So, it's my pleasure in Mark's place today to welcome our speaker on behalf of the McLean Center, the Center for Health and the Social Sciences and the Bucks Baum Institute for Clinical Excellence. Our speaker in today's instance of our lecture series on the present and future of the doctor-patient relationship is Dr. Andrea Leep. She is an Assistant Professor of Neurology at the Mayo-Alex School of Medicine located in Rochester, Minnesota. She's a consultant there in the Education Division of the Department of Neurology, and in addition to her consulting, she's Director of the Learning Environment and Education Culture for the Mayo Clinic School of Medicine, also the Co-Director of the Karen National Network for Caring and Character in Medicine and Associate Director of the Mayo Clinic in Professionalism and Value, and the Quality Chair for the Department of Neurology at Mayo. Dr. Leep received her medical degree at Mayo Clinic and then stayed there completing her residency in Neurology and a fellowship in Clinical Neurophysiology before joining the faculty there. Somewhere along the way, she also obtained a Master's in Health Professions Education from the University of Illinois in Chicago, and we have some of our faculty who have also done that, and we really love that program. Dr. Leep's mission is to support healthcare faculty, staff, students, and leaders in co-creating environments that reflect shared professional values to promote learning and to serve patients. Her professional interests include professional identity formation and professionalism, character formation and expression, as well as performance assessment and performance enhancement. She also strives to teach her trainees about the cost-effectiveness of care, and her talk today is entitled, High Value Care, Counting the Cost. Please join me in welcoming Dr. Leep. Thank you all for having me here today. I want to start out by inviting you all to reflect, to think back to the last time that you had an encounter with a physician or some sort of healthcare clinic. Why were you there? How did you feel? That situation in your mind. And then think, did you notice anything about cost-conscious care and that in account? Did you notice anything? If you did, do you think it promoted your relationship with that individual or maybe you didn't notice it at all and wished you had, or noticed it and wished you hadn't? Did you even think you had a relationship with a person you saw? Those are some of the questions I'm hoping we'll be able to unpack together. But before we dive into the details, let's step back a little bit and ask ourselves why we're talking about cost-conscious care and the physician-patient or patient relationship in the first place. How many of you have seen a graph that looks something like this? Yeah, most of us have, right? Healthcare spending is, you know, relentlessly increasing over time. One out of five dollars in our economy spent on healthcare, totaling 8.2 trillion dollars in 2019. This is twice what's spent on healthcare in other developed countries. Without a commensurate return on that investment in terms of health outcomes. At least that's what many argue, showing charts like this, where life expectancy is plotted against per capita spending. And you can see that the U.S. is a clear outlier here, spending more than anyone else without a life expectancy gain to show for it. More sobering are estimates that the order of the spending is wasted on inefficient, ineffective, unnecessary, overpriced, or fraudulent services. Now as a physician, this is startling to me. If I didn't go to medical school to treat the GDP, right? And we've heard people say that. We're here to think about the physician-commissioned patient relationship. So what do these individuals think about this, what's been called crisis of health care costs? The surveys of physicians show that the majority agree they should be solely devoted to individual patients' best interests, even if that's expensive. The Mayo Clinic would say the needs of the patients are first. And the vast majority disagree with what could be described as rationing, denying beneficial but costly services to certain patients because they should go to other patients who need them the most. But at the same time, 85% of physicians think they have a responsibility to try to contain costs and think physicians should take a more prominent role in limiting the use of unnecessary tests. These survey responses seem potentially conflicting and likely reflect the tensions that we in health care face between meeting the needs of the patients in front of us and stewarding societal resources on behalf of all patients. Folks have asked them what they think too and the vast majority agree health care costs are a major problem in the United States. But when you bring it down to that clinician-patient relationship you want to see that conversation happening there. How do I feel it costs the society a part of the conversation? Physicians supposed to be my advocates. Cost of my insurance company? Let's debate that in the halls of Congress. I don't want to have this debate in my physician's office to my health and that statement. Let my doctor be my doctor. Let's keep the two separate. And I think this one sums up how many feel. How can you put a price on my wife? Some tests are only going to save a few lives. But what if one of those lies is true? And it's understandable when you're in a situation where your health is at risk, the health of someone you care about is threatened, that that's going to be the most salient thing in your mind. Not the more infangible idea of societal resources. So different strategies have been devised to help clinicians engage patients in cost-conscious conversations to help them weigh that cost to society when making decisions. I'm going to share five of them and I want you to listen and think. Because at the end I'm going to ask people to raise their hand and both for which of the five they think patients like the best. So here's number one, fairness. Everyone's interested in keeping health care costs down and we're trying to do it in a fair way. In this situation, I would recommend a CT scan to all of my patients instead of an MRI. Okay, strategy one, fairness. Strategy two, shared sacrifice. It's good for us to share responsibility for keeping costs down. At the end of the day, we all pick up at the tab and we pursue an expensive fare because premiums rise.  Number three, good enough. I really think a CT scan is a reasonable option. You might not find quite as many things as an MRI but I believe it will find the important things and it's certainly good enough for what we're trying to do. Four, shared decision-making. What are your thoughts about going with a CT scan? Let's talk whether the MRI's worth that extra $500 that your insurance or Medicare Medicaid are going to do. Or maybe five, all should miss the appeals. Not taking antibiotics for your sinus symptoms now will help prevent antibiotic resistance. And that means when someone else needs antibiotics for a serious infection, they'll be more likely to help. So what do you think? Who thinks number one, fairness, which one do you like the best? Any votes for number one? Okay, I have a couple votes for number one. It's fair, treating all the patients the same way. How about number two, shared sacrifice. People don't like that one as much, right? Sacrifice means having unpleasant. How about good enough? Never argue better, but a CT's good enough for what our purposes. So we have at least a vote for good enough. Two, three, yeah, four. How about shared decision-making? All right, you want to be able to like weigh the societal cost across your insurance company and let them decide. How about altruistic appeals? I kind of like this one. You know I'm making a decision that's pretty good with everybody. But people have studied these approaches with patients and have been react to different types of strategies. And guess what? They didn't like any of them. Basically, the quads for these qualitative focus groups are something like this. The doctor's going to tell me to recommend a CT scan basically because it's cheaper. There's nothing he can say to make that sound right. Or this one I got a kick out of. It's totally funny because I agree with that thing about keeping costs down and helping me in the long run. But I don't want my doctor to say that to me. I might say it to him, but I don't know how he can say it to me. So none of these strategies really seem to resonate with most patients. Learning about what conditions and what patients think about this idea of societal costs and considering those costs of the physician-patient relationship. But what did it actually do in practice? And this is the work of the Dartmouth Atlas Group who's been creating maps like this for quite a long time when they look at regional variations in healthcare spending. And you can see this one's from some years ago now. But I grew up in Earl, Montana. And it's usually the pale end, right? It's not a lot of the capital spending relative to other places in the country where there's much, much more. And you think this difference in spending might be related to better outcomes. More bang for your buck. Well, there's more services. In higher spending areas, there's more beds. There's more physicians. There's more specialists. But you can see on this slide there's not a little convincing case to be made that outcomes are better for all that extra expense. Higher mortality, worse care coordination. And even if patients aren't that much happier, well, sometimes they are less happy with their care. So this mismatch also, it provided another way of highlighting the fact that there's waste in the system and that some of the spending must be unnecessary. And how like spending more leads to worse outcomes? That's sort of counterintuitive. But you can see that the more care there's more diagnosis, more treatment, more review, and more potential for all sorts of harms. It's also interested in my role of learning environment of how these regional variations impact our future physician workforce, our learners. And studies of residents have shown that the intensity of care in the region where they live through the residency training predicts their future knowledge, their future attitudes, and their future behaviors with respect to cost-conscious care. These associations have led folks who have hypothesized that there may be this imprinting process whereby residents start to develop practice patterns that resemble those they see in their learning environment. But what about medical students? So we did some surveys of medical students across the country at 9 or 10 different schools, geographically dispersed. We first looked at their attitudes for cost-conscious care and they differ significantly from physicians, even those that were youngest and most proximate to them in age. And overall, we're more favorable toward cost-conscious care. We can talk about why that may be. And they report engaging in cost-conscious, high-value behaviors themselves. So they'll ask questions about the cost of care or try to figure out how much something costs. But they also report engaging in behaviors that are not very cost-conscious and are low-value, such as ordering a test just to show off their ability to generate a wide differential diagnosis. I remember wanting to do that at medius-wipples disease, you know, something along the lines. Or satisfy curiosity or build clinical experience when you're ordering an ABG because you're trying to learn how to draw blood gaps. Right? Some of these examples are widely lit for medical students of things not to do. And we looked at whether these self-recorded behaviors related to care intensity in the region of their medical school. And indeed, the students who were in more intense utilization regions recorded more low-value behaviors. So this imprinting process may start even earlier than residency for affecting our medical students in their very beginning work shifts. What is it in the learning environment? And we hypothesized that role modeling may have a particularly influential role. So we then did surveys to look at what role modeling behaviors our students were recording seeing in a clinical learning environment. And they see cost-conscious behaviors. They see physicians discussing costs of care or explaining why a test is unnecessary and would generate an unnecessary cost. But they also see potentially wasteful behaviors. Unnecessary referrals ordering more expensive things because that's what a patient asked for. Or criticizing a training for failing to order something on a stable routine labs on a stable patient. And when we combined these into cost-conscious and potentially wasteful role modeling scales we saw that students in regions with more intense use of resources higher spending saw fewer cost-conscious role modeling behaviors or reported seeing fewer such behaviors. So it's clear, I think, that our learning environment the culture of the practice of medicine is not only an issue for clinicians and patients now, but it's something we need to think about for the future physicians that we're training up to engage in those relationships down the road. This is my first place-holder slide to pause and see if you have any questions. I think we can make time for a couple questions now and we'll have a couple more opportunities a lot more later. I have a question. Yeah. So how much do you think somebody like me and Dr. McGregor really affects how the really good student has to do in the future? So- How much can we learn and how much can- I mean, how much of what we do here is teaching What do you- That's a great- It's a great question. So people have asked the students that question. There's an interest in measuring the learning environment as part of the accreditation expectations of medical schools. So people have measured all sorts of different dimensions of the learning environment and asked students to write the things that are the most influential and role-modeling consistent in relationships with faculty consistently comes out on top. So the students say it makes a difference. Now, how durable is that difference? Well, those studies- Now, these are of residence, but where they train predicts their practice patterns by 10, 15 years down the road. So that suggests it has a pretty durable response, at least in residence. Now, whether that- What happens during medical school may be trumped by what happens in medical studies. Yeah. I don't know if anyone has looked into that, but it's an interesting and important question. Yeah. How do you expect attending presidents to teach and educate patients and students and people lower their guard about cost-conscious care when they don't even know how much of something costs themselves? Right. So lab of cost transparency is a big barrier for every stakeholder, right? It's a barrier for the clinicians, for the patients, for the workers. So- And we'll touch on this later about what people have advocated Dr. Aurora and others for this idea of having universal precautions. We don't know how much the test is going to cost for this patient right here with their insurance in this hospital at this time and place in the world, but let's treat as if it could be a burdensome expense to them and the rest of the society and what can't you do to be mindful of that? I think also just being explicit because sometimes this reasoning is happening inside our heads, but it's not coming out of our mouths in a way that's explicit to learners. So one of the theories I have if we go back around why aren't regional practice patterns associated with more potentially wasteful behaviors? And it could be that a student's not in a position to recognize how much something costs or whether it was necessary or unnecessary or if the attendee ordered the test just to protect against malpractice or for some other reason. So those influences in the environment might be less visible to students and it's under reform. We want to be there. Yeah? I imagine it's hard to change the culture in medical school and instead of trying to do that I wonder about just rating medical schools on cost consciousness and that way applicants can direct themselves according to their career. That's an important thing to them in their career. So the Dartmouth Atlas has done just that as they used to have a website that was targeting the students and shared this type of data with them you might want to think about where you go to train and make a choice deliberately that's going to inculcate you with this high value lens. There's also some of the more provocative conclusions from those studies and residents where should the U.S. government allocate the money to GME education according to regional healthcare intensity you're spending and try to shift it in that fashion. So those are some of the conversations that have definitely happened as a result of this one. Yeah, one more question. I would like to look at this and looking at trends and training evaluations and cost consciousness. Yeah, I think that's something we've thought long about at Mayo Clinic because I know that I was a student I think if I had said, are you sure that might not I don't think the results are going to change management or I didn't order a lot of things I would be worried that I might get a worse evaluation. So how could we put these items at a more granular level on the students of faculty evaluations faculty and students evaluations as something we are priming our faculty and students to watch for and think about. One more. So, we have other tools that we also use to train control resource utilization like payment models, managed care and so on. Has anyone ever studied whether the correlation between where a resident comes from and what medical students and their spending varies according to the environment in which they go? Other than this, these studies of residents, so they were actually studies of physicians looking at. Their practice patterns resembled the residency environment more than the current environment. Yeah, it would be interesting to see whether if you look at a bunch of positions varying environments within a given payment environment to understand how much it still plays out there or whether in fact there's a tremendous amount of homogenization that happens once people arrive and my guess anytime anyone's ever looked at any unit of analysis there's a lot of variations. So I'm guessing that we would continue to see individual level variation. I've looked at the folks in my own department there's huge individual variation in the same sort of practice setting in terms of resource utilization. People have looked at patients who moved and the intensity, you know, because people many doctors will say, well since patients asking me for all of these unnecessary things I want to have good scores it's linked to my salary, you know my payment my salary and so people looked at patients and when they moved the care they received resembles the practice pattern of that region not where they came from. So patients may be less of a driver's Now, we've been thinking about the clinician-patient relationship as this dyad but to your point in reality since the mid-1900s correct me if I'm wrong there's almost always some third party payer involved. We've done one study looking at simultaneously measuring the perspectives of these three different stakeholders we didn't ask the administrators and operations managers and the sort of people who think about the bottom line and they were the most likely to think physicians have a responsibility to be cost-conscious to incorporate costs in the daily practice and they saw far fewer drawbacks to cost-conscious care than either physicians or patients so these different stakeholders have different perspectives so how did we get to this place So looking backward for a moment this is a chart showing different sorts of payment models from fee-for-service on the left to capitated payments for an entire population on the right and the attendant risk of overuse on the one side and underuse on the other Early on fee-for-service was the predominant model it still is in many respects and around the 1980s here is recognized that healthcare costs are going up and at this point it's 10% of the GDP and it's already being called a crisis it's double that now it's still being called a crisis so there was this big interest in cost containment cost reduction so what happened? so Medicare created their diagnosis-related group system where they bundled payments for episodes of care in the hospital and there was this big movement toward HMOs which were managed by insurance companies and promised to control costs without passing along the financial risk to patients but they did that by using primary care providers as gatekeepers so you couldn't get access to testing or specialists without going through your primary care factor and there was this over its the approval utilization review process through the insurance company that was matched by that's a supply side intervention so forgive me if this is a big simplification but there were also demand side efforts underway including this famous study that looked at how patients utilize healthcare services when they have different skin in the game so you can see that patients in the purple here had access to care for free and they used more care and the patients in the white group had to pay 95% of the cost and they used less care and overall there were no huge differences in health outcomes between these two groups so there was this demand side I heard to have patients have some skin in the game now unfortunately patients when they have access to care they use more necessary and unnecessary care and when they have more skin in the game they use less unnecessary care and less unnecessary care so this isn't a perfect solution but this is the type of work that was happening at that time and sure enough there was a plateau that was contributed to a plateau in health care spending growth during that decade and even a reduction in out of pocket costs however this was not popular physicians lamented the loss of professional autonomy and having to get approval for everything they thought was right for their patient all the administrative hassle that came along with that and then this perception among clinicians and patients that insurance companies were rationing putting profit before the needs of patients and that led to a big erosion of trust and I think we still see that erosion now this is from a study looking at patient perspectives on evidence-based medicine and there's this kind of underlying currents of skepticism that many have is this information driven by research or by someone wanting to save money I think they're thinking about the whole hard calculations they don't want to pay out so we're still facing this erosion of trust around anything that might be smack of being intended to save costs so in the early 2000s professional societies like the AMA and others came out with statements about how physicians do need to individual patients comes first but that physicians also have this professional obligation to provide healthcare resources and in 2008 the healthcare community really rallied around the Institute for Healthcare Improvement Triple A which included costs which had dominated the conversation before but it also included costs in relation to patient experience of care and the quality of care population health outcomes and by considering costs in relation to quality from cost consciousness to a language that talked about value and the appropriateness of care and that's on a continuum I think you heard some of this from Dr. Levinson perhaps when she was here recently so overuse care of unnecessary ineffective and potentially harmful underuse of effective care and misuse where it's inappropriately used and appropriate use and this language seems to resonate a lot more with the healthcare community and gave rise to the choosing wisely campaign trying to bring this into the professional and public consciousness and if you look at clinicians 87% will say they talk to their patients about avoiding unnecessary tests but only 20% talk to their patients about costs so I think this illustrates how value and appropriateness of care is going to resonate more with physicians and other clinicians and patients the same way they get this idea that a doctor can recommend against a test or treatment if it's unlikely to be beneficial and that I can play role in reducing costs by not requesting unnecessary potentially harmful care and I think what makes this easy at first blush is that much of the conversation about overuse and misuse is in this square down here it's bad for the patient and it's bad for society so we can all agree not to do it but there's a lot of gray area here because these concepts exist for the continuum and so there's still a lot of situations in practice where it's going to be difficult to judge if this is something that's clearly overuse or appropriate care so where has that taken us now well we have this tryout of the payers I think we also need to step one step a little bit further back to talk about the policy makers there's been a shift in payment models from trying to reimburse based on the volume of care provided to the value of care provided and so the Affordable Care Act MACRA these are now they're built on top of that fee for service model that continues to be so common in our payment systems but it layers on this mandatory reporting for quality safety patient experience outcomes and then offers shared savings if costs come in below or shared widths if costs come in above so they're trying to link incentives to value reimbursement to value the DRG bundling system didn't use to include the physician fees those were added in 2016 and some of the more alternative payment models are moving toward the other new spectrum here so they're more of a capitated approach but you may at first thing well that sounds like those HMOs that nobody liked back in the 90s but these are going to be managed by care delivery groups not by insurance companies the idea being that they're in a better position to make those judgments about what's appropriate for patients and how they can care more efficiently these are the goals of this value based reimbursement strategy providing accountability promoting innovation improving quality and reducing costs that's that triple aim whether this will achieve the goal there's some debate concerns about playing to the game trying to perform well on one quality measure might lead you to perform worse on another or to triage out patients who are going to bring down their scores and worsen inequities of care it's expensive to measure all those quality and safety metrics but most or many agree that this is nevertheless the direction that you can continue to try to go is not perfect yet and the percentage payment is linked to these types of models which gradually increase over time and there's corresponding efforts to build health insurance programs that incentivize value too if I want to see my primary care provider incentivize care I can do that for free if I want to get cosmetic surgery or lift up my eyebrows I'm going to pay a lot more and that's built into my insurance so we've stepped back a little to look at payers and policy makers any questions at this point in the conversation it's not or comments I know you have a lot of questions add a little question my concern about these value based models and all the quality metrics is that the quality metrics are inadequately reflective of the experience of the small number of people in the system who experience the most complex episodes of care and in fact all the incentives are to do much much less for those people and in fact to do more for the people who actually don't need care but respond to the patient side of the actions surveys and everything else I just had a conference yesterday organized in Chicago about safety net providers and I even heard a speaker I won't even mention who the speaker was sort of politically sensitive but I would say I was dismayed that everyone of my peers was supported by how value based care was really being implemented and so you know you sort of said well there's a lot of agreement that this is happening I think what your slide showed was that it was growing it's growing I think there's agreement that the direction is right I'm not sure the implementation might be wrong so this is sort of like what I am convinced is that people making a whole big pile of money in health care agree that this is happening and that it's important and that managed care this is their business and I will add on top of that that the business of government is very often very closely tied to the business of health care business so if you're involved in administering public benefits, managed care is sort of your best because you can offload your own play responsibility for pretty much everything financial and political into another area so I guess that's kind of my push back but also sort of my question in fact is there broad enthusiasm for these approaches outside of payers and people making money out of it I heard from your first comment the answer may be it's very perhaps no I've seen some you know, proposals that we need to think about we need to focus on our most needy populations chronic, multiple chronic illnesses mental health and that our quality measures are not targeting the patients who need them the most so I've seen arguments to try to align our measurement being more strategic about that one of the most compelling things I've seen which I don't think I had in this version of the talk is when you plot health care spending compared to other developed countries we look so much higher but when you add spending on social services those other countries are right up there with us so there may be bigger questions we need to ask about where is the right place to invest our national dollars I was really happy to bring in say what he said about driving this and it seems that as a physician who's taking care of patients this seems so onerous having to just be watched everything you do with the assumption that you're going to commit fraud and this goes back to like the 90s when the costs were just going crazy because there are a lot of doctors who were just charging the highest rate for everything and just using the system but that became the common practice because they were encouraged to build the highest rate by administrators so people felt powerless and now basically we're all being punished for and this idea of always thinking about costs is just such a waste of time because what you really need to do is take care of the patient this is what the patient needs is what they tell me the cost of what it actually is going to come down to is really a secondary phenomenon and a lot of those costs are deeply inflated by people who are making tons of money on this I think it's time we address the elephant in the room which is the huge amounts of money that people are making including many doctors so it's time for us to perhaps make less money and get people out of there seeing this is the investment I mean people are making huge amounts of money on death and dying of our patients and it seems like basically we have a misalignment of incentives and interests that are not centered on patients the way they should be I mean yeah but making a chemical therapy move they make because it's just going to add so much waste and so much wasted documentation and time and money keeping track of all that nonsense but I don't understand why you're so excited about I'll show you that I've also heard that people from Minnesota say they're excited they might not actually be I think you've all raised some really excellent points and there is a slide showing the drivers of waste and how well a lot of the burden of documentation to be put on physicians and that frontline dyad the biggest drivers of waste live in other places that we need to think about in other ways so yeah probably a little bit picture question we don't have a similar one single cost structure for any of the other services in this country or anywhere so if you want to travel with a plane you can choose to be coach, business first class if I want to send an envelope it could be USPS, FedEx but now it feels like we're trying to create this one cost structure for the entire population is it even feasible or is it reasonable to do that why don't we give people different options so I'm just the economist in the front row have any thoughts about that well I'm not even sure it's true about planes I mean we're going to draw on the same plane and we're dyadic so that doesn't exactly work some people get bigger seats yeah that's true you know I think part of the complexity of all of this is that there's a societal interest in the health of everyone and that probably opposes a minimum we probably do have a tier to the reality if we admit it you know we're moving even closer to it now probably including in our locality that we weren't in the past complicated complicated and contentious do I have a somber Minnesota case so this is where we've been and I think the conversation just now highlights we're talking about payers we're talking about policy makers the complexity that surrounds that how something that sounds good in theory might really fall flat in its goal in practice or even be antithetical to what it's trying to achieve I think the things that he's written a great paper about eras re in medicine moving from all this measurements to more of a professionalism model that doesn't punish all the physicians for the few that are doing things fraudulently and irresponsibly and he raises this important point that anytime you're talking about value there's this question the elephant in the room of value from whose perspective is this the payer and the people profiting off of this model or is this the clinicians and their patients in health care because it's set up as a profession this sort of implication is that we professionals are in the best position to judge the value of their care but in other industries service industries and products excellence is in the eye of the consumer so I think that begs the question I mean there's a bigger question of whether payers or policy makers see eye to eye with what patients need and want but also whether we as clinicians and physicians see eye to eye with our patients I know as a neurologist you know at a tertiary referral center we get unusual things we do these big workups and get really excited to make a new security diagnosis but then at the end of the day what the patient really wants is to feel better to be able to hold their granddaughter to play their saxophone in their band and all of that energy around the diagnosis people care about knowing that information and what to expect on the line but it falls a little flat the excitement that's in the workroom when you're rounding can fall a little flat when you're at the bedside of the patient and when you think about how patients judge value what patients tell us is that they're referring value from the quality of their relationship with the clinician and the degree to which the care they receive makes them able to achieve their life goals and live in alignment with their priorities their ability to live life as normally as possible and this isn't always how we as doctors think about things patient-centered care I think can be taken to a whole new level and this idea of having respect for patients on their terms helps me understand why my grandpa is a farmer in Montana when his cardiologist told him he needed a pacemaker and a stimulator he said heck no why not sudden test and he says well the place where they're going to put that pacemaker I use that shoulder to open gates I do open gates that didn't make sense to me but that was really important to him and it wasn't until his cardiac condition that his ability to open gates that he was ready to think about that and a similar conversation with his brother who had a diagnosis of esophageal cancer I heard this every girl in Montana I quickly scrambled to try to get him an appointment with an oncologist at Mayo I didn't get you in next week and he said but it's harvest I said well you have cancer he said but it's harvest so there could be this mismatch and I think the same with evidence based medicine we look at these studies of populations that give results that are averages the patients are individuals they want to be seen as individuals not only as individuals but as individuals with a unique life story unique context people who think about health in different ways different ways that people in the U.S. conceptualize health capacity control physical well-being psychosocial well-being and they might prioritize health in different ways relative to other dimensions of human worship so for my grandpa deriving a lot of meaning and purpose from being able to work on a farm and my uncle to finish harvest was more important to them to optimize their physical health which is the land that I was bringing to my conversations so if we look toward the future I think we need to ask some of these hard questions about what my colleague Dr. Victor Montori says do we care more about value than we value caring? Have we gotten this order backwards and what does this mean for the physician-patient relationship you know in the olden days was more holistic some patients wanted a more autonomous relationship there's a smooth to share decision-making and more equitable that requires a lot more transparency around data than we have right now well maybe a collaborative model where we recognize that each brings their own expertise physician-supportive of a patient proactive to create this understanding together and recognize a care plan that is right for that person's life one of my jobs is quality chairs in the department neurologies to read our patient experience survey comments this is one I came across that I think highlights this idea she should lose that I'm a doctor and you're not an attitude her talents speak for themselves I wasn't there to dispute anything but it's my life, my body I live with it every day I think we need to think about patients as being experts in their own life we're experts in medicine and that combination can really take patient-centered care and what we mean when we talk about value in a more patient-centered direction and there's movements on the patient side of things the society for participatory medicine talks about being patients and I think any of you who are in practice will recognize this idea equipped, enabled, empowered, engaged evaluating patients who are looking you up before they come to see you to see what your stories are and you're not going to be treated as a patient now that doesn't mean that that collaborative or participatory model is the right for every setting but I think we're going to see more of that this is a five-step framework for promoting value and clinical encounters taking it all the way back down to that clinician-patient dyad and again with understanding the benefits, harms and well as it comes so that your point about we don't even have access to that data there's a long way we need to go to even do step one but it's worth it needs to happen and then having what we call less is more conversations but not framing it as appeals to save societal resources but using more of that choosing wisely lens of this is unnecessary care that you don't need to be harmed you and this is an infographic we've created out of some of Dr. Aurora's work and others about how to have these less is more conversations with students listening to where the patient's coming from making it clear that you're on their side explaining your reasoning without appeals to society because that comes across and rationing or putting costs first and then having a clear plan for follow which is part of that relationship using interventions and care settings that will achieve the tripling basically maximize the benefits minimize harms and reduce costs and then this important part of customizing care to the individual in front of you that can be done using decision aids and I know there are many places that you can go to access these we've created some at the Mayo Clinic as well you can really see when you watch the videos how these change interactions be much more collaborative this is one that I like it's designed for patients with multiple chronic illnesses to think more broadly about what areas of their life are a satisfaction or a burden or both and how maybe the care we're providing is aggravating the problem versus helping it and try to have those more customized individualized conversations about what's high values for that person and their life we haven't talked a lot about out of pocket costs those are going up to to your point about you don't know what the cost is to society much less the cost to a patient you can screen for financial harm using questions like are you worried about how your care will be paid for do you sometimes skip medications or cut back because of the cost and that will help crime you to pick up these concerns patients are sometimes reluctant to bring it up but when you ask many of them would like to talk about it so we can help with that and then finally not forgetting about those systems level opportunities to create a more high value system that's focused on the needs of the patient and to your point about sources of waste you know the physicians if I look at this list which of the ones fits out to me is where I can have the most immediate impact is that overuse low value care but the biggest drivers there are administrative complexity from so many different models and all of the work that goes into that pricing failures that's a whole complex issue of its own and then lack of care delivery and coordination which is really where some of the systems energy could be focused what's a pricing failure so that's how a price is so look for example at multiple sclerosis drugs there's you know 15 or so of them and the cost even the ones that have been around for 20 years that's a success for the people who are failure for whose perspective yeah I actually learned the other day that the government pays more for the like 15 MS drugs three times more than all of your models I mean I kind of could have started perspective to me around this pricing issue or pricing success I suppose if you ask someone else now we've also asked medical students you know there's an interest in getting students engaged in promoting value and when you ask them what they're interested in doing they tend to rate patient care things that's the blue bars hires they're more interested in that than systems things that's the red it's just harder to kind of get your head around the system what it means to improve a system so helping I think as educators and role models we can help our learners really see what the end who are all here for right it's the patients and when you're working on a quality improvement project or a systems project this is you know that the end beneficiary of that effort and hopefully that will help bolster interest in engagement so that someday we have a system that is more centered around the patient it seems to me that some of the problems it lies in a couple of the slide you showed before I'm not a sociologist but I study some of this 10% of the cost of medicine is to go from right so that's the cost of medicine but who is supposed to prevent it from second 10% of them is of the malpractice not just lawyers say it's 2 to 3% but it is 10% when we call unnecessary questions a lot of MRI that they do one after each other and that's estimated to be the cost 10% of that is waste in other words people have medicine they don't use if you take the medicine that some of the nurses have collected you could give it for another sitting and do that so 10% of the cost are social illness that it comes to the cost of medicine now people not different from animal behave the way that environment imposes something so if the cost is very high then the people charge very more I could say that if you cancel all MRI and you put it CT scan the cost of CT will go up as much as MRI if you just only do an x-ray and nothing else the cost is going just as much because the people have to pay for their expenses now when I was the president here we had one lawyer another real lawyer a secretary on the fifth floor in order to fill out charge somebody wants it now we have a corridor okay department of surgery I was a secretary one for the chief of American houses and the other one for the whole we have a corridor for the people because they have to be with insurance so the cost is very high that's what bring it that's why you could get an MRI scan in another country for $1,000 and read for you but here is $7,000 and $2,000 for reading so you cannot separate saving and all these good things that you take from our social illnesses that's a very important point and if you look at you know drivers of overuse when it comes you know physicians will talk about patients asking for this test but concern about no practice is right up there and that's not teased out on the table like this and I was shocked too talking to one of our leaders in the quality something like 15 million dollars just on the measures um I had my jaw dropped when I heard that number for an organization to collect and report all of that so it's a complicated issue and as clinicians and patients we're embedded in the middle of that so trying to find tools to navigate the system as best we can while advocating for change and broader ways this morning we our resident presented two bullet injuries to the brain now these patients require cost a lot of they don't have insurance so because the bullet and all is a number bullet the number is 100 times more than many other countries that is a social illness that we cannot calculate and then we tell someone okay you don't have an MRI and I will see a nurse there maybe we need to be thinking not just about physical loss I think you have to be a economist and sociologist and all get together in order to come something that will follow up to that I just want to bring up another idea about the patient because the way if you look at really carefully is a kind of pain sight perspective after things happen then you look back saying oh this shouldn't happen because it's ways you didn't use that but if we look forward as a doctor as a physician when prescribing drugs or assignments examinations you should have a reason to do that you're not thinking oh it's a waste and then I do this no it's the way you look forward but you look back and you know it's waste so I don't think that really works this is one of the idea of waste is the kind of thing that you look pain sight perspective and the other thing is there was this live showing that expanding American healthcare is really exploding like a hail going out to work but if you look at the S&P 500 the stock market index is going the same way why that? because of the economy the Federal Reserve are giving out money, giving way money to this economy the economy is going up forward so we have more money so our spending is increasing and because people are able to pay their medical medical costs either because the government insurance or private insurance so doctors can prescribe these drugs and they can do these donations so the spending are increasing the same speed as S&P 500 is going up because of the economy if the economy is not going up like those poor countries or like the European countries you may just mention their economy is going like flat then their healthcare expanding if you take a look into it aren't just like flat because healthcare spending is part of our economy it goes outward we is our economy so this is not if you see this in a bigger picture and there is another thing I want to mention about your talk to the patient is that there is an old economic joke saying that there is a farmer that wants to sell rice to a customer and they have did exist coffee because the farmer wants to make the price higher and the customer wants to make the price lower and they want to make the deal done if they think too much about other the other one then the deal will not be done let's think about that if the farmer wants to your student do too hard I want to give you free lunch and the student think oh your farmer you making this too hard I really want you to I really want to give you more money then they will not make the deal done so as a doctor and patient we need to make give good help not making the cost lower just like Dr. Daniel said the main target should be give good help just like the farmer and the customer make the deal done I want to rice I want the money to go on keep a high price on these devices so the economy can work otherwise the deal will not be done because I think maybe that's why I smile when I think about value because I see value is headed in the right direction from just thinking about cost because at least it's a more synthetic term it's bringing the quality and the safety the patient experience the timeliness the equity and the efficiency of care together relative to cost and not just cost but cost over time so by bringing those together it lets us at least in theory focus more on what's the right thing to do what we need to do and what's for instead of what's the cost of the patient it seems like you're using value in a couple different ways here and in one way it's tied to cost but in other ways it's not it's tied to what the patient was wanting and the benefit and so I think it's very confusing well so they talk about value as quality over cost some people do some people do that's that common way of thinking about value even in that frame quality has different dimensions of which patient-centered care is one and that's lost in our our discourse today is really an industrial economic discourse that talks about value is really thinking about dollar science and I think also you're thinking about being on the side of the patient I think medical students when they get in they actually are on the side of the patients and I think pretty soon after they become residents they're no longer on the same side and I think that they switch they switch sides because the patient becomes this person that you want to get out of the hospital and I think that that's inculcated in residency and I think it continues relationship I think that raises another really important point about how we need a richer understanding of quality that elevates the patient perspective beyond where it is today and we need a more nuanced understanding of the cost that's not just money there's a cost to me as a resident being on call admitting all these people and there's a cost to patients having to disrupt their lives and coming to see us time and convenience, anxiety financial taxes and all of those things so thinking about quality in a more multi-dimensional way thinking about cost in a more nuanced way thinking about maybe we just need to completely shift our discourse my colleague Dr. Montori says is healthcare an industrial enterprise where we're mobilizing we're focusing on care to achieve our industrial needs or should we be thinking about care as a goal that we're mobilizing all our needs toward and do we need to rethink our whole language maybe value is so steeped in the money that it's lost its ability to serve that purpose and maybe thinking more about something like kind and careful care is what he has proposed doesn't tolerate hate doesn't tolerate waste it's kind and careful to the person in front of us so that may be a whole change of discourse maybe what's required to navigate for question me the focus on quality if that's what we need to move but that also requires measurement time and costly measurement of outcome and I think it's just to kind of throw that to you don't want to do, you don't want to miss that extra time or that extra money into this but we already spend a lot of time working on billing for services the cost side of care it seems disproportionate we're willing to invest the time when it's going to reimburse us but maybe not when it's good I'd like to ask a question and then one more from the audience well thank you so I shared just before your talk that I've recently seen this documentary about the Mayo Clinic made by Ken Burns and anyone who hasn't seen this I really recommend it I know it's officially part of the American Experience series or not but it's really extraordinary because the Mayo Clinic Mayo Clinic's history is a referral center people coming from very far away with problems they feel have gotten not adequately addressed wherever they are and I would imagine often looking for a very deep dive into a question and what I'm curious about is as you train medical students and residents in that environment and as you treat both people from the community and people who come from the opposite side of the world how does the value discussion feed into the discussion about the difference between those two sets of patients does everyone get the same treatment or do people get different treatments because of who they are or where they come from or what they want so the the truism that circulates from the Mayo Clinic said by one of our sisters who helped found Mayo Clinic together with the Mayo Brothers and it's no money, no mission, no mission, no money so a lot of times when these debates and tensions come up somebody will say that quote and will think about what does that mean in this particular instance in terms of trying to serve different populations I think the cost that's at the front of my mind when I am taking care of patients is time you know somebody's traveled a long ways away they're paying for a hotel a dog center, a lady's center airline tickets time away from work and they're looking for answers so the cost that I have in mind is less so money and more so time whereas if we have community patients that lens is different because they would write down the streets and it's easier to provide longitudinal follow up and not rely on tests which don't have the luxury of that sort of time so I think that illustrates how and I try to like make sure that I make that difference explicit for the trainees because I found doing all this destination medical center care I had to sort of like flip a switch and have a different mindset in the community practice because that would be an undue burden to those folks whereas it was maybe a high value to these folks so I didn't think of it I don't think of it so much as a tear as thinking about costs in a different way and those are the kind of complicated tradeoffs that we make as clinicians and patients yet another example which as an economist I was pointing out is fascinating because people pay for their own time in their own air ticket but they don't pay for their own tests so it's this interesting societal personal experience and most of them have insurance yeah but that's what I mean you're happy to go there without insurance you are now trauma centered I'm not sure not so many people go there with bullets and with the injury and the car you can see the person who fell in the tractor yeah any last questions listen, thank you so much what a wonderful talk


Hi guys, welcome to part 10 in our reading of the book of Jubilee. Today is going to be a little bit of a shorter reading again, because we did not get through chapter 35 in our Dark Outpost reading the week before. And so I'm trying to keep us on the same pace from the Dark Outpost channel as well as here on Esoteric Atlanta. So today we are just going to be reading through chapter 36 and 37, ending at chapter 38. I hope that makes sense. So if you're following along with us on the Dark Outpost as well, you probably know what I'm talking about. But if not, just know I'm trying to keep us at the same pace. So that's why today's reading is going to be a little bit shorter, just so we can allow the Dark Outpost channel where we're doing this as well to catch up with this channel. As always, if you want to join us on the Dark Outpost, please do. We go live on Tuesdays at 1 p.m. Eastern Standard Time. The link to the Dark Outpost channel is down in the description box below. It's its own separate platform, its own separate channel that's not on YouTube. But you can also find some of David's videos from the Dark Outpost on Bitshoot and Rumble as well. All right, let's go ahead and dive into chapter 36. So chapter 36 is Isaac's last words, his death, the death of Leah. In the sixth year of this week, Isaac called his two sons, Esau and Jacob, and they came to him and he said unto them, My sons, I am going the way of my fathers, to the eternal house where my fathers are, where for a very meaner Abraham, my father, in the double cave in the field of Ephron, the Hittite, where Abraham purchased a sepulcher to bury in, the sepulcher which I dig for myself, there bury me. In this I command you, my sons, that ye practice righteousness and uprightness on the earth, so that the Lord may bring upon you all the Lord said that he would do to Abraham and to his seed. And if y'all remember from the last reading we saw, Esau and Jacob kind of swear that they would always kind of be each other's keeper and brother and like love each other. I don't know if y'all remember that from last week, which also brings me to another point. This is my first time tuning in to this reading. It might be helpful to start all the way over again with part one, starting with chapter one of the book of Jubilees, so you're not super lost on what's going on. And I will place a link to the playlist. The playlist is from the dark outpost. In the description box below so you can just click on that link and then find part one and go from there. So picking up again with verse four of chapter 36, and love one another, my sons, your brothers, as a man who loveth his own soul and let each seek in what he may benefit his brother and act together on the earth and let them love each other as their own souls. Sounds a bit like do unto others as you would have them do unto you, right? And concerning the question of idols, I command and abonish you to reject them and hate them and love them not, for they are full of deceptions for those that worship them and for those that bow down to them. For ye, my sons, the Lord God of Abraham, your father, and how I too worshiped him and served him in righteousness and in joy, that he might multiply you and increase your seed as the stars of heaven in multitude and establish you on the earth as the plant of righteousness, which will not be rooted out unto all the generations forever. And now I shall make you swear a great oath, for there is no oath which is greater than it by the name of the glorious and honored and great and splendid and wonderful and mighty which created the heavens and the earth and all things together, that ye will fear him and worship him, and that each will love his brother with affection and righteousness, and that neither will desire evil against his brother from henceforth forever all the days of your life, so that ye may prosper in all your deeds and not be destroyed. And if either of you, devious evil against his brother, know that from henceforth everyone that devious evil against his brother will fall into his hands and will be rooted out of the land of the living and his seed will be destroyed from under heaven. But on the day of turbulence and excretion and indignation and anger, with flaming and devouring fire as he burnt Sodom, so likewise will he burn his land in his cities and all that is his, and he will be blotted out of the book of the discipline of the children of men and not be recorded in the book of life, but in that which is appointed to destruction, and he will depart into eternal excretion, so that in their commandment may be always renewed in hate and excretion in the wrath and in indignation and in place and in disease forever. Now we talked about this a lot last week on David's channel from the last section we read, and we also talked about this a little bit with Tamara last week when she was on the on the channel, where we talked about the severity of what these Canaanites do and their worship, how they go about their religion, and their religion is obviously that of worshiping Lucifer in forms of also other gods of the underworld like Moloch or Baal, you know what I'm talking about, and Tamara and I talked about that extensively as well as with David's channel. We talked about how this is a choice, people have a choice, so yes we do talk about these bloodline families that are caught up in this nonsense and this evil evil evil evil religion that they practice, but regardless of whether you are born into a particular bloodline or not, we all have a choice to make, and to choose to do these rituals to Moloch, which I can't really go into detail about on this channel, but you guys know what I'm talking about. That is a level of evil that one doesn't just do hastily or one doesn't accidentally do because they're having a bad day. You know we think of people making mistakes or sinning or doing something bad, sometimes those sins are done in haste, you know, maybe someone will steal something because you know it's a hasty decision or you know have an affair because it's a hasty decision or lie because you know they're trying to survive or protect themselves, these are all done in haste, but to actually make that conscious choice to participate in the rituals in which these Canaanites participate in, to go through with what they do. It's not something that you wake up one day and just decide to do, right? There's a lot of thought behind that because I know for me if I were to witness any of these ceremonies, I would probably throw up, like it would be traumatizing for me. So as young Pharaoh once said, and I really like the way he said it, somebody who does bad, someone who is bad, you can hug them back to good. You can help them return back to good, but when you cross that line of evil, there's no coming back from that. You have sold your soul. So I hope that makes sense and we see this a lot in the book of Jubilee where God is telling Moses on Mount Sinai, this story where he's saying, listen, once you make that decision to serve Lucifer and you make that decision to participate in these rituals, there's not a whole lot coming back from that, if that makes sense. Alright, verse 11, I say and testify to you my sons according to the judgment which will come upon the man who wished to injure his brother and he divided all his possessions between the two on that day and he gave the larger portion to him that was the firstborn and the tower and all that it was about and all that Abraham possessed at the well of the oath and he said the larger portion I shall give to the firstborn and Esau said I have sold to Jacob and given up my birthright to Jacob to let it be given and I have not a single word to say regarding it for it is his and Isaac said may a blessing rest upon you my sons and upon your seed this day for you have given me rest and my heart is not pained concerning the birthright least thou shouldest work wickedness on account of it may the most high God bless the man that worketh righteousness him and his seed forever and he ended commanding them and blessing them and they ate and drank together before him and he rejoiced because there was one line between them and they went forth from him and rested that day and slept and Isaac slept on his bed that day rejoicing and he slept the eternal sleep and died 180 years old he completed 25 weeks five years and his two son Esau and Jacob buried him and Esau went to the land of Edon to the mountains of Seir and dwelt there and Jacob and Jacob dwelt in the mountains of Abraham in the tower of the land of the sojouring of his father of Abraham so the land of Abraham's journey and he worshiped the Lord with all his heart and according to this visible commands according as he had divided the day of his generations and Leah his wife died the fourth year of the second week of the 45th Jubilee and he buried her in the double cave near Rebecca his mother to the left of the grave of Sarah his father's mother and all her sons and his sons came to mourn over Leah his wife with him and to comfort him regarding her for he was laminating her so at least at some point he obviously felt loved for Leah because we know when he first was forced to marry Leah he was not very happy about that so that's good at least there was some love there for he loved her exceedingly after Rachel her sister died for there you go so there you go after Rachel died who was really his favorite he grew to love Leah for she was perfect and upright in all her ways and honor Jacob and all the days that she lived with him he did not hear from her mouth a harsh word for she was gentle and peaceable and upright and honorable and he remembered all her deeds which she had done during her life and he laminated her exceedingly for he loved her with all his heart and with all his soul so this brings us to chapter 37 Esau and his sons wage war with Jacob okay so the tides are turning now they made these promises these emotional promises to love and support each other but it looks like some foreshadowing here that that's probably not going to happen all right so chapter 37 and on the day that Isaac the father of Jacob and Esau died the sons of Esau heard that Isaac had given the portion of elder to his younger son Jacob and they were angry okay so here they go they're mad their uncle got what was supposed to go to their father by birthright and just remember Esau and Jacob were twins and Esau was obviously came out first so I can see how there would also be a lot of confusion here too because they were twins and they strove with their father saying why have my father given Jacob the portion of the elder and passed over thee although thou aren't the elder and Jacob the younger and he said unto him because I sold my birthright to Jacob for a small mess of lentils and on the day of my father sent me to hunt and catch and bring him something that he should eat and bless me he came with guile and brought my father food and drink and my father blessed him and put me under his hand and now our father have cost us to swear me and him that we shall not mutually devise evil against his brother and that we shall continue in love and in peace with his brother and not out and not make our ways corrupt and they said unto him we shall not harken until thee to make peace with him for our strength is greater than his strength and we are more powerful than he and we shall go against him and slay him and destroy him and his sons if that will not go with us he shall do hurt to be also and now harken unto us let us sin to Iran the Philistia and Moab and Maan and let us choose ourselves chosen men who are ardent for battle and let us go against him and do battle with him and let us exterminate him from the earth before he groweth strong and their father said unto him do not go and do not make war with him least he fall before him and they said unto him this too is exactly thy mode of action from thy youth until this day and thou art putting thy neck under his yoke we shall not harken to these words so basically his sons are like come on dad like you've always had a soft spot for Jacob even though he got really mad at Jacob at one point but you you've always kind of let Jacob just do what Jacob wants to do and this is really pissing us off because it means that we haven't inherited what we feel like our birthright is to inherit as well so this is just basically Isaac's grandson's very upset which i guess i can kind of understand but different times you know in today's in today's reality most kids are inherit equally from their parents regardless of their birth order so definitely different times all right so here we go to verse nine and they sent to Iran to a drum i hope i'm saying that right probably not but it is what it is to the friends of their father and they hired along with them one thousand fighting men chosen men of war and there came to them from moab and from the children of aman those who were hired one thousand chosen men and from philista one thousand chosen men of war and from adan and from the horites one thousand chosen fighting men and from kitam that mighty men of war so they're gaining this army to now charge Jacob and his 12 sons right and they're rude you know this is common throughout history if you think about all the royal families warring with each other and they are also cousins of each other so i guess in a lot of cases nothing really ever changes right human nature always kind of stays the same and they set into their father go forth with them and lead them else we shall slay be so they're threatening their father if you don't come with us we're going to kill you and he was filled with wrath and indignation on seeing that his sons were forcing to go before them to lead against jacob his brother but afterward he remembered all the evil which lay hidden in his heart against jacob his brother and he remembered not the oath which he had sworn to his father and to his mother and that he would desire no evil all his days against jacob his brother and notwithstanding all of this jacob knew not that they were coming against him to battle he was mourning for lia his wife until they approached very near to the tower with four thousand warriors and chosen men of war and the men of Iran sent to him saying behold thy brother have come against thee to fight thee with four thousand gert with sword and they carry shields and weapons for they love jacob more than esau so they told him for jacob was more liberal and merciful a man than esau and yes so esau obviously i think this is true of a lot of siblings anyway you kind of have like you know when you grow up with somebody and you go through growing pains with somebody and you share parents and you share a house together you have probably grudges deep down against your sibling for certain things that might not be at the forefront of your mind on a daily basis but when it's triggered it's triggered and it looks like um esau got triggered from all the stuff that had kind of been taken from him from jacob as how he would see it or how his sons see it and if my sister is listening to this no i don't have any grudges against you so don't don't worry about that but i can i can understand how that might happen okay verse verse 16 but jacob would not believe until they came very near to the tower and close the gate to the tower and he stood on the battlements and spake to his brother esau and said noble is the comfort where with thou has come to comfort me for my wife who hath died is this the oath that thou distswear to thy father and again to thy mother before they died thou has broken the oath on the moment that thou distswear to thy father wast thou condemned and esau answered and said unto him neither the children of men nor the beasts of the earth have any oath of righteousness which in swearing they have sworn an oath valid forever but every day they devise evil against one another and how each may slay his adversary and foe and now dust hates me and my children forever and there is no observing the tie of brotherhood with thee so he's basically saying you aren't my brother anymore hear these words which i declare unto thee if the boar can change its skin and make its bristles as soft as wool or it can cause horns to sprout forth on its head like the horns of a stag or of a sheep then i shall observe the tie of brotherhood with thee and if the beasts separate themselves from their mother for thou hast not been a brother to me and if the wolves make peace with the lambs so as not to devour or do violence them and if their hearts are towards them for good then there will be peace in my heart towards thee and the lions become with the friend of the ox and make peace with him and if he is bound under one oak with him and ploweth with him then i shall make peace with thee and when the raven becomeeth white as the raza i hope i'm saying that right then know that i have loved thee and shall make peace with thee thou shalt be rooted out and my sons shall be rooted out and there shall be no peace for thee and when jacob saw this he was so evilly disposed towards him with his heart and with all his soul as to slay him and that he had come springing like the wild boar which cometh up the spear that pierceeth and killeth it and reconcile not from it and then he spake his own to his servants that they should attack him and all his companions and that is where we are leaving it for today kind of like a cliffhanger there that now there's a war declared between these two brothers but again we're stopping here just to kind of have both channels on the same path so ooh it's getting good i know i said this last week and i will say it again there needs to be a movie made out of the book of jubilee there's way more details in the book of jubilee than there are in the book of genesis but this is a very very epic epic book so with that being said next week we will start with chapter 38 all right guys i hope you're having a fantastic day and a fantastic week thank you again to josh mckay for doing our music many people have asked me about the music when i first started youtube we were required to have like an opening theme song and josh mckay is a friend of mine and a really good friend of my boyfriend he's my boyfriend's best friend and he is a a musician that's been working for a really long time and so i'm really grateful to have one of his songs to have the rights to one of his songs to play on this channel for you guys if you do like the opening song the whole song is really great if you do like it there is a link down in the description box where you can like purchase the full song if you want it for your own music library and again thank you to Todd Roderick for helping me get this out to you guys today all right i will talk to you guys soon bye


In this lecture, we will study the longitudinal beam dynamics. So far we studied mainly transverse beam dynamics. So this lecture concentrates on a new domain of dynamics that is longitudinal dynamics. Actually, we have accelerator coordinate system like this. This is the design trajectory and design trajectory itself as origin of coordinate system and opposite to radius of curvature, we generally take x axis and vertical to this we take y and in the direction of beam propagation we take t. Now we were talking about the horizontal bitatron motion means oscillations are taking place along the x axis while the beam is moving along the z axis means these oscillations were like this in this plane like this and another motion was vertical bitatron motion in which oscillations were along the vertical axis while the beam was moving in the z axis. So these motion was like this these were the oscillations. Now we will talk about the third axis that is the z instead of talking about the z and z prime we will take two new variables what are those variables you will see it. So for the dynamics which is study about the bitatron motion is known as transverse beam dynamics and now the dynamics this transverse dynamics mainly commands by the arrangement of the magnets that how we are arranging the magnets where we are putting the quadrupole magnets what is the strength of this what is the length of the drift space what kind of dipole magnet and what is the angle etc and how we are arranging these magnets in making our optics how the periodicity is there these all things affects the transverse beam dynamics. Longitudinal beam dynamics mainly governs by energy manipulation of the particle means how we are manipulating the energies of the particle and when we talk about the energy means we are talking about the RF cavity in which radio frequency electric field is confined and that field is providing the energy to the particle whenever particle is traversing through that cavity in a turn it gets energy. So longitudinal beam dynamics mainly governs by the RF cavity. So these are two basic realm of the beam dynamics some other classification of beam dynamics can also be there that when we talk about single particle beam dynamics single particle beam dynamics means we are talking about trajectories of a single particle or how the coordinates in six dimension means x x prime y y prime are the transverse coordinates and other two variables which we talk about that will form the longitudinal coordinates how these coordinates are evolving in single particle beam dynamics the presence of one particle doesn't affect the motion of the other particle in the beam means we have the collection of particles in the beam but each particle sets its own trajectory without getting affected by the other particles of the beam in reality it is not so there because all the particles are having charges so when all particles move together then they can affect the motion of each other via direct coulomb repulsion or magnetic attraction or via the vacuum chamber via the vacuum chamber means the charge particle induces image charges in the vacuum chamber and those image charges can affect the other particles so when one particle gets affected by the presence of the other particle and we study those phenomena then we are in the realm of the multi particle beam dynamics or collective in this course we will mainly concentrate on the single particle dynamics under linear approximations even single particle beam dynamics can be broken down into two parts one is the linear beam dynamics and the other one is the non-linear beam dynamics in last lecture we have seen that introduction of the sex to pole can lead to a non-linear motion for the particles so that kind of motion where we are introducing non-linear terms in the hits equation and we are trying to solve that equation in which can give rise to this stable and unstable motion of the heat at one oscillations that kind of studies are known as non-linear beam dynamics so in this course we will not touch that kind of dynamics we will restrict ourselves to linear approximation and mainly single particle beam dynamics i will give one example of collective phenomena in the later lectures let us suppose that this is the cavity this is the cavity rf cavity and this is the orbit in the synchrotron now a particle when it crosses the rf cavity it gets energy and how much energy is it it is q v same phi v is the peak voltage and phi is the phase of the rf at the instant when a particle is crossing the cavity now particle can take some time to cross the cavity and then phi may change dealing its course of motion inside the cavity means length of cavity has some impact on the motion however in this course we are not talking about that effect means we are taking rf cavity as a thin element means we are ignoring its length thin element like we did many times in transverse dynamics we took quadrupole as a thin element here we are taking rf cavity as a thin element means it is a point where the particle is when particle is crossing this point it gets some energy now consider a particle which is on exactly on the design orbit means it has x is equal to zero x prime is equal to zero y is equal to zero and y prime is equal to zero means it is following the design trajectory it is not exhibiting any synchrotron oscillation bit of oscillations and it reaches exactly on the desired phase in the rf means there is a phase on which particle when arrives it gets energy in such a way that its evolution time on the orbit is always an integer multiple of the time period of the radio frequency field means we can have t revolution is equal to hti so it gets energy such that this relation remains always true for this particle means this particle is always coming on the synchronous phase and the radius of curvature of this particle when it passes through the magnetic field v is given by this relation r is equal to p upon qv we have seen this relation many times p is the momentum or design momentum correct momentum of the particle so this particle is known as synchronous particle so we are characterizing this particle by two variables one is how much energy it is getting and what is the phase in which it arrives at the rf cavity so this is the correct phase we say this is a synchronous phase and its energy which exactly follow the orbit or design orbit in the synchrotron that is the correct energy so this energy in of this particle and phase of this particle in the rf these two makes a reference for us means in longitudinal dynamics we have two coordinates one is the energy and one is the phase and synchronous particles energy and phase make the reference means any particle which is deviated either in phase or in energy we will study the motion of that particle with respect to this synchronous one as we did in transverse dynamics we studied the motion with respect to design trajectory means an ideal particle which is following exactly the design orbit we topped the displacement 19 with respect to that trajectory in the transverse dynamics in longitudinal dynamics we will talk about how much energy is deviated from the synchronous one and how much phase is deviated from the synchronous phase so e and phi makes the coordinate plane forest in the longitudinal dynamics so now we have x x prime y y prime these are the coordinates in the transverse plane and in longitudinal plane delta e delta e means energy deviation from the synchronous particle and delta phi that is the how much phase is deviated from the synchronous particle these six coordinates make the complete state of the particle now how the synchrotron operates synchrotron operates on the basis that its orbit remains constant in cyclotron as the energy was increasing orbit radius was increasing and particle was making an spiral path like this there were d when particle crosses the d it gets energy and it's make a circular path here and here again it crosses the d so this hit this time it will make a larger path because magnetic field which we are applying for guiding the particle is constant so in this fashion a spiral path is there in the cyclotron the major problem with cyclotron was that if you want to increase the energy first thing was that due to increasing gamma synchronism may break and other thing is that the size of the magnet becomes larger and larger and making such large magnets is a really difficult job so how we can reduce the size or aperture of these magnets instead of increasing the radius continuously take some action so that radius remains constant means particle always revolve on the same orbit so only this path has to be covered by the magnetic field so this was major principle on which synchrotron works and that's the way in which it reduces the requirement of the aperture of the magnets than the cyclotron so in this case as the energy if you want to increase the energy you want to increase the energy we increase the magnetic field also to keep the radius constant so suppose p is the correct momentum means momentum of the synchronous particle then radius of curvature of this particle will be given by this relation p is equal to q p is the applied magnetic field now as due to rf cavity electric field impart some energy to the particle means it has changed the momentum of the particle so we have certain dp by dt and if we have dp by dt then it will be q r dp by dt means we have to change the magnetic field also to keep the r constant means we have to ramp the magnetic field with energy now how much change in momentum will be there in one term so now this relation you can see dp by dt is equal to q r dp by dt so this is dp by dt so in one term delta p for the one term will be dp by dt into t revolution so this will be q r b dot t revolution dot dot means b by dt whenever in this course i am using the dot it means this is d by dt and if i am using the prime it means it is d by ds so dp by dt has been written here as b dot so q r b dot t revolution not t revolution can be written down as l by v and because we are talking about some kind of closer path may not be exactly circular so we can take it as a 2 to 2 pi and some average radius r upon v so at the place of t we have written this 2 pi some r mean r average upon v we can multiply v here so we get v delta p one term is equal to 2 pi r this r is the bending radius and this r is the average radius of the orbit into d by dt here you can see that v delta p is basically the energy k delta p you can prove very easily that v delta p is delta p you can take the relation e square is equal to c square e square plus m square c so if you take the change in energy means you can take 2 e d e is equal to c square 2p d these are constants so differentiation will be 0 and this 2 will be cancelled out this so you can calculate d e is equal to c square p upon e dp now p itself is beta e by c p itself is beta e by c so by this you will get d e is equal to v dp which is written here so this is the energy now this energy gain is due to rf cavity means this energy gain v dp is q v sine phi so these two values must be equal so that we will get the correct value of dv by dt for the keeping r constant so this gives you what should be the synchronous phase corresponding to dv by dt in a synchrotome so that particle will remain on the constant on it this is valid for this synchronous particle means this phase is synchronous phase now one beautiful thing is here that you can see that if dv by dt is 0 synchronous phase becomes 0 synchronous phase becomes 0 means here it is the time and this is the voltage and the cavity so synchronous phase is 0 means particle is here or here means it is not catching any energy from the field means particle is revolving on the constant energy this mode of operation of a synchrotome is known as a storage mode means being revolves in synchrotome at constant energy if we don't raise the field of the magnets as we raise the field of the magnet b synchronous phase 5 changes and particle reaches the synchronous phase here say and it gets energy so this mode of operation in which we ramp the magnetic field or change the magnetic field where the energy increases we say this is the boosting mode of the synchrotome so if you will see if you will hear synchrotome or booster synchrotome it means these are the synchrotome where the energy is ranked energy is increased and if you hear the names storage ring accumulator ring etc then these are the synchrotones need for the constant energy means beam is revolving in these synchrotones at constant energy so there are two modes of operation for this kind of machine any machine can be operated in both the modes if we have such kind of design means single accelerator can be operated in the booster mode as well as in storage or it can be dedicated storage ring means no boosting is possible so such kind of designs are possible