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Ok. So you make it up here as well. Hi, everyone. So I'm Ashton. Do count. I'm a chairman elect uh uh for the next few hours. Uh, the world pretty concerned. So, uh we'll introduce our first guest who's a, yeah colleague of mine from uh former times and now a colleague within Beser Howard Davies who's on the International Education Committee. Er, and both of us are doing quite a lot, a lot of outreach work would be uh low and middle income countries and I've been pioneering certain um different, er, courses and things. And so further ado I'll ask, uh how would you step up and come and tell us about it? How it is a consultant here? I have to do anything together. Four or four. Try that. Right. Making. Do it one fine. Anyway. Um, morning everyone and welcome to Sheffield. Um, those of you aren't from around here. This has been my adopted home for about 12 years, uh famous for steel, obviously. Er, and we actually turned out we make more steel now than we've ever made. It's just fairly specialist. Uh Sheffield's a, a pretty, er, industrial city but we are the greenest city in Europe, er, 250 Ars in Sheffield and uh a third of the chef, a third of Sheffield lives within the National Park. So if you get any chance over today or over the next couple of days, then, er, visit us famous for some of our really poor, er, sports teams and, uh, music here is not too bad either. Um, so why me, as Ash said, we met in 2018 when he came to fellowship in Sheffield. And in that year, I was also elected to the um education committee in both of us. So I guess that ticks quite a few boxes as to uh while we here today a bit nepotistic. But uh thanks for the invite, Ashley. So as I said, I'm on the Financial Society Education Committee and Ash wanted to talk about our work in, in countries really. And so I thought what we'd do is um, talk about um how we got to where we are, what we're doing now and really a vision for, for the future, which is why you guys come in cos I think we, we do need a bit of help and a bit of direction and a bit of steer on that. So the backbone of both education is, is the principal course really. And that was developed by a hero Tanaka who you may know from the B OA in 2010. The first course was run in Newport, basically, what he wanted was a standardized approach to training in foot ankle surgery. Um, he's always told that it's not an Fr CS course. It's about the principles of examination, history and treatment of foot and ankle problems. But really that's what the guys do we have until recently run three courses a year, a couple of courses over two days, which is the mainstay of the program with one course that was Cadaveric. But what we found is that following sort of COVID pandemic, we really paired it down. There's just not the interest that there used to be. There are lots of other courses, lots of commercial courses. So at the moment, we are sort of revisiting whether we hold two or three courses a year in the UK. And initially, we could, we could run it for free. But as times have changed as we lost a lot of money as a society canceling a meeting in COVID, then we've had to start to introduce a fee, which we thought was normal, but not everyone's got 300 quid to spare in this day and age. So that's what we've been doing in the UK for a long time. Um, in 2015, the British Indian orthopedic society of whom a lot of members are in, um, in be fast approach is to say, look, we think this course is pretty reasonable and you do something similar in India. So in, er, one with the Indian for society. And in 2017, uh some of our team went out to, to Delhi 35. This was a three day course or one day was caliber, all costs were paid in country by the Indian for society. They managed to fund that. Uh And I think for the delegates, it was free at the point of access. BOFA paid for the flights for the UK faculty, sent five UK BOFA members out. So we wanted a local faculty as well, you know, to help with, to help with the sort of things on the ground. So what we did was appointed a local course, co director for local faculty who also involved very much in the teacher of that course itself was changed. We thought at no point telling people about replacing ankles, you know, we need to concentrate on other things. And so we decided with the help of IFA and with the help of the British Indian orthopedic society to concentrate on things like posttrauma reconstruction thoughts. Although we're not a pediatric society, adult acquired deformity, those kind of things fractures, delayed unions, non unions. Everybody as in the UK gets a pre course reading test if available, we do it electronically. So if the facilities are available, we do that. And then when we get there two days of lectures, a lot of focus on clinical examination and examining patients and current management plans depending on the local resources available. And then a categoric day, if possible. So obviously in the subcontinent, we've uh now run four courses. The fifth is about to happen imminently in Delhi. I'm going out to Bangladesh uh in October of this year. There's a, a big Bangladesh contingent in Bes and a couple of guys approached us and we've got this course up and running in in less than 12 months. Uh Pakistan next year and then hopefully moving to Sri Lanka and Nepal to roll it out in 2026. Uh Once we'd got the Indian course of I running, uh there was then a couple of my senior colleagues, Rick Brown and Paul Cook who were sort of dien of the foot ankle world. Both past presidents society uh were examiners for CO E countries out in, out in Africa. And so they really wanted to try and roll this out sort of further afield into the, into Africa. Um very similar format to the Indian courses. First course was in Zambia in 2018. We, we went back there here, Tanzania was an interesting course because it was funded solely by a Sheffield businessman. So when we sort of to chat about funding later on, one of my colleagues who's now a guy called Mark Davis, had a Tanzanian patient who knew what work was going on and kindly sort of funded that course on its own. The guys were out in Rwanda, I think in July and then were moving on to sort of Nigeria, hopefully to Malawi in 2026. Moving forward though, funding for courses has sometimes proved difficult. Os can't really fund the whole thing anymore. And so we're trying to look at a shared model. We reckon it costs about 15,000 a year of a course to, to fund it. We're trying to move to more of a, a local government, a local industry model. And as you guys know, as I was just speaking to Alberto about the problem with industry is it doesn't really exist in India, in Africa the way it exists here. So we can't go speak to Phil Cleary and say it's 15 grand. We'll put a poster up and we'll uh we'll try and deliver some education. So all we try to do is get some more local funding involved. Be fs are always happy to pay for flights for the UK faculty, but we're really thinking about doing is making a transition. So that really we don't need to go as often, but local, local surgeons can carry the mantle and develop the program and deliver the education themselves. And if we can get that funding in place, then we can run at least two or three courses a year rather than the one course we're trying to run at the moment. So the lady on the left Eth Ethel um came to see us on the Zambian course last year and she then came to on the basis of that. Uh The women on a course is the best delegate prize, which is usually uh flights, accommodation and a mini fellowship to the UK, which coincides with our Belfast meeting every year. So Apple was the best delegate in Zambia in September last year. So we funded her and a couple of her colleagues actually to come to Belfast this year. Um that all works out in Nigeria. And so on the basis, she's been over here, she's now decided to run a course in Nigeria itself. So she's now become a course director. And so, uh hopefully, um she will now be able to then educate the guys in Nigeria and there'll be a spin off from that. And so it just makes it a self fulfilling uh of course, really and hope we obviously send some support out from the UK, but really try to make things home grown and in house and that will obviously save a lot of money and probably make the course appropriate to a local level moving forward then. So we've got er, and a UK faculty in, in Nigeria 2025 but hopefully by 2026 principals course will be completely run by sex. So the guy in left is James MUFA, who some of you will know, had a surgery uh in the University of Zambia and he is gonna take on the course and run it solely with local faculty in 2026. So hopefully, that's a fairly sustainable model and he can roll it out along with a guy called Brian Mala who is a, a newly appointed consultant in Zambia who again came to Belfast this year uh as a a OVA funded sort of mini fellowship. So, fellowships, what else are we trying to do at the moment? So that's the courses. So, fellowships, um we fund three UK trainees on traveling fellowships a year. So a gold award 7500 silver, 5000, bronze, 2, 2500. They don't exclusively have to go to countries, but a lot of people do and they usually go for around about six months, as I mentioned, really the best delegate on the African courses and the, the new courses are sponsored to attend a BOFA conference. So hopefully they will then go back and spread the word. Um And what we're attempting to do at some point is have a co funded Cope Bos Fellowship to a UK center for anything up to 12 months. We also just as a sideline do provide some remote support. So, um one of the er, a guy came for a short fellowship in 2018. I'm not sure if, when you were there a guy, a Ahmed who is from Bangladesh and he's then set up a group in about 46 Bangladesh. So I think it's 33 guys from the UK on it and in the middle of the night they'll always ping an X ray and say, what do you think? So, there's a very informal network set up as well. So it'd be quite nice to meet those guys when we get out to Bangladesh in October. Um So both traveling fellowship, um they'll, they'll come to BOFA and then you usually get supported uh in one of the local hospitals for two or three weeks afterwards. Um We'll do a program, a guy called Jonathan Sita came to Sheffield when we had BOFA here in 2017, probably slightly before your time, Ash. But uh he was then on faculty in the Zambia meeting. So it's really nice, it's just a nice circular way of, of getting around things. And as I said, Ethel is course director in Nigeria. Uh other things we're doing at the moment. So we do sponsor people to go out to Blantyre um usually six weeks to six months. But I think for political reasons unknown to me that may be coming to an end. So what we're trying to do is develop a relationship with er Sven Jen the long way and try it with the British hand society model. I know Jonathan's gonna talk about later. Um So we need to pick his brain this afternoon, but what we're trying to do is for a three year program result of presence basically exactly in the same model, I think the hand society and so that a lot of missions um and the other thing we're reaching out to at the moment is EA s the European Financial Society. So they have seen the work we're doing and they're quite keen to establish similar principles courses in French Spanish and Portuguese speaking countries. So using our model, they're trying to move out there, hopefully using that huge pot of cash, we can call some of that back and again, help with the ro Surgical program in the long Wait and health and other courses for English speaking countries as well. So that's just a bit of a vision and a fingers crossed finger. So, thank you very much. Thanks so much for that. I would stay here. We've got about five minutes of question. So you've done very well with. Thank you very much. Hold back some time. So this is, yeah, some really exciting developments. And I think this is definitely something that's gonna grow in time. Do you have any questions in the audience itself? Um I'm curious about how you uh customize your course for a very different healthcare economy. It's a very different healthcare pathology. Yeah, and it, and it is difficult. We spend a lot of time chatting to um the local faculty basically. So we, we get a local faculty and we're basically very much guided by them. It is really hard um chatting to Alberta. You know, we, we will go in and talk about fracture fixation and things and then they only got plaster to the hospital we were in, in Zambia apparently hasn't had any anesthetics for six months. So it's really hard and, you know, we don't know the quality of what we deliver really. And we, we don't know the outcomes cos I guess we don't check. Uh, we're very conscious of not rolling in with a load of kit and we're very conscious about trying to just give principles rather than treatment plans. Well, I think that is a massively unsolved problem from BOFA. You change to Alberto and some of your other colleagues, I think that may be something what can help us with moving forward. Good. Thanks very much. It was a really great talk. Um and it, it's very encouraging to see the consistency and the legacy from the earlier courses and how you've managed to, um, you know, basically pass something on that's really good to then lead to a, a course actually running on its own. Um And it's partnership um and looking forward to chatting, you know, more about the B SSH, um uh be kind of hook up in, in a long way excited about the possibility of the BFAs H, you know, hand and foot, you know, one day, hand and uh wrist and, and the other, the other day uh wrist and which we've done before with, with Harvard orthopedics. But, um uh you know, lots of spin offs from that I'm interested to know on your, on the teaching aspects. Of the course, whether, whether you bring in on the anesthetic side with, well, and I mean, obviously we, we go a bit crazy about that in hand and wrist, but in an ankle has its look, we don't, it was something that came up yesterday. So I'm trying to organize a program for Bangladesh at the moment and a hangover from one of the previous India courses where there was a talk about ankle blocks. And we were just debating literally yesterday, whether we keep that in or not because one of the UK guys do that. We've got, I've got the world's best anesthetist who will just block it, you know, in a eye. So I really think about it and it's hugely pertinent, isn't it? Because if these guys don't have any access to anesthetics, then you need that. And so we haven't thought about that at all. And as of yesterday, I'm acutely aware, it's a huge deficiency. And so, um and again, it's equivalent on the ground so I could take my anesthetist, Tim who's a genus at ultrasound, guided nerve blocks. Is that any good for a country that may not have an, probably doesn't have an ultrasound machine. And so it, it's something we need to sort of sit down and, and square that circle and maybe if you guys got really good experience in that, maybe it's something we need to sort of tap into, but we're trying to push it a bit further. Um, but, uh, it's early days as well for us but, um, as I've thought, um, Don Hollande, um, with the American Society and the British Society, they basically did a course on one hand surgery in her in for all of these, the whole muscular system. Um, and they, then they, we basically cosponsored two trainees from each of the countries. So that was, I think it was 10, um, trainees came and they all went to Mombasa and they basically had a, a fest on one surgery in uh including, and, and you know, that's a nice way of just catalyzing it as a thought so much. Thank you so much. How, um, one last question, 01 last question, please. Yeah, I see. I didn't see it was a low hunt. So, um, I was just gonna ask you think there's a scope within the specialist societies to all, all specialist societies to fund some sort of um, platform for recordings of, um, the, the, the lectures delivered, for example, um, that's one of the things that we did when I worked in Phnom Penh was to basically do an audio of the powerpoint presentations and leave that with them. So that there's a, we do have, there's something called lectures, distinction that you won't be aware of. Uh So through the pandemic mo um I think about 60 lectures or some cover whole foot ankle so that you can possibly think of available free to the country online. So that is really high level, which may be, you know, if we're talking about, you know, do you replaced ankle? There is a bit of a, there may be some of it beyond the general principles are all there treatment that are, that are absolutely available for like both ahead of the curve, to be honest. And, uh, just on the subject of anesthetists when I worked there, I got my brother to come out, he was a console an and the anesthetists there were really pleased. He, he, he taught them all sorts of regional blocks and stuff that they were dead interested in. So a week of like constant block everything uh it worked out really well. No, that's a really good, I think you are doing things today. I got that same vision. Haven't about sharing, advertise it. All those lectures are on youtube if there's 60 of them. Yeah. Yeah, that's phenomenal at. Right. And, and maybe what has a role in being a platform where we can um link up to all these because I think amalgamating everything is not gonna be possible. Everybody has a different kind of message. They wanna, you advertise a link, putting, putting AAA link on the web on the website will be absolutely the way forward. Um Is it Martin just mentioned that the American Society was starting a bit of work to try and bring together on the online. There's really, as you said it's a huge amount out there but it is under the right. It's very good. Yeah, thank you. Right. Er next uh we got John C friend of Sheffield, not, not local to Sheffield but working locally in Sheffield. So you can, who will be very modest, I'm sure here. So John er I met John about 15 years ago when I was in Malawi accompanying my wife for a uh tropical medicine course And John was already a consultant in Q hospital there and he spent um nearly 10 years consultant away from the UK, having just finished his training, starting off there and then had to face the reverse challenge of getting back into the UK system. I thought that is a very unique experience, a rare experience that in a way, you know, scares a lot of us from actually leaving our UK practice for fear of what's gonna happen when we come back and stuff like that. And I thought somebody who's lived through that who can tell us all about it and he's done some amazing work whose legacy II see every time I go back to Malawi with the perfect person to invite here. So John Cashman, er, consultant, er um pediatric surgeon at Chef Computer, I don't know whether there's someone else I'll leave that to you. It's completely flattering and it's worth the retainer. I pay him to say. Um, but it's really nice to me. I feel really embarrassed that this is our home manner and I'm actually not even going to be here the whole day because our department, I don't, I don't, I don't understand it. Our department is in such disarray that I actually have to go back and do some clinical work this afternoon. But really, really nice to be with you all. Um, and I really used to reiterate the thing about courses, you know, after many years in Malawi and lots of people asking how they can help. Uh there's a lot of experience in this room, but I think um having the right contextual course is a really good way of harnessing goodwill and support from around the world. Our local trainees and surgeons used to sometimes find the messages delivered from delivered from uh the northern sort of a advanced uh orthopedic faculty a little bit irrelevant in some ways. But they always really appreciated the interest and the support and the relationships and the networks that followed on. And I was gonna say, uh a little bit just that I didn't have time. But it's always, we, we really found how that, you know, that post course evaluation is a really good way of rapidly improving courses year on year. And of course it is different, you know, Ethiopia is very different, isn't it to Mali to Malawi Toe? But um but we found that really good actually, we have done that. But also we find that the guys are very much wanting to please. Yeah, they do want to please but they don't quite go all. Well, the nicer Ethiopia is people just generally be a bit more honest always. Or I don't know what you think. But, but yeah, it is a bit, at least that gave that, that opportunity. Actually, in other word, it's really good, fun working with people, um, who are educationist to completely, you know, start afresh you think about delivering courses for low income countries and not be bound by conventions that we have about. We must have powerpoints in XY and Z. But really, I look at the best way of delivering education. That was really quite exciting as well. Oh, here we are, we're up anyway. Um So after that flattering but very untrue uh introduction. Um I mean, I talk about what it's like to come back to the UK and the answer is very easy. I'm sure I had it out a little bit more than that. Ah It's a USB Dongle there we are. Perfect. Thank you. Um So what I do, it's just uh by way of reflection, eight years of spend in Malawi, it's just a little bit about my journey and I'd deliberately not try and do that, you know, lots of pitch postcard stuff about my experiences, but more just a little bit of background about who I am and what happened to our family. Then some misconceptions I had about returning home and maybe some advice and, and some and planning anyone who's thinking about doing the same and a return back to the UK, although on file and some recommendations at the end, but it won't take very long and there'll be plenty of time for chat at the end. So my journey is II was originally a Wessex. Uh I graduate, II qualified for Southampton did all my training in the Southwest um fellowships up here in Sheffield, which was fantastic. You thinking, Alice, thank you for training. Come to Sheffield, great place to train a very proud reputation and training education and also did some time in, in Russia and America. Um And then I started working in uh Bristol and Bath as a young consultant in 2002. And you probably, I don't know whether you recognize Martin G FG. And um well, that was us in the kids hospital in the old days. And then after, you know, about four years in here international as charity wrote to me and said, will I be interested in helping them um the first sort of fellowship trained pediatric orthopedic surgeon to help drive their, their unit in hospital Malawi. And that really was for me like a job from Heaven. II had no real excuse to say no. So a year later, II came to a gentleman's agreement with the medical director that I was probably gonna leave, but I'd do a two year sabbatical and give them uh a FAA form of binding um response after a year about when I was gonna stay. And I really recommend that for anyone who's thinking about going abroad, take a sabbatical, don't burn your boats necessarily. Um And then come to an agreement with the medical director about maybe after a year, you will let them know and see what your intentions are, whether to come back after the second year or stay on. And that worked really well for us. So many of you have been to Malawi and know exactly where it is. But for those who don't just down there in the southern part of eastern Africa and we left there for two in 2007 with the family. Malawi is a lovely place occupied about third with this great big freshwater inland sea and bla high where we were based is in the south area there where this custom built children's orthopedic hospital, which is quite niche and absolutely lovely. II say it's a beautiful country. It's really not too much of a hardship to go to Malawi. It's got this lovely, lovely lake and beautiful mountains all quite and it's a bit like the New Zealand, isn't it? For those? It's like the New Zealand of Africa, everything. All the geography is quite compact so you can actually get to it all quite easily. It's not like Australia or somewhere silly and like many other countries that we all have experiences uh about you know, um most of the population over 50% is under the age of 16. So it's a very different demographic that exists in this country and it's one of the, the poorest countries in the world. The hospital itself is lovely. It's uh it's not that old. It's got good facilities. It's got a digital X ray and arthroscopy and ac arm and safe anesthetics delivered by clinical officers at a children's ward that takes up to 40 kids. Some of the power tools are a bit sort of homemade, but they all work really well and uh at uh 1/100 price of the ones we use. Um and we have a really good fellowship program at the time. So UK fellows used to come to us for a year at a time and it was a really happy uh environment in 2015. My parents are getting old and uh as it was with our kids, there was like a window of opportunity coming out of their education that if we were gonna go back, we should think about it. We ended up hearing over the edge of the cliff with no intention of leaving, but I thought, well, I ought to at least put it out there that I might come back. And then suddenly we found ourselves on a downhill slide back to the UK with uh with job offers. But in a good way, I'd always wanted to leave wanting more And that was, that was great. What, what happened, you know, we left with reticence, which is a good thing to do. Um And also we've been really fortunate, we managed to train a big harder of clinical officers and uh surgical trainees. So actually I II wasn't really needed and others could do my job better than me. Um So I had some misconceptions uh about, about coming back. I think the first one I've really alluded to already is one I thought it'd be really difficult having spent the best about 10 years out of the NHS to get back in the system. Actually, that wasn't the case. And I mean, you'll probably obviously recognize Chris Larva. I mean, the the the actual my predecessors had done it and none of them struggled. Chris Larva obviously went to chair at Oxford er Jim Harrison Chester. He's got say fresh as well. He's a medical director of the AO Alliance in Africa. Carl James, one of our fellows then took over for me in Malawi. He came back to um a very good job in Brighton and he's a really inspiring and gifted li construction surgeon. And then, Mo more recently, uh Rick um Gardner who's one of our fellows then went on to here in for several years has been head hunted to be a head honcho in the kids hospital in Toronto. So they're not exactly second rate jobs and uh it's not, you know, I'm I am the odd one of the pack, but they're all gifted people that are going on to fantastic um careers. So I don't think it is career suicide. And when I look back at our fellows over the years, I won't go through all their names, but they've all gone on to basically jobs of their choice in the NHS or um in uh Matt Primes case. I think he's VP of a wing of Rosch in Ba in Switzerland. So again, not doing that badly for himself. Um So it's not, it's not career suicide considering spending protracted time away in a low income country. But I think there is some issues about planning which are probably good to address in advance. I think the thing that struck me is that took a lot of time actually to do the transitioning process when you factor into things like your children's education, where jobs are available and succession planning for the job you're leaving in whichever country you're working. It takes about a year um to get that all the ducks in order. I think what really helped me is having friends in the NHS for my five years working in the NHS was really helpful being enmeshed in, in surgical societies. In my case, it was Brisco the children's society, but we're all different. But I think letting national society know that you're thinking about coming back is really useful because people will, will try and help and they'll point out where potential jobs are coming up. I think being I was very open for the outset that basically I wasn't gonna do any brown nosing II wasn't able to come back. Everything was gonna be done over here in dodgy phone lines. Er, and there, there are lots of emails and things were gonna be inevitable and people were really happy about that as long as they knew everything upfront. So finally, um, there are just some, some recommendations. Um, I think the first one is if you're thinking about coming back to whatever domicile you come from, whichever country it's really good to keep, it's really good to, that wasn't here. It's really good to keep up to date with the, with the requirements of your own Medical Council. And these days it is a bit of a hassle, isn't it? The GMC? They're, they're not particularly, er, b but actually, um, I think it says something but keeping up to date with your appraisal is a bit of a, a, a schlep. But actually there are, I don't know, people use meds here. There are sort of independent providers of, of consultant appraisal now around the country, um, that you could do digitally online actually, although in theory, your practice is meant to be based in the UK. Let me tell you, there's lots of people who aren't and it is possible now to do an annual UK appraisal and not be, do as in the UK. Um but it is useful to come back. Um At least every now and then probably every five year validation cycle is quite useful to have worked a locum. So what went really well for me is to keep my honorary contract in Bristol and come back and with the birth of each child, which is every four years, I came back and did a short locum for like literally two weeks. The boys and girls were really kind to me, gave me some waiting list initiative clinics to do. Just meant I retained a, an NHS email address and it meant that um I could get things like patient three sixties and, you know, colleague, three sixties for your appraisals. That was all really easy to do. Um, and that certainly facilitated the annual appraisal process and when it came to getting my, er, re validation, it also helped. It's actually easier now with organizations like Meds Suit cos you can, they will provide a responsible officer. But in my day, really Bristol were very kind and acted as my ro throughout my whole time in, in Bali, which was really good at them. But these little things are probably worth thinking about uh in advance. So I didn't touch it when you tell them it was exactly. I don't really decide. Um, so keeping your appraisal and your GMC in line is good. And on the back of that, I feel such a hypocrite here but, but actually uh keeping an up to date record of all your quality insurance projects, like audits, training courses you've been to are all really good, really kind to me. They invited me over at least once to as a guest speaker and paid for my airfare. I remember giving a talk to very fast and Busso did it as well. So that gave me two sort of British society meetings. I could put down on my CV. All those sort of things that really helped if you're now in charge of those societies, think about people you can invite to, uh you know, li construction to, you know, whatever and bring them over because that really helps as well. I mean, so keep your home special society up to date with your plans. And I think attending an annual conference where you can, is really helpful, logging all your online uh training and trying to keep good about keeping all those things up to date, really helps with uh satiating the GM C's desire for lots of tick boxes. Um on return, things are probably going forgot. I feel like I probably am a bit of a Malawi Bo. I think people are so fed up with me. You know, I can't believe we do it like that. Even in Malawi, we did it better than that. And believe you me in the NHS is quite common. Um So I think, you know, stay humble and uh and it's great isn't it to work in the N HSI? Mean, I coming back, I'm so grateful to have pediatric colleagues that can their opinion. I'm so grateful to have supportive colleagues to chat about cases. You know, it is so grateful. There's an ambulance service. I don't worry about my Children continually. You know, there's lots of good stuff. So not being a, not being a dot dot dot Bo I think is quite important. It very humble. I think the work all of you who going to other countries will know you get back to the NHS. And really we doing this, the work can be a bit tedious, can't it, it, it's not as exciting and it's, we're not, we were talking earlier. Um So about how we're not very efficient at in NHS, we don't use our consultant time very well. Um NHS is not geared up for efficiency so it can be a bit mundane. So I think keeping it interesting has been really important for me, you know, keeping your focus on teaching, you know, and being involved in the courses that how I was talking about uh helping sometimes just direct and uh uh syllabus of those courses have been really good. Uh keeping teaching links with uh countries we've worked in before getting involved in contextual research is really important, isn't it? We are now in a position in this room to influence how your registrar, senior registrars were ever even take on a phd. Uh and, and direct them towards contextual research that really matters in the world. Not just another paper about ACL S which, you know, no one ever died of an ACL injury. Um But, you know, people die every day of my life. So contextual research with me just getting back to it. I thought I'd become an examiner because that keeps me involved with training in this country and that's really helpful and then being involved in our own special societies. Uh the B OA, the College of Surgeons, you know, helping just at some level, improve the profile of our worldwide stewardship is really important. Um And, you know, if, if you're bent on management, even get involved with NHS management, that would be the last thing I would do. Um And I think, you know, it's really easy, all of us, it's really easy, isn't it to suddenly get assimilated by our own culture once again and lose focus on what's really important? And I kind of promised myself that I keep my focus is really, you know, but it is quite hard, isn't it? We get assimilated into a Western culture once again. But I think, you know, keeping our priorities really clear is really important. And for me, um again, having a commitment to low income country work has been really helpful. Um But, you know, just keeping an adventure going in a, in a NHS that's kind of applied for lots of problems um, so keeping a sense of adventure and a sense of perspective and, you know, whatever our personal priorities are to keep them uh forefront and central, this is my commute to work on good day and that's how I, how I keep my focus. Yeah, there's a lot to be grateful for. So, in the middle of a, a sort of the crushing, er, pressure of the NHS to, er, to keep effective and, and, and keep grateful, I think is really helpful and to avoid that, that you, that developed country thing of being comparison, you know, if you've been away for a while, you'll never have the same private practice. Not that I want one, but as your colleagues. So self comparison is just a, a is a, is a bit of an evil route to unhappiness. Um So even the main thing, I think the main thing. So in summary, you a privilege of time of life, um I think reintegration would be much easier than I would ever thought. And I think to speak to anyone in the audience here who's done it, they'll tell you the same, it's not really been very difficult, it should never be a reason not to do it. Um I think time also does give you unexpected insights and contributions. I think, you know, in the modern context of the MO NHS, a lot of heads are down and having to spend time in other cultures, in other countries. Gives us a unique um perhaps perspective of uh of what the good things are. And II think, you know, I love that Napoleon quote that um to be a leader is really be a purveyor or a dealer in hope. I think that is something we can all do well equipped to do and not to get dragged down by, by the the pressures of the NHS um hero of my own church or, and I love that, that thing of actually just, uh, just keeping optimistic, stumbling fairly, fairly, without loss of enthusiasm, certainly could be the prescription of my surgical career and then just keep adventuring. And that was my kids this last week. Any questions extremely unhelpful whenever, um, it doesn't really, really powerful thought anyway. Um, but I'm, I'm very um aware of the, er, this sort of misconception sometimes of, of what it means to go and work overseas all in, in, in low resource countries, say Martin and I, and, er, the, the Ate L trying to encourage and, and get people consultants to come and join the program and lots and lots of fantastic input. Um, but it's drying up and, uh, I think I've probably had about sort of 30 consultants who all say. Yeah, maybe, maybe when the kids have grown up. Uh, well, it's a bit kind of bad but there is this sort of, um, and there's such fear, you know, going to a place where there might be by snake or by a hippo or something like that. So, I think there's this, er, I think making this, as you say, it's global, um, awareness and, er, stewardship for making it. So the trans position for people to go for even short periods of time, you even get people to go for, we can get people to go for three weeks, but that's not enough, we want people to go for six weeks minimum. So, uh, but you're talking about, you know, someone who's gone for eight years and predecessor of yours, but it starts off with a spat, doesn't it? You know, it starts off with a six week and that's what you can't give it to something they don't know about. So that's why they're doing courses and things like this is not for everyone. Of course, it's not, not gonna be for everyone nor should it be, um, in order to encourage the right people, I think, you know, improving exposure is really good and we all know actually the biggest danger for myself and my family. It's not eight years in Africa. It's actually going immersing young kids back into teenagers, into, you know, mainstream schools in this country. I'll tell you what, that's a lot more fraught with difficulties and challenges than living with a few, uh, snakes. Yeah. Ok. A parent in my life? Ah, fantastic. Really good. I mean, my kids have not forgiven me to bring them back. You know, ii honestly mean that eldest is on her way back out to Africa as soon as you can. And, um, no, it's fine. It's, it's absolutely great, you know, not just Malawi, but I know in Ethiopia in, before, you know, there's great international schools wherever you go, you feel the same in Cambodia, in Penh, you know, and actually that international education is, is equipping them much more for the world in which we now live, isn't it? So, it's been, my kids had a, had a ball and, um, yeah, and their education quality of education. Great. I wouldn't worry about it at all. Does the mild feeling of regret ever go away? No, it doesn't. But, but also gratitude. You know what I mean? That, you know, II, II, weight lifted off my shoulder in some ways and I turned to him. Well, I, you know, landed at Heathrow because I II stopped worrying about it falling ill with something and, you know, there are no ambulances and, you know, all that kind of stuff goes away. It just substitute for another set of anxieties about what my daughter's doing. Social media and that kind of stuff. Um, but it's just, it's just different. Yeah. But the families, it's, uh, you, everyone here will know it's been a pool. II mean, ii know Gaza and things are exceptions. They're very dangerous. There are war zones where these things aren't appropriate but in a lot of low income companies, um, risks are of security maybe but psychologically and family Arima, I'm gonna, I'm, I've got a bottle of contention with you. Um, it'll be contentious and your throwaway comment about management. Yeah. No, it might be. You are. I mean, I'm not dissing it. I just said not silly. No. No. My point is actually people, the NHS would benefit from medical leaders such as yourself. What do you think? They absolutely would. And you know, and I am, I am confronted by it. I've got lovely management teams around me. Uh And they're lovely but they have a, an, they're constrained by an NHS mentality. I could, no, I could so half Robin student hospital in, in one hour if I was let loose with a ruthless pen. But I, you know, that's never gonna be the way and un unfortunately, that's not my skill set. I hate committee meetings. I'm a man of action. I like to get stuff done very little interest in being politically correct. No, I'll just leave that to people who that is their skill set. I, you know, recognize my own weaknesses is not my skill set, spend time training or having fun. Maybe that's the problem with management is that the, there aren't enough of us, slightly more broad minded people within that, within that group. I think you need to have to, uh you know, you need to stay awake for more than 30 minutes in the committee meeting. I just, it's not me. But if someone needs to do a job and I'm delighted that, you know, your people like yours yourself do that. And you know, John, would your reflections of how we be any different if you had been in National hospital? University Hospital, a central hospital? It's very interesting. So I went out, first of was a registrar and had a, spent three months there, then this was there. And when I came back, I realized, couldn't fix the government system and, um, I had to do part of it but I couldn't fix it. And uh uh cos I watch people like nyen but canI who's Malawian and, you know, train this country and I watched him really struggle. I thought if Nyen is highly respected, fluent vernacular, you know, and he can't make big changes, then the chances of me just getting frustrated are extremely high. Um So again, it's about recognizing your skill set. Now, I did, I would, did work in the government hospital. I did AAA day a week and on calls every week there. It was not, I didn't have an experience there. We had, we had the training of um uh of uh the, you know, the Maori trainees. So II do have insight and we used to do visits. But, um, and it would be, there's bates who's not here but now lives three, yeah, three miles away was um lead orthopedic surgeon in, in ti for either the day best, about 20 years. And um you know, he did an amazing job in much more difficult. So, and I suggested in a much more difficult situation than me fortunately. Um but it's a hard graft and it takes its toll and it's all about setting the example and building the next generation of leaders rather than trying to systemically change things. Really apple setting. That's a hard, hard graft. He speaks good to show her to talk to you. Thank you very much. And I hope all of you are energized and fired up to go abroad and do something like John has Don, even if I if it's on a smaller scale, and I take this opportunity to bring out a couple of uh things that we are developing at the moment, which is basically the creation of a database for volunteers and for people who want to go and join existing programs abroad. So uh this is something that's gonna be delivered through the walk website over the course of a year. Today is the day of a launch, trial launch and we'll probably have to have a proper launch in the BBO A in um in September. So there's a uh green um QR code form here for anybody who is interested, register your details on there. And uh we will hopefully be able to somehow match you with a suitable object that's already up and running abroad. So the likes of B ssh and Beast will make the most use of that cos they've already got established programs, but offer has got a program feed first has got loads of things that you will be able to now find in one repository. And I think that's something based on the feedback we've had over the years from people who come to our stands at the B OA. So can I encourage any of you who's running a project to fill that in? It's all confidential at the moment? It's not being rolled out. So it's all password protected at some point. We'll, these are all these sort of, er, DDR B kind of, er, issues with it, but at the moment we just want to see how it works. So this is a trial, I'd encourage all the trainees and all the trainers in here to fill that in and without further ado I would introduce our next speaker. Who's Ros Tucker, who's current, er, secretary with Ros is a pa in queen. Yeah, I always forget which it is. Sorry? Yeah. Yeah. Yeah, exactly. Um, so Ros and I have worked together in, in Malawi and on the basis on the back of that, Ros really has come up with the idea of kind of studying a little bit some of the workload that we're getting, um, through our project and, um, I'll introduce her to talk to us about it now. Very much good. Um, yes, I'm, uh, Ros and we decided to, um, try and audit what we were doing in Malawi in 2023. So feet first was founded in 2004 with the aim of preventing Clubfoot, um, as well as providing education and training. Um, ok. Um, the surgery, um, when needed, the clinical officers who work out down there now are very, um, well trained as well as the physiotherapist who treat comfort with, um, the technique. Um However, feet first continue to support. Um Are we in the clinical offices um with 3 to 4 visits per year um and prior to sort of pediatric um presentations uh and club foot care, but we provide surgery for if possible. So, um in 23 2023 there were three visits. The first was in um July uh in me and, and the second in um and the third inu and M Zimba, all of these places are up um in the northern region as you can see the long way. And Blantyre are down in the south and they have um a lot of NGO S and uh there's a they have large central hospitals with support but in these rural areas um and the district hospitals, uh it isn't as much so with each visit. Um they were quite different. So, Qianjin and Ka Bay, um the data we were able to gather for each visit was also quite different. Um This uh in at this visit, 266 patients were seen and 35 operations were provided, we only have the data for the um operative management um which we can see here. Um The top three being Fracture virus and Clubfoot. Um The next two trips, we have more data. We have the data of all the presenting complaints that seen in the maternity visit. There were 100 and five patients with 26 operations carried out this um trip over one week, whereas the other trips are over two weeks. Um Again, we've got fracture high up there with osteomyelitis and General Valgus three. And uh the trip that I was involved with, um we went to Maz Maza and Kasungu. Um and this was two weeks, we saw 234 patients with uh 51 operations carried out and here um again, fracture and J val. All these are the presenting complaints. Um uh uh So all an seen and the, the top three here uh fractured any ga and um deformity. So, what we want to do is combine all this data and really try and have, have a look at what um the charity is doing. Overall, we can see um that fracture, Jenny Valgum and Osteomyelitis are the sort of top three complaints, miscellaneous and deformity are up there mainly because they cover quite a broad spectrum. So in the miscellaneous character degree, um there was a, a number of things including length discrepancy, nerve injuries, plantar, fasciitis, lipoma. In the deformity category, there was things like flat feet, radial club hands, macrodactyly. So only of two of those patients were seen. Yeah, that you try and help better understanding. Um Also I just wanted to bring your attention to some of the categories that we didn't see as many of, but in the POSTOP um category, uh most of uh so we saw this, sorry, what I mean by POSTOP is that we saw patients who had been operated on previously and this may well have been in a large central hospital or it may well have been um a first visit. Um So some they were coming back with um a lot of questions and queries. Most of um those we were able to uh help with advice and possibly needing referral on or referral back to where they'd had their operation. One only one POSTOP patient was actually operated on that on the mai visit with a um a redo of a to PMR Foot. Um Other things. So the types of the order as we saw with, with club foot neuropathies and um uh fracture management, uh cerebral palsy was seen um very good. Um And we were able to help these patients mainly with education advice and physiotherapy, which um it very difficult for patients trying to seek um physiotherapy. Um Other places to get to those appointments is is very challenging for them. Um and then um Perthes was uh we saw five patients with herpes and that this treatment was really um conservative. So we didn't operate. Um This is a combined data of the operations completed. So that's from all three visits. So, um the top operation um was due to um fracture and then we can see January and osteomyelitis. So from this data, we can see, we've got some common themes that um these, these are the types of patients. We're seeing patients with fractures, J virus and valgus osteomyelitis. But you syndactyly. Yes. Um And I'm gonna go uh further into these. So with the um because we can see that um uh the chronic um patients and by this, I mean, um patients who presented with nonunion, um nonunion or neglected fractures, we saw far more, more of these than um the acute fracture types. And this is likely because um the the acute fractures do go to um the local hospitals and um and to get seen, however, we know that these are overburdened. Um we had a lot, we had more upper limb than lower limb fractures. Um And uh looking at the patient type, we had a similar number of pediatric and adults. Um we were able to offer operative management um when needed, but a lot of these were able to be treated conservatively valgus. Um We can uh we had an age range of between one and uh sorry, two and 18 with a, a bit of an anomaly of a 42 year old in there. Um, and we can see that most of these patients were very young, um which isn't surprising. And, uh because of the such young age, we were able to treat a lot of these with um conservative management, asking them to return when they're older to see if the deformity has improved. But for some of these patients, we were able to offer um the surgical management when appropriate. And I think we see a similar pattern here in the Jenny Vows type patients. Um with an age range of one up to 19. Again, mostly naught to five year olds with osteomyelitis. I've split the age a bit further because um so sorry when looking at these uh plus the top bar is the one that's labeled. So the age 4 to 5 is the, the top bar which is 10 and um the rest were aged over five, which is so um this age category, the, the top bar is the naught to five year olds and then from 5 to 1815 patients. Um uh the last part, the 16, but over 18. So we had a majority of pediatric patients, um but not as big a majority of the naught to five year olds we saw in other show that um and conservative management of osteomyelitis involved um antibiotics or watchable weight um observing and we were able um or asking patients to sort of come back in a year and be followed up by uh the ot OS or possibly on another feet first camp to um monitor how they were doing. However, when surgery was needed, we were able to provide that with um debridement and sequestrectomy. And whilst in Kasungu, we were able to use stimulan thanks to very um to help treat that. It's um the foot, the um um something to remember about these patients is that they were preselected for us by the clinical officers um who work in Malawi. So it's a fairly skewed group of patients. It's not your day to day um presentations of club foot. So as I've said, they're very good at, at treating with Ponti. So they would only ask us to see patients if they were concerned or felt they might need a surgical intervention. Uh Some um we were able to provide um surgery when needed but also provide advice or us to continue with the pro uh technique or what for weight. Um Interestingly, um with Clubfoot, not many were seen on the first two trips, but on our trip, this is all of these patients. I think one is from the Kung. It's a trip. Um It's uh polydactyly and Syndactyly. Again, there are very few seen all on the other trips. And um whereas in the King Maz trip, we um have a number of presentations, Polydactyly and Syndactyly. Um then because they were very young sometimes, um, we ask them to come back in a year with an X ray, um, or if the case was about too complex, we may need, we may have needed to refer that on to a plastics, plastic surgery, but we were able to, um, provide surgery for 50% of these. Um, and the, this is similar with, uh, syndactyly as well. Um, again seen in the very, um, young naught five age group, um, burns contracture. Again for some reason, Kissinger and Mosima saw um a lot of these but the other, other trips um did not, um this may well be due to that preselection by the um clinical offices. Um. Mhm. That, yeah. And so the question, um um, whether these are appropriate referrals to feet first or, or not. And we, um most of the ones we saw we felt weren't particularly appropriate and needed to be referred on to a more specialist team um with plastic and um with arthritis, this gent was very happy with his um injection. Uh and he, he saw 15 patients with 19 joints. He injected most of them one had loose bodies and he actually been seen by feet first the year before and had those um removed. So he's very happy to come back and get, get some more taken out and he does like to take them home. That was good. Um So, um that concludes all, um as uh I've, I've pointed out throughout um the presentation, we did have limited um data. Unfortunately, we could not obtain that um data of all the different presentations from the first trip. So there was um a difference there. Um There are differences in in each visit with geography um and the surgeon and their team. Um And again, with the, the clinical offices, preselect patients, it is not reflective of a, of a, a specific pattern. Um It's curated and uh um like being referred through the, through the GP um and what we wanted to do was try and um uh establish book. Uh we see most commonly so we can be prepared for future um future trips. And I think um we've done this um that there are a significant number of pediatric patients. Um and the conditions that we um see on these visits, Malawi just doesn't have the capacity to see the district um hospitals and central hospitals are overburdened with, with trauma and that's really all they have um time and space for um by keeping an audit trail. Um we can keep track of, of these conditions we can see um and our operating practices. However, each visit is, please be, be mindful of that. It's gone wrong, it says recommendations. Um uh I think it's really important to try as best we can. So it's very difficult um to, to eat good data because you're seeing a lot of patients during the day. You don't have the same resources we do here. But as much as possible, really try and, and keep, get that documentation and it would be really useful to have a designated person on each of these visits to try and that all of that data. Um I think we should um continue audit, process and monitor presentations and what um surgery we are carrying out. Um This will help um inform uh what we can then communicate with the clinical offices um before and after the the the visits. So um we can ensure we're seeing the, the right kind of patients. Um And with more data, we could um identify different practices um how we're selecting patients, surgery. That's all I have to say. Thank you very much. Um Right, there'll be another visit you need that funded. So please um have a look at this uh in this QR code on your phone and if you would like to help, that would be very great. Any questions? Sorry. How did you capture the data? Is it um electronic or is it paper based? And number two who made that diagnosis? Sorry, is it the OC O or is it the operating surgeon? Sorry, the data um for the visit that I went on um uh uh each day in clinic, the uh we have a, a book you write down and you just down the very simple information in a book and then I took that and put it into an Excel um spreadsheet. I then contacted the surgeons from the other visits and asked them to do the same as I've said. 11 visit. Unfortunately, we were able, we could get that. Um And the other one, the, the data that I was given was um from the clinical officers who had selected the patients had put it on a computer. Um uh and, and written that data down and then there was a few scribbles on there as well. So, yes, the, the that's why it's sort of presenting complaint diagnosis slash it. I can't claim that it will be 100% accurate. I have to admit I'm, it's a very difficult area. But have you, is there any, is there any uh scope for a localized bespoke um collection? Try to assess the outcome in yourself? I think that would be a very good next step. I probably come up in Luke Store cos that, that goes into the follow up side of things which is, you know, for an interventional visit as opposed to just a, you know, a, a, an educational visit which most visits are that, that something very cool to do that. Yeah, Sarah. So what's going on? I mean, I'm not sure about mau but obviously in other places, um you can get lots of different teams and charities visiting and, and, and therefore you'll have patients or parents who will take their kids or whatever to lots of different people that makes it difficult because you may be seeing something, someone else's software is gone or treated and said something different. Have you considered patient health notes or is that something that is not feasible? I can answer that, er, because patient health notes are available, they carry a health passport in Malawi and that's really useful. So for our point of view, we spend a lot of time documenting very clearly in legible handwriting, what we do and what the diagnosis is and what the plan is sometimes. We disagree. There are very few people actually who've seen more than one teams uh because our selected areas where we work are underserved by anybody else. So that is ra on de of this charity first to serve that population. But yeah, but we, we do, we have had other um other teams from other places operate on them or, or see them and give them sometimes conflicting advice and, but it's good. They have a health passport, they are very good at keeping them. Yeah. So are you using the um government hospitals to do the operating? Yes, the Ministry of Health Formula. Yes, we are all registered with the uh Malawi orthopedic Council, um Malawi Medical Council. And uh we have basically links with the hospital. So wi long way if anything goes wrong and with Mizui. So um as I say, operating in this kind of environment is difficult to say you have to do these things. That's right. So the pest almost is like a, a bit like mercy ships but on wheels, you know, we bring all our stuff with us and, uh, you know, all the equipment and, er, try and do as little metal work as possible. So, sort of stuff. Soft tissue correction and Osteomyelitis where all the stuff that they were all to go to the central hospital. Beer. 25 greater, really interesting, very busy camps and lots of patients. See, um, what was the, I know the feet? Er, so it be first and it feet first, isn't it? Cos we, we also get cascaded with bee first and feet sounds similar. So feet first obviously got a legacy of lots of recurrent trips and people on the ground. What's the rehab set up for uh patients? You know, obviously there, there's physios there in the rehab departments. But do you take a physio with you or is that how do, how does the rehab part of it work? So, um from my experience, um the, the local physios, um he asked the clinical officers to ensure follow up and if patients need it follow up with physiotherapy. Um and we did have physiotherapists, um, local physiotherapists um interacting with us, they were, they were bringing us patients. Um equally, we were saying that this on this patient sort of thing. But I think um on other trips, there have been those who got um gone over. Well. Um I got you. So I mean there is an em memorandum of understanding with the government, the Minister of Health to do this as an outreach essentially for the government because there is no government resource to do it. Um The there are physiotherapists from Malawian that will come in the camp. Their idea is as supposed to, they come from a long way and do some teaching inhouse at the time, The clinic, the patients that come are brought by clinical officers and physiotherapists also come to the clinic. So you have the local physiotherapists there who get advised, get taught, especially with the prince. It was one of the big problems Zeti, there's no plaster in the country uh and what to do with the ones. Um Some of the physiotherapists are very good and they actually go to the toy stage and will do very good manipulations when they have plaster. Um And a lot of them actually, what happens is you provide this a, a distance advice by whatsapp. There are clinics, we actually review the patients at six weeks by whatsapp. So it's an extension of what's there because there is nothing there. They're in trauma, they get used to other things they will get once it's, it's, you know, it's for all changed has also change, you hand it over to uh operation walk and they've changed the funding. So the plaster that was supposed to be in the country for a club feet is not there. So we have to carry a lot of plaster and Alex has just been there and there's been a change in what cure does and doesn't do. The other problem is it's a huge country in terms of length. And when you say it to a patient, you need to go to the wrong way. They just look at you pack up the child and go home because they can't do it. There's no money. And even occasionally, I mean, even in Zambia, we occasionally give money to patients to actually do the travel and they often don't ever appear because the money is used for food because they're starving. So there's a lot and I just, we continue the discussion in the coffee room. We've only got a very short break and we'll come back here and, uh, and do the next. I know my trust.