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Now marks the beginning of the specialties. Part of the, of the day where you're here talks about every single specialty. So without further ado, I'll pass you over to Mr Matt Browning to talk about ot surgery, the flaws. All yours. Ah, thanks very much John. Um, hopefully everyone can hear me. Please let me know in the chat if you can't, I've muted myself accidentally. So my name, my name is Matt Browning. I'm S TA in General Surgery and Upper Gi in Torbay in South seven NHS. Trust down in the south of England, um, which is a great place to train and I'm very lucky to work there. Um If you're considering a career in uh upper gi surgery, I'd strongly recommend joining a switch for um, training members is only 50 lbs a year, I think. Uh, and the RO group is the trainee part of that and they provide a lot of education and training. Uh, and there's yearly conferences that we put on, um, which are great, you're probably members of asset already. Um, but if you want to join the British Benign Upper Gi Society, um, then that is free and that's a, that's a good resource for guidelines and things like that with regards to upper gi issues. Um, so what, what is a gi surgery? Well, surgery, surgery's about tension and pains and hard work and diligence and all those things. But it's really about blood supply. So you can't remove an organ, uh, un unless you've safely, uh, dealt with its blood supply and, uh, you can't leave an organ in unless it still has a blood supply. So you need to know where the blood's coming from. Uh, and either take that supply or leave it. And up g eye surgery focuses on the organs which are supplied by the celiac axis. So I never really knew why that was an axis till I saw it. And it's, it's called that non artery cos, it's only about a centimeter long. It's just a tiny little stub that comes off the aorta. Uh, and then it branches and supplies the stomach, the liver spleen gallbladder, uh the pancreas and the first part of the duodenum and branches also head up to the lower esophagus as well. So, um, so it's very important and we operate as upper gi surgeons on all those areas and also on the higher esophagus as well, which is supply segmentally. Uh So to get into upper gi surgery, you need to train in general surgery, which probably should be renamed gastrointestinal surgery or gastrointestinal abdominal surgery. Um, although it hasn't quite been yet because we still have breast, we used to have vascular and, you know, general surgeons used to do all operating really um when there were a few of us, but it is now subspecialized. Uh and it's just gi surgery in breast really. Um all general surgeons have to train in emergency general surgery, breast surgeons only up to ST six. but if you colorectal, an upper gi you'll have to do a credit in emergency general surgery. Um, colorectal is covered by somebody else later on. And uh, upper gi is split really into several sections. Hepatopancreatic bi surgery will be, uh, spoke about in more depth by a colleague of mine later on. Um, so I won't go too much into that, but it's surgery on the liver and the pancreas and the pilary system. Um, upper g eyes also split into esophagogastric cancer surgery, um, and also into bariatric or weight management surgery where you might rearrange somebody's stomach and intestines in order to, uh, to induce a weight loss state, er, and into benign upper gi surgery, er, which is what I do, which, where we don't operate on cancer. We don't operate for weight management. Uh, but we operate for reflux and for gallstones and benign conditions of the stomach. Um, we also do a lot of abdominal wall and hernia work and uh, and provide emergency general surgery. If you want to do esophagogastric cancer surgery, you can do the other two as well So your center will be somewhere quite big. Um And you will be able to do bariatrics if you want to and uh a lot of benign upper gi work, uh, whatever upper gi specialty you do, a lot of it will be based on gallstones. Um I just looking at bariatrics there. You may not be that familiar with, uh, with weight management surgery, but that is a diagram of a gastric bypass. So you just make a tiny little pouch of the stomach. Most of the stomach is bypassed by the food and then you rearrange things to lower down so that food can go through without bile coming back up your esophagus. The alternative is a gastric sleeve where you just remove most of the stomach, leaving a thin sleeve, um shaped bit of stomach. That operation has been shown to be clearly inferior by the by band sleeve trial. It's less good for weight loss and that directly uh links into quality of life and well being. Um it also gives you horrible acid reflux, but nevertheless, it is still performed because I think it's easier and quicker to do than a gastric bypass. Um So as a benign upper gi surgeon or as an upper gi surgeon, uh in OG be HPV, what might we do? Well, I mean, you might say that uh gallstones are an HPV thing, but in fact, they're dealt with by all upper gi surgeons. Um If you don't like taking out gallbladders, then you should probably do colorectal surgery if you wanna be an abdominal surgeon because, um, there's an awful lot of gallbladders in upper gi and you can see there that's a nice gallbladder. You can see the goat ducts and bile ducts, uh, gallbladder top left and the assisted in between. That's a photo of somebody anesthetizing an esophagus, uh, to a stomach. So, uh, when you take out the esophagus, you make a conduit of stomach to reconstruct the lower part of it. Um That's a photo of a gastric sleeve. You see most of the stomach has been stapled off and removed from the abdomen. Um This is a, a photo of an antireflux operation. So, uh I mean, there is a good treatment for reflux but um that just makes your reflux non acidic, it doesn't necessarily stop it coming up. And for people that are still getting non acidic volume reflux come up in the mouth all the time. Their life could be really miserable. And surgery is um you know, offers them a solution to that. You can see that the stomach's been wrapped around the back of the esophagus secured with sutures. Uh the crural pillars of the diaphragm have been repaired and that provides good reflux control uh and is a very satisfying lifestyle operation to do. Um We also might get involved in assessment for reflux. So this is a manometry study assessing whether the esophagus functions. Well, uh and we also do a lot of endoscopies. So that's something to consider if you do gi surgery, whether you want to do colonoscopy or uh upper gi endoscopy as those people are doing. So that's uh quite a bit of the specialist work. But also we all, I think almost all of us will commit to emergency general surgery unless that's provided by a completely separate group of people in your trust. Um, so you might do a laparotomy, you might do an appendicectomy. Uh, you may even do a colectomy. I did a right hemicolectomy on Saturday night who I'm police say has survived so far. Um, you might get involved in abdominal wall reconstruction and me work, uh, or laparoscopic or open inguinal hernia and other abdominal hernia work. It's a very nice picture of the artery there. Um, and increasingly all of these things are gonna be done robotically. So I think there's quite a wide range of stuff that we do. Um, and, uh, I actually quite enjoy doing a bit of colorectal without having to do only colorectal. Whereas if you do colorectal, you really won't do any gallbladder. So I think you, you maybe get more of a span if you do banana giant, er, and a bit of so if abdominal surgery is for you, you know, why wouldn't it be? Um, but you don't like poo and that's not real one. That's just, uh, a toy for a joke shop. Apparently, um, then upper gi surgery is the one for you. Um, some people are put off general surgery because they think it's hard or, you know, it's difficult, stressful, you know, you work all hours of the day and night and I think some of those views are out of date really. Um, the on calls can be harder but as a consultant, because your, on calls take up a lot of your programmed activities. You'll only work 3.5 days during the week, the rest of the time. So, actually the work life balance is pretty good. I, if you want your life, your work life balance spread out quite easily, then something like breast surgery is quite good. There's no out of hours or no one calls, but you have to work five days a week. Whereas if you prefer peaks and troughs, you know. Yes, I work hard but now I've got five easy weeks then. Uh general surgeon upper gi could be good for you. Um, it is sometimes stressful. Any, any, any demanding job will sometimes be stressful, but it's almost ever boring and most enjoyable. Um, I enjoy going to work. It's good. Uh, I hate being bored. So, um, so surgery is good for me. Most work. It's currently laparoscopic. Make sure you like this. I mean, give it a go. Uh, it's not easy to learn so you can try on a box straight and you'll find it difficult um, but, you know, once you get the hang of it, it is nice that your instruments start to feel like uh they're an extension of your hands. You just think about what you want them to do and it happens just like driving a car. You know, you don't think about moving the wheel. It will become second nature. Um, consider taking up yoga or Pilates now to ensure your core is strong enough. Um muscular injuries among surgeons of all types are extremely common and they can be career limiting. So, um look after yourself, um less than full time training, er, is easily arranged. So I've got three Children, which I had two during co training and 11 in specialty training. Uh uh you know, that is tough, but II was able to train at 60% and then 80% for quite a lot of my training. Um and that was really helpful and the Deanery just agreed it straight away. So, um your work life balance can be what you want really. Um and it's, you know, satisfying you really help people that they'll be very grateful. And my wife met a patient in clinic this week, um who said that I'd repaired the hernia three years ago and he was really happy with it and he's still very pleased. So, you know, people, um people appreciate what you do and they remember it and it, you know, it is very satisfying. Uh I also like the teaching training, the team working. It's really rewarding. If you're a GP, you're just in your office by yourself all the time, uh, bes by patients. Whereas in surgery you're always working in a team that's always really nice. You know, people come and go, you meet lots of people, uh, lots of fantastic people. Um, and I find that really enjoyable. Um, if you do do cancer H PB or OG then, um, you, you need to be prepared to have a pretty full on life. You know, you'll be very, very dedicated. Um You got to work very hard to make sure your results are as good as possible. Um But, but people might find that more rewarding. Um And I think the bottom line really is that surgery is fun. Uh, operating is, is really fun, you know, it's enjoyable and satisfying. And, uh, if you don't enjoy it, then then you shouldn't, you shouldn't do this career cos the rest of it can be quite tough. Um, you know, long hours nights, weekends, early starts commuting. But, um, but if you enjoy your job, then actually it doesn't feel like work, you know, II look at my rota for the week theater sessions, maybe endoscopy clinic, endoscopy clinic and all my favorites. But I never look at my week and think, oh God, I can't, I can't do it, you know, I think II look forward to it. It's quite exciting. Um So you know, is it sustainable? And what will change? Well, robotics is a bit changed to make sure you've got some interest in that before considering cos I think more and more surgery is going that way, centralization of the on call, er, to reduce spend as a big current driver in the NHS. So that's something to consider, you know, where you work, you may not be able to work in very peripheral places. Um, cancer treatments are changing really rapidly. There's incredible research going on in oncology, um and cancer radio, um chemo radiotherapy and immunotherapy results are improving dramatically for esophageal cancer. So currently with neoadjuvant chemotherapy and surgery, the, the three year survival esophageal cancer is 55%. But I can conceive at a time in the near future where medical treatment alone might equal that and then, you know, doing an esophagectomy via a thoracotomy is really barbaric. So I II can see that fading a bit. I mean, who knows if it will disappear altogether. Weight management surgery also is gonna be impacted by GLP one agonists, solut and Moro and those things um difficult to know how, uh exactly. I mean, I think it'll be a bit like PC and cardiothoracic. I mean, there were training huge numbers of cardiothoracic surgeons and then they started doing everything percutaneously. So I think there will be a reduction in weight management surgery and a reduction in esophageal cancer surgery, but it probably won't disappear altogether. Um, in terms of benign surgery, I don't think there'll be a medicine for gallstones. People won't want to take something prophylactically that they don't need for something they might not ever have a problem from. Um, it will inevitably have some side effects and then by the time you have gallstones there won't be something that takes them away quickly enough to, to solve your symptoms. So I think there will still be surgery for that. There's a good medicine for reflux, you know, PPI S have taken away an awful lot of emergency ulcer surgery. But nevertheless, people still get reflux. Uh, people want to take less of their PPI uh, they want to come off thermop sole, they're worried about the bone health. So I think there will still be a need for reflux surgery. Although weight management drugs might, uh, might reduce that, um, and a hernia will never go away. I mean, it's a physical problem. There's not gonna be a tablet that toughens up your collagen prophylactically that people will take. So there will always be hernia surgery and there will always be emergency surgery. I don't think there will be a, a magic treatment that, um, treats a bowel perforation or appendicitis or, um, all the things that we see. And in fact, given colorectal cancer often presents as emergency up to a third of the time. So there will still be emergency surgery. How about training in the future? Well, there's you know, there's an awful lot of work with training to try and make it better because you, you know, you don't do 100 hours of operating every week like you used to in the seventies, which did make you a good surgeon in terms of technicalities. But, uh, it left you perhaps a little broken as a person. Um, so there have been moves to sort of improve the, er, low number of contact hours by introducing simulation and things like that. And II think that's all really useful when you're inexperienced, you know, you can learn the basics on a model, but it doesn't really substitute properly for the real thing. So you're still gonna have to um train in the way that we do. Now, I'm not sure that will uh uh there'll be more robotic training, but I don't think hands on schedule training will go away. Um So how do you actually get into surgical training? So, uh two years um of foundation, two years of co six years of specialty training, you can extend that with research for some full time working, maybe a fellowship. If you want to do something subspecialty, there are sort of gates that prevent your progress unless you pass them. So you need the MRC S during call. In fact, I would recommend getting that as soon as possible because um core training is a really busy time. You need to pack a lot in to improve your portfolio to get an ST three number. Uh And if you don't have to do your exam, cos you've done it as F two, then that's brilliant. You're ahead of the game. Um Similarly to get out of specialty training, you need to fr CS exam, which you can't do till ST six. And that, um I found it easier than MRC S because doing 10 years of surgical training prepares you quite well for that, to be honest. So, you know, you, you need to revise but you have a lot of the knowledge already. And then after that consultancy for life, um I had to get into course surgical training. When I mentioned this in the chat earlier, I found this website just by Googling course surgical training requirements. Er, it was quite well set out and comprehensive. It shows you what you need to do. Um I summarized the requirements there which I won't go through cos I'm, I'm probably pushed for time but um essentially these goalposts change frequently. This is quite different from last year. They're now focusing on your best publications rather than the number of them. Um And they're really weighted heavily towards audit and quality improvement and um governance in terms of the scoring. So just make sure you've checked what the hoops are and just jump through them. I mean, they're um they require a bit of work but they're not, they're not difficult, you know, you can get support from your consultants with projects and things, you just have to put the work in and take the boxes that are, you know, they show you what the boxes are, just hit them. Um I'd say, don't do something, you've already maxed out, you know, just learn to beer and say, oh, I'm really sorry, boss. I've uh I need to focus on other areas of my portfolio at the moment if they bring you an audit when you've already got amazing audits. Um So how to prepare for training? I mean, this is probably covered in other talk to an extent. But so what I did was three years of ATC S anesthesia thinking that would uh be my career. But um but I found that boring and frustrating, but it did give me a good portfolio for getting act job, you know, lots of teaching research and auditing exams, ability to manage sick people. Um It didn't help so much for ST three training. Um And for ST three interviews, uh because I think I was expecting the wrong thing from the interview partly. Um And, and I spent a lot of time as an sho uh I did plastics in the NT as well. II didn't really have the operative skills I needed at ST three and took some time to catch up. So that's what I did and I wouldn't recommend it. I'd say you should learn the basics outside of theater. So how to scrub. Um not tying suturing lap skill, even lap suturing, you can learn at home if you get good at those. You know, you're a bit ahead of the game, come to theater as much as possible and do that in the right way. So, you know, pretend you're the sho meet the patients before. So the cases be humble but keen and persistent. You know, if you're there three days, you know, three lists in a row, the consultants gonna feel a bit awkward about not letting you close the skin. So you'll start to get some training and then once you can do that, you'll move on. Um If you sort of wandering halfway through, they're not gonna feel. So, um obliged to train you keep a log book of what you've done, keep googling the course of training application criteria and yeah, tick all those boxes evenly. You're probably not gonna get a phd. So, you know, don't, maybe, don't waste three years on five points, maybe double down on the audits, try and get a be audit and a better journal. Just be a bit smart about what you're trying to um put in your portfolio and you have a consultant with lots of projects. Every trust has somebody with lots of things going on. If you can complete some for them, they'll give you more so soon you'll find you've got a whole run of publications and presentations and then I'd say sit down, you know, by yourself or with your partner and, and plan your life, sort of vaguely, you can't decide exactly where you work or anything but you can make a vague plan. So, what do you want to do? And when, and what do you want to comprise on, uh, do you want to comprise on where you live or what your specialty is? If you want to do something niche like plastic surgery or HPV, or esophagogastric cancer surgery, you can only work in a few places and there are small numbers of jobs. So you're gonna potentially have to sacrifice, you know, where you live or, or other things to try and get that. So just consider what you're willing to comprise on, get your MRC S as soon as possible if you want Children. Obviously, it's not a command to do whatever's best for you, but I would recommend getting your national training number first cos you're a bit more secure for five or six years. Um I had kids as a core trainee and it, and it was really tough. You gotta fit a lot into those two years to try and get a training number. Um There's never a good time. So, you know, do it whenever you, whatever's best for you, but I think it would be easier if you had your national train number. Um, try and do some research at a junior reg. That's a good time to raise a family. So ST 45 don't be afraid to ask to work less than full time. It can be quite satisfying. Er, I was able to just skip clinic and ward round and just come to the theater. It actually worked out really well. No need to rush. Enjoy the process. Um, if you're not enjoying it, consider something else, you know. Yeah, you've gotta be at work all the time. So make sure you enjoy it. Um, and I think try and get ahead of the curve and get in as many cases as you can. So I say this to trainees all the time. I think the learning curve in surgery is fairly exponential with a very long flat tail at the bottom. So you can't operate until you can operate, you know, it's dangerous. So you're not allowed to do anything because you can't do anything. So you spend quite a long time with very flat skills and they increase gradually because yeah, you can't do it till you can do it. So you can only do a tiny bit in each stone, but then suddenly you can do it and then the consultants will make you do everything cos you can do it and then suddenly you'll, you'll be doing all of the operating all of the time. Um And your skills will take off. So the quicker you get through that flat bit, you know, the the higher your, your final trajectory would be, I would say, you know, if you wanna be world class at somebody. If you want to be the greatest ever, you gotta start when you're two years old or four years old, you know, none of us will be, um, will be Lionel Messi at surgery because we start when we're 25 it's not possible to be as good at surgery as some people are at other things because of that limitation. So start as early as you can and get off that flat bit onto the steep upward curve as quickly as possible. Um So in summary, general surgery is great, don't be put off by people saying it's difficult, hard work. But if you wanna make lots of money, consider orthopedics, if you want a restful life, consider otology or urology. If you have to be busy, get stuff done, save lives and cure cancer. General surgery is really good. Ok, so, um any questions, I mean, I can answer them in the chat as you if you want. Lovely. Thank you so much for your time, Matt. I really appreciate you. Um No, I'm I'm sure it was. We don't have any questions at present, but I definitely reflect a lot on what you said during my CT one general surgery rotation. Um But thank you very much for taking the time to come today just for the sake of time. I've asked uh attendees just to post questions in the chat. There may or may not be some but would you be happy to type out your answers if that's ok. Sure.