Home
This site is intended for healthcare professionals
Advertisement
Share
Advertisement
Advertisement
 
 
 

Summary

Join us for our on-demand teaching session: The Annual Asset 48 conference, led by our newly elected president. She will discuss how significant challenges in surgical training have been faced under her leadership. Highlights include a focus on advocacy for trainees and finding solutions in a supportive and constructive community. The session welcomes over 400 online delegates from 459 countries. Don't miss our first plenary session: Meet the presidents' question and answer, where personnel such as the President of the Royal College of Surgeons England and the Vice President of Royal College of Surgeons of Edinburgh will discuss what drove them to pursue a career in surgery. This interactive and insightful session offers a unique opportunity for educational growth and inspiration.
Generated by MedBot

Description

Welcome to our ASiT annual conference - we are delighted you could join us!

A couple of things that might be helpful for you to enjoy the weekend:

  • If joining online - the main stage is being streamed (breakout sessions are for in person attendees only)
  • There are some networking sessions in the breakout - please do pop in at break times
  • Use the chat to ask your questions - the team will do their best to get them answered for you
  • Share on socials by using #asit2024 and #TheTimeisNow
  • Take a look at the sponsors and poster hall area

CALLING ALL ASPIRING SURGEONS!

Join us at the biggest surgical pan-grade, pan speciality event!

  • Unveil cutting edge research presentations
  • Engage in informative breakout sessions
  • Be inspired by captivating keynote speeches
  • Enhance your skills in pre-conference workshops
  • Elevate your career with expert career development insights

All UK & Ireland tickets can be purchased here: https://www.asit.org/conference/overview

Learning objectives

1. By the end of the session, participants will be able to understand the different pathways and motivations that can lead to a career in surgery. 2. Participants will be able to identify the skills and attributes important for a successful career in the surgical profession. 3. Participants will gain insight into the realities and challenges faced in the field of surgery from a panel of esteemed professionals. 4. Participants will learn how surgery as a specialty can significantly impact patient lives and or society in a meaningful way. 5. Participants will have the opportunity to actively engage and ask questions, promoting a critical understanding of the evolving nature of surgery.
Generated by MedBot

Related content

Similar communities

Sponsors

View all

Similar events and on demand videos

Advertisement
 
 
 
                
                

Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Good morning. It is great to see so many of you here in Bournemouth for Asset 48 annual conference. I've had the pleasure to serve as Asset Vice president over the past year and I am proud to have been elected the next Asset president on International Women's Day. It is my honor to speak on behalf of the Asset team and our president Srinivas, I start by thanking him for his dedication. Over the past year, the surgical training community has faced significant challenges under his direction. Has it has continued to advocate for trainees and face challenges head on dear President. Thank you for your incredible leadership. Your commitment has been an inspiration to us all the theme for this year's conference. The theme for this year's conference is a clear call to action. The time is now we are here to inspire each other discuss challenges but also find solutions. Most importantly, we are here to continue fostering a supportive and constructive trainees community. We are so grateful to have you here. I would also like to welcome our 400 online delegates from 459 countries around the world. We are delighted to have you online and I hope you will feel part of this community interacting virtually via the medal platform in time honored fashion. It is now time to officially start with our first plenary session. Meet the president's question and answers. I will hand over to our vice president Lara Manley to introduce our guest. Welcome again to as it Asset 2024. The time is now thank you. Good morning, everyone and welcome to Bournemouth for this morning's president's Q session. We're delighted to have Mr Tim Mitchell with us today, the president of the Royal College of Surgeons England. We also have MS Claire mcnaught, the Vice president of the Royal College of Surgeons of Edinburgh. We also have Professor Deborah mcnamara who is Vice President of the Royal College of Surgeons of Ireland. And at the end, we have Mr Mike mcker, who is the president of the Royal College of Physicians and Surgeons of Glasgow. So just to make you aware of how you can ask questions this morning, so many of you will have a sheet on your chairs with a QR code. If you want to submit questions to our presidents this morning, please just scan the code and submit your questions and we'll be able to ask them up here. So I'd just like to start off the morning again. Welcome to Bournemouth. Um Just to say really, if you could say a little bit more about yourself and what made you want to start a career in surgery in the first place. I'll start at the end. Um, well, first Lara, I definitely did not want to be a surgeon because the first a surgical unit I was attached to was staffed by three very grumpy men in the late fifties who it was really not a pleasure to be around. Um, and that was my first experience of a surgical unit way back in 1982. Long time ago, I then went on a student elective and was very unhappy to be attached to a surgeon because my experience of surgeons up to that point and not been a very positive one. But this fellow was a great surgeon. He was a kind man. It was a real pleasure to be with him. And he had me in theater and scrubbed and I came back after that elective and thought, yeah, there's something in the surgery and it has been for me a wonderful career. And I'm very glad that I had that entirely serendipitous experience on a student elective of working very close to somebody who was a very good surgeon, a good teacher and a very kind human being. And I thought, yeah, I want to be that man when I grew up. Thank you very much. Thank you. And so serendipity is really interesting and the people that you meet, I suppose, um when I was in university, II had I vividly remember finishing um an exam and we were all in the bar afterwards as she did. And my tutor came up and said, have you ever thought about doing surgery? And I said, God, no, I want to be a cardiologist. And so I went off and did my first three months as an intern. And on my first day I went to a cardiology outpatient and I thought, what was I thinking? So, uh, that was the end of cardiology for me. And then my next job was in surgery. And actually I, you know, it, it seemed to suit me and I enjoyed it a lot. And like that, I met a consultant at that who was, you know, super supportive of me and, you know, helped me get the first step on the ladder of getting on to training. And um you know, for me, it's been a fantastic career and I can't imagine having done anything else. Um So, yeah, that was how I ended up here. Thank you. It's really nice to hear actually about the sort of personalities that you're mentioning that have sort of endeared you to surgery as well. It's always reassuring, I think, particularly for the medical students and perhaps junior trainees in the audience to hear. So ve very much like my colleagues. Um I didn't think I was going to be a surgeon. I, I'd always done well at me at medicine medical school and I was had the professorial medical house job and and uh I remember my very first ward round a bit like you, Debbie II spent six hours going around with these physicians to change one tablet. And I thought this is not for me, I'm gonna have to do something, something else. So my best friend at that time decided that she was going to do surgery. And I thought, well, that sounds like fun. And, and when we trained, um there was a bit more flexibility about what you could do. You could go and have do six months here, six months there and kind of make up your own jobs, even if you wanted to go into general practice. So I just went and II ended up in a cardiothoracic unit in Aberdeen and a bit like yourselves. I just had a, a great time I was allowed to, to do lots of cutting and I just love the fact that you made such an instant impact to patients lives. And I knew that that was, that was what I wanted to do going forward. So, and like my colleagues now, looking back, I had an absolutely wonderful career and, you know, I can't think of a better thing to do and it's so great to see all you young, inspiring surgeons out there. You know, it's, it's fantastic. So, keep going. Thank you, Miss Mitchell. Thank you. Uh First of all, great to be here in Bournemouth. Uh the relationship we have with as it as with the other colleges is very important to us and fantastic to be sitting next to fry today and seeing him uh, well, on the road to recovery and we wish you all the very best. Uh First of all, it's fascinating hearing what my colleagues have to say because it's, it's about the people and it's about the subject, I think. Um, and it's a sort of sorting house in Harry Potter, isn't it? Does the subject choose you or do you choose the subjects? But when I thought I wanted to be an ent surgeon as a medical student, and I think there were three principal reasons for that one is that I thought the subject was really, really interesting. It was a little esoteric, somewhat different and of course, medical school, uh I was only a little behind mic uh in timing. Uh And in those days, clinical medical training was very much about general medicine, general surgery, big blocks of those three. And then you sort of went around the other specialties as a sort of filler in a sense, was it? Um So it's changed dramatically and so ent of course, is one of those fillers and there wasn't much more ent in the curriculum in those days than there is now. So there was a two week block which I think was mixed in with ophthalmology and dermatology. And I have to say there probably wasn't an expectation that people would turn up to the attachment very much if at all. So I did turn up. It was interesting, the people were very welcoming and the final thing that was important was back in those days, ent surgeons were still wearing head mirrors and of course, in cartoons, all doctors have a head mirror on. So it seemed to be the logical specialist to go into. And to be quite honest, I never had the now to change. After that, I sought out jobs that had ent in them and it's also a specialty which is very practical and some pretty simple procedures that you can do a very early stage in your career, taking fish bones out of people's tonsils. And if you've done that, one of the most satisfying things you can do probably secondary to catheterizing someone in urinary retention, packing noses, sucking ears out all those things which you can do at a very junior level, which is very, very rewarding and sort of self reinforcing. So that's how I ended up where I am. Thank you so much. I wondered if I could from there. Surgery is ever changing and quite a dynamic specialty. I wonder, have your career sort of lived up to your expectations and, and what's your favorite aspect of your job currently, if I could go maybe back down the line, sorry to put you in a hot seat again, Mister Mitchell, well as my career developed and again, it's serendipity. I was fortunate enough to get a registrar post that rotated into Cambridge, which was very strong for the e part of Ent and otology ear surgery, not so strong on the other part. So it was inevitable. I think I was going to become an ear surgeon and I was supported by a mentor there. Someone called Roger Gray, which anybody who's been through Cambridge may know him very enthusiastic, very keen on teaching, very keen on teaching the medical students. And he said you've got to go and apply this Cockle Implant Fellowship in Sydney in Australia. And I was very junior at the time actually, but he pushed me forward and I was fortunate enough to get it. And because of that, I've ended up as a Cochal implant surgeon and that is just the most rewarding field to be in to take people who are profoundly deaf and who have dropped out of society effectively. They socially isolated, unable to communicate with their families and to give them back some hearing which allows them to function is quite extraordinary. And then if you take a child who is born deaf and who without any sound input will not develop speech and language and all the implications of that from an educational point of view, occupational point of view and give them two cochlear implants and put them back on track with normal speech and language development is an amazing thing to be able to do and very, very humbling. I have to say. So. That's, and unfortunately I don't get to do quite as much of that now as I used to. But it's very fulfilling and as are all other branches of surgery. May I see. And it's a fantastic, fantastic career to be in. Thank you so much. So, I, I'd love to sit here and tell you that it's all smooth sailing when you have a career in surgery. It's not, um, you're gonna go through your career. And I'm telling you, you're gonna have times where it's really difficult. You know, you're, um, you may have a difficult complaint, you may even have a patient death, which, and I tell you when you have your first elective death, that has a massive impact on you and obviously your patients and their families and all of these things as surgeons, you have to learn to, to overcome and, and that's when you need to. Yeah, it's really important that you developed a good network of people to support you through those difficult parts of your career because every one of you in this room will have them and I think everyone here will have had them too. It's important that you speak to your friends, you, you share these hard times because asking for help isn't a sign of weakness, is a sign of strength. So going forward, it's really important in your career that when you do have your difficult times that you, you use your friends and your peers and your mentors to, to help you help you through that. But in saying that, you know, I've had an absolutely wonderful time. Um I'm a colorectal surgeon, which isn't perhaps the most glamorous part of a surgery, but it's incredibly rewarding. I mean, you truly do cure people from cancer and you see people's lives when they come in with peritonitis. So in terms of my, my day to day job, my favorite time is obviously being a theater like most of you, I love the cutting and not just the cutting. It's actually being in theater with a team, you know, of, of, of allied health professionals and and my trainees and actually, you know, actually taking my trainees through cases and seeing them flourish as, as clinicians and surgeons. So I get such a reward from that. And so that's probably what my favorite part of my job. Thank you so much. So like Claire, I'm a colorectal surgeon. And I mean, I again, I remember when I, when I realized that that was for me, II, like many of you when I went to a conference and heard someone speak and I heard Bill Heal speak. And I remember looking at the data and I didn't know anything about surgery at this stage. I was just a very young first year and it really struck me the difference that high quality surgery made to someone's life. Um And to know that statistically a good TME was worth two years of chemo, you know, something that you could do in three or four hours could make such an impact. So, and that was really compelling to me. So I suppose my, my kind of passion through my career has really been rectal cancer and just when you think you have a crack, something new comes along and like the paradigm has just changed so much over that period of time. It's, it's really interesting to see. Um, so I suppose one thing that, that I've learned from it is, is about really that need to change, you know, that, you know, you think when you're starting out, or at least I thought, you know, I can do a good TME. So that's rectal cancer sorted. So, and that evolution and, you know, a lot of, a lot of what I spend my days doing now surgically didn't exist when I was training or ways of doing things didn't exist. So I think that that need to, um, learn how to learn and to be agile about it. And then I guess the second thing and on to Claire's point about, you know, and the hard times that you have for me kind of having now, I won't call it. I suppose my only hobbies are surgical hobbies and they've been being involved in the college and being involved in, you know, research and improvement. They're the things II do in my spare time. How pathetic is that um, you know, those things actually help you when times are tough in your hospital or when you do have difficulties because, you know, you will have hard times, you will have patches where you're not sure you'll get into your next job or you'll worry about where your consultant post will be or, or you'll have bad outcomes with patients. I think that variety and having something else that you're also passionate about in your field is really protective for me that I think that was hugely protective against getting burnt out because I think that's something we just have to mind ourselves about. And that variety that surgery allows us, I think is, is something that I love about it. So II agree with, with what's been said so far. II think we need to remember with, with surgery as my career met my expectations for certain. It has it's tremendous privilege for our fellow human beings to allow us to operate on them and take care of them. And that is as I reflect now towards the end of my career, that I'm still humbled by that um privilege that we have as surgeons to take other people's bodies in our hands. And as others have said, changed their lives by our capacity as surgeons. So that's a really tremendous thing and that certainly met my expectation and I by chance ended up doing oncoplastic breast surgery and that's been very fulfilling over the last 25 years, the curriculum for that has changed and developed and what procedures we're doing now were not imagined 25 years ago when I started out. So that's been fortunate to be in an ever changing specialty. And I think as, as, um, Claire and de have alluded to, there are difficulties. Absolutely. One of the ways of keeping your own, um, your own well being and going and, and doing your job well, is to take opportunities to um do something which interests you as your career come a lot develops. And over the years, and I've got a lot to thank as for LA than that, I came to do this session to represent our college in 2013. And the session before and we were on stage was about global surgery. And I really knew very little about global surgery and I sat fascinated while trainees talked about their experience of being involved in surgery in low and middle income countries. And that interest has sustained me for the last 10 or 11 years in my college life because I did get interested in it. And thanks to college colleagues at R CSI in particular, who have a, a tremendous record in uh in that fear of global surgery that has sustained me. So you may have an expectation now of what your career is going to be, but it will change over the next 25 or 30 years. And it's a good thing that it changes. It will be refreshing for you that it changes and be open to opportunities as you go along because that will sustain you. Thank you so much. It seems a common theme as well as overcoming adversity for many of you and the challenges that you faced. We've just celebrated International Women's Day. We've a question from one of our audience members, which is about some of what the challenges are for women in surgery at the moment and what the colleges do to support women wanting to go into the surgical field. Maybe I'll start again at the other end if that's ok. So I II think we must be doing something right over the last 2530 years because there are no more women in surgery. So that's a good thing that we need to celebrate that is there more to be done? Yes, there is. Um I think that encouraging women, you can't be what you can't see is often said. And isn't it marvelous that in this panel today, there are two women here as well as two men. And so we are a diverse panel and that should be encouraging for all young woman surgeons to see that you can become a college president, college vice president. And there's no limitation to what you can do in your career. Is there more to be done? Yeah, I think there probably is. We need to keep on encouraging women and medical students to be interested in careers in surgery. We need to be clear that we identify the barriers that there are less than full time training when it was first suggested 25 years ago, it was thought that that wouldn't be appropriate for surgeons. We now know it's perfectly straightforward to train uh less than full time. But we know there are some snags and difficulties in coming back after a period of leave might be difficult. Getting all the experience you need might be difficult, but you need support in a different way. And I think we've learned to do some of those things. Are we at the perfect place yet? No, we're not. But it's a journey. And certainly, I think if we were sitting at an asset meeting when I was a senior registrar, obviously a long time ago, there would have been very, very few women in the room. And isn't it marvelous that we now have uh a profession in which the younger people coming through are 5050 split or perhaps slightly biased towards more women than men because they are more female medical students than male. So it's a journey. We need to do more. We need to keep listening to what our female trainees are telling us. Female medical students are saying, what are the barriers? Why are people not thinking about surgery? So we as colleges need to listen and learn from our female trainees and pick up those ideas and put them into action. Thank you so much. II take maybe a slightly different perspective on the question because I'm, I'm, I'm asked very, very often about the challenges of being a woman. Um, and it's not the hardest thing I do every day. And so I think that's something for us to remember. And certainly from, you know, I think women have brought wonderful things to our profession. I think they have, um improved our profession immeasurably. If we look certainly in my college, if we look at the, the most distinguished young academic surgeons, we have a majority of women in that category right now. Um If we look at the types of conversations and the types of changes that have happened, we're just having better conversations around the table because there's a mixture of people from different backgrounds, men and women and, and we have a lot more to do on improving diversity and inclusion in our college is not to say we're all done. But um I'm really passionate about saying, you know, let's stop talking about the challenges of being a woman surgeon. Let's start talking about the great things that women bring to surgery. Um Because I think, you know, together we're going to do a lot more. It's not about putting ourselves in conflict with one another. I think we each bring different things to our profession and I think our profession is improving all the time because of the different things that we're bringing. Thank you so much. Oh, there you are. Thanks Debbie. So I think that there's absolutely, I agree with my colleagues. We've made huge strides with women in surgery over the last couple of decades. But if you actually look at what the GMC workforce reports in terms of speciality, we are the slowest speciality to attract women. So almost other me, all medical specialties have got to gender parity already and we are lagging significantly behind. So we can't ignore that data. We and we have to ask the question. Well, why is that? Why aren't we attracting more people into surgery? It's about 35% at the moment when 64% of medical students are women and there's lots of reasons for this and, and Mike and has alluded to some of them, but some of it I'm sadly is about um is workplace culture, you know, and I think we, we have to recognize that that recently there's been some very negative press about um about culture in the NHS and the sexual misconduct and surgery. I have to pay testament to who has seen the audience, the chair of the working party sex with conduct and surgery, which has shown that actually, although that this affects all sexes, it's predominantly a woman, a woman issue. And I think that as, as colleges, I think we're all working very hard together and actually trying to address this and actually seeing that these types of cultures, there should be no tolerance for that type of behavior anymore. And we have to challenge these behaviors and all stand together. And that change really starts with everybody here. Each one of us looking at our own behaviors and then hopefully being role models for, for going forward. So I think, um as Debbie says, we have so much to offer um but you know, such as a team and, and there's room for everybody here. Um No matter what sex, sex and, or gender or ethnic background you are, and that's what we have to work on. We have to work on culture in our, in our, in our surgical profession. Absolutely. I think the report was quite a sobering read. I think for many of us. Thank you. Thank you. Um I mean, as my colleagues have said, I think we should acknowledge the progress that's been made. One of our recently demit council members, Scarlett mcnally sent through a photograph of the council of our college when she joined it about just over 10 years ago. It now looks completely different in terms of its make up and it did then. But we do have to acknowledge that there's still a long way to go. And there are in my view, both structural and cultural barriers that we need to address some of those structural barriers. We as a college are looking to address in terms of having our women in surgery. Forum. And the great, again, great to see Tamsin coming here today are the members of the forum, our parents in surgery initiative. And we have to recognize, I think that we need greater flexibility in a surgical career. I think that probably speaks to why it's been more difficult in surgery than other disciplines where they have had that degree of flexibility. It distresses me when medical students come to my clinic and they ask me questions, like, is it possible for a woman to do surgery? And they still say that, is it possible to do surgery on a less than full time basis? And they still say that. And so somehow those thoughts have got into their heads before they've even really thought about a surgical career where they have come from. I don't know, but we have, we do have to address that. We, I think we need much more flexibility in surgical careers at all stages for a whole variety of reasons. And as you will be very well aware of the issues around rotations and particularly if you're trying to coordinate two careers, make life particularly difficult. And at those times when people are thinking about having a family or having a family, it is particularly difficult and we do need to address that. Thank you so much. It is really inspiring and reassuring, I think for the audience and for us to know that you understand the issue and then also you champion women in surgery and all the great things that women can bring to the profession. We will change topic completely with a different question and not any easier. I'm afraid how can the colleges inspire and recruit doctors into surgical training in the context of industrial action? High rate of burn out and the satisfaction of training. Mr Mitchell will start with you this time. Well, II think we have to acknowledge that that the medical professionals is a low ebb at the moment and we have to change that and get into a virtuous spiral. Um And in, in my view, the the industrial action is, is symptomatic of that. Um Obviously, for the, the BMA, the issues around pay and that's very important and, and they're addressing that. And I think we all like to see the end of industrial action as soon as possible and that requires the two sides to get together and find a way through the negotiations. And let's hope that can happen quickly. Although I have to say, I don't see any immediate prospect of that, but that's what we would like to see. But pay as I don't really need to tell you is only part of the issue. It's, it touches on what we've, I've already mentioned. It's around working conditions, it's around how people feel valued, it's their working lives, uh how fulfilled they feel in their roles, what they see their prospects being. And that is particularly acute. I think for those in training, it's particularly acute for those at the beginning of their training, foundation years and core training, which I think we really desperately have to address. And part of the problem is also it's affecting consultants. And they are the ones together with colleagues who probably can help most to resolve the problem. And I think it is for us as a profession to take control of our working environment and make it better. And part of that is for us to work together to support each other, to value each other and to change what we can in terms of the working environment ourselves and push employers and other organizations to improve everybody's working lives. It won't be a quick process, I'm afraid, but I am an eternal optimist and I think we have to look to the future. We have to be enthusiastic and I hope that we can get things better quickly, but it will take a little time. I'm afraid. Thank you. Yeah. And I think Tim Tim, all I think that the problem is at the moment is that I think as medical professional and surgeons, we all feel really undervalued. And I think that's really the key, the key thing and obviously the industrial action and, and um the challenges around your financial recompense. I think we all fully support you on that. And it's a really difficult, a really difficult thing. But I know that your training is suffering and that again makes you feel less valued because you actually can't, if you don't feel you're progressing in your career, what can we do about this? I see. Well, it's, it's difficult. Um, but what we have to do is try, despite all these difficult workplace conditions at the moment is to try and, you know, prioritize your training as best we can and make sure that, that at least that, that can, can be, can continue and to do that. We also, so we're really talking to organizations to try and protect trainers time because because of the, the, the, the the backlog, a lot of this has been squeezed. You know, there's the concept of training less has almost got out of the, the window because there's so much pressure to get through all these long waiters and we have to, you know, give our um our trainers the permission to push back in that and say no, that's not acceptable because as we said during COVID, if you don't train today, you'll have no surgeons tomorrow and that's unacceptable. So I promise you that we are working with health boards and, and and government agencies to try and push, push to protect training time and to make sure that we've got the next generation surgeons that are fully trained. I suppose I can't comment too much on the industrial situation. Our health service is a little different and um thankfully the, the pay aspect and some of the working conditions, aspects in our system um are are, are somewhat better at the minute. Um But for sure, we have the same issues with recruitment and with the workplace culture. Um And I think, you know, the comments that my colleagues have made, I would very much agree with on that front. Um I think the orthopedic surgeons have done something really interesting in kind of prioritizing respect and talking about respect. And, and I think that that's actually quite a powerful tool that we need to role model one with one another because I suppose um there is, there is an appearance that, you know, perhaps doctors aren't valued to the extent that we might have been historically and that perhaps we're not treated with that sort of respect that we had before. And I think sometimes that can be confused with a hierarchical respect. Um but respecting the work that doctors do doesn't mean you're disrespecting the work that our other colleagues and hospitals do. Um And I think sometimes as doctors and as surgeons, we maybe could do more to demonstrate visibly that we respect one another. Um So I think that's actually very powerful to respect the other people on your team, to respect people who are training with you to respect trainers. And just to demonstrate that we value the contribution that everyone else is making. Um because I think if we role model that it gets harder for other people to behave differently actually. Um um Whereas I think if we are divided as a profession of surgeons, I think we're infinitely weaker. And so I think it's really, really important that we, that we stick together in this and that trainees, trainers, colleges work together to, to build a better culture. I think that will go quite a long way actually. So I think if we, if we take a bit of a step back, I think the satisfaction with life is um in short supply across the country at the moment. Um And it's in short supply in many parts of the world. Um optimism is in short supply. Human happiness is in short supply. If we look at the background rate of common mental health disorder, it's effectively doubled for people under the age of 40 over the last four years, from a background rate of about 15 to 18% up to 30 35%. And that's not all because everybody works for the NHS. So we need to step back and realize there is a societal issue here. And part of that has been the experience of the COVID pandemic and which just this time four years ago, and we might have been a bit wary about holding this conference in the middle of March 2020. So we've been through a lot in the last few years for those of us in surgery or working in the health service. Generally, there are some particular problems. So all doctors pay has been driven down since 2010. We can argue about the number, but it's about 30% or thereby, whichever way you measure it in real terms. And that's for trainees, it's for consultants, general practitioners. And actually, it's widely across all the other staff groups we work with in our multidisciplinary teams because the NHS is the biggest employer in the UK. And if you're the government, you're looking to save some money, then driving down pay in the health service is a, is an, an achievable aim. So we're feeling a bit undervalued and that's being uh seen in the industrial action that's taking place in 2020. And in 2021 satisfaction with being a doctor actually went up for a bit because we felt very valued. Remember all those Thursday evenings when came out, people come out of their houses and applauded the health service and bang pots and pans and so on, we were respected. We were doing something for the nation. The NHS was our pride and joy, but actually hasn't really delivered after that to be a happy place to work because we know, hear only negative stories about the NHS, the number of people waiting for care, all the problems that are in the NHS. And so the most media stories are negative and some or other that is affecting all of our wellbeing and therefore people are feeling burned out. I think what my colleagues have all said is there is a real role here for us as doctors, as surgeons, as presidents of colleges to help provide some leadership in that situation and to begin in the long haul, to return to an area that is a place that is more optimistic that it there is more satisfaction with being doctors and surgeons and that's not going to happen quickly. You all know that, but we as college presidents need to be showing some leadership things can get better, we can deliver better care. We need to show that leadership at the time of COVID. Certainly in our institution, a lot of people who had been feeling they were running the health service disappeared very quickly. We as the medical profession showed a lot of leadership at that time to help get through and prepare for the pandemic to treat the patients who are coming in to reorganize the health service. We need to remember, we still have those leadership capacities now in 2024 and begin to demonstrate them to begin to bring down the waiting list to show people that we care as the medical profession that we can restore the health service to be a better place to work. It's not gonna be easy. But you young people have got 25 30 35 years ahead of you in doing that is much better to start from a position of, let's say we can change this for the better rather than there's nothing we can do. So, some leadership and optimism I think is what we need to demonstrate. Thank you very much. I think we've touched on many of the issues that perhaps contributing to low morale at the moment within the profession. We have a rather nice question online which I hope will brighten the mood of the room a little bit, which is what are the advantages, what advantages are there to training in surgery within the United Kingdom and Ireland compared to perhaps a board? So I think, I think there are lots actually and it's very interesting. I just was on a, on a visit to Pakistan last week. Um Our trading schemes here are held in very high regard in Pakistan. Interesting, they held in very high regard in any other part of the world. That's my privilege to go to as a, as a college president. I obviously we go to a lot of international meetings. So I think there are good things about surgical training here. Um We have clearly identified specialties, we have clearly identified training programs. Uh We have progression through those programs over a period of of eight years by and large, obviously some with a break after a couple of years. But that allows people to reshuffle themselves in that sorting hat perhaps. But we do have a degree of job security over that period of eight years towards taking up a consultant post. That's a big change. We did not have that in my day. And the longest you could get a contract for was one year, maybe if you're very lucky two years. So we have good opportunities for career progression. I think we have a culture of teaching and training, it could get better, but we do have a culture of training. We as the colleges take your training and your feedback on your training really seriously. Um And so as institutions working as colleges with the postgraduate deaneries, with the Statutory Education Bodies, there's really a lot of care and concern about what happens about your training. So I think there are some good things in the UK about training. Um There's always challenges, there's always things we could do better. But I think we do need to recognize that if you look from elsewhere in the world, people really are in admiration of UK and Irish surgical training. And one last though, isn't that a great thing that we do it together in the UK and Ireland with four colleges working together to try and improve a training and teaching and education and surgery? Thank you. Yeah, and, and I mean, I very much agree with, with, with what um Mike mccarty says on, on, on the value to us of working together with other colleges and, and of the various things he's mentioned. I think there's a couple of other of other things that when you talk to people around the world that they do admire. And, you know, our selection processes, they're very fair and they're very objective. They're difficult and, you know, it's not a set piece that people will get a job, but the criteria are defined, there's an objectivity to it and that's not always the case. Um, hand on heart. I can say that there. Certainly in, in Ireland, there's no situation that I've ever observed in my career where one individual person could stop another trainee, stop a trainee from progressing in their career. And, and that's different than many parts of the world where there's a very hierarchical structure. And there isn't necessarily that openness and ability to move around. I think that's very valuable. And even when you look at really developed health systems, like, for example, North America, although you could argue about their health system a lot. And I know that we, you know, we're really lucky to, to work in publicly funded health systems and to be employees in a publicly funded health system that has massive advantages. And I think that's been key to the progression that women have made in our profession. You know, having generous paid maternity leave is an enormous asset. And that's not available in North America for women surgeons. Um having access to less than full time training and less than full time working is not available by and large to surgeons in North America. So I think we've got some real strengths and of course, we can always be better and, you know, we can't ever give up wanting to be better. Um But I think it's a really good question to acknowledge what we have. We do have a lot. Yeah, I mean, really, just echoing what my, my colleagues have said, I think that um sometimes we underplay how, how good we are in the UK education and, you know, in terms of medical education, undoubtedly with the, with the world leaders, um like Debbie Mike, I, I've, I've traveled and, and, and, and worked in many healthcare system and even when I go to America in terms of things like competency based training, um work based assessments, I mean, really, they're a decade behind us where we were in terms of being able to assess our trainees objectively as you see, to stop that, that bias that used to, you know, that happens in, in many systems where people just didn't go on because they didn't go on with the boss. So I think that uh people who still value the training that we, that we have, we have here, particularly in how we assess people and their competencies. Thank you. I think my colleagues have said it all. But I take a step back and say, I think people look to this country because of its principles of integrity and fairness and that's across the medical profession. It's across the legal profession. Are they perfect? No, but they are very much better than they are in some places in the world. I won't say which country I was in as an mrcs examiner when one of the candidates came in and he took his wallet out of his back pocket and put it on the side. I'm pleased to say that the, the other examiner picked the wallet up and gave it back and said we won't be needing that. So that, that is one of the things that people look to this country for as a consequence of the past, there are many countries around the world. We still have close relations with. Indeed oncologist still have close relations with where we have been instrumental in establishing their legal and medical services and they very much value that and very much value the principles that underpin that. I absolutely agree. I think the principle of a publicly funded health service which is free at the point of use is absolutely key. I think that is key to the integrity of our medical profession because it removes the incentive to do work to be reimbursed for it. And that comes across in the training and is absolutely embedded in the principles of the NHS in the UK and the health service in Ireland, with regard to the training itself, we have a very structured training program as Mike has said, which has not necessarily been the case in the past. And we do have people who have defined dedicated educational roles who are there to support people in training, which is absolutely key. And so I come back to the principles of integrity and fairness and we don't have the system of nepotism and patronage that exists in many other parts of the world which we see when we travel. And one of the reasons and Mike mentioned global surgery earlier, one of the reasons that we are involved internationally across all the colleges is because people are looking to the UK and Ireland for that support because they recognize the importance of those principles. So the next question is about something very topical at the moment and it's come from a few people in the audience and what challenges to the college foresee regarding the GMC regulation of pas and how will they be overcome to preserve the quality of surgical training and especially how are you going to support the more junior trainees who are losing training opportunities at the moment to other professions? I guess we're starting at this end. Yes, we will. Well, this is obviously a topical, contentious issue and we need to get through this uh uh particular period of time and get it right. Um II think it's fair to say and physicians, associates of course, as we know, have been around since 2003, but I don't think most of us realize that was the case and, and they've been brought to the fore by the NHS England long term workforce plan projecting an increase to 10,000 over the next few years at the moment, as far as we can tell, there are very few in surgery and it may well be that surgery will be less effective than other disciplines within medicine. But nevertheless, we have to get it right. I think it's incredibly important that physicians, associates are regulated and that needs to happen soon. I'm aware that some people would like to see an alternative regulator. But I think we've probably move beyond that at this stage. I think with the process going through parliament, it is inevitable that the GMC is going to be the regulator of physicians associates, whether we like it or not. We and others were very clear in our message to the GMC that we thought was incredibly important that there was a distinguishing way of registering physicians, associates and anesthesia associates. The GMC initially were very resistant to that and suggested that the reasons that we didn't fully understand that was not possible. I'm pleased to say that they moved on that position as you will have seen from their announcement this week. There are two key principles that I think we can all sign up to. One is that patient care is paramount patients deserve the best possible care that they can get. And we know there are difficulties around that at the moment and that's brought to the fore by the industrial action, which we've talked about already. And the second principle is the principle that surgical training must absolutely be protected and every surgical training opportunity must be offered in the two surgical trainees. And I think we on the panel here, I think everybody in this room is committed to that. It's about how do we get to that point? Is there a role for additional medical professionals of different uh different titles, different roles. Yes, they've been around for a long time. We will work with them. It's about integrating them into teams, making sure the governance is right, making sure they're supervised appropriately. I work in a multidisciplinary team in the Cochrane plant world with audiologists and speech therapists and others, all of whom have defined roles we work together and that works extremely well. There are clearly stories that we hear that cause concern, but equally, we hear stories where physicians associates have been integrated into teams well and are adding to the team and not detracting from them. So we need to get this right. We are very clear that as the colleges are working together on this to make sure that we come up with guidance that's appropriate for surgery and that will be with you very soon. II think that this is a very difficult issue and there's sadly so much anger about it. I think it's stopping us having a very um you know, a coherent conversation about it because that's what we need to have. Firstly, I'd like to thank us for the terrific survey they did uh um on this issue and I think all of us here, um, can tell you, we hear you, you know, we've read your report, we can see how strongly you feel about this issue and the impact that PS appear to be having on your training and, and we're not ignoring that. And in fact, we've, we've set up an inter work group to actually look at this issue because we actually agree with many of what you said is that, you know, ps are not doctors, they're completely distinct medical body, they do need to be registered. And as Tim has already explained, that's going to happen to the GMC, whether we like that or not. But I think it is good that the GMC now have come out with a, a separate um number. They will, they will all pas will have an a in front of the GMC number. So quite clearly show that these people are not uh you know, medical practitioners. So I think that's been a positive thing. The next thing we have to think about is scope of practice. And I think that's a really key thing and we all believe that that has to be nationally determined, it can't be so strict that these people can't do anything and they don't have any career progressions because as you see that these, these people in the right places in the right jobs can bring value to a medical team that they are professional colleagues. And if they're working in the right team and doing the right type of jobs, and I think they can be very helpful and actually take some of the workload away away from us because there's no doubt that in, in all of your careers, there's going to be a tsunami of demand coming or we, you know, we know that with the aging population comorbidities, they reckon there's going to be a, a deficit of over 300,000 m medical people and you know, in the work and the workforce. So we have to do something. And I think my last point I want to say today is that remember in the workforce plan, although they are going to employ 10,000 PS and mostly will not be in our speciality of surgery. Um It's the same plan has also said they're going to train 60,000 more doctors. So, uh the challenge I think for colleges now is what we're trying to think about is how do we train all these new doctors? Not particularly pas is how we, how we actually going to do that and we're going to and we're looking at innovative ways of actually training people simulation, you know, A IVR, all of these things are going to be more important in training going forward. So that, that's, that's training that this the new workforce for the future is going to be going to be challenging for us all, but we are looking at it. Thanks. Um I suppose I'm conscious that uh we, we don't work in the NHS in Ireland. And so we're very considerably behind where Scotland, England and Wales are on this, on this issue in terms of numbers. And we really have a very, very tiny profession of pa. So I think we have the opportunity to learn a lot from the experiences that, that you've had here. And like Claire, I really like to acknowledge the value of the asset work in this space because it does help us to focus, you know, our direction of travel and we're committed to working with the other colleges um in this area, one thing for us kind of at a slightly bringing it up a level is, you know, it has brought into fairly sharp focus for many of us. What is the distinguishing factor of being a doctor? What is that unique value to being a registered medical practitioner as we all are? Um And I think intrinsically all of us, we all sort of know that that's got massive value, but it's not a story that we tell in a compelling way. Um And I think it's interesting that we're very threatened and challenged by this group because I think as doctors, we bring quite a lot to patient care. And I think that's just something for us to reflect on, you know, how how do we show that added value of the sort of training and experience we've had um certainly for, for doctors in training, for surgeons in training, especially, you know, the very, the very lower end of, of procedures. And and increasingly perhaps some of the intermediate procedures, I understand the concerns about reducing the access to those types of training procedures. And we need to be really careful about that. Um And to an extent, possibly we also need to think about is it, you know, is there a way for us to learn from everyone we work with? And, and I suppose, um I was struck when, when Mike said, you know, you can't be what you can't see. I certainly when I was training as a surgeon, you know, I didn't see a lot of women surgeons around, but I saw some really great nurses around. I saw some really great consultant dens around. I learned an awful lot from them. So I think in certain areas, we can learn a lot actually from an experienced pa um you know, if you have an experience pa working in your hospital, they, they're a massive asset to junior doctors um moving from firm to firm because they know how things happen and they can get things done and you know what we can find a role. So I think we just need to work together and understand the concern and, and and continue to support the other colleges and in developing some policies. So I ii absolutely agree with, with all that's been said there. I think, I think if we step back again, it's really good that PS are gonna be regulated because they were the one part of the profession of health care team that were not regulated in any way. So it was a good thing that they're going to be regulated. I think we need to welcome that. It will be the GMC, who's the regulator that's now passed through parliament. And so it is going to be the GMC. And as, and Tim has very Coly argued in other meetings that needed to be in a separate way in an easily identifiable way from doctors and as clear as alluded to, there'll be a prefix and a number and so on. It should be a different register. Part of the value of being a doctor is we've been regulated for over 100 and 70 years. And so people understand that a regulated profession maintains standards and they look to us and they trust us. So we need to take that trust and help with this change of having an increase of 7000 ups between now and 2037 in that same period, up to 2035 players. Absolutely right. There have been an extra 60,000 doctors to 2037. There'll be 75,000 more doctors in the UK if the government plan goes through. So these two things are part of the same long term workforce plan that was published in June of 2023 for the NHS 7000 more PA S and 75,000 more doctors, an increase of 25% in the medical profession. So I think while we've really discussed psi, I feel in great depth over the last 69 months across the medical profession, we've been kind of missing the fact. There's gonna be a lot more medical students to teach. There's gonna be a lot more foundation doctors to supervise. There's gonna be a lot more surgical trainees. Isn't that gonna be a good thing? There'll be far more new surgical trainees and there are gonna be pas working in surgical teams. So we need to get surgical training, right? As the four colleges were working together, I think, as you know, and as it's involved in those discussions through a task and finish group on the extended surgical team, which takes into account, not just all of us as surgeons, but all the other members of the team we work with. And we've tasked that and it's a good, good, strong group because it's got all four colleges working together on that, all 10 specialty associations and all 10 special trainee specialty associations. So in our part of the house surgery, we're really doing a good piece of work and have been over the last few months trying to work out, how do we create good extended surgical teams. And absolutely at the front of all of our minds. And that is how do we protect training for those who want to be surgeons? And that's you, that's the doctors who want to be surgeons because that's the surgeons of the future. It's not actually nurses or surgical care practitioners or P ES. You are the surgical future. So, absolutely agree with what my colleagues have said. I hope we can put this issue to one side and concentrate. And actually the really quite big challenges that are coming down the line numerically with the long term workforce plan and pa is are a very small part of that. Thank you very much. Thank you very much for sharing your thoughts on that and for touching on other areas of the workforce plan as well. We have a few questions from the audience specifically about the colleges, thoughts on the new proposed route to Speciality register again, if we could maybe come back down the line, Mr Mcker, that'd be great. So the the change that came in on the 30th of November 2023 was called the Portfolio Route. And that's because the Caesar process um a certificate of equivalence of specialist to specialist registration which has been in existence for a number of years now is a really cumbersome process. Some of you may have been involved or worked with colleagues who go through that Caesar process of old amassing huge amounts of evidence uh to try and demonstrate equivalence of training to somebody who has come through the National Training Number program. We have many colleagues in the S ES grades who are absolutely capable of being on the specialist register. And we all know that and there should be a more valued part of our workforce. All of the portfolio route has done is make streamline that process of presenting evidence. And we're in support of that because we as a surgical colleges have to sift through all that evidence. And we recommend through the joint committee and surgical training is us who makes recommendations to the GMC as to whether or not somebody has achieved the standard to be on the specialist register. And we've had to employ teams of people to sift through evidence in the past. So we created specialty specific guidance SSG S for all 10 surgical specialties by the GM C's deadline on the 30th of November by working together across the surgical communities, colleges and specialty associations defining what evidence would be required. And the process has only started in December. So we'll need to wait and see how that works out. But we are as colleges absolutely aligned on maintaining surgical standards and being on the specialist register needs to mean being a specialist and being on the specialist register and the equivalence with CCT somebody who's completed national training. Um again, this is an area that's slightly different. We have a different regulator. And so, um but, but clearly, we also have parallel pathways to progress and we, we also have the complexity of, of being European and having other definitions of specialists across Europe. So it's, it's really a very challenging area. Um But I think Mike has touched on the most important part, really our role as colleges is about standards and making certain that when someone is on the specialist register, that they actually have the competencies to deliver a safe and high quality care to patients. So I think the focus on standards is, is is where we are. And obviously we're working closely with the colleges. And I think this is one area that's massively helpful to us to have the support of our sister colleges in because as as as quite a small country and particularly when we move into specialties, having that externality and have and and knowing that our trainees are meeting the same standards as trainees across the UK is really incredibly valuable to us and, and it's a really important part of the relationship that we're keen to protect. Yeah, I what my colleagues said that, you know, that SAS and local employed doctors are about 40 or 50% even now of the surgical workforce. And I think it's been incredibly difficult through the Caesar process for people to progress in their careers even though they had reached all the competencies. And so this, I think this this new pathways is the first step in actually making this um making getting onto the specialist register uh easier for people who have this the required knowledge, skills and experience um to become um consultant surgeons. And that's where we all come in. As colleges. We, we um you know, we, we assess um all of these applications and you know, we have to ensure and maintain standards that everyone who comes through that alternative pathway has absolutely got the same knowledge, skills and experience as all of you who come through a standard training pathway and we won't be moved on that. Now. I know that many of you, um some of the, the things on Twitter or it's called X now, isn't it? But by the F RC exam not being mandatory for that, that's actually true. However, it is extremely difficult for someone to prove that they've got the knowledge and surgery without having had, have passed that exam because that exam internationally is, is almost, um is, is probably the highest standard. So let me reassure you that, uh that, you know, still, you know, doing these exams coming through a traditional pathway for training at the moment probably still is the easiest way to get onto the specialist register for all of you. But it's a, it's only fair in our other colleagues who work, who do a lot of the service commitment of the NHS that they have a uh a pathway to get onto specialist registrar should they be able to demonstrate that they have those capabilities? And so I think, I think this is a very positive thing for the profession. To be honest. Thank you. As my colleagues have said, the standard is absolutely key. And we were very clear in our discussions with the GMC that with the change from the Caesar to the portfolio route, there could be no change in the standard required to meet the bar. Absolutely equivalent to, to go on to the specialist register. Absolutely no question about that and absolutely clear that we uh were absolutely united in thinking that the colleges needed to be involved in that process so that we had a handle on what was going on. Um We do have to recognize that across surgery, there are people who are following different career trajectories. There are international medical graduates who come into the country at different points in their training. And I think it's fair to say that over the years and indeed decades that SAS surgeons locally employed doctors as we now call them have not been well supported in the workplace to be frank, they've been used and abused for service and their own professional and educational needs and development has been overlooked and that is not right. And we as colleges recognize the importance of supporting that very important part of the workforce and a growing part of the workforce. Uh We as a college have our SAS action plan which came out of the Kennedy report a few years back. And it's absolutely right and proper that we do that at the same time, it's absolutely key that we continue to support the traditional training pathway and make that attractive and have the same degree of flexibility built into that. So that, that remains first of all attractive. And as Claire has said, actually, it is the easiest way of progressing to the specialist register and we're committed to doing that as well so that everybody has the appropriate support that they need to develop in their career in whichever direction they feel they want to go. Thank you very much and thank you everybody for all the questions that you've asked online. We don't have time to go through all of them, but we have time for one last one and a lot of people have really asked and it's not gonna be an easy one that really you mentioned the need for more doctors and surgeons, the issues we have with waiting list and the morale. But yeah, there are many applications and not enough training posts both for CS C and higher surgical training and consultancy posts as well. So how are you going to advocate for trainees to increase numbers of trainees in surgery? Well, it's absolutely clear that that has to happen. We've talked about the long term workforce plan. We've talked about the expansion of medical school places to double the number of people coming out of medical school, they've got to go somewhere. There's got to be an infrastructure for that. Now, of course, it is fair to say that there is a little time but not a lot of time to look at that because there's a lag phase and we are already having those discussions and it's absolutely critical. And of course, the other thing to bear in mind is that there will be as it were a little bit of horse trading going on because every specialty will want to have those people coming towards their own discipline. And of course, our perspective is very much that we want to see as many people coming into surgery. We've talked about how we want to make it more attractive. Uh, we do have the massive backlog of work and waiting lists and if we're gonna get that down, we need to have, er, surgeons, we might even need some anesthetists as well by the way. But we certainly will need more surgeons to address that. Yeah. And I think it's the age old workforce planning nightmare and actually trying to predict what surgical workforce we're going to do in 10 years can be really difficult because we know that technology changes, there's new treatments for cancers that perhaps mean that people don't have to have surgery. And so, you know, this, this can change. Um, but we know there's going to be an increased demand, particularly in the acute specialities and, and for me, um you know, as time going on, there's no way, no doubt that they, they're going to have to be um uh expanded um in terms of very super specialist doctors, um you know, that there may not be the need for see, doubling number of cardio thoracic surgeons perhaps, but we probably may have to double the number of acute emergency surgeons to deal with the emergency workload because, you know, and we actually have to develop a workforce that reflects the population's needs. And I think that, you know, we have to, we have to support that and make sure that we are training surgeons of the future to meet those needs and, and be able to serve the public because actually, that's what we're here to do. So we've had some success in increasing numbers of core and higher trainees. Um And we are in a workforce planning phase with, with, with the HSE who's generally our employer and who employ our trainees. Um But, and one opportunity that we're, we're pushing quite hard with them and we haven't yet had success on is that, you know, as training becomes more flexible as we have more or less than full time training, as people take breaks in training, to do research or to travel abroad. Um We do have vacant posts as a result of that. And I mean, my personal opinion is that we should be recruiting a higher number of trainees bearing in mind that, you know, spare capacity and training that we have as a result of the increased tendency towards flexibility and training. So actually, I do think we have capacity to train more. Um I think there is a challenge always in increasing training numbers because um it's really important that training numbers mean something and that you can actually train that there's a sufficient volume of work that there's sufficient consultant, trainers and and that the sources are in place for those training posts to be high quality training posts. But I think we can do more um bearing in mind the flexible way of training that in my view is likely to translate into a flexible way of working at consultant level. And so I do think we really need to expand our numbers and, and use every possible way to do that. So workforce planning traditionally hasn't been done very well in the NHS over the last 75 years, that's for certain. Um We've had some success in Scotland with persuading the Scottish government to increase training numbers and a number of specialties. As Tim says, there's always a bit of um horse trading about whether we need more or more surgeons or more of both. But we have been able to increase numbers. One of the reasons why we're able to persuade governments to do that kind of thing which costs them, money takes a risk on those people being employed in due course, and we have made mistakes on that in the past, in neurosurgery, in particular, here in the UK, we got that wrong. But one of the reasons why governments will work with us on that is if they trust our advice. And that means we as a surgical community behaving responsibly and with integrity. When we interact with governments, we had a wonderful meeting on the surgical workforce of the future at the Royal College of Surgeons of England, hosted by Tim as the surgical forum, all four colleges, all the specialty associations, trainees and the Statutory Education Bodies in the room. And we discuss the surgical workforce of the future and it's not possible to predict just now how many nt Ns we will need in any surgical specialty in five or 10 years time because as Clare says, practice will change, things will change, but we need to keep on doing our business really well as a surgical community. And this interaction with you as college presidents. Meeting all of you today is part of that. We're open to hearing from you. And can I maybe just finish from where we started in all of this? All four of us explained that we became surgeons because of the example of somebody we met a good example. Last word to the old man who's retiring at the end of this year, be the very best examples. You can be as surgical trainees to medical students, to your fellow trainees to nurses and other people be the very best surgical trainees you can be because that's what's gonna make things better for the future. Thank you so much for finishing. On that note. I think it's been clear from this morning that there's a lot of scope and space for change and a key from what I've heard from yourselves this morning is that that's going to really require good communication and collaboration with across all of us and many of the other stakeholders involved. There are so many questions we really could keep you here all day, but you'll be relieved to hear that. That was the last one. So I just want to finish by saying, thank you very much for your time this morning. Thank you. Thank you. Thank you. Thank you.