Most people using recurrent neural nets don't use simple recurrent neural nets. They often use ones with some sort of gating, gated recurrent units or LSTMs, long short-term memory networks. These allow for somewhat better memory of things that happened much earlier in the sequence. I will look in some detail at how these work. There's a bunch of different variations, but they all have the same idea. Now, the fundamental problem of recurrent neural nets, simple ones, is that they forget stuff. If you have an input x to 0, it's now passed through a whole bunch of weights, and then that gets then put through a hidden node that's passed through a whole bunch of multiplications and layers again and again and again and again, and by the time we try and find something over as an output that should depend on it, it's been multiplied by a whole bunch of matrices all the way along the way. Now, every time you multiply something by a matrix, it effectively tends to forget. People have seen hidden Markov models will remember that the Markov transition matrix, each time you multiply by that, what you knew before shrinks by a factor of the largest eigenvalue other than the one. Basically, networks tend to forget exponentially quickly. Each multiplication makes it remember less about what it knew before. Multiply, multiply, multiply. If it's 0.9, 0.9, 0.9, 0.9, after 10 steps, it's 0.9 to the 10th and you've forgotten it. So how can we fix that problem without having something that actually is a real memory unit where we store things like a neural Turing machine, store it somewhere where it stays forever and retrieve it. We're not going to build it in this course SQL queries where we store things in a database and retrieve them, but we want something that's differentiable, but has that style of storing things. So let's think of a simple task to illustrate where this comes into play. Imagine you have a sequence of length L and you've got a bunch of stuff that's irrelevant of length T, and then the answer. And what you want to do, now what you want the neural net to automatically do, is to figure out that all of that junk in the irrelevant sequence is irrelevant. Remember the stuff at the basic L part, take that hit in the state, save it away, and then much later retrieve it.  Okay, so let's take that again. We want the neural net to say, hey, we've got some hidden states. Take these hidden states, store them away. We need it to learn when to store them, when to retrieve them, when to forget them and replace them with something else. Note that this feels like discrete logic. Store things, retrieve things. We can approximate yes-no logic with like a hyperbolic tangent, push things to minus one plus one. We can estimate the whole thing with gradient descent. It's a little bit tricky for the descent because you're solving something that in some weird sense could be NP-hard if it's discrete logic. But it does allow you to store things and remember them in a differentiable way so you can use gradient descent. And that's really magic. Okay, so let's look through all of the gory details of the components in a LSTM network. Think of one copy of my unrolled network here, right? There's three copies network A. Each of them take in a current X and the hidden state from the previous one. The simplest version of a standard recurrent net takes in X, multiplies it by matrix, takes in H of t minus one, multiplies it by matrix, adds it together plus a bias term, passes it through a hyperbolic tangent. We got a new hidden state to pass on to the next time step. Cool, that's what we've seen before. But now we want to put a whole bunch of other stuff in the middle, which I'm going to walk you through in a number of slides.  You take two vectors and point-wise multiply it. You multiply each of the elements of it. Some of them are just vector copies, transfers. Some of them split things and send them to places, like the hidden output goes both here and out to the next thing. And some things are concatenated, like we concatenate X and the hidden output from the preceding one. So we'll see each of these coming together. So let's step through it. Imagine we have seen something and we want to store something of one. If the last image was a puppy, but the last word was, quote, puppy or something, otherwise we store a zero. So we want to know, should we store something? So we're going to take in our inputs, our current X and our hidden state from last time, and we're going to pass it through a function where we concatenate the previous hidden state H and the X, multiply it by a weight matrix, add a bias term, pass it through a sigmoidal unit, and we get something we're going to call a forgetting term, right? Should we forget this? Previous version, should we remember it, okay? So should I forget the value in the cell? It's some function of the input, X and preceding state. Well, along with should we forget the last thing, it should be remember something new. So we're going to have an I for input. We have the forgetting mark, we have the input. This I is going to look exactly the same. It's also a sigmoidal function with a different weight multiplied again by the concatenation of the current X and the preceding hidden state and a new bias term. So that's should I remember this new value? And then the question is, what should I remember? Well, what should I remember? It's going to be something that, oh, this looks familiar, is again the concatenation of the current X and the preceding hidden state multiplied by a weight plus a bias term through a hyperbolic tangent. Okay, could have been sigmoidal hyperbolic tangent. People like these, there are lots of variations. But this is all sort of binarizing things. We're moving towards something store, not store, forget not to forget store a one, something toward a one, or something away from a one. And so now what are we going to do? We're going to say, well, our new value we want is going to be the forgetting the output from that sigmoidal model times point wise times that's for each of the elements of the state times the preceding C we had, right? Hidden value style from before plus I, the input, which is also there with the neural net, times the new C tilde, which we just computed based on the inputs. So we've got something that says our new value of C is the old value of C times the forgetting plus a new value times the input. Again, note that F, I and C tilde are all computed as a function of X and H of T minus one. And note that the star here is point wise multiplication for each of the elements in this thing, which is sort of like a hidden state, but it's not. We have the hidden state, which we kept, and we have the C, which is our memory, right? So old stuff in memory, new stuff to be added to memory, new memory going out to be sent to the next time step. And of course, we're gonna unroll this in time, so this same network will show over and over again. So what do we have then? We're now going to say, okay, we need to take this piece here, our hidden state for this time step H will be some O, which is O, once again a sigma times sigmoidal function of the same input X and H multiplied concatenated by a new weight, yet another weight matrix plus a bias times the hyperbolic tangent of C, which is our memory. So what do we do? Our hidden state is a product of something we've computed based on the input, point wise multiplied, right? For each of the elements that hit the state times something which is our memory. So we've computed for each of these things how much to keep. Now we have a hidden state we've computed, which we can pass to some output to predict maybe a label, pass to the next time step, and we have a C which we've updated. So we put the whole thing together, what is there, one Mongo set of equations, all of which look pretty much the same, but with different weights in them. We have a forgetting factor based on the inputs, how much should I forget the memory? We have a remembering factor based on how much I remember, and we have this output, how much should I output. Oh, and just to be fancy, we've added in one more term, we've added in the memory. So how much to forget depends not just on the input, but also on the remembered part, and how much new stuff to store depends not just on the previous input, but also on the part that we've remembered from before, and how much to output depends upon. So we've got ourselves something cool that uses both the inputs and the memory, and it's a super flexible, equational form which we solve all with gradient descent. Now it works really well. Does one need all of this fancy forgetting and remembering and storing, or could one do some other arbitrary similar sort of thing that has a bunch of sigboidal functions and hyperbolic tangents in it? And the answer is, yep, it's deep learning. You can do lots of different things. So one simple version says instead of a forgetting and a storage, you can do a forgetting and a one minus forgetting as the storage. So now we don't actually have a separate piece here. It allows deleting and writing, but it doesn't quite have the same flexibility. Lots of people, instead of using LSTMs, use gated recurrent units, GRUs, which look a lot like the LSTMs, but have a couple less pieces of moving parts. It looks more like this other piece instead of a forgetting and remembering. I've got a one minus Z and a Z, and it works directly on the hidden state rather on the separate memory C. So now what are we doing? We're taking a hidden state which has a certain amount of remembering the hidden state and a certain amount of forgetting and updating. It all looks similar and yet a little bit different. Personally, I'm not too attached to any one of the architectures. The LSTM is as good as any other one, but people optimize these and try different forms. There are also variations we'll talk about later about by LSTMs, but for now, give it a try, run the LSTM, see how it works. In general, they work much better than the simpler recurrent neural nets.


Hello and welcome back to the craft box. My name is Brenton today. We are looking at the best ways to get event points in the spiral showcase Obviously, I have zero points event has just started I would recommend before we start to have energy gear on just in order to start if you're not doing the fishing or the pit stuff That's fine But it does require energy gear for the fist bit or should probably have it just in case Obviously my energy is not full Which is fine. I have Not wearing this energy gear for a while First off what you need to do is go to archetype and get five black coal and five simple vials Those are for crafting later I've already done so because I was not actually planning to make this video today And then we're gonna go over to storm ribbon go and catch some fish Gotta go fishing. I believe we will be catching basically fire fish. I don't actually do fishing much And I think this is like the second time that I've actually done fishing for this event So yeah, just bear with me as I make my way over to the fish in storm ribbon Okay, so first off what you should probably do is set it up for catching fire fish We're only gonna be catching fire fish if they get away. That's unfortunate if you have fishing luck gear I would recommend using it just because essentially every time that you catch a fish I mean one point and That also Multiplicates or adds if there's a rank to it as well. Obviously, this is a rank one fish So we're gonna be getting one one point, which is fine This doesn't guarantee you will always get the three points that you can get from them But it's this is just how I do it But yeah, the fishing is probably the part that will take the longest Obviously because fish are the most fickle things ever and I really dislike them so much Can you just frickin bite the thing please that would be great I would appreciate if you could just you know bite it and chew it and enjoy it Please please bite it chew it and enjoy it. So yeah, I'll be back once I've collected all of these fish for the next step Okay, that is all of the fishing points 20 the higher the level of the best it is So I would I would really recommend if you have Winnow Winnow ranked two or something in this pond and You get only ranked two apart from sentinels, but they easily dealt with and you can also sink chests probably an ideal Thing if you have that if you've done as ticker fishing just because it is Very very frustrating getting the chest because I don't give any points But anyway after you've done that we then head over to the pet pavilion So I usually head home and I go Straight through my tapestry. I would highly recommend if you don't get a to definitely get a tapestry to The hatchery or the pit pavilion of some form just because it's so easy to get over there And I would recommend you put on a baby pit for this just because you lose less energy So I am trying to maximize the energy that you save Luckily, I have quite a few baby pits that I hatched more recently we're gonna do this one. This is working on my fire pit and Essentially, you just go into the dance game you go here Obviously, it's only gonna cost two if I put on my normal pit, which is a What a mega pit it costs um 10 so definitely use a more cheap pit like a baby or a teen or an adult even And just go to the first one or whatever and then just press the down arrow as soon as the game starts like right now Just press the down arrow and Unless it's all down you'll be fine and it will automatically do that for what how three rounds and You know then you're fine and then basically just feed them the lowest pit snack so you can Maximize how much energy you can have so finish or you play again play again doesn't really work They've kind of broke that button, but it's fine and you should see one one point should have happened Yeah, one point. So you just need 20 of those to do that 20 times also We can click about first reward will click them all at the end though So yeah, I'll be back once I've trained up 20 times or 19 more Okay, just fed all of those snacks to the pet that only took 20 minutes ish Slightly less. Um, but anyway now what I do is I change to my heading gear.  Oh, we got to do a daily quest. So I go home. I Go home real quick and I go and click the daily assignment thing. Hello and we need to go and defeat a Beghastian crowcaller and the plaza of conquest. I get gold. So it's fine. Here we go Look at people here already amazing. So yeah, usually you'll find some people who are just doing daily assignments as well Which is quite quite a nice way to make friends or find new friends See, I will just grab these guys We've got a shad right off the bat. That is so good. We're just gonna Lulu right off the bat easy clap Otherwise, I would have played it but super duper easy Easy 20 event points just like that Which will take us up to what two four sixty, which is crazy sixty in one day Whoo, amazing and all we've done is spend what like a bit that is a weird camera angle That is a really weird camera angle. What the heck was that? I don't even know but we killed them So that's fine easy peasy daily assignment completed 20 special event points and we got to watch it spin Because I love watching it spin and get a tick I don't know why I just always like that and then we go home and we go and do some crafting. I Generally craft these broken planks, which is why I got the simple vial in the black hole This can be collected from Adora and Wizard City Basically basic crafting station Then you just spam click create until you can't create anymore And that's how you do it. The other thing that I sometimes do is I create the Balanced moon seeds or the beast moon seeds if I have a lot of the moon stone things which I do at the moment, so probably Future in the event cycle. I will go and do that But yeah, there we go We've done all the crafting and we now need to go and use the team up kiosk, which is right here I would highly recommend getting a team up kiosk for your house if you don't already it has to be the The highest world so obviously we have to do this I really like doing the astral forest or any of the Dungeons that you can farm for gear, but sometimes that just doesn't work out So we just go with whatever is there. I do always wait until everybody's in the fight before I kill though So that's a very important thing that you should probably do if you're doing team up Just wait until everybody's in the fight before you kill Otherwise it is quite rude And also some of the credit doesn't get given if you don't wait for everybody in there So yeah, even though this is a dungeon. You still should probably wait. What is the stats go to check his stats? How how trash are they? Oh really trash? Okay? If you might want to get some better gear dude just saying No wonder you need help if you have this terrible gear and why would you spend crowns on this? I'm actually kind of disappointed in this.  Oh, we got a shad again. Wow, okay Why does he have elemental spear trained? Why? Why? Wow nice block unlucky Okay, Gigi Gigi Gigi Nice 20 special event points. We did it boys and that concludes our fantastically fantastic How to get points for the spiral showcase, we're gonna go and open everything up because that's fun Hopefully we're back in our house. Yeah, we are look at that fantastic So we managed to get a hundred points from that so doing everything a hundred points easy-peasy We can get this gold how much was that one thousand we can get these snacks Which is like terrible, but that's fine We can also get these treasure cards, which are again terrible, but hey, that's fine And next up we get three mega reagents. So that's fun. We also have the scroll of fortune So we get a unlock a new thing. What was this? This was a To get long balance tower pack. So all of that sort stuff. Oh balance plate. That's not too bad I would definitely take that and those and then we get a new emote. Wow abracadabra Interesting And what are we on to here? This is a sonic spring. Oh, that's gonna be so good. That's actually really good Let's do the abracadabra as we do the outro But anyway, thank you for watching room to the back and subscribe if you're already subscribed press the little bell Soon or exactly when I post another video remember craft outside the box


Hi everyone, Joe for jaspyscasebreaks.com coming at you with 2020 tops clearly authentic baseball ten box half case Random team break number five one spot gets you two teams the combos Diamondbacks Marlin, and we took out the Pirates. They got no hit. They have no autographs in this big Thanks to these folks for getting into the action again one spot gets to so let's Double you guys up. Let's roll it. Let's randomize it There you go six and a three nine times two three And ninth and final time after nine we've got Jeff down to Adam After nine all right six and a three nine times for the teams Good luck ninth and final time after nine. We got the twins down to the ems All right, Jeff with the twins Josh with the Indians Josh Proust with the Royals Josh with the Rays Carol Diamondbacks Marlins combo Chris with the Cubbies Josh with the brew crew Jeff with the Red Sox Carol with the Rangers James With the Rockies and the Braves Matt Gomes the Angels and Padres Carol with the Giants Aaron with the Mets Josh Proust with the Tigers Josh K with the Cardinals Chris with the Yankees Aaron with the Blue Jays David with the Nationals Carol with the Astros David with the O's Jeff with the White Sox Josh with the Reds Adam with the A's Jeff He got my Dodgers Josh with the Phillies and Adam with the Seattle Mariners trades are allowed Feel free to trade if you'd like anyone anyone gonna trade I think I've seen a lot of trades in these if any Let's see. Here's a checklist if you're watching live We've got a diehard Mets fan in Williams Aaron Hayes if you want to Move that Carol Williams now I'm gonna switch screens just for a quick second We're gonna see which half we're gonna do Ten boxes on the left side right here, and that's another set of ten right here one two three Four five six on the dice roll. We're gonna use that And it's gonna be one so it's gonna be that side right there this side We're actually just gonna save right over here because break six is coming up It's coming up next so you can see the top camera. You can see it kind of peeking right here on the main camera All right. It looks like no trades. So TWC trade window close. Let's print. Let's rip. This makes it official. All right there. Good luck We got Wilson Contreras for the Cubs Use this blank card to kind of show you the background there a little bit say pretty cool Chris Walker with the cubbies next box is Jalen Davis, yeah Rookie Otto for the Giants My rivals that's gonna go to Carol Williams Nolan Ryan Rangers Edition. Wow that is for Carol Williams and the Rangers 45 out of 50 I could have been part of a trade For the Mets Ryan Express nice There's Eric Davis Cincinnati Reds Eric Davis that'll be for Josh Kainan El Cano and the fifth box here is Jordan Yamamoto 89 out of 99 A picture showing off showing off his hitting Those days are gone ladies and gentlemen These are gone Miami Marlins Diamondbacks combo Carol Williams There's Jose Canseco A's that'll be for Adam Copperman Next one Is max Muncie That's him hitting a home run off of a Maz and bum garner and then telling him to go Get it out of the ocean That'll be for Jeff Goldhaver last bond mojo Dodger Joe mojo and we've got Matt Heiss 71 out of 99 Is there a number that I thought oh, yeah, 71 out of 99 and said that angels that'll be for Matt Gomes and the halos two more And there's Dylan Cease White Sox also for Jeff and we've got oh, I don't think I've seen this. This is the first decade's best Autograph it's pretty sweet. That's twins edition of rod karoo And that's kind of hard to see the number right there 12 out of 25 Jeff gold hit. Wow. Nice nice break for for Jeff jay in the chat That's it. We're done ran him team five in the books. That was a solid break Joe for jaspyscasebreaks.com. I'll see you for the next half. Bye. Bye


Good afternoon everyone my name is Kevin Mullen chair of the board and I'll call this meeting to order and we'll start with the executive director's report Susan Barrett. Good good afternoon and thank you Mr. Chair. A few announcements a couple of upcoming off-cycle meetings so they're not on Wednesdays. For this Friday at 1 p.m. we will be hearing from the NORC from the University of Chicago team who did the federal evaluation of the Vermont's all-payer model for the first two years. Again that starts at 1 p.m. and then additionally on Monday November 8th starting at 8 30 a.m. we will hear Springfield Vermont hospitals revised FY 21 budget with a potential vote. In addition we have a couple of public comment periods that I will remind folks about. The first is the FY 22 one care Vermont but ACO budget and we are accepting public comments until December 1st. We accept public comments every day but in order for them to be considered by the board and staff please get them in by December 1st and then we have our ongoing public comment on a potential next agreement with the federal government for an all-payer model. We are sharing those with our partners at AHS and the governor's office as they are leading the negotiations and that is all I have to report out. I'll turn it back to you Mr. Chair. Thank you Susan Abigail could you tell me what the date of the the last minutes are? October 27th. Great so next on the agenda are the minutes of Wednesday October 27th. Is there a motion? It's been moved by Tom and seconded by Jess to approve the minutes of Wednesday October 27th without any additions deletions or corrections. Is there any discussion? Hearing none all those in favor of the motion please signify by saying aye. Aye. Any opposed signify by saying nay. But the record show that the motion carried unanimously. So at this point I'm going to turn the meeting over to Christina McLaughlin who will tee up our conversation on the healthcare workforce strategic development plan so Christina. Thank you Chair Mullen. Hello everyone my name is Christina McLaughlin I'm a health policy analyst here at the Green Mountain Care Board and I have been supporting the board's work and review in the draft healthcare workforce strategic plan. I'm going to share my screen soon these slides are posted to our website under today's board meeting date if folks are interested in having them. So just give me one minute. Can everyone see my screen? We can. Perfect so today we are here to just review quickly the draft healthcare workforce strategic plan language and statute and the feedback that the board received during its review. So with that just a quick review of Act 155 of 2020 which is the language that changed the current statute of the healthcare workforce strategic plan and directed the director of healthcare reform to maintain a current workforce development strategic plan that continues efforts to ensure that Vermont has the healthcare workforce needed to provide care to all Vermont residents and maintaining the plan the director or designee shall to consult with an advisory group composed of the 11 following members and it was noted that at least one has to be a nurse to develop and maintain the strategic plan and you'll see the 11 members listed there which includes the a rep from the Green Mountain Care Board's primary care advisory group someone from the Vermont State College is from a heck from an FQHC Vermont hospitals, a representative of physicians, a representative mental health professionals of dentists, naturopathic physicians, home health agencies and lastly a representative of long term care facilities and is also noted in Act 155 that the director or designee is to serve as the chair as this advisory group. Act 155 of 2020 also notes that the director of healthcare reform shall ensure that the strategic plan includes recommendations and recommendations on how to develop Vermont's healthcare workforce including the three items listed below. So the first is the current capacity and capacity issues of the healthcare workforce and delivery system in Vermont including the shortages of healthcare professionals, specialty practice areas that regularly face shortages of qualified healthcare professionals, issues with geographic access to services and unmet healthcare needs of Vermonters. Second is how a state government universities and colleges, the state's educational system entities providing education and training programs related to healthcare workforce and others may develop the resources in the healthcare workforce and delivery system to educate, recruit and retain healthcare professionals to achieve Vermont's healthcare reform principles and purposes and finally to also assess the availability of state and federal funds for healthcare workforce development. The original Act 155 language included an earlier date for this past summer but given the impact of COVID-19, the dates were revised in 2021 per Act 74 which was the budget bill to delay the submission of the draft plan to the board and consequently also the submission date to the legislature to allow for more time. So the draft plan was submitted to the Greenmount Care Board. In this case on October 15th and the board has to review and approve within 30 days following receipt and then honor before December 1st the director then is to provide the updated plan to the House Committee on Appropriations, House Healthcare, House Commerce and Economic Development and the Senate Committee's on Appropriations, Health and Welfare and Economic Development and Housing, Economic Development Housing and General Affairs. So just quickly to review the board's review timeline. We received the draft plan as I mentioned on October 15th which was a Friday and at that time we did post and share the draft plan with interested parties and stakeholders and posted to our website and that is when the special comment period began. The following Wednesday on October 20th is when the director of healthcare reform, Ina Bacchus presented the draft plan to the board and a public meeting where we took public comment and the board discussed the draft plan. Then the following Monday the board met with the general advisory committee and they provided feedback on the draft plan and in preparation that group had received the draft plan and information related to the 10-20 board meeting and then we ended the special comment period on November 1st to allow for time for the board to review any public comments that were submitted before today's meeting. Here we are today on November 3rd so the board can discuss and potentially vote on the draft plan. We did tweak the timeline a bit to allow for the board to vote on the more finalized version of the draft plan later on. So we will be receiving on Monday November 8th an updated draft plan to the board which will be posted to our website once we receive it and then after that we have added a final vote on the draft plan for November 10th and that I believe is happening at the end of the day on November 10th but we will update the press release and agenda accordingly. So with that part of the board's review process included as I said feedback from our general advisory committee. And I noted here this is a very brief summary of what was proposed during the two-hour meeting on the 25th of October and I'll just quickly run through these so that folks who are on the phone or for folks who are interested. So the first part of the feedback was to include representation from all state nursing programs a member of the public and more practicing nurses in general to the state interagency task team. Second to include nursing faculty and scholarship and loan repayment programs specifically incentivize sites agencies and preceptors to take UVM Medical Center and in-state students. D includes specific language and programs to address retention to prioritize retaining our current workforce. E was to look into 6 to 12 month onboarding programs for APRN residents. Currently we do not have those for APRNs in the state of Vermont. F other than pay look at how to retain our current nursing workforce. There was an example put out during our general advisory committee meeting that joint appointments between academic nursing programs and facilities would be a good example as to how to keep our nurses without just paying them more. G is created a formal process of exit interviews to find out why they they meaning the workforce are leaving their job to help address retention issues. Increase the number of ultrasonautographers diagnostic imaging service and echocardiographers as they are in high demand. It was noted that when these services or positions aren't available create access issues and burden issues in our workforce. I is to train higher levels of workforce other than doctors and de specifically it was noted that an associate's degree in physical therapy is very valuable in an office setting to get work done. But Vermont does not specifically have a PT program offering associate's degree in that field and then higher change management experts and support hospital leaders to utilize executive training programs to improve leadership and work environment. And finally investigate if we are using current staff effectively and why nurses are retiring early. This obviously was part of a much larger discussion and if folks are interested there are some notes on this meeting on our website and we do have a video teams recording of that meeting if folks would like to know more. As I mentioned we also held a special comment period from October 15th through November 1st. During that special comment period we received six public comments in total for which are posted to the website. We did receive one after the deadline which is also posted to the website. So there are now five on that public comment page on our Green Mountain Care Board website. Just to summarize the public comments that we received in writing. I added a list of bullets here which include adding the UVM College of Nursing and Health Sciences to the list of entities to act on education and training recommendations. Add critical access hospitals and employees of FQHCs to funding and tuition reimbursement list. Third to address issues with consultation notes sent to private primary care providers. It was noted that this can worsen care and contribute to burnout. Increased scholarship and loan forgiveness dollars so not only extend those programs but to increase the amount of money put into them. Create incentives to further education so scholarships for graduate degrees and increase mentorship and job support overall. Increase housing to help recruit and retain Vermont workers. That was that was actually mentioned specifically in the report as well but folks did support that. Promote and fund more training for PAs and PEs and nurses and provide adequate pay and benefits and increase staff at treatment centers. So again while this is a summary the special comment period comments that we received are posted to the website that we were that were granted for us to post. And with that I included a slide with the resources which includes the two acts Act 155 and Act 74 that I mentioned. A draft of the health care workforce strategic plan. I also included a link to the 10-20 board meeting presentation as well as our general advisory committee meeting page in case folks would like to see those notes and related materials. And then finally a link to the public comments that we've posted to our website. And then with that I will turn it over to Chair Mullen so we can move to board discussion or public comment at this point. So I will say that I originally had hoped to have a vote on this today but because of the volume of public comment and the fact that at the last discussion that we had as a board with the director of health care reform one of the things that she felt was important to put in and I can't remember if it was Jessie who suggested or who but it was the breakdown between short-term mid-term and long-term strategies. And my understanding Christina is she will have that to us by Monday. Yes that will be incorporated in the updated version submitted by the end of the day on Monday. So it would be much better for us to devote on a more final version of this plan than to vote on something with a bunch of suggestions that may or may not already be being incorporated. So that's why I don't think we're going to be voting today but certainly the other board members could correct me. So with that I'll turn it over to board members for comments and questions. Well I'll go ahead and start. It makes sense to me to hold the vote until we see the revised plan because that would also give the director of health care reform some time to think about how she might be able to incorporate some of the comments that we received. Some of which may be. And many of which were already in there too by the way. Yeah. I just want to point out that a lot of the comments were in there. Yes. So I think having that information be clear would be helpful. I overall I would say I liked Jess's suggestion of incorporating sort of short medium long term initiatives that dovetails with my thought that I do think we having some sort of timeline or timeframe is needs to be incorporated into the report so I think that meets that need. I would like to put out there that I think it would be good for us as a board to get periodic updates because I think that one of the challenges of course with an inter with this kind of topic is it spread throughout state government. Different parts of state government have different pieces of the workforce at least on the government side sort of the workforce initiatives. And so I like the idea of the task force but I worry about the urgency getting lost. And so I think one way that we can help keep people's feet to the fire is to ask for public updates so that we can hear how that's going. So that was something I wanted to throw out for people to think about. What's the time interview that you're thinking about Robin? Is it bi-monthly quarterly? What would be the time period? Because I think you've got a very valuable point that we offer a forum where people can hear in an open manner exactly what has happened, what hasn't happened and hold people's feet to the fire. So the question really is what is the appropriate time period? I think that is the key question and I guess my one thing I would wonder is it wasn't necessarily clear to me and maybe it was clear in the report and I am not recalling it, how often the state interagency task team would be meeting. And so certainly I think our updates would need to be tied to the frequency of the activities. But so not knowing that I'm not sure but I was thinking maybe just to start quarterly and then once the ball is kind of rolling we could potentially roll back that frequency but not knowing whether that agency would be meeting monthly or bi-monthly or whatever, I'm not exactly sure. I actually think bi-monthly might be better in the beginning and then we could make it longer but that's just where I'm thinking initially but. Yeah, and again, I don't, my goal as I said is to just make sure that there's some transparency and we're really pushing folks across state government to keep this issue highlighted given the importance of it. I do think one of the tricky things that was reflected in some of the comments is the balancing the clinician representation which I think would actually probably be on the advisory group. It looked to me like the interagency task team is meant to be state government officials to coordinate across state government and prioritize existing state initiatives or the creation of new state initiatives. Whereas the advisory group which is in statute is the appropriate place to have the state broader stakeholder representation. And I guess my, I don't know that this needs to be added to the plan but like my thought on that is to try and be a little fluid with the advisory group. So if you are really focusing on nursing issues, bring in like create a little subgroup on nursing issues and bring in more representation. I think otherwise an advisory group that gets much bigger than 11 becomes tough to actually get anything done in because it becomes too big. I don't, again, I'm just saying that as a suggestion I don't really expect that necessarily to be spelled out in the report. The other area that really stood out to me is we did get a public comment and this is actually a recurring theme that I think we've heard in other areas about the limitations in Medicare around mental health and substance use disorder provider types. So I'm gonna, I'll just say out loud that I'm gonna file that away in the back of my mind as something we should think about when the administration comes forward with their proposal around APM 2.0 because that's something that could potentially be folded in. So I think that's just something for us to keep in mind. So those were my initial thoughts. Other people's thoughts may spark more from me but I'll let other people speak. That's great Robin, thank you. Maybe I'll go because I can build a little bit off of some of the comments Robin made and you made Kevin. So first of all, I mean, I thought it was a pretty comprehensive report and I appreciated the work that Ina Bacchus and the advisory group did. I agree that I'd like to see more accountability at least made more explicit in this plan. I had thought in my head and my notes that the interagency task force should be required to submit quarterly reports on their progress, on the timeline, on milestones, how they're planning to judge success. And I think having the report presented in a public setting, I think makes a lot of sense. This is an urgent issue affecting the entire state and I think the transparency on the progress would be important. I hadn't thought about until you just mentioned at the frequency of their meetings but I actually think that should be included in the plan. So I would add that as something that the director of healthcare reform should maybe consider putting in there explicitly, how frequently she and the advisory group think that this interagency should meet. My preference would be a lot in the beginning as we have, this is a critical issue. So once a week, every other week in the beginning to get this off the ground, I think is important. If they're meeting once a month, it's gonna just take that much longer to implement the recommendations. And I'm glad to hear that there's gonna be an incorporation of the short-term, medium-term and long-term recommendations. I think that will help prioritize but I also think it will be helpful if one of the first tasks of that interagency task force should be, even within that, to start prioritizing based on evidence of effectiveness, based on resource needs and based on operational efficiency or feasibility, rather. I think in some sense doing a cost-benefit analysis, I know I'm sounding like an economist here, but the return on investment of a dollar spent on loan repayment is not the same, may not be the same as a dollar spent on scholarships, may not be the same as a dollar spent on preceptors. And we have scarce resources here. We have a big problem. So I would like to see that interagency task force really thinking about how to prioritize along those kinds of dimensions. And then I think around, there were some small considerations I wanted to throw out there for comment, but in their demand and supply analysis, which I think is a good idea to really understand where there's unmet need. I think, and I mentioned this in the meeting last week, but having that licensing census data, which is mentioned in the report, I would like to see it include a question on whether the provider is actively practicing in Vermont, part-time or full-time. If we really want to understand supply, we have to understand who's actively practicing and at what level they're practicing, meaning 20 hours a week, 40 hours a week, something like that. That's how you're gonna get a handle on supply. So I think that's a recommendation that could be made to OPR. And then on the demand side, I think we're gonna need a better understanding of wait times. And I think to the degree that we're trying to collect demand and excess demand or unmet need, we need better ways to understand wait times on a consistent basis and on a uniform basis. So I would maybe mention that as well as something to consider. And then the last point I wanted to make was, I would love to see the plan put greater emphasis on K-12. So on that K-12 pipeline, and this is something that Kevin, you talk about all the time, we have to grow our own. Most of the report emphasis is on the college post-secondary training. And K-12 is actually largely relegated to future considerations in the back of the report. And I think the reference, really the reference to anything K-12 is that there should be a recommendation that we make middle students aware of careers in the healthcare sector. I guess I would just say, I don't think that's enough. I think we need more than that. And I think it needs to be front and center, not in future considerations. I think it needs to be in now considerations. I would love to see the agency of education working with high schools, working with tech centers and career centers now to help create clearer pathways for high school students to the healthcare sector, more training in high school, internship opportunities, you know, high school curricula that actually prepare students for careers in healthcare, bio courses that are designed for healthcare workers, training for guidance counselors to identify students with early interests in healthcare. I think we need to start recruiting early. And I would love to see that part of the report pulled up into the meat of it, not a future consideration. I tend to think this may be one of the lower resource, higher impact, higher feasibility, types of recommendations that could be done in state. So I may be wrong on that, but I would like to, you know, hear some feedback, I suppose, from others on that. And then I guess the other thing, you know, there were some pretty good comments that we received. And so to your point, Kevin, about not voting today, I would love to hear feedback from the director of healthcare reform on some of those recommendations, because I think some of them were quite good, helpful. And, you know, to hear whether or not they make the final cut or not from the director of healthcare reform. And if they don't, why? They don't make the final cut would be helpful. And I agree with you, some of them are already in there, but I'm talking about those that are new recommendations. So those are my thoughts. Thanks, Jess. Tom? Well, let me add to the pile. I'm listening to Robin and Jess and you. And, you know, I think we're all kind of thinking in the same direction. And it's just how to get from where we are to where we want to go. And that is the thing that worries me the most. That, you know, I agree that the plan that Enos presented to us was a comprehensive list, pretty much a comprehensive list of some good ideas. And it was improved by our advisory committee. I thought that that discussion was a very helpful and energetic discussion. And I also think that some of the written comments, especially there's one comment that where the comment or didn't want it to go public, which I thought was a, and I don't know if it's okay for me to say that, but I thought it was an excellent insightful comment from somebody who is on the ground and kind of looking up at us as to what we're doing. So the, you know, as I said at the end of the last meeting on this, there were five shells and only, and 73 shoulds in the state workforce plan. And what I worry about is that we have this effort focused on workforce, but there's so much else that's going on that is related and, you know, to this effort that I worry that somehow, you know, if this effort can be embedded in a group of people that have kind of a larger view of stuff, I mean, I see that their report to establish a state interagency task force, obviously, you know, that's needed, but it's just combined, you know, comprised of six people, you know, from state government. And then to integrate it with the State Workforce Development Board, I'm not quite sure what value added that is given, you know, I would think that might take quite a bit of time and it would be nice to be integrated with the State Workforce Development Board, but I'm not quite sure what that does for healthcare, specifically given the magnitude of the issues before us. So, you know, and I also worry about this unfolding in the context of other moving parts that are also at play, that aren't settled, but they're at play. And those that would include the wait times task force, the all-payer model renewal, the sustainable ability effort and the burns and BRG suggestions, the ACO budget, which we'll have next week, the benchmark plan review, which is due to the legislature on January 15th. And, you know, I'm kind of looking at that, thinking about, well, where is all the money gonna come from or where are the efficiencies gonna come from to pay for it? I mean, there's two ways to pay for it. And I just am not sure that this state interagency task force, whether the report quarterly or monthly, is big enough to kind of allow this project to unfold in the context of an awareness of what else is going on across government in these other efforts. So, you know, I would be open to suggesting that this, I mean, we don't want a big group that's unwieldy, but this is six people. If this were 10 or 11 people, you know, with a few others from kind of outside the workforce issue, whether it's the commissioner of DFR who is gonna lead the charge on the benchmark plan or if it's maybe a couple of legislators or the hospital association, you know, just trying to get it to a size where the discussion is robust and the focus is workforce, but it's done in a context of people around the table who collectively are aware of things going on elsewhere. You know, I look at the state budget, something obviously I haven't interest in. And I'm thinking, well, you know, Diva ended their year with, you know, in terms of their Medicaid programs with the $16 million underspend. The state general fund now is $28 million ahead of target through the end of the last month.  So as much as we could keep the task force reasonable in terms of the number of people, but allow it to have folks on it that can offer insights to what else is going on in other areas related to the workforce, I would think would be helpful. That was my big concern is the coordination on this is essential. And even within the workforce plans, there's some of those things are gonna have to be thrown overboard. You know, it's just, we can't do everything for everybody. But I worry that the task force is in this corner and there are other areas that actually could be helpful to the task force that are just off the screen of the task force because there's nobody on it that is engaged with the state fiscal affairs or DFR and insurance companies, et cetera. So that's my take on it. I thought it was, you know, did a great job. I think the commenters have been a great job. It's been a, you know, a very positive experience to see people supporting something and trying to make it better. But I worry that it's just, it's not gonna get lost. Definitely it will not get lost, but that it's gonna be diminished in the context of all the other things that are going on. I think all valid points and something that we all should be very concerned about with there's a limited amount of resources and how they get allocated. As we know, there's a lot of competition for that allocation and the encouraging thing that I think that we're at a point in time where everybody's rowing in the right direction. When you hear the governor and our US senators and our legislative leaders all talking in support of shoring up the healthcare workforce, then I think this is an opportunity. It's a rare opportunity for us to make some progress. And it's a little later than I would like for that progress to be made, but you have to start sometime. So now's that time. Well, you've been very good on this, Kevin. And when I walked into that Kasselton meeting and I was late because I got a little bit lost, you know, the topic of that meeting was workforce. And it was a fascinating eye-opening meeting for me where you have somebody standing in front of the room at that point in time, saying that we're gonna be 1900 nurses short in X number of years. And here we are down the road X number of years and it's worse than imagined. Yep. Any other comments from board members before I open it up to the public for public comment? So I would just jump back in and say I really like Jess's suggestion of some sort of prioritization because I think to the point that Tom made and you, Kevin, as well as Jess that it's a very long list and not everything is gonna get prioritized. And I would rather see a shorter list of things get done than the long list slowly moving forward potentially but not actually getting a call, not really having things move. So I think having something that clearly states who is going to prioritize the items by what date would be good. And I'd like the idea of trying to come up with, I mean, there's no dollars in the report. Like you can tell the things that are gonna cost money but are they small money or big money? Some of them could be as big or small as you choose, right? Like with loan forgiveness and that sort of thing you could fund it a little or you could fund it a lot. There probably is a right amount in there that we should be targeting but we don't really know that yet. So I think having something clear in the plan that talks about prioritization and coming up with dollar estimates so that you can realistically try and figure out what makes sense to move forward with is important. So I agree with what everyone else has been saying. Okay, anything else from the board? If not, I'll open it up for public comment. Any member of the public who wishes to comment you can either raise your hand in teams or if you're calling in, you could just speak up. So does anybody wish to comment at this time? And I do see a hand raised, let me get to there. And the hand is from Dale Hackett, Dale. Yes, I just wanted to make a quick comment that a shorter list, I can see where that would be helpful but the items on the shorter list would need to be synchronized in such a way like if you're gonna have long forgiveness, you still have to have a college though that they were able to attend to get the education in the first place. I'm just using that as an example to try to say that the shorter the list gets, you're still gonna have synchronicity, otherwise it's very fragmented and what would the return be if we're too fragmented? That's all. Great points, Dale, and we will not have success if we do not expand the educational opportunities for Vermonters. Is there other public comment? Next I'll go to Walter Carpenter. Walter, how are ya? Hey, Kevin, not too bad. Sitting here watching the rainfall and the sun come out, facing the windows while I've got the hat on. I'm waiting for the snow. I agree with Dale, I actually agree with everyone else on the board about the list, the items on the list being a whole lot. Dale made a good point on the education, which I hadn't thought of, so thanks to Dale for that one. Again, I repeat once more pay benefits, workforce burnout, in other words, don't short-staff your staffing on the hospital levels. And I know I didn't really see that on Ena's report, but when you're on the ground, that's the big cause of it. But again, I think a list, Robin's idea about the board was one I agreed with, but if they're gonna study it, have perhaps more or make it not too unwieldy and so you can at least get something down. That was a good idea.  Thanks, Walter. Dale, I see your hands raised again. Did you have another comment? No, I guess it just didn't go down.  Cause it doesn't say on on my end. Okay, it's off on my end now. So somebody took care of it. Is there any other public comment? And next I'll go to Rick Dooley. Rick, how are you? I'm good, thanks. I appreciate the report and the certainly the emphasis on workforce. One thing I just wanted to sort of bring to the attention is that one of the ways that independent folks have been able to recruit provider to the state has been through the Green Mountain Surgery Center. There are, I know we had a pretty robust conversation at the advisory committee about, you know, some employers are not prepped coveted as employers and that some of the bigger institutions sometimes struggle with that. And for a lot of providers moving into the state, that's an issue and they don't necessarily want to work for a big, huge hospital. But having some of that autonomy that comes with an independent practice and an independent place to do their surgeries or procedures makes a huge difference. So that's something that I don't know that I saw it called out specifically in the report was something I just want to sort of draw attention to that certainly supporting independent practices and independent surgery centers may help retain some of the providers we're looking for. Thank you. Thank you, Rick. Is there other public comment? Other public comment? Hearing none, we'll come back to this conversation next week. And we look forward to getting the revised draft from Ina Bacchus. And again, I applaud her tremendous efforts and those of her group that's worked with her throughout this process and we're getting there. So. Kevin, just a process question. Will the comments and discussion today from the board be sent over to Ina Bacchus for potential incorporation? Is that how it's gonna work? And then we'll get. So Christina is going to send that over to Ina and so I'm sure that Christina took great notes. Great. Thank you. I'm reading seriously. I have all my notes. And she does a great job of getting them to succinct bullets too, which I truly appreciate. Okay. With that, we'll move away from this discussion and is there any old business to come before the board? So Kevin, I was hoping that we might just have a process conversation and follow up to our discussion last week. That'd be great. Okay. So I'll go ahead and kick it off if you want unless you. Go for it. Okay. So I just wanted to... So it was great to get the tons of information that we got last week and just personally in thinking and mulling of the last week about it, I think it would be important for us to at a future board meeting have more of a discussion around next steps and where we see ourselves and maybe even suggestions for others. Taking the information and moving forward as well as certainly there were some suggestions around potential future areas of analysis we might consider. So obviously the issue of hospital sustainability is much bigger than just us. We're not gonna be able to fix all of the issues with the current regulatory system that's in place and our current boundaries of authority certainly. And it's gonna need engagement with legislators at the community level, hospital boards of directors. So I do think it would be great if we could plan on having a scheduled discussion in terms of our takeaways and what potential next steps might be. I think it's an excellent suggestion Robin and we will work to try to figure out a date when we can next bring it back to the board. We've got a few things coming up but I'm sure that we can fit this in and make that work. If I could just add to that and I really appreciate thank you Robin for bringing this up today. I do think this is the start of a much longer conversation. And I'm just wondering if our staff might also weigh in at some point in those conversations. For example, the data analysis used 2009-19 data, right? That was the baseline. It's a first pass at it for obvious reasons 2020 and 2021 were unique in their own way. And I guess I would love to hear from the data analytics team about what they took away from the data that was provided. What could they do going forward? How do we use data in the future in our regulatory processes? This was enlightening data to be sure. So how should data like this better inform our hospital budget process, our rate review process, our ACO process? So I'd love to hear from those teams how they are absorbing the information and thinking about the regulatory processes that they lead. And I also think part of the future conversation should be how do we take this information and how does it inform our next agreement with the federal government? So those are the areas that I think need further conversation with some help from staff too, to hear what they thought. All of that data might better make our decision process better and make our next agreement with the federal government better. I think that's a great point, Jess. I think in thinking about the APM, I know there was some of the comments that we sort of heard about or saw in the press. There was, I think people were wondering why you would look back to fee for service when thinking about value-based payment. But of course, you need to know where you start and where you are and what the issues are with where you are in order to redesign those payment models. So I think that having this base understanding will be really important because there certainly tends to be a focus at the federal government and cost containment. And we certainly know that affordability of commercial insurance is vitally important. We've seen the degradation in our small group and commercial marketplace over time. I think the question then is how do we balance that and still ensure that Vermonters get the services that they need where they need them? And that's the really hard balancing act. But I think it needs to be part of the conversation with the federal government. So Susan, if you could work with staff to try to put that board meeting together, that would be appreciated. Okay, is there any other old business to come before the board? Is there any new business to come before the board? Is there a motion to adjourn? So moved. Second. It's been moved and seconded to adjourn. All those in favor of the motion signify by saying aye. Aye. Aye. Any opposed signify by saying nay. So have a great rest of the day everyone. Thank you. And Robin, we were wondering if you're getting an endorsement stipend from TD Bank. Oh yeah, I didn't even realize their name was there. Nope. Just like the Valentine Day banded cheeriness. Maybe it's time to change the background. Okay, have a great day everyone. Bye. Bye bye.


What? I can't explain why it took me this long. Heh, Star Wars. Hey guys, this is my review for Star Wars Revenge of the Sith. And you may be asking why it took me this long. I honestly can't give you a solid reason. I think maybe one thing that I've been kind of holding off on is my review of this film, just actually putting my emotions into words about this film. I'll admit maybe I was a bit too harsh on the first one, The Phantom Menace, but honestly guys, I can't watch that movie in full without falling asleep. I've tried four times over the years. Attack of the Clones is an absolute mess in terms of the story, the acting, the writing, but at least it's kind of so bad it's good on a level. Revenge of the Sith kind of falls into that category, but at the same time it's also not a bad movie in terms of entertainment value. This is arguably the best film in the trilogy. I don't think there's really any disputing that. It has the fastest pacing. It has the best pacing. It has the best character moments. It has some of the best fights in the film. It has some of the best grandiose stages. Is it hammy throughout pretty much the whole goddamn film? Oh, no doubt. It doesn't even wait long really. Within the first fight scene between Obi, Anakin and Dooku. At the end of that, when Palpatine is just like, do it! At this point, Lucas had done such a kind of a poor job of building up the Emperor as a hidden villain. In the first film, as Red Letter Media has pointed out, it makes no goddamn sense. His plan made no sense.  In Attack of the Clones, it's kind of hinted, like maybe very barely if at all. And then in the third one, it's like, yeah, he's the bad guy. I remember playing the video game before I went and saw the film, and I remember getting to the point where you actually had to fight Mace Windu and thinking, oh wow, the Emperor's been bad this whole time? Yeah, I'm not the smartest of kids, but I was, what, 14 when this movie came out, 15. So then when the movie starts, and then Emperor says, do it! It's like, wow, yeah, he's the bad guy. Now, kind of going back to the bad writing, the bad dialogue, it's very bad in this. There's some parts of the film that make me cringe, particularly the lovey-dovey scene between Anakin Skywalker and Padme. Like, I am nervous because I am so in love with you. Yee-hee-hee-hee-hee-hee. But I'm going to give the actors a bit of credit because at this point, Lucas did not like the idea of a physical realm at all. Everything in this film is green-screened, and he is not very good at putting the actors into a realm of where they can figure out what they're doing. Like, Ewan McGregor is basically carrying the movie on his goddamn back. But he's also sharing the low of the John Williams. John Williams has probably one of the best scores of the entire Star Wars trilogy in this film. It's bombastic, it's constant. It is lifting you up when the whole film otherwise should be bringing you down. It is a spectacle. Is it a good spectacle? Not all the time. Is it an entertaining spectacle?  From the opening battle in Coruscant to the weird bike slash... Do-bo-bo-bo-bo. Lizard dog chase on Utipao to the obvious big, big climax fight on Mustafa. There's never a moment where you're not, ooh, at what's going on in the film. There's always a great visual representation, and the fact that this film came out in 2005, I'm still blown away by how good this movie looks. give Lucasfilm's credit because by God they did a great job with keeping the CG and the VFX to hold strong. It beats some movies nowadays still, but does the film work in terms of an actual well-structured film? Yes and no. The build-up to Anakin Skywalker Becoming Bad has been done decently. It's not done the best, admittedly, but it's at least built up to this moment. We understand why he's going in this direction, especially with the idea of trying to save Padme, and the Emperor obviously being like, hey, I can save your lady, you just got to kind of listen to me. And I'll admit, I always get hyped up when Mace goes to confront the Emperor because this is kind of like those moments in films like Romeo and Juliet are the ending of the Titanic.  But more so movies that you know what's going to happen, but you still dread it, you still go, oh no, maybe it'll be different this time, even though you know it won't be.  I like that. I enjoy that I still get that sense of dread and worry and anxiety from a movie that I have watched countless times in the last 15 years. Admittedly afterwards though, it jumps the gun a bit because he goes from, what have I done?  He doesn't even get a progression meter. He just jumps over to child slaughter. Like he makes the warlords of Sierra Leone and whatnot look like chump change in comparison. So I always find that this part it's asking a lot. And considering the Emperor says, I don't even really know how to beat death either, but maybe we'll figure it out together, it's like, man, if I had been Anakin, I'd be like, whoa, whoa, I just murdered a man.   And honestly, I think that's what would have happened too actually had they, you know, had it gone a different way. That was the possible ending. I think that was Anakin's plan, had he not, you know, gone a little bit on Padme and been cut to pieces by Obi-Wan. That fight scene as absolutely over-dramatic as it is, it's still really cool to watch. It's fun. It has great choreography, overly flashy choreography. Yes, but it's still really fun. And John Williams' score is just banging it at you. It's not as good as Duel of the Fates. He kind of hit gold with that one. So he just kind of goes to the silver mine and just bangs out some pretty damn good silver with this score. I enjoy Revenge of the Sith. It has a lot of narrative problems in terms of the writing.  But in terms of a spectacle, it's the best one of the prequels. I could rewatch Revenge of the Sith far more than Rise of Skywalker.  I'm just legitimately saying that Revenge of the Sith is a better structured film than Rise of Skywalker. At least it has a purpose.  But anyways, I enjoy the Revenge of the Sith. It's definitely one of the funnest films to watch in the entire saga. It is one of my favorite ones to watch. It's not one of the best ones, but it is one of my favorite ones to view because I get a kick out of watching it every goddamn time. Anyways, I'm gonna give Revenge of the Sith a 4 out of 7. Oh man, I was aiming for a 3 for so goddamn long, but I can't deny how many times I've watched this movie. And it's not just because I'm a Star Wars nerd. It's actually just that enjoyable. Anyways guys, I hope you enjoyed this review. If you did, leave a like and if you're interested in more subscribe. Otherwise, what's another trilogy that I haven't finished? Oh well, I guess I could continue one with this one, but oh man, the Fast and the Furious movies are on Netflix. I could watch the fourth one now. Anyways, that's all from me. I'll see you guys next time. Thanks for watching the video. You're probably wondering who I am. My name is Nitz, and you might remember me from the animated cult classic TV show Undergrads. It's been a while, but I'm happy to say the click is finally getting back together in an all new movie thanks to a successful Kickstarter campaign. But we are still asking for your support. You know, Nitz, you can't get more money unless you offer questionable favors. Yeah guy, unless of course those favors involve the ladies guy. By support, I mean getting the word out guys. Oh well, couldn't you find a better means than this guy? All he seems to talk about is supernatural or hold a coffee mug real awkward. Why didn't you ask a Kardashian or something? Yeah guy, get in with the ladies guy. Hey, he's trying to help out. Like you've been trying with Kimmy Burton? I've seen Jabba the Hutt finish a marathon faster.  To see any and all updates about the upcoming Undergrads movie, be sure to check out and like the Bring Back Undergrads Facebook page. And with any luck, we'll see you guys soon.


Have you ever felt really, really tired over a long period of time?  I think when you Google kind of internet advice on how to feel less tired, you really, really, really rarely get very specific advice. It's usually typically generic. And that's kind of the best you can do with an article usually. But I thought in this video today, I would share three common types of fatigue that I see and the different routes where I see that they come from according to Chinese medicine. Hey, guys, Dr. Alex Hine, author of the health book, Master of the Day, Doctor of Chinese Medicine. Now, before we jump into this video, there are two very important links right below the video. The first is if you'd like to become a patient of mine locally in Los Angeles or virtually via telemedicine, there's a link below to contact my private practice and reach out that way. And the second, there's a free guide for daily rituals that could potentially help you add years to your life with Chinese medicine. And that is also right below this video. So when it comes to exhaustion and just chronically feeling tired, obviously, there are a lot of reasons for that, right? And that's where the skill differential diagnosis comes in. Is this fatigue because the person isn't sleeping well? Is it fatigue due to an underlying medical problem? Is it fatigue due to something else that's going on? So I thought I would share three patterns in Chinese medicine that I see as the most common patterns that fatigue come from. Now, brief overview. The first one is what I call digestive exhaustion. The second one I call nervous system exhaustion. And the third I call adrenal exhaustion, just to try my best to loosely translate them into plain English. So let's talk about digestive exhaustion first. This typically falls into two different sides of the coin, right? The first one is typically the person who has very low appetite, especially low appetite for hours in the morning, often are prone to more food allergies, food sensitivities, loose stools, frequent loose bowel movements or incomplete bowel movements. Now on the other side of this coin, we have the digestive exhaustion type, which is really more of a person who typically has constipation. And they're more prone to going several days or even a week or sometimes two or three weeks with minimal bowel movements or incomplete bowel movements, more prone to hard dry stools. So in one case, this person is more prone to what Chinese medicine considers deficiency. They're having these low appetite, loose stools, food sensitivities. And on the other side, it's really a problem of congestion for lack of a better word.  It's very interesting to see. So the formulas for this approach that I use for the one type, we typically give herbs with ginseng and with ginger that increase metabolism and help drain what we call dampness. So that's often why these people have very low appetite and why they're having these frequent loose stools or a kind of diarrhea prone. And on the other side, really, these people tend to do better with herbs that essentially are purgatives that help get things going a little better. After a week of having more frequent or regular bowel movements, they often will feel a lot more energized. Now, when it comes to these kind of digestive exhaustion patterns, for these people in terms of general life advice, they tend to do better feel better fatigue wise by really focusing on diet. That's it. It's not by focusing on sleep more or working less. It's just if they're disciplined about their diet, they will often feel the best. So that kind of becomes the the chink in their armor, their Achilles heel, they have to pay very close attention to. So let's go to the second type, nervous system exhaustion. Now, for this kind of pattern, this is what it looks like. These people are often sensitive people. They often have issues with sleep with their heart rate, typically tachycardia racing heart easily, they notice their heartbeat a lot, anxiety, palpitations. And they're very prone to feeling anxious, typically, these are usually sensitive people or the nervous system is just buzzing with too much activity. And it's way too hyper vigilant. It's picking up way too much way too many threats out in the bushes over there, right? It's just a blue jay, but it thinks it's you know, it's a tiger or a lion. And they think everything out there is going to harm me. But it's all really subconscious. It's really the body is is perceiving too many threats that are not real. That's what it looks like. Typically, I see a lot of sleep issues, anxiety issues, and issues with tachycardia. So the pulse rate of these people is often very, very elevated. Double triple quadruple a standard pulse rate, you know, 90 plus often for a lot of people. Some people it's 130 at rest. I mean, it's crazy. Or they have symptoms of POTS where they get dizziness, and they stand up too quick and they feel like they're going to faint orthostatic hypertension. But generally, the heart is a key focus here. It's in particular. So the formulas here, typically, are we used to regulate the nervous system in the most general sense. So when I give people these formulas for this kind of pattern, the first thing I monitor is really the resting heart rate when I feel their pulse. So it goes from being 130 or 90 down to 68 72. And that's a really clear sign of the nervous system is really dropping down quite a lot. And that's almost always correlated with better sleep and less than zombie anxiety, that kind of thing. Now in terms of life advice for this kind of exhaustion pattern, really, what I would say is, because these people have a very sensitive nervous system, they have to absolutely prioritize stress and lower levels of stimulation in their life, which usually means nowhere less coffee, more physical exercise, because very grounding to the nervous system, time out in nature, or in the woods, maybe even avoiding city life, or if you are in a city, making sure your living area is very, very quiet, very, very restful for your nervous system. And in general, these people have to just be careful of general life stress. So everyone is born different, some people can tolerate a lot of stress, some people can't. And then we layer on our habits and our decisions every day that can improve that.  But these people in general, because it's the nervous system, have to be very careful about the way they live their life in regard to stress, pressure, deadlines, stimulation. Now the third kind that I call adrenal exhaustion, it overlaps a lot with a nervous system exhaustion. But typically, these kind of people have heavy fatigue, and more depressive symptoms as part of their picture. So often there are issues with sleep, more depression, but often anxiety to often issues with urination, exhausted all the time, heavy, heavy, heavy fatigue. So when it comes to formulas that we use, we typically use formulas that are, I guess you could say more stimulating in nature formulas that work to help increase the energy reserves of the person, these people tend to do better with stimulants just genetically, this kind of person often tolerates coffee well, for example, they could drink a cup of coffee and go to bed, no problem. But on this side, they're more prone to somnones. So they will often be able to sleep 10, 12 hours, no problem. But they will still have a level of fatigue and malaise and lack of motivation, that kind of thing. So this is the more somnone body type, let's just say, nervous system type, where kind of struggles to get motivated, can sleep a lot more depressive in nature, more or a little bit more sluggish in nature, not typically anxiety prone. So for the formulas, we discussed that but for the life advice for this person, these people often do better with stimulants, or tolerate them or maybe they will help them. But they often deal better with exercise, exercise helps them a lot. Often have to be careful with their diet as well. I find that a lot of my friends with this pattern do better with fasting, just eating irregularly or eating just one meal a day seems to be something that helps a lot of them. But in general, eating frequently for them tends to produce a lot of fatigue and a lot of tiredness. Sometimes it overlaps with diabetes or pre diabetes. But this pattern, I just think of it as adrenal exhaustion. But there's a lot of overlap with these other types as well. But I try to categorize this a little bit differently. This is from Chinese medicine perspective, we're treating the kidney and the heart often. So those are three common types of fatigue or chronic exhaustion that I see that they all get treated differently. Right? The first type, I'm often giving formulas for digestion. But there's plenty of herbs in there that improve fatigue, because that is the weak link in the person's armor. Right? We don't think biometically in Chinese medicine, we don't think, Oh, fatigue, ginseng every single person doesn't work like that. Some people will have increased fatigue on ginseng, for example, the other type, you know, we're often using herbs that are calming to the nervous system. You don't usually think of a sedative as being more energizing. But for the person that's anxious and their nervous system is like this, they will be more energized because they are more calm, they have more steady focus. And for the last type, give them some uppers, something that helps, you know, get activity in their mind, their body and their their spirit, so to speak, and physical exercise being really important for them. So I hope those help something a little bit more specific than drink water and get sleep. It doesn't really help anyone. That's not a revelation there. But I hope that gives you some insights if you're dealing with fatigue or tiredness every day on how you can approach it. Alright, that's all I have for today. Check out these related videos before you go. And I'll catch you in the next video.


I think we should all have a person of the year. Who's yours?  Who has been there for you this year? Who has shown up for you constantly this year in a way that perhaps others haven't? Who is a standout person in your life this year? Why don't you tell them? Text them, mail them, tell them to their face. You are my person of the year. That'd be a good thing to go viral, wouldn't it? Have you guys? Thanks for being here.