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Okay, good morning everybody. My name is Henry Marsh. I'm a retired neurosurgeon, although I still lecture a lot and teach. In fact, I'm just back from spending two weeks in Ukraine. The title of this talk is Patient Safety on the Program. But what this really is about is this title you're seeing. Now, other people are better at seeing my mistakes than I am. And as the excellent American surgical writer, Atal go Wandy has said the problem is not stopping bad doctors making mistakes. The problem is stopping good doctors making mistakes. And of course, the point is that medicine is dangerous. It's dangerous for our patient's, it's dangerous for their families and you'll discover as the years go by. It's dangerous for us as well. A recent study from mistakes and Johns Hopkins estimated I finally slightly hard to believe, but it's a robust study. They reckoned about quarter of a million people every year in America alone die from medical errors. These are good doctors, good nurse is doing their best and yet they make mistakes and patient's die. So these researchers reckon that medical errors so called iatrogenic um problems caused by doctors and nurses are the third leasing course of death after heart disease and cancer. So it's a huge problem. Now, there are of course various types of the a tra genic doctor induced errors. There are medication areas, writing up the wrong drug or the wrong dosage. There are surgical mistakes which is a neurosurgeon I'm bitterly familiar with and I'll give you some examples as the talk goes on, there is misdiagnosis which particularly applies for instances to family doctors and their infections which are often missed or treated inappropriately as medical students and young doctors and even as older doctors, we have a huge body of factual information to learn. This is the standard textbook for neurosurgery. Nobody can possibly know it all. But there is a vast amount of factual knowledge which we need to absorb. Although now with the internet is more readily accessible than when I was a trainee. But the trouble is we have to use judgment to use this factual knowledge. Most medical decisions. In fact, all medical decisions almost are not black or white, they're not either or there are many shades of gray between, for instance, recommending surgery and not recommending a surgery. Using a neurosurgical example. You'll have to forgive me for neurosurgical examples, but I am a neurosurgeon on the left. We see a classical extradural hematoma. In fact, they're rather rare. It's a head injury when the skull has been fractured. That many MGS, the juror underneath is torn and typically the middle meningeal artery bleeds and causes an expanding hematoma. So the brain itself is not damaged by the initial head injury. But as the hematoma gets bigger, it will cause life threatening compression of the brain. The decision making here is easy. If we don't operate, the patient will die. If we do operate quickly, it often is a matter of minutes, we will save the patient's life. And because there was no initial brain damage, the patient hopefully will make a complete recovery. But that's unusual. The much more common situation is you have a hemorrhage within the brain itself. This has caused extensive brain damage. If we operate, probably the patient will survive but be severely disabled. If we don't operate, the patient probably will desert die and maybe left even more disabled than if he didn't operate. And the problem is, should we operate? How old is the patient? What more co morbidities do they have? This is not a simple decision. You can make it a simple decision and operate upon everybody. But if you do that, you will cause a lot of morbidity and damage. And we can't even appeal the good robust evidence. There are no clinical trials telling us whether it's better to operate or not. All the trials done have shown no difference between operating and not operating. So how do we decide the answer is it's very difficult. So the point about this is medicine is all about uncertainty and estimating probabilities are patient's one certainty. When I was diagnosed with advanced cancer myself, I want to know what would happen to me. But all the doctors can tell me is, well, there's an X percentage of living that long. A white percentage of living that long. We never know for certain. Not until the very end. This is an example of a terrible postoperative complication, which was entirely my fault. Um And I'll come back to it, come back to it later. We make mistakes. And of course, in neurosurgery, the mistakes are very terrible and dramatic, but every medical specialty has mistakes. The psychiatrist is when a patient commit suicide. For GPS is when they miss a fatal diagnosis and so on and so forth. Here is another example of another catastrophic is a mistake I made when I misinterpreted a brain scan showing some shunts plastic tubing in the brain. And as a result, the patient suffered a terrible hemorrhage. So mistakes happen even though you're doing your best. And as the great French surgeon, Licorice wrote every surgeon carries within himself a small cemetery, Jewish. You must go from time to time to contemplate. It's a place full of bitterness and regret, a place where he must look for an explanation for his failures. And even in retirement now, I stopped operating three years ago. I still a day will never pass without my remembering. Patient's where I feel for one reason or another. I failed. This comes with the territory. Medicine is dangerous to be a good doctor is difficult. Now, we're all familiar with optical illusions, so called Muller Lear illusion. These two lines, in fact of the same length, but our brain automatically is hardwired to think that one is shorter than that one. However hard you look at that they still look a different length. Similarly square A is actually the same shade of gray square be. But again, our visual cortex is pre programmed because of the checkerboard pattern because of a shadow to see them as being a different color perception is in large part expectation. Now, the problem is this doesn't just apply to a simple optical illusions. You may have come across the famous Invisible Carrillo to experiment. I can't show you the video but people are asked to count the number of times these players and white T shirts pass the ball to each other. And then in the middle of the video, a man runs into the middle of the room in a gorilla suit and beats his chest. It's hard to believe. But 50% of people do not see the gorilla because they're concentrating so hard on the people in white T shirts visit so called in attentional blindness. So we have optical illusions, we have in attentional blindness and we have what are called cognitive biases. These are hardwired, inbuilt errors in thinking and estimating probabilities and medicine. As I said, earlier is all about using all the knowledge we have to estimate probabilities, we have to make an informed guess about what will happen if the patient has the operation, if the patient doesn't have the operation to use a surgical example. And this is all dealt with in this incredibly important book. Slightly hard going in places. But it's really worth reading. Thinking Fast and Slow by Danny Kerr Newman, who got the Nobel Prize in Economics. Although he's a psychologist and he showed when we have to estimate probabilities were often inconsistent. There he is. And there's a good, very good book about it as well. There are many of these so called cognitive biases. Almost all of them apply to surgical decision making and medical decision making. I'll illustrate one or two. There's a halo effect. This is if we like somebody for one particular quality, we tend to overestimate their ability at other things. As a trainer, as a senior surgeon, you have to decide how much to delegate operations to your trainees. If you don't delegate anything, they'll never learn. Some surgeons find this very difficult. But if you, you have to make a judgment as to how good your train is. And in the early years of my time as a consultant, I made some terrible mistakes and I thought my trainees were more competent than they actually were because I like them. Um And as the years went by, I got better at knowing at being detached and objective about what my trainees really work capable of the availability, heuristic. It's rather a bit of a mouthful. What it simply means is that when we face a problem, our estimates of the probabilities of what will happen are distorted by the emotional consequences of when we faced a similar problem in the past. In other words, if you're an obstetrician and your last breech delivery, when terribly wrong, you'll probably have an unnecessarily low threshold for doing a Cesarean section. Next time you see a breach and then that the priming effect in irrelevant information given to you immediately before you have to make a decision, will again distort your judgment. And there are many biases like this. Here is an example of what's called the framing effect. The way information is presented to us is often just as important as the actual content of the information. It's a famous Carmen, Carmen and Chesky, his colleague, question problem one, you are preparing for the outbreak of an unusual Asian disease. Funny enough. This is written years before the pandemic which is expected to kill 600 people and you have to alternative programs to combat it. And you have to make a choice between a certainty and a probability. If you use program, a 200 people will definitely be saved for sure. If you go over program be, there's a third probability 600 people will be safe, but there's a two thirds probability, but no people will be saved. Now, there's no right or wrong answer to this. But it's a question of how you feel about a gamble as opposed to a certainty. Almost everybody. And this has been given to doctors, non doctors, epidemiologists all over the world. Almost everybody goes for a program. A we'd rather definitely save 200 people rather than run the risk of losing everybody. And then the next question is I have had two other programs, programs, see, 400 people will definitely die. Program D well, there's a third probability nobody will die. And a two thirds probability 600 people die. And now almost everybody pops four programs. See, sorry, I mean, program program D it's our program D the probability. Why is that? We'll simply, we've changed the words program A was 200 people will be saved. Programs, see, 400 people will die. So we're inconsistent and it's a very, very standard way human way of thinking. So this is the coming back to this terrible slide I showed you earlier. This is a woman, a young woman with a benign condition called a chiari malformation. At the base of the skull operation went perfectly. I've done at least 100 identical operations without serious problems. He goes home after a few days, comes back a week later, ill. In a way, I don't, it's an odd clinical picture. I was confused and I did a scan which showed that and I it was staring me in the face. There is pus around the brain step, but cerebellum has been squeezed out of the skull. This is a catastrophe and yet I, I didn't see it. I was so in attentional, I was biased by my availability, heuristic and I delayed re operating. It is called a post operative subdural empyema. Incredibly rare. I've never seen one before. I've never seen one since and she was left utterly and completely disabled or trashed as my American trainees used to call it. And if I had asked somebody else to look at it, they would not have had my biases. And then I said, Henry look, you know, is obviously as a terrible post operative infection. And here's another example, an elderly man who presents of a very long history of confusion, scan shows a rare but well recognized neurosurgical problem of a colloid cyst which can cause severe hydrocephalus. And one presentation could be confusion, but the degree of hydro careful is actually is quite slight. Um And, and the brain isn't particularly swollen, but I was one of the last was shortly before I retired. My training had been appointed to replace me. He'd never done a colloid cyst operation was very keen. I should take him through one. So I said, sure we'll do it and we operated removed a colloid cyst patient was much worse afterwards which was puzzling. And then in retrospect, look what's that going on here. So we then got another scan, an MRI scan. And in fact, the patient has a diffuse um white matter degenerative disease, which I misdiagnosed. And that again was the sort of framing effect of my trainee wanted to operate. I wanted to show him how to do it and we got the judgment wrong, easily done. So the beginning of wisdom is in the Bible somewhere. It says the Christian Bible, the beginning of wisdom is not fear of the Lord in my opinion. But of understanding, we all make mistakes. And in other words, coming back to the title of this talk, other people are better at saying my mistakes and I am and I'm better at seeing there's because they don't have my cognitive biases. They are emotionally less involved in my decision making. So we come to the subject of team working if other people are better at seeing my mistakes. And I am surely if it is a good argument for team working, the word team working certainly in England and the National Health Service has become terribly debased. It means sitting in boring committee is nobody making decisions or being bossed around myself, important managers, but true team working is something else. I prefer to call it being a good colleague and having a good colleague, you'll make better decisions, you'll make fewer mistakes is better for your mental health. The practice of medicine is very stressful, particularly in countries like England at the moment where the NHS is struggling because of lack of money. And you share experience and learning on the whole now. Certainly in England and Europe, young doctors work much shorter hours, although very intense than my generation. So it's taking much longer to acquire experience. And all branches of medicine are practical skills you learn by practicing it obviously, in the case of surgery because of the hand work, but it's all about experience because it's so much about uncertainty and unpredictability. So there are lots of very good arguments being a good colleague and having good colleagues. And of course, the first rule is you won't have good colleagues if you're not a good colleague yourself, but there are problems of team working. It's not a panacea for the problem of making mistakes. Firstly, if a team is too large as human beings, we work best in small groups. If the membership of a team is constantly changing, it's very difficult to establish a good functioning team. It needs good leadership because a good team is not about everybody agreeing. It's about conflict discussion, criticizing each other, but in a constructive way and that needs good leadership because that's going to work well. And good leadership is hard to find and rarely taught. I like this little picture, a traditional model of medicine and in many of the countries I've worked in over the years are very much like this. The employees are basically a pyramid and the bosses on top. Um I like the idea of a more modern structure where actually the leader is supporting and empowering the teen. This leaves us with the problem of responsibility. The leader has to carry, carry the can when things go wrong. Um This sort of pattern is becoming slightly better established, certainly in Western countries in medicine, but there are further problems, of course, of team working. A big one is personal conflicts and jealousy, particularly with surgeons, I think. Um And that's because of what I call the surgical ego, surgery tends to attract ambitious, maybe narcissistic driven people, which I certainly was when I was young. And it reminds me of, you know, um Snow white in the seven doors, the fairy story of the evil stepmother who is constantly looking in the mirror saying, am I the most beautiful person in the world? And all of us, the surgeons are also looking over our shoulder feeling a bit worried. Maybe we're not as good as we, we want to be. We're not as good as we, our patient's have to believe we are. Um And this often leads to jealousy and defensiveness and conflict between surgeons. And secondly, as surgeons, we have great power over our patient's. And there's a great historian, Lord Acton said, power corrupts and absolute power corrupts. Absolutely. So the surgical ego being self important is that a combination of defensiveness against your anxiety as your other people might be better than you. And also the fact you have such power of your patient's. You end up having an inflated opinion of how good you are. And yet at the same time to be a doctor, you need self confidence um to do the work. And then a third problem with team working is what's called diver psychologist group. Think this is an example of groupthink. It was a patient presented at the multidisciplinary team meeting shortly after I had retired from full time work. I was still working part time and going into the hospital. And this was at the brain tumor weekly meeting, a new case, very challenging difficult tumor called. Uh So our humanity of last tumor right down over the brain stem, my colleague had taken, my job had been appointed to replace me, was reluctant to operate. It was his patient and he said, oh, it's very dangerous. Um We ought to have a patient should have radiotherapy and the radiotherapist then. All right, we'll do it now. I said, well, actually, you know, I've done operations like this is dangerous. But no, I think we, I could operate, I'll help you do it. But I was hesitant because I didn't want to offend my colleague and make him feel I was saying I'm better than you are. I was more experienced. So I didn't really push it and the patient did disastrous and the radiotherapy did not work and everything went horribly wrong. Now, as an example, a group thinking, but I put the interest of the group ahead of my judgment as to what was best for the patient. So that again is one of the problems with, with team thinking, with teamwork. Now, this is a book you should all read. Hopefully you can find it called Black box thinking. And it's about the way we learn most from mistakes. And the most successful projects in human life often are based on recognizing mistakes and side uses many examples of the airline industry which I'll talk about in a moment. This is a who checklist, believe it or not. When it was introduced into my hospital about 15 years ago, I was very sniffy and angry. I said, well, I don't want, I don't keep telling me whether I'm operating on the right side or not, how to do things. And then my niece test was a very good friend, Henry. You did want to start an operation on the wrong side. Uh And the point about this story is why was I say reluctant to accept something as simple as a checklist? Which could only and the answer is it's so difficult to think badly of oneself. You know, we all of these optimists called the optimism by us, we all need and I think we're better than we are checking. Well, I have criticisms of a checklist. I think it's better if it's designed by the people are going to use it in each individual department rather than the one size fits all imposed from above. But that's another story. But how stupid I was now side quote several um famous airline crashes. I used to be rather sniffy is the word critical about using aviation safety where there's this new blame culture as a model for medicine. The famous one famous crash was this one Korean Airlines landing in in bad conditions on the island of Guam in the Pacific. The on the radar on the ground wasn't working properly. And the black box recorder, you can hear the copilot saying to the pilot 200 m 150 m 50 m and then they're all dead. And the conclusion Korean Airlines had to draw withdraw from this was they had to retrain their crew so that the co pilot would dare to say to the fighter a boss we're about to crash. And what I took away from science book is highly trained, highly skilled, highly motivated, good people can make terrible mistakes. All of you as doctors will make terrible mistakes at some stage in your career is because the work is intrinsically dangerous is what attracts many of us to it. We like the risk. I certainly was drawn to neurosurgery by that. But we need to understand we have this tendency to make mistakes and not just self criticism but criticism from colleagues is a terribly important part of trying to make things as safe as possible for our patient's. And this is all tied up with the fact that there is nothing more frightening for a patient in a frightened doctor. Nobody have told me this. When I was a young doctor, you can't just automatically realize that you have to radiate confidence and calm and competence to your patient's. Even when internally, you know, you're not as experienced or as good as the patient's desperately hope we are. And as the Great French epigram edis wrote the steadfastness of the wise is, but the art of keeping their agitation, which we would call stress locked in their hearts. And there are three ways of hiding stress. You could not have it in the first place. In which case, you're a psychopath because the stress of medicine is our act is our concern. Our patient's should not come to harm. It's our empathy which makes a work stressful and psychopaths typically don't have it. We can hide it from others from colleagues. And above all, we hide it from ourselves because the best way of coming overcoming stress is to deny it to ourselves. And there's a wonderful book by the great evolutionary theorist Bob Trevor's who was one of the originators of the famous selfish gene theory. Why? How do selfish genes produce altruistic organisms? Because we are altruistic organisms? And he says deception is everywhere in nature camouflaged were all parts of food chains, either prey or predators are often both. So it's everywhere in nature, but human beings were unique. Get dropped the eye in that capacity for self deception. Why are we so good at deceiving ourselves? And he says, self deception makes us better lions and therefore more successful. So he says evolution is hardwired us to have a tendency to deceive ourselves. And you don't have to look very far in the world to see this that hang on. Let's go back. It's very people who believe their own lies are very successful. Having said all that this is a child I operated upon. In fact, before the pandemic in Ukraine operation went wonderfully well tremendous. Well. When I was younger, I felt a great sense of triumph and a difficult operation. Right. Well, uh as time went by, I just felt great relief that things had got away with it, so to speak. And it also there was uh but obvious, sorry, there's the pleasure of teaching and training because I was actually teaching Ukrainian colleagues, helping them do the operation. But the next operation I did in that hospital went disastrously wrong and the child died from a post operative hemorrhage. And in a way that was my fault because I chosen not investigate what the post operative care would be like. And actually the post operative care was terrible and no proper analgesia BP, wind up post operative bleed disaster. But of course, the point is the triumphs or any triumphant because of the disaster's in neurosurgery. They're very obvious and terrible and dramatic with the supplies. As I said, at the beginning to order medicine, it is intrinsically dangerous, which is what makes it attractive and why if everything was easy in medicine, there'd be nothing very special about it. So, in many ways, being a good doctor is about balance, there's no easy, right or wrong answers. But rather than just one tight rope, we have to traverse. It's a whole series of balancing acts we have to perform. And in many ways, this became more obvious to me as I approached retirement, rather than as in the middle of it. When you're actually on a tightrope, you don't want to look down at the ground too much. You're more likely to lose your balance. And there's a whole series of tightropes where there's a risk of falling. All of us have to find a balance between compassion and caring for our patient's and being detached. You can get too involved and then you can't do the work. And the last thing patient's want is a doctor breaking down in tears. Um At the same time, you can become too cold and detached and lose your humanity. You have to find a balance between being a ambitious, dedicated, enthusiastic individual and being a good member of a team. All modern medicine is about teamwork. Now, I can't emphasize that strongly enough. You have to find a balance between your conscience. What's best for the individual patient and loyalty and even obedience to the system you work in. And the groupthink example I gave you as an example of that. If you can work in the country where state medicine is impoverished, annual patient's going to get good treatment by paying, you have to find a balance between his medicine, the vocation or is it a way of making money? Some doctors are saints, Not many, some doctors are rogues and Gangsters. Not many. This is another balance. We have to find, we have to find a balance between being self confident. So when we walk, if you're a surgeon, when you walk into the operating theater, you're not shaking with anxiety and nervousness, but being endlessly self critical as well. And if you're part of a good team, your colleagues will help you find that balance. You have to find a balance of patient's between being honest about what's on offer, how much treatment really will achieve. But at the same time giving them hope sometimes quite often in medicine, there isn't any hope and how you deal with that is incredibly difficult, is easy to lapse into overtreatment, which is a growing problem in modern medicine where both doctors and patient's find it difficult to say it's time to stop. And the problem often is with the doctors. If you do difficult things, dangerous things, you have to find a bath. Am I being brave or am I being reckless and the converse if you decide not to do it, are you being a coward or are you being wise? And finally, you have to find a balance between work and life. Medicine is a very demanding job. Most of my career, I had no balance. It was all work and no life and both in retrospect, my family and myself paid a price for that or I'm lucky. But now in old age, I get on very well with all my family. I scarcely deserve it. But that's another of these difficult balances. Um And it's very easy to fall off. It. Coming back to where I started, medicine is dangerous. But if there wouldn't, but there wouldn't be 100 and 70 dead bodies in deep freeze on mind Everest, there wouldn't be a queue to get to the top. If he wasn't dangerous. We have to understand that and realize that we are fallible. We make mistakes and that is the beginning of wisdom that's possible in Ukraine where I was working when I did the upper of a child is again one of the great joys of being a doctor for many of us. Not all of us is teaching were part of a great tradition. Everything we do has actually been developed by other doctors. We may feel very personal and self important about it, but it's all been developed over centuries by our predecessors. And if we're lucky, we may cast one or two small pedals on the pile ourselves. So I've enjoyed delivering this lecture arise. You're not probably for all students. You're not yet having to apply it. Um, but if I'm often asked, what if you were asked and what's your advice? Two young doctors. And I say, well, it's very simple. It's asked for help and to ask for help is not a sign of weakness. It's a sign of strength, you know, your limitations and hopefully you will work in departments where you're not look thought you're being pathetic or feeble by asking for help. I knew as a trainer that my most dangerous trainees were the ones who are self competent, who were better than they really were. I preferred my trainees to be slightly actions, act just excited, but to know their limitations. And I hope when you reach the end of your career as I've reached nine more or less, you'll look back on it and think how incredibly privileged we are to be doctors even though it's so often so very difficult. Thank you very much. Thank you very much doctor for an amazing lecture. I'm assuming you're open to taking questions. Yes. Yes. I'm happy to answer questions. Yeah. So if anyone has any questions, you can write them in the chat or you can use the reactions to raise your hands so you can ask out loud. Uh So please take the opportunity. I think Assad has a question when I mute yourself. Uh Yes, ma'am. Uh What is it like to uh part to recall in the medicine to give the bad news or the Asians other parents? Like, how is stuff like the first time or do you get a temperature to it? Um, well, you should never get used to it. If you get used to it, you're losing your humanity. Um It's, it's very difficult. You get certain England you get very little train, you get some training about it. Um And, and often these conversations are in private between one doctor and the patient and family. Um I asked, I said, my advice is asked for help. Do I have regrets? Yes, I have one big regret actually, which is that when I was doing outpatient clinics, I would never have anybody else with me other than the patient and the family because I wanted the experience with the interviewed not to be institutional. I think that was a mistake because my trainees could never see how I, how I spoke to patient's in terms of breaking bad news. I think I would say there are two simple rules, one is always sit down or three rules, never appear to be in a hurry and a bubble tolerate silence. Often the news is so terrible. Your the person you love is going to die or you have cancer, but the patient will be so the patient in the family will be so shocked by this there's really very little else to say at that time. And you want to have a tendency, which I, I have noticed in myself when I was younger and in other doctors is to talk too much poor patient and family are so shocked they can't think of anything to say or maybe they burst into tears. The tendency is either say that's it. Walk. I leave the room, ask the nurse to give them a cup of tea or to stop talking too much and going into technical detail just sitting there quietly listening to their grief and horror is probably the best thing you can do. And then as time goes by, you might be able to answer their questions, but it's much better to let them think about it and ask questions you answer rather than shower them with a lot of stuff about what dying is going to be like or what treatment may or may not help you. Really, the conversation in a way should be laid if possible by the patient or by the patient's family. Do you have another question? Hazard? Uh Yes, it was one of the uh biases you talked about. For example, if a patient uh sorry resident is trying to work on a case and the case is very difficult and he feels that he or she fails in that case, like and the patient is dead. Now you said like there will be a bias against that if the patient, the doctor will get the same case again. He will or she will be scared again. Just let the the doctors get encourages again. No, this time, I will not make any mistakes and I'll try to save the patient do as my best. But again, that happens. So in a manner where he she's trying to do against space, the same case again again and failing again and again, uh there will be a consequences in psychologically that, that either that page or the doctors will think he's not, he or she is not cut out for it or there is something wrong with himself or it's the case itself. So how, how will the doctor will cope up with this? Well, I mean, if you would make, if, if the same operation is regularly going wrong, it means you're not being supervised properly by your senior doctors. Um There's the answer you shouldn't be if you're getting it wrong all the time, you shouldn't be doing it without seeking help, seeking advice as a trainee. And that's a reflection on bad leadership that the, the role of the senior doctor is supervising and monitoring what his trainees are doing. And if there are consistent mistakes, you need to do something about it. It's not the trainees fault because we cannot assign a number. Like one of the old saying is gonna many people die. It's a statistics when a one person die. It's a tragedy. We cannot assigned numbers to the patient's again and again. Oh, let's try again. Let's try again because these are people and with the wrong and every time we are feeling we are killing, like, rather, rather kill than misdiagnose someone. So it's, it's so we have to look every, we have to take a step back and we have to discuss everything, what is going on. Right. Exactly. Does anyone else have any questions? Would you like to raise your hands using reactions or you can write them in the chat and I'll read them out, please do take the opportunity. Now, I'm asking too much from you Dr Marsh. But will it be possible that you will come again for these uh sessions and lectures is up, it's up to the organizers. Okay. If I'm asked, I probably, I find it difficult to say no. Okay, because I saw you uh in the documentary, whether when you came to Ukraine. Yeah, all that complete documentary. And uh uh I myself, I'm aspiring to be a neurosurgeon itself, but it's a long process. Where, where are you based right now? I'm at my native home, Mumbai. But uh actually the last year, last year, I'm about to graduate from Ukraine itself. Really? Which, which, which city, uh Kiev itself? Okay. As I was there, I was there last week, uh because I wanted to go back. But our government is not allowing us to, because of the situation of the invasion. Yes. Understood. Yeah, I was hoping that if, like, I know you're retired, but would it possible to have some lectures regarding neurosurgery itself? Uh, I'd have to think about that. I mean, I, I know that neurosurgery hasn't changed since I hung up my gloves but I'm very busy at the moment. I'll have to think about it is the answer. And, I mean, you have to liaise with the crisis, medical foundation about that. But neurosurgery of course, is a small part of medical practice. So they may feel that it's not really sufficiently important other than maybe the management of trauma, we can definitely discuss it offline. We'd be on, we speak again, doctor. Okay. All right. Um I think if no one else has any more questions, does anyone else want to ask something quickly otherwise, shall we wrap up now? Okay, I will leave it. Thank you very much. Thank you so much as they say in the supermarkets. Have a nice day. Thank you very much. Have a great question. Thank you so much. Uh For everyone that's still here. Please do fill in the feedback form like I've said multiple times, it's very important for us to have your feedback so we can continue supplying these free medical lectures. Um So I've sent it a few times, I'll resend it now. It takes literally a minute or two to fill in. So please please do that. Um As a reminder for those of you who aren't aware. Also uh the feedback, sorry, the attendance certificate is sent as a template via email. Now, if you're registered, um so you can edit it yourself with lectures that you've attended. I have to stop.