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OK, I think we're good to start. Probably. OK, so hi everyone, welcome to our webinar today about the elements of research for medical students. I'm so happy that you're able to join us today and we're really looking forward to a super informative event. Um I know that studying in Bulgaria can be quite tough. It does have its um unique set of challenges. Um And sometimes it does feel like maybe you're not able to reap the benefits of studying medicine sometimes. And um something like research is something that we don't really have much information about, especially studying abroad. So we're just hoping that this is gonna be a lot of new information for you and we do hope that it's gonna give you a lot of confidence in pursuing your interests in research whilst at medical school. Um just a bit of housekeeping. If you do have any questions or queries, just put them in the chat and we're gonna circle back to them at the end. So we'll have like a brief Q and A session with Doctor Shanker and he'll be able to answer whatever queries you have about research. Um Just to tell you a bit more about Doctor Shanker. He is an experienced researcher and physician. Um He has a deep interest in surgical research and it's published in areas of onco surgery, general surgery, onco gynecology, cardiothoracic surgery, public health and forensic medicine. Um, he's supervised over eight multicenter trials and he's supervised multiple research groups in for surgery. With his experience, he has been, he has taught research methods and surgery and has been an invited guest for multiple international organizations. And he's been able to help guide a load of medical students through the incredibly rewarding jour journey of research. So I gonna hand over to Doctor Shankar. Thank you very much. Thank you, Jemaa. Thank you so much for first inviting me and for that very warm welcome. Um So, hello, everybody today, I'm going to try to talk to you about the elements of research for medical students and I hope you guys can uh can see my screen as well. Yes. OK. That's brilliant. So uh I'm going to just rehash a little bit about myself. Uh You know, I have like four years of research experience. I have seven peer review publications uh online right now. Um I have supervised nine research projects and I've attended a lot of different conferences, both as an active speaker and as well as an invited guest. And I have a lot of surgical experience, but my research experiences are a lot more diversified. So for example, I've done colorectal surgery, research, onco gynecology, research, forensic medicine, public health, uh, and so on so forth. So a lot of times, uh, when I'm ta, when I'm asked to talk about research and how, uh, students should get involved in research, um, I always find that it is helpful for me to first go into, you know, what, uh, research actually is. So, in today's talk, I'm going, going to talk about these four things. So what is research and why should you get involved in the first place and how you can get involved and where you can get involved. So, with this, uh you know, with this uh framework, sort of, we are going to try to get into the different aspects of research itself and you know, how you can increase your own participation. So a a bit of a disclaimer, I started research work when I was in the second year of med school and that's medical research. Um Otherwise I have been involved in other types of research projects uh since I was in school. Uh But uh I did come into medicine with uh some amount of experience uh in terms of research itself. But however, there's a vast difference between generalized research, you know, for other things. So for example, humanities or uh politics or defense or whatever. So those were the areas that I used to do research report. But in medicine, you have uh different kinds of research and you have very good research methodology. So medical research is actually one of those areas where there is something for everyone, uh more or less. So let's go with first with our first section here as to what is medical research. So when you think about yourself and think about what medical research is, uh you know, most of you would come uh would think of medical research maybe as like lab work or maybe something to do with clinical trials. But if you look at the screens, now, you will see that we have different types of research that is constitute that constitutes medical research as a whole. So for example, we have letters to the editor, we have surveys, uh case studies, systematic reviews, uh case history analysis and multicenter audits. Now, this is not the entirety of medical research. Uh This is just a small snapshot of what you can do and whatever is on the screen right now are things that you can participate in as a medical student. Now, uh a lot of times um people do ask whether they can take part in laboratory research, which when you think about medical research, you may think about working in a laboratory. And that is kind of true for some types of research, but for medical students, it is far easier to get involved in the research projects or types of research that you see on on the screen right now. Excuse me. So let's go further and talk about research and surgery. So my primary research right now is research and surgery and there's not much difference between, you know, surgical research and medical research in general. So even if you uh are interested in something like oncology, research or research in cardiology, uh both of which I've done uh as well. You will find that you have a lot of similarities with research and surgery as well. So on your screen, you will see that there are different types of research products. So you know this that case reports, surgical audits, retrospective observational observational studies, uh randomized control trials, uh prospective cohorts and case series, right? So what's a case support essentially? So a case report is when uh you try to report uh on the treatment and management of one single disease with only one patient, right? So it could be something rare or it could be a new technique or uh a new procedure or a new medication for one patient, a new or a very novel uh or unique way of treating a patient with an existing kind of disease, right? Even reporting of certain types of complications can be counted as a case report, right? And oftentimes a lot of students begin with case reports uh because case reports are kind of simpler to do now, you also have retrospective observational studies. So retrospective observational studies um essentially examine uh fem phenomena that have already occurred. So that would mean for us in medicine, that you just take a look at a series of case history reports from your hospital over a certain time period and then you can make a observational study. So for example, um if I take just an example of the top of my head, you could look at all the uh patients admitted to the cardiology unit for myocardial infarction and then just report how many of them have a concurrent uh thyroid dysfunction disorder, for example, or how many of them have type two diabetes. So those things are observational studies, you observe the phenomena that has already occurred, right? And then you just report on it. Now, of course, a very famous type of of uh surgical and non surgical research is the randomized control trial. And this is used to uh uh to sort of establish the superiority of one treatment method over the other. And a lot of you may have heard of some uh like placebos and uh and target drugs and target groups and all that. So all of that comes through randomized control trials and randomized control trials usually are considered to be the gold standard of evidence based medicine, right? And then of course, we have case series so much like case reports, there are a series of cases that are similar in some way. So one example would be that uh we are looking at a series of uh patients with cholecystitis and we're just going to compare them uh compare the type of uh operative cholecystectomy that was performed between one group and the other. So we could compare say a laparoscopic cholecystectomy versus robotic cholecystectomy. It is a research project that is currently uh uh currently under way at our research group. And then we have something called a surgical audit. And so what a surgical audit does is essentially it is an examination of how well uh your patients are faring. And so you have different types of ways you can measure this. And throughout the course of this lecture, I will delve deeply into each type of uh of uh uh research method in uh that you see on this slide right now. Now, one of these things is called a prospective cohort study. And this is a very uh very popular one nowadays. Uh because one of the easiest ways to get involved in a big multicenter trial is to act as a data collector for these prospective cohort studies. So for example, I have supervised uh like uh six of them, uh seven sorry of uh pro of seven prospective cohort studies and they measure different things. But in general, it's uh you, you are given an instruction manual essentially where you are told that, OK, you have to include this kind of patient with. So maybe uh patients who undergo major abdominal surgery. So that is like anything that requires open incision or incisions and entering the peritoneum and then you just report on all their postoperative data. So uh why they're operated on what kind of operation they underwent, uh what kind of closure technique was used and then what happens to them after 30 days? Right. And the reason we do cohort studies is because a cohort essentially is a, is a group of patients that have a similar uh have some similar characteristics. So for example, a a group of patients with uh a colorectal cancer would be considered a cohort. Now, normally a cohort is a lot more well defined than that. So it could, it would probably mean something like uh patients with right sided uh colorectal cancer, for example, uh or all patients with pancreatic cancer. So that is what a cohort essentially is. And we talk about prospective because prospective means looking into the future. So you collect data as uh patients come and go, you don't make any changes or anything. And it is just to try to observe uh the workings of or the observe data and collect data in the most natural environment as possible. That's the purpose of prospective cohort studies. So um now that we've established what different types of research projects there are. Um it will be very important for you to try to ask yourself as to why should you get involved in medical research? Right. So your motivations are entirely your own and you may have your own reasons. But as a good way of sign posting, I will tell you why I got involved into in uh medical research. So when I was in second year, I, I was very impatient to start, you know, clinical work. Um I like going to the hospital, but I also wanted to take a more active role in uh clinical care. And one of the reasons uh one of the main things that I saw was that uh I could take part in research because research tries to establish the truth, right? It tries to improve patients uh patient outcomes. And the primary purpose of research has always been to improve and enhance patient outcomes based on evidence, right? So if you can provide the evidence and that evidence can be used to improve patient outcomes, that is the main purpose of research, right? And then the second thing of course is that um being published uh taking part in audits, taking part in research projects is very important for you when you apply for jobs in the UK or in other countries. And also when you try to apply for residency or specialization training. So for example, um I am a surgical resident and it was very important for me to already be published because there is a lot of um there are many ex there are very high expectations of surgeons nowadays because we have to uh do research work and do quality improvement audit so that we can serve our patients better. And one of the most important reasons why I entered medical research was also because I want you to be a more active participant in the research and learning process. So it is very easy. So, you know, I noticed that when I was in second year, I spent most of my time just reading, um, reading textbooks all the time and like, not really taking part in anything. I would go and see some patients during my classes or doing like my uh lectures or whatever. And I was not really satisfied with that process, you know, because I wanted to take a greater part. I wanted to do something more. Now, obviously, as a second year student, you can only observe, you can't really assist anywhere that came much later. But I thought, OK, I can help in with my patients now by trying to do, trying to do some research on what would affect them in a positive way. So there must be something that I can work on so that remember even as a medical student, remember that you should always uh believe in the idea that your research work can mean something right? There is no research project, too small, no uh role in a research project that is too small because every person in the research team uh contributes in some way. OK. And one of the, the my first research paper essentially was a paper on public health for an aging population. And what I had done was that I had created a survey and I had done all the literature review on the existing protocols for public health when it came to aging and elderly people. And I established that, you know, because Bulgaria has a very as the world's second largest aging population by percentage and it has a rapidly shrinking population. There are certain things that the public health system in Bulgaria needs to address to better serve elderly patients now and in the future. So for that, what I did was that I needed to establish a, a questionnaire to assess patient uh asses the public's understanding of what healthy aging is. Do we understand? Do we have access to proper medical care or not or what do they think about uh the fact that the there's a massive demographic, demographic shift in Bulgaria and towards aging and then I put it all together to try to study uh appropriate changes in our policy framework. So my first paper was a public health paper and it tried to address uh specific points in tackling the demographic issue, which was that there is a falling population and the number of elderly people is increasing, but the number of people getting into employment is decreasing by the year. So that paper was reasonably well received. I received an award for the most impact research paper for that year and it was, it was published and I presented the paper at the M Ds C conference, which is the university's conference conference here in back in 2018. And that started essentially my journey through medical research because I also met other researchers. And um unfortunately, what happened with me was that I was the only second year student involved in research at the time. And then when I went to third year, I presented, I presented another paper and turns out I was again the only third year student presenting. So most of the other people who are presenting with either already doctors or they were in fifth or sixth year. And I met a lot of other researchers from other countries who are older than me. And uh they uh very helpfully took me under their wing. So I have uh so my first entry into research was on my own. But eventually I started working on different projects with different people. So that is one of the best steps uh you can take if you want to participate in research. So now let's go to the y of research and the y of surgical research. So we do research for two things. The first is that we want to try to improve patient outcomes, right? We've established that. But the important key word here is that we need the evidence. And so without evidence, it is not possible to create or generate good data on which we can base policy or other changes. And of course, if you have a deep interest in finding more. If you have a natural sense of curiosity, then of course, research is just for you, you're a good fit for research, right? Then of course, the post graduate training requirements and you know, you can contribute to research. There's a very famous quote by a scientist called Richard Dawkins who said that all scientists are nothing more than brief candles in the dark. So all our research work just seems to, you know, sort of eliminate a small spot in the darkness, but even that small spot in the darkness can guide the way for other people coming after you. Right? So that is a very important uh philosophy to sort of uh and to sort of live by now. Uh One of the main ideas of surgical research and medical research is this that it's not just that you're trying to improve patient outcomes, you also have to try to establish what works for patients and what doesn't, right. So uh for uh for a long time, different types of operative uh techniques or medicines or medical medical regimens were considered the gold standard simply because there was no evidence to prove otherwise. Of course, there was a massive uh uh there was a explosive research study that proved that this drug is ineffective or this drug in this combination could be deadly for patients. But one very famous example I will give is about the use of uh lipid lowering drugs. So statins like like atorvastatin or pravastatin. Uh the use of these drugs um actually increases uh life expectancy in patients with uh cardiac disease and it also reduces all cause cardiac mortality. So what does this mean? This essentially means that if you give a patient who has a a heart disease, a myocardial infarction, no types, uh ont angina, whatever. And if you start the like anti lipid therapy as soon as it possible, not only do you increase their life expectancy, they are less likely to die of a cardiac event, right? So it is very important for us to consider all aspects of research in different ways because research is not just about proving something works, it's also about proving that something works in different ways. One other common example is a drug called topiramate. So topiramate is a anti epileptic drug. Now, a few years ago, um someone uh who was just observing patients with epilepsy, uh discovered that patients who are on this topiramate drug ha are less likely to also come to the department or to the hospital with alcohol use disorders, right? And so what sparked interest in the researcher? Was it? Ok. Maybe the tomate itself which is only licensed uh and only authorized for use in epilepsy. Maybe it has something to do with alcohol use disorder. So the next thing that the researcher did was that they took this tomate and they administered it to veterans of Vietnam, uh veterans of Iraq as well. Er, and veterans coming back from Afghanistan, who already has already had certain types of substance abuse disorders, but predominantly alcohol use disorder. And it turns out that if you administer tomate to patients with PTSD who have, uh, a concurrent substance use disorder, the incidence of substance use disorder goes down, they are better able to manage the substance use disorder simply because they're taking. So you understand what is happening here, like what is happening is that one drug uh you know, which is licensed for one thing for one disease or one disease process can also be used for other things. And there was one very famous paper that said that uh patients who had the depression, for example. So a uh saw a massive reduction in their symptoms when they were prescribed beta blockers, right? And it also turns out that patients who have well-controlled hypertension uh uh have much lower incidence rates of uh depressive comorbidity. So what is happening here is that, you know, the one drug can be used for multiple different things in different titrations and solutions. And that is very important because sometimes we can't wait for a new drug to be tested and released to the public and tested again. If you already have an arsenal of drugs, it is it is more efficient for us to try to find new uses for them. So throughout medical research, you will find that there are lots of inspiring stories like this. And um yes, of course, that nobody makes a film about these kinds of movies or of these kinds of moments or these kinds of people, but they have a direct impact on patients lives and patient care. So that is the main purpose of why we do surgical research as well. So now let's try to examine uh what surgical research in specific to investigate. So my area like I've said is in surgical research and surgical research tries to do basically these three things uh what you see on your screen. So the first thing is that, you know, we want to try to improve our patients outcomes on based on evidence. Right? Second is knowing when to operate and when not to. So the patient selection criterias are always changing and they're getting more and more optimized simply because we do a lot of research on these things, right? The the one of the most important things is when you are trying to operate on a patient, which is the central idea of surgery. Of course, you you also have to consider whether this operation at this time is good for the patient or not, right. So in some cases, can you delay the operation? Is there something else you can improve from the patient's physiology before operating? Right. So one of the other things that is very important from this uh aspect of knowing when to operate and and not to uh is the idea that uh for colorectal surgery, for example, uh it is always important to try to operate early because you cannot rely on chemotherapy or radiotherapy. So, uh one of the main things that establish the superiority of colorectal surgery for colorectal cancer was the idea that patients who undergo early detection and early management of disease and including early colorectal resections often have better uh um have better survival rates than those in whom we wait right now. Con conversely to this uh like you can say that yes, operating early is very good. That's great. But for example, let's take a look at acute cholecystitis, right. So, in acute cholecystitis, what happens is that a patient has an inflamed gallbladder and the standard operating procedure now is doing a laparoscopic cholecystectomy. But here is the catch, you don't always do a laparoscopic cholecystectomy for all cholecyst cholecystectomy patients. So, for example, if a patient comes to you after 48 hours, then it is better to let the inflammation subside using antibiotics. And then two weeks after they present to the hospital is when you can operate and remove the gallbladder and that has the best outcomes for the patients, right. So, for example, if a patient comes to you with like 96 hours of uh very specific right, abdominal quadrant pain with signs of uh with Murphy's sign and with uh you know, an inflamed gallbladder, but you notice that it's been more than 48 hours, then just do conservative management and then after two weeks, you can remove the gallbladder. Now, why is this important? This is important because this can help to improve our outcomes for every single patient. So knowing when to operate, when not to operate, the best time for operation, the best type of patient for a certain type of procedure. All of this comes from surgical research, from extensive research, from multicenter trials, from audits randomized control trials. Everything right now, the medical examples of this are the same thing. You know, for example, using different type, different combinations of therapy sometimes is best for patients with hypertension. Um early early administration of anti anti hyperglycemic drugs for patients with suspected type two diabetes always leads to better outcomes. So all of these things are examples of how your direct clinical management of a patient is improved simply because of evidence that tells you when and how to administer your drugs. And as we go more into, uh as we move further in the modern world, we will discover that it is extremely important for us to conduct our own research so that we can also uh sort of establish the safety of our drugs, the safety of our interventions. And of course, try to improve patient uh a patient's quality of life. So with that said, let's go on to the next slide here. Um Here, we're going to try to talk about factors to consider So, now, hopefully I've tried to given, I've given you a good idea of what medical research is all about. Uh, why we do it? What are the different types? Now, let's try to conduct, let's try to ask ourselves, how can you conduct, uh, or take part in the medical research program? Now, the first thing that I want all of you to, uh, sort of agree with or not agree, don just agree with, but just get into your heads. Essentially. Is this idea that even as a medical student, you can do a lot of research work. Now, I am living proof. I have written textbooks. I have done a lot of different types of research work. I've done, I've taken part in research projects across multiple different fields. So if I can do it, so can you essentially? No, no. The only thing that I would say is that when you embark on a research project, uh remember that it's very important to have realistic ideas. Uh Normally the reason why a lot of people uh start a research project and it doesn't end well for them or they can't get publications or they can't get uh uh published anywhere or it doesn't, it just seems to hit a block is because maybe they've been a little too ambitious in that case for the uh research dream essentially. So the first thing I want all of you to understand is that ask yourself whether you are able to take full responsibility for the project you undertake. So if you want to write a case report, uh it is up to you to go and speak to the doctors, get the, get the patient information, get all of the uh pictures that you would need. Uh look for a journal, uh try to uh do the background literature review. So you have to have at least one person responsible for the whole project who can see it from start to finish, right? The second thing is that you know, your hospital does need to have a support structure for research. So you know it it if there is a culture of research at your hospital, then it is more easy for you to get into research. Because if you don't know somebody uh at the hospital, somebody else knows someone who's doing some kind of research. And nowadays in most hospitals, there's always some kind of research what is going on like case reports uh treating complex patients. Uh maybe they are all part of some kind of multicenter audit or something. So always ask, right? And the third thing is to ask yourself whether you have the support you need for your project. So for example, that would mean we have support from the senior staff. Do you have support from other students who are with you who share the same objective goals uh for getting published? Right? So ask yourself if you have these three things. Right. And then we're going to go on to this other thing I have, uh, uh, I think are important. Uh, number one are the skills that you need. Right. So, what skills do you actually need? Do you need to be a genius? Do you need to be, uh, you know, gifted in some way? Now, evidently not. Uh, now most researchers nowadays are not, you know, they're not all Oben Heimer. Right. They're not all Einsteins or, you know, they're not all rich dawkins or whatever. Uh, most research work comes from dedicated and persistent and consistent work. That's it. Right. You don't particularly need to be a genius in anything, you know, up until second year, I was also not very good at academics. Most like everybody else. I struggled a little bit, uh, here and there and, and your academic success is not actually a predictor for how well your research work is conducted. Those are two different things. Academics test how good you are at a certain exam, how good you are at giving a certain exam. Whereas research work entirely is entirely focused on you investigating a certain type of, uh, disease or a disease process or a procedure. Right. So if you look at your screens now, you will see that, you know, one of the most important skills is reading a paper. So most of research work is just reading, reading and reading. All you are going to do is read So the first thing on how to read the research paper is search ed, subscribe to all the journals you can find, subscribe to these news aggregate websites which uh collect information right uh about and report information on the latest uh developments in medical resource, right? And the second thing is the critical appraisal of a paper. Now, critical appraisal, for example, is very difficult. It's a kind of a long process. But when you read a medical resource paper, what you can do is to first read the paper itself, you read the title, you read the abstract. If it's interesting for you, then you open the full text links and then you read the introduction, first the discussion section and then the conclusions, right? And then your second part is when you read the whole paper, including the results and statistical analysis and everything. So the first idea is always to start simple and go a little bit higher and higher and higher, right? So always remember that research is not uh something that is extremely complex. It's usually just a question of how much you can dedicate your time to it and how consistent you can be. Now all of these skills like if you look at the blue section, it's about writing an abstract and organizing yourself. Uh these are all things that you can double, right. So when you want to write an abstract, you have to read an abstract, right? And the more abstract, you read the better you get at writing the uh abstract yourself. Now, the second thing is also organizing yourself. So remember that you always have to organize your team and organize your work. Now, in my experience uh in total uh from 2022 to now, I have supervised almost 100 students uh through our multicenter trials and research projects and uh some of my own projects as well. And the only way we could do this was by organizing them properly, set up a whatsapp group, set up a Google Excel sheet with all the data of all of your patients, of all your patients and all of your students and everything and assigned roles. You know, nowadays, there are so many collaborative tools that you can use you. There is no limit to what you can do with the current software available. Now, I can, I would like to digress a little bit and compare this with my own experience of this research when I was OK. So I was a kid a long time ago. Um I'm not as, as ancient as I look, but uh I went to boarding school when I was a kid and when I was a kid during that time, we didn't have access to the internet at all. Right. So when we have to do research work, most of my research work revolve around writing speeches for my debate topics. So I was, I was the captain of the debate team uh for a long time. And one of the main things that we have to do was to go to very deep analytical research on the topics we were discussing. So, you know, the ethics of the Iraq war, for example, comparing coalition government to a non coalition government, uh comparing different types of state systems, debating whether the United Nations is a helpful international organization or not. So all of these things required us to do very in depth research. But at that time, uh this was back in the early 2000, uh 2010, like 2010 11, we didn't have access to the internet at all, especially in my boarding school. So we have to manually go through old textbooks, journals, magazines and newspapers. And sometimes I would have to do uh enlist the help of the librarian and the librarian would uh look at my question and then try to find some books for me that would be helpful. It was a long tedious and intensive process, right? And I always had a bunch of uh team members with me. Uh So I had someone who would do something called uh red cell analysis. So red cell analysis is when uh you come up with a point, a series of points uh or a position essentially. And the other side's job is to just dismantle it. They have to look for flaws in your arguments, right. So he would do his set of research. I would do mine and then you would compare and see, uh, which one of us has the better position, so to speak. Now, all of those habits, you know, they're very important. And as I move into medical research, I realized that, ok, the one thing that worked for me was that now I can access data from anywhere in the world. Uh, I can sit at my computer and within, uh, if I'm given a topic by the end of the day, I'll have read at least 10 papers re relevant to the topic. So I can make a very informed, um, position on, uh, on any topic in the world right now. The good thing with that is that when you are trying to do research nowadays, your job is much, much easier. You can do searches. Now, there is a technique to doing a database search and maybe I can, uh, teach you all of that later. But these things are all skills that you can learn. These are skills that can be developed upon and improved upon and there are no skills that require you to have a separate degree in research. Now, in a lot of places they ask, do you have a degree in research? It's not necessary per say, I don't have a degree in research, but I'm a published author. Um, and I'm also a supervisor of the onco surgery research group. So remember that all of these things with the access of the internet, with all of these, all of these different resources available for you right now, you have everything at your fingertips and you can use them. These are, these things are all designed to be as simple as possible as well. They follow a very simple logic and don't be intimidated by, you know, complex Softwares. Uh they're not complex, they're very easy to use, right? So now I am going to take this as a way to enter into statistics. Now, statistics is for me also a scary word. And after all these years, because um the problem with sta statistics, I'll tell you is that see, you don't generally need to know an in depth analysis of statistics because most of the time in a research group, uh there'll always be one person who is a dedicated data analyst. Their job is to only do statistics, right? You collect the data, they analyze the data and they will interpret the data for you by you just telling them what you are trying to search for what you're trying to understand and they will be able to frame the statistics in a certain way. But in general, it would also be helpful to uh read about certain very basic types of statistics that are used in all of these papers. So there's like the R value, the P value uh square test, the student test E test the whole thing and all of these things can be learned online. And of course, um at this point, we are more or less halfway through the lecture. Um I'm also setting up my own research group, which is called the Medical Re Research Division. And we will send out a link at the end of the chat. And I would like also to sign up for it. And what that will do is that I will be able to send you very specific research related materials. And you will also get a chance to work at our research group, right? So this is a good way to express your interest as well. And which is what will be going on in the next slide. But remember for statistical analysis and data analysis, these are important to moderately important. Uh I'll tell you why without appropriate data and without interpreting the data in the correct way, uh sometimes you can make a lot of errors. Uh So recently, there was a new uh research paper that came out that analyzed the status of randomized control trials across the world. And this researcher uh found out that 40% of um research uh related to randomized control trials over the last year or so, uh have errors of some kind like statistical errors stat anomalies because they didn't do the data analysis properly. Now, all of those, all of that research, all of those errors are made by very experienced researchers. So what does that tell you that tells you that look, some things are objectively difficult, right? Uh, but that doesn't mean that you don't try them and making errors is all part of the process. You know, don't be afraid of making mistakes, especially in research because if you are afraid of making errors, then you will now be able to actually move ahead with your research work. Right. So it is also very important to have a larger group than a smaller research group. Because if you can see things in a certain way, someone else has their own perspective. And the only way to reduce errors is when you reduce, uh when you increase the number of participants you have and when you have more eyes on the data, right? So now let's finally go to study design. Now, for most of you as medical students, uh study design is not that important for the simple reason that it is very unlikely that you will be designing your own study, right? But the only way to actually understand the important bits of study design is that you have to try to see whether an existing paper or an existing study has tried to reduce the amount of bias they have or not. And the best way to do that is to have some understanding that when we design any research project, the first thing we try to do is randomization. The second thing is blind. So randomization is when we take a group of patients, right? So 30 patients and we divide them randomly into two groups and then one group is going to get the controlled drug like, you know, uh pla blue whatever sugar pills maybe. And the other group will get the drugs that is under testing, right? So that is the the most basic idea for study design that you basically have a selection criteria of which kinds of patients are gonna take, then you're going to try to randomize them and which randomization method you use. And then of course, you also have like an end point. So you don't do research forever research. Usually you observe patients say maybe over a 30 day period, 90 day period, maybe one year, five years. So you have fixed end points, right? So these things constitute the study design essentially. So now with that said, let's try to understand some things about how to get involved as well. So this is the more juicy part of the research of today's talk. So there are different ways to get involved. And regardless of whether you're in Bulgaria or the UK or India or wherever it is that you're from, the first thing that you always must do is participate in scientific conferences. You you will see that there are lots and lots of conferences both online and in person, right? So participate in one when you participate in a scientific conference, even as a passive participant that you're just there to watch the proceedings, take part in workshops. You will realize that it is immensely helpful in getting you started with research because you will be in touch with other people who are there uh presenting their own research work. Right? Second is join local scientific organizations. So uh at every university, there will be a research group. Uh for example, my department has a resource group called the Onco Surgery Research Group, right? So you can join us as well if you're from. And, but I know for a fact that other universities also have their own research organizations. Now, the third thing is that if you're at a university hospital or working in close uh association with the university, try to speak to the phd students then because phd students are not only uh they undertake their own research, of course, uh what the phd S are on. Uh but they also undertake a lot of other lateral projects and they're always looking for help. So you can always go and speak to the phd students and they will also be able to help you with like statistics or they can help you with like study design and everything because phd students are selected into phd programs because they know quite a lot about their current uh social work and also any associated fields around that resource. Right now, the other three things or four things you can do is that, you know, you can speak to your assistants and professors and normally just go up to any of your assistants and ask them if they have a case report or if they are working on some research or do they have opinions about what could be an important research topic to, uh, talk about or to present other conferences? Right? Now, your assistants and your professors, uh, they are academic surgeons or academic physicians from the start. They already have a lot of research experience under their belt, which is why they are professors and assistants, right? So it is important to take their lead when you're trying to get started with research work, right? And of course, you can always contact your friends if you know people who are involved in a research project, go and speak to them and maybe they'll let you on right now. The final thing that I will say for this slide is that if you have an idea or any kind of idea, so whatever it may be just start working, right? There's no point waiting for the most appropriate uh time or just the most appropriate uh set of circumstances that doesn't usually happen. Now, for example, I will tell you a lot of my research projects take a long time simply because. So I started a research project in 2021. Then I had to suspend it for a while because I was busy with exams and busy with like fellowship and whatever and then I uh could resume it again this year. So you understand what happens is that if you have an idea, just write it down somewhere. So, for example, I use obsidian and notion to take down all of my research ideas and then I can go through them afterwards in a year or so whenever I have some time so I can take a look and see. Ok. Yeah, I already have an existing research plan somewhere and then I can work on it first. OK. Now we are going to talk about something called the escalator of complexity. So the escalator of complexity is this conceptual design framework that I came up with through my own research experience, right? And what it says is that like, you know, when you're going to decide which research project you want to take part in use the escalator of complexity, right? So when you look at the escalator of complexity, you will see that this is the escalator, it starts at the very bottom with case reports which are the easiest and then it goes up to case series, retrospective observational studies and so on. Now when you look at the kind of research project that you want to get uh involved in, remember that you have to consider two factors, right? The most important is whether you have the infrastructure. So do you have data? Can you access patient data in a timely manner? Can you do it effectively, second is whether patients are available for the kind of study that you want to do, right, your own knowledge and support from senior staff, right? And again, the availability of data, which is also very, very important. Now, the second thing I want to inform everybody about is the importance of the support from senior staff. Now, um for example, our department, the department of onco surgery is an academic department. So all of the uh uh all of the surgery residents and consultants who are working in this department, all of them have some research experience, right? So what that does is that uh we always have someone to ask questions to, we always have proper guidance. So senior staff support is actually very, very important, right? And it is very crucial to have senior support because senior support can help you actually get published or not, right? Because senior surgeons, senior staff, senior doctors, professors, they have already gone through this whole process. So they will always have an interesting insight, right? And of course, their value and their depth of knowledge about certain areas is unparalleled, right? Because they have spent a lot of time in their field. So for example, if you want to do a colorectal surgery project, then you can speak to my head of department, uh Professor de or the head of our clinic, Doctor Carman, you know, so they they have a depth of knowledge that is unparalleled anywhere else. So you can ask them any questions, they will probably not no matter how is it is. Right. Now, the most important thing about senior staff is that they can point you in the right direction, especially when you are confused about what to do next, right? So now with that said, um I want to just uh talk about how to come up with a hypothesis. So in, in research in general, there are lots of useful like frameworks and stuff like that. And one of the most useful frameworks is called fine art. So uh it stands for feasible, interesting novel, ethical and re right. So when you look at this in greater de detail, like remember that the study has to be feasible, right? So it has to make a lot of sense. You should have the data available for you to study it, you should have the infrastructure, you should have the knowledge you should have the team, right. So for example, right now, it is uh not possible, for example, to study a very new drug like tazobactam. So Tao Batan is this uh antibiotic that uh has just been discovered uh in I think 2015 or 16 and it is used for Vancomycin uh Vancomycin resistance strains of clos aureus. Now, I can't study the effects of tachy tacho Batam because Tacho Batam is not available, you know, in Bulgaria right now, right. So quite obviously, this feasibility of a study on Pao Baton is not gonna be, you know, it's not gonna be right? So always remember that when you're trying to make a research project, the thought process that should go into this is see if your research hypothesis is feasible in the first place. Can you actually do it? You know the the real or logistical question that do you have the data? Can you analyze more data if you need it? Do you have somebody who can help you with questions if you get stuck somewhere? Now, after that, it has to be an interesting project. Now, interest is largely subjective. So I'm not gonna go into that any further. It's sort of uh effects of explanatory. Now, all ideas have to be new. Uh you know, if already, if someone has already done a type of research work, then you know, it's no point attempting it again, right? Unless, and this is unless you want to actually test whether someone else's observations are correct or not, right? So for example, if a certain uh person says, or you read a uh you read a paper that says operation A is good for disease A right now, you can do one thing which is to test whether operation A is actually uh good for operation A or not like operation A is good for disease A or not like that is also a novel idea because you're trying to verify someone else's study design, right? So remember that uh it is very rare to have an idea that is uh completely new, right? But also it is very rare to come across an idea that has been done so many times that, you know, you're not the first person, most of the time your ideas are likelihood to be unique, right? The only question you have to ask yourself is whether you can feasibly do this, right? And whether you have ethical approvals in place because ethical approvals are central to doing your research work, including for case supports. Now, back in the Union subcontinent, uh you have a lot of case reports there, like it, the because of the sheer volume of patients, you can do many, many interesting case reports right now a few years ago, er, I was a younger guy, er, I, I had gone back to India just once and that was an emergency uh like I was in the emergency department and I managed to er come across this case of this woman. She was six months pregnant and she had gotten attacked by a bear, like quite literally a bear and you know, she had a damage to her carotid glands or a grade three facial injuries to the uh to the cheeks and she had to undergo um a facial reconstruction to an extent, but the baby was fine. She gave birth to a healthy daughter a few months later. Right. So now the point here is that the patient who was in this case, this patient was a tribal woman, right? She lived in a very, in a very isolated village outside of where my hospital was. It was 40 kilometers away in the forest right now. Our uh our thing was that we needed to get ethical consent because even if this patient may never read this paper, she may never even be aware that uh that doctor Shrunk is going to be speaking about this case at all in Bulgaria, for example, maybe she doesn't even know where Bulgaria is on the map, right? Um That doesn't matter. It's her case. It's, it's her, uh it's her illness, it's her injury that we are discussing and we are using her injury to try to educate more people. You know, she is very important for the case report. So I had to send out, I don't even know how many people who could actually go and contact her, find her in the forest somewhere. It was difficult to track her down, but we managed to track her down and we explained to her what the purpose of the research project was and then she gave us her consent. The whole process maybe took me three months, right? I had everything else. I had the, the data, I had the uh supervising physician and the supervising surgeon's notes and everything. But her consent was important right now. Of course, I got her consent and everything. It uh like once she heard what I was using it for. She was completely down with it. Uh It was just very difficult to track her down and I was here in Bulgaria and trying to send people off on a bi go cha to the forest in India. Um It's a very difficult task. Uh Let me put it that way, but it was worth it at the end right now. The second thing about ethics is that remember that whatever you're trying to study should not be known to actively harm the patient. So for example, right now, you would not, you, you would not conduct studies on thalidomide on pregnant patients because it is already known that thalidomide can cause kerat and both defects in patients, right? Especially it is at a high risk. It's a high risk drug for pregnant patients. So remember that your ethical uh your ethical approach is very, very important. It is something that you cannot give up on. You can compromise the visibility a little bit, you can make changes, you can work harder, whatever you can make with like lesser data points, but you cannot ever, you cannot ever work on a research project without every ethical approval in place. It's best not to, right? So now that we've gone through this, now, let's go to the next uh important research framework is this is called PICO. So what PICO stands for is population intervention comparator outcome, right? So when you're trying to do a study. This is a good way of looking at it. So, let's give an, uh, I'll give you an example. I want to study, uh, the rates of patients with acute cholecystitis, cholecystitis who have undergone uh, robotic or laparoscopic surgery. Right. And I want to find out at 30 days what is the level of pain they have? That's it. Right. So, my population is, uh, all the patients who have had acute cholecystitis, right? And the intervention that I'm trying to study is that who have undergone laparoscopic or robotic cholecystectomy. The comparator is the comparator is the level of pain at the 30 day uh point after surgery and then I can understand their outcomes. So, uh hypothetical would be that patients with robotic surgery have uh show or report lower levels of pain than those who undergo laparoscopic surgery, right? So this is a very small, very direct example of how PICO works. Now, most systematic reviews and most reviews, uh most scientific studies actually use PICO because PICO is a very good framework. So please familiarize yourself with this one. So again, we can talk about uh case reports. Now, in case reports, like I've said, you know, you would just take one patient and you just, you know, sort of report on that patient, it could be a disease, it could be a rare complication, a rare new type of procedure, those are called index cases. So index cases are for when you are trying to attempt a new type of surgery for a patient or a new diagnostic uh on a patient. So you can report on those using case reports. And the most important uh thing about case reports is that you have this thing called the care guidelines. So what the care guidelines do is that they actually give you like this full structure or about what information you need to add for your case. So in this case, you can see that you need to have a title, you need to have patient information, you know, what kind of primary concerns were there? Uh clinical findings, diagnostic assessment, therapeutics, and the most important here called follow up and outcomes, right? So when you are going to write a case report, it's not just, you know, you don't just report that yes, this patient had a rare disease and we treated it this way. No, you have to also include uh that what happened to them at 30 days. You know, that's in throat result. We use the standardized 30 days after intervention to see whether the patient is doing well or not or whether they have any further complications, right? The second thing is also patient perspective. So nowadays, there's a trend in research that we have to try to include the patient's own perspective on how they would treat it and the impact of the treatment on their personal lives, right? So an example, I will give you is that I wrote a case report last year uh on a patient who had grade three breast cancer. Uh and she underwent uh a bilateral mastectomy with a sentinel lymph node, uh biopsy, right? And she also had breast augmentation done immediately. So nowadays, for breast surgeries and breast cancer, uh we attempt to do immediate breast reconstruction because that has the best outcomes for patients. So we did that for her and then we uh we gave her a questionnaire first said 30 days after surgery and then after 60 days after surgery, right? So what happened here was that? Um unfortunately, for us, I mean, I won't say unfortunately, but fortunately for us, this, this is the first time we've ever done this. And in the entirety of the European Union, Eastern European region, we were the first resource group to actually include patient perspectives within our case. So we gave her two questionnaires. These are standardized questionnaires where they, where we asked her about her postoperative pain, her postoperative, you know, uh sense of the self, whether she felt comfortable whether she had any kind of uh remaining complications or anything, what her mental health status was like, how did she feel about the cancer? Uh whether she felt uh more closer to her family, things like that. Now, why is all of that important? All of that is important because again, uh this needs to be reiterated. You are doing treatments to a patient you're not treating a disease, you're treating a patient, right? And when you're treating a patient or conducting research on a patient, remember that you have to give them their voice too as your, as doctors, the your primary duty is towards your patients, right? So it does not just go into protecting your patients. It goes a little more than that. You have to try to empower your patients by giving them a voice because most of the time when a patient is sick, they don't have anybody advocating for them, right? And oftentimes you will be the only people as future doctors and researchers advocating for patients. And everything that we do in medicine is centered around patients. It's not centered on some grand idea of treating disease, you know, you treat disease or you fight disease, but you actually treat the patients, you know, you are doing all of these manipulations or procedures or operations on patients. So it is very, very important to focus on that, right? So now we're gonna just go briefly over what an audit is. So an audit is a a very specific way of improving the quality of care that we give to patients, right? And it assists in the education of surgeons and other the staff. These are the two primary aims of surgical audits. It's a critical analysis of actual surgical performance and outcomes. So an audit uh is conducted through an audit cycle. So the first thing is you determine scope and your problem. So for example, I want to know whether all the patients in my department who underwent, say uh uh right hemicolectomy, for example, uh I want to know whether they've been given appropriate pain relieving medication. So what I do is that I determine my scope. I'm only going to select patients who underwent a right hemicolectomy. And I'm going to see the kind of pain management options they were given right after surgery. Then I'm going to select my standards. So there's the who standards on postoperative pain management, right? And then I think the Royal College of Surgeons also has their own guidelines. And then the nice guidelines from the UK which give you uh uh like a proper guidelines on what kind of pain management management you should do. And then I'm going to collect the data. So I'm going to go through all the patients in the last year who underwent a right chemical colectomy. Then I'm going to start asking them whether they received appropriate pain medication within 30 days of the surgery. And then I'm going to interpret the results. So for example, if the results say that, ok, only 2% of the patients said that they had received inadequate uh pain medication. Then in that case, my audit is done, there's no quality improvement that needs to be done because we have a very low uh rate of patients who didn't get adequate pain relief, right. Or for example, I can make changes, I can say that, OK, even 2% is too much. Let's try to investigate what happened here. And then I discovered that ok, maybe uh there was a certain, they were allergic to certain types of pain medication, they were not advised of comorbidities. Then I will come up with a policy framework that says that, OK, for patients with this, with this, with this specific type of comorbidity in which this type of pain medication is contraindicated, we should administer the other one, right? And then I do the cycle again to see whether I have reduced the 2% rate from 2% to say 1.5% or 1%. And that would be a demonstration of change that I identified a problem area. I came up with a policy framework to fix it and then I fixed it. So that is what an audit is. Now. Why is an audit so important? So um if you are friends with doctors currently going to the UK, um I am friends with quite a few of uh people who uh most of my cohort is going to the UK to work. And most of us have this problem that uh most of my colleagues have not participated in an audit. And because they haven't participated in an audit in any capacity, you don't have to generate the full audit on your own. It could be a data collector. Uh because they have not taken part in an audit, they cannot get a job. So remember that the there are two things at play here first is improving your own uh surgical performance at the department, right? But the second thing is it is very, very important for your job and it is almost essential uh to getting a proper job, right in the UK S especially. And I am noticing that this is also happening in Germany and Switzerland uh in America. This was a, this was a thing from a long time, but these are very, very important, right? So now I'm just gonna go briefly over what randomized control trials are in surgery, right? Uh because in surgery, what happens is that we don't have ideal conditions. So, you know, we have two types of, uh we have two types of studies. We have a pragmatic study and we have an explanatory study. So what a pragmatic study does is that we try to study uh the effect of a drug and effect of a surgery or what or whatever under the usual condition. So, you know, we don't try to change anything. We just look at the normal working of a department or a hospital and then try to see whether their use or their uh approach to a type of procedure or operation is good or not. Whereas an explanatory RCT is when you try to replicate ideal conditions as much as possible. So, in that case, you know, you select your patients very well, you only fit, choose the most fit patients. Your patient selection criteria is extremely, extremely narrow, right? So these are the two differences essentially. So finally, one of the characteristics is, let's see in surgery, if you're interested in surgery in general, uh in surgery, remember that we face certain types of challenges that you don't face in general medical research, right? Or in laboratory research. So in surgery, for example, blinding is very difficult, right? So for example, if I want to compare laparoscopic surgery to robotic surgery, and I want to blind my patients, it's not possible, right? Uh because a patient will know whether they've undergone surgery or not, it is the most and even the examining physician, the examining surgeon will know that a patient has undergone some kind of surgery or the other right now, one way that uh social scientists have come up with this idea that um supposing if I want to do an appendectomy, which is the removal of the appendix, and I want to compare this with non removal of the appendix with conservative management, right. So they have come up with a way of blinding in which the surgeon makes the incision, right? But they do not remove the appendix in patients who are in the control group. Now, quite obviously, you can see the ethical problems with that kind of thing. Uh uh it is on very, it's a it's on a very slippery slope uh when it comes to ethics. So, for example, I would not participate in a study like that. Uh uh I'm sure that other people are more confident with this kind of ethical uh liberty, but I'm not, right. So remember that in surgery in general, we have certain difficulties, but we do have other statistical methods as well. Uh So normally we use different types of statistics and surgery and that helps us to carry out very good research work, right? So finally, um I want to thank all of you, right? Um I want all of you to remember just these four things on your slide today. Uh which is that it's never too early to start with the research work. Second, that research always takes a lot of time in patients. You know, research projects can go on for months, sometimes like, you know, sometimes they can go on for years, sometimes they, sometimes if you're lucky, it's only three or four days, sometimes it's like upwards of a year, right? So remember to be very, very patient. Now, one of the most important and most challenging things that I've encountered in research is that there is something called publication help. So what happens is that you've written your paper, you've done, say nine months of work, whatever. And now you are trying to get it published on a manuscript. Uh You are going to try to get it published on a journal. So what the journals do is that they'll send it back to you with like uh some changes need to be done. The second reviewer has some problems with the data, then you make the changes and then you send it back again and then it takes them two weeks to respond and then, you know, there's this back and forth and you know, you can only submit to one journal at a time. So what happens is that supposing one journal does not want to accept it, you have to wait for them to reject your manuscript before you can send it to someone that So what happens is that, you know, sometimes you uh like, for example, I wrote a paper uh back in 2021 and it was published in 2023 because it took the publishers one year to publish one paper. And to be honest, it was not one paper, it was a textbook chapter in uh cardiothoracic surgery. And uh of course, that would correlate all of the other information and all the other chapters. Uh But uh you can understand that the timelines here are very long right now. That brings me to a second thing about plagiarism and exploitation, right? So quite obviously that, you know, the area of medical research is not free from exploitative behavior. So, uh and I'm speaking from experience as well, so let's take the example of the textbook chapter that I wrote for cardiothoracic surgery. Now I was 1/5 year student at the time and I wrote the entire paper from start to finish, you know, uh the non operative management, operative management and everything. And then instead of getting the first authorship, you know, I was given second authorship simply because the first author was uh friends with the project managers. Right. So the first author, uh she was just given that by default, right? Also because she was the most senior to me, uh she was a ph a candidate at the time. So she was given that uh first authorship, regardless of whether I wrote it, regardless of the fact that I wrote the paper, right? So remember that it is very easy to get exported simply because you know, some somebody will be like, oh yeah, yeah, we will invite you to our research group, right? But you do all the work and someone else takes the credit. It's uh unfortunately, it's very common in academia. Now, one thing I can say is that in the surgery research group, uh we follow certain guidelines. So there is the IC MJ guideline on authorship which says that if you like the paper and it is your idea and you've done most of the work, then you are supposed to be first author. Now that is something that I guarantee to all of my students and all of the research part participants that if you're going to take part in a research project, make sure that you just try to solve whether you will get the appropriate credit that you need. Right? Because that is very, very important. Now, for example, like years later when I get cited, for example, um even if I have written the full paper, I am not the author that gets the citation credit directly, right? The first author does. And the only difference between me and the first author was that the first author was the most senior researcher and you know, they were in, they were ph a candidate or they already a phd or whatever and I was only a medical student, right? So remember that uh one of the most important things that I focus on is that in research, there is no such rule that says that only your MD phd phd C with a AD M and a Nobel Prize can be the first author that is not the case at all. If you do the work, you deserve to be first off, right? So make sure that you insist uh you insist that you get the credit that you deserve right now. Finally, I would say that you have to read uh the entirety of research boils down mostly to reading, reading, reading, reading, reading, you have to keep reading all the time and it's not just reading. Uh you have to do active reading, which is like you take notes, you underline you scratch out. There are lots of different software that can help you uh with research and with like getting uh access to research papers and you can also contact your university. You can contact the university library or I don't know if I'm allowed to say this, Jemaah. I'm very sorry, but you can prate resource papers too. Uh If you need to. Now, before you go into prating a research paper, which I think is completely ethical in my opinion, and I'll stand by it to no matter the consequences. But one thing you can do is that if you see a resource paper that you would like to read, but you cannot access it because it's behind a table. Remember that there is underneath every authorship credit, there is a uh corresponding author. So a corresponding author is person who is the contact person for the research that has written a paper, you can always request them for papers. Now in the past, I've had to, I don't even know how many times I've had to request papers from scientists and 100% of the time they've gotten back to me and sent me the research paper that I wanted, right? So you can do the same, you know, you know, as scientific people and you know, researchers in general, we always strive to give our students and you know, young people as much leadership as we can. It is very important because we know where you were, right. Sometimes even at my level, you know, there are some papers I just can't access, no matter what I try, I have to write down request emails to people across the world. Right. So, you know, there could be in Germany, there could be in India, there could be in Finland, Sweden, uh Switzerland, for example, America and every single time they have given me their papers. Right? And that is a, that is something that I find to be the most uh the best thing about medical research that if two researchers come together, they will have this common point. And you know, most of my friends are researchers. I have very good colleagues from across the world. Um I've worked with colleagues from I think 12 or 13 different countries. Now, they're very close friends even now. So the point is that they, it is when you embark on this research journey, uh you're going to be making teammates for life, right? Because, you know, once you start helping out research paper on one project, another project comes up, comes up, another opportunity comes up, someone else requires a help or your leadership. So you understand that once you get in, uh you will always find it easier to continue and then go forward, right? So now that I've come to the end of my talk, um yeah. So if you want to contact me, there are two ways uh ara dot com and the medical trench and I'm just gonna stop sharing for a second here. Uh Yeah, so I'm gonna stop sharing my screen. And uh now if you have any questions, please let me know. And I will also put the link to my research group uh called the Medical re Research group on the chat. Uh And if you want to join us, you can just have to write in your name, email, phone number and your uh university or country where you're from. And we will assign research projects to you. You will also get regular access to training and all of this is free like this is not a charged or paid uh thing at all. All of that will be on anyway. But uh I am looking for a lot of motivated students and if you have made the time to come this evening to my talk and listen to me, go on for the last hour, uh I would say that your motivation is in the right place. So uh this is the link uh if you want to, you can just sign up there and uh me or somebody from my administrative team will get back to you very shortly. You'll also get like a poster with like uh uh all the like a guide to start getting started with research and everything. It's a very useful uh thing if I may say so myself. And uh yeah, so thank you very much and Jemima, it's up to you. Thank you so much, Doctor Shanker. I really appreciate all your effort. Um So yeah, if anyone has any questions, please just write them in the chat. Um We'll wait for people to type or yeah, we'll just wait and see. And also I just posted the feedback form. Um Please fill that in if you're able to and then you can um get your attendance certificate as well. Um Yeah, thank you. Thank you. Thank you. Thank you. So, let's see. Ok, so Francesco is asking what if we are finished with the university and we want to focus on for a period of time only research, what would you recommend so that we can get a place? Um So uh see, this is a very common thing. Um You can, so when you're in the last year of university or something, you can just start like uh asking uh professors or whatever if you can take part in the resource projects. One thing is that uh like, see, I'll tell you what your workflow should technically look like. Um Look at, look for all, like even at your own university or whatever, just look at all the people who have, who are leading resource projects or our heads of department and then just send out an email that uh I am. So and so I've just graduated in medicine or I just finished university and I will be very interested in getting uh uh to be a part of any one of your resource projects that you have. And if you're doing a Multicenter trial or if you have any case reports for me, uh can I get involved? Right. That's the first step. The second thing that you can also do is that um So, you know, right now, for example, if you've graduated, you know, you have a lot of free time uh there during the summer, there are lots and lots of different conferences, so attend a conference, speak to the people there. Uh uh Most of these conferences have social uh some kind of social activity. So you will be like a formal dinner or there'll be some kind of thing like a group workshop or like a TLS or operations or something and then just try to make friends and then you will always find somebody looking for someone and alternate of alternately uh of course, you know, shameless plug right here, you can join my research group. Uh We are looking for people who are, who are both students currently or if you graduated, it doesn't matter. We are looking for research uh participants because we have a lot of different research projects and without the manpower, it is not possible. So I hope that that answers your question. Yeah, super. Um I hope that answers your question, Francesco. Um OK. Does anyone else have any questions? Any comments? Let's just go and see if they won't. Let me type it. Yeah, thank you. Ok. Um I'm just gonna assume there aren't any more questions. Ok. Oh, awesome. Also, if we have a license exam in university, it's difficult to concentrate also on research. Can we specify it or is it better to wait for having more time? Um, so, yeah, look, your licensing exams are very important, right. So, uh, one bit of advice I will give you is that, uh, try to finish up all of your academic work. Uh So listen, um, resource to work is good, right? There is no deny, but your licensing exam uh is more important. So just finish up your licensing exam if you have now, if, if you have it now and then you just try to contact their people afterwards. Because see, I will tell you one thing about research is that uh you need to dedicate some amount of time every week, right? So it varies. Uh, sometimes it could be just like three hours a week, sometimes it could be 10 hours a week or it could be even longer. Right? Uh For example, there was one research project that I had to supervise. Uh, it was called the Cascade. It was done last year and uh I would go to the department at eight o'clock in the morning, do my operative work. And then I would have to spend another four or five hours every day supervising all the other team members who came in to collect the data and everything was in Bulgarian. So I had to help translate and then because I've seen some of the patients myself. So sometimes it depends as well. But remember that if you're going to undertake a resource project, like try to find some time, m minimal amount of time would say is like four hours a week. So that's roughly like 30 minutes every day that you dedicate just for your research work, right? Um There's another question. Are there any medical conferences in Bulgaria for English speaking students? Yeah, quite a lot, quite a lot. So uh in Ple you have something called the M DS A conference. Uh So the MB A conference is the Medical University province like official conference. Uh It takes place in like September or October every year and it is entirely done in English. Um But there's lots of international students who present their cases there. Um I started with this one, the MBE, the second one is that in, in Pleven, there is the summer school for Obstetrics and gynecology. Uh That's also a very good conference. Uh We have very good workshops. Um I have partici I was in the organizing committee for two years for those uh uh for those two conferences, one for last year, one for this year. And you have, in addition to like research work, you can also publish your own case reports and stuff. Uh The Department of on onco gynecology and on uh and gynecology are very good. So you can ask them for like research work or case reports. They will help you out in some way or the other or if they are too busy, then they will send you to somebody else uh who is looking for students. Uh So there are lots of research projects on the way at all times, there will be something for you to work in. Uh Sophia also has it. So, Sophia has something called the IC MS. Uh I think it's, it's called the International Conference of Medical Students. It's also a very good one. It's also in English. And as far as I'm aware, uh PLV also has one, I'm not sure what it is called, but they also have one like I, I know for a fact that they have one. So yeah, one good way is that like uh just try to find uh like go on Instagram and just try to look just so for M DC level. Once you do that, you will see that they have a lot of partnership organizations. So you can do that and you will get uh like get a lot of other uh different conferences. OK. I hope that answered your question. Me, Luna. Um Anyone else before we close and please, again, don't forget to um fill in our feedback form. Um Doctor Shankar, could you put up your details again, please? So that, yeah, yeah, like uh like my contact details. Yes, please. So people can contact you if they do have a question. Yeah. Um You know what I think what I'll do is that um I'll send out the link and I will send out. Ok, my contacts. Ok, thank you. Uh You can contact me on Instagram. Of course, like it's the same as here, but it's like Roger dot com. It is my website. Uh Once you go there, you'll be able to find like my Instagram link and whatever and on Instagram, I think I don't know this. Uh like I'm OK with Instagram as well, like it's not a problem so you can contact me anywhere like you can, if you like on my website, there is a link, you press the button and you can open up on my email uh or you can write a, a contact form uh uh as well and you can follow me on Instagram. I answer questions on Instagram as well whenever I have the time. I'm so sorry. No, thank you so much everyone for joining and thank you, Doctor Shanker for your time. Really appreciate it. Um Yeah, these are his details here. So if you do have any questions or anything you want to ask, please feel free to. Um And yeah, thank you so much guys. I see you at our next talk. Thank you very much. Thank you everybody. Thank you so much and thank you Jema for having me on here. Of course. Thank you. It's always a privilege here. Thank you so much.