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Welcome back, everyone. We've now reached the last segment of our talks for the P four CS event this weekend and particularly today. So I'll now welcome on stage Ms Nicola Raftery, who is an S T three trainee in general surgery. And she's a rou asset representative. For those of you who don't know, the rule club is the upper GI Surgery Trainee Association in the UK and Ireland. Thank you, Nicola. Thanks so much. Sorry, guys ought to share my slides. Can see my slides. We can. Great. Um, so Hi, everyone. Hi, Ryan. Thanks very much for the introduction. Um, so today I'll be discussing on how to prepare for a career in upper GI surgery. Um, as Ryan was saying, I'm the acid regroup representative, and I'll speak a little bit more about the regroup a little bit later on. Um, disclaimer is that I am, uh, Republic of Ireland trainee. So, um, I've tried to keep the talk as broad as possible, as I realize that our application process is slightly different years. Um, but hopefully what I say will be relevant to you guys. And I'm happy to take any questions at the end so we'll get straight into it. So I'm just going to touch on surgical training pathway as a concept overall, um, and not go into too many specifics. As I said, our training pathways slightly different. Um, I'm going to discuss why Upper GI how to make a competitive how to be competitive in your application. Um, I'll touch on some research points teaching and leadership, um, groups and conferences to be part of and a little word on balance at the end. So to talk about surgical training. First of all, as I'm sure you're all aware, um, are start off in our medical school years, which can be a range of 4 to 6 years. We then in Ireland, we do an intern year for one year. I understand you have foundation years there. That can be 123 years. Then, at that point, you have an interview for your core specialist training. Um, where a lot of you guys would be at now. Um, core training is two years, and then you usually interview again to get onto your higher specialist training. It's at this point that you choose your speciality, which, if you're looking to do upper gi would be general surgery. This is then a six year program. Uh, then you have your fellowship, Um, or your CC s t Most people would do at least one fellowship. Um, prior to that, you would do your f r. C s exams so ways that this can be. As I said, higher specialist training can be six years. Oftentimes it's longer because a lot of people and take time out to do research. For example, out of program. Oh, sorry. Can you see my side stuff? Uh, apologies. Sorry. Could you see my slides? No. Okay. One second. Can you see them now? Okay. Uh, sorry about that. Um, so sorry just to go back here. So a lot of people take time at a program for research. This has become an increasing trend and upper GI to do a higher level, um, degree at least mch. Oftentimes it's MDs PhDs that people are doing. You can take time out as part of your core training or your special training. Your specialist training. Oftentimes it's specialist training. And then an increasing trend is this academic clinical training pathway, which is, um, an integrated PhD with your surgical training. Um, so that's another very attractive option. Um, that doesn't see you having to completely withdraw from clinical training. It actually becomes part of it. It's an amalgamated program. So surgical training. As I said, the higher specialist training is six years. As I said, if you want to pursue general surgery, then you pick general surgery. General surgery is an umbrella of a few different specialties. Upper gi being one colorectal breast and endocrine and transplant. Um, upper GI then is broken into further subspecialties. Asafa gastric resection. All, um bariatrics benign Upper GI hepatobiliary and transplant. I'll discuss each of those a little bit later. So why upper GI surgery? Well, these are my pros and cons list. So the cons Often people would say to me that Oh, upper gi But you're dealing with such sick and complex patient's and, oh, the hours are too long and they're relevant points. However, I don't necessarily agree that their absolute deterrence from the specialty the patient's can be very sick. They can indeed b complex. But I think it supports a very nice MDT, um, approach to looking after your patient's as upper GI surgeons. You have a really good relationship with your intensive ists. Um, critical care medicine. Radiologists, You know, you have You work really closely within an M d t. Um, which some people may see as a as a con. I personally don't, um the long hours, then I think all surgeries, all special surgical specialties can have this on their con list. It's It's the reality of it. Unfortunately, um, I I think that the surgery is an upper GI can certainly be longer. And this can lead to perhaps a longer working day. Um, so again, this is often what's quoted on a con list for upper GI the pros, which I'll focus on a little bit more. That's why we're here today is that I think Upper GI has extra has a massive variety associated with it. It's a very innovative specialty that's becoming more so each and every day. And just frankly, I think it's very exciting for reasons I'll touch on in just a few minutes. So just to go into those a little bit more, as I said, the variety is like, I think the different subspecialties with an upper GI are very attractive. They're all very different, very different procedures that you would be performing on a daily basis that are very challenging in their own. Right enough to keep you busy for a whole career. So, for example, of a sulfa gastric. Obviously you're dealing with your cancer surgery, bariatrics. Um, you know, you're dealing with obesity. Reducing surgeries and endoscopy has almost become a subspecialty in its own right. Um, it's becoming increasingly used not only for diagnostics, but in therapeutics as well. HPB is a massive specialty encompassing, you know, oncological resections and more benign procedures as well. And then obviously, transplant, um, is another big subspecialty. Also, in terms of innovation, um, upper GI, you know, is becoming increasingly associated with robotic surgery. Um, the urologist certainly lead. Lead the group out on the robotic front, but it's becoming increasingly amalgamated into Upper GI training now, and, um, becoming more and more utilized. Um, so not only do you have open a laproscopic surgeries, but you're only you're also having big robotic resections as well. Um, and as I said, the use of endoscopy is really pushing the boundaries as well. You. It's becoming more and more therapeutic. The use of e m more for early stage cancers. Um, and sparing the person, um, you know, a big day out in theater, Um, and dealing with it endoscopically is extremely exciting. The use of, you know, radio, radio frequency ablation in Barrett's esophagus to prevent them Ever getting to that stage is very exciting as well. So I think endoscopic, um, parap you ticks is a massive subspecialty in its own right as well. And as I said, just, quite frankly, I find it extremely exciting. Not only are the operations extremely challenging, um um, there they're just, um As I said, you know, you're dealing with open surgeries. You're dealing with laproscopic you're dealing with robotics. It's just very engaging, very challenging operations. Um, and it's exciting for a multitude of reasons, including, you know, the fact that, um, it's pushing the boundaries in terms of research. So here are two Lancet articles looking at the use of immunotherapies and a soft deal cancer, which I'm particularly interested in. Um, this is, you know, pushing the boundary of multimodal approach is to treatment in esophageal cancer, and this is a really exciting area. Hasn't been fully ironed out yet. It's an ongoing process. Um, and I find that very exciting. And then also to mention that I just find the upper GI community and group of people who do Upper gi are to me very friendly, very engaging people and good people to be around. So just to go into the subspecialties a little bit more so for those who maybe haven't done upper gi jobs. If you're working in in esophagogastric unit, for example, then your mainstay operations would be your esophagectomy and your gastrectomy for cancers. So they're all big operations. As I said, open laparoscopic robotic. Depending on where you are, esophagectomy is can be two stage or you're Ivor Lewis or your bones, which are your three stage or you're transhiatal. Um, and then your gastrectomy knees, Um, where you're removing part of the stomach you're dealing with, um, excellent anastomotic techniques and really technical surgery. That's really, um, enjoyable to perform and to watch bariatrics then is, um, just two examples here of the There's loads of different procedures that bariatrics perform. It's a massive specialty and becoming bigger every day and more important, every day. Um, to the more common procedures performed would be sleeve gastrectomy knees, which reduces the volume of the stomach by about 75%. And then your gastric bypass, which is a very common procedure that they perform also, which also just takes a good chunk of the stomach out of transit. Um, to reduce the filling volume of the stomach there and plugs it in down below. Um, so really nice surgery, Um, with a fantastic outcomes and making such a difference in many people's lives benign upper GI, then with examples would be people with, you know, um, severe reflux disease That would be refractory to medical treatments for which you would do, um, you know, And this in front application, which you've probably all heard of before, Which is really nice operation, um, dealing with the stomach and the esophagus again. Very technically. Very nice. Um, open and laproscopic options, um, out there for people and then Heather is my myotomy for a clays is another example, um, of surgery that she would be forming in benign but benign is a massive subspecialty in its own right. Also a part of jittery, then again dealing with big reception ulcer surgeries such as Whipple's, such as big liver resections, um, for, um, not only for primary, you know, liver cancers and pancreatic and cholangiocarcinoma, but also more excitingly for, um, you know, metastatic colorectal cancers. Used to be you could be working very closely with your colorectal surgeon colleagues, Um, and basically, given someone who would have thought to not have very good outcome with metastatic liver cancer um, a really good shot at a good prognosis. And then you know, all the operations to do with the biliary tree lap. Kohli's biliary duct expirations and things like that. And then transplant obviously, is a big specialty in its own right. You would be involved in retrievals and, um, liver transplantations also, which is very exciting. And I know you're getting another talk on transplant, so I won't dwell on it too long. And then, as I already mentioned your endoscopic approaches. So as I said, Ian, more is becoming more and more utilized, especially for t one, uh, tumor's that can be resected endoscopically sparing a person, um, you know, a big operation and potentially, um, a lot of morbidity, then radio frequency ablation that we can see here comes down and basically is therapeutic for Barrett's esophagus and hopefully preventing someone, um, from developing into an adenocarcinoma down the line. So that's just a flavor of what the upper GI job is like, what the subspecialties like, So just to speak a little bit on how to make yourself competitive to get into all this fun. So what I would recommend is that you start early, so a lot of people would say, Oh, don't express your interest like, you know, keep your cards, close your chest. I would not recommend that. I think if you're interested in Upper GI, start early, let everyone know that that's what you're into. Stood in, approach your mentors early. Keep a record of you know everything that you're seeing and doing in an l log book. Because when it comes to the time of your interviews, if you go in in your portfolio and say that you've attended all of these operations, it just looks really slick and really good. Um, and if you have good mentors on your side from an early stage, then you have good, relevant references also for application. Another one is just being present. So, um, even know these medical students here today as well, but become part of the team. Um, like, don't just, uh, stand back. If this team is something that you want to be in and the future get involved, ask how you can get involved. Ask to scrub in if you can. I know it's very hard for interns and foundation. Your doctor is to get the time. But if you can just let it be known to your seniors that listen, I really want to see that procedure on Thursday. Is there any way I could get into that? And even if you're not scrubbed and you have to be on the outskirts, you can still learn a lot from the way Theaterworks and everything like that. And also it looks fantastic for you to be present and be there and engaged. And then developing your portfolio is extremely important as well. So, you know, get yourself involved in audits. I have medical students on my team at the moment who aren't even close the audits, even over, like a month long. You don't need time. You don't need long at all, um, to do the likes of closed loop audits, but getting involved in research. Um again Approaching your Reg is and your seniors on the team making it known that you're available. You know you want to get involved. You want to help with data collection this and you'll be loved for it, and you will be brought on side. And that's how you develop your connections so that definitely starting early being present and developing your portfolio are three good tips. So just a little word on research then. So there are loads of different ways to conduct research. There are loads of different approaches. So, for example, what I would call local research is when you do a research project in your own hospital, Um, this can be either research project or audit. Uh, it's really useful. It's really good ways to get into your national surgical conferences. Um, even your you know, local regional surgical conferences, getting presentations, getting posters, getting experience presenting is all extremely important. Um, however, how I see the future going is through collaborative research. So the likes of star Surge covid surge Global Surge are all excellent examples of, um, initiatives that are really, you know, coming out with some fantastic data from multiple centers. So it's really high end, high level data, Um, and through a collaborative approach. So getting people from centers involved, um, it's definitely the way forward for research. Um, and I think reaching out looking at these these initiatives Star search covid search are ways to start getting, you know, to know who's who Should I contact about this? How do I get involved? And there's always a way in I find, so just look it up. Then out of program research is probably, you know, known to everyone very, very common. Um, as I said, You can do it during your core training. You can do it during your higher specialist training. You could do an MSC um ch, which are usually want to your programs. And then, more commonly, I find that people are doing MDs and PhDs when it comes to Upper GI, which can range from 2 to 4 years. Um, you can do things part time as well makes it slightly more difficult alongside a demanding clinical schedule. But it is possible, and people do do it and then academic training. As I said, you guys have integrated academic training in the UK in Ireland, we've recently developed nycap program, which is where you have a PhD alongside your surgical training. You have dedicated research days and clinical days, and, um, it prolongs your your training. It does. But, um, you essentially come out with your high GST and a PhD hand in hand. So, um, that's a really attractive way to perform your PhD also. So just a word on not to scare anyone, but just that to get your c c t At the end of your HST, you do need to have done research. So you do need to have produced three papers for general surgery, first or second author, and you do need to have presented three times. That might look like a lot to someone. But, I mean, if you think about it, you have six years of h. S t two years of core training. And if you get involved early, like I suggest, you could have all this wrapped up quite early, you know? So it's actually not as bad as it looks. Um, And as I said, if you get in there early, this will not be as scary as it looks. So ways to get involved. Um, I This is just from my personal experience approaching specialty groups that I'll touch on in the moment, especially the trainee group branches attending conferences. Even if you're going by yourself, even better, it it forces you to get out there, meet people, talk to people. Um, and attending courses that are relevant as well makes your CV look really attractive. And overall, what you're trying to do is find your mentors, um, and to kind of, you know, pave your own way. But, you know, use the light of your mentors to, um, see how you should navigate your way towards the future and a bridge I for you yourself. Um, so some of the groups to get it to look into if you're interested in Upper GI August is a big one. Um, they run fantastic events. The box is another one. It's a specialty for benign upper GI surgery. Herrick Society specifically for transplant trainees. Um, the I S t e and the yes d er for esophageal kind of cancer sectional. Um, Upper GI stuff Tugs is a fantastic organization that are so active in producing, like webinars and training days and everything like that. So I would definitely recommend looking them up. Real group who I'm part of, um is a trainee branch of August, and we run loads of days, loads of courses and webinars. And I would really invite you to look us up and consider joining if you are interested in upper Gi because, you know, we're all about helping each other up the ladder as well. And obviously you all know about assets. You wouldn't be here today if you didn't. Um, I highly recommend assets. Just run, you know, their pan specialty. But even if you know that you want to do upper GI, being involved with acid opens up so many training days And, um, you know, developing relationships with our colleagues as well. And whether you love it or hate it, I think Twitter is a really good way of finding out about all these things. I think I wouldn't have found out about half these things if I didn't use Twitter to some extent. So even if you hate it, I think just have it on at least to have access to these groups and find out about events in real time. So just two events to flag with people that are interested in developing their portfolio. As I said, there's two, um, conferences coming up in March 1 is the Rea Group Weekend one is the acid conference and you know you have time to get together an abstract, Um, for both of those and again, it's all towards developing your portfolio. So just a little word on balance, which is something that we hear about a lot. It's not the easiest thing to achieve in surgery. Just three things that I want to say is just I've just spent a lot of time saying all the things you have to do, but you can't be everything for everyone. You need to know your limits. Know, um, exactly. You know, if you're doing an MSC or an MD, then you can't necessarily be attending 100 different courses. So you need to know your limits. Learn when to say no, Um, is a really important one. There's so many projects and opportunities for, um, you know, doing projects getting involved, that almost you almost have to many things. So I think learn meant to say no, do what you can do, do it to a high like uh, standard and complete it and try not to take on 10 different things and do them to a poor standard and then let yourself down. And then your morale will be low. I think. Just stick a few things, get them out there and develop yourself like that. And then don't you know, don't completely devote every aspect of your life to surgery. Do things for yourself as well. Keep up your interest. Keep up your hobbies and you'll be a better person for it. And, um, yeah, I firmly believe that. So thank you very much for listening to me. And we've gone slightly over time, but thank you very much. And I welcome any emails. If anyone wants to get in touch with me to ask for more specific advice, I'm more than happy to take e mails, and I'm more than happy to take questions now. Thank you. Thank you very much. Nicola, I was a really interesting talk, and I really like your points on keeping balance as well as being present and starting early and finding mentors. Um I hope you guys enjoy Enjoy that talk and feel free. If you have any further questions and upper GI surgery to put them in the chat box. If not, we will move swiftly on. So we've got.