So I think we're going to go ahead and get started. Happy Valentine's Day to everyone and thanks for spending noon of your Valentine's Day with us at the McLean Center. So it's my pleasure to introduce today's speaker. Catherine Rowland is an assistant professor in the department of surgery section of pediatric surgery here at the University of Chicago. Katie received her Bachelor of Arts as a university scholar with an emphasis in biology and the medical humanities from Baylor University. She went on to receive her MD and master of population health science degrees from Washington University in St. Louis. She has been here at the University of Chicago for the past several years as a pediatric surgeon with a clinical emphasis on minimally invasive techniques. And her research focuses on moral and professional foundation in medical education. Katie is a faculty fellow at the Hyde Park Institute and the course director of the scholars in ethics and medicine program where she teaches medical and undergraduate students in the cultivation of character using a virtual ethics framework to promote flourishing as a physician and in life. And today, Katie will speak on what would a good doctor do an examination of the physician in the patient-physician relationship. So welcome, Katie. Thank you so much for having me today. I'm excited to be here and share some of my thoughts with you. Again today we're going to do an in-depth examination of the physician in the patient-physician relationship. I don't have any financial disclosures, but for those of you who are not aware of the Hyde Park Institute here at the University of Chicago, since I do mention it in my talks, I just want to state that it is a nonprofit that works alongside the university and it helps students alumni and other members of our University of Chicago community sharpen their purpose and strengthen their character to serve the common good. So there's several different things we'll be talking about today. I want to start with first defining the problem and whether it be burnout, moral injury, or a discussion of human flourishing, we'll go through kind of what is the current problem within the medical system today. I'll address briefly Aristotle's virtue theory and how character cultivation for flourishing might apply to medicine, especially its role in restoring the individual physician. I'd then like to talk a little bit about how here at the University of Chicago we've applied Aristotle's theory to medical education and how we are teaching wisdom of our undergraduate students as well as some of our early medical students. And at the end I'd like to conclude with the character of a good doctor and some future directions for growth. So what is the problem. I want to start by showing some of the statistics about our medical students today. Because despite what we all see is probably a growing number of problems within our field students are wanting to go into medicine and higher numbers than we've ever seen before. And in fact, when you look here from early 1980 to the most recent date in the past year we're seeing increasing numbers of students, very bright students applying to medical schools. 52,000 actually. And on this this graph other graph where you can see that the, the y axis has been changed, about half of those students are accepted into medical school. So we've seen an increase in the number of students accepted, but it's still really only about half of the number of students that apply. Those numerical values are depicted here on the top box shows that there were a total in 2023 of 52,000 applicants of which there were essentially 23,000 spots for those applicants. Again, these are really smart students. The mean GPA was 3.77. These are motivated smart students who want to become doctors. And yet something happens through the process of them applying and being accepted into medical school and the time in which they become doctors and the doctors and who they become. And I think some of it has to do with with what their perception of being a doctor is many of them when you ask them want to help people. So they start out applying and starting medical school. See viewing our profession is one in which we are able to help and heal people.  And the very little time they have to spend at the bedside actually helping heal patients. In fact, the state this these numbers are pre COVID. So I would suspect that these are even higher, but 54% of doctors say they are burned out. 88% are moderately to severely stressed and 59% of doctors wouldn't recommend a career in medicine to their children in ICD 11 burnout actually has its own ICD code. I'm sure that there are people in this room who can empathize with some of the feelings or the description of burnout feelings of energy depletion or exhaustion, increased mental distance from one's job and reduce professional efficacy. I'm a surgeon, so I have surgery highlighted in this graph, but I think what's interesting about this study that looked up burnout and professional fulfillment from a surgical standpoint actually surgery on the the y axis is professional there was a you know relatively high degree of professional fulfillment within my profession. And yet the, the physicians with burnout was still remarkably high. And that's depicted along the the x axis. So really no matter what your specialty is when when questioned as to physicians intention to leave their current institution secondary to burnout. Those numbers range anywhere from 20 to 40% with the, the average being about 30% I again have surgery boxed up there about 30% of surgeons intended within the next two, two years to leave their current institution. And that ranges to tendings that burnout is affecting. And in fact when internal medicine residents were measured on the mazat burnout inventory sale 4.3% at the beginning of their intern year rated as you know qualifying for having burnout so very low numbers. By the end of that same year 55% of those residents met criteria for burnout. Very male forming was happening during the process of their intern year. And in fact, residents in general surgery anesthesiology orthopedics and OBGYN are estimated to have the highest prevalence of burnout. Most likely due to the high stress work environment there in the fact that they deal with life threatening emergencies and overloaded shifts. The studies that have measured it the, the level of burnout changes a little bit depending what study you're looking at, but it's about approximately 40% in general surgery, 63% in internal medicine, 63% in neurology. And we know that burnout has very severe and adverse consequences, both in one's professional life with an increased rate of medical errors, increased depersonalization, reduce compassion and decreased interaction with patients, as well as personal consequences as well such as substance abuse, strange personal relationships, depression and even suicide. Because most of us who go into medicine are willing to jump through all the hoops, do the many things required of us to get into medical school and then into the specialty that we're in. There has been a shift to use the language instead of burnout to moral injury and I'm sure most of you are aware of this. The focus when we talk about burnout it can be very easy to focus the, the need to improve right to do better to do more yoga outside of work to come back to work fully recharge to fix burnout on an individual level. And moral injury is used to describe really the constraints within our medical system that makes some of these things outside our control. And so moral injury describes the challenge of both knowing what you need to do in order to care for patients but being able to provide that care due to constraints beyond our control. And it helps locate the source of distress on a broken system and not a broken individual. And there are many things that are broken about our system right like the electronic medical records declining reimbursements threats of litigation increasing specialization that we see just the rapid pace of innovation within medicine today. The need for 24 seven care of increasingly sick patients, non adherent patients, and the fact that physician metrics and patient satisfaction, sometimes outrank the actual care provided. And so I would argue that perhaps instead of using the terms moral injury or even burnout, we shift our focus and think about human flourishing human flourishing is the state in which all aspects of a person's life are good. And the way the reason I like to use this to think about the current problems within the medical system is that it gives us a way to acknowledge and appreciate both the role of an individual physician, as well as the role that the system has and the community that we're working on. Tyler Vander wheel who runs the, the Human Flourishing Institute at Harvard talks about the difference between flourishing and well being. And if you're around a hospital these days you've heard a lot about well being and well being initiatives right. And so well being if we think of that as the relative attainment of a state in which all aspects of a person's life are good as they retain to that individual and contrast that to flourishing in which you can attain a state in which all aspects of a person's life are good, but include the context in the community in which one lives. And so you can imagine that one might be able to attain some measure of well being in a very corrupt environment, but one isn't really truly flourishing unless the community itself is good. To speak about flourishing flourishing is not just a wellness initiative I would argue that it's more than that it's also trying to fix some of the problems within the community and the system. It certainly is not a way just to recharge your batteries and come back to the work the next day to be fully charged. It's not an answer to burnout because there are a lot of systems issues that play to. And for you to it's really not about achieving work life balance, because if you're talking about flourishing you're talking about looking at life as a whole, your work and your, your life outside of work are all your life. And so while it's very important to take care of ourselves outside of the hospital. What I'm hoping to focus on today is that what happens inside the hospital is what made us all want to become doctors in the first place. So how can we divert our attention to fixing some of the things so that we have satisfaction with the careers that we've chosen, and that we're happy with the work that we do inside of the hospital. I would argue that flourishing is acknowledging our humanity, acknowledging that our work life and our personal life are all our life. And then some aspects of flourishing will buffer against clinical burnout and be a source of resilience and fulfillment, but that's not the sole purpose of pursuing flourishing. So when we talk about flourishing what we're talking about is a theory of philosophical theory that dates back to the time of Aristotle. Aristotle's virtue theory in which character cultivation and the cultivation of character virtue leads to human flourishing. Again, this is not a new idea this dates back to the time of the ancient Greeks, and the ancient Greeks and Aristotle were concerned with the, the ethics of being of what should I become. So this, when we talk about Aristotle's theories are on the character of human beings, and he proposed that to be a moral person one must develop or cultivate their virtues and demonstrate their virtues and their actions. And by cultivating both intellect as well as moral virtue, one flourishes as a human being. So how do we then develop virtue, our virtues are habits and dispositions of character that can only be acquired through practice. So if one wanted to become a generous person one who would have to practice generous acts till being generous became second nature to become courageous one must practice acts of courage. And within thinking about these different virtues Aristotle proposed the concept of the golden mean. So that in the center right there's a virtue, but you can have a deficiency of the virtue or an excess of the virtue neither which is necessarily good. And so when we talk about courage, you can imagine, especially as a surgeon right then you need to be trained as a surgeon to be to be courageous. And then if you have a deficiency of courage and are cowardly, that's not good for you or your patients, but it's also not good to have an excess of courage right and to run fullheartedly irrationally into an operating room without a solid plan or a good management plan for the patient. And that's true for each of these virtues that are presented here, generosity, ambition, modesty, honesty, friendship, temperance and self control. And you can think of it like this, you know that the virtues sits in the middle, but there's a vice on either side. And so by cultivating virtue one will act well and flourish. And there's been recent empirical evidence that supports that virtue by developing virtue that promotes life satisfaction, well being stronger relationships mental health and an ability to deal with adversity. So what does this look like at the 21st century. Tyler Vander wheel has proposed five different flourishing domains. And I think these are important to just talk about and identify the five domains that lead into the ability to flourish that he proposes our happiness and life satisfaction, physical and mental health, meaning and purpose character and virtue and close social relationships. And then there's an additional domain for financial security which also plays a role in your ability to be able to flourish. So these five domains that are listed though are all nearly universally desired and an end in and of themselves. And so this is the flourishing scale and I recognize that the print is small, but I think it's important to hear some of the questions that that help us measure virtue and so this short scale is 12 different questions because it includes the financial ability. And each one is rated from zero which is poor to 10 which is excellent. And at the end of taking the scale you just take an average of all your numbers and that gives you your flourishing index. But some of the questions that I'd like to point out dealing with meaning and purpose and character and virtue are in the middle there. Overall to what extent do you feel that the things you do in your life are worthwhile. And so this is my purpose in life. I always act to promote good in all circumstances, even in difficult and challenging situations, and I am always able to give up some happiness now for greater happiness later. So when this, when these human flourishing skills are given in the general population this is not specific to medicine this is the general population of the US amongst adults. Typically what's been seen in the past is that people who are early on in life, which would be Gen Z which is the blue area, and then people who are later on in life, typically have the highest flourishing measures. So what's been seen in the past when this has been studies is that flourishing is high at the beginning of adulthood right takes a decline in mid adulthood and then rises again towards the end of life. So this is data post COVID though. And this data is really scary because for the first time we saw the people very young and adulthood right the group that's 18 to 25 had some of the lowest flourishing scores. And that is much different than what we've seen in society before. And so instead of that lowest point of flourishing being kind of at the midpoint in your adulthood in your life we're seeing now that people are starting out. With much lower measures of flourishing than they have in the past. When these scales are applied to residents. This was the scale that's been given to internal medicine as well as psychiatry residents and the results of that study. The mean flourishing index for residents was 6.8. This is lower than the, you know, age matched average in the United States so our residents as compared to kind of their age match controls are not flourishing. Again, this is work from Professor Vander wheel but it shows different pathways that lead to flourishing. And I presented only because it talks about the different things that lead into the domains in which we measure flourishing and family work education and community are the four pathways he proposes that lead into our domains of flourishing. And the reason I'm showing this is because during the time of training as a resident, I think that work and education and in some sense your family and your sense of community are all wrapped up in the hospital. That's part of what residency is and so I think there are people who have still strong family relationships and perhaps strong religious community relationships during the time of residency. But even if just work and education are encompassed in, you know, what they're doing here in the hospital. What we're what we're teaching residents in the hospital and teaching students in the hospital has a major effect on their pathways to be able to flourish. And yet we're not very intentional about what we try and teach them to help them flourish. I also believe that this is extremely important because when you look at the entire flourishing index. The one question that arose from the index that was most predictive of a individuals flourishing in the future was from the character and virtue domain. And so if someone answered very strongly to I always act to promote good in all circumstances, even in difficult and challenging situations that had the most robust association with their subsequent composite flourishing later on in life. So this is a space in which we can act to help promoting people and to develop in people in ways in which they feel like they are able to promote good in all circumstances, and have a huge impact potentially on the rest of their life and their subsequent flourishing. So how does this apply to medicine. All of you I'm sure in the room are are well aware of principal based medical ethics and the the four principles are pillars of autonomy beneficence now Maleficent's injustice. Principal based medical ethics trains physicians to be able to make morally permissible decisions using the principles of biomedical ethics, and for many medical students this is the only exposure that they have to ethics during their medical training. I personally believe that about principal based medical ethics provides a very important standardized framework to approach many of the difficult and complex health care decisions and situations that were put in in the hospital. But the one thing it doesn't apply to as as well is the individual physician who's helping guide or helping families. Sorry, I'm a pediatric surgeon so families are helping patients make some of these difficult decisions. In fact, one of the reasons in which we use principal based medical ethics is so that we make sure that the physicians preferences right are not being put before that of the patient it's really to focus the decision decision that's being made on the decision that the patient would want. Part of the part of doing that, you can err on the fact that it then removes some sense of a responsibility for the physician who's helping guide that decision making process, and it also removes the sense of moral agency for the person who is carrying for those people. I think it may not be as readily applicable to many of the daily ethical decisions that individual physicians are asked to make that are probably happening on a much more routine daily basis than some of the larger ethics consults and clinical situations in which an individual consult is needed, right because on a day to day basis you might be interacting with a family that is angry or upset, you might be in an interaction with a colleague who doesn't agree with the decision or a treatment plan you've made. You might be in a your own personal conflict with something that's going on with your family outside of work and so there are many ways in which virtue ethics applies to things that the principal based medical ethics aren't as well suited to when we're thinking about an individual position. And so virtue ethics gives us an avenue just to start to discuss the character formation of physicians as individuals. This is not a new idea in medical ethics right this was really first introduced by Pellegrino back in the 1980s. This idea of using and applying Aristotle's virtue theory to medical ethics. And so I'd like to talk about a few ways that I think virtue ethics is is unique and reasons maybe it should be taught alongside principal based medical ethics and ways in which it's applicable in our daily lives as physicians. And one is because our character really determines our response in times of stress. So I look at this picture as a pediatric surgeon this is a trauma Bay after traumas come through and this is probably was a pretty stressful trauma right. And on the floor there's equipment strewn everywhere I see. You know we probably line kits or other you know maybe a thoracostomy tray. There's lots of equipment that has been opened around the room and left and disarray. And so how do you respond in situations like this in high stress environments. One of the reasons that surgeons and an emergency medicine physicians are taught a TLS are given a very strong guideline of how to approach a stressful situation like this is so that you have an internal guide right you focus on airway breathing circulation primary survey secondary survey. Those of us who have been through surgical residency could probably do that and recite that in our sleep you know what to do when you come into the trauma Bay. You know what your job is, and it's well embedded in you you don't have to stop and think about it or weigh what to do in this situation you know what you need to do. And character is much the same way character is how you're going to respond in times of stress it's what's going to come out when you don't have time to think about much else. And yet we spend very little time trying to prepare medical students in the character that they'll need to respond to the stresses that we put them in in the hospital. We kind of assume we can teach them all the intellect and the technical skills that they know to be a doctor, but the stuff about their character or how to relate to patients or how to deal with controversy they'll figure that out or they've already learned how to figure that out we don't really actively invest in teaching them some of those things. And I think for two ethics is so important is because as we've discussed, we'll react within our habits there aren't always times to think, you don't always know when you're going to walk into a situation that's going to challenge your character your ethics. In fact, sometimes you knock on the door and walk in a patient room and walk into a patient who's very upset or angry. And sometimes you have warning, but sometimes you have no warning for about what you're going to walk into. You don't have the chance to say okay I got to leave the room for about 10 minutes and think about how I want to respond to you and come back. I mean you can, if you need to but also your first response is going to be the response of your character, what's been built into you. Character also informs our response to human suffering. Again, I think this is another thing we just expect students to know. We expect students to know how to to respond to people who are hurt or suffering. And as doctors were trained right to alleviate suffering so our first thought is how can I how can I make the suffering better. We don't talk necessarily or train people necessarily how to sit with suffering how to be around someone who's suffering, how to hear them how to listen to them how to show them love through the attention that we give them. And how to figure out sometimes their goals in response to suffering. And I would also argue that virtue ethics well it's applicable to patient encounters I hinted at this early earlier it's also applicable to the way in which we interact with our colleagues. We know in medicine we work very strongly in multidisciplinary teams and with other groups of people, and the way in which you treat the people that you work with I think very much as a mark of your character. And that's not something that we really always talk about within the medical education system how to, when there's a disagreement in the right, you know care for a patient how to resolve those conflicts, how to resolve conflicts when there's conflicts with the call schedule right how to respond to somebody when they say have had a bad outcome. All these things we can, we can talk about and address when we talk about how we cultivate character. And finally, we know that from from worked on that the virtue ethics is directly linked to personal flourishing and I would propose that it is probably linked to our professional flourishing as well. Medicine today is increasingly less focused on individuals. And I would argue that virtue ethics gives us a way to start thinking about medicine as an individual physician and an individual patient again. And none of these things up here are bad things right like evidence based medicine is wonderful as is quality improvement. But the one thing that evidence based medicine is done right you the assumption is that any physician who's looking at the same patient and following the evidence based guidelines would come to the same conclusion right and so it's removed a little bit of that individual autonomy that we have as physicians so it's a quality improvement for for some in some aspects the way in which you know we have to cover shift work and call coverage. None of these are bad things we're dealing with an increasingly sick system that's running 24 hours a day so we can't be on call all the time. But how do we still maintain those individual relationships we have in light of that. Even the introduction of using provider at some institutions instead of physician that you know any provider is applicable you know round peg that can be moved around and fits nicely and you know in the pegboard there. And so I believe some of this has led to the active decay of the physician in the patient physician relationship. Perhaps many of the reasons that students who go into medicine become doctors who are disillusioned with medicine is I believe many of our students. As are many of our physicians are more much more intrinsically motivated individuals and extrinsically motivated. And so medicine appeals to them because they see as an opportunity for mastery for having a meaning and purpose for having a sense of autonomy and what you do. Especially when they become physician all of a sudden all these extrinsic motivation measures are placed upon you right your salary your RVU your quality improvement you know points where you stand on patient metrics for patient satisfaction. These are all extrinsic things that we're trying to imply in and motivate people with who are naturally most likely much more intrinsically motivated individuals. Next when it was has been looked at this is a paper from John Yoon that was that was published recently. When you look at the intrinsic motivator of salary it wasn't really associated at all with physician meaning and commitment. But when we look at intrinsic motivators so a sense of calling calling was associated with highlight meeting and commitment to direct patient care. Personally rewarding hours per day were associated with career satisfaction, life satisfaction and commitment to clinical practice and having long term relationships with patients was associated with career and life satisfaction and highlight meaning. And so virtue ethics allows us to address some of these things and talk about the investment in the character of physicians embracing our privilege privilege in the patient physician relationship. Reestablishing a sense of community within the medical field and recognizing our single goal of providing the best care for patients. And so perhaps instead of being just around peg. Virtue ethics allows us a way to look at each other as larger pieces and unique pieces of a puzzle. And so I've talked a lot about how virtue ethics may apply within medicine. But the big question out there is, is can you actually teach someone character is there any data to support that right. It sounds great but can you actually teach someone character. I would argue yes you can. What are we teaching now by not intentionally trying to develop character, we're actually malforming patients right because there is a hidden curriculum that's recognized within medicine.  The rest of the hidden curriculum that that's not really publicized or widely knowledge is vulnerability privileged dehumanization hierarchy and navigation and negotiation. And so it's not surprising in light of all that that medical students in the US during the course of their training, show that they decline in empathy, decline in moral judgment and have this increase in burnout and depression. Patients have picked up on on what is happening within the medical field as well. 74% of patients had a mostly positive view of their doctor. 57% so really only a little more than half of all patients believe their doctor cared about their best interest the patient's best interest, all or most of the time. A little more than half think that physicians who went into the medicine to help take care of patients actually have the impression that patients have that that physicians care about their best interest. And only 12% thought that their doctors could admit a mistake or take responsibility. I think this might be data that you guys saw before but one of the things that I thought would always be the saving grace of our profession our ability to show empathy. It's now being shown that perhaps chat GPT is more empathetic than we as as individual physicians are. And so when patients are asked what is your ideal physician, they say that somebody who is competent empathetic humane personal forthright respectful and thorough. That's the same question to doctors when medical students residents and physicians were asked to describe a person who's a good doctor they said that that person was fair, honest, kind, a leader, a good team player and a person with good judgment. But sadly they were much more likely to report that a good doctor should be a leader and a person with good judgment, then they were to think that they possess those skills. They were not practicing physicians right as well as residents, but they recognize that a good doctor needed the skills of leadership and good judgment, but they felt like they did not possess those skills themselves. And when medical students were asked can a person can a person still be a good physician, even if they're not a very good person, the majority disagreed that you could be a good physician and not a good person. Character matter character is fundamental, especially important in helping us maintain constancy in the face of contingencies, ensuring that we stay true to our guiding values and purpose when outside events or pressures tempt us to abandon what we hold most year. I think this describes residency today but I also think this describes the experience of being an attending physician as well. And again, whether we're intentional about it or not. This character formation is happening. And I think we must agree that medical educators should be responsible for helping train medical students to have good character. So how do we cultivate and teach this can this be taught on the Oxford character initiative was one of the first programs to examine whether character cultivation could still occur in a graduate population of students and are able to demonstrate over the course of the year that for their graduate students that had enrolled within this initiative course that they demonstrated an increase in service and gratitude through the course of their their year of teaching. And they describe seven practices to cultivate character including habituation through practice so as we talked about earlier if you want to be a courageous person you practice courageous acts reflection on personal experience engagement with virtuous exemplars using dialogue that increases your virtue literacy, being aware of situation variables cultural influences and institutional incentives, having moral reminders and friendships of mutual accountability. So how does this apply for physicians. Here at the University of Chicago, we instituted the scholars and ethics and medicine course about six years ago now. It's an innovative curriculum that's really hasn't been is not done anywhere else in the country. And we bring together both pre medical students, as well as some of our MS ones and a few MS to students. The goal of the course is to help train future physicians for not only the medical knowledge in the care, but for the character traits as well that they will need to flourish in medicine and in life. And so one of the questions that I always start out our course asking students is what kind of doctor do you want to be. And as you go through medical school, you get asked this question a lot right, and usually the correct response at least if you're going into surgeries I want to be a surgeon. But it depends you students will answer this in many different ways. But the first thing we think about when we hear this question is what kind of specialty do you want to go into right. We don't stop and think about like what kind of doctor do you actually want to be not so much your, your resume virtue doctor right, but your eulogy virtue doctor like I want to be a kind and compassionate doctor. Through teaching this course we've come up with this constellation of virtues that describes different virtues or character traits that are applicable to flourishing as a physician. And we group these into three different categories. And a lot of these virtues actually you could argue could be put in different categories. But the way in which we've arranged things is to look at both the ways in which your character or virtue affects your personal infrastructure, the ways in which your characters are relationship supportive, and the ways in which character and virtue can be patient responsive. And so the goal really with our course is to try and cultivate students to think about and cultivate virtue now prior to them having really any true clinical rotations in hopes that they will be better physicians in the future. Again, it's a year long course for the undergraduate students here at University of Chicago they get course credit for this. So it shows up on their formal transcripts they get credit for having participated. The first cohort was in 2017. Initially, you know part of the purpose of this group is to create community in a space for reflection. So initially we had capped the applicants or the cohort of 25 students. Over the past few years we've seen an increasing number of students who want to be involved in this course and it's very hard to turn away anyone who wants to cultivate character. We've had 87 students supply the year before that we had close to I think 84. So this past year we've admitted 40 students 17 of which are medical students and 23 of those students are our pre med students here. And during the year long course we teach Aristotle's theory of virtue ethics, in order to provide a framework and a language to talk about cultivating character. We bring in different positions both locally here from University of Chicago as well as from across the country, so that the students have a chance to engage with physician exemplars, as well as mentors we bring back. Fourth year medical students as well as some of the residents and fellows here who serve as mentors to the younger students in the course. We try and create a sense of community and so when I show you the schedule some of the events that we host are purely social events I'll have the students over at my house just for a chance for us to get and talk and see each other kind of outside of the lecture hall or seminar. We explore the characteristics of foster humanistic medical care and try and offer students at a time in which they have space and time for reflection. This is just a sample schedule for for the year I feel like every year we add a little more I don't think I could fit this year's course schedule on here. But we have two large seminars so to Saturday seminars one in the fall and one in the winter in which we spend about five hours together. We're talking through various lectures having small group discussions, we then meet about once to twice a month throughout the the rest of the year. In which during which time we have again both local University of Chicago physicians as well as those who travel from other institutions come and talk to the students. We share a meal over dinner and then we open up for an hour long Q&A and a chance for the students to ask these physicians questions and and get to know each other better. During the course of the year we talk about different situations that call for virtue, as well as approaches and effective practices to help cultivate character and virtue. So you can say it is this effective we actually have been measuring this since the start of the cohort. And the way in which we're measuring what we're doing is using what's called the situated wise reasoning scale, which is able to assess five different aspects of wise reasoning. So basically one's ability to look at things from another's perspective, consider and change the consider how there are multiple ways in which one situation may unfold. Show intellectual humility and a recognition of your own limits of knowledge, search for compromise and view the event through the vantage point of an outsider. We have our data here. And when you look the blue is the students who participated in the course, the reds are controls so those are students here at University of Chicago who don't participate in the course. And so what we see is after a year long participation in the course that the students who are in our course show an increase in their ability to have wise reasoning, right, their blue line goes up. So students who have not participated in this course actually show that their wise reasoning deforms during the course of the year. So not only do they not increase in their wise reasoning they actually become less able to reason wisely and see another person person's perspectives. So in our in our last two minutes, I would like to talk about perhaps how this applies to which virtues might be most compelling for physicians which which are these virtues if we look at these as being important for physicians to potentially target and teach and make a true impact in. And I would like to propose that maybe the case for that in terms of the virtue to focus on as we move into the future as humility. But first I'd like to also just say that we can teach character we should be teaching character, and we can do it through intentional curricular developments, but it does involve time, attention and energy, which is something that students do in residence and so translating this into, you know, a program for residents is more challenging, just because I know for myself as a surgical resident when I was at the end of my day I barely had time to reflect on the case I did that morning and technically how I could have improved what I did in in caring for that patient much less have the space and time to reflect upon my character or much larger aspects of who I was becoming. But it is important that we create the space and time for students as well as residents, and we do that through fostering relationships, demonstrating our own vulnerability and creating a culture that both recognizes and awards character and giving people a time to think about who am I becoming through this process, and why am I doing this. So one of the new initiatives that are on the horizon. The Hyde Park Institute we're hoping to launch as extracurricular mini series this spring right after match day for the fourth year students. This is the first time we're doing this so it'll be three, you know, seminars over over a dinner and talking about with residents after they've matched and have or sorry with medical students after they've matched and have residency on their mind. It's going to be a good resident, how to have difficult conversations and deal with mistakes and bad outcomes. And then the last one what to do with your pay when your pager goes off a user's guide to maintaining compassion and caring as a resident. You guys, you may also have seen advertisements for the meaning and purpose and medicine series this also is sponsored by the, the biological science division office or faculty affairs as well as the Hyde Park Institute. And this we're hoping to try and change a little bit of institutional culture to talk about recognizing and cultivating characters really at all levels and investing in intending physicians and what it means to really have a clear sense of meaning and purpose and what you do. So I would ask as you're out there in the audience thinking about how all this applies and ties together to think of someone a physician that you know that you consider wise. And why do you consider them wise? Is it because of the reviews that they bring in? Is it, you know, a surgery, a technical skill that they have? The number of publications or how long their CV is? Do you consider them a wise person because of their clinical acumen? They always know what's happening on rounds. Or do they hold a position of leadership that makes you view them as a wise person? I would guess that many of the things that actually make you consider that person wise in addition to some of those extrinsic things or visible things are actually more character traits that that person has. And so as we think about how we can create wise physicians for the future, I think we really need to focus on how we intentionally create and cultivate character in our trainings. And one area in which we really have focused little attention on is the character trait of humility. And in fact, many people see humility as a sign of weakness. But the word humility comes from the Latin and actually means grounded or from the earth. And so you can think of it almost like a tree that is strongly rooted within the earth. Humility in medicine is fostering a culture of continuous learning and collaboration and patient centered and team based care. And it includes accurate self assessment, a recognition of one's limits, a low self focus and an appreciation of others and an awareness of being part of a larger system and universe. Humble physicians are more likely to seek out information and get feedback to listen attentively to their colleagues and stay on top of the latest research. They're more effective in multidisciplinary collaboration. They recognize and value others contributions. They respect the patient experience and they're much more likely to gain patients trust and adherence, and they mitigate errors and uncertainty they're able to seek out others insights. They acknowledge their own limitations and they learn from their missteps. And so instead of humility really being the vice of defective pride or arrogance. I would argue that humility is the golden mean humility is the state of self competence and self awareness. The device of that defect would be being under confident or timid or self conscious but humility is actually the golden mean between those two and what we should all aim and strive for. In surgery, I think this is very important and this is my own definition of surgical humility. But I think it includes confidence in one's technical abilities, a recognition of one's limits of expertise and experience, then acknowledgement that surgical outcomes are dependent upon a team approach, an expression of gratitude for all those that participate in a patient's care, recognition that the patient preferences, their support and their social consideration are very important factors in their care, a reflection on the process and the outcome of the care provided, and finally taking joy in the good one is doing while striving to continuously improve. And so character character cultivation starts very early. That's one of the reasons that I am working with the undergraduate students and the early medical students. I really believe that that provides an opportunity to build into people before they're even exposed to the hidden curriculum within within a medical center. But I don't believe it's ever too late to start thinking about character cultivation. It does take time it takes energy and it takes a lot of attention to be purposeful about cultivating character. It does also needs to be modeled at all levels and both recognized and applauded. And then really it's a conscious decision to invest in our trainees and who they are becoming to show a genuine interest in them as human beings and focus their training not just on the technical or the academic skills that they need, but really on the character traits that they need to be a good doctor in the future. And I believe that by helping people cultivate helping aspiring physicians cultivate their character, we can help lead them to a sense of professional and personal flourishing. So I conclude with with what kind of doctor do you want to be and maybe since many of us in the room have already declared what specialty we're going into perhaps now is the time where you can stop and think about what you want to be known for in your career. In terms of the type of doctor that you are. I have to give a huge thanks to my colleagues at the Hyde Park Institute who have worked closely with me and the scholars and that that's a medicine course and really have made that that course happen. I also would like to give a thanks to Jessica candell, who was the head of pediatric surgery when I started this academic pursuit as well as all of my partners within the section of pediatric surgery that allow me the time and the space to go teach the undergraduate students and accommodate the call schedule so that I can be there in the classroom with them. Things are going on. So, thank you so much for hosting me I hope this is challenged a little bit maybe how we typically think of ethics in medicine. Any questions yeah. Yeah. And I think that's very true and I think that's one of the reasons why when we talk about well being it almost makes people cringe right to a little extent because the way in which it's being done is maybe not the best way to be doing it. There's very important systems aspects to some of this the EMR being one of them and completing charts there's ways in which we could use AI or the benefits of technology to take away some of those things that remove us from the patient's bedside because again, when we think about motivation I think for people going to medicine the intrinsic motivation was was to take care of patients. And charting is important but charting is mostly linked to RV use and find you know like the hospital getting money right and that's not what necessarily motivates most of us who have become physicians. Not that it's not important but it's not the true motivator and I think that's really a pause for a lot of distress that that physicians and their trainees are feeling within medicine, because the motivation to go into medicine and help take those practices, not the same motivations being applied to them once they actually become a physician. There's data and there's certainly practices you know behind evidence based medicine but one, not every patient fits into that perfect mold either that qualified for that if you're lucky in cardiology that RCT right and surgery we don't even have RCT is fueling most of these things. Again, evidence based medicine in of itself isn't a bad thing but I feel like it does take away some of that aspect of having a relationship with your patient that you're able to know things I had a patient return to my clinic the other week with hydrodinitis now hydrodinitis there's not a lot of evidence based medicine. This patient had bad disease and I had started her on doxycycline because I was really the first person to diagnose her. And she presented a week early for her three month follow up with an abscess and called and you know can I get into the clinic right away.  And, you know, I, I, I miss that when I first met them and talk to them you know like, we, we obviously had a, we weren't on the same page and I think that happened so many times where we prescribe patients these things but we miss the other aspects of their life that are preventing them from actually being adherent with that medication. With that treatment. Yeah. And I don't think it's just empathy I think we do a bad job though, modeling how to help even distinguish between hurt and suffering and find out where a patient might be and what they might want what they might prefer right. Like, the, the teaching the hidden curriculum within medicine almost is just to get in and out of a room where they're suffering as quick as possible. And there are exceptions to that. There are doctors who do a very good job with was sitting with people who are suffering and figuring out ways to help them but there are a lot of times when there's a suffering patient on the floor the, the, the amount of time that the physicians actually spend in the room is less than the other patients they're caring for on the floor. People don't like to be, not all people like to be around suffering and so by, by not really providing any guidance or training as to how to think about this when you're a student or a trainee I feel like we're doing them a disservice. And I do not mean to imply in any ways that humility is the only virtue. I think that part of the constellation there I think all of those aspects of the constellations of virtues to think about our important traits for physicians and we're not trying to make us into round pegs. I appreciate that each of us will have our own character traits and will be stronger in some characteristics than others and that's part of which what makes us able to provide care to so many different people right like we don't want just one. In fact or one clone of one person running around and treating everybody I think there's something unique about the fact that we all have different character traits. Humility is one I think that we as physicians do a bad job at and in fact if anything, the training has been to be less humble to almost beat that out of people people who may come in with humility that's something that's almost by by the unintentional curriculum that that is happening is being forced out of people. And that's the reason I bring attention to that one because I think that's one where we could try and teach and make a true difference in the kind of the in product of residents but I don't by any means. I think that the only character trait that positions should have is humility I think there's a wide array of different characteristics that positions need to be able to treat the the wide array of characteristics that is within humanity. Yeah, Megan. So character cultivation and the path to flourishing is is a lifelong process so you can still cultivate later on in life but you're right. There is a certain age. I, I am not a psychologist so you know do not quote me on this but usually it's around the age of like 26 to 30 in which the character that you have becomes more firmly cemented, which is one of the reasons to to, you know, try and reach students where they've reached that age in which some of those character traits become not necessarily that you can't cause a change but you can't cause as large of a change they have formed their sense of identity. That might be delayed no one's ever studied it in physicians right there's a lot of things that's delayed about the process of going through medical education. And that's in terms of personal development and so maybe there's that opportunity for character development through residency as well, but it's going to become harder. And that's part of the reasons for creating a very intentional change of culture that's modeled from the leadership down, but that really takes being intentional about things because a lot of these things that we're talking about are not traditionally surgeons or physicians were awarded or recognized for, you know, there's not an award for humility that the University of Chicago awards to a physician every year. And so thinking about ways in which we can show to the younger generation that these are things that we actually value and do matter and matter more than just, you know, an email that says these are our, these are our core values, but one that we live out and show. But you know, one of the things when I went into surgery. People said that told me to my face I was too nice to be a surgeon, and I never understood why like why could you not have someone who is technically good and also technically and also has a good bedside manner. Like why do patients have to choose why should they have to choose. Why couldn't you be a nice person or a good person and also be a good technical surgeon. I don't think that we should make patients you know have to choose or compromise between having someone who is technically good and having someone who is a good person. But I those those stereotypes about different fields you know are still alive and wild today. decision making model. There's a decision making feel like I'm not yet at a point where I can actually exercise decision making. Whereas if the focus is on the focus, then even throughout the ones in decision making, even when we're not able to actually make this decision, we are able to listen to the exercise on the part. Yeah. When I have talked about this in an ideal world and I've talked to medical ethicists that are passionate about virtue ethics and teaching that I think the ideal way would be to introduce students to virtue ethics first. Because it gives them kind of an expanded view of what ethics can be, and then provide them the education and the teaching about principle ethic the principle based ethics, because if you teach principle based ethics first to medical students and almost narrows their ability to see what what the rest of ethics could be. And so I believe both are very important to be taught, but there is something to be said about teaching the character aspects first, and then providing them later on with the principle based framework to think through complex situations that they would be in. Thank you. Thank you.


Hi. In this video, we'll show you how to mock JMS using Spectmatic. Let's take the example of a consumer which makes a request to an application. The request is received by the controller, which in turn invokes the service layer. The service layer fetches data from a domain service or an HTTP dependency, and then drops a message on to a JMS queue, say something like ActiveMQ. Finally, the service layer responds back to the controller, which in turn responds back to the consumer. Now, to test this application in isolation, we take an async ABS specification, which describes the JMS queue, and the schema of the messages that it is expected to receive. And we mock it out using Spectmatic's JMS mock. With the JMS mock now in place, we can run contract tests against the application. Let's see how we do this. First, we set expectations on the JMS mock, describing the messages that it is expected to receive. Then, we also set expectations on Spectmatic's HTTP stub, which uses the open API specification for the application's HTTP dependency or the domain service. Now, if you wish to learn more about contract tests and how to stub out HTTP dependencies using open API specifications and Spectmatic, please check out other videos on this channel. Finally, Spectmatic uses the application's open API specification to run contract tests against it. Every contract test results in a request being sent to the application, which is received by the controller. The controller invokes the service layer, which in turn fetches the data now from Spectmatic's HTTP stub, and then drops a message onto Spectmatic's JMS mock. When the JMS mock receives a message, it validates the message against the schema defined in the Async API specification. If the message does not match the schema, then it will fail the test. The JMS mock has an in-memory active MQ broker, and so the service layer can communicate with it quite seamlessly just like it would with a real-time JMS queue in production. Finally, the service layer responds back to the controller, which in turn responds back to the contract test. When all contract tests are executed, Spectmatic calls the JMS mock to validate the messages that it has received. Now, let's see this in a concrete example. Over here, we have a service layer which fetches data from a domain service or an HTTP dependency, and then sends messages to a JMS queue. Let's take a look at the Spectmatic.json file of this application. Over here, we provide an Async API specification for the application's JMS dependency, and open API specification for the application's HTTP dependency or the domain service, and also an open API specification for the application itself, which Spectmatic will use to run contract tests. Since we are talking about JMS, let's have a look at the Async API specification. We've defined a queue name product queries, and this is the schema of the messages that it is expected to receive. Let's now take a look at the contract tests. In the contract tests, we first set the host and the port which Spectmatic will use to run contract tests against the application. Then we specify an endpoints API which Spectmatic will use to determine the routes exposed by this application. For this, we use the mappings endpoint provided by the Spring actuator library. Now, if you look at the controllers in this application, we can see that there are two routes defined over here. Spectmatic will use this information to generate a covered summary report, which we shall see shortly. Going back to the contract tests. Next, we create the JMS mock and set expectations on it. So what we are saying here is that we expect that a queue named product queries will receive three messages on it. Next, we create the HTTP stub, set expectations on it, start the application and run the tests. After all contract tests are executed, we check if the expectations set on the JMS mock are met. To do this, we call the verify expectations method. The verify expectations method will assert that the product queries queue received exactly three messages and all three messages match the schema defined in the specification. If either of these conditions are not met, the verify expectations method will report errors. With this background, let's try and run the contract tests. Great. So all contract tests have passed. Let's take a look at the covering summary report. As we saw before, there are two routes defined in the application. But since in the open APS specification of this application, there is only one route defined. Hence, we see only one route is reported with status covered, while the other one is reported with status missed. Let's now take a look at the API tests. So in this class, we have tests to validate each of the routes defined in the application. This is the test in which we expect messages on the JMS mock. So we start by setting expectations on the JMS mock, similar to what we saw in the contract test. So we expect three messages on the product queries queue. We then set expectations on the HTTP stub. We invoke the API or route. We validate the response. And then we assert if the expectations set on the JMS mock are met by calling the verify expectations method, similar to the way we did it in the contract test. We also further assert the actual message received by JMS mock by calling the object message received on channel method, as described here. With this background, let's try and run the API tests. Great. So all the API tests have passed as well. The JMS mock is wire compatible and can be controlled entirely from within the test. Hence, you can run this test locally or also as part of your continuous integration build to provide quick feedback early in the cycle.


What's going on everyone? Sam here with LaytonSportScarge, we've been 23 tops, Cosmic, Chrome, Baseball, Hobby, Six Box, Half Case Break, Number 14, Random Team Style. Look again at your random results, as always, you can find those on the website. Under the results, that as well as the link that's in chat. It's good luck everybody. Let's do it. Last half case of Cosmics tonight. Got some mixers coming up, a full case after, and then we're into football. Four half cases of Prism Draft picks, a full case of Prism Draft, and then a full case of NT. Beatie Alvarez Alonso, Tyler Freeman, O'Neil Cruz, Brian Baio, Michael Harris, Adley Rushman, Chuck Nasty, Refractor, and Base. Peter Downs, O'Neil Cruz, Raffy Debra, Strician Consis, and Cody Billinger. And now let's see a Pluto, man. That'd be sweet. Nucleus, Austin Riley, Refractor, Trey Turner, and Joey Manessas. Yvonne Herrera, there's J-Rod, Teal Equinox, to $199 for the Mariners. Nice one there, Mariners. And Hobby Bias. Drop you guys a link really quick to our Prism Draft picks. Still $15 to go. $14 to go now. $14 to go. John picking up a spot. Thank you, John. Silvio picking up a spot in Bundesliga. $14 to go. I don't, I think we, like I sent emails to all the, all the people in the break last night. And I don't know what we're going to do with it yet, to be honest. I'm not sure. Juan Soto, if Ohapi, if we decide to random it, obviously they'll see it if they decide to sell or something. I'm not going to disclose anything, but for privacy stuff. But I don't know, I don't know. Josh Young, there's a Nolan Aronato, $2.99 for the Cardinals. Aloha, John. What's up, John? Mahalo. Good to see you, buddy, as always. $14 to go. Prism Draft picks, Whipple. Gunner, Rutschman, Whit and Green do a dice roll on these triples. One, two, left, three, four, middle, five, six, right. That is going to be a four. Going to go to the middle. We go to the middle with Bobby Whit and whatever team is in the middle on those. Launching to orbit, Miggy Scherzer. Launching to orbit, Stanton Stores. Wow. Nice, dude. Kade Cavalli, Kodai Sengu. Yeah, whereabouts? Hoskins Turner and Schwerber. Will Smith, Wander and Reese Hoskins. Jordan Walker, Jordan Walker, Paul Reagan. Hoskins Tino, Dominic Fletcher, Pablo Lopez. Yeah, Kyle will be live in about a half hour doing personals as well. Got a couple of orders in queue right now. Harris, Riley Acunha, the Braves. Green Space Dust Auto, Max Meyer. Going to the Marlins to 75. Grats on that. Who you like, West Palm. West Palm's nice. And a Morrell. Yeah, West Palm is pretty cool. Beautiful area. Really nice place there. A lot of money up there. To they, Aaron Judge and Nolan Gorman. Yeah, especially for a bartending job. That is going to be a great place for that. Oh yeah, even big things. Oh yeah, that's awesome. Well, good stuff, John. Glad you found something down here. How far are we from West Palm? A few hours. Two hours. Okay, not bad. A little over two hours. Peña Witt, J-Rock. Not Jazz. True Jazz does have autos in this, I believe. Ryan Bale. New start. Yeah, it's a nice one, man. Jordan Walker, Aaron Nolan, Goldie and Austin Riley. I mean, even last year it was fire, but this year it looks really good. Valdez and Ohapi. Yeah, definitely stop in, John. Absolutely. We're through us and we're pretty shipping. Trey Turner, Jordan Manassas. Yeah, that's also true. Bobby Witt, Trout and Otani and Bass. We got a lot of rain yesterday. We don't have any rain now though. It's not raining now. No, we got lucky, man. It went north of us. It did, yeah. Pablo Lopez for the Twins to 199. Seal Equinox. State out, way out west. Yeah. We got a Gold. Gold. Clayton Kershaw. It's a 50. Nice one there. Dodgers. Grats LA. New Darmish. Count Castle. Thomas Carroll. Moreno. Andres Jimenez. Yeah, Martian got called up. Happy about that, man. I can text my dad about that, actually. See if he saw that. I'm texting him. Tell him to come down here and kind of tighten you up. Not on texting him. I'll say Sean also told you to come down here and straighten me out.  Don't want to start losing. Starting to lose them, yeah. Let me slip away. Yeah, storm went north of us, Puka. Yeah. Michael Harris. There's Vladdy and base. I came home last night. There was a huge branch down. I was there. Shorber. Wrecked his huge car.   Yep. Rochman. Mookie Batson Nucleus. Altuve Alvarez. Bregman. That was the one thing I was super worried about. You have a treason right here? Yeah. Because it didn't ring a lot. Kodaisenga. What happened? True. And I was able to, what was good as too, I was able to get both of me and Heather's car into the garage. Well, there you go. So there's nothing to worry about. Yoshida, at least for my car, I'm a house, different story. But the house was fine, which was good. Jayrod, I have a giant branch just sitting in my backyard. I moved for like two months. That's just too late to do it. Rochman and Henderson, every time I have the lawn people come over, it's just like in a different spot because they're moving it to get around to it. Like, my bad. Tell them to take it. No, I know. Give them a couple bucks. Tell them to take it. Right. Don't do it. Yeah. Oh, yeah. 12 pack. Yeah, you guys take this thing out of here if I give you that. Chris and Romero. Nolan Gorman. They'll stop you. I'm shooing on it. Never seen dudes do more stuff for 12 pack. Jonathan with a spot in draft picks. We're down to 12. 12 to go, everybody. 12 to go.  We're almost there. 12 to go. And we're going to get the last one filled up. 20 to go on that one, I believe, still. Launcher to orbit. Peter Lanza. Dan B. Swanson. Harper, Judge Betts and McLean. See what he said. Just laughing about what he said. Nice pole snipe, by the way. Always like it, huh? Oh, yeah. Especially SNS Express. He's always very, very, very excited for that. There's Guerrero and Bachette. Brandon Lau. Randy Rosa. Raina Refractor. Make sure you troll them. Did I? Oh, yeah. Yoshida Kori Seeger from Bervaldas. P.D. and Zack Neto. There's Troll and O.C. too. Joey Vado. That's a pot lobby. Starling Marte. Channel 2 is a pot lobby. I'm one of those. What's up? All eight of them. We got an orange. Orange. Jordan Walker. Extra terrestrial talent to 25. That is 13 of 25. Going to the Cardinals. St. Louis is going to be... Shauna E. Congrats, Shauna. Very nice. Get that into a mag for you. Jay Woff there. Matthew Libertor. Adley Rochman. Stella Nova. Case hit. Going to the Orioles. What a back-to-back-packs right there. Baltimore. Albie C. There we go, Albie. Congrats, buddy. Pretty big hit there as well. Get that into a mag as well. Verdugo. Tourist. And 1-7-7-3. Good lord. Parazzo. Volpe. And base. Paul Goldschmidt. Nick Parato. Nucleus. Javi Baez. Cortez. Refractor. Niggie. The Sultan of Statistics. Timmy is, man. Price Hartford. Extra terrestrial talent. Timmy's got the pack odds on deck. So checklist. Riley Greene. Bogarts. Thatis. And Soto. Christian Walker. Correa. Michael Toglia. Til Equinox to $1.99. Fujinami. Seager and Josh Young. Francisco Alvarez. Green. Space Dust. Cal Raleigh to $75. Nice one there for the Mariners. Foam. Corbin Carroll. And Riley Greene. On the end there. Got Jason with a spot in three. Brian with a spot in three. Chris with a couple of Cosmic PYT spots. We're down to 11, everybody. Or no, we're down to 10. 10 to go on number three, guys. 10 to go. Let's get it filled up. 60 bucks a spot. 32 autos and 64 numbered cards or parallels. Up for grabs in those breaks. Also 64 silvers. Up for grabs in that. Four autos a box. Josh Young. Launched an orbit Bobby Witt. Dalton Varshow. Launched an orbit Aaron Judge. And a Corbin Carroll. Gunnar Henderson. Fernando Tatis. Alvarez, Haltuva, and Bregman. And Edward Julian. Good pack there. Buxton and McNeil. Mike Trout. Aaron Judge. What's your favorite team for it? Rushman. How do they do pick in? Friday. Although Friday. It's not Man City. No. Kodai Senga. Josh Hader. Or West Ham. Let's go Hammers. Pena Witt. J-Rod. Ronan Morse. Dalton Varshow. Shane Bieber. I just started watching Peacock like that. Behind the scenes one. The premiere show. And Seney. The premier show. The premier show. So I'm kind of like learning about everything. Instead of just watching all of that stuff. Right. That's actually probably a pretty good idea. To get to know the entire league, you know. I'll tell you a little bit about everybody. Carol Trotto-Tani. Right. That's kind of sweet. I think it's going to be multiple times. West Ham's. West Ham's. Please. The Sun. J-Rod. Third of the Sun. J-Rod. Nice one there. Congrats Mariners. Get this one into a mat. Congrats Seattle. That'll be going to Chris A. Congrats Chris. We got another orange. Another orange of Aswaldo Cabrera. Going to the Yankees. 12-25. Nice one there. Congrats New York. Randy Arosa-Ram. Ice card. Very nice card though. And last pack of box. Four here. Mervis. Thomas Carol Moreno. And a Dre Turner. So I got a picture. So I get the picture. AI perfected. I'll track the display info on the card. And also break your stat track. That's pretty cool honestly Timmy. Not a bad idea. Launching orbit bright star for Sean Murphy. William Domus. Peña Witt. J-Rod. Joey Vado. Kyle Raleigh. Javier Asad refractor rookie. Ruchman Gunner. Manoa. Wander. Yoshida Rookie. Blue. D.L. Hall to 99. Let's go. The second Ellie has been fulfilled and delivered. Francisco Vaughn. There was one Vaughn's best case. Was it just one case? We hit him both for you Vaughn. I pulled two Ellie redemptions for Vaughn. Thomas Carol Moreno. And he just got the second one today. Really? Yeah. Let's go. Congrats Vaughn. That's awesome dude. Mike Trout. Jorge Polanco. Tommanderson. Launching orbit Jordaan. JJ Blede. Beckman. Real Muto. Nucleus. Francisco Lindor. There's a Altuve Alvarez and Bregman. Nolan Jones Rookie. Matt Mervis. Drew Waters. Refractor Gary Cole. George Kirby. Oriole Sea of the Spots. Zachary of the Spot and Three. We are into the single digits everybody. We are at nine to go. Nine to go on the third case of prison, or third half case of prison draft everybody. O'Neill Cruz and Corey Lee. 18 to go on NT as well. Back to back boxes. Wow. Walker. Trout O'tani. Spencer Strider. Sod Benson. Max Meyer. Nice one there again for the Marlins to 199. Aqua Equinox. Here's some rookie. All right. Last box of the... Please, good luck everybody. And the break. Got to get divisions filled up. Also got to get NT PYT filled up. Teams are on sale. Beatty Alvarez Alonzo. Teams are all on sale on NT PYTs. PYT I should say. Rip Beatty Rookie. Meyer and Volpe Rookie. Oh geez. Gonna be a tornado warrant. We'll stay safe, Zach. There's Manny Machado, Josh Hader. Mike Trout. Where's that? Midwest somewhere, Zach? Gage Pavalli. Lamehu Refractor. Reed Detmerz. Michael Harris. Zigil Tovar. Gunner Henderson. Rafael Devers. Trishon Kossas. James Altman. Maruti. Michael Harris. Paguerro. Zigil Tovar. Rookie for the Rockies. Aqua Equinox. And Trishon Kossas. 199 on that one. Oh, North Carolina. Got you. Blue. Ryan Nelson. Rookie. 299 for the Diamondbacks. Max Freed. Adley Rochman. Rochman Whit Green. Volpe Cabrera. Launcher Orbit. Jordan Walker. Luis Garcia. Jordon Glaber. Hoskins Turner-Schwerber. Christian Yellich. And launcher Orbit Frank Thomas. Miguel Vargas. Josh Chisel. Bogarts. Nuclear Asterisk McKenzie. Sampondair. Jordan Walker. Shohei. Extra Threshold Rural Talent. Three packs to go on the break here. Everybody, good luck. Black Eclipse coming up here. Of Miguel Vargas. 5 of 10 on the Rookie Auto for the Dodgers. Congrats, Marcus. There you go, buddy. Nice one there. The 10, Ronald Acunha. Yeah, might as well. That one, it'll be fine. I don't think it'll be anything to shipping. Paris Riley Acunha. Mike Yaz. And last pack here. Yoshida Deal Hall. It won Soto and Chai France. Okay, start off with our numbered cards. We had Ryan Nelson. These are all the 99. Deal Hall. Nolan Aronato. Green Space Dust to 75. Cal Raleigh. Gold. Clayton Kershaw to 50. Orange as Waldo Cabrera. Rookie to 25. We had Autos of Max Meyer to 75. Magged Cards. We had Miguel Vargas to 10. Black Eclipse Auto. The Sun. J-Rod. Adley Rochman. Stella Nova case hit. And Extra Threshold Rural Talent of Jordan Walker. I'm doing Orange to 25. That'll do it for the break, guys. Thanks again for the pill. Up next is the first mixer.


for his life is there any more interruptions by the public I shall order the courtroom clear. Prosecutor will continue his course examination of the defendant. How much can how much did you earn last year you mean from my machine from all sources about thirty six hundred and with this thirty six hundred dollars you have to support yourself your mother and buy equipment for the shop that's right but you're ambitious. I don't understand you're an inventor aren't you didn't you invent this super charge blowtorch marked exhibit B yes and isn't this blowtorch more powerful than any other similar piece of equipment on the market today yes but I've already told you this is the country has a commercial value then definitely is it patented no but I've already please answer the questions did you intend to patent it yes until all this and was it your intention to lease your patent to a manufacturing concern or to build these torches yourself myself I see thank you now Mr camp what would it cost to patent your invention about a thousand dollars they told me and to equip your shop to produce it commercially about about five thousand dollars yes somewhere around so you stole the five thousand dollars from the courts of professor Adrian I will rephrase the question this was that professor Sykes withdrew from his account five thousand dollars on the day he met you for the first time your bank account shows the corresponding deposit is that correct I guess so now Mr camp how would you a mechanic earning thirty six hundred dollars a year obtain such a large sum of money from professor Sykes but I've thrown him dead body after you killed him at the first occasion we'll avoid are you to show remarks with the court's permission now Mr camp are you testified that professor Sykes gave you five thousand dollars as a fee for services to be performed by you and your blowtorch now I asked you and ladies and gentlemen of the jury is it credible that a man like professor Sykes a timid archaeologist would give you a total stranger his entire life savings to accompany him on a mission I can only describe as fantastic I know it sounds fantastic contends that it is the state contends that you deliberately invented this story of non-existent caves and incredible machines to cover up a sordid case of murder for profit the case ladies and gentlemen unusual only for the horrible manner in which the crime was no I didn't kill the testimony of the witness in the case for the prosecution and defense I must point out to you that the case for the state rest solely on what you take the stand we might have done better with a temporary insanity defense don't you believe me either anyway I did the best I could but you don't believe me sounds so fantastic but it's true everything I told you was true I've told them everything I know please judge the jury but what's the use I know what it's going to be guilty and then I'll go back take it easy take it easy your task is to determine the truth on the basis of the facts presented in evidence if there exists any reasonable doubt in your minds you must in all conscience acquit the defendant the jury will now retire and consider its verdict the court is recessed nothing to do now you know I know never tell the jury gets back funny thing about you I remember a case once you'd have sworn I'd lost it and the jury had to leave me alone not guilty they said oh you could have knocked me over with a feather and I found out later that the the foreman of the let me alone don't get sore the foreman had twins that morning and he was 63 years old let me alone that's our aliens hikes I'm an archaeologist maybe you heard of me no I don't think I have no man you will before long everyone will miss the camp I've come a very long way to see I must talk to you look you can't wait till morning I'm pretty tired no it can't wait the world has been waiting long enough you see I I found the key to the past so you have look how why don't you come back tomorrow and you can tell me all about it think I'm insane don't you maybe this this would change your mind engage wire so what try to cut it give us what do you know about my torch I heard about it from a colleague at the University that's what brought me here look just what do you want I need your talks well it's not for sale now if you'll excuse me I don't want to buy it I want you to help me to open a metal another one of those where's your door professors at the first National Bank report not listen to me do you know what it means to spend your life digging into the past and getting nowhere pottery or relics dust nothing up to you yourself get part of that dust while others with less talent but the money and influence make discoveries that startle the world the tomb of king tooth and king the Rosetta store discoveries that make them famous you who have always stood in the shadows of these men on the brink of making the greatest discovery of them all that's very interesting but what can I do about everything with your torch you can open the door to my cave to your cave I found it by accident years ago inside this cave is a machine you've never seen such a machine what makes this one so different this machine has been recording on a wire every physical disterm that has taken the face of the earth for the past million years oh now really every song every every title wave it's all there on this wire this is a piece of it it took me months of work to get it sure I suppose about a million years ago some eight invented this contraption and then stuck it in the cave huh very smart monkey when I look really I've got to get to bed I've got to get up early in the morning wait perhaps this this would change your mind there's five thousand dollars there that's all I have it's yours if you will open that door five thousand I could buy machinery and start producing the torch myself yes you could okay professor you got yourself a deal when do we start right there's no time to lose tonight camp I waited for this for years I can't wait any longer okay I'll be back in a minute where you're going I'm just going to tell my no you must tell no one no be very near look professor we we drove all night to get here and we've been combing this area for hours and I'm hot and I'm tired and I'm hungry and there's no door around here must be it must be look professor I've been thinking how did you get into that cave the first time if it's sealed by a door it was open when I found it the first time when I turned the second time it was closed sealed tight who knows perhaps I was getting too close to the answer yeah perhaps but I don't understand that it it must be around I can't seem to find or maybe I can't find it because it doesn't exist now look here I paid you all the money in the world instead of grumbling please let's try to solve this problem okay professor you start figuring you must be near the cave you must be why I worked in this part of the country for years somehow it's changed it's it's different perhaps there have been some landslides there seem to be more rocks and less vegetation what time have you got 11 to my watch stuff so as mine at 1115 it's past noon that's funny why should both our watches stop at the same moment perhaps a magnetic field look at your house holy smoke look at it that's it that machine must create a magnetic field around it we must be very near come on okay it's real danger in the sands yes danger to your watch in fact what with hot weather activities and sticky temperatures and perspiration summertime is the worst time for your watch but it can be a good time and here's how take your watch to a reliable jeweler let him check up and dress up your watch let him show you how wonderful your watch can look your watch will be rejuvenated on the inside and at the same time it will be restyled on the outside when your old band is replaced by a new christler watch band and your most personal possession your watch can be personalized too with the your signal expansion watch band by christler the only watch band that's initial just for you yes your signal features your initials right in the design no other band is so completely personal so exclusively yours but be sure to ask for your signet by christler the band that makes your watch look better than you and for the ladies there's an exquisite feminine version of the your signal watch band with your personal monogram best of all these exclusive christler bands cost no more than many bands without initials only 995 for the ladies and for men only 1195 so check up and dress up your watch when your jeweler makes your watch run like new have him make it look like new with your signet by christler to your tales of tomorrow verdict from space start here but there should be a locking mechanism of some sort the church hasn't even made a dent in it yet listen professor do you hear it yes something has happened something is happening inside the door it's a heat block that's what it is a heat block but we don't even need the church to cut the door the heat alone will open that machine i've never come across anything like this this part of the machine is the record the wire running between these two spools records every physical disturbance on the earth look this mark indicates a volcanic explosion somewhere the date is the destruction of pump pay me this indentation is a minor tremor on the floor of the pacific ocean the date is the date of the san francisco earthquake it took me many years to learn what those marks meant what's this crimson this is the first mark of its kind on the wire the date was July 16th 1945 July 16 the day the first day bomb was exploded at alamogordo right and here is the second crimson euro shema who could make a machine like this a million years ago who i don't know but before i'm sure i'll find out and history will be breaking from the day i speak professor what does this part do over here i haven't gotten around to that one yet wait this isn't just another part of the this is something different it looks like like it's a transmitter but sure and this must be the antenna no it couldn't be transmitted maybe whenever this machine here was waiting until something important happened so we've got to we've got to get the army intelligence right away oh no no i tell you this machine is harmless it's been here before that real army or before there were cities or civilizations look i've listened to this rock long enough to come on we've got to get out of here so boy it's recording something right now another appointment you'll be okay if we can just get you to a doctor uh even if they don't believe you you must tell them that covered all this where it was they've reached their verdict they're coming back in and face the jury ladies and gentlemen of the jury have you reached a verdict we have your honor what is your verdict we find the defendant garden camp guilty of murder in the first degree on the basis of the facts presented in this courtroom i feel that the jury has arrived at the only possible verdict i wish to thank the jury for the fine services it has rendered to the state garden camp you've heard the verdict arrived at by a jury of your peers in open trial have you anything to say an explanation or an extension before sentences passed upon you i didn't kill professor sikes i'm not guilty i've told you that again and again you had your chance but you wouldn't listen i tried to explain what that crimp and the wire meant the day the professor and i were in the cave that wire recorded the first h bomb explosion i i didn't believe what professor sikes told me but now i know somewhere in this universe someone has been watching us for a million years waiting until until we had the secret information when we could power a super atomic type torch the deadliest enemy that we have ever had to face is out there in space ready to destroy us now that we have the h bomb right coming home mr camp who received this information i i don't know or to your wives or to your children i've tried to tell you everything i know about it everything that professor sikes told me was true they're coming i don't know when they're coming but they're coming somehow they have found i don't know when they're coming but they're coming and when they do maybe you're delivered from space and now let us leave tales of tomorrow and consider something that is very important for you today she's heading for trouble yes trouble for her watch what with playing and hot muggy weather and perspiration summertime is the worst time for your watch but it can be a good time and here's how take your watch to a reliable jeweler let him check up and dress up your watch let him show you how wonderful your watch can't look your watch will be rejuvenated on the inside and beautified on the outside when your old band is replaced by a new chrysler watch band ask your jeweler to show you the elegan today's greatest value in ladies expansion watch bands imagine elegan cost only 495 yes only 495 notice it's simple classic beauty that's always in fashion elegan goes with all your clothes and chrysler's elegan watch band is as light as a feather so delicate you can scarcely feel it on your wrist notice the convenient telescopic expansion that quickly allows you to slip your watch up out of the way for household tasks and the chrysler elegan carries the same guarantee as bands costing many times more no other telescope expansion band at so low a price is made to wear so well and last so long yes it's all yours for the unbelievably low price of 495 so check up and dress up your watch when your jeweler makes your watch run like new have you make it look like new with elegan by chrysler jack chrysler jack chrysler on my hand on your hand initial just for me and so it's my band it's your band it's chrysler it's chrysler for me too for you too makes your watch look better than you quality style and value too is chrysler make sure watch look better than you makes it personal just for you it's chrysler tomorrow show is called to us all listen next week to tell you the preceding program originally telecast by abc in new york has come to you by special video recording this is abc the american broadcasting company piece of the sound of marching feet continues in europe refugees millions of them displaced wandering aimlessly across the war-torn face of europe seeking only food to keep alive any shelter amongst ruins in which to sleep anything to clothe little bodies today 12 millions are displaced in europe alone some ethnical germans forced to return to a country they never knew because of the shuffling of boundaries joining the two million germans already unemployed each day nearly 2000 migrate into western germany underfed diseased undermined for some the displaced persons camps provide temporary relief but for the core of the unplaceables the aged and sick whom no one wants there is no hope in europe their hope must come from you to help in this cause the nonprofit organization care asks you to send packages today write care new york or contact your local care office today tales of tomorrow presents blunder starring robert allen ladies and gentlemen this is the earth just as it might look if you were standing on the planet venus instead of being here in this planetary earth being 25 meg in miles from venus our planet would not look much bigger than a giant and even at that there wouldn't be many days on venus when you the atmosphere would let you see as much of it as this now we have had so many questions about what might happen if an atomic explosion got out of hand or if a comet came swinging our way and made a collision that we have made an arrangement to let you see how it might look from out in space of course you must understand this isn't anything that's going to happen the interesting thing is that it wouldn't look like much at all even if it did happen just some light flaring up like this and perhaps going on that way for a few million years or maybe just scattering off into gas in no time at all the mathematical odds against a comet or a wild star swinging into the earth's orbit are enormous and of course there isn't any human being foolish enough to touch off anything that might get all the way out of control even with the a-bomb and the h-bomb no scientists believe that the end of the world when it comes will be a natural one not man-made and it will not come for a matter of some 15 billion years so i suppose we can all just sit back and relax i'm just getting things ready you see the activator doesn't work until the switch is now i told you the experiment wouldn't start on nine and it won't his last few minutes call he seemed to take longer than all the years you put on this experiment well at nine o'clock we'll know the answer after the activator starts the business reaction reaction but call you can't go through with it not until i'm not backing out now i've told you there isn't one chance in a hundred of any trouble one chance in a hundred i'll call it one chance in a thousand i've gone through these calculations over and over and the answer is always the same bismuth vision is possible pile we've built up down on the mine is going to start off a slow controlled reaction not an explosion but you sent down in the other to tronso call wasn't that because of the danger their work here was over jane now after the reaction starts then's when our work starts the making of contracts hiring a full workforce getting in the lines to get the power out now we'll have a natural furnace a mile square hundreds of yards deep a whole lot of ocean to draw on to supply power for all of scandinavia ever some dunning and company's going to be big business jane very big business i didn't have to make any contracts in tronso call but you wanted to send me away too well we're stuck out here in the wilderness darling why should a man ask his wife to stay here when call why should you ask me to stay here when i never could fool you could i you're not sure are you car now don't try to fool me you're worried too well maybe there is one chance in a hundred of trouble i don't suppose at any point in that facing up to it now well then you do admit that this could go wrong call that this particular way could be more dangerous than all they've done with uranium and all the other elements yes there is a remote possibility that by splitting the bismuth atom we might touch off oxygen touch off oxygen oh no wait a minute jane i just said there was a remote possibility theoretically the sun could explode tomorrow but it isn't likely this is the same but oxygen is everywhere it's in the air it's in it's in water my car the whole world could become a gigantic atom bomb that's right well then then shouldn't you be reading more data call i mean you always used to check in and recheck your information and it's time you haven't even paid any attention call there were reports from dunning and the others and and you haven't even read them why if more chemo tager gives up on this one might in the danger be the very reason i don't know that anybody's given up there things that have published a months years behind events and i could read myself blind and not be one millimeter further ahead than i am tonight and what's the point of reading anything when it's so heavily censored oh look jane this dinner was supposed to be a party wasn't it oh i'll listen to me you and dunning have been working here in secret but outside the secret stage is over jane my final report is probably already been published or taken stack hold most likely already seen it now if they want me to hold up the the experiment jane it's too late there's a time for study and a time for action we've come to the time for action sir this is carl what is it carl are you still holding to the schedule all set it goes off at nine the thing is someone's been trying to get through on the phone from london i'm not sure it's a part i can't take any messages an hour here this is important carl i'll get in touch with you when it's over i'll be busy till then so don't gotta call me back look here i told you no more talk till it's over but it's a call from london carl i'm coming out all the way now so you've been just wasting your time if you're trying to get me back here's to the fission of an element they said could never be split why hello you come here no there isn't time have you read the zuri quarterly yet it's ever since he's experimenting with that business fission theory of his yes i know i know it'll set off an oxygen reaction we know it but ever since doesn't how far has he gone i don't know i've been trying to get done in on the telephone all day i can't get through and well what shall we do i've charted a plane we've got exactly 10 minutes to get to the airport wait let me get my coat good i'll get a cab the cabbie cabbie here in the old stories elena the princess always kissed the one who was sleeping grandfather i didn't mean to wake you i was just leaving the afternoon me oh i'm wrong it was always the princess who was kissing the famous doctor or is never wrong there and if that makes you a sleeping beauty don't play me my age elena names mean little kisses mean much so whenever you see me dozing this cable came with the man yes it came about a half an hour ago i was wondering whether i should wake you and then i thought is it bad news grandfather grandfather the cable is it bad news it's from stepple in london he has seen a new report by everson uh elena the syric review with my article on pismuth the issue should have been in stock all meant us low for almost a week now no you've asked me that before it's been out there since the 12th if everson has seen my article he can't be so insane as to go ahead it wasn't warning to everson that i wrote the article got the material declassified exactly for him to see he must have seen it by now he always reads everything that you yes everson always used to read everything in this field but he has been cut off from all of us up there for years crumbs from our table that's all he has been able to get his hands on but this time crumbs aren't enough he has made a mistake grandfather is it a bad one he's going through with his mind project the one i wrote this syric article to warn him against when will they learn that censorship works both ways you mean he might start off a chain reaction that couldn't be stopped there are no absolutes it might stop when when the earth was gone and the oxygen was gone the earth and all live on it would go to of course you said this is what might happen by my equations the


What's going on, everyone? Sam here with late in sports cards, doing a quick football mixer for Travis U. We've got gold standard 2022, a 2022 Panini elements football and a 2022 iMac collegiate. Let's go ahead and do this. What do you think should go first here? What would you do first? Elements? Elements, GS, iMac? Yes, let's do elements. Here we go. Good luck here, killer Trav. That's Travis, so just that's Travis Kelsie's Instagram handle and I think Travis U, I think that's where your new nickname is gonna be, killer Trav. Najee Harris, that is 119 out of 199. Then we've got Xenon, Jonathan Taylor. That is a purple, 16 out of 54. Haha, Travis likes it, perfect. We've got nice, Fusion Lamar Jackson. 116 out of 199, Ravens. Jealous of this car, Trav. We've got 13 out of 25, it's DJ Moore. On the, that auto there for ya. And a nice one here. We've got RPS steel signatures, Hassan Haskins. Nine out of 79 for the Titans. Very cool. Grats on that one, Travis. Hassan Haskins, I love the silver ink on those, man. They're so clean. Two gold standard next. It took a few minutes, AC for sure. You can see me going through the next box and I was like, I couldn't hold anything in my left hand. Like I had to have both hands on it. My right was fine, but like passing it, I kept it really low, so if I dropped it, it's just nothing happened.  Dude, I was, I could not stop either. Like it was uncontrolled. We've got Darius Leonard, that is six out of 30. And Michael Thomas Slintman, 58 out of 75. We've got, gold plated is, Cam Acres 206 out of 299 for the Rams. Next behind that, we've got, this is cool. How about Devin White on the White Gold? Love it, man. That's a 68 out of 299 for the Bucks. We've got, behind that is going to be Dak Prescott on the Goldgear 25 out of 199. Yeah, this guy's having trouble. People say they want like a top-order camera. No, you don't. Nice one there. We've got, that is Christian Watson, Golden Bay Views 24 out of 25. Little bit of a short print rookie set there. That's cool. See what he's doing over here right now. Nice one there. And then we've got, nice 49 out of 149. Triple rookie Jersey Autos can be Kenneth Walker. For the Seahawks. He's pretty much number one back there. I mean, yeah, Rashad Penney's done for the year. So, Kenneth Walker, love it. That's more snakebid with injuries than Rashad Penney. No, I feel really bad for the guy. Cause when he's healthy, he's good. Like he's shown, I mean, not this week, but the week before he had like 31 fantasy points for me or something. He went like 170 on the ground or something crazy. And two touchdowns, he killed it. All right, here we go, Travis. Come on, baby. See something big. At least happy one of them. That's what I'm thinking. We've got Kyler Murray. That is 57 out of 99. Cardinals. We've got signature moves. That is one out of 10 of Brock Purdy. He is a 49er.  Nice, there you go, Travis. Like the Christian Watson. Love it, man. I kid you not, Travis. This year I pull Christian Watson in every break of 2022. It's like uncanny how much Christian Watson. Then I'll pull like two Christian Watsons in one break. We've got going, this is a Raven right here. 29 out of 49 is David Ajabo. He's gonna be a stodd when he's healthy. Consensus, like top 15 pick, Torres Akiles in the combine went second round to us. High hopes for him. We've got, how about some Jack Cone, 24 out of 49. Signature moves, auto. Noted in. We've got, this time nine out of 25 is gonna be Hassan Haskins. Second one of the mixer for ya. Ooh, nice one here. We've got three colored RPA, one out of 49, Garrett Wilson. There you go, congrats on that one. Travis loves some Garrett Wilson. There you go. Empty, empty. That'll do for your break there, Travis. Congrats on the hits man. Thanks as always for jumping in. We'll get him right out, see ya.