Surgery--1 by theLSJM Ltd

lsjm 15 june 2009 volume 01

EDITORIAL

Welcome to the Surgery Section of the London Student Journal of Medicine. We aim to inform all healthcare disciplines through historical pieces, reviews of fundamental topics and cutting edge research. By understanding the basis of past and current surgical science, current practice can be challenged and future practices shaped. The Surgery Section encompasses all surgical specialties, Obstetrics and Gynaecology, Anaesthetics as well as aspects of Clinical Oncology and Clinical Radiology. This first issue of the journal concerns itself with the topic of ‘unhealthy behaviours’. The Surgery Section includes a discussion around the area of patient safety and the consequences of errors in healthcare. The impact of events that have an adverse effect on patients while under the care of healthcare professionals is substantial and has been known for a very long time. The UK’s Department of Health, in 2000, released the report An Organisation with a Memory which revealed that adverse events affected 10% of hospital inpatients, translating to approximately 850,000 individuals.1 Furthermore, the report highlighted the fact that many of these adverse events were happening time and time again as lessons were not being learned. In 2004, the UK’s Chief Medical Officer spoke at the launch of the World Alliance for Patient Safety and said, ‘To err is human, to cover up is unforgivable, and to fail to learn is inexcusable’.2 This is an ‘unhealthy behaviour’ within healthcare that we must eradicate to ensure that we are not adding to the burden of illness. So how can we as healthcare professionals improve upon our ‘unhealthy behaviours’? Sebastian Yuen in his Expert Comment covers a range of strategies. What is needed first and foremost is an awareness of these issues. Speaking from our perspectives as medical students, we admit to having little exposure to patient safety, and perhaps this needs to be the first issue to be addressed. We would like to know of your experiences of patient safety as a student in a healthcare discipline around the world as well as your suggestions on how to improve patient safety. The use of the World Health Organisation Surgical Safety Checklist (see our Ask the Expert feature) is a strategy being implemented in the area of surgery to address this issue. This issue also features a review of Primary Care referral guidelines for patients with suspected colorectal cancer. Over the coming months the surgery section hopes to share with you the opinions of experts currently shaping the landscape of surgical practice. Alongside original contributions, the section includes articles of general interest and hopes to impact on student life with our perspective pieces. Making the most of a surgical placement, profiles of eminent individuals and a Mystery Object competition are a few such articles which we hope will do just this. We are always on the lookout for potential ideas and articles that can be turned into published pieces in the LSJM. To discuss an idea or submit a manuscript to the Surgery section, please e-mail us at surgery@thelsjm.co.uk. If you have an individual in mind to profile, please contact us first as there are certain questions we want all our profiles to include to create a quick and interesting comparison between them. Looking forward to subsequent issues, we hope to build an issue specifically around peri-operative care and would welcome any submissions in this area from students of all healthcare disciplines. As with any publication, feedback is essential both for reflection and improvement. We welcome your views and suggestions that our readers may have and encourage you to write to us with ‘Letter to the Editors’ as the subject line of your email. Our thanks go to everybody who has contributed to this issue including the authors, peer and expert-reviewers. They have provided insightful and pertinent comments, which have thus improved the quality of submissions. However, most thanks must go to our group of panellists for all their hard work, dedication and support. We sincerely hope you enjoy this inaugural issue of the journal, consider it as a place to publish your work and begin to make it part of your regular reading. Jonathan Cheah & Milan Makwana Section Editors of Surgery References Illustration: Robert Hare

1. 2.

Department of Health. An organisation with a memory: Report of an expert group on learning from adverse events in the NHS chaired by the Chief Medical Officer. Crownright. Department of Health. HMSO. 2000. WHO World Alliance for Patient Safety. World Health Organisation [online]. 2009. http:// www.who.int/patientsafety/en/ [Last Accessed 11 April 2009]

lsjm 15 june 2009 volume 01

EXPERT COMMENT

Why Quality Should Matter To You Sebastian Yuen MBBS DCH MRCPCH FHEA

Consultant Paediatrician, Royal Free Hospital, London Fellow, NHS Institute for Innovation and Improvement sebastian.yuen@institute.nhs.uk

Sebastian Yuen is leader of the Royal Free Hospital IHI Open School Chapter

“

In 2004 in the UK, 2180 patients died as a result of mistakes; this is not acceptable. Medicine is changing rapidly. Once, it was enough to acquire knowledge, clinical skills and expertise in a specialty. Now, however, there is increasing recognition that high quality healthcare also depends on creating reliable and effective systems and processes. Lord Darzi’s High Quality Care for All defines quality care as being safe, effective and patient-centred.1 Many patients are actually harmed by the care they receive, resulting in injury and even death. In 2004/5, 2180 deaths occurred in the UK due to error.2 Of the 16 million admissions to hospital each year in the UK, one million experience harm and half of this is preventable. The US Institute for Healthcare Improvement (IHI) is working towards a vision they call the “No Needless List”: No needless death, no needless pain or suffering, no helplessness in those served or serving, no unwanted waiting, no waste and no one left out. Healthcare students have a key role to play in making this vision a reality. The following discussion will signpost a number of organisations and resources that will help you learn to see things differently.

will beings always carry risks; human beings are fallible. Healthcare will always carry “Healthcare risks; human are fallible. However, harm to patients should not be viewed as an acceptable However, harm to patients should not be viewed as an acceptable part of modern healthcare.” Liam Donaldson, UK Chief Medical part of modern healthcare.

”

Officer Liam Donaldson, UK Chief Medical Officer

Patient safety curricula have been developed by the World Health Organisation and Medical Royal Colleges Adverse events occur, not because people intentionally hurt patients, but because of the complexity of the system of medical practice. Other high risk industries, such as aviation, have embraced the science of safety and transformed the way they operate. The Academy of Medical Royal Colleges has developed the Medical Leadership Competency Framework.3 This describes the competencies that all doctors need to know about planning and delivering services. The five domains are: personal qualities, working with others, managing others, improving services and setting direction. The competencies are outlined for students, trainees and consultants. The WHO is currently piloting its Patient Safety Curriculum Guide for Medical Schools.4 The future of healthcare will depend on a workforce that is skilled in methods of quality improvement and which can work collaboratively with

other professions. But who is teaching this? The challenge faced by most medical schools is of squeezing ever more into a crowded curriculum. The NHS Institute pre-registration training: Improvement for better, safer health and social care The NHS Institute for Innovation and Improvement aims to transform healthcare by rapidly developing and spreading new ways of working, new technology and world-class leadership. In 2006 it worked with three universities to incorporate improvement methodology training into their pre-registration programmes for healthcare professionals.5 There are currently 32 universities involved. Core principles of the training include an introduction to systems-thinking, understanding the patient’s perspective and sustainable ways to improve the service. In addition to the theory, students are encouraged to work as inter-professional teams and practise using one of the improvement tools. The programme enables them to understand that quality improvement is an everyday task, not one carried out on us by managers. 88% of participating students felt that service improvement was important or very important to their professional development. 85% agreed that knowledge of service improvement would enhance their job prospects. The NHS Institute continues to promote this training and aims for it to become compulsory in all universities. “We all have two jobs, one is to do the job we’re trained to do; We have two one is to doimprove the job we’re trained do; the second the all second one jobs, is to constantly the job we’retodoing.” one is to constantly improve the job we’re doing.” Healthcare student Healthcare student

The NPSA has created Safe Foundations, a training package for junior doctors The NHS National Patient Safety Agency (NPSA) has also produced a programme for teaching junior doctors.6 Entitled Safe Foundations and available free online, it consists of four workshops with UK examples of patient stories and videos. The first focuses on human error, which it describes as inevitable. It emphasises that you are most likely to make errors when you start as a junior doctor. The series continues by contrasting the individual’s actions with the impact of the system. Whilst error will never be eradicated, harm to patients is not inevitable and can be avoided. To achieve this, clinicians and institutions must learn from past errors and learn how to prevent future errors. Root cause analysis of critical

lsjm 15 june 2009 volume 01

EXPERT COMMENT incidents is normal in other complex industries such as aviation. Systematic investigation of adverse incidents exposes system failures that often can then be minimised or eliminated.

approximately one hour each to complete. Students are able to explore the extensive IHI literature that experts and professionals around the world read and refer to.

Doctors and other frontline staff are harm absorbers, the last line of defence in the healthcare system. Through a better understanding of human factors and systems, you will be able to recognise when things are going wrong. As an emerging clinical leader, you will be able to prevent that situation from spiralling into a patient safety incident.

Open School Chapters in the UK allow face-to-face discussion and learning The web-based resources are complimented by “chapters” where students from a variety of professions meet face-to-face. There is one chapter in London, based in the Royal Free Hospital. There are seven others in England, six in Wales and three in Scotland. Worldwide, the total has reached 122 chapters in 12 countries. Each has a chapter leader, usually a student, and a faculty advisor who will have experience of leading quality improvement. The membership and frequency of meetings will vary, but their purpose is to engage, enthuse, challenge and stimulate learning and action. The leaders have monthly calls with IHI to share experiences and ideas for activities. There are regional clusters which develop their own support networks. The UK hosted its first UK Chapter Congress in Stirling, Scotland, on 28th April 2009. As members of Open School, students are invited to attend the inspirational IHI national forum (6-9.12.2009, Florida) and International Forum (20-23.04.2010, Nice, France) with free registration.

“Great doctors are not the ones that never make errors. Rather, they are the people who expect errors to happen and who have strategies in place to cope with them, before these adverse events could cause harm to a patient.” Professor James Reason BAMMbino is developing resources for students to complement the BAMM Fit To Lead programme for consultants. BAMMbino is the junior doctor division of the British Association of Medical Managers (BAMM).7 They are supported by the senior leadership of the NHS and are currently developing resources for medical students and trainees. These will complement the BAMM Fit To Lead programme for consultants. Learn To Lead will involve two years of active participation for doctors and lead to a certificate in medical management. It will follow the Medical Leadership Competency Framework and combine courses, project work and coaching. The student development programme will target medical students in their clinical years. The format will include facilitated small group teaching, a management project and individual mentoring. “The doctor’s frequent role as head of the healthcare team and commander of considerable clinical resource requires that greater attention is paid to management and leadership skills regardless of specialism.” Professor John Tooke

A final thought Improving quality (safety, effectiveness and patient experience) is now the number one priority in the NHS. In a recession, with the NHS budget contracting after 2011, improving the quality and safety of systems will be essential. Those with experience of effectively implementing innovations and processes (however small) will be very attractive to employers. Take advantage of the above opportunities now, learn to see differently and help provide the best care for your patients.

“

Wekind can’t problems by using the same kind of “We can’t solve problems by using the same of solve thinking we thinking we used when we created them. used when we created them.” Albert Einstein Albert Einstein References

The IHI Open School is a free international interactive resource for healthcare students The IHI is an independent not-for-profit organisation helping to lead the improvement of healthcare throughout the world. During an 18 month period in 2004-6, they organised the ambitious 100,000 Lives Campaign.8 They enrolled 3,000 hospitals and introduced six interventions including rapid response teams, better medication management, and care bundles for acute myocardial infarction, ventilator-associated pneumonia and central line infections. The impact was dramatic and saved an estimated 123,000 lives. Similar techniques have spread to many countries across the world. In the UK, the IHI worked with The Health Foundation and 24 hospitals on the Safer Patient Initiative (20048). This has evolved into the Patient Safety First Campaign covering England9 and equivalent programmes in Ireland, Scotland & Wales.

IHI launched the Open School for Health Professions in 2008 to transform thinking about how healthcare should be delivered10. It is free and makes full use of Web 2.0 applications to engage its worldwide audience as fully as possible. Examples of 21st Century media used include Google Groups, WebEx, Facebook, Blogger, Twitter, Podcasts and YouTube. The curriculum covers core fields such as the science of patient safety, systems thinking, quality improvement, teamwork and communication. This is contained within six online courses, each comprising four lessons which take

lsjm 15 june 2009 volume 01

9. 10.

1. Darzi A. High Quality Care for All: NHS next stage review final report. Crownright. Department of Health. HMSO. 2008. 2. Department of Health. Safety first: a report for patients, clinicians and healthcare managers. Crownright. Department of Health. HMSO. 2006. 3. Medical Leadership Competency Framework. NHS Institute for Innovation and Improvement [online]. 2009. http://www. institute.nhs.uk/mlcf [Last Accessed 27 April 2009]. 4. WHO Patient Safety Curriculum Guide for Medical Schools. World Health Organisation [online]. 2009. http://www.who. int/patientsafety/activities/technical/medical_curriculum/ en/index.html [Last Accessed 27 April 2009]. 5. Building improvement capability into pre-registration training. NHS Institute for Innovation and Improvement [online]. 2009. http://www.institute.nhs.uk/building_capability/building_ improvement_capability/building_improvement_capability_into_ pre-registration_training.html [Last Accessed 27 April 2009]. 6. Safe foundations. National Patient Safety Agency [online]. 2008. http://www.npsa.nhs.uk/nrls/improvingpatientsafety/learningmaterials/safe-foundations/ [Last Accessed 27 April 2009]. 7. BAMMbino. The British Association of Medical Managers [online]. 2009. www.bamm.co.uk/Services/Support_&_Development/ BAMMbino_2007072440 [Last Accessed 27 April 2009]. 8. The First Campaign Initiative. Institute for Healthcare Improvement [online]. 2009. http://www.ihi.org/IHI/ Programs/Campaign/Campaign.htm?TabId=6#TheFirst CampaignInitiative [Last Accessed 27 April 2007]. 9. Home. Patient Safety First Campaign [online]. 2009. http:// www.patientsafetyfirst.nhs.uk/ [Last Accessed 27 April 2009]. 10. IHI Open School. Institute for Healthcare Improvement [online]. 2009. http://www.ihi.org/OpenSchool [Last Accessed 27 April 2009].

”

ARTICLE

The IHI Open School: Primum non nocere Andrew Carson-Stevens BSc (Hons)

Intercalated MPhil Medical Student, Cardiff University carson-stevens@doctors.net.uk doi:10.4201.lsjm/surg.002

Andrew Carson is the leader for the Wales Chapter for Healthcare Improvement

Simple interventions can save lives Lives are being saved everyday in the National Health Service (NHS) but thousands more preventable deaths and incidents of harm could be avoided. Lasting cultural change within the NHS is required to ensure this. Healthcare students, as the workforce of the future, are vital to this process.

Students, with eyes fresh to the healthcare system, are uniquely positioned to spot opportunities for improvement. Think about it. From your experience of the system - as a healthcare student on a clinical placement, as a patient, as a relative of a loved one - how often have you thought ‘this could be done so much better’?

The Wales Chapter for Healthcare Improvement1 is part of a global movement, initiated by the Institute of Healthcare Improvement’s (IHI) Open School,2 to advance healthcare quality improvement and patient safety competencies in the next generation of health professionals worldwide. The Wales Chapter was launched on April 24th 2009 on the 1st Anniversary of the Wales 1000 Lives Campaign.

A new generation of healthcare professional The IHI Open School’s free and certified courses aim to provide students with the opportunities to learn how to improve the healthcare systems in which they will work as professionals. Course content raises awareness of healthcare quality and patient safety issues, and also equips learners with the skill base to implement change which can lead to improvement.

The 1000 Lives Campaign recognises the tireless efforts of frontline NHS professionals and aims to save an additional 1000 patient lives and prevent up to 50,000 episodes of harm over two years.3 Early figures indicate that in the first six months, 410 patient lives have been saved.4 The combined and unceasing efforts of frontline NHS healthcare professionals to deliver simple, evidence-based checks and changes in practice, have contributed to this success. The Wales Chapter believes that students can assist identify areas for improvement and save even more lives.

The Open School encourage the set up of a ‘chapter’, which is the UK equivalent of ‘society’, and the courses serve as a sound starting point for generating initial buy-in from colleagues. However, once students are signed up to the chapter, what next? The Open School has generated and collected a plethora of learning resources that promote the sharing of experiences and understanding of roles between the healthcare professions. Such activities go a long way towards encouraging a student-led interprofessional learning environment.

Every system is perfectly designed to achieve exactly the results it gets The IHI is working to change the way in which medical error is understood and managed. IHI advocate that when a medical error occurs, it is important to acknowledge that the system within which it happened was perfectly designed for that error to occur.5 The same could be said for medical education. In fact, it is possible that as young professionals entering the workplace, we could actually do more harm than good, despite the very best of our intentions.

A few examples of Chapter activities: video case studies of patient experiences or interviews with experts in patient safety prompt discussion and reflection from practice; journal articles can initiate debate about current and future implications for practice; monthly audio calls given by world renowned experts in improvement can help keep momentum, generate new ideas for testing improvement locally and maintain enthusiasm amongst the group. Setting global challenges Monthly Chapter Leader calls provide direction through sharing and discussing successes and challenges. The IHI Open School has

lsjm 15 june 2009 volume 01

COMPETITION created a network of global partnership and friendship between groups of enthusiastic and dedicated students that share similar values, visions and goals, successes and challenges, across the globe. Chapter members are encouraged to use their newly identified skills in practice by getting involved in projects through established safety campaigns, or even initiating their own improvement projects to test their individual ideas for change.

A sobering thought ... By being part of an IHI Open School Chapter and completing the online courses, students can make a big difference to patient care. Changes made to create an improvement are very often the simplest ideas, and IHI Vice-President Joe McCannon reminds us, “If we can improve care for one patient, then we can do it for ten. If we can do it for ten, then we can do it for 100. And if we can do it for 100, we can do it for 1,000.”

If so, the Surgery Section has a signed copy of The Knife Man: Blood, Body-Snatching and the Birth of Modern Surgery, a biography of John Hunter, eighteenth-century surgeon by Wendy Moore, to give away. The prize has been kindly supplied by the Hunterian Museum. To enter, e-mail your answer to surgery@thelsjm.co.uk with ‘Mystery Object Competition’ as the subject line along with your name, course and year/place of study by 30 July. The winner will be the first randomly selected from all the correct entries.

We want the Surgical Safety Checklist to be used in every hospital, for every surgical procedure, by every surgical team, in Wales by 2010. Students observe procedures in operating theatres on a daily basis. We have asked our medical students to record a series of observations (e.g. Yes/No) against five key processes that are already considered standard procedure (e.g. correct site marked prior to surgery and antibiotics given within the correct time interval). In collaboration with the 1000 Lives Campaign Surgical Complications team, this baseline data will be used to encourage uptake and implementation of the Surgical Checklist in Wales. The Wales Chapter is working with colleagues at Harvard University, to establish a global drive to engage students in encouraging the spread and implementation of the WHO Surgical Checklist, through the international network of over 100 IHI Open School Chapters.

Can you identify this object from the Hunterian Museum, based at the Royal College of Surgeons of England?

A student-led improvement project conducted by the Wales Chapter involves collecting data to encourage the implementation of the WHO Surgical Checklist.6 Analogous with pre-flight checks carried out by an aeroplane pilot prior to take off, the surgical checklist involves a series of checks prior to, just before and following surgery. The checklist was implemented at eight sites across the world, in developed and developing countries, and resulted in a rate of major complication decrease by one-third and a 40% reduction in patient death.7

Mystery Object Competition

References: 1. 2. 3. 4.

6. 7.

The Wales Chapter for Healthcare Improvement [online]. 2009. http:// www.waleschapter.wales.nhs.uk [Last Accessed April 29th 2009]. IHI Open School. Institute for Healthcare Improvement [online]. 2009. http://www.ihi.org/OpenSchool [Last Accessed April 29th 2009]. 1000 Lives Campaign [online]. 2009 http://www.1000LivesCampaign. wales.nhs.uk [Last Accessed April 29th 2009]. Over 400 lives saved in first six months of Campaign. 1000 Lives Campaign [online]. 2009. http://www.wales.nhs.uk/sites3/news. cfm?orgid=781&contentid=11897 [Last Accessed April 29th 2009]. Improvement Tip: Want a New Level of Performance? Get a New System. Institute for Healthcare Improvement [online]. 2009. http://www.ihi.org/ IHI/Topics/Improvement/ImprovementMethods/ImprovementStories/ rovementTipWantaNewLevelofPerformanceGetaNewSystem. htm [Last Accessed April 29th 2009] Safe Surgery Saves Lives. World Health Organization [online]. 2009. http:// www.who.int/patientsafety/safesurgery/en/ [Last Accessed April 29th 2009] Haynes, A.B., Weiser, T.G., et al. 2009. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. N Engl J Med. 2009 Jan 29;360(5):491-9. Epub 2009 Jan 14.

lsjm 15 june 2009 volume 01

ARTICLE

A Retrospective Analysis of the ‘Two-Week Rule’ in the Diagnosis of Colorectal Cancer Mostafa Albayati

mostafa.albayati@kcl.ac.uk Intercalating BSc Medical Student, King’s College London doi:10.4201.lsjm/surg.003

Image: Courtesy of Cancer Research UK & Bobby Moore Fund

The views expressed are not necessarily those of cancer research. For the full article and references see thelsjm.co.uk. For further reading please see NICE guidelines on CRC/ TWR.

Michael Carrick Pass the message on

David James Saving lives

Rio Ferdinand Defend your body

Micah Richards Defend your body

Shaun Wright-Phillips Pass the message on

Registered Charity No. 1089464

Theo Walcott Attack the disease

Results A total of 75 referrals were made to the fast-track clinic during the study period. 68 of these were made via the TWR, of which 3 (4.4%) were diagnosed with CRC. 7 patients with CRC presented to the colorectal unit in the same study period through other means. 38 (56%) referrals complied with the DoH guidelines for appropriate TWR referral and 66 (97%) complied with the 14 working days target.

44 people die from bowel cancer every day in the UK

There is Moore to know Visit www.bobbymoorefund.org www.teamenglandfootballerscharity.com Photography by John Davis @ Soho Management; anatomical layers generated by www.TheVisualMD.com and scans by Philips Medical Ref ED078B.April2009

Abstract Objective: Colorectal cancer (CRC) is the third most common cancer in the UK. CRC patients in the UK are known to have poorer survival rates compared to other European countries, with a three-year survival rate of approximately 44%. In 2000, the Department of Health (DoH) introduced the Two-Week Rule (TWR) for fast tracking all urgent cancer referrals, with the aim of identifying 90% of bowel cancer cases. We aimed to assess the efficacy of the TWR for suspected CRC in a large university teaching hospital. Methods A retrospective study of all patients referred to the colorectal unit during a six-month period was conducted, documenting various outcomes. Parameters in the study included source of referral, CRC diagnosis and GP compliance with referral guidelines.

Conclusion The detection rate for TWR-referred CRC was low and accounts for only approximately a third of all CRC cases diagnosed during this study period. This low yield suggests that the referral guidelines are not as effective as the DoH target. Reasons for this may include poor compliance with the guidelines by GPs and poor specificity of the guidelines. Introduction Colorectal cancer (CRC) is the third most common cancer in the United Kingdom, with 32,300 new cases diagnosed and 14,000 deaths annually in England and Wales alone. In addition, patients presenting with CRC in the UK have been shown to have poorer survival rates compared to other European countries, with a three-year survival rate of approximately 44% compared to 67% in Italy.1,2 The reasons for this are unclear. CRC implies major health costs to the National Health Service (NHS) (annual expenditure of more than £300 million) and is important to overall public health strategy because it is common and frequently fatal. In order to improve cancer survival rates, the UK’s Department of Health (DoH) issued the ‘NHS Cancer Plan’ in 2000, with the introduction of the Two-Week Rule (TWR) for fast tracking all urgent cancer referrals from primary to secondary care.3 The DoH also published guidelines for General Practitioners defining those patients with high risk symptoms that required specialist assessment within the two week time frame (Table 1), with the aim to “identify up to 90 per cent of patients with bowel cancer”.4 Previous studies have commented on the impact of the TWR on the detection rate of CRC. Chohan et al. revealed that, while the TWR was successful in speeding up patients’ access to clinic, only 27% of referrals had a confirmed diagnosis of CRC.5 Similarly, a systematic literature review by Thorne et al. in 2006 indicated that only 10.3% of patients referred by the TWR were eventually diagnosed with CRC.6 Several other studies have cited pitfalls and have suggested that the poor yields may be due to the guidelines’ poor sensitivity and specificity.7

lsjm 15 june 2009 volume 01

ARTICLE Table 1: Department of Health high risk criteria for suspected colorectal cancer.

However, it has also been suggested that these findings reflect the inappropriate use of the guidelines by GPs. It has been suggested that the high numbers of nonconforming referrals made are as a result of some GPs using the TWR referral system as a quick disposal route for all patients presenting with rectal bleeding.8 Some authors have shown that approximately 60% of all CRCs identified when analysed retrospectively appeared to fit the guidelines, therefore suggesting that the guidelines, if accurately implemented, might prove useful.9

All ages • • • • •

Over 60 years • •

The principal objective of this study was to assess the CRC detection rate to determine whether the TWR is effective in identifying suspected CRC patients, and whether findings from our unit agree with those from other studies published.

Rectal bleeding with a change in bowel habit to looser stools Increased frequency of defecation persistent for 6 weeks A definite palpable right-sided abdominal mass A definitive palpable rectal mass (not pelvis) Unexplained iron deficiency anaemia (Hb < 11 g/dl in men or < 10 g/dl in postmenopausal women) Change in bowel habit as above without rectal bleeding and persistent for 6 weeks Rectal bleeding persistently without anal symptoms

Table 2: Number of colorectal cancers diagnosed Number of patients N° TWR referrals received

Methods All TWR referrals to the colorectal unit at Bassetlaw Hospital, Nottinghamshire were audited over a six month period between April 2006 and September 2006. Referrals were identified from both faxed TWR proformas and standard GP referral letters. Data collected from the referral letters included age, sex, and symptoms for referral. In addition, other outcomes were noted, including GP compliance with the TWR guidelines (patients fulfilling one or more of the six high-risk criteria), other routes of referral, investigations undertaken, the number of cancers diagnosed, timescale from referral to investigation, and the waiting time from referral to diagnosis. Diagnosis of all malignancies was confirmed histologically and graded using Dukes’ classification. Results In total, there were 75 referrals made to the colorectal unit during the six month study period, all of which were new referrals. Seven referrals were from outside of the TWR referral system and were subsequently not included in the main study. The ratio of male:female patients was 28:40 (41%:59%). Of the 68 patients seen in the fast-track clinic, only three (4.4%) were subsequently diagnosed with CRC (Table 2). A further seven patients with CRC presented to the department in the same time period via other routes; three were internal consultant referrals from other departments, two were GP urgent referrals, and two were GP routine referrals. The final diagnosis of CRC was greater from referrals outside of the TWR referral system (70% (7/10) versus 30% (3/10), respectively). Furthermore, of the three malignancies diagnosed through the TWR referral system, one was Dukes’ stage B and the remaining two were Dukes’ stage D. Compliance with the published guidelines for appropriate TWR referral by GPs was generally poor, with only 38 (56%) of the 68 referrals complying with the guidelines. The remaining 44% of patients referred did not fulfil at least one of the six referral criteria (Table 1). Table 3 documents the symptoms for referral to the fasttrack colorectal clinic. The majority of patients presented with a change in bowel habit, which was documented 47 times, followed by rectal bleeding (documented ten times). Rectal bleeding with a change in bowel habit was noted six times. Unexplained iron deficiency anaemia was noted five times, and a palpable right sided abdominal mass was noted once. Abdominal pain and weight loss were also documented as presenting symptoms (ten and four times, respectively).

lsjm 15 june 2009 volume 01

N° CRC cases identified from TWR referrals (%) Total number of CRC cases diagnosed

68 3 (4.4%) 10

Table 3: Symptoms for referral to fast-track colorectal clinic. Symptoms

Incidence in patients

Rectal bleeding in patients >55 years

Change in bowel habit: looser/increased frequency

Rectal bleeding and change in bowel habit

Unexplained iron deficiency anaemia

Right-sided abdominal mass

Abdominal pain

Weight loss

The proposed Government target of 14 working days from referral to outpatient appointment was met in 66/68 (97%) of the TWR referrals. Figure 1 shows that the majority of patients underwent colonoscopy during the course of their investigation, followed by barium enema. Other investigations included abdominal ultrasonography, flexible sigmoidoscopy and abdominal CT. The overall median time from referral to investigation was 3 weeks (range 1-6 weeks) and the overall median time from referral to diagnosis was 9 weeks (range 2-12 weeks). The most common final outcome of the fast-track patients was diverticular disease (24/68). Discussion The current DoH guidelines for suspected CRC were put in place to be used by GPs in primary care as a guideline to prioritise referral.7 Despite original targets, more than two thirds of the CRC patients in this audit were referred via routes other than the TWR referral system. The low number of CRC patients identified following a TWR referral in this study, suggests that the guidelines are not as effective in identifying CRC patients at first presentation to their GP as was hoped. Poor compliance with the guidelines has been documented at many centres as one of the major reasons for this poor CRC detection rate. The results from our study demonstrated that only 56% of referrals complied with the guidelines, reflecting many previous audits. Rai et al., in a recent review of all audits on the TWR

ARTICLE referral system published in mainstream peer-reviewed journals, found that compliance with the published guidelines by GPs at primary care level is poor in the majority of centres.10 Possible reasons for this poor compliance may be due to a lack of time in the general practice consultation, poor experience with taking colorectal histories, or exaggeration of the symptoms by the patient or GP in order to speed up their hospital appointment. The Advisory Group formulating the guidelines for the TWR referral system did, however, emphasise the importance of close adherence and implementation at the time of the guidelines’ publication.11 Ideas on improving compliance in the future include a personalised feedback system from the hospital clinician to the GP which may help to emphasise the importance of not referring patients with transient symptoms or symptoms over 18 months duration to the fast-track clinic.11,12 However, increased compliance with the TWR referral guidelines reported in some centres has not necessarily improved the diagnostic yield of CRC in the fast-tracked population. For instance, Barwick et al. reported only a 10% yield in CRC despite a 96% compliance rate with the TWR referral.13 This suggests a problem with the specificity of the guidelines. Furthermore, CRC is notoriously difficult to diagnose due to its very non-specific symptoms, dependent on the anatomical location of tumours. Patients with proximal cancers are more likely to present with anaemia and therefore be referred to medical outpatients, whereas those with more distal tumours, producing rectal bleeding, will be referred to surgical outpatients.14 This suggests that it may not just be poor GP compliance or poor guidelines that makes the detection rate using the TWR system hit-and-miss but rather due to the nature of the disease itself. More worryingly, the sharp increase in the total number of TWR referrals in England (60% increase from 13,410 referrals in 20012002 to 21,234 referrals in 2004),15 is overwhelming the system and a significant number of patients referred routinely are now being disadvantaged by longer clinic waits and delays in diagnosis, suggesting that a change is urgently needed.

provides an opportunity to identify precursors to invasive disease and polyps.19 However, recent results from the NHS Bowel Cancer Screening Pilot demonstrate that, despite the feasibility of population-based FOBt screening, this method of screening has a sensitivity of 57.7% and a positive predictive value of 5.3% for CRC. This low positive predictive value means that it has the potential to produce many false-positive results, and therefore the associated cost, risk and anxiety of colonoscopy.20 There is a need to improve the screening tool in order to produce an effective, safe, and relatively inexpensive screening method with a high positive predictive value that will function as a good addition to the TWR referral system. Conclusion Ultimately, the objective of any fast-track referral system is to diagnose and treat suspected cancer at an earlier stage in order to improve survival. The evidence presented in this paper indicates that the detection rate for TWR referred CRC was low and accounts for only approximately a third of all CRC cases diagnosed. This may be reflected by the fact that many patients referred to the fast-track clinic did not comply with the guidelines. Although the TWR remains a valuable service to GPs and their patients and that its low CRC yield may be partly due to the nonspecific nature of the disease, the results from this study and many similar audits suggest that the system is in need of independent evaluation and improvement. The effectiveness and efficiency of any future system in detecting CRC will depend on the sensitivity and specificity of the referral criteria, the ease with which GPs could identify the criteria, and the extent to which they choose to use the new service. This will require well funded programmes with increased support and feedback to GPs to encourage the appropriate use of guidelines in the decision to seek referral. Acknowledgement Advice regarding the submission was sought from Mr. Kamal Nagpal, Upper GI Research Fellow, St Mary’s Hospital, London References: 1.

Interestingly, similar outcomes in the cancer detection rate using the TWR referral system have been reported for other cancers. There has been a decline in the breast cancer detection rate since the introduction of the TWR, despite an increase in the number of fast-track referrals.16 Our study has shown that CRC is most often detected using the TWR system in patients presenting with later stage (Dukes’ stage C and D) disease. Similarly, Debnath et al. reported an early cancer detection rate of only 4.6%.17 These findings suggest that the referral system is ineffective in identifying early stage CRC and raises a question of whether it translates into any apparent future survival benefit. Earlier presentation of CRC is very non-specific, and if the TWR system is to detect these earlier malignancies, its criteria would need to be even more non-specific than it currently is. A solution to this problem would be to introduce a national screening programme for CRC. Faecal occult blood testing (FOBt) has been suggested as a possible screening tool and can detect CRC at an early and more treatable stage. It also

3. 4. 5.

10.

Gatta G, Capocaccia R, Sant M et al. Understanding variations in survival for colorectal cancer in Europe: a EUROCARE high resolution study. Gut 2000;47:533-8. Ciccolallo L, Capocaccia R, Coleman MP et al. Survival differences between European and US patients with colorectal cancer: role of stage at diagnosis and surgery. Gut 2005;54(2):268-73. Department of Health: NHS Cancer Plan. London; 2000. Department of Health: Referral Guidelines for Bowel Cancer. London; 2000. Chohan DPK, Goodwin K, Wilkinson S, Miller R, Hall NR. How has the “two-week wait” rule affected the presentation of colorectal cancer? Colorectal Dis 2005;7(5):480-5. Thorne K, Hutchings H, Elwyn G. The effects of the TwoWeek Rule on NHS colorectal cancer diagnostic services: A systematic literature review. BMC Health Serv Res 2006;6:43. John SKP, Jones OM, Horseman N et al. Inter general practice variability in use of referral guidelines for colorectal cancer. Colorectal Dis 2006;9(8):731-5. Smith RA, Oshin O, McCallum J et al. Outcomes in 2748 patients referred to a colorectal two-week rule clinic. Colorectal Dis 2006;9:340-3. Eccersley JA, Wilson EM, Makris A, Novell JR. Referral guidelines for colorectal cancer – do they work? Ann R Coll Surg Engl 2003;85:107-10. Rai S, Kelly MJ. Prioritization of colorectal referrals: a review of the 2-week wait referral system. Colorectal Dis 2006;9:195-202.

lsjm 15 june 2009 volume 01

ASK THE EXPERT

What is the WHO Surgical Safety Checklist? Sebastian Yuen MBBS DCH MRCPCH FHEA

sebastian.yuen@institute.nhs.uk Consultant Paediatrician, Royal Free Hospital, London Fellow, NHS Institute for Innovation and Improvement

In 2000, in Llanelli, South Wales, two experienced surgeons removed the wrong kidney, leaving the patient in complete renal failure. A medical student had realised the error prior to surgery and alerted the surgeons.1 She was unable to persuade them to stop and the patient died five weeks later. The root cause was the clerking, which identified the wrong side for surgery and led to the operating list being booked incorrectly. In theatre the scans were displayed back to front. Catastrophic events are seldom the result of a single error, but more commonly result from the accumulation of multiple minor errors. The World Health Organization (WHO) created the Surgical Safety Checklist as part of the Safe Surgery Saves Lives programme.2 A world-wide study with nearly 8000 consecutive patients compared complication and mortality rates before and after the introduction of the checklist.3 The results demonstrated a reduction in mortality from 1.5% to 0.8% (P = 0.003) and complications from 11.0% to 7.0% (P<0.001) when the checklist was used. The impact was greater in developing countries than high-income centres, but there were improvements in all eight sites. In January 2009, the United Kingdom’s National Patient Safety Agency released an alert requiring all hospitals to implement the checklist for every patient having surgery.4 25 items are divided into three sections, each to be read out loud. “Sign In” occurs pre-anaesthesia and confirms the patient’s identity, allergies, procedure, site (including mark) and consent. Other important checks include anticipated airway problems and risk of significant bleeding. “Time Out” occurs prior to skin incision. All team

lsjm 15 june 2009 volume 01

members introduce themselves by name and role. During the surgical pause, the surgeon and anaesthetist verbally repeat the patient, site, procedure and predictable complications. The “Sign Out” requires a written plan of management, instrument count and ensures specimens are labelled correctly. The aim is to ensure that key safety checks are made reliably for every patient, instead of relying on memory. It is important to remember that the checklist is simply a tool. Its effectiveness will depend on how it is implemented and the value placed on safety within the culture of the department. As students observing procedures in theatre, you have a duty to speak up if you have any concerns. As a result of the introduction of the checklist, the team should now respect and listen to you. The WHO website has videos of Atul Gawande using the WHO checklist.2 References 1.

2. 3.

Dyer O. Surgeon is struck off for failing to mention disciplinary action. BMJ 2005;330:274 (5 February) doi:10.1136/bmj.330.7486.274-a WHO Safe Surgery Saves Lives. World Health Organisation [online]. 2009. www.who.int/safesurgery [Last Accessed 11 April 2009] Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491-9 doi:10.1056/NEJMsa0810119 WHO Surgical Safety Checklist. National Patient Safety Agency [online]. 26 January 2009. http://www.npsa.nhs.uk/nrls/alerts-anddirectives/alerts/safer-surgery-alert [Last Accessed 11 April 2009]

STUDENT COMMENTS

Maximising your Surgical Placement Anish Amlani BSc (Hons), Amin Elmubarak BSc (Hons)

Year 5 Medicine, Imperial College London anish.amlani@imperial.ac.uk, amin.elmubarak@imperial.ac.uk

Medical students can often take some time to find their feet when AA and AE are joint co-authors on surgical placements. Upon reflection, the early weeks are Competing Interests: None often unproductive and disorganised, until familiarity, etiquette Declared and routine are eventually established. This article aims to provide anecdotal advice from two medical students who have been through this cycle too many times, and have learnt from their mistakes. Surgical placements are NOT just for ‘future surgeons’ – there’s a lot to be learnt by every medical student. The surgical rotation is often as equally revered as it is anticipated. But with the right preparation and attitude, you can not only sail through your surgical exam but also get an accurate taste of a life in surgery. Hopefully, this guide will help you get the most experience out of your placement. Keenness is the KEY There is a lot to be gained from a surgery firm, whether you want to become a surgeon or not. Surgical firms allow you to get into theatre and see anatomy first hand. You will get a chance to see all those signs and symptoms that you can recite but have yet to see. This will aid you in retaining and understanding knowledge better than any textbook can. As you will also get to see and possibly (if you play your cards right, see later) feel real abnormalities. Following a case from admission to discharge can be extremely interesting and in some cases fascinating.

Surgical firms provide an invaluable opportunity to gain proficiency in basic examination Practising examinations with other students is great, especially for exams earlier on in medical school, but at the end of the day we are in medical school to become doctors (something often lost sight of). You will be a much more confident and better prepared Foundation Year 1 (FY1) doctor if you have examined real patients throughout your medical school training and found abnormal signs yourself. Also, more importantly how can you identify organomegaly if you have never felt it? The early bird Get there as early as possible – if handover starts at 7:30, make sure you’re there 10 minutes before. At the very least it will give you a chance to skim through the handover sheet and read up on any of the conditions that the patients have. Be part of your team Talk to your team, from House Officer to Registrar and try to gauge how things are done in the firm; every firm differs from hospital to hospital, speciality to speciality and Consultant to Consultant. Do not forget that an integral part of the team are the nurses and ward clerks – ensure that you introduce yourself to them from the start – as they are on the wards for a lot longer than anyone else and are an invaluable resource for doctors and medical students alike. They are great for teaching you those basic clinical skills that are

lsjm 15 june 2009 volume 01

STUDENT COMMENTS important both for exams and your first few years as a junior doctor. Also, if you are looking for interesting or co-operative patients to examine or clerk, the nurses will always be able to point you in the right direction. Try to clerk, and if possible examine all the patients that are in the care of your firm and present to any member of the team that has time for you. Read up on as many patients’ conditions as possible including: signs, symptoms, management (surgical and medical) and prognosis. You will definitely be quizzed when presenting your history. Be useful House Officers are very busy and Surgical House Officers are very, very busy. So if you want teaching offer to do their bloods or take the histories of patients that they need to see. If the House Officers finish early with your help, they may be free to give you some teaching. Clinics Though it may sound boring in your first few visits, you will quickly learn that with the advancements in both surgical and non-surgical management, a vast majority of the modern surgeon’s time is spent in the clinic. Remember the old motto: proper preparation prevents poor performance. If you know what the clinic is about then make use of your journey by reading up on the subject and never be afraid to ask questions if things are unclear. Beyond that, the same principles apply: push yourself forward. Before you know it, the staff nurse will be giving you your own room, you will be clerking patients and coming up with your own differential diagnoses and treatment plans. Don’t be afraid of making mistakes as long as you learn from them.

Assisting Surgery like all aspects of medicine is about teamwork and a surgeon cannot perform an operation by himself or herself. Even if you are just holding a retractor, as an assistant you are performing an essential role. Is it worth it? Definitely – whilst assisting, you will be able to observe the operation from the best seat in the house. Finally Never be afraid to ask to be excused if you are feeling faint. It would be a lot worse to faint mid-surgery and land face first in an open surgical field (it has happened). Surgical firms offer incredible and rapid learning opportunities for medical students. However, they are often not exploited for the wealth of experiences available. So turn up early, make yourself a regular and get stuck in.

Box 1 : Top 10 tips for theatre 1. 2. 3.

4. 5.

From practising how to ask sensitive questions, to taking histories and practising those all-important examinations, clinics are a great time to learn. If you know what your weaknesses are you may be able to get some guidance in real relevant clinical situations and you may also be lucky enough to receive one-on-one tuition from the Registrar or Consultant – depending on how busy the clinic is. The fun bit – Theatre! Whether you are going into theatre to hone your anatomy, see some abnormalities or because you know that surgery is for you, it’s important to know what to expect and to observe the etiquette of theatre to maximise your experience. Theatres can be surprisingly small and medical students are not usually in there to contribute anything, so if you get in the way it will not go down well. So follow our ten handy hints (see Box 1): Scrubbing up This is an essential skill in theatre and one that is easily learnt. If you do not demonstrate the competence to scrub in proficiently and quickly, surgeons are never going to let you near an open surgery. Queen’s University Belfast provide easy to follow instructions (see Further Reading) – read this before your first day in theatre and never be afraid to arrange time with a scrub nurse to teach you if you are still not sure.

lsjm 15 june 2009 volume 01

6. 7. 8. 9. 10.

Try to eat and have something to drink prior to going into theatre, fainting isn’t fun and can be pretty embarrassing. Find the changing rooms. It is easy to get lost. Find some clogs that fit well because you could be standing for a while. N.B. Wearing your Consultant’s/Registrar’s clogs will NOT go down well. It is not normally worth buying your own clogs as an undergraduate but for those of you who do not want the hassle of continuously looking for clogs, go to http://www.crocs.eu/. Turn your mobile phone OFF, no one likes the medical student who leaves it on silent and then everyone hears the vibrating or worse still, tries to stop it ringing whilst scrubbed up. Prior to entering the scrub room or theatre, ensure you are wearing a scrub cap to cover your hair. (Girls tie your hair up and then put on the cap. For students that wear religious headscarves of turbans, the larger theatre caps will normally go over these. Always ask your specific consultant for advice, however, if you are unsure as to what to do.) Introduce yourself to the scrub nurse. (Re) Introduce yourself to the patient prior to them being anaesthetised. If you have not managed to clerk and examine the patients on the list, at least ask the scrub nurse or your FY1 which procedures are being performed that day. When instruments and the patient are being wheeled in, do not stand in front of anything, especially doorways – you will only be in the way. Always ask to scrub in and do not be afraid to assist.

Further Reading http://www.qub.ac.uk/cm/sur/teaching/year3/introductorycourse.pdf – Queen’s University Belfast Guide to Scrubbing The authors of this published article do not claim to be experts. If you would like to act on any advice provided, you are strongly advised to seek expert opinion in the field. Any mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the authors, editors or the London Student Journal of Medicine.

BOOK REVIEW Principles of Surgery Principles of Surgery: Everything you need to know but were frightened to ask! Sam Andrews and Luke Cascarini Publisher: TFM Publishing Ltd ISBN: 1903378575 United Kingdom Recommended Retail Price: £25 Imagine the morning ward round on your first surgical attachment. The registrar has just asked you a seemingly simple question, “Why was this patient shivering when she woke up after her operation?” You find yourself searching for a coherent answer, fully aware that the longer you keep the registrar waiting, the better the answer he expects. “They might have been cold?” you reply sheepishly, hoping they ignore your patent answer – but they push on, “and…?” demanding you to delve deeper into this conundrum. Principles of Surgery intends to sum up ‘everything you need to know but were frightened to ask’ about the field of surgery. This is a tall order for such a short text but as you read, you will quickly realise that the authors, Messrs. Andrews and Cascarini, fully appreciate the classical medical student dilemma of trying to work out what we need to know whilst still trying to learn for the career ahead. The authors - a Consultant General and Vascular surgeon and a Specialist Registrar in Maxillofacial surgery respectively - have a combined experience of fifteen years of being a student. Through an effective question and answer format, they cover the key issues that any health professional should know about peri-operative medicine. For each question posed, there is a comprehensive answer, explaining the reasons for routine tests and pertinent ‘Red-Flag’ signs and symptoms, for example: ‘what factors predispose to wound dehiscence?’ and ‘how do you recognise and treat postoperative pneumothorax?’ The book is targeted at students of any healthcare profession that have contact with surgical patients. Principles of Surgery is more than a surgical dictionary but a well-structured discussion of the medical care of a surgical patient. In this way, it can be compared to popular surgical texts such as Surgical Talk. However, this book does not describe favourite OSCE examinations: It instead fills in the gaps in a student’s knowledge that these other texts fail to cover. Written in an informal yet didactic style, the book is easily digested and allows for quick referencing with a comprehensive index and division into three sections focusing on pre-operative care, operating theatre environment and post-operative care and complications. It is all too easy on a surgical ward round to miss the opportunity to ask about a patient’s individual management. For example, students have to try and collate information from many sources to deduce why some patients are sent to ITU and others can be treated as day cases. The answers are clearly described in this book. Principles of Surgery has an excellent chapter discussing concomitant conditions and the resulting differences in the management of the elderly, emergency patients and those with co-morbidities. The authors also explain the basic principles of anaesthesia and describe the functions of basic operating equipment. It even lists commonly used drugs with the trade names printed alongside to give students a fighting chance on a lightning-fast ward round.

The pre-operative section of Principles of Surgery focuses on the clerking jobs carried out by house officers and in this respect is not directly relevant to medical students but does explain the reasoning for pre-operative haematology and biochemistry. The section about the operating theatre environment does state the obvious in places and you could be forgiven for thinking that it is written for students and junior doctors that never bothered to scrub in when at medical school. All of the information offered is extremely useful when on the wards, in theatre and when presented with a surgical patient with multiple pathologies, but will this help you in exams? The book gives students a framework on which to hang information gleaned from bedside teaching and other sources. I personally found the post-operative sections the most useful and elements of this included potentially examinable material especially for critical care OSCE stations. In conclusion, Principles of Surgery would be an excellent candidate for a companion read to other surgical, pathology and clinical examination textbooks and would certainly be of benefit whilst on the wards or just to read up before presenting a surgical case. It is surprising how much useful information is contained within this book and perhaps a more appropriate subtitle should be, ‘everything you hope you never get asked in surgery (but really should know!)’ Conrad von Stempel Year 1 Clinical Medicine, UCL Medical School vonstempel@gmail.com

lsjm 15 june 2009 volume 01

LSJM PROFILE

Mr Niall Kirkpatrick Current post Consultant Craniofacial Plastic Surgeon Lead clinician for the Craniofacial Unit, Chelsea & Westminster Hospital, London Member of the Head & Neck Unit, Charing Cross Hospital, London Medical School/Undergraduate Studies BDS Guy’s Hospital Dental School, London 1984 MBBS Guy’s Hospital Medical School, London 1990 Postgraduate MD University of London 1996 FRCS (Eng) 1996, FRCS (Plast) 2001 What do you do? Reconstruction of congenital paediatric & adult craniofacial deformities. Acute facial trauma and reconstruction following Head and Neck cancer ablative surgery. I work within a large multidisciplinary team consisting of a number of head/neck surgical specialists including ENT, Neurosurgeons, Oculoplastic and Maxillofacial Surgeons. I also participate in joint clinics with Dermatologists in the treatment of complex facial skin malignancies. Why did you get involved in surgery? My interest in surgery stems from my time as a final year dental student. During a Maxillofacial surgery elective attachment at St Richard’s Hospital, Chichester there was a large road traffic accident. I worked throughout the night with the surgical team in the reconstruction of those involved in the accident. This is where my early interest in surgery began. After completing my medical studies at Guy’s Hospital I went on to do a number of surgical jobs in A&E, Anatomy Demonstration, General Surgery, ENT and Plastic Surgery. I then went on to complete a Specialist Registrar rotation in Plastic Surgery on the Pan-Thames scheme and eventually subspecialised in Craniofacial surgery in light of the training I had completed previously, with specialist Fellowships in the Craniofacial units at the Chelsea and Westminster Hospital and Great Ormond Street Hospital as well as a Head and Neck Fellowship at the Royal Marsden Hospital. Why plastic surgery? I have always been interested in art and especially enjoyed pottery whilst at school. Plastics is a specialty where there is a meld of science, surgery and artistry. It requires the surgeon to be manually dextrous, with good visuo-spatial ability as well as the ability to plan ahead. Describe a typical day. I get up at around 6.15am. I am usually in the hospital by 7am to sort out my administrative duties. The pre-operative ward rounds start around 8am. I spend most days operating. It is not unusual for operations to last 6-8 hours with several consultants operating simultaneously. 8 hours feels like a few minutes because one becomes so engrossed in the surgery. I finish the day with a post-operative ward round at about 6.30pm and am usually back at home at 8.30pm.

lsjm 15 june 2009 volume 01

What is the most important thing you learnt as a student? To adopt a holistic approach to surgical care. The surgery itself only forms a small part of the care of a patient and one must understand their psychological and social backgrounds. Surgery as a specialty is a predominately postgraduate apprenticeship. It is important to develop your communication skills and to develop other parts of patient care whilst at medical school. I understand that you are involved with the charity ‘Facing the World’. How did you become involved and what are the charities main aims? I have been involved in the charity since its inception whilst working as the Craniofacial Fellow at Chelsea and Westminster Hospital with my colleagues Mr Norman Waterhouse and the late Mr Martin Kelly. My brother is a charity lawyer and helped found it. We, along with a number of other volunteer surgeons, offer complex facial reconstructive surgery that usually requires postoperative intensive care facilities not locally available to children across the world. These children otherwise have no chance of finding the surgery to overcome their disfigurement. We also support research and have PhD opportunities in partnership with Imperial College London. We are also in the process of collaborating with centres in Vietnam and Ghana. An exchange programme has been organised where senior surgeons from Vietnam come to train in the UK for a period of 6 months and then take back their knowledge and disseminate it within their own departments. What advice do you have for those wishing to pursue Plastic or Craniofacial surgery as a career? Firstly, be honest with yourself about whether you have good manual dexterity. It also helps if you have an artistic bent. Learn more about the profession and understand that Plastic surgery is much more than just Aesthetic/Cosmetic surgery. The main thing when choosing a career is to “follow your heart”, and if you really want to pursue something then “go all out for it”. Plastic surgery is an immensely wide ranging, and rewarding profession. Kalpesh Vaghela Year 5 Medicine, Imperial College London and LSJM Panellist vaghela04@imperial.ac.uk