What's up guys EvilD here so today I want to tell you the story about how I almost as a kid Got killed by my dad because I drove him insane so much now He didn't try to like physically kill me or anything He didn't like choke me out But it felt like it at the time that I would possibly be killed as a result of my actions Anyway before I jump directly into that story I just want to say thank you to all you guys out there because I've had so many Subscribers like people sign up to watch my videos over the last month in a bit Like I've literally had this channel for maybe a month and a half and I'm almost clocking 200 subscribers That's insane.  Don't you guys have a life? Jesus? No joking. I love you all I love you deeply from the bottom of my or the upper part of my heart rub away rub away Okay, so here's the story so at the time I think I was probably like nine maybe ten years old Somewhere around that point, but my dad was in the living room and he was watching TV and he was watching this show I don't know remember what it was but I just remember it was his favorite show anyway So me and my brothers were running around that inside the house come bang bang bang bang bang doing the cops and robbers thing and Type of thing driving my dad insane is just trying to watch this show and he got up to the point where he's like Get the hell out of my house. Do you make him too much noise? So we all run outside and then we start running around the house and now the TV is right next to the window and the couch is right next to the window and Of course when we're doing our shootouts, it's right next to his window Like shooting at each other and then you hang out the window and he's like get the hell out of here I'm trying to watch my show I can't remember the rest of it But anyway after a while my brother's like we better stop this but no I was just I don't know what I was doing I decided it was a good idea to go back into the house and then start playing with my toy trucks Like literally in front of him in the TV. I think I probably did it on purpose I don't know why I did that but anyway, I'm playing and he's like get out of here And then I think it was probably like the first time ever I just randomly swore at my dad and he just snapped like he just got up and he went straight for the wooden spoon now for those Who don't know we had this big wooden spoon It was like strategically placed above the TV and normally what he would do is he would lean forward in his couch Possibly lift his hand up towards the wooden spoon and that was it game over. We wouldn't do any more So he got up. He was about to grab the spoon like he physically got out of his chair I was a really bad thing don't make the dad get out of the chair and at that point I was still being a smart ass about this like I was like Doing something I can't remember what it was, but he didn't go for the wooden spoon He just came at me and I was like oh and I ran straight to my room and like we were in the living room at the time I ran around the corner straight to my room close the door locked it and I was like hey Like I thought this was a big game or something. I don't know why I thought that Anyway, I'm hiding the room guy.  I put my head up against the door I defeated my dad the dad monster.  Just so you guys know our house was actually like lifted off the ground like it was sitting on stilts because it was a Possible flat area, so we're literally like one floor up Maybe two I don't know exactly how I you know as a kid your perspective is all morphed and stuff Anyway, so I hear this noise and I turn around and a look and there's a window directly on the opposite of the room And I see the window and suddenly I see my dad gone Crawling through the window like it's something out of the ring You know like that scene where the woman's climbing out of the TV imagine that but a great big guy That's partially married partially white type of thing and just like full-on like murder in his face type of thing And he's not crawling slowly he's crawling with the force of a thousand evil angels behind him and he's crawling out of this window and I'm just like Like I didn't even make any noise.   Just run you'll be fine. That was me All I had to do was turn around open the door and go whoop and make a scooter out the window Oh, sorry out the door out the window. I would have been bad that would be towards him But out the door I would have been safe, but no I just stood there going Other thing is I saw you know the dad coming through the window and he's just come across the room It's like boom. I think that was like physically at one point a cabinet there And he kind of just pushed it out of the way like just you know like a feather type of thing and I was like Oh god, this is the moment.  It's flashing for my eyes It's extremely boring, but you know I'm it's coming to an end right now at this moment and you just grabbed me like literally by the clothes Lifted me up pulled my pants. It's underneath What what what type of thing okay?  I was like oh god. This is it. I better be quiet And I never messed with him again after that moment. Well, maybe that's a lie. I probably did a few times I just don't remember him and he was less brutal But anyway, that was like the one moment I learned that you should not piss off an angry dad after he's had a hard day working He's trying to watch his TV whatever it was. I don't know what it was. So yeah, that was my one moment Now I've got a question for you guys Have you guys ever done anything that's just like when you were a child that just so Peed them off that it resulted in your near like death Castration, I don't know just resulted in badness lots and lots of badness That is not even a word, but it is now So we're going with that. So yeah, tell me your stories in the comments below I would love to hear them because I just crack up every time I think about that because it's funny now Like when you think about it, but back then it was like, dear god Save me. I'm not even religious, but I will convert in a split second of a moment if it saves me type of thing So yeah, tell me your stories if you've liked this video Give it a like I share with your friends subscribe if you haven't already and I will see you in the next video And if not well, then the wooden spoon will find you in I'll climb for a window to get you


Thank you very much everybody for joining. I usually say it sounds like young and old, but we really do have young today. We have a baby in the room, so thanks to Emerald for joining us. Hopefully we keep her asleep. Anyway. Yeah, exactly. Okay, so my name is Ian Sloyne. I'm here from the International Swaps and Derivatives Association.  The common domain model being open sourced at Finos, which is really exciting. So we thought we'd do two sessions over the next hour. The first one's sort of a history of where we've come from and where we're hopefully going in the near future. And the second one we're going to hear from some implementers around how they use CDM and why it's important to them and their projects. So I'm just MC really for today. But first up, I'm going to ask my colleagues to my left here to introduce themselves. So maybe David, you go first. And I'm Amy Caruso. I'm the head of collateral initiatives at ISDA. And I am really fitting, sitting in for my colleague Vernon Aldensmith, who leads the CDM initiatives for collateral based out of London. So hopefully I'll do him proud. Okay. So I said I was going to be MC, but I'll do a little bit of talking at the start. I've been involved in the CDM project since the inception. So I'm probably the guy who needs to give the initial history lesson. So the letters or words CDM or common domain model appeared in ISDA's literature around 2016 in a paper called the future of derivatives processing and market infrastructure. And that is still on the ISDA website. If anyone would like to read it, it's a it's a riveting read. It's really, really has set the path we followed in the last few years. Now, in the conclusion of that paper, there were next steps listed. There were four next steps listed. The first one was identify and track solutions to current post trade inefficiencies. The second one was to facilitate industry collaboration and communication. The third one was, and here's the key bit, develop common domain models. And the fourth, which I had actually forgotten about until I checked the paper this week, was to promote open source. So by open sourcing the CDM at Finos, we are sort of completing the steps that were suggested in that conclusion. So it's a very, very exciting development. The key driver for us in that paper and something that our members repeatedly told us was the difficulties they had in implementing regulation. So regulations is hard. You have to do it. There's usually lots of budget for it, but you got to do it. And the implementation of regulation, particularly in derivatives market, had been quite a task since 2009 and the recommendations from the G20 meeting in Pittsburgh. So how can we do regulation easier? Having standard data model, common domain model to underpin everything, a common way of representing things was identified and that's what we took forward. Also this week, not just the announcement of Finos is digital regulatory reporting, which is a project built on the CDM using the data model, has effectively gone live in production with one of our members, BMP Paribas, using the DRR code to report to the CFTC. So it's, as I said, a really big week for us here. In that journey since 2016, we started working at ISDA in 2018 and actually codifying and building a CDM as code. And then over that period, we've been joined by ISLA and ICMA who are going to take us through some of their journey next. So yeah, I think I'll handle, I haven't gone too much into the detail, but I'll hand over to David who's going to take us through what CDM is and the journey ISLA have taken in this regard. So Ian asked me to give an overview of what is the problem that we're setting out to solve. This diagram here is a representation of the current state of, certainly the security learning industry, but I know across the panel, our funds for the industry, don't look too dissimilar to this tangled web of data representations, multi-channel communication. And the entangled isn't just in between different parties in the market, right? So the right hand side of that mess is all of the different parties. They all have their own representations. They all represent, they all have all got their own ways of representing life cycle events and transactions. But even internally, the global network picked the borrower there, literally could be any of those kind of parts, I guess. Even internally, systems for different departments often have different representations of the same data, right? I've seen nothing, and I appreciate it, probably. Okay, in some cases here. But this costs us a lot of money as an industry. So you have the administrative rework, and they attempt to determine what is real and what isn't, what the truth is that anyone is quite inside. And that's, you know, the reconciliation works, you have to deal with. But it has real-world consequences to right the risks associated with that as well. You have valuation differences and clappals, that results out of this. There's reporting as matches. There's a possibility that you will manage your reporting, your client reporting, and your regulatory reporting all coming from slightly different databases of slightly different representations of the same information. When really, it should all come from the same source, right? Big one on people's lists is that the limit of settlement there is. So data representation, agreement of life cycle events can solve those problems and resolve pure finds problem regimes such as CSPR. So the common domain model is really an attempt to standardize not just the data representation products and transactions, but where I sort of see the added value where it goes beyond some of the standards that already exist today in my space. It's around standardizing the life cycle events, the bookie models for the life cycle events, right? Standardizing the operational processes. In our industry, there's a lot of agency lending occurs and the big agent lenders will allocate their transactions and reallocate their transactions all very slightly differently, right? We have a green market practice of how that should be done. So on our journey, which I'll talk about in a minute, we have only codified what we have set up in our green market practice. There is only one way to do that application within the model. Other, the other angles are also incorporating standardized legal documentation. You can get your legal documents and objects within the model. Then you can automate your life cycle events across camp parties. Imagine a corporate action where you find something slightly different that each camp party is basically, you should be able to push upon that process of that corporate action on all your positions on that security. And it doesn't matter what you sign with each camp party. The application should know by looking at what you sign with those camp parties what the app should be. To be very clear, the CDM is the model. It is the application. Just to find the relationships between these things and the kind of people standing up for all the life cycle processes that are right in terms of what it is. And then, so if I talk a little bit about this for the journey, so I was employed to pilot in August 2020, which seems like a lot of it, because in some respects, and five minutes of others. And we did that pilot at the end of 2020, really, was to take what is for the start in a derivative space and leverage that work to build out skewed landings. So part of the principle behind this is that our associations are not looking to recreate ways of processing transactions where an analog exists already We don't want five different ways to do something just because our history says, well, we did it like this and secured landings. But for derivatives, we did this and for reports, we did that. If the same function, if it's the same functional concept, do it once, further want to reuse it. And Amy will talk about that, will encourage which is a good cross product in this case. We completed a minimum valuable product, which is the bottom part of this house metaphor.  And it was enough to get us foundation started to merge that MVP with this as well at that time. So first time in 2021, two product classes were in there. I won't dwell on the metaphor too much because I think some people will argue that minimum viable house should have a roof. In August, we, yes, sorry, we're not loud enough. So the, can we sign the memorandum of understanding between us in August 2021? Which is essentially culminating today, right? This is where we're heading to make the model open source. This year we, it is the recruited full time developer before we were using contractors. You can meet my full time developer, Chris, at our stand downstairs if you want to. Very nice guy, very approachable. And he has built out the rest of our product suite. So the legal agreements that we have cover evergreens and extendable products. Next year, so following finance migration, we will continue to do development work in this space. We will continue to look at life cycle events. We are looking at some of the trade negotiation workflows, multiple RFQ availability feeds and so on. But the bit I'm really excited about is we are actually going to integrate our standard legal documentation, the GMSLA, and we are going to codify that and actually incorporate that and mesh it with the transaction and product piece so that we have the formation of automated life cycle events. So quite excited about that. That is a very swift overview and I realize I've probably taken too much time, so I apologize. Gabrielle, do you want to cover your journey from the ICMA? ICMA's focus has been on the international debt capital markets. The CDM work we've done is focused on REAP and collateral markets. I don't know if that's better. REAP and markets play a fundamental role for the economy. They are huge. They are considered to be the plumbing of financial markets. They are a source of funding for dealers who provide liquidity. But it's also an important market to manage cash. So just to give you, to set the context and give you figures, the total value of REAP contracts outstanding in June, according to ICMA's latest survey, was more than 9.7 trillion euros. That's more than 10 trillion dollars. In the U.S., the figures around four and a half trillion dollars. And in Asia, Pacific, excluding Japan, according to ICMA's latest findings, it is in excess of 300 billion dollars. That's a huge market on the one hand, but it's also a very complex market. REAPOs can be overnight. They can run for a few days, a few weeks or a year. It can involve single securities or baskets of securities that can be traded. OTC on trading venues. Interest can be made on a fixed basis or floating rate. So there's many moving parts. At the same time, automation is on the rise. So we've been tracking very closely the number of different platforms and vendor solutions that are out there. And in 2017, there were around 80. Now looking at it in 2022, there's over 240 and that's the number here has tripled within just a few years. So there's many different vendor firms and interoperability or the risk of fragmentation is one that is a serious concern. So ICMA has embarked on the CDM journey about two years ago now. And we initially focused our objective, I think David has already covered the key drivers of this, is this approach has been more on the regulatory side, but our approach is to support market functioning, to support automation of repo markets, to reduce fragmentation and to also provide a foundation for innovation. We heard of the keynote panel earlier use cases using DLT, which rely on a standardized representation of data, for example. So last year, we initially focused on the most commonly transacted repos, repurchase agreements, which are fixed term with a single security. So from the point of when a transaction is executed, cleared and then settled. This year, our focus has been on the more complex spectrum of repos. So those that have, that are open, for example, they're linked to floating interest rates that have extended notice periods to terminate a transaction. So all those transactions that have more moving parts, more variables, that's been our key focus. And we are right now finalizing the project in the process of merging it together with the ISDA version, so that it's a common domain model that covers all the different asset classes and processes. And what's also important to heart is that if you are looking to build a solution to, say, match repo transactions, or to reconcile transaction, to execute repos, or there's many different use cases for it, you would have to think about how to translate what actually makes up a repo, the sale of a security, the repurchase, things like price, which is a bit more complex than, let's say, a simple bond transaction where you have margin that's applied, interest that plays a factor as well. And of course, what you can and what is frequently done, they would also allude it to this. There's industry guidelines, you could, for example, take ISMA's best practice guides to repos to understand that, and then translate this into code. But inevitably, every developer or each institution would come to a slightly different conclusion. And this is what's creating fragmentation and that hampers automation in that space. The other option is you take the CDM. The CDM provides essentially a blueprint of repo transactions, not only repo, but also derivatives and securities lending. So if you want to build a solution for it, or whether it's a trading application or a post rate solution, you can use a CDM that defines all those parameters. So it's a model, as I explained, that defines the domain, the relationships between different entities and the processes. So it goes very much into the detail and it removes any ambiguity in the process. And that's a real value of the CDM that you can provide different solutions depending on what your technology focus is or depending on your type of repo that you're transacting in. But you're starting from a common denominator. And that's the value of the CDM. It's a big thing, as you mentioned, for it to be open source available here, coming to finners. Our journey is reflected here on the slide, I think, Ian, you've brought it up. So right now we are at the end of what we call phase two, which is focused on the on the more complex side of repos. But importantly, collaboration is a key aspect here. And just to echo what was mentioned at the keynote panel, the model is now, has been created by three associations that represent different market segments that naturally are interconnected and interact with each other. So when you use a CDM, there's less discrepancy. It's all one common model, one common interpretation of lifecycle events. More importantly, looking ahead, I guess, let's know the real focus and something we're very excited about to be here and finners, to be able to work with the community going forward, the open source community, but also members. One key focus for ICMA and the associations now is to drive adoption. We've already heard about, and there's different sessions and we're going to hear about, about use cases, but driving adoption of the CDM, facilitating the integration of the model with messaging protocols that are used in particular in fixed income like fix and swift, that's a key area, but also how to deploy the CDM, whether it's via cloud solutions, make it more easily implementable, speed up the whole process. Then looking ahead as well, embedding some of the legal clauses from ICMA's Gold Mastery Purchase Agreement, which underpin cross-border reper transactions into the model, some of the clauses, some of the conditions to streamline on the one hand the digitalization of legal documentation, which is still very much in the, I guess, the analog world, but which is slowly progressing and bring this into the CDM, so it is actually a consistent, much more streamlined experience and operation. And then an important focus, and I know Amy is going to touch on this, I'm not going to talk too much about, is collateral. It's a key, it's a very important topic for our industry and there's a lot of, I think, potential to work together and make it work even, even better. That's, I think, you know, these are the, the elements on our roadmap. Another one that's very important to ICMA as a bond market association is automation and market functioning in bond markets. One of our key initiatives here is a common data dictionary to support the automation in the bond issues process. And on our roadmap for next year is to explore the synergies to bring together the common data dictionary and the CDM. And this is in particular looking ahead at digital assets, so digital securities to help, to promote this segment, help it take off from an operational perspective, make it easier to create a standard that defines how a digital bond can be issued, traded and cleared. So we have a shared desk downstairs, so please do feel free to, to stop by if you'd like to learn more about the CDM or to, to get involved. Thanks, thanks for your attention. Okay. I, I think we'll pass over to Amy because she can take us through one area which is the needed standardization, which actually covers the collateral. Well, I've never worked in collateral, so I'm quite, it's all the same to me. So, so I probably offend the people. But the collateral across derivatives, securities landing and repo markets, they're bonds moving from box to box, right? That's how I see it. And my, my apologies, but Amy's going to explain a project which we're going to kick off at FinNOS and there'll be a working group in the new year looking at collateral in CDM, which is building on a lot of the work we've already done, but, but it's going to be the first sort of big collaborative effort at FinNOS, I think through a working group. Okay. Well, thank you. Thank you for having me. So the, the, the picture that David showed of the, it's a messy situation. Really is between data and data transfer is not unique to securities lending. It's not unique to repo transactions. And then if you really, our, our members need to be more collaborative themselves within these three areas. We're not preaching to them. They tell us that, that they realize that. And so data interoperability and fast data, faster data transfers is definitely needed. So the work that we're doing around collateral is one example and not to take away anything away from the digital regulatory reporting initiative, which is really is this flagship at this point, but I'll let Alan and Ian and Rosetta folks in the project expo really highlight those, those topics. So in the, in the collateral space, we have two prominent use cases. One is around digital documentation. And both of you mentioned how your documents, you're looking at clause libraries and, and where these elements can be digitized. And Adrian and, and Georgina had mentioned a little bit about collaboration and also things that we do separately. And our documents are probably things that we can be somewhat synergistic, but there are proprietary elements as well. So we're excited though that we are working on data digitization in the digital documentation space. And I bet Diana Boyle from symbiote will mention that a little bit in the next session of how it can be put into use. But around collateral representation, can you imagine that a five-year treasury is not digitally represented any one particular way within all the systems of the financial services firms that are represented here today? And that's really challenging because not only when you're setting up a new firm to exchange collateral for any one of these three products that we represent, but also on an ongoing basis. And this really, we can, we can look at some examples of where interoperability could have helped in say March 2020, the energy crisis or the recent guilt liquidity crisis, that operational inefficiencies really widen the gap of challenges during those times. It's not to say that the operational inefficiencies were the root cause, but certainly there could be improvements. And not because of those predicaments, but other value propositions. We do have a number of firms who first started off maybe with ISDA. And then when the memorandum of understanding was signed, we started expanding the CDM collateral working group to not only include ISDA members. It's been very collaborative ever since. And it has expanded not only with additional member firms, but individuals say from a bank or a vendor who may have been focusing specifically on securities lending. They got to know their OTC derivatives counterparts through our working groups that really happens. We bring people together within their own firms. And as a result, there are more implementation projects. And there's a number that are public that they have said, please share like Clearstream and Bank of New York that are really looking at how they can implement collateral representation with the CDM across their collateralized products. And I'm not a derivatives person and not a collateral person by trade. I'm a marketing and PR person. So please join us. I'm going to just put it out there for the call to action of we'd love for you to join our working groups. And also, we have a pipeline slide that we're happy to share. We'd like more firms on those. So again, the collaborative efforts that we work on together the three trade associations, it only really works if the member firms contribute as well. Okay. Thank you, Amy. I do have some questions, but I think we're up nearly up to time. I think I'd reiterate what Amy just said about getting involved. There's going to be a number of working groups for the CDM at Finnost to drive forward the development of that core CDM. It only works if there's a big community of people behind it and contributing. And then the first use case, we think that's going to be quite helpful for the marketers around the development of components for collateral. As Amy said, I will pass to my colleagues to see if they have any final words. Only just to repeat, do come and see us. We have an expense card to justify having flown out. I would just like to understand, I think it's a real opportunity to continue to shape the CDM and make the most of it, even though it's going to be open source. I'm going to hop on David's expense card before I go home. But I'm based here in sort of in New York or on the East Coast. And we do have representation in London. So we do have opportunities to get involved. In person, in virtual. Just before the next session, I want to, because I said in my introduction that I've been involved since the start and inception of the CDM. But that man over there, Sunil Chaw, I haven't seen in a long time, was also there at the first meetings and arguing about all sorts of things we used to when we first came up with the idea. So I'm looking forward and I think you should stick around and hear his views too. But thank you all. Thank you to the panelists today. Thank you to Finals.


Welcome to nursing school explain in this video on next-generation NCLEX computer adaptive testing And one really determines whether you're going to pass or not pass the exam So computer adaptive testing means that the computer knows the item difficulty and takes the difficulty of that item of that question into consideration and You also get partial credit for answers that are incomplete So those select all that apply questions might give you partial credit although you don't have all that are correct correct on that item and When we talk about that it accounts for item difficulty So if you answer ten of the hardest questions, you might need three or four To answer correctly in order to pass but then of the easiest questions you might need all ten in order to pass And so there's a graph here that I've drawn out So we have this line that determines pass and not pass and then this red line here is the Inclix passing standard So it's been determined if you are getting enough points to be above that line you pass the Inclix if you are below You're not going to pass and then the item difficulty or this computer adaptive testing means That you have a standard four-point question. So this question is some Easier medium ability question. That's worth four points So you get all four points you score way over here And if you get three points, you're still in the passing section, but more towards that teetering line If you're going to get two points This is a not pass and if you get one point only on this four-point question Then you're definitely more on the not passing side But if the question now is harder so it is determined that this is a harder question You've been doing well and it's been giving you harder questions If you only get one point out of the four points, right then you're in the not passing section But you are really close to that standard line if you get two points You're passing if you get three points you even more on this continuum And if you get four points you are way over here So the item difficulty will determine what side of this pass and non pass side that you will be on and give you points depending on the difficulty of the question and that the so When you're over here in this passing side enough time and we go over this here in a moment Then it's determined that you actually pass the exact exam so for The next channel and collects you're going to get a minimum of 85 questions and a maximum of a hundred and fifty or Five-hour time frame so what determines passing and not passing so the computer adaptive testing stops When it is 95% sure that you above or below the standard So when you've been over here more than than below Then it then you're passing or if you are 95% sure that you're below the standard then you're not going to pass If you're right at the passing standard So you do well on some of the items and some not you kind of right teetering right above and below This the standard then you are not they're not a hundred percent or 95% sure you're going to pass or you're going to not pass then the 95% rule is disregarded and you're going to continue to get questions until the maximum time has reached and Then they are going to consider only your final ability Estimation if you're above in these final questions, you're going to pass if you're below you're not going to pass In case you run out of time, which means you meet that five-hour maximum here Before you're running out of time before you the maximum number of questions is reached. That's a one opportunity and Also one possibility and also if it's not determined with 95% certainty if you're passing or failing then you're going to run out of time So if you're teetering here and they are still not sure and now you're meeting that five-hour minimum Then they're going to use this alternate criteria So if you haven't answered the minimum questions of 85, you're not going to pass because that's the minimum that they've determined you need to To answer in order to pass and the other alternative question is if the minimum question The minimum number of questions has been answered Then the pass fail is determined by all the responses before the time expires and again That means have you been more on the passing or more on the non-passing side? And then at that time that the time runs out that will determine passing or not passing so in general this computer adaptive testing is actually really good because the better you do the harder questions you get and partial credit gives you more points for The harder questions than the standard or easier questions And so really don't fret over it. It's just a little bit of an explanation about how it works And they just want to determine that you're going to be a safe entry level nurse So if you do all your in-clicks practice questions, you prepare yourself for all the different questions that are out there Which is new in the case studies here in particular and I have a separate video that goes over these case studies Then you're going to pass this in-clicks exam.   Don't fret over the technicalities. Just go out take the exam Prepare yourself going confidently and you're going to pass. Thanks for watching nursing school explain. See you soon


I certainly don't mind making fun of myself for being a little self-deprecatory, whatever. Having a sense of humor about yourself, you know. Not taking myself too seriously, and that certainly is what it was with Family Guy. My name isn't Adam Wee, or is it? Who am I? What number did you dial? Don't ever call here again. I guess I told him. Nobody messes with Adam Wee. I was trying to gain superpowers. Well, that's just silly. Silly yes. Idiotic yes. So it's a shouting match, you want a? Well game on, Kohog. Ah! Ah! Ah! Ah! Ah! Ah! I'm beating you, Seth Mufah. Oh, and his own weird way is kind of a superhero too.  I wish I were Batman, but we're fated to travel in different directions.


Good morning Hank, it's Tuesday. Last night I did something, specifically I attended a live recording of one of my favorite podcasts, Harry Potter and the Sacred Text, and it was such a lovely evening of thinking hard about stuff that matters, and I emerged from it feeling different and more hopeful about the human enterprise. Like it's been spring for a couple weeks here in Indianapolis, but driving home last night I finally felt like it was spring, and I kept thinking about that E Cummings poem that begins, spring is like a perhaps hand which comes carefully out of nowhere. Anyway, all of this was quite a contrast from my usual Monday nights in which I do nothing. For me, doing nothing means not making an active choice to do something. Generally, in my case, this means after the kids go to sleep, I scroll through Netflix for like 20 minutes trying to find something to watch, and either do find something to watch or else go upstairs to read a book. Doing nothing can be lovely, of course, but generally I don't actively choose to do nothing. It's sort of like a passive thing that happens. It feels like the default state of affairs, or the natural way of being. Doing something feels like making a choice, and doing nothing feels like not making one. Slightly off topic, but there are many places in my life that feel like this. For instance, every day I take a medication for my mental illness, but taking the medication feels like doing something and not taking it feels like doing nothing? And the same is true of making the active choice to get a flu shot, or to engage in philanthropy, or to plant seeds in my garden. In all these cases, doing nothing feels like the default. It feels like it isn't a choice, and if I look for voices telling me to do nothing, I will find them. There are plenty of sources out there to tell me that my medication won't work, or isn't worth the side effects, or that the flu shot is dangerous, or that philanthropy never does any good, or that gardening is a waste of time. They may not be the most accurate or authoritative sources, the flu shot is safe, I am definitely better off taking my medication. Philanthropy can be an excellent way to improve people's lives, and gardening is only a waste of time if you don't enjoy it, but because passive choices feel natural to me, I'm vulnerable to misinformation telling me that those choices are virtuous. I struggle to make active choices every day, but the thing is, passive choices are also choices. Not taking medication that has been prescribed to me is a choice, and an unwise one. Staying home to watch Netflix is also a choice for me, sometimes a wise one, other times less so. The truth is, most nights I need to be at home in a kind of metaphysical quiet resting and recovering, but I need to see those times as the choices they are, rather than as some default or natural setting, which they aren't. Years ago, a mayoral candidate in Birmingham, Alabama, had a campaign slogan that's become kind of a catchphrase in our family. The slogan was, Larry Langford, let's do something, not like something prudent or something good, just something. Now, of course, this is a horrible campaign slogan, and indeed, the candidate in question would go on to be convicted in a huge bribery scandal, but lately, I've been thinking a lot about that slogan. Like, while we're here, we're going to do something. A lot of somethings, actually, and doing nothing is not a way out of the responsibilities and opportunities of personhood. Whether I'm playing board games with my family or watching the recording of a podcast I love, my days end up better when I remember that I'm not choosing between doing something or doing nothing, I'm choosing which something to do. Hank, thank you for doing this something with me for the last 12 years. I will see you on Friday.


Good afternoon. I'm delighted to welcome you to the second seminar in our year-long series on medical professionalism. We are absolutely delighted and honored that Dr. Ed Pellegrino, a professor emeritus of medicine and medical ethics at Georgetown University, is able to join us today. As many of you know, Dr. Pellegrino is simply the dean of American medical ethicists. He has worked in the field for many years, has been in medicine for more than 60 years, during which time he served as chair of departments, departments, deans of medical schools, vice-chancellors, presidents of medical schools, and recently served as the chair of the President's Council on Bioethics in Washington, D.C. He had been the John Carroll Professor of Medicine and Medical Ethics at the Kennedy Institute of Ethics at Georgetown and at the Center for Clinical Bioethics. Ed has been all of our teachers, whether we studied directly with him or as Dr. Salmezzi did, or whether we've learned from him from afar. It was in the early 1990s as the field of clinical ethics was being developed that Ed joined Peter Singer and me to write a series of five articles in the first five issues of the Journal of Clinical Ethics trying to lay out a framework and a foundation for the field. Ed's name associated with those papers and his contributions to the papers really helped establish the field in a way that otherwise would have been much more difficult to do. Dr. Pellegrino has written almost 600 articles, more than 20 books. He's the founding editor of the Journal of Medicine and Philosophy, a master of the American College of Physicians, a great nephrologist and internist who he tells me in the old days you couldn't be a nephrologist unless you were also trained in cardiology. So in the old days you did both cards and nephrology training before you got boarded. Well, I won't say anything more, it's a delight to welcome Ed. His title is slightly different, slightly different from the one in the brochure. The talk today is on professionalism, proletarianism or profession, which shall it be? Ed, it's a delight to welcome you to Chicago. It's wonderful to be back at the University of Chicago where I've been quite a few times and watched the growth of Mark Shigel. More ways than one. Well, I wasn't getting into that. He did grow laterally and longitudinally, but mostly cerebrally. And it's a place to talk to you about this particular subject, which is a very hot one right now. I didn't change my title. This is a subtitle. I'm approaching it from the point of view of professionalism, but where professionalism might go or could go. And I wanted to compare an ancient notion, a notion of profession, with the notion of professionalism and the possibility that professionalism may mutate into proletarianism if we don't watch what we're doing. So this is a kind of warning signal. Certainly it's acute, occurred to many of you, but I would like to explore it just a little bit if you would allow me. The life in medicine, as I've led it over the last 60 years, has been filled with nostrums, panaceas, methodic treatments for every ill that our profession is presumed to have manifested to the public, to other professions, medical schools, etc. And many of these panaceas have arisen from genuine problems in the changes in the profession itself over the years. I look at professionalism as one of those methodic treatments that needs to be looked at skeptically, and that's why I took this particular approach, because I see profession, what I call the act of profession, as the bedrock of our profession from the point of view of what it is, what it ought to be and what it should be doing. I see professionalism as a sociological look at what we do, and I see proletarianism as something which has occurred in some very, very nasty manifestations, as you undoubtedly have already thought, as you reflect on the notion, but also as a kind of thing we can slip into and not appreciate what's happening. So with that in mind, let me just do first. I thought I'd be frank and develop my line of argument from the beginning so you know where I'm going and what I'm doing. The intersection of ethics and sociocultural forces create a need for a rational set of interrelationships with individual physicians for more responsibility, whereas I come from, and responsibility to society and social needs and development and society around it. I want to take a position that professionalism does not address this problem adequately, and I'll tell you why, and that therefore I want to conclude that we do have a problem that's not imaginary, but we need to return to the focus of individual patients good, which is the concern of the physician, and a reality that will not disappear, no matter how we organize society, people will get sick, and they will get sick on the starship going to Galaxy 740293 Alpha. And we do, however, much more than ever in the past, need to focus on social good as well and on the profession as an organized body, and that's what I take to be the thrust of professionalism.  I happen to think that Elliot Freitzen, the sociologist, definition is the one that makes more sense rather than some of the multitudinous definitions we find in the multitude of papers that are coming out of institutions today, all of which have interesting things to say, but they say them in diverse ways and under different rubrics. So let me just quickly go over Elliot Freitzen's criteria. It's a specialized work to be a profession, recognized and grounded in a body of theoretical dictionary knowledge and skill. And its exclusive jurisdiction is under a particular division of labor and created and controlled by the occupational negotiation as a sheltered position in external and external labor markets. So all of these are sociological and I'm not going to argue for these, simply say I accept them as Elliot Freitzen's observations, which I think are reasonable. It has a formal training program lying outside the labor market. Number five is what I want to emphasize. This is what Freitzen says, that a profession is an ideology that asserts greater commitment to doing good work than to economic gain and to the quality rather than the economic efficiency of work. So what are the problems with that definition today? Not the definition itself, but with that last statement. As we look at those definitions of professionalism, here are some of the problems that I see that I'm going to be looking at. There's no agreed upon definition, as we've already said. You can define ideologically, define it as a social scientist would, and that's Freitzen and I have to believe that makes more sense than what the others have seen. And people are emphasizing on the one hand two things. One is the articulation of behavior and affect on the part of physicians. Behavior is relationship to each other and to patients. Effect is relationship to their values and how they see themselves. But there is no clear or firm articulation of ethics in most of the statements except one, and it's pretty confused in that one as I will say. I make that point because remember the last point of Freitzen was that all of the above had to be under the direction of ideology or it would not be, in his point of view, a professional and it would not be ideal professionalism. Emphasis on method and teaching, et cetera, et cetera, et cetera, without clarity of definition. Methods of measurement of behavior and of affect on what I take to be arguable grounds.  The ABIM charter which most of you are familiar with particularly is a mixture of ethics and commitments, three freely asserted ethical principles with a series of freely asserted commitments to behavior and to dealing with the relationships and problems. It deals mostly with commitments versus obligations. There's very little word about obligation. There's very little deontology. I've read not all the literature, God knows, but I've read perhaps 50 papers and these observations I think apply to most of them. An unclear specification of roles of various health care professions who's in charge, who's my advocate, who will answer my questions. Those of you who are clinicians know when a patient comes that wants to know some very simple answers to simple questions. What's wrong? Is it serious? Can you do something about it? What are you going to do to me? Will it hurt? Will it cost? Put the long pole. That's what it's about at the front line. Those questions are very difficult to answer when you're talking about behavior of one relationship, this profession to the other one and so on. All of which is important, but it needs an organizing principle and professionalism is not an organizing principle with those two ends in view of A, responding to the needs of the patient, and on the other hand, meeting the new challenges that come from the social engagement of medicine, which is nothing wrong about this, nothing against that please. Let's not get into the dichotomy of these guys who are only on patients and are neglecting society or society and neglecting patients. Obviously that relationship has to be developed and that's part of the thesis we're talking about. It's a bit of overcrowding bedside, I still make rounds and especially when I'm making ethical rounds, it's hard for me to find out who's in charge because there is a small matter of the moral responsibility and legal responsibility which is defined as belonging to the position of record, just trying to find who the position of record is. Again, this is not criticism, it is dilemma that I'm confronting and some of you are confronting. That overcrowding is a bedside, I can't see the patient for the crowd. Most of the freely asserted commitments have some justification, but I doubt, but there's no order of priority for resolution of conflicts. So professionalism as defined by Freitzen is a real concept, it's a concept that has meaning, but as he says, and this is particularly interesting at the end of his book more or less, under the title of the soul of professionalism is ethics and what I think is being ignored somewhat. Okay, here's what he says and then this will be the last of Freitzen. I didn't realize this. At University of Chicago Press, I don't get any royalties for that. Freitzen does. Anyway, I'll read his words again, only because I want to tie it into what I think is a valid scientific definition of professionalism and the link between it and transcendent values, which I see very little of in the literature as I review it. Transcendent values, that's a pretty fancy word for what we're talking about, transcendent for philosophy or something bigger than that. But anyway, transcendent adds moral substance to the technical content of the disciplines. Professionals claim the moral as well as the technical right to control the uses of the discipline so that they must resist economic and political restrictions that arbitrarily limit benefit to others. I'm not going to spell out the implications. You're all well aware of what's happening in the world today. While they should have no right to be the proprietors, these are the professionals, no right to be the proprietors of the knowledge and technique of their discipline and one of my big fights over and over again is that people say, this knowledge belongs to me. I paid my tuition and I respond by saying, and what is the cost in that you would allow people to invade your body as our medical students do, because they have a social sanction to do so? And to that question, who owns it? So I come now to this very pithy statement of fights. While they should have no right to be proprietors of the knowledge and technique of the disciplines, they are obliged to be their moral custodians. Fightson calls this, as I said, the soul of professionalism, that it is an organized, well functioning, presumably not discipline, but a set of people involved in a discipline with a dedication, however, that goes beyond the discipline itself. That being the case, let me look at this other side, the other end, proletarianism, which he also addresses, but I'm very much concerned about. If the profession fails to be the, these are my words, don't blame these on Fightson, if the professional fails to be the moral custodian of the nature and usage of his technique, he becomes or she becomes a proletarian, someone to be used as an instrument to advance goals other than the moral obligations of the profession. I put the worst case scenarios there, obviously we're not, I think, heavens going in that direction, but proletarianism comprises the soul of professionalism if, if that soul is lost without dedication to a moral set of beliefs which divide and direct the use of the technique and the profession. So summarization of this piece of what we're talking about, there's nothing wrong with the idea of professionalism if it's defined promptly, it's a social phenomenon and I think that's quite correct, it's a social phenomenon that has a moral substance to it and that's what I'm going to be talking about. Let's turn to the idea of profession which is entirely different than professionalism. This is a very high-flown quote from the first mention of the word profession that is in the record coming from the first century AD but also probably older than that. It comes from someone called Scribonius who was a medical attendant to one of the Roman emperors for all things. Here's what he said about it. All men and gods, in fact, should despise any physician whose heart is not filled with humanity and mercy according to the purpose of his profession and for those of you who have Latin, you'll see the word profession, professor Jonas which I'll point out in the moment has a special meaning and we don't judge people by the worth of their bank account, or by their status or anything else in life. They offer to help all who seek it and promise never to injure anybody. Beneficence is ahead of non-malificence. Beneficence is the first principle. Just a minute again, profession. It means declaring a loud, announcing a loud, making a public commitment a promise. And that's what each and every one of us does when we address the patient and say, can I help you? What's wrong? What can I do for you? Etc. Put yourself on the gurney and someone on a white coat comes along with a stethoscope around their neck and says, how can I help you? What do you interpret that to be? You're in pain, you're anxious, etc. What does that mean? That is the word profession. The public promise that you make implicitly, if they didn't think that you were going to help them, they would certainly not submit or get off that gurney. So we're talking about a different kind of profession, that is to say in terms of the etymology of the word. It's the oldest one. I am not suggesting that everybody acted the way Scobonia suggested at the highest level. That's not the point. The point he made there was the use of that word profession. And it is not something that came into existence in the 18th and 19th century. That's somewhat implied. Now, to be truly an ethic, we'll be talking now, an ethic that's related to the promise of helping, of assisting. What does that mean? Let's look at that more carefully. Remember my line of argument. I'm going to hook the care of the individual patient with their societal needs. So to be truly an ethic, you have to have an established moral philosophy or an examination of the realities and phenomena of the physician-patient relationship. I'm going to choose number two rather than number one, which would be a more difficult assignment at this point. It also requires, however, what do we think medicine is, a moral philosophy of some kind, namely norms and virtues entailed by the phenomenology of clinical medicine. That's my phraseology. What I mean by that is that the obligations we have, and we're talking about not just medicine, but all the health professions. I'm using medicine as a shorthand only because, if I say something critical, it's going to be about medicine and not about anybody else's profession. But all of us have exactly the same commitment that action of profession. When the nurse comes to the bedside, when the physical therapist says, let me look at that knee, et cetera, et cetera, et cetera, the health professional has an orientation to the good of the patient. The good of the patient is the relief of what they consider and what they define as a problem, as illness for them. So, we're talking now about, therefore, an internal ethic of medicine. Not one taking off the shelf from some existing philosophy. That's the way most of medical ethics mean to us. But are you wrong with that? When you get to that level, but you start at the very ground, which is what is it all about? Now, all of you say this, or we've heard this before. Hold on for a moment. Let's see where we go with this. The active profession, can I help you? What does it say? It says, I'm competent. I will use my knowledge for your benefit, not the insurance company, not the hospital, not anything else. And trust me, aren't those the things that run through your mind when you're on the gurney? That's what I want you now. What are we looking for? We're looking for someone who can give you a technically correct and a morally good action. It should be decided for and with you, the patient. That's what you're expecting. And it's carried out efficiently, safely, and compassionately. All this seems to be laboring the obvious. But laboring is the obvious, and not to labor the obvious, is where we go wrong. And why this whole notion of professionalism and professionalization, even worse, idea, all of that, has significance, only if, just as Fraction said, and just as the facts say, only if it is enlightened by and based in an ethics, a moral. An ideology, I object to that, but that's okay. We know what we're talking about, and he's talking about ethics. So here are the things that are phenomenologically just some quick things that are phenomenologically true about that relationship. Don't worry, we'll come to society in a moment. When you become a patient, that's an existential change. You're sitting around now listening to me, probably wishing it would all be quickly, and I wouldn't blame you one bit, but nonetheless, you're in pretty good state of relationship to yourself and who you are and your identity. And as you're sitting there, you find a little nodule in your earlobe, being physicians and physician-related or other health professions and so on. You begin to think what's going on, what's happening. The questions I talk to you about. Your life has changed, like it or not, until you get some resolution to that problem. So you have a loss of your freedom and daily routine. You're environmentally vulnerable. You don't know what's wrong, even if you're a physician lying on that gurney, having been a physician on that gurney, I know that experience. You're anxious, you're fearful. There's a certain amount of hostility. You're mad at the problem and you get mad at the physician or the nurse or the allied health worker. It's a confrontation with your affinity. Now you know that's the possibility that you may even die.  And all of this comes down to your ultimately having to trust this person who came to you and said, can I help you? You're in the most state of existence to be ill. Quick summarization, the empirical realities are there's predicament of illness, I've just talked about the change in existential states. The act of profession, your promise of help, you said, how can I help you, what can I do? And the act of healing, the decision that you will make a decision which is technically correct and morally right. What does that mean? This is a review only of medical ethics. We'll put it back into the line of argument very shortly. Certainly we talk about virtues. A great deal today, and I've written a lot about virtues, I'm not going to lecture on them. But you do expect things to be manifest to you in the way this person behaves toward you. Benevolence first, not respect for your autonomy. Benevolence first, fidelity to trust and promise, compassion, courage, honesty and suppression of self-interest. Frights and points that I was one of the elements of professionalism. Intellectual virtue, science. This is in the classical sense of knowing the knowledge that you'll be dispensing and working with. Technique prudence, the first and most important of the clinical virtues. The capacity to make the right and good decision in the face of uncertainty. Most of us make our important decisions without having all the facts and not being certain about what we make our treatment with absolute treatment. We know there are things we cannot predict and yet we must act. That's the difference of clinical ethics and this is the center of clinical ethics is not right. So, center of clinical ethics means how do we make decisions which are in the best interests of the patient. That's the virtue of prudence and it's the oldest of virtues and I'm not going to lecture on that either. Covering the background for where I'm going. That was part two. Part one was a little examination of the notion of professionalism. The second one was the idea of profession which is far older than the notion of professionalism. Now, medicine also has and so do all the other health professions let me say that over and over again not just medicine, social obligations. I put and that's dealing generally with justice, justice in the use of our technique and our knowledge. Commutative justice first. Commutative justice. That branch of justice that deals in one-to-one relationships, contracts, dealings that we go through every day with in-beings that active promise. We act as technical experts when it comes to policy decisions. We have to be and should be advocates for distributive justice. We should participate as private citizens indeed in some of the studies I've read in professionalism. There's been great emphasis in people and society wanting positions to be more active in the life of the community. Oh, leave that off for the moment. What have I said before you? A, a notion of professionalism which is a valid social notion but one which must have a moral foundation when we're in the health professions that moral foundation is that strongest focus on the promise we make to the patient as a group but particularly as individuals in moments of existential crisis. And then thirdly we have responsibilities to society and that side has been emphasized in professionalism and there's nothing wrong with it. What we need then and what some of us are working with is how to order these things one to the other. And I see in the case of professionalism an entire emphasis on the physician being trained or the nurse being trained in a milieu which emphasizes what a society want of us and so on how we should behave and what should our attitudes be important but they do not define the fundamental relationship which is the moral relationship of a promise we've made to act for the interest and the good of the patient. And therefore I think as we look more critically at the notion of look more critically at the notion of professionalism and begin to look at it from the point of view of what's missing particularly the notions of the relationship of the health professional to the person who needs their help and the moral responsibility and not in any way deviating for a very valid definition of professionalism which is frightsome namely it all depends on it all depends on having a moral orientation he makes that point that for him is the soul of ideal professionalism and so I would propose and not going to detail at this point giving you an opportunity to ask some questions I would propose that we yes should look at professionalism look at it from the point of view of how we take these questions and problems I've raised with it and put together and not abandon the patient in the interest of the community on the other hand who should do what and I'll argue further that we must remember that the heart of medical ethics nursing ethics the other health professions the patient that has to be done within the framework of what kind of society we live with and responsive to what people are asking but not designing and abandoning the technical and moral orientation we have because someone wants it this way or that way we have to justify it in an orderly systematic critical fundamental way and that is going to mean a much more serious kind of engagement than I think we're in now I think the way I see professionalism being written about is in ideology in the wrong sense that is a series of beliefs that are held strongly and powerfully but are not justified in any formally systematic critical way and so I would like to see added to our medical ethics and I've written about this and have an article in this direction medicine regarded and again nursing moral communities so that in addition to moral community as to say in addition to our acting the way we've been talking about with individuals we also act together as a body for the social good without going into finding that which is another series of discussions of another kind so that we divide these issues on the one hand dependence of the patient on or the sick person on individual health professional and the dependence of society for the changes that are being emphasized in professionalism those changes being part of the fact that we in the health professions each of us within our profession have also a moral community what do I mean by that and I'll be coming to the close by that I mean that we are committed as a group to the welfare of those we deign to treat and office ourselves to treat as a community we're not doing that our organizations always turn to the interests of our professions not to the interests of the community and society a moral community we're united together why because we have been educated together with a moral point of view not so much in the fact that we are all doctors all nurses or all allied health professions but rather the fact that we're united by a common and I'm not going to go through here because of time some kind of common common oath we've taken or a charter or what have you I think the charters have problems but we'll leave that aside at the moment thank you the professionalism movement maybe a sociological movement as you said but it's also heavily an educational movement an effort to transmit to the students behaviors, attitudes performance both in the technical realm and one would hope also in the moral realm of what it means to be a good doctor and to practice well your challenge though is really a very difficult challenge in asking in asking of educators to be able to transmit this sense of moral commitment so much easier to transmit a sense of how to perform how to behave what things are acceptable in the community it seems much more difficult to get at your wish for us that we train our people to become a part of this moral community can you give us any guidance there I mean is it the training process itself through 4, 8, 10 years of training that leads to that is it by example is it by role models how do we get there that's a long question I'll try to answer very very briefly because I've been involved in education for 6 or 5 years it's just as you know my problem is that when you start talking about teaching behaviors you have to have a foundation for a particular behavior we spoke of words of commitment commitment appears in many of these statements these charters why should I commit myself in that direction well I would like to convince if you want to talk about medical students or residents or myself what I would like to convince is that commitment is not a matter of choice it's not a matter of prestidigitation of what you feel you can do and you like to do it is what you must do and that's why I think the act of profession which commits you in this public way every time you meet a patient that can be taught only one way that weighs heavily on the medical teacher by example I can lecture for 6 weeks on medical ethics on medical comportment or any of these other things I'm talking about turn my back once at the wrong moment when I'm making rounds and I've blown the whole lesson out the window so we can talk about these behaviors the other point about the behaviors is the methods of measurement are dubious very dubious but it's much much more keeping a very similitude if you're standing there and you see someone do it the right way and you are then wanting to follow that person every medical student eventually every resident has a model someone they admire for their technical skill usually at the beginning and then they begin to pick up the habits within the non-technical realm and I think clinical teachers are not sufficiently aware of the fact that they transmit two things one how to do endocrine surgery and secondly how to treat the person who has a few chromosatoma and those two things don't always go together so I'm not opposed to having sessions in which we say what a society want of us and so on the point is how do you put those two things together and I don't think I don't think that emphasizing a list of behaviors or a list of relationships is going to take the place of a moral conviction and that moral conviction has to be actualized and concretized in the person of a clinical teacher teacher rather than going around Oprah Winfrey style I'm going to repeat your questions so that it's also recorded for the for the tape so if there are questions I'll be recognizing them and repeating them to what extent are the principles that have been articulated timeless and to what extent do they need to be adapted to particular structures in the current era economic strictures and things like duty hours well one at a time leave the duty hours for the second piece I don't think there's any conflict from what I've said because the way I would put it is if you're planning to meet an economic crisis in medical care why not do two things first ask yourself what are the requirements for an ethically defensible economic decision not let's make an economic decision and then decide where the pieces fall start with that question and I think that's a different way of approaching it you look at in the beginning what you're thinking about and the second thing is you follow what you've decided upon by examining again the ethical dimension and once the ethical dimension it's not something complicated is the change you've made beneficial or harmful and if harmful have we made a sufficient attention to preserving the good of the patient in the light of economics it's a not something you're going to get out of a mathematical formula I think that's what people are asking us what about X, Y and Z and how does that fit with our economic decision economic decision will be made I'm not someone who says well let's just forget about it that first and in the design of your system there's a great deal you can do at the beginning to look at what would be the impact on the good of the persons we are treating where do we go when some of our economic decisions fall as they might and I'm not making any political statements here at all they might on those on the margin of society what's the moral obligation of those who are writing the plan how do you balance those that's a prudential decision exactly what I was talking about but you have your ethical question preceding your economic question and then when you've made your economic choice what would be the dominant ethical point of view he said what about the persons on the front line who have not been involved in actually making those economic decisions but are simply confronted with them as facts particularly when they have to make trade-offs between the economic good of society and the good of the patient or confronted with a system of financial incentives that they didn't invent and weren't in the making process I don't think any of that changes what I said you're making a reality a reality I'm very familiar with I've been at the front lines I've been in the trenches presented with a certain set of facts which you said and I agree you're quite right with that but our job is to say what impact will that be and then think of the second thing as a profession when we suspect that a decision has been made economically is damaging to patients to people that's where the fact of being a moral community united for the good of the patient as well as individually as a group comes in and I've heard very little clear examination of the ethical implications of some of the things that are proposed without going into specifics to what extent is the individual clinician going to be beholden to third parties that have made decisions or have influence and interests in the decisions being made at the bedside beholden I think you're saying being put into a situation by those well again where are we in our answer to it where are we let's say there's no question these decisions being made away from us but where's our pushback that's what I'm talking about I'm preaching I guess revolution the question again for the tape should physicians become then activists and revolutionaries for the record Dr. Harmon for the case of for the sake of the record I'm not preaching revolutionaries however I'm using the word pushback I would like to see and I have not seen in my lifetime our profession saying look we have a common responsibility to act for the good of the patient on a one-to-one basis you can't do it as an individual but as a group and we haven't done that and that's what I'm talking about revolution is a strong word obviously but we have let me say this we have much more moral power than we've ever exerted again the comment is isn't as was said before by Dr. Chin the frontline physician who's operating within decisions that were already made by others outside the profession already proletarianized by your definition of proletarianism well as a matter of fact I didn't want to annoy you but you've come to the obvious conclusion yes that is why I put professionalism profession and proletarianism yes you're proletarian once you lose the capacity to determine how you're going to use your knowledge for the purpose that it's designed which for us should be the good of the sick person for the record the question is to what extent could physicians rather than simply responding to society actually engage with society particularly with patients in establishing the sorts of standards how much can the physician do not just the physician I remember I've confined myself to physician only because of the reason I gave you the beginning but I'm talking about all health professionals just think of the moral power 400,000 physicians 2 million nurses XYZ, dentists, etc who were really united by a moral commitment to the good of those they serve tremendous impact on society tremendous we still have some status left we're losing that status simply because we don't take that kind of position so I think we ought not to be throwing our hands up we have power and that's why I developed the notion here that on the one hand there's no question that we have to strengthen our commitment to what we do and secondly we have to be a moral community where all of us in the health professions push back when there's something that threatens the good of those we can treat maybe that's too such a dirtle I'm not preaching the point is I think that's our moral responsibility Dr. Pellegrino I was under the misguided impression that as people became more mature and senior in their standing they became more conservative your message to us is one of radical activism that changes my mind greatly but thanks so much for coming and talking to me just one comment activism but with a moral foundation yes very fabulous