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Global emergency & operative care: challenges and opportunities · Anaesthesia on Air

• 00:00:08 Eoin Dore Hello and welcome back to Anaesthesia On Air, the podcast from the Royal College of Anaesthetists. 00:00:13 Eoin Dore My name is Dr. 00:00:14 Eoin Dore Eoin Dore. 00:00:15 Eoin Dore I'm the Digital Educational Content Fellow at the college and I'm a senior registrar working in the Thames Valley region in anaesthetics. 00:00:24 Eoin Dore Today we're at the 2025 Winton Symposium. 00:00:28 Eoin Dore and we have got the pleasure of featuring some of our guest speakers from the symposium. 00:00:39 Eoin Dore Next up is Miss Rachel Hargest, who has just given her talk on the challenges and opportunities for surgeons and anaesthetists in global emergency critical operative care. 00:00:49 Eoin Dore Rachel is a recipient of the 2025 Webb Johnson Awards, given jointly by the Royal College of Anaesthetists 00:00:56 Eoin Dore and the Royal College of Surgeons of England. 00:00:59 Eoin Dore And this lectureship is given to an established senior clinician, academic expert or pioneer in their field. 00:01:06 Eoin Dore I think you'll find in this conversation, Rachel is all three. 00:01:10 Eoin Dore She graduated from Charing Cross and Chelsea and Westminster School and has worked in centres in London, Johannesburg, Toronto and many other places abroad. 00:01:22 Eoin Dore She's returned to Wales as a consultant surgeon where she specialises in intestinal failure, familial cancers and **** cancer. 00:01:29 Eoin Dore She's also an active member of the Royal Society of Medicine, previously sitting on their council and has been their treasurer for five years. 00:01:37 Eoin Dore She also is a council member and trustee of the Royal College of Surgeons. 00:01:42 Eoin Dore She is also the co-founder of the Global Surgery Policy Unit. 00:01:48 Eoin Dore I hope you enjoy the conversation today. 00:01:50 Eoin Dore She's got a wide array of expertise on a number of fascinating areas. 00:01:55 Eoin Dore I particularly enjoyed it as well. 00:01:59 Eoin Dore Welcome, Rachel. 00:02:00 Miss Rachel Hargest Thank you very much. 00:02:01 Eoin Dore Would you mind telling us about your backgrounds? 00:02:04 Miss Rachel Hargest I'm a general and colorectal surgeon practicing in Cardiff. 00:02:08 Miss Rachel Hargest I've been there about 18 years. 00:02:11 Miss Rachel Hargest I actually was born in Cardiff, came to London to medical school, went all around the world. 00:02:16 Miss Rachel Hargest I think I worked in 00:02:18 Miss Rachel Hargest 23 hospitals on 4 continents. 00:02:20 Miss Rachel Hargest And I've ended up 5 minutes from where I started, completely serendipitously. 00:02:25 Miss Rachel Hargest It wasn't the long-term plan to go back to Cardiff, but the opportunity came up and that's where I am. 00:02:31 Eoin Dore Oh, fantastic. 00:02:32 Eoin Dore And what inspired you to get into surgery? 00:02:35 Miss Rachel Hargest I come from a non-medical family, so I was the first person in my family to do medicine, so I really had no preconceived ideas 00:02:42 Miss Rachel Hargest about what careers there were. 00:02:44 Miss Rachel Hargest I mean, I knew there were GPs and I knew there were hospital doctors and that's about all I knew. 00:02:48 Miss Rachel Hargest I think there were pull factors, which was, in medical school, I loved anatomy. 00:02:53 Miss Rachel Hargest Of all the subjects that we did in pre-clinical, that was my favourite. 00:02:56 Miss Rachel Hargest And I did a BSC in anatomy. 00:02:58 Miss Rachel Hargest So that, I guess, was a good grounding for any surgeon, although at that time I wasn't thinking about surgery because I didn't know anything about it. 00:03:05 Miss Rachel Hargest And in fact, my first surgical firm as a third year medical student when we went on the wards was not very inspiring at all, to be honest. 00:03:13 Miss Rachel Hargest And I remember going home at the Christmas holidays after that first term, telling my parents about what I'd been doing on my first term on the wards. 00:03:20 Miss Rachel Hargest And the one thing I said to them, well, I know I won't be a surgeon because it was not a very good firm. 00:03:27 Miss Rachel Hargest But then six months later, I did 00:03:29 Miss Rachel Hargest a general surgical firm in a district general hospital, West Middlesex Hospital out on the west side of London, with an inspirational general surgeon who covered everything. 00:03:40 Miss Rachel Hargest He was one of these guys that did paediatrics, urology, GI surgery, breast, et cetera. 00:03:45 Miss Rachel Hargest And it was like a light bulb moment. 00:03:48 Miss Rachel Hargest I just thought, this is what doctoring is all about. 00:03:51 Miss Rachel Hargest The patient comes in, they've got something wrong, you do something, they get better and they go home. 00:03:56 Miss Rachel Hargest and from then on I was going to do surgery and that's how it worked out. 00:04:00 Eoin Dore You were mentioning there that you've been able to practice in not only the UK but many countries abroad. 00:04:07 Eoin Dore What inspired you to do that? 00:04:09 Miss Rachel Hargest I've been very fortunate in the opportunities that came up. 00:04:12 Miss Rachel Hargest Originally it dates back to actually doing that anatomy BSc because as one module of that 00:04:20 Miss Rachel Hargest We did comparative anatomy of the extinct and extant primates, which all sounds a bit rarefied, but we studied the anatomy of different types of primates, monkeys, lemurs, et cetera. 00:04:32 Miss Rachel Hargest We used to go to London Zoo for some of our tutorials to study the animals there. 00:04:37 Miss Rachel Hargest And we learned about the lemurs of Madagascar, which I thought, well, this all sounds very interesting. 00:04:43 Miss Rachel Hargest So when I got the chance to do my elective as a final year student, I thought, I shall go to Madagascar and I shall see lemurs. 00:04:50 Miss Rachel Hargest which I did. 00:04:50 Miss Rachel Hargest But the medical bit was in a mission hospital run by American Lutheran missionaries, which to be honest, provided at the time most of the health care outside of the capital city for the whole of Madagascar. 00:05:04 Miss Rachel Hargest And I saw the enormous need for medical care in countries like that and how you could actually do quite a lot with very few resources. 00:05:13 Miss Rachel Hargest but a lot of commitment, both from the Americans that were there, but also from the way they worked with the local people to build up the doctors and the medical directors and the leadership positions of the local people to take over the clinics and hospitals. 00:05:29 Miss Rachel Hargest And I guess that's what started my interest as a medical student. 00:05:32 Miss Rachel Hargest Well, of course, as a medical student, you can't do much. 00:05:35 Miss Rachel Hargest But then as I got a bit more senior, I was able to do things. 00:05:38 Miss Rachel Hargest And then my first registrar job, 00:05:40 Miss Rachel Hargest was in Johannesburg. 00:05:42 Miss Rachel Hargest And that was amazing. 00:05:44 Miss Rachel Hargest I think that was the job that was the most beneficial in terms of my training and development as a surgeon. 00:05:52 Miss Rachel Hargest The surgeons in Johannesburg are just amazing in their skill. 00:05:58 Miss Rachel Hargest They ran very tight ship. 00:05:59 Miss Rachel Hargest It wasn't just having a go at things. 00:06:01 Miss Rachel Hargest It was all done with proper audit and so on. 00:06:05 Miss Rachel Hargest And I came on in leaps and bounds, and I'm very grateful to those South African surgeons who trained me. 00:06:12 Miss Rachel Hargest And I don't think I would have the level of practice I do now if I had not done that first registrar job in Joburg. 00:06:20 Miss Rachel Hargest It was amazing and a phenomenal experience for me. 00:06:24 Miss Rachel Hargest So that was more as a trainee, I did that. 00:06:27 Miss Rachel Hargest And then obviously I've done some things. 00:06:30 Miss Rachel Hargest I worked in a little missionary hospital in Pakistan, just as I was coming to the end of my training before I became a consultant, where it was up on the Karakoram Mountains. 00:06:41 Miss Rachel Hargest I was the only doctor for hundreds, thousands of square miles with two midwives. 00:06:46 Miss Rachel Hargest Because of the laws, religious laws, I had to be dressed in the relevant clothing. 00:06:52 Miss Rachel Hargest only allowed to see women patients and males under 12. 00:06:56 Miss Rachel Hargest So I had to do a lot of obs and gynae, a lot of paediatrics. 00:07:00 Miss Rachel Hargest There was no anaesthetic facilities, so you could only do things under local or blocks or whatever. 00:07:06 Miss Rachel Hargest That was quite an experience as well. 00:07:09 Miss Rachel Hargest But a beautiful part of the world in terms of, you know, the mountains and everything, but quite rudimentary at the time. 00:07:15 Miss Rachel Hargest It's better now because the roads and things have improved, so there is better healthcare there now, I think. 00:07:21 Eoin Dore I think having to almost be a Swiss army knife of a general physician. 00:07:26 Eoin Dore I remember in 2018, I went to work in a refugee camp for three months and got told the German doctor I worked with didn't work with children, women, or pregnant women. 00:07:35 Eoin Dore I was like, oh, so you just worked with men over the age of 18. 00:07:38 Eoin Dore Lives you a very limited force. 00:07:40 Miss Rachel Hargest Yeah, I mean, to be honest, I didn't really do much surgery there. 00:07:44 Miss Rachel Hargest It was much more about treating babies with diarrhoea, just rehydrating them and looking after pregnant women. 00:07:51 Miss Rachel Hargest The midwives did all of the deliveries, really. 00:07:53 Miss Rachel Hargest They were far more skilled than I was at that sort of thing. 00:07:56 Miss Rachel Hargest But, you know, obviously we monitored pregnancies and did things about nutrition and keeping well and so on. 00:08:02 Miss Rachel Hargest I think 00:08:03 Miss Rachel Hargest and then obviously postpartum checks and child development and things like that. 00:08:06 Miss Rachel Hargest It wasn't really surgery as such, but I mean, a bit what I was saying in the talk, sometimes there's just one person and they have to turn their hand to a lot of things. 00:08:15 Eoin Dore And on that subject, given your extensive work abroad, have you had many situations in which the resource limitation has required you to problem solve creatively? 00:08:27 Miss Rachel Hargest Yes, and in some ways, doing it abroad is a lot easier than doing it here. 00:08:31 Miss Rachel Hargest I mean, we have plenty of resource limitations in the NHS. 00:08:35 Miss Rachel Hargest The trouble is, if you try to improvise, there's always some policy or somebody from some, you know, department that comes and tells you can't do that. 00:08:43 Miss Rachel Hargest It's actually quite nice when you're working abroad, because if you use 00:08:47 Miss Rachel Hargest a Foley catheter as a chest drain, nobody in Madagascar is going to object to do that. 00:08:52 Miss Rachel Hargest If we've run out of chest drains in an NHS hospital and somebody decides they'll put a Foley catheter into the chest inside, which of course does the job perfectly well, but you know, you'll have an incident form and a Datex incident and, you know, by which time, you know, you've lost the will to live and the patient probably has died by now. 00:09:12 Miss Rachel Hargest So in fact, improvising and problem solving is much, much easier. 00:09:16 Miss Rachel Hargest in countries that have less regulation, as it were, and less people trying to tell those of us that do what it is we should be doing. 00:09:24 Eoin Dore One of the themes of your talk, and given your co-directorate role at the Global Surgery Policy Unit, have quite an area of expertise on, is the challenges of surgery when they're practiced in low-income countries compared to maybe us in the NHS. 00:09:40 Eoin Dore Would it be all right to enlighten our audience on that? 00:09:43 Miss Rachel Hargest Yes, I mean, I think there is a danger of lumping all low and middle income countries together, which obviously is not the case. 00:09:52 Miss Rachel Hargest There's a huge difference between the very lowest income countries and those that are much more developed. 00:09:58 Miss Rachel Hargest And also there's a difference between countries which are politically stable, albeit poor, 00:10:05 Miss Rachel Hargest and those which are suffering from war, conflict, or major natural disasters, which can overwhelm any sort of health service. 00:10:14 Miss Rachel Hargest The issues really are around what is accessible to the general population. 00:10:20 Miss Rachel Hargest For the elites who have money, in many countries, they can access really quite acceptable surgery, either in the private sector or by going somewhere else. 00:10:34 Miss Rachel Hargest The question is how you roll out an acceptable level of surgery or indeed any kind of medicine across a large and often geographically dispersed population. 00:10:46 Miss Rachel Hargest And so even in countries, say like India or somewhere like that, where the big cities and big towns will have really very good medical and surgical services, if you go out into certain rural areas, it's 00:11:02 Miss Rachel Hargest much harder to get access to those services, either because they don't exist or the geographical and costs of transportation and so on mean that for poor people, even if the service is free or relatively cheap, can they actually take time off work or time away from their farm to go there? 00:11:23 Miss Rachel Hargest And I think there's a thing about access as well as about what services are provided. 00:11:29 Miss Rachel Hargest The 00:11:30 Miss Rachel Hargest sort of WHO list of essential procedures in surgery and anesthesia and so on, gives us guidance as to what are considered essential procedures. 00:11:40 Miss Rachel Hargest Because as we know from the NHS or any kind of health system, if you had enough money, there's always more things that could be done and there'll always be a demand for more. 00:11:51 Miss Rachel Hargest but you have to set the bar somewhere. 00:11:54 Miss Rachel Hargest And that's, we have something like NICE, which decides in the UK what is cost effective and what's not. 00:12:00 Miss Rachel Hargest Many countries don't have those bodies that rule on what should be provided by a government system. 00:12:06 Miss Rachel Hargest But I think that really is being thought about more at a sort of Ministry of Health and government level now with the development of universal health coverage packages. 00:12:15 Miss Rachel Hargest Some of the economic work about that is looking really at priority setting and cost effectiveness. 00:12:21 Miss Rachel Hargest So if the GDP of a country is X dollars per capita, what can you afford to put into a universal health coverage package? 00:12:32 Miss Rachel Hargest And there's the obvious things like vaccination, safe childbirth, something maybe about control of infectious diseases, but it's actually getting some surgery into that. 00:12:45 Miss Rachel Hargest basic package. 00:12:46 Miss Rachel Hargest And then obviously as a country's economic development improves, hopefully, you can add more things into that package. 00:12:54 Miss Rachel Hargest And I don't think any country in the world has got it completely right. 00:12:57 Miss Rachel Hargest I mean, in the UK with the NHS, which is free at the point of use, theoretically people can have all sorts of things. 00:13:03 Miss Rachel Hargest But in practice, because of waiting lists or because of the fact that certain things are centralized, 00:13:10 Miss Rachel Hargest In practice, not everybody accesses every single type of surgery that they might think they need or want. 00:13:17 Miss Rachel Hargest You've got to have some way of setting the bar and the development of UHC packages is, I think, the way things are going. 00:13:25 Miss Rachel Hargest And certainly countries that rely on funding from international donors 00:13:30 Miss Rachel Hargest I think have to be quite careful about what they say they will provide and what they won't. 00:13:35 Eoin Dore I've found it very interesting in your talk where you talked about that the Millennium Development Goals were mainly focused on infant and maternal mortality and then we haven't thought about what we do with the population that survives as a result and that surgery has not been a focus. 00:13:51 Eoin Dore Would you mind just informing the audience why you feel that there should be more development, anaesthesia and surgery for those surviving populations? 00:13:59 Miss Rachel Hargest I mean, the Millennium Development Goals were very good in a way because they did focus the attention of the world on the disparity in outcome for, particularly for children born in very low income countries around not just health, there were goals around education and so on as well. 00:14:15 Miss Rachel Hargest And in many countries, as I said, the under fives are doing considerably better than they were 20 years ago. 00:14:24 Miss Rachel Hargest The issue then is between the ages of about 5 and 30 odd, 00:14:29 Miss Rachel Hargest there are certain things which are predominantly the causes of death and disability, infectious disease being one of them. 00:14:35 Miss Rachel Hargest But of course, if the children have been vaccinated against those diseases, which can be vaccinated against, and if infrastructure around water supply has been improved, which is another issue, then surgical conditions like appendicitis, burns, trauma, hernia, make up a disproportionate 00:14:54 Miss Rachel Hargest number of causes of death and permanent disability in that age group, because on the whole, they're too young to start getting the degenerative diseases. 00:15:04 Miss Rachel Hargest And they've escaped the worst of the sort of childbirth type injuries and diseases. 00:15:10 Miss Rachel Hargest And so from an economic point of view, you need that age group of your population to either be in education or work in order for the country's development to continue. 00:15:22 Miss Rachel Hargest And we saw this, 25, 30 years ago with HIV in Africa, where it disproportionately affected young people who were not only the workforce, but were also the parents of young children at the time. 00:15:38 Miss Rachel Hargest And I remember reading articles in the BMJ and so on about how you had almost like a missing generation who'd fallen out of the active society, either by death or long-term illness, so that you had grandparents who weren't working 00:15:52 Miss Rachel Hargest and weren't economically active looking after small children because of that sort of missing generation. 00:15:59 Miss Rachel Hargest Well, HIV is a lot better under control now. 00:16:02 Miss Rachel Hargest There's been huge programs to deal with that worldwide. 00:16:04 Miss Rachel Hargest It's not solved, but it's better than it was. 00:16:07 Miss Rachel Hargest And surgery is one of those disproportionately high, or surgical conditions are disproportionately high in that age group. 00:16:16 Miss Rachel Hargest And so for a country to develop economically by having people who are active in the workforce 00:16:22 Miss Rachel Hargest And also for the life expectancy for that country to rise as the years go by, you need to avoid avoidable deaths. 00:16:29 Miss Rachel Hargest And that's where surgery comes in with anaesthesia and all the other disciplines that go with it. 00:16:34 Eoin Dore You made an incredible case there for why we need to improve surgery globally. 00:16:38 Eoin Dore But it's not just a case of sending all our surgeons out over across abroad and then hoiking them back after a week or two, is it? 00:16:46 Eoin Dore We need to think about how we can help them develop business cases. 00:16:50 Miss Rachel Hargest It's like that story, isn't it? 00:16:52 Miss Rachel Hargest of the child sitting on the beach throwing the limpets or the crabs or whatever back into the ocean who've washed up and people say, well, it makes no difference because there's still thousands of these being washed up. 00:17:02 Miss Rachel Hargest And he says, well, it makes a difference to this one crab or limpet. 00:17:05 Miss Rachel Hargest If I go out on a mission trip and repair 20 hernias or something, it makes a difference to those 20 people, but it does nothing for the infrastructure of the surgical service in wherever it is. 00:17:19 Miss Rachel Hargest So while I'm not against short-term missions, I think we need to be aware of the limited value at a sort of national or regional level that you're ever going to get by doing sort of single-handed small missions. 00:17:33 Miss Rachel Hargest The issue is really about developing, training and sustaining a workforce of people who live and work in that area and are able to provide the care that the population of that area needs. 00:17:47 Miss Rachel Hargest That's why the slide I showed about the disproportionate costs of either a mission of income in outsiders, as it were, to do some sort of surgical camp versus the investment in the local services. 00:18:02 Miss Rachel Hargest Partly it's the expense of doing it, but that paper isn't just about people going from North America or Europe all the way to the global South. 00:18:10 Miss Rachel Hargest It also included regional missions, so within Asia or within Africa from one country to another. 00:18:17 Miss Rachel Hargest And I think part of that is the expense of travel and logistics, but the other part is about what you choose to do when you get there. 00:18:23 Miss Rachel Hargest Investment in local services tends to be very focused on the actual needs of that community. 00:18:31 Miss Rachel Hargest And it's fairly obvious, it's things like caesarean section, burns, trauma, hernias, those kind of things. 00:18:38 Miss Rachel Hargest Whereas some of the incoming teams have, for whatever reason, chosen to do something they are interested in, 00:18:46 Miss Rachel Hargest which again might be important for the small number of people that require, I don't know, a kidney transplant or some major cardiac surgery or whatever it is. 00:18:55 Miss Rachel Hargest Now, I'm not against any of those things. 00:18:57 Miss Rachel Hargest Obviously, we benefit from them here in the UK, but the cost per life year that is gained is a lot more 00:19:06 Miss Rachel Hargest than what you can do with the same amount of money for more people if you concentrate on the big common disorders and diseases which either kill or disable people and can be reversed. 00:19:20 Miss Rachel Hargest Things like burns, trauma, appendicitis and so on, if you treat them properly, that person is better and goes back to school or work or whatever and restores their place in society after one intervention, usually. 00:19:34 Miss Rachel Hargest Whereas some of the complex congenital things and the degenerative things, an operation is just one in what needs to be a series of things. 00:19:45 Miss Rachel Hargest So again, is it ethical to be doing certain procedures when there's no physiotherapy, no speech therapy, no specialist nursing, no other support for somebody who's 00:19:58 Miss Rachel Hargest going to be left with a technically successful operation, but not necessarily able to restore their place in society and function as someone of their age should be functioning because they haven't got the support which they would have if they were in London or New York. 00:20:14 Miss Rachel Hargest So there's a lot of ethical as well as financial considerations about what services should be provided where. 00:20:21 Miss Rachel Hargest And in the end, I guess it comes down to money, unfortunately. 00:20:26 Miss Rachel Hargest But if you've only got a limited amount of money, one should try to do the most you can for the most people, really. 00:20:33 Miss Rachel Hargest And that's the way most government policy tends to work. 00:20:37 Eoin Dore I was interested to see in your talk that when you look at global health and global surgical research, the predominant of it is done by 00:20:46 Eoin Dore higher income countries, the vast majority really. 00:20:49 Miss Rachel Hargest Yes, well, I think there's different problems there. 00:20:53 Miss Rachel Hargest The one which up until a few weeks ago I thought was the problem was that because of issues around academic expectations and academic careers in the universities of UK, America and so on, your employer will expect you to be either the first or last author on a publication for it to count towards your own KPIs. 00:21:15 Miss Rachel Hargest and that sort of people were hogging those slots, as it were, leaving the authors from low-income countries to have the less favourable positions in the order. 00:21:25 Miss Rachel Hargest What I hadn't realised until a few weeks ago, when we've just had a special issue of the British Journal of Surgery to commemorate 10 years of the Lancet Commission on Global Surgery, is that because of the charges now for publication with many publishers, the authors have to 00:21:44 Miss Rachel Hargest pay a fee to be published. 00:21:46 Miss Rachel Hargest Now, working for a British university like myself, most of our universities have signed contracts with the big publishing houses, such as I as an author, just informed my university that I've had a paper accepted with whatever journal and the fee gets paid under this arrangement and it doesn't come out of my pocket. 00:22:08 Miss Rachel Hargest I deliberately, I edited this particular edition and I deliberately asked authors from low income countries to write papers for this journal, which were accepted after peer review and all the normal procedures. 00:22:23 Miss Rachel Hargest And then we got stuck because the publishing house didn't have an arrangement with their institutions. 00:22:31 Miss Rachel Hargest And for somebody in certain countries, the charge would be prohibitive to them publishing. 00:22:37 Miss Rachel Hargest Now, very kindly, when I contacted the publisher and explained the circumstances and the special issue and so on, arrangements were made to deal with that. 00:22:46 Miss Rachel Hargest But I hadn't realized until recently that universities, even quite well-established universities in capital cities in some 00:22:54 Miss Rachel Hargest of the poorer countries don't have those reciprocal arrangements that British or American universities would have. 00:23:01 Miss Rachel Hargest So even if you're in an academic institution in some places, you may not get the same favorable help to publish that if you were in a British university. 00:23:11 Miss Rachel Hargest So it's not just, I mean, there's the academic side as to how the academics organize themselves, but there's also an issue with the way in which publishers charge fees. 00:23:21 Miss Rachel Hargest Some publishing houses now are giving either zero or preferential rates to authors from low-income countries, but it's not universal. 00:23:30 Eoin Dore No, that's a quite big systematic barrier to getting their research out there as well and coming up with solutions that they need as opposed to ones that you think they need. 00:23:40 Eoin Dore I was quite interested to see that one of the big examples that you brought up was the Paediatric Endocrinology Society. 00:23:47 Miss Rachel Hargest Yes, they've done a fantastic job. 00:23:49 Miss Rachel Hargest Yeah, I mean, 00:23:50 Miss Rachel Hargest I think the point I wanted to make about that is that they have had a long-term commitment to developing paediatric endocrinology as a specialty in those parts of the world. 00:24:05 Miss Rachel Hargest So they've worked in a 00:24:07 Miss Rachel Hargest really coordinated fashion. 00:24:10 Miss Rachel Hargest So rather than one consultant saying, well, I've got an old registrar who's a consultant in this country and somebody else saying, oh, well, I did my elective in that country 30 years ago. 00:24:20 Miss Rachel Hargest I'd like to go back there and all the different things that you hear from different specialties. 00:24:25 Miss Rachel Hargest They made a concerted effort to work together. 00:24:30 Miss Rachel Hargest supporting, specific programs and different members of their council and membership volunteering to take roles in doing that. 00:24:40 Miss Rachel Hargest And it's been a long-term commitment, but it's paid dividends for them and been a very fruitful collaboration, yeah. 00:24:47 Eoin Dore Whereas you were saying another area that they've then helped out is a place in Eastern Europe where they have less of a need to have that, but then they put on summer workshops instead to upskill at different points. 00:24:58 Miss Rachel Hargest Yes. 00:24:59 Miss Rachel Hargest I mean, obviously paediatric endocrinology is a bit of a niche area and somebody who works as an endocrinologist with adults mainly may only have a relatively small part of their practice in paediatrics, but it's still something they might need to know 00:25:14 Miss Rachel Hargest about depending on sort of the geography of the local provision. 00:25:17 Miss Rachel Hargest My understanding is it's been very well received and the numbers that have sort of graduated from those summer schools are really quite impressive. 00:25:27 Eoin Dore There's quite a few lessons there in terms of seeing problems. 00:25:31 Eoin Dore and trying to put your own solution in there as opposed to seeing solutions really rather than the actual problems asking people what they would like. 00:25:39 Eoin Dore Do you think there's some lessons or what would you encourage us as anaesthetists to adopt from lessons in global surgery that you've encountered? 00:25:47 Miss Rachel Hargest Well, I think the interesting thing about that was the sort of training needs analysis. 00:25:53 Miss Rachel Hargest I only showed just 00:25:54 Miss Rachel Hargest one aspect of that, which was about anaesthesia providers in Somaliland, but there's a whole lot more work. 00:26:02 Miss Rachel Hargest But it's interesting because obviously when we're training as surgeons or anaesthetists, there are certain courses we all do, ATLS or BSS or various sort of basic life support courses and so on. 00:26:14 Miss Rachel Hargest And people think, great, I've done this course, it's been really good, or I teach on this course, it's been really beneficial. 00:26:20 Miss Rachel Hargest Why don't we offer to take it to such and such a country or such and such a place? 00:26:26 Miss Rachel Hargest Now, it may be a good thing to do that, but I mean, I remember when I was a registrar in Johannesburg, the first ATLS course came to Johannesburg. 00:26:37 Miss Rachel Hargest And to be honest, it was not well received by the surgeons there because they had done more trauma laparotomies and more thoracotomies and more airway manoeuvres than the entirety the faculty put together. 00:26:51 Miss Rachel Hargest And I was quite stunned when I got there as a new registrar to discover that the surgical registrar was in charge of all airway management and central line management in the hospital. 00:27:01 Miss Rachel Hargest And the anaesthetist would call you when they couldn't intubate or get a central line in. 00:27:06 Miss Rachel Hargest I was a British trainee. 00:27:07 Miss Rachel Hargest I had to, let's just say, I had to learn very fast. 00:27:10 Eoin Dore Oh, wow. 00:27:11 Miss Rachel Hargest Landing an ATLS course on surgeons with 30 years experience of doing nothing but trauma was somewhat 00:27:20 Miss Rachel Hargest let's just say, don't teach your grandmother to suck eggs was said to me more than once when they were discussing how they felt about the course. 00:27:27 Miss Rachel Hargest So I think one has to be sensitive. 00:27:29 Miss Rachel Hargest And as I showed in that slide, even though most of those anesthesia providers were not doctors, they were actually very competent in quite a range of anesthetic skills. 00:27:38 Miss Rachel Hargest There were one or two that they asked for training in, but actually basic anesthetic skills, 00:27:44 Miss Rachel Hargest their competence was really very good. 00:27:47 Miss Rachel Hargest So I think one has to ask the question as to what training do you wish us to bring to you and then try and fill those gaps rather than just assuming that somebody who's been qualified 2 years in Somaliland will be the same as someone who's been qualified 2 years in UK. 00:28:05 Miss Rachel Hargest because they're practicing in an entirely different environment. 00:28:08 Eoin Dore Just for the listeners at home, the slide that we're talking about was an element of research that one of your research fellows has done, where they asked a range of anaesthetic practitioners what they would want or what they lack competency is. 00:28:22 Eoin Dore And the main thing was front of the neck access. 00:28:25 Eoin Dore So if you were to go and teach a 12-week course, you would end up teaching the wrong thing in a way if you just went and implemented what you think. 00:28:32 Miss Rachel Hargest Yeah, because things like spinal anaesthesia. 00:28:35 Miss Rachel Hargest post-operative analgesia and other skills like that, their competence was already very good. 00:28:41 Eoin Dore And also if I take my PACU recovery package over to Somaliland, it'd be fairly useless. 00:28:47 Miss Rachel Hargest Yes, I mean, as you saw from the slide, although about 3/4 of them had SATS monitoring available, that means about 1/4 of them don't. 00:28:56 Miss Rachel Hargest Things like use of basic WHO checklist is 50% at most. 00:29:01 Miss Rachel Hargest Bearing in mind probably that 00:29:03 Miss Rachel Hargest Although we had a good response rate of almost 60% on the participation, those are probably the more engaged 60%. 00:29:10 Miss Rachel Hargest So it may be that actually access to SATS monitoring and checklist and so on is less than the figures I showed. 00:29:19 Eoin Dore Because there's 60% of the people that are actually engaged, which already is an active engagement. 00:29:23 Miss Rachel Hargest I was going to say they're more likely to be the engaged ones anyway, yeah. 00:29:26 Eoin Dore We'll come back onto global surgery if that's okay, because I think you'll be a fantastic resource for advocation for what people do to get involved. 00:29:34 Eoin Dore But one of the things that was mentioned in your intro was you were the recipient of the Silver Scalpel Award, which is for the top surgical trainer in the whole of the UK, which is a fantastic award and I'm sure is incredibly well deserved. 00:29:49 Eoin Dore served in it. 00:29:50 Eoin Dore You've been noted to support trainees really well previously. 00:29:54 Eoin Dore How do you create a positive, safe and aspirational training environment? 00:29:58 Miss Rachel Hargest Firstly, can I say the Silver Scalpel Award was a great honour. 00:30:02 Miss Rachel Hargest I think of all the things I've won or been awarded, it's probably the one I value the most. 00:30:07 Miss Rachel Hargest And the reason is that you can't apply for it. 00:30:12 Miss Rachel Hargest You can't be tapped on the shoulder for it. 00:30:14 Miss Rachel Hargest You can't be elected for it the way that normally, you get other positions or awards. 00:30:20 Miss Rachel Hargest Basically, trainees can nominate whoever they like. 00:30:25 Miss Rachel Hargest And if you get enough nominations, then the first thing you know is you get an e-mail from the office saying, you have been nominated for this, you know, and we want to come and interview and so on. 00:30:36 Miss Rachel Hargest So it's led by the trainees essentially. 00:30:39 Miss Rachel Hargest So that's quite an honor. 00:30:41 Miss Rachel Hargest I think I try to lead by example. 00:30:45 Miss Rachel Hargest So I take my job very seriously. 00:30:48 Miss Rachel Hargest I take patient care very seriously. 00:30:50 Miss Rachel Hargest And so people watch that and they notice, it's funny sometimes when you hear doctors talking about their boss, you know, what they say about us, but I think people notice how you manage the patients yourself. 00:31:06 Miss Rachel Hargest I try never to ask somebody to do something I wouldn't do myself. 00:31:09 Miss Rachel Hargest so that people don't feel that I'm kind of dumping work on them. 00:31:13 Miss Rachel Hargest I have very high expectations of myself and high expectations of people that work with me. 00:31:18 Miss Rachel Hargest I mean, I always say if they've got into medical school, they must be clever because it's competitive to get into medical school in the 1st place. 00:31:26 Miss Rachel Hargest So nobody is not going to be intellectually capable of doing whatever it is they want to do. 00:31:33 Miss Rachel Hargest Very few people have such bad coordination that they can't be a surgeon if they put their mind to it. 00:31:39 Miss Rachel Hargest I've only had one or two trainees in 20 odd years who just literally were not well coordinated. 00:31:46 Miss Rachel Hargest So the actual operating which people worry about, if you put your mind to it and put enough time in, most people can learn. 00:31:54 Miss Rachel Hargest The difficult bit, I think, is the decision making about what to do and when to do it. 00:32:00 Miss Rachel Hargest And that, I think, is where you have to think in a certain way to solve surgical problems, which is different to solving medical problems. 00:32:10 Miss Rachel Hargest So with my houseman and students who come for careers advice, before I commit to supporting them in surgery, I ask them to think quite carefully about the way in which they process information and make decisions. 00:32:25 Miss Rachel Hargest Because if you are not good 00:32:29 Miss Rachel Hargest at making binary decisions. 00:32:31 Miss Rachel Hargest And if you struggle to make decisions in a short time frame, then the acute specialties like surgical anaesthesia are going to be difficult. 00:32:42 Miss Rachel Hargest And that's not a good thing or a bad thing. 00:32:44 Miss Rachel Hargest I mean, thankfully, medicine is a broad church and it needs people with different ways of processing information and different ways of making decisions to cover all the different aspects of medicine that need to be covered. 00:32:56 Miss Rachel Hargest And I think for young doctors and students choosing their career path, whichever specialty, they need to be the square peg in the square hole. 00:33:05 Miss Rachel Hargest The most difficult thing is if somebody ends up as a square peg in a round hole. 00:33:11 Miss Rachel Hargest And I know there's specialties where if I had ended up in that specialty, I would be that square peg in that. 00:33:18 Miss Rachel Hargest round hole because it just wouldn't fit the way my brain works to decide what to do and when to do it. 00:33:25 Miss Rachel Hargest So there is a way of making surgical decisions that you get better at, but I think there's something innate about the way you process information that helps you in the acute specialties. 00:33:36 Miss Rachel Hargest And conversely, there are other people who are much better at dealing with complexity over the longer term. 00:33:44 Miss Rachel Hargest and then there will be other specialties that suit them better. 00:33:47 Miss Rachel Hargest And I think once a junior doctor or a student has worked out what way of processing information and how they feel, what situations they feel comfortable making decisions in, they will end up in the right specialty. 00:34:03 Miss Rachel Hargest And it's funny actually, when they came to interview me for the Silver Scalpel, I presume they had the same list of questions for all the candidates. 00:34:11 Miss Rachel Hargest And the last question was, what do you consider your greatest achievement as a trainer? 00:34:17 Miss Rachel Hargest So I said, oh, that's easy. 00:34:19 Miss Rachel Hargest I said, it's the trainees who have come to me over the years thinking they wanted to do surgery, but somehow during the time they were with me, they realized that they may be talents were better suited to something else. 00:34:34 Miss Rachel Hargest They've moved into that other thing as a positive move, not by failing in surgery, but just feeling that something else suited them better. 00:34:44 Miss Rachel Hargest So there's no loss of face, no failure, no ending of one thing with a problem. 00:34:50 Miss Rachel Hargest It's been a positive move to move to whatever it is they are now being very good at because they are now that square peg in that square hole. 00:34:58 Miss Rachel Hargest And they're happy, they're successful, their patients are much better off for it. 00:35:03 Miss Rachel Hargest and surgery is carrying on with the ones who it does fit. 00:35:07 Miss Rachel Hargest And it's funny, the interviewer said, oh, they said, we've never heard anyone say that before. 00:35:12 Miss Rachel Hargest They said, most people say, oh, I've supervised an MSC course, or I've supervised a PhD, or I've run a course on this, that, and the other. 00:35:19 Miss Rachel Hargest I said, well, you know, you've got my CV, you can see all that stuff. 00:35:23 Miss Rachel Hargest I said, please ask me my best achievement as a trainer. 00:35:26 Miss Rachel Hargest And I said, I think getting people to be in the career which is the right one for them. 00:35:32 Miss Rachel Hargest and therefore for their patience is actually the best thing you can do as a trainer. 00:35:38 Eoin Dore And as you've said here and said previously, not necessarily that the high flyers will fly high anyway, but helping those who are struggling can be one of the best things as a trainer. 00:35:50 Miss Rachel Hargest Yeah, well, I think actually that's probably one of the reasons why I got a lot of nominations for the Silver Scalpel, it turned out, because the other interesting thing was after you win, they give you 00:36:02 Miss Rachel Hargest all the, they've taken the names off, but you can recognize some of them by the content. 00:36:06 Miss Rachel Hargest They give you all the emails or letters or whatever they've had to nominate you. 00:36:10 Miss Rachel Hargest And it's amazing what people had said. 00:36:13 Miss Rachel Hargest And a theme that came through was that quite a lot of them were from former trainees or current trainees at the time, who felt that for whatever reason, they were on the back foot in some way, either because they were international medical graduates or they'd had some 00:36:30 Miss Rachel Hargest time out of training or they had family commitments or they failed an exam or something like that. 00:36:36 Miss Rachel Hargest And they'd felt a surgical career or whatever was slipping away from them. 00:36:42 Miss Rachel Hargest And then they'd come to me and we'd got them back on track basically. 00:36:46 Miss Rachel Hargest That's in some way quite rewarding. 00:36:48 Miss Rachel Hargest I mean, sometimes you have high flyers and to be honest, they will succeed 00:36:52 Miss Rachel Hargest Whether I train them or somebody else trains them or even nobody trains them, they'll just sort of fly through exams and move from job to job as if nothing's happening. 00:37:02 Miss Rachel Hargest And that's great for those very able people. 00:37:04 Miss Rachel Hargest But there's a lot of people who can be extremely good if they're in the right environment and if they play to their strengths and learn how to address and work around their weaknesses. 00:37:17 Miss Rachel Hargest And so that's what I've tried to do over the years. 00:37:19 Miss Rachel Hargest And I hadn't realised until I saw all these emails and things that obviously that had an effect on quite a lot of people. 00:37:27 Eoin Dore And do you have any words of advice for anaesthetists, especially those supervising juniors, about someone who's been able to create that psychologically safe environment, about creating it and allowing people almost a space to improve themselves with feedback? 00:37:45 Miss Rachel Hargest I think anesthesia and surgery are very similar, actually, even though we're on opposite sides of the so-called blood-brain barrier. 00:37:52 Miss Rachel Hargest But actually, we're both in specialties where you have a lot of routine work, yes, but you also, particularly when on call, have to make decisions under quite a lot of pressure, both emotionally and time-wise, that can have very big consequences one way or the other. 00:38:12 Miss Rachel Hargest and being able to make those decisions and then carry out the action that results is important for both our disciplines. 00:38:20 Miss Rachel Hargest I think that whoever's on call on the front line, the registrar or the core trainee or whoever, needs the safety to know that you will always come if they need you or that you'll be just around the corner waiting in case there's a problem because that empowers them 00:38:40 Miss Rachel Hargest to take the step that they need to take, and which they probably can take. 00:38:44 Miss Rachel Hargest Whereas if they think, oh, they won't come and then I'll be on my own dealing with the consequences, whatever it is, that's when people feel insecure and are likely to perform less well. 00:38:55 Miss Rachel Hargest I mean, partly because when I was a child, 00:38:58 Miss Rachel Hargest trainee, I commuted long distances here, there and everywhere. 00:39:02 Miss Rachel Hargest I swore that when I became a consultant, I would live near to my base hospital so that I didn't have a lot of hassle commuting. 00:39:09 Miss Rachel Hargest But actually it also meant that when I'm on call, if I need to get in, I can be there in five or 10 minutes. 00:39:16 Miss Rachel Hargest So it's no hassle. 00:39:18 Miss Rachel Hargest And the registrars know amongst themselves which consultants are easy to get in and which are not. 00:39:24 Miss Rachel Hargest So they know if I say to them, start this laparotomy and call me when you need me, I will be there within 5 or 10 minutes. 00:39:32 Miss Rachel Hargest or I say, they say, we think it's appendicitis, but it might be something else. 00:39:36 Miss Rachel Hargest Or if I say, well, put the scope in. 00:39:39 Miss Rachel Hargest If it's an appendix, you're more than capable of taking it out. 00:39:42 Miss Rachel Hargest If it's worse than that, call me. 00:39:44 Miss Rachel Hargest They know that they're not going to be hanging around for ages and repeating phone calls to try and get me to go. 00:39:51 Miss Rachel Hargest So I think being there as what I call the backstop, but not too far away is very important. 00:39:57 Miss Rachel Hargest Sometimes they'll say to me, I'd really like to do this, but I'd like to know you're around. 00:40:02 Miss Rachel Hargest And I'll be, okay, I'll be in the office. 00:40:05 Miss Rachel Hargest It's like 2 minutes away from theatre. 00:40:08 Miss Rachel Hargest You start the case. 00:40:09 Miss Rachel Hargest You ring me when you know what the findings are. 00:40:12 Miss Rachel Hargest You tell me what you're going to do. 00:40:14 Miss Rachel Hargest then that's fine. 00:40:16 Miss Rachel Hargest And then there's a great sense of achievement if they've done the case from skin to skin. 00:40:21 Miss Rachel Hargest Now, obviously, if it's a very sick patient where it needs to be done quickly or whatever, I'll be there assisting them. 00:40:26 Miss Rachel Hargest But I think, you know, with a senior registrar who's not far off being a consultant on their own, they like to be the lead surgeon 00:40:36 Miss Rachel Hargest and they like to be telling the assistant what to do, which is much easier if the assistant is the SHO than if the assistant is your boss, where they feel a bit awkward about telling you to move your hands. 00:40:46 Eoin Dore I've definitely found that sometimes in resource where there's multiple consultants watching at the same time, it makes your hands a little bit more shaky, not shaky, but. 00:40:55 Miss Rachel Hargest And you know, I try to have good relations with the theatre sister or the anaesthetist, so I say, look, if either of you is concerned that things aren't progressing the way they should, 00:41:05 Miss Rachel Hargest just ring me and I'll wander through, so that there's like that check as well. 00:41:10 Miss Rachel Hargest The patient is always safe. 00:41:11 Miss Rachel Hargest That's the most important thing. 00:41:13 Miss Rachel Hargest But depending on the stage, now, obviously, if it's a junior registrar, I'll be there skin to skin, you know, saying, hold the needle like this, hold the scissors like this, et cetera. 00:41:23 Miss Rachel Hargest But obviously, as somebody gets more towards being an independent practice themselves, we can't have a situation where the first time a surgeon does an operation as the senior person. 00:41:34 Miss Rachel Hargest scrubbed is after they become a consultant. 00:41:37 Miss Rachel Hargest That's dangerous for everybody, especially the patient. 00:41:40 Eoin Dore I like the psychological safety of empowering the other team members to call as well, because I think that's so important when, because sometimes on task fixation you are unable to see when you need that extra pair of hands as well. 00:41:53 Miss Rachel Hargest Yeah. 00:41:54 Eoin Dore Coming back to your global health, wealth of knowledge, we'll have lots of anaesthetists here listening who want to contribute to global health, global surgery, perioperative care. 00:42:07 Eoin Dore What are the first steps that you would recommend of maybe the do's and also the don'ts? 00:42:13 Miss Rachel Hargest The positive things that one can do really involve aligning yourself 00:42:19 Miss Rachel Hargest with some sort of professional organisation which shares the vision and the sort of ethical way of working that you are comfortable with, but also requires whatever skill set it is that you bring. 00:42:33 Miss Rachel Hargest Now, obviously, the Royal Colleges have global endeavours. 00:42:37 Miss Rachel Hargest Anaesthetists are very important in a lot of the sort of emergency response teams because you have a specific set of skills which are vital in disaster and conflict relief. 00:42:49 Miss Rachel Hargest And I think if you align yourself with one of those sort of professional organizations that you can commit to over a significant period of time, that's the best way of doing it. 00:43:00 Miss Rachel Hargest I think the way not to do it is to just sort of go off on your own on a sort of surgical or anaesthetic holiday somewhere where you think, oh, I've got two weeks of annual leave and I fancy going to such and such place. 00:43:12 Miss Rachel Hargest And I remember I had a link with somebody there who visited once or whatever. 00:43:17 Miss Rachel Hargest Those kind of very short-term, non-repeatable efforts are not strategically useful and sometimes can be counterproductive. 00:43:26 Miss Rachel Hargest I mean, it depends a bit what you do, but if you're just there for two or three weeks and then you come back, who's going to look after those patients afterwards? 00:43:34 Miss Rachel Hargest What if there's a problem? 00:43:35 Miss Rachel Hargest What if they need more treatment afterwards? 00:43:37 Miss Rachel Hargest There's a whole load of sort of moral and ethical questions that arise from those kind of short-term, one-man-band type operations. 00:43:45 Miss Rachel Hargest I think being part of a more coordinated programme is probably the best way of doing it. 00:43:49 Eoin Dore Do you have any specific programmes or networks that you would highlight to clinicians who first want to engage in the globally, the surgical perioperative care? 00:43:59 Miss Rachel Hargest UK Med obviously coordinates quite a lot of the sort of disaster relief when the British are asked to provide emergency medical teams for conflicts and disasters and anaesthetics is a vital component of that. 00:44:14 Miss Rachel Hargest There are quite a lot of charities that work around specific aspects of either trauma or children's surgery or whatever, which again would require anaesthetic services. 00:44:27 Miss Rachel Hargest Your own college has programs in global anaesthesia. 00:44:31 Miss Rachel Hargest And then for those that can't travel, there is of course the training side of things with the programs whereby doctors from 00:44:39 Miss Rachel Hargest other parts of the world come to train in the NHS for one or two years to learn specific skills. 00:44:47 Miss Rachel Hargest And your college for anaesthetists, our college for surgeons, facilitate these exchanges. 00:44:53 Miss Rachel Hargest They oversee the educational content of the role that the person is coming to so that they're not just used to do service, but they receive probably fairly similar education to what a registrar would receive in that particular specialty. 00:45:09 Miss Rachel Hargest And obviously they help with the sort of visa side of things and registration with the GMC. 00:45:14 Miss Rachel Hargest So even if you're not in a position to travel oneself at a particular stage in life, you can still be involved in helping to build the workforce capacity by the training that can be offered. 00:45:27 Eoin Dore Thank you for that. 00:45:28 Eoin Dore And coming to a close, I was just wondering what you would hope listeners today would maybe take away from your global and clinical work? 00:45:38 Miss Rachel Hargest I think we're very fortunate living where we do for all the problems of the NHS and our politicians. 00:45:44 Miss Rachel Hargest We live in a relatively stable and peaceful country and the NHS provides us with far more services than people in many parts of the world are able to access. 00:45:54 Miss Rachel Hargest So there's the huge sort of inequity side of things which whenever I come back from wherever I sort of realise how fortunate we are really. 00:46:04 Miss Rachel Hargest I think that 00:46:06 Miss Rachel Hargest Particularly since COVID, the use of electronic resources means that we can be much more interconnected around even things like running virtual MDTs for advice, training and so on. 00:46:19 Miss Rachel Hargest But I think there's still a role for face-to-face cooperation with two-way exchanges. 00:46:25 Miss Rachel Hargest There's a lot we can learn 00:46:28 Miss Rachel Hargest from surgeons and anaesthetists in other parts of the world where they deal with things extremely well, given limited resources. 00:46:36 Miss Rachel Hargest And there are things that we can share with them. 00:46:38 Miss Rachel Hargest And I think it's really more about partnerships and long-term collaboration rather than one-way learning. 00:46:44 Eoin Dore Lastly, what keeps you motivated to continually push for better surgical and better global delivery of surgery? 00:46:54 Miss Rachel Hargest I think it's about the issue of fairness. 00:46:56 Miss Rachel Hargest For example, when I worked in Pakistan, I mean, I'm fortunate as a woman that I was born into a country where women get the vote, we can own property, we can drive cars, we can have education. 00:47:08 Miss Rachel Hargest If I had been born as a girl in northern Pakistan, well, one, I'd probably be dead by now because the life expectancy is not very good. 00:47:14 Miss Rachel Hargest I'd have finished school at 11. 00:47:17 Miss Rachel Hargest I'd have been married off at 13. 00:47:19 Miss Rachel Hargest I've probably been dead before I was 40. 00:47:22 Miss Rachel Hargest Just by quirks of birth, I've had a much more fortunate life than a woman born that number of years ago in certain countries of the world. 00:47:31 Miss Rachel Hargest And the same would be true actually for men as well. 00:47:34 Miss Rachel Hargest So I think when you've been blessed with a lot of fortunate things in your life, like a good education, a good family, and living in a relatively good country, then to try and improve the lot of those less fortunate than ourselves, I think is incumbent on us, really. 00:47:49 Miss Rachel Hargest And I think that's very important. 00:47:50 Eoin Dore Thank you so much for your time today. 00:47:52 Miss Rachel Hargest Thank you very much. 00:47:53 Eoin Dore Very much enjoyed this conversation. 00:47:58 Eoin Dore Thank you for listening. 00:47:59 Eoin Dore And if you like that conversation, feel free to share it with a colleague and subscribe and review on Anesthesia on Air whilst you're there. 00:48:05 Eoin Dore We'll see you again next time. 00:48:07 Eoin Dore Thank you.