So thanks for the invitation to speak. My day job now is at Geisinger Medical Center, where I made a recent move from Brigham and Women's Hospital and Harvard Medical School. But today, as was said, I'm representing the American College of Physicians. John Tuquer has been involved in preparing this presentation along with me, but unfortunately, he couldn't make it today due to family reasons. So the ACP, the American College of Physicians, is very interested in this area and very dedicated to building collaborative efforts and meeting the needs of their membership. So with that, I'll say that for my talk, I want to just show you a few introductory slides and then talk about the description of the ACP and some of the educational tools that has developed, not specific area of genetics and genomics, but more broadly. And then in response to Jean's questions in preparation for this, we started conversations within the ACP about what was known in answer to those questions. And we've realized that while we had many opinions, we had very little data. And so the ACP actually commissioned a survey specifically getting at some of these questions, which I'll share with you. As I said, when we were preparing the survey, we had to be a little cautious for internists, practicing internists, asking them what they need as far as genetics education, or genomics education, would have been a little bit like asking one of us in the late 80s as to what we would want out of our email accounts as we start to prepare to start doing email. So most internists have not been thrown into this pool yet, but I think it's coming soon. And I always like to show this during talks that I give. So the number of genomes that have been sequenced, Nicholas Wade in the New York Times just a couple of years ago, pointed out that only seven human genomes had been fully sequenced at that point in time. Francis Collins, speaking to us at the Brigham in late 2011, pointed out that by the end of 2012, so a time point that we've already passed now by a month, the NIH alone would have completed about 73,000 genomes. That's exomes plus whole genomes. And I don't know if that number played out accurately or not, but it gives you an idea of the uptick here. And then there are people making predictions. And whether it's exactly true or not, I think it's a reasonable ballpark estimate that sometime in 2014, the one millionth person will have had their genome sequenced. So it's difficult to pin down such a number since some of this is being done in the private sector. Some of it's being done by research organizations other than the NIH. But it gives you a sense of where we're going here. And I think that when I talk to clinicians, particularly practicing internists, and they point out that we don't think this is coming that quickly, I think it's hard. It's going to be hard to keep these one million people out of the health care arena where they're going to be asking their providers to put their whole genomes or their whole exomes in context. So we had done some educational work with the ACP when I was at the Brigham. This was one of the courses that we put on. And the audience have participated as faculty. And in 2009, we got the ACP to join in this. This was a standard sort of three day event. You come to a hotel. You pay probably too much money. And you get talked to by a number of experts in the field. These were two and a half day courses. We were always struggling to get an audience. We generally got 100 to 200 practicing clinicians to sign up for these. And when the ACP joined us in 2009, Steve Weinberger, who's one of the vice presidents of the ACP, pointed out to me, well, you know, it is a spinach course. And I didn't know what that meant. So he pointed out that genetics and genomics, for internists, when that's offered, most people will choose something else from the menu. A small percentage of people will take it because they think it's good for them. And only a very small percent will actually take it because they like it. So I think that it played out that way. We struggled for six years to really make this a break-even course. And it went on permanent sabbatical in 2011. But I want to tell you a little bit about a course we're developing, and we're test driving right now. And this is being organized in the context of Robert Green's CSER awards. That's the clinical sequencing awards from the NHGRI. So in that grant, we have 20 providers who have signed up to enroll their patients to be randomized to whole genome sequencing or standard care. And those 20 providers are 10 academic internists at Brigham and Women's Hospital and 10 cardiologists. And we designed a primary care course in genomics for those 20 providers. And the way that we've designed it is that there is a live lecture, book ending, four hours of self-study. And these cases are really designed to emphasize competencies, as has been mentioned by many of the speakers. So we're not trying to teach content. We're not trying to make people experts in pharmacogenetics or in genomics, but rather giving them situations where they will be getting data back that they have to put in the context of care. So we should have the first run-through of this done in a week or two. Our hope is to publish our experience out of the U01. And then within three to six months, our hope is to have a derivation of this on Geisinger's website for wide access for providers who are getting into this area. So the American College of Physicians are familiar. It's the organization for internal medicine physicians or internists. And then, of course, they have to go on and explain who the internist is for the general public. So essentially, it's an adult care provider. The ACP has 130,000 members. It's the second largest after the AMA. And it's, of course, focused just on one specialty. And of course, they advocate and give information to their members. Interestingly, they have many tools in their toolbox for providing CME and for getting information out to their constituency. So internal medicine is their annual meeting, which is held in the spring, 260 presentations. Unfortunately, in the past, there's been very few of them on genetics and genomics. But hopefully, that's going to change in response to what we tell them after this meeting. They have what's known as MIXAP, which is the self-assessment program that is available to internists, practicing internists, as well as trainees. They have something that is called peer, so physician information and educational resource. And this is a web-based decision support tool. As you can see, there are many not modules already in place with plans to continue to expand this. And there are various resources that are available to providers on their mobile devices that take some of this information as well as create other new information. Additional CME opportunities within ACP, some relevant to genetics and genomics, of course. There are ethics cases, which cover a broad variety of clinical ethics. Touch on genetics and genomics also. There's a review course for board certification, which, of course, motivates lots of practitioners. And then there are statewide chapter meetings, which also have scientific programs and CME attached. A little bit about what ACP does in general. Regarding clinical recommendations. So they develop, through their infrastructure, three different types of clinical recommendations. Clinical practice guidelines. Clinical guidance statements and best practice advice. So this is available on your smartphone if you're an ACP member or if you sign up. But the guidelines, of course, are systematic review of the literature, evidence-based. You're familiar with these from multiple organizations that generate these. There's guidance statements, of course, regarding guidelines. And then I think this is an interesting product, which they have, which is best practice advice. So this is really trying to get into that space where there may not be current guidelines or enough evidence-based to generate clear guidance statements, but the providers are looking for information on how to take care of their patients. And I think right now in the genomic space, I could see some things moving right into that area. So the best practice advice tool, you can see here some of the best practice advice documents that they've already developed. So along with John and Arlene Weissman, who's the director of the survey group at ACP, we decided to survey some internists about genetics and genomics. This took place in November and December, so just a couple months ago, in preparation for this meeting. So the objectives were, and you can see the questions from Jean sort of paraphrased in this. We were interested in gaps in knowledge, gaps in skills related to genetics. We wanted to survey them about the changes in the volume of genetic testing taking place. We wanted to ask them about barriers that they saw when they tried to incorporate genetic testing into practice. And we wanted to ask them about their interest in educational programs. So the ACP has a very powerful survey infrastructure. A survey was designed and sent out to 806 participants from the ACP. And unlike myself, who gets surveys and seems to delete the emails in many cases, these docs are very responsive. And as you can see here, we got a 60% survey response to this survey sent out in November and December. And this is the breakdown of the respondent. So you can see it's across a broad range of practice experience, so from trainees and recent trainees throughout the lifespan of a clinician here, under 40 and over 55, as well as in between. A broad range of practice settings, most commonly the private practice, which is where most internists are. And it included both the internal medicine specialist, who is a generalist, if you follow me, and the internal medicine subspecialist, which includes all the theologists of adult care. So is their knowledge adequate? You can see here the response of those 400 to 500 individuals. So the percentage reporting adequate knowledge in, and they could answer affirmatively to as many of these as they so chose. So interestingly, 60% felt that their basic genetics knowledge was adequate. I don't know if that's been tested recently, or if an independent group would agree, but maybe they're telling us they don't want any more basic genetic teaching, or perhaps they are, in fact, up to speed on genetic principles. We didn't dive any deeper on that. Only a quarter or so felt that they had adequate knowledge in the indications for genetic and genomic testing and intervention. You can see that 3 fourths were worried about not being adequate as far as LC, ethical, legal, and social implications for genetics and genomics. And the numbers go down from there. So understanding and explaining results, when to test individuals, what to do with the results. They didn't have a good working knowledge in general about the performance and the validity of the tests, or which specific tests to order for a clinical disorder. And only 6% felt that they understood when insurance would cover the genetics test. And I can tell you that we do this all the time, and I don't understand that. So I'm interested in learning from these 6%. And we put here at the bottom some of the specific comments from the survey respondents. So adequate skills related to genetics and genomics. Again, these are those reporting adequate skills, so these are the affirmative. The finding the recommendations and guidelines for when to test, a quarter felt they could do that, and I think that's a skill that they probably apply in many areas of clinical medicine. Incorporating genetics into practice, you can see we're falling behind below 20% in all of these categories. When to test to confirm a diagnosis, when to test to confirm risk, and again confirming a suspected diagnosis using genetic biomarkers, and which tests to use to evaluate risk of developing disease. So there's a little bit of overlap here in some of the concepts, but you get the picture here. Certainly less than a quarter of these respondents felt that they were adequately prepared for most of these. So this is one that I didn't expect much action on, but this is the survey response that we got. So almost half being subspecialists versus generalists. 7% of the respondents said that they'd seen an uptick, substantial uptick in the volume of genetic tests. 42% increased somewhat, and 37% saying it stayed the same. We didn't again dive deep in this initial survey into what the same was, whether it was zero or a few, but none performed was 13%. Barriers to incorporation, the cost and the reimbursement issue again comes up large here and not understanding how to get around that tank. Charity with the tests themselves, lack of evidence about effectiveness, questions about validity. Again, ethical, legal, social issues related to genetic testing, anxiety or a barrier around whether the patients can understand the results about a quarter. And we looked into this just as many people have looking at patients obtaining testing outside of the medical system through direct to consumers and then bringing that to them about 10 to 15%. So when we asked them interestingly how much time would you be willing to spend in this area, you can see that we're gonna have a very limited amount of time for busy practicing internal medicine docs and internal medicine subspecialists. So we have one to two hours to teach all of genetics and genomics competencies for a large percentage of the respondents and then going down from there with 3% telling us to go away. The most preferred format, these categories are a little fuzzy around the edges, but you can see that people still like books and journals as a way to get their CME or their improved knowledge.  We didn't specifically ask how these would be delivered, but in the ACP structure, many are delivered through the internet. Case discussions, workshops, discussions with experts or leaders and discussions with peers. As you can see, it goes down from there. And sorry, I'm not sure whether that's 37 or 47, I don't have the original data with me and I noticed that this morning. So most people in this survey wanted to get their education delivered online, some by print and then going down from there to other techniques. And one of the problems has been, of course, in getting people to participate is that some of the things that motivate providers most to participate in CME are not currently there for practicing internist. So it's not showing up on their board examinations. To a large extent, their patients are not coming in and asking them to interpret results or get genetic tests for them. So I think that those are about to change. I hope that some of them are. But you can see here that the things that would drive them to participate more would be CME credit, a big driver, maintenance of certification, of course, extra reimbursement, never a bad idea. And with that, I think that ends the survey data that I have to share with you. John Tucker has been a big advocate for this work within ACP, Steve Weinberger, Patrick Alguire and Arlene Weissman helped to prepare the survey and the data that I presented to you. And with that, I think we have time for questions, comments, et cetera. So we have Bruce, Rex, and Gene and Erwin. So Mike, with what you've presented and what Bob presented a few minutes ago with surveys, it's pretty obvious that at least these two groups feel ill-prepared. I honestly worry sometimes, though, that there has been a kind of almost, well, a negative perception in the community that this is just so dazzlingly difficult that it's a Mount Everest to climb. And actually don't think that that's a good message for people to get, if you'll forgive me. The evolution we're talking about, we have the opportunity for it to be intelligently designed also in the, I guess my hope would be to make it clear to people that you can dock what's new to what they already know. That physicians have a lot of experience, for example, dealing with ambiguity and making decisions about clinical validity. And largely the same is true here. I think we have, again, the ability to embed things in point of care decision support and we have partners whom they can work with. And so I hope that as these various surveys are interpreted that we try to put a positive spin on things that, yes, this is a lot is new, but it really has to be docked to what is familiar. And I think that should not be so hard to do. I think that's a great point. And in the genomics course that we're developing, we're really trying to use cases where the providers will be doing a lot of what they're familiar with, putting in complex information into context for the patient is what they do all the time. And though they may be a little bit intimidated by genetics and genomics, it's just a different kind of data that they're gonna be doing the same things with. Great, thanks, Rex. So the survey data is really, really interesting, but I wanna go back to something you talked about at the beginning of your talk in terms of the fact that ACP does a lot of work in the clinical guideline space. And one of the topics that's come up it's, I think virtually every one of the previous genomic medicine meetings is the fact that there are relatively few clinical practice guidelines for any areas of genomic medicine. And A, is it just too early for that to be, for any of them to be really solidly validated or how should we be thinking about that from your perspective? So that's a great question. And I thought it was interesting that a lot of the Vox felt that they can incorporate the guidelines because there aren't any, or very few. I think that ACP has a very well organized infrastructure for generating guidelines. And it has a lot of requirements about an evidence base. And most of clinical genetics and genomics does not meet the rules for evidence-based clinical guidelines. And so we're stuck in the position of not being able to write guidelines that would meet the expectations of the evidence-based medicine group. And so that's why I was particularly interested in ACP's other kind of less rigorous types of guidelines to help with practice. And I can't speak for how to play out with an ACP, but I'm hopeful that we would be able to find instances where we could get sort of that intermediary ACP behind certain best practices until we get to the point where we can write the hard guidelines, but... Can I just follow up on that a little bit? So what process, if any, could NHGRI or the broader genomic medicine scientific community be doing to advance things in your category of I guess it would be best practice guidelines maybe, which was sort of I think the lowest bar of evidence? One of the problems we face is that for some of these things, the evidence base will forever be small because we're just not gonna have a lot of examples and we're certainly not gonna be able to do randomized clinical trials on a particular variant. So is it just inevitably we'll just be at that lowest level of clinical practice guideline or best practice? Well, I think maybe an idea for a future genomic medicine meeting would really be to get those practice guideline experts in the room together with us and start thinking about that. I mean, it's almost for a while and on many topics, we're gonna have expert opinion driving best practice and I'm not sure without the real guidelines gurus in the room, whether we can sort of lay out the intermediary steps, but I think it's a great question. I don't know if anyone else in the room has experience or ideas about that. I know that cardiologists do a lot of guidelines. So maybe asking to speak to this specific thing because we have other folks. So we had Bill first and then Donna. I think this is a great discussion here because this is the way we're gonna be able to drive some of this uncertainty of where does this field lie for the practitioner? Forget about the academic practitioner. It is the majority are in practice and they need some guide within the guidelines. Now, addressing the guidelines, obviously the OAM came in with even more rigorous criteria, if you will, particularly from a review process. And for our guidelines, actually, Donna is here, she's president of the American Heart Association and our guidelines are done jointly, American College of Cardiology, American Heart Association. Where it comes is the rigor of the scientific background and the, if you will, transparency and lack of conflict there. However, if you look at our guidelines, the vast majority are not randomized clinical trials. A lot of them are expert consensus opinion. And I think this is, so within that, we're really not that limited provided that we have clinical outcome as opposed to just testing and whether testing does really change the outcome in individuals or the way you treat them. So I think this is very important for us to address and going back to at least my opinion and we'll share that with you this afternoon is we would like to embed this in the disease process. So instead of putting guidelines for genetics, it will be if we're talking about coronary disease, if we're talking about hypertrophic cardiomyopathy, Marfan, whatever it is, where does genetic testing fit? What should you do? If particularly and consider different clinical scenarios and this is where we came about with beyond guidelines is appropriateness use of where should you in all these different clinical scenarios, where would it be appropriate to order such a test and when? So I think there's a mechanism through the guideline process to do this. And I think this is very timely. Okay, so focusing again on guidelines, we have a whole list of folks who weren't talking about guidelines. And let me just, Joan, yours is about guidelines too. Okay, so we'll do guidelines, Donna. Just to build on Bill's comments, we really don't at this moment have the evidence base in cardiovascular diseases to really develop a guideline using RCT experience. So we would be in the realm of using appropriate use criteria. So I think being that's the realm, that's where we should start and that will drive practice ultimately. Great, okay, so and Ned is about guidelines too, but I'm not calling on you, so because I think we had Alan, were you gonna talk about guidelines? No, okay. So the guideline folks who were, let's see, Mary, Joan, and someone else here, and I'm sorry, Catherine, and then Ray had a comment on, oh, and Ned. Okay, oh my goodness. So, yeah, really, now I've forgotten where I was. Mary, yeah, Mary, go ahead. So I think one of the things that's making genetic testing guidelines different than other guidelines that we're used to using in medical practice is this pressure that whole exome and whole genome and other array-based tests are being performed. So take out all of that soul searching about whether to test. And that changes the question a lot, and that's what I run CPIC, Clinical Pharmacogenetics Implementation Consortium with the firm GKB, and we are specifically aimed at pretend you already have the genetic information. What are you obligated to act upon for patient care? And that takes very practical clinical decisions. How serious is the disease? How serious are the adverse effects? What are the alternatives? If there's good alternatives, your threshold for creating an action plan based on genetic testing is completely different than if there aren't. So I think a lot of guidelines are bogged down in the whether to test, and we need to get away from that because it's going to be how should you act upon the information once you already have it. Okay, so guideline folks, I think Catherine, Ned, Joan, and possibly Ray. Okay, I just wanted to act quickly. Anybody who's been in a room with Mewing Curry is this is his favorite topic, I think, of evidence and how much evidence we really need. And we've spent a lot of time on the IOM Roundtable talking about this. One thing I think he's doing, and maybe somebody else knows more about this in the room, is convening a meeting in February with all of the players in evidence guideline development to talk about this very issue about how much we really need to do. We're not gonna have randomized control trials and what kind of things we need to do to gather the evidence to move forward. Great point, yeah. Let's see, so Ned. So that's a great segue. So I think what we may face is the fact that the methods will vary on the clinical scenario. And so a lot of work for EGAP and other groups has been based on the screening scenario and the tumor profile and the clinical scenarios that are being discussed around the table have a different imperative day-to-day clinical care. So I wanna follow up. The reality is we have the information. We're going to have to incorporate guidelines before the evidence is available. My plea is that we don't stop there as we have often in the history of medicine and not fill in the gaps of evidence and let these guidelines be evidence-based as we fill that information over time. That I think is the kind of moral imperative of evidence-based guidelines that we have to do something with the information we have now because the patient and the test are in front of us. But we need to fill in those evidence gaps and have that discipline to change those guidelines over time. Now that's an excellent point, Ned. And one of the things I think we find on the research side is we don't really know where are the areas that you need evidence and what kind of evidence do you need. And then we have to match that with our resources and being able to produce it. But somehow we need to make that link a little bit tighter in producing it. Okay, so Joan? Yeah, my comment is really a question directed to the different healthcare provider organizations who are represented here. And I realize there's a lot who are missing because usually when it gets down to the actual practice levels, practitioners look to their own societies for their own practice guidelines. And that's often a barrier, particularly in an area like this, in that every organization has its old standards, its own methods, which are often several years in making to come up with the guidelines. So I wonder if this is an opportunity for various practitioners and through different organizations to be working together around the generation of practice guidelines for genomics, as opposed to every provider organization doing their own. No, again, an excellent point. I think one of the reason we have everyone in the room, and I'm sorry, we don't have a longer lunch period so that we can be addressing it, but it will be addressed, I think, later this afternoon. So I did see you, but let me see. Anyone else about guidelines? Just one second, Mira. Ray, was your point covered? As a cardiologist, both a fellow of the AHA and the American Collegiate Cardiology, I have authored guidelines for the cardiomyopathies, genetic cardiomyopathies for the Heart Failure Society of America in 2009. It's very important. We actually discussed this issue of, of course, being a cardiologist, we expect the highest level of real evidence and we just won't have that. So I think this topic is really key if we can make headway on what the most appropriate evidence is, whether it's called the guideline or not. I do think there is intense interest in the cardiovascular community for this, and particularly as we move into whole genome and strategies for, even the Mendelian diseases, a lot of interest, and we have to address this. Ray, so I think this will be the last guideline comment. Mira, for the moment, at least, Mira. I'd actually just like to second the comment about collecting outcome data, because I think as, and embedding it within the disease process, because if whatever the healthcare system of the future turns out to be, we're gonna have to show value. And if value is outcome over cost, if we can actually show that the outcomes are better over the lifetime of a disease by doing this testing, we're gonna not have to deal as much with the cost issue. Excellent point. Okay, so I wanna then go back to the other comments that have been patiently waiting, and maybe we can get the rest of them in the lunch period. So I have Jean Pasimani, Irwin, Kate, and Alan. Were there anybody else who was waiting? And Debra, okay, we may not get to all of these, but we'll do our best. So Jean. So here's a quick one. Did you see any contrast between the generalists and the sub-specialists in your survey? So the survey was too small to tease that out, but the plan is to actually, while we're gonna discuss it in the next couple weeks, is to do a larger survey amongst the ACP wider group with the hope of looking at that. Irwin. Yeah, Mike, thanks for the very timely contribution. I was just wondering, you had in your list of genetic testing only the kind of questions that relate to disease risk, disease susceptibility, et cetera, and I was just curious whether you actually also had questions about pharmacogenetics because there may be a little bit of a different perception in pharmacogenetics compared to disease risk and susceptibility genetics. That's a great point, Irwin, and we didn't go after it in this initial survey, but we're gonna take back ideas to hopefully do a larger survey in the next couple months. That's a good point. Thank you. And Kate, I think? So as someone who's an internist and internal medicine department, I think that the uptick in referrals, and Mike, you can comment on this in the past five years, has been immense, and I think that what I find is that if you have a subspecialty in particular where they start seeing one disease, where they're interested in genetics, as soon as you get the one in there, then they start referring everybody for genetics, and that's, I think, partly why cancer was sort of on the front of this, because they sort of had a disease early on, but now we have pulmonary cardiology and decrine. Every subspecialty is consistently referring patients to us, and once you get in one place, you get the rest, and I think that we have more business than we could possibly handle, basically, and I think that what this really speaks to is a really importance of identifying physicians to be trained in internal medicine and in genetics, which is, given the dearth in other areas, is really even worse than certainly in pediatrics and other subspecialties. Excellent points. Alan, I think you're next. Ah, there you go, and Debra, I think you're next. This is not really a question, but it's a comment from the morning's discussions, which is, could I make a plea that we stop using the word whole in front of exome and genome, because I think that's gonna be just another educational hurdle for physicians in that what we do today doesn't actually get you the entire genome or even exome sequence, so we're gonna have to reeducate everybody that, and also that there are holes in the information, even if you have an exome or a genome, it's not getting to certain mutations, repetitive sequences, pseudogenes, those kinds of things, and even technically, when we get to be able to do that, there are changes that are disease significant that won't be detected by a sequence. So I think if we use the term exome sequencing and genome sequencing, it's actually more accurate, and I apologize, but it's become a pet peeve of mine. Yeah, you actually missed our last meeting where Mike actually proposed that we officially call it whole H-O-L-E genome sequencing, and so that is the convention that we use here, so. Great, all right, any other questions or comments on this topic? Oh, okay, so Bill, the last one. Thank you. I wanna make a comment and then make a suggestion. The first comment is that I'm very impressed with the amount of survey data that are out there. I think it's wonderful. We've had two or three presentations and cardiology is gonna add to that, where we've actually surveyed our members and we have data. It really is good and I think it speaks to the fact that we've all sensed holes, excuse me, for using the term, but, and that's the first step. I think that's great. Well, it sounds like a possible publication in the making if the four of you can get together. Well, and actually, Gene and I talked about that. I think that's great. The other thing is that I just wanna bring up a suggestion here that I would like for folks in the room to consider going forward, not for this meeting, but as other thoughts are pulled together and expressed. One of the services that I provided to the college, our college before I came on full-time was to be co-chair of the Medical Professional Liability Working Group. And it occurred to me as I listened to these presentations that we've made huge technological advances in medicine in genetics and genomics and that whenever there are technological advances in medicine going back to the 1850s, there are substantial liability increases. And so let's just think about that and maybe at some point it may be worth us convening a small mini-group to sort of pull together the experience to identify the risks and begin to think about how they can be mitigated because I think those would be helpful activities for our practitioners, for all of our practitioners going forward. It's interesting in the barriers that have been identified, we almost never hear that one. And yet when you talk to people, they say, what do I do with this information? I'm going to be liable for it and it doesn't come up then, very good point. Great, all right, Mike, thank you very much. You stimulated a lot of discussion and thought. This is great. So next we're hearing from Sandra Swain and Bill Powell. I think you're doing a duet from the Society for Clinical Oncology.


Now, as you all know, the Ravens and their fans have a high expectation when it comes to the team. And one way that you can definitely see that is through a lot of grumblings and complaints that have been made about this team more specifically on offense, even though the team is sitting at 4-1 right now. There have been people saying, man, you Ravens fans, you guys sure are ungrateful. See, that's not even the case. The case is that Ravens fans know what this team can do. They know the heights that this team can reach. And especially when you look at what they were able to accomplish last year and the fact that they pretty much got everybody who returned from last year, they got all of them back minus Marcia Yanda. So with the way that the offense has been, it's been a bit underwhelming. And even though in their wins, they're sitting at 4-1. So that's a beautiful thing. And in all of those wins, they've won by double digits, I think, every time. But it still just has not been enough. And a lot of Ravens fans feel like they should make different moves for different players. And we've had a lot of questions from subscribers on it. A lot of people feel like they should do this, they should do that. But let's talk about probably the most important move that the Ravens can make. And before we get into that, one of the most important moves you can make is that when you're out, you got to wear a mask. So when you're out wearing the mask, why not have it look good? Why not have it look good? You can hit up my aunt, and she can take care, like, she got the mask, the Ravens mask.  The black and purple with the Ravens, I ain't feeling the black and purple today. You know what? I'm feeling the purple and black. So you go ahead and reverse it. It's reversible. It's washable. It's good quality. And again, even if you don't get Ravens, you can get any single pattern you want to.  Whatever you want, you let her know and she'll take care of you. And again, it is my aunt. So when you hit her up, the website is mysecretdwelling.com. Again, it's mysecretdwelling.com. It's down below in the description. And when you hit her up, tell her engraving for your censure. Again, mysecretdwelling.com. And a lot of you have hit her up already, and I appreciate it. We got a number of positive feedback from her. So I appreciate y'all, man. I appreciate y'all looking out for my family. I appreciate y'all doing business with my family, with the mask, man, because that shows that you're trusting me and you're trusting her to take care, y'all, and she has taken care of everybody that's went over there. So I love y'all and I appreciate y'all. Now, again, back to what we were talking about. A lot of Ravens fans have been wondering, man, we should make this move. We should make that move. One of the hottest things right now is that the Ravens should trade for a wide receiver. And I certainly wouldn't be opposed to that. And another hot topic has been the Ravens should trade for a pass rusher. And I certainly wouldn't be opposed to that. Either y'all know me. Somebody even asked a question from a subscriber. I think of my boy, Javis Fowler. He said, man, if the Ravens, if they made every single move and all the moves that you'd be talking about on question from subscribers, how would the team look right now? And I said, man, this team would be stacked. They would be set. They would be right, man. They probably wouldn't have no money, but they would be looking good, man.  But anyway, there's a more important move. And I think it's the most important move that the Ravens can make right now that would help the team out the most. And that move is not for a wide receiver, even though I think there could definitely be some improvements at the wide receiver position. It's not for that. That move is not for a pass rusher. Even though I feel like the pass rush could definitely use some improvement, it's not there either. The biggest, most important move that I feel like the Ravens could make right now that would improve the team by a lot, a lot significantly would be an offensive lineman, a right guard to be exact. And now with this move, this doesn't even mean necessarily making a trade. It doesn't even necessarily mean bringing somebody from the outside in. It just means they need to solidify that right guard spot. Really, the interior of the offensive line, really centered because Mads score has been a little rough for them this season so far. So I know a lot of people have questioned, is he still dealing with the injury? Is he still, is he trying to get back in the shape, back in the form? And that could be it because again, there was no preseason, remember? And then he did miss a little bit of training camp, but there was no preseason. So I'm sure a lot of guys are still getting acclimated back into football shaping whatnot, but I think the most important position right now that the Ravens need to fix is the right guard spot. Now, I talked to my guy Josh Hoffman, all this offseason, he was like, man, we are going to miss Marcianda bad. I know it's coming. I don't want it to happen, but we're going to miss Marcianda bad. And he felt like not enough people were talking about it and that the Ravens, maybe they didn't address it like they really needed to. And I was thinking, hey, maybe Ben Powers is going to be that guy. Maybe he's finally going to get that chance to fill in that spot. And oh, OK, let's go. But it's still right. God is still a question mark. It's still a sweet. We're heading into week six and it's still a question mark. And that has been sort of the weak point of the offense, because again, we could trade for a receiver now and you all know I will be down. But if we trade for a receiver, how much time is Lamar going to have to get the ball off to that receiver? How much time is he going to have to actually look for that wide receiver? Because you can see throughout the games, Lamar don't trust this offensive line. He doesn't. And you see it through most of the games to where the clock in his head, it goes off a lot faster than it did last year. And of course, last year, now we know that the run set up the pass. So teams were sort of hesitant and whatnot. But now they ain't hesitant anymore. The play calling has been much different this year. And again, like somebody pointed out, maybe the Ravens are the way that they play. They they call these plays in the game. It does seem like they're practicing. They're practicing sort of simulating being down. They're simulating having to throw their way back into the game. And if that's the case, OK, cool, I see you. But anyway, you can tell like Lamar, he doesn't trust this offensive line. He really doesn't. So with him not trusting the offensive line, he's been running into sex. He's just he hasn't had much time in the pocket a lot of times.  And you can think pressure is coming when it's not coming, even though it usually is coming. But if you solidify that right guard spot. Whether it's going to be Tyree Phillips, and he can just get to playing a little bit better. And again, he's a rookie. We got to remember that Tyree Phillips is a rookie and he's a tackle. He's a tackle playing guard. We've got to put that into perspective and you have to remember that he he didn't have an offseason either. Nobody had an offseason. They didn't have a preseason. Things were much different this year. So rookies, a lot of rookies, they may hit a wall this year a lot earlier than normal. But with Tyree Phillips, you got to keep that in mind. But the Ravens, they have to solidify that right guard spot. It is so I think it's the most important position that the Ravens can do something that right now, whether it's going to be Tyree Phillips, whether it's going to be DJ Fluga, I know they tried McCurry. I think they tried Powers, too. They just been rotating, rotating, rotating. I know with Tyree Phillips, he was a guy, but then he got hurt. So he's missed, I think the past couple of games. But they've been doing this rotation where it's like, who's it going to be? Who's it going to be? And then, of course, I know against the Washington football team, Ronnie Stanley, he missed that game. So they had to put Orlando Brown, Junior at the left side. They had to do a whole remix with the offensive line. But basically, that's my point. That is the most important move that the Ravens could make right now. It's fixing not only just the right guard spot, but the entire offensive line. Because everything goes through them. Everything. The run game goes through them. The passing game goes through them. The protection for Lamar Jackson goes through them. Those receivers having time to get open on their routes. Goes through them. Everything. And then the defense benefits from that as well. Defense comes in more rested. Offense can be more efficient, more effective. More plays can happen. More big plays can happen. More intermediate plays can happen. And even the small plays that we need, those can happen as well.  Normally, it goes hand in hand. You see some of the worst, the bad offenses around the league.   But Russell Wilson, he still makes it happen. But normally, the bad offensive lines around the league they follow by bad offenses. Because what can you do if you can't find a hold through the right guard in the right tackle? What can you do if your quarterback is always under pressure? The whole game. What can you do? So I think that is the most important position that the Ravens need to address. Whether it happens via trade or whether it's going to be somebody that's on the team already. But they need to have somebody to hold down that spot because it's so important. So anyway, team keep it clean. I appreciate y'all. I love y'all. And just keep being great. Still, keep being nice to each other. Be good to people and just let somebody know you love them. I appreciate y'all and I love y'all. Team keep it clean and we out.


The topic we are going to discuss today is psychological assessment and the role of ethical issues into it. Psychological assessment is one of a very major and important component in the field of psychology and social sciences. When we talk about psychological assessment, there are different protocols in which we have to see that either ethical issues are being taken care of or not. Psychological assessment is primarily a sub-discipline of scientific psychology, which is exclusively devoted to study of a given subject with different purposes. These purposes could be varied. For instance, they could be either describing. Describing could be either in term of the clinical psychology, description could be given to elite developmental milestone and it could be any diagnosing or predicting behavior as well. Now, when it comes to diagnosis, diagnosis could be done into various field. It could be done into clinical psychology, into educational psychology, into forensic psychology maybe or any other sub-domains of psychology. Simultaneously, when we talk about the predicting behavior, the predicting behavior could be related to anything. It could be related to any developmental milestone. It could be probably related to any educational achievement or any other motivational behavior. So, these are the things that in which different settings and different sub-systems we are going to describe that how the psychological assessment could be done and then we can see that exclusively in clinical and educational settings, the importance of psychological assessment is much more than as compared to any other area. Now, looking into numerous components where psychological assessment could be done, it could be norm-based psychological tests. You know, they are the different norms according to the subject setting. For instance, then informal test and surveys, we are aware of the fact that in psychology, there are different informal tests which are being going on. Then interviews. Interviews could be of varied type. They could be formal, informal interviews, structured interviews, unstructured interviews, but they all are going to contribute as a component in psychological assessment. Then school or medical records. We are going through the all medical records, so we get to know and on the basis of that component, we can predict that in future, what kind of the educational performance that child may be going to do if no intervention is being done at this stage. Then medical records is another thing which is very important and in some cases, it could be provided as an important baseline for the patient. So these are the different ways in which the psychological assessment are being done. And then observational data. Now observation could be participant observation, it could be guided observation, it could be unguided observation or any other kind. So observational studies are another way of doing psychological assessment. So we see in different setting, different components are being used and by one way or another, they all are contributing towards assessing that what kind of issue is being going on and how we are going to assess that formally or informally. Psychologists usually undertake psychological assessment in diverse setting, taking into account the cultural and other factors. So we just can't undermine that there could be the different factors which are going to influence the psychological assessment and how we are going to do with the ethical practice during that setting. This awareness may influence psychologists. For instance, the choice of the assessment method. Up to the assessment's choice, a psychologist who is using it, its impact can be different. Either it has no acquaintance with him, its expertise is not there, or it is very much an expert and uses it on its tips. So these components can affect its practice. Then interpretation of the result. Then for the qualitative data exclusively, the interpretation could be subjectively different from one expert analysis to another expert analysis. Just here, if we talk about medical records, history, if a medical expert looks at an MRI report, then the things in that report, the things in the record, maybe that other expert is looking slightly different. Same goes with the interpretation of the psychological assessment. So there comes different issues which need to be properly taken care of. Then compilation of their reports. When we compile the reports, different factors could be taken into account and they can also influence the report of the psychologist. Then communication to their clients regarding their assessment. This is another factor. When you have the baseline data, when you know the prior factors which are the precipitating factors, which are the maintaining factors, which are the predisposing factors, then probably your opinion towards making any report could be different than otherwise. So if you are aware of all those factors, they are in total going to combine an impact on the report, whatever being created by the psychologist. Now the use of psychological assessment. A psychological assessment may be used as a foundation for two major things, understanding and then diagnosis. As far as the understanding is concerned, a person whosoever is the client, his behavior could be understood in a better way. This is something very simple to understand that the purpose of the psychological assessment is to give the better understanding. And then another important thing which is crucial and important is the diagnosis. For example, diagnosis for the cognitive impairment, diagnosis for the intellectual disability or ability for psychiatric illness and for any kind of learning disability or any other diagnosis which comes under the umbrella of DSM-5. Moving on, to measure an individual's functioning at a specific point in time and provide a snapshot of that person. For instance, that if we wanted to see that any effect, any specific point in any certain situation, the person is going to experience panic attack or a person is going to diagnose with depression, the snapshot of that very moment is going to give the measure of an individual's functioning. Then psychological assessment could be used as a planning and intervention, obtaining a baseline measure prior to the implementation of any behavioral change program and identifying preferences to guide career counseling. So at the beginning as a baseline level, we assess what an individual's status is, then to tap on it, we give any interventional plan, any training, any behavior guidance, then we do a post-assessment. So the phase of the assessment is very important for planning and intervention. Then monitoring intervention. For the purpose of assessing behavior change and psychological improvement in subjects, let's say we are talking about the decision-making. We are seeing how much change is being made after continuous training on an individual's decision-making. Like we did a pre-testing during his employment time and we saw how the individual's decision-making skills are. After that, a company is giving him continuous training, giving him guidance, participating in seminars and awareness campaigns. Apart from that, he is also getting hands-on practice on managerial work. So post-assessment can define how much change has been made in his decision-making ability. So these assessment measures can also reflect your different abilities. Then development of individuals of a group or an organization. Let's say we do different surveys that tell us about the overall growth of an organization. More recently speaking, we are talking about that Pakistan is achieving so many STGs in a better way, which is our ultimate goal. For the planning of those STGs, we first do a baseline assessment in which we see which STGs are working in Pakistan. After that, after 10 or 5 years, the data is collected from relevant stakeholders and the assessment is done on which point of view we are standing on which STG. So you know the pre- and post-test could be in terms of the person, as well as in terms of an organization.


What's up everyone? This is Two Truths and a Lie. I'm a two-time state champion volleyball player in the state of Kentucky. I'm originally from New York. My favorite quarterback growing up was Matt Hasselbeck. My favorite movie series is Transformers. I'm a one-time state champion in football in the state of Kentucky. I wrestle. My favorite candy is Dots. My second sport was soccer. I never lost a home game at college. Favorite travel spot is Hawaii. My favorite animated movie is Ride 2. I can speak a different language. The lie was, I was not a state champion in football in high school. We came really close, but came up short. The lie is, I don't really like Hawaii. The lie was the first one. My favorite quarterback growing up was Dr. Bobeck. The third one was a lie. I cannot speak a different language.


Sam here with late in sports cards ribbon 22 top scrum formula one racing sapphire edition five box break number 25 random team style So look again at your random results as always you can find those on the websites under the results tab As well as the link that's in chat. So good luck here everybody Yeah, I can double check that for you really quick PR let me double let me look it started Did Fill up you have three right Phillip are I have you down for three on this one Again guys through the years that is the next one. We got a fill up perfect. Yep. I got you for three on that one Through the years mixer one more time dropping that link 17 to go that breaks next first baseball break of the day breaks next All right, no problem. You got it Philip That's one sphere here.  I'm right For this just a hundred and under on Colors gold Max Verstappen Grand Prix winner France 2021 eight of fifty nice one there for Red Bull taking an early start here Carlos signs John DeRovola Claire Voltaire Botas It's gonna be a green pure ghastly nice one there for Alphatari 75. That's Alphatari two cards under 100 now so far very nice One of the next one Crack Verstappen and it's on our a sepia Verstappen nice one there card number one on the variation Congrats Red Bull Nice one there. Let's go Red Bull. That's gonna be It's got Red Bull Paul S. Congrats Paul. Nice one there. Well Terry Botas and Luis Hamilton There's sepia Marino Sopto to a hundred nice one there for Virtuosi base last pack here Yellow Guter Steiner to 199 or haas on the principle card and base And yeah, I 17 to go in the through the years mixture that is breaking next. Let's get that filled on up here everybody yield on Max Verstappen to 99 For Red Bull three Max Verstappen's now A number to 100 last very nice Magnuson Sergio Pettis Oh signs yellow Sebastian Beto to 199 arm strong for Nando Alonso on Duravala and base is Lance Stroll 15 of 25 for Aston Martin grats on that Aston Martin very nice very nice very nice very nice Lance Stroll and Amari Corbill. There's Fernando Alonso sepia to a hundred for Alpine It's one there on the sepia Then your car green Marcus Armstrong high-tech Grand Prix to 75 Grats on that for Nando Alonso and Lance Stroll and Frederick Vassour Clupacos on the aisle classic classic Cory Kluber Classic Cory Kluber going on the aisle. Good Lord man. I'll drop you guys a link again to through the years through the years Bowman mixer so it seems to go We're staffing on drape sidles variation that is I believe that is a first happen variation. So nice one there for Red Bull And everything in this will get sleeved in top-loaded every single card Sean is diligently working over there on that green Chambolok Bashe to 75 shiru racing system That's when they're on the green Voltaire Botans for Stappen as well Sergio Perez variation for Stappen and Joe Guan you wrote as a yellow for Stappen Nice one there card number one to 199 Variation again. Good Lord. Nice one there Red Bull. There's sepia Roy Nassani to going to dams to a hundred believe I drew Droga bitch and base Oh There's a aqua mix Schumacher to 99 nice one there for Haas Callan Williams and the base corner Joe Guan you there's yellow Charlotte clerk to 199 for Ferrari Joe Guan you and Very nice.  I was over the case of 2022 tops update jumbo. Oh, yes Be sweet base. I'll put you down for a 10 spot soon 10 minus 10 maybe yeah 101 Empty as a yellow Kevin Magnuson for damn or Haas excuse me to 199 Marcus Armstrong for nano Alonso ghastly Daravala base The green for nano Alonso to 75 Lance Stroll and a Mario court deal make Schumacher sepia to 100 Yuki Sunoda, Daniel Ricardo There's a yellow charlopler to one at 99 Nero Alonso and Lance Stroll Hamilton the sewer got a Sebastian Vettel to 99 Aston Martin color match on the aqua as about Ocon Ali Caldwell and last pack here everybody no block and base still quick recap of our color This guy I got here They do look very similar I'm just gonna do it this way. We've got Aquas 99 Verstappen Seidl Schumacher Vettel Greens to 75 Marcus Armstrong here ghastly Carlos signs friend of Alonso Chambola poshie Seppia's to 100 makes Schumacher Roy Nassani Fernando Alonso Marino Santo gold Verstappen a 50 orange Lance Stroll to 25 and two of the same Verstappen variations One sepia to 101 yellow to 199. It's gonna do it for the break guys. Thanks again for the film Let's get through the years filled on up


What's the difference between this and scalar light? So scalar light is using basically static electricity. So it's charging up the air with electricity and it's got a very aggressive kind of feeling energy. It's similar to the barrow charger. Actually barrow charger copied tesla lights and then made their own system. Look on youtube, look on bar charger versus sheet coil. I do a whole video on about that about comparing the barrow charger which is the same as resident light with the sheet coils. So the sheet coils in general it's just a lot safer to use. It costs a lot less and you actually works better according to a lot of doctors I told, talk to. This works better than a barrow charger. Now obviously the people who have bar chargers get mad at me because they say oh it's not the same but that's what they're telling me and I've tried the barrow charger too. Generally the bar charger and those tesla lights they make you feel very anxious because they're charging the air with static electricity and that kind of energy is not the right energy to balance your energy field because it doesn't have, it doesn't balance it with the yin energy. It's all the yang energy. It charges up the air with that electricity and according to like the ancient texts you know every element has a quality, has a feminine or masculine qualities. Air is actually yang which is a masculine quality. So if you charge up the air you get this really intense aggressive energy. Now if you want to go and use the energy and go fight and compete in sports the bar charger is good for that because it'll give you that really aggressive energy but then that's not what you want all the time because then you'll just be a very aggressive and mean person and so it's not healthy in the long run. So what you need is the yin to balance with the yang and most people our yin is depleted so we need to recharge our yin and we have actually plenty of yang so we don't actually need more yang for most of us. The g-coils we have them in yin and we also have them in yang so you get both so you get the balance and they cost a whole lot less so now if you're doing reiki this will amplify your reiki okay if you're energy healer this will amplify your energy healing because it will actually recharge you as the healer as well as the client that you're healing because a lot of times even qigong, pranic healing, energy healing, reiki healing once you finish with the client it kind of takes away from us and we get tired. My energy healers they love this they swear by qi coils because they just give them so much energy they can see many clients without getting tired so it's like a tool that is like a battery that recharges you and the client at the same time. Holographic awareness is like seeing many colors or things that aren't there. My interpretation of holographic awareness is just that being able to perceive something is kind of has more than one dimension like when you look at a phone or look at an object you know you can see it it's two-dimensional but then you can understand it or perceive it in the way that's three-dimensional which means it has depth and width and height or even more dimensions which basically you can see on the fourth dimension which means that you can see that it's connected to everything else in the universe if you can see informed dimensions then that means that you can see everything at the same time everything in the universe everything that happened in the past present future every point in space all in one place on the same time so holographic vision means that you can basically be omniscient that's the word like you can see everything when you use our qi coils it basically helps you to push up your health and eventually once you get high enough once you get it's such a high level the force that's trying to push it down becomes weaker so basically it's giving you this extra energy and this extra boost that comes from outside of you it comes from the energy coming from here so you don't have to use your own effort or your own willpower or your own conscious mind even to do it it does it for you so it increases and it pushes up this this energy and this frequency in your body now you see let's say there's this much space and this is all the force coming down the more there is a negative force then the heavier it gets right and it's harder for it to push up but the smaller it gets then it begins lighter because there's less so let's say your disc your disc cup or this jar and then you start with let's say a bunch of negative energy in it so what happens is it becomes very heavy and the heavier it gets the harder it is to push it back out especially with all the gmo and all the crappy food and drugs and bad frequencies and emfs it's you know all that adds up and it becomes very heavy so it's very hard for some person who is very sick to get that energy to push back all that stuff out of their jar so what it she calls does is actually help you do that it helps you to push out all that bad stuff out of your jar fill it with good energy and good frequencies and once you have this energy like fill up your jar with good frequencies energies then then even if there's like bad stuff trying to get in it doesn't have as much effect on the whole jar


As millions in Senegal prepared to mark the Muslim celebration of Eid al-Adha, health officials have warned that coronavirus cases are surging in the West African nation. Many in Senegal have relaxed their use of masks and other precautions after the country's early searches were not as severe as the outbreaks in other countries. In just weeks, new confirmed virus cases have risen from dozens a day to a record of 738 on Friday, according to the Ministry of Health. And more than 25% of 2,913 tests carried out in the past 24 hours came back positive. Faced with the dramatic increase, Senegal President Maki Sol and his cabinet have limited public gatherings and travel in an attempt to try and stop the spread of the virus. Now the government has also urged people to continue wearing masks and frequently sanitize. Hello, hope you enjoyed the news. Please do subscribe to our YouTube channel and don't forget to hit the notification button so you get notified about fresh news updates.


In today's lecture, we're going to be focusing on the origins and the roots of the modern civil rights movement in the 1950s and the 1960s. In previous lectures, we talked about how the 1950s was a decade of social stability of relative calm and order. And in many respects, the civil rights movement is the biggest challenge to that sense of sort of political conformity and social complacency. That's quite common within the 1950s society. And so the civil rights movement is very important, of course, for the fact that it helps guarantee a large segment of the American population basic civil rights. And also because it challenges and it sets the stage for other important changes in the status of rights for people of other groups as well in the 1960s, 70s, 80s, and 90s in fact to the very present period. The civil rights movement, which we'll focus on, we're going to be focusing on a number of different aspects. We're going to look at the origins. We're going to examine sort of the two different tracks that make up the civil rights movement in the 1950s and 1960s. And we'll talk a little bit about the impact of the civil rights movement on mainstream American politics and mainstream American society. We've already touched briefly in some of the previous lectures on a few of the origins of the civil rights movement. And one of the things that we talked about is that during World War II, in particular, there were lots of new opportunities for African Americans, one of these being job opportunities. So there are new jobs available for African Americans during the war in defense plants and other facilities. During the war, the NAACP, the National Association for the Advancement of Colored People, establishes the double V campaign, which is this campaign of victory over tyranny abroad and victory over discrimination at home. We also see mass migrations of African Americans from the South to the West and the North during the war, which contributes to an expansion of African Americans into other regions of the United States. Another aspect of the war that has a big impact is that it really discredits ideas about race and human biology. Many ideas that had been popular before the war and that the Nazis in Germany had embraced are largely discredited because of what the Nazis had done before and during the war. The Nazis' kind of use of race as a biological category to identify and discriminate and ultimately exterminate people. And so it became much harder for people in the United States who before the war had casually engaged in very racist behavior and had argued that people of minority of different races did what they did because of some sort of biological imperative. That became much less popular and it became really quite questionable to make arguments based on biological categories of race. And lastly, as the Cold War begins in the 1950s and early 1960s, the United States is put in a tough position because the United States, of course, was at war with the Soviet Union and it was a proxy war. In other words, it was a war that was based on trying to win friends in various countries. And as the Third World, in other words, countries that had formerly been colonized that became independent in the 50s and 60s, starts to develop, the Third World's looking at the United States and looking at how minorities are being treated in Africa. African nations are very aware of civil rights problems and abuses in the United States and they're looking to see what the U.S. is doing. So there are all these factors that are broader contributing causes of a very important engagement with civil rights that begins in the 50s, continues through the 60s and ultimately continues up in many cases until the present day. What we're going to do is we're going to talk a little bit about the two main approaches, though, that come to define the civil rights movement in the United States in the 50s and the 60s. One of these movements and the first that we'll talk about is a formal legal approach, a legal strategy to combating discrimination in the United States. And this ultimately is carried out by the NAACP. The second approach is what I would call more of an organic approach, a grass root approach that didn't necessarily have any formal order initially, but gradually becomes very important as more and more people become involved in the movement, more and more order is applied to the movement and begins to have huge changes at the grassroots level. So we have two strategies, a top-down strategy and a bottom-up strategy. So we'll first talk a little bit about the top-down strategy and the role that the NAACP plays in this top-down strategy. On the NAACP had a legal wing and had a wing that was specifically there to help fight civil rights issues and fight against discrimination in court. And the head of this, and I shouldn't say the head, but one of the major forces behind the legal wing was Thurgood Marshall, a lawyer who eventually becomes a U.S. Supreme Court justice and who was very concerned about using legal strategies to fight and stamp out discrimination nationwide. And ultimately Marshall and his legal team pursue a number of strategies to do this, and the main one they had is they were challenging the doctrine of separate but equal that had been established in 1896 in the Plessy v. Ferguson decision, talked about that in previous lectures, and had largely shaped public education in the United States, especially in southern states ever since then. The idea that you could have southern schools that were white schools and schools that were black schools, and as long as they were quote-unquote equal, then that was fine.  And then, so this is a strategy that the NAACP uses to try to stamp out the segregated educational system. They begin at the college level. They begin with college and professional schools, law schools, for instance, in the south because in the south, because of the legal doctrine, if there was a white law school in a university, then there had to be an equivalent black law school. Most states tried to ignore this provision because they didn't want to have to set up separate professional schools to train white lawyers and train black lawyers. And so the NAACP and Marshall uses this strategy to combat discrimination within these educational system. In the 1950s, they went a major decision when the University of Texas is forced by the Supreme Court to amend a black student into the white law program because the university didn't want to set up its own separate black law program. And so this is the first time that a professional school like a law school is being desegregated in the south. Based on this, they want to win a number of other major decisions at the university level that help admit African American students into institutions of higher education. But Marshall wanted to do more than that. They wanted to really go after education in the public school system, the place where the vast majority of Americans, young people were being educated across the country, both in the south and in the north. And ultimately, the strategy that Marshall and the NAACP pursue is to support the cases of local parents and local students who felt that their children were being discriminated against within the educational system due to unequal conditions. And ultimately, Marshall and the NAACP use five cases. Five cases, a case from Delaware, a case from Kansas, a case from Virginia, South Carolina, and the District of Columbia. And they argue these five cases until the US Supreme Court decides to hear these cases. And here we have the members of the Supreme Court in 1953. The only member we're missing in this picture was a new member who had been recently appointed by Dwight D. Eisenhower, who was president of the time. And this was the Justice Earl Warren, who is appointed as the Supreme Court Chief Justice, had been the California governor for a number of years, and had been appointed by Dwight Eisenhower because he was seen as a fairly moderate member of the court and moderate. And Eisenhower didn't want any radicals on the Supreme Court at the time. Well, the Supreme Court agrees to hear this decision, hear these five cases. They ultimately become known by the first case, the first name of the case, which was Brown v. Board of Education of Topeka, Kansas. And so this oftentimes is simply referred to shorthand as the Brown decision or the Brown case. Well, Marshall and his legal team argue the case in court, and they argue a number of points that relate to the case. First of all, they argue that separate but equal is not equal. And they say, no matter how you try to do it, there's impossible for there to be a separate but equal system when you have two schools when they're based on race and argue that many respects in most Southern states, minority schools were inferior to white schools in curriculum, in physical plants. In other words, the buildings were not as nice. Access to educational materials like textbooks. They also make the argument beyond that they say, not only are they not equal in terms of just the general conditions in the school, they said, even if you have a school system that has essentially equal facilities and equal opportunities for African American and for white students, they're still stigma, they're still discrimination because you can't have a two tiered system of white schools and black schools without telling African American students that they're somehow inferior to whites. And so they argue that even if you have a system of true financial equality, in other words, both schools get the exact amount of money for the facilities and everything, they're still stigma. And argues, in fact, they use a number of sociological studies in their argument to show that these systems of discrimination in the public schools were conditioning minority students to think of themselves as being inferior to whites. And they show a number of sociological studies with young children that had grown up in these segregated school systems that they associated white with beautiful or they would show them two dolls, a black doll and a white doll and say which one is the nicer doll or which one is a better doll and these black children would pick the white doll. So they show that there's a conditioning effect of segregated education. Ultimately, they argue that segregated education violated the 14th amendment to the Constitution. They argued that it violated the Equal Protection Clause, which is one of the many phrases that made up the 14th amendment and argued that all US citizens enjoy equal protection under the law. And they said that discrimination is not equal protection. And therefore you have to fight the system, you have to end this legal system that plus CV Ferguson had created in the late 19th century. Well, Warren and the court, they consider these arguments. And for the most part, the court makes it clear and then certainly Warren pushes hard for a decision that in fact rules against the school systems that says that yes, separate but equal is in violation of the Constitution, some violation of the 14th amendment. But Warren wanted very hard to afford to be a unanimous opinion. He didn't want it just to be five justices voting in favor and for abstaining or voting against or making some other sort of statement. One of those to be a clear statement of the US government in terms of the judicial system, that segregation was wrong and it was going to end. And so there's a lot of work behind the scenes, Warren lobbying the other justices for a majority opinion, for unanimous opinion. And ultimately, the opinion is issued and argues just as Thurgood Marshall had that the 14th amendment, the equal protection clause is being violated by segregation in public schools and rules that public schools must desegregate. The phrase that is that's not initially used in the decision pictured here, but that later is issued the next year. The initial decision is in 54. And then in 55, there's a second ruling to help kind of interpret the initial ruling. Warren argues that schools must be desegregated with all deliberate speed. This is a phrase that's used in the ruling. In other words, schools can't take 10 years or 15 years to integrate, they must do it right away, or they must at least show that they are attempting to do it right away. What happens as a result of this, though, is that there is a massive ground swell of resistance, especially in the deep South, against public school desegregation. The phrase that is commonly used for this is called massive, literally massive resistance. This becomes a policy that southern states pursue in order to try to fight or delay desegregation within the school systems. So many states, Virginia included and in other states as well, passed laws to block desegregation to try to literally legally prevent school systems even if they wanted to desegregate, which many didn't, but to prevent school systems from desegregating, they would lose all their state funding if they did so. Some places they simply shut down the schools in Prince Edward County in Virginia, the local school board essentially votes itself out of business and says that all public schools are shut down in order to prevent desegregation from happening. And of course, one of the ways they get around that then is they offer private funds, essentially vouchers to students to go to private schools for the next five years. So white students are still able to go to school, but African Americans are entirely excluded from any educational opportunities within the public school system because it was shut down. So massive resistance really plays a role in slowing the implementation of the Brown decision. But nevertheless, the Brown decision is law, and the US government is essentially because of the ruling tasked with ensuring that desegregation does take place. Whereas the federal government tries very hard to stay out of desegregating at the local level because it's a messy, messy subpart and Dwight De Eisenhower, who's still president until the end of the fifties, really doesn't want to get the US government involved in doing so. One of the few cases where the US government is directly involved in desegregating is in nineteen fifty seven in Little Rock, Arkansas. And in nineteen fifty seven Little Rock attempts to desegregate their public high school. And one of the things that happens is that the local level they decide to do so. But the governor of Arkansas decides to make this into a public issue and argues that he will not allow the school to be desegregated. In fact, argues that he'll stand in the doorway and block any African American students who try to enter the high school and then calls out the Arkansas National Guard to essentially barricade the building to prevent any African Americans from getting inside. And Dwight De Eisenhower says this can't stand. You can't have governors at the state level using military force in the state and National Guard to block desegregation. And so ultimately he calls out the hundred and first airborne division, one of the US Army elite units, and orders them to Little Rock to essentially escort the children into the high school in order to counter the efforts by the governor and the National Guard to intimidate and prevent students from entering. And so this becomes, you know, one of the few cases where these nine students, and of course we have this image here of now of the hundred and first airborne escorting these nine students into the high school. Of course for them it's a very difficult experience and it's a very rough year, the first year of desegregation. But ultimately it begins the trend towards desegregation at the state level, which is a trend that continues well into the 1970s and 1980s and leads the systems like busing in order to equalize the sort of levels of different national, different ethnicities within schools. And it creates a, there's a much longer story behind that that we won't get into. But needless to say this legal strategy, this top-down strategy of changing the Constitution or forcing the Supreme Court to make a ruling on the Constitution, then trickles down to local level in terms of desegregation within the public school systems. Now the other approach I mentioned at the very beginning of the lecture, which we'll talk about now, was the bottom-up approach. As I said, the bottom-up grassroots approach to civil rights. In many cases this is the story that I think many of us are familiar with, but we're going to talk a little bit about it and perhaps tell you a few things you didn't know about the Civil Rights Movement. The bottom-up movement is largely an effort to challenge Jim Crow, this idea of essentially racially segregated public and private institutions in the South. And it really comes about, again in some ways, through informal efforts by the NAACP, working within local chapters in many Southern communities. But it also comes about in some ways even beyond the NAACP's ability to control it. So the NAACP is very important in this side of the story, but not necessarily as a driving force as it was in the school desegregation cases. The initial sort of beginning of the challenge to Jim Crow begins in 1955 when Rosa Parks, here pictured, famously refuses to take a seat at the back of the bus in Montgomery, Alabama, which is in violation of the local law. And she's arrested. What's interesting and what most people don't realize is that this had actually been the same activity, refusing to give up one seat in violation of the local law, had actually been done nine months earlier by another woman named Claudette Colvin. In reality, she anticipated Rosa Parks' strategy. But unfortunately for Claudette Colvin, she was single, she got pregnant, and the local NAACP chapter decided not to represent her because they were concerned that perhaps she might not make a good sort of poster child for desegregation efforts. They're in the south being particularly socially conservative at this time, that a pregnant single woman wouldn't look good in court. And so they ultimately decide not to proceed with her case. But when Rosa Parks nine months later does the same thing, she, it looks better and doesn't have sort of the problems that Claudette Colvin had at the time. And as a result, she becomes the person who the local chapter and local lawyers use to fight the case. Well, when Parks violates the law is arrested, this precipitates the Montgomery bus boycott that begins in December and lasts for an entire year. And African-Americans in the community refuse to ride the public transit system. And this of course attracted support from across the nation, attracted publicity from across the nation. And ultimately, the case Rosa Parks case makes its way through the federal courts and to the local courts, to the federal courts, to the Supreme Court, who eventually does rule that laws that segregated public transportation, such as at the local level, are unconstitutional. And so this has a huge impact on the legal side of things. It also has a huge impact because this is the first time that a young minister, Martin Luther King, Jr., becomes involved in the civil rights movement. King had been, was from Atlanta. He had been educated both in the South and in the North. And he had recently arrived at a local Baptist church branch in Montgomery. And he helps coordinate the boycott of the buses and argues very much in favor of non-violence as a source of protest. He's inspired by Thoreau, he's inspired by Gandhi, argues that non-violence can be effective for challenging legal systems and challenging social institutions. And so he really is inspirational for the grassroots evolution of this movement by his insistence on peaceful civil disobedience. Now, African Americans will not engage in violent activities to challenge this Jim Crow legal and social institution. And so King becomes well known through his efforts in the Montgomery bus boycott and begins to play a broader role in the civil rights movement beginning in the late 1950s. This time period of the late 50s and early 60s is very, very vibrant period within, as I said, this grassroots aspect of the civil rights movement because you have a lot of different people and a lot of different groups acting at different levels challenging Jim Crow legal and social institutions. When King is successful and Montgomery is successfully, the Montgomery bus system is successfully integrated, he and a number of other Christian ministers go on to form an organization known as the Southern Christian Leadership Conference. And the SCLC, as it's known SCLC, helps to play an important role in organizing civil rights movements throughout the South beginning in 1957. King and other members of the SCLC use it as a way to help regionalize the individual civil rights protests that had broken out in places like Birmingham. So the SCLC plays an important role within the growing grassroots civil rights movement of the American South in the late 50s and the early 1960s. And the SCLC embraces King's ideas of civil protests, of refusal to engage in violence, if people hit you or abuse you you accept it you don't simply fight back. And this becomes really a hallmark of King and the SCLC's actions. Now there are also other sides of the civil rights movement, there's a student side and you begin to see young African-American students growing to increasingly dissatisfied with the set situation in the South and beginning to stage their own protests. In many cases young people were more willing to take greater we're willing to take greater chances than adults. Perhaps they felt they had less to lose than adults and so young people really are sort of the foot soldiers of much of this protest. The early example that's a successful example of integration by young people takes place in Greensboro, North Carolina. Here we have an image from this protest and this is a protest that becomes known as a sit-in. And the first of these sit-ins for the civil rights movement for by young people beginning in Greensboro, Alabama in 1960 four students from the local North Carolina Ag and Tech State University decide to sit at the all-white lunch counter at the Woolworths, the local store, local kind of department store that also had a lunch counter for food. This was well known that Woolworths policy was they didn't serve African-Americans at the lunch counter. If you wanted food you had to go to the back of the store basically in order from the kitchen. Well the staff refused to sit them, refused to serve them but the young African-Americans refused to leave the store until it closes and they sit there nonetheless and they return the next day and more more African-American students return with them until the number is grown into the hundreds demanding you know sitting but at the same time demanding service and not leaving when the staff asked them to. Eventually they have to call the police in to maintain order. Well the sit-ins start to spread across the south led by student organizations and eventually within five months Woolworths at the national level just the publicity is bad they're not they don't want it anymore. They agree to serve African-Americans at their lunch counters and integrate this very segregated this very segregated facility in the south and this is a huge success for young people for young college students. This helps bring about the formation of an organization called SNCC the Student Nonviolent Coordinating Committee and this is another organization somewhat of a parallel to the SCLC to help young people organize and challenge segregation to fight for racial justice and power African-Americans to take control in their over their lives to help fight for equality within their communities and in many respects as the sixties goes on SNCC emerges as a more radical alternative to the SCLC to sort of summarize a little bit as we go ahead these movements gradually continue to expand the SCLC and Martin Luther King SNCC and various student leaders push for more more rights in 1963 the SCLC engages in a campaign campaign in Birmingham, Alabama and the Birmingham campaign is important because Birmingham had essentially very segregated public stores and other facilities that employ African-Americans and the local community was extremely upset about this and the SCLC organizes protests to try to combat this extreme segregation within the community. They are violently repressed peaceful marches are attacked by police with dogs they use water cannons on the protesters and it's an extremely violent reaction against actions of peaceful protesters houses are bombed here is a picture of a house where a bomb was thrown into it during the during the protest period Birmingham becomes among protesters known as bombing him because of all these bombs that are set in churches and in homes and to try to kill or scare African-Americans into giving up the protest Martin Luther King gets arrested during this period for his actions but ultimately this campaign draws nationwide attention forces the people of Birmingham and of Alabama in general under a very negative light as the national news broadcaster showing what's happening in Birmingham every night or in every day and ultimately forces local leaders to negotiate and into the campaign by promising greater access for African-Americans to businesses promising to hire African-Americans to work in businesses and so it's ultimately a success for the SCLC for African-Americans for King because of these nonviolent activities King and the SCLC continue they begin to grow more bold in their objectives and the next major project that the SCLC and a number of other organizations engage in is a march on Washington DC this is something that actually had originally been proposed by another African-American A. Philip Randolph who was a union leader during World War II and because of arguing against segregation in wartime industries and actually at the last minute President Franklin Roosevelt had made some decisions to help avert this huge march that was threatened on Washington well King and his supporters go ahead with this march and it becomes ultimately the largest public demonstration in U.S. history 250,000 black and white attendees march to DC to the National Mall and campaign for civil rights legislation as well as for legislation that would help promote jobs help in segregation in the workplace by far probably the most famous outcome of this is of course Martin Luther King gives his I Have a Dream speech which is inspiring to those who are in attendance and widely reported to those who can't attend and ultimately it reflects a peak of the nonviolent integrationist movement in the United States this movement spurred by the NAACP by SCLC to peacefully bring about the end of segregation and to promote integration of African-Americans and other minorities into white society in the United States both in the South and throughout the United States and ultimately part of the outcome of this is that the United States government accepts the demands of protesters to play a greater role in ensuring equality for under the law for those of different races and to ensure equality for those of different genders as a result of these march on Washington and the other protests in 1964 the new president President Lyndon Johnson who takes office after Robert F. Kennedy is assassinated in 1963 Johnson puts pressure on Congress who passed the 1964 Civil Rights Act and here are Johnson's signing the Civil Rights Act which is a hallmark piece of legislation and outlawed racial and gender-based discrimination in employment public institutions and commercial facilities gave the U.S. government the U.S. Attorney in general power to sue in federal court in any circumstances where there was discrimination and this was a huge amount of power the next year the Voting Rights Act is passed which allows the federal government to oversee elections especially elections in the South where there was a lot of discrimination and intimidation of voters later the same year the 24th Amendment is passed which bans poll taxes which was a technique that many Southern states use by forcing you to have to pay a fee every year in order to vote and most African Americans couldn't afford or just weren't willing to pay this fee and therefore were excluded the final outcome of this great series of events that take place in 1963 and 1964 is that in 1964 something called freedom summer is launched and this is a summer where young people mostly college age students go to the South and try to bring about voter registration drives for African Americans they start freedom schools to help educate African Americans about civics and things like that and it really helps bring about a very strong awareness among the general population about what's going on in the South this also massively resisted there's a lot of violence directed at these people who were in the South for freedom summer and for those who were engaging in another activity called freedom rides that took place even before freedom summer or as an attempt to try to bring about the desegregation of interstate transportation systems and here are images of young people who were attacked during these freedom rides on buses by those in the community who resisted this desegregation so between all these activities by 64 dramatic progress have been made in civil rights in the United States from 1954 to 64 this is a decade of huge changes within American society bringing about at the national level the end of separate but equal bringing about at the local level the integration of public and private institutions and ultimately mentally bringing about federal legislation guaranteeing civil rights guaranteeing both gender as well as racial equality and putting the federal government in a position to deal with any sort of inequality as the federal government being the final arbiter of solving those problems now of course as we'll talk about in the next lecture this doesn't end the situation while great strides are made between 54 and 64 there's still a great deal of white resistance against civil rights and there's also a lot of frustration by many African Americans who felt who feel that the well you know the results of the decade are positive that it hasn't had an immediate impact on their lives and so as we'll talk about in the next lecture how these two forces interact with each other in the second half of the 1960s