E115 Wesley Francis, Don Major, and Greg Padmore on the Carribean Surgical Program
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Chad Ball 00:12
Welcome to the Cold Steel podcast hosted by Ameer Farooq and myself, Chad Ball. We consider it an absolute privilege to bring you guests from around the world who are truly experts in their craft. Our mission is to offer you a combination of not only master classes on clinical surgery topics, but also insights into achieving personal growth, productivity, and fulfillment as a surgeon, and perhaps more importantly, as a human. We're absolutely thrilled to have a very special edition of the Cold Steel podcast today. We're actually joined by three surgeons, Greg Padmore, Don Major and Wesley Francis from the Caribbean. I was hoping maybe at the beginning, for those folks across Canada and surgeons across Canada, listeners, who may not know you super well, at this point, if you could tell us which island you're from, how you grew up, and then really what your training pathway has been to date. Maybe Greg, we could start with you.
Greg Padmore 01:18
Alright, thanks. Good afternoon, everyone. Thanks for having us, Chad. Really appreciate it. So my name is Greg Padmore. I'm from Barbados. In terms of my training pathway, I would have started my training in terms of medical school at the University of The West Indies. So, in the Caribbean, we have different campuses. So for me, I did my first three years of medical school at the Mona campus in Jamaica. And then I finished my final two years back home in Barbados, which were the clinical years. So I graduated - that would have been in 2011. And subsequently during that time, pretty much from my third year is where my love for surgery definitely grew. So for the internship year, which would be a year where we - throughout the Caribbean - we do one year where we rotate through the major specialties, so three months in internal medicine, three months in surgery, three months O & G, and three months in pediatrics. And then once you complete that internship year, you are licensed to practise medicine. From there afterwards, I would have moved into general surgery right after internship. And then I got into the postgraduate program, at the same University of The West Indies, but this would be the Cave Hill campus, which is in Barbados. And I graduated from my general surgery in December 2018. And along that way, my love for hepatobiliary and surgical oncology grew. So I would have sought through Dr. Francis's advice in Bahamas, because even though we're in many different islands the communities is pretty small in terms of the surgical community. So through my fourth year of residency, which is what we call the elective year, I spent some time - two months in Trinidad, a month with Dr. Francis in Bahamas, and with Don, and then from there, I did three months at the University of Calgary with Chad and the surgical oncology team. And through that relationship, then we kind of helped me foster my plans for fellowships. So after graduating, I was able to match for HPB fellowship, currently finishing that up now to do one more year of surgical oncology here in Calgary. So that's kind of the background for me, Chad, if that answers all the different questions.
Chad Ball 04:18
Yeah, that's great. Greg, what about for you Don, what was your pathway?
Don Major 04:24
Well, again, thanks for having us Chad. My name is Dr. Major - Don Major, and my pathway started similar to Greg's. We both went to The University of West Indies, but my own started off in Jamaica. And after Jamaica, I spent a few years in Trinidad, where I did my undergrad, preclinical years. And once that was completed, I came back to Nassau and I did my two years of clinical training, and at the end of that, that was in 2009, I became a medical physician. And then from now on, I did a year of internship where I rotated through everything. And that's where I decided that surgery is the only area in which I feel we actually help people. The majority of other areas, is more or less giving them medications and hoping that they take the medications. And after my internship, I started in the general surgery residency program at The University of West Indies in the Bahamas, where there was a five-year program. And in my fourth or fifth year, is when I actually rotated to Calgary for a bit for a couple of electives in both surgical oncology and in hepatobiliary. And again, like Greg said, it was Dr. Francis, who kinda put me on to this because I spent quite a bit of time operating with him with respect to my general surgery training. And he would always ask, "What do you want to do all day?" "Do you want to do a bunch of hernias and gallbladders or do you want to do these complex operations?" I always loved the complex procedures. So that is how I kind of ended up in Calgary. I completed my general surgery residency in 2017 in December - actually December 2015. It was 2017 when I actually started my fellowship, there in Calgary in both surgical oncology and hepatobiliary. And I completed that in 2019. Presently, I'm practising at both hospitals here in the Bahamas, on the main island of Nassau, and doing both surgical oncology and HPB. So that's a little about how I kind of got here.
Chad Ball 06:42
That's perfect, Don. So Wes, you're the senior most individual on the call from the Caribbean. What was your pathway like?
Wesley Francis 06:51
Well, my pathway, again, was similar. I went to medical school, and Jamaica, the Mona campus. I spent all five years there. And then came home to Nassau and did the same rotating internship. After internship, I then enrolled into the surgery department; I worked for about a year and a half. And then I matched into a program in the US, which is in Detroit, Wayne State University, Detroit Medical Center. I spent actually six years in residency there. The first year was a preliminary year and then they took me on as categorical. And I finished that in 2007. And then, you know, I was on the circuit, the interview circuit for surgical oncology and I actually matched in Calgary. And the rest is history. I spent two years in Calgary doing HPB and surg onc. And I came home in 2009. And I've been home, just practising basically HPB and surg onc since then. And so that's been my path.
Chad Ball 07:44
You know, I'm curious, Wes. As a guy who has worked extensively in really three countries, you know, the Bahamas, and really the Caribbean in general, so more than three countries, the US and Canada, how would you compare and contrast our ability to deliver surgical care and sort of the surgical culture across those different sites?
Wesley Francis 08:34
You know, that's a great question. So, I guess I could start in the US. You know, during my residency, it was really sort of a hardcore culture. Surgical residency, I mean, the training was tough, I would say, getting up four or five o'clock in the morning to be the and, I mean, I served in different hospitals. One was sort of, you know, a hospital where indigent care was, and then there was the other hospitals with people with more insurance were taken care of. And I mean, we still delivered the same level of care, but the resources were very different. And the US culture was really a demanding culture. And, you know, [inaudible], you got to get this done; you got to move. And I found a distinct contrast as to when I went to Canada. It was very different for me and I don't know if it was just being a fellow at that level. But when I got to Canada, to me it was more civil. I enjoyed more, not free time, but more leisure time. And it was then that I really began to enjoy surgery and it was not so labour intensive. And we started to take care of people from all walks of life, it wasn't just the people who could afford the care. I didn't really see a whole lot of indigent, or the disparity in Canada that I saw in the US with respect to those who had insurance from those who didn't, because in Canada, the health care system is very different. I mean, we took care of everybody. One of the patients that really impacted my time, really in Canada, was I remember, we did this big HIPEC operation on a homeless lady. And, the biggest part of the whole experience of the procedure was actually trying to get her home, because she didn't have a home to go to, but yet she was able to access medical care and get this huge operation, which I knew if I was in the US, that probably would not happen. So that was the big difference. And on the whole, I thought the Canadians were culturally more easy to get along with. I mean, I had a really great time. And so, when you come back home now, in the Bahamas, you start to see more of that disparity of care, because our health care system is the same way, I think basically, imitates the US - those who have insurance and then those who don't. And so you sort of disparity of care; it wasn't that universal health care. So we practise in the public sector, which is resource challenged. And then you go into the private sector, where you literally had everything that you needed to take care of those who could access that level of care. So really, the socialized medicine in Canada, or universal health care, really, that showed how I think medicine should be, you know, health care for all, and everybody should be able to access the same level of care. And that's what I saw in Canada. And I think that impacted me a lot.
Chad Ball 12:39
That's fascinating. Don, I'm curious if we come back over to you, as you pointed out, you have trained in a number of countries as well. And I believe you were just over in Europe doing some additional training after your HPB fellowship as well, and certainly correct me if I'm wrong. I'm curious if you have any thoughts about the transition as a trainee, there are certainly, as Wes has pointed out many, many similarities between countries and cultures, but certainly some big differences. I'm curious what some of the things that were really highlights for you in coming over for fellowship training, as well as maybe some challenges.
Don Major 13:21
I mean, one of the main challenges that I had in transitioning from the Bahamas to Canada wasn't necessarily the training itself, because a lot of it was more or less dealing with immigration and trying to get my work visa and those things sorted out. I had a great challenge with that. That took much longer than I expected and caused some delays with respect to starting my fellowship training. So my advice for anybody that's, you know, coming from the Caribbean, and maybe listening to this podcast and wanting to go to Canada, and they get a spot that you try and get on an application relatively early or as soon as you get acceptance that you try and get on that application. The other challenge that I kind of found was that again, coming from the Bahamas, most operations usually start at around 8:00/8:30, sometimes a bit later. And most days, you get to work probably 7:00/7:30. But coming to a patobiliary program, having to be to work for 5:00 am, religiously every morning, was kind of a kick to the system with respect to making sure that you prioritize your evenings from the day before so you can always be ready and prepared to kind of get up in the morning and get going. And then the other thing that I found is a challenge again, coming from the Caribbean, not being ever exposed to snow before and coming to Canada and experiencing -10, -15, -30-degree weather and having to work through that; it was a bit was an eye opener. But after a few months, I was able to kind of get used to it, I was able to prepare myself with respect to the appropriate clothing, etc. And it actually all worked out in the end. And the final thing I would say is that what I really enjoyed about the Canadian experience was that, you know, everybody was friendly. And everybody, you can just approach them at any point in time, and you can have a conversation with them. And there's no real envy or jealousy, or anyone just being negative towards you. And I did get quite a bit of operative experience. And that's one thing I can say that I truly appreciated as well about the Canadian experience. Coming from the Bahamas, our cases were rather limited. But once I got there in Calgary, that's when it really opened up my eyes to the extent of cases that can be done. And the amount of cases that can actually get done in a particular operative time.
Chad Ball 16:10
I want all of our listeners to know that I think you acclimatized to the cold and winter quite well, because the picture of you barbecuing in your backyard with shorts at -30 has done the global tour for sure. Yeah, it was great. You know, Greg, you had an almost unique experience. And I think it might be, at least in my working life, a singularly unique experience having to deal with COVID. You know, I remember when you got here, and maybe the only benefit of COVID to your entire time here has been the discount - the COVID-related health care worker discount, that you were able to buy some of the winter clothes that Don speaks about. But beyond that, I was wondering if you had any comments on some of the advice that Don has given our listeners as well as some of the individual and unique struggles you've had with COVID potentially, or challenges even that you've dealt with.
Greg Padmore 17:17
Yeah, thanks. Nice question, Chad. Thanks a lot. What I would say is, first of all, I would just kind of second everything, Wes and Don said about how welcoming the Canadian structure is and the staff because, as my colleagues know, in the Caribbean, it can be different in terms of the support, and not just support by just being present, but sometimes the genuineness behind persons and how they support you, as a young surgeon. It's hard to kind of sometimes get it in the Caribbean, like across the board. I mean, you do have mentors, around. But I can say when I came here, generally everyone was very welcoming, everyone looks to try to optimize the experience for you. In terms of COVID, it was indeed a challenge for me; the main thing I would say - one thing that stood out was, you know, being here alone, not having my wife here with me. And again, it was mainly because of the COVID situation and the travel restrictions, which are still in place in terms with the Canadian border. So, I mean, it has its pros, and it has its cons for sure. You know, you're here for this period of time; I was able to put down my head, focus on the HPB. And just push and push, and as Don would say the operative experience is amazing. So you get to operate a whole heap more compared to the Caribbean in terms of the volume. The amount of cases that you see here is well surpassed what we would see at home. So from a operative point of view and academics as well, I find the Canadian experience was very good. And COVID for sure has it challenges, but for HPB for sure, it didn't really affect the operative exposure because of the cases we do. For sure some other fellowship programs took a little hit based on being restricted by the government. But for sure, yes, things were worse. Its challenge is more from a social aspect of things, being here alone, but again, you know, everything is for a time and I found the experience is still quite good, despite the challenges COVID had brought to us.
Chad Ball 20:18
Wes, I'd like to come back to you. You know, you three gents are special guys not only in terms of your personality and your operative talent and the clinical work that you do, and I would add to that the stuff that we all learned from you guys individually up here - this was a bidirectional relationship and one we're very proud of in Canada. Having said that, though, I'm curious if I push you a little bit on the harder side and ask you: What are some of the gaps in surgical care that you see? It may be in the Caribbean as a whole, but certainly in the Bahamas. And I'm curious too if you're able to flip that question around a little bit. And maybe talk about if there's things - and I would imagine that there are many - that are maybe better in the Caribbean, that you guys do in a much more impactful or helpful way than we do in Canada and something we can learn from?
Wesley Francis 21:20
Well the one thing I would say, Chad, that I thought that there was a gap. And again, I think it's in itself, a function of the health care system, the universal health care - that that system there. I remember when I was on the service, there were quite a few people who presented in a delayed fashion even after being worked up. Having gone through the primary care, getting the imaging, and seeing them in clinic and they're on a waitlist. And by the time we saw them, I think we found that a number of them - that their disease are advanced. And so I think that was one of the things that I noticed I didn't see that much in the US when I was there. And certainly, that's something that you know, in the Bahamas, people, when they access the system, they can probably move through the system much, much quicker. That's the only thing that I saw in Canada, that was a challenge. But I mean, that's the challenge, but I understand that that's the health care system there, and especially in a referral centre, where you're basically dealing with the entire region. So there is a weight. And I remember personally when I was in Canada and my wife was pregnant, was having our last child there. And it was so hard to find a gynecologist to access to get into the system, even though I worked in the hospital, it was hard. And it wasn't until much later, I think in the second trimester, and not for lack of trying, but that we actually finally got hooked up with a gynecologist and got in the system and got the care that we needed. And so I think that that, while I think the delivery is great, accessing, to me, was where I felt like there was a gap in the Canadian health care system.
Chad Ball 23:41
That's well said. And I think, you know, that still exists today. And I think we've closed some of those issues or improved on them in some areas, but you know, other areas of surgical care in particular need to continue to improve for sure. What about in the area of the Bahamas, Don? I'm curious for our Canadian listeners maybe who haven't experienced the health care system in the Caribbean in general, what are some of the gaps that that you see? And I'm curious how you guys as a threesome on a couple of different islands, obviously, plug into that and try and address that and improve that.
Don Major 24:22
Okay, well, just back to the Bahamas. If you know a bit about our health care system, it's more of a two-tier system where we have public system as well as a private system. And the majority of the gaps that we tend to see are with respect to the public health care system. As in, you know, the majority - I would say probably about 60% to 70% of our patients that come to the public health care system don't have insurance, and it's considered the major hospital there in the Bahamas. And of these individuals, they tend to have some gaps with respect to diagnosis and treatment. And what we notice with to respect to hepatobiliary and surgical oncology is that we tend to get them rather late. Because our subset of people in the Caribbean, they're kind of afraid of doctors. So they tend to stay at home, and wait and wait. And they pray. And they put this medicine that they got out of the bushes on it, and hope that whatever their problem is, goes away. And usually, by the time you see them, they've gotten some biopsy or some imaging, it's kind of late in their course, and there's not really much that we can do for them. So that is one of the challenges that we experienced quite a bit within the health care system in general, in respect to the Caribbean. Now, I know that we do have some connections with different islands with respect to the Caribbean to try and close some other gaps. As in, I remember Dr. Francis going down probably a few years ago to assist with a HIPEC procedure there in Jamaica. And sometimes their patients from Tobago and Barbados would come down to the Bahamas to get these complex procedures done. So that is one other way in which we're trying to close some of the gaps. But that cultural gap or that cultural issue that we have with respect to, you know, wanting to get medical care early on in the disease process, or even just going to a family physician to check out what's happening with you is something that we really have to try and get over in order to get these patients in earlier in order to be able to help them.
Chad Ball 26:53
Well said. Greg, I'm curious, is there anything that's special or unique in that regard to the Barbados and what are some of the Barbados-specific issues that you might have?
Greg Padmore 27:05
From a Barbados point of view, I think it is kind of similar in terms of the health care structure like Bahamas as well, where we have similar public and private care available. Of course, as similarly with COVID, and I'm pretty sure is all the way around the Caribbean as well, the budget for the health care in terms of public care is definitely cut a lot. So the issue always boils down to the resources available in the public system. And Barbados is also unique in that there's only one tertiary care hospital available. So patients, similarly, it's not a mandatory thing to have insurance. So if you can afford it, definitely in the private sector, you will get timely care, pretty much as gold standard care, but publicly, we are always limited to, as Dr. Francis would have said, to the resources available to the public patients. But I think what one of the gaps are where we have started to improve in the Caribbean is first of all, trying to get the expertise in these different subspecialties available. And I think definitely through the Caribbean, the Caribbean HPB Association, we're trying to create this network of surgeons, HPB surgeons, surgical oncologists, where we potentially will be able to discuss cases. You know, we taken away kind of checking that box of having expert care available, because before and probably still going on is persons who pretty much can would say they can do this procedure, and they're doing it, but of course the outcomes are not as optimal we would be expecting. So I think one of the steps that we're making progress in in the Caribbean is improving on the expertise in this subspecialty. And I think once we can say for sure we have established expertise in Bahamas, in Barbados, Trinidad, Jamaica, then we can try to start making further progress in terms of improving the care. But the challenge in the Caribbean is that each island is individual in terms of their health care systems. So it still boils back down to the resources and improving the public aspect of things. But I think it is possible; it is doable, and I think we're moving - starting to move in the right direction in terms of having the expertise available.
Chad Ball 29:54
I'm curious, Wes, in the era of COVID with all the changes that have come into surgical care, and particularly what comes to my mind in this regard is Zoom-based or telehealth-based education, telehealth-based consultations with patients. I'm curious, to Greg's point, do you see the uptake and the potential of maybe multi-island consultation and surgeon collaboration being greater and brighter going forward because of COVID? Or is it sort of independent of the cultural ability to absorb that kind of change?
Wesley Francis 30:45
No, you know, I think that that's the single benefit of COVID. I mean, COVID forced us to use a digital platform to communicate. And in doing so, it brought us together, you know, COVID, we were all faced with lockdowns and separation and patients not being able to access care and all of that. But what it did do - it brought the whole surgical community together. In fact, the Caribbean College of Surgeons, we could not do our annual meeting where we would travel from different territories within the region. But we did it, we had a monthly Zoom-based meeting, where we had residents and attendings alike presenting their academic, the product of their work, and it happened every month. Usually, we did this only on an annual basis, but we were doing it every month. And it really brought more collaboration. And so I see this going forward, and also from an education perspective. The University of West Indies, the way they examine the residents was that once or twice a year, we would all come from different territories, we'd meet in Jamaica, meet in Barbados, meet in Trinidad. But we couldn't do that because of COVID, but we all had to do it using this Zoom and digital platform. So we were able to execute the exams and still examine our students that way. And again, it's a little impersonal, but you saw how far it took us; we were still able to accomplish the academic and educational goals using the same platform. And even in the preparation for the exams, you had students in Jamaica, students in Bahamas, and in Trinidad, all in one review session. So COVID has brought us together. And personal experience, I mean, I saw a patient in Barbados, who needed HIPEC. And before that would be an issue. But I was able to communicate with her via Zoom; we would never have thought about that before if COVID was not around. So it is positive and it had a positive impact on education and on actually meeting with patients. So I think overall, it was good.
Chad Ball 33:47
Yeah, it's interesting to think about because I think we've seen that across many different scenarios. And when I think of the impact of the pandemic, in regard to this topic and Canada, it's a bit of a different challenge, right? We have these vast distances and populations that are hours and hours and hours away from tertiary care centres, for example, that provide the high-end specialty care that you guys are doing in the Caribbean. So it's almost more of a distance problem, potentially, at least in a linear sense. But really, the core issues are the same. And I would argue, in Canada, I would agree that really the cultural change attached to it is maybe the most significant thing, whether you're talking about clinical care or education, as you point out. Don, I'm curious, in putting this whole conversation together, what does it mean to leave the Caribbean and go and do a fellowship in some surgical subspecialty abroad, whether that's Europe or America or Canada, wherever that is? In other words, when you come back to the Caribbean, what does it get you? How does it help? And how do you - assuming it's positive - continue that lineage going forward?
Don Major 35:13
Yeah, great question. So what it gets you, when you've actually completed your fellowship, wherever it may be, like you said, in the public sector it gets you a consultant post. So usually before we would finish our general surgery residency, you'd become a senior registrar, which is just beneath consultant. And then once you've gone off and done a fellowship somewhere, regardless of the area, then you're eligible to become a consultant. And a consultant is just a staff physician on attending in the public sector. With respect to the private sector, once you've completed your general surgery training, then you can go ahead and once you get your licence and you're up to date with your CME credits, and you can go ahead and start practising in your private sector. Now, with respect to what it does for you, one of the things, too, I realize is that it's really a confidence booster as well. Because yes, you may have done your five years of general surgery training, you've done quite a bit of operating in the Caribbean, but once you've gotten the volume, and you've gotten comfortable with doing these cases for a period of one to two years, then you come back, and you start doing these cases, you get a lot more confidence with it. And I can say that because just when I finished my general surgery training, I practiced at home for about a year prior to doing my fellowship. And I could have seen the difference in myself when I was just fresh out of general surgery residency compared to when I actually completed my fellowship. So I would recommend for anyone doing general surgery in the Caribbean, to try and get themselves a fellowship with respect to Canada, the US. And one of the ways in which they can get there is having a mentor that has done it already, has been through it already and can show you the way with respect to, "okay, maybe you can go here for a possible elective and see how you like it, or this is an area in which you like, and probably we can try here to get you into an elective." And once you get into an elective, and you give it your best and show the guys what you're capable of, then you can talk about getting a possible interview or even working with the guys closer with respect to trying to get a spot at some point. But yeah, it does boost your confidence; it does give you a spot with respect to a consultant post. And it's pretty effective.
Chad Ball 38:02
Yeah, that's well said, Don. You know, I'm curious to come back to you, Wes. If I go back a few months, Greg was kind enough to invite me to watch, via Zoom, one of the Caribbean surgical annual meetings. And, I shouldn't be surprised, and I wouldn't say maybe even surprised is the right word, but I was really impressed with the quality and the training and just the whole two-day meeting and in general, it was such a pleasure to watch it. You know, you've had some interesting experiences outside of the Caribbean as well. And outside of training, obviously, the one that comes to mind is your trip to Honduras. I'm curious, how common is that sort of endeavor amongst Caribbean surgeons, and how did you sort of frame your surgical experience in Caribbean HPB Association as a volunteer and how did it impact your practice or the way you look at things?
Wesley Francis 39:05
That experience was great, because Honduras, again resource challenge, but Honduras did not have the capacity in terms of expertise of surg onc or hepatobiliary and we were able to go there and do that. And I think the greatest experience from Honduras is the ultimate outcome of Honduras, even though we went and we operated and we did some cool cases. I'm sure the patients benefited from what we brought there. But ultimately, we were able to get someone from Honduras trained, and then he then went back to Honduras and is now functioning there. At that same level, he brought the expertise. So it was more of a capacity building. And, you know, I want to say this and I say it with a lot of graciousness, because, you know, Chad, you guys from Calgary and also from Toronto, are responsible for HPB in the entire Caribbean. And not only HPB, but some other extensive or subspecialty training like laparoscopy of the upper GI. And it's because the capacity got built. It may have started with me in Calgary, but then now you have two other guys who are trained, they were taking that down and then coming back to the Caribbean. And so now the Caribbean has those expertise, just as now Honduras has. So it's the relationship that we develop and the capacity building. And so in years to come, I think if we continue on with that, you will see now that the whole region, whether it's Latin America, and also the Caribbean, would have the subspecialty expertise because of this relationship. And I mean, this podcast is really because of that relationship that we have with you also. But I think it's capacity building with the Canadian community for Honduras - a Latin American country, and also for the Caribbean. I thought that that was the greatest success, I think from all of this.
Chad Ball 41:49
That's kind of you to say and I certainly can tell you not only through our guests on the podcast, but just knowing so many great surgeons across this country that the idea of global surgery, which I use with a bit of hesitation, right? Because global always means everywhere where you don't live and can sound a bit patriarchal, and I don't want it to. But the interest of Canadian surgeons in global surgery really at all levels, whether that's resource plenty, or whether that's resource challenged, I think run runs deep. Culturally, and I don't know exactly why that is, but I think we should all be proud of that as Canadians and we're certainly proud of you guys. I mean, to all your accomplishments, you guys are great human beings individually and collectively as well. Greg, I'd love to end with you if that's okay and ask you, specifically, what your plans are and as the sort of newest young gun coming out of training here very soon: How do you see collaboration with guys like Wes and guys like Don, maybe, specifically and other physicians and surgeons in the Caribbean community in general?
Greg Padmore 43:14
Thanks for the question, Chad. In terms of the collaboration, well, what I see is that islands for example, like for me at home, there's no other HPB or surgical oncology. So, I will be the first, but as you know, Chad, with these cases, the complexity can get quite high. So, for example, if I have like a pretty complex hilar case, for example, there is the potential to, for example, call on Don, a wise leader, to help with the assisting with that case. Because you know you have a colleague in a nearby island who may be able to help and most of the time everyone is in a small community. And I think that is the importance of the strengths of the Caribbean. Yes, there are many islands; the travel between islands is not difficult. And I think that this whole collaboration and improving on the subspecialty care would be the strongest. But overall, I'm happy and I'm very proud to be involved in the development of HPB and surgical oncology in the Caribbean, and I definitely saw and really appreciated what persons like Wes, Don and yourself and Calgary, Chad, did for me. And for sure it's not going to stop here but also will help to continue that lineage and help continue to encourage younger surgeons. As Don said, to seek fellowship training, because with the fellowship training, this is where for sure the competency and the confidence is definitely built. And I do see the benefits of it from my personal experience for sure. So I surely will be looking to continue that along. And definitely think it is gonna be positive for the Caribbean going forward.
Ameer Farooq 45:34
You've been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you've liked what you've been listening to, please leave us a review on iTunes. We'd love to hear your thoughts, comments or feedback. Send us an email at [email protected] or tweet at us @CanJSurg. Thanks again.