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Hello, everyone. My name is Isabel, currently an F one in North London. I'm also a doctor's rep for widening participation Medicine Network, and I've been working with the Events team to put together these talks. Firstly, I just want to thank you all for attending the first of our women in surgery series. We're really excited to bring to you a monthly webinar series, which hopes to inspire the next generation of surgeons and gives you surgical role models that look like you. So, yes, surgery has definitely improved in recent years, and we're certainly seeing more women in training. Compared to those that consultant level, However, there is still a long way to go with regards to diversity, inclusivity and widening access. Each month we have women from different surgical specialties, from vascular to orthopedics to ent to general surgery or from hospitals across the country. And each surgeon will be talking about their journey into surgery or a typical day or week. Looks like some topics for applying and an interesting case they have seen after the talk Q. And a session, Um, so please use the chat function, do send in your questions and I'll ask Mr Ross at the end. So to kick off the series, um, we have someone that not only has broken down barriers in the orthopedic world, but in May medicine as a whole. She has paid the way for women of Afro Caribbean ancestry in a highly male dominated specialty. She currently works as the lead orthopedic consultant at the hospital, and she is a passionate advocate for diversity and surgery and was part of the Royal College of Surgeons Diversity Review panel. So without further ado, the amazing Ms Samantha draws Thank you so much as a bell for that very, very warm and generous welcome. Good evening, everybody. I'm delighted to speak to you tonight, right? So I am, as you heard, a consultant orthopedic surgeon. I specialize in treating conditions of the hip and knee. I work at London Northwest University. Health care that Just trust me. I've been a consultant since 2005. When I became a consultant, I became the first female of African Caribbean origin to become a consultant in the United Kingdom within the specialty. And I scored another first in 2018 when I became the first woman in Europe to perform MCO robotic hip surgery. I'm a very passionate advocate for diversity equity and inclusion and surgery, and I'll talk to you a bit later. But some of the work that I've done I was born in Guiana, in South America. It's a country that's geographically place in South America, but it's part of the Caribbean community. It is bordered by Venezuela to the west, Brazil to the south. So going on to the east and to the north is the Caribbean. See. The nearest island to Guyana is Trinidad and Tobago. The ethnic makeup of Diana are predominantly people of Indian origin who make up about 4 to 4% of those of African Caribbean origin, about 30% 17% of mixed. We have with 9% of 7% of, uh, Native American Indians and only 12% of Portuguese people of European descent and Chinese so predominantly black a nation. My parents are both Afro Guyanese, and like many parents of their generation, there were certain careers that they had a desire for their Children to to go into, and they were medicine, law, engineering or accountancy. So there was a very subliminal message given to me very early one, but it never forced me into into this particular career. I was exposed to hospitals at a young age because my mom was a nurse, and so I spent time seeing her there. And also I had elderly relatives who died when I was very young. So I was. I witnessed death at a young age. So the combination of visiting my mom in the hospital, witnessing death at a young age and I was a very avid reader, no doubt must have read about doctors, um, in books. I decided that I wanted to be a surgeon, and it's funny. I didn't say I was going to be a doctor. But a party at age seven, I stood in the middle of the living room and declared, I'm going to be a surgeon when I grew up. I'm not entirely sure that I was clear with that involved, but it sounds very good, and I certainly kept the desire to pursue a current medicine always through my schooling school was tough. Back in the day, we were certainly ruled by the cane, and you have to get at least 80% in your subjects or as you were cane in front of the class. So I learned very early that I had to apply myself to achieve, and so I can avoid being caned. The downside of that is that I would say, even till today, I know the downsides of failing and therefore, I often I have to push myself to go into situations where I'm not sure if I'm going to succeed, Uh, and so I'm sure many of you will have some insecurities. What we have to do is just feel that fear and push through and go for it anyway. Growing up in Guiana with people who were predominantly of Africa have been an Asian origin method. I saw people that look like me in positions of authority, and therefore I never felt that my color would be a deterrent to me succeeding. And I think that's been very important for me because of my father's job. And he was working with the Commonwealth secretary it and sent to Africa, and his job entail traveling to different countries. He decided after being advised by one of his senior colleagues to consider boarding school in England. And that's where myself and my siblings came. That was very difficult because it was not only being separated from my parents, I was only 11, but being in a completely different cultural environment, So I had to learn very quickly. I had to learn how to integrate and particularly of being, You know, a gyne was cosmopolitan enough, but I was used to being in the majority. So here I was suddenly in the minority, and I certainly have to get used to that. I had to learn to be self reliant, although I was there with my siblings. We were separated in boarding. House is according to age, so I was very much on my own and I had to rely on myself and and get through. Of course, I had the support of my parents from afar, but I had to learn to rely on myself. I had to become resilient. There was a lot of teasing. I know people often say I still have my West Indian accent, my Caribbean accent, but it is nothing compared to the one I had when I first came. Uh and I was teased heavily and so I had to learn to be resilient. I had to remain focused on my career goal. I had teachers who were trying to deter me, saying that medicine was a very tough career, particularly for a woman and particularly one, uh, an African Caribbean descent. But I remained very focused on the goal that I wanted to achieve. And as I said, it was the fact that I had seen a role models that looked like me, that helped me navigate and push through the negativity that I received. No, not from all teachers, but from some I learned about leadership. I was for Captain, uh, sports team captain and picked out for head Girl. But I decided to leave school before the sixth floor, and I learned a bit competitiveness. I was very, very keen sportswoman, a specialist and 102 100 m and long jump and became a national champion for the long job was at school. And so all these characteristics self reliance, resilience, focus, all the qualities one needs for a successful career. I developed at school medical school was at University College and Middlesex School of Medicine. It was the first year of the joint school. I was the only black female. In the class of over 200 students, there were five black males. Only one came through the UK system. The West were exchange students from Malawi. I saw no black representation in my lectures or consultants. While I was in medical school, the first person that looked like me as a consultant, I came across as a as a as a house officer. But having had the experience that I had at school and gone through that and being used to being in the minority meant that I found it easier to navigate being in medical school. And I have to say that overall, I found the experience very positive, particularly coming from boarding school and then being in the center of London at UCL. Uh, it was absolutely fantastic. So why did I decide to choose orthopedics as a S H o S H o. For those of you don't know, it's anonymous to a foundation year to trainee. I did a rotation of the Royal London. I was lucky enough to rotate through vascular surgery, general surgery, neurosurgery, plastic surgery and orthopedic surgery. And of all the specialties, the orthopedic surgeons were the most friendly and supportive with all the specialties. There were times when you felt as a medical student you were getting in the way you were annoyance, a mild annoyance, but that that was a totally different feeling in orthopedics. The first female surgeon I ever saw as a medical student was a registrar whilst working at the Whittington Hospital, and she happened to be an orthopedic surgeon. That's her name is Allison Hume. She's not a consultant. Chelsea in Westminster. I love the fact that the the specialty was technically challenging. I was always very keen on building and fixing things and puzzles when I was young, I was never interested in playing with dolls, and so it really fed to to my own natural desires and curiosity. And it's every evolving, and I love the kit that we had to use. There's something for everyone in orthopedics we treat young and old, male and female, and then you've got the subspecialties. You have the more delicate end of surgery pediatric orthopedics hand surgery towards the more physical end, which where I've ended up doing hips and knees. But in between, you can be a shoulder surgeon. You can be a spinal surgeon. You can do sports medicine, foot and ankle, et cetera. There really is something for everybody. And one of the things that I really love about this specialty is that you have the opportunity to have a significant impact in someone's life and to see your results very, very quickly. As a hip and knee surgeon, I often have patients who come in barely able to walk, and within two days they're going home. Pain. I'm not completely pain free, but the pain is significantly improved. Even at that stage, some of them are pain free because of the anesthetics that we use, not just what they get. Uh, so I don't understand the the painkillers, not just when they get intravenously or orally, but I actually inject painkillers around the joint capsule so some of them are paying three straight away. But you know patients when they come back and you see that or the other end of the spectrum is dealing with a trauma patient and somebody comes with a very deformed limb and you have the ability to put that back together. It's so gratifying to see that and the patients are very, very happy very, very, very, very grateful. So another very key reason why I chose orthopedics is that unless you're working in the trauma center, most surgery is done within daylight. Or should we say, respectful of hours? Uh, and and for me, sleep is very important. So that's another great thing about orthopedics versus something like versus observation, which I was also interested in, where babies can come at any time. So what was my journey like having finished it, Uh, medical school? I did my house jobs, and that further consolidated to me the fact that I wanted to do surgery because I didn't like the long, laborious medical board rounds and also the chronicity of disease. I realize, and everyone has to understand what actually appeals to them. And you've got to go for something that you really like and feel passionate about. And so I realized that surgery is for me at that stage. As I said, I had to go through the different surgical specialties before it became clear that of all the surgical specialties, it was going to be orthopedics, and I applied, and it was fortunate enough to get on to the Southeast terms rotation now. When I got onto the rotation, I wasn't given a training number straight away. I was appointed as a locum appointment for training, and I don't think these posts exist anymore. So when you apply for the training program, you either we're fortunate enough to get a number or you were a locum and it could be a local appointment for training or local appointment for service. The local appointment for training meant that despite having to apply the following you to get on to the program once you got on any time spent, the locum would count towards your final training so you would do that particular time less what you would have to do. But if you got a local appointment for service, it didn't count. So I was lucky enough to get a local appointment for training. Unfortunately enough for me, a training number came up before the year was up, so I didn't have to reapply. I was immediately converted to a training number. Uh, training was six years going through the different subspecialties in orthopedics. Uh, and then I decided that with hips and knee surgery is what I was interested in. And after my training program. I went for fellowship, which most people are encouraged to do if you can. And the fellowship I did after finishing my surgical exams and most fellowships these days require you to be post fellowship, uh, in terms of fellowship of the Royal College of Surgeons exam. I then went to Toronto, Canada, and Sidney, Australia, learning different hip and knee arthroplasty as well as hip arthroscopy. And then I was fortunate enough to get my consultant job. Now, at the end of my training, Um, there wasn't a job available straight away, so I did an extension for six months, and then I did a local consultant Job guys in Saint Thomas is, and whilst doing the local job was pointed into my current post during my time of training. Of course, there was some negativity. I I experienced racism, sexism, bullying, harassment, microaggressions to To be honest, some of these things still exist today, but I don't want that to deter you because attitudes are changing. Number one. It was only a small minority of people, Uh, I would say the majority of people within the training program we're very supportive. So and attitudes are changing. And as we increase the diversity within our training programs, this sort of behavior will certainly go away. Uh, these will be diminished significantly. You do find that people's behaviors change when there's a diverse environment. And, um, they were positive things. Also on a training program. The fact that I was in the minority meant that I stood out and I made sure that it counted. So I made sure that when I was doing things, I did it to the best of my ability. I always got noticed, and that meant that I was able to secure very good sponsors and mentors who helped me throughout my career. And also I had a very good, supportive network that I had outside of the medical arena. And those things are very important to help you through your career. If you can get a mentor but certainly have a good support network, that is necessary, or I should say beneficial. So what have I done in terms of widening participation? Because I told you it struck me when I was a medical student that I wasn't coming across many people that looked like me. Um, now not only in terms of those who were given the lectures. But I was the only black girl in the class, and there was only one black guy that came through the English system, and I felt that something had to change. So I spent the last 19 years speaking at schools either independently, because the teachers have met me and they've invited me to come and speak or via various charities that I'm affiliated with, such as urban Synergy, Tomorrow's leaders, the Powerless Foundation, which is now a little foundation. And I've done a lot of work with Bristol University, their engineering department, because they found that they had very few people of African origin applying to engineering, particularly women, and they wanted someone to come along and give some talks. And I talked about the engineering side of orthopedics. I've spoken at various medical school surgical societies, and I've been involved in mentorship with both these charities and schools that have talked about and more recently, via the Cultural and Diversity Committee of the British Ship Society. So the British Ship Society has launched a mentorship program. For those of you who are interested, I'll tell you a bit more about that later. I've been involved in wins. The International Orthopedic Society, which is Symbicort and the International Orthopedic Diversity Alliance. I'm a trustee and found a member of really recently um founded association called the British Association of Black Surgeons. I'm also a member of the British Carb Doctors and Dentists Association. And via those organizations, we will continue doing work to increase, uh, participation from the Afro Caribbean Community. So why should you choose? Author? I've told you why I've chosen it. Um, but I just want to emphasize to reiterate it is a very, um, exciting, interesting specialty. The people are very nice. They're fun loving. They're very supportive. You get a chance to use your technical skills, you get access to great technology and equipment. There's medicine as well. It's not just about surgeon's operating. You have to apply medicine. We have patients with young and also the geriatric side, as well as a younger medicine. For younger people, the training can be flexible, and it is absolutely possible to have a family because these are some of the considerations that people have are some of the concerns while they don't choose orthopedics. I know of a number of of of, uh, female orthopedic surgeons who have successfully navigated the family as well as their career. I don't have any Children, but I know it's absolutely possible. And as I said now, they're really has been an emphasis, uh, within orthopedics and all the different sense a subspecialty committees to try and increase The diversity and participation in the specialty and the industry have also got on board, and they are now looking at ways to modify the equipment so that women can have a more positive operative experience. So what does it take to become an orthopedic surgeon? Well, let me tell you a little bit more of a specialty to begin with, it is the specialty. Uh, so far it has the fewest number of women. But hopefully following this talk and the work that's being carried out, that will change as we can invite more of you to come into the specialty. Currently, uh, female orthopedic consultants make up just about on the 6% of the consultant body and in terms of trainees, as 18% of all the orthopedic trainees are currently female. So what's the pathway? As a medical student, you Obviously you have to get through medical school and you apply to the foundation scheme. You become a foundation doctor and you spend 1 to 2 years. Sometimes you can do a third foundation year. At that point, you go through a selection process that you go into course surgical training. And during your course surgical training, you get the opportunity to rotate through different specialties, align to surgery so that can involve I t u r a n e, but also the different surgical specialties. And during the time, well, as a foundation doctor, you you're coming towards the end of your foundation years, you might decide you want to do surgery, you got the opportunity to do the part a the MRCS exam. Uh, if you haven't done that and certainly during your course surgical training, you have to complete both parts of the MRCS exam. Uh, and then you have to go through an interview and selection process to get into the specialty training program during the day. Especially that specialty training problem is six years, and at the end of that you have to do your fellowship in surgery exam, and most people then also go off for a fellowship overseas. You maybe do one in the UK, but you do a fellowship where you get a chance to really get experience in a particular sub specialty area. After you've done that, you can apply for your certificate of completion of training, and you require that for you to be able to apply to become a consultant. So how, what is required to get onto the training program to become an S T. Three? It's an online application process via, uh oh, really online service. And you can certainly register with that before the application is open so they can keep you notified as to when it's time to to apply. And it's important to know that you can request for deferred start. Anybody have to have a valid reason for doing so, and you can apply for less than full time training. As I said before, you must have the MRCS exam and you have completed your course surgical training competencies. You've got to be registered with a GMC, and you should have a minimum of 10 months Experienced an orthopedic surgery that would include your time as a foundation doctor. You should have completed your competencies within the previous 24 months. As I said, hopefully, during your course surgical training, you have had time to rotate through the different specialties aligned to surgery, general surgery, plastics, neurosurgery, vascular in the I, T. U characteristics, urology and oromaxillofacial surgery. A TLS having the 80 and less advanced trauma life support, uh, certificate is important. You need that, and it's notoriously very difficult to get onto this course. So if it is that you want to apply for surgery, you've got to think about this early and really try and get on to at least a waiting list to get this course done. But you must have secured that before you come for your your interview to go to ST three. There's certain personal skills that are required, and these are things which you would have to provide evidence on your portfolio, and you're going to show some commitment to the specialty, and that's in terms of doing audits or presentation. So when you get onto your attachment and orthopedics, or even if you before you, you you you get onto your attachment, you can find one of the orthopaedic doctors. You may come across them in a any wherever it is you're working and ask them if there are any projects that are taking place. They're always looking for someone to help them collect data and so on, and so you can get involved in an auditory presentation. If you can get a publication of a case report or something like that, then that would be fantastic. So so look into that and just keep, um, be aware and look for opportunities. And although it's it's not a requirement now, what I would like to see is some evidence of someone that's engaged with diversity, equity and inclusion because we want to have the people of the right mindset coming into the field of surgery. If we want the landscape to change now, there's a lot of information you can find out about the S T. Three interview on w w dot also interview dot com. And, uh, that will tell you give you more information about different stations that you will go through during the interview. You obviously will provide your portfolio, and you have to show that you've gotten through the course surgical training and got a satisfactory ercp outcome. They will go through your portfolio and talk to you A different aspects that you've presented in there. There'll be a clinical station where they're gonna assess your anatomy of knowledge. Uh, interactive station where they're going to be a different scenarios roleplay scenarios, and they see how you manage those. They'll you have to be given. You were given a topic and perhaps having to do a little presentation. So you get time to prepare that, and then you have to go through a list planning exercise where they give you a theater list with different cases, and you have to order the list in terms of priority and be able to justify why you put that order. And then there will be a test on your technical skills. Now, the good thing about that website is that there are lots of exam questions there, uh, and scenarios that they will inform you about so you can get lots of practice, uh, prior to your interview and no better than also if you, uh when you're in the hospital, try and find someone, perhaps someone who is a newly qualified registrar specialty training, and ask them a bit more about the interview process so they can give you some some insight. It's a long time since I did that. So So find someone who has recently gone through it and let them give you some advice. So you've become a consultant. What is the job entail? Well, I'm a hip and knee surgeon, so mine is often, Um uh, my my role is to perform primarily hip and knee replacement surgery, although there also is a trauma aspect of the job. Uh, to the left of the screen, you see an X ray radiograph of the pelvis with a right hip replacement in situ, and the patients about to have the other side done. And what you see there is part of a plan that we do before surgery. So we superimpose the prosthesis that we hope to use for the patient. And we look for the best fit to recreate the patient's anatomy on the right side of the screen. And there I am, performing a robotic knee replacement operation. So what is the role of consultant involved? I work both in the N h s as well as a private sector, and you've got that opportunity as a consultant you can. You don't have to do. Private practice is entirely a choice, and your private practice may consist of clinical work like mine. Or it could be a medical legal work. Um, but there's also an opportunity to do things outside of medicine you may be we want to get involved in a charity or something. So so, apart from the NHS work, you can't do all the things. The clinical role involves seeing patients in clinic as well as performing operations. I got two types of clinic. I've got my elective clinic, where patients are referred from the GP with conditions usually affecting the hip and knee. And they come for for assessment and for me to decide whether their management, the further management, will be non operative or operative. Uh, the clinic is also made up of patients who have come back following the procedure, and I'm just monitoring them to see how they're progressing. Then I have a fracture clinic. This is where patients come who have had acute emergencies, and they've either been referred via the accident in the emergency department or they have come to the clinic following having had a procedure, uh, having had come to the access to the emergency department, and and, of course, I will then monitor them and, uh, see how they are progressing. Some patients come in, they have an injury, they need to be monitored. And they progress because things can change. Even though I put them in a plaster, the fracture can move, so they need to be closely monitored. And if it if it moves, one would have to consider intervening. I'm a clinical and educational supervisor. As a clinical supervisor, I'm in charge of a trainee with in my department, uh, oversee their training while they're in my department and as an educational supervisor. I'm in charge of the trainees progress throughout the year that they are based at my hospital, and that's year may or may not involved in passing through my department. But the point of contact, um, and someone just to oversee their training is going along, as it should do. I teach not only the junior doctors in my department that includes not only the foundation doctors, but the registrar's, but also medical students. My hospital is affiliated with Imperial College, and so we teach their medical students as a leader of the department. I've got a lot of managerial duties that involves making sure that the service provision is both efficient and effective. And I work with the managers to, uh, ensure that I'm an examiner for IMP your college medical school final examinations, as well as an external examiner for the University of the West Cities in the Caribbean in Trinidad and Tobago. I'm an associate editor for the Journal of Medical Case Reports. And I'm in various committees aligned, too, of course. Orthopedics, uh, the Cultural Diversity Committee of the British Ship Society. Because I'm, as I said, very passionate about including increasing diversity within our specialty, the societies I've talked about the British Association of Black Surgeons and British Caribbean Doctors and Dentists Association, because not only do we have a fewer number of women in the specialty, but the cultural diversity, particularly from those of African Caribbean origin, is poor. And within the African American community, it's particularly bad for women. And so it's so important that, uh, raised the profile of orthopedics so that we can get more people to come involved. And I put their personal time because despite all those other things that what I do, it's so important that you make time for your personal life and I will say this to you. We expect you to come and apply yourself and work hard. It wouldn't hopefully seem too much like hard work because you're doing something that you're passionate about. But it's so important that you look after your mental well being and it's very good to have interest outside of work. So my typical day might start off with a trauma meeting where we discussed the patients that have been admitted the night before. And, uh, not not not necessarily only admit it, but those that have been referred to it. There's a virtual fracture clinic that we do. So if the people, the doctors and they and they have any concerns, they can refer patient to this virtual fracture clinic. We then go through the X rays the next morning and decide whether patients are have been appropriately managed the any, whether they need to come in to clinic, whether they need to just be referred for physio or they can be discharged to the GP. Those patients have been admitted after the meeting will go and review them on the ward. If it's a day that I'm not the on call admitting consultant, I may be doing a war drug anyway, just to see my in patients from my previous, uh on called duty. Then I'm either going to go into a clinic or go into surgery and in part of that day, maybe involved with teaching, maybe some administration, the on call service for trauma. You normally have a day that your allocated to to trauma and, of course, that involves weekends as well. But it depends on the size of your department as to the frequency of those calls. So I was asked to prepare an interesting case as well. Just keep an eye on the time. Uh, and I'm just going to whiz through this because I really want to leave some time for questions. And this is a case that been referred to me for a total hip replacement because he has sustained a fracture of his hip, which has failed to unite. So 42 year old gentleman he fell onto the floor while under the influence of alcohol or recreational drugs. Marijuana is his drug of choice, and he sustained a right Basicervical fracture neck of the femur. So busy cervical means at the base of the neck of the femur. This gentleman had a raised creatinine kinase when he presented because he'd been immobilized before For many hours before he was able to get any help. And he had a background of the alcohol and drug dependence. And of course, these things had to be addressed prior to his surgery. So I had to make sure he was well hydrated. Um, your creatinine is back to normal, and he was referred to the relevant, uh, counselors for his alcohol or drug dependence. He was then taken to theatre on the left hand side. You see the fracture there? Unfortunately, when you got the AP view, But there's a fracture here. If you look across here centonze line, Remember? Um, the line going from the inferior part of the superior pubic Ramus around the media board of the neck and shaft. The fever should be all one continuous line, but it's broken here. There's a step here. Uh, and this patient was treated with this device, which is called a dynamic hip screw a screw, which goes into the femoral head this crew enters a barrel through which is allowed to slide as the femoral head collapses and the patient mobilizes. That's what you want. You need compression fracture site for it to heal. This mechanism allows for the screw to slide in the barrel and allow compression. If that sliding um device was not present. Then, as the head collapsed down as a fracture collapse, the screw would come through the head. So that's why we've got this dynamic aspect of the of the of the screw, and that barrel is held onto the shaft with a number of screws. So this is a lateral view now when you're placing the screw. Ideally, you want to school to be placed in the center of the firm ahead on the AP as well as the lateral. Here you can see it's slightly posterior. If you're not able to get it directly into the center of the head, then you want to go. If anything slightly posterior and inferior on the neck, if it's too superior to risk it, cutting out five months post off. This patient represented the clinic, and the inferior school of the plate was broken. There's been some collapsing sclerosis here at the fracture site. And there was hope by his treating surgeon that the fracture was uniting. They decided to observe the patient, and he was in too much discomfort at that time to monitor his progress Nearly a year. Post surgery. He he wasn't, uh, returning to clinic regularly. Um, he came back, um, in a in a lot of pain. And it is a CT scan. And on this, you can see there was absolutely no evidence of any fracture union. Uh, he initially wasn't particularly keen to consider further surgical intervention, but the pain has persisted, and he's now agreed to come for hip replacement. And, uh, he's He's due to be done very shortly. My plan is to remove the metal work and to put in an unscented hip replacement with an UN cemented hip replacement. I don't have to worry about the cement coming through the screw holes, and I've got a device that's much longer than the screw hold. Because once I have to open up the bone here to to remove that screw, uh, and that defect with a liter, an area where the bone is potentially weaker. Uh, and So we need to have a prosthesis that significantly bypasses that to reduce any risk of further, uh, bone injury. So when you have a fracture neck of FEMA, your treatment will depend on the location of the fracture as well as the degree of displacement. Now, why is the location the fracture important? It's all to do with the blood supply. The femoral head neck area gets its blood supply from two sources. You got the operator artery given an artery to the fovea. Um, and this blood supply is predominant in the in the young child. As you get older, the blood supply here reduces and you become more dependent on the blood supply coming through the capsule, which comes from the femoral artery. You've got the circumplex in the media and lateral circumplex artery. The capsule comes around the front of the femoral neck all the way down to the base on the back of the neck. It only goes halfway along, and so fractures in the base of the femur femoral neck are thought to be outside of the capsule. If you have a fracture just below the head, this is called a subcapital fraction of the area or through the neck transcervical fracture. They are thought to be intracapsular. Now, if you have a fracture here but you, the fracture is minimally displaced. On this place is a high likelihood that the blood supply would not be compromised so that type of fracture can be fixed. The important for the reason that the blood supply is important is that you need a rich blood supply in order for them to be healing. Fractures of the base of the of the femoral neck or around the Trochanteric region tend to have a rich blood supply, and therefore fixation is satisfactory for inter capsule fractures. You either fix in situ if it's on displaced or minimally displaced, or you do a partial or total hip replacement but an extra capsule fracture. You're looking at a dynamic hip school or some type of intramedullary device, and these are devices that 1 may use the dynamic hip screw as you've seen previously. Only this one has a four whole plate on this side. You've got the intramedullary device. This is biomechanically stronger because the main shot here of the nail is actually closer to the mechanical access to the body, and therefore there's less bending moment here at the level of the factory site. But there's a technical element to this, Um, and also in terms of cost, this device here is cheaper, uh, easier to insert. Uh, and therefore, one has to balance, uh, the capability of the surgeon as to choosing the device. And in fact, is it gives adequate results. So one of the complications with the dynamic hip screw it can fracture can go into a nonunion. It can be delayed union or even mild union. You may not be able to completely reduce the fracture from where it came. The lag screw in the family head might cut out if you don't put it in centrally. Uh, and of course, there may be screwed breakage, as has happened in this case, there comes a question here about the plate on the DHS. Only a two whole plate was chosen. Uh, there's this. That is this is contentious. I know there are some surgeons that use the two whole plate for these fractures. Um, I personally use a four whole plate. Uh, and this is a good study Taiwanese study, which is that really looked at the stress is generated across the legs group the barrel and the distal screws, using a four whole area to whole a four hole in the six whole plate. And what they found was, the stress is across the lab school. Whether you use the 246 whole plate was actually the same the majority of the stress being at the level of the fracture site. But the more stress on the whole construct was actually in the distal screws. And when you have only a two whole plate, significant more stress was on the inferior screw. When you have four or six whole, the stress is more evenly dissipated across the the screws. So this is the reason why that that, uh, inferior school, the two whole plate probably broken this patient. So the studies are out there that show that the two whole paid can be used. But if you have a fracture which is not fully reduced as this case wasn't, uh then it was inevitable that that inferior screwed break. So the pitfalls for using the dynamic it's true are placing this through X centrally and not making sure the factor is adequately reduced. I think in these cases you have to think about using a longer plate if you haven't got full reduction of the plate, and you've got to restrict the weight bearing of the patients. Postoperatively. We've got a patient here who probably wasn't going to comply with instructions and so, perhaps even consideration for doing a nail for someone like him. I should have been considered. But now that it's failed, the treatment options are either to try and refix and do bone grafting. But it's unpredicted know as to whether the bone graph and uh will take whether he will restrict his weight bearing comply with instructions. And so I decided to go for total hip replacement. So in summary, sometimes we're faced with these very challenging cases. But the important thing is to try and get it right. First time for the patient. You got to consider patient factors. Uh, is a patient, someone who's going to obey instructions. Do they have other medical comorbidities? Are they able to partially weight, bear or restrict their weight bearing, if necessary? The surgeon factors and what was the experience with using a particular device and then the choice of equipment that's available. And always there is the option when dealing with difficult cases to get a second opinion. Uh, from this particular chart, I discussed him in a multidisciplinary meeting with my other colleagues, and we all agreed with a treatment for the total hip replacement. So in summary, orthopedics is a fun specialty. You really have the ability to make a significant impact in someone's life. Uh, today I had a patient who said to me, uh, I mean, they were left waiting for a long time because of cove ID that they they were. They were almost suicidal because of the pain. And they were so grateful that they had a total hip replacement done by me, and it's transformed their life. That's the kind of impact that you can have in a patient when you do orthopedics and you see the benefits very, very quickly. So don't leave me having all this fun by myself. Please come and join me. Thank you very much. Thank you very much, Mr Ross. Thank you so much for sharing some personal stories and giving us some insight into your life and career. As an orthopedic surgeon, I am certain you have inspired many bidding orthopedic surgeons in the audience tonight, and we'll move on to the Q and A. What was it like during medical school? And was there a lot of independent study involved? Yes, you know. Gosh, I was a long time to think back to medical school. I made a dinosaur. I don't look like it. I don't think, but But I am, you know, I mean, there was Yes, you know, there is no one. I mean, I guess I learned from school. Anyway, There's no one there looking over your shoulder for putting you to work. So, yes, there was a lot of self study and one had to learn to be disciplined. Why do you think there is less African Caribbean representation in surgery today, especially in leadership roles, the numbers in terms of medical school. So you've got a smaller pool to choose from. And then, of course, people are dissuaded by not seeing representation that look like them. So they're afraid of applying, because they I mean, I'm just speculating. We don't know. I'm sure it's a combination of all these things. So there may be some reluctance to go for a particular rule, and then those in the committee's who are selecting they have their biases as well. Uh, it may not mean be conscious to you, but you're the criteria that you use for selecting is based on your own personal experience, you're more likely to choose someone that looks like yourself. So a combination of all those factors, any cases of patients you've dealt with that have really stuck with you. There's lots of things that have stuff with me. Um, you know, dealing with patients who have come with also, uh, sort of almost mangled the deformity, but something that you've managed to salvage. And then they've done very well, uh, dealing with a patient who I've replaced both hips and both knees. Um, they kept coming and they even came back after that, asked me to do their shoulder, and I had to say, Well, now this is outside of my remit. Uh, but as good as they trusted me enough that I want to keep coming back. Um, I had a patient who was the mother of one of my colleagues who who he likes, by the way, but, uh, so and asked me to do the operation. Of course. That's gonna be something that touched me when you when your colleague chooses you. Um uh, patients in whom I remember the first patient I did a bilateral hip replacement on. So there are different reasons why people stay in your mind, but, yes, I I remember. A lot of my patients are very fondly once you've done an operation. How long do you see the patient for afterwards. How many years does the follow up go on for? I usually follow them up for a year. Yeah. Yeah. You know, some hospitals are trying to get us to discharge if a patient something like 96 or something. I don't have replacements in the patient up to 99. Um, then I'm not going to keep following them up. You know, you get them 1st. 1st 6 to 12 weeks. And if they're fine and let them go, um, but But usually I try and follow my patients up for a year, and then after that, I have to discharge them. But I I do recommend that they come back for ideological review of 5 to 7 years. Um and so you know, they they don't have to see me. They need to have that review. And if there are any concerns to come back and see me, how did you narrow down which committees you want to join? As I'm sure there's an incredible amount of them out. Then go for something you're passionate about. Anything that takes up your time, you're going to be invested. What advice In terms of extracurricular activities would you give to an aspiring surgeon currently in medical school? I think you know you want to go for something that's going to support your application in some ways. So it may be something in which you're doing a leadership role. For instance, um, or some kind of management. If it's something to do with surgery in terms of maybe you're volunteering with with with an ambulance service or some other health care, you know, like professional organization, Um, something like that. But always be thinking about how can I use this? I mean, you're doing it because you enjoy it, Okay, so I can't. I don't want life to be only about work. I think it's really important to stress. Definitely. You've got to have that balance. But if it can, um, support what you want to do career wise as well. Then look at how that can support it and what what, what qualities that you're having to use for that you can use in your application. When you're struggling at work and lose motivation, what keeps you going? What gives me going? I think my my patients keep me going. You know, when when they come back and they are so grateful. That's that's what and and and having just just I am, I am grateful just being in gratitude, grateful that I'm in the position that I can have that impact in someone's life that gives a great colleagues choose well, as a as a trainee, you don't always have a choice where you go, but when you become a consultant, choose well. Make sure you have good colleagues, and they can also help rally around and boost you when you're feeling a bit demotivated as a black female core training surgery, what is your advice to stay motivated and focused despite challenges in training and discrimination, And also, how would you recommend going about finding a good mentor? Well, you've got to have a good support network that is absolutely key. And people it can be people within medicine. It can people outside the medicine, but someone who has a listening air that you know, has your best interest at heart and someone who you trust that is absolutely key. Because no matter who you are there, they're going to be moments when you when you feel a bit down and you need to be boosted. So that support now that's what keeps me going, remembering what it is you want a chief. So I had some negative experiences during my training program and I had to think what was my end goal? I want to be a consultant, so I'm not going to let this deter me. You have to somehow find the way through, and and and and it's different for different people. For me, I had to confront the particular issue because it just tested if I do didn't do it. But some people don't have the strength or whatever to so to just to confront the particular individual, so you find another way to do it. But you have to remember what your focus is, and don't let anyone deter you. in terms of securing a mentor. Look, I was lucky. My mentors found me. I took every opportunity. I worked really hard. I try to try to stand out and people took notice. And it was easy to take notice because I was the only back over there, Um, and and And they offered to be my mentors, so So that was easy. But, you know, I'm sure if you go and ask somebody, um, you know, can you please support and mentally people would be delighted. Um, as a woman in surgery, what do you think is the biggest challenge in your job? My biggest challenge, I think, was overcoming self belt. Yeah, bigger than any other challenge out there is me. And when I say self doubt, of course, I didn't feel like my I said color was a was a deterrent. But you're in an environment and not many women, of course. After a while, some of the micro aggressions and so I get to you. Um and you started out yourself and and so I think that's my biggest challenge. And it's something I still but with every day, some of these challenges don't go away. but you got to just push through What is the best piece of advice that you have received during your career? Whoa. Um, what is a bit? I guess there was a point. You know, when I I guess I was a little bit frustrated because most of my friends were outside of medical school and and And it was so tough at medical school and we always had some exam to do, and my friends were out party and so on. And so I went to my consult, and I said, Look, you know, I'm having doubts. So even someone who was passionate about surgery kind of have doubts, you know? And I was I always want to be a surgeon. For the time I was seven. I was, you know, keen and orthopedics. But I went through some some somebody. It was I think it was a particularly tough attachment. Um uh, and I were and he said, Look, first of all, he asked me, Do you have another career in mind? But I didn't have anything else in mind. And he just pointed out all the benefits that they were in in in this job. The career progression and so on. Um, and what orthopedics had to offer? Um, and I write it myself. You know, um, I think that, uh, that was as s h o that. And that was the time when I was doing an on call, a one and two, so it started to get to me. I mean, these days, you know, you don't do jobs like that. Um, and I think that the fatigue got to me a little bit and made me start it out. But what I would say to someone, and you know, I would say to you is that, um which I think is a great piece of ice. It necessarily get him as a medical student. But the times when you are most, um, uncomfortable is when there's the opportunity for the most growth. And I think we always try to resist getting into situations where we don't feel comfortable when we're outside of our comfort zone. But that's when you're going to grow. And the the other side of of that uncertainty is growth. And and and and I just think that we shouldn't fear failure so much that that that's what I would say It's always a big thing when you remember that, but I did my fellowship example. Share this with you. I feel my exam the first time. I, you know, I felt as though my life could have ended at that point. It was such a big disaster and really in in the scheme of things in life was going on that really it wasn't as significant as I made it out to be. So even if you do drop down, sometimes just pull yourself back up. I need your advice. How to solve problems with bullying, gender discrimination, sexual harassment. That's a very, um, a question to answer. The thing is to remember, you're not alone, okay? There are lots of people out there who are going through the same thing. And this is why it's important to have that support network, someone who's confidence, Um, you've got and whose opinion that you value that you can actually share your concerns with them. Um, now, if that's well within the medical arena, um, you got your educational, your clinical supervisor, your educational supervisor. If if that doesn't work, you're training program director. Uh, So there there's a There's a step that you can follow. There is also the in the hospitals. Uh, I've forgotten what it is. The feel something guardian. I've forgotten the name is two. Slipped my mind. Um, speak up guardians or something? You got it within the hospitals. So there there are lots of different places that you can go to get that support. Now, if you are someone who is an African Caribbean origin, let's say you have got these other societies you got the the British Association of Black Surgeon. You got the Caribbean Doctors and Dentists Association. You have organizations UK Black Surgeons Network where you can reach out and find people who can give you support and and the same with other ethnicities. You've got the richest association of Indian surgeons and so on. So so there. There are societies as well where you can reach out to people. What advice do you have on possible pitfalls in the pursuit of orthopedics? Well, 11 of the pitfalls is the exam. But don't be deterred. You won't be the first person not the last person to fail on exam. So that that that definitely is a pitfall. I don't know what the percentage pass rate is these days. Um, but a lot of a lot of very eminent surgeons have had to do the exam, so that that was one pitfall and certainly one that I fell into. Uh, you have the pitfall. I guess we're, you know, negativity. Um, bullying and and and that sort of thing. Um, but but don't let people deter you from your particular goal. And as I mentioned before, how to how to overcome that with with, you know, finding someone that you can speak to, um, one of the pitfalls, you know, mental well being. There are times when you would be absolutely not only physically but mentally exhausted. You know, as I said, the in terms of the on call is not like doing a one and two or anything. I'm not I'm not saying that one still can't get tired, But having a balance outside of work also really helps. And that's why I really want to stress that that you must think about finding things that make you happy outside of work and also spend time thinking about your private life. You know, if you want to have a family and so on. Don't leave it too late. These are things that people don't tell you. It's so important. When you look back in life, you're chasing the medical career. These are things that are going to be very important later on. So give them equal attention. Have a question from Kathy. He says that she has been to talks from women in medicine societies. That med school and the surgeons have said things regarding to sexism. If you don't look for it, it isn't there. Has anybody ever said this to you And would you agree? If you don't? Well, I don't agree with that. Uh, it is there, but, uh, there is a little bit of truth in the sense that you know, people can say whatever they want to you. It is up to you with what you do with that information I eat. It's up to you how you react to it. Okay, um, they can't make you feel, uh, bullied or insecure. That's what you do to yourself as a consequence of what they have said. So remember the power is with you, and and so if you you know you can't fight every single battle as Well, so sometimes, yes, you have to, uh, it's there. You recognize it, but you just decide I'm not going. I'm not going to make this an issue for myself. You know, I'm not going to give this that particular attention, because I want to get from a to B. So So how you deal with it is important. Um, and and remember, you have the power and you have some control there. That's just what I'm saying. I don't see anything else you want to say about how you achieve a good work. Life balance. You know, it's never going to be perfect. There are times when the work has to has to come first, and you you have to give it that that attention. But then, you know, I do take the time water afterwards and readdress that. I mean, I I've been going through a particularly very, very busy period, and I have decided that this year I'm going to take a sabbatical. It's going to be the first sabbatical I've taken in my career, but a recognition that there needs to be a little bit of a redress of the imbalance, and that's what I plan to do this year. So you it's up to you. There are times when Yes, of course you have. It's not going to be perfect all the time, That balance. But make sure you carve that time out for yourself. Are there any recent advancements in orthopedics? Um, in general, that we we should look out for lots of X exciting stuff going on. I mean, my friend, Professor Shafia man, is doing a lot of stuff in the metaverse and teaching in the metaverse, which I find extremely exciting. I don't want to know too much about it, but that's that's certainly the future. Um, robotic surgery is certainly developing. Um, and all the other interesting changes. I'm very keen that the the companies are looking at ways to, uh, improve the the equipment that we use because, you know, sometimes the my side of orthopedics is very, very physical. And some of the hammers and things that we have to use don't always sit well in the hand. So these are advances that excite me. Um, but yes, that this this this That's why the specialty is so exciting, is constantly evolving. There's always new things coming up we'll end there. So I just want to say thank you again, Mr Ross, for a very interesting and inspiring talk. We really do appreciate you, um, sparing your time to talk for us. You know, it's a pleasure. Um, and I hope I made a few converts tonight. We want to run. I'm excited to begin the career and surgery remind you to please fill in the feedback form. It's super helpful and remind you all that we do have a couple more talks in the pipeline. So our next women in surgery talk is the 23rd of February, and that's with one of our general surgery. Registrars is Roxanna Sakiri. So she'll be talking then. And W PMN are also doing a talk for Military Medic. So anybody interested in working in the Army, we should definitely look out for that. And that's on the seventh of that. Thank you very much for everybody.