Ryan Crane: Malpractice and Accountability in Engineering—A Surgeon’s Take

Are you a listener who thinks, "I want to bring strong towns to my community?" Visit Strongtowns.org/events to set up face-to-face conversations about the future of our cities. When you host a Strongtowns event, you're bringing together residents, local leaders, and professionals to build a shared understanding and real momentum in your community. If you're ready for bottom-up momentum and making places people truly love, visit Strongtowns.org/events to learn more. Hey everybody, this is Chuck Marone. Welcome back to the Strongtowns podcast. Before we get started today, I just want to say, first of all, thank you for your patience. I had about seven weeks in a row there where I was out on the road, not all week long, but seven weeks sequentially with a trip of, you know, one night, two nights, sometimes four nights. And, man, things just got away from me and I didn't get to keep up with the podcast like I wanted to. So, I appreciate you all being patient. I got a lot of kind emails and messages from a lot of you who listen. So, we're back now. I'm going to be back in the office for quite a while. And I've got some trips coming up, one in May and a little bit in June and July. But, should be able to keep back with you now pretty consistently at least for a while. We'll see how it's going. I'm super psyched about the podcast today. The guests that we've got on Ryan Crane as a guy, I've been trying to get on for a long time. We've been working on it. You're going to absolutely love this. One final thing, if you haven't checked out the local motive courses, we just wrapped up with 10 weeks. Well, it was eight weeks plus two additional courses on the local motive tour. We have people all the time saying, Chuck, I love the Strongtown stuff. How do I do this in my place? This is the second year we've done the local motive courses. We priced them really cheaply. It's 25 bucks a course or 125 bucks for like all the courses together. You can get 10 hours of stuff. And it's all about how to do Strongtowns. Like, here's how you go about doing this. Go to academy.strongtowns.org. Click on local motive. You'll get this year's tour. You'll get last year's tour. And we're talking already about what we're going to do next year. These courses are really helping people who want to roll up their sleeves and do Strongtowns stuff. So, on with the show. You're listening to The Strongtowns podcast. Hey, everybody, this is Chuck Merle and welcome back to The Strongtowns podcast. It's actually been a while and I'm super excited because I've been trying to set up this particular podcast for a long time. It's been all my fault that it hasn't happened up to this point. But I was giving a presentation in San Diego last November as part of the Confessions Book tour. And a gentleman came up to me afterwards and started to chat. And I'm one of these people who loves, loves, loves. People who think across disciplines. People who can pull in ideas from different place. And this guy was a doctor. He started talking to me about things in the medical profession and how it analogizes to what I was talking about. And we had this great conversation. I said, can we do this on a podcast? And he said, absolutely. So with me is Ryan Crane. Ryan is a doctor and Ryan. I wrote down the type of doctor you are, but I can't pronounce it. I think the medical term for it, I guess it would be an auto-layeringologist, but we go by ear, nose, and throat. Okay. Seem, ear, nose, and throat seems a lot. Simple. Say that again, auto-layering, gologist. So auto- for ear, layering, for larynx, or, you know, the voice box. Yeah. Yeah. Sometimes we throw Rhino in there for the nose part, but that just even too much mouthful for us. Well, you are living in San Diego now. You did some of your university in Cincinnati, some of it in, I think Indiana, you said. And then your final class. Yeah, some medical school in Indiana and then residency at the University of Cincinnati. And then I was, you know, I grew up in O'Claire, Wisconsin, so up in the upper Midwest or your neck of the woods there. Yeah. What does it mean to be in the Navy in terms of like a medical? Because I was in the Army National Guard and I know how, you know, the service is done there. But like, you're not wearing a uniform or have a buzz haircut or anything or. I'm on active duty for another couple of months here. You know, I'm paying back a medical scholarship that I got for medical school. So since you mentioned it, I am a lieutenant commander in the Navy. I do wear my uniform on occasion, although a lot of times it scrubs just doing clinical, clinical duty. But, you know, I have the privilege of interacting with our active duty service members and rendering them the medical care to pay back the scholarship that I got for medical school. My sense of army doctors is they were very unsympathetic to poor troops. So I'm guessing. Well, you know, is the Navy a little kind of defense and where you are in the in the system. I remember, you know, I think the boot camp physicals and the sort of on the ground cares probably a little bit different than than what I would I provide here. Sure. My poor daughter. She'd hate shots, right? People have different feelings with with getting shots. And of course, in the last couple of years, there's been flu shots and COVID shots and booster shots. And she's been very traumatized by having to go get shots all the time. And I just remember being in the line at boot camp and they're giving you like multiple injections with some gun. Like not really carrying out it felt and I don't have to I don't have to be that assembly line. Uh-huh. Thankfully have been I have a little bit of a cushier role. Okay. Nice. Well, I'm not traumatizing too many of our service members. San Diego is not a bad place to be stationed. You have a family and a couple of kids you said. Uh, you know, I just have the one kid we have a we have a three year old son. He was born out here just a few months after we moved. Okay. Okay. Okay. I'll foreign you boy. Wonderful. Wonderful. Do you I mean, do you ever go out on a ship? You ever out. I guess my service pathway was a little bit different. A lot of our physicians do end up going on what's called a general medical officer tour. But I went through a different pathway where I went straight straight through residency training in a in you know, even more unusual in a civilian. I think that's a good way to do that. So, uh, residency. So, I. We do have active duty residents as well. And a lot of them do end up getting attached to what we call an operational unit. So they'll go out on ships or, um, you know, be with a marine unit or something like that. You know, since we are talking a little bit about my military or I should, I guess, insert a little bit of the disclaimer that. You know, none of what I say on this. I think that's the, the department of defense or absolutely more than 80. So just absolutely run a foul of the powers that be. And I think you can. Yeah. I can totally sympathize. I have been there. You reside under multiple jurisdictions because you have not just the Navy, but you also have medical licensing boards and all these things that you. You deal with. So let's get to that and a sec. I want to start with the observation that you had for me at the end of my talk. Part of my talk that I gave was about street design and about how engineers approach street design. And I make the case that I'm not very. I don't like tiptoe around the fact that I think engine hears are committing a form of malpractice and how they approach these things. So that's why society tends to accept a large rate of attrition in terms of driving crashes without a lot of introspection on that. And you and I got to talking about my analogy with the NTSB and plane crashes and how. You know, when a plane crashes, we, even if it's a tiny crash, we're just like one person dies because they went. And we look at every potential cause of this, you know, were they too tired, were they disoriented? Is there something wrong with the design of the plane? Is there something wrong with the. And we try to tear everything apart and learn from it. You brought up, I want to make sure I get the term right. It's the morbidity and mortality process of physicians, which I was like vaguely aware of, but not really. And we talk a little bit about just what it's like to be a doctor and and kind of how that relates to this morbidity and mortality process and the learning feedback loop that goes along with that. Yeah, I think describing it as a learning and feedback loop is important and it isn't a really important part of our training, you know, I'm coming at this from a surgical standpoint. And so, you know, it's a very humbling process to especially now, you know, I've been out of training for a few years when you're a resident, you know, you are in the operating room, assisting a, you know, what we call an attending surgeon on a procedure and, you know, some of these procedures are very high stakes and things can go wrong. And, you know, sometimes, you know, sometimes it, especially if it's like a really sick patient or a serious operation for cancer or something these people are oftentimes have a lot of. You know, other health problems or they're very intense procedures and there's large blood vessels and things can go wrong absolutely. Every month, you know, our residency training, this is, this is, as I understand it part of like the accreditation process for our residency training programs, at least in surgical field, just to do what's called a morbidity and mortality conference where, you know, at least in my training, it was the head, you know, senior resident would select cases where someone had been seriously injured or somebody died and they would go through a very systematic process of looking at. you know, the preoperative workup, you know, the workup of the evaluation of the patient's suitability for the operation before the procedure was performed, what happened, what procedure was done, did anything go, you know, were there deviations from what we would think of like the usual course of the procedure, and then, you know, their hospital course afterwards, what the, you know, what was the thing that went wrong, did they have, you know, a blood clot that went to their lung, did they believe from the major blood vessel, did their reconstruction fail, all these sorts of serious things that either, you know, in the, the, the comp, what we would call the complication can run from, you know, an infection to, you know, returns to the operating room for major bleeding to an airway problem, especially in my field that happens fairly frequently. Like serious life threatening injuries and even, and even death, and so, you know, we go through these in a systematic way and, and try and go through the process of what could have gone, what did we, was there anything that we missed? Was there something about the patient that we didn't identify, did we fail as surgeons, was there a communication breakdown with the nursing staff did an order not getting like, and so, when you, you know, and the reason that I thought of this is when I was reading the confessions of a recovering engineer, and you go through the, was it Springfield, yeah, Springfield, right? I mean, that's exactly the process and you know, maybe an engineer would refer to this as like a root cause analysis, but it's the same thing, but where I see a huge part of the breakdown here, from my personal perspective and looking at this and, you know, being a relative neophyte to the whole street design and, and transportation safety field as a complete amateur is that there's the missing accountability aspect to it where, you know, when I pick a patient to operate on and something goes wrong or I, or I hurt them, they come back to my office and I have to look them in the face and tell them this is what happened and I'm sorry. And like they're getting into some liability aspects and sometimes the lawyers say that, you know, don't directly apologize, just explain. You know, I find that patients generally, when you tell them, when you own up to your mistakes, generally, they're very receptive to that. But that's where I think that feedback loop really breaks down, at least from an outsider's perspective, looking at, you know, in this instance street design is, where's that, when, when somebody dies in Springfield, Massachusetts, who's ultimately responsible for talking to that family or not only responsible talking to that family, but fixing the problem, the process is very similar from what we go through in the medical field. It's just that I think that the feedback loop, you know, as, as a surgeon, especially now as an attending surgeon, where I'm not only responsible for the patient, but I'm responsible for managing my trainee surgeons, which is just another level of complexity and potential for error. There's that ultimate accountability aspect of it is really, I think, where the breakdown is. Yeah. I want to walk you through this process. And I want to give you an engineering take, and I want you to kind of talk about the medical side of this, because none of us, I think, are going to sit here and say the medical profession is perfect. It has absolutely not. Yeah. That's a whole other kind of work. Yeah. Yeah. So we're not holding up like a bad way of doing it and the perfect way of doing it. But I do think that it's interesting. The parallels here. So when I'm starting out with a street design, I am as an engineer, starting with a few parameters of what I'm trying to accomplish. And I go to a book, a manual. And the manual says, basically, like, here's the way to approach the situation. And if it's a standard situation, I really don't have a lot of leeway professionally, even though I have a license and I'm professional and I, I don't really have a lot of leeway to vary from that. And if it's a nonstandard situation, I guess the default always is to try to find a way to make it fit in a book, in a manual. In like, is there some standard I can fall back on? Now, you have a patient come to your office and the patient has a standard issue that needs surgery, or maybe there's some complications in there. What would be, I'm guessing there is certain standard practice that you rely on. How does that relate to your own individual decision making and assessment process and going through that? Yeah, see, that's interesting because, you know, we have, in the field, we in medicine, we have what's called the standard of care. So, and I'm not a lawyer and I thankfully haven't had to go through the process where somebody is questioning my adherence to the standard of care is to sort of like the generally accepted, you know, what most physicians would do in that particular case where it gets interesting and maybe a little bit different with medicine is, you know, especially in, I think, especially in a surgical field where the patient has to consent to the operation. There's a whole conversation that goes on with that. So, you know, let's just take a fairly simple complaint that I see a lot. So it's like, somebody comes to my office and they say, I can't breathe through them through my nose. And they have a fairly straightforward thing we call a deviated septum. Like their nose is crooked and they can't breathe through. Hey, dude, I have a, I got, I got punched and got my nose broke when I was in eighth grade and I have a deviated septum. I do, and I've, I've had, I've talked to like getting it fixed and I haven't done it. And yeah, so we're, I know exactly what you know where I'm going with this. So, yeah, so, you know, it's a fairly straightforward problem and I just grabbed part of it is they come to me. They're asking for my help. And I look at the problem. I say, you know, have you tried the basic medications? So like, you know, prescription over the counter decongestance, do they work for you? Do you have allergies that are poorly controlled? Like are, it's because one of the things that in, in most instances is, and this is a whole, like, there's a lot of more checks and balances in the medical system. From my perspective, then perhaps there are in this particular street design where, you know, like if I go for procedure, especially if it's a procedure that takes a lot of time or it's expensive for the third, the insurer, I have to show through my documentation and through my interview with the patient that I have tried medical therapy first in most instances because we know that exposing somebody to the operating room to the hospital isn't intrinsically dangerous. I mean, low risk, high risk, intermediate risk, whatever, but we know that things, you know, maybe they're going to sleep and they have, you know, somebody is in their mid 50s and they have a heart attack or something like that because the anesthesia is itself stressful. So this is the do-no-harmed concept. The idea that you would start with a minimum intervention and then kind of ramp up over the course. Yeah, exactly. And so I think, you know, from, it's not as perhaps protocol driven as street design is. And I think, you know, one thing, especially as, you know, a deviated system is a fairly straightforward problem for me to solve, I describe it as the surgery that's indicated for the patient and they say, yes, I want that. I don't know why you're not. Then there's the consent process where I say, you know, there's the risk of this. There's the risk of bleeding. There's the risk. It doesn't fix your problem. There's the risk that you have a problem with the anesthesia. Like, I, there's this conversation process between me and the patient about, you know, these are some of the risks. They happen relatively and frequently. Most people are generally happy with it. There's the chance that you don't like the outcome. Do you want to do this or not? Because the problems get more complex as the patients generally, you know, just to generalize as they get older or they have more medical problems, we have to do a lot more sort of weighing and thinking about, you know, what's the problem I'm trying to solve and how risk, how much risk am I exposing the patient to? And there's a huge part of this that I think sometimes physicians aren't as upfront with people about, but it's hard to explain to a lay person, highly technical knowledge. The way that you present things can bias people's decision-making. Let me say it from an engineer standpoint. We often, as engineers, don't trust the public to be able to grasp or the, even the elected officials to grasp all the nuance of our background and education and training that we know. And so we simplify it down into almost oversimplified adages, you know, that we can pass on. And I get, there's a part of me that gets that, but yet there's also a danger in that too, right? Right. Well, and the thing is, you know, especially in residents who were doing cancer operations, which are incredibly intense. They last hours. The people are generally, at least in my long-term smokers, they have heart disease, they have lung disease. Like those are high-risk patients for anesthesia. And, you know, we better be sure that we're exposing the patient to an operation that's appropriate because they very well could die. Say they have a horrible stroke and are crippled the rest of their life. And we have to see them back. And then, you know, in my, you know, we have to look at ourselves and say like we did, you know, I mean, we're partnering with the patient because they have a serious problem with regards to the cancer, but we did that. You know, we participated in a very serious, intimate way with that harm. And so, you know, especially when I sort of feel like I could go both ways and like, whether my confidence that I'm going to solve their problem, or do they have reasonable expectations about what I can do? Personally, I am trying my best to be very careful about the way I present [BLANK_AUDIO] I can do for them because the thing that I really want to avoid is I don't want to over-promise and under-deliver and mess up. Right. Because totally no matter what I try to do is under-promise and over-deliver. And this is one of the things that I think is interesting with your approach to street design is you, from my perspective, really emphasize some of the sort of like psychological or intuitive aspects of how people interact with the street. And the clues that you take from how big the street is, are there trees, do I have indications that there are pedestrians around, all these sorts of things that operate in system, what is it system to? System one, yeah. To a intuitive system. Right. And there's a lot of that that goes on in a clinical encounter that, how am I presenting myself, how am I presenting my confidence that I am diagnosing the problem correctly? And there's all these other things other than just like the rigid, like you have a septum problem I will fix. Right. Rigid protocol, it's how is the patient perceiving me, how am I perceiving the patient, how am I presenting the problem to the patient? Am I minimizing risks, am I over-emphasizing potential for improvement? And all of these sort of, I guess I think of them as sort of rhetorical. Yeah. Let me try to summarize this. What do you, if I go to a doctor that has really poor bedside manner and communication skills, maybe I would hear their advice differently than I go to someone who's very confident and very outwardly like, hey, no problem here and reassures me quite a bit, even though it might be the same exact advice. Right. Absolutely. And I mean, those things are real, right? It's a human. Right. Yeah. So, and the thing I think that is important, you mentioned the first do no harm. And I think that that helps sort of, hopefully, grounds, physicians as, you know, from my perspective surgeons about, you know, you are partnering with somebody who you are, you are working with, they are choosing to expose themselves to serious risk at your hands. Right. They need to trust me and I need to trust myself that I'm not leading them astray. And the other aspect of this that I think is important is like, you know, in some patient populations, I may be working with somebody who has high school education or less. And you know, here I am. I have years of postgraduate training and all this sort of stuff. You have to be aware of all of these sort of intuitive or like educational socioeconomic background, like, you know, racial aspects of it. This sort of stuff matters. People may not trust trust a man or have, you know, like, there's a whole bunch of issues that can go into making a good decision, right? As an affluent white man, like, people may distrust me or other people may trust me more than other physicians because of who I am. They may have too much trust in you. Right. And like, if I turn up the charm and I'm like, hey, this is going to, you know, or if I, if I didn't like, and you can do that, right? In a rhetorical way, you can say, well, like, I'm not sure that this is going to be, there's caution people like, I can't guarantee that this is going to fix your, like, so there's a lot of what I sort of describe as more intuitive or psychological aspects of how we approach, or at least I do. I mean, I'm speaking for myself, I think, other things would agree, but, you know, there's a lot of that stuff to it that I think, you know, gets us away from this really rigid, what I would describe as a rigid or regimented protocol eyes, like, I'm just going to open the book and, you know, it says, do this procedure on this person because, you know, in clinical medicine, there's also this huge interpretive aspect to it, right? Am I actually perceiving the problem correctly, which is a huge, like, complicating factor as well. And like, you can, you can get into how physicians make medical and diagnostic mistakes, like the repeatable errors in cognition that you make. And that's one of the things that I think is sort of where my personal approach to medicine, I think, lines up with some of the things you're talking about, these repeatable cognitive errors that people may. Well, this is where I feel like as an engineer and for the engineering profession, I think we like to think of ourselves in this way as kind of aware of our own biases, aware, kind of conscious of how we approach things. I don't experience the rigor in this way. And this is what I want to, I want to kind of transition into you've, you've made a recommendation now to a patient in dialogue with them. They have, in a sense, consented and concurred with that recommendation. And you're going forward a procedure and something goes wrong. Let's set this up because I think this is one of the important things, especially in, in us, emailing back and forth that I took from some of the things you wrote. Humans are complex systems, right? They're complex organisms. You can be very, very confident going in that you have something noble and understandable and that you've done a thousand times before. And then something very unforeseen happens and it doesn't work out as you had predicted. What is that instance like? And I want to kind of transition into this morbidity and mortality discussion. But you know, you do something and it doesn't work out the way you intended. How has a doctor, do you get that feedback? Like what is that, that kind of immediate feedback loop even before you meet with your colleagues and discuss it? Sometimes things go wrong with insurgery and those are, you know, those are scary moments. You know, those are, you know, I read with terror or a description of your near car accident. It feels a little bit like that. Yeah. And everything slows down. Everything slows down and, you know, maybe a major blood vessel starts bleeding or you need to intubate the patient and you can't get the tube in and they're, you know, they're not breathing and, you know, those are sort of the terror moments and you try and stay calm and save the person. There's also sort of complications. Most complications, thankfully, in my field at least are sort of on the realm of, you know, they have a bad nose bleed after the surgery or they, you know, it's something doesn't heal right and they have a bad scar or, you know, sometimes I try and fix a hole in an ear drum and the hole doesn't close. And so we have to like, subject them to another surgery. These are, I guess, surgical failures, but don't result in severe, more bitter, like, harm to the patient. And thankfully, that's true in my field. It may not be true in the field of like general surgery, for example, or, you know, cardiothoracic surgery where they're doing bypass surgery and that sort of stuff. But, you know, it's, it's very humbling to sit there with the patient and say, you know, hey, I'm sorry. I did my best and, you know, the whole of your year, your drum didn't close and, you know, we can try again. You know, here's some things that I might do differently. The main thing that I wanted to try to emphasize is that I, you're not getting this feedback as a statistic in a report. No, it's a person in front of you. Yeah. Yeah. As a licensed professional, as someone who's working in a profession that has a license and is dealing with instances where people are frequently dying, we get that information as a statistic in a report, right? At the most intensive, we'll get a police report that will have like an accident recreation and then some check boxes of, you know, how much was the driver to blame, you know, were they speeding, were they drinking, were they, was there blood alcohol level? All these things that I'm going to say from an engineer's perspective, in a sense like dismisses you from being culpable for that. And I throw something in here. So these things are really stressful and maybe sometimes, you know, would be you to as a little bit flippant, but like, say, as a chief resident, I had to stand up there and talk about a case. And if I, you know, focused on all like this patient had coronary, severe coronary artery disease and they had bad COPD and, you know, they were an alcoholic or all these other things that were going on, absolutely my supervising physicians would say do not blame the patient. And that's where it's really because the whole point of the exercise is you are going to operate on sick people. You're going to operate on people who are lower socioeconomic status. They don't have high levels of education. They're not compliant. Like, you have to understand you're not operating always on athletes in the pinnacle of their life, right? Yeah, yeah, like that's like, maybe translating this to like street designs. Like the streets not always going to be well lit and dry and it's, you know, this, it's going to be raining. People are going to be drinking. It's going to be dark. Sometimes drivers are sleepy and not attentive and I mean, right, again, I'm not familiar with the air analysis process and street design. But when I, it's okay, there is no, but I mean, it's just, I don't want to, I recognize that I'm perhaps being critical as an outsider and I don't understand all of it. Can I read something from a report? So there's a report. Go for it. And this is about the medical field because as you mentioned at the beginning of the discussion here, the medical field itself is absolutely rife with air and with people getting hurt. You know, the field has been very scrutinized. We have to engage in a culture change to try and improve some of these errors because people get sick and dial the time because of things that we do in the hospital. So, so this is from a report from the Institute of Medicine called to air as human building a safer health system. I'm going to draw distinction here between active errors and latent errors. It sounds to me like in analysis of crashes and throat fatalities or whatever, there's a huge focus on active errors, which I would say are what the drivers doing wrong. So I'm going to read this, just snip it from the report and just see if it rings true to you. So it says active errors occur at the level of the frontline operator and their effects are felt almost immediately. Laten errors tend to be removed from the direct control of the operator and include things such as poor design, incorrect installation, faulty maintenance, bad management decisions and poorly structured organizations. Laten errors pose the greatest threat to safety in a complex system because they are often unrecognized and have the capacity to result in multiple types of active errors. This resonates. The thing for me is I read this and I hear what you're saying about how road design has done, how crashes are analyzed and what you from reading your work and following strong times and other safety advocates and things is that there needs to be, it seems, more of a focus on the latent errors. Blaming the driver to me is analogous to blaming the patient for their coronary artery disease or their smoking habit. Smoking habit or drinking too much or whatever it is. It's like, well, did they need the operation in the first place? I can go to the National Highway Transportation Safety Board and I can look up the grant programs they have for improving safety and they have like multiple programs and they're every single one is based around reckless driving, driver error, blaming, but it starts with a blaming of the driver. Right. And that's not to say that drivers aren't to blame, but you induce them to to misbehave. Yes. Let me draw this distinction. I think if someone comes in and they are a two-pack a day smoker and they tell you they're two-pack a day smoker and you probably talk to them about that being something they should deal with, but at some point someone's going to say, look, Doc, I'm not going to deal with it. You would have the opportunity to change your diagnosis for them. Yeah, or the treatment plan. Or the treatment plan. I'm sorry, the treatment plan. Or say, I just give it your health factors. I just don't think you're a good candidate for this surgery. Right. So let me keep that analogy going. If I have the equivalent of the two-pack cigarette smoker a day as a driver, I don't have the option to say that person can't be a driver, right? Like my system has to compensate for that upfront. It has to assume that a certain percentage of my drivers are reckless drivers or tired drivers or impaired drivers or what have you. And it seems like we assume that every driver is not smoking and not drinking and not, you know, you go back to the medical analogy, is the 28-year-old athlete in the prime of their life, right? Yeah, it's been a little bit of a culture shock for me practicing in the military because, you know, I came from a, I guess the term would be sort of like a tertiary referral, safety net, hospital with a lot of indigent sick patients who come there because that's the only place they can get health care versus a military population who, you know, works out seven times a week and doesn't, you know, they smoke, but, you know, they're still, their hearts are good, their lungs are good, you know, whatever. I have my sort of routine like do you smoke, do you drink it? And I'm like, nah, I'm good, like, doc, you know, it's fine. But it's like, I'm so used to like just like trying to turn over every, you know, every rock to find where their health risk is. The thing that I think is interesting and like you've talked about complexity a lot. And I think what I try to bring that back to like me bringing a patient through the hospital, it's, you know, it's not just me and the patient, right? It's me and the patient and the pre-op process and they have to like get a lot of work up done. They have to go. There's so many, you know, contact points and like in intersection design is a conflict points, right? Like the number of Lexi points, like each of those interactions with like the nursing staff and me and the anesthesia providers and like getting the tubins for their sleep, like all of those things are risk points. And you know, maybe I'm working with, you know, new trainees where their decision making isn't as coached up as where we want it to be or we have nurse trainees on the floor who are taking care of these people after surgery with my best efforts. I have to be aware of where those risk points are and not only like what I'm doing and what my patient's doing, but like, is this nurse a nurse I'm used to working with? How is this resident, how is this resident compared to that resident? Do they work well as a team? Do they communicate on the team? Like it's just the complexity, you know, who is exponentially as the patient is shepherded through the hospital and, you know, as I became a more senior resident, you know, you get, I remember the mistakes I make and then I see, you know, my junior resident just about to make that same mistake and it's like, don't do that. But you have to be, you have to be aware of everybody else and like the predictable cognitive errors people make or their inexperience or, you know, you get the nurse. In your OR who's covering for lunch break and like all these things that just create risk and so my response to that is I try to, you know, if I can just simplify, right? Like simplify what I'm doing and that's what where I think, you know, I really appreciate some of the things you talk about is like, I think there's this attempt to just try and control so much of the risk. But it's always there and you can't control what that driver is going to do. But you can't change in some ways how they respond to the system that you design. So yes, let me go to the next step then, which is this morbidity and mortality process. Because I, I, there is not for street design and for street safety and for crashes that happen. There is no equivalent process. There's, there's what in a sense is an insurance process where we go out and try to allocate within an insurance paradigm, who is to blame percentage wise so that their insurance company will pay more or less than that. But there, there is no feedback loop and what feedback loop there is is really long and detached, right? Like we might say, well, there's, there's 20 crashes at this place. So maybe we should do something here. But, but there's never a process where we go by and try to discover those, those latent errors, right? Like that's just not part of what we do. Can you, can you describe to us who have not been in one of these morbidity and mortality processes? Like what, what does that look like? And I'm, I'm most interested kind of into what the power dynamic is because you've got to have people who are senior in there and junior and maybe a senior person made some mistake or was part of a mistake. And, and so yeah, there are definitely those sorts. I don't know if you want to call them cultural factors or what, but the power dynamic can sometimes be an issue. And you know, especially, you know, if you've got, and that's where some of the sort of psychological or like the personality aspects really come in. And I think there's been, you know, hopefully a change in culture in surgery, you know, the stereotype, I think is the really like, domineering, aggressive, narcissistic surgeon who's like controlling the OR and like people are afraid to speak up and correct. And the culture shift that we're still working on is, you know, sort of empowering all team members to really speak up. You know, there are in most, in every hospital I've worked in, there's a, there's a mechanism by which, you know, everyone in the chain or everybody who's involved in patient care can submit what's called a patient safety report or something similar. So, you know, we have like error classifications like near misses where something almost happened but nothing went wrong but it like the propensity for harm is there. And then there's things like Sentinel events where a review is automatically initiated. This is actually a different process for morbidium mortality. So, this happens within the hospital system and then, you know, in surgery and the, the medical professional sort of police themselves through the morbidium mortality process at least in academic centers. And so, you know, there's, within the hospital system, there's been really intentional efforts to empower all people like get rid of the hierarchy issue. So there's a, even anonymous reporting mechanisms by which, you know, a nursing students sees something, they can report it to this, you know, the patient's safety committee and they'll review the incident. And so, there's that process and a lot of times the accrediting bodies want to see that sort of process instituted within the hospital itself. And so, you know, every hospital I've worked at has something similar to that, the sort of patient safety reporting mechanism that can be anonymous where a medical student can report the chief of surgery for doing something wrong or not even not doing something wrong but like they're concerned about something happening. And could you imagine like an engineer getting a report every time somebody ran a stop sign? You know, and that's sort of the deal there, right? Like, that's, that would be like a near miss where. That would be amazing. I think a lot of people listening this are probably going to wow, that would be really amazing. And I'm not going to idealize the hospital system like that doesn't, it's not a perfect process but that mechanism exists. And then, you know, I would describe the morbidity and mortality, comfort, and the need For instance, more of sort of like a cultural, it's definitely within the accrediting for surgery, they have, you have to participate in this more midi and mortality. I haven't practiced in sort of a civilian community hospital. I don't believe the more, that what we call M&M processes routine within more community hospitals. But I think the idea is to build up this process within trainees and so that you internalize the process when you're out on your own. So like when I'm in charge of my residence or I'm looking at a patient, I'm presenting them with various options, I sort of imagine myself justifying this to my colleagues, or I mean frankly, even in a court of law. And there's a formal process within training whereby you have to stand up in front of your supervising physicians or in front of your colleagues and say this is what we did, this is what went wrong. And that really internalizes creates this process and the goal is that it internalizes that personal review system that's sort of self policing so that when you go out in your in brain or in Minnesota and you're practicing in a community hospital and nobody's looking over your shoulder that you're doing it yourself. And I don't know what the way to do that would be in engineering. - Well, let me ask you a couple of questions about just that because I find that to be an interesting concept. There was one thing you said in particular, you said I imagine myself standing up in front of my peers and colleagues and explaining my actions. And you might even have said liability at some point, but I know a lot of times when engineers are working in their profession, they will talk about making certain recommendations because of liability. And it seems to me like the liability in traffic engineering is about varying from established standards. So even if I know the standard is leading to bad outcomes, I protect myself and my client, aka the city or whoever. I protect them from liability by following a standard even when that standard causes harm. Well, how would you define liability or how would the medical profession? 'Cause I know, I mean, there's defensive medicine, there's not a perfect system, right? - Yeah, so that's the thing that came to mind for me when you're describing this, I'm gonna adhere to this rigid, or I'm gonna over-design the roadway because I want to give in the choice of exercising professional judgment and adhering to a standard. I'm gonna make sure I veer towards adhering to the standard to me that feels most like the practice of defensive medicine. So, I have the choice, I think it's like, oh, maybe somebody needs a CT scan, but I'm not sure. But if I'm wrong and like it comes back that they did have X, Y, or Z condition and somebody else catches it, they come back to me and say, oh, you missed the diagnosis. So I'm gonna order the tests. - But the big difference to me is that no one dies from a CT scan, right? - I agree. - It would be like, I'm not sure if they need, I'm not sure if they need a surgery or not. So I'm gonna order triple bypass surgery, you know? - Yeah, no, I totally agree. And it's a difference, it's not a perfect, that's the only thing that feels most like that, like where given a choice of doing something or not doing something or like under treating or over treating, I'm gonna over treat because I'm scared of liability. That feels most like defensive medicine to me, although it's certainly an imperfect analogy. And I think the harm is more due to excess, you know, resource expenditure as opposed to personal injury, where, you know, in the medical field, like, and again, I'm not an expert in malpractice or I've never been through a court case like this, but, you know, the standard for physicians, if in cases of harm or questions of malpractice is deviations from the standard of care. And so there's no cookbook for that, you know? And it's mostly, you know, was your decision-making sound based on the information you had at the time? Would most physicians have behaved in a similar way? What judgments did you make? Were they questionable? Did you, you know, all these sorts of things? And, you know, in a malpractice case, they'll call in expert witnesses and they're gonna criticize your decision-making and say, you missed this test or you didn't interpret this result correctly or all these sorts of things. And so, you know, that's a stress inducing process. And like, I, you know, I'm relatively young in my career. I hope I don't have to sit through a case like that, but most physicians get sued at some point in malpractice. So, you know, it's, but I don't think there's a perfect analogy and I think the thing that's different, it seems different from outside of perspective for street design is that there does appear to be what you call the top down dictation of what is the standard of care. And there's like no question about what it is. And so, it seems to me that I don't know if the like, it's proper to refer to a chilling effect, but like engineers perhaps are scared to deviate from the powers that be. And that is a, that's a hard, that's a hard thing to change, right? Cause what is it? Is it the, is it the, the federal DOT that's making the manual or like, I don't know who's doing it? But I mean, like that's, that seems like the, the professional authority, you know, I talked to another patient safety advocate about some of these sorts of things. And I was sort of lamenting the sort of proliferation of checklists for the sake of checklist. Like, let's just follow checklist because checklists are good rather than saying like, what's the checklist for? Does it meaningfully simplify a complex process? And his, you know, he was a military aviation expert. And he said, you know, one of the things that we always say at the start of our checklist is that, you know, a checklist is, is no substitute for good judgment. And so it seems to me that there's this sort of like, supplementing of good professional judgment for the big desk manual. And I sympathize with engineers in that, like, it's hard to wait a lot of that. I think one of my biggest frustrations when I started practicing, you know, you engineers are supposed to be problem solvers. And then when you get out of school and you realize, well, like all the problems have been solved, I'm just applying received wisdom in a sense, in a code book to this. Let me ask you this 'cause I think this is, to me, the most interesting part of this. And that is how these, we've kind of established that there's a shorter feedback loop between the patient and the doctor than there is between the driver and the engineer, right? Particularly when something goes wrong. How does the introspection, the formal process, the patient relationship, the liability dynamic, internal to the medical profession? How does all of this manifest to actually inform and change systems and behaviors and process? And particularly identify some of these latent errors and correct them. I'm sure it's not perfect, but there's always like the old story that everybody hears, where nobody wash their hands. And then the guys, if we just wash their hands, people will stop dying and they made fun of them and laughed and then pretty soon figured it out. There's really no equivalent in the engineering profession. If we stop doing this, talk in a modern sense about how these mobility and mortality process and all this leads to change. How does this work? I'll just say I'm not an expert. I've never sat on one of these committees and I don't have any advanced credentials. I've seen some of these things play out. I've been in morbidity and mortality conferences. The process is, and this is why I thought of it as because reading your analysis of the road in Springfield is what would happen, right? You would go step by step, ideally. Some residents or physicians are more thorough than others. The morbidity and mortality conference, typically incorporates a review of the scientific literature, which is a varying quality often. We look at the available data. We go through in a systematic way, the flow from initial clinical encounter through complication and recovery, and the end result, highlighting the factors around the actual incident in a very systematic way. It's ideally very non-blaming, so it's very systems focused as opposed to this older blame and shame, which seems to me like maybe traffic engineering stuck in a little bit of a blame and shame attitude. The analysis of the Springfield accident is very much what we would do. I know that strong times is working on maybe formalizing that process with looking for some grants and things, and that's what it is. I think that, frankly, there's accrediting organizations require this from us in medicine, in the hospital regulations, and accrediting for training programs. All of these things, again, I don't know how traffic engineering is structured. There's more oversight. There's more competing bodies. There's the patient safety commission. There's the nurse safety officer. When nurses empower to oversee a physician, what sort of disrupt some of the hierarchy problems, the nurses are very, you know, dismissively referred to as the low-hanging fruit of washing your hands or some of the simple infection control things are very protocolized at this point. Again, we're not perfect, and surgical infections still happen, and that's something we struggle with. But you do, you do, sometimes run into like a diminishing returns aspect of it of like chasing that smaller and smaller incremental improvement. And sometimes people are sick, sometimes, you know, you, you know, you, you have to classify the error. It's like, you know, maybe as a surgeon, I just cut a nerve. I just did something wrong. You know, I technically failed. And that's part of it too. And the, the, the, the correction there is to, you know, look at how I was doing the operation. Did I, did I use a technique that was, was uncommon or like, could I talk to a senior surgeon about how I can, my technique and like accept the responsibility of the technical error. Not, not every review results in some drastic systems change. Right. Yeah. Yeah. And it's hard because systems are complicated and like there's chaos within the system. And you know, especially like, you know, the quote unquote low hanging fruit of like wash your hands, sterilize your equipment, like administer antibiotics, you know, within an hour of incision, like all these sorts of things that, you know, a tool Galanda refers to in the checklist manifesto, like those are those, those things are really heavily focused on because they make, he talks about in the book. Those are the things that make a big difference. Like we're, we're simplifying around the important things really gives you a big boost. And a lot of times it's like, did, did we, did, is there a nursing process that we need to fix? Did we process the specimen correctly? You know, did we have a poorly supervised resident? You know, is it, is it safe to say though that most of those or all of those came out of some process where that is a question. Right. Yeah. Yeah. And that this instant, the morbidity and mortality conferences are old in medicine. This is, it's not a particularly new concept. The patient's safety push with the like to air as human this report from the Institute of Medicine and some of these, you know, health and like outcomes based reimbursement measures and quality. There's a lot of advocacy that was involved in that. A lot of sort of governmental oversight. And I think one of the complicating factors for me in looking at, you know, transportation at the outside is that the government seems to fund a lot of this. And so, well, it does fund a huge portion of it. It's not just seems to it's, yeah. Yeah. But it's like, it's, it's, to me, it strikes me a little bit as like a, of a who's watching the watchman sort of problem, where the, it's very, whereas in a, you know, a private hospital system, the government is a major payer. And so they want to make sure that their money is well spent as opposed to like, you know, funding and designing it. So the, the financial aspect of it is a little bit tricky. Yeah. And so, but you know, for me, it seems like there's more, there's more competing interests. And like, as a surgeon, it's less like I'm the king of the castle. It's like the nursing safety officers are just going to report me if I don't do the right process. And so it's really sort of level that. And again, it's not perfect. But it's, you know, that's something that the medical field has been working on for a couple of decades now. And I think that one of the reasons I brought it up to you is I see some similar problems maybe. And like, an older emphasis on active air as opposed to the latent errors that you point out. And so how do, what's, how do you get the process focused on some of these latent errors that induce people to make repeated predictable cognitive errors and interpreting how they're driving on the street? Like, how do you fix that? Like narrowing the lanes and all this sort of stuff. And then how do you get the funding for that? Because you can, you can write as many letters to your city councils you want. But if there's no money, there's no money. And that's where some of the tactical urbanism stuff comes in. Yeah. Well, let me ask you one last question about this. And then I want to ask a little bit about the medical boards and stuff. One of the things that people outside the medical profession get a lot of, particularly when we're talking about how we fund things and, you know, insurance costs going up and dot, dot, dot, there's this underlying thing about medical malpractice. And oh, it's just rife with lawsuits and, and, you know, money sloshing around and, I know that doctors are attuned to the liability question and being liable for mistakes and, you know, malpractice insurance and what have you? How much do you think your liability situation as a practitioner? Let's maybe look at it as a profession is improved by this process of introspection as opposed to we're now laying out all the things we've screwed up because I'll say this from an engineering perspective. There's a lot of like don't ask, don't tell, right? Like we don't talk about that because it will open it up to liability. So it's better just to not have that conversation. And to me, there's a sense of like that will work for a period of time. And then it ceases to work. And I'm wondering where you think the medical profession is in terms of we don't talk about it and that helps us from a liability or we talk about it aggressively. And then that helps us with liability. I don't know. I hesitate to idealize the medical profession. I think that it's because they're human, right? Yeah, yeah, yeah. I mean, you know, I don't want to sit here like as this, you know, pretending to be this perfect physician saying, like, oh, I'm perfect and I've never screwed up and blah, blah, blah. I do think it's important that, you know, we have the feedback loops where we present our mistakes in front of people. That's a very humbling experience. I think more, even more humbling is talking to the patient directly after you screwed up, right? It's like you trusted me to help you and I not only didn't help you, but I actually like caused harm. And that's like really hard. And you know, from a formal malpractice standpoint, I've heard different things. So I've heard lawyers advise to never apologize directly just to explain in neutral terms like what happened. Or, you know, I've also heard statistics where, you know, patients are less likely to sue if they like the physician. And so some people will say that, you know, making sure that you have a strong bond with the physician and own up to your mistakes, may decrease the like. So it's, I don't know what the data says on that. My, you know, I hope that my personal approach is that if I feel like, you know, if my spider senses are tingling a little bit that like maybe this is like it's a, it's sort of a 50/50 call, I'll just be really up front and have a long talk with the patient about like, I'm not sold. This, you know, if you, you have to tell me that this problem is worth these risks. And then, you know, if it's like that, it's like, I may suggest a second opinion. But, you know, there are plenty of physicians. I think that I just personally tend to be like on the more cautious side. The thing is like, I hate that feeling of sitting in front of somebody telling them, I heard them. So I want to avoid that. And so I try and, you know, lay as much groundwork to they understand the risk to the best of my ability. And if there's any question, like I'll say, hey, like let's go talk to somebody else or, you know, you refer them to the specialist who does a million of these procedures a year where I do a handful. From a strict liability standpoint, if we're different things about how do you address it with the patient, I think, you know, working on your connection with the patient, some of these more cultural, psychological, rhetorical, charismatic factors to make sure that the patient trusts you and a trust, you know, so if you, something goes wrong, they trust that you did your best. And it's a very like internalized process, I would say. And it's hard to systematize that, I think, in the medical field, we have some mechanisms by which that's sort of inculcated. It's certainly not perfect though. And I mean, you know, there, I've seen people avoid discussion problems and things get sort of swept under the rug or, you know, if it's a process problem, we're one of these near misses where something almost goes wrong. Like, you know, we may review it internally in the hospital, but, you know, the patient may or may not be informed, you know, whatever. And I hesitate to comment too much in some of the like strict legal liability aspects, because I just don't, I don't think I have like the expertise to, yeah. So, you have a medical license. And you have a licensing board that issues that license and overseas it. What, what, what kind of things is that licensing board interested in and what role do they, do they play? How is that an appropriate, or I suppose you can't really say how it's inappropriate maybe, but talk a little bit about, because I'm guessing that you think doctors should be licensed, just like I think that engineers should be licensed. I have no problem with engineers being licensed. I'm wondering what you think the role of the medical licensing board is in ensuring, you know, what's the proper role of that board? Yeah, I mean, the role, as I understand it again, I don't get it. I don't have a lot of direct experience in interacting with the medical board or these sorts of things, but you know, the medical board, as I understand it, is a way to really discipline like gross professionalness conduct. And you know, people can be reported for doing certain, you know, I'm aware of cases where, you know, surgeons in my field in some part of the country, you know, do procedures that aren't indicated or, you know, especially like not to, not to give to intimate a peek behind the curtain, but like sinus surgery is one of these areas where there's a lot of variability in like it's all inside. So like there's no external stuff. And so it's easy to sort of see the quality. Like if somebody comes to me and they have a recurrent problem, I can get a scan and see the quality, you know, of the surgery. And frankly, I've done in like suboptimal sinus surgery myself and my patients come back and I have to operate again. I get the scan and it's like, oh man, that's not great. My understanding of the medical board is to discipline what I would call sort of like good. misconduct where people are getting surgeries they don't need, people are getting hurt repeatedly, somebody just frankly incompetent. You know there's the podcast doctor death about that neurosurgeon in Texas who was just flagrantly incompetent and really harming people. That and some of these like ethical things where you're you're billing for procedures you didn't perform or like you know just really shady stuff it's really just strict ethical stuff and you know maintaining standards of the profession and so that's minor standing in the medical board. A lot of these things these sort of oversight mechanisms are sort of internal to the profession you know the site where you practice it's more like at the ground level as opposed stuff that rises to the medical board and minor standing is like gross misconduct and and pretty severe. I'm assuming that reports made to the licensing board come from other doctors or I suppose the public can probably make them too if they wanted to but my guess is it's like the profession in a sense policing itself to a degree. Yeah yeah and the ones that I'm familiar with are like that. Would there be complaints made to in your estimation I'm sure you obviously you don't know every complaint that's ever been made. But ones that would be serious enough for the board to like proceed if a doctor had like a blog and was writing about changes they thought they should see in the profession. Yeah so that wouldn't be something that's what I mean. So here's the thing that frustrates me about the whole strong towns lawsuit. I'm just going to put it in medical terms. What you're offering from my perspective is a second opinion. You're saying that you're in your professional judgment this street design is not good. You would recommend doing it a different way. You have a lot of evidence to justify your criticism of x, y, or z street design and it's not like you're not you're not you're not getting contracts to do that stuff right. I mean it's just you're just criticizing stuff and it's like I know that there's some other issues at play in your particular instance but you know the idea that somebody could report me and it gets a little dicey I know but no it's okay it does it to me it seems like a misuse of the process your opinions are based in it from an outsider's perspective and clearly in good data like it makes intuitive sense that like wide lanes make people drive fast like that's not a hard thing to do it's an honest professional opinion like the fact that the board could be brought into something like that seems like a gross like seem like a misuse of state power frankly. And I know that there's issues tied up in like the use of the credential and all that sort of stuff and the idea that for example that using a credential could endanger the public safety when really all you're advocating for is like improving public safety like just seems like this circular thing and like not to get not to like be too overt about this but the fact that the initial complaint called you a fraud is a little bit hard to stomach as like a professional in a different field because if somebody called me a fraud for rendering my honest opinion and I just like forgot to pay my licensing dues I would be pretty upset there's the issue with the credentialing but to for somebody who's opposed to what strong towns is saying when you're rendering an honest what I would call second opinion what is what is going on and you know it seems so transparent that that sort of but you know it seems to me just not being involved in just looking from an outsider's perspective and hearing the strong town's side of the story like it's snowballed into this this whole thing and it's gotten crazy and you know it just seems like you know to me it seems like the the the the board has allowed itself to sort of be manipulated into something that it could have very easily exercised a different judgment and said like you know Chuck is clearly qualified to be to use the letters PE he forgot to root new his license as soon as he renewed his license we gave it back to him because he never at any point had like it's just it beggars we've from like if somebody if that was me as a physician like obviously I can't be credentialed to practice at a hospital without a valid license so like it's a little bit different but you know just like how the board got pulled into this thing seems a little bit diced to me and like and again it's it's taken on a life of its own it seems to me it's an interesting observation because I do think that I mean I'll say this civil engineering is you know it's a difficult license to obtain you you you have to get a pretty technical degree you have to work for a number of years you have to take a couple of really rigorous tests you know there's a few things I think that are credentialed by the state that are more difficult to get one of them is a medical license you know that that is more difficult to obtain than a civil engineering license I mean the degrees are are are similar but but different that you have way more schooling you have the residency requirement you you have all these things you go through but at the end of the day when you're exercising state power it does seem to me like what we're looking out for is is this person you know a menace to society right yeah the state's interest is not in controlling speech right you know which when I get the licensing boards file on me it's all about things I've written and yeah well I read the I'll just be honest I read the initial complaint from the guy and the fact that he you know it's one thing to disagree with what you're saying and I mean it's another it's it's one thing to highlight the use of the letters it's another thing to just like overtly call you a fraud and then for the board to like get into it on the like essentially validating the idea that you're a fraud when they themselves have have resertified you almost immediately so like clearly you're competent as an engineer so like what's the real issue here and it just I I asked the question what is the issue here then it just seems to me like the board has allowed themselves to get involved in something that maybe is a little bit more than they bargained for or you know maybe it's one of those instances where you know just a just a misjudgment and both you know people are afraid to back down once they're sort of in the thick of it and yeah maybe there's a way to save face for both sides yeah yeah we tried that to while back and I hear it it seems a little obstinate and sort of like it to me it's like a tiki-tak foul and I don't know sorry that you're I sympathize with what you know I really appreciate it yeah I mean there was a point in time where I'm like oh look I'll pay a fine I'll accept a reprimand you know let's move on but why do you insist on me signing a document saying I committed fraud and I misrepresented myself and I lied to the public and yeah yeah I mean that's the question and I think your attorney talked about this this question of intent to misrepresent yourself and all this sort of stuff and clearly you know as a layman who's sympathetic to the strong-town side of the story you know it seems like there's no intent here I mean you're just you're you're used to putting a P on there you clearly have the qualifications for it it seems like the board allowed themselves to get drawn into something by a guy who had a motive that you know again calling somebody a fraud is a fairly heavy claim and you know that I can understand feeling really angry about being called a fraud in a public forum at the state level so appreciate that yeah well Ryan it has been delightful to chat with you again I hope we don't go a long time without without you are one of these interesting people to me who you know are doing something very important and very technical and and you know I congratulate you on getting to the end of your Navy service time and and all that I know that's a liberating feeling in some ways and I love the fact that you also think across disciplines are able to take some of this knowledge and say all right let me apply this in other realms and I just I love the critical thinking and I appreciate you taking the time to talk through some of this stuff with me I I I've I learned a lot and I think our listeners probably learned a lot too so hopefully hopefully it was worthwhile for the listeners glad to be a part of the the podcast I'm a long-time listener first time caller as they said thanks my friend to be a part of it and you know I wish you the best with the whole credentialing silliness and thank you that's I guess well and when you get to Cincinnati let me know because we do some great strong towns people in Cincinnati yeah I'd love to do and cool work and I'd love to connect you with them they would they would appreciate having you around well I'll tell you you know when covid hit the the hospital slowdown and you know start a look for for other things to do and I'll tell you a listening to some of the first strong towns and urban three YouTubes it was like you know the scene in the matrix were neo zero zeroes for the first time uh-huh it's sort of like that was like it then being in California where it's like the most advanced disease possible right yeah it's a fantastic size it's it's hard to unsee it and sometimes it's a little bit disconcerning so yeah I'm staying grounded cool well thank you so much uh nice and chat and thanks everybody for listening I keep doing what you can to build a strong town take care everybody transitoids require what Press the pressure, yes! Push that down! They know that America's one big pothole right now. Bill, Bill, Bill, Bill. That's a story. Chuck, her role in this has been fascinating. Oh, thank that, Teddy! I like you. I like your vision of the world. The United Nations Earth Summit, Agenda 21. [Music]