Surgeons' News December 2014

SPECIALTY

GROWING UP FAST

The development of paediatric surgery from its mid-20th century origins

TRAINEES AND STUDENTS

TOMORROW’S WORLD

ASiT’s role in boosting doctor numbers in East Africa

HISTORY

BLOOD BROTHER IN ARMS

Norman Bethune’s transfusion lifeline in the fight against fascism

Surgeonsnews December 2014

The magazine of The Royal College of Surgeons of Edinburgh

Shaping better trainers New standards set the framework for today’s health service

www.surgeonsnews.com

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Annals of Surgery Cognitive Skills to Avoid Errors & Achieve Results

Smart Surgeons; Sharp Decisions Smart Surgeons; Sharp Decisions • GBP £27.50; USD $50; EUR ∈40 Uttam Shiralkar • ISBN 9781903378816 Smart Surgeons; Decisions Cognitive Skills to Avoid Errors Achieve Results Cognitive Skills toSharp Avoid Errors & Medical Achieve Results HIGHLY COMMENDED —& BMA Book Competition A vital and valid Cognitive Skills Avoid Errors & Achieve Results Smart Surgeons; Sharp Decisions question concerns many surgeons: how toUSD make surgery safer?

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WELCOME

FROM THE EDITOR

John Duncan introduces the final edition of the year

A

ccording to the College’s Seal of Cause from 1505: “Every man ought to know the nature and substance of everything with which he works, else he be negligent.”

Have we had a set of standards against which to measure our performance as trainers and ensure that we are providing the highest standards for our trainees, and therefore for our patients? The Standards for Surgical Trainers, produced by the Faculty of Surgical Trainers, set out to do just that. How well that has been achieved can be assessed by the extent to which they have already been taken up by others outside surgery and modified for use as generic standards for the profession. Craig McIlhenny and colleagues deserve congratulation for this contribution to surgery and the wider profession. Bruce Keogh has endorsed these Standards in an article on page 26, reflecting on their application to the important issue of seven-day working. We look at the standards and the issues surrounding them in our cover features, from page 22.

Every November, the College undergoes some degree of renewal.

We bring you up to date with

changes in Council membership and introduce a new convenor of examinations and a new director of education.

I am grateful for the support of our regular columnists. None is more regular than our wine columnist Bernard Ferrie, who this issue turns his attention to Scotland’s national drink.

Another regular feature has been articles on the history of our profession. Iain Macintyre has written previously about Norman Bethune, who served in the army of Mao Zedong and created and operated a blood transfusion service during the Spanish Civil War. Iain has reviewed a new book about Bethune and we publish some extracts from it on page 30.

Each year the President’s Meeting addresses an important issue for the care of our patients.

For 2015 it is the field of surgical oncology.

On page 34 we publish an interview with the keynote speaker, Professor Timothy Eberlein from St Louis. He speaks to Bob Steele about providing cancer services in North America.

Coming soon will be an app that will allow enhanced digital access to Surgeons’ News, to make it more accessible and to give our overseas readers better access to the main magazine as well as to their own version, SN Global.

John Duncan editor@surgeonsnews.com

Have we had a set of standards against which to measure our performance as trainers and ensure that we are providing the highest standards for our trainees, and therefore for our patients? www.rcsed.ac.uk | 1

28

Surgeonsnews

SPECIALTY

GROWING UP FAST

The development of paediatric surgery from its mid-20th century origins

TRAINEES AND STUDENTS

TOMORROW’S WORLD

ASiT’s role in boosting doctor numbers in East Africa

HISTORY

BLOOD BROTHER IN ARMS

Norman Bethune’s transfusion lifeline in the fight against fascism

Surgeonsnews December 2014

The magazine of The Royal College of Surgeons of Edinburgh

DECEMBER 2014 • VOLUME 13 • ISSUE 4

30

Shaping better trainers New standards set the framework for today’s health service

www.surgeonsnews.com

EDITOR John Duncan DEPUTY EDITOR Robyn Webber EDITORIAL BOARD Richard McGregor Peter Lamb Peter Douglas Sarah Allen Chris Henry Dr Yvonne Hurst Aoife O’Sullivan Mark Baillie FOR ADVERTISING ENQUIRIES Tom Grant Barker Brooks Communications Tom.Grant@barkerbrooks.co.uk Tel: +44 (0)844 858 2890 PUBLISHED BY The Royal College of Surgeons of Edinburgh, Nicolson Street, Edinburgh EH8 9DW Registered Charity No. SC005317 contributions@surgeonsnews.com Tel: +44 (0)131 527 1600 For editorial enquiries contact Mark Baillie: Tel: +44 (0)131 527 3405

Contents

December 2014

04

AGENDA News and views from the College and the profession, including recent Council appointments

20

THE PRESIDENT WRITES Ian Ritchie on the value of teamwork in the modern NHS

22

STANDARDS FOR SURGICAL TRAINERS The FST sets out the criteria for training excellence and the profession gives its verdict

28

CONFERENCE Key messages from the FST’s conference, ‘Who Makes the Cut? Assessment in Surgical Training’

DESIGN AND PRODUCTION

Think Publishing Ltd, Suite 2.3, Red Tree Business Suites, 33 Dalmarnock Road, Glasgow G40 4LA Tel: +44 (0)141 375 0504 www.thinkpublishing.co.uk ACCOUNT MANAGER Sian Campbell DESIGN Mark Davies, Alistair McGown SUB EDITORS Sam Bartlett, Kirsty Fortune MEDICAL SUB EDITOR Arshad Makhdum GROUP ACCOUNT DIRECTOR John Innes john.innes@thinkpublishing.co.uk PRINTED BY Acorn Web Offset Ltd, Yorkshire, UK ISSN 1750-7995 The views expressed in Surgeons’ News are not necessarily those of the editorial team or the Royal College of Surgeons of Edinburgh.

Information printed in this edition of Surgeons’ News is believed to be correct at the time of going to press.

2 | Surgeons’ News | December 2014

Stand ards f or Su rgical MR C Traine RA on be half o IG MCILHE f the FACU NNY AND LTY O F

M SURG R DAVID P I ICAL T RAIN E

22

30

HISTORY Norman Bethune and his blood transfusion service

34

INTERVIEW Professor Timothy Eberlein on cancer care in the United States

50

36

PAEDIATRICS Developments in the specialty that is still in the first flush of youth

40

DENTAL Interview with the new dean, Bill Saunders; Crispian Scully’s King James IV lecture; other Faculty news

47

TRAINEES AND STUDENTS How to audit and publish outcome data; route to neurosurgical selection; doctors in Rwanda

54

COLLEGE INFORMATION Diploma ceremony listings and awards and grants

62 64

OUT OF HOURS Graham Layer dines out FROM THE COLLECTIONS An ‘aegagrophile’ gives insight into some gruesome practices

Stay Updated Visit our new website - www.cuschieri.dundee.ac.uk/

Basic, Intermediate and Advanced Masterclasses General Surgery ENT Gastroenterology Orthopaedics Urology Gynaecology General Practice Anaesthetics Interventional Radiology Cadaveric courses using Thiel embalmed cadavers Cuschieri Skills Centre, University of Dundee Level 5, Ninewells Hospital, DUNDEE, DD1 9SY Phone: +44(0)1382 383400 Fax: +44(0)1382 646042 Web: www.cuschieri.dundee.ac.uk/ Email: cscbookings@dundee.ac.uk

Agenda The latest news from the College and profession / NHS SERVICES

Sir Bruce Keogh calls for seven-day NHS services

N

HS England’s medical director, Sir Bruce Keogh, visited the RCSEd’s Birmingham Regional Centre on 31 October to discuss the quality framework for the NHS. At the event, which was exclusive to RCSEd Fellows, Sir Bruce discussed changes affecting the NHS before a question and answer session with attendees.

Making the case for seven-day services, Sir Bruce said it offered a way to provide more support to junior doctors, address issues of higher mortality

over the weekend and the ‘flawed economics’ of diagnostic equipment and services lying dormant over the weekend while patients were waiting for treatment.

Sir Bruce said: “I believe this [seven-day services] is a worthy cause to pursue. We have a moral and social obligation to do so and I think it is best led by the professions. But if we don’t lead it, there is enough momentum that society will insist upon it.”

The full video of Sir Bruce Keogh’s talk is available on the College website.

/ TRAINING

Trainees’ Shape of Training warning The trainees’ committees of four Royal Colleges and the Scottish Academy Trainee Doctors’ Group have issued a stark warning about plans to implement recommendations from the Shape of Training report.

Representatives from the Royal College of Physicians of Edinburgh, Royal College of Physicians and Surgeons of Glasgow, Royal College of Physicians of London, RCSEd and the Scottish Academy Trainee Doctors’ Group have said that current proposals are insufficient to address recruitment problems and could cause disaster if implemented wrongly.

The group commented: “We welcome many aspects of the Shape of Training Review: broad-based training programmes in the early

4 | Surgeons’ News | December 2014

Securing the future of excellent patient care Final report of the independent review Led by Professor David Greenaway

years of training, apprenticeship-based training, transferable competencies and greater flexibility during training. However, the proposals will not solve the current problem at the front door of medicine. If we get this wrong, it will have a disastrous impact on future recruitment of doctors, and therefore patient care. We must not forget the lessons of Modernising Medical Careers (MMC).”

The statement goes on to highlight five areas of training that need special attention to ensure high-quality and safe patient care.

For more, see the website

The Forth Bridge by the late Allan Pendreigh / FUNDRAISING

Edinburgh University to host exhibition The University of Edinburgh has invited RCSEd Fellows to a private viewing of an exhibition by the Scottish Society of Architect Artists (SSAA). Art4X is an exhibition and art sale organised by SSAA with the University of Edinburgh to raise funds in support of the university’s Patrick Wild Centre.

The aim of the Patrick Wild Centre is to understand the neuronal basis of, and to test new therapies for autism, fragile X syndrome and intellectual disabilities by fostering collaborations between world-class basic science and clinical research at Edinburgh University.

A private view will be held on 20 January 2015 from 6pm to 9pm. For details, contact kerry. mackay@ed.ac.uk, 0131 650 9221.

/ CAMPAIGN

RCSEd prescribes patients to get fit for surgery

T

he RCSEd is aiming to harness the leadership potential of its 22,000 members to highlight the benefits of physical activity to patients undergoing surgery.

Studies have identified anaerobic threshold as the single most significant predictor of complications and mortality in surgery, significantly more accurate than age alone. To tackle this issue, for the first time ever the RCSEd is launching a UK-wide education campaign to get patients moving in the run-up to surgery.

Data published in the Annals of Surgery demonstrated that postsurgical mortality could be as

high as 22% in patients with low levels of fitness, whereas patients who were fitter had only a 4% mortality rate. Many studies have also found an inverse relation between cardiorespiratory health and complications in heart, lung, colorectal and bariatric surgery.

Addressing this costly and avoidable matter, the College is asking patients to speak with their surgeon or GP to work out an exercise plan that suits their condition and the type of operation they will undergo.

Consultant orthopaedic surgeon and regional surgical adviser for the RCSEd Mr Jon Dearing is leading the campaign, which comprises a variety of support materials, including video content and an

/ HERITAGE

Prince Philip draws crowds on 1955 visit

Mr Jon Dearing is leading the campaign to increase pre-op patient fitness

information leaflet. He said: “A simple 30 minutes of physical activity per day in the lead-up to surgery not only can significantly reduce avoidable complications and mortality, but in some instances can even improve the chances of ‘borderline’ or unsuitable surgical candidates.

“We’re not talking necessarily about donning Lycra and getting sweaty at a gym – just straightforward measures such as walking or cycling instead of driving, taking the stairs instead of the lift and parking further away from the shops. Simple steps such as this can improve surgical outcomes, aid the recovery process and even enhance the patient’s own psychological wellbeing as they get better faster. Most waiting times for surgery are around 12 weeks – this is plenty of time to work on increasing the likelihood of a successful operation.”

Mr Dearing added: “Many people have asked me why this is a job for surgeons. My response is that it’s a healthcare issue and as good doctors it is what we should be doing.

Undergraduates are not taught about a prescription for physical activity, but as consultants we are expected to have all of the answers – it only takes about 30 seconds to give advice during a consultation and those are 30 seconds that could save lives and significantly reduce costs.

Millions can be saved in prescription costs alone if the fitness levels of patients were improved.”

The Duke of Edinburgh visited the College in 1955 to accept an Honorary Fellowship

His Royal Highness Prince Philip, Duke of Edinburgh, visited the College on 20 June 1955 to be awarded an Honorary Fellowship. The visit from the Patron of the RCSEd was timed to coincide with the College’s 450th anniversary celebrations.

The visit was recorded in the proceedings of the Scottish Society for the History of Medicine, which reported: “On 20th and 21st June, 1955, the Royal College of Surgeons of Edinburgh celebrated the four hundred and fiftieth anniversary of its foundation. On the first of the two-day meetings there were operating sessions and clinical and pathological demonstrations in the various Edinburgh hospitals and elsewhere, and in the evening a banquet in the College Hall at which His Royal Highness the Duke of Edinburgh was admitted an Honorary Fellow of the College.”

www.rcsed.ac.uk | 5

AGENDA

NEWS IN BRIEF Subscription rate changes for 2015 Attendees at the Annual Meeting of Fellows and Members of the College held on Friday 14 November 2014 passed a motion to amend the annual subscription for Fellows and Members with effect from 1 January 2015.

In the new rates, the UK membership rate has been frozen for the fourth consecutive year and the rate for UK Fellows has been increased to £433.

Other rates have increased by an average of 2%, with no changes to election fees or other charges.

Further information is available on the College website.

Communication skills video competition

Medical students, doctors and trainees have been invited to submit entries for the College’s new communication skills video competition.

Entrants need to demonstrate good communication skills by creating a video that highlights one of the three elements examined in the MRCS OSCE. All entrants will receive one year’s free affiliation with the RCSEd Affiliate Network, and the winners can choose to attend any College course or the 2015 President’s Meeting and Audit Symposium.

The closing date is 9 January 2015.

For more, please visit videocompetition.rcsed.ac.uk

Vacancies on specialty advisory committees

The JCST is looking for practising NHS consultants who are committed to surgical training and would like to make a contribution to general surgery, neurosurgery, oral and maxillofacial surgery, otolaryngology, plastic surgery, trauma and orthopaedic surgery, and urology.

For more, visit www.jcst.org

6 | Surgeons’ News | December 2014

Left to right: Aditya Naidu, Nick Barker, Louise McAllister and Andrew Shelley

/ DENTAL

MPDC study group launches in south-east

T

he Dental Faculty’s advisory board for Primary Dental Care (PDC) is promoting its diploma with a new range of study groups throughout the UK. Among the first was a group of 16 dentists who met in Colchester on 15 October.

Hosted by North Essex postgraduate dental tutor Nick Barker, and presented by PDC advisory board chair Andrew Shelley and past vice-dean Rob Chate, the event offered a valuable opportunity to promote professional development options beyond the Membership

in Primary Dental Care (MPDC), with particular emphasis on the FDS by Assessment. Three quarters of the delegates signed up to take part in regular, longitudinal study groups, with the intention of sitting the MPDC in approximately one year’s time.

The plan to launch regular study groups comes following the recent revision of the regulations for the MPDC RCSEd, with the College’s Colmore Row offices in Birmingham catering for PDC Members in the Midlands with individual postgraduate medical centres being used elsewhere in England.

/ RSA RECRUITMENT

RCSEd recruiting for RSA network As the regional surgical adviser (RSA) network goes from strength to strength, RCSEd is inviting applications from UK-based Fellows to join the network. We are recruiting in the locations listed below and we also welcome interest from Fellows in plastic surgery, paediatric surgery and urology.

East of Scotland To succeed Graham Cormack and Sam Majumdar Northern Ireland To succeed Sean Patton in Belfast North of England To succeed Jonathan Ferguson in Middlesbrough and to work alongside Mike Clarke and Ian Hawthorn

North West of England To succeed Chelliah Selvasekar in Manchester and work alongside Stuart Clark and Jeremy Ward South West (Severn) To succeed Davinder Sandhu West Midlands To work alongside Ishan Bhoora, Rajiv Vohra and Ling Wong Applicants must be Fellows in good standing and hold a consultant post in a surgical specialty. For more information, and to receive the job description, please contact the Outreach Section at outreach@ rcsed.ac.uk. Applications and supporting paperwork must be received by Friday 9 January 2015.

Foremost experts in Tartan and Highland Dress since 1868 Designers and Suppliers of The Royal College of Surgeons of Edinburgh Tartan Renowned for made to measure Made to order Trousers in the College tartan or tartan of your choice A wide range of ladies tartan and tweed Skirts Kinloch Anderson Ltd Commercial Street/Dock Street Leith, Edinburgh, EH6 6EY Tel: 0131 555 1390 E-mail: theshop@kinlochanderson.com www.kinlochanderson.com

Receive 20% discount on all Surgery titles with promo code BBN11 when ordering online at http://bit.ly/CRCSurgery plus free shipping

www.crcpress.com

TELL US WHAT YOU THINK

The RCSEd is asking all Fellows, Members, Associates and Affiliates to take part in a new membership survey.

The survey invites members to give their views on a range of topics, from the services of the College to issues affecting healthcare.

The RCSEd strives to provide excellent service and promote the highest standards in surgery and dental surgery on behalf of its membership and patients.

To do this, it is important for the College to understand the professional views

and requirements of its 22,000 members across the world.

The survey should only take 10 minutes, after which you will be able to enter a free prize draw to win one of three iPad Minis.

Look out for further communication about the survey via email.

We value your continuing membership and look forward receiving your views.

www.rcsed.ac.uk | 7

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THE LISTER PROJECT Director of Heritage Chris Henry provides an update on the project to restore the College’s ‘Playfair’ Building

8 | Surgeons’ News | December 2014

TAM DOUGLAS

A

nyone visiting the RCSEd at the moment will notice that the College’s main building – the Playfair – is encased in a new skin of steel poles and nylon netting. This is the strongest evidence yet that the Lister Project is forging ahead.

The stonework repairs, going on behind the screens, require an intimate mixture of technical know-how and skill built up over many years. The building is being cleaned and treated so that its future is assured.

Years of pollution and pests have taken their toll on the delicate stonework since the last repairs were carried out in the 1990s.

The College is fortunate to have conservation architect Andrew Wright to oversee the works along with stonemasons Stone Restore. The conservation of the intricate decorative work will be carried out by stone conservator Graciela Ainsworth.

After working for five years at the College, I was lucky to go up on the scaffolding with site manager Tam Douglas for a close-up look at the stonework. As you can see from the images, many repairs have been

The Lister Project is due for completion in September 2015. For more information, visit museum. rcsed.ac.uk

It is quite clear that William Playfair expected a great deal from the masons who worked for him in 1832 carried out over the years, and later repairs are highlighted by the changes in the colour of the stone. What is striking is the very high level of craftsmanship that is exhibited on the honeysuckle carvings on the portico. It is quite clear that William Playfair expected a great deal from the masons who worked for him in 1832.

PRESIDENT’S MEETING & AUDIT SYMPOSIUM 2015 SURGICAL ONCOLOGY FRIDAY 20 MARCH 2015 Advances in surgical technique and in the organisation and delivery of care have contributed significantly to improved outcomes for patients with cancer. This meeting will provide an update on contemporary management of various malignancies, with a major focus on surgical treatments, as well as updates on oncological therapies. This meeting will include contributions from all the surgical specialty associations.

KEY SPEAKERS INCLUDE: Professor Timothy J. Eberlein (Bixby Professor and Chairman of the Department of Surgery at Washington University School of Medicine, St. Louis and Surgeon-in-Chief at Barnes-Jewish Hospital) Professor Arnold Hill (Professor and Chair of Surgery and the Head of the Medical School at the Royal College of Surgeons in Ireland) Professor Alastair Munro (Professor of Radiation Oncology at the University of Dundee and Honorary Consultant Oncologist NHS Tayside)

Professor Graeme Poston (Consultant Hepato-biliary Surgeon at University Hospital Aintree, Liverpool, and Professor of Surgery at the University of Liverpool) Professor Tom Treasure (Consultant Cardiothoracic Surgeon, Clinical Operational Research Unit, University College London Abstracts can be submitted via the Education pages of the RCSEd website. Closing date is 5pm on Monday 5 January 2015. www.rcsed.ac.uk/presidentsmeeting

AGENDA

RECTAL CANCER EVENT GENERATES RESEARCH IDEAS Delegates debated the treatment of low rectal cancer at the Edinburgh International Coloproctology Festival 2014

T

he second Edinburgh International Coloproctology Festival, on 1 and 2 September this year, focused on the treatment of low rectal cancer with a particular emphasis on the debate around radical resectional surgery of the rectum and rectal preservation.

In the first session, the treatment of the rectal adenoma (the precursor of rectal cancer) was addressed.

Bob Steele, professor of surgery and head of cancer research at Ninewells Hospital, Dundee, and convenor of the meeting, introduced the session with a critical appraisal of the different methods of excising rectal adenomas. Frank Carey from Dundee followed with a comprehensive review of the histology of rectal adenomas and Jim Hill from Manchester finished off with a thoughtful approach to the situation whereby a lesion thought to be benign turns out to be malignant.

The second session addressed the assessment of rectal cancer, and had contributions on clinical assessment from Jim Hill, trans-anal ultrasound from Neil Borley (Cheltenham), MRI from Gina Brown (London’s Royal Marsden) and histopathology from Frank Carey (Ninewells, Dundee).

The following day was devoted to the treatment of rectal cancer. The first debate of the morning was on the relative merits of laparoscopic surgery and open surgery for rectal cancer, with laparoscopic surgery being promoted by Amjad Parvaiz from Portsmouth and open surgery by David Anderson from Edinburgh. A second debate centred round robotic surgery, starting with a spirited defence of the technology by David Jayne from Leeds, followed by an equally robust rebuttal by Malcolm Dunlop from Edinburgh. Roel Hompes from Oxford also gave an elegant presentation on the new technology of per-anal total mesorectal excision.

The meeting moved on to deal with abdominoperineal excision of the rectum with a state-of-theart lecture from Torbjörn Holm from Stockholm and a comprehensive account of how the perineal defect is closed by Ken Campbell from Dundee. Chris Cunningham from Oxford then addressed the issue of quality of life after anterior resection and abdominal perineal excision. The morning finished with the Bill Heald Lecture by David Sebag-Montefiore from Leeds, who provided a masterly account of the current standing of adjuvant therapy for rectal cancer. This lecture was chaired by Asha Senapati, 10 | Surgeons’ News | December 2014

The most controversial section of the meeting was the issue of rectal preservation in early cancer the president of the Association of Coloproctology of Great Britain and Ireland, and she gave a vote of thanks and presented the lecturer with a scroll and a quaich from the College.

In the afternoon the most controversial section of the meeting took place – the issue of rectal preservation in early rectal cancer. Chris Cunningham gave an account of techniques of local excision and Simon Bach from Birmingham addressed the concept of treating early rectal cancer with a combination of radiotherapy and local excision by highlighting the TREC and STARTREC Trials.

Geerard Beets from Maastricht dealt with the tricky topic of what to do when a rectal cancer responds completely to pre-operative adjuvant therapy. Sun Myint from Liverpool talked about the current state of contact radiotherapy for rectal cancer and Regina Beets-Tan (Netherlands) rounded off the day with an excellent account of the use of MRI in the follow-up of patients treated by a local therapy for early rectal cancer.

The meeting was a great success, prompting intense and lively debate. There was also a sense that ideas around this difficult area had moved on as a result of the meeting, and we look forward to development of the research ideas that were initiated in the discussion.

Support our Heritage and Future Education and Research Become a member of the RCSEd Heritage Society The Heritage Society has been developed as a focal point for the recognition of the essential role which philanthropy plays in our work; a channel through which our membership and the public can support the work of the College in the areas of Heritage, Research and Education.

The first project to be supported through the Heritage Society is the College’s plan to develop the existing Museum and its internationally-important collections. This £4.2m project will transform the experience and access for our 30,000 worldwide visitors each year.

To find out more about this exciting project, visit our Surgeons’ Hall Museums or visit www.rcsed.ac.uk/heritagesociety Registered Charity No. SC005317

AGENDA

RCSEd joins the College of Surgeons of Hong Kong to mark the start of its 25th-anniversary-year events programme

SILVER CELEBRATIONS

I

n September, the College was proud to take part in the ceremonies marking the beginning of the College of Surgeons of Hong Kong (CSHK) silver jubilee year. The events took place around the Hong Kong Intercollegiate Board of Surgical Colleges Membership examination held at the Prince of Wales Hospital, Shatin, and the RCSEd/CSHK Conjoint Scientific Congress, which was held at the Hong Kong Academy of Medicine.

Assessment constantly evolves and, since 2009, the Joint MRCS Intercollegiate (Surgery) Examination for the Diplomas of Membership in Hong Kong has been replaced by the Hong Kong Intercollegiate Board Examination, which is run wholly by the Hong Kong College, with quality assurance and a number

12 | Surgeons’ News | December 2014

of examiners provided, as on this occasion, by the Edinburgh College. The examination, which is now in an OSCE format, has been developed in partnership between our Colleges and has a similar format to the UK OSCE examination. Successful candidates may take up the option to become Members of the Edinburgh College as well as of their parent Hong Kong College.

This year’s scientific congress was opened by Professor Steven Wing-Keung Cheng, President of the College of Surgeons of Hong Kong, and by Mr Ian Ritchie, President of the RCSEd. The theme of this year’s scientific congress was ‘Improving Functional Outcomes and Quality of Life after Surgery’ and was attended by more than 350 delegates. The organising team, co-chaired by Professor Kent-man Chiu and Professor Bob Steele, created a

LEFT: Dr Peter Barnard (centre) receives a Fellowship Ad Hominem from the Faculty of Dental Surgery.

He is pictured with RCSEd Vice-President Mr Mike Lavelle-Jones (left) and RCSEd President Mr Ian Ritchie (right)

BELOW: Professor Lord Ara Darzi of University College Hospital, London, gives the GB Ong Lecture on ’Surgical Innovation: Frugal Trends to Improve Patient Outcomes’

diverse programme, with themed sessions in all the major specialities, along with free-paper and motionpicture sessions.

A highlight of this annual meeting is the GB Ong Lecture, delivered in memory of Professor GB Ong, who was chair of the Department of Surgery at the University of Hong Kong between 1964 and 1982 and who made huge contributions in the field of oesophageal and liver surgery. This year’s lecture was delivered by Professor Lord Ara Darzi of University College Hospital, London.

His chosen topic, entitled ‘Surgical Innovation: Frugal Trends to Improve Patient Outcomes’, was thoughtprovoking and gave the audience the opportunity to reflect upon how western medicine might derive benefit from the good practices that have evolved elsewhere in the face of extremely limited resources.

Of course, work must be balanced by relaxation and this year’s joint meeting was no exception. The conjoint diploma conferment ceremony and CSHK silver jubilee opening ceremony and annual dinner held in the Sir Run Run Shaw Hall at the Hong Kong Academy of Medicine was a convivial event enjoyed by all – not least by the diplomats and prize winners from the academic sessions earlier in the day.

Seven CSHK presidents, past and present, were able to attend this celebratory event and were recorded together for posterity.

Another lasting memory was the breathtaking night-time view of the city of Hong Kong and Kowloon from the Peak, which was savoured by us all during a memorable dinner hosted by President Stephen Cheng and his council at the Café Deco earlier in the week.

Finally, I should pay tribute to Stephanie Hung, Claudia Chung and Jasmine Wong and their hardworking teams who made sure that all these events were possible.

Mr Mike Lavelle-Jones Vice-President, The Royal College of Surgeons of Edinburgh

AGENDA

Meet the representatives who have taken their places on Council and in the key professional areas of education and examinations

RECENT APPOINTMENTS SURGEONS’ COUNCIL Clare McNaught In 1996, I graduated from Aberdeen University then moved to Yorkshire to complete my registrar rotation in general and colorectal surgery. I took up my consultant post at Scarborough Hospital in 2008 and began to develop my interest in training and education. In 2010, I joined the Court of Examiners and was appointed as regional surgical adviser for Yorkshire in 2011.

Over the last three years, I have been involved in many College events with trainees, including the Lister Surgical Skills Competition and the National Medical Student Conference in Sheffield. I was fortunate to represent the College at the Australasian Younger Fellows Forum in Singapore this year and this experience inspired me to stand for election to Council. During my five-year term, I hope to intensify College engagement with our younger Fellows, represent their concerns to Council and try to influence the development of working practices that protect patients but are compatible with a rewarding and sustainable professional career.

Rowan Parks At present I am professor of surgical sciences at the University of Edinburgh and honorary consultant surgeon at the Royal Infirmary of Edinburgh with a specialist interest in hepatobiliary and pancreatic surgery. In addition, I am currently seconded for a proportion of my working week to NHS Education for Scotland as deputy medical director and have a significant interest in postgraduate medical education and training. I am a graduate of Queen’s University Belfast and did my surgical training in Northern Ireland and Edinburgh. I have enjoyed a number of leadership roles in a variety of national and international specialty associations. It has been an immense privilege to have been a Member of Council for the past five years and to have had the opportunity to contribute to various College committees and activities.

I was delighted to be re-elected to Council and will endeavour to further contribute to the strategic and varied ambitions of the College.

14 | Surgeons’ News | December 2014

Dr Sunil Kumar I am senior consultant, professor and head of the department of surgery at Tata Main Hospital in Jamshedpur, India.

After postgraduate training in India, I worked initially as senior resident and later as assistant professor of GI surgery in the Indira Gandhi Institute of Medical Sciences, Patna. In the UK, I worked in the NHS as a specialty registrar after completing my FRCS. I returned to India in 2001 and have since worked in Tata Main Hospital.

I stood for Council to maintain and continue my link with the College and also to participate and contribute to surgical education and training for young and prospective surgeons. Since 2003 I have been a regular examiner for the College and was a Member of Council in 2003 for one year. I was also invited faculty at the quincentenary celebrations in 2005.

I will make sincere efforts to further the interests of the College and to organise meetings in India.

John Duncan I am a consultant general and vascular surgeon at Raigmore Hospital and the director of undergraduate teaching for the University of Aberdeen in Inverness.

For the last 13 years we have undertaken aortic aneurysm screening in the Highlands and I am now the clinical lead for aneurysm screening in the Highland and Western Isles within the Scottish National Screening Programme.

I trained in Aberdeen, Inverness and Sheffield and did a research year in Boston.

It has been a privilege to serve as an Office Bearer in the College, first as Honorary Secretary for two years and then Honorary Treasurer for five years.

I have been editor of Surgeons’ News for the past six years and am a director of Surgeons’ Lodge Ltd, the company which runs the hotel and events business for the College. It was an honour to be elected to Council and I am eager to contribute to the ongoing work of the College.

EDUCATION AND EXAMINATIONS Gerald McGarry Convener of Education and Wade Professor of Surgical Studies I became consultant ENT surgeon in Glasgow Royal Infirmary in 1995, specialising in head and neck surgery, endoscopic management of sinonasal tumours and endoscopic anterior skullbase surgery. I am active in clinical research and surgical education in the UK and worldwide and have designed numerous courses, including Advanced Endoscopic Sinus Surgery (RCSEd). Previous responsibilities include membership of the ENT SAB, RCSEd representative to the Digital Design Studio and chair of the SSG in otolaryngology. Other posts held include lead cancer clinician for WoScan Head and Neck Cancer Network, clinical director for ENT Greater Glasgow and Clyde NHS, and team leader for GMC Performance Procedures.

I see my appointment to this College position as a great opportunity to develop further the excellent programme of high-quality educational provision. The expansion of College activities throughout the world and the rapidly changing way we deliver educational resource makes this a most exciting time to be involved in surgical education.

I look forward to working with Fellows and Members who form the ‘Corps of Educators’, designing and delivering RCSEd-badged educational events and materials.

Simon Frostick I qualified from Oxford in 1978 and underwent training in Oxford and Nottingham. In 1995, I was appointed professor of orthopaedics in Liverpool and I am honorary consultant at Royal Liverpool and Broadgreen University Hospitals NHS Trust.

I stood for election to Council because there is a lot of work to be done in improving postgraduate medical education both in the UK and overseas. Being a Member of Council will enable me to influence the College’s policy in regard to training surgeons.

The Edinburgh College has a long tradition of engaging with overseas surgeons and my experience and expertise gained in collaboration with a number of countries will help to bolster the College’s international standing.

In 2013, I became an adviser to the College on international curriculum development and hope to bring to Council my experience and knowledge as a practising clinician with an international reputation as a shoulder and elbow surgeon.

Being a surgeon still remains exciting and challenging.

I will always bring enthusiasm and the intention to get things done.

Peter McCollum Convener of Examinations After graduating from medical school in Dublin, my training included posts in Dundee and Sydney. I was consultant vascular surgeon and honorary senior lecturer for Dundee’s Ninewells Hospital from 1990 to 1997, and then appointed foundation professor of vascular surgery and honorary consultant vascular surgeon for Hull and East Yorkshire Hospitals NHS Trust. I was also associate medical director for Hull and East Yorkshire from 2001 to 2006 and am currently serving as director of clinical effectiveness.

My main clinical interests are complex aortic aneurysm surgery and carotid surgery.

I have been an examiner in postgraduate surgery since 1988 and have examined in the old FRCSI and FRCSEd part 1 and 2 and the MRCSEd (OCC) exams. I have been involved in the MRCS OSCE since its inception. I have been an examiner in the intercollegiate FRCS exam since 2003 and was in the first overseas diet of this exam last year.

As a college, I believe we need to deliver on education as well as assessment. Assessment drives learning but we must provide the resource as a college, both for candidates and examiners in the UK and overseas.

www.rcsed.ac.uk | 15

AGENDA

SURGICAL SAFETY UPDATE More cases from the Confidential Reporting System for Surgery RUPTURED ECTOPIC PREGNANCY

As the general surgery registrar, I was called to the emergency department by the on-call orthopaedic senior house officer (SHO) covering gynaecology and orthopaedics to see a 38-year-old female with a positive pregnancy test and lower abdominal pain. I was told that the patient was haemodynamically stable. The SHO had discussed the patient with the on-call gynaecology consultant, who had requested surgical review to rule out appendicitis before seeing the patient.

When I saw the patient at 2.30am she was in a side room in the Minors section of the emergency department, with a blood pressure of 50/38. She had no IV access and was pale and dizzy, having been admitted at 9pm.

Since admission she had experienced lower abdominal pain, distension and a number of syncopal episodes.

I transferred her immediately to the resuscitation bay, gained IV access, administered fluids, cross-matched four units of blood and inserted a catheter. Her blood pressure recovered transiently to a systolic pressure of 117mmHg before falling to around 70mmHg, with a tachycardia of 90–150 bpm. I contacted the gynaecology SHO and asked him to see the patient and to discuss this case with his consultant.

The gynaecology consultant eventually attended and obtained consent from the patient for emergency laparotomy, subsequently undertaking a right salpingectomy for a ruptured ectopic pregnancy.

The patient had 5 litres of blood in her pelvis. Postoperatively she made an uncomplicated recovery.

Reporter’s comments

The covering SHO had not been trained in cross-specialty cover and failed to recognise a critically unwell patient with clinical signs of a classical gynaecological emergency. ED staff also neglected to flag up grossly abnormal observations to other medical staff. Trainees covering specialties other than their own, in an on-call capacity, should be given adequate training in advance.

16 | Surgeons’ News | December 2014

CORESS comments

With the introduction of shift systems, inadequate exposure of trainees to emergency cases and reduced staffing at night, specialty cross-cover in hospitals may become dysfunctional. The patient in this case presented with classic progressive signs of hypovolaemic shock, and symptoms that should have alerted admitting clinicians to the possible diagnosis of ruptured ectopic pregnancy. A concomitant feature of this report is the element of patient ‘ping-pong’, in which no senior clinician, including emergency department staff, appeared to take responsibility for the patient until she had deteriorated significantly. Trusts should provide adequate training and induction for trainees cross-covering other specialties, together with clear mechanisms of expediting senior review for prioritised cases. The Association of Surgeons in Training (ASiT) has published Consensus Recommendations on Emergency Cross-Cover of Surgical Specialties1, and reports significant demand for their recently convened courses on cross-cover emergencies (www.asit.org/events/courses/ECC).

‘BEAR TRAP’ BITES BACK

A young woman was admitted electively for endoscopy and fitting of an ‘over the scope’ clip (OTSC) to manage a leaking percutaneous gastrostomy site, under the care of a gastroenterology team. An experienced registrar performed the procedure and the clip was deployed under direct vision. However, upon trying to remove the endoscope it became stuck, seemingly at the upper oesophagus. The endoscope was advanced into the stomach again and it was noted that the clip had deployed onto the scope rather than in a forward direction onto the PEG site as intended. A consultant took over the procedure but was unable to dislodge the clip from the endoscope or to remove the endoscope.

A second endoscope was passed and the complication was confirmed. The general surgeon on call was summoned and performed an upper midline laparotomy to remove the clip. The endoscope could be removed

only by cutting off the end with a hacksaw and cutters.

The ENT surgeon on call attended to assess the oesophagus and found a deep laceration in the cricopharyngeus muscle. The oesophageal laceration was managed conservatively and the patient recovered after an extended hospital stay.

Reporter’s comments

This was an equipment malfunction. None of the team had encountered this complication previously. In using OTSCs for the management of enterocutaneous fistulae, the complication of deployment onto the endoscope can occur.

CORESS comments

The OTSC is a clip made of shape-memory nitinol alloy used to close fistulae, perforations, anastomotic leaks, and to seal bleeding vessels2, 3 in the GI tract. The clip is mounted onto a silicone cap (similar to a band ligation device), placed onto the tip of an endoscope, and applied by stretching a wire by means of a hand-wheel installed on the entrance of the endoscopic working channel. When the clip is released from the applicator, it closes because of the ‘shape-memory’ effect and the high elasticity of the nitinol alloy, thereby occluding the defect. This is similar to a ‘bear-trap’ closure mechanism and applies a permanent force to tissues. During introduction of the scope, migration (retraction) of the hood can occur2. The operator should ensure that appropriate deployment and visualisation of the clip has taken place before the endoscope is withdrawn.

THINGS CAN GO WRONG WHEN A PATIENT SAYS ‘YES’

During an ophthalmology outpatient laser clinic, a patient came to my clinic room who wasn’t the

patient I had actually called. I think she must have misheard the name. We discussed the scheduled treatment (laser iridotomy), she signed a consent form with the other patient’s sticker at the top, and I performed YAG laser iridotomies on her. Unfortunately, the patient I treated had been listed for selective laser trabeculoplasty, and so she ended up having the wrong laser procedure.

I did not check her date of birth, and the patient had answered “Yes” when I asked her if she was Mrs X. Soon afterwards, I realised what I had done – I immediately told the patient what had happened and notified this event to my Trust as a Serious Untoward Incident. Thankfully, no harm was done.

CORESS comments

This case illustrates the dangers of ‘passive’ identification of patients. It is easy for a patient to mishear a question and then inadvertently agree with the clinician. This problem would not have occurred if the clinician had actively followed the principles of the WHO pre-operative checklist. Patients should be asked to state their name, as well as other facts, such as their date of birth, address, planned procedure and side to be treated.

This principle applies to many other situations in medicine and surgery. Positive identification of the patient, procedure, and side to be operated on is also vital in many other situations, including ordering and interpretation of tests.

CORESS is grateful to the clinicians who have provided the material for these reports.

The online reporting form can be found at www. coress.org.uk Published contributions will be acknowledged by a Certificate of Contribution, which may be included in the contributor’s record of continuing professional development or appraisal.

Frank CT Smith Programme Director on behalf of the CORESS Advisory Board www.coress.org.uk

1 Emergency cross-cover of surgical specialties: consensus recommendations by the Association of Surgeons in Training. Int J Surg 2013; 11: 584–588.

2 Diagnostic and Therapeutic Endoscopy Volume 2013 (2013), Article ID 381873 http://dx.doi.org/10.1155/2013/381873.

3 Gut 2013; 62: A145 DOI: 10.1136/gutjnl-2013-304907.326.

www.rcsed.ac.uk | 17

AGENDA

The latest guidelines, articles and studies

IN BRIEF HOSPITAL READMISSIONS: NECESSARY EVIL OR PREVENTABLE TARGET FOR QUALITY IMPROVEMENT?

This retrospective review evaluated readmission rates and associated factors to identify potentially preventable readmissions for 2,517,886 patients hospitalised for cancer treatment.

Readmission rates at 7, 14 and 30 days were 2.2%, 3.7% and 5.6%, respectively.

Only a minority was readmitted with potentially preventable conditions such as nausea, vomiting, dehydration and pain. In addition, high-volume centres and designated cancer centres had higher readmission rates.

Authors concluded that readmission rates may not be an appropriate marker for quality improvement.

Brown E, Burgess D, Li CS, Canter R, Bold R. Ann Surg 2014; 260(4): 583–9

IMPACT OF FAECAL OCCULT BLOOD TEST SCREENING ON EMERGENCY ADMISSIONS AND SHORT-TERM OUTCOMES FOR COLORECTAL CANCER

This study compared 2,981 patients in the Scottish arm of the UK pilot of FOBT who had CRC with 9,842 other patients diagnosed with CRC in the same time period. Comparing participants with controls, there were fewer emergency admissions (OR 0·59) and shorter lengths of stay in hospital. Short-term mortality was lower in the screened than the nonscreened population. The impact of FOBT participation on emergency admissions was independent of deprivation level.

Libby G, Brewster DH, Steele RJC. Br J Surg 2014; 101(12): 1607–15

COST-EFFECTIVENESS OF TREATMENT FOR PRIMARY VARICOSE VEINS FROM THE RANDOMISED CLASS TRIAL

This study evaluated the cost-

18 | Surgeons’ News | December 2014

effectiveness of ultrasound-guided foam sclerotherapy (UGFS) and endovenous laser ablation (EVLA) compared with conventional surgery as treatment for primary varicose veins. Compared with surgery at six months, UGFS and EVLA reduced mean costs to the health service by £655 and £160 respectively.

UGFS produced 0.005 fewer QALYs, whereas EVLA produced 0.011 additional QALYs. Authors concluded that for patients considered eligible for all treatment options, EVLA has the highest probability of being cost-effective.

Tassie E, Scotland G, Brittenden J, et al.

Br J Surg 2014; 101(12): 1532–40

COST ANALYSIS OF INTERNAL FIXATION VERSUS NONOPERATIVE TREATMENT IN ADULT MID-SHAFT CLAVICLE FRACTURES

This study evaluated four randomised trials comparing operative and nonoperative treatment for displaced, mid-shaft clavicle fractures in adults. A decision tree was then created using reoperation for those treated with surgery or delayed operative treatment for those treated non-operatively as endpoints. The expected costs for operative and nonoperative treatment were $14,763.21 and $3,112.65 respectively.

Authors concluded that initial nonoperative treatment of mid-shaft clavicle fractures followed by delayed surgery as needed is less costly than initial operative fixation.

Walton B, Meijer K, Melancon K. J Orthop Trauma 2014

PERIOPERATIVE BETABLOCKERS FOR PREVENTING SURGERY-RELATED MORTALITY AND MORBIDITY

This study reviewed 89 randomised trials of perioperative beta-blockers

for prevention of surgery-related mortality and morbidity. Authors found the application of beta-blockers has a role in cardiac surgery because they reduce supraventricular and ventricular arrhythmias after surgery. Their influence on mortality, AMI, stroke, heart failure, hypotension and bradycardia was unclear. In non-cardiac surgery, evidence from trials with a low risk of bias showed an increase in all-cause mortality and stroke with the use of beta-blockers.

The substantial reduction in supraventricular arrhythmias and AMI in this setting was offset by the increase in mortality and stroke.

Authors stated that more evidence is needed before a definitive conclusion can be drawn.

Blessberger H, Kammler J, Domanovits H, et al. Cochrane Database Syst Rev 2014

EFFECT OF A PERIOPERATIVE, CARDIAC OUTPUT-GUIDED HAEMODYNAMIC THERAPY ALGORITHM ON OUTCOMES FOLLOWING MAJOR GASTROINTESTINAL SURGERY: A RANDOMISED CLINICAL TRIAL

This trial randomised 734 highrisk patients undergoing major gastrointestinal surgery to a cardiac output-guided haemodynamic therapy algorithm for intravenous fluid and inotrope (dopexamine) infusion during and six hours following surgery (n=368) or to usual care (n=366).

There was no difference between groups in a composite outcome of complications and 30-day mortality.

However, authors found that inclusion of these data in an updated metaanalysis indicated that the intervention was associated with a reduction in complication rates.

Pearse RM, Harrison DA, MacDonald N, et al. JAMA 2014; 311(21): 2181–90

RCSED TO HOST WORLD CARDIOTHORACIC CONGRESS

T

he College will be hosting the 25th World Cardiothoracic Congress in September 2015.

The 25th anniversary meeting will be a celebration congress and will have as its theme ‘Remembering History, Understanding Recent Advances’. There will be a plethora of postgraduate educational symposia covering a wide range of topics from the entire spectrum of cardiac and thoracic surgery. Delegates will have free access to all postgraduate lectures.

RCSEd President Ian Ritchie said: “History is everywhere evident in the Royal College of Surgeons of Edinburgh. It is well said that unless we learn the lessons of history, we will be doomed to repeat its mistakes. Cardiothoracic surgery has led the way for the surgical community in dealing with the problems relating to mistakes and in this College we celebrate the activities of your community as we look forward to the future.”

In addition to hosting the event, the College’s commercial events team will manage the programme, logistics, sponsorship and abstract submissions (which will open in January 2015). There will be special sessions for allied health professionals, including nurses, perfusionists, surgical care practitioners, and surgical assistants. Up to 28 CPD points will be available to delegates.

In selecting the College as the host venue, Congress chairman Vipin Zamvar (pictured below) commented: “The location of this meeting couldn’t be more suited as the Royal College of Surgeons of Edinburgh will have been in existence for over 510 years at the time of the Congress and its membership remains as committed to excellence and innovation in surgical practice as those who have gone before us.”

The Cardiothoracic Congress is expected to attract up to 600 delegates and runs 19–22 September 2015. www.WSCTS2015.org

Review On the centenary of the start of WWI, we assess this military medicine tome

Wars, Pestilence and the Surgeon’s Blade: The Evolution of British Military Medicine and Surgery During the Nineteenth Century Thomas Scotland and Steven Heys (Eds) Helion & Company, 2014

ISBN 978-1909384095

£34.95

The motivation to buy one book rather than another is complex. Many of us make selections based on the author.

Have we enjoyed their previous work? Having enjoyed the previous book by Tom Scotland and Steve Heys about the development of the medical services treating casualties in the First World War, I looked forward to reading this one. I was not disappointed.

The previous book, War Surgery 1914–1918, is fascinating, gets a five-star rating on Amazon and I see is now available in paperback and for the Kindle. Their most recent book maintains this high standard and expands the subject of the development of medical services for war casualties by examining their development from the Peninsular War up to the beginning of the First World War. As well as all of the conflicts involving British forces over this period, it includes the developments in medical care by other countries, examining the American Civil War, the Franco-Prussian War, and Russo-Japanese War. As Mike Stewart says in the foreword, the theme which repeats itself is the failure to learn from the hard-fought lessons of successive conflicts, including those of other countries. The consequence was that at the beginning of the next war, innumerable soldiers were denied the standards of care received by those at the end of the previous conflict.

Anyone with an interest in medical history, or military history, will be interested in this fascinating book. A great Christmas present – add it to your wish list.

Thomas Scotland will be speaking at the Royal Australasian College of Surgeons Annual Scientific Congress, being held jointly with RCSEd, 4–8 May 2015, Perth, Western Australia.

For details, see page 33.

John Duncan

www.rcsed.ac.uk | 19

AGENDA

THE PRESIDENT WRITES Ian Ritchie provides his final update for the year

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oliticians direct healthcare policy and allocate budgets, but health service managers provide the mechanisms and infrastructure to allow healthcare to be delivered. Managers in the health service have a difficult job because they are subject to a degree of political control and micromanagement that is not found in other managerial roles. If that were not enough, they then have to contend with clinicians who may occasionally feel that they are better equipped to take on the management role, although they have had no formal training for it. It is no surprise, then, that medical managers do not stay in post for long, with the exception being the CEO who remains in one institution for more than five years.

On the other hand, consultants are part of the health service workforce who deliver care over a lifetime, extending up to and beyond 40 years of service. Thus, it is easy to see how conflict between managers and clinicians can arise.

However, the common objective is care of the patient – and it is worth remembering that whether we are a politician, a manager, a healthcare worker or a member of the public, we are all potential patients.

At a recent AoMRC policy day, Academy chair Terence Stephenson talked about a meeting he attended in a major hospital some years ago between the consultants and the hospital management where the debate was polarised into a ‘you and us’ confrontation. It took a manager to point out that the real issue is about all of us, working together to solve the problems of the NHS. No one group can provide all the solutions. It requires mutual respect to be shown by all parties and a willingness to engage in discussing the problems and offering solutions. An added dimension in the immediate future is that there will be minimal additional resources to deal with the problems.

So when we face problems to do with queues of ambulances at a Welsh A&E, importing a doctor from India to do 48-hour

20 | Surgeons’ News | December 2014

shift in a Scottish hospital, concerns about overcrowded wards, multiple moves for patients, safari ward rounds and recent reports about failures of care for patients of all ages in the NHS, we must accept that we will have to set about finding the solutions to these problems from within our own resources and by thinking differently about how we deliver care.

Clearly, to do this, consultants will have to devote time to thinking about subjects that are not in their usual areas of responsibility or practice, and for which they have not necessarily had training or experience. That needs time. This is part of what sessions for Supporting Professional Activities (SPAs) are for, and a 9:1 contract is not enough to promote a culture of holistic problemsolving in the day-to-day delivery of patient care.

Anecdotally from colleagues, and from personal experience, I believe that the way we as consultants organise ourselves and the services for which we are responsible will have to change. It is no longer acceptable to have the on-call senior decisionmaker elsewhere in the hospital or at home when the need is for them to be in the workplace making the necessary and definitive decisions for patients. No consultant who turns up in hospital on a Friday night as a patient would accept the partial decision of a secondyear Foundation doctor about their care as a viable plan until midday on Monday when the consultant arrives. If it is acceptable for a doctor to get an immediate decision about their own care, then it should be similarly acceptable for all patients.

This will involve us as senior clinicians examining our working practices for the benefit of patient care. While this will be uncomfortable, I believe it will have benefits for patients, trainees, other professional colleagues and clinicians – ultimately to our personal satisfaction.

It is more efficient for all concerned and might result in reduced costs in the long term.

Implicit in that change in practice is the need for better access to diagnostic services.

Such changes also result in the virtuous coincidence of a trainer, trainee and patient being in the same place at the same time. This should mean that the trainee would benefit from a dialogue that will enhance their training and the trainer will be in a better position to deliver high-quality training. It will allow trainees to gain both competence and experience, but the quality of their training is ultimately not simply a question of when and how they are trained, but also the standards to which their trainers are accountable.

Despite all the challenges that face us in everyday work in the NHS, we do well to remember the points made by Sir Bruce Keogh when he spoke recently to a meeting of Fellows of the College at our Birmingham centre. He emphasised that the NHS does deliver a high level of care for the vast majority of patients, free at the point of delivery.

That is a better standard than is delivered in most of Europe and in the US. We should be proud of our collective achievements, but we should not be shy of facing the challenges that inevitably arise. I believe in the NHS and I believe in the ability of surgeons to move with the times and create exceptional solutions to difficult problems.

One such solution is the Standards for Surgical Trainers document published by the College and launched by Sir Bruce at our Birmingham centre. It is a landmark in the evolution of surgical training and gives trainers a framework of excellence that has not existed anywhere before. The Faculty of Surgical Trainers is

I believe in the NHS and I believe in the ability of surgeons to move with the times and create exceptional solutions to difficult problems

The problems of the NHS are best dealt with by managers and clinicians working together

very successfully influencing the training agenda for the benefit of both trainers and trainees. Surgeons across the world now have access to a single and eminently usable template to allow them to record their training activity so that they can prove they are effective. In addition, the standards acknowledge that excellence in surgical training and the role of surgical trainer itself must be fully and formally recognised. Importantly, the GMC has recognised the value of this in advance of its plans to accredit all trainers in 2016.

Sir Bruce Keogh has commended the FST’s development of these standards as providing evidence that the profession can adapt and drive forward change to deliver tangible improvements to our health service. I believe that we must all commit to doing the same.

Ian Ritchie president@rcsed.ac.uk

www.rcsed.ac.uk | 21

TRAINING STANDARDS

FRAMEWORK FOR EXCELLENCE The Faculty of Surgical Trainers (FST) has published new standards, setting out the criteria for training excellence in the health service

A

s surgeons, we are all aware of how important good surgical training is to the quality and safety of the care we can deliver for the benefit of our future patients. While we still recognise Dr William Halsted’s maxim “See one, Do one, Teach one”, I am sure we all now realise that this paradigm is no longer fit for purpose in our modern NHS. Shorter working hours and more fragmented working patterns have decreased the face-toface time we once had with our trainees.

We must now strive to provide highquality training in less time and in a far more distributed environment than before. This shift is not unique to surgical practice, and affects medical education and training as a whole, but surgery feels these changes most acutely because it is a craft specialty with a breadth of knowledge, skills and attitudes.

This can only mean increased dependence on the already vital role of the surgical trainer to provide high-quality training. Time, financial and service pressures are often seen to erode time set aside for training, and this will no longer be acceptable if we are to continue to produce highly trained and safe surgeons. We now need to ensure that all time with trainees is effective training time.

To date, there has been no stipulation of the standard needed to become a surgical trainer, and no in-depth description of what an effective surgical trainer should do. There has been no single recognised route into becoming a surgical trainer, and indeed most surgeons expect to become trainers upon appointment. This situation differs in primary care, in which there is a rigorous selection and training process to be recognised as a GP trainer. This means that

our colleagues in primary care are able to ensure that training remains of the highest quality. It also means that GP trainers are properly recognised and remunerated for their role, whereas in surgery the training role is rarely rewarded.

This situation is set to change from 2016: the GMC has stipulated that all those in secondary care with a named training role will need to be recognised and approved.

This GMC process of trainer recognition will entail demonstrating your activity as a trainer. The GMC has chosen a framework originally devised by the Academy of Medical Educators (AoME). This framework consists of seven domains in the field of education and training. Each domain has descriptors of what an effective and an excellent clinical or educational supervisor should be doing. While these domains are basically sound, they lack a surgical context and do not accurately reflect real-life surgical training practices. These domains will be used to ensure that you carry out your job as a trainer effectively.

As a Faculty we support wholeheartedly developments to protect and enhance the high quality of surgical training. The GMC process to recognise and approve trainers has the potential to drive an increase in such quality, and also potentially to reward dedicated surgical trainers by giving them increased recognition for this important role. Until now there has not been a standard set for what defines an effective surgical trainer, or any descriptor of what an effective surgical trainer actually does. This process needs to avoid

Until now there has not been a standard set for what defines an effective surgical trainer, or any descriptor of what an effective surgical trainer actually does 22 | Surgeons’ News | December 2014

Standards for Surgical Trainers FRAMEWORK AREA 1: Ensuring safe and effective patient care through training As a trainer you demonstrate the highest standards of safe surgical care, and are able to incorporate high-quality training into your care delivery.

FRAMEWORK AREA 2: Establishing and maintaining an environment for learning As a trainer you are able to identify and use a wide variety of learning opportunities and promote a culture of learning within your unit.

FRAMEWORK AREA 3: Teaching and facilitating learning As a trainer you plan and implement suitable learning and training activities for all your trainees.

FRAMEWORK AREA 4: Enhancing learning through assessment As a trainer you are able to use available

assessment tools to assess and progress your trainee’s performance in all aspects of surgical care.

FRAMEWORK AREA 5: Supporting and monitoring educational progress As a trainer you are able to set appropriate goals and review your trainee’s progress in regard to these goals and the agreed curriculum.

Standards for Surgical Traine rs MR CRAIG MCILHENNY AND MR DAVID PITTS on behalf of the FACULTY OF SURGICAL TRAINERS

FRAMEWORK AREA 6: Guiding personal and professional development As a trainer you are able to act as a role model and source of guidance in the wider sphere of professionalism in the surgical workforce.

FRAMEWORK AREA 7: Continuing professional development as a trainer As a surgical trainer you continuously review and enhance your own performance as a trainer.

becoming an administrative burden on the trainer, and the AoME domains do not really reflect current surgical training practice. The Faculty has, therefore, adapted the existing standards and rewritten them with the surgical trainer in mind. Rather than a simple and superficial rewrite, an in-depth process of analysis and adaptation has been carried out and resulted in the Standards for Surgical Trainers (see above).

Retention of the original domain headings has ensured that this process will satisfy the GMC trainer-approval process. This adaptation process has also taken care to accurately depict what an effective surgical trainer actually does in their day-to-day training job. The FST has compiled detailed and multiple sources of evidence that can be used to demonstrate that a trainer meets the

GMC trainer-approval standard. Throughout this process, emphasis was placed on being practical and not forcing onerous paperwork on the trainer.

Although the original domain headings and the concept of the effective and excellent trainer were retained, all the descriptors were altered to ensure that they reflect real-world surgical training practice. These descriptors all describe behaviours that any surgical trainer would recognise and would carry out in their training role. For each descriptor, the Faculty spent time detailing a list of sources of possible evidence that could be used by trainers to prove they satisfy that particular descriptor and can map to that domain.

A complex list of descriptors was drawn up for each domain, and then was distilled into a smaller set of behaviours that were indicative of effective surgical training. This forms our Standards for Surgical Trainers. This document will make it easier for surgical trainers to fulfil the GMC trainer-approval process. While the Faculty welcomes efforts to enhance the quality of training, it is important to ensure that dedicated trainers do not relinquish their training role in light of this impending legislation. The production of a dedicated set of standards for a surgical trainer, rather than the generic AoME standards, should help support surgeons to remain as recognised trainers. www.rcsed.ac.uk | 23

TRAINING STANDARDS

Voices from across the profession give their views on the importance of clear guidance for trainers

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he launch of the Faculty of Surgical Trainers’ (FST) standards and GMC accreditation of trainers will have ramifications across the profession – from training programmes, to CPD and daily clinical practice. We spoke to representatives from different sides of training about what the standards can offer in an era when both time and financial pressures on the NHS seem to be greater than ever.

“The pressures of today’s NHS, which include a disintegration of the surgical firm, increased complexity in patient care, a fall in operating time, and shift patterns of working, mean there has never been a more critical point for surgeons in training to have appropriate and effective mentorship, guidance and teaching,” comments Richard McGregor, chair of the College’s Trainees’ Committee and RCSEd Trainee Representative on Council.

Mr McGregor continues, “The NHS comprises many gifted surgeons, yet teaching surgery to others requires an entirely different aptitude and skill set. Effective mentoring of the surgical workforce of tomorrow throughout their critical period of learning will protect and promote high levels of patient care and safety in our shared future.”

The UK’s largest trainee body, ASiT, welcomes the fact that the standards have been developed in consultation with trainees, who they see as having a crucial role in the improvement of standards. They believe trainee feedback is vital to this, along with trainers and trainees collaborating on initiatives that allow more time for training.

Mr Bill Allum, surgical director of the Intercollegiate Surgical Curriculum Programme (ISCP), agrees that trainee feedback is vital to improve training, adding that quality is founded on clarity in the maintenance and development of teaching skills. Here, he believes the FST has succeeded in

STAND UP F

With finite resources within the NHS it is important that both time and money are not wasted on trainers who are not going to provide quality training. The formalised set of standards provides trusts with the ability to determine who is providing such training and who is not 24 | Surgeons’ News | December 2014

defining what is expected of surgeons who wish to provide training and that the integration of the standards into parts of the ISCP would support trainers by providing a resource for recording activity and a means of reflection to identify professional development needs.

The prestigious Silver Scalpel Award is proof that exemplary training does exist and, of course, there are many very good surgeons who acknowledge that their strengths lie outside the provision of training. For Mr Steve Hornby, ASiT’s past president, defined standards are most relevant for two other groups in surgery: outstanding trainers who receive no recognition, support or remuneration, and those who take credit for training when in fact they offer very little. He said: “When excellent trainers can be supported both financially and in time in their job plan, then a rise in standards will naturally occur. However, with finite resources within the NHS, it is important that both time and money are not wasted on trainers who are not going to provide quality training. The formalised set of standards provides trusts with the ability to determine who is providing such training and who is not.”

He also cautions against too much rigidity in the interpretation of standards: “Superb trainers often find unique ways of providing training that are bespoke to their particular fields, patient communities and facilities.”

Moving on to how the standards can be implemented in practice, those at ASiT believe that NHS trusts will be able to use the frameworks to determine with whom trainees are placed and who is remunerated for training.

However, they stress the importance of NHS trusts allowing enough time within job plans to enable highquality training.

FOR STANDARDS David Pitts worked with a dedicated group on creating Standards for Surgical Trainers. He explains the two-year process to publication

Writing the rules on quality

IN MARCH 2012 the GMC published its generic Standards for Trainers document, based on an earlier publication from the Academy of Medical Educators.

Contained within that was the request that specialties review and adapt the standards for their own communities.

The FST responded by forming a working group to review the standards. The results of our efforts over the last two years have now been published and welcomed by the GMC.

IDENTIFYING THE NEED FOR CHANGE

The group was committed to keeping the major framework domains to maintain compatibility with other

specialties. Our review found four major areas where the elements supporting those domains needed attention: • Rephrasing in order to have meaning in a surgical context.

• Replacement of items inapplicable to surgical training.

• Additions of important surgical training elements not already in the document.

• Adaptation of elements that could not be assessed or easily supported by evidence.

PRODUCING A DETAILED REVIEW

We broke down the original GMC standards into a table to identify all areas for editing.

We focused on establishing the practicability of the standards

in a surgical context with reference to language and assessability. Although the original standards made broad suggestions as to general sources of evidence, we identified specific measures necessary to generate evidence for all elements.

We believed that if evidence could not be found, then an element should be omitted or replaced.

IDENTIFYING EVIDENCE

With the eventual aim that the FST’s standards would form the basis for appraisal and accreditation, a detailed list of possible evidence was compiled. We replaced the original ‘broad brush’ references to evidence with a

detailed list linked to specific standards and mapped against the elements.

TRAINER’S JOURNAL

Having created a workable document and performed a background analysis, we produced an outline of evidence that would support the trainer in demonstrating that they had achieved the standards. This became the Trainer’s Journal, which describes a variety of evidence possibilities in addition to defining items considered essential or mandatory. The Trainer’s Journal is now an ongoing project to tackle the difficulties of evidence gathering, without which the standards will be impossible to implement.

www.rcsed.ac.uk | 25

TRAINING STANDARDS

The new surgical training standards from the College’s FST are vital to seven-day service innovation, writes Professor Sir Bruce Keogh

TIME TO INNOVATE

I

nitially conceived in 1940s America to respect Christian and Jewish practices, the weekend has been universally adopted in Western countries as protected personal time.

In the UK, challenges from high-street retailers resulted in a change to the Sunday trading law in 1994.

Since then, social behaviour has changed profoundly.

Public expectations of service provision for customer convenience have resulted in routine services being available seven days a week in many industries – but not healthcare.

This is a shame, as extending the service would offer the opportunity to improve clinical outcomes with the added benefit of offering a much more patientfocused service.

In the NHS we have offered essential emergency care, but not regular routine services on either Saturday or Sunday. Yet we have hard evidence that mortality for patients admitted to hospitals on both sides of the Atlantic is higher at weekends, that our junior doctors feel clinically exposed at weekends and hospital chief executives are worried about weekend cover.

This has led to calls for greater consultant presence at the weekend from Medical Education England, the Academy of Medical Royal Colleges, the Royal College of Physicians and Royal College of Surgeons.

It is important to have the debate about service configuration not because the profession is blind to it and should have change forced upon it, but because doctors recognise and understand the wider context in which we deliver healthcare. They are good at solving problems and are the natural leaders for clinical change.

The recently published Standards for Surgical Trainers from the RCSEd’s Faculty of Surgical Trainers (FST) are a fine example of this. They provide clear evidence that the profession can adapt in the right way, at the right time, driven by the right people – those who deliver our health service.

Put simply, the FST’s Standards for Surgical Trainers offer a solution to changing needs and expectations in the health service in a way that protects standards and patient care, and help facilitate broader changes such as NHS England’s seven-day services programme.

26 | Surgeons’ News | December 2014

Increasingly, surgical trainees no longer work under supervision from one consultant, as per the traditional ‘master and apprentice’ model, but more frequently work across different clinical teams. If it was not obvious before, this makes clear the importance of consultants who can provide training to the same standard. Standards for Surgical Trainers offer a way to achieve just this – continuity, security and consistency for today’s trainees.

Surgical training is unique in that it is mainly delivered in the critical setting of the operating theatre, where the surgical needs of the patient must always take precedence. Here, it is reassuring to see the FST has set out an expectation that effective trainers will plan and select the best training opportunities from across theatre lists and clinics.

A move towards seven-day services complements this in many ways: it will be easier to protect training time, it will be less pressured and surgical trainers will have more scope to select the best training opportunities for their trainees.

Accredited surgical trainers providing a service at the weekend will help junior doctors feel more supported and that they are not simply plugging service gaps. It will help junior doctors gain supervised experience that counts towards their professional development.

Seven-day services will provide a fuller picture of how trainers and trainees are performing as demands on the service fluctuate throughout the week. This, too, goes hand in hand with the FST’s aspirations to create a more robust and accountable training system.

It is also encouraging that the standards have been created with the efficient aim of keeping any added bureaucracy to a minimum, functioning more as a ‘roadmap’ for self-evaluation, accreditation and perhaps peer review.

The clinical, compassionate and patient convenience arguments in favour of moving to seven-day services are compelling. Initiatives such as Standards for Surgical Trainers show we can both adapt our health service to make it more patient focused and continue a drive towards ‘professionalisation’ in one of the most challenging areas of medical training.

Sir Bruce Keogh is Medical Director of the NHS in England and National Medical Director of the NHS Commissioning Board

Seven-day services will provide a fuller picture of how trainers and trainees are performing as demands on the service fluctuate throughout the week.

This, too, goes hand in hand with the FST’s aspirations to create a more robust and accountable training system

www.rcsed.ac.uk | 27

FST CONFERENCE

Professor Moya Kelly

Professor John Norcini

ASSESSMENT ISSUES

T

he Surgical Trainers’ meeting was opened

by RCSEd president Ian Ritchie, who introduced Professor John Norcini as the first keynote speaker of the well-attended event.

Professor Norcini is president and CEO of the Foundation for Advancement of International Medical Education and Research and is one of the world’s leading experts in workplace-based assessment (WBA).

Formative assessment in postgraduate medical education is vital and depends on the quality of feedback given to the trainee, said Professor Norcini. He addressed the issue of whether national training programmes improve the quality of care; reassuringly, the evidence suggests that they do.

Chair of the Intercollegiate Surgical Curriculum Programme (ISCP) Professor Bill Allum discussed the state of trainee assessment in the UK, concentrating on data from the ISCP website. This provided an insight into the current usage of the ISCP and highlighted that,

Surgeons are gaining increasing awareness of the importance of non-technical skills in ensuring good outcomes, but they are rarely formally taught or assessed in the UK 28 | Surgeons’ News | December 2014

‘Assessment drives learning’ was a key message at the Faculty of Surgical Trainers’ conference ‘Who Makes the Cut? Assessment in Surgical Training’, held in Edinburgh on 22 October although engagement with the ISCP portfolio has increased over time, the quality of assessments and reports remains variable.

The evidence behind WBA tools and how they have become more valid was picked up by Jonathan Beard, RCSEng professor of surgical education. Professor Beard highlighted the difference between formative and summative assessment, stressing that surgeons tend to see all assessment as a ‘test’, emphasising the need to improve the use of WBAs as assessments for learning rather than as a test of learning.

The trainee perspective was provided by Mr Steve Hornby, an ST8 in upper GI surgery and past-president of the Association of Surgeons in Training. Mr Hornby highlighted that WBAs are like any other tool; it doesn’t matter how good a tool is – if it is used incorrectly it won’t work, and he hoped to see better trainer engagement with the process.

Captain Gordon Graham, Royal Navy, enthralled and captivated the audience with a high-tech presentation

Professor Jonathan Beard

Mr Steve Hornby

SLICED AND DICED on training in the military. He drew many parallels with training in surgery and put forward several interesting concepts that could be applied to surgical training and, in particular, how trainers are selected and trained. In the Navy, an officer’s aptitude for being a trainer is assessed from the moment they enter the service and those with skills in this area are selected and trained as trainers from the start. As a trainer himself, Captain Graham also said he could expect at any point that “someone with a clipboard” could turn up to any of his training events and assess his performance as a trainer. Both these points certainly gave the audience pause for thought when compared with our current system of selecting and assessing surgical trainers.

Our primary care colleagues have had a rigorous system in place for many years when it comes to selecting and assessing medical trainers. Professor Moya Kelly, director of postgraduate general practice education, gave an insight into this system and how it helps maintain the quality of GP education and training. Although the system of trainer selection in general practice could be seen as onerous and being a GP trainer involves a significant workload, Professor Kelly pointed out that this was not seen as a barrier to GPs wishing to train – an important point to remember as surgeons move towards a system of trainer recognition and approval by the GMC. The meeting moved back into the surgical domain with an examination of what impending GMC trainer recognition and approval might mean for surgical trainers. Mr David Pitts, senior education adviser to RCSEd, illustrated what the process of assessing a

surgical trainer could look like and previewed the FST’s Standards for Surgical Trainers.

The differences between the primary care system and surgical training were highlighted by consultant colorectal surgeon Mr Humphrey Scott, who concluded with a plea for a system where all trainers are adequately trained and assessed to ensure that they can be properly accredited and rewarded.

The second keynote lecture came from Harvard’s Dr Steven Yule, who explained that surgeons are gaining increasing awareness of the importance of non-technical skills in ensuring good outcomes, but that they are rarely formally taught or assessed in the UK. At Boston’s Brigham and Women’s Hospital, Dr Yule and his team have embedded non-technical skills training and assessment into the surgical curriculum.

His key message that we are most likely to underperform as surgeons in areas in which we do not formally train or assess was a powerful argument for more explicit incorporation of non-technical skills training and assessment into UK surgical curricula.

Congratulations to Vairavan Narayanan, winner of the oral presentation prize, for his presentation ‘Standardised operative skills assessment with custom printed 3D models’ and to Aphrodite Lacovidou, who took the best poster prize for ‘A novel tonsillectomy simulator: using silicone to train future surgeons’.

SAVE THE DATE! The 2015 FST conference will be held in Birmingham on 22 October on the topic of ‘Achieving excellence in surgical training’

Visit fst.rcsed.ac.uk for more on this year’s conference www.rcsed.ac.uk | 29

HISTORY

BLOOD BROTHER Chronicling the work of Canadian surgeon Norman Bethune who travelled to Spain in the 1930s to help in the fight against fascism

N

orman Bethune FRCSEd (1890–1939) was the Canadian surgeon whose political and humanitarian convictions led him to join the Spanish Civil War, on the side of the Republican (Loyalist) forces in 1936. In Bethune in Spain, authors Roderick Stewart and Jesús Majada describe how Bethune became deeply involved in the anti-fascist effort and chronicled events through his writings and talks. The following excerpts, taken from Bethune’s own letters and reports, cover his creation and operation of a blood transfusion service, the commitment of the International Brigades and the rescue of fleeing Loyalist civilians during the Málaga– Almeria road tragedy.

THROUGH THE PRESS AND OVER THE RADIO WE BROADCAST APPEALS FOR BLOOD DONORS. AS A RESULT WE HAVE THOUSANDS OF VOLUNTEERS AND ARE BUSY GROUPING AND CARD INDEXING THEM 30 | Surgeons’ News | December 2014

BETHUNE SHOWED GREAT DETERMINATION AND INNOVATION IN STARTING A BLOOD TRANSFUSION SERVICE FROM SCRATCH I will use the latest Russian-American methods of collecting blood, storing it at suitable temperatures in vacuum bottles and transmitting it to any hospital needing it within 25 miles. Three girls on eight-hour shifts are on the telephones. A card index of 500 voluntary blood donors (all must have Wasserman tests) are some other essentials.

Through the press and daily over the local radio we broadcast appeals for blood donors.

As a result we have thousands of volunteers and are busy grouping them and card indexing them.

We have now 800 and in a few days will have more than 1,000. There are about 56 hospitals in the city. We have surveyed the entire situation and have a list of them containing the information as to size, capacity, addresses, under what organisation, telephone, chief surgeon, type of service, etc.

A large map of the city (4 µ 5ft) in our office (the former library,

Norman Bethune, left, set up a blood transfusion service in Spain during its civil war and, right, with some of the people he volunteered with in his dangerous yet life-saving work

THEY LEFT THEIR WIVES AND FAMILIES AND IN THE PRIDE OF THEIR YOUNG STRENGTH AND POLITICAL CONVICTIONS, DIED UNDER THIS OLD SPANISH SUN, AMONG THE OLIVE TREES the walls entirely lined by 8,000 books, gold brocade curtains and Aubusson carpets!) gives at once the route to the hospitals.

ON 1 JANUARY 1937, BETHUNE GAVE A PASSIONATE RADIO BROADCAST DESCRIBING THE DEAD AND WOUNDED OF THE INTERNATIONAL BRIGADES These young men volunteered fully and they travelled, many in disguise, thousands of miles from their native lands, working their way out secretly to escape the police terrorism. They left their wives and families and in the pride of their young strength and fine political convictions, died under this old Spanish sun, on the bare hills, among the vines and olive trees of this beautiful land surrounded by people of whom not more than a handful could speak their own language, facing overwhelming odds of trained mercenary professional troops. Against a military machine dominated by German and Italian Staff Officers, fighting with rifles, some of them dating before the so-called Great War of 1914, against modern German and Italian machine guns, without steel helmets or proper clothing.

RUNNING A BLOOD TRANSFUSION SERVICE IN THE MIDST OF A CIVIL WAR WAS DIFFICULT AND HIGHLY RISKY Our night work is very eerie! We get a phone call for blood, snatch up our packed bag, take two bottles (each 500 c.c.) – one of group IV and one of group II blood – out of the refrigerator and with our armed guard off we go through the absolutely pitch dark streets and the guns and machine guns and rifle shots sound as if they are in the next block, although they are really half a mile away. Without lights we drive, stop at the hospital and with a search light in our hands find our way into the cellar principally. All the operating rooms in the hospitals have been moved into the basement www.rcsed.ac.uk | 31

HISTORY

to avoid falling shrapnel, bricks and stones coming through the operating room ceiling.

Then the proper blood is warmed in a pan of water and we are ready to start. The man is usually as white as the paper, mostly shocked, with an imperceptible pulse. He may be exsanguinated also and not so much shocked, but usually is both shocked and exsanguinated. We now inject novo-caine over the vein in the bend of the elbow, cut down and find the vein and insert a small glass canula, then run the blood in. The change in most cases is spectacular. We give him always 500 c.c. of preserved blood and sometimes more and follow it up with saline or 5% glucose solution.

The pulse can now be felt and his pale lips have some colour.

BETHUNE WAS INVOLVED IN THE DRAMATIC RESCUE OF 150,000 CIVILIANS TRAVELLING ON FOOT FROM MÁLAGA TO ALMERIA WHEN THOSE FLEEING CAME UNDER ATTACK FROM NATIONALIST FORCES Now imagine 150,000 men, women and children setting out for safety to the town situated more than 100 miles away.

There is only one road they can take.

There is no other way of escape. This road, bordered on one side by the high Sierra Nevada mountains and on the other by the sea, is cut into the side of the cliffs and climbs up and down from sea level to

Bethune in Spain Roderick Stewart and Jésus Majada McGill-Queen’s University Press, 2014

NORMAN BETHUNE, a Canadian of Scots descent, one of the most complex surgical figures of the 20th century and renowned to this day in China, was drawn to the Spanish Civil War to fight fascism. This book describes, often using his own words, how he established, from scratch and under constant bombardment, a mobile blood transfusion service serving the Republican wounded.

We are given a brief account of his early life, his active service in the First

32 | Surgeons’ News | December 2014

more than 500 feet. The city they must reach is Almeria, and it is more than 200 kilometers away. A strong, healthy young man can walk on foot 40 or 50 kilometers a day.

The journey these women, children and old people must face will take five days and five nights at least. There will be no food to be found in the villages, no trains, no buses to transport them. They must walk and as they walked, staggered and stumbled with cut, bruised feet along that flint, white road, the fascists bombed them from the air and fired at them from their ships at sea.

World War, his failed relationships, his artistic flair, his surgical training in Britain and the visit to Russia that convinced him to join the communist party and become a passionate advocate of socialised medicine.

He arrived in 1936 to a Madrid under siege by Franco’s army. Yet, seemingly because he didn’t speak Spanish, his offer to serve as an experienced thoracic surgeon was rejected by several hospitals and even by the International Brigades.

Undeterred and recognising the need, he bought and converted a station wagon, kitted it out with fridge, autoclave, grouping sets and donor kits to establish a mobile blood transfusion service. His service, initially supplying 56 hospitals in war-torn Madrid, expanded to serve a 1,000km front line serving around 100 hospitals

WE INJECT NOVO-CAINE OVER THE VEIN, AND INSERT A GLASS CANULA, THEN RUN THE BLOOD IN. THE CHANGE IS SPECTACULAR

and casualty clearing stations from Barcelona to Málaga.

It is a remarkable story of innovation and determination driven by passionately held political and humanitarian views. Stewart and Majada weave the narrative around Bethune’s first-hand account of a participant in the war, one who endured the privation and the bombing.

His graphic account of the attacks on the 150,000 refugees fleeing from Málaga is particularly poignant. This account of Bethune’s commitment to his beliefs, of his pioneering service established in the face of considerable odds, is an inspiring read for any doctor.

Iain Macintyre FRCSEd Copies of Bethune in Spain can be ordered from McGill-Queen’s University Press, www.mqup.ca

Call for Abstracts

Abstract deadline 30 January 2015

Flight discounts available from Qatar Airways

PHOTOGRAPH: DAVID TORRENCE

PRESIDENT’S MEETING

34 | Surgeons’ News | December 2014

MAPPING CANCER CARE Professor Timothy J Eberlein is an expert in the delivery of cancer care and has held surgical chairs at Harvard and now at Washington University. Here he speaks to Professor Robert Steele about the state of oncology services in a country as large and diverse as the USA What are the main challenges in providing uniformly high-quality cancer care across the US?

The main challenges are twofold. Physicians in the United States tend to be independent practitioners.

Adapting multidisciplinary care that is patient focused, and making recommendations with the patient’s best interest in mind, would improve quality. The second issue in the United States is access to cancer care. Patients without insurance or poor-quality insurance tend not to avail themselves of routine preventative care. They do not undergo screenings and, therefore, are more likely to present with more advanced cancer. Alleviation of these two issues would dramatically improve the quality of cancer care in the United States.

How does deprivation affect access to cancer care?

To use the state of Missouri as a surrogate, if one were to divide the state into counties and then perform a ‘heat map’ showing the mortality due to cancer of all types, one would see that four of the top six counties in the United States are located in Missouri. If one were to superimpose a map of food-stamp utilisation (a surrogate for deprivation and low income), the maps would almost match up. This emphasises the need for preventative care and intervention as well as education, communication and screening mechanisms.

How can you address escalating costs for cancer drugs?

This is becoming a major detriment to good cancer care. In the United States, the Centers for Medicare and Medicaid Services (CMS) are prohibited by law from negotiating best price to purchase pharmaceuticals, despite being the largest purchasers of pharmaceuticals in the world. It is also sad that the same drugs can be sold (for a profit) in Europe, Asia, and elsewhere at substantially reduced costs than the same drugs

sold in the United States. Obviously this is a multifaceted problem and very complex, but it needs to be addressed if we are to afford high-quality cancer care in the future.

What, in your opinion, are the main advances in breast cancer care in the last five years?

There have been remarkable advances. Clearly, imaging has improved dramatically. We are beginning to determine which group of patients may not even require sentinel lymph node biopsies. There have been a large number of systemic agents that have improved longevity in patients with breast cancer.

As we develop better expertise in genomics, we will begin to identify markers for specific treatments and, more importantly, markers for patients who will not require additional adjuvant therapies.

Professor Eberlein will deliver the McKeown Lecture at the President’s Meeting on 20 March 2015.

For details visit presmeeting. rcsed.ac.uk

How are the results of breast cancer treatment monitored in the US?

Several new ongoing initiatives are documenting the outcomes of breast cancer treatment. The National Surgical Quality Improvement Project as well as the National Comprehensive Cancer Network have ongoing programmes to track treatment interventions. This is supplemented by insurers and government agencies such as the UHC consortium and CMS. There are very tight regulations for all breast cancer treatment patients on clinical trials, with data safety monitoring and transparent reporting to the National Cancer Institute, the study sponsor and the FDA.

The Centers for Medicare and Medicaid Services are prohibited by law from negotiating best price to buy pharmaceuticals, despite being the largest purchasers in the world www.rcsed.ac.uk | 35

PAEDIATRICS

NEW KID ON THE BLOCK

Paediatric surgery is relatively new within the disciplines of surgery, developing in the UK in the middle third of the 20th century

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Alan Dickson Consultant Paediatric Urologist, Royal Manchester Children’s Hospital

pecialisation of surgery in children had a difficult road to recognition. Even the founder of the Great Ormond Street Hospital for Sick Children in 1852, Dr Charles West, had the view that “there were no surgical problems which demanded special skill or study”. How wrong he was, his own hospital eventually becoming one of the foremost internationally in advancing the surgical care of children and training surgeons for careers in paediatric surgery not just in the UK, but all over the world.

Scotland initiated the specialisation of children’s surgery in the UK. The Scottish children’s hospitals in Edinburgh, Glasgow and Aberdeen all appointed specialist surgeons for children in the late 19th century and the foundations were then laid for further developments.

The earliest surgeons in these hospitals, respectively, were Joseph Bell, Kennedy Dalziel and Sir Alexander Ogden. Thereafter, there was a long list of famous surgical names in these same hospitals, intent on establishing the specialty. Denis Browne, from Australia, was the founding figure for paediatric surgery in England, being appointed as consultant at Great Ormond Street in 1928.

36 | Surgeons’ News | December 201414

In spite of these steps in the right direction, surgery on children continued to be generally delivered by adult surgeons well into the 20th century. Children are obviously not just “small adults”, but it took some time for that view to be generally accepted within the surgical community and to eventually facilitate the development of surgeons expert in the pathophysiology of sick children as well as the delicate technical aspects of operating on tiny infants. Denis Browne, at Great Ormond Street, trained many surgeons, some of whom became the first generation of English paediatric surgeons, gradually appointed throughout the major children’s hospitals of England, including Liverpool, Manchester and Newcastle.

BAPS was the first international association of paediatric surgery in the world and has continued to maintain a leading position to this day

WHEN I GROW UP… Although not the most well covered specialty in undergraduate curricula, paediatric surgery attracts a healthy number of training-post applications

Isabella Forshall and Peter Rickham at Alder Hey Children’s Hospital in Liverpool were pioneers, whose work did much to establish paediatric surgery as a recognised branch of UK surgery. They initiated considerable advances in the surgical treatment of children, probably most importantly in 1953 with the foundation of the Liverpool Neonatal Surgical Centre, the first of its type in the UK. During the first six years of its activity, the mortality of infants with surgically treatable congenital abnormalities in the Liverpool region fell from 72% to 24%. Soon afterwards, the Ministry of Health published a report on surgery of the newborn that strongly recommended the establishment of similar units in all regions of the country.

Denis Browne, with other surgeons of his time, including Edinburgh’s JJ Mason Browne, was instrumental in founding the British Association of Paediatric Surgeons (BAPS) in 1953. BAPS was the first international association of paediatric surgery in the world and has continued to maintain a leading position to this day.

The primary aim of BAPS is to set the standards of care of paediatric surgical practice in the UK and Ireland.

BAPS, through the British Association of Paediatric Surgeons Congenital Anomalies Surveillance System (BAPSCASS), seeks to establish statistics and outcomes for congenital abnormalities in the UK.

AS IN other surgical specialties, some experience may be applicable to paediatric surgery from the Foundation period, but training starts seriously in core years. To be appointed to a national training number for ST3–ST8, applicants should have at least 24 months’ experience in surgery (not including Foundation modules, but including paediatric or neonatal critical care) by time of appointment, which must include a minimum of six months’ experience in paediatric surgery and six months’ experience in general surgery1.

The MRCS examination would be passed during the core years.

Appointment to the training programme is through a national centralised process and successful applicants will be able to demonstrate competencies to a level at least commensurate with the totality of their period of training. Assessment at the recruitment event includes aptitude testing for practical skills and good manual dexterity.

Successful applicants will usually have evidence of significant academic achievement.

Training in the British Isles is organised in groups of university hospitals, known as training consortia. There are five consortia in the UK: Scotland: Glasgow, Edinburgh and Aberdeen Northwest England: Liverpool and Manchester East of England: Newcastle, Leeds, Sheffield, Nottingham and Leicester Southeast England: London hospitals, Norwich, Cambridge, Brighton and Southampton (this consortium holds half of UK trainees) Southwest England: Birmingham, Bristol and Cardiff Ireland: Belfast and Dublin are

standalone training centres but trainees are required to obtain a period of training in another centre.

During the six ST years, trainees are rotated through at least two centres in their consortium. All will have the opportunity to be trained across the spectrum of paediatric surgery, including gastrointestinal surgery, oncology, thoracic, urology and neonatal.

Following successful training and ARCP outcomes through to ST6, trainees will take the FRCS Paediatric Surgery in ST7/ST8.

During the training programme, some trainees can, with approval, take out of programme clinical

Specialty trainees have the opportunity to be trained across the spectrum of paediatric surgery, including gastrointestinal surgery, oncology, thoracic, urology and neonatal experience (OOPE) or out of programme experience for training (OOPT). These possibilities allow trainees to go overseas or develop focused areas of interest within the specialty. Trainees are required to develop a portfolio of audits, courses, research presentations and publications as well as operative and work-based assessment records.

REFERENCE

1. http://specialtytraining.hee.nhs.uk/ files/2013/03/2015-PS-Paediatric Surgery-ST3-1-01.pdf

www.rcsed.ac.uk | 37

PAEDIATRICS

ACROSS THE BOARD

From babies weighing 400g to young adults with ongoing chronic conditions, paediatric surgeons operate on children of all ages with a range of needs

P

aediatric surgery includes several clearly identifiable areas: general and gastrointestinal, oncology, thoracic, urology and neonatal surgery.

Table 1 lists sample conditions in each area to illustrate the breadth of diseases covered by paediatric surgery. In the last 10 years or so, there has been a gradual drift towards subspecialisation.

This has occurred to allow concentration of interest and to facilitate research, but mainly to allow specialists to gain concentrated surgical experience in their own areas.

Many of the conditions paediatric surgeons deal with are relatively uncommon, so it makes sense for them to gain their volume of experience in one or two areas. In the main, therefore, most paediatric surgeons have a special interest in either gastrointestinal surgery, oncology, thoracic or urology, but most have ongoing involvement with neonatal surgery. The emergency commitment of consultant paediatric surgeons is heavy, with tiny neonates and acutely ill children requiring top-level expertise and experience.

Table 1: Spectrum of conditions Neonatal Oesophageal atresia Intestinal atresias and meconium ileus Abdominal wall defects Anorectal anomalies Sacrococcygeal teratoma Gastrointestinal Gastro-oesophageal reflux Inflammatory bowel disease Follow-up neonatal conditions Oncology Neuroblastoma Wilms’ tumour Rhabdomyosarcoma Thoracic Congenital cystic adenomatoid malformation Empyema Pectus excavatum Urology Urinary tract obstruction Vesico-ureteric reflux Hypospadias and disorders of sexual differentiation Neuropathic bladder Bladder exstrophy and epispadias

38 | Surgeons’ News | December 2014

Foetal medicine also links strongly with all five areas of paediatric surgery, each with conditions that present on maternal antenatal scans and then require postnatal management. Much of the major activity of paediatric surgeons, therefore, involves the surgery and/or management of children with congenital anomalies, not just to maintain life but to provide good-quality life. As children get older, the congenital issues become more prominent and cause difficulties. Many children will require further significant interventions in childhood and adolescence.

Urology constitutes 30–40% of paediatric surgery and was the first of the subspecialties to establish itself. Since 2002, there have been nationally funded two-year fellowship posts in paediatric urology, based in the major centres, providing training up to consultant paediatric urologist level. In general, applicants would now not be appointed to specialist posts in paediatric urology without doing higher training in one of these posts or equivalent posts overseas. (In the USA, paediatric urology is a subspecialty of adult urology and virtually all paediatric urologists have been adult urologists first. In the UK, the majority of paediatric urologists come from the specialty of paediatric surgery.)

Paediatric surgeons require good medical, surgical and communication skills, as well as an understanding of the holistic side of medicine. It is important to have the skill and patience to communicate with children. The emotional involvement of parents with their children is complex and trainees must be taught effective sympathetic understanding and communication. Many of the serious surgical problems that affect children cannot be resolved by single operations. They often have long-term chronic aspects to them and require monitoring and later interventions. In these situations, paediatric surgeons must take all aspects of the child’s (and possibly the family’s) needs into consideration, including psychological, physical and social. The case study below illustrates this very well.

Real-life events in a child with spina bifida Newborn myelomeningocele

Parents’ distress at birth Parents have to learn clean intermittent catheterisation

Age 1

Complications of ventriculoperitoneal shunt – multiple operations

Age 2

Recurrent febrile urinary infection leads to renal scarring

Age 3–6

Urinary infection, urinary incontinence, faecal incontinence

Age 7

Cystoplasty, Mitrofanoff appendicovesicostomy

Age 7

Complications of ventriculoperitoneal shunt post-cystoplasty

Age 10

Child still incontinent of urine – artificial urinary sphincter

Age 12

Child refusing to attend school due to bullying

Age 12

Child refusing to self-catheterise – bladder perforation

DEVELOPMENTS ACROSS THE specialty there has been an ongoing desire for achievement, improvement and research. This is perhaps best illustrated by the emergence of several specialty interest associations along the lines of what has happened in other surgical specialties. Virtually all areas Thoracoscopically of our specialty are now included in repaired thriving large UK and/or European oesophageal atresia groups, such as the British Association of Paediatric Endoscopic Surgery, International Paediatric Endoscopy Group, British Association of Paediatric Urology, European Society of Paediatric Urology, BAPS/CCLG Oncology Group Children’s Cancer and Leukaemia Group, International Society of Paediatric Oncology – the list could go on. There is huge opportunity for any aspiring paediatric surgeon to become involved with surgical improvement.

The development and benefits of the multidisciplinary team are probably as well realised in paediatric surgery as in any other branch of surgery.

The improvements in the surgical care of children over the past 20 years have been achieved only by the contributions of other healthcare specialties, including nephrology, anaesthetics, intensive care, radiology, oncology, gastroenterology, foetal medicine and, last but not least, specialised nursing.

The outstanding advances during the period of the author’s career are numerous. Paediatric endoscopic surgery has advanced behind our adult colleagues but is now applicable to all areas of paediatric surgery. The picture above illustrates its application in neonatal oesophageal reconstruction.

Outcomes for children with the following conditions have improved greatly in the last 25 years by both surgical technique and other care. This list is not meant to be exhaustive but to illustrate the past, and provide encouragement for the future: Anorectal anomaly Inflammatory bowel disease Gastro-oesophageal reflux Empyema Pectus excavatum Neuropathic bladder Bladder exstrophy Hypospadias Wilms’ tumour There remain, however, many unresolved problems in all areas of paediatric surgery that adversely affect the lives of children and their families significantly. Yet the specialty has a record of research and innovation. With the advent of subspecialisation and new technology, there is much to expect from our enthusiastic young paediatric surgeons of the future and there is real hope for further improvement in outcomes for our patients.

www.rcsed.ac.uk | 39

DENTAL: INTERVIEW

Past dean Richard Ibbetson quizzes Bill Saunders as he steps into the role of leader of the College’s Dental Faculty

FROM ONE DENTAL DEAN TO ANOTHER Bill, I’m delighted that you have taken over the role of dean, which I’m sure you’ll discharge with your usual skill and style.

Can you tell me about when you first became involved with the Faculty?

I first became involved in 1982 when I passed my Fellowship. This was somewhat later than most others because I’d been in the Air Force and in practice. I’m now on my third term on Council and during that time I’ve been associated with the SAB in restorative dentistry, initially as deputy chair and then as chair for six years.

You’ve combined many things in your professional career and you’ve also had a very distinguished academic career. Can you tell me more about that?

My academic career has always been in Scotland. I received a lectureship in Dundee in 1981 and then did my higher training, as it was then, in restorative dentistry.

In fact, I was the first accredited academic to do formal higher training. After my PhD, I was lucky enough to get a senior lecturer’s post in Glasgow and then in 1993 I was given a personal chair in Glasgow; first in clinical practice and then, in 1995, I became the first professor of endodontology in the UK because that was my clinical and research interest. In 2000, I was reappointed in Dundee.

In that same year I took over as dean and served for 11 years. In 2008, I was elected chair of the Dental Schools Council, having been on their Executive for a while, and I found that a very rewarding experience.

What are the major challenges facing dental schools in the UK? Probably the biggest challenge is dental school 40 | Surgeons’ News | December 2014

undergraduate numbers. It’s very difficult to predict workforce requirements. I was the only dentist other than the chief dental officer to be involved with a review of the medical and dental workforce in England and it was very difficult to ascertain career aspirations for dentists.

Added to that, immigration from the European Union was difficult to predict. So going from having too few dentists to now probably having too many has been difficult for UK dental schools; they’ve all had the number of places reduced and, of course, that makes balancing the books very difficult. So I think that is a big challenge.

What do you think the priorities are for the Faculty and what do you think you might want to pursue as dean?

The rapport with the General Dental Council is very important and I think we have a critical role in managing postgraduate clinical dental education. The provision of that and assessment of specialties and indeed general dental practice are important areas. There’s also a potential role for us in assessing sub-specialty groups of ‘dentists with enhanced skills’.

which I would like to see enhanced. We have opportunities elsewhere in the world and I would like us to get more involved in Africa.

We’ve always been a very forward-looking College and our conjoint exams are very good for the parent institutions and our College, but I think there are opportunities for us to improve them.

Do you have any thoughts about the steps that the College has taken to improve our profile in the UK? I welcomed the opening of the Birmingham regional centre. I’m due to visit the House of Commons to speak to the Dental Committee there, which I don’t think we’ve had much opportunity to do in the past and that’s all been facilitated through the policy team at the Birmingham centre. We’ve also had meetings there which have been very helpful because it is quite easy for our regional advisers based in England to go to Birmingham.

What do you think our role is in supporting our Dental Fellows and Members?

Bill Saunders, left, has taken over as dental dean from Richard Ibbetson, right

We’ve always been a very forward-looking College and our conjoint exams are very good for the parent institutions and our College, but I think there are opportunities for us to improve them We clearly are a College situated in Scotland, yet we have an enormous UK-wide and international presence. What are your thoughts about our international work?

Our international presence is strong and I would like to see us expanding further. We have developed a very good reputation in the quality assurance of various examinations and we now have conjoint exams throughout the world. A lot of work was done by predecessors to spread the influence of the College.

This is evident in the USA, and in the Middle and Far East. Over the last few years, we have also developed a very good relationship with the Australasian College,

In the past, some Fellows and Members have perceived that once they get their qualification the royal colleges become less relevant to them. I don’t believe that at all. One of the most exciting developments recently is the plan for the Faculty of Dental Trainers, where there will be a formal pathway for training as an examiner and some recognition of that. One of the problems we’ve had recently is that NHS trusts have been reluctant to release people to examine, and good examinations and good examiners are critical to the profession. So I think the Faculty of Dental Trainers will make a considerable difference in enhancing the skills of the examiners that we already have.

One of this College’s key strengths is the Education Department. Dr Yvonne Hurst and Dr Cara Featherstone are doing a fantastic job to help us develop the highest quality of assessment.

Do you think doing significant work for royal colleges is becoming very difficult, if not impossible, to fit round the demands of an employer?

Certainly, from the experience I’ve had in the last three months where I’ve been copied into all the emails that you’ve been receiving, it seems to me an immense amount of work and that employers should allow flexibility for this. It’s a very prestigious job; I’m so proud to have been elected to this post and employers should take due cognisance of the importance of the role because it does influence dentistry overall.

You are coming into your post with a new team of Office Bearers in the Faculty. Michael Manogue is continuing as our secretary until December and he’s done a very good job. But www.rcsed.ac.uk | 41

DENTAL: INTERVIEW

you have a new vice-dean in Sarah Manton and a relatively new examinations convenor in Fraser McDonald. How do you see that team shaping up?

I’ve known Fraser and Sarah for a very long time. I’ve known Fraser for virtually the whole of my academic career and I worked with Sarah in Dundee. We have a very strong Council, some newly elected Members and those that are staying on. So this is an excellent Council and I don’t believe we will have any problems in meeting the various challenges that face us.

There is a point of view that dentistry would be better served by the creation of a College of Dentistry, which would be separate from any of the royal colleges. With that in mind, how do you view the RCSEd’s Faculty of Dental Surgery being inside a college of surgeons and, indeed, what are your thoughts on the fact that there are three faculties of dental surgery in the UK? Is there merit in the idea of a College of Dentistry or do you think we are better served being closely allied to the surgical colleges and RCSEd in particular?

I’m a bit of a traditionalist. I believe the Edinburgh College has served dentistry very well over the years and the relationship that we have with the surgeons is a very good one. The surgeons, who have clearly a lot more influence than dental surgery, have also 42 | Surgeons’ News | December 2014

NHS trusts have been reluctant to release staff to examine and good examination and examiners are critical to the profession supported dentistry in a big way and will continue to do that. I think it’s healthy that we have the various faculties of dental surgery and there is a possibility that coming together under one umbrella would actually dilute our efforts.

It’s certainly been my experience that there have been enormous benefits in being part of this overall College and the support, as you say, that we receive from our surgical colleagues is exemplary.

I think the element of cooperation but competitiveness between the dental faculties is indeed beneficial.

That’s exactly my view. An element of competition, but ultimately cooperation, really does strengthen the profession.

Bill, it’s been a great pleasure to talk to you.

I wish you every success and I hope I’ve not left too many skeletons in the cupboard – no doubt there’ll be one or two.

No, I’ve just been in the cupboard, you showed me the cupboard and it’s empty at the moment.

/ FACULTY EVENT

Trainee roadshow rolls on

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n 10 October, the Dental Faculty presented its third, updated educational roadshow event to support foundation training. Held at the Leeds Marriott Hotel for the Yorkshire Deanery, the day was organised and hosted by Brian Nattress, RCSEd regional dental adviser and Dental Council member, and attended by around 110 Yorkshire dental foundation trainees.

As previously, high-calibre education was used to raise the Faculty’s profile among young professionals as they consider embarking on a lifetime of postgraduate development and choosing which College may best support them in their ambitions.

Providing an evidence-based cautionary perspective of the risks associated with cosmetic dentistry and short-term cosmetic orthodontics was the day’s overall aim. Senior Fellows with (inter)national reputations in their fields made presentations, including Professor Callum Youngson from the University of Liverpool, who outlined the key elements in planning restorative treatment, and how to avoid common pitfalls through minimal interventions that do not compromise outcomes.

Mr John Scholey, consultant orthodontist from the University Hospital of North Staffordshire, summarised the risks of short-term orthodontics for cosmetic general dental practitioners, in contrast to the virtues

The Dental Foundation trainee book prize winners – Jennifer Kwa (left) and Jane Booker (right) – with Brian Nattress

of carefully planned multidisciplinary treatments that were slower to deliver but which gave superior long-term results.

Mr Robin Gray, former senior lecturer in dental medicine and surgery at the University of Manchester, outlined the evidence base for treating TMD disorders and Mr Sanjay Chopra, oral surgery specialist, described the role of dental implants in contemporary clinical practice.

Mr Mike Clark, dental protection dentolegal adviser, provided risk-management strategies in relation to cosmetic dentistry procedures and, concluding the day, Mr

Robert Chate, vice-dean, discussed the MFDS diploma as well as the range of professional development opportunities available through the College.

The success of the day was assured by the generous sponsorship of Dental Protection and the organisational support of Siobhan Whittaker and Andrew Mullinex from the College’s regional centre in Colmore Row, Birmingham. The event finished with a prize draw, where Miss Jane Booker and Miss Jennifer Kwa were presented with clinical textbooks generously donated by Oxford University Press.

/ COUNCIL ELECTIONS

New Dental Council Members Elected

Professor Crispian Scully Re-elected

Mr Rob Chate From vice-dean to Member of Dental Council

Mr Will McLaughlin Newly elected Member of Dental Council

Congratulations to the recently elected members of Dental Council who took their seats or remained on Dental Council following the Dental AGM on Friday 24 October 2014. Members of Dental Council are elected for five years from the date of the Dental AGM.

Mr Grant McIntyre Newly elected Member of Dental Council

Professor Elizabeth Davenport Re-elected

Mr Simon J Wardle Members’ Representative on Dental Council www.rcsed.ac.uk | 43

DENTAL

ORAL OUTCOME OF A CHANGING WORLD / KING JAMES IV LECTURE

Professor Crispian Scully shares his lecture, ‘Emerging Infections in Health, Disease and Oral Healthcare’

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ignificant changes in lifestyle, social and health care, have led to the emergence of several infections, particularly human immunodeficiency virus (HIV) and the resultant acquired immune deficiency syndrome (AIDS).

Immunosuppressive therapy is increasingly used in a range of conditions – especially in transplantation to prevent T-cell rejection.

Immunodeficiencies and immunosuppression lead to immunoincompetence and a liability to infections and malignant disease. Infections: are mainly with mycobacteria, fungi and viruses; are often recurrent; may spread rapidly, be clinically silent or atypical; and are transmissible in saliva. They affect especially skin, mucosae and the respiratory tract. Neoplasms include melanoma, basal cell carcinoma, Kaposi sarcoma, lymphomas/ lymphoproliferative disorders, and carcinomas of the skin, lip, genitalia, and perineum. Many new primary immune defects are also now recognised; we have described their orofacial features1–5 and have been involved in classifying lesions in HIV/AIDS6–9.

HERPES VIRUSES Herpes viruses are DNA viruses typically contracted in early life, transmitted in saliva, characterised by latency and able to be reactivated during immunosuppression.

Herpes viruses often cause orofacial disorders.

Herpes simplex virus (HSV-1) can cause oral or oropharyngeal infection, and is most frequent in resourcepoor groups. HSV-2 can cause severe oropharyngeal infection, usually via orogenital or oro-anal sexual contact, and is more common in the sexually active, particularly among female prostitutes and men who have sex with men (MSM). Varicella-zoster virus (VZV) causes chickenpox but, perhaps more importantly, also shingles (zoster), mainly in older or immunocompromised patients. Zoster is a fairly common feature in HIV-infected patients treated with anti-retrovirals who develop immune reconstitution inflammatory syndrome.

Patients with immune defects are liable to severe and/or protracted and/or disseminated herpes virus infections – HSV, VZV, EBV (Epstein–Barr virus), CMV (cytomegalovirus) or KSHV (Kaposi sarcoma herpes virus: HHV-8). We have described their involvement and management in various lesions10–30.

44 | Surgeons’ News | December 2014

Professor Crispian Scully CBE, FMedSci, DSc

is Emeritus Professor, University College London [UCL]; Professor [King James IV], Royal College of Surgeons of Edinburgh; visiting professor, Athens, Edinburgh, Granada and Helsinki universities; President, British Society for Oral Medicine; past President, International Academy of Oral Oncology; and Co-director, WHO Collaborating Centre – Oral Health/General Health

HUMAN PAPILLOMAVIRUSES (HPV) Papillomas, common warts (verruca vulgaris), genital warts (condyloma acuminatum) and focal epithelial hyperplasia (Heck’s disease) are caused by different HPV. A higher prevalence is seen in immunocompromised patients or those with sexually shared infections (SSI).

Papillomas are uncommon in the mouth, typically affecting fauces, soft palate or tongue. Warts are rare, usually transmitted from skin lesions, found predominantly on the lips, or from genital or anal lesions, and found mainly on the tongue or palate. We have demonstrated their viral aetiology31.

VIRUSES AND POTENTIALLY MALIGNANT DISORDERS AND CANCER Oral cancer appears to be increasing in incidence.

We were the first to show a rise in Britain, and the epidemiology in Scotland32 (where it is more frequent), and confirmed rises worldwide33. It is the result of DNA mutations arising spontaneously and from the action of various mutagens, mainly tobacco, betel and alcohol. We revealed an association with viruses that others have since confirmed. We first demonstrated RNA complementary to HSV in lip cancer34, 35 and a new human papillomavirus in oral carcinoma36. Our and other more recent studies have shown oncogene and tumour-suppressor changes, especially involving 3p, in oral carcinoma37, 38.

Potentially malignant (premalignant or precancerous) disorders that precede some neoplasms include erythroplasia (erythroplakia) – the most likely lesion to progress to severe dysplasia or carcinoma-leukoplakia, lichen planus and submucous fibrosis. Our studies on HPV found viruses in some premalignant disorders39–43 and we have examined possible pathogenic mechanisms44.

Based on this work, early on I hypothesised that oral cancer might be an SSI45, 46, a hypothesis vindicated by others mainly in oropharyngeal cancer. Research on HPV as well as oral and oropharyngeal cancer has placed us in an exciting position since HPV vaccines became available, and the question as to whether these will influence the rising incidence (especially in the young) remains to be answered. Nevertheless, most oral cancer remains related to tobacco and alcohol, and our and other ongoing studies support this finding47–54.

BLOOD-BORNE VIRUSES (BBV) Infection with RNA retroviruses (HIV) produces infection, which eventually damages T lymphocytes, thus causing HIV disease and ultimately AIDS. CD4+ T immunocytes are crucial to host defences against fungi, viruses, mycobacteria and parasites, and HIV disease

predisposes to infection with these, and the appearance of clinical diseases.

We have shown in the early days of the HIV epidemic the range of oral lesions55–58 – mainly infections and malignancies – and a reluctance on the part of dental heathcare staff in the early days to care for HIV-infected people59–61, despite the low risk of transmissibility and the lack of complications related to oral healthcare procedures62, 63, as well as showing the role of various herpes viruses and other infective agents64–75.

Hepatitis B, D and C viruses are among BBV transmitted in blood, blood products and other body fluids, particularly if needle- or syringe-sharing or skin breaches has occurred. Outbreaks have also occurred in healthcare – in dental and other outpatient settings, haemodialysis units, long-term care facilities, and hospitals – primarily from unsafe injection practices, needle re-use, needle stick injuries, and syringes and other infection-control lapses.

Hepatitis B has long been of greatest importance and we conducted a series of studies to highlight this, the prevalence of other forms of hepatitis, and the need for routine immunisation, glove use and infection control76–98 which slowly but surely helped campaigns designed to introduce infection control and immunisation. Standard precautions against infection transmission are nowadays universal, so in the absence of a vaccine, hepatitis C virus (HCV) has become the major issue and we have demonstrated orofacial sequelae from HCV infection – such as lichen planus99–105 and Sjögren’s syndrome.

FUNGI Some 50% of the population are ‘Candida carriers’. This pathogen grows opportunistically either as yeasts or hyphae, mainly in people with immune defects; candidosis is thus a ‘disease of the diseased’106–107. The importance increased greatly as the HIV pandemic extended. In immunocompromised people Candida typically colonises mucocutaneous surfaces, commonly oropharyngeal, and can result in invasive candidosis. We have shown its role in HIV/AIDS108–110 and other immune defects such as in Down syndrome111–113 and have examined aspects of aetiopathogenesis in rats114–115, and therapeutics116, 117.

Before global travel, paracoccidioidomycosis (South American blastomycosis), caused by Paracoccidioides brasiliensis, was seen mainly in South America, especially Brazil – but we have shown the importance of orofacial lesions, aetiopathogenetic mechanisms and the increased association with HIV and travel118–121.

Histoplasmosis is found worldwide, the causal agent Histoplasma capsulatum being present in bird and bat faeces. Disseminated and potentially fatal histoplasmosis is seen typically in immunocompromised patients, especially those with HIV/AIDS. Orofacial lesions may be indicative of that infection122, 123.

BACTERIA We have studied the bacterial pathogenesis in gingivitis and periodontitis in animal models and in patients with HIV/AIDS and other immune disorders, and also aspects of dental abscess pathogenesis and therapy124–135. Syphilis, an SSI caused by Treponema

pallidum, is transmitted by direct contact with lesions via vaginal, anal or oral sexual contact. Oral lesions have been reported136.

Endemic in Asia, Africa and Latin America, leprosy is also seen occasionally in southern Europe. The outcome of infection with Mycobacterium leprae is dependent upon immune reactions, which, if intact, result in the localised form (tuberculoid leprosy) but which, if deficient, cause generalised (lepromatous) leprosy and may cause orofacial lesions, as we reported137.

Professor Crispian Scully delivering the King James IV lecture

PARASITES Since the appearance of the HIV/AIDS pandemic, more parasitic infestations are now being recognised.

Leishmaniasis – common in the tropics and around the Mediterranean – may cause skin or orofacial lesions, especially in HIV/AIDS, as we have reported138, 139.

Myiasis is a condition in which fly maggots invade living tissue, or if they are harboured in the intestine or any part of the body and feed on the host’s organs.

Human myiasis is most common in the tropics and, as we have reported, may affect the mouth140, 141, mainly where hygiene is defective as in some resource-poor situations.

Larvae burrow through tissue and may produce a type of larva migrans-creeping eruption. When they mature, they migrate, and may then become visible, even in the mouth142.

INFECTION CONTROL. Our research on dental healthcare infections (particularly hepatitis viruses, herpes viruses and HIV), was, I believe, pivotal to the national and international introduction and uptake of immunisation, infection control and promotion of oral healthcare of people with HIV/AIDS, and led to personal involvement in producing guidance from the British Dental Association143, General Dental Council144 and National Institute for Health and Care Excellence (NICE; subcommittee on CJD [Creutzfeldt–Jakob disease145]).

REFERENCES For a full list of references, please visit www. surgeonsnews. com

www.rcsed.ac.uk | 45

COLLEGE INFORMATION

DENTAL REGIONAL ADVISERS IN YOUR AREA The Faculty of Dental Surgery’s support and advice network throughout the UK and Ireland SCOTLAND

NORTH EAST OF SCOTLAND 1 Martin Donachie, Aberdeen Royal Infirmary SOUTH EAST OF SCOTLAND 2 Donald Thomson, Dundee Dental School

1

ENGLAND

EAST OF ENGLAND 3 Simon Wardle, James Paget University Hospital, Great Yarmouth

2

KENT, SURREY & SUSSEX 4 Lindsay Winchester, Queen Victoria Hospital, East Grinstead NORTH EAST OF ENGLAND 5 Francis Nohl, Newcastle Dental Hospital, Newcastle upon Tyne

5

NORTH WEST OF ENGLAND 6 Alex Milosevic, Liverpool University Dental Hospital 7 Mike Pemberton, University Dental Hospital of Manchester 8 Callum Youngson, School of Dentistry, Liverpool

16

19 17

6

7 8

13

NORTH LONDON 9 Phil Taylor, Barts and the London School of Medicine and Dentistry, London NORTH EAST LONDON 10 Nick Lewis, UCL Eastman Dental Institute, London

3

18

10 Crispian Scully, UCL Eastman Dental Institute, London

12 11

NORTH WEST LONDON 11 Sumithra Hewage, Northwick Park Hospital, Harrow

15

10 9

14

4

OXFORD 12 Mary McKnight, John Radcliffe Hospital, Oxford SOUTH YORKSHIRE/EAST MIDLANDS 13 Philip Benson, Charles Clifford Dental Hospital, Sheffield SOUTH WEST OF ENGLAND 14 Pamela Ellis, Dorset County Hospital, Dorset 15 Matthew Moore, Royal Devon & Exeter NHS Foundation Trust, Exeter YORKSHIRE 16 Brian Nattress, Leeds Dental Institute, Leeds

46 | Surgeons’ News | December 2014

WALES

17 Joy Hickman, Glan Clywyd Hospital, Clwyd

18 Alan Gilmour, Cardiff University

REPUBLIC OF IRELAND

19 Simon Wolstencroft, St James’ Hospital, Dublin

TRAINEES AND STUDENTS

NAVIGATING THE NUMBERS GAME Michael Moran reports on the College’s forthcoming ‘Forewarned is Forearmed’ workshop on how to audit and publish outcome data

S

urgery is a highly demanding medical career.

As well as technical proficiency, surgeons are required to have many skills outside of the operating room to equip them to be experts in their field. In addition, with so many surgical specialties and subspecialties, each surgeon must be able to carry out a dazzling array of procedures and techniques.

It is almost two years since the NHS in England asked 10 specialties, including surgery, to produce clinical outcomes data. In surgery, this process is in danger of becoming a numbers game, with this complex clinical art categorised into simplistic categorical variables.

Surgical trainees are expected each year to conduct clinical audit and research, so there is a great opportunity to develop knowledge and understanding of surgical quality. As consultant surgeons of the future, it is imperative that trainees are fully prepared to audit and publish their own outcome data.

The ‘Forewarned is Forearmed: Quality Improvement and Surgical Outcomes’ workshop provides a unique opportunity to learn about this emerging topic from leaders in the field.

Professor Craig White, the clinical lead of the Quality Unit (NHS Scotland), will present data from largescale national studies, demonstrating how much this information can tell us, and how healthcare quality impacts on patient safety at an individual level.

Professor Ben Bridgewater, consultant cardiac surgeon and honorary professor of translational medicine, will then discuss surgical outcomes data at local level, giving specialist advice on how to gather and present this information at hospital level.

This event has been organised by the RCSEd Trainees’ Committee, with the needs of surgical trainees in mind. Measuring surgical outcomes will be part of all our futures, but currently we are ill-equipped to conduct research and audit in this area. This workshop will stimulate ideas, emphasise the importance of this information to patients and provide practical advice about data collection that will be relevant to all surgical specialties.

The workshop is free of charge for Members of the College, and provides a great opportunity to meet with

other surgical colleagues in the beautiful new RCSEd Centre in Birmingham. We look forward to seeing you there!

Forewarned is Forearmed: Quality Improvement and Surgical Outcomes for Trainees takes place on 4 December at the RCSEd Birmingham Regional Centre. For details, contact Naseem Akhtar: 0121 647 1567 or n.akhtar@rcsed.ac.uk

Measuring surgical outcomes will be part of our future, but currently we are ill-equipped to conduct research and audit in this area www.rcsed.ac.uk | 47

TRAINEES AND STUDENTS

THE LONG AND WINDING ROAD Simon Lammy describes the twists and turns of pursuing a national training number in neurosurgery

48 | Surgeons’ News | December 2014

MR TIARNAN MAGOS MRCS (ENT)

I

n December 2011, Surgeons’ News published a piece I had written detailing my long-held neurosurgical ambition. I have wanted to be a neurosurgeon since I was nine years of age, and during medical school in London and foundation programme training in Aberdeen and Wick I prepared to undergo national neurosurgical selection.

Unfortunately, in February 2012 I was unsuccessful in obtaining a neurosurgical national training number (NTN) in FY2, but was offered a fixed-term specialty training appointment for one year (FTSTA 1) in neurosurgery in Manchester. Simultaneously, I had applied for core surgical training (CST) and ranked fourth in Scotland, obtaining a cardiothoracic-themed CST programme and I chose to pursue it instead.

I rejected the FTSTA because it did not provide a statistical advantage in obtaining a NTN. For example, the number of NTNs awarded to FY2s, FTSTAs and CSTs appears balanced, and it theoretically propels a trainee down a slippery slope of ‘FTSTA-hood’ courtesy of neurosurgical psychology: it might be easier to accept an FTSTA 2 if twice unsuccessful at selection because taking up a CST post following FTSTA 1 makes no sense if you plan on trying three times.

This poses a serious risk that if twice unsuccessful a trainee is locked out of being eligible for CST, and consequently every other surgical specialty (e.g. due to the maximum 18 month post-FY2 surgical experience mandate). Therefore, a trainee subsequently becomes locked into neurosurgical FTSTAs in an ever-diminishing hope of obtaining an elusive NTN from FTSTA 3 upwards.

It is a potential trap and bittersweet reward for an incredible amount of hard work.

Consequently, I took each surgical specialty during CST seriously, learning to adapt and thrive in each in case I never achieved a neurosurgical NTN and had to pursue ST3 in another surgical specialty post-CST. This dramatically increased my clinical and academic commitments, ensuring I had to dig even deeper in a seemingly never-ending quest to strengthen my CV in two completely unrelated specialties.

In February 2013 I was again unsuccessful in securing a neurosurgical NTN as a CT1 in Edinburgh, but again

Simon Lammy ST1 Neurological Surgery (Neurosurgery), Institute of Neurological Sciences, Southern General Hospital

was offered an FTSTA 1 in Bristol. Since medical school, I had planned that if I was unsuccessful on two successive occasions, I would acknowledge the futility and go to Oxford to pursue academic surgery.

A man must recognise a dead end and, in March 2013 during CT1, I decided to relinquish my childhood dream, stick to my final-year plan and submit an application for a surgical National Institute for Health Research Academic Clinical Fellowship in Oxford, whereupon I ranked first (more than 40 people applied for that post) to obtain an NTN (a).

Oxford enabled me to refine a rigorous independence of purpose, and I have never worked harder. But, due to some kaleidoscopic challenges – for example, experiencing a phenomenal acceleration in learning that a thousandyear-old institution such as Oxford impresses upon its students – I uncharacteristically deviated from that finalyear plan and decided to try a third time for neurosurgical selection, because I owed it to the hard graft I had put in.

Contrary to my strategy on the previous two attempts, I simply turned up to neurosurgical selection in February 2014 blowing the dust off my portfolio, having dry-cleaned my 18-year-old suit the week before. Having been unsuccessful on two occasions I could not justify the months of preparation and decided instead to

focus on extracting as much from Oxford as possible as an NTN(a).

In February 2014, I finally obtained a neurosurgical NTN. My joy was indescribable. On reflection, I feel privileged at having tried three times for several reasons and thank family, friends and colleagues who have permitted me to indulge in unrelenting single-mindedness since high school.

First, trying three times ensured I remained under significant competitive pressure for three years. This helped me maintain a high standard of discipline and transformed the once-exhausting academic pursuits into pleasures. It has become highly enjoyable to become more inquisitive about evidence-based medicine. Second, it exposed me to thoracic surgery in Edinburgh and ensured I got an education in surgery-in-general during 12 months of emergency general surgery in Oxford.

Instead of indulging in self-congratulations and counting down towards August, I worked even harder to make the most of opportunities at Oxford – for example, by completing a postgraduate diploma in one academic year at the same time as fulfilling my fulltime clinical commitments and keeping on top of a substantial academic workload. Every scrap of annual leave was dedicated to enhancing generic academic skills, developing research plans, teaching medical students and completing articles for publication.

The challenges I experienced are a lesson to those dedicated colleagues preparing to undergo national neurosurgical selection to continue working, but to develop a methodical backup plan – I had an NTN(a) in Oxford in an intriguing specialty. The numerous twists and turns in thrice pursuing neurosurgery and working in Aberdeen, Wick, Edinburgh, Livingston, Oxford, Banbury and subsequently Glasgow provide an even sturdier canvas on which to paint my future.

Contrary to my strategy on the previous two attempts, I simply turned up to neurosurgical selection in February 2014, blowing the dust off my portfolio and having dry-cleaned my 18-year-old suit the week before www.rcsed.ac.uk | 49

TRAINEES AND STUDENTS

TOMORROW’S DOCTORS

The Association of Surgeons in Training travelled to Rwanda, East Africa, to deliver its ‘Foundation Skills in Surgery’ course

A

lmost one million people, mostly ethnic Tutsis, were killed during the Rwandan genocide of 1994. In this period, and for many years after, Rwanda had the lowest life expectancy of any country in the world1. Since then the economy and healthcare system have made remarkable progress, with adult mortality rates decreasing and life expectancy almost doubling.

Nonetheless, Rwanda remains extraordinarily poor, with a per capita income of $1,500 a year, and many citizens unable to access even the most basic healthcare1. With only 50 surgeons serving a population of 11.8 million, the need for surgical training is particularly great2.

With a growing interest in surgery worldwide, the Association of Surgeons in Training (ASiT) set about organising a pilot surgical skills course at the Central University Teaching Hospital (CHUK) in Kigali, the Rwandan capital. The Foundation Skills in Surgery course, developed by ASiT, has been run within the UK and

REFERENCES 1. World Health Organization Global Health Observatory Data: Rwanda. www.who.int/ countries/rwa/ en/ (accessed 25/09/2014).

2. Petroze RT, Nzayisenga A, Rusanganwa V, Ntakiyiruta G, Calland JF. Comprehensive national analysis of emergency and essential surgical capacity in Rwanda. Br J Surg 2012; 99: 436–443.

Rwanda has made great strides in increasing life expectancy

Republic of Ireland for several years. This one-day course aims to teach medical students and foundation doctors the fundamental skills for safe surgical practice during the early years of surgical training. Topics covered include: sterile gloving and gowning; safe handling of instruments; knot-tying and suturing techniques. This course content was adapted for delivery in a resource-poor setting, and combined with work undertaken previously in Rwanda by Ed Fitzgerald for the Lifebox Foundation (www.lifebox. org), a non-governmental organisation working to make surgery safer in low and middle-income countries.

With only 50 surgeons serving a population of 11.8 million, the need for surgical training is particularly great – so the skills teaching we were able to provide these final-year medical students seemed incredibly valued 50 | Surgeons’ News | December 2014

A clinical skills session includes suturing techniques

Trainees learn about good practice

The target audience for this course was final-year medical students at the University of Rwanda. Rwandan medical education is delivered predominantly through traditional observational experiences, and there is a real shortage of dedicated practical surgical skills training.

Next year, this cohort of students will become interns and will be performing tasks such as Caesarian sections in the district hospitals of Rwanda, so the surgical skills teaching we were able to provide seemed incredibly valued.

Over two days, 55 final-year medical students attended the course, many of whom had travelled for many hours to attend and arrived more than an hour early. The morning talks covered the importance of good medical record-keeping and the basics of suturing, drains and instruments, with much interaction from the students.

This was followed by the clinical skills session, in which students practised sterile gloving and gowning (surprisingly difficult in an uncomfortable 29°C heat), hand and instrument knot-tying, safe handling of sharps, and suturing techniques – such as interrupted, mattress and subcuticular – alongside skin-lesion excision.

Afternoon talks covered the importance of auditing and research to maintain good clinical practice, and the concepts of collaborative research and the GlobalSurg programme. The final session covered surgical safety and

FURTHER READING ASiT Rwanda Foundation Skills in Surgery blog: www.asit. org/news/FSS_ Rwanda_2014 Lifebox Foundation: www.lifebox.org GlobalSurg: http:// globalsurg.org If you are interested in supporting future ASiT international surgical training ventures please donate at www.givey.com/ asitrwanda or email info@asit.org

Lifebox’s work on the implementation of the surgical safety checklist, and pulse oximetry.

The course was concluded with a prize-giving session of donated books and equipment. The remainder of these donations was divided between the surgical section of CHUK’s library and the University of Rwanda Student Surgical Society for distribution throughout the country’s district hospitals.

Feedback demonstrated that the course was highly appreciated by the students, with a median rating of 9.25/10. Qualitative feedback was universally positive, with themes including a desire for longer and repeated training.

The venture was a truly eye-opening experience – providing insight into the healthcare and social challenges doctors face within low-income countries, and giving an opportunity to develop cross-cultural communication skills and working relationships. There are plans to return to Rwanda next year, with the focus on engaging local senior doctors and securing further funding, both essential in order to create a genuinely sustainable training programme.

ASiT is thankful for the support of Dr Georges Ntakiyiruta, Chief of Surgery at CHUK, as well as Zeta Mutabazi and Philippe Nyembo, two enthusiastic medical student coordinators who took charge of local arrangements – including ensuring that porcine tissue had accompanying veterinary authorisation – one of many lessons we learned.

ASiT is extremely grateful for support from the Royal College of Surgeons of England, the Royal College of Physicians and Surgeons of Glasgow, Lifebox Foundation, Swann-Morton and MedAID, together with all the individual trainees who donated money and equipment.

RLH, AB and WM were awarded the Rex & Jean Lawrie Fellowship and JEFF, AJB and VG were awarded the Stefan & Anna Galeski Fellowship, all in association with the Royal College of Surgeons of England.

Rhiannon L Harries, J Edward F Fitzgerald, Andrew J Beamish, William Muirhead, Aneel Bhangu, Vimal Gokani Association of Surgeons in Training, @ASiTOfficial www.rcsed.ac.uk | 51

TRAINEES AND STUDENTS / CONFERENCE

Welsh student research success

F

Round-up of fifth symposium

Students and faculty at the Aberdeen event, held on 28 October / UNDERGRADUATES

Workshop set for take-off The RCSEd has successfully piloted a surgical anatomy workshop for senior medical undergraduates

S

tudents in Norwich and Aberdeen attended evening workshops in October designed to increase awareness of the important links between anatomy and surgical practice.

The evening began with an engaging talk from David Sinclair, professor of anatomy at the RCSEd, entitled ‘Surgery and Anatomy – Partners in Time and Space’, followed by three practical sessions, using cadaveric specimens, on the surgical anatomy of the head and neck, trunk and limbs.

Eighteen students took part in each session, which provided an excellent opportunity to learn about the importance of surgical anatomy, relating it to real-life clinical examples. Delegates were split into groups and rotated around the three half-hour cadaveric

sessions, during which the faculty, using a case-based approach, demonstrated the importance of knowledge of surgical anatomy to all aspects of surgical practice, particularly in relation to ensuring patient safety.

“The workshop is also designed to introduce senior clinical students with an interest in a surgical career to the type of surgical anatomy examined in the Intercollegiate MRCS examination, as well as informing participants of the many benefits of becoming Affiliates of our College,” said Professor Sinclair.

The RCSEd is grateful to Professor Simon Parson from the University of Aberdeen and Sue O’Connor from Norwich Medical School for their support and generosity and to the faculty and students. Further workshops are planned for 2015.

[It] provided an excellent opportunity to learn about the importance of surgical anatomy, relating it to real-life examples 52 | Surgeons’ News | December 2014

or the fifth consecutive year, in October more than 100 students, faculty and VIP guests from across Wales descended upon Margam Park’s Orangery in South Wales for the College’s All Wales Medical Student Surgical and Dental Research Symposium.

The Symposium, incorporating dental students for the first time this year, gave undergraduates in Wales a chance to present audits and research to an array of student colleagues and a multitude of judges and guests, including College Fellows and Welsh academic, government and commercial luminaries.

Opening the event, RCSEd Wade Professor of Anatomy David Sinclair discussed the importance of students developing a sound surgical anatomical knowledge at medical school.

Thus followed 10 oral and more than 30 poster presentations which reflected the high-quality, heterogeneous research being undertaken by students in Wales. All delegates received constructive and valuable feedback on their work from the enthusiastic judging faculty members.

Ryan Preece and Elen Hanna Hughes were named winners of the oral and poster presentations respectively. Both received RCSEd ‘Golden Tickets’ guaranteeing an all-expenses paid opportunity to present their research at the RCSEd National Student Research Symposium in Edinburgh.

Finalists of the RCSEd ‘Sixth Form Schools Surgical Essay’ were also at the conference to receive their prizes and gain further insight into the opportunities a surgical career can provide.

All involved with the conference would like to thank the sponsors MED-EL, DTR Medical, MEDA, Rocialle, BMA, BMJ, Wesleyan and the 1000Lives+ Campaign. Furthermore, the SMTL (Wales) Science trophy and DTR Medical Innovation and Design award solidify the intent of local Welsh industries to immerse students into translational surgical research.

Elen Hanna Hughes receives her award from Mr Michael Stechman

A new book from an award winning publisher

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The enthusiastic feedback received from readers of the international bestseller Schein's Common Sense Emergency Abdominal Surgery (now in its 3rd edition, translated to seven languages; Springer Verlag; ISBN 978 3540748205) inspired the Editors to do a similar book dedicated to surgical complications: practical, non formal, internationally relevant (in all types of practice and levels of hospitals) – and definitely not politically correct: what is considered taboo by others is not taboo for us; here we discuss everything!

As in the Editors’ previous book, the use of references is restricted to the absolute minimum, and citing figures and percentages is avoided as much as possible. The chapters in this book are the opinion of experts – each contributor has a vast personal knowledge and clinical experience in the field he is writing about. This book will help all surgeons (and their patients), avoid the misery of complications, and will provide advice on the management of those that are unavoidable. Complications and death are an integral component of surgery. Surgeons have to look death in the eyes, try to prevent it and vanquish it – this is what this book is all about.

Schein’s books are always terrific reads, conveying pithy observations and practical advice and doing so with wit and scholarship. This latest is surely a must for every surgeon’s bookshelf.

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COLLEGE INFORMATION

All the latest grants, fellowships and bursaries from the RCSEd

AWARDS & GRANTS ETHICON FOUNDATION FUND TRAVEL GRANTS

Grants are awarded towards travel overseas to gain further training or experience and are restricted to the cost of one return airfare only. Travel for the sole purpose of attending a scientific meeting will not be supported. Requests for retrospective awards will not be considered.

Closing date for receipt of applications is Friday 1 May 2015.

MEDICAL STUDENT ELECTIVE TRAVEL BURSARIES

The RCSEd, in association with Ethicon, is offering a travel bursary towards an elective in surgery. Bursaries to the value

of £250 are open to medical students in the UK and Ireland who are affiliates of RCSEd and who are undertaking approved surgical electives overseas.

Each bursary will normally be in the region of £500, which can be used towards travel and accommodation costs or other expenses involved with the placement.

Closing date for receipt of applications is Friday 1 May 2015.

Closing date for receipt of applications is Friday 9 January 2015.

BURSARIES FOR AFFILIATE MEDICAL STUDENT ELECTIVE PLACEMENTS IN AFRICA 2015

Bursaries are available to undergraduate affiliates of the RCSEd enrolled at UK universities who plan to carry out their elective placements in Africa. The elective does not have to be in a surgical unit but priority may be given to students demonstrating a special interest in surgery.

FOR MORE INFORMATION ABOUT THE COLLEGE’S AWARDS AND GRANTS CONTACT: Cathy McCartney, Awards and Grants Administrator The Royal College of Surgeons of Edinburgh Nicolson Street, Edinburgh EH8 9DW Tel: +44 (0)131 527 1618 Email: c.mccartney@rcsed.ac.uk Only Fellows, Members and Affiliates in good standing are eligible to apply.

The RCSEd collects personal data from you during the application process for awards and grants. We will not share this information with any third parties, and your data will be used solely for the purpose of processing and administrating applications.

54 | Surgeons’ News | December 2014

UNDERGRADUATE BURSARIES

The RCSEd is offering bursaries to undergraduate students of medicine or dentistry to enable them to work for elective or vacation periods in universities, medical schools, NHS laboratories or research institutes in the UK and Ireland. Proposals for any branch of surgery are eligible for consideration.

Closing date for receipt of applications is Wednesday 25 March 2015.

LORNA SMITH CHARITABLE TRUST RESEARCH FELLOWSHIP Administered by RCSEd. Applications are invited from trainee doctors who wish to research disorders of a rheumatic, arthritic or inflammatory nature. Applications can be made for a period of one year and the Trust will provide a sum of up to £50k to fund salary and research costs.

Closing date for applications is Friday 28 March 2015.

DIARY

The latest surgical and dental events, seminars and courses

DECEMBER 2014 1 RCSEd Christmas Lecture 2–3 Vascular Access for Haemodialysis 5 What I Wish I Knew on Day 1 as a Consultant (Birmingham) 8–9 Core Skills in Urology Course Module 3 & 4 11–12 Core Skills in Ureteroscopy (Bothwell) 11–12 Surgery of Aorta – Cadaver Course (Coventry) 12 Future Surgeons: Key Skills (Nottingham) 16–17 Essential Skills in Cardiothoracic Surgery

4–6

The Edinburgh Head and Neck Course – Module II (Head and Neck Reconstruction) 14–15 Foundation of Clinical Surgery (Birmingham) 26–27 Basic Surgical Skills Course 28 – 1 March Foundation of Gastroenterology (Birmingham)

JANUARY 2015 8–9 Anatomy for MRCS OSCEs (Wade Programme in Surgical Anatomy) 10–11 The Edinburgh MRCS OSCE Preparation Course 11–13 Mock MRCS OCE Exam Course (Aberdeen) 20–21 Basic Surgical Skills Course 23–24 MFDS Part 2 Revision Course (Dubai) 28–30 Advanced Trauma Life Support (ATLS)

MARCH 2015 3 How to Improve Your Surgical Skills at Home: A Refreshing Way to Look at the Acquisition Skills and Practice of Surgery 5–6 Basic Surgical Skills 7 Conference for Dental Care Professionals 7–8 Basic Surgical Skills Course (Manchester) 20 President’s Meeting and Annual Audit Symposium: Surgical Oncology 23–25 The Edinburgh Hand Course 26–27 Endovascular Aneurysm Repair (EVAR): Planning and Deployment for Endovascular Surgeons 27 Professionalism and Excellence in Scottish Healthcare: Our Future

FEBRUARY 2015 2–3 The Edinburgh Head and Neck Course – Module I (Resectional Tactics in Head and Neck Surgery)

For further information please email education@rcsed.ac.uk or telephone +44 (0)131 527 1600.

All events in Edinburgh unless otherwise stated.

CONGRATULATIONS TO THE FOLLOWING AWARDS AND GRANTS RECIPIENTS RCSED/SOMS/ SHANGHAI HEAD AND NECK FELLOWSHIP

Thomas Handley, Specialty Registrar, Oral & Maxillofacial Surgery: Fellowship in Head and Neck Oncology in Shanghai at the Department of Cranio-Maxillofacial Science, School of Stomatology, Ninth People’s Hospital, Shanghai Jiao Tong University, China

CUTNER TRAVELLING FELLOWSHIP IN ORTHOPAEDICS

Alexander Aarvold, ST7 Trauma & Orthopaedics, Wessex Deanery: Fellowship in Paediatric Orthopaedic Surgery, University of British Columbia Children’s Hospital, Vancouver, Canada Jamie Ferguson, ST6 Trauma & Orthopaedics, Oxford Rotation: International Fellowship in Paediatric Orthopaedics, Beit CURE International Hospital, Blantyre, Malawi

JOHN STEYN TRAVELLING FELLOWSHIP IN UROLOGY

Alastair Lamb, Clinical Lecturer/Hon SpR: Robotic Surgery Fellowship, Royal Melbourne Hospital, Australia

SMALL RESEARCH GRANTS

Ernest Azzopardi, Swansea University: Amylase activity in localised infection Jason Wong, University of Manchester: The role of macrophages in vascularisation and tissue formation in an AV loop model of tissue generation Jaimin Bhatt, University Health Network, Canada: An old landscape through new eyes – aminoglycosides as a potential therapy for renal cancer Jay Nath, University of Birmingham: Metabolic characterisation of machine-perfused kidneys

Vinnie During: An investigation of the immune microenvironment of bladder cancer and its clinical application

SYME MEDAL

Aman Chandra, Vitreoretinal Fellow, Royal Victoria Eye & Ear Hospital, Australia, and Moorfields Eye Hospital London: The genetic associations of rhegmatogenous retinal detachment and ectopia lentis Grant Stewart, Clinical Senior Lecturer and Honorary Consultant in Urological Surgery, University of Edinburgh: Prognostic and predictive biomarker development in renal cell cancer

ETHICON BURSARY

Cameron Alexander, The James Buchanan Brady, Urological Institute, Johns Hopkins Hospital, Baltimore, USA

Xuxin Lim, Tissue Engineering & Wound Healing Laboratory, Department of Surgery, Harvard Medical School, Brigham and Women’s Hospital, Boston, USA Caitland MacLeod, Aswan Heart Centre, Egypt Sayinthen Vivekanantham, Department of Neurosurgery, Christian Medical College, Vellore, India Rishma Gohil, Ophthalmology Department, Australia Matthew King, Foothills Medical Centre, Calgary, Canada & Global ENT outreach project, Ukraine

WONG CHOON HEE BURSARY

Priyadarsssini Karunakaran, Children’s Hospital of Philadelphia, USA; Hospital for Sick Children, Toronto, Canada; Great Ormond Street Hospital, London Caitlin MacLeod, Aswan Heart Centre, Egypt Nigel Ng, John Hopkins University Burn Center, USA

www.rcsed.ac.uk | 55

COLLEGE INFORMATION

Congratulations to all our new Fellows and Members who were presented with diplomas at ceremonies in September and October

DIPLOMA CEREMONIES FRIDAY 5 SEPTEMBER 2014 ADMISSION TO HONORARY FELLOWSHIP Professor Philippe Dartevelle, Director, Department of Thoracic and Vascular Surgery and Heart–Lung Transplantation, Marie Lannelongue Hospital, Paris ADMISSION TO FELLOWSHIP AD HOMINEM Professor Jean-Claude Givel FACS FRCSEng, Associate Partner, Cabinet de Chirurgie Viscerale, Lausanne; Honorary Professor of Surgery, Lausanne University Professor Patrick Ronan O’Connell FRCPSGlasg (Hon) FRCSIrel, Professor of Surgery, St Vincent’s University Hospital, Dublin; Visiting Surgeon, Mater Misericordiae University Hospital, Dublin; Visiting Surgeon, National Maternity Hospital, Dublin AWARD OF FELLOWSHIPS WITHOUT EXAMINATION Dr Thaier Al Meheidi FRCSIrel FICS FRCPSGlasg FRCSEng FACS, Consultant Surgeon and Head of Surgical Department, Al-Dhaid Teaching Hospital, UAE; Assistant Professor, Sharjah University, UAE Professor Sabarual Mokhtar, Associate Professor and Head of Research Unit, Division of Spinal Surgery, Universiti Kevangsaan, Malaysia Professor Dhananjaya Sharma FRCSGlasg FRCSIrel, Professor and Head of Department of Surgery, Government Medical College, Jabalpur

56 | Surgeons’ News | December 2014

AWARD OF FELLOWSHIP IN DENTAL SURGERY WITHOUT EXAMINATION Professor Hassan Selim, Director of Internship Programmes and Postgraduate Programme for Clinical Teaching, Riyadh College of Dentistry and Pharmacy, Saudi Arabia PRESENTATION OF DIPLOMAS OF FELLOWSHIP IN THE SPECIALTY OF CARDIOTHORACIC SURGERY Ihab Abdelrazek Ismail Mohammed Ali, Ain Shams University, Egypt Kirkpatrick Clyde Santo, University of the West Indies PRESENTATION OF DIPLOMAS OF FELLOWSHIP IN THE SPECIALTY OF GENERAL SURGERY Shwetal Shirish Dighe, University of Bombay, India Tarek Abdurahman Garsaa, Al Fateh University, Libya Chern Beverly Brenda Lim, University of London Tariq Ali Nasser, University of Jordan PRESENTATION OF DIPLOMA OF FELLOWSHIP IN THE SPECIALTY OF OTOLARYNGOLOGY Simon John Prowse, University of Wales PRESENTATION OF DIPLOMAS OF FELLOWSHIP IN THE SPECIALTY OF PAEDIATRIC SURGERY Milan Gopal, Mahatma Gandhi University, India Iain Andrew Marcel Hennessey, University of Edinburgh

PRESENTATION OF DIPLOMA OF FELLOWSHIP IN THE SPECIALTY OF PLASTIC SURGERY Zakir Shariff, Gulbarga University, India PRESENTATION OF DIPLOMAS OF FELLOWSHIP IN THE SPECIALTY OF TRAUMA & ORTHOPAEDIC SURGERY Sumit Batra, University of Delhi, India Parthasaradhi Gajula, Manipal University, India Joshua Thomas Jacob, Mangalore University, India Kiran Kumar Lingutla, Manipal University, India James Dixon Wilson, Newcastle University PRESENTATION OF DIPLOMA OF FELLOWSHIP IN THE SPECIALTY OF UROLOGY Sarfraz Ahmad, Bahauddin Zakariya University, Pakistan PRESENTATION OF THE SYME MEDAL Ernest Anthony Azzopardi, University of Malta

PRESENTATION OF MEMBERSHIP OF THE FACULTY OF SURGICAL TRAINERS Kawan Shalli, Salahaddin University, Iraq PRESENTATION OF INTERCOLLEGIATE DIPLOMAS OF MEMBERSHIP IN OTOLARYNGOLOGY Leanne Olivia Wilson Hamilton, Queen’s University, Belfast Shailesh Ramhari Khode, Maharashtra University of Health Sciences, India PRESENTATION OF INTERCOLLEGIATE DIPLOMAS OF MEMBERSHIP IN SURGERY IN GENERAL Zaid Suleiman Moh’d Abual-Rub, University of Jordan Noel Kochitty Aruparayil, Tver State Medical Academy, Vrach Iryna Atamanyuk, Kiev National Medical University Imed Ben Moussa, University of Malta Douglas Black, University of Aberdeen

Alison Bradley, University of Dundee Sharat Chopra, University of Pune, India Alexander Philip Coupland, Hull York Medical School Ojas Prince Krishnan, University of Birmingham Dileep Kumar, Liaquat University of Medical & Health Sciences, Pakistan Tin Maung Lin, University of Mandalay, Myanmar Q M Morshed Mahbub Abir, University of Dacca, Bangladesh Rachael Elizabeth Mary McBride, Newcastle University Colin Mizzi, University of Malta Wafaa Nour Elddin Elhadi Moh Ahmed, University of Khartoum, Sudan Viswa Retnasingam Rajalingam, University of Birmingham Eyad Walid Rawashdeh, University of Jordan Somaiya Rehman, University of Peshawar, Pakistan Rohini Sahay, Rajiv Gandhi University of Health Sciences, India Sajid Sainuddin, University of Wales Tin May Saw, University of Mandalay, Myanmar Nazlie Syyed, University of Glasgow

Syer Ree Tee, National University of Ireland Jasmine Winter Beatty, University of London PRESENTATION OF DIPLOMAS OF FELLOWSHIP IN DENTAL SURGERY WITHOUT EXAMINATION (by application) Rami Ibrahim Abu-Halimeh, University of Jordan Adli Mohammad Qasem AlGazzawi, University of Jordan Tracy Michelle Dellinger, University of Texas Harold Mark Livingston, University of Tennessee Anna Louise Macdonald, University of Dundee PRESENTATION OF DIPLOMA OF FELLOWSHIP IN THE SPECIALTY OF ORAL MEDICINE Clare Marney, University of Glasgow PRESENTATION OF DIPLOMA OF FELLOWSHIP IN THE SPECIALTY OF ORTHODONTICS Ross James McDowall, Newcastle University www.rcsed.ac.uk | 57

COLLEGE INFORMATION

IN MEMORY HONORARY FELLOWS Samuel Laird GALBRAITH (FRCSEd Hon 2000) Thomas Richard RUSSELL (FRCSEd Hon 2005) Gerald WESTBURY (FRCSEd Hon 1993) FELLOWS WITHOUT EXAMINATION Arthur Siew Ming LIM (FRCSEd 1990) FELLOWS Manikavasagar BALASEGARAM (FRCSEd 1960) Edward George BROWNSTEIN (FRCSEd 1961) Duncan John CAMPBELL (FRCSEd 1973) Francis Ronald CLARK (FRCSEd 1964) William Michael GOULD (FRCSEd 1964) William Stewart HILLIS (FRCSEd 1999) John Francis HICKEY (FRCSEd 1959) William LLOYD-JONES (FRCSEd 1967)

PRESENTATION OF DIPLOMA OF MEMBERSHIP IN ENDODONTICS Jonathan James Cowie, University of Bristol PRESENTATION OF DIPLOMAS OF MEMBERSHIP IN ORTHODONTICS Ahmed Mohamed Farouk El-Angbawi, Alexandria University, Egypt Rohit Madan, Rajiv Gandhi University of Health Sciences, India Nicky David Stanford, Queen’s University, Belfast PRESENTATION OF DIPLOMA OF MEMBERSHIP IN PROSTHODONTICS Alireza Hajiheshmati, Azad University, Iran PRESENTATION OF DIPLOMA OF MEMBERSHIP OF THE FACULTY OF DENTAL SURGERY Vipin Allen, Chaudhary Charan Singh University, India Huma Batool, University of Karachi, Pakistan Jonathan Douglas Ivan Dennis, University of Liverpool Daniel Joshua Finn, University of Liverpool Matthew Rhys Heming, Peninsula College of Medicine & Dentistry Carys Edgcumbe Hipwell, University of Leeds Kiran Jumbu, University of Liverpool

58 | Surgeons’ News | December 2014

Michael Roebourne MADIGAN (FRCSEd 1959) Arthur Leyland Robinson MORRIS (FRCSEd 1965) William Joseph O’SULLIVAN (FRCSEd 1963) Samie Bashir SAFAR (FRCSEd 1974) John Desmond TAYLOR (FRCSEd 1982) Cheok Fai THAM (FRCSEd 1958) Laurance Arthur WATSON (FRCSEd 1961) Bernhard Johannes WOLFF (FRCSEd 1966) DECEASED DENTAL FELLOWS Julius August KIESER (FDS RCSEd 2004) Sol SILVERMAN (FDS RCSEd 2008) Gerhardt Michael WEIDMANN (FDS RCSEd 1941) DENTAL MEMBERS Stuart Peter Edwin TUCKER (MGDS RCSEd 1994)

Stavros Karampatos, University of Athens, Greece Sana Amir Khan, University of Peshawar, Pakistan Kathryn Ann Lee, University of Liverpool Amanda AbouelKhair Henry Mady, Alexandria University, Egypt Taghreed G Majeed, University of Mosul, Iraq Anupam Kumari Rai, Maharashtra University of Health Sciences, India Esther Frances Stephenson, University of Liverpool Ben Wang, University of London Leila Yacoub, University of Dundee

FRIDAY 10 OCTOBER 2014 ADMISSION TO HONORARY FELLOWSHIP Professor Patrick James Broe FRCSIrel, Immediate Past President, Royal College of Surgeons in Ireland; Consultant General Surgeon, Beaumont Hospital, Dublin; Clinical Professor of Surgery, RCSI ADMISSION TO FELLOWSHIP AD HOMINEM Professor Paolo Castelnuovo, Professor & Chairman/Head of Department of Otorhinolaryngology; Director, Surgical Specialties Department; Director & Chairman, Neurological Surgery Department, University of Insubria, Varese, Italy

Professor Ronald Vitt Maier FACS, Professor of Surgery; Vice Chairman, Department of Surgery, University of Washington School of Medicine; Jane & Donald D Trunkey Endowed Chair in Trauma Surgery, University of Washington School of Medicine Professor Keith Malcolm Willett FRCSEng, Professor of Orthopaedic Trauma Surgery, University of Oxford; Honorary Consultant Orthopaedic Trauma Surgeon, John Radcliffe Hospital; National Director for Acute Episodes of Care, NHS England AWARD OF FELLOWSHIPS WITHOUT EXAMINATION Dr Razman Bin Jarmin, Consultant Surgeon in Hepatobiliary & General Surgery, Faculty of Medicine, Universiti Kebangsaan, Malaysia Dr Manickam Ramalingam, Professor, Department of Urology, PSG Institute of Medical Sciences and Research, Coimbatore, Honorary Consultant Urologist, GKNM Hospital, Coimbatore Dr April Camilla Roslani, Professor, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur AWARD OF FELLOWSHIP IN DENTAL SURGERY WITHOUT EXAMINATION Mr Francis Sebastian Alexander Nohl FDS RCSEng, Consultant in Restorative Dentistry, Newcastle Dental Hospital; Honorary Senior Clinical Lecturer in Restorative Dentistry, Newcastle University PRESENTATION OF DIPLOMA OF FELLOWSHIP IN THE SPECIALTY OF CARDIOTHORACIC SURGERY Jane Louise Atkins, University of Wales PRESENTATION OF DIPLOMAS OF FELLOWSHIP IN THE SPECIALTY OF GENERAL SURGERY Claire Carden, University of Aberdeen Claire Jones, Queen’s University, Belfast Vijaykumar Anaveerappa Korwar, Gulbarga University, India Muhammad Asad Parvaiz, University of The Punjab, Pakistan Arun Prasath Shanmuganandan, Dr MGR Medical University, India Jennifer Ann Smith, University of Liverpool Susan Yoong, University of Glasgow

PRESENTATION OF DIPLOMA OF FELLOWSHIP IN THE SPECIALTY OF NEUROSURGERY Babak Homapour, University of Dundee PRESENTATION OF DIPLOMA OF FELLOWSHIP IN THE SPECIALTY OF OTOLARYNGOLOGY Ceilidh Rhona Kennedy, University of Glasgow PRESENTATION OF DIPLOMAS OF FELLOWSHIP IN THE SPECIALTY OF TRAUMA & ORTHOPAEDIC SURGERY Santosh Baliga, University of Aberdeen Niall Patrick Breen, Queen’s University, Belfast Gerard Raymond Cousins, University of Glasgow Saifullah Hadi, University of Oxford Vijaya Kumar Hosahalli Kempanna, Bangalore University, India Andrew William James, Queen’s University, Belfast Andrew Paul Monk, University of London Conor James Mullan, Queen’s University, Belfast Nick Rouholamin, University of Southampton Chloe Elizabeth Henderson Scott, University of Edinburgh Vinay Kumar Singh, University of Allahabad, India Suresh Thomas, Manipal University, India Edwin John Pradeep Vedraj, University of Mysore, India PRESENTATION OF DIPLOMA OF FELLOWSHIP IN THE SPECIALTY OF UROLOGY Susan Fiona Willis, University of Leeds PRESENTATION OF THE LISTER MEDAL Harveer Singh Dev, University of Cambridge PRESENTATION OF INTERCOLLEGIATE DIPLOMA OF MEMBERSHIP IN OTOLARYNGOLOGY Craig James McCaffer, University of Edinburgh PRESENTATION OF INTERCOLLEGIATE DIPLOMA OF MEMBERSHIP IN OPHTHALMOLOGY Than Htun Aung, University of Yangon, Myanmar

PRESENTATION OF INTERCOLLEGIATE DIPLOMAS OF MEMBERSHIP IN SURGERY IN GENERAL James Cragg, University of Wales Joseph El Khalil, American University of Beirut Alaaeldin Mohamed Nadir Taha Ginawi, Khartoum College of Medical Sciences Ioan-Rares Hard, University of ClujNapoca, Romania Cho Nwe Hlaing, University of Yangon, Myanmar Michelle Clare Horridge, University of Sheffield Raviprasad Kattimani, Rajiv Gandhi University of Health Sciences, India Israr Ahmed Khan, Gandhara University, Pakistan Sifat Zereen Khan, University of Dacca, Bangladesh Victor Yeewai Kong, University of Otago, New Zealand Sitara Kuruvilla, University of Manchester Parijat Mathur, Guru Gobind Singh Indraprastha University, India Akmal Hisham Miswan, University of Manchester Sonia Rahman, University of Dacca, Bangladesh Pradyumna Ramchandra Raval, Maharashtra University of Health Sciences, India Andrew Douglas Ross, University of Dundee Sivagnanasundram Srineethan, University of Jaffna, Sri Lanka Yadav Srinivasan, Sri Ramachandra University, India PRESENTATION OF DIPLOMA IN REMOTE AND OFFSHORE MEDICINE David Lee, IHCD, Paramedic PRESENTATION OF DIPLOMA OF FELLOWSHIP IN THE SPECIALTY OF ORTHODONTICS John Nicholas O’Mahony, National University of Ireland PRESENTATION OF THE MRD HOME MEDAL Philip Michael Taylor, University of Leeds PRESENTATION OF DIPLOMA OF MEMBERSHIP IN ENDODONTICS Rose Marie Mulvey, National University of Ireland

PRESENTATION OF DIPLOMAS OF MEMBERSHIP IN ORTHODONTICS Shadi Abdelfattah Alhourani, University of Jordan Erum Aurangzeb, University of Peshawar, Pakistan Gilda Behnam Roudsari, Ajman University of Science and Technology, United Arab Emirates Amir Ashraf Mohamed Sewelam, Mansoura University, Egypt PRESENTATION OF DIPLOMAS OF MEMBERSHIP IN PROSTHODONTICS Assif Ahmed, University of London Farah Yousef Ali Al-Saqobi, Misr University for Science and Technology, Egypt Abid Al-Tamimy, University of Manchester Matthew James Brennand Roper, University of Bristol Zulaikha Ali Burki, National University of Science & Technology, Pakistan Georgios Ioannidis, Aristotle University of Thessaloniki, Greece Philip Michael Taylor, University of Leeds PRESENTATION OF DIPLOMA OF MEMBERSHIP OF THE FACULTY OF DENTAL SURGERY Don Kuriakose Abraham, Kuvempu University, India William George Lechmere Anderson, University of Aberdeen Suzanne Lynsey Cooke, Queen’s University, Belfast Alison Joan Green, Newcastle University Michael James Hicks, University of Manchester Hamera Hussain, University of London Emma Louise Hyndman, Queen’s University, Belfast Andrew David Carmichael Jones, University of Liverpool Joanne Victoria Lamb, University of Sheffield Zhwan Tariq Muhamad, Salahaddin University, Iraq Fiona Aderonke Oluwatayo Osilaja, University of Bristol Teniola Oyeleye, University of Manchester Suhail Shahzad, University of Peshawar, Pakistan Sarmistha Solanky, University of Sheffield Matthew Paul Tushingham, University of Liverpool

www.rcsed.ac.uk | 59

COLLEGE INFORMATION

REGIONAL SURGICAL ADVISERS IN YOUR AREA

3

4

The College’s support and advice network throughout the country 1 Director of the Advisery Network

5

Davinder Sandhu, University of Bristol, Bristol, Severn 2 Deputy Director of the Advisery Network Steven Backhouse, Princess of Wales Hospital, Bridgend, Wales

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9

7

8

11 12

10 31

SCOTLAND

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NORTH OF SCOTLAND 3 Morag Hogg, Raigmore Hospital, Inverness 3 Sean Kelly, Raigmore Hospital, Inverness 4 Aileen McKinley, Aberdeen Royal Infirmary, Aberdeen 4 Euan Munro, Aberdeen Royal Infirmary, Aberdeen

32 30 42

44 43 28

WEST OF SCOTLAND 5 Lindsey Chisholm, Royal Alexandra Hospital, Paisley 6 Jon Dearing, Ayr Hospital, Ayr 7 Martyn Flett, Royal Hospital for Sick Children, Glasgow 8 Calan Mathieson, Southern General Hospital, Glasgow 9 Chris Rodger, Forth Valley Royal Hospital, Larbert 10 Mary Shanks, Crosshouse Hospital, Kilmarnock

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25

46

42

26

19

20 38

17 18 40

SOUTH EAST OF SCOTLAND 11 Farhat Din, Western General Hospital, Edinburgh 12 Anna Paisley, Royal Infirmary of Edinburgh, Edinburgh 12 Zahid Raza, Royal Infirmary of Edinburgh, Edinburgh

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EAST OF ENGLAND 13 Vivek Chitre, James Paget University Hospital, Great Yarmouth 14 Andrew Gibbons, Peterborough City Hospital, Peterborough 15 Milind Kulkarni, Norfolk and Norwich University Hospital, Norwich 16 Vijayaranjan Santhanam, Addenbrooke’s Hospital, Cambridge

KENT, SURREY & SUSSEX 21 Jonathan Clasper, Frimley Park Hospital, Surrey 22 Mike Lewis, Royal Sussex County Hospital, Brighton 23 Mike Williams, Eastbourne District General Hospital, Eastbourne LONDON 24 Ziali Sivardeen, Homerton University Hospital MERSEY 25 Azher Siddiq, St Helen’s Hospital, St Helen’s 26 Venkat Srinivasan, Arrowe Park Hospital, Wirral NORTH WESTERN 27 Stuart Clark, Manchester Royal Infirmary, Manchester 28 Jeremy Ward, Royal Preston Hospital NORTHERN 29 Mike Clarke, Freeman Hospital, Newcastle 30 Jonathan Ferguson, James Cook University Hospital, Middlesbrough 31 Paul Gallagher, Wansbeck Hospital, Northumberland 32 Ian Hawthorn, University Hospital of North Durham

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16

34

24

ENGLAND

EAST MIDLANDS 17 David Exon, Leicester Royal Infirmary, Leicester 18 Sridhar Rathinam, Glenfield Hospital, Leicester 19 Vel Sakthivel, Lincoln County Hospital, Lincoln 20 Bill Tennant, Queen’s Medical Centre, Nottingham University Hospital

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OXFORD 33 Chris Cunningham, Churchill Hospital, Oxford 34 Richard O’Hara, Milton Keynes Hospital, Milton Keynes 33 Mike Silva, Churchill Hospital, Oxford SOUTH WEST PENINSULA 35 Simeon Brundell, Derriford Hospital, Plymouth 35 Ken Hosie, Derriford Hospital, Plymouth WESSEX 36 Anthony Evans, Portsmouth Hospital, Portsmouth 37 Dominic Hodgson, Queen Alexandra Hospital, Portsmouth WEST MIDLANDS 38 Ishan Bhoora, Cannock Chase Hospital, Staffordshire 39 Rajiv Vohra, Queen Elizabeth Hospital Birmingham, Birmingham 40 Ling Wong, University Hospital Coventry and Warwickshire, Coventry YORKSHIRE & HUMBER 41 Aidan Fitzgerald, Northern General Hospital, Sheffield 42 Clare McNaught, Scarborough Hospital, Scarborough 43 David O’Regan, Leeds General Infirmary, Leeds 44 Mark Steward, Bradford City Hospital, Bradford

WALES

45 Samjeev Agarwal, University Hospital Wales, Cardiff 46 Vaikuntam Srinivasan, Glan Clywd Hospital, Rhyl

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ASSOCIATION EVENTS WITH EXCELLENCE AND INDIVIDUALITY

T: 0131 527 3434

E:

W:

OUT OF HOURS

From Hong Kong to London, from the straightforward to the exquisite, Graham Layer goes on a worldwide culinary tour

Laser lights and lobster

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Graham Layer is Consultant Surgeon at the Royal Surrey County Hospital and RCSEd Honorary Secretary

s I prepare to fly to San Francisco for my 20th American College of Surgeons Meeting, where I have a number of official duties, I’ve booked Gary Danko and Michael Mina again. My hard work in America will be rewarded with the ultimate treat at The French Laundry in the Napa Valley, the Michelin threestar restaurant with the nine-course tasting menu. Getting a reservation involved three telephones, two iPads and a well-rehearsed team working with surgical precision two months prior to the required reservation date. You should be able to read in the New Year about the gustatory delights of this holy of holies, which will not be inexpensive.

At the other end of the dining spectrum and halfway around the world is Maxim’s Palace on the second floor of the City Hall on Hong Kong island. The char sui pork buns are superb, stuffed with sticky brown meaty bits mixed in with something more unrecognisable. I always enjoy those little parcels with huge prawns, or chopped up pork and seafood, accompanied by spring rolls and wantons. This year’s visit to Hong Kong included a New York diner in the Langham Hotel complex, Main St Deli.

Straightforward, massive burgers and pastrami dishes, washed down with local beer. I revisited the lobster linguini at Cucina, which now comes in a smaller portion, but remains great value and totally delicious, with perfect herbs and spices.

BLT is a more upmarket large ‘steak and sides’ place with a terrific view of the nightly laser light show over

62 | Surgeons’ News | December 2014

Victoria Harbour. It is related to the restaurant of the same name in Miami, but not quite as good. The best discovery is the Café Deco, high on the Peak, with panoramic views facing north above the tram station towards Kowloon and the fabulous skyline. And the food is outstanding – scallop carpaccio and plenty of it, frothy pea cappuccino with snail ravioli, foie gras, fillet steak and lobster, plus a few in-between mini courses and a fruity dessert. A must on a clear evening, but that is more difficult to predict than the food, which is well worth the struggle in the queue for the Peak Tram.

And now another island, Guernsey, snuggling up close to the French coast, and a haunt of numerous small restaurants. The Brasserie at Old Government House Hotel is one of the elegant hotel’s restaurants above St Peter Port with a great sea view, and reservations are essential. Strongly recommended, with superb classical staff, impeccably dressed, and a great fresh menu highlighting local fish in addition to excellent-quality smoked salmon and the like. There was unbelievable crab with an amazing flavour. Skate wing was served off the bone, or at least off those extraordinary multiple cartilaginous struts. I marvel at the dissection technique.

It was the best I have ever tasted. Perfect chunky sea bass served interestingly with roasted Mediterranean vegetables and a large, flat, thin mushroom. This was followed by entertaining dessert flambés of which fresh cherries were a huge success on more than one evening, served with homemade ice cream and lashings

Hong Kong’s upmarket ‘steak and sides’ eaterie BLT offers a terrific view of the nightly laser light show over Victoria Harbour

The Brasserie at Old Government House Hotel, Guernsey, offers fine fare and superb service

of alcoholic sauce. The steak Diane was good too and its charred ingredients could be modified to your own tastes.

Breakfast and lunch in this institution are also to be strongly recommended. The corned beef hash Benedict style is outrageous and the kippers ooze gorgeous juices.

At the other end of the seafood spectrum I must mention The Albert Arms, a restaurant attached to a pub in the centre of Esher, haunt of certain football players who wear blue and are based in south-west London and Surrey. We had lunch there on the recommendation of an eye surgeon colleague. The grills were massive and really enough for two but the prices were fine for one. So yes, a good find, with a slightly weird empty feeling at lunchtime apart from the bar, and inexperienced service, but it comes up with the goods in terms of ‘comfort food’.

Back in London and another couple of visits to The Delaunay before the theatre – the veal escalopes in breadcrumbs served with anchovies, capers and an egg are really excellent and mouth-watering. But at lunchtime, after a saunter through the magnificent Matisse Cut-outs exhibition, lunch in the Restaurant Tate Modern with another view north, to St Paul’s across the river. What a discovery for a relaxed and delicious lunch.

We ordered off the à la carte menu: Scottish razor clams, in a white wine and shallot sauce as a starter, and a monkfish loin with shrimps as a main course were generous and thoroughly delicious. The duck flying by to another guest looked and smelled wonderful with celeriac and a lemon and thyme sauce, and was cooked pink and tender; there was no sawing or struggling with the knife blade from my guest cutting out the meat. The choice of English cheeses with chutney to follow rounded off a thoroughly good colourful, cultural and gastronomic visit.

Spirit of ’14 Bernard Ferrie breaks with convention to sample Scotland’s whiskies

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n eventful year-long campaign; admirals, Chinese politicos, the Pope and US presidents, present and future, had their say. Finally, Joe McPublic and his wife have been heard. Here’s a celebration of Scotland’s national drink – the turn of John Barleycorn.

Our journey starts in Dumbarton. Ballantine’s (£20); only three years old but well developed with distinctive personality – like our eldest grandson.

Used to buy eggs from the farm where the distillery now stands. Short run up the A82 to Auchentoshan (£27); triple-distilled lowland malt, light and floral.

A few more miles to Glasgow (“Ah belang to Glesca”) – Whyte & Mackay’s Special (£17) is the default house tipple in many a golf club. Knew a chap who had a bottle a week and still made it to over 90.

Striking north next to Glengoyne (£37.50) on the road to Drymen and in spite of the flat terrain a Highland malt rich and fruity: serious, high-end, quality stuff.

Perth next – Bell’s (£20); eight years old, balanced, reliable, dependable big seller. At last, Speyside whisky – Nirvanah – Glenfiddich; a mature 12-year-old but surprisingly light and floral. £12, yes, but only for 20cl.

But this is a wine column so champagne – “In victory I deserve it, in defeat I need it”. Try BillecartSalmon brut reserve (Berry Bros & Rudd, £39.95) and you get a nice colourful tin for your rich Abernethy biscuits after draining the fine toasty bubbles of chardonnay and pinot meunier.

Nice try Alex, but mine’s an Irn-Bru wi’ a Tunnock’s tea cake. The dream lives on.

www.rcsed.ac.uk | 63

FROM THE COLLECTIONS

An aegagropile from a donkey’s stomach, presented by Dr S Oliver, gives an insight into some gruesome practices related to poisoning

FOREIGN BODY WITH A HAIR-RAISING HERITAGE

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he aegagropile, also called a bezoar, is a mass of indigestible foreign material which accumulates and forms in the gastrointestinal tract, oesophagus or trachea. More specifically the trichobezoar is a mass of hair or fur which is found in humans and ruminant animals.

This bezoar measures 65mm and was taken from a donkey. The original cause of the animal’s suffering was unknown until the post mortem revealed multiple hairballs in the stomach.

One of the hairballs was preserved. The other hairball was bisected, and the results showed that the entire structure consisted of short hairs.

The term bezoar is thought to come from Persian ‘pahnzehr’ or Arabic ‘badzher’ meaning ‘counter-poison’ or ‘antidote’1. It was believed that animal bezoar stones could provide protection against poisoning, and some who feared this had them set in rings or on gold chains for dipping into suspect drinks.

Charles IX had great faith in this method until 1575, when Ambroise Paré challenged its validity.

Paré described how he and Charles IX tried to determine the truth by experimenting with poison and bezoar stones on a condemned prisoner2.

A cook, who had been sentenced to death by hanging and strangulation for stealing two silver plates from his master, was approached and asked if he would participate in the experiment. If the bezoar antidote was successful, the prisoner would be granted freedom. The prisoner agreed as he considered death by poison in private to be better than public execution.

An apothecary gave the prisoner poison, then a bezoar stone for ingestion. Even though he pleaded for water to aid his burning stomach, assistance was denied. The prisoner was left for an hour. When Paré returned, he found “the poor cook on all fours, going like an animal, his tongue hanging from his mouth, his eyes and face flaming, retching and in a cold sweat, bleeding from his ears, nose and mouth”. Paré tried to save the prisoner by giving him oil to drink. It was too late and the prisoner took seven hours to die. Paré’s post mortem showed he had died from ‘gastroenteritis from corrosive sublimate poisoning’.

64 | Surgeons’ News | December 2014

This was not an isolated incident. An account from 1712 tells of a prisoner who ingested poison and a bezoar surviving and gaining freedom3 – though this account does stress that eight hours of agony were endured during the process.

Emma Black Public Engagement and Marketing Officer, Surgeons’ Hall Museum

REFERENCES 1. Williams RS. The fascinating history of bezoars. Med J Aust, 1986; 145 (11–12): 613–614.

2. Packard FR (translation).

Life and times of Ambroise Paré (1510–1590) with a new translation of his apology and an account of his journeys in divers places (1921) (see https://archive. org/details/ lifeandtimes amb00 pargoog).

3. Kunz GF. The magic of jewels and charms (1915) (see https:// archive.org/ details/ magicjewels andc00kunz goog).

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outstanding

quality everytime first time All medical devices are CE marked in accordance with the Medical Device Directive (93/42/EEC)

For more information on the complete range of surgical blades, handles, scalpels, disposable, fine and retractable scalpels please go to our website.

The world’s leading surgeons and healthcare professionals can always rely on the consistent quality, precision and performance of surgical blades, handles and scalpels from Swann-Morton.

Our extensive range includes over 70 blade shapes and a selection of 27 handles.

Used in various disciplines for both general and specialist surgery, all our products are subject to the strictest quality control procedures and are guaranteed never to let you down.

Where only Swann-Morton will do.

Owlerton Green, Sheffield S6 2BJ Telephone: 0114 2344231, Sales: 0114 2344223, Fax: 0114 2314966 uksales@swann-morton.com, exportsales@swann-morton.com ‘Swann-Morton’ and the ‘Ring Pattern Logo’ are the registered trade marks of Swann-Morton Limited and related companies.

www.swann-morton.com

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