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ST free um seem to be ST four who is currently training in the south east of Scotland. So in Edinburgh, um and yes, the talk today is entitled to diversity in medical education. So let's go. So diversity. So what exactly is it, it's a terminology that's used quite frequently and can often be funded about without much understanding about what it really is and why it's so important. So it's defined as recognizing respecting and valuing differences based on race, ethnicity, gender, age, religion, disability and sexual orientation. And today we're gonna be focusing on diversity with regards to race and ethnicity. So why is it important? Um It's important that we have a diverse healthcare system as that will enable it to be equitable for all the people who are involved and attend the health system. Um It's well documented and well known that ethnically minor groups have poorer health outcomes. So, as Imella mentioned, I worked in Australia and there's a significant health gap between the indigenous population and the non-indigenous population with the indigenous population having a 5 to 10 year, a difference in their age expectancy. Obviously, throughout COVID-19, we saw the significant increase in mortality and morbidity in ethnically Mooris groups. And the UK embrace study has been widely spread and um popularized for show and demonstrating the fact that black mothers are four times more likely to die during childbirth um than their kind of like age matched um white counterparts. And actually a less publicized paper by Greenwood et all in 2020 showed and this was a, this was a study that was done in the US. It showed that black infants were more were more likely to die with racially discordant physicians. So what that means is if a black infant was being looked after by a white pediatrician, they were more likely to die than they were if they were being looked after by a black or racially concordant physician. So what does all of this mean? It shows that racism is actually a public health crisis and we need to call it as such so that people understand that it is something that is important that is a crisis and more importantly that we have the tools and ability to change. So just to talk a little bit about terminology before we move any further, you may have noticed that I have been using the term ethnically minor as opposed to um ethnic minorities or bain or BPO. Um And I've done this because there has been increasing discontent and um yet people basically not being happy with the terms BA and BIPOC and ones that kind of loop group, a whole bunch of ethnic minorities or ethically minor people together. So it's felt to be Eurocentric, as I said before, homogenesis and also politicized. So as I said, there's a lot of talk and discussion about these terminologies now and the fact that they're not really appropriate to talk about disparate and very different groups of people. So there are a number of papers which have been supporting and promoting the use of the term ethnically minorities and the kind of definition of it there is that individuals and populations including if they're in a numerical majority. So, but whose collective culture, economic, political and social power has been eroded through active processes. So a kind of good example of being an ethnically minor IZED group is in South Africa where actually they are the numerical black people are the numerical majority, but they are still ethnically minorities because their access to economic success and advantage to political spheres to social power has been eroded by the white supremacy. And the kind of white structures that have been put in place to keep those ethnically minor groups down. And what it all kind of boils down to is is power. It's like who in the dynamic has power and the use of minorities makes it a verb, it makes it a doing word. So it implies that somebody is doing the minor as opposed to the noun minority, which makes it sound like it's something that we don't have any power to change. So once again, words are important, it's all about ensuring that we use the correct words and terminologies that we, that we feel comfortable with and that other people feel comfortable with. So another bit about terminology is you'll notice that we use the term equity and inequitable services as opposed to equality and unequal services. Um And this is because, well, actually what we're aiming for is justice, but that's a, we gotta gotta have manageable and achievable goals. Um And justice is kind of like a very, very long, long term goal. But for now, what I would be happy with is equity and this is where everybody gets the appropriate support that they need in order to achieve the same outcomes as you can see with equality, equality is where you give everybody the same. But what this implies is that everybody has the same starting point. And I really like this image because it shows that actually if you give everybody the same, they really short person or in, in our kind of instance or case, the individual or group, who, who are disadvantaged and who are coming kind of like at situation and at life on the back foot, like they're still not able to achieve the, the goals and the standards that they want or that their peers are able to because they were starting from behind anyway. And what equity does it acknowledges the fact that everybody's coming at life from different vantage points and different advantages and disadvantages. And it takes that into account when providing support to others. So as you can see in the equity picture, the little guy has more boxes, the kind of like medium size guy has one and the tall guy has none cos he doesn't need any. And this way, they're all able to see the game from an equal vantage point and are all kind of like above the fence once again in justice, like I said, there would be no barriers in place and everybody would be able to have the same access. And in this analogy view of the game without needing any support, but that's not where we are now and we're a long way away from that unfortunately. So moving on. So I've got a little quiz for people. So if you can get out your phone, scan the QR code, it should take you to a little ment meter and this quiz isn't about it isn't testing your medical knowledge. It's just having a look, seeing how you can do. Don't get too stressed out about it. It's 7 p.m. on a Tuesday evening. It's very chill. It's just gonna be a talking point for afterwards. So what I'm gonna have to do now, hopefully you've had a chance to get the ment meter up is I'm gonna have to escape this view here and then just get up there. We go my ment so that I can see. Perfect. So somebody has already responded. Excellent. So you'll probably be able to see this on your screen yourself. But we've had eczema. We've got cellulitis, another eczema. We'll just leave it a little bit for some more responses. And I'm also going and shut the door to my living room while you guys are doing this. Ok. Yeah. Perfect. Ok. So you've had quite a lot of eczema and cellulitis. I don't know if other people, oh take a bit of hypothermia like that. That's good. Excellent. So I don't know if people have been influenced by um what's gone on previously, but that's good. So I'll move on to the next question now and then hopefully that will update for you. This one is a um multichoice question. OK. Interesting. So a good mix of responses almost equal for all of them. Oh Somebody's changed. Um So like I said at the end, I'll go through and talk about the answers, but for now it's more like I said, just, just a topic for discussion at the at the moment. So that's good. Bye. So what is this rash commonly known as? Cool, you guys real quick off the mark of this one? Nobody is gonna go wrong. Perfect. Right. The next one. So what is the diagnosis of this rash? OK. Who and then what condition is associated with this rash? So slightly more difficult, potentially loving the question mark at the end of IGA nephritis any more for any more before I Yeah, that's fine. Not sure. Like I said, it's not about the answer. So it's all good. Just feel free to have a little go good. We'll move on to the next one. Yeah, multiple choice. All good. The options are there for you. Just got to pick one, one important. Okie Dokie and the next one. I'm sorry, what does this picture show? Somebody's so excited to write their response first. They got a little mos I bring in the Contagium. Very helpful that Oh and pop. Nice. I can't any more for any more. I know that there's about 13 of you here slash 13 of you that are able to participate on the ment meter. Is there any more for any more before I move on? Not sure. All good. Fox love it. Fox of any variety. Love it. Keep it broad. Oh, that's so good. We can go on to the next one. So what does this picture show another multiple choice? You've had a good range of answers there? Interesting. Right. The next OK. What condition does this image show? And this is our penultimate one. So we've got one more after this and then we'll be having a bit of a discussion and I think OK, the measles very, very current uh may good. Quite a few chicken pox coming on. Did somebody doesn't know? And that's OK. Oh, pustules whiteheads, it's gonna keep them with the kind of acne image. OK. And then last one, what condition does this? I Michelle Okie dokey. So a good variety of answers. Meningitis. OK, cool. What happened? OK. Good, good. So what I'm going to ask now is if people could have a think and right in the chat, why they think I got you to do this quiz or what they think I was trying to get up with this quiz because like I said, it's not so much about your ability to um diagnose wild and wonderful conditions based on pictures. I was trying to get you to think a little bit more so people could pop in the chat and then me if you wouldn't mind reading out what people have said that would be grand. I don't hear blood what people have said. So one said how skin conditions vary in different skin types? Perfect. Uh Anybody else? Let's see, that's it. That's ok. That's all good. Um So yeah, so what I'd like people to think about and ask themselves is how did they feel equally as comfortable diagnosing the conditions on lighter skin tones as they did on darker skin tones? Because what I've actually done is every condition in here has been duplicated, but just on different skin tones. So I'll take it back to the beginning. There's a lot more now everything out for you. Um So someone said to see what conditions we are aware of. Someone said, um skin rashes can often be more subtle. Um how similar some different skin conditions can present as um how it may be difficult to be diagnosed based on a photo. And someone said it's the same might look different on this. Yeah, exactly that. So it's, yeah, you guys basically got it. It's that different diseases and disorders and conditions and syndromes look very, very different in different skin tones. Um So, as I kind of said before, every condition here has been duplicated. So this picture which you should hopefully be able to see if you've still got your ment meter up. So the first one with the little child with a darker skin tone, he had kind of like a dark kind of like purply rash on the toes and fingers and kind of extending up the um dorsal aspect of their feet. So this was actually a child who had meningitis. So that is a meningitic rash and that is how that would present in a child with darker skin tone. And unfortunately, nobody was able to, to get that or thought about that, which is fine. Like that's not a like criticism on anybody here. Like I would struggle to pick that up as a meningitic rash and I'm a pediatric doctor should literally be the one thing I should know how to diagnose. Um So this was infected eczema. Um And once again, this is a child of mixed Easter, East Asian and Australian heritage. This is a picture that I took for the, don't forget the bubbles Skin Deep Project. Um And then really interestingly actually is pretty much everybody got cradle cap for this one, which is completely right. But then the other infant scalp that I showed you was also cradle cap, but just on a child with darker skin. And actually, if we go to that one, so that was Mosk, which loads of you got, which is good. This was also actually a meningitic rash which nobody got, which is also fine. So it shows that you're equally, at least, at least you're equal in your understanding of meningitis, both in light skin tones and dark skin tones love a bit of equity. And then this picture is of eczema. Um But once again, just in a darker skin tone and then this was Milos again and once again, you guys are quite good at getting that, but just have a think about, did you find it easier? And was it, were you quicker at diagnosing it in the lighter skin tone than you were in the darker skin tone? And then once again, yeah, interesting. Only four people got that. This was Rele Cap. Um Whereas everybody apart from one person who was a bit unsure, got it in the lighter skin tone. And then once again, actually, you guys did very well with this cos both this image and the next image are both chicken pox. Um And you both put chicken pox along with some of the good differentials as well. So you guys actually did better than other people have on this quiz. Um But it is quite interesting if you have a little thing and be like, actually was I able to like really quickly be like lo um cradle cap blah, blah, blah and the lighter skin tones? And did you have to think a bit more um when it came to the darker skin tones? So I'm just gonna skip through these bits because these are the same but just not ment meter and then do that for you guys. Perfect. So that kind of leads on to because I don't know whether you, the people who are attending are students or dermatologists or consultants are educated. But I'm assuming that you're all medics in some or on your medical training pathway in some way, shape or form and this will impact you as there is a significant lack of diversity in medical training. So there's been a paper by Rodriguez et all in 2018, which showed that three quarters of Australian dermatologists were not comfortable performing procedures on skin of color. And that 80% of them would like more teaching with regard to skin of color. And another study showed that in America. So once again, in a country with significant amount of diversity in people have lots of different skin tones that only 25% of the lectures in the subspeciality that deals with the skin, had anything to do about individuals with skin of color with and only 30% of them during 30% of of American dermatologists during their training, received any experience in treating patients with darker skin tones. So and I'm sure you'll all have examples yourself with how kind of Eurocentric um medical teaching and medical training is. Um And the image that I've got up here is the Etone kind of scale of color. And it's been something that has been debated as being brought in to replace the um Fitzpatrick skin scale, which tries to simplify all skin colors to into five groups which as you can see from this simple diagram is just is not, is not appropriate, it's not a thing. So once again, and that's what we're ta when we're talking about people having different risks of melanoma and things like that, that we look at the Fitzpatrick scale. Um So once again, it shows how, how poor our training is and how we're not trying to, to move forward and diversify, despite the fact that our patient populations are diversifying and the um medical staff are also diversifying. Same also a lack of diversity in medical resources. So from textbooks to powerpoint slides to the images that are used in journals, like the vast majority of the images that you'll see and resources that you'll be able to engage with will be uh people with lighter skin tones. Um What I find quite interesting and also disconcerting is a, a review of this, the mannequins that you can get for SIM simulation, which is obviously one of the kind of key cornerstones of medical teaching at the moment um shows that the vast majority of Sim Manikins were either light, were light skinned, well proportioned male. Um And that if you were able to get darker skinned mannequins or darker skin, body parts, they were mainly available for contraception, breastfeeding, female genital mutilation and trauma. So like stabs, stab um wounds, gunshots and the like and this also proves an important point that we want diversity, but we also don't want diversity to be stereo stereotypical um in, in its manner in the way in which it's teaching. So for example, I don't, I'm hoping that medical school exams have moved on somewhat. But I definitely remember in my medical school, it would be like an Indian person walks in with a cough and you'd be like TB and it's like a person from some African country has come in complaining of like a recurrent chest infection and it's HIV. So there's also even if we do have diversity in our exams and our resources, it's important that it is that it isn't stereotypical and that it isn't reinforcing negative stereotypes of ethnically minorities and vulnerable groups. So unfortunately, there's also a lack of diversity in medical staff. So once again, looking at Australia and taking a more global view, only 0.15% of all doctors in Australia um identify as indigenous or Torres Strait Islander. Um which once again for the indigenous population of a country is a small number and of that small number of all the doctors in Australia, 50% of them or almost 50% of them received abuse as a result of their cultural cultural identity multiple times a month. So we're not even saying that this is happening on an um an infrequent or random basis. It's happening multiple times a month. Um Once again, looking in America and looking more towards academia and clinical academics. Um that study showed that there was no significant change in Black Latinx or Native American staff in us academic medical centers in the past 20 years. If you think about how much we have advanced technologically um voters generally and in the medical sphere over the past 20 years, the fact that we haven't been able to increase or improve the numbers of ethical minor individuals in medical academia is embarrassing and significantly problematic. Um Also, especially because a lot of the us academic centers are world leading with regards to research and their impact and and the change that they have in the medical sphere. Also looking kind of like more locally with regards to the Royal College of Pediatrics and Child Health that showed a significant underrepresentation of Black Middle Eastern Pediatric trainees in college positions. Um and as a individual who identifies as black and who is a member of the Royal College of Pediatrics and Child Health, this will significantly impact on me because when you're applying for consultant jobs and the like people look at whether you have had positions in colleges and things like that um to determine your suitability and applicability for a job. So once again, looking at the lack of diversity in medical staff, so you can see in foundation year one, there is a relative degree of diversity. Um So the kind of largest proportion of of ethnically minor doctors are Asian, obviously, the largest proportion in general is white. Um With there being a relative mix of black Chinese and mixed race um individuals. However, when you then compare that to the amount of doctors that are able to make it to consultancy or obtain consultancy posts, you'll see that interestingly, the proportion of doctors who identifies why it goes up by almost 10%. Um the proportion of Asian doctors increases by like 0.5 of a percent, but all the other ethnic minorities decrease. So it shows that even if there is a diversity of medical students and people entering medical training, that then doesn't see itself through into consultancy. And obviously, that's significantly, that's very significant and important because consultants, as we're all aware are the people who have the power to change the work culture, um who are able to provide mentorship to younger and racially concordant doctors um who are able to be advocate for both patients and their staff. So it's massively important that we have significant diversity in the consultant body. And it's showing that that actually isn't the case. And this is relatively recent data taken from June um 2020 2022. So importantly, how does this all impact on healthcare? So from a communication point of view, it's been shown that patients themselves report better communication if they have a racially concordant doctor. So say, for example, I as a black woman was going into my GPI would report that I had a better communication and a better patient experience. Um If that doctor was black and just from a personal point of view, I can say that myself as a patient that that is something that I feel and that if I have somebody who is racially concordant to me, I do feel that there's a certain level of understanding that is there implicitly that isn't there when you have a doctor who isn't racially concordant to you. Um And also on the other side of the table. So as the doctor, I have had patients make comments when they've come in and they've seen me as a black woman and they're also black. They've been like like an an audible sigh of relief that they're like, oh, so glad to see you here, sister. So glad to see you here. Doc like, oh, good to know that like we're doing things and like, oh, your parents must be proud and just that, that kind of sense that they know that they, they will be seen and that their experiences will be validated and will likely be similar to, to mine. And the data also like bears reference to this as well. And then how does it impact on health care in general? So once again, looking from a pediatric point of view, as that's my background outcomes are worse for ethnically minor Children. Um and as a mother of an ethnically minor child, it breaks and a pediatrician as well, it breaks my heart to say this. But that is unfortunately the case globally. So in the US black infants make up 25% of conicus cases. And for those of you who don't know conicus is the like life changing neurological disorder that comes as a result of hyperbilirubinemia and obviously, which is otherwise known as jaundice and jaundice is obviously much easier to detect in individuals with lighter skin tones than it is with darker skin tones. Um Once again, looking at meningococcal septicemia and the mortality of that that's higher in Children with ethnically mo from ethnically Mooris backgrounds, you know, that kind of showed in the quiz, it's quite hard to see those cardinal signs of meningococcal septicemia in darker skin tones and it is in lighter skin tones, looking at COVID. So PIMS Ts which was the kind of hyper inflammatory disorder that Children who had COVID suffered with. It was found that Children who were ethically, minorities were significantly more effective and made of the vast majority of Children who presented with PIMS Ts. And this was a life threatening condition and looking at just kind of about the machinery and technology that we use. 11% of patients who have normal arterial oxygen um levels. Sorry, let me just rephrase that. So when they were comparing arterial oxygen levels and SATS probe readings in individuals who identified as white or had lighter skin tones compared to individuals who had darker skin tones. Um A significant proportion of patients with darker skin tones were having their s ATS readings be discon with their oxygen levels. So there are two oxygen levels with reading as low and their SAS monitored readings were saying that actually their oxygen levels were fine implying that there's a significant proportion of darker skin tone people who are actually hypoxic and they say they're being picked up on the technology that we have at the moment because it's all been tested and focused on lighter skin tones and then just looking once again the pediatric population. So this is the mortality rates for infants in the UK. Um And as you can see, Black Caribbean Children make up the highest percentage of infant mortality rates which are the Black Caribbean woman is horrific to see. And once again, this actually, this infographic highlights the reason why using terms such as ba and trying to group all ethnically minor individuals together isn't useful because just between Black Caribbean and Black African, there's a significant difference in infant mortality and also between Pakistani and Indian and Bangladeshi. There's a significant difference between all of these groups. So trying to just say that we're all black and minority ethnic groups just isn't just doesn't cut it because there's significant differences even within individuals who you would argue that kind of face value are, are similar. So gonna move on to a case study now. Um So feel free to type into the chat if you have any ideas, I wanna ask questions. Um Let me just double check what time it is. So we're not running over. Perfect. I've got time. Um So uh this is based on a case study that I had or a patient that I saw when I was in Australia working with the pediatric reg. So a 2.5 year old boy presents to the emergency department with a florid rash. He's been generally unwell prior to this and looking at his observations, he's febrile, a temperature of 38.9 he's tachycardic but only mildly. So with a heart rate of 100 and 50 which for a child of his age is tachycardic but not crazily. So just for those of you who haven't done pediatrics yet and he's exceptionally miserable and irritable in the emergency department. And obviously, this is a picture of a neonate, but this is what the rash looked like. And this is a good example of this rash um in an ethnically Mooris child. So what would you guys like to do? So once again, I'm just gonna ask Imella if she could monitor the chat, if people can just type in what type of things they'd like to do when presented with this situation, give her one second to type doesn't be, doesn't have to be anything wild and fantastic. Just simple things. What you do, anybody saying anything. Exactly. Yeah, even if it's just go bell, that's all good. We can move on. So, so what you'd wanna do start with taking uh obviously a assessment and ensuring that the child would at least seem kind of relatively medically stable. Um You would wanna do a history and even if the child was slightly medically unstable, you want to get a bit more of a history. So you knew kind of what you were doing and kind of where your differential diagnosis should be going to and therefore where your management plan should be going to. So, in the history, um so once again, this was in Australia, the child was indigenous and the mum's kind of English wasn't great and just kind of culturally, the indigenous population um tend not to be particularly forthcoming. They tend to be quite reticent and reserved when it comes to interacting with healthcare professionals. Um And unfortunately, it was a night shift. So we weren't able to get an Aboriginal liaison officer um to kind of out to the Cultural Bridge. So mum just stated that the rash had been getting worse over the past few days, the child had been a bit hot, not eating as much, but the rash looked really bad today. So they came to A&E um and once again, just to give some perspective, this was when I was working in Alice Springs in Australia, which is Bang in the middle. And we cover a kind of geographic location, which was almost the equivalent of Europe to be honest. Um So in order for a person in a rural community to come to A&E, they'd often have to like get a like multiple hour bus or like try and see if they could find transport from somebody else in the local community who had a car that was working, who was going that way anyway. So often the fact that they present to A&E means that they, that they think that it was quite significant. So they want to examine the child, it was very difficult to examine the child as they were acceptedly distressed and their skin was very friable. Um They were alert and a and active, they were very, very active, very combative. Um So that kind of reassured me that they were kind of like that their G CS was ok. Um There were widespread areas of blistering and desquamation with underlying erythema along with some areas of crusting. So they were seen by the doctor in the emergency department, first of all, and then referred to me as a pediatric reg and they had some child protection concerns. So they were concerned that they hadn't presented earlier if the rash was this bad, they were concerned that maybe there had been a degree of potentially non accidental injury. Um, maybe the child had been burnt or they just weren't very happy with the way the mum was interacting. Felt the mum was a bit aloof that yeah, they just weren't, they felt the whole situation, um, felt a bit dodgy to them and they wondered whether there was calls for concern from a child protection and safeguarding point of view. So my, oh, actually, I was meant to, I was gonna ask you guys what you thought, but I will move on given the fact that my last attempt to engage you did not go very well. Um So the differential diagnosis for a child who presented like this would be Staph Staph Scold Skin Syndrome, which is what this child had. Um, you'd also want to be thinking of Steven Johnson syndrome or toxic epidermal necrolysis. So, taking a good history about any new medications they've started, um, also be thinking of bullous and PTI but that would be slightly um, less common. So from an investigation point of view, you'd want to be doing an F PC to look for infection markers. UVC cos given the significant desquamation, they're likely to be losing, having quite a lot of intenible losses through the skin. Um So wanting to have a look at their kidney function to make sure they weren't in an AK I also C RP with regards to infection. Um LFT S just to make sure they hadn't been a liver hit or anything like that. And then a blood culture, obviously to check for sepsis and very importantly, a skin swab and then the treatment for Staph called the skin is IV fluoxil in and then fluids just to make sure that the individual is um appropriately hydrated. And for Children, we give 0.9 0.9 and five, I even forgot to put the normal saline. So 0.9% normal saline and 5% dextrose. So the kind of learning points from this and kind of what I gathered is that people can have an unconscious bias. So the ed registrar I'd worked with her multiple times. She's very, very good, very competent. Um But I felt that in this case, she had had an unconscious bias with regards to this and preconceived ideas with regards to this family. Cos when I actually spoke to the mum having a bit more understanding of the indigenous culture, um and how they interact with medical staff. I knew that by virtue of her bringing her child to the emergency department in Alice Springs. She felt that this was very severe and that, that was kind of the upper limit of what an individual in that community would do. That's like their highest escalation point cos they do have local clinics in their community and area that they can bring a child to. If they think they're kind of generally unwell and have an ear infection or need an antibiotic. It's kind of like the equivalent of GPS. And rather than doing that, she, she took a very long journey to bring the child to the emergency department. So I actually felt that she had responded appropriately to a very concerning rash. Her interaction with medical staff was appropriate given her cultural background um that the doctor in the emergency department actually didn't think of staphylococcal Scalish skin syndrome. She just thought that it was a general rash that had like gotten worse and that the mum had allowed to get infected and kind of like sat watching her child, like watching her child's skin peel off days on end. Whereas actually in Staph Scalish skin, it can escalate quite quickly. So you can have a kind of baseliner femur and then in kind of like a 24 48 hour period, that's when you kind of start to get the actual desquamation of the skin and where it starts to look quite bad. And when the Children obviously then start to like drop off with regard to their oral intake. And the like. So I actually felt like the mum responded appropriately in that this doctor didn't understand the natural progression of this disorder. And also wasn't used to seeing it in Children with a darker skin tone where actually the baseline E femur wouldn't be present or would be more difficult to, to identify and that this probably all brought down to a lack of education with regards to this disorder. And as we've spoken about um skin disorders and syndromes in darker skin tones in general and a lack of cultural awareness on that doctor's behalf. So, 00, should I skip a page? So what can we do because it's all well and good saying here are all the issues. Isn't everything terrible. You also need to think about how we as individuals can impact and change the systems that we work in. So we can look at it in kind of three different areas. So we can look at staff. So we can look at implicit bias testing and bystander awareness um for non ethically minor doctors and staff to ensure that they're aware of their implicit biases and to make them explicit. So they know and can be aware of when they're um when they're exhibiting them and monitor them and kind of curb them. Also putting in scholarships and bursaries who people who want to study and work in the medical sphere who aren't from backgrounds that um typically do well. So for example, Black Caribbean individuals, Pakistani individuals, people from low socioeconomic groups and low income households provided scholarships and bursaries because with the increase in cost of oh sorry, there's just a fly in the house with the increase in cost um of attending university and the length of time that it takes to qualify as a doctor. Um financial difficulties are becoming a significant barrier to certain groups applying and going into medicine. And as I said, we need not only a more diverse medical population, we need them to be able to continue on to consultancy. Um I want to get that these nicely into the mentorship scheme. So once again, once we do have these um minor doctors who have been in medicine and being in that particular subspecialty for a prolonged period of time, encouraging them to mentor um doctors who are of the same background and ethnic and racial background as them. Um because it's so important, there is something about being able to go up to a doctrine, a superior of yours and be like, it's just so nice to see somebody who looks like me and who's doing well and who's like progressing through the system and like, what difficulty did you have? And did you find this doctor a bit funny and sometimes just even just talking in your own language with them and it's just so important. Um and has also been shown to um to be beneficial both to the mentor and the mentee and also to improve. Um Yeah, also to improve retention of these um ethnically moorit doctors, particularly just having support for international medical graduates because they have the additional disadvantage, often of not having trained in the NHS or coming not only to a new country and a new system, but also sometimes not speaking the language and then also being a different skin tone and background from a lot of the other people who they're working with. Um So additional support for international medical graduates to ensure that we're able to retain them and that they feel um appropriately supported and appreciated by the NHS. Um And then an example of a very good and impactful group is a, a in Australia. So that's basically a group for Aboriginal and Torres Strait Islander doctors who produce a report kind of like every couple of years, about the number of doctors who are indigenous, about the difficulties that they face, the barriers that they face and what each different kind of subspecialties, the pediatrics, emergency medicine, general medicine, surgery, um et cetera can do to help these doctors feel like they belong in the system to help combat the racism that they face and to ensure their longevity and persistence in their in their chosen career and pathway. And then once again, where your training is important. So you need to think about your patient population. For example, my patient population actually isn't particularly diverse because I now work in Edinburgh before. It was much more diverse when I was in um certain areas of Australia and when I worked in um Liverpool and the like, but if you know that your patient population is um, is not particularly diverse, then it's on you to go out of your way to ensure that you educate yourself and teach yourself about um different presentations and different conditions that happen in patient populations that you may not see in your training. Because if you want to go and do some specialty training or if you want to go and work abroad, or if you get a consultancy post in another part of the country, you might be dropped into a patient population that's exceptionally diverse and encounter a whole bunch of conditions that you've never even thought of or never seen. And the only person who will come out negatively, the at the other end is the patient and that's not ok. So ensuring that you educate yourself and if you're doing any teaching sessions, make sure that you make them diverse and make them about racial diversity and teach them about different conditions and disorders. So that you're also having um an impact in, in the place where you work. Once again, the resources that you use, try and make sure that you use um diverse resources and just try and be the example for change um within your department. And then looking at resources themselves, so support resources that support diversity and try and contribute to diverse, diverse resources. And then this leads me on to Skin Deep um which Imella mentioned earlier on that I and the organizations lead for Skin Deep. So it's a project that, that is aimed at diversifying medical education. Um and particularly with regards to different skin tones and different conditions and different skin tones. If you Google Skin deep, um DF TB, which is, don't forget the bubbles, which is a kind of pediatric emergency medicine teaching program. Um You'll be able to find the website and without tooting my own horn cos it's not just me, it's many, many people that are involved in this, but it is a great website. I use it myself. Um You can search based on kind of like symptoms or disorders. It gives you kind of like a DERM net um kind of approach. It will give you the picture, it will give you a bit of information about the disorder. Um And what's important is that it's anybody and then lots of different medical professionals and patients can submit their images to be used on the website. So it's very, very collaborative. We've got pictures from pretty much all of the continents in the world. Um We've got support from a lot of influential institutions such as the British Association of Dermatologists. Um And we're keen for more hospitals and more images and more people to get involved. And I should note that all of the images are vetted by pediatric dermatologists. So also to highlight only pediatrics, um I know images of kind of Children and Children, skin conditions, but all of the images are vetted by pediatric dermatologists and the information is written by them and other learned professionals. So yeah, it's a great resource. If you would like to get involved, feel free to get in contact with me and get my contact details from Emla. Um Or if you want to use it, just feel free to have a look and use it as a learning result. And if you're using any images for any teaching that you do just have a look on there, see if they've got any examples. And the vast majority of the images that I used for the quiz came from skin deep and some of the pictures were taken by none other than yourself. Um So yes, thank you ever so much for listening to my talk and for joining me and arguably antisocial time on a Tuesday evening. Um I hope that it's been informative. I hope that it's been empowering. Um Yeah, and I look forward to answering any questions that you might have. And this is my own personal feedback form, which I would be very appreciative if you could um feedback on that as well as the feedback form that you have to do to get your certificate. Sorry to make you do two, lots of feedback, but it is important for me to get as much feedback as possible. Thank you for listening so much today um for that session. Um I've done it twice now and each time it's been great. Um And it's been really interesting to think about um how things present in different skin tones, in different places. And I guess also thinking about what you can do. So, like you said, there's so much um that is inequitable about our system. But thinking about what is the way, how, what a way that we as medical professionals can try and make it more equitable is really, is really great. Um So, is there any questions at all in four K? Um And I'm happy to read them out. Oh, someone says someone's wondering about your process of moving to Australia for work. Um So that road's quite long and involved. Um But what I basically did was find, basically I just banned pretty much all hospitals in the area that I wanted to go to. Um So initially, I wanted to go to Melbourne, but that was quite hard. Um So what I would recommend if you do want to go over to Australia is try and go to the areas that are, that are slightly less popular. So I, when I first moved over to Australia, went to the Gold Coast. Um and there were a number of English and Irish doctors there, but not as many as you'd find in like Melbourne or Sydney or some of the bigger places. So it's easier for you to get into. And it also means that it's a nicer environment to start in because it's often slightly less busy. They've got more time to support you. Um, so, yeah, so I basically just found, went on, kind of looked at all the different hospitals, went on, all the websites saw you by the pediatric department cos that's what I wanted to do. Um, found the kind of email address for either the kind of admin person for the department or the clinical lead for the department, email them with my CV. And then often they would then forward you on to whoever the appropriate person was or they'd ignore your email. Um So it was a long and arduous process, but it was definitely worth it. And what I would also say is if you've had any friends who have been to Australia before, have any Australian contacts, try and touch base with them cos often if somebody's gone and has been successful there and they're in a hospital that like, likes them. It's often easier if they can be like, oh, my friend wants to come over. We studied at the same place, blah, blah, blah, blah, blah, they can kind of hype you up a bit for them and it makes it easier for you to come across, um, from England that way as Well, so that would be great. Thank you. Um He was saying um and that helped them a lot. So um I wasn't sure if anyone had any other questions at all before I close. Give it a minute. Yeah, yeah, quite a bunch today. Um So yeah, I thank you again. K um and I'd like to remind everyone again that you'll get a certificate of attendance once you've completed the feedback form. Um it comes automatically afterwards and next week we have another session um called treating the patient, not the diagnosis with the Na Natasha Noel Barker. So, um if you're interested, um the sign up link will be on our medical page as well. Um But yeah, thank you everyone for attending and enjoy the rest of your evening. Bye. Thanks guys. Bye.