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Oh, Liquid Spirit in I about. Yeah. Hello. The plan was, yeah, 15, they one you hunting? Ok. Well, good afternoon, everybody. Um, and welcome to the afternoon session of what I understand has been a very good day so far. Um, this afternoon you're going to suffer as chairs to vascular surgeons. My colleague, Jenny Borick and myself, I'm Frank Smith from Bristol and we've got an afternoon of diverse academic um, subjects again, which we hope you enjoy. And I'm going to hand over to Jenny. I wouldn't say it's suffering. I'd say it's the way forward. Um, I'm going to introduce Frank. Frank is a professor of vascular surgery and surgical education at the University of Bristol. He's also a member of council, um, for the Royal College of Surgeons of England. He has had many roles within education including being a skills tutor for the RCs, England membership of both vascular and general acs led that vascular national selection ST three level and including all his other roles, examine and assessor for mrcs fcs and the European Board. Thank you. Thank you very much. Well, good afternoon, ladies, gentlemen, we're going to talk a little bit about the national undergraduate curriculum in surgery this afternoon. Um And you might say why has the Royal College of Surgeons got an undergraduate curriculum for surgery when there are multiple medical schools around the country who have their own curricula. So in 2023 we have rewritten a curriculum that previously existed in 2015. I explain why in a minute or two and the curriculum that has emerged is for students, it's for their teachers and it's for curriculum organizers within the medical schools. It provides evidence of the R CS England's commitment to national undergraduate standards and that is the pool of people who are going to be future surgeons. It sets uniform standards and it provides topics of primary importance for the undergraduate student who is emerging as a day one fy one doctor. It provides a basis of a continuum for surgical training. So if you're a trainee in the room, you know, you've been through the foundation years training, you've done core training, you've then gone to the ISCP and on to higher training programs. And we view the undergraduate curriculum as the basis or the initial building block for that continuum. Um There have been revised GMC standards which I'll come on to. And as of 2024 there's going to be a medical licensing assessment which we'll also talk about in a second. So very briefly, I'm going to go through the curriculum as it appears in the published version. Um We will talk a little bit about part one, which is the introduction in part two. I'll just allude to the syllabus. I'm not going to go through anything in great detail because it is online, you can download it. Um, both from this afternoon's talks and from the college website. And then there are two appendices and we all overlook the appendices in any document usually. Uh but these are important because they list the new GMC requirements and and those for the medical licensing assessment. So the last curriculum was written in 2015 and one of our colleagues, Scarlett mcnally brought together a team of educators, medical students, trainees, university academic staff to try and analyze what was really important for the fy one doctor who is beginning training with respect to an undergraduate um surgical curriculum. They pulled together a good curriculum but it was in the light of tomorrow's doctors, the GMC publication of 2009. Since that time, the GMC have revised um their criteria for out for undergraduates. And in 2018, they base they published um a new set of guidelines called outcomes for graduates, er which again was based on the two and then 17 version of the generic professional capabilities through which all post graduates um courses are, are structured now. And this outcome for graduates is a summary of what newly qualified doctors are supposed to know and be able to do. And it's helpful for those designing postgraduate training. It's a guide for students as to what they're expected to know and to learn during their time at medical school. It helps medical schools develop their own curricula and their programs of learning. And then it provides a blueprint for the assessments that undergraduates undergo. And indeed, the GMC will use it as a framework to regulate medical schools. And that's perhaps particularly relevant with the new planned influx of a vast number of doctors and more places at medical schools with new medical schools emerging. Basically, there are three sections to this in terms of outcomes for graduates and 26 learning outcomes associated with the three sections. They relate to things like professional values and behaviors, professional skills and professional knowledge. And in this particular handbook, which you can find in the back of our curriculum as appendix, one, those 26 skills are, are, are noted, there's more emphasis in this than there was in, in um tomorrow's doctors on community care as you might expect on the aging population of multiple morbidities, mental health, integrated social care, health promotion and lifelong learning. You may notice that surgery doesn't feature highly in this list of improvements in inverted commas. And that's at a time when there are 7 million patients on the NHS waiting list, perhaps the most important driver for interventional specialties that we've ever had in the um in the life of the NHS. And then the other thing that medical students will have to take note of is the fact that this medical licensing assessment will come in in 2024. And that's designed to make sure that there's um a common threshold for safe surgical practice on graduation. There has been variability across various medical schools in terms of curricula and what students are expected to know. You may know that from your own experiences. And this will also apply to doctors coming from without the United Kingdom who want to practice here. It will consist of an applied knowledge test which will probably be an MC Q of some sort and a clinical professional skills assessment. And these will be delivered and set by the UK medical schools in the um administered in the penultimate or final year. And they will look at a student's readiness for safe practice, their ability to manage uncertainty. And I'd say that that's something that most consultants in this room have to deal with all the time. I think our whole medical careers have been full of uncertainty and they will concentrate also on the delivery of patient centered care and I'm afraid we're still on the boring Gano grams. But these are the six domains of the ML the medical licensing assessment content map. There are areas of clinical practice, clinical and professional capabilities and areas of professional knowledge. And you would see for instance, that surgery falls into one of the areas of clinical practice and there they have a list of things that students should know about. So, with respect to knowledge, they classify those as patient presentations and er, conditions. And I'll just come on to illustrate those a little bit further down the line in terms of clinical and professional capabilities, practical skills and procedures are listed there. The GMC have 23 of those that they expect a final year student to be able to master. We have felt that within the college of Surgeons, there are a few other skills that we feel all medical students should be apprised of and I'll list those and then there are areas of professional knowledge. So this is how, for instance, an MML a content map topics might be listed and they've got a whole range of about 20 pages of these topics. So this relates to cancer and you can see there's a list of er, presentations and a list of conditions. There are no learning outcomes here. So that makes it difficult in a way for the student. So let's pick one. Let's go to jaundice, that's a presentation. So a student would be expected to learn about jaundice. And when we looked at our skills, um in terms of the skills we've listed in the curriculum, we clarify some learning objectives for that. Here's a picture of a jaundice. Clear, a very nice little spider nevus out naturally. I think if you see it carefully and then if we look at conditions again, under the heading of cancer, there are all these different cancers. So let's just pick one at random and go for basal cell carcinoma. You might expect students to be able to know a bit about the basal cell carcinoma. And from that, I interpret that they should know a bit about the pathology. They should know how to take a history and examine the patient and describe the little nodule or lump size site, surface fixate lymph nodes, all of those things, perhaps how the cancer spreads its prognosis and some basic terms for intervention. And that's what I think we would expect of the final year medical student just about to become a doctor. So back to the curriculum, that's the basis of why we've had to revise the curriculum curriculum. Part one, this lists the sections and I'm not going to go through them all in detail. But we have to have a rationale for an undergraduate exposure to surgery, the GMC and perhaps many other organizations might say students don't need to know anything about surgery. We need a vast population of general practitioners. Surgery is largely irrelevant, but we're not going to be asking students um how to do a heart transplant or the major sort of revascularization of aorta or liver transplantation. What we do want students know about because it's relevant to all areas. Practice completely transferrable are the signs and symptoms of surgical diseases. And that hasn't changed since any of us were medical students, students at university have very little exposure to the 10 surgical specialties that exist. And that's important in terms of career choice later on. If people do want to be surgeons, how do they ever become a plastic surgeon or a neurosurgeon if they've never seen any? So we think that that's important and we talk a little bit about that in the part one, the expectations of doctors learning opportunities in surgery, where can a student go to actually learn something about surgery and how should they be treated in that situation? What should they try to attempt to entail sort of self self administered? Learning the future of surgeons. It's discussed a little bit. Consent, ethics, risk and clinical judgment are discussed. We talk about team working and in an era in which we've just had the publication of the Kennedy report and some very uncomfortable publicity in the last couple of weeks about misogyny and surgery. There is a section on teamwork, avoidance of bullying and harassment and on diversity and careers in surgery which the college regards as phenomenally important. So those are the surgical specialties. I won't go into those in any detail. But what we would say to students is if you get placements, there are transferrable skills across all of those specialties taking history, examining patients recognition of the sick patient consent processes, surgery safety in surgery pre admissions testing, the care of the postoperative patient, all of those are generalized across all of these specialties. And um we would encourage students to pick up as much as they can from each separate specialty. And what about the learning opportunities? Where can a student actually go to get learning in surgery? And here, I think it's enormously important for career organizers um that or um for undergraduate curriculum organizers that they structure a student program. So for instance, I had a, a student turn up in clinic this week on Monday, we knew she was coming to clinic because the, the curriculum organizers had told us we had a set plan of what we were going to do in the clinic. It worked out quite well and I think she had a reasonable day there, there's nothing worse as a student as you will know and turning up on the ward or in theater and being completely ignored, regarded as a nuisance and um nobody contributing to your learning. So a structured, um a structured and coherent progress for a student. I think when they in turn, turn up in any of these settings is important. We as trainees and consultants should regard medical student teaching as part of our job. It's not something we get paid extra for that. If a student turns up in clinic, that's part of what we're expected to do and we should sort of welcome them. And when a teaching session goes well through morning. That's actually usually a good feeling at the end of the day. So I'd encourage you all to think about that. We should try as surgeons to get back to have some sort of control of the curriculum. And if you have any interest in teaching, perhaps doing teaching qualifications with a view to educating undergraduates is important. And we all know that the most formative um sort of recruitment tool for bringing people into surgery is that of being a good role model and giving support and help to students. So that's, that's really important. I remember this from one of our textbooks when I was a medical student, um William Osler, and he said that the thing that really underpins underpins all medical education is encounters with patients. And um actually I will do this and I was just thinking about this, who here, who is a trainee or a senior doctor remembers even one patient in detail that you saw as a first year medical student. And I certainly, so we all, you know, almost everybody does that and these patients were patients, we saw, we perhaps don't remember our patients from clinic last week, but those are very formative cases along the way. And really making sure that um students meet patients is the most important thing of all here. And that's really what Oslo was saying. I brought the first draft of this um curriculum to council and there was a slightly bored atmosphere and a few yawns around the table. And I think actually it was BJ who was sitting halfway down the, the aisle today who said, well, he said, can't you make there something exciting in this curriculum? Otherwise nobody is going to want to do surgery if it's GMC outcomes, you know, forget it, nobody's interested. So, we've got to do something exciting. So the council said we had to talk about what the future held for surgeons and the future holds all sorts of good things. Josh Burke, one of our senior trainees compiled a list of things that he felt would stimulate surgeons. Simulation is a major factor in surgical training and that will continue to develop. As you heard already from Kenya, the college runs all sorts of skills courses on the left, a basic surgical skills course. I think that we ran in Tanzania at some stage, but that was taken back into undergraduate training and most um surgical courses in universities have some sort of skills training. Now slide on the right was taken yesterday at the European Boards of vascular surgery exams in Belfast. And there in those examinations, simulation is used to be able to demonstrate skills training and that you have to do a variety of anastomoses, an open aortic anastomosis, femoral anastomosis and the role of virtual reality, augmented reality is coming and will provide immersive simulation facilities, robotics. Well, colleagues think robotics are great. They've stuck a blooming great robot in the hall downstairs, you probably tripped over it on the way in. Um But there's no doubt that our surgical colleagues are all excited about it. You should see people fighting over the robot even if they haven't worked out what they're going to do with it yet. But the future of surgery does include robotics. Um And for many of you who are technologically interested that may be interesting genomics and the, you know, the identification discovery of the human genome means that the future holds all sorts of promise for tailored individual treatments which may augment and act as adjunct to surgical treatments. And that will be exciting, sustainable and frugal surgery. The NHS is a major source of carbon dioxide production, big um carbon footprint and there are many areas in which we're looking at more sustainable and frugal surgery and that will interest many undergraduates who will want to do good for the planet. And then finally, the future of surgery also involves global surgery. And if you're really interested in this, you need to talk to Miss Hargis. But this really means looking at health care systems around the world and providing better health care and equitable health care er for areas often er, which don't have the same sort of facilities we do and it's a marvelous way of interacting with colleagues and peers around the world. So there is a section on team working and avoiding bullying behavior. Um Neil Mortensen said this following the publication of the Kennedy report, he recognized that we have had in the areas in which students have been bullied. And there is a very good resource which you can access the surgical tutor handbook, which was republished in 2022. And that's downloadable from the college publication lists. So very quickly going through the second part of the curriculum, I won't dwell on it much. That's the syllabus. There are 36 key conditions which have been prioritized according to the importance, that's their potential detrimental um significance for the patient and also the frequency in which the undergraduate may encounter them. And then we've included 44 key skills, 23 of which are required by the GMC. We've added a few others, some of which include examination of various systems which haven't been detailed by the GMC and the levels of competence required. There's a link to resources including links to the basic science, syllabi of the anatomical and physiological societies and links to all of the surgical trainee specialty association. So for instance, in the key surgical conditions there, number 15 might be neck lumps. We think those are important. Um And certainly for otology and max facts and they've asked us to include these in the key conditions and they're a set of learning objectives um that a, a student can pick up and needs to try and fulfill another one might be, for instance, number four vomiting blood. And there again, there are a set of learning conditions, learning objectives which will help guide the student as to what they should be reading about and what they should be trying to learn about. And in terms of skills, um there are a number of skills. Um in fact, we've gone up to about 32 skills. Some of the skills we have suggested are those including skin suturing, which is transferable. For instance, pathology needs that the general practitioner often needs that Anestis need suturing tubes, removal of skin sutures and staples, safe disposable and handling of sharps are things that weren't included under the GMC surgical skills thing. But we think all undergraduates should be able to do that. And finally, in conclusion, therefore, we feel that an undergraduate surgical curriculum does remain relevant that um that students do need to know about surgical conditions, signs and symptoms. The new curriculum does map onto the GMC principles. There is a need for continued innovation and development in surgical education. Patience remain the cornerstone of clinical experience. Patient encounter is most important and mentorship support and role models are vital in recruiting future surgeons. And several of my colleagues put a great deal of work into this. I'd like to thank the people up there. Thank you very much. Oh, we have got time for a for a couple of questions if there are any questions, anyone, any online or in the room. Um Over here. Great. Hi there, Andy Stevenson, co-chair of the Sustainability and Surgery Group here at the RT S. Um, sustainability isn't on any of the curricula or syllabi yet. Um, I know that GMC was asked about this and they declined to put it in their most recent iteration. Um, is the Royal College going to put it in theirs? We've alluded to it. There's a paragraph on it in, in that first, um, part of the syllabus, the curriculum. Um, so it's on our radar and we know very well what you and your group are doing. So, if you'd like to write the curriculum for that, we'd be very grateful but offer. But as you know, these things have to be tailored in. And in fact, a lot of the problem with an undergraduate curriculum is, is keeping out stuff that, that is nice to know rather than need to know along the way. Ok. Thank you. Are there any other questions or is there one online? Ok. You, we've got a question online if we could have the, the microphone, please. Thank you. I think leading on from that actually. So, um, the questions about how to maximize exposure for undergraduate students in surgery since the rotation in surgery is only for a few weeks. Well, there are two ways, one is to take back the curriculum. So a lot of people in this room, people attending this conference, by definition are interested in education and, and they should flex their muscles and be involved with their local medical schools and usually the medical schools be delighted if somebody's interested and comes forward. Um So the, when somebody's involved in the curriculum and delivery of teaching, it's much easier to bring back things we think are important. But beyond that, it is using the opportunities. It's a mixture of being receptive to having medical students and us as consultants and trainees making opportunities for medical students. And there's got to be a bit of self directed learning. Some of the the students we all know who we see in clinic are just dynamic. They know what they want to do with their lives. They want to be surgeon and they're often the people who have the greatest interaction with. But some you can turn around just by um you know, being interactive with them and giving them a good time in clinic. And I think that's the way forward there. Thank you. I think we need to now move on to the next session. Thank you very much. Um Professor Smith Frank. So our next speaker if I can introduce them is Professor Mahan. Professor Mohan is a Professor of Education at the Faculty of Medicine and Dentistry at Queen Mary University of London, and consultant transplant surgeon at Bars Health Trust. She is committed to making learning accessible and authentic, leading a diverse expert faculty to co create medical education with a socially minded student body Professor Mahre is the 2023 national teaching fellow and multi award winner for educational research and innovations in learning and teaching. And just to summarize her research interests, explore the philosophy of practices of thinking, knowing and doing across disciplines in professional medical and clinical education. Welcome. Thank you, Jenny. Hi, everyone. Um It's a pleasure to be here. It's lovely to see um Louise and Rebecca and, and colleagues that we've worked together on in the past. Um So when we had a conversation about what, um I should probably talk about today, I think talking about education and leadership and how surgery is actually a route to those things was a theme that came up. Um So I've kind of entitled the talk. It's, it's not, you know, firm but how a Korea in surgery can cultivate inherent capacities and passions. And so I, I'll go into a little bit of that in a moment. So it's fair to say that um since my medical student days, my career has had many twists and turns, but I'm very certain that choosing to pursue a career in surgery is one of the best decisions I ever made. And it has gone on to platform all the things I've gone on to do later on. Um So I'm going to share with you today just some of my reflections on being a surgeon, um being an educator, being a leader in health care, with the aim of asking you to think a bit more broadly about what a career in surgery can enable and empower an individual to achieve. Now, surgery and learning is a way for a surgeon to tap into those skills and qualities that are inherent. But that we find once we enter surgical training, those kinds of capacities get a little bit quietened down sometimes um or are neglected simply because of the, the pace and the demands of what surgical training requires from us. So I'm going to start um just by reading a short excerpt to you from my training journal. So this is from about 10 years ago uh when I was a senior registrar and it captures the reality of surgical practice and I thought it would be good to just kind of touch on this to remind ourselves what surgical education is really about. It's 3:37 a.m. operating theater 14, Mister Cunningham, the recipient of a shiny new liver transplant lies on the operating table. His abdomen sliced open behind me is a blue tub which holds his shiny new liver bathed in special juices glistening under the theater lights like a precious jewel. I pack the in inside of his belly with pristine, crisp white swabs, the whites of which instantly disappear drenched in a deep crimson hue. I glanced at the cavity in the abdomen. A concave hollow occupied until a few minutes ago by a cirrhotic liver, ugly rotting bulbous flesh. My hands move quickly and methodically across the four corners of the abdomen, removing blood soaked swabs, squeezing out a shower of sticky scarlet juice that sloshes around in a bucket while the cell saver Hoovers up each precious red cell and pumps it back into the patient. The operating theater is littered with empty bags of various blood products all given in what is fast becoming a futile attempt to stem catastrophic bleeding. I say nothing. I am mute. My feet squelch inside my clogs. I keep going. This is not what I'm here to do. Not. At 3 37 Ami think increasingly angry and irritated. I didn't come here to watch this man exsanguinate to oblivion. Yeah. Here I am ej the consultant surgeon is annoyed and exasperated. We have to do better over Randi. Really, we do this operation. It's not going to work out for this man. Someone get me, Eva Fernandez on the phone. Now, I want to know why we decided on this man for this transplant. Has he got family outside Jesus who brought him to the hospital? This is just not good enough. I've noticed that the conversation at these moments always takes on the same tone, the same exasperation, the same questions, the same need to rationalize when things don't go according to plan. When patients don't return from the operating theater, leave alone, make it off the operating table. In such moments. There is a tendency for surgeons to believe that we can somehow pinpoint a patient's demise to one particular decision, one wrong move in what is otherwise presented as a flawless game of chess. Careful calculation and evaluation gets the patient from waiting list to the operating theater. The worlds of the operating theater, excitement, good things, heroics and success transform in minutes or hours to a place of failure, despair and death. Many worlds inhabit one space. Yes, I struggle to figure out just where I should tread where I should belong. I return to Mr Cunningham's belly which still weeps red. I continue to pack and squeeze. Yeah, I realize this comes just after lunch. So my apologies, I think whatever specialties we're in, whether we're surgeons, surgical care practitioners or the team, the multidisciplinary team responsible for carrying out surgery. I think we can all relate to stories like this, to emotions, to sentiment, to the decision making, to the feelings of despair and failure, etcetera. So these, these are very common things that as a community we can recognize and come around and it illustrates the realities of surgical practice. So grappling with uncertainty and Frank touched on that responding to unpredictable events, the steep learning curve for the trainee and indeed the consultant in the room, the nature of team dynamics, bringing people together, deploying them. And in the mid in the midst of all of this is what in philosophy, you call the stubborn existence of the human being, the patient who's there. The person who has entrusted themselves to us and, and, and, and we as guardians are throwing everything at them, including the kitchen sink to make sure they survive and they thrive. So, so these, these are um ambitions, emotions, um intentions, wishes, desires we can all relate to. And it's this very peculiar nature of surgery that drew me into education. And throughout my training, I kept thinking but why, but why. Um and I wanted to understand why surgeons do what they do, why they think the way they do, um how they then come out of surgical mode, how we develop our codes of practice. So with this sort of background, I enter the world of education and I started asking these questions. So the first thing I'm going to start by asking is what does me look like. So I'm not just necessarily talking about me myself, but you as individuals, when you enter surgery, it's almost like asking to sort of shed things aside and step into this bubble and assume this persona and these, these skills. But I'm going to say something a little bit different. Um Being a surgeon, actually, I find at least and definitely in discussions with my colleagues is about who we are as an individual and as persons and looking at some of the inclusive work that the education team are doing for me. So this is the me that is inescapable. So I'm a wife and a mother to two very small Children. Um I'm a carer to my elderly parents. Um And then in myself, my kind of community work is around social equity. Um And I work a lot around that and then there are the personal motivations um which Kenny talked about earlier on. So what kind of drives me? Well, these are the things outside of work that drive me, that kind of remind me of who I am. That these two spheres, they are constantly in contact and they create the world of my work and the way in which I envisage education and what healthcare training means. So these are some of the kind of, you know, formal roles that I have at the moment. So I'm director of the Barcelona Queen Mary Medical School. So that is a uh a medical school program of about 2200 undergraduates. Um It also includes physician associates. It includes people on masters in education, uh prehospital medicine. And increasingly the other programs that we are developing at Queen Mary are around apprenticeships for the physician associate profession as well as doctors um professor of education. So I will talk a little bit of about my education journey. Um A bit later on um I'm a surgeon, that's where this journey kind of begun for me. And then my personal interests in surgery and health care are around equity and inclusion. So what does that mean? And I think I stand here as a small brown woman. And that's a direct quote from my, my surgical mentor when I walked in. He is a small brown woman. Um, it's really impacted the way I experience surgery. So I walk in, I'm the only one who's five ft three. There isn't a stool tall enough for me to reach the operating table and the operating table doesn't go down low enough. There aren't size 5.5 gloves. So everything is just a little tricky and I can see some nodding heads in the room, you know what that's like? Um So you've got that kind of practical aspect, but stepping into a world that maybe not intentionally has excluded people that look like me and are like me. So that kind of background and negotiating at surgical training, both in the UK and the US has made equity and inclusion quite an important thing for me. Um And so whenever I'm in the operating theaters, you know, most instruments are heavy, they're very long, they don't need to be, but that's how we've designed them. Um trying to get trainees to understand that actually they can still operate and still be brilliant surgeons, but it's just, you know, history didn't really think about them as the future. And so that's why a lot of the um hurdles we have are there. Um And then higher education. So it's interesting because we talk a lot about surgeon education and medical education. But actually the specialty. The discipline of surgery has so much to teach higher education. So that's university education. It's undergrad graduates in everything from English history, et cetera all the way through to medical education. And that is an area that I'm now sort of developing within Queen Mary and an area particularly our undergraduates are interested that a career in medical education or surgical education actually equips you to thinking about the bigger questions such as why are we still putting Children in uniform to come to school? Um when the world of work doesn't use uniform anymore, but these are all important questions because they constitute the world in which we live and learn in. So we know this, this, this are the list of, you know, skills and qualities that are traditionally associated with surgeons and surgery. So people who go into surgery tend to enjoy practical skills. They're quite pragmatic. Um they're technical experts, resilience is a big part of, of um our toolbox. If you like, we're used to making high pressured decisions. Um Surgeons tend to be very ambitious. Um People call it arrogance, we call it grit. Um And of course, there's the whole multidisciplinary team working. OK. So the these are very common, easily identifiable things. But what about these? So these are qualities and values that are definitely cultivated through surgical training. But I say they're not really noticed and they're not valued in the way we do. And I think as a specialty. We particularly bring this to medicine, to health care, to education in general. So complex conversations, everything we do to patients is hugely interventional and yet within, you know, think about an on call, within five minutes of meeting us, they're agreeing to be spliced by us. You know, it's, it's, it's a complex conversation. It's a complex relationship. There's not many professions where people would do that, they just wouldn't. But within surgery for all the jokes about, you know, the the surgeon who can't communicate. The fact is we have enormously complex conversations, particularly when things go wrong and if not even go wrong, even if the outcome is not what you expected. It very, very interesting. And that's the skill that isn't actually taught in surgery. It's something that we kind of imbibe. There's a lot of about communication skills, but we don't really cultivate the complexity of conversations, diverse teams. Kenny talked about this. Yes, we work in diverse teams. So we have multi professions within a theater team on a ward. Um and the hospital at night teams and you'll often find the surgeons are the coaches, we bring people together, we deploy them, we um upskill people, we support them. So being a coach is kind of intrinsic to being a surgeon and this is really important. There was a great paragraph in the workforce paper released in June which basically said the future of healthcare is unknown and it was quite nice to see that because for all the work around or what, what do we, what do we need to do? Do we need to think about A I do we need to think about sustainability, planetary health, et cetera. It was great to see that word unknown because it is unknown. And one of the things that surgeons do extremely well is we are the interface between human teams and technology. And the other specialties don't have this close relationship, but we do because of the nature of what we do. And so the future, we talk about the future of healthcare as being inclusive teams, but that includes not just people from different backgrounds and and different um professions. It also includes working with robots. So the inclusive teams of the future are humans and technology and surgeons are brilliantly placed as coordinators of that and finally, equity through innovation. A lot of surgical innovation is really about improving patient outcomes. But in improving patient outcomes, what we're really pushing for is equity. We want everyone to do as well as they possibly can. And when people don't we look for ways in which to redress that balance. So I would say that again, what surgical education addresses is how innovation brings equity into society. These kind of four areas are quite important because apart from anything else, they make surgeons just that little bit more unique and they give us something that the other professions don't necessarily bring to the table. So this is this bit. And then finally, just to kind of very quickly talk about my journey, I'm not gonna go through all of it. Um But people often ask me, well, how did you get particularly into higher education as a, as a transplant surgeon? And I have to say it was not a plan. I actually just followed my passions. And that's one of the things I will say to all our trainees when you're in training, you're so um kind of focused on the next stage. The next stage, the next stage, the next stage, because there's so many hoops to jump through. You don't actually stop to think about what kind of life as a surgeon do I want to have. And for me quite early on, I loved um teaching and I realized that when I was giving music lessons as a teenager and I followed that through. Um and I kind of developed a parallel stream in education and that's how I ended up doing what I do. And my phd was actually in education. So I left a really great place which did medical education. And I went to um an art arts university Goldsmith where I did my ph D in education, looking at how surgeons develop. Um And one of the great things about being able to step outside medical education is actually starting to look at it as an outsider insider. So you appreciate the complexities that make the profession, but you're then able to step outside and analyze it from the perspective of someone who doesn't belong in that group. So I'm going to stop there. Um And then just really ask if anyone's got any questions. Thank you. Do you have any questions for the, I've got one that I just start off while we're moving the microphone you put up there about resilience. That's quite interesting. Is it the, the concept of the resilience from inside or the resilience of what's around us? How do you view that? That's a really great question. Um So I, I see resilience actually as being comfortable with exactly how you feel. So for example, if I, if I'm, if I'm feeling anxious, upset, being able to actually just accept, that's how I feel and being fine with that rather than the kind of, can you push it down and, and, and how do we kind of come out of this? Um Sometimes the resilience around us as you, as you kind of called it um is about how you interact with the members of your team and sometimes the patient um listening to those ideas and thoughts, but again, being quite comfortable to be uncomfortable and that's probably how I talk about resilience. Just being comfortable being uncomfortable. Thank you. Where do we get to them? I, sorry. Hi, I'm Vivian and I'm ac T two in general surgery. I'm really interested in medical education. That's why I'm here today. So what would you say to trainee towards the beginning of their career in terms of practically how I get into medical education, build that portfolio that you mentioned at the end, it's a great question. So I think engage with the college because the college have got great things going on and then just grab all opportunities to teach. So at your stage, I used to do a lot of medical student teaching. Um And that was a really good way for me to develop my own teaching techniques. So, yes, there's lots of courses, but actually, we're all natural teachers as well. So by giving yourself opportunities to teach your innovating in your own way and discovering what works for you. Um and start thinking about sort of what kind of education you'd like to do, start thinking about other courses you could do when you would take, be able to take some time and go out and do a master's maybe or um you know, maybe later on a research degree, start planning now, but don't, don't see surgery as something that you can't, you can't marry education with um at the back. Thank you for that thoroughly engaging talk. You've packed so much into your life. Um I flummoxed how you managed it, but congratulations. I just wanted to ask you um about, um I don't know if you mentioned about your musical um career and how that's fed into your surgical career. I think the same applies a little bit to sport as well. I remember reading the other day, the former Ireland rugby captain Paul o'connell, he was saying, how did they get good at being a coherent rugby team and get as good as they are now? And that was, they said to themselves, well, the things that we're not talented that they're the things that we're gonna get good at because it doesn't need talent to get good at it. And that's how they became good. Can you see any parallel with that in, in your work? Your line of work? Absolutely. It's a great question. Um, yes. So I think one of the things that music taught me and I didn't take this into surgery, but it's medicine as well. Music is a performance art. So, is surgery. We get out every day and we perform and, and the craft of surgery is also an art form. Um, so for me, there have been lots of parallels around that. Um, and again, so I sing and I went to music school when I was younger and I still apply those sorts of principles even in my surgical and my education practice. So I've always got dedicated time set aside to practice. Um, not just sort of singing in the piano, but also, you know, if, if I'm doing a procedure tomorrow, there's the time I set aside to go through the anatomy, get my grays out and it sounds very old fashioned, but that's what I still do. Um, so I think again, this goes back to kind of finding the areas in your life that you get mo that motivate you and drive you and then just find ways to bring that into your surgery. Because for me, when I do that, my surgical practice is more meaningful. I don't know if I answered your question. We've, we've got one question online, Louise is going to read that out, please. Thank you. Um I think if you have an answer to this, we all want this silver bullet. Um How were you able to manage, doing your job and building a career in education whilst keeping the balance in your personal life? Yeah, I'm still trying to figure that out is the honest answer. I am still trying to figure that out. Um This morning there was like a crisis at work. My eldest child refused to go to school. I couldn't find my USB for the talk. So it is um it's not easy, but I, I think what I'd say is it's that whole thing of just try and be kind to yourself. You can only do what you can do and, and some days I guess horribly wrong. Um So I was just talking to some colleagues. We we had our new undergraduate start. So medical school opened this week and the pipes burst and so there's just sewage everywhere. So um there's just always something. And I, and I think um I think you can only just bit by bit. There's no magical answer to that. And despite that, you look like you're gliding like a swan. Are there any questions? Um Anyone else want to ask any questions? Anyone else? No. Thank you so much. Thanks. You al I got a fill of that. Always fill that. Well, ladies and gentleman, my next pleasure is to introduce Ginny. It, it's like a twin show today, Jenny is a consultant vascular surgeon at East Kent Hospitals, University Foundation Trust. She's held a number of posts in education. She started out in education really quite early on. Um and she is currently the training pro or was the training program director of the Thames General Surgery STC. She led National selection for vascular surgery in 2021 and she is chair of the S AC in vascular surgery. And since that time, she's also become head of the School of Surgery for Kent Surry Sussex. She's done quite a lot of work in the field in which she's talking about today in terms of trainee expansion and distribution. She's clinical advisor to the Medical Workforce Alignment Program and she examines for the MRCS amongst other things. She's a member of Council of the Royal College of Surgeons for England. I think she would want it mentioned that she was a founding member of the Pride in Surgery Forum of the Royal College of Surgeons. She's chair of that and she works very hard for both diversity and also in the fields of autism and help for neuro diverse trainees. And I think that's very important. So Jennet, we look forward to hearing what you've got to say, just having a little technical glitch while my slides don't come up there. They are. Thank you. Um And thank you so much for putting me after that amazing talk from Randi. Thank you. Um So I want to make it very clear that although I have, I, I wear many hats today, I'm speaking capacity as a clinical advisor um for work, medical workforce alignment and N HSE WTE. And that's the capacity in which I am speaking. Um Although I do have to wear my conflicts uh very carefully when I had, when I was appointed to this post about a year ago, I looked up about what he stood for and like it all lo that this is what hee as was and is now N HSE WTE stated as their one reason to exist and that was to ensure that the workforce of today and tomorrow has the right numbers, skills values and behaviors at the right time and crucially in the right place. And that is a lot of what distribution is to do with. So this is the problem the population is growing, it is set to increase by about 30 odd percent for those who are over 65 in the next 10 years. Um It is slowing in growth um for those who are under 16 are Children and almost non existent in that region. And quite crucially, actually, the working age group isn't set to grow very much, which is very important when you're looking about who's actually going to pay for it all. Um So within that, this demographic just shows it a little bit better. And this is because of the baby boomers, we had baby boom in um post war, 1946 2nd world war and in the 19 sixties and then a smaller baby boom in the 19 eighties and 20 tens. But you can see the effect of the baby boom that we're going to, to face now with the increasing um in that over 65 population and that means they're going to need more health care, they're going to need more social care. But there's a real north and, and I have to just state that what I'm talking about is about England and the devolved nations, the three devolved nations are watching what we're doing in England. But this primarily what's about distribution is about England. So the health inequalities across England is quite a clear north, south divide for life expectancy and you can break that down even further within those regions to see pockets of where that's um isn't quite so bad in those areas in the north and where it is, where it is worse for both men and for women. This is um in the last 2017 to 2019. And the problem that we have um is that life expectancy is less for those who live in deprived areas, which is on the left of the graft to those that are in more affluent areas for both men and women. So there are a number of factors that can influence life expectancy. Um and access to health care is one of those. But if you actually break it down into the the causes for premature death, you can see that healthcare access to health care is a contribution by 10%. And I would say that access to health care will affect the behavioral pattern of 40%. So health care is probably going to influence about 50% of that for those who have a premature death and whatever you want to call it, health economics, leveling up health inequalities, health disparities. It's clear that any the range of conditions are amenable to intervention through the skills of doctors in training throughout their careers. But this is the problem that for historical reasons, trainees are set in there in certain areas in England. And we know that of those training, 48% will become consultants or specialists um within 10 miles of where they train and 80% within 50 miles. And it's not surprising you put down routes, you want to stay where you are. So two recent documents have focused on these health inequalities related to geography, Chris Whitty in his CMO report in 2021 particularly focused on the remote rural and coastal inequalities and in the long term workforce plan that a number of us have discussed. Today, there's reference to the health inequalities and the requirement to level up care. It's quite confusing because there are a number of projects that are going on at the moment. Um And it's keeping track of which one we're talking about. And I'm going to touch on a couple of these in the next few slides. So there is distribution of tariff funded posts. There is expansion of tariff funded posts. We've also had this year some expansion of trust funded posts and in the background. Now we have the long term workforce plan. So it's keeping track of what these different programs are. One of the main is is that distribution of tariff funded posts is a permanent change of the location of the post, expansion of tariff and trust funded posts is only for the life cycle of a training post. So depending on your specialty, five or six years now, that's what's been set now, but there's never been an expansion that hasn't then become more permanent. Um So we hope that these expansion posts will be permanent, but we haven't been promised that we may have to wait for a change of government, for example, to know the reality of that. So first of all, within the distribution of postgraduate specialty training, um it's looking to align the posts by geography because where they are now is historical and it's principally centered around tertiary referral centers and large cities and not in the more remote and rural um communities where there is the inequality of health care. So if we can move where the training is undertaken, then hopefully those trainees will become specialists within close proximity of where they train, where there is a lack of um doctors and surgeons. It's very important that in this piece of work, we acknowledge that there is no area in the country that is over doctored, every area is under doctor, but we're just trying to make the best of the um of, of the funding um and of the place and posts that we have and also that no trainee moves, it's only the posts that move so no trainee moves within it. The acknowledges the relationship between having trainees and training programs and safety in hospitals. So that's a long time been acknowledged that where you have training and they allow the patient safety is better, there are less medical legal um cases brought. Um and that um uh sorry, I've lost my train of thought at that moment. I apologize. Um And that the speed of this increase of distribution will be very much related within the ability to deliver quality of training and educational capacity. There are four different opportunities to align the education um within the training of a doctor. And this program for distribution is only focusing on that last circle, which is the specialty program, specialty training at the end. And not looking at how medical um or undergraduate training and foundation training. Although there are many initiatives for um for for the change in geography, for example, with the increase in number of medical schools that are in extra traditional places than they have been before, such as in my own region in Kent and Medway. So we will be, as we say, we'll be concentrating on this latter half of training, whether that be by GP um or or secondary care. And I put this slide up just to show the complexity of funding um of, of training posts. So 80% of posts are tariff funded and that means that N hse wte pay a contribution to salary, which amounts now to about 40% of salary, but 20% of posts are trust funded. But then when you start talking things like palliative medicine, there are charities involved and it becomes very much more complicated as to how all of this funding occurs. So, within the distribution, um it's looking at it, it's not saying that um it's not a substitute for the numbers of doctors that we have, as we've said, it's just to move those doctors to the right areas. Um and that we do acknowledge that greater numbers will be needed. Um It's only considering the tariff funded posts and it's actually looking opportunities to change, to transform the workforce and how that's how that's working. There's a specialized commissioning is taken into account to look at those procedures that are low volume and high complexity. So for example, there's a high amount of specialized commissioning in um cardiology, but in BBS and Gyne, it's a very small amount. So that has to, you know, it's not one size fits all. We have to look at the different individual programs as to how they, they function. And we have got expansion going alongside it, which we have taken into account. There are 65 GMC recognized specialties um and 31 subspecialties and the methodology that's been used is the same from the perspective of population requirements, but specialty considerations are taken into account. So for example, if you've only got one or two trainees in the whole country doing something like aviation medicine, you're not going to be able to redistribute those around the whole of the country or for something like tropical medicine where um they need to spend a year in, in London, Liverpool or Birmingham where their specialist infectious disease units are. Um but it's a complex modeling and there's a um the team have given, give me some lovely graphs to show you and I can get quite lost in these graphs. I hope I'm sorry that probably shows I'm a bit geeky about them. Um But this is the population growth by geography which we use. And it's showing that those areas that are, that are blue and where we're going to see the population growth and those in orange where we're not going to see um growth. So therefore, how do we align the number of doctors in those areas? A decline in the population of Children? Actually, the only areas where we won't see a decline is in the West Midlands and a little pocket there in Bristol. Other than that, we're going to see less um under sixteens and there'll be a growth in the number of older people over 65 us baby boomers and I'll be in that generation of over 60 fives in the next 10 years as well. But if you actually look at it as the percentage of population, places like the South west and the east of England come 10 years time, a third of the population will be over 65. And therefore, um retired health um use of the services, the older you get, um you will become a higher, you're like more likely to be a higher user of the services. So although they'll be less in the over 90 age group of that age group, they will be the highest percentage user of, of services. This was specifically to look at the remote and rural areas to look at them by age on the left deprivation on the right. But then when you come to the middle one, using COPD as an example of the high numbers of COPD where is lower access and lower numbers of doctors and specialist nurses for them to access care. And that's quite a stark picture in the middle. When you realize their inability to access, um the care the distribution has been divided into three phases and I've, I've put in highlighted in yellow. Those are the surgical specialties phase A is running now between 23 to 25 and phase B from 26 to 28 and then phase C 29 to 31. Um But for the moves, the che moves of, of posts, there's a seven year pace of change. So though you may say we're going to move 10 trainees um from the West Midlands, for example, in a, in a, in a particular specialty that will be over a seven year period. So it may only be one or two posts per year. Cardiology was one of the um pilots um in the distribution. I'm not sure how it does translate onto that. Um There was cardiology, hematology, and OBS and Gyne were the three pilots before we started phase A. So you can see within this, on the left hand side, the beginning and on the right hand side, the end. And in general terms, there's a movement of um posts out of London um into KSS or the east of England. Um But what you're seeing at the top there on the second, on the second slide from the left is the amount of specialized commissioning, which is 25%. So without that specialized commissioning, there would have been more movement to posts out of London um into the, into the um for example, KSS or east of England or the South West, which is a, is one of the biggest gainers um of distribution. Um But that took into account um the specialized commissioning and that just repeats the, that slide in a bit more detail. A lot of what you hear people talking about is the pipeline. That's the phrase that everyone says it's, it's um ensuring the pipeline for the future um is, is, is, is um I can't think of my word. I'm losing words today is set and that will be there for the future for our workforce. This is a complex program that's been long overdue. Um And it's not without um it's uh those that like it and those that don't those detractors, the modeling has taken account of local population demographics and health needs. And it's probably one of the first times that that's been looked at within the program to ensure that the funding is in the right place for the population and patients needs. And one of the high and 11 thing that um is very frequently mentioned is the needs of remote rural and coastal. So the second, this is horrendous slide and I've only put it up um because it shows the expansion overall. So this is expansion numbers for 2024. So there's been a program running over the last three years, 22 23 24 there are 1000 posts across all of the England um expansion posts um for all specialties. So within my own specialty, vascular surgery, we had in the first year, an extra 20 posts and 15 posts and we will get another 15 posts. Um And this, this is really to show that it's across all specialties and across all regions. The approach to expansion has been different depending on whether that specialty is a group, A or a group B specialty. So this is a group, a specialty. This is vascular, I think Tom who sent me the slides was just playing to my, to my interest as being vascular surgeon. So because it's a distribution um specialty in phase A, the distribution, the baseline numbers on the left have been taken into account when we're giving the expansion. This is for Ent as well. And you can see where the gainer regions are in darker colors on the right. And expansion was used to offset those that donated. And you can see from the north west of England, they were set to lose but actually didn't because expansion buffered and their distribution if, if it's a specialty that's in phase B then the baseline numbers um haven't been taken into account. Um Sorry, the distribution and distribution numbers haven't been taken into account because of the life cycle of the expansion posts that we perceive and then what will happen after that with distribution. So this is urology. Um and this last one is, is T and T and have had a large expansion and I think that's because of the waiting list, um issues for arthroplasty and very briefly, just to touch on the long term workforce plan which was published this June that's looking at 15 years of workforce growth and it's going to be refreshed every two years. Um The funding is there at 2.4 billion for the next five years, but it hasn't been costed out funded further than that. Um Although there's some expectation that there will be savings within um lower use of agency staffing and efficiencies in the NHS and what they're looking to do is to fill the 100,000 vacancies and create um more roles. These are the sort of headline figures like the, the documents over 100 pages long. So I'm just giving some headline figures for it. But the ones that have been quoted is the massive expansion of medical undergraduate places, but also um creating in medical schools which would not have been which are new medical schools to change the inequalities in, in population, in, in, in inequalities of health access. Um and GP places will go up by 50% from 4000 to 6000. Actually, London is set to see one of the biggest increases. Their GP training numbers will go up by 50%. GP. Numbers will go up by 50%. Um And then the other er areas headlines from it included about the medic medical apprenticeship models. Um and potentially they're looking to reduce medical school training, undergraduate training and all of the changes came under to train retain and reform. They were all the headlines that all of these reforms came within and retention. Of course, as we said is most important because there's a time lag with this long term workforce plan of about 15 years and that's why distribution still needs to go ahead. Now, a lot of people have said, why are we still doing distribution if we're going to get this expansion with the long term workforce plan? And that's because actually to take the long term workforce plan, we need the educators in the right place for when we have the increase of um undergrads and foundation doctors, which leads me on to my last slide. You'll be pleased tonight. Um What, what's the problem real, really big problem about all of this expansion and distribution and that's education, educational capacity. There's only so many of us who can train, there's only so many of us who are educational supervisors. And at the moment, we need to ensure that the maths adds up for all the extra um doctors that will be training all the like healthcare professionals, undergraduates. Um And with the Caesar reforms, the um locally employed doctors and SAS grades. So we actually do need to see the role of medical education more formalized um within it's not a soft topic to do because you didn't want to do leadership or research. It's actually a crucial part of our role as doctors to educate the next generation of surgeons. And this is the education educator, workforce strategy, which is probably one of the last documents that was published as hee um looking at how to undertake this. Thank you. Thank you very much, Jenny. Can we take questions in some? Yes, Rachel, thanks Jenny. Coming from Wales. I didn't know much about that and that such a clear presentation. Fantastic. It's really clarified a lot. Can I just ask in terms of engagement? I know asset and the trainees have had a lot of concerns about as is here, what engagement have you had with either as or trainee representatives generally across the specialties to work this out. They been key and crucial to it all. Um So for every specialty, there's a task and finish group which in the first, well, last year that each group had three meetings for each specialty. So it's quite intense and that was with stakeholders, whether that was from colleges, a CS engaging with IBS of donor regions, heads of school of donor regions because that's where the issue is about creating that capacity and with trainee representatives. So they've been involved um with those then moving forward yearly for each group, there'll be a yearly meeting to see how the progress of the distribution program we've obviously learned from, from um phase A to phase B and phase B, we're going to start rolling out a little bit earlier. So more in advance of actually the distribution rather than while the distribution is sort of happening because there were things to learn. For example, we found that there were still many trainees in post vascular trainees which were badged as general surgery posts. And that has to be completely unpicked. And that changed the modeling for both vascular and general surgery. 12 years later, it still wasn't correct, but we've made it correct. There was also, for example, when we were looking at neurology and stroke medicine. So stroke medicine had been in phase B but actually a large part of neurology training now is in stroke medicine. So stroke medicine had to move up into phase A so they could be aligned. So there had to be that flexibility of what we learned in those um task and finish groups. So within the phase B, still the trainees will be obviously a key part of that, but we'll also be engaging with GF um and with the IBS in more detail than we were before. Thanks gi it's a really clear presentation, I suppose. My question is, it's really interesting about the fact that the trainees stay where they train and that's the basis of this. But is this the only method that we're trying to do to level up the health inequalities or is there anything else being done to try and encourage, you know, trainees to go and work in those areas? Apart from this, I think that um when you're trying to say to trainees, working in the South West where you may never have considered working before is really great. It's how or up in or in K si think KSS is great, but you know, many trainees prefer to be in London. Um You're quite right that it's how do you sell that and that comes down to the quality of training, ensuring curricular coverage. I think that to trainees, that's one of the most important thing, what quality of training, what quality of education or supervision there have been within some programs in some regions. And this isn't part of this program but a local deanie. Um so I think in the North East they did some financial incentives for GP training. Um So that hasn't been unknown to have those financial incentives. Um but that's not a sort of a national type of scheme. So that would be local. But for, it's very hard because we accept that people have lives, they have mortgages, they have houses. Um And it may not always be possible to move. But we hope that with the expansion as well, that will still provide enough post within those regions, if someone really is set to be in London rather than to move out of it. For example, are there any other questions? Yes. Oh, deeper. It's gonna be about orthopedics. I'm not going to talk about orthopedics at all. Thanks, a great presentation. And as you said, I think this is the first time this has been looked at sensibly. So it's a huge step forward. But my question is about the educators, as you've rightly mentioned. So you will know that we are struggling now, how are we going to cope with that expansion? I mean, again, I know that you know that we were pretty close to the wire this time for national recruitment. Yeah, absolutely. So what are the practical steps that are being taken? So part of this work and part of the work stream is looking at educational capacity, obviously, I couldn't really go into that in much detail and there have been pilots that we've run to look at how that could work. So that's whether we use, for example, ST sevens to be educational supervisor to foundation or core, whether we use retired doctors, whether we use SAS grade, whether we have remote supervision, all sorts of ways that we've had pilots and we're creating um Toolkit is the wrong phrase, but sort of like an area of our website where it will give people the opportunity to look at other areas of trial to see whether that would fit with, um with what they want to do. And we're going to discuss that DME in, we've got a workshop in D MC in December in Manchester for that. Um But it, it comes down to also and very importantly how tariff is used by trusts. So there aren't many D MS who have control of their money um because it's top sliced by the trust or they just don't get access to it. Um So that's one of the crucial things that, that, you know, the tariff is there to be used for education. Um And that the DME should have control to be able to pay for the educational time and to ensure that those trainers get reer remunerated correctly. Um To do that also, that part of ensuring sp a time because that's where things like national selection and being on the SEC come from to be in your sp a time. So ensuring, and that, that a difficult answer because there's no equity in how that's distributed for trainers. But it's recognizing that being an educator is a crucial part. And, and one of the key, there's a very large part of the document, the long term workforce plan is about the importance of education and hopefully, we can raise its profile and how it's viewed and that's come will come from interaction with the I CBS via the Deans and raffling back tariff. I think in how it's used and what's about the death, the training. We'll have to ask Professor Brig. That sounds like a great idea. Go out, go for training. Yeah, thank you. Well, I think there are no more questions. Thank you very much. Indeed, Jenny. Now, this next part of the session is a triumph. Three people are going to help us out here and the topic in discussion is the educational supervisor and how can I help? And we've got three experts from different parts of the, the scale of surgery and surgical interest in education. I'll introduce them very quickly and I'll ask them then to come to the microphone if they would and just introduce themselves for a minute or two each. And then we will take questions and see where we go from there. So, first of all, we have Mr Dan Bere who's a consultant, colorectal and general surgeon and he's Director of Education at Doncaster and Basset Law teaching hospitals. He's been an associate director of Education for some time and has been a college tutor for many years. He's got a great interest in surgical education and he's delivered the Ist pilot in that region and is a clinical lead for excellence and surgical supervision. And Robin Brown, where's Robin? Can you pop your hand up? Robin? He's an ST four in trauma and orthopedics within the se we should probably know Children in that, but I apologize if we haven't met yet and she's got various leadership roles around trauma care and training and she has an interest in surgical education. Um She has an interest in the emerging leadership program that the college runs, which is so important and she's looking forward to developing that role. So, Robyn, if you introduce yourself and talk a little bit about that as well, and finally, Alastair Sha who's head of assessment at the college here and he will come and introduce himself and talk as well. So I don't know how you want to do this. So, are you three going to come up, take the panel and perhaps we'll retire and ask questions of you? I think that's the, is that right? Oh, we get another chair up. If we get another chair, there's one that we can see I can put another chair. Yeah, you're welcome. I mean, I've done my best to introduce you, but um perhaps you would just each talk about yourselves for a little bit and explain what we're trying to do with this session. So I'm going to go first. So, hi, I'm Dan Barre. As you've heard a few of my job roles and the main reason I'm here is as clinical lead for the excellence in surgical supervision course that the college runs, which kind of does what it says on the tin. So when somebody was asking earlier about how do we support trainers and educators to develop those skills as a trainer or as a supervisor. Come on the course. Um I quite like this session to be a little bit more about listening than talking, but I wanted to set the scene. So we're all attending this conference virtually or in person because we're interested in surgical education. But how can you train or supervise and, or how can you learn and be trained if you're burnt out if your wellbeing has suffered? How are you able to train and learn if you're from a group where we know that training and learning is more difficult and that covers ed issues and also um to be slightly more topical, how can you train and learn if you're the subject of sexual misconduct? And then when we come along in a minute, we'll talk a little bit as well about differential attainment. So this is where we are not here as experts. We're here to listen to know how the college can support you whether you are a trainee or as a supervisor or trainer because all of these issues you will come across in your day to day life and will present challenges to you. So we're here to listen, Robyn. Um I'm Robyn Brown. I've just about crapped into ST five now. Um, in orthopedics you'll all be pleased to hear. Um So a lot of what I have sort of basically happened across over the last few years. Um through getting to know colleagues and learning that we don't just experience training in a clinical sense. During our train years, we also experience non clinical issues. Um some that are good, some that are bad and all of which we have to incorporate into our work and our life um to help us feel like we're not just surviving, but that we're thriving at work. Um There are certainly things that we as trainees can do to support each other and things that we can do to help ourselves. Um But what I started to think about more and more is how our supervisors could help to support us both in checking in regularly in the form of the meetings that are already part of our um surgical um training scheme, something that's already there. It's not additional, it's not making you go to any sort of resilience training or well being training, but a way to informally catch up and how that works on a practical level in terms of how comfortable our trainers and our trainees are in having those conversations. Um So that led me really to get in contact with the college, um and with Dan, um and try and hear from you and develop a little bit more of an idea about what we feel comfortable and uncomfortable talking about at the moment, whether what kind of training we have at the moment and what we would like to have in order to make sure that we are making trainees feel valued, not just as someone who is part of the, er, is not a retractor holder on a day to day, but also someone who's got a life has to travel to and from work is having bereavement family, um, and burnout, which is what we've talked about a lot today. Um, so that's where my push is, um, for hopefully the college to get these conversations going a bit more. Hi. Um, my name is Alastair Shaw. I'm the college's head of assessment and I'm really here today because I'm leading the college's work on um, differential attainment. And so one of the recommendations from the Kennedy Review was that we look into and we undertake a study into differential attainment. Um I CBSC who are responsible for the MRCS have done a huge amount of work already understanding the nature and scale of that. But over the past year to 18 months, I've been working on a piece of work trying to understand some of the reasons behind that. Why is it that some trainees and why is it that trainees from minority backgrounds perform less well in the MRC S than others? And really the reason I'm part of this conversation today is that the relationship between trainees and their supervisors and their trainers is absolutely key in making sure there are successful outcomes. And we've recently published a summary of that, that work of that study and it's available on the colleges and diversity website. But what we want to do is not just publish a study, we want to actually move to a place where we can support obviously the trainees themselves, but also the trainers and the supervisors who can help the trainees to overcome some of those differences that we see in attainment, particularly in the ML CS. And as I said, it, it's really the both the evidence that is out there already around. Um the relationship between um the environment in which a trainee is learning and their outcomes in examinations. Plus a piece of work that we've done, um which is actually talking to recent candidates. You've sat and passed the MRC all these things together show that that the relationship between trainees and their trainers or supervisors is really important and what we want to be able to do as a college is to listen and understand what is it that we can provide along with IC BS E who oversee the exam to support people in preparing specifically for the examinations. But also in managing all the stuff that goes around preparing for an examination whilst whilst you're training. So that's why I'm here and that's my area of contribution to the discussion. So it's interesting when I read the report around differential attainment, how much came out in that. And that's based on the research that a supportive trainer and supervisor and a supportive relationship between the trainee and the supervisor is really a key part of differential attainment and that if you don't have that as well as lots of other things like other access to support networks and so on. But how key that was and you know, still come on ESS, but the, the ethos of ESS is, it's all about the relationship. We're trying to encourage trainers and supervisors to develop a relationship with their trainee. That is more than just the tip boxes to actually care about them as a human being, not just as a trainee. And from that, we hope that trainers and trainees get the most out of any placement that they go on. So we're going to, I think now open it up to the floor because we want to hear from you with your experiences as both trainees and as supervisors you've seen perhaps the questions that we've put out there. What are the challenges you face as a trainee or a supervisor around these sorts of issues? Well, being differential attainment ed. And there was a session at A S GB I this year that one of my former trainees attended where they were talking about, it was an Ed I session everywhere has an Ed I session now, right? So they were talking about it and a trainer stood up and said, but nobody's given me any support training or advice in how to look after a trainee who does experience some of these issues. I mean, step one just care, just actually care about the trainee. But what are the challenges? What are the issues? Sunday? Yeah. At least that surgeon had insight is because I'm going to give you, I'm going to turn around and give you a bigger problem because I think you're absolutely right. Well, a good, a good trainer is gold dust and will get good training. I think what we don't always think about is that a not good trainer. And we all know that being a good surgeon doesn't make you a good trainer can actually do harm. I think, you know, I mean, we know explicitly from the reports and things that come out, but I think that's a difficult square to circle when we haven't got in the trainers and we're not recognizing the trainers we've already got. But, you know, we need to not only encourage the surgeons that have got insight and want to be good trainers to be good and recognize them and professionalize them, we also need to eradicate the bad trainers somehow, don't we? And so I just put that to you as a, you're not going to have to answer it but an extra challenge. So I'll put it out there and, and go to Robyn as well. But, um, how many people in their own department or the department they're working in at the moment know that there are trainers there that are not the good ones. We all have them. But you're right. We don't do anything about them because doing anything about things like this is difficult and it's uncomfortable and there aren't enough trainers or supervisors around to do what we're currently doing, let alone any expansion or redistribution and the workforce as it might look like. So, we tend not to da, I wonder if I could just prompt, can we prompt a surge of activity from the floor here, do you think, and see if we can get any trainees to think of some good examples of supervision that you've heard of and you might be willing to share with us. Um, if we get more examples of bad supervision that be depressing, but we'll go for that next. Yes lady over there. Hi, I'm Vivian. I'm a CT two in general surgery. So I'm my first f one job was in general surgery and before then I was not interested in surgery at all. Um, and my consultant I had at the time, um, still was more old school and still had that, um, ethos of, um, um, what's the word basically bringing them along? Teaching as you go along, um, apprenticeship model. And um, it's because of that experience of him, encouraging me to come to theater with him, um, teaching me different techniques that I'm a surgeon today. So, um I think that it can have a really big impact um, on the future career of those that come after us. Um, if we're willing to put in that work. And that's why I'm here today because I'm really interested in passing that along. I think that go on k me first. Um uh I have a similar story to you. I didn't want to be a surgeon and then I was inspired by good surgeons as well. Um Who the key thing I think to pull out from that and from my experience was feeling valued. So again, exactly what we're saying as a trainee, feeling cared about and feeling valued. Um And coming back to your question briefly about sort of what can we do about the bad ones. Um It's, it's obviously a diff difficult question. Some of the things that we've done locally to try and address that to an extent, um is trying to create a minimum standard um and remove the excuses that were previously there. Um One thing being that the trainees are aware of what they should expect from all of their trainers and that being in writing at the induction from the training program director, that's a good thing like the policies and guidance that we talk about. Something that you have in writing that empowers a trainee to go back to the TPD and go, I didn't get this and you said I would um I'm not saying it's easy to do that, but that is, that is something. Um Another thing being the provision of resources, um some of the feedback that I've had from trainers where I've had these conversations was well, I don't know what to do when a trainee gets pregnant or I don't know what to do if someone is having financial difficulty. Um So again, something that we've done locally is create resource pacts and all of the trainees in the region have contributed towards those training packs of all about what to do if you have a pregnant trainee or all about what to do if you have a trainee that is off sick for a long period of time. Um And as well as that being helpful for trainees, because it's again, something that they can access to know what their rights are and what they should expect that goes out to all of the educational supervisors in the deary providing them with the knowledge that they can then use to try and be more helpful for their trainees if they want to be. So it's not a golden, it's got not the golden answer, but it's something and this is um where Robin and I start looking at Louise and Rebecca and wondering whether the college has a role in providing the resources and the support, at least sign posting for trainers and supervisors. So that when you are dealing with a trainee who has a particular set of issues, you have the support because you can't be an expert at everything. You know, who am I? I'm a middle aged white bloke up here. Talking about ed and, and sexual misconduct. I know nothing about these things. I have no lived experience of these things. What I'm up here to do is to listen and to facilitate the support that is required to both for both trainees and for supervisors who might be experiencing some of those same issues themselves. Who knows? And I think just to add from a, from an examination perspective with my exams hat and what we want to make sure is a central part of that as well is that supervisor trainers can support in the preparation for the examination. Um Also with failure and feedback, you know, the the failure rates are higher for the MRC S, particularly at the part, a more people than not will fail it. The first time round, we need to make sure that people can support in that because we know that in medicine, in general, surgery failure can be really stigmatizing can be really stigmatizing, particularly if you come from a from a minority background, you feel that that's, that's something that's always preceded you into, into, into where you are. And so we want to make sure that we provide that information so that you were talking about the bare minimum of what people should have part of that should be a guide to this examination that you're going to have to sit that is really stressful and really difficult on top of a job that is already hugely stressful. And hugely difficult. And how can we make sure that everyone has a level of support, not just someone who happens to have someone who is an M RT S examiner or who sat the exam really recently, but that everyone can have, have access to those resources. It's 20 years since I sat the MRT S. It's changed. I'm not on the court of examiners. I need the college and the court and the exam minister to support me to be able to support my trainees. Nick just in front of you there, please. So I just wanted some advice on a practical basis, really um with, with all the strikes that have happening and with the increasing workload on consultants, when you are an educational supervisor, it's actually quite difficult in your normal clinical week to try to find time for the trainees if you want to sit down for the meeting at the beginning of the year in the middle of the, at the end of the year. And also now with on the new ISP, having the multi consultant report or multi consultant feedback. So is there any practical advice or strategies that people have used to try to make this happen in a cohesive and a regular way or because it's actually really difficult to actually do this on a daily basis and meet up with your colleagues to actually sit down and discuss the trainees. So what strategies have people employed to try to achieve this. So at number one, yes, it is really hard. I'm not up here to be an expert. My supervisory practice is not perfect. We are all living within a very constrained system, living and working within a constrained system. So when we deliver ss here and around the country, we do get examples of how different departments do the MCR meetings for as an example. Um and maybe we can talk about that over coffee so that we don't get too bogged down in the details. But essentially, yes, it is hard. But step one as an educational supervisor is to actually care and actually want to do something and we all work above and beyond. We know we do whether we're a trainee or a consultant. Um But no, II, I don't have a time turner for the Harry Potter enthusiasts out there. Um I can't imagine time out of nowhere when you've got a busy job plan and clinical pressures and, you know, trainees are not always there because of the shift systems that they work. And because of the way we work as concerns, there are no magic answers but any checking in with a trainee is better than none. It could be a text message or whatsapp, you know, how was your on call today? And anything is better than nothing. I think I, I would really echo that as a trainee. I can't, I can't, I can't reiterate the value enough to you of a text message, um, from your trainer just asking how things are or even if you're both busy arranging a time, just a telephone conversation that obviously doesn't, it's not the same as having a meeting but like, we've already talked about everyone's time pressured and just checking in with something is better than, than, than not saying anything at all. We, we know from the work done by, er, there's a lot of work done by the Samaritans, um, mainly around things like suicide but, um, emphasizes really about saying even if it feels a little bit awkward or you're not really sure what to say, saying something along the lines of, you know, um, wasn't, this wasn't teaching, the, wasn't the teaching this morning good or, you know? Oh, did you get in? Ok. It was really, it was really rainy this morning. It seems really awkward to you but for the person at the other end, just having that contact makes a real difference and it's so much easier to check in regularly and a little bit both for you as trainers and your time management. And also for, if there are issues there that they can be really nipped in the bud and addressed at an early stage before they get to the point where we're losing trainees and we're seeing headlines and tragic things about that are happening to our trainees and are still happening despite what we're trying to do. Um, so, yeah, just send your trainees a text every so often to check. They're all right. Can I just say to Dan? Just put my head of school hat on? Just temporary use of having been DME? I think it's also making sure your job planned because there are so many educational supervisor out there who don't get given the appropriate time in their job plan and if you don't, or it's not being respected by your managers, you should talk to your DME. What do you think of that? Dan, please come and talk to me. I will do what I can within the limitations of what our trust has set because I don't think anywhere really follows the national guidelines perhaps as much as they should. But the guidelines are all there from um organizations like medical education leaders UK formally act, you know, um the guidelines are there in terms of what you should expect for supervision and louise you look poised. I am just a little round up from what's going on online. So some of the, some of the topics that people have been saying, oh, it keeps moving every time I talk. Some of the topics people have been saying would be useful for them. How do you guide and support under performing trainees, for example, failing exams and with things like incomplete log books and surgical. We've had a couple of questions, one in an earlier session and one in this session around. How can we reward good trainers to show them that they've done a great job and maybe there are some examples of how people feel valued and recognized. Yeah. So and again, it's a shameless plug ess does have a section on the underperforming trainee. And we um we use that term very specifically um trainees requiring additional support would be the my other favorite term with my DM hat on. And we want specifics such as supporting trainees through exams or exam failure. But also the generalities of how you support a trainee who does require additional support for whatever reason that additional support is required. So ess is one of the ways in which we can support supervisors. Um Obviously, again, with my DM hat, that's another way with my medical education leaders UK hat on, you know, they have support and advice and, and documents that are produced, all are there to support. But I do think there is a role for us to start collating that and sign posting it so that we have a, a pool of resources and available for trainers and supervisors question Clare Murphy. I'm an associate post graduate dean in Yorkshire. And and just want to highlight the importance of awareness of undiagnosed neurodiversity in trainees who are failing exams or struggling. So, one of the reasons that trainees avoid log books and is it might be neurodiversity, something to be aware of. And also so in a lot of schools, if one exam failure triggers triggers a, a referral or a question about whether dyslexia is a reason for exam. I know it's something that the Deans and H or are grappling with how we support those trainees now. And certainly in Yorkshire and Hubo, we're putting on training for trainers, not just in surgery but across the board to increase awareness and increase the ability to support trainees. I could perhaps forget Jenny just to respond to. Um No, you're quite right. And I mean, neuro diversity, it's very wide and it can depend on whether it's ADHD or autism or parts or dyslexia, which parts of neuro diversity it is that can impact on training at different points, whether that's reading the papers or actually concentrating or whichever part of that. Um I've been part of that task and finish group to create the training, which has been gone through co med and being piloted for all trainers as to how to um how to supervise the neuro diverse trainee. Um And um within that. Um So that's coming. Um but you're quite right in the support. I mean, it's variable support with PSU, some regions have very interactive. PS some don't have any PS U and where do you refer your trainee to? But one of the first signs can be failure of exams and picking it up at that stage. But we need to accept actually that there's higher, high proportion u diverse population are doctors because there are some excellent skills about being you're diverse, which make people such excellent surgeons and we need to concentrate on those positives as well as the negatives, such as sort of pursuit of a diagnosis, thinking outside of the box and all sorts of things. So I think to concentrate on all of the positives and the negatives. But yes, that's, that, that training is coming and it's very good just before we get to vio we're having conversations now that we would not have had five or 10 or 20 years ago. And they do feel a bit new and uncomfortable to a lot of people, but we're having the conversations um that we just wouldn't have had before and it's a good thing and, you know, surgery will only become a better place for all of us, the more openly we have these conversations BJ. Thank you, Dan. And my question is actually about exactly what you said. But I'll preface that by saying that I've been very fortunate to have some excellent trainees in my time and three of them have come back to be consultant colleagues and are not shy about telling me about my in, in, as a trainer. But what I wanted to say was in those times that you mentioned not that long ago, training was relatively simple in the sense that you taught your trainee the practical side of work. And that was what training was thought to be about. But now there are all sorts of other things that we are bound to think about and discuss and deal with our trainees about Claire's mentioned about neuro diversity. There are a whole host of other things that if you, you might bracket them in sort of social as a social category for want of a better expression. And some people are very good at that, they naturally turn to that kind of thing very well. Others who might have been good at training, the practical things aren't so good that and that's where ESS comes in. But one of my colleagues who wanted to go on it said, and I'm sorry, Dan, it's not your business, but they said it just too expensive. I can't afford to go on it. Um Are there any other options, other sources of, of training that people can access besides as good as it is? So that, I mean, that's kind of what we're talking about. I should point out VJ was my registrar when I was a house officer. He was obviously an excellent trainer despite the fact that he doesn't remember me, but it was a long time ago. So, um I think that's what we're talking about. So, yes, the college has AES S of course, there are other supervision courses out there. The deaneries will do them for free, but they're not surgical supervision. They don't come with a faculty that have experience of being surgeons and training and supervising other surgeons. So it does come with a bit of A US P but, you know, I accept it comes with a cost as well. So obviously I'm going to say it's great. Please do come and consider using your study budget for it. But that's what we're talking about really is the ways in which the college can support supervisors with freely available resources, documents, sign posting. You know, we've already got things on there like the unconscious bias, uh stuff that you can go through. Um I don't have a magic answer for, you know, how much ess costs. But what I do think is that the college is trying its hardest to support across these areas. A little shout out for something which um louise forwarded on to me a few weeks ago, um which links in very nicely with our previous speaker. And you know, how do you support surgeons who have gone through a patient having an adverse outcome? And the college is doing some work called the Support Program I believe, um which I'm hoping my trust is about to sign up to, um which is looking at how we create networks of people who can support colleagues who are going through difficult times because like London buses, sometimes your complications come along in threes and it feels really bad whether you're a trainee or an experienced consultant. So, you know, again, conversations we just wouldn't have had 5, 10, 15 years ago are being had the college is doing more and more, it recognizes its role and I'm not here as a spokesperson for the college, but I have the privilege of being in a role where I and the clinical leave for an S course. But it does give me other opportunities, for example, linking in with some of the other work around differential attainment around supporting well being that we can put through the the ass course and hopefully freely available as well. One thing I would say as well if um in the absence of the SS, so I know the first course was only done, was it, when was the first? I mean, it's a while ago now, but the, the, the rollout has been a bit slow. But anyway, we'll bruise over that. Um from a trainee's perspective though, and, and as someone who lives in the Southwest, um something that I did to try and push a bit more effort earlier on was to just, I'd say, ask your trainees. So, you know, if you're not sure how to be a good supervisor, a ask your trainees what they want from their supervisors and it, it, it may vary from region to region as well, which is why I'm talking about, I think the college having a big effort is brilliant from a national level and there's certainly things that need to be done nationally to support trainees. Um But there are reasonable, there are regional nuances that need to be kept there. And we, the way that we developed our resources region was just as a group of trainees, asking anyone who'd had experience in that area and pooling all of our opinions and resources together and just presenting it to the, the supervisors. And that's the best way to find out how to be a good supervisor is ask the people that you're actually supervising what they want. We're all individuals, trainees are individuals, the relationship you have with one trainee won't be the same as the relationship you have with another trainee because you don't have the same relationship with each family member or each of your friends in your social circle. They're not exactly the same. The point is to have a relationship that is more than just, you know, an initial meeting, a final meeting and maybe one in the middle, if you're lucky, a bit more than that is what we as supervisors should be aspiring to. And it's what trainees tell me. They value, they value being valued. I have a last question then. Thank you. Sorry. It seems to you're asking a lot of questions today. I'm sorry about that. But I think 11 thing which I really wanna say is that ok, this is anecdotal and if it's online, I'm sorry if it's taken the wrong way. But a lot of trainees have come up to me and they say what? And I asked them, what's your good who was a good trainer to you. I'd say 40 to 50% always preface it by saying, oh, I had so and so he was old school. Like what Vivien said, that seems to be, you know, a harkening to the past that the, those are good trainers, you know, he was old school or she was old school. Whereas the new school or trying to be progressive about things reflective practice the IC P the assessments there seems to be an undercurrent that this is very little to zero, sorry, less than what is anticipated validity. I think there's a difference between an educational supervisor there and a clinical supervisor. So yeah, but I'm trying to say what I'm trying to say is there needs to be a kind of change in the narrative or the popular perception of education. Now, I know I tried to bring some of my colleagues with me today, but half of them are August. So the other point which I'd like to say is that this sort of day MB presentation was fantastic. That should have been center piece at a S GB I on a keynote day because that's really important information that a lot of my colleague would have wanted to know about that. What's happening for the future, you know, uh I mean, like, just to see it's like, it's like, it's like uh uh or, or I in Star Wars, you know, the uh the, the, the second horrible movie. You know, when they all mutiny because you have no idea what the commanders are doing. It's, it's like that if we know that there is a plan and that people that are good people thinking about it, that make a lot of difference. So I'm just saying this sort of day should have taken pride of place. Now, I, I know there is everything so much. I mean, this, this year's A S GB O is fantastic, but maybe this should have been there. So to deal with that one briefly, I mean, I know that sort of presentation has been presented elsewhere and other venues. I've not seen your presentation, but I've seen that was a year. Hang in. But, you know, I've seen redistribution presented before. So it is being presented out there. So sorry to speak on your behalf. We have got a session actually with Adrian Brook and Aidan Fowler at Future Surgery. And we'll be sort of presenting this and having discussions that's having a, a quite a prominent place at future Surgery. Um to tell your colleagues. But to go back to your first point, you know, the old school surgeon, you can't throw the baby out with the bath water. You need to take the good bits of what training has looked like over a long period of time. And also remember that there was a lot of bad that went on with old school surgeons. Um and you need to try and find something that works for the individual trainee for the individual trainer and supervisor. But there was a lot of, um, I do, as I say, not as I do, there was a lot of poor role modeling that used to happen. There was a lot of bullying and intimidation and exclusion of groups. And in my view, we can't have that anymore and there is a better way. So there will be some good aspects of old school training. But what you need to do when people say that is drill down. Well, what do you mean by that? What about? Oh, he was an old school surgeon. That was really good, was good. And some of that relates to structural things. Like, you know, actually they spent a lot of time with me like the old firm structure and our rose tinted view of that looking back, but it was about developing a relationship and they took me through cases and it might be that they're picking out the good bits of the old school surgeon and not recognizing that they didn't like the bad bits or that that person actually isn't an old school surgeon. They're just taking the good bits of what an old school surgeon was. I think what it, it's important to say as well is I'm certainly not here to say that everyone has to spend their educational supervisor meeting, talking about their feelings and holding hands at all. Um, don't hold hands, don't hold hands, my God, don't hold hands. Um But um I think it's about giving it, giving each trainee the option. Like Dan was saying, like this individualized approach to your supervision where you're giving people the option and saying that you're here if you, if they need you and then if that door is open, then people can either choose to talk about things that they want to talk about or choose not to, which is also absolutely fine. Some people are more private and have other support and that is absolutely fine. I think pushing it is it is completely the wrong way to go about this. But letting your trainees know that the door is open means that there is an open. They, that's the value, that's where they feel valued. And then from there, the people that need it can always and, and sometimes you want to have the door shut, you don't want to talk about it and sometimes you do and you don't know what's going to happen in your life when you're particularly when you're between the ages of 25 and 35 that it's volatile and sometimes you'll feel like you don't need help. Sometimes you feel like you do. So, um yeah, I'm not here to, to push feelings on everyone. Um But just to say that have it so that it's something that your trainees feel able to approach if they need to. Thank you. Robin, that's very positive. And let me tell you, it goes on till 65 it doesn't stop. So, um, we'd just like to thank all of our speakers today, Dan Robin Alastair and Jenny, you, you talk came across very well in detail, everybody else want to join. We just want to say that there are other courses to the SS available in other providers. I thank the floor for your participation. Go and have coffee. Thank you very much. Mm ok. Yeah.