SN Global June 2014

COUNTRY PROFILE

EXCELLENCE IN INDIA

The RCSEd’s presence in the subcontinent continues to grow

TRENCH MEDICINE

OPERATING ON THE FRONT LINE

TEMPORARY POSTS

Tracing RMO Charles McKerrow’s casualty care in the First World War

LIVING LA VIDA LOCUM

From Malawi to New Zealand, why the locum life is never dull

Snglobal June 2014

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TAILOR-MADE

Innovative solutions to the emergency surgery dilemma from around the world

The international magazine of The Royal College of Surgeons of Edinburgh

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

WELCOME

FROM THE EDITOR Robyn Webber introduces the June edition of SN Global

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MIKE WILKINSON

AMASTE, and welcome to the latest edition of SN Global. In this issue we profile the role of the College in India, where there are around 900 members and fellows.

Many of them have completed the surgical membership and fellowship examinations in one of several cities. RCSEd members and fellows in the country are supported by a team of ISAs (international surgical advisers), working in four different regions. As part of the profile, each ISA has given us their perspective on surgery in India.

From my own point of view, several years ago I travelled to New Delhi as part of a UK examining team for the MRCS, and it has been one of my highlights (so far!) of my involvement with the RCSEd. Apart from taking part in the exam process, I saw some high-quality hospital facilities and was made very welcome by our hosts (one of whom, Professor Lal, has contributed to this edition’s feature) and local medical students who made chai for us. The ISAs who have contributed hail from several parts of India, but if you feel your region has missed out, please contact me, as potential articles for future editions will always be considered.

Another theme we are following this year is the role of doctors in World War One. In this issue, Emily Mayhew recounts the experiences of Dr Charles McKerrow, who in 1915 travelled from Scotland to the Western Front to work as a regimental medical officer.

Charles McKerrow was a GP, but like many GPs at that time had some surgical knowledge, which he put to use on the battlefields of France, developing a reputation for

bravery and his skill as a surgeon. Dr Mayhew’s article makes for thought-provoking reading.

If you are an orthopaedic surgeon (or even if you are not), I would draw your attention to Mr Colin Howie’s discussion of patients’ views on the outcome of their surgery. Some patients are more satisfied with the outcome of their orthopaedic operation than with the service they receive from their bank. The use of outcome data has become very relevant to modern surgery, and Mr Howie raises some very important issues with regard to the different kinds of outcome data that can be collected and interpreted.

Elsewhere in SN Global, consultant surgeon Trevor Crofts considers the life of the surgical locum. Many of us consider locum work during our careers, and Mr Croft provides useful and practical advice on the good and (sometimes) bad points of becoming a surgical locum.

This issue of SN Global should, I believe, contain something to interest everyone, and I trust you will enjoy reading it.

See you next issue.

Robyn Webber editor@surgeonsnews.com

The use of outcome data has become very relevant to modern surgery, and Mr Howie raises some very important issues with regard to the different kinds of outcome data that can be collected and interpreted

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EDITOR Robyn Webber EDITORIAL BOARD Richard McGregor Peter Lamb Peter Douglas Sarah Allen Chris Henry Dr Yvonne Hurst Aoife O’Sullivan Mark Baillie Catriona Gorry 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 DESIGN AND PRODUCTION

Think Publishing Ltd, Woodside House, 20-23 Woodside Place, Glasgow G3 7QF Tel: +44 (0)141 582 1280 www.thinkpublishing.co.uk ACCOUNT MANAGER Clare Harris DESIGN Mark Davies, Alistair McGown SUB EDITORS Sam Bartlett, Sian Campbell 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 SN Global are not necessarily those of the editorial team or the Royal College of Surgeons of Edinburgh.

Information printed in this edition of SN Global is believed to be correct at the time of going to press.

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Contents June 2014 04

GENDA A The latest from the College and the surgical profession

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THE PRESIDENT WRITES Empowering trainees and tackling bullying using the CUSS algorithm

14

THE PRESIDENT’S MEETING Surgeons gathered at the College conference to debate and discuss the path of emergency surgery around the world in the 21st century

22

LOCUM LIFE Trevor Crofts on the trials and triumphs of being a locum

26

RONT-LINE SURGERY F RMO Charles McKerrow’s casualty care in the First World War

30

SERVICE DELIVERY BOA vice-president Colin Howie on measuring service provision in orthopaedics

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COUNTRY PROFILE Surgical advisers on their professional challenges in their roles as RCSEd representatives in India, a seat of surgical excellence

35

DENTAL SURGERY The latest news and views from the Faculty of Dental Surgery

37

TRAINEES AND STUDENTS Paediatrics surgery provision; STARSurg and Trauma conferences; the impact of the European Working Time Directive

42

COLLEGE INFORMATION Awards and grants, diary of surgical and dental events, plus the latest Diploma Ceremony listings

48

FROM THE COLLECTIONS A 19th century deck hand’s tibia

surgeons_news_colour_page_out 13/11/2013 13:58 Page 2

outstanding

CONTENTS

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Agenda The latest news from the College and profession / REGIONAL CENTRE

RCSEd opens new regional centre in Birmingham

I

n April, RCSEd opened its first-ever regional centre in England with a series of innovative educational events aimed at the 80% of its UK membership based in England and Wales.

From career development workshops, to presentations on theatre checklists, and discussions on patient safety, the centre at Birmingham’s Colmore Row hosted a unique week of events covering some of the most important issues facing the profession.

For more, turn to pages 8-9

/ AWARDS

Silver Scalpel for College VP RCSEd vice-president Mr Mike Lavelle-Jones has received one of the most prestigious awards in UK surgery.

Mr Lavelle-Jones (pictured second from right), a colorectal and paediatric surgeon at Ninewells Hospital in Dundee, was named winner of the Silver Scalpel Award by the Association of Surgeons in Training (ASiT) for his outstanding contribution to training in surgery.

On receiving the award, Mr Lavelle-Jones said: “There are few things in the career of a consultant surgeon more satisfying than steering a surgical trainee from novice through to stand-alone competence. The award of the coveted Silver Scalpel is one of the most important moments of my professional life.

“As vice-president of the RCSEd, I know that support and guidance of trainees in the workplace is vital. I’m particularly pleased that

4 | Surgeons’ News Global | June 2014

Mike Lavelle-Jones (second from right) with his Silver Scalpel award

this award has been made while I am serving as an RCSEd office bearer – an organisation that is so strongly committed to supporting trainees.”

The ASiT Silver Scalpel Award has been recognising excellence in surgical training since 2000. It is awarded annually to inspirational

trainers who have scored highly across five categories: leadership, resourcefulness, training and development, professionalism, and communication. Mr Lavelle-Jones received the award at the ASiT Annual Conference, held in Belfast on 28–30 March.

/ APPOINTMENTS

Treasurer named Richard Montgomery (above) has been appointed as honorary treasurer to the RCSEd, and will take over from John Duncan at the AGM in November.

Mr Montgomery has been a member of RCSEd Council since 2011 and is consultant trauma and orthopaedic surgeon at the James Cook University Hospital in Middlesbrough.

Commenting on his appointment, he said: “It will be an honour to succeed John Duncan, who has been a fantastic treasurer for the past five years. The next three years will be an interesting and challenging time for the College, with development in both Edinburgh and in Birmingham. I look forward to getting more involved in the running of our historic organisation.” / AWARDS

Leadership fellowship Mr Nathan Stephens (pictured) has been awarded a prestigious Scottish Clinical Leadership Fellowship, jointly funded by the Scottish Government, the GMC and the Scottish Academy of Medical Royal Colleges. The scheme aims to provide NHS Scotland with a cadre of doctors who are committed to living and working in Scotland and have enhanced capability to offer leadership in their workplace.

Surgery fails to relieve knee pain in thousands of patients / RESEARCH

College supports study into post-TKR knee pain

T

The RCSEd is supporting a research project investigating why 20% of patients who undergo total knee replacement (TKR) continue to experience pain after treatment. The research is aiming to improve treatment for around 15,000 patients each year for whom surgery fails to relieve knee pain.

The College’s Clinical Research Training Fellowship (a joint grant with the Medical Research Council) was awarded to Mr Tom Kurien of the University of Nottingham for his project ‘Bone Marrow Lesions and the Central and Peripheral Drivers of Knee Osteoarthritis Pain. A Pre and

Post Total Knee Replacement Study’. Mr Kurien commented: “Despite the success of surgery, 20% of all patients who undergo TKR have ongoing pain. I will undertake the first study to assess whether retained bone-marrow lesions cause pain after surgery using novel MRI sequences in the knee. This could lead to the development of new treatments to prevent and treat post-operative knee pain.

“This novel research will lead to a more individualised medical approach for the treatment of patients suffering from pain due to knee osteoarthritis. I aim to be able to predict who will comprise the 80% of patients that benefit from TKR surgery in the treatment of knee osteoarthritis.”

/ REPORT

Taskforce reports on impact of EWTD The College has given its support to the findings of a report from the Independent Working Time Regulations taskforce.

Its key recommendations included exploring the possibility of protected education and training time for trainees and promoting the right to opt out by individual doctors. In a statement, RCSEd said departments and services must consider changing work practices and redesigning services to ensure maximum training opportunities and efficient service delivery within the existing rules.

www.rcsed.ac.uk | 5

AGENDA

NEWS IN BRIEF SAS seat on Council In May, the RCSEd agreed to create a new post on its Council for an SAS representative, to be elected by the College’s SAS grades. With the term of office set for five years, the detail of identifying the electorate and the process of running the election are now being taken forward.

Training talk Professor Eduardo Salas, trustee chair and Pegasus professor of psychology at the University of Central Florida, delivered the RCSEd Sir Robert Shields Lecture, entitled ‘Does Medical Team Training Work?’, at the ASGBI annual conference on 2 May.

/ RESEARCH

RCSEd Member leads national CADS audit

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n RCSEd Member is leading a major project aiming to provide ‘landmark data’ in a national audit of complicated acute diverticulitis (CADS).

Shafaque Shaikh, academic clinical lecturer in colorectal surgery at Leeds University, launched the multicentre prospective audit exploring the impact of variability in clinical practice on short-term patient outcomes in diverticulitis.

Mrs Shaikh said: “Acute diverticulitis is a common problem in the UK. However, the

current guidelines are not adequate for its management. Because good quality trials are inadequate, surgical units often adopt variable policies to manage this condition.”

The national audit aims to provide the largest ever dataset on the national incidence, management strategies, short-term patient outcomes, stoma rates and the role of surgical and radiological intervention for CADS. Registration is now open, with data collection taking place for three months from July. www.cadsaudit.org.uk

Ageing issues The College is to host the ‘Ageing Practice – Implications for Healthcare Professionals and Patient Safety’ Symposium on 15 October 2014. The Symposium will explore the problems associated with increasing the retirement age for healthcare professionals and develop an action plan to present to government. The event is bookable through the RCSEd website or by contacting education@rcsed.ac.uk

Annual DCP meeting On 8 March, 145 delegates were in Edinburgh for the 18th Conference for Dental Care Professionals. The programme, organised by Mrs Lorraine Keith, included Charlie Maran’s ‘The Highs and Lows of Periodontal and Implant Therapy’, John Gibson on mouth cancer and smoking cessation, and Mike Wanless on ‘Communication – The Essential DCP’.

Museum overhaul Surgeons’ Hall Museum closed on 18 May for a major redevelopment. It will open again in summer 2015 as a major visitor attraction (see artist’s impression, right).

Before it closed, the College celebrated the Museum with a day of events.

6 | Surgeons’ News Global | June 2014

Left to right: Ben Green, president UKMSA; Cutting Edge Leeds’ James Barnard (secretary), Omar Khalil (president-elect), Gayatri Raghuram (president); and Dr Jonathan Sheffield, chief executive of the NIHR Clinical Research Network / AWARDS

Leeds students pick up Surgical Society prize Undergraduates from Leeds University have won the RCSEd’s prestigious 2014 Student Surgical Society prize. Cutting Edge Leeds was named best society on 2 May at the UKMSA conference, in which finalists from across the UK were invited to present posters about their work.

President of Cutting Edge Leeds, Gayatri Raghuram, said, “We are one of the smaller societies in comparison with the big southern societies, so I’m really glad that the work we’ve done this year has been recognised.”

Mr Steven Backhouse, associate surgical director of the RSA Network, and Mr Aidan Fitzgerald, RSA, shortlisted the abstracts and the judges of the posters on the day were Miss Anna Paisley, RSA, and Mr Fanus Dreyer, consultant general surgeon.

Previous winners from 2012, Nottingham Scrubs, were named runners-up with Anna Paisley commenting: “The overall quality of entrants was very high. I was impressed by the organisation behind the societies and by their breadth of work.”

The latest guidelines, papers and studies

IN BRIEF SIGN GUIDELINES Care of deteriorating patients

This important document provides consensus recommendations for best practice in the management of deteriorating adult patients. Implications of the recommendations include: a requirement to ensure adequate training for healthcare workers in the detection of and response to deteriorating patients; a requirement to ensure adequate levels of appropriately qualified staff to detect and respond to deteriorating patients; implementation of a National Early Warning Score is a desired future state for acute adult care in NHS Scotland.

SIGN 139, May 2014

ANTIBIOTIC PROPHYLAXIS IN SURGERY

This SIGN guideline evaluates the risk factors for surgical site infection, the benefits and risks of antibiotic prophylaxis (including risk of Clostridium difficile infection), indications for surgical antibiotic prophylaxis and the administration of prophylactic antibiotics (type, timing, dosage, duration and route).

LONG-TERM COSTEFFECTIVENESS ANALYSIS OF ENDOVASCULAR VERSUS OPEN REPAIR FOR ABDOMINAL AORTIC ANEURYSM

This paper reviewed four RCTs and found the EVAR-1, DREAM and ACE trials did not find EVAR to be cost-effective at thresholds used in the UK (up to ÂŁ30,000 per QALY). EVAR seemed cost-effective according to models based on the OVER trial. Authors concluded that EVAR was not cost-effective compared with open repair in the long term in trials conducted in European centres. EVAR did appear to be cost-effective based on the OVER trial, conducted in the USA. Epstein D, Sculpher MJ, Powell JT et al.

Br J Surg 2014; b623

REDUCING THE BURDEN OF SURGICAL HARM: A SYSTEMATIC REVIEW OF THE INTERVENTIONS USED TO REDUCE ADVERSE EVENTS IN SURGERY

This meta-analysis evaluated seven RCTs, including a total of 382 patients. Compared with the emergency surgery group, the colonic stent group achieved significantly more favourable rates of permanent stoma, primary anastomosis, wound infection, and overall complications. There was no difference between the two groups in anastomotic leakage, mortality, or intra-abdominal infection. The authors concluded that self-expanding metal stents are a safe and effective bridge to subsequent surgery in patients with obstructing left-sided colon cancer.

This systematic review evaluated interventions which have been introduced to improve patient safety and to reduce adverse events in surgery. Only 17 (of 42 medium to high-quality studies) reported an intervention that produced a significant decrease in morbidity and mortality. Structural interventions were: improving nurse-to-patient ratios and Intensive Care Unit (ITU) physician involvement in post-operative care.

Subspecialisation in surgery reduced technical complications. Effective process interventions were submission of outcome data to national audit, use of safety checklists, and adherence to a care pathway. Certain safety technology significantly reduced harm, and team training had a positive effect on patient outcome. Authors concluded that it is important that future research is focused on demonstrating a measurable reduction in adverse events from patient safety initiatives.

Huang X, Lv B, Zhang S, Meng L. J Gastrointest Surg 2014; 18(3): b584

Panesar S, Burns E, Donaldson LJ, Darzi A. Ann Surg 2014; 259(4): b630

SIGN 104, 2014

JOURNALS Pre-operative colonic stents versus emergency surgery for acute left-sided malignant colonic obstruction

SAFETY OF SHORT, IN-HOSPITAL DELAYS BEFORE SURGERY FOR ACUTE APPENDICITIS: MULTICENTRE COHORT STUDY, SYSTEMATIC REVIEW, AND META-ANALYSIS

This cohort study included 2,510 patients with acute appendicitis, of whom 812 (32.4%) had complex findings. The timing of operation was not related to risk of complex appendicitis. However, after 48 hours, the risk of surgical site infection and 30-day adverse events both increased. A meta-analysis of 11 non-randomised studies (8,858 patients) confirmed that delay of 12 to 24 hours after admission did not increase the risk of complex appendicitis. Authors concluded that short delays of less than 24 hours before appendicectomy were not associated with increased rates of complex pathology in selected patients.

These organisational delays may aid service provision.

UK National Surgical Research Collaborative. Ann Surg 2014; 259(5): b894

ROBOTIC VERSUS LAPAROSCOPIC ADRENALECTOMY: A SYSTEMATIC REVIEW AND META-ANALYSIS

This systematic review identified nine studies including 600 patients who underwent minimally invasive adrenalectomy. There was no significant difference between the groups in terms of conversion rate and operative time.

There was a longer hospital stay in the conventional laparoscopic group as well as a higher blood loss. There was no difference in terms of postoperative complication rate. Authors concluded that the results support the use of robotics for minimally invasive adrenalectomy, although the analysis was limited by sample size and only one low-quality RCT. Brandao LF, Autorino R, Laydner H, et al.

Eur Urol 2014; 65(6): b1154

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AGENDA

BULLYING CONCERNS RAISED AT TRAINEES’ EVENT The RCSEd has used the opening week of its Birmingham centre to engage with Fellows and Members on a range of professional issues

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group of surgical trainees have given the RCSEd their views on the extent of bullying within surgery, with 90% reporting that they have observed bullying or undermining behaviour and 60% saying they have been the victim of it.

Despite the large proportion that had experienced bullying, only 44% of those questioned felt comfortable enough to raise concerns about it at their hospital.

The RCSEd was speaking to a group of around 40 trainees about professional issues and concerns during the opening week of its new centre in Birmingham in April. Attendees were asked for their views on a series of topics, which included WTR, patient safety, and the publication of individual outcome data; 67% said the European Working Time Directive was not good for training and 25% said they would not wish for a relative to be treated in the hospital where they worked.

Patient safety was a key theme at the event, which included talks on surgical safety checklists, the role of anatomical education in surgical safety, and non-technical skills in surgery.

RCSEd’s trainee representative on Council, Richard McGregor, said: “The trainees’ event gave us an immensely valuable opportunity to hear from Members, who joined us from across the UK, about the issues which matter to them. The results from the interactive voting and the discussions that followed highlighted, among other things, the alarming fact that, a year on from the Francis report, trainees are still witnessing and experiencing bullying and harassment within surgical training.

“The College is working hard to explore this issue further and to seek solutions which will allow us to be at

Guests pack into the new Colmore Row centre

8 | Surgeons’ News Global | June 2014

Professor George Youngson CBE leads the NOTSS session of the trainees’ seminar

Professor Davinder Sandhu, surgical director of the College’s RSA network

Patient safety was a key theme at the event, which included talks on surgical safety checklists, and the role of anatomical education and non-technical skills Professor David Sinclair discusses the importance of anatomical education for patient safety

the vanguard of the cultural change that is so obviously needed. Events like those in Birmingham help us along this path as they allow us to engage directly with our membership. The Trainees’ Committee and I are looking forward to holding more events like this in the future.”

The findings on bullying come following the publication in November of the GMC’s trainees’ survey, which found surgery to have one of the highest reporting rates for bullying and undermining of all medical specialties. The RCSEd responded by holding a roundtable discussion which identified cultural issues within surgery as well as pressures upon the service as factors in the prevalence of bullying (Surgeons’ News, March 2014, p46). In September, the College is also due to hold the first of a series of training seminars aimed at improving surgery by addressing cultural aspects of the specialty.

The seminar was part of the opening week programme for the RCSEd’s new centre in Colmore Row, Birmingham. Other highlights included events for SAS grades, regional surgical and dental advisers as well as meetings between College representatives and key stakeholders from the Midlands area.

With the launch of RCSEd’s first presence in England, where it has around 8,000 Fellows and Members, the opening week provided valuable feedback on the views of trainees and this will inform future activity from the College.

HEALTHCARE LEADERS WELCOME COLLEGE’S BIRMINGHAM PRESENCE The College’s centre in Birmingham was formally opened on 3 April 2014. RCSEd representatives gave a warm welcome to key stakeholders as well as Fellows and Members from Birmingham and across the Midlands.

Guests included Professor Ray Linforth, vice-chancellor, University College Birmingham; Elisabeth Buggins, chair of Birmingham Women’s NHS Trust, and Richard Steyn, associate medical director surgery, Heart of England NHS.

RCSEd President Ian Ritchie said: “I hope our Fellows, Members and Affiliates, and healthcare colleagues will feel at home in both our Birmingham base and Edinburgh headquarters for many years to come.”

Elisabeth Buggins, Birmingham Women’s NHS Foundation Trust, Michael Singh, Birmingham Children’s Hospital and Professor Graham Layer, RCSEd

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AGENDA

THE PRESIDENT WRITES Ian Ritchie provides his regular update on the College’s latest activities

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n my last article for Surgeons’ News, I wrote about trust. I believe that when people are trusted, and when we have mutual respect, we are able to achieve much more. Intrinsically, this means a willingness to give up some autonomy and allow others to make decisions and take responsibility, which helps the whole team function more efficiently and safely. In my experience, most organisations are set up to prevent people from doing the wrong thing, rather than to encourage and reward them for doing the right thing. However, I have observed that when people work in teams where there is mutual respect and therefore empowerment, they are far more effective than a group of disconnected individuals who are struggling to avoid doing the wrong thing.

During my time as a trainee, the high points were the occasions when my trainer allowed me the responsibility of decision-making and action because he trusted me to do the right thing. Under these circumstances, I felt good and I was motivated to do more. It should go without saying that this can only happen when a trainer and trainee know each other well because they have worked together for a period of time.

Admittedly, it is difficult to develop that type and

strength of relationship when shift work is a major part of the way we work.

However, as trainers and consultants we can help empower our trainees and other team members by teaching them things they can do to become less dependent on us. That is the essence of teamwork and, while we often apply it to teams of physicians, the reality is that our teams are much broader these days, and reflect our acceptance of the need to have flatter hierarchies which respect the unique knowledge and contribution that comes from all our colleagues in other disciplines.

The first week of April saw the successful launch of our base in Birmingham. For the first time in 500 years, the Royal College of Surgeons of Edinburgh has established a physical presence outside Edinburgh. It was a productive and successful week. We were able to establish good local contacts in the City of Birmingham and among the local deaneries and universities, with whom we identified great potential for collaboration. We used the facilities for meetings and courses and received a great deal of positive feedback from those who joined us from across England and Wales and, indeed, from around the world. Our fellows and members who live and work in England and Wales have been particularly appreciative of the opportunity to attend courses and meetings in a central location, which allows them to go to an event for a day or even half a day without having to be away from home overnight.

The successful events that we held in Birmingham included a day for staff and associate specialists; a meeting for the regional dental advisers; and a meeting for our regional surgical advisers at which they reflected on their progress over the last year in supporting our fellows and members and planned for future activity. One of the high points of this day was a presentation by Peter Lees, director of the Faculty of Medical Leadership and Management. We also ran a very successful PBA course and we finished off the week with

The meeting highlighted the fact that bullying and harassment is still a significant issue for trainees and one which the College is determined to address

Trainee representative on Council Mr Richard McGregor introduces the trainees’ event at RCSEd’s new Birmingham centre

a very useful session for Council examining the College’s strategic plan.

For me as president, one of the most invigorating events was the day for trainees organised by the College’s Trainees’ Committee led by Richard McGregor, our elected trainee member of Council. The event was very successful, attracting a full house of 40 trainees from within the College’s membership. The topics covered during a very stimulating day included the European Working Time Regulations and their effects on training; patient safety; Professor Greenaway’s Shape of Training Report; and the issue of bullying and harassment.

Interactive voting and discussions at the meeting highlighted the fact that bullying and harassment is still a significant issue for trainees and one which the College is determined to address. Teams cannot function where bullying and harassment is present. For those who are subject to such behaviour it can have a significant and lasting impact, but those who witness it within their team can also be affected deeply. As a consequence, trust, the cornerstone of any team, cannot be established, and a climate of fear and mistrust can develop.

This clearly has an effect on patient safety and a related area, which stimulated a lot of discussion, is how trainees can influence those consultants with whom they work who are disinclined to follow the principles of the World Health Organization Patient Safety Checklist – even for those who have not experienced bullying this can be a difficult subject to broach.

Professor George Youngson discussed the CUSS algorithm for escalating concern about patient safety where: C = I am Concerned U = I am Uncomfortable S = I am Seriously Concerned, and S = STOP While we know that there is increasing adherence to the principles of patient safety, a recent survey of our UK fellows has shown that a significant minority feel the checklist wastes time and diminishes efficiency.

Given the evidence that exists about the beneficial effects of team-working and checklists on patient safety, perhaps we should be encouraging a bit more “cussedness” on the part of our trainees so that patient safety becomes an accepted position, which is acknowledged in practice as well as in theory.

I look forward to the day when we can all be sure that whenever anyone in the surgical team expresses concern about an action that might jeopardise patient safety, the whole team takes it seriously. That is surely evidence that we are empowering our teams to give reality to the concept of patient safety in operating theatres across the country.

Ian Ritchie president@rcsed.ac.uk www.rcsed.ac.uk | 11

AGENDA

Reviews Cold comfort

PICTURE COURTESY OF HILOTHERM

A look at the latest surgical technology and books

Hilotherapy is a simple treatment to reduce the pain and swelling caused by surgery. In this technique, water at a precisely controlled temperature (10–38°C) is pumped into fitted masks around the injured area for defined periods of time. It has been known for many years (probably centuries), that cooling injured tissues with ice packs or cold compresses, for example, reduces swelling and relieves pain by decreasing the metabolic rate and the activity of pain receptors in the injured tissue. However, the use of ice packs does not allow control of temperature at the damaged site. If the temperature is too cold (<10°C) and prolonged, the ice-pack treatment becomes uncomfortable and may hinder the healing process by disrupting local microcirculation and nerve function. In the extreme this can cause ischaemic damage to tissue.

Hilotherapy eliminates ischaemic damage by circulating water at a temperature cool enough to stop bleeding, decrease swelling and reduce pain (10–15°C), but not so cold as to cause the deleterious effects associated with prolonged icepack treatment. It is particularly effective in the treatment of haemorrhage, bruising, oedema and inflammation and, therefore, useful in cases of trauma, be it iatrogenic or accidental. Specially designed hollow masks, through which water at a controlled temperature circulates, are available.

The ability to control the temperature of the circulating water allows the use not only of cold water (<15°C) for reduction of pain and swelling, but also of warmer water (up to 38°C) during the healing process to facilitate repair of tissues by causing vasodilatation and increasing the local blood supply.

Lindsay White StR Oral & Maxillofacial Surgeon, Sheffield Teaching Hospitals NHS Foundation Trust Nicholas Lee Consultant Oral & Maxillofacial Surgeon, Sheffield Teaching Hospitals NHS Foundation Trust

12 | Surgeons’ News Global | June 2014

Churchill – The. Supreme Survivor .

AW Beasley Mercer Books, 2013 ISBN 978-0955712739 £25.00 Churchill remains ever popular into the 21st century, recently topping yet another poll as ‘the greatest ever Briton’. Much has been written about him but here, at last, is a biography of Churchill that, although written for a lay readership, is of particular interest to doctors. Wyn Beasley, orthopaedic surgeon turned medical historian, is particularly well suited to describe, explain and analyse the many illnesses and injuries that beset Churchill throughout his long life, and how he survived them.

The title is an apt one, for Churchill famously survived frontline action in two wars and more than 40 years of political conflict in the top echelons of British politics, but his survival from a long and varied catalogue of accidents and illnesses is perhaps even more remarkable.

During his first seven decades he was fortunate to survive several bouts of pneumonia, still a frequent killer in the pre-antibiotic era. His Wyn Beasley first myocardial infarction (on a visit to the is a long-standing White House) was not treated with the six contributor to weeks of bed rest customary at the time – Surgeons’ News – his as wartime leader, Churchill had too historical reviews are available at much to do. www.surgeons Anatomy of Courage, the biography by his news.com personal physician, Lord Moran – widely regarded as breaching patient confidentiality – comes under particular scrutiny. Beasley debunks a couple of Moran’s conclusions – ‘black dog’ did not indicate a major depressive illness and while Churchill’s alcohol consumption was high, there is no evidence that this impaired his judgement or damaged his health. Beasley’s biography – unlike Moran’s – has the blessing of the Churchill family.

Written in Wyn Beasley’s characteristic clear and engaging style, richly illustrated and laid out in a modern design, this book is a joy to read.

Mr Iain Macintyre Past Vice-President of RCSEd

A new book from an award‐winning publisher

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THE PRESIDENT’S MEETING 2014

EMERGENCY SURGERY IN THE 21ST CENTURY 14 | Surgeons’ News Global | June 2014

All sides in the emergency surgery debate came together in March for the College’s annual conference. Discussion on the best configuration for emergency services goes on, but the event provided a valuable opportunity for sharing best practice and innovative solutions from around the world.

John Duncan reports

John Duncan

E

mergency surgery has been described as a ‘Cinderella’ specialty. If that means something which unexpectedly achieves recognition after a period of obscurity or neglect, then the term is undoubtedly accurate. Emergency surgery has been starved of resources, leadership and kudos for too long. It is often regarded as the part of a consultant’s workload that gets in the way of his/her subspecialty work, which is seen as more important and more deserving of investment in research, organisation and visibility. Yet emergency surgery is the area of practice responsible for the majority of surgical bed days and, most importantly, it has the worst outcomes.

A mortality of 15% for laparotomy in an elective case would not be tolerated in any subspecialty, yet we acknowledge this sort of mortality for patients presenting as an emergency. For too long we have tolerated variations in outcomes across hospitals and accepted differential levels of care between week days from 9am to

Perhaps there is no system that is suitable in all hospitals and each will develop a system that works for them 5pm and the care at weekends and out of hours. It is not surprising, therefore, that emergency surgery was chosen as the subject for the President’s Meeting in 2014.

This ‘Cinderella’ is probably in the process of achieving the recognition she deserves after the period of obscurity.

She may not yet have found her prince, but the ugly sisters are being sidelined. Reports have been written emphasising the problems and their solutions. Gradually things are changing, but there are still issues about how change is achieved in different hospitals serving different communities.

Components of the system are similar in different specialties. New patients have to be assessed and complex patients reviewed and managed. A proportion of patients need some degree of critical care and a subset of patients requires operative management.

In the high-volume specialties, there is a need to ensure that only patients who have to be admitted take up valuable hospital bed space. If they are not going to be admitted, there should be an alternative way of managing them as outpatients. In the UK we probably

The College’s Ian Ritchie delivers his address to the President’s Meeting

don’t do as well as our colleagues in other countries in providing ambulatory care, or full outpatient care, for many of these patients.

Some actions seem clear. There needs to be a change of mindset to move the organisation of the care of emergency patients much further up the priority list.

For the individuals providing the care, emergency duty must be reasonable and manageable, and effort needs to go into managing the change necessary to bring about these improvements.

In general surgery, the issue of who should undertake the consultant management of these patients is controversial. The entity of the emergency general surgeon has appeared and individual hospitals have made this system work. Others have organised their care on a subspecialty basis, but this probably works only for large conurbations. Perhaps there is no system that is suitable in all hospitals and each will develop a system that works for them. The two different approaches were outlined at the meeting by Simon Patterson-Brown and Richard Ward in a debate (see the following article).

Different countries handle these issues in different ways. North America went down the trauma centre route many years ago, and the meeting heard from Professor Ernest Moore from Denver about their concept of the acute care surgeon. It would be fair to say that this is an entity which has a particularly North American flavour and is unlikely to find support in the UK. Nonetheless, it brings a very interesting perspective to the problem of a balance between elective and emergency work.

The remainder of the meeting included specialty sessions (see p25), the McKeown lecture by Professor Gordon Carlson on ‘Abdominal Catastrophe: The Salvage of Surgical Disaster’ and a lecture by Sir Keith Porter on the role of prehospital care in delivering the patient alive to secondary care.

Videos of these excellent talks are available on the College website www.rcsed.ac.uk | 15

THE PRESIDENT’S MEETING 2014

Debate: emergency surgery as a defined specialty

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report from the Scottish Audit of Surgical Mortality in 2006 showed that 40% of patients who died were never in an intensive care or high-dependency unit.

This illustrates a fundamental point about surgical patients, yet we, as surgeons, are hardly ever trained in the expertise of emergency surgery and that limits our ability not just to care for patients, but also to know when to involve our ITU colleagues.

In 2005, a colleague of mine carried out a study on his team’s emergency take over a two-week period and discovered frightening results (see Figure 1). It showed that a rise in emergency admissions over the weekends quadrupled the burden on his team. These patients were not all in one ward, but were located in different departments all over the hospital. If that isn’t a patient safety disaster in the making, then what is? Furthermore, the surgical division of bed occupancy showed that emergency admissions took well over half of the beds.

Non-emergency surgeons are used to managing a mixture of elective and emergency patients, but these cases have competing interests and they are located all over the hospital – only now there are additional pressures: WTR, MDTs, the two-week rule, referral-to-treatment time targets; this reduces the incentive to get involved in emergency surgery.

In response, Aintree University Hospital set up the Emergency General Surgical Unit (EGSU), managed by a named emergency consultant surgeon and patients remained under the care of that consultant until they were transferred to an appropriate specialty. This initiative was welcomed by the elective consultants and greatly improved morale at the trust. Within six months, the 16 | Surgeons’ News Global | June 2014

FOR: Richard Ward

Medical Director and Emergency General Surgeon, Aintree University Hospital

percentage of patients discharged home from the EGSU had climbed from around 30% to almost 80%.

From an NHS management point of view, this not only offered a better service, but also saved money. It freed elective surgeons to focus on their core duties and alleviated the workload of the junior team. A registrar looked at how many cases he dealt with during six months on a conventional rota compared with six months inside the EGSU. This suggested a four-fold increase from 300 cases on the conventional rota to 1,200 cases at the emergency unit; that is an amazing learning opportunity for trainees. Similarly, 93% of the diagnostic workload for an SpR in the unit was for common problems, including 23% for upper GI complaints.

The drive to earlier specialisation and reduced core training time has meant the loss of the emergency competence element, which always underpinned specialty training, but was never truly enforced. This could be regained with an emergency surgery training programme with specialties such as general surgery, urology and gynaecology in the core element and vascular, upper and lower GI, and trauma in the higher element.

The Aintree EGSU has shown that surgery in the NHS can be transformed with increased patient safety and cost-effectiveness. Training needs for emergency surgery are very different from elective subspecialty surgery and, hopefully, we’ve demonstrated the case for this to be continued with a specialist training programme.

Six months at Aintree’s Emergency Surgery Unit offered trainees a four-fold increase in cases compared with a conventional rota; that is an amazing learning opportunity

Figure 1: Emergency general surgical workload – two weeks in 2005 F2 annual leave

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20 15 Elective pathway inpatients & subspeciality emergencies

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Consultant oncall periods Grand round, list cancellation

AGAINST: Simon PatersonBrown

Consultant General and Upper GI Surgeon at the Royal Infirmary of Edinburgh

T

he emergency workload represents 50–70% of general surgical practice in the UK and recent reports have revealed a significant difference in outcome between units.1 The question remains as to how this problem might be addressed. What is clear to everyone is that more consultant involvement is required, not only at an earlier stage in the management of patients, but throughout their in-hospital care. The problem is how to achieve this. Will making emergency surgery a defined specialty solve the problem? I would argue ‘no’ for the following discussed below.

Emergency care involves all aspects of general surgery, including the management of post-operative elective patients and general surgeons, irrespective of their elective subspecialty interest, must maintain their emergency skills and be involved in the management of emergency patients on a regular basis. Indeed, the danger of ‘emergency surgeons’ taking over the on-call rota from ‘elective’ surgeons will expose many hospitals to the risk of not being able to maintain a rota.

Once surgeons come off the on-call rota it will be very difficult, if not impossible, to get them back on – as has been the experience of our general medical colleagues. And do we really want our most experienced

Three session list

surgeons, most of whom have a substantial subspecialist elective practice, to come off the on-call rota? I would again say no. They are the backbone of the emergency service and their experience is essential to help nurture and support their younger colleagues. And will trainees apply for purely ‘emergency surgical’ posts? I think not. They must be permitted to develop their own elective interest. A surgeon’s career is long and arduous, experience gained is incremental and maintaining and developing an elective subspecialty interest is a major factor in keeping a consultant surgeon’s interest and enthusiasm.

So how would I propose to address the current problems in service delivery? Firstly, let us look at how we might envisage a ‘gold standard’ service, based on current recommendations2–3: l E arly assessment by a consultant who is available all day and late into the evening seven days per week l Early access to investigations and theatre l G ood continuity of care from all staff members, which will require them to be allocated to the emergency team for a period of time, recognising that shift work for all will still exist by necessity.

This type of emergency team is becoming more common around the UK.4 Clearly, the period of time www.rcsed.ac.uk | 17

THE PRESIDENT’S MEETING 2014

Simon PatersonBrown on why he is against emergency surgery as a specialty

spent on the emergency team may vary between hospitals depending on workload and one consultant cannot cover this workload on his/her own. However, another consultant coming in and taking over from a colleague for a late afternoon/evening shift and then on call overnight from home with compensatory time off the following day is an increasing occurrence.

In order for this to happen, the culture in our hospitals must change and emergency patients must be treated as a priority with appropriate resources allocated to their management before elective activity. Most consultants’ job descriptions when they are appointed include wording along the lines: ‘general surgeon with a subspecialty interest including emergency activity’.

Furthermore, the new consultant contract makes it very clear that in job planning, emergency activity requirements take priority.

There is, therefore, no obstacle to all general surgeons having a major commitment to emergency surgery in their current job plan. They would all rotate into the ‘emergency team’ for a period of time, with no elective activities, providing early and ongoing assessment and management of all patients admitted under their 18 | Surgeons’ News Global | June 2014

The danger of ‘emergency surgeons’ taking over the on-call rota from ‘elective’ surgeons will expose many hospitals to the risk of being unable to maintain a rota care.4 Some larger hospitals have even separated upper and lower emergency GI services and demonstrated a significant improvement in outcome in certain conditions.5–7 What is now required is commitment and time from the consultants, not a defined specialty of emergency surgery. The solution is there for all to see; what is needed is for politicians, health service managers and clinical directors to recognise these priorities and reorganise surgical services accordingly.

References are available at: www.surgeonsnews.com

In session

From orthopaedics to ENT, a broad range of associations and societies discuss specialty surgery

Common fractures account for 75% of orthopaedic trauma workload

Session One British Orthopaedic Association, Society for Cardiothoracic Surgery and the Vascular Society. Chaired by Robert Jeffrey and Richard Montgomery

Robert Jeffrey

Richard Montgomery

M

r John Keating, consultant orthopaedic surgeon at the Royal Infirmary of Edinburgh, provided data illustrating the distribution of straightforward ordinary and more complex fractures. He indicated that the majority of the ordinary fractures could be dealt with by general orthopaedic surgeons working within the district general hospital environment.

He identified that 10 common fractures account for 75% of orthopaedic trauma workload. However, the more complex injuries were probably better dealt with in bigger units where there were surgeons with a subspecialty interest.

The management of cardiothoracic trauma was detailed by Mr Richard Steyn from Birmingham, who considered the indications for thoracotomy in the patient with chest trauma and presented a classification for thoracotomy in trauma: resuscitative thoracotomy

for intrathoracic catastrophes, and damage-control thoracotomy for limiting the consequences of trauma and urgent thoracotomy for definitive surgery undertaken by those with the necessary expertise.

He highlighted the importance of specialist input in the management of chest trauma.

Mr Paul Blair, a vascular surgeon from Belfast, presented several scenarios in which vascular surgical input was of major benefit to patients and reiterated a common factor in all the presentations that early communication with specialists led to better outcomes.

Other common themes alluded to by all presenters were the adverse impact of changes in training programmes, reduced staffing levels and the impact of the European Working Time Directive.

The symposium was appreciated by a well-attended audience who interrogated the presenters with appropriate questions. www.rcsed.ac.uk | 19

THE PRESIDENT’S MEETING 2014

Session Two The British Association of Urological Surgeons, the British Association of Plastic Surgeons and British Association of Plastic, Reconstructive and Aesthetic Surgeons.

Chaired by John Duncan and Judy Evans

Judy Evans

John Duncan

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his session looked at the difficulties experienced by teams in highly specialised fields, and brought into the discussion some very different issues, as well as reiterating that some problems run through all disciplines.

Mark Speakman, presidentelect of BAUS and consultant urologist at Taunton, talked about the evolution of urology as a specialty, and showed how more and more procedures that do not require long hospital stays have developed. The dilemma for such specialties is how to marry up, and indeed rota, such training pressures with sufficient good-quality on-call teaching to deal with relevant emergencies in the best way for patients and trainees.

BAPS’ Bruce Okoye presented a dilemma for paediatric

surgeons, asking “Who should be operating on children’s emergencies?” He pointed out that many paediatric emergencies require specialist paediatric anaesthetists. He posed the crucial question, which went outside his discipline: “Should all surgeons who run an emergency rota have a duty to assess and treat children?”

Consultant in reconstructive and plastic surgery in Bristol, Umraz Khan, gave a very eloquent, visual description of what modern microsurgical repair can achieve and highlighted some of the difficulties of when and when not to perform such salvage surgery.

All three speakers to some extent highlighted the underprovision of a country-wide comprehensive service, and put forward different views of the solutions, which led to a vigorous debate that was stopped only when time ran out.

Session Three The Association of Surgeons of Great Britain and Ireland, the Association of Coloproctology and the Association of Upper Gastrointestinal Surgeons.

Chaired by Michael Griffin and Robert Steele

T

he president of ASGBI, Professor John Primrose, talked about the Shape of Training report and how this would affect the general surgeon of the future. He went through the key messages from the review, which outlines the need for more doctors capable of providing general care in a range of different settings.

Professor Primrose gave a personal view of some of the drivers for these changes and expressed the view that, while some may represent a threat, there are also opportunities. Much of the detail is lacking and how it is implemented is key to the long term. His bottom line was that current training does not produce a surgeon who is suited to manage unselected emergencies in a district general hospital. The two ways forward were either to close the emergency service in most district general hospitals, creating very large hospitals with a specialised emergency service, or to change training, and therefore the subsequent configuration of consultant posts, to produce a surgeon who can provide an excellent emergency service in a district general hospital.

Mr John Hartley from the Association of Coloproctology talked about improving the outcomes in emergency colon and rectal surgery, emphasising 20 | Surgeons’ News Global | June 2014

Michael Griffin

Robert Steele

the morbidity and mortality that arise from high-risk emergency general surgical admissions. These facts were emphasised by others on the day. His concern was that the management of complex colorectal emergencies required specialist colorectal expertise. It also required high-quality radiological intervention across a range of clinical problems.

Mr Ian Beckingham talked about the development of a subspecialist HPB emergency admission system in Nottingham. This was providing a split HPB and general GI service and he explained how this benefited patients by improving, for instance, the number of hot cholecystectomies, as well as improved ward care for HPB elective patients.

From maxillofacial implants to prosthetics, the â&#x20AC;&#x2DC;3D: Printing The Futureâ&#x20AC;&#x2122; exhibition at the Science Museum, London, shows how 3D printing can be used in surgery

Session Four

Roger Curry

Cate Scally

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he head and neck session began with an update on the changing clinical environment in ENT practice and the developments in simulation training in designated clinical skills centres. Professor Nirmal Kumar described the improved facilities for maintaining emergency skills and a general on-call practice in the world of increasing subspecialisation in ENT service. Blended learning and NOTTS courses were discussed.

Mr Roger Currie explained that 75% of facial trauma is now due to assault in young men and took us through the improvements in OMF management using ATLSTM principles. Face transplantation and improvements in fixation techniques by preoperative

modelling aided by 3D printing were discussed. The advances in endoscopic approaches were demonstrated.

The session was completed by Mr Richard Nelson discussing how neurosurgery has worked to achieve a balance between managing emergencies while trying to 3D printed prosthetic maintain elective practice and hand and, below, hip the challenges this has brought. and knee implants Emergency activity forms 50% of the workload. Interventional radiology has allowed 90% of subarachnoid aneurysms to be coiled, but leaves the difficult ones. The risks of surgical deskilling versus specialist centres and subspecialist networks were discussed in relation to cranial and spinal trauma.

An informal and wide-ranging discussion after the presentations proved very useful and highlighted issues for all the smaller specialties within surgery. www.rcsed.ac.uk | 21

IMAGES COURTESY OF 3D: PRINTING THE FUTURE, SCIENCE MUSEUM

ENT UK, the British Association of Oral and Maxillofacial Surgeons and the Society of British Neurological Surgeons. Chaired by Roger Curry and Cate Scally

TEMPORARY WORK

From language barriers to financial costs, the role of locum doctors has come in for criticism in recent years. Trevor Crofts wonders whether the value of locum work is being overlooked

LIVING THE LOCUM LIFE

Trevor J Crofts

is a retired general surgeon, formerly at Edinburgh Royal Infirmary. His last locum post was in New Zealand and he regularly teaches in Malawi

I

f ever there were a denigrated surgical group it has to be the surgical locum tenens. Their history is littered with examples of horrendous misfortune to practitioner and patient. Rarely is the short-term practitioner out of the headlines, by virtue of perceived incompetence, whether in technique, cultural awareness or language.

Management, especially within the NHS, tends to regard locums as a necessary, but at times almost prohibitively expensive, evil. Such attitudes have hardened during my professional life with each reorganisation of the NHS. Unlike Dorian Gray or Faust, I have aged and my surgical life extends back to 1970 when it was commonplace to earn the odd few quid through locum work and, dare I say it, occasionally moonlighting. But remember, this was at a time when my pay cheque was a princely £28 after tax.

Now the cycle of my surgical life is almost complete, the question for me is whether revisiting the past as a locum is a worthy pursuit. Certainly, the medical press seem preoccupied with the ‘wastage’ of manpower and expertise relating to early retirement from the NHS for a variety of reasons, at least some of them justified. In 2007 I fell into this category of premature departures and these are my own observations on the experience.

Firstly, the locum state is not an easy option. To do it well the job in hand has to be embraced with enthusiasm and an abiding love of one’s profession. For many surgeons, the nature of their practice has left them prematurely exhausted and they yearn for an existence far removed from the operating theatre. Others, like myself, valued enormously the fellowship of surgery, which sustained me during 25 fulfilling years in Edinburgh, but wish to take advantage of their enduring good health to broaden their experience and share their knowledge and expertise in a different environment.

The successful surgical locum has always prepared well.

Their family must be conversant with and sympathetic to his/her ambitions. Appropriate financial arrangements have to be agreed for peace of mind, especially if travelling abroad.

One’s children, hopefully well on the way to adulthood, must need to feel secure in their forthcoming ‘independent’ state in the absence of their parent(s). Home rental may have to be considered, with modification to insurance policies etc.

Sufficient time is needed to formalise proper arrangements for employment, especially overseas. It is one thing to be

22 | Surgeons’ News Global | June 2014

offered a position in Australia, but the bureaucracy can be formidable, time consuming and may take months.

One must be aware of the limitations of any short-term contract in terms of gaining the confidence of colleagues, the geography of the workplace, the spectra of disease and cultural attitudes to illness. Additionally, integrating yourself into a group of professionals, with all the nuances of local political challenges confronting them, can be difficult.

Much of the above may seem obvious, and I apologise if it sounds patronising, but to enter into the locum psyche effectively requires diplomacy, humility, generosity of spirit and a willingness to adapt, but not to compromise principles of practice in alien environs. For example, my first locum position was 10 months in Blantyre, Malawi. How does one adjust to the apparent insensitivity to suffering and death displayed by local staff who have been immersed in it for years and become desensitised by the pathological tidal

To enter into the locum psyche requires diplomacy, humility, generosity of spirit and a willingness to adapt, but not to compromise principles of practice in alien environs wave of the HIV epidemic? There are daily ward rounds where up to 20% of the patients ‘disappear’ overnight and the explanation offered is “gone to heaven, Doctor”, “stopped breathing, Doctor” or “taken by the Lord”.

Such factors may be the ultimate challenges to cultural understanding in an environment of deprivation.

But what of the ‘developed world’? For a number of years I have escaped the northern winter for the antipodean summer. I have worked in some of the best-equipped hospitals in the world, where money didn’t seem to be a problem, and with surgeons who appreciate one’s contribution and are willing to help in a whole variety of ways. But beware human nature. Waiting lists are part of surgical life and tend to contain a spectrum of patients that do not belong to the fitter ASA grades. Some of these patients

CHALLENGES

HONESTY

PRINCIPLES TACT HUMILITY

ADAPT CARE

GENEROSITY OF SPIRIT DIPLOMACY

www.rcsed.ac.uk | 23

TEMPORARY WORK Trevor Crofts with two colleagues during his first locum position, in which he spent 10 months in Blantyre, Malawi

remain at the lower end of the waiting list until the locum comes, when suddenly there is a rapid rise up the list of all the gallbladder sufferers with BMIs in excess of 40. A more experienced surgeon will initially reject such a list of patients to reinterview and reassess in outpatients, but younger, less experienced colleagues may feel the weight of expectation, sometimes with unfortunate results. It is true what they say about surgical reputations: a lifetime to build, a day to destroy.

Which brings me to the next obstacle to good locum practice; ‘specialisation creep’. In Britain, it seems that the majority of surgeons have a specialist interest for which they have refined expertise and the majority of their work may involve that specialism. In many areas dependent on locums, the demands are for a more general experience, which can seduce the unwary surgeon out of his comfort zone. Many of us would feel happy performing a right hemicolectomy, but some of us would baulk at doing a low anterior resection if not specifically trained. The pressures and demands to acquiesce to such requests have to be resisted and indeed pre-empted by describing one’s capabilities prior to signing any contract. That is only fair to all parties.

Not to say one should rigidly exclude oneself from such situations, but it requires fine judgment. For example, if I was familiar with a final-year registrar’s capabilities and respected his/her work, I would certainly assist them through such an operation if it was helpful to them.

Locums, by virtue of their very nature, tend to be vulnerable to exploitation by management and colleagues alike and horror stories abound. I am pleased to relate that in six years of locum work my reception has always been welcoming and supportive. Such feelings can be enhanced 24 | Surgeons’ News Global | June 2014

My philosophy has always been that as I am working as a locum only for a finite time, I am more than willing to do the odd couple of extra duties or surgeries to oblige; knowing perhaps that prior to my arrival some departments may have been very stretched on the manpower front only by the recipient being open, honest and receptive to the environment in which he/she must work with their new colleagues. A willingness to go the extra mile is soon noticed and my philosophy has always been that as I am working as a locum only for a finite time, I am more than willing to do the odd couple of extra duties or surgeries to oblige; knowing perhaps that prior to my arrival some departments may have been very stretched on the manpower front.

My locum life is coming to an end, and with some considerable sorrow. But, again, I am aware that practitioners in our profession can go on too long. How many of us have offered encouraging words to our more senior colleagues when they criticise themselves for their troublesome tremor, when really we should have been prompting them to go and find their fly rod? It must be right to quit while you are ahead with a reputation still intact.

Teaching is an option; a chance to maintain that association with young questioning minds who are fascinated, as we have been, by the wonders and privileges of our profession.

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FRONT-LINE SURGERY

Working amid the horror of the front line, Charles McKerrow led a new system of casualty care during WW1 to treat wounds inflicted by high-powered weapons. Emily Mayhew writes

INTO THE ABYSS C harles McKerrow left his practice in Barns Street, Ayr, in August 1915 to take up a position as regimental medical officer (RMO) for the 10th Northumberland Fusiliers on the Western Front in the Great War’s second year. RMOs had responsibility for the primary health and sanitation of the battalion in their care on a day-to-day basis, and for the provision of emergency treatment during periods of fighting.

Many RMOs, like McKerrow, were general practitioners from both urban and rural practices, and some were general or specialist surgeons from metropolitan teaching hospitals.

What they had in common was the commitment to frontline service. McKerrow was hiding the truth when he wrote to his wife that he could “hide amongst the baggage” – he and his colleagues went into the very thick of the fighting to retrieve injured soldiers. McKerrow was more honest in his diary: “It is a queer thing that, as soon as one gets to work amongst the wounded, one ceases to notice the shelling.”

As RMO, McKerrow led a team of 32 stretcher bearers and orderlies at the front. It was an entirely new system of casualty care, driven by the severity of the wounds inflicted by new high-powered rifles and artillery. Casualties required rapid treatment, as close to the point of wounding as possible. Fundamental to this were RMOs, who could not only provide emergency surgery at aid posts and casualty clearing stations on severe wounds, but also supply teams of expert stretcher bearers. These teams could stop a haemorrhage, splint fractures and control shock, keeping casualties alive long enough to get to the aid post, and then from there to the field hospital. Such severe wounds had been the exception in previous wars, where most of the occupants of military hospitals had been suffering from disease. Throughout the Great War, ragged, open trauma with accompanying blast injury would be the norm.

The emphasis on the surgical repair of such wounds did not mean that GPs who became RMOs were less skilled 26 | Surgeons’ News Global | June 2014

Right: Dr Charles McKerrow: “absolutely fearless in the performance of his duty”

I am only a doctor and can hide amongst the baggage Dr Charles McKerrow, Regimental Medical Officer

Gangrenous foot showing two blackened, shrivelled toes and damage to surrounding tissue

or experienced than their general or specialist surgeon counterparts. The responsibilities of GPs in the period were very different from those of today. For men such as McKerrow, who had no large teaching hospital close to their practice, surgery would have been a regular requirement.

McKerrow would have been expected to be able to set fractures, perform tonsillectomies and appendectomies, deal with skull fractures, and other forms of serious injury.

GPs could manage sepsis and anaesthetise their patients, either with the help of a medical student intern or on their own. There was a range of textbooks on surgery in general practice whose authors positively encouraged doctors to perform immediate surgical intervention. John Sluss’s work of 1910, Emergency Surgery for the General Practitioner, described this as “a reforming impulse” for the profession as a whole, although what it actually provided was first-class preparation for service in the war. Sluss included a chapter on the treatment of gunshot wounds and drew up a list of equipment that a GP would need for performing surgery away from his practice rooms in difficult circumstances.

On the Western Front, McKerrow’s operating room was usually a dugout in a trench under fire. Here he set fractures, repaired haemorrhages, cleansed and dressed complex wound traumas, including burns, head injuries and abdominal cases (these dreaded most of all by both medics and soldiers alike). In such places, the volume of work was inconceivable to those not actually at the front. At the Battle of the Somme in July 1916, McKerrow’s medical team was alongside the battalion in the front line at La Boiselle. He treated 1,000 casualties in three days without stopping.

In his medical dugout, dressings and bandages were trodden down into the mud because there was no time to clear them out. Supplies ran low despite his judicious www.rcsed.ac.uk | 27

FRONT-LINE SURGERY

hoarding of essentials prior to the offensive. One of his stretcher bearers was killed and five were wounded. In the battalion as a whole, 2,440 men were lost, including 70 officers and 70 men from one small mining village alone.

McKerrow stepped away from the operating table only when his chief orderly prevailed upon him to rest. Writing home, he gave credit to the men who had brought the wounded to him: “No-one could possibly have equalled my stretcher bearers. As one hardbitten chap said to me: ‘They are doing what Christ would do.’ It really is very fine to see these chaps passing through storms of shell to help their comrades. I am very proud of them and hope they will get some rewards apart from the usual ones of conscience.”

After a short rest, McKerrow was back at the front line.

The nature of the fighting meant that his aid post was pushed back and forth, making emergency surgery even more complicated. On 28 July he had to improvise an aid post out of sticks and greatcoats to save the lives of his wounded men. Losses increased everywhere. By 10 August he was the only RMO left in his brigade, and only three stretcher bearers remained from the original team he had assembled in August 1915. Finally, in October, McKerrow’s battalion and their medics were moved to the rear for a real rest. McKerrow had time to restock his exhausted supplies and send his surgical tools for sharpening at one of the dedicated military knife grinders set up for the purpose behind the lines.

The break gave McKerrow time to assess his own work and purpose at the front. As reinforcements arrived to bring the battalion back up to strength, he realised how important it was for the soldiers to know that he had noticed them. To them, being spotted by the RMO meant that he was more likely to bring them in if they were wounded. So McKerrow took special care to go round the lines every day and introduce himself to everyone there.

His courage and dedication at the Somme had given McKerrow a reputation as the bravest and best RMO in the entire division. Men from other battalions sneaked into his sick parades rather than rely on their newer, less experienced RMOs. Together with the surviving team members, he trained up a new contingent of stretcher bearers. The new recruits learned that Doc McKerrow was prepared to give them as much responsibility as they could handle. Bearers performed inoculations, for instance. Noone who had seen the filth of the battlefield or the rust of the barbed wire objected, although the youngest and newest soldiers sometimes flinched at the sight of the syringe.

By December 1916, McKerrow was ordered back to the front line in the Ypres Salient. For the sake of his family, he had requested a move to a field hospital to the rear and was waiting for news of the transfer. On 20 December, young conscript reinforcements arrived in his battalion trenches.

McKerrow and his bearer team leader went to meet them. As they crossed from one trench to another, a shell exploded nearby, and its fragments wounded both men. The

On the Western Front, McKerrow’s operating room was usually a dugout in a trench under fire 28 | Surgeons’ News Global | June 2014

Top: Surgical instruments from World War One, part of the collection of the RCSEd Right: Brain of a soldier wounded by shrapnel in France in 1915. He later developed traumatic epilepsy and survived his injuries for only a few months

Northumberlands rushed their beloved RMO to the nearest field hospital. Surgeons worked as hard as they could, but all his abdominal blood vessels were ruptured and they could not save him. Sister Constance Druce, who was with him when he died, wrote to his wife that: “I was with him to the last and apparently he did not suffer much pain. He was drowsy from the effects of morphia, not quite unconscious and took a keen interest in his symptoms.”

He was buried in Lijssenthoek Military Cemetery, where his grave may be seen at plot IX.B.15. At his son’s death, McKerrow’s father closed the practice in Barns Street and eventually his wife moved away from Ayr. There is no memorial in the town to the RMO whose achievements were best summed up by his commanding officer who wrote that he had “formed a high opinion of him both as a gallant soldier and a skilful surgeon. He was absolutely fearless in the performance of his duty”.

Dr Emily Mayhew Research Associate, Imperial College London

ASSOCIATION EVENTS WITH EXCELLENCE AND INDIVIDUALITY We are now delighted to be working in partnership with the Festival Theatre and National Museums Scotland to offer Associations a complete package for their Conference.

• Auditorium for 1,000 delegates • 24 Break-out rooms • Exhibition Space for Sponsors • Refreshment Areas • Stunning Playfair Hall for Speakers Welcome Dinner • Gardens and Surgeons’ Hall Museums for Drinks Receptions • National Museums Scotland for a spectacular dinner for 1,000 delegates • Ten Hill Place Hotel for delegate accommodation • Exciting new event space to be opened at the Royal College of Surgeons of Edinburgh in 2014 Please tell your Association that your College can offer a great venue in the city of Edinburgh, and take care of all the arrangements.

T: 0131 527 3434

E: events@surgeonshall.com

W: www.surgeonshall.com

ORTHOPAEDICS

BOA’s vice-president Mr Colin Howie speaks to Mark Baillie about the role of patient feedback and outcome data in improving service provision

DELIVERY DRIVER

30 | Surgeons’ News Global | June 2014

PHOTOGRAPHY: MALCOLM COCHRANE

T

he idea that patients undergoing surgery should rate the arthroplasty experience more highly than customers rate dealing with certain banks and major international companies may come as a surprise to some – although perhaps not all – but it is a finding of a soon-to-be-published article from Mr Colin Howie and his co-authors.

This paper marks the latest phase in outcomes research from the Edinburgh Orthopaedic unit looking into PROMS (patient-reported We have improved outcome measurement).

A consultant orthopaedic surgeon and an honorary lecturer in our clinical Edinburgh, Mr Howie explains how this type of measurement came performance but we into use in orthopaedics: “Orthopaedics has to justify much of its workload to healthcare purchasers; we have been asking patients how much have a problem with surgery has improved their health and standard of living – and we’ve been managing patient doing this for years. Other specialties have used it to some extent, but orthopaedics has used it most widely.” expectations of Explaining more about his forthcoming paper, he highlights healthcare delivery a remarkable set of comparisons: “Based on data we’ve gathered over eight years we can show that patient satisfaction with certain Advisory Committee. However, it was his work in establishing the types of orthopaedic procedure is better than public Scottish Arthroplasty Project (SAP) that testifies to his interest in satisfaction with Apple products and better than public improving service delivery. satisfaction with Royal Bank of Scotland.”

In 1999, with the support of colleagues around Scotland, the He admits there are challenges gaining acceptance routinely gathered administrative dataset on joint replacements for the collection and use of this type of qualitative was sent back to the surgeon involved. By 2001, this had matured data. However, Mr Howie believes it is important into the SAP, concentrating on using personal, individual feedback for clinicians to have an awareness of the full range to manage change rather than collecting implant information of factors that influence patient satisfaction with for research. care, including the whole healthcare experience. He Fifteen years on, the SAP runs almost automatically. ‘Outlying’ says: “Clinicians tend to concentrate on what they individual data are queried with the consultant concerned. The know and do best. They are very good at managing system is checked monthly and consultants respond anonymously. the clinical outcomes, there is good evidence of a Every consultant orthopaedic surgeon doing arthroplasty in reduction in infections and post-operative mortality.

Scotland takes part. So far, all those asked to clarify or review We have improved our clinical performance but we their figures have responded. have a problem with managing patient expectations of What were the key factors that made the system a success? healthcare delivery. Sometimes we create unrealistic “One example is the key difference between the Scottish and expectations of surgery and treatment in general. What English systems. The Scottish system was set up by consultants we are about to publish shows that a third of overall in Scotland with the cooperation of the government – whereas patient satisfaction comes from clinical excellence, a the English system was set up by the government with the third from achieving pre-operative expectation and a cooperation of surgeons. third from patient experience of healthcare delivery.

“Because of individual feedback, ownership and local “More importantly, patient experience of care is knowledge, the dislocation rate following joint replacement significant. For example, they may be moved between in Scotland is much lower than it is elsewhere. The SAP is not wards during the night, their operation might be a unique way of operating, having taken its lead from the cancelled at the last minute, or they may even be Swedish system.” disturbed by a noisy patient in the bed next to them.

Although Mr Howie is a clear advocate of developing the All of these elements have an impact on patient use of outcome data, he sounds a note of caution on the use of satisfaction with healthcare delivery and their overall individual-surgeon mortality figures. He says: “Because death is satisfaction with surgery.” rare in orthopaedics, the use of mortality data is of limited use.

Critics of PROMs data (and the closely linked The numbers are so variable and difficult to case-mix adjust PREMs data – patient-reported experience measures) when looking at 30-day results that publishing individual results argue that they do not reflect the surgical or clinical is probably not helpful. For the SAP’s work, we publish identified excellence of staff and that it can be difficult to influence hospital results. Surgeon results are part of this, but they are either patient expectation or the wider experience not identified. Interestingly, the very successful, anonymous, of healthcare delivery. But Mr Howie believes that Scottish feedback and response process is being proposed in other clinicians, as key influencers on the system, should countries around the world. To some extent, the Scottish system is be interested in the whole experience of healthcare regarded as the way forward.” delivery to achieve the optimum results for patients During his consultant career he has seen waiting times come in their unit. down from five years to 10 weeks. However, many challenges Influencing the system is an area where Mr Howie continue to face the specialty – pressures on theatre time and has had considerable experience. He is nine months demand for beds. Despite these challenges, the BOA can be into a term as president-elect of BOA, is a specialty assured that its current president-elect has an eye on both the advisor to the Chief Medical Officer for Scotland and detail and the broader elements of service delivery. a member of the NICE Interventional Procedures www.rcsed.ac.uk | 31

COUNTRY PROFILE

The RCSEd continues to build on its rich history of promoting top-quality surgery in India

CENTURIES OF EXCELLENCE

I

ndia boasts one of the largest RCSEd memberships outside the UK, with close to 900 Fellows and Members supported by international surgical advisers in Chennai, New Delhi, Hyderabad and Kolkata.

The cities of Kerala, Chennai, Hyderabad, Mumbai, Kolkata and New Delhi are the country’s examination centres, which between them have hosted the MRCS Parts A and B (including the OSCE), and MFDS Part 1, while there is also an MRCS (OSCE) preparation course.

In 2009, the RCSEd marked 10 years of delivering the basic surgical skills course in India, helping to educate more than 1,000 trainees and strengthen the College’s presence in the country.

There are records of many College Fellows and Licentiates practising in India from the early 19th century and Alice Mabel Headwards Hunter, the first woman to become a Fellow of the RCSEd, spent her professional life in India, caring mainly for women and children. The Indian government recognised her service by the award of the Kaiser-i-Hind medal.

THE COLLEGE’S PROFILE IS HEALTHIER THAN EVER The most recent RCSEd activity in India took place in April with a series of courses, examinations and meetings. On 14–15 April, 59 candidates travelled to New Delhi for the MRCS Part B (OSCE) examination.

The exam was convened locally by Professor Pawanindra Lal, with the UK faculty including College vice-president Mr Mike Lavelle-Jones and deputy examinations convener and Council member Peter McCollum.

Following the exam, prospective candidates attended the College’s OSCE preparation course to hear expert advice on technique and plan their own approach for future diets of the examination. Course convener Gwynne Howell explained why the course is a vital tool in preparing for the exam: “The preparation course for OSCE examinations provides an invaluable insight into the examination itself. It is not a revision course and it is 32 | Surgeons’ News Global | June 2014

INDIA

expected that participants are adequately knowledgeable about the subject on which they are to be examined.

“The course demonstrates areas of weakness, but it is designed to develop examination technique and not to assess knowledge.

“Participants on our recent course in New Delhi all rated it as ‘excellent’ and said they would advise their colleagues to attend prior to sitting the exam. In my opinion, the course is an essential part of the preparation for the OSCE examination and should be taken about six months before the examination. However, please note it does not guarantee a pass!”

Later events included examiner training and ‘training the trainers’ workshops for representatives of the National Board of Examinations. Taster

The College’s international surgical advisers in India explain more about their roles as RCSEd representatives and the professional challenges within their respective regions Mr Sai Krishna Vittal Consultant Endocrine and Laparoscopic Surgeon, Sree Sai Krishna Hospital & Vittals Institute of Endocrine and Laparoscopic Surgery, Chennai It is a great privilege and honour to be one of the international surgical advisers (ISA) of the College, one of the oldest surgical colleges in the world. As an ISA, it is fulfilling to be able to guide many junior surgical trainees in their career progression. Chennai has always been one of the ‘beehives’ of College activity in India. Since the 1990s, it has hosted many RCSEd events, such as academic meetings, courses and exams, from the old-style FRCS to the present MRCS OSCE exams. As the convenor of exams in Chennai, it was satisfying to host the recent diets in December 2013, which attracted trainees from India and abroad.

One of the common queries trainees have is regarding guidance preparation for the MRCS examination. Some trainees also ask about the FRCS exams and their eligibility criteria. Trainees are also keen to know about training and job opportunities in the UK. As an ISA, I am always happy to assist them and help in their career progression.

The Edinburgh College is not only one of the oldest surgical colleges, it is also the friendliest. It seems to me hardly surprising that the RCSEd is the most sought-after College among the Royal Colleges in the UK – not only among surgical trainees but also with established consultants.

sessions were also offered for the non-technical skills for surgeons course, safer operative surgery, and workplace-based assessments.

The popularity of the College in south India is an historical relationship sustained by the altruistic contributions of the RCSEd in surgical teaching, training and examination activities Uma Krishnaswamy

Uma Krishnaswamy Consultant Breast Surgeon, Apollo (Main) Hospitals, Chennai My appointment as an ISA in May 2012 brought a continuation of my work from the year 2000 as an overseas tutor, old-style FRCS examiner and convener of basic surgical skills courses in Chennai.

The College presence in south India has always been strong and I sustain the vibrancy of its presence by teaching, training and mentoring trainees through the IC MRCS pathway. The recent successful OSCE preparatory courses that I organised on behalf of the College had a definite impact and have been followed by demand for more in the region.

A current challenge facing Indian trainees is the fiercely competitive environment, with disparate streams of training such as the state-level MS, the national-level NBE, and the stand-alone IC MRCS. That none leads in a structured manner to the JSCFE is of concern, despite the immense interest and demand from both trainees and trainers to introduce this examination in India.

The popularity of the College in south India is a historical relationship sustained by the altruistic contributions of the RCSEd in surgical teaching, training and examination activities. Personal warmth and professional fair play make this college a winner. www.rcsed.ac.uk | 33

COUNTRY PROFILE

Sanjay De Bakshi Consultant Surgeon, General and GI Surgery CMRI, Kolkata I have been an ISA since June 2012.

The constant question that I have had to face is: “How do I further my training in surgery and how can the College help me with this?”

The major challenge for surgical training in India is that while facilities have stayed the same, the number of seats has increased. This has led to shortening of time available for hands-on training. Therefore, another common question is: “Will the MRCS degree help me get a job?”

There are two major reasons that Indian medical students take the MRCS examination. Indian postgraduatedegree holders take the examination to embellish their other degrees to enhance their prospects. The worry is that some MBBS graduates with inadequate surgical training may start to practise surgery after an MRCS degree. The decision by the Indian Medical Association to discourage this practice has led to a general decline in the number of applicants for the MRCS. Pawanindra Lal Professor of Surgery, Maulana Azad Medical College, New Delhi I have been an ISA since 2010 and an examiner for the MRCS since 2004. Until then, I had held the role of a College tutor since 2000. As an ISA, I have been able to project, promote and showcase the presence of the College in my region. I provide advice to prospective candidates about courses and examinations, and offer guidance for improving their outcomes. The newer style of OSCE has been a source of much anxiety among the candidates and I have received a lot of questions about this style of examination.

Though MRCS is the only examination conducted in India, there is a lot of excitement about the arrival of the international FRCS, because most of the candidates appearing for the College examination in India are qualified surgeons, and only a small number are actually in training.

The RCSEd has enjoyed high levels of support since India became independent. This is largely because the College is seen as being very friendly and has reached out in south Asian countries long before the others did.

Also, prominent and senior surgeons in the country, both in the government and private sector, have been RCSEd Fellows and have served as ambassadors for the College among their students and junior colleagues.

The fact that the College is so proactive in organising courses and helping candidates perform better is seen very positively and is one of the important reasons why the College enjoys so much popularity in the surgical community.

Dr Raghu Ram Pillarisetti Director and Consultant Oncoplastic Breast Surgeon, KIMS-USHALAKSHMI Centre for Breast Diseases, Hyderabad Since assuming the role of ISA in 2013, the majority of enquiries I have had from doctors in India centre around surgical training 34 | Surgeons’ News Global | June 2014

A place for reflection: the Taj Mahal in Agra

There is an urgent need to make the surgical training programmes in India more robust, with regular annual recording of in-training assessments, so deficiencies and lacunae with both trainees and trainers can be addressed at regular intervals Dr Raghu Ram Pillarisetti

opportunities in the UK and the exit FRCS. I have helped doctors who have been looking for information about training opportunities in the UK and have encouraged many to complete postgraduate surgical training in India before applying for entry to short-term subspeciality higher surgical training positions in the UK. There is an urgent need to make the surgical training programmes in India more robust, along the lines of the UK higher surgical training programme, with regular annual recording of in-training assessments so that deficiencies and lacunae with both trainees and trainers can be addressed at regular intervals, rather than following the current end-of-training assessment, which leaves very little room for introspection and improvement.

Over the years, friendships have been reinforced between key representatives of RCSEd and their Indian counterparts. Many presidents of the RCSEd have been honoured with the Honorary Fellowship of the Association of Surgeons of India in recognition of their outstanding contribution to surgery and for their unwavering efforts to help surgical trainees from India achieve their goals and ambitions.

DENTAL

Richard Ibbetson reports on the GDC’s regulation of the dental specialties in the United Kingdom

CALL’S MOTIVES UNDER QUESTION

O

ne of the roles of the Dental Faculty is to respond on behalf of its Members and Fellows to consultations from health organisations, government and regulatory authorities to assist in the development of policy and to ensure that the best interests of patients are maintained.

These consultations usually take the form of a document outlining what is proposed and a number of questions seeking the views of respondents.

The General Dental Council has issued a “call for information” in respect of its role in regulating the dental specialties. This is not a “consultation” as the GDC does not propose an alternative to the present system and its questions request “evidence” for the benefits of the specialist lists.

The dental specialist lists were established in the United Kingdom in 1998 following the publication of the Mouatt report1 into UK specialist dental training in 1995 which was the dental supplement to the Calman report on specialist medical training2.

The driver for their introduction was the view formed within the GDC that there was a need to act to protect the public in relation to claims of specialism and practices which restricted their activities to various aspects of dentistry3.

There was no requirement at that time for such practitioners to have additional training or be specialists.

History records that the GDC fought hard with the Surgical Royal Colleges as to which body would be the competent authority.

However, the GDC had previously been given responsibility as the single competent authority for dentistry and was keen to exercise this for the dental specialties.

The current request for information from the General Dental Council therefore comes

as a surprise. The original reasons for setting up the dental specialist lists will not have changed and the risks to the patient of individuals claiming to have “specialist” skills remains the same.

UK dental specialist training is well organised, carefully discharged, and extensively monitored and reviewed.

The request for information from the GDC comes as a surprise, as the reasons for setting up the dental specialist lists will not have changed The benefit to patients of the GDC’s regulation of the dental specialist lists is to allow colleagues in primary care to know that the individual to whom a patient is referred has the requisite skills and expertise4.

The existence of this system protects patients and provides a quality-assured service which is reflected in the low level of complaints to the General Dental Council about care provided by registered specialists.

Richard Ibbetson Dean, Faculty of Dental Surgery References

1Mouatt RB, UK Specialist Dental

Training, NHS Executive. 1995 2Calman KC. Consultation on the Report of the Working Group on Specialist Medical Training, Department of Health England. 1993 3John McLean Oral History Archive: Witness Seminar 1. Regulation of the dental profession. 2011. http:// mcleanarchive.bda.org/witness/ seminar1/default.aspx 4Owall B, Welfare R, Garefis P, et al. Specialisation and Specialist Education in Prosthetic Dentistry in Europe. Eur J Prosthodont Rest Dent 2006; 14: 105–110

www.rcsed.ac.uk | 35

DENTAL

WINNER CROWNED

Hannah Crane from the University of Sheffield triumphs in RCSEd’s first undergraduate UK-wide Dental Clinical Skills Competition

A

first-of-its-kind Dental Clinical Skills Competition organised by the College’s Faculty of Dental Surgery saw the top 14 final-year dental students, from all corners of Britain, gather at the Edinburgh College in March to compete in the final. The ultimate prize for which the participants were competing was an expenses-paid trip to the Chicago Dental Society’s Midwinter Meeting.

Sponsored by DENTSPLY, the Dental Clinical Skills Competition featured a series of regional heats in autumn/winter 2013, in which final-year dental students from 14 of the UK’s dental schools undertook a series of dental challenges to test their abilities.

Out of 300 students who registered to take part in the competition, 258 participated, with the top student from each dental school shortlisted for the grand final.

The grand final tested a variety of complex skills and techniques, including suturing, restoring a fractured tooth, working on root canals, and communication skills with patients. This was followed by a dinner at the College’s Surgeons’ Hall Museum, at which presentations were made to the winner and two runners-up.

Hannah Crane from the University of Sheffield was crowned the overall winner of the competition. Second place was awarded to Lloyd Bovensiepen from Newcastle University and third place to Manas Hamal from Cardiff University.

All participants in the competition received a certificate of participation and 12

Left to right: Manas Hamal, Hannah Crane and Lloyd Bovensiepen

months’ affiliation with The Royal College of Surgeons of Edinburgh, and prizes were awarded to the runners-up.

Commenting on her victory, Hannah Crane said: “I’m really excited to have won the competition – it’s a fantastic privilege and it’s been a wonderful experience. It’s been great to affiliate with The Royal College of Surgeons of Edinburgh as it’s given me the opportunity to learn about postgraduate examinations early on. I definitely want to do a postgraduate examination when I finish my course, and I’m starting to think about that now, so it’s been very beneficial to speak with Fellows from the RCSEd Dental Faculty.

Professor Richard Ibbetson, Dean of the Faculty of Dental Surgery, commented: “We are dedicated to providing comprehensive educational and assessment opportunities to support all men and women who have chosen the rewarding and competitive career of dentistry. We were delighted to have held this exciting UK-wide competition offering the next generation of dentists a chance to showcase their knowledge and skills. Hannah demonstrated extraordinary talent, as did all our finalists. Their emerging talent will be a credit to the profession.” www.rcsed.ac.uk/dental-skills-comp

The finalists

The top 14 UK finalists from the UK Dental Clinical Skills Competition 2014 with Faculty of Dental Surgery Dean Professor Ibbetson.

Front row, left to right: Manas Hamal (Cardiff); Imrana Ishaque (Manchester); Shona Hamlet (Dundee); Hannah Geller (Aberdeen); Imogen Bexfield (Leeds); Hannah Crane (Sheffield); Jaya Pindoria (Barts and the London School of Medicine and Dentistry); Amelia Voss (Bristol) Back row, left to right: Luke Puente De La Vega (Glasgow); Elizabeth Barry (King’s College London School of Dentistry); Lucy Wright (Peninsula College of Medicine and Dentistry); RCSEd Dental Dean Professor Richard Ibbetson; Miesha Virdi (Birmingham); Lloyd Bovensiepen (Newcastle); Gareth Elgan Rees (Liverpool)

36 | Surgeons’ News Global | June 2014

Can we avoid a crisis in the field’s general surgery service provision, and how has the situation come to this?

PAEDIATRIC PROSPECTS

M

any children will be brought to their GP with a potential surgical problem.

Common reasons for referral to a paediatric surgeon include umbilical and inguinal herniae, hydrocoeles, skin lesions, phimosis, or tongue tie.

Previously, this would only have involved being referred locally to a general surgeon with an interest in paediatric surgery. However, since the advent of paediatric surgery as a specialty, more children are being referred to tertiary centres, with a concurrent decrease in paediatric general surgery provision in district general hospitals.

The 2008 General Paediatric Surgery Survey reported that 23,000 elective paediatric general surgical cases are seen by non-specialist paediatric surgeons each year1. The Cochrane and Tanner report showed a nearly 30% decrease in cases

being dealt with at a secondary care level2. One third of acute NHS hospitals did not provide a general paediatric surgery service, and 68% of those that did had concerns about being able to maintain that service after 2013 due to staffing issues.

Whether by fault or by design, it would seem that uptake of training in non-specialist paediatric surgery has reduced in recent years, as evidenced by the low uptake of available training posts. The Great North Children’s Hospital in Newcastle has had only three adult surgical trainees rotating through it in the last seven years. It was felt that more needed to be done to raise awareness of the specialty, as a potential crisis in paediatric surgery service provision looms, with overload of specialist centres by minor cases.

General paediatric surgery is governed by the General Surgery Joint Committee on Surgical Training (JCST). Guidance exists on the JCST website regarding

REFERENCES 1. Pye JK. Survey of general paediatric surgery provision in England, Wales and Northern Ireland. Ann R Coll Surg Engl 2008; 90: 193-197 2. Cochrane H, Tanner S. Trends in children’s surgery in England. Arch Dis Child 2007; 92: 664–667

The Great North Children’s Hospital has had only three adult surgical trainees rotating through it in the last seven years. It was felt more needed to be done to raise awareness of the specialty, as a potential crisis in paediatric surgery service provision looms www.rcsed.ac.uk | 37

TRAINEES AND STUDENTS

Table 1: Author experience and JCST minimum requirements for core procedures Procedure Supervised Performed Assisting

scrubbed or training

juniors

JCST recommended minimum SS/P level (percentage attained during specialty post)

Pre-specialty post experience

Inguinal herniotomy/ ligation of PPV

27

0

5

20 (135%)

7

Acute scrotal exploration

0

16

0

5 (320%)

9

Elective orchidopexy

11

1

2

10 (120%)

4

Pyloromyotomy

6

0

2

6 (100%)

0

Abscess drainage

0

6

0

5 (120%)

50 recorded

Paediatric appendectomy

1

5

0

10 (40%)

25

Circumcision/foreskinpreserving procedures

1 & 1 unscrubbed

6

0

15 (53%)

20

Umbilical/paraumbilical epigastric hernia

3

4

0

5 (140%)

15

Exomphalos surgery

0

0

1

–

0

Tracheoesophageal fistula repair

0

0

1

–

0

Table 2: Author experience of non-core procedures relevant to paediatric surgery Procedure Number Number

performed assisted

or training juniors Laparotomy (including small bowel resection)

3

8

Mainly for necrotising enterocolitis

Major GI resections, all laparoscopic

0

6

Included 2 ileo-anal pouch formations

Laparoscopic minor GI procedures

13

7

Fundoplication/rectopexy/ACE procedures

Endoscopies

11

0

Included 2 PEG insertions

undertaking training (see www.jcst.org/quality-assurance/ documents/cct-guidelines/paediatric-surgery-cctguidelines/view).

Assessment of trainee competency is part of the ARCP process for general surgery. The programme director appoints an assigned educational supervisor (AES) and clinical supervisor who ensure the curriculum is delivered. The trainee is assessed in the usual manner with workplace-based assessments, JCST forms, and ISCP portfolio. If appropriate, the AES will sign off the trainee as ‘competent to perform without direct supervision’ the core procedures. No extra examinations are necessary, and the exit examination remains the same. As OOPT rather than experience (OOPE) the time counts towards CCT. 38 | Surgeons’ News Global | June 2014

It is possible for all competencies to be attained during the specialist post, or by regular formal assessment by specialist paediatric surgeons in a training module based in a non-specialist unit. It is recognised that a combination of both a specialist training post and ongoing exposure in other posts is probably the best option.

TRAINEE SURVEY A SurveyMonkeyTM questionnaire was sent to all Northern Deanery general surgery trainees, to which 40 responded.

This article aims to answer the issues raised. Of the trainees, 40% expressed an interest in training in general paediatric surgery, while 50% were unaware such training was available prior to the survey. No trainees felt such a post should be compulsory for general surgery trainees. And 35%

Mike Kipling MRCS

Specialty Training Registrar, Department of Paediatric Surgery, Great North Children’s Hospital, and RCSEd Trainee Committee member

David Macafee FRCS Laparoscopic Colorectal and General Surgeon of Childhood, James Cook University Hospital, Middlesbrough

Gareth Hosie FRCS

Consultant, Paediatric Surgeon, Great North Children’s Hospital, Newcastle

A combination of ongoing training in the DGH as well as the specialist post is best to provide sufficient exposure to all aspects of the curriculum and core procedures, and the trainee found the post extremely enjoyable and rewarding did not realise paediatric general surgery was part of their syllabus and exit examination, and may be in for a shock at exam time.

TRAINEE OPERATIVE EXPOSURE MK (“the trainee”) undertook a six-month StR6 specialist training post in general paediatric surgery (see Table 1).

Most procedures are supervised trainer scrubbed by nature of the need for continuous assessment.

The trainee was involved in 228 procedures, as documented in Table 2 (excludes very minor operations).

These data support the JCST viewpoint: that a combination of ongoing training in the DGH as well as the specialist post is best to provide sufficient exposure to all aspects of the curriculum and core procedures. The trainee found the post extremely enjoyable and rewarding, and it has enhanced his training.

One significant barrier to uptake of the posts is the complex process of applying – this took 14 months (see summary, right).

CONCLUSION The JCST is correct in stating that general paediatric surgery training should take place in a mixture of specialist and non-specialist posts over the totality of training to ensure adequate experience, acquisition and maintenance of skills. To increase the uptake of training, more advertisement of these posts should occur, and the process of applying should be streamlined.

Units that provide PGS training posts Aberdeen, Belfast, Bristol, Cambridge, Cardiff, Edinburgh, Hull, Leeds, Manchester, Mersey, Newcastle, Norwich, Oxford and Southampton.

Many other units have stopped providing the posts due to the lack of uptake.

The authors welcome notification of training post availability in other units, and will gladly publish a more comprehensive list of training units as a follow-up correspondence as an aid to trainees.

MK can also provide advice to trainees about the training and organisation of a post, though processes vary from deanery to deanery.

Application process timeline

2011 AUG 2011 Trainee approaches deanery, programme director approves the approach

SEP 2011 Trainee directly approaches training unit, visits, meets clinical lead and agrees to apply for the post: submits deanery OOPT forms. Clinical lead issues job offer letter

OCT 2011 Application processed by deanery, programme director and dean give approval

DEC 2011 Trainee approaches JCST: submits CV, job timetable, job offer letter, signed OOPT forms, educational contract

2012 JAN 2012 Clinical lead arranges funding for the post

JUL 2012 JCST approves the post, deanery coordinator applies for GMC approval for the post

AUG 2012 GMC approval granted, post set up for October 2012 OCT 2012 Post commences, ongoing assessment throughout

2013 APR 2013 Post ends

JUN 2013 Deanery sends yellow form and ARCP outcome to JCST, trainee sends copy of signed logbook, green form, evidence of GMC approval

MAY 2013 ARCP governing the post occurs, ISCP portfolio reviewed. Extra forms include both yellow and green JCST forms, educational supervisors’ OOPT report

www.rcsed.ac.uk | 39

WORKING TIME DIRECTIVE

Patient safety lies at the heart of the European Working Time Directive’s provisions. So is it a problem or a solution to the question of training?

TIME TO WORK OUT THE BEST WAY FORWARD

40 | Surgeons’ News Global | June 2014

I

n October 2013, Health Secretary Jeremy Hunt tasked Professor Norman Williams (President, RCS England) to gather views on the European Working Time Directive (EWTD) in medicine. The findings were released on 3 April.1 Recommendations include reviewing best practice, addressing the lack of flexibility in European Working Time Regulations (EWTR), and use of individual opt-outs.

EWTR were fully implemented for UK doctors in training in 2009. This required the working week to be no more than 48 hours, averaged over a 26-week period.

The rationale is based on workers’ health and safety and, critically, patient safety. Subsequent European Court of Justice rulings have clarified ‘work’.2,3 The SiMAP and Jaeger rulings specified that time spent on site is work, even if sleeping. Thus, resident-on-call rotas have become unworkable within EWTR. The SiMAP ruling clarified that non-resident on-call does not count as hours worked unless engaging in work activity. Therefore, night-time cover by doctors in training has become, by necessity, either full shift or non-resident on-call.

SHOULD IT STAY? EWTD is favoured by the trainee groups of all Royal Colleges, except surgery. Patient safety, reduced trainee fatigue and predicted recruitment problems if hours rise (especially for those who work less than full time) are cited as reasons to persevere with EWTR. Those favouring EWTR do not believe increased hours worked by trainees result in improved training. Other drivers for poor training – which include Department of Health targets and the consequent increased pressure to deliver service at the expense of training time – are also important. If such pressures were removed it is logical that training opportunities could be improved without an increase in hours.

SHOULD IT GO? The Association of Surgeons in Training (ASIT) and the British Orthopaedic Trainees Association (BOTA) believe EWTR should be relaxed.4,5 These bodies favour up to a 65-hour week to maximise exposure, aid continuity of care and remain within safe fatigue limits.

EWTR as implemented by many UK trusts and health boards, paradoxically, can compromise patient safety. Loss of 24-hour on-call necessitates frequent handovers, which can lead to mistakes and other negative impacts.4,6 In rotas run at breaking point, as many trainees report, there is no contingency to facilitate study leave or illness, further reducing training opportunities, while the shift system results in an inability to follow a patient’s journey through acute or elective settings. Another consequence is the fragmentation of valued trainer-trainee relationships and apprenticeship-style training.4,6 Shift work features irregular hours and increased tiredness. The need for out-of-hours cover has led to week-long night shifts, often adding up to 100 hours’ duty in a seven-day period. While technically EWTR compliant if followed by a week of zero hours, it defies the spirit of the directive. Thus, the status quo cannot be permitted.

REFERENCES

1. Independent Working Time Regulations Taskforce Report.

The implementation of the Working Time Directive, and its impact on the NHS and health professionals. 2014 2. SiMAP v Conselleria de Sanidad y Consumo de la Generalidad Valencia. Case C-303/98 EC 2000 3. Landeshauptsadt Kiel v Norbert Jaeger. Case C-152/02 EC 2003 4. Editorial. The EWTD: A Practical Review for Surgical Trainees. Int J Surg 2010;10:399-403 5. BOTA Position statement on the EWTD and training in T&O surgery. 2009 6. General Medical Council. The Impact of the Working Time Regulations on Medical Education and Training: Lit Rev. 2012 7. Temple J. Time for Training: A Review of the impact of the EWTD on the quality of training. 2010

IMAGINATIVE SOLUTIONS Imaginative solutions can be found across the UK that allow the retention of surgical team structures and training. Some trusts utilise a non-resident on-call system for registrars, preserving trainees’ daytime contact with their consultant/trainer. A 24/7 consultant-delivered service, with trainers appropriately trained and accredited, should lead to improved training and patient care. Adequate surgical training within a 48-hour working week may be achieved under these circumstances.7 However, the full engagement of Health Education England/NHS Education for Scotland is essential to enact necessary changes in service delivery and training. Such a cultural change within the NHS may seem insurmountable, while change to European law is unlikely and is notable for its absence as a recommendation by Professor Williams.1 Mr Alexander Aarvold, ST7 T&O, Wessex Deanery, RCSEd Trainees Committee Mr Iain McCallum, ST5 General Surgery, Northern Deanery, RCSEd Trainees Committee Mr Richard McGregor, Clinical Lecturer in General Surgery, SE Scotland, Trainee Member of Council

View of the RCSEd Trainees Committee EUROPEAN Working Time Regulations (EWTR) strike at the very heart of how all doctors in training live their lives and, perhaps as importantly, how we deliver safe, patient-centred care.

The RCSEd Trainees Committee believes that the highest quality of surgical training can and should be delivered within the remit of EWTR. However, the road ahead to achieving this goal is far from straightforward. Pivotally, it would involve redressing the imbalance between service provision and training, focusing on the highest quality of surgical training at accredited centres, and by supporting those consultants who are accredited trainers. In many units across the United Kingdom, EWTR as implemented are not fit for purpose. They have led to the

loss of the traditional surgical firm, teamwork and apprenticeship crucial for excellence in both patient care and training.

We consider that extending working hours as a visceral reaction to these failing systems may be a lost opportunity for resetting the balance between service and training. We cannot support the extension of hours unless the time is protected for training alone. It is our view that an opt-out of EWTR for surgeons in training would only lead to this time being directed towards outof-hours service provision and, crucially, discourage those who wish to train less than full time.

Thus, EWTR have the potential to be used as the necessary lever for improved surgical training, rather than be seen as an obstacle.

www.rcsed.ac.uk | 41

COLLEGE INFORMATION

All the latest grants, fellowships and bursaries from the RCSEd

AWARDS & GRANTS SMALL RESEARCH GRANTS (UP TO £10K)

Applications are invited from surgical trainees and recently appointed consultants who are Fellows or Members. Grants are awarded for pump-priming projects for a period of one year only. Research project submissions should satisfy one or more of the College’s four priority areas: Surgical/dental translational research Surgical/dental health services research Research into surgical aspects of patient safety, simulation and non-operative technical skills Cancer research of demonstrable direct clinical relevance to the management of solid tumours.

The application should also include a well-defined exit strategy (ie how the project will be taken forward).

Closing date for applications is Friday 27 June 2014.

THE ROBERTSON TRUST RESEARCH/TRAINING FELLOWSHIP

Applications for funding (£50,000 for one year) are invited from Fellows/ Members of the College in good standing. The successful candidate must be from Scotland and working within the UK, or the research itself must be undertaken in Scotland. Surgical trainees who are within a year of completing the MRCS and would want to join the RCSEd are also eligible.

OPHTHALMOLOGY RESEARCH GRANTS (SPONSORED BY ROYAL BLIND)

ajor project grants (up to £50,000) M Small research support grants for ongoing research (up to £10,000) Applications for funding under the above categories are invited from ophthalmologists currently working in Scotland and all Fellows/Members of the College in good standing undertaking research projects in the UK. Closing date for applications is Friday 7 November 2014.

WONG CHOON HEE MEDICAL STUDENT ELECTIVE TRAVEL BURSARIES (IN ASSOCIATION WITH MEDUCATUS.COM)

This award is open to medical students in the UK and Ireland undertaking approved surgical electives abroad. These awards will be advertised and awarded annually.

The award provides a contribution towards the overall costs of travel and subsistence.

Closing date for applications is Friday 25 July 2014.

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 applications is Friday 24 October 2014.

Closing date for applications is Friday 21 November 2014.

ALASTAIR F. JAMIESON FELLOWSHIP IN GENERAL SURGERY

MEDICAL STUDENT ELECTIVE TRAVEL BURSARIES

This General Surgery Fellowship is dedicated to Alastair F. Jamieson and signifies a donation from A. Jamieson FRCSEd and Mrs Theresa Jamieson in the name of their son.

The sum of £50,000 will be awarded to the successful applicant and will cover salary and costs only for one year.

In association with Ethicon, the RCSEd is pleased to offer medical students an opportunity to apply for a travel bursary towards their elective in surgery.

The 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.

Closing date for applications is Friday 24 October 2014.

Closing date for applications is Friday 21 November 2014.

42 | Surgeons’ News Global | June 2014

JOINT RCSED/SOMS/SHANGHAI HEAD & NECK FELLOWSHIP 2014

Applications are invited from Members/ Fellows of the RCSEd and the Scottish Oral and Maxillofacial Society (SOMS) for a four to six-week fellowship in the Head and Neck Oncology Training Centre in the Department of Oral & Maxillofacial – Head & Neck Oncology, 9th People’s Hospital Affiliated to Shanghai Jiaotong University School of Medicine.

The funding for this fellowship is up to £3,000 to cover costs.

Application is by letter and CV (no more than four pages) along with two current references which should be sent to Mrs Cathy McCartney at c.mccartney@rcsed.ac.uk.

Closing date for applications is Friday 18 July 2014. Applicants may be invited to interview if required. Further information can be obtained from Mr Roger Currie at r.currie@rcsed.ac.uk

CONGRATULATIONS TO THE FOLLOWING AWARDS AND GRANTS RECIPIENTS

Joint RCSEd/MRC Clinical Research Fellowship Thomas Kurien, University of Nottingham: “Bone marrow lesions and central and peripheral drivers of knee osteoarthritis pain: A pre- and post-total knee replacement study” Maurice Wohl Research Fellowship in Surgery/Dental Surgery Kavita Sharma, University of Sheffield: “Development of a biodegradable membrane to be used with skin explants for a one-stage full-thickness skin defect reconstruction” The Joint RCSEd/Cutner Fellowship in Orthopaedics Rhys Clement, University of Edinburgh: “Elucidatingthecausesofchondrocytedeath in Staphylococcus aureus septic arthritis” Small Research Grants Diederik Bulters, University of Southampton: “Haptoglobin and haemopexin supplementation in subarachnoid haemorrhage” Chris Johnston, University of Edinburgh:

“Investigation of helminth-induced changes in gene expression effecting immunological tolerance” David Izadi, University of Oxford: “Investigating the role of TNF receptors and TNF signalling in Dupuytren’s disease” Africa Bursary Emily Vaughan, University of Birmingham: Visit to Hospital Lutherien Antanimalandy, Madagascar James Glasbey, Cardiff University: Visit to Chris Hani Baragwanath, Academic Hospital, South Africa Keiran Clement, University of Aberdeen: Visit to Queen Elizabeth Central Hospital, Malawi Eleanor Crossley, University of Birmingham: Visit to Kasangati Health Centre IV, Uganda Terry Evans, Imperial College London: Visit to Connaught Hospital, Sierra Leone Ethicon Travel Grant Samuel Leong, Waitemata Health Board, Auckland, New Zealand: Clinical Fellowship in advanced Rhinology & Anterior Skull Base Fellowship Kenneth Elder, The Royal Melbourne and Royal Women’s Hospital: Research towards an MD qualification from Melbourne University Nandita Pal, Royal Adelaide Hospital, Australia: Endovascular/Vascular Fellowship Ethicon Bursary James Glasbey, Cardiff University: Visit to the Department of Surgery, Chris Hani Baragwanath Academic Hospital, South Africa Mr Rory Piper, University of Edinburgh:

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.

Visit to the Department of Neurosurgery, Boston Children’s Hospital, Boston Miss Georgina Phillips, Imperial College London: Visit to the Department of Plastic Surgery, Midddlemore Hospital, New Zealand, and Trauma Department, Groote Schuur Hospital, South Africa Miss Alice Baggaley, University of Oxford: Visit to the Comprehensive Rehabilitation Services in Uganda (CoRSU) Luke Curwell, Imperial College London: Visit to the Department of Ophthalmology, Auckland University, New Zealand Mr Howard Chu, University of Bristol: Visit to the University of Hong Kong Ophthalmology Grants – Major Project Grants John Forrester, School of Medicine and Dentistry, University of Aberdeen: “Invitroevaluationofimmunologicalproperties of cross-linked recombinant human collagen hydrogels used in corneal regeneration for pre-clinical applications”

David Charteris, Tennent Institute of Ophthalmology (Glasgow) & Moorfields Eye Hospital (London): “A randomised controlled trial to reduce retinal displacement and symptoms of distortion following retinal detachment repair” Robert MacLaren, Nuffield Laboratory of Ophthalmology, University of Oxford: “Development of cone photoreceptor transplantation” Ophthalmology Grants – Small Project Grant Stewart Gillan, Department of Ophthalmology, Ninewells Hospital, Dundee: “Stereopsis in cataract surgery simulation” Umiya Agraval, Tennent Institute of Ophthalmology, Gartnavel General Hospital, Glasgow: “Bacterial endotoxin: culprit in the worsening of corneal ulcers and ocular surface conditions? (pilot study)”

PROFESSIONAL EXCELLENCE GROUPS: CREATING BETTER LEADERSHIP IN SURGERY 19 SEPTEMBER 2014 • ROYAL COLLEGE OF SURGEONS OF EDINBURGH THE aim of this course is to develop the skills and methodology for participation in Professional Excellence Groups (PEGs) to gain maximum benefit from them.

Attendees will establish the purpose and key characteristics of PEGs, develop key skills (listening, contributing, questioning, providing feedback) and provide and review a model of a PEG experience.

CONVENOR Lorna Marson FRCSEd, Senior Lecturer in Transplant Surgery, University of Edinburgh FACULTY David Pitts, Cupar | Anne Maree Wallace, Edinburgh Juliette Murray, Edinburgh | Angus Watson, Inverness COURSE FEE £115 (£95 for RCSEd Fellows and Members) Book online www.rcsed.ac.uk or email education@rcsed.ac.uk / +44 (0)131 527 1600

www.rcsed.ac.uk | 43

COLLEGE INFORMATION

DIPLOMA CEREMONIES Congratulations to all our new Fellows and Members who were presented with diplomas at ceremonies in March and April FRIDAY, 7 MARCH 2014 ADMISSION TO THE COURT OF REGENTS Mr Bruce W Minto, Managing Partner, Dickson Minto WS, Edinburgh ADMISSION TO FELLOWSHIP AD HOMINEM Professor D Stewart Irvine FRCOG, Director of Medicine, NHS Education for Scotland ADMISSION TO FELLOWSHIP IN DENTAL SURGERY AD HOMINEM Professor Christopher Franklin OBE FRCPath FDS RCSEng FFGDP, Retired Regional Postgraduate Dean, South Yorkshire & East Midlands Postgraduate Medical & Dental Deaneries PRESENTATION OF THE DENTAL FACULTY MEDAL Professor James P McDonald FDS RCSEd FRCSEd(Hon), Professor of Orthodontics, University of Glasgow & Honorary Consultant Orthodontist to Greater Glasgow Health Board AWARD OF FELLOWSHIP IN DENTAL SURGERY WITHOUT EXAMINATION Professor Bun San Chong FDS RCSEng, Professor of Restorative Dentistry & Honorary Consultant, Endodontic Lead & Director, Postgraduate Endodontics, Institute of Dentistry, Barts & London School of Medicine and Dentistry, University of London Mr Allan R Thom FDS RCSEng LLM, Retired Consultant Orthodontist, Queen Victoria Hospital, East Grinstead & Guy’s Hospital, London 44 | Surgeons’ News Global | June 2014

AWARD OF FELLOWSHIP WITHOUT EXAMINATION Dr Lik Thai Lim FRCOphth, Glaucoma Fellow, Gartnavel General Hospital, Glasgow Mr Sunil S Thomas FRCSEng (Plast), Plastic Surgery Consultant, Queen Elizabeth University Hospital, Birmingham DIPLOMA OF FELLOWSHIP IN THE SPECIALTY OF GENERAL SURGERY William Reginald Joseph Carr, Newcastle University DIPLOMA OF JOINT SPECIALTY FELLOWSHIP IN GENERAL SURGERY Rajesh Babu Dharmaraj, Rajiv Gandhi University of Health Sciences, India DIPLOMA OF FELLOWSHIP IN THE SPECIALTY OF PLASTIC SURGERY Salim Ullah Ahmed, University of Southampton DIPLOMAS OF FELLOWSHIP IN THE SPECIALTY OF TRAUMA & ORTHOPAEDIC SURGERY Kemparaju Narayanasetty, Bangalore University, India Balaji Purushothaman, Dr MGR Medical University, India DIPLOMAS OF FELLOWSHIP IN THE SPECIALTY OF UROLOGY Ivo Dukic, University of Manchester David Alistair Bryant, University of Liverpool Samer Ali Mah’d Obeidat, University of Jordan DIPLOMAS OF MEMBERSHIP IN OPHTHALMOLOGY Mya Thandar So, University of Yangon, Myanmar

May Zun Aung Win, University of Yangon, Myanmar INTERCOLLEGIATE DIPLOMAS OF MEMBERSHIP IN SURGERY IN GENERAL Ossama Zakareia Sayed Ahmed Abdelrazek, Alexandria University, Egypt Vinay Kumar Aggarwal, University of Delhi, India Abdul Kareem Rashid Aldaoseri, University of Basrah, Iraq Omar Al-Hadeedi, National University of Ireland Vaibhav Mohan Aterkar, Maharaja Sayajirao University of Baroda, India Phyo Aung, University of Yangon, Myanmar Paul Stephen Cullis, University of Glasgow Stephan Ben Dreyer, University of Dundee Ye Nay Myo Han, University of Mandalay, Myanmar Niamh Mary Haughey, University of London Syed Suhaib Jameel, Rajiv Gandhi University of Health Sciences, India May Kasone, University of Yangon, Myanmar Siddhant Khare, All India Institute of Medical Sciences, India Mohamed Abdulmoniem Ibraheem Ahmed Khogali, University of Medical Sciences & Technology, Sudan

Ashley Sarah Logan, Newcastle University Jane Elizabeth McAnally, Newcastle University Claire Rosemary McDevitt, Charles University, Czech Republic Laura Ann McGrath, National University of Ireland Julia Aileen Nicola McGurk, University of Dundee Nadia Jayne McMinn, University of Dundee Sridhar Narasimha Murthy, Bangalore University, India Manon Fflur Pritchard, University of Wales Nafeesa Qureshi, University of Kashmir, India Fadi Atef Elshahidy Abdelshahid Said, Alexandria University, Egypt Keerthi Kumar Ujjini Basavaiah, Bangalore University, India Saurab Singh Virdi, University of Nairobi, Kenya Stephanie Jane Folbigg Wischhusen, University of Liverpool PRESENTATION OF THE JOHN SMITH MEDAL Julia Aileen, Nicola McGurk Sein Lynn, University of Yangon, Myanmar Mudassar Majeed, University of the Punjab, Pakistan Indrani Mukherji, University of Calcutta, India Muslim, University of Karachi, Pakistan Abdul Rauf, University of Health Sciences Lahore, Pakistan G Ravikumar, University of Madras, India Bernard Fergus Mark Robertson, University of Edinburgh Gregory Aidan James Robertson, University of Edinburgh Zena Julia Mary Rokan, University of Liverpool Tin May Saw, University of Mandalay, Myanmar Darren Leonard Scroggie, Queenâ&#x20AC;&#x2122;s University Belfast Peter John Webster, University of Leeds May Thwe Thwe Win, University of Yangon, Myanmar Phyo Zin Win, University of Yangon, Myanmar Sein Win, University of Yangon, Myanmar DIPLOMAS OF FELLOWSHIP IN DENTAL SURGERY WITHOUT EXAMINATION (by application) Trudee Ann Hoyte, University of the West Indies

Jane Avril Macpherson, University of Edinburgh DIPLOMA OF MEMBERSHIP IN PAEDIATRIC DENTISTRY Dania Siddik, Statutory Examination, General Dental Council DIPLOMAS OF MEMBERSHIP OF THE FACULTY OF DENTAL SURGERY Aya M Abbas, University of Jordan Anisa Ali, University of the Punjab, Pakistan Asmaa Al-Maliky, University of Baghdad, Iraq Atif Bashir, University of Glasgow Katherine Bromhall, University of Manchester Alaa Hassan Daud, University of Baghdad, Iraq Niamh Galligan, University of Dublin Yehya Esame Khalil Gamie, University of Sheffield Satish Maruti Gangurde, University of Bombay, India Rodrigo Jose Gutierres Madrigal, National Autonomous University of Nicaragua Robert Samuel Hardy, University of Wales Peter Hole, University of Sheffield Deborah Yvonne Hughes, University of Sheffield Mujtaba Hussain Lakho, University of Dublin, Ireland

DIPLOMAS IN ORTHODONTIC THERAPY Linda Creagh, School of Postgraduate Medical & Dental Education, University of Central Lancashire Sophie Gannon, School of Postgraduate Medical & Dental Education, University of Central Lancashire Sharon Hill, School of Postgraduate Medical & Dental Education, University of Central Lancashire Carrie Anne Hughes, School of Postgraduate Medical & Dental Education, University of Central Lancashire Monika Kaczmarek-Olayemi, School of Postgraduate Medical & Dental Education, University of Central Lancashire Louise Anne MacDonald, Central Manchester School of Dental Care Keely Hannah Sheppard, School of Postgraduate Medical & Dental Education, University of Central Lancashire Lisa Jane Taylor, School of Postgraduate Medical & Dental Education, University of Central Lancashire Amy Louise Westrope, School of Postgraduate Medical & Dental Education, University of Central Lancashire www.rcsed.ac.uk | 45

COLLEGE INFORMATION

IN MEMORY HONORARY SURGICAL FELLOWS David Ralph MILLARD (FRCSEd Hon 1986) SURGICAL FELLOWS WITHOUT EXAMINATION John Beocher SCRIMGEOUR (FRCSEd 1987) SURGICAL FELLOWS Derek Pitcairn ANDERSON (FIMC 2002) William Leke ASONG (FRCSEd 1975) Kenneth Leonard CLEMINSON (FRCSEd 1963) Cecil Paul COTTERILL (FRCSEd 1957) Lawrence Aubrey EMTAGE (FRCSEd 1982) David Glyn EVANS (FRCSEd 1971) Christopher Sapara GRANT (FRCSEd 1976)

FRIDAY, 25 APRIL 2014 ADMISSION TO HONORARY FELLOWSHIP Professor Sir Michael Richards CBE FRCP, Chief Inspector of Hospitals, Care Quality Commission; ImmediatePast National Cancer Director, Department of Health Professor Andrew L Warshaw FACS, Surgeon in Chief, Emeritus, and Senior Consultant in International & Regional Clinical Relations, Massachusetts General Hospital; W Gerald Austen Professor of Surgery, Harvard Medical School; President-elect, American College of Surgeons ADMISSION TO FELLOWSHIP AD HOMINEM Dr Aileen M Keel CBE FRCPSGlasg FRCPEd FRCPath, Deputy Chief Medical Officer for Scotland ADMISSION TO HONORARY FELLOWSHIP IN DENTAL SURGERY Professor Jatin P Shah FACS FRCSEd(Hon) FDS RCSEng(Hon) FRACS(Hon)

46 | Surgeons’ News Global | June 2014

Kenneth Edmund GUEST (FRCSEd 1947) Derek HALL (FRCSEd 1986) David LEES (FRCSEd 1968) Richard Anthony McARTHUR (FRCSEd 1969) George Mtutuzezi Funisela MBOLEKWA (FRCSEd 1970) Victor Anomah NGU (FRCSEd 1959) George John ROMANES CBE (FRCSEd 1958) Ralph Neville SAPSFORD (FRCSEd 1967) Angela Jane STOCKWELL (FRCSEd 1985) Peter William Harold WOODRUFF (FRCSEd 1971) DENTAL FELLOWS WITHOUT EXAMINATION Bertram COHEN CBE (FDS 1967) Jack Stuart BERESFORD (FDS 1965)

Elliot W Strong Chair in Head and Neck Oncology, Memorial Sloan-Kettering Cancer Center, New York City AWARD OF FELLOWSHIP IN DENTAL SURGERY WITHOUT EXAMINATION Mr Richard M Graham FRCSEd (OMFS) FDS RCSEng, Consultant in Oral and Maxillofacial Surgery, North Manchester General Hospital AWARD OF FELLOWSHIP WITHOUT EXAMINATION Professor Sandeep Saxena, Professor and Chief of Retina Service, Department of Ophthalmology, King George’s Medical University, Lucknow, India PRESENTATION OF DIPLOMA OF FELLOWSHIP IN THE SPECIALTY OF CARDIOTHORACIC SURGERY Vivek Srivastava, Barkatullah University, India PRESENTATION OF DIPLOMAS OF FELLOWSHIP IN THE SPECIALTY OF GENERAL SURGERY Peter Edward Coyne, Newcastle University Maruthesh Gowda Chikkappa,

Rajiv Gandhi University of Health Sciences, India Mei-Ju Hwang, University of Leicester Khalid Abdalla Mohamed Nour Osman, United Examining Board, England Nafees Ahmad Qureshi, University of Peshawar, Pakistan Zeyad Ali Sallami, Sana’a University, Yemen Richard John Edward Skipworth, University of Edinburgh Nicholas James Ward, University of London PRESENTATION OF DIPLOMA OF FELLOWSHIP IN THE SPECIALTY OF OTOLARYNGOLOGY Anil Joshi, Bangalore University, India PRESENTATION OF DIPLOMAS OF FELLOWSHIP IN THE SPECIALTY OF TRAUMA & ORTHOPAEDIC SURGERY Neeraj Subhash Ahuja, Gujarat University, India Aryan Dawoodi, Al-Mustansirya University, Iraq Fraser Harrold, University of Dundee Thayur Raghavendra Madhusudhan, Bangalore University, India Jitendra Mangwani, Agra University, India Apurv Sinha, Devi Ahilya Vishwavidyalaya University, India Michelle Spiteri, University of Malta Veronique Spiteri, University of Malta PRESENTATION OF DIPLOMA OF FELLOWSHIP IN THE SPECIALTY OF UROLOGY Jawad-Ul Islam, University of the Punjab, Pakistan PRESENTATION OF THE SYME MEDAL Richard John Edward Skipworth, University of Edinburgh PRESENTATION OF DIPLOMAS OF MEMBERSHIP IN OTOLARYNGOLOGY Jyothi Peddireddy, Andra University, India PRESENTATION OF INTERCOLLEGIATE DIPLOMAS OF MEMBERSHIP IN SURGERY IN GENERAL Mussammet Dilafroza Ahmed, University of Chittagong, Bangladesh

Ruhina Alam, University of Dhaka, Bangladesh Nitin Kumar Aucharaz, University College, Dublin Soofiyah Parveen Ayaani, University of Birmingham Kathryn Mary Boyce, University of Liverpool Hannah Beth Bradman, University of Bristol Silviu Ioan Buderi, Universitatea de Vest din Timisoara, Romania Christine Cannataci, University of Malta Daniel David Moore Dawson, Queen’s University, Belfast Niall James Dempster, University of Edinburgh Maeve Dooher, Queen’s University, Belfast Sara Louise Dorman, University of Dundee Ahmed El Murtaga El Mugtaba, University of Gezira, Sudan Malcolm John Farquharson, University of Glasgow David Farrugia, University of Malta Norman James Galbraith, University of Glasgow David Gamble, University of Edinburgh Ye Nay Myo Han, University of Mandalay, Myanmar John Charles Hardman, University of Birmingham Yida Benjamin Joseph Kang, National University of Singapore B Karthikeyan, Sri Ramachandra University, India Ai Ye Janise Lee, National University of Singapore Vivek Mahajan, Manipal University, India Michael McLean, University of Dundee Ashish Madanlal Narang, Maharashtra University of Health Sciences, India Lavinia Onos, Carol Davila University of Medicine and Pharmacy, Romania Rajeshwar Balaji Ranganathan, Annamalai University, India Haroon Rehman, University of Aberdeen James Shelton, University of Dundee Robert Andrew Joseph Spence, Queen’s University, Belfast Lucy Rebecca Webster, University of Glasgow PRESENTATION OF DIPLOMA OF MEMBERSHIP IN THE FACULTY OF SURGICAL TRAINERS Jonathan Richard Lawson Wild, University of Sheffield

PRESENTATION OF DIPLOMA OF FELLOWSHIP IN DENTAL SURGERY WITHOUT EXAMINATION (by application) Folakemi Adenike Oredugba, University of Benin, Nigeria PRESENTATION OF DIPLOMA OF MEMBERSHIP IN ORAL SURGERY Norma O’Connor, National University of Ireland PRESENTATION OF DIPLOMAS OF MEMBERSHIP IN ORTHODONTICS Ameera Khalil Al Mosali, Bangalore University, India Gurprit Kaur Bhamrah, University of Manchester Natalia Lozinsky, National University of Kiev, Ukraine PRESENTATION OF DIPLOMAS OF MEMBERSHIP OF THE FACULTY OF DENTAL SURGERY Nicholas Anscomb, University of Sheffield Satish Maruti Gangurde, University of Bombay, India Deepak Harinathan, Bangalore University, India Princy Sree Harshan, Dr MGR Medical University, India

Deepika Jakileti, Rajiv Gandhi University of Health Sciences, India Melekote Palaksha Jayashree, Rajiv Gandhi University of Health Sciences, India Kuldeep Reddy Jetty, Dr MGR Medical University, India Rhona Anne Park, University of Glasgow Haifa Saleh, Karolinska Institutet, Sweden Preetha Sankarankutty, Rajiv Gandhi University of Health Sciences, India Sameera Teli, University of Leeds Amy Warnes, University of Sheffield PRESENTATION OF DIPLOMA OF MEMBERSHIP IN PROSTHODONTICS Emad Khalid Alijudaibi, University of Dhaka, Bangladesh PRESENTATION OF DIPLOMA IN ORTHODONTIC THERAPY Amy Louise Barron, School of Postgraduate Medical & Dental Education, University of Central Lancashire

DIARY

The latest surgical and dental events, seminars and courses JUNE 2014 1 Future Surgeons: Key Skills (Manchester) 4 Training the Trainer: Foundation Essentials (Birmingham) 5–6 Training the Trainer (Birmingham) 6–7 Higher Surgical Skills Course 12 Decision Making in Restorative Dentistry 12–13 Basic Surgical Skills Course JULY 2014 3–4 Basic Surgical Skills Course 10 Preparation for Diploma in Implant Dentistry (Birmingham) AUGUST 2014 16–17 The Edinburgh MRCS OSCE Preparation Course (Kuala Lumpur) 21–24 MFDS Part I Revision Course (Dubai) 30–31 The Edinburgh MRCS OSCE Preparation Course (Chennai) 31–2 Sept Mock MRCS OSCE Exam Course (Aberdeen) For further information please email education@rcsed.ac.uk or telephone +44 (0)131 527 1600 All events in Edinburgh unless otherwise stated.

www.rcsed.ac.uk | 47

FROM THE COLLECTIONS

Emma Black records the treatment in the early 19th century of a deck hand’s injured leg and the measures taken that delayed amputation for almost 14 years

THE TIBIA OF CHARLES ANDERSON

C

harles Anderson was employed as a hand on a sailing vessel which travelled between Riga and Leith. In 1814, when Anderson was 17 years old, he fell on deck with his leg doubled under him.

While the sailing vessel was docked at Riga, he consulted a surgeon who gave him a liniment to rub on to the wound as a way of dealing with the pain and the swelling of the knee. Anderson had to walk with crutches, but began to feel a little better.

However, while in Riga he fell again and was confined to hospital for six weeks; here he was told that “the bones beneath the knee were splintered”. In the following year he was admitted to the Royal Infirmary of Edinburgh, after refusing amputation, and was discharged after a two-week stay.

Almost three years after the initial accident, Anderson was attended to in Dundee, and the swelling in his leg was incised. Later in that year, Anderson’s temperature rose and a permanent sinus appeared in his leg. To manage the cleaning of the wound and deal with the discomfort caused by the continual build-up of discharge which accumulated in the wound, Anderson inserted a plug into the wound. The plug would be made of either sponge or wood and increased in size as the wound grew, until the opening measured 25mm. He would remove the plug once or twice a day, drain the fluid and wash the wound with salt water.

Anderson reported that he was in better health and was able to walk on both legs. From 1820, Anderson was employed as a clerk to a manufacturer, often weighing flax and “sometimes walked upwards of 24 miles in one day”. Anderson enjoyed 12 years of “good health” until he began to deteriorate and suffered from recurrent attacks of hectic fever. At the age of 31, Anderson finally agreed to amputation. At a time when amputation was the primary treatment for this kind of injury, Anderson had delayed the loss of his limb for almost 14 years.

Emma Black Public Engagement and Marketing Officer, Surgeons’ Hall Museum 48 | Surgeons’ News Global | June 2014

HERITAGE SOCIETY Become a member of the RCSEd Heritage Society www.rcsed.ac.uk/ heritagesociety

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FACULTY OF SURGICAL TRAINERS ANNUAL MEETING – WHO MAKES THE CUT? ASSESSMENT IN SURGICAL TRAINING WEDNESDAY 22 OCTOBER 2014 KEYNOTE SPEAKERS: l P rofessor John Norcini, one of the world’s foremost experts on the assessment of physician performance l D r Stephen Yule, Harvard Medical School – an expert on the assessment of non-technical skills in surgeons l M r William Allum, Surgical Director of the Intercollegiate Surgical Curriculum Project and Consultant Upper GI Surgeon at the Royal Marsden NHS Foundation Trust l Professor Jonathan Beard, Professor of Surgical Education at RCSEng and Consultant Vascular Surgeon at the Sheffield Vascular Institute l P lus more to be announced

The FST conference will be preceded on Tuesday 21 October by a joint meeting with the RSM: ‘Surgical crises and “never events” – recognise, understand, rescue and avoid’.

Reduced fees will be available for those attending both events.

This year’s meeting will focus on all aspects of assessment in surgical training. The focus will be on current methods of assessing surgical trainees’ technical and non-technical skills and how trainers can optimise their use of current workplace-based assessments. We will also look

at the assessment of trainers in light of impending GMC proposals to approve all surgical trainers in the near future.

The use of assessment in selection into surgical training and at the exit of surgical training will be addressed, while the current UK system of training and future developments will be covered. The meeting will present the current state of the art in assessment and its place in best practice in surgical training.

It will be of relevance to all surgeons with an interest in training.

Book online now or for further information email: fst@rcsed.ac.uk