ASGBI_Ep1_2025 ===

[00:00:00] Hello everyone and welcome to Behind the Knife. We're back with another installment of our BTK and A-S-G-B-I collaborative series. For our listeners who might not be familiar with the series A-S-G-B-I is the Association of Surgeons of Great Britain and Ireland. And within these podcasts, we compare and contrast various aspects of surgery and the US and UK to see who does it better.

In our past few episodes, we've discussed surgical training, compensation research, and sustainability within these two landscapes. And we have another exciting episodes lined up for you today, so stay tuned. My name is Agnes Kumar. I'm one of the behind the Knife fellows for this year, and I'm a general surgery resident that will be representing the US side.

I'm joined along with our UK based co-host, Jared Vmu. Jared, please feel free to introduce yourself. Sure. Hi my name's Jared Vmu. I am a surgical resident based in the UK and the president of the Moan Academy, which is the resident group associated with the Association of Surgeons of Great Britain and Ireland.

It's great to be here. Once again, thank you so much for collaborating with [00:01:00] us on this series. So today's episode is gonna be a brief overview of the differences in surgical training between the US and the uk. And then we will go on to discuss current challenges and our hopes for what future surgical training might look like in both of these environments.

And to help us discuss this further, we have two amazing surgeons deeply invested in surgical education and willing to share their experience and pearls of wisdom with us. We are lucky to be joined by Mr. Phil Pierce, consultant in emergency general surgery in Oxford with interest in trauma, complex biliary disease, and most importantly, a passion for training.

I'd like to introduce Dr. Jeremy Lipman, who's a colorectal surgeon at the Cleveland Clinic. He also serves as a director of graduate medical Education and an associate Dean for graduate medical Education at Case Western Reserve University. He's passionate about surgical training and he holds the James z Sam liner endowed chair in surgical education.

Thank you again for joining us. Let's start off [00:02:00] briefly by going through the general pathway to become a general surgeon in the UK and the us. Dr. Pierce, would you like to start us off? Great. Thank you very much. Agnes, it's a, a pleasure to be here. So to just go through the system briefly in the UK for those unfamiliar so it's a bit different to the US in that generally most people go to medical school.

Straight from school rather than having a, another university degree beforehand. So most people around 18 there is an entrance exam that's common to most of those med schools called the ucap that, that most of them, most of med schools offer, are they? Not all of them. And then medical degree costs consist of about five to six years.

Again, depending on the on which school you go to. The, there is a shared curriculum across those, and more recently there's a final set of final exams that are common to all of them. But there certainly is a difference in how much clinical exposure or certainly surgical exposure is offered by the different schools and the way that is taught following graduation.

In a [00:03:00] real contrast to the us there's no specialty admission at that time. When a new doctors graduate, they're assigned to what we call a foundation school that period last two years, and can some degree be anywhere in the country. It used to be that new doctors were assigned with a ranking based on their medical school performance.

That's no longer the case. And so there's a, an area of randomness in that for, for good or for worse. Those two year training programs are structured so that everyone does two years across a variety of different specialties to give a sort of fulfill do some more rounded medical education generally, and also give some rounded experience before people apply for their specialty training.

So some people will then apply straightforward what we call core surgical training. Which does normally have a bit of a theme to it. So maybe that you are general, general surgically themed core surgical trainee. But we do other things be that orthopedics, ENT plastics within that two year period and after that [00:04:00] two year period, so we're now four years out from medical school you'd enter higher surgical training.

Which then takes an additional six years for general surgery. And that's not withstanding any peers out for extra training or fellowships or for research. So as it stands from finishing a five or six year medical school degree, it is at least 10 years. Until someone finishes their training in, in general surgery gets what we call a certificate of training.

And there are a number of bottlenecks throughout that training where people need to apply to get into. And the numbers of applications very frequently is far greater than the number of places which something else that adds, adds stress to, to the system. Dr. Lipman, how does the US process compare to that?

It's it's very different. So coming out of high school where your students are going directly into medical school, our students going to undergraduate or, or just college where really they're only [00:05:00] required to take seven classes in order to be considered pre-med or eligible for medical school admission.

Biology, chemistry, organic chemistry, physics math and English. Some require biochemistry as well. From there, they take the medical college admission test, which the mcat which is a standardized national exam that provides a score that helps medical schools to decide if they're going to accept or not.

And so right now there are. A little over 200 accredited medical schools in the United States. 160 of those provide allopathic training and 40 odd provide osteopathic training. So that is a limitation. That sort of one of the big stepping blocks between. Of selection of who's going to get to become a surgeon.

That's probably the first big break point. From there, people applied through our national matching program the NRMP [00:06:00] into one of 258 accredited general surgery residency programs. And so that process is, complicated. Trainees fill out a, a common application through a centralized service.

They are invited for interviews and a selection process by the different residency programs. And then ultimately the trainees compile a list in order of where they would like to do their training. The programs compile a list in order. Of whom they would like to train. It goes into an algorithm that's the same algorithm used for transplant organ matching.

That algorithm, actually, the people that came up with it, received the Nobel Prize in economics some years ago. So complicated enough to, to warrant a Nobel Prize. Person to come up with it. And then on match day at the specified hour, minute and second, boom, it pops out where you're going for your residency training, which will [00:07:00] be between five and seven years.

And that's a binding commitment. That's harder to get out of than a merit. So we usually encourage people to think about their match first and then to think about whether or not they want to do it with a partner or not. From there, people have the option to go on to do specialty fellowship training about 80% of residents in the United States do.

And those can be through a variety of different systems whether it's another matching system or sometimes just a direct application before they finally complete their training. Great. Thank you both for that comprehensive overview. Let's discuss some of the nuances within the training. It seems like residents usually get their general surgical training at just one center or hospital system in the us.

Is that correct? They don't change hospitals every six to 12 months. Yes. People match into a single. System or a single program. Now, often that will involve [00:08:00] rotations at different hospitals, but it's all gonna be within one system for the most part. Okay. Well, the UK system is a fair bit different from that.

Dr. Pierce, would you like to speak about that? It, it is, yeah. It's it varies a little up and down the country, but certainly in, in higher training, a, a training will be placed within a geographical region called the deanery. Those deanaries vary in size. I think the largest of them are sort of 15 to 20 hospitals.

The smallest of them are past five or six. And they'll rotate through that deanery, depending on both service needs and the trainees needs. And typically the more senior through that process gets, the more say the trainee will have in in their training where they go. And also because a bit more clear what their need is.

So within a particular deanery, if it's a small one that there may perhaps only be one, let's say an HPB resection center. So if you're interested in HPV resection, then it's pretty clear [00:09:00] where you need to go. But there is a little bit of variability depending on the system. I think for that reason, that there are certain advantages to it.

It does mean that trainees have the opportunity to. Learn from different people to learn different techniques to see things done in different ways, to, to see both the good and bad ways of doing it. And argue, because each year, or sometimes six months, depending on the placement, is quite compartmentalized.

It, it does offer a bit of flexibility between those different rotations. So you finish one rotation, then it can be quite easy to say, well, now's a stopping point to do something else. Be that research or something else. The big disadvantage at least as I see it is that by moving around we probably miss out on a little bit of the sort of the master apprentice relationships that I think could be more easily hosted if trainees are staying within one center or within one smaller system.

And particularly if you're doing six month jobs or even a year job. [00:10:00] You start in one location, it takes quite a while before the trainers and trainees get to know each other. It takes a while before the trainees get to know how to do the new system. And so there's always a few months per job that you're not necessarily progressing just when you feel like you might be getting your feet moved on again.

So it's advantages, but disadvantages. And of course the big thing geographically is that it's quite difficult, particularly if you're in one of the larger deaneries. To know where you're going to live are, you're gonna be moving, you know, every year for that six year period. But it's unfortunately the best we've got at the moment.

I completely agree with that sentiment about apprenticeship model as well, Dr. Pierce, I can test that. There are some attendings that I've worked with and have develop a strong relationship with since I've worked with them over the past three years, and I know that it often translates to more honest feedback and also more autonomy in the operating room with them.

So I've heard in the grapevine and that in the US you're moving towards something called EPAs or Entrustable professional [00:11:00] activities within surgeries. And this is supposed to standardize surgical curriculum through competency-based education. What are your thoughts on this, Dr. Lipman? Do you think this is going to make a difference in the feedback quality that trainees get?

I think the EPAs have been a really exciting development. It eval, it allows for these micro assessments that happen on a day-to-day basis. And so in the ideal state, at the end of every encounter, someone can pick up their phone and, do a very short three item assessment on a trainee. So we saw a patient in clinic that meets one of the EPA criteria.

I'm a colorectal surgeon, so we have a few the perioperative management of, of anorectal disease for instance, or colon cancer. And I can provide them an assessment with how they're doing in, in that moment, on that patient at that time. And this taken in collaboration with all of the other. Faculty and everyone else who's working with this trainee.

Every six months when our [00:12:00] clinical competency committee gets together to assess how people are progressing, they have this really rich data that can come up with sort of a sense for how they're progressing along their entrust ability. Now the EPAs are really focused on. The expectation of the faculty that the trainee can do something independently, how they're making that progress.

But their actual skill and progression along their competencies is done in concert with that, using the A-C-G-M-E milestones. And so you have both of these things that provide. Very focused assessments of how someone is moving along through their path to make sure they're getting the experiences they need and and doing it at the right, at, at an appropriate rate.

I think that's one of the things where you know, what el, what was brought about the UK system, because you have people moving around, you may miss out on that opportunity where, you know, I have [00:13:00] the trainees. Working with me for five, sometimes seven or even longer years, so I can really provide an assessment of.

How they're moving along versus someone who's coming in fresh to me and then leaving and someone else comes in, so that, that may create some barriers to that system. Awesome. And then turning it to our UK colleagues here, how is feedback handled in your institutions? Is there something similar to an EPA there?

Yeah, we have, we have similar systems systems. So ours have, they, they've changed a little bit over the last few years. Curriculum and our surgical portfolios and structures has changed. And there is now a mixture of formal written or electronic feedback both technical and non-technical with case-based discussions and or, or procedure based assessments that talk go through, you know, step by step when or not someone can do procedures.

And that is interwoven with more subjective feedback from [00:14:00] trainers or actually from the group of trainers using what we call MCLs or of multi consultant reports. But it stands just as Dr. Lipman says, that, that all those things are slightly more difficult when you simply don't know the trainees and you're starting from scratch a little bit each time.

And to assess whether, not particularly looking at complex cases, someone who is. On paper Senior, but you haven't met them, haven't worked with 'em before. Yeah. The, it is, it takes a little while to build up that bond and that degree of trust, both, both ways so that I can trust them to get on with it and that they can trust me to help 'em out.

And so it does take them a while. I think what's even perhaps more important than that formal feedback is the less formal one and being able to. Have very frank conversations. The, the electronic system is great as, as a tool and to provide some of that objective evidence, but I don't think it replaces good candid discussions with trainees.

And mentorship goes with it, [00:15:00] and that's, that's hard because you need to find time to do it. Certainly one fundamental issue that we have. And I'm sure is the same across many different healthcare systems in the US is balancing service provision and training. So, I would love to be able to have both the time and the bandwidth to sit down with all the trainees and to go in-depth feedback and in-depth discussion and go through all the cases and look at all the videos.

It's just that that is not always possible with the time constraints. Mm-hmm. And sometimes because you don't, difficult to have that candid discussions and say, because you don't necessarily have a trusting relationship. I've certainly, I've benefited throughout my training from having both good trainers, but separate and as part of that, having really good mentors and I've something I've sort tried to carry forward and pay forward, and I like to think that people have benefited from it.

But certainly as a message to UK. Trainees, trainees. I, I tell 'em [00:16:00] very clearly to try and go out there and try and find mentors as well as their trainers and to, to my trainer colleagues. I try and ask 'em to be mentors to their trainees. Yeah, I think there's a great point. Mentorship is vital across every stage of training.

I know I've had excellent mentors over the years, and I think everyone can benefit from having someone to guide you along the way. Just to shift gears a little bit, I think you touched on this earlier, Dr. Pierce, but currently in the uk it is quite challenging to get onto a specialty training position in the NHS.

The competition ratios have increased year on year recently. What do you think are some changes that you foresee in the future to try to address this challenge? Yeah, it is. It is a big challenge. I say there, there are a number of bottlenecks in the system at the moment for a number of reasons.

The, every year there are thousands of people who, who struggle to get the especially training posts of choice. I gathered for this year there were sort of [00:17:00] 30,000. Doctors competing for 10,000 spots. And there's a push from the government to try and increase number of medical school admissions and try and get more doctors as us everyone, us aware.

Our healthcare system is largely public funded with any very small minority people seeking private healthcare. And as a consequence. I don't think I'm being too missed to say that we are often largely underfunded under-resourced. And one of the big question is from the government is to try and increase the number of medical training spots or medical, medical increase number of doctors, but.

Crucially, that means not only increase the number of medical students, but also getting them medically trained and having them in training spots. And that's causing a bit of a bit of tension. There's an increasing number of international medical graduates also competing for the similar spots.

And certainly there's no guarantee that if you train the UK there'll be a, a UK advanced specialist training spot for you. Which of course is. It's stressful, it's diff and it's very difficult when we have [00:18:00] doctors, they think they're in a nice safe career for the rest of our life, and actually they're struggling to get jobs to, you know, get a, a fixed location to start families to pay off all of loans and things.

So, difficult and the NHS has has recently published a 10 year plan with various measures to try and address these issues to includes to include increased number of trading spots. Potentially decreasing the number of international recruits and optimizing and innovating within the training pipelines.

And we all hope to see they'll get accomplished. It's whether or not it's all doable. There's an awful lot going on in the world at the moment and it's to what extent we are able to prioritize those issues. Does lemon, do you have the sort of similar bottlenecks in the US or are there the jobs for anyone that wants them?

You know, the bottleneck seemed to be more at the earlier on in training. So as I was saying, like even just making that jump from well, getting the jump from [00:19:00] college into medical school is a huge reduction. And then medical school to general surgery residency, there are about 1800 general surgery residency positions.

Available each year in the US and they, they fill a hundred percent of the time. So, and there's many, many people who go unmatched. So that becomes a cutoff right there where people are. Or bottlenecked out of, of surgical training. Going from there into Fellowship is really dependent on the fellowship that people want to do.

For instance, you know, those going into HPB who want to do a fellowship, there's only 12 programs in the us 14 in North America, so that's a, an incredibly. Small number of places to go pediatric surgery as well. Having said that, things like surgical critical care, those programs tend not to fill, and so people can go [00:20:00] into those specialties much more easily.

So it, it starts to separate out by desired final outcome as to where the bottlenecks show up. And it, you know, in, in some cases it provides new avenues for people. You know, somebody thought they wanted to be an HPB surgeon and then. Do a critical care fellowship and, and find that that's a great path for them.

And others. It just leads to in some cases disappointment where they can't get where they want to be. Coming out of training though pretty much everyone is able to find a, a job know whether it's the job, the one that they've been dreaming of mm-hmm. Since they started. This whole process at 18 years old is, remains to be determined, but, there's something out there for almost everybody. I've also heard from many colleagues how difficult, but also how rewarding it can be transitioning from being a trainee to a consultant or being a junior, junior faculty. What are some resources or [00:21:00] tips that you had for your own transition between being a senior resident and becoming a consultant?

So, I. It is difficult. It's a bit of a shock to the system, I think most people would find. And I think most of us probably don't realize how much as, as a resident or as a trainee, you are protected without necessarily appreciated. Both protected from the. Sort of clinical realities.

There's always someone looking over your shoulder, but also protected from all the admin that you don't necessarily realize is there. So it is a bit of a shock, and I think most of us probably, that a lot of the jobs that we do, we don't necessarily appreciate that we would do. I, I say that particularly I think in the uk, where as I suspect we do.

Probably a lot less operating on a sort of day-to-day basis than our US colleagues do, and a lot more admin. That said, I, I would certainly [00:22:00] encourage some senior residents who are looking for consultant jobs to look for jobs with teams that they're gonna get on with. I'm very lucky here at Oxford that I've got a great team of, of colleagues and friends that we.

Support each other. We bounce things off each other. We make fun of each other to the appropriate degree. And, you know, very commonly wandering out of each other's theaters both to see what's going on but also to help out if necessary. And actually it takes the stress out of it an awful lot.

Certainly I know people who are. Working in other centers throughout the country where there isn't that sense of camaraderie. And I think it can be quite a lonely place because all of us will certainly find or get involved with difficult cases. And you wanna be in a position that you can call a friend for help or to bounce ideas off if that's the case.

So look for those jobs where you are certainly not abundant. I'd also say that, and again, I'm sure it's the same in the us, that you absolutely don't stop learning when you. [00:23:00] Finish formal training either with, you know, with or without fellowships. But even starting as starting as attending or starting as a consultant in the uk I have, I hope continue to learn a great deal, continue to improve my own skillset.

And I think it's really important to remember that ideally to. Try and stay humble and appreciate your shortcomings and what you can do well and what you can't do well, and things that you need to build on and develop. And I hope that I'm a long way yet from, from reaching my peak. But that I know that will only come with being honest with myself.

Yeah. I think it gets back to, something Mr. Piercers had said earlier about the mentorship and the, the critical nature of that, and I think transitioning into practice, finding a position where there will be mentorship available or you have those very close ties to someone that you can. Call when you need help is, is really critical.

'cause as you pointed out, those [00:24:00] those first five years or so really are formative and it's, I I think it's almost impossible to, to understand what it's like until you're there. And many graduates. Leave their last day of their training, feeling ready to go, and they've, they've got their knives sharpened and they're, they're all set.

And then they walk into their first or, and it's like, oh man, this is, this is much different than I thought. I recall my first case, which was a laparoscopic appendectomy. I had done many, many of those. I was ready to go, Dr. Lipman. Which drapes set would you like? The one we usually use, but it's my first day.

There's not really a usual. Then you gotta figure these things out and you know, so pulled aside, one of my senior partners is like, Hey, which, which drape set do we use? Like, oh yeah, you want this and that and this. You know, these little things you just don't think much about as a [00:25:00] trainee. I think that, you know, also getting back to the EPA conversation, this may provide an opportunity to make that transition a little bit easier, especially with people that are identified as progressing along that entrust ability pathway rapidly, where they may have an opportunity to I believe the term is advance in place, so where they can.

Begin to function much more autonomously and with less oversight once they've achieved and trustability in. Variety of different EPAs so that they can start to have some more of that independent practice while they're still in the bubble of their training program so that those people are built in may make it a little easier for those that wish to leave and go somewhere like, rural US Practice where perhaps those support systems aren't as readily [00:26:00] available.

Those are great pieces of advice. Thank you. One of the last things we wanted to highlight is training as an attendee or a consultant. So once you've become a consultant or an attending having sort of continuing professional development and developing your skillset, the field of surgeries is exciting and it obviously changes rapidly with new techniques and new knowledge.

How do you both stay aware of the new ideas and techniques and incorporate them into your daily practice? So, I would say I, I, I've certainly. Try and get to meetings where I can. I appreciate this is an A-S-G-B-I chat, but I do generally go to the SGBI stuff partly because I've got do it and actually it is a.

A really good meeting for innovation and people candidly sharing stuff. I think viewing, even just looking, watching YouTube videos now as a consultant is very different to watching them as a resident where you're watching them and learning. Then there's now a [00:27:00] lot more stuff that I watch with.

Well sort of head in hands and eyes behind you because I'm terrified by what I'm watching the surgeon is doing. And actually that that's an important point, that there is so much educational surgical content out there that you do need to be a little bit wary 'cause there's not necessarily a quality control on it.

But it's difficult to, in honesty, keeping up to date when you are slightly outside the educational program. Now you, you do have to try and it's very easy, I suspect, to become a dinosaur. Technology is constantly changing. Robotics is probably lagging behind slightly in the uk, but without doubt, at some point it will be everywhere.

Within my own world of largely emergency general surgery, it's, it's not so much a thing as yet, but inevitably that's coming. And so that's an area that I know that I'm gonna have to train myself up. And how. That's gonna work when I'm bouncing the needs of, again, of both of the patient needs and of the training needs.

It's complicated. [00:28:00] So, it doesn't stop. As I said, I think you you need to be very clear on what you do, know, what you don't know, and, and how you can match those two things up. Yeah, I think, you know, there's so much information coming in from so many different places, it could be really hard.

So, you know, again, taking advice from my mentors, I subscribe to a bunch of the ETOC updates. So, you know, the journals will, regardless of whether you're a subscriber or not, they'll send you the, the table of contents with up abstracts from a few key journals. So I find that very helpful. I include in there like New England Journal of Medicine and jama, just to keep up on sort of what's happening generally in, in healthcare.

I was, I like BTK, of course, it's the best podcast out there. Other than that, though I've sort of dropped off from that. The trainees honestly are a great source. They'll bring [00:29:00] up an idea or a concept and, you know, we can explore it and, and sort of learn more about it and figure out if something's outta left field or not.

And yeah, meetings of course as well try to go to some specialty meetings and some education focused meetings every year. And attending sessions even where I think I've, I've heard it all you know, go to the diverticulitis session at our colorectal meeting every year. There's not a lot of new diverticulitis stuff going on, but you never know, so it's worth checking it out.

Awesome. It sounds like we always have to be learning, huh? Just curious, have you seen your practice change or have you adopted new procedures since you started as an attending? I, you know, I have you know, I think the most notable thing in, I, I do mostly inflammatory bowel disease surgery and the, the Kono s anastomosis was a newer thing.

The data was very strong. So it's something that I and a few others from our group adopted and started doing. [00:30:00] And again, that came about through, heard about it at a meeting, read the articles and, and heard it also to trainees, hey, or you know, what about this technique and this procedure and mm-hmm. And so we started doing it.

So yeah, I think those things. Come along. The robot's obviously a, a good example. That's something that's evolved in the time since I was in training. I've also seen things disappear. You know, when I was applying to fellowship al endoscopic microsurgery was the thing. If you went to a program that didn't have that, you were, you were foolish, you were gonna be left in the dust.

And now those devices are. Nowhere. I don't think anyone does that anymore, but I'm very good at it. If you ever need somebody, you know who to turn to. Yeah. Gimme a call. Yeah. I, I would say that there is, there is sort of a responsibility on everyone to try and maintain that culture of innovation and of asking why things are done.

It's so [00:31:00] easy both for individually and for units to just do things. 'cause that's the way it's always been done. We have in our unit, we have a, you know, a couple of different journal clubs. One of which is presented by our by our FY one, by our interns, who each week allocated a a recent paper.

And so they get an opportunity both to critique that paper to present it to us and everyone learned something. And I would say. Nearly every week. Maybe one of those papers. I've had some sort of really useful takeaway point in which I may not have read about 'cause it might have been a journal that was site the outside of my interest.

So I think it's really important that there is a culture of asking why things are done and a culture of innovation. Awesome. Thank you everyone for that great discussion. Dr. Pierce and Dr. Lipman, I just wanted to turn it over to you both finally to give us a few take home points for each side.

So, I would say without doubt our, our training system's a bit longer. I don't really think that's a problem in all honesty. I, I think [00:32:00] that by the time I was spat outta training, I felt ready for it, both in my technical skills and my non-technical skills. I think we are we probably have, at least in our last couple of years of training, as I understand it, more autonomy than we do in the US system.

And that probably helped that transition period a little bit more. I would also say to trainees that, yeah, it's it is stressful. Think about that, where that next step is where that consultant job is gonna be. And it is nice to be able to settle down and know where you're gonna be. But it is also a fairly stressful transition and.

Whilst I enjoy my job it is a bit weird when you come into work and I think this is what I'm gonna be doing every day for a really long time. And actually some of the opportunities to move around, see new things, do things, they do disappear a little bit when you finish training. So don't be in a rush to get through.

Yeah, I think some of the innovations in education that are coming up are gonna hopefully allow for [00:33:00] even more autonomy amongst our, our trainees as they progress along. I guess I would say that sometimes disappointments can be opportunities that when people get boxed out of a specialty they really thought they wanted, or the position that they really thought they needed it will turn out to be in their best interest in the long run.

And, you know, it's finding it's, it is impossible to chart that pathway. It's so long. There's so many variables, it's impossible to really chart it. So just being flexible and, and trying to enjoy that, that trip along the journey will make it much better. And I think that also the, you know, although our training systems are different, they both produce outstanding surgeons in the long run.

And so the. Doubt and concerns people have as they're moving along that I'm not gonna be [00:34:00] ready, I'm never gonna be as good as this one or that one. In the end, almost everyone will be. With rare exception, people are going to finish their training, get into practice, and do a great job taking care of patients and doing outstanding technical elements of surgery as well.

So I think keeping that in the back of the mind is key. Perfect. Thank you again everyone for this wonderful discussion. There's definitely a lot of similarities within these two systems and along with similar challenges as well. It'll be interesting to see how education overall evolves in this training space and changes that will come in these both systems.

Thank you again to our wonderful speakers, Dr. Pears and Dr. Lipman. We truly enjoyed hearing your perspectives and your pearls for wisdom. And thank you to all of our listeners for tuning in. We have more exciting episodes lined up with our UK colleagues later on in this year. So until then, ate the day.