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Hello. Can you hear me? I can hear you. Nice and clear. When, how are you? I'm good, thank you. How are you? Good. Excellent. So, we'll just, we have quite a few people who've already joined so we can wait for a few more minutes. Ok. That's ok. So, what have you done today? Um, I'm actually on study leave. So, um, I have my sys in a few weeks. Um, so I'm preparing for that. Um, I'm in final year so I'm also in the process of ranking all the jobs for my foundation years. Oh, so what starting in August your foundation? Yes. Ok. And what college are you at? Um, I'm at the University of Cambridge, Mary Edwards College. Ok. Cambridge. Yeah. Ok. Good, good, good. And what, what's your choices for your foundation? Um, so I got the Essex area. So that's kind of Chelmsford Harlow, Bethel Southend. Um, and I'm just trying to maximize the number of surgical rotations that I can get. Is that what you wanna do? Yes. Yeah. Um, that's, that's also why I joined the, the surgical wing of the British Indian Medical Association. Yeah. The website looks quite nice. You quite busy. You guys looks like the website. Sorry. Mm. Yeah. Your med all website. Not the beer website. Yeah. Yeah. So is this all from beer or medal? Is all um anybody and everybody involved with that? Oh, it's everyone. So there are lots of different events that take place um on medal but be a, uses that platform because it's quite good. And how, how active I know I've done this, you know, I did another session with um Ria and Saran for the suturing. I see because about two weeks ago. Yeah. So you're quite well acquainted with the being the community then. Yes. Yes. Yes, absolutely. Um I think we'll start and then people will just come and join us. They please. Ok. Um So hi everyone. Thank you all for joining. I hope you can hear me. Ok. Um So this is our third session of our special of our surgical specialty series. And today we have Professor Singh who is a consultant upper limb orthopedic surgeon at Medway Maritime Hospital. Um Professor Singh, thank you so much for joining us. Um And if anyone has any questions, please feel free to put it on the chat and then we can get them answered as well. Um So just to kind of start of the session, um Professor Singh, if you could tell us about your journey from kind of graduating medical school to being a consultant surgeon. So, um I actually trained and qualified in India first. Um So I joined medical school in 1986 qualified 92. Then I did my master's there and finished that in 95. Then I was working as an assistant professor for about two years. And um I always wanted to come to UK for a short period of time. Um I finally landed in March 98. And yeah, and I went through the whole training program again, uh doing the basic surgical training to specialist registrar and then I've been a consultant since 2007. Um I specialize as you said, uh in upper limb and trauma surgery. Um I'm also my professor title comes from Canterbury Christchurch University uh where we run a master's program MC H in orthopedics and, and I, as you can see, I'm from India. Um I go frequently there for teaching and training and last year, um all in the ent of medical sciences gave me my second visiting professor title as I go on the beach there. So, yeah, I visit about three or four times a year. Um to India, is that specifically at a? No. So Ames, I go, yeah, I generally go Ames. My parents are still in India so I have that opportunity of going and seeing them as well. And uh yeah, I teach postgraduate students there. I see. And what made you choose orthopedic surgery. So, um when I was training, uh when I was finishing my medical school in nineties. Um, well, first of all, II from second year medical school I knew I was going to be a surgeon. Um, you know, medicine didn't, sort of, not that I didn't like it. But, yeah, I knew I was going to be a surgeon. And then as I was coming towards the end of my training, you start to look at what things you can do. And at that time, orthopedics wasn't as subspecialized as it is now. So this is what, 30 years ago, 32 years ago and orthopedics, I thought I'll just do three years of masters and that would be it because in general surgery, they had started to um develop subspecialties like your um, neurourology, plastics and those kind of things. So I thought that and, um, and then also at um, the time the application and your choices were dependent on your merit to your final AMB score merit. And interestingly at the time, so if you had a surgical, you know, if you like surgery, then the top one would be orthopedics. If you like medicine, it would be pediatrics and things like dermatology and radiology were taken by people who didn't get much choices. So things have changed in the last years. So it seems it sounds like you chose orthopedics because it was the most kind of varied and broad and you didn't really want to specialize. No, that's correct. And, and also look, I mean, not at that time, there was not many people telling me that, you know, what you should do. Now, I tell people that you should take a specialty that you like, really? Because it's not impossible, but it's very difficult to change your specialty. Uh, from, you know, even in surgical branches, it's difficult to change from, let's say, orthopedics into colorectal or ent or eye surgeon. So, and, uh, at that time, orthopedic was the top, uh even from a sort of, um, your education point of view financially as well. Um, orthopedic was um, considered quite good and with all those things, um, I took up orthopedics. So you did end up subspecialized to upper limb or the lower limb. Is there a reason you preferred that? Um, again, I mean, because when we, when you, so the, I'm not sure whether the uh students who are listening are aware of the training pathways uh in the UK. Um So if you want, I can talk a bit about that and then that. So, uh, so basically at the moment, you'll do your two years of foundation here and then some of you will go and do some research. A lot of you will take another year out, which is the f three year to see what you want to do. And then you get into your core training, which is another two years. Some of the specialties do have a run through core training and specialist training and then you do your um specialty training and depending on which field you are in, it's anywhere for to six years plus another one or two years of fellowships. Uh Before you get into a consultant, uh consultant job, why I chose a was um I got interested into the lyme. And also, or when you start to look at things, there are lots of hips and knee surgeons around and I like the idea of doing day case procedures um and not having a significant uh inpatient workload. Um And I worked with, I think it's mainly I worked with a couple of shoulder and upper li guys who I really enjoyed. So that's what made me interested in doing upper li and then I did a fellowship in Australia and us uh in that. Um And I read that kind of alongside aim, you're also interested in sports medicine. So how did you get into that? So sports medicine II is, you know, so, although a lot of people with sports medicine think about knee injuries, mainly an occasional ankle injury, but there's a lot of um shoulder and elbow sports injury as well, you know. So if you look at UK sports or rugby is not that much, but any of the racket sports are throwing and people who are not involved in that side would do would be doing sort of weight training and things like that so that can have an impact on a variety of shoulder and elbow pathologies. So when did you decide that you wanted to do sports medicine alongside doing, is that alongside your training? So sports medicine as such in the UK is not a recognized separate entity, most people, you know, so you will find a handful of surgeons in the UK who will do shoulder and knee sports medicine. Although if you go to us or Australia or even India, there are people who would do that. And then what then happens is that because the training is such that you become sort of focused towards one side of the anatomy and that's why you then end up doing sports medicine of the upper limb or the lower limb. And it, it's fascinating. I mean, you know, you deal with different type of uh people there, expectation is different things like that. Are there any specific, you said racket sports and kind of weightlifting? But any specific sports that you see a lot of? So it's mainly the bracket sports and, and again, with the weightlifting, it's not as commonly understood uh pathologies with the um weightlifters because um they often put it down to having done a bit of an extra work and things like that. Um But yeah, weightlifters do have um both the glenohumeral joint and rotator cuff problems. Yeah. Um as medical students, we often told to find out what the life of a consultant looks like because that's what our life is gonna look like for most of it, you know. Um So could you tell us what, like, what does your typical day look like or what you do day to day? So my typical day is very variable. Ok. So, um I wake up early in the morning, five o'clock and then I do spend a bit of time meditating for a few minutes. Uh It helps, it helps, I know people think um, while meditate, but it just keeps you focused. Uh And then I have a dog who I take for a short walk for about 25 minutes, half an hour and then I get ready, make my lunch, make my lunches for my daughters. Um And then generally I'm out of the house about 7715 on a Monday, I would normally have three clinics between the NHS and one private. So finish about so finish about eight, half, eight in the evening. Uh Tuesday, one week, I would be on doing post on calls alternate Mondays is my on call days. So on a Tuesday morning, then I would do a trauma meeting where we discuss all the patients who are referred or admitted by the ed. And then I'd run a trauma list, uh with a variety of fractures in the morning. Generally we do neck or feur fractures. And then in the afternoon, I have specialty trauma. So somebody with a complex uh shoulder injury or complex elbow injuries that I would do and then Wednesday, Thursday is, um, I would do, I've got private practice, um, and um, Thursday. So Wednesday, I normally variable finish. So sometimes I finish around one occasionally, about 62 weeks. And then Thursday is another long day where I have an operating list in private from 8 to 4 and then a clinic from 4 to 8 Friday. I would do my elective operating in the NHS. So that generally finishes around six. We also do one in 12 weekends on call. Uh, so Saturday and Sunday where we have trauma patients to operate on and I do one a month maybe. Uh, another, um, list um, in the NHS or waiting list work. I see. I probably do about 60 64 hours a week on an average. Oh, wow. Ok. That's very intense. That shouldn't put people off. The advantage of working in the NHS is that you can choose what lifestyle suits you. Um, you know, you can do just the NHS work or even in the NHS, you can do reduced hours of part time work. It's become quite flexible these days or the last, certainly in the last 10 years. I see. Um, and you mentioned that you do private work as well. I think I read that you work at Kims Hospital, which is, I don't think a lot of doctors really talk about private practice. So, do you think you could shed some light about how you get into private work, but also how your experiences differ from the NHS. So the way, so generally what happens is once you come to an end of your, not the end of your training, once you get a consultant job, OK. Uh most uh places will have one or two private hospitals in the local area, local community. And so it's a two way process. You have to apply to the private hospitals to get practicing privileges and then you have to apply to the insurance companies um as well to get recognized with them and they have their own tariff, um how they send patients and how you get paid from them. Now, treatment wise and advice wise, whether it's an NHS patient or a private patient, it's always the same. You cannot differentiate, I certainly don't differentiate between what advice I give to an NHS patient or a private patient. The difference is that in the NHS. So for example, on a Monday, uh I normally have three clinics running under my name. So I do one clinic, I have a registrar and I also have an upper limb fellow. So they run the clinics as well. So unless the patient is wanting or if there's anything complex, they may not see me all the time in the private, they will always have the consultant who will see them. And the same thing applies to the treatment as well in private hospital. Um Most of not most of us all of us do our own operating. You may have an assistant um in the NHS because it's a training environment as well. Um You, you know, bound to train but what's changed in what, 26 years that I've been in the UK is that most of the operating is done under direct consultant supervision. So even if my registrar is operating, I will be either scrubbed with the registrar or the fellow or be around to um advise and support them as required. Ok. But you don't feel any different in terms of the patient care. No, it's so you feel more involved in, oh, you have to be in the, yes, you, you are more involved in the sense that um the patient comes directly with any cure queries via your secretary or depending on where you are and what sort of practice it is. Sometimes patients contact you directly, but generally it's through the secretary. Um it's no different than the NHS. But yeah, you're more involved in the sense that you directly look after them. Mm. Ok. And just in general, um I think I read that you, you use quite advanced technology in your work. So II don't know about the technical details of this, but I read about um not less technology and um computer guided replacement surgery. So you took us a bit more about that. Yes. So it, it, it's like with as um technology and science develops, you must keep up to date, you know, and I'm sure you all will um as things move on. So when I first started a lot of the shoulder surgeries were done to open a mini open approach. And so nowadays, most of the, let's say the rotator cuff or people who, or young ones who have um to dislocation or recurrent dislocations, we treat all of them through arthroscopy, um surgery. And when the, and we use a small anchors that we put, which has got loaded sutures in it. And so when I first started, we used to either have an open or you had to tie knots. So there are different instruments that you can use to tie a knot, um, and leave the knots within the soft tissue of the joints. Um But over the last, certainly in the last sort of 15 years, things have moved on and we rarely used to need to make any not uh for doing these kind of repairs. The computer navigation. So, uh I know these medical students don't get to go to do much orthopedics, uh, in the medical school years. Uh So computer navigation is not new that way. Um Even when I was training, the navigation was used for knees predominantly, but it fell out of repute because time taken was long and there was not a significant clinical improvements in the outcomes now where it slightly different in the shoulders is that I don't know if any one of you, either you or the people who are listening have seen any shoulder replacements. And the access to the socket of the glenoid can be quite tricky and often they get worn in a way where the precise placement can be difficult. So the computer navigation helps to position the implant. And the glenoid implant is about 25 millimeters tall to about 20 millimeters wide because the glenoid is quite a shallow and a small thing. So that just allows more precision placement of the of the prosthesis. The other thing new that I do is um you may have heard in the news about P RP injections or what a lot of the people call as um stem cell therapy for it to be actually be stem cell. You need to use technically an infant blood bone marrow, but you can use bone marrow of the patient as well and spin that and use that as a kind of a stem cell. But using that is um not technically demanding, but because its efficacy is proven it's not used but platelet rich plasma or PRP as it's um called, I use it on a fairly regular basis uh for tendinopathies. So, uh if you understand tendinopathies, the common one is the tennis elbow or golfer elbow and even the shoulder pain, the most common reason for a shoulder pain is rotator cuff tendinopathy. So even in those, um I've been using it for about four years now. And that has reduced the number of patients that come for surgery because it provides healing. So the platelets have different types of growth factors which allow for the tissue to heal. Traditionally, most patients with the tennis elbow would get a steroid injection. Yeah. And the steroid injection, although it helps with the symptom is actually counterintuitive in the sense that the pathology for all of these tendinopathies is microvascular injury, partial tendon tears and things like that. And when you put steroid in that area, it makes those things worse. So, over a longer period of time. Yeah, certainly with tennis elbow, there's lots of literature to say that um it actually doesn't help but it is still quite common practice to have. So after physiotherapy, I think it is like steroid injections. It is, it is. But hopefully um with more and more people doing the P RP for the uh tendinopathies and it, it's quite simple actually. Uh so the way I do it, I do it in clinic, outpatients for private patients and I take the blood uh there's a centrifuge machine, you spin it and then you inject it. Very interesting. Yeah. Um and so how would you, what advice could you give us, you know, to stay up to date with technology and techniques and you know, whatever field that we go into? So I OK, so I think what you need, you know, educating teaching is the best way. OK? Because I mean, not today, but if I've got to go and, you know, I have to go and talk to anybody, be it shoulder surgeons or registrars or medical students on a topic I would read about the topic. I would do some research about the topic. And, um, and, and so that provides me with, you know, up to date information, uh, when I go and talk to people about it. So, teaching definitely is the best way to um keep yourself up to date. And once you, whichever speciality you go in, um there will be the different societies. So in the upper limb, we have the, I mean, obviously the parent societies, the British orthopedic Association, then we've got the British Hand society than there is they push shoulder and elbow society. So every subspeciality you can think about the foot and ankle, have their knee, has hip spine, pediatrics. Um So there's all societies and they have their meetings and um annual meetings as well as various programs that are run. Then there are different international programs that are also arranged by either, you know, different educational societies. So the same thing will be there on the European level, there's a European builder and no society and there's an European hand society. Um Yeah, so that's the best way to keep up to date. Hm. So kind of staying proactive and making sure that you go to those kind of teachings or conferences. Um Is there any you know, particular type of cases that you enjoy or that has been quite memorable for you. So I seriously enjoyed trauma, ok. Uh, trauma surgery, elective surgery can get a bit boring and mundane because, you know, there's less element of surprises, you know, so if you're going to do somebody's shoulder replacement, yes, they may have a different type of wear and whatnot. But, you know, at the end of the day it will be similar. Um So for example, I today I did one elective shoulder replacement. I helped another guy do it and that was pretty much straightforward. Then we had a 60 year old lady who smashed her shoulder. And um so for that one, also, we did a replacement because it was not fixable. She had lots of other medical comorbidities. Um So yeah, so that doing that is always challenging and interesting. And the third lady I did, she broke her humeral shaft about three months ago. So vast majority of the humeral shaft fractures are treated um in a brace, in a humeral brace, non surgically. Unfortunately, she also had a radial nerve um palsy at the time of the, at the time of the injury. And um when we opened her up, I'm just trying to see if I can show this picture to you. A radial nerve was actually um impaled by the uh by the fragment. I don't know if you can see. So that's the radial nerve in that lobe and the artery clip and um and the fracture fragment was which is on this side of the fragment. So that was impaling her. So we released the nerve as well as fixed the fixed the fracture. So hopefully have a good recovery. So it sounds like kind of the more complex cases are the ones that you enjoy the more. Absolutely. Absolutely. And on the side of that, do you feel like there are any particular challenges that you face during your surgical training? So, so in the surgical training, um I mean, it still happens, you know, the challenges are when you get a patient who um you didn't expect the outcome. So for, you know, complications is part of life. And even now after being a consultant for so many years, you know, if I get any complication, I feel a bit sad and depressed depending on the severity of the complication. So, for example, uh I did a lady in November a shoulder replacement, she had a fall and then she dislocated the uh shoulder joint and also she had a fracture across the socket in the scapula. Um So it was so bad that, you know, I couldn't fix, I couldn't re reconstruct it again. So then you had, you know, all I had to do was take the prosthesis out for her. Um So she'll be left with a flail shoulder but hopefully not be painful. No. Um in terms of kind of pursuing orthopedic surgery with from previous speakers, we know that, you know, there's things like research and audits that, um, kind of need to be done as kind of a tick box exercise. Um, one speaker mentioned, you know, doing community work and charity work. So, do you have anything else that you think would make a more competitive application for orthopedic surgery? So, I think for orthopedic surgery. So it's, um, and, and what I said, you know, teaching. So I had one fy to come and do a test c section a couple of weeks ago, uh, because she was interested to know and that's what I would suggest, you know, and I'm not sure if that's been told or, or you all have been informed about that. You can do a taste a week, uh, where, you know, if you want to find out whether you like that specialty or not, uh, go and spend the whole week, uh, with that, uh, team and see it close by because when you're fy one and Fy two, certainly in the fy ones you sort of, um, almost stuck on the wards or Ed, you're a clouting machine. And I think one of the other things, what I find is not wrong but, you know, it's an apprentice model. Ok. Yes, you're contracted to do 9 to 5 or whatever. But if something's taken, uh, interest, there's nothing stopping you to go and, you know, maybe in an evening or when you've got a half day off or on a weekend to go and see what, what interests you. And I can assure you that most of the senior surgeons as the consultants and the registrars will be more than happy and willing to teach you, get you to do things when you are there. Um, so II would certainly do that if you're interested, whichever one, you know, I'm not, I'm not expecting that. You know, whoever is listening to me, I is going to be interested in orthopedics and in a poly. And I say that too when we have fy ones and Fy two S, you know, that I don't expect but wherever you are enjoy do the best you can even if you don't, like, you know, say, for example, like you said, you want to be a surgeon, but I don't know where, you know, you will certainly get a posting in GP surgery. Likely you might get a posting in care of elderly, but you must use those opportunities to, to learn. And one of the things that I did when I was doing my registrar and my training here in the UK is whatever projects you do, you should try and aim that you will either get uh more than just a hospital presentation from it. Ok. Yeah. A and, and it, it does, it does involve a lot of hard work, you know, but that's what, um, the field is about, you know, when you say projects, do you mean research and audit kind of? Yeah. So if you've done AQ II mean, unless it's like looking at the notes audit or something like that. But if you've done something different, if you follow the guideline, uh then you can do a and send it to the relevant society. So for example, I'll give you in orthopedics. Um There are different um guidelines that the baa the British Orthopedic Association have come up with. And so the Q I project or audit can be on looking at how well the um guidelines have been followed. And one of my current, she was my CTT one uh last uh posting. Have we looked at the green list in a green surgical checklist? Have you guys heard of it? Um I've had the Who checklist. No. So the, so, so the who checklist is standard now everywhere there is a new thing which is called as the green checklist. Have a look. It's, it's done by the Royal Colleges and it's basically trying to reduce the amount of emissions and energy that is spent a simple thing like I can, which you might appreciate this, you know, a lot of people just put on gloves for no reason. Yeah, all those thousands of papers that are printed off before and after a meeting. Uh So tho those kind of things or one of my biggest bugbears is the um is the tap in theaters when you're scrubbing, you know, you turn the tap on, you scrub for whatever five minutes and that tap is on all the time. And if you've got your, a scrub nurse, your consultant, one assistant, you know, and that is, you know, done 456 times in a day in one theater multiply that by 15 theaters in the hospital. And this is one day. So they are simple, small things that, um, we become too much reliant on single use stuff which will change. I'm sure it will change. So I've grown up where even in this country, the single use was very uncommon. So we used to have uh cloth gowns, cloth drapes, the, if you've been in any orthopedic surgeries. So if you're putting a plate and screws, then they used to be all on one tray and you took out which now it all comes separately packed. So that also means that, you know, you're spending more time, a lot of packaging that is required. So, so that's the green checklist and, and are you involved in kind of making more sustainable practices in theater? I would like to. But what you, what I also realize is that it's not easy. You've got to think like the NHS is like a big oil tanker to make it move. It's a very slow process. But you've got to, uh, you, you've got to strive and I can only do what I can do and I always try and do it. Yeah. Um I have read that you are involved in research. Um Could you tell us a bit more about that? So I don't do many basic science research. OK. Because uh to do that, you need to be in a place like where your medical schools are Cambridge Kings where you have all that support. So what I do is clinical research. So for example, um we're currently starting on. Uh so I did the one where you know the clavicle fractures. Yeah, whether traditionally they are all put in a sling and left. So then the trial was whether fixing them gives a better outcome or not. So that's one, the other one which I myself uh did and got through the ethics was using uh clips versus subcuticular sutures following hip fractures. And so that showed that, you know, using the subcuticular sutures were cheaper and they cause less complications after, after the skin closure because what a lot of people don't realize is that the skin staple that we use has got a fair amount of nickel. And you might have heard people talk about that or I'm allergic to fake metal. Yeah. Fake jewelry. Yeah. Yeah. So the fake jewelry, most of the sensitivity is to nickel and the, and the fake jewelry has got a lot of nickel in it. Uh My sister had it. So when uh used to go to, you know, the singing and dancing one. When she used to go, she used to wear fake jewelry and for the 1012 days, her ears were swollen, red infected. But when she wore gold jewelry, it was fine. And we used to make a joke about it that because she wanted gold jewelry. She said she's got the same thing applies to the skin clips. The clips have a lot of nickel in it. So, although it may not cause infection, but it does cause quite a lot of redness around the wound. And when the clips are taken out, it's uncomfortable for the patient. So if you imagine the clips go like that and to remove it, it needs the other reactions. So they're spread out and then it comes out. So it's uncomfortable as well and they are about 56 times more costly than using a suture. So I do, I do, you know, fairly regularly get involved in clinical research. Um And do you have, um might be a bit of af question but medical students involved in your research or anyone used them? Oh, yeah. So, so um uh actually I've also got a clinical lecturer title from King's College because I have a, a student who I am. He's actually finished his um I don't know how King's College, they finished their exams. He's on holiday. Um So he's starting his fy one, I've been his educational supervisor uh over the last three years and uh as you may know there is a new medical school in Canterbury, the KM MS um is the medical school where we are now starting to get medical students on a regular, regular basis. But one of the issues that I noticed is that be because in medical school, the placement in orthopedics is very minimal. It's two weeks or so if you're lucky. So I had a medical student sit with me in my fracture clinic. So there isn't a significant amount of time actually to develop that Rapho and understanding with the medical students. But now I have published on, you know, I've had medical students where we published on distal radius fractures. Um if they're interested. Ok, that's great. Um And if anyone has any questions, please do feel free to put it in the chart. Um I think my last question was just, um you know, there's a lot of emphasis on work life balance. And so is there anything kind of outside of medicine that you are quite passionate about? So, before I say what I do, I think, you know, I'm sure you all have something going on along with medicine and often you may feel it's daunting. But if you make the place for it now it the rest of the things fall in place. So I don't know what you do. What do you enjoy doing well? So I, you know, spend time with family friends. Um I quite like badminton. Um So that I play badminton as well. Um II, in my school days, I was the local champion around where we live. Um But when I came here, I just found an excuse not to do anything apart from, apart from working because I was an immigrant. I had to retrain, I had to do everything and I had a family to support. Um But now, so what I do now, I obviously do meditate. I walk, I started learning golf last year and I read when I get time, not just the medical journals but some books that I can lay my hands on. II listen to music. So, yeah. Oh, yeah. No, you must, you must, uh, keep that going. It keeps you sane. Yeah, I guess that's true. Um, I don't think we have any questions on the chart but it's been really helpful and really, you know, a lot of interesting things that you've said. Um, I think if anyone does contact me, would you be happy to e email address? So, interestingly, I've had an e-mail from a medical student in York who must be, I think his parents are, who wants to come and do an elective with me, uh, in all this time. So I do that as well. If anybody is interested. Oh, amazing then, uh, yeah, we can arrange for medical electives as well for that. And just general, you know, uh, not just about medicine and if any questions, yeah, you can share my email, you can share my phone number as well. That's no problem. Uh Well, thank you so much for fusing, for talking to us today. I really appreciate it. Um And if there's no other questions, I think I'll end the session. Thank you very much. Thank you. Bye, take care, take care.