Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello, good evening. Good day. Good afternoon, wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. My name is David Regan. I'm a retired cardiac surgeon from Leeds in the United Kingdom, a visiting professor at Imperial College, London and the immediate past director of the Faculty of Surgical Trainers. The Blackburn Academy is delighted that has a global following in 96 countries. Last week, we were live from Kuala Lumpur and why we're looking perhaps a little disheveled this this evening is I got off a plane from Kuala Lumpur and back in the UK. But tonight is very special because I am joined by an esteemed well informed educator to talk about what it means to be a doctor Linda de Coard is a retired cardiac surgeon, a past vice president of the Royal College of Surgeons of England. She's been awarded a CBE for her services to education and continues in postgraduate education as a professor across in Cheltenham, Cheshire, Chester Chester Chester Chester. We've had many conversations about the direction of medicine and we are sharing a few papers on the same conversation that we're having this evening. I would like to start off with what is the doctor in the modern era or what is the doctor historically and what it means now, Linda. Well, David, it is, it is uh as you know, a a question very close to my heart because I don't think we ask the question often enough in order to act like good um educators exploring uh the actual meaning of the word because words are important. And I think the word doctor now has so many connotations that sometimes we lose sight of what the clinical practitioner, the doctor in clinical medicine actually is and actually where they've come from. Um And, and I think really so much of our time, certainly in the United Kingdom is concentrating at the moment, keeping the whole service running and keeping things going through hospitals, general practice and the whole of clinical life that the time to spend um in a bit of quiet to discuss this matter has been lost from the agenda of of many of us. Um And, and that is exactly why we need to have it on the a gender for the black part cade surgical skill and to the young to remind the new generation. So Linda and I might be accused of being an old fashioned generation. But I hope with our discussion that you realize that there are certain talents and principles that perhaps in the Holy Bursley business of clinical practice that we forget. So Linda, what are the attributes of a doctor or good doctor? Well, obviously, I mean, there are, there are very obvious at uh attributes in the sense that they need to be well informed about um the basic science of medicine, anatomy, physiology, pharmacology, biochemistry, the whole gamut of what can be learned to understand how the body functions and therefore begin to have uh an opportunity to investigate it when it malfunctions. Um So, so there's that very basic thing and of course, those in some ways are the easy things to learn and the easy things to manipulate, to teach others because they are facts which, which, which come about from the investigation and the scientific analysis of what the human, how the human body technically and physically works. But what we have to remember, I think within medicine that um we are treating human beings who have other elements to their being rather than just the technology and physiology of their, their, their structural functioning. And I think that element makes it a a much more complex endeavor. Um when it comes to how we treat how we engage with and how we consider what benefits other people. Um If you stick. So, so really what I'm talking about is the art and science of medicine. Um um the science um has very much, I think in the last, certainly the last 50 years taken preeminence. I think in how we approach the teaching and learning within doctors and, and therefore also how we think about what a doctor should be. We think they should be somebody who uh knows all the facts who actually can reverberate all the facts and then apply those facts to caring and treating a patient. And I think, II know that you and I would agree that that, um, um, word of applying is a difficult one in the domain of education, in which I've worked for many years. The word apply through my education or colleague that I've worked with for years was banned because you can't apply physiology and anatomy. Well, anatomy perhaps a little bit, but you can't apply it to patients. You have to use it to inform the style of practice, the quality of practice that you offer to patients as a human being yourself, um engaging with another human being who is now vulnerable, who is actually suffering and who is expecting of you, um your wise judgment in how they are cared for. So I think when one is looking at the attributes of what makes a doctor, it makes AAA person who is able to engage in the learning of what we need to do of the facts of the sign, but is also able to engage in recognizing the complexity of human behavior and human being and is able to use those facts in a way that they can engage with the other human being and what they need, which may not always be what we think they need. Um So it, so the combination of, of, of the science and the way of using that as a clinical practitioner is, I think what sometimes we miss and what sometimes I think certainly they're improving at the moment, but certainly the postgraduate curricula of bit of um medicine in England, I think sometimes has left out of its curriculum for developing and growing young professionals into how they are able to engage with and therefore care best with patients. There is a lot in there, Linda and we've discussed this before you and I would both recognize there's been an explosion in the science and the knowledge of the human physiology, anatomy. But the facts and the knowledge can all be looked up. And we both recognize that in undergraduate curriculum pouring more and more into the curriculum because we're getting more and more facts in what stage did he actually say? That's enough fact for you to actually start applying the art because it would appear that the facts and the science takes precedent over what you've alluded to. Uh II indeed does. And I think in the United Kingdom, it began in terms of a challenge for those who regulate medicine. The DNC, the General Medical Council in the nineties when they were looking at the undergraduate curriculum and the new doctor, um which came out at that point of reordering, the undergraduate curriculum became a great challenge because of all the new knowledge that was emerging from the science and the development and a better understanding of, of medical physiology, uh anatomy, biochemistry, and pharmacology, and those basic sciences really. Um And I think as a consequence of trying to cram too much in, we have lost the need to engage uh those who are going to be and those who are already practicing as post graduate doctors in actually realizing the complexity of practice of allowing them to have a certain uncertainty in how they see things and how um they are going to use their knowledge, but being guided by uh mature members of the profession in how they have learned to assimilate those facts and knowledge into a humanistic approach to their fellow patients who are also human beings. Um So, so, II don't know that we can stop ever um um engaging in the new knowledge. But I think since that is going to potentially rise and continue to rise in such a fast manner over the next 50 years, I mean, I've spent 50 years as a clinician in, in, in, in, in, well, I qualified more than 50 years ago. And so I was employed in the health service for 43 years as a, as a, as a young doctor and finally, as a, as a vascular surgeon, not as a cardiac surgeon, you, you're the clever cardiac surgeon, I'm the peripheral one. not at all. And um I think the knowledge has just gone off the scale. Really what I was challenged with very much from my seniors as a young doctor was, um, what I was going to do, what was I thinking? How was I making my decisions? How did I use the facts and signs that I had in order to get engage well with patients? And I learned that from discussions and conversations with my seniors, which certainly in British practice these days, the opportunity for conversations and discussion of cases amongst doctors. And that is seniors, particularly those supervising, the younger ones has been streamlined and almost cut out in some cases. And I know that because I can tell to teach senior doctors now how to be better teachers and, and one of the things that they constantly complain of as they did three months ago when we just finished one of our modules, um, we don't have time to do those with those that we supervise. So I think, um, er, how we engage young doctors in developing themselves and how we then supervise them safely to carry out the functions of the job is something that has lost its way in the United Kingdom. I believe, sadly, by giving way to needing to ensure they know the facts before they're allowed to do anything by being regulated on what they can do. So stringently that we almost stop them doing some things. And so I think that the control of how they learn the facts must be uh to learn the current state of affairs, the very basic state of affairs that can be used the anatomy and physiology at a basic level of principle, at least, but then know how to find those facts, but not just to use the fact itself to treat, but to use the fact as a resource for uh mixing into the recipe for how you are going to engage specifically for an individual patient to how they then should um engage with them and treat them. So this is more than experiential learning and bedside teaching and discussion and asking. So, knowing what, you know, and having examined the patient, what are you going to do? Indeed. And what evidence are you going to bring to the table? Absolutely. To justify what you're doing indeed. Is that, is that in essence what it is? Yes, it is. And I think in the days when I certainly was brought up and you too, perhaps we actually spent and I'm not advocating for going back to this, I'll explain a little more in a minute. I don't want to be seen as somebody that says that we have to spend 90 hours a week doing a job in order to experientially learn how to do the job. I think that is completely off the wall. I had quite a good developmental career, but I'm not in any, there were things I missed out in my life which I'm sorry about and I'm not advocating in going back to that. So if we're not going back to the hours spent, how do we improve the quality of that complex thinking and the, and the use of facts and ex um evidence based knowledge and um experiential knowledge into those trainees. And I think that has to be done by the curriculum emphasizing far more the supervision of young doctors by seniors, seniors who are properly themselves, developed to engage well with them to bring out of them every, every element of their innate capabilities of engaging with um this job of being a doctor. Um II, I'm impressed with young people. I meet both as undergraduates and as postgraduates. I am depressed by the fact that I don't think we're giving them enough of time of seniors engaging with them and challenging them because challenge is part of how you learn. Um and educationally if you've engaged in a care pattern with a patient and you come away worried, then that's good because it means you go and investigate, you go and research the subject you go and look it up. Um I was on one on, I think it was at my senior registrar interview by the professor, you know, um how do you best learn Linda? And a and this is now, you know, 35 years ago. Um Well, I best learn, I think by not knowing something engaging with a patient and then going away and researching it. And I think that model of idea of, of you not knowing, um, and, and then having to go and look it up as it were is actually very important. But that can only happen if that mix of, of, of book knowledge to cover a whole way of learning that isn't on the job. Um, II think it needs to be complemented by learning and talking and, um, are making your argument with other senior clinicians about um uh what they have done, what they've learned and how you are going to use that knowledge yourself and then you have to go out and do it and you have to be trusted by your supervisors and by your patients to do it to the best that you can. Um So, so starting at the beginning of this process, then are we selecting the right people into medicine if we're setting it as three A for three A stars? Uh I don't think the ability to do well in exams is necessarily um perhaps the best way to select young doctors. No, I don't, I don't know that that is. But then again, in the United Kingdom, with the concentration of progress being related to the various standards, which in England, for those of you who are not there. Um We have two levels really, um G CSE S done at age of about 15 and then at a levels that are done at age approximately 18 and it's the a levels that get you into medical school and we have gone from, um, um, still very importantly, high grades, but nowadays into having absolutely the top end scale, um, because so many people have been applying and it seems the easiest way to select people. Um, I was interested in the paper I read just last week, um, um, which was looking at asking questions of those entering medical school and following people up and those who chose an inquisitive state of mind actually, um um rarely at the end of five years of a follow up longitudinal study actually were engaging best with medicine than those who didn't. Um So I certainly think the acquisitive mind and the continuing ability to have an acquisitive mind. I think, I think there are countries that have seen the acquisitiveness driven out of those who were acquisitive in their early careers by the demands of knowledge, factual knowledge being necessary to show your competence in before you're allowed to do anything. So II, and I don't think there's an easy answer to this, but I do think that we've gone too far in, in using um exam performance and everything else in order to assess how people enter what is a privileged and a very complex profession, which is medicine being inquisitive, the capability for critical thinking, curious and willingness to learn. Mm In essence what we're talking about at the present. Yes. Moving from the science to the art. How do you bring about the art and the human element of what we're doing? How, how best should we be teaching that? How? Well, there's two things aren't there? There's how you select somebody to go into that form of teaching and then there's how you do it just to stick on the selection because I think somebody in the chat, I think Rinku, um I said that correctly, um, is asking, how else would you choose? Well, I think there are other ways to choose. You have to get to know people, you have to get to people. I think people have to see a bit of life. I, I've talked about this to managers in the UK before, about actually in Britain, you know, people start being what I was, I was 40 before I came a consultant and I'd done a lot of interesting things before that within my medical career, I had four years out doing research and all sorts of other things. Um, how, how do you select into it? Well, I think you take a bit more time to select into it and you use things other than facts to, to, to select your people. And one of the things that is difficult is that in many people's cases, they don't get the opportunity to do anything other than study for the exams from the ages of about 14 years of age. And so by the time they get into medical school, they then get on another treadmill where they're studying for facts for longer and longer and they become a fact, obtaining a simulating regurgitating machine if you're not careful. Um A a and uh I II think, I think we haven't got that right. I think almost the idea of working alongside within the profession and, and even being able to move sideways, I have seen as program director in postgraduate medicine in general, quite a lot of young doctors coming into medicine chosen for their excellence of four star and finding that the whole environment in which they're working something they don't like because medicine actually is a very social activity. You engage with people, both your colleagues, um your your colleagues within the profession, your colleagues within the wider health care provision, nurses, physiotherapists, pharmacologists, all of these people who are growing in their expertise and who you have to engage with. So the social nature of medicine is actually very important. And if you don't like the social nature, you won't like the job. So, although we have an aptitude test, I'm not sure aptitude tests actually pick out all the best. I'm not sure that the longitudinal studies actually support the selection process at the beginning. And if I if I don't know the papers that have told you that then um I'm sorry, but um ii have certain concerns that they don't do it. The best way to do it is to take people into the profession, having engaged them and allowed them the opportunities to find themselves before they get there. It would take time out, take a year out, do something different other than just be on the treadmill of the machine and allow that to then come back and bring a richness into your career as a doctor. This is not easy when you have 100s of people wanting to get into a job, wanting to get into a medical school and the people selecting. And I certainly know from having 250 applications for 25 jobs in a training program that you develop quick methods of selecting who you select for. And one of the things I managed to persuade my committee to do at one point was to have really quite considerable marks for those that had done interesting things and it was quite interesting how that changed the whole thing and how we engage in questioning people when they come for uh whatever interview process they do. Um um I think industry has that slightly better and their interviews go on for days rather than being a one off three quarters of an hour of, of cross questioning. So II think in medicine, we have a lot to learn about how to get the people into the job and then how to bring out of the best of them, how to bring out the best of them in that role. Yeah, one would all graduate schemes would be useful work experience would be useful. You almost hinting at an apprenticeship and learning on the job. I would argue that medicine isn't an apprenticeship, but the, the principle of engaging within the job, within the profession of, of being in a hospital in a clinical situation is quite valuable before you actually become a doctor. Certainly, I did six months. Uh for one reason for 100 set of reasons I took a year out. It wasn't, you know, 55 years ago, it wasn't quite a gap year that of some of the exotic things that young people do these days. Um But I had a year out and I spent six months as a nurse, as a very junior nurse and worked in the hospital. And I learned a lot during that time, not least how to take a case history. I had no idea what it meant, but wrote wise, I learned how to take a history of a patient by listening to doctors, taking histories from patients in the clinic. And um, but what I really learned was to understand what nurses did, understand what the wider health care profession did understand that I really liked being in the atmosphere of the outpatients and, and the smell of medicine as it were. Um, rather than just the intellectual challenge of medicine, we need the intellectual challenge and that should not be lost. But I really also do feel that um both the selectors of those intimates and certainly those who are responsible for teaching doctors after they graduate in medicine, have a great responsibility in continuing to, to, to bring out of them that thing. And certainly in the UK, I think with the consultants now being driven to do more and more of the day to day activities of practice their time to do all of those other things has been cut down a lot. Um And, and I think that is a shame. So you went, you, you asked about apprenticeship. So you may start that apprenticeship by doing something before you go to medical school by engaging the whole process. But it may even be that you, you, I II like the idea of doing the basic sciences degree first as some uh some medical schools do in the United Kingdom, I didn't do that myself, but I find it a very attractive. You do three years and you come out with a um a degree which is not medicine but is in all of the basic sciences and then you go on and do your clinical medicine following that within that basic degree, you will have exposure to some clinical practice but not all. I think the um problem based learning process which works very well in some places has failed significantly in many other places, including my alma mater university. Um uh because it really wasn't set up to supervise people properly, even within an apprenticeship. Scheme. If you don't have a good master, you will not learn the best practice. And so I think the quality has to be first on the master who can then engage those who are going to learn. And if the master is no good or he's not encouraged to have the time to do it well, they may be good in their specialty as a doctor. But whether they have the time to develop others is questionable. So an apprenticeship scheme won't work unless the master actually has been carefully prepared and he knows what they're doing to develop others. Well, as you know, we run, I've been running the silver scalpel award for 23 years to identify the ideal trainer. And I've often said, always said you can have the most innovative program you like, but it's not gonna go anywhere without a good trainer or master. You imply that those people necessarily need to have spent time on the road. And in the Japanese term, si be longer on the road longer in the tooth. So, experience and learned experiential knowledge is important to that process. Yes. Uh Indeed, absolutely. But, and, and we're all still on the road. I still learn things about medicine. I still learn things about teaching um my educational career. Um um uh II certainly is endless really. And I think that's just so we're always on, on the road and I think it's a bit of hubris really. If we think we've got some, I agree that and, and, and as soon as you think you've got some certainly in surgery, I was brought up to say, you know, once you, I worked for a consultant vascular surgeon who was a great man and still remains a very good friend who always used to say when you think things are going well, you're being seduced because you then have to stop and consider what you're doing. You know. Um Are you really, are you really um not seeing the situation actually as it is um or are you, you may be, it may be ok. But if you get that sort of rosy glow feeling, just stop and take a breath because um uh you may actually not be doing the right thing, you know. And I and II think that was good advice really because I continued to keep that little, little voice on my shoulder as I progress through my career. And, and, and so I think that that is an element that we have to encourage people to think about, you know, stop really um self-awareness and the capacity for critical reflection. Hm Yeah, the essential. Uh Absolutely. And you, as you know, David, I have a particular interest in reflective practice in um medicine and we've written extensively on it and we have a website with those things on if people wanted to look at it called Ed for me prac. Um But I do think that reflection on your everyday practice for individuals learning within the practice is, uh I would argue it's an essential way of learning who you are and how you are. Uh uh how you are working as, as a, as a doctor. Um, reflective practice in England has been abused. It hasn't been done very well. It's getting a bit better. People are beginning to understand its educational value again though, that requires the teacher to know what they're doing with it. And I have been engaged for the last 1015 years in teaching teachers to be better supervisors of reflection. And, um, I hope that that continues to help them in the complex job they have as postgraduate tutors. Um, but it, it always surprises people that the things we're exploring, uh the way people think, um, how you make decisions, what your judgements are and how you should proceed with care of patients. And, um, I think, er, reflection is key to that. Um, and I, but I don't think it's done well. What went well, what went bad? What went well, what went badly, which is, which has been a very standard mantra within the British system of reflective practice for post graduates is a banal process of learning what you do. It doesn't get to the depth of thinking that is required of a practitioner within the complexities of what medicine and surgery are all about. And I would argue that some of the things that, um, the generation that I've worked through and worked for, uh, the people I've worked for, um, and even my generation have made me look a bit easy. Um, elaborate. I think we've made it easy to when you watch what we do and when you watch people who are very expert at what they do, engage with patients operate, um, discuss very complex things with patients with cancer disease and they do it with the art and performance measures of an expert. It seems to say, well, I could do that. You know, I've seen it happen. People say, well, I could do that, you know, I can talk nicely to patients. What they don't see is what is going on in the head of that person. All of the very complex things, they're actually um assimilating within their mind while they do that in order to be able to act in the way they are. So reflecting in action again, reflecting in action. Absolutely good old. She taught us those terms, reflection in action, reflection on action, I think both of those things. So if you're going to reflect well in action, you have to have a reverse rehearsed how to reflect, well, to consider your decision making and thinking uh by reflecting on action what you've already done. And so the two things that are actually very important, she actually did that very much as part of an auditory experience of talking with people, I think sadly, he hadn't died quite as young as he did. He would have gone on probably to do what we have been advocating is not only to talk about it, talk is important, but to write about it and to, and to consider that in, in how you write about it and that, and it's often the writing that brings out the insights and it's another element of uh what is good for being a doctor, good insight, uh good understanding of what makes you take. I see that John is talking about physician's assistants. I don't know how much we'll come on to that. We'll come on to that at the moment. But what would you recommend to people embarking upon a career in medicine and thinking about how do they start to learn to practice what we've been talking about? Keep a journal, keep a diary, write a thinking. What would you advocate? Certainly keep a diary? Look at what others are doing, find somebody you like and trust who uh you get on with, who is a senior to you and engage with them. What would they do spend time with them? Talk to them? Um That comes down to the important element of mentoring and coaching, doesn't it? Yes, we've couched them in those terms. I think it comes back to, I think we've made mentoring and coaching too difficult in that we've created two things which are almost doing overlapping things. And I know there are differences but, but we've, we've made too many choices about what you might do. Do you choose a mentor? You choose a coach? I think they're all wound up into the same thing personally. And I will be challenged on that. I know. But, um I think there's coaching and mentoring in, engaged in both of the things of what I'm talking about, which is to engage with somebody that you respect that who has a good reputation that you get on with and that you can learn from. So, so certainly find somebody that you can engage with and make a relationship, a professional relationship with those people to help you along that track. And it would be better if that person can vocalize their own uncertainties. Oh, indeed. And trials and tribulations and decision processes because that doesn't appear to be regarded as the thing to do as a consultant or an educator to show your fallibility. And yes, you know, confusion sometimes indeed. And actually, that's what we are often accused of at the beginning of our reflection processes. Um, and we had very interesting discussions in the group. I was with just before Christmas. Well, Linda, for goodness sake, you know, this reflective practice process you're teaching, we do that anyway. Ah, yes, you do it. But do you think about the fact you do it because if you don't think about the fact you do it and you don't know what you're doing, how can you engage or even unpack your thinking to those that you're trying to develop themselves. Uh um, and if you cannot actually talk about both, what goes well and, and the complexities of sometimes things that don't go so well, uh in the treatments that you're offering, you have to be able to communicate to those you're teaching exactly what you're doing. The demands of, of, of expediency of clinical medicine these days, I think do not allow that to happen as it were on your feet on the job. So there has to be space in the system where the supervisors and the teachers can spend time uh with those, they're teaching to do those very things really. Um And there's lots of, there's lots of um opportunity because everybody has lots of patients. If you're seeing patients, your ground for what you're exploring is there before you, you don't have to spend money on finding something to tell you about what is going on. The patient. Is there their disease, is there? Their needs are there and then you need the teacher, the expenses in the teacher. We don't know, put enough expense into the teacher. Basically, I would totally agree that with A I taking on new dimensions, people are often thinking A I is going to replace the doctor. And my reply to a level students recently on that question was, well, the computer does not pass the turing test. It cannot say I don't know, it will not say uh Let me think about it and it will not say I'll come back. How do you see A I fitting in with what we are talking about? Well, it's very interesting. II think A I is going through all uh digital mechanisms. I'll use that broad term. Um I'm, I'm not an expert in A I but digital mechanisms of, of various sorts of things we've been using for years. Um And, and II regard them as a great asset really as long as they're used well and how we ignore them, they can refine what we do, they can enhance the speed sometimes of what we do the analysis of minute data through those systems. Both now with chat GBT stuff, both written data and what we've done for many years, statistical data for numbers. Um that has um we've used in our, in our positivistic research processes of finding out the right statistical analysis of numerical data. We've been using those systems for a long time. I don't believe, I think like you and we do think alike in this, that they will replace the human brain until the, the understanding of, of feelings and of the influence of feelings. Despite what you may think about them on the context of how we practice. Because the context in which we practice changes every time we see a patient, it changes every day of the week is every way of the week is different. So, so constantly we're in this um rolling sea if you like of what we have to do. And um, so I think, I think the restraints on what we, if we go into something, a believing it's going to change something, we'll turn the car over. What we have to do is use something intelligently if we then find that it replaces certain things that we do all well and good. But in the end of the day, the people that are designing A I need the expertise to decide the direction of A I travel. And until such time that we create an A I system that is so, so, so sophisticated that it does it for itself and who knows that may well happen a long way off. Uh I think it's a way off. Um But I think you have to be sure that you are using the right people to write the questions, right? The algorithms create the mechanism of the A I system. And if you don't have intelligent humans, let's be clear, maybe that will happen. I don't see that happening for some time. I do see disasters happening if we're not careful about the use of A I, supposedly by those people who watch what we do and think it's easy to enumerate if you like because after all, all A I systems are enumerated ways of how humans work, what humans do. They're just their algorithms with numbers in them. Their binary processes that yes, no, in millions of formats. Um So, so if we think we can do that personally, I think that is a step too far. II have an open mind in where it will go. And I, I'm very annoyed that what, that sooner, rather than later, I will leave this planet. I just hope there's another one I can sit on and watch what, watch what's going on here. Um we are going to close with it. Topical question that came up in the chat, pas two years of study, becoming a doctor replacing a doctor. Yeah, just to put people who don't know me. Um, I have a great sympathy with the need for widening the healthcare force. And in the early two thousands, I think it came out in 2006, I was, I chaired for two years, the surgical care practitioner program which wrote the first Calligerum for surgical care practitioners who were people who were going to take over elements of surgical practice, uh, in order to ease the burden of the need to have these things there. Uh, it was a very, it was, it was a multidisciplinary committee of Great People. II. It was one of the most enjoyable things I've ever done in terms of engaging with the people. As far as writing, the curriculum is concerned. I was absolutely certain that if somebody was going to do a surgical job, they would be under the care and supervision of a master in surgery if you like of a consultant, a teacher. Yeah. Um, that is still the case in the, in the, the, the, the curriculum has been refined somewhat. Um, recently a few years ago, the College of Surgeons of England actually produced a new curriculum and that fact is still there. The physician's assistant, I think, seem almost to be a clutching at straws thing that the government has laid its hands on and they think they can do things. I feel very sorry for those that are going into physician's assistant roles at the moment because I think they're being, I think they're actually being led into something. They're not quite sure what it is. I think the curriculum that has been laid down for them is very disparate. It doesn't seem to have a national program for it. The regulation of those within those roles and even the surgical care practitioner roles actually is still out with the medical regulation process, which I don't think it should be and, and I'm disappointed about that. And, um, so, II think physician's assistants can do an excellent role under the right thing. And certainly in my own practice setting up a vascular service in Merseyside or in Cheshire in, in South Merseyside, which is now the South Mersey Vascular Unit. Um I couldn't have done my work without my nurses and my specialist nurses and my advanced practitioners. They were wonderful, you know, they were my right hand people in many of the things that they did, we all knew our place. They knew their place really, which was to turn me off when I wasn't actually obeying the rules. And, but, but, but we had our place with each other and to be fair, the people I worked with never wanted to be me in a sense, but they knew what they could do and they became very expert in what they could do. So I must be, I think we have to be very careful that we don't put people into positions that they aren't prepared for that. There isn't a cohort of people around them that will if you like a paternalistic word, but protect them yes from systems and processes outside their will. I think we could do the whole engagement of that, of widening the healthcare profession rather badly. So I think it needs a degree of wisdom and a lack of hubris in how we create those by those that are creating the people that are going in, going in with. II think as much altruism as maybe people go into medicine, they will not doctors. Not least because of the fact of the shortness of their training, although that's one element, but they won't be under the wing of those that have followed the traditions of me. The traditions of medicine are millennia old. The actual way we see the development of, of meds of doctors and surgeons in the western world is several 100 years old. You know, there wasn't a college of surgeons until 1800. There had been a college of physicians. Prior to that I II give deference to the Edinburgh College who had a college of surgeons a little before that. But, but really, we're only talking about three or 400 years of, of the regulation and control of me, the university graduates and all of that, it's a very short time. So, so the profession is still very new and of course, the ancient healers, of course, not only took on the physical aspect of illness, but understood the mental and spiritual aspect indeed. And we shouldn't believe without saying that there spiritual elements of that I believe are very important, the sense of touch, the voice, the belief that somebody actually cared about you, you know, as he's often said, you know, you remember the doctor for what they said to you rather than actually what they did to you, you know, um and I've had experience with that, my pain students used to cheer me up, they used to come and play to clinic and claim I looked unhappy today. So what were they going to do to make me feel better? You know, there's a two way road here which I think young doctors again don't always get the benefit of because follow up clinics are dero or they're not dero go, they're actually not regarded as good things in current practice because of the need to get through the system. We're firefighting all of the time at the moment. And the consequences of that is the development of our young doctors is very much compromised by that. Not least this idea of the spiritual nature of it, words how you care rather than necessarily how you treat. Indeed, I think that is an excellent point to finish our discussion on And I'm extremely grateful to you for joining us and I would commend the audience to look out the work of Linda and DEA Fish as well and others in this field and like to thank you very much indeed for attending. I am sure we're going to continue this conversation and theme in many forms going forward and Gabrielle. Thank you very much for the production and medal for powering the event and connecting everybody across the globe. Thank you very much, David. Thank you. Thank you. Bye.