But welcome everyone, thank you so much for joining today's webinar and titled What You Need to Know to Get the Most Out of Your Healthcare Visit. My name is Sarah Miller and I am our Director of Partnerships here at the Patient Safety Movement Foundation and I'm very excited to be the facilitator for today's webinar. So I do want to go ahead and jump into a few housekeeping items. So I will start by going through the objectives. So the first objective is understand the importance of being part of the care team. The second is discuss challenges associated with optimizing clinical visits. The third, describe attributes of a successful clinical visit.  This webinar has been approved for one BCPA credit. Please note that the that the BCPA CE credit only applies for those who are joining today's live webinar. If you have any questions about this CE, it will take about five to seven days to process. If you have any questions at all, please feel free to email educationatpatientsafetymovement.org. One other housekeeping item that I do want to note, this discussion will be about 45 minutes long with 15 minutes at the end for a Q&A session. If anybody has a question for our fellow panelists, we do have a Q&A box at the very bottom right hand corner of the Zoom link. So please pop your questions in there to ensure that everyone on our side will receive them and we can answer those appropriately. And then we do have a chat box on the left hand side here. So if you have any general comments that you want to share with our fellow attendees and our panelists, please pop those in there. But just I want to reiterate the importance questions for our panelists go in the Q&A and any general comments for our panelists and other attendees will go in the chat feature. Another housekeeping item is we do have a fun interactive polling feature for today's presentation. It is called Slido. You'll see here that there is a QR code that you can scan that will take you directly to the link or you can join at slido.com and type in pound 439-438. Again, the slides will be up shortly for those questions, but I would encourage you all to please take part in this and have a fun interactive discussion with us. So with that said, I'm really excited to kind of share the light with Marilyn Whitley. She is today's moderator for our panel. So Marilyn, would you like to introduce yourself? Absolutely. Good morning, everybody. My name is Marilyn Whitley and I have been a nurse by trade for over 25 years and I am an independent patient advocate. Live in North Carolina and mostly do a fair bit of independent patient advocate work here and has been in healthcare for a very long time. So this topic of what you need to know is very dear to my heart as I would say. I do this every day with clients as an independent patient advocate and make such a big difference to the outcome. So we are getting ready to get started today to talk about that and I'm just going to turn it over to each of the panelists to introduce themselves and we'll just go in order. Karen, if you want to start first, that would be great. Thank you, Marilyn. I'm Karen Curtis, also a board certified patient advocate, though not in private practice. I founded and now lead the Care Partner Project which offers a variety of checklists for quick patient and family education for navigating and managing our very complex healthcare system. And Lois? Hi everyone. I'm delighted to be here. I'm Lois Cameron. I'm managing director of a social enterprise in Scotland called Talking Maps whose vision is to support people with communication difficulties to express their views. By background, I am a speech and language therapist. So I'm particularly interested in the interface between communication and how that impacts on healthcare interactions. Great. And then Dr. Moyle? To everyone, my name is Dingani Moyle. I'm an occupational medicine specialist trained by the Royal College of Physicians of Ireland. I've been in the clinical management field for the past 25 years and I've been involved quite extensively in terms of patient care. I'm also a university lecturer at the University of Witwatersrand in South Africa, as well as the Midland State University. The greater part of my career really has been spent in looking after patients and also advocating for patients' safety within the healthcare services. Thank you. Well, it's great to have everybody here today and we've got some great questions to start with and we look forward to some of the comments and questions and answers at the end as well. And we'll get started today. We'd like each of our panelists to answer the questions from their level, their area of expertise and we'll start with Lois today.  Well, your healthcare visits are the sort of bedrock of being able to explore health issues and if communication is a major issue then that is going to be an ineffective visit. And I think we need to remember that all of us could potentially have a communication difficulty at some point in our lives. Twenty percent of us will have a communication difficulty at some point of our lives. That might be caused through dementia, through stroke, through all sorts of things, learning disability. And so it's really important that we remember it takes to communicate and that the advantage of the fact that it takes to to communicate means that it's always possible to improve communication by the by one partner reaching over to use more creative or inclusive methods of communication. So for me communication is fundamental to good quality healthcare and I'm already beginning to see the poll that it's a bit of a major problem. So that's I'll leave it there for now. Thank you, Lois. And yes, we posted our first Slido question of today and if you know our audience could do the active poll and the question is I've experienced poor communication during my healthcare visit. And so far we've had it's looking like you said 100%. It is Dr. Mayo, we'd love to hear some feedback from you on this question about optimizing a clinical visit. Okay, thank you very much. In the optimization of a clinical visit really determines the outcome of one's treatment and ultimately also determines the prognosis of your medical condition. So optimizing a clinical visit basically refers to where the patient comes in and is consulted, giving all their complaints with clarity in abundance as well in a comprehensive and logical manner and not under any duration. So it can enable the healthcare professional to be able to come to a diagnosis and ultimately influence the treatment. So optimization of that clinical visit ensures that the patient will have the optimum service provided by the healthcare provider. Therefore, it has to be assert in a very clear, comprehensive, simple articulation in order to give as much information to the healthcare provider as well. And being part of the healthcare team in that aspect ensures that this is not a one-sided activity where it's only the healthcare professional who is determining the outcome of your treatment, but also as patients themselves. They are also part of the decision-making also influenced by the nature in which they collaborate and also provide information to the healthcare provider. Thank you. Thank you, Dr. Mayer. That is great information. I love the part where you said about being clear and that kind of ties in what Lois had said about communication. Karen, if you could jump in here from your perspective, your expertise in the roles of the family, if you could answer that question, that would be great. Well, all of the education that we've created is actually aimed at the family member care partners or the patient advocate that a patient may bring into their onto their care team. And the reason for that is that patients usually, unless it's just a routine wellness visit, are really under duress, as Dr. Moyo said. The stakes can be very high. And in those instances, it's very hard for a patient to attend to all of the important details that are coming at them. And that extra set of eyes and ears are critically important. And we have strategies of how that care partner can participate while still keeping the focus on the patient. Because that's really what I think we're all about is that patient-centered focus where it's the patient's needs that drive everything. But having that assistance can help in so many different ways of keeping track of information to review later on, whether it's in notes or recorded on an iPhone, which is a very simple valuable tool. And that every patient, it then gets that extra layer of support, post visit, even, to make sure that the, you know, every word that the patient that the doctor communicates is memorialized and understood and can be acted upon. Hearing that, that's just like great comments. And so that kind of ties into another question that I want to ask. And Dr. Moyo, if you'll jump in on this one, that will be great. Firstly, when we ask why are clinical visits not already optimized? Like where, why do you think that is? Thank you very much. There are a number of factors that lead to failure to optimize the current clinical visits. Number one, I think one of the major challenges really with both with patients and even on the healthcare provider side is lack of preparation. If one is going to be going for a clinical visit, one major issue that currently hasn't been optimized is lack of preparation. How are you going to describe your symptoms or your issues in terms of the chronological and simple manner? I think oftentimes patients, because they are overly in pain, they end up not being able to clearly prepare so as to define and set forth to their healthcare providers, they are major problems. Secondly, we have seen from my experience, I've realized that at times patients overly summarize their complaints to the point that the healthcare provider is to be poking in to try and elicit information, which ideally shouldn't be the case. Information must be presented in abundance and clear in certain terms and with, and that takes preparation from the patient side, which apparently in often in most cases is not the case. And the other issue that is not commonly found amongst clinical visits is that at times the patient and the healthcare provider, they fail to establish a rapport so that it's a collaborative, discursive interaction without any fear or any uncertainties where all the necessary information that is required for making a diagnosis and coming up with a treatment plan is clearly speltile. So key issues lack of preparation, overly summarized complaints, lack of rapport, both on either side the patient and also the healthcare providers. I think those are the some of the major issues which have led to the suboptimization of these clinical visits. Thank you. Dr. Moio, that is, oh sorry, Karen, would you like to jump in? Just to add one more point, I agree with everything that Dr. Moio says and and this kind of goes hand in hand with Lois's comment too, when you have people who are impaired in some way and able to communicate, I think it's very important to know when setting up the appointment, how much time do you actually have? You know, is it a seven-minute visit? Is it a 15-minute visit or do you have the luxury of 30 to 45 minutes? And so that preparation informed by the amount of time you actually have can help inform the preparation for that visit. And that's a really good point, Karen, and most of the time in my experience that's not volunteered to the patient, correct? You kind of have to ask because it's not always, unless it's a first time in a, you know, a bigger concern it may be brought up in the beginning but not typically. Lois, would you like to jump in here? You know, it seems like the whole communication thing is kind of floating around. I'm sure you would have some great comments to put in at this point. Well, I do think time is a major issue and I think being explicit, I think that would be a really helpful starting point and that's often not explicit. You have to kind of guess at it but I think to follow on from Dr Maya's point about rapport, I think that is a fundamental building block and about six years we did a study with people who had communication difficulties on their experience of healthcare interactions and actually 75% great healthcare interactions. So that's 75% where it was working well. So you might think that's a good new story but actually that means it's not working well for 25%. So one in four, it's not working well and when you take that with what Dr Maya was saying earlier about that that's a fundamental plank to effective healthcare, you've got to really question that and when we dug down on that, actually a lot of that was to do with healthcare staff's attitudes or fear of communicating with somebody differently and I think we need to create a culture where you can actually discuss some of those things so that in a way that you can name the problem to address the problem because it's great for so many people but that's still a significant number for whom they didn't feel the communication was going well and for whom health is then threatened because they haven't maximized their visits. And then sometimes Lois it seems to be that it also comes up that the relationship between the provider and the patient and the family are not always a good fit. What do you see in your practice about that? What would you recommend if they said we feel like we don't have a great relationship or it's maybe not a good fit? Could you tell us a little bit about that? I think there needs to be much more openness about that and that's probably on both sides too so that you can actually address that. So what is the problem with the good fit? Is it that somebody's not looking at the person when they're communicating? Is it maybe that they do need to think well actually you'd get on better with somebody else but at the moment that's not really talked about or it's very difficult to do without causing a major problem to actually shift provider. And I just think we need to be more open about it but in a kind of way that's supportive to the individuals not in a way that's confrontational. Dr. Moyle do you have anything to add to that? I know that kind of puts you in there from a provider perspective but I would imagine that this probably happened in your practice as well. Sometimes things are you know may not be a good fit. True, oftentimes you find that patients they lose that precious of golden moment in terms of articulating their issues and then we end up with repeated visits clinical visits which are really unnecessary because they would have been caused by the initial contact to the healthcare provider where information was never clearly spelt out and it is my encouragement to both patients and health providers to ensure that there is clarity at any point in time during a clinical consultation. Thank you. I like that golden moment that's really you know because when you're in that relationship you know as a provider that's really really important for sure. Moving to the next question we'd like to ask today is and we'll start with you on this one Lois. What are the different challenges for different groups of patients and family members? Well I'm going to focus on people with communication difficulties and I absolutely think that communication is not seen enough as a patient safety issue and that we need to actually acknowledge that that is a patient safety issue so for example in my profession and speech and language therapy swallowing is often seen as a patient safety issue but communication's not seen and isn't given the same degree of attention and for me that is absolutely wrong because I think if you do not get the communication right Dr. Moyer has highlighted that you do not get the treatment right and that can either cause erroneous treatment, long-term suffering and at its danger point death. If you look at serious case reviews of when things have gone wrong nearly always in every single one there's some communication issue there so we have to start naming communication as a patient safety issue and addressing it as a patient safety issue. That is a fantastic you know a great point Lois like a patient safety issue for communication. Karen would you like to jump in here because I know this is dear to you and you were you know where you've done your work over the years in the patient safety world you know I feel like you probably have a lot to bring to this question as well. Well I think I'd like to propose something kind of radical and that is that we don't look at doctor visits or doctor appointments it in quite that way we've been talking about rapport it takes time to build rapport and in the reality of our healthcare system time is golden. What I propose is that we look at these as meetings where the patient comes prepared with yes there are a list of concerns and complaints and pains and so forth and and summaries of their of their their histories but that they come and first and foremost what are their objectives so this is a meeting this is a this is where the the patient leads by stating what are my objectives I want to walk out of here with x y and z answered resolved next steps and flow from there so that the satisfaction with the doctor's appointment or visit or meeting flows from I've been heard because my objectives are leading this discussion and that this can all be done hopefully very efficiently you know if if the doctor feels respected for their time because they know they don't have to guess it flows from very clear communication coming from the patient themselves about themselves so that's in an ideal world I'd like to sort of reframe it as we are peers meeting about solving the problem together led by these objectives. I think that is you know that kind of ties together what all of you have said right that you can't be successful in any meeting without two partners whether it's the communication piece or the preparation piece and all of those together make it you know much more successful at the end of the day and I think Sarah were we going to move into another slide or question shortly or I think we're getting I'm happy to call it up I think we're moving into I'm just looking at my little notes here as we will start on we've got another a question kind of tying I guess trying to tie everything in together today and I think this will take probably a little bit from everybody but we'd love to hear from each panelist if they could you know prioritize two or three things like tell our audience two or three things that would really make a difference to optimizing you know your clinical visit so what can patients and families do before they go for their clinical visit and like I said if each of you could kind of summarize maybe two to three things while we're running this little poll and then we'll kind of comment on that as we get in through so I feel like I've started with you most of the day lowest how about you want you want to start with this last question that we will probably take a little bit but what family members can do to prepare you know for the best optimization of their clinical visit that me Marilyn yes ma'am you look miss Lois thank you thank you um sorry I think my internet dropped out there um uh well we've talked about um preparation and I think that is key um and obviously you know I come uh you know we've developed a communication tool called talking mats that allows people to reflect on their health and I think using something like that that allows them to actually detail what are the key issues so that actually you can get you know because we've we we recognize that time is precious but I really liked Karen's idea too of accepting that this is a meeting where both sides come together and that if people have clarity around their health needs and have begin to thought things through that will make it easier for the health provider or it may also identify those things that they need more information about because you can't make a decision until you've got that information so it's also about being clear about what other questions you want answered and because it's all about balancing those things up so that you can work for you can work out a way forward and that that is you know in summary Lois those are great points when we we can look at our little question we just asked in the act of poll what do you excuse me what do you do to improve communication during your healthcare visit and most people have said they have pen and paper available um you know to supplement and and 60 percent said I bring a loved one with me to be an advocate or an interpreter um which is you know I think for us as panelists that's no surprise that's the most common um that we tell people and as an independent patient advocate I tell people all the time as a nurse either you know family friends that you know that writing things down and bringing it or bringing someone with you especially when it's uh or her time so Karen I think you know if you want to go next we'd love to hear your thoughts for preparation you know what do you think would be two or three tips you know the the most important things to optimize clinical visits two or three things it's hard to you know that I know and as in life you know preparation is uh is uh really leads to a lot of success so I would say beforehand you know setting up the appointment and understanding you know the time that you have if you're accompanying if you're as a family member accompanying a loved one who is has some communication challenges or developmental challenges try to get that first appointment in the morning so you're not in the waiting room or the first appointment after lunch that's just a very practical tip because it's hard for somebody um for example if you you know we have something like 40 to 60 percent of of family members are now acting as as caregivers to loved ones with challenges and um you know their time is is valuable too so to be able to get in and you don't have to deal with waiting rooms and and to call in advance the doctor running on time um just simple things like that and then of course bringing um uh your your list of concerns all of your medication records you know making sure that you're that you're checking out that electronic portal regularly to make sure that it's accurate enough to date if it's not just bring a list of the corrections that you need to have happen fill out all of the electronic usually doctors now are giving you all the forms to fill out in advance so you don't have to sit there with our clipboards anymore um get that done so those are just a few things quickly more than three sorry it was but those are great Karen and the theme for me when I listen to you say that is all about being proactive right it's all about yeah being that um which is so good and it's taking ownership for your you know your healthcare and and moving in there um Dr. Moi you've brought so much insight to us today from a provider perspective you know ideally if you could have um give your your patients your families two to three good tips you know things that would really benefit their provider visit what would those be for you number one when you visit your provider always remember that you will never be taken by surprise in terms of questions the healthcare provider always ask you what is the problem when did this start what else is associated with your problem what medications are you on what investigations have been done so those things you should go to your healthcare provider expecting those questions and you must give answers i think louis has also just mentioned that you need to know about your medication year strength record you can list those medications down the different tests that have been done so that's number one number two before you go to the health service provider always make sure that by the time you come out of that consultation room you fully understand what your medical condition or health condition is fully and what are the medications or the treatment plan and also the prognosis of your condition oftentimes people come out of a health uh provider's office without really being very clear about what is their condition what medication are they taking is this lifelong or not make sure before you even leave for consultation you will make sure that those questions you ask your health service provide so that by the time you're very quite we are very clear about um those are the your your condition i think those are the key issues that i would ask patients to pay in mind that is you know those are great points and as you said the last thing about knowing your diagnosis you know sometimes it's hard for providers to even pinpoint one particular you know or they may not have a definitive when um individuals leave the office and sometimes that leaves them a little uncertain do you have any suggestions for how you know it sounds like when you were saying your tips like being able to summary summarize or tell your provider back what you have discussed right would be helpful and you understanding is there anything else when it's a you know sometimes a confusion where a miss not a full diagnosis you're still kind of um looking at or you have other tests to do is there something else that you would suggest that patients and family do um to help them understand better right um maybe if you're still on my side one another important issue is to ensure that um patients or clients who always volunteered all the truth to the health service care provider we've got oftentimes where we have clients who do shopping of health care providers but when they come to our clinic office they never volunteer that information someone is hidden uh without really disclosing that we have visited so many health care practitioners and this is the advice that you have been doing that they have been giving you so when uh during um consultation and show that we disclose everything that has happened uh with regards to your condition with regards to treatments and investigations uh even also we discourage uh health care provider shopping where you really want to get a diagnosis or rather a preferred diagnosis rather I think just be objective volunteer all the information to the health care provider and then they will string that together uh for your own good in terms of diagnosis treatment uh and follow up those are some some great points and I love the way you emphasize being truthful um you know one of the things I often say to our clients is you know our providers are only as good as the information they're giving and they sometimes don't know what they you know don't know if they've not been told so um that's a really really good point and and I think that is very um important as well Karen or Lois do you guys have anything else to add to that you know I think you some of that works into trust too I'm sure but I didn't know if you either one of you had any um points you'd like to bring up at this point just that at the end of the day trust is always going to be um what underlines good communication and we will only you know that's we will only communicate as much as we feel safe and trusting with the other person so that's important on both sides of the dynamic that there is trust how about you Karen do you have anything this has been a terrific discussion and and you know getting the perspective of a position is rounds out the picture I think for all of us and for Lois to bring up something that about you know very real practical considerations in communication um that are have you know potential limitations and I think my main takeaway from this discussion is that we at the care partner project will develop a tool kit so we will amass you know um you know checklists based on this thank you very much to the patient safety movement for bringing us together we will bring this work forward you won't have to take notes here because we'll put it all on the care partner project um website for tools for patients and family members to be prepared and to do their part to um fully communicate um openly and honestly with their positions and we'll we'll provide all of that so look for that put your email address in the chat box if you'd like for us to send it to you directly or check in with the care partner project but this has been very very important discussion thank you yeah and you know from as someone that works as an independent patient advocate so I work closely in the community with with patients and families um you know we we do do a lot of prep work with our clients you know and our patients families before visits um so that they can get the most out of it that and that is a very common theme so you know as I said in the beginning that's dear to me because it is um but having something all put together with all the pieces in there you know like lois you had said about communication and then Dr. Moyn talks about preparation and being truthful and and all those those are just so important to the keys to being successful you know and getting the information you need so I think we are getting um for me close to the question do we have any questions in our question Sarah from our group or yeah so with excuse me with about 15 minutes left I do want to kind of kick start the Q&A session Marilyn I'm happy to kind of filter through um the questions that have come through but thank you all for you know having it looks like there have been some great conversations going on through the chat but the first question that's come through um is from an anonymous attendee and the question is does the panel agree that communication requires only two people does a second listener have a role in improving effective communication does anyone um want to start off by answering that um that might have come when I talked about the the communication always involves two people it can of course involve more than two people but is a dynamic interaction so at least needs uh face-to-face communication needs at least two people and I mean I think that is one of the advantages of it because as I said the one person can bridge across to support another person's communication so you almost don't know what you don't know if you don't put the supports in you can't see how you can help that person to communicate more effectively and yes of course um particularly when you're in a stressful situation or you're having to process information having another pair of ears there to actually take in what is said and to repeat that back can be really really useful um I think what's key is though that the focus is on the person with the health issue and the other person is there to support and that everybody understands that dynamic so that the other person doesn't take over I think is what I'm trying to say they're there in a support in a supporting role that's my answer don't know what Karen and Dr. Mario think I completely concur with what you've just said absolutely correct thank you perfect um well the next question that we have um I do want to start with you Dr. Mario but the question is are providers open to having visits recorded and is there any time when this is not allowed that's a difficult question so to speak but uh look it all depends um or with the health care providers in terms of those recordings whether the the health care provider is comfortable with that and also in compliance with the regulatory provisions that guide um the the practice of medicine or nursing in that particular aspect so really there is no one science fits so it has to be contextual uh but lightly driven um from from the understanding of the health care provider and also the ethical provisions within the profession as well as the regulatory provisions in that particular set such things will vary uh especially from country to country or from region to region so it depends on the preference of the health care provider but one thing that I must say is that um a patient ideally is going to write of access in terms of their health conditions they need to know fully about what is happening about them what is being planned or nothing really should be done without a patient's full understanding in in clear terms but specifically in terms of um recording those sessions really I wouldn't give you a very um one size fits all answer but just to say is contextual or circumstantial are depending on where is being practiced thank you thank you dr moya um the next question that we have I'll I'll read through it a little bit so it says if we have met with a provider and as a result need to go to another specialized individual is it a requirement if we ask to get written records to ensure that what's in the record is correct that's perfectly fine ideally when you are moving from one health provider to the other records both from who has been treating you all this far are always required such that um it makes life easier even for the attending physician whom you have been referred to um in order to fully understand because some of the information or some of the results will be in medical jargon that the client times may not fully understand and therefore these need are normally referral letters from one service provider to the other ideal although in some cases you will find that a person will move from one healthcare provider even uh behind their back and um go to the next service provider the next service provider who is not like they will turn them away but it suffices to say it's always ideal to have a referral from one practitioner to the other to so as to clearly um facilitate the patient care even to at a higher specialist level okay Dr. moya um it looks like we have one more question um and I'd like to get everybody's thoughts on this one um but the question is can the panelists comment on the pros and cons of using a family member versus an independent advocate to support the patient as the family member may have their own agenda Marilyn do you want to start that is um you know uh that's a great question and there's not one simple answer I would say that but what I would comment on is that again it depends on the patient and the family member I always think you know someone that knows the patient the best is the best person to be with them of course knowing them inside and out family know them very very well an independent patient advocate would know the medical side and some other pieces as well um but I would say the biggest point in that is that the focus has to be on that person so if it's family they look at but they're not sure that family would be um you know totally objective family would be totally understanding just being in that listening mode because of course as patient advocates most of the time we do listen um we do summarize at the end that kind of a a role we take or that's what the way I do in practice so I think it would be a good discussion to have with somebody if you wondered if your family member would not you know totally understand so when we talk to people and when I do like education information and that I always tell our you know audience that they could easily have a family member that could be their advocate right like a patient advocate but again it it focuses in on that do they have their best interest and are they you know going to leave that patient to be the center of the conversation and the meeting I like the meeting Karen tell me about the meeting today Karen did you have any comments you know I agree with Marilyn um because we try to frame that issue gently at the care partner project where I like one one line that we have in our childbirth checklist is that if you know we spell it out if you don't think that you can be you know objective put the the mom to be needs first you know really basically suspend your you know your yourself um then maybe the best parent care partner you can be is to find someone else to fill that role whether it's a professional or you know a best friend because it is tough even though uh you know family members you know we all have families we all have opinions so so being able to suspend that is kind of a challenge um so it's it's really um it's a very good point um on the other hand sometimes you know family members you know can read their loved one in a way that nobody else can't and so they can kind of fill in um it's it's it's it's it's just something that needs to be aired I think transparency and a good discussion is the best start for it and and this just brings me to another point when you said that Karen I actually I can give you an example of a client that I do have and I support the daughter more than I you know in that she is her mom's best advocate and nearly every conversation we have somewhere in there I always said you know your mom better than anybody um so that is you know again you know for us we kind of play the situation because in this situation that daughter just needs a little bit of coaching from us as patient advocates for her to be her mom's best advocate so um I think it sometimes is a little bit different in each situation but but that is another you know thought I think it is it is different in each situation and it is a case by case um scenario but I really liked Marilyn your comment there that you were coaching the family member or supporting the family member because sometimes it becomes an either or and actually that's not particularly helpful because if you're a family member taking on that role then having some sort of coaching or mentoring to allow you to be reflective and think about your own agendas and think about how to put your loved one's views across is really really helpful so it's not an either or either and family members if they're in that role need some active support because it's not an easy role it's really not and and you know for me we always say you know I'm being a great patient advocate if I can work myself out of a job like if I can get with individuals and families and support them and empower them to be able to make good decisions and feel good about what they're doing then that is you know they don't really need me as much anymore and those are the great situations in the great you know cases that we get to work on I think to where somebody's got a communication difficulty it's often the family member that can interpret the speech much more quickly and effectively than a non-familiar speaker to but I I like the idea of them being supported it's really helpful okay well I don't excuse me I don't see any other questions that have come through um but if anyone that is here for the live webinar if you guys have any other questions that you'd like our panelists to answer I will give it about a minute for you guys to pop them in there otherwise we'll ensure that um if you want to email us we can get those questions answered and send those back to you um Marilyn is there anything else that you'd like to say before I close this out I don't I think the last question did someone ask about um you know which type of patient advocate to get if you were getting seemed like I was reading the question I'm not sure but um yeah but there was something there I think yeah this is an activity um in the chat about that as well uh so you know and Karen um I know that you know a lot I mean Karen and I are board certified patient advocates and we are nationally internationally sort of um you know recognizing that and for me and I'm sure Karen would say we we always recommend if you're going to get somebody I would recommend that you get someone that's board certified um you know from an ethical they've done their um homework they've you know they've tested they're certified but there's a lot of great you know advocates that are out there and there's different avenues we always tell people to start in that and then you you know depending on the type of person you are whether you want someone who's medically licensed along with that board certification to support um or depending on your situation Karen do you have anything that you'd like to add because I know that you have a lot you've been doing this longer than me even as a um from the and knowing the board certified patient advocates and and who we you know have in the United States and Canada what your thoughts are well I the only thing that I would add to what you just said is that if somebody is medically there are a lot of nurses who go into advocacy well like you did um but part of the advocacy role is not delivering care or actually even making any recommendations based on medical knowledge it's all about helping people to to get to the right information the right sort resources to make an informed decision on their own um and that's really what you know um advocates are just wired into collecting and organizing and helping people understand all of the pieces of information um that are out there because it's it's it's very it's very we have complicated systems no matter where in the world you are um so it's the quarterback really that they advocate does but ultimately it falls on the patient to make their own decisions based on what fits for them but we you can't look to an RN patient advocate for any you know sort of advice that a that a physician would give yeah and somebody in the chat says can the advocates get involved in incorrect billing issues yes we see that a lot a lot a lot of our practice is that yeah um the the last question that we had here it's more of a statement but um they said dr moya stated that the provider should share written information with the patient i wonder if that needs to be translated for the patient to clarify medical terms i think that's interesting dr moya do you want to comment on that i didn't get you quite clearly in terms of the the patients having signed to the medical records is it what you say yeah so um i'll reread it it says dr moya stated that the provider should share written information with the patient i wonder if that needs to be translated for the patient to clarify medical terms yeah ideally the the the information like for instance every medical record that relates to a patient is their information and ideally they need to be able to understand especially where letters are written in terms of medical information either to employers or even to the other doctors or even the the the full record in general patients are supposed to have access at least from my experience and where i practice the a patient should have access to their medical records and even if there is medical job when etc it needs to be explained to them in simple terms so that they fully understand because it's information about them and they need to understand what's happening because this is particularly important where that information is to be transmitted from one doctor or one healthcare provider to the other and we've often seen these things even in in work situations where a medical report is written to any employer and um the standard drill is to make sure that the the the patient must see that record and must also agree with the record that is being said about themselves before it's transmitted so that there is clarity and um uh good harmonious um uh relationship between the health service provider and the patient themselves can can i also just say that i've popped into the chat and sign posted uh a new organization called card medic who were formed really during the pandemic when they realized that uh particularly patients weren't understanding with everything and PPE and all the communication problems so they've set up this app that basically allows easy read accessible health information about the major conditions to be part of the app so i've just point popped the link in there in case anybody's interested in it but i think it's a great initiative because i think getting fast easy read information is a challenge and i'm glad that somebody's trying to tackle that great thank you los um well we are right at the top of the hour so um i'm happy to kind of close this out i did want to say thank you to everyone that's joined live today um i hope you found value in today's discussion and thank you for um participating in the interactive poll um thank you so so much um to all of our panelists and this was a lovely discussion and i hope everybody found value in this as well um if you again just want to reiterate a couple of housekeeping items if you did join late um this webinar was approved for one vcpa credit for ce hours um please email education at patient safety movement dot org if you have any questions but just wanted to note that this might take about five to seven days to process um but again if you join late um feel free to email us if you have any questions um and then last but not least here at the patient safety movement we do strive to present the highest level of you know quality educational content to you all free of charge um as a non-profit we do rely on donations from individuals so we do kindly ask you to consider donating so that we can continue um to kind of ramp up our educational programs and do what we can to support you all um so if you have any questions again please email us or visit our website for more information um but again thank you all so much um this webinar will be has been recorded and will be posted on our website shortly thank you


I was in Philadelphia earlier this week to announce that our market was going to be staying in Philadelphia and moving to a new headquarters at 2400 Market Street. It's a great company, it's great for Philadelphia, great for Pennsylvania, and I'm happy that the state was able to participate in making sure they stay here and we retain those jobs. This week, Pennsylvania was honored to be chosen as one of seven states in the country by the National Governors Association to receive grants for an opioid learning center. This is going to be a great help to us in our battle against opioid addiction, but it's also a great affirmation of the good work we're all doing in Pennsylvania, Republicans and Democrats to make this program work to address the challenge, the epidemic we all face here in Pennsylvania. The best social policy is a good family sustaining job and the Commonwealth can play a role in making sure that we have sites that are ready, shovel ready for businesses to create those jobs and the industrial park that I went to last week in Berks County was one of those the Commonwealth has worked with local officials to make sure that project gets underway and that we have shovel ready sites when businesses are ready to create the jobs we need them to create in Pennsylvania. So I was happy this week to go back to my home county, your county, to the city school district, to the Ferguson school and welcome the kids back to school, Ferguson school and elementary school. Great to be there for three reasons. First of all, it's my home county, second of all, I take education seriously and have done as much as I can to promote investment increases in investment in education at all levels. Finally, I was there because your city school district is working through a recovery plan that seems to be working. They're ahead of schedule, they're doing a good job and I wanted to foresee how they were doing but also compliment them on the progress they've made. What I saw in York, one of the poorest school districts in the Commonwealth, was a lot of teachers teaching with resources, a lot of kids doing some good learning. I saw the future of Pennsylvania in those classrooms and that's what should make all of us happy that we're investing in education.


What is going on guys it's your boy DPJ here today with another Destiny video and in today's Destiny video I'm showing you guys some scotch cannons game play before we get into the video if I could ask you guys to leave a like that would be absolutely insane it's at the end you enjoyed the video if you could leave a like let's try and reach 4,000 likes that'll be incredible but getting into the video now there's been a lot and I mean a lot of speculation surrounding this weapon over the past two weeks people thinking it's a hidden weapon people thinking it's a rocket launcher primary or secondary due to that image where you saw a guardian welding this and having a rocket launcher on his back but actually it's none of the above it's something that drops as a reward from Valix the loyal while you're playing the prison of Aldous for me and my team it dropped during the second round which we basically had to take out three waves of enemies and three splinter mines which we took out the three splinter mines it was rewarded it dropped on the floor we could pick up and use it on the third wave of enemies I picked up and just started firing I saw it I was like fuck yeah that is mine so I basically picked up and started shooting I died not long after so it didn't last too long and use it in its different modes now I was told that it does shoot in different modes like I said I was just tapping it but I've been told you can charge it by holding the trigger unfortunately I haven't seen this in action so this could be a million miles off how it actually works I do have more footage of this scorch cannon from the prison of Aldous and it was given to me by my friend easy now one three three seven who does pulse daily destiny if you guys do want to check my is linked in the video description it just showed you him basically run around firing it's like a fucking maniac the weapon also dropped us briefly after beating the boss in the shadow thief strike which is the new strike that comes out with the house of wolves also but my teammates being greedy thoughts they wouldn't give me a go of it so I just actually basically witness them to spy into the ground so that is it guys it ain't a weapon you keep it so that you pick up for a limited time only both in the prison of Aldous and in the shadow thief strike hope this clears some things up for a few you guys and all there's been a lot of confusion surrounding this weapon but there it is the scorch cannon is a weapon that drops as a reward which you use for a limited time in both the prison of Aldous and the shadow thief strike I'm not gonna deny it's rewarded you in other mods I'm just saying I played the prison of Aldous and the shadow thief strike and as rewarded to us both in them but guys that is it for another destiny video if you guys are new to my channel and enjoy daily destiny be sure to subscribe do drop a like I do appreciate the support thanks for stopping by as always and peace out until next time


page at Y254 on Twitter and it just you can equally follow us on Instagram that is Y244 underscore channel. My name is Michelle Lashira and again thank you. So this time around we have another interview by Nana other than an artist who has been into the game for more than a decade and Tim Milano's like you and I cannot cannot relate to the fact that he has been into the game by his taste of music and how far he has come is a story that you need to stick around for and he'll be telling us more about his new projects and what he has been doing in these couple of few years and they are make sure he's taking because this is another it's a revolution yes because you need to hear more about these particular artists voxies in the building thank you for coming through. First of all I want to introduce to you the time when I heard you on that track I was 100 percent sure that you were TZ and then after long after why then I was like I went through your bio I was like wow this is our fellow Kenyan artists so probably start off by telling us inspiration integral optimistic extreme influence so you've been into the game for more than 10 years and listening to your kind of music that you're doing it's it's classic because it can stay it can prolong generation from generation we can still listen to your kind of music and you can still relate to the issues that you're addressing so once you start uh falling in love with music so this is a music and in the music studio in Ketambu. His own music is a genre of music. He has tapes and songs. He has a lot of mangoes. I like to fall in love, fall in love with music. I love it with the time. I think hip-hop is a generation of music that is related to music. Hip-hop is a culture that relates to music. There is no agency like Gielaiza. Hip-hop is a generation of hip-hop revolutionaries. It's been over 40 years. So I remember when I was 16, I recorded in Bahakuanza. Before I recorded in Bahakuanza, I was in La Saba. I recorded in Bahakuanza in 2006. Okay, so from 2006 up on the Lanza Mziki it's not professionally. This is what I'm going to do for the day. Professionally, because of the recording of the studio, from really coming in 2012, because of the recording of the studio, because of the quality, I was able to get into the radio for the station, the home of KBC. Later on, when I started working on it, I was able to get into the work of the studio, the quality work of the studio. Later on, when I started working on the music, I was able to get into the work of the studio. Okay, now, in the way that you're doing it, we are asking this question. Like, you've been in this game for a while. You've been playing the music for a long time. But when you were doing it, it was because I came to you and I was able to get into your music. I was able to address social issues, injustices, and I was able to get into the work of the studio. It's reality. And I was able to say, you were able to get into the work of the studio. So, the question I'm asking is, what do you think about it? What do you think are the benefits and the advantages of music for the passion and preaching the message of what you're going through in the society? I'm not sure. I think that music is a key concept. Music is a key concept that's focused on the song. It's a key concept that's focused on the song.  I don't know if it's because I'm a big fan of the radio, the radio Tyfa, the radio KBC. Bad Apple, as I said, I'm a studio director, I record the quality and quality of the music. I'm a big fan of the work and the money I make in the studio. I don't know if it's because I'm a big fan of the safari, but I don't know if it's because I'm a big fan of the music. I don't know if it's because I'm a big star, but I think it's because I'm a big fan of the music. The pattern is that I work as an assistant to the type of music. I run the company as a recording artist. I work with the studio and record albums. I also use albums online and upload them to music. I make the music through advertising. Produce it through that product. they tend to portray a different lifestyle which they are not living. your pressure just to maintain the kind of life that's the reason why they get into depression and also drug addictions and any other form of addictions so your thoughts on the fact that just being real in the type of music that you're doing and your lifestyle just don't fake it for the lifestyle of the kind of music that you're doing In general, how do you deal with the kind of music that you're doing that's just for the lifestyle of the kind of music that you're doing? How do I deal with it? How do I deal with it? How do I deal with it? I've been waiting for this day and I've been saying that if you're being like, they get used to their actions, or do something, you know? But these kids are my friends, know? In a sense, they're smart like a role model who can teach me to be a musician. My brothers and sister are super stars. There are some kids like that who come to my family, and they say, I know everything about money. My mother was the one who was there. She was the only one who was there. She was the one who was there. After she left, I was left alone, I was with my mother as a family. I was with my mother, but I didn't know what social media was. I didn't know anything about women, I didn't know how to read, I didn't know how to read, So they're not singing on their own, they're just singing in a different way. I think we have a lot of problems with our children. We're not in a generation of depression. If we are in this world, we will be in a bad situation. Now, what we have to do is increase the pressure that young people are facing. That gets us to your first album... ...which is actually my album. It's coming in. I'm going to do a free domain change. What I'm seeing is personal experiences that you've gone through. And you address them in the album. In the music, yeah. I'm a free domain change. But I'm going to do a free domain change. I'm going to do a free domain change. I'm going to do a free domain change. I'm going to do a free domain change. I'm going to do a free domain change. I'm going to do a free domain change. I'm going to do a free domain change. I'm going to do a free domain change. I'm going to do a free domain change. I'm going to do a free domain change. I'm going to do a free domain change. I'm going to do a free domain change. I'm going to do a free domain change. I'm going to do a free domain change. I'm going to do a free domain change. I'm going to do a free domain change. I'm going to do a free domain change. I'm going to do a free domain change. I'm going to do a free domain change. I'm going to do a free domain change. I'm going to do a free domain change. I'm going to do a free domain change. I'm going to do a free domain change.


Hello everyone and all, my name is Shelfoy and I am here to share about what economics is and why it is necessary. Well, when we talk about economics, all that strikes our mind is mathematics, right? But let me tell you, it is also about the study of how we make decisions in a world where resources are needed. It studies about how goods and services are produced, distributed among the people and consumed. Moreover, it helps us to think strategically and make proper decisions in our life, which helps in reducing the heat of house. It helps us in every possible way. And by an all-experience, I can say that studying economics will help us to develop our capacities and reach our fields such as communication and management, problem solving and many other things. So, consequently, of all such things, across a degree books in economics can help and provide an ample of job opportunities in main fields such as business, banking, foreign managers or any other financial institutions. You can always opt for the economy course because it is where you are at your best. And with the facility provided by the Petso College, believe me, learning takes place in all our learning. So, I wish all of you all the best and make the right choice. Thank you.


Majorist Vice President Kashim Shatima, all Progressive Congress APC National Chairman Abdulahi Ghanduje, have hailed the judgment of the Presidential Election Petition Court. Senator Shatima, who spoke with reporters after the judgment, said the judgment has shown that the voice of the people cannot be silenced. He said democracy is the winner, urging the petitioners to join President Bola Tunubu in the task of national building. Well, Daniel has come to judgment. Today is a great day for Nigeria. The Nigerian judiciary had proved itself to be the guidance for justice and fairness against the sirens of deception. It's a battle between the will of the people and the process of misinformation and disinformation. But democracy has finally triumphed. Like the bird phoenix, the rice is from the ashes, resolute and unyielding. And in this age of information, disarmament is our greatest armor and unity. It's our strongest force. Remember, ladies and gentlemen, in this battle for the survival of the nation, in this grand symphony of democracy, your voice, your voice is a note that cannot be silenced. This is the beginning of the maturity of democracy in this country. We have to thank the politicians, even the leaders of the political parties. We have to thank them for showing maturity, especially the presidential candidate for PDP and that of Labour Party. We have to appreciate them. We have to thank them because they also do contribute to the stability of democracy in this country. We have to inform you that we respect the judiciary because if you see how five of them are unanimous on the verdict that they have shown this evening, and not only that, all the other consolidated, you know, allegations, complaints by the opposition, all the three consolidated partitions have been exhausted, especially the issue of disqualification of our presidential candidate and his running mate, or the vice president at the moment. You can see how that one was dispensed. Also, the issue of malpractices in the election, you could see how the judges were able to treat it and dispensed everything and we're happy that this program was done. So you get notified about fresh news updates.


Welcome to uncovering the sophisticated Kubernetes attack in real time. Kubernetes has become the de facto cloud operating system, and every day, more and more critical applications are containerized and moved to Kubernetes. This means Kubernetes is quickly becoming a crucial component to secure. Today, we as defenders are in the dark because we lack the observability needed to detect or respond to attacks on our workloads. Today, we'll show you how we can build out a detection program to uncover a sophisticated attack against a Kubernetes cluster. Hi, I'm Jed Salazar, Platform Security at Tesla. I like mountains and distributed systems. Hey, my name is Natalia, and I'm a security engineer at Isabel and I really like traveling and flying on planes. Observability in distributed systems is a crucial element in detecting issues and making changes to improve the stability and security of the system. So for SRE, we use things like Prometheus to actually come up with metrics to define how we can actually improve the reliability of a service. What we're advocating for is that security takes the same approach, being data driven and using data to drive forward security improvements within our system. So a lot of security today practices, they really focus on the pre-fail and post-fail approach to security. Pre-fail tries to predict the necessary protections that a system is going to require based on threat modeling or an assumption of risk. Post-fail ensures that you have the necessary logs for intrusion detection to be notified if you get compromised despite those protections. What we're advocating for is that we actually change that paradigm and we move from a pre-fail and post-fail to a pre-data and post-data paradigm. Data allows us to continually measure that our hardening and security configurations are suitable to protect against real-world threats that are detected by observability within our environment. With observability, we will open your eyes to the reality of the threats in your environment. So how do we secure this? This is the CNCF landscape, basically the set of tools and systems that make up the Kubernetes ecosystem. I like to call this the CNCF threat landscape. If you're tasked with securing Kubernetes, you might look at this landscape and become overwhelmed. It takes a lot of resources and time to successfully build an operated cloud-native environment, let alone secure it. However, different components of your stack have different levels of risk and prioritizing your focus where there's the least trust and the most risk is a good way to get started. For example, it's reasonable to assume that the Kubernetes scheduler is less of an attack vector for your cluster than an internet-exposed pod that handles untrusted user input. But what if I'm following CIS benchmarks and scanning my container images? Is that enough? Don't do this. Not to say that vulnerability scanning isn't important, you should definitely not deploy vulnerabilities in the problem. There are a number of different protections that we can implement within a system. Admission controls like OPA can define security standards and enforce policy for objects before they're persisted to LCD. You can protect your containers by removing dangerous debugging tools like interactive shells, package managers, compilers, and unneeded runtimes with distro-less base images. Vulnerability scanning should be integrated to a container image build stage and runtime sandboxing such as Setcomp, AppArmor, GVisor, and Firecracker can limit the potential of privilege escalation or container escapes. Still, each of these tools offer varying degrees of locking things down. So how can we verify that these protections give us sufficient protections from the real world attacks that we're actually going to see within our Kubernetes environment? So the way that we can enable that is by making security look more like SRE. So if I were to ask, how secure are you today? Could you provide a quantifiable answer to that question?  We need to make security more like SRE by sharing a lot of the same SRE principles, like being data-driven and measuring the data that we actually receive within an environment. In this new paradigm, where security shares SRE practices, security collects data, observes the feedback, and then makes continuous data-driven decisions to improve the security of our systems. Are you scanning your images? Do you apply network policy? Are you encrypting your data at rest? How are you measuring the efficacy of these protections? And then can we detect if the service running in our environment is outside of our security policy? The way that we do that is we trust but verify. This is an old security adage. So you place a lot of trust in your systems at deployment time. For example, if you build up a container image, you should have this container image represented as infrastructure as code. So the configs that we deploy are pretty much well understood. For example, when the Kubelet launches our workload, we can assert that the configs have been statically analyzed, hardening measures have been applied, and we can basically account for every bit in the deployment. However, over time, entropy reduces that trust. For example, an internet-exposed workload gets attacked. An SRE runs kubectl exec and installs some debugging tool and fails to clean up after themselves. Over time, this entropy becomes a problem and observability verifies the trust that we place in a system throughout its entire lifecycle until that trust is broken by some type of compromise. That's what we call detection. So we wanna test our security assumptions and measure whether the protections that we're applying are suitable for the threats that we actually detect within our environment. So DevSecOps integrates security into DevOps and DevOps writes tests for code. For example, unit testing, which is ensuring that the behavior of a system is understood. Observability continually validates this behavior. If you have security controls applied, for example, a network policy, do you have the observability, for example, via network flow logs or DNS queries to verify that that network policy is suitable for the type of protections that are needed? Capturing system calls and file system access from a container can validate the efficacy of our SecComp and app armor profiles. On the left, we actually have unit testing and on the right, we have the observability that can test and verify that unit test. These measurements can continually inform us whether the protections that we're utilizing are sufficient based on the attacks that we've identified in our environment or if we need better protections. So why BPF? BPF is really the optimal tool to provide this observability in Kubernetes. Because a pod is just a set of Linux processes running in the context of a kernel namespace, the pod makes system calls and implements CNI network functions within the kernel where eBPF resides. eBPF acts as a virtual machine in the kernel with a generic set of 64-bit registers and eBPF programs that are attached to kernel code paths. This means eBPF can intercept system call events and react in real time with fully programmable logic. Using eBPF, we can build out a detection program and the best way to get started is to work with your red team or just attack your systems yourself. Even as a beginner, you can start to collect the knowledge of tools and techniques and use eBPF to detect these attacks and configure alerting options to detect attacks in real time. But the best way to detect is first knowing how to attack. So in this talk for detection, we are going to use Celium and show how it uses eBPF to very efficiently monitor our malicious network and process behavior inside of a Kubernetes workload and give you identity of our visibility into those malicious behaviors. So a little bit of background, Celium deploys as a demon set inside of a Kubernetes environment. This means that there is a Celium agent running on each one of your Kubernetes worker nodes. These agents are communicating with the Kubernetes API server to understand pod identities, network policies, services, and so on. And based on those identities of each one of the workloads deployed inside the Kubernetes environment, Celium generates a customized and highly efficient eBPF program to do connectivity, observability, and security for those workloads. Celium is able to both enforce what behavior happened inside of a Linux system as well as very efficiently observed that behavior. It can collect and filter out observability data directly in the kernel and export it to user space as JSON events where it can be sent to many external system, for example, a CM to do investigation and alerting. In this talk, we are focusing on the security use cases and security teams and how they would like to consume those data. So this is how our JSON event looks like, which was exported to user space by an eBPF program. You can see the Kubernetes identity of our information like pods, containers, labels, and the OS level process visibility information like binary arguments, Docker ID, and the PID. For simplicity, we will just use some Python scripts directly consuming the JSON events that would be otherwise sent to an external system like CM system, like Elasticsearch or Splunk. In this talk, we are going to see two attacks both happening on a live GKE cluster. In the first one, we are going to reach the host file system and break out from the container. And on the second one, we are going to download some sensitive data from an external S3 packet. And for detection, we are going to use Selim and the power of eBPF. So from an environment perspective, let's assume that chat has already accessed a GKE cluster. That's what we can see on the right terminal. And on the same cluster, I have Selim setup and running, which monitors all the Kubernetes workloads and provide observability, connectivity, and security for them. For simplicity, I'm going to use a Python script which would parse all the JSON events coming from the kernel and export it to user space via an eBPF program, and then which would look for malicious behaviors. Now the question is, can JED get access to the host file system? So let's find it out. So the easiest thing to do would be to spin up a pod with the privilege equals true flag. Note that Kubernetes allows us by default and this disables all of the sandboxing mechanisms inside of a pod. Okay, let's apply to the privilege pod spec. Now we have a privilege pod which gives us the same permissions as root on the node. Why is it so powerful? Privilege enables the capabilities, all of the capabilities which the pod, as you can see has started. This includes Capsis Admin, which is basically the new root in Linux. And on the left terminal, we can see that the generated eBPF program was able to pick up the new container that has started. We can also see the privileges that include Capsis Admin. So now let's try to queue Cuddle exec into that pod. Let's see if we have access to the host's file system. I'm gonna run cat, etsy, or sorry, cat proc partitions and see if we have access to the resources on that host. Here we see that the partitions listed are actually partitions from the host. And on the left terminal, the generated eBPF program was able to pick up the sensitive command detected. So now let's mount the host's file system inside the container, breaking the boundary between the container and the host. This is also known as a container escape. And on the left side, we can actually see the namespace, the source, but then the container. So now that we have access to the host's file system, we can just directly CD into that mount. This gives us direct root privileges over that file system, which is effectively game over. And we have full root access to the file system, which means that we can mutate things like, the roots, bash, trc, we can change, we can add users, we can really do whatever we want at this point. So the container escape is not the only thing that you want to monitor for. Sadly, most of the people are only looking for this. In the second demo, we will detect an attack where it is able to download sensitive data from an external S3 bucket. From an environment perspective, the setup is the same. So let's assume that Jet has access to a GKE cluster, and from a workload perspective, he's currently seeing running application with multiple services like Joe posting and Recreater, and with multiple data databases like Elasticsearch and ZooKeeper. So let's assume that he has already compromised the core API service and got into the core API pod. That's what we can see on the right arm now. So now he can run arbitrary commands to discover the environment, do any lateral movements, connect to external services, and get access to any sensitive data. And on the left terminal, I'm going to run a custom Python script which processes the JSON events exported by the ABPF program directed from the kernel, and which monitors all the malicious behavior that he will do. So now that I've compromised the pod, I'm gonna run the end command to see if there are any credentials or secrets mounted in the pod that I can take advantage of. Excellent. We can see that there's an AWS access key and secret key as well as an S3 bucket name that I can use. So ideally, secrets are mounted in a volume inside the container to avoid having to restart the container if a secret is rotated. But in this case, I'm able to take advantage of the fact that they're environment variables. And on the left terminal, I can see that the sensitive command got picked up by the generated ABPF program. I can see the namespace, the source, but then the container. So let's access the S3 bucket and list the contents. So here we see three folders. What's this super secret PDF? And on the left side, I can see that the sensitive command get picked up by the generated ABPF program. So let's download this super secret file. And we can see this was successful. Excellent. And on the left terminal, I can see that the sensitive command got picked up by the ABPF program with all the namespace, the source, but then the container. And then the network socket that was initiated was identified as well. So now that we've downloaded the super secret file, let's inspect the contents and see what it contains. Ah, okay. I don't know what to say there. I'm just like, yeah. All right. But how do we translate system calls and network flows into an attack? Not everyone has the detection skills to identify an attack based on these signals alone. The image on the right comes from a blog post called the Pyramid of Pain. And it identifies the value of detection data progressively from trivial to collect and the relative value that that data provides. In a regular environment, at the bottom you have a hash of a file. If you flip a single bit in a file, its hash value completely changes. So its value is minimal. However, in the environment of Kubernetes, we can start to deploy the concept of immutability. Immutability enables us to declare patterns to understand the behavior of an object. If you need to change an object, you don't change it in place or patch it, you replace it all together. So we can use this immutability to unlock the detection of tactics, techniques and procedures or TTPs. For example, if there's an execution of a binary that's not part of the container image, we immediately know it's suspicious. Immutability really brings a lot of benefits to security. All the binaries in a container should be packaged into a container image. Using a hardened base image like Distralis, it makes it easy to identify all the binaries in the container and those that should be running. Downloading binaries in a production container for purposes other than debugging is an anti-pattern. So if there's a execution of a binary inside of that container image that isn't part of the container image, you immediately know that it's suspect. What this further allows is those hash values that are trivial in value actually become very critical inside of an immutable environment because we don't make any changes to any of the files inside of that environment. So a change to a hash in the case of immutability might actually become a tactic, technique or procedure. So wrapping up, just wanted to kind of go over some of the things that we talked about through this talk. So first is that to measure the efficacy of the security in your environment, that requires observability. So the key thing here is starting to collect the right data so that you're actually gonna be positioned to be able to detect the sophisticated attack that occurs within your environment. Today we've talked about a couple of kind of simple attacks, but the key here is that we're actually measuring that data to be able to detect those things. Oh, and by the way, Cilium is going to open source the EBPF observability tool that was used today for the demos. Awesome. So when we actually start with this observability, we can detect the types of behavior that we expect in a system. When things go wrong, for example, whether we have a compromise in the environment, that's called detection. And really, if you don't collect this data, if you're actually lacking this data, hope is your best strategy. And if I can take one thing away from the SRE book, it's that hope is not a good strategy. And lastly, we just wanted to give a huge shout out to everyone on the slide. Everyone here has given us either feedback directly or helped us somehow throughout our Kubernetes security learning journey. This talk wouldn't be what it is without these people. So thank you very much. Thank you.