Surgeons Scope Magazine Issue 2 - 2023 by RCSI

THE MAGAZINE EXCLUSIVELY FOR RCSI FELLOWS AND MEMBERS ISSUE 2 2023

A SURGEON IN PENANG DR PRABHU RAMASAMY

BACK TO THE BEGINNING PROFESSOR GRAEME CLARK

ON THE RISE MORE WOMEN IN UROLOGY

COLLES Q&A MR EAMON MACKLE

› Letter

A LETTER FROM THE PRESIDENT, RCSI PROFESSOR LAURA VIANI

RCSI Fellows and Members, It is my pleasure to welcome you to the third edition of Surgeons Scope since my Presidency began in June, 2022. This year has been a productive one and I have enjoyed many opportunities to meet with you both at home in Ireland and abroad. With a global professional network of over 11,000 Fellows and Members in 89 countries, we are all too familiar with the major challenges facing healthcare delivery around the world, and I am privileged, as your President, to represent you and advocate on your behalf on the issues that impact us all. Robotic Surgery It has been a very busy year in the College, and we have made much progress. We have seen a rapid rise in technological-enhanced surgery and AI. Robotic Surgery and training are now becoming the norm across medical hospitals and institutions around the world. RCSI, in partnership with the International Medical Robotics Academy (IMRA), recently announced a unique online robotics course, the ‘Foundations of Robotics’. Developed by surgeons for surgeons, its curriculum is delivered using virtual reality, 3D videos, simulators and advanced synthetic organ models. We intend to offer global access to this online robotic surgery course to doctors around the world. Gender Parity The issue of gender parity among consultant surgeons has been of particular importance to me during my Presidency, and RCSI has made major strides in the promotion of diversity and gender equality. It gives me particular pleasure to report that the proportion of female candidates joining the National Surgical Training Programme has increased from 27% in 2017 to 48% this year, and applications came from 34 different nationalities, up from just 12 in 2017, which shows great progress. We continue to deliver exceptional postgraduate surgical education and training and medical education programmes and our surgeons, male and female, hold leading positions in institutions around the world. Commitment to Better Patient Care RCSI is committed to supporting doctors worldwide in reaching their full potential and we will continue to expand our relationships with global medical institutions for the benefit of patient care. As RCSI strives to make patient care safer worldwide, we have become one of the leading institutions globally in the field of Human Factors in Patient Safety. Interprofessional learning has been the driver of our online Human Factors in Patient Safety programme, and it fits the needs of our global network of busy healthcare professionals. Online education has allowed us to expand into 30 countries, teaching the importance of non-technical skills to create positive change in practice.

RCSI President, Professor Laura Viani.

New RCSI Strategy RCSI recently launched the strategic plan for 2023-2027. Outlining how RCSI will fulfil our mission to ‘Educate, Nurture and Discover for the Benefit of Human Health’, it is a roadmap for the next five years, uniting the RCSI community in supporting the UN Sustainable Development Goals – with a particular focus on good health and wellbeing. This strategy is particularly fitting at a time when RCSI is the highest-ranked institution in the world for impact on health and wellbeing. It is very exciting to see the ambitious plans set out in this new strategy, and I look forward to seeing its impact over the coming five years. MRCS Growth With the rapid growth of the MRCS Examinations, RCSI now delivers the Part A examination to over 65 countries. This demonstrates our dedication to helping our global surgical community reach their full potential. As we expand our MRCS Part A numbers, we have developed multiple supports for exam candidates so that aspiring surgeons can strive towards career success. RCSI recently announced the official agreement with the Armed Forces SURGEONS SCOPE / 1

› Letter

More than ever now it is so important that we remain connected, encouraging conversations and ensuring a diverse voice and global representation.

Professor Patricia Joy Numann, Lloyd S. Rogers Professor of Surgery Emeritus, State University of New York Upstate Medical University, New York.

College of Medicine (AFCM), Cairo, Egypt for the delivery of the MRCS Part B examinations. The facilities within the AFCM in Cairo are truly outstanding and will provide our ever-growing global candidates an opportunity to sit the MRCS examinations worldwide. Charter Day February 2024 As you know, Charter Week is RCSI’s major surgical conference, which we host annually in Dublin. Charter Week celebrates the foundation of the College and the granting of the Charter by George V in 1784. This year our theme will be ‘Rising to Challenges in a Changing World’, a theme that resonates with us all. Charter Week 2024 will take place from 6 to 9 February. I hope you agree this presents a great excuse to pay a visit to Dublin, and I warmly invite and encourage you to attend. More than ever now it is so important that we remain connected, encouraging conversations and ensuring a diverse voice and global representation. These conversations will guide us and ensure that we are focused on the issues of greatest concern to our global community. Surgeons Scope and our monthly newsletter are a wonderful means of communication with leaders and innovators in healthcare around the world. We seek out and look forward to featuring stories of innovation and inspiration from RCSI Fellows and Members who are making a difference every day. In this issue of Surgeons Scope, my friend and mentor Professor Graeme Clarke, pioneer of the bionic ear, or multi-channel cochlear implant, who was recently awarded an Honorary Fellowship of RCSI, provides us with a fascinating account of his life’s work thus far (page 22). What a wonderful story of commitment and a lifetime dedicated to helping severely-to-profoundly deaf people to understand speech. Also, in this issue, surgeon Dr Prabhu Ramasamy tells of life and work in Malaysia, specifically on the island of Penang, where he grew up (page 18). We also hear about Operation Childlife (page 14), an initiative which brings lifesaving and life-transforming surgeries to children in less developed countries. In an extract from his recently published book Oops! Why Things Go Wrong (page 26), Niall Downey, a cardiothoracic surgeon who retrained as an airline pilot, reveals how he believes that healthcare could learn from aviation’s safety management systems to improve patient safety. In RCSI Women in Urology (page 10), female urologists reflect on the rising number of women in this subspecialty, a worldwide trend that is to be welcomed. I hope you enjoy this issue, which reflects the work of wonderful, talented surgeons, exciting collaborations and innovation, and our continued commitment to better healthcare delivery. Since being elected President of RCSI, with your support we have made much progress and I have the utmost confidence that, working together, we can continue to contribute positively to health science education and delivery in the coming years. Finally, I would like to take this opportunity to wish you and your loved ones a very happy holiday and I hope that 2024 brings you health and happiness. Best wishes

Professor Paul Brennan, Consultant Radiologist, Bon Secours Hospital, Dublin.

Professor James Drake, Surgeon in Chief, The Hospital for Sick Children, Toronto.

SURGEONS

THE MAGAZINE EXCLUSIVELY FOR RCSI FELLOWS AND MEMBERS

Contents 04

14 THE MAGAZINE EXCLUSIVELY FOR RCSI FELLOWS AND MEMBERS ISSUE 2 2023

A SURGEON IN PENANG DR PRABHU RAMASAMY

BACK TO THE BEGINNING PROFESSOR GRAEME CLARK

ON THE RISE MORE WOMEN IN UROLOGY

COLLES Q&A MR EAMON MACKLE

ON OUR COVER

Dr Prabhu Ramasamy, Loh Guan Lye Specialists Centre, Penang, Malaysia.

Scope News

26 26

It’s Complicated

Colles Q&A

Scope Events and Diary

Appointments, awards and RCSI’s new strategy 2023-2027

The Cutting Edge

Urology in Focus

Operation Childlife

In Memoriam

A Surgeon in ... Penang

Back to the Beginning

A piece of Dr Ronan Kelly’s new history of RCSI

Airline pilot and former surgeon Neil Downey on the management of medical error

Mr Eamon Mackle on work, life and wishful thinking

Conferrings, gatherings, occasions at RCSI

Female urologists on the gender equation

Consultants contribute to global paediatric healthcare

Remembering Professor Sean Tierney

Meet Mr Prabhu Ramasamy, colorectal and general surgeon in Malaysia

Eminence grise: Professor Graeme Clark on his life and work

RCSI SURGEONS SCOPE MAGAZINE is published bi-annually by RCSI for surgical Fellows and Members. Issues are available online at www.rcsi.com. Your comments, ideas, updates and letters are welcome. Please contact Catherine Jordan, Managing Editor, in the Fellows and Members Office, 111 St Stephen’s Green, Dublin 2; telephone: +353 1 402 2116; email: catherinejordan@rcsi.com. RCSI Surgeons Scope is posted bi-annually to Fellows and Members in Good Standing. To ensure you continue to receive your copy, please send your current contact details to fellows@ rcsi.com. RCSI Surgeons Scope is produced by Gloss Publications Ltd, The Courtyard, 40 Main Street, Blackrock, Co Dublin. Copyright Gloss Publications.

OUR HERITAGE RCSI’s mission is to educate, nurture and discover for the benefit of human health. Founded in 1784 with surgery at our core, we are an independent, not-for-profit, world leading international health sciences education and research institution, with a deep professional responsibility to enhance human health. SURGEONS SCOPE / 3

› News

SCOPE NEWS Appointments, awards, safe surgery and a new strategy for RCSI MR BARRY MCGUIRE APPOINTED AS PROFESSOR OF SURGICAL EDUCATION AND ACADEMIC DEVELOPMENT RCSI is delighted to announce the appointment of Barry McGuire as Professor of Surgical Education and Academic Development. Barry is a graduate of RCSI and the specialist urology training scheme in Ireland. He completed a fellowship in Northwestern Memorial Hospital, Chicago in the area of robotics, laparoscopic and percutaneous surgery. He was appointed as a consultant urologist in Beaumont Hospital in 2015 and subsequently to St Vincent’s University Hospital in 2017 where he has worked to date.

RCSI Vice President, Professor Deborah McNamara, awarded Honorary Fellowship of American College of Surgeons Professor Deborah

McNamara, Consultant General & Colorectal Surgeon at Beaumont Hospital, Dublin; Clinical Professor in Surgery at the Royal College of Surgeons in Ireland; Co-Lead of the National Clinical Programme for Surgery and a member of Council at RCSI, has been made an Honorary Fellow of the American College of Surgeons.

SURGICAL HUBS LAUNCH In May, we welcomed the announcement from the Minister for Health that sites have been selected for new surgical hubs. We hope that the expansion of elective surgical services, through these new hubs, will help improve access to timely, scheduled surgical care for patients and increase much-needed surgical capacity in Ireland.

Pictured (l-r) at the launch of the e-learning module in RCSI’s state-of-the-art simulation suite is Professor Deborah McNamara (Vice President of RCSI and Co-Lead for NCPS); Ruth Kiely, Programme Manager for NCPTOS; Ciara Hughes, Programme Manager for NCPS; Aileen O’Brien, Nurse Lead for NCPA; and Professor Laura Viani, RCSI President.

NEW E-LEARNING MODULE FOR SAFE SURGERY A new e-learning module has been developed to support the HSE

National Policy and Procedure for Safe Surgery, which was updated in 2022. The policy highlights the importance of respecting the ﬁve stages of safe surgery, including the checklist process. The module encourages all staff working within the operating department to ensure that safe surgery guidelines are followed by all team members in order to deliver safe, quality care to patients.

MRCS B Exam Centres In September, RCSI launched our new North Africa MRCS Part B Exam Centre adding to current centres in Europe, the Gulf Regions and South East Asia and increasing much needed exam capacity. The Surgical Affairs team need Fellows to volunteer to become Examiners. Please email examiners@rcsi.ie if you think you can help.

RCSI launches new electronic logbook for NCHDs

A new eLogbook for non-consultant hospital doctors (NCHDs) registered on the Continuous Professional Development Support Scheme has been launched by RCSI. The RCSI eLogbook was developed to provide surgical NCHDs in non-training places access the same electronic logbook as surgical trainees in core and higher surgical training programmes in Ireland. NCHDs who avail of the RCSI eLogbook will be able to upload future and historic procedures they carried out in Ireland. This service is available free of charge to surgical NCHDs registered on the RCSI CPD Support Scheme and is voluntary for NCHDs to use. 4

NATIONAL PERIOPERATIVE PATIENT PATHWAY ENHANCEMENT PROGRAMME As an integral part of a system-wide effort to improve

patient access to scheduled care and reduce waiting lists, RCSI has commenced a new programme aimed at enabling a more efﬁcient and effective use of HSE theatre and procedure room resources.The National Perioperative Patient Pathway Enhancement Programme (NPPPEP) is an 18-month, data-driven programme which will bring together knowledge and insights from frontline theatre staff and operations departments from hospitals across Ireland.

› News

STEPHEN MURPHY ANNOUNCED AS WINNER OF RCSI ART AWARD 2023 Stephen Murphy has been announced as the winner of the RCSI Art Award 2023 in association with the Royal Hibernian Academy (RHA) and The Irish Times. The Cork-born artist was awarded the prize for his sculptural work, ‘Newborn (The hardest day of your short life yet)’. It was selected from a shortlist of five pieces drawn from more than 560 works on display at the 193rd RHA Annual Exhibition, Ireland’s largest and longest-running exhibition of visual arts. Now in its eighth year, the RCSI Art Award celebrates the long-standing association between art, medicine and wellbeing. At an event held in the RHA, Stephen Murphy was awarded the RCSI Silver Medal, a prize fund of ¤5,000 to progress his practice, and a ¤10,000 commission to create a new piece for the RCSI Art Collection. For further information on the RHA Annual Exhibition, visit www.rhagallery.ie.

Topping Out Ceremony, Connolly Hospital RCSI President, Professor Laura Viani officiated a ceremony in June to mark the topping out of the new RCSI Education and Research Centre at Connolly Hospital. Due to open in September 2024, it will be RCSI’s second clinical centre of academic excellence in Ireland. Spanning three floors, the new facilities include lecture theatres, tutorial rooms, a public café and atrium, student recreation space and new state-ofthe-art HSE laboratories.

CELEBRATING THE LEGACY OF PIONEERING IRISH SURGEON ABRAHAM COLLES On the 250th anniversary of his birth, we celebrate the life and legacy of pioneering Irish surgeon Abraham Colles. Abraham Colles (1773-1843) was a surgeon, physician and anatomist, and a leading figure in the golden age of Irish medicine in the 19th century. He also had a strong connection with RCSI, being a past pupil, professor and President. Colles revolutionised the teaching of anatomy in medical schools around the world with the publication of his groundbreaking Treatise on Surgical Anatomy in 1811. This work prompted a radical departure from established approaches to the study of human anatomy and proposed a new model of teaching that lent itself much more readily to the realities of clinical practice for surgeons and physicians in the 19th century.

RCSI Charter Meeting 2024 has as its theme ‘Rising to Challenges in a Changing World’, and takes place on Tuesday, 6 February – Friday, 9 February at RCSI Dublin. Key sessions include: Surgery Responding to Global & Environmental Change; Transitions in a Surgical Career; Crisis Management: What Have We Learnt; and Technology of the Future for Irish Surgery. The 31st Carmichael Lecture will be delivered by Mr Fergal Keane OBE. The 99th Abraham Colles Lecture will be delivered by Professor David Nott, OBE DSc, MD, FRCS. View the programme on page 32 and register now at www.rcsi.com.

Charter Meeting 2023.

Professor Cathal Kelly, Vice Chancellor, RCSI; Professor Laura Viani, President, RCSI; and Connor Lenihan, President, RCSI Students’ Union, pictured at the launch of RCSI’s new strategic plan.

New strategy will see RCSI enhance health and wellbeing and sustainable development In October, RCSI's strategic plan

for 2023-2027 was announced. Built around four themes, the strategy outlines how we will fulfil our mission to ‘Educate, Nurture and Discover for the Benefit of Human Health' and innovate for a healthier future. The strategy sets out a roadmap for the next five years and unites the RCSI community in supporting the UN Sustainable Development Goals – with a particular focus on Goal 3, which targets good health and wellbeing. It is fitting that this strategy is launched when RCSI is the highest-ranked institution in the world for its impact on health and wellbeing.

MINIMUM STANDARDS FOR ACUTE SURGICAL ASSESSMENT UNITS PUBLISHED The National Clinical Programme in Surgery, in collaboration with HSE Acute Operations and the Healthcare Pricing Office, have launched updated standards for acute surgical assessment units in Ireland. Acute surgical assessment units (ASAUs) have reshaped the way that unscheduled care is delivered to patients who present to higher-volume hospitals with an acute surgical condition. These units allow senior surgical decision-makers to see patients promptly, thereby facilitating efficient and effective care. SURGEONS SCOPE / 5

› History of RCSI

THE CUTTING EDGE An extract from a new book on the history of RCSI, Every Branch of the Healing Art by Dr Ronan Kelly, charts the state of surgery before the College was established

We join the narrative in the year 1780, when the Dublin Society of Surgeons meet for the ﬁrst time in a Dublin tavern to plot their escape from the Guild of Barber-Surgeons… ll of these divorce proceedings beg the question: why were the surgeons yoked to the barbers in the first place? Surgery as a profession is defined by its ‘authority to cure by means of bodily invasion’. As a practice, there is evidence of rudimentary procedures – such as trepanation – going back to Neolithic times. Any regulation of the practice, however, comes much later. By the Middle Ages, most medical ‘treatment’ in Europe took place under religious auspices, usually at a monastery (‘treatment’ perhaps overstates what was essentially symptom control and a preparation for death; illness and disease being considered just rewards for sin). Two papal edicts – in 1163 and 1215 – forbade clergy from coming in contact with blood and other bodily fluids, after which they confined themselves to the more intellectual, book-based aspects of healing. Responsibility for bloodletting – by far the favourite response to just about any ailment – and other minor procedures devolved to the barbitonsores, those lay servants who already wielded sharp instruments for taking care of the monks’ tonsures. This division of medical labour fostered an already-evolving distinction between medicine, also known as physic (hence ‘physicians’) – and surgery, also known as chirurgerie (etymologically, the word comes from the union of ‘hand’ and ‘work’ in ancient Greek). As secularisation continued, the study of medicine found a new home in the early universities at Montpellier, Bologna, Paris, Oxford, Cambridge and elsewhere. In Ireland, the sole university, Trinity College, Dublin (established 1592), opened its ‘School of Physic’ in 1711. Physicians, then, were learned, literate, obtained medical degrees and called themselves ‘doctors’; it was not until the 19th century that they even used any instruments in making their diagnoses. Unfortunately for their patients, their diagnoses were largely based on the second-century teachings of Galen (CE 129 c.216). In his theory, human health depended on an internal balance of four fluids, or humours: blood, phlegm, 6

and black and yellow bile. The physician’s task was to interpret external signs – fevers, rashes, spots, diarrhoea – and prescribe a cure. More often than not, this was bloodletting (for which, call the barber-surgeon). Alternatively, he might prescribe the ingestion or application of herbs, purgatives or emetics (for which he sent the patient to the third branch of medieval healthcare, the apothecary). For a millennium and half, until the Renaissance, Western medicine hardly moved on from Galen’s theories. Nor did it question his anatomical teachings, which were based on his dissection of cattle, sheep, pigs, goats – even elephants – but not human corpses, which was entirely taboo. In general, physicians did not (physically) intervene into the fabric of the body. Rightly or wrongly, then, medicine enjoyed high status in medieval Europe. Surgical practice, meanwhile, as it spread beyond the monastic setting, endeared itself to few. Only when a patient had exhausted the expertise of their physician (or, for the poor, the local wise woman or folk healer) was surgical intervention contemplated. The practice inevitably meant pain, sometimes to excruciating degrees; operations had to be performed fast, often mercilessly; and anaesthesia, needless to say, was non-existent, though both patient and surgeon might swig something high-proof to steady nerves and lessen the horror. Some operators were better than others, but there was little meaningful distinction between a barber and a surgeon; with the necessary sharp blade, one could lance an abscess as easily as shave a beard. As guilds evolved as units of medieval civic society, the hybrid barber-surgeons were considered as one. For the benefit of their largely illiterate customers, they placed a sign above their door: the helical red-and-white pole still familiar in barbershops today (the occasional addition of a blue stripe is a much later American invention). Red and white remain the colours of RCSI’s livery. The surgeons were further separated from the physicians by the range of instruments they carried: saws, knives, hooks, needles and lancets. Having such tools of the trade identified surgeons as practical, hands-on craftsmen. And like other craftsmen – blacksmiths, say, or coopers or tailors – aspirant surgeons were trained by apprenticeship. Training began at age 13 or 14 and lasted about seven to nine years. How competent anyone turned out was a case-by-case affair, entirely dependent on the master’s diligence – or lack thereof. (As far as guilds were concerned, regulation was largely about protecting their exclusive rights and

› History of RCSI

The practice inevitably meant pain, sometimes to excruciating degrees; operations had to be performed fast, often mercilessly; and anaesthesia, needless to say, was non-existent ... prosecuting outsiders, as opposed to overseeing its members). Exceptional figures did of course appear, such as Roger Frugardi of Salerno (before 1140–c.1195), Guido Lanfranchi of Milan (c.1250–1315), France’s Guy de Chauliac (c.1300–1368) and the Englishman known as John of Arderne (1307–1392). War also advanced surgical knowledge, with barbers retained by armies for their ability to treat wounds. Even so, military surgery itself was limited; at a later date, looking back, an early RCSI President, Clement Archer (1748–1803) noted that so-called ‘capital’ operations were undertaken by ‘itinerant empiricks, hardened in butchery, ready to commit such acts of cruelty as the sober regular practitioners would shudder to think of ’. What drove a wedge between some barbers and the surgeons was the Renaissance revolution in anatomical understanding, exemplified in the work of Brussels-born Andries van Wesel (1514–1564) – aka Vesalius. His 1543 publication, De Humani Corporis Fabrica, overturned much Galenic thought, not least as Vesalius was a dedicated dissector of human cadavers. Across Europe, the provision of executed criminals for dissection was legalised, albeit in extremely limited circumstances. The first recorded anatomical dissection in Ireland took place in 1676, under the auspices of the Royal College of Physicians (founded 20 years earlier). The endeavour remained controversial, and on that occasion soldiers had to be posted outside to prevent relatives and sympathisers from seizing the body. (Vesalius, incidentally, was much maligned by his elders for threatening the Galenic system on which they had based their careers; eventually he burnt his unpublished works, abandoned his scientific career and took up private practice in Padua). In France, the barber-surgeons were less prevalent than elsewhere, and surgery developed differently. In 1268, a group of surgeons succeeded in registering themselves as a confrérie, or confraternity, in the Livre des Métiers (Book of Trades). Soon after, Louis IX’s surgeon, Jean Pitard, established them as a hierarchically structured guild: surgeons who wore a long robe were entitled to carry out medical procedures; those who wore a short robe were essentially confined to barbering. The confrérie was under the invocation of St Cosmas and

TOP A barber-surgeon attending to a man’s forehead (oil painting; Wellcome Collection). ABOVE The minute book of the Dublin Society of Surgeons, 1780. ABOVE RIGHT The Charter of the Royal College of Surgeons in Ireland (1784). RIGHT Proposals for the Advancement of Surgery in Ireland (1765). SURGEONS SCOPE / 7

› History of RCSI

O’Halloran’s Proposals may be considered the blueprint for RCSI. When the surgeons received their Royal Charter ... the connection with their barber brethren was finally cut.

TOP Remembering RCSI’s medieval origins. ABOVE LEFT RCSI in the 18th century. ABOVE Sylvester O’Halloran. LEFT Andreas Vesalius, often referred to as the founder of the human anatomy.

St Damian – two third-century Arabic doctors who were martyred under the emperor Diocletian – and was variously known as the Collège de St Côme, or the Collège des Chirurgiens (in both instances, the word collège is used in the sense of a collective professional grouping, as opposed to a teaching establishment). This spiritual dedication bore fruit several centuries later, when Louis XIII (1601–1643) took a special interest in the Collège for the simple reason that he had been born on the saints’ feast day, 27 September. He was made an honorary member of the Collège and, in turn, he give it the right to add the royal fleur-de-lis to its heraldic blazon of three little ointment boxes; he also endowed it with a motto, Consiloque Manuque – a shortened form of consiloque manuque morte artem pellet (thanks to his wisdom and his hand, death is kept in check). When the Collège was superseded in 1731 by the Académie Royale de Chirurgerie, the heraldry and motto endured. In all other respects, however, the new Académie was the most forward-thinking and – crucially – scientifically-minded surgical institution of its time. Someone who admired the innovative spirit of the Académie Royale de Chirurgerie was Sylvester O’Halloran (1728–1807). This Limerick-born surgeon had a particular interest in ophthalmology, publishing – at age 22 – A New Treatise on the Glaucoma, or Cataract (1750), based on his experiments with recently killed calves and living dogs. He also published on amputation (1763), gangrene (1765) and cranial injuries (1793), the last apparently derived from his experience in attending to the aftermaths of local-faction fights. As a young man, O’Halloran had furthered his training in Paris, London and possibly Leiden. He brought back from the French capital a singular sartorial style – a contemporary remembered him as ‘the tall, thin doctor, in his quaint French dress, with his goldheaded cane, beautiful Parisian wig, and cocked hat’. In addition, he brought first-hand knowledge of the Académie Royale, whose many achievements (‘the great advantages of which are universally acknowledged’) threw into relief their egregious absence in Ireland. So he published a document called Proposals for the Advancement of Surgery in Ireland (1765), laying out, as he saw it, what needed to be done. The Dublin Society of Surgeons was well aware of this document when it met 15 years later. Indeed, O’Halloran’s Proposals may be considered the blueprint for RCSI. When the surgeons received their Royal Charter – dated 11 February 1784 – the connection with their barber brethren was finally cut. ■ Dr Ronan Kelly is Heritage Research and Outreach Officer at RCSI. Every Branch of the Healing Art: A History of the Royal College of Surgeons in Ireland (Wordwell Books, €40) is available from www.wordwellbooks.com and good bookshops.

Make the most of your membership Use your post-nominals

RCSI Fellows and Members in Good Standing are entitled to many benefits, supports and resources. The most fundamental benefit is the use of your post-nominals. The FRCSI and MRCSI letters are globally respected and recognised for excellence. Make the most of your membership and use your post-nominals to highlight your affiliation to RCSI and your commitment to maintaining standards within our industry. Award

Post Nominals

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MRCSI (Ophth)

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DO-HNS

Fellowship of RCSI – Neurosurgery

FRCSI (Neuro.Surg)

Fellowship of RCSI – Cardiothoracic Surgery

FRCSI (C-Th)

Fellowship of RCSI – General Surgery

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Fellowship of RCSI – Paediatric Surgery

FRCSI (Paed.Surg)

Fellowship of RCSI – Plastic Surgery

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Fellowship of RCSI – Trauma and Orthopaedic Surgery

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For Fellows who affiliate with RCSI having passed the Collegiate Fellowship examinations that existed prior to 2002, Fellowship Ad Eundem and Honorary Fellows

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intFRCSI

For Fellows who affiliate with RCSI following success in a JSCFE examination

There is an annual subscription fee to maintain your membership and use your RCSI post-nominals. Find out more on rcsi.com/surgery/membership VERIFICATION All requests for award verifications can be sent directly to RCSI’s Records and Regulations Office by email to registry@rcsi.ie CONTACT INFORMATION

T: +353 (0)1 402 2116 | E: Fellows@rcsi.ie | rcsi.com/surgery/membership

› RCSI Women in Urology

RCSI WOMEN IN UROLOGY A review of two recent papers on gender equality in urology by three RCSI alumni in the subspecialty, led to reﬂection on the wider issues facing female surgeons ith gender imbalance more marked in urology than in many other specialties, the focus now is on whether enough is being done to address the historical barriers, biases and cultural characteristics stopping women taking up urology. Two recent papers provide data illustrating the current extent of gender inequality, while offering hope this is set to improve. Earlier this year, Women in Urology: Breaking Down the Barriers (wchh. onlinelibrary.wiley.com) addressed the topic of gender inequality in urology in the UK. As of 2021, 12% of consultant urologists in the UK were female, compared with 13% across all specialties. However, 37.5% of current UK urology trainees are female. In Ireland, the percentage is higher at 58%. In Women in Irish Urology: An examination of female representation amongst attendees of the Irish Society of Urology annual meeting 2008-2020 (pubmed. ncbi.nim.nih.gov), the authors drilled down into the detail of women’s underrepresentation at surgical conferences. It will not come as a surprise to learn that session chairs and guest speakers were overwhelmingly male, as were oral and poster presentations. However, the authors noted increased representation of women in recent years. They called on societies to increase female representation as the best way to perpetuate a positive feedback loop, and encourage future female trainees to pursue urological surgery. Ms Catherine Dowling, FRCSI (2013), Consultant Urologist at University Hospital Galway, one of the authors of Women in Irish Urology, links the current gender imbalance to the historically lower number of women pursuing careers in surgery. “Surgery is perceived as a longer and more diﬃcult path, attracting a harder, tougher person,” she says. “The low number of female urology consultants in the past meant a lack of female role models, and perhaps female medical students and early career doctors did not consider it a suitable career option.” Ms Bolton, FRCSI (2017), Consultant Urological Surgeon at Imperial College Healthcare NHS Trust in London, who credits Ms Dowling as an important mentor, did most of her urology training in Dublin, before going to the UK on Fellowship in 2018. She has been based there ever since, and was appointed as a consultant in 2020. She is one of two women on a 15-doctor urology team. She says that while gender balance has improved greatly over the last decade, there remain barriers to attracting women to urology. 10

Ms Catherine Dowling, FRCSI (2013).

“The low number of female urology consultants in the past meant a lack of female role models, and perhaps female medical students and early career doctors did not consider it a suitable career option.”

“Societal stereotyping and gender bias remain the greatest obstacles,” she believes, “as well as the lack of female urologists in leadership roles, as mentors and role models.” Ms Bolton points out that as 88% of urology consultants in the UK are male, medical students and junior trainees experience unconscious bias early on in their training, at a formative stage when they are developing interests and considering the direction of their future career. “It is important to recruit females in urology to deliver medical education and lectures in medical schools, as this is where the process starts,” says Ms Bolton, who remembers clearly the few female surgeons, including Professor Carmel Malone, FRCSI (2005), and Ms Ruth Pritchard, who delivered lectures and teaching and made her believe a surgical career was possible. “A lack of visible representation can make it diﬃcult for aspiring female urologists to envision themselves succeeding in this profession. Carmel Malone was very charismatic and hugely inspiring to my generation of undergraduate students.” Ms Clíodhna Browne, FRCSI (2019) has recently been appointed to her first consultant post at Tallaght Hospital, having returned from Fellowship in Australia, and is heartened by the progress she sees. “Over 50% of urology trainees across all years are now female,” she notes, “so although we are still lagging behind in terms of consultants the pool of trainees has broadened. A good job is being done to attract women to the specialty but that takes a while to translate to consultant appointments.”

› RCSI Women in Urology

Despite the paucity of female urologists who trod the path ahead of them, Ms Dowling, Ms Bolton and Ms Browne all say they were encouraged to pursue the specialty. “I never met with any resistance,” says Ms Dowling. “As a medical student I decided I wanted to do surgery, and as soon as I worked in urology I knew it was the specialty for me. I never once felt discouraged by anyone.” Ms Browne and Ms Bolton had a similar experience. “Personally, I always felt encouraged in my choice of specialty,” says Ms Browne. “I had positive experiences both as a medical student and during a urology job during my intern year in Tallaght.” “I have been lucky to have been met with nothing but encouragement both personally and professionally,” says Ms Bolton. “In terms of ‘seeing is believing’, I was lucky enough to be raised in a home where my mother worked full time and emphasis was placed on allowing her to develop her career and achieve her goals, so I have always had a good support system as a starting point. And I am fortunate to have a partner who understands the unpredictability and demands that are the nature of this profession. “At NUIG, the surgical department under Professor Michael Kerin, FRCSI (1988), was notably diverse. There were many outstanding female trainees, including Professor Helen Heneghan, FRCSI (2016), Professor Aoife Lowry, FRCSI (2013), who helped mentor junior trainees. As both an intern and SHO, I worked with Ms Catherine Dowling who was a registrar on the team. She was held in high regard by the all-male consultant body, involved in operating on the major cases in theatre, and loved by all patients. I knew I liked the field of urology and watching Catherine helped me realise that I could also thrive in such an environment. “I’ve never felt disadvantaged by anyone because I’m a woman. Urology in Ireland is a small community, and while the majority of consultants and mentors I have worked with have been men, they never treated me any differently to male trainees. My male colleagues have been a source of mentorship, friendship and encouragement.” Anecdotally, some female urologists have felt pressure to specialise in areas such as female incontinence, urogynecology and conditions more commonly affecting women, due to assumptions about their patient preferences or expertise. “I never felt pigeonholed into any subspecialty areas,” says Ms Dowling. “Early on I developed an interest in oncologic urology. I recall one of my consultants saying I should do what I love as I’d be doing it for many years. It was one of the best pieces of advice I ever received.”

“It is important to recruit females in urology to deliver medical education and lectures in medical schools, as this is where the process starts.”

Ms Eva Bolton, FRCSI (2017).

Ms Clíodhna Browne, FRCSI (2019).

“Although we are still lagging behind in terms of consultants the pool of trainees has broadened. A good job is being done to attract women to the specialty ...”

“From early on I expressed an interest in pursuing urological oncology as a subspecialty. I was encouraged to pursue this and helped to secure a fellowship,” says Ms Bolton. “There are plenty of women involved in high-volume oncology and robotic work. I treat bladder and kidney cancer now but I have also been fellowship-trained in prostate and testis cancer management and it was never suggested that I should not pursue either of these tumour groups because I am a woman.” Neither Ms Dowling, Ms Bolton nor Ms Browne has met with any serious resistance from patients to their gender. “I can recall very few instances when a patients demonstrated resistance or requested a male practitioner,” says Ms Bolton. “If anything, of late, I have experienced the opposite in light of media reports stating that patients have better outcomes with female surgeons. I have had patients mention this to me in a jovial way, commenting on the attention to detail they see from female surgeons. I don’t work in andrology and it might be different in a genital area of specialty. The odd time in clinic a patient with scrotal pain or needing circumcision might say, 'I thought I’d be seeing a man' but it’s more surprise than resistance. Most patients are open to receiving care from healthcare providers of any gender, as long as they are competent and compassionate.” “Other than on one occasion while working outside of Ireland a patient, due to his religious beliefs, declined to have me examine him. I never met with any resistance from patients on the basis of gender.” says Ms Dowling. All three say some of their biggest challenges come from achieving work-life balance, while acknowledging this can be an issue in any medical specialty, and for both genders. “Medicine is a demanding job,” says Ms Dowling, “but it is important to prioritise personal and family life where possible. Early on in surgical training the hours are long but that improves as you progress. I am fortunate that I can drop my children to school a few mornings a week and still get in for the start of the working day.” “Urology is associated with demanding and unpredictable work hours, which can be a deterrent for women, especially if they have caregiving responsibilities at home,” says Ms Bolton. “Work-life balance can vary depending on factors such as the type of practice, stage of career, and personal preferences. Recruiting additional consultants and maintaining a skilled workforce helps reduce on-call frequency and minimise the reliance of a small number within the group. I am now on a one-in-15 on-call rota which means that my work-life balance has improved greatly since being a trainee. S U R G E O N S S C O P E / 11

› RCSI Women in Urology

“Having women in prominent positions within the field,” she says, “is crucial “On-call responsibilities depend not only on the frequency of the on-call but for encouraging and supporting the progression of other female urologists.” also the intensity of the on-call and on the skillset of the other consultants in the “I haven’t encountered barriers,” says Ms Browne. “I never felt that I hadn’t group. Our catchment area is 1.5 million and includes the trauma centre for West been given an opportunity or been selected for a job or a project because of being London, so the on-calls can be quite demanding. I currently work a reduced a woman, but that’s not to say that women do not encounter those issues – I have frequency rota but often help out with major on-call emergencies out of hours no doubt it does happen. I think there has been a significant shift in the landscape when I am not on call.” of surgical training and the legacy issues are being adequately addressed.” As a urologist specialising in major oncology surgeries which are physically It is clear that for each woman, mentorship has been a key factor in the and mentally demanding, highly complex patient volumes impact Ms Bolton’s development of their careers, but that the gender of those mentors has been largely work life balance as patients need to be rounded multiple times during the day. irrelevant. Ms Bolton makes the point that the best mentorship relationships are “I was once advised not to leave more than eight weeks between periods of those that happen naturally when there is mutual respect, trust, and a shared leave and I have found this crucial to keeping fresh,” she says. “Time management commitment to the mentee’s professional growth and success. is easier now that I have completed training and have a fixed job plan. There is “I had informal mentors throughout my training,” says Ms Dowling. “Most still some unpredictability if called upon to help with cases in other specialties, of these were male but some female. Rather than seeking on-call or with surgical complications. As a trainee and a mentor because they were male or female it tended to be fellow, I did have a more demanding schedule as I wanted someone who I thought similarly to and whose opinion I to build my skills and reputation and so I ensured I was trusted and valued.” always available to see patients and help with cases. “I do think that Ms Browne acknowledges the support of both male and “Achieving a healthy work-life balance can be challenging in the medical field. I think it is really important that we seeing Professor Laura female mentors. “Part of the reason I decided to pursue urology was all remember that each of our colleagues’ time outside of Viani and Professor because I encountered supportive mentors early on,” she work is valuable, regardless of what that time is used for.” Deborah McNamara says. “I felt from the outset it was a supportive, cohesive Ms Browne agrees that work-life balance is “tricky”, but specialty with a culture of bringing people along. as President and says that is the same for women in any demanding career. Personally, I found all consultants were very supportive “Obviously timewise, training can be challenging Vice-President in terms of me coming off the call rota when I was because fellowship comes at a time of life when you may of RCSI, leads to pregnant, taking maternity leave, and transitioning back be in your mid-30s and thinking about starting a family,” to work afterwards.” greater visibility of she says, “but that is a situation by no means unique to According to Ms Bolton, “I have also had many male surgery. I have friends who are in different careers who women in surgery.” mentors, including Professor Thomas Lynch, FRCSI have experienced the same issues. I do think that seeing (1988), who made a point of taking time out to tell me how Professor Laura Viani, FRCSI (1987) and Professor important it is to aspire for gender equality in urology. He Deborah McNamara, FRCSI (1997) as President and also helped me build a professional network within the surgical community Vice-President of RCSI, leads to greater visibility of women in surgery. A huge by introducing me to key contacts and providing me with opportunities for amount of work has been done with the Women in Surgery Fellowship and there collaboration and mentorship from other individuals. is wider availability of flexible training. Personally, I chose to pause my training “We need mentors at all stages of our careers and as a junior consultant I am for maternity leave twice, but never did less than full-time training, which meant still in need of a mentor. I am lucky to be in a department with another female that my training took longer but in a procedure-based specialty there is no urologist, Ms Norma Gibbons, FRCSI (1998), who continues to provide me with replacement for the hours and the cases logged. That made sense for me but for opportunities for skill development, leadership roles and career progression. She other people it may be different.” also provides me with constructive feedback and guidance, helping me identify While Ms Dowling observes that the barriers to career progression in urology, areas for further improvement and offering strategies for growth.” such as higher degrees and publications, are the same for both genders due to In her turn, Ms Bolton feels a responsibility to mentor female trainees, as a the competitive nature of the speciality, Ms Bolton feels that women in surgery lack of support in education, training and employment can hinder their progress generally have to prove their ability in the operating theatre more than men. and confidence in the field. “Gender bias and stereotypes are still prevalent in society in general,” she says, “Less than full-time training has meant that many women can achieve their “and this can affect how female urologists are perceived by colleagues, superiors, career objectives in parallel with personal choices,” she explains. “However, there and patients. I have never experienced this first hand, but I have heard from other is still a stigma attached to this, with trainees nervous about making this choice female colleagues and female trainees that these biases can lead to challenges in and feeling they may not be as attractive for jobs as their male counterparts. being taken seriously, earning respect, and gaining leadership opportunities.” In my own department, Ms Norma Gibbons has paved the way for female Ms Bolton points to the historical scarcity of female urologists in leadership colleagues in urological oncology, but there are still very few less-than-full-time roles which has limited the availability of role models, mentors and advocates for female consultants in the UK or Ireland.” career advancement, but notes that this has improved greatly in Irish urology. 12

› RCSI Women in Urology

automatically thought that meant a man? Certainly every time I started a new With the increase in the number of female urology trainees do the three job I felt I had to prove myself, to be as good as the boys. That said, I have never women feel enough is being done? worked in an environment where I have been made to feel less important as a “I think the issues around historical gender imbalance are being addressed,” male trainee, but maybe I have just been lucky.” says Ms Dowling. “RCSI’s flexible training programme allows trainees to avail Ms Bolton suggests training to deal with issues such as imposter syndrome of part-time training if they wish. I think it is extremely encouraging for young should begin in medical school. female trainees to see both a female President and Vice-President of RCSI. She also points to recent media coverage of discrimination against and The gender imbalance will only continue to exist if doctors are not choosing harassment of women in surgical specialties. surgery and then choosing urology, so the focus needs to be about encouraging “Fortunately I have never experienced this firsthand,” she says. “But the them to choose these careers early on. As medical students see that half of our perception of a hostile environment can discourage women from pursuing specialist registrars in urology are female it will not appear to them to be a maleor continuing their careers in urology, so it is important to implement clear dominated specialty.” policies and procedures for reporting and addressing discrimination and However, while flexible training is available in Ireland, the take-up rate is far harassment within the field.” less in Ireland than in the UK. In conclusion, Ms Bolton notes that by virtue of the topic “Flexible training doesn’t seem to be very common in being covered in publications such as Surgeons Scope, the Ireland in my experience, but perhaps this is something that issues surrounding historical gender imbalance in surgical will became more common as years go on.” careers are being addressed. Ms Bolton agrees that attitudes to women in urology in “It is clear that “But,” she continues, “there is still much more that needs to Ireland are more progressive than they are in the UK. be done to achieve full gender equity in surgical specialties. “Professor Viani’s and Professor McNamara’s work in this for each woman, It has certainly been an easier journey for me thanks to area pre-dates similar conversations in the UK, but flexible mentorship has the female urologists who carved out that path before me. working is much more of a thing in the UK where it’s almost been a key factor in We must continue to maintain increased awareness of expected that female trainees who have children will work the gender imbalance in surgical careers. Many surgical less than full-time contracts, whereas this is never spoken the development societies and organisations are now actively discussing and about in Ireland. of their careers, acknowledging the issue and proactively inviting women “I did full-time training, but I have worked with some but that the gender to sit on panels and to speak at meetings. This increased trainees in the UK who do less than full-time training and awareness has been an important first step in addressing the there is anxiety around that in terms of time and exposure. of those mentors problem. I think it is accepted in my generation that there It does inevitably prolong the duration of training. has been largely are more female surgeons, and now the older generation is “I can only speak for myself, in that I don’t take those who irrelevant.” aware that they need to learn to adapt to that. do less than full-time training less seriously, but urology “The work of Professor Viani and Professor McNamara trainees in London who have opted for less than full-time and the unveiling of the Women on Walls at RCSI have raised significant training have told me they are expected to come in on days they shouldn’t be awareness about gender diversity in surgery. Their visibility and advocacy there by consultants who say they must fit their needs around the service rather efforts are helping to inspire and guide the next generation of female surgeons. than the other way round. The danger with flexible working is that people may Hopefully with more women inspired by surgical careers, the inherent, implicit feel under pressure to work outside their contractual hours because they don’t biases and stereotypes about the capabilities and roles of women in surgery that want to be seen as not pulling their weight within a team. In order to attract continue to affect hiring, promotion, and workplace dynamics will be eroded. women into surgical training at a time when childcare is very expensive, we do I think it is also important to develop clear career pathways early on so that have to come to terms with flexible working as a reality.” women are attracted into surgical subspecialties in the knowledge that they As for representation on panels and at conferences, the focus of Ms Dowling’s know they can advance. paper, Ms Bolton notes that things have changed dramatically for the better in “Whilst mentorship is usually a natural process, structured mentorship recent years. programmes that pair female urologists with experienced mentors who can “When I started training ten years ago,” she says, “it was really rare to see provide guidance, support, and career advice may be useful. women on panels in international meetings. The Canadian urologist Larry “Women face unique societal expectations and caregiving responsibilities that Klotz first kicked off the discussion about the lack of female representation on can affect their ability to advance in their careers. I think there needs to be more panels, and since then there has been a conscious effort made to invite women. I discussion and openness about flexible work arrangements and parental leave think it is up to us then if we are invited to make the effort and sit on the panels. policies which can be beneficial in attracting women into surgical specialties. People talk about imposter syndrome and I think that is something of a genuine “By addressing these barriers and promoting gender diversity and inclusivity, issue with a lot of women. As you come up the ranks you deal with it better but the field of urology can become more welcoming and attractive to women, only by experience. Maybe as a woman you feel you have to prove yourself a ultimately benefiting both the profession and patient care,” says Ms Bolton. ■ little more at the start, because growing up you heard the word surgeon and you S U R G E O N S S C O P E / 13

› Operation Childlife

OPERATION CHILDLIFE Operation Childlife is comprised of surgical, paediatric and nursing volunteers who donate their time freely to helping local communities develop skills that will in turn help their own communities ave The Children estimates that 1.1 billion infants and children in low-income and middle-income countries (LMICs) in Africa and Asia have limited access to basic healthcare. In Sub-Saharan Africa and South-Asia, over five million children under the age of five are dying from treatable illnesses such as diarrhoea and pneumonia or from neglected injuries, every year. Families in these countries often exist just above the breadline and can be precipitated into financial crisis if faced with illness, especially if this is surgical. The problem is compounded further if access to public healthcare and surgery is limited or impossible. Operation Childlife (OCL) believes it can make a difference through specific interventions, and has developed a model that can be replicated and scaled by healthcare professionals across the world. OCL was established in 2004 when a number of Irish medical professionals received a request from the Christina Noble Children’s Foundation (CNCF). They were asked to carry out a number of complex surgeries and to upskill and mentor paediatric doctors and nurses in Children’s Hospital Number 2, Ho Chi Minh City. Since that inititaive, OCL has treated more than 2,000 children and has expanded to Tanzania, Mongolia and Jordan. More than 60 senior-level consultants have travelled as volunteers for one- and two-week missions, conducting complex surgeries, providing pre- and post-operative support, guidance, training, mentoring and developing local colleagues on a continual basis. “It is impossible to adequately describe the opportunity we have been given to help our colleagues in Tanzania, Vietnam and Mongolia develop new skills and practices that will result in higher quality patient care. Each and every member of OCL is humbled to share in this privilege,” says Professor Martin Corbally, FRCSI (1991), Chief of Staff and Consultant Paediatric Surgeon, King Hamad University Hospital, Bahrain, Professor & Chairman, Dept. of Surgery, RCSI-Medical University of Bahrain and Programme Director of Operation Childlife.” OCL operates where there is limited expertise in key disciplines such as paediatric cardiology, surgical oncology, orthopaedics, intensive care, anaesthesia, interventional radiology, neurosurgery, urology, plastic surgery, ear, nose and throat surgery and related nursing care. Collectively OCL’s paediatric partners have a fast- growing catchment of 45 million people, with 15 million under the age of five years. OCL’s stated mission “to provide optimal surgical, anaesthetic, medical and nursing care to infants and children of low-and middle-income countries”, is underpinned by its vision that all children deserve compassionate and expert healthcare, which should be delivered in their own environment. The organisation prioritises authentic medical altruism – and goes where it is invited, not where it thinks it should go, it only engages in countries in equal partnership with local institutions, and undertakes those cases, which are mutually agreed as the highest priority. “The workload over the years has been diverse and challenging and always gives a great sense of fulfilment and, indeed, repeatedly reminds me why I chose medicine as a career in the first place,” says Professor J. Mark Ryan, Interventional 14

Radiologist, Clinical Professor at Trinity College Dublin and Non-Executive Director of OCL. The process of educating and training local colleagues moves OCL’s activities from “point in time” interventions that affect a small number of children, to a more systemic impact that can improve the lives and outcomes of more children into the future. The work of OCL is also strongly aligned to the UN Sustainable Development Goals, in particular, SDG 3 (Good Health and Wellbeing), 4 (Quality Education) and 10 (Reduced Inequalities). Financial support has evolved from ad hoc, mission-based, grant aid and individual donations, to more focused philanthropy, through the solicitation of donations from high net worth individuals, moved by OCL’s impact and commitment to transforming the plight of sick children in some of the world’s most deprived countries. OCL is supported by a board of non-executive directors, with a skills mix of business, strategy and fundraising, in addition to the core medical and surgical skillsets. Until 2022, OCL was supported entirely by voluntary activity, but a half-time administrator has now been recruited. OCL is in the process of developing a further number of collaborations with international medical organisations. Such collaborations are evaluated and agreed against the core mission and values of OCL, ensuring that all collaborative activities enhance and develop its mission while avoiding mission drift or the stretching of core resources inappropriately. Education, Mentoring and Support are key to upskilling local teams. As well as consultation at the pre-operative and post-operative levels in the form of preand post-op support, OCL delivers a PASS (Paediatric Acute Surgical Scenarios) module, which is a taught three-day course to recognise and treat the acutely compromised child. OCL will take this course to Tanzania in 2024, and to Mongolia and Jordan in 2025. Over the past decade, nursing and medical students from RCSI Bahrain have accompanied OCL teams to Vietnam and Tanzania and have gained insights into the challenges of healthcare delivery in LMICs. It is planned that this programme will expand to include Mongolia and Jordan. According to Professor Mark Redmond, FRCSI (1982), Consultant Cardiothoracic Surgeon and National Clinical Lead for Cardiothoracic Surgery: “It’s very simple for me and my Operation Childlife colleagues. We go where we are needed. We go to Vietnam every year to save children’s lives … to support the work of Vietnamese paediatric surgeons … to make a meaningful difference.” RCSI has also agreed a clinical travel fellowship programme, which will be open to members of the paediatric community (nurses, surgeons, anaesthetists, paediatricians) in Ireland, providing an individual with a unique opportunity to complete a placement on an Operation Childlife medical mission providing paediatric surgical care. The first recipients of this award will travel to Mongolia and Tanzania this year. OCL is also developing a virtual service which will formally consolidate current consultations and will provide an ongoing virtual service for all its host institutions.

›

Professor Martin Corbally, Operation Childlife Programme Director, with colleagues.

Dr Khadija Abu Hassan, Consultant Anaesthetist, second from the right, and Dr Omar Sabra, Consultant Otolaryngologist, ISE KHUH Bahrain, last on the right, with member of the team. Dr Brendan O’Hare, Consultant Paediatric Anaesthetist, CHI Crumlin, and OCL board member, checking on a patient.

Dr Khadija Abu Hassan, Consultant Anaesthetist, KHUH Bahrain, with a patient.

Operation Childlife

ON-SITE INTERVENTIONS AND IMPACT OCL’s core purpose is to conduct on-site missions to perform complex surgeries. Some examples of its work are summarised below: Vietnam – in collaboration with the Christina Noble Children’s Foundation Children’s Hospital No 2 has become a centre of excellence in Vietnam: • Volunteers helped establish an open-heart surgical programme. • Established first interventional radiology programme. • Helped establish first cardiac catheterisation and cardiac intervention and a paediatric cardiac ICU. • Formal training in paediatric surgical oncology. • Assisted with the development of a paediatric pathology unit. • Six new clinical programmes established: a. paediatric surgery, paediatric oncology surgery, paediatric anesthesia b. paediatric OT nursing c. esophageal reconstruction d. imperforate anus surgery e. paediatric urology f. paediatric neurosurgery • Local medical teams have demonstrated great skills and motivation in acquiring new skills and OCL’s programme is regarded as a model of care intervention. • Cardiac surgery is now at the complex end of the disease spectrum and between open surgery and intervention; approximately 15-30 patients are treated each trip. • OCL volunteers have trained three cardiac surgeons to date. Tanzania – in collaboration with Their Lives Matter (TLM) • Paediatric urology Consultant has visited 1-4 times each year for the past 15 years. a. Paediatric surgery since 2007 b. Paediatric Surg Oncology since 2007 c. Paediatric Consultant Orthopaedic surgeon – two visits in total 2017 and 2018 d. Paediatric Radiologist two visits in 2014 and 2015 e. Paediatric Infectious disease – 2 visits in 2014 and 2015 • OCL has been upskilling local surgeons in safe and effective hepatectomy, radical nephrectomy and other aspects of paediatric surgical oncology. • Through collaboration with Their Lives Matter (TLM), OCL volunteers have treated approximately 300 cases. • Over the last 15 years, through the commitment of Dr Trish Scanlan (Head of the Paediatric Oncology Ward, supported by INCTR), there has been a dramatic improvement in survival rates of children admitted to the ward, from approximately 20% up to current levels of around 65%. Jordan This year (2023), saw the launch of an OCL programme in the Jordanian Red Crescent Hospital in Amman, Jordan. OCL is committed to assisting with the surgical care of refugee children and started this process with an ENT, Eye and General Surgical team. OCL plans to continue this agreement for five years and in the course of this time will also run the PASS course on site. ■

S U R G E O N S S C O P E / 15

› IN MEMORIAM

IN MEMORIAM PROFESSOR SEAN TIERNEY (1963-2023)

n July 2023, RCSI lost a dear friend and colleague, Professor Sean Tierney, FRCSI and Dean of Professional Development and Practice at RCSI since 2011. Sean was a wonderful colleague with time for everyone. He always offered invaluable advice, imparted with a wicked sense of humour, which will be missed by everyone who knew him. His contribution to RCSI is immeasurable and it would be impossible to list all his many accomplishments. His impact on Irish medical life is more than anyone can really appreciate. He was an inspirational leader and colleague to everyone who had the honour of working with him at RCSI, and among the wider surgical community in Ireland and beyond. Kieran Ryan, Director of Surgical Affairs, RCSI, remembers fondly: “Whenever I was trying to figure something out I had two approaches, the first was to ask myself “what would Sean do?” and the second was to ask him. He was intelligent, thoughtful and selfless, and these traits made him a formidable advocate for the best of patient care, Irish surgery and the wider medical community. Sean was the friend and colleague that we should all aspire to be.” Sean’s legacy to RCSI is immense. As an educator, he was devoted to promoting the highest quality surgical training in Ireland and was a champion of lifelong 16

learning. As a former President of the Irish Medical Organisation, he ensured that the highest quality standards were maintained. “As RCSI President, I had the honour to work closely with Sean and received great counsel from him over the past 12 months and previously. Sean was a very humble man but his contribution to RCSI and to international surgery over the years are inestimable and the college will feel his loss profoundly,” says Professor Laura Viani, RCSI President. A dedicated humanitarian, he was clinical lead on the RCSI/COSECSA collaboration since its inception in 2007. He was recently awarded an Honorary Fellowship to mark his contribution to the collaboration, which has improved the standard of surgical care in East, Central and Southern Africa by advancing He was an surgical education, training and inspirational leader examinations. On awarding the and colleague to Honorary Fellowship, Professor Eric Borgstein, Registrar, COSECSA, everyone who had said: “As a key figure in the the honour of longstanding collaboration between working with him. COSECSA and RCSI, Professor Sean Tierney has been hugely influential in the growth and development of surgery in East and Central Africa. COSECSA is where it is today, over a thousand surgeons graduated, thanks to this collaboration and thanks to Professor Tierney.” As a Consultant Vascular Surgeon at Tallaght University Hospital, Sean was deeply committed to his patients, ensuring access for all to high-quality care. He was a doctor of the highest integrity. A constant innovator, Sean was an early adopter of the latest technologies, techniques and procedures. His one and only motivation was to provide the highest-quality care to patients. He was a gifted surgeon and a mentor to his colleagues within the specialty and to the next generation of vascular surgeons. Sean was a deeply devoted family man and our deepest sympathies go to his wife Mary-Jane, son Daniel, his brother Tom and his extended family on their immense loss. We will remember Sean for his integrity, humour, generosity and wisdom. May Sean’s gentle soul rest in peace. ■

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› A Surgeon In

A SURGEON IN PENANG DR PRABHU RAMASAMY There’s nowhere in the world that Dr Prabhu Ramasamy (FRCSI 2016) would rather live than Penang, and no more rewarding career, he says, than surgery. He recounts how medicine has inspired three generations of his family

Dr Prabhu Ramasamy.

› A Surgeon In

grew up and went to school on the beautiful island of Penang in Malaysia, where I live now. I am the youngest of three boys, my two brothers are doctors too and we are the second generation of doctors in my family. My brothers are in practice in Kuala Lumpur. When I was in school my initial plan was to join the armed forces, but coming from a typical Tamil family that was not an acceptable profession. My parents wanted us to be professionals, so even though after high school people thought I might study engineering I was influenced by my brothers going to medical school and followed in their footsteps. My father, Dr PK Ramasamy, was a paediatrician, my uncle an ophthalmologist and my aunt a gynaecologist. I grew up watching them serve the community and develop their practices. Everywhere they went people recognised them and they had status in the community. That influenced me, I thought medicine did not Penang state comprises Seberang Perai look like a bad career. Of course, I only saw the end result of doing medicine on the mainland and Penang Island. and getting to where they were; I did not see how incredibly hard they worked. My father was a government servant and did his paediatrics training in the 1970s, working in different places around Malaysia. I was born on the east coast in the state of Kelantan. We came to Penang in 1979 when I was five and my mother, Saraswady, fell in love with this beautiful place and after that refused to move anywhere else. There are two parts to the state of Penang: the island and the part on the mainland. I grew up on the island and still live there. My father is 84 now, he worked until the age of 79; my parents still live on the island. I graduated from Jawaharlal Nehru Medical College in Belgaum (Belagavi), Dr Prabhu Ramasamy, Chairman of the India in 1998. Following a year of internship there, I returned to work in Malaysian Medical Association Penang Malaysia. In 1999, I was assigned as a house officer at Hospital Pulau Pinang branch, 2022 and 2023. (Penang Hospital). I did obs and gynae, then general medicine and then surgery. Upon completing my housemanship, I was transferred to Hospital Seberang tremendous support of my mother Jaya in the state of Penang as a medical officer. The hospital covered all the basic and mother-in-law I don’t know how specialties but had no sub-specialty units. At that time, the hospital faced a Dr Prabhu Ramasamy we would have coped. severe shortage of doctors. I became the third medical officer in the department and family. My training was gruelling. Surgery of surgery, as we had no resident surgeon and relied on cover provided by was not a popular specialty at the visiting surgeons from Hospital Pulau Pinang, 20km away. Often they provided time and there was an acute shortage of surgeons. Over the next four years, I cover over the phone. The hospital was located close to the intersection of three returned to the Department of Surgery at Hospital Pulau Pinang. Dato Dr Manjit major highways and we saw plenty of trauma, it was terrible. At that time I Singh, Mr Premanth and Mr Tan Wee Jin played significant thought I wanted to do radiology, and that later I would do roles in my training as a general surgeon. During this period, interventional radiology. I had no intention of pursuing a I actively participated in the training of undergraduates from career in surgery. Penang Medical College (RSCI and UCD programmes), But about a month after joining the department, Mr Khoo Colorectal cancers house officers, medical students, and fellow Masters students Boo Beng, who was to become my mentor, arrived. Working in the Department of Surgery. under his guidance was a source of great joy and inspiration. had become the I successfully completed my Masters in Surgery in 2007 and Under Mr Khoo the department grew and he and Mr Naga, second most was then assigned back to Hospital Pulau Pinang. In 2009, the second surgeon posted to Seberang Jaya Hospital, common type of I was accepted into the Fellowship in Colorectal Surgery encouraged me to pursue a career in general surgery. under the Ministry of Health Malaysia. I underwent training After working for two and a half years at Seberang Jaya cancer among under Professor Azmi at the International Islamic University Hospital, I became eligible to apply for my Masters in Malaysians and (IIUM) in Kuantan, Malaysia. For the second year of my Surgery. I applied to the same university where Mr Khoo had the leading cancer fellowship, I was posted under Dato Dr Wan Khamizar at completed his training, based on his recommendation. In Sultanah Bahiyah Hospital in Alor Setar, Kedah. My overseas 2003, I enrolled in the Masters in General Surgery external among Malaysian attachment in colorectal surgery took place at Christian programme at the University Kebangsaan Malaysia (National males. There was Medical College (CMC) Vellore in India. University of Malaysia). a pressing need During my Masters of Surgery training, a significant My wife Shanty is a doctor too and she started her Masters component of my curriculum involved teaching in Medicine the same year. Our son, Hiresh had been born the for expertise in undergraduate students from the medical school. During that previous year and our daughter, Raveena, during the second colorectal surgery. period, the Head of the Surgical Department at the medical year of training. It was a very busy time and without the S U R G E O N S S C O P E / 19

› A Surgeon In

Health checks for the B40 Group in Penang.

Dr Prabhu Ramasamy and his brother at the beginning of their surgical training 22 years ago at RCSI’s Basic surgical skills course at the RUMC campus in Penang.

Outreach medical check-up programme by the Malaysian Medical Association Penang Branch for seniors.

school was Professor Peter William Ray Lee, a colorectal surgeon himself. I had the privilege of spending considerable time with him, and he later became my Master’s thesis supervisor. Another crucial factor influencing my decision to specialise in colorectal surgery was the shortage of colorectal surgeons in Malaysia. Colorectal cancers had become the second most common type of cancer among Malaysians and the leading cancer among Malaysian males. There was a pressing need for expertise in colorectal surgery. Seven years ago, I made the decision to move into private practice and I’m currently at Loh Guan Lye Hospital in George Town, Penang, where I serve as the Head of Surgery and also lead the OT (Operating Theatre) committee. Prior to the COVID-19 pandemic, I was actively involved in teaching, dedicating at least an hour each week to undergraduate students. I typically accept around five elective students annually. Additionally, I allocate a day each month to engage with postgraduate students from Hospital Pulau Pinang and Hospital Seberang Jaya. I actively participate in workshops related to colorectal surgery for postgraduate and junior surgeons. Furthermore, I am a member of the Court of Examiners for the MRCS exams conducted by RCSI in Penang. My work week typically spans six days, from Monday to Saturday, and most days I work between 10 and 12 hours per day. My schedule includes two days dedicated to surgical procedures, during which I have two operating Dr Prabhu Ramasamy lists. Additionally, I allocate 90-minute slots with his colorectal Mentor for endoscopy procedures from Monday to Dato Dr Wan Kharmizar. Friday. This rigorous work routine allows me to maintain a busy and fulfilling practice in the field of surgery and endoscopy. One of the specific challenges I encounter in my work in Penang, despite it being a relatively small city, is the escalating cost of healthcare. While the hospital I work in offers a range of multidisciplinary services, the increasing costs can pose difficulties, particularly for economically disadvantaged patients. Ensuring that quality healthcare remains accessible and affordable to all residents of Penang is an ongoing concern for me. Government hospitals are very well-equipped but hugely overcrowded. While the ratio of doctors per head of population has improved in recent years and 20

now stands at 1:420, I would like to see the introduction of universal healthcare, perhaps following the model in Australia. When I left government employment, I was Head of Surgery at Hospital Pulau Pinang, and the principal motivation to move to private practice was financial. I wanted to be able to provide a good tertiary education for my children and could not do that on a government salary. The wage difference means that instead of Malaysia having a brain drain to other countries, there is a brain drain from the public to the private sector which threatens to paralyse the whole system. Penang holds a special place in my heart, it is my lifelong home. The city’s liveability, renowned food, and the presence of family and friends, make it a cherished location for me. However, I do have concerns about excessive development that may be eroding the unique charm that Penang has long been known for. Sometimes I think developers are trying to make it like Singapore. Unfortunately, that has involved deforestation and it is much warmer now than it was when I was a child, and I don’t hear the birds as much as I used to. As the population has increased, the roads have become more congested. I live about 10km away from the hospital in a suburb called Green Lane. During the pandemic it used to take me only eight minutes to get to work, but now Dr Prabhu Ramasamy at the Penang Gurney Drive with his it takes 40. general surgery mentor, the late Eating is a culture in Penang and we Mr Tan Wee Jin, to the right and to have the best food in the world. We are his left, his trainee Dr Kelvin Voon. known for our street food, which is truly wonderful. Usually we eat at home during the week, but on Sundays we go out for lunch and try somewhere different each time. My son, Hiresh, is 21 and currently studying biomedical science at the University of Leeds. My daughter, Raveena, is 19 and a pre-med student at a private university in Kuala Lumpur. Shanty and I did not pressure them into choosing medicine as a career, we are trying to break with the old ways. I used to play golf until I became a houseman but that and all my other hobbies fell by the wayside due to the pressures of work. Now, when I’m not working, I like to spend my time with my parents and family. I have recently completed my term as the Chairman of the Malaysian Medical Association, Penang branch. In the short to medium term, my goals involve continuing my private practice and providing my children with the best education possible. I also intend to engage in more social services through the Malaysian Medical Association, with a focus on serving the public and advocating for the rights of doctors in Malaysia. Malaysian laws do not permit the formation of unions for doctors. Looking a little further into the future, once the children are settled and I have paid off all the university fees, I hope to return to teaching, possibly on a full-time basis. I love teaching – that’s the reason I look forward to elective students coming to do classes with me. I find teaching rewards me more than it rewards the students, as the love for the subject comes back. I find it very enriching. I always try to convert my students, drag them over to the dark side, and encourage them to join and pursue a career in surgery. ■

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› Back to the Beginning

BACK TO THE BEGINNING Professor Graeme Clark, Honorary Fellow, RCSI is a Professor of Otolaryngology at the University of Melbourne. As well as having a stellar career in ENT surgery, Professor Clark’s groundbreaking research into electronics and speech science contributed towards the development of the multiple-channel cochlear implant. Professor Clark’s first multi-channel cochlear implant operation in 1978 was followed in 1985 by FDA approval for implantation in adults; in 1990, implantation in children was approved. Professor Clark was made an Honorary Fellow of RCSI this year.

was born in 1935 in Camden, New South Wales, a country town 65km southwest of Sydney, the eldest of three, with a younger sister, Robin, and brother, Bruce. I was free to roam the beautiful countryside, meet people from all walks of life, play a variety of sports, and observe how my father, Colin, who was severely deaf, managed his pharmacy. He started to go deaf in his teens and in his early twenties was told that he would lose his hearing completely. My mother, Dorothy, was musical and artistic and a great support to him. I was a curious child and schoolwork came easily but I enjoyed life outside school with friends more. I was fortunate to obtain a scholarship to board at The Scots College in Sydney, a prestigious private school, and completed my secondary education there. At the age of five, I told my kindergarten teacher that when I grew up I wanted to ‘fix ears’, and at ten years old, told our church minister that I wanted to be an Eye & Ear specialist. I remember being inspired by biographies of Louis Pasteur and Marie Curie. My mother would have preferred I become a pharmacist like my father as she thought medicine would be too stressful. My father was more pragmatic and sent me for aptitude tests, which indicated that medicine would be a fine choice, but that I should also consider the new field of electronic engineering. I think my father had always wanted to do medicine himself but couldn’t afford to; he and my uncle were both very encouraging of me. At 16, I enrolled to study Medicine at the University of Sydney. I found the basic studies exciting and did well at anatomy. I turned down the offer of a scholarship to take a year off to do a Bachelor of Medical Science degree in visual neurophysiology as I believed it was more important to study auditory neurophysiology if I were to discover how electrical stimulation of the auditory brain could reproduce the coding of speech sounds. I knew I would need to be both a clinician and a research scientist to lead the development of artificial hearing with electrical stimulation, but that research training could come later. After a blip in fourth year when I had to repeat some exams, for finals I used study methods I’d learned from my English master at Scots and prepared so well 22

Professor Graeme Clark on the occasion of the publication in 2021 of his book I Want To Fix Ears: Inside the Cochlear Implant Story.

› Back to the Beginning

I was able to take five days off to relax and surf before the exams commenced. I graduated first in my class at the age of 22. I was appointed as a Junior Resident Officer at the Royal Prince Alfred Hospital (RPAH) in Sydney, the biggest and busiest hospital in Australia. At times, I found the workload overwhelming. My next appointment was as a Senior Resident Officer at the Royal North Shore Hospital, where I was assigned to surgical units. I learned the importance of teamwork and the value of experimental animal research. With my career headed for surgery, I obtained a position as a tutor and parttime Lecturer in Anatomy at the University of Sydney so that my anatomical knowledge would enable me to pass the first part exam for the Fellowship of the Royal Australasian College of Surgeons. During that year I became engaged to Margaret Burtenshaw. I was invited back to RPAH as a Surgical Registrar in 1961. My first term was in Neurosurgery and then a vacancy occurred in Otolaryngology where microsurgery and stapedectomies had just commenced. It was a new and fascinating world compared to general surgery, but I still had to do my share of acute general surgical emergencies. In order to complete my training I needed overseas experience, but I could not secure a position without appearing in person. Margaret and I, now married, sailed to the UK. I went My aim had been to straight to Edinburgh so I could sit the FRCS (Edin) in General Surgery and Pathology. On passing, I went to London in the help severely deaf hope of gaining a position at the Royal National Throat, Nose people like my father, and Ear Hospital. I was appointed for six months as a Senior but I was surprised House Officer at the hospital and seconded to the Golden Square section. To continue my training, I was appointed as a by how few such Senior Registrar at the Bristol Royal Infirmary, an extremely people one saw in busy job with considerable responsibility. I passed my English ENT practice. They Fellowship in ENT surgery, FRCS (Eng) before returning home to enter private practice. had been told there My aim had been to help severely deaf people like my father, was nothing that but I was surprised by how few such people one saw in ENT practice. They had been told there was nothing that could be could be done to done to help them, and so they disappeared into the woodwork. help them ... I became inspired to discover how the brain codes sound, and to see whether the code could be reproduced by electrical stimulation. So, after three years in practice, I returned to the University of Sydney as a PhD student of auditory brain science. There I discovered why single-channel electrical stimulation using a temporal code would not achieve speech understanding and that my only chance for success was multi-channel stimulation using place coding of frequency. Unfortunately, many senior scientists and clinicians had already failed in this endeavour and there was no support for me to continue the research; I could not get a job. Thankfully, the University of Melbourne was prepared to take the risk and, at the age of 34, I was appointed the first Professor of Otolaryngology in Australasia based at The Royal Victorian Eye and Ear Hospital. I was given an office and an assistant but I had very little funding, and had to raise whatever money I needed at the same time as meeting my teaching commitments. So I went to charitable clubs and earned AUD$100 for a lunchtime address, AUD$200 for this, AUD$200 for that. Then I got AUD$2,000 from one club and it was a news item, and Sir Reginald Ansett, the businessman and aviator, needed a telethon and my research appealed to him and so for three

TOP The Clark family in 1950. ABOVE Professor Clark and his wife Margaret. BELOW The RCSI Honorary Fellowship investiture in 2023.

S U R G E O N S S C O P E / 23

› Back to the Beginning

Looking back, I would not have done things much differently. I was the right age, had the right amount of energy and the best colleagues one could hope for. years I went to fundraising events and shook tins on street corners and at rock concerts around Melbourne, the sort of things most professors didn’t do. Rod Saunders with At the time there was growing competition to be the first to do the Professor Clark operation, but I was intent on making it as safe as possible. I commenced who is holding the first multi-channel research on electrical stimulation of the central auditory brain pathways cochlear implant. in 1970. I considered it essential to develop an implantable multi-channel receiver-stimulator unit to go under the skin rather than use a plug and socket, which meant a whole new era of electronic engineering. My aim was to gain as much information as possible from as small a group of patients as possible, and to use psychophysics to learn what the patient was perceiving. In 1976 I took study leave and went with my family to Keele in the UK to work with the research group there to develop my knowledge of speech understanding. I worked closely with colleagues in Electrical Engineering and, in 1977, we produced a prototype receiver-stimulator for implantation in my first patient, Rod Saunders, which my colleague Brian Pyman and I implanted at the Eye & Ear Hospital on 1st August 1978. The money was running out at this stage and we were under pressure. At Rod’s early test sessions, we confirmed the physiological findings by showing he could only discriminate rate of stimulation up to 300 pulses/s which is much less than the 4,000Hz needed for speech. However, the crucial question was whether he could hear different pitches when stimulating sites around the cochlea. I was disappointed when this did not happen. But I was pleased he did hear changes in timbre, the quality of sound that distinguishes musical instruments playing the same note. They varied from dull at the apical or low Professor Clark with Bryn Davies and Scott Smith in 1986. frequency end of the cochlea to sharp at the basal or high frequency end. My first “eureka” moment occurred when Rod experienced timbre stimulator, the government gave us the go ahead to seek FDA approval and in as well as vowels when different frequency sites in the cochlea were stimulated. 1985 this became the first multi-channel cochlear implant to receive approval The vowels corresponded to the frequency site best representing the key second from the FDA or any world health regulatory body. formants of vowels. Over the next few years, there were two parallel streams of work. The first This finding led, in 1978, to us coding the second formant speech frequencies was making our implant smarter and better. The second – and I was passionate (F2) as place of stimulation, loudness (A0) as current amplitude and voicing about this – was developing an implant for deaf children, which had to be (F0) as rate of stimulation. I asked audiologist Angela Marshall to test Rod with smaller and have a magnet. Cochlear Ltd created a smaller device which Rob open sets of words and he got 10% correct. I knew then we had achieved a result Webb and I implanted in ten-year-old Scott Smith in 1985, the same year I got not previously obtained, and that Rod would understand conversation without approval to start a world trial in children. This was not completed until 1990 needing to lipread. when, following a world trial for the FDA, the Nucleus multi-electrode system After 11 years of tumultuous struggle, I was so moved I went into the next lab was approved as safe and effective for use in children from two to 17 years of age. and burst into tears of joy as I knew then it would work. It was the first implant of any sort to be approved by a world health regulatory We got some government funding for the first time. This helped with body for use in children and the first significant help for deaf children since the securing an industry partner and led to the creation of the company Cochlear introduction of sign language 250 years previously. Ltd. After additional surgeries with a more robust and better-designed receiver24

› Back to the Beginning

Professor Clark and Margaret with their family in 2016.

I feel extremely honoured to have been awarded an Honorary Fellowship of the Royal College of Surgeons in Ireland (RCSI) and to have been inducted into the College by RCSI President Professor Laura Viani on her visit to Australia early in 2023. I have always held Irish medicine and surgery in high regard and have been inspired by the skills and surgical judgement of Irish colleagues such as Professor Gerard O’Donoghue from Nottingham University and Professor Laura Viani, Director of the National Cochlear Implant Programme in Ireland. Over the course of my career I have been honoured with a number of other awards for scientific research including the Lasker Award in 2013, considered the American Nobel in clinical medical research, and the Zotterman Medal in 2011 from the Nobel Institute for Neurophysiology, Karolinska Institutet, Sweden. Also in 2011, I was awarded the CSL-Florey medal from the Australian Institute of Policy and Science and Commonwealth Serum Laboratories. Previously, in 2007, I was the recipient of the Zülch Prize in 2007 from the Gertrud Reemtsma Foundation administered by Max Planck Society, Germany, and made a Fellow of the Royal Society in London (FRS) in 2004, the same year I was awarded the Prime Minister’s Prize for Science. I am also an Honorary Fellow of The Royal Society of Medicine, London and a Fellow of the Australian Academy of Science. I have also received awards for industrial innovation, engineering and innovation, as a medical pioneer and doctor, alongside a number of civil awards. I am fortunate to have a Building, Institute, Foundation and Chair named after me in Australia. Margaret and I have been happily married for over 60 years and have five children, 12 grandchildren and one great-grandchild. I have tried to dedicate time to them, even during the most demanding period of developing the cochlear implant. I never worked on Sundays. We have lived in the “bush” on the outskirts of Melbourne overlooking the Yarra River where we have been visited by kangaroos, wombats, echidnas, blue tongue lizards and our fair share of tiger snakes. We enjoy the many native birds that settle on our property. As a family we have participated in canoeing the rapids, bushwalking, skiing and pottery, and we play tennis on a court in our backyard. I am still attached to the University of Melbourne and pursuing my passion to achieve normal hearing and speech understanding for severely to profoundly

ABOVE Professor Clark and Margaret Clark at the Royal College of Surgeons England. RIGHT Professor Clark receiving the Shambaugh prize. BELOW Professor Clark receiving the Lasker-De Bakey Clinical Medical Research Award in 2013.

deaf people by electrical stimulation of the brain. At this stage of my life, I have time to reflect on the journey to date and to encourage the next generation to take up the baton and to be imaginative and dedicated. It is very exciting to see progress in creating a totally implantable cochlear implant powered by rechargeable batteries where the microphone is under the skin and hearing in noise is possible through Artificial Intelligence (AI). Looking back, I would not have done things much differently. I was the right age, had the right amount of energy and the best colleagues one could hope for. I do regret that we would have been 12 months quicker if I could have persuaded the government to grant AUD$20,000 for a custom-made chip to complete the design of the first prototype instead of using a cheaper alternative. I should have used my own money or borrowed the funds. I was so criticised at the beginning that I have lost any sense of pride in my work, I am just relieved, pleased and grateful that it worked out the way that it did, when it could have gone the other way. I felt someone had to do it. ■ I Want to Fix Ears: Inside the Cochlear Implant Story by Graeme Clark was published in 2021. S U R G E O N S S C O P E / 25

› Patient Safety

IT’S COMPLICATED A cardiothoracic surgeon who retrained as an airline pilot, Niall Downey FRCSI (1997) believes that healthcare could benefit from aviation’s safety management systems to improve patient safety. Here is an extract from his recently published book Oops! Why Things Go Wrong

Niall Downey qualified as a doctor from Trinity College, Dublin in 1993. He trained as a surgeon in Belfast and received his FRCSI in 1997. He was a trainee in cardiothoracic surgery working as an SHO in the Royal Victoria Hospital before returning to Dublin where he worked as a registrar in the National Cardiac Surgery Unit. He subsequently retrained as an airline pilot with Aer Lingus in 1999 and combined working full-time in aviation with medicine by working as an Accident & Emergency doctor for six years before focusing fully on aviation. After operating as a co-pilot on both the European and Transatlantic fleets, he qualified as a captain in 2010. He has held commands on their A320, A321 neo and Boeing 757 fleets since then and is currently operating as a captain on their Airbus A330 Transatlantic fleet. In 2011, he formed Frameworkhealth Ltd, a company providing aviation-style safety training modified specifically for healthcare which draws on his 35 years of experience between both industries. This project aims to share aviation’s Safety Management System with healthcare in order to address the huge issue of Adverse Events, usually caused by systemic faults but often blamed on the last individual to have touched the ball. Niall aims to encourage healthcare to adopt a Just Culture, embed a systemic Human Factors approach and empower patients and their families to speak up as part of the crew. He has provided courses for GP practice-based pharmacists, has spoken at conferences all over the world and was also appointed as an Expert Advisor to advise the Northern Ireland Executive’s new Improvement Institute, which was set up under the Bengoa Report on how aviation can help healthcare address the huge issue of human error and learn to manage it. 26

› Patient Safety

s my six-year course in Medicine in Dublin progressed from the pre-clinical years on campus on College Green to the clinical training with patients in St James’s Hospital, avoidance of error literally became a matter of life and death. Our training focused on how to extract a diagnosis from a patient and then to decide on an appropriate treatment strategy to give them the best possible prognosis. For example, if a patient presents with chest pains, we take their history, do an examination and once we collate all this data, we might make our pronouncement that, ‘This patient is having an Acute Myocardial Infarction!’ Bit of Latin always sounds more impressive than saying, ‘He’s having a heart attack!’ At this point, we briefly acknowledge the possibility of an error by offering an alternative diagnosis in case we are wrong, although each step in our carefully followed process is intended to reduce this chance of error further and further. Research shows that once we have invested our reputation in a diagnosis, we are loath to change it to avoid losing face and looking incompetent. Studies also show that colleagues are loath to correct you too and will not contradict your diagnosis unless it’s very far off the mark. A study in the BMJ published in 2000 asked a group of clinicians and also a group of pilots in the USA if your senior colleague (consultant/attending or captain) made a mistake, would you speak up and tell them? Of the pilots, 97 per cent said yes, they would. But only 55 per cent of the clinicians (made up of junior surgeons and scrub nurses) said they would! In other words, we pay lip service to the possibility of error but our fragile egos don’t allow us to seriously consider it as an option. In the case of the junior surgeons, the constant six-month contracts probably don’t entice staff to speak up either, although some units now encourage assertiveness using an escalating ladder to express concern. A simplified version of this goes along the following lines: ‘I’m not sure that’s a good idea.’ ‘Are you sure that’s a good idea?’ ‘That’s not a good idea!’ ‘Okay, stop now!’ A patient admitted to the hospital has a ten per cent chance of suffering an adverse event caused by an error in our care, not because of the underlying illness. The emphasis throughout my training was on being right. I remember very little coverage of the possibility that I might make a mistake, nor do I remember being taught a strategy that would reduce the chance of an error or its impact if it’s not spotted until late in the process. They were simply called ‘complications’, which lumped together genuinely unfortunate bits of bad luck along with our self-made failures. We weren’t encouraged to admit that we may have messed up to the patient so as not to prejudice any possible legal proceedings in the future. Having successfully navigated medical school, I was now released into the wild as an intern on the cardiothoracic surgery ward where I started learning the practical skills that would keep me afloat, largely with the help of the hugely experienced nursing team there. The system dictated that I had an SHO (Senior House Officer) above me who I could call for help or advice but the really senior team members (registrars and consultants) were often in our main cardiac unit in a different hospital across town. At night, two of us interns covered around 350 surgical patients from various specialities, clocking up a 36-hour shift every four or five days with little or no sleep and sporadic food.

A patient admitted to the hospital has a ten per cent chance of suffering an adverse event ... The emphasis throughout my training was on being right. I remember very little coverage of the possibility that I might make a mistake ...

So, given what we have learnt so far, what was the chance of error? High to certain, I would guess. Yet there was no discussion of error and no mention of an error management strategy. Speaking to staff now when I give presentations in hospitals, little appears to have changed. Some hospitals are making inroads to a Human Factors approach with some pockets of excellent work such as Professor Peter Brennan’s Head and Neck Surgery Unit in the Queen Alexandra Hospital in Portsmouth, but no hospital as far as I’m aware is regularly training all staff in Human Factors and Error Management, despite it being one of the biggest issues in healthcare. After jumping ship to aviation, the transformation of my understanding of the value of error began. The whole concept of error being accepted and, indeed, welcomed, was totally alien to me and it took a while to get my head around the idea. My understanding at the start was that error is a sign of incompetence and was to be rooted out by studying and working harder. This was the mindset that was trained into me during my medical career and, after twelve years of training, I found it hard to let go. The turning point was the realisation during my command check training that it really wasn’t expected that I would know everything and perform flawlessly whilst in command of a $100 million aeroplane. It was expected that I would be able to access and find the information I needed using the extensive resources made available, and that I could keep the plane and everyone on it safe whilst I was doing that. My understanding of error has moved on immeasurably since my schooldays and it has freed up much of my already quite limited mental capacity. This extra capacity has, I hope, been put to better use managing the inevitable errors that I still make every day, even after 20 years in aviation, than it was spent furiously trying to be perfect and totally error-free. Life in a fast-moving, risky, complex industry doesn’t afford that luxury; we need to learn to work safely within the parameters of the inevitable errors. Most safety critical industries have embraced this idea already but there are other areas such as agriculture, finance, education and the justice system where this approach could pay dividends both in cost savings and in transforming lives. ■ Oops! Why Things Go Wrong, Understanding and Controlling Error was published by The Liffey Press in June, and is already in its second print run. S U R G E O N S S C O P E / 27

› Q&A

THE COLLES Q&A MR EAMON MACKLE A consultant surgeon based in Northern Ireland, Mr Eamon Mackle has many leadership roles at hospital and national level

Mr Eamon Mackle is a Consultant Surgeon at Craigavon Area Hospital in Northern Ireland. He is an Honorary Clinical Lecturer in Surgery at Queen’s University of Belfast. He was awarded his Fellowship of RCSI in 1984 and was appointed as a consultant in 1992. Mr Mackle is a current member of the Executive Committee of RCSI’s Court of Examiners, Supervising Examiner in RCSI for the IMRCS, Vice Chair of IMRCS MCQ Paper Panel, an RCSI representative on Intercollegiate Committee Basic Surgical Exams, External Examiner at Glasgow University, a past NUI External Examiner at the Medical University Bahrain, Past President of the Ulster Medical Society and Past President of the Ulster Society of Gastroenterology.

Eamon Mackle, MB BCH, BAO, MCh, FRCSI.

When and where are you happiest? Anywhere when watching Man City win. What is your ideal evening? Good friends, good food, good wine and good craic. If you could research and write a book on any subject, what would it be? My family tree. Hopefully it will be full of tales of determination, happiness and resilience. What relaxes you most? A good night’s sleep (not so easy as you get older)! What is your greatest fear? Man United winning the treble for the second time. Where would you be if you decided not to become a surgeon? I would have been a pharmacist like my father. When did you decide you wanted to become a surgeon? The very first time I saw an appendectomy. Would you have any advice for your younger self? Life is not a rehearsal. The time that your children spend developing and growing up is time that you can never recapture. In what way do women in medicine struggle/ what issues do women in medicine today face? I may not the best person to ask but it can’t be easy juggling work and family life. The two shouldn’t be mutually exclusive but the system doesn’t make it easy. What has been your proudest moment? Seeing my parents’ faces at my graduation. Who have you learned the most from in

your life? My parents, who instilled in me a sense of duty, care and social responsibility. How does a surgeon in 2023 cope with pressure? The advent of multidisciplinary teamwork means that surgeons no longer routinely take sole responsibility for patient care. Working in a highly functioning team affords a level of job satisfaction and psychological safety which can mitigate against the pressure of the job. What is your greatest extravagance? Convertible cars. My favourite is a Ferrari convertible but it looks like I’ll have to wait until I win the Lotto before I get my hands on one! Do you have a mantra to live by? I don’t have a specific mantra but I believe in the positive benefits of Martin Seligman’s ‘Three Good Things’, which help me maintain a positive outlook on life. The Three Good Things exercise, also known as “The Three Blessings,” is arguably one of the most well-known positive psychology interventions. This exercise entails writing down three things that went well and reflecting on these things at the end of each day (Seligman, Steen, Park, & Peterson, 2005). What do you consider your greatest achievement? Having helped to raise three lovely children. What living world figure do you admire? David Attenborough, who at the age of 97 is presenting Planet Earth III. His calm manner and soft voice, coupled with his descriptions of the natural world, make him a fascinating person. What is your favourite memory? Camping in

› Q&A

Working in a highly functioning team affords a level of job satisfaction and psychological safety which can mitigate against the pressure of the job.

France when the children were young. Name your favourite writer? I would like to say that I love reading the original works of Victor Hugo or Alexander Pushkin. The truthful answer is less erudite and would probably be John Grisham as I tend to read for relaxation when I am on holiday and at that time I do not want to read anything too deep or meaningful. If you could invite any historical figure to dinner, who would it be? I would love to have met Nelson Mandela and I imagine listening to him over dinner say: “What counts in life is not the mere fact that we have lived. It is what difference we have made to the lives of others that will determine the significance of the life we lead.” Which talent would you most like to have? I would love to be able to swim in something deeper than the bath! What is the wisest thing you have ever said? “Thanks”. This short and simple word is underused. Too often we take for granted the contribution of others. We all like to know we are appreciated and I regret not having said thanks more often myself. How do you have fun? See question 2! Name one virtue all surgeons ought to have? Humility. Name one vice no surgeon should have? Arrogance. I don’t see a role for Sir Lancelot Spratt in modern surgical practice. Name three things you would like in your future? I don’t want to be greedy and will stop at health and happiness. ■

ADMIRING: Sir David Attenborough at 97, presenting Planet Earth III.

NELSON MANDELA: An inspiring dinner table guest.

WISHFUL THINKING: A Ferrari convertible.

MUST READ: Anything by John Grisham.

NO ROLE MODEL: The pompous and dictatorial doctor Sir Lancelot Spratt. S U R G E O N S S C O P E / 29

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Scope Events

SCOPE EVENTS PENANG CONFERRING Congratulations to the 20 new Fellows and Members who were awarded their FRCSI and MRCSI by RCSI in Penang.

DUBLIN CONFERRING

RCSI congratulates 198 new RCSI Fellows and Members who were awarded their FRCSI and MRCSI in person and in absentia by RCSI in July.

› Scope Events

HONORARY FELLOWS At the Dublin Conferring, the College also conferred three Honorary Fellowships on Professor Paul Brennan, Professor James M. Drake and Professor Patricia Joy Numann. The Honorary Fellowship of RCSI is the highest distinction the College bestows, recognising outstanding achievement in surgery and in other areas.

RCSI President, Professor Laura Viani, Professor Patricia Joy Numann, Lloyd S. Rogers Professor of Surgery Emeritus, State University of New York Upstate Medical University, New York, Ms Bridget Egan, RCSI Council Member.

Professor James Drake, Surgeon in Chief, The Hospital for Sick Children, Toronto, RCSI President, Professor Laura Viani, Mr John Caird, RCSI Council Member.

Professor K. Simon Cross, RCSI Council Member, Mr Paul Brennan, Consultant Radiologist, Bon Secours Hospital, Dublin, RCSI President, Professor Laura Viani.

RCSI NORTH AMERICAN CHAPTER OF FELLOWS RECEPTION AT AMERICAN COLLEGE OF SURGEONS

CORK DOING THE ROUNDS ROADSHOW

RCSI visited Cork on Thursday, 5 October as part of the Doing the Rounds Roadshow series and enjoyed meeting Fellows, Members and trainees to learn more about how the College can offer support locally.

Mr Brian G. Moriarty, Consultant ENT surgeon, University Hospital Kerry and RCSI President, Professor Laura Viani.

Ms Sandra Eguare, Mr Emanuel Eguare, Mr Kieran Ryan, Director of Surgical Affairs, and RCSI President, Professor Laura Viani.

Dr Ali Basil Ali.

Ms Catherine Jordan, Membership Manager: Fellows and Members Department, RCSI, Ms Jenelle Sherlock, Engagement Marketing Executive, Fellows and Members Department, RCSI.

Mr Kieran Ryan, Managing Director of Surgical Affairs, Mr Mark Dolan, Trauma and Orthopaedic surgeon at CUH, RCSI President, Professor Laura Viani, and Mr Padraig Kelly, Associate Director, Surgical Affairs.

RCSI President, Professor Laura Viani and RCSI Vice President Deborah McNamara.

Professor Zubair Muhammad, Mr Mamoun Abdelraham, and Mr Shabaz Mansoor.

Professor Kevin Barry, Director of National Surgical Training, RCSI.

RCSI’s North American Chapter of Fellows Reception at the ACS Clinical Congress on Monday, 23 October, was a wonderful networking event with over 60 RCSI surgical Fellows and Members attending the reception from North America, Ireland and internationally. Congratulations to RCSI Vice-President Professor Deborah McNamara, who has been awarded Honorary Fellowship of American College of Surgeons and to Professor Kevin Barry, Director of National Surgical Training Programmes at RCSI, who has been inducted into ACS Academy of Master Surgeon Educators. S U R G E O N S S C O P E / 31

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Scope Events

SCOPE DIARY RCSI CHARTER MEETING 2024 ‘Rising to Challenges in a Changing World’, Tuesday, 6 February – Friday, 9 February 2024 PROGRAMME OVERVIEW Tuesday, 6 February 2024

• 14.45 – 16.15: Parallel Group II

• 10.00 – 16.00: National Ofﬁce of Clinical Audit (NOCA) Conference • 19.00 – 21.30: Intercollegiate Case Presentations Wednesday, 7 February 2024 • 09.00 – 16.00: Annual Health Service Quality Improvement and Innovations Conference (Hosted by NCPS) • 16.00 – 19.00: Irish Surgical Training Group (ISTG) Meeting Thursday, 8 February 2024 • 09.00 – 10.30: Parallel Group I Afﬁliate Members Programme Cardiothoracic Surgery General Surgery 1: Breast, Endocrine & HPB Surgery Neurosurgery Urology

Faculty of Dentistry Faculty of Nursing and Midwifery Faculty of Radiology and Radiation Oncology and the Faculty of Sports and Exercise Medicine (joint session) Irish Institute of Pharmacy (IIOP) Ophthalmic Surgery • 17.30 – 20.00: 34th Annual Videosurgery Meeting Friday, 9 February 2024 • 09.00 – 10.30: Parallel Group III Trauma and Orthopaedic Surgery (07.30–10.30) Emergency Medicine ENT/Otolaryngology, Head and Neck Surgery General Surgery 2: Emergency and General Surgery Plastic and Reconstructive Surgery Oral and Maxillofacial Surgery Vascular Surgery

• 11.00 – 13.00: Symposium I – Surgery Responding to Global & Environmental Change

• 11.00 – 11.30: 31st Carmichael Lecture – by Mr Fergal Keane OBE

• 14.00 – 14.30: Johnson & Johnson Lecture – Leading Healthcare into Transformational Change, by Mr Michael J. Dowling

• 11.30 – 13.00: Symposium III – Crisis Management: What Have We Learnt?

• 14.30 – 14.45: Awards and Medal Presentations

• 14.00 – 14.30: 99th Abraham Colles Lecture – by Professor David Nott, OBE DSc, MD, FRCS

• 14.45 – 17.15: Symposium II – Transitions in a Surgical Career

• 14.30 – 16.00: Symposium IV – Technology of the Future for Irish Surgery

PROGRAMME, REGISTRATION & QUERIES Charter Meeting 2024 will be a fully in-person event, taking place at RCSI, St Stephen’s Green, Dublin 2. Online registration is essential. Registration and the draft programme is available at www.rcsi.com/Charter2024. CPD will be available for all sessions. For queries, please email charter@rcsi.ie. Please note the above event dates are correct at the time of printing and may be subject to change 32

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Surgeons Scope Magazine Issue 2 - 2023

Articles inside

Surgeons Scope Magazine Issue 2 - 2023

Surgeons Scope Magazine Issue 2 - 2023