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What we need in colorectal surgery. So we've been working on this and we've been working on this problem since COVID. So this is the first project I'm going to talk to you about. We've just been funded by UK R. Our project is called indicate, we started working on this during the beginning of the COVID pandemic and I had a meeting with the head of A I Aws and I was supposed to be talking to him about how we can leverage cloud computing to prove the validity of robotic systems in colorectal surgery. And we said actually there's a bigger problem now, we're not going to be doing any surgery for a bit. Could we please talk about the info dem use case? And we built an indem use case engine to try and make sense of the of the chaos and, and this slide won't come up on the big screen. But this is our, our methodology which we've published and the link is there. And we built a huge web crawl architecture and we built a human in the loop methodology for surfacing massive qualities of data quite quickly upon which you can start to build large languages models. Uh And it worked quite well. In fact, using just 42 data curators, we could surface 1500 datas in about two weeks. We had the largest COVID data set on the planet because if anybody produced one, we just ingested it. Uh And then we started to work through uh different ways of changing how you create those kind of autonomous data summary reports. We then got funded by Nr Hr and we've now turned that into cancer. So we now have our own colorectal cancer data set. We've ingested PUBMED, we've ingested anything that uh any of our peer reviews and our experts think is a useful resource for cancer. We ingest Gray literature, social data as well as um uh published uh abstracts. Now, there's a key challenge around all of this, how you get behind firewalls, et cetera. We have, you know, I think we've got there. What's that? 37,973 web domains, terabytes of data, which is continuously annotated, continuously surfaced and continuously updated. We're now, so we're now working with the BM. Nice to create a tool where we can really transform systematic review methodology. If you've done systematic review, it's a tremendous waste of your time. This is exactly a job that A I should be doing. You should not be wasting your time on it. And so we want to do a system metric review of everything all of the time always. And that's our goal with indicate if you're interested in working in that, please contact me. We're currently recruiting. What about planning? Well? OK. You can't read a journal at the moment without A I titles on any form of automated workflow such as histology, endoscopy, radio mix, workforce planning team. And this, I've just pulled out at random. It's a paper that came out in Jamma open this year looking at using A I to improve pathology analysis of polyps, it improves accuracy, it reduces time. You're going to see lots and lots of these works. We've seen massive adoption of A I in endoscopy, uh typically used for adenoma detection rates and we've got commercially viable tools for doing that. So G I genius would be an example. I don't know if the video is going to play. So you can see the system here. This is a Penta system. This is videos from Buha, my colleague at King's and you'll see the little blue, the, the little blue box will light up and show you where the adenoma detection rates. We've got randomized control trials that show that it does work. Um But it brings with its own sets of challenges. The BSG has an A I task force. I know we don't have one in surgery, we need one. And of course A I is going to transform, not just how you perform endoscopy, it's going to change treatment algorithms. You've just had a fascinating IBD CANCER NDT. That would be a really good example where it could be, it could be very powerful. So decision support. So many of you will be robotic surgeons, many of you will be trialing robotic systems. Um And there is a rapid growth in robotics uh platforms which we've, which we've um published on. It's not about the robot. Of course, it's about the data. And what these companies are banking on is actually um you're actually going to start purchasing software, not robots and those Softwares will update and they will measure your performance and they've measured your performance by the way for decades. It's just that they didn't tell us that raises a significant ethical challenge. So the future of course, is leveraging that analytical power to tell you something useful that improves the outcome of your patient and also improves the outcome of your uh technical performance. We have lots of start ups at the moment. You'll all be aware of proxim, maybe you aware of the chip or concentric similar technologies trying to do the same thing. Can we leverage video data to try and improve outcomes? This is a paper again, just, just to give you some evidence that actually these things are happening in real time. This is a Japanese group leveraging convoluted neural networks of video data to try and identify key structures during laparoscopic resection and it's pretty accurate and it works pretty well. They developed a net and they also developed a, a neurone for damaging for, for preventing nerve damage. And actually, it can identify the hypogastric nerves and the ureteric nerves in pretty good uh in pretty with pretty good accuracy and it highlights the ureter there, for example, with the green dot So you don't need fluoroscopy, you don't need any of that stuff. It will do it for you. Anyway, we have A I tools that will help us not just manage the individual technical performance of the surgeon, but the team. So an example of that would be A I coach. If you're performing complex surgical tasks outside of the operating theater, you need help such as A I medic and actually umbrella A I technologies that manage the entire workflow of an operating room. And there's a really good project called um smart or I've put the do I there. If you're interested, you can check it out. These are open source programs that you can subscribe to. We've been using touch surgery, which is one of the early er er medtronic um tools, of course, that was for helping teams plan their surgical procedures. And, and actually, Jasmine Winter be one of our phd students has been looking at how you can improve team performance using these technologies. These are not tomorrow, technologies, they're today's technologies, they're all here. But I just want to make one really key point with these technologies. Um Carl Lam, one of our phd S who's just writing up did this quite nice systematic review of machine learning technologies for surgical skill assessment and was looking at various various approaches for doing it. And the key thing is that most of these technologies in these algorithms are going to be built on your technical performance. So when you're in the or performing these procedures and you're being videoed and watched, actually, uh you are an incredibly valuable data source. And unless you have a good understanding of how those algorithms are being built, used and distributed and and your role in it, it's very difficult to really, really understand them. What we also see is that in machine learning and in A I applications in surgery, there's a sort of Piloti there's a plethora of very large number of small scale studies with 20 or 30 patients with proof of concept work and no real attempt to bring them together and to validate them at scale and to do that in a way that kind of benefits us more broadly. But you can also see in that graph there, there's just been a massive growth from 2001 to 2020. So training is obviously going to be transformed. We've known from JD Bear's work, you know, in the, in the um Michigan Bariatric cohort, we know from lap co that when you measure performance in training and you objectively stratify it and you give that feedback that actually improved performance. Well, the obvious um Next step is to automate that process and that's exactly what's happening. Again, this is Carl's work looking at um trying to develop um machine learning methodologies for assessing technical performance during actually, this is a bariatric procedure. This is a sleeve gastrectomy which you can see there. And again, you don't need to be a data scientist or to be to have any how an algorithm works to work out that there are differences between experts and trainees and how they use their hooks. The different, the difficulty here is that in how you um um begin to apply those algorithms, I think, and we'll talk about the ethical implications of that, but that is already happening at the scale. So to give you an example of that, this is CS A scats is an ethic on J and J software application. They're basically building a closed youtube for surgery and er that youtube um video uh is um not just it can be open or closed, but it's also subjected to autonomous analysis that measures your performance and gives you feedback on your performance based on an algorithm. But actually they combine that with subjective analysis. So surgeons in America watch your videos and, and say things like good job and great tissue handling um on your course, which is fun. Um So we tried that an imperial and this is what it looks like. Uh This is the little video that goes onto the stack every single video that you're doing every single case you're doing, you just press a button and it records, it goes to the cloud, it goes to the cloud enormously A I edits the video, it segments it, it annotates it, it analyses it and it presents it back to you. Um And this was what we do. We had a 44 week pilot study of all trainees. Uh And we were really excited about this. We thought this is gonna transform training, transform clinical practice and lo and behold, this is what happened. This is our usage data. Uh This is when we installed it and this is when we uninstalled it. Uh We have real problems with uh clinical trainees changing over having to re onboard them onto the system. Uh And only 16 of 30 potential users actually uploaded anything. So this is a free tool designed to improve training and only half of people used it. We only uploaded 57 videos which was usually disappointing. Why? Well, we've done some quality quantitative analysis to try and understand this and effectively what you're asking to people to do is to change their behavior and actually changing behavior is really, really difficult A I or no A I. Er and there are quite significant barriers to adopting A I technology such as this in your clinical practice. People are actually people don't like being videoed and they worry about it and they worry that actually there might be medical, legal implications of being video and they don't like their crap surgical performance being out there on the for the whole web to be able to see. So actually, you need to really drive these to, to really drive these technologies, a lot of engagement. There are resource challenges, both both infrastructure, financial and security challenges. But there are major major governance problems around how we really do this, how we really consent these um patients and surgeons for using this software. And I'm going to talk about that a little bit safety. Well, this is the obvious obvious use. Um We've been working the surgical metaverse for quite some time. We started um you know, running um online social events back in 2008 which we published actually in, in BMJ. Um And we've, we, we've elevated that into augmented reality. We now use, we had a number of different project running at the moment. This is a bit onco plastic for you. Sorry, this is a bit um trauma, trauma orthopedic for you. This is us using um CT Angio which we 3D reconstructed using hol lens and we're overlaying it onto the patient. So you can do image guided real time, image guided surgery to identify perforator vessels. We've been, we've been playing with the same technology in code, but we've also been building A I enhanced virtual patients. So what you can see on the right image there is an OSI with a completely virtual augmented reality patient. That's a I driven and we've assessed that for quality assurance and lo and behold, it works pretty well compared to a normal patient. Um But I conceptualize the surgical metaverse in a different way. So I don't think about it as a visual visual metaverse. I also think about it as a data metaverse. And you can think about the data metaverse as a patient, maybe the team data or maybe the operating theater environment data and there'll be lots of different data silos within those meta verses uh or multiverses depending on what you want to think. And, and the issue is what happens when there's an error. What happens when there's an error both in the delivery of the service for a patient and operation or an er in a data base? Well, it kind of sends out rings, doesn't it like a ripple on a pond? And so we thought, well, what if we could measure those rings? What if we could use A I to measure those latent signals in those ripple effects in, in safe as they, as they ripple out? And we thought about er maybe we could use those to create a Maestro like literally er an orchestra, er like like a Maestro conducts an orchestra to sit above it all. So we were funded by EP SLC to do that. And what we did was we created a cloud infrastructure that sits above the or R and sucks up lots of data streams, anything that produces data and or it comes up to our is o regulated cloud device. And then you can start to do artificial intelligence consistently and constantly. And then you don't need checklists because you're constantly monitoring the system without human biases without education. And this is what our simulator environment looked like. So we started to play with lots of different senses that might measure cognitive workload that might look about automating particular processes or driving sorry or driving particular um devices like endoscopy. And we publish that and I put the D in there. So you can, you can see that methodology and we've been working with AWS on how to scale that. What about autonomy? Are we really going to get towards completely autonomous colorectal surgery? Well, I don't know. Um but this is our autonomous robot. So this is an intuitive system and you can see there's an ultrasound for docile there. What you can see or not see is a chicken liver inside a port liver. Um And the robot knows where that is in three dimensional space, in its, in its to dissect it. And what it's doing actually is we're combining technologies here. This is a robot combined with something called the eye knife. So it's sensing the chemistry of the tissue as it dissects and then it's adjusting its dissection strategy based on real time feedback and the chemistry of those two different tissue types, there is no human driving that machine. Um You should also worry about that if you're an endoscopist. So we gastroenterologist should be more worried than us because autonomous gastro autonomous colonoscopy is definitely on the on the on the highway, on the road map. So this is work done by leads. This is a magnetically driven endoscopy system and you can see in the in the in the bar chart top right hand that semi autonomous navigation is, is pretty effective and certainly faster than a direct robot operation. So I don't, I think it's really hard to make autonomous systems much harder than driving an autonomous taxi, but that is definitely going to happen. So is a I really the end of the world for us? Does it mean that actually we're gonna be out of a job? Does it mean that we're gonna be creating harm? Well, I don't know, it's certainly interesting. Um a little bit of light reading for you. Er I don't know if you know who Shisha Zubov is, but I highly recommend her book to you. Um I also really recommend this book. I won't say the name. Uh uh And I also really recommend this book as well. All right. So if you're interested in A I and you're, you're interested in the misuse of data and the threat of it and how to create a more ethical framework for leveraging A I, then I really recommend it to you, we are um there are very significant ethical challenges around leveraging this technology. Uh And um we have no ethical or legal framework or precedent for using this within the operating room environment. And you're the first generation that's really going to have to deal with this. So actually, it's really up to you as to what we do next. And I think you're very, very important. We tried to create a framework for beginning to understand this and we published a defi exercise in nature of digital medicine last year where we felt that actually the first thing to do was to try and define digital surgery because A I is a technology that forms part of put a digital surgery framework and this was the, this was the definition that we came up with. So digital surgery is the use of technology for the enhancement of preoperative planning, surgical performance, therapeutic support or training to improve outcomes and reduce harm. And that is how I think A I is going to transform colorectal surgery. And A I is just a tool that we're going to use to be able to do that. And if you don't have good data sets and you don't have um uh robust uh processes, you will put rubbish in and you will get rubbish out and there are a number of barriers and a number of research priorities and that's all in the paper for you. So this is where we are in the summary, don't fall into the hype cycle A I is transformative, but it's not ready to make your surgical decisions yet. It's going to, but it won't replace you. It will augment you. All right. And that's the key. Um It's going to not just impact on every aspect of your patient's care, it's going to impact on every aspect of your training and that's going to be lifelong and it's going to transform how you measure surgical quality and surgical performance for the duration of your sorry, for the duration of your, I've not, I've really struggled with my, with my slides here. So forgive me, uh it's going to transform how you, how you are um assessed going forward and we have major ethical and technical challenges in place if we're really going to have safe equitable and precise A I in colorectal surgery. And I do worry deeply that we're heading towards a two tier system. There will be the digital surgeons, the digital centers that are engaged and there will be those that are not. If you're not, you will be um I'm afraid having a poorer experience than those who are connected and that requires that we're going to prevent that effective leadership. And therefore, I think there is a real role for the GS club to take the lead. You need a trainee voice. The trainees have got to be vocal and they've got to be leading this change. You cannot let companies come into your or, and, and, and, and um let you become dependent on training te for which you have no voice or control and you, you really need to change that. So I think you should be creating open data sets. You need a digital surgical policy, you need an A I policy and you should be at the table when these decisions are being made about the future of colorectal surgery. Um Lots of people to thank who did these slides? Thank you very much. I'm very happy to take any questions. Thank you. We got two questions. Thanks. Thank you, MS Kin Ross. Excellent talk. Um So really excellent points made. But my first question is CS A TS brilliant tool, touch surgery chip we've got outside, obviously proximate. So my question is, how do you foresee the wider implementation of the tools? So speaking from personal experience, we were going to get cats in. We were going to be the second trust after Imperial. Um And the reason we couldn't is because we didn't have the infrastructure to, to support IE we didn't have a high enough bandwidth sounds trivial, but we're ad GH and also the funding. So when the pricing came through from Ben Griffiths, it was something like 36 K for a few months. So how do you suggest that we go about funding for these tools? So, um I I think you, your question is incredibly pertinent and I think funding is just one barrier. So what I do know from some of my engagement with health education, England is that it's not just surgical education tools that are struggling to be implemented. It is, it's a number of different educational tools. So the answer to your question is is that you need, do you need a two prong strategy? You need a bottom up and you need a top down this, if this isn't driven by um effective leadership, who are saying, look, we're going to implement these in a scalable way, then it's going to fail. And a really good example, like we have to keep learning lessons in surgery, don't we? Like we failed in robotics with this and we're failing again with this technology. So there's no point in every hospital in the country adopting these technologies, we need a hub and spoke system which is properly led, properly implemented and where we create an evidence base for their implementation and it has to be bottom up driven by trainees, you say, look, hang on. If you're going to apply these things, I need to understand how this is going to impact in my assessment and in my training and what it means for me more practically day to day at the moment. We have neither of these things, you have ad hoc adoption of things like proxy, er, or er, you know, er, which are, which have got a lot of hype and very little data to support them. So that only works if you've got effective collaboration. And I do think our surgical societies need to be doing a lot more. I think they have failed us. To be honest. If I'm being really brutal about it, they just abdicated all responsibility for this. We get white paper reports that don't do anything and don't change practice. We need meaningful action. So I want open surgical databases. I want scalable data governance practices that I can apply from one hospital to another. I want central funding. I want digitally trained fellows. I want digital fellowships for clinical research fellows where they're taught what an algorithms, how it works, how to code in Python, the frailties and limitations of algorithms, data governance. We need surgical cio s, right? So it's about an entire changing culture and it's you need a top and you need a bottom up. And I wondered more broadly having read surveillance capitalism. I mean, the mo Oan, most of these multinational corporations that have a monopoly on compute power and the best uh technicians on the planet. How do you kind of square the sort of divergent aims of miles in the the typical way of doing things is they come with a shiny toy and we all all sign up for free and then slowly we're sure that they extract the data. How do we ensure that that data isn't used for uh purposes which you wouldn't necessarily want it I'm thinking, I, I can kind of see a scenario, for example. So in the US system whereby they're taking health data in order to start titrating um health insurance and the like, how do you, how do we say that? But also kind of utilize the expertise? Yeah. So, so that's just an amazingly good question and probably needs an hour to break your proper down. But I'll try and I'll tell you what I think roughly. So I talk to quite a lot of these companies. And what I say to them is that the company that's going to win this game is the one that has the most amount of trust, the trust, not just with um surgeons, but all stakeholders in the process. And actually a lot of big companies at the moment have behaved appallingly in surgery, right. I'm not going to name names because I'm being videoed, but there are a lot of surgical manufacturers that have been hoovering up data for a decade and lying about it. And that is not good enough. We've also had to learn lessons repeatedly with companies like Deepmind and Google Health who have just acquired data through various national scandals. And we don't seem to be on the lessons. So the way that you prevent that from happening, I think is by putting the um the horse before the cart got that the right way around. Yeah. And by creating um um a, a data governance and research and ethical frameworks that are fit for purpose and scalable. And that by, by having effective um surgical and clinical leadership that drives the process rather than industry driving the process. And I think we're on the back foot on that in surgery to be frank. Um And um I think that's the only way you can defend against it and the implications of not doing that are really concerning. So for example, you might worry at the moment that a manager comes down to your operating room and says, oh, I'm sorry, Mr Kyros, you're a bit low today, which they often do. Um But actually, when the machine is measuring every single aspect of your component of your performance, suddenly that becomes a much more challenging environment. They might say to you, Mr Kris, I'm afraid we don't like using that instrument today or that's too expensive or we're not going to, we're going to stop you doing this procedure or actually you're not capable of being a surgeon. Uh you know, or miss trainee, we're just going to stop you from being a surgeon actually. Now because we don't, the data says the algorithm says you're not going to do it. Maybe the algorithm says, actually, your surgical practice isn't really very good at the moment. And that links to your insurance on, I don't know other aspects in your life and your insurance premiums go up, I'm making this stuff up, but it's not, it seems implausible but it isn't. So. So I think these, these are really big ethical challenges that we as surgeons should be thinking about. The the operating room is a priceless gold mine of data. Everybody knows it. There's a brace on to try and harvest it. Thank you very much. Thank you. Good luck. Yeah. Yeah. Thank you so much for talking to us about training in the PC P. OK. Yes. OK. What, what have you handed me? God? Is it, is it cost in my data? I don't know. Um Oh A is it a microphone? Do I need it for the online screen? Ok. Thank you. And have I got a clicker and a microphone? Yes. OK. I might not look at this. I might look at uh this. Then I've got too many things, right? Can you hear me? So um thank you for the introduction. So I have been invited to speak because I am chair of the Education and Training committee of AC P GBI. And I've been asked to talk about colorectal trainees and their um their role there, how they fit into AC P GB I, they separate from the JUS club. So if you log on to the AC P GBI website, you'll see how you um become a member of AC P GBI. If you join, you become automatically a member of the Dukes Club. So it seems a no brainer that uh you join AC P GB, I as well as Dukes Club. And then if you look at the list, it gives you a whole load of uh uh of uh benefits from joining. Now, if you have a look at these very few of them will actually be perhaps relevant to you. So I'm going to go through uh over the next uh few minutes, I'll try and make it quick because I know it's been a long day for you. Uh Some of the, some of the um uh uh things that AC P can do to help support your train. So first of all, if you become a member, you'll get um a newsletter that's sent out biweekly. And this is a valuable resource. So this um includes a few of the, the things in yesterday's newsletter that was sent out which um if you're a member of AC P, uh you may have already have had a look at. So there's a huge amount of things that are going on within the association. So if you have a look at some of the things we've got um the Z A defi consensus outcome measurement set for uh crypto glandular anal fistula. If you want to get involved in that, there's a link to get involved in that. There's a, a research study that's going on. If you want to get involved in that you can uh do that. There's, there's various um events and um um um things that are happening up and down the country and there are loads of links in there and um lots of things that uh you might want to get involved in. So I'm going to talk about a few courses and things that AC P offer. Um Some of you may be aware of them already. Some of you may not be. Um I I'm putting a few QR codes in there if you want to take the details down um because these are quite valuable resources. So, first of all, the fundamentals of color pot course, now, some of you are on the practical component of this yesterday. So the fundamentals of color Pott course has been developed from the basic color pot course. It's been going for a for a number of years and it's been revamped over the last year to make it more relevant to trainees and what they, what they want from training. So it's aimed at more junior trainees. Perhaps they'll do a ST three ST four. And the idea is it gives you an overview of all the common colorectal conditions that you'll come across in clinics on call um in the operating theater on ward drowns. It's done in two parts. So there's a part one course, which is the theory which is done online. We had our first course in June and it's available free on demand uh via the med platform. And the part two practical workshop, the first course was delivered in June in Sheffield and the second course was delivered yesterday here. So this has all been designed by trainees for trainees. A lot of work has gone into this to give you what you need to, to perform well clinically and the feedback so far has been good. So here's some examples from presentations from the virtual course. Um You can see they're all, it's all very practically based. So, you know, the emergency session, how to do an E A. What do you need to do when you're on call, you know, on the ward round? How do you identify the patients with the anastomotic leak in theory? So how do you set the patient up in the operating theater? What should you be doing? Because these are things that often no one teaches you very well. What should you be doing in clinic? You know, something as simple as hemorrhoids. Everyone assumes that hemorrhoids are easy. Everyone knows about hemorrhoids. But actually when you're seeing hemorrhoids for the first time in clinic, you may not really know what you're looking at. So the um course that we delivered in June is available on demand. Um Now on meow. Um So if you want to have a look at that, it's a great resource. It's not just for colorectal trainees, it's basically any general surgical trainee on the on call rota will find this invaluable. Then we've got the practical workshop. So this has been again targeted at what trainees need. So we have various various things that are covered. So things like a staple on colic anastomosis, stapled colorectal anastomosis, hand sewn anastomoses and the more common things um and common things like stoma formation. Again, sometimes things that you just left to do as a trainee because it's easy, just bring out a stoma just close the abdomen. So we have a session on small bite closure as well. So the first two pictures that from the record in Sheffield in June and um the one the right is from yesterday and see a rest is enjoying himself there. So another course that we do um which is very popular um and as colorectal trainees, um I'd recommend that you all um register for this. So the vascular pathology course. So this is the AC P GBI S flagship course and it has been running in one form or another for over 30 years. So, prior to COVID, it was done in the traditional way, it was done like this in a hotel in Sheffield. Um and we had about 100 people come each year. Um And that was a, a combination of registrars and consultants generally and then COVID happened and the course couldn't happen. And so we have to think about how do we continue to deliver the calls? We didn't know what was going to happen with COVID, how, how long were the uh uh effects going to be? So, um we turned it into a virtual course. And what we didn't want is a standard of webinar because webinars are boring. Everyone. You know, webinars were exciting to begin with. But then they, they got a little bit boring and uh you know, we have to think how can we deliver a course? That's, that's a bit a bit different. So, um so we, we did, we used to um uh a company where they stream the um uh calls from a TV studio and it's done like a chat show essentially. And there's interaction from the delegates at home. And the thing about this is that it's also available on demand so you can watch it whenever and you run up to your exam. Um It's mapped the ICP curriculum and it's done on a three year um cycle so that we need to cover the majority of the curriculum over three years. And we cover not just colorectal but, but other things that are in the curriculum, emergency, general surgery, um perioperative care. And it's not just aimed at, at senior Train. It's, it's aimed at, at everyone and the virtual nature of it allows it to be more accessible than previously. So, uh in 2023 of course, this year, we had over 1000 registrations from uh uh around the world. So um uh um and the feedback has been excellent and we try and keep the course costs as low as possible. So it's a fine balance um between uh um uh um just about covering costs or, or making a loss. Everyone thinks the course of this kind of, it's online, it must be cheap to run. It's not, it's very expensive to uh to run, but we're able to keep the cost as low as possible. Only 50 lbs for Dus club members for the two day course. And that is um in no part thanks to who are um AC PGV I ST education partner. Um So this is what the course looks like if you join it live or if you go online now and have a look. Um, we've got a, a panel for, for each of the sessions, we've got a panel and a speaker, the topics are chosen, um to, to be interesting, to not be too niche. It's, um, again covering um, the important topics in the IC P curriculum and we choose speakers who we think are going to be good speakers. You know, we don't want people who are boring. We don't want people, you know, that you're going to sort of, you know, get distracted, go off and do your washing. Um, you know, we, we want, we want people to be engaged with this. We pick um, chairs and um, speakers who we think will be good in a, in a discussion because we want discussion at the end of the talks. And this course allows people who are sat at home to send in questions. So I don't know whether you can see the the chairs have got an ipad. So if you're at home, you can send in questions which are then push through to the to the chairs. You can, you can ask the the panel members. Now, obviously, we can get a lot of questions sent in and we don't necessarily get the opportunity for the panel to answer all of the questions. Um but we have a panel behind the scenes answering questions as well. Um It's very clinically focused. So, you know, these are, these are questions that are relevant to all of us. It's not, it's not your, your rare pathology. It's the the common stuff that you're dealing with on call in clinics. Um that can be just quite hard to manage. So what we found with this, the course in the current format is we've actually had a significant increase in consultants coming along for a for a general update. Um We have the opportunity to have online polls so you can sit at home and um um um answer poll questions. It's, it's quite reassuring if you get the right answer. Um And because you sat at home and it's all done anonymously. If you get it wrong, no one knows which is quite good. It's not like when you have to put your hand up um in a face to face setting. And we have a fantastic team behind the scenes who, who answer questions that can't necessarily be all asked to the, the um um to the chairs and the, the panel and they also put guidelines and links and things. So if you join real time, um you get a whole load of extra resources, it's all available online afterwards. Um Until the next course comes up, we don't leave it there indefinitely because things might um go out of date. Um Another part of the course which is great is the fiber workshop. So we start each morning with workshop. So we actually have people that volunteer to be vivos in front of everyone who turns up for the vir workshop sessions. Um They're very brave. These sessions aren't recorded um out of um respect for the people who are being volunteers who, who are volunteers. Um And these sessions are very good. So you get to see them being vivid as would happen in the exam and then they get feedback as well and then they go through the topics. So if you're coming up to the exam or even if you're not coming up to the exam, you get to see what common topics might be asked. Um Everyone who registers also gets an abstract book with which is another valuable resource. Um This has an abstract of every talk in the um in the course, including sort of key references um and important things for the exam and the feedback has been exceptional. So we're going to continue to run it in this format. So if you want to look at the course that happened in March this year, um uh there's a QR code for that and um say the date for the 2024 course, it is 20th and 21st of March. So another thing that um is really valuable for trainees and it is becoming more trainee focused now is the annual meetings. So annual meetings used to be um you just turned up, you listen to people present papers um and it could be a little bit dull and it was great for going out in the evenings and meeting up with your colleagues and things. Um but it wasn't necessarily focus on trainees whereas now there's a lot more focus um on trainees. So you get to present you, you research your all date, it's an update, but there are various other education and workshop opportunities that are available um to you and the networking opportunities at the annual meeting are, are really, are really important and not to be um overlooked. So it was in Manchester, er in July this year and at the bottom is um Celtic Manor, which is a, a fantastic resort apparently in Cardiff, which is where it's going to be held, er, held next year. So these are just two of the examples of the workshops that were held in um Manchester this year. So we had a clinical skills workshop. So um we had um techniques such Asan annu anal jane pouch cones, anastomosis being taught. Um And there was also an endoscopy um village. So people had the opportunity to go and learn some endoscopy skills. Um as well as the education opportunities we have for training. We also support fellowships. So AC P um support the Royal College of Surgeons of England Research Fellowship Scheme, we jointly credit colorectal fellowships. Um So if you go on to the Royal College of Surgeons website, you'll see which fellowships are on there, which are um jointly backed by AC P GBI and watch this space intuitive have given AC P GBI some funding for robotic um fellows. And so we will be shortly advertising for units to um um have um one or two of these fellows and we'll also be advertising for fellows. So, so watch this space, these will be new fellowships and these will be AC P GB Robotic Fellowships. Um Colorectal Disease is the um uh journal of the AC P GBI. It's owned by AC P GBI and I just want to draw attention to their youtube channel. Um So if you have a look, they've got a over 1000 videos on there. Um and these are all peer-reviewed videos before they go on there. So if you, you're doing a case on Monday and you've never done it before and you want to, and you want to be um you know, you don't really know the details about it and you want to, to get a good video, go on to the colorectal disease, um youtube channel. Um Interestingly when you look at the most popular at the top 27 videos are all proctology and benign um um proctology and pelvic floor. Um And coming in number 28 you've got a robotic DME. So it's interesting that everyone wants proctology and perhaps that's because we don't do it very often. It's, you know, perhaps we're not too sure what we uh you know what we're doing, how to do a good operation. But if you go on to the um youtube channel, there's some great videos on there. Yes. Um Can you get involved in AC P GBI? I absolutely. Um there's a huge amount of things that we have trainees involved in. So we have trainee representatives on, on pretty much all of the committees and subcommittees. So there's the education and training committee, Jordan's um trainee representative there. We've got research and audit abdominal wall subcommittee. You name it, all of, all of the committees will have a trainee representative. And so it's your, your chance of uh to get involved with things. There's also a consultant network. Um This is um this has been start, this was started a few years ago to support trainees as they went into consultant practice in the first few years of consultant practice. Um because that's a um difficult to sort of negotiate time in your um in your career as you're getting used to your, to your new role. Um And as a senior trainee, if you're ST eight, you can get involved with, with ECN. So I definitely suggest that you look out for that and get involved in that. It's been a fantastic initiative with a lot to be gained by the mentors and mentees. So, um just a uh a couple of things uh before I finish um social media, the AC P GB I has got various social media accounts that are run by the team. Um uh We've got a Twitter account that's, that's um good for sort of keeping up to date with the uh with various uh events that are coming up various um uh courses, webinars meetings. Um The AC P GB I Education Training Committee has a separate account. Again, these are things that are more educationally relevant. Um So if you follow by those two accounts, then you should come across a lot of opportunities. Um And as an example, we did the fundamentals of color pot course yesterday, we did the small bike closure with the South Locking Knott. Um There is a nice tweet with a nice video from July this year as an example of one of the things we, we um you'll be able to find on there. So um there's probably no time for questions. Uh Now, perhaps as everyone's trying to get through to finishing and dinner. So, um if there's anything pressing, I'll answer them or else I'll be around later. Thanks. While one in the spine we have, um, you, you can start it in the, um, the, the, uh, so before you leave, you just please make sure that you, uh, on the call, on your way out, please. I don't think, uh, we let all those I it on tonight. So I'm just gonna wait for my slides to come up while they're coming up. Thanks very much. Not quite sure why I was invited. Disasters from the Masters. Is that because I have loads of disasters? I'm afraid I left the master at home. Cos you've double booked his diary. Um, so I'm Jill Tierney. I'm a colorectal surgeon from Derby. Um If anybody wants to talk about robotics in the curriculum or sexual misconduct and surgery, can we talk about it after I've done my presentation? But very happy to take any questions about those two hot topics. Here we go. And so I thought I'd change it to a positive spin to be that disasters are an opportunity for learning. Um, I've got tons of slides. This is the graveyard shift. So I will counter anybody, any of my trainees who have been in theater with me know this is gonna be fast, we'll be fast. We may not have a I, we might not be that minimal access, but we're really fast. Um So disasters are an opportunity for learning. Do you have to do it for me then. Ok. Um, so first off, um, disasters are an opportunity and experience is simply the name. We give our mistakes. So we're all good at surgery, but it's much clever to be good at literature. So, who's on the top left? Oscar Wild? Brilliant. And on the bottom right. Is your one Iwvys. Anyway, mistakes are the portals of discovery. So, disasters come in many forms. This is gonna be quick. Um Disasters will be clinical and we'll have a few cases and I might sort out a way that's going to freak out the organizers for getting some interaction. But you'll also have wider professional disasters. When you're a consultant, you will be sued and we're supposed to expect at least once in a career to be reported to the GMC. What a terrible disaster. And the coroner will get to you at some stage to discuss things that have happened and litigation happens and then you may have personal disasters. We're all frail humans, there'll be illness, either yourself, your parents, your Children, marriages get very stressed by this job that we do. So, lots of learning in this talk. So I was asked to do stuff that would be useful for the Fr CS and I'm conscious of the audio visual set up. So I have somebody in the room who has recently been successful in the Fr CS Mr Phil Herro, who was going to come up to the where the Mike thing is. Otherwise I asked Charlotte all the questions. Now we've got another mic. OK. We have a mic coming to fill. So OK, you're going to stand on stage. Phil, no pressure. Just Yeah. So um Ovarian cancer patients. So these are some exam questions that we will cancel through some images. We will finish. We will not by six o'clock. It's 10 2, isn't it? 10 past right? 68 year old lady with stage three C ovarian cancer or CISplatin. What is stage three C? Ovarian cancer, Mister Howard. Honestly, I'm not that sure, but it sounds like she's probably got no more disease as, as I said, and it sounds pretty bad. Um Still on chemotherapy. Excellent. So advanced disease. So the actual definition of stage three C is up there. So both ovaries or tubes spread to organs outside the pelvis with deposits more than two centimeter in nodes. So you're absolutely right. Highly likely to have no retroperitoneal disease. Um It's a Sunday afternoon. It's that bit. You've done your own call. The end is in sight. You're planning the curry, you're gonna order for when you get home, you get called by oncology to say she's had a massive pr bleed. How are you going to manage that situation? So I would uh go to see the patient straight away and I would try to resuscitate the patient using an airway breathing and circulation focused approach. Make sure she's got a large wall on the access and, uh, check a hemody status and it sounds like she's going to need to activate the massive transfusion protocol. Ok. So, so far so good. What investigation you going to, what you've done on it? It's easy. Ok. So here is a picture from your CT Angio. The lighting's not fabulous. What can you see any sort of abnormal stuff? What was going on here? So, the left kidney looks a bit better. And then why'd you have a G I bleed? So it doesn't like there's any contrast in that scan either, but not yet. So there's something funny going on with this kidney and D 34 looks a bit weird and there's some gas here and then there's kind of lumpiness gas in the retroperitoneum around it. We said she had nodal disease. Cancer. Cancer is bad, isn't it? Eats into stuff anyway. Uh, next slide, we've got some contrast. So we've now got contrast in the aorta and contrast in the bowel. So that's why she's having a G I bleed and this is gas outside the bowel. So there's a connection, what would we call an abnormal communication between losses, fistula. So she has made, oh, it's great. But now the old lady can't see the pointer properly. So, the, um, she's made a fistula between her tumor mass, her right renal artery and D three. So she's having a torrential G I bleed caused by this malignancy. Um So here we have the um now interventional angiogram. What can you see on that? So, it's contrasting the aorta there. They've got an access catheter up there and is that there? Yeah. So she's got a little false aneurysm, a pseudoaneurysm of that. Right renal artery. How would you manage that? Hopefully, they, our end radio will be able to call that an Neli sounds great, doesn't it? So they put the catheter up, they deploy a little blocking stent. You can still see it there. That's it opened. It doesn't, doesn't show terribly well, but that's the self expanding tiny stent opened up to exclude the um false aneurysm and they do the post deployment angiogram and unfortunately, it still fills, what would you do? Now, I'll ask them to see if they can put a second stent in. Maybe they can coil it or they might have to embolize the entire renal artery and they embolize the entire thing. So there we go. Um, not as one candidate who is a bit more senior than you and you know, said, do a nephrectomy. So you're just going to do nice simple things in the exam. That makes sense. So, moving on, I hope, yeah, 59 year old male has a massive pr bleed heart rate. 100 and 20 a little bit hypotensive gcs down slightly, nothing significant in the past. How would you manage that? Uh So similarly, I do an airway breathing circulation effects a very large access massive transfusion protocol and he's got a shock index both than once he needs an urgent ct angiogram. Perfect. So he has a gastroscopy. His CT angio is done. Um this is his precontrast film maybe a little bit thick in the right eye. Yeah, so you can maybe it was a bit big. They they then contrast. Now this we can see just um let me go back on this one. There's no contrast in the aorta, a little bit of contrast in the bowel. So that's where he's bled. Then we have contrast in the aorta contrast in the bowel where it was. So that's not a new thing because that was there already. And what's that one? So it looks like it's fresh contrast and what's it in? But I'm not sure they brought it up and down. Yeah. So, absolutely. And it's OK in the exam to say this is very artificial. Ideally, I would see several slices. I would look this whole section. I would discuss it with my consultant, radiology colleague because you would so don't be forced into playing poker with the examiner. Um Again, the other way, no contrast. This one, we know contrast. And the reason we know contrast is because we can see the um inferior epigastric with contrast in and then the same thing, same place which radiology confidently told them was terminal ilium. So you got to this place and nobody could find anything. Oh, so what would you do? So it's good not to end up in that situation. What would you do if you got to the point where we're not really sure what's going on? So, stop and take, take stock and I think you do an all and take a Laos there. So that sounds like a good idea. You think you might be this small? That's, and that was what they were told. So yeah, there, but there are great guidelines for the management of G I bleeding A CP GBI badge guidelines. Lead author Richard Guy. Anybody doing the exam definitely read them. Um So next case 70 year old man, abdominal pain and breathlessness, tachycardic, normotensive, tachypneic little normal temperature. How are you going to manage that? Uh So currently he's quite stable. So I need a full history examination. We've done some blood testing to the blood gas and then I probably proceed to do a CT scan. I got a stethoscope. Oh, no. When you borrow your friend's stethoscope, you can't hear any breathing breath sounds or anything. He's a little bit hyper resonant in the left chest. 00 dear. Um chest x-ray. So you get a chest x-ray and what do you see on that chest x-ray. So I think so you could be convinced that's a pneumothorax, but I'm not sure. Is that very raised left any diaphragm? Yeah, lots of lots of benefits side have said pneumothorax. Well, I'm an idiot. Um, so you put a chest drain into pneumothorax. It kind of makes things worse, not better. Um, let's just anyway, we proceeded to a CT scan where we saw the gas was cause he had a VV, he had a diametric diaphragmatic even administration with a huge Volve colon underneath the diaphragm in the left chest space radiologically. And now it's got a chest drain in it. How would you manage that situation? So it as a trans start to get deep compression and they speak more volume. Exactly right. Another approach. Uh would a, I recommend the use of that because that's chat to your PT. Um So I think you make sure it's stable to start with. Um, we've got a CT scan and some antibiotics and then we need to see how fit is the patient because he's afraid of. He's had a sigmoid bul because he might not be at the theater, but he's probably going to be needing a laparotomy and repair of the whole of his sigmoid colon. Do you do a stoma? Depends on, on it. Ok. So yeah, lots of options. We'll pick a nice safe one. A little bit more. 35 year old man found her a round about motorbike, far away helmet on, visa ripped off. Not very well tubed and transferred. Um, these things, tachycardia, normotensive abrasions and this is his CT. How would you manage that? So I can see his spleen looks like it's, it's at least a grade or maybe, probably a shattered spleen actually with lots of fluid around the spleen and another slice. I think we're that. Oh, I know another slice. So I discussed it with the radiologist but I think if he's got his shot of spleen and there's a lot of hematoma around it, he's probably going to end up needing an UPO toy. But I want to be sla injury four gra him first because if he's hemody, if he's stable with like a grade three or red fourplay ration might actually conservative. Yeah, absolutely. Anyway, he went to the and they found 1500 mils of blood but also a massive hole in the greater of the stomach that wasn't recognized on CT. So I'd agree. I think if you've got a huge injury, it's great that we can conservative. Yada ya. If you, if you think end of the bed, you want to go to theater, go to theater because there might need to be something else, isn't there? I need to just acknowledge at this point, Mr JJ Riley from the Nottingham Trauma Center who gave me lots of slides um of images Sunday afternoon. You'll call to the medical ward to see a breathless 55 year old man with nausea. A CRP love a CRP, don't they? Of 200 white cell count of 22. How you can imagine that airway breathing circulation brought her antibiotics and a CT scan and did a CT cause we thought he might have pneumonia. What do you think? Has he got pneumonia? It actually looks like he wants it or lighter than pneumonia? It does, doesn't it? So you got that CT anyway, and the CT looked like that. I see his liver he has. Is that a good thing or a bad thing? The only bad thing. In fact, I can see Jennifer in the audience who has published on gas in the liver, which was supposed to be an unsurvivable thing. But increasingly we realized people survived. So what etiology could there be for gas in the liver and liver abscess? So it's portal pla yeah. So he could have my dead small bowel and that, I guess what we going going into his lain or he could have some kind of double liver abscess like you say. But I can't actually see it on obviously. Absolutely. Look fine. Gas gas around the liver does. Anyway, they throw his mix. They put a drain in, they got a bit of pus and he got better. Um 01 more. So I'm telling us two more 70 year old man altercation with his wife. Your wife. Learning point today is always right. That is the one lesson to take home from today. Anyway, he's not very well and he comes to a, how are you going to manage that? It's a very expensive kitchen life which she will regret having deployed in anger because the set will now no longer be completed. So AVC S um tra acid is less than three hours and then he needs to go to the theater. I think so. And he in the theater at theater, we found this massive hematoma around the second part of the Judy. And how are you going to manage that? You're in there? Now, you took him for April to me. So I would uh so it depends on how stable he is to start with. So he's all stable. He gets down to control packing and things. Um probably need to start exploring as it is to be penetrating injury going right through your du that's going to be the rep there. You going to do that, you're going to call it up a G I colleague. Yeah, I think so. Ok. Next one, we're nearly at the end of the cases. We're not the end of the talk. Sadly, 35 year old female, recent honeymoon comes back, tender left breast lump, went somewhere quite exotic for her honeymoon. How would you manage that? Uh So history examination, uh do some blood tests and examination if we do one. So it looks like that. Um It looks like a breast abscess, doesn't it? So if I could feel some blood and stuff, I'm going to pass a whiny little bit and see if I can Caspi some pus at the bedside. See if that helps give you some antibiotics and then we go to the breast surgeons. OK? And that's what happened. And your breast surgical colleague in the end cause it just kept coming back with the antibiotics never really went away. She went somewhere really, really exotic. Any thoughts from the audience? Lyme Lyme disease? It's not dissimilar TV, not TB. It's always TB. Um Anyway, it is a bot fly. So you shouldn't antibiotics don't work. Try not to squeeze it cause they release this histamine thing. And patients can have major anaphylaxis. You're supposed to suffocate them by putting Ky jelly Vaseline on the skin and surgically excise them. And there is a video clip of this where it wriggles and the scrub screams, but I can work out to get it on my very old laptop, Jordan. Um So that you may now step down. Thank you so much. Um Unsurprisingly, Mr Howard has passed his F CS recently. So POSTOP disasters require early recognition and rescue. Um So you've got to have, I took part in one of Nicola's a two, the Nicholas AC C courses and one of Laura Hancocks. And they are utterly brilliant. I have to say, and there's quite a prestige to being asked to talk on them. So the talks are all is well prepared. So these are some slides that I have got in mind. If something happens, you've got to ask how something happened, what has happened, why did it happen and how can I make this better? And it's important because we record the deaths we have from our elective and emergency practices. And when you're a consultant, you'll suddenly become really hyper into that because suddenly you're there published nationally. Um It all appears in our, our cancer audit length of stay is impacted by complication and return unplanned readmission. Oh, dear. It's like watching your granny, isn't it? Right? So, rescue from complication involves prevention, recognition and intervention. Our pre op processes should have protocols. I love a CPET. CPET is my best friend. If you see somebody in the clinic that you know, isn't going to be a good candidate for theater, but the family and the patient and everybody doesn't believe you, you can show them some number and they can tell you how they felt on the bicycle when they were peddling their work. So I think C PT is super valuable and now we are becoming more intelligent as surgeons. We realize we should assess royalty and nutrition and all those things. So in your practice, be sure and do all of those things and remember the decision to operate is a shared decision. It's not just yours anymore. I don't think anybody in this room would think that share decision making. There are some non modifiable risk factors. Sometimes you're faced with a patient who, you know, isn't going to have a straightforward operation, but there are plenty of modifiable risk factors and modern surgery is all about identifying those and changing those in advance of surgery. Our techniques will have an implication and we should make bespoke plans for each patient. You shouldn't just always do the same thing because that would not involve engaging your brain and you should try to recognize things early and that's by having similar teams around. Not a luxury. We have these days working according to protocols and having rapid response systems. Looking at the news score, I think the news score was rubbish. Increasingly. I realize it does tell you something isn't quite right. So you ought to pay a bit of attention to it. Use that mantra has something happened. What has happened? Why did it happen? And that's for people who, when they're not quite right, new score is up their blood, especially their CRP is just a bit higher than you'd like. Um, don't forget to examine the patient. It's a really helpful thing to do. Sometimes I think we all forget that on the wardrobe cause it is so busy logging into the computer. Um, medical things can happen. So if you're not really sure what it is, it's going to be a heart attack or a pulmonary embolism, isn't it? Because we're usually dead good at the abdominal stuff. Um, surgical complications. Those are the four commonest that we see in our practice. Surgical site infections leaks, bleeding and IIS and I'll just skip through these because we should all know these off by heart, the signs of a leak. It's easy when it's peritonitis, isn't it? It's when it's that more subtle, not quite rightness. Um, what to do, Jim Tinnon gives a great talk, which I think is on the AC C database. Um, and is you could Google it anyway. He's done it so many times. It's a great talk about anastomotic league interventions, whether to go for broke and take the whole thing apart or whether to watch like a hawk and do something less invasive surgical site infection. Look at the wound, take the dressing off and let some clips out easy interventions to make things better and speak to the microbiologists, they know their stuff. And then IES, there's a great paper I have to put it up because it's got your ex president Charles Maxwell Armstrong as one of the authors. So it's a very valuable piece of work on postoperative ie um because was sounding really insincere bleeding. Um More patients on cleverer drugs that we don't know the names of that have no easy reversal. Um And everybody is anticoagulated for a touch of af these days, aren't there? So, be aware of that, that's my favorite left upper quadrant organ, the spleen. Just, just be really honest with yourself at the procedure. If you think you've given it a little bit of a knock, be really sure that it's not bleeding before you finish the operation. So the mantra has something happened what's happened? Why did it happen? And how can I make it better? This is another case. We'll just rush through this. It's not for asking. So this man came in with APR bleed. Um, he was tacky and a little bit shocked. And so he had a plain film scana gram, didn't really show anything. And then he had a CT which sort of looked unexciting and again, unexciting, slightly dilated colon. So we thought he got a bit of diverticulitis until our clever radiology consultant, um, showed us that when you put something on these windows, you can often see a foreign body that's made of material that doesn't show up on a plain CT. So this was inadvertently a large object he'd inserted into his rectum and it had begun to perforate at the top. It's, um, that thing there. So, um, gastrointestinal foreign body ingestion and insertion is a very common, um, event in colorectal and emergency. General surgical practice. Lots of literature about it. Children tend to eat things and adults tend to insert them. These little toy soldiers are a nightmare. These are the, I mean, people in this room must have removed lots of, of things from people's bottoms. These are a few of the things that I have removed, not the actual ones, pictures of over the years. Um And so we're on to the next, the last bit. That's all right. We're on to the human factors bit. So I think surgery, cataract surgery, surgery in general. If you do what you love, you will love what you do. And so I'm president of the Association of Surgeons. I'm head of school of surgery, but I am a relentless optimist and an incurable, romantic and surgery is a lifelong love affair. And I think especially in weeks, like this one we've all had this week, it is important to remember that. So like any love affair, your career in surgery will go from captivation to contentment. You have that phase of in initial attraction, then you become infatuated, then you make a commitment, you have Children and parenthood and then you go through a phase of disillusionment and disappointment emerging. We hope for everybody in this room into mature love and contentment. So just to prove that I apologize for anybody who was in Oxford when I gave this talk last year, I think um these are the numbers from Oriel June 22 pretty much 100% fill rate. So no matter what you hear anybody saying about, nobody wants to do surgery anymore, it's not true. The figures would go against that. Um We get infatuated. We love a club, don't we? So we all get badges and we join societies and we pay our membership and we're all in the same gang. It's like a human thing we commit and this little worrying, tiny little pink bit is self and that, that's like a life in surgery. Really, that's training and it's being a consultant. Um We do operating but we do all these other things. We pay our I SCP fe we join colleges and specialty associations. It is a huge commitment. Um Along the way we have this Dunning Kruger effect. I love this because it's really true. So you have that bit where you know, nothing and you can't do anything and then you think you are the absolute dogs and you can do everything and that is the peak of Mount stupid just before you have a terrible disaster. And you enter the valley of despair and you realize your frailty and humanity and slowly climb up scope of enlightenment to be on the plateau of sustainability where you will need to be for a long career in the NHS before you can claim your pensions and you people will be about 75 before you can claim your pensions. And it's a phase of Children and parenthood. And I think we're lo better at acknowledging that professionally nowadays, I haven't been to a conference where there isn't a parent and the child room. Um College of Surgeons is all over it for, for many reasons. And there are lots of organizations publish about it. So it's not the thing we don't talk about anymore, which is good. Um So somebody said hee earlier, now we're called NHS WTE just more initials to keep up with. But it does support flexibility because they put loads of money into training people. So they don't want people to leave in order to, to have a life. So very keen to support people having any sort of flexibility that you want out of program pauses out of program career breaks less than full time just because you want to, without having to give a particular reason though. Do remember less than full time is less than full salary as well. It's not pro rata, but it's still less money, which is important at some stages in your life though, there is this disillusionment and disappointment. So COVID that wasn't great for surgical training, was it? I think we'll skim over that numbers in log books. Everybody's seen this graph, everybody's numbers got a big hit and the numbers still haven't caught up because the waiting list still hasn't caught up. So you have all done less than you would have done. Normally at this stage in your careers, training extensions are very common. Loads of people are having, you know, if you're not getting access to the thing you need to do with a craft specialty, to learn to do it. Of course, you're going to need longer impact on patients. These extensions mean people aren't becoming consultants, which means people aren't running clinics and doing listen things. So it has an impact nationally in addition to the waiting list backlog. So, Doom Gloom, I wrote these slides before last week. I think we're all aware of it. As I said, we'll talk about it over dinner, but it's a reality. So bad stuff happens in our profession and in lots of other professions. But we want to reach this phase of mature love and contentment, which I think we will because there is a will out there to be better. I hope that all the statements and missives and panicked phone calls from various learned elderly people and societies last week shows that people do take these things seriously. GMC very strongly anti-bullying health education England too and all the specialty association and training associations. I think that ancient anesthetist that wrote that letter was hilarious and brilliant because it made everybody realize how wrong that is and yet people still say that and think it's ok to say it. So it was wonderful. Um Don't worry about not getting trained. This is a health economic analysis which shows that a quick fix for waiting lists is not training, but that results in long time disaster and a problem for waiting lists. So they know that they need to keep training people. Otherwise waiting lists will simply build up again on the rebound worse. So you will be trained. These are some people that inspire me. Farrah Roslin was a med student in Nottingham and did all the stuff about surgical hijabs and took it all over the world and you know, just amazing. These are the two presents and vice president of the Irish College, Laura and Debbie who are fantastic women. And then the College of Surgeons Kennedy Report and Victoria is in the room. So I probably won't say any more about that. And she'll tell you all about it over dinner. Um, surgery. We do great stuff, don't we? That A I talk was fabulous. So, we have on the left here, Mike Nicholson transplant surgeon. You don't need to be as related as you needed to be match wise for organ donation now, they can modify it. That's fantastic. Um Tom Seth here taking out the entire gastrointestinal tract and transplanting it for pseudomyxoma. Just wonderful um fluorescent technology capsule technology. You're in an amazing specialty. There couldn't be anything more exciting. Um I, I'm completely ignorant what he said. Um Kin Ross, all this stuff is just great. I think appropriately cynical is right as well. Um But it's a great time. So I would end saying be kind whenever possible. That is the secret to success and it is always possible. And then a couple of shameless plugs is the um A S GB I emergency surgery day in Glasgow and it's our conference in Belfast next year. I look forward to seeing. Thank you very much and P check, I say she's had 67. Yeah. Uh I, oh