Ooh. So quiet. I love it. Hi. How was lunch? Was it good? Welcome back. No, it's good. It's good. Welcome back. Were y'all in here? Yes, we're good. Come on in. Come on in. Come on in. All right, let's get started. Let's get started. Our next talk features Stephen Nevella, Harriet Hall. We've added some names. Paul, Ophid, Scott Lillianfield, and David Gorsky is our moderator. It's the psychology of pseudoscience in medicine. Here's the limerick. We often scoff at the painful reliance of a psychology's regretful appliance of stuff that's not true, but hey, what can you do? There's big bucks in medical pseudoscience. All right, please welcome to the stage Stephen Nevella, Harriet Hall, David Gorsky, Paul, Ophid, and Scott Lillianfield. Thank you. Oh, all right. One of the areas of pseudoscience that we see in a lot of what we call supplementary and alternative medicine has to do with psychology, and we thought to start this discussion that we would talk about perhaps the most pervasive area, because it also, some of it might not all be quackery. So let's talk about, and the slide's not coming, we're going to talk about mind-body therapies. Is it showing up? Because I can't see it on my monitor. All right, so there are two definitions that you see before you. One from the National Center for Complementary and Alternative Medicine. Is it showing? I'll just wing it here. The definitions both basically talk about interventions for the mind and body or the mind-body connection that can be either therapeutic relief symptoms or improve immune function, improve physiology, whatever. And there are a whole number of them that range from things like meditation, exercise, and even aromatherapy. So I think what we'll do is I'll just start by asking each panelist what they consider, what do they think of when they hear mind-body medicine? What does it mean? Well, in the first place, mind, to me, means an emergent phenomenon of the physical and chemical processes in the brain. And it's a handy shorthand that covers a lot of things. It doesn't cover everything the brain does, because the brain does a lot of automatic housekeeping functions. But I think of the mind as including anything that consciousness has access to, things like emotions and thoughts and memories. And when I was in medical school, our professor of psychiatry told us we could not use the word mind because he thought it led to fuzzy thinking. And when somebody tells me I can't do something, I tend to react and people who know me will understand. I rebelled and we had to write a term paper and I wrote the term paper and I used the word mind over and over and over again throughout the paper. And I got it back. It was all covered with red marks. He'd underlined every time I'd used the word mind. He'd written nasty notes in the outline in the margins. But he gave me an A-plus because I had explained what I meant by mind and I justified the way I was using it. And mind is a word that's handy in a lot of ways. How could we say things like I'll keep that in mind or I changed my mind if we didn't have a label like that? And it's kind of like a metaphor, like we say from the bottom of my heart. Well, we know that doesn't have anything to do with that little pump in your chest. But it's very useful in getting ideas across to other people. So when I hear the word mind, I don't think about anything ineffable or immaterial. And it certainly doesn't remind me of a dualistic philosophy or a vitalistic philosophy. And I think it's a good word to use as long as we understand how we're using it. But I think the idea of mind-body medicine is just stupid. Because... No, Harriet, how do you really feel about that? Because there is no division. It's all one thing. Things that happen in the mind affect what happens in the body. If you're afraid, your heart rate speeds up. And things that happen in the body affect the mind. If the body is sending pain signals to the brain, the brain interprets it as suffering.  So good medicine always considers mind and body together. And there shouldn't be a separate category. Okay, before we move on to Scott, we finally have the slide up there. There are the two definitions. One from NCAM. And the other one from the NCI Office of Cancer, Complementary and Alternative Medicine, which has the most unfortunate acronym ever, ACAM. It's not on the big screen. Alright, never mind. I give up. I give up. Scott, you're next. Let me guess, it's on the screen now. Anyway, this is the list here of some of the things that fall under mind, body, medicine according to our government. And you can all see the list now. And we'll leave it up a few more seconds while the discussion continues. So I'm not sure what mind, body, medicine is, to be honest. Like Harriet, when I think of mind, I don't think of anything spooky or spiritual or non-material. I'm a non-reductive physicalist. I do think the mind is what the brain does or partly does. When I use the term mind, like Harriet, I use it to refer to an emergent property of lower-order neural elements. However, I think that when most people use the term mind, body, medicine, they're not using it that way. At least that's my impression. My impression is they're using it in a pretty dualistic way, either implicitly or explicitly. So I think one reason that is popular in many circles is this assumption that these interventions, including some of those that are listed there, I'm surprised to see cognitive behavioral therapy, which I was trained in on there. I think a lot of people who support these techniques may believe that these methods are working not through the brain, but through some kind of quasi-spiritual non-material essence. So I don't have any problem with people looking at the efficacy of meditation for anxiety or exercise. In fact, there's some pretty good evidence. I think the exercise is helpful for depression. But when I say that exercise works or cognitive behavioral therapy, which I know fairly well works, what I mean when I say that is I think what you're learning to do with cognitive behavioral therapy is you're learning to harness one part of your brain to control another part of your brain. I don't think you're harnessing the mind or some non-material essence to harness the brain, but I fear that that's often the implication. I'm often worried that that implication is almost left dangling out there because it may be appealing to some people. Paul? I guess I have a very simplistic view of this, which is I would define it as that one's emotional state influences your susceptibility to illness or your ability to recover from illness, but I completely agree with Harriet. It's all of one piece.  I think it's true, but there is to the degree that there's a physiological response. It is explainable. For example, you have nerve endings in your thymus and your bone marrow and your spleen. These are immunological organs. It's not surprising then that one can learn to in some ways influence one's immune system. I agree with Harriet though. I think it's certainly all of one piece. There's nothing magical about it. Steve, give us the definitive answer. I don't know either. I don't use the term mind, body, and medicine because I don't think it has a usable definition. It doesn't have what I would call an operational definition. If you have these features and have these occlusion and every feature, then that's considered mind, body, and medicine. So it's kind of like a wizard's definition, like Gandalf. It means exactly what camp opponents wanted to mean at any point in time, nothing more, nothing less. I agree with Harriet. A lot of it comes from vagaries of the term mind. We can use it as a metaphor. I just sort of sometimes just bypass it by saying, well, I'll keep that in the synaptic connections of the neurons in my neocortex. Mind tends to flow a little bit easier, so it's a useful shorthand metaphor, but when you try to use that as a scientific definition or a clinical definition, you run into trouble because it is a metaphor. It doesn't really have an operational definition. And to the extent that it has any meaning, it is just the functioning of the brain. The brain is not the mind-body. The brain is the body. It's part of the body. It's the same thing. It's just the different parts of the body connecting and working together. And so it's completely artificial, I think, when you really try to break it down to what it might mean. Okay, so among this list of therapies, are there any that you'd consider to be perhaps evidence-based? Well, evidence-based for what? Well, I mean, you can give specific indications. So, I mean, there's a lot of things on the list. This is one of the things that drives me crazy with alternative medicine claims is that they're often nonspecific. There's Tai Chi is on there. And yoga. Those are both exercise. And what the evidence shows is that they have the effects you would predict they would have for exercising and stretching and practicing balance. But saying exercise isn't as sexy as saying Tai Chi or yoga. And so there's study or meditation is another great one. There's lots of studies on meditation. I've tried to look through as much of the literature. Perhaps we should define meditation. Is there a science-based definition of meditation? So again, that's the rub is what's the operational definition of meditation? Virtually all of the studies, clinical studies looking at meditation showing it lowers your heart rate and lowers your blood pressure and reduces whatever, reduces your blood sugar and all the wonderful things that meditation does. What they never do is have a control group where you're just relaxing. So how do I know that meditation or some particular kind of meditation, transcendental meditation or whatever is any different than me just sitting on the couch and relaxing for the same amount of time? They don't do that study. I have to wonder why. The two possibilities are not to be false dichotomy, but two certainly plausible possibilities are. One is they're just terrible scientists and they're not asking the obvious question they should be asking. Or two is they don't want to know the answer to that question. They want to do the study that shows that transcendental meditation lowers your blood pressure. They don't want to show as well as sitting on the couch and doing nothing.  Yeah, well if you're eating Cheetos it doesn't help. So that's why they live for vague definitions. They live in the gray zone because that way it means exactly what they wanted to mean and you could never nail them down. It's like nailing Jell-O to the wall, right? You could never do it because if you have to actually define your variables it all falls apart because it's all marketing. It's not science. Some of the ambiguity Steve also that some of the proponents of these techniques are not always clear about what they mean about specific versus not specific effect. So for example one argument I hear is that if you compare meditation with a relaxation condition and a few studies have done that and as you know the results are kind of equivocal so that's how you do that and the results are kind of you know not so good. So they might say yeah but sure what you're calling a placebo effect is in part what I think is part of the technique and I'm not defending that but I just wonder part of it is just an ambiguity about what actually the active component is is that part of the problem I think is just the theoretical mechanisms are rather vague. That's the other shell game that they play is when you show that they have quote-unquote only placebo effects they go well there you go. Placebo effects are mind-body medicine. So that's one that becomes their definition of mind-body medicine because that's the placebo effect is the mind effect in the body even though it really isn't. So they just turn the whole logic of scientific research on its head by saying that only having a placebo effect is a real effect even though it's mainly nonspecific or illusory effects and it's not a real effect but it fits within their fiction that they've erected about mind-body medicine which is really what it is just a narrative. I guess if you want to really break it down. But see I think here's what I would say it's just because something doesn't work better than placebo doesn't mean the placebo doesn't work. I mean you could argue as you just did I think Steve that if you take all of this whether you call it Tai Chi or Kuigang or meditation or yoga or whatever that you can at times at least define that you are affecting the release of stress mediators which have an effect on the immune system or have an effect on blood pressure and so that's what that is. I mean I think that there is a physiological basis to that that is effective or can be effective. It's just the part that's upsetting and I think it's upsetting to Steve too is that it's sort of sold as something mystical and greater and magical and that's I think we're in danger of lies. Yeah let's call it sorry let's just call it what it is. It's relaxation. It's exercise. It's stretching.  Relaxation, massage, whatever. Repackaged over and over again with the different BS around it and that's that can so is confusion. Science is supposed to win away the confusion to what's actually happening. They're going in the opposite direction. They're embellishing the real effect with fake stuff. Most of the things on that list are feel good things. They're like comfort measures. They make people subjectively feel good. There are very few things on that list that have been shown to have any really significant effect on the outcome of illnesses. Some of them may have some physiologic effects but are they big enough effects to really make a difference? There's no real good evidence that there is for most of those. Yeah, I think for CBT cognitive behavioral therapy I think there is some. I think even there there's some question about whether the cognitive parts which involves restructuring the way we think about things add a lot above and beyond behavioral parts. That's a controversial issue right now. But I think there's some evidence. Pretty good evidence that CBT is efficacious for depression and also good for prophylaxis of depression. Yeah, I was actually about to ask about CBT cognitive behavioral therapy. It is used for many indications. So how does it get lumped in with mind-body medicine? I mean, Steve and I have talked about this sort of thing for a lot of other things. This is basically, and I'd like you to comment on this, this is basically a rebranding of potentially science-based therapy. Again, I wonder, I don't know, I'm sort of bewildered by it but I do wonder if again some of it reflects this implicit dualism that the cognitive part when you're changing people's thoughts you're actually, you are going through their minds but not their brains. I wonder if that's almost the assumption that is being made here. So that's what makes it a mind-body technique because you're changing their mental processes which somehow is not material. Again, all of us on the panel would agree that doesn't make any sense but intuitively I wonder if that's the way a lot of people think about it. I think they lumped in the cognitive behavioral therapies because they needed something on their list that really worked. So can there be mind-body medicine without dualism as an assumption? Does the whole category require...? I don't think it requires dualism and just to define what we're talking about. Dualism, there's different flavors of it but basically it's any philosophy of mind and Daniel Dennett is here so I'm sure he's going to talk about this. But it's any philosophy of mind that says that the mind is somehow something other than just what the brain is doing. It's something more. Cartesian dualism it means it says it's completely separate. There's this spiritual thing outside of, metaphysical thing outside of the brain but there's other types of dualism that blur the lines even further. So I think the blurring of those lines with dualism is useful for including whatever you want into the category keeping it nice and vague so we can mean whatever you want. But you can have a concept of mind-body medicine that doesn't involve dualism all you're saying is that, again like Paul said, your emotions affect your health. It's like okay, that's true in a very trivial sense and we know that it's true because the brain is your health, it is your body and it's all connected. So of course your stress hormones are released by stress and that has an effect on the physiology of your body which can affect all sorts of things. So it's true in a way that's reductionist scientific that we've known for decades that's not controversial but to the extent that it's true in that sense that it has no meaning and it's not dualistic when you go beyond what we know from biology and physiology then they start to incorporate dualism to expand their list to whatever they want like guided imagery or things that are more than just the basics of relaxation and exercise and massage and whatever. There was one study that was done in 1957 it was sort of a landmark study done by John Inboden who was a researcher at Johns Hopkins University he did this study at Fort Dietrich and what he did was it was fortuitous he went to an army barracks at Fort Dietrich, Maryland he did a sort of series of psychological profiles defining then these soldiers as being sort of more or less depressed and then the fortuitous part came that was right during the big Asian flu pandemic of 1957 which then swept across the barracks and then affected those soldiers differently and what he found that was interesting because it was really very clear that those who were more depressed were more likely to get sick that when they got sick they were more likely to develop symptoms for longer and they were more likely to shed virus for longer I think which served in some ways as a proof that mood can determine illness I don't think it's trivial but it's harnessable at some level we sort of surround it with this kind of mystical bullshit it's painful we know that it's stress, depression, emotional stress releases corticosteroids which suppress the immune system we completely reduced that access we know exactly what's happening there's no mystery there whatsoever I agree, if I could just go back to one quick point that resonates with what Paul was saying before is I think one mistake would sometimes make and I think I was guilty of a two for a while I think the question is Technique X effective or does it work and I think and also relates to what Steve's talking about as part of our role as skeptics I think it's to be clear thinkers and to sort of make distinctions so I think it's I've come around to the view that's not a very meaningful question if we ask does X work well what does that mean does it mean work better than doing nothing which oftentimes is not as we know a very informative comparison especially given placebo effects and a host of other non-specific factors that can account does it mean working better than a placebo does it mean working better than a rival intervention does it mean working better than treatment as usual in terms of what's typical it can mean any or all of those things and I think part of the problem with mind-body medicine is sometimes it has been vague about what that question actually means and going back to Steve's point I think the question whether something works above and beyond placebo it's often a pretty rigorous test especially in my own field of psychotherapy it's actually a controversial issue first of all it's really hard to get a good placebo control well that's actually what you've just brought up something I wanted to get to how do you test you know one of the things that CAM practitioners will say is well you can't do a randomized double-blind trial on these interventions you can't test and you know how do you how can you say they don't work so can you test these with you know what's the most rigorous way that you can test some of these we could talk about say cognitive behavioral therapy but you could pick any other one if you have if you thought how would you test it what's the control how do you control for the placebo effect like how do you make it as rigorous as possible well you definitely can't do a or it's almost impossible many people argue to do a strict double-blinded test of psychotherapy sure you can do a single blind sometimes but even there it's really hard because typically both client patient both client patient and therapist know who's in which group and they know what to expect and so on so it's impossible to do it strictly blinded on the other hand you can still use randomization and one of the old principles I always teach my students in psychology is if you can't eliminate a source of error at least try to measure it and certainly you can get closer to a blinded trial by measuring expectancies you can measure clients expectancies at the beginning throughout treatment at the end of treatment and so on and often use that as sort of statistical covariates in terms of psychotherapy what is a good control condition say for cognitive behavioral therapy boy that's a tough one that's why I asked it it is really hard what people have typically done is use what are called attention placebo control groups attention placebo control groups typical what people do is rather than actually do therapy itself they will talk to a therapist typically the same level of training expertise for the same amount of time but they will not do strict cognitive behavioral therapy they will talk about their problems use emotional support and so on usually what you find by the way when you do that when you compare a reasonably well supported therapy like cognitive behavioral therapy with an attention placebo control group you typically still get a difference but it's not as great as the difference with a say a weightless control condition where the person is getting no treatment at all so the difference often goes down by about a half or so but one of the controversies which maybe gets the question you're getting at is are you taking out too much because after all part of what works in psychotherapy is support part of what works is the ability to talk to a caring professional so that's always the question again to me and I agree fully with Steve on this to me a lot of this is what are you claiming that it's the nature of the claims you are making if you are claiming that your technique works better than just talking to somebody for a particular period of time than you better damn well have good evidence for if you're claiming that okay this is just a technique that works we don't quite know why it helps to talk to someone for a period of time then it may not be as important but the fact of the matter is almost always in my field of psychotherapy when people are proponents of a particular therapeutic technique they are claiming that that technique has some specific techniques and specific stuff in it that other therapies don't any other comments just as an example I think the one for me that I always like to go to with CBT is like the eye movement desensitization and reprocessing where you follow the finger of the therapist and moving your eyes is supposed to get you to integrate the cognitive therapy better it's based upon a completely nonsensical notion of how the brain works and again there is almost an inherent dualism in there where the mind is reprogramming the brain in some way it's all nonsense but the the researchers who claim or the proponents of that who EMDR claim there is a specific benefit to doing that that's something you can control for and you can compare it to CBT without EMDR and it may be hard to fully blind it but you can at least do some kind of controlled comparison between the two and what they don't do is they don't show that there is a specific added benefit to that isolated variable component they really just show that there is a nonspecific benefit of introducing something novel and doing the interaction between the therapist so they haven't isolated the variable and when you do you tend to isolate those variables they don't have any specific benefit so then they fall back on saying yeah but there is a nonspecific benefit and that is equivalent to working and again I agree Scott says they have a vague definition of what it means to work to the point that placebo effects will be working and so it's a win-win they can't ever possibly lose and when you can't ever prove that something doesn't work then you can't prove that it does work either in a way it becomes non-falsifiable therefore it's not science and that's what we get interested in when they're going outside the boundaries of science by essentially rendering their claims immune to falsification real quick note about that in terms of rendering claims immune to falsification there's a ad hoc hypothesis in science that does that actually concerns EMDR arm movement, desensitization, reprocessing so someone did a study if there had been a couple of these studies where they have compared EMDR with the eyes wagging back and forth and then there's more of an EMDR than that like also processing the memory so they had a condition, a typical EMDR condition where the person's following the therapist's eyes and then they had a control condition which was a fixed eye movement condition they were all in a spot without the eyes and it worked just as well there was no difference at all they both worked better than a weightless control but they worked equally well so which would seem to refute at least to me or call it a strong question the theoretical mechanism underlying EMDR well, no, not so fast because the proponent of EMDR the main proponent of EMDR actually wrote on a list server I think I have this email somewhere saying no, that actually vindicates my hypothesis about EMDR because when the person is staring at a dot the eyes want to move so at some level it's still working because the eyes at some unconscious level are actually moving because the brain is simulating the eye so again it becomes possibly I guess but it becomes impossible to falsify after a while you looked like you wanted to say something I just want to say that I can see you looking over here certainly as a conventional therapist I would argue in our hospital we're certainly not above practicing placebo medicine I think we do it subtly when you come into our hospital and you see one of our doctors they have on a white coat with red stenciling not a t-shirt that says Iggy and the squirrels on the back of it we have these big machines that make fancy noises when we give medicine the machine that goes ping the machine that goes ping in the night when we give a medicine to a patient we often say I really think this is going to work for you that all matters but at some level it has an effect so it's subtle but I think it's we all do this at some level that's been studied to show that the more expensive the medicine is the more it's being good so another aspect of mind body is that it's evolving and in fact the NCAM strategic plan for the last five years is now refers to it as mind and body medicine which expanded to include things like therapeutic touch, energy medicine you know like glommed on to all of this so I guess my question here is what is it about mind body medicine whether you accept the concept or not that it attracts so much woo I mean how can we stop that I mean energy medicine is about as quackery as much quackery as you can get that's hardcore wouldn't it be wonderful if there was really such a thing as mind over matter if you could think yourself out of illness I mean that's a very seductive concept I agree I think it's a lot of things that we've been talking about it lends itself to the woo to a lot of alternative practices because it deals with vague definitions because it's essentially a rebranding of non-specific and placebo effects so it's a setup it's actually a brand that was created to create a space for things like energy medicine and things that are not scientific so it's not a surprise but let me ask this so the hospital the University of Pennsylvania which is next to our hospital I'm at Children's Hospital Philadelphia the division of oncology has a reiki master so you can go there and you know you get your healing energies manipulated now it's nonsense but you could argue that you know that in that patient who is stressed out this is decreasing stress and it's a value and it's certainly of low risk and low burden it just promotes magical thinking how about I give you my I'm going to step out of the moderator role for like 10 seconds 30 seconds my answer to that is I don't have a problem with reiki masters in the same way that I don't have a problem with chaplains because if it's mystical religious thinking they should they could be treated the same way but there is a chaplain and anyone if it's marketed that way but that's not what they do but that's not what they do that's right that's not what they do they spin it into something that's real medicine you know because I think you recently pointed this out the universities that promote reiki and I looked at Yale's website the Yale hospital does it but they were very careful in how they worded it they made no actual medical claims some people feel better when they have somebody wave their hands over them they were very vague about it which had to be deliberate they didn't make any actual claims but then other hospitals and other centers really go way over the line this is a system of medicine well Dr. Oz it'll promote healing once you start saying healing that's another vague term it doesn't mean anything like wellness it promotes your inner wellness so there's lots of ways that you could make pseudo non-scientific claims that sound good as good marketing good branding that is avoiding anything specific and then there are other sites still that actually say this will cure your cancer then they go all the way to this is going to treat your disease and that's way over the line that's where you get into the real hardcore quackery so it's a continuum the whole spectrum which is why I don't accept things like Raikey because it is on the spectrum as Paul said it promotes uncritical thinking we can't underestimate how much harm that that does because people get on that they think this is good for me to relax as an adjunct to my treatment and then the next step is I know this sounds like a slippery slope argument but this is how they do it what about acupuncture? they get you in there and say they make all the non-specific claims that they can slip past the academic goal post but when you're in the office they're like oh yeah this is going to align your chakras and cure your cancer then they really hit you it's definitely the Trojan Horse David and I have used that analogy before the soft stuff that we're like okay who cares about that it's touchy-feely, it's nice the soft stuff really is the Trojan Horse but in their heart of hearts they believe they can cure cancer with acupuncture and that's what they tell you once they have you in their office and they're not trying to sell themselves to the Dean of a medical school who isn't going to buy that so it really is a deliberate deception and we can't fall for it I think so getting to your question why is it appealing that was the question so why is it so appealing obviously it's very appealing that if you can think yourself well, especially if you're sick I think for the same reason the chaplain's appealing there's this notion that there's something greater than you out there that can sort of reach down and make you feel better or be better, you know what I'm saying it's just that incredible need to believe there is something greater than yourself I think that's what part of the appeal I agree, I think I think two other pieces one, again this is more my psychological background I think again not too much of the dualism issue but I think it is pretty deeply embedded in the way most people think Paul Bloom has argued this that a lot of us are implicitly dualists and so developmentally we know that kids are dualists we ask preschoolers for example questions like it's interesting you ask them like what part of you can do a math problem like do add stuff together most of them will say the brain but if you ask them what part of you loves your mother they'll say the mind and Bloom and others have argued that there's a bit of this residue in all of us or is it just cultural and I think it's both I think it may be cultural I think it may also be a natural unfolding of development in terms of our understanding of the way our bodies work I think the other piece of course is that I'm the one non-MD on this panel but the one thing I always hear and I'm sure you folks have heard this too is this sort of complaint that traditional medicine is kind of cold uncaring, unfeeling harsh and I reject that view but I understand it's a widespread view and certainly there's a core of truth and obviously we're coming around to the view that some of these placebo effects that Paul talks about like being caring and having good rapport and so on are an important part of medicine it's not a dichotomy it's actually part of good medicine as being caring and being supportive but I think looking at that list that was up there before is that a lot of them are kind of feel good things a lot of them involve touch and being relaxed and mellowing out and getting in time it makes me feel good kind of thinking about it meditation, relaxing aroma therapy it's all kind of nice and I think to a lot of people it reminds them of what bothers them rightly or wrongly about traditional Western medicine which may often seem sort of cold and impersonal but has that kind of warm fuzzy feeling again to me the answer to that is to make sure that Western medicine is caring and is not cold and unfeeling rather than to resort to unscientific claims but look I can understand the temptation part of it might be due to a common understanding of something that hasn't been mentioned yet and that psychosomatic medicine you know there is a thing called somatization disorder where people's mental discomfort is expressed as physical symptoms and most people have heard about psychosomatic things I used to belong to the American Psychosomatic Association I remember reading things in my less skeptical days for instance they looked at people who had stomach ulcers and they interviewed them and they got all of them to say something to the effect that that burns me or that really makes me sick to my stomach so they thought there was something symbolic going on that caused ulcers and I don't remember the studies ever having control groups and asking lots of people the same questions and seeing how many of them said that something burned them they would say things like people with chronic back pain will say something to the effect that they'd like to run away from that problem and people who have heard that kind of thing and been indoctrinated into that kind of thinking find mind-body medicine a lot more convincing than most of us do alright I think we got about 15 minutes left and we want to have time for a fair number of questions so our MC will if we want to form a line here I'll grab the first one right there but let's form a line if you want a question just so we don't block anyone's view so feel free to come on up we got a little bit of time here here's the first one you guys take on detailing the placebo effect and people's popular conception of exactly what's going on there I seem to run into people that literally think that their mind is healing their body and that that can go towards things like outcomes in cancer how widespread is that just my anecdotal you know are there good numbers on how widespread that is you know I'll just start by saying something very quickly I think most people when they hear the term placebo effect think that you're dismissing them they think that you're saying that this is just a trivial thing it's all in your mind it's really not real and it's a dismissive I think perceived as a dismissive term that's my sense I agree or it's perceived as the mind healing the body that's the other way it's interpreted when it's like a positive thing either it's dismissive or it's exaggerated so but you're right that's not what it is I mean it's been studied enough but we know that there isn't any actual healing going on there's no physiological effect it's all the perception it's all you know illusory effects like regression to the mean etc so and again we get into the problem of the operational definition of what is actually being measured as a placebo effect versus what are the components of that go into that placebo effect it's a lot of things but it's not a mind over matter actual healing but in my personal anecdotal experience 100% of the people that I talk to thinks that's what it is and that's the opposite of the truth it's actually not what it is it's the one thing that it isn't because we know that because researchers who have tried to show that's what it is have ended up proving that there's no real healing effect going on that it really is all just transient subjective illusory effects so I had thoughts to you some of you it's my own ignorance it's been a little a while since I checked this out but I thought there was some evidence justing that placebo effect sometimes can be blocked by like the lock zone or other opiate blockers wouldn't that suggest there's some learning of endorphin release? yeah so I think you have to carve the other because that's a good point the other point is you have to see the placebo effect for what pain the problem the thing is pain is subjective and it's an experience in the brain that's it's a complicated biological experience with a lot of components and there's a lot of built in ways of modifying the pain experience at multiple levels at the peripheral level and at the central level and there's different components of pain that are modifiable by different brain mechanisms there's an emotional component to pain there's an attentional component to pain and there's a tactile they're feeling all manipulable manipulatable but with with the functioning of your brain so yes when you're in a good mood pain doesn't bother you as much when you're in a bad mood if you look at your right arm and your left arm hurts your left arm will hurt less because you're diverting your attention from the arm that hurts and I'm sure you know yes dopamine and endorphins those are that's how the brain works and so that when you measure how the brain works those are the things that are happening when your brain is modifying its own kind of all reduces down to a no kind of obviously that's the way the brain works kind of mechanism but it does mean and this is the big question we always get about placebo effects if patients feel better who cares and I agree in that if you're talking about subjective symptoms it's okay and in my opinion this is kind of come up you know already does that mean you're going to send your patients for acupuncture if they don't have my approach is that's good bedside manner you know that's something that we've been doing for hundreds of years before science-based medicine that was all we had was good bedside manner that's you know just the touchy-feely part of having a positive therapeutic interaction you know just practical ways of getting people to deal with their pain pain is a psychological experience in many ways it's all part of standard chronic pain management because yes pain is psychological but again they try to spin it into something magical something more than it is by fuzzy definitions and by really just ignoring the reductionist our reductionist understanding scientific understanding of what pain actually is I mean one other case real quickly and I'm sure you know this much better than I do but where I think of a physiological basis for placebo effect is the work on sham surgery for Parkinson's which I think is holding up pretty well so if you for example do a a sham surgery with people Parkinson's that is you actually don't do any I guess they open up the skull but don't actually do anything right what you will see is that the tremors will go down and there's actually at least a short term doesn't last very long yes but a short term relief and symptoms and it's actually a physiological improvement and some of that probably and I believe the evidence suggests it's dopaminergically mediated. Dopamine is a neurotransmitter very involved in hope so when the person feels they're getting the sham surgery they don't know which condition they're assigned to they start getting a boost in morale their dopamine starts squirting out and that actually of course Parkinson's is a dopaminergic illness it actually results in a short term improvement in the symptoms which is physiological so in a sense it's a placebo effect of course because it's an artifact of hope and morale but it's a genuine physiological effect that produces dopamine increase which in turn alleviates the symptoms of Parkinson's. Yeah I agree I reviewed that literature as well and that's my understanding as well but again so just like pain there is or like corticosteroids you know when there's an actual neurotransmitter that you know that responds to emotion then that neurotransmitter has effects or that hormone whatever's being released then yes it can have the effects that it has so again it kind of reduces down to known mechanisms but as you say it's short-lived because the emotional component is short-lived and kind of goes hand in hand with that so I still think that research is preliminary but even if we just accept that they face value it's just another thing like pain where there's a transient effect because it's directly resulting from brain function. Should we go on to the next question? This is one about the psychology of what goes on in a person's mind when they see an alternative medicine person versus a doctor the common thing in Australia is they say the doctors are greedy and they want my money and they ask and the alternative medicine doc isn't? So in Australia the situation is that the doctor cannot benefit financially from the advice they give so they cannot own a pharmacy and they cannot sell you medications and yet in my experience everybody I've spoken to who's gone to see an alternative medicine practitioner is after an examination told there's something wrong with your liver luckily I have some liver tablets that will cost you only $90 and yet they say that the doctors are in it for the money when the alternative medicine people take more over to you. It's amazing isn't it? They've completely flipped it around but it's true. The same is true in the US by the way where we're getting the next speaker up here is that the ethical sort of standard has shifted to where physicians can't own the lab that they send their patients to or the MRI scan that they send their patients to. They can't essentially do self-referrals or have a conflict of interest where they make money off of doing stuff or making specific recommendations to you. It's not an absolute rule or law but the ethics are definitely moving in that direction in the last 20 years in my experience pretty significantly. And it varies by state. Yeah, it varies by state. I'm glad you guys brought up the subject of pain because I mean that's sort of the area, the area of chronic pain is the area where as much of a skeptic as I am I like to start to look at other areas because I struggle with chronic pain people in my family have and often there's just not enough satisfaction to be gotten when you see the doctor and so you want to look like is there something anyway that I could do and I guess it's a bit off topic but I'm wondering is medical science making advances to learn more about pain? Is this something that maybe we could get more happiness out of real, bonafide medicine from in the future? I think I can go with someone else. So the short answer is yes. Pain is a very active area of research. We're learning stuff about it all the time and again good old reductionist science which chemicals are getting released in response to trauma that increases or decreases the amount of pain being generated or being experienced exactly what are the neuro anatomical correlates of different components of pain. We actually know a lot about it and we're learning more about it. There are a lot of other benefits that are really interesting for maybe new pharmaceutical approaches and at the other end pain as a specialty which does intersect with my specialty of neurology and I do have kind of I treat migraine and I treat neuropathic pain so I do have a little bit of a clinical interest in chronic pain so there is a huge psychological component and that is part of any treatment of chronic pain. Any pain clinic all the ones that I know of personally have a psychiatrist or a psychologist with a multidisciplinary approach to pain and there's lots of studies going on looking at how can we get people. That's why I know about the fact that if you look at the other arm your pain goes down because I read a study about it a couple years ago. So there's a lot of legitimate scientific interest in pain. It's a very complicated biological and psychological phenomenon and also it's a huge there's a lot of financial incentive for pharmaceutical companies to learn about pain it's a big big big problem and while we have a lot of options we don't have enough. We absolutely need more absolutely. So you're going to see increasing options in the future. The alternative medicine people are nibbling around the edges with nonspecific effects that you will get also as part and this has also been studied you get the same placebo effects out of real medicine.  Well it really isn't because if you look at it it's really not cost effective because upfront costs may be less but if you look at cost effectiveness it actually is less cost effective because it's not as efficient they're doing a lot of stuff that doesn't work and they also suck you in for a lot of recurrent treatments that are unnecessary whereas largely because it's cash on the barrel a lot of it's outside of insurance companies. Insurance companies I'm not going to defend them they have a huge pain in my ass but they do have an incentive to keep you efficient and cost effective and sometimes what their interests are the patients and medicine's best interest although I would one quick again I don't think there was a clear bright line between the alternative practitioner and the conventional practitioner I had microfactor surgery on my knee a few years ago and my University of Pennsylvania trained you know orthopedist sports medicine orthopedist recommended that for my pain I should take chondroitin sulfate and glucosamine. Now if you look at that this is actually only it's been studied I mean there's no evidence that it works any better than placebo for the pain of osteoarthritis um you know but he did that he did that because I think he is doing what many conventional practitioners are doing. They see this as something that it's a marketplace they think that there's a demand for this and there's you know and so he asked for this. Now you could argue that by taking this kind of if I had done that and not actually looked up this has been such a jerk to look up the studies to see that it actually doesn't work better than placebo if I had believed in him believed in him as a guru and that would have avoided my taking n-sids or cox-2 inhibitors that there may have been some value in that maybe I would have learned to release my own endorphins by believing this was going to work I mean I guess that's possible but it is a slippery slope I think we have time for one more yeah we should have one more along the excuse me along the same lines as pain therapy in regards to like mirror box therapy where you're trying to treat the pain experience in a phantom limb where does that fall in line in that spectrum is the mechanism understood behind that do we question whether or not that's effective therapy for treating pain in that regard you're talking about like Ramachandran's work on mirror box therapy for phantom limbs is that right yeah is anyone do you know about my understanding is it's promising but I think there's been some recent failures to replicate that but I think in principle I think what you're trying to do is you're trying to sort of harness brain plasticity you're trying to get another part of the brain which is recognizing a limb that's not there as getting it to understanding maybe I'm well I guess it's called a muriological fallacy I'm referring to part of the brain as a person but getting a part of the brain to understand that that limb is no longer there but I think some of the recent research suggests that doesn't work as well as people initially thought yeah I mean the clinical data is preliminary and ambiguous but the idea here is like a phantom limb is when you like if you have an amputation for example it's essentially a mismatch between your brain's model of your physical body and the physical body that's there the amputation of that has been described clinically you can have supernumerary phantom limbs that don't really exist you can have part of your body that you don't think is part of you or you could have a phantom limb that is no longer there which is the most common syndrome and the problem is is when your brain it's not getting that input and this is a generic phenomenon that we see when part of the brain ceases to get sensory feedback or the input that it normally has and keeping itself in homeostasis it goes off the rails sometimes so like for example if you have visual if you lose your sight you can hold your visual cortex may start hallucinating just generating its own stimulation same thing your brain says there's no limb there it's not getting the feedback so it just sort of generates its own feedback and that could be painful sometimes you could feel like your hand is clenched or something and so it's just ways of tricking the brain into not doing that into basically no longer creating these phantom experiences and it is trying to provoke plasticity which means that the brain adapting to changing sensory input and sadly we are out of time I would like to thank the panel thank you all for coming I hope you enjoyed it


down to our last speaker of the afternoon.  Now before she jumps into this and she finishes and everybody runs out the door. I need to say a couple of thank yous. In absentia, Elaine Peterson, who was our official catherter in terms of residents, faculty and educational efforts. And now Kelly Nelson, who has joined us in the role of official catherter. Welcome. We are glad you are here. And this is, you got off to a really good start with us. I also need to give a big shout out to Ethan Peterson, Megan Johnson. They're the ones who made the physical aspects of this technical aspects fly, connected zoom with what's going on here in person, made people's computers do what they were supposed to do. We're grateful. Who have I forgotten? Well, and I also wanna thank you, looking around the room here in years past, the number of people have dwindled significantly when we get to this point. And I'm saying about the same number of faces here now that I saw here at the beginning of the morning. I'm very impressed. Thanks for being here.  Sorry to hold you up. No, you're dead. Somehow I found myself at the end of this session as well. So thank you for not significantly dwindling. No, thank you. So some of you will be a little familiar with this if you attended one or both of the workshops that I held earlier this year, but just as a brief background, a recent study based out of the University of Iowa showed that gender-based discrimination and harassment are highly prevalent amongst US ophthalmology trainees. And unfortunately, patients are the most common source of this harassment. However, very few trainees have received formal guidance or training for how to respond to patient-initiated sexual harassment. To try to bridge that gap, my QI project has focused on integrating a workshop for responding to patient-initiated sexual harassment for both trainees and faculty at the Moran Eye Center with the overall goal of improving participants' preparedness to respond to patient-initiated harassment towards themselves and towards others. To do this, we implemented two sessions of an interactive workshop that was originally developed by the University of Iowa Department of Ophthalmology. And the workshop included interactive discussion and role-play scenarios in order to highlight various communication techniques for responding to harassment, both for physicians who experience harassment themselves and for physicians who observe harassment of others like trainees or colleagues. And this slide just summarizes some of the different communication strategies that were included in the workshop. Participants then completed a survey retrospectively that assessed their pre- and post-workshop preparedness to respond to harassment. And survey responses were analyzed using primarily paired T-tests. So here's a breakdown of the 27 workshop participants, including 12 faculty and 15 trainees. And there was a fairly even split between male and female participants. Prior to the workshop, 74.1% of all participants and 100% of female participants had experienced some form of patient-initiated sexual harassment. And almost 80% of participants had witnessed harassment of a colleague or a trainee. However, only six people, so 22% had actually received formal training to handle sexual harassment from patients. Based on ratings on a five-point Likert scale, we found that after the workshop, participants reported significant improvements in their ability to recognize forms of patient-initiated sexual harassment and to discuss the prevalence and impact of this harassment. They also reported significant improvements in their preparedness to respond to sexual harassment towards themselves or towards trainees after the workshop. So these findings suggest that interactive discussion and rehearsal of communication techniques, like the role-play scenarios, can be really helpful for improving faculty and trainee preparedness to respond to patient-initiated sexual harassment. And although this particular workshop primarily addressed sexual harassment, I just wanna emphasize that similar strategies could be used to address other forms of harassment as well. In the future, we're hoping to incorporate this kind of training more formally into resident and medical student education. We also, and this is one of my goals for next year, we really wanna expand this particular workshop to other groups at the Moran Eye Center, such as our technicians and our surgical staff who are also interfacing with patients on a day-to-day basis. And of course, we always wanna promote open dialogue about this topic so that both trainees and faculty can feel empowered and prepared to call out harassment when it occurs. Here's some of the relevant references. And I really wanna thank Doctors Long, Jacoby and Katz for supporting me in the implementation of this workshop. Thank you to Dr. Katz who kind of had the original idea to do this and approached me. I really appreciate you thinking of me for this. And I just submitted an abstract for the upcoming Women in Ophthalmology Summer Session. So I'll hopefully get to present these findings on a beach in Florida in a couple of months. But thanks for listening.


Welcome to the Hindu News Analysis by Shankar A. S. Akademi. The displayed articles have been chosen for today's analysis from Chennai, Bengaluru, Delhi, Hyderabad and Tiruvananthapuram Editions. Now let us start our discussion. This news article is about the financial stability on development council meeting. The discussion can be linked to the syllabus that is given here for your reference. The news article mentions that recently our finance minister held a review meeting with the Financial Stability and Development Council, that is FSDC, during which the state of the economy of India was discussed in detail. The council reviewed the current global and domestic macroeconomic situation and then the financial stability and issues of vulnerabilities also discussed. The council also took note of the activities undertaken by the FSDC subcommittee and the initiatives taken by the various regulators in the financial sector. Now in this article what we have to focus from the examination point of view is that the Financial Stability and Development Council and its subcommittee. This topic is important as already there was prelims question on FSDC in 2016 prelims examination. So let us discuss about FSDC. Note that the financial stability and development council was set up by the government as the apex level forum in December 2010. It was set up as a body to strengthen and institutionalize the mechanism for maintaining financial stability to enhance the inter-regulatory coordination and also to promote the financial sector development. Now let us look at the composition of this council. The council has a chairman and members. The chairman of the council is the union finance minister. Its members include ministry of state in charge of department of economic affairs then heads of all financial sector regulators such as governor of reserve bank of India chairperson of securities and exchange board of India that is SEBI then chairperson of pension fund regulatory and development authority then chairperson of insurance regulatory and development authority of India and chairperson of insolvency and bankruptcy board of India then the finance secretary or secretary of the department of economic affairs are also members then secretary of department of revenue secretary of department of financial services secretary of ministry of corporate affairs then secretary of ministry of electronics and information technology and chief economic advisor are the members of the council. The council also can invite experts to its meeting if required. Now let us see the responsibility of the council. The council deals with the issues relating to financial stability, financial sector development, inter-regulatory coordination, financial literacy and financial inclusion. The council also deals with the macro-prudential supervision of the economy. Note that macro-prudential policy is a novel way of looking into financial regulation and these policies aim to prevent the excessive build-up of risk which is a result of external factors on market failures. Then the council also has a subcommittee. The FSDC subcommittee has been set up under the chairmanship of governor of RBI. This subcommittee meets more often than the full council. Note that all the members of FSDC are also members of this subcommittee. In addition, all four deputy governors of RBI and additional secretary of department of external affairs who is in charge of FSDC are also the members of this subcommittee. Note that the financial stability unit of RBI is the secretariat for the FSDC subcommittee. So these are the relevant information that you should know with respect to FSDC and its subcommittee. The displayed practice question will be discussed at the end of the session. Now let us move on to the next news article. This news article is with reference to the proposal of the union home ministry to merge the Assam rifles into the Indo-Tibetan border police. The proposal by merging aims to bring Assam rifles under the operational control of Ministry of Home Affairs. The syllabus relevant for the analysis of this open editorial article has been highlighted here for your reference. Now note that at present there are seven central armed police forces. They are Assam rifles, border security force that is BSF, central industrial security force, central reserve police force, Indo-Tibetan border police, national security guard, then Sushasra seamable that is SSB. In this news article we will be discussing two of these central armed police forces. They are Assam rifles and Indo-Tibetan border police. The purpose of Assam rifles at present is to guard the Indo-Mainmar border and conducting counter-insentancy operations in the north-eastern region. Among the central armed police forces except Assam rifles, all forces have their chiefs from the IPS offices. In case of Assam rifles, the chief of Assam rifles that is the Director General of Assam rifles is not from the IPS offices but from the Indian Army. Officers in the rank of Lieutenant General in Indian Army are appointed as the Director General in the Assam rifles. This is because though Assam rifles come under the administrative control of the Union Home Ministry, the operational control of Assam rifles is with the Indian Army. In terms of ministry, the operational control is with the Ministry of Defense. The author mentions that this dual control or the concept of having two masters for an organization is not only absurd but also it leads to various problems in terms of coordination. Also there have been several litigations in various courts of law that are filed by Retail Personnel of Assam rifles saying that they are facing difficulties in getting their pension because of this dual control. Therefore because of these issues and some other issues, the Ministry of Home Affairs in the last five-year National Democratic Alliance rule took up this matter with the Cabinet Committee of Security. At the time, Mr. Rajnath Singh was the Union Home Minister and interestingly now he is the Union Defense Minister. See that the Union Home Ministry proposes two things. One is that the operational control of Assam rifles to be given to the Home Ministry from the Defense Ministry. Second, the Assam rifles has to be merged with the Indo-Tibetan border police force. If you see about Indo-Tibetan border police, initially its purpose was getting border intelligence and security along the Indo-Tibetan border from Ladakh to Kuman Hills in Uttarakhand. Since the government recommendation of One Border One Force in 2004, ITBP has been assigned to guard the entire Indo-China border. Therefore, the ITBP has replaced Assam rifles in the borders of Sikkim and Arunachal Pradesh. Earlier, Assam rifles used to guard along the Sikkim and Arunachal Pradesh borders. Know that the government recommendation of One Border One Force was also recommended by the group of ministers in 2001. This group of ministers was set up by the then Prime Minister and to review the national security system in the country and to consider the recommendations of the Kargil Review Committee. Know that the ministers of four ministries were part of this group of ministers. They are Minister of Home Affairs, Minister of Defense, Minister of External Affairs and Minister of Finance. In this article, the author discusses the history of Assam rifles. Now, let us see the history of Assam rifles in brief. The Assam rifles date back to 1835. This is because it was formed in 1835 in the name of Kachar Levy. At that time, its purpose was to assist the British rulers in maintaining peace in the northeast. From the colonial lens, their purpose was to primarily protect British tea estates and British settlements against tribal raids. This force was later expanded and in 1870 it was converted into the Assam Military Police Battalion. And during the First World War, they served assisting the British forces in Europe and West Asia. The British recognized their support by fighting soldiers shoulder to shoulder with rifle regiments of the regular British army. As an honor, the name of the force was changed to Assam rifles. This force is fondly called as the Friends of the Northeast People. The author states that the Assam rifles was placed under the operational control of the army after the Chinese aggression in 1962 in Arnauchal Pradesh. One of the reasons is that the personnel of Assam rifles were adjusted to the northeastern region and therefore they were better suited for operations at those times. You may think that why such a decision was taken after 1962 Sino-Indian War. This is because during the Chinese aggression in 1962, the regular units of Indian army could not unleash terror on Chinese forces in Arnauchal Pradesh. This is because at that time the regular army units were not easy to extreme weather in Arnauchal Pradesh and other northeastern regions. And this is also one of the reasons for India's retreat or defeat in 1962 Sino-Indian War. So after the war the Assam rifles came under the operational control of the Indian army. Now let us come to our discussion on the proposals of home ministry and who are opposing these proposals. The opposition is from the Indian army and also the defense ministry. One of the reasons is that the Indian army feels that if the operational control goes to home of ice and if Assam rifles is measured with ITBP it may weaken the national security. It even asked to match the Assam rifles completely with Indian army and ministry of defense. Another reason for opposition is that at present in Assam rifles around 80% of officers from the rank of major and above are from Indian army. If a major happens these officers have to be repatriated or sent back to the Indian army. Next the author discusses the way forward. If the operational control is also given to home of ice for timing an IPS officer could be appointed as a chief but here is a tussle. This is the tussle between IPS officers and officers of central armed police forces. This tussle is with respect to the matters of enjoying pay benefits under organized group a service category. These matters are about the extinction of benefit of non-functional financial upgradation and non-functional selection grade to the officers of CAPF. These benefits are with respect to getting pay benefits when a person has to be promoted but not promoted because of lack of vacancies. Earlier in February month of 2019 the Supreme Court has granted the organized group a service status to the CAPF officers and thus the CAPF officers are at par with the officials from IIS, IPS, IRS and other central services after the Supreme Court verdict. But the government initially was not supporting this move to bring IPS officers and senior CAPF officers at par in these matters. As a result of these developments if an IPS officer is appointed as chief there could be lack of cooperation among the battalions of ASAM rifles. So the author suggests that only for the initial period an IPS officer could be a chief. Later the top post in ASAM rifles shall be given to the directly recruited officers in ASAM rifles. Then the author asks the cabinet committee of security to take the major issue on priority basis so that the doubts related to major operational control will be cleared. Then the author is also suggesting to work out the modalities of absorbing officers into the ASAM rifles or matched ITBP once the deputed Indian Army officials are repatriated back to the Indian Army from ASAM rifles. This is required to avoid any situation of vacuum in ASAM rifles once the Army officials leave the force. Note that if there is a vacuum the anti-Indian or enemy forces could take advantage and carry out operations against India. That is why the author is asking to work out the modalities of observing officers. Therefore with reference to this news article we saw about ASAM rifles and Indo-Tibetan border police and also we have discussed the proposals of Home Ministry and we discussed the points supporting the proposal and also suggesting the proposals against of Home Ministry and also some way forward suggested by the author. So with this we come to the end of the analysis of this news article. The displayed practice question will be discussed at the end of the session. Now let us move on to the next news article. This article is with respect to internet connection in the state of Kerala with respect to India Internet 2019 report and a report by Troy. The syllabus linking of this news article is given here for your reference. The news article mentions about the Kerala fiber optic network project. This project once it is completed will provide internet to every household in the state of Kerala. The project is expected to provide free internet for about 20 lakh below poverty line households that is known as BPL households. This project is to be completed by December 2020. So we can see how Kerala is going to perform well in providing internet connections to the households in the future. Now this inference on Kerala is also proved by other two reports. One report is that India Internet 2019 report. The report gives data on the number of internet users in India and it also provides the basic profile of the internet users in India. Note that the report is released jointly by internet and mobile association of India that is IAMAI and Nielsen company. Note that IAMAI is a not per profit industry body that is resisted under the Societies Act of 1896. Its mandate is to expand and enhance the online and mobile value added services sectors and the Nielsen company is a global measurement and data analytics company. Now with respect to this report you should understand one terminology that is internet penetration. It is the relationship between the number of internet users in a country and its demographic data. This means the portion of the population that has access to the internet. The term defines a portion of the digital divide in the country. Digital divide is between those who have ready access to computers and the internet and those who don't have the access to computers and the internet. So simply we can say that internet penetration indicates the percentage of internet users in any country. Next let us see some of the facts mentioned in the report with respect to internet penetration in our country. According to the report India has about 451 million active internet users in the first quarter of this year. More interestingly around 6.6 crore users are in the age group of 5 years to 11 years. These children access internet through devices of the family members. So from this we can see how much data protection is important in our country. As children are gaining more access to internet services and their data is also available on internet which can be easily exploited. Then two-thirds of internet users in India are in the age group of about 12 years to 29 years. Then the report notes that internet penetration is higher in urban India. This is due to better internet connectivity and there is an on-the-go consumption in urban areas as many are accessing internet while traveling through their mobile phones. Then with respect to internet penetration in rural India, a sizable portion of population in rural areas is divided of internet. That is they lack internet connection. So the report notes that there is an immense space for growth in rural areas which will contribute to an increase in overall internet penetration in the country. The report also mentions that the penetration of internet goes down as we descend to lower town classes. This means that the metropolitan cities have high level of internet penetration as compared to the villages and the rural areas. At the state level, the national capital territory of Delhi or NCT of Delhi has registered highest internet penetration that is about 69%. It is followed by the state of Kerala with 54% internet penetration. That is why the article mentions that Kerala is already off-way to its goal of 100% coverage of internet. That is to be achieved by the Kerala Fiber Optic Network project. Then low internet penetration is seen in the states of Odisha, Jharkhand, Bihar, West Bengal, Andhra Pradesh, Telangana and Madhya Pradesh. The report also notes that even though there is an increase in internet population, there is a visible gender divide. This means that there are fewer female internet users in India as compared to males. As compared to males, females internet population is only half of the male internet population. This disparity or inequality is more clear in rural areas. The report also found that the states of Kerala, Tamil Nadu and Delhi have higher female internet users. Let us see the second report. The report is the Indian Telecom Services Performance Indicators for April to June of 2019. This report is released by the Telecom Regulatory Authority of India, that is TROY. The report provides data on the number of internet subscribers per 100 people, among many other things. As per the report, Delhi has a high number of internet subscribers per 100 people. It is followed by Punjab and Himachal. Then Kerala is at the fourth position. In Kerala, there are about 70 internet subscriptions per 100 people across service areas. So this data also shows that Kerala is performing well in providing internet connections to the households. Then Bihar is at the lowest position with respect to the number of internet subscribers per 100 population. Note that only there are 29 subscriptions per 100 people in Bihar. Now you may think that what is the importance of having internet connectivity? Firstly, you can watch our videos. That is, it provides access to information that is available across worldwide. Sitting at a single place, we can access information. It is helpful in every sector from education to deploying nuclear weapons. This is also true in our context as with the help of internet only, we are able to provide this analysis and you are also able to get information for free. So more the internet connection, more is the accessibility to information. It not only provides access to information, but it also helps in instant exchange of information through the modes of messaging, images, voice texting and so forth and so on. Next, internet helps to stay connected always. Then along with getting information on the internet, you can also shop online. So it promotes e-commerce. Note that our government is working hard to provide e-governance and to provide paperless governance also. So to have access to the services on e-governance platforms, we need internet connections. So like this, we can keep on listing the uses and advantages of internet connection. With this, we finish this analysis of this topic. The displayed practice question will be discussed at the end of the session. Now let us move on to the next news article. This news article is about the recently released India Justice Report of 2019 by Tata Trust in collaboration with the various NGOs. The report ranks the states based on their score out of 10 in their capacity to deliver justice. The syllabus linking of the news article is given here for your reference. The report measures capacity of the states to justice delivery based on the four pillars that is police, judiciary, prisons and legal aid. As we know that access to justice is a public good which is important to all of us. Note that the Supreme Court has mentioned in several times that access to justice is a fundamental right guaranteed by the Article 14 and the Article 21. Note that Article 14 says that equality before law and equal protection of law and the Article 21 says that the right to life and the personal liberty. Now the report says that it is the first initiative to rank the Indian states in relation to their capacity to deliver access to justice. Now let us look at the news article. The report classifies Indian states into two categories that is into 18 large medium states and seven small states. Note that the report has not covered the Indian Territory of Jamun Kashmir, the Indian Territory of Ladakh, Assam, Manipur and the Nagaland. Among the large medium states, Maharashtra topped the list with a score of about 5.92 out of 10 and the other best performing states are Kerala, Tamil Nadu and Punjab. But here we have to note that even the best performing state is not scoring above 60 percent which is a worrying factor. In this category, Uttar Pradesh is at the bottom with a score of about 3.32 and the other states in the bottom category are Bihar and the Jharkhand. See in case of the smaller states, Goa is the best performer with a score of about 4.85 and Tripura with a score of 3.42 is at the bottom in the overall ranking. Now let us compare the top and the bottom performing states with reference to the four pillars that is prison, police, judiciary and legal aid. The ranking of the states in the category of prison is based on like overcrowding, number of women's staff, correctional staff and budget utilization. Here note that Kerala with a score of 7.18 is at the top and the Jharkhand with a score of 3.46 is at the bottom. Now the ranking on police is based on the resources like human resources, modernization, filling vacancies and the percentage of women in the police. Here Tamil Nadu with a score of 6.49 is at the top and Uttar Pradesh with a score of 2.48 is at the bottom category. Now the data on judiciary is based on vacancies in high courts and subordinate courts, then the clearance rate and the budget allocation. In this list, Tamil Nadu with a score of 6.99 is at the top and Bihar with a score of 2.41 is at the bottom. The ranking on legal aid is based on central and state budgets, the percentage of human liars, rural coverage of legal services. In this list, Kerala with a score of 6.58 is on top and Uttar Pradesh with a score of 2.50 is at the bottom. According to the news article, the findings of the report exposes the very serious lack in our justice delivery system. So we can say that the report covers a wide range of data on justice delivery. But when we compare the top and bottom performing states in each pillar, we can see a big difference in score. This shows that the people across India are far away from getting equal access to justice. This needs to be addressed, otherwise access to justice will remain as a fundamental right on the paper but not in reality. Now let us compare the overall summary of the report, which would be helpful for your mains preparation. That is when it comes to police force training, only about 6.4% of the police force have been provided in service training over the last five years. This means that about 90% of the police deal with the public without any up to date training. In addition, the representation of women is even worrying. Women account for just about 7% of the 2.4 million police persons in the country. Similarly, they account for 28% in the lowest judiciary and about 12% at the high court level. These figures are far from the equality in the representation. Even the judiciary, which had to upload the right to equal opportunity, itself is underrepresented. Now we will look at the statistics of under trial prisons in Indian prisons. In 2016, about 67.7% of India's prison population were under trial prisoners. This percentage is higher than what it was a decade ago, that is about 66%. This means that a large part of the prisoners are suffering in the jail terms even before they are convicted. This is one of the reason for over occupation of Indian prisons. At present, that is that about 114% of the Indian prisons capacity. Now, when it comes to the diversity in police staff, the report says that the representation of SS, STs, OBCs and women in the police is poor with huge vacancies in the reserved positions. This means that the vulnerable sections of Indian population are underrepresented even in the seats reserved for them. Now let us come to the most important data on pending court cases. The report says that there are about 2.8 crore cases pending in Indian subordinate courts and about 24% have been pending for more than five years. In addition, about 23 lakh cases are pending for more than 10 years. This long pendency shows the inefficiency of the Indian justice system. Therefore, one can rightly say that justice delayed is justice denied. Note that this delay in justice delivery is despite the fact that the poor Indians have to struggle to take their issues to the judiciary. This is proven by the fact that the per capita public spending on legal aid is only about 0.75 rupees per annum. This is proven by the fact that the per capita public spending on legal aid is only about less than 1 rupee per annum. This shows that the poor in India are still unable to reach the court to protect their rights when violated. If the government spending on free legal aid is not increased drastically, the Indian judiciary will remain accessible only to the allied sections of the population. With this, we have come to the end of this analysis of this news article. With reference to this news article, we have discussed India justice report of 2019, which was released by the Tata Trust in collaboration with various NGOs. The displayed practice question will be discussed at the end of the session. Now, let us start our practice prelims question section. Now, look at this question. This question is with reference to financial stability and development council, and it is a reference question which was asked in 2016 UPSC prelims examination. The three statements are given, and we have to choose the correct option. The first statement is that the FSDC is an organ of Neetayok. Note that FSDC is established by the government of India, not as an organ of Neetayok. Therefore, the statement one is incorrect. Note that FSDC was set up by the government as the apex level forum in December 2010, and it was set up as a body to strengthen and institutionalize the mechanism for maintaining the financial stability to enhance the interregulated coordination and also to promote the financial sector development. And the second statement is that it is saying that it is headed by the union finance minister. Note that the chairman of the council is also the union finance minister, and the council is having so large composition of the members. And these members include minister of state in charge of the department of economic affairs, then the heads of all important financial sector regulators such as governor of RBI, chairperson of SEBI, chairperson of pension fund regulatory and development authority, chairperson of insurance regulatory and development authority of India, then also the chairperson of insolvency on bankruptcy board of India. And these are the important persons also being the members of this council. Note that the chief economic advisor is also member of this council. Therefore, the second statement is correct. Now look at the third statement. It says that it monitors macro prudential supervision of the economy. Note that the council also deals with the macro prudential supervision of the economy. And this policy is a novel way of looking into financial regulation. And these policies aim to prevent the excessive buildup of risk, which is a result of external factors and market failures. Therefore, the given statement is also correct. So, out of the given statements, first statement is incorrect. And the second and third statements are correct. And the correct option for this question is option C2 and 3 only. Now look at this practice problems question. This question is with reference to again financial stability and development council. This is a two statement question. The first statement says that the council and its subcommittee are headed by union finance minister. Note that the council chairperson is the union finance minister, but the subcommittee is headed by the governor of reserve bank of India. Therefore, the first statement is incorrect. The second statement is about the composition of the subcommittee. It says that the governor of RBI and the chief economic advisor are the members of subcommittee. Note that all members of FSDC are also members of subcommittee. In addition, all four deputy governors of RBI and additional secretary of department of external affairs who is in charge of FSDC are also members of this subcommittee. Note that the financial stability unit of RBI is the secretariat for the FSDC subcommittee. Therefore, the second statement is correct, but you have to choose the incorrect statements. Thus statement one that is option A one only is correct for this question. Now look at this question. This question is based on India internet 2019 report and they are asking who releases this report and they have given the options like telecom regulatory authority of India, international telecommunication union, internet corporation for assigned names and members and internet and mobile association of India. Note that this India internet report is jointly released by internet and mobile association of India and Nielsen company and this IAMAI is a not for profit industry body that is resisted under society's act of 1896 and its mandate is to expand and enhance the online and mobile value added services. Then Nielsen company is a global measurement and data analytics company. Therefore, for this question option D is correct option. Note that try that is telecom regulatory authority of India also releases one of the important report that is the Indian telecom services performance indicators and this international telecommunication union is the United Nations specialized agency for information and communication technologies and in case of ICANN that is internet corporation for assigned names and members is also a not for profit public benefit corporation and it has participants from all over the world who are dedicated to keeping the internet secure stable and interoperable. Now answer this question. So this question is about who releases the India justice report. See that they have given four options that is Nithya Yoke and option B ministry of law and justice then taught at trust then the ministry of social justice and empowerment. Note that this India justice report is released by taught at trust in partnership with certain NGOs and here these NGOs are not important but for your understanding important NGOs mentioned here are Center for Social Justice Common Cause Common Wealth Human Rights Initiative that is in short CHRI. So for this question option C is correct option. Note that this India justice report classifies the states of India into two categories that is into 18 large and medium sized states and the seven small states according to their capacity to deliver justice and this report is based on data and to assess the budgets infrastructure human resources workload and diversity and also presence judiciary and legal aid in each state and these are very important to make the Indian judiciary system or the Indian justice system to be effective and efficient. Note that in the large and medium sized states category state of Maharashtra is in the top category and in case of smaller states Goa has performed better in terms of Indian justice report given by the taught at trust. So with this we'll proceed to next question. Now look at this practice mains question. The question says that the administrative and operational coordination among the different CAPF that is central armed police forces is the need of the hour. That is the suitable measures to increase the administrative and operational efficiency of the CAPF in the light of the above statement. Now for this practice mains question you are requested to write and post your answer in the comments section and your posted answer would be reviewed and suitable guidance will be given. So note that for this question first you have to justify why the coordination is required in terms of administrative and operational matters. Then you should justify with the suitable measures how this measures would improve the overall efficiency of central armed police force. Then you can also give the example of avoiding the dual control taking the case of assault rifles. Also you can mention the policy of one border and one force and how it is going to increase the overall efficiency of the CAPF and these are the certain points you can mention for this question. Now with this we have come to the end of the analysis of today's session. Please do share like comment our Shankara IS Academy YouTube channel. Thank you.


Local faith leaders and medical professionals joined in front of Highlands ARH for a moment of prayer to assist those fighting COVID-19. Friday we spoke with Dr. Terry Hall about the session. Well, I think it shows that there's a strong undercurrent of faith in our community. I believe there are many people here that have strong faith in God who believe that he is in control, that he can change things, and we just wanted to gather today to ask for his help in getting us through this pandemic. Afterward, Dr. Hall shared words of encouragement to those COVID-19 warriors. Well, I think that this time, this pandemic, there are many issues that have arisen that can divide people. And I would just encourage people to come together in faith and love to let's help each other get through this pandemic together. For Mountaintop News, I'm Joel Korjol.


Hello, everyone. This is Melissa with the Stocks Russian Review in Apple. Apple was a nice option call that I called. It was late, but still profitable last week. And I called the 195 calls in the morning. It was around lunch or something on 321. Stock ran up through the strike into the closest day and then ran up almost $3 over the strike here on the second day. Really nice move in this. If you held a piece of this, you're down in it. If you get out of it the second day or the first day, you had a nice profitable trade. If you're still in the entire position, I don't know where this goes now. You still have time though. It's Tuesday, but again, I think the fast trades are the best unless you have some amazing gap. So this was a nice profitable move though that happened very quickly. And again, just a rally up here, wasn't earnings or anything else like that. Just a nice buying, one, two days of buying here into the market or with the market in Apple. But then this fell off after the market fell, which you're seeing some selling in the market today. But I think this was a nice quick, easy book the money and done trade last week. If you have any questions or you'd like to sign up for the options letter, email me at melissa at the stockswush.com and you can feel free to ask me any questions about the letter. You get the trades emailed to you and you take the trades. When you get them, I give the targets and usually the strike is the first target or through the strike, you look for an exit. Nice move here in Apple. We'll see where it goes from here. Earnings in Apple aren't out for another more than a month. I think it's the end of April. I think the 29th of 30th is Apple earnings. So I'll be watching the stock and see what it does between now and then because it's really finally, I mean, for the first time in months, months and months and months, does it look like it's going to go somewhere again with its life? You know, the next point to watch should be 200. Whether or not it gets over there before the earnings are not, I don't know, we'll have to see what happens here. And remember, Apple plays in part and moves with the market so you got to really watch both. Have a great day everyone and email me if you're interested in the options letter. Have a great day.