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Chelsea & Westminster Postgraduate Medical Education, Hot Topics in Global Health Presents...

  • Panel Discussion: Working in Low- and Middle-income Countries Chaired by Dr Omar Mustafa, with co-chair Dr Bhanu Williams (Associated Medical Director for Medical Education)
  • Panel Members: Dr Rashmi D’Souza (previous Global Links Fellow), Dr Amrit Visvanathan (previous HEE Global Health Fellow), Dr Rachel Burge (previous Refugee Health Volunteer), Dr Joy Clarke (Acute Registrar/MSF medic), Dr Hilal Al Saffar (RCP Global international advisor & Chair of RCP Iraq Network), Dr Tamara Phiri (President of the Malawi College of Physicians/Registrar of the East, Central and Southern Africa College of Physicians)

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

If we can get everyone to just um listen for the last session of the day, which is a panel discussion. Um So we've got doctor who we introduced earlier, who is going to be uh facilitating and co chairing this panel discussion. And we've got doctor Williams who is online for the ha uh currently um who will be co chair as I read out the speaker bios. If I can get the trainees who are on the panel today to come up to the stage as well, that would be great. So uh I'll start by introducing Doctor B Williams. Doctor Williams is a consultant in pediatric infectious diseases and acute general pediatrics and associate medical director for Education at Northolt Park Hospital and assistant dean for NHS England. She has previously served as an RC PC H Global Officer to strengthen health systems for critically unwell Children in lower income settings. She has worked in low resource settings in Africa for over a decade most recently with the R CPC H on emergency triage assessments and treatments for critically ill Children in Uganda. Doctor Rashmi De Souza, Doctor De Souza is a former Royal College of Pediatrics. And Child Health Global Links mental and is currently an ST four pediatric trainee in London. She spent six months in 2023 with the Royal College of Pediatrics and Child Health Global Links Scheme in Nepal. While she was involved in training local healthcare professionals in emergency triage and treatment and quality improvement projects. She embarked on a population health phd at University University College London in March 2024. She also like that. She is my sister. I must have fell and an ST three pediatrics trainee. His fellowship was in Cambodia looking at policies in global health including including child malnutrition. He gained with Mr CPH prior prior to the fellowship and is interested in child mental health. Um Our final family member is Doctor Rachel Burr. She is a former refugee health volunteer and an NHS poor psychiatry trainee at South London and the NHS. Before training, she competed in NHS England Population Health Fellowship in homeless and inclusion health and volunteered in a refugee camp group to continue throughout the organizations of supporting asylum seekers and refugees in the UK. And as a member of the medical panel that migrants organized, sorry, just to add and joy is also going to discuss with any of the. Thank you very much. And we also have uh last time he was visiting us and the college doctor who's a cardiologist uh from Iraq. He's uh the RCP international adviser in Iraq and the chair of the R CPR. That's a pleasure to have you here today and welcome to the meeting. Thank you very much for being here. II guess it's um and for our audience online, um how to start with questions and then we can move to discussion from there. Yes, yes, please. I was going to ask about the state of medical education in the UK in regards to global health and reflecting on my own um undergraduate postgraduate medical education. II, don't think there was a lot about perspectives on health and disease going through and where, where are we at at the moment, both undergraduate and postgraduate and what do you see is going forward? Yes, thank you. Um I'm not need, that's all one of that. So they, and uh OK, and you a beautiful sorry, just bear with us, you get not writing. So but yes, just, just from my own experience um from, from a postgraduate perspective there, from a position per a new set of curriculum which some of you may be aware of. But in 2022 the late situation of all the best graduate for inter medicine were update and, and a strong element in those. Although it doesn't mention the word global and health focuses on diversity and other aspects of care that for example, we see in the UK and train ourselves in. So I think we're heading in the right direction. And II think I always look at the term global health with a degree of skepticism. Um I don't know the Global Health Conference but I think we need to think about the people's needs wherever they are as opposed to north. Oh, there we go. He's got it top of it. What, what was the question? Yeah. Yeah. Just certainly the question. Um, I wanted to ask about the state of medical education in the U A, um both undergraduate and postgraduate in regards to global perspectives on, on health where we're at at the moment. And what do we see arthritis she had? Yeah, cause I did get it. That's a question until we get the answer, the question I can answer for you. But uh I tell the questions, please, if you don't know, you might be able to talk about what, what are the challenges that you will see maybe over the years and not advice that you give to the interest of people here in their interest in setting up partnerships in the future. Thank you Tamara on online. She just talk about how it works for them in Mexico and Tamara. Yeah, sure. So, II um the first part, institutional partnerships need to work on sustainable development. So it's not about us going to develop something in there. I think it really needs to work on developing local workforce based on local needs. And using a strategy, you can, you can apply the mentorship model to so they can start develop. It's not an easy journey. But that's for example, from our experience, learning from the ex of what we're going through. We're still learning from that even from 15 onwards, twice you seen when they started. So it's, it's about how you can, how and develop local uh project in there. And I have seen some of the local projects that your colleagues are presented for, I would say grow, improve on, on sustainability. And that's really the bigger problem. The second half of the question I may ask but isn't that how they did it? But I'll, I'll comment on that. Do you wanna I Oh yeah, thank you. So, um hi, everyone. Can someone give me a thumbs up if they can hear me? Can you hear me? OK, great, perfect. Thank you. So, um I only heard unfortunately, this sounds been going very in and out and the, the question that I heard was about uh medical education in the state of global health in medical education in the UK. So I was going to respond to that bit. But if there's another question that I can hear, I'm happy to try and have a go at that as well. So I think that um very undergraduate level, there are a lot of medical schools that are now doing global health BSE S even more so than there were um 5, 10 years ago. And I think they offer a very holistic view of global health. They're looking at structural determinants of health, not just the sort of the medical model of, you know, tropical medicine or how one might practice in a lower income setting. Um with regards to post graduate curricula, um about uh eight years ago now I tried to write a global health. Uh we called it a competency framework for pediatricians who are interested um in global child health and the GMC were not interested at all um in it becoming a subspecialty which I can sort of, I can, I can see why um There is in the pediatric curriculum. Um One of the competencies that maps to an understanding of health systems determinants. Um how pediatrics might be in a global context but nothing is very structured on any of the curricula that I'm aware of which, which I think is a shame. Um I'll, I'll pause there because I don't know what else has already been said. So I don't want to waffle on if this has already been answered already and if there's any other questions that have been asked, I could have. Thank you. I think that complements what I've talked about from my first graduate perspective. Thank you. Um The second half of the question is about finding opportunities uh for people who are interested and how do they get involved with that? It should, I should I try not to that as well. Um So, um I think, oh, there's a bit of echo. Um I think that a good time to try and go is after. Um people have done, I think personally people should have done their membership if they're going to work on a low income setting. Because I think that you should, you should be able to function as an independent, relatively senior decision maker in a setting where patients are probably sicker than they are at home. And there's less support. I think there's lots of different ways that people can get involved. VSO was the way that I got involved initially. Um There are various projects through the Medical Royal Colleges um that people can go and work on specific projects in, in linked hospitals. Um Places like MSF often tend to want more experience quite, quite understandably before, before you go and work in those specific settings. And there are some deaneries that I think offer specific um specific placements in hospitals in South Africa. I think it's one of the um Southern deaneries um which you can do as part of your training. But I think it's quite important to go and embed in a local context for a period of at least six months, post membership before it's possible to go in and out in a way that I'm, I'm in Kathmandu at the moment, but I'm just here for a week. But I think in order to have credibility in those settings, you do need to have lived and worked alongside um in low income settings for a certain period of time before you can sort of go forwards and backwards. I think now that's a sort of a more, I'm doing more, sort of more clinical and teaching work. There is obviously a sort of a research uh research framework as well that you could go with. So a lot of the sort of the research groups like vaccine groups um and uh and other, if you can get a grant to go and work under someone else's AEGIS, and then research is a good way to get involved as well. But, and quite quite correctly, these opportunities which perhaps 30 years ago may have, may have gone to UK, trainees are now going to trainees from the Global South. Um which I, which I think is, is it is right. Uh But I think it also makes it a little bit more difficult to, to get in to global health. I'll pause there and see if anyone wants to ask anything else. Thank you. Um I'll just come to Rachel. Um I have an experience of how to go involved and that will come to me. Um Yeah, so I II took time. Uh I spent some time, not a long time. I was there for about three months in um in, well, the second after the fire, which is the largest refugee camp um in Europe at the time, I would say my three years. So I had full membership at the time, but um, the way that the setting was, was that it was primary care level IGP. And, um, also around the same as well as primary care in the same house for Children. And I found out that I did, um, of care that I was, was well in and my abilities full time, it wasn't a hospital Saturday and I went, um, uh, I didn't work in the emergency care facility. Um, and yeah, it was really valuable. I really enjoyed it. And II think it was a great first experience of working in the setting. I learned an awful lot about how these organizations work, how we work together. Um How, how, how they don't well together. And I would recommend it actually to anybody who, who was at a similar level. And I'm also mind that a lot of organization like things later on for past experience. And so it is II would recommend it. Thank you very much. Um Come to Yes, please. So yeah, as, as trainees, there seems to be some opportunities like our experiences and taking time between training like and training things. I was just wondering if as consultants, there are any schemes or patterns or ways in which people can working their life to regular setting rather than just taking. Some people have talked about splitting their job plan with people for consultants. So I don't know if you have experience with that. Any, any advice. I dont know if that work Yeah, I mean, what happens the best to as, as, as a medical director? Uh what's, how, how does that work? I II have, I have my personal answer that Andrew is a medical director at um Romford II, think there are two parts to it. So in terms of getting the experience of this stage and most of you here are, are making too regulated, I think may be erro so the things you are doing, taking the post call, medical train or train of off and some of the program where and then get the regulations that may actually do what you meant to do. What happens at the moment, you sort it out yourself by talking to people where you need to go what you want to do and you as much advice as possible for you before as you go into any of traps. Um Perhaps you can set up some programs where you're kind of half a year um with an attachment to in a low income, setting half a year, um doing enough money for the year. Um So we sort of make it a little bit or when it comes to as consultant, it's really difficult. I think there are some people who do I where it's just built into your job and spend some time overseas and working in that like or partner. Um There are people in places like kings which uh haven't got a really good uh for over to do work and they have understanding medical that to happen. And then there are other, what I do is just taking but I, at a stage in my, I do that. It's gonna be much harder to e everything is a simple solution and it's kind of work with the senior trust and you may have some very uh do they have to help you and support you? You might have other who are, are just concentrating along to trust, trust. And my argument with him is we have taken so many overseas stuff with doctors and nurses and others from the countries that we wanna go and help you need to get something back. And so that's be fine. You know, I very about um for 20 years. Um Yeah, thanks. I would, I would echo what Andrew said, I think um I think one of the ways that people get around it for going for longer period of times is around annualized, annualized job plans and then job sharing. So, um you may, you may volunteer to, uh to work, for example, if you don't have young holidays, some of the school holidays should you wish? Um And that might make you very popular with um, a job share partner who's happy to work perhaps more like during term time. But then would like some of the school holidays off. There are some ways of doing it as, as job shares. I think, I think that is possible. Um I think a lot of the time, a lot of us doing it in annual leave, professional leave. Um but you can get as a consultant two weeks, essentially of study and professional leave together usually a year. So that can be, that can be very challenging. So, I mean, a lot of what I do is, is is in my annual leave. Uh I think um the other things to think about and apologies if this has already been discussed is how you might be able to do global health within your own setting. So for example, um I run a clinic for unaccompanied asylum seeking Children offering ID screening, but also trying to pick up some of the stuff that hadn't been picked up on the looked after child medical. Um and, and referral onwards from there and there's a lot of sort of fever in the returned traveler tropical medicine at hospital at which I work. Um So there are as well as looking to do things abroad. There are things that people can think about doing in a um in their own setting, particularly around sort of migrant health. Um And also there's quite a lot of remote support that can be done now as well. Uh which particularly if you've already established links by having been there in person. Some of that follow up work can be done remotely in terms of support and teaching and mentoring and, and cole thanks and, and just now to, to point about there are a number of hospitals who UK hospitals who do, for example, have bases elsewhere or other types of engagements. Some of them do have global health specific projects. So things are here, do um and other centers. So I think it's searching about the, what you want to do first is really important and then finding out a bit how about the way around. Uh but of course, if, if your job doesn't allow you to, then that becomes a problem. I II mean, I'm aware that PRE COVID, they, it was used to be much more like you went to that, but for example, I think that's gone downhill since then, but hopefully it may come back any more questions or comments. Yes, sir. I just want to ask, I'm, I'm actually, yeah. Um I II do agree with you in this. Um I think there are different things you can do at different stages in training, coming back to the question. Um That was asked earlier about when is the right time to go? And um we were sent some questions in advance and that did come up. I think firstly, for me personally, it felt like you have to have, I don't know what the right medicine is, but you have to have all your ducks in a row to find the right time to go forward to work. Um balancing, having enough clinical experience and also set it in the right time training, getting a move between all like high efficiency training, family um life. So I think that's one thing. Um But the other thing I wanted to say is that experience abroad can come in many different ways. And, and even if you're not going out in a clinical capacity, um if you're going out in a, in a different role, whether it's QR um or helping in terms of a support, you know, there might be situations you find yourself where you are asked a clinical question. So II do agree that some experience is necessary. But if you're, if you do before you go and you think you're going out with a support team that that's very important and find the right role you going out. So I, you know, I don't think there's definitely one time for every role and that's what I wanted to say. I don't know what you think. Um I did slightly, I actually initially find it um but it was different. No um fellowship. So mainly m system building um and reduce co I actually ended up doing it after I got my um and I didn't feel, I think in, in many ways, it was a good thing to do prior to doing experience and understanding of working in a different environment without responsibility and the way that, that NGO is set up, I mean, if I was asked to do physical work, I would have felt uncomfortable with it because I was the young doctor in the region and I didn't understand the or environment. Um But then having also, I haven't done even though it happened to be the program. And I went into the, also give me a while I was saying, um but um um so the first time I went abroad was in my four year. Um So if you think about every country in the world, they all have their own junior doctors as well. So actually, I don't think you need to delay and delay until you're a consultant to go abroad. Um So I was like, I researched where I was gonna work really health. I work at Frances Hospital in Zambia. So you've got a of um like Juniors Ambien doctors, doctors, some British F three or four doctors. And on top of that, you've got consultants, consultants and some Dutch consultants. You're very well supported. It's a really good opportunity to sort of get experience working in a different setting, learn about the challenges, um sort of experience, a team work there. Um So I think there's opportunities at all different levels of care with you and your sort of experiences at that time. Thank you. Three months. Yeah, of course. And so the system such as a new medicine work, how do you know about to provide health? Do doctor want to volunteer in primary care? Um Thanks to your question. Um I would say that I will speak to people who've been out and I will speak to people who've been out recently on the ground as this seems to change very, very rapidly. Um There are loads of organizations who have approved doctors that very and sometimes I my feeling from being on the ground, depending on who is the medical coordinator and who well at that time, it, it can be quite and it can work really well. So I think my, my advice would be to speak to people, reach out to organizations and ask to speak to speak to somebody who was there at the time. Um That's certainly how II found the organization that I worked in. Um, I work in the registrar who has gone out with his wife a few months before. Um, and it was really, really valuable in order to speak to him about what to expect when I got there. Sometimes, um, in organizing these placements, things can be quite last minute. Um, I was meant to go earlier but there was a fire in and he got, and at the time of my, so doctors were leaving, um, and there was a change in medical coordinators but it, it, it actually went quite well in the end. But, um, that's something which I was surprising to me. So I would just say to somebody who's been there. And, um, I mean, once you've got, once you'll probably have connections with people who remain there or people who work in elsewhere such as, thank you. Yes. Ok. That was more of a practical question. But, uh, maybe that's the last one. But what about the finance, uh, you know, you there. So I wanted to do since I was a junior doctor and I never made it, uh, you know, kids, you know, drugs alive. And now I'm at the other end of the questions asked already is I want to do it as I tell them. But I have now with children's education and et cetera. So currently I've been doing uh volunteer work in my like um and they are short and they self funded. So if I was to somehow buy some get as probably not, I might have to design and then do it for a year or two and then come back. I don't know. But how do I find myself whilst I'm out there? Who will pay for me to get out there? But I use my savings I owe. Um Thanks. Do call me Barnett. Yeah, it's an excellent question. Um I've got a bit of a gloomy answer which is global health. Is it, it does massively impact your income. Um Most of us doing it, I think unless people are in a sort of a, a very sort of swanky NGO job where they're one of the, the exec within it. Uh do it in a voluntary basis or just have your expenses covered uh When I went with VS O and I think VS A do still do this. Um They pay for your travel out there. Um They pay a stipend while you're out there which allows you to live in a very sort of basic way in a low income country and they'll cover accommodation. Um but they, but nothing will cover your mortgage back home or your children's care, that kind of thing. Uh It, it, it's, you lose money by doing it. The people, my friends who have not done global health live in much nicer houses than my husband and I, so it is. Um, and, and that is, I don't know, I don't know of any other way around it but I wouldn't, I wouldn't change it. But, um, I agree. It is, um, it can be, it can be a challenge, um, to try and work out the finance of finances of it. Um, it's, I don't think there's any easy way around it, places like this. So will at least they'll at least pay into your pension or at least they used to. And I think they probably still do. Um, but yeah, most people who do it are making a loss financially but the richness of your experience and that, you know, and all the rest of it is, I think, definitely worth it. But it is. Yeah, it's challenging. Thank you. I see that this isn't so much as a question but it's more of a sort of a, some that people could look into is, um, the Global Health Fellowship, which is organized by health education and, um, is a fellowship that is paid for at the moment by the Jets to allow, uh, trainees in different specialties to go and work for about six months in different countries in Africa. Um, and up to, it's up to next September. It's great. I think there's some discussion as to whether that's gonna continue. But, um, if there are some trainers that are interested, it is a really good opportunity to, um, in November for six months and we're not out, but it's just something to look into. People are. I think it's just, it, I think it is something I have. They got as far as I know they got just jokes but that changed. Thank you. Yeah, I just add some point about that. There are also sometimes opportunities to work with charities, but I'm very short time, for example, on expeditions or charitable events or something that you can use your clinical expertise, uh, whilst doing something else. Um, so for example, climbing or walking or some events where you work as a medic or part of a team. Um, but, and we've got another question online if that's ok. It's a question for doctor experience. Lot of and set up and maintaining partner with organization. Yeah, if you're not working with the MG technology. Hi, everybody. I am, uh, cardiologist has introduced me and uh the national adviser RCP and then I'm the chair of the R CPR, as well as I am the only education adviser at the University in Europe. Um Let uh just a brief about what you mean by this network and what is the main objectives? Uh It is a dream uh for many years is that you become a group of uh fellows and members of the RCP CP, working together to improve the health service provision as well as. And then in late 2020 the, our drug for this established network was approved by the RCP Global. And we started our one just by sending an email from the RCP to the members in inviting them anyone who want to participate in this project. The main issue is that or the main um objectives we at that time is that health education and health service provision in Iran. And uh depending on our consultants, seniors, faculty members uh distributed all of Iraq as you know, uh health system and clinical educational system was number one for among the, the, the, the, the, the, the, the first in the middle region that uh in the late 19 9 nineties. But because of the circumstance, we all know happened, it went down and down and then we tried to build up again. And uh since that time, we have four sub groups working including medical education, subgroup, uh research subgroup, CPD, uh subgroup and MTI uh And since that time, we have increasing large numbers of, uh, participants usually announce our activities from, uh, January, uh, until December. Uh, and as, as I, uh, the last year in 23 we were 30 activities in different items of these uh four groups. And as I success of this network was that, you know, to start at 2020 ranking 21st among all our countries as the number of some of our members with the RCP. But in December 2023 rankings, the second uh uh after India uh uh with the number of pillows and numbers. Uh uh in 2023 more than 1066 participants in our activities. And we are now one of the most important educational but providing education across here. And now we are starting uh more quality, more higher quality project with four universities that sign a collaboration with our uh networking for improvement of education as well as any other project. If I understand the question well, is that the relation it was, what was your experience being good and not so good and setting up and maintaining partnerships with outside organizations? Yeah. Uh It is one of the main objective people to start with is part to as, as part of our CB. Uh we try to on um a Nongovernmental uh uh organizations inside and outside the and this is because to maintain sustainability uh on our project. Otherwise, whenever any policy maker change from this history, the any project will went down and anything will be finished. And therefore we are now approaching the uh uh completing our fourth year uh since our establishment. And I think the uh our uh network as a showcase uh for other areas in the world. Thank you once, how her like to bring in tomorrow if she's still on the call um from about and she uh an article about uh their experience with Ecol and how, how did she find the last 10 question about partnership with external organizations and sustainable development tomorrow? She's not, she's not a OK, sorry about that. Thank you. Yeah, sure. I was very interested for the question of my saying about graduate, global health uh as uh and postgraduate uh as I have a long experience in modernization curriculum of college, Nottingham and Sheffield universities, uh we reach to a conclusion everything has to be set up in undergraduate and then completed in the postgraduate. One of them is the global health but I don't know to which extent the um UK uh uh medical schools uh uh address that issue and their in what the dimensions um how for how many years uh even uh for the but you like me one and one of their standard, they are looking for the global health uh uh term or item, whether it is being involved in the mission statement of any academic institution. Uh So I wonder, uh, about the UK, uh, to which extent they put that terminology, nobody else in their curer. It's, I think it's mixed. Yeah. Yeah. It's depends on the design. Um, and he wanted to change the direction discussion a little bit. I think he was touched upon by one of the speakers earlier on. II think that our curriculum, the way we train doctors in the UK. And I suspect much of the world is so geared to using modern technology. CT scans. MRI s. It stops us thinking about how important examination and the history is. I just wondered how the pan feel about that. I think it's true. I think it's, it, I think we, in terms of training, you really have to train the the future doctors to utilize their resources effectively, how, wherever they are and how they do most of the time you do really need to have good clinical experience before you embark on using technology. However, we won't be, I mean, we are experiencing huge advances in technology, in varieties of ways and I don't think that should be an excuse not to learn technology, but I think you always need to start from the basic level of which is history examination. I don't think this will let them go away on you. Um I think that's a really, really good, I think that's a really, really good point. Um, actually, and um I do think with pediatrics, I don't know if other people will agree. Um, we tend to, if I remember rightly, we tend to use few investigations or at least think twice compared to my experience. And as I mentioned, um, but you're absolutely right even in the UK, compared to, um, you know, my experience in projects a um, there is a difference. Um, and I thought it was absolutely visionary and what the speak of the LC OG yesterday said about imagining that experience abroad in um be set has so much staff in terms of clinical experience. Can you imagine it, accounting training and it is coming back to that financial point, I do think you need to come from a certain place of privilege to be able to do global health work. Um And I don't think that's close enough either. So, you know, II think those two points are internet. Thank you. Bye. Thank you. Um Yeah, I think that it is, it's depressingly true that I think there is less focus placed now on history and examination um in the UK workplace. Um than is then there should be a much more of a shift towards, but we must do investigation. But I think that's partly driven by the patients and families that we look after that. Actually, I can't, you know, actually there's a lot of challenge around your child doesn't need an ultrasound because I can tell clinically they don't have appendicitis that but can we not have an ultrasound because they've got a tummy ache and actually the time spent the time spent saying, actually I think it's just functional abdominal pain. There isn't actually anything organic wrong. Um, sometimes people just go, oh, let's just try and get an ultrasound just, you know, just for them to be quiet and, and speaking that, um, as was saying that she at the moment and was on, on the P IC on AP ICU ward round, uh this morning and we were talking about the different about how pretty much every investigation gets charged the to the families. Um And I think that if we were charging individually rather than it being available on the NHS to clear all of, of course, I think healthcare should be free at the point of care would be doing if we thought about how much that cost that more. And I think the opportunity to see um an amazing range of pathology and really hone history taking and examination skills because medications which may be available are actually very, very expensive to use. Um It is a really, really good opportunity for doctors at all stages of training and experienced consultants to really improve things about pain. Oh, sorry. Oh, sorry. What was the last thing you heard? Um, we heard about if we a long time along the lines of if we charged or if we made people pay and then, and then we came to the ICU and the ultrasound. Oh, ok. Sorry. Um, um, so, um, the point I was trying to make was, um, I think that history and examination can end up being a little bit of a dying art in a UK practice. There's a lot more drive in a UK setting. Far more so than in a lower income setting in my experience in multiple different settings now, investigation, but that's partly driven by families, whereas in low income settings, away from the NHS where families have to pay for these investigations, which may or may not actually be a contributory. Um There's much more focus placed on history and examination because it's cheaper to do and can be, you know, I think I heard one of the previous speakers say 90% of your diagnosis is on a good history and examination and I would completely agree with that, but I think that we're moving away a bit more from that in the N A in, in the pool this week, they were talking all the doctors knew exactly how much investigation cost um were very wary about over when families couldn't afford it because it becomes a catastrophic out of pocket expenditure that the family will may well never recover from. I hope you heard some of that and it makes sense. You much. Thank you very much. Yes. Mhm. Thank you. I've got another online question and I think this is aimed at the Chinese and what can do to prepare themselves the culture um, that, oh, sorry. And so, um, I think in terms of preparing yourself and culturally, um, I think if you are working in a new setting, just taking time to sit and listen to what your patients who want to, the staff don't try and change anything within a system, just sort of, um, sort of gently settle in so as part of the team, but not on top of any team. Um, it highly depends on what work environment you're in. Um But when I write for MS abroad, you've got a national staff and a couple of international staff and it's really important for us to understand why do we do things the way we do things at the current time and then sort of maybe with time, if there's some opportunities to generally develop things, then sort of I can get into how, how best to go about that. Thank you. Thank you. Um I was just gonna say that um I have done that um in some different work for charities in London, which um would be appropriate for anybody. Um So, um whether a doctor or not I went to the doctor, which was really valuable experience and we enjoyed it. I started it one that and they clinic which is for patients who um most patients have access to care, but lots of patients who are, who are difficult to access health care clinic targeting those groups. Um And I was, I was doing some education sessions in a local women center again for women who was seeking asylum. So it was to understand the local health system and also information about um uh contraception, really basic things which you know, as a medical professional. Um and and some other foundation doctors at the time. So just ideas of things which can help build some experience. Um and also it's things that you can continue to do um in a sustainable way. I think that's a brilliant question as well. And just to help you prepare yourself from a cultural point of view. And it's really hard, I think if you're working until the day before you go out for whatever period of time but impossible. I in the ideal world, I don't know, II read about the context of the place that you're going very historic and what's going on in the political sense and about, you know, most of the um groups of people who live there and the religions and public holidays. Um and then definitely, definitely speak to the people who been there before, whether or not through your project, but to find out, you know, what were their experiences? Um II think that would be really important. Obviously, it's all time dependent and that sort. So that would be, uh you know, that I think going to Cambodia we had before and they really, really, really us to where we were and what's been happening in the last week, I think that was very, um, to have some and, and then the other thing that they, they, you can never get six months later, so not doing anything for the first month. And they're trying to, um, gain that, that's not opportunities in the UK, there's a huge need for medical work and asylum seekers and people going through the asylum process. And there's a number of organizations justice and for medical service that all out for doctors to support them with report writing. Um when there's, which can really sort of if they've got a medical report behind them as like the case, um its the chances of getting refugee status. Um So if anyone's interested in having health within the UK, and also you end up learning so much about people's journeys and stories and, and the context in some of the countries that people have come from. Ok, thank you. Um So once, yeah, to explain a bit about options for training in medicine, in the diploma in medicine. But I know there's online options, there's a possibility can give it, there's various courses in the UK. I'm not a little expecting general health, but if there are any. Yes, of course. Um So I went, went into the room and their course is absolutely fantastic. So you're in the tertiary center every day meeting patients um learning about their, their radiology, histology. Um It's taught by improving doctors who all world experts in their field. It's really, really fantastic. Um Bangkok, really good course. And there's a new course as well in Japan and which I think link to the Philippines. You can also do it in Liverpool and London. And everyone will tell you that course is the best course. So my friends that have done the Liverpool course at the London course have also absolutely loved it. Um, but it's just a slightly different flavor you've got patients to see versus sort of more the side of the knowledge. Thank you. Yeah, of course. And I'm just gonna add on to that. And I think last year, I absolutely loved it and I'm back in, I feel like I've lost my ma with that state and II was wondering how you guys stay, um keep up, you know, II came back to see um in terms of, you know, about opportunities you can get money. I mean, that's a brilliant question. So, I mean, I've with loads of that. So I, um I spent six months in the last year and came back in September in some time training and playing hard to see such with the project, even though that was my absolute goal, you know, and I do think a couple of people have said, I do think the initial stages require time commitments actually going really. But when you come back, I actually think it's much harder than giving out there because you're trying to balance and training alongside that. Um The way that I managed to say involvement, the team is to pick up one strand that I was really interested in here anyway. Um And that was sort of data and, and try and be involved just in that one strand effectively with the same team that I was working out there. And then I going back to Nepal to do work specifically with this project as opposed to what I was working with about last year, but it's definitely not been easy. And I, I've been really interested to know how other people have found that as well. Experience some flu. OK. Right. We knew. Yeah. Um No, not, not, not now here. Yes, I can. Brilliant. Um Yeah. Have you heard a lot of the interest um from colleagues here uh from an perspective. Uh There's two questions here. One is your experience about working with other partnerships, sound organizations. And how do you ensure that provides sustainable development for what you want to achieve? The second question is how can people will help you with all that expertise here to achieve your mission? OK. Um So your first question on uh working with partnerships and making them sustainable? I think we've learned a lot um through the process itself. So in the beginning, every partner that comes on board says that they want to help you and they uh share your interests. But I think it takes quite a lot of time and and uh experience to see whether your interest really align. And we found that when the partnership is, is mutually beneficial, it's more likely to be sustainable. And also if um the locals perceive it to be useful and they take ownership of the project or the work, then they're more likely to carry it on. Um So we've also found that um skills transfer is, is something that really keeps these partnerships going. So people want uh to learn from experts and then see what they can take and then apply that in their day to day uh work that also works um very, very well. So I think uh in terms of sustainability in general, it has to be something that uh gives value to both uh sides of the partnership. And that's what has worked very well for us. If it's too one sided or if one side just looks like they have a checklist that they want to go through. Uh those kinds of partnerships tend to fizzle out and uh are not uh very um sustainable in the long term. So in general, that's what I would say. And then on the second question on how people can help, there's a couple of ways you can help. So one is teaching um if you're interested in teaching um uh uh the, the trainees uh in this uh course or sharing your experience. That is very, very welcome. Uh We run a one year long teaching program, uh uh going through the different systems and the subspecialties and we're really trying to increase our base of experts that we can reach out to for the teaching. Um So that would be really, really good. Um The other is to become a fellow. Um, if you're interested and get um, more involved in the activities and participate in the activities. And the third one, would be funding, uh whether that means sponsoring some trainees or sponsoring some exchange programs for the trainees or even just um uh sending funds uh to the institution that will go um a very long way um in supporting the trainers and also the trainees program. No questions or any, we make your information available so that people want to contact you through the organ. Yeah. Question there. Sorry. And I'm not doing three and, and I didn't know, but it might be interesting to talk about and I was in Panama just like a month ago volunteering with the medical organization. And, and what shocked me the most was how much processed food has infiltrated even the most remote communities in China. Um And they was just talking that in areas where they wouldn't have access to clean water to put nutrition that they have a or coming in and bringing the products in. And I was just wondering if you kind of witnessed or experienced some of the things on your travels, what you think of it and if you're aware of any kind of government or regulations in place for that anybody will pick up. Um So the brain project, I was working with a child project while we were seeing um level of the one thing that was available in up with our person. Um and it being the market as well, every event you go to ed by the company. Um and interestingly for years and the breastfeeding um quite aggressively and, and especially in Europe, really nice um, 9 to 10 and then actually seen a bit where companies are also now um a market and I, you know, they are that um and then they are some people that so, yeah, you probably want to read the book about, I'm talking about just from the RCP about this. And uh one of the big things globally I think for is actually the infrastructure, invest in the infrastructure for their drug. Course it comes another body. Yeah, he's good. I think we need to rationalize the last two days and see how much deprivation there is out in the world and that, that we're having to rely on and then investigations and, and having just point of care access and then we have the NHS and do not know the fact that it's at the point of view, but it's seen as a better risk that you can to the end degree that doesn exist. I just find that really hard to that comfort gap. In my mind. So if you are as trainees and consultants are going out into those, those countries to learn from them and, and learn from us is how do we bring that knowledge back to the UK? So that we have to have some sort of feeling of how much we investigate in the UK. Because I part of uh one of the trips that I did uh in my was also health care and how clinical history and examination really doesn't exist anymore. And it's just about doing a whole MRI. And then it, you think we've gone from using our eyes and ears and touching and feeding the patient to tell you where you can't examine the patient anymore to not even bothering to take the history and just for the whole body, MRI and you have so I think feel the difference between the hand and the hi not is so right that as a clinician, I find that hard it goes back down. It is a common drug of discussion for OK. I think it's a really, really interesting challenge and it's whether it's something that's happened at an organization level with nice guidelines, telling us, stop doing investigations when you reach this point or whether it's individual clinicians that are pragmatic about things. But it's so incredibly difficult, especially with things being increasingly in the UK and you don't have so much time of each patient. Um because I know different things like investigating for p, if I can physically see someone, I'm more likely to say they don't need a scan. But if one of the sho is discussing someone and I don't have time to see them, they've got a po, they're probably gonna end up getting a scan anyway. And that's that sort of supervision aspect. And, yeah, just a whole change in culture would really be needed to sort of bring ourselves back a bit. Um But I guess it could also be patients actually, if you ask patients what they really want, some patients don't want to be investigated from head to toe and on sort of the balance of probabilities are sort of happy for a bit more risk to be taken. Like healthcare settings have more, for example, focused. Um And I think forums like this normal things like this, more gathering people who can transfer that would be in helpful to bring it back to exchange that knowledge. Yeah, that's just a more general question, I guess. But with the back of technology, I was wondering if you in that the public health knowledge for health care and how to keep healthy is sufficiently around the world. And if not, how would you use technology to increase that for yourself and and also just world. But I think there's no shortage of information on that. It's how you utilize those. So there's, you know, there's pl there's petabytes and terabytes of data on Instagram, tiktok and all sorts. I think it's, it's how you make sure that for example, the algorithms focus on the right things not polarize opinion. So that's a different discussion. And I think it's, it's a challenge for a public health specialist to actually use the existing technologies. I also think about what new technologies can do and we can change perspectives because that's I think the challenge of going to facing has some extent facing. Yes, I'd be interested to hear from doctor is still available about how best to, I suppose deliver the most important patient to secondary care from the community in the u very well structure care system. I just wonder um from and point of view, the first assistants have set up a pass through the first set up in the in the come to you tomorrow. You know, the health system is uh originally based on the UK system, education and health. Yes, the primary health center is not very well uh used that there are a few uh it remains the hospital, the uh the surgery in the hospital, the site where the first patient come asking for a consultation and it's, you know, make a burden on the on on these hospitals as well as well as on the resources. And there is long queue and uh you know, body disease, et cetera, et cetera. Even the culture, the way they are thinking the patient think that going to the hospital, they have primary health level. And now uh the policy policy of the of health is that you create um um an idle uh or a high quality level of primary health centers everywhere. Uh So that uh and, and meet with the consultants have been part time uh uh providing service at these areas. So that uh but I think at this time it's time and uh awareness and uh you know, everything until that uh time occurrence, things uh a lot of you have tomorrow. Yeah. So um we've got a similar experience in Malawi because we also adopted the British uh sort of uh system with primary secondary and tertiary level care. Um But in reality, the tertiary centers are still doing primary care because the primary facilities are not uh well stocked with uh resources or drugs or personnel still bypass the system and uh end up in um in a tertiary hospital, which means you're not really doing the tertiary things that that hospital is supposed to be doing. Um But having said that uh there are quite a number of steps that are being done to correct this. Uh One is to get um the specialists and the doctors into the primary care and secondary level hospitals uh which wasn't the case in the past and then make their um enumeration and um incentives attractive for them to go and work in those places. Um And also a deliberate um investment into the primary care service itself. Once that's working, then the rest of the uh tears in the health system starts to work as well. So it's a slow uh sort of frustrating process. Um But there are steps that are being done to rectify that um so that we can get a better referral, a function and referral system. Thank you. So, the 55% of the health service provision is by the private sector, by private hospitals and uh clinics and even the the culture that are in that going to these uh centers having better health center. Uh So, you know, things is complicated. It means a long time to thank you on that point for me, I think because there's a huge talent in this room and this huge experience and it's, it's really good to actually think about how you can utilize this to exchange that knowledge and, and, and use that experience to help others who may not be in the room may not know about this and how to talk about that outside of him. And this is something really well worth it about. How do you connect like minded people to generate that action and advance that agenda forward? Because it's really good to see social media stay. We uh seven well, 18 minutes of this discussion. Um Any last question or last comments before? Yes, we have the support and, and, and discuss if you want to get in touch. I mean, as our CP expected very wacky idea, I guess. But, um, there's a lot of, there's a few companies in the world that kind of run as a non profit situation in kind of drug making and distribution. If the NHS decided to kind of run that system, I was very, do you think that would be possible? Would they be able to make drugs could be donated to countries and all that ready? I think, from a vaccine perspective, the the COVID vaccine initiative trying to do some of that where they tried to get vaccines to other parts of the world that are the parts of the world that has its own challenges as far as I can read and see what others may have more direct experience with it. Yeah, that there's a lot that can do. Ok. Well, not too long, but thank you so much. Thanks everyone.