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Hello, good evening. Good morning. Good afternoon, wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. My name is David o'regan. I'm a retired cardiac surgeon, the immediate past president of the Royal of the Faculty of Surgical Trainers of the Royal College of Surgeons of Edinburgh and a visiting professor at Temper College. Tonight is a very special night for a number of reasons. I'm actually delivering this live session to you from the 49th floor of an empowerment block in Kuala Lumpur. It's three o'clock in the morning. To my right behind me is the Paterna Towers and to the left is the Kuala Lumpur Tower, but tonight is also very special as well because I'd like to announce that we've received formal accreditation for the Black Belt Academy from the Royal College of Services of Edinburgh. And that is the logo that we can now use on all our broadcasts and our advertising and we'll put it on our CPD certificate as well. I'm also delighted to tell you that our first paper exploring the principles of what we're trying to teach in the Black Belt Academy of Surgical skills has been accepted by the journal of surgical education. We noted on 100 and nine photographs of adverts of basic surgical skills courses, teaching stitching that was all being done sitting down and we'll come onto this theme later. The third good news is we now have a sensei in America. Malvin Mackel is a associate professor of plastic surgery at Saint Louis Hospital. He wrote the book, The Way Of The Surgeon, The Intersection of martial arts and Surgery in the mindset. And we'll be interviewing him in November tonight is very special because we are introducing three new sens and a new generation who's going to hopefully take the Black Belt Academy forward. I met Alice Alec and Ish on the Power Excellence course in the 1st and 2nd of September. He and how early this year I didn't know their full backgrounds, but what struck me watching them practice, they had it. They understood what we were trying to achieve. They were keen to improve their technique and, and inquiring minds. They epitomized what I thought was described by Carl Dack as a growth mindset. I did not realize how talented these three individuals were until I had invited them to become sensors and they shared their C VS. And it's on the back of that, I would like to introduce them or they get to introduce themselves and we're gonna talk about how their achievements have reflected their development. As surgeons, sir, Alice would you like to start off and introduce yourself, please. Hi, everyone. I'm Alex Coppery. Um, I currently live in Leicester. I'm originally from Norfolk. Um, that's where I went to school. I went on to do a biology Zoology degree in Manchester initially. And then after that for four years I studied medicine in Leicester. Um, I did my foundation training in Leicester and I'm currently working as a clinical teaching fellow in Peterborough in the general surgical department and teaching third year medical students. I'm applying for cardiac surgery, cardiothoracic surgery this year. Deaths. I hi. Uh, so my name is Ayush. I actually grew up in Japan and I moved to the UK in 2021. I'm currently based in North Yorkshire. I'm in my third year of medical school at the Holy York Medical School and I wanna go into congenital cardiac surgery and hopefully soon we'll be applying in a few years' time. But you were born in India as I was, I was born in India. You were born in and how many languages do you, do you speak, speak currently? Four languages and you're learning, learning a few more. Yeah. And Alex. Uh, yes. Um, Alex, uh, I am at the moment, uh, a foundation doctor in London, uh UK. Before that I went to school in Belgrade Serbia, er, did relatively well under my exams and then moved to the UK back in 2016. Now, uh to study medicine at university College London. Uh during that time, I also did uh a Bachelor's in anatomy, cell and developmental biology. Uh works a lot with the, the neuroscience department uh here at UCL. Uh looking at how different parts of the brain orientate ourselves in space. Um And then after that, uh yeah, I continued my medical training. Uh and I'm currently uh working towards applying to co surgical training uh in the UK. Thank you. So, our three new sensors are at the beginning of their careers. Alex, what surgery do you want to go into? So I'm interested in plastic and reconstructive surgery. Uh mainly. Yeah, excellent. Now, very impressive. But there's something more and I'm gonna ask you to describe that something more. Alice. So, um what is that you have on your CV? So, outside of medicine, one of my main focuses is Olympic weightlifting. So this is traditionally the movements of clean and jerk and snatch. Um I started uh over six years ago. Um in the meantime, I did a bit of crossfit in the middle which uses these movements and I competed in crossfit in national competitions. Um I've recently gone back just to the Olympic weightlifting and trained 56 times a week working towards some competitions. And what's your personal best for? Is it a deadlift, personal best? So, yeah, so it clean and jerk. So the team moves have between clean and jerk and snatch. My clean and jerk is 75 and my snatch is 61. And then outside of that sort of the supporting movements, deadlift is 145 and my squat is 136. So for being 5 ft three, I suppose it's all right. Always room to improve though. And you weigh significantly less than 145 kg significantly. That's yeah, it's double body weight over double. You can lift double your body weight. How long my body weight above my head? So, um how long you been? Yeah, weightlifting, I would say it would have been when I started um medicine. So we're talking sort of eight years now. But the Olympic weightlifting really was six years. But a lot of that has been disrupted partly by COVID and partly by starting work as a junior doctor. Obviously, it's taken time to adjust to getting back into the swing of things. So six years, but you know, a couple of years in the middle were a bit cos I started work as a doctor, a junior doctor during COVID. So it all kind of came at once. Yeah. Wow. A yourself. So, uh outside of medicine, I do like to do a lot of things. Um I originally trained in martial arts, specifically karate back in Japan for around 10 years. Um Apart from that, my, my sport of choice is archery, which uh I used to compete back in Japan. I placed well at my district level and I was planning to go for national level, but then uh an injury cut short of my career, but at the moment, I'm going back into it, starting the whole rehab and training process and uh like Alice, not as great as Alice doing Olympic weightlifting. I'm a powerlifter at the moment and um, I do like to scuba dive as well. I'm a trained rescue diver. I'm a train rescue diver. The, the artery is that using a Japanese bow or a regular western bow? It's using an Olympic recurve bow. So you shoot at 100 at 80 to 100 m distance target. No magnification. And, and, and what's the pound pull on the, the bow itself? That was a boy. It's around 45 lbs and then the weight of the bow itself can vary. So I like my bow quite heavy. So my bow weighs around, I'd say seven ish kilos. Wow. And Alex, I was just gonna say, shall I, you've been, shall I leave the conversation after uh listening to people uh holding seven KGB. No Alex firing it. That's what you've done. So I used to train uh track and field competitively. Uh But I came back to when I was younger. So premedical school uh used to compete for the Serbian National team. So I used to run uh 400 m uh width without SCD 200 m 100 m. Uh used to be uh part uh of the four by 100 m relay as well. Uh, which was probably, uh, the, the funnest activity that we did. Um, and then, yeah, that, that was mainly it, uh, lots of competitions, thankfully, lots of medals, knock on wood. Uh, it was a very fruitful, uh, fruitful time. Uh, and I really enjoyed it but like ash, unfortunately I had a career ending injury, uh, injured my leg, uh, during cradles and I just couldn't come back from it. It was just, uh, unfortunately the end, um, but I do still run, um, um, yeah, quite a lot at the moment. And you, you hold the Serbian record. Yes. Yes. Uh, well, uh, the last time I checked, I still did. Um, so we broke the national records, uh, back in 2013. So quite a while ago, uh, and the four by 100 m relay, uh, and sort of a, uh, well, I wouldn't say European championship but it was sort of at that level, uh, because there were the teams that usually competed. So from the UK, France, Italy all over Europe. Uh, and we were quite, quite successful place for, uh, beat a record at that time. Uh, that was in place I think for more than two decades. Um, then got a record beaten by a different team from Belgrad, uh, from Serbia and then re beat the record again in a subsequent competition. So it was a really a, a, you know, fierce competition at the time between the different clubs. And, uh, yeah, it was, it was quite cool. You said there was a Serbian record of 22 years. Yeah, 22 years, 20 years, 20 years. Yeah, it was, it was amazing. I mean, we didn't really realize at the time we were what's in our sort of early teens, uh, interested in other stuff at the time. But, um, yeah, it was, it was amazing. I mean, going to the competition meeting other people who are as motivated. Uh And it was just a fantastic vibe uh generally and I mean, you know, we'll, we'll speak of this probably later. But, you know, the preparation and everything that led up to that, I think I enjoyed that even more than, than the competitions and everything else. So to get to the level of sporting achievement, the three of you have had to put in practice. Now, one of the questions we ask the audience is how often they practice and you've also urged the fact that now in medical training, you have less time. But could you talk us through your preparation and practice for this competition? Alice. So, um I have, there are classes every evening apart from Wednesdays. Um They're either an hour or a couple of hours. Um So I try and go to those um so that I would try and go to the gym five or six times a week averaging sort of 78 hours. Um The classes are good cos there's a coach there. But if I can't go at that time for whatever reason, due to shift work or say tonight, because I knew cos it clashes with this. I went straight after work and went for an hour straight after work. Um It's obviously challenging, like trying to fit it in and you just have to find what works for you. So for the first couple of years when I was a doctor, I did just mainly crossfit and I went to the 5 a.m. classes or 6 a.m. classes just because that was the best time it worked for me. And if I was on a long day it could work like that. But it does take that, um, it does take commitment to see progression and to not get sort of. So if I don't go for a while and I suddenly go, I'll get a lot of doms. So, like muscle soreness and then that limits how much I can go that week. So it's trying to stay, um, consistent is really, really key. Um, and especially like when I've had. So I recently had an exam. So I kind of cut back a lot on my training and it's just trying to build it up slowly to become consistent again because otherwise I'll just tire myself out. So, yeah. So most evenings and the evenings at the moment for me work really, really well and I train really well in the evenings but it varies. You know, if I was on a different rotation, maybe I'd go back to some mornings. So the two ways that struck me there was consistency and commitment and obviously you on a busy job, you're fitting in, in, out of hours effectively. Yeah, I, what about you? I kind of like to structure my training as direct and indirect training. So, uh, when I used to train competitively for Archer, I used to be in the range three days a week and then two days a week, I would train at the gym or at home using AIDS. And then the other two days, it would kind of be the recoup, kind of work on just form. And we like to call it like shadow training where you just get used to the form of how you hold the bow. A lot of, um, you try to train your mind as well cause a lot of the things with archery is you wanna figure out how you can actually pinpoint the target. You wanna work on your breathing, you wanna work on how you can actually calm yourself down before you take the shot. And, uh, now after the injury, working back towards it, a lot of it has been kind of strengthening the joints around my shoulder, around my back. So it's been, uh, working in the gym. So I usually go to the gym six days a week. Uh, if I don't have the time I try to make the time. So, uh, somewhere to Alice, if I don't have the time and, uh, a day I'll try to go early in the morning or late at night. You know, lots of times I've been yelled at by housemates or even my friends saying, why did you go to the gym at one in the morning? Uh, I think at the end of the day, it's about just, uh figuring out the balance and if you have a goal stick to that work towards it. Thank you. So, from what I take about that, from that is you need to go, that you got to work on your technique and form, but also you need to be fit Alex. So back in the day it was a very different time. I had much more uh, time to spare. Uh, thankfully then, so it was very long sessions. We would be, uh, usually six times a week and it would be 3 to 4 hours a day. Um, either in one long stretch or twice a day. So two hours in the morning, two hours in the afternoon. Uh really depending on the type of work that we were doing. Um, the type of work done, er, was quite different to what I do now. Um, it involved, so we had uh weightlifting sessions usually twice a week, sometimes three times a week, depending on the race, we were preparing for the type of events, et cetera. And that would be purely in the gym uh doing a lot of Olympic weightlifting. Uh and then also working on specific movements against resistance. Um That was part of it. Uh Then twice a week, usually we had uh trainings dedicated to the technical aspects of doing hurdles or running. Uh So that would involve usually uh three hours of different exercises specifically allocated to improving technique, improving efficacy, uh essentially diastolic practice, more or less. So how to prepare to get to that hurdle uh, in the best possible way and then the rest was usually endurance training. Um So depending on where we were in the season, whether it was the preseason or actually the running season, that would greatly vary. Uh If it was competition time, we would keep it short and sweet with bursts of training and then if it was preseason, it would be very long distance, uh, 1015, 20 kilometers, uh, building up that endurance so that we don't have to really think about it when it comes, uh, when race time, when race time comes. Uh, nowadays I do work out still quite a lot. Uh, I compete well, I don't really compete in track and field, uh, anymore. I do long distance running now. Uh, but it's mostly in insurance training now and strength training. Uh, so it's divided. Uh, I go to the gym usually four or five times a week, uh, sometimes six. I do a lot of yoga. Uh I do a lot of uh yeah, I yoga is one of my main things and core body strengthening. Uh And then I do a lot of distance, so 15 kilometers, 10 kilometers, occasionally, 20 kilometers, depending on where I am and when that race is coming. Um But, but it's, it's really AAA different way of training at the moment uh compared to before. So I would like to just move on. Then we've got a weightlifter, an archer and a hurdler who reached national levels in their various sports. And you have hinted to it already. Can you describe Alice, how do you lift 100 and 45 kg? Can you just go pick the bar up or is there something more to it? So obviously there's practice. Yeah. And it's not, you don't spend your whole time practicing at 100 and 45 kg or 100 and 40 kg. It's um repetition, volume training. So at the moment, we're sort of working through a eight week program, we're on week five. So right at the beginning, you start with high volume but low reps, er, high reps, low weight. So it's much more about getting that movement to become second nature working on your technique at a lower weight, um getting feedback when you know, you're most likely to do the lift successfully and in the correct form and as the weeks progress, you put more weight on the bar, but you decrease the reps so that you can still move all that. Um, you learn early on about, you know, where do your feet need to be? Where do your hands need to be? What's the angle of your hips to your knees, to your feet? They're the basics. You can't just walk up to a bar and pick it up even if you're really, really strong. So taking Olympic weightlifting with a clean and jerk, you could be a powerlifter and lift 100 and 45 kg. But unless you know how to do a clean and jerk, you're never gonna move the bar because it's all a process of feet hits over feet, hands in the right position, the correct grip, the correct stance and knowing imagining that bar pa so, you know where you're gonna be moving, it, it's a combination of like the strength and the technical skills and then also your mind's got to you in the correct place cos if you walk up to a bar and think I'm never gonna do it. It's not gonna work tonight. My lifting coach, he was doing his snatches, he lifts very heavy weights and he was saying to himself, it's much better than it normally is. I don't know what's going on. I don't know what's going on. I'm never this, normally, it's normally not this good. And the next lift after him saying all that to me, he failed and I think that was because in his mind, he'd said I shouldn't be able to do this this easily. So even the coaches have that hindrance at times. Interesting. So Irish, perhaps he could actually elaborate on the technique of a 45 lb bow and you're indicating you're standing there just pulling the string, explain how you're taught how to do that. Um, so to be honest with a bow, it gets easier, the more you draw it. So that's how you think about it. So when you're at your full draw length and you're fully set up, that's when you wanna feel the most stable. So if you just pick up a bow, uh, so if you're right handed, you pick up a bow with your left hand. If you just hold it out there, you're holding the entire weight of the bow on just your left shoulder. So I don't know if anyone's ever tried to lift up. I don't know a water can with just their shoulder and hold it up like that. It's not a very easy task, but once you set it up and you get into the right position and you're fully locked into place and all the smaller muscles of your back and you're able to spread out the load equally. Uh, before you actually put in your first arrow. Uh, during training, we used to just practice drawing the bow getting to the draw and just feeling exactly where we were at full draw. And uh, before we would actually step foot in front of a target, we just get some hay bales in front of us with not even a meter's distance away and just get used to looking at ourselves in the mirror, looking at ourselves in front of that hay bale, take away all the destructions just getting a feel for exactly where our draw length is. Um, the feeling of actually holding the full weight of the boat in your position. And you wanna replicate that because when you're in front of a target, the only difference is you're choosing exactly where the arrow should point. So you wanna get it as fluid as possible. If you get the technique perfect, then the arrow will go exactly where you want it to. And actually, I had a really good example. So I once had a three week long slump where I was trying to figure out uh what was going on because I kept missing the target by just a few inches, things like that. And I actually just realized it was the shoes I was wearing. Uh, I wasn't able to center over the balls of my feet. And what was happening was every other shot I was, I kept moving just a bit off center and when you're even 50 m away from a target, a one millimeter deviation of your foot is about 23 inches off the target face. And in archery, we look at grouping. So even if you're missing the center in every single shot provided all of your shots kind of come into the same grouping, then you still know that your shots, the shots. All right. The problem was you weren't aiming at the right spot and Alex, it's not just jumping the hurdle, is it? And you mentioned the diastolic be ex explain. Yeah, of course. So I mean, ii it, it, it's similar to sort of diastolic practice. Uh You could argue that more or less the time you fly over a hurdle is the same for everyone. Uh But it's everything else that it's im important. So running hurdles, you have the portion in between the hurdles, then the portion where you attack the hurdle and where you come off the hurdle. Those are sort of the three things. So in between it's all done on pacing and you sort of have a certain number of steps that you do in between the hurdles. Uh the, depending on what your stride length is. How tall are you? How fast are you? How strong are you? And it's usually around 13 steps if I remember now, it's been a quite a while. And so essentially with 13 steps, you always attack the hurdle with a different leg. So that has to be very close to the hurdle. You have to be uh crunched, you want that attack to be as efficacious as possible. So that's why you see a lot of the 110 m hurdler actually, Nick the top of the hurdle when they run, uh, because you don't want to be going too high up, uh, or anything similar, you just lose time. It's a matter of tens or even 100s of seconds that wins races. And then the other portion is how you come off the hurdle, uh, which is also quite important in 400 m hurdles. It's important because it sets you up to start pacing again. Uh You need it to be solid, you need to be in the right position. Uh your hands need to be well adjusted. There is a lot of elements to it. Um And II mean, it, it's super similar to, to how you pass a needle through tissue when you suture, really, uh it's more or less the same principle. Um How you position yourself, how you uh go with the needle through the tissue and then how you then position the needle so that you can take it again with the instrument. It's, it's very similar in principle, uh how you run hurdles. Um So yeah, it's, it's, it's quite a big set up that you have to do and people don't really realize it. Um But it, it, it comes through practice. That's, that's, that's the bottom line. You, you've all put a lot of practice in, but also you've been coached as well and people have broken this down and they take me down to various elements. So compare contrast, your learning of surgical skills with your learning of your sporting activity. Anybody. Um II think for, for me personally, I think prob probably others will agree. It, it's been extremely similar. I think that the fundamental principles of practice are, are the same across different disciplines. Uh the content might be different but, but there are some of the, you know, founding pillars uh that we already touched upon that, that you have to have. So commitment, uh you have to be guided by someone in initially, well, at least initially, uh and it has to be mindful practice, I think. So you have to, you know, be directed and know what you're doing cos you can practice the wrong things again and again and again. But at the same time, you're just going to end up doing the wrong thing. Um So I, for me personally, it's been very similar a as I sort of compared it to passing a needle through tissue. You have the preparatory phase, which is really important, then you have the same act of going across the hurdle and you have the act of coming off the hurdle or grabbing the needle as the most basic principle. But, but those are some of the basic surgical skills. Uh the, the same principles apply to basic surgical skills that, that we all do. Uh And we talked about this, it's the art of diastolic practice I think. Yeah. Well, you, you say Diastolic Practice and you've broken it down to three sections. Had anybody broken that down into three sections previously for you? Well, you sort of did well you did during the Par excellence course. Uh, really? Uh, so I think your, your philosophy and II absolutely love that. I have a notebook now that's titled The Art of Diastolic Practice where I document my surgical skills practice. Uh, It's essentially, I mean, when you look at people, the best surgeons in the world, uh including yourself and then other esteemed surgeons, we've all had the pleasure of seeing or working with the time it takes them to pass the needle through the tissue, more or less really stays the same. But it's everything else around that. That makes one an efficacious surgeon and it's the preparation. It's how they position their arm, you know, all the way from their shoulders, the height of the table, everything everything comes into that one smooth movement that we don't really realize. And then in the end, I mean, when you need to take that needle, you want to be ready to take the next bite. Uh or I mean, whether you're cutting or whether you're holding the forceps, moving the tissue, it can be applied to anything that you do in the surgery you want to anticipate what's coming next. Uh And that's really important. So you want to position your needle so that it's just in the right spot. So when you take it, you're ready to take that another bite and move on. So it, it's, it's, yeah, that's, that's part of, I guess the Black Belt Academy of Surgical Skills Philosophy. I think it's one of the founding principles we have, isn't it? Indeed? Just to explain to the audience that the heart when you look at it rocks in the chest between atrial contraction and ventricular contraction and sly ventricular contraction is fixed as the heart speeds up. It's a diastolic element that shortens. So the filling of the heart shortens, obviously, if it goes too fast, it doesn't fill enough. But there is an optimum period. And the whole thing about the set up is, is this diastolic element that the rhythm and the flow is still there, but it's a bit faster because you've set up and attended to what Alex is saying. What are your thoughts Alice from your weightlifting and stance and grip and holes? So, what I find really interesting is I never quite appreciated. It is how sometimes my weightlifting coach would just walk up to me and say, no step away from the bar or no sort your grip out, sort your feet out and like he could instantly see what was wrong before I'd even lifted the weight. It wasn't like I'd done a lift and I failed and said, what have I done wrong? He walked up and said, right, reset. Um And as I've mentioned to you, David, I was teaching medical students the other day, I've got some third year medical students on their first place and then they're on their surgical block. So I thought, let's get some early on, let's get some suturing in. And someone said, II just can't get it. Alex. I can't, I keep going too deep. I keep doing this and I walked up and instantly I recognized they were stood wrong. They were holding the, um, needle holder wrong and they were, had the needle mounted wrong. And I said, right, that's just straight back to the basics. Strip it all back and does that help? And it did. Yes, there was always something else that could then be approved, but that gave a 95% improvement to them and they understood what was going on. And the other thing is that if you make sure those, the set up is correct, then the variables that affect the lift or the variables that affect your skills become smaller because you've got that basis. That's there. It, it's not how you're holding it. That's wrong. It's not potentially how it's mounted, that it's wrong. It's not potentially you, you know, your body that's wrong. Something else is going on. So like that, that's what I'd never quite appreciated. And I do think that this whole sort of this three step that like the parkour talks about effectively. My coach was always doing that with me, it was always where my feet were under the bar, how I was holding the bar and how my body was positioned in relation to the bar. They were like three, that's three main steps and it just always happened like that. But um, yeah, and, and the other thing is what we're just mentioning is that this focused um practice. You sometimes get people that say, oh I've been lifting at home, I've watched it on youtube and I've been doing it at home and they, they, they 50% there but nothing like if they'd have been coached in a decent technique and practiced with a purpose. So yeah, it's really, really applicable. Um And I think for me as a weightlifter that makes it much easier to learn the skills, you know, I take my training from that into how I learn the skills and knowing that it comes with time. Yeah, I do like the phrase technique with purpose. I assure thoughts you've already alluded to the fact of grouping and one millimeter over 50 m could be a, a mess. Mm To be honest, rather than comparing it to archery, if I go back to the martial arts element. Um Just thinking about before you can throw a punch, you have to think about your statins. You have to think about where. And uh one of the things that my, my sense actually taught me that resonates with me to this day is the strength of your punch doesn't depend on how hard you can hit. It's about how fast you can pull back your other hand and kind of that diastolic time and getting that rhythm. And it's also thinking about a lot of the factors around it and I think just similar to surgery. So I was teaching some other students the other day on just some basic skills on how to palm the needle holder, things like that. And people were saying, oh, it's very difficult. Why can't I just use my fingers? Why can't I just pop it through? Is there for a reason? And I just said, why don't you try it with the, why don't you try just palming the needle holder and passing this piece of straw in between, between each of you without using your fingers through the holes and just active practicing that instantly. I said, ok, let's try getting some needles out and let's try putting it through some tissue and just getting it getting used to it. I didn't have to supervise a single one of them to, uh, keep their fingers from going in because once they've learned, oh, this actually works. It kind of, I like the inquisitive thinking mindset like you mentioned as well. If you think like, if I, if you teach them one way they'll try to figure out, oh, this is an interesting way. What can I do with it? And I think that should be the way that surgical skills are practiced as well. Cause when you start off learning one way you wanna try and develop that to suit yourself. And I've had the pleasure of having some really great mentors to teach me and walk me through the process. But again, like uh Alice said as well, there's a lot of people who just say, oh, I've watched a few youtube videos and I learned off of this. But if you don't have that practice with purpose and practice with the right kind of guidance, you develop bad habits. So if you just watch some of the videos on youtube, you'll have your fingers all the way through. And uh even the other day, I was at a course and um one of the, one of the surgeons teaching me, tell me that the way I handled the um uh the Mets and bone scissors. He said, if you're holding the, holding the scissors, like a tailor would, if you were like a surgeon, you'd only have the tips of your fingers through it. But I just thought to myself, I never actually thought how I held scissors. I always thought about the needle holder, but never about how I held the scissors. And just that subtle change made such a big difference in creating a plane between the tissues and things like that. So again, it, what's interesting as you've already alluded to, it's the technique, your posture and how you hold the instrument before you actually use it and setting yourself up each and every time. Now. Have you done basic surgical skills courses? The mandatory courses that are available. Um, yes. Yeah. Yes. Yes. Yes. Yeah. Yeah, I've done it as well. So, yeah, compare contrast to thinking. I um, oh, go, go for it, go for it. No, I just say the thinking with it is the end goal, not the process to how you get there. It's, can you suture this? Can you tie this? Can you do this? Anastomosis? That's what they're trying to test in those courses. Not, how do you do it? What is the best technique? What's the most efficient technique? And there's a lot to be said because then if someone's struggling on those courses, it's quite difficult to give feedback. I think I've never taught on one of the courses, but from what I've experienced and having my limited taught, teaching medical students. Yeah, it's difficult to then get feedback cos you don't quite know where they're going wrong. It's quite easy to say, just do this. There's no such thing as just do this. I think that's generally the problem and often surgical training. Yeah. Hm. I think it's the problem surgical training in, in the UK. Uh, or, I mean, probably wider, um, you just don't, it, it's viewed sort of as a thing that, you know, things will come naturally. The technical aspect of surgery isn't the biggest part of surgery. And then what happens is at least here you sort of watch a few trainers, then they let you start off small, you know, you suture the skin once, twice in front of them. If they're happy, they might let you do it on your own or you might go through the layers a bit deeper, et cetera, et cetera. Uh, but nobody really emphasizes the technical aspects of it really. Um, those are sort of, you know, yy, you sort of accept it as, as it is. Uh, a and people do struggle and I think it's visible, um, you know, uh, throughout when you, when you see some of the new registrars, some of the sh OS uh who've come through a lot of training and then, you know, they, they're the ones who have to suture something overnight or they're the ones who need to close the wound. It really isn't on the level you would expect someone um, to be yet, but that's not because they're at fault or they're not good enough. It's because firstly, they haven't been really thought, they haven't had much, uh, opportunities to develop their skills. A and thirdly because surgery isn't really thought in the right way, I think. Um, generally, um, and surgery is a skill with every skill you need practice. Uh, you need guided practice and you need to standardize that view of practice. Uh, and, uh, ii always thought that, uh, you know, selection into surgery as well should place as much as an emphasis as on audits and everything else, uh, as on the technical aspects of it. Because at the end of the day, I don't think really patients or anyone else is going to care whether you've done a quality improvement project more, uh, or something like that, uh, as opposed to how good you actually are at doing the craft that you're doing your full, I think, like I said, it's a lot of, a lot focused on the end goal. Can you do this? Can you do that? And I think it does come back into the grand scheme of things of, are you an adequate surgeon versus are you an excellent surgeon? And I think there are shifting mindsets and different trainers do treat it different ways. So I've had some trainers who've been very, very meticulous. They've watch me through every single step and they look at everything from, oh, you're holding the needle holder wrong to, oh your needle could be angled just a bit this way, you're going through the skin and you're missing that small layer, just go just a bit more versus some others who say, oh, just close it. As long as you don't have any spaces you're fine. So I think you can see that clear contrast between two ways of thinking about. One, one's looking at just let get the skin closed. Whereas the other person is looking at let's get the skin closed nicely as well as teach them really good practice. And I've had some registrars. You tell me if you can stitch the skin perfectly, then I'm more likely to trust you to stitch maybe some deeper layers and then get into it. Because if you can do the skin perfectly, it shows me that you have the principles of how to use the instruments. You understand the spatial awareness and you understand the technique itself because at the end of the day, the thing that you might be stitching is different, but the technique remains the same indeed. So you, you've all had coaching in your sport, where do you think coaching could come in, in surgery or have you experienced coaching and surgery? Um y yeah, definitely. I mean, uh you would expect coaching to be there every day, you know, when you come to work and from the moment you're there until the moment you leave work or at least while you're in the operating theater, we're talking about the technical aspects of coaching. Uh But unfortunately, that isn't always the case uh as I alluded to or, or said, actually very fine. I think when he hit the nail on the head, uh there's a very big difference from being an adequate surgeon to being an excellent surgeon. And I think unfortunately, the general theme nowadays is, you know, as long as you're adequate, as long as you can do this without many complications. It's fine. And II had this discussion the other day with one of my senior colleagues back at uh Georgia's. I mean, when you look at the diff how many different ways are of closing the wound or an approach to a single operation, you do realize that the human body is very forgiving. Uh You can apply a lot of different techniques, but at the end of the day, the end result will be OK. A and my thought is, well, well, why do we rely on the forgiving of the human body? What results could we achieve if, you know, we, we actually do strive for excellence. Uh So I think coaching should be there all the time, but unfortunately, you have to look for it on your own and, and one of the places where you can find it is, you know, surgical courses, but not every surgical course par excellence was phenomenal. It really focused on the technical aspects of things which a lot of courses don't do. So I think it's a hit and miss type of thing and you know, you go through your rotations, see the things you like, keep them to yourselves if they're not detrimental to patient safety, the things you don't like, you keep quiet and run away from them. I think that's the general principle. Uh Well, at least that I uh I apply, I like this demarcation between average surgeon and purpose to be excellent surgeon. And I agree with you. We should be aiming to be the very best your thoughts are you? And I completely agree with what, uh Alex said and, um, in the sense that practice is what makes perfect. And like you say, you don't practice to, uh, you don't practice to, you get perfect, you practice that, you can't get it wrong. And I think that's a really, really good philosophy and it's a really good message because I think if you start practicing with the purpose of you can never get it wrong, you'll never get it wrong. Um And I think when we look at the grand scheme of things, excellent surgeon versus adequate surgeon. I think surgical practice specifically has a lot of space where we can actually improve upon at home training or training outside because uh for example, all this would probably be a really good example of this. When you are training to lift, I don't know, 100 5200 kg overhead or even dead lifting or anything like that. You don't just look at your time in the gym, you look at your sleep quality, you look at your diet, you look at your mobility, you look at so many different things. Whereas within surgical practice, a lot of it is what you're doing in the operating theater. And I think with the par excellence course, a lot of things that you did teach like the at home models and even just practicing with a needle holder. And this is something that I've seen in Japan as well where a lot of trainees, they spend every moment that they have free time practicing different skills. Or I've seen trainees who just carry a needle holder in their, it just opening and closing, palming it just so that they get really good at it. Cause that's things that you can actually reduce in a diastolic time. If it takes you two seconds to open the needle holder by palming it, then it's not, then that's two seconds wasted. Whereas you're not actually doing, accomplishing anything in those two seconds. So what is the champion mindset? Then can you sum up a champion mindset? This is aiming for excellence and how do we teach that? So I'd say the champion mindset is like you said, it's aiming for excellence every time and not settling for subpar in order to leave early, get out on time, get your coffee. Whatever a champion mindset is always aiming to be the best you can be. I say to my students, you know, you're doing great, you'll pass your exams, but you shouldn't be aiming to pass, you should be aiming to come top. You should always be looking for those ways you can improve. You shouldn't just, you know, I was in theater and I was closing some port sites and I was with a very good trainer. It was a consultant that made the registrar do the op notes as I was there and he let me close it and he went right. What do you think about that? I said, I think it's, I don't think it's good enough. He went, no, we could easily put steri strips over. It would probably heal. Like Alex said, the body's forgiving, it would heal. They wouldn't be left with a scar. He was like, but what's wrong? And I said, well, it's not like opposed, the skin edges aren't together. He went why I was like, I don't think I was at the right angle and he said exactly, take it out, do it again. So it's that, that's the champion mindset is accepting your faults. A accepting where you've gone wrong and learning from your mistakes so that the next time you do it, you don't make those mistakes, committing to it. And yeah, really sort of. So it's that commitment and then aiming for the best. What say aish your thoughts, I think one of your quotes actually makes, makes a really good point. The enemy of excellence is the word OK? If that's ok or that's all right. Cause at the end of the day, if you're, if something is just OK, that means there's room for it to be better. And I think sports surgery, all of it comes together and you can think about it. Do you want to be in a place where something is just OK? Or do you want to be in a place where that looks absolutely phenomenal and there's nothing that I could have changed with that. And I think with outcome back to the artery concept where if I can feel a shot, feel completely perfect. And I can say I can't make any room for improvement on that shot. If that shot doesn't hit the target, then I know that there's something fundamentally wrong in everything that I've done. But if I think, hm, yeah, even though it hit the center, it's like, oh, that shot felt ok. I'm not really sure how, how can I actually distinguish that from coincidence. So I think coming back to surgery in that sense is being able to do it so you can't get it wrong. So I know for a fact that the skin edges are perfectly opposed. Uh, I saw a joke the other day where it said when the medical student closes, it's a race between the medical student and the fibroblasts. And I was just thinking to myself, if I can do as good a job as a fibroblast can, then I'll be happy Alex your fault. Um, so I think champions mindset, um, very difficult to define different for different people. Uh, for me personally, uh, it's sort of, uh, a constant chase for that idyllic state where everything sort of fits in and everything is perfect. I don't think it's achievable but you attempting to reach it. That's sort of the champion mindset. So constantly trying to improve and constantly trying to be better. Um And I mean, ss some of the best surgeons that I, that I've met and that I know are never satisfied with their surgeries and they're never satisfied fully with the operations. Because II, II mean, by all parameters, you could say that is absolutely phenomenal. What you've just done, that is great, small scar, perfect outcome, fantastic. But, but settling for any type of results um that you've already accomplished, II think sort of defeats the purpose of improvement. And I think that's what I've seen in them, never being satisfied with what they've done. Always striving to do a bit better uh to sort of, you know, spread that mindset uh across. I think the NHS definitely needs a culture change. If we're talking about the NHS in particular, it's very difficult for all doctors across the board to fall into that mindset where when you're dealing with, you know, work force problems when you're dealing with problems at work, that don't necessarily relate to what you're doing. Uh that when you're dealing with, you know, not having a place to sleep or not having any food in the fridge or having a nonfunctioning things like that. II, it just propagates a culture of this will do, this will do because that's what the hospitals around us are sort of settling for. And, you know, it's very difficult to maintain, you know, to keep motivated in in that environment. Uh I'm not saying that people shouldn't. But, but I think if we're going to take the motto of Championship mindset and instill it as the norm across the healthcare workforce, be it in the UK or anywhere else in the world. It has to stem from the organization. You have to feel very proud, you know, when you come in to work and you say goddamn it, I'm a doctor. I belong here. I've worked really hard to be here and all of these people around me, you know, sort of propagate that same energy a at the present moment, if we're, you know, realistically speaking, II think we're very far away from, from the championship mindset, unfortunately, across the NHS. And I think it's very sad to see hopefully in the future it will change. But, you know, I think if we're going to achieve that ideal perfect state, that's unachievable. A lot of things will have to change to even start thinking about how to get there. Ish, you got your hand up. Yeah, I actually wanted to add a lot of, uh, one of the things that we kind of did miss out was the competition aspect of the championship championship mindset. And I think it's really good to think about it in the sense that when you're practicing on your own, you're competing against yourself and you're trying to be the best version of yourself. And again, Alice and Alex, you probably agree as well when you're training for an event or, uh, training to lift 100 and something kilo, you wanna be at least 1 kg heavier than you lifted the week before, or you wanna be 1/100 of a second faster than you were the week before. And then in actual competition, you're trying to be the best of everyone and I think that's a similar mindset that we should have in surgery as well where you're always trying to get better than you were the day before and you're trying to be the best possible surgeon you could ever be. Alice Alex, you've said everything I wanted you to say without prompting you that sums it up. Uh You're quite right. I think Alex, you went into the conditions of work and the conditions of the self that is part of a bigger debate. Am I to despair? But you do have to b challenging yourself every day to be better than yesterday. That is the growth mindset described at Carol D an ok, is a dirty two lettered word we shouldn't be looking for, ok. We should be looking for perfection each and every day. And I think quality is a restless discontent of the status quo. And if you say that's ok or because we've always done it around here that way, complacency sets in. And as you've already alluded to that is not the champion mindset, commitment, practice time, technique coaching and an absolute desire to be the best you can are the tenants of being a good surgeon, as we've heard from a three new sense this evening who have brought their mindset of sport into surgery. And I'd like to see more of that. Thank you very much. Indeed, Alice Ish and Alex for joining us Gabrielle. Thank you very much indeed for the production. There was one question here about the length of the scar for access. The answer to that is rinku wounds heal from side to side and not end to end. And the other adage was the smaller the hole, the bigger the mistake. Thank you very much indeed for joining the Blackard Academy of Surgical Skills do practice. We are offering at home models that do give you feedback when it's not going well. I look forward to seeing you next week where we'll be talking about putting the principles of stitching together as we join things together. So now thinking of three dimensional movement of your needle. Thank you very much. Wish you well and goodnight.