the University of Melbourne. And I'm guessing given that the weather's pretty shitty here, he's probably currently in Melbourne rather than Sussex. No disrespect to the gentleman from Rye, I'm just saying that I imagine he organises his life that way around. And it's called the Experience Machine. And it has, it takes effectively not a completely new theory, because the originator of the theory was really in the 19th century and a guy called Herman von Helmholtz. But the theory is, the theory is that most of what we perceive is actually an internally generated prediction with our eyes, noses, ears and other senses effectively used to correct for what we expected not to generate the data fresh. Now let me explain this, those of you who are into digital photography or anybody with a television for that matter or anybody who uses a computer knows that there are things called jpegs. If you like you can take your digital camera if it's reasonably expensive and you can shoot in raw mode, which means that every pixel is described in painstaking detail. Now raw mode is what you use as a digital photographer if you're planning to do a lot of editing, because you need to have a value for every pixel in order to do really, really effective kind of photoshopping. The reason almost none of us, unless you're a professional or prosumer photographer, the reason none of us shoot in raw mode is that a raw image is literally sort of 50 times larger or 30 times larger in terms of the space it takes up on your phone or your camera than a jpeg. And the reason the jpeg achieves this data compression is that it assigns to each pixel or each pixel in each frame in the case of mpegs in video an expectation value, which is based on what the adjoining pixels are. And if you've had three brown pixels in a row you expect the fourth pixel to be brown. So you just describe that kind of as you'd expect. Very little data needs to be used and you only use the data to describe the pixels that are doing something that wasn't predicted or expected. And that's what digital cameras have arrived at as a data architecture for efficient use of bandwidth. And the theory of Helmholtz, which came before there was such a thing as jpegs obviously because it was the 19th century in Germany, and then later espoused by people like for example William James and a few other people I think also bought into this idea is that the brain has the same data architecture, that we don't actually use the seven megabits or whatever it is that our optic nerve provides to form a picture. What we do is our brain generates an expectation and we use the limited bandwidth within the optic nerve effectively to correct where reality differs from expectation. And so most of what we taste, most of what we smell, most of what we see is generated internally from an expectation and then corrected for if conflicting information emerges. So in other words we use our bandwidth, our perceptual bandwidth to go here is what you weren't expecting, not here's everything. Okay? Does that make sense? Because it makes sense in the design of jpegs and the design of televisions, sky wouldn't work without data compression of imagery. You'd simply need vastly more bandwidth and in the same way our brains wouldn't work if we tried to use the optic nerve effectively to every single or 30 times a second or whatever it is to basically give us a complete up-to-date accurate depiction of reality. Most of what we're seeing is internally generated. And if you wanted to summarize the book in a sentence you could say well the science is in and the marketers were right all along by which I mean that what we expect of something has a fundamentally significant bearing on how we perceive it and how we experience it. And so you know I think it explains things that have often baffled me. It explains the fact that 3D TV never takes off. It explains the fact you want my prediction that Apple's immersive 3D virtual reality thing will never be popular for significant lengths of time because for various reasons it's not how we it's not how we think or experience the world. And actually 3D TV most of the 3Dness that we perceive is actually done internally in the brain.  Okay and so it but it also explains why stage magic works because effectively what always amazes me about stage magic I've got a friend Paul Craven who's not only a very good behavioral scientist he's also a brilliant magician he's a member of the magic circle and he makes the point now it's not that surprising that stage magic works in front of an audience of 200 people but what's amazing is that it still works on TV okay when you've got an audience of millions who can pause and rewind as often as they like and nobody can see what it's done and the reason is that what the magician does is he creates an expectation flip from right flip from hand from hand okay you create the expectation and then you disguise the deviation for the expectation because you keep the coin in one hand and pretend to move it to the other one and when you go your hand is miraculously empty you've amazed you've effectively confounded someone's reasonable expectation and once you accept this fact that actually most perception is internally generated uh the case for marketing I think becomes about five times stronger because what you perceive is what you get and it's fascinating because I've just come off a call from the founder uh Lena who founded air up I don't know if anybody has an air up water bottle did anybody hear and effectively is a water bottle that you fill with water either still or sparkling and then if you pull up the little nodule the little capsule of scent it scents the water okay and effectively the reason she developed this extraordinary product so you can effectively use tap water in combination with a small scent pod and basically create taste you can't create 100 percent of the taste of say lemonade or phanta but you can create about 70 percent of it and the reason that works is she basically was studying neuroscience and went to a neuroscientist who said that actually it only works one way around so our smell if the smell originates in our mouth and in the water and then permeate through to the nose that creates the illusion of a taste if you had a pod and stuck it to your nose and breathed in while you drank water um olifaction that comes in through the nostrils does not get processed as if it's taste okay it gets separately processed and allocated to a department of perception called smell but then there's this separate form of olifaction which is mouth up to nose where effectively we process it as part of the taste experience because the tongue only detects what is it five things sweet sour whatever it is something rather an umami I'd never remember what they are bitter sweet something something else and umami okay or monosodium glutamate if you're a fan of chinese food and that just struck me as a brilliant innovation which has come about um in part because people are starting to realize that we need to optimize the world for perception not for objective reality and if we spend our time and if or if ai spends its available bandwidth effectively optimizing for what we can easily measure which is what is rather than for optimizing around how we feel okay this will lead to an extraordinary misdirection of effort and so that book is I think one of the essential you know it's a kind of I would say that theory is kind of foundational in doing what we do because essentially it explains why I think okay I mean you may have read this in my book I think I mentioned in the book if you want to save money on a new car just get your existing car and have it validated okay now not only will you have a cleaner car it'll drive a hell of a lot better it'll feel smoother it'll accelerate better it'll be quieter it'll corner better every aspect of your car will become a bit better when you have your car validated and I had a friend who was an engineer who was driven insane by this because he thought why is it that my car's quieter after I've had it validated why does it feel like a limo rather than the kind of you know a little bit of a banger after and he said he thought he had this bizarre engineering theory that the act of polishing the car tortened the panels on the bodywork which reduced vibration it isn't that it's just your brain going new car therefore I'm going to generate nice new car feeling when I drive it and you know I find those things just endlessly really fascinating I mean you know you know maybe you know but also it frankly explains why we process surprising information differently from expected information which is why perhaps you know creative advertising always has that slightly gratuitous element of okay about it because essentially you know there's one form of attention which is business as usual attention and there's another form of attention which kicks in and generates effectively you know effectively we attach much greater importance to what's surprising that what isn't and that that brings me to things like you know thought insights in customer experience which is that everybody benchmarks around what a hotel should do and by the way you should generally try and minimize nasty surprises in customer experience I think that's an important thing to do but it also suggests that we can do we can achieve extraordinary and actually very very cost effective emotional effects by doing remarkably small things that weren't expected I mean if anybody's here wanting a brief over Christmas the great brief and challenge for behavioral sciences if you're a hotel how do you make the checkout experience feel really great in other words how do you how do you exploit the peak end rule to go oh that's really good you know you know now I did jokingly say the one thing I'd like from a five-star hotel which they never do is a person to go to your room and check you haven't left a sock or a pair of shoes behind or anything like that but that's probably too time-consuming so a friend of mine who stayed at the Manuel cat saison in Oxfordshire they actually because everybody drives there because it's in the middle of nowhere and a lot of people stay the night because obviously they've had a lot to drink and when you leave they give you a box of hand baked biscuits or cookies to the American audience and say here's something for your journey home okay now obviously you can do that if you're the Manuel cat saison and you can afford to do it because the the buggers have spent best part of 1200 quid on a dinner and an overnight stay okay probably not that much but not far off but is there a way no you know I notice things like I don't know if they still do this but selfridges if you pay by credit card they say thank you very much mr. Sutherland okay now that's meaningful it's unbelievably meaningful because nobody else does it okay it's not difficult the name is on the card assuming you're not using a stolen credit card it's generally really flattering and pleasant but for whatever weird reason nobody else does it by the way that's what we were talking about here I owe Gareth an email so thank you enormously the Stilton in particular but all of them absolutely fantastic so Gareth I'm very conscious of the fact that I owe you a huge vote of thanks which is hugely delayed because it ended up in the parcel room of Ogilby for a few days but if anything that only served to improve the Stilton so double thanks to Gareth there sorry about that a second way into a cheese story so that was the experience machine by Andy Clark that we were talking about that it actually reminded me Rory of one of your guests at Nudge Stock and that was Guy Leshzina now he's written a book on the senses I think it's called The Man Who Tasted Words but his films video that he showed during his talk on stage were quite amazing weren't they of people who were asleep but to all extents and purposes as we watched the film it was as if they were awake and you have exactly this phenomenon where I suppose dreams are partly explained by this by the way in the book Andy Clark takes it even further and says there are things we should look at in in people who are neuro non-typical in particular things like ass mergers okay which is to do with the calibration of incoming data versus expectation now I'll give you just a very interesting where I think the reason I'm telling you this is because the theory is really really interesting but the theory also has very very wide applications and there's a really interesting finding in the book where people with a very large number of people with autism okay an extraordinary large number cut the labels out of their clothing because they find things like that really irritating okay and he suggests there's something to be learned here from this which is that you know if you if you don't have autism if you're neurotypical when you put a new piece of clothing on you probably sense that I can sense it now when I think about it the label on the back of my shirt that's touching my neck but after about three seconds of wearing the shirt it goes into expectation value and you no longer sense it that's very very interesting that people with autism are continually irritated by this thing which is where you get this problem of over stimulation for example okay and then then the argument is that something like schizophrenia may happen the other way around where actually what your brain is generating overwhelms your perception of reality to an extent where you start to get voices in your head and so on so it's really it's you know I think this theory it also explains by the way the whole patterns of brain movement where if perception work the way we conventionally think which is top down you'd expect to see a lot of neural activity in one direction and not much in the other as it were and yet if you look at the actual brain activity it's actually dominated by kind of bottom up generated internally expectation corrected by and this has a bearing on robotics for example so movement is you imagine a further a future state that you find desirable like holding a mug and then you move towards the mug constantly error correcting as you go which is why children are effectively learning to move and the process is Bayesian effectively okay I don't want to get too nerdy here okay but what's fascinating there is that it looks like the big advances I met Sir Patrick Vallance at a dinner it was a by the way I had to do an after-dinner speech at the annual Harvey and dinner of the Royal College of Physicians and I must have been still about four days beforehand I was mentally just thinking okay after dinner speech to alerted doctors you know I better tee up a few off the cuff knob gags and make sure it's a bit of a laugh and then about four days beforehand I checked the invitation list which included Chris Whitty and Sir Patrick Vallance and I thought I think I probably need to raise my game here a bit but the really I think it's I think this is fun to what Patrick Vallance was saying is that the big progress in robotic movement because robots find really difficult to do the things that humans find really easy to do opening a door knob for a robot is like a fumbling messy hopeless experience okay and similarly picking up that mug or holding an egg is something it's really really difficult to do and the progress that's been made in robotics is effectively to make the process kind of work backwards effectively very very interesting I mean I would say by the way one of the reasons the book's so good I'm interesting is I've always thought that actually the creative solution in so many cases or the most one of the most useful creative kind of techniques is think about this backwards you know the most creativity most real breakthroughs happen backwards okay and actually maybe maybe this kind of process of expectation followed by correction is actually much more fundamental to the world than the process we prefer to think about which is forward intention and so I'm going to mention you mentioned other books I'm going to mention another business actually which has fascinated me and I had this conversation I don't know very much about Mentec but the guy who is one of the co-founders of this Cambridge biosciences company I was just chatting about this and he said much to my surprise because I thought what I was saying was fairly obvious he said thank you you've just helped me clarify something that's been confusing me for 12 years okay and this company effectively one of the co-founders was the co-discoverer of Viagra which is famous for being a discovery that happened backwards okay now if you look at the history of science nobody was trying to invent steam engines just as nobody was trying to invent red bull okay no one was going we really need a disgusting tasting drink get right okay no one was trying to invent apparently the walls via netta came about because there was a wonky conveyor belt which juddered which caused normal slabs of ice cream to be produced in a kind of scroll work okay so so from Viagra to Penicillin to the walls via netta to graphene to whatever most of this stuff actually happens backwards it's also if you like weirdly the intellectual justification for a kind of conservatism I'm not making a political point here which is someone once described socialism as the mistaken belief you can get something right first time in other words you solve it in theory implemented in practice and actually the extent to which and I won't talk about the bees again because everybody will have heard me say that but the extent to which there's this explore exploits trade-off and that most real progress comes from exposing yourself to surprises not in actually seeking out something that you've envisaged in advance okay I think that's a fundamental kind of question in epistemology but interestingly it's kind of a fundamental problem it's fundamental issue in creativity as well and you know talking to John Cleese that's another book I recommend probably I read it the year before in fact although I've read it since because it's one of those books I reread along with Obvious Adams by the way Robert Uptograph's book Obvious Adams which looks like the hokeyest like 1960 in American kind of get rich quick business book when you first open it but when you actually read it it's it's very it was one of David Ogilvy's favorite books by the way just just to give it a bit more imprimatur if you like but but this this this really interesting question in creativity that one of the reasons creative people are really annoying is they have a different methodology to most people now occasionally okay I give a talk like this typically to junior marketers okay it tends to be more junior marketers and I give such a talk and then I'm told afterwards by five of them not all of them but a few people right back again this was no use to me I want to be told what to do okay I don't want to be told how to think I want you to tell me if if you have to do this then do these five things in this order okay and they get really really frustrated with information which actually requires interpretation they just want instruction they just want an algorithm okay and I always say look if that if your audience is like that go and get somebody else there are loads of people who know more about that than me and you know frankly that's not my forte because my forte is sitting around going I don't know what to do next okay and John Cleese's book um which is called creativity a short and cheerful guy makes the point that real imagination happens from people who effectively procrastinate okay and the reason they procrastinate is not as but is not because they're lazy although they might also be lazy okay the reason they procrastinate is because they're waiting for inspiration to strike they're waiting to get lucky and Cleese describes this experiment which was done with architects and they got a cross section of architects to nominate the most creative architects people who are generally regarded to be brilliant inventive okay and then rather more furtively they got those same architects to nominate 10 really worker day uninteresting boring kind of lackluster architects and they went and looked at how they worked and the absolutely unvarying um pattern that emerged was that the worker day architects started work straight away they got the drawing board out and the bloody ruler and the routine they got that out straight away as soon as they got back they started planning for the thing and the interesting creative architects didn't do they doodled or they wandered around or whatever right and their their time appeared to be totally wasted in the beginning of the process okay and um what they were doing effectively was waiting to get lucky waiting for some surprising information to either arise externally or to emerge in their own brain which would give them effectively a head start okay so in the case of a classic architectural case Frank Lloyd Wright was briefed to build a house uh falling water as it subsequently became near riverrun Pennsylvania if ever you find yourself in western Pennsylvania and go there because it's fantastic okay it's one of the best you've got a book in advance at all but it's very well organized and you'll probably get in if you book the day before but it's great okay and um the original brief was this is our favorite place the family likes to swim in the waterfall so can you build us a house overlooking the waterfall and Wright's you know ticks around for eight days or months or whatever it is I don't know his working patterns and then he suddenly has the inspiration why don't you just give them the rocks why don't you build a house on top of the waterfall okay in other words let's rethink this and it always interests me how you have we have these mental blind spots and we have to wait for them to go away and so this business of procrastination of starting late and waiting to get lucky or waiting for a a lot of getting lucky is actually not actually seeing something new it's sometimes waiting for a blind spot to disappear it's waiting for an assumption to disappear and that takes time and I think it suddenly occurred to me that of course creative people are kind of weird because they are really really annoying if you want something done straight away to your exact specifications they're the they're the worst people in the world if that's what you want but on the other hand if you want us a breakthrough innovation or at least the chance of a breakthrough innovation which solves the problem not incrementally but by an order of magnitude that's exactly what you need to do and so I you know I'm intrigued about how we eventually end up with what is creative AI and how is it different from the standard AI we're starting to see at the moment uh you know um you know well done draper on his couch uh no no well I mean that what was interesting about that was I mean particularly of course the final sequence in the film weighs in an ashram in California and has the inspiration for the cocad which is I keep realizing that the real excitement comes when you in many cases it's actually when you stop see you either start seeing or you stop assuming and that's why a large part of creativity is actually reductive you know I always tell the story by the way um it's another train story but not the usual train story the guy who designed the high speed train anybody in britain here the intercity 125 high speed train was almost produced as a kind of stop gap solution two banging great diesel engines at either end of a train going really fast and it turned out to be in a way one of the most successful things ever done in rail in britain it was a fantastic train for the diesel age they were basically pretty reliable they were bloody fast they did tend to make then there was the stink of the of the brake pads that kind of got into the air conditioning I think they solved that eventually but basically it was a brilliant train very simply put together but when the guy had the specification it included buffers behind the reason it looked unlike any other carrying uh train is it was one of the earliest trains not to have separate carriages the train looked like one long tube and the original brief the original specification required buffers for shunting and the guy who designed the train said uh we actually said why does the specification include buffers and they said it's for shunting are we ever going to shunt this train given there's a diesel at both ends um no right well we don't need buffers then and it's those kind of things which is the you know a specification had got kind of rooted into procurement and what the guy realized was that circumstances had changed and so that assumed requirement for a railway carriage no longer applied I think there's an awful lot that happens with technology which is what no longer needs to happen now we have this technology okay I mean I'm fascinated by the psychology of zoom calls which is why do we still make meetings an hour long okay you know and funny enough we said we suggested this to zoom and they didn't take it up which is you need to create a little format and a name for a 10 minute zoom call okay you know particularly if it's one to one you know maybe an hour is just too tiring maybe people can't commit but you need you need to create a little thing called a zoomet that wasn't our recommended name but you need to create a little thing which is by the way just fancy 10 minutes on zoom yeah okay the elevator pitch equivalent of zoom and we said well the main reason meetings are hour long is if you travel to a meeting or you have to be in a place for a meeting it's discourteous to make someone travel to something and then give them 10 minutes of your time and make them go away you know you feel as if you've been kind of slightly um hard done by it was an absolute pain in the ass when we were based in canary wharf because quite often people will come and see me in canary wharf and they go da da da da this is my work all right I might think this is a really good book I need to put you in touch with the creative director who's currently hired okay now I could do that in 10 minutes but because they traveled out to canary wharf you have to give them an hour of your time because otherwise you looked a bit of an asshole okay and then I suddenly realized you know I suddenly realized there are a load of assumptions here now I've had a load of a few NHS and one one private medical procedure okay and this came from a kind of thinking about zoom which is with a few people we had we met up fairly regularly and I said look this is really easy why don't we just block half an hour on zoom on Monday and half an hour on Thursday and if the Monday meeting it doesn't happen we'll do it on the Thursday okay so we've got a bit of wiggle room because nobody minds having one meeting cancelled it's half an hour back in your day right cancelling a physical meeting is an absolute insult because someone might have planned their entire day around traveling to see you traveling as zoom cancelling a zoom calls you know not really it doesn't inconvenience the other party at all right and then I suddenly thought well there must be a better way for the NHS to do waiting lists my impression of the NHS by the way is that it's actually an extremely good service in terms of the medical care you receive with a very bad user interface okay and by the way the Ogilvy chap called Dishwan Dhomant who's the Ogilvy's head of kind of UX he's actually from the United States okay I said to him what's your impression of the NHS as an American of course as a UX expert and he said exactly the same thing unprompted he said it's a great great service for the terrible user interface and one of the things I said doing the NHS thing is why don't they give me three appointments okay right and say it'll probably be the middle one but if we need to bring you if we can bring you forward because we have a vacancy or a cancellation why don't you block out three days out now I'm having an operation it's a day procedure okay but it's a day operation I can easily not go on holiday and not and agree with my employer that I don't take any strong commitments on three fourth coming okay in order and yet we also have the psychological benefit okay and you wouldn't feel you wouldn't feel oh god now I'm back to the back of the queue again oh god I had to cancel my procedure now I'm back on the waiting list you just go okay I'll default to apartment number two now all I'm saying I'm not saying by the way I'm right and this will require a whole load of economists who specialise in kind of coordination problems to see how you could improve things this way what I just spotted was there's this underlying association sorry there's this underlying assumption that when you make an appointment you just make one and actually you know a great thing would be look we'll block out because free time is wasted if you you know if you're I'm sitting here if you all cancel this I would have been offended if everybody simultaneously had decided to cancel me but what I'm saying is I just go okay we'll do another time that's fine I'll get on with some other stuff and so it really interests me that there are these what happens is we carry over the assumptions from one technological context to another you know I find it really interesting in electric cars because I suddenly realised that you know electric car charging points unlike petrol stations aren't very visible so actually if you're driving in your electric car and you say uh find me charging stations if you're driving through London you're bombarded with there are tons of the bloody things but unlike a BP station they're not on a main thoroughfare and they don't have a massive great light so you know as a consequence what's happening is people go oh I don't know where I charged my car well actually that's a change because petrol stations existed in an age before GPS and their locations predates GPS so they had to be on a high traffic road with high visibility and high advanced visibility so you could decelerate enough to turn off and go and buy your six gallons of five-star and a pork pie from M&S Simply Foods of course that doesn't apply anymore there's no point in taking up what you might call prime retail real estate for an electric car charging point and it isn't very big and you can't see it okay so that's the that's the kind of that's the kind of point I'm making which is that an awful lot of our behaviours come from failing to do this business of correcting for new information we're effectively thinking with a with a kind of prediction and expectation which might have been formed in circumstances different to the ones we find ourselves in I'm in the Insights Rory and I was mentioning there Don Draper we've heard about books that have been important to you in 2023 has that you've had a more of an audio year it seems than actually a visual year but have there been things that have caught your eye films or television or podcasts yes by the way I'll give you a story about this if you're invited to go on a podcast generally go on a podcast okay and the maths I give as an example for that is two things okay one of which is that it's much more efficient spending one hour talking to a hundred people than spending a hundred hours talking to a hundred people one at a time okay simple as that okay we've got 98 people here okay well okay if you subtract me that's 97 now if I wanted to go and have a coffee with all of you it would take three weeks of my entire working life I don't think we're fully conscious of these multiplier effects I always make that case which is the second thing I make the case for and I always have massive arguments with Ogilvy's press people about this okay is the Ogilvy press people it was going you've got to have a strategy you've got to be really efficient with your time you've got to be really ruthless you've got to dedicate your your conferences you've only got to go to the conferences which you know genuinely have large numbers of people who are marketing directors and blah blah blah blah and I get I'm telling you sorry but that's bollocks okay and the reason is that the the mentality to adopt in promoting yourself is one which is opportunistic not which is efficiency focused what you're trying to do is optimize expectation sorry optimal this isn't a seem Talib language optimize your increase your surface area exposure to possible upside optionality now the reason I got invited to do a TED talk was because I gave a talk to Nokia after we just won the Motorola account and the people in the Ogilvy press office were going oh my goodness what if you do this what if you I said look I promise this before we won the Motorola account so I'm going to do it because I promise to do it and you I'm just going to I'll write an email to anybody and say look you know I'm not presenting anything I wouldn't present to you and of course the client's totally unconcerned okay now there was someone there who was from Nokia unsurprisingly because it was a Nokia conference who said we'd like you to speak at Nokia world and I speak at Nokia world which is 2000 people in Rotterdam or somewhere I can't remember where it was the Hague okay and then at Nokia world at the time Chris Anderson from TED was sitting at the back and he came up to me and said I'd like you to do a TED talk that's actually how it works okay that actually the extent to which you can predict and therefore focus on looking for success in a world which is high on opportunity okay now I'll tell you the other story of that I mean I don't know if anybody's else is a fan of Chris Williamson's podcast okay what is the name of that podcast it's called Modern Wisdom and he's actually been so successful with that okay now I've been on twice that the late the later one hasn't come out yet he's been so successful that he's moved to Austin Texas he's actually a Smoggy which I understand is a type of like in the northeast you have Smoggy's monkey hangers and Jordies I don't fully understand that but anyway he's a Smoggy but he's moved to Austin Texas because it's like podcasting central okay now the funny thing is when I agreed to go on his podcast I hadn't it was quite in the early days of his podcast I hadn't got a clue who he was okay so what I what I'm suggesting is that there is this trade-off between effectively there's this trade-off which which I obsess about which is the exploit explore trade-off and that's I won't mention the bees again because you've all heard me talk about the bees but there is this trade-off between exploiting what you already know okay which means that if you happen to know Chris Williams and ask to go on his podcast again or ask him to recommend you to other podcasters in Austin who might like you on the show you don't get in other words there's a trade-off between being long-term lucky and resilient and being short-term efficient and most modern companies are completely blind to that trade-off they think that short-term efficiency and exploitation of what they already know is a proxy for long-term success and it really really isn't and I think that's that that's a what what has happened now in business is we have the procurement finance nexus which makes it impossible for businesses to innovate because finance are busy trying to impress procure I mean the thing that really worries me in the advertising industry I've been on a robin bond podcast talking about this is that the advertising industry is trying to optimize what's profitable okay in terms of billable hours but what's profitable in advertising is not what's valuable okay the things you do which make money are not the things which actually add value it's an oblique business okay the real value comes from sort of insights that arise from the process of producing an advertisement and creativity and things like that most of the money is made doing sort of time-consuming you know programmatic kind of stuff okay and so you have the finance department during that the procurement it's very difficult to innovate because the procurement department are only interested in how much they're paying they're not remotely interested in how much value you're creating because value is indeterminate and impossible to predict in advance whereas costs and cost reduction are certain are certainties and so once you create this loop of kind of left brain Ian McGilchrist left hemisphere thinking it's very very difficult to escape from in other words once you put two left hemisphere people together and you give them a spreadsheet okay you create something which is actually effectively a you know a feedback loop of reductionism and it never goes away and it you know we've I think you know my great concern is it's killing the you know it's killing the advertising industry and to all extents and purposes I think 2023 has been the year of AI chat gpt and the the dry fryer so looking forward can I can I give you this is actually a message of so you mentioned the air fryer one of the things I mentioned in my book I'm gonna know I'm gonna mention a present which if you have a relative or friend who's over let's say 65 or indeed under 65 okay this is the most interesting thing in the world in terms of a failure the standard thing we always talk about is how do we put a man on the moon before we put wheels on luggage okay how come that literally the wheeled suitcase appeared on this earth after we'd actually done the moon landings in 69 and you know let's face it it doesn't require a huge leap of imagination now it happens that I think inline wheels developed for skateboarding and things were actually highly decisive in making really good smooth smooth flowing luggage there was also an element of snobbery which was that you know wheel luggage or luggage trolleys were either you expect to have a porter in the 1940s you would have had a person who carried your luggage and you would have tipped them so there were status considerations and also did wheel luggage make you look a bit elderly okay but here's the weirdest thing okay 98 percent of the world's trays are two handled trays that you carry in front of you like a servant effectively okay and you have a teapot and cups and sauces okay now there is such a thing you can buy as a tray with a handle by which I mean it's got a big handle that comes out of the middle of the tray or two handles and you hold it with one hand okay now that is a far more extreme case of a failure to innovate than the wheel luggage okay because it because when you have two hands on a tray you can't open a door you have to sort of go through doors with your bum first you have to constantly keep the thing level by correcting between your two hands with no work being done with gravity at all okay and the and if you go up or downstairs you can't hold the banisters because you need both hands to hold the fucking tray okay if you go on sites there are a few interesting ones which are like ethnic Moroccan trays which come with a handle so you hold it with one hand gravity keeps it then level because a pot of tea is quite heavy and you walk around opening doors sweeping this tray through everything like a pro you know you're like a french waiter okay you just pick up this thing and you go and here's your tea oh he wouldn't quite do that but you get my point and the gravity keeps it level now the weird thing is the only place you can buy these are on disability websites handle trays I think apps has them but they're manufactured by a company which specializes for disabled people you know who either have root you know problem with a hand or they have problem obviously you know sorry but we should actually burn all existing trays and replace them with these and the reason is if you know anybody as I said over 60 buy them one of these fucking things I bought my parents in law one I bought my father one they're both absolute evangelists for the tray with a sodding handle okay but the reason you should also buy them one is the likelihood that they fall downstairs my father's best friend died falling backwards downstairs while carrying a tray of tea upstairs at the age of about 88 the likelihood that someone has a fall while carrying a tray strikes me as insanely likely so if you wanted I wouldn't be surprised if the tray with a handle if it were made universal added like three months to average average life expectancy and yet for whatever wacko reason most trays don't have a handle okay that's what I mean by you know effectively spotting blind spots and then asking you know and the extent to which we we optimize for what we expect to be thinking oh that's a nice tray and nobody's actually thinking what fucking stupid thing that requires two hands for you to carry a pot of tea and three sauces and cups around sort of answered Raju's question now I was just going to bring Raju in Raju Neera said looking ahead if you had a crystal ball what are two top consumer trends in 2024 I sort of hate to break it to you but I feel it's not going to be the one handled tray but seriously it should be because once you bought one of these things you go shit why did I ever put up with anything else so it is one of those things which I call a bit of a you know it's a one-way door once you've experienced it you never go back um I would like to make that a trend for serious reasons which I think it's genuinely you know after this everybody you need to look out on google trends see if there's a search for trays one handled trays and you remember you remember the behavioural science uh ogle behavioural science practice mantra which is dare to be trivial which is that don't necessarily when solving a problem one of the greatest mistakes is people assume that the scale of the intervention has to be proportionate to the scale of the desired effect and in a complex world like the one we live in and actually to be honest the one we've always lived in um there are butterfly effects everywhere start by hunting butterflies before you then try and have a massive intervention I was quite impressed by the way um um I'll tell you a reason why people from um uh one reason of many why people from uh often immigrant backgrounds are very very successful entrepreneurs okay and it's quite simple which is a lot of them grow up in a shop and if you grow up in a shop or a restaurant it's like a free mba because you get the whole of a business that is just about comprehensible and you understand the interdependent parts of that business what happens now is we produce a load of graduates and they go into a specialized field like procurement where they're optimizing for one thing okay and there's a really really important point which we need to understand that there there are things which are micro rational and macro stupid okay where if you optimize for a narrow measure what you're doing makes complete sense within the sphere of your own particular silo but is actually dumb in terms of the interest of the organization you work for particularly a male problem by the way since I think men it's both a virtue and a weakness of men that men will compete over anything even if there's absolutely no points to it okay right I would I would give it as a female virtue which is there more likely to say are you sure we should be doing this whereas you're just as men will compete over stupid sports or kind of you know place bets on who can get it you know that that male competitive hyper competitive urge is both valuable and a curse I think depending on how it's actually harnessed but this thing about things that we're often doing things that are micro rational and then you look at it systemically and you go actually those two things we're trying to do are in opposition to each other you know they're not they're actually contradictory you know one of the worst things I think you can do is feel that you're efficient when you're busy because the extent to which you're working effectively I mean you know one one really interesting thing with flexible work is the extent to which you know they said oh people are two percent less productive if they work from home well tell them to work five minutes longer they'll take that trade off it's not that big a deal right okay right it's not that that is rocket science but also the extent to which a lot of people I think in we don't really in the office in knowledge economies we don't really measure outputs we measure we measure inputs and I think that's led I think in the open plan visible office it's led to a lot of actually toxic behavior presenteeism being the most obvious one but effectively you know to be honest if you're in a knowledge economy really you should be spending one day of you know seven or eight hours a week just hanging out and chilling and trying to get lucky but you get these people who are basically sort of you know micro focused on meeting some bonus objective I think is I think we've done a terrible thing when we did that I mean literally a terrible thing where you bonus people on a very specific metric um and so you know a lot of what I'm doing is basically you know it's it's uh sublevel Ian McGillchrist it's just the fight against reductionist quantification in everything really and big yeah I mentioned when you joined us Rory more than anyone you are able to speak without prompting and we've all really enjoyed hearing your uh your insights into life today with only a couple of prompts from myself we can we're doing a rapid fire we can do a bit of rapid fire a little bit of rapid okay all right okay that's a challenge so I'll have a look at the chat because there are lots on the chat so there are a few questions last thing you bought and loved how's that for a rapid fire last thing you bought and loved last thing I bought and loved um that's a really interesting question uh actually okay I'll give you another Christmas tip um along with mattress toppers air fryers and Japanese toilets there is an interesting technology which I think is under exploited which is bone conducting headphones now bone connecting headphones by the way if you know anybody over 70 you could buy them some bone conducting headphones because they actually they vibrate through the cheekbones okay and they send the vibrations straight to the inner air now what's often happened in older people is what one of the reasons they're deaf is that the the mechanical bit that connects the ear drum to the inner ear the stirrup and the anvil and all those things has become a bit I'm really fascinating in oldie tech and disabled tech and by the way another great book to read by the way um Helen Edwards from marginal to mainstream you know Helen Edwards if you know her from marketing week she's one of the people along with you know Ritzen people who I kind of venerate in the marketing sphere she's absolutely fantastic and her book from marginal to mainstream which also shares the prediction which I've also made which is that you know in 10 to 20 years 10 to 15 percent of the population might be nomadic in other words don't buy a house buy an electric motorhome because if you've got a big American luxury motorhome and you've got a 200 kilowatt hour battery man you can go off the grid and run you an espresso machine and your telly and you'll have your Elon Musk's you know skylink thing whatever it's called okay right we can actually go off the grid now the toilets the last remaining problem really and we just need a microwave toilet and we're done we can just go off the grid and if you look at an American a huge luxury American motorhome okay costs less than a totally shit flat in London now admittedly it's not going to go up in value but then maybe the flat in London isn't going to go up in value for the next 15 years so it's time to get on the road okay but but um sorry I digress don't get out headphones could be very good if you're elderly and have impaired hearing they're mostly marketed to joggers who are the opposite of the demographic thing typically because you don't lose situational awareness and end up using your massive over-the-ear noise-canceling headphones and run under a bus which can happen okay and you can also weirdly use them in a swimming pool although I don't plan to do that that strikes me as weird okay but there are very the other application for this it strikes me as podcast listening which is actually wandering around the house now okay I'm going to get cancelled for this but bear in mind this is reversible okay it's not sexist okay I occasionally call my Sony over the air WF whatever they are WH-005s my wife cancelling headphones okay they're noise cancelling headphones you can equally call them husband cancelling headphones it's just that they basically they're noise cancelling and for certain things like immersion like music that's really really powerful you know there are times when we want to be immersed I think that this apple goggle thing I don't think fundamentally humans like being visually immersed I think there are loads of times where actually we can just listen to music and immerse ourselves in the music without losing complete vision of what's going on around us okay but I think for podcasts and spoken word uh we don't actually want that level of immersion if you look at digital radios they started as pieces of hi-fi equipment but nobody wants to listen to radio for on a massive powerful speaker you want a little box in the corner of them because it's like a person talking to you now I wouldn't recommend bone bone conducting headphones which are usually made by a company called shocks but there are other competitors I wouldn't recommend it for uh audio files or for music listening but if you're a fan of spoken word stuff I think it's a bit of a breakthrough so that that would be another tech tip along with a tray with a handle fantastic thanks so much Rory um well I don't think we're going to have anything as much as a rapid fire but uh Rory it's been an absolute honor to have you join us here again with 42 courses you're very supportive of 42 courses in general anyone visiting our website will see that Rory is a host and in many of our courses and of course if anyone on the call wants training for their company please reach out to Chris at 42courses.com and also we have a new ad 101 course that has just launched on the website it's absolutely fantastic uh you all as joining us today can use the voucher Don Draper VIP to get a discount on the ad 101 course if you search around you might find it will be valid for discounts on other courses oh someone's just someone's just put themselves up here as Alex Hormozzi's buddy now that's another book I really recommend 100 million dollar offers by Alex Hormozzi he's a big regular on the podcast scene so if you like get into what he says what is interesting I think is you're beginning to find these people who are marketers and I include myself on the fringes of this who actually and I think this is really welcome marketing people from a marketing standpoint starting to pronounce on wider issues other than brand comms and I think I think that's a really important trend and any of you who have an appetite for doing that kind of thing uh you know I make the joke which is only half a joke okay you have a load of economists deciding what the top rate of tax should be in the UK it's currently 40% or 45% above a certain threshold okay now I don't want to be rude but anybody in retail would tell you the top rate of tax should be 39.99 shouldn't it not 40% okay any retailer would have told you that right because what you want is the lowest perceived rate that minimizes the downside effect it has on incentives to work while raising the most revenue okay it's a retail problem it's not an economic problem okay right so and the Alex Hormozzi book by the way he's a really really interesting guy I've connected with him a couple times there's also a book called by a guy who founded a restaurant in New York which is service I think it's called service beyond reason by will something or other and it's about it's about customer experience and it's absolute I've actually quoted it in I'm flattered to say it's but but not for that reason it's a really astonishing book thank you so much anybody anybody in the experience economy go there straight away he's great we'll think of you Bob yeah I'll remember we'll think of you Bob well yeah thank you so much Rory for joining us sharing so many of your insights thank you all so much for joining us on this call it's so great to see you familiar faces familiar names and to see new names as well and have a marvellous Christmas we'll share the recording of this on Monday with everybody and we hope that you all have a very merry Christmas happy new year thank you again Rory and shout out to Amelia Amilia Turode who I've just noticed I've noticed quite a few familiar names here so but all of you have a really really great Christmas and don't work too hard you know thank you thanks everybody


You need a financial advisor with the freedom to focus on your specific needs. Whatever your goals, Reid Potter can create a game plan tailored to you. Call Reid at 432-0777 at Pikeville, Kentucky to learn more. This Thursday, May 26th, the West Virginia Mine Wars Museum is inviting residents to speak with muralist Joel Duggan to get ideas and input for their next mural. Wednesday, Mountain Top spoke with communications manager Kirsten Uten about their next project. So tomorrow's meeting is actually the first time that the community will meet our recently hired muralist Joel Duggan. He is based in Fairmont and is a professor down there. And he has a lot of backgrounds doing murals across West Virginia and Appalachia. So tomorrow the community will get to meet him for the first time. And they will talk a little bit and let him know what their ideas are for the space and for the mural. And then, yeah, that's basically what's going to happen tomorrow and then it's going to be about a year's process. The mural, which will be painted within the walls of the Nenny building, will be the beginning of the museum's possible expansion. Uten adds more. The Nenny building has served a variety of purposes throughout the years. It began as a miners' union headquarters. It went to the town jewelry store. And then it's most famously known for being the home of mate one chief of police, Sid Hatfield. His apartment was located on the second floor. He was a beloved champion for his community. He stood up for all of his residents' rights to unionals during the modern wars. And that actually ultimately costs him his life. We are creating a mural, but we're also deciding on what we want to put in this historic building as well. So we've had mentions of expanding museum exhibitions to talk about immigrant life during the modern wars era. But nothing is set in stone quite yet, so I can't speak much on that. If you would like to join in on the meeting, you can visit the Nenny building at 6 p.m. May 26th. Pizza and drinks will be provided. For Mountain Top News, I'm Joel Korgel.


Verily, the number of months in the sight of Allah is 12, determined the day he created the heavens and the earth, and from those months there are four which are inviolable. That is the upright life path, the upright religion. So do not harm yourselves during them, do not harm yourselves during them, and fight against the idolaters altogether, as they fight against you altogether. And this verse of Allah, of course, he points out many different things, but he begins by highlighting that when he created this planet, he had determined that this particular planet would take 12 months in his revolution around the sun. Now, of course, as Muslims we calculate our time according to a lunar calendar. So it's a little bit short of a little bit more than what we would call 12 months in the Islamic calendar, but a few extra days. Fundamentally, Allah swt made this determination, that this particular earth, this planet would have or take 12 months to complete that revolution around the sun. And he said from those months, four of them are inviolable, and what it means by those months being inviolable is that these are months wherein we are to pursue good, we are to increase our efforts to avoid evil, and it was extremely important, even for the Jahidi Arabs, that during these months fighting could not be initiated. They were not supposed to fight one another. The months of the Ashur-ur-Huram are four, as mentioned by the Qur'an. The Qaeda is followed by the Hidja, followed by the Maharram. All three of these months are Ashur-ur-Huram. And the other one is the Mantarajah. Now, it is said that the reason of the wisdom behind making these months in a role inviolable was that in the former martial order, that people all throughout the world were subject to invasion at any moment. They were subject to raid at any moment. And so Allah swt chose Mecca, a moqarama, of all of the places on the earth to be a place where people should have no fear when they come to that place, no fear that they have their wealth and their property taken from them, fear, no fear that their lives would be taken, that there be no fear that other types of violations against their honor happen and occur. But on their way to Mecca, it may take some people an entire month to get there. So they're given the Qaeda to travel without fear. So this is all throughout Arabia. So it's not only for Mecca, it's all throughout Arabia because these are those special months. Travel to Mecca and then you have a month to perform your pilgrimage and do other things. And then a month in addition to a month to return home, safety, security given. The month of Rajab was special because people generally perform Umrah in the month of Rajab. So it was also singled out as an inviolable month. As people, Allah swt tells us that the human being is disposed to be ungrateful, that we forget the way that things used to be in this world. We forget the fact that we are on a large boulder, if we could say that, floating in outer space, spinning on its axis 1,000 miles per hour. We don't even feel it or notice it that we're going so fast. But even more extraordinary than that is that as the earth moves throughout space on its revolution around the sun, it is moving almost 67,000 miles per hour. It's 88 times the speed of sound. So you're not only doing this, but you're doing this as well at the same time. We don't experience or feel any of those things. We're so grateful and we're, I mean, we're so ungrateful, I would say. We forgive these things. We're ungrateful for security that Allah swt has given us. And that former martial order, again, people could raid and when they raid, they take your wealth. When they raid, they take your life. When they raid, they make you into a slave. They capture you. Those are the things that used to exist. And then Allah swt gave us Makkah and Makarrama. It gave us Makkah and Makarrama. Now compare that to what we constantly experience. 10 people dead in New York, 19 children and two teachers in Texas. Security is the blessing. Now, of course, there are two fundamental types of security. Physical security, but then also spiritual, psychological, emotional security. We can sort of multiply those things, but generally, I sort of placed them under two general categories. Courses easier for us to protect ourselves physically. We imagine, God forbid, that someone comes into the masjid with a gun. I would hope that enough of us would be willing to charge for that person. Some of us may get hit. Some of us may get hurt, but we're going to get him too, wherever that person is. Spiritual security is much more difficult. We let things in and poison our hearts and our minds and the television and the news and social media. Security is something to be grateful for. And we have to understand too that our sense of insecurity is not only... It's just not organic, an organic phenomenon that there are people who want us to constantly feel insecure. Consider this fact. While we are focusing on New York and Texas and Memorial Day weekend in Philadelphia, 13 people were killed. Not a national outcry about that. Yesterday, a 16-year-old boy in Berkeley was arrested for allegedly planning to have a shootout or a match shooting and bombing even of his high school. He was trying to recruit others to do the same. That's pretty close to home. But put things in perspective. We outrage when these things occur. But there is definitely something wrong with the culture in which we live. Taking away all the guns won't solve the murder problem. It won't. But it's okay, I think, is reasonable to want certain restrictions on people who are not mentally stable. But we need to be concerned about trying to address problems from their roots. In 2021, in Chicago, there were 797 homicides. There were over 3,000 shootings that year in Chicago alone. Compare that to mass shootings throughout the country. 61 mass shootings and 103 deaths across 30 states. In other words, mass shootings are terrible incidents. But they are far more normal or not mass shootings happening throughout the country because there's something wrong with the culture. There's something wrong with our culture. There was a man who came to the Prophet Sallallahu Alaihi Wasallam. He was from the Quraysh. He was a mushrik and he came with a group of people and he said, we know that you are the messenger of Allah. We know you are the messenger of Allah, but we are afraid that if we follow the guidance with you, then we're going to be snatched away from our lands. In other words, we're going to be killed. We're going to be massacred by the other tribes, all the tribes of Arabia. We're afraid. Now, Allah mentions this in the Qur'an and then he responds saying, So you say this and you believe that the security that you experience and you feel is because of the Quraysh or is because of the other tribes here in Makkah. But Allah said, no, no, no, this is not why. This reflect upon the fact that I have created a secure sanctuary and the people all around the outside of that sanctuary and those precincts, their lives are ended on a regular basis. This sanctuary fruits of all kinds have been brought to it. A provision from us from Allah, but most of them don't know. They don't know this is the case. Who is it that places it or inspires one to want to come to Makkah? Who is the one who makes their hearts attached to the millah of Ibrahim? Allah said, no, no, that security is not from the Quraysh, it's from me. So don't be afraid to enter into the Deen of Muhammad, SallAllahu Alaihi Wasallam. Imagine if they banned every cigarette to prevent lung disease. Imagine if they banned the cell of wine to prevent liver disease. Imagine if they banned the entry of every narcotic to prevent overdose. Imagine if they outlawed promiscuity and intravenous drugs to prevent the spread of HIV and hepatitis C. Imagine if they banned the sale of every fighter jet, every tank, every missile, tank buster, bomb and military grade rifle to spare the innocent victims of war. Imagine if they charged and imprisoned those guilty of war crimes against the people of Gaza and the Rohingya and the Uighurs and those dropping bombs and starving the people of Yemen, the people claiming that they are trying to save us. Those who tell us that they're saving us from pathogens and from mass shootings are the very people who are profiting from the sale of weapons, profiting from the sale of vaccines, profiting from the sale of therapeutics. And those are the same people who tell us that we have too many people on the planet. There are too many humans and that is a danger to the earth. The point being that there are some things we can control, brothers and sisters, we can control physical threats ourselves. We can protect ourselves from physical threats easily. We can't protect ourselves from the threats we can't see. We can only do what we can do. We can't protect ourselves from COVID. We've massed, we still got COVID. We social distanced, we still got COVID. We faxed and we boosted ourselves, still got COVID. But now, same people telling us, do the same thing that didn't work the last time. And I'm not saying that people shouldn't comply with expectations of an institution. But we just need to understand who's really in control. And I don't mean them.   The disease will pass you by if he decides it will pass you by. Especially when there's nothing left for you to do. Just put your trust in Allah SWT. You can control yourself and protect yourself from physical threats. Those you can't see, listen, put out your tongue. Allah SWT, security is a blessing, it's a great blessing. But we also have to be sure that we don't create unnecessary anxiety in ourselves. And so it is important for us to understand that all of the care and concern that those in power they have for us, that is not sincere. And one of my favorite verses in the Bible, Ephesians 6-12 reads like this. For we wrestle not against flesh and blood, but against principalities, against powers, against the rules of the darkness of this world, against spiritual wickedness in high places. They don't care about us. They care about narratives. They don't care about democracy in the Middle East nor anywhere else. They care about the fiction of democracy to further control of the planet. They don't care about black lives. They care about the story they can create when whites take black lives. They don't care about the lives of children. They care about the narrative they can create from the massacre of children. They don't care about your health. They care about the narrative they can build from health crises in order to profit financially and expand their power. We ask Allah to be our protector from those who mean to continue to manipulate us and control us and to cause us harm. I say this. El Hamdulillahir Rahmanir Ar-Armene. Again, a side put into side the things that we know we can control and the things that we cannot control. We have put here to worship Allah subhanahu wa ta'ala to increase our faith, to increase our closeness to him, and Allah has given us Islam for that. Islam is the source of salvation for our humanity. And what we can do, of course, are fulfill our obligations. We can make our prayers on time. We can continue to fast on voluntary days. But we also acknowledge that we are not equal in terms of our level of consciousness of God. That Allah, Subh'anaHu al-Ta'ala, he expects from us to be patient with one another. There was a man who came to the Prophet, peace be upon him, as we know, many of us know this story. He said, Ya Rasulullah, I read the letter to Maktubat, and I said, What if I only performed the five prayers, and I only fast Ramadan, and I declare the haram to be haram, and I don't add anything to that. Will I go to Jannah? He said, Yes. Yes, some of us are there. Sahaba, many of them came to the Prophet, peace be upon him, and they were asked him, Ya Rasulullah, give me more. I've already protected the five. I've perfected my five, and I fast. Give me something. What else can I do? Abdullah ibn Umar, he wanted to fast every day. The Prophet, peace be upon him, told him that the best fast is the fast of Dawud, al-Alih As-Salaam. Fast one day, don't fast the next day, fast the next day. But Hamza ibn Umar, al-Aslami, he came to the Prophet, peace be upon him, and asked him the same question. Can I fast every day?  And then the Prophet, he said, Yes, go right ahead. Because the messenger, peace be upon him, was able to discern the level of people's strengths and their capacity, their iman. He was able to do that. There were people, Abu Hurairah, he wanted to make a vow to continue to pray to Hajjud every night.  Why? Because Abu Hurairah, he found it difficult to get up after he went to sleep. On the other hand, he would go out to the home of Ali and Fatima, to make sure that they were praying to Hajjud, to make sure that they were praying to Hajjud. He said, Abdullah ibn Umar, Nama al-Rajul ibn Umar.  If only he would pray at night, if only he would pray at night, encouraging them to do different things. We are on different levels. That's just the way it is. And we have to understand that. That we are here to try to make it easy for one another to do better. Shaytan, his olia, are trying to do the opposite. And they can continue to do the opposite. Just remember that Allah is ultimately in control of all of this. At any moment, he can decide, you know what? No more rotation of that plan. Stop. No more revolution. Stop. At any moment. You see, that heart, stop working. That Allah is in control of that. When people died, they died because it was their time. And if you live, you survive in illness, you survive because it was not your time. Again, oh, if he didn't get the vaccine, he wouldn't have, no, no. He didn't die because Allah said it's not time to go. It wasn't because of the vaccine, because it wasn't time for him to go. That's all. I know it can be somewhat complicated at times. But again, the fundamental point is that we should share security, understand the ways that we can protect ourselves, the type of security, which is easy for us to defend ourselves from harm against. And the other types of security, we have to arm ourselves mentally and spiritually against the baghals of Shaytan and his olia, because they're hard at work right now. The world is in crisis. Of course, it's been in crisis for a long time. But in this time, in this age, it is really serious, as Allah says, that he protects us and grant us the knowledge and the tools that we need in order to face these challenges and to not allow for our face to be taken away from us. InshaAllah. Subhana rabbika rabbil az-zati amma yasifoon wa salamu ala ala al-mussareen walhamdulillahi rabbil alamin maqim.


Okay, so now we are going to continue with hypertrophic cardiomyopathy. Hope you have survived the first part of the lecture. So the second part is basically going to... We are going to be talking about hypertrophic obstructive cardiomyopathy. But before we start with that, we are going to talk about what kind of inheritance we are going to have in a patient that has hypertrophic cardiomyopathy. So as you well know, the most typical... It's autosomic dominant. It's mostly like common... It's the most common genetic cardiomyopathy with a 0.2% of prevalence. And it's the second most common cardiomyopathy after that kind of cardiomyopathy. So when we talk about the type of hypertrophy, it is very characteristic from hypertrophic cardiomyopathy to be asymmetric. The systolic function is almost always preserved or increased, but there is a 2-5% of end-stage hypertrophic cardiomyopathy where the LBEF is less than 50%. Despite say that in the group of the 95%, where they have a preserved systolic function, if you do a longitudinal strain into the ventricle, you are going to see that it's decreased. So they are starting to use longitudinal strain to follow up on those patients. The diastolic function is almost 99.9% of the time impaired, and there is diastolic dysfunction. And the morbid mortality for those patients normally is based on the amount of arrhythmias, cause of the pseudandem, and an overall mortality of less than 1% per year. Okay, so how many types of hypertrophic cardiomyopathy do we have? We have three types. We have the non-obstructive, where the LBOT, peak gradient, and that's the important part from our tichestanosis, that you need to differentiate. In our tichestanosis, we are measuring mean gradients. Here we don't care about the mean gradients, we all care about the peak gradients, okay? So if the peak gradients are below 30 mmHg at rest or provocations, those are considered non-obstructive. The moment that they are equal, or above 30 mmHg, so that's when you call it obstructive, hypertrophic cardiomyopathy, or HACCOM. The latent obstructive at rest is less than 30 mmHg, but with provocations, you actually increase the peak gradients up to 30 mmHg. Okay, so there are four types, not based on obstruction, there are four types based on the type of hypertrophy myocardium that you have. So the type one, which is the most frequent, is sigmoidal, and it's isolated to the basal anterior septal wall. The type two, which is the second most frequent, is the hypertrophy of the basal, but it's going to be not the anterior septal, this time it's going to be the anterior and the inferior septal walls, and there is going to be a sprain of the rest of the walls. The type three, which is 10% of the hypertrophic cardiomyopathy, is an extensive hypertrophy that only spurs the basal inferrolateral wall, and that's very important, because the basal inferrolateral wall is always going to be a spur in hypertrophic cardiomyopathy, and that's a very, like, pathognomic sign of this disease. In the type four, you have an isolated apical, which is only 10%. So this article from Dr. Martijn Bosch and colleagues that was published in 2008 is very well brightened, and it actually illustrates very nicely the four different types of hypertrophic cardiomyopathy that we have. Here we can see the septal, the basal anterior inferior septal, and the type three, which is spurs the basal inferrolateral. So it's important in this type of disease to measure that an apical hypertrophic cardiomyopathy and apical aneurysm can be missed without contrast in the echocardiography. It's not something that we do a bit like that we don't usually do with TE, but then that's the recommendation of the guidelines. You need to use contrast when you have an apical hypertrophic cardiomyopathy and when you have apical aneurysms to actually be able to this in. So what are the types of LVOT obstructions that we can find? So basically we can find subaortic obstruction, which is the 95% of the cases, or we can find a mid-cavitary obstruction, which is only seen in 5% of the cases. There is something that we call dynamic subaortic obstruction, which you can see in 25% of the cases of hypertrophic cardiomyopathy, and do you know what's the most frequent cause of dynamic subaortic obstruction in the LVOT? So you're right. So systolic anterior motion of the anterior mitral leaflet that gets sucked into the LVOT and it actually produces dynamic subaortic obstruction. So mechanisms of hypertrophic cardiomyopathy. So obstruction, as we were mentioning, is present in 30% to 50% of the hypertrophic cardiomyopathy patients. It can be due to obstruction, it can be due to venturi, to systolic anterior motion and in 5% of the cases, sometimes in the anterior lateral papillary muscle interposition. So when you get this kind of LVOT obstruction, sometimes the anterior mitral leaflet is going to be sucked into the LVOT and this is going to generate a posteriorly directed mitral regurgitation jet that can be moderate or severe and is going to produce turbulent flow in the LVOT, which instead of having the normal color between red and blue, you're going to have an intermittent color as yellow is with pixels all around the LVOT showing the flow acceleration in this area. There is always a systolic dysfunction and there are patients that have a tendency to have subendocardial ischemia because of the thickening of the ventricle and that predisposes them to have arrhythmias with ventricular tachycardia being one of the worst and they normally require the insertion of an AICB. Okay, so what can we do with TE? So from the American Society of Echo guidelines published in 2011, we are going to give you what are the tools that we can use in Hong Kong medicine TE. So the recommendation from the American Society of Echo is that ecographies, the non-invasive method of choice for the evaluation of functional normalities in Hong Kong. The recommendation continues with Doppler, Colorful Doppler and M-Mole. We will talk when to use those and the criterion for actually defining hypertrophic cardiomyopathy is going to be the ventricular hypertrophy which is usually going to be asymmetric. They require a wild thickness greater than 15 mm or no, well, not increase or any wild thickness but having a positive mood and gene for the hypertrophic cardiomyopathy. So in the table one, the guidelines reflect what do we need to assess. So you need to assess that there is hypertrophy, that you should measure the dimensions of the ventricle and the wild thickness, the septal, the posterior and the maximum. You should assess the systolic function, you should assess the right ventricle hypertrophy, the left atrium volume. This is going to be a problem in TE because the left atrium volume should be indexed and the best that correlates with the apical BU in the TTE on TE is going to be your fourth chamber and you are going to foreshorten in the left atrium. You need to assess the diastology on the left ventricle, the pulmonary artery systolic pressure, if there is or not dynamic obstruction, if there is mitral regurgitation. So there is many, many things that we need to do when we assess those patients and it's not only to measure the thickness of the patient. So as per definition in the American Society of the FECCO, anything higher than 11 millimeters in the left ventricle is hypertrophy, anything higher than 5 millimeters in the right ventricle is hypertrophy. So to assess the left ventricle walls, we put the same... I wanted to actually put again the same image. So in the fourth chamber view on the left side of the screen, the walls that we can see is the inferior septal and in the right side it's the anterior lateral. And why? Because when we cut the heart, the heart decided to be tilted and that's where at zero degrees angle should be giving you. As soon as we go to the two chamber view which is at 90 degrees, the wall that is in contact with the left lateral appendix is the anterior, the wall that is in contact with the coronary senors is the inferior. And as soon as we increase the plane to an aortic valve long axis, the wall that is in contact with the right ventricle is going to be the anterior septal and the wall that is distal to it is going to be the inferior lateral. So this inferior lateral at the basal segment is the only wall that is always a spur in hypertrophic cardiomyopathy. Okay, so examples, type one, sigmoidal. So you are expected to see in the anterior septal wall. Okay, and it's the most frequent one as you can see here. And it's limited to it. So if you go to the fourth chamber and you have it in the anterior septal, you are not supposed to see it there, okay? So type two. So the type two, we are going to have at the basal level of the anterior septal and the inferior septal wall. So you are going to be able to see it, not only in the long axis view of, not only in the long axis view of the, in the long axis view of the aortic valve, you are going to be able to see this hypertrophy in the fourth chamber view, okay? And this is the second most common. Third type. So this one is going to be affected an extensive hypertrophy in the whole heart. And the only thing that is spurring is the inferrolateral wall, which we are going to be able to see in the aortic valve long axis view. And the fourth type, which is only 10% too, is when the apical. This apical can be missed. Again, remember, if we don't give contrast, the same thing as apical aneurysms, okay? So just be aware of that. So evaluation of hypertrophic cardiomyopathy requires to determine if there is some with dynamics of active obstructions where we can see up to 25% of those patients, okay? And as you can see here, as soon as the mitral valve closes the mitral leaflets even touches the septum and occludes the LBUT. And I think it's a really good example on what happens. And if you can see, the artery wall is opening and it's flickering. At the same time that it's open because it's open and close, it's open and close due to the dynamics of our aortic obstruction. Okay, so measurements. What are the measurements that are required in those patients? So first of all, frame before the mitral valve closure. Okay, so what are the three measurements that we want to do? You need to make a four. That's the way to remember. So if you try to look up there. So the first measurement that you can do is the distance between the artery valve annulus and the impact lesion. You call impact lesion at a lesion that the anterior mitral leaflet does when it touches the septum. Okay, and that's one of the description. That distance is very important for the surgeon because he's going to perform the myectomy there. So he needs to know how far to go when he's doing the myectomy. Second really important maxim is how thick is the ventricle because the cardiac surgeon needs to know how deep he can go when he's actually performing the myectomy. Okay, and the maximum thickness is going to be measured from the impact lesion to the maximum thickness of the septum. And the last measurement from the artery valve annulus you are going to go to the apical stand of the septum bulge. Those are the three measurements that you want to know. So C-sept distance. So what's C-sept distance? So the C-sept distance was developed for mitral valve repairs. So they came up with this idea as we were measuring the regular measurements you need to go to NC study. The frame before the artery valve closes so then you want to measure the distance which is between the co-optation point and your septum. So if this distance is below 2.75 centimeters that implies an anterior displacement of the quantation so you need to have some after repair. And that's something very typical that we can see in a hypertrophic heart. So what we do is we measure that before going on pump unless that has not been validated for hypertrophic obstructive cardiomyopathy and we let the surgeon know because what we want to do is after the surgeon we want to know what's the space and what's the risk for this patient to develop some. So if you can actually do that you can actually do that that will give him an idea if he needs to do something about the anterior vital valve lipid before and not only a myectomy to try to avoid some after the myectomy is being performed intraperatively. This article was described by Dr. Ma with colleagues in 2015 in anesthesia and analgesia. So another classical design for hypertrophic for how patients is the use of M-mode through the leaflets of the aortic valve where we can see the leaflet flatter or notch in as a sign of early closure when you have subaortic dynamic construction on the LVOT. Here is an example of color flow Doppler and the typical pattern of flow acceleration in the LVOT with this turbulent flow with a combination of colors due to the flow acceleration and this posteriorly directed vital valve jet due to sauna. So LVOT's function as we mentioned before is normally going to be normal or increased but despite that is because you have a super thick muscle that is able to pump a lot. But when we say that we need to be aware that a very specific characteristic of hypertrophic cardiomyopathy is to have a reduction in the global in the global longitudinal longitudinal strain. So there are three types of strain we have radial, longitudinal or circumferential and the one that we are assessing in TE is the longitudinal which is the capacity of the LVOT to actually shrink and the more the better and this is being affected the longitudinal strains despite normally in hypertrophic cardiomyopathy patients. So diastology so the diastology is almost always in pair the recommendation as per the guidelines is to do the to assess the A wave of the metrolene flow remember that when we are assessing that you need to actually put your pulse rate Doppler at the level of the annulus of the mitral valve and what it's been seen is in this pathology you have a short mitral A so you do pulse rate Doppler through the pulmonary veins you have an increased amplitude in the AR of the pulmonary veins that those are two very typical signs for the hyperdiastology in hypertrophic cardiomyopathy. If you do if you use tissue Doppler if you use tissue Doppler what you are going to be able to actually assess is the E prime on the septal wall and the E prime on the medial wall and you are going to be able to get the parameters based on the new guidelines as you can see here you need to have two of more parameters so you need to do your septal E which is going to be less than 7 cm per second your lateral E prime that is the one that we were measuring here in this example which should be below 10 to be abnormal and then you need to do the peak EE and remember when you are doing the peak EE at the level of the annulus should be measured at the mitral valve tips and compare it with the E prime ratio and if it's more than 14 is abnormal you should do the volume of the left atrium indexed if it's more than 34 mm per meters to the square it's abnormal and the TR velocity more than 2.8 m per second so that's how we assess diastology so long access view in a patient with Hong Kong that's the classical thing that we expect to have is this nice septum the anterior mitral valve that is getting in the middle of the LVOT this severely posteriorly directed MRJET turbulence LVOT flow the flickering the R2 valves all the signs that we have been describing so far so an important part that I think we need to actually explore a little bit more is when you have a subarctic LVOT obstruction you need to differentiate between dynamic and fix the dynamic is more or less what we are going to find in a Hong Kong patient the fix is the classical one that we are going to find what we have a subarctic membrane the subarctic membrane of fixed subarctic LVOT obstruction is going to give you a continuous with doctor shape form similar to the arctic stenosis curve the important one that is the one that we are assessing here is the dynamic subarbular so the classical signs for this Doppler profile is a dagger or a shark tooth shape which is characteristic for having a mid to late systole, a late peak LVOT signal which is what the yellow arrow is actually showing here in the bigger shape Doppler profile when we assess fixed subarbular obstruction which is the one that you will see with a subarctic membrane there is an early peak LVOT signal and you can see the presence of AI too which is typical with this kind of pathologies treatment for hypertrophic cardiomyopathy there is the description of the alcoholic septal ablation through septal perforators resynchronization but the one that actually is important for us is the fact that the patient will need a myectomy so the indications for myectomy are going to be based on echocardiography so peak reading of more than 30 at rest or more than 50 with provocation myotomy is myectomy is going to be performed and you are going to remove from 5 to 10 grams of septum and risk of complications almost 60% of LVOT only 3% of complete heart block and 1% of PSD or aortic insufficiency the mortality is up to 2% so 3D echo can perfectly be used to assess those patients too we were able to estimate the septum and we were able to get more accurate measurements of the multiplane reconstruction to the surgeon that we 2D so the classical view that we are going to get is like that so we wrote it said in those images and what we are going to get is this view which is the classical surgical surgeon view or amphis view with the mitral valve below and the aortic valve on top to the right and then on top of the aorta the pulmonic valve so the surgeon is going to put the retractor to the right coronary casp and the interventricular septum is going to be on the right side of the screen and that's where he actually performs the myectomy so once the myectomy is performed so what should be should be addressing so the first that you need to address is is there any residual LVOT obstruction if there is any residual or mitral regurgitation due to that is there any VSD is there residual AI so those are the questions that we mainly want to ask so as per the guidelines again that's what we got so in a patient with surgical myectomy so the recommendation is the presence of some surgical obstruction, mitral regurgitation and ventricular septum's defects so if you pay attention to this image we go over here so you can certainly see stop the image there okay so you see the aortic valve is closed so if you pay a little bit of attention it goes away and then it sits to the and then again there it is and you see in the diastole with the mitral valve open so this, so what do you guys think that this is due to so this is a septal perforator so that's very typical after a myectomy that doesn't mean that the patient has a VSD that's actually the artery from the coronary arteries that comes and they use to actually use the septal colablation and it's always in diastole and not in cystole as you will be expecting a possible VSD from coming from there okay in a VSD so post myectomy a successful septal myectomy is considered when there is no significant rest in LVOT gradient so as per the papers LVOT gradient less than 16 millimeters per mercury is considered appropriate and nonsignificant we normally again can use the deep transgastric or the transgastric long axis recommended from my point of view the deep transgastric has a more better possibility to align the plane than the transgastric long axis congratulations you made it so please if you have any questions email me and all the best


Hi, I'm hospital corpsman, first class Brittany Berkeley from Hampton, Virginia. I'm stationed here currently on the U.S. NS Comfort. I am a member of the ground team here with patient transport. Our job is to make sure that patients are getting where they need to be with the correct care at the correct time. So we have to manage three different types of communication from our radio and three different chat groups or information systems. So we have a system where we have people out in town who are generating information from the patients and finding patients that will match our needs or what we have here at the comfort and from there the information gets translated to the mock and the mock is a medical officer in charge and once that information gets to him it gets disseminated out to the various departments so that we know where they're going, what their needs are and who's coming and when they're going to be here, which allows us to provide that proper transportation for our patients. So how it works is the mock communicates with different parties and because we're also part of that communication we also get the information. So when there's a vehicle here to come in we're notified that that vehicle is here. We call the transport team so that they're here when the vehicle arrives and then we have the information on who the patient is so that if they need extra care like if they're going to the ICU and they need some ventilation we have that information as well. It's been a lot of interesting pieces and kind of building this from the ground up it started from three chairs and three people in the colds now we have two tents currently and three teams working effectively so it's been a great experience seeing these people come and being super grateful and super amazed at kind of what they're actually being a part of and here it is one of those once-in-a-lifetime opportunities that we get to be a part of because this has never happened before. So when patients are arriving to us some are super excited to be here and be a part of the process and some are a little apprehensive just because we are intimidating coming up on a group of people in yellow gowns gloves and masks and seeing white tents can be extremely scary so myself and my nursing staff here we try to make them as comfortable as possible giving them great eye contact talking to them smiling with them communicating with them making sure that they have everything that they need from also the EMS staff as well as we so that kind of alleviates a lot of the apprehension as well as the nervousness. It is a scary time for a lot of the older population so we try to make them at ease as much as possible.  When patients come down they're super grateful I actually talked to one of the members that was getting discharged the other day and he was super happy to not only be going home but to be able to receive the care that he did. There was also another gentleman that was being discharged and he was the most sweetest older man he was so happy he almost tried to pay some people but we're like no sir we're here for you so we're just happy that you're healthy you're able to go home. So everybody seems to be really really happy with the care they're receiving on board with the hospitality and the bedside manner. So I've heard nothing but great things so I'm hoping that the momentum keeps going we keep getting patients in and also getting them out because that's our goal to hear. So when we receive patients that are getting discharged a lot of the feedback is genuine happiness. They are excited about the care that they received they the hospitality that they receive between the nursing staff as well as our corpsmen staff. They rave about the people that are on the wards. Some of them don't want to go so we can't keep them as much as we want to we can't but they love it here. They definitely appreciate the time and the effort that we've all taken to participate and alleviate some of the madness that's currently going on. I am a nurturer by nature so being able to put that into practice and help people and save lives and change your lives is an awesome opportunity for us. I'm a hospital corpsman by trade nurtured by nature so it kind of plays into that and just being able to see people leave healthy and happy so as long as I can do that and we can be a part of that couldn't ask for anything else.