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

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.

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

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.

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 during the COVID-19 National Surgical Skills Competition 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.” ■