Surgeons Scope Magazine

THE MAGAZINE EXCLUSIVELY FOR RCSI FELLOWS AND MEMBERS ISSUE 2 2021

BACK TO THE

BEGINNING

PROFESSOR TARIQ SAEED FROM BAHRAIN TO DUBLIN AND BACK AGAIN

SPECIALTY SPOTLIGHT PLASTIC SURGERY PROFESSOR BRIAN KNEAFSEY

A LEANER MACHINE MAXIMISING THEATRE EFFICIENCY A SURGEON IN…MELBOURNE MS HELEN MOHAN

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› Letter

A Letter from the President, RCSI PROFESSOR P RONAN O’CONNELL Dear RCSI Fellows and Members, I hope you will enjoy this issue of Surgeons Scope which will bring you up to date with events in RCSI. Sadly, in Ireland as around the world, COVID-19 pervades all we do. Fears that lifting restrictions on social activities in October might lead to a resurgence in case numbers and hospital admissions have been justified, notwithstanding the extraordinary level of vaccination within our society (92% of adults). Thankfully ‘booster’ vaccines are now widely available for healthcare workers in Ireland and the roll-out to the general population is beginning. As I write, however, there are new concerns regarding a B.1.1.529 variant. We may be facing a long and difficult winter.

Despite COVID-19, there have been many positives for RCSI. Our Dublin, Bahrain and Malaysia campuses reopened on time in September with reconfigured timetables to allow full course delivery in a COVID-19 safe manner. There was a full uptake of available places, indeed every course was oversubscribed. Great credit is due to the academic and administrative staff who worked without pause to ensure the safe reopening of our campuses.

Postgraduate training has continued throughout COVID-19. While case numbers returned to close to pre-COVID-19 levels over the summer months, the ‘fourth wave’ of COVID-19 infections has predictably had a serious effect on scheduled care. Throughout, our Fellows and Members have been exemplary in their dedication to patient care. Training continues and every effort has been made to maintain surgical skills and human factors courses at the RCSI National Surgical Training Centre. Professor Kevin Barry, who has succeeded Professor Oscar Traynor as Director of the National Surgical Training Programmes, brings enormous experience in medical and surgical education, having been the lead for the NUIG Mayo Medical Academy in Castlebar, Intercollegiate Fellowship examiner and most recently Programme Director for General Surgical Training in Ireland.

Membership and Fellowship examinations have continued. However, the January 2022 Part A MRCS examination has had to be deferred in order to reassess the online method of delivery. It is expected that three diets of the examination will take place in 2022 as originally planned. Every effort will be made to ensure trainees will not be disadvantaged and that career progression will not be affected. Resumption of overseas diets of Part B examinations remains problematic but RCSI, in consultation with our sister Royal Surgical Colleges, is determined to resume these as soon as possible.

It is hard to believe that Professor Oscar Traynor has stepped back from some of his onerous roles within the College. He has been a driving force in surgical education and training for more than 20 years. In this issue, his interview with Claire O’Connell charts a career of many firsts, most especially the establishment of the liver transplantation programme at St Vincent’s University Hospital in January 1993. Remarkably, the recipient is alive and doing well nearly 30 years later. Professor Traynor’s contribution to surgical training both in Ireland and abroad was recently recognised by the award of an Honorary Fellowship of the American College of Surgeons (ACS) at its Clinical Congress held (virtually) in

Professor P Ronan O’Connell, President, RCSI

Great credit is due to the academic and administrative staff who worked without pause to ensure the safe reopening of our campuses.

Chicago. ACS President-elect Dr Chris Ellison has assured me that, COVID-19 permitting, next year’s ACS congress will feature a convocation that will recognise all who have received ‘virtual’ honours.

In this issue, the spotlight is on Plastic Surgery. Dr Tariq Saeed’s life story of determination, struggle and success is uplifting and a reminder to all that obstacles can be overcome, mentorship is invaluable, and that opportunities will arise and should be taken. His association with RCSI has spanned his surgical career leading to his appointment as Associate Professor in RCSI Bahrain. His three children have followed him into medical careers – all graduating from RCSI. What a wonderful endorsement.

When he was appointed as a consultant Plastic Surgeon to Beaumont Hospital in 1998, Professor Brian Kneafsey was single handed, now there are seven providing a 24/7 service to the RCSI Hospital Group. In that time, Plastic Surgery – or more correctly Plastic, Reconstructive and Aesthetic Surgery – has evolved into a multidisciplinary service with subspecialty expertise covering all aspects of reconstructive surgery. Yet, as Professor Kneafsey points out, only six of the eight cancer centres in Ireland have Plastic Surgery units and the number of SURGEONS SCOPE / 1

› Letter

Professor P Ronan O’Connell, President, RCSI

These have been difficult times – indeed to paraphrase Charles Dickens in A Tale of Two Cities – it has been the worst of times; it has been the best of times.

consultants in Ireland is well below international norms. Clearly there remains a significant service need that must be filled.

The success of our trainees in obtaining world-class fellowship overseas is testament to the quality of the training provided in Ireland and the ambition and resilience of our trainees. It is wonderful to read of Eamon Francis’ experience as the RCSI Colles Travelling Fellow in Plastic and Reconstructive Surgery in Chang Gung Memorial Hospital, Taiwan – an institution with 3,800 beds, 90 operating rooms and a 24-bed dedicated microsurgical ICU! In addition, Eamon is taking a masters degree in Reconstructive Microsurgery through Chang Gung University. Equally impressive is Helen Mohan’s account of the challenges she has had to overcome in getting to the Peter MacCallum Cancer Centre in Melbourne during the pandemic, with three small children in tow. Elaine Redmond has gained enormously from her experience in paediatric urology in British Columbia Children’s Hospital, Vancouver. These and all our other trainees on international fellowships will ensure that the next generation of Irish surgeons will be the brightest and the best.

I was delighted to read of the publication of The Hospital Pass by Con Feighery, Michael Farrell and Morgan Crowe. The oldest rugby trophy continuously contested, the Hospitals Cup has been one of the highlights of Dublin hospitals’ sporting and social activity since 1881. The amalgamation of so many smaller hospitals in Dublin may have reduced the number of teams competing (my alma mater Sir Patrick Dun’s Hospital was the team to beat throughout the first part of the last century), but fearsome rivalry remains. I am sure it will be an enjoyable read (Christmas is coming) and I look forward to learning of all the skulduggery that went on – including the two Australian medical students on route to electives at St James’s Hospital who somehow played for the Mater team that year. Only one of them returned to Australia in plaster!

In the Colles Q&A article, Professor Freddie Wood, former Council Member and past President of the Irish Medical Council, looks back on a life of enormous contribution to Irish healthcare, pioneering surgery for congenital heart disease and cardiac transplantation. Interesting that the advice he would give a younger self is to qualify in something other than surgery! I think probably not, although he might have made a good barrister. In that regard, Imogen McGrath gives insights into the tort system as it applies to medical negligence claims in the Irish legal system. Anyone unfortunate enough to have been subject to litigation will know just how stressful and prejudicial this can be to one’s practice.

These have been difficult times – indeed to paraphrase Charles Dickens in A Tale of Two Cities – it has been the worst of times; it has been the best of times. We are in the midst of a pandemic the like of which we thought had been consigned to history, but we have seen courage and resilience, social cohesion, disruptive innovation, novel vaccine discovery. As December begins, perhaps, for once, the true meaning of family, community and repurposing (aka, New Year resolutions) will triumph over the commercial tsunami that often overtakes the ‘festive season’.

I am grateful to Catherine Jordan and her team in the Fellows and Members Office who have assembled this excellent edition of Surgeons Scope.

Happy Christmas, stay safe.

Best wishes Professor P Ronan O’Connell President, RCSI

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SURGEONS

THE MAGAZINE EXCLUSIVELY FOR RCSI FELLOWS AND MEMBERS

Contents 04

Scope News

06

From Transplants to Transforming Surgical Education

The impact of COVID-19, lengthening waiting lists, surgical training

Professor Oscar Traynor receives an Honorary Fellowship from the American College of Surgeons

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08

12

16

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24 THE MAGAZINE EXCLUSIVELY FOR RCSI FELLOWS AND MEMBERS ISSUE 2 2021

BACK TO THE

BEGINNING

PROFESSOR TARIQ SAEED FROM BAHRAIN TO DUBLIN AND BACK AGAIN

SPECIALTY SPOTLIGHT PLASTIC SURGERY PROFESSOR BRIAN KNEAFSEY

A LEANER MACHINE MAXIMISING THEATRE EFFICIENCY A SURGEON IN…MELBOURNE MS HELEN MOHAN

+

MEDICO-LEGAL MATTERS THE DUBLIN HOSPITALS CUP WAITING LISTS 4

ON OUR COVER

Professor Tariq Saeed, Consultant Plastic Surgeon and RCSI Fellow (1984). Photograph

by Haitham Isa Al-Ghurair

Back to the Beginning

From Bahrain to RCSI Dublin and back again, Dr Tariq Saeed’s path to establishing a “compact hospital” devoted to plastic surgery

Specialty Spotlight

Plastic Surgery: Professor Brian Kneafsey’s perspective on the opportunities and challenges

Transforming Theatre

Clinical Lead of the Transforming Theatre programme, Professor Deborah McNamara on ensuring scarce theatre resources are used as efficiently as possible

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The Dublin Hospitals Cup

24

A Surgeon in…Melbourne

04 26

Broadening the Mind

28

A Fairer Hearing

30

The Colles Q&A

32

Scope Diary

Why international Fellowships count: Mr Eamon Francis and Ms Elaine Redmond share their experiences

Barrister Imogen McGrath on recent judgments that serve to tighten procedural safeguards for defendants

Professor Freddie Wood on work, life and the importance of hobbies

Charter Day Programme 2022 and upcoming Fellows and Members events

As a new book on this age-old rugby competition is published, it’s time to reflect on the characters and the contests

Packing up the family for an adventure down under, Ms Helen Mohan is convinced to extend her stay

RCSI SURGEONS SCOPE MAGAZINE is published bi-annually by RCSI for its 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 (0) 1 402 2116; email: catherinejordan@rcsi.com.

RCSI Surgeons Scope is posted bi-annually to our 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.

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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 IMPACT OF COVID-19, WAITING LISTS, SURGICAL TRAINING

NCPS REPORT PUBLISHED

There were 17% fewer emergency surgeries and 30% fewer elective surgeries performed during the COVID-19 pandemic, according to a new report published by RCSI’s National Clinical Programme in Surgery (NCPS).

The most significant reduction in surgical discharges occurred in April and May 2020, dropping to 34.7% of 2019 average monthly volumes.

The report, which examines the impact of COVID-19 on surgical activity in Ireland, also details the impact of the pandemic on waiting lists, showing a 153% increase from April 2020 to April 2021 in the number of surgical patients waiting longer than twelve months for their procedures. The total surgical outpatient waiting list increased by 15%.

General surgery is the specialty that accounts for the highest number of patients on waiting lists (31,517 patients), followed by orthopaedics (10,393) and urology (9,797). As of April 2021, 27.1% of 76,949 cases on the waiting list for inpatient care, day cases and endoscopies were deemed urgent.

Patient access to urgent ear, nose and throat (ENT) surgery was significantly curtailed, resulting in over 100,000 patients now waiting for their first specialist appointment.

In March and April 2020, when it was unclear whether any functioning surgical activity would be possible, NCPS developed a document to assist in planning the system-wide response to the pandemic in an attempt to maintain surgical services during the emergency phase.

Comprehensive guidance was provided to surgical teams, including recommendations on actions to maintain surgical capacity during an outbreak and actions to allow for activity to resume when an outbreak is reducing.

A care pathway for surgical patient triage and treatment during the pandemic was defined and a GP-Surgeon Connect service which allowed GPs to rapidly connect with surgical experts, resulting in a greater number of patients being managed in the community.

Addressing reforms in the delivery of surgical care, RCSI Council Member and Past President Mr Kenneth Mealy, Co-Lead, NCPS said: “The pandemic has exacerbated what were already unsustainable waiting lists. The HSE must act to immediately protect capacity for scheduled surgery. RCSI and the Irish surgical community will work with the HSE and hospital managers to maximise the use of surgical capacity, ensuring that patients have swifter access to care, once that capacity is ring-fenced.”

APPOINTMENT OF DIRECTOR OF NATIONAL SURGICAL TRAINING PROGRAMMES

Professor Kevin Barry

RCSI has appointed Professor Kevin Barry as Director of the National Surgical Training Programmes.

Professor Barry is an established 4

leader in undergraduate and postgraduate surgical training, most recently as the National Training Programme Director in General Surgery. An intercollegiate examiner since 2007, he was instrumental in the establishment of the Mayo Medical Academy affiliated with National University of Ireland, Galway (NUIG) School of Medicine.

Professor Barry has been a Consultant General Surgeon at Mayo University Hospital since 1999, where he established a symptomatic breast clinic. He subsequently joined the symptomatic breast team at Galway University Hospital in 2008, where

he continues to work closely with the multidisciplinary team.

A graduate of University College Cork (UCC), Professor Barry obtained his FRCSI in 1990 before completing further training in the USA. He was awarded an MD by UCC on the basis of his research and has authored more than 130 peerreviewed publications.

RCSI President, Professor P Ronan O’Connell said: “The Director of the National Surgical Training Programmes plays a pivotal role in maintaining the highest standards of excellence within our surgical training programmes. I am delighted that Professor Barry has been appointed to this role, bringing with him a wealth of experience of surgical training at both a

national and international level. I look forward to his leadership and guidance in support of our surgeons in training.”

Professor Barry said: “I am delighted to be appointed to the role of Director of National Surgical Training Programmes. I look forward to working with the team at RCSI, as we map out and deal with the challenges and opportunities that lie ahead in relation to surgical education, training and assessment.

I am particularly focused on the need to expand the various surgical training programmes in a coordinated and meaningful fashion, in order to meet projected consultant workforce requirements and in accordance with national health policy by 2028.”

› News

Surgical Bootcamp Trains Next Generation

RCSI APPOINTS FELLOWS AND MEMBERS MEMBERSHIP MANAGER

Catherine Jordan has recently been appointed Membership Manager of RCSI Fellows and Members Office, bringing to the role more than 25 years of experience in marketing, business development and relationship management. One of Catherine’s Catherine Jordan responsibilities is Surgeons Scope.

Catherine looks forward to learning more about surgical matters and to helping Fellows and Members deepen their relationships with RCSI, ensuring they optimise the benefits of membership, both in Ireland and internationally.

Catherine would like to reach out to as many Fellows and Members as possible to gather perspectives on RCSI and what it means to be a Fellow or Member. Please contact her at catherinejordan@rcsi.com or on +353 1 4022116.

NEXT GENERATION RCSI SURGERY & EMERGENCY MEDICINE TRAINEES INTAKE IN GREAT SHAPE FOR 2022

RCSI’s internationally recognised training programmes ensure the highest standards of medical practice in Ireland by delivering high-quality accredited training through stateof- the-art facilities, fellowship opportunities and extensive trainee supports.

Speaking about the significance of the National Surgical Training Programme (NSTP), Professor Kevin Barry, Director of National Surgical Training Programmes at RCSI, said: “In recent years, a positive trend has emerged of increasing applications for our Core Surgical Training (CST) programmes. I very much welcome this development. This year’s intake has brought 286 applications from 38 countries, an increase of 14% of which 42% were submitted by female applicants. This bodes well for the planned expansion of our national surgical training programmes over the next seven years, an exciting time to consider a career in surgery.

The role of the surgeon will remain pivotal in the management of many disease processes in the future, both benign and malignant. Many forces are combining to increase the demand for surgical care in the years to come. As a result, there will be a very significant expansion in the Surgical Consultant

workforce over the next ten years to meet the demand for care.”

Dr Gareth Quin, Dean of Emergency Medicine Postgraduate Training and Education at RCSI, noted the key role of RCSI’s Core and Advanced emergency medicine training programmes: “Recruitment to the emergency medicine training programme is one of the highlights of our calendar, as we seek the emergency medicine specialists of the future. The ongoing development of the specialty in Ireland is reflected in increasing numbers applying for Core training, and more Core trainees progressing to advanced training, year on year.

“Both Core and Advanced programmes continue to develop, with a growing schedule of workshops and simulation training complementing ED-based training in our busy training sites. We retain close links to the Royal College of Emergency Medicine, whose curriculum and programme of examinations are a core component of our training.”

More than 80 surgical trainees have completed RCSI’s Surgical Bootcamp.

Now in its eighth year, the intensive 40-hour course was developed to immerse surgical trainees in the technical and non-technical skills needed as a surgeon.

Over three weeks, this year’s programme saw each core surgical trainee complete a week of training sessions in person at the National Surgical and Clinical Skills Centre at RCSI’s 26 York Street, with additional online training.

RCSI published the PROGRESS: Promoting Gender Equality in Surgery report in 2017, identifying the complex barriers to female progression in surgery. Since its publication, the number of female candidates to surgical training continues to grow.

Ms Dara O’Keeffe, Simulation Lead in Postgraduate Surgical Education and Training at RCSI, said: “The surgical training programme seeks to recruit the best trainees, regardless of gender, based on a robust and transparent selection system. In 2017,

Surgical Bootcamp

27% of successful applicants were female, but this has grown year on year. This year, 46% of core surgical trainees are female. As their training body, RCSI is committed to their success and to ensuring that surgery is a profession in which male and female doctors can thrive.”

Surgical Bootcamp was supported by 40 RCSI faculty members from across the range of surgical specialties and emergency medicine. It was led

by Ms Dara O’Keeffe, RCSI Member (2001) and Simulation Lead; Professor Eva Doherty, Director, RCSI Human Factors in Patient Safety; Dr Angela O’Dea, Senior Lecturer, RCSI Surgical Affairs; and Mr Donncha Ryan, Lead Technology Officer, RCSI Surgical Affairs, with technical support from the RCSI Simulation Department.

LAUNCH OF NATIONAL SURGICAL RESEARCH CENTRE

RCSI has announced the establishment of a National Surgical Research Support Centre to implement the recommendations of the RCSI Short Life Working Group report ‘towards improved collaboration and coordination of surgical research in Ireland’.

The Centre will support those involved in surgical research across the island of Ireland, facilitate integration of clinical trials networks across hospital groups and foster interest in surgical research among the surgical community in Ireland.

Professor Michael Kerin, Chair of the RCSI Council Research Committee, said: “The best clinical outcomes come from a research-rich environment and the opening of this centre will help to build this environment for surgery in Ireland.

Appropriate supports will be needed for those involved in surgical research to better assist researchers with the fundamentals such as grant writing, statistical support and study design. We also need to establish a model to recruit, retain and develop surgeons for a career in academic surgery.”

RCSI President, Professor P Ronan O’Connell added, “I am very optimistic and heartened by the investment from RCSI with the development of the new RCSI National Surgical Research Support Centre, which will help to create a research rich surgical infrastructure for the betterment of human health and improved surgical care for our patients.”

The RCSI Council Research Committee works in collaboration with the traineeled surgical collaborative, Irish Forum of Surgical Research (IFSR) and the Irish Surgical Research Collaborative (ISRC).

A recruitment process is now underway to appoint a Clinical Lead and Programme Manager for the RCSI National Surgical Research Support Centre.

For further information on these roles, visit www.rcsi.com/careers. ■ SURGEONS SCOPE / 5

› Interview

From Transplants to Transforming Surgical Education AS PROFESSOR OSCAR TRAYNOR RECEIVES AN HONORARY FELLOWSHIP OF THE AMERICAN COLLEGE OF SURGEONS, CLAIRE O’ CONNELL SPOKE TO HIM ABOUT HIS ROLE IN DRIVING CHANGES IN SURGERY IN IRELAND

For much of this period, Professor Traynor has also worked at RCSI to pioneer new approaches to surgical training, including online delivery, simulation and the all-important art of managing human factors.

In recognition of his contribution to surgery and surgical education, in October 2021 Professor Traynor was made an Honorary Fellow of the American College of Surgeons (ACS). He received the prestigious honour at a virtual Convocation ceremony before the opening of the virtual ACS Clinical Congress 2021, one of the largest educational meetings of surgeons in the world.

Not one to rest on his laurels, Professor Traynor continues to be at the forefront of surgical training in his role as Professor of Postgraduate Surgical Education at RCSI, this year unveiling a brand new curriculum that takes a holistic approach to educating and assessing trainee surgeons.

SURGERY – THE OBVIOUS CHOICE

Professor Oscar Traynor, RCSI Fellow (1978) and Professor of Postgraduate Surgical Education at RCSI.

rofessor Oscar Traynor remembers it well. It was January 1993, and years of work were culminating in a landmark day for Ireland. He and colleague Mr Gerry McEntee, RCSI Fellow (1982) were about to carry out the first liver transplant in the country at St Vincent’s University Hospital (SVUH).

“It was such an exciting day for the whole hospital,” recalls Professor Traynor. “The whole operation went smoothly and that patient is still alive nearly 30 years later, and continuing to do well.”

Since then, the National Liver Transplant Programme, which Professor Traynor directed until 2014, has continued to save lives, caring for almost 1,500 patients to date.

6

Surgery became an obvious choice for Professor Traynor when he was studying medicine in University College Dublin (UCD). Initially, it was orthopaedics that lit the fire.

“My first clinical placement in St Vincent’s was with the famous orthopaedic surgeon, Mr Jimmy Sheehan, RCSI Fellow. He was young, just back from the UK and this was the early 1970s when operations like hip replacements were brand new and he was bringing them to Ireland. The type of work he was doing was inspiring and caught my imagination,” says Professor Traynor. “I went on and did several other clinical placements in surgery – and I got more and more interested in it.”

Back then, surgical training took longer than it typically does today, and Professor Traynor spent more than 13 years learning the craft. He moved to London, getting exposure to operations in busy hospitals at Ealing and Hammersmith. It was in the latter hospital that he met Professor Leslie Blumgart, a pioneer of liver surgery. “There were very few people in the world doing liver surgery in the late 1970s, and again that sparked my interest,” he says.

Professor Traynor continued his training at the Mayo Clinic in Rochester, USA, and in Ireland before honing his expertise in the liver in Paris with Professor Henri Bismuth.

By now it was the mid-1980s and the arrival of immunosuppressant drugs – most notably cyclosporine – was making liver transplants a safer and more effective option for patients, explains Professor Traynor. “Paris had the biggest programme in Europe for liver transplantation and it was an excellent place to learn,” he says.

› Interview

NATIONAL TRANSPLANT PROGRAMME

Returning to Dublin to take up a consultant post at SVUH, Professor Traynor drove forward plans to set up a national programme for liver transplantation in Ireland along with Professor Niall O’Higgins, RSCI Fellow (1970), the late Professor Eddie Guiney and Professor John Hegarty, RCSI Fellow (1978). Initially there was debate about whether such a programme could be supported, but eventually it got the green light in 1990, and a multi-disciplinary team trained up, with many medical, nursing and paramedical staff moving to King’s College Hospital in London to specialise.

Then, in 1993, the red-letter day rolled around when the first patient in Ireland received a donated liver through the National Liver Transplant Programme, kickstarting a service that would prove successful beyond expectations.

As Director of the Programme, Professor Traynor quickly grew it from supporting 15-20 transplants a year to more than 60 transplants annually.

The programme has also built a large and successful body of research on the liver – including ground-breaking insights into the liver’s immune system – led by Professor Cliona O’Farrelly. “The Programme has been phenomenally successful,” he says, noting that the clinical indications for liver transplantation have changed across the decades. “When we started in the 1990s, the biggest causes of liver failure leading to transplantation were Hepatitis C and alcohol.

Today, we are seeing a rapidly rising incidence of fatty liver disease linked to the obesity epidemic, something we would have rarely seen 30 years ago.”

PIONEERING SURGICAL TRAINING

Following surgery on his back, Professor Traynor retired from performing liver transplant operations (which typically take several hours) in 2014. He took up the opportunity to expand the roles he had held with RCSI in surgical training since the late 1990s.

“With RCSI, the first big change we introduced was in the early 2000s, when we developed an online learning programme for surgical trainees, the first of its kind in the world,” he explains.

In the following years, Professor Traynor continued to drive innovation in surgical training at RCSI, bringing simulation into training, where surgeons learn first in a simulated environment before operating on patients. While it was new in the mid-2000s, today simulation is a mandatory part of many programmes worldwide and continues to grow.

“Simulation will have a bigger and bigger role in training going forward,” says Professor Traynor. “Not even five years ago, we opened a brand new simulation facility at 26 York Street and already we need more space and facilities to support the demand.”

Professor Traynor was also a pioneer of bringing “human factors” into surgical training. These are the non-technical skills such as communication, teamwork, crisis management and conflict resolution that enable teams to work smoothly under pressure.

“I was captivated by the factors that influence critical decision-making,” he says. “It became clear to me that this was important for surgeons, so together with surgeons Professor David Bouchier-Hayes and Professor Sean Tierney and psychologist Professor Ciaran O’Boyle at RCSI, we decided to develop a curriculum for human factors.”

The move was met with raised eyebrows in some quarters, but human factors have since become an essential part of surgical training. “It took a while for the concept of human factors as part of surgical training to gain widespread acceptance,” says Professor Traynor. “But now it is well recognised, and regulatory bodies around the world mandate it as part of training.”

“It took a while for the concept of human factors as part of surgical training to gain widespread acceptance.

But now it is well recognised.”

NEW SURGICAL TRAINING CURRICULUM

Cognisant of the ever-evolving needs of surgical trainees, Professor Traynor and colleagues have led the implementation of a new curriculum for surgical training in RCSI. This curriculum was developed as a collaborative venture between the four surgical Royal Colleges of the UK and Ireland under the umbrella of the Joint Committee on Surgical Training (JCST).

“It is brand new, shiny and completely and radically updated,” he says. “We have continued to evolve the emphasis on human factors and professionalism, we have updated the assessment and documentation of competence and an essential part is the input from all consultants involved in a trainee’s journey when assessing the trainee’s performance. The new curriculum takes a holistic overview.”

Much of the curriculum was developed and refined National Surgical Skills Competition during the COVID-19 pandemic, and while this has helped to inform the future needs of trainees, Professor Traynor has serious concerns about the long-term impact of the crisis.

“COVID-19 has had a catastrophic effect on surgical training,” he says.

“Elective surgeries were cancelled, and we have seen as many as 70% of operations not going ahead overall during some periods. This means that surgical trainees were getting just a fraction of the operative exposure that helps them to learn. And while online training and simulations have helped to compensate, I think we may not realise the full impact of COVID-19 on surgical training for a couple of years yet.”

ROBOTS, AI AND SURGEONS

On a brighter note, Professor Traynor is excited about the emerging developments in surgery. “Technology is becoming much more embedded in practice,” he says. “We are seeing advances in robotics that allow assisted and remote surgeries to explore new limits, and we will see a big growth in artificial intelligence (AI) supporting surgeons in real time as they make decisions, drawing on outcome data from comparable procedures and relating them to the patient undergoing surgery. This is really going to change the landscape.”

Professor Traynor will continue to influence that landscape through developments in surgical training, counting himself as an “interested spectator” while also wistful for the experience of hands-on operations. “The coming decade is going to be so exciting,” he says. “I almost regret that I am not starting out again in my surgical training now.” ■ SURGEONS SCOPE / 7

› Back to the Beginning

Back to the Beginning IN BAHRAIN IN 1996, RENOWNED PLASTIC SURGEON, PROFESSOR TARIQ SAEED FOUNDED A CLINIC WHICH GREW TO BECOME A HOSPITAL DEVOTED TO PLASTIC SURGERY AND ALLIED SPECIALTIES. HE TRAINED IN IRELAND, THE UK AND THE USA AND HOLDS FELLOWSHIPS IN SURGERY FROM THE ROYAL COLLEGES OF SURGEONS IN IRELAND AND EDINBURGH. WE SPOKE TO HIM ABOUT HIS CAREER, HIS VARIED EXPERIENCES AND HIS LIFE OUTSIDE WORK… rofessor Tariq Saeed was born and grew up in Bahrain, as one of eight children – “like a big Irish family”, he says, educated initially by Italian nuns at the Sacred Heart School. “They instilled in me discipline and a love of art,” he remembers.

“First woodcarving, then later drawing and painting.” From the Sacred Heart School, he progressed to the local government school, where he did well academically.

“My father, Mohamed Saeed, was a college graduate. He studied literature, wrote poetry and published a number of books,” explains Professor Saeed, “but he was a manager by profession. When I was around five or six, he was offered a job in Saudi Arabia working with an oil company. It was a difficult decision for him to make, leaving Bahrain and his family of nine, at a time when the only means of travel was by boat. He knew, however, that it would allow him to provide better for his family, and so for most of our lives my father lived abroad.

My mother Sakina was a very wise, gentle lady and an excellent mother. She made sure we were all loved, supported and educated.”

Professor Saeed’s father inspired the young Tariq to pursue medicine as a career. Bahrain did not have a medical school at the time, so in order to achieve this, he too had to leave home. “Despite not having any medical background, my father always held the profession in the highest regard,” Professor Saeed explains. “He would always say that as a doctor, you could go anywhere in the world, and be able to help and provide care for others, while leading a comfortable life. My father passed away in 2016 at the age of 89. Talking to him in his later years, it was clear that had he got the opportunity, he would have become a doctor himself.”

“If I’m being honest, at that time my love and passion was for art. I would have loved to pursue a career as an artist, but I was drawn to the idea of learning how to be able to care for people in their time of need. So when I finished school, and the opportunity arose to study medicine, I jumped at the chance. I left home to study at Basra University in Iraq.

“Iraq was a prosperous country in the 1970s, bustling with life. Basra University was one of the best universities in the Arab world and the standard of education we received there was excellent. Despite this, the first couple of years were a struggle. I was fascinated by what I was learning through my studies, but leaving home for the first time and being away from my mother and siblings was immensely difficult. The only contact I had with home was through letters, which took three or four weeks to arrive. Not only was I homesick, but I also struggled with the politics of Iraq, which impacted on everyone’s lives, including its students’. Thankfully, as the years went by, I was able to overcome my homesickness, and navigate the politics by focusing on my studies.

“The defining moment for me came in my third year of medical school,” 8

Professor Tariq Saeed, FRCSI (1984)

› Back to the Beginning

“We call it a compact hospital.

We have twelve full-time doctors between Plastic Surgeons, dermatologists and anaesthetists.”

Opening ceremony of Dr Tariq Hospital.

Dr Tariq Hospital

Professor Saeed says. “I was fortunate to have met an inspiring professor, Alaa Bashir. Not only was he a magnificent teacher, from whom I gained my first insight into the principles of wound healing, he was also an innovative and highly respected Plastic Surgeon. He would later go on to establish a hospital dedicated to treating wounded soldiers and victims of the Iran-Iraq War in the 1980s, developing new surgical techniques and inventing several pieces of surgical equipment in the process.

“To my amazement, I discovered that he was also an accomplished artist!

I attended an exhibition of his work and I was completely blown away.

Suddenly, I could see a path forward – artist, doctor, Plastic Surgeon. I had found my way. I went to observe one of his operations and saw him drawing out the steps of the surgery on a board in the operating theatre; I knew then that I had found the specialty that combined my love of art and medicine.

I subscribed to the British Journal of Plastic Surgery as a third-year medical student. Although I couldn’t understand any of what was in it, having the copies on my bookshelves and seeing Professor Bashir’s work being published inspired me to push on and work even harder. I was excited about my future career.”

Professor Saeed graduated in 1977, then returned home to Bahrain and worked in the government hospital for a year and a half. “At that time, the Ministry of Health in Bahrain sent young doctors abroad to specialise, mainly to Ireland and the UK. I told them I wanted to be a Plastic Surgeon,” recalls Professor Saeed, “and I remember being told: ‘No, we have no need for Plastic Surgery in Bahrain. Our people are beautiful enough as they are!’ That was how the specialty was perceived at that stage. To make matters worse, the Minister for Health then met with all the young doctors and told us that for financial reasons the government was no longer sending us abroad on scholarships. The two options were to train locally as a general surgeon or as a physician. There was to be no more sub-specialisation.”

Professor Saeed was heartbroken at having his dream snatched away from him. “I immediately wrote to RCSI saying that I wanted to come and do my fellowship in Ireland,” he says. “Thankfully, I was accepted and I decided to go.

I applied for a year of unpaid leave from my job at the government hospital,

Professor Tariq Saeed

but my application was rejected. I was so clear in my mind, and I knew exactly what I wanted to do, that I resigned and left for Ireland.”

The 27-year-old Tariq arrived in Dublin on New Year’s Day of January 1979 with a thousand punts to his name. “I couldn’t believe the amount of snow,” he remembers. “I had never seen snow in my life. There were no taxis at the airport, just a bus that dropped me off at Busáras. I was there with a light jacket, and a large suitcase full of books. I had the address of another Bahraini doctor, Isa Sammak, who lived on Harcourt Street, so I walked all the way there dragging my suitcase alongin the snow. I eventually arrived, with frozen hands and feet, only to discover that Isa had travelled to London for Christmas and New Year! No one had mobile phones then, so I had no way of contacting him. There was a small hotel next door that managed to spare their cold attic for me for a couple of days, as their rooms were all occupied. I stayed there until Isa’s return.”

Professor Saeed commenced his primary fellowship course in Dublin, but soon found himself running low on funds. “I thought I would be able to work as a surgeon in Dublin and support myself through my studies,” he says,

Professor Saeed, explaining the technique of his art work to the then Prime Minister of Bahrain, HRH Prince Khalifa Bin Salman Alkhalifa.

SURGEONS SCOPE / 9

› Back to the Beginning

“but many accomplished international doctors with PhDs and masters degrees couldn’t get jobs at that time. There was nothing for a young surgeon like myself with only a year’s experience, and I couldn’t ArabiaPlast Conference, 2006. go back to Bahrain because I had burned my bridges there.

As WB Yeats wrote: ‘I was young and foolish’. As if by fate, the Kuwaiti Minister for Health, Dr Abdul Rahman Al Awadhi, came to meet with the Kuwaiti students and doctors at RCSI. I was Honouring Professor Michael Earley. fortunate to be introduced to him, and I mentioned the predicament I was in. In a matter of weeks, I flew to Kuwait to start a new job, while taking the same fellowship courses I was taking in Ireland. Dr Al Awadhi had arranged for me to work and study in Kuwait, having only spent six months in Ireland at the time.”

Professor Saeed spent three years working in Kuwait, after completing his primary fellowship. He received a call from Dr Hagop Yacoubian and Dr Abdul Wahab Mohamed from the Surgical Department at Salmaniya Medical Centre, the government hospital in Bahrain. They were implementing a new ten-year plan for the hospital, and were now looking for doctors to specialise in fields such as Cardio-thoracics, Orthopaedics, and Plastic Surgery.

“They offered to send me back to Ireland on a scholarship to work towards my FRCS, and specialise in Plastic Surgery,” explains Professor Saeed. “Myself and a number of my fellow residents, surgeons Salman Al Khalifa, Habib Tareif, Ali Jaffar, Mohamed Durazi, Mohamed Sameai, and physicians A Hadi Khalil and Saeed Al Saffar, went to Dublin in 1982 to complete our training.

I spent five wonderful years in Ireland, where I had the opportunity to meet and work with many gifted surgeons, some of whom I am still in contact with to this day. My first position was a clinical attachment at Dr Steevens’ Hospital, the main hospital for Burns and Plastic Surgery, under Mr Brendan Prendiville.

Soon that became a paid, full-time job after a gruelling interview process! I also worked with Mr G Edwards, Mr Matt McHugh and Mr Denis Lawlor RCSI Fellow (1973). The position involved working between Dr Steevens’ Hospital, St Vincent’s University Hospital and Our Lady’s Hospital for Sick Children in Crumlin.

“At Dr Steevens’, we were still treating patients from the 1981 Stardust Fire disaster and the hospital would continue to do so for many years to come. At St Vincent’s Hospital, my experience in hand and microsurgery developed under the guidance of Professor Seamus Ó Riain, a real gentleman, with whom I wrote several papers. “It was while working in Dublin that I was able to pass the FRCS exams in both the Royal College of Surgeons in Ireland and in Edinburgh.”

Professor Saeed left Dublin for Cork in 1985 to take up a position as a Registrar in Plastic Surgery under Mr Cal Condon and Mr T P O’Connor, RCSI Fellow (1972) at Cork Regional Hospital, now Cork University Hospital (CUH).

“Mr Condon was a very dynamic and exacting surgeon who expected only the highest of standards from his registrars. If he ever felt we had 10

underperformed, we’d be sure to hear about it!” jokes Professor Saeed. “I still have the letter he would dictate with great flourish to his secretary Mary-Ellen, letters that bring back many fond memories,” remembers Professor Saeed.

“I worked and trained with a great team including Mr Tom O’Reilly, RCSI Fellow (1983), my fellow registrar, and Mr Jack McCann, Senior Registrar in the famous Theatre 9 in the Accident and Emergency Department. What I remember most is the kindness I experienced from all those around me. I recall Mr Condon inviting me for Christmas dinner with his family at their home, which was a wonderful and heart-warming experience. I also remember when my mother fell ill when she came to visit, and was admitted to CUH for treatment. The staff at CUH looked after her with the utmost care and attention. I appreciate that to this day.”

When Mr O’Connor took temporary leave from work, Professor Saeed was interviewed for the post of Locum Consultant and was excited to be offered the opportunity. “With my work in Ireland and support from Bahrain, I had the backing from both sides to help complete my training. I was able to successfully achieve my Higher Training Fellowship in Plastic Surgery from RCSI, in the days before the FRCSPlast came into existence,” says Professor Saeed. “I had many great colleagues, friends, mentors and teachers. Brilliant people who inspired me and gave me a very solid base on which to develop my career.

“Ireland and Bahrain have a lot in common,” he says. “Families are big and the people are warm and friendly. You can make friends anywhere you go. I first met my wife, June Molloy, who is from Dublin, at a Plastic Surgery conference in London, and six months later I met her again at St Vincent’s University Hospital and that’s how it all started. We got married in January 1987.”

From Ireland, the newlyweds moved to Slough in the UK, where Professor Saeed took up a fellowship position with Consultant Plastic Surgeon Mr Magdy N Saad, co-author of the acclaimed Barron and Saad Operative Plastic and Reconstructive Surgery books (1980). “We were based at the Wexham Park and Nuffield Hospitals,” says Professor Saeed. “This was my introduction to the world of Aesthetic Plastic Surgery. Mr Saad was the epitome of kindness and a superb mentor; I learned so much under his tutelage.”

After completing his fellowship in the UK, the couple moved to Bahrain.

“We discussed the move a lot,” says Professor Saeed, “and although June hadn’t visited Bahrain at that time, she had done her research, read a lot about the Bahraini culture, and had met members of my family as well as Bahraini colleagues in Ireland. She had an idea of what to expect when she arrived, which made things easier for both of us.”

In early 1987, Professor Saeed was appointed as the first Consultant Plastic and Reconstructive Surgeon in Bahrain at Salmaniya Medical Centre. His colleague, Dr Aziz Hamza, joined the department thereafter, on completion of his training in Egypt.

“We established the department,” explains Professor Saeed. “We hired and trained the staff, and bought the equipment and instruments needed to establish a very high standard plastic surgery unit. During my training I had developed a deep interest in skin culture for burns. Together with my colleagues, I managed to successfully culture skin cells in the laboratory at the Arabian Gulf University Medical School. These cultured epithelial grafts were used to successfully treat a number of burns patients at our hospital. This was published in the journal Burns in 1989. This established Bahrain as one of the few countries in the world at the forefront of skin culture. Around the same time, myself and my orthopaedic colleagues carried out the first microsurgical replantation of a forearm, alongside multiple digit replantations. Those early days were exciting and full of “firsts” for Bahrain.”

In 1989, Professor Saeed had a chance meeting with Dr D Ralph Millard Jr,

› Back to the Beginning

“Being a Fellow of the D Ralph Millard Society has meant a lot to me. Over the years I have had the privilege of meeting many iconic Plastic Surgeons.” a giant in the field and one of the founders of modern reconstructive plastic surgery. He was nominated as one of the ‘10 Plastic Surgeons of the Millennium’ by the American Society of Plastic Surgeons (ASPS) in 2000. Dr Millard was visiting the Ministry of Health in Bahrain at the time. This meeting led to Professor Saeed being invited to take up a final fellowship opportunity at the University of Miami later that year. He remembers the trip as eye-opening.

“We arrived in Miami five days before Hurricane Hugo was due to hit Florida and had a crash course in how to prepare,” he recalls. “It changed its course and made landfall in South Carolina. On the same trip, we attended the ASPS Conference in San Francisco which took place just two weeks after the Bay Area was hit by a 6.9 earthquake. Many delegates did not attend but when Dr Millard aka ‘The Boss’ decided he was going, the ‘Millard Fellows’ had to follow. It was an amazing experience, but with aftershocks still being felt on a daily basis, we were glad to get back to Miami. Being a Fellow of the D Ralph Millard Society has meant a lot to me. Over the years I have had the privilege of meeting many iconic Plastic Surgeons, some of whom we have had the honour of hosting here in Bahrain.” Ever since that first trip to San Francisco, Professor Saeed has made the effort to attend an ASPS or ASAPS meeting once every two years.

“Our part of the world has seen many upheavals. After Operation Desert Storm at the beginning of 1991, the health services in Kuwait were seriously depleted and a number of countries sent in medical teams to aid the Kuwaiti healthcare system. I headed a medical team travelling from Bahrain in March 1991, where we treated the casualties of the war including major trauma and severe burns patients. It was a frightening yet surreal experience, operating without electricity for most of the day, with very little communication with June and my family at home. The beautiful Kuwait I knew from my time there was destroyed.

“I continued with my work at Salmaniya Medical Centre, and in 1996, I took the difficult decision to leave the government service to enter private practice. I had a dream and an opportunity, and both were too exciting to ignore,” he says.

“I had begun private practice in 1991 on a part-time basis in a joint clinic with my dear colleague, Dr Mohamed Al Durazi. No one believed it was feasible at the time, but this first grew into a standalone clinic, then a medical centre and now a hospital devoted to Plastic Surgery and allied specialties.

“It is a compact hospital that is Joint Commission International (JCI) accredited. We have twelve full-time doctors including plastic surgeons, dermatologists and anaesthetists. We also have visiting doctors with particular specialisation interests who come a few times a year to see patients. We have a capacity of 19 beds, all in private en suite rooms, three operating theatres, and the largest laser centre in the region, with 55 laser machines. Our aim is to offer holistic care to patients who need it, with the aim of restoring form or function, as well as rejuvenating and delaying the effects of ageing.”

Professor Saeed’s wife, June Molloy, has an MBA and is her husband’s management partner at the hospital. “June has played a vital part in establishing our practice and our hospital,” says Professor Saeed. “We have a good partnership, I take care of the medical side, while she takes care of management.

Caption Members of the D Ralph Millard Society at the White House.

“Along the way, we have organised three major international Plastic, Reconstructive and Aesthetic Surgery Conferences in Bahrain under the GulfPlast and ArabiaPlast series. These were initiated in Bahrain in 1997, followed by another in 2006 and the most recent conference in 2017. We have been able to bring leading Plastic Surgeons from around the world to share their experience and knowledge with our local and regional Plastic Surgeons.

Professors Ivo Pitanguy from Brazil, Fuad Nahai, Ian Jackson and Peter Neligan from the USA, Danial Marchac from France, and Giovanni Botti from Italy to mention a few. RCSI, in Dublin and in Bahrain, has supported each of these events and has been vital to their success. Irish Plastic Surgeons Professor Michael Early, Professor Sean Carroll and Mr Tom O’Reilly, among others have attended, presented papers and given workshops at our conferences.”

Following in their father’s footsteps, the couple’s three children are all doctors, and all studied medicine at RCSI in Dublin. “We didn’t push them into it, I promise!” laughs Professor Saeed. The family divides their time between Bahrain and Dublin and the younger Saeeds are very close to their Irish grandparents, aunts, uncles, cousins and family friends.

“During their RCSI college years, this was incredibly important. The support they received from family during difficult times in their student careers was invaluable,” says Professor Saeed. “June and I tried to ensure we were in Ireland to support them through their exams as often as possible. They are all currently working in the UK. Nina (31) and Ayman (29) are both in the Plastic Surgery national training scheme and our youngest daughter Dana (27) is a Lifestyle Medicine Physician.

“I would like to reduce my clinical work and have more time for art, reading and writing. I have kept up my painting over the years, have won a few awards and have had four solo art exhibitions. I’ve exhibited my work in Cork, London, Paris, Saudi Arabia and Bahrain. Recently, I was going through Arabic diaries I have kept since my schooldays, through college and my years in Ireland.

There is some poetry, philosophy and records of experiences, both physical and emotional, that I went through. Perhaps I will put them together in a small book. That is my current project.

“My links with RCSI span the entire length of my surgical career. The institution is incredibly important to me and my family. My appointment as Professor at the College is a great honour and privilege for me. I have been very fortunate to reach the stage I am at and achieve many of my lifelong ambitions.

None of this would have been possible without the guidance of my parents, the love and support of my family, colleagues and friends over the years.” ■ S U R G E O N S S C O P E / 11

› A Surgeon in…

A Surgeon in…Melbourne MS HELEN MOHAN FRCSI, RECIPIENT OF THE SECOND PROGRESS WOMEN IN SURGERY FELLOWSHIP, SUPPORTED BY JOHNSON & JOHNSON, HAS TAKEN UP A FELLOWSHIP IN COLORECTAL SURGERY AT PETER MACCALLUM CANCER CENTRE IN MELBOURNE, AUSTRALIA he PROGRESS Women in Surgery Fellowship, supported by Johnson & Johnson, is a prestigious bursary awarded

by RCSI to promote female participation in surgical training at fellowship level. Ms Helen Mohan travelled with her family to Melbourne earlier this year. “This Fellowship is hugely significant for me, allowing me to advance my career in colorectal surgery and to focus on providing high quality patient care, promoting research and surgical education.”

Helen grew up in Raheny on the northside of Dublin, with her parents and younger sister, Sara. “There were no medics in the family,” says Helen. “I was the first, and then I married someone from my class, Rory Whelan, and Sara is now an SpR in Obstetrics and Gynaecology so my poor parents are surrounded by medics!”

Helen graduated from the School of Medicine at University College Dublin in 2007 with first class honours. “We were one of the last years in Earlsfort Terrace,” she says. “I was in St Vincent’s University Hospital (SVUH) for final med and did my intern year there, followed by Basic Surgical Training between SVUH and St Michael’s.”

Her interest in surgery was first sparked on an elective Ms Helen Mohan, FRCSI in Tanzania. “I worked with a very inspirational surgeon from New Zealand, Dr Tom Gibson, who ignited my interest in surgery, and then during my intern year I had some excellent mentors, including Professors John Hyland and Oscar Traynor.”

After the BST, Helen undertook a PhD in Pathophysiology of Inflammation and Cancer, working in RCSI Fellow, Professor Des Winter’s and Professor Alan Baird’s laboratory at SVUH and UCD. “It was a mixture of science and clinical research, looking at orphan nuclear receptors in colon cancer and inflammatory bowel disease, and also analysing the colorectal cancer database,” explains Helen. “As part of the PhD I had the opportunity to spend eight weeks in Denver at the University of Colorado Mucosal Inflammation Programme with Dr Sean Colgan carrying out research on intestinal inflammation and IBD, as well as a month at Arizona State University where I got to work with Dr Raymond Dubois, who had published on the orphan nuclear receptor NR4A2.”

Helen’s strong research background is evidenced by more than 60 publications over the course of her career to date.

After the PhD, Helen spent a year as a non-training Registrar in Wexford 12

General Hospital before being accepted onto the Higher Surgical Training Programme in 2013. “I did my first year in Wexford, which was great because I already knew people there and had good relationships,” she says.

“The following year I went to Cork University Hospital and did six months of colorectal surgery and six months of vascular surgery, and from there I went to the Mater for six months. I took maternity leave when I had my first child, Domhnall, in 2017, and then went to SVUH. It was nice, I had spent so much time there, it felt like coming home.”

From SVUH, Helen moved to University Hospital Limerick – “I was pregnant with twins and suffered from severe hyperemesis which was challenging but I was very well supported,” she says.

After Oisín and Sophie were born, in June 2019, Helen took maternity leave during which she sat her exams. She was awarded her FRCSI in 2019 and CCST in 2020. Next came a stint at St James’s University Hospital with Professor John Reynolds RSCI Fellow (1998) focused on Upper GI, which is where she was based when COVID-19 hit in March 2020. She spent the last six months before she left for Australia back at SVUH on colorectal with Mr Sean Martin, Professor Des Winter, RSCI Fellow (1998), Ms Ann Hanly, RSCI Fellow (2010) and Mr Rory Kennelly, RSCI Fellow (2014).

“There is a lot of moving around,” she says, “but I think we gain from working in different places. You get a real breadth of experience, and working in different units shows you there is more than one way of doing things. You pick up little tricks and tips from everyone you work with. Logistically it can be challenging, particularly when you have little ones. I’ve been lucky in that I have a very supportive partner. When I moved to Limerick with baby Domhnall I was lucky that my husband had finished his training scheme and was able to get a consultant job there at the same time. But when we had the twins, he was still in Limerick commuting while I was back in Dublin. That was tricky.”

The family was supposed to leave for Melbourne in January of this year, but shortly before they were due to depart Helen and her three children all got COVID-19.

“We had the whole house packed up in crates when we got sick,” she says. “I’d been planning the Fellowship since 2015 and put a lot of energy into it. When Domhnall was five months old I had gone to a conference in Seattle to meet the consultants from the Peter MacCallum Cancer Centre for my interview, and

› A Surgeon in…

“The funding was really the difference between being able to come and not.”

I knew it was a Fellowship I really wanted to do. I did worry when we got sick and had to cancel our flights that we weren’t going to get to go at all. The price of the flights became astronomical and it was so hard even to get into Australia because of the caps on visas. We eventually left a month later than we were supposed to. Five days after we arrived, they stopped international arrivals to Melbourne, and the whole travel situation was very unstable.”

After the stress prior to the family’s departure for Melbourne, the two weeks in hotel quarantine with three small children were not as bad as Helen had feared.

“When we had COVID-19 I was very concerned that someone was going to get really sick or give it to someone else who would get sick, so the whole lead-up was quite emotional. We never got to say goodbye to my parents. But once we were in quarantine, I breathed a sigh of relief, because we were finally here on our big adventure. We were mentally prepared, we had a nice airy room, and at least once we were in the hotel the kids – now aged four and 18 months – weren’t disturbing anyone else.”

“There are three main areas of the work here,” explains Helen. “Firstly, the Centre is pushing boundaries in terms of locally advanced tumours in the pelvis and pelvic exenteration, with pioneering techniques for dealing with locally advanced tumours in patients who require surgery beyond standard resection.

“The second group of patients are those with peritoneal malignancy, who we treat with cytoreductive surgery and HIPEC. And then the third aspect, and a key part of my Fellowship, is the huge volume of robotic colorectal surgeries, and standard resections, and we are applying robotic techniques to locally advanced tumours.”

Helen explains that the Centre’s approach is to harness all the new and innovative technology available to improve quality of life and quality outcomes for patients.

“Also it’s a great opportunity for me to be involved in research and bring together some of the things I have been interested in over the years to improve patient care.”

Helen has found her colleagues at the Centre, including Mr Peader Waters, Colorectal Consultant, very welcoming. “They are a super team and the whole ethos and environment is exciting to be in,” she says. “It’s a very energetic unit. There are excellent mentors and I am getting very good technical training. The head of unit, Professor Alexander Heriot, places a strong emphasis in preparing fellows for the management and leadership aspects of consultant practice and is an incredible role model. In Ireland on the higher surgical training programme, we are very well trained and that puts you in a good position when you are leaving Ireland to go on Fellowship to be able to take advantage of the opportunities In theatre at the Peter that are presented.

MacCallum Cancer Centre.

“The patients come to the Centre

from all over the State of Victoria, from Tasmania, and from as far away as Western Australia. In one of my first clinics, when I was making appointments for people to return, someone said, ‘We need to get you a map!’. Patients might live six hours away, the scale of distances takes a bit of getting used to.”

Melbourne has been in lockdown for much of the time that Helen has been there, and she and her family have not got to explore very much yet.

“It’s been quite intense and I’ve been working hard doing a lot of twilight In quarantine: Oisín and Sophie and Saturday lists with RCSI alumnus Dr Satish Warrier, who is an excellent technical trainer and has pioneered a lot of robotic techniques. It would be very hard to get volume like this at home. Because it is a dedicated advanced cancer centre, you see cases every single week. Initially, my husband was working in Geelong, over an hour outside the city, and commuting but he recently got a job closer to home which will make things easier.”

Helen says that without the RCSI Ms Helen Mohan and Mr Peader PROGRESS Women in Surgery Waters, Colorectal Consultant Fellowship funding she probably would not have been able to get to Melbourne at all. “It helped to cover the cost of the flights, which were considerable. The funding was really the difference between being able to come and not. It’s also helped to defray the costs of childcare so that I could participate in lots of extra dual console robotic training lists in the evenings, which adds quite substantially to volume and experience. I had a lot of support from my family at home and hadn’t appreciated how much more challenging things are when you have no one other than yourself, and your husband is working an hour away.”

As a past-president of the Association of Surgeons in Training, Helen is passionate about promoting diversity in surgical training, and encouraging other women to take up fellowships abroad.

“Fellowships are so important in terms of surgeons being as trained as possible and being able to bring back a skillset that is adaptable and can be used to improve patient care.”

Now that she and her family are settled in Melbourne, Helen has decided to stay on for a second year. “I am staying on to do a further colorectal fellowship affiliated with the Austin Hospital,” she says. “The emphasis there will be on robotic techniques again and on a wider spectrum of colorectal disease including inflammatory bowel disease and specialist endometriosis work.

I’m hugely grateful to my trainers and mentors at home, and to RCSI for the support of the PROGRESS Women in Surgery Fellowship and to my family for their ongoing support.” ■ The RCSI PROGRESS Women in Surgery Fellowship, funded by Johnson & Johnson Medical Devices Companies through an educational grant, is a prestigious bursary awarded to promote female participation in surgical training at fellowship level.

S U R G E O N S S C O P E / 13

› International Fellowships

Broadening The Mind RECENT RECIPIENTS OF RCSI COLLES TRAVELLING FELLOWSHIPS IN SURGERY, MR EAMON FRANCIS AND MS ELAINE REDMOND RECOUNT THEIR EXPERIENCES, AND RECORD THE IMPACT OF THEIR AWARDS

he RCSI Colles Travelling Fellowship in Surgery is an award to promote the acquisition of additional surgical skills and knowledge that will contribute to the advancement of surgical science and practice in Ireland. The Fellowship is open to Fellows and Members of the College (in good standing) who are in, or have completed within the previous two years, a higher surgical training programme in Ireland. The Fellowship, which must be full-time, is tenable for one year abroad and includes a College Medal, stipend and travel allowance up to €20,000.

Additional grants up to a maximum of €30,000 may also be awarded.

Surgical Fellowships continue to provide additional focused training opportunities across the surgical specialties for RCSI Fellows and Members, according to Director of National Surgical Training Programmes, Professor Kevin Barry. “The award of Fellowship is a significant personal achievement with obvious benefits in terms of continuing professional development and career progression. On a societal level, it creates long-term benefits in respect of enhanced patient care, education, training and research.” In recent years, RCSI has expanded the range of Fellowships available.

“I wish to acknowledge the dedication of all surgical trainees and to congratulate those who have been awarded Fellowships,” says Professor Barry.

14

Mr Eamon Francis, FRCSI

MR EAMON FRANCIS MB BCH BAO, MA, MCh, MSc (Burns), MSc (Microsurgery), FRCSI Eamon Francis graduated from Trinity College Dublin in 2010 with an honours degree and the Seton-Pringle and Arthur Ball prizes in Surgery. He completed his internship at St James’s Hospital, followed by basic surgical training in Dublin (St Vincent’s University Hospital, St James’s and Our Lady’s Childrens Hospital Crumlin).

Eamon completed a number of higher degrees in parallel with his surgical training and he is completing his masters degree in Reconstructive Microsurgery through Chang Gung University Fellowship in Plastic and Reconstructive Surgery in Chang Gung Memorial Hospital, Taiwan.

“I commenced my Fellowship at Chang Gung Memorial Hospital, Taiwan in July 2020. As a 3,800-bed hospital with 90 operating rooms and a 24-bed dedicated Microsurgical ICU, this is perhaps the world’s highest-volume centre for free tissue transfer.

“This Fellowship radically changed my attitude to microsurgery.

The mantra here is replace “likewith-like” and its seeming ease of application through planning and immaculate execution converted me to this approach. The focused training across all the realms of microsurgery, encompassing all the latest technological and technical innovations, was inspiring. The hands-on training, in combination with mentorship by the most preeminent leaders in their fields of

reconstruction, has been incredibly special. The technical tips and tricks I learned, along with strategies to deal with “difficult” scenarios are priceless.

The introduction to new skills such as “supermicrosurgery” have made me more eager than ever to push my abilities further.

“The outpatient environment, while restricted somewhat by my inability to speak or understand the language, was still a great source of education. I learned how to evaluate and manage patients. I saw the results of reconstructions I was involved in and the patients’ feedback relating to these results. It helped me understand the neccessity of limiting donor site morbidity here, as it really detracted from any percieved benefit of the reconstruction by patients.

“This Fellowship is operatively heavy, but through twice-weekly microsurgical conferences and weekly specialist microsurgical webinars, I was provided with both the technical skills and clinical acumen in reconstructing complex defects in both elective and traumatic settings.

“I am now armed with the expertise to deal with the full range of demands of Reconstructive Microsurgery in both Elective and Trauma settings.”

› International Fellowships

“The objectives of the Fellowship – for me to acquire clinical training in Reconstructive Microsurgery across all sub-specialties including Head & Neck, Breast & Lymphedema, Hand, Trauma and Extemity reconstruction, and Facial reanimation and Peripheral Nerve surgery – were fulfilled. Concurrently, I was involved with a research project for a masters in Reconstructive Microsurgery, under the supervision of Professor Fu-Chan Wei, awarded through Chang Gung University.

“The Fellowship enabled me to build on the clinical and technical skill I learned in my training in Ireland. I am now sufficently armed with the expertise to deal with the full range of demands of Reconstructive Microsurgery in both Elective and Trauma settings.

I have also added another higher degree to my academic portfolio and collaborated on a number of peer-reviewed research papers. I have connected with a diverse network of peers and mentors who will provide support as my career progresses.

This has only been possible through the support of RCSI to whom I am most appreciative. I believe I have represented RCSI, my mentors and the Irish specialist training scheme to the best of my ability this year. I was the first Fellow from Ireland at Chang Gung and, as I rotated through all the microsurgical subspecialties, I received positive feedback with regard to attitude, knowledge and ability.

I believe that despite the cultural differences, the Taiwanese and Irish have very similar values and I know the Fellowship will welcome any Irish trainee who wishes to pursue advanced Microsurgical training.

“My training has provided me with invaluable experience in reconstructing complex oncological and traumatic defects across all the microsurgical disciplines and this will have a positive impact on patients in Ireland.”

“I feel well positioned to provide continuity of care for patients.”

Ms Elaine Redmond, FRCSI

MS ELAINE REDMOND MB, BCh, BAO (Hons), BMedSci (Hons), FRCSI Elaine Redmond qualified from University College Cork in 2008. She became a Fellow of the Royal College of Surgeons (FRCS Urol) in 2017, and completed her Higher Surgical Training in Urology with RCSI in 2019.

Elaine was awarded a Doctorate in Medicine (MD) from the University of Limerick in 2018 for her research which examined the effect of bladderfilling rate on the sensation of urgency.

She also holds a masters in Human Factors and Patient Safety from RCSI (2014). She has received numerous awards and grants for her work including the Irish Society of Urology Research Medal (2013) and the Ainsworth Scholarship (2019-2021).

In 2019, Elaine completed a GURS accredited fellowship in Reconstructive Urology at the University of Alberta Hospital, Edmonton, Canada. During this time, she worked with Professor Keith Rourke, an international expert and one of the world’s highest-volume surgeons in urethral stricture disease

and male incontinence. In 2020, Elaine was the beneficiary of a Colles Travelling Fellowship in support of her Paediatric Urology Fellowship at BC Children’s Hospital, Vancouver, Canada. She returned to Ireland in August 2021 and has taken up practice as a Consultant Urologist at Cork University Hospital.

“British Columbia Children’s Hospital (BCCH) in Vancouver is the only tertiary paediatric centre in the province of British Columbia, serving a population of 4.7 million.

The division of Paediatric Urology performs more than 800 surgical procedures and cares for more than 5,500 children a year. As the sole Fellow, supported by one-two residents, the Fellowship programme offers an extremely high surgical caseload.

“I operated three/four days per week throughout the Fellowship which provided me with the opportunity to become proficient in all aspects of paediatric urological surgery including proximal hypospadias repair and complex urinary tract reconstruction. I

attended regular outpatient clinics and a weekly multidisciplinary spinal cord clinic which ensured a high level of exposure to a wide range of pathologies, including dysfunctional voiding, neurogenic bladder, disorders of sexual differentiation and spina bifida care. There was a strong academic component to the Fellowship and I made a significant contribution to the research output of the department during my time there.

I had the opportunity to present some of this research at the American Urological Association annual meeting, the Society of Pediatric Urology annual meeting and the Lorne D Sullivan research symposium.

“The Colles Fellowship grant enabled me to subsidise the significant travel and relocation costs incurred in moving my family to Vancouver. I am very grateful to the RCSI for their support of my Fellowship training. This Fellowship has enabled me to achieve operative independence in a wide range of complex paediatric genitourinary procedures. I feel confident in managing the many different cohorts of patients who may require paediatric urological surgery, including the care of patients with complex hypospadias, upper tract dysfunction and spina bifida/spinal cord injuries. I hope to have left BC Children’s Hospital with a long-lasting and meaningful connection to Ireland and I look forward to establishing clinical and academic links between our urology departments in the future.” ■ S U R G E O N S S C O P E / 15

› Tr a n s f o r m i n g T h e a t r e

Transforming Theatre IN RESPONSE TO LONG WAITING LISTS FOR SURGICAL CARE, RCSI HAS DESIGNED THE TRANSFORMING THEATRE PROGRAMME TO HELP HOSPITALS MAXIMISE THEIR THEATRE RESOURCES AS EFFICIENTLY AS POSSIBLE

Professor Deborah McNamara, MD, FRCSI

rofessor Deborah McNamara, MD, FRCSI is a Consultant General and Colorectal Surgeon at Beaumont Hospital in Dublin, a Clinical Professor of Surgery at RCSI, Co-Lead on the National Clinical Programme in Surgery and the chair of RCSI’s Working Group on Gender Diversity. Professor McNamara is also Clinical Lead for the Transforming Theatre Programme established by RCSI and, as the initial two-year pilot with the South/South West Hospital Group (SSWHG) draws to a close, she is currently seeking a second hospital group to participate in the programme.

“RCSI has been working in the area for some time,” explains Professor McNamara. “Our focus from the outset has been to make the patient’s journey in the operating theatre department the focus of standardised measurement and quality improvement.”

Professor McNamara has worked closely with Programme Manager, Charlie Dineen of RCSI, a process improvement expert, to develop and deliver the Programme using the principles of lean methodology – a way of optimising the people, resources, effort, and energy of organisations toward creating value for the customer.

16

“The Transforming Theatre Programme design is a result of carefully constructed elements of lean methodology and principles, steeped in clinical knowledge and expertise,” says Dineen. “It is this coming together of lean experience coupled with clinical insights and awareness which has created a model specifically applicable to a healthcare environment.”

Dineen explains that some of the lean principles paramount in the Transforming Theatre Programme are Value, Flow and Respect for People.

“Value is to the fore in relation to people’s time,” he says. “For instance, we try to maximise the time surgical teams are engaged in surgical activity as opposed to waiting and other non-value activities, and likewise, from a patient’s perspective, prioritise timely access to the surgical care they require.

“Patient flow through theatre is captured using five standardised key milestones which in turn generate a balanced suite of theatre metrics in a cascading tiered structure designed for frontline theatre teams, hospital managers and Hospital Group leaders. The measurement system also identifies the impact upstream and downstream processes have on the smooth transition of patients through theatre.

“To demonstrate respect for people, it is critical to engage and empower people closest to the work – in this situation, the operating theatre staff.

The Transforming Theatre Core Team at each site includes a surgical lead, anaesthetic lead and nurse lead, and together they determine locally the overall direction of the programme, while aligning with the suite of metrics provided.

Lean tools are deployed as appropriate during Quality Improvement projects which are captured within an overall Theatre Management System providing effective action-based reviews and support.”

At the outset of the pilot, Professor McNamara was delighted when Professor Mark Corrigan, FRCSI, Clinical Lead within the SSWHG and Consultant Breast Surgeon in Cork University Hospital (CUH), volunteered to be the local surgical leader of the Programme.

“Surgeons hate waiting lists,” says Professor Corrigan, explaining his motivation for taking on the role. “We all want to work and our reward is seeing patients progress. If the service is to make the case for additional theatres, we need improved patient flow using the resources we have.

What appealed to me about Transforming Theatre is that it is one of the few initiatives that empowers clinical staff from the frontline rather than from management down.

“Often when management talks about efficiencies without providing the tools to achieve them, it can mean working people who are already stretched thin even harder. They lose the locker room. The beauty of Transforming Theatre is that it provides hospital sites locally with their own data from within. It’s a truism that what you measure, you improve, but once you start

› Tr a n s f o r m i n g T h e a t r e

seeing holes, projects start happening organically and being delivered. The greatest reward for the team is in seeing patients treated in a more timely fashion. And because you have buy-in from the Group, not just the hospital, the impact is horizontal and not just vertical.”

As Clinical Lead of the SSWHG, Professor Corrigan has found the experience of working with Professor Professor Mark Corrigan, FRCSI McNamara, Charlie Dineen and Grace Reidy, Transforming Theatre Project Executive, refreshing. “Together they immediately prioritised the quick wins which would encourage everyone,” he says. “The network of support from them has been outstanding; it feels as if we are wearing a common jersey.

Nobody is cracking the whip making people work harder, and there is support from management.

“Surgeons hate waiting lists,” says Professor Corrigan…“We all want to work and our reward is seeing patients progress.”

“If we might need more resources in the future, we need data to make the case for those and the Programme adds a level of strategy to what we do. Because the data has to be interpreted locally, the system is built from the bottom up, and there is support to interpret the data and deliver improvement. The RCSI team was very visible on the ground in helping us to set up the database and people definitely respond more positively if they feel they are in it together. It is quite refreshing and we have seen some encouraging outcomes.”

In his role as Consultant Breast Surgeon at CUH, Professor Corrigan has also seen the direct impact of the Programme on his day-to day-work. “At CUH we don’t have enough of anything and there is always more demand than capacity,” he says, “so by marrying together the hospitals in the group we are seeing tangible wins. As Bantry and Mallow develop daycase surgery, minor operations and endoscopy, they help and assist CUH with theatre capacity. Elsewhere in the SSWHG, Waterford and the SIVUH are two other hospitals which have done tremendous work looking at elective surgery. There is enthusiasm across the group and we have increased the number of patients going through. Our experience shows that the Transforming Theatre Programme is applicable to big hospitals such as University Hospital Waterford, and smaller hospitals such as Bantry General Hospital, and across all activities. That is very rewarding.”

At Mallow General Hospital, Denise Kearney, Assistant Director of Nursing over Day Services, has played a key role in the implementation of the Programme, and says it has been a wholly positive and empowering experience.

“From the outset, Charlie and Grace, and hospital manager, Claire Crowley, have been amazing at explaining what they were trying to achieve in terms of making the theatre more efficient. Initially we had to identify the core team – Mr Aamir Majid as surgical lead, Dr Mike Pead as anaesthetic lead, Sheila Foley as nurse

TRANSFORMING THEATRE PROGRAMME PROFESSOR DEBORAH MCNAMARA, CLINICAL LEAD The Transforming Theatre Programme is a collaboration between the Health Service Executive (HSE), the National Clinical Programme in Surgery (NCPS), the National Clinical Programme in Anaesthesia (NCPA) and each participating Hospital Group (HG).

It is an integrative approach to identifying and improving patient flow through the operating theatre.

Unlike other theatre measurement systems, it is based wholly on the patient’s journey through the theatre department.

AIMS OF THE PROGRAMME 1. To embed a system of standardised theatre metrics enabling both locally-led improvements and high-level Hospital Group development opportunities.

2. To establish a process for routine review and action of these metrics locally by theatre staff and Hospital Theatre Governance Group, and collectively by a Hospital Group Theatre Governance Group.

3. To provide a structured Quality Improvement (QI) methodology to achieve tangible improvements through a multidisciplinary teams (MDT) approach.

4. To advance QI capability for all by providing training, facilitation and coaching at all stages of the programme.

Nationally, the Transforming Theatre Steering Group is chaired by Dr Siobhán Ní Bhriain, Integrated Care Lead, HSE Executive Sponsor with representation from NCAGL, the participating Hospital Group Senior Executive team and National Clinical leads from the NCPA & NCPS. The CEO of the participating

HG is the Authorising Sponsor for the programme within that HG. At the hospital level, ongoing support is provided by the National Transforming Theatre team to each site including training, facilitation and coaching but there are key elements of the programme that each hospital and hospital group must deliver on for this support to continue. The aim of the support is to ensure independent sustainability of the programme by the hospital group.

Key to this is having the right multidisciplinary governance in place to lead, drive and own the programme locally. It is essential that this governance includes a consultant anaesthetic lead, consultant surgeon lead, perioperative nurse lead and a programme lead for the hospital.

The operating theatre is a complex, resource-intensive environment and careful oversight of theatre capacity is vital to ensure this resource is used to optimal effect. RCSI has designed a Theatre Measurement Model to deliver a standard set of cascading metrics that are relevant for use at each theatre, theatre department, hospital and hospital group level.

Standardisation of key terms used to document critical points in the patient’s journey through the operating theatre department in this measurement model enables consistency in measuring across all hospitals. Training is provided to ensure consistency and accuracy in the data input and how to interpret and use data to optimal effect.

Each hospital’s Transforming Theatre team identifies an initial quality improvement objective relevant to improving the use of their theatre(s). This objective

S U R G E O N S S C O P E / 17

› Tr a n s f o r m i n g T h e a t r e

must be linked directly to the Theatre Measurement Model metrics to ensure the impact of what is being improved is tangible and measurable. Each local team’s improvement project is supported by the National Transforming Theatre team in using a structured Improvement methodology thereby building internal QI capability to support further improvement work.

Embedding the Theatre Measurement Model as part of ‘everyday practice’ will ensure that current, consistent data is available for data-informed decisionmaking and it is critical to have the perioperative practice in place for regular review and action of these metrics.

From an operational point of view, this measurement model provides hospital theatre teams and theatre managers with standardised metrics on the use of their theatre resource including on-time starts, inter-operative interval times, overruns, underruns, throughput of cases and overall theatre utilisation by day.

To be of value, these metrics must be reviewed regularly by key staff working in the theatre department and the data used to inform potential improvements to support better use of the theatre resource locally, thereby improving patient flow.

Through the Transforming Theatre Programme, the HG has access to standardised theatre metrics from the participating hospitals at the Tier 4 level. The HG executive leads, clinical leads from the NCPS and NCPA engage in regular ‘site traction calls’ with individual hospital teams where information is shared, and key learnings are disseminated throughout this programme network.

18

Charlie Dineen, Programme Manager

Denise Kearney, Assistant Director of Nursing/Programme Lead

Denise Kearney is full of praise for the positive attitude inherent in the way the Programme is implemented.

lead and myself and Claire – and get buy-in from all the theatre staff.”

The Mallow team set their first objective as starting on time. “We thought it would be an easy fix,” says Kearney, “but it turned out to be more difficult than we had envisaged. Reassuringly, lots of theatres find this difficult but it makes the most impact. There were simple, simple things, like our clocks being set to different times and we needed to ensure they were all in sync.

“Charlie and Grace helped us to develop a simple template that everyone could use to record data; we had to learn how to use the software and generate charts, and we created a theatre transformation wall which we update each month with graphs and charts, so everyone can see the improvements easily.

COVID-19 impacted our progress but we are now starting to hit our target of starting on time 40% of the time, two days a week. One simple fix identified by our Multi Task Attendant (MTA) was that he needed to come in 15 minutes earlier to help get the first patient over. We involved everyone from the Health Care Assistants (HCAs) to nurses to anaesthetists to surgeons.”

Professor McNamara says she has been impressed by the positive attitude of everyone at Mallow General to the pilot, and credits Kearney and her colleagues there with the idea for the second initiative under the Programme. “We could see as many as 15 local anaesthetics taking place in the general theatre on any given day,” says Kearney, “which explained why the theatre was only being used to 33% of capacity. We looked to see if those procedures could be done elsewhere and identified a space adjacent to the theatre and Day Services ward, and spoke to senior management. Thanks to Charlie and Grace, we had the data and knew how to discuss it. We needed equipment but management backed us and we have now set up a minor procedure unit. We are now a couple of months into the trial and it is going well, we are getting through eight lists a month of six patients with no expansion of staffing, and reduced locals to theatre, and now we are starting cystoscopies.”

Denise Kearney is full of praise for the positive attitude inherent in the way the Programme is implemented. “Oversight is not negative so we have been honest about the challenges and we never got negative feedback which might have been discouraging,” she says. “We might have failed without the continuous support and encouragement, Charlie’s IT expertise and Grace’s theatre experience – it’s like having access to a constant helpline!

“Every three months they have brought the team together, and Professor McNamara came down herself, which was huge for us – someone of her calibre demonstrating such an understanding of a small hospital. It’s all about getting the right patient to the right place at the right time. We are taught to drill down and figure out the problems, no one is ever publicly outed for mistakes and staffing problems, such as time-keeping, are dealt with on a peer-to-peer basis, surgeon to surgeon, or nurse to nurse. Some of the people you least expect, such as HCAs, feel really involved and are excited by the Programme. They all realise that the data we are collecting is being looked at and listened to. We are not perfect, but there’s great power in non-biased data.

“As a Model 2 hospital we feel we have a place in the Group, and we were never once made to feel inferior. Everyone talks about Model 4 hospitals, but for a Model 2 it’s really important to have a purpose. I feel we have shown a bit of grit and resilience; we want our theatre to stay and it won’t if we don’t make it work.”

For ProfessorMcNamara and her colleagues, the project is already rewarding and they see the potential impact on surgical waiting lists as a huge motivation for progressing the Transforming Theatre Programme.

“We also believe that additional investment could allow many more surgical patients to be treated using our existing infrastructure,” she says. ■

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› Rugby

The Dublin Hospitals Cup THE DUBLIN HOSPITALS RUGBY CUP HAS BEEN CONTESTED BY THE TEACHING HOSPITALS IN DUBLIN SINCE 1881. A NEW BOOK BY DRS CONLETH FEIGHERY, MICHAEL FARRELL AND MORGAN CROWE, CELEBRATING 140 YEARS OF THE COMPETITION, IS PUBLISHED THIS MONTH Jervis Street Hospital

Richmond Hospital

much loved and fiercely contested trophy played annually between competing hospital teams, the Dublin Hospitals Rugby Cup was established in 1881 by a group of surgeons and physicians from Dublin hospitals. Sport played a huge part in the student experience throughout the medical schools and teaching hospitals of Britain and Ireland in the Victorian and Edwardian periods, and team sports were preferable to individual sports as they were considered to promote responsiveness to authority and discipline, as well as fostering character development and loyalty to each other.

The Richmond, Jervis St and Mercer’s Hospitals, the major teaching hospitals of the Royal College of Surgeons in Ireland (RCSI), participated in the competition from its earliest years, with Richmond winning the cup for the first time in 1896 when they were captained by Larry Bulger. He received the first of his eight caps for Ireland eight weeks later on 30 March against England in Leeds. Later that year, Bulger was selected to tour South Africa with the British Isles touring party. The Richmond Hospital was represented at the inaugural meeting of the Dublin Hospital Rugby Committee by FR Cassidi and Henry Stoker, cousin of Bram. Richmond went on to win the cup on a further nine occasions and were most successful in the mid 1920’s when led by Paul Murray and Morgan Crowe. Both were selected for the 1930 Lions tour of New Zealand and Australia but only Murray travelled, Crowe having broken his collarbone in the drawn 1929-30 Hospitals Cup final against Sir Patrick Duns.

Jervis St was led to its single victory in 1948 by Karl Mullen, the only man in history to have captained the British and Irish Lions, Ireland and a Hospitals Cup winning team! His first Irish cap came when Ireland lost 8-12 to France in Lansdowne Road on 25 January 1947. Just ten days previously, Mullen led 20

Mercer’s Hospital

Beaumont Hospital

out the Dublin Hospitals against their London counterparts in Richmond Rugby Club’s home ground in southwest London.

In spite of reaching a few finals, Mercer’s Hospital never managed a victory and in later years joined the Federated Hospitals. In anticipation of the move to the Beaumont campus, Richmond and Jervis St joined forces, winning their first cup as a combined team in 1976 followed by further victories in ‘77 and ‘79 and an incredible five in a row from 1981 to 1985 in teams which featured players such as Dave Fennelly, Bill Twomey, Jim McShane and Conor O’Brien. Their dominance was total, repeatedly defeating Vincent’s sides that included icons of medicine and surgery in Dublin and abroad, such as Arnie Hill, Justin Geoghegan, David Moore and Hugh Brady!

Finally, when transfer to the Beaumont campus was completed in 1987, the new Beaumont team in their blue Dublin strip won the cup at the first attempt and went on to dominate the competition, winning another five in a row. Eventually, the other hospitals began to adopt Beaumont’s methodical approach. According to a notable St Vincent’s rugby man, himself a medallist and perennial competition administrator, “We were fed up losing to the Blazers from the northside” – a reference to the very professional Beaumont squad who always turned up to the final resplendent in white shirt, RCSI tie and blazer. Beaumont last won the cup in 2017.

Of the many students who played hospitals rugby and later went on to achieve fame as surgeons several stand out. Michael “Mickey” Butler, William “Billy” Hederman, Frank Keane, Stanley McCollum, Thomas Myles, Eoin O’Malley, Harry Meade all became Presidents of RCSI as indeed did Frederick Conway-Dwyer, Francis Crawley and William de Courcy-Wheeler in the earlier years of the competition. Perhaps the most famous of all rugby-playing surgeons was the great Terence Millin who captained Duns to victory in 1926-27 Hospitals Cup, captained the Trinity

› Rugby

Professor Arnold Hill, RCSI Fellow (1992)

Professor Frank Keane, RCSI Fellow (1991), President 2005-2010

Mr David Moore, RCSI Fellow (1985)

Sir William de Courcy Wheeler, RCSI Fellow (1874), President 1922-1924

Dr Terence Millin, Michael “Mickey” Butler RCSI Fellow, President 1963-1966

Sir Frederick Conway Dwyer, RCSI Fellow, President 1914-1916

team to victory in the Leinster Senior Cup, scored a try on his debut in Ireland’s victory over Wales on 14 March, 1925, in Belfast, became FRCSI two years after graduation from Trinity and by the early 1940s stood on the threshold of a majestic career in the new field of urology. Famously, in a seminal Lancet publication on 1 December, 1945, he gave details of a new extravesical technique for prostatectomy that was to project his career into the stratosphere.

Amidst all the calls on his skills he still found time to take on the role of Vice-President of London Irish RFC. Millin’s work as President of RCSI for an unprecedented three terms witnessed his influence on the implementation of the highest standards in Irish surgery. An enormous debt is owed to Millin for the work he and Harry O’Flanagan carried out to secure the future of the undergraduate medical school in RCSI. Commemorated in the annual Millin Lecture at RCSI, Terence Millin’s legacy will never wane.

“Playing rugby was never a barrier to a successful career in medicine.”

Rugby established itself as the most popular team sport in the Dublin and Cork teaching hospitals despite Gaelic games and soccer being more popular throughout the country at large. Reasons for this were varied. Many medical students came from schools where rugby was the main sport. Even if a student had not previously played rugby, the game of rugby lends itself to individuals of different sporting backgrounds, skills, and physiques, with a potential place for everyone on the hospital XV. Rugby was and still is strongly supported by hospital consultants and many had trained in England including some in the British Army where rugby was played to a high level.

The relationship between rugby and medicine was exemplified by the experience of Michael Davitt’s two sons who, despite their father’s strong

Mr Billy Hederman, RCSI Fellow, President 1990-1992

Sir Thomas Myles, RCSI Fellow, President 1900-1902

Mr Harry Meade, RCSI Fellow, President 1948-1950

nationalist and GAA credentials, both captained the Mater Hospital’s rugby XV and played for the UCD club where both would serve as honorary secretary.

A third son Cahir, who became a high court judge, was also president of UCD Rugby Club on two occasions.

The interest of the medical profession in rugby was demonstrated by its involvement at committee level in rugby clubs in the 1960s and 1970s; for example, in UCD RFC, to be elected as president of the club at that time, a sine qua non was to be medically qualified! Back then, medical students were commonly playing first team rugby, with many achieving higher honours, playing for the provinces or even for the national side such as Con Feighery, Barry Bresnihan and the more than 70 Irish, South African, Canadian and Romanian internationals who played in the competition. Playing rugby was never a barrier to a successful career in medicine.

In recent years, however, rugby has changed from being a bastion of amateurism to a highly professional business with downsides – as can be seen in the failure of new international teams to emerge, and the continued trawl of the Pacific Islands and South African schools by professional club sides from New Zealand and the northern hemisphere. Player weight, speed and strength have reached unprecedented proportions leading to increasing numbers of severe musculoskeletal injuries and concussions which have prompted rule changes to enhance player safety.

Although the amateur game continues, it is poorly supported and some clubs struggle to field teams. Previous high-profile competitions such as the Leinster League and Leinster Senior Cup no longer occupy key dates in the rugby calendar. A recent ESRI report (2019) commissioned by the IRFU reveals that although increased numbers are playing rugby, there has been a dramatic drop S U R G E O N S S C O P E / 21

› Rugby

In 2017, RCSI-Beaumont Hospital won the 129th Dublin Hospitals Cup.

off in participation when students leave second level education. Rugby is not alone in this post-school failure to participate in team-based field sports. For medical students and their teachers, the urge to squeeze more and more information into the medical curriculum must be arrested before it is too late. Already the demands of an increasingly busy undergraduate

The competition between rival hospitals has retained its essential vibrancy to this day and games are fought with an intensity and skill that is a testament to rugby as a sport. curriculum combined with postgraduate intern and registrar duties make it difficult for a player to meet the training and playing commitments of an All-Ireland League club team. Medical students, doctors and surgeons now rarely feature on club senior sides with participation by doctors in club administration dropping dramatically.

Never in the history of medicine has the team approach become so important to patient care whilst, paradoxically, involvement in teamwork on the field of play has declined for today’s medical students. There is now compelling scientific evidence to link physical activity with reduced risk of several diseases with doctors encouraged to prescribe exercise for patients and to extol the psychological and social benefits from involvement in team sports.

In this era of declining participation in team sports, the Dublin Hospitals Cup competition represents an opportunity for medical students and junior doctors to play a competitive team sport in a tournament which is well organised by an enthusiastic group of senior physicians and surgeons. Staged over a short time period, the competition and its round-robin format lends itself to maximum participation by students and doctors. In addition to the physical benefits of training and playing rugby, other advantages include being part of a squad which promotes social interaction with fellow students, doctors, and senior staff which in turn creates loyalty to a hospital.

The Dublin Hospitals Cup final, played at the same venue in Anglesea Road 22

Raising the Cup, 2017.

Captain of RCSI-Beaumont Hospital winning team 2017, Martin Davey.

on the last Friday before Christmas, has become a major sporting occasion in the Dublin medical school calendar. Despite the seismic changes in the status of Rugby Union in recent years and the rapidly increasing academic and service demands on medical students and doctors, the competition for the Dublin Hospitals Cup is now more organised and more competitive than at any time in its 140-year history. The competition between rival hospitals has retained its essential vibrancy to this day and games are fought with an intensity and skill that is a testament to rugby as a sport.

Written by Drs Con Feighery, Michael Farrell and Morgan Crowe and designed by Garrett Bennis, The Hospital Pass is a riveting account of the history of the Dublin hospitals rugby competition which dates back to 1881, just three years after the IRFU was founded. The book describes in glorious detail the players, mentors, rows, injuries, and skulduggery that have characterised the competition right up to the present day. The personalities are brought to life and the photographs, mainly black and white, are rich in detail with several dating back over 100 years. The influence of Dublin physicians on the very foundation of the IRFU deservedly receives a lot of attention.

Even a glance through this carefully researched history will stoke memories among the hundreds, still living, who competed with varying skill levels in the competition over the years. ■

TO BUY THE BOOK

The Hospital Pass by Conleth Feighery, Michael Farrell and Morgan Crowe celebrates the story of the Dublin Hospitals Cup competition, one of the oldest world rugby tournaments. With the Competition’s long history of characters, anecdotes and controversies, the book offers a window on the evolution of Irish rugby and the changing face of Dublin medicine.To order your copy of The Hospital Pass, €50+ delivery, please go to https://shop.rcpi.ie/

› Advertorial

Clinical Imaging – Issues to consider CLINICAL IMAGES SHOULD BE TREATED LIKE ALL OTHER MEDICAL RECORDS, EXPLAINS MEDISEC’S LEGAL EXPERTS

T

hey say a picture paints a thousand words and that can undoubtedly be true in the case of clinical imaging. Taking and sending clinical images has become a common feature of medical practice, in particular since the current pandemic with the increased use of remote consultations. In appropriate cases, sharing clinical images can be a beneficial addition and can lead to more efficient delivery of patient care.

However, there are some important factors to consider when receiving or sharing clinical images.

MEDICAL COUNCIL’S ETHICAL GUIDE The Medical Council’s Guide to Professional Conduct and Ethics for Registered Medical Practitioners states the following in respect of recording: “Audio, visual or photographic recordings of a patient, or a relative of a patient, in which that person is identifiable should only be made with their express consent. You should keep these recordings confidential as part of the patient’s record. You should be aware of security when sharing information by electronic means, including text, other electronic messaging or emailing, and you should do all you reasonably can to protect confidentiality. You should get consent before sharing videos, photos or other images of patients.

“In exceptional circumstances, you may take images of patients using your personal mobile device. You should do so only when this is necessary for the patient’s care. The images must not identify the patient, must be kept for the minimum time needed, and must be deleted as soon as possible.

Medisec is an Irish not-for-profit company owned by its medical practitioner members.

You are responsible for data protection in this regard and you must comply with any rules and procedures of your employer.”

GDPR AND CONSENT Article 9.2(h) GDPR provides a lawful basis for the processing of special categories of personal data in medical practice. However, in the context of clinical images, we also recommend keeping a record of having obtained explicit patient consent to taking / receiving and storing the imaging.

Your records should always reflect why you considered clinical imaging necessary in the context of a patient’s care.

Consent to clinical imaging should be sought from a parent / legal guardian in respect of children. Where a patient lacks capacity and there is no-one with legal authority to make decisions on their behalf, you must have regard to where the patient’s best interests lie, and whether clinical imaging is necessary in the context of their clinical care.

REMOTE CONSULTATIONS In the absence of a face-to-face consultation, if clinical imaging is

provided or requested as an aid to diagnosis or treatment, you should consider the following: • Discussing with the patient the limitations of relying on imaging and conducting examinations remotely. Explain that ultimately, a physical examination may still be required.

• Whether it would be in the patient’s best interests to wait until they can attend in person. If this is not feasible and / or delaying could potentially cause further harm or delay further investigation, you may decide the use of clinical imaging and a remote examination is appropriate. Your records should reflect your decision making in this regard.

• Obtaining the patient’s informed consent to proceed.

• Deciding on the most appropriate modality for the imaging. A video consultation may provide a better overview whereas a photograph typically provides better resolution.

• Considering the patient’s need for privacy and comfort with their environment and ensuring no interruptions at your end.

IT CONSIDERATIONS • Doctors should ideally use a secure platform for processing clinical images, rather than rely on freeware apps or personal devices. If a patient is planning to send you a clinical image, you should advise the patient to send it to a secure account.

• You should also let the patient know that any personal device they may be using to take and send the imaging may not be secure.

• Any device which you use to take or receive clinical imagery should be properly secured.

• Clinical images should be transferred securely from personal devices to the correct patient’s records as soon as possible. All images should be securely deleted from the personal device afterwards.

• Just like clinical records, clinical images should be protected with back-up (disaster recovery), robust security, encrypted data transmission and appropriate user access controls. Clinical IT providers can provide best practice guidance on IT safeguards and controls.

Whilst the use of clinical images has become more prevalent in clinical care, it is important to remember that they should be treated like all other medical records, and should be transmitted and stored securely in the patient’s records with adequate security systems in place.

If you are unsure about how to approach any particular aspect of dealing with clinical images, please contact your i ndemnifier for specific advice.

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

› Specialty Spotlight

Specialty Spotlight Plastic Surgery AS HIS TERM AS PRESIDENT OF THE IRISH ASSOCIATION OF PLASTIC SURGEONS COMES TO A CLOSE, PROFESSOR BRIAN KNEAFSEY TELLS US OF THE SPECIALTY’S STRENGTHS AND CHALLENGES rofessor Brian Kneafsey is an influential leader in the field of Plastic Surgery in both practice and training in Ireland. He was responsible for developing Plastic Surgery services to the RCSI Hospital Group over more than 20 years, following his appointment as the sole Consultant Plastic and Reconstructive Surgeon in Beaumont and Connolly Hospitals in 1998. Professor Kneafsey’s career began after he qualified with honours in surgery in UCD in 1986 and was appointed to the three-year Basic Surgical Training Programme in Cork University Hospital (CUH), obtaining the FRCSI in 1990.

He then commenced in the specialty of Plastic & Reconstructive Surgery, spending two years in Cork before continuing his training in the UK. He was appointed Senior Registrar in the Northern Ireland unit in Belfast in 1995. After obtaining his Intercollegiate Specialty Fellowship Examination in Plastic & Reconstructive Surgery in 1996, he spent a year on a fellowship in Reconstructive Plastic Surgery/Craniofacial Surgery in the Australian Craniofacial Unit & Dept of Plastic & Reconstructive Surgery in Adelaide, Australia in 1997.

After his appointment in 1998 as the only Consultant Plastic & Reconstructive Surgeon in Beaumont & Connolly Hospitals, the following nine-year period was spent establishing and developing Plastic Surgery services to both hospitals, including the introduction of microsurgery in the areas of head & neck/craniofacial cancer and trauma reconstruction, breast reconstruction, major lower limb trauma, hand surgery, facial palsy as well as a service for hand and facial injuries. Professor Kneafsey developed close working relations with many different specialties to build up these services including Neurosurgery, ENT Surgery, Breast Surgery, General Surgery, Orthopaedics, Dermatology and Oncology. In 2007, a second consultant was appointed but there remained just two consultants in Beaumont/Connolly for another seven years until 2014 when a third consultant was appointed. The number of consultants in Beaumont/Connolly/RCSI Hospital Group has now grown to seven.

The Plastic Surgery Department in Beaumont/Connolly/RCSI Hospial Group provides 24-hour services in trauma (especially hand surgery) and cancer reconstruction and other areas of Plastic Surgery to the entire RCSI Hospital group – a population of almost one million, incorporating Beaumont Hospital, Connolly Hospital and Our Lady of Lourdes Drogheda as well as Cavan, Monaghan and Dundalk hospitals.

Professor Kneafsey has always been involved in teaching and training locally, nationally and internationally. He was Programme Director of the Irish Plastic Surgery Training Scheme from 2003-2008, and served on multiple RCSI committees over the last two decades. “I am currently the Irish SAC (Specialist Advisory Committee) representative in Plastic & 24

Professor Brian Kneafsey, RCSI Fellow (1990)

Reconstructive Surgery, which deals with all intercollegiate training matters in each specialty, based in RCS, London,” he explains. “I have also been involved Professor Brian Kneafsey for many years in European training in Plastic Surgery and am a member of the European Board of Plastic Surgeons (EBOPRAS) and the the Irish national delegate on the Plastic Surgery Section of the European Specialist Bodies (UEMS).” He is an examiner in EBOPRAS European examinations and sits on the European Leadership Forum of the European Society of Plastic, Reconstructive & Aesthetic Surgery (ESPRAS). He is also a council member of the British Association of Plastic Reconstructive & Aesthetic Surgeons (BAPRAS), and a member of the American Society of Plastic Surgeons(ASPS), representing Ireland on the ASPS Global Leadership Forum.

As Clinical Lead for Skin Cancer in Beaumont, Professor Kneafsey is closely involved with the NCCP (National Cancer Control Programme) Skin Cancer Clinical Leads Group in melanoma and non-melanoma skin cancer (NMSC) and chairs the NCCP working group committee looking at the management of complex NMSC. “In 2019, I was appointed to the HSE SIMT (Safety Incident Management Team) which addressed the new entity of Breast Implant Associated-Anaplastic Large Cell Lymphoma (BIA-ALCL) associated with certain breast implants. I am also on to the expert review group of the HSE to review BIA-ALCL with the aim of establishing a National Breast Implant Registry and developing guidelines for follow of patients with breast implants”.

› Specialty Spotlight HOW MANY CONSULTANTS?

peripheral units providing service in Roscommon; Beaumont Hospital/ RCSI Group provides Plastic Surgery trauma services for the whole RCSI Hospital Group including Drogheda, HOW MANY FELLOWSHIPS ARE Cavan, Dundalk, Monaghan in AVAILABLE IN IRELAND? A number Connolly Hospital and with new of Fellowships have been developed Plastic Surgery services commencing over the last number of years – the in Drogheda. The Cork unit is based RSCI Fellowship in Microsurgery / in both Cork University Hospital and Breast Surgery (Beaumont Hospital), South Infirmary/Victoria Hospital the Aspire Fellowship in Upper Limb and provides services in Kerry General & Microsurgery (Mater Hospital), the Hospital.

Hand Surgery Fellowship (Irish Hand Each centre requires sub-specialty Surgery Society) and the Cleft Lip & expertise to a varying degree in the Palate Fellowship (CHI – Children’s different areas of Plastic Surgery, such Hospital Ireland) IS THERE A GAP as hand surgery, skin cancer, breast BETWEEN THE NUMBER OF surgery, head & neck reconstructive CONSULTANTS IN THE SPECIALTY surgery, lower limb trauma, burns, AND THE NUMBER REQUIRED? cleft lip & palate, craniofacial surgery, Yes, there is a gap between the number facial palsy etc. This requires adequate of consultants in the specialty and manpower and facilities in each centre. the number required to provide The establishment of new Plastic an adequate, equitable service. The Surgery units is also a strategic number of consultants in public initiative. Plastic Surgery services are practice in Ireland (32) is well below not available or provided in many international norms. Countries with parts of the country. While there are very similar populations to Ireland eight cancer centres in Ireland, there such as Scotland [53 consultants], New is no Plastic Surgery unit in two of Zealand [72 consultants], Finland the cancer centres – Waterford and [100 consultants] or Denmark [150 Limerick – and the Mid-West Hospital consultants] have far more consultants Group has no Plastic Surgery service in public practice. International data at all. Thus, in the absence of a Plastic consistently shows the ratio of Plastic Professor Brian Kneafsey Surgery department providing services Surgeons per head of population is way for trauma, skin cancer, complex below norms in Ireland, where the cancer reconstruction and other ratio is currently about 1:150,000. The Plastic Surgery services, these patients current ratios are about 1:100,000 in “International data consistently shows currently have to be referred elsewhere Scotland & England, about 1:70,000 to a Plastic Surgery unit or managed in Australia & New Zealand, about the ratio of Plastic Surgeons per head of by other surgeons. Most other 1:50,000 in Scandinavia and in much population is way below norms in Ireland.” locally surgical specialties have units in of Europe. The recommended ratio Limerick and Waterford (e.g. ENT, advised by BAPRAS is 1:80,000 and Urology, Vascular Surgery, Orthopaedics, General Surgery). There is currently the ratio in Ireland is about twice this. HOW MANY CONSULTANT also a need to establish a local Plastic Surgery unit for the northwest such POSTS ARE LIKELY TO BECOME VACANT OVER THE NEXT TWO, FIVE, as Letterkenny.

TEN YEARS? Over the next three years there are likely to be three consultants retiring and in the following five years, a further three retirements, making YOUR KEY OBJECTIVES/PRIORITIES WHILE IN OFFICE, WHICH at least six in total over the next five years. There are likely to be six more COINCIDED WITH THE COVID-19 PANDEMIC? The worldwide pandemic retirements in the five years after that, making a total of twelve posts vacant greatly reduced the ability to meet face-to-face, thus maintaining virtual in the next ten years. This does not take into account the new posts required communication with Plastic Surgeons and other colleagues was a key priority. to develop the services in both the existing six units as well as the two cancer Our Association members have not met face-to-face since February 2020. I centres which currently do not have a Plastic Surgery service [Limerick and participated in many virtual meetings with numerous international Plastic Waterford]. WHAT ARE THE STRATEGIC INITIATIVES FOR THE SPECIALTY? Surgery organisations including the European (EASAPS), American (ASPS) and Global (ICOPLAST) associations, societies and confederations to discuss similar Expansion of the specialty in the six existing centres and development of issues for Plastic Surgery during the pandemic. Other objectives and priorities existing centres including “hub & spoke” arrangements with peripheral included the following: Model 2 and 3 hospitals. Many of these are already running: for example, the main Plastic Surgery unit in Galway University Hospital has associated Cancer Care Plastic Surgery provides cancer care services both in skin cancer Approx 32 (public), with a further ten in private practice. HOW MANY TRAINEES? About 24 SpRs.

S U R G E O N S S C O P E / 25

› Specialty Spotlight

(melanoma and non-melanoma skin cancer) as well as complex reconstruction in other cancers such as breast cancer, head & neck cancer, ano-perineal cancers and sarcoma reconstruction, usually done in conjunction with other specialties.

Weekly virtual meetings were held by NCCP during the various COVID-19 crises over the last 18 months so all surgical specialties providing cancer care, including Plastic Surgery, could discuss and assess cancer contingency plans during the pandemic. IAPS provided information on the clinical issues with skin cancers as well as complex cancer reconstruction.

Skin Cancer IAPS developed guidelines for the management of skin cancers during the pandemic in conjunction with RCSI as part of RCSI’s guidelines for surgical practice during COVID-19.

Expansion of skin cancer services by Plastic Surgery remains a priority as the population ages. Melanoma and NMSC guidelines, protocols and KPIs are being established by the NCCP (National Cancer Control Programme) with input from IAPS. Complex Cancer Reconstruction The need for Plastic Surgeons to provide a cancer reconstructive service, including microsurgery, continues to increase.

1. Breast cancer. The further development of an immediate breast reconstruction service using microsurgical techniques is urgently required.

This is occurring to a variable extent in existing Plastic Surgery units, often limited by consultant manpower and facilities, but not occurring in breast cancer units without Plastic Surgery on site.

2. Head & neck cancer. There is also increasing need for microsurgical head & neck reconstruction in the centres dealing with head & neck cancer.

3. Ano-rectal/perineal cancers. Newer reconstructive services are increasingly required in advanced distal ano-rectal and perineal cancers, requested by colorectal surgeons and gynaecological cancer surgeons.

Trauma Care Trauma is an integral part of Plastic Surgery, comprising 30-50% of the workload. The most common injuries referred are hand injuries, such as complex lacerations, tendon, nerve injuries or compound open fractures.

Developing trauma services where plastic surgical trauma can be dealt with in an efficient manner within dedicated Plastic Surgery trauma units used to dealing with a large number of hand, lower limb and facial injuries requires adequate Plastic Surgery manpower with Plastic Surgery trauma clinics and daily Plastic Surgery trauma theatre facilities. Daily dedicated Plastic Surgery 26

trauma theatre facilities currently only exist in two units (Cork & Beaumont/ Connolly) but are required in all units to avoid repeated cancellations of Plastic Surgery trauma due to other specialties’ emergency cases being prioritised and/ or scheduled cases being cancelled to do the trauma cases instead. The planned development of Major Trauma Centres will also require major Plastic Surgery involvement, with the recent Trauma Report recommending “at least twelve Plastic Surgeons as a minimum” in each major trauma centre.

Consultant and Service Expansion Much work is ongoing to ensure adequate consultant expansion in conjunction with RCSI and the NDTP (National Doctors Training & Planning) section of the HSE. IAPS has set up a Consultant Manpower Committee to identify and plan for adequate consultant expansion over the next decade. In addition, the National Clinical Programme in Surgery (a HSE/RCSI initiative) has recently established a Clinical Lead in Plastic Surgery who is working to develop a Model of Care in Plastic Surgery. IAPS are working with the Clinical Lead, RCSI & HSE to develop adequate and equitable Plastic Surgery services throughout the country Breast Implants and BIA-ALCL The identification of a rare new malignancy associated with certain Breast Implants called Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) was recognised by the WHO as a new entity in 2016. This has had increasing recognition over the last few years by doctors, patients and the media. The HSE established a SIMT (Safety Incident Management Team) to investigate this new entity in Ireland and to recommend how to manage patients with breast implants, both for breast cancer reconstruction and cosmetic augmentation. The SIMT identified patients who had breast implants in the public hospitals and contacted them to explain and discuss BIA-ALCL. This resulted in a considerable amount of work for Plastic Surgeons to explain this rare cancer to patients and the generally very good outcome with early detection and treatment. Guidelines for follow-up of breast implant patients are being developed. It is recognised now that a major priority is to establish a National Breast Implant Registry as many countries worldwide have done over the last decade. This work is ongoing and IAPS remains closely involved and committed to establishing a Registry.

Cosmetic Surgery Regulation Cosmetic/Aesthetic Surgery is an integral part of the specialty of Plastic, Reconstructive & Aesthetic Surgery, but currently the regulation of Cosmetic/Aesthetic Surgery services is lacking in Ireland. This has been recognised in several European countries, many of which have instituted a more robust regulation of Cosmetic Surgery for the protection of patients.

During my term, RCSI established a Short Life Working Group (SLWG) to review cosmetic surgery and make recommendations concerning regulation.

A past President of IAPS, who is also a member of RCSI Council, chairs this SLWG. This work is ongoing and regulation of this area of Plastic Surgery remains a major issue in Ireland.

WHICH PARTICULAR CHALLENGES, IF ANY, ARE FACED BY YOUR SPECIALTY IN IRELAND AT PRESENT? Consultant and Service Expansion As outlined above – to expand current

existing units and services as well as establish new units, particularly in the major cancer trauma centres in Limerick and Waterford.

Cancer Care To improve skin cancer care in both melanoma and NMSC in all areas of Ireland. Complex cancer reconstructive services in conjunction with other specialties, with all reconstructive options available to all patients regardless of location, remains a challenge. This is particularly the case with both immediate and delayed breast reconstruction techniques utilising microsurgical techniques to use the patients’ autologous tissue only to reconstruct the breast, thus avoiding the need for breast implants. This service is not available to patients who attend cancer centres that do not have a Plastic Surgery unit and to a varying degree in other units who do have a Plastic

› Specialty Spotlight Surgery unit due to inadequate manpower, theatre resources or both.

Trauma Provision Establishing an efficient trauma service to deal with the large volume of injuries referred to Plastic Surgery, which requires a dedicated daily Plastic Surgery trauma theatre in all centres. This facility currently only occurs in two hospitals/hospital groups, Cork and Beaumont/Connolly.

The Major Trauma Report has recommended two major trauma centres to deal with major truama, one in Cork and one in Dublin. This will require an increased number of Plastic Surgeons, resources and facilities to deal with as outlined above.

Cosmetic Surgery and its Regulation As outlined above, cosmetic/aesthetic surgery is an integral part of Plastic Surgery but currently the regulation of Plastic Surgery services is lacking. This has been an ongoing challenge for the specialty of Plastic, Reconstructive & Aesthetic Surgery in many countries for some time, although many jurisdictions have instituted a regulatory framework.

IAPS and RCSI are working together to urge the regulatory authorities in Ireland to address this deficit, which puts patients at risk.

Breast Implants, BIA-ALCL and Other Issues with Implants This is outlined above. Although a rare malignancy, BIA-ALCL can result in significant patient concern, especially in breast reconstruction patients, who have already had a breast cancer. Many patients are now requesting removal of breast implants or conversion from a poor aesthetic outcome of their breast reconstruction where breast implants were inserted, to autologous tissue reconstruction, mainly with the “DIEP” (Deep Inferior Epigastric Perforator) flap. A priority is the establishment of a Breast Implant Registry (similar to those existing for other implants such as hip replacements) in Ireland, as has occurred in many countries in North America, Europe and Australasia.

ARE THERE ANY SUBSPECIALTY AREAS THAT YOU SEE PARTICULAR NEEDS IN, AND HOW CAN THEY BE ADDRESSED? Cancer Care and Microsurgical Reconstructive Services There is a specific

need for an adequate and equitable cancer reconstructive services in the entire country.

As outlined above, this is available in some cancer centres and availability is limited in others due to inadequate manpower and resources. This is especially the case with breast reconstruction, especially immediate reconstruction using autologous tissue such as the DIEP flap. The same issue exists for advanced head & neck cancer, which requires a complete reconstructive service, including microsurgery, to allow more extensive curative resections to be carried out. This resource

varies from centre to centre and requires improvement as the need for complex reconstruction of these cancers continues to increase.

Hand and Trauma Services There is particular need for hand surgery emergency services which should be available in all centres on a daily basis but only occurs in one or two centres and needs to be increased. It would still require most hand injuries to be managed in the local trauma units rather than the major trauma centre. The establishment of major trauma centres requires considerable expansion in Plastic Surgery manpower and services to deal with complex lower limb compound fractures, extensive limb degloving injuries and soft tissue loss, major burns, extensive cranial/facial injuries which will be triaged to these major trauma units and dealt with in conjunction with other specialists, particularly orthopaedic surgeons in lower limb trauma.

Reconfiguration of Paediatric Plastic Surgery With the new Children’s Hospital opening in the next few years, this will require reorganisation of current services for Paediatric Plastic Surgery, which currently occurs in both the existing Children’s Hospitals in Temple Street and in Crumlin. These services include cleft lip & palate, paediatric craniofacial surgery, congenital hand surgery, congenital vascular malformations, ear deformities, congenital facial palsy and paediatric burns. While currently all consultants who deal with Paediatric Plastic Surgery are specialised in their various areas, they are also all attached to an adjacent public hospital, either St James’s or the Mater hospital.

When the Children’s Hospital opens, it will require both reconfiguration of current consultant’s practice as well as consultant expansion to provide an adequate service. This is also likely to have an effect on the adult Plastic Surgery services provided.

WHAT WOULD YOU SAY TO SURGICAL TRAINEES CONSIDERING A CAREER IN THIS SPECIALTY? I would strongly encourage trainees to consider

a career in the specialty of Plastic, Reconstructive & Aesthetic Surgery. Plastic Surgeons are referred a huge variety of problems in many different areas including hand surgery and hand injuries, trauma services including upper limb, major lower limb and facial injuries, skin cancer and reconstruction, breast reconstructive surgery, head & neck cancer and reconstruction, facial palsy surgery, burns, Paediatric Plastic Surgery such as cleft lip & palate, aesthetic surgery, and many others. All ages are dealt with, from babies with congenital deformities to very elderly patients with complex cancer or degenerative problems.

Plastic Surgeons have always been surgical innovators, developing new techniques and ways to approach a particular problem, evolving as newer ways of managing problems and new techniques are described and developed.

More recent advances developed by Plastic Surgeons include microsurgery, tissue expansion, autologous fat transfer, skin substitutes, negative pressure wound therapy techniques, to name but a few. Collaborative surgery with other specialties is an integral part of Plastic Surgery. Plastic Surgeons require flexibility to work with other specialties as well as constantly adjusting to new techniques during their career. Research in Plastic Surgery is also an exciting field, with many opportunities both nationally and internationally.

In Ireland, the specialty of Plastic, Reconstructive & Aesthetic Surgery continues to expand, with consultant numbers having almost tripled in the last 25 years from ten in 1996 to over 30 in 2020. The need and demand for Plastic Surgeons will continue to increase, which is a challenge and a great opportunity for any future surgeon.

DATES FOR YOUR DIARY

The Irish Association of Plastic Surgery Winter Meeting will take place, now virtually, on 10 December 2021; Charter Day; Plastic Surgery Section, Friday 24 February 2022; Plastic Surgery SpR interviews, 16 March 2022. ■ S U R G E O N S S C O P E / 27

› Medico-Legal Matters

A Fairer Hearing THERE IS A WIDESPREAD PERCEPTION THAT THE LEGAL SYSTEM IS STACKED AGAINST DOCTORS, BUT THERE ARE SIGNS TOWARDS INCREASING THE SCRUTINY OF A PLAINTIFF’S EVIDENCE. BARRISTER IMOGEN MCGRATH EXPLAINS

edical negligence claims have increased significantly in number over the past few years. This is not indicative of a fall in the standard of medical care. Rather, it is evidence that surgeons operate in an increasingly litigious environment.

To an observer, it can appear that the legal system is stacked against the medical profession with plaintiffs pushing an open door to compensation at the expense of professional reputations. Such a perception is understandable. However, it does not take account of a number of recent important judgments. The appellate courts have, in the last two years, both stridently reaffirmed the threshold to be reached for establishing negligence and tightened procedural safeguards for the benefit of defendants.

JUDICIAL APPRECIATION OF REPUTATIONAL IMPACT The Supreme Court recently acknowledged the toll that negligence claims take on medical practitioners (Mangan v Mount Carmel Hospital [2020] IESC 67). The Court referred to the rule that claims cannot be made against doctor without independent expert evidence of negligence or breach of duty, and said: “The reasons for there being this rule in respect of professional malpractice, are readily understandable, particularly but evidently not solely, in the case of doctors … Reputation is a crucial component of one’s right to earn a livelihood at a personal level, as it is for public confidence in the profession of which that 28

person is a member, at an institutional level ... Therefore, by instituting practice related proceedings against such a person or body, is to put their reputational integrity in issue, at least to some extent, and thus should only be undertaken if there is justifiable reason for so doing. ” The Court of Appeal has also emphasised the principle that unsustainable legal claims are not in the common good and held (Kelly v UCC and the Southern Health Board [2020] IECA 293): “… the law in this jurisdiction requires that if a plaintiff makes damaging allegations of negligent treatment against a professional skilled in a particular branch of medicine, then that plaintiff must have the evidence of another professional, of equivalent skill and standing, who has formed the opinion that the treatment administered fell below the necessary standard required of such a professional and that it did, in fact, constitute negligence and/or a breach of professional duty. Such a high threshold has been set by the courts because of the ‘Serious consequences’ that an unfounded allegation of medical negligence may have for clinical practitioners. Without ‘professional evidence from another professional’ supporting a claim of medical negligence, a court could never make a finding of negligence ...’

CONFIRMATION OF THE STANDARD OF CARE In what was effectively the cervical screening check ‘test case’, Ruth Morrissey v HSE ([2020] IESC 6), the Supreme Court confirmed that the core principles established in the seminal case of Dunne v Maternity Hospital ([1989] IR 91)

› Medico-Legal Matters

Delay in prosecuting a claim can be particularly pernicious from a defendant’s perspective … remain paramount. Despite widespread concern in the aftermath of the High Court judgment that the criterion of ‘absolute confidence’ would extend beyond cytoscreening, the Supreme Court confirmed that the standard of approach is to be judged by reference to the ordinary competent professional.

The Dunne principles were summarised and reduced to one overarching principle by Chief Justice Clarke as being “The standard of approach of a medical professional is to apply a standard appropriate to a person of equal specialist or general status acting with ordinary care. A failure to act in that way will amount to negligence”. The Chief Justice further stated ‘… in many cases, the court has no role in determining the standard to be applied other than to assess the evidence given by professionals as to the standard to which they themselves regard as being appropriate to someone of the standing and skill of the defendant.”

PROCEDURAL CONTROLS Allied to the reinforcement of the threshold for establishing negligence is a palpable move towards enhanced judicial control over the progress of medical claims. This should reduce the time that professionals have a claim hanging over them.

One example of procedural tightening is that plaintiffs now face a higher hurdle if they delay in serving their claim on defendants. In order to avoid the impact of the Statute of Limitations, plaintiffs often issue what is referred to as a ‘protective writ’, a personal injuries summons issued in advance of receipt of expert evidence. The practice, often, is not to serve such a summons unless and until expert evidence is acquired. The summons expires after one year and the threshold for its renewal was elevated this year from the requirement to have ‘good reason’ to the existence of ‘special circumstances’ (Murphy v Health Service Executive [2021] IECA 3). This has led to the dismissal of plaintiffs’ medical negligence actions at a very early juncture.

Delay in prosecuting a claim can be particularly pernicious from a defendant’s perspective, not least where there are issues of informed consent which turn on viva voce evidence. This was the finding made by the High Court in a recent case where the Judge held: ‘There is an undoubted prejudice to parties who are called upon to remember events many years later. Their ability to defend themselves adequately diminishes with time. Accordingly, the court holds that there is a discernible prejudice to the second defendant in the failure of the plaintiff ’s solicitor to serve the summons on him in a timely manner’ (Young v St Vincent’s Health Care Group Limited & Ors [2021] IEHC 386).

ROLE OF INDEPENDENT EXPERTS Anyone who has been involved in litigation will have borne witness to its mercurial nature. While a plaintiff may allege one thing in a personal injuries summons, an entirely different argument is sometimes advanced by his or her expert at trial. There is a well-established rule that litigants must plead their cases properly, but all too often this is honoured more in the breach than in the observance.

In the Expert Group Report to Review the Law of Torts and the Current Systems for the Management of Clinical Negligence Claims (17 January 2020)

there were recommendations for the meetings of experts in advance of the trial so that areas of conflict can be defined. This is a practice common in other areas of law and there is no reason in principle why it should not occur in medical negligence litigation and every reason why it should.

The Court of Appeal has also encouraged parties in medical negligence litigation to seek case management from the High Court and agree lists of issues to be determined by the trial judge (McCormack v Mater Private Hospital [2021] IECA 96). It can be expected that, in particular, defence practitioners will rely on the recent Court of Appeal decision to ensure, first, that plaintiffs make out their case with precision and, second, that there is no ambush at trial by way of new expert reports or pleas which were not contained in the original claim.

CAUSATION Causation remains a cornerstone of many defences to medical claims. The question of causation only arises on the hypothesis that the defendant was negligent. Persuading a judge that established negligence did not cause the injuries complained of is not easy. Where an expert report is obtained to the effect that any negligent treatment did not cause the plaintiff ’s injuries, this provides a solid basis for defending a claim. While it may not result in a full trial and dismissal of a plaintiff ’s claim, it can precipitate a settlement at a significantly discounted value. This usually results in the claim being struck out without an admission of liability. Although this does not mitigate the emotional impact of being sued, it does obviate the need for court appearances and avoids any negative reputational finding.

CONCLUSION It is readily accepted at judicial level that there is a great deal at stake on both sides of medical negligence litigation (McCormack v Mater Private Hospital [2021] IECA 96s). Lawyers who defend medical negligence claims are acutely mindful of the reputational impact of litigation and the strain it places both on the way a surgeon practices medicine and their personal well-being. The architecture of the adversarial system for dealing with medical negligence claims needs reform. While far-reaching recommendations have been made, their implementation is slow. In the interim, however, there is a tangible trend towards reinforcing the existing rules and ensuring that claims will not be prosecuted in the absence of “professional evidence from another professional supporting the assertion of the claim of negligence …”, As Chief Justice Finlay in Dunne observed: “The development of medical science and the supreme importance of that development to humanity makes it particularly undesirable and inconsistent with the common good that doctors should be obliged to carry out their professional duties under frequent threat of unsustainable legal claims.”

Pending revision of the litigation rules for medical negligence claims, there is good reason for enforcing rigorous procedural controls and maintaining the high threshold for establishing negligence. ■ Imogen McGrath is a junior counsel barrister specialising in commercial, EU and medical negligence litigation. She routinely represents hospitals and doctors in defending claims. Imogen has been admitted to the Bar of New York and the Bar of England & Wales and is currently a committee member of the Commercial Litigation Association of Ireland and the EU Bar Association.

S U R G E O N S S C O P E / 29

› Q&A

The Colles

Q&A

Professor Freddie Wood RENOWNED HEART SURGEON FOR ALMOST 30 YEARS, PROFESSOR FREDDIE WOOD TRANSFORMED CARDIAC SURGERY AND HEART AND LUNG TRANSPLANT SURGERY

Professor Freddie Wood RCSI Fellow (1975)

Professor AE (Freddie) Wood graduated from University College Dublin in 1971 and obtained FRCSI in 1975. He trained in Cardiothoracic Surgery first in Dublin, then in the Royal Victoria Hospital Belfast in the late 1970s during the Troubles before completing his training in the Hospital for Sick Children Toronto. He was appointed to the Mater Hospital in 1983, and Our Lady’s Children’s Hospital Crumlin in 1985 pioneering complex infant congenital heart surgery and reparative valve surgery.

With the late Maurice Neligan he pioneered heart transplantation in 1985. From 1999 to 2010 he served as Director of Heart & Lung Transplantation at the Mater Hospital and led the development of the Lung Transplantation Programme culminating in successful lung 30

transplantation in 2005.

He served on the Council of RCSI in Ireland from 2000 to 2014 and was the first Chairman of Governance in 2008, as well as the Chair of the Finance Committee. He retired from the Mater Hospital and Our Lady’s Children’s Hospital in autumn 2010.

Between 2011 and 2013, Professor Wood was Consultant CardioThoracic Surgeon in Congenital Heart Disease to the Royal Victoria Hospital Belfast to direct, manage, mentor and provide surgery whilst a solution for its all island provision was finalised.

He served as President of the Medical Council from June 2013-2018 during which time he raised concerns about physician health and wellbeing. Now he spends time teaching anatomy as a Surgeon Prosector in the Department of Anatomy RCSI.

When and where are you happiest? In the operating room operating on a newborn baby with complex heart disease using profound hypothermia and circulatory arrest or performing and managing a heart or lung transplantreal life applications of science and surgical skill.

What is your ideal evening?

Sharing good burgundy with great food and conversation with close friends after a game of bridge which I have only recently taken up.

If you could research and write a book on any subject, what would it be? Probably the history of Thoracic and Cardiac Surgery with particular reference to the island of Ireland and Irish surgeons both here and abroad who contributed to the specialty.

What relaxes you most? Going for a long run (regrettably now much shorter at 73 years) or a long hike/ climb in the mountains.

What is your greatest fear?

Drowning or being caught in a crevasse and freezing to death.

When did you decide you wanted to become a surgeon?

At 15, I decided to try and become a doctor hoping to become a surgeon. I liked fixing things and wanted to help people. In late 1967, the first heart transplant was performed, I had just started in my second medical year and I was fascinated. Then, in autumn 1968, I was privileged to hear Christian Barnard speak in St Vincent’s Hospital when he visited Ireland on the invitation of Dr John

O’Connell, TD later to be Minister of Health. My goal was set.

Would you have any advice for your younger self? Go a bit slower. Qualify in something else other than surgery such as law, economics, education or regulation.

Have the ability to change career mid-career.

How do you have fun? Sail competitively, hill walk, alpine trek/climb.

Where would you be if you decided not to become a surgeon? Probably a barrister. The research, attention to detail and the cut and thrust of the courtroom I find fascinating.

In what ways do surgeons struggle and what issues do surgeons today face? Now more than ever surgeons’ outcomes are being scrutinised. An active, progressive surgeon over three decades of practice can expect to be litigated at least once and possibly appear in the High Court, attend the Coroner’s Court, be complained about to the Medical Council, have a HSE-instigated Serious Adverse Event Inquiry and lastly be the subject of a HIQA investigation. I have had all of these to contend with except the last but I expect there will be more instances in the profession and clinicians and surgeons will have to endure them. Surgeons will need confidential and counselling support that is independent of employment or college. It is important that surgeons so challenged are not lost to the profession.

› Q&A

At 15, I decided to try and become a doctor hoping to become a surgeon.

I liked fixing things and wanted to help people.

What has been your proudest moment? Standing on the steps of the Mater hospital alongside Maurice Neligan on the 26th of September 1985 watching the first heart transplant go home.

Who have you learned the most from in your life? My wife, Thérèse in the first instance. Professionally, my trainers in Dublin (Professor Eoin O’Malley, Mr Keith Shaw and Mr Maurice Neligan), Belfast RVH (Mr Jack Cleland, Mr Hugh O’Kane and Mr Maurice Stevenson) and finally, Dr George Trusler in the Hospital for Sick Children Toronto.

How does a surgeon in 2021 cope with pressure? They very much need outside interests especially physical activity. And have a good support/family structure. The COVID-19 pandemic is creating huge concern for surgeons and surgical trainees. Surgeons like doing things and fixing things. Prior to COVID-19, 65% of all surgery was being performed in the “independent” private hospitals – 33% of which was on publicly funded patients through the NTPF. Since the arrival of COVID-19, much surgery in the public hospitals has been stopped/ deferred with the result that surgeons and surgical teams are finding it difficult to maintain their skills.

What is the best thing about the system of training young doctors in Ireland? Bedside teaching and clinical exposure – though it is considerably less than when I went through medical school.

Edward Jenner

What is your greatest extravagance? It is hard to say, owning a small yacht maybe.

Recently, I bought a Mark 1 Mini Morris Minor which was assembled in Dublin for me to modify and tune up. Wine as I get older.

Do you have a mantra to live by? Greet everyone as I would like to be greeted. Leave everyone as a friend and happy, you may never see them again.

What do you consider your greatest achievement Hard to say, I suppose the Heart-Lung Transplant programme which I worked on from 1997 but I am proudest of the All-Island Congenital Heart Disease programme which now provides surgery for all newborn children with congenital heart disease on the island of Ireland.

It was possible to structure this on foot of Appendix 8 in the 1998 Good Friday Peace Agreement.

In your profession, a historical figure you admire? I admire a number of figures: Edward Jenner for vaccination, William Morton for introducing general anaesthesia, Ignaz Semmelweis for antisepsis, Joseph Lister for asepsis, Marie Curie for x-rays, C Walt Lillehei for open heart surgery and Norman Shumway for heart and lung transplantation. All showed tremendous courage and resilience in the face of considerable professional opposition.

Joseph Lister

Norman Shumway

What is your favourite memory?

Getting married.

Do you have any hobbies and if so, what do you enjoy about them? I probably have too many hobbies – old cars, radio-controlled model sailing boats and planes, sketching and now gardening. What I like about them is you have to make them work. Sketching I like because you can leave something personal that’s timeless.

Name your favourite writer?

I don’t have a particular favourite. I like biographies and European history.

I have just finished a book on Dr Barry O’Meara, Napoleon’s surgeon on St Helena. It transpires he was born in Newtown House, Blackrock just down the road from where I live.

If you could invite any historical figure to dinner, who would it be? Napoleon Bonaparte, Florence Nightingale. One changed the landscape of Europe, the other changed the assessment of medical and nursing care with a focus on patient outcomes.

Which talent would you most like to have? To be able to make music – play the piano or the violin.

What is the wisest thing you have ever said? Asking my wife Thérèse to marry me.

Name virtues all surgeons ought to have. Humility and Courage.

Name vices no surgeon should have. Arrogance and deafness. ■ S U R G E O N S S C O P E / 31

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