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Hello, everyone. Welcome to today's webinar. My name is Vanessa and I'm going to take you through the pathway of higher surgical training in the UK. If you guys wouldn't mind just um texting me in the chat that whether you can hear me and can you see the slides? Ok. Right. Um I'm just assuming that you guys can hear me and um see the slides properly. So I'll just move forward. Um I'll give you a little bit of background of myself and um which may give you a perspective why I'm talking to you about um this pathway. Uh So I am a international medical graduate. I graduated from um my M BS is from Bangladesh and then I moved to UK in 2016 following my post graduation um back in home, um which included M CPS and F CPS, which stands for Fellowship of um college of Physicians and Surgeons while doing that. I also um finished my MRC S and then moved to UK as an um in an a service post. The first post I joined was a trust grade post in a warden hospital down south in UK. Um After that, the post graduation I initially pursued was a postgraduate certificate in the Royal College of Surgeons of England, which is an online um course and is divided into modules so anybody can do it while they're working. And um recently going through the training program, then I have subsequently completed my FR CS. Um I'm a current surgical trainee. I am in my final year of surgical training, which is called ST eight and I'll take you through the, the training program and stages. Uh I'm associated with the University of Aberdeen because I work um in Aberdeen, Roy Infi and uh with my full time training, I'm also doing an online master's which on oncoplastic um the breast surgery under the University of East Anglia. Ok. Um I'm currently the Secretary of um Mammary Fold, uh which is a training forum for the association of breast surgeon. And I think um above all, I am a mother of two Children and a wife. Yeah. So in moving forward, the surgical program in UK is in different phase. So when you have become a medical graduate, you initially start your training as a foundation year doctor in, in my um country back home, it was called Interni Internship and I'm sure it has got a different name in different part of the world. So that's before you get your full registration, you do your foundation year one and foundation year two and then you progress to a subsequent different stages of your training program, the higher surgical training program itself in divided into two phase, which is um initially you do um the phase two and um which is four years and then you do your final phase three, which is two years. So altogether it's a six year training. Um the people who are uncoupled trainee, which means that you may have come across the board, that core trainee when they have completed the core surgical training, which is phase one, which lasts for two years. And that's the duration when you do your MRC S, then you go for applying for a national training pro training selection process. And you are given a national training number, that's a competitive interview process and you have to um qualify to get the national training number and you then placed in different parts of the UK for your heart surgical training. So this is the basic pathway. So following your undergraduate completion, you do found in year one and found in year two. And most of us will have, if we are international medical graduate, most of us may have had done it in our own country and then may have come to um UK or you may have continued to work there and have significant substantial amount of your experience and then you move to UK in different level of um so post so to go get into the higher surgical training program, you need to either completed the core training program or you need to have ac alternative certificate for this um core training pathway which can be achieved while you are doing your service post in different hospitals as a trust grade trainee, as a trust grade doctor or in different levels of clinical fellow. Um You can get that certificate signed off in an alternative pathway, which is what I have done. I have worked in Nottingham. Um So I did my um alternative certificate for course training while I was working as a trust grade doctor in Nottingham. And then the the standard pathway would be, you would then do complete your course surgical training. You have completed your MRC S and you would apply for the surgical training. If you are selected, then you get the post called specialty registrar or ST three and your ST three post will take you to your ST six. So four year of training and when you are going through this training, you will be placed in different hospital uh under as gene. So you the UK is as divided in multiple genes. For example, the Scotland is as a whole, a single gene. However, we have got north of Scotland, west of Scotland, um et cetera where you would be then under the diary. And it may mean that you have got a couple of hospital to rotate through your training. For example, in my instance, I am north of Scotland trainee. So I have the options of working in Aberdeen Roll Infirmary um and Inverness which is um Wigmore Hospital. However, if you are in Glasgow, there are multiple other hospitals. For example, if you are in a London trainee, you will have multiple hospitals that you have to rotate through um and so on and so forth. So while going through these four years of training, you will have been exposed to different specialty. So the mandatory specialties that you have to have is one year of upper gi, one year of lower gi six months of different other specialties which can include pediatric surgery, breast surgery, endocrine surgery, uh or transplant. However, these are optional. You must have the colorectal and upper gi which also includes H PB by your year um four, meaning when you are before your special ST six, you would then need to declare your interest of the subspecialty. So whether you want to be an upper G IHP surgeon, colorectal breast, endocrine and transplant, whatever you choose, you have to declare to your supervisor and the training program director. And depending on your choice, then you will be placed into your final years, two years of training in that particular specialty. So going through this training program, that training program aimed to prepare you for your consultant job. For example, you if you are coming an international medical graduate with a significant amount of experience in under your belt, you may decide to go to the alternate pathway and try and to seize achieve the registration and go for a consultant job. The same thing is while you are in the training program, the training program is mandated to train you, which actually means that you are ready for a day one consultant. So the training program has now been resigned in recently in 2021 which then identified the areas capabilities in practice and um general professional capabilities to achieve and how you do it is going through the work process by your self detective learning, attending different courses. Um You can achieve these things in the training program. You are assessed in on these five different capabilities in practice, which includes your outpatient clinic, unselected emergency, take your ward round and ongoing patient care, which is the inpatient care basically and how you lead and manage your operation list and managing the multidisciplinary team working. The contrast to what I have been trained back home and you probably for many of you is our main attention was in the training program to be competent in surgical skill. Whereas you can see that this is one part of the five different capabilities which are get assessed. And I believe I don't have any experience in seizure pathway. However, if you have to achieve the seizure pathway, you will have to prove your abilities in these five different areas as well. Ok. And then you have this nine different general professional capabilities and which includes a professional values and behavior, professional skill, which is basically our surgical skill, professional knowledge, which can then get assessed by your case based discussion or your passing your exam capabilities in health promotion and um fitness. And this will be assessed by, you know, different modalities that can be feedback from your colleague that can be different assessment that you go through um capabilities and leadership and team working. So while in the training program, you have to prove your leadership skill by doing different um roles. So for example, um managing AORTA managing um MDT or man doing a journal club or running um the different societies, et cetera. Um Domain six is the capabilities in patient safety and quality event, which is, you know, which a very um has got quite weightage when you are applying for your consultant post. Um where you have to show your understanding and commitment to patient safety and quality improvement, which translate into a practice is whether you are able to do an audit, whether you're able to lead an audit and identify the patients have tissues where things can be improved. Um Domain seven is capabilities in safeguarding uh vulnerable groups. For example, if you are coming across a um child abuse um identified in the clinic or identified in the A&E. So whether you are our of the process of, you know, child safety and safeguards, and there is a always a pathway in your individual hospital, knowing about the pathway and being able to um refer the particular child or if it's an even a adult knowing that pathway and being able to execute. That is one of the abilities that gets, gets assessed. Um capabilities in education and training, whether you are a teaching field or not. As a doctor in UK, you are managed to contribute in training um and teaching. So teaching your junior doctors, teaching your junior colleagues, medical students, having a um clinical teaching fellow post and being you know, in involved in medical education, et cetera, all counts and all um get assessed finally um capabilities and research and scholarship previously for your CCT. That means completion of your training certificate. You would need three first daughter um publication, which has been changed now. So you don't necessarily need uh publications you need is um to prove that you are involved in research. And um if you have got publication, that's great. And how do you prove that you are involved in research? So you can get involved in different um Multicentric studies. You can help with national studies and trials for recruiting patients. You can become uh one of the associate P I or a trainee lead for your hospital um while you can contribute data to the Multicentric um National Audits and that also prove your capabilities in research and scholarship. Yeah, please do. Let me know if, if I'm going through very quickly or if you have got um anything that's not clear sorry for this busy slide, but it just shows you the things that I have just talked about you, the CPS and GPC S are actually altogether, all the descriptors altogether is assessed as how, whether you are fit to become a consultant, general surgeon or not, each of these component will be assessed in a different by, by different um assessment process. And how as I have allured before that by how you would achieve all those um SPN GPC S is via working or getting um teaching and attending different courses. So the UK um working pattern would be that if you are in a team where you do acute work, so your, you will have nominated elective days and there you will have your oncall days which is the receiving. So some like in um our hospital in Scotland, we call Receiving Day, which means that you are on call, you'll be carrying a bleep or Ascom where you get referrals from different emergency patients, from A and D from different part of your hospital. And then you would manage those patients under the supervision of your consultant. There'll be always a named consultant. But um if you are the higher surgical trainee registrar or as a trust grade doctor or a senior clinical fellow, you may be doing the same job where you carry the bleep and as common and you are the leading of your junior team, just one step down to your consultant. So actually, you are running the hospital especially overnight. You are the one that making all the decision, whether you want your consultant to come in hospital, whether this patient needs to go to theater now and or if not now, can this patient wait until morning, et cetera? And obviously some of the training program um is um delivered via different courses and teaching days. So each gene you will have different um pattern. So there are some of the gene has got once monthly every one day for teaching day. Some of the gene will have every three months or every four month dedicated 34 days of teaching. And there will be some mandated training uh courses that you have to attend or there will be um some prescription that these courses should be done. For example, um before you apply for your high surgical training ATL S and um the cris of course, are what mandated. And obviously, when you join the training program, then the laparoscopic basic laparoscopic skill course, advanced skills course and your evaluation of a R revalidation of the uh trauma courses, either you do a L ATL S or a different one, but you would need one. So this is the J CST, which is the joint committee of surgical Training who um the committee looks after the training program. And if you go to that website, I have the link at the end of the presentation where you can use that link to go to the website and find out as the what are the different training pathway as you get trainee, how, what to expect the certification type. And if you are wanting to do an CASA pathway, et cetera, all is populated there along with them curriculum. So, um so far I have talked about that how the training program is deliberate. So now while you are going through the training program every year, you from your ST three on you have got um assessment program which I see whether you are progressing as expected. So um it's not such an exam, but it's just you will have to provide all the evidence and a me review meeting will happen where your portfolio will be looked at and whether you have achieved the competencies and whether you are good to go to your next level is decided, most of the trainees will do, but there will be always um at one stage or other stage of your training that can be um issues raised and which can be then raised in different ways. So how this um training program is monitored is via one thing called ICP. So Interco or Surgical Curriculum program, which is an paid website where you can document um your progression, you will be assigned an educational supervisor. So for every six month, you go to an hospital under your diary, they will nominate one of the consultant as their educational supervisor. And I guess if you are a um not a trainee but a service post. When you specialty doctor or you are a clinical fellow, you, when you get your service post, you can always speak to your manager and make sure that you have a nominated um supervisor and you can actually use the ICP and E log book as the trainees and keep documenting things. Um So ICP is the program where you can document your case based discussion, your assessment of your work based assessment by doing a PDI I will, I'll show you guys how to do that in a minute. And the E log book is the log book where you can probably, you have had that same thing back home. We had a paper form where you have to collect the patient details and what procedures you have done and what level of competency you have done that. All this gets assessed in your RP every six month and every year at the end of your, every um special trainee year, then you get an outcome from your RP. Outcomes can be 1 to 6. If it's all good, you progress to the next stage. So it's RP one. And finally, we have, when you have finally, everything um is done in your ST eight, then you get to proceed to apply for your CCT. So what, whatever you do the in your CP and GPC, they get assessed in different level and the level that you have to achieve um to end of your training is a day one consultant. So different phases of your training, you are expected to achieve different competencies. So for example, if you are finishing your phase one, level two is acceptable, but there will be particular um certain capabilities that you would be expected to be level four. For example, you would expect a court trainee to be able to prep and drop a patient um safely inject local anesthetics safely, close a wound. And same again, when you have progressed to your heart surgical training, and you're finishing your phase two, meaning that you are est six, then you will be expected to have those competencies up to the level of at least level three. And finally, in, in your stage phase three in your ST six and ST um sorry, seven and eight years, you're expected to then um start to show your abilities at level four. So you are independently doing uh things as a day one consultant. So um yes, it is the same summary that I have just talked to you through that. If capabilities of practice in individual all five domains, you will have to have level three at phase two, meaning at the end of your ST six year and phase three at the end of your S TA R, you need to have level four. And um this is just to show you that how this assessment system um leads, helps the AES to produce a report. So depending on your work based assessment and depending on the multiple um MSF uh a different feedback from your colleagues, MCR which multi consultant report, all these get assessed and the result of your examination, all these get concern, get um consulted and your educational supervisor then will write a report for you every year, whether you are achieving in the same pace that's expected and whether you can progress to the next level that will lead to the annual review of competency program RP or a RCP outcome. So, um for recording your progressions to the ICP, I'll break it down at each stage. So the J CST has this ICP website which you have to go and subscribe. I'll show you the link and how to do it next. When you have done. Um you and you are in a training program, then your TPD will allocate an, a educational supervisor and you then have to create in your portfolio in your learning portfolio. You have to then create a learning agreement and create um the different um learning outcomes that you would want to achieve within this six month. That will be agreed with your educational supervisor. And subsequently, you will have three different meeting in over the six month, which is initial meeting, midterm meeting, and final meeting. And you will be then um initially will be given a target and then whether you are achieving it and how then supervisor can facilitate. That is what this um the meeting is supposed to be for you will uh add rest of your consultant group as a clinical supervisor who will be also assessing you because your assessment is not only done by your supervisor, but the other consultants that you work, you can get assessment for different procedures that you do or case based discussion from individually from them as well. And remember that for your CT, you have to have all those um PBA or work assessment signed by three different consultant. So it's not that for example, uh you, you are able to do an appendicectomy, but it needs to be level four PBA signed by your educational supervisor and two other different consultant. It doesn't necessarily need to be a educational supervisor, but it needs to be three different consultant signing you off for level four for each of the procedures. So this is a summary that I have already au two is um under each gene, there will be multiple hospital and the trainee will rotate through different hospitals for six month. And I have been lucky that I have actually did my all phase two in Aberdeen roll infirmary. But most of the hospital you work, you will have to rotate every six month if not every one year. And as a trainee, you get um certain number of study leave and annual leave. So you can um use those suddenly for different courses, conferences or exam preparation. Every has got a certain amount of budget for you to help you to attend different courses. But you have to have that agreed with your educational supervisor and then approved by your TPD. So, um I think I will skip this because I've already covered that. And this is just to give you a glimpse of the sa conditions that you have to have level four from three different consultant. So for example, um you will have to have strangulated, obstructed hernia, intestinal ischemia, intestinal obstruction. So all this procedure, acute pancreatitis is a physical perforation, upper g anastomatic leg. All this individual topic is named as a critical conditions and you have to have level four from your consultant. And for surgical procedure, there are certain cases named index procedure and you have to have level four for those cases or certain um cases maybe level three, but that'll be already described in the IP that which are the cases that you have to have level for. So, um and the level four just explain that level two means that you can do the procedure, but you need guidance in most of all, all the proce, all the steps level three is you can perform, but they're probably the consultant had to do a little bit or has to show you um a certain step. And when you are level four, that you can actually do the procedure, um when you maybe you have done it with your junior colleague and your consultant wasn't scrubbed. And in level four B well expected that you can do the procedure by yourself. And you can also, um, anticipate or deal with the complications. So, these are the index procedure for general surgery. Well, in your phase two, you will have to achieve the number of this. So, inguinal hernia, you need 50 laparoscopic cholecystectomy. You need uh whether it says cholecystectomy but mostly laparoscopic cholecystectomy, total of 40 segmental colectomy, 15 emergency laparotomy, 45 appendicectomy 60. And these are the cases which you actually have done assisting. A procedure doesn't count here. So it'll be supervisor trainer, scrubbed, supervisor, trainer and scrub or whether you have performed and whether you have trained somebody else, if you are a experienced doctor who is going through um planning for Caesar pathway, you probably still can count all the cases that you train your junior or you have your other colleague doing it. So it's a reciprocal, you know, win, win situation where you get your number and you are also training um your other colleague who can then get that number in the logbook as and supervise a trainer scrubbed and you get the same number as a trainer. So all those um count, but at these are the certain cases and at the end of phase two, this is the number that you have to achieve. I mean that by your ST six, you have to have this number in your logbook because ST six is a landmark where you, your RP actually ask us quite details about the achievement that you have done so far. And the end of um phase three, while you are ready for your toxicity, then you have to have emergency laparotomy 100 appendicectomy, 80 cholecystectomy 50 segmental colectomy 20. And obviously, you can see that by this time, we will have to have level four signed by three different consultants for this. And this is to record that. How many level four have you got? For, for example, for emergency laparotomy, you have got nine different consultants or nine different PBA signed up as level four. So you will record that here and these are the numbers for different specialties. So if you are special interest is colorectal upper gi you will need this number even though to, you know, on paper, it looks like some of the cases, things like, oh, this is not many cases but yes, sometimes in training program, it's depending on where you're working. The number may not be easy to um get all under your belt or under your name. So for example, um I think there should be one for um for major HP procedure 35 in your phase three probably will be the time when you will just start to do the major procedure. For example, pancreatectomy or you know, part of HS procedure and you have getting those signed off as level four in your just final two years isn't an easy process. So um there are some topics in the syllabus that probably is better trained by through the courses. So for example, the trauma scenarios and emergency um situations where the the training program is best delivered by the simulation. And um it is a safe environment for you to practice and rectify yourself if there's anything needs to be improved um for trauma scenarios. So for trauma, you don't necessarily need to have ATL S, you can also do European trauma course and a definitive surgical trauma skill course or equivalent local providers which has also have the same outcomes. You can also do those. Um you have to remember that whether you are doing breast transplant, um vascular, all of this specialties trainee will need to have some sort of trauma course certificate under their belt when they're applying for the CCT. And if you have done your ATL S before your ST three for surely, that will expire and you will have to evaluate it near at the time. Um So now I will take you through the ICP. If you guys have um a mobile device along with your laptop or vice versa. If you are watching in one device, you can use your other device and you can type this ICP WW dot I scp.ac.uk. If this is something new, I'll take you, take you through the steps, but people who are already oriented. Uh and know about this apology if this is very simple for you, but this is mainly for the new people who are um trying to get into the surgical training program. So this is um paid website when you can register yourself. So if you go into the website, seeing this, um on your left hand side, you will see that login. If you have got it already, your account, you can log in by your email and password. If you're not a member yet, you can register here. Ok? It's a very simple process. Um So you just click on the website and then the website will ask you whether you are a trainee who wants to use the ICP for recording progression or you are somebody who wants to evaluate other people's or assessment for other people. And if you are a trainee who use, you need to pay and if you are just registering because you want to access other people, you don't have to pay. Ok. So when you have gone into that, um ICP, you will see that there is on the top bar, there are menu dashboard, learning a portfolio and frequent questions. So in the main thing to go for to II think the the most important thing is a. So by clicking the ad, you will have different uh dropdown option to add different work based assessment. However, if you are a trainee, I think learning will be your other important area to work on. So if you click on the learning, then this um that will come out where it's, you have to then select who you want you to be your lead clinical supervisor. So I have told you before that you will be domina, you will have a nominated educational supervisor. And then in this um area, you will have to decide who is your lead clinical supervisor in a smaller uh hospital. And in smaller specialties, usually the lead um clinical supervisor in a is the same person, but it's good to have two different supervisors if you can. So you will then nominate one of the other consultant who is not your educational supervisor as a clinical supervisor, lead clinical supervisor. And the reason behind this be, you will have to have um multiple consultant reporting system in at least two times during your six month placement and they will be the one who will initiate that. So we call it MCR. Obviously, in your first meeting, you will have an objective setting meeting where you would decide within this six month what you are expecting to learn and what you want to achieve from this. And in the midpoint, you will have an MCR. So the multiple consultant who have worked with you, they will give their feedback and you yourself will self assess yourself that what you have achieved. What do you think? And obviously, then you, when you have done your meeting, this meeting will be completed and then you will be able to progress to your final MCR self assessment and final meeting. And this all needs to be done before your RP. So say, for example, you are doing a six month placement and your usually the placements run from February to August, even though it's February to August, your RP meeting is usually um early June. So you will have to finish all those meetings, et cetera within May at the end of May at best. So these meetings, I believe as if you are doing a Caesar pathway and if you're a specialty doctor, you still can use this ICP, you still can use this uh platform with your educational name, supervisor to record the progression. Different hospital will have a other portfolio options as well. I'm sure if you attend other webinars where see the pathways are more discussed in detail, they will able to be guide you next. Um The same continuation of your registration process, which is very self-explanatory, a little bit of yourself and uh creating a password. Now, when next I'll talk you through the ad tab where you click the ad, then this different um options will come through. And I think the most use buttons are this one where you can use record assessment of your audit case based discussion, case, um clinic, uh consent, clinical assessment, um so on and so forth. And the most important thing, the most um commonly used. One are your case based discussion that's called CBD or your procedure based assessment or PBA. And these are the other evidences. Remember that the CP and the GPC is that gonna be assessed? And you will have to have uh something under each of these heading to prove your competencies. So I'll just give you an example that how you can um record your assessments. So if you have done an acute appendicitis or, or if you dealt with a patient of an acute appendicitis, say, for example, you were on call, you saw a patient, you diagnosed the patient with acute appendicitis and then you managed to perform the procedure. So the assessment that you can get out of that is you can get a case based discussion, the on call consultant with who you have discussed the case presented the case in your handover and um discuss the management option, et cetera that can be documented as a case based discussion. So what did you do is you go to your ICP, you click a click the case based discussion, fill up the form at the end. There'll be a button to say, click if you want to send just now via email. So your consultant will get the email for the link of this assessment. And when they have signed you off, given you a level, then that gets added to your portfolio. Same, you could have a clinical evolution exercise um assessment done. If, if your consultant has that were present when you are clinically assessing the patient and you have discussed with that um that also can be documented. And if you have consent, the um the patient for the procedure, you can also get an assessment for clinically reation exercise for consent. Finally, when you have done the operation independently or you know, supervisor scrubbed or uns, you can then document that by doing a procedure based assessment, which is called PPA. Yeah. So this is the tab where you will, when you have said click add and you have decided to um do an CBD and this is the part where your supervisor will get comments. So they will give comments under the heading of general, your general assessment, your strength, what you have done really well where it's at for the development and what what will be their recommendation and you yourself will also record um that what you have learned from this individual experience, what you did well you think and what you can improve and how you're gonna achieve this first for individual cases. And the procedure, we will have to document that. When you send for in case of case discussion in the ideal world, you would want to sit down with your consultant, have a discussion about you present the case and, and discuss the pros and cons and then get the record um signed off. But most of the time it's like on the go. So if you have done it on call, if you have got a few cases you have dealt with, you can always request you consultant that can I send you an work based assessment? Can I do an CBD with you? Um And just a team that you know, everybody is different and the consultant has got their 100 other things to do. And this is one of the other um admin work we are adding when we are sending, even though it's, it's part of the responsibility, but the clinical work is um gets priority. So you could maybe ask your consultant whether they want you to fill up everything. So some of the consultant will like you to assess yourself and you write your reflection and what you and think that what the consultant is thinking about you. So you write everything and they can always have um if they agree, they can keep it and if not, they can always edit it for you. And at the end, this is the global summary where they individually have to give you a level for whatever um case based discussion or work based assessment you have send them for now. And I don't know, this is very um but you guys can read it because it's um I just wanted to give you guys a flavor that how it looks like. So this is an uh I think this, this is one of my reflective um case based discussion where I had dealt with a patient who was having a suspected gi bleed and how I dealt with it. And what I thought that I have learned from the lesson of this um case and how can I get better? And this is the feedback I got from my consultant. So when a work assessment completed, it will look like this, so that'll be filled up. Um Most of the time, you don't necessarily have to have, you know, filled up every single areas, but it'll be good for you to do all the um the reflection that you have to do. And I myself initially found this very irrelevant. But as I go, um going far and far through my training, I actually find now it's very useful. So if I am writing a reflection of a case, um a procedure that I have done and then I'll go through the steps in my head that actually what I have done what I could have actually done differently or no better, whether I could do this thing or that thing to get improved. And I also now started to pick up while the consultants you are doing the procedure, they will say something passively, either an appreciation or a criticism. And when I'm writing the reflection, this all comes back to me and I think that adds to my thought process and contributes to my improvement. Now, you have um done the assessment on your IP So this is an ongoing process. So you have to carry on recording your progression in the ICP. However, for your particularly for surgical procedure, you have to have your logbook where, yeah, we'll document the procedures that you have done, whether you're assisted, done under supervision without supervisor scrub, you have to document it. And the most popular one, the one that we use in UK is ww.logbook.org and it has, it is free access. So uh all four different uh Royal colleges commonly using this website. And it's again, um very easy to register. You go and you register with your name and email. And then when you start logging in, there is an button called a operation. When you click on it and you will have then the option of adding the patient, the you will need the patient ID, but you shouldn't record anything which can identify the patient. So patient ID, date of birth and then your procedure, uh what procedure you have done and whether it's you have done at what level so that all gets recorded and you can produce a consolidated report from this logbook which will tell you that how many different cases you have done and what was the level that you have achieved? Whether you have assisted or whether you have performed it. So at the end of your six month or one year before your RP, you can produce this consolidated report and submit to your A Yes or submit to the ARPI panel, right? So I think that the two main chunk is dealing with I SCP and log book. And when you have um achieved your ST six sign off, then it's a stage when you will be applying for your FR CS. So for your exam, you have to have your RP outcome one for your ST six and you have to have a recommendation from three different consultant that you are ready to sit for your Fr CS. And then you will go to your J CS two website and apply for the examination. It's um usually near ST seven or you can do it in ST eight, your Fr CS and when you have done, completed your F DH training and you have done um your past your exam and you have achieved all the other evidences required. You'll be then able to apply for certification CCT. But the CCT can be applied in the seizure pathway. If you go to the J CST, they have got a uh dedicated area where they will guide you how you can achieve what are the evidences you need. And there are different webinars and a different group. Every Royal colleges is not supporting this SAS or specialty doctor for going through this pathway and they will be able to help you. Now, I am almost at the end of my long presentation and these are the websites that I have used in this presentation and most of the things that I have used here is either a screenshot or exactly, um, taken in the wording that, that is on that website. I have tried an IZED thing and there shouldn't be anything, um, identifiable. However, if there is anything, my apology and it is very unintentional. Sorry. That's the end of my, um, presentation. And I'll be really thankful if you guys would take a few minutes to give me some feedback for future reference. And um anything specific that I can improve on you guys can write down the question um in the question answer, um tab or if any of you would like to speak. Um Please let me know. I would um then bring you to the stage. I have randomly um picked two people and send invitation to the stage so that you guys can speak. So if anyone of you would like to say anything particularly any question, I'll try and answer that it's a long presentation and there's um so many things covered if you are new and it's and really heavy presentation. But if you are used to working in the UK, you know, a little bit and you are trying to organize yourself um a bit more. Probably it's a bit easy on you. Thank you doctor that it was a nice and thank you. Um So far Bucker, I just have seen a glimpse of yourself. Um Yeah, I if you wouldn't mind. Um, if you would like to keep your video of that. Um Yeah, it's all right. You have a question, please. Um feel free to ask and demand. Dar has asked after entering into the specialty training, when the trainees will be given placement in breast surgery. If they want to pass car ons breast surgery. It's a very important question iman and very close to my heart because I am a breast trainee. Um So when you have decided that you want to be a breast trainee, um you would then have to declare it uh before your ST six. And as you know, or may not know that in breast, there is two different pathway. Uh you can do a general and breast surgery, you can do oncoplastic breast surgery. You have to declare that. And if you want to do general and breast surgery, that means you will continue to work um on with the general emergency, general surgery plus breast surgery in your final years. But if you are planning to do the oncoplastic breast surgery pathway, the recommendation is that you stop your emergency on call um around ST six and then you progress to just do dedicated breast. But um for example, I have stopped working um the emergency work after the first six month of my ST seven when I have completed my examination because the Fr CS is a general surgery examination and you would um need to really keep in touch with the uh practicing general surgery. I would say if you are going for the Fr CS exam, um for oncoplastic breast surgery, this is now a challenging time for us where we are just going through this phase and not all hospital, all unit will equally offer you the oncoplastic procedures. So, um if you are, if you can um qualify in your interview well enough, then you'll be placed in the higher ranking units where obviously they'll be doing more on procedures that gets easier. However, if your training program, the diary is not able to offer you everything. You can always speak to your TPD to go out of diary in different other centers where they can help you achieve your numbers, your competencies. I hope that answers your question. Hello. Hello. Do you hear me? Um So far baa whether this session will be recorded, I'm hoping that it will be recorded on the medal and should be um available after this event um as on demand, but I'm not 100% sure. II have not used myself a medal individually and I have places you know, presented in different other uh under a different other association. I have got a breast surgery presentation if you guys interested under the preparing a carrier in surgery um by Aci Association of Surgeons in training. And you could maybe have a look in that maybe demand that you will find it useful. Um It's just my head on as a secretary of the Memory Fold, which is the training Association for um Association of Breast Surgeons in the UK. You can get a membership which the link here and you can use the QR code as well. Um where you, if you are ast three, trainee or earlier years trainee um you up to 33 and after that, it's just 50 lb subscription, but you get um the regular newsletter telling you different information about courses, conferences, important national audience that you can get involved. So it is very useful. And um obviously you can apply for different roles like being a regional rep, which also can then count in under your leadership um and management capabilities that you, you can prove that you have done um a role. Um you know, as, as equally, you can be a rota coordinator in your department that counts if you are running an um journal club, an Equality Assurance meeting, everything counts. I think II will stop here today. And obviously, if you guys are interested, let me know I can then maybe go and speak about the other stuff, the other evidences that we need in our portfolio. I hope this is helpful for you guys and good luck and keep myself in your prayers as well and we will grow altogether. Bye for now. Everybody then have a good night.