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Every time um the host comes on it automatically records we added to all of it out. Ok. Hi everyone. Um It's Isabel from WP MN. Uh We have our women's surgery webinar. So I'll just let Jonathan our um sponsor kick off with a little intro and then we will go on to our webinar. Fantastic. Thank you for the instruction. A as usual. We are so as usual, I think you should be able to hear me now. Perfect as usual. Um We are delighted to sponsor these events and we're more than happy to sponsor these um events for you. So, my name is Jonathan Darwin and I am the relationship manager for our hospital doctors at Medical Protection Society. Um You may know us as NPS. So I just wanted to cover a quick um summary of MPS and what we um provide to our members and how we support you. So, as you may be aware, Medical Protection Society is a medical defense organization. So we provide you the right to request assistance with claims complaints, discipline proceedings, GMC, investigations, hearings, commoner court hearings, et cetera. Um in the UK, it's a GMC requirement to have adequate indemnity in place. But as if you're working for the NHS, you may be already covered by NHS indemnity, which will cover in a little bit more detail. However, really only covers um the patient um pay out or the sort of compensation for the patients. It's really important and you are strongly recommended to make sure you do have your own Medical Defense Organization membership. So here are medical protection. We are actually the world's leading medical defense organization for healthcare professionals across the world. More doctors, um more doctors trust us than any other medical defense organization. We are the best rated medical defense organization in the UK. So you are in capable hands. We're non for profit and we're owned by our members. So we're run by doctors for doctors um to support doctors and we support our members from university level to um beyond retirement. So there's just a quick table there. So as mentioned earlier, the NHS indemnity, if you are going to be working solely for the NHS, really only covers the patient compensation. If there is a um claim that is made whilst you're working in the NHS, it doesn't cover you for your legal advice. So you'll see um everything um that your medical protection membership will cover you for such as GMC proceedings being a big one there. Um On average, we're looking at around about two clinical ne claims per doctor per typical career length now, which is a massive increase to where it was 30 years ago. And on average, legal cost would cost 85,000 lb per GC investigation. So it is really important that you have it um have this membership or have a medical defense organization membership. Um As you have the right to request that legal support through your membership and your subscription. But as you see, there's loads of different benefits there such as good Samaritan's Act um in the UK as a doctor, the GMC say you have a professional obligation to support in an emergency and we provide you the good Samaritans Act um which is indemnity for good Samaritans Act. So you can request that if you're ever called to an emergency which is outside your clinical setting um as mentioned. So, student membership is completely free. So if you are a student viewer today, please do use the student joiner QR form V code to scan that if you're an F one or above F one membership is also free um with Medical Protection Society. And we're the only organization that provides you free F one indemnity. Um So if you're currently not a member and you're an F one, feel free to join, we're also the most price competitive as well as being the U KS best rated ende. And also at the end of the day, you'll be given an evaluation form for this event. So anyone that does complete that evaluation form, you'll be entered into a 200 lb prize draw. My information's there. My email address. So please do reach out to me if you do have any questions, but thank you so much for having me and enjoy the event. Thanks very much, Jonathan. Um I will just move on to introduce um, everybody. So, um, hello, everyone that's tuned in. Um My name is Isabel. Um So for those of you who haven't attended, um the previous women in surgery webinars, I'll just quickly introduce the series um that we've been running, running since January. So, um I'm currently in F one in North London and I'm working with the WP and then to put together this series and we are super excited to bring to you a monthly webinar series which helps to inspire the next generation of surgeons and gives you surgical role models that look like you. Um So each month we've had women from different surgical specialties from hospitals across the country, um Each surgeon will talk about their journey into surgery. Uh What a typical day or week looks like for them, some tips for applying. Um And an interesting case that they have seen um this webinar as well. We have AQ and a section. Um So please do drop your questions into the chat function. Um And I will ask the speaker kind of throughout and then also at the end, so just drop anything um as we go through. So just as Well, before I introduce our speaker, I want to remind you to please fill in the feedback form at the end of each talk. Um And doing so, we'll get you a certificate of attendance. Um So I am really excited to introduce this speaker. Um She is a registrar in Cardiothoracic, which remains to be one of the most highly male dominated surgical specialties. She's currently based at the Freeman Hospital in Newcastle where she is a phd candidate and a clinical research fellow in the exciting world of cardiothoracic transplantation um through her research and roles on various committees. She has developed interest in changing surgical culture, widening access and increasing equity and inclusivity. So without be the amazing Joe Hardman, thank you so so much for inviting me and thank you everyone for turning up tonight. I'll just share my screen uh and for being so gushing in your amazing and brilliant. I hope I can live up to those expectations. Um So as we said, I'm Jill Hardman. I'm an ST seven in Cardio Classic Surgery, normally based in the northwest of England, but currently up in the northeast doing my phd. Um I have no conflicts of interest and no um financial disclaimers to make. Um So as we've already mentioned, there's kind of a uh an outline that's usually followed this evening and I really want to talk about what is cardiothoracic surgery and what do we do as cardiothoracic surgeons because I am very aware that most people in undergraduate medicine and even in foundation and core surgical training might never come across cardiothoracic surgery. So, um I am very aware of that. We can talk about some of those reasons if you want to. Um But I'm going to start by just telling you a little bit about what we do as cardiac surgeons. And then I wanna talk about life in cardiothoracic surgery and the best life I know about is my own. So I'll talk about my own experiences. Uh my career path so far, how I got here, why I got here and what happens next. Um And then I very happy to talk a little bit more for people who are thinking seriously about applying to surgical training. Uh And obviously this will have a cardiothoracic focus to it. Um But I've put surgical training in brackets there because there's a huge amount of overlap between ST one cardiac and ST three cardiac between all of the subspecialty. Oh, sorry, the specialty applications in surgery uh and also within core surgical training. So I'm very happy to touch upon that. And more importantly, as we've already mentioned, I don't want to spend the whole of tonight doing all of the talking. So please please please take this opportunity to put any comments or questions in the chat uh and make sure you ask anything that you think of and if there are things that you remember later or you think about or you don't want to ask in front of other people. I will put my email address at the end. So feel free to contact me. Uh Lots, lots of people do and I'm very happy to answer those questions. So, first of all, what is cardiothoracic surgery? Well, we essentially deal with the surgical management of conditions in the thorax, er, which includes the heart, the great vessels, the lungs and once upon a time, the esophagus, although most of that has now gone over to our friends, the upper gi surgeons and essentially cardiothoracic surgery is becoming increasingly two quite distinct specialties. We've got cardiac surgery which predominantly looks at adult patients and we have subspeciation, which I'll talk about in terms of the types of diseases we manage. We have cardiothoracic transplantation, pediatric cardiac surgery, and adult congenital cardiac surgery. And then in the sister specialty in thoracic surgery, they deal predominantly with lung cancer, but also benign lung disease, thoracic trauma, they do some lung transpl lung transplantation and some surgeons still do a little bit of esophagus. We all train in both of those areas and we all have to sit and exam at the end where we cover all of those topics. But essentially since 2017, all trainees have had to um decide which specialty they want to choose uh and pick one area. So you can no longer practice in both cardiac and thoracic surgery. Um and as we move towards this more subspecialized training program, this really makes sense because a lot of what we do in our working week becomes really focused into specific areas and specific diseases. So, thinking about cardiac surgery, um the majority of our bread and butter work is around coronary artery disease and ischemic heart disease. And it's worth noting here that ischemic heart disease is still the biggest killer of both men and women in the UK and worldwide. So this is quite a heavy disease burden. And essentially, when it comes to the surgical management of ischemic heart disease, we're talking about what you can see here, which is coronary artery bypass surgery. Uh So here we're anastomosing the left internal mammary artery onto the L ad uh the left anterior descending artery of the heart, which you can also see in the angiogram there. Uh And this has been performed using cardiopulmonary bypass. And essentially, this is the finished result where you can see those two vein grafts there on the heart, they're still on bypass with the pipes in the aorta and the atrium. And there's just a diagrammatic representation of what we do. We also deal with heart valve disease. This is an aortic valve. It's a very disease, tri leaflet, heavily calcified aortic valve with aortic stenosis. And essentially we stop the heart, open the aorta, take the old valve out and suture in a new valve. Here, you've got a tissue prosthetic valve and it's being sutured in and lowered into place into the aortic position and you have the aorta up here which will be closed over the top of it at the end. Now, cardiothoracic surgery is a relatively young specialty. And one of the reasons for that is that in order to be able to do these types of operations, to safely correct the pathology, to stop the heart, to remove the disease and to keep the patient alive while you're doing it. We needed this technology and this is a cardiopulmonary bypass machine. They come in various different forms, but essentially the first cardiac operations were started in around the 19 twenties and thirties. But it wasn't until the sixties and seventies when we had this technology. And we had these individuals on the right hand side of the screen here, the clinical perfusion scientists or perfusionist who were able to run the bypass machine for us while we operated. Um And I think it's also interesting, I'm not sure what the demographic of all the viewers are here, but clinical fusion science is an area that I have no idea existed until I worked in cardiac surgery. They are not medics, but they are trained to a master's degree level for three years with research and they administer drugs and they essentially are responsible for our patients while we're on bypass. So they are a key important part in what we do. We also do some operations off pump and this is what we'd call the set up for off pump, coronary artery bypass grafts. The other important valve that we operate on is the mitral valve and this is a mitral valve repair. Sorry, I think I got muted but I'm back um where we suture in an annuloplasty ring and remove some of the valve tissue and close the defect. And increasingly now we're moving towards doing these operations by keyhole approaches. So, endoscopic approaches down here at the bottom with a small incision and a camera. And increasingly in some centers using robotic approaches to be able to do this type of surgery. So just to finish up in cardiac, we also operate on the thoracic aorta. I don't know if you can all see this and know that it's an aortic dissection. So, one of the acute aortic syndromes that we operate on as an emergency and we also operate on aneurysmal disease of the aorta. I think you can appreciate that when we're doing extensive um surgery like this that you can see here on the right thoracoabdominal aortic surgery. This requires a huge amount of thought and planning and skill as to how you keep a patient alive and all of their organs perfused while we remove diseased bits of aortas. And one of the ways that we do that, which is quite interesting is to cool a patient down to around 16 degrees and stop the bypass machine. So effectively, those patients are not alive, they're not being perfused, but they're very, very cold. So we are able then to relatively quickly do an operation and then gently warm the back up again and start the perfusion. So moving on to thoracic surgery, they, as I mentioned, deal predominantly with lung cancer. This is some data from the US. But again, it's worth pointing out that lung cancer is the biggest cause of cancer, death for both men and women all over the world. And in the UK and most of these operations nowadays where we're removing either whole lungs, lobes of lungs or sections of lungs are done through what we call a keyhole approach or video thoracoscopic approaches. So, um the equivalent of laparoscopy in the abdomen is thoracoscopy in the thorax and this is the view you get inside of the chest. So the majority of this surgery is now perf performed during doing AAA thoracoscopic procedure. They also deal with benign disease of the chest. Um This is the dreaded X ray that you should never see. Um but we perform pneumothorax surgery. This is a tension pneumothorax. We're also involved or in surgery of the airway, particularly the lower airways ent is for the upper upper airway and we perform surgery in the lower airways, but also um chest wall disease and thoracic trauma, which you can see there on the right hand side. Now, some people are born with heart disease and pediatric cardiothoracic surgeons will repair that in childhood. Things like tetrology of fallow, which you can see here and other diseases like a SDS or V SDS. Sometimes those diseases are not picked up in childhood and people might grow into adulthood and then need a corrective operation. And often the diseases that are treated in Children require a second operation as they get older and they grow. And so we have a whole subsection of people who specialize in adult congenital surgery as well to do those operations. And of course, for Children who require a transplant to fix their congenital heart disease, that's performed by the cardiothoracic congenital surgeons as well and transplantation. So, as I mentioned, the majority of both heart and lung transplantation is performed by cardiac surgeons. Um We have lots of technologies now to try and improve the way that we identify donor organs. You can see here a heart on what we call the organ care system, which is being perfused and kept warm and beating in order to transfer that heart to a recipient from a donor hospital. And a similar set up here with the lungs, what we call ex vivo lung perfusion. They're being ventilated and people are measuring the gas exchange to try and understand how well they're functioning before they're implanted into a recipient. And increasingly now, for those patients who don't um get a heart or who become more unwell while waiting for a heart transplant, we have other technologies such as artificial hearts, left ventricular assist devices, right ventricular assist devices that are shown here, which are used to help um palliate patients or get them through a period while they're waiting for transplant when they have heart failure and heart failure symptoms. So essentially that is cardiothoracic surgery. We don't do a lot, but it's quite important. So just to highlight then why cardiothoracic surgery for me. Well, the main thing, the number one reason was always the heart. Um and it is still really special for me no matter how long I've been doing it, opening a chest and opening up the pericardium and seeing a heart that is beating and moving, that is also very easily identifiable. It's, it's colored and looks just like the textbooks. There's something really special about that and everything that, that brings with it about our ideas about life and human life. So that was always very important to me. The next thing is that we don't do a lot of operations, we do the same things over and over again. And as you've seen, we subspecialized a lot. So there will be surgeons who stick to one valve, but that's what they do all the time. And the reason for that is that it allows us then to be very repetitive, to be very meticulous and to be really, really good at what we do in order to achieve what is actually quite a complex skilled process. And we get really good at it. And that idea about performance is really important to me. We also, as I mentioned before, have the ability to affect the whole patient. The operations that we do really are physiology and action. Putting someone on a bypass machine affects every organ and every part of the patient. All of our patients go to the cardiac ICU after their surgery. So for me, it really was about physiology and understanding how to manage the whole patient. And that leads on to the final thing, which is really about the fact that we work in a much wider team than some of the specialties. So we have a perfusionist and anesthetist. And although we're carrying out this really complex technically challenging surgery, one of the biggest challenge is making sure that we're aware of everyone in the room, what everyone else in our team is doing, communicating with them and coordinating with them and making sure that we get the best outcome for the patient using some of those more non technical skills that we might talk about. So that was why I chose cardiac surgery, but I always like to give a nice balanced view. So I think it's really important that when you're thinking about specialties, you think about what the future looks like. And although the cardiac surgical training pathway is changing, it is long, it's getting shorter. But most people don't have a linear process during their training, they usually take time out for various reasons. They usually have extra time, particularly in cardiac surgery. They might do research like I'm doing and typically we do fellowship. So this is a long process. It is a marathon, not a sprint. And although I mentioned that we do big good operations, that often means that we do quite long operations. And some of those exciting, challenging things that all come together brilliantly on your good days are some of the things that actually on your bad days can be incredibly difficult and can lead to things like fatigue burnout. Um They can be quite demoralizing and upsetting. We also work in a culture that isn't always very supportive of each other and of the people we work with and we still tolerate some behaviors that I don't find acceptable and I know a lot of people don't, but we still sometimes view those characteristics and traits as being what it takes to be a good surgeon. And that can be quite difficult. And I didn't mention at the end of the last slide, but one of the biggest rewarding features of cardiac surgery is that the operations we do fix people, we take away something that is broken and we put something new in its place. So often patients have really impressive outcomes, they feel much better, their symptoms are better, they have a better quality of life and we often save life. But the flip side of that is that we sometimes don't save life. And we do have to deal with the fact that some of our patients will die whilst they're under our care. And you shouldn't ever underestimate the impact that that can have on you as a clinician, especially when you work in an environment that isn't always best suited to supporting yourself your own wellbeing and supporting others. So that's some of the things that I just want people to think about when they think about what career choices they might want to make in future. So I'm gonna have a brief pause there to remind everyone to ask questions and I can see that there's a few comments in the chat. So does anyone have any questions that they want to ask now particularly about what is cardiac surgery? Uh And what does all of this mean? Maybe um I will just have a little look at the chart. I got a couple myself but oh, come through as well. Um So Beni is asking about the run through training program. I don't know if you're gonna talk about that in the next part. Um Yeah, absolutely. We won't cover that pause that question for now. Um OK. And then has asked, it seems that many specialties are moving towards subspecialized earlier or offering run through training. Do you feel there are disadvantages of this, for example, not having a broader training experience? Yeah. So interesting question I think and perhaps II didn't mention it yet. Usually I do. But one of the reasons that we are getting more specialized in cardiac surgery is because as you can probably appreciate the disease types and the pathologies that we treat in cardiac versus thoracic are quite different actually. And as we've got more and more um developed in our surgical practice, the more technologies we have, the more we take an MDT approach, the more we're involved in decision making you can appreciate then that it's very hard to spend your working week dedicating yourself to all of that practice and covering all of those areas. When you're covering both cardiac and thoracic. I think from the point of view of training, I think you hit up on something really important, which is that as a medical student, I do think it's really important that you see as many things as possible. And I appreciate that the medical uh student curriculum isn't really set up that way. You're not designed to uh have access to everything you're designed to learn what you need to be a junior doctor and to pass your exams and get out the other side and be a good doctor, which is essential. But it does mean that maybe some of your special study modules, your electives, um some of the ways you might spend your weekends or if you're on a surgical placement, you might go in and do a night shift or an on call with a registrar. It means that you get to see other things. The difficulty then becomes when it, it turns into the specialty training is that it would be great if we could all spend a long period of time doing lots of different operating. But the reality is that if you're an sho in one specialty, you're probably not going to have the access anymore to the same types of things, the same kind of training operations, et cetera that maybe you did in the past. And so actually the best place to be is on a training program, what you lose out in breadth of experience, you gain in the specialization of experience. So it's always a balance. And ultimately, there's no reason if you go into one specialty or you go into core surgical training thinking you want to do one thing. It doesn't mean that you can't go and try something else. Take an f three year, have a year as a clinical fellow, do other things so that you can experience lots of other things if that's what you want to do. And again, that's why we need to be quite flexible in, in, in our approach to our training. I think, I hope that answers the question. Yeah, I think so. Um We've got a few coming in. So Maria would like to know because you mentioned about research, how vital is a phd to becoming a consultant? Yeah, so I'll talk about this a little bit more in the next section. Um II don't think it is vital. It's um certainly different in different specialties. Um The how necessary it is to becoming a consultant. Um But I will touch upon that in the next section if that's ok. Yeah. Yeah, of course. There's a few questions about, obviously you mentioned about it sometimes the environment being unsupportive um and any ways that you have strategies to tackle that. Um Yeah, another huge question and a really important one. Um It's probably not one that I will talk about at great length tonight, but I will come back to it at the end and I will direct you to some other resources that talk much more specifically about that if that's OK. Um But I'm very happy to talk about this and those sorts of things uh as we get through. Yeah, the rest of the presentation definitely. And one last question from myself because I'm on cardiology at the moment. So, um I'm seeing a lot of the kind of patients that you will see. Um And I just think for everyone here, what, what demographics do you see commonly? What kind of patients come through the door? Um What do we need to look out for? So it's a really good question and I think um it makes me think of a couple of things. So first of all, as we talk about in cardiology and cardiac surgery, um we're really treating a range of diseases even though we're only talking about ischemic heart disease and valve disease, but there's quite a different profile of individuals presenting with ischemic heart disease versus um aortic valve disease, aortic stenosis, aortic regurg mitral valve disease. So I think it's quite difficult to, to pin down what our patients actually look like because all of those diseases have different types of profiles. The other thing is we're not very good and we know this from work that's been presented on the outcomes for women after cardiac surgery and other surgery in general. But specifically for cardiac, we often misdiagnose women because they don't present in what we call the typical way, particularly with ischemic heart disease. Um And I always like to point out that something is only typical and atypical if you actually only look at 50% of the population. So we've only ever studied men and when something doesn't fit the average man, we call it atypical. But actually, we're probably missing a lot of women who present much later and have worse outcomes because of it. So that's something we need to be aware of. And the final big thing I would stress everyone to think about. I showed the picture earlier of the um thoracic aortic aneurysm and the thoracic aortic dissection. There's a big campaign at the moment that some of you might have seen called fin aorta because we often have usually younger patients. But anyone between the ages of sort of 30 to 60 presenting with chest pain, very sudden and sharp chest pain radiating through to the back and they end up going down. This primary ischemic heart disease type route, the semi and the end semi route, the A CS pathway. When actually, we've missed the fact that they have an aortic dissection. Now, aortic dissection isn't common, but when it happens, it's time critical and it is life threatening. So we need to be really sure for that population of patients that we always think about the aorta when we're feeding people into that a CS pathway because it it could be the aorta. So always think aorta. Yeah. Awesome. Um I will hand back over to you for the next section. Yeah. So um I noticed a few things about balancing work and life, which is a favorite um question of mine. So I will touch upon that next and I will talk a little bit more now about my path. So how did I get here? Well, this is me. Um I decided when I was seven years old that I wanted to be a surgeon. I don't the family to go to university and I think it was this game operation that led to me wanting to be a surgeon. When I said I wanted to be a surgeon. My mum said, you know what, Jill, you have to be dead clever to be a doctor. And that was the last we spoke about it. It was very much considered that people like us don't become surgeons. And I guess when I did my A levels, that was probably true because I didn't get the A level grades that I needed. I ended up going to uh Newcastle Sorry Liverpool University through clearing. Um And I did a BSE in physiology. This is my BSE dissertation from 2003, 4. Um And on the back of that, I then started working as a healthcare assistant. And then I traveled to Honduras in Central America to do some voluntary work with Children with cancer. And that allowed me then in combination at that time to be able to apply to medical school. And I got a few offers and I chose Barts and the London er School of Medicine and Dentistry. And so I carried on during that time working as a healthcare assistant, knowing that I wanted to do surgery, seeing lots of different types of operations as a healthcare assistant in theater. So I made sure that all my special study mo modules go into Great Ormond Street, my elective in pediatric cardiac surgery in Bogota Colombia, which is here on the screen. All of those things were done with this idea that I probably wanted to be a cardiac surgeon. Uh And at the end of it, I um got my degree um with uh a distinction in clinical studies uh from Arts in the London. And so after that, I desperately wanted to stay in London. Of course, I did, it was my home, it was where I wanted to be. But I got a job in the east of England in Papworth in Cambridge because the reality is that we have very little control about where we work, especially in the system that we have for foundation doctors, but also in core surgical training. So after Paw and Cambridge, I then applied to London again And I got a core surgical training job offer in London, which didn't have any cardiothoracic. And I got another core surgical training job offer with a cardiothoracic theme in Yorkshire. So I ended up going to Hull for a year. This is Castle Hill Hospital in Hull and then I went to Leeds for a year. So again, this was another move across the country to do the job that I wanted to do. But even though I didn't really choose those things and I didn't really want to do them, it did allow me to pass my MRC S and I also got access to people and data and research and it allowed me to do some publications and presentations, some abstracts. So that meant then that when it came to my ST three application, I was actually successful at my first attempt. This is me in theater waiting for my patient to come in. And I got my third choice Deanery, which was the Northwest, which also happens to be where I'm from, I have a big um social circle in Manchester. But actually I ended up initially working in Blackpool, which again was another hugely distressing uh piece of news, like missing out on my London job, having to move to Blackpool. And in the northwest, we work between Manchester Blackpool and I also did some pediatric surgery at Alder Hay Children's Hospital. And while I was um working as a trainee, so between ST four and ST six, I decided that I wanted to pursue some of my medical education interests. And I went to the University of Manchester part time and did a master's degree in medical education, which I got in 2018. This is my research dissertation. Uh And essentially I looked for my research at how we teach human factors and non technical skills to surgeons in postgraduate surgical training. And after about a year or so I found or I saw an advert for a phd job role up at Newcastle, which was linked to Newcastle University for phd research and was supported by NHS blood and transplant. So although these weren't particular areas that I was hugely interested in from a clinical point of view, it provided me with the funding a salary and a job role to pursue a phd, which for me was something I was very interested in. It's not essential. You don't need a phd to get a job, certainly not a training post anymore. And you don't need a phd in order to be a consultant, but it does allow you to then develop your research interests, build your academic network. It gives you the opportunity to explore some of those deeper reasoning and research methods that you might not otherwise get access to. And for me, what was really important combining the medical education and the academic work was that I want to be in a position as a consultant where I can support and um supervise and train others in future and help them to achieve their academic achievements as well. So that's why I did it. So then a little bit about my research, as we mentioned at the start. So it's, it's um supported by NHS blood and Transplant, which is the National Network for Blood and solid organ donation in the UK. And it's essentially focused around lung transplantation. So most of you will know that we've done a lot of work in the UK to try and improve the number of people who donate their organs for transplant. But you probably don't know that we only use around 12% of those organs for heart and lung transplantation. So we get a lot of people who want to donate and can donate, but we don't actually accept their organs. And that's the process called utilization. So my work is focused on how we can improve utilization so that we make better use of the donor population and also try and save more people's lives who are waiting for transplant. And a lot of that is working with the six main or the six cardiac and heart and lung transplant units in the UK and using some database analysis to devise a long risk scoring system. But also all of this has happened in the time of COVID. Uh And again, in the spirit of recognizing that a lot of this is about maximizing the opportunities that you have that you didn't know were coming. Um Just to highlight there that I've managed to get quite a few publications during COVID um because of the opportunities that came my way. So in terms of surgical training life, what does the working week of a cardiothoracic registrar look like? Well, this is a sort of typical rota, we tend to have two days in the theater. We often combine that with a night shift. So we'll work 24 hours on one day and then the rest of the time is split between clinic admin, we'll get a day off post on call and then other things like MDT activities. So what do we do? Well in most units still in the UK, it is the cardiothoracic registrar who looks after patients postoperatively. So the reason for that is that our patients have a very predictable postoperative course. So a lot of what we spend our time doing on call is watching drains, watching patients bleed after cardiac surgery, taking them back to theater if we need to and also managing things like low cardiac output. Here, you can see a patient in ICU with a balloon pump. They've got lots of infusions of inotropes and that is all the domain of the cardiothoracic registrar are on call. The other thing that we do is take on emergencies. Now, obviously operating in the middle of the night is not done as widely as it used to be because we know that human beings don't function at their best in the middle of the night. But sometimes things like aortic dissection trauma, some forms of A CS that require immediate surgery will come to us in the middle of the night. So this is me at four in the morning um in a break between uh finishing up an aortic dissection. Er, and this is what I call an NHS special, which is the crappy white bread you get in the theater coffee room, er, and two different types of packets of crisps from the vending machine. That's the, that's the secret. Uh because that's all that's available to you at four in the morning. So that's quite typical. And it's about recognizing that actually, as I say, this is a training pathway, you enter this during your twenties and thirties and what you're trying to do is get to the end of it. What is an extremely steep learning curve in terms of operative skills and learning to be a competent adult, cardiac surgeon as well as balancing all the other things that you have to do and taking every bit of, of negative outcome negatively and being very personally affected by all of the negative feedback that you, that you receive. So then actually what your we look working week tends to look like is a lot more like this. So you might go in early to see your pre ops for theater. You'll then do a ward round before you start in theater. The theater list will overrun. You have to stay behind and wait and see if they have any complications. You might do a clinic on Tuesday afternoon and think that you can finish on time. But actually you have to admit a patient and put a chest drain in you then probably see your pre ops again for the following day on a night shift. You sit up watching patients bleeding, hoping you don't have to take them back to theater and it just stops on your day off post on call. You probably review your ward patients. Everyone you've operated on earlier in the week. You might then take the opportunity to do some other things. Simulation teaching audits. Those are the things that you have to do during your weekend on call. You probably have a paper to write or an abstract to submit to a presentation or an exam to revise for and it's worth bearing in mind that often still in a lot of cardiac units. If you operate on a Friday, you go in on a Saturday and check on those patients. And if you operate on a Monday, you go in on a Sunday and check on those patients. So actually what looks like a normal working week suddenly becomes very much filled with all of these activities. And it's worth pointing out here as well. I think this is really important, especially when you're thinking about surgical careers. There's a lot of specialties, things like orthopedics, which when you become a consultant, you are to some extent able to hand over some of this to the registrar. The most demanding time is for the registrar in cardiac surgery. It's very top down lead. So if you are a consultant cardiac surgeon, it is very likely that you will be in at the weekend. It is very likely that you will be called in overnight. It is very likely that you might have to operate overnight. So it's always important to look at those people ahead of you in this game and see what their lives look like. Because for us in cardiac, this is something that doesn't really end this type of w of work life continues into consultant practice. So that's worth thinking about when you look at the surgical specialties. And as I think you can recognize we're all on this training progression program. And just because you get a job and you get on the start of it doesn't mean that you can then sit back and enjoy the training process. Because actually every year you have to sit down at your annual review of competency progression and you have to prove that you've ticked all of those boxes. Usually the same ones that got you into training in the first place. So all of those are the things like audit presentations, publications, leadership roles, passing your exams, they all have to be done alongside training to be a surgeon. And we move through that training program. If we tick all of those boxes, we then usually do a fellowship at the end and then we can hopefully then apply to be a consultant surgeon. And I will talk a bit more about this pathway shortly. So for me wanting to be a consultant surgeon at the end of all of this, my CV is about some of the other things that I enjoy doing. So I have several leadership and committee roles within the Royal College of Surgeons on the trainees committee. Uh I'm now the trainee representative on the um specialty surgical board. I work with the Herri Society. I'm also heavily involved in undergraduate teaching um surgical skills, but also non technical skills. And this is the, the brochure for our National non Technical Skills for Surgeons Masterclass and also locally, this is uh an emergencies in cardiac. We ran in the CF labs in Blackpool a couple of years ago where we simulate emergencies to practice uh how we work as a team in response to them. So these are all the kind of voluntary work bits on the side that you do alongside your day job, which means that when it comes to life outside of work, there's not really an awful lot of room for much else. Having spent your week working in the way that we do. It's often just enough to have a rest and to watch Netflix and do very little. Obviously, all of us need downtime and balancing work and life are really important things. So part of it is about understanding what you want to do, what you love, what revitalizes you and restores you and prioritizing those things. But I don't think anyone would ever say that it's easy to do that. You have to recognize that it can be a very difficult challenge to balance all of those things. So when I do these careers presentations, I think it's really important to just outline the sort of successes, the things that we're proud of. And this is something that I talk to my mentees about. Um I think it's really important that we all recognize our achievements because a lot of this can sometimes feel like you are ticking boxes and moving on to the next thing in order to achieve something, which is a training number or a consultant post when actually we should be enjoying the process and enjoying what we're doing. And I also think it's important to mention the failures. They're obviously not failures. But please be aware that for every single exam that I pass, there may have been a couple that I failed for every application that I did get. There may have been a couple that I didn't for all of those abstracts that I submitted that were accepted. There were many that I didn't even submit in the first place and lots of manuscripts that are knocking around that have never been published. And finally, on this point, for all of you sitting in the audience cos I remember when I was sitting on your side of things looking and thinking about careers and role models. If you're looking at this list of things in the successes pile of thinking. Oh, that sounds really interesting. I want to do that. That's what I want my career to look like. I just want you all to remember that this has taken me the last 12 years since I graduated to achieve. I didn't go to bed one day as a core trainee and wake up an ST seven with all of these things. This really, really is a process and it's a marathon, not a sprint, this all takes time. So that begs the question where to next for me. Um And the reason I've left this slide blank is because I want to emphasize that I have no idea. Um I returned to training in August and I will go back to Blackpool for what is the last 18 months of my training? And hopefully at the end of that, I will get my CCT my completion of surgical training and then I will do a fellowship and I will be eligible to apply for a consultant post when it comes to consultant posts. Um This is a map of all the cardiothoracic units in the UK and this probably highlights why as medical students and junior doctors, you don't tend to see us that much because we are really crammed into big cities, tertiary quaternary referral centers and we're not everywhere. And when it comes to consultant posts, it's really about a unit advertising a job. And if you think competition at trainee level is, is big competition gets even harder at consultant level. So the reality of this and the reality for a lot of surgical training is that you actually have very little control over where you might end up where you're going to work where you want to settle down. Uh And just to highlight that in cardiothoracic transplant, we only have six centers in the UK. So that gets even narrower again. So the reality is I have no idea where I'll be in three or four years time and I've done a lot of work to make that acceptable to me because I can't change those things. But it's worth bearing in mind when you think about a surgical career. So before I go on to careers. Does anyone else have any questions? Comments, things they wanted me to clear up at this stage and then I'll just spend the last 15 minutes talking about surgical careers. Um, so there's a few questions about work life balance, which we've covered a little bit. But would you mind, are you going to talk about that next or? Uh, no. So I'm, I'm happy um, to talk about it a little bit more in terms of, I guess when people talk about work life balance balance, there's looking after yourself, prioritizing yourself doing the things that matter to you. And I guess also we can't ignore the fact that as women in surgery often, what worklife balance means is Children and family. Um So I don't know if that is what you mean by the question, but I'm certainly happy to talk about that. The question that often comes through is can you have Children and be a cardiac surgeon as a woman? And the answer is yes, of course. And there are female cardiac surgeons in the country who have Children. What I would point out is that there are, in fact, most of my male colleagues have Children. So then the question comes, OK, so how can the male colleagues do it? But the female colleagues can't. And the reality of that is that still in 2022 in the UK and most of the world, the majority of caring responsibility falls to women. And that's not just for Children, but that's caring, responsibility for older relatives. It's the emotional labor that we have to do. It's the work, it's the home life building and running a home and all of those organizational things. And so the question then becomes, can you do all of that to the way it's expected of women and be a cardiac surgeon and look after yourself and have a bath and do some self care and look great. And the answer to that is no. And this idea that you can have it all is just not true and actually was probably constructed by the patriarchy to make us all even more subservient. Um So it is a balance. It is exactly that it is about choosing what matters to you and prioritizing those things and being able to have support. So it is not necessary that mum always has to be the primary carer. And if mum has a very demanding job, maybe dad will have to be more involved as a primary carer and maybe that will fluctuate at different times. And obviously, I'm talking about heterosexual relationships. So maybe there'll be other options and other ways of looking at that. And I think that is a really important acknowledgement that you cannot have it all. Um and you certainly cannot have it all all of the time. So think about what you want and prioritize those things and get some good support networks and people around you. We do make that difficult for ourselves in surgical training though, because of the amount of moving and the way that you can't be certain about where you're going to end up and where you're going to work. So that is unfortunately the, the reality of, of what we do. Mhm. And support networks. Um, do you find it difficult in your specialty compared to other specialties? What kind of people do you lean on for support at work or outside of work? Yeah, I think that is a really good question. And certainly we have those sorts of formal networks now that are, are increasing. So, um, certainly women in surgery, women in cardiothoracic surgery, which is run through the Society of Cardiothoracic Surgeons of Great Britain Ct S. We have mentorship programs with them now. Um, and so there's a lot more formal arrangements and then the more informal relationships where I think everyone, no matter where you work, even in some of my most difficult and frustrating departments, you can usually find one or two people who you do feel comfortable talking to, who you do feel will support you often, there are people at the same level as you so other trainees as well as consultants. But I think in most places, you will always find your team, you will always find your, um, your friends and your allies and it's important that you look out for them and that they look out for you. And then again, I guess the important thing is that you build up a network outside of work where you have the opportunity to just forget about some of this sometimes. So you can go out with friends, you can, um, you know, do nice things at the weekend. The difficulty comes when you have such a demanding job that you might work on calls and things like that. But it is important that you make time for those things as well. Uh And, and help your family understand that you need some downtime, but you also need to prioritize work sometimes too and that can be a difficult sell. Mhm. Mhm. Ok. I think um all of the other questions we might come to towards the end and then I'll let you kind of do the last part if that's all right. Yeah, of course. So I just want to touch upon um the career section for those of you who are thinking seriously about careers. Um And as we've already mentioned, so there is a pathway um you move from undergraduate training into foundation training and then usually there are two options within surgical training. So one is co core surgical training and the other is what we call run through. So most specialties now when I say most things like cardiothoracic neurosurgery have moved to this model of ST one application. So you go straight from F two to ST one application Um and that happened for us from about 2013 onwards. And since then, we've had both ST one and ST three entry, but certainly it, over the next 2 to 3 years, ST three will be phased out and we will move solely towards an ST one level entry. So that's both be worth bearing in mind when it comes to the fact that you will be applying for an ST one job usually within the first six months of, of F two. It's around the December time of F two. So that's quite early. So if you do want to do this, just recognize that it comes around pretty early after you've started work as a foundation doctor. And um of course, having said that a lot of people take an F three year or they take time out and do something different between F two and applying for surgical training. So that's also an option but essentially for cardiothoracic surgery. National selection is run through the Wessex scenery. It's a written online application and the closing date, as I said is in December and then you are invited to interviews in February. And essentially, if you're shortlisted, using an A scoring matrix for the application, you will be invited to interview and an interview. There are several stations. So there's a portfolio station, an interview station, a clinical skills and communication station and then some technical skills sort of small ay stations. Usually 2 to 3 of those. And a lot of this is very similar to the core surgical training applications and to the other ST one and ST three specialty applications. So there's a lot of overlap here. If you're working towards one of these areas, you'll often find that they're quite transferrable to other areas as well. Now, the difference is I've put them both up here. But you can see there's a lot of similarities actually with ST one application, you're essentially looking for an individual who will be competent to start as a first day cardiothoracic sho level job with S D3. You're looking for a first day registrar and essentially, it's about being able to show that you have progressed in your career that you want to do cardiothoracic surgery. And you know what it's about that you have some clinical skills, some research, audit management and leadership skills and that you have shown some commitment and you can learn and develop and that's pretty much the same for both of these applications. So I'll just talk about that a little bit in detail. Uh And again, just to echo the core surgical training application is incredibly similar to that ST one cardiothoracic application. So all of those same areas and I've interviewed on the core surgical training panel. So I can tell you that they are very, very similar approaches. I've put the um webpage up there for course surgical training because I think the really important point with all of this is that you can Google these and find a lot of information online about what is required at national selection, what the scoring matrix looks like and how you score points. So if you're really serious about applying for this job, then you can be doing that at any stage, Googling, having a look, having a read and seeing what it takes to do this. And this is an example of the shortlisting matrix. It i it's not meant for you to look in detail, but this is the kind of thing that it looks like you can score points from 0 to 3. And on the left hand side, there will be all of those things. So things like research audits, prizes, um leadership commitment to specialty and you will score points for having done certain things. So if you've done an elective or an attachment, that's greater than two weeks, you'll get one point for undergraduate clinical electives and one of the best pieces of advice I had about this. So number one, get a hold of the matrix. It's online. Anyone can see this. I printed this out when I was in F two and I stuck it on my fridge and I just left it there so that it reminded me what I was working towards and it helped me to kind of focus OK? This is the area where my CV isn't as strong. I'm gonna focus on that and I've got six months to try and score three points in that area on the matrix and that's how you do it and that's how you get a job, no matter how you feel about that, whether you think that's the right thing or the wrong thing, that's how you do it. And they are the rules of the game, but those rules are very easily available to everyone. So you just have to do it. The other best piece of advice that I got was that you could have a Nobel Prize in Well, Peace, you could have a Nobel Peace Prize or a Nobel Prize in medicine and you'll still only score three points on the application matrix. OK? Cos you've just got an international prize. If you have a Nobel Peace Prize and nothing else, you won't score very highly in SD applications. So the best thing to do is to score 1 to 2 points in every area, not three in one area and none in the others. So score some points in each area. That's all you need to do. And that will stand you in a better position than maximizing one area of the um, of the application system. And that's just to show that this is readily available and there's all the different sections to it, as I mentioned before. When you think about something like cardio classic surgery, it's worth thinking about where you might end up working because you will be restricted to the areas that cover cardiothoracic surgical training. And I've put these on here just to emphasize, but again, they're readily available online. These are the core surgical training scoring matrices. And you can see again it's point score from 0 to 5 and it's very similar things to those ST applications. So if you want to do this, get hold of it, learn what you need to do and just start ticking the boxes And I've put a few of them up there for you to see all of those things that I've already mentioned. Things like clinical skills, research, audit management, leadership, they're the same things that you will be doing for the rest of your career. This is nothing new or wildly different. So it's always worth thinking about starting early and collecting evidence even if you're not quite sure what that evidence will contribute to or what it will lead to. But if it could be used to show your commitment to specialty, just keep hold of it. If it could be used to show that you've done some management or leadership work, you've been in a committee, you've done something at medical school, just keep hold of it because it's the evidence that you have to provide when it comes to the application. And I stole this from one of my colleagues because it's really worth pointing out again that this is a marathon, not a sprint. And actually all of this takes a lot of time. It doesn't mean that if you're an F two and you've suddenly decided you wanted to do cardiac surgery, you simply can't because you haven't got enough time. That's not the case. You can always make the time and there are other options. So don't think that, but the earlier you start, the easier it will be. And also a lot of these things cost money, things like basic surgical skills courses, um, access to MRC S MRC S practice exams, all of those sorts of things cost money. So the earlier the you start, the easier it is to spread the work and also spread the cost of a lot of this. But I think this is a really nice slide to show what sorts of things you can do at different stages in order to start building up your CV. So that it puts you in a good position to apply for specialty training. And then just a few points when it comes to interview, I know someone's mentioned about reverting to in person format. I don't actually know for next year, I know the last two years we've had an online uh interview format specifically for um core surgical training. I understand that we are planning to go back to in person interviews for cardiothoracic. But I don't know about um core surgical training. I I'm afraid, but either way the interview process is around the same things. And I just wanted to point out a few of these resources because they are really, really good. And in fact, the medical interviews book, um a friend of mine used for a consultant interview recently and I used it when I had my interview for my phd job. So just get hold of it and keep it on your shelf. Cos it's actually really, really good to help you structure those interview style questions that actually we don't do a lot of in medicine. We tend to get on this training pathway. We don't get interviewed for foundation jobs. And then suddenly you get to consultant practice and you're like, oh my goodness, how, how do you do a job interview? So it's a really useful resource and my take home messages about this are essentially this is all the same stuff. What you will do as a trainee is the same stuff that you need to do in foundation training and medical school in order to start building up your CV for applications. And it's all the same stuff you need at the end to make yourself attractive and appoint as a consultant surgeon start early because it's actually a relatively short time period before the application starts, particularly when you're working hard in your first jobs in your foundation training, you wanna concentrate on the day job, but actually, you do just need to have in the back of your mind what you need to do for the next stage, spread all of your work across all those different aspects of the scoring system. Don't just focus on one area and dedicate a lot of time and energy and money to one area and neglect other areas and it is a marathon, not a sprint, but the rules of the game are very much available to everyone. So as long as you learn the rules and put the time in, there is no reason why you can't get a job, make sure you record everything. So again, even for medical students just keeping an Excel spreadsheet where you note down dates and times that you went to theater who the consultant was. Um what bits of it you did, even if it's just observing, the reason that matters is because it, it gives you a log book, it gives you an idea of what surgical skills you might have. But also it shows people particularly if I'm sat, sat in a course surgical training interview. If you produce something that looks like a surgical log book, it makes me think, ok, this person knows what it is to keep a logbook, they want to do surgery, they know how important it is to record what they're doing. So it's important in and of itself. But the sooner you start doing that, the bigger that long be will be and the more you can record. And as I mentioned, it's ok to change your mind. You don't have to decide tonight what it is. You wanna do. And although we think about this training as a linear process, there are lots of different options at lots of different stages. So if you do change your mind or you want to try something else out, go for it. Just a brief word on competition. Cos people always want to know about this. This is from 2019. So I know it's a little bit out of date, but the numbers for last year were very, very similar. Cardiothoracic SD one entry is competitive. OK. We have a lot of applicants and a small number of posts because you don't need 100s of cardiac surgeons in the UK. So that isn't really going to change. This is the same data, but looking at some of the other specialties and again, you can see that we, we are the top um for competition uh closely followed by neurosurgery. So this is a competitive process. But as I said, the rules of the game are out there and there's no reason why any one of you listening today won't be one of those 12 people who get a job or get one of those posts, especially if you've ticked all the boxes that you need to tick to get a job. So I think there's just some time for some final questions and comments which I'm happy to take and perhaps while you're typing them in the chat box, I'll just emphasize my take home messages. Um I'm not sure we touched upon this too much, but I always want to make sure that when I talk about my journey, it is mine and no one else will have exactly the same journey. And I think that's really important because there is no one way to do this job. Although there are rules and there's a scoring matrix. Actually, the way you go about this can be very different for very different people. And that's absolutely OK. We all need to think a bit more flexibly about training. You won't know where you're working from one year to the next, you won't know what the rota looks like for the next six months because that's how the system works. And also it might be that you take a step out and do some research or you go on maternity leave or you do um an out of program experience somewhere else in the country. It's about thinking more flexibly about how we train and what we do. My final two big points. Um And again, I don't think we've really touched upon this, but I strongly believe and a lot of people laugh at me at this, that anyone can do this job if they want to. And there isn't a particular type or personality or set of characteristics that is suited to this job. So please don't sit there and think that you don't have what it takes because I can tell you now that everyone listening here tonight. Absolutely does if this is what they choose to do and that brings me to the point of finding what you love and what interests you and working hard at it. And I've put up a list there for anyone who wants to sort of take screenshots. This is just really useful resources for cardiothoracic in particular access to those um ST one and ST three recruitment and the scoring matrix. Er and also just to make a note of things like the S CT S student section is a fantastic resource to help people who want to become cardiac surgeons also CT S net um and the RSM cardiothoracic section uh and then a shameless plug for some of my own work. I know we all have our favorite webinars and podcasts and things like that. But I would just point out that R CS have done a really good series. In fact, I'm doing one tomorrow night um where there's such a broad range of different topics. So if anyone is interested in surgery and just wants to listen to some other things, we've done topics like changing the workplace. Last night, we had a surgeon talking about climbing Everest. On Monday night, we talked about how surgeons cope when things go wrong. Um Tomorrow night, I'm talking about the surgeon personality. So just have a look, see if anything interests you and I've put my email address on there as well because I know um we are coming to the end of tonight, but if you do have questions, if you want to email me about anything, please do. Um I won't always immediately reply, but I will get back to you eventually. Um So yeah, just drop me an email and, and ask away. Um Thank you so much, Jill. Um Those webinars sound really interesting. So I'm definitely going to have a look at those topics. Um I have some questions in the chat, so I'm just gonna run through those. Um We have some quite a variety of questions actually. Um So Grace would like to know about becoming a heart transplant surgeon. Is there any further training? How do you get into that? Yeah. So really good question. So it's essentially the same training pathway that I've already showed you. Uh but when it comes to finishing your training, so around the time of getting your CT, which is your completion of surgical training. So, after ST seven or eight, your transplant training takes the form of a transplant fellowship. Uh And you will do that for 1 to 2 years of transplantation in cardiothoracic surgery. Uh And then you're eligible to apply for a consultant cardiac transplant post. It's worth bearing in mind that transplant is a bit of a, it's a bit of a side gig in cardiac surgery. It's something that, but you do your day job and then you go and transplant overnight or you do transplants at the weekend, that sort of thing. So happy to answer any questions about transplants specifically. But, um yeah, it's, it's part of the same pathway, but we focus on it towards the end of training. Mhm. Um Brill. And then there's been a few questions about, I think people wanting to explore surgery, cardiothoracic different specialties whilst being at medical school and foundation. Um, because there are, I mean, I'm f one and there's very rarely cardiothoracic jobs. So how does somebody get exposure to those areas? Absolutely. And you know, we do recognize that and actually, there's a lot of resource on CT S students. There's a lot of resource through R CS, um particularly the SSB, which I now sit on. Um, I know this is a lot of acronyms and abbreviations, but, um, you can find them if you Google them. But essentially when we talk about experiencing cardiac surgery, we're talking about elective SSE S, we're talking about taste of weeks. We're talking about maybe taking a week of annual leave and going and working in a center. And the way that you facilitate that is by either in the center that you currently work in. If you're in cardiology, you could ask the cardiologist to introduce you to the surgeons and maybe one day a week you could go to surgery, for example, um, you could ask, um, in a find some email addresses CTS net actually allows you to Google um or it allows you to search for any cardiac surgeon in any city in the world. So I did that for my elective. I simply put in a city that I wanted to go to and it gave me a list of surgeons and I just emailed them all and I think one replied and that's where I ended up going. Um, and although we are um, a special bunch of people in cardiac surgery, most of us are quite approachable. So if it's something that you want to do, if you want to come for a week, if you want to do a placement, if you want to do a special study module, those sorts of things, you just need to reach out and it might be that you reach out to 10 people and one of them applies four months later, replies, four months later, but all you need is one of them. So it can be a bit demoralizing. It's not going to be handed to you. You won't get placements, but you can seek out these opportunities. Absolutely, yeah, definitely. Um Just scanning through the chart to have a look. I know one that keeps coming up about. Um, do people refuse care because you're a woman? And I think this is really interesting and actually, um I really would love for you to listen to the webinar tomorrow night at R CS where we talk about the surgeon personality and what that means to people and it will be recorded so you can listen to it at a later date. But I've never had anyone refuse treatment from me. But of course, I've had a lot of people who will say, oh, really? You're doing the operation or I will talk them through the operation. I'll consent them for the procedure. I'll see them in the operating theater and they'll still ask me who is doing the surgery. Um, you know, there's a lot of that, but I guess linking with the webinar tomorrow, it's this idea that we all have an image in our head about what a surgeon is. You know, my mum did when I told her I wanted to be one. So if my mum does and I have one, of course, our patients will have one. So it's very normal for them to look at us and go, oh, that's not what I thought a surgeon looked like or that's not what I thought this surgeon would be. And that's ok. Um But it is something we need to work on and you have to be kind, you have to kind of explore that with them. You have to not get offended when they call you, you know, the nurse or the secretary. I once got asked if I was my boss's girlfriend by a patient. Um You know, so this is real, it's really annoying. It's a microaggression. It's not OK, but I've never had anyone refuse to be operated on by me. Um, so I think that's part of the way that you have to work through that with people. You can't just get annoyed and upset as much as you might want to. Mhm. Do you have, um, a set way to, like, challenge it or like, comment because, I mean, I get, I get a lot of the comments as well about, oh, are you the nurse or? Um, and as soon as you tell them you do that you're the doctor, they completely change how they're interacting with you. Um So yeah, so I have a big thing and this is um something that I've talked to medical students about before and my mentees. So I have adopted an approach and this works for me. It doesn't work for everyone. But my approach is always to say when someone says, oh nurse, could you get me something? Then I always say, I'm sorry, I'm not the nurse, I'm the surgeon. And what can I get you? Let me find someone who can help you. And normally the reason it feels so uncomfortable is because they do this awful like, oh God. Oh I'm so sorry. Oh, you're the surgeon. Oh Yeah. Yeah. Um And then we both end up feeling awkward, but the problem is if we don't do that, we then end up in a situation where people still perceive me as being a nurse because that's what I look like. And our idea of the default surgeon then never changes. So I have to accept some of that discomfort and feeling like, oh, this poor person feels terrible now because I pointed out that I'm the surgeon, I'm not the nurse, but that works for me because hopefully I can do it in a kind way that makes sure they recognize that to look at someone and make an assumption isn't always correct and we could all learn that lesson. So that's how I do it. Yeah, definitely. Um Do you think as well that things are changing? Obviously, you've been 12 years since graduating. So, have you noticed a change? Um Yeah, sorry, I keep interrupting you. I'm just, no, no, no. So I don't know if anyone listens to desert Islanders, you're probably um all a bit too young, but it's a program on radio for and they get famous people to talk about their, their music of their lives and um a few, well, probably a couple of years ago now. Um and I've completely forgotten her name, but one of the first vascular surgeons, female vascular surgeons in the UK and she's from Blackpool from the northwest and she became a professor of, of vascular surgery. Um But I, her name has escaped me now, but essentially she was, I was in the car listening to this and she was describing how, you know, she could spend all day with patients, but they still didn't quite believe that she would do her operation and she would consent them and all of those things that I've just said, and my mum looked at me cos she was in the car and she was like, oh, my goodness, that's, that's what happens with you, isn't it? Um, and she was 70. So she was talking about a career that had been going for the last 50 years and I thought, oh, my goodness. Yeah. And that's exactly the same as what's happening to me. So I don't want to be wholly negative. Of course, we in the UK, and especially as white women, it is very different for women of other races. I completely appreciate that. Of course, we have had improvements on the way the world views women and society treats women, but it hasn't been fixed. There's a lot of stuff that we still need to sort out and if it hasn't been fixed in society, I can tell you that it won't be fixed in surgery because that's still a very much male dominated workplace. So it's better, but a lot of it is still the same. We've not been quick enough or active enough in our change. I don't think in a way that we need to be given the fact that it's 2022 and we're still having the same conversations. Yeah, 100%. Um, yeah, definitely feels like a really, no, but it's, um, it's refreshing and also very nice of you to be very honest about it because I do find sometimes I attend women in surgery webinars and that's kind of the, one of the reasons I set this up and people weren't honest about and it just made me completely be put off from surgery. So, um, and I think it's really, um, that's ok and I think just as a final point on that, I think it's really important. I, as I mentioned before we started, I've often been told that I'm too honest and I don't want to scare you and don't put them off. And you know, the problem is I recognize that all of you, if you want to do surgery as women, you will walk into operating theaters, you will walk into departments and you will see with your own eyes because you are grown up individuals just because you're students or junior doctors, you will see what you can see in front of you and you will see that men and women are treated differently and you will see that there is racism and bullying and harassment. So it's no good me saying, oh no, everything is much better. And then you go and walk into the operation theater and think gosh, that's not what I want. Like why is that person treating that person that way? So you will see that you will recognize that. But I also want you to know that we are all working hard to change that. And I certainly wouldn't want any of you to not pursue this because you are worried about that kind of working environment. If you decide you don't want to having experienced it. That is absolutely your call. But I do hope that all of you go and have a look and keep your eyes open and find the opportunities to see what it's really like. Mhm Yeah. Um And I'm just reading some very positive comments, lots of people just saying thank you. Inspiring talk. Um Thank you for being honest. Any final questions um Before we just to say thank you to you all as well. Again, the very fact that you're here listening to webinars at, you know, 78 o'clock in the, in the evening, you wanna do this and you're interested and I really appreciate the opportunity to do it and genuinely, I've put, I put my email address up there for a reason. Um Lots of people do contact me. I used to have this thing about not con contacting anyone because you know, why would they wanna talk to me? Um But if you have comments or questions, just drop me an email. Um What's the worst that could happen? Uh I don't reply, that's all. Um So yeah, get in touch. Awesome. Thank you so much jo um for dedicating your Wednesday evening to talking to all um all of us. Um And I just wanna remind you please to fill in the feedback form it would be really helpful for us and we have a couple interesting talks coming up um on June the fifth, I think we have somebody talking about being a doctor in New Zealand. Um and then we have a lot of U A um stuff coming up because I know it is that time of year um for all people applying. Um So yeah, so just a final. Thank you so much. J um I really enjoyed that talk and um all of the questions and everything. So um yeah, goodbye from us. Thank you, everyone.