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Um So good evening, everyone. You're all really welcome um to our careers evening. Um So, first of all, we have Miss Abigail Nelson who is a urology reg. Um And she's gonna be talking about urology, um and then lesson full time training. And after that, then we have Mr Joshua Clemons and he will be speaking on general surgery. Um So Abigail, I'm gonna let you start. Um And then at the end of that, we'll do some questions. Thank you very much, Grace and thanks for the opportunity to speak. It's always nice to talk about your specialty and I would put it to you that urology is one of surgery's best kept secrets and it's a really good specialty as we will discuss. But it's one that I don't think people know an awful lot about it. There's not fantastic exposure in university and then not many jobs as well, even from a core training point of view. So it's one that people don't know an awful lot about. So I thought I would take you through just some of the typical procedures and the typical week um that we would have and hopefully that is helpful. Um So what is urology? This is a quote from the website, which is our specialty um organization, the British Association of Urological Surgeons. So, urology is one of the most varied branches of surgery apparently and encompasses diseases of the kidneys, bladder and prostate, including incontinence, impotence, infertility, cancer, recon um both sexes, all ages and that's from the, the website and then plenty of subspecialties as well. Um All the big cancer stuff and a lot of it was done in Belfast. There's female and recon endourology mostly treating stone disease. Um and which is diseases of the male genitalia and academic as well. It's quite a small specialty in Northern Ireland. So um I've badly photoshopped this trust map um to show the four areas in which you can find urology on site. So, Alt Malvin Craigavon Ulster and then Belfast City and the Royal is taken more or less as one. So you can see there's no hospitals in Northern in the Northern Trust that have um urology on site. Now, there is a certain amount of, I suppose outreach work. We would do work in Oma Lagan Valley from a day procedure point of view. Um There are lists for things like flexible cystoscopies in Causeway. Um So there's a little bit of, of outreach work and cross cover um clinics in el in um in South Hospital. But those are the four main basis. There are only I think 12 trainees. Um and two of them are all sick at the minute. So essentially 10 trainees at the minute. It is a very small specialty. And when I was trying to count it up briefly, um I think there's probably more clinical fellows slash specialty doctors in urology than trainees. There are small numbers, not many consultant jobs in terms of getting an ST three number, sometimes there's none. Um The first year I was to apply, there wasn't any Northern Ireland numbers just because uh, nobody had ct the year before. Um, or there might be one or two. I think this year there were two, we do pretty much everything in Northern Ireland for urology. There are some um bigger rarer things like uh retro peroneal lymph node dissection following testicular cancer or um artificial sphincter work that you would have to go to England for. But um pretty much everything else is done here. So we'll chat through the different ways that we do surgery and hopefully that's a helpful way to think about it. So, endoscopic work is a huge part of urology. So most of it's done in that lithotomy position. Um And here's some of the procedures that we would do um with, with a scope essentially. So prostate work in terms of TERP is a common procedure, thankfully becoming more common post COVID. There was a while where we weren't doing any of them. Um A lot of work is done with flexible cystoscopies under local anesthetic. And that's that picture on the bottom left there. So this is a, a fantastic tool. It's a disposable scope um that we can take to A&E if we want. Um And you can have a look inside the urethra for a difficult catheter because of stricture disease, put a wire in, dilate up the urethra and put in an open top catheter. Um And then this cystoscope is also used for a flexible cystoscopy, which is a huge burden of work for urology because that's one of the main diagnostic tests for hematuria in terms of urothelial cancer, but also follow up. Um Once you have a bladder cancer, you tend to have cystoscopic follow up um for several years. So loads of cystoscopy done um insertion of stents. That's what the X ray is. So we do stents under X ray guidance. So that's a a formal abdominal X ray. So that's not the mini urine that we'd use in theater. But it gives you the idea of what a stent looks like. Uh running from the, the kidney to the bladder on X ray, bladder Botox can be done as a day procedure unit um for overactive bladder symptoms again, with that flexible cystoscope. Um Stone surgery, I've got a few pictures in the next slide, uh bladder cancers as well. So this bottom right picture is a resectoscope and that's what you would use to resect uh bladder cancers. You've got another picture of that next. Yeah. So this one, this one here with a little loop inside the bladder. That's what it looks like when you're resecting a bladder cancer. So often they tend to be that papillary appearance. Um, and then you, you cut it off really with the, the diathermy loop and use your, your diathermy to coagulate or stop the bleeding underneath. So, a huge amount of work is done with scopes, you're going into the bladder. Um, it's quite fun. Actually. I think if anybody's into video games, it would probably appeal. Um, because you're looking at a screen the whole time, you're looking at an X ray, um, monitor as well. If you're doing any work in the ureters, you're going into the bladder, you can see this little helpful, labeled left ureteric orifice. And usually the first step if you're doing work in the ureters is to put a wire up there, follow up with a rigid or flexible ureters, cope and then do whatever it is you're doing, whether that's lasering stones that you can see on the bottom left. Um, and maybe I'm a big geek, but it just feels like you're in Star Wars or something. Lasering your little kidney stone, it's quite good fun. And no matter how many times I do it, it never ceases to amaze me that you can get a, often a rigid scope, certainly in females, but sometimes in males from the urethral matus, pretty much to kidney um in a straight line. Like that's, that's amazing humor me there, but certainly flexible scopes if you're doing work up around the kidney. So you can see that diagram there with a flexible scope through the ter up into the ureter, into the kidney and then lasering your stones. So then um moving on to laparoscopy and robotic work, um Josh could probably correct me but I think the robot in, in Belfast, I actually haven't worked in Belfast for urology is still only used by urologists. So as far as I know, that's your only opportunity to see robotic surgery at the minute in urology in Belfast. But I'm sure in the coming years that will change. Um So with the robot, I think nearly all prostatectomies are done with the Da Vinci robot and partial nephrectomies as well where you're taking a bit of the kidney because of kidney cancer. Um And then from a laparoscopic point of view, nephrectomy, often nephroureterectomy, mostly both of those are done for cancer, but sometimes nephrectomy for benign stone disease as well. Um Pylas, we're reconstructing um the anatomy of somebody with P UJ obstruction, um and some recon work as well is done laparoscopically. And then all the things we've mentioned before, if there's complicating factors may be done as an open procedure as well if you have muscle invasive bladder cancer and are fit for it, um you would then get a cystectomy, um which is done with the open approach with an annual conduit as well. So you don't get away from bowel when you're in urology. Um, you're still making, um, your conduit with Ileum uh recon. So we would be called two things like, um, ac section where the gynecologists think there's a bladder or ureteric injury, um, to assist with general surgery as well if that's the case or sometimes to put stents in, um, prior to a big colorectal operation. Um incontinence surgery again with COVID. Uh that's only beginning to start again thankfully. Um So things like autologous slings are, are starting again, actually, mostly in Craig A at the minute. In Architomy, a very common operation for us for testicular cancer. Uh groin dissection is done in al Malvin sometimes following penile cancers and then all your scrotal work in terms of hydroceles, abscesses, scrotal ation, prot a vasectomy, penile work in terms of circumcision, very, very common dorsal slits. Um and a bad PSIS and penile cancers again, mostly done in the albumin, the cancer, the penile cancer. Um and then slightly more rare procedures paron which is abnormal curvature of the penis. Um and urethroplasty aren't done an awful lot at the minute. Um But we do have the expertise to do them in Northern Ireland. So those are pictures of testicular implants. So if you are, you're already sho you're all reg what are you being called about? You could probably guess most of these, I would imagine So a lot of hematuria that would form a lot of our calls from Ed and a lot of our inpatient numbers as well. So a lot of those people are needing three way catheters irrigation occasionally taken to, to theater query torsion you can imagine is a, is a very common one as well with a lot of scrotal expirations. So we're obviously very worried about particularly teenage boys with testicular pain catheter issues. We are called to a lot um difficult catheters, strictures false passages, unable to get a catheter in super pubic catheters. And we're called about all those things ureteric stones. Um So hopefully you're aware that an infected obstructive system. So a stone that has fallen down into the ureter associated with infection is a surgical emergency and needs to be treated either with a nephrostomy insertion, which is done by interventional radiology or the insertion of a JJ stent, which we've chatted about briefly at the um endoscopy part and that can be done by um a urology reg or consultant at any time of the day or night. Whereas nephrostomy can be more difficult to access. Um So that'll be a big one as well. We called about scans, hydronephrosis on scans. Um sclerotic lesions in conjunction with high psa s query, metastatic prostate cancer. Nephrostomy issues are the bane of our lives. Um They're always getting blocked and falling out and quite a few in patients are in with nephrostomy issues. Um which can be slightly frustrating because we don't want to put them in. But anyway, it is the reality of it, uh, retention queries, paraphimosis. That's just some of the things that we would get called about. Commonly, the ones I've highlighted. Um, I think it's nice to think ahead about your life as a rage or indeed a consultant in terms of what is actually gonna get you in overnight. It might not bother you as much in your twenties or maybe your thirties. But imagine by our forties, fifties, sixties, we don't want to be in as much overnight. Um Now again, things might change in the future, but in hospitals where you don't have a urology reg on call every single night, um Often the general surgery reg will be covering things like query torsion. Um Depending on experience might be happy to put in a your pubic catheter if needed or aspirate the bladder. Um So as a consultant, you're unlikely to be doing things like torsion or difficult catheters unless you do need to support somebody who isn't as experienced, probably the most likely thing. Um as a consultant would be putting a stent in for an infected obstructed system if you don't have a urology reg on with you. Now, obviously, there's big rare things that could happen like trauma and needing to do a traumatic nephrectomy in the middle of the night. But that is really, really unusual. Um So urology is uh a reasonably good one from the worklife balance point of view. There's not that many things um that get you out of bed, but uh those are a few of them. So what would your standard week be like? Uh You often would have one or two inpatient lists and the commonest procedures are probably your bladder tumors, turps, and stone work. Um You would have access to day procedure lists, so slightly smaller day case procedures such as Hydrocele cystoscopy, Botox circumcision, um and some stone uh patients are appropriate for places like Lagan Valley as well as I've said before. A big part of urology work is flexible cystoscopy. So depending on the hospital and you may be doing a flexible cystoscopy list as a as a RTP biopsy is often done by consultants or some specialist nurses. So that's an important part of the diagnostic pathway for prostate cancer. In terms of the out of hours as a ridge, depending on where you work. If you're in Craigavon, you'll work until 11 p.m. which often drags on and then you don't cover overnight. It's just the consultant or the General Surgery ridge in Belfast and Gavan, there's a, a full complement of urology regs who cover all night 24 hours. Belfast has night shifts. Um And in the ulster, you'll have a reg on once or twice a week overnight. So we do 24 hours there as well. Um Like many inpatient specialties if your ward rounds, clinics, teaching and then on call for queries as well. And then we have regional teaching every month, which is good as well. So it's nice to network with the the other regs in the region. And then of course, you're expected to everything in the background, your courses, conferences and teaching portfolio work as with any of the surgical specialties. So why should you think about urology? Hopefully, you've seen that there is a big variety of things you can do. Um massive recall cancer cases, open work, robotic work, laparoscopy. Um a lot you can do and it's a really rapidly developing specialty. I have been in it for a short time, comparatively a couple of years. But even since I started the changes in the technology and the equipment that you use, um II can see a clear development. It is a busy specialty. Um For example, urology, I'm the only training reg in the Trust in the Southeastern Trust at the minute. So your days are very, very busy. Um But the oncall burden I would say is not quite as heavy as some other specialties. Um and a lot of your out of hour on call shifts, you don't have to be on site either. And I think most people would say that urologists on the whole are are friendly and approachable. Hopefully, all surgeons are. But that is something that often comes out with why people choose urology. I thought it might be helpful just to show some competition um ratios. So last year, the places were 3 to 1 the year before that it was pretty much 4 to 1. So it tends to, to be around that three or 4 to 1 competition ratios for ST three urology posts. And then in the corner there, I put up the 2023 ratios for for other popular specialties. So you can see they're all kind of 3 to 14 to 1 competition ratios. So if you are interested, um do give it a go. There are a few jobs for core surgical training. Um You could pick to do surgery in hospitals, you know, have urology, you can do a taste a week in your foundation uh time, the bo website is very, very good. Um I would have to say membership for students and foundation trainees is only 20 lbs for the year, which is really, really good. Um I think the consultants pay something like two or 300 lbs a year. So you're getting quite a good deal there and they're always running appropriate to your stage such as competitions courses and so on the conference every year is very good as well. If you're thinking about it and this goes for all surgical specialties, look up the portfolio self assessment, even at this stage, see what you're aiming for and see where you can pick up points and that will guide you over the next few years. Um, myself and some of the other regs are working on a urology app specifically for Northern Ireland. So hopefully that will be, um, released within the next year. And that's really to guide anybody who is cross covering urology out of ours. Um, I know when I started in general surgery as an F two, I hated getting urology calls because you just don't have the teaching or the experience in it. But hopefully that will help. And then this is a textbook done by um a urology registrar in England. He might be a consultant at this stage. I'm not sure, but he wrote this textbook and made it free of charge so you can download it. Um Hopefully that's still the right QR code to put on. But if you're interested in reading a bit more that might be helpful for you, I think that's all I've got to say on urology. So, oh, here's, this is the best website essentially. So if you sign up for membership, you can look at these webinars, really good information for patients, leaflets and so on. And then that is the page that specifically for medical students. So a really good resource. So I'm gonna have we cough to myself if there's any questions about urology, um feel free to put them in and then we'll chat briefly about less than full time um for the first session. Um So just one question that I have, I guess. Um, so have you any advice to someone who's covering urology out of ours? Um If they're covering like cross covering, that's a very big question. Um, because it really depends what it is. I think if your hospital that you're in doesn't do your urology induction of some sort, you should ask for one and if they don't give it to you, email me and I will personally give you one. I'm quite passionate about this because I remember what it was like to start off covering urology with no real clue. Um I it's probably too big a question to go through individual scenarios really, but like in any situation, if you're out of your depth call for help, um II think I might be doing the, the Saturday session in June um for you guys and we'll go through, uh if I can make that, we'll go through practical uh answer to that question and hopefully some demonstrations. Um So probably not enough time to go through everything, but ask for help, get induction if you don't get induction, give me a shout, I'll take you through some stuff. Perfect. Thank you. I don't think there's any other questions. So I'm gonna let you keep going grand. Um So just a couple of slides unless I'm full time working, I appreciate this will not be applicable to everybody, but just as nice to have a few things in mind if you would consider it in the future. I think it will become more common. So this is the reason that I am less than full time. I think that's me at 36 or 37 weeks operating um in 2021 over COVID. Um So if you go on the NDO website, there are two categories really as to why people can consider less and full time training. So you can probably guess the kind of the main priorities, which is called category one. So disability, ill health responsibility for caring for Children. Um And that's men and women, it's more common in women. But um I know male regs as well who are part time from a childcare point of view and caring for unwell people, it doesn't say on the website, but I read somewhere else that, that ill health can cover people undergoing fertility treatment. Um So if you're going through IVF as far as I know, that's a legitimate reason to go lesson full time as well. And then category two, these are also reasons to apply for it. So personal professional development, if anybody is an international sporting star, you could consider this religious commitment if you're training for a religious role, um law courses and fine arts courses. I've never come across anyone being less full time to do a fine arts course. But there you have it and research and academia as well and certainly in emergency medicine, there's a category three, which is essentially you can go less than full time just because you want to, I don't think that's the thing in surgery yet, but you never know, perhaps it will become a thing. So how do you apply? It's quite an easy process to actually apply for it to be fair. You discuss it with your TPD and if there are no objections, you fill out a form essentially, um, and send it to Nimda and then you reapply every year just saying what percentage you want to work and that you do want to remain less than full time. Obviously, the ideal for less than full time would be to share a ro of line with somebody else in practice, especially in surgery. I don't think that happens an awful lot. Um I've never been in a job where I was sharing a slot. Um But that would be the ideal in terms of your percentage. Most people work either three days, which is often 60% or four days, which is roughly 80%. I actually work 70%. So it just depends on the rota. Um And you have to be organized and find out where you're going. Uh as, as early as you can and make contact with hr as early as you can to say, look, I'm working three days a week, four days a week. What does this look like? Hours wise? Did you know that I'm less than full time? I've contacted trust before working there who haven't been told. Um So you just have to be on the ball and organize things with hr quite early. Um, you have the same study leave budget in terms of money, but it's a proportionate number of days which is fair enough. Um, in terms of leave, it can be quite complicated to understand, but essentially, um instead of having bank holidays and annual leave separately, it's all added up into one pot and then multiplied by the percentage that you work and that's how you figure it out. Um I said applying was quite easy. II found it is quite difficult in terms of sorting out Rotas and pay and holidays aside from that, and you have to be very well informed yourself. Um, you have to educate yourself as much as possible because um, not all trainers or hr departments um are always very knowledgeable about it. So if it's something you're thinking about, I would have a look at the lesson full time trainees, Facebook group, which has a lot of practical information. Um, and just reading as much as you can and talking to other trainees who lesson full time for advice. Um, obviously, there are some cons training is longer. Um, obviously you get less pay, obviously. Um And you do find that well, II find that you feel like you're falling behind a little bit. I think that can be unavoidable and especially because surgery is so practical. Um, when you're at an early stage, particularly I can lessen full time my entire reg training. And so when you're, you feel so junior in a way and you're trying to learn an operation and then it might be, um, a week or a month or two before you get to do that again. Um, that can be slightly frustrating. Uh, you, you can feel guilty because you're being less than full time, Uh You feel like you're causing a bit of a rota gap. Um And again, I think that's unavoidable. You just have to reassure yourself that it's not your fault. You know, that Rotas are understaffed whether or not there's less than full time trainees. Um I find as well, you can get less protected time. The guidance says that you should have protected time to do things like audit or teaching. But the reality is if you're only working three or four days a week, you want those to be clinical sessions and you're aiming to get to theater to get to clinics. So you're less likely than full time trainees to have an afternoon where you're not particularly scheduled for anything. Um So I do find I do a lot of things on my own time. Um But if you're well organized, um you can combat that there's less continuity of care. Um because if you're doing inpatient ward round only a couple of times a week, you don't know the patients as Well, but again, I kind of have to compensate for that by just familiarizing myself with the patients getting home access, looking at who's in. Um, and I'm sure people have different ways of approaching it. Um, but I just find you have to be very organized. Um, it's a big long list of cons. I would say it's really good and don't be put off by all of those. I'm just trying to be realistic. Um, I wouldn't change it. It's great to have a work life balance. Um, you're not doing that commute every single day. You're not feeling that you're tied to the workplace. Um, if it is for something like childcare, you are getting spend time with your Children. Um, and I think even surgery, it will be increasingly common. I'd have to say I've never had anybody say anything negative to me about being lessened full time. Everybody has been very supportive. Um, so if it's something that works with your life, I would recommend it. I'm happy to take questions about that as well. That's great. Thank you very much abigail. Um There's a couple of questions just to start off with, um, in the chat. So, um the first question was, is it possible to share the link to the resource for the book? Um Yeah, if I, well, I don't know if I could find it just now, but if I emailed it to you, could you distribute it? Mhm. That's perfect. Or if you want us to go ahead and try to find it and put it in the chat, would that do? Um Yeah, that's perfect. There was just one other question as well. Um, so Josh may have answered it. Um, it's just about his history. So how are you enroll in his history? Um, to be honest, I never did one. I'm not sure I could answer that. Very practically I think you have to identify where you want to go and ideally somebody you want to do it with. And then I would imagine there's a form to fill out. Um I haven't actually done it myself though. Um There must be a forum on Nimda. You know, you can arrange it with somebody you've met or if you don't know anybody, ask for advice. Um Certainly from this committee, I'm sure you seem to have lots of links and can put you in touch with somebody. Um If it's in neurology, you're very welcome to, to get in touch with me. But yeah, NF two, you can do. You can, I think it's a week. Um II would imagine there's guidance on NDA again if you want to, if you want to carry on, I will have a wee look for a link about that, but I gather it's relatively easy to do. Um And just one final question for me as well abigail. So, um how much longer, you know, is your trip? Um Compared to, if you were doing full time, it just depends on your percentage. Um So I think, I think for me it's going to be 2.5 to 3 extra years. Um, but if you're doing 80% that's going to be faster. So you would just have to sit down with a calculator and it just depends on your, your percentages, um, that you've worked throughout your training. The other thing is, um, certainly urology, I would imagine. And other specialties are supposed to be a move towards competency based training as opposed to you must do your so many years. And what I should have said actually about urology is you already seven years as opposed to eight years and other specialties, it might be another pro. But, um, anyway, it's supposed to be a move away from that to competency based training, I think practically I'm not sure that is always accepted. I haven't heard of many people who have been able to finish earlier because they had everything ticked off. Maybe it will become more normal. Um, but that is possible in the future that even though you don't have whatever, 100 and something months, um, it might be possible to finish earlier. But yeah, it just depends on what percentage you've worked. You'd have to figure it out for individual cases. Perfect. Thank you very much. Um, abigail. I don't know if there's any more questions that we have for you. Um, there was just a question about the the results. Yeah, I'll see if I can find that and pop it into the, the chat here. That's perfect. Um So I'm now gonna let Joshua um take over, um, and I'll let him share his slides. Fantastic. Thank you. See, let me know. Sure. Let's see where we're at here. So hopefully if I move across, can you see that? Ok. Now, um, not yet. Let's see here. I put the textbook link in the chart to distract everybody while Josh went his slides. That's great. Thanks very much. Can you see that? Now? It's still on abigail's? Ok. Let me see. Yeah. Oh, I wonder if, if I can, it doesn't allow me. It's not changing over to, that's the easiest thing to do. I'll see if this is a PDF and then I'll move it across so that I can stop no more questions. Um So, um there was another question as well just about your out of hours. Um So did you find that you had to do more of your training out of hours or more of your shifts as less than full time? No, you just do a percentage of, um, you know, like I'm 70% I do 70% of what everybody else does. And I find that that has meant I have to really sit down and calculate everything depending on how knowledgeable the, the hr departments are. Um But for example, in the Ulster, there's a rolling rota for the regs. Well, there's only one reg but the reg and special doctor, um, where you have an on call every week, for example. So I work Monday, Tuesday, Thursday. So if there's an on call on a Monday, Tuesday, Thursday, I do it as per the ROTA. So it should work out at a percentage of what the full time trainees do in terms of your, out of hours and in terms of your pay, essentially. So, again, all in percentage, but no, not any more than you should. That's good bye. That's perfect. Great. Um, so just to clarify, you can, you can see that. Ok. Yeah. All right. Well, uh, firstly, thanks very much for the invitation to speak. Um, I'm for those that are on the, the call this evening. I'm Josh Clements. Um, so I'm an ST seven now, um, in H PB, primarily in the city. Um, and obviously we cover, er, general surgery on the whole, particularly in the emergency sense, really just to take on a lovely sunny day, about 15 minutes just to really just give you a run through of, in terms of what a career in general surgery is like a little bit of my own experience. Um, what you're likely to, to sort of endeavor over a career, certainly as a reg and then potentially, then lifelong and then also, then just a little final few pointers just generically irrespective of what subspecialty you choose. Um So in terms of the training path, typically in general surgery or if you were to acquire a high, a higher surgical training number, should I say? Um, so that would be somebody that has done foundation or an equivalent has done core surgical training in years, one and two. Um and has decided that they wanted to go ahead and then apply to general surgery. And the entry to higher surgical training in general surgery is, is at ST three level. So typically you'll have all your core competencies of a core trainee and then you'll apply to a six year training program, which is through national recruitment. Er, that process usually starts in the November of your, either your CT two year or whatever year you're ultimately applying. It usually starts in November and that process whereby online through oral, which most people will have used, um for core training will do exactly the same for, for general surgery and high surgical training. Er, then usually after the Christmas periods, um you will be shortlisted and then typically will attend in a national interview. II when I, when I attended it, um I flew to London and I um and I went through the national recruitment process in the London Deanery headquarters, um close to Lincoln's Infield at the Royal, near the Royal Royal College in Holborn. Um But now over the last number of years, particularly post COVID, it's, it is online but typically those people that have an ambition to do breast surgery, transplant, endocrine vascular is a separate entity. And certainly it moved now. Um But if you're interested in it, trauma, general surgery of childhood, doing something like remote rural surgery, colorectal, upper gi and that includes HPV, and esophagogastric surgery. All of those people that have that ambition will go through a six year higher national training recruitment. Um It probably doesn't come out that. So it's easier just to. But ultimately, now in, in 2021 we moved to a competency based curriculum and what we mean by that is, and as abigail has touched upon is that typically the, the program was six years whereby for the first, um from ST 345 and six, you would do what would be phase two training, whereby you would do some elective general surgery. Typically you will do some emergency general surgery and then you will then also then do AAA subspecialty interest module and then your final two years at which point, once you, once you get an, an ACP outcome one at ST six, then you're eligible to sit the FRC S exam in whatever your chosen subspecialty interest is. In my case, that's heat surgery. And then I will usually have uh an emergency, generally general surgery commitment. The only caveat to that is that if your ambition is to do breast surgery, typically at the end of ST six, you then no longer have to be part of an emergency, general surgical rota. So, therefore your day to day will, rather than being an on call commitment, usually, then it will just be 98 to 5 or 9 to 5 with no nights, no weekends, nothing like that. Which, um, for quite some, quite a few people is largely quite, quite an attractive thing in terms of a wide general surgery. You know, it's by definition, it's, it's the largest and we know it's the largest subspecialty. And you can see from the things that I've described already, there's a number of different subspecialty interests you can ultimately go into um in terms of job prospects. Well, it's the biggest subspecialty. So there will always be a requirement for a general surgeon, both in a district, general sense, rural hospitals, but also in major teaching hospitals. You know, for those people that have an interest in doing major resectional cancer cases, hepatobilliary esophagogastric, that type of thing. You will always, you know, typically lifelong in the absence of breast surgery and probably transplant as well. You will have an emergency and an elective commitment. Um And you have obviously a nice breadth of, of cases that we do both benign and malignant. Again, we cover the masses. Now, typically in Northern Ireland at this moment in time, whilst laparoscopy and open surgery is standard, the robot will probably come in in years to come. And certainly for those people, certainly me at the end of my training, have, you know, have ambitions and of subs, you know, in their subspecialty interest will like to do some form of robotics. Um Mainly because probably in 5, 10 years, it will be mainstream. Again, you can, depending on your, your interest, you could be really, really highly subspecialized or you can then take on a stunt whereby you can work in a district general hospital and do a whole variety of general type uh cases. You'll see you again for the upper gi specialties. You'll come across this not infrequently, you get to do lots of endoscopy similar. So you'll come across trauma and, and certainly in working in the major trauma center in royal your emergency general commitments, you'll have exposure to that. And in this unfortunate guy case, he got himself impaled in the left axilla. So there's lots and lots and lots of stuff, hernias, small bowel resections, you know, the list goes on and on and on and on. You can do some really some really at the end of your training, some really big fancy cases like this whereby we've taken out. So the the left side of somebody's liver and essentially we're bringing, we'll bring a bit of small ball on and anastomose it on to um you know, 2nd, 2nd levels bile duct. So really quite intricate stuff, um which is really, really a lot of fun. So, so we spend a lot of our time reviewing our own imaging. So you usually whilst yes, you're not going down a radiology path. You do get very, very good at looking at your own imaging and making decisions about, you know, your the patients that you look after in terms of it. And this goes for, you know, not just general surgery but beyond that. So ultimately, your decision making for most people, it will be multifactorial and the same goes for less than full time training, there will be lots and lots of personal factors that will impact your decision. There will be then lots of professional factors. So personal being, family circumstance where you live where you might like to work. Certainly. So then in terms of um your ambition to do potentially less than full time, you know, the the beautiful thing now is, and as a had mentioned, it won't be very long. Certainly in some, if you work in medicine, the category three for working less than full time, whereby you don't have to have any reason for doing. So you can choose off your own volition that that is mainstream now in, in, in medicine and in, in emergency medicine as well. And it won't be long probably before that is the case in, in, in all of the surgical subspecialties. So in terms of that flexible working, it is becoming mainstream now and and and overall it, it's, it really is quite a good thing professionally. Again, it comes down to what your, what type of um patients you, you, you, you want to look after from an emergency point of view. You look from, from my perspective, you look after young and old. If you work in Craigavon, you might do a pediatric appendicectomy on a five year old as, as, as easily as you do in laparotomy in somebody that's 95. So we, you know, we, we will often operate right across the board in a broad range of age groups and pathologies as well. Again, we've, I've already talked about the sort of sub super subspecialisation, the robotic surgery, you name it. If you want to go down that avenue, you can, again, you will come across cancer work across the board in all of the subspecialties. Sometimes, you know, in, in terms of, in a sense of vascular beyond sort of chemodectomas and, and things like that, typically there, there isn't any cancer. So you can sort of see the subtle differences between subspecialties. But ultimately, what you will find is that when you come to decide what you, what you want to do, there will, there will be a combination of things that will do it in terms of from a general surgical point of view, from a career point of view. If you go down the line that isn't breast orientated or, you know, generally ge gastrotest surgery, for instance, he had a bi colorectal somebody that's gonna be working in the emer emergency, general surgery. Take something to consider is that there's a reasonable likelihood that you will as in your forties, fifties, sixties be called in overnight whilst you're on call, it's, it is one of those facts. And again, whilst it's a very attractive thing to be doing laparotomies in your late twenties, early thirties being called at four in the morning to come in and do a laparotomy may not be as attractive when you're in your late fifties for various reasons. Typically as, as, as the general surgical registrar, you, there's no doubt you, you, you will often be the busiest registrar in the subspecialties i in the hospital. It would be very, very rare for me in the E MSU in Belfast, the emergency general surgical unit to not be awake for the entire 24 hours of my on call shift because generally speaking, the volume of referrals that we get the operating that we do and when we cover all the trauma stuff as well, it is something to factor in and that hasn't changed from from when I started an ST three, as I say an ST seven now. But with two years of research, I'm pretty much more or less finished my training that I found is that you will, that, you know, there's no doubt, no matter where you work. Craig Avan Antrim alt Elvan Causeway, you will find you will be busy as the General surgical registrar. The caveat to that is, well, you will often be well remunerated. We work in a 24 hour on call shift pattern. And as a result, most if not all of the ros that you will work on will be band three. So that would mean is that your base salary is essentially doubled. So you generally will find that you towards the end of your reg training, probably you'll find is that your salary will be equivalent if not better than somebody in their first few years as a consultant purely through your on call commitment. As I mentioned, CCT and ST three recruitment are very similar. Apart from the fact that core training, you will have local recruitment here as well as national recruitment. However, an ST three recruitment will be at a at a national level things to touch upon. Well, and as abigail has mentioned, if you are interested in that career path, and if you've already decided that that is your ambition, the one thing what you will find in your postgraduate training, whilst you sort of think you have lots of time, typically, time moves on pretty quickly and in trying to try and obtain a lot of the things that, that are apparent on the personal personal specification, public presentations, doing those types of things. Whilst there, there's lots of opportunities out there often from, from uh conceiving an idea to running a study and or doing anything like that often will take time and it's something certainly to factor in the one thing that we do have. Now the luxury of is most of the time in whatever subspecialty interest you're interested in. You. You can easily go online now and find out what the general personal specification is for that subspecialty interest. And as a result, then you can start to prepare as early as, as you possibly can. It definitely the more time you have the, the the the sort of slightly greater advantage that you will have when you come to the the personal specification. Now, that being said that that only accounts for only a third of your overall mark at ST three recruitment. And as a result, then with your clinical knowledge alongside, then your management um or or your abilities to manage complex scenarios and the way that they're presented in those three elements at national recruitment there, there are. So there is a lot of other aspects to the interview process whereby you will develop and you, you will often develop day to day in your own subspecialty jobs as you come through foundation and then in dec co as well. So, but just some generic slides, you know, so whatever you ultimately decide to do, there's certainly for me looking back and having perspective, somebody right at the very end of training that I think would be really, really valuable to you is that everybody thinks that you, you, you will naturally go from whether, whether it be foundation to core ed one C D2, you might do a clinical fellow year year or you may go straight into higher, higher surgical training. Everybody's path that I know. And, and there's maybe 40 or 45 registrars in the General surgical, um rota at this moment in time across all of the hospitals, you'll probably find if you, if you lined everybody up and spoke to every single one, they all will have a different path, whether they've done different projects, they've taken some time out, they've gone abroad, w whatever they've done there isn't one specific key path. And that historically, when I came through at core and then at ST three, the assumption was, is, well, you have to go from foundation to core and you have to go from core to, to ST three. The only time I've really had out of training was when I did a higher degree between ST six and ST seven. And I'd, and I'd always wanted to do that from an academic point of view. Um But aside from that, things have changed now with the flexible, working less and full time, all of those things, there isn't really one particular path and that's one of the big sort of takeaways and reflections. Now, I suppose if I had more time, I probably would have done even wider breadth of subspecialty interests. One really, really big one is that if you can find somebody, you know, as as a mentor, there's lots of good mentorship programs out there. Um finding a good mentor that can sort of, and, and the fundamental difference here is, is in terms of the having mentorship is different from having someone, somebody that will just simply give you advice or tell you you should do this or you should do that. Fundamentally. Finding a mentor is that typically they will often, you know, they may not have any, um you know, they may, you know, they're not a friend necessarily, they'll be completely impartial to you and they'll usually instruct you or allow you to try. And if, you know, if you have something that you're trying to get towards or you find something difficult or, you know, you're working on something, they'll usually be that vehicle for you to essentially find a way to work that out um of your own accord rather than necessarily saying you should do this or one particular. I've had some really great mentors over the years, both in many domains, just clinically academically, you name it. Um There is always someone out there and it's just finding the right person that's going to give you, um, you know, give you that sort of pastoral support right the way through your training. Certainly, you know, if, if you know, there will be lots of opportunities out there, whether it be an academic project, whether it be clinically, whether it be an operation, whether it be a presentation an opportunity to go somewhere. You know, typically I've always said yes, I've probably said yes, too many times. But overall, I have to say, I want to look back. There's, I've never had it whereby I've said, oh, you know, I really regret it and I didn't do that when, you know, when somebody offered it to me, but you'll find it will hold you in really good stead because you'll prioritize your time, you'll always be busy, you'll find ways to do it. And what you'll often find is people find that the most, the busiest people will often be, be asked to do a lot, you know, most jobs um as you go along, collaborate. Um I've, you know, I've worked now with lots of people all over the world in various different things, both academically clinically. I've got loads of friends all over the world. Um Again, don't hold back in terms of who you speak to. And typically, when you go to conferences and things like that, speak to as many people as you can, especially, you know, the big international conferences if you get the opportunity to go and do it, um because you'll find, you'll be amazed at what other people are doing across lots of parts of the world. Um And it gives you a different way of thinking, you'll always learn something new. Um And that in itself allows you to just continually evolve um and get better and I think that's really, really valuable again, more so academically than anything. You know, I've been fortunate, traveled lots of places all over the world. Um, it's a really, really good way to use some of your study, leave, getting to travel to a really nice conference. Um, and also see some, another part of the world itself. I've been all over Miami. Um, you know, Rome, lots of parts of Europe, Australasia. It's really the, you know, work is great. Um And the job that you do day to day is always fun. But if you have the chance to get the opportunity to travel, definitely, definitely do it. Certainly you'll find as you go along more so than anything as you get more and more and more senior, the things that probably give you most satisfaction on as all, you know, more so than most is to be able to teach. Um And if you create an environment whereby the team around you are interested, and there's an ethos of everybody learning, whether that be in theater where by each person is, has very clearly identified a, a part of the case that they might be able to do or, you know, actively going out of your way as a senior trainee to help people with their portfolios and allow them to learn and to progress um is really, really, really valuable. No, again, no substitute for practice. Um And again, you know, access to everything is amazing. Now, it's, you can buy certainly from a general surgical sense for open cases. You can buy really cheap instruments on, on online very, very readily. Um, and even now for me, I've, you know, you, you create a little simple laparoscopic simulator for me, laparoscopic suturing things like that and even, you know, you know, for the open things for me, like I'll still try and recreate and ensure that I'm as efficient as possible for doing things like the anastomosis that I might do as part of a whipple procedure mainly because you'll find that. And certainly at a very junior stage, you can see very, very quickly who, who will put a little bit of time in at home, whether it be a piece of string around, you know, when you've tied 10,000 knots, you'll be able to tell very quickly as a senior edge and a junior edge. And those are the things that we want to see because when you see somebody as junior that is interested, it's great because then you can really nurture them along, um, and, and help them to progress again, finally, you know, whilst I love work and I love, and I'd love to keep myself busy from that sense. There's lots and lots of other things outside of medicine that's really, really important that you find time for as well. And the key really is that whilst you're busy and whilst you're doing this, that you just work them into your routine, whether it's, you know, if it's the gym or it's this particular hobby, musical instrument, singing, whatever it may be is that you identify a part of the week that you can just set aside. Um, and, and do that cos what you'll find is that when you still have all these other avenues whilst you're busy, you know, you, you, you, you will create balance for yourself and you'll find you'll be infinitely more productive when you are at work. I know if you do that, then you'll always enjoy what you do to be honest. Again. Well, what can you do now again, whether you, it's looking at a personal specification, whether it's um preparing for, you know, your interviews as early as possible. Tho those are, those are things that will certainly keep you ahead of the curve. Again. What I would say is that those people that are per, you know, that will persevere the ratios. Yes, everything's competitive. Um But that's not to say that that anybody that I've worked with that has been interested and shown an interest. Typically, you know, all the people that are on this call tonight are, are self selecting, you know, you're clearly motivated individuals who are trying to identify ways to, to progress in whatever career path that is. Um So, you know, most, most of this may not come as a surprise to you and largely what I've said, most of it, you may already have already made tracks to do. Um But ultimately, as I say, that's pretty much all I have to say. But you, anybody that's on the call this evening, you, you're more than welcome to, to email me, I don't really use social media apart from the Twitter, although it's X now mainly because it's quite useful. A lot of the journals are on it. A lot of the big academic institutions that would be relevant for my stage of training are on it. So typically I use it pretty well from an educational point of view. Um So by all means, if you know, if you don't have any questions this evening, by all means, I'm more than happy for you to contact me personally um and continue the conversations further if you like. Uh but otherwise I will stop there. Thank you very much. Um I just admire your passion for general surgery. Um But yeah, just a few questions for me as well. Um So what made you choose HPV? Um So a Patil for me is, it's very well one, it's technically challenging in terms of certainly the resectional element of it. Um You deal with often the, the anatomy is beautiful. It's pristine, you know, in terms of the upper gi tract whilst I enjoyed colorectal and I enjoyed everything that I did, urology, plastics, vascular. Um For me, it gives you that technical challenge. Um Typically the the patients that have that have malignancies. So the patients with pancreatic cancer and, and, and liver cancer, um, the options for them are limited in a sense. Um, not, not everybody will get to an operative intervention. So both, technically, the challenge is good. You know, you're, you're, you're offering and extending somebody's life potentially, otherwise you wouldn't be. Um, I love the benign bilary stuff. So, symptomatic gallstone disease really, really common presentation. Typically a young person's disease, massive impact. You know, if you can get very good at doing, you know, managing galler disease, cholecystectomies, ball expirations, all those types of things, you make a lot of young patients. Well, again, who otherwise have really poor quality of life, you know, symptomatic, right, upper quadrant pain, jaundice, time out of work, unable to look after their kids, not able to eat. So you have both the, the, the malignant side, but also you have, um, the benign side as well, which is, which is enjoyable. Um, so those are probably some of the things. Um, there's lots and lots of other, other reasons as well. But for me, I was always keen to do upper gi surgery, whether that was esophagogastric or HPV. Um, but for me, my heart lay with HPV over OG. Um, and that's, that's what I decided to do again technologically, you know, there's a, you know, the, the robot is coming for the bigger stuff. Um, and that's exciting and it just so happens that the end of my training has sort of led into that robotic era. So that's again another natural progression um for me. So, um those are a few of the and I, again, outside of HPV, I'll, you know, I'll cover an emergency general on call. You'll still manage appendicitis, you'll still manage small bowel obstruction. You'll still come across in, in Belfast. It's subtly different. You've got a dedicated emergency colorectal take and then an upper gi take. Um So for me, you're segregated to upper gi but if you work somewhere else, um you'll cover the whole breadth of emergency general surgery. So it goes beyond your subspecialty interest. But um I'll maybe not say that when I'm 50. I don't know. Um And Josh, she also took time out um to do some research and is there a particular time? So do you think se six is the best time to take time out or can you do it anywhere in your right? Yeah. So it depends. So you can do lots of different things. So some people will do an undergraduate, they'll do an extra year where they'll do an intergrated degree. I looked at that option. There was never really, I studied in Liverpool. Um There wasn't really something that really stood out to that I would have enjoyed at that time. So I didn't do it. I moved back to Northern Ireland. I got a foundation training program here. I got into core training here. So there isn't an interestingly there isn't a formal academic core training pathway here in Northern Ireland. It's different in, across, in the UK. So I could have pursued that if I, you know, I have a I II have a massive academic interest. But again, there wasn't a pathway that facilitated that and I didn't want to travel or move away to do that. And suddenly, so then at an se three or higher, you know, you can do an academic pathway there too. But again, it, it didn't fit with what I wanted to do. So the next best thing for me was to take a formal out of program period of research, which can be as little as two years, could be as many as three or four, um depending on what you wanted. So I did an MD over those two years. Now, again, you can do com you can be completely out of clinical and, and formally just do research on nothing else. But the way I worked it was, I did a, I worked as a clinical research fellow at the Ulster. So I did, you know, all my daytime was research orientated and that's where my clinical research project was. But I also did then on call. So I still maintained an emergency general surgery commitment. So one day a week, I a 24 hours on call, but I was off the next day. Um and 70. So I might have contributed to then registrar or consultant of the consultant of the week model where I worked one week in every seven or eight. So, once every two months I did a full week of emergency general surgery. So I was able to keep up my skills as, as easily as, you know, I didn't really feel as though some people worry. Oh, you come out of program, you lose your skills. Not really. And I've done 3.5 years of, of general edge training. So I'd done a whole lot of stuff and didn't really feel as though it was, you know, you weren't at all. Final thing to say is in terms of time to come out of program, I could easily have done ST three for instance and decided it just, it just so happened that the research project that I wanted to do and pursue it just worked out that, that that was the time that suited me to come out of program again. You'll find that lots of people will do different things coming out early, means that you might do the research and then find you. Then you have just an uninterrupted period of training for me. I did a ha I sort of got to halfway did my research, still did some emergency work. And then I then largely the end of my training, um, it has been just largely then focused on my subspecialty interest, but it's a good, you know, certainly I would highly recommend if people have an academic interest, if they aren't going to formally go down a program of academic academia, um which there will be limitations to here in Northern Ireland in surgery. That is, um, certainly I would highly recommend an out of program, you know, not necessarily research, but you can, there's lots and lots of other avenues of out of program experiences, adept fellowships, you know, people can do entrepreneurial things, you know, the words your oyster. There's so many things that you can do above and beyond just that pathway and the more, the more experience you have whatever that may be will hold you in. Good stead to be honest, that's great because I know it's something that a lot of people think about. Um and it's always like, you know, knowing when the right time is to take time out of training um and do that, but thank you very much. Um Abigail and Josh um there should be a feedback form um that Sarah um might pop in um that you can fill out just to get a certificate. Um But yeah, thank you very much. Um If you have any more questions, you can pop them in the chat. Um The fore head off, I don't think we have anything else. Um But yeah, thank you very much. No worries at all and I appreciate you giving up your time. No worries at all. Any time. No, that's good. Um Yeah, and as Abil said, um, feel free to get in touch if you have any questions and Josh has left his email as well. So, thank you very much guys. Cheers. Ok, thanks.