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And thank you and welcome everybody. Welcome to those of you here at the college and a special welcome to those of you online. This is your day. This is a day for trainers, for trainees, for those interested in education. The college means different things to different people. But really what our ra on Dery is about the training and improvement of quality in surgery. So, although there are many things that the college does and you may have interacted with the college over many different issues which are all important in their own way. The education of current and future surgeons is really core to what we do and that is the reason for today's conference and for many of the activities of the college, I particularly like to thank Jane and the events team for putting on the event and for all the practical arrangements. And I'll say a bit more about that later and also to Louise and the education team for setting together the program and so on. Now, Jane has done the sort of housekeeping announcements, but there's a few other things I need to mention at the beginning because otherwise I'll forget later. On in the day. Um If we come to the end of the day first, we are celebrating 30 years of the basic surgical skills course this year and there is an event later on this afternoon and this evening to celebrate that, um I don't know if I should ask for a show of hands in the room. How many of you have either done BS S or tutored BS S virtually everyone. So it's meant something to all of us in our careers. And, um, you're all welcome to join us in the library, which is on the first floor below here. Sorry, the people online. Unless you can rush up to London, you're not going to be able to have tea and cake or drinks and cake or whatever it is. And for those of you that haven't seen it, the, er, newly refurbished and reopened Teron Museum will be staying open and I would say that if you haven't seen, um, The Hunter in the New Hunter in Museum, it is definitely worth a look. It is an absolutely fabulous collection of specimens, photographs, paintings and the history of anatomy and surgery. You won't see anything like it and it's worth a trip to the college just to see the museum. So they're holding it open for us and anybody is welcome to go down there at the end of the afternoon. So that's later in the day. Now, during the day, we'll have a mixture of podium speakers and breakout sessions, which I believe you have all signed up in advance for whichever one you want. And you should find it on your badge. If you've forgotten which one you signed up for, if somebody desperately wants to change the session that you signed up for, then, um, see Jane or Louise or one of the team. But in general, hopefully you'll be ok with the one that's on your badge. And the people online, there are online breakout sessions which again, I think you've signed up for in advance in terms of interacting when we come to the sort of question and answer or free sessions. If you're in the room and you wish to either ask a question or make a comment. Could you raise your hand and wait for somebody to bring you a microphone? Because otherwise the people at online won't be able to hear what you're saying. And likewise for people online, if you wish to ask a question or make a comment, um please type it into the chat function and somebody here is monitoring an ipad which will ask the question for you. Um As I say, it's your day interaction is the name of the game. Now, we're going to cover quite a number of different issues today. I hope that the program will provide at least something for everyone. It's a very varied program covering lots of different topics related to surgical education and training each of you may have particular areas that interest you or which you have a particular um view about. Hopefully there is something on the program that appeals to each of you and maybe there's some of you which everything on the program will appeal to. So hopefully it would be a good day for everybody. Um The platform that we're using for the event today to do the sort of it and online bit and please don't ask me anything about how it works because I know nothing about it but what I am told, so you'll have to ask someone else if this doesn't make sense. But there are some extra features to the program if you've registered through the um system, which is that there's um a reading list for those who want to read around any of the topics. There is um a bonus session from Josh Burke on the future surgery test report and there is further information regarding our conference sponsors. On which note, as you can see from your badges, we have four sponsors who are in the room where coffee and so on and lunch and so on will be served. Please do visit the spon. Um We rely very heavily on partnerships with industry and educational um organizations to put on conferences like this. So please do visit their stands during the breaks. Um Now we'll move on towards the um first session. I'm delighted that my co-chair for this session is Mr Richard Kerr. Um Many of you will know him either through his work as a neurosurgeon or for many years, he was a council member here at the Royal College of Surgeons of England. And he chaired the learning committee. It is his wise leadership that has brought together this conference. He was instrumental in so many developments that the college has done in the educational field over the last few years. Um And I personally would like to say thank you to him. I, I joined Council in 2020 which was rather a strange time because we went online and we didn't meet in person for the first year or so that I was on council. And so getting to know people and how things worked was very difficult. And I would personally like to say that I found Richard's wisdom and thoughtful and measured approach to so many of the really contentious and difficult issues that we do face as surgeons to be an enormous help to me in understanding how the college worked and how to think about difficult issues. And I think there's a lot, we, we are grateful to him and a lot I personally have learned from him. So I personally like to thank Richard for that. Now, he's, I'd like to invite him to come and um co-chair with me, probably the thing that many of you will know him best for is that he um led the um future of surgery report, which will come up today. And that I think has been a helpful blueprint for how things go forward. So the first session today is very much around the work of the future of Surgery Group and report and Richard, thank you so much for the work you've done. And may I hand over to you to introduce our speakers in the session? Thank you, Rachel. Thank you very much. Good morning, everybody. A huge welcome from me to the, the revamped Royal College of Surgeons. I hope you have an opportunity to look round my thanks to the sponsors without you. These events just don't happen and we're very grateful to you for supporting events like this, but also for the continued support you offer us as the months and the years go by. Um I also just want to say thank you to the, the sort of team who are involved with putting all this together and the continued work particularly of the learning department. You are amazing. You need that recognition and I'm only too pleased to give it to you. So, thank you for that. Um, er Rachel, I'm very pleased to be able to hand over the learning committee to you. I know it's in very safe hands and I look forward to watching as it develops as the years go by. So, er, again, er, thanks for that. Um We're going to talk about, er, er, just in brief, the future of surgery and how that came about. And then we're going to move on to a much more contemporary look at what the college is actually doing at the moment, given the findings of the commission on the future of surgery. Um, so I need to get on to the first presentation, which is the, um, the, there we go. Uh, so the, um, the commission was really brought about following a discussion that I had with the then president of the College of Surgeons Derek Alderson back in 2017. Um And the, the reason why we felt it was important to do this was that so much of surgery, the delivery of surgery and to some extent, the training of surgeons was, was short termism. It was all about the next few years and how we were going to do this. But it was also apparent that there was a, we were in the middle of a digital revolution at that time and that digital revolution was going to affect all aspects of our life, not just health care, but every aspect of our life. And it felt really important that a, a learned body such as the College of Surgeons of England had a voice in the discussions about where surgery was going and it wasn't about what was happening five years down the line or 10 years down the line. It was about looking much further, perhaps 20 years down the line. And from that we could begin to position ourselves in terms of expectation of what would be the needs of surgeons and surgical teams for the future. But also how do we train those surgeons and surgical teams for the future? And today is about how do we train those surgeons and surgical teams for the future, embracing the new technologies as they come along. So it was set up in October 2017 and we had an amazing group of, of people with a range of skills, many of whom were not surgeons, they came from the world of genomics, they came from the world of engineering, they came from the world of robotics. Um But the aim was to try to, to look forward and produce a document that could act basically as a a blueprint for how we we go forward. We had a whole series of written contributions, we had days of oral evidence, er which was extraordinary and then the document was finally published right at the end of 2018. And what it demonstrated was that there were going to be four major areas of technical development that would impact how we deliver surgery. I have to say when I started this, I thought we were going to be talking about new operations and new ways of doing old operations. But actually, the majority of this wasn't about surgery, it wasn't about how we actually do something. And the majority of this was about the use of, of new technology, the various forms of of reality, whether it's augmented reality, virtual reality, mixed reality. So the immersive spaces, it was about using data to move towards personalized care. It was about the importance of genomics and the assessment of data using A I. And then it was about some other specialized interventions like the use of xeno transplantation. And I obviously was fascinated to see that we're now doing xeno transplants. The second one was done in the U si think just this week for someone with end stage cardiac failure, in terms of surgery per se, it was increasing use of minimally invasive surgery. Um and particularly the use of robotics as a way of delivering that surgery. But I, I wouldn't want to forget that it moved beyond robotics into the world of nano robotics as well and how that too might be applied in surgery as we go forward. So, um what it meant for patients in terms of what came out of the commission, er, was certainly moving from treatment advanced disease, so to try to diagnose disease earlier, so that we can move much more towards organ sparing er, surgery. That was really important. If we could pick up the disease at a much earlier stage, there needs to be a shift in our health care away from playing catch up er to um much more preventative healthcare and identifying disease at an earlier stage. Um There needs to be a development of the surgical team in its broadest sense and that incorporates working obviously with patients as part of that. Um and looking towards surgery aimed much more at trying to improve quality of life rather than I say, playing catch up as we seem to have done all the way through. That also meant changes in surgical training. You can't bring in those sort of alterations for patients unless we change the way that we trained and, and published at the same time was the top pole report, you'll remember. And that too, um noted the importance of the whole team delivering surgery, being educated in digital health care at its broadest sense. So training curricula are going to need to change and we need to bring in flexibility in that training curricula. Recognizing that we're probably gonna move away from the classical coal face surgeon who's doing the same sort of thing for the 30 or 40 years of their career. There may be different phases in our, in our surgical careers going forward from yes, being a coal face surgeon, but maybe being an innovator or researcher or an administrator or a teacher. And the importance of recognizing teaching as such a major part of surgical training, the training's got to be more diverse so that we can engage in those discussions about computing engineering, molecular biology. We've got to know the language that our colleagues are speaking. If we're truly going to innovate in the way that we want to, um we've got to make sure that when we're bringing in this new technology that, that important relationship between doctor and patient is maintained, the humanity has to be there as we go forward and, and as we become more technically orientated, there's always a risk that humanity gets lost in that data analytics are going to drive this. If we can analyze big data sets, we can get towards personalization of, of care. And that too is really important and that may bring about the need for a much more diverse entry into medical school which to some extent has been fairly narrow in the, in the years that have gone in terms of minimally invasive surgery. Number one in that list that I mentioned um developments in laparoscopy and endoscopic surgery, but also robot assisted surgery and we've seen robot assisted surgery literally explode in the last five years since the commission was published. Um It's, it's involving much more diverse areas of surgery for much wider groups of patients and the benefits. I think we're beginning to see as we collect the data. But in the longer term, are we going to move to a point where we get robotic autonomy? Um There's still a lot of people out there, a lot of patients, a lot of members of the general public who actually thinks that's what robotic surgery means. It's robots doing operations. Of course, it's not, we know that it's a really posh tool. It's a really good tool, but it's a posh tool. Nano robots. I've mentioned, what will this bring hopefully less variation in surgical outcome? That has to be that, that Gaussian distribution of outcome becomes much narrower as a consequence of refinement of techniques and standardization of techniques. And will we move towards evolution of surgical technicians instead of of surgeons doing all these procedures? Lots of questions are set by this. So in order to answer the question, what happened next? I'm gonna ask Ralph Thomson to come and speak to us who is a a trusted and dear colleague based here at the college. So Ralph is director of research, quality improvement, professional clinical standards. He has a long background of working with doctors and health care organizations looking at performance issues and he's been pivotal in driving these changes that we're talking about through the college. What he also does gives him a great insight into what's happening is he runs the, the IRM program, the invited review mechanism program here at the college. And that looks at um some of the issues that colleagues and institutions are facing particularly at these times of great pressure within healthcare. So, Ralph, I look forward to hearing your thoughts on what happened next. Thank you very. Thank you very much, Richard and for all the brilliant work you've done with the future of surgery program, we couldn't have got to this point without you. Thank you. Um, I think what happened next? The question for everyone in March 2020 is there's probably a very obvious answer and you can probably all get it. Um, but Richard has done all this enormously brilliant work in the future of surgery reports. Um, and then Coronavirus hit and we were all locked down from March 2020 onwards and we've all got our own different individual stories to tell about that. So, I mean, who could have predicted that? Well, in fact, actually Richard himself in the future of surgery report on page 92 said this and I won't read you all of it, but the second paragraph is most pertinent. Um So you heard it here first, Richard was spotting Coronavirus before it was even known. And if you want your lottery numbers for this week, please get in touch with him afterwards. Of course, my time. So, so we're next for R CS England. Um Like every organization we had to dramatically change what we do, how we do it and respond to that challenge. I could talk for hours about how we did it, but I think we did some fantastic work and really took on that challenge and, and responded quite brilliantly to some of those challenges. Lots to learn from it, but lots of things I think we did really well as things settled down, we regrouped and I'm sure you'll all seen this document, but we published a strategy when we reopened this brilliant building in 2021 as a five year strategy, I'm sure you'll all be very steeped in the strategic aims. But I'm very proud to say that I lead a lot of the work in the improving practice. One of these five strate strategic aims particularly take forward that and really just kind of show you how we cited this work in our future work as a college within that strategic plan. We have this aim where we're seeking to lead innovation and change in our pioneering work in the future of surgery, particularly use advances in science and technology to drive improvement, training, education practice and hopefully therefore through that patient outcomes. At the same time, we had through Derek Alderson's foresight, set up a robotics program, Professor Naam Suru and also Professor Simon Bark Naim is in Newcastle, a urologist and Simon's in Birmingham, a colorectal surgeon galvanized the program of work in robotics and some people might have attended a webinar. We ran to launch that program of work in the first three years of our work, I'm just going to cover now in terms of what we've done and then where we're going next with the next three years from 23 to 26. So the first thing we did, we wanted to influence um if there is a technology company out there or public body that has an interest in the future of surgery or future of surgery training that Richard hasn't met, I'd like to meet them because he had a whole series of different meetings both before and across lockdown with all these different people trying to influence and affect change, which I think is a really difficult and subtle thing to achieve. But I think we can demonstrate that we've managed to get a lot of progress in a number of important areas. A really interesting first research output as a systematic review, I commend to you in BS open in 2020 done by a team in Oxford. Looking at the evidence base for robotic assisted surgery, lots of interesting findings within that and then also lots of discussions with industry to start off with and then the N I hr to get two big research projects going, one called mastery and one called Reinforce. One's more focusing on the technology and how the data recorders in robotic surgery can be used to develop practice. And the other looking at the qualitative study of the accelerants and barriers to introducing robotic assisted surgery. Um really pleased that reinforce has got an N I hr significant N I hr grant for phase two of their work and they continue a pace. We've been delighted to work with health education England appointing a joint fellow to undertake some research in development of robotic assisted surgical training. Charlotte. L sayed in Birmingham has been undertaking a really interesting research project. She's getting to the third year of that piece of work now and lots of interesting stuff going on there. We've also got as hopefully, people have seen the future of surgery e-learning resources within that as a dedicated robotic assisted surgery module which provides a really good introduction into this subject matter area. And you'll hear from Matt about the fantastic work that he and the team did with the test report in a minute. We're very pleased to support that and work very closely with Josh to get that off the ground and going delighted that we've just announced we are entering into or have entered into a funding partnership with intuitive supporting our program management for the next three years. So that's really going to galvanize a lot of the activity that we're doing. Um And we've just launched some pump priming grants on research in robotic assisted surgery through the support of a particular long standing thro that supports our work. And we're delighted to have that program of grants live on our website. I think it went live last week. So overall, we have a really thriving and dynamic program of work in robotic assisted surgery across these four different domains, facilitating research, improving training, using data to improve practice and raising participation and public and policy awareness. Hopefully, people who have seen our good practice guide to robotic assisted surgery we published across the summer. Again, another really good resource talking specifically about our learning activity. There are other experts within the room that can speak to this much better than me. Um But we have a current portfolio of learning activity um and what we want to do is look in a structured and systematic way in which robotic assisted surgery can be integrated into each of those different components of that offer. Initially, looking at the existing offer and looking at that as I say, pragmatic systematic review and then integration into the portfolio thinking of all the different dimensions of it as much, how we support faculty within that as we support trainees and people attending the courses within that. So just trying to really think things through systematically and not just think there is one single solution to this and have a much more kind of strategic approach to integration across all the current portfolio. Couple of examples of that already talked about the e-learning module, looking at core lap and inter lap as two examples of things that are being reviewed and renewed. Um We're also looking at a human factors element of robotics. I think there's a particular area of unmet need there in terms of what's available and scoping that and looking how we could support the better discussion of human factors in robotics and all the different dimensions that at each stage of the surgical career and have different offers for each. Um So alongside that, that's what the college is thinking through currently. How can we extend our influence through our accreditation services as well. There's lots of robotic assisted surgery training going on all across the UK. In the last 3 to 5 years, we've really put a lot of energy into our accreditation services as well. And I can show you slides like this demonstrating our sort of multi national accreditation presence across lots of different providers of robotic assisted surgery. Um and we have a huge global portfolio now of accredited centers, more details in the slides, I'm sure are going to be shared after the meeting. But we across the globe now accredit about 75 surgical education centers, major impact through that UK centers are also really important to us. There's probably about 25 to 30 of those and then single accredited courses also exist within our portfolio. Um Another critical area for us is supporting the end stage trainee transitioning into consultant practice and particularly the senior clinical fellowship approval process. And we have an increasing number of robotic assisted surgery, senior clinical fellowships. And we're keen to further strengthen that. And then finally, we're looking at engaging with emerging training across the UK. People might have heard about this excellent pilot that's taking place in the North East between He Newcastle um to take forward opportunities for robotic assisted surgery and training. So there's lots going on. In summary, we're leading the future of surgery. We've got an exciting program of work. We're just really keen to facilitate the safe and systematic integration of robotic assisted surgery into UK health care, major programs of work across those four areas. I've mentioned education is absolutely critical to that. We're trying to link it all up through our robotic assisted surgery network. And there's opportunities for everyone to get involved in that. Our next meeting if people want details is on Thursday, the 30th of November. So please do get in touch and thank you. Good. Um We did. Um Are there any specific questions from the floor when I drop this thing on the floor? Uh Any questions anyone wants to ask anything at this stage? No, Ralph, you're going to be here all day, aren't you? I'm here all day, but I've got a NIP house at 11 so I can see people at various points during day. So there will be opportunities during the day very much that Chuck. But thanks Ralph for that. Um ok, we're going to move on um to two presentations which I think are crucially important. Um So we've sort of set the scene in terms of where the college is going and the areas of importance, but now we want to focus down a little bit more on. Ok, that's all very well. You saying that, but how you gonna do that? How are you actually going to bring some of these things into place? Um And so we've got er, presentations, er, from Matt Harris who's going to look at the test report and then also a presentation from Andrew Stevenson, who's going to look at the questions of sustainability in surgical health care and, and how we're going to deliver this for the surgical community. So I'm going to ask Matt to come up, first of all, just to introduce Matt, he's a general surgery reg in the North West, but he's actually doing a phd at the moment. It started in April, I believe. Um looking at how obesity will impact on the development of, of colorectal cancer. Um He's also completed a postgraduate diploma in surgical innovation with Imperial College and he's been integral as he sits on the executive Committee of Assets and his particular area that he covers is robotic and digital surgery. Um He's part of the executive of the A S GBI, the Rou group and the British Association of Day Surgery trainee representation. And he's passionate about how we develop and implement evidence based surgical training, particularly when things are moving so quickly. So, Matt, thank you so much and we look forward to hearing your thoughts on this. So thank you very much for a very thorough introduction and thank you for the organizing committee, especially for having me here to talk about technology enhanced surgical training um and really where things are going to go. So, um we've already kind of touched on the fantastic future of surgery report. Um And a second report that's come out of this is the technology enhance surgical training report. The test report published just last year chaired by a colleague, Josh Burke. And what that really kind of looks at is what are the unmet needs of trainees. Um And where are we going to go? So if you haven't read these already, they're free and available online, I would really, really encourage you to do so. Um I'll show you these QR codes again at the end just so you can pick them up. Um So it's difficult to talk about surgical training at the moment without at least briefly mentioning COVID. And this is a graph predicting how we may recover these lost logbook cases from June 2021. And I think it's, it's probably fair to say looking at the data that actually we've really gone along with kind of that, that normal activity type of trajectory with a massive amount of lost cases over that time. But actually, it's not just COVID that's caused some difficulties with surgical training. I think it's just highlighted there. It's multifactorial leading to what has really been a reduction in overall training time for trainees over the past number of years, whether that's the way they we work um in terms of our contracts, whether that's how our pedagogy has changed. Um moving away from that kind of apprentice model to something more curriculum based, more outcome based and even the way that we're supervised. So with having um our trainers and consult consultant led to care more there in the hospital, which of course is great. Um but equally can potentially contribute to this training time. It's also staffing and workforce pressures that can contribute to trainee burnout changes in the capacity and efficiency. And of course, even the changes in the way that we operate. So we've, we've talked about robotics already and that comes with its, its whole other challenge in terms of our trainers also being on the learning curve at the same time as that we're experiencing this. So with less time, how do we make sure that as a trainee, we progress up this learning curve to the top and become safe surgeons. So this potentially is where technology can come in. And this is what's been highlighted from from the technology enhanced surgical training report is it that we can address this very first part of the training curve and we can progress trainees up this part with without even having to be in theater. Whether that's with advanced simulation methods. Can we affect this steep acceleration part of the curve? Can we make the most of our time in theater in clinical practice or even shift the plateau higher with decision making tools with more advanced surgical tools? So the three key aims of the test report were to define current unmet needs, assess the evidence of current technologies and future technologies and then make recommendations about what how we can develop and put these into practice. So the unmet needs were defined by a series of of kind of the synthesis of evidence and some couple of days of hackathons. Um and really the the um kind of the themes were very similar to what we've talked about already about this reduction in operative cases, reduction of time in hospital workforce pressures, difficulties without accessing simulation, difficulties with accessing teaching and to quickly go through five of the domains that's outlined in the report. Um how can technology increase exposure to operating? And these five will go through? And I think it highlights some really important points and then we'll talk a little bit about potentially how we can progress from this report. And what little bit about what we're doing at the moment. So firstly, how can technology increase exposure to operating? So we talked about that very first part of the learning curve and over the past 10 years, simulation fidelity has not been fantastic, but actually recently, it's really becoming quite impressive. And you know, you can see you can even do almost full operations with the um with the help of extended reality. Also consider advances in 3d printing and this higher fidelity simulation allowing this kind of early part of the learning curve to get closer to reality um and help kind of progress up that early part of the learning curve. And of course, the ability to er have access to operations without even having to be in an operation. Yet, I think that's particularly important to make the most of your time in theater. So you, you know, you've seen it, you know, the steps you can take that bit out of your brain and then you can go and really learn what you need to learn in terms of procedural and decision making skills at the higher part of the learning curve, perhaps not necessarily available yet. Um but certainly potentially will be in the future the use of big data, whether that will be intraoperative imaging and intraoperative decision making, helping trainees make those decisions. And again, kind of take away some of that attentional capacity that's required in theater. One thing that I think is, is easy to forget with all of this kind of cool technology on the go is innovation in education. Actually, this can be some of the the most impactful things that we can do. So this is a surgical education checklist. It's something that I use myself. I try to do it with trainers or even when I, you know, I have an sho in theater, it's based on the who checklist. It's um from Poppy Redman, it's really, really useful. Um I would definitely ask you to have a look and see what you think about this. It's available here. Um It's available kind of free on the internet, really worth a look and we talked a little bit about already the inclusion of robotic curriculum. So robotic surgical training is new. It's obviously here to stay. And this, I think is a really important point of time where we need to really kind of progress with this and make sure it's evidence based and robust. And to highlight this, about 86% of prostatectomies are done robotically. Um But there's no mention of robotics within the surgical curriculum um to highlight kind of trainee involvement in robotics. This is a study from Christina Fleming and some of the team at asset in 2021. Um that actually 72% of surgical trainees hadn't had any access to robotics at all at that time. Now, of course, that's probably changed a little bit and it's something that we'll plan to update in the next few months. But I think it highlights some of the difficulty in kind of the inequity of access across the country. Um And this is literally just been published actually. Um we've talked a little bit about getting this kind of this curriculum sorted and robust. It's a delta consensus from, from Jo be al. Um And I think this is a really great basis to start having um kind of evidence based curriculum in robotic surgery. And it's also been progressed with Charlottes side who's already had a mention this morning. Um in terms of the kind of the qualitative aspect of how a core surgical robotic curriculum may work. But what next? So we've got the core surgical curriculum sorted. One interesting paper from the US that was published in the last year or so was about credentialing between platforms. And how do you tell whether a a robotic surgeon is um safe? I think it's an interesting piece of work perhaps to explore whether this is applicable to this country. I'm not sure, but they go and of course, with um with asset and with the Royal College of Surgeons of England, it's really important to have these forms to discuss like today and make sure that we kind of we progressing these discussions and having the right stakeholders on board. And the final kind of point of robotics at the moment is to not forget that this is a pan specialty issue. Um It's easy to get bogged down in intuitive and da Vinci um in general surgery because that's where it's used most. But actually we see orthopedics, head and neck surgery already thoracic surgery, pediatric surgery, plastic surgery, I think it's really important to, you know, have pan specialty involvement from the very start. So how can technology enhance training on the patient pathway? And I think this is mostly about digital literacy um and having trainees and trainers have a good understanding of what's going on whether that be the uptake of virtual wards and tele clinics. Um whether that's the inclusion of art artificial intelligence decision aids, not, not even necessarily in just in endoscopy that we see at the moment, but also even in things like operative scheduling or even rota management, something like that, having a good idea about how this is, this is going and how we can do things may help training and trainees benefit. Um And an understanding about how wearable technology can, can get data. We talked about big data and data analytics. Um I think it's really important and I think the the need at the moment is highlighted by the fact that the only surgical specialty curriculum that mentions anything about technology is plastic surgery. And I'm sure that this is something that's going to change. And we've already spoken today about the need for having this ability for trainee to innovate and understand technology. So how could technology support assessment of competence? We already have the technology for video storage. Um And this is something we'll talk a little bit more in detail. Um This is something that I think can really be beneficial in terms of the ability of trainees to kind of reflect and get the most out of every case, also potentially even remote competency testing and recording of operative metrics. And this is um part of the CMR core surgical training curriculum where part of it is done during virtual reality and you can even do that at home. Um And finally, we need to consider as well kind of trainer recording perhaps um operative storage. There may be some barriers to this, I suppose. Um But to recognize kind of how excellence in training can happen with this technology, I think is important. So to highlight potentially the need for um kind of improving our workplace based assessments and reflection. Um This was a study led by Asset and Andrew Bish. In 2020 40% of trainers were aware of unobserved sign off of their workplace based assessments. So trainee are just doing it themselves. And actually 34% of trainers had disclosed their passwords so they didn't even have to bother with it. I think that highlights perhaps that perhaps it's not the best way of efficiently getting that reflection time. Um Whether having the ability to do this via kind of reflection via video, it may be more efficient even if it's more time consuming. Um personally, I think it may be more worth it because the technology is there. But also the really important point is that we make sure that if we do employ intervention like this, it's evidence based, it's robust and it's applicable to this country. So how can innovation help the surgical workforce? And um this is really important, there was recently this census which will be really interesting to see what the outcomes were in terms of workforce planning. Um And that kind of leads on to potentially one of the most important parts of this presentation in that if we're making training interventions, these interventions have to be centered on the trainee. Um You know, are we creating more work, more hassle to trainees who are already at record levels of burnout. Um I think it's absolutely critical to have focus things on unmet need, focus things on education rather than implementing technology there because it's, it's cool, essentially, there's also kind of novel digital mentorship um methods, whether that will be kind of virtual or or otherwise that can help kind of tackle this side of things potentially. So kind of final section, what needs to happen to embrace technology enhanced surgical training? Now, there's obviously a huge amount of potential barriers and this is the need for having all stakeholders on board throughout the entire process. Um And you can see through the work of the future future surgery report and through the test report, there's a massive number of people, people who are at these evidence submission sessions are totally multidisciplinary, including, you know, public industry, even politicians. And this is a really interesting schematic that I think highlights the importance of going through and making sure anything that we're going to adopt for surgical training um has been assessed properly. Um As I've mentioned, what we don't want is to find a cool technology, put it into practice and find that A it costs loads of money. B it's a hassle for trainees and see if it makes no difference. So really importantly, focusing on the unmet needs of the trainee as as the the start and the potential solutions at the start together, making sure there's a robust evidence base considering the the scalability, sustainability, cost effectiveness and feasibility um before kind of going on to, to adopt this into the, into the NHS and potentially thinking something like along the lines of an ideal framework for a specialized surgical training intervention, um kind of a phase by phase type study looking potentially something like this. So we've talked about all of this evidence based, making sure it's it's trainer centered sustainable. But actually the other thing to highlight is we need to make sure that it's all it's acceptable to patients. Um That the the whole point of what we're doing here is to drive improvement in patient care. And I think that's it's sometimes easily forgotten um when we're talking about this. So there are seven key recommendations that came out of this report. Um We need to make sure there's an evidence base that that any interventions are well resourced. There is training in digital technology for everybody. We have industry collaboration and multifactorial collaboration. There's a clear outcomes framework for any intervention. We have research initiatives set up to set up this evidence base and that we safeguard our patients. So what does this mean for trainers? Um it's similar but perhaps there are some other things to think about. So one thing I think that's really important is if we are going down the lines of these technological interventions, keep in mind how this is going to affect between regions specialties and even different ed groups, how they are able to access these training interventions. Um making sure that it's equitable across the country so that no trainees are left behind. And we don't kind of encourage any differential attainment between groups to also make sure that surgical research training for everybody, not just trainees, but trainers and the importance of evidence acquisition and also considering human factors, which again is something that has been touched on already this morning. If you're bringing in technology into the operating theater, this is going to change how your trainee are thinking it, you know, having something else to think about reduces your attention capacity. Um and the kind of that awareness and understanding of human factors and something that you're doing um is really important to consider. So again, we've already talked about having a defined pathway for innovation development. This is something in the pipeline with the ideal collaborative um making sure that there is digital literacy across the board from, from trainers and trainees and really encouraging that um having inter interdisciplinary collaboration, whether that's from industry, but also considering the extended surgical team and pan specialty and even the public and making sure that we have all of those stakeholders on board. And finally, um one point to think about as big data and artificial intelligence improves is the ethical considerations of decision making. Um taking over kind of, you know, our decision making and patient care. So finally, kind of a few things to touch on in terms of things that we're doing at the Royal College of Surgeons of England. And as it from a training point of view, um we've talked about this robotic core consensus that was published just last month. Um And the next steps will I think be be thinking about more consensus work in, in terms of training interventions and where things will go. We'll have our robotics for trainees conference, hopefully mid next year, which is going to be a really important platform. I think now is a really a really important time for this. And also of course the um the Innovation Summit at the Future Surgery Show in November. If you don't have a ticket, get one, it's free. It's absolutely brilliant. The speakers coming from literally all over the world, something that we haven't touched on really yet today, just because there is a bit of lack of time, but something that we'll touch on now is making sure that retain and encourage innovation for trainees and whether this could be potentially be through an integrated innovation skills pathway, much like kind of an academic pathway. Um making sure that we don't lose these trainees to places like industry. Um but also making sure that trainees are involved throughout the entire process. And this is something again that the Royal College is really supporting with the Innovation skills course. So it's also not just surgical trainees, the augment study is er Telep proctoring for undergraduates. How can we um kind of train and how can we affect undergraduate teaching with, with the aid of live operating? And we touched on our video log book study and hopefully this will be similar to our kind of phase no phase one part of our, our pathway and that we will be undertaking relatively soon. And our ideal framework for training, which is er which is currently under development. So that's kind of the kind of the bones of what I have to say. Um I think a real turning point in terms of technology, being involved in surgical training and it's really important that we make sure these things um you know, are evidence based and that we're doing these things for the benefits of education and training rather than for the sake of bringing in technology. Um You can access these things here. Um I'll be around all day to have a chat about anything. Um Of course, asset. We, we love to collaborate um if you have any ideas or any or wants to collaborate at all. Of course, feel free to email me, talk to me, dm me on social media or anything like that. So thank you very much for listening. Thank you, Matt. That was a really comprehensive and clear presentation to us. I certainly learned a lot. I hope everybody else has as well and I think it just raises so many issues. As Matt said, he'll be around to speak to people in the interest of time would be ok if we move straight on. Thank you. Um Our next speaker is Mr Andrew Stevenson and now Andrew is an orthopedic surgeon in Taunton and he's going to come and speak to us today about the work that he was involved in as co chair of the Sustainability and Surgery Group. And many of you will have read the report that they did, um which very much integrates with our work for the future of surgical, of surgery and surgical training. So, Andrew, thank you so much. We're looking forward to hearing about the work of the group and about sustainable health care and education. Thank you. Great Rachel. Thank you very much. Thanks to the speaker so far. Thanks to everyone joining us online and in the room. Um I am a trauma and an orthopedic consultant. I work in Somerset. I've been a consultant there for almost seven years. I do hip and knee replacements and, and a lot of trauma as well. I'm also um fortunate happy um to be the co-chair of the sustainability group. Er, the reason I'm here is um, we're in a bit of a mess, aren't we? Um the climate crisis, the ecological crisis, you don't really even have to open newspapers to realize what's going on. There's climate change going on with regards to extreme weather events, there's climate instability that's impacting every single zone of the planet. Um We're living through an unprecedented time, well, not unprecedented. We're living through the sixth time that has been a mass extinction event and we're living through a time where there's increase pollution. You probably saw the research recently about how over 90% of the world's population are breathing unclean air. So we're really in a, we're in a, in a bit of a state and as doctors, as surgeons, we're gonna have to help with this. And why is it? It, it's mainly this really, in fact, it's entirely this. It's, it's, we have built our civilization, our modern civilization should I say um on fossil fuels and it's a fantastic energy source. We're all here. We're all beneficiaries of this. Um It's versatile. We've been able to get it pretty cheaply and we are all beneficiaries of having had this power source, but it has caused problems and this is the number one problem. We have put CO2 into our atmosphere. And you can see on the graph, the current level is over four, about 420 parts per million. It hasn't been anywhere close to that for over 800,000 years and it's causing warming. We're getting hotter, the hotter the hotter the planet gets, um the more unstable the climate becomes. Um And we're seeing the effects of that. We're on the sixth iteration of the IPCC report, um which is the largest synthesis of science ever created 27,000 signatories to this, over 10,000 pieces of research. Um, and it's, it's, it's fairly stark. We've got, you know, Gutierrez said we've got 10 years to act. Yeah, that's about it. Um, and how's it going to play out? I mean, the reason that I'm stood here is that once you own all these facts and you're a doctor and you want to help people, um, you realize that this is gonna, this is going to play out in, in terms of health, air pollution is the world's, this is, this is kind of the obvious one. Air pollution is now the world's number one killer, the most um amount of the air pollution comes from fossil fuels. Um And so not only is our fossil fuels contributing to a change in climate, they're also causing things that cause um a direct impact on every single aspect of our life. Um from before, um that humans are born to all the way up until their final years of life. It impacts not only the cardiovascular system, but there's increasing evidence to show um that it causes um it contributes to dementia diabetes and all those other things. Another risk factor that you might not think about when you think about climate change. Um is obesity, obesity is now the leading, um sorry, it's the leading cause of cancer in the western world. Um It is also a major contributor to diabetes. I'm an trauma orthopedic consultant. I do hip and knee replacements. It's a major contributor to people developing osteoarthritis and musculoskeletal conditions. Um, it affects a huge amount of people, um, in, in this country and beyond. Um, and it costs a vast amount of money. We all know that prevention is better than the cure. And you're probably still wondering where this fits into the climate crisis. The lancet produced this, um, in the last couple of years and has basically done a really interesting and quite wide ranging study looking at obesity, undernutrition and climate change and these three things intersect and you might think it's a difficult thing. It's, there's so many things that intersect with regards to the climate crisis that I'm just going to pick out one aspect of it. So there's the, the, the, the the this is a quote from the bottom study basically showing that access to meat is the single biggest risk factor for developing obesity. Ok. A third of all the emissions we produce are to do with agriculture and the vast majority of that is to do with animal farming. And then when it comes to habitat loss and the intersection of that with emissions, this is a big problem. Ok. So, deforestation that is being seen globally is almost exclusively driven by either er er clearance for er farming on that land, either for the cattle to graze that or for er mono croc agriculture to make plant feed for cattle. So by addressing these things by, by advising people to look after themselves a bit more to not eat as much meat. We are not only helping them prevent disease which they will present to us with, but we're also helping prevent the climate crisis, which is also going to roll out with the problem um, throughout our lives. Now, it wouldn't be right to have a talk on sustainability. Um without just briefly mentioning the other things, this is Somerset. Um Somerset er is this is where I'm from um 25% and under sea level. Um And this is, this is, this is what's been happening for many, many years and this is what will increasingly happen. Um My father's an engineer, he helped build the um the Thames Barrier and though that's going to keep out um the sea, it's also going to keep in any excess flooding that we're going to see. So we've really got to be very careful. It's very difficult to get people to hospital when you've got conditions like this, food security is a big problem in terms of the change in climate and obviously not having access to um nutrition um is, is a real problem and this is something we're seeing lots of, isn't it? It's very topical at the moment given some of the comments recently made. Um and that if you can't grow your own food, if you can't look after your family, you're going to move. So how does healthcare fit into this climate crisis plays out in the, in, in, in um health outcomes, but also it is a contributor. So we are a really resource intensive um er endeavor healthcare. Almost 5% of the UK S carbon emissions are associated um with the NHS. I think it's about one in 12 vehicles on the road is associated with the NHS. And operating theaters are the most resource intensive environment in the hospital. Ok. They use more energy and they use more materials than anywhere else. We produce more waste as well. And this is just a, this is just a function of the fact that we use more energy and more materials. So I'm really, I really apologize for giving a, a big gloom and doom. So I'm going to start with a of getting a bit better. So just trying, trying to frame this, it's, it's um you know, we have to take all this a little bit at a time. Um And so what can we do so broadly speaking, when it comes to sustainability actions can fit into one of two elements. It's either mitigation or adaption. So, mitigation is to try and reduce our environmental impact. So it's reduced the amount of fossil fuels that we use for energy and for making materials and for making smarter choices. So we need to think about renewable energy generation, active transport. Um and, and being a bit smarter with regards to the amount of energy we use and we need to adapt to the changing environment. Ok. We need to be prepared for extreme weather events, we need to be prepared for the heat. Um And there are some things in the middle there that you can see with regards to um looking after our water sources that kind of cross both of those. So what can health care professionals do? Actually, quite a lot has already been done. Simon Stevens before he er er stepped down as chair of NHS England. Um was the the force behind this. If you're not aware of it, I suggest you have a read of it delivering a net zero NHS system er aim for net zero by 2040. Um And in terms of sustainability hierarchy, if you don't know the, if you don't know it, this is it in a in a nutshell, we need to reduce all the interventions that we do that are low quality. We need to reuse as much of the equipment that we have that we have. Um so that we don't have to keep using it over, over and over again. We need to recycle um that which we can't reuse and we need to research and we need to rethink that which doesn't fit in to this circular economy rather than the linear economy that we currently use for the majority of the things that we do in healthcare. Now, II I just going to ask for those people in the room. Has anyone heard of the triple bottom line? So this is why I'm really glad that I'm here. So the triple bottom line is the way of um of, of framing sustainability when it comes to actually measuring um how to do it. So sustainability is the ability of a system to continue in perpetuity. Ok. It has to be acceptable to people. Ok. There's no point in coming up with a great plan. If people go, I'm not going to do that. That's, that's crazy. It needs to be acceptable economically. If it doesn't work within the economic framework that we are currently working in, it's not going to work. So it has to, it has to fit into that and it has to be acceptable to the planet, has to fit into and with and has to exist within our planetary boundaries. Ok? And it's in that happy little zone in the middle that we find sustainability and people think it's a really hard thing to do. It's a lot closer than you think. It's just such a big problem. We need to break it down into, into smaller, into smaller elements. So what is the Royal College of Surgeons doing? We had recently, um, a few weeks back our first sustainability conference, but I'd really like you all to, to have, take a look at this. This was produced almost a year ago. Now, it's the Green green theater checklist. It's a truly intercollegiate project. It's um the reference document for making surgical care typically in theaters more sustainable. It's evidence based. It's got over 80 citations in the back with a compendium with essentially abstract long um summaries of why we should be doing each of the things. So I'd really urge all of you to look at this. So there are things that we can do and this is the most concrete thing with regards to delivery of surgical care that I'd like you to look at. I'd also like you to look at um UK hack. So this is an organization that advocates for action with regards to climate change inside the health community. And the Royal College of Surgeons sits within practically every single one of the Medical Royal Colleges to advocate for um sustainable future with regards to health care delivery and with regards to the wider patient population. So where does sustainability and climate change fit into medical education? This is, this is really the big question, isn't it for this conference specifically? Is because it's so it's there are so many different facets um from microplastics through to diet, through to air quality, through to sustainable ways of delivering health care, through to, you know, virtual appointments. I mean, that's something that I do as an orthopedic consultant. About 30% of our appointments are virtual. We've, we've slashed the number of we actually see in our follow up clinics with regards to hip and knee replacements because we know we don't need to see them. You know, we just had brought them back every two years, five years, seven years, 10 years, we know that joint replacements work really well. And so we know that we don't need to see them as regularly as that. We just need to look at things and really think, do they do they add value? But this is, it, prevention is better than cure. And so, as I said earlier, the, the advice about active transport, healthy lifestyles um are all going to positively impact with regards to the climate crisis and with regards to our patients health and well being. So advocating for a healthy diet is, is, is really, really important. And some of you will know there is actually red meat in there. You might think that I'm a, you know, I'm an advocate for um an absolution. I'm not at all. I mean, I'm not, I'm not a vegetarian but I, but I only eat meat about once a month now. Um And it's about balance. Not everyone has to be a vegetarian, but we do need to eat less meat. You know, not everyone has to ride a bicycle, but we do need to burn less fuel. Um So when it comes to advocacy, we need to think about how our training, we talked about this actually at our conference, how we can um lessen the impact of the travel that trainees have to go through with regards to all the training they receive and the talk that we had just earlier about how technology can bridge that gap. You know, if you can, if you can actually have worthwhile training experiences and not have to travel 60 miles each way to get them, that's a really valuable thing. And technology and sustainability are, you know, there's an intersection there, you know, it can really, really help. I'm gonna come back to this. Um because I really want you to have a look at this. If you type it in it, will it cut, cut the green theater checklist. If you come, if you type it in, it will come up. It's, it's a, it's like the who checklist, you don't need to do it at the beginning of every case. But I would suggest you have a look at this. I'd also like, I imagine a lot of you will be going to the futures and surgery conference. There is going to be the green surgery report that is going to be launched at that and which is an even bigger compendium of evidence with regards to sustainable surgical care. And I'll leave you with. This is really how we embed the idea that healthy body starts with a healthy planet. And then how we chart a course with regards to prevention of disease, but then also sustainable treatment of disease. So we need to, we need to figure out which, which path we're going to go down. Ok, whether it is, um, the same one that has got us here or whether it is a different path that is within touching distance and that hopefully will, will, will take us somewhere that we want to be, that we'll be proud of. Um, and I'll give it back to the chairs at this point. Thank you very much. Thank you very sobering and challenging as well. I think that gives us all something to think about. Um Are there any quick questions from the, we maybe got time for just one or two? Yes, please. We've got a microphone gentleman here. Thanks. Thanks. Hi, I'm Jalyn, former trainee at Musgrove Park. How did your consultants body react to the green checklist or what, what uh rewards can we put inside that to encourage people to take it up? OK. Can you hear me here? So the green theater checklist, this is one of the challenges that we have is because um the first section is anesthetics. Then the second section preop in interop and POSTOP. And so, and it's time consuming. So our, our organization has accepted it but in but kind of quietly, um the anesthetists have, have pretty much done the whole lot so they don't use any desflurane um or, or any any other anesthetic gasses, they've rapidly cut down on N 2 O2 use. Um And we've actually decommissioned all of the manifolds for the nitrous oxide. So that's kind of done now, uh, the interop bit where, um, we're still using lots of single use stuff. And so that's so that's a problem. And especially in orthopedics is a concern with regards to infection prevention and I'm kind of girding myself to try and get the drapes as reusable rather than, rather than single use drapes. And so, but on the whole, it's pushing against an open door, most people want to do this. And actually, um they, most, most of the consultants are very happy to go along with a lot of it. It's just as was mentioned previously, the NHS is a really straightened place to work in at the moment, isn't it? It's a tough place. And so trying to push change is a difficult, is a difficult thing. And so I've pushed this very softly um in our organization and actually, we're doing most of the things on the checklist and what I'd suggest to anyone here is you, find your allies, find who's going to help you um with it and then just take off each one separately. And that's something that we're going to be launching with regards to the, the, with, with the checklist, we're going to be taking individual elements from it. Um We're going to be getting our sustainability champions doing Q IP local Q IP projects on that and then we're going to amplify that to show people how, how that can be done in, in kind of the Real World. Thank you. I think we just had a question came in online. Can we have a microphone for? Thank you. Um We've got a number of questions that we can pick up either later in the day or we'll reply online, but we've had a few around um introducing technology within developing countries. So um maybe from that, but also Rachel Richard, you might want to come in on that. It's around how can people prepare themselves and particularly for that transition. And also whether it will increase the cost of training, particularly in developing countries. Do you want to start um difficult question to be fair. Um I think again, I I kind of would circle back around to the one of the points that I've made at the very beginning really is that if you, if we're going and I think it highlights the the importance of it that there is a limited amount of money to use for technology to enhance training. So it's so important to make sure that things are evidence based. Um and also evidence based applicable in the place that they're going to be used. Um The other thing about especially in kind of low middle income countries is actually simple technology, perhaps that we take for granted can actually make the biggest impact in surgical training. Um So whether it necessarily increases the cost of surgical training, it's difficult really to say. But I think it's just important to be cognizant that highlights the importance of the need for a really strong evidence base and be kind of really specific about where this technology, technology is being implemented. Um because you know that can make a huge difference, potentially can reduce costs, like we talked about reducing travel with intervention. So it's a fine balance if I could just make a comment on that with with my sort of other hat on with the Global Surgery Policy Unit. This is a matter that exercises us a lot. But I actually think COVID has been wonderful in a way for the uptake of online learning, online education and different platforms um which have reduced the need for as much traveling either in terms of faculty, going from one place to another or of, of people from low and middle income countries, having to go to high income countries at vast expense to learn certain things. Um because organizations like the college and many other bodies, not just in the UK, but worldwide are set up with a charitable ethos, actually distributing that kind of um intellectual property for want of a better term, actually sits very well with the ethos of not just the college but also other organizations in this space and to be fair, many industry partners will make their technology or platforms or so unavailable at a much cheaper or even free rate for the countries which fall into the sort of lowest income bracket. So I think there are improvements that have come about on the back of COVID. The other thing I think we should always remember is that just because we have developed in a linear fashion, doesn't mean that everybody else has to. If you think about phones, um, in Britain or America or whatever, we had cabling into every village and town, taking a landline to those places for, I don't know, best part of 100 years and then along came mobile phones and now many people don't even have a landline. If you look across parts of Africa and other places, they've just jumped, they haven't bothered to take a landline into every tiny little village, but you can take your mobile phone practically anywhere on the African continent now and get a signal probably better than I can get in my office in Wales, to be honest. Um So we do need to think that actually for some, it may be better actually with the technology that we've heard about today to actually just jump and not to have to do it in the same sort of 100 year stepwise progression that we have got to the place where we're fortunate enough to sit today. So I think it's an amazing time of opportunity even though as people have said, there are some huge problems to address. Um I, I guess I haven't got very much to add you, you've covered it all. But I think some of the comments you made there, Matt were really important that just because something is applicable in one place doesn't necessarily mean that it's applicable everywhere. And we just have to be sure that what we're involved with rolling out trying to help with is appropriate for where it's going to be done. And that's quite a difficult thing to do. I think we're just about at the time for the coffee break, which will be served across in the room opposite. Please visit our sponsors while you're there about 15 minutes or so. And then we'll come back in for the panel discussion. Matt and Andrew will be around. Please do ask questions circulate and your chance for dealing, answering asking questions of the panel after the break. Thank you very much. Oh.