Cases medic transcript — SMP305 lecture transcript

I I But I was like, you should Hi, good afternoon, everyone. Jen Uh, so, Good afternoon, everyone. 3 A. Yes. So I'm Sean Consultant vascular surgeon teacher And The The reason I do this that. I was, I'm sort of involved in management. That shepherd teaching OK, so what we're gonna do. hour and a bit. spoke about What do we mean by Secondly, We talk about why You as medical some of the drivers My doctors In management Either formally, Informally, we're all going to be. Involved, but some of us may Then we'll talk a little bit about why The Loughton Get involved in And then we'll talk a little bit about What are the qualities Knowledge Yeah. And OK with this field How we should And then, uh, uh, we'll finally talk about some, Specific models of leadership. There are many more polls We'll just give some Your son you might choose. To adopt Go all the way to involved Then we'll talk at the end. about clearly highlights some Does that sound OK, guys? You will not be tested on this, so you can relax. It's just more about, Getting you guys To start thinking about Even if you choose You don't wanna be involved in any management. Unfortunately will encounter. have to work with people who are in And it's just to try and start that journey of building your understanding. This is an Where things start. When I was a medical student many years talk anything about The first time I In a formal way. was when I was a senior registrar. Week's course But the are quite keen. We begin that journey much earlier. That And That's why It's the best crack on. So let's first of all talk about the two terms that I've used already. OK. And just to get an idea about, You know, you'll have come across these terms. Just to try and get some understanding. you think. To you what Before we delve into those two definitions, There is something called, Medical science, clinical There's something called social sciences. OK, so medicine falls into, of medical clinical sciences. As does Then there are subjects which fall under social science. Uh, And it's, it's quite a different. Sort of subject and sometimes for people who come from a sort of a Traditional medical science, clinical science, or science type of background. social Quite difficult Try to Ideas and concept of social Somebody give me an example of a subject. in social sciences. Sorry? Sociology, yes, yeah. I mean, even subjects like history. Languages, they all fall under social. lots of And management leadership Also the subject of man. As a discipline depth of study also I'm sure you'll have read some papers in the British Medical Journal or The Lancet or the Who's read the paper Any paper on any topic in any of these Fantastic. Tell me what paper you read? Which journal was it? In the BMJ OK. Has anybody read any papers in social science type journals?

What What, when you read this paper, how long was this paper? 4 pages there would have been some diagrams and some tape. Some statistic So the first thing you notice Sort of a science type paper. As much B It might be, you know, a shortest social science paper, you know, study, for example, this one was a study. You know, studying any The first thing Much bigger Maybe 1520 pages. As opposed to You know, they don't like the BMJ. Journal of Medicine in the Barnes and have a very strict word count. Can't go above that. To have a strict page count, you can't go above that. They have strict diagrams and tables count, you can't go above. Well the social science of German, they're not so restrictive So it's, it's, so the topics and the subjects are much bigger. and also When you apply statistics, You're coming up with conclusion. The conclusions aren't as concrete. So things are not as black and white. The sciences Useful Walnut and In social science One on one might equal to Another setting, it might actually be So social science, so I'm just trying to get you to start. You know, thinking about This field, OK. Right. So coming back to these two terms, um, as I said, I'm sure you've come across them. Who's going to be brave enough to say what they understand by management or Yeah, go on. Sorry, which one? Yeah, influencing others, yeah, OK. Anything else? Any other? Oh Does management like delegating.

Yeah Potentially you can also do the tasks like you. part of the group OK, so management is more about delegation, whereas leadership perhaps you want to lead by example. Do it yourself Then gets to do it, yes. Any other thoughts on Man It OK, OK, so, so another approach, OK, is, you know, is that. Where does the buck stop? the response and the ultimate Somebody clearly in Any other thoughts on that? Right, I thought. Definition according to some people, OK, and as I said in social sciences, you know, things aren't quite as black and white. And, and it does depend and vary on lots of other things, OK? So I have a quick read of that. So the above definition is. About management, so somebody in a management position. So in healthcare, you know, for example, You'll have all been in hospitals and in primary care where there will have been a manager, OK. Either in the primary care setting, in the GP practice, or perhaps you might not have been exposed to, but there will have been some managers in your place, clinical placements. So That's one way of thinking. OK, about what a manager might want to do, OK? Yeah, the providing all the stability, making sure the team has what it needs to do to, you know what it wants to achieve, OK, providing those resources, OK. Whereas leadership is more about. That providing the vision, OK? A direction, setting the direction, OK. The first one is more operational side aspect. Right, whereas this one is more about setting the direct. Leadership sets the direction. The management operationalize that vision. Does that make sense? OK. So again, I'd say that's one. As one sort of potential way to think about management leadership, but there may be others, OK? And if you Google it, I'm sure you'll find lots of other definitions of management leadership. OK. So the next thing we want to go on, talk a bit briefly about is. So now we've got an idea about. You know, a manager might Be wanting to do and what a leader might. Be required to do OK. is less to talk about What qualities. They might need, OK? or the type of knowledge So any thoughts about the qualities OK. I mean, what I want to do now is, is not strictly separate these two entities. that sort of Lump them together Think about what the qualities. a person in a position in management. You think what kind of qualities they might need or should have thoughts Due diligence, yes? OK, good. Sorry? Competence. Competence, yeah? Or confidence, yeah. Particularly people in leadership. Looking Anything else? So this side of the The And from the back. Any qualities that you think? Values relations So yes, values, relationships, yeah, so that, you know, both managers but perhaps more leaders. There's a relationship between and the followers, and that's a very important relationship. And and and and sort of building that relationship, developing that. importance of in so Anything else? Before I put up some Again. You know, you may find lots of other qualities, OK. So confidence, somebody mentioned. Humility should have humility. You think they should be just out of? will It creativity What about this Emotional intelligence. Who's come across that? Anybody come across this? Term or this concept, this idea of emotional What do you think it might mean? OK, so understanding people's emotions. And then the reactions of And why people Any other thoughts? OK, so if somebody perhaps. So because you're talking about understanding other people. You're you're coming from is is perhaps that they need to understand their own emotions. violence I feel I'm more likely to Like OK, yeah So this term actually was coined in the 70s. Uh The scholar of Social sciences, Charco. Came from Who studied a lot about You know People's emotions. So it's, it's, it's actually not understanding other people, but it's actually understanding. Your own self What are your strengths? OK. What are your weaknesses? And and how you respond In certain situations. For example, if it's So A situation An argument, a heated debate, how you and so on. So, so, so he coined this term emotional intelligence, is that, is, is, is mastering your own emotions. And the reactions That you have On in different situations. Example, you know, all of us, you know, as human beings. have a different Sort of, you know, personalities, how we respond to different. Situations Some people Quite sensitive Cried is Really upset Other people And withstand criticism. These terms that we use, OK? And they can, For example, you know, can withstand criticism much more. others. So this this this sort of field, this study was all about empowering people. Understand their own emotions, OK, how they react. And then actually develop strategies. to deal with So that it doesn't need So there's no right or wrong way to respond to any particular situation, but if that response leads to a poor or bad outcome, then that's not. So Have to develop those skills. Manage It's more about Understanding your own self. As I said, then developing those skills, how to manage. How And as doctors, You will come across situation Yes Challenging You have Spaceships And those people have good understanding of their own How they respond. Behave you So this is what emotional intelligence is. OK, so the next thing is, what are, so that's the sort of qualities aspect of it. What are the sort of, sort of areas of knowledge. That should be taught. Preparing people Potential management I said you know We began this journey of getting you guys to think about managing. Even as I say, you don't take on formal roles, you will still need necessarily need to Is And you may even have some role, you know, not a sort of formal senior. will still have some might be given responsibility, let's say, Yeah Of this particular surgery. Leave this So What, what are the, the sort of Fields of knowledge or areas. thing Patting somebody We've all taught you medicine. We're preparing you to be doctors. Because this is what you need. Anatomy, some physiology, normal anatomy, and then when things go wrong, diseases, we need to teach you, you know, when things go wrong. And then how to make is. How to treat, OK? And obviously that journey will continue. graduate But are we giving you anything, any. Potentially manages not. But what are the areas that we think we, we should Any thoughts on if you're all in a A management leader What do you think would be nice, For us to have taught you to prepare you. If we hadn't taught you some normal anatomy and physiology, You're gonna be struggling. You know, to manage patients. So, similarly, a all the signs Sorry? Time management. Time management, yeah. OK. Sorry? Finances. Finances, yes. Normally as doctors. OK, but for your own, far from your own. Anything else? Yes, communication, working with others. I mean Sorry? Conflict resolution, yeah. OK. Dealing with difficult colleagues. Anything else? Yeah, so, and then I've got a list here. Again, I'm sure you'll be able to add to this. OK, you've mentioned some of those already, teamwork, communication, and obviously, management. OK Quality improvement, medical legal aspects of healthcare and health delivery. Understanding about policies and how how policies impact on health outcomes. OK, finances. Accounts OK, and leadership. So these are some, uh The areas of knowledge that we need to teach people if they're going to take on management leadership positions, OK? So, the next thing I want to think about, what, what's the best way of teaching you, OK? So, when we teach you medicine, the first year, we teach you normal anatomy and physiology, OK? And that is mostly delivered through, How's that talked to you? Yes, a big lecture. One person, so-called expert, stands at the front and tells you about Physiology of the cardiovascular. How the heart functions. How the heart pumps, starlings curve, does that ring a bell, starlings? No? Lost in the mist. One thing, guys. Bit of advice. Physiology is very important. Remember Physiology help you What field of Tell you Why your patients, Things have gone wrong, what problem they've got, how Anatomy, less so, less so, but physiology very important. So That's taught by lectures, OK? You also, of course, have other ways that we deliver the curriculum to you. On a small group teaching. There are placements where, like an apprentice OK. What about if we're teaching you? Management and leadership, we talked about The qualities that we need to teach you, the knowledge that we need to teach. How should we teach? Should there be lectures? Other forms Any thoughts Sorry? Yes, OK, so actually. Being in that sort of field, in that position, perhaps working with A manager or leader, OK. Like the clinical placements. You're on the wards in the GP practice with the people who you're going to be doctors. Teaching you how to be a doctor. And not only do they teach you clinical medicine, they teach you how doctors behave. OK, how the community OK, there's sort of your. You're sort of role models. And that's how you perform. I think And you start off studying medicine, OK, you feel, you don't sort of Feel that you're a doctor yet. Identify yourself But as you progress through those five years, and particularly the last, you know, year. When you start doing things that doctors do. Then you stop. Thinking and feeling, yeah. and sometimes unknowingly, you might introduce yourself. You OK? You're not quite passed the final exams. And your master introduced Just It may be better. So, so the same thing here. OK. Any other ways that we might, Teach management. What about lectures? Is that a good way of teaching? Any thoughts? Right, so this is, OK, so small group teaching, a bit like this, OK. Group is quite OK. Uh, Being involved in simulation exercises. For example, you might be all right. You know, in a primary care setting, right, that we have. Group of patients You know, who are presenting late, but struggle to manage And we struggle to manage. So what could we So that's a sort of project. And it might be done in the real world or it might be in a simulation setting, OK? Mentoring, you know, somebody talked about, you know, getting involved with a manager, a leader, OK, working with. Involved in quality improvement projects. OK. So that's different ways of learning about management and leadership, and then you learn all those qualities that are talked about and those skills, that knowledge that we learned we talked about as well. OK, so the next thing I want to talk about is why. It's been increasingly recognized over the last You know, perhaps 1020 years to get doctors involved in formal management leadership. Before, you know, you had. the. People usually from a finance. or business background In management Position We had doctors They were quite separate. With very little sort of interaction. OK. Sort of people in management issue were kind of responsible. Or, you know, how should we deliver care. To this group of patients, you know, for example, you know, The population of Sheffield. What are the needs, what What are the resources, etc. etc. It became increasingly obvious that you do need doctors, OK, to work with management. in a formal setting rather than an informal OK. But there, but certain things have happened. last 2030 years, which have really Strong Yeah. You know, doctors to be involved in the formal, and this is where the sort of teaching about management. obviously You can ask doctors to act in formal management leadership positions, then they they need that knowledge and skill. You can't just run them from the ward into a leadership position and I expect mind. that direction and that strategy. And, and, and we can split those drivers into financial drivers and quality drivers, OK? So these are some of the things that have happened over the years, mainly in relation to finances within the NHS. OK. So how is the NHS funded? Anybody know? It's not a trick question, guys. It's, Yeah, OK, so 100%. Of the NHS is funded by Income tax that people of this country pay. That model is different in different parts of the world. In other areas of the world, there are various other models in which healthcare is funded. But in the UK. The NHS, which provides healthcare, is funded 100% entirely by So every single person, well, obviously, you open it. Uh, everybody else, OK, are paying. Taxes, OK, and some of that as As sort of providers of healthcare, are responsible every single taxpayer I have the money, So each penny that we spend We are, uh, just bear with me. Functional And I'll phone you back. Yes. OK. So We're all responsible to make sure that that penny that we spend is spent wisely. And we are obviously there is the health minister. Ha a mandate from the people. To ensure that we as providers are spending each penny and 1 pound wise. We can't just waste They are all accountable Each penny that we spend in providing So just as we should be able to defend ourselves about the care we provide to our patients, equally we should be able to defend ourselves how we've spent the money. So, these are some of the things that have happened, OK? So, you can read about these, OK? About the sort of financial changes and restructuring that happened over the years in which it has been increasingly recognized. The doctors need to be involved in those decisions which are made at a higher level about the. The doctor isn't just thinking about the patient in front of him or her, but actually is thinking about the bigger picture is how do we deliver the care to this. Group of people, this community Or this city or this OK The next thing is about the quality. Again, have a read about this yourself, OK? But these are some of the things that happened. Other things have happened as well. I don't know if anybody's familiar with any of this. The Mid Staffordshire. inquiry that took place. This was in the 90s, OK. When there was a big issue. The hospital, Mid Staffordshire Hospital, OK, and the person called Kennedy, I don't know. Mount was asked to look into Issues that occurred In Mid Staffordshire Hospital, and it was to do with Hu excess mortality. Does anybody know what that means? Anybody? Familiar with that term, so. So crude mortality, for example, if you look at the hospitals in this country, and what you do is you look at the number of people that have died in that hospital or within 30 days of discharge from that hospital in that one year. And you don't take into account anything else. Yeah, and that's why you called But then you need to take into things like what kind of hospital If it's a cancer hospital, then you'd expect more deaths. If it's a hospital that You know, serves, you know, a population where there's a lot of deprivation. Again, you might etc. etc. So those are adjusted mortality, but the crude mortality is just, you just look at the total number of people. So and and what the Care Quality Commission does is it takes those figures and it puts it on the table, OK, and then it looks at, for example, you know, Mid Staffordshire Hospital. And say, well, it's a similar hospital to let's say in Rotherham or mom's. a similar population, so you'd expect You know, roughly a similar Mortal. They give us And what they found was consistently each year for a number of There was a higher mortality in this particular And then they looked at Detail found lots of concerns from family. Relatives of patients, issues And of course then Kennedy was asked to look into minded, a very detailed So if you Google it, Kennedy's report with Staffordshire inquiry, it'll come up. OK. The actual report is hundreds of pages long, but Nearly worth reading the executive summary. 3 or 4 pages, OK. And then similar other things have happened, for example, in Bristol, there was a similar scandal about cardiac surgery. And Telford about obstetric care. Recently, of course, obstetric care has been in the news, hasn't it? Lots of issues, Nottingham So OK. So, so, so these are some of the quality drivers, OK? And, and all of the reports consistently, one of the recommendations That we need doctors to be involved in managing. They are making decisions. How, what care to provide and how to What skill makes me what competencies how many people should be on the ship, etc. etc. So, these are some of the drivers, OK? So, the next thing I want to talk about is, I mentioned that at the beginning is why doctors may not get involved. don't want to be involved As I've said, in an informal way, You won't have a choice. You But in more formal positions, you will have Again, well, dream. So, why do you think doctors may not want to get? So we kind of Hinted on some of the reasons, thoughts? Not heard much from this side of the table. Mhm Sorry? Time Yeah, time is a key thing, isn't it? You know, how can I do this and that? OK. Anything else? Yeah. And you can say, well, I didn't sign up to be a manager, I signed up to be a doctor. That's what I wanted to be. All I'm interested in is looking after my patients. That where the money comes, how it's spent, etc. etc. OK. Any other thoughts? What about this? This exceptionally bright group at the front. On this side, any thoughts? Don't be nodding You. So Well, Sort of touched upon some. You might say, well, I, I'm not, don't have the necessary. I haven't been You know, years of medical school, Teach me any of this. So, so doctors, rightly so, they feel they don't have the necessary knowledge. And the skills That's a common Not And another one is that many doctors actually feel there might be a conflict of interest. You know, on one hand, they don't want to be, in any way influenced about the care they provide to that one patient. They want to be clear OK, not be affected by anything. Saying, right, I've got this patient in front of me. I've got to do the best for that patient and for I can't be worried about anything. Yes, so doctors may well feel There's a conflict of interest. those decisions About how we provide Group the whole population versus that one patient. So these are some of the The, uh, reasons, OK? The doctors, you know, don't get involved. There'll be many others, OK. Right. The last thing I want to talk about, about management leadership is some specific models, OK? There are many models. And there is a really fantastic book. By North On leader OK. It's not a big book either. So if you're going on holiday, You can read, probably read the whole book on the plains. Unless, of course, you're just flying to, But otherwise you'll be able to, it's a really good book, so if you just Google North House we And there are a number of leadership models, but I want to just focus on some sort of Uh, sort of The approach to management, sorry, to leadership over the last sort of I would say 60 years. OK. The studies into leadership really began in the 60s. And up to that, there was, you know, if you Googled papers on leadership, you'll find very little before the 60s, OK. But after that you'll find, you know, and increasingly you'll find more and more papers, OK. So the approach to leadership prior to the 60s and up to the What's what we call the traits. Anybody? What's what we're talking about when we say the traits. Why So the trade's approach is essentially simple. You either have it or you don't. Alright, so you'll have heard of this term, born leader, yeah? That's where the traits approach comes from. You're either a leader or you're not, and that's it. There's nothing else you can. So that was the dominant thinking about leadership up to the 60s, OK? But then when people started studying leadership and studying people in leadership, Then with the thinking shifted, that it's not just about the sort of the trait or the quality the individual may. But actually, the behavior is quite important. OK, so from the 70s onwards, the behavioral approach to It's not just the qualities. Well actually how What they do, how they interact. And so, so a number of models were developed based on Again, based on research And then sort of from the 80s onwards. Another dimension was added as more research was That it's not just the individual's qualities or traits or their behavior, but the actual context of the environment is important. And you may well find that one individual in this particular setting or context of this project, they are more suited A leader, but when that context or the environment or the project changes, that person may not be. In fact This person OK? So, so, so the, so you can see the evolution in thinking about the approach. Of the models of leadership, that traits approach, i.e. the quality OK. Behavioral approach from the 70s. It's not just the quality How the person behaves interacts. And then of course the situation context. So that's where the studies and thinking of leadership has been happening over the last 50, 60 years. And then many models of leadership have developed from those. Frameworks, OK. One particular model that I want to just discuss briefly. is this Laissez-faire, transactional and transformational. So first of all, laissez-faire, anybody familiar with this term? Just as the term rather than a hands off.

Not So that's how it's applied in the OK, the laissez-faire, I think it's a French word. And I like relax and do. What did they say? I think it refers to like relaxed. B Less effect, yeah, so essentially it's hands off approach. OK, so what do you, when do you think that kind of approach from a leader might be good. And when do you think you may, When is it, when do you think it might be a good, Leader person, the person in leadership position might take that laissez-faire. have Indeed, yeah. So you've got a highly functional. Team, they know what they're doing, so you'll say, well, hang on a minute. Everybody knows what they're doing. I'll just sit back, you crack on. If there's any problems. And you know, we might take a similar approach, for example, in a clinical setting. An experienced registrar with me. Clinic, I'm happy for you to see the patients. OK, on your own. If there is a problem, more supervisory Be required gotten a relatively new or more junior So, so it doesn't work well when the team. I competent, not organized. I'm not sure what they're doing, then of course you can't do that. What about transactional? Anybody know what we mean by transaction? So this is another approach to You might Useful approach. What, what do we mean by transactional? Anybody? Not heard anything from this backbencher there, true backbenchers. Well, sometimes backbenchers have to stand up and speak. Particularly when they want to get rid of the Prime Minister. Yes. a new prime minister OK, come on guys. Transactional. What do you think? Yes, OK, so this is another way of thinking is, you know, the character. So So if you do well, you give them a

cabin. And if they don't do well, you So that's what the transaction. So again, it might be useful in some settings. Where you want to incentivize people Improve outcomes, improve performance, OK? So right, like the football players. The England football team, if you win the World Cup, we're all going to give you a Porsche. That's what I think Keir Starmer promised. For So, and if you And then, of course, if you don't, then you might get demoted. The bonuses, the salary may be reduced or whatever. So that's the kind So in some settings it can be quite a powerful incentive to In other settings, of course, it may not work. Particularly when the carrot. When they see the characters, not really adding much. Let's say you said we're going to give you a Toyota Yaris. Football players who are bloody getting paid a million. I We get up in the middle of the night OK. So, if you said to the right, you're going to give you a Toyota. That's not much of an incentive. So this carrot stick and carrot approach can work really well in some sectors. Not so in others. OK. All right, last one. Transformational, any, Any thoughts on what that might moral approach might be? in a leadership And Transformation So here it's all about The leader empowering Actually Sort of Transforming Word transformation So that they are they are they are brought in to your vision. You thinking, they signed up. So that the leader, you know, sells the The project, OK, what needs to be done. And guest people signed up to They are thinking the same. The the leader's problem becomes their problem. You are empowering people. They feel this is their job, they need to. This is their problem. They need to Right, so that's that transformational. OK, and this is, this approach is more. Various sort of arms at length bodies. Advise the NHS. Approaches Oh Per They feel they can make. They are responsible So they don't feel disengaged, disempowered. So they don't feel that they're just there. Call No, I'm I do Uhm He that And there's a problem Good, right, there's a problem. So that's that transformational approach. Right, let's take a little breather. Will not do that. OK, so, final bit. What time is it? Oh, just going to check. You guys tired or are you OK? Whose diet uh Right. The eyes and the nose. OK, so the last few minutes I've spent just talking a little bit about teamwork. OK? Because all of you are going to be working as a part of a team in providing care to your patients. You know, this sort of team, this kind of uh On and on Be responsible for the care of patients, those days are gone. In the surname, secondary, tertiary care setting. all be working And even in primary care now, the model has evolved and changed. You're providing care, you're providing And the other team, the other members of that team, it's not just other doctors. But All of them bring their own skills, knowledge, and competencies so that we all work together. And of course, as we are going to be increasingly working this We need to have some understanding. how teams work Well Sort of the the understanding behind Some of the theory and and some of the knowledge. So I'm just gonna mention some key things for you guys. A bit of further reading, OK, as you, So Head towards graduation. It can be quite useful knowledge to have an understanding. So when we're thinking about the team, then these are the key things to think about. What is the task? So here the task might be to provide care. But that one patient or Is, OK? What are the various roles within those teams and, and, and what are the relationships between. Unfortunately medicine is very hierarchical. Lots of work going on to try and flatten those structures, OK, so everybody feels empowered, you know, that's what I transfer So that even a medical student can stand up and speak up when they see something. That doesn't make sense. Then why are we doing this? Should we not be doing Everybody's here. So we're flattening the Right, but unfortunately, Particularly So roles and relationships, the interactions that occur. The various team players. Obviously, leadership is important. And reflexivity, you know, thinking about and reflecting on what's happening. When things go well, when things don't go. You know, in, in a, in a productive and positive Not in Blame free approach And 99.9% of the time, it isn't any single Where the system has fallen apart. Patient has I'm trying to find an individual to Usually results Nothing And it never is 99 them haven't thought about So that reflection is very important in teamwork, OK? Not, you know. And then the two key people, ah, if you get a chance on that journey. Plane journey back. Going to the Red North House, coming back, you can read about these two people who've done quite a lot of work. and research Teamwork in Belbin and Tuck. So Belbin developed an inventory, OK, where he sort of looked at the role and tasks aspect of teamwork. and sort of said that roles and tasks fall into these three broad categories of socializing, acting, things. OK, and then Tuchman did some work looking at the relationship and interaction aspect. OK, and, and, and coin these key concepts, OK, forming, storming. So Have a little read about those, OK? So In understanding And work done Right. Any questions, guys? Or does it all make sense? Any questions? Well, hopefully, We have achieved. Just giving you some key concepts. For you to sort of hopefully build on. Maybe start thinking Would I like to Man Wherever you were will be opportunities You know, formally, and you may well enjoy. You know, and that may be something that you find Actually they're not just thinking about the patient, that one individual patient in front of you, but you're thinking about the entire. Care, the envelope of care that you And what's the best And those decisions that are made can have huge impact. on that So you might feel quite strongly I want to be Around those Where those That's for me. I want to Obviously it comes with challenges, OK, and difficulties. It and there will be lots of It just is a So piss off all your colleagues and I. OK, well, you know. Uh, nevertheless, that's, you know, something, That that one has to learn. The build that is Some of the Things we talked about and developing those qualities. normally OK Fantastic. Have a nice afternoon. We're finished.

So. Not I All the water. Take care. I Yeah Good. So I just For tones. If 5 sessions 5 sessions. Yeah, at least. I mean, like many people, When, when does it start when those cases, It's The I And I was quite late to the shared Google doc. I was like 3 or 4 topics left and I was like I did I did IMMS I did genetics and cell biology. Yeah, the 2A I oh I I had 9 people be like, can we please do it on a Saturday morning. Yeah, and that's us enjoying like. We, we redid the transcription. The, the steps and get there. I think one person did. Did you do it? I think only one person is left to the la, the other is like, I think I got a message being like no one from your teacher. I would like to see. I I might be able to contact. I might, it's just. Yay This You have to I I just Office I'm just gonna So Benign. Do a I could just stay. I. there's been. It's been an hour and a half since they left. I Oh Find out I was, I was gonna They're watching OK. Yeah OK. especially with the. of That's I. I 3 Oh Um, I I like. Don't one of my braces. I got so it's not the. I. It would be good if I was not. I'll Right. Yeah. Oh yeah. I I. I don't know if it works I think they have like all of the students you can go into like. Lasts like 2 hours. I kind of that all of us all. I This is. I. I. I. I don't need a pro. I just need someone that knows about the sport. like a charity or something like. Right I like that. Oh Look I I Yeah, like that it'll be less obvious. It. Anything else. Yeah. HR Oh this sounds drain. raid. That's what happened to me on. But I'll still be able to, yeah. a Oh. no protein. Well, the physiott knee swell up so much of the ligament like the swellings. OK. Like because of I. That's all. Mine was really bad, but like if you did the test that was probably like too large. 2. The thing. 10 minutes. I like. I. Yeah What Yeah. the place for that but I don't think. This one's side that might just. Good Breathe like that. I'm sure Where It's also A OK. Sits, you know, like It's depressive episode you know people talking about like heroin and the other other drugs, it's like peaceful. Oh, I get Two new researchers are going. It just slows your breathing and you're still breathing. Yeah, it's your thing, right? I'm not gonna take Oh Where and then you don't get I'm. how much how much of the. you don't know what's going on around you. And. you Really we're going They. Yeah, I did see one very very study looking at like the bumpology of it, especially. Not in assisted dying, but more like in. Like capital punishment And it basically said that they can feel everything so it gives them. I That's not dissociative. It's uh like a paralytic agent so that they can't react and they can't think and then feel like the, the potassium slowing your heart. Nice to meet you Were you up there. I feel like it's going. Yeah. uh. Yeah. Right. Yeah, I, I did hear about that. That's not a great way to go. Just let slip something into it. I'm thinking maybe flowering this one is better. Same strangulation and suffocation. Oh, OK. That's what I was thinking. the night.