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So if there aren't any questions, I'll be happy to answer them in a chatterbox later. That we can move on to Mr Castle. Catherine Hanan, who is a neurosurgery registrar. And he is the asset representative for the British Neurosurgical Training Association. Thank you, Kathy, for agreeing to speak today. And we look forward to hearing why Neurosurgery is the best. Yeah, yeah, thanks very much. And I really enjoyed that talk actually was great. How do I put my slides up there present now? Yeah. So my name is Callahan, and I'm in your surgery trainee in Liverpool, um, in the Mercy diary. And I just thought it would give you a brief overview of, um of our specialty. Um, and just maybe try and address some some common questions that I often have from medical students and foundation doctors that are interested in a career in your surgery. Um, so the you can use every training has recently changed, and it's in keeping with an awful lot of surgical specialties now, in that they are trying more and more to push people into entry at ST one. And so s t three entry has been done away with completely now and and they do have a very limited number of places available for entry at ST too. But for context, I think there was only one place, um, last year and there were 59 separate applicants for that. So it's becoming less and less realistic, really to enter into UK neurosurgical training at any stage other than other than that s t one. And and the early years of neurosurgical training was typically speaking are the first two years are really composed of you know, what was previously known as or referred to officially and everyone still calls it and being an S H O. So that is largely award based job and working in working in neurosurgery primarily, but also in other Allied surgery Surgical, another specialty. So I spent three months in plastic surgery during that time as well as three months in a and E and went along to some neurology clinics and all of that, you know, the name of all of this is to give you a really good broad foundation of knowledge and skills to enable you. Then usually it s t three level to step up on to the to the registrar wrote in neurosurgery and then depending on which unit you work in and the registrar, the Registrar road is typically divided into, um, senior and junior registrars. Um, although some of the smaller units don't have this dichotomy and then the second phase of neurosurgical training, which you know is indicative Lee usually undertaken between s t three and S t seven. That's when you learn your bread and butter and neurosurgery so and effectively training you to be a neurosurgical generalist during that time and such that by the end of it you should have the knowledge of a day one consultant and be able to manage the the UN selected, um emergency neurosurgical take and you know, your emergency neurosurgeons, a very large portion of our work load. About 50% of our operative cases are done on emergent basis, and neurosurgical units are very busy and they're frequently up to maybe the admission of about between five and 10 patients a day. So the management of the emergency take is very important and and it's important that all neurosurgeons, regardless of their subsequent subspecialty, are able to manage that. And then the final phase of training is is the final training phases that's referred to. And that's where by where patients are certain patients where neurosurgery trainees develop, develop a subspecialty, a subspecialty interest and your training is your training is usually directed specifically what your subspecialty interest would be. And people can also use this time to to pursue external fellowship as well, and with regard to the, um to neurosurgical practice then and what we actually spent most of our time doing. So everyone thinks that neurosurgeons operate on the brain and what that is true, the overwhelming majority of our work is actually, um, undertaking on the spine so well over 50% and probably approaching. I would say 75% of the work is in the form of them addressing spinal pathology. And that's, you know, both again elective and emergency work. So patients with degenerative spinal conditions form you know, the vast majority of our patients, and but there are also patients who present emergency following trauma or or with metastatic spinal cord compression, and then next on the list would probably be a neuro oncology. So that's tumors that arise both within the brain itself and such as glioblastoma as astrocytoma oligodendroglioma. And then, increasingly, what's increasingly forming a large portion of our work is metastatic disease to the brain. And there's a significant proportion of those patients that are amenable to neurosurgical resection. Trauma will always form a very large portion of the of the neurosurgical workload, and what you'll find is that most neurosurgical units either are situated directly in or have strong links with their regional major trauma centers. Just because of the high security of these patients, you know they will. Patients who are severely injured trauma patients who have neurosurgical pathology really need neurosurgery on site or very close at hand to get in their management. And hydrocephalus is the As you all know, it's the It's the imbalance between the production and re absorption of service, spinal fluid and and particularly in pediatric neurosurgeon, that forms a very big part of the workload. And then each of these things is forms. And, as you can see, sort of by this pyramid here, each of these separate subspecialties forms in an increasingly small part of the work and so operating on and the intracranial vasculature and similar to what Ryan was doing that for me now A very, very small part of operative neurosurgical practice. Because the vast majority of these patients are managed by our colleagues in interventional neuroradiology and similarly, um, tumors arising from the skull base. And those were 20 years ago. They were almost exclusively managed by surgeons. But now a large proportion of these patients can be managed with stereotactic radiosurgery. So these are the sort of shrinking areas in neurosurgery. And whereas spine and your oncology will probably always be there, I would imagine, um and so the pros and cons of New York surgery as a specialty. So, you know, for me personally, I'm biased, of course. But you know, similar to Ryan, I don't really regard my job as a chore or something that I do for work. I do it because I love it, but I realize that it certainly isn't for everybody. And so the pros of it, as I said, or, you know, we do very complex and highly technical surgery and the vast majority of which is done using an operating microscope and, you know, involving dexterity of, you know, submit the metric proportions and in some cases, and there's a nice balance between elective an emergency work. And there's also a high volume of benign disease. So particularly patients with degenerative spinal conditions. You can do an operation and for patients who are in terrible pain and, you know in some cases cure them from that pain. And so, although, you know, people can sometimes be a little bit nihilistic about neurosurgery and that, you know thinking of, you know, all of our patients die are left severely disabled. And once that is unfortunately true for a proportion of our patients that certain, it certainly isn't the case for all of them. And the, you know, the anatomy that we encounter in your surgery is absolutely, stunningly beautiful and particularly anatomy of the cerebral vascular and the and the skull base. And I think you know, it's amongst the most beautiful things you can witness in nature, actually, and that's a very big part. Um, a very you know, part of the job that I really enjoy, and another part that we and that I really enjoyed about neurosurgeons, that it's a highly academic specialty. You know, there's opportunities to get involved in research in nearly every unit in the country. And, you know, there have been big advances and in neurosurgery worldwide that have been driven by research has been performed in the UK And that's definitely something part that we can all, um, we can all contribute to as trainees. And this could, I suppose, to be regarded as either a pro or con. But neurosurgery, because you're a surgical pathology is very rare, and you know, the vast majority of neurosurgical units. In fact, I think all of them are based in big cities in the territory or coronary centers. And so that means that it sort of limits your limit, your opportunities to work if you want to work in somewhere, that's in some of those rural or in smaller, more general hospitals. And we do get to interface quite a lot with the neurologists and and the pain physicians, and particularly in the in the area of functional neurosurgery, where we can offer surgery to patients with, um, and movement disorders as well as, uh, facial pain syndromes. Um, it's not all rosy in the garden, you know. And there are definitely some significant shortcomings to a career in your surgery. You know, there's a very high volume of out of ours work and, you know, to start an operation at four in the morning. It's certainly not unheard of, and it to be operating right throughout the night. It's certainly not unheard of, and, you know, that's that's something that you definitely have to consider. It's not going to be a case of doing your own calls from home and never having to come into the hospital. Um, entry into your surgery is very competitive, and it's becoming increasingly so because of something that will come back too later on, which is the lack of consultant post. So, unfortunately, there wasn't a great oversight of the the allocation of neurosurgical training positions in recent years, which led to a large over recruitment of trainees, which has led us to the very unfortunate situation where there are now at present far too many neurosurgical trainees for the number of consultants that the UK requires. And that's something that's been corrected now, which is why neurosurgery training is becoming even more competitive to enter into. But that's a really quite substantial problem for trainees of trainees in my generation, and there may be a requirement for relocation. And, you know, as you can tell from my accent, I'm certainly not from Liverpool. And that was, you know, that's something that's something else that you're going to have to consider and that, you know, it's unlikely that any applicant is going to get a job in your surgery simply by looking at the numbers alone. But to get one where you live presently is something that's even more unlikely. So I think that you really have to be have to be prepared to move if you want to. If you want to undergo a training program in neurosurgery. And you know I alluded to this earlier on, there is really quite significant morbidity and mortality associated with our specialty, where you often have, unfortunately, very young people who are left either permanently disabled or dead Um, as a result as a consequence of their neurosurgical pathology. And that's something that can that can wear people down. And it's definitely something that you would want to consider before you before you start. Um, and I apologize profusely for the poor quality of this picture. It was taken on my taking on my mobile phone from a presentation and, uh, sorry is, um, meaning that I attended recently. But what you can see in this graph here. So the blue, the blue bars or the blue columns indicate the number of applicants per year, and I think the most recent, the most recent, is on the far right hand side, and that's 2020 or perhaps 2021. And the orange indicates the number of post that are available. And as you can see, there's a significant increase in the number of applicants and a significant decrease in the number of posts that are available. So there's roughly around between 20 and 25 post per year, um, across the entire, uh, across the entire UK in Ireland for four neurosurgery now, and that leads to a competition ratio of about 16, 16 to 1. And so your surgery training is definitely is definitely something that's very highly competitive and becoming increasingly so. So I would imagine that they probably have got the numbers about right in between 20 and 25 I think that'll be that'll be the number going forward and which leads naturally into how How does one get a get a training number in neurosurgery then. So the sort of things that I would typically recommend would be, um, early involvement with the surgical society at the medical school. I think most medical schools now will have a society dedicated to dedicated to training and surgery. And there's a lot of those will offer sort of, um, careers, evenings and surgical skills, evenings and the opportunity to network with surgeons working in the area, which is something that's, um, something that's very useful. And increasingly, there's, um, there's actually neurosurgery, neurosurgery and neurology societies in medical school. I know certainly that University of Liverpool in the University of Manchester both have that. And there's a national neurology neurosurgery student interest group, and they run sort of national national level collaborative projects and that allows people to get involved in neurosurgical projects. Another thing I would really advise is, um, undertaking an elective neurosurgery. Um, and as many as you can and and the same thing goes for students elected modules, because those are the things Where and those are the those are the places where you're going to get the opportunities to take part in all of the all the things that we know we need to do to have a competitive application. And that's, you know, audit and quality improvement projects and neurosurgical research and certainly academic performance at medical school matters. And it matters really from when you're applying for your foundation jobs. Um, one thing that I was told when I was when I was first expressed interest in applying for neurosurgery is that it becomes very apparent very quickly and neurosurgical interview those who have worked in neurosurgery before and those that haven't. And I was lucky enough to have, um, an F two, a four month block of my F two in the neurosurgical department. And that was that was something that was a massive help to me when I was when I was going for my interview. And as we all know, the academic performance at medical school dictates how likely it is that you're going to get your top top choice foundation job. And not only that, there's also, you know, of course, points for an honors degree, and I think that typically speaking and you know when when consultants are looking for medical students to give research projects or call the improvement projects to it tends to be the well motivated, well read medical students who know stuff about, especially that they're applying for. So you know, I can't really emphasize this enough. To be honest, it's very, very important to try and maximize your academic performance in medical school when you're when you're considering a career in your surgery and then definitely an intercollegiate degree. And if that's something that's possible, would be would be a great advantage as well. And these are two books that very often recommend to people who are interested in your surgery is sort of a starter guide, and I think that you know that this book is available on It's on the print at the moment, unfortunately, is still widely available on Amazon and this book on the right hand side neurology, neurosurgery illustrated widely available. And I think if you were to read both of those books, and that would be enough knowledge to take you right up to S C three level in your surgery, they're really excellent. Easy to read and focusing on the high yield topics, and, you know, I would still refer to them occasionally, so I think that they're they're really great. And when going through the specifics of the shortest in Matrix. So I suppose the short word about the about the m s are a So the M S r A. I know has, uh, recently been introduced as a as a component of the application system for, um, course surgical training. But it's actually been part of neurosurgical training applications for quite a significant period of time. So I applied for neurosurgery in 2018, and we had to We had to sit. The m S are at that time. And so that's something that's definitely amenable to, you know, your score is probably directly reflected and by how much work you put into it. And that's, you know, because it formed such a substantial proportion of the short listing score. It's really, really important to focus in on that from, uh, probably around the August or September of when you when you're intending to apply and the things that matter. Then, um, other than the MSIR A on your short listing, our of course taking part in the in the things that I've mentioned then so research audit any quality improvement projects and if you were to win any prizes or awards in medical school. And these don't have to be related to neurosurgery. Of course, anything, anything would count on these. Um um, for these points on the application system, um, expressed an interest in neurosurgery through undergraduate clinical electives and attachments. So, you know, there's sort of a graded scale here of people who have attended the two weeks of neurology neurosurgery that's that's available at the medical school up to people who have arranged multiple attachments in different departments throughout the country and maybe even outside the country. Um, you know, very few people, I would say I would apply having had a higher research degree, um, at the prior to prior to applying for neurosurgery. I mean, I certainly didn't have it at that point, and I didn't know anyone else who did. But I suppose that, you know, with neurosurgery becoming more competitive, that this is this is something that we may see more of. But I don't think it's really something that you know you should direct your attention towards and really the other. And the other aspects of the shortest in matrix are probably higher yield. And as I mentioned so having had having had an integrated degree really helps as well. Um, other degrees in diplomacy, really, This just means the MRCS. Um, so and I think that the MRCS party in particular is something that's really amenable to, um to sitting during your foundation training. I don't think you have to have done a surgical job to do well on this exam. And the MRCS Part B is slightly different, but that actually isn't part of the of the shortest in matrix and clinical courses. And so there, you know there's a wide array of clinical course is directed towards neurosurgery right throughout the country now, and and then, you know, any number of these would make it would, uh, would give you points on your neurosurgical application and then the clinical audit and quality improvement projects making a reappearance again. And I would just emphasize what Ryan said. So you know, first, the first thing to say is that these don't have to be related to neurosurgery specifically, and although, of course it helps if they are, and but, you know, you don't have to redesign the admissions process for an entire hospital for this to count you know, very short and easy to achieve projects that make a substantive difference to the department and can be included in this. And, you know, this is something that you could try and arrange during what I mentioned earlier on your students Selected components and your neurosurgical electives. Um, and of course, research plays plays a reasonable, a reasonable role in the in the short lifting matrix for neurosurgery. So, uh, publications and presentations, you know, with a grading scale for people who have perhaps one paper or second author on a couple of papers, right up to the people who have three or four publications in neurosurgery and and similar for presentations. And what I would say about that is again is trying not to worry about this too much. You know, I certainly didn't have a large number of publications under my belt when I applied. And the and you know, there's a There's a very wide array of forums whereby you can you can present on your surgery related topics, and you know whether that's at the Society of British Neurological Surgeons and the neurology neurosurgery Student Interest group running running annual annual meeting every year And of course, the asset conference is a very valuable resource for students looking to present there, particularly, they're sort of first initial steps in in surgical research. And these publications and presentations do not have to be specific to neurosurgery, although of course it would be better if that's possible. You know, it's certainly not preclude into including them on your on your application. Um, teaching and management is something that is, um, something that's highly valued in the application process as well. And so, you know, being involved in the teaching of even more more junior medical students. I know that that's something that I did when I was a medical student. And there's no reason why you can't teach medical students at the bedside as a foundation doctor and then ask them to fill in feedback forms for you, and then you can you can include. That is not only evidence of teaching, but also something that you've taken the impetus to organize by yourself. So that would fall under both teaching and organization and leadership skills. And again, acid is something that's very valuable in this regard. You know, there's plenty of room for medical students um, to get involved with regional representatives and for foundation doctors to do the same thing in asset and practical and cycle motor skills again. You know if you have any evidence of playing sport or being interested in the arts or music. And these are all things that can be included on your on your application form from your surgery. Um, so I apologize for the brevity of the talk, and it's quite a quite a significant thing to cover in such a short period of time. But I'm very happy to be contacted by anyone else and using the contact details below, and I'll try my best to help you out. And I'm also very happy to answer any questions now. Thank you very much for that, too, or cattle. And it's really refreshing to to hear your enthusiasm for for your job and the specialty, even after several years of training. So it's brilliant, brilliant. Everyone's doing neurosurgery. Everyone's doing neurosurgery. That's that's my That's my take home message. Absolutely, is their specialty. If you hadn't done your surgery, you would have potentially considered. Yeah, I think probably E n t. Plastics or vascular vascular surgery. Actually, and I really like what plastics are are sorry. What vascular are doing with them integrating. They're surgical trainees into the interventional radiology aspect of their of their training. And that's something that neurosurgery are making early strides towards. But it really is something that we should have had the foresight to arrange a very long time ago. And the Americans have been doing it now for 10 or 15 years. And so, you know, I think that's a really positive thing that the vascular the vascular surgeons are doing. And hopefully something that gets translated into neurosurgery pretty soon. Fantastic. Okay, well, if there aren't any questions, we'll move on to the next.