Good afternoon. I'd like to talk to you today about Project NEL. A Tool for Educating Nurse Scientists for the Age of Information. My name is Vicky Hertzberg. I'm a statistician and I direct the Center for Data Science at the Nell Hodson Woodruff School of Nursing of Emory University in Atlanta, Georgia. I came to the School of Nursing in 2015. And a few months after I got here, there was a story on NPR about medical students at NYU using big data sources to better understand healthcare trends. And I thought if medical students can do this, why not nurses? So today I'm going to talk about why we're doing Project NEL, what it is, what our history is, the challenges, the usage to date, and what we see in our future. Well, it seems to me, not let me advance. In full disclosure, I have part of the ownership of Project NEL, intellectual property. In the Center for Data Science, we firmly believe that if you can change nursing, you can change healthcare. And we're all about developing the tools and the talent to help change nursing. Nurses are the largest segment of the healthcare workforce and they spend the most time with patients. And that's why we believe that if we can change nursing, we can change healthcare. And if you want an example, I'll just say Florence Nightingale, a nurse who changed healthcare, also a statistician. So how can we support nurses in changing healthcare? We can help them in implementing evidence-based practices as they accumulate. We can help them develop evidence-based practices where none exists. And we can enable nurses to develop data-driven evidence-based practices. And that's where Project NEL comes in. Yes? We're actually seeing your presenter view. Can you hit that swap displays button up there in the left-hand corner? Oh my goodness. I'm sorry. No worries. Perfect. Thank you so much. It's my camera's on one screen, my presenter views on the other. So my apologies. So we want to put nurses on the data information knowledge wisdom spectrum, where we're going from data, which is the naming, collecting and organize of simple measurements of objects, and to information where we organize and interpret them to knowledge, where we interpret and integrate and understand to wisdom where we understand we apply. And in nursing, we apply with compassion. The framework was developed by Doctors Patricia Brennan and Sue Bakken. Dr. Brennan is the current director of the National Library of Medicine, and Dr. Bakken is the editor-in-chief of the Germany American Medical Informatics Association, and both are renowned data science, renowned nurse scientists. To ask the question, what happens? What should a nurse do when they have a hunch? And that's where Project NEL comes in. Project NEL stands for Nursing Electronic Learning Laboratory, and it's comprised of the de-identified electronic health records taken from our clinical data warehouse for a randomly selected sample of every healthcare patients across the care continuum, so we get both outpatient and inpatient. This was done across four hospitals. We've recently expanded to more hospitals, and we'll be getting those in too. We started off in response to this NPR story. Let's get a small data set to help nursing students learn how to use an EHR data set to support their hunches in a clinical setting. And what is that involved? Well, we need to get the patients and their demographics, but then we need to categorize all of their encounters with every healthcare. And so every records indexed by the patient ID, the encounter ID, and those encounters comprise every hospital and clinic visit, the diagnostic codes, the administer medications, procedures, orders, medication and medical history, lab values, and other test measurements. We started off with 20,000 patients, which in nursing is an incredibly large data set. We were able to accomplish this easily using an access database with an Oracle back end. And we accomplished this so easily, and we thought, well, that was so easy. Let's go to 100,000 patients. And that necessitated a change in our back end to Postgres SQL and necessitated a change in our front end as well. And I'll talk about that in a minute. And that took a little longer. And then we were challenged to go to a million patients, necessitating another change in our back end. And so we're now with the MongoDB NoSQL back end. And we've tagged all of our variables to an OMOP standard. And we're really glad we did for another reason I'll talk about in a minute. So we developed our database, and it's now residing on the Amazon Cloud. Project Now Today is in what I call the version one stage, comprised of over a million patients. It's all electronic health records for these patients going back to 2012, up to about 2020. And right now we're adding in the records from 2021. And we'll soon be tackling 2022 as well. But that's kind of another wrinkle. The data have been thoroughly cleaned. And there's a data dictionary that we've developed that even every healthcare doesn't have. The database also includes clinical notes. Our front end is shiny, hence my presentation here. And it's a shiny amp with a series of drop down menus that allowed nurses or other users to select what patient populations, what tables they want to see, and has various blow up points where they can do finer selections. Nella's also comprises short courses. About quantitative tools for large data sources that are available through the every nursing experience, our continuing education arm as online courses. We've been distributing it to other schools of nursing for use in courses for doctoral students, both PhD and DMP. And we're also developing a series of case studies about its use so that we can use it in our curricula at all levels, which will help us. When we undergo re accreditation because we've got new accreditation standards involving increased attention to data and information technology tools. We've got had a few PhD dissertations that have come out of this. A couple dozen DMP quality improvement projects that's their capstone experience in that program. Several students in our BSN honors program have based their thesis on data from project now. First, we've had a variety of faculty research project and presentations that have arisen from using the data available and now our current challenge is that in October 1st of 2022, every healthcare changed electronic health vendor from Surner to Epic. Totally different system. So we're looking to that to change that that's being tagged to the OMAP standard so we can hopefully integrate that seamlessly into version into now the operative words being hopefully and seamlessly looking to incorporate data from Children's Healthcare of Atlanta. Every health care is exclusively adult and pediatric data is a real missing element, especially for nursing. And so we really want to get that in. And we also want to integrate data from the Grady Health System that being the public medical system of Fulton and cap counties where every is located. Those are both on Epic. And so it's really critical that we get the integration of every health care data into our system right before we go about seeking data from these other sources. With this, I'd like to leave you with this thought. When things go wrong because they sometimes will. When the funds are low and the debts are high, and you want to smile, we have to sigh.  Life is queer with its twists and turns. As every one of us sometimes learns. And many a failure turns about when he might have one feet stuck it out. Don't give up to the base seems slow. You might succeed with another blow. Often the struggle has given up. When he might have captured the victor's cup. And he learned too late and the night slipped down. How close it was to the golden crown. Success is failure turned inside out the silver tint of clouds of doubt. And you never can tell how close you are, maybe near and it seems a farm. So stick to the fight when your heart is hit. It's when things seem worse, you mustn't quit. And with that, since I'm the only one standing between you and your dinner, I'd like to close and thank you for your attention and ask what questions you have. That was an awesome talk, Dr. Hitchcock. Thank you so much. I think Dr. Higgins have one question, just around the size of the data saying that ended up being larger than RAM data. I mean, I don't have any issue with R and I was just wondering as well. I'm guessing guys maybe have like a positive connect instance. I know that you're, it's in the cloud. So you haven't had any issues with that. We haven't had any issues that I know of, but then I am, I mean, that's, I don't get down in the weeds with this. That's why I have a team that does this. So, So I'm sure it probably does, but not at this point. There's a question about OMOP. Supposedly the OMOP mapping should help with the EHR change, because instead of going, you know, variable A over here to variable C over here, it's going label to label. Label here, label there, put them together. That's my understanding of it at a very simplistic level. We'll really see what happens when we start to tackle that. We've recently introduced clinical notes into this, which is a really valuable resource. And that took a long time to happen. It's been a real process because it has to be de-identified. Even though the record took de-identified, you know, then there's still stuff that pops up in notes that is identifiable. So we had to de-identify that. But then we had to make sure that it's not over-reacted because there are things like walker or Simpson forceps that might be considered identifiable data, but they're actually medical terms as well. Yeah, do you guys have like a natural language processing team that's helping with that or how are you guys attacking that? That's being done by an entirely different group at our institution. And so we just, there's a lot of politics involved in this because we're outside of what's considered the covered entity. And so we have to go to the trusted whatever and they do all of that for us. And then we get the data and then, you know, we started this in 2017. And by 2018, 2019 was when we got the challenge to go to a million. And it hasn't been until recently that we've really maybe the last year that we've really gotten to that million because of first with the pandemic and the same team had to build all of these dashboards and everything. And then we then the same team got charged with the epic conversion. So it's been a real journey. Yep. I bet. Okay. Well, thank you so much. And I think I see any other questions. I really appreciate that was a great talk.


You don't have to chase atmospheres, you become one. You don't have to go following signs, signs will follow you. Your presence and God's presence become one. Where you step, God steps. Where you go, God goes. When you walk into rooms, the atmosphere changes. When you walk into rooms, sickness starts to lose its hold. When you walk into rooms, demons begin to tremble because of the presence of the Holy Spirit in you.


So I believe that Judge Greerson is here after his narrow victory in the retention. We're back live. Congratulations on your retention. You deserve it. Thank you very much, Senator. It's good to be back. Let's put it that way. It's actually a very strong vote. And thank you for all of you for your support. Thank you. So are we ready to go ahead then, Senator, on H-195? Yes. Okay. For the record, Brian Greerson, Chief Superior Judge, thank the chair and the committee for inviting the judiciary to testify on H-195. My testimony will be very brief because from our perspective, it's certainly a policy decision on the part of the legislature and the court judiciary does not take a position on the bill itself, only to say that if it is passed, I do not see any impact on the judiciary or on operations on the judiciary. And that's really all I have to say on this particular bill. Thank you. Hey, thank you. Are there any questions of Judge Greerson? Senator Nitka. So Judge Greerson, I had asked Commander Proudy about this and he explained it, but I'm just wondering still with regard to a confidential piece of evidence, I didn't know those existed before, but in terms of the court, if it has materials, what Commander Raymond said, I believe if I've got this right, that they might show a video that includes an image of a child and after the trial was over, they wouldn't leave the image there, but he mentioned that the court has a, does the court have a, explain to me what the court might have with regard to keeping something that came into court confidentially, confidential. How do you protect that from, and say a criminal case from being seen later? Let me first apologize for not being able to be present earlier. So I did not hear that testimony and I'm not sure exactly what type of evidence he's referring to, but there are different ways that that's handled. Oftentimes when someone is submitting a potential exhibit that may have confidential or information that is not going to be public, that is brought to our attention usually in the form of what we refer to as a motion to seal. And so the court is alerted in advance that there may be something within a document or a proposed exhibit that is confidential so that we can address that before we actually get into the process. And then during the course of a trial or proceeding, it may be necessary that the information be disclosed in that context, but then it could remain under seal. If it's evidence that's introduced in a trial, we do have to preserve the record. So it's there and it could remain under seal from the public, but it would still be part of a court record if that answers your question. It does and should it go unappealed to the Supreme Court? Obviously they could see it also, but I'm wondering are those records also in perpetuity sealed and protected? If something is maintained under seal, it would still be under seal or unconfidential within the file. In other words, think also, for instance, of our new case management system, juvenile records are all confidential. So they remain, we maintain the records, but they are maintained as confidential meaning access to those records is limited to whatever individuals, entities that are entitled to see them under the statutes. So there is a means within our system to mark documents as confidential even within this new case management system. Okay, thank you. Any other questions of Judge Gerrison? Thank you very much, Judge. Thank you, thank you. Before everybody leaves, I want to explain most of you are invited for the 1030 on H-128. Most of you have already testified. My intent was to just have, after we hear from Representative Small, to just have a discussion of the bill and to move forward with that. So there may be some confusion. I know John Campbell said he's gonna be late, which is fine, but it was inviting all of you for the markup period, not necessarily for more testimony, except hopefully clearer. All right, I don't know what Michelle, could you join us while I was stepping away from my electronic media? I missed part of the conversation, but are we square away with the use of the term electronic media rather than electronic devices? I'm fine with that. Commander Raymond was very helpful on that. Good. So is there any reason not move forward with this today? I believe you heard from everybody who testified in the other body, so. It truly is. I mean, it's rare that we have agreement from all sides. Probably take advantage of that. Are there any amendments that anybody has? I was very tempted to want to note down April 9th as the first time on my judicial committee career that there was actually a simple bill that turned out to be simple, but Phillip had too many questions, so I'm not sure I can put it into that category. I could mess it up by adding it to H18 instead in 103, but it really, H18 is the same area. Anyway, but I think we better off not to mess it up. So I take that Senator Benning as a motion to report favorably H195 as it came to us. There's no amendments, then we're just voting on the bill. Is that correct? Correct. Any further discussion? All right, hearing none. Peggy, would you please call the roll? Senator Benning. Yes. Senator Nica. Yes. Senator White. Yes. Senator Baruth. Yes. Senator Sears. Yes. While we've got all these people in the room, it might be helpful to have a little bit of a discussion about H103 as it relates to H18. Good Samaritan language. Yeah. Peggy, did we, we, next week we have markup of that bill, right? Hold on. Let me just look at the schedule and pretty sure. Yes, we do at 11 from 1115 to 1130 on Tuesday. Yeah. And that was just for markup, right? S18. S103, H1, S103. No, H18, S103. Okay, hold on. I was looking at the wrong one. S, okay. We have S103. Testimony from 10, 1015 to 1115. And then we have markup. 1115 to 12. Who do we have testimony from? David chair, Chris Fennell, Sarah Robinson and Matt Valerio. Remember why we have that we already heard from everybody. I think that's just on one, on the good Sam. Oh, okay. I think you've heard from everyone on H18. Okay. So are we good with H18? That's your bill, right? Yes. If you're good. What? Are you asking me if you're good? Yeah. We've got any changes to H18. That's the bill that would. Right. We don't have that on the agenda next week at all. The only, um, The only thing outstanding that I remember was. There was some back and forth about. I'm looking at it now. See on page two. Simulation applies to conduct, not to a simulated child. But I think that. AG's office had said that they were okay with removing that. But the committee hadn't taken any position. I don't, I don't think I missed any later discussion on that. But. I think the last bit was that to change that to, you know, I don't know if I can strike the last clause. I see. You could just take it out. If you wanted to as well. And I thought that the AG's office was going to check. What their folks, but. My bills. That was a question here too. I think someone else. Here's, I have written down as the decision. With regard to see. Leave the child. As it is without the. New words actual in front of it. That was a decision we made. I thought that was another piece. So there was a, there was a question over whether to add the word actual to child. And then there was a, I thought a separate question about the phrase simulated child. In C. In C. I would be personally, I'm fine with either eliminating it or making a change that Michelle. Just suggested changing it to only. And getting rid of not to a simulated child. But maybe we should hear from. David share again on that. Not sure. Do you want to comment? Sure. David share with the attorney general's office. I think we're okay with that. I don't have any objection to. Any of the three options that are being discussed with that, either keeping it, eliminating it or Michelle's. Idea of. Only conduct and then eliminating everything after the comma. I think we're okay with any of those. And just to be clear, we would still oppose this with any of those changes. But we would still oppose this with any of those changes. We would still oppose this with any of those changes. But we would still oppose this with any of those changes. It would still be an actual child or a real child. Because that's the language that the courts use. So Marshall. Yes. In other words, your, your objection. To. Different. Regardless of what we do with C. It's the same issue because it's both different ways to capture the same concept. Which is that this can't apply to. Simulated children. And it's not clear enough. What the law is. What the law clearly dealt with. Is the way that the courts have dealt with it, which is by saying that the victim has to be a real child or an actual child. Whereas the change to say. Conduct applied or simulation applies to conduct, not to child. We think is not clear enough. And in such a serious. Offense. It's important to be very clear and to have the language. And to have. You know, Absent language that says. Actual child or real child. We're going to continue to oppose it. Well, it's not settled. But we're going to have this argument. No matter what. It's an argument that. That's, that's why I wrote down what the decision. That we seem to have come to. And underlined it in red. So we already sort of. At least that was my take on it. Yeah. My, my sense was that the, the committee. Didn't want to go in the direction of saying actual child. Earlier on, and then. If you're not going to do that. I don't think it makes sense to do. The simulated child. Language and C. So it seems like you either do both. Or neither. So that's, that's why I would get rid of not to a simulated child and just say. Applies to conduct only. Is that the way you see it, Michelle? I don't, I mean, I see them as the same issue. And I think if you're not going to have actual child. I think it is good to have seven C in there. I think if you're discomfort is saying not to a simulated child, I would take that out. But even though. If you take out that last clause, seven C is just reiterating what you have earlier in the intro language and seven, which is clear that it's just applying to conduct, but I think it is helpful. I don't think, I mean, certainly you have established in this body as well as the other body, a clear legislative record. That is that it is no one's intent that this. Is a simulated child. So while the, the, there may, if you choose not to include the word actual child in the definition, it's not going to, I don't think it's going to be particularly difficult for the court to ascertain that the intention was, you know, by the language that you have in there in seven saying that it only applies to conduct. Plus the legislative record. Plus all the previous cases and the common understanding that simulated children should not be a part of this. I don't think I'm not concerned that the court's not going to know what you're doing here, but I do think having a little something in seven C. Belts and suspenders in terms of the language on the page when you open up the statute without knowing the context behind it. So I would recommend that you do have a little something in seven C. That was the, that was the way because there was a disagreement between the defender general's office and the attorney general's office about whether or not. Child in the definition. The inclusion of seven C was to try to strike a balance there to address the issue, but in a way that was palatable to the attorney general's office and not changing the definition of child for that chapter. So I think do you have concerns with the language that I proposed about just kind of tweaking it. And then just not amending the definition. Or you just feel like it's superfluous. I'm good. No. Yeah, I was, I was arguing in favor of what you. Okay. Suggested. Yeah. I don't have the same concerns as the defender general's office. If you have that and then you have the legislative record and then you have the appropriate information. So. That's fine. And we'll just, we'll just go into your context. I think it's pretty clear in there that it's just applying to. And your language, Michelle is what. I would just, if you look at. Can I ask, can you see. Yes. Which it's mine. I can't see it. So on seven C as it passed from the house, it just says simulation applies to conduct, not to a simulated child. It's somewhat repetitive because if you look at the lead in on seven a simulation means the explicit depiction of any conduct. You know, I think I, I like, see the way that it is there and as passed by the house but I think you could strike that second clause in there if that's, if that's your preference. This simulation means the explicit depiction of any conduct described in sublation to a through after this section. And then you would now have C reading simulation applies only to conducts. Yeah, right. Yep. And I. So that would be the change to make to 18. I'm still wrestling with it. I think it would be presidency and not using the term actual child. I think the disagreement was that it would present to a court as new language. Is that right Michelle. There's a there's a couple issues one is that it's changing the definition of child we have a definition of child, you know throughout the statutes. You're amending the definition and then you have the same and you can obviously have this the same word and it can mean different things in different chapters for purposes only of that chapter. But there are it. It does kind of beg the question of when it's different in one place well why is it. If you're specifically saying that definition, you know, that it means an actual child, then you have that term elsewhere in the titles, and it does and you don't amend it to say actual child. Well then the question in those other definitions. Is there something contemplated beyond an actual child. Do you have saying so through. So it kind of calls those other definitions in a question and then again it's a it's a definition section that's applying to the whole chapter and then the Attorney General's office had a concern about having, I think an additional burden of proof there but I would let David make that argument because it. I didn't share it so I so. But making it clear for legislative intent. I would not intend to loop in a simulated depiction. You're comfortable if we struck seven C's last phrase that it would be consistent with current case law. Yeah, I think see the way it is, is the best approach, if you're not going to amend it to say act and or say in somewhere at the term actual child which is what the Attorney General's office is trying to avoid I think that seven C as what you have presented and then the house pass version is the best way to go about it but that was my initial reaction when you first read it to us and I'm just agree a little bit with Marshall here but that's okay because I think the intent we have been talking about is pretty clear on the record, but to strike that phrase seems to me to almost muddy up that intent to some. It would not be my preference I'm trying to try to make everybody happy or at least everybody not happy. I, my, my objection to. I don't put it this way I don't object to having the phrase simulated child. I think in one way it makes what we're doing clearer. But what I said initially was then there should be a definition of simulated child is a simulated child, a computer generated child, or as a simulated child, a living person who is role playing as a child, what, what does simulated child entail. So, if we're going to have the phrase simulated child, I think there needs to be a definition seems to me if we don't want to do that, and we want to take a more elegant approach we can just get rid of that phrase in a way that Michelle suggests. She asked us to take a look back at section one 28 21 definitions as used in this chapter, child means any person under 16 years of age. You look back and you look at seven a little I involves a child as defined in subsection one of the section. One child means any person under 16 years of age and come down to see as a simulation applies only to conduct, clearly involving a child as defined in subsection one go back child means any person under 16 years of age. Not simulated. I agree with, with Philip that you adding in the words simulated child then kind of does put money. I don't know that it would I think it is somewhat clearer by taking out that phrase and doing so that seven series simulation applies only to conduct, you could add with a child. Just looking at the plain meaning the plain language definition for simulated it means manufactured an imitation. I'm not indicating the conditions of something. Yeah, I just, I just think it's a larger. It's a larger field of reference. We already exclude up above drawings. Non visual written descriptions, but then when you talk about a simulated child. Those, those paintings drawings, non visual or written descriptions might not capture other forms of computer simulation. I, I guess my way of looking at it is with the time we have left and given what we're going to need to do on the language that we're adding. This seems to me like not a big problem. If we get rid of not to a simulated child with noting Marshall Paul's objection. I guess what I was saying originally was either we trust the definition is clear that it's an actual child. You know the definition of what a, of what a child is at the top of the bill. And if we trust that then we don't need that simulated child language later. So the reading that the chair just did from that definition forward, I think it's pretty clear. Okay. I think we any objection to doing that to doing actually. To change the change see the final see section one simulation applies only to conduct. Okay, I'm okay with that striking the words not to a simulated child. I'm okay with that. I'm going to say I live with it only because I think the record is pretty clear of what our intent is. All right, so that takes care of that. And then when we get to S 103. We will hear some testimony next week, I think we know we can finish that off this has been helpful anyway. And we're going to take a break until 1030. Was that okay. I was there anything more. Oh, who's going to report S one. H 195 the facial recognition. Don't all jump. I will do it if, if no one else is, I guess you can announce it's a simple little bill. Yeah. So I, I think center birth you just need to let secretary bloomer and Vanessa know the vote because they already have the, the bill. Okay. And I'll get you in this list. And that was 500. Yep. Did you get the, the other bill as 99. I sent it on to bloomer. But I'm assuming it went to rules and I have to get it out of. You know, I, I was thought under the old system, I thought we could send hours out after crossover and then they went to jail in the house. I didn't think they had to be voted out on both sides. Yeah, you're, you're right. I don't understand why. Because the, the point of crossover is to give the other chamber time to work on it. And if they, if it's something that they feel is important and they want to get they'll, they'll make that appeal to their rules committee but we keep working on S bills all the time, and they might deal with them in January. Yeah, I don't, I think it, I think it got confused with under COVID at the beginning, things had to be ordered out. And, and that was a new regime. So it's not clear what why it would go to rules now unless it's the COVID piece. I might ask Becca about that because I'm, I'm concerned that it means that any S bills that we're continuing to address that we would like. Maybe they want to take them up this year because they have time, or maybe they want to wait until January but we, we have every, I think right to get them out and keep working on them. So, I'm going to check with Becca on that. Okay.


And the first time, like I studied every word. I could basically recite it and I got like a 98 on that one.  And then sure enough, like I let off after that. Cause like you can't, that's not sustainable. You can't study that much for every test. It's just not possible. Obviously besides the fact of like physical exam where you have to be hands on for the most part, everything for me has just been, okay, I'll read it and just try to memorize it there on the spot. And that's been working for me. Helping others is a calling. It's not a job. Elijah. Hello. Hey, Boris. It has been a long time. Been a couple of months. Been hiding away in didactic gear. Yeah. In your cave. In my, uh, in my didactic health. Yeah. Your didactic health. Your study, study cave. Yup. Just nine to five classroom and then come home and study some more. Risen repeat seven days a week. If you had to guess on average, like how many more hours after the nine to five do you have to study? Um, if I don't have any exams within that week, I'll study like an hour or two a day and then the rest of the day, I'll just spend time with my son or just like watch shows. I've been watching a lot of shows. Yeah. What are you into right now? Oh, well, I watched a lot of like, like Japanese cartoons, like anime. That's the stuff I'm into. So nice.  I watched it with my son. He loves it. Like, uh, like Dragon Ball Z. Yeah. Dragon Ball Z Demon Slayer. Like some of the newer ones. Yeah. I think I saw a story about Dragon Ball Z. Like the guy who created it just died or something. Yeah. Yeah. He died recently. I forgot his name, but yeah, he passed away like a couple of weeks ago. He was like a legend, right? Cause he, he created Dragon Ball Z, which is huge.  Oh yeah. Yeah. He's, he's well known. That's awesome. But yeah, that's been, uh, it's hard to explain the semester. So I'm in my first year, uh, second semester of my first year. And it's been going well. I, um, pretty much got straight A's the first semester. Oh, a couple like A minuses. But I'm going to count that. I'm going to count that. Cause I was like less than a percent away from that flat A, but I found it. But, um, yeah. So this second semester has definitely been challenging in a different way. So my first semester was a lot of like just head into books kind of stuff. And it's kind of the same thing now, but a little bit more clinically related. We've had like some pretty cool classes like EKG. I liked that one a lot. I'm doing real well in that one. Sonography, that one just ended. Uh, that one was really fun. Uh, we have a class called clinical lab where we're learning about like, like lab values and stuff like that. And like a different management and like what labs to order. Um, so like more hands-on, uh, classes with regards to the, that I did get here. So it's been, I'd say more fun, but I definitely feel like I'm still not getting a lot of sleep. Uh, you're not going to get sleep until school's over. Yeah. I kind of, I kind of got that from, uh, experiencing this, this easier semester because a lot of our second year's kind of prefaced it with, uh, Oh yeah. The second year's a second semester is a lot easier. It's like, you know, funner classes and I'm like, they're fun, but I'm still like, I'm still studying a lot for it. Well, it's easier because you're used to the pace and it's just like not new to you anymore. And it's easier because it's, yeah, like you said, it's more fun stuff. It's not like biochemistry and this and that. It's like, it's actual stuff that's clinical, you know, and if you like medicine, it's kind of cool. I think my, one of my favorite classes is, uh, it's called fog or skills of patient assessment. So we're kind of doing like physical exams and like just really applying like what we learned last semester, it's a like different, uh, you know, how you perform a physical exam. Yep. There you go. But is that Bates? It's Bates. It's, uh, yep, I read every single page and it's, uh, it's pretty killer. Yep. Bates guide to physical exam and all the quizlets that come with it. This is, uh, this definitely got me through physical diagnosis. It, um, that's a great book. Yeah. There's a lot of videos online too, where they perform the actual exam. So that's been pretty helpful. It's actually, it's amazing how well that one's written because I feel like a lot of times you read the book and it's like, yeah, yeah, yeah, like one, I don't understand a lot of this stuff or I don't like the way it's presented or it's just not clear. Bates, like literally every topic I feel like is presented very, very well and it gives you exactly what you need without anything more. So I actually really appreciate Bates. There's a, there's a couple like parts where I'm just kind of confused because they'll like try to over explain the maneuver. Like, for example, uh, just like, just like flexing the arm, like they'll explain it and like the most like, like specific way, whether they're like, can you get a hold like, like five inches from here and two centimeters from here and, uh, palms have to be like supine, uh, and then you got to ask the patient like, and like things like that. And I'm just like, oh God, it's so specific. And they just want me to do that. It's true. I mean, I don't know. You don't want it to mess it up because people will mess everything up. Yeah, I mean, it's, it's, it's awesome because there's anatomy review and then they tell you what you're looking for and how to do the exam and those are like the main, the main things. And you know, actually it's all tying into what I learned in anatomy last year. And like, so some of the things like we're learning in pathophysiology, like the pathology of things like why we palpate or why we all sculpted like things like that. Actually, you brought up a really good point that I think I can't remember who made it. I think this was a medical student I interviewed whose interview I haven't edited or posted yet because it's going to be a lot of editing, but I will. It's coming soon. But I think she said she became an EMT and for the first time ever in EMT school is when she actually enjoyed school because she felt like it was something that's actually applicable to what she's going to do, not just like learning for the sake of learning. Right. So second year of PA school or for you like second semester, I guess is a lot like that you actually learn stuff you're actually going to do. So it's actually, it's cool. It's kind of like the silver lining on all the work and all the sleepless nights. Right. Oh, yeah, especially like tying in things to my old job like EKG and clinical lab. Like I'm I understand like why we ordered like certain labs and like now I know how to read EKG. So I'm like, oh, no, like that's what that doctor was talking about. Like, yeah, yeah, like things like that. And I'm just like, oh, this is so interesting. Like granted, I'm tired. I'm still not getting enough sleep, but it's more fun than, you know, redoing anatomy and in micro and all that again. Yeah, it's cool stuff to know. It's really cool. Like you don't appreciate the process of it going into your brain, but it's cool to like know this stuff that you heard like a doctor say and you heard like, hey, what the heck even is that? I don't know. And I'm too tired to look it up.  Now I know this stuff. Like I remember perfect example. So you know, like AFib, right? Yeah. Irregularly irregular. Atria is just doing whatever it wants to do. And it's just like not getting through the ventricle consistently and blah, blah, blah. I remember when I was a scribe back in the day, one of the doctors said atrial flutter. And it was the first time I heard that. And I was like, I think he means AFib, but I'll write it down. Maybe there's like different ways of saying it. And then sure enough, in EKG class, we like learn like, no, a flutter is a totally different rhythm. Yeah, so when I learned that, yeah. Yeah, exactly. The sawtooth pattern. And I remember learning that and like it was just so gratifying because it's like, wait a minute. No, he that was a different thing. And this thing that I thought was so wrong. And now I know better. It's just it's so gratifying to learn medicine. It's just it's really cool. It's cool to know it. It's cool to learn it. Or like when I when I was an ED tech, I had to say almost like a similar experience.  Or like it would like. Like someone would be like throwing PVCs, right? But sometimes that's like normal, depending on, you know, the patient. But I would see that as a tech. I'm like, I would show it to the doctor and he'd be like, oh, yeah, it's fine. What is that big thing? You, you just wait.  And then the next time it happens, you're like, no, it's fine.  And I'm like, yeah, I'm sure. Yeah. Yeah. It's it's cool. Like the more you learn and sometimes just from experience, it's just it's cool to know more. You know, we also had a very, very interesting class related to our EKG class. It was called EKG SIM or short for simulation. So we kind of got to be in this like SIM lab where there's like a mechanical doll. We've had one of our professors behind like a one sided mirror or window. And she was kind of speaking to us through the doll and we were asking a question history, like why they came in, you know, alleviating things that alleviate the symptoms, things that make it worse and wait a minute. The doll was talking. Yeah, the doll. Well, it was the doll was talking through a professor was speaking into a mic in like the control room. And it was speaking through the doll. They were speaking through the through the doll. I don't like that. It was it was freaky. I thought it was all like automated responses by the robot until I realized like, wow, like these responses are quite complicated. I don't think this is like AI or anything. Like it was like someone in the room over speaking into a microphone that it was being conveyed through the doll.  It was it was super fun. I I really enjoyed it.  Like the person was in like. Was going was going into torsades and then all of a sudden VTAC wait, did the did the doll look like this? Oh, no, I mean, it looks like a mannequin, like almost like like the normal mannequins, but it was so cool. Like it's like it had pulse. It had crowded pulses. It had people pulses. It had I bet you this doll has no pulses whatsoever. That doll does have a pulse when it's haunted. No, this doll definitely doesn't have pulses and it's freaking me the F out. Like you tell me talking doll. I'm out like I'll choose a different program. How about mannequins talking mannequin? Thank you. Don't. Yeah, don't don't use the word talking doll because then like I think this yeah, that's what I think when I think talking doll. That's so creepy. Did I say doll? I said doll. OK, I've been mannequin.  Wait, why am I back in this enchanted forest thing? Oh, that's right, because now I'm trying to go back to to this. OK, anyway, speaking of which, and also minds, it's a bit of a lag. So sorry. That's OK. OK, so thank you for crawling out of your study cave. Elijah and for joining the land of the living away from the land of Annabelle and joining me in this enchanted forest that you see on the screen and telling me about your first year PA school experience. So basically what you said is you're still very tired or not sleeping much, but it's more fun. Yeah, no, no sleep, but it's bearable because it's fun. Good. You're OK. Well, what's the truth? I like to tell my classmates just like getting used to the abuse. Kind of kind of. It's necessary abuse. Yeah, necessary abuse, fun abuse. It doesn't make it any less abusive, but it's it's necessary abuse. Just plug my laptop in. OK, so I mean, you're still surviving. You're still there, right? You haven't failed out. Have you failed a single exam? No, I'm not one. I got was probably a T, but I still got in that class. But no, my lowest grade in an exam was a C. Um, I don't I don't know. I haven't failed yet. I feel like it's because every time I study, I think like this is the only time I'm going to have to study for this one test. I want to do the best I can for this test and then move on with my life. Yeah. And I get what I get.   I'll get like A pluses. Some I'll get like B minuses, you know, just kind of depends on how much I actually like the subject. Yeah, it's like, yeah, as long as you're not constantly hanging around like on the edge, like constantly getting B minuses, then you're pretty stress-free or just like, all right, I know I'll probably do well enough on the next one.  You're just like, okay, I can do this, right? But just like some words of reassurance for like those going into P school or like even those in P school. Like once you get to like the clinically applicable stuff, like, like I said earlier, like EKG and lab, like I noticed like the class average like shot way up. It was probably like a mirror. Yeah, mid B for all the classes last semester during like the really like didactic heavy courses. And now that we're doing more hands-on things, like everyone's grades is like, like, I think we all average like a low to mid A most of our classes. And it's not easy. Yeah, these aren't easy classes. Like they're still hard. That's awesome. Nobody's like on the verge of a failing or nothing. Like everyone's pretty strong. Not that I know of, I have seen a couple of low grades because you can see the whole like grade scale and see who's got the highest average and the lowest, but no one consistently like failing, you know, exams. Like we've all been pretty much been having high averages. That's so, I remember that like as soon as the test is done and everyone submitted, you're like constantly hitting refresh. Like, all right, let me see the high, the average and the low and then see what I got. And then like as long as it's not the low, then you're like happy. As long as it's like above average, even by one point you're stoked. And then like the one time a year that you get to be the high grade, you're like, whoo, yes. That was me during finals. I absolutely crushed last semester's finals. And I think one test, and it was the hardest class we had. I got the highest, I think I got like a 96% or 97%. And it was a hard exam. I think that was the highest. I was like at the top of the bar. And I was like, ooh, I did it. I'm that guy. Right? You never thought you'd be that guy, right? Yeah. I always hit the people up there. I'm like, oh God, look at nerds. Right? And it like, it doesn't happen all the time I'm assuming, but like you get like, you set the curve one time and that's memorable. Oh yeah. Yeah. I remember that. That was the coolest feeling ever. I only did it once. I only did it once. Same so far, same. Yeah. I tell the story a billion times. So I'm not gonna tell it, but like basically there was like very TLDR version. Our anatomy class was taught by just the sweetest human being ever. I forgot her name, Dr. Sterns, I think. It was like literally like a living encyclopedia. Like she can zoom in in her mind to like the nano, whatever, like scale of something, like a cell and she can go all the way back out to the whole body. She's like brilliant. So she's awesome, but not super communicative. So basically it took me a half a semester to figure out that most of the study material was in this like Microsoft Word document that she just like didn't even tell us about. But that happens to be like in the folder on the Blackboard or something. So once I discovered this document, I was like, wait a minute, this is where all this stuff is? Like that I'm supposed to be studying? Like what?  I could basically recite it. And I got like a 98 on that one. And everyone was like freaking out because there was so much information. And I was like, huh, peasants. And then sure enough, like I let off after that because like you can't, that's not sustainable. You can't study that much for every test. It's just not possible. Oh yeah. The one time, the one time I actually had all the information and took all the time possible to study it and like had it was like, dude. Yeah. That feels good, huh? And never again, like you don't have that much time to study for every test. It's a high that you only experience like the first like hour after you get that those exam results. And then by the time the next exam comes up, you're like, oh God, now I got a study hard again. Yeah, exactly. It's like, all right, this was nice, but yeah. It's not repeatable.  And I just like turned my laptop around. That was nice. So with regards to like, I guess just moving forward a little bit with the first, my second semester of didactic. I think just some things that I've said with me since the first semester is I kind of have kept the same almost kind of similar, even though it's like more hands on kind of similar study habits. And that's just going directly by like what slides of professors are giving me. Cause that's exactly the material you're getting tested on. So I like last semester, I just kept reading, reading, reading the slides and that's worked for me. That's worked for like a couple of the people that I talked to about when we study for exams and so far it's been going, well, I mean, obviously besides the fact of like physical exam where you have to be hands on, for the most part, everything for me has just been, okay, I'll read it and just try to memorize it there on the spot and that's been working for me. And now my like memory palace is like, so it's so big now like compared to what it was before. Did you say memory palace? Yeah, I think that's like a concept where it's like almost like a mind map. Like it's hard to explain it, but in my mind, like if I read a certain slide or if I remember something from anatomy before, like it's like certain like visual things. Like have you watched The Good Doctor? Where it kind of like, it's almost like that, but not as vivid, obviously. I don't have imagination like that, but it's kind of like that where I'm just like, sometimes you'll see like my hands like because I'm trying to connect the dots in my mind. It was weird, super weird. I didn't know I had this. Do you know Dr. Jubbal? Yeah, yeah, yeah, yeah, Med School, Med School Insiders. Med School Insiders, yeah. Yeah, he's nuts. He's like, he got into like plastic surgery residency which is like the craziest residency to get into. And then he decided he didn't wanna be a doctor anymore because he like founded some company. He's nuts, super brilliant. But I think he talks about that. He like, I don't know if he calls it the memory palace but he says he like goes into like a certain room and then like imagines details in that room and then like puts whatever he's learning in there. Somehow, I don't know how it works for him, but I'm after the concept. Something like that. I think you're a very visual person if that's how you memorize. Yeah, yeah, like I can memorize like, like we had an exam today, like there's a certain slide with a question and an answer on it. And I couldn't tell you like where on that slide that answer was like things like that. Yeah, I don't think. But then like it's gone. I would like, I won't know years from now unless it's like an important concept, like I'm not going to retain it. But this is just for like little details, like for like what's called level one questions. So basically just route memorization, just like, okay, it's on the slide, just know it. That's what I mainly use that for. That's I feel like a majority of the test sometimes. Oh, okay. Anyway, yeah, that's cool. I'm just trying to think, should we stay on the study skills topic or do we want to get to everything else we want to talk about? I think we could probably... We could move on. Yeah. We could probably move on. If you guys want, we can make a separate like study skills dedicated video. I've got plenty of them on the channel, but if you guys want me in Elijah to make one, put that in the comments, we'll be happy to try to make some actual like step-by-step type study stuff.


All things can be coded as capital with the right legal coding. Property rights, collateral law, trust, corporate law, contract law, and bankruptcy law. All of these institutions are coded in the laws of England, in the laws of a state in the United States, such as New York or Delaware, in Germany, in France, and many other jurisdictions, but they're national, they're domestic, they're not international. At the same time, we're observing that we have a global capitalist system. Financial assets are being transferred by click of a mouse to different jurisdictions in every nanosecond that you can think of. So the question is, how can that be? Either my argument is wrong, capital actually exists outside the law and doesn't need the structures that I have suggested, or maybe we have to think again how the global system really works. My answer to this puzzle, how can we have a global system that is actually created with private law institutions that are national law is that you could have, in theory, a global system that is sustained by only a single domestic legal system. As long as all other jurisdictions, all other states say, we will recognize this law and we will also make sure that it will be enforced in our countries. That's the system we have. And we have not one system that sustains global capitalism, but the two hegemons at the top of globalization are two legal systems. The laws of England and the laws of the United States are more specifically of New York for financial assets and of Delaware for corporations because in the United States these laws are state law, not federal law. So we have not a patchwork of multiple different jurisdictions where people would really shop around and get different legal systems from different parts of the world. In fact, typically if there is a choice, some systems are more attractive than others and the most attractive system for international trade, for international finance, for most financial assets that are being traded globally are the laws of England and the laws of New York or Delaware. That has a long tradition. England, as you know, has been a global sea power, but that's how you create the capacity to become a global center, not only for finance and commerce, but also for the law. It has to do with a lot of power, a lot of economic, political and legal power. So you create standards, you have courts that learn how to deal with complex commercial transactions and you attract more people to those jurisdictions because they might be escaping their own legal systems where these things have not been allowed yet or they're more rigid rules that they don't really like. So picking and choosing the law brings most people to some dominant jurisdictions. Another factor is that most lawyers are trained in their own home jurisdictions at home, in Germany, in France, in the United States. But the US and the UK have also been very successful in attracting young lawyers to come to their law schools and their countries and do a master of laws. Thousands of foreign students have been trained since the 1980s in English or in American law and they know how this works. They also know how to pick an American or English law if they can't do a transaction. So we have created a network of knowledge in two major legal systems and they become then the default legal systems to create capital for the globe. Let's step back a little bit and take a look at where these legal systems come from. I've used the term common law quite a bit and I've talked about civil law jurisdictions. Just take a map of the world during the period of imperialism and look where the colonial powers went. So the colonial empire of Britain is basically the common law world as we know it today. Of course, North America, both the United States and Canada, they received law from England not in a formal transplant way but because all the settlers that came over brought the law with them that they already knew and then the states that were created here like Virginia or Massachusetts, the New English state that would adopt new laws based on models that they had brought with them. It became common law. Now, the civil law jurisdictions are those who have some remnants of Roman law, we would typically say, and the two important civil law jurisdictions are France and Germany. They have major codifications. They don't work by case law so much, although they use it as well but they codified their entire legal system of private law. They're less malleable because they have stricter principles embodied in the law and they give basically parties and also the lawyers a little less flexibility than they would have in the common law. They're a little bit more top-down rather than bottom-up but it's not the case that everything that you would need to know for a transaction is actually written down in the code. The codes are open-ended. They were enacted for centuries to come. The French code Seville from 1804 is still in force so of course it had to be adapted to changes over time and the German code is from 1900, same thing. When you turn to Latin America, it's all French today. Of course it used to be Portuguese or Spanish but after these countries became independent in the early 19th century, they adopted French law because Spain had become French after the Napoleonic troops brought the French civil code. So again, political power goes hand in hand with legal power and you basically disseminated French law through the off-shots Spain and Portugal then to Latin America. Africa is basically a patchwork of different legal systems with different colonial powers that came. South Africa is a good case in point. There's still Dutch Roman law before codification in South Africa and then the Brits came common law. India, it's common law even though there's a lot of Muslim law Hindu law and other customary laws are still there. Japan was never colonized. So what is its legal system? Interestingly enough, it's German. It adopted German law in the late 19th century and then transposed German law to Taiwan which was a colony of Japan, Korea and also to China which is why when China opened up in the late 1970s it looked back to civil law, to German law before it became a bit more eclectic and picked and chose law from different jurisdictions as well so it's much more harder today to pitch the Chinese legal system precisely. So how has globalization really occurred? Very often people think there's a space out there outside states that is free where people can do transactions without being constrained by legal rules. In fact, we had to create a global system through law. One important thing was of course that we would lower entry barriers. We would say you cannot trade your goods but more importantly we also allow you to bring finance here and then convert the currency that you bring into domestic currencies for different purposes not only to invest in real property or real assets but also to speculate in financial assets and once you allow that you have a very different system where you can bring a lot of capital from the outside and invest it inside a different country. That requires legal techniques. At the same time we also have expanded the choice of law. It wasn't the case that everybody could just pick and choose the laws by which they wish to be governed in commerce and trade and finance. It was much more restricted. States have also done something else. They have actually standardized the law making it much easier for parties to go around and know that they have the same or similar legal rules elsewhere. So even if they don't pick only one legal system sometimes they can't. Regulations are still territorial bound so they can't just pick and choose different regulations but if we standardize them for them if we basically agree on the law's common denominator then they know what they can expect and they're much more likely to go to different jurisdictions. Standardizing the law, creating the conditions for commerce and trade is a precondition for creating global financial markets and global markets more generally. A very good example is also the financial system in Europe. So the European Union created something which they called a European passport. If you were regulated by one country in Europe for the financial stuff that you did you could do the financial activities and sell your financial assets throughout the European Union. That caused a real problem when the UK left the European Union under Brexit because the financial intermediaries in London lost their European passport. So that's why we actually have seen a migration from London which had become the major hub for financial and legal services in the European Union even to Paris or Amsterdam or Frankfurt to offer their services in Europe. But it just shows this example how important the legal coding is.  It's all embedded in the law. And last but not least, we also have international conventions for intellectual property rights, for example. The TRIPS agreement, the agreement on trade-related aspects of intellectual property was adopted as part of the World Trade Organization package. Kind of ironically because the World Trade Organization was about creating free markets, free of monopolies and something that we embodied into the freedom of trade was a monopoly for intellectual property holders and that was modeled very much after the interest of industry which organized effectively led by some major American firms that brought the European companies on board and lobbed hard for TRIPS which basically requires countries from around the world to adopt certain minimum standards for intellectual property rights and that allows companies who had already had registered in their own jurisdictions to extend these property rights to other jurisdictions and then claim what you can always claim under the Code of Capital Priority, Durability, Universality and for financial assets, perhaps, Convertibility. Finally, there's also soft law. So we have binding law made through processes of lawmaking, case law or legislation. We also have informal adaptation of formal law in the ways that I discussed. But we also have a lot of soft law. Sometimes model codes that are adopted, which are not binding, you get a couple of experts together and you say this is a model code for corporate governance. The OECD did this, for example. And not surprisingly, it sort of said shareholder primacy is really the thing that we wanted to endorse with this model code. You don't have to take it, but as a member of the OECD it might be nice if you follow our particular model code. Model codes are really influential, not because they're binding, but they set standards and other countries might then go by them. And you see this sometimes even stronger when you look at the World Bank or the IMF, for example. The World Bank used to have an index called the Ease of Doing Business Index, which they created in the early 2000s. And they measured formal law and they measured how long it would take, for example, to establish a business in a certain country or whether they had certain protections to protect creditors or shareholders, et cetera. Standardized as for countries around the globe and then created an index. So every year in the fall, you would get a publication which told you which country was on top of things and if they were on top, they were lauded by this and the bank would also say how much this has helped these countries to develop and grow. There's been some manipulation about the index and a lot of critique and finally, last fall, it was closed down, but it has had enormous influence. Many countries changed their laws to comply with the index to go up in the ranking so that they would have better access to, for finance, for grants and loans that they would get from the bank but also from others. And so soft law can have a lot of power if the soft law is stipulated by powerful organizations such as the World Bank. So we have the World Bank creating these indicators. What are the models that they use? That's what we have to ask. And the models again are typically the hegemon models identified earlier, the laws of the United States and the laws of the UK. So when you think back and you think about our globe, it's not a free space. It's not a space free of law, but it's a space of layers of the law. So you can think about customs and practices that you do in your everyday life which can happen in small little communities in a locality but could also be transnational practices. So you can have customs and practices that are not bounded by territory, not bounded by the state, as long as they don't openly conflict with the state, they can flourish and develop. Then we have private law, which in principle is off the state but can be made portable. Portable because we can pick and choose from different systems or we standardize the law according to some systems, some become hegemonic. It's off a state, but it can be used in other states as well. Then we have domestic law that is actually territorial bounded, which is our constitution, regulations, criminal law. Basically all of them are not extraterritorial but only applicable in the jurisdictions of a particular state. And last but not least, we have international law, could be hard or soft law that governs the relationships between states and also sometimes between states and private parties.  It's a deeply lawyer networked space. Where does this leave us in thinking about law and the use of law for other purposes? After all, many countries wish to be democracies or have declared to be democracies and the idea of democracies are that people get together, create certain institutions and govern themselves through law. That's basically how we can scale not only economic relations but also political relations. Getting together and writing a constitution or somebody writes a constitution that is ratified by the people in one way or another. That's the binding document. It's the foundation of a polity. And then based on that constitution, we are setting up legislatures and courts and regulators and executives to define the relationship between them. We govern ourselves through law. That's one part of the legal system and the other part of the legal system, the private law institutions I've been discussing, gives private parties the opportunity to opt out of private law constraints. So yes, I'm still a citizen of this country. I'm subject to criminal law. I'm subject to binding regulations but I could also do my transaction actually in the Cayman Islands and then I won't have to pay taxes. I'm subject to legal violations to London and can make money there. I can still recoup the profits from these operations and be still based here. You can do this because we can code. What I'm trying to say is we have a tension here, fundamental tension between our aspirations as democracies to govern ourselves through law and a legal system, a global legal system that has been created over centuries but accelerated over the last couple of decades that allows some to create their own legal system, legal rules by which they are governed, which are outside our democratic controls and they will fight like hell. To keep them outside our democratic controls, they will typically say the market knows better. It's efficient, government is the problem, not the solution, which essentially says there shouldn't be democratic control over what we're doing. We want to be empowered by the law. We want to use the resource of the law to protect our interests but we don't want to be constrained by that law. That's something we have to get under control because it erodes our ability to govern ourselves. If the most powerful actors know how to get out of the law, legislatures can't really do so much even if they want to do something for the public at large or for social welfare or for redistribution, some of the gains that we have seen and people basically feel powerless because they vote for different parties and bring them into government and none of these parties can really effectively change their lives again because they have outsourced so much of the lawmaking private sector. I regard this as a fundamental problem. Let me give you a final example to illustrate this. Bilateral Investment Treaties. It's a wonderful example to show how states enable powerful private actors to claim property rights, priority, core modules of the Code of Capital for themselves and use them against the interest and the laws, even the constitution of another state. The Bilateral Investment Treaties state I, state B. They're basically saying if an investor from state B comes to state A and for some reason his investments are infringed, whatever that exactly means. So we can say our investments have been affected negatively, but whatever state A has done, we don't trust the courts of state A because it will probably be biased in favor of state A. And so we go outside. We take arbiters. Arbiters are typically private attorneys, other people with some expertise in investment law. So now we have a panel of three arbiters sitting somewhere, some country, could be in the province, could be somewhere else, and they're looking at the dispute between the two parties. What do they use to solve the dispute? They use the Bilateral Investment Treaty, which two states have signed. But the Bilateral Investment Treaty basically says you have to protect the investments of foreign investors in your jurisdiction and if the investments have been infringed, then there might be reasons for expropriation like damages or they can also get damages for unfair and inequitable treatment. What does it mean? Well, it has to be interpreted. Who interprets this? The arbiters. What is the source? The treaty. Nothing else. They're explicitly not tasked to look into the constitution or domestic rules because this is treaty law that governs them. So now you have a powerful international legal device that creates rights for foreign investors without obligations. And that is enforceable outside a state against that state and can cost millions of dollars. Now the justification is because you have to protect foreign investors against expropriation, otherwise they will not come to your shore, which is why so many countries have signed up to them. We have over 3,000 Bilateral Investment Treaties that states have entered into with one another. The factor we haven't seen all that much expropriation in the past and most of the cases these days are not about outright expropriation but about what we would call regulatory takings. A state adopts a new regulation. For example the Netherlands said we want to phase out coal. What happens next? A German company that has invested in coal in the Netherlands will bring the Netherlands to an arbitration under the Energy Charter Treaty which is a multilateral treaty but with similar mechanisms. And say you can't do this to us because we have expected to be forever in the Netherlands and make a lot of money on coal. We have used international law over the last 30 years in the form of Bilateral Investment Treaties to reinforce the notion that private rights have primacy against the interests of the public at large and that again erodes democracy because we might adopt laws for climate change or other laws to protect labour or whatever and then investors can come in and say this will cost you hundreds of millions of dollars and just the threat of that lawsuit might prevent countries from adopting these kinds of rules. So the Code of Capital in another word is a challenge. It's intention with principles of democracies. We have to rethink how to bring the two together.


Today, your favorite topic, sex.  BDSM is a very confusing catch-all phrase, because it includes SM. SM means sadism, and masochism, or sadomasochism. But actually BDSM is not the same as classic overt sexual sadism and classic overt sexual masochism, and I will try to help you disambiguate a bit. Both laymen and scholars confuse sexual submission and masochism. They think that a sexually submissive person is a masochist. Sexual submissive person is also known as a sub-rebotom in the parlance of this community of BDSM and assorted characters. But sexual submission is not the same as masochism.   I'm not talking about sadistic rape, but I'm talking about consenting adults. Consenting adults who participate in these practices, enjoy them, get aroused by them, and seek them actively. But they are important differences. Submission and domination are usually intra-diadic practices. In other words, they take place in couples. They involve intimate partners. Submission and domination are rarely conducted in public. In other words, they are not exhibitionistic. Exhibitionism is a totally different behavior, totally different complex of traits and behaviors, which is not necessarily attached or attendant upon submission and domination. Actually, very rarely. Submission and domination take place in couples among intimate partners, not in full view of others, and they involve the ritualistic and rigidly boundaryed exchange of pain and power between the parties. That's very important, because the parties are actually intimate partners. There is a lot of compassion a lot of affection, a lot of attachment, a lot of bonding between the partners. Everything they do to each other which actually involve an exchange, an exchange of power a power gradient, a power symmetry involves an exchange of pain, a pain giver and a pain receiver all this is highly ritualized. They follow strict steps. They have words which they can use to immediately cease everything they're doing. These are red words. They are rigidly boundaryed. They know each other. They know what is acceptable, what is not acceptable, what they can do to each other and what they are not allowed to do to each other. These boundaries are strictly observed. The dome and the sum collaborate as equals. Actually many would tell you that it is the sub, the allegedly ostensibly submissive partner, who is in control of the whole interaction. The sub dictates to the dome how to behave and what to do to her. I'm saying her because the majority of submissive people are actually women not all, but the majority. Sexual arousal in BDSM is the outcome of the suspension of the bottom's autonomy.  She submits. It's very similar to hypnosis. It's more or less the same psychodynamic of hypnosis. She becomes an extension of the dome. She is a kind of outlier skin of the dome. She and the dome merge and fuse in some ways. There's an outsourcing of potentially self-harming decision-making to a loving, compassionate or caring partner, the dominant partner, the dome. So while theoretically and technically, especially if the dome is not experienced or a bit sadistic or dysregulated, there is risk. Choking, for example, ends very often, very badly. Even harmless practices such as slapping and spanking sometimes end in bloodshed and bruising. So the decision-making in BDSM is potentially self-harming. It is this affinity to self-arm that is actually the cause of the arousal. There is also an element of degradation and humiliation, self-despoiling and self-trashing. But overall BDSM is a ritualized extended fantasy. A role-play. Nothing much more than that. At the end, the two parties snap out of it and go back to being utterly normal people. I mean, BDSM is normal, but I mean to being utterly conventional people. BDSM is also frequently followed with vanilla sex, regular sex, missionary otherwise sex.  It's not the main dish. It's a dessert. Mazookism is an entirely different thing. Sexual Mazookism revolves around self-objectification.  Dehumanization. Losing one's identity. Sometimes faceless self-ponography. The inflection and reception of real pain. Real the kind that makes you scream and shriek in agony. It also, Mazookism also usually involves public exhibitionism because there is a strong element of shame, of egocintony, of dissonance. There's a lot of ambivalence and this is exactly the foundation of the sexual arousal. The Mazookist needs to degrade herself to humiliate herself, to debase, to self-objectify and to self-trash in front of an audience. So she is very likely to be also an exhibitionist. Mazookism is sometimes embedded in a fantasy of intimacy with a partner and the partner can be real or the partner can be imaginary. So many Mazookies convert their Mazookistic experiences into a figment of some overriding, overarching fantasy which involves love or friendship or a relationship. It's of course a fantasy and very often the partners in the fantasy are not aware that they are involved in the fantasy. They just happen to be there and the Mazookies projects the fantasy onto them. Physical pain and physical dispoiling are the forms of arousal of the Mazookies and some Mazookies are into humiliation or transient choreographed healthlessness but the majority of Mazookies are more body oriented they are more somatic. So the locus of the arousal is in the physical pain. Now this is not the case in BDSM. BDSM the emphasis is not about pain it's about the relegation and delegation of one's free will. It's about submission, it's about giving up control. It's not about the pain itself. The pain in BDSM is just an indicator and a reminder of this abrogation of self-discipline, self-control, autonomy and agency. While in Mazookies sometimes there is full control. Sometimes the Mazookies is fully in control of a situation but she just wants to get hurt. She wants pain.  Kraft Ebbing and others had described sadism and sadistic practices in sex in the 19th century. So sadism is when the sadist is aroused by causing pain to another person, by inflicting pain on another person. And that person could be, usually is an intimate partner but not always. Observing the agony observing the writhing, observing the physical changes, observing the uncontrolled, dysregulated reactions to pain, observing the disintegration the tears. All this turns on the sadist. And never mind if the pain is actually egocintonic. In other words, never mind if the victim if the recipient of the pain likes the pain. Never mind if the partner is a Mazookist and she actually climaxes. She has an orgasm when she is tortured. It doesn't matter it's the infliction of pain that matters. And the ineditable, ineluctable physical, physiological reactions to pain. Even if the outcome, the final outcome is arousal and orgasm on the part of the recipient of the pain on the part of the Mazookistic partner, the sadistic partner is still gratified Never mind how momentary and how fleeting the pain, it still causes for extreme arousal. The pain in sexual sadism need not involve humiliating the partner and does not usually involve public exposure. But if the partner is averse to public exposure, is against exhibitionism. If the partner does not seek humiliation then of course subjecting her to humiliation and to public shaming and to public degradation are forms of torture.  But if the Mazookist is averse to public degradation and public humiliation, if she happens to be not exhibitionistic, the sadist will exhibit her. He will degrade her publicly. And if she is not into humiliation the emphasis of the sexual sadist would be on humiliation.    But these kind of arrangements don't last long.  There are even communities and underground communities with extreme practices like blood drinking and so on. So they gravitate towards each other. They find each other in special clubs in special venues. But though the BDSM community also has special venues and special implements and special practices and special rituals BDSM is a much more benign form. It involves sex tangentially. It's not about sex. It's about submission and domination in ways which do not bridge the boundaries of the intimate partners involved.  They are the bridge of boundaries. Physical boundaries mental boundaries, emotional boundaries and behavioral boundaries. This bridge of boundaries is actually at the core of the sexual practices and the reason what gives rise to the ultimate sexual arousal and orgasm. Now don't try any of this at home. You're not old enough.