 Welcome to this Cleaner Recession. I'm Anna Staudel, a family doctor and university teacher in Oslo, Norway. I wonka euro pass president and newly inaugurated president of Wonka World. And this is one of my duties on my first day as president. What a privilege. Selection and training of future family doctors. It couldn't have been better. I will be the moderator of this Cleaner Recession with two speakers representing the younger family doctors among us. They have both been active in the young doctor movements over the last decade. They will give one presentation each and we hope that you, the audience, will engage in the discussion they provoke with questions, reflections and your own experience. The title of this session is Selection and training of future family doctors. A fundamental topic. Let's start. And Nagwa, you are the first one out. Nagwa is assistant professor of family medicine. Currently Wonka EMR East Mediterranean region honorary secretary and previously founder of Alarasi young doctor movement. We are looking forward to your presentation. After your presentation, we will hear Anna known as Parata. She's a family doctor in Portugal, and she has served two terms as a young doctor representative on the Wonka World executive. I wish you good luck with your presentations and I'm looking forward to the discussion. So off you go, Nagwa. Let's play your presentation. It's a pleasure to be with you in this Cleaner Recession. We are thankful for the host organizing committee for choosing such an important topic. And I'm glad to be with you with Anna. Together, we hope the future selection and training of future family doctor. I am Nagwansh Apegezi from Pages. First of all, you would like to ask why it's important to establish selection and training for future family doctors. And in order to answer that question, we need to dig deep slightly. We need to understand the health systems. Health systems simply according to the WHO report in 2000 simply had emphasized it's all the institutions, people and actions whose primary purpose is to improve health. So the main objectives of these health systems is simply to improve the people's health and wellbeing to respond to the people's expectation to provide protection against the costs of health. So health systems are very important to achieve their targets. So in order to achieve their objective and their target, we need simply to strengthen the health system. Why we need to strengthen these health systems? Because once we are going to do that, all people and communities will receive a quality of health services they need without any financial problem. So SDG3, which is health for all that's going to be achieved. Once it's going to be achieved, all the other SDGs are subsequently going to be achieved because there is going to be no poverty, the quality of education is going to be assured. There is going to be a gender equality, inclusive societies and a quotable health outcome and wellbeing, global public health security, resilient societies, plus inclusive economic growth and decent jobs. So what do we need to strengthen the health systems? We simply need adequate, well qualified health human resources. The adequate, well qualified human health resources also need a presence of an evidence-based retention strategy. It's crucial core for any health system to have adequate number. So we need adequate number that is also well trained and having a good experience because it is the central point for delivery of the patient-centered health care. And this is going to be across the continuum of health care. In the human health literature, in the human health resources literature, it occurred that there is a crucial and critical shortage of the health worker in many countries around the globe. This was specifically documented among physicians and nurses. And we can find that in the WHO statistics and this map, that simply resembles the density of the physicians in the yellow color, nurses in the gray color, dentists in the orange and pharmacists in the blue. This is 2019 statistics that is talking about the density of the health workforce, the 10,000 population. We are going to notice that there is unequal distribution of the physicians besides unequal presence of different health providers. We are going to find that the most of the physicians are in Europe, followed by America, then West Pacific, followed by East Mediterranean, Southeast Africa is the least one. And looking for to the nurses, you're going to find that the maximum number is in America, followed by Europe with a shortage of the number in other places that doesn't suit the density of the physicians. Now, looking much more close into the medical doctors who are 10,000 population, we are going to find that the light color resembles the lower density and the deep color, the deeper the color, the higher the density is. So this is the medical doctors bear 10,000 population, according to the WHO, and looking further close into the generalist practitioner number, according to the WHO 2019. We are going to find that the numbers, some places there's no data regarding that, and also the lighter the color, the lower the number, and the deeper the color, the highest the number. The sustainability of any primary health care services had been challenged by the global shortage of the human health resources, which is exacerbated in the developing countries, as we see in this map. Looking into the stock of healthcare workers in 2013, and what we would like to achieve in 2030, we are going to find that there is much lower numbers and a lot of required physicians and doctors by 2030 to achieve the universal health coverage. So what is the solution for the health system? Alma Ata declaration, which officially launched in 1978 was launching the primary health care service, because the declaration of Alma Ata was called health for all, and it was supposed to be attained by the 2000s. All required making primary health care the cornerstone for the health care systems, which is very important to achieve health for all. Primary health care remained a high priority on the international agenda, where it was the theme of the WHO efforts in 2008, now more than ever. This renewed the commitment toward the primary health care from the universal belief that it is the most effective and efficient approach to maintain the population health and to prevent the disease progression. Despite all of these advantages and progression, there has been uneven and health care become more inequitable. Some of that could be the concrete form of the Millennium Development Goal that had changed it later into the Sustainable Development Goal, and in emphasis and importance of primary health care had occurred again with more structured interest into the practice in the Asitana Declaration in 2018, where we are convinced that strength in the primary health care is the most inclusive, effective and efficient approach to enhance people's physical and mental health as well as social well-being. And the primary health care is the cornerstone of sustainable health system for universal health coverage and health related sustainable development goal. That was the Asitana Declaration that simply and anonymously endorsed by the WHO member states makes pledges in four key areas to make bold political choices for health across all the sectors to build sustainable primary health care to empower individuals and communities and to align stakeholders support to national policies, strategies and plan. So we have health systems, we have primary health care that is the key for the universal health coverage, and we have to empower the individuals and the communities. So we have health proficient training. In 19 and 2016, the WHO assembly adopted the global strategy on the human resources for health. It simply emphasized the necessity for increasing the investment to build a sustainable skill mix of health workforce to respond to the population needs. This commission also emphasized on the relationship of health and proficient education program to the development of a well-prepared workforce to address the needs of the patient population. So training of the health workforce of the family physician is crucial and important in order to achieve the required goals of the universal health coverage. Universal health coverage cannot be achieved without a well trained, motivated and supported family physicians. And this simply was done in the regional committee for the East Mediterranean 63rd session, which is the RC 63 that was held in September 2016. It was simply talking about scaling up family practice, progressing toward the health coverage. This is was a report, which was talking about scaling the family practice and the importance of having different bridging program to decrease the gap and have more qualified family physicians and health workforce. It was also emphasizing about the importance of the family physicians and the density of the family physicians per population, where the report had described that there are three categories of countries where the first category had achieved the three family physician per 10,000 population. The second category needs to strike policies and require major policy shift to reform the primary healthcare increased investment to establish and string the discipline of family medicine region so that the required number by 2030 can be produced. Group three is much more beyond and they need a more strict and more advanced policy in order to achieve that change and more commitment from the policymaker. So, training is important. We need to understand the training scope was going to do it was going to receive it and what is the approach. What's going to do it is the universities and academic institutions being the governing body and in the in the community. And because it's their social accountability responsibility was going to receive that it's the undergraduate and the postgraduate, and it was noticed in different literature that exposure of the undergraduate into family medicine during their medical journey is important for choosing the career later on was the graduate for continuous professional development and for helping them to achieve their, the policy and the objective of the health services. What is the approach it's simply bringing the students into the primary healthcare communities which is community based education and primary healthcare task force into the universities. What is the approach for the undergraduate it's the important to have a vertical undergraduate program with effect for purpose that is aligned with the community needs. Bringing the students into the primary healthcare communities. Bringing the task force into the campus interact and develop. It's important to do scaling up for family medicine training program to increase the number of the licensed physicians. Family medicine training should be established and string, because the traditional way of training is hard right now. It's important to bridge the gap to different programs that can facilitate having exceeding number of family physicians to achieve the plan of the health for all is the three students need to be trained in primary healthcare. So they need to be trained in primary healthcare for primary healthcare purpose. Why students. Why don't students choose general practice or family medicine. There had been a record by choice, not by chance, my values in UK simply emphasizes of the revision of 294 papers and reviewing them. A lot of points one of them is why don't students choose general practice or family medicine. It's because of the hitting curriculum. Res per stage loss less money and more debt by the years of the study intellectual under stimulating adverse work condition negative experience during placement. However, in the regional part in the Middle East doesn't make a lot of differences, because in a study that was done also in Iraq, recently, why students don't like to choose family medicine pressure of the care and practice lack of personal time. Office work plus dealing with problematic medical clients. So, while asking medical students why they don't prefer to take the specialty, most of them were thinking because of the less understanding by other specialties and lower awareness of the community. So the contextual part is playing an important role here for choosing that speciality. Literature over the past two decades has examined the escalating primary health care human health resources crisis, elaborating on the centrality of recruitment and retention of primary health care human resources. For building balance and effective and sustainable primary care services. Moreover, the rule of human health resources had been acknowledged to be more even and more important in the community based curve which tends to use less advanced equipment and is more dependent and competent personal. So, we have a lot of high turnover. Why do we have a lot of high turnover in the specialty, the simply because of job dissatisfaction, due to the organizational characteristic, it's due to work characteristic and individual characteristic organization characteristic in the form of the employment centers, salaries and work condition work characteristic due to the working hours type of the work team cohesion individual characteristic due to the burnout training and development safety digitalization and privacy, which are examples for the reasons of the job dissatisfaction. However, some of people, some of physicians choose this specialty. Why, because of the previous exposure to primary health care, which is, which is goes and echo the study of why choice not by chance and study other and echo other studies. Why they choose that because opportunity to teach opportunity for research about the preference perceived influence on the content about the opportunity for the research opportunity to work and deal with the case about the emphasis of continuity of health. Early exposure to the desk with all these ability to work with wide range of skills and behavior, all these really important factor emphasizing the choice of family medicine specialty. A global picture of family medicine, which is a view from the Lucas story pool, it's family doctors around the world sharing their stories about their profession and presenting heterogeneous factor about the attribute of the specialty and why they choose that specialty. So, it may inspire, it may serve as a positive example for family medicine program perspective students advocates and others stakeholders. So our take home message. Add a good supply of qualified human resources for health services have been highly correlated with better quality community health outcomes. Policy makers need a recognize the recruitment and retention policies and procedures for sustainable primary health care workforce and development. We need to understand that the selection and training is not one size fits all and that contextual factor needs to be taken in consideration, depending on the local national and international contextual factor. Thank you. Hello everyone. So my name is Anna known as barata. I'm from Portugal, and I'm going to follow up on my colleagues Naguas presentation on the topic together, we own the future. I really want to thank the host organizing committee for organizing this plenary. It's a very inspiring topic and challenging as well. And we hope that with this presentation with this plenary. We can really inspire you and show you what family medicine can offer you and both, and most importantly, what we can achieve by collaborating with all church throughout countries for the improvement of family health care. So, starting off with the definitions. We already saw with Nagua Universal Health coverage primary health care, and looking back into the basic definition, which is the definition by the world's health organization. We really see how primary health care is a holistic specialty. Because primary health care is care for all at all ages. All people everywhere deserve the right care right in their community. This is a holistic care, a care of proximity, a care that is accessible for everyone. However, if the world has organization already defines primary health care like this. Why is there still some trouble in some communities to assess health care itself. This leads to us to another discussion, which is how health care systems are built. So basically, we have four big health care system models. So we have the beverage model, we have the Bismarck model, the national health insurance model, and the out of pocket model. Starting off with the beverage model. This one is a health care system in which the government provides health care for all its citizens through income tax tax payments. So, like this, the government is the single player in the health care system. There is no competition in the health care market, and therefore the prices are kept low. The Bismarck model, which is a limited health care system where people pay a fee to fund that in turn pays health care activities that can be provided or by state owned institutions, or by government body owned institutions, or even a private institution. Then we have the national health insurance model, which is driven, namely by private providers. But the payments come from a government run insurance program there that is paid by every citizen. Essentially, it's like, it's an it's an universal insurance that doesn't make a profit. And finally, we have the out of pocket model, which is the model in the poorest countries, where it's basically either you have the money to access health care, or you don't. So it's really based on the individual fund of everyone. So with this, with these four models competing against each other, we can see that there, there is not an equitable access to health care system. And there is not an equitable access to primary health care. So the system itself can be a barrier for people to access primary health care. And then another issue, which comes to the definitions. So it's always the big war or big discussion about is it general medicine, is it family medicine is a general practice, or even people ask if primary health care or family medicine is even a medical specialty. Because for many ages, primary health care physicians were the ones who finished medical school started their small clinic, they did no. No university degree, they did nothing and this suddenly just started being the kind family doctor that went from house to house offering care. If we see the definitions, the European Academy of Teachers and General Practice defines that there is a really a necessity to define both these disciplines. In which academic foundation and framework they are built. So defining this, we can really inform the development of education research and quality improvement. And so this is needed to translate this academic definition into reality of the specialist family doctor that works with patients in health care systems throughout the world. Therefore, general practice or family medicine needs to be seen as an academic and scientific discipline, with its own educational content, research evidence base and clinical activity. And this is the clinical specialty oriented to primary care. This really needs to be settled. And we really need to see primary health care as one of the most important medical specialties and the clinical specialties in the health care system. So just as we see, it's the base for everything. And it's the cornerstone. And again, even another point that I would like to raise is, if we see family medicine or general practice. And how it is organized, it's completely different from country to country from continent to continent. So the activities, for example, you can have family medicine practitioners who do routine visits, the same day visits, home visits, some don't do home visits. Then the health care systems that the health service that they provide for special groups like pregnant women, children, family planning, diabetes hypertension. This is not everywhere the same, not all family doctors provide care to pregnant women, not all family doctors to family planning. So even in our activities worldwide, there is a great number and a great variety. So this is another challenge again in the definition of primary health care and what we really do and how to form what we need to be prepared for. In the teams where we work in, there are family doctors that work solo, there are family doctors that work in a team with nurses with social workers with dentists with psychologists pharmacologists. So the team can be from one person to a multidisciplinary team from with with the big multi-disciplinary integration of care. Then again, the settings, the settings also influence the activity of the primary health care. They work in the community, do they work in schools and they're very kind homes, even now with the COVID wave. What was the role of family doctors during the COVID wave? Did we participate in the vaccination campaigns? Did we only attend the COVID people that had the disease? So what was our activity there? And then the contracts, the contracts are also different, but that is also again dependent on the health care system where we work. So we have the staff workers and we have the private insurance. How do we work? So if we work for the state, maybe we have a bigger scope of work. And if we work in a private setting, we are the ones who define what we would like to work in. So maybe there is a more liberty in terms of organizing our own practice and our own clinic. And this impacts then in the curricula. The curricula of a family doctor, a general practitioner, it differs from continent to continent, it differs from country to country, and it differs from area to area. So if I was speaking about area, I mean what a person needs to be prepared for in a rural setting or in the city setting is completely different. How really to prepare the young doctors for all these variables? We saw that there are many variables that define primary health care, and together we really need to see and how to promote this variety. And to prepare the young doctors for all these challenges that are coming forward. And last but not the least. And this is also the question of social recognition. This is a difficult topic, but sometimes we already seen the people who choose to go and choose to opt for family medicine. Our colleagues choose to opt for family medicine as a medical specialty, but sometimes it also has to do with the social recognition. I think that if the choose family that medicine, they are less of a doctor than the other colleagues. But is it really so? Is it really to feel that we are less than the others? We work in a holistic care, we work with people from all ages. We are always there, we are there for the family. So it's really social recognition needs to start from us, from ourselves, from the young doctors. But also we need to work with the community. We need to also teach them and train them and tell them the family doctor is not just any kind of doctor. It's the family doctor is a doctor with training with a specialty and who provides holistic care throughout time. So all in all, now I'll question you. What is the role of primary health care? I invite you to think about this because we saw all the variables. But then we are the cornerstone of everything. So the primary health care is the most important medical specialty of all, if I can say so. Or in my view at least, but primary health care is really the cornerstone of every health care system. And it's the first access to health care. So the health care systems need to be built around primary health care so that we can have an equitable access to health care. But now we saw everything about the health care systems. And now I invite you to think out of the books a little. Sometimes thinking out of the books allows us to see new horizons. And we never know when those or how far those horizons will stretch. But it's having those horizons that inspire us to really look outside our practice, look outside what we do every day. And to seek new possibilities and new collaborations. And of course now I need to start off all with Wonka. Wonka, the World Organization of Family Doctors. It's a special organization and it really is our organization that we cater for with all our hearts. It brings us together. It lets us exchange our knowledge and it facilitates that we are here and speaking about family medicine and integrating our knowledge. And thankfully, there is the Wonka Young Doctors movements. There is one movement per region. And they can be this first door for the world and for people to experience and for our colleagues to experience what is beyond their family medicine practice, what is beyond their daily practice. So I'm sure that you are all familiar with the structure of Wonka. But basically the Young Doctors movements are a group and committee inside Wonka. And as said, there is one group per region. So we have Polaris from the North American region. And we have Vasco de Gama movement from the European region. Al-Razi from the Middle Eastern region. Afri one from Africa. Spice from the South Asia region. Rajakumar from the Asia Pacific region and the Wainake movement from the Latin American region. So as you see there is one movement per region. Why are they so important? They are so important because they allow us to collaborate on a global network. We can exchange our knowledge in an intercultural setting. And then Young Doctors have the possibility to make our voice heard. We have national and regional representation. And we sit in Wonka executives. So we really can speak out to the seniors and to let our voice known. So the gains at an individual level are immense. Experience from collaboration can go from research, healthcare strategies and initiatives. Organizing your practice, what can you learn from your colleagues, how they have organized their daily settings. And most importantly, innovation. And the Young Doctors innovation is the key for everything. And to innovate, I mean we need to be a little bit like a child. We need to cater for this child's curiosity inside us. We need to ask, ask, ask, and most importantly, be creative. So some of the results of this collaboration are the newsletter, the Global Exchange Program, the Family Medicine 360, the Global Fund for the Young Doctors movements, the webinars that we did this year. And the form to join the Wonka Young Doctors movements. And this was the collaboration between the young doctors, but it's not only us. We also stretch our collaboration further and look for external collaborations. And we developed a SPIR. So there was the collaboration with the SPIR program, which is the Global Leaders Program. We have the collaboration with the rural seats, which is the Young Doctors rural group. And we collaborate with the whole World Health Organization and also with the International Federation of Medical Students Association. So our scope is much bigger than we think. And reaching out this year. We have the first virtual World Young Doctors movements pre-conference, embracing diversity. I'm sure many of you attended it, and I hope you enjoyed it. But it was really important that even in this phase, we managed to organize World Young Doctors pre-conference. So all in all, come together, see what the young doctors allow you to do. Stretch your horizon. Don't stay only in your practice because together we're really on the future. Thank you very much. Thank you both. So far, we have no questions in the chat, but I have some questions to you. What I'm curious about, if we look at other specialties in medicine. If you meet an ophthalmologist, a neurologist, urologist, a surgeon of any kind or internal medicine specialist, they would recognize each other all over the world. They know what they're doing. They could define on the spot what they're doing. Why is it that we can't? And how would you, as young doctors, when explaining the specialty in order to recruit the right people to have a specialty? What would be your pitch? So let's start with Nagwa. What would you say you have, let's say 30 seconds now to say this is why and what? This is a very tough question. And actually, I'm going to say that this is a comprehensive care for the family and you are going to be recognized by all the family member for the whole of their lives with you. So this is the specialty of your dream to accomplish something and to leave legacy to people to remember you with. Yeah. Good. You're not finished. Yeah, go on. So it will be important because you are going to play a role in achieving health for all. So you are playing an important role in the in the current and in the future of your country. So I think this is the better that I'm going to use to justify for them and to tell them, but I have to say that from their own perspective, they need a clear pathway for them. So we need to ensure that indeed. Thank you. Over to you, Anna. Yeah, Anna, what would be your question? What has you been offering? I mean, now you've been the global young doctor now for five years. What's been your message when you meet young doctors, medical students, why to choose our specialty? I'll try to answer this question. And it's a little bit like the elevator pitch. How are we going to market family medicine because that's always the challenge. Family medicine is so broad that getting it in 30 second message can sometimes be challenging to get across. But if I want to put it in one sentence, maybe it would be something like choose family medicine. If you want to be next to the people. If you want to be, if you want to do holistic care. And if you are looking into doing a little bit of everything. Because family medicine is the specialty where we can't really say, this is not with us, because if we go to other specialties, okay, you have come all just to just see the eyes. And they can easily say, no, this is not with us, please go to your family doctor. So you are the person you are the referral person to this, to this family, to the patient, because you are the one who can follow the whole process of life from birth until death. And you can always be there when he needs you. So, maybe the best way to to encourage young doctors to choose family medicine is really to be to be there so that you are able to be the direct and it's not recognition to be the key person in handling the whole life of the person in front of you. Okay, yeah, let's move on from from there because when we are building curricula in family medicine. You said something about that Anna in your presentation that the curricula should be should be tailored to context. Does this mean that family medicine is the volatile thing which is different, whether it is in. Well, very remote areas in low and middle income countries, or in Lisbon where you're where you yourself practice where which is a high income country. In Europe. Should the curricula be different for doctors who are there will be prepared to work in those different contexts. The curricula. I believe there should have global standardization of the basic. So what is expected from a family doctor and including this holistic care. However, the tail, the tailored part really needs to be also included in the curricula because, for example, if you're taking Australia where, where it's very remote areas. Where people need to know surgery where people need to know other competences that you don't need to know in in Lisbon, but even in Lisbon. Sometimes in practice. It also differentiates where you are practicing use, for example, in my practice, I need to have a lot of look out into the social circumstances of people. And this should be included in the curricula. However, sometimes these things are not seen and the curricula is is very lacking. It's, it's difficult to do it the basic competences all over the world, but there should be one base for everyone and then have it tailored and constructed around the necessities of the area that is what I would suggest. What are your reflections now go on on this question. Yeah, as an academician as a person who had this discussion with you and previously, I think we had agreed on something that there are common principles that should be delivered. So the principles, there is no argue about that. What the particulars are, this is could be the contextual that can suit each place according to its needs. So the principles, I think there's an update for the one coaches the 10 C is the rule of the family medicine. So this is could be as a start off and you have to identify the principles among the world in order to have a bottom line for understanding for all of us. And there could be something like 10% or 20% which could be the particulars that are specified for each country or each context, because yes we are diverse in practice in communities in needs. So this is could be the specification that needs to be adjusted according to the needs and over to him. Okay. Another aspect of our topic tonight. Selection of colleagues to family medicine. What would be your list of criteria 231 maybe, I don't know, maybe more characteristics of the person if I'm now a young medical student and I come to you and I say, do you think I will suit family medicine. I think it will suit me do you think I can serve the purpose of family medicine. What would be your question to that person to find out whether you would advise him or her to take this song. So you can choose to ask first. But this is, this is the real question. Who do we select on what basis. This is a huge step question because the selection is not an easy thing but as I said that the report which had been done by the NHS with one of our colleague. She said that by chance not by by choice not by chance is that the exposure of the students make their chances choices for choosing the family medicine specialty is high, and they do agree with that. The matter of selection after they choose that specialty because one of the important parameter is that they should have choose it first. I do not need to take them without them choosing it's not they are not going to be motivated. So motivation for the specialty should be playing an important role after motivation then we can list a few questions like do you like to work with the community. What is your perspective regarding the comprehensive care, checking the leadership skills, looking for the managerial issues, searching a critical appraisal mind, advocacy and so on. But motivation for that specialty I think is going to play rule number one and choosing and then selection. After that comes the other issues. And over to you. Thank you. You managed to reply to as you say a broad question, a big question. Now I don't find the right English word but it's precise maybe. Anna, what would be your approach in such a situation. Maybe what I would ask the person is if they can see the patients as I think this may seem a little bit emotional but probably if the person can see a patient as their friend. When you are a family doctor and you follow people all over their life you, you build some sort of relationship of trust with this person. So it's not like it's your friend that you hang out with, but you need to build this relationship of trust because if you cannot build a relationship of trust with your, with your patient then you aren't a good family doctor. And also one important thing in family medicine is to be able to multitask a lot. We skip from one aspect to the other, and we need to take care of everything so I would advise a person to have really this multitasking skills because it comes really handy and in family medicine. Anna, thank you Anna. It never fails when I mean we need some time to, to, to start the conversation and here we have two questions and that is what we, we have time for so we will be quick on both. Good questions. The first one from Maria, Jaune Obre in Portugal. We are facing an escape of doctors, including family doctors for other careers. What is lacking in family medicine to keep young doctors motivated in our specialty. I, I suggest that goes to you Anna, and Nagua you will have the next one. What's lacking Anna, and you have now another pitch of a minute. Okay. So what is lacking in family medicine maybe it's not the specialty that is lacking, but the working conditions that are lacking. So it all depends on not really what your actions are as a family doctor, but the pressure of the work the system puts you into. So if the system puts you in a lot of pressure, then you maybe be not so motivated to follow family medicine, then, and choose other specialties. However, if you can have a stable practice if you can have a good work life balance, and the family medicine is really a specialty that you love, then you will not choose other specialties so maybe I wouldn't put it so much in the specialty itself, but all that surrounds it. Thank you Anna. One minute answer from you Nagua to the question from Jose Miguel Bueno Ortiz. Together we own the future. How to see the future in 10 years how will core values of family medicine prevail. Okay, I'll try to make it precise. I was the first family physician resident in my department here's I won't say when. At that time it was newly clinical under a clinical department and it was the third in order in Egypt. So no one use anything and it was, they were just only the health sector reform. I was very optimistic. And today from my place, we have the universal health coverage, and we have a whole sector of places where we have family physicians are working and people are competing instead of troubling to work in these places because of the high incentive there. And the salary that career pathway. So, how do I see family medicine after 10 years I'm an optimistic person, I think we are going to have a large number, and I think the UHC are going to approach that 20, 30, maybe not as much as we need to, but at least we are going on the right way from my point of view. Thank you both. Let me try to sum up, which is not easy because this is an ongoing discussion should be an ongoing discussion. We've raised a few issues here I think, which are very important to look more into. To develop a collective approach to an understanding of our role in the healthcare system, despite the local context. So I encourage you, young doctors to take part in that dialogue in the years to come I very much welcome you to do that. I also have. Well, this is something I always say when I meet. Not let's, let's not say young doctors with younger doctors than myself, just some steps behind me in age and career. Keep the clinical skills. In clinic. Remember, that is the core. Whatever path where you would take, and that is our main source of inspiration and understanding. We're there for people. I think that our technical hosts will be very happy if I now sum up. So thank you so much to Anna and now I'm looking forward to meeting you again soon. And I hope that will be a physical meeting where we can take this discussion further. If not, it'll be physical it will be on screen and I welcome your input so thank you very much. Thank you. Thank you so much. Thank you.