combining your relationship with your doctor. But they don't listen to what you're saying or they go so quick that you don't understand what it is all for. The doctor is going to spend enough time with the patients that come in. Just in case. It is the end point. You've got to be quick. I think they always explain to the patient in the same way that the patient would understand. From what we've done so far everybody is not the same level and sometimes I think they're the same. They go to college, they went to work, so much school and they imagine that they can have a son. Does anybody think that Spider-Man has kind of a focus over a baby? So these are the objectives to divine health literacy, discuss the scope of the problem and how it impacts health outcomes and then at the end we'll talk about a little bit of tools and skills to make our practice patient better. So now this is... I think to make this session this is a very small group more interactive than anything. So what I'd like for you to do is to read this paragraph out loud so that I know when you finish and some of these words are still the backwards. Let's start with the national action. Alright, so I'll stop you there. I'll stop you there. I'll look at what I can tell you and you'll understand the context. And so I just kind of want to give you a flavor of what some patients might go through that maybe they're going to a few years of school and they can actually read but at the end of the day they understand what they're reading. And that's what they may know because they may have known the words but they're trying to concentrate on reading the words that they don't get the meaning of it. And so this is... Yes, go ahead. This is a time magazine from 2006 and I think this is really outdated but unfortunately the information is still very similar. And so it's telling us about the dropout nation that one out of three public high school students will not graduate and if you are a African-American or a Latino background the numbers are going to be worth about 50% if you're not graduating. And this is a website that I like to follow in terms of looking at the America's most literate cities and these are the larger cities more than 250,000 in the population. And is anybody here from Oregon? So a few years ago I read that they actually closed down their last bookstore maybe two or three years ago so I suspect that if there were these bigger cities that would be really at the bottom of that list. But they're looking at newspaper circulation of course, library resources education attainment and then they have Iraqi cities and I just want to share with you where we are in San Antonio out of 77 cities, 77 is the worst and we are 71. Only El Paso is worse than that in Texas. Austin usually writes higher and I suspect because they're a college town. Washington D.C. was number one and the most recent numbers was I think Minneapolis and Edom and I think it's still the most recent one is 70. So it hasn't really moved a whole lot. So this kind of just kind of gives you the ranking that essentially if you go from 2005 to the most recent we're in the 60s, 70s they need to miss getting the worst so it's not getting any better so there's a lot of work for us to do. So in 2004 the Institute of Medicine realized that there should be problems and they published this book called Health Literacy and Rescription to End Confusion and so that's actually when the Center for the Health Literacy Initiative also was born out of this this book and this awareness and so we've been in place, I think this is another pull up I can tell what that says. So these are the Health Literacy Basics Literacy and Health Literacy are different so you may read those words over just a bit but you don't really understand and I can think about it as a chemical engineer who might be a very right person but not only in the context of cancer and health he's going to hear words like test cancer, chemotherapy all these words that he may have to be familiar with in the same way if you talk to me about mechanics I wouldn't know anything about mechanic literacy so even though I can read it I wouldn't know anything about that the same thing in health literacy so there are some patients at higher risk but just because you know that it's a very common problem it's also a particular health status it's a famous major barrier so a lot of times you may not know that the patient has a literacy problem because they're not telling you they have an issue or you can't tell we do know that it's associated with health care costs and I'll just have some slides to share that with you you can't tell by looking and we have providers nurses, doctors, dentists all across the board but I've learned to train in health literacy but slowly but surely we're changing that in fact this morning from 9 through 11 myself and my colleague we actually taught a health literacy and day exact same one to our medical students in the first year just across the street at the Health Science Center but this is after 20 years of this so this is the definition by the Institute of Medicine health literacy is a degree to which individuals have the capacity to obtain to process and understand basic information and services needed to make appropriate health decisions so first can they get the right information can they process it, can they understand and can they act to actually make the right decisions for their health and use it in one of my favorite videos low health versus a hidden epidemic in America it causes needless suffering to millions of patients and their families which translates into billions of dollars in unnecessary health care costs fortunately this problem is starting to get national attention next is world leaders you're both taking a closer look at something that is vastly made into Americans how to make their way to the second instruction the direction and the guidelines given to them by their doctors now 40 million Americans are functionally illiterate which means they read at a below the fifth grade level they have an impossible time but even littering Americans can be overwhelmed here's a piece you have to find it's estimated that one of three Americans struggles with what is called low health literacy many can't read but many others are simply overwhelmed by the direction they're given from doctors and pharmacists it used to be when you went to the hospital and stayed so you got better but with different drugs and technology and the never ending push to cut costs patients are often sent home before they understand what they have to do to take care of themselves average Americans are struggling with modern health care it's hard to be a patient these days what's it like to be a patient what challenges do they face they'll show us just how complex and overwhelming health care can be so I'm going to pause right there because I want to hear from you because I suspect that you already went into this and that's why you're here because you want to learn more about it what to do about it so let me hear from you what challenges does your population think you might not be in an health field but something really did to that's what they think think about it the low income by medications and they can't go to the doctor okay good what else they don't have things in Spanish yes in the language issue and I always say this mother that went to California had a daughter that had epilepsy so they prescribed dialysis for her and the bottle said take once daily dialysis is a pretty powerful seizure medicine and so this is a little girl that said take once daily the mother only knew how to raise Chinese so once in the English is so that's 11 the mother gave the child 11 captures of the dialysis so the story was that the child you mentioned you didn't apply because of the orders because of the miscommunication that was written in English but she left on sick and it was just a harmful mistake so that's a language issue can you see in your your clients your potential yes yes you cannot be so I'll show you a video that this is longer she's very eloquent but she says I want out of that that doctor's office I hope I remember everything and he just told me because he doesn't know that I know and don't read so yes changes the communication so we need to make sure that we make it okay for them to share that with us and at the end of the day when I explain to them I'm hearing how good it's okay if you don't but if I don't know that then I can't tell you one more? yes the favorite way of learning maybe it's by reading, maybe it's by video maybe it's by computer so just knowing that okay these are just some examples well I'm here to transplant transplant for about 15 and a half years but I've been sick forever okay well I'll take a baby aspirin that's something to do cyclosporine, regizones and when I make the doctor's appointments I have to be sure that it doesn't interfere with his doctor's appointments my doctor's appointments are their doctor's appointments so you don't like to go to the hospital where they give you a lot of papers paper work why is that you can't read that well what does it feel like when somebody hands you a lot of paper work and you can't read still like in another controversy when you enter a doctor's office the first thing that your first time patient in they're going to give you a clip for it sometimes that is very discouraging for a patient who cannot read I'm really embarrassed to worry about things ringing or worried about my child being all upset I would not be able to read things I know wouldn't read every day some of the words that the Sanjeev Ramplasty and all of that is that several things or one thing or it's just a language that I'm not permitted with if the patient was transferred to that facility and to any and all insurance companies or other book parties or anything or obligated to play this is this is not like in any sense do you have any idea what a normal blood pressure is there's no no, it's not normal it's high have you or anyone ever had to sign with a symptom? yes I have hereby all for a conference seeking others to know all education and reading levels and one thing in common low health literacy it's so easy and I clumply and costly out of the space just to listen to what they have to teach us so what you do, you come out of that room, that examination room with this intelligent woman or man thank you God, I hope I don't make a mistake of my medicine because I did not understand anybody, who you're seeing what do you usually get? a motion or a normal motion because that's what the doctor recommended she gets more I would get her the 4 to 5 a table spoon and a half so you get a table spoon and a half can you find great coffee how many in the UK? the dosage? three in a day take three to two no leaders and I don't actually read this because I know what it says so if I had to sound it out it was where I knew it because I've heard it so many times I would not be able to read that every three to four hours as needed for pain what's the other meaning? the medication that was giving to her was not boring what would you use it? she ran out of her blood pressure most she didn't like it she didn't call me to tell me to do it so finally I found out that she had not been having it I said mother you can't do that you have to keep taking the blood pressure most and then it says just continue what does that mean? no how many times do you take being star world close? once a day and you take one of each of these so you take two star world close no I take one but I've got a lot to go out and mess with and I got revealed and then are these stickers out there? don't even look at them they just put them through and you tell them I am not the baby love out there they didn't even find any of the rubles that they made the longer the longer they did how many milliliters is in the table 15 in the table and a teaspoon is five so he has three times in those what else? that gentleman with the high blood pressure it was always that he knew his numbers this is a three of eight he said three because I was not even close to what the instructions were and these are actually real patients they were coming to Atlanta Atlanta Georgia many years ago can you see if any of these videos are so powerful? does anybody recognize the newscaster Peter Jennings the older of us so he was actually a high school drama and he kind of wanted to be a newscaster do you have a question or a problem? just that a little bit more entirely they don't want you to cook they don't want you to cook they don't want you to cook the table yes you're not computer literate so other issues that just a patient this issue of communication medication instructions that's on the pharmacist so I see that all the time they do this they follow up appointments they use to be in a clinic or they have to sign in for their appointments so I was walking through the lobby today and gentlemen I think he must have been in a 70 he takes out this IU card he gives it to me and says can you sign in for me or the follow up pharmacist they give him a piece of paper and they see the words but they don't know what it is they have to highlight and write for them health information pamphlets you know I think we spend so much effort in translating English to Spanish that I like to know whether that really helps any because even the great ones in English sometimes are not helpful I see many of them are written such highly that they're not useful a form consent when you guys are working you have to get a form consent or even if you're a patient you always have to sign these SIPA forms patients giving it to the history public health training directions to clinic we have a clinic where they have 3 buildings and they only connect on the 2nd floor to build within the 3rd floor and the 3rd floor but they didn't connect so it was really confusing for the patients to get around this is one of our own clinic signs so here is the sign by the elevators it says auto-rival radiology clinic on the 3rd floor that's the sign right there and then it kind of made it easy in English it says gear goes and goes so that they understand that auto-rival radiology means gear goes and goes what do you think it says in Spanish auto-rival radiology okay which is probably not useful to most of our either English or Spanish patients so I took a picture this is literally our own clinic but thankfully we now have a new clinic and this is one of our initiatives that's why I can share that so this medicine said that they have a framework actually that health literacy is actually impacted by several different things we are in the healthcare system most of us are but it's also impacted by 1812 education so those types of students that I talked about earlier that I drop out eventually become my patients eventually get medications and they make mistakes so the patient system actually affects the health literacy the social issues in society so as we mentioned about low income we have patients that have insurance what are the social issues sandwich language or whatever other language we have refugees from other countries as well culture yes, just a different culture so different issues and they all have an effect on health literacy and then at the end the health outcomes and costs we'll talk about that later so this is a graduation rate in 50 cities the average is 53 but I looked at this a few years ago but again just to reiterate San Antonio at that time was about 47% so it was about 38 out of the 50 cities so not very good and this is a question locally this is a data poll that is very similar still 40% of the population in Salter County does not have a high school education so yes 45% and this is the information from the health collaborative and the loss assessment and so you can tell these are the real numbers and this is 2010 now that the south is 45% and they've lived there in our north central it was 6.9% 7%, big difference and the most recent health collaborative assessment also tells us that not only is education different but how long you live also depends on where you live so low health literacy is common and this is on the survey that was done in 19,000 adults looking at literacy on the silly health literacy where they get adequate health literacy questions so they divided into low basic basic intermediate and proficient where do patients need to be to navigate the health system for that, for the efficient so this is what we want them to be in the grade and this that he tells us that only 12% of the population who are in the proficient which is more than one of our patients to be but below basic they basically ask if you're a patient so she's a paper and they said start with the date of their appointment and 12% or 14% would not do that so what percent of America enjoys is considered below basic considering this national health and resources this is a recall test of 5 seconds it's almost been attention yes that's the right one so we go back the below basic is the worst so 14% or what should be in the proficient so if you have the basic and the below basic gets 36% that's a lot of patients if you consider the old United States population more exactly it's about 89, 90,000 or 90,000 people with the below basic and basic and we actually did not exactly the same but we just wanted to know what the health literacy was in San Antonio so we went out to Walmart and we did basically a test of functional literacy and the bills and we tested them and we found something very similar that patients I think was 12% in our 14% was like 12% below basic but when you consider the population that ends up being like 250,000 San Antonio literacy level these are the patients at highest risk think about what you have in the area the elderly persons with limited education they have members of ethnic minority they do not speak English before starting school they are unemployed or they are provided with Medicare Medicaid who works for this population I know I do anybody else? yeah so I think most of us do have the low health literacy so there is a way to measure how literacy these are more formal the most that we use at the Walmart survey was the first one test of functional health literacy in adults and there is others but basically I just want to share that there is a way to measure that I'll show you but you can actually get to that point with just a couple of questions this is a question that I would like to answer what is the strongest predictor of a person's health status is it age income, literacy skills employment status, education level and all so the word is strong guest I agree that the album should be I asked another student this morning and said what kind of class is this students so how kind is the class so C is the answer which was surprising to me when I first read that as well you know like when you say all of them contribute but the strong guest according to the Gemma1999 article was literacy skills so we know that health literacy is a predictor of health status and that's why we're really interested in this because it does affect health so we know that the links between education and outcomes are strongly established so again literacy is one of the strongest predictors more than income, employment status and educational rates this is just an example of where well health literacy affects just your knowledge so this was studies done in cases that had diabetes and hypertension they had an inadequate margin or adequate literacy and that's a question about their diabetes and as you would expect in cases that had higher literacy levels knew more knowledge about their diabetes and knew more about their hypertension those that knew less health literacy skills so this is kind of what we would expect we also know that in general the lower the health literacy the poorer the health status the lower the health literacy the poorer their blood sugar control the value of this is less control we also know that they also have less healthy behaviors so they don't get the vaccines, they don't get their colonoscopies, they don't get they don't use their suitcases all those things that we consider healthy behaviors they are less likely to be those things and we also know that if they have lower health literacy they have more hospitalizations what does that do for a system? more hospitalizations, more consciousness and even more importantly that the worst health status is you died on the road if you died more higher mortality if you have lower health literacy so this was a study done in 2007 2006 in the elderly so they looked at the elderly and their literacy levels and what they found was that if they had adequate health literacy the mortality rate was about let's say around 20% those that had low health literacy rounded up 40% so 20% versus 40% in mortality then someone said well maybe they are just sicker or they have lower socioeconomic status so they said let's control for all those things and they did and what they found is that there is still an azure ratio for increased mortality in 1.52 so there are still 50% higher in terms of the mortality we had lower health literacy so if I don't want this to affect outcomes it also affects mortality so that's why this is really important medications so people again this is my area people with basic and below basic health literacy were 5 times more likely to misinterpret prescriptions and those would have a good scale and I'm going to show you just the data that I like well sometimes doctors make mistakes and I need to try twice as hard to fix them are you using your inhaler? all the time, go through one a week are you sure you are using it right? do I look like an idiot? no let me see how your killer works we think it's funny but unfortunately I see this all the time and it's amazing what the patients can do we don't understand how to use their inhalers or medications whatever is an insulin I have a patient that has diabetes and I started her out on insulin so the nurse part of her use a pen it's an insulin pen so she showed her how to use it they were like 300 normal is less than 120 and so they kept on being at 300 so I kept on increasing the dose and so I kind of had to start around another insulin and so the patient received an insulin from the pharmacy with a pathway and she was reading the instructions and she called me and she said I think I know what I did wrong and I said what? she said well the nurse didn't tell me to push the pen so she was just poking herself with a pen every day poking herself so the blood for the insulin was not being injected into her skin and so of course once she started using it right then her blood sugar just came down and it's just amazing I'm sure the nurse she even injected herself in front of me but somehow she was going that up and she was just poking herself every day and her blood sugars were not going up and she was getting injected into her skin so it's just amazing but if you're a mom and you get this prescription you have one teaspoon full by now through times daily you go home this is what you get to see in your kitchen which one is a teaspoon can you even know? it's a strict question because you have to know which one is 5 milliliters and you have one teaspoon of 5 milliliters but they can be 5 milliliters it can be non-milliliters there was a little study that but they just measured adding this as a longer health release workshop but the point is that if you don't have the exact measurement and you have a tiny baby you're giving them 2 milliliters or 9 milliliters instead of 2 we can over dose them easily we need to make sure that the patient understand the correct dose and maybe give them a syringe with a sharpie marker for the correct doses 4% of patients forget that the doctor tells them as soon as they may be on so yes, 80% and I told this to this morning the side part is that 20% of them remember half of it is wrong so they only understand about 10% of what you tell them and so one of the things to do is actually that doctor in the house and he actually did what he was supposed to do he said show me show me how you're using the inhaler so that's a key skill okay, I'm going to show you how to use it and you show me that I can make sure I talk you well okay, so on the onus is on us and on the patient so shameless stigma associated with limited literacy skills or major barriers to improvement health literacy and this is what we're talking about whether you're embarrassed or ashamed it stings to someone and really it paralyzes your thoughts completely to think that you may say something or something is putting it for you to read and you can't read I mean you live with that on my daily basis so I try to make sure that the patient know that it's okay I don't want to read but just trying to pull that out of there this far so I usually ask them where you're from from San Antonio what high school did you go to they tell me where I'm from so then I ask them where did you go to they tell me I just went to the surgery where I dropped out so they tell me so then I ask them are the letters easy for you to read or too small for you and then they eventually tell me why can't I read or I'm reading my glasses so I said I just want to make sure that you understand how to read because reading instructions is important and I want to make sure that I'm here to help you so I want to make sure that whatever I give you that you can understand so eventually they know that you're there to help them and they're okay telling you but sometimes when the doctors they don't feel like really interpreting the doctor because they're busy, they've got something else to do they're reducing to make sure that in whatever area we're working that they feel comfortable telling us okay I'm not sure I understand limited health literacy has been associated with higher healthcare costs so those of you in administration are probably interested in this or any of those of you that are taxpayers so this is a study that was done by Dr. White so this is actually the end of our after medicine department a few years ago and because those patients that are in the Medicaid we're a close system so we can actually look at how much they spend in their health so he took pregnant women and they can measure their literacy skills and then look at how much they cost to help their system so those with lower literacy skills were costing more almost $100,000 or $10,000 in 16 days with those with adequate skills and so about $3,000 so $3,000 versus almost $11,000 so big difference in cost the only difference was just the received level we also know again in my studies that up to 6% they have 6% more hospital visits and those that are hospitalized tend to stay in the hospital longer approximately maybe 2 days longer then they have more literacy skills where they get hospitalized more often and they stay in the hospital longer so again that translates to more cost and just to give you an idea some people do just all these models and projections that the economic impact is about up to $238,000,000 70% to 70% of all personal health care expenditure and they say this is enough to cover all of those people that are under insurance more than $7,000,000 and if you don't do anything about this then this is going to add up to $2,000,000 and that has been in this morning they say no it costs so much and we know people are making mistakes why don't we just hire people to do this what we think about this so it's kind of hard to inspire someone to do just one thing but I think it's all of our tasks to help in whatever area because you know we were thinking more of pharmacy and pharmacists are supposed to counsel on the medications but when the doctor prescribes it about the medication how to use it when the nurse dismisses it that's also their job and the pharmacist prescribes it that's their job too and that's just medications and there's also what to do about your diabetes what to do about your surgery your procedure there's so many things that we can make mistakes as patients so it's not just one area but it's just such a big task that's allowed you to continue to it so you can't tell by looking at the state's study that 50% of patients with reading difficulties have never told their spouses although some of you that are not here you know if your spouse has ever been in difficulty or in this nation so that was interesting so they never told their spouse about it and decisions could only identify 20% of their patients who are at the lowest and worst level so if the doctor goes into the office they can't tell, okay this patient has low literacy this one has high literacy and they're very eloquent in their speech and they're real patient and this is Ms. Walker talking about high units and that's what we can't tell one of the things that most of us know how to do is to hide it sectionally well because it's a terrible embarrassment you know and the shame that goes with it is death savings so the last thing to worry you want an intelligent doctor to know that you have any kind of problems other than the ones that you dare to see them about so how first and basic number 7 health professionals and staff have limited education, training CE, practice opportunities to develop skills for the health literacy so we've been doing health literacy through the salaries in 12 years and I've been doing this problem longer than that in 20 years and this is now just the second year that we're teaching this class to the first year medical students and so I know that pharmacists really tend to constitute a little bit more in the dental schools and the physical therapy schools and the every health professional schools that we have so health literacy basics again literacy and health literacy are different it's common, could they sell status change the major barrier associated with higher cost we can't tell other people and we have limited training so some of the recommendations in general first recognize that it is a problem and how do we recognize it I just know that it is very common in the widespread and just some clues at least in the clinical area patients may be routinely late to the refills they may be frequent medication terrors so and I see that all the time that patients are just making mistakes so when I see that when I start getting more I realize okay the patient doesn't know how to read or they may not understand or they're just afraid of something or they actually have to sign some forms a lot of times they will just fill out their name and the rest of the behavior can't read it or they don't understand and so I mentioned earlier about economic status well at least as a patient that needs to fill out has to fully write on their page and care for their exchange programs and that's just very complicated so that's how we need to help fill these things out other patients if you ask them to read something they say oh I forgot my glasses can you read what the lady wants medication says oh I forgot my glasses could probably aid me on how to read or if I know something they'll say like I'll read it when I get home or their husband or wife can just give it to them and they're there with them or they just show a lot of interest because they're just not understanding what you're telling them anything else that you guys can think of of people that you work with clients, customers where you say somebody has a low literacy skill somebody need more help if they come to Mexico so first language maybe or they may not read it anybody else anybody else anybody else should ask them what about your language whatever do you work with what about yourself what about yourself well the answer to that is to make sure it's exactly my time anybody else what ever do you work with I'm definitely better at speaking okay professor I know you're one of my primary students anybody else right there what about minister he's going to find more of our helpfulnessy educators good anything else right there go ahead is that again you're just saying it's okay if you're going to are you a mom and a case manager or a tutor with patient navigators okay so you need more patient navigators to help the patient but I'm going to do that what's your name I'm Ziek you need more assistants I had many runs with a type of sort of infection, where she wasn't even writing her results. She was a doctor. She was a regular medical case engineer. And as I helped her to get her, they sent her back to me so we could kind of figure out what the result was for her. And she had a language barrier. I kind of, I'm not going to ask her about the pill box. I'm going to use it as a tool. I'm going to ask her to show me how she was using it. And she couldn't make out what the result was like. And it was a tool that she had. And I started talking on the station there. And then she opened the camera. And so then she did not come around to me. The doctor was not getting the results after months of progress that she was going to have in the case. She actually ran. I started the second night. I was in her night. It was me. And the second night was very nice. But the communication was good. And then I was just working for months prior. So she had me in the open room. There was no fear of taking it. Yes, that's a good way that we should find out. So I looked at the prescription bottle. Today is October 6th. And the prescription is still in January 5th. And it's set for 30 days. So this is good. What happened? She said, well, we can do this with you. This is like five pills in there. Or the idea of getting them not to be there. You better not try. Another example. I had a lady that I actually didn't know. Maybe also children. She was very busy. And so she was there. The doctor asked for a few minutes. And she was like, try and go. Right on by. It was very interesting. And there is a little bit there. I tried to, I don't know how to advocate for this. And the doctor gave us a few minutes, right? A few words that would kind of get the doctor's attention. But they were invested, right? And so we had another issue with the answer. They sent her back to me. She only did it in our agency. As we planned. We took her there. And we started to get her to attend. I think on the third visit, it took me an hour. She was very guarded. But we figured out that it was going on. And she was taking medication with food. The doctor had sent a ticket to get food. This particular lady was going to have to be taken on her about the exact same time of day. And we had already got the bed at the time of the medication. So she was taking it in the morning with food. And we took it in the next day of the week. One day in the morning. So she was taking it sporadically. So we never got the end result. And we got her to kind of pick it up. Yes. It's amazing what patients understand. We had a gentleman that he saw the label and said, take good food. He had a picture of the hamburger. He says, I can afford to buy hamburgers three times a day. Every day. And so, but yeah. So, you know, I was telling the students they were happy to spend the whole day story after story. Because it happens every single time I'm in clinic. But we're just kind of continuing. So another recommendation is to create a shape for your environment. So that the patient is free to actually admit to you what you're looking for. This limitation is fine. So be helpful. Answer films in person if possible. Help complete the forms. Like our nice navigator would probably use. We do the instructions. Encourage questions. So, does anybody have any questions right now? Do you have any questions? No. So the answer to be there, yes or no? Right. So that's a close ended question. So we probably do not want to do that. But what kind of questions do you have that I can answer to you? As opposed to do you have any questions in the answer to there yes or no? No. But what questions in that kind of encourage is that? Develop easy to read materials. So we're going to give them 10,000. Make sure they have plenty of white space, pictures, you know, easy to understand words. Clearly more bright and healthy. So accreditation standards. So, you know, the accreditation bodies that have accredited hospitals and clinics, they need to say, okay, we really need to make sure we have clear science, make sure patients understand that we have HMM theaters, health educators and pharmacists. And more of everything to make sure the patients understand. So, recommendation number six. This is one of my favorite, a lot of people have not heard the line, you know, about health literacy, and medication use chapter. And he advocates for this in myself as well. So if anybody has any access to our political and politicians, I really would love to see this incorporated in our pharmacies to make the levels more easily understood. Because generally, it's the pharmacy name, the pharmacy phone number, and the address that is huge. But then the patient instructions are in time to print. So we're advocating that the biggest information need for the instructions and what it's for, and with some pictures perhaps, as opposed to the current levels that we have now. We talked about schools and measuring. So we know that the one, two, three, the fourth one is a 92% and the other 92% accurate. But the fourth one is the schools, that may not be very, when you have a little toddler, they're going to fight you, so you might still love it. So the recommendation is to use the second one, the syringe, and mark it with a sharpie so that they know what the correct person is. Improve your communication skills. Show empathy, be an active listener, use simple language, slow down, avoid information overload, get possible and include family and friends. Tell stories and make sure you understand the cultural context. I know we're in San Antonio, so it's usually the Hispanic population when we have more poor refugees, and then we have a good number of other patients in our clinic that come for me to use a translator. So I ask you English and Spanish when we're in Korea or another language that I have to use that I can see political and trying to communicate with patients. And that's it. Just show it's up, which is possible. We teach that kind of thing. Really important. So Mrs. Lyft, this is how you use your enabler.  Just so that any share that I explain to you correctly shows me how you can use it. And hopefully it's not like a lady that does. Well, if they do it like a lady, when they do this, it's okay, well, I might be shook, but let's kind of go to it again. And so we kind of keep on going. They call it the teach back loop. So teach them, if they do it wrong, you can teach them again. But one of my physicians are attending. He says, you know, I know that Dr. Maeson Tumas says this, but I'm only good if you have a heart. And I didn't know what he meant and what he explained as he's your physician. So he tried that one time and he saw he explained something to the patient. And the patient got it wrong. So he had to teach him again and he got it wrong. So he says, only if you have a heart to realize that you're not a very good educator to do that. But, you know, the good thing is that we have, and we realize this is a clinic direction, we realize that we need more help. So we have health educators, we have politicians, we have pharmacologists. So we're blessed to have a good team to actually have a good team. So the teach back method is important. So it basically is asked the client to review instructions back to you in their own words. And I'm going to just end with this video because of everything this is telling one of the most important places to actually treat our clients our patients with respect. We didn't choose to do this way. And we would never choose this way. And I don't want to think about that one way or another, but I don't care who you are and how high or how low your IQ is. It's very important for people to be treated with respect. I don't care what your financial wealth is or any of those things. Respect is very important. It's very important. And if you take a person who has a low IQ, a low respect problem, and God knows they have some very little hold on to them at first points. Do you really? Can you imagine how much that person has to diminish when they got that offense? You want to melt it to the floor. So I think we have just a few more minutes for just a question so that anyone has any comments about what we just kind of discovered. And there's so much more that we can talk about. There's a study that came out a few years just to maybe not that long maybe a year or two ago about you know how we the administrators are really so they count the cost the emergency rooms in the hospitals but there's one study that actually looked at 30-day re-admission rates. They found that those patients with lower effectiveness actually got re-admitted to the hospital more often than 30 days. And so that's the, of course, we don't remember to get re-adversed with those patients. So health literacy really has effects again and the health outcomes, mortality in costs and you know, not to mention the quality of life in our patient and patient's appliance. Any other comments, questions that I can clarify? Answer? This was just kind of a, the ABCs, the health literacy 101, there's so much more to discuss but you know, the mirror to this conference we usually try to to have this session so at least you kind of have a baseline background before we go to the other sessions but I hope this was helpful and I hope you enjoy the rest of your conference. Thanks very much for this patient.


One of the reasons we learned more math is that more powerful tools allow us to solve old problems more easily. So earlier we found the plane tangent to a surface at some point by taking x equal to x0, and this gave us a curve in the yz plane, so we could find dz dy. And we can interpret this as a vector. Then we let y equals y0, and that gave us a curve in the xz plane, and so we could find dz dx, and that would also give us a second vector. Now this actually gave us the direction vectors for two tangent lines, so we took the cross product to get a vector normal to the plane. And once we have that normal vector to the plane, we can write the equation. But now we know a little more calculus. Since holding one variable constant and differentiating with respect to the other is the same as finding the partial derivative, we can restate our process. First, find the vector 1, 0, the partial of f with respect to x. Also we'll find the vector 0, 1, the partial of f with respect to y. And again, since these are the direction vectors for two tangent lines, the cross product will give us a vector normal to the plane. So for example, let's find the equation of the plane tangent to z equals x cubed minus y cubed at the point 2, 1, 7. So we'll find our partial derivatives. And at the point 2, 1, 7, those values will be. And so two lines tangent to the plane have direction vectors. Well, this partial of z with respect to x, we can think about that as a rise over run. So z has increased by 12 when x has increased by 1. And since it's a partial of z with respect to x, y hasn't changed. And so that's the vector 1, 0, 12. Similarly, our partial of z with respect to y, again, rise over run. z has increased by, well, negative 3 while y has increased by 1. And again, since this is a partial of z with respect to y, x hasn't changed. And so that's our vector 0, 1, negative 3. To find a vector orthogonal to both of these, we can find their cross product. Now there's two different cross products we can take, and it doesn't really matter which one. And so we'll find the second. And so the normal vector will be 12, 3, negative 1. So remember the normal vector will be orthogonal to every vector in the plane. And so if x, y, z is a point in the plane, then a vector from 2, 1, 7, which we know is in the plane, to the point x, y, z will be x minus 2, y minus 1, z minus 7. And the requirement that this vector be orthogonal to this vector 12, 3, negative 1, well, that gives us the equation where the dot product is equal to 0. And if we expand that, we get the equation of the plane. Now one of the advantages to being able to speak the language of math is we can solve a problem generically once, and then come up with a formula that will solve the problem for all possibilities. So let's think about this. The plane tangent to z equals f of x, y, it'll include the vector 1, 0, and the partial of f with respect to x. Likewise, it will include the vector 0, 1, the partial of f with respect to y. And since these are two vectors in the plane, we can find the normal vector, and again we'll take the cross product this way, and we get, and so the normal vector will be the partial of f with respect to x, the partial of f with respect to y, negative 1. And here's an important idea I'd like all of you future engineers to think about, because one day I might be driving over a bridge you design. If somebody says, here's a new way of doing things, always test a new method on a problem where you already know the answer. This allows you to check to see whether the method actually works. So we've already solved this problem the old way, let's solve it the new way. A vector normal to the plane will be the partial of z with respect to x, partial of z with respect to y, negative 1. And so we find our partial derivatives, which gives us our normal vector, and so the equation of the plane will be, which is the same answer we got before, and so we have some faith that this new method will actually give us correct results. So let's try it on a case where we don't already know the answer. So again a vector normal to the plane will be the partial derivatives with respect to x and y, negative 1. So we find those partial derivatives evaluated at the point, that gives us our normal vector, and then we can write the equation of the plane.


I'm Deb Stanley McCauley, Chief Diversity Officer at Yale University. If I had an opportunity to ride the elevator with every college president or university president, the single piece of advice that I would give them is that diversity has to be woven into the fabric of the organization. That diversity is not a standalone activity, that it's an activity that everyone needs to embrace, and that I imagine every member of an organization being a diversity champion. So it's finding the solutions that weave diversity into the mission, the vision, the strategy, the goals and objectives of an organization. And then I think we've reached that next level in the elevator, so time to get off. When I think about retention and the many reasons why individuals leave an organization, I think some are very similar by diversity dimension and some are very different. I can think specifically about Yale University and our millennial population, our young professionals. At one point in time, our young professionals were leaving the organization because they didn't feel included, and when we teased apart inclusion, what we learned is language within organizations didn't make them feel like they were a contributing member of the team. Things like being referred to as kid as opposed to their name, then bringing ideas forward and being told we've done that before we've tried that and it wasn't successful. And so those opportunities to have your voice be heard and your ideas be incorporated seem to not exist. Diversity training doesn't change behaviors. And so if our expectation is that we want to send someone to diversity training and expect that after three hours we're going to get this totally transformed individual, I think it's a misconception. What we will get at the end of three hours or 90 minutes or one hour, depending on the length of time, is I think you'll get an employee that is much more aware of the terminology or the techniques that we're introducing. I think they'll leave with more skills that can be applied when they return back to their team and to their workplace. What I would encourage leaders to do should they embed diversity training into any of their goals or objectives is to create a system when the employee returns from the training workshop or completes the online training that allows the employee to have those skills reinforced. And I think a manager can do that a variety of ways. One way is to simply check in and say, how was the class and what did you learn? The second would be to say, how can I support you in instituting these new techniques? But I think the best would be for the manager to say, I've completed that training and here is how I've been able to institute them. I look forward to supporting you as you begin to practice, create that expectation, begin to practice this new language, this new technique, this new way of creating an inclusive workplace. I guess I'd give them a couple of pieces of advice. One, I think it's important that diversity education be part of their goals and objectives. I think it's how we go about making diversity education available to team members and to leaders. It could be the one pitfall or the one opportunity for success. My personal belief is that D&I training and workshops should not be made mandatory. I think they should be, again, part of the fabric of an organization. If the organization has a developmental strategy, diversity is one of the dimensions or competencies that would get addressed. If I were to give a second piece of advice to IT leader, it would be to weave in mentoring opportunities. Mentoring programs, I think, add value to both the mentor, the mentee, as well as the organization. And then I would say it also ties to our retention strategies. So if we can think of diversity as a developmental opportunity and not as a punishment or a mandatory commitment, then I think we'll make more traction. And it feels more natural as opposed to an exercise or a task that someone needs to simply just check off the list.


Let's make sure we're coming in live and we are nice nice nice hi everyone This is chichu welcome to my channel and welcome to another live stream today today is April 20th 2023 That's a happy 420 live stream and this is something we do on a yearly basis I think since the first year that we started doing live streams so this is this should be our fourth year in a row that we're doing a happy 420 live stream and 420 something I've been celebrating for a very very very long time very long time over two decades now So it's it's sort of a annual thing That I participated in to celebrate the The bounty of nature Toxy 9 yo, hope you're doing well and it's a day to celebrate a beautiful plant Probably the most versatile plant the most beneficial plant to humanity just smoke some ash nice Happy holidays Thrift ETP thrift happy holidays happy holidays so it's a day to recognize the importance of cannabis in our lives in civilization and humanity and to sort of come together and Sort of state that the state centralized power has no right to dictate To human beings how they should live their lives consume food think so sort of a day of Being human Celebration of being human. Hey chicho. Happy 420 brother. Happy 420 to you as well the real MC Mike. Hope you're having a great day. I'm having a good day. I hope you're having a good day I'm having a great day So good so far so good has my students in the morning. So I taught them and I've been Doing lots of prep Brought out the harvest cannabis harvest. We've had for last two years. I got a couple more jars randomly placed What you see here is the cannabis harvest we had for the last two years on our patio, right? So and I'm a chronic I guess if you call it This is still what we have and this is a growing season beginning again ice magma max first time chat. Salute. Salute Oh, I only have tea right now.  Happy 420 before 20 to you as well Awesome. I want Sweden to legalize Sweden gone down the fascist for it. Sweden's become a clown world I'll tell you the truth As soon as they went after Julian Assange They went down the dark road and you can see where Sweden's headed, right? I hope they legalize. I really do Toxic really I have I've had many friends. Well, not many I've had some friends throughout the years that have been from Sweden It was a place that I really wanted to visit at some point when I was in Europe. I thought about going There but it was just too expensive For my blood at the time. This was in the late 1990s I saw Sweden play against Brazil in 1994 in the semi-finals of the World Cup Some would say Sweden deserve to win right So but you know, there's there's got to be a separation between the government of Sweden and the people of Sweden People of Sweden beautiful government Sweden nasty nasty nasty nasty, right? Lions. How are you doing? Good evening. Cheecho. How's life? Life is good. It's 420, baby I smag my max. I hope Italy will legalize soon too, but I think that's never gonna happen I hope they do as well. I think European Union at some point they're gonna legalize and they have to a certain degree and Like Holland legal they actually kick it kicked it back a little bit Germany From where I stand partially legal, right? Spain partially legal or not legal like that. I can't I lost track of what's really going on there But I know some countries are making it illegal or decriminalizing in Portugal decriminalized everything, right? so slowly it's gonna go in that direction especially since the European Union is completely bankrupt and European countries are headed into crazy economic turmoil and They're gonna need tax monies to roll in and you're gonna need Certain other things socially to take place, right? Lions none rolled out, but have a have a brownie with some special hurt for the day Brownies are gonna be strong brownies can be strong by the way gang. It's Stormy here. You can hear it. I have our patio door open this much so kitty cats are sleeping So I kept it open because when they wake up they like going to the patio So you're gonna hear the wind Which is fine with us, right? It's it's sort of a It's an amazing day just to relax and just Look at the weather, right? Appreciate the weather Toxy there was a real popular politician in Sweden that talked about legalization But she just got trashed in the media. Yeah. Yeah, that's what they do, right? They must be Puppets of some regimes or whatever it is. It's crazy. It's crazy. Yeah I'm gonna do our little intro before I continue reading in the chat because this is a 420 live stream and It's open discussion.  So there's no way by the way dark matter Dark matter bar matter is wintery. We're gonna drink some dark matter. I got some Oh Cornelian cherry liqueur that we made last year that I haven't cracked open yet. So we're gonna crack that open I made myself some bacon and greens and I got cucumbers Here I got I got I don't know dates and cheese. Sorry. Sorry. Oh god. Oh god. How you doing? I got some other snacks and stuff here, but let's crack open the beer do our little intro and And Tell the censor to people you to people that there's no way we can continue this discussion On the censor to because an open discussion. Let's pour us some beer and let's get this going first cuz I'm thirsty Right.   Why not give it a little not too much not too much Give it a little head. Okay. Just a teeny-weeny little head. Have a sip salute gang. Welcome to our 420 live stream I hope you're having a fantastic day. Here's the freedom, right? Let's stop it up Let's pour it up. Let's put this baby here because we're gonna hit it up We'll put this guy here Okay gang if you want to follow this work, I'm on patreon substack subscribe star You can follow the work there for those of you that support this work on patreon on substack on Twitch where we're live streaming. Thank you very much gang for the support. Thank you for being here on the live streams I hope I hope you're enjoying the content and it is in large part because of the support We're getting on patreon on substack on twitch and the handful of people that are sporting us on censor to gang Thank you very much for the support for those of you that are on censor to We cannot upload this live stream to censor to we only have I believe our first ever 420 live stream loaded on censor to and then after that we've been shadowed on on censor to so I Don't think we uploaded number two number three and I believe this is number four that we've been doing fourth year in a row So the links will be in the description of the video This little intro segment full live stream will be on bit shoot or rumble and Odyssey Okay, and that we do announce these last three minutes 30 minutes 45 minutes an hour before we go live on Twitter mines we can gap no more parlor getter and Definitely on I've been out announcing it on gilded as well Which is our server where you can join us and participate in our discussions Okay, and we are and we will be uploading the Panic I hope you're doing well the audio of this live stream. No, you just made it. We just started It's not the end. Okay audio of this live stream to Soundcollar.com for slash chico as a podcast and this podcast should be available in your favorite podcasting platform Okay, aside from that Thanks Aside from that game. Thank you very much for joining us. This is a day that it's it's a holiday for me I do put my students front and center. Okay Sometimes I cancel everyone if no one has exams, but I had a couple of students that had to you know I had some stuff coming up tomorrow. So I taught them canceled half my students today today is a holiday for me it's one of the holidays that I do celebrate and again, it's in celebration of The most important plant on this planet That has been provided to humanity to me and you to use for our lives and it's about and it's about really It's about freedom. Okay. So again gang. Thank you very much for being here Here's to freedom for those of you on sensor tube I hope you join us on bitchy rumble on Odyssey the links that will be in the description of this video


The airline operators of Nigeria, AON, has suspended his decision to withdraw his services across all airports in the country. Bellier Day, before the association planned to effect the withdrawal, it explained that it was suspending the decision in the interest of the national economy and security considerations. AON president, Abdul Munaf Serena, announced a suspension in a statement jointly signed by six members of the association. Earlier, the Ministry of Aviation had assured Nigerians that members of AON were reviewing their decision to withdraw services on Monday, May 9th. It confirmed that Ibon Air, Green Africa Airlines, Ibroke Air, Dana Air, and others said they would carry on with their normal flight shadows. We are now being joined by Dr. Abdul Munaf, East Unusa, President, airline operators of Nigeria and the Chairman, Azman Air. Glad to have you, Mr. Unusa. Okay, we also have Mr. Waleh Shadare, an aviation expert on the news tonight. Mr. Shadare, are you with us? Mr. Shadare, can you hear me? Good evening, Mr. Shadare. Okay, it looks like we're having a bit of... Mr. Shadare, good evening. Good evening. Can you hear me? Yes, I can. Welcome to the news. I can hear you loud and clear. Very good. Good evening to you. Dr. Unusa, are you with us? Yeah, I'm with you. All right, very good. Glad to have you, gentlemen. Thank you. Okay, so let's go straight into it. Have the issues which led to the planned flight suspensions been sorted out? Hello. I start with you, Dr. Unusa. The issues which led to the planned flight suspension, have they been addressed? Okay, can you hear me then, Mr. Shadare? It looks like Dr. Unusa is not... You see our efforts. Are you with me? Okay, go ahead. Hello. Go ahead. Okay. So due to the federal government intervening on the issue of the suspension of strike, so because of the interests of the masses and the interests of the federal government, would they call us and say that he want us to have a table meeting with them tomorrow and next tomorrow? So we decided to step down for our action. So that is why we decided to say that our members should go back for his normal operation pending our meeting with the federal government tomorrow and next tomorrow. Okay, so it's just few days before we know exactly... Yeah, the important is to give them 48 hours so we agree to give them 48 hours. Okay, well the astronomical rise in the price of aviation fuel, that's jet fuel A1 from 190 Naira to 700 Naira per liter is disturbing and disheartening. The issue has been persistent, especially as well as unavailability. How can a complete resolution be achieved? Unisa, I'm still with you. Dr. Unisa, I'm still with you. Okay, you see the aviation fuel like how you said that we used to buy it 190 now ready to 700 Naira, which is very, very difficult to continue of raising on that one. Because if you see that if we can continue by aviation point at 700 Naira, we have to raise our ticket fare to 120 which is too high considering the masses. Even the 50,000, 60, 70 we are selling some of the people cannot afford to make that money. So that is why we say that we have to bring the attention of the federal government so that it will come to this our business to see how we are going to continue on this business. If not, everybody will stop and keep this. We cannot do it. Considering that the dollar, we are buying the dollar was 300, 360. Now the dollar is getting to 600 Naira. You see the aviation business, even the carpet of the aircraft, we are not doing it in Nigeria. We buy it abroad. Every soon we buy it by dollar. 90% of the purchase for the aircraft is by dollar. So all this one caused this problem, the aviation and the dollar.  Can you come in and tell us how you are analyzing all of this? How are you taking all of this in and what's your assessment of what's going on? Thank you very much. We know that if we get to this level that the airlines, we decide to take the action that they plan to take. If we remember closely, some few months ago, aviation's work rose from almost 250 Naira per liter to 500 and 600 Naira per liter. And the airline operators had the meeting and decided to adjust fare to 50,000 Naira for one week. And that was the base fare, that was the least fare. And there were a lot of them outcry against the airline operators. But if you look at it holistically, you'll find out that the airlines are going through some of the difficult times. Aviation for takes about 40, 45% of the revenue of airlines. Even at 50%, it becomes very, very difficult for them to remain afloat. What are they going to do? The best thing for them to do, which they did was to raise that fare to 50,000 Naira. But if you look at the situation very well, you'll find out that how many people, like the AOM president said, how many people can really afford 50,000 Naira per liter in this economy? I do not know how the airlines are going to survive because if they try to adjust this fare more, they have competitors in Jibo, they have competitors in Mazemaza, they have competitors in Uinibo. And these competitors are the road transporters. A lot of people who take road transportation, even with the attendant security on our roads. I do not know how we're going to do it. Aviation for has been designated a long time ago, and the oil marketers will tell you that they are selling to the airlines at the rate at which they bought. Well, at least I've said that an efficient review of the field subsidy system will bring down the prices. Do you agree? If we had the refinery, it would have probably, perhaps, brought down the price of aviation fuel. But we do not have that. So the pressure is so much on the airline operators. If you look at it, the Russian-Ukrainian world has also contributed largely to this. But honestly, I don't know where we go from here. The operators are really, really crying. It is very, very difficult for them to operate. And if nothing is done, we pray the airlines will not start cutting corners. If they start cutting corners, we all know what is going to happen. Is it a disaster waiting to happen? If you look at it, the airlines are finding it very, very difficult to even sell dollar. They cannot even get dollars to do their operation. And airline operation or airline business anywhere in the world is dollarized. So where do we go from here? Where do we go from here? Let me return to Dr. Unisa. Dr. Unisa. Yeah. Yeah, well, the pipeline bridging the supply of fuel from Ejibu to the MMA has not been repaired by the NNPC since 1992. That's 30 years after it got ruptured. What is the government saying in this regard? Or is it part of what you're going to discuss with them within this 48 hours? No. That's why it's not a part we are going to discuss with them. Because that's, you see, what we want out is immediate, the immediate supply of the aviation for it. You see, the aviation business is not like other business. I am an oil company. So I know that this aviation foil, NNPC is the major importer of this aviation foil. And NNPC is the one who is important this aviation foil. The majority of this aviation foil is NNPC imported it. And it is distributed it to the market. Dr. Unisa. The request from such allocation, this is our allocation. We fit them together with them. We spend about seven days with our members. With our marketers, with the NNPC people, that this is our daily demand. This is our weekly demand. This is our monthly demand. They agree that they are going to give us but that one didn't work. The issue of this pie, we are saying that that one, we cannot say that we are talking of that one. We need the immediate supply. Immediate supply at what cost? The man who is the expert aviation man who is saying is saying the truth because the aviation business is not like other business. It's not like other business. We cannot like what he said that if they didn't do anything, we can make a corner. No, no, no, no, no. We cannot make a corner. What we want is to see that we bring the attention of the concerned authority to see how we are going to resolve this issue. Instead of make a corner, we can just pack our aircraft if we cannot do it. Thank you. Well, thank you. That's perhaps a good place to leave it until we hear your through with your meeting with the government within the time frame of 48 hours and then air travelers will be able to tell if they can still fly or not. Thank you so much, Dr. Abdul Munaf. It's you, Nisa. You're the president airline operators of Nigeria and chairman Azman Air. Thank you for your time and Mr. Wale Shadari, an aviation expert. Thank you, gentlemen, for your time tonight. Mr. Wale, good evening, Alaji. Dr. Wale, very much. I pray that this problem will be resolved as quickly as possible by the way that is what we're afraid. We don't want this.


Two people escaped without injury from a house fire near Wadena yesterday. Firefighters were called to the scene in Wing River Township around 8 30 yesterday morning and found the main floor of the home fully engulfed in flames and the fire was already venting out through the roof. Both people inside got out safely and fire departments from Verndale, Wadena, Sabika and Managa worked for several hours in sub-zero temperatures to extinguish the blaze. The cause of the fire is pending investigation by the Minnesota State Fire Marshal's office. If you enjoyed this segment of Lakeland News, please consider making a tax deductible contribution to Lakeland PBS.


So, you want to build an open soft software, don't you? All you need is to go to your computer and start coding. Then publish your software release. But life is in a ways that is, isn't it? I mean, what is a journey if out some challenges? Look, you even got some help now! Just some problems to solve before the glory.


So, we will continue our discussion on non-collisive oligopoly model also in this session. So, if you remember in the last class, we discussed about the connoit models and connoit models typically a duopoly market situation, where the basic characteristic is that it operates in zero cost of production and that is why we get a marginal cost which is equal to zero. And here, even if the firm they knows that they are interdependent on each other, but when they fix their output, when they fix their price, they are not taking into consideration the what will be the rivals plan on the basis of their revised plan. And that is the reason if you remember in the last class, we discussed a situation when in the period they one-fourth of the market remain unexplored, no one produce in that one-fourth market, the rest three-fourth market is got produced by both the firms A and B. So, we will continue our discussion on the connoit model, we will see that how the equilibrium solution can be achieved or how the equilibrium can be achieved with the reaction and action patterns of the reaction and action pattern of the two firms. So, in the last class, if you remember, we talked about a situation where the three-fourth of the market generally. So, in that case, if you remember, then a, b together they were just producing three-fourth of the market and one-fourth was not produced either by firm A or firm B at least in the first period. Now, what will happen in period two? So, this in the first case, three-fourth was produced together by a and b and one-fourth was not. Now, how it will happen in period two? From A, assume that B is just going to produce one-fourth of it and he will feel that three-fourth is his own market typically for firm A. So, if three-fourth is his own market, now generally he is producing only half of it, so he will produce half of three-fourth in the market and that will come to three-eighth of total market. So, A is going to produce three-eighth of total market. A, assume that B is just going to produce one-fourth of the market. So, A will think that he is just going to produce only three-fourth, the rest three-fourth is his own market and since A produce only half of the total market, in this case the half of total market is half multiplied by three-fourth and that comes to three-eighth as the total market. Now, we will see how B is going to react to this. So, B will consider that again when it comes to B, what will be the assumption for B? The assumption for B is A will continue to produce three-eighth of the market means what is the market available for B, the remaining market that is less by three-eighth, so this is one by three-eighth is the market available to B. Now, B will produce again half of this because half of one by one minus three-eighth, so this is five by sixteen, so A is going to produce three-eighth and B is going to produce five by sixteen. Now, this action-reaction pattern continues from always assume that A always assume that B is going to produce half and from B is always going to assume that A is going to produce half. So, they take out that half and they feel that the rest of the market whatever they could produce and again it comes the half of the total market demand. So, this action-reaction pattern for form A and B will continue. Now, what is the outcome of this action-reaction pattern of form A and B? So, it is just goes on with the share that is half of share, half of the total market except the share of A for B and half of the total market except the share of B for A. So, this action-reaction will continue. So, in this action-reaction generally share of A goes on decreasing and share of B goes on increasing and this will lead to a situation where each form supplies to an equal market that is one-third of the total market. So, this if you look at initially the share of A was higher than share of B. So, this action-reaction pattern will continue and with the action-reaction pattern finally each form will reach to a situation where they are just producing one-third of the total market and remaining this one-third of total market is produced by A, one-third of total market is produced by B and remaining one-third is not getting produced either by A or by B. So, we will just take the graph to understand this that how this reach to a situation where they just produce one-third, one-third and leads to a case where rest one-third is remain on produce either by A and B. So, if you remember your reaction function R 1, R 1 dash is the reaction function of form A, R 2, R 2 dash is the reaction function of form B. So, ideally this should be the situation where this is the amount of Q 1, this is the amount of Q 2. Q 1 is produced by A, Q 2 is produced by B. Now, how they reach to this Q 1 A to Q 1 B? It is not they start from here, rather they start from here and what is this R 1 dash here? At this point the total market demand is we can say O R 2 dash is the total market demand. So, out of this initially A will just produce this much and from there actually this action reaction pattern happens. So, if this A is producing this corresponding to this B will produce here that is the reaction curve of B. R 2, R 2 dash is the reaction curve function of B, R 1, R 1 is the reaction curve function of A. So, if you look at if initially A produce this much, now with reaction to this B will produce take a point corresponding to this in the reaction function of B that is R 2, R 2 dash corresponding to this again A will react to this and choose a combination where in the reaction function of A. And if you remember what is reaction function? Reaction function gives the different quantity of Q 1 and Q 2 combination of Q 1 and Q 2 where profit is maximum. So, whether B chooses any combination in reaction function 2, A chooses any combination on reaction function 1 ideally they maximize the profit. So, to start with they will do this with A start with this point corresponding to this B choose a combination over here. Now, suppose this is combination 1, then this is combination 2 again chosen by A with respect to the reaction to a combination B by this 1, then corresponding to this again B will choose a combination here. And corresponding to this A will choose a combination here, then corresponding to this again B will choose a combination here and here A will choose a combination here. This action reaction will continue till the time they are not reaching this point E. And after reaching the point E, the generally they reach the equilibrium solution where A produce Q 1 unit of output and B produce Q 2 unit of output. So, graphically how we reach the Carnot's equilibrium? We reach the Carnot equilibrium through the reaction function approach. We take the reaction function 1, reaction function 2 and the reaction of both the forms get captured in their own reaction function. And finally, eventually this reaction action pattern leads time to the equilibrium where they this is generally stable and after that at least in that time period again the reaction action pattern never continue. Then we will see the detailed description that how this one-third of this total market output comes to form 1. We will just take period wise that how this final yield comes to one-third for form A and one-third for form B. So, if you generally we will just take a form of equation in order to understand this. So, period 1 we will see what is form A, what is form B. So, form A is half of total market. So, this is half, form B is half of half market that is A share that comes to one-fourth. Then period 2, what will be for form A? Half of 1 minus 1 4, 1 4 is the B share that comes to 3 by 8. Then what will be for form B? That is half of 1 minus 3 by 8 that comes to 5 by 16. Now, what will be in period 3 form A? That is half of 1 minus 5 by 16. This is B share that comes to 11 by 32. So, this is B share 1 minus this half of it going to be produced by form A, form B again half of 1 minus 11 by 32 this is share of A. So, this comes to 21 by 64. Then we will take out period 4 output of form A and form B. So, this is nothing but just taking the share and making a half of it, but eventually we will see how they just produce one-third of the total output. So, for period 4 this is again half of 1 minus 11 by 32. So, that comes to sorry 1 minus 21 by 64. So, that comes to 43 divided by 128 and form B again half by 1 minus 43 by 128. So, that comes to 85 by 256. Now, this continue till the time period n. So, we will see how what will be the value in period n because n takes any number. So, it is 1 to n. So, in period n what will be the share of form A and form B? Eventually it is form A half by 1 minus 1 by 3. So, that comes to 1 by 3 and form B half of 1 by 1 minus 3 that is coming to 1 by 3. Now, what is A's equilibrium output now? A's equilibrium output will be half minus 1 by 8 by 1 by 1 minus 4. So, that comes to half minus 1 by 8 by 3 by 4 which comes to 8 by 24 and 1 by 3. This is form A equilibrium output. Similarly, we will find form B's equilibrium output. So, form B's equilibrium output 1 4 by 1 minus 1 4. So, this is 1 by 4 divided by 3 by 4 which comes to 1 by 3. And for n number of form what will be the industry output and what will be the firms output? Industry output will be n by n plus 1 or to again describe this. This is e is equal to 1 summation e 1 to n 1 by n plus 1. And what will be the individual firms output and 1 by n plus 1? This will be the individual firms output both for A and B. So, ideally what we want to check over here? We want to check over here is that when the action reaction pattern happens they assume the same behavior from other firms. And that is why they if you find some of this is remain on utilize that is not being produced either by firm A or firm B. And that is why they are just producing one-third of the total output of the market and remaining one-third is not being produced either by A and B. Next we will say we will just take an example to understand this Connard model. We will just take a numerical to understand the Connard's model and then we will move into the next model that is Stackelberg model and Paul Swigic King demand curve model. So, P is equal to 100 minus 0.5 x this is the demand function. This is cost function of firm A which is it is a constant cost function. For firm B it is the increasing cost function. We need to find out the profit maximizing level of output for both the firm A and B. And how we will find out this? We generally take the profit maximizing rule that is marginal revenue is equal to marginal cost. So, what is this P? P we can simplify this as 100 minus 0.5 x A plus x B because this x is the total output is the summation of output of A and B. And what will be the profit of firm A? That is total revenue minus total cost. And what is total revenue over here? So, total revenue minus total cost will give us the profit of A. So, this is P x A this is the output this is the price minus 5 x A this is the cost function of the firm A. So, what is P x A that is 100 minus 0.5 that is x. So, this is x A plus x B multiplied by x A minus 5 x A. So, this is cost function this is P and this is x A. So, if you simplify this then it comes to 100 x A minus 0.5 x A square plus sorry if you open the bracket this is minus plus minus 0.5 x A x B minus 5 x A. Simplifying this again this is 95 x A because this 5 x A will get deducted from here minus 0.5 x A square minus 0.5 x A and x B. Simplifying this 95 minus x A minus 0.5 x B is equal to 0. So, this is our marginal that is our this profit. So, this comes to marginal revenue equal to minus marginal cost has to be equal to 0. So, this is 95 if you take the derivative then this comes to 95 this comes to x A this comes to 0.5 x B. So, if you simplify this in term of x A this comes as a 95 minus 0.5 x B and what is this x A in term of x B this is the reaction function of A this is the reaction function of A. Similarly, we will find the reaction function of B and if you remember what is the reaction function of A this combination gives the maximum level of profit to the firm A. Similarly, we will now find it for B. So, if you simplify this for x B we get its 50 minus 0.25 x A. So, I am not just doing a detailed calculation for B you need to follow the same formula to find out the what we did for A the same formula to find out the reaction curve function for B. Basically, you need to find out the pi then you to maximize it pi is the difference between total revenue total cost you need to maximize this and then solve for the value in term of x B in term of x A and that will give us the reaction curve function for reaction curve function for B. Now, to find this value of x A and x B we need to need to put the reaction curve of reaction curve function of B in A and reaction and we can solve the value for x A. So, in this case you can find out x B is equal to 50 minus 0.25 x A. So, now what we will do we will put the value of x A in order to solve for x B. So, this is equal to 50 minus 0.25 by 95 minus 0.5 x B. So, that comes to 50 minus 23.75 plus 0.125 x B. So, solving for this x B will be equal to 30, x A is equal to 80 and putting a value of x A and x B that is 80 plus 30 that comes to 120 and putting the value of this will get the value of B which is equal to 45. So, this is the output of the B, this is the output of A and this is the profit maximizing level of output of A and B using the cornered model or generally using the reaction curve approach. So, what we discuss in case of cornered model this is a typical situation where two firms engage with each other they know the interdependence, but they are not considering the fact that they are interdependent to each other in order to decide the output plan. And that is the reason when they are revising their plan they are not considering the what will be the rivals reaction to the revised plan and ultimately they are reaching to a equilibrium which is stable, but in that case they are not exploring the output for the entire the market. And here we take the assumption that there is zero cost of production and we also discuss in case of cornered model that when we assume the zero cost and there is a linear demand curve the output of perfect the output of monopoly is half of your competitive output and the duopoly output is the two-third of competitive output. So, to summarize this H4 cornered solution equilibrium is stable and each firm will be maximizing profit by selling equal amount of output at the same price. So, price same they are selling the equal amount of output like one-third one-third of the total market and equilibrium is reached when both the firm earns maximum profit and have no tendency to change their output.


Hello, this is boring from one dot TV and today I want to give my first impressions of Borderlands 3 I was given this key from from 2k and I appreciate them for providing the key I did not pay for this out of my pocket again disclaimer. I was given this key this game is a sequel to Borderlands 1 and Borderlands 2 which were the birth of the shooter looter shooter genre and It presented a whole new addictive flair and flavor to What we like to play first-person shooters, you know prior to games like this We were addicted to games like Hall of Duty where you grind it out different types of unlocks and Prestiges and stuff, but now a game like Borderlands came around where you grinded guns and stats And you know the whole RPG thing you got from Diablo was applied to a first-person shooter So Borderlands 3 has been a long time coming It's been six almost six years since the previous Borderlands and a lot of people have been waiting for a long time So there's a lot of hype surrounding the game and a lot of controversy too, but we're gonna be focusing on the game itself So let's start with the bad. I always like to start with the bad because I feel like my videos are better when I do that Your favorite reviewer probably doesn't do that But I do anyway the bad the first thing and the probably the the biggest sore thumb I think everybody can agree this if they don't agree with it You know, I just I just look at them and go. What were you thinking the map? The map is absolutely Atrocious here's a map in a game which rotates around the player by default and both the mini map and the full blown map Now you may think well one. That's probably not too bad. Well when you play the game I think you'll probably see what I'm talking about They give you the option to lock the map due north on the mini map Which helps but it's zoomed in so far that you can't see anything So you constantly while playing the game and trying to complete quest you constantly have to Go to the bigger map now the problem with the big map is that it constantly rotates to the direction that you're looking So if you're trying to complete a quest and you don't know where you're going Which is going to be the case if this is your first time playing the game You're not gonna know where you're going So it's hard to orient yourself and to decide which way to go and which way the way point is and what the Landscape is doing. It just makes it a lot more difficult. Give us the option that to Orient the map to stay due north. That's a simple fix. I don't understand why they didn't do that They have to fix this. This is the biggest issue when going through the game the first time I actually got very very frustrated Questing with this because I was you know, I'd go a little bit and the mini map You know, I could I could lock that due north, but I couldn't Couldn't see beyond a certain amount of the map and so I Will constantly bring open this other map and then I have to reorient myself like alright Where's this landmark? Where's this landmark? It was a lot of extra work and just bad design Really really bad design on the map and I I think that's that's that's gonna work against them And a lot of different ways for new people to the series and People who are who are familiar with the series. It is really bad It's the number one thing every time somebody asked me about borderlands And they go one of what was the thing you hated the most and what was the worst thing? I'm gonna say the map every single time it is so Awful the next thing is something that's kind of carried over from borderlands one and borderlands two And you're probably gonna guess what I'm gonna say it is the UI the user interface is still just horrible It is terrible. It is It's like they haven't learned how to to take a console-based interface and bring it over to PC and Effectively, you know make it usable in 2019. I find that hard to just fathom They Bethesda and a couple other people just don't know how to do that I don't get it. This is really really weird. This is I guess it's just a very old-school mentality stubbornness But the UI is just still bad There's there's so many parts of it that I just wish would go away like hitting tab to do things just is wrong Tab to go from the next screen to the next or to the previous screen Escape doesn't doesn't do what you think it should do you got buttons like z and c to go to different screens and The right click and left click don't do what you think they'll do and a lot of these you user interfaces It's just something that's carried over more lens to and more lens one that is just can't fix So the UI very very bad The next bad part about this is performance performance is bad. It is very very bad And I'm gonna say it like this because it just like every PC release that comes out Every PC game that I can remember especially AAA you're gonna have varying levels of performance problems I didn't have any performance problems on my machine, but I have a very high-end machine Mid-tier low-tier machines were reporting a lot of stuttering and a lot of performance problems So that's that was kind of normal on PC. So I think PC needs additional optimization However on console it was on it was just unacceptable You had to run these get you had to run this game in performance mode in order to get some decent frames And even then if you went to split screen, it was just unplayable And I'm going on other reports not mine myself because I don't have I don't have a console version So the performance is definitely bad on consoles, especially But PC definitely can use additional optimizations for certain configurations on mid and low-tier And like I said, some people had no issues like myself and others had a lot of lots of issues So performance is a problem as well cloud save well cloud save is a new feature that came with the epic games store I say a new feature because they just added it with games like rubble galaxy outlaw Which didn't have any issue with cloud saves, but apparently board lines is struggling with a little bit People were losing their entire saves Reportedly now. I didn't confirm this when anybody I know Personally or I didn't experience it myself, but it's enough to make you go. Wow. That's a possibility I don't want that to happen to me. I've had this happen with other steam games in the past where cloud saves would be corrupted I'm trying to think of the latest game because I had I had turned cloud saves off because they were corrupting I think it was thief. I think that was the game I'm trying to think of the name of it But I think it was thief one of the games had some cloud save problems and I turned off cloud saves And it's something that creeps up every now and then but it shouldn't be very common I haven't seen widespread reports of this But this is such a major thing that when it does happen It can be it can be really really really really bad the most recent bug Which I heard of as early as today is that people were losing items in their bank So I don't think that's a specific cloud base problem I think that's a borderlands 3 problem, which is probably further exacerbated by how they're using cloud saves Just specific parts of your inventory are missing. I think that's a game bug that needs to be addressed I think they need to work closer with epic to figure out what's going on if it is related to cloud saves So now let's talk about the good things the good things in borderlands 3 number one the quests The quests feel very very very good They feel a lot better design than they did in borderlands 2 and in borderlands 1 I remember especially in borderlands 1 some of the quest designs you Growned when you had to do some of the things It was just I don't want to go and do all that and then the mechanics that they put in the game didn't feel Satisfying and it felt like a chore it was improved a little bit in borderlands 2 But I just in my last playthrough of borderlands 2 I encountered several quests that I just didn't want to do I was like I don't feel like no that this it just seems clunky But everything seems smoother It seems a little bit easier to do and you can just coast through the story without having to worry about that Which means that they actually put some thought into the quest design I think they simplified a lot of the quests which made it easier to go through the story and that's always a great thing The next thing are the guns the guns feel awesome in terms of gunplay in terms of aiming in terms of a variety of recoil and non recoil options and and Just borderlands has always been known for the gun design and just gun wackiness and they've added So many great features to make the guns actually feel good when you're firing them And the looter shooter like this that's very important and on top of the guns feels the movement feels great as well So you can jump around do air shot gunshots and it just feels very fluid and very good and I think borderlands 2 Probably had one of the biggest improvements in this area And they've kind of brought that over to borderlands 3 and even improved it a little bit more I think the jump from 1 to 2 was a lot better than the jump from 2 to 3 But there's only so much you can do in this area They kept the borderlands humor intact The the the very slapstick like humor very low-hanging fruit type of jokes They definitely kept that in there and it made you chuckle. It was one. It's one of those chuckle games.  So if you if you appreciate the humor of borderlands 1 and 2 You'll be happy to know that borderlands 3 maintains that type of humor The end game feels really really fleshed out and I think this is a very important thing because borderlands is all about Endgame you go through the story, you know, you go through the quest You go through all these things to get to the point to where you need to farm and min-max these awesome Pool of guns. There's so many guns and so many builds that you can do And they've added a mayhem 1 through 3 in true vault hunter and true vault hunter mode And it is very very very very good Mayhem applies some modifiers very similar to what you see in games like path of exile when you do maps You know enemies do more elemental damage. You do less damage this type of thing and as a reward you get more loot You get better XP, etc. etc Same is true for true vault hunter mode. It is a new game plus type of a deal and Essentially the monsters just get better and better I Think this is gonna add a lot of life to the game until we get our first set of DLC Which is gonna be as soon as as Halloween. I hear that is that they're working on a Halloween event This is gonna give players a lot to do because there's so many guns so many variations and they've mixed it up quite a bit Now let's talk about the story the story is mediocre at best I put it under good because it was what I expected the story was Borderlands It wasn't the greatest story ever and I want to qualify this be saying that it's a looter shooter And I can't think of any other looter shooter where I actually cared about the story Division 2 warframe Even destiny at the very forgettable stories. I don't care about them And the story in Borderlands 1 and the story in Borderlands 2 are very very forgettable We remember some of the memorable characters, but the story itself We're opening a vault pretty much and we're looking for loot. That's it So the story is mediocre at best. I wouldn't expect the best story in a game And tons and tons and tons and tons and tons of quality of life improvements Quality of life is the name of Borderlands 3 It's like they took Borderlands 2 and they just wanted to polish it to death All right, they really really paid attention to a lot of detail a lot of voiceovers lines and and just Little it's just a lot of little things that add up to a great experience the gun stats the variety You can combine parts from different manufacturers to mix and match builds It is a very very very big quality of life update to the Borderlands series Which is why my overall opinion if you want to get to the to the overall the TLDR the TLDW Too long didn't watch Overall it is the best Borderlands to date it is better than two is better than one Borderlands 3 is the best Borderlands to date If you want to compare it to other games like Division You want to compare it to Warframe you want to compare it to destiny other little shooters It becomes a little bit more complicated And I'd rather not focus on that until I do a lot more in-game. I've just started doing in-game I'm not even level 50 yet. I got into mayhem one did some stuff. I started true vault hunter mode I've seen some footage and I've seen some people do some stuff with mayhem And I've seen the mixture of the stats and the mixture of the of the modifier So I'm aware of how they work, but I haven't played it myself. So I really feel like I can't really compare Borderlands 3 to these other shooters just yet But I definitely feel like I can compare it to Borderlands 2 and Borderlands 1 based on my experience with those games. It is the best Borderlands game to date So if you're on the fence and if you like Borderlands get the game. This is easy. It's not even hard to to To to to even say anything otherwise. It's a very easy recommend for Borderlands 3 This is one from 1.TV. This is my first impressions. I may put up another video following this talking about More mayhem and true vault hunter mode TVHM and how that all plays out But man, it's a good game. It's a good Borderlands game. And I think you can enjoy it. Take care. Have a good day


In this video, we will show you how to replace the battery. First of all, you need to open the battery drawer. You're using L to pull onto the lip of the battery drawer and simply pull it open. To remove the battery, you lift the battery out of the compartment. You then get a new battery. You peel off the orange tab to reveal the positive of the battery. It is important when you have the hearing aid held in front of you in this orientation to put the battery in with a flat side to the left, like so. You'll see it slides in easily. If you have the battery the wrong way around, you'll find it doesn't sit in the battery drawer properly. Do not attempt to turn the hearing aid on with the battery the wrong way around as it can damage the hearing aid. The correct orientation is with the flat side towards the left. Close the door to activate the hearing aid. This is how you change a battery.