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so it's just loading. Let's hope can everyone here? Me, I hope. Fab. Okay, we are live. So, um Good evening, everyone. Thanks for joining us for our next talk on women and surgery. So tonight we have, um, our orthopedic surgeon who's Miss Jackson, who's kindly agreed to share her journey and her experiences of being a successful woman and surgery in particular orthopedics. And she is a foot and ankle specialist and also operated on myself in the past. So, um, I'll let her share some wise words of wisdom for us all. Great. Thanks so much for inviting me to talk. I'm just going to share my screen and hopefully get my slides up and good to go. Um, can can everybody see my slides? Okay. Now? Yeah, yeah, but we can see them. Great. So, Yeah. Thanks, Charlotte. Um, as you said, I am an orthopedic surgeon. Um, I work at a university teaching hospitals up in Merseyside. Um, a specialized in the foot and ankle surgery. Um, and I'm just going to tell you a little bit about the specialty of trauma orthopedics. A bit about my journey and what my job is like day today, I'm gonna talk to you about work force and some recruitment issues. And I am going to touch on some ongoing challenges that we've definitely got in trauma Orthopedics when it comes to, um, women in the surgical workplace. Um, so the first thing to notice is, I'm definitely representing the biggest surgical specialty. Overall, we're bigger than them even general surgery now, But unfortunately, we're the most under represented by women. Um, about 7% of consultants and about 20% of trainees. Um, but what's fascinating about trauma orthopedics is even though we're the biggest surgical specialties. In actual fact, we are umbrella term for loads of other subspecialties. So if you get your CT, CT and trauma and orthopedics, you've got a wealth of opportunity and areas that you can go into, and that's pretty much something for everybody. So obviously there's hip hemiarthroplasty is probably the most common job within trauma and orthopedics revision Arthroplasty is becoming, um, much, much more required. A popular popular choice. Um, but also there's pediatric orthopedic surgery, which is really delicate work hand and wrist surgery, foot and ankle, which is what I do. Even orthopedic spinal surgery and spinal deformity. Correction. Um, and there's some oncology work with them primary and bone tumors, but also dealing with the effects of metastatic bone disease. So yet we're a massive specialty, but we encompass lots of opportunities for lots of different people with different interests. Um, there's lots of different places you can end up working. Um, you can work in a major trauma center with the helipad work in the multidisciplinary trauma team. Really, that's life, and I'm saving surgery on a daily basis. You can work in a trauma unit, which is a D G. H based orthopedic unit, which is where I work. There's also the option to set your sights on an elective specialist center, and you might have heard of Stand More Rural National Orthopedic Hospital. That's where Princess Eugeni had her scoliosis surgery and some of the some of the great research work and big advances come out of there. And there's also writing tongue, which is the equivalent up north, where I worked for part of my training and earlier my consultant career home of John Charnley and essentially the invention of modern hip replacement. And they're still really pushing the boundaries of that. So there's lots of different places you can end up working as an orthopedic surgeon, and then there's different ways that you can work. You can do what most of us do, which is a mixture of trauma and elective work. So fixing broken bones and then deformity correction and treating arthritis in our specialist area. Or you can do major trauma, which again you probably to be a major trauma center in a big city. Um, and that's a lot more up at night. Um, and the major case is purely elective again. Some people aspire to do that throughout their career. In an elective specialist center, some people find that as they move forward in their career matures, they do less trauma, uh, and more specialist elective work. And that's certainly something that we see in the unit that I'm working in. And it's, um, it's a common path, which is quite nice as your priorities for family and lifestyle change. And there's definitely a role for clinical scientist, so part research part surgeon. And you probably have to hook up with the University Teaching Hospital to have that sort of role. And there's definitely options to be full or less than full time in trauma and orthopedics. And you know, there are people doing week on week off job shares or part week working. Um, and again, not being involved in trauma care can sometimes add to that that pure elective work. And then, if you're interested, um, orthopedics. You might know very early on on where you think you're fit because you've always loved shoulders or love trauma. But actually, as you go along your career, you tend to find that it's inspiring mentors and trainers that will get you interested in specialties or just getting a feel for what the teams are like and And what kind of team members that you want to work with? Um, so certainly my journey. I was pre modernizing medical careers. So, um, I was on the old common training program, but essentially, I graduated in 2001 from Manchester. I had all my exam milestones, and I got my C c T 10 years later, which is pretty much what you guys can do, um, with the current curriculum and progresses, you can you can get to be a consultant within 10 years. I would say I got there pretty quick, and I've been a consultant now for about 12 years, which I can hardly believe. And I'll tell you, your longtime consultant, so definitely don't worry about it. Don't rush it and enjoy the journey. Yeah, Even after I was appointed, I got a PG certain in medical education because I realized that what I really love to do is train. And that's one of my passions. Is, um, letting trainees operate and teaching on the skills that they need to become independent surgeons? And then two of the greatest things that happened to me since I became a consultant was I was given the award of trainer of the Year in Mercy, and the same year I got awarded the Traveling Fellowship by the American Foot and Ankle Society, which was a massive on because I was only the second woman to ever do that in the history of the fellowship. Um, currently, as well as working full time as a trauma orthopedic surgeon and foot and ankle, I'm also the regional advisor for Mercy and Cheshire, which is a B o, a Royal College appointment. I chair the specialty training Committee, so I basically keep the T P. D and the director of education and check and make sure that everybody immerses hopefully getting trained well in whatever hospitals they're in. And and I'm also involved in the national selection for specialty trainees in Trauma Orthopedic. So I'm involved with questions setting and making sure that the process is fair and transparent and that it doesn't discriminate against anybody. Um, so that's those are the roles that I've got currently the, um, impact on my career. Um, just to mention a little bit about my travel fellowship. I just thought it was really important to mention as a woman in surgery that I think that we don't always put herself forward for for these sorts of things. I didn't get the opportunity to go on a international fellowship when I came to the end of my training because of personal commitments. Um, and it's just to say that even when you become a consultant, you should look for opportunities to apply for fellowships because you can get sponsorship and funding, and I, as a consultant of six years, got the opportunity to take nearly a month of work, and I got to go with four other guys from around the world, including American military. Um, that's Kevin there in his uniform, making the photo look great. And and I got the opportunity to visit four centers in the United States and Canada. And, um, I got the opportunity to visit world renowned surgeons, watching them operate, discussing cases and really sharing ideas and experiences. And it was one of the best things I ever did. And because it's only a 3 to 4 week fellowship, it's something that's definitely worth considering, even when your work life balance might not allow you to go away for long periods of time, Um, a bit about While of orthopedics, I think what I really love about it is that it's usually pretty clean cut. You diagnose an injury or a condition so the bone is broken or there's arthritis of a joint. Um, and then you look at the options. You come up with a treatment plan. There's conservative and surgical options. If they need an operation, you do it. The patient read abilities, they recover and hopefully you to improve the quality of life. And, you know you get a lot of job satisfaction from it, Um, there's no doubt it is practical. Think you do have to be good with your hands? Not everybody starts with the same dexterity and ability. But that's what training is for is um, teaching you the techniques and the skills? It is technically challenging, and some of it is heavy work. But modern modern power tools and and patient set up really doesn't cause a problem with size or fitness. But definitely the more you do things, the better you get at it. And even though I'm pretty small like I can, sometimes some of the strength of the 10 tigers, if need be, um, just a bit of like problem solving and thinking about how to get around. The more physical aspects of things I think have led me to be a more thoughtful surgeon, actually, because I can't always fly on brute strength. Um, I love the fact that it's a mix of bonus soft tissue surgery, so there's never a dull moment. And as I said, there's a lot of job satisfaction. I think it's really nice and problem solving and and depending on what specialty urine you can do different types of mg t working. So I spent a lot of time working with physios and orthoptist. And I also work with my Diabetologia colleagues in my rheumatology colleagues because as you guys know, there's so much, uh, general disease, diabetes, heart disease, rheumatological conditions where we can see the signs and symptoms in the feet. And, um, and surgery can play a really important role, not just in treating those, but actually, sometimes somebody appears in my clinic with the foot condition, and I'm the first person who has the has the ability to see the signs and actually spot that they've got significant systemic pathology. And so definitely anybody who says that orthopedic surgeon, um perhaps, is for the less intelligent amongst us. I would beg to differ, Um, and so in terms of my working week, I'm on 10.75 p s, which basically is a full time contract. But actually, if you look at my working week, I actually work on Monday or Tuesday. I don't work on a Wednesday and I work Thursday and Friday and I do fracture clinic, elective clinic. Some trauma lists were fixed, broken bones and elective theater. I've got some time for admin and war drones and also to support my professional activities, doing, teaching and CPD. So actually, it's a really balanced week. I don't do private practice. If I did, I would probably do it on a Wednesday and maybe we'll do a couple of evenings a week because that's what my colleagues do. But I don't do private practice, Um, and so actually, I've got quite nice balance of work and life because of that. My own calls one in 12. Which means I do one weekend pretty much every three months, which isn't too bad. And I do every third Monday on call, and most of what I do on call is daytime operating, and I don't get called out that much at night. And if I do, it's usually for something really important, like impulsive supracondylar fracture, Um, which is again really rewarding work. Um, so on the weekends, I go back to my general trauma skills. So nailing, um, femoral fractures doing hemiarthroplasty have hip replacement for fracture neck customers dealing with bone and joint infection and then on the weekday trauma list. This is more of my specialist area fixing complex ankle and foot and ankle fractures. This is the kit I use. This is the kind of equipment I'm used to using. Um, lots of choice of plates, screws, reduction tools. Um, so it's quite technically minded, and a lot of them a lot of problem solving and preop planning involved and decisions on the table. Um, so really rewarding. So some of the cases that I might be involved in this is a tailor neck fracture, Um, really badly displaced at the ankle joint. This was a 16 year old girl, and this is really a disaster, because if that Taylor body dies, she's going to get from the Avastin across. She's going to get severe arthritis. And so it's a life changing injury, and we've opened that up and fix it just with some simple screws. And she's gone on to have a really good results. Um, this is a what looks like a simple by malleolar ankle fracture, unstable injury. But you can probably tell from the soft tissue envelope that this is a pretty large leg. It's going to be really hard to control this in plaster. So she got referred to me to consider surgery, but that's her soft tissue envelope, so she's a massive risk if I do open surgery. This is a sort of limb threatening situation if I make the wrong choice. So we go back to basic principles of what we got to splint the leg on the inside and and she's got a nail that's come up from the sole of the foot. Essentially, it's the same kind of device that we put down femoral fractures. Um, and we managed to. We managed to get that healed and save her leg, which is super rewarding in terms of my elective practice. We do ankle replacements for arthritis is probably the most interesting evolution of elective foot and ankle surgery. Um, and then the most common thing I do is to sort out ladies' bunions, which is again, Um, it's a hugely rewarding because, um, the patients are usually really grateful afterwards because they can get back into footwear and walk around pain free. And then the other important bit of my job is I deal with the ever increasing burden of diabetic foot disease. So this is somebody who was really poorly with a severe untreated infection. They've had a little ulcer underneath the fifth metatarsal head. They can't feel the foot because of diabetic neuropathy. So they basically been walking around, and the foot has been absolutely cooking, filling with puss and necrosis on the inside. Um, and so it's important to debride that and, um, and then think about reconstructive options So the patient doesn't lose their leg, and we managed to get him healed with the Transmetatarsal amputation, whereas potentially 10, 15 years ago, he would have ended up either dying of sepsis or with a bologna amputation. So he gets to ambulate and continue to him to live in an independent life. So that's another big part of my work. So just kind of going back to If my jobs that great, then what's the problem with women in North with women coming into the specialty? And this is a B M G article, which really shows that trauma, an orthopedics and cardiothoracic surgery are the least represented by women. And if more than 50% of medical students are women, then why are we not attracting a high volume of women into the specialty, and actually, how are we going to populate our workforce moving forward? Because people are living longer. They're getting more diabetes, more arthritis. We're going to continue to see more injuries. And we We need to encourage women, Um, as well as continue to encourage men and people from all backgrounds to be involved with orthopedics. Um, And the way things are going, this is the predicted trajectory of how we get to gender. Um, parity. Um, and it doesn't look like intro and orthopedics. We're going to get there until the second half of the 21st century. And, um, which is interesting because that means we're really falling behind general surgery, urology and a lot of the other surgical specialties. And it is interesting, because in my role with national recruitment, I get the opportunity to see the statistics first hand. And you can see here that it isn't that we're definitely isn't that we're not appointing enough women. We genuinely aren't getting a high percentage of women applying. And, you know, at times we're getting, you know, maybe 20% of applicants for females. But actually, when you look at how they how women score in comparison to men, actually, the women always score slightly better. Um and so there doesn't appear to be any bias in the interviewers and how they're how they're scoring women. And so of the people of the women who apply a really high percentage will get appointed of the women who apply. But unfortunately, as an overall percentage, on average, it's still looking at about 20% of the work force every every year. Um, in trauma, an orthopedics, Um, and this is a really interesting article, which, if you're interested, a career in orthopedics is definitely worth the read. And this is Laura Hamilton, who's on the national selection committee with me, who is a really interesting, um, hardworking female hand surgeon who is on the Royal College Committee. And she has researched this article on current challenges for women in orthopedics. And, um, she talks about the fact that we have to acknowledge that we've got some challenges that we've got to work through as a specialty, and that these are challenges that can be not always visible to the people who are already in the workforce well established, that can be really visible to medical students and trainees. And a lot of it is about perception. Um, so there's definitely this hidden curriculum um, that people assume that it's an old boys club and that it's very male dominated, and it's the classic public school rugby boy. But in actual fact, some of that is really outdated stereotypes. Um, and what we actually think is sometimes happening is that doctor's and other specialties who perhaps went through orthopedics many years ago are perhaps negatively talk about orthopedic surgeons. I think there's definitely an element of that. I definitely think there is an element of, Of course, there are, uh, all specialties, people who are caricatures of themselves who perhaps don't portray us in the best light. But I would say, overall, some of the really challenging stereotypes are outdated, and it's just about trying to trying to send out a positive message about what orthopedics really does look like, Um, in this day and age, we've already talked about requiring physical strength, and I think that people will realize in any orthopedic department, both males and females come in all shapes and sizes, all ages and an actual fact. We have to consider people's physicality throughout their career. Um, you know, when people are recovering from injury as they're getting older, so this is no longer a male female. This is about actually supporting everybody in the workforce to do the best job they can, including the physical elements of it. Um and certainly, you know, um, there's now issues coming out about the fact that radiology protection has been sub optimal in theaters because it's predominantly been for male colleagues and because of that, and the evidence is showing that actually, women in theaters in particular orthopedic surgeons have been at increased risk of breast cancer because the big downs with the great big apertures for for the arms and the armpits in larger people in fact aren't aren't covering our breast tissue. And so things are starting to come out in the open thing. Hang on a minute, and we actually have to support the entire work force with appropriate protective equipment. Um, there's no doubt about it that micro aggressions do exist, and I think that there are micro aggressions towards women in the work place, but also we have to think about the way that we respond to them. So, um, there's that historical feeling that to be a woman in orthopedics, you have to leave your gender at the door and not be yourself. And in actual fact, I would say You can be yourself. I and you can be a feminine female and you can bring your stuff. You're strong, positive, feminine attributes, and I think they add value to the team. The theater teams, the clinic, teams the patients and will will definitely value what you've got to bring to the table. I think there's a definite feeling from women in orthopedics that we have either naturally, feel inferior or people have made us feel inferior. And therefore we've over compensated by, you know, agreeing to do extra, be slightly bullied by our colleagues. And I know in myself one of the silliest things I did was ignore the fact I had really bad hip pain, having increased my running and I was desperate, was desperate to prove that I'm just as capable and, um, and I and I'm invincible. And in actual fact, it took three months for me to be diagnosed. The stress fracture of my femoral neck. So there I was, beavering away, operating on broken hips and pushing on through, and in actual fact, I didn't really have anything to prove. I think I was just trying to prove it to myself, and I potentially put myself at a bigger risk of them of long term consequences. So I think that there's definitely an element of them. We have to be careful as women that we don't that we don't try too hard and that we rely on our own, um, our own surgical and medical abilities. Um, but, yeah, I would be lying if I didn't see that. I've experienced bias and I think we all have, and some of it is from colleagues. Some is. It is from patients, although I've hardly ever experienced that some of it is historical from other staff. Um, so the first race, just our job. I did. They never had a female registrar in the department before, and I got a lot of comments about People were expecting me to look like a Russian shot putter, a Russian Olympic weight lifter and and again it was just trying to be nice to people myself, and people will respect you for who you are, are and trying to break down and what people's preconceived ideas are of an orthopedic surgeon and then the one that I think probably catches people out. Is the implant reps. So we deal a lot with the reps that that supply the hospitals with joint replacements and plates and screws. And I I sometimes like in these people. They are salespeople and and they have certain sales techniques. And again, they're very used to, um, selling to a certain demographic which has historically been the orthopedic mail. And in actual fact, most of these companies now are engaging with female orthopedic surgeons and with the British Orthopedic Society beginning to get a feel for an actual fact, it's important that they are inclusive when they think about designing implants, designing tools and also about how they approach surgeons and treat them fairly and respectfully. So I definitely think things are moving forward in that respect. Um, you know, I'm kind of kind of stand by. If you can see it, you can be it. I didn't see a lot of females in orthopedics, but the ones I did really inspired me. And I think that as we see more people undertaking flexible training, being pregnant whilst um while being orthopedic surgeons, seeing women in leadership roles and having them as role models and mentors. Then, in actual fact, that's what's going to hopefully encourage more people, um, to feel confident that orthopedic surgery is a place that they can be successful. They can be happy and they can find it rewarding. Um, there's a big push for podium visibility at the moment, and I certainly noticed that I'm being asked to get on, get on the podium, um, and talk national conferences. And I must admit, I do always ask the question, Why are you asking me? Because I feel really strongly that I don't want to be asked because I'm a woman. I want to be asked because people value what I have to see because because I'm good as an orthopedic surgeon and a foot and ankle surgeon. Um, and so I do. I like to always double check that, because I think the worst possible thing is I would hate to be put on a podium just because I'm a woman and because they want to get their, um, diversity numbers up. Because if I let if I let myself down, I potential because I'm not ready to undertake that presentation. Then I let myself down. Um that plays into my imposter syndrome, and I potentially devalue, um, all the other women coming forward. So I think whilst I really believe that, we should be encouraging, um, women into leadership positions and on to the podium. I believe that it should be merit based, um, and that we that we put our best face, um, and foot forward and just on the right. There is just a really nice document for any of you that are interested, which is the B o A, which has finally produced, um, supporting two trainees through pregnancy, maternity, shared parenting and adoption. We even return to work, and some of it obviously is women's specific. But actually, it can relate to, um to father's as well and anybody who is, um, anybody who is returning to work. And it's got some really important information about the risks of radiation in pregnancy, but also the risks of them of bone cement, PM A and how how important it is to, um to have a proper risk assessment and be and be supported through your pregnancy and your return to work. So I definitely think that orthopedics, as a community has recognized that we're further behind other surgical specialties and that we've got our own unique challenges, um, and risks. And we're starting to, um we're starting to face it head on, Um, in terms of other really positive things. Um, I was approached by the Royal College of Surgeons, Ontario Museum. Um, because the college recognizes that it is very, um, the halls are filled with pictures of male surgeons, which, of course, is the truth in history. Um, just as a just as in life and in in every specialty history was the male dominated and it's about how to again, if you can see it, you can be it in the front area. Museum is moving away from just displaying the historical pictures of surgery, and they've changed their changing their exhibits to open in 2023. Um, and it's going to be a journey through the history of surgery up until modern times. And they wanted to have an operation, um, on time lapse from start to finish, being projected onto the wall in the last exhibit hall. And I was really privileged to be asked because they wanted an orthopedic operation and they wanted a foot and ankle extremity surgery. Um, it was they felt it was important that it was a female, but also, they felt it was really important that the entire team was viewed through the operation. So, um, and a lot of the work I do with the college is about valuing other team members in theater and the surgeons only just one part of that and nothing I do is possible without the rest of the team. And so we filmed the operation in my in my trust and hopefully you'll be able to see when you go to the College of Surgeons. But the thing that was really great for me is that the time I was asked my registrar Xenia was working with me. So it was great because we were We were an all female team and what know But he knew back then was that Zetia was actually pregnant. So, um so that's kind of a really nice story for us that hopefully will come through in the front area museum and really support and the push to get more women into orthopedic surgery. And this is just my final slide. And this is the 58 Society um, annual meeting, Um, in mercy and that's me sat next to court. And Kevin, who's our TPD Zegna, who was also the 58 society secretary. And next to her is Joe Banks, who has just been appointed as our next T p D. To start in January. Which means that I think that we're the first region in the country to pretty much have who's going to have an all female team of a. T. P. D. And a regional advisor who both female and you can see that once. Yet it's still a slightly male dominated picture. In actual fact, there's a lot of diversity in that picture and were super friendly region. We got some really good feedback on our teaching. We get really good exam results. And so if you're interested career in orthopedics, um, definitely think about coming and training with us because we'd love to have you, Um, and so, yeah, that's me. And if there's any questions that you have on anything that I haven't covered, I'm happy to take it in the chat now. And thanks so much for inviting me. Uh, thank you, Miss Jackson. It's been really, really good um I suppose one of the other questions that people have asked has been, um, in your day to day life, Have you seen an evolution of the way you've been treated as a woman in surgery, Even in, like, a theater environment, I suppose from when you first started how you are now. Yeah, definitely. I would say I am My first ever experience in orthopedics, I think was really artificial because I turned up as an S H o. So my first s h o job job. I was 24 I just so happened to have one of the few female registrars in the Manchester region. And so I certainly thought, Well, this is just normal and totally unknown to me that of 60 trainees, she was pretty much the only female. So I got this feeling of like, Oh, yeah, this is something I can do. And then all of a sudden, when I I got my, um when I got my register, our job, I was only going to hospitals where they've never had a female, and there was no doubt about it. I honestly felt that some of the theater staff found it really hard to relate to me, particularly some of the actually the female theater staff, and I think that's because they had been I understand that they've been so used to interacting with the strong male characters for so many years that they actually just didn't know what to make of me and how to relate to me. But I think over time people have realized that I'm just me and they can just relate to me as a human being as a person. I'm just Gillian and and actually the bad experiences that I used to have, where I genuinely thought people were hoping to see me fail. People sometimes almost did take pleasure, and when I couldn't reduce things or I couldn't, you know, couldn't reduce a dislocated hips or whatever, I genuinely you could you could feel some of that. I definitely feel that a lot of that has gone now, and I think part of that is because actually we are seeing female orthopedic consultants who set the tone in theater who really valued by other team members for our approach to them for are considerate approach to the patients for are considerate approach to the trainees. And I definitely think a lot of this goes hand in hand, just with a lot of the human factors stuff that is happening naturally anyway. And surgery, which is an actual fact. We should value everybody in the theater team. Um, so actually, um, I think that's it's not just about women being being accepted as the as the surgeon and the leader in theater. It's about the fact that it doesn't matter if you're the HCA, um or, um, anesthetic support. If you see something, you can call it out. Um, and everybody's valued. So I definitely think things have changed a lot in the time that I've been a surgeon. Yeah, it's interesting that you said, um, also, sometimes you initially felt that difference in the way you treated from senior kind of female stuff themselves, because I think that's definitely something that I've come across, you know, in the clinical setting. Senior nurses or senior staff don't really value you on the same level. And I don't know if that probably is more than likely an old traditional, um, again like how it used to be. So I suppose hopefully it will and should modernize with the way that they see, especially foundation doctors, when they're, you know, young females and obviously do look really young. And I think that's always a tough relationship at the start. Yeah, I think it is tough, and I think there's no I think there's no doubt that, um, responding to responding to that that attitude or that vibe I'm kind of a believer in, um, kind of killing it with kindness and just being you and just being yourself. And I I just I tend to find that it doesn't take that long before you can find some common ground. And it's whether you're talking about you know, how blonde to go with your next Valley, a seizure or you know who's what. You what box sets you've been watching, you know, just like find common ground. It's just like it's just like getting on with people. But yeah, definitely. Sometimes you gotta sometimes you got to bite your lip and you've got to work a little bit harder on the relationship. No doubt about it, you know. But by the same token, I kind of, um, I sometimes find that even a even a strong character mail trainee that would sometimes work with me. That's an interesting dynamic. Sometimes. So somebody that perceptively you would you would expect to, um, be of a different be of a different generation, um, and perhaps not have preconceived ideas. But in actual fact, if they've only ever worked with that that stereotypical mail trainer, um, then that's just an interesting that that's just an interesting dynamic getting used to me and not being able to to talk to me, perhaps about the same kind of stuff, because I might not be able to talk about the football at the weekend or I might not share the same sit share the same interests. So, yeah, I think I think the dynamic, the dynamic can be challenging in lots of different in lots of different directions. So, yeah, and I just try and bring it back to I want to do the best job for my patient. I want to feel it. I want everybody to feel valued in theater, and, um, you know, I want to get my trainees doing as much as possible, and I'm feeling really valued as part of the team, and I just stick with that sometimes I lose out, you know, because there's times I could probably be where I would maybe need to be more assertive. Um and, um, it takes me a little bit longer to, um to reach my to reach my goal, but I reach it in a way that is works for my personality. Um, I think Shereen just asking the chat about How did you find your clinical practice in the US? How does it differ from the UK and did your time in the US influence your current practice? Yeah, So it was really It was really interesting for me to to see what it's like in the US and realize the extent to which, um, they're very They're very operatively minded, actually. So what they bring to the table is they've got so much more involvement in design and industry and technology, So they really they really kind of lift your a lift your surgical skills up and and and thinking outside of the box of tools that you can use for surgery. But what I realized is actually because they are, to a certain extent, surgically driven and it's financed driven because so much of it is private practice payment by insurance companies. In actual fact, I don't think that they have the art of conservative management the way that we have in the UK And so the idea of being able to talk to patients through a journey that involves rationalizing analgesia, physiotherapy, um, footwear, modifications, insoles, um, that sort of thing. I definitely think that in the National Health Service, I think we're a lot slower, smarter with them, multimodal treatment and and probably respecting members of the multidisciplinary team. But, yeah, I had an amazing time out there, and I met some amazing female orthopedic surgeons from all sorts of different from all sorts of different backgrounds. And it's fascinating to hear there challenges as well, getting into getting into orthopedics because for them, it isn't just the preconceived ideas of women in surgery, but also it's the fact that they've got to really believe in themselves because so much of what they're doing is self funding and taking out huge amounts of debt. So they've got, you know, they're taking a gamble, that they're gonna be able to set up a good practice to be able to pay all that back. So I was pretty inspired by them and made some friends for life good and do in America. Do they have the same, like Ortho Jerry support, you know, because now the inpatient on an orthopedic ward is very much co morbidity and, you know, they break the hip, but there's a lot of other things that needs sorting as well. Do they have that still same links? I suppose with the medicine on the ward's as much as you say Or was it more segregated? So, to be honest, I didn't I didn't get a sense of that because a lot of what I was doing was a lot of what I was doing was foot and ankle, rather than rather than the hip fracture stuff When I when I was out there, Um, But I would say again, my impression was depending on where you were working in America, there was a real, like a post code or like a state lottery, Um, in terms of the kind of treatment you were getting, particularly if you were just partially insured or you were in, you were in a state hospital. Um, you were either getting absolutely everything because it was available, or it was that you were getting that you were getting the bare minimum. So definitely I did not walk away from it thinking, Oh, my God. Like patients get much better treatment in America. I did not think that I thought, you know what we do. All things considered, we do pretty well in the NHS because because we're all in it. We're all in it together. And then the money is not a big player to the same extent. Yeah, there's not as much influence determining where the patient pathway is, I suppose. Yeah, well, no, that's really useful. Is there any other questions do you want in the chat? And if not, I'm sure through email as well. If anyone isn't confident enough to say or whatever, I'm sure I can pass on any questions to yourself, Miss Jackson, if that's okay. Yeah, definitely. And, um, I haven't really I guess I haven't really touched on. If you were interested in orthopedics. You know what you should do for your portfolio on that kind of stuff? Because, you know, I think there's loads of people have talked about that, and I think in others in other sessions, but definitely if you had to protect if people wanted any advice about, um I'm thinking about getting a number in trauma, an orthopedics, and I got a bit of insight into that because I'm I'm on this election design committee, and I have looked at so many portfolios and scored them and up scored them and down scored them. So if anybody want bit of advice about what to include or not include, yeah, I'd be really happy to help out on the email. Brilliant. Thank you. We've got one last question as well. It says, Thank you for your beautiful and encouraging presentation. How do you train your strength? How do you change your strength? But I'll tell you, um, 22 things. Um, I do yoga, which is like lots of upper body strength, actually. So that's that. I would say that's the only real exercise I do. So I do. Um, I do yoga, and that's really helped out with a lot of my upper body strength in particular. Um, that's a lot of wrist and forearm and shoulder stuff, but also just being in theater and just, um, just actually getting really stuck into the cases. And again, I think one thing I see trainees do a lot is I see them stand back because they're a little bit hesitant to be involved in the operation. And, um and actually just little things like getting in there to do the prep and drape and holding the limb whilst it's being prepped and draped. And during the procedure, there's lots of stuff that you're if you're just really if you're just really proactive assistant, you're actually just you're getting a lot of muscle memory and you're just doing a lot of moving handling. So that would be my top tip is actually just absolutely get stuck in and, you know, never missed the opportunity. Never missed the opportunity to say to the consultant, Can I put the patient on the fracture table? Can I have a go at reducing the dislocated hip? Yeah, and just and just put yourself out there. But yeah, otherwise, um, I'm actually just use your smarts because there's been loads of times where I've been, like, hanging off the leg, trying to reduce a hemiarthroplasty, and actually, sometimes what you got to do is just stop, take a look, make sure there's no soft tissue in the way and maybe switch positions with you and your assistant. And so there's lots of little tricks that you can. There are little tricks that you can do. Yeah, a question to end on. Good practical advice to everyone. Um, Bob. Well, thank you very much, Mr Jackson. We've all really, really, really enjoyed it. And as I said, I'll forward on any questions we get later on or anything like that. Amazing. Okay, thanks a lot, then you very much. Bye bye. Bye bye.