Lecture: Women Leaders in Eye Health Coffee Hour: Simulation Training in Ophthalmology

[Maria] Hi everybody, welcome to our Wednesday. We’re here in Doha, we’ve been broadcasting the entire week. And today we’re going to have the coffee hour that’s also part of the collaboration that Orbis has with Women in Ophthalmology and SEVA. Back in May, we held together a conference and a series of four webinars and the audience told us that they were lacking more engagement and they really craved more of these coffee hours. Now this is our first coffee hour that we are going to have in person. This is very exciting. As you can see I have here a lovely group of women and as usual we’re going to discuss our first topic that’s going to be about simulation. Because here in Doha, like I’ve told you guys the days before, we are doing a simulation week training residents in ophthalmology from the Middle East. And it’s very exciting to have all women mentors too. We’re going to talk about simulation, yes. But we’re also, as usual, going to discuss issues of wellness and healthcare too. Please, I’m going to reintroduce myself. I’m Dr. Maria Montero and I’m the Associate Director for the Flying Eye Hospital. [Amani] Thank you, Dr. Maria. Good afternoon, everyone. My name is Amani Al Bakri, I’m a pediatric ophthalmologist from Saudi Arabia. [Samita] Good afternoon, I’m Dr. Samita Moolani. I practice in Pune, India. I’m an anterior segment surgeon and I am training cataract and phacoemulsification on this program this week. [Samar] Good afternoon, everybody. I’m so delighted to participate in this wonderful collaboration with women in ophthalmology, SEVA, and Orbis. Dr. Samar Shoeir from Egypt. I’m an ophthalmology consultant at the Al Fayoum Ophthalmology Hospital and I’m here to teach manual small incision cataract surgery. [Kimberly] Hi, good afternoon, everyone. I’m Dr. Kim Leighton and I’m the Executive Director of the Itqan Clinical Simulation and Innovation Center here in Doha, Qatar. I’m an ER nurse by background and have been working with simulation about 20 years. [Catherine] Hello, I’m Dr. Catherine Hansen. It’s wonderful to be here with everyone. I am here representing Orbis Canada. I’m the director on the board for Orbis Canada and my training is in obstetrics and gynecology. But my real passion is education and women’s empowerment. [Samita] Today we’re going to start with the current topic that is important to this week in Doha which is training the students that we have coming in from, especially this region, and one of the keystones of this project is simulation. I’m going to ask a few questions to our honorable panelists here and see how they feel. Let’s start with you, Dr. Amani. What is your favorite simulation tool and have you had the opportunity to try out the simulator on the Flying Eye Hospital? [Amani] Thank you, Dr. Samita. When I was in training as a resident, phaco was the most favorite tool to me. But as you know, when you’re involved in training to try wet labs, animal eyes, you get different opportunities. On board I’m training our young ladies on strabismus surgery. We’re using nice artificial eyes that have all five muscles attached to the globe with the different layers. They have the feeling of how to do surgery and I get the chance to teach them how to practice and master the skills of doing strabismus surgery. [Samita] That’s great, thank you. And Dr. Samar, you’re teaching manual small incision cataract surgery. Have you had a chance to try the simulator on board? And how similar do you think the simulation experience onboard that we are using to teach these students is to real life? And how would you compare the two? [Samar] Okay, simulation completely changes from the traditional learn of the wand to a more confident form. Which allows the trainee to train easily, not only surgical stats but only complications are created in some systems. Which definitely allow him to get more experience with surgical skills. Another one I think also is the eye hand coordination of the motor coordination. It gives him confidence to ask different types of questions like why not the more anterior or not more posterior, more temporal, more superior and so on? This definitely these types of questions will turn out enhancing the health surgically and even enhances, he become more confident. It provides a realistic way of learning such skills. [Samita] Right, I think back in the day when we used to learn and we weren’t able to have access to simulators, a lot of our practice was on actual patients. And now that we have the hands on skills on simulations that reduces the potential risks that the patients are technically trained upon have to face. I think it’s a really big asset to training in medical field. Dr. Kim, how do you feel about simulation? You’ve been doing this for 20 years. How do you feel about simulation and how do you think it can be an asset to different branches and fields? [Kim] Thank you. Just a follow up on what you were saying. It’s all about patient safety, right? Simulation gives us this opportunity to replicate reality to some level so that practitioners can literally practice over and over and over again. I’m obviously not an ophthalmology surgeon but what if I need eye surgery someday? That makes me really nervous because we don’t usually question the skills of our surgeons. How many of these surgeries have you done? But I want to know, I will ask because I want to know how many times you train on a task trainer? I want to know how many times you’ve trained using a plastic eyeball and muscles? How many times a synthetic one? A real cadaver one? Virtual reality? I want to make sure that you’ve practiced on something other than me before you come to do my eye surgery. I think that’s the true value of simulation is that potential impact that it has on patient’s safety. And I like to go to museums and if you go to the part of the museums that have old medical stuff, there are always simulators. And some of these simulators are really complex and complete and created 3,000 years ago. That tells me that providing safe patient care has been a goal for thousands of years. Now we’ve got it to the point where we’ve really refined it, especially with virtual reality, because now not only do you get the feedback from the instructor when you’re using the plastic and the, right, the synthetic. But on the virtual reality, you get the feedback from the machine. It can tell you how deep did that needle go? How much pressure was behind that needle? Is it displaced somewhere? It gives us so much feedback. And things like that have supported the growth of research that shows that these methods are effective for reducing complications. I’m a big fan of simulation in case that wasn’t obvious. (all laughing) [Samita] Thank you so much. [Maria] Also remember that it’s very, very important to have a structured curriculum. It’s not about all fun and games, it’s not playing a video game in your home or wherever you’re teaching. It needs to have structure for it to be real and for the students to get the feedback that they need. If you don’t get the feedback about any activity that you do, how can you improve it? You may think that you’re doing it the best and nobody’s telling you that you’re not. Or where to improve, where there’s room for this. It’s always good to have a structured curriculum. [Kim] People can do something incorrectly over and over and over again. That’s why that feedback is so important with this practice. Either feedback from a person or from a machine, otherwise you learn it the wrong way and you’re going to perform it the wrong way. Even as simple as putting on sterile gloves each time. If you don’t do that enough every single time, you run the risk of negative transfer of training, you’re going to take that practice into your clinic or hospital environment. And you’re not going to put the gloves on because you trained not to put the gloves on. [Amani] Thank you, I’ve worked with that. Nice talk. I also believe that residents are given me more confidence when going to a real patient after they do the simulation training. When I was a resident I remember I go to the lab on weekends to practice more so I would not feel guilty practicing on a patient. We’re going to our second favorite topic and I think after the pandemic most of us are aware about how much is wellness is important, how much is the balance between, how it’s important to have a healthy mental and physical well being. And I’m going to start asking my question to my friend, who I got to know during this trip, Dr. Samar. She’s a wife and mother of two, and I’m just curious with this family obligation, how do you manage to balance the work and family? [Samar] Okay. Let’s start with all physicians, I think, all physicians whether male or female, especially frontline surgeons are suffering. And they are more likely to be dissatisfied with what’s called work-life balance. Due to many factors, we are always under stress. They usually, every day, they dealing with patients, they are dealing with pain, we are dealing with visits. That’s why they’re more liable to develop what’s called burning out, exhaustion, sometimes depression. According to any doctor, I think if there are extra responsibilities on them, a child they are providing, or domestic activities, cooking, housekeeping. It’s all. (poor audio) (all laughing) And surprisingly with all this specific observation…(poor audio) [Amani] Thank you, that was great advice. I personally went through a burn out two years ago and it was not easy to know that I had a burn out. It’s difficult sometimes to know that you’re in a problem until you ask someone for help. Is what I’m going through normal? Is it abnormal? What should I do? Since we arrived at Orbis, Dr. Maria is taking care of most of this stuff. She’s almost the leader here on the trip. And I just learned today that you’re a mother of a small baby. I just want to know how do you prioritize your health and wellness in your clinic? [Maria] Thank you, Amani, thank you, Dr. Sumar. I think it’s very, very important and I love to use airplane references, so you have to put your oxygen mask on first in order for you to be able to help another person. Right? It’s very important, and us as women feel confident enough to do that. Sometimes you don’t. I think that is very, very important. For example, take a few minutes of your time each day to meditate or give yourself an hour per week to do something fun, to go with your friends, or do something that you love. Because it’s not all about action and work and mama and all of those things. You just have to remember that it’s you first in order for you to be able to operate and function for others. [Amani] Thank you so much. Our last question is going to the most busy subspeciality in ophthalmology medicine. Interior segment is not an easy one and you do have a lot of stressful cases. And training others on open eye is not an easy task. A question goes to you, how do you manage your stress and anxiety? [Samita] Thank you for that question. I would like to share that I actually was diagnosed with anxiety last year. We constantly dismiss high stress as just stress or a situation where we are under high pressure. But there is such a large difference between just being tensed or stressed in a high pressure situation which is normal for everybody else. Or going into a state of anxiety which is an actual clinical diagnosis. For the first thing, like you said, is you need to identify that you have a problem and you need to be open to getting the help that you need. Because sometimes getting someone to speak to who is professionally trained, especially counselors, can make such a big, dramatic difference in your life. You don’t have to constantly be on some medication or anything else. But for me, for example, my anxiety was creating a non ending vertigo, it was causing palpitations. And when the mental issues or the psychological issues translate into physical manifestations, you really need to stop and think that something has definitely gone wrong and you need to get help for it. That said, later on I realized that I probably had a few clues and signs of these things for years and I ignored them. Because as women we are so used to suppressing our emotion or weakness or not discussing it with people because in a level playing field where we are competing against men or other people in our professional life, we don’t want to appear to be weaker. But we have to embrace everything and use these things as our strengths. Today I find that I’ve come out of the whole experience stronger because I’m so much more self-aware. And self awareness is where the first step is, that there’s something going wrong and I need to get help. And always, like Dr. Maria has already said, you can only fill other people’s cups if you have your own full cup. You have to, as a mother, or as a daughter, or a daughter-in-law, or a provider, or a career-oriented person, you have to prioritize your mental and physical well being before everything else. [Amani] Totally true. Maybe Dr. Catherine, you would like to add? [Catherine] Yeah, I absolutely love this conversation about taking care of ourselves, putting on our oxygen masks, filling our own cup. We can only really give from our own energy stores if we’ve replenished them, for sure. We’re going to shift our conversation to gender and we have all of our attendees are women, our faculty, a lot of us are women. And we are coming from diverse areas and diverse cultures, diverse countries. And yet we’re professional women and sometimes it’s not easy to be a professional woman in the world. And being in medicine, wearing all of those hats, it’s very important for us in this project and in this program to open dialogue about gender issues. First question I’m going to ask Dr. Amani. When you see gender inequity on the podium, on awards, in programs, how do you deal with it, how would you recommend one deal with that obvious level of gender inequity? [Amani] Thank you for raising this point. As you mentioned, we come from diverse cultures, countries from all over the world. I’m sure most of us have passed by an incident that we felt there is some gender inequity. Honestly speaking about myself, as I grow older in age and get more mature, I tend to look at things with patience. I try to look positively but if I’m sure, positive, that there is some kind of gender inequity I would talk. And that’s what I would advise young women. Whenever you feel that there is something you’re not happy with, you’re not comfortable with, you do your best at your job, just talk about it. Don’t keep silent. The world is changing and cultures are changing. And I guess I’m going through a good period of time now. Most of the physicians in my country, at least, are women leaders. Men are starting to complain. But maybe before we had some issues but now things are better. [Catherine] Lovely. Thank you so much for that. And we continue to make progress. We’re all a work in progress. And so I know that bringing women together for circle, for example, which is what I often do, we have absolutely magical conversations. I’d like to ask you, Dr. Samita, why is it important to have women’s organizations or programming specific for women? Why would that be valuable? [Samita] For me, personally, growing up I have been exposed in the world of ophthalmology very young because I am a second generation ophthalmologist. And my dad, my father, is an ophthalmologist. Growing up I have seen and witnessed conferences and have often wondered where the women were. Looking at the leadership positions, of course this is changing, there’s no doubt about it. But I think that we have such a long way to go because the proportion is still extremely skewed. And for someone growing up and wanting to go into this profession, most female medical students or aspiring doctors, for me I yearned for that leader who was a woman who I could relate to. And of course I had a good example in my father, but I still yearned to have that mentorship from someone in a leadership position as a woman. As I went through my studies and my training, I did manage to meet some wonderful women leaders. And I just feel that we have a long way to go and these organizations and I see them doing this, are training women to be in leadership roles and to use our actual strengths that differ a lot from men. And I think Dr. Hansen, you and I have had several conversations over this week about gender equity versus gender equality. There’s no one better than you to talk about it. I would love to throw this question back at you and hear from you about how you feel. [Katherine] Yeah, thank you. Really, really important question is the difference between equality and equity. And what we’re really seeking, I believe, what we’re really yearning for is equity. A lot of us have had to become mini men to succeed in this world, really elevating those traits of drive and ambition and forward-driving energy, and accomplishment, and task-oriented, and sometimes very linear in our thinking. And what we innately, generally as women, bring to our professional lives and all of our lives, if we can bring all of us into our professional lives are what we would consider more feminine traits, they’re more natural. They’re also in men but they’re more natural to us. Nurturing and bringing people together in community and compassion and negotiating resolution, really opening dialogue and caring and nurturing. And all of those things that we really naturally do, and men as well, but we just bring that to the world as some of our greatest strengths. To be able to raise the value on the importance of those characteristics to the same level that we hold dear the drive and accomplishment. Because we can do those things too, but we really want to be in a world or imagine what it would be like to be in a world where we value those traits and characteristics in people as much as we value what we already know to be successful by definition. It’s a wonderful question and we’ve already had some conversations with the attendees about that. Again, a work in progress, we’ll keep that dialogue going. We have another question for Dr. Samar. Knowing that this is an example of a woman only program, what have you personally gained from the Flying Eye Hospital program over this past week? [Samar] A lot. (laughs) First of all it was a great opportunity to meet, discuss and share ideas and insights for future collaboration and for career development. Another point is that I’m so happy to participate and share in raising awareness regarding gender issues and trying to decrease the gender gap in the workplaces and even career progression. Another point, I don’t know if you feel what I feel or not, but being a volunteer is like a gift. I feel like it’s like a gift. Because when you provide affordable and reliable training to those in need it adds a great impact, not only in community, but in yourself. You feel like a part of something which is greater than yourself. And you feel a sense of purpose how that personal ecos turns into community programs and you can see this every day. Also gives me an opportunity to feel like bridging over generation gap. (laughs) It’s a very nice feeling. And usually volunteering is keeping me out of my comfort zone, which is healthy. To get out of this area all the time. [Amani] Honestly when I was called by Dr. Hunter and invited me, I was like, I had some imagination of what kind of young ladies I’m going to meet. But after I met most of them, I’m honestly surprised and every one of them had a story that touched my heart in a way. They’re amazing, they’re amazing, they’re amazing. I’m so proud of you. Yes, I am from this region, by the way, I am from this region. But this trip taught me so a lot about other ladies in other countries, how much do they suffer and how much they want to learn. And you are the future. I’m so proud of you all, I’m so proud of you all. As she mentioned, Dr. Samar, volunteering is an excellent opportunity to meet other people. I’m so happy to be here and I look forward to serve all countries as Dr. Samar in volunteering. Thank you. [Maria] Thank you Dr. Amani. Actually I have a question here for you, Dr. Amani. [Amani] Oh, is there? [Maria] Yeah, what is your? (laughs) And please feel free to ask us any questions that you may have. [Amani] You’re here! [Maria] I still have you for another day! What’s your advice as an eye doctor for parents who let their children spend their whole day on electronic devices? [Amani] Can I skip this question? (all laughing) [Maria] Are there any proven effects on their children’s eyes? [Amani] I don’t know from which region is this question. But from my country, I’m also asked in every clinic how many hours should I let my child sit on the TV. Now, per the American Academy of Pediatrics, not the Pediatric Ophthalmology, there is a certain time. Less than two years, they should not sit on the TV. But honestly after the pandemic and after the distant learning through the computers, I personally feel it’s difficult to control the child’s time on TV, on screens, let’s say screens. But what I advise for mothers who have children older than two years and the child would like to sit, just make your child visit other activities. Take them outside, put them in other outdoor activities. Because our problem mainly is we’re indoors and that’s why where the child has to sit more on the TV. There is some side effects of watching screens, such as dryness, such as a possible increase of myopia. And the recommendation comes from the American Academy of Pediatrics rather than ophthalmology for certain timing on the TV. [Maria] Thanks, Amani. I have another question here. What is the advantage and the disadvantage of the simulation training? [Samita] I personally don’t see any disadvantages of this training in any way. No. But I do see only advantages that we’ve already mentioned. Of course one of the major ones is giving students an opportunity to get a feel of a surgery before they try it on a patient. Which, of course, like Dr. Kim has already said, brings the patient safety up, brings up your results, allows the students to practice at a particular standard. And especially with simulators, irrespective of who you are taught by the standard remains the same. You wouldn’t be learning anything in the wrong way. We, as students, in the early days pre-simulation, we would learn whatever we were taught by our consultants. And sometimes, and I was teaching my incision to some of my students and I showed them the one that I was taught which was wrong. Sometimes there’s transmitted information and techniques that are actually wrong that everybody just assumed was right. Simulation is a great way to eliminate that error as well. But those are the advantages. And of course, confidence. Another conversation that I’ve had with Dr. Hansen today was about women inherently have a lower confidence level which is pre-programmed into us since we are children compared to men. So this program being directed at these young women ophthalmologists will help to enhance your confidence as surgeons tomorrow. [Kim] I thought of a couple disadvantages. It can be expensive. Simulation can be very expensive. Not only the equipment but you need to do simulation in small groups or individually. When you have a trainer one-to-one with a student, or one-to-six in an immersive simulation, that’s expensive training. When you compare that to a model where everybody’s sitting in a classroom and you’re teaching 400 people this same thing at the same time, it is seen as a disadvantage. But I think it’s a necessary disadvantage. And like you said, there is the risk of having you go out and do things wrong if the facilitator isn’t really crystal clear on what they’re doing. And then lastly, there’s something called psychological safety when we do simulation, that we have to create an environment where it’s okay to make mistakes because we all learn more from the mistakes that we make then when we do everything right. Just a fact of life. We have to let you make those mistakes and we have to stop telling you what to do and let you do it and let you experience it. That’s something really hard for us because we want to be helpful. But yeah, I would say those are some random disadvantages. But still, simulation is better. (all laughing) [Amina] No no, that’s okay. [Maria] So Kim. (laughs) Specifically for ophthalmology, there are now papers that simulation costs this much. But a complication on a real patient will cost you this much. They did a study when they compared these costs. The costs of their wet lab simulation and the cost of the year that they had their residents not doing simulation and therefore they show and prove that it was worth it for phacoemulsification. That’s the thing, right? And obviously the cost of having a complication, a patient that you have to follow and be helpful for them for life if you have a complication. That’s another one. (laughs) [Kim] Some malpractice insurance companies in the US will decrease their premiums if the surgeons have practiced on simulation. They don’t have to pay as much for malpractice. I’m American, I live here, but I’m American. One of the things that we like to do a lot in America is sue people for making mistakes. If you can decrease that, that fits back into the money part of it. Lawsuits are expensive from start to payout and it more than justifies the cost of simulation training. [Maria] And I was also going to say that one of the best things about these practices and these eyes is that you can fake complications. You can fake a complication and have our resident and our ophthalmologist solve it by themselves and walk us through the steps that they would do. Maybe even, what if someone bumps into you in the OR? Like, ah, no! (laughs) That’s one of the beauties of it, you can fake a complication because like you said, you learn more from your mistakes. And obviously with our real patient you’re trying not to make mistakes. So when you do have a complication and you’re by yourself, because you’re done with training, that’s the moment when you’re like, oh, no what do I do? You want to have a complication. (laughs) I have another question here. It says, in Arab culture it is preferable to deal with men as an ophthalmologist and they see him as more qualified. While in fact I believe that women as ophthalmologists are especially proficient with their manual skills and patient during the operation. But the opportunities for training are always more for men than women. And they may even limit their women to the operations of the cosmic related to the eyes? [Samita] Cosmetic? [Maria] Uh huh. In your experience, which operations are the most easy for an ophthalmologist to master and what are the most difficult ones? [Amani] Can I comment? Which culture did he say? Arab culture? [Maria] Arab culture. [Amani] Arab culture, yes. I applied for ophthalmology in 2010. And to be honest, I was told that you will not be accepted because they usually take two women and six men. When I applied I was pregnant six months. And I was like all the doors are closed. But when I went into the interview, you know when you have that dream that you want to pursue, I sat in that interview there were 12 doctors and I told them, “I’m passionate, I want ophthalmology.” And that year was the first year they started to increase the number of women getting accepted. That year we became three women, three ladies. And the year after it, nowadays I see them getting accepted almost half. There is some old men, when they visit us in the clinic, I always laugh about it. They think the resident that’s working with me, he’s the consultant. (laughs) And I’m like, “Oh, no, I’m the consultant.” But actually most of them support and they get happy when they see young women practicing ophthalmology. And I do hear nice words in the clinic. However, there are some clients who trust men more than women, which I help that. But with the Arab culture, which procedures do you think it’s more difficult and easy in ophthalmology? (all laughing) [Samita] I think I’m going to get into trouble here. (all laughing) I think that any procedure when learned well can be easier but of course because most ophthalmic students start with cataract, most of the other branches call cataract the easier surgery. We’re going to have some fights here. Stay tuned. But yes, of course, retina and vitreous is way more technical. The prognosis on those surgeries are tougher. And of course we have glaucoma which is also a lower prognosis. Because cataract is something that everybody eventually does develop the numbers that we are able to do. And at the end of the day the more you operate the better you get. I would say that from the easy, I would not call it easy, but from something that is probably we are all exposed to more, cataracts tend to be easier for most ophthalmic surgeons. And the more technical, super specialities such as retina, vitreous, and glaucoma are a little more challenging according to me. What do you think, Dr. Samar? [Samar] Yes, I think glaucoma surgery’s learning curve is easier than cataract, it’s not yes. It’s not more difficult, it’s easier in learning. But the difficulty comes after. In follow-up patients, how to keep the patient in a safe zone, this is a problem in glaucoma surgeries. And I totally agree with you, there’s no simple surgeries and there is no easy surgery, there is no difficult surgery. Depends on how much surgeries you did and how much simulations you attend. That’s what I want to say. [Kim] I don’t get to answer this one. [Catherine] Yeah, I probably shouldn’t either. I’m not going to comment on the surgeries. I love that you said anyone can learn anything with enough practice and mentoring. And all ophthalmology surgeries are technically challenging from what I’ve observed this week. I just want to make a comment that there was a publication in the last couple of years in the US that patients of female surgeons actually have better outcomes and less complications than those of male surgeons. There was a really well done gendered trial on that. And we won’t speculate on reasons but we know that patients can do as well or better in our hands. I think that’s an important takeaway for surgeons. [Amani] For that question about what surgeries are easy or difficult, if it’s a question for someone who’s choosing their subspecialty, I would advise to follow your passion. Try every speciality, try it in a different institute. Some institutes train them better than others and that’s the way you choose your speciality. It’s not based on easy or difficult. Thank you. [Maria] I love that. I also agree with Samita about the prognosis. Cataract surgery, it has very good results, it’s the most reproducible surgery there is available out there. But also the outcome, the patient can almost immediately see and you change their lives. Where in retina, you really need to learn how to tell the patient the prognosis. And make sure that they get it or otherwise there will be a lot of issues surrounding this. I have another question here. How do you deal with salary negotiation especially when it comes to promotions in the workplace? [Amani] Honestly talking about where I work, there’s no salary difference between men and women. Yeah, we all get the same. We do get 60 days maternity leave and that’s also a bonus. But there’s no difference in sex, regarding the payment. [Samita] I agree. In most places in India as well, it’s more about your speciality and your years of experience rather than any gender disparity. You would deal with your negotiation of salary based purely on your experience and your subspeciality rather than any other way. There’s no special way. If you feel that you have the experience and other people with the same level of experience are getting more, then you need to have that conversation with your HR and with your management. But I don’t think, personally, that I have witnessed any difference in the medical field because we are all treating the same diseases. [Catherine] Not ophthalmology specific, but in the US, in North America actually, good studies showing surgeons were making less, sorry, female surgeons were making less than male surgeons. And that was also within the last couple of years. I think related to the trial I just mentioned, some good gendered work coming out. And it was attributed to women spending more time with their patients and potentially booking surgeries with more time or further apart, maybe having less OR time as well. And I think the question was about salary negotiations and I think that that really needs to be related to quality and provision of care as opposed to numbers. I would also come back to what Dr. Samita was saying around our discussion on the confidence gap. We know that as women we can sometimes have to feel like we really, really know something before we can advocate on our own behalf versus we see a lot of times men will have more confidence even if they don’t necessarily know the answers, and that’s a true fact. And so I think that just knowing that that’s a true fact, having that awareness. When you’re negotiating on your own behalf to be really understanding that I might not feel really secure about this negotiation but I am worthy of what I’m asking for and go in with that level of confidence that will get you what you deserve. [Maria] We’re going to share our emails so that you can be in touch with us. If you have any questions, again, about anything in ophthalmology but also about gender and wellness, please feel free to contact us. And we’re here for you. Thank you for joining us again, live from Doha. And of course, thank you to all my beautiful, strong powered panelists. Thank you!