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Family Matters: Have you ever Fasted so Hard that you thought you would never Fast ever again? Well Mike and Mike have..Fast Family Forever....Not All Blood Is Family....Justice Is Coming...Dominic "Dom" Toretto is leading a quiet life off the grid with Letty and his son, little Brian, but they know that danger always lurks just over their peaceful horizon.

During this episode, Dr. Janet Patterson, Chief of Audiology & Speech-Language Pathology Service at the VA Northern California Health Care System, talks with Dr. Michael Biel about theories of motivation and their application and value in aphasia rehabilitation.  Guest Bio: Michael Biel is an Associate Professor in the Communication Disorders and Sciences department of California State University, Northridge and senior speech-language pathologist at UCLA Medical Center.  From 1993 to 2012, Michael was a full-time speech-language pathologist working in the Los Angeles and Pittsburgh VA healthcare systems.  Michael is board certified in neurologic communication disorders from the Academy of Neurologic Communication Disorders and Sciences and specializes in working with persons with aphasia. In today’s episode you will hear about: Self-Determination Theory, and Flow, and Aphasia rehabilitation Psychological nutrients of competency, autonomy, and relatedness, including a short list of actions one can take to satisfy these nutrients Intrinsic and extrinsic motivation, and therapeutic engagement as a process. Interview Transcript Dr. Janet Patterson:  Welcome to Aphasia Access Conversations. Today, I am delighted to be speaking with my dear friend, research partner, and pioneer in the study of engagement, motivation and aphasia. Dr. Michael Biel. Dr. Biel earned his master's degree in Communicative Disorders from California State University Northridge, and clinical doctorate degree in medical speech language pathology from the University of Pittsburgh. Mike dedicates much of his clinical practice and research efforts to understanding the science of motivation, and how to translate well established theories in the psychology literature to clinical practice and research in aphasia rehabilitation. He also has an interest in the role of the arts and humanities in adult neurorehabilitation, and with his wife, Francie Schwarz, started a book club for persons with aphasia. You can hear about that book club in Aphasia Access Podversation # 12, where Francie describes the aphasia book club within the Los Angeles Public Library System.  Before joining the faculty at CSUN, Dr. Biel worked as a speech-language pathologist for the VA Healthcare System, and the UCLA Medical Center. Mike is Board Certified in Neurologic Communication Disorders from the Academy of Neurologic Communication Disorders and Sciences or ANCDS.  Welcome, Mike. I am pleased to have a conversation with you today, and to turn the tables on you so to speak, as you are typically a podcast interviewer with ANCDS. Today you are our aphasia expert on motivation and engagement. Thank you for talking with me today about aphasia, rehabilitation, motivation, and engaging patients, family and clinicians in the treatment enterprise. Dr. Michael Biel: Great, thank you so much for having me. Janet: Mike, I would like to start our conversation by asking you about motivation, and how we might think about it as a concept in rehabilitation. People scatter their conversations with the word motivation, attributing all sorts of their actions and reactions to motivation or the lack thereof. Knowing that this is a vast topic, can you help our listeners develop a frame of reference for thinking about how motivation fits into aphasia rehabilitation? Mike: Well, Janet, you're right. Motivation is a broad term. I think one author said that motivation is the why behind all human behavior. Some years ago, a paper was published, exploring the definition of motivation, and I think the author catalogued something like 200 different definitions. In its simplest form, I think we could say that motivation is the energy that causes us to do something, to act. Typically, whether motivation is effective, the many theories of motivation, are regarding its strength. The stronger the motivation, the more someone's going to pursue their goals and, and persist. Another way to think about motivation, one that I've kind of subscribed to comes from Self-determination Theory, and they focus more on the quality of motivation. They acknowledge that the strength is important, but they argue that more than the strength the quality is important and in its simplest terms, they define motivation as being either intrinsic or extrinsic. Intrinsic motivation is motivation where we're moved to act, because the activity itself is enjoyable, interesting, or satisfying. When people play video games that would probably be an example of intrinsic motivation. I use the example of going dancing, right, we dance because we'd like to dance not because we're expecting some kind of outcome after we're done. And so, if we are expecting an outcome, or if we have a goal in mind, then that would be considered extrinsic motivation. When I teach my students about motivation, they are in some ways, very tied to this notion that intrinsic motivation is good, an extrinsic motivation is bad. Extrinsic motivation is not necessarily bad. Much of adult life is characterized by us having to do things that we don't always enjoy. But if we're working towards a valued goal, and we're doing something because we desire to achieve that goal, then we're in a positive state of motivation, I guess you could say. Self-determination Theory divides extrinsic motivation into controlled and autonomous forms. In controlled forms of motivation, we’re acting out of some pressure to act. That can be due to some external threat, such as the client in acute rehab, who's told that if they don't participate, more, there'll be discharged, or even the pressure to secure a reward. And in this case, the care and the positive regard of a health care provider. Even we can put pressure on ourselves, wherein we have this “should” voice in our head. In Self-Determination Theory, this is thought of as some recommendation, or belief or value or goal that's been internalized, but to a shallow degree. In a better way of saying it, the authentic self is not really integrated and identified with this goal, and so it simply remains kind of a “should” voice in our head. Janet: That's fascinating, all the ways to think about motivation, several different perspectives. As I was listening to you, I was thinking about all of them, or at least, most, I think, have in common, that you're motivated to engage in something behavior, whether it's intrinsically motivated, or extrinsically motivated. But let me ask you a little bit about motivation from the perspective of engagement in the rehab process, because you mentioned that as an example of using motivation to keep people engaged in that process. I looked at the definition of engagement and found these two examples. One is, the fact of being involved with something. And another that adds a psychosocial component specifically says emotional involvement or commitment, which is exactly what I think you were talking about in differentiating the kinds of motivation.  I also found this interesting description of how engagement feels when riding a horse. Now, I am not a horse person. However, this description resonates with me, and I wonder if it does with you as well. I think it has application in how we think about aphasia rehabilitation. Paraphrasing from the site, Happy-HorseTraining.com, and I bet you never thought that aphasia and happy horse training would be in the same sentence, but there they are. “There are different degrees of engagement, and it can come and go when we are writing in itself. It is a particular gymnastic state when the horse brings into action, a specific set of postural muscles, which fundamentally alter the dynamic of how he carries himself. It is only in this state that the horse is able to carry the rider in balance, and without the damaging effects that otherwise a rider inevitably has on the horse. This is why any educated rider who cares about their horse’s well-being will make engagement a priority when they ride. Apart from the fact that an unbalanced horse is never a pleasure to ride, nor is it safe. The engagement of the horse gives you the following sensations: you feel the power from the hind legs feeding underneath your seat, instead of pushing out behind, and you feel lifted up by the horse’s back underneath the saddle, instead of dropped into a hollow. Above all, engagement is an incredibly good feeling for both the horse and the rider, because we instinctively enjoy the feeling of balance and power. Instead of always focusing on what you are doing when you ride, start to become aware of the moments when it simply feels good. This is the most reliable way of finding the direction towards a correct engagement.” Several phrases in this description such as being engaged is a good feeling for both patient and clinicians (those are my words, replacing horse and rider) they resonate with me because I think we instinctively enjoy the feeling of balance and power. What do you think, Mike? Mike: I completely agree, I think we all have a sense of what that feels like. Some people might call it flow. And in fact, there's a theory of flow and in that theory, they say, essentially, that we get into a flow state, when there is a particular balance between our skills and ability, and the degree of challenge that we're facing such that if the challenge is too great for our skills, then flow is lost. If there isn't enough challenge to capture our attention, then we're not going to have the kind of absorption that we might have in that flow state. I certainly think most of us have had that experience working with a client where, particularly after we get to know them for a while, and we've developed some skill at facilitating their communication abilities, or some aspect of a treatment that we're working on and things are starting to flow. I know that when I was at the VA in Pittsburgh, working in their Intensive Aphasia Treatment Program, one of the things I noticed was that, we worked with people for a whole month, and after about a week or two, I felt as if I was really dialed in. I was like an instrument that was being tuned, so that I could really exquisitely cue my client and facilitate their production. When we think about engagement, people have written about engagement as an experience that is co-constructed, it is a process. People have also talked about it as a state, and flow state would be an example. In going back to Self-Determination Theory, intrinsic motivation would probably be very closely related to this idea of a flow state in the sense that when we're intrinsically motivated, we're drawn to do something because we get some satisfaction out of the very act of doing it. In Self-Determination Theory, the ingredients that contribute to intrinsic motivation are that our sense of competency is being satisfied, we're feeling effective. In fact, one of the details of that competency satisfaction is that there's an optimal challenge, that we're meeting, a challenge that is not too hard, not too easy. The other ingredient that's being addressed is we're it we're doing it truly out of our own choice freely, without a sense of pressure, because we genuinely want to. Janet: That makes a lot of sense to me as you talk about engagement and motivation, and how we can apply it in the aphasia rehabilitation sessions that we do in in our program planning. I wonder if you had any other additional thoughts you might want to share at the moment about how we can think theoretically, the theories of motivation and how we can apply those to our aphasia rehabilitation practice? Mike: Sure, you know, when I started off as a therapist, and I was thinking about ways to motivate my clients and to increase their engagement, I think I often thought about the stimulus. I thought about making the activity more interesting to them. I thought about incorporating their hobbies, or something like that. And I think that practices is fairly common. But again, it tends to be focused on the interesting aspects of the stimuli. I think when we look at theories of motivation, we realize that there are deeper needs, that people have needs that are going to provide more of this motivational energy and provide a kind of energy that sustains itself for longer. I think when we focus on some of these more superficial aspects, quite honestly, of therapy, they just don't have the staying power. And at least in Self-Determination Theory, there's a concept of basic psychological needs. In this theory, they've identified three, (1) the need to feel autonomous, to feel that what we're doing is truly of our own choice that we desire to do it, (2) the need to feel competent at doing those things that we want to do, and (3) the need to feel connected to other people, what's called the need for relatedness, to feel that there are people who care about us, there are people we care about, and that this care is unconditional. I think if therapy and rehabilitation is constructed in a way where these needs are satisfied, then we're going to have a lot more fuel for engagement, and particularly when we hit the different challenges that people have to cope with.  Now, the listener may be wondering, well, exactly how did these needs influence motivation, and, to be honest, I probably don't have time to go into that in much detail, but essentially, it contributes to motivation in two ways. Number one is, at least according to Self-Determination Theory, these needs are innate. We tend to be drawn towards activities, goals and contacts, where these needs are being satisfied. These needs fuel a process called internalization, which is the human tendency to kick in the recommendations that belief, the values, the practices of important people around us, and to identify with them and to make them our own beliefs and practices and what not.  I think in rehabilitation, we do a fair amount of teaching in one way or another and recommending and espousing certain beliefs and values that we think will serve people in positive ways. In the dynamics of a relationship and satisfying these needs, there is a kind of a security and a trust, and a nurturance that our clients feel and that increases the likelihood that they do take on what we have to offer and make it their own and, develop some ownership over it. Of course, that really is going to form the foundation of a more persistent engagement. Janet: Mike, in the past year during the pandemic, and its requirement for social isolation, which perhaps may continue for several months into the future, increased mental health challenges, such as depression, have appeared in the general population, and likely also in persons with aphasia. How do you think that fostering engagement in aphasia rehabilitation and in communication interaction can help persons with aphasia cope and indeed thrive during these challenging times? Mike: Yeah, that's a that's a really interesting question. Staying on this notion of a psychological need. Self-Determination Theory is not the only psychological theory that proposes that humans have psychological needs. What these theories tend to have in common, these needs-based theories, is that it's the satisfaction of these needs that is necessary for us to be psychologically healthy. In fact, in Self-Determination Theory, these needs for autonomy, competence and relatedness are sometimes referred to as psychological nutrients, communicating the idea that just like physical, dietary nutrition, that these elements really do need to be addressed for us to be optimally healthy. I think that as therapists, of course, we have our limits. In my sessions with clients and the dynamics of our interaction, I do the best I can to address and satisfy these needs. That would also include the kind of goals, collaborative goal setting that we might do, and, and I will frankly discuss these needs with clients and family members, too, and people seem to get it. Other examples are, let's take the need for relatedness, which is not just satisfied between individuals, a client-clinician relationship, or a romantic relationship, or a parent child relationship, but it's also satisfied when people have a sense of belongingness to community. I think, right now, I've noticed that a couple of the aphasia groups that I belong to and facilitate seem to be playing a really important role in helping people feel connected to a community. Hopefully that is having a prophylactic effect in terms of helping people stay psychologically well. Janet: Which again makes sense. But as you are interacting with people, both patients with aphasia and their caregivers, what are some of the indicators you see, that suggest a client is engaged in rehabilitation, or not engaged? How do you measure engagement or feel confident in identifying when a patient is engaged with you in the rehab process? Mike: There are some measurements of engagement out there. Off the top of my head I don't know how valid they are. There are most definitely a number of measurements of motivation and Self-Determination Theory related measures of intrinsic motivation, of autonomous versus controlled forms of motivation, and need satisfaction. I don't administer those tests myself in my clinical practice, although I sometimes pull one aside to guide the kind of conversation that I might have with a client so that I can kind of get a sense for whether they're really struggling with this need for autonomy. In other words, they're not feeling as if they're having much choice over their life, that they have a sense of doing what is important to them, or steering the conversation towards getting a sense of how competent they feel, doing the things that are important to them, how connected they are to friends and family, etc. In general, I guess I rely more on my interactions with people and my observations. I think in terms of kind of markers of engagement, I think it does look different at different stages of rehabilitation. Early after a stroke, for example, or early in a clinical relationship, our clients often don't understand enough about their disorder, about the process of rehabilitation, to be real engaged the collaborators. At that point engagement is more focused on them being engaged in wanting to learn about aphasia, and the options for rehabilitation and whatnot. In so in the beginning, I'm spending more effort supporting people developing some competencies that will help them become more true collaborators, so that later on engagement is manifest much more in the sense of them participating in decision making and sharing their opinions on different treatment approaches, for example, then sharing their observations of what's going on with them and their progress towards their goals. So, I guess, overall, my experience has been when things are going well, that people start off most definitely curious and engaged in that way. Over time, they develop more ownership over the process and become, if not collaborators, maybe even more than that, for lack of a better word, become their own therapist. Then, of course, there are, I guess you could say, the more traditional observation observations of engagement, adherence to treatment schedules, home practice schedules, following up on recommendations, things of that nature. As a kind of an example, I think of the way one can use a theory of motivation to maybe start to think about some of the patterns of behavior that we see. I'll sometimes see clients who are using an app on their iPad and so I can monitor their practice how often they're practicing, when they're practicing. I might see that they kind of don't practice much until the day before their scheduled session with me. And to me, that's really one example of someone being in a more controlled form of motivation, wherein the reason for them to be motivated is perhaps the desire to maintain my approval of them. When our motives are external to us they don't really exert much influence until they're in proximity. And so, as we get closer to the scheduled appointment, all of a sudden, this external motivator starts to kick in, and they'll do some practice. I might look at that and realize that there's something missing in terms of addressing goals, etc. so that people are more truly, the genuinely autonomously motivated, in which case, the pattern would be more like, not just that people are more persistent on their own, but at times, they're even asking for more. Janet: That is a good place to leave it because you've been helping me visualize this picture of engagement as a process. Everything's so new in the beginning of a person's journey through aphasia. And as the clinician, you are helping them become more comfortable with that and take more of an active role, if you will, owning the aphasia and what to do about it. Let me ask from your experience and research, what advice or techniques or suggestions can you give to our listeners that they can take and incorporate into their clinical practice? I know you've described a little bit about how you use your observations, but are there some specific pieces of information you can impart to our listeners? Mike: Sure. I think engagement starts with me. If I am truly engaged, then that tends to facilitate the engagement of my clients. If we think about when someone listens to us, let's say and listens to our story, in a manner in which they genuinely seem to be trying to understand our perspective, that tends to cause us to be a little bit more interested in in it ourselves. I think engagement is contagious. You will read in in qualitative studies, rehab patients particularly in the acute phase, talk about this need to kind of draw on the positive energy of their clinicians to carry them through this difficult time. Now, there are some specific practices that have been described that are focused on satisfying these basic psychological needs, which are kind of the ingredients of motivation, and therefore, engagement. Maybe it would be helpful for me to just go through the list of them, or the short list, so people can kind of get a flavor for what this might look like.  The need for a satisfying people's autonomy is often achieved through first doing what is called perspective taking, listening to people, their concerns, their stories, with the particular intention to try and see the world through their eyes. That kind of listening interest is an acknowledgement of a person's autonomy, and therefore, its autonomy satisfying. Providing choice has been studied quite a bit in terms of satisfying the need for autonomy. I think most of us are familiar with that, because it plays a role in shared decision-making and client-centered goal setting, providing rationales for any of the recommendations we make, rationales that are meaningful, from the client’s perspective, that allow people to genuinely self-endorse them and to kind of take ownership of them. That's believed to be autonomy supportive. Finally, establishing an environment that is not pressuring. In other words, that we don't set up contingencies either explicitly or implicitly. What I mean by that, specifically, is that people don't feel that they need to be a certain way, or behave in a certain way, in order to secure our approval, and our energy, and also to some degree, that means paying attention to the language that we use. Those people who are familiar with motivational interviewing will know that, in motivational interviewing, you pay quite close attention to the language your client is using, the language you're using. For example, you may make an extra effort to stay away from controlling language such as “you should”, “you must”, “you need to”, etc. As far as satisfying the need for competency, that starts by providing the kind of structure that makes people feel secure, that makes them feel supported in making progress. It’s not chaotic, therapy is not a chaotic experience, it's somewhat predictable. I mentioned previously optimal challenge, such as finding tasks, goals that are optimally challenging. The nature of the feedback that we give can support people's needs to feel competent, in other words, that our feedback is more informational than evaluative. It's informational in the sense that, once we give it people have a sense of how to do better next time. It's useful a feedback. And then of course, monitoring progress is an important component of satisfying people's needs to feel competency within rehabilitation and measuring progress in a way that is meaningful to clients. As far as the need for relatedness. In general, it means that we do not send any overt or covert signals that our positive regard for our clients is in any way dependent on what they say or do. Let them know that our care for them is unconditional, and that our motivation is autonomous. In other words, that they are not an object to us. What I mean by that is, they are not a means to an end for us they are not a productivity requirement, they are not a means of generating income, they are not a means of stroking our egos, that we genuinely empathize with them and want to help. And they that is their experience of us. Janet: It does sound to me like you've spent a lot of time thinking about motivation and engagement, and also applying it in your everyday work with patients and their family members. Would you describe for us one of the successful experiences you've had and engaging patients and family members in your rehab process? Mike: Sure. I can honestly say that all of my clients now and in recent memory, or I think, successes. One of the things, as I mentioned before, that I've been experimenting with more is working with caregivers and talking about these basic psychological needs and how we, the people around the person with aphasia, can sometimes out of good intention, thwart those needs, and how they can do some simple things, to help people feel autonomous, to help them feel competent, to help them feel connected to others. I've gotten a lot of good feedback from starting to do that. Another thing I've been experimenting with are very, very short term goals. In goal setting theory, which is referenced now and then in rehab literature, proximal goals, very short term goals are thought to be more motivating than long term goals. My PT colleagues are fortunate in the sense that the kinds of goals their clients are working towards her so much more concrete and tangible. A person could not transfer from their bed to their wheelchair independently. Now, they can. It's easy to observe. Communication improvements are more abstract. To some degree, I think my patients suffer from struggling more to have a tangible, concrete sense that they're making improvements towards their goal. And so I've been working with super short term goals. In other words, goals, like,” Okay, what would you like to achieve by next week.” What's been really interesting about that process is that when we think about a goal in that short of a term, it tends to focus the mind in ways that longer term goals, one month, two months, three months, just don't. It seems to cause people to really reflect carefully on their strengths, what they can do. Then there’s this heightened sense of expectation that people have, because they're going to experience meeting a goal in a very short timeframe. Now, of course if we can link these one week goals up towards some longer term valued goal, all the better. But that's been a very interesting process, and really helpful not just for my clients, but for me as a as a clinician, too. Janet: I can imagine it has. It must, again, thinking back to the definitions we talked about earlier on engagement, make you feel good, help you and your client feel good that you're in balance with each other. You're working together, little steps, baby steps to achieve some larger goal in future time. Mike: Yeah, I think setting goals and thinking about goals is, is difficult for all of us. And by really shortening the distance. It makes it easier to conceptualize, Janet: I can imagine. Well Mike, as we bring this conversation to a close, and quite frankly, I would rather not. I'd rather go on talking to you for hours and hours because I know that you've spent a good deal of time studying this topic, and practicing this topic, and can talk for days with us about motivation and engagement and its value and importance in our rehabilitation activities. But we are limited on time, so as we bring this conversation to a close, are there any last comments on engagement or motivation? Or in particular Self-Determination Theory, that you would like to share with us?  Mike: Yeah, I think there may be two things. First is that we don't motivate people. We support people's motivation. We support people in ways that contributes to their need for motivation to show up. I want to make that statement because I know that earlier in my career, I spent a lot of time trying to persuade people to believe certain things, to do certain things, and whatnot. In a related way, you know, for me, motivation was a thorn in my side, because I often felt that my clients were not as engaged in a persistent way as they needed to be to kind of reap the benefits that treatment had to offer. That wasn't just my perspective, they felt the same way, and they often didn't know why. It was some time before it dawned on me that there was this factor - motivation - that I put a lot of emphasis on, but I essentially knew nothing about it, I followed my intuition. Learning some theories of motivation, not just Self-Determination Theory, although I think that's my favorite one, I think it's the best fit for the people that I see in my practice, but I draw from other theories, too, this has really transformed my practice and made me more comfortable in my skin, as well as I think more effective. I'd suggest that people who are interested in this topic to start to read about it. One thing about motivation is that the factors that influence motivation tend to be universal, so that we can read about motivation in the context of education or even the workplace, and I think with some confidence, translate that into our own practice. So even though their research is really not there, in speech pathology land, there is a lot of useful research that we can draw upon. Janet: Thank you, that's a good recommendation. I hope that our listeners will take that recommendation, and I hope they will to learn from a project, Mike, that I know you and I with some other people are working on to really examine how people in speech language pathology are reporting motivation when they report their clinical work. We look forward to disseminating that information in a future venue. I want to thank you so much for your time today, Mike, and for chatting with me about motivation and engagement in aphasia rehabilitation.    This is Janet Patterson speaking from the VA in Northern California, and along with Aphasia Access, I would like to thank my guest, Mike Biel for sharing his knowledge, wisdom and experience in studying and practicing principles of motivation, and engagement in aphasia rehabilitation. You can find references and links in the Show Notes from today's podcast interview with Dr. Michael Biel, at Aphasia Access under the Resource Tab on the Homepage. On behalf of Aphasia Access, we thank you for listening to this episode of The Aphasia Access Conversation Podcast project. For more information on Aphasia Access, and to access our growing library of materials, please go to www.aphasiaaccess.org. If you have an idea for a future podcast topic, please email us at info@aphasiaaccess.org  Thank you again for your ongoing support of Aphasia Access. Resources   @mebiel  https://twitter.com/Mebiel  Self-Determination Theory http://selfdeterminationtheory.org/  VA Pittsburgh Program for Intensive Residential Aphasia Treatment & Education (PIRATE) https://www.va.gov/pittsburgh-health-care/programs/pirate/

For this week's Feature Discussion, please join authors Michael Ackerman, Christopher Haggerty, editorialist Michael Rosenberg, and Associate Editor Nicholas Mills as they discuss the original research articles “Artificial Intelligence-Enabled Assessment of the Heart Rate Corrected QT Interval Using a Mobile Electrocardiogram Device,” “ Deep Neural Networks Can Predict New-Onset Atrial Fibrillation From the 12-Lead Electrocardiogram and Help Identify Those at Risk of AF-Related Stroke,” and “Trusting Magic: Interpretability of Predictions from Machine Learning Algorithms.”   TRANSCRIPT BELOW: Dr. Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and its editors. We're your cohosts. I'm doctor Carolyn Lam, associate editor from the National Heart Center and Duke National University of Singapore. Dr. Greg Hundley: And I'm Greg Hundley, associate editor, director of the Pauley Heart Center at VCU Health in Richmond, Virginia. Well Carolyn, this week's feature, it's kind of a new thing for us. It's more than our double feature; it's actually a forum, where we're going to have two papers discussed, we'll have both authors represented from each of those two papers, we'll have an editorialist, and we'll have one of our associate editors. And the topic, Carolyn, just to keep you in suspense, is really on machine learning and actually how that can be applied to 12 lead electrocardiograms. But before we get to that, how about we grab a cup of coffee and start off on some of the other articles in this issue? Would you like to go first? Dr. Carolyn Lam: Yes, I would, but you're really keeping me in suspense. But first, let's focus on health related quality of life. We know that poor quality of life is common in heart failure, but there are few data on heart health related quality of life and its association with mortality outside of the Western countries. Well, until today's paper. And it's from the Global Congestive Heart Failure, or GCHF study, the largest study that has systematically examined health-related quality of life as measured by the Kansas City cardiomyopathy questionnaire 12, or KCCQ, and its association with outcomes in more than 23,000 patients with heart failure across 40 countries, in eight major geographic regions, spanning five continents. Dr. Greg Hundley: Wow, Carolyn. That KCCQ 12, that has been such an interesting tool for us to use in patients with heart failure. So what did they find in this study? Dr. Carolyn Lam: Really important. So the health-related quality of life differs considerably between geographic regions with markedly lower quality of life related to heart failure in Africa than elsewhere. Quality of life was a strong predictor of death and heart failure hospitalization in all regions, irrespective of symptoms class, and in both preserved and reduced ejection fraction. So there are some important clinical implications, namely that health-related quality of life is an inexpensive and simple prognostic marker that may be useful in characterizing symptom severity and prognosis in patients with heart failure. And there is certainly a need to address disparities that impact quality of life in patients with heart failure in different regions of the world. Dr. Greg Hundley: Very nice, Carolyn. Well, I'm going to turn to the world of basic science and bring us a paper from David Merryman from Vanderbilt University. So Carolyn, myocardial infarction induces an intense injury response, which ultimately generates a collagen dominated scar. Cardiac myofibroblasts are the cells tasked with depositing and remodeling collagen and are a prime target to limit the fibrotic process post myocardial infarction. Now Carolyn, serotonin 2B receptor signaling has been shown to be harmful in a variety of cardiopulmonary pathologies, and could play an important role in mediating scar formation after MI. So Carolyn, these investigators employed two pharmacologic antagonists to explore the effect of serotonin 2B receptor inhibition on outcomes post myocardial infarction and characterized the histological and micro structural changes involved in tissue remodeling. Dr. Carolyn Lam: Oh, that's very interesting, Greg. What did they find? Dr. Greg Hundley: So Carolyn, serotonin 2B receptor antagonism preserved cardiac structure and function by facilitating a less fibrotic scar, indicated in their results by decreased scar thickness and decreased border zone area. Serotonin 2B receptor antagonism resulted in collagen fiber redistribution to a thinner collagen fiber. And they were more anisotropic. They enhanced left ventricular contractility and the fibrotic tissue stiffness was decreased, thereby limiting the hypertrophic response of the uninjured cardiomyocytes. Dr. Carolyn Lam: Wow. That is really fascinating, Greg. Summarize it for us. Dr. Greg Hundley: Yeah, sure. So this study, Carolyn, suggests that early inhibition of serotonin 2B receptor signaling after myocardial infarction is sufficient to optimize scar formation, resulting in a functional scar, which is less likely to expand beyond the initial infarct and cause long-term remodeling. The prolonged presence of the antagonist was not required to maintain the benefits observed in the early stages after injury, indicating that acute treatment can alter chronic remodeling. So Carolyn, it's really going to be interesting to see how this research question is pursued in studies of larger animals, including us, or human subjects. Dr. Carolyn Lam: Wow, that is really interesting. And so is this next paper. Well, we know that genetic variation in coding regions of genes are known to cause inherited cardiomyopathies and heart failure. For example, mutations in MYH7 are a common cause of hypertrophic cardiomyopathy, while mutations in LMNA are a common cause of dilated cardiomyopathy with arrhythmias. Now, to define the contribution of non-coding variations, though, today's authors, led by Dr. Elizabeth McNelly from Northwestern University Feinberg School of Medicine in Chicago and colleagues evaluated the regulatory regions for these two commonly mutated cardiomyopathy genes, namely MYH7 and LMNA. Dr. Greg Hundley: Wow, Carolyn. So this is really interesting. So how did they do this and what did they find? Dr. Carolyn Lam: You asked the top questions, because the method is just as interesting as the findings here. They used an integrative analysis that relied on more than 20 heart enhancer function and enhancer target datasets to identify MYH7 and LMNA left ventricular enhancer regions. They confirmed the activity of these regions using reporter assay and CRISPR mediated deletion of human cardiomyocytes derived from induced pluripotent STEM cells. These regulatory regions contained sequence variants within transcription factor binding sites that altered enhancer function. Extending the strategy genome-wide, they identified an enhancer modifying variant upstream of MYH7. One specific genetic variant correlated with cardiomyopathy features derived from biobank and electronic health record information, including a more dilated left ventricle over time. So these findings really link non-coding enhancer variation to cardiomyopathy phenotypes, and provide direct evidence of the importance of genetic background. Beautiful paper. Dr. Greg Hundley: Very nice, Carolyn. Dr. Carolyn Lam: But let me quickly tell you what else is in this issue. We have an ECG Challenge by Dr. Lutz on flash pulmonary edema in a 70-year-old; there's an On My Mind paper by Dr. Halushka, entitled (An) Urgent Need for Studies of the Late Effects of SARS-CoV-2 on the Cardiovascular System. Dr. Greg Hundley: Ah, Carolyn. Well, in the mailbox, there are two Research Letters, one from Dr. Soman entitled (The) Prevalence of Atrial Fibrillation and Thromboembolic Risk in Wild-Type Transthyretin Amyloid Cardiomyopathy, and a second letter from Dr. Berger entitled Multiple Biomarker Approaches to Risk Stratification in COVID-19. Well Carolyn, now let's get on to that forum discussion and hear a little bit more about using machine learning in the interpretation of a 12 lead ECG. Dr. Carolyn Lam: Wow, can't wait. Thanks, Greg. Dr. Greg Hundley: Well listeners, we are here today for a double feature, but this double feature is somewhat unique, in that we are going to discuss together two papers that focus on machine learning applications as they relate to the interpretation of the electrocardiogram. With us today, we have Mike Ackerman from Mayo Clinic, Chris Haggerty from Geisinger, Mike Rosenberg as an editorialist from University of Colorado, and then our own Nick Mills, an associate editor with Circulation. Welcome, gentlemen. Well, Mike Ackerman, we will start with you first. Could you describe for us the hypothesis that you wanted to test, and what was your study population and your study design? Dr. Michael Ackerman: Thanks, Greg. The hypothesis was pretty simple, and that is could an artificial intelligence based approach, machine learning, deep neural network, could that solve the QT problem? Which is one of the big secrets among cardiologists, which, as you know, one of your associate editors, Sammy Biskin, published a sobering paper over a decade ago, showing and revealing the secret that cardiologists are not so hot at measuring the QT interval, and heart rhythm specialists sometimes don't get it right either. And we all know that the 12 lead ECG itself is vexed by its computer algorithms at getting the QTC just right, compared to those of us who would view ourselves as QT aficionados. And so we were hoping that a machine learning approach would solve this and help us glean, one, a very accurate QTC, as accurate as I can make it when I measure it, or core labs that do QT measuring for living. Dr. Michael Ackerman: And two, could we get that QTC from just a couple of leads to be as accurate as what the whole 12 lead ECG would be seeing so that we can move it to a mobile smartphone enabled solution? And so that was our hypothesis going forward, and we studied a lot of patients. And that's something that machine learning and the power of computation does, that in my world, I'm used to studying a hundred or a thousand patients with congenital long QT syndrome and thinking that I've assembled a large cohort, but for this study, we started with over two and a half million ECGs from over 650,000 people. And then ultimately, through training, testing, and validation of about 1.6 million ECGs from over a half a million individuals to sort of teach the computer or have the AI algorithm get the QT interval not too hot, not too cold, but just right. And as we'll discuss, I think we hit the mark. Dr. Greg Hundley: Thanks so much, Mike, what did you find? Dr. Michael Ackerman: Ultimately, we were able to show that with this drill, we could get the deep neural network derived QTC to be give or take two plus minus 20 milliseconds from what would the standard of care, and that being a technician over-read QTC. But then we took, I would say, pretty unique to AI studies, as many AI studies, just do training, testing, and validation for study number one. And then a future paper of a prospective study. But we did that prospective study within this single paper with a subsequent about two year enrollment of nearly 700 patients that I evaluated in our genetic heart rhythm clinic at Mayo Clinic. And half of those patients have congenital long QT syndrome, half did not. And what we showed was that the deep neural network derived QTC from a mobile ECG approximated the subsequent or the just prior 12 lead ECG within one millisecond, +/- 20 millisecond territory. Dr. Michael Ackerman: And it's ability to say is the QTC above or below 500, which we all know is sort of a warning sign, that's a very actionable ECG finding, do something about it, that that 500 millisecond cutoff by the deep neural network gave us an area under the curve of 0.97, which from a screening perspective, that AUC is far higher than a lot of AUCs for a lot of screening tests done in the cancer world and so forth. And so we think we are very close to what I've called a pivot point, where we will soon pivot from the way we've been doing the QTC since Eindhoven over a century ago to a fundamentally new way of deriving a QTC that's precise and accurate and mobile enabled. Dr. Greg Hundley: Very nice, Mike. So using machine learning to accurately assess the QTC from just two leads of an electrocardiogram. Well Chris, you also have a paper in this issue of circulation that pertains to another application of machine learning and looking at the electrocardiogram. Can you describe for us your study population, study design, and then also the question you were trying to address? Dr. Christopher Haggerty: Sure. Yeah, thanks Greg. Great to be here with you all today. Very similar to Mike's study, the motivation for us was we believe very strongly that there's opportunities with using deep learning applied to ECG data to uncover not only new knowledge latent in the ECG itself related to the current patient context, but also to try to predict future outcomes, future events. And that was really our motivation, was to take that paradigm of looking forward, in this case to predict new onset of atrial fibrillation within a year. We used our Geisinger patient cohort, which is a largely rural population in central Pennsylvania. We have very longitudinal data for a lot of our patients, which allows us to have this kind of design going back in our electronic health records, in this case, our ECG database to 30 plus years. Dr. Christopher Haggerty: Similar big numbers that Mike described, and in our case, 1.6 million ECGs over 430,000 patients used to train the model. And we had several different study designs that we employed. One just being a simple proof of concept, asking can we accurately predict new onset atrial fibrillation one year? And then a second study design that was intended to simulate a real world deployment scenario. Obviously the main rationale for trying to predict atrial fibrillation is to then be able to treat and try to prevent stroke. And so we tried to, as best we can in a retrospective fashion, simulate a scenario in which we might use this model to identify patients who went on to have a presumably AFib associated stroke. Dr. Greg Hundley: And what did you find, Chris? Dr. Christopher Haggerty: So I think there are three main findings that we highlighted here. So first, obviously we were building on the great work that Mike and some of his colleagues at the Mayo Clinic have done, showing that looking at AFib using deep neural networks needs to be feasible. We extended it in this case by looking out further than just an acute sense, looking at that one-year outcome. And we had an area under the curve for our proof of concept of 0.85. So area under the curve of 0.85 to identify patients with new onset of atrial fibrillation within one year in our millions of ECGs. Looking at it another way, the second main finding was that that one year prediction was shown to have prognostic significance beyond that one year, which is really interesting and warrants a lot of further study. Looking over 30 years of follow-up, patients predicted to be at high risk at baseline had a hazard ratio of 7.2 for developing atrial fibrillation, compared to those deemed to be low risk. Dr. Christopher Haggerty: And then really the third, and I think perhaps the most exciting finding that we had here, was this simulated stroke experiment that we had, where we identified patients from an internal stroke registry and identified patients who had new diagnosis of AFib at the time or up to a year after the stroke. So we can assume that they were an AFib associated stroke. And subsequently, or I should say previously, had an ECG that we could use to run through the algorithm to predict their atrial fibrillation risk. And we showed that the model performed well in this setting, that of the 375 strokes that we identified, for example, over a five-year period in our registry, we were able to identify 62% of them within three years based on that ECG. So a number needed to screen for an atrial fibrillation associated with stroke about 162, which compares favorably well to other screening techniques that are out there, obviously. So we took that as a great proof of concept that this type of AI technique might have benefits for screening for atrial fibrillation and preventing strokes. Dr. Greg Hundley: Well congratulations, Chris. Well, we're now going to turn to our associate editor, Dr. Nick Mills. And Nick, you have a lot of manuscripts come across your desk. What attracted you to these two papers, and what are the significance of the results as they apply to ECG applications as we move forward? Nick Mills: Thanks, Greg. Yeah, this is a rapidly growing field, where the availability of data scale with digital archiving and lots of really interesting new methodologies are available to our researchers. So we are receiving a lot of content in this area. What I loved about these two papers is not just the quality of the work, but also the really tangible benefits, potentially, for patients. So AI does not need to be complex, but it does need to solve a tangible problem. I guess what we look for in the journal, beyond the kind of innovation and methodology, is quality, and these studies used prospective validation, really reliable end points, ascertainments, transparency, reporting, all the things that we know are important for high quality clinical research. I think the idea that we can bring QT monitoring to the drug store on a portable device for our patients is potentially transformative. I also think that to take a technology, the electrocardiogram that we've been using for over a century, and provide new insights that go way beyond my ability to interpret the ECG, that might help us recommend a different course of action for our patients is also just really exciting. Dr. Greg Hundley: Very nice. Thank you, Nick. Well Mike ... we're going to turn to Mike Rosenberg now, listeners. And Mike wrote a wonderful editorial, and I would invite you to work through this. As you have an opportunity to read the journal and interact with it. Mike, there are two different types of machine learning, I think, that you described were used by the two respective investigative groups. Could you describe those for our cardiology listeners? What were the differences in those two approaches? Dr. Michael Rosenberg: Yeah, sure. And thank you for the opportunity to write the editorial. Two very fascinating papers. I should say that they both use the same approach of what's called supervised learning, where you basically have a set of data inputs, and you're trying to predict a labeled outcome. And what I talk about in the paper is that what we've learned is if you have enough data and enough computing power, you can predict almost anything highly accurately. What's interesting about the two papers, and what I sort of tried to contrast in the editorial, is that the one from the Mayo Group and Dr. Ackerman, was basically predicting what's already a known biomarker for sudden death, which is the QT interval. And essentially, almost trying to automate that process of predicting it accurately and in a way that, in essence, could allow a home monitoring of patients for QT prolongation, which obviously would be a huge benefit for clinicians, all those alerts and things, to be able to have patients taking drugs that are known to prolong the QT interval and feeling comfortable that if they have any prolongation, it could be detected accurately. Dr. Michael Rosenberg: The second one, which is sort of interesting, and in contrast is from the Geisinger Group and Dr. Haggerty, was the approach of ... where actually the prediction itself is actually the biomarker. And we don't actually know exactly what it's using, which I talk about a little bit of what that means and the implications clinically, but in essence, what they showed was that it actually is a very good biomarker and on par with what a lot of us would consider to be very strong predictors of agents. So I think it was two very interesting approaches to, again, applying the same type of machine learning, but really approaching it one from a more discovery side and another from sort of validated or almost automating something that we do on a daily basis. Dr. Greg Hundley: Thank you, Mike. So Mike, just coming back to you again, as we read the literature, and most of us are clinicians or researchers practicing, what should we look for when these new machine learning manuscripts and research studies come out as to gauge, "Ah, this is a really good study," or maybe not so much? Dr. Michael Rosenberg: Yeah. And it's a good question. I think one of the biggest challenges, as I talked about, is interpretability. I think in the clinical world, we're used to understanding the code for the variables that go into our risk prediction model. And so I think first and foremost is can I even understand what this is predicting or am I sort of expected to take the predictions as sort of a black box, it is what it is type of approach? I think that there's other things that I just look at when I'm reviewing these manuscripts. I mean, as I sort of mentioned, what these models are really doing, it's not anything magical. What they're doing is identifying patterns in the data and then using those to make predictions, again, toward whatever label that you've assigned them to. Dr. Michael Rosenberg: It's important that your data sets are split and that you're training at one data set and then testing it in one that's separate. And again, you can't ignore epidemiology. Is the data set that you're training it reflective of the population that you're going to be using those models in? And we know from outside of healthcare, there's issues with models that have been trained in one population where it's potentially biased or it's potentially offering predictions that are using information we may not necessarily want to use. Recidivism is a big example of that. So I think that that's, first and foremost, it's sort of taking a step back as a clinician and saying, "If this was a biomarker that someone was proposing to use to predict some new disease, what would I expect to use to evaluate that?" And that's probably what I would start with. Dr. Greg Hundley: Excellent. Well, I'm going to turn back and go back to our panelists here, listeners. And we're going to ask each of our panelists in about 20 seconds to describe for us what they think is the next most important aspect of research in their respective areas. So first I'll start with Mike Ackerman. Mike, can you tell us what's coming next in this area of assessment of QT prolongation or other aspects of the electrocardiogram? Dr. Michael Ackerman: I think next is implementing this in the real world. We are having our suite of the AI ECG as a  hypertrophic cardiomyopathy detector. We've shown that as an ejection fraction detector, and now as a QT detector in AFib, from our work and Chris's work. And for the QT itself, I think where we are is we're really, really close to now having a mobile enabled digital QT meter. And a digital QT meter, once FDA cleared, then allows the QTC to truly emerge as the next vital sign. And it really deserves to be a vital sign. We use it as a vital sign. We know I want to know my patient's QTC every bit as I want to know his or her weight, blood pressure, saturation. It's an actionable finding, and we're now getting really close. We're just on the cusp of having a true digital QT meter. Dr. Greg Hundley: Excellent. Chris? Dr. Christopher Haggerty: I think for us to, in part address some of the comments that Mike brought up about the reproducibility of these types of models, we're very keen to demonstrate the prospective capabilities of our models to enroll patients in a prospective fashion, run their ECG through our predictor, and then screen them for AFib to determine how well we actually do moving forward, instead of just relying solely on our retrospective data. So we're very excited to do that. We're ramping up for that trial now and hope to be able to demonstrate similarly positive findings from our technique. Dr. Greg Hundley: Great. How about you, Nick? Nick Mills: I'd like to see the same quality and rigor applied to the implementation of these technologies as we have to other important areas in cardiovascular medicine. I think that's a really important step, not just to develop the tools, but to demonstrate their value. But I also think what we've done so far is relatively simplistic. We've taken an ECG and we've ignored almost all the other information that we have in front of us. And as these algorithms are trained and evolved, these and other vital clinical biomarkers and information, and integrating them into these neural networks will really enhance their performance for predicting things that are less tangible, like sudden death in the future or stroke. Dr. Greg Hundley: And then finally, Mike Rosenberg. Dr. Michael Rosenberg: Yeah, I actually see two challenging areas in this field. One is the access to data. And I think one of the things that a lot of companies are realizing is that even if they make hardware, that the data may be more valuable than the technology that they're getting the data from. So I think one is figuring out ways to get access to data so that people can reproduce findings from these studies. And the second is deliverable. A bottle like this is not like the CHADS-VASc score that I can calculate in my head in the clinic. I mean I need a way to actually run these models within an EHR, within a computer system like that. And I think it's going to be a big challenge to take a model like this and to deploy it at scale the way we would with the drug or any other innovation. Dr. Greg Hundley: Fantastic. Well listeners, we want to thank Mike Ackerman from Mayo Clinic, Chris Haggerty from Geisinger, Mike Rosenberg from University of Colorado, and Nick Mills from University of Edinburgh for really providing us with a wonderful discussion regarding the use of machine learning applications in one study to predict the QTC interval from two leads that may be applicable to wearable devices. And in the second study, predicting the future occurrence of atrial fibrillation and even stroke as an adverse event in people at risk. Dr. Greg Hundley: On behalf of both Carolyn and myself, I want to wish you a great week and we will catch you next week on the run. This program is copyright of the American Heart Association, 2021.  

Jace chats with Mike Philips about his current Kickstarter campaign. It is a great story idea with a clever structure. We've all thought about how the choices & events in our lives have led us down certain paths and wondered how things might have been different if we had chosen or acted differently. Well Mike's comic Tessellation attempts to answer that question for his main character as we look at several different timelines that diverge from a single event. Join us to learn more about it.

If you own a home, you know what it's like to have neighbors. Well Mike and Frank tell some stories of interactions with their neighbors and the rules and guidelines to follow. They also take a look at some of the recent NFL hires, MLB signings and the big trade in the NHL. Mo Money is back for his picks this weekend! 

Michelle Oates: I've learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel," by Maya Angelou. I am Michelle Oates, and I'm a Tri-Cities Influencer. Paul Casey: Your brain does not see the word "not". So if you're like "I am not going to eat chocolate," you know what your brain hears, is chocolate. So then you start moving toward it, and then you have actually more of a craving for it because the brain doesn't see that word. It's just a fun fact about the brain.   Raising the water level of leadership in the Tri-Cities of eastern Washington, it's the Tri-Cities Influencer Podcast. Welcome to the TCI Podcast, where local leadership and self leadership expert Paul Casey interviews local CEOs, entrepreneurs, and nonprofit executives, to hear how they lead themselves and their teams, so we can all benefit from their wisdom and expect. Here's your host, Paul Casey Growing Forward Services. Coaching and equipping individuals and teams to spark breakthrough success. Paul Casey: Thanks for joining me for today's episode with Mike Miller. Mike is the President of Moon Security here in the Tri-Cities. I always ask for something funny about each of my guests, and Mike's got this legal pad that he's always carrying around. Mike, what's the story of the legal pad? Mike Miller: I have a folder and it always has the yellow pads that I can write stuff on, take notes. I try to make sure I'm following up on stuff, and as I'm looking, hearing, listening to all of the different things that I have to deal with, and things will come to me, I just, "Oh, I'd better write that down," and I write it down for follow-up. So you can always count on me to follow up. Paul Casey: That's good. You don't even have a pocket protector on there. Mike Miller: No, no pocket protector. Paul Casey: But you're tucking it in your polo there. Mike Miller: I always have the pin right at my chest there. Paul Casey: Nice. Well we're going to dive in with Mike after checking in with our Tricity Influencer sponsor. Paul Casey: Barracuda Coffee, born and brewed in the Tri-Cities since 2003. At Barracuda Coffee it's people first, then great coffee. Barracuda Coffee features drinks that are sure to satisfy everyone. Everything from straight espresso to fruit smoothies, lattes, Americanos, and mochas, to lavender green tea or matcha, chai, or chocolate milk, you are sure to find a new favorite from the menu. Try one of Barracuda's signature coffee drinks, like the Fou Sel Caramel, a salted caramel macchiato with French vanilla. It's tres bien, oui! Or the Flapjack. It's just like it sounds, it tastes like breakfast, maple syrup and all. Not a huge coffee fan? Barracuda also has Red Bull infusions with about 20 flavors to mix. For a next level hack try a fruit flavor and add a touch of vanilla. It's a game changer. Barracuda's is on Kellogg Street in Kennewick, or on Van Giesen in Richland, and you can find them on Facebook. Thank you for your support of leadership in the Tri-Cities. Paul Casey: Mike, so our Tri-City Influencers can get to know you, take us through a couple of career highlights that led you to your current position, and throw in there why you love what you do. Mike Miller: Well I've been working for Moon Security since, actually, I was 11 years of age. I'm turning 63 in a couple of weeks, and I will have been there 51 years now, 52 years. You say well how'd you do that? Well, I worked school time and whatnot. So I've been involved with that, I've always grown up knowing that I was programmed to be able to run Moon Security down the road, second generation. We've had other families go, but one of the things that happened along the way is, parents divorced and remarried different people, and the gentleman that married my mother was in security, and that's how we got to meet Mr. Moon, and that's why we have Moon Security named Moon Security. Paul Casey: Wow. Mike Miller: So we have some of that, and when we bought the company from my stepfather then, "Okay Mike, you're the face of the company," and that's how come I'm involved with so many boards and committees across my life. I have served as President of several different entities, including Goodwill, Tricity Chamber of Commerce, or actually their previous name before that, before they changed that name. Then I have served as President for Alarm Association at the state level, and President for the national for a two-year period of time too. I'm a joiner, I'm a connector, I try to help where I can, and that's allowed me to help grow our business at the same time, just because we're involved in so many different ways. Paul Casey: It's funny, when you said "in security" I went "Oh, they're insecure." But yes, so it's a family business. What were some of the dynamics of family business throughout the years? Mike Miller: Speaking of family dynamics and insecurity, there are days when I just don't feel like I'm up to it to the level that I should be when it comes to, how do I deal with certain kinds of family actions, reactions, and people getting upset and all of that. That's a whole different level of, sometimes you just don't want to wish it on anybody. You should be smart enough not to hire family members. Paul Casey: You mentioned you're a joiner and a connector. Is that part of why you love what you do? Mike Miller: First of all, Moon Security itself has been providing security services, products and services, for the last 50-plus years. It allows us to really have a passion for our community we're here to protect. We have thousands of customers that we have protected over the years, and we save lives and properties, and we have stories talking about how systems that worked and got help when the customer or client needed to have help. So that's always a feel-good there for you to have, that you know what you're doing is important. Mike Miller: Then, when it comes to the connecting, I'm a Tricity Sunrise Rotary member as well, and it's really important that we give back to our community, and we can do that in so many different ways, whether it's money, resources, time. And I'm part of a group of people that do that, and we have a lot of volunteers. I'm not doing it alone. The other people step up and do things, depending on what their passion is for who they're wanting to be an advocate for. So I like that, I like to see how other people are doing what they do, and if we can, we can be a part of it. Paul Casey: Yeah, I really like that. I feel like part of your answer was saying that, from this base of stability that Moon has had in our community, that you can then look out at the community and go, "How can we add value". Sometimes when you're at the beginning of an entrepreneur journey, or in a new venture, you can't think out yet. You have to sort of stabilize, get your foundations strong, get your client base strong, and then you can look out. That's usually a sign of, all right, that person's got it together, because now they're reaching out to other people here in our community. Mike Miller: That's a good point, because cycle-wise, life cycle, let's face it, when you're early in the cycle you may not have the cashflow that you can help there, so what do you try to do? You use your brain power to provide, or you use your time to give. And all three are important, so it's pretty exciting when you start to see how you can give. Mike Miller: One of the things that we've kind of verbalized, or I have to myself, is how can we be helpful out there, and we've identified that we really like to be where, is it helping children, is it helping education? For many years I was part of an organization, the Bond Levy Committee, that did work for the Pasco School District. It's a separate entity, not to be wrapped into Pasco School District, but that Bond Levy Committee created lots of dollars by getting people to say yes on who they voted for, for helping build schools. So that helps kids and so forth. My other interaction is with Lourdes Foundation and all the work that we've done there to try to help from a medical standpoint too. You try to be a contributor in that way as well. Paul Casey: I teased you for years of all the boards you're on. Tricity Influencers, this guy was on so many boards that he couldn't even rattle them off to me at one point. So every time he walks up to me now he's like, "Paul, I divested myself of yet another one." So how many are we on now, Mike? Mike Miller: At the time that we talked about it I had 22 boards and communities I was on. Paul Casey: That's right. Mike Miller: So we decided and agreed that I was being stupid about it, and so the real word is, I'm trying to get fired. I try to fulfill my term of office and then it's just like, no, it's time for me to go. You need to get some new blood in there and all. So I think I'm down to five or six now, that I'm pretty active in. Paul Casey: Wow, that's impressive. Well throughout your journey, Mike, you've hit obstacles to success. So what's one of the biggest hurdles you overcame in your career? Mike Miller: Boy, that's always a tough question, because I got plenty of hurdles to deal with. One is just brain power. I've had to recognize ... And maybe wisdom is another. I have several people around me that help support me in so many different ways, within and without the business itself. So it's really important to have ... In my case, I'm a firm believer in having the insurance man, or woman, please no gender issues here, but a CPA, my banker, and my attorney. And you have those four key people, and then I still have some key people that I work with at the office to help keep us going, to be creative. You still have to deal with compliance issues and all of those kinds of things, but I'm not doing it by myself, by any means whatsoever. It's a team effort. Paul Casey: Yeah, hear, hear. We all need that rebar underneath us that helps us do, especially those things that we may not be the best at, but we know somebody else is. They're an expert at that area, so it relieves the load on us, but it also shores up that area of our business. So way to go for that team, that support team, and giving them the credit. Because they really are a support team. And leadership is difficult. Paul Casey: So let's bring it to today, Mike. What's your biggest ongoing challenge as a leader, and what's really stretching you? Mike Miller: It's funny, because we're going through the process of PPP, trying to make sure that we can get everything forgiven, and then of course we're waiting for the bankers and SBA to come out with whatever the requirements are. I'm getting stressed right now on a refinance with our line of credit, and loan activity. That's going to require buying out sisters, and I'll become 100% owner of the company. When they talk about 300 stress points in a year's time, I think I'm at 305. So a lot of things are happening there, and still having sales go, and keeping people happified. Mike Miller: Probably one thing, I've got a new HR manager who's bringing to me the concept of HR as a growth strategy. So we have some technicians who are apprentices, as an example, and they're about ready to become journeymen. So Mike, what are you going to do when you do that? So you go through this process, we're going to get them a vehicle, we have to then have more sales going on to accommodate their cost and so forth, and she's got the and-and question, and I'm going "What?" So she says, "You're going to hire two more apprentices. Because the only way you're going to grow the business is to grow your technical grid. Paul Casey: The pipeline, yeah. Mike Miller: Have a pipeline. Just like what you think of in sales, you've got to do the same thing with your line employees that are out there working their butts off to help grow the business too. So I've been getting to learn through some of those concepts, as well as to all of that. It's been an interesting ride this last year, with my new HR manager. She's awesome. Paul Casey: I love the word happified. It's another word for boosting morale on your team, is to help your team get happified. Well Mike, if you had a leadership philosophy that you would put front and center on a bulletin board in your office for all to see, what would those messages say? Mike Miller: I think one we talk about, it's probably more than just one, but "steady as she goes". In some cases, for us sometimes chaos reigns. You just have to understand that. So how do you deal with that appropriately? My job is to increase revenue, reduce cost, and reduce liability. Some of the other issues that I'll have, that's always in forefront of me, in fact it's on my yellow pad, is having a sense of urgency. When things happen, we need to take care of it and we need to take care of it now. Why? Because it's code compliant, for one thing, and then it's also just life safety concerns that we might have. Then once we know about something then we need to figure out how to resolve the issues, and then recognize that importance, and have clarity and focus to keep everyone going. Mike Miller: Probably the more important thing on all of that is, and I'm terrible at it, I'll put it that way, is to make sure that we're continuously communicating that out to our management group and our employees, that this is how they can contribute to the bottom line. Mike Miller: Probably the other thing I have to work on a lot is just celebrating the 95% that we do good. And what we tend to do is, we tend to concentrate 95% of the time on the 5% that we are not good. So we do have to take care of that 5%, but at the same time, not beat ourselves up so badly. Mike Miller: Then I guess the other one for me is just, what's the plan? I'm getting to that point where other people are in a position where they have to be more hands-on than me. So tell me what the plan is. If you've got a couple different ways to go, I might suggest one way or the other, but just get it done and make the client happy. At the end of the day that's really the issue, is what are we doing to make sure the client gets happified. Paul Casey: That question, what's the plan. I got certified in DISC survey, being able to do that for teams this year. The D style, the lion style, always asks "What". And I think probably the top leader in an organization probably asks "What" more than anybody else. The I style, which I call the otter, asks "Who". The golden retriever, or the C style, asks "How," because it's all about, are we getting along with one another, how are the relationships. Then the S style, or the beaver style, always asks "Why". It's all about the data and the reasons. I just thought that was interesting, the questions that the various personality styles tend to ask. Mike Miller: When it comes to the DISC I think I'm a ... What was C again? Paul Casey: Conscientious. Mike Miller: Conscientious, I'm not sure that's going to be the word. Paul Casey: You've got some D in you. Mike Miller: I'm dominant and controlling, is the big D? Paul Casey: Yeah, you're ID. Most influencers I know have a bit of visionary inside of them, in order to take that next hill. Where do you take time to dream about the future, and what does that look like for you? Mike Miller: I get to go to Hawaii every so often, I really love that. Paul Casey: Oh, nice. Mike Miller: Hawaii is my happy place. You know what, I actually have three groups that are conference calls now, that we do best practices. We will do, "How are you dealing with this HR issue, how are you dealing with job costing, how are you dealing with ..." Whatever the case may be. And we can get input from somebody else. So that's always a coaching, networking, mentoring kind of thing. I can call these people up any time, anywhere, any day, and send out an email, "Help, I'm suffering here," because I can't figure out how to get it going. I go to a couple different security conventions, and they're starting to learn, it's not the product. Most people have a similar product, but it's how you deal with the client, the customer service, and what your approach is, and how you communicate that, and all of that kind of thing. Mike Miller: I think I mentioned, in our last setting that we were to get together, I'm working, reading, trying to go through it, a book called Traction, with ... Paul Casey: Yes, Gino Wickman. Mike Miller: Yeah, okay, Wickman. Trying to be a little bit more specific in terms of the questions that I ask, and how we're getting there, and trying to set some processes in place that way. Paul Casey: It almost sounds like you do your best thinking with others. Is that true, or is there a solitude time as well for things to crystallize in your head? Mike Miller: Probably with others. Like I say ... when I served as President of National, it allowed me to meet all sorts of people all across the nation. So diversity is really a key word there for my ability to be able to grab somebody that I think might have the expertise that would help me and all of that. But I do tend to, when we're away on vacation or whatever, then there's always some quiet time that I am able to get, to allow, just to sit down with my yellow pad, and where do we need to improve, and just kind of cover different areas. Paul Casey: Fantastic. So Tricity Influencers, do you have a group? Do you have a small group of fellow colleagues, maybe there's a mentor in there, maybe there's just a mastermind kind of a group, where you get to play with ideas, and ask those hard questions, and really get some good feedback to make wise decisions? Because it's critical. Mike Miller: A part of that, just do not let your pride get in the way. Paul Casey: Be open to everything, right. Mike Miller: You are going to get some questions that are just going to tick you off and upset you, make you embarrassed and all of that. But sometimes you have to be able to look in the mirror and get that feedback, and then sit down and say "I might have to admit that I suck at whatever," and all of that. You have to be willing and able to take the feedback, and "Let me think about it, and let me come back and see how I'm going to respond to those things." Do not let pride get in the way. Paul Casey: Yep, because "ego" stands for edging greatness out. So if you want greatness, you've got to put the ego aside. Mike Miller: Amen. Paul Casey: Before we head into our next question for Mike, on his typical morning routine, a shoutout to our sponsor. Paul Casey: Barracuda Coffee, born and brewed in the Tri-Cities since 2003. At Barracuda Coffee it's people first, then great coffee. Barracuda features freshly roasted coffees from their own signature roastery, Charis Coffee Roasting Company. With fresh coffee always on the shelf from all over the world, you can taste the distinct floral flavors of Latin American coffees from countries like Costa Rica, Guatemala, and Honduras. Savior the delicate berry notes that are dominant in African coffees from Burundi, Rwanda, Ethiopia, or Kenya. Or go for the full earthy tones of the South Pacific coffees, from Timor, Indonesia, or Sumatra. Ask your barista what's fresh and try something new today. Barracuda has two locations, over on Van Giesen in Richland or on Kellogg Street in Kennewick, and you can find them on Facebook. Paul Casey: So Mike, what is your typical morning routine before you go to work? And maybe if you have any rituals when you arrive at work that helps you start your day out strong? Mike Miller: It's so funny, because I'll actually get up and take a shower, clean ... Paul Casey: We don't need to know those details. Mike Miller: Thank you. After I get my medicine, then I say a prayer with my wife, and then I walk out the door, and I'll have whatever food that I'm going to eat on the way, or pick up. But one of the things that happens is, when I get to the office, then I think people call it email management. So I'm swiftly going through my email stuff first before I get to do anything else, unless there's some crisis that's going on. So it allows me to be able to look and see what's happening, what questions, who's following up with what, and all that kind of thing. And I’m on enough of the email groups in the company, obviously I have to be on all of them, and so there's some that will catch my attention, and I just make sure that they're getting worked on. That's number one priority there, to do it. But then I'll have whatever schedules that I have going. Mike Miller: It's prepping your mind towards, how's my day going to go, good or bad. It's just, that's the day. Then I just try to make sure that I'm working on it, and I fail miserably sometimes, just what's my reaction supposed to be to make sure, what is my outcome that I want to have come out of it. Can't say that it's really anything there. I will have a cup of hot tea as I'm going through all of the stuff, just to kind of relax and get my day in order. Paul Casey: So it's sort of like you're on a vista point looking out at your day, and seeing what the big priorities are, any fires that are going. It's a great first thing to do in the morning instead of just coming in with your hair on fire, and off the races, and then realize at the end of the day, what did I get done today? Mike Miller: That would go back to the yellow pad again. Because I already have my day laid out for the whole week. Then there's stuff that gets filled in. So I'm one of those that, "This is my day, this is how it's going to work," and "I'm going to accomplish this, this, and this." That's a feel-good. Paul Casey: That's right. Eat that frog, get it done. Mike Miller: Yeah. Paul Casey: How do you deal with the everyday grind of your work without burning out? Mike Miller: I try to get proper rest, I'll golf every so often, weekly, and I might sit outside with the dogs and play with them, and just do yard work or whatever. Just something else physically to take away. You know what, burned out, sometimes you can get tired about stuff, and then that's when you have to recognize that you have to schedule a vacation, a three-day, four-day weekend, that kind of thing. It's okay to do that for yourself on there, and whether it's staying at home. Mike Miller: As an example, my wife is, I have 11 grandchildren, and my wife has said "We want to see more of them. I see that you're not really getting ready to retire too soon, so I want some W days." So we take a couple of days, a couple Fridays each month. It could be going somewhere, but it very easily could be just staying at home and relaxing. And that allows us to talk about where we're at, fun stuff, budget stuff, and all of that kind of thing, to just kind of see where we're at, and then how we're wanting to do things as well. Paul Casey: That's a really good one. W days. You'll of course have to name it after your spouse. The principle here, of course, is to have something to look forward to as a couple, because if you see that on your calendar you're like, "I could plow through a little bit longer." As long as I see that time coming, I tend to stack my days very tightly, but I do it on purpose if I see a vacation coming, because then I'm completely off the clock, I'm not going to check my email, and I'm going to pour it into my family. That really helps. Mike Miller: It's called delayed gratification. Paul Casey: Oh yeah. Mike Miller: That's real important to have. Paul Casey: Eat your vegetables before you have dessert, right. Mike Miller: True. My guys that I have, my executive team, they won't let me buy a vehicle. Because we're on a mission for debt reduction and that kind of thing at the office. And I'm going, "Are you sure? I could really use a new vehicle." So I'm running around with an older vehicle. But drives nice. Paul Casey: Because you're keeping your purpose in mind. Mike Miller: That's right. Paul Casey: Love it. And family is a big deal to most people. You mentioned the W days. Anything over the years ... We've got some listeners that have young children, some married, some maybe not married. How do you keep family in that number one slot, and yet still be a high performer at work. Mike Miller: I think I fail miserably in that area. My wife would probably say that, and maybe my kids every so often would too. So maybe I'm the leader in telling you what not to do versus what to do. Paul Casey: Well step out of the confession booth for a moment. Mike Miller: That's right. But I have four kids, 11 grandchildren, and I find that I'm a better grandfather than I was a parent. Paul Casey: Wow. Mike Miller: It's always easier that way, because they get to go home, and so forth. Paul Casey: Sugar them up and let them go. Mike Miller: That's right. But if I were to do it again, I would say not as many boards and committees. That would be one thing. And you need to focus on the growth of your company. It's important that you do serve on some boards and committees, just so that you can do the networking and the service that you want to do. But at the same time, the number one deal here that anybody should be, if you're religious or not, is God, and then family, and then work down three or four. The issue then becomes one of, "Did I do that? No." There has been pain where, if I had done it differently, I wouldn't have that pain. You just have to make sure that, when you're at home then, you're not working at home. Which I tended to do anyway, because it's a full-time job. It's not an 8:00 to 5:00. Paul Casey: Never off the clock, yeah. Mike Miller: Yeah, so you have to be able to make sure that you're committing whatever time. Even if it's a half hour and you have a date with your wife, better not be working, unless you're asking her for advice on something. But you'd better not be working, you need to make sure that you're committing that time to the family that you need to. Paul Casey: Yes. You said the CEO, or the leader of a business, or a leader of a team, focuses on the growth of your company, focuses on the growth of your team. And we can just add on there, focuses on the growth of your family relationships. And I would add on there the focus on the growth of yourself. So leaders are leaders, they're not know-it-alls. You've shared that you go to some groups for wise advice. Who are some others that you've gone to through the years, and maybe still do, for wise advice? It could be literally live people, or live virtual people now, or maybe there's some authors, or motivators or industry professionals, that you tend to draw good ideas from. Mike Miller: Well because of the Alarm Association stuff, I usually get in two, sometimes three different conventions that you're able to go, so you get to hear speakers ... I've got one coming up, it's going to be a virtual one, that's all about, it's from Ritz Carlton, and they are known for their customer service. Paul Casey: Yes, they are. Mike Miller: So it's perfect timing for being able to have something like that. But back again to alarm industry, I have some people that I just called yesterday, probably one of them to see what the heck I was doing and keeping up. So I was able to call him back today and say "Here's what's happening," and all of that, and love you, brother, and on to the next. You have those people that reach out. Same way in Rotary, we have different people that we can talk to and enjoy, and they provide their, if you ask, you'll get them. Mike Miller: By the way, that reminded me of something too, that I think I talked about, was, are you able to learn? I have a couple of guys that, had kind of a rocky relationship when we first met, they're golfers with me, and invariably they were better golfers than me, so I would have to admit that too. But I would have some crappy shots that I did, and I would be upset with myself, and they'd come up to me and ask, "Mike, do you want to get better?" "Yeah, I want to get better." Then the second question was, "Can I give you some advice?" That was an opportunity for them to then, with those two questions, then give me advice. Then they watched to see if I would use the advice. Mike Miller: Then I realized later, I'm a slow learner and it took me a while later to realize that, if I had not tried to use their advice, then they would've said "Well up yours then," and not tried to provide me any more advice. But they saw that. I find that more and more, I've started to use that somewhat too, for asking permission. "Do you want to get better," and, "Can I give you some advice". Paul Casey: That's a real respectful way to go into giving feedback. Mike Miller: Yeah. It's real smooth, and not as offensive and all that. So I get stuff like that from my golfers, from my rotary, from my Alarm Association, from chamber, from our leadership classes that we had along the way. So you can learn something from somebody if you ask the questions to get what you need to have. Again, back to the pride thing, just ask. People are always willing to share. There's not too many secrets really out there involved. Paul Casey: Do you find it's harder, in this virtual world that we're in right now, that people aren't asking as much, because it's yet another Zoom call, or another one-to-one, or have you not seen a dip in the sharing of information? Mike Miller: You know what, I'm on the Tridec board, and we have Carl Dye, he's the new Executive Director, CEO, of Tridec. He's been doing these one-on-ones, coffee with Carl, on Fridays. It's fantastic. I've told him that he's doing a fantastic job for one thing, but the second thing is, it's allowing him to be able to share what other people are doing, so that then they can become a part of that, and it's basic education for all of us that are on the Zoom to watch it. Paul Casey: Nice. Mike Miller: For me, I think Zoom actually has been, in some ways, more efficient. We still miss the social distancing, we still miss getting to see each other and hug and handshake and all of that kind of thing, but in other ways it's allowed us to learn a lot more. So I tend not to look at it as a negative, other than the socializing aspect of it. But we're getting to learn a lot more. Paul Casey: The resources are plentiful. Mike Miller: Yeah. Paul Casey: And if you want to reach out one-to-one, you do have to be initiator and say, "I'm going to build my network," or "I'm going to reach out to my fellow influencers to try to get the best information that I need." Mike Miller: Yep. Paul Casey: Finally Mike, what advice would you give the new leaders, or anyone who wants to keep growing and gaining more influence? Mike Miller: Like I said earlier, don't let pride get in the way. And I really would say, make sure you're having fun. Whatever you're doing, have fun. Make money. It is okay to make money. Make sure you're paying yourself first, make sure that you're paying your taxes and all that so that you can make sure you take care of my social security down the road. Just be willing to listen, ask questions, read, network. Those are all things that come off, those are easy things to say, but do not let pride get in the way of asking what those questions are. You need to be prepared for tough answers, tough questions, that put you on the spot. Then, you don't have to say "I know right now." Let me think about that and I'll get back with you. Paul Casey: That's right, I'll get back to you. Well thanks, Mike, for all that you do to make the Tri-Cities a great place, and keep leading well. Mike Miller: Thank you. Paul Casey: Let me wrap up our podcast today with a leadership resource to recommend. If you're looking for one-on-one questions to do with your direct reports, I always feel like that's a great leadership activity to do each and every week, whether that's with one person or with your entire team, but there are some great questions, one-on-one questions, that great managers ask. And if you go to the website GetLighthouse.com/blog, you're going to find a whole slew of great questions to ask in your one-on-ones to keep them fresh, and to really probe for answers that are going to help your employees develop. Paul Casey: Again, this is Paul Casey. I want to thank my guest Mike Miller from Moon Security for being here today on the Tri-Cities Influencer Podcast. I want to thank our Tricity Influencer sponsor and invite you to support them, and we appreciate them making this possible so we can collaborate to help inspire leaders in our community. Paul Casey: Finally, one more leadership tidbit for the road to help you make a difference in your circle of influence. Oprah Winfrey said "Passion is energy." Feel the power that comes from focusing on what excites you. Until next time, KGF, keep growing forward.   Thank you to our listeners for tuning in to today's show. Paul Casey is on a mission to add value to leaders by providing practical tools and strategies that reduce stress in their lives and on their teams, so that they can enjoy life and leadership and experience their key desired results. If you'd like more help from Paul in your leadership development, connect with him at GrowingForward@PaulCasey.org, for a consultation that can help you move past your current challenges and create a strategy for growing your life or your team forward. Paul would also like to help you restore your sanity to your crazy schedule and getting your priorities done every day, but offering you his free Control My Calender Checklist. Go to www.TakeBackMyCalendar.com for that productivity tool, or open a text message to 72000 and type the word "Growing." Paul Casey: The Tri-Cities Influencer Podcast was recorded at Fuse SPC, by Bill Wagner of Safe Strategies.  

With no new movies what do we do? Well Mike and Katie continue their 2020 RADnesia episodes! This week they dive into Christopher Nolan's BATMAN BEGINS How did this 15 year old film hold up? How was it showing it to their son? And this week it's safe for work! Grab your Cup and let's fill it with some RAD!!! ~  Enjoy the positive pop pop culture vibes ~

Ever heed to hire a hitman? Well Mike has got a site for you...

Ever heed to hire a hitman? Well Mike has got a site for you...

When we were doing research for this episode, these 2 beer selections sort of went together. Well Mike and Medlock decided that since they were having, 21st Amendment Hell or High Watermelon and Wild Heaven Emergency Drinking Beer, why not have a "Last Meal"... Check out how we review these brews! Don't forget to Subscribe and leave us a 5 star review! Facebook: facebook.com/beerandshenanigans Twitter: @ShenanigansBeer Home Page: tinyurl.com/beerandshenanigans email: beerandshenaniganspodcast@gmail.com Online Store: teepublic.com/user/beerandshenanigans YouTube Channel: tinyurl.com/beerandshenanigansvideo --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app --- Send in a voice message: https://anchor.fm/beerandshenanigans/message

Ever wonder what happens when you want to sell your house, and it happens to also be home to a bunch of ghosts? Well Mike's lesson this weeks is about the house that set a precedent for the sale of all haunted houses to follow. That's right, a house can be declared legally haunted. To find out how, just hit play!

Well Mike convinced Paul to comeback and watch a movie about college boobs and a demon, but mostly about college boobs. This episode is probably exactly what you think this […]

Never released! This episode was recorded right after the infamous "Be Where Your Feet Are" speech. We never released this because we figured people might be butt hurt if they weren't mentioned. Well Mike was sick so we went into the vault to see what we were holding onto. Ultimately this is a great episode we scrapped. Just know that this is not a complete list of Mike's favorite clients! If you want to send us hate mail after this, direct it to roughruggedandrawpodcast@gmail.com Brought to you by Vince's Muscle Shop in Columbus, Ohio! The best customer service and prices on supplements anywhere!

Mike the Giver. They say when your down and out, to go and makes someones day, or better yet make them smile and it will brighten your day. Well Mike has devoted his life to giving back to those whom are homeless just like him. He found that in his troubles life isn't so bad, when your giving to others. Interviewed July 27, 2019.

Well Mike and Grizz are back in studio for another show of random silliness. They talk about Grizz... CATERING?! Along with a bunch of strain reviews based on the time of day you use it. Tell a friend and subscribe to keep us alive. Visit our site Visit The Pod Plant

Guys. Synchronicity seams to be the big thing nowa days. Some people see synchronicities as funny little things that just happen. Some folks take them as messages from beyond! Some think they are such strong indicators of proof of the paranormal, they make entire documentaries on them!    Well Mike wanted more than similarities and coincidences. So he went into hardcore mode. Quit the pills, switched from whiskey to beer and started making some pretty interesting connections to a lot of things that are going on in the world of the paranormal.    Sit back and listen to Mike shares what dots he connected, how weird it gets and then join us in special celebration for a friend of ours who's been given some pretty awesome news.    As a side note, Mike worked his smelly, tiny, unwashed pecker off on this show for weeks and in a bit of even more synchronicity, a rather big, much better podcast just released an episode covering the same thing, even hitting on some of the same points that Mike brings up. All similarities were purely coincidental. So send him some love. Give him a pat on the back. Let him know soap will help. It's not the size of the boat, but the motion of the ocean. Maybe go on twitter and send this: https://www.youtube.com/watch?v=pTQh3HRJSAc  to @lastbonestands?   CONGRATULATIONS MIKE! WE TOLD YOU WE WOULD CELEBRATE WITH YOU!

LIVE from the Combined Sections Meeting in Washington DC, I welcome Dr. Mike Pascoe on the show to discuss the use of social media to disseminate physical therapy educational resources.  Mike Pascoe, PhD, is a neurophysiologist and assistant professor in the physical therapy program at University of Colorado.  His scholarly efforts center around the investigation of constructivist approaches in technology-enabled learning environments (e.g., wiki usage, interactive modules, cadaver skin examination, etc..) to improve learning outcomes and student satisfaction in anatomy courses. In this episode, we discuss: -Research highlights in the field of cadaver anatomy -How Mike utilizes social media and live blogging during his anatomy courses -How the Anatomical Board serves anatomy educational goals in Colorado -Cognitive principles of learning for success in PT school -And so much more!   Resources: #APTACSM Twitter Mike Pascoe Twitter Mike Pascoe Website  Mike Pascoe Snapchat TedxBoulder - Mike Pascoe - The Ultimate Gift - Donating your Body to Science Learning Scientists Website My wife Stephanie’s website - https://spascoedpt.com/training/ University webprofile - https://som.ucdenver.edu/Profiles/Faculty/Profile/15328 Research Gate profile - https://www.researchgate.net/profile/Michael_Pascoe2 Academic website - http://mikepascoe.strikingly.com Light field photography - article Student created wiki - article Live blogging - article State Anatomical Board, body donation - TEDx Talk Writings on medium.com - https://medium.com/@mpascoe AnatomySnap information - https://www.snapdex.com/anatomysnap YouTube channel - https://www.youtube.com/user/redbnr22/videos Vimeo channel - https://vimeo.com/pascoe Add me on SnapChat - https://www.snapchat.com/add/anatomysnap Publons peer review profile - https://publons.com/researcher/1374925/michael-a-pascoe/     For more information on Mike: Mike received his PhD in neurophysiology from the University of Colorado (Boulder) in Dec 2010. He then joined the faculty of the Physical Therapy Program in the School of Medicine at the University of Colorado, Anschutz Medical Campus. He teaches clinical anatomy and in his spare time loves hanging out with his wife Stephanie and their dog Maia.             Read the full transcript below: Karen Litzy:                   00:01                Hey everybody, this is your host, Karen Litzy and we are coming to you live from the combined sections meeting in Washington DC. And I have the pleasure of once again seeing assistant professor Mike Pascoe. I saw him late last year in Denver. So Mike, Welcome to the podcast. Thank you for coming on. Mike Pascoe:                00:18                It's my pleasure. Thanks for having me. Karen Litzy:                   00:20                All right, so we read your bio, but what I would love to hear from you is a little bit more about yourself so the listeners kind of know where you're coming from and what we have in store for our talk today. Mike Pascoe:                00:32                Yeah, let me give you some things about myself that I really just drive who I am and what I do. So I am a Colorado native, so there's just a lot of fun things to do in Colorado and I've managed to stay in a really awesome place. And so there's a lot of fun to have there and a lot of that fun I have with my family. So I'm married to Stephanie Pascoe, she's a PT, so she's the clinical half of the marriage. And so we liked doing a lot of things together and we like keeping our two daughters busy as well. So very family driven and we've got a lot of fun with a five year old and a three year old girls. So I like to bill myself as a minority in a sorority. That's what things look like around my house. Lots of pink and yeah, so I basically am here at CSM with Stephanie and we both get to go do our own things and check out the various different talks, different posters, different presentations. And I've been able to come to CSM since I started at CU in 2011 so yeah, it's been a great conference. Great to catch up with old friends and make some new ones. Karen Litzy:                   01:36                And so today we're only on day one of the conference, but have you gone to any lectures or any poster presentations that really stand out in your mind? Mike Pascoe:                01:45                Yeah, I really wanted to see what Chad Cook and others had to say about predatory publishing. So that was very informative. I'm aware of the concept and fortunately have not fallen prey myself, but it was good to just see the numbers and how big of a problem in this, you could, you could call it an epidemic. So Karen Litzy:                   02:03                Yeah, package that really well. Predatory journals, predatory conferences, things like that. I mean it's a thing and people fall for it. Mike Pascoe:                02:11                Yeah, they said that the analogy is everyone's got a rich relative in Africa that just died and wants to offer you $1 billion. So it's a new spin on that old email tactic. Karen Litzy:                   02:23                Exactly, exactly. And it's unfortunate. It's unfortunate, but hopefully they're chorus kind of gave you a little bit of insight on what to watch out. Mike Pascoe:                02:33                Yeah. If you go onto Twitter, which if you're not on Twitter, then I don't know what's going on. It's the best way to find out what's going on, at the conference. Great #APTACSM. And that's where a lot of us are sharing the real pearls from the session. So there's a lot to catch up on there. But then following that was a real exciting meeting of special interest group with the Academy of physical therapy education. Then that's the anatomy educators special interest group. So that grew last year was the first year there were maybe 50 of us and now there's 133 so we're really growing a nice base and we're really starting to cut our teeth on what we wanted to find and how we want to really enhance PT education specifically in the anatomy domain. Karen Litzy:                   03:16                Great. So now let's talk about that. So let's talk about your teaching background and what you’re doing over there at the University of Colorado medical campus. Mike Pascoe:                03:27                Yeah, so about 80% of my time on campus in my role is as a teacher. So I'm really striving for excellence there. And basically I started in 2011 they hired me with very little teaching experience at the professional level, but I really had a passion for teaching undergraduate students when I was a graduate ta. So that's where I first fell in love with teaching anatomy. And then I got on board with CUPT and I teach PT anatomy. That's my main role. About 50% of my job is designing and delivering the content for the PT students. But I've also been able to extend into the physician assistant and a medical student anatomy courses. So that keeps me pretty busy. It's a lot of gross anatomy. It's a lecture in the morning and then going into the lab in the afternoon and looking at the cadaver donors. Karen Litzy:                   04:17                I remember those days. Mike Pascoe:                04:20                I'm telling Ya, it's the most memorable and favorite course of all PT students Karen Litzy:                   04:26                It actually was my favorite course and I firmly believe every human being should take gross anatomy because you should know what's going on in your body. Mike Pascoe:                04:35                You should know how the equipment operates. And there's some real good research out there and you know, a lot of people can identify where the heart is, but you ask them where the liver is and that's where we need a little bit of improvement. Karen Litzy:                   04:46                Absolutely. So now outside of teaching, what other things are you working on? Any kind of research? Mike Pascoe:                04:53                Absolutely. And you know what I've learned from all the excellent mentoring I've had in my role is that you should really cover your basis. It should really be optimized in what you're doing with your research as an educator. So what you do is you do education scholarships. So I walked away from bench research and neurophysiology and now my laboratory is the classroom. So I do educational research. It's every bit as rigorous as looking through a microscope and you know, modifying genes in a lab. But basically the students are my subjects and I will take an idea that I think is going to be a way to improve my anatomy, teaching, design a protocol, get my IRB approval, collect the data, get some graduate students under my mentorship to help run through the project. Sometimes we find a positive result and sometimes we don't, but we send those results out anyway and I've been able to get some projects out the door. Mike Pascoe:                05:46                Just a couple of highlights. There's a type of photography called light field photography, so that's been really interesting to see how you could change the focal point of a cadaver photo after the photo's been taken. Lot of anatomy clustered together, so it's often hard to get everything in focus so that gets around that. But also publishing on students using a Wiki to organize their study materials and why blogging. Actually I got to do a lot of live blogging, have a PT conference and we surveyed the people using a viewing the coverage and they really had positive rankings and satisfaction with the coverage. So I'm really promoting that and hoping that more PT conference organizers jump on top of that. It's a compliment to Twitter. Karen Litzy:                   06:31                So how were you live blogging and how is that different? I was going to ask is that, what kind of platform is that? Mike Pascoe:                06:37                Yeah, we use a platform called cover it live. They're still out there. No conflict of interest, no disclosure, no relation, but basically what you do with live blogging as you can really issue more of a transcript of what's going on there. No character limits. Like Twitter, Twitter is usually more about the bite size pieces, but a live blogging is much more of a script and you can really capture a lot. You can integrate photos. And what's been really fun is to capture the question and answer session part of the session. People really rated that as a really good feature of live blogging. Karen Litzy:                   07:11                So you pretty much have to know how to type well to do that. Mike Pascoe:                07:14                Right. Karen Litzy:                   07:16                Because for someone like me who has to look at the keys at the same time, cause I never learned how to type. Yeah, that would be my problem. Mike Pascoe:                07:23                Hunting and pecking is hard, but the bigger skill is contextualization and knowing your audience. And it was real good for me to learn about how to interpret what a physical therapist was saying about a whiplash and the anatomy of neck muscles and how that can be put together so that way a PT audience would benefit the most. So yeah, that's a big skill as well. Karen Litzy:                   07:47                That's awesome. I've never heard of that. I mean I don't think I can do it because like I said, I can't really type, but I love the fact that it's long form. And so if I wanted to, if, if I wanted to watch you do this, how do you, how do you do that Mike as not for you as a person blogging but as the consumer. Mike Pascoe:                08:09                So we have to get a marketing campaign out there. And what we ended up doing was just promoting the link to the webpage through social media. So fortunately people are very aware of that conference has come with their own hashtags and people are having conversations around the conference leading up to the conference. So we took advantage of that. Now we would just publish in advance, these are the sessions Mike is going to be covering. So come back this day at this time for the live coverage. The real beauty of this platform too, as you can play them back, well you don't play them back, you, you scroll through a timeline and you get to look at the content that way. So it was really rewarding to know that you're helping people real time, but for the busy clinician that can't step of treating patients at 2:00 PM that could come in and look at it later. That's really good. Karen Litzy:                   08:59                Sounds great. So aside from being a little more innovative in your teaching and in academia, in education, which obviously, is a must these days. What else are you doing as your role at CU or your role as an educator? Mike Pascoe:                09:19                So another real cool role that I took over about a year ago was, it's an administrative role, but it's for the state, Anatomical Board of Colorado. I serve as the secretary treasurer. And so I oversee the day to day operations at the anatomical board. And basically this is still educational because what we do with the anatomical board, our big mission is to serve the educational goals of anatomy education in the state of Colorado. So think of every health care profession program, PT, OT, MD, dental graduate programs. Whenever a program would like to use a donor for an educational resource, they approach us, they make a request, we take a look at how many donors we have available. And we're very fortunate in Colorado that we have a very large donor pool, a large donor base, and I help assign the donors. And so indirectly I'm able to impact thousands of students a year with anatomy education simply by facilitating the use of cadaver dissection. Karen Litzy:                   10:21                That's awesome. Very cool. I often wondered how that worked now, well at least now I know how it works in Colorado. So you had mentioned earlier the use of social media. So if people are listening to this and they're not familiar with you, I obviously suggest following you on social media, but how has your use of social media impacted the way that you teach and the way that you sort of view education in physical therapy? Mike Pascoe:                10:51                Yeah, so I incorporate social media into my teaching directly and indirectly. So directly I have recognized that there's a real power behind this, this cognitive psychological principle called retrieval practice. So any way you can get your students to practice retrieving information without the learning materials in front of them, they're going to benefit. Studies have shown that for decades. So how am I going to, aside from doing like the polling audience response system, how can I really get their attention? And I found what's really successful is to use social media and people are doing Twitter, people are doing Instagram, but students really pay the most attention to content on snapchat. And if you're not familiar with snapchat, the thing that makes it different, what sets it apart is that the content disappears after 24 hours. So when you're doing retrieval practice, you don't need it necessarily for the student to preserve the questions and answers. Mike Pascoe:                11:49                They just need practice interacting with the content that goes away. And they know this. So there's something about the way the brain is wired and the brain pays more attention to ephemeral content so they know it's going to go away. And so I, I push out questions during the semester and they get the question, they get the answer later. So it's great for the students, but it's great for me, the educator I found with Twitter and Instagram, it really took so much time, to perfectly create the right content. But everybody on snapchat understands that it's raw, it's unedited and it's uncurated. So as long as I put the correct information out there, it's quality enough. So it's very quick. It's very rapid. And every time the students find out that I run in anatomy related snapchat account, they can't believe it. At first they’re in disbelief like what's going on. Mike Pascoe:                12:38                But once I convinced them that this is educationally based on sound pedagogy, they're onboard. And then I'll have a break from it and they'll bug me. We need more snaps. Pascoe put some more content out there. So if you want to check out what I'm talking about, the handle, the username on snapchat is anatomy snap. I'm all one continuous word and I'm telling you, it's been really exciting. I collected data this summer. I'm looking at the data now and hoping to see, number one, if students found it satisfactory, but number two, how did their exam scores look? They could have been the same. They could have been worse, it could have been better. The exciting thing is I've learned how to put a protocol together that will allow me to level up beyond satisfaction. And did your learning change has your knowledge base change? So stay tuned for that publication. Karen Litzy:                   13:28                Awesome. And now can you give an example of some of your snaps? So yeah, give me a couple of examples so that people kind of get an idea of what you mean. Like what do you mean you're putting stuff out for anatomy? Like just taking a picture of like a muscle or dissected bodies. So give me an example, but before you do well give me an example for us then I have another question. Mike Pascoe:                13:53                Yeah, no, it's good to leverage it. Leverage the principles, you can get retrieval practice and you can also get leverage examples and just to like real life examples. So you're at a table, you're just going through the upper extremity anatomy and you're between lectures or whatever you're doing as an educator. Put your hand on the table and elevate your thumb and get the extensor pollicis longus tendon to pop up. Take a picture, add text. What tendon end do you see here? Drawn Arrow. Then you can take it further. Just keep building, keep elaborating. What's the line of inquiry that the student would go through? How would you go through this at the cadaver? What anatomical region does this tendon define? Anatomical snuffbox? The next snap question is now what structures as a physical therapist are you most interested in finding in the stock box? So then you could go through that. You can step through a very sequential Socratic series of snaps, and then you can say, okay, everybody send me a snap of your snuffbox if you so choose. They'll usually do this without solicitation. But that's an example. Karen Litzy:                   14:59                So I think that's great and it actually leads perfectly into my next question is, are you creating a curriculum for your snaps or is it just off the cuff? Mike Pascoe:                15:10                You know, I'm very mindful and aware that doing things intentionally is the best way to go. So what I did for the summer is I did focus my snaps on a specific aspect of anatomy in the course and that was blood flow diagrams. So I do look at my learning objectives and those informed my teaching methods. So these snaps, although they seem frivolous and accessory, what they really do is there a direct extension of being able to describe the path that blood takes from the left ventricle to a distant site in the body. So it is very informed. It's very intentional, it's in the curriculum, but you have to be mindful that not all students are going to go there. It has to remain optional. I do not think it's appropriate to push your students into social media. There's a lot of valid reasons students don't want to go there, but for the ones that are there, I've found it's 90 to 95% of the students. And you know what? It's a great way to role model and show them how to be professor professional and how to use social media in an appropriate way. That's beyond tearing down somebody's beliefs and ideals. Karen Litzy:                   16:16                Well said. So there is a method to your madness is what you're saying. There is not, it's not random like, oh, I stub my toe today, I know I'm going to do something on the foot. Mike Pascoe:                16:28                Yeah, exactly. It's intentional and yeah, it's been out for so long that it's just time that everybody had a good understanding of how to use it appropriately and then how we can really think about incorporating it into education. Karen Litzy:                   16:40                I think that's a great way to incorporate into education and hopefully people listening to this will now follow anatomySnap. No S. I follow you on snapchat and I can say that it's really interesting. It's really interesting even as a, a more quote unquote seasoned PT because I feel like you can never have too much anatomy. That's so great. Now, anything else that you're doing that's kind of outside of the box with your students or even without your students as far as furthering your education? Mike Pascoe:                17:16                I think that another thing to bring up here is how there's a real need for physical therapists that are anatomy instructors to understand what is needed to know and what is nice to know. So that's my second area of work. The first area is the technology integration, but I've really developed some nice ways to look at what do anatomist that teach physical therapy students need to teach their students. So I'm just looking at the data now, but I recently put out a survey to about 200 people in the, that our stakeholders for the physical therapy programs, talking faculty, clinical instructors, recent graduates, the two most recent classes. Do you and your opinion think that in your practice you need to name all 10 bronco pulmonary segments of the lung? That was an example of an objective for which most people rated. No. Mike Pascoe:                18:11                Like that is not essential. So I take that feedback and I improve my curriculum. On the other hand, should a PT student be able to know name every spinal segment that is serving a muscle, the myotomal innovation and most people, the majority came back saying, yes, that's neat to know. So it's been really nice not being a PT to survey a wide base of people. The next step is going to be to survey the community at large to kind of level up the methodology, get a consensus document together and then present that to the educators in the PT Community. Karen Litzy:                   18:49                Great. Well it sounds to me like you're up to some really fun stuff and I look forward to touching base again when you have a lot of this data together and you're ready to present. So is there anything that we didn't touch on? Mike Pascoe:                19:03                Well, Gosh, let's see here. Anything else? I guess if you're really interested in body donation, it's often, it's often confused with my driver's license has a heart. Mike Pascoe:                19:17                But that's organ donation and that's totally separate. You do need to opt into whole body donation. And I go through this concept in a six minute ted talk and basically if you, if you just search youtube for Pascoe Ted x, you'll find a nice little talk I was able to put together for Tedx Boulder in Colorado and just kind of let people know what body donation is all about. And the title of the talk is the ultimate gift because we have extreme gratitude to the individuals that make this choice to, to give us the ultimate gift, the body that has served them all of their life. And now we'll go on to serve health care professionals as they work toward being able to take care of, to treat those patients. Karen Litzy:                   20:04                I love it. So everyone, don't worry, we will have links to everything on the show notes under this episode. So before we wrap things up, I have one more question. Given where you are now in your life and in your career, what advice would you give to yourself as a new Grad or to your students? Like when you were a student, what advice would you give to yourself? Mike Pascoe:                20:40                So there's two I want to give you. One is more like the life side of things and learning to say no, I had definitely gotten myself in trouble. Okay. So I'm super passionate about teaching and every time I was approached with a teaching opportunity I rationalized how I could make it work and I trick myself and I got way overloaded with teaching. So I would go back to, you know, 27 year old Mike. Like you're going to have a lot of opportunities, but there's a, there's a tactful way to say no. And even though that time may not be the right time, things do cycle back around, you'll get another pass at it if it was meant to be. And then the other more practical. For those of you that are PT students, those of you that are looking at getting into PT school, you have to look at your study techniques. Mike Pascoe:                21:27                So I've totally revolutionized the way I do office hours. When students come in and they've had a bad performance on an anatomy exam and they say, I don't understand, I studied so much, I blow a whistle and I throw a yellow flag on the ground and I say, hold up. The penalty on the field is quantity does not equal good learning. So you have to look at these psychological, cognitive principles of learning and what got you through in Undergrad will not get you through in PT school. The volume is too much. So in the show notes, I'll give you a link to a really excellent website that summarizes these key principles of learning and you've got to look at your study habits. Then you've got to be prepared to change them. Otherwise you're in for a really painful and arduous path through your physical therapy curriculum, in other programs that you might be pursuing. Karen Litzy:                   22:20                Amazing advice. Thank you so much. What's the name of the website? Mike Pascoe:                22:24                So the name of the website is a learning scientist. And I believe if you just Google learning scientists, you're gonna find a website that has principles of effective learning. Karen Litzy:                   22:36                Thank you so much for sharing that. And I'm sure the students and myself will greatly benefit from that. So thank you. And now where can people find you on Twitter? We know where they can find you on snapchat. How about Twitter? Mike Pascoe:                22:49                Yeah, go ahead and look for me @mpascoe. You know what, if you're looking at the Hashtag for the conference, I'm tweeting up a storm here, so that will be a good place to catch some of my contributions and go from there. Karen Litzy:                   23:05                Awesome. Well Mike, thank you so much for taking the time out at CSM where we, everybody's busy. I get it. We're all busy. So I really appreciate you for taking the time out coming on the podcast and sharing all this great info. So thank you so much. Mike Pascoe:                23:19                Yeah, my privilege and thanks to you, Karen, for getting everyone together and being a vessel for getting this information out. Karen Litzy:                   23:25                Thank you very much. And to all the listeners, have a great couple of days and stay healthy, wealthy, and smart.     Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on iTunes!  

The ends of the world!  When the guests get the flu what do you do?  Well Mike and I take on the news you can use!  The Turpin Family, What happens when you think the world is ending, and jsut where will Google put their new headquarters!  Karl and Mike take on the world...and WIN! TODAYS SPONSORS RADSOCKS.CA .  Mike and I checked the mail today and found new socks from RADSOCK.CA.  These things rock as usual and this month you get socks with DONUTS.  Don’t be a fuddy duddy and instead sport the coolest feet in the office!  RADSOCKS.CA will hook you up and you get a 20% discount just for listening to us!! Go to http://www.radsocks.ca/podcast and SAVE!! Share the link and get your feet into what they deserve! And hey, we are sponsoring our self.  If you have enjoyed any of our musings at all then please support the show!  Do so by checking out our Patreon Page below Patreon, support the show with dough! And if you want to look great then get our Musing While Boozing wear!  T-Shirts, Hoodies and everything else you might need can be found RIGHT HERE. CHECK OUT OUR SHOP! Love ya! Mike and Karl!

Mike, Tom, Tad, and SS Jeff in studio.   Well Mike has gone and done it.  He talked about it with Sloppy Matt, but he did it.  Mike is the proud owner of a 2011 Chevy Tahoe, and we have no doubt that HP tuners will put Mike in an an institution.  The oddest part of all of this Mike actually witnessed a crime! We love repeat guests, and tonights guest could not come at a better time.  Greg Banish of Calibrated Success is one of the best resources for the process of calibration while taking into account the OEM perspective.  Greg has worked directly for quite a few top tier manufactures as a calibrater and has direct insights into why they do what they do.  Greg has produced quite a few educational books and DVDs and we highly suggest you check them out.   Live again next week Monday night at 7:00 PM EST on Mixlr.com.  Call in number 908 751 0211.  Live callers welcome, and this will be the line for giveaways. Like us on Facebook by going to Power and Speed Podcast and follow us on Twitter @powerspeedpod.  Listen to past archives on your favorite Podcast App, Tunein, YouTube, and SoundCloud on the web and your Sonos system.

Well Mike fell off the airwaves but he's back to help Ben and John discuss games that never made it to North America; for good reason in most cases. John scares a Reddit HORROR story about cunnilungus gone awry. John and Mike discover a shared disablility Batman ain't a gentleman and more!  

Ever have a band you listen to and don't know why? Well Mike and Steve open up and talk about some the bands they listen to despite popular opinion.

Well Mike sits down with Soundguy this week and we just enjoy a nice casual converasation. Which leads to him berating everyone of course. 

Micheal & Andrew look at Fantastic Four #1 and The Avengers #1 but from the Heroes Return Relaunch rather than their 60's debut. What do they think fo these? Well Mike doesn't like George Perez's artwork, which makes Andrew wonder were he went wrong as a parent. For other SHOCKERS! listen to this exciting episode all FOR FREE!Feedback for this show can be sent to: heykidscomics@virginmedia.comHey Kids, Comics! is a proud member of the Comics Podcast Network (http://www.comicspodcasts.com/) and the League of Comic Book Podcasts (http://www.comicbooknoise.com/league/) but also the TWO TRUE FREAKS Internet Radio network!! You can now "Friend" either Micheal or Andrew on Facebook or on Twitter. THANK YOU for listening to Hey Kids, Comics!!! A part of the TWO TRUE FREAKS Internet Radio Network!

Micheal & Andrew look at Fantastic Four #1 and The Avengers #1 but from the Heroes Return Relaunch rather than their 60's debut. What do they think fo these? Well Mike doesn't like George Perez's artwork, which makes Andrew wonder were he went wrong as a parent. For other SHOCKERS! listen to this exciting episode all FOR FREE!Feedback for this show can be sent to: heykidscomics@virginmedia.comHey Kids, Comics! is a proud member of the Comics Podcast Network (http://www.comicspodcasts.com/) and the League of Comic Book Podcasts (http://www.comicbooknoise.com/league/) but also the TWO TRUE FREAKS Internet Radio network!! You can now "Friend" either Micheal or Andrew on Facebook or on Twitter. THANK YOU for listening to Hey Kids, Comics!!! A part of the TWO TRUE FREAKS Internet Radio Network!