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BOTA Congress 2022 | Managing trainee needs to avoid burnout - TPD perspective | Prim Achan

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Summary

This on demand teaching session will bring medical professionals up to speed with the rapidly growing issue of burnout within their field and how to recognize early signs of it. Mr Premature Son, former clinical director of Barts Health and a subspecialist in lower limb joint surgery, is the Teaching Professional Delegate for Percival Pot rotation. He will draw on his experience to provide practical advice and tools on how to assess and avoid burnout. He will take us back in time to various theories and look at the history of burnout and its application to healthcare workers, research from McKinsey on the impact of burnout, and the distinctions between stress, depression and fatigue. With insights and advice from one of the most experienced clinicians in the field, this session is not one to be missed!

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Description

This video is about burnout and how to avoid it as an orthopaedic registrar. Prim Achan is the former clinical director at Barts Health and the TPD of the Percivall Pot orthopaedics rotation. He discusses the history of burnout and its relationship to work, as well as the changing landscape of healthcare and the impact it has on burnout. The speaker also discusses the symptoms of burnout and strategies for avoiding it, such as building resilience, finding support, and prioritizing self-care. He concludes by emphasizing the importance of addressing burnout in order to maintain a healthy work-life balance.

Learning objectives

Learning Objectives:

  1. To define burnout and the different stages it can occur in.
  2. To identify the symptoms of burnout across different professions.
  3. To explain the relationships between stress, depression and fatigue and burnout.
  4. To discuss strategies for recognizing and managing burnout, both individually and in a team.
  5. To utilize the MBI-GC burnout inventory to assess for burnout.
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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.

next we have Mr Premature Son who is known to many of you. For those who don't know him. He is the former clinical director of Barts Health and oversaw transformation of the orthopedic department there and the major trauma care that they provide in East London. He is also a former ABC fellow and has an interest and sub specialist interest in lower limb joint preservation surgery. Importantly for us here and those on the program. He's also the T p. D of the Percival Pot rotation, which in the last few years has consistently had some of the highest scoring applicants in the country applied to it. And that primarily is because of the help and support that he puts into his trainees the care and the direction that he provides. And it's an absolute pleasure to welcome here today to talk about what he does from a t p d perspective to help on the topic of burn out. Wow, that reminds me of yesterday evening. So hello, everyone. Uh, thank you, David, for asking me to come and talk. It's great to see so many of you here. I'm slightly troubled by the fact that Botha keep asking me to talk about what, in essence, very difficult subjects. Um, and burnout is one of them. Uh, So when they said to me, how do you avoid burnout? Um, this is kind of the image that I grew up with, which is, well, you know what is burnout? It's just you need to toughen up. You need to man up. You need to be resilient. Back in my day, we did X y and Zed. Um, but actually, we all know that's not true, right? Not only is it a changing landscape that we all work in, but actually, this is a real problem. And, um, I'm going to take you back a little bit in history now. So the term burnout was first coined by William Shakespeare. I think that's the first written evidence and it was talking about love. Um, and and the burnout in love was was linking in emotion with with your real life situation. But actually, by the time Graham Greene wrote the book a burnt out case, it was all about an architect who lived in London who got burnt out because of the pressures of work and then moved out to a leper colony in Congo, where he then interacted with a doctor there. So, you know, that was from, uh, from the sixties. Um, and there's a quote there, which is a doctor is not immune from the long despair of doing nothing. Well, um, and I think that kind of links into the sensation people have when they're having burnout. Right? And the first case report was in a psychology journal, Um, 1953 Schwartz and will. But it was the case of Ms Jones, who was a disillusioned, psychia psychiatric nurse. And it was all about the pressures that that she faced in common parlance. Now Freud in Burger is the person who came up with the term burnout linking it to again healthcare workers. So the origins are heavily embedded in what we do. Um, and this was around people who are working in a free hospital in Greenwich Village, uh, New York City, and how they became disillusioned with their inability to help their patient's, um, and facing burnout as a consequence. Now, of course, it's a well defined condition, and the key thing about this condition in in it's, uh, I c. D definition is the fact that it's linked to work. So there's a direct correlation between this concept of burnout being an occupational phenomenon. So it is the situation that you not only feel as an individual, but actually your work environment contributes to, um, now this. This is some work that literally has come out of McKinsey this week. So if any of you subscribe to McKinsey insights, one of the interesting things of looking at these big management consultancy ease and the work that they do is they spend an awful lot of money into this sort of project. So if it is big enough for them to be looking at it, the one thing is, it's real right. And they talk about this as being the great attrition. And, of course, they're interested in it outside of healthcare. But if you look at if you look at the numbers, they're looking across the world at what the impact of of burnout is, and the numbers are just growing consistently and they sit at about 25% not just within healthcare, but across all of the high performing uh, kind of academic requiring job places, Um, and that that's consistent across all of those countries. So it's not just a developed world problem. It's a developing world problem, too. And then, if you look at what the negative contributing factors are, a toxic workplace stands out by a country mile and what you mean by a toxic workplace they have defined for us. Which is, um, it is about employees feeling unveil you'd belittled or unsafe right, unfair or demeaning treatment, non inclusive behavior cut through competition, abusive management. Now, if I just without any of this background, read those terms out, they would absolute reason absolutely resonate in terms of the work places that were all involved in in the NHS, whether we like it or not. And the question to all of you is, what can you do to contribute to changing that? Because we can easily sit in this position of being victims and saying, Well, our managers do this. Our consultants do that. The NHS has no revenue, our patient's and our workload is ever increasing. But there is a role that we can play to change that if we recognize that a toxic workplace is something that all of us contribute to. Um So when we look at burnout in doctors, specifically, it definitely is a growing problem. Right? Um, this this is so there's a lot of work that was done around burn out that is pre covid. So the impact of covid is obviously just accelerated a lot of things. Um, but this is a paper from Elizabeth Pace. So she was the dean of the London dean ary when I was a trainee, Um, with Hamilton fairly. And they talk about what Stop. This is the sensation that doctors generally feel when they're coming up to burn out. It's what started out as an important, meaningful and challenging work becomes unpleasant, unfulfilling and meaningless. And it's these little transitions from energy into exhaustion. I think Tom touched a bit on that involve government into cynicism. Kind of. I can't do any more. Efficacy turns into ineffectiveness. These are all long standing traditions within our profession. In a way, um, and the question is, how do we recognize them early, And how do we move out? Right. And so this is something you may have seen before. Which is your stress levels at work relative to your performance. And you can see the optimum stress. You need some in order to perform well, so having no stress when you're as bright as you guys are all of you, uh, leads to some slight in activity in boredom. You don't get the best out of you, but you can see as you move into this transition when the stress level increases, your performance starts to tail away. And I think, Tom, you talked about the hierarchy of needs, right? So this is famous. I put it in my last, um, talk that I gave to bow to. But you can see that in order to perform right, which is what all of us want to do right up at the top. There are a lot of things that you need in this basic need equation, right that they described and actually things the physiological needs probably don't touch on it. But as soon as you go to the next level, which is around personal security and then you look of friendship and intimacy and self esteem and respect, you see that burnout can have a massive impact on what we're able to do. Uh, if we're aspiring either as trainees or his final doctors, um, final consultants to to perform Well, I touched on this earlier, which is the distinction between your personal burnout scenario versus the institutional. And I think one of the things we have to worry about as a collective group it's amazing to see the job that Botha are doing, um, in getting you all together and giving you a single voice is trying to change that work environment, right? But the personal situation is going to be unique to all of you. Um, so what are the early signs of burnout? You know, we've acknowledged it's real. These are some of the subtle changes that you might notice right, particularly sleep appetite, negative emotions. And Tom, you touched on that. And there are stages described. There are loads of papers around this, and I'll show you on the next stage that this is just a nice, convenient five stages. But majority of us are performing in that balancing act, right, and you can see it's a very early thing. The honeymoon stage is when you start a new job that could be an F one. It could be in court. It could be as a consultant, but when you get to chronic symptoms, the question is, is anyone picking them up before you get into these bits, which are the crisis and the investment? And that's where this, I think, is more interesting for me, which is expanding it into 12 stages. And you will recognize that actually, the first three or four we pretty much all deal with every day, right? It's this compulsion to prove working harder, neglecting your own personal needs because the work is calling for you. Uh, and the displacement of conflict you can see as you get into this bit, which is denial of emerging problems withdrawal. You're actually sinking into a bit of a hole, and without help, you won't get out of it, right, And it's very important, I think, for all of us working with colleagues, whether it's upwards or downwards, is to try and recognize these things before you get into the orange, let alone the red. Um, and this is another classification about stages of burn out. But again, if you look at subtle dissatisfaction and subconscious disregard the majority of doctors. If you look at the landscape now with the pensions issue, etcetera are all sitting in this in those two spaces, which is two out of five of this stage, two full blown trauma, right? So I I do think it's a real problem and it's there. Um, so everyone knows burnout is a big issue in healthcare. Um, physicians are disproportionately represented when you look at it, right, so nurses may have a part, but the rest of the hospital team that we all think you know, they're always saying we're all in this together. They don't experience the same the same thing. And this is another important slide. What burnout is not is it is not stress. It is not depression. It is not fatigue, right? It is something that is is well defined but is distinct from those things. Uh, and I think you have to recognize that not only in yourself, but in the people that that you might be working with If you're looking out for them. I put this slide on because one of the most common ways in which you assess burnout is the muscle AC burnout inventory, right? And if you go into the psychology space around burnout, then one of the big criticisms of this is it doesn't use any negative terms. And it is not a million miles away from the Occupational Depression inventory. Right? And the thing with that is it looks for suicidal ideation, and I think that's how serious for me it is, right. If people are on that journey going towards burn out. If they get into that mode where they're thinking like that, then it is a serious problem. And if we are unable to identify it early, we can end up with trainees. And we know as a profession we are disproportionate, right as doctors as a whole. Anethe anesthetists, of course, trump everybody else followed by psychiatrist. But surgeons are quite high up, right? In terms of the rates of suicide as a profession. Um, this is 2014 Mayo Clinic data. Okay, pre covid. Everything has accelerated since then, but 88% of doctors are moderately stressed. Um, if you work in isolations in right, so you don't work and the break up of the firm's and the way that we used to operate as a team is being broken down. You're forced to work rotors. You do work. Uh, night shifts a week at a time, possibly. Then you can see that your risk of burnout is much greater if you work in isolation as opposed to a team. Um, what are the factors that lead to doctor burnout? This is fairly consistent, and I'll put up a few slides like this, but too many bureaucratic tasks. Too many hours at work. Tom. You touched on this. Love the discipline, right, but that that's what you need. A lack of respect, insufficient compensation or reimbursement is a funny thing, right? And I can touch on it in the Q and A if you like. People always think that money is the driver, and it's a solution for everything. It isn't. Doctors aren't driven by money. It's just having enough money to not worry about the basic needs in life in that Maslow hierarchy. That's all that doctors need, right? And I think you have to remember that, um, back to McKinsey right again, they're doing work. This is their work. The first slide I put up from McKinsey was across all professions, but this is their work in healthcare. Specifically, you can see that 48% feel under stress, right? But the top group is once again a quarter, so it's around 25% of feeling frustration at work burnout symptoms or completely burnt out right And that quarter is is a significant number. If you think about it, it's one in four. Um, what puts healthcare practitioners at an increased risk? We've all seen this, which is a vicious cycle of not recognizing the boundaries, and Tom touched on it in a nice way. I would implore all of you to start setting these boundaries because we know what happens is if you're good at something. Paper writing is a classic example. Outside of your clinical work, if you got more people, lay that on you and you take on more and more tasks and the boundaries become blurred. And it's a kind of a recurring cycle of expectations, increasing more on your plate. You sacrifice more of your own personal need, right? And that time with the family or whatever the hobby is, um, so which physicians are most at risk. It'll be interesting. So this was Medscape data, and you see there that there's no orthopedic surgery there, but what you do see is that everyone is growing right in terms of the burnout rate from 2020 to 2021. Again, the contributory factors are pretty much the same. But then, if you look at one that does include orthopedic surgery, not only will you see is it is a factor, but it is growing too, right? So the burnout rates are growing again. Unfavorable organizational culture, administrative tasks, chaotic work environment. Uh, and some of it is conditioning too. Right? Were all taught to tolerate, uh, work environment that just because that's the space that we work in Um, this is looking at who's at increased risk, Right? And you will see there that a white male heterosexual is at less risk of burnout than obey. My don't like that term female LGBTQ and trainees versus consultants is the same discrepancy. So you're at greater risk as a trainee who falls into any of those categories, too. But 90% of us are falling into the category of being on that framework, right? So even in the early stages of being at risk, um, I put that slide of the picture at the top up, which is looking at burnout in vascular surgery trainees and the reason was that when they look at solutions, if you notice they're they've got no organized social program and no formal mentoring program, lower levels of social support, right? And it's the first time I've seen the recognition in a workplace about him, how important our face to face social interactions are. And any of you who are out either at the dinner or later last night will recognize that that does provide value in spending time with people who are facing the same challenges and doing it. And yet, if you look at formal work programs anywhere that we work, we phased out that kind of doctors mess. Junior doctors mess the activity that they do in the social program. And I would implore Botha to say This is actually a key part of what the offering for any training program and any hospital is is that you have a social program, right, and it's part it's part of your well being. Um, when you look at, um, orthopedic residents, right, you can see that the trainees is the blue versus the consultant. So I've touched on this before. You're a greater risk of burnout. Um, this is another paper but similar studies in terms of what they were looking at. But females are at greater risk of burnout and the feeling there, um, is nothing to do with, Oh, it's not that they they're not coping. That's not the story. Here it's. Females traditionally have greater attention to detail and find it harder to let go. So they take things back home, whereas males are able to detach a little bit more, not brilliantly, right? So it's still a problem. But for all the female trainees, that's that's something that you need to take away that you are at greater risk. Um, the ABC traveling fellows who came not not the current bunch, but the bunch before um, collected data on their travels, right, looking at orthopedics in different countries, that they were traveling to, uh and then collating the data. And again, it's very much around that 25% mark. Not much discrepancy between the US, the UK Candida, uh, and Australia. These are a selection of papers looking at orthopedic trainees in different countries. We've got Singapore, South Africa, the UK, all of them very similar data, uh, sets right In terms of that, 25% risk. And this is some work that some of my trainees did. So, um, Sandeep is not here, I think. Frank, where's Frank? Um, but, you know, he contributed to this work again. You would see that this is you guys. As a group who responded. 369 responses of British trainees 252 had moderate levels, but 81 which is again around that 25% mark, had severe signs of burnout. And that's a great concern to me. Um, all of the other stuff really fitted with the demographics I've described around insufficient staff numbers, overload of administrative work, uh, work overload being the kind of key factors that contribute to it. Um, slide showing that literally everyone who looks at this finds a very common theme. But when you look for solutions and that's what David asked me to talk about how to prevent burnout, it's hilarious because you look at this stuff and all of these advisory things professionally, uh, apply to people in in industries different to ours. And you almost look through that list and you think, God, I I can't do any of these things right in healthcare. You know, when you says learn to delegate, set up your workspace, manage your time. Um, there's something around. Get lots of rest. I love that one with the, uh, take regular breaks and days off, Um, you know, it just doesn't work with the workforce. So a lot of the solutions that are on offer to us don't really exist. Um, So when you look directly at what benefits physicians, then investing in leadership development is one of the key things, right? I think, um, we talked about less than full time working. It is very much the trend, and good trainers will support you to do that. Uh, medical technology is costly in this country, so we it's very difficult for us to implement the latest, uh, state of the art stuff and minimize your non clinician responsibilities. We'd love to see more of that, either automating it or delegating it to the administrative staff. I'll flip through that quickly. So when we look at burnout, one of the things that is is protective of burnout is resilience. And the other thing is grit. Okay? And these are both measurable now. Resilience Got a bad reputation, particularly I I saw in the kind of medical Twitter community, because resilience was being used as, uh, something that you guys needed to build in order to tolerate bad behavior at work. Right? So consultants who were behaving badly, uh, cultural organizational behavior that was unacceptable. That is not what resilience. For me resilience is about avoiding burnout because you care about your patient so you will all have to talk to a family where a child has died in a trauma or somebody's cancer has come back or somebody has passed away. And if you don't have a degree of resilience that we try and train you to have, then you're going to be at increased risk of burnout. Um, so some of the interventions that they proposed mindfulness is a very common one. Um, some people respond to it. I don't It doesn't mean I think it's a waste of time. It's a bit like when people ask me about taking glucosamine and chondroitin sulfate, right. If it works great, take it right. If it doesn't, then you've got to stop pretty early because it's not going to help you. Mindfulness is very similar. If you're one of those people who respond to it, then it's great for you. Forcing people who don't respond to do mindfulness is a waste of time. In fact, it aggravates their stress of anything. Um, Schwartz rounds take a lot of time reduction. Working hours we don't have the liberty to do. Um, identification of at risk individuals is is quite important. Um, I don't know if these are projecting, okay, but resilience is defined. But the key thing about the resilience, I would say is it's it's evidence based, right, so that every person can have a measurable amount of resilience that can then be improved right with support. And one of the things you would say is that I like this quote, which is Everyone is on a staircase, and it may be that somebody is on the fourth step and somebody is on the first step. But we can all keep climbing that ladder to increase Our resilience was talking to someone in the pub yesterday about what is innate resilience that we have and what can be what can be delivered. And this bottom right quote, I think, is the key to what I was saying earlier, Which is you don't teach resilience by being bad to people and and them toughing it out and building resilience. You do it by supporting them right as a trainer. So grit is the other thing that is measurable, right, and each one of us can do. There's some online scores that will measure your grit. And it's not about if you have a lot of grit that you're great. And if you have low grit, your not it's If you have low grit, then you need to recognize it because you can be supported as a T P D. Identifying people who have a lower grit score will help, because that is a real risk factor for burnout. And there are a number of papers that that look at grit in residents, particularly in surgery to show That's my own score there. I thought I'd get higher. To be honest, Um, this is another thing, which is effective adaptability. So if you're flexible and adaptable at in your training program, then the idea is that you will actually build more resilience and be resistive to burn out. But it doesn't compensate enough in in environments that are toxic. So however adaptable you are, it's not enough to take the pressure away. Is what? So I come back to this having told you all the background, how do you avoid it? Um, this is what my training program looked like in in the 19 eighties, right? And what you see there is is almost just one person. It's a white public school boy dressed in black tie. Probably played rugby, you know, a member of the local golf club. So if it is one person then actually advocating as a T. P. D. What the protection for burnout is might be simple, right? But if you look at my training program now, since you know we've seen a massive transition right, and this is an active transition on my program to increase its diversity and increase still the best people we want to recruit the best people. But once you've got that group, you can see that by definition, it's not one answer that is going to solve all their problems. And so I teach in a clinical leadership program for the consultants at Bart's, and I've divided up into three modules. One is leading yourself. One is leading teams and one is leading systems. And leading yourself is probably the most important thing for all of you to learn, right? And if you take the 14 500 C E. O s, then they know how to lead teams. And they know how to lead within their system, where they grow in leadership training, coaching, mentoring is all about leading themselves right, And that's a journey of discovery. And I think some of you may have seen me talk about the Djuhari window about what's known to yourself and what's the unknown? Um, it is a crucial part of you recognizing what it is that you aspire to and what it is that's going to make you happy at work. Um, so, uh, knowing yourself I think, is the key thing. And this is an honesty journey that you can't really share with anyone apart from one mentor that you trust immensely. Most of you haven't even shared it with your partners and people who are very close to you. And that is what do you really want? Okay. And writing it down somewhere for yourself is going to be immensely helpful. And I don't just mean What do you want in terms of your career? So this I put this slide up because when David asked me, he he came and said, Can I can I take six months off to cycle around the world? And basically, I have trainees coming and asking me all this stuff, and my first response is no right? No. And they're always a bit disappointed. They said, Oh, God, we thought you were a cooler TPD in that, um, and the reason I say no is you need to sell it to me, right? You need to show me that you have thought through what you're gonna do, because I think there is immense value in all of these things. But if you're not setting out to do it because of that value, then you haven't thought it through. And it may not be the right thing for you to do, right. But think through. So have a really clear strategy of why you're doing what you're doing. And, you know, if Tom was my trainee and he hadn't had that s h o year out, it may well have been that we had a discussion he took that year. out in the middle of his training to go and do the ice skating stuff and refresh and recharge. But we have to think of what are you going to put down? And the thing is that conversation once you've you've worked through it and you've justified it to me in that fashion. By the time you apply to the Dean ary, they sign it off because it is so well constructed and well thought through that actually, they can see what the value it's providing to you is in whichever one of those spaces. Um And so when I ask you to say, What do you want? We touched on the clinical work. This is a A grid. I draw for all of my senior trainees. So a lot of you guys haven't seen it yet. But this is when you're thinking about your consultant job, right? And I say to you, what consultant job do you want? This is how you need to think of it. The consultant job is going to offer you clinical work. It's going to offer you non clinical medical work. So that's if you're a researcher and education list. Then there are needs in your consultant job that your friends and your family and your your your support system need. And then they're actually selfish needs to. And these two aren't the same, right? What your friends and family need or what your family expects of you or what you want to give them is very distinct from what you want, right, and that is important, too. And you need to factor all of these things in to the consultant job that you apply for, because only you really know the answers to those right. And for me, when you say, Are your trainees successful? They're only successful. If they get what they wanted. They're not successful. If they get a teaching hospital job or they get a professorship, that's not success. Success is getting the job that you wanted that filled the criteria that you wanted for yourself, right? And that could be a D. G H. Job doing something very quiet, maybe less than full time, because you've got these other interests for me that is more successful than the person who got the teaching hospital job that looks high caliber and they're going on the lecture circuit. If that job doesn't fulfill their criteria. Right? So it is a very curated thing that is very specific for all of you. Um and I put these slides up now because these are different houses you could live in, right? And each of us, at some point in our life, have probably thought when I get the job that I want and I settle down, this is the house, and you probably haven't written down or even taken a photo of what the house might look like. But if you don't get that house right, you're always going to be unhappy, right? And the same is true of how you get to work. There are people amongst us and and don't judge them. What I'm asking you to do is to have clarity on what you want, right? I remember when I was first a consultant. I used to take the bus. I still do, um, take public transport to work. But I was waiting at the bus stop for a bus and a plastic surgeon came out and said, What are you doing? I said, I'm waiting for the bus. He said, Do you need some money for a taxi? Um so So don't judge people. And and And this is holidays, right? There are some people I know who just love going up to the Yorkshire Dales and their family holidays, camping in the rain and walking through mud. And there are other people who love going to the Four Seasons, uh, in Southeast Asia and having a luxury trip. It is not about judging what other people think is right for you. It's knowing what kind of holidays you want, what kind of house you want to live in, how your commute needs to look. And then you need to get that because if you don't get that, then it's going to contribute to unhappiness at work. Um, I'm almost done. Um, this is a book by a guy called Daniel Pink, which is around motivation, right? So it's called Drive, and he What he's trying to do is understand what drives brilliant people. And he says there are three factors to it, right? Um, this is based on some studies that were done kind of in the early sixties, where they gave monkeys a task so through through the 19 hundreds, the whole concept of rewarding clever people was either you give them a bonus, so you innovate them the carrot, which is financial bonuses in the city, or you drive them with a stick. So you hit them from behind and say we're going to sack the bottom 10%. Um, what they saw with monkey studies is the reward works for about three or four cycles, and then it doesn't matter once they've done it. If they're bright, whatever the task is, how much more you reward them, they're not really interested or motivated to do it. Okay? And that's what promoted this study, which is largely, uh, this kind of work. But actually, what motivates most of you, you'll be surprised to know, is three things right. One is purpose and in healthcare purposes, fairly straightforward. This is us wanting to help our patient's right. It governs us. Then there is something about mastery which is wanting to be very good at what you do. So whatever task we give to you deep down each one of you, if I show you how to fix the distal radius or two, whether you like it or not, you want to get better at that right? That's an inane, innate thing that all of us have in surgery. So you want to be a master of what you do, and then the last thing is autonomy. And this is one of my gripes with things like curved and boast guidelines. Is is they're taking away your autonomy and with the mastery with robotic surgery, they're taking away your mastery. And these are the two things that actually drive you. And in his book, he talks about two types of work. One is algorithmic work, which is where you you take somebody and they just follow an algorithm, and they describe it as someone at a Tesco check out, right, so they just scan the thing, and that's that's what they do. And there's heuristic work, which is where there's a problem and you take a bright person. You say, Solve this problem. And traditionally, medicine, particularly orthopedic surgery, has been really heuristic and not at all algorithmic. And we have to work because all of these guidelines and these definitions and robotics and artificial intelligence is all moving us from a heuristic profession to an algorithmic profession. And that's not a good thing because you will lose your motivation, Um, and and that's a concern for me. So, as I said before, this is a very important thing for British orthopedics at the moment, and we're moving in that direction. You can see I'm standing here. I'm a brown guy. I spent some time growing up in India, Uh, and yet I run a training program and I'm given the opportunity to talk to you. But in absorbing diversity, we have to acknowledge that that presents more challenges for us. So when we say if we're going to be more diverse than we need load more solutions to avoid burnout than just the single solution that they needed in that picture that I showed you. Um, and I like this as a final slide, which is you've all seen this, especially the education. It's about Miller's pyramid. So Miller was a medic in Chicago, Um, who's head of education at the University of Chicago, who described this pyramid around competency, right? And this guy, Jeremy Ferguson, who's actually a G P down the South Coast, actually used that about a hidden pyramid that leads into burnout where people's vulnerability and this is the people around you. They have different layers of vulnerability. And although you look at the top bit of the pyramid and that's largely our responsibility as trainers and T. P. D s, I would put it to you that the bottom half of the pyramid is all our responsibility. So when you see colleagues who are slipping into that bit of vulnerability, that is going to lead to burnout if you can't help, I think we all have a responsibility to flag it up to somebody who can. Right? Because if we don't look out for each other, uh, nobody's going to Thanks very much. It's fantastic. Mr. Chan, Thank you so much for that yet hugely insightful and thoroughly well researched presentation. Thank you. Do you have any questions for Mr Action? Thanks, Mr. Uh, quick question. Why do you think it's taking so long for us to get to this stage? And where do you think we're going to go from here? Is it instead of being, um, you know, supported to go less than full time? We'll be encouraged. For example, where do you think we're heading? Uh, look, the fact with the backlogs and all of that stuff is nobody's going to encourage anybody to do anything apart from work your nuts off. Right. But, um, what I would say is, if it occurs to you that you want to, the landscape is very different. Right? So in in my day, I think if you went to a boss, uh, and you said I'd like some type time off to be with my family, right? The parental leave That would almost be career ending. I would say right in that original slide I showed you when alan letting ran my program. Whereas now you know, I know the T. P. D s. I know the S a c. I'm a member of both. Um they would be hugely supportive, and it's it's really good to see. Why is it taking so long to get here? I don't I don't know Is the honest answer for me it was very much when I was sitting where you are, or even before that. Um, it was a great challenge for me. I looked up and there were no I was the first Brown person on the personal pop program, right? I was the first Brown consultant to be appointed at Bart's. Um I didn't have role models, right, But my approach at that point was, I'm as good as anyone here. I'm going to get there and try and change it. That's always been My aspiration is get there and try and change it so I can tell you that the change now is not just down to me, right? But if you look around you, you will see that as people infiltrate, change has to follow right and equally the people at the top. Looking down there is a point at which they probably didn't look and and see it because it was just the way things were. But the minute it has been flagged up, I have to say, I mean, I look at Rob who I look up to Deborah Eastwood, who's spoken to you. But there are There are a lot of people who who have been through this and not necessarily seen it. But it's their response to when it's been shown to them. That has been inspiring for me because it has been hugely supportive and so I think, yeah, I don't really answer your question in terms of why is it taking so long? But I I think we're in a great place now and that people do recognize it. And whatever your needs are as individuals, there are people you can go and talk to. And nobody is going to say if you do that, you're never working in the south of England. Somebody said that to me. You're never working in the south of England again. Um, yeah. Thank very much indeed for that talk. Who are you? Uh, well from Well, yeah, um I was wondering, talks anything. We've got a responsibility. And, uh, you talked about people's choosing people's job at the end of the road as an orthopedic consultant and understanding what you want. And I'm running to what extent? You think that a lot of a lot of the decision about what we want and what we get has been made a long time ago when we actually entered orthopedics in the first place. And I'm wondering to what extent we should be more up front with people who are going to go down different specialty training routes and kind of be be more open about what things might might involve in the future and be a bit more so I would challenge you slightly in saying that that decision. So I think the decision to do orthopedics has narrowed you down to a certain clinical space, right? But even with an orthopedics, there's a huge spectrum of that top left corner of what your clinical work is. I don't think at any point, even where I sit, now that I've not got choices in the other three spaces, right? And I think that's constantly evolving and and it changes as you know, as Tom said when he had a baby that changed everything for him. There are other people for whom having a child means very little in terms of their professional direction, right, so there's a whole spectrum in between, so I don't think any of it's fixed any of it's the same for two people. And that's the challenge is when you say, I think we all know when we're going to, um, an orthopedic career. I'm always amazed at what the aspirations different people are. You know, there are people who are just Ian Bailey. I don't I don't know if you know the name. He's a very famous shoulder surgeon who retired. He never moved from his house. He lived in a small, semi detached house in Kenton, in Harrow, Right? It's not a particularly affluent area. He lived there when he was a registrar, and they never moved and people would go. And this this guy's world famous, one of the best shoulder surgeons in the world. People would go to his house and I go, Oh, my God, He lives in this really small place. He was happy, right? He didn't need any of those houses I put up there, right? But other people wouldn't be happy, so I don't think you can. It'll always amaze you about what people want and what makes them happy. But my point is, this is if you know what you want and you don't get it, then you're going to be unhappy, and that's going to contribute to burn out. We'll have one last question, if you can. Just in the interest of time, just while that's coming, I do know will. But he chose not to come onto our program, which is why I said, Who are you? Hi, Mr Asher. And thank you very much for your talk. My question was around. How you chose to run your own training program. Is there anything based on what you've said? And I know you've said there's no bespoke solution for all your trainees. Anything you've introduced into your program to try and prevent this or help with this this issue so well, so one of the advantages I have and this is no disrespect to any other of the T. P. D s that I've run a very small program. And one of the things I've been doing it for 12 years now, which is one of the longest serving T P. D s, um, is I know all my trainees personally, right? So they come to my house or I meet with them for a coffee and write the start before they start on the program. We sit down and we talk about life, and then we meet regularly and I touch base so I could tell you stuff about, you know, their family situation, what their interests are all all of the stuff around them, and the reason I take that interest and I can't do it You can't mentor many people because you're investing in them is to identify stuff like This is what it is that drives them, what it is that's going to help them, where they're falling behind, where they need support. Um, and in that 12 years, I've had everything right, Marriages fall apart, cancer diagnoses, people wanting to give up for a variety of reasons. Young people having heart attacks. And I've been through that journey with all of them. And what I would say to you is find a mental who you're willing and you're trusting enough to open up to so that they know you. And if they take a vested interest in you, then that's that's the biggest step. Now, some of these T pds just don't can't do that. I I don't think if you've got 60 trainees on your program that you can do that. I struggle with my 23. But I tell you what. It's very important to me, and that's what I've done differently on my program. And so each one of them I'm having a different conversation. I'm not saying this is what you need to do a p G certain education and then going to a fellowship at writing tongue and go for this job where Gant chinos and a blue blazer know right? It's It's literally Each one has a different story because I'm trying to get them to be the best person they can, but also to identify what it is that they want. Fantastic. Mr. Uh, thank you so very much for your time. It's been a real privilege to have you with us here today.