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Good evening, everybody. My name is Philippa. I'm the chair of the Yorkshire Foundation Training Surgical Society and welcome to our first event of our specialty series where we're going to be talking through different surgical specialties. Uh What the registrars love about them and why they chose to go into them kicking us off this evening. We've got Mr Thomas Marks who is an S T three in Yorkshire. Um We, he's got a fantastic presentation for us. If you've got any questions for him. If you want to put them in the chat, I'll feed them through as we're going through. Um We're planning on doing multiple specialties of um in this series about once every two weeks. So keep an eye out on our social media pages and our medal, our next event is going to be about the general surgery team and also less than full time working in the NHS. So it should be really interesting. So even if you're not thinking of general surgery, just tips about how surgery can combine with the less than full time career. So thank you very much, Tom over to you. Thanks Philip and just to ask as Well, Philip, can you still hear me? Mhm. Uh, the slides aren't moving forward then? Just let me know. I don't want people to, to sign off because of the board. Right. Well, good evening. Like, like Philippa introduced, I'm Tom and I've just started my off Peter training in Yorkshire. And, uh, I was asked by Varun, one of court trainees if I would have a chat to you about my experience leading up to this point and sort of my short but steep learning curve experience so far in, uh, orthopedic training. So, uh, hopefully the slides are moving on. So we've sort of introduced. So a little bit about me. I am, uh, this is my fiance here as well. Taylor. And, uh, this is before we got lost with my awful map reading skills, but that's me in the background. Uh, I like to get outdoors and this is a picture of me with my basketball team when I was down in Plymouth. That's my other big hobby in life. So that's, that's kind of me. Um, I'm quite tall, no one in the middle on the picture. So, uh, what I was going to talk about today was why I sort of went into orthopedics and what sort of interested me. And I've kind of done a very sort of long convoluted route to, to decide and that's what I wanted to do. So I might be a good person to ask. Um, I'll talk about a week of what I've done last week as a trainee to give you a flavor of what, what we do, um, and explain the pathway to training and then also talk and talk about the application and then afterwards I'll talk about sort of the, what I've got for the years ahead of me. Um, so the first thing, obviously, majority of you're going to know what orthopedics is in Latin, it means straight child. And so the first orthopedic surgeons dealt solely with straightening Children and by that, they meant the spines and, and then after that, they decided they might have a go at some other things. So now we do quite a lot of things. Um So it's quite well branched out and it's obviously split largely between the trauma side, which can be any fracture of bones, including the spine. We don't normally deal with the brain. Uh and then sort of the more elective side which again incorporates any joint or bone. And, and so we've got a real breadth of operating that we do. Uh And so the approach is, and the variety and anatomy that you sort of have to learn and the number of different conditions that can happen within the muscular skeletal system is is something that is really fascinating and obviously keeps, keeps you learning. So in terms of what we are the largest group of surgeons within, within, within the UK. So just pipping the general surgeons So, I mean, by laws of statistics, you're most likely to become a trauma orthopedic surgeon if you're going to do surgery. And uh two of our operations are arguably to our most uh effective operations are the 2nd and 3rd most common operations performed in the UK. So these were, these were the 2013, 14 statistics and 200,000 joint major, joint arthroplasty is were performed. And uh 5000 either consultants or trainees or associate specialists, working orthopedics in the UK. So there's a lot of us. And so I was asked to say why I enjoy orthopedics. Well, first off, I think, and this applies to a lot of the surgical specialties. But uh I think you get instant feedback from what you do and you get some really great outcomes. And I've used Andy Murray here with his hip resurfacing and a picture of him maybe not quite as good as he was before the arthritis, but, you know, still managing to play elite level tennis with hip resurfacing in situ. So, and I use this as an example, but you know, we really do see patient's having arthritic hips, particularly day one, they're up and walking and they're thanking you and you've changed the quality of their life. So it can be really great and I put some great outcomes because obviously, we don't always have great outcomes that it's being mindful of that, that any surgery has its complications. And it always has the, the ones that don't do as well. So, but what I love about it is you get that instant feedback from uh from an intervention that you, that you put in. Uh my next thing was I, I thought that the problem solving element of orthopedics is really great. So we, we do a lot of stuff, preoperative lee whether that sat in the trauma meeting, as you can see there on the right uh sulfur. Uh and you, you discuss cases between you and think of there's many ways to skin a cat is that is the good analogy. And so things can be treated in different ways and it's about optimizing for what looking at an individual patient um and the resources you have available and planning an operation for them, that is the right solution. And we use things like templating which you can see in the middle there to sort of decide on what implants we're going to use and how that would work. Top left. We use things like joint uh diagrams to look at the physics of uh of things to look at the forces that may go through through an implant or your joint to explain how phenomenons occur. And then we also look at the configuration of fractures like on the bottom left in order to just to one so that we can classify them to decide what treatments work best. It's quite an exact specialty in that respect and we're quite good at refining things down to 22 different different classification systems. Uh So, so it's quite, you're, you're not very often left in a situation where you don't know what's going on that, I'd say a lot of the time compared to other specialties that uh worked in, you can come to a diagnosis relatively quickly and then the treatment is that sometimes a discussion point. The next point is I felt that were quite a reconstructive rather than receptive specialty. So we, we do a lot of stuff that isn't involved in just chopping out because it doesn't work. We try our best to preserve or improve function by keeping as much of the native bone or the native joints and ligaments that, that we, that we can. So, uh this is quite an extreme example that I've used and taken it off the internet and I can't confess to this being my own work. But uh, yeah, so open for uh with a little bit of help from the plastic surgery team and a bit of metal work with this patient's up and walking again and not having their leg amputated. So in that's point of view, it's, uh it's really interesting from a, from a reconstructive point of view. Uh Communication I thought is, is a great point. I work in a big team of people. So we're just one part of it. Uh Potentially, not even, probably not the most important part, we, we work with our nursing staff, we work with our occupational therapy staff, physiotherapy staff, plus technicians are scrub staff. So the team is huge and you have to communicate with all of them effectively to get the best for the patient, our patient group, which is the bottom left picture stems right from kids up to the oldest of patient. So we have to have that interaction with, with every single different kind of patient you can imagine which I really, really enjoy. And then it's also just in different environments, whether that's in the clinic or in the theater environment, we get to spend time in different areas, communicate with different people. And so it's just the job is very varied in that, that, that, that, that respect I find which I really enjoyed the, the human side of it. Uh What I felt as well is unlike a lot of medicine, which has unfortunately sort of gone to this service based and you often feel like your left on your own. What I really like about surgery. And I found it very particular about orthopedic surgery was this apprenticeship style of learning. And you often work for one consultant and they'll teach you their trade, they'll teach you how to do it and they're way is always the best way and uh and you just learn in that respect and, and the way that you then work hard for your consultant to make their life easier in other respects, like when they're on call and work it, sorting out admin, it kind of has this two way flow. And if you're working with a good consultant, then it's, it doesn't feel like work, it really feels like a, just a great, uh very supportive environment. And uh that's not the case everywhere. But when I was going through my foundation training, I really struggled with this idea that no one seemed to give a damn. And I think once I moved into the surgical area and showed an interest, I think that was when I start to go this, this is where, you know, and I found that in particular with the orthopedics, but to be fair, I also saw that in general surgery as well. Uh and lastly, innovation. So we're in a time when things just progressed so fast in whatever we do. And uh we've got some really interesting areas that orthopedics is moving into. And I've given you some examples here. So top left is uh is robotics. Uh And, and you can see here this is a knee replacement being planned. And rather than just using by I, the cuts are going to be sort of a very accurate and, and we still do the procedure, we still get to use our hands. But the level of accuracy involved with the cuts is a bit uh better. And so we can reproduce things better. And hopefully I get outcomes is even better than they are. The middle one is three D printing. Uh uh And we can create implants that are personalized to an individual to put in there. And they're already starting to become available to write was osteo integrated um prosthesis. So now there's a movement towards if a limb isn't salvageable or there is things that are just end stage then looking at osteo integrating a prosthesis. So that is actually part of the patient, which is amazing metrics, bottom left, we've got so much data in orthopedics in terms of our outcomes. And it's really uh it's about harnessing that data in, in, in, in these programs that are becoming available. And it's just a real interesting field in, in the sense that patient's are filling out questionnaires before procedures from the home and then they're following up after and, and they can get in contact with. It's a lot easier and we can, there's just a lot of data that we can, we can get from orthopedic procedures and the outcomes and, and harnessing that in these programs which are starting to be used by the NHS is really excited. Lastly is smart implants. So we started to see implants with sensors in them so that we can better understand how patient's are using them, how patient's forces are getting through them and in, in, in ways Taylor those implants better to the uses of patient's. So it's all really fascinating stuff and that will connect to your phone and you get rewards for doing more steps and things like that. So it's, it's really cool what, what we can achieve. And I think orthopedics isn't a really unique sense place in that sense is that, that innovation just goes hand in hand with improving patient outcomes. So, yeah, really looking forward to that. So I just thought I'd give you an idea of what I did last week. Maybe not the most interesting week, but it was the one most current to my mind. So I work for one consultant uh in a Statistic General Hospital in Scarborough at the moment and I'll be here for a year. So I'm six, working for this consultant for six months and he does foot and ankle work both uh electively uh and hip and knee surgery as well. And he also does trauma. So I work with him and I basically follow his job plan. So it's a one on one in eight week, on call. So when he's on call, I'm on call. So I'll do one weekend in eight weeks which, you know, compared to a lot. That's, that's pretty good. Uh And I'll do one trauma four weeks. So we do a full week. So every single day we do trauma and that's when he's on call. And then the other thing to add as well. It was one day during that week. Uh pretty much every week, I'll stay and do a sleep over at the hospital. And that's because this hospital is quite small. So it doesn't follow that standard, uh sort of shift based system if it just has it where you basically have your night where you, you man the hospital from an orthopedic point of view. So you can see the elective click on on a Monday and I'll go through all of those uh as the week goes on and there's time for other things as well, other than just the day to day work. And that's uh I'll go into those in more detail. So, so Monday was, are elective clinic day and uh in a, in a day, we probably have about 30 patient's and that's a combination of telephone and elective appointment. And between myself and the consultant, we will see all of those patients' and we'll make plans for them. All. A lot of them are follow ups as well. So Monday morning start at nine o'clock. So nice and allegedly nine o'clock start. And one of my patient's was this lady who had a hip replacement done six weeks earlier and she's come in. She's like I said, they do really well. She was extremely happy and uh we just charged her. So it was a life changing operation for her and it made us feel really good. So we get those great outcomes. And then in the afternoon, I had this chap who uh got a collapsing arch to his foot uh he's still relatively young, he's still wanting to work. And unfortunately, there isn't a really good surgical solution for this. So it's having that conversation with the patient about, uh, the last thing they want to hear is that an insult? Maybe something that might help, help their symptoms, they want something big, they want you to sort their problems out. So it's not like I said, the outcomes aren't always amazing. Uh And it's about having those communications with the patient's, having those consultations about being realistic uh and holistic as well because you need to think about other things like lifestyle factors. How can they adjust that? How can other people help like orthotics, physiotherapists? Uh and then sort surgery is often sometimes the Last Chance Saloon. And so it's interesting in, in one day, you can have the straight to operation really great outcomes. But then in the afternoon, you've got to be a bit more pragmatic, a little bit more realistic, deal with potentially a difficult communication um situation. So, uh yeah, it can be quite varied in clinic. So then Tuesday, so the Tuesday morning, I get time to do something that I need to do for this part of my portfolio. So, so I got there in the morning and I'm undertaking accu I project looking at the way that we run our virtual fracture clinics service in uh in Scarborough. And I'm too trying to improve things for both ourselves and also the patient. So we've got some time in the morning to, to have a look at bits in that respect. And then from one o'clock I get given all the phones and told you have to listen to everybody that's got any bone break in the whole of East Yorkshire. They're going to be your problem. Uh And you're gonna have to tell us how to manage them. So that was my job from one o'clock til eight o'clock next morning. And like I said, you stay on, on site. So you've got this for the first time ever. As a, as a doctor, I managed to get something that you can actually sleep in. So I do get a bed, which is, which is appreciated. Uh And this is one of the cases I saw that night. So a chat with a forklift had driven over his foot. Uh, and uh, he was actually delivered to the ward in this situation and I, I had seen him before the war and I got to, I got there and I thought this looks very odd this injury and you can see there that there's a bone which is this navicular sticking out completely, which is a very rare injury, but it was compromised in the skin. So I had to take into theater overnight and as an S T three, that's relatively daunting experience. But the great thing about training these days is your very well supported. So the consultant wanted to come in. Um And so came and gave me a hand at 22 o'clock in the morning. Uh and it ended up being relatively easy to reduce. Uh So another joint saved as we like to think in orthopedics. But uh so, so you do, even in addition, general, you occasionally see things that are urgent and interesting for when you're on call. It's not always just your standard stuff. So, um and so that, that was that and then I try to get some sleep because uh the way my job plan is that the next day, I actually, I'm in theater from eight o'clock in the morning. So I basically set up my own theater lists. Uh And so in the morning, I did a couple of operations, but one of them were with the assistance of the consultant who again, because I'm an S D three, the expectation isn't that I'm gonna be competent in much to be honest that things have changed very significantly. So uh most, most list will initially be consultant so supported. And then as you get better that they'll slowly remove that and, and let, let you start doing some of the less complex stuff with them, maybe in the coffee room and slowly they sort of walk further and further out the door. So this was a typical, typical and young lad who's pulled it off. He was a young gymnast. And so uh standard off thing just fix it back down again. So just a couple of screws in that and, and that, that should heal really quickly and getting back up and going pretty quickly. And then we did a few more operations on that list and then in the afternoon down to clinic to see the ones that the victims that we had operated on, on, on weeks before. So, um, yeah, this was just an example of, uh, of a fracture that we'd, we'd operated on two weeks earlier and it's been jumped on by uh somebody was my understanding and uh and, and sustain this injury, quite a young patient. So the key was to try and get back the alignment. Uh So that even if he were to get arthritis in the future, we'd have some bone to put a knee replacement into that. But uh so he came back in at two weeks and we're just seeing him to, to progress him through his rehabilitation. So, yeah, so it was kind of uh two cases that we saw on that Wednesday, Thursday is the day that we do elective clinic. So on, sorry, elective theater. So again, with the support of a consultant, I was able to do a hip replacement. Uh And a here, we've got an example of uh A M T P J fusion that, that I did were using a plate and again, very well supported by consultants. They really want to educate, you, learn in a graded fashion that is safe for both you and the patient and your and stop you getting palpitations. You, you're only expected to, to be able to do things that are within your comedy. See, with the support that you need, which is really, really great. I was a bit worried about that when I first came to somewhere that was a little bit um, out in the sticks. Shall we say that, that, that I might be just expected to get on with it? And that really hasn't been the case. So I'm given plenty of experience and opportunity without necessarily feeling too stressed. You need to feel a bit stressed of always you don't learn, but I think it needs to be done in a sensible way. And lastly Friday is uh it's like being a university student again and having your Wednesdays off. So, every Friday afternoon, uh we have regional teaching and that can be a combination of virtual, which is easier for me from Scarborough. Although in person, when you reach your much better because it's, it's an opportunity to network with your, with your fellow colleagues, talk about the case that you messed up all the embarrassing thing that you did. Uh And uh and so make yourself feel a little bit better because when, when you're out on your own, you can sometimes feel like you can't have people to discuss those things with mornings on a Friday. I tend to go in and try and do get involved in any operating. So there's an additional opportunity really. So, so that's kind of a given week. And uh like I said, every eight weeks, all I do is trauma every single day, which is a great opportunity um to just learn lots of the operating um in a very short condensed period of time, but that's just a general week there for, for me. Um I hope that kind of makes sense and I really love it. You know, it's, it's a great job plan and I much prefer that old style of following your consultant because you just, like I said, it's an apprenticeship style thing. They know where you're at with each operation and you, and you can sort of learn in, in the graded fashion. So if that sounds like something you would like to do and I'm mindful that I'm not sure where everybody is in where they are there, some that be medical students. Um that will be foundation doctors and court trainees. And I, I can't imagine there'd be any uh orthopedic registrars us into this. So where, so I've kind of pitched it right from the start. So I'm sorry if it's a little bit uh some people, I'm teaching people to suck eggs in certain scenarios. So the training route, obviously you start off with your foundation training and then you move through court surgical training. Um All run through the majority of orthopedics is separated into court surgical training and then reapplying at the ST three grade. I think the exception to that is Scotland has quite a lot of run through. They did consider introducing it in England with the uh improving surgical training I S T posts. And I think they are sort of winding back on that some extent. So I, I think if you want to stay in England, then the majority of people will be going through, they're called surgical training route to, to get there and then applying for S T three and then I'll talk about the rest of the pathway afterwards. So, uh so I'll just give you an idea of what I've done so far. So I grew up in reading, if anyone that's interested in that and uh then went to Manchester Medical School uh at that. And then at that time, I wanted to, to work in neurology, I think was kind of what I was doing. I interrelated in neurology. Uh I then set myself up to go to Salford Royal, which is a, has, has, has neurology and neuroscience and uh and neurosurgery. And so in two years there, and I kind of became a bit dis not the solutions. I enjoyed everything I did, but I just, I just didn't find, I think what you realize is that the things that you enjoy academically, I when you're a medical student don't necessarily translate to jobs that you may enjoy as a foundation doctor or the, you know, the realities of day to day life in that specialty. So I think, you know, for people that early on it's worth being mindful, just keep an open mind. Even if, if, you know, the brain is extremely fascinating, don't get me wrong. But the job that, uh from my perspective wasn't what I wanted because it didn't give me that instants feedback and, and, and, and, and I just didn't suit me. So it's important to sort of keep an open mind as a consequence of that. I didn't really have a particularly good portfolio. Um And so I ended up having an F three and an F four U which unfortunately COVID been in it. Uh Spain, we stayed and sulfur for that eventually got a job in des referred implement to do my core surgical training. So I went about seven hours down south. Uh And then after two years there, I've come up to, to Yorkshire, which is where you find me now on the east coast over here. So I got a bit of moving. Unfortunately, Taylor, my partner, she's been very forgiving in that sense and that can be quite hard and there's obviously a downside to this kind of training. Um So that's kind of my story and you can ask me any questions in particular about that, but I'll kind of go into more detail as we move through. So you're getting into Court Surgical training and I know somebody else will probably come into this and somebody who already be called surgical trainees. But it, but it is hard and I think that's because other areas have become less desirable. People aren't as interested in becoming general practice gps at the moment just because it is a hard job and medicine. Unfortunately, the training is, has, has got a bit of a bad reputation. So more people are seeing surgery as, as as an option. Hence why there's been this upsurge as you can see there and it does tend to ebb and flow and uh and I find it really hard and uh it's this national application process with around about competition ratios of around the 3 to 5 mark per place. And everybody is really good and that's the problem. Uh It's been virtual since COVID. So I think I was the last year. I did two interviews processes in a row and they were both in person in London. Uh I think it's likely to stay virtual for the see able future. And there's three stations, leadership management and Clinical. And I just found it quite a frustrating process. It's really hard to do well in it or it doesn't feel like it reflects on who you are as individual, how good you are at your day to day job, but it's all about the practice and you can do good in it. I think it's hard to excel, but you can do well in it by just practicing a lot and uh and you will eventually get there. And I think, you know, uh it, it took me two years and on the second year I didn't necessarily get the job 100% I wanted, but it, I got in and uh you know, I was, I was happy with it in the end. So my core surgical experience was at this beautifully architecture Hospital of Hereford in Plymouth. And, and you know what? I had an absolutely fantastic time. So I'd already done a year of orthopedics in my fellow, they might sort of clinical fellow year. So my, my, my, my tract was more general surgery theme. So I only got six months of orthopedics, which might sound odd, but I didn't mind the breadth of experience that I got and I got, I did urology, colorectal and upper gi and actually is not a problem to just do something that's got a broad because the skills are very transferable. You learn a lot more about how to manage. For example, a polytrauma patient, you'd have a better understanding of what the general surgery role will be in that. So it's, it's certainly wouldn't discourage you, but you will have to remember that if you to take a role at that in the mindset that you're going to then go and do a specialty that you've only had six months in, you will definitely need to have another year, either before or after, to get you to sort of improve your skills in that domain before the sort of endeavoring to become a registrar, just for your own sanity. They've actually removed a lot of the stipulation that you have to have a certain amount of experience. Like it's only desirable in orthopedics now to have 18 months of experience, whereas it used to be, you needed it. So, um, but it's, I, I wouldn't want to come into this job, having only done six months of orthopedics. And so, uh, it wasn't the end of the world for me. And, and so I had that I had a great experience in all of those specialties. Uh, and I just had a really great time and a lot of people don't like to move around. But for me, it was, it was, I really enjoyed it and we had a great time down there. We, we bought a house, um, which we would not have able to afford in any other part of the country apart from Plymouth, I think. And we renovated that and during the months of COVID when there was lockdown, I went to the beach loads with our friends visited more than we've ever had the visit before because it was like holiday for them. And, uh, we went into loads of walking as well. Um, which was, which was really great and I was really sad to leave actually, but that's the commitment that you make to, to, to, to these jobs. So I, the advice I've got from a court surgical training point of view is, is just consider other options. So sounds silly as I just talked it all up. But I got down there and realized that there was people that were creating their own course surgical training and then getting signed off at the end of it and, and that was just as in the eyes of the application process that was just as valid. Uh So if, if, for example, you don't get in your first time around or you're really keen on staying in one particular area because of family or friend commitments. Um Then, then the other option is to, to, to formulate your own plan of political fell blow jobs which get you some experience and then following the I SCP portfolio to the tea and then getting somebody to sign you off at the end of that, there's a form in your see, if you, when you go on to any of the applications for S T three and its signature of I forget the actual terminology, but it basically just means that someone can sign you off to say that you are at the level, of course, seed like CT too. And you've completed all your competencies, which is, you know, fantastic. And you just follow the same curriculum as everybody else, but you haven't moved halfway across the country, get your exams done early. I've done mine before I even started. But that's because I have years beforehand. And so, so that made it a lot easier for me. But, uh, there's no, and, and I think now I think that, I think, uh, starting it's, it's actively encouraged now. So if you thought that having a year out was, was a bad thing, most people that I know even not doing anything relevant to surgery for some of that is certainly not something that's going to set you back anymore, which is great and then start looking at the, the registrar criteria early, which is I'll talk about because you just need to work towards it from the start because it just makes life easier. And in the same, you just got to work smart, you've got to, you've got to just focus on one project that can get you all the things so that it gets you an audit from that you can do some sort of presentation and then maybe you'll take that off and part of that could involve a publication but don't get, uh, focus on the easy things and, and try and get it all under one sort of umbrella project, which is great. Um, and I just think trying to get a job that stays in the same place. Yorkshire is really bad for it in terms of sending you every six months to a different hospital. And it's really hard to get the experience you want to stay settled at home and two. Uh, and, and, and to just get to know how to do things when you're just trying to learn what color fire extinguisher. You use that every hospital or where, you know, doing the e learning every time. And I was quite fortunate. I just stayed in one place for two years and by the end of it I knew everyone and knew how to get things done. So I could actually learn how to do things. Uh You know, the 90% of the job is that is the admin. So the 10% on the top is, is learning how to do the operating. So, you know, if you're focusing too much on that, so my advice would be really to try and find a job where you just stay somewhere all the time. Um And then obviously applying for registrar post. So unfortunately, with every single course, surgical training, I think, well, of the general and trauma, I can't really talk for anything else, but there's, there is a big bottleneck S T three and it is a, is a challenging time and I can't say that I didn't, I did find the end of CT to quite a stressful period because as as I will come to later on, like the the chance of getting a job dwindles after a couple of years. So, so it is a stressful time cause because you kind of feel like you're in limbo. Um There's a personal certification which is, is relatively, uh it's relatively all encompassing of anybody really. And like I said, it doesn't stipulate a great deal. Other than that, you've, that you've got completely the equivalent of something that would be C T two. And there's much like the core training, there's a self assessment score and this changes year on year and it's nuances, but I'll go for a little bit more details or afterwards. But last, this year, there was 100 and 37 jobs across um England. Uh And again, they do a virtual interval interview process which is based around three interviews, three interviews all done by the same panel. Uh And you're in, in the process at the same time. So there's lots of talks on these and it does change in, in, in slightly each year. But one of them stations is uh sort of prioritization of theater uh listing uh creating an operating list and justifying. Uh So it's a bit of lateral thinking which is a hard one to, to, to plan for, but it just shows how much experience you've got, I guess. Uh then you have another station which is a clinical situation. So that's one that you just have to revise for and then you have one that's a portfolio base station. So one where you have to, they don't have access to your portfolio on the day. It's just basically asked, answering questions and you just got to do your best to big yourself up, which I know it doesn't always come naturally to everybody. But so the year that I applied, this was the competition competition ratio. So there was 500 applications and it was 100 and 42 posts. It's fairly consistent year on year. Uh And the competition ratio that year was 3.71. So uh God knows why they picked me. So, all right. And this just gives you an idea of what you're looking at again and, and, and some of these dina is a huge. So, so, so when you're applying, you're, you're applying to an area of the country and you're committing to the idea that you will spend the six years of your life in a car driving around these, I mean, uh the southwest one is, is big and here there's, there is a, is cut in half. But for example, urology can go from Swindon to Touro, but we are cut in half on that one, but Yorkshire is probably one of the biggest ones and there's a consequence. Uh it's, I guess deemed less desirable in that respect that the training up here is, is fantastic. So that's why. So I guess it's, it's still a popular place to come to some extent, unfortunately, because I had this as animated and now it's on PDF, we can't fully read it, but I'll give you the gist of it. My so advice when applying for, for orthopedic training uh as in from ST three onwards, is that the sweet spot is around that three or four year after foundation. So that's what I was saying that I was at the four year mark last year because of the two years before and after that, as you can already see on this thing, there's this end number, this elusive end number and after you get past 39 months, your end number goes from 1 to 2. And that's basically what your application score in certain domains is divided by. So you can see year on year that goes up. So every year you have to do, for example, if you want to get two points for audit the first year, you due to audits the second year, well, after you reach that next threshold, you have to do four. And by the end of it, you're doing 10 and some of those other domains is it, it's like publication realistically, you're going to get one if any uh you might be super whiz kid and have a few. But the point is that it very quickly gets divided by a number that makes it almost impossible to to to to get a decent score in that respect. So the sweet spot is around about three or four years. So having a year, either side to get some more experience, go to Australia is, you know, it's definitely achievable a lot of people have done that now and I think underneath this point is you're not going to get full marks and it's about being smart again and going right all. It's easy. I'll get all of those. The presentations are reasonably easy or not reasonably easy. But they're, they're achievable and I'll go for those publications. Well, I might get one and if I get one I'll be happy with that because I've got to enjoy my life as well. Uh phd. Well, I'm not gonna get phd. Am I so just forget about that. So it's, it's about being smart doing one or two projects and not saying yes to everything. And I think, you know, you've got to balance that and regarding the interview process, it's all about practice with your friends, there's loads of courses and they all tell you that, that, that they get 90% of people get jobs from them and there's no substitute for practice. I don't think the courses of benefit. I think the courses that are free three that give you the general idea of what the interview is going to be a great and tune into those. But don't, don't pay. It's scare tactics to try and make you pay. And actually just like you have found with your, all your other examples, nothing can replace, just practice. Uh Although I talked about core training, they're being the other option of just doing it yourself doing an ISIS CP and then get inside off at the end. I don't think Cesar is as greater option at the moment, but that may change, but it is certainly a consideration for motivated people. And what Cesar is, is rather than getting an S T three job. There's plenty of non training, registrar posts around the country and depending on those units, some of them will offer good training out of training without necessarily having a stipulation from the Dean Ary to do that. But say if you get on with, with, with, with the place with, with the hospital, they offer you the opportunity to stay in one hospital and they'll train you. Uh And that's fantastic. You just don't have as much protection. You do a lot of the admin side of it yourself. But if you're motivated, it's certainly achievable. And uh you know, and, and so Caesar is an option. So C C T is what you get after S T A and that stands for completion of training. And Caesar is like the equivalent specialist registrar training. So uh specialty register listing. So you're still a consultant at that point. So it's, it is an option. But I just, I think really if you want to do it, it's a lot easier to do it down this National Training Group at the moment, things may change at the moment. That's how I feel. It's obviously only my advice, right? So that was us with the mattress in the back of the car and driving back up to uh lovely house in Plymouth that we just renovated. And, uh, I told Taylor, we're going to move to Yorkshire. So, uh for a period of time, we live separately while we were selling the house and I just lived on this mattress in a, in a rented property. Uh, like I've gone back to my student Day. So it was, it was, it's a commitment and they're only just coming to the end of it. We've only just sold our house. We were only just sort of starting to stabilize our life again. So, you know, it's, uh, I didn't get the exact jobs that every time that I, I may be wanted that would have made my life easier. But sometimes the variety is, keeps it interesting and, and if you're not really fixed in one area, your life is a lot easier in respect to getting through training. And obviously I've been lucky that Taylor's been willing to move around with me. So this is kind of what I've got ahead of me in terms of my, my training and it's uh the first four years you're split, you basically rotate through every subspecialty. So hip, knee, foot, ankle, pediatric spines, shoulders, elbow, hand and wrist and major trauma. So you'll probably spend at least 18 months in a major trauma center. And in Yorkshire's, I'll show you on the map next as whole and leads. So you spend some time there and some, some district generals, you work for lots of different consultants. Uh You learn lots of different techniques, lots of different approaches, lots of different ways and you'll formulate your practice and start to get an idea of which specialty you'd be interested. Most people still do general trauma and then they'll be there more niche trauma that's more specialized that they'll do and then they will do some sort of elective practice within that sort of niche specialty as well. After four years, you get people look more harshly at your portfolio, decide whether you're ready to start thinking about sitting the final exit exams and then you start doing those there and your last two years of training. So it's six years in total are all about sort of starting to prime yourself towards thinking about what you're going to do as a consultant and also starting to put out feelers as to where there might be jobs coming up. So the whole process is an interview process for a consultant job. And uh but those last two years are certainly where you start to behave more like you're working as a consultant and uh under supervision, uh really holding your skills at that point. So that's kind of the general flow of things. And they more recently that made that distinction of separate into four and two and this is Yorkshire. So as I said, it's a big Dean Ary and you can see that I'm right over in Scarborough and the, and the right at the moment, but a lot of the hospitals are more West Yorkshire. So it's a lot of the Dean Aries are like this. They, they have a lot of hospitals, a few outliers that they will probably spend at least six months in. And so it is, you know, there will be driving involved and there will be commuting and there won't be that stability. Uh And that is the trade off at the moment. I think there is a movement towards trying to uh I mean, from a green point of view, it would make more sense for us to work in less hospitals, but also just from a from a quality of life point of view, I don't think you need to do the breadth of it. And I know places like K S S have moved towards the base hospital and a few hospitals around it. And then obviously a few Dean Aries are quite significantly smaller than Yorkshire. But for me, it's okay. I I don't mind, I don't have kids and uh and I don't have those real commitments in that respect, so I can move around. It's for me, it's quite exciting, you obviously want that stability in the end. But at the moment, I'm quite happy with the process. Um So the training as, as all of you were well versed in now is work based based assessed and it's now actually competency based. So technically, you can finish the training quicker than six years. However, I'm yet to hear of anyone to do that yet. And that's obviously because of COVID, but also just because of the formulate nature of it, you do end up needing the six years. Um It's now moved to these general competencies of practice, which is outlined by the G M C as well as six, which are competencies in practice. And it's basically just assessing on a fairly frequently basis, how good you are in theater, how close to being a consultant you are in an M D T scenario clinic scenario. So you're constantly being assessed by your consultant and you're the other consultants within that department, you have to complete a certain number of index procedures and that's 1800 within the six years. So that works out 300 a year, 150 a placement, which is completely achievable. And within those index procedures, you have to do a certain joint replacements yourself. You have to get to a certain competency level with them. So there's all these metrics that they're, they're, they're constantly assessing you want. And then you also just discuss cases like you already used to uh audit and research is again, they removed away from having very didactic, very specific points that you need to do. But obviously you need to engage in these processes and show evidence that you're doing them. And teaching. Um, it's something that they actively want you to get engaged in. Um, so I get plenty of time to attend courses and it's really encouraged. So I probably get about 25 study leave days and I won't use them all. But there is a budget which is relatively flexible. And then obviously we got these exams that you have to take, which we pay for them yourself. But, you know, I'm not worried about those yet, but they're later on in training, we get reviewed twice a year by our training program director and to make sure we're on track and it's, it's part for the first time ever. It's actually in people's interest to see how you're getting on because before everything was kind of off going back to some extent. But it is nice when you get into training, people have a real engagement in the process and, and, and, and, and want you to succeed, which is, you know, you've got to work hard, but it's nice when other people there to support, um, and time out of training is now encouraged, which I just go on to. So, in Yorkshire, we have this thing which is not just orthopedics or even surgery is applies to a lot of different specialties, but then also allied health care, uh members as well like physios and it's, uh this future leader program. So you can get involved in a project for a whole year. You'll be paid and to, to work in some sort of service improvement project that you can some extent deciding yourself. And I know a lot of areas have these, a lot of Dean Aries have these uh opportunities now. So it's a great opportunity to a year out. If you feel a bit burnt out from work, to do something a bit different and develop some different skills. Research is, is obviously a big thing and you can go into orthopedics from a, from a, from a academic point of view. So I didn't really touch on this, but academic S T three posts are not national training posts, they're actually um interviewed for in their specific Dean Aries. So when I was down in, uh start in the Southwest, in Peninsula every year, they would have either one or two shared between renal and orthopedics as an opportunity to get research. So it's a, it's another way if you're, if you're good with your research and you've already got some of that stuff under your belt to get into a particular location. If that's where you want to be, obviously, it comes with the provision that you're going to do some uh some research along the way. So this, you've got to want to do it essentially because your job is going to be job planned around it. You'll have a day a week allocated to it likely. And depending on the Dean Ary and it will also be expected that you want to take time out to do an MD or potentially a phd. A common theme is, is to be an N J are so an NJ are academic and do a project within the National Joint Registry. And these can be really big projects that have big implications and, and so particularly if you're looking at doing a job that maybe is going to have research as part of it, as a consultant, you'd want to be going down this route. It's not something that's particularly interested me. So I've kind of shied away from it and I've always been relatively weak in the, in the research avenue. So, um so, but it's certainly an option and it's something that you can come to later on as well. So even if you go in the standard ST three route, you can certainly take time out to do a phd or a different project. I think in that scenario, you, you have to do a lot of the work yourself in terms of finding those funded roles. But it's certainly still achievable. Uh Lastly, there's a real movement towards people even before their fellowship, taking a year out to go and see how health care is provided in of areas. And I just use this picture as an example of traction as an idea of what we don't do in this country anymore, which would leave patient's in beds on traction for a number of weeks, letting things here, we tend to go in and fix these ones. So it's an opportunity to go abroad and learn different techniques. Um And how things work in areas that maybe have different resources. Uh And it can help you to sort of bring back ideas to the UK because we've become very reliant on expensive things when actually sometimes the simple things can work as well. So, um yeah, so that, that is a thing that I know within Yorkshire is, is encouraged to, that you can take time out to, to, to go to another country and uh and learn. So and then obviously, so you get through all of that training, you do all your exams. Uh and your after those two years, most people will often do two fellowships now. So these fellowships are all about sub specializing. So it's all about having a specific thing that you could bring to a department as a consultant. So a common thing now is to do one trauma uh elective, sorry, one trauma fellowship where you'll just do a high volume maybe abroad uh learning how to uh so that you can go into a job being very trauma competent and then one in a subspecialty of your choice. Um uh And that will allow you to have an area of practice that you could bring to a hospital, this girth thing that is getting right first time. And so there's a real movement towards surgeons doing this, a lot of the same procedure in order for good outcomes to take place. So there is a movement towards her specialization. People don't necessarily always like that because the variety can be more interesting. But ultimately, you've got to bring something to the table in terms of a subspecialty so, so that you can perform that procedure. So, uh so for example, you may want to go and do an elbow uh replacement and uh elective in Canada's or something like that where there's a very good fellowship there and, and then that will allow you to get jobs. So there's lots of opportunities to travel at that point. And people love that, that part. They're training because they've done all the hard work and they're just holding their skills then um and then you start applying for consultant jobs. A lot of people start in the area that they started uh that they did their training, but a lot of people move around these days and consultant job isn't a consultant job for life. They used to be and a lot of people often will move and after a few years. So it's, and that's certainly a thing and you start working independently with all the stress that that comes with as well. Uh I was asked to sort of mention work life balance. And so I've always found this difficult and we just have to accept our job is very all encompassing whatever you do within medicine. Uh and it will define you. Uh, I think, I think there's been times when I've been pulling my hair out and even time that I've had off to enjoy, I find myself thinking about work and stressing about it, but I think it's got a lot better since I side, uh, my orthopedic training. You, you feel more relaxed into the job. You know, this is what you're gonna do and anything actually that I do is kind of the things that I want to do. So it doesn't feel like a chore anymore. I feel like you've got more flexibility as a registrar and that applies to everything you're not as tied to award as much. And yes, you have to make big commitments, but it's, but it's, it's definitely definitely a better balance. I have to say which, which is kind of kind of intuitive, but it definitely is more flexible. I've been, I'm sure that by still playing basketball. So I joined the team up in New Yorkshire and I play a couple of times a week and I've managed to continue with that. And yes, that, that means that sometimes I'm out of the house all day, but it feels worth it to me. So it's definitely possible to have a work life balance. Uh I think compared to other surgical specialties, the consultants are a lot more interested in what you're up to out of work and, and don't put that pressure on you to have done everything all the time, which is quite nice because it's recognizing that, you know, there is more to life than work. We all want to have a job that we enjoy and turn up to. But, uh, and, you know, we, we are willing to do a lot, but ultimately, there is other avenues that we will want to explore less than full time. And, uh, by the sounds that you're going to have another talk on this, it's certainly an option and I haven't considered it myself, but I know some people that, that, that have gone down that route, very happy uh and still get all the relevant training, obviously extends their training, but they, they're happy with this. Um But like I said, depart, despite all of this, I think it's got the right balance. It's a committed job that you really have to commit to, but it's rewarding and, and demanding in a good way. I really, really enjoy it. So the highs and the lows. So just to sort of go through the last bits, I feel like it's a really rewarding job with a really large emphasis on training in an apprenticeship rather than just service position turning up every day, doing the same things for the same forms. I think there's very little evidence at the moment that there's any midlevel creep. Which, what, what I mean by that is that you very much have to be a doctor to become an orthopedic surgeon. So there's a very much defined route. You won't find that there's a lot of movement coming in from different domains. For example, physician associates, for example, nurse practitioners, they may have some limited scope within orthopedics. But ultimately, at the moment, you still very much feel like you're quite protected role. I feel it's quite future proof at the moment. I think a lot about what the future holds in terms of the technology. And I do particularly from a trauma point of view, feel that orthopedic surgery will continue. It's very, very unpredictable trauma and I think it would be very hard to replicate it currently with robotics that didn't need human input. So I do think that elective will be first to go and uh particularly if a better cure for arthritis were to to come about, but trauma certainly will have a role for the foreseeable future. And as everyone talks about this potential for private practice is not as good as people talk about though. And I think, you know, it's worth being mindful of that. Your majority of your work will be within the NHS pay structure. Uh and you get paid exactly the same amount for doing a job that potentially needs less commitment from a movement point of view and aspects like that negatives is competitive, but it's definitely achievable. If I can get the job, you can get a job you present, it just requires a bit of uh persistence and just hard work. And uh but unfortunately, is unsettling despite that for family yourself, but mainly family. Uh and there's a lot of commuting involved. Uh and always you will be proceeded by the stereotype reputation of an orthopod, um which we've got to try and break down but still exists unfortunately, but on balance is really great job and I enjoy it and I encourage it and I'm more than happy to talk to anyone about how to sort of get into it. Uh Yeah, this is as unfortunately, uh any questions at all? Thank you so much for that. Talked on. That was fantastic and really encompassed that all the different reasons, orthopedics, persisting and the training pathways. Um If people want to post in the chat, that'd be great. Well, hang around for another five minutes or so to answer. Um Or if you, so if you could do our feedback form, that would be incredibly helpful. It helps us target our teaching sessions to be more focused for people and also gives Tom some good point to his portfolio as well. Yeah. Thank you. Thank you. Thank you for listening. I hope it was useful. I haven't had much experience with and stuff like this. So any feedback would be really useful. And like I said, if people want, I don't know how it would be best to give out my email if anyone wants to just contact me. Uh If you, if people wanted to contact Tom directly. If you message the, should I put it in the chat? You can pop it on the chart. That would work. Yeah, I'll just pop it in there now. Feel free to. Uh, so the question is, is there a minimum cut off for self assessment at S T three in order to get an interview? Yes. So there, there, there is, although now that they're doing them virtually the last two years, they've, they've interviewed, I think around about 80 to 90% of people have gotten uh sorry. No, I'm I'm I'm making that up. Actually, I think previously used to be around about 50% got interview. They've increased that to around about, I believe around about 60 70%. And from what I heard from the interview of processes that they were really trying to move towards where everybody got an interview had uh there is a cut off at the moment. Um And it's, it's relatively low, like you don't have to score a huge score to get that interview. And like I said, once you're in there with the interview process, I really feel a lot of it comes down to how you perform on the day. So it's, it's definitely achievable even with not like the biggest best portfolio I have to say. But yeah, there is a cut off. Um The next question is, do you have to have completed mrcs before or drawing course surgical training to apply. So I'm sorry if I didn't make that particularly clear. So mrcs has to be completed by the end of course surgical training too. So you don't, you can apply and have a job lined up for S T three under the provisions that you complete that, that you, that you get your exam completed by the end of that year. In all. Honestly, most people will have done it before then. So, so my, my idea would be that you get part A done. It's a two piece, two part exam, get part A done before starting training, either in your f two year or in a year out. And then that leaves you the opportunity to do part B in your first course surgical training. You because the last year you really want to be just focusing on the interview. I don't know many people that managed to be doing part B and do well in the interview. At the same time, I think you kind of want to have done it before then. Um We've got a question about swapping course surgical training jobs. Um So what do you do if you're in? Is there usually flexibility of switching rotations in a really good question? I, I thought that that might be possible for me in there for when I went down there because my job wasn't exactly tailored towards someone that had an interest in orthopedics, which in the end, like I said, it didn't matter at all. And uh the expectation is you're coming to ST three as a fresh person anyway. Now you're not expected to be good at anything really. But I had a breadth of experience. I asked to rotate, I asked to move my placements around and they were really, uh they were really not particularly, they, they weren't supportive to do that at all. I, I have heard of examples of particular. It's a very dina re TPD specific decision. Um, uh, particularly if a court surgical training pathway comes up because someone drops out then definitely you can move into that. Otherwise, they're very rigid because they feel like they can't offer the training. Uh, if more than people move into that specialty, for example. So it's very region dependent. Unfortunately, that, that question, uh, to answer his, sorry, I saw the rest of the question. We didn't get the job that you wanted. Uh I'd still consider taking it if it's got at least some experience in the area that you're interested because I, I, I really enjoyed the experience that I had in general surgery. Uh, it almost made me want to because so many skills in that area that I still use today. So I do carefully about it. Has anybody get any other jobs? If not? Thank you ever so much. That's not any of the jobs, any other, any other questions. Um If anyone's got any other questions, we'll hang around for another minute. But if not, thank you ever so much for joining us this evening and we hope to see you all our, our next surgical series talk, which will be advertising on medal and also through our social media channels. And thank you Tom for a problem. Thank you so much. Oh, well, fantastic presentations. Yeah. And like I said, if anyone wants to get in contact pretty good with my email. So just, just give us a shout. I'm more than happy to, to answer any questions or give anyone assistance. Should I stop presented? Yeah, there we go. Is that all right? Perfect. Thank you so much. No problem at all. Yeah, I'll uh yeah, if you need anybody for future years, just let them know. I'm more than happy to talk again, like from down the line unless I don't enjoy it. In which case I'll be discouraging people from uh nice to meet you and good luck with I'll probably, we'll probably cross paths somewhere.