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Hello Good Evening, Good Day, Good afternoon, Good Morning, wherever you are in the world and welcome to the Black Belt Academy of surgical skills, my name is david regan, I'm a retired cardiac surgeon in yorkshire, in the United Kingdom, the past director, the faculty of surgical trainers for the Royal College of surgeons of Edinburgh, and a visiting professor at Imperial College London, I'm extremely grateful to Medal to, for hosting the Black Belt Academy because this has enabled me this year to invite distinguished guest talk upon important subjects and this evening, I am extremely grateful to Trevor dale for joining me to discuss a very important element in surgery. Trevor has spent the past 20 years observing coaching and training across healthcare with a focus on surgery. Prior to that, he spent 34 years flying around the world, culminating in being a jumbo jet training, captain, and a human factor specialist now comparing the two professions as we all know, everybody does their a lot of similarities, both involved risk management. It's crucial safety procedures related to behavior both suffer from avoidable errors, although one involves a greater degree of jeopardy. It said the pilot goes down with the plane and the passengers. The airline industry has that lots of the past years, but in surgery, we continue to fumble in the dark. Trevor, has been part of a human factors team with british airways since 1991 and continued that role to 2005. He joined a research team in cut with cardiac surgeons, a great Ormond street, looking at team interactions, then followed with work with the Royal College of surgeons, co authoring the productive operating theater program for the n. H. S, his company, a train ability, is recognized as one of the leading providers of in house Human factors training, four critical teams, and he's worked extensively for the NHS since 2002, I've had the pleasure of chatting with trevor and a number of occasions, and although some people might think that human factors is something that you get to once you become a consultant, I don't think that is the case and the sooner you learn about it and recognize it's your behavior that actually makes a difference in theater the better, so I wanted to ask a simple question and present a poll before we start and simply ask are you a jack put your hand up answer yes, have you ever been a Jack now. I attended the Institute of Health Improvement, patient safety executive officer program in 2008 as part of the Rescue Fellowship with the Society of cardiothoracic surgeons and returned to the UK and asked the same question to the audience of cardiothoracic surgeons, so bruce Keogh was at the presidente of the time, and when I asked the question, I noted he was standing in the back and he was one of the few who put their hand up to have you ever been a joke, so please answer, and we'll see, and I'm pleased to see that 62% of you recognize that is the case and that is a good start, so trevor welcome, thank you very much indeed, and you've seen it from the surgical side and the airline side. We are training to be a consultant surgeons. You are training and flying to be a captain, How do they compare in this regard and what is the captain's role. It's a very interesting one um david. I suppose if I can start with a bit about comparing a lot of people have a very unrealistic view of what commercial airline pilots actually do. They seem to think you know you start the engines, find your way out to the runway, press the big button and off it goes and then you fly all the time on automatic and some hours later whatever you press another button and the thing lands, then you head off to the hotel, go and relax and lay on the beach or whatever you do for a couple of days. Um What they don't seem to realize is that there are an awful lot of situations you encounter um in the every day course of normal roof line that people just wouldn't think about uh whether um problems with passengers, air traffic control strikes, and airspace closure and, and technical issues and for those of you that are a bit nervous about flying. Can I just say I did 34 years of commercial flying and never once had a real emergency and that was quite funny when I spoke to a lot of a and e consultant because they said well, we're faced with emergencies every day and a trauma surgeons, We're faced with emergencies every day. I said yeah okay, but none of what I faced was ever what I'd call an emergency, but we did have some pretty decision pretty difficult decisions like landing at airports. We weren't planning on landing at. For all sorts of reasons, technical reasons, had a passionate die one time and chucked 40 tons of fuel over the side because we were too heavy to land at the diversion airfield, um but the thing about pilots is, I know, we're going to get onto it later about about appraisals and about accreditation, but pilots go into the simulator every six months and they practice the emergencies which they hope they will never face in real life in a very high fidelity situation And believe me if you think you're going to crash the simulator and some of you, I'm sure will have had the beauty of a ride in a simulator or even maybe got to fly one you crush the simulator, you would have crashed the real plane. You know pretty much and um there's a bit about the psychological damage that does to you and this recognition of the jeopardy you're in what goes along with that is a lot of people think well, you know you must be worried about crashing all the time you're flying how on earth do you, how do you go to work every day with that well. Actually you don't you you you, you, I I used to fly the 7 47 with anything up to 400 people on board and 20 old crew, but you you you you can't go to work every day thinking about that, but you're kind of you're ready for it in your mind, you know you you keep your awareness going and the longest flight I ever did, I think was 15 hours London Buenos aires uh something like that and there's an element of readiness for what could go wrong watchfulness, which a lot of you well. I'm sure will be quite used to, although in a different scenario and you just think all the time what could go wrong and that now, I think is another useful parallel with surgery because you look at a safe aircrew and they thought in advance what could go wrong realistically and they got a plan for it. What would you do if an engine failed mid atlantic well, we'll have to think about it, what's the weather like where could we get the aircraft repaired what's best for the passengers. There's all these things you you kind of juggle um in your brain. Um you know you translate that into surgery, what would happen if I pranked a vein or an artery or um what would happen if their patient throw their through uh anaphylactic reaction to one of the drugs that anesthetist is chucking in and so on and so forth and it's actually much like driving a car or everyday life. You know the safe people where am I okay carrying on at the moment, david. Uh the the parallel with this is professionalism and it's you know there's there's this whole thing. I think we're gonna talk about where people are pushing their luck and I love that question you know have you ever been a jerk yeah. I've been a jerk you know where I've push my luck, um not much in the aviation area maybe once or twice um For reasons, which I'm I can explain, but I'm not proud of, but for my money, this whole thing we were talking about this evening really comes down to what makes you a professional and I think I just want to check out there really is next time you get on an airplane. Do you want a lucky pilot and for me if I have to undergo surgery, do, I want a lucky surgeon or a lucky anesthetist or a lucky nurse. When you start to think about what's the difference between pushing your luck or running on luck, being a jerk, I think was a great question to being a professional and uh you know, I'll come back to you with that david, but I think that's really what what being an airline pilots about It's about looking after being responsible and accountable for other people's lives much like surgery, so we we do it with 400 people up you know, we're more in an 83 80 case, uh 400 people at one time, so it's more than just technical skills and flying the plane, so in your simulated training, how do they look at that and what do they look for, trevor well, It's an interesting interesting one that, so when I started flying in about 1971 that's how how old I am now um started flying commercially. That was 1971. We were, we worked as a team, but we were checked every six months in the simulator, really as individuals and so your debriefing that you had your feedback that you had was all about your technical performance and there was nothing about your behavior unless maybe you'd shouted or screamed or burst into tears or something like that. I didn't normally happen by the way, um but most of it was about technical you know you were five knots too fast, you didn't keep the heading accurately uh and so on and so forth, this thing or your landing was a bit heavy. Um When you analyze black box recorders, which of course the airline industry has the benefit of you got two black box recorders, you probably know that one is the flight data recorder, which records everything that the aircraft's doing you know which way it's pointing whether it's the right way up or not how fast it's going what power you've got set whether all the technical hydraulics and pneumatics systems are working, and then they've got the other one, the cockpit voice recorder, which records everything you say obviously and that includes if anyone comes in the flight, take an office you a cup of tea. If you're really lucky when you analyze accident black boxes, nearly always there's a behavioral issue, which is underlying the end technical problem. Let's say what it was like like crash and what they found years ago, and this is a frightening thought for a lot of people. Is that first of all most air crashes happened when the captain was actually flying a plane, and the other thing that came up quite a lot was that the co pilot quite often was trying to say, excuse me captain, but we're about to fly into a mountain or you shut down the wrong engine, or you've you're about to land on the wrong runway, or can you see that plane in front of you. Something like that and a voice recorder often had somebody trying to speak up and say you're doing the wrong thing and as like as not it was the captain that was doing the flying at that time and that actually lead to uh certainly in a lot of major airlines, my experience in in british airways where I flew was that in my working lifetime, we brought in a new procedure, and it went like this when the aircraft was in any kind of emergency or urgent or let's say non normal situation, that's what they prefer to call it, non normal situation, the captain would hand flying the aircraft copilot and what that does is the copilot should be able to fly the thing okay because they're you know. The only real difference between captains and copilots is which seat they sit in their experience level, though not necessarily but normally, the captain would be the more experienced one, um but also it's about accountability, responsibility, leadership, and all those associated behaviors, So if you picture it you hand over control to the junior of the two pilots, and that frees up the captain, who is the commander to have more free capacity to think number one, to think so he or she can monitor what the copilot's doing, make sure they're heading in the right direction. They've now got additional space which they don't have when they're trying to fly the plane and all is going well and now they're supposed to lead to manage to communicate and to obviously delegate the actual handling of the situation. Now, I know in an operating theater, you can't always do that you don't always have an assistant, and it could be that your assistant may or may not have the appropriate skills, but I've been in a lot of operating theaters watching, and actually the assistant has had sufficient skills, but the person in charge, let's say the consultant has not for whatever reason I wanted to let go david. I'm going to throw that one back at you because you must have experienced that one form or another, possibly not being handed over to when you were a junior, but have you got comments on that one. I think that I think that is very accurate. It's that capacity to pause and think and I've previously said in surgery, there's not much in the way of catastrophe that you cannot control with a finger. Usually, it's a hemorrhage and the biggest catastrophe in theater is an anesthetist losing an airway and that takes priority. The other thing is when being on problems before I hit the right ventricle opening up er redo patient. They needed to, said you need help. I said yes, please thank you and he went off and got help and help came in another consultant and expert who said what do we do. I said, change of plan and live patient, do this, do that and create a time and space for me to actually think to get out of the problem. The patient did very well yeah but again with the trainee is one the trainees having the confidence to speak up and to the power difference in theater between the captain and the assistant. Whereas you say that they both can fly the plane and it's just a position of the seat, but it comes down to the question you were saying you mentioned previously in our discussion's open questions, you know somebody had done a fabulous technical exercise flying a simulator, but I understand they didn't do very well in passing because of their the way they tackled the problem. Yeah Actually it's an interesting one. My youngest son is a training copilot now uh big airways uh uh We were only talking yesterday about it and he he had a chap in the simulator last week, who exactly the same thing happened on his check, and this chap um was very forthright, very um closed questions, so it is that isn't it we are doing the right thing aren't we you do that and none of that actually opening it up and saying like I would say to you david. What do you think uh you know and rather than I remember one of the classic ones, it's not a cardiac thing, but it's um the old uh laparoscopic cholecystectomy. You know the one where you've got the classic. What am I going to do here is it going to be the common bile duct or the cystic cystic duct is that right. I think it's correct, uh and you know when you say that is the common bile duct, isn't it or do you say which one do you think is the common bile duct here or you know, there would be another situation in which rather than saying I'm right tell me I'm right which is the classic leading question close question stuff. Um you instead you, you, you encouraged team participation by saying what do you, what do you think that is then or which one do you think it is or what do you think we should do next, and I bet when you were training those guys that you really respected, who brought you on, probably the more would be the ones who gave you the opportunity to to participate. You know you know to be a valued member of the team and to feel it, what what about that uh that is that is very true and indeed having that relationship with the training surgeon at the table, or the person opposite is important because they can and will point out when things are not quite right, and I can think of many instances in my training where that actually happened, so how do we, how do we train, or how do we encourage the audience who training surgeons to embrace this mindset and recognize that jerks kill and that learning despite errors because we know, we're in a blame culture and the nhs, Unfortunately, how do we, how do we get over this for the next generation, yeah it's okay uh someone else oh just a little question, then um can I can I just step a little bit away from that and tell you how we did it in the airline business, so we realized that well let me put it this way, I'm old enough that when I started flying as the most junior second officer uh In 1971 some of the captain's had had flown in the Second World War. They've become a captain at the age of 18, they've been shot at and they had gone from something that fluid about 100 and 80 miles an hour. There's something that's actually started on the jumbo. I went off to other aircraft, but they're they were at the age of 50. Something coping with this 354 100 ton monster, I mean, I'm amazed that that you know they were able to make that progression. It's just fantastic careers, but a lot of them were very difficult characters, and I can still remember my very first trip, which was to new york and the captain was sir on and off the aircraft, And you know, we even ended up in the pub just off Fifth Avenue, and I said excuse me captain you know may I be permitted to buy you a beer and there was that's one of the things that's gone because you know, there's a time and place for hierarchy and a time and a place for authority. Probably when things aren't going well, but it builds barriers, which when you need that help, it makes life very very difficult um and it can make somebody think twice before speaking up and pointing out that you're about to make a mistake and um what a lot of the younger generation will find is that they might say you know like I would hi, I'm trevor, call me Trevor, and some people might find that difficult who've been older school. They might not feel comfortable doing that and we had the same with some of the older generation cabin crew who wanted to call me captain all the time and that was that and sometimes you're going to let him Because you you know you, you you move the culture bit by bit by bit but the thing that I really want to get to is this and you and I have had a discussion about qualification of trainers before and one thing that aviation does certainly big Airlines do is they standardize their trainers. Once you are selected as a trainer, you go through a course to be a trainer and the airline, and I was on the team that I was a very small part of the team that wrote the trainers course, which was the first bit was a five day residential course, and it included how to teach and train and to demonstrate technical skills, but also how to train and teach behavioral skills, nontechnical skills like leadership, communication, share ing, situation awareness, decision making, and the thing that we realized was that a lot of the old school trainers and you see this in health right across healthcare. Why are they trainers have they been selected uh have do, They all tell the same story, no, in the airline industry, they select the trainers, they train them, and the trainers get appraised at least every I think it's every every year within the company and every two years independently from your. The equivalent will be the g m. C. In England, but from from us, it's the Civil Aviation Authority and they check you doing the job of training or checking somebody else, and it's an an appraisal of your abilities as a trainer technically and non technically. How you give your briefings, how you know and also how you give your debriefings, how you give your feedback and can you analyze the problem, and here's uh while I'm on a roll here if I may there was something we found that most technical issues and let's call them surgical issues. If you like have an underlying nontechnical main causal factor and one of the biggest ones is situation awareness, so if you have the wrong picture in your head, like which side am I operating on which patient am I operating on, do, they have any allergies, you know previous scarring, whatever that might be, that is probably the real root cause and and having everybody on the flight deck. Everybody in the operating theater, all having the same situation awareness is crucial and the same goes for any other medication you know wrong drug, wrong route, wrong dose, wrong, patient, situation awareness, wrong side procedure wrong, prosthetic um situation awareness you know and, and that's uh and the share ing of situation awareness is communication dependent. So if you've got all these barriers of hierarchy that we were talking about and behavioral barriers, it's likely to lead at some point or rather to a loss of situation awareness, and that goes back to the professionalism versus luck, I probably said too much how do we inculcate that in training surgeons, how do we actually instill, in them the importance of the way they conduct and communicate is going to have a direct effect on outcome well. You know the most powerful feedback of all on that is your video, someone I hope you play it back and say I have a look at what it's a very funny one you say to someone you know so how many times did you use bad or inappropriate language. I didn't do it at all all really have a look at this, you find it. Um You know are you an advocate then for black box in theater, voice, yeah, in theater, yeah well, and when we did that, you you know you mentioned that I worked at Great Ormond Street um with mark D level and co back in about 2 2003 and ken katchpole uh may I just say was the researcher on that when we first met and a chap turned up there, I think it was less the university, where the black box recorder for the operator back in about 2 2003, and there was all this on that, um but actually you know if you're a true professional, why would you worry you know if you're a real professional, you you want to be the best you can, can't you know what what's the definition of professional, why wouldn't you it might be painful, but isn't that, really what what you paid for you know you, you've got other people's lives and the safety in your hands literally in your case and uh why would you not want the most accurate um feedback, and it's not a spy there's all this rubbish in the press about Spy in the Sky and all this thing you know, yeah, okay, but the, but the real professional just takes it in their stride, so trevor, that takes us on to the difference between confidence and arrogance because the patient would like to see a confident surgeon, but also can see through the confidence in spot arrogance yeah well. I mean that's an interesting one. I I've run courses on this and done, talks on it and I've got a picture of a really wobbly tightrope with a doctor walking on this tightrope and it's it's getting progressively more uh about to throw you off, Let's say my my thinking goes like this. You make a mistake. Do you have a voice in your head and I certainly do if I make a mistake, Mine says trevor you blithering idiot what the heck are you doing you know you're being a jerk back to your one again, and so I've got to deal with that in my own head and I go and talk to my colleagues, my colleagues, say you idiot what were you doing, why did you do that and I might go to my manager or whoever, and they to call me a clot. I go home. I talked to my wife and she says you idiot and I might go and talk to my friends for a bit of solace and they call me a clot as well. How do you, how do you deal with that. You know how, do you cope, especially even worse if you have caused harm to a patient. How do you live with that and let's be really brutal about this. We know that there are some doctors, nurses, etcetera who have not been able to live with the outcome and they have committed suicide. You know I mean this is not a joke. This is serious dear stuff and we talk about psychological safety okay, so here am I at my grand age, I'm still flying after 50 odd years of flying um and I make mistakes occasionally um did one the other day, I'm not gonna tell you what it was, but it was, I got away with it, I'm still here um and I feel a bit silly because I did make a very small mistake um While I was actually airborne and what I do is because I can work out because if you like steeped in human factors, I can work out why and how I made the mistake, so this bit about staying on this tightrope of confidence and arrogance, right the confidence bit how do you get back on the, on the tight rope get back on the horse, whatever you want to call it and I think it's because if you can understand how you made a mistake, it does a lot of it is you know. Um I was distracted, I was interrupted, I hadn't prepared properly, hadn't thought it through and the one you get more often, I think than anything else is just wasn't thinking I just wasn't thinking why did you give the wrong, I just wasn't thinking why did you make the incision in the wrong place. I don't know, I just wasn't thinking if you can work that out, now, comes the road to rebuilding yourself and rebuilding your true confidence you know, we're all fallible. You've got to start with that by the way. If you anybody whoever some of you out there may have learned to fly. You may remember you go to a flying school the first thing they tell you is, you will make mistakes not you might, but you will and our job is to help you not make a mistake that will kill you and maybe other people, so if you look at the arrogant side, what does the arrogant side look like the, what does behavior look like well. It looks like to someone who you know david, you let me down why didn't you tell me and it's all somebody else's fault, we've all met people like that. I've met a few in aviation, um certainly met plenty in the operating theater over the last few years, quick to blame everybody else and very slow to swallow hard and use that word humility, so it's hubris versus humility, and one of the things that we did in aviation was we we got people to to really ask fight for feedback was that sort of phrase fight for feedback, can you give me some honest feedback on how I was today, can you can you you know how did I really do and that's going to be a real struggle for someone as eminent as yourself david, that's going to be incredibly difficult and to put it in perspective. My son is a training copilot, he's in his thirties, um He's not yet a captain, but he's a trainer and a checker, so he will check captains in the simulator. He can't do it on the aircraft, only captains can do that, but as a copilot, he can do it in the sim, and I said to him last week, how do you get on for feedback. These days, he went uh dad the eternal problem you know nobody wants to give the trainer the checker any real honest feedback because they're always worried about you know what if I have you in six months time on my next check and you decide to take it out on me. You know, I mean if you like they're actually transferring their own thoughts aren't they you know it's a, it's an interesting one, but really what you want is honest feedback on your behavior. How do you do that well. Of course it exists, there are the knots, the nontechnical skills for surgeons, which came out of Aberdeen University and the excellent professor Rhona Flynn and her team many many moons ago based on her work in aviation where the nontechnical skills came in on and all of the behaviors I've actually downloaded them here and they're freely available on the, on the web. Of course the knots, but you look down here at and this is the actual nontechnical skills for surgeons um good behaviors of leadership setting and maintaining standards, and it says, introduce itself the new or unfamiliar members of the theater team clearly follows. Theater protocol, requires all team members to observe standards, poor behaviors, failed to observe standards rates. Theater protocol shows disrespect, it says here to the patient, but I would argue, shows disrespect to anyone can. I just tell you the last time I was in an operating theatre was actually cardiac surgery in a London teaching hospital. We can't language, we can't no, I wouldn't dream of it, and in the morning we had the huddle, the briefing, and there must have been about 12 or 15 people. I was one I was in scrubs and the consultant came in and he said uh we don't need to bother with introductions, do, we, we all know each other, but of course you know, I tried to stifle my laughter and I just excuse me, but I I don't I don't think you've ever met me before and by the way I'm a human factors training you know oh, dear okay, that's, that's the thing about the who checklist that I coming back from my trip to the i. H. I. The, who checklist is really who is on the table and who is working with the and chatting to peter, provide dust and barry sexton who came up with this. They agreed that it need to be adapted for your own working environment, but we had within the health service in the u. K. A. Stipulated template that you had to use and could not be adapted, but certainly in theater, I'd start theater with how is everybody today anything to celebrate. We had Bar mitzvah's marriages, divorces, I don't want to ask, has anybody troubled by anything, and I didn't have a reply, but on one occasion, the adp followed me out and said actually I'm going to a tribunal this afternoon how I could be sacked. I know this was a senior operating department physician who was in theater in the afternoon going to a tribunal where they might be sacked. I didn't think they would actually be thinking about the job and when I inquired as to why I actually thought was grossly unfair and I piled it, I said you can't do this. This is ridiculous, but that's that is it, so your advice to learning surgeons, then, on one hand, they are very worried about learning the technical skills and worried about making mistakes in an environment that at the present moment does not recognize mistakes happen in in our learning opportunities, and as we discussed last week on the Black Belt Academy, we have to, they're performing, we're not creating islands of learning where it's okay to make a mistake and okay to learn because within the hospital environment, you're performing you're flying you can't how do we reconcile that and what would your advice be to hearing surgeries well. I I think one of the things is it's fine to just I mentioned earlier on asking for feedback, but what you want is honest evidence based feedback, So if someone says well, I don't think much of your, I don't know you're you're not very good team worker, what does that mean you know well. You didn't speak up when okay. Uh You know it's about getting into observable behavior, which is where the non technical skills for my money come in and it's really my specialty. I suppose I would go on about that, um but it's about having a format that you can you can frame that feedback on so you and I had a discussion the other day about this thing called airmanship, which everyone used to talk about a lot in the aviation, very difficult to define um And it's more than just leadership. It's it's about having that judgment, it's probably the sort of thing that you've got david based over many years and it's about trying to work out what is it, what is it that david actually does so someone who's working with you um they might uh they would be able to observe you. They can't hear what you're thinking unless you verbalize it um And it's about share ing your thoughts and your I guess role modeling. I suppose so, it's it's when you go to as a junior surgeon or junior team member, whatever you're doing when you go in and you start to observe other people and not just their technical, observe what they do behaviorally, you know how, do they treat other people, um are they do they make eye contact are there, and I know there's all this stuff about you know sort of surgical sterility, so you're doing all this quite often, but do they, when it's appropriate, do they make open hand just because and again, I know we're dealing with the international audience and so nonverbal body language can vary tremendously around the world, but whatever you would consider to be if you like good human to human contact, do they do that and what are those little things that they do that you think well, that's that's special, that's really interesting so from a you've said way back about captains and copilots, what do they do so. I did 18 years as a co pilot and 16 years as a captain and in the 18 years, I, I was watching not always consciously but kind of picking up what is it that this guy does and that girl does and would I, who would I want to be like who would who would I model myself on, but I know having them become a trainer that a lot of people don't do that. They just don't have that um uh Maybe it's a power to observe and to analyse. I seem to just have it, I'm very fortunate to have it you can teach it, but it's a bit about thinking about a little bit maybe outside of the box. There must be a huge tendency because you've got a lot to learn as surgeons and focusing very much on on the how you make incisions, how you suture, how you get things out of the way and you know you can, I think you can over, focus purely on the surgical, the clinical aspects, and I think it's about widening your awareness of of the other bits and one thing that's looking at the clock. 11 thing I would say is, do not neglect when it goes well because when it goes well is that there's been a big buzz in the uk, it seems to have faded a little bit about learning from excellence, but let me run this one by you right, so how often do things go wrong, let's say 2% of the time, so twice in 100 so you would focus on those and especially as a trainee. You're going to focus on when it's gone wrong what that means is. There's 98% of your work has gone really well, but you may just take it for granted and not think about it and taking success for granted is as an outsider, something I observe across healthcare far too much you say to someone great job nurse just doing my job and they kind of shrug it off and what I would urge you to do is focus on when it's gone well and try and why did it go well today why was it so much better and you dig into that and then try and repeat it. Don't focus on when it's gone wrong, don't ignore it, but don't over focus on it, but I think that is very appropriate and a good place to actually bring our conversation to the end because in healthcare and in surgery in particular, we don't celebrate success enough and I'm thinking of a phrase in training dogs wag more, bark less and get and and you train dogs by rewarding them on good behaviours all the time, I was just noting trevor you did this insurgent did that for completeness sake. I would actually say to my viewing trainees. Please don't ever let when you stare out, your hands pass the midline, come above your nipples or below your your waist the best place to keep your hands are folded in front of you, the mast, er and thank you very good and that is down at Rose, Iffy sternum and sterile, it is open, it is sterile and trevor. Thank you very much Indeed for the insight. Thank you share in your experience and thank you Gabrielle for the production. Behind Thank you to the audience, we're going to see you next week, where we talk about what I think is the first cause, The Blackbird Academy is trying to bring together the principles of your thinking, behavior, communication, and technical skills, all of which make a precision. Next week, we'll be talking about posture, how you stand, and how to maximize the operational efficiency of the beautiful thing the human hand. The following week, we are joined by Professor Roger knee Bone, who is the countries, if not global. I think er on how to become an expert in technical skills for this evening. Thank you for joining the Black Belt Academy of surgical skills be well wherever you are and thank you Gabrielle and Trevor for your insight. Thank you. Thank you very much indeed, david. Thank you every