Healthcare system overview

WEBVTT
Kind: captions
Language: en

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SALMAN KHAN: I'm here
with Professor Laurence

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Baker at Stanford
Medical School.

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And what we're going
to talk about now

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is the overview of the
health care system.

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LAURENCE BAKER: What is
the health care system?

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SALMAN KHAN: Yeah,
and who's in it?

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LAURENCE BAKER: And who's in it?

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And what are they doing?

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SALMAN KHAN: I think I
could give a go at it.

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LAURENCE BAKER: Go for it.

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SALMAN KHAN: And
then correct me.

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Expose my ignorance.

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So clearly, you
have your providers.

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Those would be your doctors,
and nurses, and all the rest.

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LAURENCE BAKER:
Hospitals, pharmacies,

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all kinds of people
are your providers.

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SALMAN KHAN: OK, so everyone
who's providing health care.

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So that's right over there.

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So that's hospitals, doctors,
pharmacies, all the rest.

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And then they are providing
the health care to someone.

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So those would be the patients.

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Let me do that in another color.

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LAURENCE BAKER:
Call them patients.

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Yeah, sometimes
you get the details

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like people become patients
after they need health care.

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But some people just
have a question.

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They're not really patients,
they're just asking.

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SALMAN KHAN: OK.

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What would you call them then?

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LAURENCE BAKER: Call
them population.

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SALMAN KHAN: Population.

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So just the population of
the world, or of the country,

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or whatever-- people.

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And then someone
has to pay for this.

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And so for the most
part, this is insurers.

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LAURENCE BAKER: Yup.

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Insurance companies.

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In the olden days--
like if you go back

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100 years-- we didn't
really have insurers.

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We had patients and providers.

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And patients would-- if they had
a question, they had a concern,

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they go to the provider.

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They'd make some deal,
pay them some money,

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do some service for
them and work it out.

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We got insurance
companies really

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only in the last
100 years, maybe.

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Really starting in
the US in maybe 1930.

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1940, they started
to become popular.

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So that's kind of
a new renovation.

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And those three
things work together.

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SALMAN KHAN: And the
general term-- and this

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is a word I've seen a
lot, and sometimes it's

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a little confusing because
it's very close to payer,

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you hear of these payors.

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And that would be
including anyone

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who's paying for the
paying for the service.

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And insurance companies
would be included there.

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LAURENCE BAKER: Right.

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So we have-- we
call them payors.

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Sometimes we call
them health plans

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because they arrange for some
of the care that people get.

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And payors could be private
insurance companies,

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or they could be government
payors-- government insurance

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companies like Medicare.

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SALMAN KHAN: And the insurance
companies themselves,

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they're not doing this out of
the goodness of their heart.

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Someone is paying them.

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And for the most part
in the United States,

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it tends to be employers.

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LAURENCE BAKER: So right.

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So if we made another
arrow on your diagram here,

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it would be from
the population--

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or maybe from the patients--
to the insurance companies that

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provides the money for
the insurance companies

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to use to pay for the provider.

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So patients might buy
an insurance company--

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or not an insurance company,
buy an insurance policy.

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SALMAN KHAN: Only if
they're very well healed.

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LAURENCE BAKER: Some of
them buy the whole thing.

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But they just might
buy their own policy.

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Go buy an insurance policy,
pay them a premium directly,

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the insurance company
collects that money.

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Or, for most people, they
work for an employer.

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The employer makes
the arrangement

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to buy that insurance and
then implicitly charges

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the population, the
patients for that.

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Maybe directly by
having them contribute

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some of their salary.

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Maybe implicitly by just
reducing the amount of cash

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they give them every
month, and instead

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giving them this
insurance policy.

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So people do that.

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And the other piece that's
floating around in here

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is that in some cases,
the population pays taxes

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to the government that
then functions essentially

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as an insurer, like the
Medicare program, where there's

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insurance provided to people
that's paid for by taxes.

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So there's some different
funds flows going around here,

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but always money
going from patients

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to insurers, through employers
from taxes, by direct payments.

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Those insurers
collecting the money

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and then paying for a
bunch of the care that's

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provided by the providers.

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And that's the
basic arrangement.

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There's one more
tiny piece, which

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is that sometimes patients pay
the doctors or the hospitals

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directly.

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You go you have
a $20 co-payment.

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And so there's a small payment
that goes back and forth.

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SALMAN KHAN: Your
copay is kind of there

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just so that-- it kind of makes
the insurance company feel

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good that you're not just
using it willy-nilly--

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that you have to
pay your $10 or $50.

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LAURENCE BAKER: Absolutely.

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So insurers know
that once they start

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paying the providers
for the care,

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and the patient says
it's totally free,

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people might use
stuff that might

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be worth a little tiny bit, but
it costs a lot for everybody

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to pay for.

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So if you put a
co-payment on there,

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it makes people think
twice about using things

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that they don't really need.

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SALMAN KHAN: Right.

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That makes complete sense.

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And then within this ecosystem--
we hear a lot about HMOs.

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My perception is that's a
combination of the insurance

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company and the provider.

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It's kind of in one package.

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LAURENCE BAKER: Right.

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So over time, the US has had
different kinds of insurers

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out there.

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In the private market,
especially, there's

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been a lot of innovation
in the last 30,

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40 years in types of
insurers that are out there.

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So we have different
insurers that

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have behaved in
different ways as we've

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gone through those
evolutionary cycles.

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So one version of that is
what we call an HMO-- a health

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maintenance organization.

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And that's really just jargon.

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You have to dig into it to
figure out what it means.

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But in a lot of
cases, what that is

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is a company that's
acting as insurance.

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So you pay a premium to them if
you're a patient or a person,

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and you buy some coverage.

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And then they'll
cover your care.

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But they'll do that by trying
to integrate themselves

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with the providers.

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And so the
organizations either are

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integrated because the HMO hires
doctors directly, or maybe owns

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the hospitals-- like Kaiser
Permanente, for example.

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Or, in some cases it's a
contractual relationship.

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It's not exactly the same.

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SALMAN KHAN: So not all of them
is tightly linked as a Kaiser,

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where it's like, you go
to this building that

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says Kaiser on it.

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And that's where your doctor is.

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It could be doctors just
have their practices,

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but they're tightly
linked with a-- I think

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that's how, what Blue Shield?

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Or one of those.

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LAURENCE BAKER: Yeah,
Blue Shield, or Aetna,

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or some of these
different companies.

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And you can start to
dig into the details

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and every one will be a little
bit different from the other,

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but they're contractual
relationships.

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SALMAN KHAN: And
the difference--

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I think this is something
everyone faces when they sign

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up with insurance
with their employer--

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I had to do it recently--
is-- they all say,

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you have to pick HMO versus PPO.

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And they're within
the same policy.

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And so my perception is HMO is
you have set list of doctors

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that they probably
pre-negotiated pricing with.

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LAURENCE BAKER: Yeah.

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So the difference
between HMOs and PPOs

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gets a little bit
into the details

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SALMAN KHAN: OK.

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I don't want to get too into--

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LAURENCE BAKER: We can sort
of think about it in the way

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that you're talking about it.

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So an HMO will have
a list of doctors

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that you're supposed to see.

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And you'll have to go see
the doctors on that list.

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And a stereotypical one, if
you don't see the doctors

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on that list, the
insurance company's

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not going to pay
for you care, you're

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going to pay for yourself.

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And in the stereotypical
HMO, there's

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going to be a fairly
tight management

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between the insurance company
and the doctors about what's

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going to be done, what's
allowable, and so on.

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SALMAN KHAN: And in the
most tightly linked case,

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they'll be the same.

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They doctors will be
employed by the company.

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That's like Kaiser.

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LAURENCE BAKER: As you think
about it as a spectrum,

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if you move a little bit
away from that to a PPO.

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What's happening in
a PPO is you're still

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going to get a list,
so you're going

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to be encouraged to
see those doctors,

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but maybe it'll be a
little more flexibility.

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Like, if you decided not
to see someone on the list,

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the plan would still
pay some amount.

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Maybe not as much as they would
if you saw someone on a list,

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but something.

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Whereas in an HMO,
maybe nothing.

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And the plan will probably
work a little less hard

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at managing what those doctors
are doing to try and limit

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access to, say,
high cost services.

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HMO will tend to
work harder, PPO

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tends to work a
little less hard.

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So it's a little
bit of a spectrum.

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You're kind of moving from more
managed and more concentrated

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to a little less managed, but
still more so than the system

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we had, say, in
the '50s or '60s,

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where anybody went
to any doctor,

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and any doctor did
whatever they wanted.

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And the insurance company
just paid the bill,

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and there was no integration.

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So it's a little bit of a--

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SALMAN KHAN: So that's
the main motivation

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why insurance
companies are trying

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to get more integrated
with the providers,

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is because-- just like you
said, in the '50s and '60s,

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you have the provider
providing a service.

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And obviously the
patient like the service.

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And then you have a third
party paying for it.

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And so there's no check
on-- the person deciding

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and the person getting it says,
yeah, let's get more service.

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And someone else is-- right.

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LAURENCE BAKER: So we
created a big issue.

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Insurance companies are
kind of an interesting thing

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in a health policy world.

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Because we have to have them.

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We have to have them to
manage the risk associated

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with getting sick.

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You get sick today
and get a huge bill.

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And so we can't leave people
on their own for that.

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We got to have
insurance companies.

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But as soon as you create
insurance companies,

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and I can have, implicitly,
all my neighbors

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pay for the health
care that I want, then

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I might start using things that
turn out to be an efficient.

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And so you got to have
them-- insurance companies.

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But you got to manage what
happens when you have them

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also.

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And so that's the
integration between providers

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or co-payments and utilization
review, and all these things,

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are basically attempts
by insurance companies

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to try and manage
what economists

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would call the moral hazard.

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The using additional services
that you don't necessarily

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need because everybody else is
going to pay for it for you.

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SALMAN KHAN: It
makes complete sense.

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Well thanks.

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That makes a ton of sense.


Paying doctors

WEBVTT
Kind: captions
Language: en

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SPEAKER 1: I'm here with
Professor Laurence Baker who's

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a professor here at
Stanford Medical School,

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and what are we
going to talk about?

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LAURENCE BAKER: Well,
we pay physicians

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a lot of different
ways in this country.

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And I thought it would be useful
to spend a minute thinking

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about the different
ways that we do

00:00:11.958 --> 00:00:13.585
that, the concepts,
organizations,

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different practices
that are out there.

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SPEAKER 1: So, literally,
how do physicians

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receive their compensation?

00:00:18.050 --> 00:00:18.490
LAURENCE BAKER: Yes.

00:00:18.490 --> 00:00:18.920
SPEAKER 1: OK.

00:00:18.920 --> 00:00:19.770
LAURENCE BAKER: Yes.

00:00:19.770 --> 00:00:22.103
So we can go through this in
a couple of different ways,

00:00:22.103 --> 00:00:24.680
but there are three ways that
we can start out talking about,

00:00:24.680 --> 00:00:26.277
three general ways
that we organize

00:00:26.277 --> 00:00:27.360
the payment of physicians.

00:00:27.360 --> 00:00:30.160
And they turn out to
be fee for service--

00:00:30.160 --> 00:00:31.320
SPEAKER 1: Fee for service.

00:00:31.320 --> 00:00:31.960
Let me write this.

00:00:31.960 --> 00:00:32.560
Fee for service.

00:00:32.560 --> 00:00:33.060
Keep going.

00:00:33.060 --> 00:00:33.792
I'll catch up.

00:00:33.792 --> 00:00:36.250
LAURENCE BAKER: Yes, sometimes
we say FFS, Fee For Service.

00:00:36.250 --> 00:00:36.635
SPEAKER 1: FFS.

00:00:36.635 --> 00:00:37.134
OK.

00:00:37.134 --> 00:00:38.320
Makes sense.

00:00:38.320 --> 00:00:41.090
LAURENCE BAKER: Second
one, we call capitation.

00:00:41.090 --> 00:00:42.817
And the third one,
of course, salary.

00:00:42.817 --> 00:00:44.650
SPEAKER 1: Too close
to decapitation for me,

00:00:44.650 --> 00:00:45.800
but maybe it's not related.

00:00:45.800 --> 00:00:47.460
But OK.

00:00:47.460 --> 00:00:48.310
And then salary.

00:00:48.310 --> 00:00:49.070
LAURENCE BAKER: And then salary.

00:00:49.070 --> 00:00:49.800
SPEAKER 1: OK.

00:00:49.800 --> 00:00:50.939
And so fee for service.

00:00:50.939 --> 00:00:52.730
That seems to be a
little bit common sense.

00:00:52.730 --> 00:00:53.687
Is that literally it?

00:00:53.687 --> 00:00:55.020
LAURENCE BAKER: Fee for service.

00:00:55.020 --> 00:00:57.300
In a fee for service
system, a physician

00:00:57.300 --> 00:00:59.894
gets paid a fee for every
service that they do.

00:00:59.894 --> 00:01:01.560
It's kind of like
going to a restaurant.

00:01:01.560 --> 00:01:02.830
You order the drink.

00:01:02.830 --> 00:01:05.050
You order a salad, maybe
an entree, a dessert.

00:01:05.050 --> 00:01:06.940
The restaurant keeps a
list of all the things

00:01:06.940 --> 00:01:09.100
that you ordered and,
at the end of the night,

00:01:09.100 --> 00:01:10.950
there's a price
associated with each one.

00:01:10.950 --> 00:01:12.200
And you add up the
price associated

00:01:12.200 --> 00:01:13.533
with each of the things you got.

00:01:13.533 --> 00:01:14.834
That makes your total bill.

00:01:14.834 --> 00:01:16.000
That's the fee for service--

00:01:16.000 --> 00:01:16.700
SPEAKER 1: I see.

00:01:16.700 --> 00:01:19.033
And so this is kind of what
a doctor in private practice

00:01:19.033 --> 00:01:19.970
would face.

00:01:19.970 --> 00:01:21.870
LAURENCE BAKER: Well, doctors
can be paid fee for service

00:01:21.870 --> 00:01:22.950
in a lot of different
arrangements.

00:01:22.950 --> 00:01:25.330
So they might be in private
practice paid this way.

00:01:25.330 --> 00:01:27.150
Some physician groups
are paid this way,

00:01:27.150 --> 00:01:29.180
and fee for service
concepts come up, even,

00:01:29.180 --> 00:01:32.430
in large organizations, like the
Stanford Medical School where

00:01:32.430 --> 00:01:34.960
some people are sometimes paid
for their work in a hospital

00:01:34.960 --> 00:01:35.460
according--

00:01:35.460 --> 00:01:35.588
SPEAKER 1: I see.

00:01:35.588 --> 00:01:37.490
But the general idea is that if
they're not providing service

00:01:37.490 --> 00:01:38.870
or if there's a slow
day then they're

00:01:38.870 --> 00:01:40.500
not going to be
making money that day.

00:01:40.500 --> 00:01:41.110
LAURENCE BAKER: Right.

00:01:41.110 --> 00:01:41.610
Right.

00:01:41.610 --> 00:01:44.040
The more services they do,
the more expensive services

00:01:44.040 --> 00:01:45.390
they do, the more
costly that they do,

00:01:45.390 --> 00:01:47.250
the more revenue that their
practice will generate.

00:01:47.250 --> 00:01:47.958
SPEAKER 1: I see.

00:01:47.958 --> 00:01:50.510
And we'll talk later about
whether that's a good idea.

00:01:50.510 --> 00:01:52.510
LAURENCE BAKER: Of course,
that has implications

00:01:52.510 --> 00:01:54.970
for the way that physicians act
and the way that they practice.

00:01:54.970 --> 00:01:56.303
SPEAKER 1: So what's capitation?

00:01:56.303 --> 00:01:58.090
Because I'm not
familiar with that.

00:01:58.090 --> 00:02:00.090
LAURENCE BAKER: So
capitation-- the general idea

00:02:00.090 --> 00:02:03.120
is to do something quite
different than fee for service.

00:02:03.120 --> 00:02:06.134
The term capitation comes
from the Latin, per head.

00:02:06.134 --> 00:02:08.550
SPEAKER 1: Oh so it is related
to decapitation, literally,

00:02:08.550 --> 00:02:09.050
per head.

00:02:09.050 --> 00:02:11.422
[INTERPOSING VOICES]

00:02:11.422 --> 00:02:13.880
LAURENCE BAKER: So we're going
to pay physicians per person

00:02:13.880 --> 00:02:15.254
that they have in
their practice,

00:02:15.254 --> 00:02:17.740
and the kind of building
blocks of a capitation system

00:02:17.740 --> 00:02:19.910
would be, one, a
panel of patients

00:02:19.910 --> 00:02:21.645
who are assigned to a doctor.

00:02:21.645 --> 00:02:24.110
So the doctor might
have 1,000 patients

00:02:24.110 --> 00:02:25.715
for which he or
she is responsible.

00:02:25.715 --> 00:02:29.720
We'll call that group
their members, their panel.

00:02:29.720 --> 00:02:31.714
Sometimes people call
it their covered lives.

00:02:31.714 --> 00:02:33.380
Second piece of a
capitation arrangement

00:02:33.380 --> 00:02:35.610
is an agreement about
what the physician is

00:02:35.610 --> 00:02:37.610
going to be responsible
for under the agreement.

00:02:37.610 --> 00:02:40.880
So we might say it's primary
care services, all the office

00:02:40.880 --> 00:02:42.840
visits, and basic
tests, and follow-ups

00:02:42.840 --> 00:02:44.830
that those patients
might need, but maybe not

00:02:44.830 --> 00:02:47.350
their hospitalizations or their
expensive surgeries, things

00:02:47.350 --> 00:02:47.750
like that.

00:02:47.750 --> 00:02:49.190
So you have some
group of patients.

00:02:49.190 --> 00:02:50.731
You have some agreed
set of services,

00:02:50.731 --> 00:02:53.430
and then you would define a
payment, which in the jargon

00:02:53.430 --> 00:02:56.790
gets called the PMPM the
Per-Member Per-Month.

00:02:56.790 --> 00:02:59.850
SPEAKER 1: Per-Member Per-Month.

00:02:59.850 --> 00:03:01.300
And who is making this payment?

00:03:01.300 --> 00:03:03.470
It is, I guess, the
employer of the doctor.

00:03:03.470 --> 00:03:06.095
So this definitely would not be
the case with a-- oh, go ahead.

00:03:06.095 --> 00:03:08.303
LAURENCE BAKER: So it would
be the insurance company,

00:03:08.303 --> 00:03:11.060
generally, that's going to
pay the doctor this payment.

00:03:11.060 --> 00:03:12.820
So when an insurance
company, let's

00:03:12.820 --> 00:03:16.055
say Blue Shield Blue
Cross, Aetna, Cigna,

00:03:16.055 --> 00:03:17.430
any number of
different companies

00:03:17.430 --> 00:03:20.270
that might be out there, has
an arrangement with a physician

00:03:20.270 --> 00:03:25.760
that they take-- some number
of their insured people

00:03:25.760 --> 00:03:27.650
become part of the
panel of that doctor,

00:03:27.650 --> 00:03:31.020
they could arrange to pay that
doctor on a capitation basis,

00:03:31.020 --> 00:03:32.950
by saying, you've got
1,000 of our patients.

00:03:32.950 --> 00:03:35.100
Here's what we're going to
pay you to take care of them.

00:03:35.100 --> 00:03:35.460
SPEAKER 1: I see.

00:03:35.460 --> 00:03:36.870
And it seems to
make a lot of sense

00:03:36.870 --> 00:03:38.620
for the insurance
company, because now you

00:03:38.620 --> 00:03:40.549
don't have this incentive
for the doctor to--

00:03:40.549 --> 00:03:43.090
LAURENCE BAKER: You change the
way the whole incentive works.

00:03:43.090 --> 00:03:45.410
So now, if a
physician gets, say,

00:03:45.410 --> 00:03:48.300
$25 per member per month for
taking care of their 1,000

00:03:48.300 --> 00:03:50.352
patients-- they get
$25,000 a month--

00:03:50.352 --> 00:03:52.810
they've got to do what needs
to be done for those patients.

00:03:52.810 --> 00:03:55.393
But they don't get paid extra
if they do something additional,

00:03:55.393 --> 00:03:58.211
if they do a more expensive test
as opposed to a cheaper test,

00:03:58.211 --> 00:03:59.460
they get paid the same amount.

00:03:59.460 --> 00:04:00.970
So you take away
the incentive that

00:04:00.970 --> 00:04:02.910
exists in a
fee-for-service system that

00:04:02.910 --> 00:04:04.892
tends to get people to
try to do more things,

00:04:04.892 --> 00:04:06.600
or at least creates
a world in which it's

00:04:06.600 --> 00:04:09.294
possible to do more things
and get paid for it.

00:04:09.294 --> 00:04:11.460
SPEAKER 1: And it's more
predictable for the doctor,

00:04:11.460 --> 00:04:12.370
too.

00:04:12.370 --> 00:04:13.850
LAURENCE BAKER: Well, it could
be predictable for the doctor.

00:04:13.850 --> 00:04:15.689
Although, in some
sense, it's predictable.

00:04:15.689 --> 00:04:16.980
And in another sense, it's not.

00:04:16.980 --> 00:04:20.209
An important difference between
fee-for-service and capitation,

00:04:20.209 --> 00:04:22.150
we'll say, in health
policy, is associated

00:04:22.150 --> 00:04:24.850
with risk or this
concept of risk.

00:04:24.850 --> 00:04:26.620
And when we talk
about risk here,

00:04:26.620 --> 00:04:28.970
we mean financial
risk associated

00:04:28.970 --> 00:04:30.950
with the health of the
patients or variations

00:04:30.950 --> 00:04:33.260
in the needs of the
patients in a given month.

00:04:33.260 --> 00:04:36.230
So if you're being
paid fee-for-service,

00:04:36.230 --> 00:04:38.600
the doctor doesn't
face any real risk.

00:04:38.600 --> 00:04:40.390
If it's a bad month,
everybody's sick,

00:04:40.390 --> 00:04:42.090
everybody needs lots
of care, they're

00:04:42.090 --> 00:04:45.030
going to get paid for
delivering that care.

00:04:45.030 --> 00:04:47.420
Under capitation, the doctor
does face more of that risk.

00:04:47.420 --> 00:04:48.920
They're getting
paid a fixed amount.

00:04:48.920 --> 00:04:49.890
They've got to deal with
whatever the patients need.

00:04:49.890 --> 00:04:50.598
SPEAKER 1: I see.

00:04:50.598 --> 00:04:53.194
In a high-volume
month, the doctor

00:04:53.194 --> 00:04:54.360
takes the hit in capitation.

00:04:54.360 --> 00:04:56.607
But in a low-volume month,
the insurance company

00:04:56.607 --> 00:04:57.190
takes the hit.

00:04:57.190 --> 00:04:58.981
So it goes both ways
and kind of evens out.

00:04:58.981 --> 00:05:00.600
LAURENCE BAKER: Right.

00:05:00.600 --> 00:05:03.180
The doctor benefits in
the low-volume months.

00:05:03.180 --> 00:05:03.680
Right?

00:05:03.680 --> 00:05:05.270
The doctor kind of averages out.

00:05:05.270 --> 00:05:07.940
In a good arrangement, this
will be sort of even over time.

00:05:07.940 --> 00:05:09.420
The doctors will come out OK.

00:05:09.420 --> 00:05:12.210
But these risk issues have been
problems in some capitation

00:05:12.210 --> 00:05:14.900
arrangements, especially if
you're a small doctor practice

00:05:14.900 --> 00:05:16.840
and you've got a lot of
variation from month to month.

00:05:16.840 --> 00:05:18.080
Maybe you're not
a great manager.

00:05:18.080 --> 00:05:20.450
You can go out of business
if you have a few bad months.

00:05:20.450 --> 00:05:22.046
SPEAKER 1: Who
decides that it will

00:05:22.046 --> 00:05:23.420
be capitation or
fee-for-service?

00:05:23.420 --> 00:05:24.860
Is it the doctor's
choice or the insurance

00:05:24.860 --> 00:05:26.430
company says, you will do this?

00:05:26.430 --> 00:05:27.290
LAURENCE BAKER:
So, over time, it's

00:05:27.290 --> 00:05:28.998
been a bit of negotiation
back and forth.

00:05:28.998 --> 00:05:30.740
So insurance companies
have preferences

00:05:30.740 --> 00:05:32.650
about how they do
this, and doctors

00:05:32.650 --> 00:05:34.440
have preferences about
how this happens.

00:05:34.440 --> 00:05:37.220
And so sometimes some of
it's driven just by history.

00:05:37.220 --> 00:05:38.840
The Medicare
program, for example,

00:05:38.840 --> 00:05:41.500
got started in the 1960s
when fee-for-service

00:05:41.500 --> 00:05:43.700
was the most common way
for physicians to be paid,

00:05:43.700 --> 00:05:46.310
and that's largely
persisted in that program

00:05:46.310 --> 00:05:47.370
for historical reasons.

00:05:47.370 --> 00:05:48.630
It's just worked out that way.

00:05:48.630 --> 00:05:50.870
In the 1990s, a
lot of health plans

00:05:50.870 --> 00:05:52.772
decided, the insurance
companies decided,

00:05:52.772 --> 00:05:54.230
that, in the private
market, they'd

00:05:54.230 --> 00:05:56.610
like to do more
capitation, so they did.

00:05:56.610 --> 00:05:58.840
And they started pushing
these arrangements,

00:05:58.840 --> 00:06:00.286
trying to get
physicians to agree.

00:06:00.286 --> 00:06:01.660
They were successful
for a while.

00:06:01.660 --> 00:06:03.240
And then, lately, it's been
a little more-- physicians

00:06:03.240 --> 00:06:05.040
have said, we don't
like capitation so well.

00:06:05.040 --> 00:06:06.550
We'd rather go back
to fee-for-service.

00:06:06.550 --> 00:06:07.310
That's working better.

00:06:07.310 --> 00:06:09.480
So the negotiations have gone
a little more the other way.

00:06:09.480 --> 00:06:10.896
SPEAKER 1: Have
there been studies

00:06:10.896 --> 00:06:15.430
that showed when doctors who
are compensated under capitation

00:06:15.430 --> 00:06:19.152
don't order as many services
or perform as many services?

00:06:19.152 --> 00:06:20.860
LAURENCE BAKER: So
the literature on this

00:06:20.860 --> 00:06:23.670
is pretty clear that
it makes a difference.

00:06:23.670 --> 00:06:26.600
We would like to think that
it doesn't make a difference.

00:06:26.600 --> 00:06:28.600
SPEAKER 1: Most of them
are all about the health

00:06:28.600 --> 00:06:30.310
of the patient, but--

00:06:30.310 --> 00:06:33.770
LAURENCE BAKER: Well, so there
are hundreds of thousands

00:06:33.770 --> 00:06:36.004
of doctors in the country
and, undoubtedly, out there

00:06:36.004 --> 00:06:38.170
are some that pay close
attention to the financials.

00:06:38.170 --> 00:06:39.670
But I think, actually,
you're right.

00:06:39.670 --> 00:06:41.920
Most of them probably don't,
on a day-to-day basis,

00:06:41.920 --> 00:06:42.960
pay close attention.

00:06:42.960 --> 00:06:44.710
And at the end of year,
they'll see the financials

00:06:44.710 --> 00:06:45.300
from their practice.

00:06:45.300 --> 00:06:46.410
Maybe they don't
think it through.

00:06:46.410 --> 00:06:47.760
SPEAKER 1: But if you got
to pay the college tuition,

00:06:47.760 --> 00:06:49.750
then all of a sudden,
hey, maybe an MRI

00:06:49.750 --> 00:06:52.180
wouldn't hurt or a little
extra this or that.

00:06:52.180 --> 00:06:53.930
LAURENCE BAKER: I think
that's part of it.

00:06:53.930 --> 00:06:56.513
But the other thing that I think
is going on in the background

00:06:56.513 --> 00:06:59.310
is the general, maybe
almost subtle-- the things

00:06:59.310 --> 00:07:01.060
that you don't notice
that create a system

00:07:01.060 --> 00:07:03.060
and let a system evolve
in a particular way.

00:07:03.060 --> 00:07:05.260
So doctors like to do
things for their patients.

00:07:05.260 --> 00:07:07.170
Patients like to have
things done for them.

00:07:07.170 --> 00:07:08.880
A fee-for-service
system creates a world

00:07:08.880 --> 00:07:10.754
in which everybody
is fine with that.

00:07:10.754 --> 00:07:11.420
You can do that.

00:07:11.420 --> 00:07:13.360
And so, pretty soon, you
get used to doing that.

00:07:13.360 --> 00:07:14.510
Which becomes the
first thing you

00:07:14.510 --> 00:07:16.030
think of when you do
these extra things.

00:07:16.030 --> 00:07:16.170
SPEAKER 1: Right.

00:07:16.170 --> 00:07:18.253
Neither party, neither the
doctor nor the patient,

00:07:18.253 --> 00:07:21.564
has any incentive,
really, of saying, wait.

00:07:21.564 --> 00:07:22.480
Who's paying for that?

00:07:22.480 --> 00:07:23.438
Oh no, someone else is.

00:07:23.438 --> 00:07:24.590
OK.

00:07:24.590 --> 00:07:26.590
LAURENCE BAKER: And it
creates in the background

00:07:26.590 --> 00:07:28.410
these incentives for people
who develop new products

00:07:28.410 --> 00:07:29.710
and services to develop them.

00:07:29.710 --> 00:07:31.690
And it makes it
easy for a hospital,

00:07:31.690 --> 00:07:34.180
say, to put in a big
new piece of equipment

00:07:34.180 --> 00:07:35.995
that they're pretty
sure they can pay for.

00:07:35.995 --> 00:07:38.370
And once it's sitting there
and you pass it every morning

00:07:38.370 --> 00:07:39.570
on your way into the
hospital, it just

00:07:39.570 --> 00:07:41.150
becomes that much
easier to use it.

00:07:41.150 --> 00:07:44.290
And so it sort of guides
the evolution of our system

00:07:44.290 --> 00:07:46.000
in a way that has
led us to a point

00:07:46.000 --> 00:07:47.899
now where we consume
a lot of health care,

00:07:47.899 --> 00:07:49.940
maybe, sometimes, health
care that we don't need.

00:07:49.940 --> 00:07:51.648
It's often health care
that's beneficial,

00:07:51.648 --> 00:07:53.474
but it's all costly,
and so that sets us up

00:07:53.474 --> 00:07:55.890
for the kind of dynamics and
the challenges we have today.

00:07:55.890 --> 00:07:58.850
SPEAKER 1: How common is-- maybe
we should talk about salary

00:07:58.850 --> 00:08:01.850
before we talk about
how common they are.

00:08:01.850 --> 00:08:04.270
LAURENCE BAKER: Yeah, we can
pick that up as we go along.

00:08:04.270 --> 00:08:07.390
Fee-for-service and capitation
have been ebbing and flowing.

00:08:07.390 --> 00:08:10.750
Frankly, in the US at the
moment, fee for service

00:08:10.750 --> 00:08:13.220
is a very common way
for people to be paid.

00:08:13.220 --> 00:08:15.160
Capitation is declining.

00:08:15.160 --> 00:08:16.712
There are still places--

00:08:16.712 --> 00:08:18.420
SPEAKER 1: So even
though fee for service

00:08:18.420 --> 00:08:20.860
was where everyone
started, capitation kind of

00:08:20.860 --> 00:08:22.870
went a little bit
[INAUDIBLE] and then no one's

00:08:22.870 --> 00:08:24.230
really a fan of it.

00:08:24.230 --> 00:08:25.720
Or the doctors
aren't a fan of it.

00:08:25.720 --> 00:08:25.776
LAURENCE BAKER: Picked up.

00:08:25.776 --> 00:08:28.431
The doctors were less of a
fan, and so the arrangements

00:08:28.431 --> 00:08:30.930
have been shifting more toward--
insurance arrangements that

00:08:30.930 --> 00:08:32.690
would use more
fee-for-service these days.

00:08:32.690 --> 00:08:34.360
So the US is,
definitely, I think,

00:08:34.360 --> 00:08:35.640
majority fee-for-service.

00:08:35.640 --> 00:08:37.130
SPEAKER 1: Who decides what
the panel-- because it sounded

00:08:37.130 --> 00:08:38.546
like the insurance
companies would

00:08:38.546 --> 00:08:40.969
pay for part of the
panel of a doctor who

00:08:40.969 --> 00:08:42.133
would be under capitation.

00:08:42.133 --> 00:08:44.049
LAURENCE BAKER: So these
kinds of arrangements

00:08:44.049 --> 00:08:46.560
can, in practice, get
kind of complicated.

00:08:46.560 --> 00:08:49.090
So the concept of paying
per head is clear,

00:08:49.090 --> 00:08:50.830
but there will be
variations that go on.

00:08:50.830 --> 00:08:53.004
So if you change the
scope of services,

00:08:53.004 --> 00:08:55.295
you change the arrangement--
If you have a primary care

00:08:55.295 --> 00:08:57.580
arrangement for capitation,
that's one piece but,

00:08:57.580 --> 00:09:00.380
of course, it leaves off
the MRI or the surgery.

00:09:00.380 --> 00:09:01.950
And what would
happen in those cases

00:09:01.950 --> 00:09:04.630
is the health plan would have
an arrangement for primary care

00:09:04.630 --> 00:09:06.705
services with some
doctors under capitation.

00:09:06.705 --> 00:09:08.330
Then they would have
other arrangements

00:09:08.330 --> 00:09:09.121
with other doctors.

00:09:09.121 --> 00:09:11.120
They might, say, have
a capitated arrangement

00:09:11.120 --> 00:09:13.605
with some cardiologist
to do the cardiology.

00:09:13.605 --> 00:09:14.980
Or they might have
an arrangement

00:09:14.980 --> 00:09:16.940
with some cardiologists
to pay fee for service

00:09:16.940 --> 00:09:17.750
to those cardiologists,
so when the--

00:09:17.750 --> 00:09:19.380
SPEAKER 1: I see, so
it's a big mix-up,

00:09:19.380 --> 00:09:21.420
but obviously
there's an incentive.

00:09:21.420 --> 00:09:22.810
If you are being
paid capitation,

00:09:22.810 --> 00:09:25.707
you want the healthiest people
in that capitation panel.

00:09:25.707 --> 00:09:27.540
LAURENCE BAKER: So
there's another incentive

00:09:27.540 --> 00:09:28.581
that's in the background.

00:09:28.581 --> 00:09:30.730
And that's a selection
kind of incentive.

00:09:30.730 --> 00:09:33.160
So it's, again, a thing where
I think doctors probably

00:09:33.160 --> 00:09:35.930
don't think about this, most
doctors, on a day-to-day basis.

00:09:35.930 --> 00:09:39.050
But it's a subtle force
operating in the background.

00:09:39.050 --> 00:09:40.580
If you're getting
capitation and you

00:09:40.580 --> 00:09:44.380
can take actions that would
get you a healthier patient

00:09:44.380 --> 00:09:48.121
bunch for that same $25,000,
say, you end up a little bit

00:09:48.121 --> 00:09:49.370
ahead at the end of the month.

00:09:49.370 --> 00:09:52.510
And doctors don't, I think,
like to shift patients off.

00:09:52.510 --> 00:09:55.230
And there's laws that prevent
certain kinds of activities.

00:09:55.230 --> 00:09:56.841
But, subtly in
the background, it

00:09:56.841 --> 00:09:58.590
helps the system evolve
in that direction.

00:09:58.590 --> 00:10:00.670
And so we would probably see
some of that kind of thing

00:10:00.670 --> 00:10:01.210
happen.

00:10:01.210 --> 00:10:01.793
SPEAKER 1: OK.

00:10:01.793 --> 00:10:03.320
And salary is what we imagine.

00:10:03.320 --> 00:10:05.030
This is how most of us get paid.

00:10:05.030 --> 00:10:06.280
LAURENCE BAKER: Salary
is what you imagine.

00:10:06.280 --> 00:10:08.530
It's an agreement to be paid
a certain amount per year

00:10:08.530 --> 00:10:10.200
for some amount of
work [INAUDIBLE].

00:10:10.200 --> 00:10:11.510
SPEAKER 1: This would be
from the insurance companies,

00:10:11.510 --> 00:10:11.800
wouldn't it?

00:10:11.800 --> 00:10:12.500
LAURENCE BAKER:
So what happens--

00:10:12.500 --> 00:10:14.960
we talk about these three
as being different things,

00:10:14.960 --> 00:10:17.240
but when you get to the
real-world interpretation,

00:10:17.240 --> 00:10:21.120
or real-world looking at
systems that are out there,

00:10:21.120 --> 00:10:23.470
what you'll see is often
mixes between these.

00:10:23.470 --> 00:10:27.450
And so one of the pieces
of disentangling this

00:10:27.450 --> 00:10:29.025
is multilevel systems.

00:10:29.025 --> 00:10:30.650
And that's where
salary becomes kind of

00:10:30.650 --> 00:10:31.691
important to think about.

00:10:31.691 --> 00:10:35.220
So one common thing that happens
is physicians group together

00:10:35.220 --> 00:10:36.940
into larger practices.

00:10:36.940 --> 00:10:39.660
And that larger practice
collects the activity

00:10:39.660 --> 00:10:42.010
of all the doctors that
work in that practice, bills

00:10:42.010 --> 00:10:44.385
for that from an insurance
company, and then disseminates

00:10:44.385 --> 00:10:46.296
or distributes the
money among the doctors.

00:10:46.296 --> 00:10:48.170
And so what you will
often see in real life--

00:10:48.170 --> 00:10:50.190
and that complicates
the inference here--

00:10:50.190 --> 00:10:52.410
is, say, a large practice
that billed an insurance

00:10:52.410 --> 00:10:54.190
company on a
fee-for-service basis

00:10:54.190 --> 00:10:56.430
for the collective activity
of all the doctors,

00:10:56.430 --> 00:10:58.750
takes that resulting pool
of money and divides it up.

00:10:58.750 --> 00:11:00.820
Maybe pay some of
the doctors a salary.

00:11:00.820 --> 00:11:02.880
Maybe pays them a salary
with some sort of bonus

00:11:02.880 --> 00:11:04.674
that depends on how
much work they did.

00:11:04.674 --> 00:11:05.590
And does other things.

00:11:05.590 --> 00:11:08.360
And so sometimes the incentive
that an individual doctor,

00:11:08.360 --> 00:11:10.670
sitting in a room with
a patient is looking at,

00:11:10.670 --> 00:11:12.630
might be different than
the incentive based

00:11:12.630 --> 00:11:14.706
on the managers of that
practice who might then

00:11:14.706 --> 00:11:16.330
want to get the
doctors to do something

00:11:16.330 --> 00:11:17.360
that's different than--

00:11:17.360 --> 00:11:18.470
SPEAKER 1: But the general
idea is that-- I mean,

00:11:18.470 --> 00:11:20.580
the only way to get a salary
is if there's some organization

00:11:20.580 --> 00:11:22.829
between the doctor and the
insurance companies to kind

00:11:22.829 --> 00:11:23.660
of--

00:11:23.660 --> 00:11:23.990
LAURENCE BAKER: Yes.

00:11:23.990 --> 00:11:24.940
SPEAKER 1: --insulate
the doctor.

00:11:24.940 --> 00:11:27.370
LAURENCE BAKER: So one of
the important pieces here

00:11:27.370 --> 00:11:30.750
that we think about is that
fee-for-service works in almost

00:11:30.750 --> 00:11:33.840
any physician practice, a
solo practitioner, one person

00:11:33.840 --> 00:11:36.160
working by themselves, or
two together could do this.

00:11:36.160 --> 00:11:38.880
Capitation almost
always works in any kind

00:11:38.880 --> 00:11:40.770
of physician practice,
with the exception

00:11:40.770 --> 00:11:43.470
that, if you're a very small
practice, the risk you face

00:11:43.470 --> 00:11:45.410
from month to month,
depending on the sickness

00:11:45.410 --> 00:11:47.370
of your patients, might put you
out of business if you're not

00:11:47.370 --> 00:11:48.417
really on top of it.

00:11:48.417 --> 00:11:50.250
So we like to think
capitation could work in

00:11:50.250 --> 00:11:52.570
any practice, but
really only larger ones.

00:11:52.570 --> 00:11:55.179
And salary is a nice
incentive in a lot of ways

00:11:55.179 --> 00:11:56.970
but requires you to
have a big organization

00:11:56.970 --> 00:11:58.090
to be able to do this.

00:11:58.090 --> 00:12:00.590
And so some of the differences
you see in how physicians get

00:12:00.590 --> 00:12:02.420
paid have a lot to do with
the size of the organization

00:12:02.420 --> 00:12:03.240
they work in.

00:12:03.240 --> 00:12:04.573
SPEAKER 1: Makes complete sense.

00:12:04.573 --> 00:12:05.936
Well, thanks for that.


Intro to the endocrine system

WEBVTT
Kind: captions
Language: en

00:00:00.250 --> 00:00:02.250
SALMAN KHAN: I'm here at
Stanford Medical School

00:00:02.250 --> 00:00:06.210
with Neil Gesundheit,
who's a faculty member here

00:00:06.210 --> 00:00:08.046
at the med school.

00:00:08.046 --> 00:00:09.229
NEIL GESUNDHEIT: Hi, Sal.

00:00:09.229 --> 00:00:11.270
SALMAN KHAN: So, what are
we going to talk about?

00:00:11.270 --> 00:00:13.020
NEIL GESUNDHEIT: Well,
the topic for today

00:00:13.020 --> 00:00:15.500
is endocrinology, which
is the study of hormones.

00:00:15.500 --> 00:00:18.930
And the word hormone is
derived from the Greek word

00:00:18.930 --> 00:00:21.170
which means arouse the activity.

00:00:21.170 --> 00:00:24.610
And what hormones do is they're
chemical messengers that

00:00:24.610 --> 00:00:27.540
are made at one part of
the body and typically go

00:00:27.540 --> 00:00:30.620
to another part of the
body to, as suggested,

00:00:30.620 --> 00:00:34.822
arouse the activity and give
function to another organ.

00:00:34.822 --> 00:00:36.280
SALMAN KHAN: So
they're essentially

00:00:36.280 --> 00:00:38.020
kind of signaling,
a way to communicate

00:00:38.020 --> 00:00:39.390
between one part of
the body and the other.

00:00:39.390 --> 00:00:39.800
NEIL GESUNDHEIT: Exactly.

00:00:39.800 --> 00:00:41.380
They're very sophisticated
communicators.

00:00:41.380 --> 00:00:42.640
I think that's a perfect term.

00:00:42.640 --> 00:00:44.306
And I think the other
way to think of it

00:00:44.306 --> 00:00:46.520
is our body communicates
in some ways directly.

00:00:46.520 --> 00:00:49.140
For instance, nerves
innervate muscle.

00:00:49.140 --> 00:00:50.890
And when you want to
contract your muscle,

00:00:50.890 --> 00:00:53.306
you give a signal from your
brain, it goes down the nerve,

00:00:53.306 --> 00:00:55.140
and it directly
attaches to the muscle

00:00:55.140 --> 00:00:57.060
and causes it to contract.

00:00:57.060 --> 00:01:01.120
Whereas, hormones are more like
the Wi-Fi of the human body.

00:01:01.120 --> 00:01:02.720
They're wireless.

00:01:02.720 --> 00:01:04.599
They are made at one place.

00:01:04.599 --> 00:01:06.980
They go into the bloodstream,
which is like the airwaves,

00:01:06.980 --> 00:01:08.010
if you will.

00:01:08.010 --> 00:01:13.220
And then they work on another
part of the body at a distance,

00:01:13.220 --> 00:01:19.610
without directly connecting
to that part of the body

00:01:19.610 --> 00:01:20.860
mechanically.

00:01:20.860 --> 00:01:23.850
SALMAN KHAN: And hormones, are
they a specific type of protein

00:01:23.850 --> 00:01:24.670
or a specific type of chemical?

00:01:24.670 --> 00:01:26.980
Or are they really anything that
does what you just described?

00:01:26.980 --> 00:01:28.771
NEIL GESUNDHEIT: It's
pretty much anything,

00:01:28.771 --> 00:01:30.674
but they fall into
two major categories.

00:01:30.674 --> 00:01:32.340
There are small
molecules that typically

00:01:32.340 --> 00:01:34.400
derive from amino acids.

00:01:34.400 --> 00:01:38.470
And those molecules
are just 300 to 500,

00:01:38.470 --> 00:01:42.360
at most, daltons, which are
molecular mass units, up

00:01:42.360 --> 00:01:45.060
to large proteins
that can be hundreds

00:01:45.060 --> 00:01:46.969
and hundreds of
amino acids in size.

00:01:46.969 --> 00:01:47.760
SALMAN KHAN: I see.

00:01:47.760 --> 00:01:49.926
So anything, anything that
really has this signaling

00:01:49.926 --> 00:01:50.790
function.

00:01:50.790 --> 00:01:52.750
NEIL GESUNDHEIT: That's right,
would be considered a hormone.

00:01:52.750 --> 00:01:54.625
And the other thing is
we talk about hormones

00:01:54.625 --> 00:01:56.210
in three sort of subcategories.

00:01:56.210 --> 00:01:57.901
We call some of them
endocrine hormones,

00:01:57.901 --> 00:01:59.650
where they really get
into the bloodstream

00:01:59.650 --> 00:02:01.804
and work at a far distance.

00:02:01.804 --> 00:02:03.720
And we'll give some
examples with your diagram

00:02:03.720 --> 00:02:05.240
right there in just a minute.

00:02:05.240 --> 00:02:08.280
But there are others that are
called paracrine hormones.

00:02:08.280 --> 00:02:11.640
And paracrine hormones are
more regionally active.

00:02:11.640 --> 00:02:14.210
So they might be made, let's
say, in one part of the body

00:02:14.210 --> 00:02:18.760
and work within a small distance
of that site of synthesis.

00:02:18.760 --> 00:02:21.260
And then the third category,
which is less common,

00:02:21.260 --> 00:02:23.780
would be autocrine hormones.

00:02:23.780 --> 00:02:26.160
And the autocrine
hormones are actually

00:02:26.160 --> 00:02:29.700
made directly at one cell
and work on that same cell

00:02:29.700 --> 00:02:33.869
or in this cell right next door,
at a very, very small distance.

00:02:33.869 --> 00:02:34.660
SALMAN KHAN: I see.

00:02:37.492 --> 00:02:38.950
So, the endocrine
hormones, I think

00:02:38.950 --> 00:02:40.158
I have a mental model for it.

00:02:40.158 --> 00:02:43.589
They're kind of released far
away in the body someplace.

00:02:43.589 --> 00:02:45.380
If they're picked up
by the right receptor,

00:02:45.380 --> 00:02:47.080
they'll have the right function.

00:02:47.080 --> 00:02:49.891
The paracrine hormones,
is their effect small

00:02:49.891 --> 00:02:52.140
because they only are able
to travel a small distance?

00:02:52.140 --> 00:02:53.970
Or is it something else?

00:02:53.970 --> 00:02:56.740
NEIL GESUNDHEIT: Typically
the paracrine hormones

00:02:56.740 --> 00:02:59.120
do get into the bloodstream,
but the concentration

00:02:59.120 --> 00:03:01.810
of the receptor, the receiving
end, as you suggested,

00:03:01.810 --> 00:03:03.490
is right close by.

00:03:03.490 --> 00:03:05.510
So what tends to make
a paracrine hormone

00:03:05.510 --> 00:03:08.630
work regionally is that the high
concentration of the receptors

00:03:08.630 --> 00:03:12.640
are very close to the
site of synthesis.

00:03:12.640 --> 00:03:15.760
And the same with autocrine,
is often they're made,

00:03:15.760 --> 00:03:18.190
and there's a very high
concentration of the receiving

00:03:18.190 --> 00:03:21.250
end right at that cell,
right next to that cell.

00:03:21.250 --> 00:03:23.250
SALMAN KHAN: And this
might be a silly question,

00:03:23.250 --> 00:03:25.220
but it's called endocrinology.

00:03:25.220 --> 00:03:27.622
Are there paracrinologists?

00:03:27.622 --> 00:03:29.330
NEIL GESUNDHEIT: Well,
it's a good point.

00:03:29.330 --> 00:03:30.150
I don't think so.

00:03:30.150 --> 00:03:32.810
I think we just, perhaps
because the paracrine function

00:03:32.810 --> 00:03:34.820
of hormones was
discovered later,

00:03:34.820 --> 00:03:37.569
we still carry this all under
the umbrella of endocrinology.

00:03:37.569 --> 00:03:38.360
SALMAN KHAN: Right.

00:03:38.360 --> 00:03:40.190
So all of hormones
is endocrinology,

00:03:40.190 --> 00:03:41.175
even though endocrine
hormones are

00:03:41.175 --> 00:03:42.520
the ones that act
at far distances.

00:03:42.520 --> 00:03:43.110
NEIL GESUNDHEIT: That's right.

00:03:43.110 --> 00:03:44.390
I think that's a good
way to summarize it.

00:03:44.390 --> 00:03:46.620
Now I like the diagram
that you created here

00:03:46.620 --> 00:03:49.250
because it illustrates some
of the major endocrine organs,

00:03:49.250 --> 00:03:52.070
the ones we'll be focusing
on in later lectures.

00:03:52.070 --> 00:03:54.690
So the first one that you
showed very nicely in the head,

00:03:54.690 --> 00:03:57.745
at the base of the brain,
is that orange structure.

00:03:57.745 --> 00:04:00.410
And that would be
the pituitary gland.

00:04:00.410 --> 00:04:01.350
That's right.

00:04:01.350 --> 00:04:03.970
And the pituitary gland
is called the master gland

00:04:03.970 --> 00:04:06.540
because from the
pituitary, we make hormones

00:04:06.540 --> 00:04:09.230
that work on yet other organs.

00:04:09.230 --> 00:04:10.640
So I'll give you an example.

00:04:10.640 --> 00:04:12.680
One of the hormones that's
made by the pituitary

00:04:12.680 --> 00:04:16.600
is called thyroid
stimulating hormone, or TSH.

00:04:16.600 --> 00:04:18.970
And after it leaves
the pituitary,

00:04:18.970 --> 00:04:21.459
it goes into the
circulation and it

00:04:21.459 --> 00:04:23.260
acts on the thyroid
gland, where there

00:04:23.260 --> 00:04:26.280
are high receptors for TSH
on the surface of the thyroid

00:04:26.280 --> 00:04:27.250
cells.

00:04:27.250 --> 00:04:29.950
And it stimulates the thyroid
gland to make thyroid hormone,

00:04:29.950 --> 00:04:35.265
typically thyroxine T4
or triodothyronine, T3.

00:04:35.265 --> 00:04:37.640
Those would be the two main
circulating thyroid hormones.

00:04:37.640 --> 00:04:38.830
SALMAN KHAN: And
what do those do?

00:04:38.830 --> 00:04:40.621
NEIL GESUNDHEIT: Those
regulate metabolism,

00:04:40.621 --> 00:04:43.220
they regulate appetite,
they regulate thermogenesis,

00:04:43.220 --> 00:04:45.050
they regulate muscle function.

00:04:45.050 --> 00:04:47.509
They have widespread activities
on other parts of the body.

00:04:47.509 --> 00:04:49.841
SALMAN KHAN: But it kind of
upregulates or downregulates

00:04:49.841 --> 00:04:51.370
the entire body
and the metabolism.

00:04:51.370 --> 00:04:52.620
NEIL GESUNDHEIT: That's right.

00:04:52.620 --> 00:04:54.240
So someone with
hyperthyroidism would

00:04:54.240 --> 00:04:56.000
have very high metabolism.

00:04:56.000 --> 00:04:58.240
You may know the
classic picture someone

00:04:58.240 --> 00:05:00.892
with a high heart rate, rapid
metabolism, weight loss.

00:05:00.892 --> 00:05:02.600
That would be someone
with excess amounts

00:05:02.600 --> 00:05:03.950
of thyroid hormone.

00:05:03.950 --> 00:05:06.170
And then you see pretty
much the inverse picture

00:05:06.170 --> 00:05:08.950
when someone has a deficiency
of thyroid hormone and someone

00:05:08.950 --> 00:05:10.020
with hypothyroidism.

00:05:10.020 --> 00:05:12.932
So it's critical to maintain
just the right amount of almost

00:05:12.932 --> 00:05:14.890
all of these hormones,
and the thyroid hormones

00:05:14.890 --> 00:05:16.100
are good examples of this.

00:05:16.100 --> 00:05:18.990
But the ultimate regulation
is from that pituitary gland.

00:05:18.990 --> 00:05:19.870
SALMAN KHAN: This is
kind of the master one.

00:05:19.870 --> 00:05:22.310
It sends a signal there, and
then that kind of does the--

00:05:22.310 --> 00:05:23.400
NEIL GESUNDHEIT: That's right.

00:05:23.400 --> 00:05:25.180
And we'll talk later
about feedback loops,

00:05:25.180 --> 00:05:29.150
because how does the pituitary
know when to stop making TSH?

00:05:29.150 --> 00:05:30.990
And basically,
like a thermostat,

00:05:30.990 --> 00:05:33.280
it can sense the levels
of thyroid hormone.

00:05:33.280 --> 00:05:35.460
And when those levels are
just at the right level,

00:05:35.460 --> 00:05:38.210
and not too high, it'll decrease
the amount of TSH it makes.

00:05:38.210 --> 00:05:40.300
If the levels are too
low, it'll increase

00:05:40.300 --> 00:05:42.670
TSH to try to stimulate the
thyroid gland to make yet

00:05:42.670 --> 00:05:44.530
more thyroid hormone.

00:05:44.530 --> 00:05:45.650
SALMAN KHAN: Very cool.

00:05:45.650 --> 00:05:46.450
And what else do we have here?

00:05:46.450 --> 00:05:46.770
NEIL GESUNDHEIT: OK.

00:05:46.770 --> 00:05:48.686
So the other hormones,
some of the major ones.

00:05:48.686 --> 00:05:51.700
The pituitary, in addition to
making the thyroid stimulating

00:05:51.700 --> 00:05:53.570
hormones, it makes
a hormone called

00:05:53.570 --> 00:05:57.840
ACTH, adrenal
corticotrophic hormone,

00:05:57.840 --> 00:06:00.730
which acts on the
adrenal cortex.

00:06:00.730 --> 00:06:02.310
And the adrenal is
that gland exactly

00:06:02.310 --> 00:06:04.590
that sits on top of the kidney.

00:06:04.590 --> 00:06:06.850
And the outer layers
of the adrenal gland

00:06:06.850 --> 00:06:11.875
are the adrenal cortex, and
those are stimulated by ACTH.

00:06:11.875 --> 00:06:14.000
SALMAN KHAN: And they're
not related to the kidney.

00:06:14.000 --> 00:06:15.370
They just sit on top there.

00:06:15.370 --> 00:06:16.495
They're structurally there.

00:06:16.495 --> 00:06:19.260
NEIL GESUNDHEIT: Right They're
related only in that sense

00:06:19.260 --> 00:06:23.540
that the blood supply is rich
like the kidneys' blood supply,

00:06:23.540 --> 00:06:26.100
and they happen to
sit above the kidney.

00:06:26.100 --> 00:06:28.160
And they're called
adrenal because they're

00:06:28.160 --> 00:06:31.110
adjacent to the kidney,
which is the renal part.

00:06:31.110 --> 00:06:31.680
SALMAN KHAN: That should
have been obvious.

00:06:31.680 --> 00:06:32.596
I never realized that.

00:06:32.596 --> 00:06:35.200
NEIL GESUNDHEIT: But
they don't per se

00:06:35.200 --> 00:06:37.840
filter blood or do any
of the key functions

00:06:37.840 --> 00:06:39.179
that the kidney serves.

00:06:39.179 --> 00:06:39.970
SALMAN KHAN: I see.

00:06:39.970 --> 00:06:41.177
And what's their role?

00:06:41.177 --> 00:06:42.760
NEIL GESUNDHEIT: So
the adrenal glands

00:06:42.760 --> 00:06:45.900
make the adrenal
hormones like cortisol,

00:06:45.900 --> 00:06:47.930
which regulates
glucose metabolism

00:06:47.930 --> 00:06:51.100
and is important to maintaining
blood pressure and well-being.

00:06:51.100 --> 00:06:53.850
And then it makes
mineralocorticoids

00:06:53.850 --> 00:06:56.790
like aldosterone, which is
important for regulating

00:06:56.790 --> 00:06:59.020
salt and water balance.

00:06:59.020 --> 00:07:03.150
You also have adrenal androgens,
which are somewhat important.

00:07:03.150 --> 00:07:05.100
And those three hormones
are the main hormones

00:07:05.100 --> 00:07:09.200
made by the adrenal cortex.

00:07:09.200 --> 00:07:12.230
The ACTH primarily
regulates the cortisol

00:07:12.230 --> 00:07:14.410
and the adrenal androgens.

00:07:14.410 --> 00:07:16.360
And there's another
system that regulates

00:07:16.360 --> 00:07:19.095
the mineralocorticoids that
we'll talk about later.

00:07:19.095 --> 00:07:21.220
SALMAN KHAN: OK And we have
a few more organs here.

00:07:21.220 --> 00:07:21.480
NEIL GESUNDHEIT: Yeah.

00:07:21.480 --> 00:07:23.200
So Also add out
of the pituitary,

00:07:23.200 --> 00:07:27.010
we make luteinizing hormone and
follicle stimulating hormone.

00:07:27.010 --> 00:07:28.920
Those would be
abbreviated LH and FSH.

00:07:32.280 --> 00:07:33.650
And those act on the gonads.

00:07:33.650 --> 00:07:36.820
So in the male, it'll act on
the testes, and in the female,

00:07:36.820 --> 00:07:39.930
it'll act on the
ovaries to stimulate

00:07:39.930 --> 00:07:44.360
the development of sperm
in the male and oocytes,

00:07:44.360 --> 00:07:46.780
or eggs in the female,
and also the production

00:07:46.780 --> 00:07:49.690
of gonadal steroids, primarily
testosterone in the male

00:07:49.690 --> 00:07:51.650
and estradiol in the female.

00:07:51.650 --> 00:07:53.776
SALMAN KHAN: Right And
are we missing anything?

00:07:53.776 --> 00:07:55.900
NEIL GESUNDHEIT: Well,
there are two other hormones

00:07:55.900 --> 00:07:58.970
that also derive from
the anterior pituitary.

00:07:58.970 --> 00:08:00.830
And those would
be growth hormone

00:08:00.830 --> 00:08:03.711
that's critical for optimal
growth of long bones.

00:08:03.711 --> 00:08:05.710
SALMAN KHAN: The pituitary
really does do a lot.

00:08:05.710 --> 00:08:06.920
NEIL GESUNDHEIT: It does.

00:08:06.920 --> 00:08:08.570
Yeah.

00:08:08.570 --> 00:08:10.740
SALMAN KHAN: So it's HGH,
human growth hormone.

00:08:10.740 --> 00:08:11.010
NEIL GESUNDHEIT: Yeah.

00:08:11.010 --> 00:08:13.301
Human growth hormone, and
that would act on long bones,

00:08:13.301 --> 00:08:14.050
for instance.

00:08:14.050 --> 00:08:15.610
And then we would
have prolactin,

00:08:15.610 --> 00:08:19.340
which is important in
women for lactation,

00:08:19.340 --> 00:08:21.500
being able to breastfeed
after delivering a child.

00:08:21.500 --> 00:08:22.846
SALMAN KHAN: And insulin is?

00:08:22.846 --> 00:08:24.470
NEIL GESUNDHEIT:
Insulin is key, but it

00:08:24.470 --> 00:08:25.630
doesn't come from the pituitary.

00:08:25.630 --> 00:08:27.210
So now we're going to work
our way down a little bit.

00:08:27.210 --> 00:08:29.937
We talked about the thyroid
gland making thyroid hormone.

00:08:29.937 --> 00:08:31.770
And then when you get
to the pancreas, which

00:08:31.770 --> 00:08:34.440
is that yellow structure
right in the middle,

00:08:34.440 --> 00:08:37.640
inside the pancreas,
there are small islands

00:08:37.640 --> 00:08:40.940
called the islets of Langerhans.

00:08:40.940 --> 00:08:43.740
And the islets
within the pancreas

00:08:43.740 --> 00:08:48.310
make endocrine hormones
like insulin and glucagon.

00:08:48.310 --> 00:08:49.780
But insulin is vital.

00:08:49.780 --> 00:08:52.400
Without insulin,
you have diabetes.

00:08:52.400 --> 00:08:55.890
And without insulin, you don't
transport glucose into muscle

00:08:55.890 --> 00:08:59.080
and remove glucose from
the bloodstream normally.

00:08:59.080 --> 00:09:00.850
The absence of
insulin can produce

00:09:00.850 --> 00:09:03.477
all of the symptoms of diabetes
that we'll talk about later.

00:09:03.477 --> 00:09:05.310
SALMAN KHAN: It seems
just structurally, you

00:09:05.310 --> 00:09:06.750
have the pancreas right here.

00:09:06.750 --> 00:09:08.710
You have the adrenal
glands right there,

00:09:08.710 --> 00:09:11.310
that they're all near kind
of that interchange on the--

00:09:11.310 --> 00:09:13.462
because they're all
so important to get

00:09:13.462 --> 00:09:14.670
to where they need to get to.

00:09:14.670 --> 00:09:16.461
NEIL GESUNDHEIT: That's
a good observation.

00:09:16.461 --> 00:09:19.059
They all have a lot of
venous drainage from them

00:09:19.059 --> 00:09:20.600
so that when they
make their hormone,

00:09:20.600 --> 00:09:22.933
it gets into the bloodstream
rather quickly because they

00:09:22.933 --> 00:09:24.262
are vital structures.

00:09:24.262 --> 00:09:25.220
SALMAN KHAN: Very cool.

00:09:25.220 --> 00:09:26.400
So I think we can
leave it there.

00:09:26.400 --> 00:09:28.170
And in the next video,
you have some pictures

00:09:28.170 --> 00:09:29.510
that I think will be
pretty interesting.

00:09:29.510 --> 00:09:29.710
NEIL GESUNDHEIT: OK.

00:09:29.710 --> 00:09:29.890
Yeah.

00:09:29.890 --> 00:09:31.500
In the next video,
we'll talk about how

00:09:31.500 --> 00:09:33.916
you have to the right amount
of the hormone or else things

00:09:33.916 --> 00:09:34.530
go awry.

00:09:34.530 --> 00:09:34.960
SALMAN KHAN: Very cool.

00:09:34.960 --> 00:09:35.610
Thanks a bunch.

00:09:35.610 --> 00:09:36.443
NEIL GESUNDHEIT: OK.

00:09:36.443 --> 00:09:37.510
Thank you.


Richter scale

WEBVTT
Kind: captions
Language: en

00:00:00.500 --> 00:00:03.400
I've been doing a bunch of
videos about logarithmic scale.

00:00:03.400 --> 00:00:07.110
And we've also, unfortunately,
had many notable earthquakes

00:00:07.110 --> 00:00:07.610
this year.

00:00:07.610 --> 00:00:10.460
So I thought I would do a video
on the Richter scale, which

00:00:10.460 --> 00:00:14.900
is a way to measure
earthquake magnitudes.

00:00:14.900 --> 00:00:17.260
And just to be clear, although
we associate the Richter

00:00:17.260 --> 00:00:19.540
scale as the way we
measure earthquakes now,

00:00:19.540 --> 00:00:21.470
the one that we
actually use now is

00:00:21.470 --> 00:00:23.670
the moment of magnitude scale.

00:00:23.670 --> 00:00:25.520
And the reason why
most people don't

00:00:25.520 --> 00:00:27.990
make a huge differentiation
between the two,

00:00:27.990 --> 00:00:30.000
is that the moment
magnitude scale

00:00:30.000 --> 00:00:32.186
was calibrated to
the Richter scale.

00:00:32.186 --> 00:00:34.560
But the whole reason why we
moved to the moment magnitude

00:00:34.560 --> 00:00:38.090
scale is that the Richter
scale starts to kind of max out

00:00:38.090 --> 00:00:40.340
at around magnitude
7 earthquakes.

00:00:40.340 --> 00:00:42.150
So this gives us
a much better way

00:00:42.150 --> 00:00:45.180
to measure things that
are above a magnitude 7.

00:00:45.180 --> 00:00:48.040
So this right here is a
picture of Charles Richter.

00:00:48.040 --> 00:00:50.230
He's passed away.

00:00:50.230 --> 00:00:52.386
But this is from an
interview that he gave,

00:00:52.386 --> 00:00:54.260
and it's interesting
because it kind of gives

00:00:54.260 --> 00:00:57.400
the rationale for how he came
up with the Richter scale.

00:00:57.400 --> 00:01:01.050
I found a paper by Professor
K. Wadati of Japan,

00:01:01.050 --> 00:01:03.430
in which he compared large
earthquakes by plotting

00:01:03.430 --> 00:01:06.340
the maximum ground motion
against the distance

00:01:06.340 --> 00:01:07.720
to the epicenter.

00:01:07.720 --> 00:01:11.030
So this Professor K. Wadati
would, you could imagine,

00:01:11.030 --> 00:01:14.470
he did a plot like this,
where this is distance.

00:01:14.470 --> 00:01:16.460
So if you have an
earthquake someplace,

00:01:16.460 --> 00:01:18.936
you aren't always sitting
right on top of the epicenter,

00:01:18.936 --> 00:01:19.810
where you measure it.

00:01:19.810 --> 00:01:21.101
You might be sitting over here.

00:01:21.101 --> 00:01:25.620
Your measuring stations
might be some distance away.

00:01:25.620 --> 00:01:27.747
So he looks at how far
the measuring station was,

00:01:27.747 --> 00:01:29.330
and then he looks
at the ground motion

00:01:29.330 --> 00:01:30.980
at the measuring station.

00:01:30.980 --> 00:01:34.540
So that would be some
earthquake over there.

00:01:34.540 --> 00:01:36.870
Let's say that's a
relatively medium earthquake.

00:01:36.870 --> 00:01:38.870
This right over here would
be a weak earthquake,

00:01:38.870 --> 00:01:40.610
because you're close
to the earthquake,

00:01:40.610 --> 00:01:42.720
and it still didn't
move the ground much.

00:01:42.720 --> 00:01:45.680
This is the magnitude,
this axis is the magnitude,

00:01:45.680 --> 00:01:47.730
how much the ground is moving.

00:01:47.730 --> 00:01:49.630
And then, for
example, this would

00:01:49.630 --> 00:01:51.852
be a very strong earthquake.

00:01:51.852 --> 00:01:53.810
And then Charles Richter
said in the interview,

00:01:53.810 --> 00:01:56.120
I tried a similar
procedure for our stations.

00:01:56.120 --> 00:01:58.840
But the range between the
largest and smallest magnitudes

00:01:58.840 --> 00:02:01.079
seemed unmanageably large.

00:02:01.079 --> 00:02:02.620
So what he's saying
is, when he tried

00:02:02.620 --> 00:02:05.170
to plot it like
Professor Wadati,

00:02:05.170 --> 00:02:07.539
he found that OK, you
could get some earthquakes

00:02:07.539 --> 00:02:08.789
that you can plot around here.

00:02:08.789 --> 00:02:14.030
But no matter how you
create a linear scale,

00:02:14.030 --> 00:02:15.740
if you want any
resolution down here,

00:02:15.740 --> 00:02:17.810
the stronger earthquakes
just go off the charts.

00:02:17.810 --> 00:02:18.999
Or maybe off the page.

00:02:18.999 --> 00:02:20.540
So the stronger
earthquakes you might

00:02:20.540 --> 00:02:22.200
have to start plotting
here, or here.

00:02:22.200 --> 00:02:24.900
Or maybe they don't
even fit on the page.

00:02:24.900 --> 00:02:27.311
And so he says, Doctor
Beno Gutenberg--

00:02:27.311 --> 00:02:29.560
and they were all working
at Caltech when they came up

00:02:29.560 --> 00:02:32.210
with the Richter scale--
Doctor Beno Gutenberg

00:02:32.210 --> 00:02:35.540
then made the natural suggestion
to plot the amplitudes

00:02:35.540 --> 00:02:37.210
logarithmically.

00:02:37.210 --> 00:02:40.490
I was lucky, because
logarithmic plots

00:02:40.490 --> 00:02:41.980
are a device of the devil.

00:02:41.980 --> 00:02:43.540
And I'm not really
sure what he means

00:02:43.540 --> 00:02:45.915
when he says that they
were a device of the devil.

00:02:45.915 --> 00:02:48.040
I'm assuming he means that
they're kind of magical.

00:02:48.040 --> 00:02:50.081
That all of a sudden, you
could take these things

00:02:50.081 --> 00:02:52.060
that you want your
resolution down here,

00:02:52.060 --> 00:02:53.340
you want to be able
to tell the difference

00:02:53.340 --> 00:02:54.750
between those weak earthquakes.

00:02:54.750 --> 00:02:56.330
But at the same
time, you want to be

00:02:56.330 --> 00:02:58.280
able to compare them to
the large earthquakes.

00:02:58.280 --> 00:02:59.863
And he thought, I
guess he viewed them

00:02:59.863 --> 00:03:02.240
as a bit of a
magical instrument.

00:03:02.240 --> 00:03:04.320
And we say that
they're logarithmic,

00:03:04.320 --> 00:03:06.270
or he plotted on a
logarithmic scale.

00:03:06.270 --> 00:03:08.250
What essentially
he's saying is, he's

00:03:08.250 --> 00:03:12.110
essentially taking the
logarithm of the magnitude

00:03:12.110 --> 00:03:13.887
of every one of
those earthquakes.

00:03:13.887 --> 00:03:15.720
So if you're measuring
the earthquake, maybe

00:03:15.720 --> 00:03:18.070
on a seismograph, so this
is before the earthquake,

00:03:18.070 --> 00:03:19.530
then the earthquake hits.

00:03:19.530 --> 00:03:22.050
And then the earthquake stops.

00:03:22.050 --> 00:03:24.414
And then you measure the
amplitude of this earthquake.

00:03:24.414 --> 00:03:25.830
If you just plotted
them linearly,

00:03:25.830 --> 00:03:28.210
you would have the
problem that he saw.

00:03:28.210 --> 00:03:31.100
Or if you try to plot them the
way Professor Wadati did it,

00:03:31.100 --> 00:03:32.430
you would have that problem.

00:03:32.430 --> 00:03:34.138
But what he does is
he measures this now,

00:03:34.138 --> 00:03:37.870
and he plots the
logarithm of that.

00:03:37.870 --> 00:03:40.870
And so what happens is that you
get a scale that is plotted--

00:03:40.870 --> 00:03:43.992
or you get a logarithmic scale,
for lack of a better word.

00:03:43.992 --> 00:03:45.450
But what I want to
do in this video

00:03:45.450 --> 00:03:47.460
is think about what
implication that

00:03:47.460 --> 00:03:49.110
has for the magnitude
of earthquakes,

00:03:49.110 --> 00:03:50.860
especially some of the
earthquakes that we

00:03:50.860 --> 00:03:52.241
have seen recently.

00:03:52.241 --> 00:03:53.740
So this right here
is the earthquake

00:03:53.740 --> 00:03:56.610
that occurred August 23, on
the east coast of the United

00:03:56.610 --> 00:03:57.119
States.

00:03:57.119 --> 00:03:58.910
And it wasn't that
strong of an earthquake.

00:03:58.910 --> 00:03:59.900
It was a 5.8.

00:03:59.900 --> 00:04:01.775
That's not a small earthquake,
you would definitely feel it.

00:04:01.775 --> 00:04:03.399
It's a good bit of
shaking, it can even

00:04:03.399 --> 00:04:05.195
cause some minor damage.

00:04:05.195 --> 00:04:06.840
But the reason why
it's notable is

00:04:06.840 --> 00:04:08.840
it happened in a part of
the world that does not

00:04:08.840 --> 00:04:10.710
see earthquakes too frequently.

00:04:10.710 --> 00:04:12.900
So let's just take
that on our scale.

00:04:12.900 --> 00:04:14.830
I'm going to go down
all the way over here.

00:04:14.830 --> 00:04:16.246
So I'm going to
do our scale here.

00:04:16.246 --> 00:04:18.700
So let's just put that as a 5.8.

00:04:18.700 --> 00:04:21.970
And if you shake your
seat fairly vigorously,

00:04:21.970 --> 00:04:23.470
that'll give you a
good idea of what

00:04:23.470 --> 00:04:25.810
it might feel like on the
top of that earthquake.

00:04:25.810 --> 00:04:28.695
So this is 2011, east
coast earthquake.

00:04:31.780 --> 00:04:33.909
And then probably the
most famous earthquake

00:04:33.909 --> 00:04:35.450
in the United States
in recent memory

00:04:35.450 --> 00:04:37.720
was the one that
occurred at Loma Prieta.

00:04:37.720 --> 00:04:40.370
This is Loma Prieta
right over here, about 40

00:04:40.370 --> 00:04:42.664
or 50 miles south
of San Francisco.

00:04:42.664 --> 00:04:44.830
And this is damage that was
caused in San Francisco,

00:04:44.830 --> 00:04:46.731
an actual freeway
collapsed right over here.

00:04:46.731 --> 00:04:48.980
And this whole area has
actually now become very nice,

00:04:48.980 --> 00:04:50.730
after they removed this freeway.

00:04:50.730 --> 00:04:52.540
But you can imagine
how powerful it

00:04:52.540 --> 00:04:55.270
was, that it was able to cause
this type of damage this far

00:04:55.270 --> 00:04:55.980
away.

00:04:55.980 --> 00:04:58.080
And actually I live
right over here,

00:04:58.080 --> 00:05:01.370
so I'm glad I wasn't around,
or I wasn't in the Bay Area,

00:05:01.370 --> 00:05:03.420
during that earthquake.

00:05:03.420 --> 00:05:05.700
But that earthquake,
depending on your measurement,

00:05:05.700 --> 00:05:08.080
but we'll just call it a 7.0.

00:05:08.080 --> 00:05:10.890
So that earthquake
measured at a 7.0.

00:05:10.890 --> 00:05:13.830
So let's call this 7.

00:05:13.830 --> 00:05:16.480
Let me do that in a color
you're more likely to see.

00:05:16.480 --> 00:05:19.880
So that earthquake was a 7.0.

00:05:19.880 --> 00:05:24.650
Loma Prieta, that was in
the San Francisco Bay Area.

00:05:24.650 --> 00:05:26.670
And this was in 1989.

00:05:26.670 --> 00:05:29.360
It happened right actually
before the World Series.

00:05:29.360 --> 00:05:32.990
And then of course 2011, a
very unfortunate earthquake

00:05:32.990 --> 00:05:34.100
in Japan.

00:05:34.100 --> 00:05:36.760
The Tohoku earthquake,
right over here,

00:05:36.760 --> 00:05:38.999
this circle shows the
magnitude of that earthquake.

00:05:38.999 --> 00:05:40.790
It was off the coast
of Japan, all of these

00:05:40.790 --> 00:05:41.924
were the aftershocks.

00:05:41.924 --> 00:05:43.590
And the real damage
it caused was really

00:05:43.590 --> 00:05:45.920
the tsunami and
the damage it did

00:05:45.920 --> 00:05:48.230
to the Fukushima
nuclear power plant.

00:05:48.230 --> 00:05:51.357
But that was an 8.-- well,
sometimes it's called 8.9,

00:05:51.357 --> 00:05:53.440
sometimes a 9.0, depending
on how you measure it--

00:05:53.440 --> 00:05:55.910
let's just call it a
9.0 for simplicity.

00:05:55.910 --> 00:05:58.790
So let's say this is almost
6, and this would be 7,

00:05:58.790 --> 00:06:01.150
then an 8 would get
us right over there.

00:06:01.150 --> 00:06:04.370
So 9.0 is right over there.

00:06:04.370 --> 00:06:10.640
So this is 2011 the earthquake
in Japan, the Tohoku

00:06:10.640 --> 00:06:11.410
earthquake.

00:06:11.410 --> 00:06:13.880
And then the largest
earthquake ever recorded

00:06:13.880 --> 00:06:16.530
was the great Chilean
earthquake in 1960.

00:06:16.530 --> 00:06:19.050
And that was a 9.5.

00:06:19.050 --> 00:06:21.980
So 9.5 would stick
us right over,

00:06:21.980 --> 00:06:24.350
let's say right over here.

00:06:24.350 --> 00:06:28.970
And this is the 1960
earthquake in Chile.

00:06:28.970 --> 00:06:31.520
And just to give a sense,
when you look at this, if you

00:06:31.520 --> 00:06:33.570
thought this was a linear
scale you'd say, OK,

00:06:33.570 --> 00:06:34.986
the Chilean
earthquake, maybe that

00:06:34.986 --> 00:06:36.615
was a little bit
less than twice as

00:06:36.615 --> 00:06:37.990
bad as the east
coast earthquake.

00:06:37.990 --> 00:06:39.430
And it doesn't seem too bad.

00:06:39.430 --> 00:06:42.050
Until you realize that
it is not a linear scale.

00:06:42.050 --> 00:06:44.380
It is a logarithmic scale.

00:06:44.380 --> 00:06:47.450
And the way that
you interpret it

00:06:47.450 --> 00:06:52.550
is thinking about how
many powers of 10 one

00:06:52.550 --> 00:06:54.610
of these earthquakes
is from another.

00:06:54.610 --> 00:06:57.100
So you can view these
as powers of 10.

00:06:57.100 --> 00:07:01.470
So if you take, go
from 5.8 to 7.0,

00:07:01.470 --> 00:07:04.840
that was 1.2, a 1.2 difference.

00:07:04.840 --> 00:07:06.590
But remember, this is
a logarithmic scale.

00:07:06.590 --> 00:07:08.215
And I encourage you
to watch the videos

00:07:08.215 --> 00:07:10.050
we made on the
logarithmic scale.

00:07:10.050 --> 00:07:12.490
On a logarithmic
scale, a fixed distance

00:07:12.490 --> 00:07:15.620
is not a fixed amount of
movement on that scale.

00:07:15.620 --> 00:07:20.535
Or a change on that scale is
not a fixed linear distance.

00:07:20.535 --> 00:07:22.710
It is actually a scaling factor.

00:07:22.710 --> 00:07:25.050
And you're not scaling
by 1.2 over here.

00:07:25.050 --> 00:07:27.730
You're scaling by
10 to the 1.2 power.

00:07:27.730 --> 00:07:33.270
So this is times 10
to the 1.2 power.

00:07:33.270 --> 00:07:35.695
So I'll get my calculator
out right over here.

00:07:35.695 --> 00:07:37.140
And let's figure what that is.

00:07:37.140 --> 00:07:38.931
So you could imagine
what it's going to be.

00:07:38.931 --> 00:07:40.520
10 to the first power is 10.

00:07:40.520 --> 00:07:41.600
And then you have 0.2.

00:07:41.600 --> 00:07:48.280
So it's going to be, let's just
do it, 10 to the 1.2 power.

00:07:48.280 --> 00:07:49.710
It's 15.8.

00:07:49.710 --> 00:07:52.170
So it's roughly
16 times stronger.

00:07:52.170 --> 00:07:54.760
So whatever shaking that was
just felt on the east coast,

00:07:54.760 --> 00:07:56.176
and maybe some of
you all watching

00:07:56.176 --> 00:07:58.910
this might have felt it,
Loma Prieta earthquake

00:07:58.910 --> 00:08:03.210
was 16 times stronger
than the earthquake-- let

00:08:03.210 --> 00:08:07.682
me write this-- this is 16
times stronger than the one

00:08:07.682 --> 00:08:09.140
that we just had
on the east coast.

00:08:09.140 --> 00:08:10.473
So that's a dramatic difference.

00:08:10.473 --> 00:08:12.910
Even though this caused
some damage, and this

00:08:12.910 --> 00:08:17.450
is kind of shaking on
a pretty good scale.

00:08:17.450 --> 00:08:19.589
Imagine 16 times
as much shaking.

00:08:19.589 --> 00:08:21.130
And how much damage
that would cause.

00:08:21.130 --> 00:08:22.700
I actually just
met a reporter who

00:08:22.700 --> 00:08:24.225
told me that she
was in her backyard

00:08:24.225 --> 00:08:25.641
during the Loma
Prieta earthquake,

00:08:25.641 --> 00:08:27.137
not too far from
where I live now.

00:08:27.137 --> 00:08:29.470
And she says all the cars
were like jumping up and down.

00:08:29.470 --> 00:08:31.873
So it was a massive,
massive earthquake.

00:08:31.873 --> 00:08:33.789
Now let's think about
the Japanese earthquake.

00:08:33.789 --> 00:08:35.372
We could think about
how much stronger

00:08:35.372 --> 00:08:36.450
it was than Loma Prieta.

00:08:36.450 --> 00:08:38.120
So remember, this
isn't, you don't just

00:08:38.120 --> 00:08:42.240
think of this as just
2 times stronger.

00:08:42.240 --> 00:08:44.672
It is 10 to the
second times stronger.

00:08:44.672 --> 00:08:46.130
And we know how to
figure that out.

00:08:46.130 --> 00:08:48.240
10 to the second power is 100.

00:08:48.240 --> 00:08:49.730
So this right over here.

00:08:49.730 --> 00:08:52.370
So cars were jumping up and down
at the Loma Prieta earthquake.

00:08:52.370 --> 00:08:56.840
The Japanese earthquake
was 100 times stronger.

00:08:56.840 --> 00:09:00.230
100 times stronger
than Loma Prieta.

00:09:00.230 --> 00:09:02.360
And if you compare it to
the east coast earthquake,

00:09:02.360 --> 00:09:08.600
it would be 1,600 times
the east coast earthquake

00:09:08.600 --> 00:09:10.610
that occurred in August of 2011.

00:09:10.610 --> 00:09:13.430
So massive, massive,
massive earthquake.

00:09:13.430 --> 00:09:15.460
And just to get a sense
of how much stronger

00:09:15.460 --> 00:09:18.140
the Chilean earthquake was in
1960-- and just to-- there's

00:09:18.140 --> 00:09:22.090
some fascinating outcomes
of the Japanese earthquake.

00:09:22.090 --> 00:09:25.010
It was estimated
that Japan, just

00:09:25.010 --> 00:09:28.530
over the course of the
earthquake got 13 feet wider.

00:09:28.530 --> 00:09:31.830
So this is doing something
to the actual shape

00:09:31.830 --> 00:09:35.330
of a huge island.

00:09:35.330 --> 00:09:37.340
And on top of that,
it's estimated

00:09:37.340 --> 00:09:40.720
that because of the shaking,
and the distortions in earth

00:09:40.720 --> 00:09:44.320
caused by that shaking,
that the day on earth

00:09:44.320 --> 00:09:46.264
got one millionth
of a second shorter.

00:09:46.264 --> 00:09:48.180
A little over a millionth
of a second shorter.

00:09:48.180 --> 00:09:49.870
So you might say, hey, that's
only a millionth of a second.

00:09:49.870 --> 00:09:51.286
But I'd say, hey,
look it actually

00:09:51.286 --> 00:09:53.300
changed the day of the earth.

00:09:53.300 --> 00:09:54.420
A very fundamental thing.

00:09:54.420 --> 00:09:56.711
It actually matters when
people send things into space,

00:09:56.711 --> 00:09:59.064
and probes into
Mars, is that they

00:09:59.064 --> 00:10:00.730
are to be able to
know that our day just

00:10:00.730 --> 00:10:03.060
got a millionth of
a second shorter.

00:10:03.060 --> 00:10:05.342
So this was already
a massive quake.

00:10:05.342 --> 00:10:06.800
And the Chilean
earthquake is going

00:10:06.800 --> 00:10:10.440
to be 10 to the 0.5
times stronger than that.

00:10:10.440 --> 00:10:11.899
So let's get our calculator out.

00:10:11.899 --> 00:10:14.190
So you really could view this
as the square root of 10.

00:10:14.190 --> 00:10:17.310
So 10 to the 0.5 is the
same thing as 10 to the 1/2,

00:10:17.310 --> 00:10:20.960
which is just the same thing
as the square root of 10.

00:10:20.960 --> 00:10:22.660
Which is 3.16.

00:10:22.660 --> 00:10:25.200
So the strongest
earthquake on record

00:10:25.200 --> 00:10:30.020
was 3.16 times stronger than
the Japanese earthquake.

00:10:30.020 --> 00:10:31.910
The one that shortened
the day of the planet.

00:10:31.910 --> 00:10:35.870
The one that made
Japan 13 feet wider.

00:10:35.870 --> 00:10:39.730
And so this was-- if you wanted
to compare it to the east coast

00:10:39.730 --> 00:10:41.750
earthquake-- this
would be almost,

00:10:41.750 --> 00:10:46.000
or about 5,000 times stronger.

00:10:46.000 --> 00:10:47.610
So massive, massive earthquake.

00:10:47.610 --> 00:10:50.195
So one, hopefully
that gives you a sense

00:10:50.195 --> 00:10:51.820
of what the Richter
scale is all about.

00:10:51.820 --> 00:10:53.610
And also gives you a
sense of how massive

00:10:53.610 --> 00:10:55.684
some of these super
massive earthquakes are.

00:10:55.684 --> 00:10:58.350
And you can also appreciate what
Charles Richter's first problem

00:10:58.350 --> 00:10:58.850
was.

00:10:58.850 --> 00:11:01.340
If you wanted to plot all of
these on the same linear plot,

00:11:01.340 --> 00:11:06.310
you would have to stick
this one 5,000 times further

00:11:06.310 --> 00:11:08.570
along an axis than you would
have to stick this one.

00:11:08.570 --> 00:11:12.460
And this one itself, this is
still a pretty big earthquake.

00:11:12.460 --> 00:11:15.640
So this would have to be
5,000 times further than some

00:11:15.640 --> 00:11:19.380
of the earthquakes at the
low end of the Richter scale.


The Gates Notes:  Students in Los Altos

WEBVTT
Kind: captions
Language: en

00:00:12.381 --> 00:00:14.158
Boy in blue: Our teacher
would have the textbook

00:00:14.158 --> 00:00:17.256
up on the overhead projector
so we could all see it.

00:00:17.256 --> 00:00:21.855
Boy in gray: We kind of just sat there
and we did like different sections.

00:00:21.855 --> 00:00:25.933
Girl in green: i'm a daydreamer
so I kind of zone out sometimes.

00:00:25.933 --> 00:00:28.823
Boy in blue: Read the lesson
and then we would get homework.

00:00:28.823 --> 00:00:31.658
Girl in green: There's always
at the end of each section.

00:00:31.658 --> 00:00:33.453
Boy in blue: Yeah,
that's how it was before.

00:00:33.453 --> 00:00:36.447
Girl in green: I used to
get like B's all the time

00:00:36.447 --> 00:00:40.821
but since Khan Academy it's brought
me up to an A so that was really cool.

00:00:40.835 --> 00:00:45.522
Girl in pink: In a way I use Khan
Academy is I do the exercises

00:00:45.522 --> 00:00:48.906
and it really helps me
improve my Math skills,

00:00:48.906 --> 00:00:53.917
and I watch the videos if I'm having
trouble with some of the exercises,

00:00:53.917 --> 00:00:57.108
and then I'm able to get a streak of 10.

00:00:57.108 --> 00:01:01.087
Boy with eyeglass: She can see what you're
doing and so if you're messing around

00:01:01.087 --> 00:01:04.313
she'll tell you to just
do these set of problems.

00:01:04.313 --> 00:01:07.182
If you're really struggling with
it she'll help you out with it,

00:01:07.182 --> 00:01:10.038
if you just don't get what the
video is trying to ask you.

00:01:10.038 --> 00:01:12.842
Girl in pink: I like how it's
different than the Math book

00:01:12.842 --> 00:01:15.739
when everyone's doing pretty
much the same level of things,

00:01:15.739 --> 00:01:18.630
and if you're like higher
then it's boring for them.

00:01:18.630 --> 00:01:21.240
If they're like lower they're
not exactly understanding it.

00:01:21.240 --> 00:01:25.751
Girl in pink: I used to be afraid to
like tell her what I'm struggling on

00:01:25.751 --> 00:01:29.509
and now that she can see how
we're doing on the Khan Academy

00:01:29.509 --> 00:01:33.256
it helps me feel more
comfortable talking to her

00:01:33.256 --> 00:01:35.070
about what I'm having trouble with.

00:01:35.070 --> 00:01:36.924
Boy in blue: You get to move
at your own pace with it

00:01:36.924 --> 00:01:39.396
because there are all sorts
of challenging exercises

00:01:39.396 --> 00:01:40.798
and there are easy exercises.

00:01:40.798 --> 00:01:43.920
Girl in pink: It's really fun
because you can try to get badges

00:01:43.920 --> 00:01:46.502
and you can challenge yourself
and do different kinds of Math.

00:01:46.502 --> 00:01:49.408
Boy in black: There's meteor
badge, moon badge, earth badge,

00:01:49.408 --> 00:01:51.042
sun badge, and black hole badge.

00:01:51.042 --> 00:01:56.603
Girl in green: I didn't really remember
exponents even though I did it once.

00:01:56.603 --> 00:01:59.674
I didn't remember it very much
and then I watched the video

00:01:59.674 --> 00:02:02.903
and now I know exponents, really easy.

00:02:02.903 --> 00:02:07.552
Boy in blue: The guy who makes them,
Sal, he teaches the subject really well.

00:02:07.552 --> 00:02:10.258
Girl in pink: It's like he's
probably like writing on the computer

00:02:10.258 --> 00:02:13.723
because it shows this little mouse
and he talks into the microphone.

00:02:13.723 --> 00:02:18.694
He explains all the subjects in a way,
it just makes it really easy to learn.

00:02:18.694 --> 00:02:20.754
Boy in black: Well my parents
think it's really cool,

00:02:20.754 --> 00:02:22.913
they think it's a great idea
that we're doing this site.

00:02:22.913 --> 00:02:26.246
The good thing is we don't have
to be at school to learn Math.

00:02:26.246 --> 00:02:28.973
We can just be at home on our
computers basically doing it.

00:02:28.973 --> 00:02:30.620
Girl in pink: Like if it's a
rainy day you can just do it

00:02:30.620 --> 00:02:33.066
and then you can energy
points and get badges.

00:02:33.066 --> 00:02:35.633
Boy in blue: I really like it when I
finish one of the really hard ones.

00:02:35.633 --> 00:02:37.053
Boy with eyeglass: It's a tool for life.

00:02:37.053 --> 00:02:40.544
Everybody needs to know how
to do certain things in Math,

00:02:40.544 --> 00:02:42.472
not just if you're going to be

00:02:42.472 --> 00:02:46.724
like an astronomist you
have to know everything.

00:02:46.724 --> 00:02:49.862
Boy in gray: One night I was
just working on this lesson

00:02:49.862 --> 00:02:51.706
and I just couldn't finish it.

00:02:51.706 --> 00:02:57.079
My Dad said you can't play with your
friends until you finish that lesson.

00:02:57.079 --> 00:03:02.568
Then i finally finished it because I
watched the video and I really learned it.


The Gates Notes: Teachers in Los Altos

WEBVTT
Kind: captions
Language: en

00:00:12.216 --> 00:00:14.340
RICHARD JULIAN: It's a
tremendous impact, actually,

00:00:14.340 --> 00:00:15.950
that I'm seeing
through Khan Academy.

00:00:15.950 --> 00:00:18.690
The most impact I see
are for those kids

00:00:18.690 --> 00:00:20.820
who really need the challenge.

00:00:20.820 --> 00:00:24.150
And I also see the spark in
the kids who've struggled,

00:00:24.150 --> 00:00:26.110
who, in a whole
group math lesson,

00:00:26.110 --> 00:00:30.630
can appear to be lost and
then shy and then try to hide.

00:00:30.630 --> 00:00:33.690
And now they can hide behind
their computer screen,

00:00:33.690 --> 00:00:36.010
so to speak, and continue
to work at their own pace.

00:00:36.010 --> 00:00:37.468
COURTNEY CADWELL:
A lot of students

00:00:37.468 --> 00:00:40.230
are very cognizant of where they
are in relation to their peers.

00:00:40.230 --> 00:00:42.640
Some of them won't
want to appear smarter.

00:00:42.640 --> 00:00:44.410
Some won't want
to appear slower.

00:00:44.410 --> 00:00:47.590
Those students will
hesitate to ask questions.

00:00:47.590 --> 00:00:49.580
They just want to be
right there in the middle.

00:00:49.580 --> 00:00:52.150
Teaching to the middle
only does the middle good.

00:00:52.150 --> 00:00:55.740
And it seems like you're leaving
out 2/3 of the class that way.

00:00:55.740 --> 00:00:57.990
And so there has to be
a better way to do it.

00:00:57.990 --> 00:00:58.760
KAMI THORDARSON:
The Khan Academy

00:00:58.760 --> 00:01:00.865
offers an assessment
piece that's incredible.

00:01:00.865 --> 00:01:03.890
It's so right there
and immediate.

00:01:03.890 --> 00:01:05.960
It's a quick picture of
where students are at,

00:01:05.960 --> 00:01:09.030
where they are having issues,
where their struggles are.

00:01:09.030 --> 00:01:11.690
COURTNEY CADWELL: So I know
who I need to visit with,

00:01:11.690 --> 00:01:13.400
and where I can
help them, where I

00:01:13.400 --> 00:01:15.375
can come alongside, and
remediate and support.

00:01:15.375 --> 00:01:17.000
KAMI THORDARSON: They
love those "aha!"

00:01:17.000 --> 00:01:18.583
moments where they
can be the teacher.

00:01:18.583 --> 00:01:20.260
And they can tell
me about something

00:01:20.260 --> 00:01:22.065
that they think I
don't know how to do.

00:01:22.065 --> 00:01:24.250
RICHARD JULIAN: My students
select weekly goals

00:01:24.250 --> 00:01:26.310
for themselves, based
on their own data.

00:01:26.310 --> 00:01:28.690
So I have them looking
at their own data now.

00:01:28.690 --> 00:01:30.210
COURTNEY CADWELL:
In a graphic way,

00:01:30.210 --> 00:01:33.200
they're able to visualize,
in a very concrete way,

00:01:33.200 --> 00:01:34.452
their progress.

00:01:34.452 --> 00:01:36.410
Usually you just move
through a math classroom.

00:01:36.410 --> 00:01:38.230
It's like, OK, we
finished this chapter.

00:01:38.230 --> 00:01:39.500
We finished that book.

00:01:39.500 --> 00:01:42.160
But the kids don't
really see everything

00:01:42.160 --> 00:01:43.250
that they've accomplished.

00:01:43.250 --> 00:01:46.094
And this lets them see it,
and it makes it real for them.

00:01:46.094 --> 00:01:47.760
RICHARD JULIAN: And
then, at that point,

00:01:47.760 --> 00:01:51.060
I was excited for my kids,
because I saw that, again,

00:01:51.060 --> 00:01:54.880
as being a tool for them that
ultimately would help them

00:01:54.880 --> 00:01:57.660
become responsible for their
own learning, and deciding hey,

00:01:57.660 --> 00:01:58.940
this is where I need work.

00:01:58.940 --> 00:02:00.930
COURTNEY CADWELL: The
kids are enjoying it

00:02:00.930 --> 00:02:03.330
because it's very
engaging for them.

00:02:03.330 --> 00:02:05.998
I'm enjoying it because my
kids do, my students do.

00:02:05.998 --> 00:02:08.039
KAMI THORDARSON: Kids go
home excited about math,

00:02:08.039 --> 00:02:09.400
and that's what parents see.

00:02:09.400 --> 00:02:11.670
They see that kids are
talking about math.

00:02:11.670 --> 00:02:13.630
They're discussing
what they did in class.

00:02:13.630 --> 00:02:15.620
They're showing them
something on the computer

00:02:15.620 --> 00:02:16.995
that they just
learned how to do.

00:02:16.995 --> 00:02:19.536
COURTNEY CADWELL: Parents know
their kids better than anyone.

00:02:19.536 --> 00:02:21.472
So they can encounter
a Khan Academy problem

00:02:21.472 --> 00:02:23.430
if they're working through
it with their child.

00:02:23.430 --> 00:02:25.680
They can say, hey, remember
when we were at the beach?

00:02:25.680 --> 00:02:29.290
And we did this, and this
is what was involved.

00:02:29.290 --> 00:02:33.380
And so they can really help
me tie these new concepts

00:02:33.380 --> 00:02:36.570
to previous learning if they
get involved with their kids,

00:02:36.570 --> 00:02:38.230
with the Khan Academy, at home.

00:02:38.230 --> 00:02:40.070
RICHARD JULIAN:
Math, I always found

00:02:40.070 --> 00:02:42.420
after teaching for 21
years, kids love it

00:02:42.420 --> 00:02:44.350
or kids don't love it.

00:02:44.350 --> 00:02:46.900
And now I think I've
got 27 kids in my class

00:02:46.900 --> 00:02:50.920
who could, at some point during
the day say, hey, I love math.