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Hello, everyone. I hope that you can hear me. We'll continue letting people join the session, but we will be starting very shortly. I would just like to introduce Jonathan who's part of mps and they are our sponsor for this series. So I'll let Jonathan say a few words before we get into the talk. Thank you so much, Jonathan for joining us. Thank you. And so, hello, everyone. My name is Jonathan Dobson and I am the National Relationship Manager here at Medical Protection Society. So we're probably all aware of what indemnity is and what medical defenses. So I just want to give you a quick introduction to me and how I can help. So, medical protection, where the world's leading medical defense organization with more in 300,000 members across the world helping protect careers, reputations of finances. So you're probably wondering what medical defense means and how it can help you. So medical defense organization can help you a wide range of legal and ethical problems that can arrive from, arise from a doctor's professional practice such as clinical negligence, claims, complaints, legal ethical dilemmas, disciplinary proceedings, general, Medical Council investigations, inquests and fatal accident inquiries. So even when you're working for the NHS, it is really important to make sure you do have a membership with a medical defense organization as NHS indemnity is only limited to the patient compensation and the financial consequence to the patient. So there's support for a doctor if you are working for the NHS and face acclaim in the UK. It is a G M C and legal requirement to have adequate and appropriate indemnity in place and the keywords being adequate and appropriate NHS indemnity is considered adequate and appropriate as the patient is looked after. But from the side of a doctor, unfortunately, that protection is limited by the NHS. So that's why you are strongly recommended to have indemnity in place and over our membership, as you can see by the grid on the screen there. Um As part of your medical defense organization membership like medical protection, you have the right to request support in GMC investigations, which can be quite expensive if you need legal aid and you don't have that protection in place. Help the disciplinary proceedings, assistance with coroner's inquests to the big things that I'd like to highlight to you, which I think you should all be using where free things is. If you ever receive a patient complaint, don't act on that patient complaint on your own speech, your medical defense organization and we can draft up your response and tell you how you could respond to that complaint and give you that advice to hopefully, hopefully mitigate it can be a bigger issue. You've also got a medical legal advice 24 hours, seven days a week. So just to give you an example, if you are facing an ethical dilemma, for example, such as the police officers walked on board and would like information about patient which could breach patient confidentiality and you're unsure what to do. As a member, you have access to that medical legal help line to seek that medical legal advice any time in the day night or any day in the week. But lots of other benefits there to do make sure you're using them um from the case files and that we look at. So from our case files, doctors on average have at least two clinical negligence claims over a typical career. Don't be alarmed. Some of these and the majority of these are throwing out at the early stages. But you do need your medical defense organization to help you with that and assistance with an average 99 claims matters. So that can be disciplinary proceedings, responding to complaints, help to reports and inquests. Um But yeah, I do make sure you are a member member and we have more than we support more than 100 and 40,000 members working in the UK. Um And as I said, you have access to that support the use of the medical defense organizations. You can choose from or as being one of the main options for you too. And what makes us different is that if our membership is free. F two membership is 20 lbs for the whole year and we fix, our membership price is between ST one and S T 3 48 lbs a year or 4 lb 80 a month. So there is a considerable saving and if you are a student, student memberships free, but that's it from me. I'll hand over to the expert speaker today, but thank you so much for your time. Hello, everyone. My name is Krishna. I'm one of the foundation doctors helping Louis deliver this webinar series. And it's my pleasure to introduce MS Jem Ick. Uh MS Jem Neck is a plastic surgery consultant who currently works in Toronto with the background of working um in Central London teaching hospitals for 17 years. She is a founding chairman of the British Foundation for International Reconstructive Surgery and training and has that extent experience of working with British society projects abroad in places such as Ghana, Mali, a Bolivia and Bangladesh, working to working with local surgeons there to expand their repertoire of reconstructive procedures and improving patient care. So I'll hand it over now. Brilliant. Thank you very much. Hello, everyone. As you can see, I'm wearing my special hand broach which was gifted to me by one of my very dear friends who's a therapist. Okay. So uh without further a do, let's start the uh screen sharing, which we just ran through before lose. Fantastic. Okay, cool. So we're going to talk about what is hand surgery and why, you know, you might consider becoming a hand surgeon. Thanks. So let's first look at, you might have heard Professor Simond K who is uh he did the first willed uh did the first double hand transplant in the UK in 2016, Chris kind was the recipient. So it hit the headlines and there is Chris in 2021 with uh you know, trimming the hedge. So that's pretty good use of both hands. And he said it actually changed his life. Now most hands, instants don't do this. Okay. So there is if you want to do it, you can. But if you don't do so let's have a look at see what we uh use a hand for. So we obviously eat it for eating and drinking. Even if you use implements or use your hand, you use it for working, you use this for socializing. So you signal acceptance, you signal welcoming, you use it for talking, you use it for personal care, simply getting dressed and buttoning up your buttons and use it for transport. So you have it's easier to drive the car. If you have hands, you can not use hands, of course. And so the hand is quite important, which is one of the reasons I got into hand surgery. Next slide, please So how do you become a handset? And because before you all collectively grown at this long list of things is so first you have to get into medical school, then you would want to have to do surgery. If you don't want to do surgery, you're not going to be a hand surgeon, then you need to take the first hurdle exams is the membership of the Royal College of Surgeons. And then you have to think about getting a higher degree if you wish to go into plastic surgery. So, orthopedic surgery do what is called long listing. So everybody who applies that, it used to be like that gets an interview and plastic surgery there a little bit more selective. So that you are, you get graded and then you get an interview to get into the specialty and then you do your orthopedic or plastic surgical training and then you have an X L exam, which is the fellowship of the World College of Surgeons. And that is depending on where you are, whether it's England, Ireland, uh Glasgow. So um you, there are some protect, there are some absolute essential course is that you have to do through that training, which of course is something like A T L s and stuff like that. But there's also specific courses enhancer. So how to fix a fracture, how to do microsurgery and that kind of stuff. There is a whole list of things, then you probably need a fellowship in the UK or abroad. And I say that because if you have done orthopedic surgery, then you might want to have the overlap to plastic surgery. And if you've done plastic surgery, you might want to have the overlap over to orthopedic surgery. So plastic surgeons don't do a lot of risks. Orthopedic surgeons don't always do a lot of free tissue transfers. So there is like an overlap and you could easily spend another year doing that to make yourself better equipped to when it's you at the end of the decision tree completely. And then you can and I guess that this is something that is going to be much more required uh that you do the European or the British Hand Surgically Diploma. So to do that, you also have to attend some courses through you out your um training. It's on weekends. They are super good. They're up in Manchester. Absolutely recommendable if you want to or not become a hand surgeon. Okay. Next one. So I'm guessing this is all of you right now thinking, well, I'm not doing that anyway. Let's explore the field a little bit further. Next slide. So I try to have a little look and see what the gender diversity in the surgical specialties were. Uh So because interesting enough, there is no survey of ethnical diversity in surgery. There are for the overall NHS but not for a specific surgical specialities. So there is a paper for you if you wanted to. So at the training level, about 40 to 40% of plastic surgeons of female orthopedic surgeons, only 20% at consultant level, about 21% are female consultants and about 7% are female orthopedic consultants. You know, Debra Eastward is currently the orthopedic chief. So she's the presidente of the association. Uh she's a very prominent figure, but there is perhaps still a lot of things uh for us to work on here. Thank you next laid. So uh we talked about this is the whole um everybody in the NHS. So this is the NHS. Uh it doesn't matter what, whether your medical or a surgeon or whatever you are and you can see the distribution. So if we look at U K, which was quite surprising to me. So in the 2021 census, it's still an 82% of people in England and Wales are white and having come and lived in London for 30 years, I actually thought it was different. So uh you can see. So the senior doctors is a career grade and a junior doctor are slightly different, a slightly different in representation at uh which, which people are mostly represented. And we can certainly see that there is an underrepresentation of the ethnicity that they have here in this questionnaire put together as black Chinese or mixed or even other. Okay. Next. So this is from America. So I don't know what the figures are in the UK. But this is something that, you know, I'm sure. So the in America it's on the up and up. So that's excellent. Next one, the other group of people that perhaps is under represented, well, clearly is represented, is that 4% of doctors in the UK identifies disabled from last year, 2021. It would be nice to make room for them. And currently I have an ankle fracture. So I am momentarily somewhat disabled and I can see that hand surgery's great because I can sit down for my operations and I'm sitting down from my examination of patient's. So if mobility is a problem, I can thoroughly recommend it. Okay. Next one. So let's look at the positives and negatives of hand surgery. So the positives are we work in a multidisciplinary team. So there is the patient, there is the doctor and there is the hand therapist. Uh this is in the clinic, then there is that this group moves along to the theater and then afterwards, the patient's expectations are usually okay. They come with you to with a problem and you're going to fix it. So they already have a pre existing problem and we're going to make them better. Uh As I mentioned, you sit down for operations so you don't get America's veins from standing up too long. And there is an enormous amount of different operations that you can do with lots of different kit. And if you use soft tissue, that's great for you are more for bones, you can do that for sure. And then unless you work in a center that has re plants, the uncles are actually fairly easy. Uh, there aren't that many things that will get me out of night, out of bed at night. Touch wood. Ok. Negatives. So, uh because it's a to specialty as in plastics and orthopedic, sometimes we can have a little bit of headbutting but there you go. Uh the results aren't particularly, always perfect. Some of them are amazing and they're really, really operations which you can see this is the problem. You do this and people get better, they get back to normal activity. But some of the results aren't, aren't quite perfect because a lot of what we do deals with trauma, you know, somebody's punch somebody else and in that whole episode have injured their hands. You know, you might be dealing with your fair share of aggressive drunk patient's, which usually, you know, are quite nice. Once they sober up, we've talked about the education. So it's a subspecialty of both plastics and orthopedic and therefore the whole education is longer. But sometimes, you know, enjoy the journey. It's the end result. You're going to be a consultant for years and years and years, you know what? It's fine. You're, you're, it's okay to wait another year to get there. Um, and we're not really seen a saving lives, right? We usually say I save the world of finger at the time. I think it's okay. Next one. So back to the kit. Look at us who wouldn't fall in love with us. Ok. So we have the microscope for micro re plantations to do fine work. We wear loops. So they're magnifying glasses. So they're on top of your own glasses in the magnifying things for up to six times. If you, if you want to do that, you could do microsurgery that there was the whole drawer of all your metal work that you put, you put plates, you put screws, you put K wires which are long thin wires that goes into bones and hold them steady. You can do, you can even have more kit and do arthroscopies. So into the wrist joint, which is a very orthopedic thing and I don't do them, but I've taken a picture here from the internet next one. So, okay. So all of that sounds perhaps a little bit interesting. But you know what do we do? So what, what do I do? Ok. So hand surgery is honestly from cradle to grave, right? So there is congenital abnormalities, there is lots of trauma, there is cancer, there is arthritis and inflammatory conditions and all of this can improve. What we do is we improve hand function and you reconstruct both the bone, the muscle, the skin, the tendons, the joint, the nerves, the nerves that supply the muscles and even vessels. If something is cut off, well, join it off again. And as I said before, it's a close collaboration between you, the hand therapist and the patient. Right? There's a three legged stool and that doesn't work without one of you. And it is all about function. I mean, there is a small part of hand surgery that actually deals with cosmetic hand surgical operations, but I don't think we'll get into that. This is about function. Next one right now, you might think and some people might say that. All right. So I'm just a technician. You know, I can fix the joint or I can put a screw in and that's it. Well, no, no, no, no, no, no, no, no. What you also need to know about as a hand surgeon is specific nail abnormalities, how they relate to internal medicine problems. A lot of pediatrics, rheumatology. You need to be able to look at your own CT scans or your x rays. For sure. Radiology is fantastic, but you also need to see them yourself. You need to know about infectious diseases and what could cause some pretty horrendous hand infections. You need to know about the genetics that are behind both congenital abnormalities and anything that has to do with wound healing. So a whole lot of medicine, not, not just surgery and not just anatomy. Okay. Next. So let's start with some congenital abnormalities that we see and treat next. So this is a plethora of problems. So, on the top left hand, uh the giant middle finger is hypertrophy. So some people are born with the metabolism of certain tissues that makes them grow bigger. So this is obviously um something that you discover at birth. So you can either make the you you recognize when that finger has reached the size of the adult counterpart of mom or dad And then you can stop it from growing anymore, at least in the length. But a lot of these people end up with partial amputations. The next picture long as you can see, we're missing a couple of fingers here. But this is just to illustrate that you don't actually have to have a fully, you know, a full hands, a full complement before you're absolutely able to do all sorts of things. And this little uh person is writing, the two next pictures are together. Uh So you can see, you might remember there are two forearm bones and in one of these, you can see on the X ray, there is one of them missing. So this is a radio because this is the one that's missing, its the radial side that just hasn't developed. The eagle eyed of. You will also see that sometimes you don't even have a thumb. So everything on this side is missing. So you concentrate on getting the hand out to length and then you can make another thumb picture underneath is what we called SIM bracket, doctorly sim, meaning together bracket, meaning short dactyl is anything with fingers where you have a condition where you have short stubby fingers, you can make them longer, you can use some toes to make them longer or you can distract the bones and then we have polydactyly. So poly many Doctor Lee again, fingers is the most common. One is seen there at the bottom of the middle, which is just an extra little nubbin, which usually gets tied off or you have something like that, which is central polydactyly. So in the center of the hand that you got too many and if this interferes with function, we like to get them back to or down to a more manageable number of fingers. Okay. Next trauma, big part of my life is trauma. You wouldn't believe what people do. Okay. So we have the of course, uh person separated from bitter finger. Can we put it back on again? Well, we usually can, if it's a nice, fairly nice clean cut, if it's something that's been torn off, it becomes very, very much different, then we have a lot of fractures where you can use your kit to fix them, then we have open injuries, especially if you live and work in an industrial area with machines if and that is with or without safety measures. But you have soft tissues underneath the picture at the bottom of the middle is from an electrical burn. So if people live in areas where electricity is a little bit hard to come by and you perhaps uh the cables sound insulated or you might get your electricity. Uh not sort of in a conventional way, you'll have more exposure to electrical burns which don't just and destroy the skin and it also destroys the underlying tendons and nerves. Uh Then we have the long term sequela of burns. The one in the bottom right corner is a hand burn. So you imagine that hand burns becomes, it becomes pretty tight and stiff and in something that's as movable as a hand that becomes a problem. And so you don't just deal with that at the initial stage to get the hand covered with skin, but also long term next. So more trauma. Okay. Lots of kits, lots of fancy stuff. You can put screws in to all of the screws, stay in forever. The plates for the distal radius fracture, you can take them out, you can take plates out of the fingers if they irritate patient's. But we often have constructs that leads the fingers to be able to move at a continuous rate, obviously not using them completely normal. What's the fracture heals next? So we also try and reconstruct things of the things. So everything in plastic surgery is to reconstruct things to make things heal faster and to give people back function. So the little finger tip there, you can leave it to heal by secondary in tension, which means you just heal it with dressings or you can move a little bit of skin, which is just attached with the, the end vessels that supply the tip of your finger and it is sensate. So that's really neat. Next, if you have bigger areas, you can take more skin, you can incorporate skin and tendon in a flap to make sure that you reconstruct the area that's injured and then you can close the primary, that's great primary uh, donor site. Next. So this is, uh, this is a rollover from a car. It's a typical injury. You have your car on the top of the roof, but then the car rolls over and your hand stays on there. So not a particularly happy hand, but you need, you need to cover those tendons so that we can get a good, uh, good function out of that. And that's better to do with something that comes from the same arm that's vascularized. That'll be nice and soft and pliable rather than the skin graft, which become tight and not working so well. Okay. So the last thing we do, I suppose, which is sort of the, one of the pinnacles of, of hand surgery is that we take to's for and make new thumbs so we can make a toe, we can either take it from the big toe. Uh, and there has been lots of studies about this that you don't, you lose, that you don't lose in gate as in running, walking or you can take the second toe. So this is applicable both to congenital abnormalities of the thumb where this just isn't there or if you've managed to lose it at another time. Next cancer. Yeah, you can have hand cancer. But you know, it's the tissues in the hand that makes the cancer. So most uh most of these, these pictures on your left are from uh immunocompromised patient. So, immunocompromised patient, especially kidney transplants have get a medication that makes their chances of having a skin cancer as a white person far, far, far higher. So 200 times. So it's all the sun exposed areas that are out and they get cancer, that's it. So this is skin cancer. But because there isn't that much between the skin and the underlying tissues, you get invasion and have to reconstruct much more than just the skin. If you're not white, a lot of people get not a lot. Thank God for that. But some people will get a subungual melanoma. So you're all probably aware of melanoma. It's a very malignant skin cancer. It can develop in pre existing malls, but it can also be in other places, especially around nails or the palms of hands or in the soles of your feet. So that would be another specific hand cancer for sure. Next, then there are other tumors of the hands. So the most common one is on your right hand side, which is a simple ganglion. But you can see that that looks pretty large and probably isn't conducive to good range of movement of the wrist. They can burst there. A simple out patching from a sleeve around the joint. So you produce a little bit of uh fluid inside the joint. And if there is a little abnormality in the sleeve surrounding the joint, it will come out and produces a ganglion, the ones on your left hand side about the X ray and the clinical picture of somebody who has bony abnormality. So these are in Condor MS, that means that they're made out of cartilaginous tissue. Uh they can be solitary, they can be multiple and if they're multiple, they can be on both hands and they can, you say is you can see produce a decreased range of movement and therefore decreased ability to use the hands. Next, arthritis. Yep. Next, arthritis comes in a variety of forms. You can have juvenile arthritis too. But you know, the bigger ones are, are rheumatoid and osteoarthritis. And what happens is because the thumb is so strong and because the way they tendon lies and the joint becomes expanded with the disease process in the joint itself. And if you can imagine it's like blowing up a balloon. But all the tissues that otherwise that snugly around the joint now gets pushed out and stretched and then your thumb pushes them over to the other side to the onerous side of the hand. And once that happens, you actually get a dislocation, as you can see on the large X ray on the right, you get a dislocation of the joints in the, at the MCP joint. Now, that doesn't good for, that isn't very good for function because you lose your strength and tendons that everything is finally balanced. So it has to be at a certain length, we can replace the joints and we can rebalance the hands to get those fingers straighter in a better position for the tendons to pull correctly. And the joint replacements take, take away the pain. So that's a good one. Next contractions. Yep. Next contractors come from a variety of things. Okay. They can be congenital, bottom right hand corner with both the, the little fingers, it's kind of actively. So it's a contracture of all the tissues on the volar of the palmer side of the finger. Then we have in the middle with the very, very long fingernails that was trying to illustrate that these contractions can be so bad that you can't get to cut the nails and they'll cut into the palm. So this can either be from a stroke from Parkinson's from any, any events in the head. It can also be from do patrons, which is the left hand where you can see the little finger is also contracted which is a disease that mostly is seen in Nordic people but is prevalent all over the world. You'll find somebody from everywhere in the world that has that. The top left hand picture is a post contracture, post trauma, uh contracture, there wasn't treated initially. And the top right hand will just show you one of the one of the ways that we can, when we're short of skin, we can replace it with skin from somewhere else. And then they have to have a lot of hand therapy to get going again. Next. No pauses, okay. So no pauses makes you not be able to use your hand. There is no input to the muscles that move the hand. And this can be either up from the brachial plexus or it can be further down the um so we can reanimated, you can make it work again. Um And you can do that. So the earlier you get this, when you have nice supple joints again, here's your hand therapist is key, right? You need to have supple joints, otherwise you can reanimate the hand as much as you like and nothing's gonna work. And then we'll just have a look at the next slide. And this is we're talking about break a Plexus, you're unable to use the whole upper limb next. And we do this with different ways. So we do this with tendon transfers. So if we have some functioning muscles and uh some functioning muscles. We can use an expendable muscle to do something that's really important for the patient. We confuse joints and you, I'm sure you're sitting there thinking, well, how if she refuses joints that surely doesn't, you know, increase the range of movement? No, it doesn't increase the range of movement, but it gives a stable platform on which you let you work on. So if you have a brachial plexus injury where your whole hand is a whole upper limb is affected and we make the shoulder stiff, but reanimate the shoulder girdle, then we can build to make the rest of it work. And then you can put in, you can use the nerves that go to specific muscle and instead of transferring the tendon and muscle, you can just take the nerve and connected to a different muscle to make that muscle respond to a certain nerve stimulus. And then in the end, we can also take a completely different set of muscle and nerve and plug it in and make that do work for us next one. So to recap, I know that you all know the brachial plexus by heart, right? Okay. Hand on heart. Yes, of course, you do. Okay. It is a lot. And this is so anything that has to do with brachial plexus, it's a systematic going through every single muscle, what there is and what there isn't. And then you make a plan that's all there is to it. So systematic slow gruntwork to find out what works and what you can use next. So we talked a little bit about free functional uh muscle transfers because I think it's quite exciting. Okay. So you can use it for the deltoid. So you can get some shoulder movement, you can use it for biceps and triceps. You can use it for flexes and extensive is and then you can also use it to get your some moving better. So these are the thinner muscles, the thinner muscles and the hype athena muscles. Next one. So if you had somebody who had a dreadful crush injury and lost all the muscles on the back of the hand, or you had a fracture of the forearm and all the muscles that was in the back or the front of the hand died and couldn't work anymore. You can take another muscle from the leg which you don't use the grass and this is the muscle on the inside of the leg that you can use and you can plug that in and then you plug the nerve that would have supplied the original muscles into the nerve for the grassless and you get moment next. So I really hope that you'll consider hand surgery's a path because I think it's exciting and I there's new things happening all the time and I'll just end up with giving you a couple of places to look for. If you were looking for Bursaries Fellowships tasters, you know, courses that you might be interested. So you can both get them through the B S S H, which is the British Society for Surgery at the hand. And there are also some through bad press, which is the British Association for Plastic reconstructive and aesthetic surgeons. So absolute best of luck and go home surgery. Thank you so much, Miss Jamaica. Let me just remove the slides. Thank you so much. That was really, really, really great talk. That's exactly what we were looking for because we saw a really great range of different cases and we looked at all the different types of cancer trauma arthritis, all these things that I, I think that's really great because it's given our audience a really good overview of the hand surgery. So, thank you so much. We really appreciate you joining us today. You're very welcome. Um If anyone would like to put any questions in the chat, we can ask them to Miss Jamaica, um, and see what she thinks. Um, just to kick things off. I actually had a question 1st, 1st off, I was just wondering if you had a particular sort of subspecialty within hand surgery yourself or, or a specialist interest, I guess within hand surgery, you can always make it even more specialist interest. So I would say that my specialist interest is, um, if there are problems, there are always different ways of solving them. And I think that one of the reasons I entered plastic surgery is to do because you can do so many things and there are many ways of solving one particular problem itself. Now, I am supposed to be a specialist in two pitchers disease because that's what I wrote my thesis on. And so I get a lot of, a lot of uh referrals for that. Um I personally like, I think those are very exciting operations to do because it's a lot about technique and how you get them back from something where just completely nonfunctional to something that can work again. Trauma, but trauma is probably what I really like. That's, that's really cool. Yeah, I imagine it must be really cool to just see someone with that big transformation after a single what it is. I cannot emphasize enough. How much is a group effort? Right. Yeah. For sure. Right. I can do whatever I like in the theater. If they don't have the therapy follow up and if the patient doesn't engage and can't engage for whatever reason, it doesn't really work. Yeah. And, and within trauma, do you do many re plantations yourself? So, I am working at Toronto Western, which is one of the to replant centers in Toronto. So, yes, but let's not talk about that because I have a weekend on call coming up. So, you know what it's like if you talk about how quiet you want to have it and it's gonna be help So, yes, we do re plants and we do them with regular intervals. Um, but here's to not doing any of this weekend. Yeah. Um, fair enough. Um, I know it's a little bit besides the topic of the talk. But I was wondering if you would be able to tell us a little bit about your experience working in Candida. Um, and compare it maybe to England a little bit. Sure. Okay. So, medical school in Candida and I know I'm glad you're sitting down. Okay. It can be three years. Wow, some are four years. But before they get into medical school, they have another degree beforehand. So it would be anything to do with uh not medical health sciences, for instance, some are biochemists, some are completely different. So you have to do it some kind of degree beforehand and then you go into medicine, then they don't have this. So when you decide to become a surgeon, for instance, you arrange for you, you get a little taste a week from, from time. So through the, towards the end of your rotation, you get put through different uh departments and they get put through, put through to plastic surgery. If you have a specific interest, you must arrange your own attachments because when you're finished with medical school, that's it. That's your first day of whatever you matched into, right? So there is uh and in the first year of your, let's say that they become plastic surgeons. In the first year, they have very targeted training. So they have a boot camp, a plastic surgery where they hear about all the different sub specialty they get into, they go to flat courses to micro surgical courses, they have attachments to allied professions. So also general I T U and aesthetics, all sorts of things in that first year. So that first year is kind of preparing you for the rest of your career. And then they go into uh and then they have four years, my heart cries because it's a lot shorter than the UK, four years of plastic surgery. At which point they have an exit exam and that's it. Okay. That is a pretty fast system compared to what we used to, for sure. Yeah, as a consultant, you are self employed. So the hospital does not pay me okay. Yeah, they pay me a small amount for being on call, but I bill for every single patient. I see. So I will say that there are both pros and cons. Okay. So in the UK, you have a system where I can see five patient's the clinic if I want to. And here I can have a system where the more patient's I see the more money I get, but you have to find a personal balance so that you're able to actually sit down and talk to your patient's appropriately and institute the appropriate treatment. So in a system which pays you, there is an incentive to intervene in a system which doesn't reward that there is a none. So, somewhere in between is the right balance. Okay. And do you have any, um, I guess comparing the health service in Canada's and England, do you have a preference or other aspects that you like about one and not the other? Um, okay. Well, quite a difficult question. Yes. So I will say that the National Health Service and most of the UK is a been fire at the moment. Right? Yeah. Okay. So fully support the uh the all the doctors are going to go and strike. Absolutely. For 100%. I think that um I, you know what, it, ultimately, it all boils down to interpersonal relationships and I have had great interpersonal relationships in the UK and I have great people here. There are pros and cons of each system and you just have to turn those to the patient's advantage. Most of all. That's what you, that's what you have to do if your moral, you know, so moral compass is important. Uh I like that. There is um because people are perhaps well, the better renew, berated as a physician, as a surgeon, but not as a nurse. And I don't think as an allied profession here. Uh So the, but the constant undermining and underpayment and lack of resources in the N H S is a massive problem and it undermines morale and I don't think you can diminish that um feeling and especially now after we've been through the pandemic where people have worked under appalling, you know, absolutely appalling circumstances. That's very true. Um um I've just seen in the chat that someone has said Thank you Ahmed. Thank you for giving, for giving your praise. Um I was just wondering if Krishna, if you had any questions for MS Jem. It, yeah, I had a couple. So the first one is what in your opinion is the most exciting new techniques sort of emerging within hand reconstruction. So why you think that the most important, the most exciting thing is that we're using, that we're getting finer and finer in what we can reconstruct that were so the arthroplasty. So the joint replacements of any of the finger joints is getting finer and finer. We're also developing the methods where we can take one toe joint, not the whole toe would be also uh to, to reconstruct a hand joint, so smaller and smaller um things that we can do that makes a difference. Okay. And the second one was in medical school, it might just be my own medical school were frequently taught that D Point Terance has unknown etiology. I was just wondering if you sort of knew there is an etiology that's emerging with it or sort of like pathophysiology. Okay. So do Britain's uh Deputies disease is connected to chromosome 16. There is the Oxford Group that map the whole genome. It's connected to probably free radical uh in the palm is connected to fibromatosis in other parts of your body, like your frozen shoulder, you have later hoses, you have Peruvians disease, you know, Lederhosen Xyz in the soldiers of feet and Perones disease is only for the boys. Uh So there is, it happens on a on a very basic level so that something triggers off the change. So all the, all the court, all the bands that become cause in the hand or pre existing, right? So there must be something that triggers that off and probably your genetic predisposition, predisposition to this, you know, pushes you over the edge. You can have trauma, you can have repetitive trauma, you can have single trauma, you can have a judge wear and tear. That could be another thing I have just reviewed a paper from India where they've had 2020 cases of do patrons disease. It was over quite a long time. But so, but my, my point to here this is the weekend pinpointed to wanna, we always used to say it was the Viking disease. Okay. Now, I know I'm born in Denmark. There was zero Viking in my blood line, but yet my dad and my granddad had it very interesting. And my last question is within the UK. Are there any places that you recommend for training uh for sort of blooding plastic surgeons? Right. Yes, I do. Right? Right. Right. So I must say so the, so I think that the, the units who offer hand surgical training per se are mostly orthopedic units because they've obviously got, they're much better together. So, however, I would say that. So the orthopedics there is a hand surgical unit in Derby, which is fantastic. You want to do that for wrist? Okay. Then I would look to Manchester, uh to look at the, at the hand training there. Of course, there's great Ormond Street Hospital in London, which was fantastic. There is Dean Boys Wales who does a really good, amazing job for a pediatric hand surgery. So there are particular are hand surgical things. So, so the thing to do is to go to a hand surgical conference, go to be SSH surgical conference meet people, right? See what there is. Find out to people who are already in those already in those um posts and see what they say about them. So don't forget it's not a closed book, right? You can you, you get onto your clinical rotation and you'll find out that, you know, your colleague who's is near completion, their training is has done something you say? So what was it like? You know, did you actually learn something or is it just something you put on your CV? Yeah, that I think that's really great advice. Thank you. Thank you, Paul macarthur Vivian Lease, right? Lots, lots and lots. Chelsea and Westminster Rupert Eckersley Yes. Lots. I was just wondering, um, I had one last question myself. Um, this is about one of your earlier slides and also slightly, I guess, not related to answer every per se. But, um, when you mentioned these gender disparities in the different specialties, um I thought that was quite an interesting and important statistic to mention. And I was just wondering about the difference between the plastics, plastic surgery and orthopaedics. Why there was such a big difference between those two specialties in your, in your mind? You know what I would love to think. Unfortunately, pediatric surgery beat us, didn't they? And ent beat as well? But I would like to think that, you know, plastic surgery is always on the forefront, you know, we'll be there first off. Right. Okay. Maybe a little bit lagging behind with the gender thing. I don't know. I honestly don't know. I think, you know, if I, I think it's, there are so many more women in plastic surgical training now and they'll just have to, I think we're at the time where we're just going to filter through that, you know, that we have lots of trainees and they're just need to filter through to the, to the other side. I think we're on the cusp. Right. Right. On the cusp. Yeah. Yeah. Um, I hasn't been any other questions so far. Nobody has asked me anything, why myself to sleep tonight? Don't worry about me. Well, I can say that for me myself, I've learned a lot and, um, I definitely, I personally, I've not had thought about hand surgery too much myself. I'm quite interested in plastic. It's definitely opened my eyes a little bit more to like the variety of hand surgery for sure. So I really appreciate that and I hope our audience as well. I've learned something. So, thank you again, Mr Make for, for joining us. You're very, very welcome, take care and I wish you all the best in all your careers, just the very, very best for your future. Thank you so much. Thank you. Bye bye. Thank you everyone for joining us. I hope you learned something. I'm just gonna put a few links in the chat, there's the feedback form there and I'm just gonna put a few links to join w few men. And um also just to let you know about our next talk, which will be in two weeks time, this time it will be by MS Elizabeth Chip who is a consultant burn surgeon. Um It the Birmingham Child's Hospital, pediatric hospital. So I think it'll be a really, really good, great talk. Um If you're interested in burns and plastic surgery generally as well, um we'll dive deep into that subspecialty and hope to see you there. So let me just add those links and a reminder for our next talk and yeah, thank you for joining us and thank you again, Krishna for introducing our speaker and um asking your questions. But those some really good, great, great questions. Bye for now everyone.