Dr Olivia Bell is currently on the ACCS (anaesthetics) training pathway - in her CT2. She will talk briefly about how she applied and got into ACCS anaesthetics training and the general stages of training. She will also talk about her current experiences of the training programme and what you can expect to learn on this pathway.
ACCS - A day in the life
Summary
This teaching session is tailored to medical professionals looking to pursue a career in anelsthetics. In the session, Doctor Olivia Bell will discuss her experience on the A CCS Anesthetics training pathway and offer an insight into what a day in the life of an anethesiologists looks like. She will provide beneficial information about the training and the pros and cons of taking this route. Also, valuable advice will be given on the application and training pathways, which will help professionals better prepare for their journey.
Description
Learning objectives
Learning Objectives
- Understand the pros and cons of the anesthesiology CCS training pathway.
- Learn the day-to-day responsibilities of an anesthesiologist.
- Learn the skills and competencies gained from a core anesthesiology training.
- Become familiar with the recruiting and assessment processes for anesthesiology CCS training.
- Understand the curriculum and timeline of the CCS anesthesiology training pathway.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.
Ok, perfect. So let's, let's start. Um, my name is Maria, I'm the new lead for the, um, A CCS sub team for Mind Bleep. Um, and I think we're gonna kick off with our day in the life series with Doctor Olivia Bell. Um, who's currently ac T two on the A CCS Anesthetics training pathway. Um, I think she's about two months deep. Um, so she'll just really talk about her normal day to day. What training's like? Um, I guess the benefits and cons of doing an A A CCS training pathway. Um, but yeah, so I'll let her introduce herself further and get on with it. Great. Thanks very much Maria. Right. I'm just gonna try and share my sites. Uh, give me just a second, sorry, a little bit technologically incompetent. Um, sorry about that. It's just all right, I can. Ok. Now, can everybody see the opening kind of presentation slide? Yeah, perfect. All right. So as Maria said, my name is Liv, I'm currently an A CCS anesthetics CT two in the Northern Deery. Um, so just start with a little bit about myself just so that you kind of know roughly what kind of path I've taken and I suppose that you feel vaguely confident that I'm someone who's qualified to talk to you about this. So I went straight to medical school from school. Um, went to Oxford did a two year foundation program in the northeast, um, which is home for me. I wanted to come home. Um, I was unfortunately a foundation doctor during the pandemic which meant that everything was a little bit strange. Rotations got moved around, I think by the end of that, I was quite tired and wanted to break. Um but it wasn't the best time to travel. So I did a trust grade job rather than applying for training first time around. Um That trust grade job was sort of an easy job with about 30% special interest in fem. So prehospital emergency medicine. So through that I did some shifts with the local ambulance service and organized some um trauma first aid courses for farm and forestry workers. I applied to training this time around two years ago. Um having to think back there um and got in first time. Um was my first choice. Um So when I was in the process of planning for training, there were lots of things that I was a little bit uncertain about. Um One of them was, you know, do I want to do anesthetics in the first place? Um So we'll sort of move on to some of the things that I found that I really like about it. Essentially. I was torn between whether I want to do anesthetics or whether I wanted to do ed. Um, and I have to say about two weeks into starting anesthetics, all those sort of feelings of, have I done the right thing of that completely disappeared, which is reassuring. Um, the other thought that I had was, you know, is it worth doing a CCS or should I just try and apply for core anesthetics? Now in the northeast? Actually, it wasn't really that much of a consideration because most of the jobs here are for a CCS trainees. But I know in some of the regions there's a difference between call and a CCS. So if, if at the end, anybody has any questions about that or wants to talk a little bit more about pros and cons of that, I'm happy to do so, but I'm aware that kind of the remit of what we're doing today is mainly talking about um experience kind of as an anesthetic, new starter and through a CCS. Um So we'll talk a little bit about what anesthetics is like day to day. Um kind of the, I suppose the remit of what the job can entail later on as well because it's a massive specialty. It's the biggest hospital specialty and it's also really, really broad in its scope, which is why a lot of people are attracted to it. I've put applications and training pathway in brackets. Um Simply because mind the bleep, we've already got an absolutely fantastic seminar uploaded online, which goes into loads of detail about that. And I think focusing more on what life as a trainee is actually like in this talk might be useful, just, just sort of so that we're doing something different. But I have sort of briefly included some things about that as well. Um The bulk of the talk is going to be a day in the life. So for me, it was a day in a, in an elective theater, do a large case. Um, through sort of all of the previous points, I guess we're gonna end up discussing some of the skills and competencies. You can hope to get out of core anesthetic training. Um And then hopefully we have some time for questions. Um, I realize we started a little bit late so I'll try and be quick so that if anybody does have any questions, you've got plenty of time for it. Um, so again, already touched on this a little bit, but anesthetics is an absolutely enormous specialty. Um, personally, as a medical student, I didn't have an enormous amount of exposure to it until I sort it out. Um, as an SSC um, so what I was exposed to in medical school essentially was, you know, sometimes floating up to the head and having a chat to the anesthetist when I was getting a little bit bored in general surgery. Um, but actually, you know, that, that sort of elective theater side of things is just one very small part of what an anesthetist does. So the responsibilities that you can take on later on kind of throughout your training, but also as a consultant are massive. Um, you know, I've listed some of them here, but it's something where actually there's a lot of scope to kind of subs specialize and actually change up your job plan later on. So, anesthetists overall tend to be pretty happy and they tend not to get bored and they tend to have relatively more control over their lives than some of the other consultants I've met, which is nice. Um So some of the things that I was considering when I was trying to figure out whether this was something that I wanted to do, um were some of the things I've got listed here. So, what I've got here essentially are a list of things that I probably would consider to be pros of anesthetics. Um which hopefully a lot of them, I'll demonstrate to you while talking through my day as a trainee. Um, you know, one on one consultant, teaching. Um I don't know about the rest of you, but as a foundation doctor, particularly during the pandemic teaching sort of disappeared and we were kind of just left to get on with it and actually being back in an environment where we're not really expected to know that much in the beginning. And most, most if not all of the time that we're spending at the moment is one among consultants. Um So during that time, yes, you're looking after patients and things, but there's times during the case where actually you can use it sort of as a tutorial really, you know, if you wanted to, you could go in on a certain day and say, actually today, I want to learn about ventilators and the consultant would just talk to you about ventilators. Um So it's really, really good from a sort of learning point of view, which is something that I was probably beginning to, was beginning to think didn't really exist in kind of the post grad medic world before I started this. Um again, procedural skills absolutely loads every patient that you've got that, you know, you're at least going to be cannulate and you're gonna be probably intubate and, you know, otherwise would be put in an eye gel. Larger cases, there are outlines, central lines, spinals, regional anesthetics, things like that. Um Speaking to a lot of the consultants who I've worked with in anesthetics and in other specialties, it seems like anesthetics is one of the specialties where the job that you start doing as a trainee and the job that you end up doing as a consultant are the most similar. Um You know, obviously the consultants have a vast amount more knowledge than we do as very junior trainees, but they're doing the same type of thing just on a sort of bigger and more complex scale, which is quite nice. And I think it, you know, it seems that it's stopped them from kind of getting as disillusioned as maybe some consultants on the specialties. Um, you know, I think I'm not gonna list all of these things, but I suppose my point is it's very, very, it's very different to a lot of the other specialties that you're exposed to as foundation doctors and during your time in medical school and if it's something you're interested in, um, these are what I would see as the pros, but I would definitely try and just get a little bit of exposure to see if it's something that is for you. You know, even a taste a week as an F two or a taste a couple of days if that's what you can manage or, you know, trying to get on to sort of recess and simulation courses and things like that and actually just having a chat to, um, trainees who've been through it. So if you don't know any anesthetists or don't know, kind of even how you'd get to speak to them, speak to your A&E reg because they've done an A CCS CT two year and they've done six months of anesthetics and they'll be able to give you at least a little bit of insight on what that's like fine. Um So applications I'm not really going to go into too much detail about this. Just I suppose my main pieces of advice really would be make sure that you very thoroughly read the person's specification. Um And if you are lucky enough to get um to MSRA, make sure you prepare for it. And there are plenty of resources available online and likewise for interview, there are lots of really helpful resources online. I'm sorry if any of you were hoping to hear a little bit more about that from this talk, but there is a previous mind, the believe seminar which goes into all of this stuff in really great detail um which I've linked at the end of my presentation. Um So hopefully that'll be really helpful for you. Um So the training pathway now, I've just put this slide in here just to make you guys aware that the shape of anesthetic training has changed in the last couple of years. So there was a new curriculum introduced in 2021 which essentially changed, changed where the gap between sh and registrar training was. So now for core anesthetic training, you do a CT 12 and three year or if you're an A CCS trainee, then it's 123 and four with 23 and four being your anesthetic years. Um The reason for that was largely to help with the fact that a lot of trainees were struggling to get through the exams on time. So it just sort of gives a little bit more wiggle room there. Um But again, the um curriculum has been restructured. That was something I was asked about in my interview. So just if you do get to that point, just be aware and have a little look into it. Um, again, rather than having sort of specific sign offs, a lot of the things in the curriculum have changed um to sort of everything being measured in terms of higher learning outcomes. So seven clinical and seven non clinical, which again, I'm not going to list every single one of them. Um But I, I'm just trying to highlight it so that you're aware that the curriculum is change, it might be something might be something that you'll be asked about and it also might be something that you want to look into just to sort of help you figure out whether, you know, whether it's something you want to get into. Fine. So we're going to get on to the bulk of the talk, um which is me talking through a day in theaters. So this is the admin building at the RBI, the Royal Victoria Infirmary in Newcastle, which is where I currently work. Um So we'll start with, when I get to work, I thought about including all of this stuff about, you know, my alarm goes off at six and then I sneeze it and then I end up getting up at 10 past and rushing for the metro and all that stuff. But anyway, on the road to that, I'm currently on. I'm expected to be in 8 38 until 5 30 Monday to Friday. Um, and I'm due to start, um, due to start some on calls in the next few weeks after I finish my I AC which is something that we'll talk about a little bit more later on, but essentially in the Northern Deery during your first few months as a novice anesthetist, you are completely super and you're not put on the on call roter. So that's kind of where I'm at at the moment two months in. So for an eight o'clock start, I usually arrive about 7 45 and go along to theaters and collect my theater list. Um, so essentially what that is, is just a list of patients who are to be operated on in that particular theater on that day. Um, it includes things like their hospital number, their date of birth, what procedure they're having any important clinical risks and any, um, specific requirements. Um, so I do that. I get changed. Then I go and meet the consultant on the ward. Um, so my rota tells me each day which consultant I'm going to be working with. Um, if it's someone I've never met before, I kind of just have to hope that I see someone I do recognize and say, have you seen B Smith and then they'll point me in the right direction. Um The idea of meeting the consultant on the ward is that before the day of operating begins, we go and assess all of our patients so that we can make appropriate anesthetic plans for them. Now, for elective patients, they'll have already been through a pre assessment clinic um which is really useful because anybody with um sort of complex comorbidities and things like that, then they will have had a consultant assessment, which will have helped a figure out whether there's anything that can be optimized in terms of their health prior to the operation. But B would give a clue as to sort of specific difficulties that we might anticipate. So that is really good. But the idea, um as I said, the idea of the pre of the assessment on the morning um is trying to assess patients specific risks um which might kind of influence the type of anesthetic you want to give. So examples of that might be um potentially difficult airway um which we'll go into a little bit later on or if somebody had um for example, a respiratory condition like asthma or COPD that might make them more difficult to ventilate or if somebody had heart failure, um you know, that, that they would be the sort of things that you would want to know um and would want to kind of factor into your anesthetic plan. So once we have been to assess the patients, you know, if there are multiple, then the consultant might go and see some of the patients, the trainee might go and see the other, then you kind of meet back up at the end and say, well, this is what I think, what do you think and then go to theater? Um So these are just a couple of scoring systems that we use to kind of try and assess anesthetic risk. Um So the A S A grade that's American Society of Anesthesiologists, essentially, it's a score that roughly correlates to sort of degree of morbidity and therefore expected operative risk from a patient point of view. Um Malay score is just one of the things that we use during an airway assessment, essentially, it's to assess a patient's mouth opening. And therefore, in theory, how likely we think it's gonna be that we'll have difficulty trying to intubate things like that. Now again, we'll go on to it a little bit later. There can be airway difficulties for other reasons that we don't anticipate. Um But if, for example, you saw somebody who had a malady score of four, had really poor mouth opening and he knew that needed to be intubated. That might be something that you consider, you might think. Well, actually, let's plan for that. Let's think about using um different equipment like a video scope or something like that. So, um next thing that we do is go along to the anesthetic room. Um do some machine checks and meet the anesthetic assistant who is either an anesthetic nurse or an OD P. Um Now they do the same job but they have very different training and they don't really like to be confused with each other. So I would suggest if you ever end up, um you know, when you end up in training and you end up working with an anesthetic assistant, just ask them early on whether they're a nurse or an ODP because it matters to them. Um So one of the things that we have to do every morning is do a machine check. Um So the anesthetic machine that we've got here on the right is fairly typical of the ones that I use every day. Um Essentially there are some a GBI guidelines on how to perform a machine check. It's something that needs to be done every day, but it's just to make sure that there's not gonna be any problems intraoperatively. So making sure that things like there aren't any leaks in the circuit, like the ventilator is working like the oxygen and the gas flows are working and all of the monitoring is appropriate. Um So once we've done that, we have a chat to the assistant, usually go through what the list is going to be like and what um our plans would be for each of the patients so that they can start getting them ready. Um Or if there was any special equipment that we might need, then we would let the assistant know at that point. Um So I suppose anyone who's been in an operating theater, you know, either from the surgical or the anesthetic point of view will have done a who briefing in the, in the morning where everybody kind of introduces themselves, says what their role is. Um This again is just a chance to discuss the patients once again, get the um perspective of the surgical team and see if they have any anticipated difficulties. Sometimes this is the time when you know, we might think about changing the order on the list or think actually, you know, we need this specific bit of equipment for this patient that we didn't think about before. Um So very useful and also helps you get to know your team members, which is always helpful when you're kind of moving around every day. Fine. So 8 41st patient, well, the patient for the day in this case arrives. Um So I've just included the who surgical safety checklist here, which hopefully most of you will have seen before. Um Essentially when the patient arrives, then we go through all of these checks. The assistant does even more checks, asking them about things like allergies, metal wear, whether they've been in hospitals outside of the region, all that sort of stuff we put monitoring on. Um So, ecg dots BP cuff SAS probe, a best monitor which I'll show you in a minute um and getting some IV access so we can actually put them to sleep. Um So the particular patient that I had on this day, I think last Tuesday it was that I've decided to talk to you about was um a fairly young patient who was having um a laparotomy um for a bowel resection. Um So young la cros who was having a bowel resection. So because it was a very large procedure, um and he was going to be in theater for a long time, he had sort of a higher, a high operative risk. And again, this is a chap who was otherwise fit and well, but the surgery itself was very risky. So we had a plan to admit him electively to h POSTOP um because it was a long procedure and because he was going to be admitted to h and because there was potential for sort of hemodynamic instability during surgery, um placed an out just so that we could have invasive BP monitoring and also so that we could take gasses off and things during surgery. Um So that was something that I did. Um Now the other diagram that I've drawn there on the other side is of an intra fecal injection. So something that the um anesthetic team at the hospital where I work are quite keen on is offering spinal anesthetic as an adjunct to um pain relief during the big laparotomy cases. Um There's evidence showing that it basically helps patients have much better kind of POSTOP analgesia outcomes. Um And it also reduces the need to give them um intraoperative opiates and remi fentaNYL and things like that. Um I believe, don't quote me on that. So anyway, the next thing that we did was we placed um a spinal anesthetic which was, you know, really, really good for me from a sort of procedural point of view to be able to be doing things like this. So early on into the anesthetic training, all the consultants that I've worked with are really, really helpful, really friendly and very keen to get us involved early on. Um This is something that, you know, outside of anesthetics, you're unlikely to be doing um spinal injections. But, you know, as an A CCS CT one, an acute medicine or, you know, in medicine in general, I guess, you know, LP S are something that you'll be doing quite frequently and really, it's no different other than um you know, introducing the, the medication through the fecal syringe at the end. Um So once we had done all the preparation, um it was time to induce anesthesia. So the patient was going to have a TIVA anesthetic, which is total intravenous anesthesia. Um That is, again, that's something that is very variable depending on where you work. The hospital where I work uses a lot of TIVA. Um So we gave the patient some opiates to begin. Um and then started a propofol infusion. Once we were happy that they were asleep, we gave some rocuronium to paralyze, um which is really important for intubation. Um So the next thing I did with the consultant kind of in the room was I intubate the patient. Um which is something that, you know, two months ago I wasn't very familiar with, but being in theaters every day and, you know, most days having multiple patients, it's a really, really good chance to kind of get your skills up quite quickly on that side of things. Um At the end, we'll talk a little bit more about the sort of teaching you get as an anesthetic trainee. Um But yeah, that's, that's something that kind of the consultants are really keen to get you involved in very early on. Um fine. So intubation just gives me a chance to talk a little bit about um the difficult airway society guidelines um for situations where you're struggling to intubate. Um and ventilate, this isn't something that you guys need to know about at the minute. I I'm just putting them in so that you're aware of them. Um and also do a lot of really useful courses and things if anyone's interested in any of that kind of stuff. Fine. Ok. So once the patient is asleep and paralyzed and we're happy that all of the parameters are stable, we transfer them into theater. Now for a big case like a laparotomy or like a free flap or anything like that, there will be a lot of faffing around from, you know, the time when you induce anesthesia to them being appropriately positioned and draped and everything, you know, for the surgeons to be ready to start operating. So this monitor on the right is a this monitor. Um essentially what that is is a machine which uses eg wave forms to estimate depth of anesthesia. Um really, really useful in patients having um intravenous anesthetic. Um And actually, it's, it's now a national guideline, but essentially this number and also the waveform and some of those sort of spectral arrays help us figure out whether we're over or under anesthetizing our patient or whether we've got it just right. Um Fine. So during this kind of period of the scrub stuff, getting the patient ready to be operated on, um the patient dropped their BP. Um you know, at this point, they were fairly deeply Anestis, we had given them a bunch of drugs that caused them to um cause them to vasodilate and there wasn't any surgical stimulus going on. So that's something that's quite common. Um So when I noticed that I spoke to the consultant said that patients just dropped their BP a bit. Should we give some vasopressors? Now, that wasn't because the consultant didn't spot it, but that was because that was the type of teaching that we were doing that day. He was sort of trying to let me notice things and figure out how I wanted to treat them. Um, so patient dropped their BP and we gave some meal, which is an alpha one agonist, I believe. Um, and once the patient was stabilized, um, and the surgeons had started the operation. Um, there was actually quite a bit of time for us to just chat. Um, so that sort of episode of the patient dropping their BP prompted quite an extensive discussion on hypotension, um, and all the different things that can cause it. So I've, what I've done there is I've copied out, um, a slightly newer version of the scribblings that the consultant did during the morning in that case. Um, just more to show you that even aside from all of the procedural stuff that we've already talked about every day in the theater, there, there is usually an opportunity to learn something, um, sort of in terms of physiology or in terms of pharmacology or whatever you want to be. So we talked about all of that stuff quite extensively, um, which I really like, I really like that kind of learning style and actually, it felt quite nice to be able to finally put the first year physiology and pharmacology that was about 10 years back in the brain somewhere and it to good use, which is nice. Um So another thing, any tests are very, very keen on making sure that everybody is appropriately rested and has a good number of breaks throughout the day. Um So anesthetic consultants will always say, you know, go get coffee, go and have a little bit of rest, go and get yourself something to drink, go for a walk. Um, which I think in the beginning I worried a little bit that they didn't want me to be there. And actually, that's not the case at all. They're just making sure that, you know, you looked after and you're well rested. Um, the reason I've put a picture of a lasagna in here is because one of the consultants I worked with last week said that giving an anesthetic is a lot like making a lasagna. And if you ask 10 different people how to do it, they'll all give you a different recipe and I'll be convinced that theirs is the best, but there's no one right way. Um, that kind of why I put that there. So afternoon was largely very similar to the morning, to be honest. Um, more chance to have a chat about physiology, but just also about, you know, other things, the consultant was telling me that he was hoping that the case finished on time so that he could get his son to his football match and things like that. Um, everyone is really, really friendly and it's just a really nice environment to be in and we finished on time, which was great. Um So another analogy um that a lot of people like to apply to anesthetics is to say that it's a lot like flying. Um with intubation being sort of take off, um the majority of the time of the procedure being be in a cruise in altitude and then extubation is the landing. Um Now that's something that some people underestimate a little bit. Um You know, they think it's just pulling the tube out. But actually, again, I'm not going to sort of go through all the details, but I'm just putting some extubation guidelines from the difficult airway society in here just to make you aware that it's an important time to focus at the end of the case. Um So again, this is something that I did with the consultant kind of beside me, but I was trying to do all of the things myself to anticipate extubation, get the patient ready. So turning off oxygen, getting muscle relaxant, revered um doing suction fly in the anesthesia, things like that. Um So once the patient was extubated and was awake and was breathing, um we moved around to recovery, handed over to the, moved around to recovery, the recovery staff and then came back to check on him about 15 minutes later just to check that he was ok. Um And then that was kind of the end of my day. So the um last thing I'm going to talk about here is the IC, which is the initial assessment of anesthetic competence. Um I realized that I sort of briefly talked about it earlier on. Essentially, this is the certificate that you get at the end of sort of your 1st 3 to 6 months of practice, which says this doctor is competent to work on their own. Um, for some simple cases. Um, now in practice, it doesn't mean that you're going to be left on your own all the time at three months. Definitely not. But the reason I'm putting this in here is just to highlight how much learning you can do in such a short period of time and how steep learning curve it is over the first few months. Um I saw this a few months ago and thought it looked really intimidating, but actually two months and I feel like it's achievable. So that's, I suppose quite a positive thing from a teaching point of view. Um The other thing that we get as trainees in Northern Deanery, which I think is probably the case in other deaneries. But I can't sort of say for certain is that we get regular simba teaching in the form of the new starter course. So that is six full day sessions over the first two months, at least in my region. That's what we get where we're taught kind of basics of anesthesia. So, um inducing anesthesia in a patient dealing with common comorbidities, dealing with difficult airways, um, critical incidents, things like that. Um, which again, sounds scary but it's really, really good, fun and massively valuable learning experience. Um, so I realize that's been a bit of a whistle stop tour. Um, but that's kind of all that I wanted to cover. Um, I'd be happy to take any questions if anybody has them, I've got some resources there. So if anyone has any questions, just pop them in the chat function. Um And because I think you guys can speak on here um and we can just read them out and discuss them, but otherwise I think that was, that was great. It was very informative. Um What's your favorite thing about, about being an A CCS trainee? Um I suppose in terms of A CCS versus um core anesthetics, do you mean or do you mean just no, just in general, just in general? What? Um I think, I think I'm the sort of person who kind of likes to understand everything that I'm doing um in a lot of detail. And for me, although I felt like, you know, the ct one year was tough in terms of roter and in terms of curriculum requirements and portfolio and all that stuff, having just more experience of unwell patients resource scenarios and things in is something that is really helpful and it's actually in a strange way, made me feel more prepared for those kind of things happening in theater loads of completely different environments. You know, if I'm used to dealing with a hypoxic patient or I'm used to dealing with a hypotensive patient or whatever. For me, then I feel like a lot of those skills are transferrable at the moment. From a ct two point of view, it's completely different to ct one. So in the Northern Deanery, we do um ed and acute med in first year and then anesthetics I to in second year. Um, so this is completely different in that. I kind of spent the last four years doing versions of similar jobs, um, you know, kind of ward jobs, A&E medicine surgery, the ps, um, jobs that I vaguely, you know, I had an idea how to do and now I've just come into something completely new where I've not getting experience of it before, but actually nothing's expected of me, but the teaching quality is just really, really great and actually speaking to friends in other specialties, they haven't. Uh, you know, I'm sure the specialties do have really great teaching at various points, but none of them have quite that kind of apprenticeship style of learning that, that you do as an anesthetic new starter. And I think that's something that I'm really enjoying at the moment. Um So I've got a question from Jennifer in the chat which says, which f two rotations do you recommend for A CCS? Um I think I can only really tell you about my experience. What I did was GP PS and A&E, um, the reason that I did those was because I thought it would give me fairly broad base of training. And I think trying to get specialties that have a degree of acuity is helpful if you can. But I also know trainees who didn't do those kind of specialties. Um, you know, people who've only done things like Gyne and psychiatry and stuff like that and they don't struggle, you know, I think probably having done A&E before as an F two and especially an extra year as an F three, I probably found the step up to CT one a little bit less intense than some people who've never done it before. Um But by the end of that period, everyone kind of ends up. Ok. So I suppose my advice would be if you can get things like A&E um or ICU, then that's great if you can't, don't worry about it because it's not gonna be the thing that means you do or don't get a training number or if you do that, you do. I don't struggle. Um, question from Oliver. How concerned are trainees about the registrar bottleneck? Um To be honest, I, I am a little bit concerned about it. Um But I think that's possibly say a little bit more about me as a person than it does about the um about the kind of situation in general. What I've been told by um some of my consultant colleagues is that the college are trying to do things at the moment to shift the training numbers a little bit, at least temporarily to try and get more people through. Um I think the other thing to bear in mind is yes, there's a bottleneck, but training at the beginning is also competitive. So, you know, if you're capable of getting in once you're capable of getting in again. Um And just because there is a competition ratio doesn't mean that you won't get um a red training number. Um I suppose the only thing that's kind of making me do that otherwise wouldn't is be a little bit more on the ball about things like Q I and audit and all of that sort of stuff a little bit earlier on. Um But again, by early on, I mean, now CT two for me, I do not mean at your stage. So don't worry about an ST four bottle neck at the moment. Um ok, so got a question from the he why do I choose a CC S anesthetics training instead of core? Um And so a few things. So firstly, the region that I'm in um that I wanted to stay in mainly does a CT S anesthetics training. Um One of the other things though that I was thinking was at the time when I was applying, I actually wasn't sure whether I want to do anesthetics or whether I want to do and I've done a lot of A&E, I really enjoyed it. I have to say I don't have those doubts anymore. Um, I really, really enjoy anesthetics and I think it's the right thing for me to do. Um, but, you know, at the time I thought, well, a CCS if I do a CT s and it would be easier to transfer the other way if, if I decided I didn't like anesthetics. Um Another thing that some people think about is if you want to do it in the future, at some point, you need to do six months as an echo S. If you do a CC training, then it's done. If you don't, then you can still do ICU you just need to go back and do your medicine later on. Um So just all things like that really? Um Again, I think also the time that you spend in your CT one year does get your points at ST four application at the moment in terms of time spent in the complementary specialty. Um And I'm kind of of the belief that more experience and time spent probably would have made me better. And that's absolutely not to say that going straight into core from F two or anything like that is a bad thing. I just prefer to kind of take a little bit more time. Um So hopefully that answers your question need. Yeah. Any other questions, doesn't look like there's any more questions on the chart? Ok. Um, what I will do, um, I, I'm happy to, if anybody does have any questions, I'm happy for you to get in touch with the team and they can forward them on to me or I can, well, I can put my email address in the chart. Now, um, the only reason doing that rather than putting it on the, um, rather than on the kind of presentation is, I don't know how long the presentation is going to be up for. And the idea of my email address being on there forever for anyone to just indefinitely ask me questions, doesn't seem great, but I'm happy to answer questions for a finite group of people. Um So I've put that in the chat now and if anyone does have any further questions that you maybe didn't want to ask on the chat or anything that you think of later on, then just, just send me an email. Great. Well, thank you very much for your time. Um Guys, please do fill out the feedback form. Um And we can get you guys sent over some attendance certificates. Um And again, as Olivia said, if you have any questions, email her, email us. Um And let us know if there's any other things in particular you want. I think we've got a series of webinars coming up. Um But if there's anything in particular, you guys want to see drop us an email um and we can see if we can get it done. Perfect. Well, thank you very much for your time. No worries. Thank you. Bye bye bye.