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Summary

This on-demand teaching session will give medical professionals insight into the surgical specialty series. The series aims to raise awareness about different surgical specialties and provides a glimpse into the life of surgeons practicing in these specialties. The session features Miss Daniel Milas, a consultant neonatal and pediatric surgeon from Great Wall Street Hospital, who will share her experiences in diverse training locations and the complexities of a consultant's day-to-day work. Miss Milas will review memorable cases, delineate the technical and emotional challenges of the role, the impact of multidisciplinary work, and the importance of research in the field. This session promises stimulating discussions, allowing attendees to ask questions and understand this challenging and rewarding medical specialty.

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Description

We are proud to introduce our first speaker, Miss Dhanya Mullassery - a consultant neonatal and paediatric surgeon at Great Ormond Street Hospital. She has a special interest in upper gastrointestinal surgery, thoracic surgery and oncosurgery in neonates and children. In addition, Ms Mullassery is currently an Honorary Senior Lecturer at University College London and a Royal College of Surgeons Co-tutor at Great Ormond Street Hospital. Miss Mullassery completed a PhD investigating cell signalling pathways in neuroblastomas and remains an active researcher.

Learning objectives

  1. By the end of this session, the learner will be able to understand the role of a pediatric surgeon, especially within a multidisciplinary team setup.
  2. The learner will be able to identify the key tasks performed by a pediatric surgeon in their daily work.
  3. The learner will gain knowledge on the surgical training pathway and the specific challenges encountered by pediatric surgeons.
  4. By analysing complex case scenarios, the learner will gain insights into the decision-making process in managing pediatric surgical cases.
  5. The learner will be able to understand the emotional, intellectual, and technical challenges faced by pediatric surgeons and the rewards of their role in transforming lives of children and families.
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Computer generated transcript

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

Hello, Miss Melao. Can you hear me? Hello? Hi, Venetia. Yes, I can hear you. Oh, amazing. Ok, great. This is working. Um, so I think we're live. Um, let me just check if it's got everyone, right? Ok. So, um, should we make a start? Yeah, I'm happy. Um, can I just check that the audience can hear me too? I don't know if you can give a thumbs up or put something on the chart? Ok. Amazing. Thank you, Aisling. Ok. Excellent. Ok. That's great. So, um, hi, everyone. This is, we're starting our surgical specialty series and the aim of the series is to kind of bring awareness to the different specialties and find out what, um, like the life is of the surgeon in these specialties. Um, and see, you know, what they do both within and outside of medicine. Um, so as we have the talk, please feel free to put in questions on the chat. Um, and then we can get those answers at the end as well. Is that ok? I assume that's fine. Um, so today I'd like to intro introduce our first speaker, Miss Daniel. Milas, who's a consultant neonatal and pediatric surgeon at Great Wall Street Hospital. Um Miss Mala, thank you so much for joining us. How are you? I'm good. Thank you. Thank you for inviting me Ria. Um So I guess before we kind of delve into the clinical part of your life, could you just tell us a bit more about yourself, kind of as a person? Sure. So my name is Daniel Masheri. I uh I was um a Indian medical graduate. I came over after my primary degree and uh I've done my rotations across Liverpool, Cambridge and London. Um And as you said, I now work in Great Damon Street Hospital as a pediatric surgeon. Yeah, actually, that was going to be my first question. So kind of your um journey from graduating medicine um to being a consultant now. So you mentioned that you've worked in quite a few different places. That's right. Yeah. And how has your experience been throughout kind of your journey training? Um It's been really good. It's an interesting experience. Um It, some of you might know because pediatric surgery is a small specialty. We have very few uh posts across the country and generally the training pathway will involve a few different centers. Um because you have to uh see different things from different centers. So it's quite normal for people to have to have worked in quite a wide area, even across different regions. Um It's a bit of a challenge but um that's pretty much normal for pediatric surgery. Ok. Um, and I guess during my time in placement we're always told to kind of, um, talk to consultants and find out what their life looks like because training is kind of a very small part of our life and we're gonna spend more time being a consultant. So, could you tell us a bit more about what your day to day life looks like? Yeah. So if you look at the um uh different parts of our daily work, there's probably five main parts. Um The first one would be the clinics where you see the patients initially for elective uh referrals, make decisions regarding the surgery or assess operative outcomes following, make follow up plans. Then the second part will be the operation theaters where we go and do the planned surgery for these patients. You have the inpatients who we have to look after. So there's ward rounds where we manage these patients in the perioperative faces of these Children in most pediatric surgical centers. Um There is a lot of multidisciplinary team meetings. Um even more so in specialist pediatric hospitals, like right on the street where Children with complex pathology come in from across different specialties and need input and discussion with colleagues from a lot of specialties such as neonatology, oncology, gastroenterology, et cetera. Um And then uh there's emergency and on call um where we manage the Children who present with acute uh presentations that need surgery in addition to these, as with most other hospital specialties, we spend irregularly time on teaching and training future pediatric surgeons keeping up to date with developments in our field and contributing to research to continuously improve the outcome for our patients. That sounds really great. Thank you. And so that's something that you're kind of doing all the time. Yeah. Yeah. Um and so could you maybe tell us about, I guess a surgical case that was particularly memorable to you? Yes, of course. So there are different reasons why different cases can be memorable. Some can be purely from the technical aspects of challenges and um what's required to complete a procedure such as the difficulty uh tumor, which can be quite challenging at times or doing a minimally invasive procedure such as esophageal atresia in a, in a newborn. Um Sometimes it's for simple things that make a big difference to a child and a family as something as routine as placing a feeding tube to keep them going to, you know, maintain the quality of life, et cetera. And sometimes it's because of other aspects like training where I can see my trainees progressing through different phases of competence and confidence as it goes, go from the novice to seeing an operation for the first time to becoming really proficient at it and can run through it independently. So when you talk about particular cases themselves, II can think of one in the last few months a child who presented antenatally with some uh lesions detected in the lung after the baby was born, they were looked after by the neonatologist and the respiratory physicians. Then we found out that the baby has also got some problems with opening their bowels. We started investigating the abdomen. We found that um the baby had uh multiple lesions in the bowel which was similar to what they had in the chest. Um And then we had to embark on a complex um procedure procedures involving removal of some of these lesions from the abdomen, which were multiple tumors in the bowel. Um as well as treating some of the other lesions in the chest and the body wall with some chemotherapy agents. A lot of input as you can imagine from the neonatologist, the respiratory physicians, the oncologists ourselves, plastic surgeons. And so that gives you an idea of the type of patients that we come across in specialist pediatric surgery. It, they usually um requiring more than one team's input. They have quite often uh multiple systems which are involved in their pathology and therefore input from not only multiple clinical teams, but a lot of input from supporting teams such as specialist nursing teams, um family liaison teams, psychology, social work, and all of that. Um So yes, there, there have been lots of instances where the reason why a particular child becomes memorable is not just the operation part of it, which was also quite challenging in this child that because their tumors involved a significant part of their bowel. We were the challenges included, how much bowel can we salvage to, can you save the child, the child keep them alive? So, apart from the technical challenges, there were a lot of overall aspects of the child who has never gone home for months on a child who might not survive. Um, how, how do you help support the family who now has to take time off work as a sibling who's supposed to go to school? A lot of psychosocial aspects that you have to manage along with the, the surgical parts of the uh problem as well. Yeah. And actually my next question was going to be about what kind of challenges you face in your career. But I feel like both of them have overlapped. So it's a, the challenges that you do face is also part of what makes your career so interesting. Absolutely. Is that you enjoy. Is that right? Yes. Yes, you're absolutely right. I think um what makes pediatric surgery hugely rewarding is how you can make a big difference in the life of a child and their family by taking on their surgical management. So the technical aspects of course, are challenging, but also the multidisciplinary links make it a very inactive speciality. Um And there's still so much unknown. Um and you know, therefore the interest and participation in, in research um in several aspects of several conditions that need to still be understood. And, and similarly, the challenges are on the same lines in that there are technical challenges, there are intellectual and emotional challenges. So it involves a lot of time and energy you get interested and invested therefore, in patients and families and your team. Um And at times, I it does affect your life significantly. Um II think from our audience, most of us are medical students. And so um do you find that there are different challenges specific to your surgical training pathway? Um Yes. Um um if you go across, you know, um medical and surgical fields, you will start seeing a difference between them and it, and again, it, it there will be slight differences between surgical specialties. Some of it is to do with the length of training because surgical specialties are all very much um based on core surgical hand skills and that, that means time and practice um that you have to put in and there isn't any other alternative to that. Um pediatric surgery is interesting in that it is quite a unique combination of having, needing all of those surgical um aspects of the training, but also bringing a lot of the, the other side of pediatrics, which is about a holistic um approach to Children and the family. Um and having a very significant amount of medical knowledge in terms of pediatrics, pediatric specialties, neonatology, embryology. So um that's the, it's, it's quite interesting in that you bring a lot of those aspects into it. Um, but it, it's also, you know, uh, uh, uh, how you go through that as you're going through training, you will imbibe a lot of, lots of these specialties just by having worked with other teams who have learned this, your exams involve all of these things, even up to the point that you get your final FRCS in pediatric surgery And as a consultant, you're continuing to do this, bring these two worlds together. Um And also it's probably one of the few surgical only surgical specialty probably, which still has such a breadth of um conditions because for us, although we have some subspecialisation within pediatric surgery, pediatric surgeons generally would look after surgical conditions in the chest and the abdomen, sometimes in the neck, the face, the legs. So it it is way more um broad, but also then deep in that we have to delve right down to fetal surgery on one end to looking after a bump on a 1516 year old or inflammatory bowel disease, which is pretty much an adult surgical condition. So the breadth is large and so is the depth and therefore the knowledge base has to be quite big, but it's exciting, quite exciting. Um Yeah, it sounds very exciting from what you've told us. Um So II did my elective at gosh and I saw an MDT work together and what I thought was quite great is how the patient came in and you had all of the different, um, specialties in one room. Um, instead of the patient having to go to each specialty. Is that something specific to, gosh, or is that quite common in pediatrics? Um, it's, it is not specific to gosh, but it is to lots of specialties and lots of hospitals do manage that and not just in pediatrics. I'm sure that happens in others too. But uh, the reason probably it's more common in pediatrics is because a lot of the conditions that we see, particularly the congenital problems are usually not isolated. They do have more than one system involvement. So that becomes imperative that you have multiple teams involved for a prolonged period of their care. And, uh, gosh is probably just more common because you have the most of the complexity of cases. We probably, uh attract the highest amount of complexity and therefore the need for MDT working is also highest. So there are very few Children who can avoid, um, an MDT type of work in Gosh, because they, they are, you know, for just from start involving multiple teams. Ok. Um, the question that I also had, I think from what I've read pediatric surgery is a run through program, I think so. Um, no, no, it's not. They were piloting, I think, yeah, they piloted it a few years ago and then they stopped again and they're considering starting it again, but at the moment, it is still, you have to complete your core training and then you have to apply for, um, three, which is essentially the beginning of the specialist training in pediatric surgery, except for the run through a program is still open for academic training. So if you start as an academic, um, fellow in ST one in and that those are again, even fewer spots in that in the country, then you can go through a run through training for pediatric surgery. Ok. So for medical students here who, I think there's quite limited exposure of pediatric surgery in our medical school curriculum. Um, and even now that I'm looking at foundation new jobs, there's quite a, quite a, there's not many um jobs with pediatric surgery. So what could you recommend that we do to kind of increase our exposure, pediatric surgery? Uh I think um, one is what you're rightly doing, looking at where. So there are 25 centers who do pediatric surgery in the country, specialist pediatric hospital. So it's not that many you can look at, look it up and find and, and depending on where you're looking at the regions for your foundation training. Uh, see if that, where would that become part of foundation programs? Not many pediatric surgical jobs will be in foundation, for example, gosh, does not start anyone until they have finished their um foundation training. So just because they are just too super specialized but there are some centers which will have foundation trainees in them. So that would be one option. The other ones, which is more commonly done is that when you are in foundation, um, you apply for a taste a week or two and you use that time, um, to look at what aspects of pediatric surgery you want to do, you could even use that time to attend specialist aspects, um, of the clinical work, but also to look at audit research, et cetera to, to in, in, in that because that will one give you an idea flavor of what pediatric surgery working is in a short period. Uh But at the same time, we'll give you something to put in your CV, to show that you have shown commitment, you have shown an interest and how have you tried to put in an effort because the the numbers for pediatric surgery are quite small. Um and therefore the application does need to be quite competitive. Uh Yeah, so I was actually gonna ask that next. So you've mentioned research and audits. Is there anything else that we can think about now to make our comp our application more competitive later on? I think at the stage that you're in medical school, it is anything that you can get to have additional points on your CV. So on your um portfolio station and that's not just for pediatric surgery, I think for any surgical specialty that the things that will count are um research projects, publications. It as you know, and I if you can get a first of the publication, that would be even better, you get more scores for that, but at least having uh publications with your name in it before you get into co training. And then because by the time you apply, you will have to apply for your ST three when you are in ST two. So you would only be halfway through your co training. So you cannot wait for entering co training and then looking at projects to then become publications, it will just take too long. So in your foundation or medical school, if you can get participation or be get, you know, a little bit of input into research projects that gives you a name on a paper somewhere that will definitely help um and things like audits, you can clearly start from when your foundation um projects, but uh doing your foundation jobs, you can get in contact with pediatric surgical training um society. So there is a network called pediatric surgical trainees Research Network and they do uh many um pan um uh national projects so they can do and they will be looking for people in different centers, including medical students to input data, et cetera. And that is a relatively easier way to get into uh that network, but also then to contribute towards projects which can help build your CV and your portfolio. And it also gets you in touch with senior colleagues and you know, trainees in pediatric surgery who can guide you in your processes of application and interview, et cetera. That sounds really helpful. Thank you. Uh Really great advice. Um uh I think you mentioned when I asked you about your day to day life, you mentioned that research is also a big part of your life. Um And um I read that you have done a phd um as well in I think cell signaling in neoblast services. Yeah. So what kind of led you to take on a phd? I think there were several things. Um One is that I've always been interested in pediatric oncology and neuroblastoma. Um It was, and it still remains uh quite an enigma. It's, it's unique in terms of a tumor in that it is one which has poor outcome, still 50% more than 50% are diagnosed in quite late stages and mortality is still very high. And on the other aspect, there is a a spectrum of neuroblastoma where they can, despite having some lesions in even which appear as metastatic, such as in the liver, they can spontaneously regress and disappear. So it is, it is unique in the ability of having one which is a killer and of the spectrum where we are struggling with management. And then the other spectrum end of the spectrum, having this ability to spontaneously dissolve, disappear, regress or um mature uh into normal cells. And, and that is a reflection of how it's originating from embryonal cells which can differentiate or which can turn malignant. Oh, so interesting in many ways is what the reason why one of that was. And the second thing was that I um have II II have seen lots of my senior colleagues doing research having had done research in when they were um in their early years of training. And I found how much it had help them both in trying to uh develop a lot of transferrable skills by working in a team of multidisciplinary researchers, clinical as well as scientific um members of the team um and uh learning those basic skills in publishing, presenting, discussing and literature and all of that. Um And I, although I'm not doing any basic science research at this point, it has continued to help me to develop, continue to do the clinical research part of things. So I really enjoyed the time I spent in doing that and I would recommend people look into it. But I, I'm also aware that there are, it's not suited for everybody. So I wouldn't say everybody needs to go and do research. Um but being aware of research, being able to understand research is absolutely essential for any pediatric surgeon, how much you put into it. And and it really will make a difference if you are involved in some aspects of research, at least clinical research sometime during your training because as you, as you come out as a consultant, it's important you're able to again help your trainees when they come and ask you about these to say, how do you do it? How, what are the pros, what are the cons? Um And at least for that, it's important that you do some of it during your training. Yeah. II completely agree. I do think research is very important for all kind of clinicians to get into. Um I guess it's like another way of helping the general community. Um I think my question was, you know, PhD is just such a, a big kind of like such a large commitment to research. Is it possible to do it part time or does it take time out of your training? I II did take time out of training. Um And you will find that most universities now do, will want you to take uh showing a commitment by doing it full time um for Medics particularly. So there are, there is a lot of support for um doing that to take time out and grants which are specific for Medics and by the Royal College, MRC, et cetera. Um And uh they help and having a strong supervisor for your project will help to understand and having, you know, a few discussions with a few different centers who do um research to understand what projects are you interested in? What are um it, it it's a little bit about what's the clinical context, but also a little bit about what are the methods, what is their track record record? What do you want to get out of it? Um, and that can help you decide where do you want to do research or if you're thinking about, you don't want to spend that much time and energy and money. Of course, because that, that's four years of, um, time that if you're doing it during your training, you take a big cut on your earning because you don't, you have your basic salaries the most you can expect. Um So, um it, it is a lot to take on but ways that you can work around it is having a strong team and a clinical supervisor with a good track record. Um making sure that you have a re relatively good funding in place before you start it or at least get, have enough funding to start your project to get you off to a good grant that you can apply for within a year. So for uh that's what I did, for example, I had a pump priming grant that I got for the first year. And during that period, I was able to apply for a Royal College with MC Fellowship um research fellowship grant. So, um and then during that period, although it is a full time phd you, depending on your level of training, you can also do some clinical work. Is anyone else experiencing problems? I feel like everyone else has disappeared for me. Oh, can you not hear me? Can you hear me? Venetia? Ok. Oh II can hear you Venetia. Do you wanna try talking? Otherwise you can type your questions in the, in the chat. I'm so sorry about that. I couldn't, that's ok. Don't worry. Uh Yeah. Yeah, I think I was asking you about your phd and you said that you did take time out of your training um to do it full time. Um So you mentioned that at the moment, you're doing clinical research. Can you tell us a bit more about that? So now most of my research is linked to my clinical subspecialties of interest. So I do uh upper gi surgery, oncology and thoracic surgery that those are my areas of interest. So my current uh research is based um on esophageal atresia outcomes. Um esophageal replacement for Children who are born with long gap esophageal atresia and achalasia cardia outcomes and management in Children. Um I'm also doing a little bit of work on follow up and outcomes for Children who have sacral coccygeal teratoma. Um and that's as part of a, a national study that's being done as well. Um This might be a bit forward but is there any scope for medical students to get involved in your research or help out in any way? Yes. So we, you're probably aware that when medical students come to, gosh, depending on how long they are with us. Uh because some would come for an elective, which can be a month or two. So I think when people are there for about a month, that's a reasonable time for us to look into uh enough time to get involved with some projects. It can sometimes be a mini audit or something, but something that can come to at least an abstract, if not a publication. Um And yes, so some medical students have done work which we have been able to um percent or published in different places. Uh But it's very challenging for those who are not uh you know, there for long enough, two or three days is usually not enough to get you enough um to go through that and doing it completely remotely is also quite challenging because it's not uh it's not a fully research, the the programs are not running independent of clinical work. So everything that we do is linked to what we're doing clinically. So it needs to happen along with everything else during the day. We don't have set times for doing research, et cetera. Um We have a really great question on the chart from liver. Uh What made you pursue pediatric surgery? Yeah, that's a good one. I II think I've mentioned a couple of aspects of it. It, it's, it is one is really the breath of pediatric surgery. What inspired me was the first seven days that I spent as a medical student in a pediatric surgery unit back home. Um, and it, it really, one showed me how exciting it is technically challenging, working in really tiny spaces, um quite demanding, challenging expertise of that, but also the dedication of the pediatric surgeons who were there, you know, quite long hours, a lot of the time out of their working time, how much involvement they had in the care of the child, how much they knew, not only about the operations, but also about the whole child, but also actually about, you know, when, when they came to clinic, my professor would be asking about the sibling and the, the father and it, it, they just seem to know the whole so that holistic approach with the technical challenges and the interaction and the teamwork really, that's what put me into pediatric surgery. Um So my last question before I hand it over to the audience is um I think a lot of us are, are told constantly by other um healthcare professionals to have a work life balance and to make sure that you can like come home and destress. Is there something that you're particularly passionate outside of medicine that helps you do that? Uh A lot of few little things. II, II don't have another. Um I, you know, I'm not great at anything else outside pediatric surgery, but II love spending time with my uh family and friends. My kids and my husband, we, we play board games or I try to make them play board games. They are trying to teach me video games, which I'm still not good at. Um We do a little bit of gardening when the, when the weather is good and it, that's a nice, you know, way to relax. And I find mindfulness, meditation very useful for me to take a break from things as well. So yeah, li little things um go a long way in trying to get you that balance. OK. So thank you so much for answering the questions that I had. Is there any more questions? Um the question from John, we um oh I think we have touched on this but um because pediatric surgery is so competitive, how would you recommend we optimize our portfolio? So you mentioned research and audits and kind of getting involved in? Yeah. So if you start, so I would say that if you're looking at this as a potential carrier, you need to start looking at the three entry points. So first one would be your foundation and to look at where do you want to do your foundation, which will get you some of the jobs which will get you into the appropriate core training program and then to look at your ST application, so your core training application and also to look at your ST three application before you start your foundation training. So you will have to kind of work backwards to say, what do I need for the ST three training and to get, get into that ST three application, what are the core training requirements I need? And where do I need to do that job? And then look back and say, what do I need in my foundation and overall a strong portfolio which has research audit. And if the reason I say, look at the application because it will give you the points you get for each thing. So for example, if you say involvement in research, it might get you one point. If you have a phd, it will give you four points. Similarly for if you are doing weekly, monthly teaching for medical students as a foundation here or a co trainee, you, you, I think uh it's about again, basic starting point is one point. But if you've got a postgraduate certificate, it gets you two points. And if you have got a uh master's, it will get you extra points. So everything has a score attached to it and it's to look at clearly, you can't do everything because there is you're not going to otherwise get into by the time you do all of these things, it's going to be you gonna take too long, but it's trying to see in the limited time that you have what is the best way of getting the most number of points. Um So try and pick the jobs which will give review that. Um and also little things like whenever there's an opportunity about teaching, look at what aspects of it's going to be useful. Teaching is interesting and exciting for all of us. But if you can help develop a program that gives you extra points, if you can initiate an audit, that gives you extra points, if you can close, complete an audit loop of be in this. So you can, you know, do the first half and the second half yourself that gives you extra points. And so it's knowing what are not just say, knowing that tick, I've done an audit or tick, I've been involved in research, but what actually gives you the point in auditor research and things like um we have uh teaching uh training but also leadership so that most of you are doing some aspects of leadership already in medical schools. But again, it's looking at the application form for each level to understand what will give you those points. It's, it's, it can be something as basic as you know, what you have set up like this, the, the British Indian Surgical Society or how do, how do you say, what were the qualities that you showed through by doing that? What what did you achieve through that? So be specific about what you are doing in that role and how you can bring that into your portfolio and your interview. Um Another question on the chat, I think again, we have touched on this about what your day to day job looks like. And you mentioned that actually, there's quite a variety. So we like to assume that you don't really have a typical day as such and it's just always changing. No, it's, it's, I mean, typical days as in uh any consultant work uh involves around what you call a job plan. So there is a, there is a structure of framework. So what you will have is for example, on, on Mondays, I have my clinic. So this morning, I had my clinic, then there's ward round and then several meetings in the afternoon, some educational supervisory meetings, et cetera. Tuesday is my all day operating Wednesday sometimes is operating sometimes is education supervision. Thursdays, it's almost all day of M BT starting from eight o'clock to about 637 in the evening. And Friday again, it's, it's a mix of MMB T clinics as well as some simulation, teaching training and some education supervision meetings and things like that. So, and, and then once every, depending on your rota, every few weeks, you will have a week of attending where I'm doing just on call activities. So there's ward rounds, there's some teaching in that too. There's a lot of emergency operating in the day and the night. So that, but all of these aspects in, in on average, all the period surgeons have to do all of these in, in some ways fitted into their weeks and months. Um, I actually quite like the sound of that. It just, it feels like your week is just kept interesting with all of the different things that you do. Um, we have another, I think a really great question on the chat from my show here. Um, how do you manage when pediatric surgeries don't necessarily go to plan or you're unable to help the child. Uh, I think you start off with knowing that things do not always go to plan. Um So you have to be quite realistic about what you can achieve. And that is part of um becoming a consultant in any specialty because there is in any aspect of medicine, there are things that we cannot do. So first, first of all, is trying to have a realistic um understanding about what can we offer to this child and family so that you do not give them too much hope and yourself by committing to too much and, and sometimes that can lead to uh giving false hopes, but also putting the child through unnecessary risky procedures, which can have complications, et cetera. So starting point of knowing what is realistic. And as pediatric surgeons, we, we are quite an optimistic group of people. So we would do, you know, we'd probably we, we do everything we can but being realistic about it so that you start with that, do your best, you know, make sure that you're working closely and being open about your concerns and uh taking suggestions from other experts in your field as well as with others. And then the outcome can still be bad. But that, that is, that is what is expected. That's what we are here for. Because if, if we are able to fix everything, then we're probably not doing a challenging enough work. If we can fix, you know, 95% of the things make things better. It's not really fixed, it's make things better. We're doing a great job. And if we weren't doing that, half of those Children would not be able to get better. So we are trying to push the limits of what we can do and being aware that that is what we are trying to do and in trying to do that, we are finding new challenges and we are, we are realistic about what we cannot do because medicine is not miracles. It, it is about science and it is about putting your work in and it is about, um you know, being open with parents and your team about what we can achieve and sometimes what we cannot. So it sounds like it's important to have a balance between being realistic, but also pushing yourself to do the best. Absolutely. And also knowing that when things do not work you want or the team had hoped for that you are there to be open about why that had not happened. You are able to look back objectively and also empathetically with everybody to, to see where is everybody coming from? Listen to everybody to see. Could we have done things better learn from that, be supportive of each other? And sometimes it might, it might mean that you have to let people know our vulnerability as a surgeon to say that yes, I am upset. I am, I am sad that this happened and that makes you only even more stronger in the eyes of the rest of the team because everybody is going through that tough time. Yeah. Um another question on the chart. So in pediatric surgery, I think you mentioned that you can operate on multiple organs. And uh is it possible to, I guess subspecialise for specific organs or you know how, how, what are your thoughts on working on various organs versus just kind of specializing in one? So uh pediatric surgeons as we, we train as general generalists for pediatric surgery, but increasingly we are subspecialized at least in the UK and there are two reasons for it. We know that surgical training, um the the the number of hours that you spend in training is significantly reduced if you compared to 30 years ago, for example. So whereas people were doing day and night for 345 years, sometimes eight years until you get the job was how it used to work and then you moved on to um W TD working time directives, the 48 hour rule, um 48 you know, in a week, et cetera. So there is limitations of how much a trainee can actually have in terms of experience, not only operating, but also seeing patients, what happens when things would go wrong, et cetera. And there isn't actually a lot you can do to replace that time that's lost, which would mean that a consultant who is even, you know, in the, in the, the pre retirement couple of years compared to a consultant who's just come in the last couple of years has a huge world of difference in their first two years as a consultant in what you have seen, what you have experienced, what you're able to manage um confidently and in an attempt to try and concentrate the skills and your experience, the only way we can think of in small areas such as the UK is that you try and do more of the same thing. That would mean that everybody does more of some particular thing rather than if you're trying to look after 10 conditions, you will probably see only one of them each year. Whereas if you try to operate on everybody who has this one condition, you might see five of them in that year. Even with the that subspecialisation, our, our numbers are because the, the um birth rate is not increasing. In fact, it's reducing in the UK and most of the first world countries the number of pediatric surgeons have significantly increased. I mean, although we are probably still one of the smallest number of group of people. You, we have about 300 pediatric surgeons in the country as opposed to about 100 and 50 about 10 years ago. So it's a massive increase in the number of people who are operating on the same number of Children. Um and, and that needs to be balanced by what you focus on. And that is a one of the drivers for subspecialisation. And also that means that people who see a particular condition more and it's not like adult general surgery where you have huge number of patients in whatever you have all of these conditions. If you take an of esophageal atresia or in erectile malformation, the biggest centers in the UK would have 10 to 15 patients in a year. So if you have 10 consultants working there, if everybody did all of it, all of you will end up doing one operation as to if, if you get three people doing that, you have five of those done and who wouldn't want their child to be looked at by, by a person who's, you know, done more, seen more has the experience understands um better. So that's the drive of for subspecialisation. It, it's still a process which is evolving based on the needs of today's training. And um and also a little bit of, you know, trying to develop that work life balance. Uh because otherwise we, we wouldn't have enough time to try and get to grips with everything that we need to know by the time we are even in your, into your mid consultant. Yes. Ok. I that makes a lot of sense to be honest with. Yes. Thank you. Um I think our last question um was is asking what's your favorite part of working as a pediatric surgeon, which I think we talked about earlier, which was, I guess a combination of challenges and seeing your trainees get better. None of that. Um Are there any more questions on the chart? No, I don't think so. I guess we can end the session here then. Thank you so much Mr Malai for giving up your time and talking to us. It was such a great, like such a great information that I don't think we could get, you know, anywhere else or just looking on the internet. So thank you so much for coming on. Um Thank you. Lovely to see you and um to talk to all of you and to know that um uh you know, there are lots of young people like yourselves who are interested in joining. Um I also want to thank everyone in the audience for being so engaging. Um It was really great and yes, everyone's thanking you on the chat as well. Thank you. Thank you, everyone and good luck to all of you in whichever uh part of medicine that you want to go into. Look forward to seeing some of you. Thank you. So I'll end the session now. Thank you. Thank you. Bye bye.