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right. Have we lost connection? We are alive. Thank you. Hello. Good evening. Good afternoon. Good morning. Wherever you are in the world. And thank you for joining the Black Belt Academy of Surgical Skills. My name is David Regan. I am retired cardiac surgeon, living in Yorkshire in the United Kingdom. The past director of the Faculty of Surgical Trainers for the Royal College of Surgeons. Put better and your if you're returning thank you very much. And thank you to the 3293 fours on Facebook and the 528 on Instagram. You peripheral presence is most welcome. This is your first time. We're beginning the series by addressing theoretical things and hopefully capture your imagination and you come back. I'd like to thank Medal for supporting this platform. And Gabriel, who's behind the scenes, who will take questions in the chat and call them out as we progress. Now you're talking this evening about perfect practice, and I want it by administration introduce my son who has been at the assistant at the table over the past couple of years. But this evening is going to do something different Welcome and step. We're going to look at the physical activity of juggling. Thanks. Uh, could you show me how you throw one ball, please? Yeah. Continue that. Okay. Stay one, then. Two balls. When? When you can do some tricks like that. Can't you as well? There's a few balls. No, it's just a sensation. Okay. No, please, Please. €3000. Old surgeons watching me to come. There you go for a reason. Here we go. Four balls. Okay. You can put a couple of tricks up your sleeve for that, don't you? And you've been aiming for five balls, haven't you? Yes. There you go. Five balls. Well, that's not this for statins. And are you sure? Yes. Okay, fantastic. Precisely. No, but you're aiming for five balls. And at five polls, we dropped some and you heard a thud on the floor. Now I'm not, and I think to myself, this is work. A trainee, a training doctor sees an expert surgeon is juggling all the balls. However, basically, uh, you can do your three trick, and I'm throwing this wall up up in the air, and I'm trying to actually set up to get the other one up at the same time. And as I'm doing that, I'm actually feeling quite silly to perhaps intense, true, and perhaps a bit nervous because I'm doing this as a concern, trying to juggle balls and my coordination is up window. What do you reckon? How do I start out stuff? Yes. You need throwing balls and have confidence to let go of the second or so foetus in the earth. Okay. And where do I look when I'm throwing the ball? As I said to you earlier, you need to focus your eyes on the space where you want the ball to change direction. Okay? And that's where it should change. So that's why, as the balls get high, you're looking up enough enough. And you're not looking at your hands or No, no. Okay, I'm just starting. And as I'm doing that, I'm thinking to myself, this isn't feeling. I've got at the present moment trying to throw and catch the ball and showing complete poor coordination. This is how a training surgeon, in doing something, probably feels because I'm feeling nervous. I'm feeling a bit offered trying to do it because I'm trying to perform and then trying to perform when the mistake happens. Feeling very nervous, very stupid and very silly. But I would say you do your three for me and there you go. It is as simple as that. What is it? Can they say Yes, yes, carry on. It is as simple as that. But it's as simple as that, because at the beginning of Covid, Allah said, because we're in lockdown decided that he wanted to learn to juggle, and that was the first step he wanted to improve. And the bottom line is we can all improve. But how do we improve is The important thing is that before we go from one ball to two balls to three balls to five balls, that's an iterative process. You can't start juggling five balls and expect it to work. I mean understanding. Here, Do that again. Uh, I'm standing here struggling to catch and throw two balls. So in learning, I need to step Fuck! And too simple. Throw, catch, throw, catch, and then learning to juggle standing up against the wall to ensure that the alignment can catch exactly one of the time. But I'm in a safe space at the moment, learning this because I can drop the ball and it has no consequences. The problem is being operating theater. When we're trying to learn, dropping the ball is often taken as an error mistake blame and has potential catastrophic problems. And, well, I'm not sure if I should know. They talk. Yes, miss mistakes are stigmatized, such exactly mistakes. But the problem is what we forget is that we learn from mistakes. So when the boy that's obvious, that mistake is clear. There's a thud on the floor and that's why they call thuds. There's no bounce and they don't roll away. But the problem is when we're teaching Saturday, we say not like that like this and we don't expect any mistakes. But we do not really explain each constituent part that goes to make up the Axion. The thing is, we're trying to learn and teach surgery in a high stakes situation, whereas we need to bring it back to a low stakes situation and I put it to you. You can do it at home where you allow to make mistakes. You can see them, but we also need to do it on low Fidelity models. The thing is, we need to grid the time and the space, and this is what practice is all about. Everybody can improve by nature. People are very similar this divergence as a result of the practice. But that person needs to be deliberate, purposeful, executive and additive. And the practice should give you feedback showing you where you're wrong. And it's the making of the mistake and understanding you make a mistake that enables you learning, I think Answer One more juggle. I know you want to get an early night. Show me one more forward, One trick the four balls, please. Me too for you. And I think ladies and gentlemen, a big round of applause because I've asked Alison to perform and he too was feeling slightly nervous performing, thinking that mistakes were not acceptable. So we have to separate the performing from the learning. And I think we need to separate that in hospital practice in surgery. I don't think we should be expecting our training surgeons to perform in theater. We should be learning in theater, but we need to be safe and psychologically safe as well. So what's interesting? This whole philosophy of practice and deliberate practice. It's basically down to what Carol Drag would describe as a growth mindset and what is interesting When you start martial arts, the most significant belt we given you any is your white belt. This really is acknowledging you're starting a journey, and from then on, as you get more involved, the color gets darker. The red boat teaches you the basic principles, because mastery is understanding the basics in practicing until you cannot get it wrong. Through that, we go to yell about and from hell about. We go to orange about orange belt to Greenbelt, then two blue count, and then we have Purple belt brown belt, which is brown and white. And all those stages are learning, learning on a journey, building on basic skills that are prescribed, described and in the deja. You're learning each skill, and you watched by the center sure to get it correct, and the movement is specific, directed and corrected. Every time throughout the belts you're learning each stage. Then you're building on the one ball to two balls to three balls to fireballs and then able to drug more balls. Thing is, then it could become a consultant and everybody goes, Whoa, respect The problem is that most experts black belts when they become a consultant. After two years, we tend to stagnate. We don't even progress beyond that. And the reason why is because we expected to perform or I'm and we don't step back and learn. During my tenure as a consultant surgeon for 20 years, learn, Trinity's only came through the trainees working with me and feeding back and me being open to that feedback enabled me to learn. The crazy thing is, even though we're all black box, that we don't take the opportunity to go round and help each other and feedback and learn. And I think that is a failure on the system. But an expert and a person who's wanting to improve will deliberately examine their performance, reflect Internet, adjust Russian, practice it in a safe environment and then learn. And I recall a trainee who is helping me, inadvertently not very coordinated and not their problem, because they're relatively junior and I, by internal mammary artery to L. A. G. N s stenosis in the usual fashion, because that's the way I was trained holding the internal medicine er against the side of the wound and the heart was here, and my actions was taking a stitch here. Up there, down, up, down the good following etcetera was not as good as I was used to, and I was frustrated. But that's not because of the person's fault because they weren't trained. I had to think how do it again and on this occasion brought the money down next to my anastomosis, flipped it over 180 degrees like that, and I'm stitching inside inside flip of the top outside, outside. Minimize the movement, minimized interference and improved my an osmosis. And so there have been these little iterations throughout my career where I've actually thought about it. Deconstructed practice isn't standing there. Just throwing the ball is understanding exactly what you're doing. And the problem with surgical training is that we say not like that like this, and very few people have deconstructed exactly what you need to do. And once you know how to stand how to hold the instrument, how to align everything and then practice on low fidelity models in a relaxed environment 20 minutes a day, 10 to 20 minutes a day, you'll find that your skills will improve dramatically. Mhm. So part of what we're trying to teach in the Black Mark Academy is we've taken what you think. It's a basic juggling, and we have deconstructed that with each skill, using models that are available to you at home and trying to give you direction and how to set up to complete the Axion. Now no model is going to fulfill that are for operating. But each model develops a different skill, and each skill builds and adds to another skill when put together, enable you to actually operate in the environment that we find ourselves. But part of what I'm trying to teach as well is not just the movement and the flow and the rhythm and the field, and the feel gives you the haptic feedback of the tissues and therefore lightness of touch. The problem is that all these simulators and plastic suture pads are exactly that not only is not good for the environment, but to be honest. In 20 years of surgical practice, I have not come across any synthetic material that is kin to an organic material in feed for feedback. So What I'm trying to do is a practice in the Black Belt Academy is offer you skills. They do can practice at home that focus on one particular element of the movement, and you practice it, and the models do give you the feedback that you require. What do I mean? Well, let's just take you over to the top to what Black Belt Academy is recognized for. We go bananas. We'll be covering this in detail later on as we go through the syllabus. But my point being is that the models that we use must give you feedback when you get it wrong. So the rotation of a needle through the tissue is dependent on many things. But the right and clean rotation can be seen by the needle coming out perfectly. Pure content. If you imagine an Olympic diver hitting a pool, the maximum point is gained. If they hit the pool and there's no splash in this model, the idea is to be able to take the needle I/O of the banana in the same place. Repetitive Lee, without skipping it through the model, shows you if you've done it right or done it wrong. You can see that the exit wins on the banana. Likewise, the potato This is microwave potato, Ms. Soft skin. If I'm careless, turn you I/O. We'll see that the potato tears. I start mashing it. Simple model gives me feedback because I can see how clean the rotation is. Knife skills are likewise very important not only how to hold the knife properly and we'll be going through all of these with a black belt academy properly using the field, the tips of your fingers and feeling the knife through the skin to a tangerine without the flesh underneath. So you appreciate the pressure, and this is very similar to a cortex on the lung. Just take that off. There you go. I have not cut the tissue underneath and what this model is. Check that and feel likewise, a clean cut and a sponge clean cut. You can't see any of the blue on the edges. If my knife is not perpendicular, then you can see all the blue and it bacon sliced cutting with a pair of scissors we take for granted, but can you cut circles out, holding it with a piece of forceps and gently cutting around circles. All these we laugh at as basic skills because we did that in primary school. But these simple skills are all additive. Tape. A column of ink. Can you cut straight down one of those gently without leaving any white on one side? And that's pretty Dedge on the other. The other models that I use socks to simulate stitching of, but a water, blood, vessels or bow. And you know, these ridges here in the sock. They give me beautiful moment to practice the alignment of my needle two I/O, directly opposite, yeah. And so, uh, naturally aligned grooves that you can use to practice. And just by looking at it, you can see that your needle comes I/O on the same rib of the sock, and you practice that until you can't four steps we use in both hands, right and left hands and simply taking difference. Eat whatever you've got at home. It is in the first instance, picking it up and putting it in a spoon. The mustard seeds are small, round and hard. Never grab it. They go flying across the table, and I get feedback rice. Put rice into straws and orientate the diameter on the straw with the length of the rice, and you find that you have to turn it around to get it into the straw. Put different straws on the plate. Practice picking it up, turning it around to put it in. We've got a new one. Charlie's in Sienna suggested peas. Frozen peas are hard and we're scared across the table, but boiled soft peas. If you grab you're All of these are teaching you accuracy, precision, lightness of touch. So when we think about the complex bit of operating, it is built up of a whole lot of things a little bit. And the important thing is for us to practice and masters each of these little bits each of these stages. The idea in the Black Belt Academy of Surgical Skills is that we have taken each of these and you'll see it on the website. Deconstructed it intuits continue constituent paths, and each part will build on the other. The good thing about doing it at home in a relaxed atmosphere, Not only do I have the feedback, I'm not under pressure because you don't have to make a mistake. Wow. I mean, I can make a mistake, and I learned for it. And that's what this fall about learning the zone where you can challenge your skills, push them to the next level and move on. So this is Do, move, learn. And when I reflect martial arts, But like we tried to juggle this evening, I started that journey and they said, Go on. Go on. You can do this. Hello? Mm. And I looked okay. Then I would get beyond Greenbelt. No, if it, um But it doesn't mean to say that I can do, uh, as high as my son. On the contrary, the mast er in the dojo said martial arts is a personal journey. It's your mastery. It's improvement of yourself. And even if you can't do a big sidekick, that doesn't matter, because it's your improvement that counts and not being benchmarked against. Uh, because as one of the anesthetist said to me, that I've worked with over many years, the favorite saying was good. Better best never let it rest until your good is better and you're better is best. All the models that we're going to show you are based on these principles. They're designed to give you feedback on the Axion and the practice we describe. We'll show you how to set up and how to align, how to stand, how to move to maximize the Axion. The thing is, if you go in and start stitching without deconstructing and understanding what you're doing and why bad habits come in. And it's very difficult indeed to undo bad habits because what has to learn again. And there's a resistance to learning from a scratch and very difficult to get rid of motor Axion that you've learned. So thank you very much indeed for joining the Black Part Academy. I hope you're going to enjoy this process of not only developing your motor skills and the way you think about practice and how you practice at home. My son's been doing it for two years. He left off for six months but literally has been doing this for 10 minutes a day, and now I can manage five balls. I stand there and marvel, thinking, I don't know how I'm going to get there. And as I tried to show it to you, I felt silly and felt stupid, and that's not too dissimilar to what I think you might be feeling in the work. Don't worry about it. Practice at home. Be comfortable making mistakes at learn at home. Learn from them from the models we offer you because they give you feedback. And lastly, I think it's vitally important that we bring the fun back into surgery and you should enjoy it. My son and I before coming on but laughing at my incompetence, trying to throw two balls in the air, he said. The problem is that you got to look at the ball up there and not in the hand and focus and trust where your hands are. He then went on to just and said, Problem is with surgeons that you put your hand out to the side and the scrub nurse puts the instrument in your hand and your focus is on the field. True. Pick it up and you're focusing on the field. But this is a synthesis of basic skills and actions that the Black Belt Academy has deconstructed invite you to participate in and hope that you two will enjoy your journey of mastery. Thank you very much. indeed for joining the Black about Academy of Surgical Skills this evening and thank you for your feedback on the line that you put on Facebook, a not time video that describes the nuances of not time to a song. I hope it is making sense. I note that it's had 23,000 play throughs already. I hope you've seen it. If not, please look at it and let me know. Part of this journey, as you'll understand, is not only developing your motor skills but also developing your mindset. I have to reflect on the recent masters and martial arts who has buried the ceremony in Japan, and he asked to be buried with his white belt on, not with his black belt. He has to be begged for his wife button. Even at his esteemed level, he still believed is on a journey of learning. And that's what I'd like to implore upon you. It is a journey, and you're always learning as I am learning, and I think I need to take some time and practice my juggling skills. Thank you very much indeed for joining the Black Part Academy. Well, describe all these models in detail as we go through next week is part of the mindset of surgery. I'll be talking to be a captain Trevor Dale, about confidence and arrogance, practice and what we should be doing when things go wrong in the high performance area of theater or inner aircraft. Gabrielle, thank you very much indeed for being the producer this evening, and I wondered if we had any questions. Thank you. Um, so today we don't have any questions, No questions. They're probably rolling in the owls in my lack of very impressed by the juggling. But I hope you appreciate it. Waited the analogy and the iterations of this and what I wanted in part upon you watching my son juggle with ease and fluid fluidity of me trying to learn, I felt as uncomfortable as I probably felt. Well, I know. I thought when I first started to learn surgery, I wish you all a good night. Thank you very much, Gabrielle, and we'll see you next week.