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Session 2: General Surgery - Training application & the IMG perspective

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SESSION 2: GENERAL SURGERY - TRAINING APPLICATION & THE IMG PERSPECTIVE

Description

Welcome to the second FTSS surgical specialty teaching session. This is a collaborative initiative between the West Midlands Foundation Trainees Surgical Society(FTSS) and the Surgical Society of International Doctors(SSID).

This teaching series offers insider perspectives from trainees across diverse surgical specialities. An exclusive look into their weekly routines, shedding light on the pros and cons of their chosen specialities, the challenges they’ve faced and a succinct review of common cases they often encounter. Additionally, we also delve into details about the application process for their respective training programs.

In this second session, we are excited to feature Mr. Saad Rehman MRCS, a General and Vascular Surgery specialty trainee from the West Midlands. Mr Rehman will give us an exclusive look into his journey through core surgical training and specialty training as an IMG!

Join us on the 12th of June 2023!!!

Organisers: Dr Jefferson George, Dr Fraser Morgan, Ms Rebecca Lefroy, Mr Sriram Rajagopalan

Learning objectives

1. Understand a typical day in the life of an Ophthalmologist. 2. Have an overview of the bread and butter of Ophthalmology. 3. Assess the advantages and drawbacks of the specialty. 4. Analyze the process of applying for specialty training in Ophthalmology. 5. Understand the MSRA exam and how best to prepare for it.

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Computer generated transcript

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

Unfortunately, my internet is misbehaving, so I guess we just have to start. Right. I've just gone live there, Jefferson. Sorry. Hello, everyone. Um There's a bit of a rush start to this because there a bit of internet problems with, er, with Jefferson. So if he's still, if he can hear me, Jefferson, do I kick us off? Sure. Absolutely. Uh how many uh people have mind? Do you want to wait another minute? Um Let's start just chatting through things, get people sign posts to the right places and then we can obviously wait for a few more people as they, as they turn up. Absolutely. Yeah. All right. Hello, everybody. Welcome. Welcome to the second session of the FTSS surgical specialty session. My name is Jefferson and I have with me Fraser and our speaker today is Mister Sad Rahman. The station series is a collaborative initiative between the West Middle Foundation trainee Surgical Society and the Surgical Society of International Doctors. All these sessions are conducted under the ages of the Royal College of Surgeons of Edinburgh. So I am an surgery at the Roy Shrewsbury Hospital and uh so is Fraser and we have organized the FTSS surgical specialty sessions for all you guys cause that you can have understanding about the specialties of surgery. So I'll let Fraser, uh, introduce you to today's session and introduce the speaker. Right. Yeah. So as, as Jefferson said, we're both, um, sho grades from Shrewsbury and the, these talks have basically come about from us talking through the best ways to approach, applying to surgery. Um, so we've been looking through the application criteria trying to find the best ways, tips, tricks of progressing through, er, core training into ST three. Um, something that we thought a lot of people look at and a lot of people must be going through and, you know, struggling to, to pick apart all the bits and bobs that you need to do in order to, to get to that point. Um, so we thought we'd try and share as widely as possible, all the things that we, we've come up with and all the people that we've spoken to about how best to approach this journey. Um, so these, the end of these talks really is to give an idea about, um, specialist trainees in the West Midlands or, or, or from, from a sort of area, an idea about their speciality. Um, some clinical information about things that they perhaps see on a day to day basis, you know, um, how, where they are and how they got to where they are. Um, anything useful they may have picked up on the way or things they perhaps would have done differently or things to avoid if they were applying again. Um, these sessions we're looking to do, you know, 2 to 3 on Mondays with different surgical specialities. This week we've got sad. He was an ST three in general surgery and vascular surgery in the West Midlands. He's currently working at the Royal Shrewsbury Hospital. Um Sad is from the UK, but he studied and worked abroad so he's got quite a unique perspective on moving between systems and applying for a job from an international graduates perspective. Um, so if Sad can hear me, Sad's there. So, um, we, we'll get moving and started, um, on his stuff. Right. But just so we know during the presentation, feel free to use the chat to type out any questions that you may have. Um, I'll have a bit of a, a question and answer session towards the end, um, where we can sort of pick through more specific questions about things that you might want to know about the portfolio, how to apply and, and, and where to go from there. And there are a few, um, there are a few questions on the, er, on the, er, polls about, you know, where people are from. So if, if you could, if you answer those then that would be great. I think there is a little bit of problem with Sad's mic. So let's just have a bit of a, I just, I just asked, sad to see if he can rejoin the session to see if the noise goes away. Um, let's give him a minute. Ok. So, yeah, like I said, there is these poll on the side about, um, oh, no, it's back. Maybe if you got headphones. Uh, I was in, no, I was trying to find some, but my headphones don't, uh, connect to this computer. Ok. Ok. Well, we can hear you. Um, it's, it's survival, I'll survive. It's not too annoying for one. But if it gets to be an issue then we can always get worse, then just let me know and I'll see what I can potentially do. Ok. Absolutely. So you get started with your presentation says, right? Let's get Yeah. Uh just obviously if it gets worse guys just um um in and drop me. Ok, in the middle. All right, guys feel free to type in any questions in the chat box while sad is doing his presentation. We will get your questions towards the end of the session. Thank you. Thank you. Is that first one up? First line up? Can everyone see this light? Yeah. All good. Mm Kasa. Can we just check that? Everyone can uh you a slide? Yeah, I think we can. Cheers. I think it's all, it's all working. I'm not sure it was working one second guys. Yeah, I think it was, it, it's working, it's up. So we just had the home screen there. So, at your computer now. Yeah. Yeah, we got it. That's it. Ok. Um, hope this is working. Apologies. Right. So, um, I'm sad. I'm one of the general surgical registrars. I'm currently working in the West Midland. Um, I got sort of got round about half an hour and then, uh, we'll have a couple of, uh, minutes at the end or 20 or seven minutes, have a quick chat about any questions or anything. So hopefully gonna plan to talk about a couple of things. Um, with the main point towards the end also is have a quick chat about how is the general surgery application from a international, um, graduate point of view as well because I think that's quite key and I think I, we've got a lot of people here from, um, abroad and who are quite keen, uh, for a general, uh, SS surgery. Uh, so we'll see how things go, right. So some of the aims which we'll try to cover, um, just insight into general surgery as a whole, mainly into the UK. So I'm currently working as a registrar. So hopefully I'll have a quick chat about what that is, uh, like as well. Some of the interest, interesting cases. I just only recently had, um, the application process from an img point of view. Um, we'll just touch on vascular surgery as well and I'll tell you why. And this presentation, yes, it is. Here to persuade you to do general surgery. Obviously, I'm a general surgical and, uh, so obviously, I think it's the best uh speciality along with uh SAR as well. So obviously I will try to persuade you. However, at the same time, this talks one more to give you a bit about the real realistic, um, what we expect every day and what we to do every day and how it might just not be what you guys expect back home or, and what it is like here in the NHS as well. Um Right. So just a little bit about myself and then uh it will give you decent idea about the with other people take, there's no set pathway. Um Like everyone according to their own personal circumstances, they obviously have to take their own routes. But basically, I was born in the UK, I've done my G CS ES and A levels here finished that in 2011. Personal circumstances, took me to where I graduated in, I think, five years and then I did my F one in there and I used my uh time to complete the English exam and the PLA two and then the three month gap between um F one and the non non training F two post. That's where I did my PLA two and my, I got my um G GMC registration. So that took total around about 5 to 6 months. Um I did an extra every year to get my portfolio a bit up to scratch because I felt I wasn't on par with, um, some of the graduates from the UK. And since then, it's pretty much uh been course surgical training in the West Midlands, uh two years and then I've started uh general surgery initially and I will be starting on a vascular surgery from October. Uh uh sorry, that was meant to be October 2023. I will be starting from not 24. And I'll explain to you why that's general surgery and not vascular surgery and why it's not the same thing. So first we're just gonna touch on general surgery as a speciality and the training and how uh long it is because I know in different countries there's a different time period. I in Pakistan where I was, I think it was 56 years until you get done with your fcps, for example. But if you're a UK graduate, you got your fy 122 years, two years of core training, then you got at least six years of your higher specialty training. So that's a 10 year training in total. That's at least simply because these days, I also feel, I mean, but if you, if you're in the UK, you're done in med school at 23 and you don't take any breaks, you're a consultant by the age, by the age of 33 34. I mean, personally, I feel that's a bit too young. I mean, there's no, there's no rush I feel to become a consultant. And what people do actually, when they're in a high special speciality uh training, they take time out, they take some teaching that is maybe because they're keen on these things, how it is to build up their CV. So by the time that they come to applying for a, a consultant level post, they obviously need something to sit down out as compared to someone who's just done a ten-year thing. Um You do have options for going less than full time and the recruitment is for the high special training and the course surgical training, you apply for all across the UK. So England, Scotland, Northern Ireland and Wales as well. And then you get to frank your jobs as to where you would like to be and then depending on your scores, you'll get where you wanna be. I'm not gonna lie, I'm not here to paint a pretty picture. It is intense. Um, but it's enjoyable and I enjoy general surgery and that's why I've never really found it to be. You could say work because whenever I go it's something that I really enjoy. So that takes the like intense side out of it, like in a way. So in general surgery, it basically, if you do decide to do general surgery, it opens it up, you've got a lot of options here. You've got top of G I benign and malignant within the colorectal work itself. You can focus on IBD cancers pelvic floor. If you wanna do something a bit more different, a bit more niche, you've got transplant, which is uh liver or kidney. Keeping in mind in the UK, the transplant center is only five in total. And uh so when you come to apply for a consultant job, you really do need your CV to sit, stand out H PB. You got the rest and quite open. I'm gonna be honest, if you wanna do general surgery, but you're not a fan of the on call life, you don't want to be doing all those on calls as a consultant, then maybe breast is a speciality you could consider. And up to, I think it was 2012, the vascular surgery was, was considered a same branch of general. However, it kind of specialize itself now. So now vascular surgery like general surgery, it's its own application. And if you wanna do vascular surgery, you, you basically have to submit a s a second application and a second interview and a second um self assessment score and everything as well. So when you start your higher specialty training, they kind of want you to decide qu quite early on maybe ST three or four, what do you wanna do? Because therefore they can ask you. Ok. So we'll try to get your upper G I stuff out of the way if you wanna do co or we'll place you at certain hospitals where we think that, for example, the colorectal training is more inclined, um, in your, um, SD 678 years se 3 to 6, generally you go around in all the different sub specialities, ST seven that you're fixed and you have to give your Fr CS in ST six and seven as well. Um, so I'm working currently as a general surgical reg and these are the things that um when I go towards the end of the year in my, in my, in my A RCP, these are things I'm going to be asked about. So have I got enough index procedures? So sc three level they're looking at. So um your cholecystectomy, your inguinal hernias, your appendicectomy, um your hiprot. Um And so not obviously an entire nepro which can be uh variable, but they are looking at a good mix as to what can you do the clinic? And are you starting your endoscopies as well? Um And audits Q IP research, I would touch upon these because they're very important in your application. I'll touch upon these um in the presentation. So when I started this year, um I got told that I should be having this a week three, the sessions, one session is half a day, one endoscopy, one clinic, one initial consultant supervised, then you go and do them on your own um as a reg and half a day of admin. So this is all minimum. Do I get this every single week? No, I don't. Um, I have to do on calls. Um, which kind of takes it away and some days some people take annual leave. So, for example, our team is six or seven registrars. We might only be left with three. Therefore, you can't manage to do everything. So even though we have these at the start, they try to stick to these as much as they can. But realistically, no, it, it doesn't happen. Um But if it continues to be a trend, then you have to, to escalate, speak to your supervisors and try to get as close to that as you can. For example, my week, I think only a couple of weeks ago, uh it was a bit like this. This is probably my, my average week. Um So Monday in the morning, the consultant has done the on call round uh on call. So I have to go with them around and see all of their uh patience and then sort out everything else afterwards, followed by an M BT two days around and two days of a full day operating list. So therefore I've got more than the uh minimum three sessions of operating. I've had days where I've been um Monday operating, Tuesday operating, uh where Wednesday around Thursday operating and Friday just admin, it really just depends on where you are, what your hospital is like, what your staffing is like, uh this can really be up and down, but realistically as a general surgical reg that is basically what you do. So obviously we do do on cause this is something where, you know, specialities you, you might be able to avoid. Um I had a lot of friends who came from Pakistan and abroad and uh with a high expectation that yes, we wanna do uh general surgery, we wanna do cardioplasty surgery. And, uh, then as soon as they find out that actually you're doing your on course and you have to do night on call from ST three all the way to ST eight. They thought, ok, that's not something we really wanna do. We wanna do something else. Um, so you do have to take, take into account that you are, do have to do these on calls all the way through to ST eight. Most hospitals you reg sh and F one, consultants are not there unless you require them, then they'll come in if there's a case that needs to go overnight, most likely the consultant will come in some hospitals, the registrars, not on site, but as a general surgical reg most hospitals you will have to, uh be there. There's only a handful, maybe where the general surgical rate is not there in hospital just because for the extra support to the SHNF one, you kind of do have to be that. So, um, for example, I'm pretty sure a lot of, you have seen uh similar uh a cases to this, but um this is a case where you don't see that often. I counted it over the weekend, there was a 50 year old male recently diagnosed with cancer waiting chemo high metallic heart valve was on Warfarin five days of peral swelling, pain discharge and it got worse in the past three days. And um before going to see the patient, uh my teacher gave me all of the history. So I knew um about all of that as well. I knew his temperature was up. I knew his CRP was 210. And my shok, he told me he was concerned because he said that there is something black there. So automatically some I something starts gone in my mind. C could this be something else? I don't need to see the patient? I just step into the room and just that smell, that's all you need. And when I actually saw the patient, there was Crepitus brown dis stars pu mixed with that. There was gas. This was uh am M Decors Bursitis. Now, what happens here? So as a general surgical race, we got the diagnosis at two o'clock. Um yes. Uh what we say the sepsis six screen, all of that was done um resuscitation. And I called the consultant and he agreed that we need to take this patient overnight. Um Could we have taken this patient straight away No, because he's, his inr A was above 10. Thankfully, his observations were stable. So as a reg obviously, you can't do everything, you wanna do everything but you can't. So I asked my sh A who was very good. He called the hematologist on call at 3 a.m. saying, what do we, what can we do? He advised to give some, some Ople, some vit K and uh some uh pro protamine as well called the anesthetic team. Call the scrub team who off site and then all in all getting everything together around about six o'clock, we were set to go to operate. So, as the reg this is all your responsibility, you have to call the consultant, you have to call the anesthetic team. You have to call the scrub team who are not on site. Then it's important. You have a team with you, you need to delegate your team and you need to see what they can do and to get him sorted. Bearing in mind there's also five other patients on the board that have to be seen as well. So that's something on a typical G on call. What we have to base second case was seen the day before. It was a male in his seventies. Nursing, a resident couldn't give a lot of history at all. Er, but he had a stroke, hyperthyroid, uh, burning um, difficulties as well. And, um, the collateral history was that he's not opened his bowels for five days that was taken from the, um, and the person who was with him at that time and, er, we saw that his CRP was 2 60. His white cell count were, um, 13 and something was not. Right. So, what I recommended is that we get him a CT scan overnight. And, uh, that's what we did and it showed a perforated somewhere. So most likely small bowel, kidney, small bowel is quite, um, distended as well. Now, what you gonna do here? I mean, remember first question is, do you even operate? Ok. Um, he's 70 plus nursing home resident, non, um, d doesn't really speak to you. Um, things come into your mind that even if you did operate, what quality of life would he have afterwards and would he even survive the operation? Um, again, it's 2 a.m. but you need to get your consultant involved. You don't really think that, oh, no, my consultant in the sleep at home, I shouldn't, uh, wake him up. Um, you need to ge get them involved. So, in the end, looking at all of that high risk may not survived the operation. Even if he did what would be the quality of life after the operation? Not very good, had, had a talk with the, uh, family, very important to get the family involved, had a talk with them as well. And in the end we decided not for operation and the best, uh, problem that some of the cases you have to deal with overnight. Yes, you'll get your, um, patients with appendicitis cholecystitis and all of these things as well. They will come. But it's those problems that come up in the middle of the night and knowing even as a sho, for example, Sh Ma is first, then we have to speak to the Red and the Reds will speak to the, er, consultant as well. So these are the common things that you see as every day and what you can expect. But I'm sure, I think we've got a lot of people from abroad and these are a lot of things that you encounter even where you are as well. But it's just basically maybe how things are done in the NHS are slightly in a different way. For example, as how example, they were done mainly for me back home in Pakistan as well because, because I think I remember when I was in F one in Pakistan, there was a professor and head of department. I mean, as a F one, I saw the postgraduate um year one trainee contact the reg and then the red had to contact the is in your red. Um but when did I ever see that the professor ever come in to scrub? I don't think I ever did. It's very different here. Your consultants, sport, you, they back you and you should never be scared of calling your consultant in. Um because in fact, you'll be more trouble if you do not. And something happens overnight and they come in at the start of the day and they will ask you. So, WW why could you not uh give me a call and guys just give me one minute? That's ok. Uh I thought about that, that, that was just my dad who was coming to my room. Um So, right. So the application process, so the standard application process is uh this is it, this is what if you graduate from the UK, this is what you go through. You do five years of med school, you think that's tough, all done. And you think yes, I'm done with med school. I'm ready to be an F one. Fantastic. And then when you go to an F one, you realize, OK, now thing, now things are actually starting. So now you've got your two years of foundation training in ideally what some people do. But in your first week of foundation training F one, I have to say you have to open up this, ok? You have to open up or if you're abroad, which I'll touch on. In the next slide, you have to open up this CS D application. I mean, there's no, if you were serious about doing general surgery and due to the competition that there is, you need to be early, you need, you need to open it up, you need to look at it from the previous year, the personal specification, the self assessment scores. What do I need to do? Ok, look at it early. It's really self explanatory. It will tell you what you need to do. It'll tell you where the marks are and that's where you need to work towards. Ok. Every three months in your fy one period, your fy two really? In your fy one? Because in your first three months of fy two you have to apply. Um, you look at WW in these three months, what can I do in these three months? What can I work on in my application to increase my self assessment score? Ok. You'll quickly realize that a lot of the things you've done in your CST application you can use in your higher speciality training application as well. Ok? I'll touch on those in a bit more detail, but that's generally the pathway that you follow if you've graduated from the UK. Now, if you're from abroad, unfortunately, it's not that easy as you can tell you've got all these extra things that you have to do and this is just only one route that you can take. This is the route that I took. I've had a couple of friends who've come from Pakistan, my very good friends, they've all had a different idea that we're gonna go on a different route. We're gonna do MRC PM RC. Si said, yes, that's fine. You can do that. However, this is the route I recommend and I made them change their mind. Ok. So I'm not sure what stage some of you are who are in this um presentation. However, after your med school, I believe most countries you do a house job, which is what I did, which is equivalent to fy one. Now, I knew from a very early stage that I was gonna come back to England however much of life I enjoyed in Pakistan, which I did. I'm not gonna lie. I did, but I always knew that I was gonna come back. So in my house job, I knew that if I get start, if I start doing things early, get things out of the way, then I can really focus on other things as time um goes on as well. So in my health shop, I did my, I did my, I did my English exam back then. It was just a but now you've got a ore exam as well and I did my plan one. So and now I think in 2024 it's talk about it being changed to a UK mini which the uh even the graduates from the UK have to do as well. So I did these two, I thought that would be a better option. I mean, why would you, why would I go for a year, not do anything then spend another six months after that trying to clear my li my, my, my English exam and the plan on as well. Ok. In that gap of coming back to the UK, um I gave my plan to, now I'm gonna openly admit I didn't have the extra stress that a lot of you will have of um that you need to come to the UK as a non UK uh international and need to apply for a visa, get a sponsor, find somewhere to live for the Academy for PLA two and all of those things. Yes, I did stay at an academy. I didn't stay at home, but yes, I admit I did have to go through that stress. So that is probably a gap there that an extra stress that you have to go through as well. I got a non trading job and I opened up the CRE form within my, almost my first month and I looked at both the Cres form and the CS D application within almost my first month of training. And I looked at, I said, what can I do? I quickly realized I've actually done a lot of things back in Pakistan in my house job. I didn't audit back over there. I did have a leadership role in a charity back over there as well. And then one of my colleagues told me so you can use that as well. There's no reason why you can't. All you need is a consultant to give you something, a piece of evidence to say you have done this back over there as well. Ok. And you can use that in your application. So don't think whatever you've done back home is a waste. It's never a waste. You've done something it can be used. Ok. So thankfully I got into core surgical training at Westminster. I first go, I gave my MRC SS in my F three year, my part A, ok. And I gave my part B in CST one. Therefore, I didn't have the stress of a part B in CST two. Ok. So I think the kind of theme that I'm trying to follow is you really need to decide early general surgery is what you wanna do and you need to state in mind that this is the pathway that I wanna go. I need to work towards it. Ok. So there are other routes, er, for some whatever reason, some people don't know that they want to come to the UK straight away. They have a family commitments, personal reasons and they can't follow the route that I've said for whatever reason. Therefore, people can start their training back in Pakistan or India, et cetera. Wherever I do apologize, I keep on saying Pakistan, but that's where I, I hid it from. So, um, they start their training there. Ok. Advantage is, um, you can stay in your home country for a longer time, you can take a bit more time to decide. Actually, this is, is this exactly what I want to do or do I actually want to go to the States? Do I want to go to Australia? And, yeah, I'm not sure what exactly it is I want to do. And the other advantage recently is you can still apply into round one previously. Um, up to two years ago, all of the international graduate you could not apply. Oh, apologies for that. Everyone, I think, um, s been having some ongoing technical issues we've seen from the, we'll try and get him back and just just bear with us for a second, I think. Yeah, it looks like he's been having some connectivity issues from the start. Please please bear with us five minutes guys and just while we try and get him back there, everyone um just keep putting the messages in the chat. Obviously, I know it's a bit of a, a bit frustrating and it's cutting out but um we are looking at the messages and um you know, if you got questions that we are seeing them come through, so we'll make sure they're all answered at the end. So it it's all it's all gonna be worthwhile. Uh He's back. Apologies. I do not know what happened. I, I think might be suboptimal ate slightly. I would try. Let me see what I can do. Let me see what I can do. I'm, I'm sitting right next to where the internet connection is but it is, there is a storm outside which might have interfering with, it's classic British weather. Ok. I appreciate, appreciate bearing with us and I do apologize. I'll see what I can do. Yeah, it's all right. No problem. Well, um, everyone's very kind and, and bearing with us, we've got some more questions rolling in. So just take time, we'll get back. So I'll try to get done with this as soon as I can give some time for all of the, uh, questions as well. Absolutely. So you, you've got the M as well. So generally this was the competition in uh, 2022. In general surgery. You had 5 32 applicants for 1 32 jobs and there's a 3.48 ratio, vascular surgery was slightly higher at 5.31. But if you come, if you think that's higher and you wanna go for something else, but you quickly realize that that orthopedics and plastics are generally the same. So, whichever general surgical speciality you wanna go for? Yes, I'm so sorry. That is roughly, um, what it is. Don't get disheartened. People sometimes are fixed to one location. For example, um, if they don't get a job in the West. Mmm, Midlands, um, they will not take their job. Therefore, it goes to the next person. Someone may apply for vascular and general surgery and may actually only want a single job. Ok. So don't get disheartened things that this do occur and believe it or not, some people don't even attend, um don't interview very rare, but that does also occur. So as I mentioned, start early CST HST. Look at the applicant guideline book. Honestly, I could spend the next 20 minutes and put the next 20 slides up with a screenshot of every single page. But honestly, you really need to know that book inside and out. OK. That's where all of the marks are you and that's how you'll get your basically interview. If you look at the self assessment score in the applicate guidelines, book in the highest uh s surgical training, it's marked out of 32 ok? Normally, I think you need something around 2021 to get a interview. That's not a guarantee that you can get a job. That's just a guarantee that you'll get an interview and then you'll sit the interview and then there's a whole different procedure and how to prepare for the, for the interview as well, ok. So and Mr R CS, before you start higher speciality training, it needs to be done. If for example, you've done part one, you get a ST three job and by the time of October, for example, 23 you have not passed your part B you will not get that job, that job's gone, ok? You will have to then apply all over. Yeah, there's not really, I think in COVID it got a bit relaxed because um part BS were not happening. So and I actually got an email saying that um if you've not passed your part B by this date, please withdraw yourself from the application. Ok. So now when I was in Pakistan, these things to me were like no idea. Ok, back then, um I was in F one, I did general surgeries as my last rotation. That's where my excitement started. I remember the PGY gave me a blade on my second appendix and head start and then I was like, wow, OK, this is really good. It's really exciting. Um Is that gonna get you a job in core surgical training? No. Is that gonna get you a job in high speciality training? It will help you but it's not gonna get you a job. You need these five things. OK? A quality improvement project publications, not a must, but they really do help a presentation evidence of leadership and teaching. So I'm gonna give you an example of where I managed to achieve all of these. OK? Quality improvement projects, quality improvement project is basically a audit. An audit is you look at what's basically you look at what's being done in your hospital, you compare it to a set standards and then you see how your hospital is doing. For example, most recent audit I'm working on is um a small bowel obstruction. We sometimes can give a, a gastro grap in oral dye at 36 to 48 hours. Not only to help diagnose but sometimes that relieves the obstruction in a additional obstruction as well. So the audit we're doing and the uh national guidance from the A S GB I is that you should be giving this at approximately 36 to 48 hours after a trial of conservative treatment. So my audit is, are we doing this? Ok. Now, so we have to get all of the data for three months. Have a look. Are we doing this? Compare it to that then presented? Therefore, I've done an audit and I've done a presentation now, a quality improvement is when you then implement a change. OK. That may simply be something as simple as a education or a class or a lecture. And then you say I have educated someone, I'm gonna then repeat that audit and now I've done a quality improvement project and I'm gonna hope to see a improvement. OK? That is a Q IP in your core surgical training application, not your general, not your for the registrar. If you do a Q IP and present it at your local hospital, I think that gets you a AQ IP will get you maybe six out of eight, I think when it was OK? And um if you're doing a surgical job that gets you an extra mark. Um and if however, you present it at a um not just in your hospital but in your region and then in the UK as a national level that will get you the highest marks, OK? Now, the difference between core surgical training and the highest surgical speciality training application is that in your CST, you might get away with just one and that same one you can use for presentation. And if it's that good, you can even get a publication, ok? Now that will get you very good marks on your CST application. Difference between that and higher surgical is you may need about of these. You need maybe three or four. OK? Maybe not Q IP, but at least a audit, OK, then you can use those to get a publication. Basically, if you choose a good audit and a good um Q IP, the, the exact same thing can be used for, for a publication as well. OK. So l leadership looking at things like in hospital, if you manage the uh voter, for example, I did charity work on an international uh level in Pakistan that counted as leadership and teaching like for example, like what Fraser and um are doing OK. This is more of a uh nnnn no national thing you need to organize and run something similar to this. Therefore, you may do the most beautiful AAA repair ever. But if you've not done any of this, you will not get a CS D number, you will not get a higher surgical training job. No one's gonna care that you can do the most beautiful 22 a day, OK. This is why it's very important and this is why I said to try to follow the recommended route. Ok? So say, for example, you've done four Q IP S and that's got you. So one Q IP was two marks. So that's given you eight marks, you've got publication, one publication was four marks. You've done two, you've done eight. So that's 16 and the rest of them you've got uh two marks each. OK? So you've got 22 in your self assessment just based on that. Ok? Now look by the end of July 2022 or by the in complete of core surgical training. After how many months have you spent in any job, post your foundation program? So after fy two, OK, how many months have you spent basically in your CT one and two? That's only 24 months? Anything over that? You're looking at 36 48? They're gonna start to use this, ok? Now this is for high speciality training. So if you've just done your core surgical training, you've just done 24 months, you're 22 they're gonna divide by one. So therefore you've just got 22 marks. Your marks haven't changed. If for whatever reason you've done s 60 months, your score is gonna get divided by four. So 22 divided by four. So you're looking at therefore, is it 5.5? Ok. So therefore your score from 22 has gone down to 5.5. Therefore, you don't need four Q IP S. Now you automatically think actually I need eight or I need 12. That's kind of what I was going to when I said this, this you need to and how I mentioned, you need to start early. I did decide early. This is what you want to do. Therefore, to try to keep this N number as down as you can. For example, someone who's done a post GG graduate degree in abroad in Asia Pakistan and after their house job, they've been working for 10 years, you automatic out of five, ok? Doesn't mean it's still not possible for you to get to a job a lot more of these then, ok? And you really need to build these up in the time that you have now if you are here here or here, ok? That's why I kind of keep going back to the point to start early, ok? Um, and here it is as well. This is again, pretty similar. They basically have said if you've done, if you've got a, if you've worked in general vascular surgery for 21 to 30 months, we'll give you maximum marks, we'll give you eight marks. If you've gone one month over you, you are down to four and if you've got more than 60 you're down to one, gonna be gonna be extremely honest with you guys. The UK, it has opened up its application to rou to everyone in round one. OK. However, it is doing things like these, which means that the application, it favors those people who are maybe not, for example, have 20 years of experience. OK? Because then you got a thing, you've got an ST three who is at, who's applying after CST. And then you've got someone at the level of a consultant back home in India or Pakistan and they're applying for this same job and the UK is trying to work its way towards that. We wanna give that person who is just an ST three ct two, a bit of a higher chance. Therefore, that goes to one again, if you're here, it's not impossible, not impossible at all. It just means that you need more of these. OK? And in the other parts of the application, you need to be stronger, something similar. Again, it's done the same thing again, by the time of the application, how many appendicectomy have you done? If you've done 50 55 maximum marks, you go over 99 to 100. Again, it's gonna go all the way back down to a single mark again, kind of backs up what I'm trying to say, you need to find the pathway that's going to take the shortest amount of time, get to these applications in the shortest amount of time that you can know that you wanna do this at the earliest stage. Therefore, these numbers will stay low, the more time you take, you decide the more time you're not sure what you wanna do. It is gonna get more challenging, not impossible, but it will get more challenging. So, brief chat on vascular. So basically, I applied for both general surgery and vascular surgery. Last year, I got general surgery. I didn't get vascular. Um, but in my mind, vascular surgery is kind of what I wanted to do. So I thought to myself, I'm gonna give it a single more shot if I get it. Fantastic. If I don't, I don't, um, I applied, I just put the West Midlands down as jobs because that's where I live. And, uh, that's for where it's home. And thankfully I got a job. So after much consideration, I took it vascular surgery just this as a backup for general surgery. These guys, it's a different speciality, it's different work. General surgery is different. Vascular surgery is different. They do have similar things. Ok. But it's a different speciality. Some people go into vascular wanting to do general surgery. They don't enjoy it and they leave. Ok. So, just be careful if you do do that. I enjoyed it. I like it because it's got a bit of like endovascular work now as well. And you've still got that open and guys who does not love the excitement of a AAA those acute limbs, dark emergency work. Ok? Who doesn't enjoy that? Www What I do? And that's why, um, that's the application that I have uh gone for. So summarize be early, decide early, that's what you wanna do. Ok? Even if you haven't decided early and you're a bit further down the line, it's ok. It's not the end of the world, ok? But you just need to now open up that the personal specification for ST three and look at it and see what can I do and what can I work on and where can I improve? There are no shortcuts. I mean that is as it is, if you want a general surgical number, you need to put in the hard work, ok? Um That's it. I mean there's no really two ways to uh work or work about that, ok? Um That's my email. Make a note of it if there's anything that you wanna ask me. Um I'm more than happy to try to answer your questions. If I don't get back to you straight away, I would at some point. Ok. Uh But that's my email taking a note and if there's not any questions that are coming up right now and you're going to ask me at a later date, then I'd be more than happy to answer those as well. Ok. Thank you. Thank you, sir. I will stop sharing. That was great. Thank you. We've got loads of questions for you. Everyone's firing away. Would you, would you mind just putting your email in the, in the chat there for everyone's sake. II I think the, but I appreciate everyone there for. I think we're done. Yeah, absolutely. Can you, can you hear me sal can you hear me? Can, can you hear me roar? I think starts having an intimate problem. OK. What I can do so uh fine, I think what we'll do. I need to like in and out again, Jefferson will um just in contact with, I'll just, we'll just send the, the, the questions through so he can, he can read, uh, to you talk to mate email. I'm just gonna go through some of these questions. I'm not sure where Jefferson or Fraser R. Um I've got a message from Jefferson. You're just typing on whatsapp. I do apologize. I'm just having a look at that uh, side by side. Oh, good bye. You got me there, sad your back. Can you see us? Can you hear us? Let me one limit, right? Ok. Thanks for bearing with us through that everyone. It's, um, it's quite bad weather in the UK at the minute. We've had a lot of, lot of sun and hot stuff. So we, we've got the, uh, we've got the storms now that's, that's making up for all, all our sunburn. So, so I, I appreciate you, uh, bearing with us. Ok. So, uh, can you hear us? Ok, what we'll do is Jefferson, you want to send him a, uh, another, another invite through and we'll just get back on to the, the, uh, the questions. Ok. So we're seeing all your questions coming through, so we'll get around to them as, as soon as we've got sa but obviously he's having a bit of a issue with storms over his head. I do it, it, it is actually quite bad work at the moment. I do apologize. You can hear me now. Brilliant. Hear you. Right. So, so thank you for, for the talk there. Um I think it's pretty interesting seeing some of the parallels between your talk there and our previous talk in the first session about how, you know, it's basically a lot about commitment and perseverance and not working super hard, but actually working clever and efficiently with your portfolios to get things, get things put together. I suppose the specifics of the day to day job is quite interesting, see as well. And I think it's quite clear from your talk, how, you know, you, you sort of treat surgery as a bit more of a vocation rather than just a career. Um So I think what we'll do, we quite a lot of questions coming through. Can you see the chat at all? What I will do is I can, um, shall I go to the top and try to work it down? Yeah, absolutely. Yeah, you, you could do that or we could read the questions out to you how, how you let me see if I can get so a lot of people saying about the noise. I do apologize about the noise. I do hope it, it wasn't that bad. Um I think it is basically basically because of the storm. Um I, it's improved a lot since you, er, joined back in. So it's, it's good. Ok. So I will reconsider coming to the UK. Right. So I've got a question from Shahan. I hope they're still there. Kindly. Can you please tell if anyone joins after completing C be Pakistan and gets done with Mr CS, what posts will be available to them? How long will it take for the FRC in the UK? Right. So there's two routes you can take to becoming a consultant. One is to do your ST three. So apply for the higher speciality training number. However, as you can see from the application that I've talked about, the more expe the more experienced you are, the more challenging it gets, right. So some pe some people take a different route and that is known as a uh uh routes as well. And the C A pathway is a second pathway which um sometimes people can take to becoming a consultant and that basically you need the backing of at least 2 to 3 good consultants and um on your side and there is a checklist that you need to complete a lot more challenging than higher speciality training and you need to work a lot harder and find the opportunities yourself ok, whereas in higher end surgical training where you work is their responsibility to give you the response, give you those to, to training and list. But as a non trainee, you kinda need to work a lot harder. Now, what post, um, you could come and do your Fr CS pretty much, uh, when you can. Ok. That's not really anything on that. Hello? From Mexico. Hello? Um, hi. Or unfortunately Mr Sa, I do apologize. Uh, what is a junior K CAFO job? What is their duties? So a junior job, I'm gonna be eye is a bit like AAA sho as far as I know. And um, and they sometimes have some other uh you see as an sho or a reg, but basically you're not in a training job. Ok. That's the main thing that you need to remember these clinical fellow jobs and a first grade sho you're not in a training job. Ok. So you need to really need to do that as experience basically um to for the UK and get your personal specs and specifications uh looked into to get them. So you need to find a job that's gonna allow you to work on those and on to improve on those. Ok. So what are the requirements for an IMG postgraduate with Mr CS to get into SD three? Is it mandated to do a non training job before? So, so as I explained, you don't need to do a non training job in the UK. Um But if you come from directly from abroad and straight into SC three, as I explained, you might get a bit of a culture shock. So I do recommend you doing a non training job. Ok. Um What requirements? So there is a personal specification if you go onto the, just type it into uh Google, actually, um the tw 2023 personal s uh specification for general uh vascular surgery, you should see what are the minimum requirements you need to apply. Ok. Um and that's it, you just need to make sure you have those, then you need to look at the self assessment score and see what you're gonna score. Ok? What are the requirements for IMG So I think that's the same question as above. So from and pardon, I could not secure a non training job after 100 and 60 applicants. Would it really helpful if I get help on this a little bit out of scope from this talk? I've, I am a part of the IMG group on Facebook as well and I've seen people are struggling with getting a non training number. It's more challenging than it was back in the day. Um I actually know consultants who say they basically open up the post for 24 hours and they get 200 applicants within 24 hours. That's how competitive it is now to get a job briefly. If you get a clinical attachment. Um If you maybe get a contact through one of the people already working in the NHS, work on your audits presentations, get more on your CV. These things can help. I do apologize. That's uh is a big topic and a big question. And uh if allows, we can have another further talk at some point more about that as well. But it's a quiet, big one on there. How di how difficult is it to for an IMG who has done the Mr CS to get a job or get into high HST. It's not possible by no means it's impossible. And I really hope that this talk has not scared you. It's just to tell you that um look at the self assessment scores, look at the guidelines and that will really, it will help you. You can find all of these online. Ok. If you just type it in the self assessment scores and the applicants uh guideline, if you go on the, on the aio page, it's all there. Ok. Um And that's what you need to go and that's what you need to follow and that's what you need to work uh towards. So depending on how many years now it's been since you're on R CS, as I explained. Are you now going to fall into the um number and is it gonna be going up to four or five? Um So, yeah, hopefully, I think that question was at 6 35 and I touched upon those things a bit after. So I'm hoping when I talked about those, um, it, it, that it has helped can img maintain surgical log book. Of course they can. Um, there's a e look at log book dot org is the website. Um, go onto there, please. Please, please. Everything you do in your international country accounts log all your cases and just at the end, print it out, get it signed by your consultant. If there's a consultant abroad who's got a GMC number. Fantastic. But even if they haven't, it's ok, but it has to be a kin consultant. I am planning to go to a four D train in. I see you soon. I have vanished. I hope I'm still there. Turn off camera, turn on camera. Let me just check with Jefferson again. Oh, yeah, you're, you're absolutely fine. Yeah, yeah. So yeah, a my camera. It, it turned off. I am planning to go back to do training post and currently start in my pa I'm going to sit for, can I get my Crestor signed? You can you can indeed get your Crestor signed over there. Um But if you in Pakistan, I know there's a lot of consultants who have gone from Pakistan to the UK UK back to Pakistan. If you can get it signed by, maybe someone who's been in the UK and has got a GMC number. That's fantastic. And actually if you look at the personal specification. I think it actually says who your CRE form has to be signed by. Ok. Um So has, so for example, if you're Pakistan, I would say your head of department, your professor, OK. Who is your most senior person? Them? Ok. Or someone who's worked in the UK and is happy to sign off then yes, to get SD training after non training posts. All that's required is a side crust and Mr CS along with good portfolio. Um if the non training will be required to send IC if you not really, uh again, I think that question was at six 39. So to be eligible to apply for high speciality training, as you correctly mentioned, you've got your Cres form for high speciality training. You've got your Mr CS, you can now basically apply, ok. Now you need to work on your self assessment score and get as much of that as you can. And OK. Now these CBD S and mini catches unfortunately, on the uh high speciality training application, they don't have any uh bearing there. The only bearing is how many appendis Omy have you done? Ok. Um And how much experience you got in a um a surgical special speciality of people as well? Ok. So um IC P CBD S, they will ask you but not really where these things will be beneficial is if you get an interview and they ask you to talk about your portfolio then. Yes, you can say I've got CBD S that are subs are signed off and I've got mini catches that are signed off on this, this and this and the level three and four. So come to interview, they'll help at the time of the self assessment score. Unfortunately. No, not really. Also how do keep portfolio in Pakistan for all the surgical procedures I do. Is it like a log book? Yes. So is the E um log book that I discussed in the application for CST? Does the surgical experience in our home country count towards commitment on the surgery if I have assist? Um I might, yes, 100%. That's kind of what I'm saying that guys, everything you've done back in your home country, it counts, just get evidence, get it signed off, go to that professor, the head of department who you're scared of who you might have never spoken to. Um but get it signed off, get them to give you a stamp, get it assigned all these things count, for example. So what saying is there, there's, there's a website called the E log book where you can create a profile and add the procedures that you've assisted in, done yourself and then ultimately print that out as a consolidation sheet and get it signed from your professor. Have I said that right? So yeah, 100% right. OK. I put in a link to that log book website in the chart for like if you have a moment, do you mind seeing if you can find the links to the personal specification online as well? And just S3? Yeah, let me have a quick look. I have the PDF but I'm unsure how I can. Uh but you want to see whether you can find it online somewhere. You can uh let me quickly check while you uh go through the question. What are the over qualifications for CST? I believe? Now, if you've done more than 18 months in a surgical speciality, post foundation training, um you're not allowed to apply for CST if I'm not mistaken. I think that is now true. Q IP S are not super prevalent now, institution will they accept for collaborate, someone who works in the UK? Yes, they will. Um But again, you need evidence from someone or something signed to say that you have worked on this. OK. And what was your role? And what exactly did you do? Um So in hospitals and we do not have written standard guidelines. So what can be used as guidelines? So, um for example, some of the audits that I've done um the majority of an audit and the definition is that you need, do need to have a set standard. OK. And you do need to have it uh compared um sometimes you can do, sometimes we can do audits uh where there is not a guideline. Um I remember I did a couple or for example, then they're not technically audits, but you can work on a project. For example, I'm just trying to think about any of that that I've done. Um, so let me think, uh, for example, there was one, project where I couldn't find, we looked at, uh, here in the UK, patients who have had a bariatric procedure and some of them are going back again to have a second procedure. So we were looking at to see why was that basically occurring? Ok. And what was the cause? Was there a specific patient cohort behind it? I don't think there was any specific guidelines that are found or we found, but we just wanted to see. Ok. And um the guidelines we kind of used and followed are we looked at online other people who have done similar work and we compared our work to that work? Ok. So that's an example of something else that you can also do. Does index procedures have to be validated by consultants to count as sts or can they be validated by str? So um they can. So when I do my log book, um I don't, yes, it does give you an option to get it validated. Um I don't always do that. But what if you don't do that, then you have to make sure that when you print it out, you need to have a consultant who is happy to sign at the end and say yes, I'm happy that this person has done. Basically, basically all of this. OK? Because you get validation is not always easy and where to find all these P point systems that should be available on Google. And if not, if maybe one of you sends me your email, I can uh sign it to an email. Um but um we take it from there, any form that we discussed would, would you want to do uh do a trans information? So, interventional radiology is a, a different field for that. You need to do radiology, four or five years training, then an extra year as interventional radiology um as a vascular surgeon, you now need to be trained to do um angiogram. Oh, I think we've dropped out again. Um We're just trying to get S A back again. Um I appreciate that the comments are still coming in. I've just put a link in there for the Oh, hi, s a back. I'm just, I just signed up, I'll put a link in there for the uh CST um person specification. Um And that's found through a website called higher Education England and you can look at the specific specific speciality. We call ST three pathways through that website as well. Um Sorry, I just um let's start. No, it's ok. Um So yeah. Um in vascular surgery now you need to do a mixture of intervention and yes, an interventional radiology ve may do the similar things as you, but as a vascular registry and consultant, now you need to be endo vascular terrain as well. Now, um right for you shared email ID, which is done. Um Are we gonna get a recording? I don't know Jefferson Frazer, is that a possibility? So we can absolutely help with the recording. It will be put on the med website in a few weeks time with submitting tickets from ready to help us ct uploading evidence. So I think um in the CST application, if you have a look, I think um if you do upload some mini catches, I'm not sure whether it does get you any marks. But again, as I um discuss these mini catches and CBD S are, are much better to talk about in your interview. So just because they're not there on the application that doesn't mean they don't count, please do make sure that you talk, talk about them in your, in your interview as well. No worries. Thank you for the mention. The problem. Is it ok if we record procedures? And so, and there is no consultant? Uh Yes. So basically, do you mean that uh if you're in the procedure and the consultants not there? I, yeah, I mean, look, we, we, we w whichever even if you're in your home country, there is a uh maybe a assistant professor or associate professor. And uh you simply say that even if they're not there in the operation, you say that you put the consultant as them and you find the PM DC number online and you put it in. Um they don't have to be there. For example, if I as a register, a case with a senior registrar um but the patient is admitted under a specific consultant. So the consultant is that one. So I do pod it as them. OK. In self assessment, they don't count technical tips and articles and publications. What can you can you provide any cloud to? So um in the highest speciality training they want pub med published or a publication with a pub med link. Ok. That's for higher speciality training. Um The CST they might accept a abstract, OK? But for highest surgical training, they only accept a pub med linked uh publication. What's your advice for Mrs A exam? Ok, guys, I'm very sorry. Um I know they only introduce the MRS A exam this year. I was quite fortunate when I applied to stuff. I think it's the MS R am RS A is a bug. Oh, yeah, sorry, my bad. Yeah. Um the I know the exam that you are talking about. Unfortunately, I did not give that exam. Um So I don't want to be providing advice and giving something that I didn't do because I might not be giving the right advice. I'm sorry, let head. Yeah, of course. I don't see a reason why not. And thank you, I've done am multiple three months speciality. I said rather than four months, I will discount anything or happy four months that you need. For example, I've done three months plastics. Uh Well, I think for that you're gonna have to, that self assessment score is quite strict. Ok? And they're gonna ask you to sub to submit evidence of everything you've done. And if they're written four months, uh my suspicion is that they will want four, you can send them an email to ask them. They are quite good at replying to you again, but generally the self assessment score is there and that is what, what they want and that's not normally they go away from that. Ok? For example, I think in a CS D application, um they said any evidence you do has to be signed by consultant with their GFC number or et cetera. I know one of my friends um he submitted evidence and he didn't include the consultants GMC uh numbers on there. And in the end, all they said was that we do apologize that you did um submit it all, but you did not follow what we asked for and uh but that was it. Ok. Uh Right. So I am confused between cardiology and vascular surgery. Which one would you recommend? Ok. Um So cardiology is a medical speciality, vascular surgery is a surgical, some medical specialities like cardiology, respiratory gastroenterology, have a in interventional side. Ok. And that's why they're a nice mix of someone who still likes to do, uh, gen med bearing in mind. You still got to do the general, um, mm, me, me, me medicine on call, the registrar live. You got to do the, an MRCP and not M RT s and, uh, so you're doing medicine and not surgery. So you gotta ask yourself, what do I like more, more intervention and more surgery or do I like? Mm Edison as well? Obviously, there's cardio Thor Thor Thoracic surgery as well. Um, as, as an option is the E log book only for practicing UK. And Ireland student with the extended surgical team, which should I choose as an img applying for non training? So, uh, no, you can use your E log book even if you're a editor student as well. And I know a lot of students start their el log books quite, quite early as well. So, uh, you don't have to be in the UK specifically to be doing that. Um, I think I've managed to reach the end. I just like to apologize again to everyone. I know my, uh, co connection wasn't great. I disconnected a few times. I'm gonna, I would like to blame that on the storm. That that's outside. It was the, the, the, the, the, the weather entire day was absolutely amazing and great and the sun was out and everything. But just as the presentation started, it's like to rade which um, it has messed up with my internet connection to my house in the past. So, um, I do like to apologize. I hope I have, uh, managed to answer all questions. Um, I have dropped my email and, um, uh, if you have any further questions do email me, I try to get back to you. Ok. And as soon as I can, if I don't do it immediately, I do apologize but I will um get back to you at some point. Um If there's any other further topics you like for us to cover, just put it in the uh feedback form. And I'm sure Fraser and uh Jefferson can have a look and we can have a talk about that about that as well. Um All I can say as a final point getting AC S3 getting a ST three number as an IMG is easier than before. You now apply straight to round one. There's no round two. If it was round two, you wouldn't even, there was a basically a chance. Ok. So you there is a good chance. Start early. If you're still doing your, if you're still doing your house job, start to look at these things. Now, if you um start to look into your club, now, I know dates for clubs these days are ridiculous because of COVID and therefore your time expands, et cetera, but try to make the most of that time out and please mmm maybe work on, for example, a audit or A Q IP. So, always try to make the, uh, um, host of all of that as well. Ok. And, uh, otherwise, yeah, hopefully this talk has helped. I'm sorry, we've gone a little bit over. I think there is a feedback form and yes, you are allowed to put that the protection and, uh, it wasn't great for which I do apologize for again. But, but as I said, if there any, thank you for anything, please send me an email and I'll try to get back to you as soon as I can. Thank you, Jefferson and Fraser. So uh so in, in the upcoming sessions, uh we will have a similar surgical specialties. We'll keep our focus on core surgical training, training application. We also bring in log in and out again and um we will listen to your feedback and tailor your tailor our sessions accordingly. Thank you very much sad for, for today's amazing session. I know we had some trouble starting out but, but I think it was a very good session. What, what do you think Fraser? No, absolutely. I think it's um it's quite interesting seeing a different perspective from, you know, obviously myself as a UK medical graduate coming into the system. It's quite interesting to see all the different pathways that people can, can use to access that and the actual issues that people find along the way. So, you know, to address that I think is quite an important thing to do. Um And like we said, there's plenty more sessions coming up and plenty more um opportunities for people to ask questions um and get an idea of what the system here is like. Um We've got a couple of people lined up from um other specialities, vascular ophthalmology. And, you know, we, we any, any other speciality that you want to, to have a look at, we can, we can obviously see if there's anyone who, who can um, who can talk about that. So thanks a lot for attending everyone. It's been er, it's been a great talk, so I appreciate thank you. So for, for going through all that. It was, it was an amazing talk. Thank you. You guys see my time. Bye bye.

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