscious of it tends to influence behavior feelings of obligation are not related to the size of the gift so the notion that in fact the current as far as I know with the current AMA guidelines on accepting gifts from industry is that a gift of less than $100 is permissible anything over than that is objectionable but gifts of less than $100 is at least by their assessment in keeping with professional behavior I would question the evidence to support that that recommendation well how do doctors rationalize their behavior I mean this is not knowledge that's been kept under a rock I mean people know about these various things what the doctors say in their attempt to explain or to rationalize their behavior well the common thing is I am not influenced but I know that other doctors are and here are some data this was a study by Steinman who did a survey of doctors asking them what do you think about yourself are you influenced by industry giving you gifts 1% admitted yeah that influences me another roughly third said well a little bit it influences me a little bit but well over 60% said not at all I'm not influenced by this stuff it doesn't bother me I take the gifts but I ignore it I just do whatever I need to do but my colleagues whoa they are a different lot a third of them are very heavily influenced by gifts another 50% a little influenced 16% of my colleagues don't have any influence and you believe the cognitive dissonance that this I mean it is remarkable it's hilarious but it's also quite serious and I think very disturbing to realize how we perceive ourselves relative to what we think is the proper behavior of other people so it's quite an astonishing finding in my view well another rationalization is that well everybody's doing it I mean I'm not going to be outlier I'm going to help myself as well as others doing it too as we just saw other business people business people get perks the notion that doctors are simply in business and are not behaving any differently than other business people who also get perks from industry that supports them the industry overall has contributed enormously to health outcomes true related I'm not sure I mean how one goes from that observation to a feeling that well I'm going to be nice to them they've done a lot of good things for the public maybe that's the connection and finally the relationship between industry and doctors brings such great benefits that conflicts of interest are a small price to pay again another very interesting thing I don't have a slide for this but I just also maybe have seen this article about a year ago in academic medicine where the investigators looked at groups of residents from family medicine from pediatrics and they did an interesting thing they divided these residents into three groups this was a laboratory study not a real life observation but they in the control group they simply asked them whether they thought that it was okay to accept gifts from industry in one group they gave them a survey of the kind of work hours and things that they were experiencing in their day to day activities at the time of the incident bringing out some negative experiences that they were having and in the third group they gave them a rationalization that is say well because you've worked so hard you've gone through such difficult times don't you think you deserve to have some benefits from the pharmaceutical industry in return well the control group almost I think was like 16% thought it was okay to accept gifts the group that just was in work it was about 28 to 29% the group that had a rationalization offered to them 60% then said it was okay to accept gifts so this was just a sort of a paper exercise but it again illustrates how malleable or how flexible or flimsy maybe is our ability to hold on to some of these value concepts well then even again a quote from Howard Brody I'm not sure which is more severe condemnation of our professionalism our willingness to be bought or our willingness to rationalize and deny in order to make it seem as if we're not being bought in any event if there is a part of medicine that ought to be as free from industry influence as possible it is our own education and again I would subscribe entirely to that view well let me move now to the way in which industry interacts with organizations like this and again I really don't know what the circumstances here at the University of Chicago and I may be bringing all this information to Newcastle but in any event you should be knowing what's going on elsewhere in any event well does industry how does industry support medical education in academic medical centers well they give gifts and free meals I assume the lunch I ate here before you all came was not provided by okay so I'm still good well but in many cases as you know they are payment for invited speakers to grand rounds or other kinds of presentations is a common activity a reimbursement for travel expenses to meetings both for faculty as well as for students and residents payment for attending lectures and conferences and online presentations something relatively new in the world that when doctors sign up for online educational activities there's often a reward for that activity of payment payment for faculty to participate in industry speakers bureau speakers by the way if you don't know are I think without exception departments of the marketing divisions of pharmaceutical industries so these speakers are recognized by the marketing division that entice prominent faculty sometimes medical school faculty also practicing physicians in some cases to become speakers on behalf of the industry are done under the guise of the promotional activities of the industry and consulting fees for faculty that are paid well how prevalent is industry support of medical education for medical centers well in terms of department shares Eric Campbell in 2007 reported these data that 80% of clinical departments received some form of industry support for their educational activities two thirds for CME another more than a third for graduate medical education food and beverages for lunches and grand rounds and the like is very common and travel support for meetings acknowledged by 30% of these respondents in terms of residency programs survey of 381 internal medicine program directors with a 62% response rate yielded these data 72% thought that industry support was undesirable that's encouraging right 56% of them accepted industry support again another cognitive dissonance here that is hard to understand the likelihood of support by the way Holly you'll be interested in this was inversely correlated with the program directors ABIM pass rate so the more I don't know what adjective to use here the more successful these programs were in preparing their residents for the boards at least the less likely they were to have involvement with industry support of their education what about medical students well over a thousand third year medical students in eight schools was surveyed and 93% claimed that they were required to attend at least one industry sponsored lunch 86% had accepted at least one gift 86% didn't know whether the school had a policy about these issues and 69% believed that gifts of course would not influence their practice this is all well and good but is it really a matter of concern well I'm going to give you now my take on this question and this is followed that if we tolerate commercial intrusion into what's our core mission which is education I think it sends a very powerful message to our learners about what we really value in these matters it also signals to the public that we are in fact for sale I mean this is the message that again the taxi driver understood quite readily it also questions whether we really do place patients interest uppermost I mean this is the core value of professionalism is to place patients interest ahead of all other things and the fact that we are willing to allow ourselves to be influenced in ways that are not necessarily evidence based I think does at least suggest that we are not entirely committed to that value and it does belie our commitment to evidence based information it undermines the teaching of cost effective prescribing it also I think impedes adoption of more effective educational methodologies if it's easy to get money to support sort of the traditional ways of doing things it somehow stifles the motivation to think about how we can do things better with the limited resources that we have and finally and in my view perhaps most importantly I think this kind of behavior validates a sense of entitlement on the part of our learners and I think it's one thing about the profession that I think is most worrisome to me anyway is this sense of entitlement that somehow because we're doctors because we've gone through this arduous education and training we're somehow entitled to special privilege we are entitled to special privileges as part of our contract with society we are entitled to set our own rules and regulations we're entitled to set our own research agenda we're entitled to a lot of autonomy even though that may be not as much as it once was it still is an enormous privilege to be as autonomous as we are in the way we deal with our professional activities but it doesn't make us entitled to special treatment on the part of the industry that is gaining advantage financial advantage from the activities that we engage in so this sense of entitlement I think is a very important thing to think about and how we can ensure that our learners in particular are coming out of our training environments without a sense that they are entitled to some special privileges in this regard well the Institute of Medicine is a profession which is one of the Soros activities David Rothman you may know from his work in this area they did a survey of residents in connection with a piece of work I'll show you in a minute to sort of get what residents comments were kind of an anecdotal way but here was a representative comment about this issue I think they are very smart in the way they train reps a lot of ways residents are not respected we have terrible hours this was before the duty hour thing by the way they are not out of the totem pole and they are so courteous they make you feel important and that you're the doctor and they have all this stuff they want to tell you and give you and respect you but I think it does feel good and so in some ways it's nice that they are waiting for you and they show up at conferences and such it must have an impact psychologically there's an introspective resident who I think put his finger on it another comment these things definitely can change your prescribing patterns there are hundreds of birth control options that you can prescribe but Orth jumps right out because they buy my textbooks every year and they give me a ton of samples well let me introduce now an important caveat and I hope I haven't suggested otherwise I want to make it clear that gifts clearly have a potential for influencing behavior but that is not in my view a reason to demonize the industry in our capitalist society for profit activities like the pharmaceutical industry have an obligation to serve their shareholders that's what they are primarily committed to do marketing drugs and devices directly to physicians is a sound and legal activity if you or I were in their position we would be motivated to do precisely the same thing physicians are the ones that are the final common pathway to prescribing and to ensuring that these products and services are profitable so of course we would try to influence those individuals to do the things that are in keeping with our bottom line so it's the onus is on us the onus is on the profession to protect the public's interest by safeguarding ourselves with proper kinds of guidance so I think again we can complain about what the industry does but I think we have to remember that what they're doing is absolutely in keeping with what their obligations are it's what we're doing that I think needs to be scrutinized and we need to take some stock of so in that context there have been three recent guidelines for academic medical centers to consider in terms of how they are going to safeguard themselves and their faculty and their learners in these settings the first comes from this study that I alluded to before which was a joint effort of the ABIM Foundation and the Institute for Medicine as a profession which is the Soros organization that David Rothman runs they came up with this set of guidelines in this article from 2006 another 2008 set of guidelines that's provided by the AAMC and the Industry Funding of Medical Education the report of the task force that was actually co-chaired by Roy Vagelos was one of the co-chairs, the former CEO of Merck and more recently in 2009 Bernie Lowe chaired a group that came up with this report Conflicts of Interest in Medical Research Education and Practice was remarkable about these three largely independent there was some overlap in membership but largely independent reports was that they came to virtually identical recommendations across these multiple areas of potential influence prohibiting all gifts of any size including free meals all of them came up with that recommendation, no direct support for doctors travel to meetings not permitting manufacturers to provide support from CME even through these subsidiary organizations eliminate direct provision of drug samples a couple of these recommendations acknowledged that pooling samples in some central repository that could then be distributed by the institution if there were guidelines for that would be permitted but not direct involvement of the industry in those sampling activities excuse me prohibiting no strings attached faculty grants that is grants that didn't have a clear deliverable as a part of it with transparency and a fair market value for those services with something that was targeted consulting arrangements and research again that must be transparent in its nature no physicians with financial ties to drug companies could be on formulary committees that make decisions about what drugs are in fact available prescribed in the institution ghost riding by industry seems a no brainer why that needed to have to be even called out I think is a question but nevertheless all of them prohibited that suggested that be prohibited whether or not industry should participate in speakers bureaus was the JAMA article came down hard on that issue the AAMC and the IOM were a little equivocal on that matter which raises some questions but the event all recognized that there was some issue here about having faculty who are primarily responsible for educating the next generation of health care providers to also be shills for the pharmaceutical and device industries and limiting access of drug reps to non-patient areas and only by appointment was singled out by the double AMC and by the IOM so these are a set of pretty clear recommendations from some pretty well-respected prominent national organizations the question is what's happened has there been any uptake of these recommendations by academic medical centers well again the Susan Shimonas who's one of David Rothman's colleagues at the Institute for Medicine as a profession published an article earlier this month in academic medicine which was a result of surveys of all major academic medical centers they got responses from 77 academic medical centers trying to calibrate the strength of the institutional guidelines or policies that are in place that govern these various levels of activities they went through an exhaustive process of trying to weigh each of the guidelines against this 10 or 11 areas of interest and trying to come up with some assessment of the strength the robustness of their guidelines and then in the aggregate they developed a policy strength index that has shown on this slide I have to take a pause and tell you about this slide I came across this I had clipped this article out it was published I think it was earlier in this year I clipped it and I put it in my file and I forgot about it and preparing these remarks I said oh that's a very interesting slide I didn't have time to make a slide of it so I won't impress the back row here you kids but I took my iPhone and I took a picture I took a picture of the thing in the paper emailed it to myself put it in the PowerPoint presentation look at this why are you impressed come on alright so anyway these are the data this is the policy strength average along these 77 academic medical centers against these again I think it was 10 or 11 different items that they evaluated and here's the array of institutions along what they regarded as how strong their policy was you can see 17 of the 77 had no policy whatsoever and the strength of the remaining policies was really quite variable I don't know I tried to find out where the University of Chicago was on this slide do you know anybody know I don't know you had a B from from Amsterdam you're updating it well I don't know I don't I don't have identifiers for any of them but I think what is what to me is remarkable is how bad it is not how good it is okay we have still I think have to look at those with some curiosity so here's my final thought the relationship between academic medical centers and industry without questions serves extraordinarily important public purposes let's not forget that that I think our ability to interact with industry in terms of translation research in terms of doing things that are clearly important in terms of translating discovery into useful products and services I think is an absolutely strong public purpose that we need to respect and support it in every way that we can but those relationships must remain principled they must protect the integrity of medical education for sure as well as clinical research and clinical decision making and they must be capable of withstanding intense public scrutiny if we're going to maintain the trust that we need to have with our public in terms of its support for all of our activities we've got to pay attention it seems to me to to these issues so in final we still have I believe a long way to go to put the genie back in the bottle I think we're getting there slowly but the genie has been out for a long time and it's been feasting on this kind of opportunities that we've made available to it and it's going to be hard I think to get us back to where we need to be so with that I'll open to questions thank you thank you Dr. Cohen it's great to see you again I was really struck by your last few slides about medical school policy because in some of our work here with Dr. Humphrey and others when that started when I was a resident where you things have improved since then we we showed that medical students residents who came from medical schools that had stronger policies actually espoused much stricter beliefs and held themselves more accountable than residents who came from medical schools that had less stringent policies so I'll speak up a little bit so in thinking about how the importance of medical school policy I was just curious what you thought about the whole initiative by AMSA to do the scorecard because I think in being on our committee that updates our response to the scorecard and for those of you that don't know you can publicly go online and AMSA grades every medical school according to their policies and we are a B as Holly mentioned but we were always a B we never had an F which I'm proud of and in our first go around when we had a B it was actually lauded as Pritzker got a B while other famous schools elsewhere got Fs and so one of the reasons I think we have a B is our disclosure policy and we don't enforce we enforce disclosures more for research but not on an annual basis for every faculty so what's interesting is as we've started affiliating with a lot of other community centers which I know is something you're interested in we then absorb the risk of those faculty policies there and then have to meet and revise those so that's been sort of something we've been undertaking but I feel there has been a C change at least with people moving their policy and so I was wondering what if you've seen it or what thoughts that you've had on that you don't need this thank you for those comments they're encouraging it and I share your I think it was optimism that you were expressing cautious optimism I do think there has been first of all there's talking about this now there hadn't been any discussions of these matters a decade ago as far as I know can remember so the fact that we're actually talking about it and bringing some of these issues to the surface I think has got to have a useful impact on further development of these issues and I think the evidence is that schools are in fact adopting more stringent policies how they are being applied I think is harder to really assess and I know that there are some policies that look pretty good on paper but at least individuals in those schools are not necessarily compliant but again having said that I do think we have come quite a ways from where we were but on the other hand I think again recognizing how long we've had this experience in our profession in terms of having such an easy access to these sizable perks, money most importantly has I think inert us to what it really means and it's also made it difficult to wean ourselves away from it where else can you find those kind of resources to support see and meet or to support residents educational activities and the like medical schools and academic medical centers are increasingly under financial pressures it's very difficult to find the flexible dollars to support these things so I think there are some real barriers that we have to recognize and they are at least in part a product of the long standing traditional relationships that we've had and the habitual ways in which we have and the sense of entitlement that I think we have sort of perhaps unconsciously but nevertheless strongly adopted as a consequence of this history. The three major recent papers that you cited that try to produce some guidelines for how we should behave in medical education with industry those are very silent on the issue of leadership of academic medical centers and individual specific roles so my specific question is is it appropriate for leaders in academic medical centers to serve on the boards of directors in a way in which they get compensated often several hundred thousand dollars a year in salary or is that a perceived conflict of interest because the work that's been done seems to focus on the trenches those in private practice those in the academic medical center specifically that come in the form of teaching faculty and residents and are silent on issues of deans, department chairs division chiefs who may well have been involved with the industry because of their research background expertise and have helped bring a product to market then those individuals get promoted to leadership positions and in just looking at what's happened around the country it seems to me the public has a feeling about that in some cases we've watched deans lose their jobs when they have served in a public institution that has taken a point of view and in other cases we watch as recently as a few months ago a new dean appointed on the east coast where the New York Times had a fair amount to say about that relationship so I wonder if you have a perspective on that. Terrific question I really share your angst about that if I were czar I would say no you can't serve on boards of industries that have a direct financial stake in the kind of activities that your institution is involved with I think it does the optics of it are just so bad in my view in terms of the way the public again perceives that whether or not there's any real harm done I think is not really the point in this case it really is the perception as the reality. Now having said that I think there and institutional conflicts of interest as I say are more complicated to try to sort through because they just are they're more complicated they're more layered nuances about how those relationships evolve and who actually is involved in implementing them there have been attempts to try to set out some guidance the AAU and the AAMC have developed some guidelines about institutional conflicts of interest that speak mostly to transparency that is full disclosure getting back to the disclosure issue disclosure I think is a de minimis requirement simply because one discloses one's conflict doesn't necessarily free that individual or the audience that they're presenting to from any obligation to not be biased so but I do think that is an important issue particularly in the areas that you point out these leadership positions are visible and I think to the extent that they are transparent about and fully disclose their interactions that has I do think a somewhat clarifying then whether prescription of those relationships is something that will ever be countenance I think is a question mark I would prefer that myself John Ellis I have a question about academic detail you said that physicians don't want to pay we're in an austere environment where institutions think they can't pay is there a role for payors government to pay for academic detailing in the hopes that it leads to more cost effective practice are you all familiar with academic detailing is this is where non-industry individuals academics are doing the detailing bringing evidence to the physicians in practice about best practices and about evidence based prescribing I think that's a very very healthy movement and whether the government should be providing support for that activity I think is an interesting possibility I haven't really thought that through I think I would prefer it being a professional obligation I think the profession should be able to find the resources to ensure that these kind of educational activities are in fact evidence based and what have you and I think the at least as far as I know the limited amount of academic detailing that's currently going on is non-governmental support unless I'm mistaken about that many people who have conflict of interest they believe that they are honest they truly believe that they are honest and and so for example in our profession neurosurgery anyone I talked to them they said as you said for science now the companies develop certain screws or something for the back before publication often they go different countries here China various well talk about it and most of these people already buy the equipment hundred thousand dollar equipment by the time actually you find out that it is not necessary the company has sold millions of dollars and the person has already gotten hundred of thousand dollars in addition to travel for honorarium and so this is not really recognized that somehow before the publication come out people already know it some of my colleagues felt if they don't do it actually be considered my practice so you would have today a disc surgery which is simply you could take it out somebody take a little disc out you fuse from the front you fuse from the back and you get a lot of instrument and then later on you find out it was not necessary so I am not so sure telling people don't do it or you know declare what you do is sufficient has to be a system in which the science has to be proven before it become propagated. I agree with that first of all in your first comment is there anybody in the room who thinks they are dishonest is there anybody in the room who doesn't have a conflict of interest no we all have conflicts of interest it's a complex world we live in we have all kinds of competing interests that are not completely aligned so it's not a question of eliminating conflicts of interest I think we ought to get over the idea that we can actually there are some conflicts about which we can proscribe but there are vast majority of them are not conflicts about which we can eliminate them we simply have to manage them we have to put them in priority order so we know what's more important and what can trump other interests that we have and that's I think the nature of what we're talking about here and I think you pointed out an area about which I don't know very much but which is clear needs to have individuals understand that they have an obligation as professionals to subjugate their self-interest in these $100,000 opportunities that they're provided by industry until there's evidence that this is really in the patient's interest well I hope you'll join me and thank you Dr. Cohen again


Last week, the U.S. dollar finished the week mixed despite higher inflation data from the U.S. The British pound was the biggest loser of the week, knocked down by increasing odds of a no-deal Brexit, and it's likely that the rising cases of coronavirus infections in the U.K. brought pressure to the British pound as well. Welcome to the Tick-Mill Update. I'm Kiana Daniela, founder of the Investiva Movement. Make sure to subscribe to the Tick-Mill YouTube channel and support us by liking and sharing this video with your forex trading friends. On Monday, we're not expecting any high-risk events besides Australia's RBA meetings and a bunch of data from China, including their retail sales and unemployment rate. Today, I'm looking at the Aussie dollar pair, which lost its bullish momentum last weekend and is now consolidating below the 0.74 resistance level and the HMCL on the four-hour chart. Key support levels are at the 23% and 38% from the last retracement levels of 0.72 and 0.71 respectively. And unless we see a brand-new bullish momentum, the pair is likely to head down towards these support levels being under current pressures. Will you be shorting the Aussie dollar pair this week? Head over to the comment section and let me know. Of course, trading the financial markets involves a risk of loss and you should only trade the money that you can afford to lose. If you liked this video, give it a thumbs up and I'll get back to you with more updates tomorrow.


I'm sorry to late. Let's start talks. I'm from Alexa, and with WPS2 API to make GYLess WordPress applications. Today I talk three things. First, change GUI to GYLess. Second, how to create, how to use WordPress application as GYLess. And think about GYLess WordPress application. My name is Hidetaka, and I'm from Japan Kyoto. And I work as an engineer in DigitalCube and organize Japanese WordPress Local Community named World Bench Kyoto. And today I bring my assistant. This is my assistant. Name Amazon Alexa. This is a voice service made by Amazon. I'll show you. Alexa, hello. Oh, Alexa, hello. Hello. Alexa, Alexa, who are you? Oops, one more second. Alexa, who are you? I'm Alexa, and I'm designed around your voice. You can ask me to play music, answer questions, get the weather and sports scores, create to-do lists and much more. Yeah. Today I talk and cheat on two persons' sake. Sometimes I say Japanese and never mind. First, change GUI to GYLess application. Do you know this book? The best interface is no interface. I like this book. And this book tells us why is GUI important? Why is no GUI important? GUI, a web application, browser, and many applications, needs many tasks for us. For example, I contact my friend. First, use GUI like some message app. I open my phone and disable sleep mode, and set up messenger application, and find my friend's name, and join, and create store group, and input type message, and check message, and send. We need eight steps to contact my friend. But in iPhone, use Siri, only three steps. Open your phone, and long tap phone button, and wake up Siri, and say call John, or my friend, name. GUI needs many things to control interface. But GUI less application do very few things. And interface is not only GUI. For example, touch interface, like smart home or tablet, voice interface, for example, Siri, iPhone Siri, or Alexa, and Google Cloud Speech API, and more. And perceptual user interface. This is named, for example, Kinect. Kinect is a motion capture system, and you can easy to control not voice, not touch, just motion. And of course, command line is not GUI interface. I like terminal. And second, how to use WordPress as GUI less? And our team make example application named Alexa. Sorry, I didn't understand the question I heard. Alexa disabled here. Sorry. Yeah, Alexa makes that. We make application into this device, talk about our product, our team, and WordPress, named Amazon. We say here, we say here, what is WordPress. And Alexa, call back WordPress is web service, and more, and more, and more, and introduce WordPress. And this skill, why we make this skill? Because we having sponsors, and automatically introduce our product using voice interface. And I believe we bring the world camp to you, and many people come to our booth, and talk with Alexa. I'm a Moto Ninja using the WPS2 API. And WPS2, how to use WPS2 API? I'm a Moto Ninja. I'm a Moto Ninja here, your impression. You talk to Alexa, say, this skill is good. And Alexa here, Alexa capture your voice, and convert to string, and learn some code, learn some application, and convert, post, and get string, and post to WPS2 API as a comment. And so we use this point to use WPS2 API, and post comments, if post comments succeed, call back to audio playback. Alexa, say, thank you for coming to this booth. Of course, this comment can see our website using the React JS, and showing the username and impression, and when you say impression to Alexa. And OK, next, how to create Alexa application? To create Alexa application, need to three things. First is AWS account. Second is Amazon.com account. And third is Alexa device. For example, like Amazon Echo, or more small thing, Amazon Tap, and more and more. Of course, we can make your own device, like use Raspberry Pi and more device, including Alexa skill. And second, we need to create Alexa back end. Alexa is your own code using by AWS Lambda. Alexa capture your voice and combatant stream, and back end learn your own code using the AWS Lambda. AWS Lambda is one of the web service in Amazon web service, and just learn your own code. Bring upload your source code, and just learn this application, this service, not maintain web server, and never mind cost. And I'm not a ninja, like to connect a WPOS API, written in Python. Getting Amazon AWS Lambda only learn Node.js, Java, or Python. So we should learn JavaScript, or Java, or Python, to connect another application. And this is a sample to connect WPOS API using Python. Import three library to contact PostAction and leave JSON. And thank you. This is the important library. And define API and the point, and add that query. And this is PostCode, like a WP-demote-post or WP-demote-get. And JSON.close is leave request result. And if you finish to create AWS script, and set up to Alex's key, Alex, we need to install this device, this Lambda, access Amazon Developer Console. And there's a Alexa tab you should create that you should click. After click, we can see two types of application. And if you want to Alexa application, like the Amioto Ninja, you should click Alexa skill kit. And Alexa skill kit need to define some interaction model. Like Alexa shares your voice as into some path or some query, combat query, need to define. And second, connect to define AWS Lambda's ID and connect. Input this, set this ID. Alexa can contact to your created AWS Lambda. After that, tap this button. This button is a Alexa skill change developer mode. And this button changes in level. You can use your Alexa on device. And if you want to publish your application, we need to review like a WordPress scene or WordPress plug-in. Let's demonstration. Alexa, talk World Camp Singapore. World Camp Singapore is a community-organized WordPress conference that brings together bloggers, developers, designers, artists, small business owners, entrepreneurs, and educators from Singapore and all across Asia. World Camp Singapore looks to offer something for everyone, from blogging newbies to professional developers, from marketing professionals to experienced designers, from tech enthusiasts to leading technologists. Most importantly, it aims to provide a welcoming, engaging, and safe space for WordPress users to get to know one another. This is the second time WordCamp is being held in Singapore. WordCamp Singapore 2016 will feature a good mix of interesting speakers, both local and international. All our sessions will be conducted in English. This application, I say. Do you have any other question? Thank you. This application, I say, talk World Camp Singapore. And Alexa, come back to my intent, talk World Camp Singapore, and wake up, start to my script on AWS Lambda, and getting the double-quested API on World Camp Singapore org, and get this post state. And she said, this content. Finally, I think GILS application. WPOS API changed the WordPress development for... Ah, okay. We can support many type of enterprise by the WPOS API, not only GUI, for example, voice enterprise or motion world touch and GLI. Like that. You don't do something like say something, touch something, or move something. And many service like Kinect or Alexa or Google API and more and more and more capture your... Capture user action and come back to string or some query and run some code and call WPOS API. And WPOS API do action in the WordPress and like a save post or get post or comment or user to create new multi-site.  And if you want to try to create many type, many GILS application, we can use many type client. WPOS API have many type client. Backbone.js library is already included WordPress code. Easy to just apply to WPOS script. And Node.js is using the LAPR library using the super agent. And Angular.js is very similar to easy to write WPOS function like the post. You can use it to get the post or get the content to get accepted to have post loop. And if you want to another language, for example, we can use library Ruby or Go. So if you're interested in it, please come to AmiMotopus and let's try this skill. And enjoy WPOS API and start to try and enjoy GILS application. And thank you. If you have any questions, like we said, you can leave it to me. Or if you want to ask something right here, and now you can do that also. Would someone try it? Try Alexa? All right. How are you? Need to pass Alexa? Alexa, welcome to Singapore. Sorry, I can't find the answer to the question. It doesn't work, but it just takes everything with question, doesn't it? OK, so I think we are kind of running like five minutes away. So anyway, let's take a quick break. Quick, same break. We can come back here by 3.15. So how are you going to break? So, let's meet you all. Goodbye.


Hey coaches in today's video I'm gonna show you the three traits that you need to be better at sales and all of the coaches that I've worked with That are really good at sales. They do these three things and they do these three things very well We're gonna do this under one minute number one. You need to be a clear communicator when you speak You have to be clear. You can't mumble You need to be clear and you need to be excited about your service that you have that's number one number two You need to ask really good questions There's a difference between asking questions and really good questions when you do that You put yourself in a position as being the expert and from there you just listen All right, you ask questions you shut up and you listen number three You need to have a pathway for every single call that you have This way there's a start to the call. There's a middle and there's an end by having that pathway set up You cannot fail and sales. That's it. See you later You


Three questions I know to ask about money. One, who has the power to create money? Two, what character does it have? Does it bear interest or bear a dimmerage where it loses value of time? And three, what can it be useful? This determines our relationships, our behavior, and inequality. And it is the most powerful question I know about money from Bernard Lyotard. I hope this is exactly the kind of thing that will be discussed at the Money Question. I think the Money Question website is a really nice idea. Money has been exercising people's imagination for centuries because it infiltrates into every corner of our economic life. All these questions are still, believe it or not, up in the air after centuries of discussion. So let's hope that this website improves that debate and comes up with some really interesting conclusions. The Global Financial Crisis in 2008 has shown the institutions we were supposed to have faith in didn't know what they were talking about. The Money Question is a pluralist platform with a large and grown group of heretics around the globe that think they have better answers to the Money Question than the ones that have failed us repeatedly. What we learned from the Financial Crisis was that there was a lack of understanding of money and the monetary system. And with the Money Question website, we are definitely trying to create some pluralism and better understanding of money. This is like one of the core elements of getting a better understanding of society and the economy is to understand money and the monetary system. The Money Question is a place for everyone. It's a place for students and journalists, for economists and historians. Be part of the conversation, share your research, read blogs and find out where the conversation is right now. If we get it right, that will lead to a better monetary system that better serves society.


Warbreaker! It's like everything else Brandon Sanderson writes, except not all that good. This is the introduction song. It's not very good, but it's not too long. Now, let me be clear. This book isn't bad, okay?  Overall, I would just say it is decent, okay? To me, it's somewhere between being okay and good. There is some stuff in here that's worth praising. There's some stuff in here that's interesting. But overall, I would just say it's like a regular book in the Cosmere at around 50% enjoyment. You know, the characters are about 50% as interesting and likable. The setting and the magic system is about 50% as in-depth and 50% as cool. The storyline is about 50% as interesting, 50% as fast-paced. You know, it's all the same stuff that we're used to, but just at a lower level. So the plots of this one is actually pretty simple and easy to follow. There are these two kingdoms which are... They have a lot of tension between them, essentially. And so the king of one, Idris, sends his daughter, a princess named Ciri, to Halandrin to marry the god king of Halandrin. And her older sister... Now, Ciri was actually not supposed to go. Her older sister was the one that was supposed to. And so her older sister, Vivanna, decides, you know what? My sister shouldn't be there, so she runs off to Halandrin to try and rescue her. And while this is going on, there is another god living in Halandrin named Lightsong, who is just experiencing some political stuff going on. It's left pretty vague, even while you're reading it. And he's just thinking, okay, there's some sort of conspiracy happening here, but he doesn't know exactly what it is, and it doesn't play into the story much until near the end. And finally, there is a guy named Vashr, who is running around with a talking sword, and he is also up to something that we don't really know about until near the end. Probably my biggest issue with this book is the plots, because, like I said, it's about 50% of what a Cosmere plot is normally like. You know, it's 50% as fun, 50% as enjoyable. Because Ciri's storyline, where she's just in the palace being married to the god king, is pretty boring at first. Because at first it's just her kind of wandering around, taking in the sights, and well, that's about it. You know, there's hints that there might be some stuff brewing for later, but there's not much happening right then. And later on, as she gets to know the god king better, it becomes more interesting, but that's like, that's character-driven rather than plot-driven. So her storyline is really bad. Lightsongs, which I already kind of mentioned is, again, it gets better near the end, but for the most part it's just him kind of hanging around drinking wine and stuff. And Lightsong himself is not a very interesting character, I'll get to that in a minute. But, yeah, his storyline isn't that great. And then we've got Vashar's storyline, which is not even really a storyline, because he's not in this a lot until the last third. For the first two thirds he only pops in every now and again, and he just kind of gets into trouble. And we don't know what he's doing, so he's not that interesting either. The only storyline that was consistently pretty good was Vevenna's, because after she arrives in Helandrin, she just meets up with this group of mercenaries who are working for her father, the king of Idris, or Idrian. I already forgot, I'm sorry. But they're working for her father, and so she's helping them with the war effort, essentially, because they're thinking, okay, a war's gonna start soon, let's try and make sure it goes our way. And so Vevenna's storyline is actually pretty interesting, because there's always some stuff going on. It's still not amazing, but it is pretty good. There are two really big twists in this story, which I won't go into a lot of detail now, I'll save that for the spoiler section. But one of them, the first one to happen, is pretty good as well. And it happens in Vevenna's storyline, which is part of what makes it a good storyline, and it works because there are hints leading up to it, and then when it happens, it caught me off guard, I was thinking, wow, okay, that actually shocked me. That's a good twist. The second twist is just... It's not very good. It caught me off guard, but there also wasn't much leading up to it, so it just kind of comes out of nowhere, and you're thinking, oh, well, all right, that's cool, I guess. I think the biggest single issue with the plot is that there isn't really a villain until near the end, which I know I keep mentioning near the end, and that's because the climax is still pretty good. You know, it's not on the level of something like Mistborn or Stormlight Archive, but it's a pretty good climax, and because that's when, you know, villains pop up, and until then, we don't really have one. It's just the characters wandering around doing stuff. You know, they don't have, like, the Kingdom of Hallandrin itself isn't a villain, and they don't really have any individuals that are villains or organizations, it's just them doing stuff. So, and honestly, I would say that villains is one area where Sanderson kind of struggles. Not that they're terrible, just that out of all the aspects I was writing that I love, villains usually aren't one of them. You know, he has a couple of really good ones, like Elantris and the Stormlight Archives, he has some great ones, but other than that, they're not that interesting, and so Warbreaker is a pretty good showcase of that. And as for the main characters, they're, again, they're about 50% of what you'd expect, with the exception of Vivena, I'll talk about her in a sec, but Light's song is actually less than 50%, he's really annoying is the thing. Like, he's built up to be like this wise-cracking Joker guy, and he's just kind of lazy and lounges around and he's sarcastic, and he's clearly meant to be funny, but he's not funny.  I don't think I even cracked a smile reading this. It's just, he just came across as an obnoxious prick, honestly, that's it. And he redeems himself a bit at the end and he becomes, you know, more serious and he becomes a better person, he becomes worthy of the power he has, but that really doesn't make up for all the annoying conversations he has with all the people around him before then. And then there's Ciri, who is, she's alright, you know, she is just a scared kid that gets thrust into a situation she doesn't want to be in, and then she kind of makes the most of it and she does a lot of growing up over the course of the story, and again, she's not like particularly interesting, but she's a likable person, you know, she's a decent person and she does some good, so, again, she's fine. That's really all I can say about her, she's fine. And Vivena, on the other hand, is actually really good, because she starts off as kind of, or at least she seems like a very mature young woman, like okay, she's very educated, she has herself under control, and when the story goes on, she realizes that she's actually a pretty naive person, she doesn't know a lot about the world, and as it goes on, she becomes much tougher, much stronger, and just realizes, you know what, I wasn't really cut out to be a princess, maybe. And so that struggle between her wanting to continue to be the old princess that she always had been and her wanting to be this new person is actually really interesting, and watching her become smarter, is also really cool. And of course I can't talk about a Sanderson book without mentioning the setting and the magic, and those are, again, fine. You know, like the setting, I didn't really get a feel for it the way I did in the Stormlight Archive, or in Mistborn, or in Elantris. It's just kind of these two kingdoms that we know about, and we know about one city where the story takes place in, the capital of Elandrin, and the thing is, it doesn't feel that much like a distinct city. You know, it has character to it. There is some talk of the unique culture that it has, and, well, no, that's mostly it. Well, no, it talks a little bit about the economy too, there's that, but it's just not really all that deep. You know, there's not that much depth to it, that's just immersed in this alien world. Like, the first Mistborn book also mostly took place in one city, but that was a totally weird city, okay? It was huge. There were, you know, gangs and thieves running around all over the place.  The whole place was ruled by an immortal demigod. He had his goons wandering around. Like, there was a lot of stuff in Luthadel that was really, really cool, but it's missing here. And segwaying into the magic system, that's also kind of neat, but it's missing something. You know, it needs to take a couple extra steps in order to become as good as something like Allomancy or Stormlight, because in this, the way magic works is that every person is born with something called breath, and that's kind of like their soul, but not really, because if you take it from them, they live, and the thing about breath is, you know, you can't forcibly take it from someone. They have to give it to you.  So, for example, in the prologue, one of the characters makes his cloak come to life and start fighting people, and that's, I mean, that's pretty neat, but they don't go quite far enough with it, you know, they don't show all the different applications that you could do with that. They show a couple, but, you know, it just doesn't feel like the same hard magic systems that, you know, things like Allomancy are. I know I keep comparing this to other Cosmere books, but, well, that's kind of what a lot of people are going to expect going into this, so I think that's only fair. So, the magic is still unique, and it still has some interesting aspects to it, but it doesn't go far enough with it. You know, if it went just a little bit farther, I think it could have been a really, really cool magic system, and we could have had a lot of fun with it, but as it stands now, it's just mmm, it's just meh. That's it. As for the positives, I think that the pros is still really good, you know, it's Sanderson, so it's still very straightforward. You can always tell what's happening and who's doing what, and it's never confusing as to what's going on, so that's good. This one has a little bit of talk of religion in it, which comes at it from a different angle than some something, sorry, something like Mistborn or Launtrested, and I enjoyed that. You know, it's not, there's not a lot of it, but it's there, it's kind of neat, and like I said before, the Climax is pretty good. It's not amazing, but everything ramps up at the end, and a whole bunch of stuff happens, and it's cool. I liked it. So, that's about it for the non-spoiler section. Would I really recommend this? And... Man, it's a difficult question to answer, because like, if you're a huge fan of the Cosmere and you want to know how this connects with everything else and you want to get just a little bit of extra info about how the universe works, then yeah, you should obviously read it.  I can't say you shouldn't read this. I just don't think it's that great. Like, there's other stuff I would say before that there's stuff I would say you should read before this, I mean. But, you know, it's not terrible, so if you hear the plot synopsis and that sounds interesting to you, go ahead and check it out.  Okay, so now for the brief spoiler section here. If you don't want to be spoiled, then leave. So, first thing I want to talk about here is Light Song and his death near the end. So Light Song gave up his life to heal the God King and allow him to use his magic properly and then the God King just comes and saves the day. And... Okay, on paper that sounds pretty good, but before that, Light Song was just kind of whining about his dead girlfriend who... I mean, they didn't really spend time building up their relationship at all, so I felt very little. You know, I didn't have the same emotional impact that I... or I didn't have the same emotional response that I probably should have or that Sanderson was hoping I would have. And, well, yeah, that's about it. You know, if Light Song had been a better character, if it had been more likable, then that would have hit a lot harder, but as it stands it's just kind of, oh, okay, well he died, but that leads to cool stuff. And now I want to talk about the two twists. Now, the one where Denth betrays Vevenna, and it turns out that he's been manipulating her the whole time, I really liked because looking back you can kind of see, oh yeah, like this was all his idea and she was kind of just going along with it. She felt like she was in charge, but she really wasn't. And so that's great twist. I have no issues with that one. The other one where it turns out that Pon Call and Blue Fingers were the ones that were trying to get Halandrin and Idris to go to war, no. That was dumb because there was almost nothing that built up to it. And that's really another issue with the plot is just that all that time they spent with people just kind of wandering around talking and stuff they could have been trying to solve a mystery basically and then that could have led up to oh hey, Blue Fingers is he's the one behind all this. And so if they had cleverly laid out a couple of clues then it would be just like any other mystery or any other good mystery where you're like oh, okay, I know what it is before the characters do or at least you think you do and then it happens and you find out, oh, that surprised me. I can't believe I didn't see it coming. And finally Vivena leaving at the end. I really liked that decision actually, you know, because again over the course of the book watching Vivena's development from a really naive young woman to a much more experienced, intelligent person well, I don't know if she could go back to being a princess after that. So I would like to see where Vivena's character goes after this and I know she appears in Stormlight briefly but I want to see where she goes in her own story. I want a sequel to Warbreaker essentially where she continues on and we get to see more of her and we get to see more of her journey basically. I think there's sequels to Warbreaker planned and that's what I want the sequels to be about. So that's about it for the spoiler section now and again, recommendations I can kind of recommend it to people who are really big fans of the Cosmere and kind of recommend it to people who are into fantasy and well, that's about it. Thanks again to Desk Brennan and all my other patrons whose names are going along the screen now I couldn't do it without you guys and if you want to consider being a patron please do that and please subscribe and please like and comment on the videos so that other people see it and that's everything, bye.