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Now, can you hear us? Do maybe pan on it might connect to because you know others. Ok. Ok. Someone said yes. Yeah. So which, which one is it going through? Hello? Can you hear us? Ok. Ok. Right. So they can hear us? Ok. Um, so unfortunately, um, so before anything, good evening everyone. Um, I'm Daniel, I'm the current president for Aberdeen, um Neurological and Neurosurgical Society. Um, and just want to apologize in advance for the delay. We just had a bit of an issue with connecting to the um, system and the computer because we're doing this with the lecture theater. Um, and this is a bit different from what we used to with the computer. Um, so thank you very much for everyone who's attending online. Um, we're doing this as a hybrid session. So essentially, um, we have um, attendees that are in person in the lecture theater and also uh people who are joining us online um through Medal. So, um um, yeah, just, just without further ado, um, thank you very much for joining and I'd like you to, unfortunately, we can't put the camera on, but I would like you to introduce you to Mr Prs Bat. So he is the, he is a consultant neurosurgeon um in Aberdeen Royal Infirmary. And um yeah, so he's our clinical lead for the Aberdeen Neuros Society. He's part of different um international National Societies at the neurosurgical level. And it is a big pleasure for us to have him tonight. Give some, give part of his time to show us what neurosurgery is like. So um I'll let Mr Bat take over and um thank you. Good evening, ladies and gentlemen, since you are not able to see me, I can confirm that I look exactly the same as I was earlier. One of the things that happened to me when I came to this country 35 years ago, roughly my boss then told me that there's no point because I was already a qualified neurosurgeon from India. Are you able to hear me if you are able to hear me? And if the voice quality is good, say yes in the chat box? Ok, thank you. So the boss said that there is no point in only being good at operating which I was of course, because I was already qualified. He said you need to be all rounded and I took it literally. So those who are able to see me in person will agree that I look all rounded. The title here says neurosurgery, what's it all about? But basically, it is the same talk that I have given previous years. So you want to be neurosurgeon and I'm going to give what I feel you need to know, but you are free to ask questions during or after. I always believe in those who know me would vouch that education does not to be heavy and boring. And tonight also, you all have sacrificed your better plans to attend this 45 minutes or so. So I want to make it as interesting. Some of you might have seen this picture and of course, you all know this person. Some of you may be knowing this person also. Now, I don't know whether you can write who this person is, but I will also ask the audience here. Does anybody know who this person is? Yes, cussing father of neurosurgery. And the second one, anyone want to write in the chat box, who that second person I have just shown I haven't had work with them and I must be maybe third or fourth generation from the people who have worked with these two giants. Anybody here want to say who the second person is? Walter Dandy. Thank you. They were both in job and Hopkins, they both had a very different personality, little bit different approach to problems and different outcomes as well. But whatever we are doing in today's age in neurosurgery is largely thanks to these two people. And I wanted to put my own two bosses for somebody who trained me in India and uh passed away almost 10 years ago and very active till early eighties. And the current boss who trained me in UK is 75 plus and still full time working 12 hours a day, possibly a little more than me. So I sell them. I pay my respect to them. And I go to the main presentation when I have tried to get in touch with other neurosurgeons to see what made them interested in neurosurgery. These are some of the quotes that they have said neurosurgery. When I started neurosurgery training almost 40 years ago, it was relatively new specialty. It was in infancy. And uh I personally feel even today that the greatest pleasure comes from clinical medicine. How to diagnose, how to unravel the mystery as one of my colleagues used to say, and then of course, operating with the modern gadgets has become more enjoyable. What I'm going to cover is what is neurosurgery? Why to do neurosurgery? And how and when I started training again, we used to be called brain surgeons and it looks very sexy to say so, but neurosurgery is not just brain surgery, it has spinal cord, it has got peripheral nerves and what most of the others don't realize and those who want to embark on this specialty should realize now is that we do not have a planned life. I'm on call and I've actually got because mobiles don't work here. I've got the uh work phone here as well. So our practice is 60 to 65% non elective. Can I just check whether you are able to see the slides? I know you are not able to see me, but that's not a big loss. Ok, thank you. So, the most important thing to remember is that 60 to 65% is non elective and uh, therefore our life is not very planned. Of course, we have on call and off call system and uh we, when we are off call or we are not on duty, we can have other things. But when we are on duty, for example, I am on duty today. I don't know what will happen till morning tomorrow. I have an operating list tomorrow. It may change what I have planned, may not happen. What I have not planned might have to be done. So that's all the important thing. Now, this is a newspaper cutting from previous P and J which is a local newspaper. And if you have gone through the Aberdeen airport and when you are coming in, you would have seen lots of advertisement and information about Aberdeen. And one of that is the P NJ is the oldest newspaper and this was one of my first patients. When I came here in 2008, you can see plain x rays lateral and ap, in fact, it is called AP towns view. And you can see a metal object. Do you know what this is. Yes, butter knife more importantly. Now you may wonder how the hell a blunt butter knife can pierce the skull. And therefore you need to know the anatomy that when I show you the next picture, this is a patient brought in an accident in the emergency. It was a weekend and somewhere in late morning, 10 to 11, somewhere in between, you can see the butter knife is stuck through the medial, near medial cancers and the bridge of the nose where there are thin bones and in the skull base also there is a crib from plate and various thin parts of the bone through which it was driven into the skull. Again, you see the plain x rays and you can see on the right side of the screen, in fact, on the left side of the screen, as I see it is right, but you may see it on the left side of the screen, it looks a little twisted because the x-ray is twisted, but it's basically the same knife. And you can see how deep it has gone. Now, I can tell you without navigation that we are all used to. No neurosurgeon will be able to achieve this, what this uh fellow, the person who pushed the knife. What I was given the story at that time that this was a Polish young man who in the morning had some differences with another person on the breakfast table and that was achieved. There's a lot of fun later on. Recently, one of the managers told me because he knew this case because it was very well known. In those days. You must be in some sort of secondary school then or even primary school. It seems that he did not pay in the morning, the prostitute, whatever he owed to the prostitute and that led to the fight. But these are the ct scan images and you can see metal artifact in the central one and in the first one, you are able to see little speck of blood. Now, the knee jerk creation might be for those who are in experiencing accident and emergency to remove the knife. But because they had called me, I stopped them doing that. And what I did was got a CT angiogram done. Instead, this is CT angiogram again because of the metal artifact, you are not able to see it well, but I don't know whether you are able to see my cursor, but these are the middle re vessels on the opposite side and the same middle central vessels will be running here. And it is very likely that this uh knife might have breached one of the walls and might be causing tampon. So patient was not bleeding to death. And if you had to remove it, he may bleed to death. And that was the only important contribution as a neurosurgeon I did rather than any trauma surgeon would have done it was removed successfully. This is a POSTOP scan. You can see a little bit of blood now better without many metal artifact and patient actually recovered very well. So that's a very simple example. Very rare though penetrating head injuries are rare. Such a butter knife injury is first time in my life and many people I spoke to have not had seen this, they have seen other things but not this one. So these are not very common, but they are not technically very challenging. But what is next time showing is images of a 43 year old man. I looked after when I was in New Zealand for a year on a sabbatical which is almost 78 years ago. And you can see the neurologist had done lots of investigations with a simple MRI scan T two weighted images with fancy MRI scan showing the abnormal tuft of blood vessels. Then a formal angiogram with a very tiny blood vessel and early trending vein here you can see. So this is arterial phase and this is capillary phase, but you are seeing early draining vein with an AVM here. And this is a 3d angiogram, the same thing you are seeing and this operative photograph of the same you can see same loop is seen here, which is seen here and the abnormal blood vessels stuff is seen here and here and he was successfully operated. And what modern medicine allows us to do is an intraoperative uh ICG which is indocyanine green. This is a dye uh fluorescence dye. We inject anesthetic injects to the uh artery and it goes through the circulation, sorry vein. And we can see that here. And then we did this. Uh this is a surgical microsurgical picture. You can see the AVM is taken out now and we confirmed it on repeat angiogram. You can see a little metal artifact here which is a small silver clip we apply. This was very good. And again, this is a s Cushing's uh invention, silver clips were known by Cushing's clips. So this is a on the other hand, from the previous case, I saw completely different and much technically challenging and enjoyable operation. So this is the whole spectrum. Why, so why choose neurosurgery? This used to be a prior in our junior doctor's office because what matters most is how you see yourself, what you want to be tomorrow. When you look in the mirror, the advantages are it is in forefront of medical and surgical advances, I would say of all the cousins like cardiology and cardio surgery, nephrology, and urology. I would say neurology and neurosurgery are the closest cousins. I would say almost uh conjoined twins or CS or whatever you want to call. In fact, when I trained, we used to be called surgical neurologist or a neurologist who could operate or neurological surgeon as they say in Britain. So you need to know lots of medicine. And uh as I said, it was young man. So we had lots of uh advances both in diagnostic and uh technical and they are still, I mean, today's neurosurgical theater is like a modern artificial intelligence, uh set of sort of things, we have opportunity to improve the quality of patients life. Of course, everybody has. But some of the simple things like hydrocephalus or chronic sub hematoma or lumbar disc or even carpal tunnel can make so much of a difference. We have variety of patients and v diseases. There are diagnostic challenges and I once again cannot emphasize enough that uh clinical medicine is still interesting. Um We have a run through training nowadays for last 1520 years, we have now in Britain embarked on run through training. We were one of the first specialties to embark on, run through training. That means once you are in, if you don't create any trouble at the end of eight years, under normal circumstances, you will get consultant job. This is no more the case and I will dwell with later on which is a sorry state of affair. The gadgets I was mentioning one of the greatest invention and uh unfortunately, neurosurgeons were not the first one to engage in its use. They were ent surgeons but one living legend who is in nineties called Gazi Yaar, who is a Turkish neurosurgeon who practiced most of his life in Zurich Switzerland after retirement, possibly at my age, he was invited to us and worked for 1220 years there up to 85 and then returned to Turkey, his own place, Istanbul. And in uh pa practice for another 10 years and only when he was in nineties, he's still active. He still engages with teaching, regularly attends the medical establishments and he still worshiped as a living legend. He was in 1999 also awarded the title of uh neurosurgeon of the millennium. The previous recipient was Harvey Cushing and the current one is he he. So he was the first one in the late sixties to embark on use of microscope. And by and large, I would say then onwards and at least all current generation neurosurgeons from my time onwards have been trained extensively in use of surgical microscope during most of the operations. This is another piece of equipment which is a very fancy succin machine. It has got uh pi electric crystal which uh vibrates fragments, the tumor tissue can irrigate and suck away. In theory, it differentiates between important neurovascular structures and abnormal tumor. And therefore, when we are taking it out, it saves the neurovascular tissues and takes away the abnormal tumor tissue. So this is a very interesting invention. We have a newer version called Son. I have no particular interest. This is another thing in I would say in the last 1520 years, we have embarked upon using navigation which is very useful because it allows us to be minimally invasive do focused approaches to most of the pathologies. Very small craniotomies in my time, we used to do big craniotomies. There are still occasions where we do big craniotomies. But nowadays, we are very focused and very pinpoint small craniotomies and smaller incisions and good outcome. So navigation has become in thing, I do not think any neurosurgeons in developed world would be doing intracranial procedures without navigation. There is a uh also a group of people who would also do simple procedures like shunt insertion under navigation. And there are various types of navigation. I won't bore you with that one. The disadvantages on the other hand are owners on call duties, which sometimes during your training, you will be a resident on call. The units are also far apart. So I mean, the the people my current trainee uh rotates between Edinburgh and Aberdeen and of course, like similarly Glasgow and Dundee, but that's the list in Birmingham rotation, people are in Birmingham in stroke content and in Coventry and you may have to do that sort of job. And of course, neurosurgery won't be there in Orkney or Inverness. So those who want to have remote practice will be not uh likely to enjoy this. Uh There is a constant patient load and pressure on beds which is unique to UK rather than many other things. But uh the fact remains that uh we have a lot of non uh scheduled work. No, before my generation, even my teachers had a struggle to establish neurosurgery as a specialty because let's say head injuries, general surgeons used to manage head injuries. And even now, uh general surgeons in Shetland and Orkney and of course, in Inverness occasionally manage uh head injuries. So it was a challenge then. But during my time and now of course, most of the neurosurgeons have chosen one of the subspecialisation as I am mentioning here, the first one was actually pediatric neurosurgery. Then spine surgery became very specialized and of course, uh skull base and vascular are almost uh linked together. Currently, there is a very big drive for neuro oncology, especially with awake craniotomy and other facilities that we embark on and the functional and stereotactic neurosurgery. In fact, there is a very big group of what we would call neuromodulation or epilepsy surgery, which is part of functional surgery and then peripheral nerve surgery. And in peripheral nerve surgery. Also, people have made carrier, especially racial bra injury, which used to be New Man's land and there are very rewarding results. Uh in Britain, I think there are only one or two centers, one in Glasgow and one in Stanmore in London, who are specializing in peripheral no surgery. But there is a market for that as well. You must have seen these sort of photos in books, if not in person, this young baby with a massive head and you can see and gosu vessels typical of hydrocephalus. These other young boy with uh you can see the swelling on the left side of his temple. And uh on the CT scan, you are able to see a hypodense lesion, which is basically an e electroid cyst as it has happened during the developmental phase. There is a Boeing of the temporal lobe which coincide with the swelling on the temple. Uh These conditions need treating coming back to the spine in pediatric, this is known as lipomyelomeningocele. So there is a dural defect or spinal defect which we call spina bifida, occulta uh or APERTA here with you can see a skin tag or a dimple and it presents in all varieties. Uh It's not an easy surgical proposition. Spinal surgery, as I was mentioning, we do come across lots of degenerative spine conditions both in cervical and lumbar. Sometimes there is an interesting tumor as you can see behind the C two and C three cervical vertebrae which has pushed the spinal cord back. Patient presented with quadriparesis. And this is a surgical photograph. You can see the spinal cord. This is through the microscope. You can see the cervical nerve roots. There is a meningoma peeping behind and we tried to do it minimally invasive. The black stitches are on the stitches on the dura and patient. This is a POSTOP scan. You can see these are surgical defect at the back, but the tumor has gone. The cord has come back to its normal position and patient recovered clinically. Skull base surgery has some clout and possible technical challenges. Acoustic neuroma or vesti or SOMA, as it should be known. It's one of the most challenging and interesting aspect, but the science has moved on now and they present with uh tinnitus or hearing loss to anti surgeons first when they are small, they can be either observed or treated by stereotactic radiosurgery, which is another fascinating field. Yeah. Does anybody know who was the father of stereotactic radiosurgery? Professor Lars Lakel in Karolinska Institute in Sweden was the one who thought about this in fifties and uh first was installed there and the second in the world was installed in Sheffield where I had the pleasure of working for six years before I came to Aberdeen. Also, Lars L cell is known for one of the course he has given most of the neurosurgeon in the modern world are after gadgets. What he gave the dictum was that fool with a tool is still a fool. So of course, you need gadgets but you need this gadget. I am pointing to the brain more than any other gadget vascular neurosurgery. We are talking about aneurysm. This is a basilar top aneurysm when I was training, this was the epitome of surgical orgasm. A surgeon who can clip the basilar tip was considered the best with the modern endovascular procedures. It is no more required to be operated and it is the outcome has changed. And uh it seems that we were all wrong in doing all this what we did for number of years. But technically, it was very pleasing. And uh one of our colleagues in Edinburgh says that ao clipping is slightly more sexy than or orgasmic than sex. Um Nowadays, we don't do catheter angiograms, this sort of sub hemorrhage presentation CT angiogram. You can see we can do the 3D reconstruction, you can see the middle cerebral artery aneurysm there. We can also do the 3D reconstruction and you can see this very well. Fortunately, we don't have to operate any of these. Nowadays, most of them are treated endovascularly but having said that the other condition AVM I just operated 10 days ago, week on Friday. Um an AVM which had ruptured in the left temporal lobe and patient is doing well going back to tomorrow. So these are the advantages of vascular neurosurgery. I would still say despite of advances in endovascular procedures, there is still need and it will always remain so for a vascular neurosurgery, but it is rare. And in Britain, there are very few neurosurgeons currently able to look after vascular pathologist, neuro oncology. This was a young lady with ac a brace and metastasis and this is uh eyebrow. You can see the eye and the brow here and through a linear incision, supraorbital minio. This is a POSTOP picture. You can see it healed well, this was immediately within a week. So that's why you still see some healing process. So a small approach and this is what one of my colleagues is currently specializing in. This is one of the advances in MRI imaging technology. This uh fiber tracks as you can see the blue one is spot uh corticospinal tract cor the radiator internal capsule and going to the brain stem so clean your chordal direction. This is the white metal bundle fibers which are called association fibers in the same sphere. And the uh this uh purple one are one with crosses like in corpus callosum and other. So we can now see how they displace the tumor and we can protect these another advances in MRI scan, which is called spectroscopy. So this is normal, there are various metabolites which by putting a pixel there, we can estimate. And in abnormal tumor, you can see these are low here and this one is a little high. So I won't bore you with that, but you can look at what your metabolites. And it is called Mr spectroscopy by which we can predict the type of tumor, whether it is benign malignant, highly malignant. And in my opinion, by the time you reach this stage, you will not need to operate so many patients because you will be able to see most of the histopathology or grading by just chemical analysis. This was a 43 year old lady. Very funny story from uh uh New Zealand again when I was there, she was a radio RG, radio joy she presented with seizure and you can see abnormality in the frontal lobe. This was treated, of course, we had uh then all the necessary investigations. This is Mr spectroscopy. This is the diffuse tensor imaging. We didn't do the fancy color, but we can see all the carpus colors and fibers which are going from right to left are displaced. So it's not infiltrating, which was helpful. This is colorful one, of course, the same thing. And then we report it. Nowadays, we go such a detailed classification. Mostly during my training, we largely relied on histopathology and later on, we started analyzing their molecular biology. The who classification has changed twice in last 10 years. The the revision first came in 2017 and the latest revision is in 2021 which has changed our understanding. And because of that, we analyzed something, all these sort of metabolites I DH one mutant P 53 positive. All this is very helpful in prognosticating and titr the treatment to individual needs because uh chemotherapy or radiotherapy or which chemotherapy can be. Now, I'm going to give you little time. You don't have to read every single word, but I will give you 30 seconds for each of these two slides to read. This is borrowed from patients own questions and uh with patient's permission who is actually no more in the world. But this was a high performing uh I think lawyer or solid hitter who had all these questions. There are two slides and all these were his questions. Sorry, I have a runny nose. So some of you might be able to hear. Only five people are fortunate to see my stiffing. So, so many questions and these days people come so well, research Google and whatnot. Half of that is good. Half of that is not good, but we still have to deal with both the good and not so good. And I think it is fair to say that patients should be well informed. And to be very honest, my most important message to my junior colleagues and trainees is communication. If you communicate well with the patients about what you are going to do, how you are going to do and what can happen good or bad as a result. And throughout the procedure, I mean, POSTOP period, then no matter what the outcome is, we always hope for well. But even if it doesn't happen, you don't end up in complaints, functional and stereotactic neurosurgery. This is a, this is a L cell frame. The same last L cell who uh invented the stereotactic radiosurgery. Also produced the first frame and the pri principle of physics that if you have three coordinates in XY and Z axes, then you can the center of this arc will be always the same point. And therefore, by localizing a target in the center of the brain by minimal needle approach. In deep treated and small lesions, you can achieve that biopsy. This is how we put the frame. Not of course, using this BN Q uh drill, we have different drills there. Navigation, I already mentioned peripheral nerve surgery, carpal tunnel. I would say of all the operations we do after tracheostomy. This is the most rewarding operation with least morbidity. 95% success, not 100% but half an hour job patients on the same night sleep well, without any tingling and numbness. So something worth considering if I do a vegetable Sonoma, which takes me 12 to 18 hours and patients left with still hearing deficit, possible facial palsy, but I do 10 carpal tunnel and give good quality of life to 10 people. So there's a mixed balance, there is still a cloud that it is brain surgery. It is intellectually stimulating. There is a lot of medicine. Of course, there are technical challenges. There is daily drama, of course, variety of conditions and the most important thing what I enjoy is that most of the patients I feel with appendix or cataract will forget who their surgeon was. But once you operated someone's brain or very important spine, they would remember. So you have long term relationship and of course, you have in the modern day opportunity to work with different specialties like skull base surgeons work with ent surgeons, ophthalmic surgeons, maxillofacial surgeons and plastic surgeons, sometimes with speech therapist, with psychologist and in oncology. We work with oncologist, oncology, specialist nurse, radiotherapist, radiologist, and so on so forth, neurologist, epileptologist. Why not? Because you have limited choices I mentioned earlier, you have to be in a bigger cities have on call high risk, a lot of medicine and lots of disability. This was in 2012 when we hosted uh conference here. This was uh something I had researched and of course, this is more us based because they had mentioned the $500 income. But this holds true that best of the best like you all are, I can see you are the cream of the Aberdeen medical School are here. This was a survey conducted by Dan Dean. She was giving uh uh oration to the conference and she had sent questionnaires to all the neurosurgeons practicing there. What was your story? And some said I was born neurosurgeon. I would not say so. Somebody said I was inspired, I think I will, I will fall in that category. Some people were advised to pursue neurosurgery and some happened to be in a place with no choice. And I know very good example. Uh our past president and a very talented neurosurgeon from Bristol. He always used to say his name is Rick Nelson, Richard Nelson, very talented vascular surgeon. He said he was looking for a job in good old days, we had to look for lots of house officer jobs and jobs and he ended up from plastic surgery. He wanted to do plastic surgery, but he ended up in neurosurgery. And then he continued and became president of the British Neurosurgical Association. So there are, these are some of the books, some of you might have heard. You are in the generation of Henry Marsh. Uh This is also very important book. This is previous neurosurgeon from Oxford. Little bit controversial and this is a very important book that once the brain is opened and where the air hits the brain, how the life changes of an individual, a very interesting book just to read other side of the story. Now I'm coming to the middle part of the talk, which is how to get in, how to get on and how to get out. I personally feel once you get in, there is no way out. But this was the old statistics up to 2012. The ratio has always been competitive but it was somewhere between 6.5 to 10.4 per per. So per position, there were either 10 or 6.5 applicants. The unfortunate part is that it has changed. Currently, the ratio has changed and it is now almost 16 to 20 per applications. And the problem is that because of the workforce imbalance, there are lots of trainees without consultant jobs. So what the society has decided is to stop entry. So instead of average entry of 30 to 32 trainees per year in the previous years, we have only last three, we have only admitted 15 to 20 trainees. Thankfully, by the time you will apply, this will this phase will pass away. So you have better prospects to get. I do not want to discourage you. What I mean is that if the competition is fierce, you need to be better than others. The training is largely in three phases, initial, intermediate, final. And you can see it is ST one to ST eight in the advanced stages. You also start choosing yourself specialization. Some people do fellowship, some people do uh research. Our current trainee has done research in the early phase. I know there are some who do it in interme, some uh don't get it until the final stage. These are old statistics but roughly we are now 450 consultants unless somebody retires, people don't get the job and there are other things, challenges. As I mentioned, microsurgery is the most important thing. Understanding neurophysiology. If I have to take a rebirth, I have concentrated anatomy in this life. I will concentrate more on physiology because it is intellectually more stimulating, treating disability. I am doing what is known as intrathecal back and pump, which is surgically, it's not a very difficult thing to do, but it makes a huge difference to the patients and carers. So I would say that's very interesting. You need to be good at time management to get on in the specialty. You need to be organized, comfortable managing acutely unwell patients. It is highly self motivated and willing to learn, get a breast of new developments and so on and so forth. Excellent communication skill, in my opinion. This is not only in neuroscience, this is important in your relationship during and outside work as well. And one has to be manually dexterous. These are the references, some of the books uh Ian Kamal is a good friend and a pediatric neurosurgeon from Manchester. Daniel Walls is a neurosurgeon in uh London and Jonathan is a neurosurgeon in Man Manchester. There are some other books also, this was something, there's a big group called Women in Neurosurgery. I'm very pleased to see that two out of five here and many and uh virtual presence are women. So thank you for that. It is not a specialty only that re re restricted to men. In fact, there are world leaders who are women neurosurgeons and there's a big group called women, women in neurosurgery. And those are interested I can put them in touch. These are the sources SB NS holds regular meeting called NZ and I believe some of you are also part of the local group. Um This is a group of the trainee. We have a very active group of neuro training called B NTA and in fact, they were the first one in the world to start a research group. So we, we have got BN RTC also. Uh and this is their website, of course, E one V one M one is very, this is a little old. Uh But since 2021 the interviews are conducted for the obvious reasons virtually um to be fair. The competition is fierce. Most of the I have short list, I have interviewed twice and this year I have short listed candidates. Most of them have post author publications. M phd at their young age and their F 51 and two. So it is becoming competitive. I personally feel that I will not get into neurosurgery if I apply today because I'm very average uh Society of British neurosurgical website says how to become a neurosurgeon and Nun Zig is the place to go. Thank you very much for patiently listening. I'm open to questions. I think we need to let the virtual presence colleagues to ask first questions because those who are physically present that can always ask. So over to you, you are most attentive. I can see and I'm here to answer any questions you can unmute yourself if the facility allows, if not, you can type your questions and I will be happy to answer. That was a question. Um Thank you very much in uh Aberdeen is second smallest unit, the smallest unit is Dundee. So we are five here. And therefore we are one in five on call, but there are centers like Manchester and Liverpool where are 2024 people. So they could be on call. But then of course, their on calls are extremely busy. I in Aberdeen am fortunate that though I'm one in five on call, that means every fifth day or night or every fifth weekend, I need to be alert and orientated but uh I don't often get called or I don't have to come to operate every time I'm on call. I do spend a lot of time on weekends doing paperwork and other things that I do. But in bigger centers, the neurosurgeons are in theater and involved all the time that was answered to Ursula Balka, apologies if I'm not pronouncing uh your name correctly. But then Reza Hamid is asking two students without phd even get into. Yes, they can. Everybody does not have to have phd. Would you recommend pursuing one other medical school just for this? I am not sure. I think you should look at the website, the website I mentioned and it is South Yorkshire and Humber side who manages the run through training and their website gives all the scoring and the detail uh about the application. So you can titrate your application according to what they want. For example, first author, publication or an MD, both will give you one mark. So if you're smart enough and work with someone and get first author publication between now and your F I two, then you don't need to spend two years doing MD. On the other hand, some people would do MD just for the sake of learning the research uh principles and enjoy a bit of time. So that's also, I think one of the things it is easy for me to say at my career age, but sometimes we miss uh the woods for the trees. Am I correct? What I mean is that to get to the destination? We should not uh not enjoy the journey. So when the students ask me, will I get publication out of these? It's nice if you can get publication out of anything, of course, but sometimes the learning for the sake of learning or going through the process of doing whatever project you are doing is good enough. If publication happens, then it will be of course, uh icing on the cake, but everybody does not have phd or MD. But in general, like I'm sure when you got into medicine, you must have all done uh some uh Duke of Edinburgh and you must have done some volunteering and you must have done some, you must be head boy or head girl in the school and piano and horse riding and God knows what all you would have done. So similarly, current trainees are very, very talented and high caliber and they have put in lots of efforts. Some people are in NZ and in Neuro society and whatnot. But I would say it is a fascinating specialty. I have been doing it for 40 years and I'm not tired yet. I enjoy every part of it. Work roughly 12 to 16 hours a day, travel extensively and I don't know which part of my job I enjoy more. Do you prefer the unplanned or emergency side? More? Very interesting question. Very interesting question. I think mixture to be very honest because there is a player in some of the major uh operations that we can plan. But I am at a carrier stage where to do on call or not is a question that has baffled me in the last few months. And every time when I have thought, whether should I continue being on call or not, I have chosen to be on call because after a while the life will get bored, the real buzz or Adren rush comes from unplugged. No, that's me. Most of the people in bigger units, especially when they have the opportunity to be off call. The first thing people want to do is being off call at a certain age to be very, I don't know what is there in age you see, posing, somebody may be knowing for Singh started running and he's in late nineties and still runs from the marathon. So he's not tired. My own boss is working 75 plus and still does long operations. He doesn't do on call, of course, but, uh, he's not tired that was answered to Noah Laam. Any. Now, I give the opportunity to ask the people who are present here. Yes. You want. Are you going to hear the question? You want to? Yeah. So, uh my question is, I think for everyone who's considering going into neurosurgery, is this uncertainty of it's getting more competitive? Um, you'll become a registrar and then perhaps you might be getting a job. So, um do you think this trend or this bottleneck will change in the next 5, 10 years? We get a regular update from our society and we have got something called specialty advisory committee. I used to be a member of that between 2013 and 16, but we still get regular updates, what is happening and there is a big headache for the association, I'm in society and all of us, our projection is that by 2028 things will even out what happened in the last few years is that there have not been so many retirements and we kept admitting. So we have got the bottle neck. Now, most of the people in their late fifties and sixties would retire in the next few years bearing me. And uh our projection is that with the reduced number, this uh uh workforce imbalance will even out. And then again, we'll go back to the usual. So I think by 2028 things are going to normal. Ase it is a very sorry state of a person and we all feel sorry, somewhat responsible and uh sorry. So people like me, I don't know whether you know this or not, but I have reduced my uh income only not working by half. So as to accommodate one of our own trainees as a new consultant that doesn't fix the problem globally, but it can fix locally and everybody have to think innovatively how we can. I would say purely from uh a realistic point of view. If you enjoy your specialty, go for it. If you believe in God or destiny, the employment will be sorted and one is best. Did you hear the question and answer both? OK. And my second question is so the interview process uh for national selection can be quite stressful on the day and it's very short. And I think my question is, how do you ensure and how can you stand out in the half an hour station that you have to an examiner or what are the qualities? How are you evaluating someone um as a potential trainee for your unit? I would only say one thing that the British system is very, very, very fair both in terms of uh interview process examinations and throughout the training period. So your, I think they are um somewhere around 255 or so applicants at the last count of which maybe 50 or 60 would be interviewed maybe more. And usually interviews conducted by two neurosurgeons with a third one on looking and there's a very strict quality control and there are set criteria. So the B or the unfair assessment is very, very, less likely we are trained and uh you all are tense on the day, but we are equally, if not more, especially for myself, I would say that when I'm examining or when I'm interviewing, it's like a motorway driving, not a single minute or second of diversion from what I'm doing. And most people who engage in this process of interviewing or examining or training are very, very conscientious. And I'm very proud to be a neurosurgeon in general to say of all the specialties if this is any consolation I have seen and this is what the nurses in theaters and anesthetists tell us that we are the most decent bunch of people of all the surgeons. And the same holds true for those who go into this. There are people who are into private practice. There are people who are into research. There are people who are into teaching. There are people who are into this training part and these are special group of people who have interest at the heart of doing something for the next generation. So I won't worry of that part. Oh, you can uh engage with the non Z and other activities. And other thing I was going to say if I have to do it in next year or you can also do it also have another presentation from a current trainee. For example, Jamie Low is a very good example. He has done excellent. He has done a research, he has done overseas painting. We had similarly earlier. Uh Damian Sarah. These are all our own trainees, they are stars. I mean, they are all pursue phd and they are in run through training and they're extremely bright and producing papers and international. Sure. So it may be worth listening to them also what they did or what the current scenario needs. But from the other side of the fence, I would say that the system is very fair and we have to think and work extremely hard to be fair and uh rational in assessing. So I wouldn't worry people of those who I have known and are present, you will fail through that. The Thank you for your talk. Um I was wondering, neurosurgery I believe is one of the fast changing specialties at the moment, probably fastest or any other specialty because of the recent findings, new developments. How do you keep up to date with the uh research with the new upcoming things such as uh robotic surgery or brain interference, chips or stuff like that as a neurosurgeon? How do you keep up? You have given me something to work on now? I was hoping to finish this talk and go home, but it seems you will make me read for at least two hours tonight. It very good question. We have to keep up to date various people do it in different ways as you know, um we all have different learning styles. Some people read in library, some people read at home. Some people read with friend. Some people uh listen to things. Some people have to make notes like me, same way, keeping up to date people like me will attend conferences and listen to the presentations. Some of my colleagues with young family who can't afford to go away, living family alone would read the journals. Uh The easiest way is to remain in company of smarter people than oneself. I am that person. I am surrounded by people smarter than me. So they will keep me right. I buddy with them. I asked them, why are you doing this? What are you doing? We are very interesting. I don't know whether you or any of you are attending. I think Dan had the pleasure to attend some of our and um you also visit, but we have a very interesting handover meeting in the morning which is very democratic open forum. Anybody can ask any questions and I'm usually the one who asked the most questions to say, why are we doing this? And you learn from your juniors even from students. Sometimes you ask a question like you asked me. I now have to think of brain interference and uh robotics, correct? Oh my God. So I'm worried now when we meet next time you'll ask Mr, but have you read it or not so surrounded by smarter people than you are. That's the way to keep up to date. But conferences, literature, reading and working with people smarter than me. That's another question. Are there any recent advances or innovations in Jersey that have? Particularly in? Absolutely. In short, I can say that the neurosurgery I learned in late eighties, I do not practice now. And what I practiced today, I didn't learn at all in my training time. Some of the things I have learned on the job, some of the things I have learned in last 10 to 15 years, we had an excellent colleague. I must mention if I'm not mistaken with the Egyptian connection. Uh Egyptian Egyptian origin. Mm I OK. Another famous neurosurgeon from Iran. Do you know who? Yes, but it s me. The ear. Gil and Masami are the living legends. We had a colleague, Mahmoud Kamel Superb neurosurgery. Unfortunately, he went to Cork and we lost him, but I mean, he was on the top of the world and together we had some of the greatest pleasure of working. So the recent ones, I would summarize imaging, I started neurosurgery when CT scan had just come to India, there was only one CT scan in the whole India in Mumbai. And that in private sector, that was the one we used to do a lot more things that you will have never even heard, myelogram, ventriculogram, and so on and so forth. From that we want to. Now MRI scan. Now with MRI scan, the various things I mentioned, spectroscopy, diff tensor imaging functional MRI scan. So advances in imaging. Number one, I think it has revolutionized neurosurgery. Secondly, advances in technology, I mean the spine surgery has become so easy we used to do without x rays then with x rays. Now we have got intraoperative cm CT scan. So and robotics as you say. So we don't have to only we plan it on the console in the computer and then the machine will do the job. And this endovascular treatment, the clipping versus coiling and the three other things that has happened. Stereotactic radiosurgery took away the pleasure of acoustic neuroma embolization and radiosurgery took away AVM S trig neuralgia. You name it functional neurosurgery. The biggest ones is functional neurosurgery. You can see some of the amazing results in the movement disorder. Parkinson's people who are unable to hold a glass of water due to the tremors are able to eat and drink and normal life, people can play musical instruments after their abnormal movements are stopped by deep brain stimulation, epilepsy surgery. So yes, there are lots of innovations I can go on and on and on and each one in its own right has made significant change. The one I mentioned about Balo and pump that I do. It is such a simple procedure but yesterday only I attended a webinar of the new type of pump that is coming. I mean, it can be remotely in intro like you are seeing the Tesla, Tesla can be charged and monitored by wherever in the world you are, you have application on your phone and you can do that. Same thing is happening in neurosurgery. So very fascinating. And one of the side specialties is there is a society of innovations in neurosurgery and the brain. People like you should be part of that. You don't have to feel obliged to ask questions and remain present. So if you are ashamed of stopping, I can facilitate that because I know you are very polite. Any questions from the virtual colleagues? Thank you very much for being there and uh encouraging me to carry on. Uh You are all welcome and uh I'm very easily available on phone in person, not so easily on email, but that's my limitation. Thank you. OK, happy. Um Thank you all for attending. And if anyone is interested, feel free to reach out to Aberdeen Euro. And um um yeah, be part of our society and even part of our committee. So hopefully we can see you in person on point and have a lovely evening.