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Oh, I've just lost pictures. Hello, good evening. Good afternoon. Good day. Wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. You'll see. We have a new year and a new look and to start the year we have a very special guest. I would like to welcome Professor VNS who's from the University of California San Francisco and is director for the center of mindfulness and surgery. She is a clinically active general surgeon who received her MD from the University of Minnesota, completed surgical residency at the University of California and did a minimally invasive surgical fellowship at the Institute at Strasbourg University of France. Since December 2015. She's been on the faculty at the University of California in the Department of Surgery and is a clinically active and minimally invasive robotic and general surgery and teaches surgical residence. Her research focus caught my attention as it focuses on stress and resilience in surgeons and the systemic factors that influence surgeon wellbeing and the development of evidence based policy and interventions to promote wellbeing. She created a mindfulness based intervention called enhanced stress resilience training and is a member of the Academy of Master Surgeons of Education and Vice Chair of the American College of Surgeons Committee on surgical wellbeing. Carter. Welcome from California. We know it's seven o'clock in the morning there and it's 11 o'clock this evening in Kuala Lumpur and Vanish is producing and our two senses, Chris Caddy and 10 Terry will join us later in the conversation of both in the UK. Thank you very much indeed for joining us. Perhaps we can start Carter, you were late into surgery. I believe cos you started your career as a biochemist. So why did you become a surgeon? Um Well, I did start as a biochemist and um I was really interested in the resilience of young people growing up in the United States in under-resourced settings. Um I grew up in a community like this. I lived around kids who were young and had a lot of promise and then I saw how the environment around them could cause so much stress that it was overwhelming and they really didn't have tools to help themselves even while the systems around them um were hopefully, you know, working and evolving to be more supportive. And so it really got me to focus, not so much to ignore the challenges that are systems level or cultural level, but rather to think about when individuals are under stress, the most immediate help we can give them is internal tools. And so it set me off on this search for what set of internal tools might help young people. Um mindfulness was pretty new then. This was in the late nineties, mid nineties. And so a lot of the early um literature that was published by John Cabot Zin and Richard Davidson at the University of Wisconsin that really began to show the scientific foundation of mindfulness had not yet been published. Um The literature around resilient science was just emerging, much of it, which was based at the University of Minnesota and really exploring how resilience could be taught to essentially provide a lifesaving set of tools to young people. So all of that was sort of swirling around in my mind and I was reading this literature as a biochemist and then reached the point where I realized if I really wanted to affect change, doing it as a, you know, wet bench scientist would be very difficult. So I asked around to the people I was working with in California biotech startups, one building houses 20 different professions and they're all within um 30 seconds of having a conversation. So I spoke to lawyers, public health advocates, physicians, ceo everyone else I could find and just asked, you know, if you could go back to school to empower you to do the things that you believe in, what would you pursue and almost down to the person, they said medicine. So it made me think that if I did wanna pursue this, I should um go to medical school and then went, went into surgery after your first laparotomy. I did. Yeah, I had all these grand designs that I would be an adoles adolescent, essentially primary healthcare provider. Um This was my goal. I went to the University of Minnesota because they were so seminal and pioneering in that work around adolescent medicine and resilience training. And then I happened to be at the bedside for my first laparotomy And it was just utterly amazing to see, you know, that, I mean, many of us on this call have seen this, whether it's in the chest or the abdomen, the pelvis, the um forehead hiatus area, it's miraculous what's in there. And to be around that, to be a part of it, the culture and the discipline of surgery um working with patients, just all the fabric of surgery is to me represents embodies some of the most amazing um experiences one can have in their life. So I couldn't get enough of it. And it is not surprising that resilience and mindfulness is much needed in surgery and you find yourself in the perfect position to affect probably the best changes. Well, it's interesting, it, it has been a hard road to um bring the legitimacy of mindfulness training into the awareness of the surgical community. And I respect that, you know, we are surgeons, clinicians, but at the heart and as part of all of our training internationally, we are scientists too even people who don't actually do research, we learn to read the scientific literature. We are trained in judiciousness, um equipoise the evaluation of data, not just whim or fancy. And so I myself in exploring the potential benefits of mindfulness, but then in the work that I've done subsequently to try to show its value to surgery. I've been very much evidence focussed. And I think being able to um not only show but scrutinize along with the surgical community, the value of this type of training has allowed it to gain legitimacy in many other communities that it probably could not have otherwise. So it sort of raises the value of it for everyone. Perhaps we can start by defining mindfulness, particularly with respect to surgery. Yeah. Well, that's a great question. Um When I talk about this to organizations or institutions or individuals, I make it really clear that um the word mindfulness or being mindful as a term is bant about a lot. And while it has many different connotations and meanings in the lay community, I very specifically mean and study um three cognitive skills. And that includes awareness which is in some areas called interoception. This is the awareness of one's thoughts, emotions and sensations in a moment to moment fashion. Um then emotional regulation is the second very specific cognitive skill and to put simply that's the ability to recognize our emotions, our feelings and not react to them. So to have some space between recognizing stress, anxiety, fear, anger, um even joy and um choosing a response rather than simply being thrown into a reaction. And then the third one is metacognition and that's very much related to the first two. Some people call metacognition frameshifting or cognitive appraisal. Um Some folks folks call it decenter. So it's the process of not looking at everything from only your individual perspective. Um So it's kind of zooming out from things not taking them personally and being able to see um all the parts of what's going on. Um in true meditative um language, people sometimes call this open monitoring. So where you're not just paying close attention to your own experience, you're also very much aware of what's going on around you. And so training in mindfulness, meditation skills um in my parlance in the research that I both read and um produce, we are very much talking about training specifically those three skills. How is this different from reflection in action? Well, I think probably the skills themselves that mindfulness meditation teaches the benefits that those skills confer on people and the side effects that we see. The the outward facing benefits in people's lives are derived from many different things. So there isn't just one answer here. Um Mindfulness, meditation training is not the only way to experience more flow in surgery or athletics. Um It is not the only way to be calm and have a judicious perspective in police work or the military or the, or there are many different ways to reach these points of balance and self-awareness. What I think is unique about mindfulness, meditation training is number one, it's very carefully codified. So just like a medication that we give a patient who has, you know, cancer, you don't Sprinkle a little of this and a little of that based on your neighbor's good advice or your own one or two time experience, we go to the recipe, the pharmacologic profile that we know works um as well as anything if not better than anything else. And we specifically give that intervention for this particular cancer. And so because John Cavitt Zin and some of the early pioneers in secular mindfulness were very precise about making a codified reproducible intervention. I think that makes mindfulness, meditation itself more accessible on a repeated fashion, but it's not necessarily better than when people reach the same point through other avenues. It's just perhaps more easily widespread in a with fidelity. So, although it's codified, it's still bespoke for the individual, the situation, the context. Well, that's true. Yes, sir. Um One of the things we've tried to do with the training we developed specifically for surgeons was to get exactly at the point you're making um many of the early codified interventions. So MB sr or mindfulness based stress reduction, which is what John Cain is famous for or also MB CT mindfulness based cognitive therapy. Um Zind Sigal and John Teale are famous for that and that has a lot of um relationship to Oxford University. Um Those two interventions are wonderful and for instance, with MB CT, there are randomized controlled trials of its effectiveness in preventing major depressive disorder relapse with equal effectiveness to pharmacologic agents. I mean, so think about that for a second, you know, that a mindfulness training practice that is codified and very um thoughtfully and specifically constructed can work to prevent depressive relapse um as well as the majority of um pharmaceuticals. So that's pretty astounding. But those interventions are very time intensive and the way they are constructed uh is somewhat rigid. And II don't mean that as a um criticism because these are really amazing inventions, but they require that the um participant moves to the culture and the language and the pacing of the intervention as it's created. And what we found in surgery was that this is just very hard. Um We're very fast paced, we're always multitasking. There are, you know, 10 patients that might get sick or already are sick on our minds while we're doing any given thing. So what we found in medicine and initially, this was true in surgery but now has been shown across other medical specialties and other high stakes professions. Um Something that is a little more straightforward, simple language, um less sort of um conceptual information that is um meandering and self evolving in terms of the process and a little bit more prescriptive and direct in its delivery just seems to land better with surgeons. So, in that way, um, we try to personalize or individualize how this particular treatment if you will, gets delivered to people. A lot of surgeons would think of this as fluffy stuff or soft stuff. How, how do you persuade them that's important and what is the evidence you have that it is beneficial for all surgeons to understand what this is about? Yeah. Well, on a, on a humorous note, I would say if you try sitting and meditating, um then you will know it's not fluffy or soft, it's incredibly hard. Um, when people equate meditation to brain pushups, I think that's absolutely accurate except to say maybe it's one armed brain pushups. Um, and I think a lot of people find it very uncomfortable and very challenging. Um I've spent a lot of time in various places around the world speaking to people who are far more expert in meditation than I am, um, about this experience and how difficult it is, how rigorous it actually is in practice. And even monks that have devoted decades of their lives to training and, and practicing, laugh and say, oh yeah, there are some days where I just wanna weep with how difficult it is and how much I wanna just get up and go wash the dishes. So when one does it, it's obvious that it's not fluffy that it is rigorous and challenging. Um But beyond that, from the very beginning, I designed and executed randomized controlled trials to be very purposeful about showing people including myself the highest quality data I could as to whether or not mindfulness training is truly beneficial. And so um back around 2015, 2016, I did two randomized controlled trials in surgical trainees and mixed specialty trainees with uh active comparative control. Um A number of different outcome measures, both selfreport, you know, how do you feel but also very ob object objective physiologic measures like circulating stress markers and functional neuroimaging. And that work has actually been reproduced, randomized controlled um tests with objective and selfreport um data endpoints uh in several other institutions now with ICU nurses, medical students um in the UK as well as in the United States. So I think the simple answer is um read the literature, there's within surgery itself, such a growing body of information that demonstrates benefits to self perceived stress. So just how stressed one actually feels but also to proinflammatory gene markers. So something that you couldn't change based on your opinion, whether you wanted to or not, it's a hard objective data point. And then also in terms of um anatomical neuro anatomical changes in the brain that occur um after just five weeks of um mindfulness training and are persistent up to at least six months. And we just haven't looked further to see if those last in the last regard in the latter regard, um those specific neuroanatomic changes um have other um research, other evidence demonstrating the same neural substrates as being essential to the execution and development of surgical expertise. And that's from work that comes out of um Asa Dar's lab in the UK. Mhm. So there's, there actually is growing but increasingly um prominent very rigorous literature showing that this truly um has benefits and you've incorporated this into the curriculum now at the University of California. So how do you start this and how do you go about teaching it? Yeah. So where do you, and where do you find the teachers? Yeah. So um we do at UCSF and UCLA. Um this training is voluntary. So it's elective, incoming surgical trainees can sign up for it if they want. Um at other institutions, University of Washington, University of Minnesota. Um A couple of others, the training is ii guess I would say mandatory, but they don't really treat it like a prescription. They just say, you know, in our program, we teach surgical knot tying and in our program, we teach essential stress um management skills in the form of mindfulness, meditation training or ES RT specifically. So people don't necessarily feel they're being forced to do this. They're just being told that part of your training is to learn skill sets that will make you a better surgeon. And this is one of them. So when an organization wants to develop a curriculum like this or if an individual wants to um learn these skills, we offer several courses. Um The Center for mindfulness and Surgery puts on online courses periodically throughout the year. They are live streamed. So we have an instructor um performing the course in the same way that you are leading this group here and people can attend in the live session as we are here today or the sessions are recorded so that you can participate asynchronously in recognition that most of our lives are often inconsistent. And so if you're late in the or, or someone gets sick and you get called back, you don't have to miss a class and um disrupt the series. There are 51 hour classes, there's a um bespoke app that was created specifically for ES RT called Strong Mind. It houses the videos of the courses. It facilitates um both the administration of the course, but also the participants being able to access the information and communicate with each other, um the other participants in the group just to share what's working, what isn't working, what's confusing, what they think is great, anything they want. Um So a person could go to the center for mindfulness and surgery and sign up just to take a class, like we have a class in February. That's one way if an organization wanted to create its own course, for instance, they took it as an individual and felt it was worthwhile and then wanted to implement it more broadly. We have several instructors um who have been trained in the ES RT, but we also have a pathway to train new people. So currently we have five or six people. Interestingly, right now, let's see. One is in ophthalmology but I think four. no, I'm sorry, another one is in trauma surgery and then the other three are all orthopedics, either pediatric orthopedic spine or adult orthopedics, um, who have come to us and said that their institutions wanna build a program, they wanna invest in their um training as an ES RT instructor. And then the institution essentially has a built in resource so they can um offer courses when they want. We do really help institutions. We've done a lot of implementation, science work to understand how does a course work, you know, how does it become sustainable and sort of incorporated into the culture of an organization? Because we know that um things that persist really need to have that kind of um rooting and foundation. And so we very closely help institutions um prepare the way, set it up, make sure that it works and um uh help their instructor until they really feel proficient and masterful. This feels like something that should be done sort of at undergraduate level before you even start the career such as you in a better position to manage one's studies in care with the right skills for the moment you start medicine. Well, some, some people have argued that there are a couple institutions in the US. Um Brown University, I'm thinking of offhand that has a whole mindfulness training track. And um there are some medical schools. Only a few, I think the University of Rochester Brown. Hm. I can't think of another offhand. There might be one more that, um, do have mindfulness training during the medical school curriculum. Um So in the US that looks like, you know, four years of college, four years of medical school and then you go on to your actual um training as a surgeon or a pediatrician, whatever. Um More and more people are interested in offering this training um a few times throughout one's career and sort of the leading edge of what we're doing right now is rather than repeating the exact same experience we're working with um other scientists and educators in this area to come up with a sort of longitudinal curriculum. So when you're a medical student, perhaps you get the kind of basic training that uh ES RT encompasses. But when you are a um training surgeon or a new young faculty or even later on in your career, 10 years in when we, when many people also feel a change um that we could have something sort of age appropriate if you will at each of those stages. Um the University Swansea Bay or I think it's called Swansea University actually school of medicine. Um they just completed a randomized controlled trial of medical students and it was found um tremendously helpful to them um both through, you know, statistically significant outcomes but also just through subjective experience. So there may be a trend towards that. Do you find that there are certain personality types or individuals that are more receptive or less receptive to this? And are there any cultural differences? Um I think the people that I find seem to pick this up most quickly and accept it most readily, typically have high-level sports training in their background or an experience in the military? Interestingly, some of the, you might think that that's um incongruent, you know, that those are very rigorous and sort of um discipline minded experiences, elite sports in the military. Um And that perhaps that wouldn't jive with mindfulness training. But in fact, the complete opposite is true as I mentioned at the beginning, um elite athletes have been using cognitive training and mental models to optimize their performance. Um for decades back as far as the sixties and seventies in some cases, um in the military, actually, some of the largest body of data that we have around the benefits of mindfulness training comes from um the US army and they have been implementing a program rigorously. Um since 2008, so many people who come from those types of backgrounds very readily appreciate that um training, one's mind having your mind and your body in sync so that you can have better um both control of yourself. But also understanding of yourself allows you to use your tool, your instrument as skillfully as possible. So that's really the, the group I see that's most culturally aligned with this, that's almost implicit in martial arts training. Mhm And what's interesting because I, I'm, I'm studying uh for third D with the sword and the word to use when using a katana is serenity. And the, the X focus and open mind and mindset are implicit in this. So what would be the opening sentence then to a an audience like the Black Belt academy who are aspiring surgeons? You probably haven't thought of mindfulness before. What would be your opening invitation to them to consider this is important. How would you start the lesson if they turned up in your, your lecture? What would you, what would be your opening sentence? Well, I think I would say think about a time when you were in a situation when everything should have fallen apart. But you rose to the occasion in a way that surprised even yourself. You found a focus of attention uh c centeredness in your response, the ability to see the whole picture that allowed you to thread the needle through a very challenging situation and have results that were surprisingly wonderful both in how you felt and in whatever it was you were doing. And then imagine that that miraculous um ability wasn't just a meteor shower that showed up once in a while in your life on surprise, but was something you could actually cultivate and then call on when you needed it. Something that you would carry with you anywhere you went everywhere you go. Wouldn't you want to have that? The answer must be yes, I know. It's for me, it's yes. For me. I just want to pick up on before I invite my fellow senses to the stage and Chris and Tim can join us. So I must pick up on this resilience element because to be honest, I've always felt in Korean surgery, it's probably the age of training we've been through. You have to be resilient. In other words, you have to be tough, you have to be hard because it's tough and hard and resilience therefore has a sort of negative connotation. But if you're in an organization that respects an individual nurtures and grows individuals and appreciate your worth, you don't necessarily have to have this resilience. So II, II have a negative connotation of the words resilience. Unfortunately. Yes. And that's probably because of my conditioning of years of surgical training. Yeah. Well, you know, you're really not alone. In fact, just like the term mindfulness, the term resilience has been sort of molested. Um, since its inception, in fact, resilient science, um comes from a group of scientists who looked at the original largest data set of information that followed um adolescents in the United States about just over 10,000 for several decades in a very 360 degree way. And this was a study um the national um longitudinal adolescent health study or a DA health. This was commissioned by the US Congress and was the first of its kind to be so sweeping and in depth and pretty miraculously the group of scientists who received the first wave of data from this work. Some for some crazy reason, bucked the trend of looking for pathology and looked instead for um salutogenesis or what was good and they focused on not just what happens to make a kid go bad, but rather what happens to make a kid thrive when everything else suggests that they should go bad. And so actually, resilience by definition means the ability to thrive despite adversity. So that's quite different than the ability to survive adversity, right? Because surviving adversity means you just make a bigger shell you put on more armor, you, you know, lose less of your sense of humor um or more of your sense of humor. But instead, it really says, how do we teach people the skills, create an environment that nurtures the skills so that you have a sense of humor, you are still an emotionally rich person, you are happy. Um You have interests and also you can do this incredibly difficult and challenging work that is rewarding and wonderful but is very hard. Does that not come down to your teacher being mentors and coaches? Mhm. It certainly does. Um, one thing we really try to stress with ES RT training is that this is just a tasting menu. Um One can't do this five session course and suddenly be fixed. It simply shows people in what we hope is a very accessible and um succinct fashion. What the possibilities are if one continues to develop um this type of training. So just like uh you know, I'm not a martial artist, but I am well aware in martial arts, you can't take one class or even take a class for one year and become a master. It's really lifelong work from what I understand and just like any training, your surgical training, um training in chemistry or martial arts or art, um your teacher makes a huge difference and so does your classroom. So we do need people who teach us role model, us, um peers around us who are learning alongside of us that we can offer our insights and receive insights from. Um You know, we can't do it alone, but neither can we do surgery alone. You know, it's a, it's a team sport. There might be a captain of the team, you know, which I would argue as the surgeon, but it's a team sport. So similarly, all these skills that we learn, we do need a team and mentors and coaches are incredibly important this, this simply synergize with that. It doesn't supplant that Tim and Chris, would you like to join the conversation as we have introduced coaches and mentors? And I know you have an active interest in mindfulness, argue that there's Tim there. I, well, I'm certainly here. So, first of all, thank you for sharing with us and opening up II. What was interesting to me is that each of us has our own journey. Uh There's a golden thread that runs through our life and the way that we come into surgery is mixed and yours starting off as a biochemist and ending up in the theater is, is ex exemplifies that. Um There was so much in what you had to say, uh All of this is very much context dependent. Um I trained in South Africa, United States and Australia before returning to the UK. So I'm aware of differences in healthcare, needs difference in educational systems across the planet. And what's interesting is the way that you have managed to introduce mindfulness into surgery. Um Cabo Zin managed to introduce mindfulness into medicine in a generality. Um But we need to reach that tipping point where it becomes. Um So we're all part of the with the early doctors of this sort of practice. And I think what we need to do is to encourage the next generation to be more mindful from the beginning. And some of that may come through selection into surgical training, but also training the trainers to be more mindful in the way that they develop the trainees. Yeah, I, you know, I couldn't agree more. I think um you know, my work intersects with research around wellbeing and that's institutional well-being surgeon, well-being systems that promote wellbeing in medicine. And one thing I am concerned about is this, I think unintended trend towards even discussing and in some cases um trying to build a surgery that's not stressful. And my concern is that at the heart of surgery is this willingness to sacrifice for people. We don't know, so to sacrifice for strangers that is very hard and can be very draining and sometimes demoralizing. But it also is on the other side of that coin is the amazing reward and fulfillment and incredible sense of usefulness to be of service like that. And so I think it's important that we're, we're very careful about not trying to make surgery um like a warm glass of milk. That's not really the answer in my mind, surgery can improve. It doesn't have to be all chewing on nails. But we also need to equip people with, as you say, you know, skills that allow us to better manage these really um profound challenges and still see the benefit and the pleasure in hard work. Can you identify that as part of the selection process into surgery? Well, there's some, yeah, people have really tried interestingly, some of the work from um Aza Darsy and uh I cannot remember the scientist's first name, but his last name is Modi Mod. I, some of their work on mapping the um neural circuits and substrates of both novices in training novices who are reaching some proficiency and then actual surgical experts um shows these very specific neural pathways that develop when people begin to have technical mastery essentially. And they have proposed maybe this could be a screening tool. Um Other people have looked at scores like grit or um the Connor Davidson resilience scale and I appreciate those ideas. But unfortunately, I think most of us have seen, you know, the young incoming trainee who has a lot of heart, but maybe less skilled and then blossoms in the most amazing way into a real star or the person who comes in with the most amazing test scores and the most impressive pedigree, but can't separate flu from hemorrhagic shock in the real world. So there might be a way to screen, but I don't think anyone's discovered that yet. I think human potential and human variation still eludes um simplistic screening. And what do you see as the importance of you have alluded to already the trainer in all of this, the relationship of the trainer and the trainee. Yeah. Well, that's really interesting. There's I have my own observations but I'm very much building on work, um, that Amish Ja has done in the Marines um in the university and she was at the University of Miami and I'm not sure where she is now, but in Florida, um she did some lovely work very meticulously showing the benefits of mindfulness training in the military along a number of different outcomes and parameters. Um And once she had established that she started to look um similarly to how I looked at how much training does one need, you know, how much of a time commitment, um how much personal practice each day, because those things matter when you're in a time compressed um profession. And along the trajectory of that work, she came to find that if she took a highly skilled MB sr trainer who came from, you know, a yoga environment or something like that and offered a course. And then um compared that to a person from the marines, from the military who learned how to teach her intervention but was not um considered a lifelong expert. And each person delivered the course, the instructor who looked like the participants who understood their experience best, that group actually had the best outcomes and others have shown similar things that the, the literal amount of benefit that a group receives very much depends on how much they like or affiliate with their instructor. So in our work, um we, we really do test people who are training to be instructors through kind of low stakes teaching to make sure that they are landing with the um group that they're trying to reach the population, they're trying to reach, we do have a number of surgeons, some retired, some still active, but then we do also have some other individuals just that just seem to be able to um meet surgeons where they're at. So I think it really does matter. Um, I don't know that it matters that you've spent your life devoted to this practice. I think it matters more that you really understand the practice for yourself and that you really understand what it's like to be, whomever it is you're trying to teach a surgeon or a person that's incarcerated or a, a police officer that would also depend on the relationship between the trainer and trainee. So that, that can't be, that has to be voluntary. Yes, it does. Um You know, interestingly, for instance, we have a, a private hospital here in San Francisco that's been offering ES RTI think for six years now to all internal medicine residents. So they were very early adopters and um they had a leader, their um department chair who read the literature. Um, came to the conclusion that this was worthwhile, had me come and do a grand rounds and help disseminate the evidence. And then just said, everyone in internal medicine who's in training has to go to this course once a year. And uh it, it isn't really voluntary because they're saying this is one of the courses that prepares you to become a doctor at this institution. But um of course, one has to participate. That's part, is very much has to be voluntary. And this last year, the instructor told me at the end of the course, she got a standing ovation and, well, she's wonderful. I, and I do think she's a great teacher. I think it may reflect more that there's now been years of this culture building and it's become something valued. So, II guess what I'm trying to say is it depends on the individual, it depends on the instructor, but it also depends on the culture surrounding this kind of thing being adopted. And I know Chris will perhaps answer this question. How would you persuade you persuaded the American College of Surgeons to go down this route? How would we persuade the Royal College of Surgeons of Edinburgh to do the same? You'll note that we're wearing our blues and we are accredited by the culture says I, are you Edinburgh College or are you home? Uh London? Oh, hold on. Yes, that's all you like. So how do we persuade the surgical professional bodies to actually say this is important? Yeah. Well, when I was designing my first randomized trial, I was very interested in objective measures, objective outcomes. So uh at that time, Telomeres were um really kind of a hot topic and their ability to evaluate cellular aging was um really an exciting frontier. And it just so happens that the woman who discovered Telomeres and got the Nobel Prize for it in um 2009 was at UCSF. And so when I was in my fellowship in France, I reached out to her and said, I'd really like to study mindfulness in surgeons. It's really important to me that I um assess this in the most rigorous way possible. And I would like to um look at Telomeres and could we talk about a collaboration? And she said, yes. And then as it turned out, she was doing a visiting professorship at um Marie Curie Institute. And so she said, well, let's meet in Paris. It was like a movie. It was so amazing to sit at this cafe with this incredible mind. And after we've gotten to know each other a little bit, II asked her, you know, you're one of the most old school crunchy, you know, um rigid thinking disciplines, you know, molecular biology in the world and your Nobel Prize laureate. So certainly you've, you know, you're cut from that cloth. How in the world could you be in support of mindfulness? And she said, well, it was two things. One was the hard neuroscience literature. So seeing really irrefutable evidence in her mind. And then number two was that as a Nobel laureate fancy person, she was invited to Stanford University when the Dalai Lama came to visit. And so she was invited to attend a meditation session that he led. And she said in that she actually experienced the sense of sort of whatever you might wanna call it flow or Peacefulness or centeredness that can happen with meditating. And she said that sold her. So what I'm getting at is I always try to focus on those two things is asking an organization um or an institution, what's the objective evidence that would convince you that this is worthwhile? And if the study isn't already out there, then I try to help design and execute the study that will speak to what matters to them. Um And then the other thing is if they're willing is to offer them the experience of taking um a course and see for themselves if they think it's stupid or useful. One of my instructors says we have to welcome people's skepticism because it can't be something that people are forced or cajoled into and for some people, it will never be useful. But I think for most of us, if we can come at it with an open mind, most of us find at least some benefit, if not a tremendous amount of benefit. I think you've taken on a profession that automatically has hostile tendencies to things such as mindfulness. But you only have to look at the data put out on the number of trainees in surgery who suffer um problems with 60% burnout each year in our training system. And similarly in yours. So clearly, there's something that really needs to be done. And I think your studies and similar studies are going to be helpful because you've got hard data to say, look, this is going on, we can see it, these things seem to help. This is how you can do it. And then the issue is going to be for these other people. Well, how are we going to finance it? How are we going to find people to do this? And I thought your courses having the app um fantastic because those simple things people will buy into them because it's low cost. But I think you've convinced me particularly with your evidence that something needs to be done and mindfulness comes in many forms and it does need to be pushed in a way that people will be less hostile. And I think that's what this lecture has produced a less hostile approach to mindfulness. Well, thank you. I certainly believe that to be true as well and delighted that you're able to join us. The proof of the pudding is in the eating and, and your story about your nobel laureate. It's a demonstration of neuron science and manifestation. It's about synchronicity and making things happen which you could not plan or make happen. So, thank you once again for that story. It is quite inspiring. All right. Well, thanks, thanks for your reception. I mean, you, you guys, your generation and your caliber of surgeons. You guys are the gatekeepers to how surgery advances and evolves. Um So seeing that people that are experienced and have, you know, wisdom and have really worked in the trenches. Um Finding some value real or theoretical here is really powerful. So, thank you. It's about asking questions in the right places and both Tim and I are in a position to do that and will uh and it, it's great to meet you and I'm sure we will meet up again. Um So my son spent five years in San Francisco and heading off to Florida at the end of this month. But we will be in touch in the Black Belt Academy of Surgical Skills. We do talk about all the different genes described in the mindset of Bushido. And the our favorite phrase is also mind like water is try and keep it calm or you're peddling frantically underneath mine like water and you're not sending ripples through the theater and as you say it and, and, and learning, continuing the journey of martial arts with the sword, the focus and the attention that is given the sword and standing opposite a sense who is communicating X and focus. You can honestly palpably feel that focus from an experienced master of the art. It, it, it, it's almost a presence and quite frankly, when you uh practicing a carters and drills and they shoot the sun, I stand there thinking I wouldn't like to be opposite you on a dark night because you can feel the intensity of concentration and presence, but in total control, which is really interesting to see at that level. And as you've alluded to that level of motor skill goes hand in hand with mental skill as well. And they're almost necessary to reach that level of mastery. Yeah. But I could, I couldn't agree more. And I, you know, I have, I think in this day and age, at least in the United States w we have done a lot to try to deconstruct the hierarchy of the or, and I understand some of the motivation behind that, you know, increasing psychological safety, um making more people accountable. So we have fewer errors. Those motivations are good. But I think those of us who are the surgeon, um the aspiring surgeon, we know that no matter the language or the culture around the, or we are singularly a alone and responsible for so much of what happens in that room and in that person's body. And that's not, that's not arrogance or um like a, a paternalistic culture. That's just a fact. I have a friend who studies heart rate variation and she was one of the first researchers to look at this. And back at Boston University, she did a study where she put um measurement straps on everyone in the or, and in multiple ors just looked to see what the oscillating um heart rate variation was going through an operation. And she said that what she found was when people walked into the or um the anesthesiologist and the surgeon were the most dyssynchronous to begin with. But after starting the case and getting into it, everyone eventually yoked, meaning they synchronized with the surgeon. And so what I'm getting at is no matter what, how we talk about it, no matter um the cultural framework around it, our leadership in the or, and I would argue even across medicine is incredibly unique and powerful and important. And so what, what we champion as being valuable um moves millions of other people. So the kinds of things you are doing and um giving value to is just incredibly important for all of us. It's been an absolute privilege car and look forward to hearing more. And perhaps I asked, perhaps you could give us an introduction session to this later on. I don't, but I have a teacher who could if you've got a teacher who could, that would be most helpful. Thank you very much. Indeed. Thank you very much to the audience. You've quietly sat in production at the back. Any questions from a prospective cardiac surgeon, a new generation surgeon because you are looking at 33 old men. Yeah. Um I don't think I have any question at the moment. It's a new concept for me as well. Mindfulness, uh especially coming from Malaysia this side that these type of things are not really spoke about. Yeah, not really. Uh I think you know, we are still focusing more on advancing surgery, the technology in surgery. But talking about these type of aspects on the mental aspects we have not really reached there. So it's really interesting lesson today to talk about this and to know that there are other aspects to surgery other than just skills and just technology. Yeah, indeed. And it would be nice to explore the cultural differences. Certainly coming from the UK and working at the University of Malaya, I've seen cultural differences and your note, our new logo with the scalpel on the top. I am reminded that the National Rifle Association talk about the weight of responsibility, carrying a gun and actually say there's far more weight of responsibility, holding a knife. Mm. And to stay sharp, you have to be sharp physically and mentally and we will continue the Black Academy next week by focusing on life skills. Thank you very much. Indeed, for your insight. I've enjoyed reading your papers and hopefully this is beginning of something that we can continue to propagate. I absolutely thank you very much for having me. Very lovely to meet all of you. You have a wonderful day, Tim. Thank you very much for joining Christopher. Thanks for the production and have a good New Year Carter. You too.