Ladies and gentlemen, today is the last professionalism seminar of the winter quarter, and we will start again with Richard Epstein from the Law School on March 28, the first Wednesday of the new quarter, and Richard will give a provocative talk on deprofessionalization of medicine. Who would have imagined anything else? But today, today we're delighted to welcome the newest endowed professor at the University of Chicago, Peter Angelos, who on Monday was officially appointed the Linda Kohler Anderson Professor of Surgery and Surgical Ethics by Dean Polanski. Peter, as you know, is a distinguished endocrine surgeon who belongs to all of the right endocrine societies and surgical societies. I think, I think he, he told me, I'm a good surgeon too. Yes. Today, today, for example, he, he and Karen were working on an extra adrenal pheochromocytoma, which I, Karen was really impressed. I remembered extra adrenal goes to the organ of Zuckerkandel. Did I get that one right yet? And, and, and that, that's one of those moments when both Karen and, and Peter said, you don't want it to get exciting. That is, you don't want the blood pressures to spike, but, but they often do anyway when you touch the tumor. And Peter is also regarded as the national leader in this new field of surgical ethics, a member of the American College of Surgeons Ethics Committee, the chair of the American Surgical Oncology Groups Ethics Committee, and, and other groups. Peter also, some of you may know, won the Peer Recognition Award this year. Shalini, what's, what's a, what's a fancy title for the, oh dear, I know, if you won the Peer Recognition Award. I apologize. It always happens to me at the restaurant, the waiter says, is everything okay? Everything is okay. The Peer Role Model Award, selected by all of the faculty at, at the medical center. And that's a great honor. Today, Peter is going to talk to us about living and teaching professionalism, a surgeon's perspective. Peter. Mark, thank you all very much. It's a, it's a pleasure, of course, to be here. And for some of you who may have heard me speak several times in the last couple of weeks, I apologize. And I have a disclosure to make, and because you know when you start every academic talk, you have to give the appropriate disclosures. So my disclosure is that Mark actually asked me for the title for this talk way back when he was printing this nice brochure. And I had absolutely no clue what I was going to talk about. And so I was trying to come up with a good generic title that would fit in the series. And I thought I came up with a pretty good one. So that's my title. Unfortunately, that is not my talk. So, so my talk is actually technology and innovation in surgery. Are we honest with our patients? And I will try to explain to you why I think that this is a very relevant talk for professionalism. But anyway, it's not as advertised. So, so of course, in during the course of this series, those of you who have been here have heard multiple people talk about lots of different ways to look at professionalism and define it and all sorts of things. And so for those of you who may have missed one or two of the talks, I'm going to just mention from Merriam-Webster's Collegiate Dictionary, the definition of professionalism is the conduct aims and qualities that characterize or mark a profession or a professional person. Now in terms of a sort of providing a goal to shoot for, it seemed to me that that's pretty bland, pretty dry, and not very helpful. And so, and I do think about professionalism very much in an aspirational manner as something that we should aim for, acting as professionals, etc. So let me give you a different, well, before I do that, of course, you know, I reviewed some of the literature. So, so in the last few years, lots of great books on professionalism in medicine. This is the one Richard and Sylvia Cruz who were here earlier, David Stern, talking about measuring medical professionalism. I'm sorry, Karen, would you mind answering that? And just say, I think the answer is yes to that question. It was just a calcium level, it's okay. So there have been many, many recent attempts at defining professionalism and books written about it. And so in an effort to kind of start with a baseline, I looked, of course, to the most essential definitions of professionalism, which are in the surgical literature. And this, in fact, unfortunately Karen just stepped out. And this is from the Canadian Journal of Surgery, no less. The basics of professionals, I would say, are nicely put forward here in return for professional autonomy, self-regulation, and a recognition of their unique place in society, the public demands of physicians, accountability, ethical standards, and an altruistic manner of delivering care. So I thought that that was very nicely put. The things I really would like you to just, in particular notice, the concepts of self-regulation, altruism, and ethical standards. And so for Karen, it's from the Canadian Journal of Surgery. So I think that this is going to be kind of my starting point. And I want to just mention a little bit about innovation in surgery. Again, some of you have heard me talk about this in the past. I think it's a really important issue for surgery and how surgeons interact with their patients. I want to talk a little bit about the lore of innovation as well as this issue of assessing innovation and how do we know if innovation results in something that's good for patients. And because I'm an endocrine surgeon, I'm going to use the example of thyroid surgery. I'm going to use this as a concrete example of what I believe is the importance of professionalism because I like the theoretical discussions. They are a lot of fun. But for me, it has to have some relevance in how we take care of patients. And I think there is a direct correlation. So in terms of technology and innovation in surgery, there's no question that innovation may lead to new technology. And similarly, new technology can be used in different innovative ways by surgeons. Frequently innovation is just having a different idea, thinking about a different way of doing things. There's another issue which is how do we disseminate the new techniques or a new approach outside of the center where it was developed. That's a whole other issue in surgery which I think is an important ethical issue, but we won't be talking about that today. So I would argue that innovation is absolutely critical to the success of surgery. And much of that innovation occurs by people trying things out. And just to give you a sense of sort of this notion that innovation is important, let me ask you to consider what it would be like going into an operating room in perhaps 1950 for colisosectomy, removal of a gallbladder. Now I wasn't in practice in 1950, but it would look something like this. This is a historical photo and I'll just point out a couple of things for you. First of all, I think it's important to note that everyone in the OR that we see here is a man. I want you to notice the gowns, they're all cloth gowns, cloth masks, cloth hats. Notice the lighting. Now we don't really see, I'm guessing that this guy is the anesthesiologist because he doesn't have gloves on. That's what I'm guessing. And what you'll notice though is that there aren't a lot of monitors up there. I'm sure he's watching the patient breathing. But we've got the lights, just sort of notice the instruments. Everybody's focused on the patient. Now this is a representative of a laparoscopic colisosectomy today. Lots of differences, okay? First of all, it looks like the primary surgeon is a woman. That's an important thing, an important difference. The anesthesiologist, interesting. Everyone is actually looking at the monitor, including the anesthesiologist. Now I'm not sure what that says other than he's paying close attention to the field, which is important. But it is interesting now that this is a laparoscopic operation. So our instruments are very different. They're completely different from the instruments you saw before. And nobody's actually looking at the patient. They're all looking at the image because that's how we operate laparoscopically. Again, so a very big change. In the background here, you can see the monitors. They're very different that the anesthesiologists are using. So I would say there's a lot of new technology. There's a lot of differences. And I would say these have been good. These are better now for patients in this context. Now, not only though, is innovation good for patients, but it's really great for surgeons. There's no question that innovation is great for marketing. It really sells. Everything you'll notice is new and improved. Because it's not enough to be just improved, it has to be new and improved. Interestingly enough, there's a tremendous value for all hospitals being innovative, but especially for surgery. Surgeons want to be innovative. And I would say, if you look, I did some high-level research. So I went to our website, the University of Chicago, which is of course at the forefront of medicine, very innovative there. And I looked up our departmental website. I'm quoting, the University of Surgeon is one of the most innovative, multifaceted surgery departments in the nation, featuring leading edge, whatever. But we're innovative, we're leading edge, we're right out in front. And that is, I would say, that's a good thing. That's where we want to be, but it's also great for marketing. And I think we can't overestimate the power of the words that we use and how it has implications for patients. Innovation is assumed to be good. And there's no question that if you ask patients, well, you can have your operation at this hospital where they do the tried and true, or you can go have it at the hospital where they use innovative techniques, patients will say, well, of course I want the innovative techniques. In addition, so they want the innovative surgeons. Now what does surgeons want? Well, surgeons also want the latest technology. They want to be doing cutting-edge stuff. And that's one of the reasons why we have things that work, but we want something a little better. And it's not just surgeons. Actually, I would say all of America is so focused on this. Why is the new iPad selling out? Doesn't everyone have an old one? Why is it that you need an iPhone that you can talk to? Why does that seem so valuable to us? Well, it's new, and it's different. It's kind of exciting. And I would say there's something along the same lines in how patients and surgeons interact. There's no question everybody wants this latest and greatest, and that's what I've pointed out. Now, I would say, though, it remains difficult to know when an innovation is actually an improvement for patients. And the reason is that how we think about progress in surgery, I would argue, has changed. So let me tell you the traditional criteria of surgical progress. And this is defined by reductions in morbidity and mortality. Morbidity and mortality goes down. We say that's good for patients. Everybody's happy. These are things that can be objectively determined. We can gather data on it. We can have P values in tables, and we can present papers on it. It's very scientific. We can measure it. And that's an important thing, to objectively define improvement. Let me just give you a case as an example. And some of you have heard this case recently, so I apologize. Again, I don't only have so many original thoughts, and in a few short weeks, I can't do that much. But anyway, so here's the case. This is in June, let's assume. June 1972, a 70-year-old woman came to the emergency room of Champlain Valley Hospital in Plattsburgh, New York. Now, you may say to yourself, why would anyone go to Champlain Valley Hospital in Plattsburgh, New York? Well, that's where my father was a general surgeon. So my father would have seen a patient like this. So if she came in after a week of intermittent recurrent left lower quadrant pain, fevers, and an elevated white blood cell count, she would be managed in a particular way. Now, I just want to remind you, this is 40 years ago, in case you're having trouble with the math. It's a long time ago. So once a diagnosis of a diverticular abscess was made, the surgeon would recommend a three-step procedure for treatment. And again, many of you may not be familiar with how we used to do this. And again, I'm saying we. I wasn't practicing surgery then, but I know. I read the books. Open the abdomen, establish a diagnosis, and perform a diverting colostom over a rod. That was step one. Step two, after antibiotics and a bowel prep, we would resect the diseased bowel and do a primary anastomosis. This is second operation. Second operation. Right. Yes, good point. So far, two operations. But the patient still has a colostomy. So then the third operation was close the colostomy. So three operations. This was very safe. People did very well. This was considered standard of care. Nobody said, oh, gosh, why did you put patients through with three operations? Said, this is how we do it, and patients do well. And patients will go back to their surgeons to say, thank you so much, you saved my life. What do we do today? Well, if I'm on call, patient comes into the emergency room with a diverticular abscess. First of all, they're kind of unlucky, because I'm on call. And I'm an endocrine surgeon, but that's OK. So let's assume a diagnosis of diverticular abscess is made. What do we do? Well, we do percutaneous drainage. We call the radiologists. We do a nonoperative management. Things cool down. We treat the patient. Everything's good. And then we do an elective colomor section with a primary anestimosis. One operation. Now, I would say most everybody would agree this is good for patients. There's been a significant reduction of morbidity and mortality. And I would argue that this is an improvement in patient care that occurred as a result of a series of innovations. It wasn't any new device. It wasn't any new technology. This was just surgeons trying something out, doing something differently. And over time, we've significantly changed how we manage things. So I would argue this is a situation in which innovation is clearly good for patients. Now, unfortunately, if you look at the history of surgery, not all innovations have actually been good. And so let me just give you a few examples of those that aren't so good. So transplanting goat testicles into humans. Again, some of you aren't familiar with this. I would recommend the book, Charlotton by Pope Brock. It explains the doctor in Missouri, who around the turn of the century decided that he could treat impotence by transplanting goat testicles into men now. And then he realized, you didn't actually need the whole testicle, just a piece of a testicle. And it didn't actually work just for impotence, but it worked for aging and being tired. And then it expanded. Women were getting it. And this guy was actually the busiest, most the richest surgeon in America. Now, in case you're wondering, how is it that we don't do this anymore? Right? But the reason is it doesn't work. So that's the problem. So this was something that thousands and thousands of patients had this surgical procedure done, but it doesn't work. So some other examples. Gallstone lithotripsy. Now, this may have completely passed you guys by. But when I was a surgical resident, this was the rage, gallstone lithotripsy. And some of my colleagues spent two years in the basic science lab working on gallstone lithotripsy. And this actually, this is from about 1992. And this is the latest device. We actually, I was a resident Northwestern. We got one of these really expensive German devices. And they renovated a whole room for it. And my friends, the residents who were in the lab, were so excited. We got the greatest lithotripsy device. Now, again, how come we don't do this anymore? Well, it doesn't work. All the patients, you could break up the gallstones, but they all come back. Well, we figured out you can treat them with a medication, but they have to be on it for the rest of their lives. So that didn't seem so good. All of a sudden, laparoscopic colisosectomy came around, and people said, well, why would I want to be on medication for the rest of my life? Just take out my gallbladder and send me home the same day. So again, this was thought to be a great innovation. It didn't really pan out. One more, this is prefrontal lobotomy. So this was done in many, many patients for the treatment of schizophrenia, for the treatment of depression, lots of things, prefrontal lobotomy, very good. And lest you think, well, those were a bunch of quacks that didn't really know, the guy who came up with this was the co-winner of the Nobel Prize in Physiology and Medicine. So this was well-established. By around the early 1950s, 20,000 patients in the US had been treated this way. Now again, we don't do it anymore. Well, why not? Well, it doesn't really work. So the question then is, how do we decide if an innovation is actually in advance? How do we know if it's actually going to be good for patients?  But at the time, it's sometimes hard to say. So let me, again, talk about something that I know something about, because I don't know anything about colons. Well, a little, but not that much. But let me talk about thyroid surgery. So this is a famous portrait, the gross clinic by Eacons. It's in Philadelphia. And this surgeon here, now again, this is a long time ago. So a couple of things that are really interesting to note. We're in the operating theater, all right? And this is actually supposed to be a self-portrait of Eacons, just for those of you who are in art history buffs.  But the surgeon who's wielding the scalpel, no mask, no white coat, no gloves, this is the person delivering anesthesia, which in those days was a lot of what we call OK anesthesia, saying, OK, OK, OK, and holding the patient down. Now it's a little bit different from today. But anyway, so Eacons, I'm sorry, so gross, his portrait is so often seen in surgical textbooks because he was a very influential surgeon. And this is what he said about thyroid surgery. This is from his textbook in 1866. Thus, whether we view this operation in relation to the difficulties which must necessarily attend its execution or with reference to the severity of the subsequent inflammation needs is equally deserving of rebuke and condemnation. No honest and sensible surgeon, it seems to me, would ever engage in it. And then if you weren't really sure how he felt, he went on to say, can a gland, when in a state of enlargement, be removed with the reasonable hope of saving the patient's experience emphatically answers no if a surgeon should be so adventurous or foolhardy as to undertake the enterprise, I shall not envy him. Every stroke of the knife will be followed by a torrent of blood. And lucky will it be for him if his victim live long enough to enable him to finish his horrid butchery. Now, a couple things to reflect on. Certainly, we don't see this kind of writing in the surgical literature today. So if you pick up any surgical journal, you see p-values. We see a graph of slightly differences in outcomes. But we don't see this kind of writing. Well, why not? Partly, it's because things aren't this bad. Now, there are only a few of you in the room who have been in the operating with me in a thyroid ectomy. But it's not that bad. And we don't even use cell saver for thyroid ectomy. For those of you who are in surgery, you know that's a joke because we lose about a teaspoon of blood. So things have changed. Well, what changed? Well, I would say a few things changed. For one, Koker, this is a theater Koker. He was actually the first surgeon to win the Nobel Prize in surgery. And his techniques in thyroid surgery allowed the mortality of treatment for thyroid ectomy to drop from 12.8% in his first series down to 0.5% in later series. A huge reduction in mortality. And I would say by the 1920s, most principles of safe thyroid surgery had been well-established. And in recent decades, the discussions in the context of thyroid surgery have largely been about minimally invasive thyroid ectomy. And this has led to a number of innovative approaches to thyroid ectomy. So let me just give you a couple examples again. Yes? Just one quick question. Yes. Did the two overlap? Gross was in Europe. Koker was in Europe. Yeah, Koker was in Europe. Gross was here. I would say Gross was probably pretty much done his career by the time Koker was. But was he alive to see that? To see that? I don't know. Yeah, that I don't know. Great question. Yeah, great question. There's a book to be written about that. All right, someone make a note. So let me talk to you a little bit about minimally invasive thyroid surgery. And I'll just go over this quickly because this is great stuff for me. But I know it may not be for you. So I'll go through it rapidly. So there's different ways to handle the approaches of scars. So one way is to make the incision very, very small. And I'll show you a couple of different ways to do that. The other is to move the incision away from the neck. So it's not as easy to see. So even if you have a big incision, if you can't see it, not so bad. And I'll just mention all these very rapidly. So this was an endoscopic approach. And I apologize. It doesn't project very well. But this is from a Japanese article. The patient's head is up here, feet are down here. And there's a number of devices to lift the skin and the platysma. And then an incision is made here. And there's a grasper coming in here and an endoscope there. And so this was a way to do a thyroidectomy without an incision in the neck. And it's effective. Took a while. But I have to say, when I looked at this, I thought, lots of hardware kind of seemed like an orthopedic procedure. I didn't think I could do it. So now this was a different approach. So this was called the video-assisted approach. And this was by a professor, Mikali, in PISA. And so this approach is incisions in the same place. And we actually use scopes and long instruments. And we just do everything through a 2 and 1 half centimeter incision. And the benefit is you use a camera to see things that you couldn't see with the naked eye. And I think this is kind of a nice approach for select patients. But you still have a small incision in the neck. Now, what about moving incisions away from the neck? Well, a couple of ways to do that. This was an axillary approach. This was from Japan. And again, patients head here, feet are down here. And the idea was the patient's arm was placed above their head. So that shortens the distance between the axilla and the thyroid. And so this was done with scopes and long instruments and very effective. Took a while. Dr. Akeda, who's the person who came up with this, would do an excellent thyroidectomy in four hours, a lobectomy. That's kind of long for a lobectomy. This was yet another approach. So this was the idea of making the incision down near the xiphoid or in multiple places and tunneling up. And again, the idea is no incision in the neck. There are still incisions. And then people said, well, we'll put it all together. We'll do the breast approach and the axillary approach. And so this is the BABA bilateral axillobrest approach. And I have to say, so multiple incisions working here on the thyroid. And this can be done. It's very effective. So this is from a study, 103 endoscopic thyroid ectomies with 198 conventional thyroid ectomies, very similar outcomes. Patients were very happy with the cosmetic results. And I have to say, when I read this, and I thought, well, gosh, if I have a young woman who has a 1.5 centimeter thyroid nodule, and I say, I can make incisions in both your breasts and both your axilla and take out your thyroid, they're going to say, let me out of here. Where can I find another surgeon? And so this, I would say, has really not taken off at all in the US. Just really, I don't know anyone in the US that has done this. It's been done in the Far East, some in New Zealand, Australia. So well, then the Koreans came up with this idea. That actually has gained some traction in the US. And this is robotic-assisted axillary thyroid ectomy. So they thought, we'll take the axillary approach, but we'll add a robot. Because what could be better than adding a robot? Because that's more technology. And pretty much everybody loves the idea of robotic. Now, I'm not sure why that is. I'm not sure if patients feel comforted knowing that there's a robot involved. I'm not sure. But in case if you don't, this operation is done with a 5 or 6 centimeter incision in the axilla. And then everything is lifted up. And everything comes in through the axilla. And the reason that you use the robot is it has these instruments that are risted so you can do everything in a small space. And this approach has gained some attention in the US not a lot. But I have found that most of my patients who I discuss this with say, why would I want that? But yet another approach. So if you all have heard of notes surgery, notes is natural orifice, transendoscopic surgery. So notes is things like going in through the stomach, like an endoscope into the stomach, opening the stomach wall, taking out the gallbladder, and then pulling it out through the stomach. And this has been done lots of places. Or you can do a transvaginal appendectomy. So no incisions on the skin. The incisions are inside. So let me just take a moment because I just thought it was so cute. When I first told my daughter, my youngest, Audrey, when Audrey was about eight years old, my colleagues at Northwestern had done a lot of work on this. And there was the report that they had done the first notes colisostectomy in Chicago. And so I try, as much as I can as a surgeon, I can't bring my work home. But I try to talk to my kids so they know what I do. And so I was explaining it. And I said, so this is what they did just as I explained to you.  I said, yes. And she said, didn't that leave a really bad aftertaste? Which is kind of how I think about note surgery. But anyway, that's an aside. So somebody said, well, if you can take a gallbladder out through the mouth, the thyroid's a lot closer. Let's do note thyroidectomy. And there is, in fact, this approach through the floor of the mouth. And you add the robot. So it's kind of like you got everything. Now, there's been a small series, maybe a dozen patients from Germany reported utilizing this approach. Actually, I don't think they used the robot because they said, well, what do we need a robot for? But anyway, the results aren't great. And again, I don't think it's going to take off, especially in the US. But it can be done. So this is the question. Are these approaches progress? And how do we know? How do we decide? I would argue there's little change in morbidity. If anything, patients have more pain than a small neck incision. If you make an incision in the axilla and tunnel all the way up to the neck, that's a lot of dissecting. If you have to do it on both sides, it's twice as much. Patients tend to have more pain, but they all recover very well, nevertheless. There's clearly no change in mortality. The mortality from thyroidectomy is so vanishingly low that you're never going to show that you can improve that. But certainly, it's no worse utilizing these techniques. The only difference is a cosmetic difference. So you don't have an incision in the neck. Now, despite what you see, if you Google images, thyroidectomy, you'll see several hundred patients that post their thyroidectomy scars on the internet. Now, most of them don't look that good. But I would argue that the people who have a thyroidectomy and their scar looks good, they don't post their images on the internet. I would also argue that it would suggest that people have way too much time on their hands. But that's, again, another story. So the question is whether only a cosmetic difference is any less important than other differences? And again, how do we assess that? Do you have any metrics on the cost differences? Well, it's very hard to assess. Certainly, in the US today, it is more expensive. And I'll come back to this in a minute, though. So let's look at a couple things in terms of how do we decide if the innovative technique or technology is in advance. Well, we look at efficacy, the ability to produce the desired effect in expert hands. And then we also look at effectiveness, which is the ability to produce the desired effect in normal usage. So if there's one guy in Korea who can do a robotic-assisted axillary thyroidectomy, and it takes him one hour, and it doesn't take any longer, he's really fast, and everything is great, that would show that it's efficacious. But the question is whether the rest of us can do it, that would be the question of effectiveness. And sometimes, that's where problems occur. Now, I would argue that these two categories do not really help us in answering this question. Because I would say that in order to decide if something is progress, we have to look at what is it that we value, because it's that decision of what we value that helps us know whether it's better or not better. And that, I would say, can't be measured purely objectively. So let's look a little bit more carefully at the ethical issues in surgical innovation. So I would say if you take a new operation, you don't really know what the risks are at the first time you do it.  They all did well. But at some point, you're going to operate on a patient, and you don't really know what the risks are. With thyroid surgery, we know that there's a 1% to 2% risk of complications. And those complications are hoarseness or low calcium. In order to show a change in something that is a 1% or 2% risk, you have to do thousands of an operation because it's such a low risk. And so as a result, you can start out and say, we don't think there's any additional risk. But you'd actually have to keep saying, we don't know. We don't know until you've done thousands to be able to assess the risks. So I think that that's a problem because early on, patients want to know what the risks are, and surgeons can't really tell them because we don't know. The other issue is, can you really know what the risks are when you first start out? The first few times you do something, there's a little bit of this leap of faith. And that, I would argue, is necessary in order to take a step forward when you don't know exactly where you're going to land. But it's very problematic in terms of explaining risks to patients. So how do we ensure patient safety? Well, we have to address the lack of surgeon experience with a new technique. Now, we all know that there is a learning curve. And in surgery, how steep that learning curve is depends on the operation. But I would argue that I'm better now at doing a thyroidectomy after having done 2,02500. I'm not sure. But I've done a lot. I'm better now than after I had done 50. Now, when you ask me after I had done 50, do you think you do a good operation? I would say yes, I do. I think I do it safe, and I do a good operation. But people get better, and so it's very difficult to know how to talk about the learning curve in general with patients, but especially with a new operation. You can raise the question, should we discuss this with patients? Well, I would argue yes, it's in fact important. But how to do it is not always so easy to define. So again, surgical progress and surgical benefit, I would say has traditionally been defined by reductions in morbidity and mortality, and that's been valuable. But today, I think that we have to think about benefit in a broader category, because patient values become important. And that's where I would say a cosmetic benefit may be beneficial. If a patient's goals are to have the smallest scar or not have a visible scar, then if we can accomplish that, we may have actually done them a service. And figuring that out, I think, is difficult. Now, with respect to this question of patient benefit, well, if you look at the easy example that we talk about much more commonly in ethics, a procedure that may shorten a patient's life but improves their quality of life, certainly nobody would say, well, that's not beneficial because the patient lived a shorter period of time. It just dependent on the patient's goals and values. So I would say in a similar way, we have to think about how do we assess the quality of life and utilize that as one component of determining whether something is surgical advancement. Now, the problem with quality of life is you can't ask a surgeon about the patient's quality of life, because that's something that patients have to determine themselves. We can use lots of tools to help do that in as rigorous a fashion as possible. But ultimately, we have to go to the patient to get that information. So surgical progress. I would argue that there's been a paradigm shift. Whereas we used to look solely at objective criteria, I would say now we have to look beyond that. We can't determine whether something is better looking solely at the objective criteria. And I would argue that if the only benefit is improved patient satisfaction, that that might actually be surgical progress. Now, it isn't necessarily surgical progress, but it might be surgical progress. Finally, to say that something is a purely cosmetic benefit, I think is to inappropriately minimize the importance. For some patients, a purely cosmetic benefit may be of particular significance. And so that may lead to improvements in their quality of life. So let me ask this question, can surgeons and patients really objectively assess the benefits of a new procedure? So just imagine, surgeon, let's assume me, has decided that a new technique, robotic-assisted axillary thyroidectomy, for example, that I've decided this is worthwhile. Other people are doing it. I should probably learn how to do it. Maybe it's actually better. We don't really know. I should study it. We should find out. So I spend time learning the technique. I read about it. I watch videos. I go watch other people do it. I do cadaver labs. It costs money. It costs time. A lot of effort. And at some point, I'm fully trained. I'm ready to do it. So in that circumstance, I want to ask you, can I objectively present the options of this operation to a patient who may already have decided that the high-tech new robotic operation must be better because they read about it on the internet? So I would argue that we're in a situation where the patient may already have in their mind, I want this because it seems so much better. And I, the surgeon, has already invested all this to say, hey, I think I need to learn how to do this. And so I think the dynamic of the doctor-patient relationship in this circumstance with a surgeon who's learned something new and a patient who's convinced, for whatever reasons, that it's better, are going to collide with the patient saying to the surgeon, I don't care what you say. That's what I want. And pardon me. I would argue that's very different from most surgery. Most cases, the patient comes to me and they don't necessarily want to have an operation. They may understand that they need one. They have thyroid cancer. The thyroid has to come out. They may not want it. But they understand, OK, there are risks. The benefit is, I'm not going to have cancer and that's going to be good. And so there's this sort of negotiation. I'm telling them what they need, what the risks are. But I don't generally have patients coming in saying, I so very much want you to take out my thyroid. I've read that having the thyroid out is so great that I want you to take it out. That's not generally the case. But that is sometimes the case with new technology. So costs. So Peter mentioned the issue of costs. There's no question that new technology is usually more costly. And in this case, it's definitely more costly. In addition, we have to spend more time utilizing the new technology. Even if it's not that expensive, it takes us longer because it's different. It's new. And so there's a tendency to say, well, if I can do a thyroid lobectomy in one hour and it takes me four hours to do it with robotic assisted axillary approach, that we could say, well, that's just crazy. Let's not do it. And you could make an argument for that. I would say that one of the problems, though, is that when you try something out the first time, you don't always know what the ultimate benefits are going to be. So again, thinking historically, when I was a resident, one of my faculty members did the first laparoscopic colisostectomy at our hospital. And all of us residents who weren't busy doing something else went to watch. And it took five hours, five hours to do a laparoscopic colisostectomy. Now these days, 30 minutes, right? Piece of cake, nothing to it. Patients go home the same day. And we watched that operation. We all left the OR thinking, this is a bad idea. This is a big mistake. And I remember this particular attending, great guy. He persevered. He got better. He got faster. But still, the old-time general surgeons would say, that's not even really surgery. You're just picking away at the tissue. Give me a real knife and a big incision. A few years later, even the old-timers were learning how to do laparoscopic colisostectomy because it was, in fact, better. It doesn't take five hours all the time. Patients' recovery is much better. Lots of parameters. So if we say no too early, we may not know what the ultimate benefits are. And that is, I think, the problem with cost. This is much more expensive. It takes a lot more time. So then I believe the tension that we are faced with is, should we be encouraging more new technology and innovation to help more patients? Or should we be protecting patients from the unbridled enthusiasm of surgical innovators? Surgeon says, I think it's a great idea. We should do it. And I'm sure the marketing department would love it. But is it actually good for patients? So I have a few concerns. I would say that individual surgeons are faced with the challenge of determining what innovative techniques should be offered to our patients. I think that that's a question that we, as an individual, I, as an individual surgeon, I have to assess that. I have to be able to make recommendations to my patients. I think that when it comes to quality of life, it's hard to assess objectively. But it can be done, but I ultimately have to ask the patient in some fashion. And we can't assess whether we're improving quality of life simply by looking at a patient. We can't look at it and say, wow, your scar looks much better. I've improved your quality of life. It doesn't work that easily. So let me try to bring this back to professionalism, because I'm sure you're thinking, well, this has been interesting, but what does this have to do with professionalism? Well, I would say that there is no group or institution that determines whether a new technology benefits patients. There isn't somebody that says, OK, you can do it. This is good. In fact, I would argue that professionalism of surgeons is necessary in order to ensure that what is new and what we offer our patients isn't automatically assumed to be better. And then finally, I would say with no oversight, it's possible that surgeons can go off the deep end on either side here. We may not want to ever try anything new, or we may want to try everything new. And that's where I think there has to be some very important judgment, and that's where I think that professionalism comes in. It's making an assessment about what is going to ultimately be beneficial for my individual patient. So how can these ethical issues and surgical innovation be managed? Well, I would just argue a couple things. First of all, I don't think that we can legislate this. I don't think that there can be any group that necessarily regulates this. I think that we have to have self-awareness. We have to have surgeons that think about this and are honest with themselves and with their patients. Informed consent has to be improved by explaining very clearly the uncertainties of innovation. So I had a patient who said to me once, I had an innovative operation and I have this complication. And she said, how could that have happened? And I said, well, it seems to me easily could have happened. And she said, well, my surgeon, who did the innovative operation, said that couldn't happen. And I said, well, it's impossible to know if it could or couldn't happen because nobody's done it enough. And then finally, I think surgeons have to gather data to determine if patients really benefit. So if a patient is convinced that something is better and we can figure out that we're not putting them at significantly increased risk, then I think with appropriate consent, it is possible to move forward. But we do need to continuously assess are we actually getting the benefits that we think we're getting? So my final conclusions, I would say not all new technology is good for patients. I think that not all innovation is great. I think that when you're looking at things like quality of life, you have to balance that against potential risks for patients. And I do think that we have to spend a lot more time thinking about informed consent, how to make it better and much more relevant to the actual procedure that's happening. I think that we need to ensure as we go forward that new technology, new innovation actually benefits our patients and not just us. And I think that's to me an absolutely critical aspect of professionalism and that is, is something really going to benefit my patients? And sort of having the thoughtful context in which to make that determination. So I thank you very much for your attention. I'd be happy to answer any questions. Jolly. One to consider is that, is the learning curve and the number of procedures that someone has done? You can say that not all innovation is good for patients, but you also have to throw in not all innovations done by every surgeon is good for patients because that learning curve is just so, such an important component. No, you're absolutely right. And again, I would say that to me is another excellent example of where we have to depend on the professionalism of an individual surgeon to say, even though Dr. Chung in Korea can do this operation with great results and in fact has done it for thyroid cancer, I shouldn't be offering that to my patients. I don't have the experience. And that's where I do think that we have a problem today. I think that it's too easy to say, so and so has done it. They've written a paper about it. It's in the literature. It's no longer, it's not innovative. And again, I think you're absolutely right. What is innovative for the expert and it's low risk for the expert may not be the same way for every surgeon. Excellent point. I think you're right that at a minimum, whatever system develops, you need to push the professionalism in terms of the individual doctor's decisions. But the house of surgery and the house of medicine historically has never been able to do it in terms of you look at the ultimate decisions, then as you mentioned, some of it may be well-intentioned in terms of people believing that the new technology is better or the patients push for it, but the economics are just so powerful in terms of both the individual physician as well as the University of Chicago in terms of an organization pushing. So therefore you see these policy things being developed, so for example, value-based insurance or you see like the New York Times talking about that tutorials where the patients paid the extra beyond what's been proven to be beneficial or in the Affordable Care Act, there's provision for that vision board separate from Congress to talk about what it may be paid for or not. So do you really sort of see a solution that really relies solely upon physicians as in your last slide or do you think that based upon the history of the past 40, 50 years that you gotta have sort of systems, legal, regulatory solutions as part of it? Yeah, it's a really excellent point that the history has not been particularly a shining example of great self-regulation. I think that's absolutely true. So I fundamentally am not in favor of lots more regulation. On the other hand, I think that there has to be some level of oversight and I think that it may be something like, I mean maybe there does need to be different tiers of things and so maybe if you want the transoral robotic thyroidectomy, maybe that should be something that you pay additional for as a way of sort of reminding the patient that what you're doing is really outside of the mainstream and to me, I mean that may be a good approach where we're not saying you can't get it and we're not necessarily saying innovation should not occur but what we're saying is patients need to know that they're really stepping outside of the mainstream and when there's significant costs associated with that then perhaps they need to bear those costs. So I would say I think as much as I hate to admit, I think some regulation or some legal approach is gonna be necessary. Just to follow up on Marshall's question. Using the concept of professionalism, could you extend it from individual surgeon's decisions to sort of the community of surgeons which might go halfway towards a regulatory approach? It wouldn't get all the way to Marshall's idea. Yes, so no, I think that that's a very good idea and there has been an attempt to do this sort of thing and so there was a task force of the Society for University Surgeons that looked at this issue and tried to make some suggestions and one of their suggestions was to have surgical innovation committees at individual hospitals to sort of provide oversight and they sort of looked at this as an alternative to an IRB as a way of surgeons kind of policing themselves. I think that the problem is that there really hasn't been, if you say to an innovative surgeon like Larry Gottlieb, hey Larry, before you do something different, come and tell us what you're gonna do and we're gonna approve it. It doesn't necessarily go over that well and so I think that there is a way to do it but I don't think we've necessarily come up with it yet. So I have a question that's somewhat similar. Innovation is very easy to recognize when you bring in a huge robotic arm and you invest thousands of dollars but sometimes innovation is more subtle than that. A surgeon goes into the operating room and decides to do something differently than he or she has done before. How do you do surgeons think about this ethical boundary between common accepted standard of care and innovation and who regulates, is there any regulation when a patient signs a release? Are they saying you can do anything you want inside that two centimeter scar? You've promised me. Yeah, so it's a great question. In fact, yes, patients do, patients say I'm giving you permission to do a thyroidectomy and anything else you would deem necessary during the course of my operation. So in fact, and we've talked about this, some of you have heard me talk about this, I mean, we find a parathyroid that's abnormal, we take it out, we find something, lymph nodes that are abnormal, we take them out. We don't wake the patient up, we don't talk to them. Now, when it comes to innovation, I think you're absolutely right. Most innovation in surgery is not the big device that costs millions of dollars. It's in fact, surgeon trying something different. So again, the SUS task force said three categories. Category number one, a minor modification of accepted technique. So that's where surgeon says, well, I usually do it this way, but in this case, instead of putting stitches in the intestine to put it back together, I'm gonna put you staples. Everybody would say, you're making a minor change. That's tinkering. It doesn't matter. You don't have to get prior authorization. You don't have to give consent. There's no disclosure, no regulation at all. There's another category, which is something that's innovative. So it's beyond what a standard accepted practice sort of locally. And that's where the feeling is if it's planned innovation, the surgeon should discuss that with a patient preoperatively. And if it's unplanned, I found something, I had to do something different, it should be disclosed soon as the patient's able to participate in that decision. Now that's the area. This innovation area is where there is no oversight. It's completely dependent on the individual surgeon to disclose or inform if it's planned or unplanned. And that's where I would say the primary discussion has to be about how do we handle those circumstances. Now, there's another issue, which I haven't really touched on, which is if I try it out and it works, and I say, hey, that's a good way to do it. I'm gonna do it again, the next case. And I do it the next case and it works really well. And now I say, you know what? I do it a third time. It's great. I say, you know, the next 10 patients, I'm gonna do it the same way and then I'm gonna write about it. Well, now that's research. Research has significant oversight. We go to an IRB, they're separate informed consent, right? But there's no oversight when I'm just trying to solve a patient's problem. So I think that you're right. That is a circumstance in which we depend on the professionalism of surgeons. I have a question for you about the side of the hospital. So if you are going to do something new, right? So you just mentioned this tinkering, but what bar is there for you not to bring in, you know, some new scope from Japan to use and what review that system had. I think you scored it around it, but I didn't get a clear answer. So you can maybe help me. And then I have a question a little more provocative. So the other thing, you've been talking about patient provider perspective, self-regulation. You mentioned at one point maybe patients should have who want to get the newest technology should pay for that. Right. Right. So, but that's a different burden, right? So where's the burden on a community of people to allow for innovation for surgeons, right? In the past, it used to be the downtrodden we're gonna experiment on them, so to speak, right? Now you're saying high tech hospitals we experiment on you and you pay for that potentially. Right, so there's the communal question or the societal question is still a little bit murky and I didn't quite get what your lasting point for us was on that or the teaching point. Well, where's the now societal burden for innovation? The next patient might do better. Sure. So while we talk about regulation, I still didn't get, well, what you think we should go towards, right? For these, this group, because we have to have surgeons doing things that are important and maybe make some mistakes while doing that. Right. Yeah, I guess I haven't answered the question because I don't know the answer. I think that it seems to me that from a societal, from a, you know, if you look at the whole society, an innovation like laparoscopic cholestectomy was a good thing. I think it's a good thing because it reduces morbidity and mortality and patients can resume their activity sooner and so I think that that's good for society. Now, during the course of getting to the point where we got that benefit, there were a lot of patients who had very long operations to have their gallbladders taken out and there were in fact many more patients that had complications, common duct injuries, things like that, that we didn't see for the open technique, okay? So there was a period of time where there was increased cost and increased risk. Now, I guess it seems to me that we have to look at every single innovation and think about what are the potential benefits before we can decide who should bear the burden, okay? So if it is in fact the case that we have an innovative technique to treat, for example, lung cancer, okay? And if that innovation may result in societal improvement, then maybe that isn't something that should be borne by the individual patient. But if the potential benefit of the innovation is a cosmetic benefit or a slight improvement in quality of life for an individual patient, then it seems to me that we have to think a little bit more carefully about should the burden of that new innovation be shared by the entire society or not? And again, I don't know the answer. I think that as we move forward, I'm not sure our health system is gonna be able to tolerate every surgeon who says, hey, I think I'm gonna use the robot to do that, just doing it. Dr. Podela's question reminded me of a very famous essay written in the 1970s by Hans Jonas. Jonas was a great philosopher of science who in those days was actually on the faculty here in the Committee on Social Thought. And has anybody in the room read this essay on clinical research? Mary has, but in that essay, Jonas says exactly what you said that in the past, the burden of new techniques and new research has largely been borne by the poor and they were often recruited to participate in clinical trials. He felt that it ought to be the wealthy and the best educated, the most powerful members of society who should be the first to be offered new techniques, new innovations. And it may be that bringing these new innovations through fancy hospitals, through their marketing departments, ends up doing exactly what Jonas had in mind. Because I mean, this complicated five-hour robotic surgery has gotta cost a fortune, I mean, to buy the robot and to play with it. So maybe we're seeing an application of Jonas's ideas about the most educated, the most powerful people in society. Shouldn't we have a regulation to share the innovations? Now the problem is everybody wants to be the first at everything. And there are 16 innovations being tried at the same time, of which the majority don't work, the minority work. So there's 16 places doing frontal abectomies. And why don't we share them? Why isn't there a regulation that different tertiary care centers who have the imperative to be the first of everything decide, pick three, and get burnt and burn their patient and do the learning curves and learn how to do it better, and then they share? I'm for competition, but not that extensive competition. Yeah, so the question for those of you who didn't hear, and I'll just paraphrase, was with respect to the learning curve, why don't the groups that are the hospitals, the high tech hospitals, the academic centers, why don't they sort of work together to sort of scale that learning curve and figure out what works, rather than compete with one another? And I think that it's an excellent point, and it would be a more rational approach to how we do things. Well, it could be regulated, I think that in the US it's very difficult because there's so little regulation of medical care at all. And so in that sense, it's very hard for, you know, especially in surgery, it's very hard for someone to tell me that I can't take care of my patient the way I want to. But I would agree with you that it's something that I think as we move forward, we have to think about new models, we have to think about new ways of doing it, and that may be the way that we have to go. So anyway, thank you all very much for your attention, it's really been a lot of fun. Thanks.


Honourable Yogida Saminaden, Minister of Technology, Communication and Innovation. Honourable Etienne Sina Tangu, Minister of Social Security, National Solidarity and Environment and Sustainable Development. His Excellency, Mr. Moniz Lafaye, Minister of Communications and Transport to Value. His Excellency, Mr. Raimony Aoufi, Vice Minister of Communications and Information Technology, Samoa. This is Doreen Bogdan-Martin, Director of the Telecommunications Development Bureau International Telecommunication Union, distinguished delegates of the ITU, representatives of the media, ladies and gentlemen, good morning. As Chairperson of the ICT Authority, which is hosting this forum, I have great pleasure in welcoming you all this morning to this very important event on disaster management. The Republic of Mauritius is getting used to facing extreme disaster and disastrous weather conditions like cycles and flash floods, as such calamities have become recurrent. The risk of disaster, therefore, is a matter of continued concern for us. In such a context, this forum, which is the third global emergency telecommunication forum, and its theme, especially, innovating together to save lives using technology in disaster management, can only be of immediate relevance to us. The use of technology, or more precisely, investigation into how the use of technology in particular ICTs may be applied towards disaster management is a matter that the ICT Authority has long been associated with. In 2009 and in 2013, with the close collaboration of the parent ministry, the Authority organized events on the subject of ICTs for disaster management with local and international stakeholders. These events generated great interest among key stakeholders involved in disaster management, and what emerged from the discussions was that there was the need for a central agency to coordinate disaster management in order to enhance response in times of emergency and urgency. The ICT Authority has been engaged in close collaboration with the National Disaster Risk Reduction and Management Center, telecom operators and other stakeholders in the endeavor to work out and establish a framework whereby existing telecommunication infrastructure and facilities can be put to use during emergencies. Additionally, the Authority has set up a conclusive licensing framework for radioamateur in Mauritius, which is based on the adoption of the frequency allocation recommended by the ITU for this segment. The use of artificial intelligence to predict the occurrence of natural calamities, just like the use of drones to assess damage and, more importantly, to assist in search and rescue operations, are living examples of how technological innovation can be a useful tool to enhance efficiency and responsiveness in disaster management. With a mobile penetration of 146% in Mauritius, the focus now is towards providing public warning systems over mobile networks. The cell broadcasting system, which resembles SMS very closely, is nevertheless in terms of implementation by far the most practical mobile-based technology. It satisfies most of the criteria defined internationally in terms of requirement for WSL broadcast operating on GSM, UMTS, and UTRAN networks. It enables prompt delivery of emergency alert messages on a one-to-many broadcast basis, and it also addresses security concerns as only authorized personnel may have access to the system for the broadcasting of alert messages. The advantage of the cell broadcasting system over the emergency SMS alert system, which is another means to reach the general public, is that it does not have the inconvenience of network congestion resulting from the transmission of voluminous SMS alerts, as is the case with the emergency SMS alert system. Thus, there is no likelihood of delay in the delivery of critical alert messages with the cell broadcasting system. Another advantage is reliability as regards the source of the message. The alert is generated by a legitimate authority, whereas with the emergency SMS alert system, there is no indication whether such is the case. Also, the cell broadcasting system does not involve any risk of spoofing of message from other phones, as is the case with the emergency SMS alert system. Thus, having regard to the fact that the cell broadcasting system offers the best combination of reach and reliability, action has already been initiated with mobile operators for its implementation in Mauritius. Concerted and critical thinking as well as collaboration are, to my mind, key components which require continuity over time in regard to disaster management. This is precisely the prime consideration of the ICT authority in hosting this forum with the blessing of the Honourable Minister of Technology, Communication and Innovation, and of the Government of Mauritius. The common target is to explore the full spectrum of innovation through the use of ICTs and technology with the objective of saving lives. It is a matter of comfort to see so many experts gathered here today to share knowledge and experience on disaster management in order to save lives. The topics of discussions will no doubt generate meaningful debate that will lead to more meaningful action in the future. I therefore wish this ITU forum innovative outcomes and wish all delegates a fruitful and enjoyable experience and an equally enjoyable stay in Mauritius. Thank you.


that's going to be fun because of the cold weather and the lack of knowledge with the the 320 we more of a familiarization out here to fire at the to zero first zero the weapon and then fire at the various targets through the four stations out here on the 320 range. Each soldier was issued 18 rounds of 40 millimeter chalk rounds so that way we can see where the fire hit and score them but we don't destroy the range. It's a little cold but that's all right we're bundled up between the grenades it's different but it's a good learning experience a little bit of a kick chalk rounds go up it's a lot of fun. For the the soldiers that were out here qualifying on the grenade range they have the M320 assigned to their weapons so that's why they were out here to qualify with those two. So basically what this allows us to do is it allows us to maintain the security of our operational area for chemical biological radiological nuclear surveillance decontamination and so that we can maintain the perimeter and security so that we can keep our soldiers and our equipment safe and just gives gives the soldiers a little bit more confidence in their ability to perform their chemical biological radiological nuclear tests. Go ahead. The soldier was issued 18 rounds of 40 millimeter chalk rounds. Okay I'm CW2 David Allen I'm the Seaburn Warrant Officer and a third platoon leader from the 704 Seaburn Company out in Harbin Hills Minnesota and today we were out here to uh we were spoke we were out here to qualify but because of the cold weather and the lack of knowledge with the the 320 we more of a familiarization out here to fire at the first zero the weapon and then fire at the various targets through the four stations out here on the 320 range at Fortwood Point Wisconsin. Tell us what the 320 is. The 320 is the updated version of the M203 the uh it's a grenade launcher that can either be fired by itself or it can be attached to the M4 and how many rounds did they fire? So each soldier was uh issued 18 rounds of 40 millimeter chalk rounds basically so you know uh unfortunately out here on the grenade range it's not too good for the range if we blow things up so instead of uh using an actual H uh high explosive rounds and HE rounds round we use chalk rounds so that way we can see where the fire hit and score them but we don't destroy the range. When's the last first time is this the first time these soldiers have fired this most of the time or? As far as I know this is the first time that most of these soldiers have fired this weapon. What's their reaction about? The reaction's been pretty good they're pretty positive pretty happy to actually get the uh piece of equipment out and fire it. So this is a chemical company how are you how are you involved in grenade launchers? Well for so even even being a chemical company we still have to know our basic soldier skills so if we get you know if we get overran or position it's overran or if we need the extra security that's where the grenade launcher comes in and just uh just overall area security. Okay and then what else have you done?  So that way when we leave this weekend we're completely qualified on all of our individual weapon systems. Okay and how many was this like a four day? Yeah four day four day drill. We drove out here on Thursday, come and went out to Port Levoix, got everything prepped. We came out here yesterday Friday and uh we we did the zero uh did the zero range and then uh we went over to the qualification range and then we continued the qualification range for the uh 24 the M4 and the M249 and then today we did the 320 range on top of that. Okay do you think that I didn't ask you that you wanted to tell American people? Uh you know thanks thanks to the taxpayers for spending the money so that we can be trained and qualified on our weapons and uh other than that uh no I think we're good. How does this make your unit ready? Uh well this this makes our unit ready for our basic soldier skills so that we uh it wouldn't call up to action we're prepared to uh defend the war or fight you know whichever you know so we can defend our soldiers, defend our equipment and then also too so we can perform our C-Burn operations in the real world. Say that again but tell us what C-Burn is. Uh C-Burn is chemical, biological, radiological and nuclear. Okay so they say that last sentence instead of say it C-Burn. Oh so about how this helps us. Yeah so basically what this allows us to do is it allows us to maintain the security of our operational area for chemical, biological, radiological and nuclear surveillance uh decontamination and so that we can maintain the perimeter and security so that we can keep our soldiers and our equipment safe and uh just uh gives gives the soldiers a little bit more confidence in their ability to uh perform their chemical, biological, radiological and nuclear tasks. Okay, perfect, thanks.


Okay, it's time to finish this sucker up. What do you say? We're going to attach the straps, the lining, and then do the loop-de-loop situation with the strap to get the adjustable, the adjustable strap happening. Okay, so first things first, you're going to take your long little, I don't know what these are called, why straps at this point, split strap, whatever it is, and you're going to do it to where the little short end is toward the middle, right? So it goes like this, right sides together, right? Where the short end is taking the innermost notch and the longer end is taking the outermost notch, like so. And go ahead and pin on the other one. Okay, and then on the back, that's where these little guys are going. So the back has notches as well, right here, and these take that. Perfect. All right, now you can base those down if you want. I'm not going to because I don't know, I don't feel like I need to. I may regret that in a second, but for now, I'm not going to do it. We're going to put the lining right side together with the bodice of the dress on zip the zipper. We are going to open the zipper. And this is deviating from the instructions just a little bit only because I know this trick works. But if you sew along here, turn the corner and come around and then turn all of this to the right side or to the inside, that'll prevent one little bit of hand sewing. You will still have to hand sew this down or stitch in the ditch, which you know me, I'm going to try. But that's how you get the, you know, this little area encased. Okay, so go ahead and pin that down. Then you're going to come around here and everything's going to match up, right? All your notches are going to match side seams, everything. Okay, just turning up the seam allowance on the bottom of the lining so that whenever I turn it, you know, to the inside, it's already kind of wanting to do its thing. Okay, now we're just going to sew around this whole thing. Okay, so I have the bodice or the lining attached. Okay, so now you can kind of see also my zipper. Now that this is all sewn and encased, I can, I can cut this off. But I was going to wait until this very moment so that I knew I wouldn't make a mistake and cut it off with the zipper, zipper, pull, attach or anything crazy happening. Okay, so now this needs to get trimmed back through here too. Okay, and now when you turn this, you can see that it encases the raw edges of your, you know, bodice and it's really pretty. Okay, so when you go to zip it, it still zips like everything should still work. It's just, you know, a prettier finish. Okay, so now we need to go understitch just like we did on the hem. We're going to be sewing, repeat after me, the seam allowances to the facing, aka lining. And on this situation too, as you get to the little straps, those are all getting pressed to the lining as well. So everything is getting sewn to that lining. And that again, will help reinforce keeping all of this to the inside. Okay, so I'm going to walk you through next steps on these straps. Okay, so you need to get the one that looks like the number eight first things first unique. I want to show you guys this with as much clarity as possible. Is this in? Okay, so this strap is right side up. Okay, this gets fed through here under the middle bar. I mean, sorry, under the first bar and then over the middle bar and then down under the first bar. So you're kind of just covering that middle bar. Okay, once this is on, you are going to find your back. Now this raw end is going to get fed through the O ring. Then it gets looped back underneath this middle bar. Okay, so I'm going to tape this and kind of try to make a point with it. Okay, so now this has to go back. We remove the tape. Okay, so now this gets turned under a quarter of an inch. And then this whole thing gets placed, they say about an inch underneath the slider. So I could do a little bit. So basically you need an inch and a quarter ish on this little tail that way. Boom and boom. Got it. Okay, so once you get that, then it gets folded over, folded over that inch, and then you're going to sew, but you're only going to attach it to the bottom part of this. All right, so yeah, give yourself some space so that and this guy should be done. All right, you guys, that is it. You are going to repeat that strap process also obviously on the other side of your dress. And then hand sew your lining down to that empire waist seam. And I'll do a big reveal where I model it and everything for you guys and post that ASAP. But I hope you make the seam work Leanne. You love it. You wear it. And remember our time together fondly. But like I said, that's going to do it for me for this sew along. Thanks so much for watching. I will see you all very soon. Bye.


What's up guys, EvilD here. Today we're going for a trip. Hey guys, we're off to a great start today. We got up, we didn't have any money so we had to quickly run straight to the ATM to get some money because we forgot to withdraw it last night. And we don't know how much we need so we just withdrew $600 as you do. I don't even know if we've booked this. Have we booked this? Have we booked this here? I'm going to bring my Mrs into this. She's running away. She hasn't got a makeup on so she's a bit terrified at the moment. Because she's like, nah, joking, joking. I've just arrived at the Australian Reptile Park. Now little did I know just before we went on this tour because my Mrs organised everything and just told me we're going on a tour. But it's a Chinese tour. Everything's in Mandarin so let's just say that I have no clue what's going on. I do have a little bit of understanding of Mandarin but yeah, not exactly up to scratch. We are now inside the Reptile Park. There's got this giant frog statue here. By the way, the word for frog in Esperanto is Parana. Parana, it's called R-A-N-O. Just in case you guys want to know that. Check out this Grande Caracodilla, a great big fricking crocodile statue. Look at these two. Look at that one right there. He's shaking his leg. What do you think he's up to right now? He better not be pounded away at that tree like I think he is. This one's trying to scowl his enclosure. He's like, come on Ben, we can get out of here. And the guy's like, no man, I've tried it already. It's futile, we can't do it. And he's like, no man, we're just going to get over this tin roof. Follow me. Onward, don't give in. For everyone watching right now, this is a very rare species. This is my wife. This is her in her natural surrounding. She has a camera out and she's taking pictures of stuff. She's quite puffy at the moment because she's wearing a lot of clothes. But you've got to be careful of this one because it can become quite adjective, quite quickly. Especially it's seen by a predator. Look at this guy right here. Look at him. He's munching away. He's loving that. Get that breakfast into you. I'm glad you can eat because I can't. I'm still starving. Yeah, I'm talking to you mate. Yeah, yeah. Do you ever get bored of that? Do you ever get bored of that food? Like, do you spice it up and add a bit of salt or anything? Maybe some pepper? No, he's happy. He's going back. He's like buggy, mate. I'm going to go find this leaf. This one looks juicier. It's greener than the last. I have a little jack. What's going on, mate? I know it's pretty early. It's early for me as well. Lots of people, isn't it? What would you do to get a koala? You'd hold it like a baby, would you? I can just imagine holes in your wall. Hello? Hello?   Do you want to scratch behind the ear? Do you want to scratch behind the ear? He bites. Oh, he loves it. He bites right there. Oh yeah, yeah, yeah, yeah. Right behind, under there. Good mate, good mate. Oh, isn't that good, huh? You like it, yeah? You like it? Right, the special spot? Special spot? Like a cuttle. Like a cuttle. He's better. He doesn't run away. He's a cuttle. A cuttle. How's it going? Oh, I know how to. Oh yeah, oh yeah. Yum, yum, yum, yum, yum, yum. Just eat my finger. Time for breakfast. I'll check this guy out. Don't be taking Sidney's work, we're going to try the world. Does it suit me? So we've just arrived at one of the local wineries that's way, way outside of Sydney. Now it's kind of funny because I actually worked full-time for a winery. So we're now on this tour and they've randomly stopped at a winery, which is kind of ironic, but anyway, let's just move inside, shall we? Come on, quick, quick, quick. You ready? That was you, sorry. Okay guys, you've got to check out this wine that they've got here. Tell me this is not troll face.   Look at him, he's like, I don't think, but yeah, I just wanted to show you that. That's pretty cool. I don't think we're meant to go this way. There's a tree there. Quickly, go under the tree. Under the tree. I'm going to kick you in the butt. Under the tree. Look, a giant spiderweb is there.  Look, look giant spiderweb. Look at that, old man. Climb, climb, little girl. Okay, so we've just arrived at our next location and it looks like we're off to see dolphins and possibly whales. So that should be fun. Check out that scenery.  Okay, so I'm currently on the boat. We're going out to see some dolphins and maybe make life as perfectly disturbing me right now. If she keeps it up, I'm going to zoom in on her pimples and then you'll get to see all of that anyway. So I just wanted to talk about a funny, well, not really a funny story, just something that happened to me. So we're out on this boat and we're having food and they bring us all our food and basically there's fish, chips and like scallops and stuff like that, but I can't eat fish. I'm not allergic to anything. I just, I just can't eat it. I just feel sick type of thing. So obviously I can fish off to my wife with that, but the reason I can't eat fish is the funny reason. So when I was a kid, we basically lived in this very small coastal town and my parents didn't have too much money. So we just went out fishing every single day and they just bring back this one type of fish called a mullet. And we just eat that over and over and over, like day after day after day breakfast, lunch, dinner, continually. So I'm not allergic to fish, but I cannot stand it.  So that is why I can't eat fish. And it's pretty funny because now on when I'm on like an airplane or something, they give me like some fish or whatever. We just tell them that I'm allergic because it's easier than trying to explain that story. Anyway, I'm going to see if we can spot any dolphins. So I'll be right back. I will start with his mother for up to three years until she decides to have another baby. They can actually choose where they're releasing him to become pregnant or not. They are the only other animals that can practice the art of making babies because they enjoy it. That's it, that's it. You see those couples off to the right actually come over and say hello. And there you are. Let's do this. Ah, come on, Canaanio. That looks really high. Holy craps. I don't know how I'm going to film this. Can you film me? Can you film me? Hey babes. You ready? Come on. Ah, come on up. There you go. You ready for round two? You ready for round two? Come on, go. Oh shoot.  That's pretty far down, eh? That's really far down. Okay, you ready? Hey, I've got one hand here. Who least you got both? Almost got on back onto it. I kept the camera off the ground. That's the important thing. Oh God, now I've got sand in my underwear. It's real sparsely. Look at me guys. I look freaking beautiful. Check out my crotch. Nice and sandy. You feel right now. You feel buggered? You tired?  Yeah, real well. Yeah, I got it up with my bum probably inside my other things. What other things? Just other things. Okay, that's young people's here. What's up guys? I'm about halfway home now. It's been pretty crazy, pretty crazy. I'm pretty tired.  I'm getting back onto that bus and then I'm just going to go home. I'm going to have a shower, possibly conk it out, maybe put this video together. I don't know. I don't know. We'll see.  If you want to see more crazy videos from me, just let me know in the comments below what your interests are and I'll try and focus a bit more on that. And yeah, subscribe if you haven't already, share this video around with your friends and I will see you in the next video. And if not, well then I will find you.


recording your life. Welcome back global supply chainers. So we are going to start with the we have received very good questions about Samsung, Hanging and Brexit. We are going to start with the Samsung case study, Professor Sheffi. So first thing, why did you think that this Samsung disruption happened? Hi everybody. Samsung was an interesting case, still is an interesting case and I will compare it or talk about it in relationship to the Volkswagen scandal because in many ways both of them happen for the same reason. Samsung tried to beat the iPhone 7 and go out with the Note 7 before the new iPhone came out. So instead of worrying about quality and making sure that everything works, they tried to get to the market too fast. By the way, they repeated the same mistake. After the problem with the batteries was discovered, they took only less than two weeks in order to say they found the problem, they fixed the problem, they can supply worldwide the new Note 7. They have a whole new system of replacing the phones and again it was too fast, turns out it was still a project. So they ended up with first a recall and then they stopped selling it. The stock dropped by more than 10%. They lost by some estimate between two and three billion dollars but more importantly is the long-term hit to the company's reputation. It is the same thing that happened with Volkswagen. Volkswagen was pushed very hard rather than worrying about the cars and the quality and the customer service. They tried to beat Toyota. They tried to make sure that they are the number one volume car producer in the world and they took their eyes off the ball in that sense and added to this, to the vanity that caused all this is the fact that they did not want to use the diesel technology used by BMW and Mercedes. They want to develop their own and the engineers simply couldn't do it. So they were pushed to the limit and at the end they simply cheated and got costs and again a huge loss. They are facing tens of billions of dollars in fines all over the world. For example in South Korea you cannot buy now a Volkswagen diesel car. The government dumps allow them to sell it in the South Korea. They are fines in the US, Europe, Asia and again the long-term problem is the hit to the reputation. So in both of these cases the company leadership took their eyes off the real reasons for being in business and tried to hit goals that had nothing to do with business like being first to the market doing things very quickly or beating Toyota instead of being the number one car server in the world with bad results. Yes I fully agree. Fully agree with this long-term impact and in terms of the impact on the competitors what are your thoughts? With Hanjin, with Samsung it's the best thing that could have happened to Apple. Most people are not likely to switch from Samsung which is based on the Android system to Apple which has it on iOS, it's on operating system because it's so different and it's tied to the whole ecosystem of Apple. But as it happens at the same time that Samsung had its trouble with the Note 7, Apple came up with a new phone that is the latest Android system. It looks very similar to the Samsung phone, it's an Android phone and it looks like it's going to be very successful in the marketplace because a lot of people are going to go want to stay with the Android system but lost some trust in the Samsung. As an aside by the way Samsung is offering $75 to anybody who returned the Note 7 and buy any other product of Samsung trying desperately to keep hold of the customer and don't let them defect. We'll see how that works. So then let's say that Google was one of the most. Google is the one and of course every other Android the LG or the Chinese ones but Apple came out with this very high-end phone the Note 7. So it's the people who buy high-end phones. These are the people who will buy the Apple, the no Google phone. Okay, so then let's move now to the Brexit. One of our students are interested in knowing about how will this breeding exit affect the trade especially with the European Union in terms of this global economy and barrier to take. Yes, Brexit was obviously a surprise to many people because a lot of the polls leading to the Brexit vote did not indicate that the levers the people who wanted to leave the EU will be successful but they were and right now it looks like we are heading towards what's called a hard Brexit. The problem is that the EU would like to keep its trade relationship with EU. The breeds need the EU. This is the biggest trading block that they have but not only this through the EU they have their trading agreement with all the rest of the world. They don't have their own trade agreement at all. They all have it through the EU but the main reasons the the levers voted to leave the EU was they wanted to control immigration into Britain and this is just incompatible with so they want to stop the free movement of people and this is one of the tenants of the EU. If the EU will give up to Britain on this the EU might as well not exist so the EU is not going to give up on this and the breeds given the vote cannot give up and cannot agree to allow immigration in which means that there will be no agreement and the chances are my estimate is we are 60 70 percent that we are heading towards what's called a hard Brexit which means Britain will not have access to the EU and we'll have to renegotiate all its trade agreement. We're starting to see the first effect of this after the initial effect of the pound losing a lot of its value and making British trade relationship more competitive. This was the first few weeks after the after the Brexit vote. Now we see reality setting in. First of all inflation is in in the UK is starting to to perk up. Some of it we saw in the relationship between Unilever and Tesco but this is just this is absolutely the start. Lots of even most of the goods that are being manufactured in Britain use parts that come from from the EU from Germany from Spain from France. Now think about what will happen. Those parts will have tariffs on them and then when car or product comes out of Europe to the EU they'll have another tariff on them. So we will have the the British product that just not going to be competitive. By the way we saw it when Carlos Ghosn the CEO of Nissan and and I know and had a meeting just last week with the new Prime Minister of England May and he came saying that she agreed to make Nissan whole if Nissan would keep investing in Britain. This means that by the way this is another thing that's illegal based on the EU rule because this is government subsidies to manufacturing. The EU does not allow this. So none of this is going to happen and in fact if they offer subsidies that you will raise the tariffs or so if Britain I believe Britain is a knowing situation and the problem is that at the beginning the real effect takes a long time and furthermore at the beginning people still were toying with the idea that Britain that the UK can retain its access to the to the EU but given the EU response to date and given the fact that for any trade agreement all 27 countries have to agree you can always count on at least five of them not to agree to anything. It's inconceivable to me that Britain will be able to get access to the to the EU and by the way they lose so-called passport rights which means the financial industry in London will take a huge hit and already we see you know I'm working in Luxembourg now and we always see people in Luxembourg in France in Germany wooing bankers in London to try to come with giving them lots of tax inventors and other in order to come in and it looks like if London is going to lose its place as the financial capital is Europe manufacturing is going to take a hit. In my estimate the Brits are up for a generation I'm talking about 25 30 years of decline unfortunately it will also impact Europe it will also impact the rest of the EU and we see we'll see problems in in the EU as well. Now I must say this will take May the the prime minister announced by end of March 2017 they'll invoke article 50 which means they have two years or two years to negotiate it's hard to imagine how ridiculous this sounds. In the last seven years the EU has been trying to do a trade agreement with Canada where both countries wanted it they still don't have it and now it looks like it's dead so it is seven years of people who are you know professional negotiators Britain by the way because doesn't have any trade negotiators they have to train somebody to do they have to train hundreds of people to do it it is hard to imagine anything but so-called hard Brexit where Britain leaves the EU has no trade agreement the country plunging to bad recession close to a depression and we'll see to me that only two options that are realistic one of them is so-called hard Brexit recession depression another one is a year and a half into the process somebody in Britain wakes up and says this was the stupidest thing they have the mechanism to do you heard it here first because Parliament has to decide on final decision on Brexit and Parliament can absolutely revoke what the with the referendum suggested so I see only two possible I would say 90% the first one maybe less than 10% the second one because the second one requires unbelievable leadership the second one requires telling people we know what you want but you were wrong and we are the Parliament and we will make the decision as good for everybody but the world is general is so missing such leadership anywhere I'm talking in the United States in Europe anywhere that it's hard to imagine anyway I give you a long answer to a short question no this is good no but connect very well with the Ajay question Ajay is one of our students he's working in Unilever and he wants to ask you what is how should companies plan for this kind of disruption what can I do I work for Unilever I just saw the dispute between Tesco and Unilever so what can we do just for those who don't realize this Unilever told Tesco that they tried to raise the price of some stuff that's actually made in England but using components that are made in Europe so the of course the average British voter said why are they raising the price it's made right here in England well but it has ingredients that are brought from Germany from France from the rest of Europe and so because of the weak pound they don't get enough to cover their costs so Unilever wants to raise the price my guess at the end of the day this is just the tip of the iceberg you'll see price as inflation going up in in pound terms we're just seeing the beginning of this and my guess we will see bad inflation companies will raise prices they have no choice but doing this there companies cannot lose on every item and make it up and it just doesn't work I mean you just lose more companies cannot for the long term they can sustain some losses to lose to keep market share and by the way you see it happening in luxury goods so if you want to buy a Prada pocketbook or some other or a world watch the cheapest place to buy today is London because you buy it in sterling and in order to keep the market share all these companies the huge margin they can withstand this when you sell something in Tesco supermarket you have very very limited margin you cannot withstand it so the most of the British population will feel it because they cannot withstand these companies that sell in Tesco and in you know any department store cannot withstand the low pound the low pound so they'll have to raise the price and the problem is the problem with the Unilever is that they had to go first but it will be a wave and it's not going to affect Unilever because everybody else will have to do it they cannot withstand it for long term yeah great answer so let's move now to the handling case our ceiling are interested in knowing the long-term effect of the handling problem perhaps yes and the question actually mentioned some of this first of all the context the handling case happened when the situation of most maritime companies is very shaky the prices are extremely low and they don't cover replacement cost companies do not do not replenish the capital to be able to replace assets or keep assets so because of these low prices this is just the first this is the the canary there are many many smaller companies that are tittering on the verge of bankruptcy which means and shippers know it so the response shippers is to make it even worse because there's a as the personal asset there's a flight to quality you want to make sure that the your cargo does not get stuck like the hunting shippers for weeks and months when you cannot take it out so you don't go to the lowest price you don't go to the small ocean carrier you go to the big one you go to mercy you go to and all these guys can expect their market share to go up which means it will only accelerate the plight of the smaller carriers the result can be you can be two results with support because of them there may be some more carriers that will go down and we'll see a wave of consolidation the small carriers will sell themselves basically to the larger carrier so we will expect the mercy of the world and the sea and others to grow and not make much money because the price is still low but in the long term the growth can help them control more more the market and actually reduce capacity and stabilize i don't increase the rates stabilize the rate the problem with this the underlying issue is that trade is not for the first time in decades trade is not growing at the level that gdp is growing trade is growing trade used to grow twice and three times faster than world gdp it's not the case furthermore you have to look at the political system in the united states both parties are against trade now both parties democratic republicans are against trade you see this you see brexit is actually a vote against trade there's a lot of parties in the in the EU who are on the right and they've become more more nationalistic more more against trade you see what's happening in the south china sea the companies are becoming leery of what's happening with china and may affect the trade so trade in general is going down which means maritime shipping is going down because that's the main engine of trade the main engine of economic growth so we are we are up for a few years of trying time all over the world okay so we have one question for an expert in supply chain mastery this is what is the difference between resilient company and an agile company okay let's define define the term resilience is the ability of a company to bounce back after a disruption resilience is a term taken from a material science it's the ability of a material to get back its former shape after it gets some type of to recover basic so we're talking about we're talking about resilient company we're talking about its ability to get back to the former level of production level of service customer service whatever after it after it's being it's being disrupted agility is one of the ways that companies can achieve it companies can achieve that by having lots of inventory it's expensive but there's a way way to achieve it companies can achieve it by having you know several you know multiple suppliers company can there are many ways that companies can achieve it being flexible and agile which means it's the ability to move fast it's a it has several elements it's a structural element of how the supply chain can be structured it has cultural element of how people in the company think about and prepare for anything that can happen i would say that one of the best quotes it's from Andy Grove who used to be the CEO of Intel to say only the paranoid survive Intel is a company that always looks behind behind its back to see if there's somebody coming coming at them and it helps them keep keep on their toes and there's one of the best companies to read some of my writing and i talk to dozens of companies i always put Intel as the good standard in terms of always being ready always thinking that they they now think on top of the world but they can be top of any any means so they watch it they try that they might try to go to a to cell phone to internet of things because they see that the pcs are going down even though they had a very good quarter last quarter pcs actually went up but they are getting into automotive big time they're getting into many other markets it's part of always looking behind the shoulders and seeing somebody's coming together even though it's amazing because they have like 80 percent of the market in most markets but they are absolutely not sitting on the lawn and just waiting for something to happen so they've been they've been in some places they've been relationship with extra suppliers they they have a lot of software that looks at everything that happens around the world to get ready for something they have a whole system of emergency operation center in each one of the plane they have a corporate emergency operation center that they communicate between all these and coordinate response to disruptions they have communication system and every one of the plane from telephone and internet the satellite phone and and hem radio in every one of them so they can always communicate they're ready they are they always expect something to go wrong and so as I said this is not only supply it is a control it is at the same time very much so very much so okay so I think we are on time thanks a lot professor today thanks for sharing your thoughts thank you everyone for joining us I hope you enjoyed the event good luck with the final exam see you soon bye see you guys good luck


I'm Jane King for the Street from the Nasdaq Market site in Times Square. Hurricane Irma was downgraded to a category four storm overnight, but its wind speeds are only a few miles per hour less than a cat five. It is still on course for South Florida. The last flights from the area will go out tonight, but most planes are sold out and more than 2,000 flights to and from Florida have been canceled. There is worry about hospitals in the affected area. The five hospital companies with the most Florida exposure are Tenant Healthcare, Envision, Surgery Partners, HCA and Community Health Systems. Meanwhile, Mexico was hit with a massive earthquake overnight. The Pacific Coast of the country was hit with an 8.1 magnitude quake, which was felt for miles it's triggered a tsunami warning in Mexico and Central America. At least five deaths have been reported as being called the most powerful earthquake in a century in that area. And shares of Equifax are sharply lower as it said it suffered a cyber security hack that potentially involved the private information of about 143 million Americans. That's almost half of the U.S. population. Criminals got access to files that included names, social security numbers, birth dates, addresses, and in some instances, driver's license numbers. It happened in May through July of this year. Also, three executives at Equifax sold stock on August 1st before the breach was made public, although they say they didn't know about the hack when the stock was sold. The FBI is actively investigating and Equifax has been cooperating. Now happening today, the Baker Hughes rig count is out, consumer credit will be reported, and Philadelphia Fed President Patrick Harker will be speaking today. That's a wrap for us. But be sure to track breaking news and analysis all day at TheStreet.com at the Nasdaq Market site in Times Square. I'm Jane King for The Street. Have a great day.