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We have MS Mal Ahmed who is uh a vascular surgery trainee, uh, currently based in London. And uh, we've got, and I think he's at work at this moment in time. So I'm so sorry for bringing you in today, but thank you so much for taking the time. Thank you so much. Thank you. Um, and thank you everyone. Um, so my name's Manal, I'm one of the Basar Registrars and also on the Asset Executive Council. Um I'll be talking to you guys about my sort of path in vascular surgery and how I've sort of gotten into it and what you can do. And yeah, and if you have any questions at any point, just ask. So I'm going to share my screen. Um, is it your window? Um, is that, is that showing up normal? Ok. Is that, yeah, I can see your signs? Yes, perfect. Super. So, um I'll be talking about what I do on a daily basis, including what I'm doing today. So, vascular surgery, um, initially was part of general surgery. It was part of the bigger curriculum and then in 2012, it sort of peeled off, it became its own independent specialty. Um And since then, it's sort of been its own separate specialty um which, which, you know, and they've had multiple recruitment rounds since then. Um In 2021 they introduced a new curriculum to the vascular around. And so previously, it was all uh based on the ACB. But as of 2021 it's been mostly based around competencies and capabilities and practice, which we'll be talking about in the next few minutes. So why vascular? Um So my journey into vascular is actually quite uh a circuitous one. II initially started off in general surgery and then did ent and I decided that neither of those were the specialties for me and I went into vascular because it was just so much more interesting to me. Um I found there was a lot more complexity to it. There was a lot more thinking and a lot of it was challenging and there was no such thing as like copy paste of like the, the management, every patient was slightly different, everything was slightly different. And whilst the principles were the same, nothing was the same at the same time. Um And vascular is quite interesting because there's, you know, there's quite a variety of things that you can consider in vascular. So there's the arterial side of things, which is the peripheral arterial disease, the lower limb revascularization. And that could be either endovascular or open. You've got the aortic uh management. So whether it's, yeah, aortic aneurysms, whether it's type B, well, type B dissections, um, and whether that's dealt with, you know, through an open endovascular repair, whether it's dealt with, um, endovascular stenting. It's, it's, it's quite interesting and then you sort of break off to the venous side of things and that, you know, superficial venous disease, uh, deep venous disease. There's diabetic foot which has gradually become a bigger part of vascular with, you know, especially in the last few years with, with a growing population and, and comorbidities. So a lot of cardiovascular disease, a lot of diabetes and the um the complications of that which all come to vascular. Um then there's the endovascular aspect, which then is, you know, within every other aspect of its own, whether there's aortic arterial venous diabetic foot. Um there's the trauma aspect to vascular, that's quite interesting. We also cover the trauma on call. Um So if there's any vascular trauma that comes in and requires revascularization, we get involved in that. And that's really interesting. And then a big part of our work is also supporting other specialties. So we get involved with um the big sort of pelvic accent administration cases um in certain orthopedic cases with certain spinal cases as well. So that's really interesting because there's a social component to it, but also you're interacting with a lot of other specialties on any given day. The other aspect of it, that's quite nice is that because it's a social specialty. It's, uh not only are you other, like supporting other specialties, but even within the, the actual specialty itself, it requires a lot of people to get, you know, something done. So whether it's a bypass, you know, or whether it's an AORTA, you know, it's not a one man job. You, you kind of need a whole team with it. You need, you know, if it's a bypass, you need two people working at the top end, two, at the, at the distal end of the anastos and, and then you need someone harvesting a vein. So it's, it's quite nice. It's, it's, it's social, it's teamwork. Um and when it's trauma, you know, you're interacting with a lot of other specialties, you're, you know, you're interacting with the anesthetic team, uh the intensivist, you're dealing with the orthopedic team with the general surgeons. Like it's, it's, it's very nice in that way. And there's a lot of different aspects to it on any given day and it's also constantly evolving. So vascular, you know, 10 years ago looks very different to vascular. Now, there's, there's just a huge endovascular component to it. The, the sort of bread and butter of vascular has changed. So, you know, 1015 years ago, there was a lot more carotid disease that we would have dealt with. Um there was a lot more open aortic work and that's all sort of gradually shifted towards endovascular, towards interventional radiology work. Um And, and we sort of interact with all of that. We do that as well and it's, it's um it's quite nice and it continues to evolve. So what's, you know, what's involved right now might change in the next 5, 10 years again. And so it's a constantly evolving field. There's a huge preventative and therapeutic component to it as well. So instead of being purely just operative, there's also a huge um preventative component to it. So say 10 years ago, there would have been a lot more carotid endarterectomies. And over time, we found that best medical therapy works a lot better. So the the shift that we've noticed with, with um with vascular has, has vastly changed over the last couple of years. And one of the things that I personally really enjoy with vascular is the amount of like planning that's involved. So whether it's, you know, whether it's a trauma case that you need to sort of decide there and then like, how are you going to revascularize this patient? It's not always like a one big straw where you just put two bits of an artery together or two bits of vein together. You have to consider how they're going to move their arm, like how it's going to revascularize later down the line. Like what functionality they'll have, you know, you're working with other specialties like plastics. Um you need to think about skin coverage, you need to think about, you know, mobility and, and, and, and the patient population is quite different. So you, you know, you're, you're managing patients who are quite young, to really elderly patients as well. Um We, we don't tend to deal with pediatric patients uh very often, but we sometimes encounter them like two or three times a year. Um And there's a lot of planning. So like whether it's an aorta or whether it's a lower limb um revascularization, you know, you need to think about, you know, what the anatomy is, how you're going to revascularize them. Like what's the best option, what's already been tried? Um What's the best way to go about it? So whether it's better to put a stent in, whether it's better to do an open operation, there's so many things and factors that you need to take into account when you're doing this as well. And there's so much scope for research. So because vascular is still sort of in comparison to other specialties, still kind of a new specialty, there's a lot happening and, and things are constantly evolving and a lot of it is based around the evidence that's coming out, you know, through trials and there's so many of them happening at any given time. So it's, it's constantly evolving. There's scope for new, you know, practices all the time. And then overall, there's a generally good balance between the emergency and elective work. So with the emergency side, you've got you know, your ruptures coming in, your acute limb coming in, um the trauma coming in, but then you have the elective side as well. So you've got the elective revascularization, you've got a lot of varicus veins um that you can do. So that's, you know, endovascular or open repairs and it's, it's quite nice. So you get a bit of balance and you get to do a little bit of everything, which is quite nice. So, continuing on with theme of variety. Um There's so much to do in vascular, there's a and, and skills that you need with var are just so vast as well. So you need to be able to like interpret and actually be able to like do the imaging yourself. So whether it's, yes, it's good to have vascular scientists helping you out. It's fantastic. But sometimes, you know, when you're in theater and you need to scan the patient yourself, you need to know exactly what you're looking at, how to interpret that imaging because that is going to help how you then do that. Patients varicose veins um and equally with the aneurysm. So that's the picture there, the, the A and B that's, that's an er, that's been done. Um And you know, it's never the same. So you always have to sort of plan it out, you need to get your angles right, you need to measure everything you need to make sure that you have the correct stents um carotid endarterectomy. So that there is a picture of the carotid endarterectomy um in the far, right. Um And that's really interesting, you know, a, a lot of these now are done under local anesthetic, but we previously used to do them under general. Um And then there's diabetic foot as well, which is actually a lot more complex than people think. So, these are patients who are vastly comorbid, they have, you know, microvascular disease, they have macrovascular disease. They are profoundly neuropathic, they have ulcers that are really difficult to treat and take a very long time to treat. And it requires a lot of multidisciplinary input between the vascular team, the endocrinologists, the podiatrists. Um and it's really interesting and nice to see when these patients actually do heal and are able to mobilize and sometimes that doesn't happen and you know, they end up with amputations. But that entire process of, of managing these really complex patients is so interesting. And then you've got the venous disease also. So you've got a lot of varicose veins, um and venous reflux and then extensive uh DVTs which you know, may require venous stenting further down the line. So there is a little bit of everything which is, which is, you know, which is the thing that sort of drew me to towards vascular to begin with. And then again with the skills. So image interpretation is so important uh being able to not just look at a scan but being able to actually interpret it and make decisions based on that. Um being able to do the dopplers, do the ultrasounds in real time, make the decisions. And then with operating skills, which I'm sure everyone else has mentioned today anyway, but you know, you need the fine motor skills, the hand eye coordination. Um and, and it's not just for the open stuff but also when you're doing the endo fast stuff. So like being able to actually, you know, use the needle while scanning the patient, these are all things that come with time and, and, and communication is such a huge part of it. So whether it's communication between the different teams, between your own team members, between the patients, um and, and getting these sort of very complex sort of concepts across and, and communicating sometimes over a very short period of time. So when it's a trauma case, for example, you have to make a judgment call and you have to make a decision, you know, over over a very short period of time, but you need to get other specialties involved and, and it's, it's, it's just really interesting to see how that process is fines over time. So um we've already sort of talked about this. Um but medical and surgical, there's the whole preventative slide of things best medical therapy, risk factor optimization, promoting cardiovascular health, improving their overall quality of life. Um because the vast majority of our patients are smokers, they are patients who may not have the healthiest lifestyle and may be quite comorbid and have, you know, other um other uh medical conditions as well, which, which take up a lot of their life sort of lifetime. So they're, you know, going for dialysis regularly um and have profound disease. Um and then the intervention side of things, there's also the renal axis part of, of vascular and that sort of depends on the deanery that you're in. So, in London, we wouldn't necessarily do the renal axis, but say in other deaneries, they would. Um And that's really interesting as well because you then learn how to develop a fistulas and how to look after them as well. So, what does a day look like in my life? Um So, you know, there's a bit of like elective, there's a bit of emergency work. It is team work, it's multidisciplinary. So my general week can look like at the moment I'm doing a phd. Um So it's slightly different but um similar. So on average, my week would look something like, you know, on a Monday, I'd be in an angio list doing lower limb angios. Um On a Tuesday, I'd do a diabetic ward round um where we see the diabetic patients and then I might have a general sort of vascular clinic. And then on a Wednesday, I might have a more specific uh type of clinics. So whether it's venous uh patients or whether it's um the pelvic congestion patients or the mouth or if it's a, it's, if it's like a uh uh an aortic dissection clinic where they're being followed up. Um So it just depends on the type of clinic that you're in. And then in the afternoon, you might have an ongoing clinic or you might have MU MDT, which is multidisciplinary team meetings. Um Or you might have a neurovascular MDT, which is where we look at all the patients who have had a stroke in the past and to see if they would be suitable or are eligible for having a carotid endarterectomy to reduce their further risk of stroke. Then on a Thursday or a Friday, it could be in theater all day and that could really vary from, you know, something, something as simple as general anesthetic va veins or it could be an open aorta, it could be an er, it could be a laure li bypass. It really varies on the day and then my Saturday and Sunday similar to today, uh I might be on call. So our on calls tend to be 24 hours. Um, and then we sort of crack on and do the next day. Um, the future of vascular surgery is so I think vascular is just going to continue to grow. It's going to look slightly different in the next 10 years. But I think it's going to actually the, the, the, the requirements for it are going to increase because if you think about the current population, the comorbidities are going to increase just given the lifestyle that current, the current population has. So it's quite a relevant specialty. Um And with the aging population, the, the demographics are generally patients who are sort of 40 plus, that's the sort of vast majority of patients that we encounter. Um And then the metabolic syndrome, you know, so sedentary lifestyles, um you know, comorbid. Um and then overall, you know, the, the the general shift at the moment is, is moving away from sort of open procedures towards more sort of minimally invasive um interventional slash endovascular procedures. But there's always scope for open procedures as well, which is what I really like about it because you can sort of, you know, it, it, no two cases are, are, are the same and that's the, that's the beauty of vascular surgery. So, pros and cons um these are sort of my personal sort of reflections on, on, on vascular. So it is quite rewarding. You do see the changes, especially, you know, when it comes with acute limb or, or chronic limb threatening ischemia, improve their blood supply, they walk out of the hospital when they weren't able to walk like more than more than 10 m when they came in. It does challenge you on a personal and intellectual level. Um The people are amazing to work with. It's, you know, it's a team based kind of specialty. There's a huge amount of variety. The complexity is quite vast and it's constantly evolving. Um The cons of it, it, it is, it is fairly competitive, um perhaps not so much as other surgical specialties, but it is competitive. There's definitely a steep learning curve, especially if you haven't done vascular before. So we'll, we'll get onto the bit about how to get exposure to vascular. But there's definitely a steep learning curve even between sort of moving from sho to, to reg, there's, you definitely do feel it, it is high stakes because obviously the, you know, the patients may end up losing their leg or, you know, their limb or their life if they come in with rupture. So, so the stakes are quite high. Um and it's the same thing with trauma as well, uh managing expectations. So sometimes you get, you know, patients coming in who have terrible disease and you have to sort of, you tell them that they're going to end up losing their leg. And that's quite a, you know, it's quite a difficult thing for a patient to hear um that they may end up losing their legs. So, so managing patients expectations, telling them about the high risks involved, but then also expectations within yourself and within your team. And I think that takes time to sort of calibrate, but it's really rewarding to be able to do that because I think when you put yourself under, you know, those kinds of pressure situations where you really learn to, to get better at them um managing stress. So I think everyone has to find sort of a different thing to do. Um some people who play sports, you know, some people have, you know, they, they like to just enjoy life. It, it really depends. Um So finding that work-life balance is really important but saying that, you know, it, it is a physically demanding job. You are standing for hours and hours and sometimes the endovascular procedures can take up to 89, 10 hours. Um and you're wearing the lead jackets. Um so it can be physically demanding but also really rewarding and you definitely have to over time, you do develop resilience. That's, that's definitely something that I've seen within myself over the last couple of years. So career opportunities, um it is slightly competitive and we'll go through the competition ratios as well. Um You would initially start off with obviously the undergraduate medical training, then you do your F one F two and sort of it's, it's quite good to have an idea of what you want to do in terms of like your surgical specialties. So you can start tailoring your CB slightly towards it and your portfolio towards it, saying that however, I when I got into vascular, my CV wasn't the most vascular oriented, but I made sure that when I got into vascular, I had all the information that I needed before I went into the specialty and sort of, you know, and so I had sort of explored the other specialties and I was like, right, this is what I've learned, but this is what I wanted to do. Um, and so when you're in sort of F one F two is where you really start to sort of, sort of zone in on what you want to do surgical training wise. Um You, we do your MC as sort of between F one to CT two. I did mine between F two and CT one and coming up to F two, I kind of knew I wanted to do surgery. So II applied for, for surgical training. Um, and it's one of the main sort of pieces of advice I would say is, you know, start early because that's the earlier you start, the, the easier it gets otherwise you're, are scrambling towards the end and a lot of these things take time as well. They don't sort of happen right away. So when it comes to sort of publications and presentations, you need to give yourself at least 6 to 8 months because from the time that you start to the time that you actually see it come to fruition is, is a lengthy of process. And then once you get to CT two, or CT three, you would then apply for ST three, which is what I did about two years ago. Um And then I applied to VR got a training number and you go through your ST three to T seven and then that's then broken down into three phases. And I'll go through that in a couple of minutes and then you get to your CT. Um And then after that, you would do a fellowship, most people will do a fellowship. So there's different sort of areas that you can decide to go towards. You can either do a trauma fellowship, you can do aortic work, only lower limb uh revascularization, either arterial, only venous, only uh renal access, dealing with just diabetic foot carotids. Although no one actually does a carotid only thing because carotids are mostly being managed medically now. And then in terms of care outcomes, you've got either the traditional route of an NHS consultant, you can go towards the academic side where you, you know, you do your phd, you then get a clinical lecturer job and then you work towards a senior uh clinical fellow or an honorary lecture or a clinical lecture. And then you then become uh a reader and then eventually a professor or you decide to go into private practice or you can do a little bit of both uh the private practice and the NHS side and then a little bit of a, so you can really pick and choose how you want your features to look. So um I'm just going to go through the competition. So, like I said, initially, you know, when you do your F one F two, you then apply for CT one. They did have run through for vascular, but I think that's been mostly stopped now. So it's all, it's all CT and then ST afterwards. Um So the competition rates for core surgical training have remained kind of similar, but they have been gradually increasing. So you can see in 2022 it was, you know, it was 3.7 then it went up to 4.17 and, and, and this year it's even higher. So it's five. So there's about five people applying for every job. And that's sort of the more difficult part because it's so general and then once you get through sort of the hump of, of, of course surgical training, then you have to work your way to ST three. And so ST three uh vascular ever since it became its own specialty has had fairly stable like competition ratio. So in, in 2022 it was, you know, about five jobs or five people applying for every job. In 2023 it was 4.5. And then in 2024 we're sort of back to the same um competition ratios again. So, um vascular curriculum, it's now broken down. And so once you finish your course surgical training or actually once you apply for F between F two and CT one CT two, you would then have your ACP, which is the annual review and you have to get your capabilities and practice done. So once you've done all of that, you get signed up for your ACP, you get to ST three and then the vascular curriculum is broken down into five capabilities of practice, which you have to show competence in over the period of your, of your surgical training. And that's broken down into ST three, ST four as phase one and then ST five and six, phase two, and then ST seven T eight is phase three. But basically, you cannot do your FRSS until you've been signed off for ST six. The other alternative route is via seizure and that requires similar sort of uh proof of evidence. Um But with regards to the basilar curriculum for, for on its own, um these are the capabilities that you need to demonstrate confidence in. And so, you know, whether you're able to manage an outpatient clinic on your own, the unselected emergency take ward rounds and the ongoing care of inpatients, managing the operating list and the multidisciplinary team working. And whilst they seem sort of simple enough, the actual nuances when you are assessed on a yearly basis is slightly different. So previously you had your or your uh clinical supervisor and your educational supervisor and they would sign you off and then you would have your ACP, now it's slightly different. So you have your multiple consultant reports. So at six months and then again, at the end of the year, um your supervisors, all of them will sit down together uh and, and decide whether you are capable of demonstrating those uh skills or not. And then based on that, you are then given sort of a level between one and four to see if you can select if you can manage the outpatient clinic, if you can do it with the emergency take, if you can do the ward rounds and the ongoing care of patients. And then essentially what you want to demonstrate is that sort of, you know, progressing from year to year and then that then is further broken down into the different domains as well. So it's about professional values, professional skills, practical skills, communication, um knowledge requirements, uh health promotion, working as a team member and also as a leader of patient safety, safeguarding education and training and research and scholarship. And so this is like all of these are all the domains that you need to show competence in when you get right to the end. And so it's good to sort of have that in mind when you're applying uh for your, for your, your sort of specialties in the beginning. And also when you start to like get your portfolio together, because a lot of the work based assessments that you're going to send further down the line are going to reflect all of this and these are all then mapped out to all of the, um basically every single thing that you do, whether it's in clinic, whether it's in theater, whether it's, you know, during the take, it's going to reflect this in some way. So this is how it works. You have your syllabus items and your GPC. And then these are all the descriptors and the domains and then eventually provided that you, your competence, you then get signed off when you get to CCT and you've done your exam, which you cannot do until you've been signed off for ST six and then you become consultant. So in between all of that, when you're demonstrating that you can, you know, operate, you can look after patients, you can uh manage the manage to take, you can, you know, communicate effectively. You're a good leader, uh You're a good team member, you then have to do all of the other stuff for your portfolio. So you have to do your audits, you have to do your publications and early on you can sort of keep it quite broad and vast. And then as you get further along your, your, your progression, then you have to start tailoring it towards what you aim to do. In, in the end, your presentations are really important teaching, you know, try and do that as early as you can, you know, get exposure to that. Um So I actually did my, so after my F one, f two, I actually did my, er, in medical education and I also did a master's because I wanted to get a bit of an exposure to research and see how it worked. And that really helped me because when I got to ST four I was like. Right. I think I have the sort of the foundations and the basics of it and this is, you know, and then it sort of laid the foundation work for my phd, which is really helpful. Um Leadership can take many different forms, whether it's within the hospital, whether it's part of governance, whether it's part of like leading, you know, the teaching, um whether it's with uh your surgical societies, there's, there's so much to do and then self development as you grow as a person as well, sort of that internal reflection that needs to take place and then your clinical skills and knowledge. So, um with regards to your applications, what I would say is start as far as, oh, sorry am II almost to the II bought like two more side left left, I thought OK, too much. Oh, sorry, sorry. II know I've like run over time. Um So what I would say, start early, talk to people, get the experience in your specialty, do as many tasters as you can, rotations and shadowing. So I've done a bit of work in, in, in my like summer holidays and that's how I sort of got myself exposed to vascular, uh familiarize yourself with the portfolio requirements, further postgraduate qualifications, it is quite useful to have that. And especially in vas where whilst there's no expectations, the general sort of trend is that everyone will have an additional qualification by the time they get to either ST four or five get involved in research and audits, you presentation opportunities, uh interview prep, try and do that as much as possible. So I would have really spoken to all of my registrars when I was at CT two and also at F two and basically got them to sit down with me and do the interview, practice as much as I could um and try and get your exams out of the early. But the main, main thing if I can sort of her home, one point is know what the portfolio criteria is and start early because all of these things take time and then that's just a repetition of what I've said. It's uh it's good, it's complex. It requires a lot of combination of different things. It's a long road ahead. So remember, it's a journey and not a race. And then these are all the resources that you can sort of look towards if you would like more information about. Not at all for me. Sorry. II realize I've uh I've gone away over time. No, don't, don't apologize. You can clearly see how passionate you are about the specialty. And I think judging by what you said, you've gone through general surgery and now vascular. It's, it's clear that means a lot to you. And I think that's what today is all about today is all about, you know, getting that experience, seeing what jobs are available out there. And I think from my thing is just get that hands on experience, don't rush to make any decisions and, and of course, as, as you said, know your portfolio so you can structure what you need to do to go forwards to achieve those goals and give yourself enough time. Thank you so much for your time. Um I do apologize. We don't have time for any questions. Um If anyone have any questions feel free to like uh email me, I think I have my email at the end in that last slide. But yeah, if you have any questions, feel free to email me or reach out to me and I'm more than happy to answer them. So if you guys take a quick screenshot, if if, if you want to uh reach out to me now, um if not, then once again, thank you so much for your time now. Sorry for dragging you away from the, but thank you so much. No worries. Take care. All right, bye. See you later.