ASGBI_3_research_11.25.24

Hello, and welcome back to behind the knife. Today, we have the next installment of our awesome collaborative series with the association of surgeons in great Britain and Ireland, where we compare and contrast various aspects of the field of surgery with experts from both sides of the pond. After a deep dive, you as the listener get to decide who does it better.

I'm John Williams, one of the behind the knife fellows. And once again, I'm, I'm joined by our incredible ASGBI co host Jared Wolgamith. Jared, do you mind talking about what topic we're going to cover today? Of course. Today's episode is dedicated to the complex and evolving world of academia in surgery.

We will take a deep dive into everything from how to get involved in surgical research early on in your career, the various aspects of academic work surgeons embark upon, the necessary resources and funding sources for surgical research, And balancing academic activities in clinical practice and so much more.

Like always, we'll need two experts to help shed light on academic

surgery in the UK and the U S. First, I'll introduce Prof Moog. Prof Susan Moog is an honorary professor at the University of Glasgow in Scotland. She is a consultant colorectal and robotic surgeon at the Golden Jubilee National University Hospital in Clydebank and at the Royal Alexandra Hospital in Paisley.

She's also the director of research for the Association of Surgeons of Great Britain and Ireland and the surgical specialty lead for colorectal research at the Royal College Surgeons of England. She has been awarded a senior fellowship from the Chief Scientist's Office of the Scottish Government and was the Chief Investigator of the ELF study, Emergency Laparotomy and Frailty, and the NOLAPS follow on study.

Essentially, she is one of the leading researchers in emergency surgery in the UK, having been awarded over 1 million in grant funding for this under researched and under funded area. So it's a great pleasure to have you with us today. Thanks for having me. All right. And from the U. S. I'm happy to introduce Dr.

Leslie Dossett. Dr. Dossett is an associate professor and surgical oncologist at the University of Michigan. After completing her undergraduate degree at Western Kentucky University, she completed both medical school and her general surgery residency at Vanderbilt University in Nashville, Tennessee, during which she obtained an Agency for Healthcare Research and Quality, or AHRQ, training grant, as well as a master's in public health during her research time.

Residency, she served as an active duty staff surgeon in the U. S. Navy for several years before ultimately pursuing a surgical oncology fellowship training at Moffitt Cancer Center in 2016. she came over to University of Michigan as faculty and ever since has held numerous academic leadership roles, both institutionally and nationally.

Including, but not limited to, Vice Chair for Faculty Development, Chief of the Division of Surgical Oncology, and the President of the Surgical Outcomes Club, which is a national surgical research group. Dr. Dasit has an impressive portfolio of research work focusing on implementation and de implementation of comprehensive cancer care,

which is funded well through multiple grants through the National Institutes of Health.

Dr. Dasit, thanks again for taking the time to join us. Thanks for having me. Alright, I'll start off. Dr. Dossett, can you start by telling us a little bit about your academic work and your focus? Where did you start off and how has it developed over the years? Yeah, thanks again for having me and for inviting us to join on this really near topic here and dear to, to my heart.

So I began thinking about health services research when I was a surgical resident, as. Jonathan mentioned, I completed my general surgery training at Vanderbilt University, which is a program where it was typical for residents to take 2 years of time between the 3rd and 4th clinical years to pursue dedicated research.

At that time, the field, I think, of surgical health services research was. Really starting to develop and take off and inspired me to pursue a master's in public health. And it was really during

that time, I was introduced to the concepts of studying surgical health care delivery. And then after completing my residency training, as Jonathan mentioned, I had a active duty service obligation for the Navy.

And so I completed that and then. Came back to clinical fellowship and surgical oncology. After transitioning to university of Michigan, I knew that pursuing grant funding would be an important goal an interest of mine. And was able to apply and secure a career development award through the agency for health research and quality.

I had done a lot of what I would say would be observational work which was common in the field of surgical health services research at the time, but was beginning to get interested in interventional work and what we could do about many of the quality and value gaps that we were describing.

And my career development award was focused on becoming an expert and learning the methods of implementation

science. During that award, I think a lot due to my personality is what I call a medical minimizer. I tend to be conservative as a clinician and try to avoid unnecessary tests and procedures.

I got interested in the concept of de implementation and low value care, and that's really the focus of my current work. We think a lot about healthcare value and working to reduce unnecessary tests and treatments in surgery and cancer care. That's fantastic. Thank you very much. Professor Moog, can you also share with us your academic journey?

How did you start off your research career and how has it developed laterally? Sure. Although if this is a competition Dr. Dossett's been in the Navy, so I feel she's immediately one. So we could probably just stop the podcast right now. She's one. So I did I did an undergrad, which is kind of similar to what you do in the States.

So I did sports science and physiology and university of Glasgow cause I've not

traveled very far. And in my last year you to do a senior honors project. So I got and managed to persuade. patients with ankylosing spondylitis to exercise in a hydrotherapy pool. And I wrote that up and I'm afraid that was it from that point on.

You just get a bug for it, I think. So then I was in medical school and my summer elective. So the time where we have off during the summer, I did some two research projects with them. Got them written up and published. And then as I became a doctor just before my residency, so my houseman years, first, second and third years, I just annoyed the people I worked with.

I was in an academic unit in Glasgow Royal infirmary. They give me some projects. They were active anyway. So it's really easy to kind of piggyback almost on to their work and get something, you know, for your CV, never mind some more experience as part of their experience too. Then I did a formal PhD. So now I am just about to become a resident.

So kind of ST3, ST4 stage is where it is now. Got my PhD and then moved on to complete my

training. Again, more projects as I went through, but then kind of what Leslie's saying there, when you become a consultant, you're kind of looking for something juicy. And I got my first big juicy grant at that point, which reassured me that this is what I wanted to do.

And this is how I wanted to try and balance being a surgeon with a researcher. So that leads me where I am now with various. Research interests and I'm interested in medical minimizing to like a bit of decision making. So I guess we have an overlap there. But it's all perioperative, my stuff, frailty, prehabilitation, and also a bit of cancer work too.

All right. Excellent. Well, it certainly sounds like, you know, for both of you, At least maybe peripherally or involvement with research work kind of came at pretty early stages in your professional journey. So I'm curious to hear what you have to say about what the various opportunities are for residents or students getting involved in academic work in the U.

S. versus the U. K. and whether you feel like there's kind of a right time to get involved in academic activities. Dr. Dasa, maybe we'll

start with you for the U. S. perspective. Yeah, I think really getting involved in scholarly work is really important for medical students and residents irrespective. If you'd like to pursue independent grant funding, I think it makes you a better clinician and understanding study design and how to evaluate the literature.

But I think in terms of thinking about getting involved to the point at which pursuing scholarly work and grant funding would want to be part of your full time effort, you know, I, I believe probably the most common and probably right time in the U. S. is sometime during the residency training.

I think demonstrating that interest in scholarly work is becoming more important for fellowship matching. And because many of the fellowships are quite short, you know, some of them one year, many of them two years, really establishing that track record and interest and

skill accumulation, I think is important in securing faculty appointments that would have the necessary resources and support to make that part of a, you know, significant part of a faculty appointment.

Okay, and what about you, Professor Moak? In the UK, what do you think are the opportunities for residents or medical students to get started in academia? And is there a right time to get involved in academic activities? I mentioned that you completed your PhD prior to starting your registrar years. I did mine a few years after starting my registrar years.

What do you think is the best way to do this? I don't think you're ever too late, but I think Liz is kind of quite right. The sooner you do it, if you want to be an academic or you want to find out if you do want to be an academic, the better. So do as far up the tree or as early as you can, I think, because it does boost your CV if nothing else, and perhaps maybe enhances your learning process as you go through surgical

residencies, whether you want to do academia or not, at least it means you can understand.

You know, the papers that you're trying to read for your exams, what your, your mentors and your colleagues are all telling you. So yes, definitely the earlier the better, but there's, there's lots of opportunities in the UK and you can jump in at any point. I think there's a, I'm going to talk a lot about this probably, but there's collaboratives in the UK and these are.

usually national led, but feed into regional collaboratives that have a massive capacity in the UK to generate funding projects that veered from cohort studies to RCTs, to getting publications in the Lancet, to really attracting high level funding. And these research collaboratives started with residents in Birmingham.

So the West Midlands Research Collaborative started at first of all, I think there's probably going to be an online fight now because someone else thought they started at first. But anyway, there's a few of them are very good. I mentioned one. And these collaboratives basically empowered anyone in any hospital from a

medical student to a surgical resident, to a consultant, to get basic research training.

So good clinical practice. It's online, depending how smart you are. It takes two to four hours to get it. That then allows you to collect data to then feed into this bigger bit of work that generates massive amounts of data in a very, very short space of time. And when can you do that? Well, the medical school one that's on at the go at the moment is Star Search.

And if you look at Star Search's recent publication, and I think it's Anesthesia or British Journal of Anesthetics, it's Cascade. And over a short period of time, they recruited from 446 hospitals across 28 European countries and got a staggering 24, 000 patients on that paper. That's medical students, that's undergrads.

These, I mean, the capacity for these is unimaginable. Phenomenal. So you can get involved at that stage. There's then collaboratives after that as a resident and there's kind of consultant led collaboratives, but that's probably more your own personal network at that

point. But otherwise, apart from the collaboratives, you can get training programs to the university.

They can link in at any stage of your formal surgical training or even your first or second year as a foundation year. just out of university, or you can kind of do a little bit what I've done, which is annoy people that you think they really like their topics and you want to work alongside them as you're doing your training.

So lots and lots of different opportunities. All right. I think that's so fascinating that there's such a rich collaborative network within the UK. And I think that's definitely a benefit that the UK has is that there's a lot of centralization of. I guess health care and research resources. I think maybe one thing that's worth talking about just for the audience out there too, is that you're both well distinguished health services and outcomes researchers, but there's different flavors of academic work.

And I'm curious to hear what you both have to say about some of the, characteristics and maybe benefits and drawbacks of those different flavors? Sure. I'll start. So I

think when I think about the scientific continuum, I lean a lot on the NIH roadmap which really outlines you know, from bench to clinical practice the various types of research and evidence that can be generated.

And certainly the most traditional Scientific discipline in surgery, at least historically has been bench and translational science, really discovery at the You know, mechanistic level and then translating those discoveries into patients. I think the benefit of that discipline is that it's extremely well recognized and very traditional.

There tends to be a lot of NIH funding that goes to that type of work. Historically the bulk of the NIH budget has gone to bench and translational research. I think the downsides tend to be that it can be it can be more difficult to balance a clinical practice with a bench lab.

But certainly there are

institutions and investigators who have done that well. Then the next discipline I think a lot about is clinical trials really testing that translational work in patients. You know, clinical trials are really important for developing evidence for how we deliver care.

I think the benefits are that it's very accessible to clinicians, you know, interacting with patients, enrolling patients. The downsides tend to be, at least in the U. S., is that most of this work is funded by industry. And that can be problematic in some academic settings in terms of what is recognized as scholarly work for promotion.

Many universities tend to value investigator initiated studies. And clinical trials are often initiated by industry. So that can be one, one drawback, but obviously really important body of work. We've talked a little bit about health services

research that can be funded through traditional science or traditional grant mechanisms.

It tends to be a little bit more straightforward to balance, I think, with the clinical practice. It tends to be less. Costly in terms of upfront investment for scientists, and then I think there's a whole body of newer scholarly work that is increasingly being recognized again in the U. S. respect to.

Academic careers, and I would include in that education research surgical innovation developing, you know, in terms of device development, global surgery, and, you know, a little bit into beyond sort of health services research in terms of health care administration, and those are all important bodies of scholarly work.

I think the downside to those is, again, they can be a little bit more difficult to get funded, Through traditional grant mechanisms. And if I lead on from that, I think that's almost mirror image of what

happens in the UK. There's a NIHR roadmap, which sounds very similar to what you've just described.

The classic cancer translation research certainly has attracted more funding, and perhaps the oncologists have driven that more in the earlier years rather than surgeons, but hopefully that's shifted now. We've got a link from very well known editor who published in the Lancet in 96, saying that surgical research had lots of really, really good opportunities in the UK, but we weren't very good at delivering them.

We were very good at case series or case reports, but we have followed that up last year with a juicy publication, which hopefully resets the balance. But I think it's been about. Surgeons trying to drive this forward and realizing that they're not just surgeons, they're not just clinicians, but they can lead and drive research within their job plans.

If you work for a university in the UK, you might get a nice fellowship or funding that does 50, 50. So 50 percent research, 50 percent surgery or clinical. If not, you might find that shifts a good bit down and you're looking at 10 percent research versus 90 percent clinical.

And I'm sure that balance exists in the UK or that tension exists in the UK as well.

The other thing that we don't have as much as you do in the U. S. is your commercial funding. That's definitely very different. A lot of ours comes from charity bodies. You've mentioned NIHR or any INIR in the U. S. We have MRC. We have Wellcome. We have CRUK. We've got a lot of them, but not a lot of commercial type support, but I think it is coming.

But to your extent, I don't think, I think we're years away from something like that. And the last thing that I think has perhaps benefited from this Lancet comments. I say it's quite damning, but I think it maybe gave us a kick up the you know what. We've now spread, I think, our remit. And I think surgical research has got really exciting because there's so many different aspects of surgery you can now pick.

And I think several new things that are happening are looking at sustainability research. And actually the last thing that I think We're really getting into now is qualitative research. We're really beginning to pull out what surgeons feel about certain things, qualitative analysis.

Patient centered research is a big, big thing in the UK.

And I think that's a massive shift away in the last 10 years from maybe lab based research. And there's nothing wrong with lab based research, but it might just not be what you want to do. And you might favor other aspects, implementation science, all these things that are really, I think, greatly evolved in the last 10, 12 years.

All right. That's excellent. Well, it certainly seems like the, you know, I think the world of surgical research continues to rapidly expand well, well beyond the the basic science lab. I'm curious to hear what you have to say, given that the world of research is so vast and diverse nowadays for a surgeon scientist, that's aspiring to you.

Achieve academic greatness. What types of infrastructure at your particular institution do you feel like are critical to have a successful research career as a surgeon? I think it depends what you want. You need to surround yourself with people that you can work with that you have similar.

overlapping interests, but perhaps separate too. You probably want a really good access to a methodologist, a statistician, ideally someone that's very good at putting in grant applications. So in the UK, we have trial centers, we have surgical trial centers, and they provide not quite a one stop service, but you get the idea.

If I say that you take your idea to them, they can develop it. And then you use the network across the UK to bring people together. I think if you're sitting thinking you all have to be in the same corridor in the same department, I think that's advantageous, but I don't see why you can't work with anyone across the world.

Now where we are. Your online capabilities, social media, everything else means you can choose your team across the world. If that's what you need. So that gives you flexibility. But I guess it means you probably have to reset your network. Every time you think about different project, I'll add a few things to that.

I mean, I think first you have to have Tom you know, high quality work that's going to compete for grant funding takes Tom and, and you know, as

surgeons that can be difficult in certain environments. And so making sure to have some degree of dedicated time to. Grants to meet with mentors, to meet with collaborators, et cetera, is really necessary.

I will echo the point around mentorship and collaboration. I think historically that has always had to be within the same institution. But I think that has changed. I think the NIH has recognized that it's possible to have meaningful mentoring relationships across institutions because of.

Virtual platforms for meeting. I think it's necessary to have resources and, you know, sort of what resources and how much really depends on the type of science that you're pursuing whether that be, you know, a bench space. Or data or salary support for the various research assistants and statisticians that are required to carry out that type of work.

And then

the last thing I'll say is I think culture is very important. Being in an environment that values the academic mission where people are generous with their time and their feedback. Sharing of ideas, sharing of grants. Sharing of providing, you know, critical. Feedback on proposals and grants I think is, can, can often be sort of a secret sauce that leads to success, so good culture is really important.

Can I add, or ask both of you, basically that the we all understand that the holy grail of research in many ways is, is clinical trials because they reduce bias and systematic reviews of well conducted clinical trials we know is the top of the tier. Thank you. But other studies that we've talked about, multi center studies outcomes based studies, are also extremely useful, especially to get real world data to try to build up to the right question or PICO for a trial.

But trials, we understand, needs ethics. Systematic

reviews, we understand, needs to go through some sort of registry, like Prospero prospectively. But see, some of these multi center studies is there a difference in the ethical approval required to get them off the ground between the U. S. and the U. K.?

I mean, what, what would you have to do if today you wanted to design a multicenter trial or study rather, asking a fairly basic question in an observational manner? You're not changing care. You're just asking, what do we do or what are the outcomes in X? If you wanted a hundred studies, Or 100 centres rather.

What would you have to do in the UK? What would you have to do in the US to get these centres on board and to launch this project? Well, I do UK. Can you feel my pain already? I bet you feel pain talking about that, asking that question, Jared. So in an answer, there is a different, And multitude and ever increasing number of levels that you have to go through, which obviously we do need approvals.

We do need to do the research, right? And we do need to make sure we're answering the right question and all the background that goes to that.

But today, what would you have to do? You would wander to your local research and development office. You would come up with your plan or your research aim, your PICO.

You would then want a methodologist to check that your methodology was correct for what you were asking. You then need the finance department to cost it. And that's, I'm sure this is pretty standard in the U S as well. And then we start approaching the approval. So if your research and development office will sign that off, you can apply.

online for ethics. So ethics is UK based. So someone in England can review my project in Scotland. So that sounds good. And the system is pretty slick. They have to give you an answer within four weeks of submission, but there's a very, very dodgy button on it, where if you change anything on that online application and Jared, I'm assuming you've done this cause you're smiling.

If you change anything, anything, if you see a typo and you change that typo, you go back to zero and have to resubmit the entire thing with all the new signatures. So I'm moaning about one blip, but I'm trying to make it sound not particularly

straightforward. So that's your ethics. Once you've got your ethics, you then need to go for national country approvals.

And because we are, we're friends, but we're slightly devolved. So Scottish approvals nationally are slightly different from England and Wales. So you need to get both sets for UK study. Then once you've got your national approvals, you then have to get local approvals because Glasgow doesn't accept that Scottish approval is just as good.

So we have to bring it all the way down to unit approvals. So that probably takes a little bit of time, but it's not. insurmountable. It's very achievable. You can make it quicker if you're just looking for a data routinely collected data cohort study. There's a separate route that's a little bit quicker called call to court approval.

But yeah, it does a lot of layers and I think I'll finish with stop moaning too much about this, but I'll finish by saying during COVID and I'd be interested to see if Leslie says the same during COVID a lot of these things got very, very quickly streamlined, which has left a lot of us as researchers thinking if they could do that during COVID Could we not do that

normally?

Yeah, I would say our experience was similar. There were certain things that were expedited or streamlined in that in that period, I would say for the most part, many of those have stuck around, thankfully. I think in the U S you know, for an observational study that involves. You know, the analysis of data the ethics approval is pretty straightforward.

Most of that type of work is going to be exempt from ongoing review the biggest scrutiny in the U. S. is going to be around data, data, security and privacy. Especially as any data would meet criteria that would be protected under HIPAA or the Health Insurance Portability and Accountability Act. So those are things that, that data elements that would identify patients.

So most of most of that type of work, a multi institutional project like that's going to require data use agreements and going to be around data security and privacy. Once you sort of meet those criteria, the

ethics approval is generally pretty straightforward. What about data held by private institutions such as insurance companies?

I mean, we have, in the NHS, we have data collectively, routinely collected by the state, essentially, the registries that are prospectively maintained that we can ask for data from. I presume you have the same type of registries, but not held by institutions, but held by private entities. Are they difficult to get ahold of?

Do they have another layer of approval processes? It really varies quite a bit. It depends on the sort of entity. Are there lots of national registries, for example, and cancer, trauma, et cetera. In terms of the ethics for that, those data sets tend to be completely be identified. So then that falls often under non human subjects research because the investigators don't have any access to any identifiable data.

In terms of access to those

data sets. Again, it varies. Some are publicly available. Many require some sort of feed to access that or Some relationship of the investigator with the with the data, for example, the National Cancer Database in order to be eligible to get the data. You have to be a member at a site that submits data to the so there are some certain relationships there.

And again, some of the data does, there is a fee associated with it. Okay. Well, we've clearly identified some challenges with research, including funding and institutional regulation, but another one I think is. Time, you know, it obviously takes a lot of time and effort to conduct quality research, especially when you're trying to be an effective surgeon at the same time.

So how do you both strike a balance between your academic work and your clinical practice? So I'm not sure I have that

balance if I'm absolutely honest. So. I'm not saying that to make it sound like I work hard. I don't mean that. So I get eight hours a week funded by the chief scientist's office in Scotland to do my research.

So I have one day a week. I think it's key to say, and I suspect Leslie feels the same, that you do this because, well, you do it for lots of reasons, but you probably do it because you really like doing research. And I think it's the same for surgery, isn't it? You spend far too many hours learning to be a surgeon, doing a surgery, doing the surgery.

And if you don't fundamentally like it, it's going to be a very long career for you. But I think if you really like research and I think I probably am a little bit of a research geek and I think there's a lot of us out there. I think it's actually really nice to blend it in with your day and it adds other aspects to your day.

So yes, I may do some of this in my own time. I may do some at some weekends, but I almost see it as a little bit of a hobby. Because I just like doing it, and you find other people that just like doing it too, so you have an enthusiastic

network, and that helps make things easier, particularly as you build up your own network, and that streamlines the time that you would spend in certain things that took a lot of time at the beginning.

I don't have a lot of NHS pressures, but, As in, I don't get paid per case or employed per case. I think that's going to be slightly different from what you're going to see in the US. But yeah, the clinical stuff's always there. But as someone once said to me, there's always going to be surgery needed. So you're never going to get to the bottom of it where you turn up one day and someone says, all surgery has been done.

We do not need you anymore. That is not how surgery works. Yeah, I'll add a few things to that. I think for me, and I think the reality in the U. S. in terms of academic practice is that pursuing funded effort or salary support. Is really critical for long term engagement and and research.

Many faculty appointments will have some sort of grace period early as you're pursuing that funding. But I think if the expectation is you're doing research long term, it does require. grant funding and some salary

support. I think the other critical element that helps with balancing time is not just funded effort for my salary, but funded effort for my team, so that I have a team of people who are working on advancing our research portfolio, even when I'm in the operating room or in the clinic.

And so, and that's The really substantial portion of the grant funding goes to, again, funding, you know, analysts, postdoctoral fellows, et cetera, who can move the work forward, even when you're in clinical work. And then I think there are some clinical practice considerations that make it a little bit easier or more difficult to balance.

With you know, research effort for me in surgical oncology, I'm fortunate to have what we would call a very high conversion rate, so it means most of the patients that I see in the clinic have a cancer diagnosis and need surgery. So the number of, sort of, hours I need to spend in the outpatient setting to fill up my OR time is

and then also work in a clinical practice where there are a few emergencies.

So not a, not a lot of you know, night and weekend work, which again, helps to balance that. You know, there are other models, for example, people in trauma and critical care that may do more shift work and they may have a week where they're on service and then a week or two where they can focus on their research and scholarly interests.

So there are certainly different models, but I think the balance of those two things, how much time and support do you have for your, your effort as well as your staff? And then how, what are the characteristics of your clinical practice and how can you make those two things work? And if I could follow that up a little bit, just by saying, if you have a nice busy clinical practice that immediately allows you access to lots of patients to recruit.

So there's, there's a balance there too, as well, isn't there? Absolutely. Well, thank you both for your excellent perspectives. This is. Really been a really

informative discussion for all of the future academic surgeons out there listening to the podcast. And I guess the final question I have for both of you is, do you have any other words of wisdom or tips for trainees or early career surgeons who are hoping to make an impact in the academic surgery world as a big portion of their career?

My biggest piece of advice is to do what you're passionate about, not what you think anyone else what, not what you think expectations are, but what actually brings you passion, particularly, you know, writing grants can be very difficult. Lots of rejections, lots of time to get there. And if it's not something that you're really passionate about doing, it can be a real uphill battle.

But that being said, you know, there's a lot of work that can be done that, you know, doesn't require grant funding that makes an impact on patients. And so I think funding the right volume of work and the

right problems that you want to pursue and that you're passionate about and that want, align well with your clinical practice.

I think those are the secrets to success. Yeah, I completely agree. You've got to be passionate about it, haven't you? You've got to pick the part of research that fits you. And there's not often research that you can do, but surgery allows you the, the strategy to identify something that you find as a challenge, but you can see that you can actually change your patient's clinical care in front of you.

Not always. I wouldn't want to say that, you know, you can cure cancer with your research, but you can certainly change process in front of your patients and see the outcomes and the benefits to them. And I'm not sure there's many jobs That you can see that you can, you can do that. It also opens up other doors for you beyond your, your career.

You get to travel the world, you get to meet different people. I work a lot with bioengineers whose brains I can't even begin to tell you how they function, but they've got some really good ideas, something that I would never come up with. And these are all just about hearing different patients, different people's

perspectives and stories.

And it's always stuff that you can learn from others and yeah, research gives you a whole wide and broad perspective on that. I think. All right. Fantastic. Thank you. So that concludes our deep dive into the world of academic surgery, both in the UK and in the United States. I hope that all the listeners found it as informative and inspiring as, as Jared and I certainly did.

Now that you've heard both sides, you can decide for yourself who does it better, the UK or the U S in terms of academic research and surgery. So thank you, professor Mogan. Thank you, Dr. Dawson, again, for spending the time with us and for sharing all of your experiences and wisdoms. We absolutely appreciate it.

So, stay tuned for more Behind the Knife and ASGBI collaborative content coming soon. And as always, if you have any thoughts, questions, or comments, please feel free to reach out to us at hello at behindthenife. org. Care to send us off, Professor Moeb? Sure. As always, surgeons, dominate the D.