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Summary

This session of the Black Belt Academy of Surgical Skills is featuring a distinguished guest and mentor, Linda Dicus Art Linda who will be discussing the journey to becoming a medical professional and the philosophy of surgery that goes beyond the technical skills. Linda has enjoyed an incredibly successful career in medicine and surgery, highlighting the importance of values and beliefs as part of the journey of mastery. The session will cover various topics, such as how to develop the physical, emotional, and spiritual elements in the practice of surgery, understanding the complexities of a practicing surgeon's journey and responsibilities, and how to gain independence and autonomy within the surgical profession. Join us to gain fresh insights about becoming a trained and qualified surgeon.

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Description

BBASS has the pleasure of introducing Linda de Cossart. Together we are going to explore what it means to be a surgeon. It involves a lot more than technical skills. Linda de Cossart argues that the development of the learner into a wise and virtuous professional should be considered as an interpersonal and moral activity.

Linda de Cossart graduated from the University of Liverpool School of Medicine in 1972 and was admitted as a fellow of the Royal College of Surgeons of England (RCS) in 1978. At the time, there were few female surgeons; de Cossart has said that "women were actively discouraged from going into surgery". After obtaining her surgical fellowship, she completed a Master of Surgery at the University of Liverpool with a thesis on venous disease. In 1988, she was appointed by the Countess of Chester Hospital as a consultant general surgeon and was tasked with establishing a specialised service for peripheral vascular surgery at the hospital. She retired from surgery in 2009,[ and remains an emeritus consultant and the director of medical education at the Countess of Chester Hospital.[5]

Linda was elected to the RCS council in 1999 and was elected vice president of the college in 2008. Her portrait was featured in a 2008 exhibition titled "Six Women Surgeons" at the RCS's London building. She was appointed a CBE in 2010 and is an honorary professor at the University of Chester.

De Cossart was frequent collaborator of Della Fish. Together, they established a master's degree programme in Postgraduate Medical Practice at the University of Chester, and they have co-authored three books aimed at doctors: Cultivating a Thinking Surgeon (2005), Developing the Wise Doctor (2007) and Reflection for Medical Appraisal (2013).

Learning objectives

Learning Objectives

  1. Understand the philosophical and psychological aspects of what it means to be a surgeon
  2. Identify the physical and intellectual components of a surgical career
  3. Demonstrate an understanding of the privileged responsibility that comes with training to be a surgeon
  4. Distinguish the difference between knowledge and practice in the work of a surgeon
  5. Implement strategies for lifelong learning and developing autonomy as a medical professional.
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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello. Good evening. Good day. Good morning. Good afternoon. Wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. It's our second break broadcast for 2023 I wish you all a happy New Year. Thank you very much indeed to the 3293 followers in the 527 on Instagram. If you're returning, Thank you. And if it's the first time you're visiting the Black Belt Academy of Surgical Skills Welcome. We started the year drawing on the philosophies of martial arts and the mindset and development of the whole individual as part of the journey of mastery because it is a journey and not a destination. But to understand the journey, we got to understand the destination, how to become a surgeon and being a surgeon. What is wonderful about being on the metal platform is I'm now able to invite distinguished Gest's to participate in these broadcasts. And the very first distinguished guest for the Black Belt Academy of Surgical Skills is Linda Dicus Art Linda It Carcinoid graduated from the University of Liverpool medicine in 1972 was then admitted as a fellow to Royal College of Surgeons of England in 1978. At the time, there were very few female surgeons, and Linda is quoted to have said women were actively discouraged from going in to surgery, and we will explore that later, After attaining her surgical fellowship, she completed a master's in surgery in venous disease at the University of Liverpool and in 1988 was appointed to the Countess of Chester Hospital as a consultant general surgeon with a task of establishing a specialized service for peripheral vascular disease. She retired in 2009, but remains an amateur's consultant and director of medical education at the Countess of Chester Hospital. Linda was elected to the Council of the Royal College of Surgeons of England in 1999 and then went on to become vicepresidente. Her portrait is featured in 2008 exhibition entitled Six Women. Insurgent Surgery in the Royal College of Surgeons of England, and she was appointed A C B in 2010 for services to surgery and education, and continues as an honorary professor at the University of Chester. Linda has collaborated with Della Fish on many articles extending and exploring the work of philosophies of education of surgeons, and established a master's degree program at the University of Chester. They have co authored many books, including Cultivating a Thinking Surgeon, Developing a Wise Doctor and Reflecting Um, Medical Appraisal and I'm Enjoying, in going through this book the transformative reflection of practicing surgeons and physicians, reclaiming professionalism, wisdom and the moral agency. It is profound and really stimulate the thinking. And I would recommend Linda, thank you very much indeed for joining this evening, and I'm prompted by you your thinking. Surgery is more than technical skills. What is surgery? Linda? Well, it's a It's a wonderful question, but it's an enormous question, David, As you know, um, and of course, surgery. Um, it will depend what context Urine, Because surgery and surgeons are seen from many contexts from their own context, from the pub general public from their patient's from the staff they work with for those they teach and for inspiring new generations of doctors both to join and become doctors and to become surgeons. Um, but I think really what you're getting to is, is it really what is it. Who? Who What is it that actually draws you to become a surgeon? How do you get that? Well, perhaps I would start by saying, in Britain, at least, being a surgeon and being a doctor is actually a very privileged position, and we don't often talk about that very much. Um, actually, we are licensed, um, twice in terms of our British accreditation process, once as a doctor and once as a as an accredited surgeon, to actually have the discretion and the the license to actually take part in interactions with patient's that are surprisingly harmful, sometimes before you get to the benefits of what we do. And so I think that actually, uh, requires of us as surgeons to be very thoughtful about who we are, why we're doing this, how we see our values and how they develop and how we underpin those things we care about and believe that are important. The reduce every relationship with the patient, how we understand ourselves in situations of complexity and complex practice, how we deal with situations that we may not agree with, how we come to terms with the tragedies that will happen in our lives. surgeons and how we cope with the both the physical and emotional demands of a complex and interesting career. I think one of the things that is again underestimated in surgery and perhaps in other specialties but certainly in surgery is both the physical as well as the intellectual components of doing the job. Uh, it requires, um, physical activity, which actually separates it from from many of the other professions and specialties within medicine. But but I do emphasize that for me, being a surgeon is about being me, Linda D. Kasser, bringing me and who I am to be a doctor and qualifying and and doing all of the knowledge, things, the exam things, the learning things get there. And then, actually, I think because of where I found myself, I found that I enjoyed surgery. I enjoyed the the fun initially, particularly of of the operating theater. I like the practice of surgery, and I found that I had reasonably good technical skills quite early on in my career, and so that set the path for then sub specializing within medicine into the practice of surgery. So it's a complex thing. I think it requires you to have a passion for the thing you're doing. It requires you to have an intellect, intellectual capacity to deal with it. Technical skills. Um, and to perhaps to concentrate a little bit more on the person that you bring to that practice. That makes sense, David. Indeed, it does. So for surgeons embarking upon a career realizing that is beyond just technical skills, that is a physical element. But you've already alluded to an emotional and perhaps spiritual element to this based on your own values and beliefs. How during your career do you start developing these elements? Well, I think in an ideal world, one should actually bring them with you and be developing them from the very beginning. Um, but that requires, um, the whole context in which you work the surroundings in which you work. To be prepared to actually deal with that and to actually have facilities, both educational and human support those who teach, um uh to have the facilities and the capabilities themselves of actually developing those elements of our careers. I wouldn't want to dwell on the difficulties in surgery, but I think people struggle more in in in medicine and in surgery with the things that are not just the everyday activities of the job people. So it must be difficult to to be a surgeon. Well, yes, it is. But actually, the technical bits, the knowledge bits are often the bits that you can do rather well, because you spend a lot of time practicing them. You spend a lot of time learning about the subtleties of the specialty that you're in. You talk to other people, and and certainly in the last 50 years of my career, with amazing developments in what one can do surgically for the for the benefits of minimizing, uh, influence in interaction and harm to patient's, you know, the minimally invasive stuff has been absolutely extraordinary. Um, and so we become very good at that. But the bit that challenges us more than anything are the things that perhaps, um, cause discomfort about what, how were made to do things, how we're treated and what independence were given as we grow within the within the environment of being a surgeon. And by that I mean, um, in my career, I've gone through the the seeing of where you know, junior doctors, registrars in surgery within the ranks of learning to become a senior surgeon under consultant. We're often regarded as students. We've got rid of that, Um and but even now there's that there is still and I've seen it emerging in some of the things that have been written that actually suggests that, you know, if you're not a consultant, you can't do anything. But our careers in surgery are very long, and I think encouraging the young to be more independent in what they do more autonomous within the boundaries of their capabilities, within the boundaries that are expected of them as a member of the profession of surgery. Um, uh, which we don't do. I think young doctors have been short changed in Britain in the last 30 years about the independence that they can achieve in the practice of surgery. Um, I don't know if you've seen that, but I I think it is one of the things that has disappointed me and which has kept me on the trail of trying to find ways of supporting young doctors to understand themselves. Better to have a vehicle with which they can talk about the things that they are doing with their teachers and for their teachers to be able to support them in developing themselves. Um, with respect, their values, how they see things, their expectations within the jobs they're in and how they engage with the people around them. Which is a big challenge, I think for everybody what leave is or what can you do to encourage us from the learner point of view? What would you advise to the learner? Because some context would enhance and immediately feel good in other contexts Not. But as we've always said, you can learn from a good surgeon as well as a bad surgeon. So how as an individual do you develop or what? Would you encourage, Linda? Well, if you can, I think the first thing I would encourage is for you to identify those surgeons that our senior to you and that you work with that. You get on with that, you see, share your ideals and values, Um, or even sometimes, uh, doctors in other specialties that you see as having similar values to you and perhaps engaging them with certainly reflectively on on the work you do and and and the the clinical practice that you actually are, uh, uh, Engaging in Sorry. I was just a bit distracted then about the messages coming up on the screen at the site. And this actually refers to lifelong learning, indeed, Prepared to learn, Yes, but the question the question for me there, I think David very much is, What is it that you are learning and don't get me wrong. We have to learn the surgeons, the technical things. We have to learn the specialty knowledge. We have to learn the medical knowledge. But it's, uh and and we spend a lot of time and certainly in my career as as as a surgeon, as a teacher, as an associate dean, as as all the roles I've had within the postgraduate educational forums that I've been involved in, we have increasingly focused down on things that we can teach knowledge. Uh uh, theoretical knowledge, things that are known evidence based knowledge, the theory of what has been written, rather than the practice of how to get that right in everyday practice. And I think we will all hear from people around us. Uh, that, actually you can know as much textbook knowledge as you possibly can, but actually Whether you can use that appropriately in the clinical workplace is another matter. And I think one of the things we've done is to move learning about things away from the clinical environment. And I think the changes in structure of both education and the practice of work in the UK shift working particularly, has not helped any who want to do it. But do your original question. I think in the first instance, if you're going to be now see as a young doctor, find somebody you can get on with who thinks on the same grounds in many places. Now you will find people from the director of medical education or clinical tutors of colleges. You will find people who are interested. And if you show an interest and do things, you can stimulate an interest from them. You've alluded to a topic that you refer to in your book as the Invisibles. Is this part of the Invisibles? Yes. Um, well, just for everybody's information, Uh, I met um, Professor Jellyfish, Um, in the early two thousands through the College of Surgeons, when we were working on the first curriculum for surgeons for basic surgical training, the first three years of practice, and we we hit it off on our ideas about how we saw practice and how we saw the values that drive the practice. They weren't just the values of a quick fix. They were the values of really understanding what drives practice and starting with practice. You investigate what somebody is doing in there really work. And I think over the last 20 years, we have worked very carefully and we have taught. And I continue to teach, um, ideas about how you can explore the really everyday practice of an individual surgeon through the process of what we have now come to call transformative, reflective writing. Um, which is taking really cases with young doctors and writing them through the prompts that we offer. And the prompts are generated by the invisibles We explored together what it was that influenced professional judgment. What I wanted to know as a as a as a clinician, working with an educator. Professor fish, um, was I want to know how to teach sound professional judgment, good clinical reasoning, good clinical judgment. Tell me how to do that. You're an educator. You've actually written about it in other professions Tell me how to do it in medicine and she sat me down one day and gave me a glass of wine and said, Well, Linda dear, it's not as simple as that. I have to understand what you do as a surgeon. And so for a couple of years we worked together and explored my decision making. She'd follow me around on ward rounds. She would actually talk to me over supper or at some convenient coffee point during the day and say, Well, why did you make that decision? How would you do it? And and and as a consequence of that we we wrote cultivating a thinking surgeon in which we introduced the idea of eight invisibles which influenced professional to two of those invisibles were professional judgment and clinical reasoning. But the other six, with the things that influenced your judgment and they were context, who you are, what you bring to the practice, the kind of professional you are, the knowledge you have, and there's loads of knowledge. We described 14 forms, and that may not be a complete number. Um, the kind of professional you are, how you see the wider context in which you work and how you engage with it and what sort of relationship you make with the patient. Those six things are the Invisibles, and we use that as a framework for getting doctors to write about individual particular cases. And in the book we have prompts to help you, right that. So I mean reflective practice, which I think is actually a very powerful educational tool if used properly, um, and should carry a health warning. Really? Because if it's done really well, it can be quite disruptive and and and anxiety making, which is which is why it requires well prepared people to do it properly. Um, but those six things promptings and the most important thing I came to realize in those six Invisibles was context, Della said. Well, I didn't know that, but I didn't want to tell you. We had to explore it to really find that what I understand from other healthcare professions, uh, was true in medicine. But the context is the biggest influencer on clinical reasoning and decision making within the environment in which you work the context, referring to the organization, the teamwork, all of it, all of it how you met, how you met the patient where you met the patient, what you were doing at the time, even what day of the week it was Friday night. Consultations are very different to Friday to Monday morning consultations. But despite the context, perhaps not being agreeable or maybe disagreeable your relationship with the patient is always paramount. And your approach and delivery of the service should be independent of your context. But to be fair, David, we are all human beings, indeed. And there is no doubt that if you're tired, um, and there's lots of evidence to support this across the patch these days. Um, and I'm not an expert on all of it, but I certainly know the principles of what has come out of research is that when you're tired when you're exhausted, um uh, when when perhaps you're constrained by other things in your own life, somebody is sick. You had a bump in the car on the way to work. It's snowing outside. Um uh, And if we look at the contingencies of practice at the moment, with all of the difficulties that are going on, think the context is highly things and It is very hard to maintain. Um, I think, um, a mindset that is always magnanimous and putting the patient first. That's not to say people don't try, and it's not to say people don't want to, but they do get exhausted in trying and what I have seen from the work we have done with senior doctors because we've tended to concentrate on teaching those who teach simply because there's a shortage of them. Understanding what reflective practice can do is that as they have worked through cases of their own and explored it in this way, they get light bulb moments about why they did something, why they thought something which engages conversation with me as a supervisor of what they're doing. And that conversation widens and deepens their understanding of their thinking. And actually, sometimes I don't want the process that we've described to be seen as a therapeutic process. But certainly it has a therapeutic element to it, which is if you've talked something through. If you come to understand something better yourself through the process of reflection, which is done best by talking with someone else after you have explored it for yourself, then actually you can. You can actually develop people's resilience. You can develop people's whole way of seeing how they practice you effectively, then making a very good argument for mentoring and coaching. And it sounds like Della was your coach. Um, she she would not like to be called about, but but But I know what you mean. Yes, yes, you might. You might call it coaching, but it's coaching with an educational bent on it. Yes, and again, it's a matter of looking at what the aim of the coaching is. What is the coaching doing? Uh, and I think good coaching and probably good mentoring to is more about listening than it is actually about telling. And and certainly we would say that education in all elements, but certainly in medicine over the last 25 years particularly, has been much more telling than it has been listening and developing and developing understanding in the person that you are is the focus of your educational endeavor. It is almost a journey of understanding the knowledge of oneself, uh, context and how you could perhaps you react to context and how you could perhaps mitigate that. Yeah, in some well I think I I think I'm making the best version of the person you wish to be. Yes, indeed. I think the first thing thing and Chris Candies just made the point there. I think on on on the messages about again coaching and mentorship, as you've just said, David. But I think what we have concentrated on is actually getting the teachers of doctors who may call themselves a coach or mentor Whatever. We have to be careful of those definitions a little bit in healthcare because within across the healthcare professions, those terms mean different things and in some healthcare professions, in physio and in nursing, particularly the mentoring role. The coaching role is seen very discreetly as a particular thing, and and and I I wouldn't like to discredit any of those important things, but I I think I would like to make a distinction between, um just having a coaching role and a mentoring role, particular because it may be rather more informal. I would like to see reflective practice, Um uh, as we have described it, making people better surgeons through a disciplined process, um, setting down aims and intentions of educational growth and development between I would call a supervisor or a teacher and a supervisor, uh, somebody who is learning from you. And we've used those terms in our writing, particularly supervisor and supervisor, because that can apply in all sorts of different levels of learning. Um, and and and the agreement of what is expected out of that is quite important. And the thing we have concentrated on is growing your quality of professional judgment. Uh, and And if you look and I have done, if you look at the curricula that are out there, um, if you look at, uh the the the words from the GM see, the whole idea of professional judgment rarely appears. And even when it does, it's beginning to appear. Now it's being added into things. But even then, there is no indication of how this can be developed. What we are talking about, what is professional, I suspect David, you and I would have intrinsically and and and subconsciously very clear ideas about what good professional judgment is. And I think many of many of the senior clinicians around and and also many of the those in in in in learning programs would also understand what it was. But whether we articulate it and whether we make it clear about what it is we're trying to get persons up to the market in, in, in maturing, as clinicians actually is rarely described. In fact, I don't think it's ever described you. You eloquently described it as attending to the learners being their values and what they who they are as people in becoming and developing their personality, their character, the spirituality there, uh, drawing on the moral code of values and bringing that into the practice. Um, and this is this is different too. As you said, the knowledge and skills. Yeah, this is the ontological, the ontological element as distinct as supposedly, uh, epistemological. Indeed, indeed, And and and And that's, uh, that again, as you have alluded, it depends on that relationship with the trainer. Absolutely. Beginning you suggested that the training surgeon should find somebody where that they can build on that relationship so you can do encourage reflective practice and writing amongst training doctors. You said it's dangerous and can be, uh, disruptive. I would say, Would you encourage training doctors to reflect on their practice? Uh, well, the first the first thing I would do about reflective practice in this country in Britain and I can't speak for the rest of the world is to ban the word reflection from everything in education and go back to basic principles and to define what it is because it's become a little bit like a virus. It's everywhere. You have to reflect on everything. And that is actually, um uh uh awful, because it's it's it's actually reduced the quality of what this profoundly important thing to do. And we've made the distinction of calling it a reflection as a reflective practice as distinct from reflection. Yes, because as a practice, just like surgery is just like medicine is, it is underpinned by tradition, by quality, by actually a professional understanding of what the boundaries of good practice are and actually for the profession working on growing that profession, Chris has just mentioned the surgical curriculum embracing professional behaviors. Well, may I just bring up one of my other points that I would very much, uh, like some critique of which is that we make a distinction between conduct and behavior. Um, the word values doesn't appear that there are several things that happen within the current curriculum, the word values doesn't appear at all. It's almost been replaced by ethics. Uh, and and that's okay, but But of course, virtue ethics is coming into the whole process now because they're actually having to come back to the idea that we've lost values. And so ethics is coming back to embed you that. But we've also lost the idea of of of the difference between conduct and behavior. I think that we have absorbed the word behavior into our parlance without considering what it is. It is a psychology term, which is a superficial observation of what people do, what drives people to do. Things are far greater, and that comes back to the Invisibles and to your values, your expectations, your experience, who you are. Uh, those are the things that we have written about. So your your your your actions, which have now we've called behavior. Uh, I think, but we would say that behavior actually can miss the whole point of values. And I use the description of behavior with Children if you take I remember as a child being taken to Grandma's on Sunday afternoon for tea. Now you behave properly or you won't. You won't be able to go out to play with your friends when you get home, you know. So you put on the coat of good behavior, which we all know about, and yet it isn't driven by your values. It's driven by some extrinsic motivation to do it right, and that element is easy to manage because it doesn't mess. It may it may be rooted in values, and I think again, the more modern writing on behaviors and the psychological education processes are bringing that out. But conduct we would argue. Your conduct is driven by your inner conviction and your intrinsically driven, uh, beliefs and, um, ideas about how things should be done for the best in your situation is a surgeon for the best for the patient and for the for the society in which you work. And though that conduct back to what we've used Aristotle's idea of the disposition of furnaces being able to make wise decisions in the heat and fuss of everyday complex practice, that's what he was talking about, and actually that I think, resonates very nicely with With With With with the practice of of wise surgeons. You can't just behave the part. You have to be the part. And and I think that discussion is something that we don't have. You know, if you can look the part somehow, we don't seem to have gone out of that. I remember very clearly just alluding to the point you made about women's surgeons and men surgeons. And I've had a great career and I've loved the people I've worked with. And I've worked for some fantastic people, men and women. Um, but, you know, when the boys passed the fellowship, they turned up in there three piece suits looking smart, you know? And they actually say to me, you know, pass from fellowship, You know that the ladies couldn't quite do the same thing, but we knew what it went, and we had an amusing conversation about it. But you can't just behave the part. You have to be the part, and we all know those who are what they value and what they claim to be. They're driven values and those who aren't and and it it reminds me of the story I quoted by Hamed Ali. He said, I'm not interested in how people treat me. I'm interested in how they treat the waiter at the table, and it it therefore, that's the real person. And I think of Barack Obama stopping on the stairs to talk to the the cleaner on the stairs. And that's where the that is the value. This is difficult then to codify or measure or quantify as part of an educational process, isn't it? And in the educational process, we're very keen on defining outcomes in measuring things. Well, what you describe cannot be measured. You can write and reflect on this. It can't be measured. But he can be felt indeed. And it can't be measured by a number or by a metric, that is codify a ble, yes, and part of the great catastrophe. I think of the last 30 years. I'm part of that and I admit my mistakes. But I've certainly, for the last 20 years I have been a thorn in the fresh of many who actually want to codify everything. Uh, and part of our metrics of even actually getting people passed the bar in surgical practice nowadays is how many of numbers have you done? Have you got up to write levels and everything else, and that can actually miss the whole point of, actually, whether we're developing people to understand themselves and understand their role in really everyday practice. So, no, you can't measure it, but you can describe it and you can see trends of how it develops in people over time. One of the things about the reflective practice process that we've described is that if you use this as part of, um, a program of education over a period of six and certainly 12 months, if you work with individual young doctors and get them to write in this particular way over a period of time, you can see the pattern of how they're developing. They can see the pattern for themselves of how they're developing, and that's even more powerful than you telling them how they're developing. Um, and and so you can build up a picture of of that growth over time, provided you have set down within the idea of what it is that you mean by good Soundwise professional judgment and what you don't and in how written, we try to define the definitions that we've made of it, our our own, but they are based on particularly the work of Aristotle and particularly exploring my practice and the practice of my colleagues. So I think you can't measure it by metrics, but you can describe it and dare I say it in some gray head, old fashioned surgeons. I think that's what they looked for when they chose people as senior registrars of who they wanted to work in their hospital and whether we like that or not. Um, the modern ways of doing things have almost sanitized the processes of selection and developmental, um, markers of growth, which have excluded those things, I think, to the detriment of the young learners, because I think they are being given short changed activities. They are the best that we have. They are the future of our profession. They should be having the best of what we can give them. And I still don't think they are. I have to agree with you that Chris Cuddy's said. You're talking about the process of journaling during supervision with this writing. Uh, I know I know Chris is a sense of the Black Belt Academy, and he's very good and registered coach and mentor uh, and, uh, talk, uh, reflecting and writing and seeing that development. And as you've said in your book, when written word carries a lot more norms perhaps, well, Britain, the written word carries more nuance. But the written word if you write and, you know, we've all heard this. In fact, I was told by the head of education at the College of Surgeons early in two thousands. There's no point in trying to get surgeons too, right, Linda? They can't write. Well, they do. Right? And I can tell you they right. Very well. All of them. Okay, I've sat in classrooms of all sorts of levels of, uh, well, all sorts of range of of doctors at senior level who say I can't write. I'm here to learn how to write, and then you set them off on this process, and they can't stop writing. The thing about writing is everybody can do it if you, um if you're if you've come out of medical school, you can write. You might not right. Very well. But you can write you can be talked to, right. It then can be refined at a later date, just like if you're writing a paper for a journal. You don't send the first draft after the editors, you get a very snotty response. I believe if you did, um, and you refine it. What's more, you can go back to it and look at it again. And that's the difference between oral conversations and learning things orally. Why do we have to write as the common question that we get asked all of the time? Well, there are benefits to writing. You can go back to it. You can refer to it yourself. You can use it as evidence of where you've come from, and supervisors can use it as evidence of actually, um, saying or accounting or evidencing why they've made statements about the development of particular individuals in their charge. So writing is very powerful, have done well, and people can do it doesn't have to be fancy writing a book sort of level, but it has to be sentences which are, you know, proper, properly constructed and make sense. You know, um, we can even cope without commas and full stops if you want to. But what one would like to think that the British system of education of English might allow people to do that. And people can do it. People can do it. There's a lot of space within the British system for writing reflections in the I S E P process. Although it is very formulaic and it is regarded as a tick box exercise, it can be with relative ease turned into a reflective exercise. But I think the reflective exercise we would argue for has to be disciplined. It should be part of a process. This has mentioned a bit about M C R. Process. I'm not sure I know what m see our processes. Uh, multi source, uh, multi consultant feedback. Oh, yeah, right. Yes. Well, multi consultant feedback. Ideally, I think if you're an individual, I mean, there is so much demand on young doctors these days about having to evidence themselves. I think it's gone over the top myself. Uh, we could do better with fewer, um, things, but things that were deeper in there, uh, exploration of understanding and development than currently some of the issues. That journaling is different to what we're doing here. Journaling you might use as recording what you've done, which is very useful as a reflective process for individual young doctors to then perhaps bring up to discussion's about the development of their practice with their supervisor. I am very specifically, uh, committed, um, convinced by using individual cases of a young doctors practice nothing young doctors like more than talking about cases in their practice and young doctors and no different to gray heads like me. Um, but, uh, it is a very good place to start, and the conversations that you can have with people are fascinating. If you as the supervisor, have the courage, the knowledge and the confidence to talk about things that that person has written because you're not actually talking on your hoof about a conversation you're having, you're actually the process that we use is to get a learner to write something to share it with you before you have your 40 minute conversation with them. And if that 40 minutes is spent you as the senior talking about key points within that written text, it is amazing the depth and the breadth of what you discuss with that individual. And I can tell you many of them, um and you've heard me say before, David, I've had a conversation with a trainee 10 years qualified in the last two years who had never had an hour's conversation with a senior consultant ever in his career. And the conversations that I had with that young man who was a perfectly good young man, um, were profound, really, and changed the way he saw things. And and and we have to do it. You don't need hours to do it. The work should mainly be done by the learner, and the teacher should be there. 40 minutes, 45 minutes of conversation focused on their writing can change people's way of seeing who they are and how they fit into the system and can inform you as the supervisor where they go next. And as you've already alluded to, not every teacher can do this, and not every one should be a teacher, as you've described. Indeed, unless they've been through a process of learning how to do it, and I would like to see, I would like to see, um, the idea, certainly that we promote because we've tested them now. Over many years I've taught it to hundreds of senior consultants. They all come very cynical There's nothing anybody can say to me anymore. Not that there ever much was, uh, that can upset me or set me off on on an anxious trail. Really? Um, you know, they all come with the same comments, and, uh, nobody has come back and said, This is a load of rubbish. It's hard work. It isn't, You know, it isn't. It isn't a breeze, but it is profoundly useful if people want to be good educators. And if the young doctors that are listening, um were to consider even exploring for themselves the way they think in the ways that we've written, that would help. But it is a much better practice if done with a good supervisor. I'm mindful of the time and also the context globally in which we find ourselves and a wise doctor and values. Would you like to comment on bringing your values to a context where you perhaps find a dissonance between your values and the context? Oh, yes, yes, yes, yes. Absolutely. And and in fact, this all started emerging when I started writing, and I was in the American Education Forum in the early two thousands, um, where reflection was a big thing for undergraduates, and they were actually beginning to talk about this moral distress, which became a really thing, which was dissonance between how the undergraduates saw the interactions of senior doctors and patient's, which seemed to go against their ideals of the doctor doing the best for the patient. And I think that moral distress of we weren't seeing it in Britain, and I still don't think we're absolute. We we weren't seeing it in educational terms in the same way, but it was coming across to me in the middle two thousands, uh, in postgraduate practice. And I think at the moment that is a significant part of where the whole distress and the dissonance of doctors is in the system in which they work. There is no doubt for many. For decades now, the idea of what you teach young doctors has been in disagreement with what clinicians think. They ought to be teaching young doctors, and they teach them because they have to pass the exam, which, of course, they have to pass the exam. But how you get there is actually the important element of how you develop them and how you how you develop their continuing ideals and their values. So dissonance does occur, I think distress, which which has been termed lack of resilience. I think it's distress more than lack of resilience. I I think I don't like the word resilience. I think it implies it can be reversed in some easy way. It can't. It's not a matter of strength. It's a matter of your coping with a dissonance between how you think things should be done and what you're being enforced to do. So so yes, it does occur, David and I think it's it's very distressing. I think the conversations that could be had between seniors and those in training could strengthen both sides. I I think this is a two way street between the learner and the teacher here, as is always between good teaching and and learning. It's not a one way street, you know. Um, um, and I think the strengthen the shared ideas of the two can harmonize better professional relationships and better, um, developmental processes for those that certainly are in in in the early years of their experience. I think that is a wonderful note to end on that we are in people growing business. Indeed. And both the teacher and the learner are growing, and together you can get the better out of each other. I'd like to thank Linda very much for her profound insights. In two training, I would like to see teachers like this in every hospital in every specialty. The context does need to enable that with time, space and reward. For those people who excel in teaching, is it more than just training absolutely about growing people and getting the best out of them and the best out of themselves and helping them to do it? And it's all part of their journey of mastery and knowledge of yourself. Linda, thank you very much indeed. For fabulous discussion. Thank you to the audience, too, for participating. And I'm delighted again that medal are able me to invite distinguished guest like Linda. And I'm really privileged that Linda has been the first on the Black Belt Academy of Surgical Skills. And of course, Gabriel. Thank you too, for being the producer of this. Thank you very much. And good luck for the future. To the black belt process. Thank you. Thank you very much. Linda. Bye bye. Thank you.