Good afternoon. On behalf of the McLean Center for Clinical and Medical Ethics and the Center for Health and Social Sciences, Dr. David Meltzer and I welcome you to the sixth talk in our 2018-19 lecture series on improving value in the US health care system. It's my pleasure now to introduce our speaker for today, Dr. John Wasson. Dr. Wasson is an emeritus distinguished professor of medicine, community and family medicine at Dartmouth and formerly had been the Herman West Professor of Geriatrics at Dartmouth Skyzell School of Medicine. At Dartmouth, Dr. Wasson has led a number of outstanding programs, including outpatient services at the Veterans Administration, the Center for Aging, and the Dartmouth Northern New England Primary Care Research Network. He also has been national co-director of the Institute for Health Care Improvement in their Idealized Office Practice program. One of Dr. Wasson's most famous papers I show it behind me and most influential was published in JAMA in 1984. The paper, as you see, is entitled Continuity of Outpatient Medical Care in Elderly Men, a Randomized Trial. So far as I know, this paper is the first and still the only randomized trial that assesses the importance and value and outcomes of doctor-patient relationships. It's quite an extraordinary paper looking in a randomized way at over 700 patients. Dr. Wasson's current area of focus is in personal information and communication technologies. He's particularly interested in the development and testing of howesyourhealth.org, which is a family of health IT tools aimed at improving communication and health care quality by patients, doctors, and communities. Another one of his howesyourhealth.org web tools are now used nationwide to improve communication and health care quality. In 2006, Dr. Wasson received an award from the Agency for Health Care Quality and Research as a pioneer for practice-based research. Additionally, since 2014, Dr. Wasson has been working with many groups and organizations to increase personal and professional health confidence so that everyone can say, quote, I am very confident that I can manage and control most of my health problems and concerns. As you see, Dr. Wasson's talk today has the somewhat unusual title of organized crime and disorganized health care discuss. I'm looking forward to the commentary and discussion. Dr. Wasson. Thank you very much. While I'm turning on the mic here. Continuity of care. I'll just digress for a moment on this. Is a fascinatingly powerful activity in clinical practice. And so many of the interventions that we think have had positive impacts in care actually under the surface depend on continuity. We often falsely in a false positive way say, well, if you train nurse practitioners to do X, or if you do something else to do Y, look at the great results you get. For example, think of one of the earliest studies, management of heart failure. And everyone got all hung up on the methodology. But in reality, the study really was just a reputation of continuity. Because one arm got usual care. And the other arm got people to contact the patients. A form of continuity. So I just bring that up as shall we say an important point to keep in mind when people start fighting and arguing about these methods that improve care. Look under the surface. If they haven't really controlled continuity for continuity, it's more than likely the major cause of the outcome that's positive. So today's talk is not a typical headline that you're probably used to. But I'm hoping that you'll see a method to my madness by the end of this exercise. And in particular, that you'll see it's both ethical, considering the McLean Center, and practical implications for your practices, and your patients, and the population at large. So let me start in the turbulent year of 1971. This is the year I graduated from medical school. Pentagon Papers were published 500,000 people marched on Washington. And you probably don't know this, but it's the year of the longest longshoremen strike in the United States. And it was the same year that Joe Colombo was giving a talk because he felt Italians were being misrepresentatives of mafia. And he took a couple bullets in the head. By the way, in 1971, it had been several years since I'd stopped working for the mafia. So why do I have here a picture of break and bolt shipping and container ships? The answer is, since World War II, it became obvious that container shipping was a better way to go. More efficient, cost effective, et cetera. And yet, break and bolt shipping was still fighting that type of modernization and mechanization. This is an old story. Weavers Guilds fought factories for clothing. It's an old story. Sears tried to fight Amazon. The taxis in Chicago have tried to fight Uber. The point I'm trying to make is that pressure like this happens.  And hopefully, you'll find it useful, at least for the purposes of this discussion. I'm going to call it anarchic intelligence. Anarchic intelligence implies and is based on the principles that intelligent devices and processes can reliably support and sometimes replace human effort. In addition to that, the devices and the processes need not be machine-based. But most importantly, to be anarchic, they are intentionally designed to be anti-status and usually disruptive. I wanted to put this term up because we all think of AI as something that is particularly destined to change the world. It isn't. It's a term that's been around since the 50s. And although anarchic intelligence can include AI, AI often is not anarchic. And in fact, I'll give an example in a few minutes to show how we often use AI to maintain the status quo or enhance our own incomes, et cetera, rather than try and undermine them in a positive way. So back to Joe Colombo with a couple of bullets in his head. This guy in the picture is connected to Joe because he got all his guys, his long shorman, to go to Joe's rally. And that increased this guy's prestige. And he was all about prestige. Just read about him. Lecturer at Harvard, considered for US Secretary of Labor, leader of the International Long Shormons Association, and of course, a guy with many high-pice political friends. And by the way, he was a Gambino guy. And I knew Joe. OK, so on to the next. So why am I juxtaposing these rather odd topics? Let's just look at the points I'm going to cover today. From Joe's point of view, on the left, here are the three points that always matter from an organized crime point of view. Successful parasites don't harm the host. Oh, by the way, it's Tony. Joe was the guy who took the bullet. Protect the brand. Use barriers to entry, some of which might be forceful. Adapt quickly and avoid anarchy, if at all possible, so that you keep the peace and stay out of the news. On the other hand, US health care must also try to serve the host, preferably through science. It also needs to protect its brand, preferably through value. And it should adapt quickly. And I'm going to show some examples of anarchic intelligence where it could adapt quickly. But currently, I don't know if we're adapting in the ways that we should. How are we treating our host? Not very well. Currently, we're extracting nearly 20% of the GDP from the population at large. Experts say 30% of that extraction is waste. We've created analyst market inefficiency, so that compared to comparable countries, we have twice the cost for procedures, drugs, administrative services, and physician payment. Medical education in this country is longer and much more expensive. And there are huge variations, in spite of our claim to be looking out for quality. And outsiders who look at us say, my god, they're just huge quality tasters. This picture illustrates how our parasitism has gotten totally out of hand. Yellow clearly indicates that if you ask yourself, as we moved in the 1980s to becoming corporate medicine using more and more administrators to make our small cottage industries, as it was called then, more efficient, what do we really have to show for those extraordinary expenditures in yellow? By the way, notice this timeline starts is nine years out of date. Things are much worse now. Speaking of worse, here's an interesting little analysis I did recently. I looked at the New York Times and Wall Street journals for health care corruption. And in the early period, you can see what it was like pre-conglomeration and corporatization. And you can see how it's gone up five to six fold since the 1980s. Most importantly, we're getting, although we may not becoming more efficient at adding value to our health care system, we're certainly being much better at extorting a fair amount of money. Notice how the median now of the stories is 30 fold greater than it was then. This is what the population is seeing every day. And this is not enhancing, as Joe would say, I mean, as Tony would say, our reputation. And speaking of reputation, I don't want to hurt the feelings of any lawyers, business guys, or insurers who might be in the audience. But doctors and nurses are hanging around with these folks as we become more and more conglomerate. And notice, where do we have to go on the reputation scale? Depends a lot on who we hang around with. We should be protecting ourselves. Now, any good corporate person would say, well, we have kind of a foul reputation building at this point in health care. Let's do something about it.  And Dartmouth has done that. Look at that. We are more powerful than medicine. Whoa, huh? Is that slightly hubris? But then again, you guys are at the forefront. OK, so let's put this in the world context. This is for 190 countries across the world. These are per capita expenditures on health care. As you all know, this is based in 2016. Currently, we're up to 11K per capita. It's gone up nicely in the last two years. You can see, as you all know, we're out costing every other country in the world in per capita health care costs. Our estimated waste alone is out costing a huge number of countries. Our administrative costs are above the median. Our estimated corruption is also above the median. And even office quality measurement, not counting hospital measurement, but the quality, the cost of measuring all that stuff, all those 500 measures and caps and this, that, and the other thing, are costing more than a lot of countries. You can see the higher ranked countries on the right. I just put positionally, Mexico and UK. And Cuba is an example below the median. So I don't know how that happened. Let me get there. OK, so sadly, this is not new news. I don't think to anyone in the audience. And I don't want everyone to get depressed at this point. But many here in the audience and elsewhere in the world have tried very much to move the gas-guzzling jalopy we call health care over the hill toward a more promised land. Unfortunately, the mountain of waste, corruption, cost, and market inefficiencies has made it really, really difficult to do. So the question is, for those of us in the audience today, what can we do? And I'm going to put forward the idea of some anarchic intelligence approaches that you can leave here today and use in your situations. But before I go on, are there any questions at this point? Any clarifications on sort of the bad news before we move on? Any? Nothing? All right. So I'm going to move to an example of anarchic intelligence that I would call a win-win. This is one that really I feel we should be testing. And in fact, I'll point out that a Medicare review committee feels we should be testing this too. So for any of you who want to start a study, this is the way to go, I think. So it works on chronic condition management. Now just to put chronic condition management in context, of the $10,000 per capita we spend each year in health care, it is estimated that about 75% of that money goes into chronic care management. So a huge percent. And any improvements we can make there puts a lot of money in play, right? 7,500 to 10% improvement is a big amount of money. So you're not saying that we spend 75% of health care trying to think about management of chronic conditions as a discrete result of treating catastrophic health But you're saying 75% of health care strategies is in people who have chronic conditions? Yes. Yeah. Sorry. Can everyone hear that? 75% is in people with the chronic condition, of which a fair amount has to be managed. Now our current method for managing this is what I'd call the top-down model. It starts during medical school where we get a whole bunch of cognitive stuff, a little technology, some supervision out in the practices. And out of all this stuff, we're supposed to figure out and apply well without a lot of variation among us management of patients with chronic conditions. And the way we can do that is through perhaps something like a model that says, oh, well, this would be the best practice if you took all this stuff that's floating around in your head and apply it through, for example, the chronic care model, a miracle will happen. And below that is indeed the chronic care model. So in summary, if you take our smarts and put it through the chronic care model as one example, in the real world, we would expect that costs would be reduced. In other words, in the jargon of today, there would be a bend in the cost curve. And most importantly, the patient outcomes would be improved. There'd be greater value. Unfortunately, the evidence isn't very strong that this has worked at all. And the question is, the comment I would make is that these results shouldn't be surprising if you just think about the fact that at the top, we really have a model. We have people with many different views on how to apply things, putting their inputs in. We have high variation, in other words, at the top, and deliver it in many different ways. So the top-down model, in essence, is a top-down model that results in some real mush at the outcome set. Now, although we can't prove easily that any of this stuff is working well, what we can see quite easily are the unintended consequences. It has inherent variation at the inputs. It's grafted onto a wasteful, increasingly corrupt and very costly health care. It's, in essence, a Band-Aid on our usual care. It stimulates large-scale top-down reimbursement schemes. Instead of front-line innovation, you hear it all the time, oh, if we change insurance this way or if the employers do that, something great's going to happen. We get these top-down dictates. It catalyzes quantifrenia and the measurement industry. It undermines smaller primary care practices that have been generally very cost-effective, and it fosters more corporatization and conglomeration and additional categories of workers as we keep adding Band-Aids to a broken system. We have so many different types of workers now, all of whom are just adding to the bottom line. This likes to jump. Whoa. Worst of all, I think, is in addition to the adverse impacts of all of this on society at large in the budget, the real victims, the ultimate victims, are at the front line. They're the clinicians, many of you here in the audience, and your patients. We often hear, and I hate this term, that we are burning out. Burnout sounds like we lack resourcefulness. We can't figure things out. We're burning out because it just, I can't find it. That's not an issue. I think we're pretty resourceful. The problem is we're experiencing what some have called moral injury, just like World War I, when it was first described, and I'll just quote it, from continuously being unable to provide high quality care and healing in the context of our healthcare mess. You get up in the morning and you just don't feel you can do the right job, and the number of doctors I sit next to and regale me with this type of story is depressingly increasing each year. However, the good news is, compared to the Longshoremen in 1971, we have two advantages, I think. Advantage number one, we still have some public trust, and number two, we have a science ability behind us that we should use more and more, rather than less and less. To use the good old jargon of the mafia, we should use our science instead of being stooges for powers like Tony, who manipulate us into doing things, and we just sit back and say, oh, poor me. So, back to the issue of the top-down model. Failure can be a useful stimulus for improvement, as we all know. Given the difficulty of top-down model model of chronic condition management, all of us who helped create the chronic care model, and I hold myself partially at fault, knew that the best evidence we had converged at one easy to understand, one easy to understand point.  That is, when you're all on the same page working together by golly, you can do good things. Unfortunately, at the time, we called that a productive interaction, which was jargon that not particularly useful. Later on, it became engagement, which is also not particularly useful because neither one of those terms we can measure. A sensible, measurable solution came up from the term health confidence. And here we see across many nations, what happens when you compare patients' ratings of health confidence with their ranking of their engagement by their clinicians, engagement being defined by getting good education, people listening to them, good explanations, et cetera. And what you see is a strong, strong correlation. The point being that health confidence is a useful proxy for engagement and productive interaction. And this represents a form of anarchic intelligence, if you think about it, because it can turn the entire chronic care model on its head. Instead of directing a top-down approach by asking patients how confident are you, we can begin to drive changes in health care from the front line up. And that's rather different than the way we're doing business right now. Whether we customarily articulate the term or not, it applies across almost all of us. Whether we are the five to 10%, the five to 10% who manage a health problem every day, the larger group in green who must manage their illness less than every day, perhaps, but chronically, and even all of us who have risks to our own health, bad habits, et cetera, is a pretty easy to apply term. How about health confidence here in Chicago? How's it going? Well, here you see in red, the non-poor, and here the blue, the poor. And based on the number of conditions, you can see how health confidence drops rather dramatically. In other words, there's a lot of room for improvement. But health confidence is not just bad for your health. It's also bad for the bottom line. And here we see patients use our patients reporting that their emergency or hospital admission was possibly avoidable. On the left-hand side are those who are not very confident versus those on the right who are very confident. This translates into a lot of moolah. Okay, so let me stop here for a minute. Is there anything I've said to this point? I've built the story of health confidence as a form of anarchic intelligence because it moves potentially from the patient up. Instead of us having all these check boxes saying, does your system provide, you know, an electronic medical record and all these process measures that are supposed to trickle down to benefit the patients. So imagine your system now asking this of everyone and responding to it. Any questions, comments? Yes. To me, the confidence is gonna be based on perception which can be based on, not necessarily based on any sort of reality. And so, stop in the notion of confidence. I mean, they often do that with medical education. And I'm often most worried about doctors with the most confidence because they often don't know what they don't know. And I think the same, Chris, is the whole implications of that. Yeah, how many agree with that? You agree? That's a common statement. If you think about it, I'll give you 100 diabetics, all right? And you ask 100 of them and you say, how confident are you, you can manage and control your diabetes? Half of them say they are and the other half say they are. Which group's gonna do better? There you go. Are there gonna be some false positives? Yeah. Are there gonna be some false negatives? Yeah. You gotta go where you can go. Okay, that's the argument for this. That's been shown again and again in large small numbers, et cetera. And a lot of it depends also, and we had this, is Joyce around some, yeah, Joyce and I had this talk because she's doing this. Joyce, do you wanna comment on that? Discharge process and trying to figure out the best way to do that. But it's been really interesting to try and identify barriers to people's health confidence and what issues we need to address with the discharge. And some of them, she felt misled her. And again, that can be a function of how you ask, hey, are you health confident? You know, I mean, there's a lot of that goes on and framing, et cetera, et cetera as well. But on balance, just think of a hundred diabetics and whoa, I think it'll answer your question. I'm gonna get into that a little more in terms of false positives and false negatives. Yes. I think they're gonna get this. This is useful. I mean, particularly, presumably the reason this is important is, it's one of two stories. I mean, it's important to know that these people are for some reason, but probably more importantly, you're gonna try to promote their health in some way. Exactly. And when you try to promote something, that's not always the same thing as having that thing arise spontaneously. It can arise for different reasons, right? And so, the concern that Dan mentioned, you know, of sort of false confidence, you can imagine that an intervention would increase false confidence and yet confidence itself could be very positive. So it's really gonna come down in the end to interventions that presumably increase confidence but ultimately matter as they change outcomes. I assume you were gonna tell us that. So we'll keep moving along, but thank you for the comments. And obviously, I wanna try and get done before one and the clinicians have to run out so I can get more questions. Okay, so we observed this. We had some of the misgivings others have mentioned. But nevertheless, we began designing and testing, building on health confidence and asking, what are the common issues that impact health confidence or as stand-alones we would want to know in either case, in any case. These five items combined into a form of anarchic intelligence, we ended up calling the what matters index. Each one is efficient, easy, totally actionable and most importantly, they correlate when summed very, very strongly with a patient's quality of life. And I wanna just set the stage with that. You could ask a patient, hey, how's your quality of life on a scale of one to five? And they can come up with a number and you can sit there and say, oh, I see you're not having a high quality of life. And then you gotta figure out, what does that mean? What am I gonna do about it? Whereas these five items, in essence, equal quality of life. The worse, the more of those, the worse the quality of life. And each one of these is immediately interpretable and actionable. And that becomes pretty powerful. We've done a number of controlled trials and basically the point is, you can take your score, you can immediately respond based on a few questions at the beginning, health confidence or the WMI, you can immediately give helpful information and then you can use it to stratify patients based on their response to, for example, a follow up question. Here we see thousands of responses to patients who felt they were not health confident in terms of what it would take for them to become more health confidence. So the standard thing, gee, Mrs. Jones, I notice that you're not health confident. What would it take for you to improve your health confidence? And they'll bring up issues. For example, notice the more other issues they have, the more they want the professionals to respond in certain ways. And each one of these are verbatim responses. So the patients telling you, I really think I need more info about diabetes, for example. Or personal changes, I really ought to quit throwing out my pills and not taking them. Or in some cases, social support they need in the community. This is just, I lumped them down. But on our How's Your Health website, this is done automatically and the report is immediately given to the doctor in verbatim terms. The basic approach is you identify someone who doesn't have health confidence and you say what would it take to make it better. How can people say I have to hate them? Sometimes they do. But it turned out you can see it's up to about 80%. Again, you gotta start somewhere. Okay, now, I haven't gotten the real attack that should be coming right now because you as a medical center and every other medical center in the country doesn't buy into starting with the patient and building up. You start with predictive analytics that tell you X number of patients are high cost. And you need to concentrate on this group who are high cost to save money. And you're going to give them high touch and the others you're gonna do something different. Now, you're gonna stratify on cost risk.   And they're gonna, depending on the clinician, the day, whatever, they're gonna ask some questions. But each clinician will ask different questions. They'll come up maybe with some sort of solution. And then they're gonna try and engage the patient and say, hey, would you like to get on our new program called whatever it is that we have for patients like you who have multiple needs? And this is pretty cool, right? You're focusing your resources on a very few who are gonna cost your money. The only trouble is it hasn't worked very well at all. And I can overload you with the increasing number of controlled trials and other studies that show this, but in reality, it shouldn't be surprising. It's because first and foremost, the predictive models give nice likelihood ratios or nice odds ratios. They sound really cool. Now, three to one, four to one, odds of patients in this group will cost more. But when you translated into true positives and false positives, which you should with any diagnostic test, you find that noise and signal are way out of step, way out of step. So here, for example, I took a proprietary, what I call instead of a predictive model because that sounds so predictive when it isn't. I call it a computerized risk model or CRM. Here we took, for interest's sake, and be able to show you on the slide, a proprietary predictive model or computerized model and came up with 25% who were at the high risk group. And you can see they were more likely to be hospitalized than the other patients in the low risk group. This is based on about 10,000 Medicaid patients. We also totaled up in those patients their what matters index, those five questions. And if you look at three or more as an example, 31% of them would be hospitalized. It turns out, you don't need to buy the computerized model, which everyone's buying, just ask the patients. And most importantly, what you see here in the red boxes are the following. Yes, in the high risk patients, you've also got a lot of patients who have problems that are predictive of future utilization. But you've got an even larger group you chose not to deal with who are gonna use a hospital and emergency room. You're in essence rationing care from a larger group of patients who deserve your attention. From a McLean center point of view, that's unethical. That's unethical. If you have such a lousy diagnostic test that it puts more false negatives out than true positives, you better ask yourself, what test am I using and why am I paying Hopkins, for example, for huge amounts of predictive analytics that are not predictive? So, in summary, if you wanted to look at this as a form of artificial, anarchic intelligence, the brief WMI deserves an anarchic intelligence seal of approval by Golly. Because it's quality of life focus, it helps clinicians by being specific instead of just giving you some sort of categorization that you gotta figure out your 10 minute visit. It immediately serves the patient's needs because they're explicitly put out, gee, Mrs. Jones, I see you think your medicines are making you sick. Huh, maybe we might wanna talk about that. It can be used to stratify just as well or as badly as current computerized resist models and it doesn't cost you a squat. Okay, and finally, I might just add that two months ago, this organization, the Physician Focus Payment Model Technical Advisory Committee that serves Medicare, suggested to the Secretary of Health and Human Services that everything I've told you should be tested. So, there is some high level visibility going in this way. Why? Because all those other things I laid out earlier aren't worked, so Medicare is concerned. I hope some of you here, and I asked Joyce, get on it. Get on the call CMMI and get some money coming into you here. I just wanna share, you were there on Thursday. We were there on Friday. That's right. And we both got recommended, but I'm assuming nothing's happened with yours on it. It's very unlikely anything will happen. I don't know, it's two months, right? Yeah, I think you probably got the same email as last week from the air, right? No, oh yes, the AMA. Yeah, yeah, I was asking if you had anything to do with it. Yeah, yeah. The AMA is covering its own, yeah. All right, so what does all this mean for education?  That's wonderful. How are we adapting to all of this? Well, I would say the current educational system, which is, you know, has some cognitive stuff, some technology stuff and tech-nay or craft stuff, does its thing, it dumps it all in our heads. We take the boards at the end of the second year and forget it. Or we could start asking ourselves, should we build a healthcare system based on what matters to patients very simply, tailor information built on that, build our workforce about it, add more behavioral stuff and motivational and all the other tools we need and keep testing and testing and testing. That's an implication. There's a lot of jobs potentially lost in medical schools if this were adopted. Speaking of loss in medical school, let's talk about that. So I'm in the next few minutes. Let's see if I'm giving enough time for the clinicians. Yeah, I'll be done before the clinicians have to run. So I'm gonna use dermatology as an example. Here you see AI, anarchic intelligence, unmasking educational and service issues. In this case, it's dermatology. Now other countries have said for public health reasons, we wanna start using a device that can read worrisome cancer, worrisome skin lesions as well as dermatologists. You've probably read this in a number of these devices. But the important thing here in the Netherlands is they're looking at it as public health. It doesn't have to go through a clinical setting. Let's get out there so we find people before because there are access issues. Now and in particular, if you go even deeper, ask yourself, what are we doing in dermatology, anyhow, from a medical education point of view. And the craziest example and anachronistic example is a Mohs surgeon. A Mohs surgeon, as you know, as I know personally, chops out little skin lesions, looks at them under the microscope, makes sure he or she got it all and that's it. How much anatomy, physiology, pharmacology, et cetera do you need? Years ago, I was involved in training medics. These were people who were high school educated. We gave them 18 months of training and then in one or two years, they were in the field precepting. One or two of ours went into dermatology and were so good that they in essence trained most of the dermatologic residents who went through Dartmouth. Compare the educational requirement and cause to society of sending a Mohs surgeon out with a scalpel and a microscope versus sending Tom at 1.3 years. You can begin to multiply this by many others. I don't have the reference here, but the same thing has been asked as we see more and more of these technologies coming along for radiology. We've seen it also for pathology. It's gonna keep nibbling and it's gonna raise a deeper question about what are we doing in medical education? Why are we spending so much time for an output that adds very little marginal value compared to a medics? Now, one other example of anarchic intelligence is a study we did actually following up on the continuity study where we substituted phone calls for seeing patients in face-to-face visits in the office. Same clinicians, same nurse practitioners, same PAs. We randomly assigned the patients both ways and we found indeed that seeing patients was actually more expensive and no better than having patients followed up by phone. And these were all chronic disease patients. If you think back on the period of that study, which is 1992, the technologies we had available were laughably archaic compared to what we have now. And in red, difficult to see, I see, is the winner of the Qualcomm XPRIZE that is now coming to market. It's capable, and I emphasize this, of diagnosing a set of 13 medical conditions independent of healthcare professional or facility. This is kind of scary stuff as you begin to think about it because we have, as I showed, an office visit for phone call mismatch and you're beginning to see, for example, across states, they're now making it much easier to offer telephone care by non-physicians and non-nurses for that matter. You can see the growth in telephone use here at Kaiser Permanente and you can see a reaction, for example, by David Pugash, I think is how you pronounce his name. You really could see an elimination of physician element from the practice environment and his hypothesis is that would be to the detriment of patients. Well, I'm not sure it's always gonna be to the detriment but in some situations there may be some trade-offs. I don't know, but given what I told you in the beginning of the story, we haven't been earning a lot of trust lately. Speaking of trust, let's go back to anarchic intelligence in general. Five years ago or so, a medallion in Chicago went for $500,000. That was routine. This summer, there was an auction. There were no takers, zero. Sears you all know about here in Chicago, they never had a chance to respond before Amazon ate their lunch and gave the coup de gras. How are we doing in healthcare? Are we also giving people exactly what they want and need, exactly when and how they want and need it? Well, here's an answer in Chicago. You can see among the poor, less than 20% feel they're getting exactly what they want and need, exactly when and how they want and need it. And for the non-poor, it's only about 40%. I didn't slide there. See, you told us earlier that we need to be careful and we need to hear the interventions that are the interventions that really have conflict. So, let me just push you on what matters. Is it what matters, is it any questions or is it a conversation involved? I think you already know the answer. The answer is, of course, it's the conversation that follows up, the interaction, the communication. So, I know this may not be the moment for this question, but is it what matters or is it having a, why that approach to a conversation versus the person who walks into your office who you don't know and they just look different with their tones, maybe the answer is, you don't know them, we've gone past them all. So, you better ask these questions, do you have no idea who's the person? Well, it gets back to an earlier point. Take 100 patients, seeing 100 clinicians, all saying, I'm not health confidence or whatever you want. How many are gonna get the same queries and the same actions? The answer is none, all right? It's just, you know, we're talking quality here. If you're talking quality, you're talking replicative. You know, you're gonna get, and by narrowing the questions to begin with, see, if you get a response like this from your patients saying, no, I'm not getting exactly what I want needed. You gotta do deeper digging, right? Yeah, why'd you say that?  I don't know, something like that, right? Whereas if you had the five questions, you've got more specificity. Let me build on all this. So, we all know their faults out there and it's the changes we fear. So if we get that jalopy at the forefront of healthcare up over the hill, we don't really know, do we? What's gonna happen on the other side? What's gonna happen to jobs and education? What about all those measuring folks who are out there measuring everything quantifrenically? What about all the sunk costs we've got in the way we do business? This is pretty scary stuff. I would argue though, let's not undervalue science. Let's ask ourselves, do we really wanna stick with a status quo that's expensive and not working or should we begin to ask ourselves the more fundamental questions I'm trying to throw in front of you today. I realize it's a bit of a fire hole as talk, but when in doubt, go back to the Godfather to ask. So after 1971, I learned that the boss was still alive. This is probably a decade later. So I went up to him and it was like a scene from the Godfather, I kid you not. I might add, both his legs had been broken. I don't know why, but in any case, the boss met me, came up, gave a hug. John, how you doing? Great, we caught up, talked about things. And then when he got to Tony, he really got animated. And the conversation went something like this. And Tony, he always said, keep a reputation and don't badly damage the host, right? Smart guy.  Doctors especially should think about Tony, guilty on all counts, up for 20 years. He didn't do much stuff. He only had tax evasion, extortion and bribery.  And with a little help from his friends, he walked in 39 months. So the question for all of us here is, are we gonna be like Tony and depend on our friends to get us out of trouble? Or are we gonna take our own initiative to begin really anarchically challenge what we're about? So let me be specific about next steps that are positive. I think, again, we should start embracing anarchic intelligence thinking. It's out there. Every one of us is capable of that type of thinking. What if, what if, but we're so bludgeoned, right? We're being stooges. We're bludgeoned by the system, I just, the conversation we had last night at dinner. There were some stooge-like comments, no offense, but you guys have been bludgeoned. We've all been bludgeoned. But the question is, can you fight it with science? And you're all capable in this audience. So when it comes to this, this is the Joyce heroin slide. She's already jumped to saying, I don't know, this guy Watson may be a nutcase, right? But there's something appealing there. I'm gonna play with it. And that's cool. That's cool, because the next day she could go on to a controlled trial or all of you and you can begin to see, is this hogwash or real? I think we have kind of an idea that it's better to build from patience up. Somehow that sounds more Hippocratic than Hippocratic, which is what we're doing right now from the top down. Next, protects the brand. I really think we ought to be snitches to use a good old mafia term. And we ought to lose the scandals. Be a snitch. Look at these headlines. They're nauseating and they're just this year. This one just blows my mind, right? And the whole idea of thinking about the fact, just try to envision, nobody knew about this guy being on 15 different boards. Come on. Or this guy, how can you as a dermatologist run up 26 million? I mean, just think of that number. Somebody's gotta start snitching. So I hope there's some snitches I'm getting going here in the audience. And these are good websites for future snitches. And then finally, I had a very off-record, we can talk about it, interesting, horrible situation. That's the whole, you're perfect for, I think you're setting me up for good responses because that's the whole thing. We're all so used to these flaws and we all benefit to some degree by the craziness of healthcare, either our salaries, our jobs, et cetera. We have real trouble seeing the faults. And yet the people out there are seeing these faults more and more. And if we don't do anything, we're guilty. That's the point. And we're not gonna have friends like Tony who are gonna be able to say, hey, you can walk after 39 months. So I think it's worrisome. My big one is this $3 billion one. You can do this tomorrow. You can go up to the head of this hospital and say, how much are you spending for PR to come up with at the forefront? Come on. We're waiting on the forefront. Oh, I know, and Dartmouth's better than you because we're better than medicine. Yeah. So I would argue that if tomorrow we took $3 billion, we could pay the tuition of every medical student in the United States and 20,000 PAs or NPs. We could cover everything. And then they wouldn't have to go out into practice into super specialties to bring in huge amounts of money, perhaps unnecessarily.  They wouldn't be so pressured. And the hospital, meanwhile, can say, our motto is helping you and our community be health confident. And they could tomorrow, you could see in the Chicago Tribune headlock, this year, University of Chicago patients, 87% are health confident compared to the national average of only filling the blank, 12%. So in summary, I've taken you through a rather crazy romp. I'm right where I wanted to be. Here are the summary points. I think clearly the McLean Fellows should look at this from the ethical components of what I've talked about. There's a huge amount of unethical stuff going on out there. And we can talk about it or maybe we should do something. Here's some ideas for doing it. And as the boss would say, if you don't, things happen. Thanks very much. So if one person expressing confidence is an educated PhD with an IQ of 130 and they're 50 years old and they're not demented and whatever. And somebody else expressing confidence has an IQ of 80 and not a high school education and maybe dementia is thrown into boot. What does confidence mean coming from the vast array of the distribution of the population that's capable of expressing it? Well, first of all, I think you threw in dementia as one of the characteristics of someone with an IQ of 80. Did you say that? Dementia is not a characteristic of somebody with an IQ of 80. Dementia is not a characteristic of someone with an IQ of 80. Yeah, the whole. I just created two opposites factor of n's and say, each of those says they're confident or they're not confident or whatever. What does it mean? Well, what it means is whatever it means to the patient and it's a follow up point that I think we pointed out that would be the key thing. So if both of them said they're fully confident, I'm gonna take them at face value at least at that point. But if they say they're not confident, then I'm gonna ask, why is it that you've responded that you're not confident? And the one with an IQ of whatever could very well say, because I'm caregiving for my wife and it's just killing me, right? And the guy who is high school educated or something like that could say, I don't have any money. And some of that we can deal with as I showed you on those bars, some of them are very socially oriented, but a lot of them, 60% or so for the people who are like the ones you care for who have multiple issues are gonna say, doc, here's an issue I have and it may be I can't use a hemoglobin A1C thing or it may be much deeper.  Does that answer the question sort of?  If we're going to assess how well we're doing by the degree of confidence that patients express, I'm not confident yet anyway that the degree of confidence that the patient expresses necessarily tells me a whole lot about how we do it. I think I'd agree with that wholeheartedly. However, if I had the five questions and the patient says, for you, all five are negative, I'm doing great. And for him, all five are doing badly across comparable patients. Let's say you start, I'd be very concerned about that, right? So the more you don't wanna get, we chose five for obvious reasons. Human memory can't really go much beyond five, number one. And number two, I was gonna show to the group afterwards we're having a briefing that the ROC curves, the receiver operation characteristic curves, it shows when you go from one question like health confidence, that's not so hot, right? It's not gonna be perfect, true positive or false positive. You go to five, you're really getting there. You go to 20, marginal, right? I mean, it's a standard game. So that's behind the five. So I'd agree with you on one question, I'm not gonna say anything, but on five, if all your patients over time stay at fives and all the his go up to zeroes, I know where I'm gonna go. Yeah. Ask about where it's even going, ask about smoking, ask about everything. And when people look at it all the time required to do those and exceed the amount of time that it would take. So I'm assuming that when you think about either the health and confidence question or what matters in this question, you're primarily not imagining a clinician literally building this into everything that you would ask me. You're thinking there's a form that's filled that however somehow this gets hidden. I don't know the answer, I'm just guessing, but I wonder if you can talk about how you imagine this being most effectively used, particularly in a longitudinal relationship. Because there are alternatives, which is the 10 second pause after how are you doing? Are you actually just a person? I agree, but that gets us back to your previous comment, that how I pause and listen versus someone else. In answer to the question, how do we fit this stuff into practice? That's the other side of my head which has been for the last 30 years longer than Google. We've been putting on the internet free of charge things like howesyourhealth.org that's been picked up by the Academy of Family Practice, that's been picked up by the American College of Physicians that we had for Medicare, we're using it statewide. The answer is we can't ask all these questions, but before an office visit, a week or two ahead, patients of all educational levels do a darn good job. If they know, A, they're getting feedback and it does it automatically, and B, if they know, you're gonna take it seriously. So if an email goes out to a patient or something like that, in fact, they answer the questions, there's some score that comes back, it may be a high level or low level or whatever or change or something like that, and then that goes back to the clinician and so when you presented your office, you see that this has changed? Yeah, so bottom line with the technologies, it can be anything, but the way it works almost 99% of the time is clinicians who use something like How's Your Health say to the patients once every year or so, would you mind having a complete health checkup? The patients immediately get information tailored to their responses. They then can send their action form back to the clinician and the action form says to the clinician, pay attention to this, this, and this. It doesn't give these little color codes and everything, you gotta figure out, it's very verbatim, and in this case, if they say I'm not health confident, you get verbatim why they said they weren't health confident. So it saved you all that 10 seconds of silence. You can immediately say, wow, I didn't know you were not health confident and you think you need, eh, let's talk about it. So that's how it works. It's pretty, it's not rocket science, but it takes the work out of the practice. Yeah, I mean, one of those things we have in our clinics, for example, just literally a tree house nurse asking, you know, why are you coming in today? Yeah. You know, and sometimes that's not that useful, but often it is. Yeah, it can be, sure. That brings us back to Alvin Feinstein. He always used to call that the iotropic episode. Yes. Yeah, I think you've convinced me that in a big population that confidence is useful, but I think that, you know, his question and what Dave is pushing it also gets to the idea that for each patient, you really have to unravel what that confidence means and why they're not confident or why they are confident. And for some patients, it will mean that they're able to take care of things better and for some it won't and untangling that. But getting back to this whole notion of anarchic intelligence, I mean, it's based on the word anarchy, right? And so the idea of using the same term every time you see a patient seems to me to be sort of a step away from a real anarchistic way of approaching care in that it's not, it's another rule about how to, you know, what you should do at this moment instead of actually responding to the person in front of you. Yeah, I agree on the second point that the anarchic implied the current hierarchy of healthcare, anarchic against that. You're stretching it further and I'm not sure. It's sort of like productive interactions. It's one of those terms that you just say, oh God, but it's the best I could do for today. In terms of your prior point, all I can say is that you should go sign up tomorrow for How's Your Health and try it on your next 20 patients and see if you like it or not. It's been built on 33 decades of clinicians who are just as skeptical as you are and out in the real world salt mining and not happy. So, you know, it works well enough and the price is right. Well, thank you all very much for putting up with a rather odd presentation. Thank you. Thank you.


And mainly, I will show results from a dry model experiment that shows the two-way interactions between MGO and the North Hemisphere, because there is no tropical processes, no connections, and this one yesterday Christina mentioned, but today I'm going to show that in more detail. And after that, I will talk about the two-way interactions between MGO and NO, and we'll again focus on the NO impact on MGO. So I should mention that the extra tropical influence on MGO is less well understood compared to tropical influence on the exotropics. There's a lot of processes, mechanisms that are not well understood, so it's an ongoing topic. So for the examples of mid-latitude influence on the MGO, there is one started by Ray and Zhang in 2009. What they did, they used a tropical tunnel, a channel model, so only in the tropics. They look at two MGO events to see what is the initialization process of those two MGO processes, events. So what we found is that the only factor that is critical to the production of the MGO initiation is the time-varying and matter-boundary condition that is in the mid-latitude. So they specify the boundary condition from reanalysis, but when such a matter-boundary condition are replaced by time-independent conditions, for example, climatology, they kill the MGO, so there's no generation of MGO. So these results just indicate that the tropical influence can be a very efficient mechanism for the generation of MGO, so that is one of the example early study. And later, they look at the mechanisms, what is the processes, they look at the momentum transport and they found that the momentum transport from the mid-latitude has a big contribution to the MGO initialization. Another example is by Hong at all, that's a very recent paper, they look at the exotropical forcing for 2015 MGO and El Nino events, and they found the southward penetration of the northward wind that is from the mid-latitude propagated to the tropics that influence the generation of MGO and El Nino in this period. And then later, Nick Hall, he will talk about more examples and his study on the mid-latitude impact on the MGO. So now I will switch to talking a little bit more detail about the tropical, exotropical interactions in dry GCN. So the model we use is a primitive equation atmospheric GCN, not to was developed by Nick Hall, I'm glad he is here this time. I think he will describe in more detail this model tomorrow. And this model is T31 and the 10 levels model is quite low resolution but able to capture the large-scale phenomenon in the atmosphere. And the special in this model is it has a time independent forcing that is calculated empirically from the real analysis, long time day-to-day analysis. So this time independent forcing is to maintain in the model a winter climate college.  And also that's only the time mean but also the challenge, the variabilities. So because it's time independent forcing, no other variation in the forcing. So all the variabilities generated in this model come from the internal dynamics of the model itself. So what we see is mainly the, for example, the barricannitability, the methanatute, that will, it's main part of the variability in the model. There is no moisture and no interactive connection. So it's a dry model. So what we did, we run the model for 3600 days, it's because of the forcing, it comes from the winter condition. So the integration is a perpetual winter integration. So we don't use the first six days that is ignored as the spin up. So we use 3600 days to do the analysis. So what we would expect is that there won't be any variability or waves in the tropics because there's no like moisture or little connections. There's no, but what we found is quite interesting is like this. So this is a model result for the 10 degree south to 10 degree north average of 250 millibar velocity potential. So that represented the divergence field in the tropics. So this is the diagram, this is time from zero to 200 days. This is a longitude. So what you can see is that in this period, you see the eastward propagation of the disturbances for velocity potential. So the propagation is eastward. And this is another period from, OK, so that's working. It's OK, just if you have that. Thank you. So this is another period from day 2800. Again, you see this kind of eastward propagation. So this is the raw data, this unfiltered data. If you do a 20-day to 100-day band pass filtering, you plot this diagram again, you see this kind of nice eastward propagation of waves. One feature is that the wave is stronger in the eastern hemisphere. And also it propagates slower in the eastern hemisphere than in the western hemisphere. So those features, it looks very much like the MGO. So when we got these results, we are intrigued by these results. Why did this happen? So as I said, this kind of model, the only thing in the atmosphere in the model is the intero dynamics. That is those kind of waves generated is the only reason that's from the middle altitude. So the time interval, if you do the two of this, if you do the wave number frequency spectral analysis, you see that this is the velocity potential at 250 millibar in the model. You see this peak is wave number one. And the frequency is about 30 days. So it's a little bit too fast compared to MGO. So you will see later it's Kelvin wave generated in the tropics. Compared to the observation, the velocity potential at 200 millibar, this is slower. It's about 50 days. That is really MGO. So that's the main structure, the wave number one. And it's close to this MGO. So what we did, we did the UFO analysis, tried to capture this wave. And for velocity potential, this is a UF1, UF2. You see the monopostructure and the dipostructure. And the PC2 lead PC1 by about seven, eight days. So that means this happened about seven, eight days later. This pattern will appear. That represents the eastward propagation. So we designed a very simple index. It's the PC2 plus PC1, eight days later. So it's like a combined consideration of these two indices. So we produce metamattitude and a tropical combined diagrams to visualize this process. So I will go through this quickly to see how the tropics is connected to the metamattitude. So the colored area, that is the velocity potential at 250 millibar. And the contour, that is 250 millibar stream function. So the stream function that will represent a Rosberg wave in the metamattitude. So if you look at the color area, you see this with time, you see the eastward propagation. But now we go back. If you focus on this metamattitude wave trends, you see at the beginning, there is a wave train in the North Pacific. But you will see with time, you will see this energy propagate to the Atlantic and then come back to the tropics. See, this is time. So now increase in the Atlantic. So there is some indication for the NNO generation. And now here increase the wave activity here. And also at the same time, the tropical divergence field intensifies this area and then propagates eastward. So this kind of like a two-way interaction, it seems it's quite clear from this kind of simulation. So we calculated the wave activity flux for this along the field of stream function using the formula by Pacaya and then Nakamura. So what you can see is at day minus 8, you see the wave activity flux from the North Pacific, from tropics into the North Pacific to North America. And eight days later, you see the wave activity, a large part of flux toward the tropics. So those kinds of wave activity will influence the tropics to generate another cycle of the tropical waves. You also see that another branch of wave activity that's eastward probably that will influence the minimum altitude Eurasia component. All right, so this is a demonstration of the dry model. So what we found is the tropical intracellular ability to generate it in the dry model. Tropical interaction are crucial in generating this model of our tropical variability. And that indicates the exotropical influence on the tropical waves. So the remaining question after this study is the contribution from moisture and connection. So probably I talked with Nick before. We can do another experiment with including moisture to see how this model behave after we include another microprocessors. And for the mechanism is how do exotropical large-scale disturbances that are equivalent to barotropic propagating the tropics to generate the tropical waves, not to baroclinic. So this is an area that's not very well understood. Right now, we are doing some kind of theoretical work to understand how this interaction happens. There's two different kinds of waves that can be influenced to each other. All right, so now I will switch to another topic. It's not a topic. It's related. It's the NGO and the NNO interactions. It's based on earlier study and also David mentioned also. So we use the NNO index, that is a pentad average. So that's a 5-day-5-day average. And the NGO index is the Weir and Hinden index. So we also have the pentad to pentad average. And the purpose is to look at the intracellular variation of NGO and NNO, how they are correlated and connected. So we look at the winter period. So because the interactions under the wave activity, roughly the generation is strong in the winter season. All right, so this shows the eight phases of NGO, phase one to eight, and the equatorial region from 15,000 to 15,000 north. So what we can see is phase one, you see the anomalous precipitation generated in the western Indian Ocean, and that's perforated eastward. So I want to draw your attention to the phase two, phase three, and the six, and the seven. That is, when there is a connection dipole structure, the enhanced precipitation in the Indian Ocean and the reduced precipitation in the western Pacific. It is in those phases that will influence the middle attitude the most. The phase two, three, and the six, and seven, they are just opposite. So this is the, if you look at the debug heating, this is cooling, this is the heating. So what we did, we look at the lag composites of NL index for different phases of NGO, one to eight. And the lag, zero, that's a simultaneous composite. For example, this is the composite when NGO is in phase four. And the positive lag means NL lags the NGO. The negative lags means NL lead the NGO phase. So if you look at this part from zero to positive, what you can see is when NGO is in phase two, three, four, that I just showed, that's a dipole in the tropics, you see this after one, two, three pentas, you see the probability of positive NL. So those numbers, they are 95% statistically significant. Those white areas is not statistically significant. I didn't plot. So the positive, the red indicates the positive NL, the blue indicates the negative NL. So that means when NGO happened in two, three, four pentas, so two, three pentas later, you see positive NL. And when in six, seven, eight, you will see about two to four pentas later negative NL. So it's very statistically significant results. And other than that, if you look at when NL leads the NGO, you will see that when negative NL happens about three to five pentas later, you see the occurrence of NGO two and three. And when positive NL happens about three or five days five pentas later, you see the probability of NGO phase six and seven. So this is like a two-way interactions. The NL and NGO, not only there's lag, and also there's lead association. So this one David showed already, you see the phase three, you see the zero pentas, one pentas, two pentas later, you see the development of a positive NL. And phase seven, that's the opposite. You see the negative phase of NL. So I just take a little bit of time to show you why this pentad and those dipole structure affected the middle attitude is the strongest. So what we did, we used the ORR, a pentad ORR to do UF analysis, that is to find the NGO, that is another representation. It's very similar to a wider index. But now we use only the ORR, because ORR is more connected to the convection. So the first UF is like a convection in the maritime continents area. But the second UF is a dipole. It's a convection in the Indian Ocean and a depressed convection in the West Pacific. So we'll see that which one is more effective in forcing the NL. So we designed thermal forcing, and the first experiment is put a heating in the maritime continents. And the second experiment is put a heating in this region and a cooling in this region is a dipole. It's trying to mimic this second UF. So this is the results for the model integration average for 500-meter-bar height anomaly, 6 to 10 days later. This is 11 to 15 days after integration. You see experiment one, the response is very weak. Almost there is no response. But experiment two, you see the response is very strong. And you do see there is indication of positive NL. So to understand this, we did a lot of experiment to put this heating at different locations to see which one is the most sensitive location for this response. So again, we do a linear integration for winter-based state with a single center heating source put on the equator for this region, 60 degrees east to south, 150 west, a 10-degree interval. So we have 16 experiments. And we look at the response at day 10 to see the sensitivity to the location. So here is the example. You put the heating at eight east, so that means the Indian Ocean, tropical Indian Ocean. You see positive anomaly response in North Pacific. So this is similar to the negative NNO response. So the response is not very sensitive to the location of the heating in this region from 60 to 100 in that area. So that means like the question David raised in the last lecture is the heating is moving. How can you follow this kind of response? But it's not really sensitive to the location. So in this region, the response is very much like this pattern. When you put the heating at 110 degree, that's nearly a maritime continent. There is almost no response. It's very weak. But when you put the heating at east of this area, the response is very similar to this pattern. So it's not very sensitive. But if you compare this pattern with this pattern, you can see they are almost opposite. So the response, if you put the heating in this region and this region is opposite. But as you see for the MGOFIS-3 and the FIS-7, they are dipole. There is a heating and a cooling. So that means because this experiment is all heating there. But if you switch this to cooling, it's the same as this one. So that's why you add this two pattern together. You got a very strong response. So that's why the response to MGOFIS-3 and FIS-7 is the strongest. So that's why the dipole structure. Now also Andy showed Friedrich's study to look at different centers forecast with respect to MGOFIS-3. So the reason for this is that the heating location with respect to the middle altitude jet. This region is, for example, in the middle altitude, the East Asia jet, the core is just close to Japan and East Asia. So this region is to the west of the jet. And this region is to the east of the jet. So this kind of behavior is really relative location to the jet. All right. So again, we can calculate the wave activity flux to see the MGOFIS-3 simultaneous wave activity flux. You see the northward propagation of waves. And one pentat later, you see more to the north east. And two pentats later, you can see the wave activity flux is many in the Atlantic. And there is a strong branch to the south. So this kind of wave activity to the south that will impact the tropics probably will generate another cycle of the MGOFIS-3. So what we did is also to look at the MAC regulation to NNO to see how the NNO impact the tropics to see the zonal wind how to propagate southward. So this is when the NNO is at the strongest, that's the MAC-0. And one pentat later, you see this kind of amplification of the zonal wind in the sub-tropical Atlantic region. And two pentat later, you see stronger that there is negative anomaly of the zonal wind in the equatorial tropical Atlantic. And again, you see this kind of movement. So that's what the last diagram shows the lag propagation of the zonal wind. If you compare to the composites of the zonal wind for different MGOFIS, you can see that when the NNO happens about four, five pentat later, it's very similar to the phase seven and the phase six and seven. So that's why in the table, I just show you at the beginning, the MGO lags the NNO about four to five pentat. So this kind of southward penetration of the zonal wind. So schematically, it's the MGO propagates eastward, send the Rosberg wave to the North Atlantic. And probably there is interactions with transients in intensified NNO. And then there is an influence to the topics. So now I'll show you some examples how the interactions between MGO and NNO impact the substance in the prediction. So this is one experiment we did to look at the NNO forecast scale for weak MGO and the strong MGO comparison. So the red curve, that's for when the initial condition has a strong MGO, you forecast the NNO. And the blue is when the initial condition has a weak MGO. So what we can see is that there is clear separation. The strong MGO initial condition produce a better forecast scale of NNO. So this indicates the tropical influence. And also, you can separate this forecast by the phase of MGO because what we saw is that the dipole phases produce the strongest impact. So we category the forecast with MGO phase 8, 1, 4, 5. So that's not a dipole. Compared with forecast with initial condition it has a phase 2, 3, 6, 7. That has a dipole. So you see the NNO scale, it's better when you have a dipole intercondition. So it's very consistent with the analysis. So this just to show the scale of 500 meter bar height for Pentas 3 and 4. This is weak MGO and the strong MGO. You see the increase of scale in the North Atlantic region. And also for temperature, you see this is a weak MGO, strong MGO. You see the better scale in this region and the European area. And this is the difference. So strong MGO minus weak MGO. So this diagram from Friedrich Wittar he looked at the different models. This is another demonstration Andy showed the diagram this morning. This shows the green one shows when the MGO is in phase 3 after three Pentas, the NNO index. So this line is the real analysis. So that's the expected observation. So most of the model has a weaker response of NNO after MGO phase 3. On this side, it's the three Pentas later after phase 7. Again, you see most of the model is weaker response. But the Environment Canada model is very close to the observation. So again, we look at the S2S handcast data to compare the NNO scale for dipole and the lung dipole. This is the dashed line that's phase 2, 3, 6, 7. That's the dipole MGO initial condition. And the solid line, that's the lung dipole. So you see the difference. It's quite clear the MGO phase when there is a dipole, you get a better forecast. So now we can look at the other direction, the impact of the NNO on the MGO forecast scale. So we separate this forecast, look at the initial condition when there is a strong NNO. And here is the scale of MGO. So what you can see, this is our model forecast compared to the persistence. The MGO, there is a scale compared to persistence. But this one is the initial condition has a weak MGO compared to a strong MGO forecast. So the bar, so we have a lot of ensemble members. So there is some period where we'll separate it. You can see in the first 10 days, there is almost no difference. But after 10 days, you see strong NNO forecast, the scale of MGO is better than a weak NNO. So because you see the lag at this table, it's about 3 to 5 pentatons. So that means the impact is up here after 10 days. So this really indicates that the mid-natitude signal has an impact on the MGO forecast scale. So there is two-way interaction. So now we look at the scale distribution for 200 millibar zonal wind scale near the tropics for strong NNO. You see that this scale, there is quite a lot of scale in this band, the tropics. But when you initialize the forecast with weak NNO, the tropical zonal wind scale, there is a lot of places is not as good as this one. This is the difference. So this is the increase of scale if you have a strong NNO in the tropics. OK, this one is the average of scale between 0 and 90. So that's mainly just the south of the North Zatomantic oscillation and the impact in the tropics. So this is the zonal wind. I think this is the near equator. This is as a function of latitude. So this is the time, lead time. What you can see is in short-range forecasts, the middle latitude, the scale is better in the tropics because we have the theory of barricade instability to support this short-range forecast. In the tropics, there is a lot of convection, precipitation, so the scale is very low. But if you go beyond 10 days, you see the scale in the tropics is better than the middle latitude. So this is the average scale. But you can categorize the strong NNO forecast and the weak NNO forecast. This is the difference. So what you can see is the strong NNO forecast. You have a better scale than weak NNO forecast after about 10 days. It's mainly in the tropics. So that means the NNO, strong NNO, really send a signal to the tropics, impact the tropical prediction. So this is why this happened in the observation. You have a strong NNO, this is composite, lack of composite, 200 millibar zonal wind alarmony after a strong NNO. So the NNO, you have a strong zonal wind in the polar area and persist until two weeks. And suddenly, there is an increase of zonal wind in the tropics. This is zero. So this is an observation. In our forecast model, we also have very similar structure. So the NNO, and after about 10 days, there is a sudden increase of zonal wind in the tropics. So if you look at, because in this region, that's really associated with MGO phase 7. To summarize my talk, this is the second part. So we see there's two interactions between NNO and MGO and the lack of association of the NNO. So I didn't show you this impact on surface air temperature. But really, we have some studies show that this kind of connection impact whether the surface air temperature, there is a very strong signal in North America after MGO. And the NNO in traditional forecast skill is influenced by the MGO. And the MGO skill is influenced by the NNO. So that's really a two-way impact. All right, that's for what?


The president of Zambia, Edgar Lungu, fainted on Sunday during the country's televised official annual ceremony for the National Defense Forces Day. That event was immediately interrupted following the incident. And the 64-year-old head of state, who is running for re-election in August, suffers from the rare disease achillacea. The condition affects the esophagus and causes hypoglychemic attacks. An official statement by the president said Lungu has since recovered and continues to perform his duties.


What's going on guys, it's your boy the E.P.J here today with another Destiny video and today we have top 5 lucky salute drops of the week. Now if you guys do enjoy the video do smash that like button but let's get straight into it. And at number 5 we have a clip sent in by Unknownish who pops A3 coins at the perfect time. Crazy luck. At number 4 we have a clip sent in by the boss XRV111. Now my entire Destiny career this has never happened to me in both PvE and PvP. My luck just must suck. At number 3 we have a clip sent in by the crazy boss 1000 and this is I have never seen before. Have you? Let's go motherfuckers.   Oh my god but my personal asset of life support and feeding frenzy. In at number 2 we have a clip sent in by King Kavir. Now you think the guy at number 5 had great timing? Check this out. He's got the relic. He needs strategy and teamwork if you want to survive At number 1 we have a clip sent in by Galease G. Now did that just happen basically within the space of a minute?  But guys at the end of my top 5 luckies the loot drops. If you enjoyed the video do smash that like button and I'd appreciate the support. So meet anybody else who could be up to the email address linked in the top of the video at least to go lipsy and I'll catch you guys on that next one. Peace out until next time. P.O.C.E.