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Good morning everybody. Uh it looks like yes, you are able to hear good. So without further ado and for the third, the third time this morning, I am going to introduce Mr Skidmore who has an incredible wealth of experience um and a career that is absolutely phenomenal with lots of stories to go with it. Um So I will hand you over now. Alright. Oh, good morning, everybody. Um and to uh those medical students who have actually decided to get up at uh uh nine o'clock in the morning rather than the usual 1130 on a Saturday. Um I hope this will be interesting to you. Um What I'm gonna say, uh it will be er contentious, politically incorrect and a complete variance with uh NHS policy, but I want to help you plan a career um in surgery and what's gonna happen in the, in the years going ahead. We're very different from what's happened previously. It you get a situation for instance, uh as happened with uh Wuhan and the uh COVID epidemic whereby people are suddenly taken out of their comfort zone and have to do have to work in a completely different way, um, when I, uh, had been qualified for 10 years, um, I've got two Fr CSS and a research MD, er, an incoming government run by Harold Wilson decided that, uh, they didn't want to have more, more surgeons doing cardiothoracic work. And so I and six other, um, gen, six other senior registrars were hung out to dry and we had to think of a, of a different career and I went into surgical oncology. So as far as what your planning is concerned, there's three groups of people, you, you should never trust. Um First of all, um never trust health ministers. Uh look at Hancock's performance um er as per the COVID inquiry um here was a man who was, was a health minister uh doing backward somersaults on policy and spending his time examining the gluteus maximus or one of his uh research assistants. Um You read with astonishment uh about the actions of pygmy politicians, er when they're w worrying about the um COVID situation. Uh So, and the second group you should not trust are managers. Um Here from a recent article in the economist are a list of what people would deem to be managerial objectives as far as I'm concerned. Uh The important aspect uh in my surgical career of managers was a to ensure that there was a clean white coat er for me at the beginning of ward rounds and in the outpatient department and also that at three o'clock in the morning when you'd been struggling with an aortic aneurysm, ruptured aortic aneurysm for about four hours that there was a, someone in the kitchens to provide bacon and eggs for the, uh, for the, for the, er, operating team. So, we've got this situation, er, in a hospital, there are the, uh, you and I, er, leaders, the surgeons and physicians making decisions. There's the managers trying to ensure that you've got the appropriate role. And then there's a hybrid uh a chief executive who will be usually medically qualified, but who's going to have to balance out these various groups uh with their different functions. But the fundamental lessons. Uh uh and I'm quite certain about this is that the moral authority to run a um, a hospital must rest with the clinical staff. Now, the third group of people you shouldn't trust are entrepreneurs who come to you and say they've got a brilliant idea for your research project or, er, particularly in, in the biochemical field. Er, you may remember this, er, smart young lady with her um, er signature uh black polar neck sweater, um who persuaded, er, people that the Theranos um method of managing er, blood test was appropriate. Er, but of course, it was a monumental lie. People were gullible. She took large, huge amount of money off, er, people, particularly in, in, er, er, Silicon Valley and she's now doing an 11 year jail sentence closer to home there was a guy called Ali Pasha who set up a company called Babylon Healthcare. Some years ago, he got a phd from uh from UCL and he persuaded Hancock that his A I system would get rid of doctors every adult would have in their pocket. Uh A little real time device which would identify disease process at an early stage. He took $4.3 billion of investors uh before the whole system collapsed. So I want to impress on you, as I said, that you've got to watch out for these people who are trying to persuade you to take a short cut. Now, a surgeon should be a physician uh who can operate. There aren't any short cuts in the necessary training to be a fast jet pilot or an Olympic athlete or a competent surgeon. The science of medicine is something that students have to pick up as part of their intellectual capacity and understand anatomy, physiology, and pathology. This er man William Osler and there's his uh timings, er, was the, he founded the, er Johns Hopkins er Department of Medicine in Baltimore. He founded the history section of the, the, the, the, the sorry, the at the Royal Society of Medicine, um the, the History of Medicine section, he trained under Weko er in Germany and returned to Philadelphia as a professor and then came to this country where he was professor of medicine at Oxford, er, a Canadian as with John Bell who's the present, er, professor and he sadly died of bronchiectasis, uh, and the flu at the end of the, the first World War. So, where to begin? Well, the science of surgery starts with a, as it were with a fertilized ova, normal anatomical growth and the recognition by clinicians and by you as students of what can go wrong in that process, pre uh predelivery due to external physical factors such as radiation or dietary deficiency or infection by virus, et cetera. And so that can be the congenital or certainly acquired congenital pattern. And then there are the other um factors which can interfere with patients, disease processes, trauma, et cetera. As life goes on through surgery has never been a, a civilized job. Don't let anybody tell you it was, you've got, I've got a promise registrars when they come, when they or I did promise when they were coming to work for me that there'll be times when they're tired, they're hungry, they're challenged, uh they're stressed and sometimes not able to be with their family for long periods. In uh when II started in about 1956 as a, as a school boy doing physics, chemistry and biology. My career options were either to go for med school, um or to join the Royal Air Force. Now, 1956 was a very strange year, there was the nationalization of the Suez Canal, uh, and the invasion uh from er Britain France and Israel. Uh there was the Russian invasion of Hungary with phosphorus bombs falling on Budapest. And we, as a bunch of 16 year olds were thinking that this could well be the Herald um, of the, er Third World War. This book, uh I picked up at about this time, this uh extraordinary man and I recommend you to see whether your uh medical school library has got this book. Um, he um, was working in Germany, which of course was the great center of surgery at the end of the 19th century Billroth Polier Koch. We uh and so in 19, in 1903, er Sark as a research registrar, er, was working with Langerhans in the Pathological Anatomy Center in Berlin. And then he got a letter from Von Miz giving him a, a place as a voluntary assistant. Now, at that time, of course, one of the great scourges uh of disease was tuberculosis and as uh Von Mikeli said, 100s of thousands of people are succumbing to tuberculosis because as yet, no one has been able to operate inside the thorax. Sarr explains that one night, he woke up with an idea and went rushing to his basement laboratory. He wanted to construct a container of glass with rubber rings at one end that would be hermetically fitting around the neck of his do the dog he was gonna operate on. And so that the head and the hindquarters were gonna be outside the container the container had to have two apertures in which he could put his hands. Now you think about an incubator for babies and what this man did was to fit a this glass container onto the chest and he realized that, that he could cope with the negative pressure inside the thorax, an absolute brilliant idea and the lead into the whole of thoracic surgery. Um He was a, he was a Prussian autocrat. Um he, um, there was one occasion when he came back from holiday and found that, um, one of his registrars um, had, had the temerity to get married. Uh, he called the man in and said, I didn't know you were going to leave us so soon. The other, as far as I was concerned, er, the other determinant for going to med school was the, was the film doctor in the house, which of course was based on ST thomas', er, experience, er, students who had ex military, they'd come out of the war as officers and they went to be medical students at Thomas's and boy, they were going to enjoy it. Now, here is a man who was of great importance in the whole history of surgery. She's going back to about 1600. Uh, he had three major components that of, of modern surgery, which we followed ligatures, amputation skills, quarterly, where necessary and then subsequently a, a career in obstetrics. Now, modern surgical s can I have the next, I'm so sorry. Yeah, that's fine. Um, but of course, surgeons have always had people, um, opposed to them that in Paris in the 17 fifties there, there was a college of, of the master surgeons but they wanted to get recognition from the physicians in Paris. But the response from the physicians were these four components. Science is obviously forbidden to surgeons. Science is difficult for surgeons and impossible for them to acquire, er, science is useless to surgeons and it's positively dangerous for surgeons to think about. Science. Get one from this and more. But trauma of course, has always been the great problems. Uh great problem and here this is uh trotter who was a physician to the fleet. And the problem there was that er, in the, in the great sailing ships, you have a ship of 1700 tons, but 600 men uh attack would mean shot and shell falls from the rigging and when a cannon ball hit the wooden er, walls of the ship, huge splinters of wood would go flying off in every directions and you would find people impaled by great big splinters. In addition, of course, the the surgeons of the fleet um had to deal with malnutrition, hypothermia, renal failure and epidemics. And when they, when they wanted to put men ashore for treatment, of course, quarantine came in and so men were being admitted late to med to medical hospitals around the world. Gibraltar, Minorca Bermuda, et cetera. So what was happening in this, in this country? Um, at the end of the first World War? Well, this is the inaugural meeting of the Association of Surgeons. And if you look at the bottom, you note, um, how war was in, was the constant, the, the, the, the, the, the, the problems of warfare were high on the list of the subjects, er, that the, the surgeons at that time would, would be dealing with. Now, here's a, here's a, a smart bunch of well dressed young, um, undergraduates. Um, no time wearing a cravat, um, and, um, central to, um, this group, er, is a, a lovely girl from Girton called, er, Cathy Duncan who, um, was, uh, engaged to an American Fulbright scholar. Um, he took her back so she did her clinical work at Harvard, progressed through pediatric surgery, professor of pediatric surgery in Washington, professor of pediatric surgery in Los Angeles. And, hey, presto, the first woman to be president of the American College of Surgeons. There's my great friend. Uh, we're in regular contact. She lives in California, but her career was absolutely outstanding. She'd been in every big center and as I said, first woman and of course the first brit, uh, to, to be uh president of the American College, uh, other undergraduates that I was with, um, you might recognize these two, Ken Clarke, er, former health minister, uh, on the right and John go now, Lord Deben and, er, the great advocate of um, uh cop 20 on the left hand side and we had so we had some interesting people around but returning to Cambridge, uh this was the extraordinary professor of anatomy who had an enormous influence uh on my career. Er, Dickson had qualified as you'll see from, um, be from Belfast, like so many of us. Um, he went across the Atlantic for some of his training to the Carnegie Institute where I did my MD on embryology or some of my work there and, and then came back as professor of anatomy um at the Royal London, er, at the age of 31 and then transferred uh to, to Cambridge. Um, we were, we were very fortunate. Uh The master of my college was a Nobel Prize winner. Um, we were taught by university academic staff, er, with, er, people like Andrew Huxley, uh Dorothy Needham, uh from Actin and my, uh Watson Crick Todd Race and Sanger Nobel Prize winners. All of them. This was uh Dickson's brilliant book which has stood the test of time. Uh I've got a copy uh on my shelf which will go to, er, my grandson who's doing first year medicine, uh do down in, in Bristol. But it's the, as is your embryology. So is your surgical anatomy and, and that's what you have to concentrate on when, when, when I, um, when I'd done three years at Cambridge, uh I went to Birmingham where again, there were some, um, here in this city were some amazing people. This, um, this individual was Professor Anatomy, but such a polymath as you will see that he became a government adviser during the war on a whole range of issues including the Manhattan project. And here's a photograph of him on the beach in tow Brooker where he was advising, uh, a about aspects of warfare in, in, in desert. That so his, when, when I came here to Birmingham, can I have the next slide? Yeah, thank you very much. Oh, yeah. And, and of course, just to tell you that, er, anatomy was still going on, er, in, in America and notice how well dressed, er, these, um, North Carolina medical students are. And, uh, of course, the reason they were outside was, uh, because the smell of formalin from the body being dissected by the prophet who is the guy in the, um, long apron under the, under the table. So Zuckerman, um, wrote a AAA brilliant textbook um, of anatomy where we got, can we go back one, do you wanna go back here back one more, I think? Yeah, here we are. This is Zuckerman's uh system of anatomy and, uh, the medical students will be interested to see what I've written in there. And that is the number of hours that Z that Zuckerman expected you to do, uh, in the, in the dissecting room. And I don't think anybody does that amount of work at the present moment. But, but that was, that was standard practice here, uh, in, in Birmingham. Uh, the next, thank you. The five went straight for surgery. The minute I got into anything to do with clinical work, it was, I just felt that I wanted to be committed to going into surgery and I trust some of you will do the same. Frank Stammers was at that time the professor of surgery, as you will see, um, he was, was born in, and his father was a GP in Dudley up the road here. But he, although he was going to come here to the medical school in 1914, he went into the army and, er, was, was an officer, was sh had a, a, um, a shrapnel wound, his leg and always had a bit of a limp, er, but he had this, er, amazing background again. He had been to the States. There's that message always of the benefit of going across to the States and came back, uh, as the first neurosurgeon in this city, but he, he then faced the second World War, ended up as a brigadier doing absolutely everything and was well known to be just behind the front line in his jeep, making sure that, that he was involved in triage of injured soldiers. But when he, he, when he came here, he set up this department of surgery with all of those four different groups, researching away fascinating people. Frank was followed by this marvelous man very much my uh father in surgery. Um Pon de Bru, um a Stony er Jesuit again with a military background and he would be sitting in his tent in the western desert, uh chatting to uh Zuckerman uh as he came past writing papers on scraps of paper with a pencil, using a paraffin lamp to get the details down. And if you look at his, if you, if you look him up on PUBMED, you'll find he wrote papers on all of these uh different subjects, penicillin, in warfare, et cetera. And this was uh his magnum opus uh uh an astounding book uh written by a whole group of his friends. But these, these men were used to huge dealing with huge numbers of patients. I was sitting talking after uh assisting Eric Turner, a neurosurgeon. Uh We, we were dealing with a, a child with a bad head injury here at the Birmingham Children's hospital and over a cup of coffee. Eric was talking about his experience a as a 30 year old neurosurgeon uh during the course from, he went on the sh on shore um in Normandy in 1940 in June, 1944. And in the following 11 months, looked after 3000 head injuries when you're learning from people with that extent of experience. Uh This is, this is what this is what you pick up. And you realize um how it is that people cope with triage. So at that time in Birmingham, I'm talking about the early sixties. Uh we were resident as students as much as possible. Those of us who are keen on being a surgeon attending daily 8 34 30 ward rounds. And we were just learning by osmosis uh from chiefs and senior registrars and also most importantly uh from the ward and theater sisters who had either been with the surgeons out in the battlefields or had been looking after patients in the big metropolitan hospitals here in Birmingham, London, er, during, during the bombing raids. But uh the hospital was continuing to run on the nice ground. Here we are, this is Christmas 1961 people singing carols around the ward, er, much to the satisfaction of the uh, of the patients. Next one please. And here um on, on the left, Sheila Churton, one of the amazing ward sisters, Sheila died a year ago at the age of 93 and on the right hand side, uh Pam Tatlow serving Christmas lunch and, er, noticed the patients all in, in, in bed at the background there and, er, the ladies er, in the foreground, the first generation of windrush ladies who came into this city a and were absolutely fundamental to managing running the hospitals. And of course, er, we had uh large number of n uh the big expansion of the universities, uh in the 19, late 19 sixties, again, part of, of Har Wilson's, er, work, um, meant that girls would decide they wanted it rather than go to university and do social science that they would go into nursing, um, or go into physiotherapy. And we had large numbers, always adequate numbers of staff, which of course is not the case now. And, um, you can see that the uh medical student in the middle um, is, is well dressed and I think wearing the same tie that I'm wearing today. Uh There, there were all sorts of other things we could get up to um, as well. Um, this notice here that I've actually got a flyer. Um and uh so the, the, but you've gotta be fast off the blocks. And um, but so one did that, there were the University Air squadrons, which one can always recommend as a great place to learn to fly for free. And also one could go abroad again, come back to this business. If you can get into the States for some training, then do so I went to uh Minneapolis and had a marvelous three months there with er Dick Varco and Walt Lilly Higher. A couple of amazing thoracic surgeons, Chris Barnard had just been there doing research and then down the road, 90 miles down the road, go to the mayo clinic which was nowhere near as big as it is now. Uh, but Kirkland was running a bypass surgery, uh, doing about six cases a day, uh, between three operating theaters and paralleling all of this experience. What were we we reading? Well, this is the fundamental book that we had, which teaches you how to examine a patient from top to toe. And it's still, still the best guide to making sure that you don't make any errors in looking after your patients. So with all this past experience passing, final MBW was a bit bit of a full gone conclusion, but it was arduous um 63 hour written papers in three days and then a a fortnight while they were being marked uh before undertaking a whole series of VRS. But as I said, we were pretty certain we were going to, we were gonna qualify. And so we turned up for our preregistration year resident apart from one weekend off in two starting salary, 686 lbs a year with uh reduction for accommodation. So take home pay about 40 quid a month and that was flat out clinical work again with no opportunity for reading. Now, can we go to the next one, please? Thank you very much. Uh And so here are the sort of books that still stay on my shelf because disease doesn't change the way we treat. Disease changes quickly. But the fundamental thing is that tuberculosis, for instance, is just the same now uh in the er Asian community as, as it was 100 years ago. Now, for anybody wanting to be a surgeon, the, the ability, the possibility of going to be an anatomy demonstrator. I is, is the best way to get in, uh, to, to, to know that you're gonna be confident taking the primary. And I, and the group of friends, er, did that at which thanks again to Dixon Boyd deciding he would take me back there. And then, uh with, with six of us doing the, uh, the Cambridge anatomy demonstrating, we, we all got primary first time and it was then a matter of doing uh a um uh uh doing sho casualty job and neurosurgery at a Brooks before moving on in two weeks. Er, this is, er, a brilliant book that I would recommend, er, to all of you to look at um, Ian A um, was uh a scot and I'll give you links to another scot in a moment but he uh wrote this book during the war, uh virtually singlehanded. It's not a, a composite textbook by any means. But again, you will get some of the best descriptions, for instance, of vascular ischemia. I still point people to this about the various stages of color of a limb and, and the sensation et cetera. And he had been teaching anatomy in Edinburgh uh with the next guy, um, this is John Bruce, um, who, um, was not the son of a, uh, not the son of a doctor. Er, John's father, was a butcher in Dalkeith. And, um, er, John, er, was again a, a, an amazing character who, uh, worked as, as you see there. Uh, he had, uh, no silver spoon in his mouth, uh, general practice in Grimsby. Um, and then tutorials at the Edinburgh Royal with, er, Ed who, uh, I've just been talking about and then going as with the other chaps going into the military and ending up as a surgeon, Brigadier um on Bill Slim's um er Burma campaign and he remained great friends er of, of um of, of Bill. And the only thing I can say about John is that he ran the hospital next one. Uh that Lincoln Red is a good impression of how John would be when dealing with a hospital administrator. You didn't argue with a guy like that. And, and this uh one to here I is someone that uh you need to be pretty careful with. Now with all this work going on burnt into my brain by this time was clinical examination of a patient, not missing anything. Um This um I hope this can be seen by you folks watching it, but this is my standard protocol for examining a patient. I haven't changed this in 45 years. This makes sure that I don't miss anything whether it's uh looking at the, the fundus um or, or, or checking peripheral nerve function and this is the key to not making mistakes and being confident in your assessment of a patient. And that's the, that's the other section of the same thing. Now, I wonder what this is all about. Well, imagine it's 1943. You are 20 years old and you are the pilot of this aircraft sitting beside you, is your navigator. There are just the two of you and you're going to go, er, 1500 miles, uh, into Germany. And the plan is that you, you're going to bomb a railway junction here is what's in front of you. You've been around the outside of the aircraft and, and looked at, um, 100 and 50 different things, kicking the tires, making sure that the, um, cover is off the Peto head so that you, you're, you're, you're working for your own safety by virtue of looking after this machine. And here is your final checklist that's before you take off and when you're coming back in, just make quite sure you've put the other carriage down. Let's go forward from that. This is Concord's flight deck. Very similar, more, more, more, more dials and look what happens next. Next one here. Just the same pilot, not being 20 years old, 55 years old, but look at him going through his checklist all the way through and this is what you've got to do. If you're not gonna make mistakes, you, you can't walk away and think that, uh, things will happen routinely. So, just for the final aspect of this part of the talk. Don't forget warfare is, is what, uh, has stimulated a large number of the advances we've got now, antibiotics, blood transfusion, uh vascular in, in, in the, in the Second World War, er, in Korea. In 1950 it was vascular surgery with some of the people II met when I went to Minneapolis who were doing vascular reconstructions uh and doing major, major thoracic surgery as well. So at this point in this lecture, I want to ask you four questions. Number one, do you agree that anatomy and disease processes in the absence of treatment are the same now as 50 or 100 years ago. Number two, are you as well informed about the totality of disease processes? Um As your predecessors as subspecialisation becomes rife and the accursed European working time, directive bites into training programs. Number three, does clinical examination and differential diagnosis matter when everybody is telling you, oh, send the patient for a scan. Do you believe your hands and your eyes and what the patient is telling you or do you believe a scan? And finally, how are you gonna cope when uh there are major problems um with the facilities where you're working in uh 2014, I er commissioned a breast cancer hospital in er Khartoum and here I am talking to a load of the registrars and from the various hospitals around this 2 million population city. What is happening now next slide, please. Here we are that hospital I was showing you was only two miles from the main airport in Khartoum. My two excellent uh local surgeons but who trained one in one in one here in Kent and the other in Dublin, er, have had to move out. And so now this is a, uh Khartoum is a complete war zone, almost, not quite as the same as, as Gaza, but the same sort of problems and you've gotta be able to cope in these circumstances and you cannot go into surgery in that sort of circumstance. Er, when you've decided that you want to live in a silo and, and only operate on the left hallux, er, rather than the right hallux, you've got to be widely experienced if you're gonna be able to help your fellow men and women in these circumstance. Now, let's go on to a surgical anatomy. Uh, in the remainder of this lecture, I wanna consider two anatomical zones which both are, are significant in terms of who does what and, and the, both the diaphragm and the pelvis need special attention. The anatomy of the diaphragm is quite wonderful. I, in so far as you, as I, when I was talking about, um, Sarr that you're dealing with the negative intrathoracic pressure, er, which of course is the way in which, er, we inspire as the, er, diaphragm goes down. Now, you can see on this diagram, I hope that, that the that with a narrow subcostal angle, not only does the rib cage uh container, the the thoracic viscera, but of course, is it is sheltering a lot of the abdominal structures as well when uh you look at the yes, please. And, and here again, you can get this impression from a lateral view um of the thorax. And you can see the ii trust you, you can see the, the the linings of the, the position of the diaphragm and it's rather like the diaphragm is here. Here, we have the, the posterior um musculature. You can see that there's the median um ligament uh over the vertebrae and then the medial and the lateral er ligaments on either side o over the, over the over the paraspinal muscles. The next one please. And the actual appearance of, of the, of the muscle slips of the diaphragm is rather analogous to this er, photograph. This is uh a gentleman's club in Central London and notice that you've got the stairs there all the way round which are going up and then we go into the middle of it down the central stairs. Then that will show us our next picture, which of course is the er structures coming through the diaphragm or behind the diaphragm, the aorta going behind the diaphragm, the vena, the vena cava, er coming through the uh fibrous element there, er not being constricted by uh by muscles but very interesting. Uh when one is talking to people um who have done deep free diving, they get an acute bra a major bradycardia in the same way that uh aquatic mammals do um when, when they dive deep and, and that's because of the, the way in which the diaphragm functions um holding um holding the thoracic cavity in a, in a straight line and reducing venous return er significantly. So there uh you see the underside of the, of the diaphragm with these various structures, aorta midline just in front of the vertebra, the cava um out to the right. Uh And if we go to the next, pleased to think you were the same sort of thing happens. Uh As far as the pelvis is concerned where we've got a series of muscles uh emanating from the three bones um which make up the pelvic girdle. So the next photograph will show those three structures um coming from the pubis uh from the ilium and from the sacrum, which, which make up this system, which allows uh urethra er er female er vagina uterus. And of course, rectum to work functionally being controlled by this pelvic diaphragm uh in the er and the, the next slide just uh and, and of course from the outside or rather from the perineum, you can see see the structure there. So these, we've got to ask ourselves who operates in these various areas. Now, as far as the diaphragm area is concerned above, above the diaphragm you've got the thoracic surgeons, you've got the people who are, who are dealing uh with, with cancer and the cardiac surgeons, obviously. Uh and you've got people who are mending hiatus, hernias, et cetera and now below the diaphragm, but close up to it, you've got the important uh posterior, posterior structures. Uh You've got the esophagogastric junction, um pancreas and adrenals all being sheltered uh by the rib cage and er, needing access to that area often by ensuring that you've got a, a really good thoracic retractor in place so that you can get to these structures. Which one please. So, and, and as far as the pelvis is concerned, um whose territory is that, is it for the vascular surgeons, the rectal surgeons, er, the, er, orthopedic surgeons or the gynecologists? Now, it's obvious in terms of that quick run through what goes in uh, or, or, or, or, or who has to be involved in these two important areas of the abdomen that you've got to be aware of the anatomy and you've gotta be aware of the way in which you or you and colleagues can combine to deal with complex surgery in these areas. If you, if one is thinking for instance about er, extra elevator, uh colorectal surgery, er, for er, advanced rectal cancer, then you're going to need to have uh a urologist with you perhaps because you're going to do an accentuation and you, you want someone who's going to plug the er ureters into a segment of small bowels so that you've got a, a urinary stoma as well as your colon stoma. And you might need to have an orthopedic surgeon to help you if the tumor is infiltrating uh into SS four and, and S3. So all of these areas are areas that you must understand and must be prepared to work with. If in fact, you're going to be a competent diagnostic surgeon. Here's a, a recent publication which I recommend to you because this is gonna help you with what I call the Mark One eyeball that is examining a patient thinking, what you, what you're thinking about what you're finding and determining how to go ahead with your initial investigations. So, going back to, to where we can, you, you've gotta be prepared for problems um, in, in, in your life. Um, as I said, it's not just cartoon where, er, things get damaged. You can be in this sort of situation, um, where you're having to determine how you're going to do an amputation because, er, to get someone who's trapped, er, an amputation, uh with whatever's around, whatever instruments are around and no anesthetic. So, surgery is a, is a very challenging career. Um, it's exciting and uh one can recommend it but it is, it is a matter where uh you've gotta be prepared for stress and hard work. I had the great privilege of knowing this amazing man, same age as me. Um when I started at uh Manchester as a university lecturer in 1974 Mike, er as a lieutenant commander, Royal Navy had just been given this toy to play with 58 at, at 1974 prices. 58 million quids worth of nuclear submarine. Crew of 100 and 12 occupation. Get under the ice in the Antarctic play three dimensional chess and try to find the Russian submarines that were trying to get out into the Atlantic. That was two months under water for 100 and 12 men on the crew. Now, that is, is an amazing, constant duty, constantly listening to the sounds around and whatever. And so please don't think that when you hear people talking about surgery being stressful, just think about what some other people have done uh in their amazing careers. So just to go back to the final bits and pieces, these, these are what you need to know about and what you need to think about long term. And number four is the important thing. Can you actually manage i in those circumstances? And can you call yourself a surgeon if you can cope with it? Thank you very much. And if anybody's got questions, I look forward to hearing from you. Lovely. Thank you so much David for that. That was an absolutely amazing and very inspiring talk. Thank you. Um As I've said in the chat already, if you, if there are any burning questions, please, er, write them there or by all means, speak up. Um, in the meantime, we've, I've got a question for you if that's ok. Um, you've talked about all these incredible and inspiring figures in the history of surgery and I very much feel like you are part of that with what you've achieved. May I ask what inspired you to be a surgeon back in the day when you were making those big career life choices? Just the fascination of being in a team and actually accepting that it was hard physical work, been doing all this swimming as well. And it did attract people who were playing in university teams very, very much so, you know, if you were up all night, you were up all night, if you miss, you miss lunch and these were the sort of people ponder, bro and Frank stammers, you know, I mean, and I mean, Laney at that time later, a president of the college, of course, um was a young vascular surgery consultant. If I'd said to Geoff, I feel a bit tired. Um He, he, you know, he would have laughed and, and po would have said, yeah, I felt tired, you know, you know, during the course of the last five years away from my family. So I think it, it, it is a, it, it is a challenge. Uh and you, you, you must be physically fit to cope with this. You cannot, um, and, and, and keeping exercising, I mean, it's no good trying to carry on rowing because you, you, you'll always disappoint the other people but you can cycle swim, run. You can play squash. Not only needs one other guy but exercise, exercise, exercise. And certainly if you've had a bad day, uh, I used to find, uh, here and wherever I've been working going and having a swim for half an hour would actually be a very good way. Um, in which to get rid of the bit of the tension. Yeah. Not stress because you've got to go back the following morning and start doing the same sort of thing again. Hm. Absolutely. I mean, you were telling me that you're still, you swim every morning, which is absolutely incredible. Um We've got one question um, from one of the audience. So, um, if that's ok, I can ask it now. So what this is from Sarah Knowles who has joined in, from home. So, what do you think has changed the most over the years? And has it been for the better? Really good question? Thank you, Sarah. Well, the answer Sarah is subspecialisation. I mean, ok, the, if, if you can, if, because of your skills, all you, all you do is spend your time, uh, doing laparoscopic cholecystectomy. That's brilliant for the patient because obviously getting through the numbers and the same with cardiac surgery, et cetera. But you, if it's rather like saying that you, you're on a motor mechanic and all you do is change, exhausts. Uh, you don't have a look under the n never do anything with the engine. I think, I think being specialized can be boring. Um, I would not want to have been that because as I said, I'm a physician who operates. Um, I, I'm making a diag, I'm making a diagnosis. Uh, I know what I need to do. I'm comfortable doing a Cesarean section or doing a craniotomy if someone's got a, uh, an acute, um, er, extradural hemorrhage. Um, and I'd, I'd rather be in that situation than being someone that just knows one particular procedure. That's me. I'm different if you want to concentrate on doing nothing other than let us say, uh, adrenal surgery, um, or some, or, or knee surgery, ankle surgery in orthopedics. That's fine. It wouldn't have suited me but it, I know it suits a lot of people but, but in terms of differential diagnosis, er, the interesting thing is that in my, uh, medical legal work, um, we have a situation in which people make strange mistakes. I've got one, an example, cardiologist, uh, uh, uh, uh, uh, pa deals, deals with a, a overweight, uh, patient, um, with a heavy smoker, um, who has got coronary artery disease. Cardiologist doesn't do a chest X ray doesn't examine the chest. Therefore, the patient turns up late with that right, lower lobe bronchogenic carcinoma, which was obvious if you think about it with the smoking history. Certainly in this city, um, in, in the 19 sixties, we wouldn't take anyone to theater, uh, over the age of 50 without a chest x-ray, everyone had a chest X ray along with blood tests. So there, there are things missed because it, more things are missed by not looking than by not knowing. The cardiologist knew that lung cancer afflicts 38,000 people a year in, in the UK that didn't cross over from coronary artery disease to thrombogenic carcinoma, which I found extraordinary. So I think that's the, that, that's the big difference. Um, and why I've actually in this talk shown you how those, those sort of people that, that, that taught me and stimulated me knew about really close clinical examination and believing your, believing your eyes and your stethoscope rather than believing a, a CT scan. Brilliant. Thank you. Er, our next question is from Suliman, er, is how would you recommend gaining varied experience such as burns c sections, gunshot wounds required to be an MSF surgeon? Well, II think there's two things. Um, obviously, um, you, there, there are certain places, I mean, it, it, one of the places that, that people used to go to, of course, was Belfast City Hospital at the time of the troubles. I mean, during the troubles, 3.5 1000 people were killed and uh, the ambulances in Belfast were, were getting people with desperate injuries into the operating theater or the ambulances were getting the, er, the patients, er, to the hospital and Belfast was running a, a really good, er, trauma ser service, er, chunky type trauma service. The other thing to do is go to the States. I um, II worked at the MD Anderson, um, in, in Houston where, um, we would get, um, over the course of the weekend or Friday we'd get about 17 knife and gunshot wounds brought in by helicopter, er, Saturday. There'd be about 2223 Sunday, uh, another 18 or 20 patients, um, mostly uh, young black males, um, uh, with, uh, as I said, knife or gunshot wounds. Um, and, and so, or Cook County in Chicago, that's another hotbed. It's on the south side of Chicago. So those sort of places will give you the experience Baragwanath in, in South Africa, in Cape Town. Uh, again, these, these are the sort of places where you, you'll find omnicompetent surgeons helping you with that sort of work. Lovely. We've now got another, our, our third question from Anita, um, which is really interesting and potentially a few people can relate to this. Um, so what would you say to someone for whom surgery was the reason to get into medicine and wanted to be a surgeon ever since they were a kid? Yeah. And that passion and burning fire was always burning until recently, uh, when they had, after they've had an extremely stressful couple of years, personal matters. And now they think that they might not be able to cope with the stress anymore and that they are a perfectionist as well and don't want to start a thing without knowing that there is a good chance that they will be great at it at the end. And that's a very good question because, you know, the jobs in very different ways, they are stressful for trainees coming through. Now, I would say, I would say, I would say go into pathology, um histopathology. Um because you, you understand from your, from, from your love of surgery, intrinsic love of surgery where people are coming from and you have got time to make up your mind. Nobody is actually pushing you to for an answer. Um, histopathology takes as long as it takes. And um, I, again, with my medical legal work, you can get problems where uh somebody has missed something. But again, you're being taught by brilliant pathologists, you can be taught uh 1 to 1 with double mic uh double microscopes. Um plenty of time to think about it. And, and I think that's a, a very good route for somebody who's I did for whatever reason. Um, that, that straight surgery isn't for them. I think you, you can, you're working with surgeons, hand in glove with surgeons, you're an essential part of the surgical team. You're looking at tumor margins. If you want to make sure you're getting uh explaining that you've got an arnault margin or, sadly, just you, you or perhaps with a Melanoma, you've got to go back and do a wider excision. You've got to look at the margins. And again, because as I said earlier, disease doesn't change, you know what the parameters are for, for instance, for axillary lymph in breast or uh in, in, in Melanoma, um you're looking at the margins when you're excising a big sarcoma from the, from the pelvic cavity, as I was mentioning. And, and so the pathologist is very fundamental to determining whether the patient is going to need um um POSTOP uh chemotherapy radiotherapy as as a follow on or whether you can avoid those because you're trusting the pathologist telling you you've got the tumor completely away. So I would say pathology um is, is a very good avenue to go into. Absolutely, really interesting answer. May I just leading on from that in your training? Did you ever have a wobble or a moment? Think? Oh, actually surgery is not for me or were you just fully focused? No, I mean, I mean, in this amazing city, um Queen Elizabeth out in the General Hospital Steel House laying down the back here. But then the other big metropolitan hospitals, the East Birmingham Dudley Road and then places around and about, we'd actually got access to 3000 beds to see patients in whatever and as a student I was chatting with somebody the other day, we were doing all the lumbar punctures on the wards, um, at the Birmingham, the Maternity Hospital, um ID delivered 45 babies during the, during the course of three months of resident there. Um, and, um, under supervision did 25 post mortems. Um, and you loved every minute of it by the time we qualified with, against that sort of background because you're an apprentice, you're not a, you're not an observer, standing, standing back to see what people are doing. You're scrubbed in, you know, up close and you're involved. No, I didn't have any qualms about it. I haven't ever since. It sounds like the has been there. We've just got two more questions. Would that be OK? Um So we've got a question from Nicholas and he says I was just wondering what you think would make a core surgical training applicant. Best stand out from the crowd. I think there's no substitute um for getting stuck into the books. Um As I've said that amazing book by Ian E, um I still go back to and he wrote it in 1956. Um For, for what I'm banging on about that is that disease doesn't change and you get a good description of disease. And when you go for an interview, you can say to the senior people, you have read this, I mean, uh Mike Kelly who was the professor of surgery following on from PO and, and, um, and Frank. Yeah, the two volume Keely and Williams Colorectal Surgery. You know, you want to know about colorectal disease. Then you're gonna have to wrap a towel around your head and you're gonna have to read the books. It's, it's no good, um, say flashing in and out of a computer. I mean, you can use that to look up ped me pub pub med when you want the latest stuff on uh cyto, um, cytology flows et cetera. But, but you've actually got to determine that you are going to be a bookworm and you're going to spend time reading. There's no substitute for getting that deep intellectual knowledge into your brain at the earliest possible time. So that you, so you are skilled to the level that we is appropriate as an sho or as a registrar. Absolutely in itself that shows interest and passion in the subject. Absolutely. I mean, when I'm interviewing people, so when I was interviewing people for med school, various places, Edinburgh or here in London or whatever, II would I would ask not just about the surgical books and there's what books have you read recently. What about, what about the history, you know, of, of, of, well stuff I'm interested in the Second World War with, with, with, with the aircraft, et cetera, et cetera. But there is so much fascinating stuff out there, whether it's trains or planes, you know, or theatrical stuff. So, you've got to show or not, you've got to show but you're a more rounded person. If you've got all these other interests, don't, don't just don't just be, you know, AAA, complete sort of, um, hermit, doing nothing further and so important, I think throughout the career to have that work life balance and have those. Oh, absolutely. Absolutely. Yeah, that's right. Um, so our final question is from Nicola. Um, her question is, do you think modern surgical training is limited by funding time and sheer amount of patience compared to before during your training time? Well, II mean, the, the fundamental thing is you cannot, you cannot be a surgical trainee on a, on a 48 hour week. You've got to be prepared um to have a situation. I mean, I had a uh you know, if, if, if I, my registrar was doing his first right? Hemicolectomy on a Thursday morning list. Um I would ensure that he came in every day through till Monday if he said, if not that he would have done, if he said, well, you know, I'm, I'm thanks for letting me do that boss. I'm now off for the weekend. Forget it. Continuity of care is absolutely fundamental and, and this is of course what's going on in general practice. You see, uh the poor patient sees six different doctors. Now, if the patient having seen that doctor comes back a couple of months later and sees the same doctor, the doctors in hell, he or she has just lost about 20 lbs in weight. I wonder why. But if you, if you see a different doctor every time, the fact that you, you know, the fact that you're losing weight and body mass isn't, isn't apparent, the patient may tell you. But, but you know, so it, it is, it is, you've got to commit yourself time wise. And certainly if you go to the States, this is what happens. The first ward round in most of the hospitals in the States is 0, 600 hours. Um, and, um, the, the then the afternoon one is about four o'clock, but a six o'clock start is pretty standard in most of the big teaching hospitals in the USA. Absolutely. I think with the European working time directive, there are certainly big challenges that you are on our training, but there are benefits that come with that as well. But that could be a whole another talk in itself. Given the time we will round up there. I can't thank you enough for offering that, giving that talk. It's been absolutely brilliant and I'm sure you've all been inspired at home as much as I have here. Can I can I, can I just say for people out and about, um, if, if anybody's got wants to contact me, um, the folk here will have my email address and I'm very happy to um, chat or have a, have a phone conversation with anybody um, who, who wants to expand on any of the things I've been talking about. Wonderful. Thank you so much. We'll, we'll round that up now. We'll just show you a few videos and then we'll start with the next talk, which is recognizing the unwell patient. All right, we'll see you back in a few minutes. Thank you. Yeah. Ok. Knowledge. It's not just a refreshing glass of water. It's an ocean, vast and deep. Waiting for you to dive in on the first of December, the Moynihan Academy in partnership with Asset Dukes and Rou present the emergency general surgery weekend. Wake up, let us open your eyes, let the scent of coffee pull you into the day. It's not just an event. It's a journey, an opportunity to mentally scrub in and learn why we operate. Join us on the first of December because at the Moynihan Academy, we don't just want to be good. We pursue excellence.