Surgeons' News March 2014 by Think Publishing

TRAINEES and students

BEATING THE BULLIES

What can be done to reduce bullying in surgical training?

DEBATE

AN OPEN OR SHUT CASE

OR vs EVAR? Experts discuss the pros and cons of both approaches

heritage

THE DEATH OF A DYNASTY

Following the fortunes of the Monro family to the end of the medical line

Surgeonsnews March 2014

The magazine of The Royal College of Surgeons of Edinburgh

the future is now Pushing the boundaries of education around the world with the latest technology

www.surgeonsnews.com

welcome

From the Editor John Duncan introduces the March edition of Surgeons’ News

hrough life there is a constant need for reinvention and change to maintain relevance and interest. In publishing Surgeons’ News we have tried to evolve the magazine and to develop its content to reflect the interests of our readers, as well as the need to communicate the activities of the College to its Fellows and Members. This edition, which marks the change of our publication company to Think UK, is the latest in our efforts to keep the magazine fresh and innovative. We have also used the opportunity to change the content, with the introduction of clinical debate, a round-table discussion and features on individual specialties. The cover of this edition reflects a series of articles on the theme of information technology in medical education, which I hope you will find informative and enjoyable. Debate is a time-honoured method of airing the legitimate differences of opinion which are held on any important subject. I am grateful to my vascular colleagues for sharing their opinions on the use of endovascular repair rather than open surgery for younger patients with screen-detected aortic aneurysm. This is the first of a series of debates which we hope will interest those of all specialties. Surgery is a diverse part of the profession, with 10 SAC-defined specialties, let alone the numerous subspecialties within each of these. Many of us know relatively little of the developments and issues outside our own specialty area, and our series of specialty features aims to help inform and educate on the work of our colleagues. ENT is the first specialty to be featured and will

“The opening of our Birmingham office will be an important milestone in the life of the College” be followed in the next edition by trauma and orthopaedic surgery. Our series of round-table discussions is designed to highlight issues which the profession in general has to address for the benefit of our patients. In this issue we publish the first of these, on bullying. We have tried to involve individuals from the wider profession and from different stages in their careers. We would very much welcome your feedback on this or any other aspect of our content. This year will be a very eventful one for the College. The opening of our Birmingham office in the spring will be an important milestone in the life of the College and in our ability to provide services for our Fellows and Members based in England. The renovation work to the premises in Colmore Row, Birmingham, is already under way with the opening in April. In the December issue of Surgeons’ News we were able to inform you that the College’s Heritage Lottery Fund application to completely upgrade the museum had been successful. It is now vital that the College delivers on the undertakings we have given the Lottery. In June, the building work on the museum begins in earnest and that, combined with the upgrading work on the new events space, has the potential for disruption to the core activities of the College. Plans to minimise this disruption are well under way but 2014 will certainly be an interesting year in the ongoing life of the College. John Duncan editor@surgeonsnews.com www.rcsed.ac.uk | 1

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

contents

TRAINEES AND STUDENTS

BEATING THE BULLIES

What can be done to reduce bullying in surgical training?

DEBATE

HERITAGE

AN OPEN OR SHUT CASE

THE DEATH OF A DYNASTY

OR vs EVAR? Experts discuss the pros and cons of both approaches

Following the fortunes of the Monro family to the end of the medical line

Surgeonsnews March 2014

The magazine of The Royal College of Surgeons of Edinburgh

36 20

THE FUTURE IS NOW Pushing the boundaries of education around the world with the latest technology

www.surgeonsnews.com

Editor John Duncan Deputy Editor Robyn Webber Editorial Board Richard McGregor Peter Lamb Peter Douglas Sarah Allen Chris Henry Dr Yvonne Hurst Aoife O’Sullivan Mark Baillie 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

Contents March 2014 05

GENDA A The latest from the College and the surgical profession

18 20

THE PRESIDENT WRITES Building trust in the surgical team

In Focus How digital technology changed the shape of education and training

Surgeons’ debate Open or EVAR? That is the question in AAA treatment

THE Monro DYNASTY Wyn Beasley charts the family fortunes into the modern era

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 Surgeons’ News are not necessarily those of the editorial team or the Royal College of Surgeons of Edinburgh. Information printed in this edition of Surgeons’ News is believed to be correct at the time of going to press.

SPecialty: ENT Charting the rise of ENT from the ancient Egyptians to the present day

SPECIALTY: ENT training Training and research in ENT

DENTal surgery Updates from the Faculty of Dental Surgery

round table on bullying Our panellists debate the extent of bullying within surgical training

TRAINEES AND STUDENTS ASiT on flexibility in postgrad training; and the growing popularity of research collaboratives; plus the latest news

college information Awards and grants, plus the latest Diploma Ceremony listings

out of hourS Graham Layer dines beneath a Damien Hirst, plus spring drinks

from the collections A 17th-century calculus www.rcsed.ac.uk | 3

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

AUSTRALIAN AND NEW ZEALAND COLLEGE OF ANAESTHETISTS FACULTY OF PAIN MEDICINE

Working together for our patients

RACS ANNUAL SCIENTIFIC CONGRESS AND ANZCA ANNUAL SCIENTIFIC MEETING

Sands Expo and Convention Center, Marina Bay Sands, Singapore

5-9 May 2014

View past ASC presentations on the Virtual Congress at http://asc.surgeons.org

Agenda The latest news from the College and profession

/ RESEARCH

Success in RCSEd-supported project for treatment of genetic blindness

CSEd Fellow Professor Robert MacLaren (pictured) has announced a major breakthrough in the use of gene therapy for the treatment of blindness. He and his research team improved the vision in a cohort of six patients with choroidaeremia using an operation to place the virus under the retina. They now believe gene therapy surgery could be used to cure other forms of genetic blindness. The project was first supported by a grant from the RCSEd in 2008, which allowed the Oxford-based team to expand and to gain further funding through the use of preliminary data. Thanking the RCSEd for the original grant, Professor MacLaren commented: “This grant was the only one I held when I transferred my research to take up a new chair at the University of Oxford. It enabled me to employ a postdoctoral assistant and continue this work straight away. We went

on to appoint three postdoctoral assistants with four clinical PhD students.” The Chairman of RCSEd’s Awards and Grants Committee, Professor Ken Fearon, said: “We are delighted to see the translational

success of Professor MacLaren’s programme of research and his generous recognition of the initial grant support he received from Royal Blind via the RCSEd. This demonstrates the importance of targeted research funding in surgery and its subspecialties.”

Professor MacLaren and his team used gene therapy surgery to treat blindness

McDonald appointed convener of dental examinations / dental

The Faculty of Dental Surgery has appointed Professor Fraser McDonald (pictured) as convener of dental examinations. Professor McDonald is currently a Member of Dental Council and chair of the College’s Specialty Advisory Board in Orthodontics. A highly experienced postgraduate teacher

and examiner, he will bring a wealth of experience of College examinations and the activities of the Faculty to his new post. Outside the RCSEd, Fraser McDonald is professor and head of orthodontics at the Dental Institute, King’s College in London, and is an honorary consultant in

orthodontics. He is a Fellow of the Dental Faculty Without Examination since 1998 and was appointed the James IV Professor of the College in 2002. He will take up his position as examinations convener in March 2014. www.rcsed.ac.uk | 5

agenda / opening

Help to celebrate launch of College’s Birmingham centre

NEWS IN BRIEF College to join Australasian colleagues in 2015 The Royal Australasian College of Surgeons (RACS) has announced it is to hold a scientific congress with the RCSEd in 2015. The RACS Annual Scientific Congress, held from 4–8 May 2015, in Perth, Western Australia, will mark the 100th anniversary of the Gallipoli campaign of the First World War. For more information visit www.surgeons.org

ellows and Members are invited to register for events at the College’s new centre of operations in Birmingham. The events programme for the opening week will include ‘The role of the surgeon in training in improving patient safety’, and ‘Training the trainers: using procedure-based assessment effectively’. In addition, local Fellows and Members are invited to join the president, office bearers and council for an informal drinks reception on Thursday 3 April at 5:30pm to celebrate the opening of the new facility. For further information, please contact: presidentpa@rcsed.ac.uk

New format for MFDS Part 1 examination

/ EVENTS

Skills centre opens at UKM

From the October 2014 examination diet, the format of the MFDS Part 1 examination will be revised and consist of a single multiple-choice question paper of three hours’ duration. This will comprise 200 single best-answer questions, including case clusterformat questions. The MFDS examination syllabus remains unchanged, and updated candidate guidance is available on the College website.

Council elections

In December, Council member Mr Pala Rajesh represented the College at the opening ceremony of the advanced surgical skills centre at the University of Kebangsaan Malaysia (UKM). Under the leadership of Hanafiah Harunarashid FRCSEd, the centre 6 | Surgeons’ News | March 2014

will be utilised for training in all the surgical specialties. Speaking at the opening ceremony, Malaysia’s Minister of Education II Dato Seri Idris Jusoh, thanked Mr Rajesh and Mr Tim Graham, JCSFE chair, for their involvement and support.

From left to right: Mr Hanafiah Harunarashid, Mr Pala Rajesh, Mr Dato Seri Idris Jusoh and Mr Tim Graham

The RCSEd is seeking nominations for four vacancies which will arise on Council at the AGM in November 2014. Any subscribing Fellow who has signified consent and the willingness to undertake the duties of Council may be nominated by two other Fellows on the nomination form enclosed with this issue. Nominations must reach the honorary secretary to the College on or before 30 May 2014. For further information, contact presidentpa@ rcsed.ac.uk

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Profile

Dr John Birkmeyer, Professor of Surgery at the University of Michigan, on surgical outcomes

Debate

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Trainees

What to consider when setting up a training course

twitter.com/surgeonsnews www.rcsed.ac.uk | 7

agenda

Speaking out on bullying and patient safety

/ BULLYING SURVEY

early one in five doctors in training has witnessed someone being bullied in their current post, and more than one in four has experienced undermining behaviour themselves, according to a major survey by the General Medical Council. In its annual survey of 54,000 doctors in training, the GMC also found that more than 2,000 (5.2%) had raised a concern about patient safety in 2013, and that 13.2% said they had experienced bullying at work. Turn to page 46 for our round-table discussion on bullying in surgical training

The GMC survey in numbers

13.2%

of trainees surveyed reported being victims of bullying

19.5% of respondents had witnessed bullying

26.5%

had experienced undermining behaviour from a senior colleague

No. 3

of the specialties reporting bullying, surgery was the third highest

/ FACILITIES The upgrade will be the first time that the building has been radically altered since 1908

Museum prepares for redevelopment The College’s Museum is getting ready for a major redevelopment following receipt of a £2.7m Heritage Lottery Fund grant. The Museum will close its doors on 18 May as the project to transform it into a modern public museum gets under way. It will be the first time that the building has been radically altered since 1908 and the funding will allow redevelopment work to create new displays and galleries, doubling the number of items which can be put on display and showcasing innovative audiovisual and interactive elements.

8 | Surgeons’ News | March 2014

The College’s internationally important collections began being amassed in the 15th century. The William Playfair-designed building will also be conserved and transformed, with contemporary additions such as a new glass atrium, providing the public with easier access. The enhanced Museum will also boast a 17th-century dissecting theatre while a new, dedicated education suite will increase opportunities for learning for school visits, families and special interest groups.

CHALLENGES

CONTROVERSIES

CONSENSUS

VASCULAR & ENDOVASCULAR

Consensus Update 5 - 8 April 2014

Gr an d Hal l , O l y m p ia , L o n d o n

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| 9

agenda

Davinder Sandhu Professor of Medical Education, University of Bristol

Steven Backhouse Consultant in Otolaryngology, Princess of Wales Hospital, Bridgend

time to engage We talk to Davinder Sandhu and Steven Backhouse, newly appointed surgical director and associate surgical director of the College’s RSA network In what way will the creation of your roles improve the existing RSA network? DS: I am delighted to be appointed as the national surgical director of the advisory network, and if there is one word that sums up what this is all about it is ‘communication’. Communication is not the wisdom of one but the many. My principal role is to create a cohesive, energetic network that has a strong focus as well as a clear direction. SB: The appointment of RSA directors will allow the creation of a more formal management and communication structure to facilitate co-ordination, co-operation and delivery of RSA regional activities while allowing the College to collate ideas and information as a ‘learning organisation’ hub. The College’s commitment to this structure is commendable, to ensure the longevity and development of the network. What difference has the presence of RSAs made to perceptions of the College? DS: The RSAs have a remit to improve surgical standards, training and, through this, improve patient care. In addition, we not only need to link between ourselves and our regions but also with the College council and President so that we harmonise our efforts for the greater good. 10 | Surgeons’ News | March 2014

SB: The Edinburgh College enjoys a reputation as the ‘friendly College’. The presence of RSAs has made the College even more visible and approachable as I am aware of members and non-members alike approaching RSAs with enquiries about involvement with the College, often after having seen their RSA presenting at a previous event. What attracted you to the role? DS: What has amazed me is the breadth of activity that has taken place under the leadership of Roger Currie. Over the past year, RSAs have been involved in all areas of training and education within the College. These include representation on the policy group and the Faculty of Surgical Trainers; running educational courses on a variety of surgical themes and interview skills, research symposia, MRCS examinations, national conferences and representation at ASGBI, ASiT and BOA. SB: I have spent four years as an RSA in South Wales and have enjoyed immensely developing networks with the regional academic, commercial and governmental bodies to facilitate their co-operation and contribution to College events (including research symposia, careers fairs and skills competitions). I am excited and honoured by the opportunity inherent in the associate director post; it will allow me to contribute my MBA training

and RSA experiences into the expanding ‘blueprint’ of the RSA role. How will the roles help the College better engage with its membership? DS: I am sure Steven and I will work hard as a team to support the RSAs and College membership. The kind of interaction created by the RSA network throughout the UK allows the membership to engage with the College, which is passionate about patient care and creating a listening forum. SB: RSAs embody the College’s influence and presence at a local level. They provide a first point of contact and a ‘face’ for the College that regional members can engage with on a personal level. The RSAs have also demonstrated that they are able to deliver a wide range of RCSEd-related events in their region, such that our College is seen to be going out to its membership rather than members needing to come to the College in Edinburgh. The directors’ role in co-ordinating RSA activities, with benchmarking, sharing and developing College events around the UK, will help ensure the College is developing uniformly high-standard activities backed up by membership feedback. What are you looking forward to most about the new role? DS: The aspect that I will enjoy the most will be witnessing the development of the leaders of our profession, and their marvellous innovative and entrepreneurial spirit. SB: Seeing the RSA network develop as a functional unit delivering uniformly high-quality events locally to the satisfaction of the College, the RSAs and the membership. I am looking forward to working with Professor Sandhu and the outreach team over the next three years to deliver these goals.

Overview The RSA network launched in 2008 as a pilot project but quickly grew to include consultants acting as RCSEd representatives across the UK. The new appointments come following the continued growth of the network to 50. Key responsibilities for the surgical director and associate surgical director include chairing the advisory network group and developing a programme of regional activities tailored to local needs. The network has proved to be a valuable source of recruitment for other College roles, such as course conveners and examiners. Turn to page 60 for a map of RSA Network members

JOIN THE NETWORK

As the regional surgical adviser (RSA) network goes from strength to strength we are inviting applications from UK-based Fellows to join the network. We are recruiting in the locations listed below and we also welcome interest from Fellows in the specialties of trauma and orthopaedics, plastic surgery, paediatric surgery and urology. Northern Ireland To succeed Stuart McIntosh in Belfast and to work alongside Sean Patton North of England To succeed Jonathan Ferguson in Middlesbrough and to work alongside Mike Clarke and Ian Hawthorn North-West of England To succeed Chelliah Selvasekar in Manchester and work alongside Stuart Clark and Jeremy Ward South Wales To succeed Angus Robertson in Cardiff and work alongside Steven Backhouse and Vaikuntam Srinivasan South-West (Severn) To succeed Davinder Sandhu London To work alongside and then succeed Robert Mason West Midlands To work alongside Rajiv Vohra and Ling Wong East of England To succeed Raaj Praseedom in Cambridge and work alongside Vivek Chitre, Milind Kulkarni and Andrew Gibbons North of Scotland To succeed Angus Watson in Inverness and work alongside Aileen McKinley and Euan Munro South-East of Scotland To succeed Zahid Raza in Edinburgh and work alongside Anna Paisley

The new directors look forward to seeing the RSA Network develop

Interested applicants must be Fellows in good standing and hold a consultant post in any surgical specialty. For more information and to receive a copy of the job description please contact the outreach section at outreach@rcsed.ac.uk. Applications and supporting paperwork must be received by Friday 28 March 2014.

www.rcsed.ac.uk | 11

agenda / COURSES

/ SPORTS & SOCIAL

College backs Christie revision course

CSEd has endorsed the FRCS exit exam course in general surgery run by the Christie NHS Foundation Trust. The intensive three-day course is designed to help candidates prepare for the intercollegiate FRCS examination in general surgery and is delivered through a combination of vivas, interactive discussions, and patients with signs and symptoms to provide the candidate with a focused revision of pertinent topics. Mr Chelliah Selvasekar, consultant general surgeon at the Christie and regional surgical adviser for the College, said: “The FRCS is an exit exam which evolves over time based on the surgical needs of patients. RCSEd approval quality assures the course and will assist with its development.” The fourth Christie FRCS exit exam course in general surgery takes place from 25–27 July.

Save the date! Faculty of Surgical Trainers Annual Meeting 2014 ‘Who Makes the Cut? Assessment in Surgical Training’ will take place at the College’s Edinburgh campus on Wednesday 22 October 2014. Book now at fst.rcsed.ac.uk For further information, email education@rcsed.ac.uk

/ In memoriam

Ian B MacLeod

Fellows and Members from around the world will be saddened to learn of the death of Ian B MacLeod (1933–2013), former Convenor of examinations and Honorary Secretary of the College

an MacLeod’s parents hailed from Lewis, but Ian was brought up in Wigan, where his father was a GP. When he came to Edinburgh to study medicine, golf replaced cricket as his main sporting pastime and he played to a high standard throughout his life. He qualified with a first-class honours degree in physiology followed by MB ChB with honours, distinctions which attested to his academic brilliance. After national service as a medical officer in the RAMC, Ian returned to Edinburgh and joined the university department of clinical surgery at the Royal Infirmary, the hospital where he stayed for the rest of his career. Those who worked with him will remember Ian as a true master of the surgical craft,

blessed with a natural talent for surgery. His technique was careful and precise, and he made every manoeuvre look easy and effortless. He was appointed Surgeon to the Queen in Scotland in 1987. Yet he bore all this with great modesty – there was never a hint of showmanship or arrogance about him. His talents were also used to great effect at the RCSEd as convenor of examinations and as editor of the College journal. His editing comments on manuscripts were always written in his characteristic clear, bold script and always in that green ink which became a trademark. His intellect and his background knowledge made him an ideal editor, and under his leadership the journal flourished. These same skills were used to good effect when he edited, along with Pat Forrest and David Carter, the first edition of Principles and Practice of Surgery (1985), a textbook which became a bestseller. And when Ian finally retired from surgical practice in 1993 he became Honorary

“One former colleague spoke for many when he said that Ian MacLeod had the safest pair of hands he had ever seen in a surgeon”

Secretary of the College, then effectively a full-time job. When the time came to look for his successor, the then president Sir Robert Shields summarised the ideal candidate. “Someone,” he said, “with all the attributes of Ian MacLeod – totally reliable and dependable, efficient, diligent, loyal, honest and a safe pair of hands.” Ian was all of these and more. The safe pair of hands to which Sir Robert referred was in a diplomatic or political sense, but one former colleague spoke for many when he said that Ian MacLeod had the safest pair of hands he had ever seen in a surgeon. Ian was reserved by nature and, indeed, much of his charm lay in that natural reticence. He was a member at Bruntsfield Links for no fewer than 47 years and enjoyed social golf with the Amblers and Doonsiders, and travelling with the Moynihan Chirurgical Club. Another Edinburgh master surgeon, from an earlier era, Professor James Syme, had this admiring tribute from a junior: “He never wasted a word, nor a drop of ink nor a drop of blood” and that could equally be said of Ian. He is survived by Gill, their children David and Alison, and six grandchildren. Iain Macintyre FRCSEd, past Vice President

RCSEd’s Birmingham base to open this month Centre of operations will launch with a series of exciting activities and events For the first time in The Royal College of Surgeons of Edinburgh’s 500-year history, the College is pleased to be opening a base outside Edinburgh – in Colmore Row, Birmingham. RCSEd is strongly committed to providing the best services, facilities and support possible to everyone who has chosen to be part of our College, wherever they are based. This move is in recognition that 80% of our UK membership is based in England and Wales – more than 11,000 professionals in total. The College hopes that many of our Fellows, Members and Affiliates will be able to take part in the meetings, lectures, courses and other events which will be held in

the new Colmore Row facility from the opening week in late March/early April; as well as our colleagues and partners in healthcare. Those in our membership who are Trainees or SAS grade may be interested in two bookable events which will be taking place in the opening week itself. In addition, we will be holding a PBA (procedure-based assessment) course at the centre within the same period. Fellows and Members local to Birmingham are also invited to attend an opening drinks reception on Thursday 3 April. Places at all events are limited so please register to attend through the website.

For further information about our new Birmingham office and events visit www.rcsed.ac.uk

Birmingham

www.rcsed.ac.uk | 13

agenda

surgical safety update The latest cases from the Confidential Reporting System for Surgery Fallopian tube mistaken for appendix

A 28-year-old patient, who was 15-weeks pregnant, presented to the Emergency Department with low abdominal and acute iliac fossa pain. A diagnosis of acute appendicitis was made by the surgical SpR and discussed with the consultant surgeon. Arrangements were made for the SpR to carry out an open appendicectomy. The consultant was happy for the SpR to undertake the surgery as he was in a non-training post and had been operating independently for some months. Surgery was undertaken late at night, at the end of a prolonged on-call period. There was no first assistant at the operation and the scrub nurse performed the dual role of assistant as well as scrub nurse. The surgical findings were recorded as a mildly inflamed very long appendix adherent to the right ovary. An inflamed structure lay between the pregnant uterus and caecum. The mesoappendix was ligated and divided. The appendix stump was tied, but not buried. The right ovary was large and contained a cyst and the gynaecology registrar was asked to attend and give an opinion. By the time he came the appendix was already separate from the ovary, so he visualised only the ovary. The opinion was that the appearance of the ovary was consistent with pregnancy. The patient made a good recovery and was discharged on the second post–operative day. Four days post-operatively a consultant histopathologist contacted the on-call surgical registrar to advise

14 | Surgeons’ News | March 2014

that the structure removed at operation was not an appendix but a fallopian tube. The consultant surgeon subsequently arranged to see the patient in outpatients. The situation was fully explained to her and a laparoscopic appendicectomy was recommended following the delivery of her baby.

Root causes as identified by the Trust investigation

A protocol regarding women presenting to A&E in early pregnancy with emergency abdominal pains for joint surgical and O&G assessment was not widely known or followed. There was a practice within the specialty to work an unacceptable on-call pattern. There was a breach of the working time directive with regards to adequate rest. The incident reporting culture and awareness among certain staff groups was poor – there was lack of clarity regarding the process and mechanisms that can be triggered and accessed via this route, which would have ensured that the patient was informed in a more timely and supportive manner, as well as providing support for the SpR and consultant.

CORESS comments

This salutary case is among a number of similar cases received by NPSA. The problems of appropriate assessment, disorientation because of disordered anatomy, and failure to request help when unsure of one’s ability to make safe progress remain common themes in reported incidents. The reader

contemplating appendicectomy in a pregnant woman or female child should consider the lessons arising from this case.

femoro-femoral cross-over bypass was undertaken. The patient was maintained on long-term antibiotics, but made an uneventful recovery.

Tunnel vision

Reporter’s comments

A 73-year-old man who had undergone an aortobifemoral bypass for bilateral iliac artery disease and debilitating claudication four weeks previously presented with blood-streaked stools on defaecation. Proctoscopy was normal, but sigmoidoscopy revealed a length of Dacron graft passing though the lumen of the distal sigmoid. Laparotomy was undertaken (pictured below). The left limb of the aorto-bifemoral graft was excised and the sigmoid exteriorised temporarily as a loop colostomy. The remainder of the arterial graft appeared well incorporated into surrounding tissues, so the proximal stump of the left limb of the graft was oversewn, and, after careful groin wound irrigation, right to left

Dacron graft penetrating the sigmoid colon as seen at laparotomy

At surgery, the initial vascular graft was tunnelled from the aorta to the left groin with the aid of a Roberts’ arterial clip. This must have inadvertently pierced the sigmoid colon and the graft was tunnelled directly through the wall of the colon with a good seal, which prevented faecal leakage and peritonitis. The risks of using forcible rigid devices blindly, as an aid to tunnelling a passage for a conduit, are selfevident. The patient was lucky to have avoided overt septic complications and peritonitis, although longterm graft infection remains a risk.

CORESS comments

Vascular surgeons, neurosurgeons and other surgical specialists often have to tunnel grafts, lines or drains subcutaneously. Although this is a common and routine procedure in most cases, there is significant risk of entering a body cavity, hollow viscus or solid organ if the tunnelling device is inadvertently misdirected or inappropriate force employed. Operator awareness of the risks is the key to avoiding this complication – “think before you tunnel”.

CORESS is grateful to the clinicians who have provided the material for these reports. The reporting form is on our website, which also includes all previous feedback reports. Published contributions will be acknowledged by a Certificate of Contribution which may be included in the contributor’s record of continuing professional development.

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

www.rcsed.ac.uk | 15

agenda

The latest guidelines, papers and studies

in brief Intravenous fluid therapy in adults in hospital

This important NICE clinical guideline contains recommendations about general principles for managing intravenous (IV) fluids, and applies to a range of conditions and different settings. The aim of the guideline is to help prescribers understand the physiological principles that underpin fluid prescribing, the indications for IV fluid therapy, and the principles of assessing fluid balance. NICE, December 2013

Negative-pressure wound therapy for the open abdomen

NICE has issued recommendations about the use of negative-pressure wound therapy for the open abdomen. NICE concludes that current evidence is adequate to support the use of this procedure provided that normal arrangements are in place for consent, audit and clinical governance. NICE encourages further research into its role, including outcomes such as healing rate and duration of hospital stay. NICE, November 2013 www.nice.org.uk

British Society of Gastroenterology (BSG) guidelines on the diagnosis and management of Barrett’s oesophagus

These guidelines provide a practical and evidence-based resource for the care of patients with Barrett’s oesophagus and related early neoplasia. For the first time, they include stratification of patients according to their estimated cancer risk based on clinical and histopathological criteria. They also advocate endoscopic therapy for high-grade dysplasia and early cancer in high-volume centres. Fitzgerald RC, di Pietro M, Ragunath K et al. BSG November 2013 www.bsg.org.uk

16 | Surgeons’ News | March 2014

Primary hip replacement prostheses and their evidence base: a systematic review

This systematic review found that 24% (57/235) of all hip replacement implants available to surgeons in the UK had no evidence for their clinical effectiveness. It also showed that 10,617 (7.8%) of the 136,593 components used in primary hip replacements in 2011 were implanted without readily identifiable evidence of clinical effectiveness. The authors conclude that a considerable proportion of prostheses have no readily available evidence of clinical effectiveness to support their use, and recommend the need for a revised process for introducing new orthopaedic devices. F Kynaston-Pearson, AM Ashmore, TT Malak et al. BMJ 2013; 347: b6956

Enhanced recovery programme in colorectal surgery

This meta-analysis of 2,376 patients in 16 RCTs found that the ERAS pathway was associated with a reduction of overall morbidity (relative ratio [RR] = 0.60) and shortened hospital stay (WMD = –2.28 days), without increasing readmission rates. Greco M, Capretti G, Beretta L et al. World J Surg. December 2013

Anastrozole for prevention of breast cancer in high-risk postmenopausal women (IBIS-II): an international, double-blind, randomised placebo-controlled trial

This trial randomised high-risk postmenopausal women to receive oral anastrozole (1920) or a matching placebo (1944) every day for five years. After a median follow-up of five years, 40 women in the anastrozole group (2%) and 85 in the placebo group (4%) had developed breast cancer (hazard ratio 0·47, p<0·0001). Authors concluded that anastrozole reduces the incidence of breast cancer in high-risk postmenopausal women.

Along with the fact that most side-effects associated with oestrogen deprivation were not attributable to treatment, this provides support for the use of anastrozole in this group. Cuzick J, Sestak I, Forbes JF et al; on behalf of the IBIS-II investigators. Lancet. December 2013

Local versus general anaesthesia for carotid endarterectomy

This Cochrane Review identified 14 randomised trials involving 4,596 operations. There was no significant difference in the proportion of patients who had a stroke or died within 30 days of surgery between the local anaesthesia group (3.6%) and general anaesthesia group (4.2%). The authors concluded that the review provides evidence to suggest that patients and surgeons can choose either anaesthetic technique depending on the clinical situation and their own preferences. Vaniyapong T, Chongruksut W, Rerkasem K. Database Syst Rev. 2013 December

Efficacy and safety profile of antibiotic prophylaxis in clean and cleancontaminated plastic and reconstructive surgery

This meta-analysis identified 12 RCTs involving 2,395 patients. Antibiotic prophylaxis in plastic and reconstructive surgery was found to be favourable over placebo in SSI prevention (OR, 0.53;) and other wound complication (OWC) prevention (OR, 0.36). Compared with short-term antibiotic prophylaxis, longterm administration showed no evidence of a difference in the risk of SSI or OWC. The authors concluded that antibiotic prophylaxis reduced postoperative SSI in clean plastic surgeries with high-risk factors and clean-contaminated plastic surgeries. A short-course administration seemed to be of adequate efficacy. Zhang Y, Dong J, Qiao Y et al. Ann Plast Surg 2014; 72: b121

Reviews

A look at the latest surgical technology and books

Fundamentals of Surgical. Practice (3rd edition). Andrew Kingsnorth and Douglas Bowley (Eds) Greenwich Medical Media ISBN 978-1900151962 £75.00

Look on the bright side OLED (organic light-emitting diode) technology has made its way into the operating theatre in the form of OLED HDTV screens. Display technology is very important for surgeons performing endoscopic/laparoscopic procedures because achieving the best visual feedback can be key to successful surgical outcomes. OLED screens include a thin layer of organic material that emits its own light. Therefore, they can be thinner and lighter than LCD backlight screens and have better image capabilities than LCD screens. My colleague, Guy Slater, Upper GI and Bariatric Surgeon, has been using OLED monitors for more than a year and has also had the opportunity to compare them side by side with non-OLED monitors. He said: “There was no doubt when comparing the images side by side – you could see that the OLED was better.” When looking at the key benefits he added: “I think they handle colour better, so I think the surgery is more accurate. The speed with which the image can cope with movement is excellent – you never get blurring as you move the telescope around the abdomen and its ability to work in low light, particularly when you have bleeding drawing the light away, allows me to work accurately despite suboptimal conditions.” This technology is relatively new and therefore relatively expensive and there may be some fatigue over time with the colour-producing material leading to colour balance issues, particularly in the blue range. My thanks to Mr Guy Slater for his help with this review. Stephen Walsh Consultant Oral & Maxillofacial Surgeon, St Richard’s Hospital, Chichester

Passing the MRCS examinations is a requirement for completing core surgical training and, with overwhelming choice, finding the right preparation book is critical for junior trainees. Fundamentals of Surgical Practice has built upon its reputation as a comprehensive text for surgeons early in their careers, having been extensively updated since the last edition with new topics such as enhanced recovery, endovascular techniques and laparoscopic surgery. Described as ‘an MRCS preparation guide’, the 31 chapters incorporate vital concepts in all subspecialties as well as surgical skills, sepsis, nutrition, radiology, pathology, oncology, as well as perioperative and critical care. The editors and many of the authors have Royal College examining roles and the contents certainly reflect this. The text mirrors the MRCS syllabus extraordinarily well. Each chapter is a concise summary of the topic, with further reading suggestions listed at the end. Written by a largely senior and academic Edinburgh group of surgeons, physicians and MRCS OSCE anaesthetists, the authors have done well to Preparation incorporate an evidence-based approach Course to surgical practice – something missing 29-30 March from rival texts. Landmark research papers Book online and the latest advances are discussed in www.rcsed.ac.uk respective chapters. While many of the minor issues from previous editions have been resolved, as a preparatory aid for exams the book continues to follow a traditional ‘text’ format and could certainly benefit from more illustrations, photographs and colour. Nevertheless, along with Raftery and Delbridge’s Basic Science for the MRCS and a basic anatomy textbook, this book is an essential study tool for the MRCS Part A, and a useful adjunct to Part B. Having recently used this book for preparing and passing the MRCS, we would recommend it to junior trainees embarking on these important exams. Paul Cullis and Norman Galbraith

www.rcsed.ac.uk | 17

AGENDA

The President writes Ian Ritchie’s regular update on issues affecting the College’s Fellows and Members

e live in a world where the concept of trust is widely debated and challenged. You only have to look at the court cases relating to mobile phone hacking and the national press. In the league tables of trustworthiness of public individuals, politicians and journalists come near the lower end but doctors are still quite high up the list. Then consider some of the high-level scandals that have afflicted the health service. Trust is an inevitable part of everyday currency because we all have to trust and we need to be trusted. Personal integrity is central to such relationships. It is no surprise, then, that we feel deeply wounded when trust is betrayed. Patient safety is clearly a matter where trust is inextricably part of the debate. As potential patients, each one of us puts trust in a colleague to do the right thing for us. Most often, this involves selecting a colleague whose personal skills and integrity we value highly and to whom we are prepared to trust our life or the lives of our families. In the same way, the general public relies on the integrity and skill of the surgeon to whom they are referred by their GP. However, the personal skill and integrity of an individual surgeon are not enough. I know that I will want to be assured if I ever become a patient in an operating theatre that the surgeon to whom I entrust my life is committed to team working in such a way that all errors in theatre are minimised. This is the arena of human factors, which is increasingly important in

the technologically advanced nature of surgical practice. It is very difficult for an individual to be fully aware of all the factors that are going on in the complex environment of an operating theatre. Therefore, any thinking surgeon will be actively seeking to ensure good relationships among the whole operating team to protect the patient from harm. A good additional outcome of this process is that the surgeon is also protected from the risks of litigation. Leadership and team working are often used together but, commonly in the surgical context, leadership is regarded as a process of “I say and you do”. While there are times when that is appropriate, in the context of well-functioning teams, where the hierarchy is much flatter, the benefit for all concerned is that communication is better and safety is improved. The

“In times of structural change it is all too easy to concentrate solely on a limited sphere of activity in an attempt to impose order in a confused world” Academy of Medical Royal Colleges recently endorsed the Patient Safety Concordat but, during the discussion at the academy, it was clear that this is not purely a surgical issue. It applies across all medical disciplines and the concepts of team working and leadership should apply across specialties and departments as well as within specialties. The organic workings of a hospital require us all to respect and develop the relationships with other specialties for the benefit of patient care. This is particularly necessary in times of structural and organisational change when it is all too easy to concentrate solely on a limited sphere of activity in an attempt to impose order in a confused world. In a similar way, the profession of surgery in the UK and Ireland is a complex series of inter-relationships between four surgical royal colleges and the 10 specialty associations, whose fellows and members are spread across all five countries of the British Isles and overlap considerably between colleges and specialty associations. In 1993, the Senate of Surgery of Great Britain and Ireland was formed in order to address the issue of several

â&#x20AC;&#x153;Any thinking surgeon will be actively seeking to ensure good relationships among the whole operating team to protect the patient from harmâ&#x20AC;?

institutions with extremely long histories which wished to work together but found that there were some tensions in their individual agendas. The Senate has had a chequered history. Its name changed in 2007 to the Surgical Forum of Great Britain and Ireland. This was designed to encourage debate but, unfortunately, debate is not what has happened. More recently, it nearly foundered and may yet disappear without full-hearted support. The Surgical Forum is an opportunity for a single voice within the British Isles on matters of great importance to surgeons, whatever their collegiate or specialty association affiliations. Our fellows and members trust college councils, office bearers and presidents to present to governments and the public a cohesive and coherent view on matters of importance to patients and to the surgical profession. It is my personal view that it is difficult for this to happen while there are so many voices not always delivering the same message. I believe in the Forum and sincerely hope that its next meeting re-energises it as we discuss the shape of training and the relevance this has to the profession of surgery. It is important that surgeons working in the NHS and elsewhere should inform their college councils and office bearers of their concerns about matters of importance to the profession and about the interactions between the profession and our political masters. This will give the various surgical bodies messages that we should deliver both by direct contact and, most powerfully, through a united voice in the Surgical Forum. In this way, I believe that surgeons who are fellows and members of colleges and specialty associations will display a unanimity of purpose which will engender increased trust from our political masters and, more importantly, from our patients. Finally, the surgical colleges have jointly embarked on delivering an examination to the international community to the same standard as the exit FRCS examinations in the UK. The first diet of this examination, called the Joint Surgical Colleges Fellowship Examination (JSCFE), was delivered in Al Ain in the United Arab Emirates in November 2013. It is a great tribute to the leadership of Mr Tim Graham, chair of the Joint Committee on Intercollegiate Examinations (JCIE), that this examination has been delivered successfully within a two-year time frame. Mr Graham has led a team of surgeons from all colleges and staff from the JCIE. They had the mammoth task of adapting curricula, preparing a syllabus and delivering two diets of the MCQ examination and one diet of the Part B oral and clinical examinations. This is an example of the team working and trust that we work towards and which I hope can continue in intercollegiate discussions and negotiations in the future. I am proud of the innovations that have been introduced as intercollegiate initiatives. They have been introduced in an environment of competition but have thrived on mutual trust and an understanding that these activities are carried out ultimately for the benefits of patients. Ian Ritchie president@rcsed.ac.uk www.rcsed.ac.uk | 19

IN focus

it in surgical education From distance learning to surgical apps, technology is making it easier to educate surgeons across the globe. Over the next eight pages we examine the latest developments and successes

Learning excellence A Queen’s Anniversary Prize is the latest accolade for a groundbreaking MSc programme that has used digital technology to deliver surgical teaching around the world, writes Professor James Garden CBE

he year 2013 was a remarkable one for our surgical distance learning programmes. We always believed that the Edinburgh Surgical Sciences Qualification (ESSQ) was groundbreaking but it was really exciting to have the innovative Masters in Surgical Sciences programme recognised by the announcement at St James’s Palace in November that it had received the highest educational award available in the country. The Queen’s Anniversary Prize for Higher and Further Education is only awarded every two years by the Royal Anniversary Trust, which seeks to ‘promote world-class excellence and achievement’. While pleasing to have this recognition, it perhaps did not come as a total surprise that the Royal College of Surgeons of Edinburgh and the University of Edinburgh were already delivering a series of surgical distance learning programmes that were highly regarded and appreciated by trainees worldwide. The programmes were always intended to support the professional development

20 | Surgeons’ News | March 2014

â&#x20AC;&#x153;Delivering quality-assured learning material on a single platform would assist the surgeon greatly in demonstrating that his or her knowledge base is currentâ&#x20AC;?

Professor James Garden CBE Programme Director for the ESSQ and RCSEd Council Member

Students have registered from more than 48 countries and recruitment is particularly strong in Australasia

of the trainee and to provide recognition of academic achievement along the way. We have observed that those MSc trainees also preparing for the MRCS have managed greater success in the examination than those who have not been supported by the programme. The level of recruitment to the programmes has been astonishing. The MSc was the fastest-recruiting masters programme in the history of the University of Edinburgh and, since its launch in 2007, there has been a steady recruitment of more than 600 postgraduate students to the suite of MSc and ChM programmes. In 2013, we had a record number of applications to the MSc programme alone, with some 250 registered students in all three years. Although the programmes have very much been aligned to the curricula of the membership and fellowship examinations, it has also been very encouraging to see that interest has been generated worldwide. Students have registered from more than 48 different countries and recruitment is particularly strong in Australasia. We have also endeavoured to open up the programmes to trainees from those parts of the world where opportunities for postgraduate training and educational support are more challenging. It was therefore very rewarding to see our first MSc in Surgical Sciences graduate from Malawi in November. Lughano Kalongolera was able to complete the entire three-year programme

without leaving Blantyre and to have his studies financed entirely with a generous education grant from the Scottish Government and Johnson & Johnson. Other Malawian trainees are being similarly supported at present and it is hoped that this initiative can be sustained in Malawi and other less privileged countries. We continue to refine the existing MSc programme and have responded to requests for similar programmes that support trainees in the later years of surgical training. The ChM programmes have built upon the success of the MSc and aim to consolidate learning towards intercollegiate FRCS examination and at the level of independent surgical practice. Our first cohort of successful ChM in General Surgery students graduated at the end of last year and this year the first graduates in Urology and in Trauma & Orthopaedics will follow. There was a very encouraging number of applicants to the new ChM in Vascular and Endovascular Surgery and, in September, we will launch a ChM in Clinical Ophthalmology alongside an MSc in Clinical Optometry, which will involve collaboration with NHS Education for Scotland. The success of all these programmes has led to interest being expressed in our capitalising on the existing expertise and learning platforms to support the continuing professional development (CPD) of the consultant surgeon wishing to keep up-todate and be aware of recent advances. As a result, CPD modules based on the distance learning programme format were launched last month. It is intended to gauge interest in this form of support for surgeons in independent practice in the coming months. We appreciate that the existing suite of programmes does not cover all 10 surgical specialities but it may be possible to provide a specialist surgical forum that supports both CPD and the academic aspirations of surgeons at the end of their specialist training in some of the smaller specialities. There is an increasing number of online resources available for the surgeon, but delivering quality-assured learning material on a single platform would assist the surgeon greatly in demonstrating that his or her knowledge base is current. The ESSQ team appreciates that there remains much to do to maintain high standards. The Queenâ&#x20AC;&#x2122;s Anniversary Prize marks a significant milestone for the collaboration of the Royal College of Surgeons of Edinburgh and the University of Edinburgh. It is timely, as the University of Edinburgh takes forward its plans to establish a new Institute of Anatomical and Surgical Sciences at Hill Square. This exciting development at the site of the old Pfizer and Lister Institutes will house the surgical distance learning programmes and the anatomy teaching provided by the university. www.rcsed.ac.uk | 21

IN focus

Dr Juana Kabba on his experience of using distance learning technology to study for the Edinburgh Surgical Sciences Qualification

The portable classroom How did you hear about the course? In 2009, as a final-year medical student, a classmate was searching the internet and came across the ESSQ website. He knew that I wanted to become a surgeon, so told me about it. I discussed it with a friend from the UK who helped me to apply and I started the course in September 2011.

Was it easy to adapt to e-learning?

Dr Kabba uses a range of technology, including a tablet part-funded by the Garden Scholarship, to study on the move or at times convenient to him

This was my first experience of ‘e-learning’. Adaptation was initially tough due to the lack of physical contact with my tutors. However, after reading the ESSQ handbook, I found it very easy to navigate my way through the online learning environment. One interesting section was ‘netiquette’ (electronic etiquette and conduct). Basically, I learned the language of this system of education.

What were the main challenges? Fee payment was a challenge and I was much relieved when I was awarded the Garden Scholarship. I then equipped myself with a laptop and, in year two, an iPad. Internet access was limited and very slow in Sierra Leone; in the first year, I would go to internet cafés to log in. Staff members such as Dr Paula Smith and the ESSQ Programme Manager Kaisey Murphy helped me overcome many challenges by providing much-needed guidance throughout the course – I know many other students would agree with me.

Did distance learning fit with your other commitments? It allowed me to control when, where and how I studied. During this period, I travelled to many cities (London, Edinburgh, Washington, Conakry, Monrovia, and Douala), but my classroom was always with me.

“I made use of the times between surgical and clinical procedures, waiting for my next flight, or while travelling on a bus or train” 22 | Surgeons’ News | March 2014

I made use of the times between surgical and clinical procedures, waiting for my next flight, or while travelling on a bus or train. In the past – for a non-distance learning qualification of this kind – I would have made huge social sacrifices and adjustments, such as moving from Freetown to Edinburgh. However, with distance learning, I did not have to resign from my job or travel far away from my family and friends.

Overall, how would you rate the ESSQ? The course has enriched every aspect of my career and life. In my job, I practise evidenced-based medicine; as

First Malawian celebrates ESSQ success In November, the first Malawian to graduate from the RCSEd’s award-winning MSc in Surgical Sciences visited Edinburgh to collect his Masters Degree Certificate. Dr Lughano Kalongolera (pictured, centre), who is based at the University of Malawi’s College of Medicine in Blantyre, said he was keen to improve his skills so that he could help tackle the many pressing health challenges in his country. He said: “Most doctors have to travel abroad to acquire such knowledge and many do not return. By studying online with the University of Edinburgh, I have been able to remain in Malawi to learn, while continuing to treat those who need me most.”

Dr Lughano Kalongolera celebrates his graduation with Professor James Garden (left), and Professor David Dewhurst (right)

Professor James Garden, Programme Director for the MSc in Surgical Sciences and a Council Member of the RCSEd, said: “Dr Kalongolera’s graduation is evidence that the professional and academic development of the surgical trainee can be delivered effectively at a distance. His experience and success underlines the versatility of our award-winning Masters programme in meeting the demands of surgical trainees, no matter where they are based.”

a surgical resident, it gave me understanding of surgical procedures and how they are applied. On the discussion boards, I was able to virtually meet and make new friends from many countries. This qualification has made me more competent and led to better job opportunities for me. I could become a lecturer; I can take membership and then fellowship exams; it has given me a firm foundation for clinical research. Finally, in June 2012, on my way back from taking the ESSQ year-one exam at Edinburgh University, I came across a lady in London who later became my wife (now Mrs Rani Kabba). www.rcsed.ac.uk | 23

IN focus

Digital door open for research Dev Mittapalli looks at how surgical trainees around the world are using information technology to share knowledge and skills

The founders of a take-home surgical simulation kit explain how they are using technology to enhance their product and improve training

BOX OF DELIGHTS

urgical training must evolve to face the challenges of the day. With working time regulations restricting time in theatre and changing public expectations, today’s trainees exist in a very different environment to even recent predecessors. These changes demand innovation rather than retrospection, and eoSurgical was born with this motivation in mind – determined to develop new tools to enhance surgical training and performance. Simulation is assuming increasing importance in surgery, supported by a 24 | Surgeons’ News | March 2014

nascent, but growing, evidence base. What was particularly frustrating for the founders of eoSurgical, however, was the inaccessibility of surgical simulation. Too often locked away in institutions, and unavailable out of hours, we wanted to democratise access by making affordable, take-home simulators. Crucially, we strive to enhance our simulators by harnessing relevant emerging information technology. eoSurgical’s primary product is a take-home, minimal access simulator: the eoSim. Roland Partridge, a paediatric specialist trainee in Edinburgh and

co-founder of eoSurgical, began the journey by experimenting with a webcam, a shoebox, and some borrowed laparoscopic instruments. From this starting point, we now have an international business that has sold in more than 25 countries from a manufacturing base in Glasgow. Going from an embryonic idea to a small portfolio of products has been an exciting challenge, met by a dedicated team. Paul Brennan (a neurosurgical specialist trainee in Edinburgh) joined Partridge at the birth of eoSurgical and set about developing the business through the excellent

ver the last two decades, universities and medical organisations have used IT to provide online portals and interfaces to deliver training and education. This has altered the delivery of medical education, but online forums have also facilitated collaboration directly between trainees. Organisations such as ASiT and the Dukes’ Club provide such platforms to a certain extent, but there is more that can be done at an individual level. For me, it has been a great learning experience to create a free online portal, TheMasterSurgeon.com, to help aspiring surgeons in their preparation towards examinations, as well as giving career advice. This has allowed me to share knowledge with a wider range of students and to build contacts around the world. These skills have also helped my involvement with the Scottish Surgical Research Group (SSRG), an emerging research collaborative of which I am a committee member.

“In the last five years there has been an increasing trend towards trainee-led research collaborations in the UK”

opportunities available for fledgling startup companies. Winning the University of Edinburgh’s growth pipeline competition, the Scottish Institute for Enterprise New Ventures competition, and then the Santander UK Universities Entrepreneurship award helped fund product development. Iain Hennessey, another paediatric surgery trainee, joined the team and set about assessing the effectiveness of the eoSim via trials at the University of Adelaide. Mark Hughes, a neurosurgery trainee with a particular interest in the application of gesture-interface technology to surgical education, then joined the team with a view to developing the product range. eoSurgical is now based at TechCube (www. techcu.be) in Edinburgh, among a diverse community of technology-based start-ups. In this environment, we collaborate and innovate to enhance our products. As a result, eoSim is now equipped with instrumenttracking software that provides real-time performance metrics (assessing instrument movement, speed, smoothness, and ‘surgeon handedness’). The ‘gamification’ that this brings is powerful. Surgeons, competitive as they are, strive to better a personal best or outperform peers. eoSim is priced to be within reach of

In the last five years there has been an increasing trend towards trainee-led research collaborations in the UK. From the first such project in the West Midlands to the SSRG, there have been various manifestations across the UK. Geographical barriers, particularly for projects that encompass large areas, have been overcome by online portals, such as Skype meetings. Furthermore, the National Research Collaborative (www.nationalresearch.org.uk) led to the bigger idea of international collaboration, with globalsurg.org, a research collaboration rapidly growing towards multinational, multicentre research projects. Any enthusiastic trainee can get involved with these collaborations at regional, national and international level and by contacting the project leads for their region. The GlobalSurg initiative has shown the great potential of trainees sharing knowledge and ideas. More such initiatives by and for trainees would surely improve surgery as a whole. Dev Mittapalli Specialty trainee, Ninewells Hospital and School of Medicine, Dundee, and core committee member, Scottish Surgical Research Group www.scottishsurgeons.com

an individual trainee and we hope this will encourage its use outside traditional institutional settings. Simulation at home removes the shackles of working time restrictions, allowing trainees to improve skills in a safe environment and in their own time. The ability to upload performance metrics, together with the option to link video of recorded performances to YouTube, means a trainer can now interact remotely and monitor a trainee’s acquisition of skills. This helps to target training during real operations. We anticipate a future where this form of interaction might usefully become integrated into the ISCP framework.

Combining surgical training with company growth has been a challenge. What is evident, however, is that skills acquired during clinical training are immensely transferable to the business arena, and vice versa. The process of product development has led us to question our own learning and, importantly, the journey so far has also been hugely enjoyable. We welcome approaches from any interested parties, be it with respect to research collaborations or product ideas. For more details, visit www.eosurgical.com

The eoSurgical simulation kit was originally developed using a webcam, a shoebox, and some borrowed laparoscopic instruments. eoSim now comes with instrumenttracking software that provides real-time performance metrics

www.rcsed.ac.uk | 25

IN focus

Navigating the app jungle The growth in medical downloads has presented opportunities and challenges for the profession

he growing market in apps for smartphones is a phenomenon. For surgeons, there are apps to assist with almost every aspect of surgery. There are practical apps such as logbooks, feedback and assessment apps, and clinical guidelines and formulary apps, such as those offered by the BNF, SIGN and NHS trusts. A number of surgical organisations have developed their own smartphone app and major medical conferences increasingly provide an accompanying delegate app. In medical publishing, surgical journals are also providing content through apps. However, the international regulation of medical apps has proven particularly difficult for agencies such as the FDA and MHRA, struggling to grapple with the number of apps, new technology and the borderless nature of this field. These agencies are working hard to provide clearer oversight for apps which change or influence patient management or fall under medical device directives. However, the current regulatory vacuum has resulted in some dubious practices. These include technically poor apps beset by bugs to cases of alleged plagiarism and apps marketed using false claims. A study of more than 40,000 healthcare apps found that over 50% were

“Agencies are working hard to provide clearer oversight for apps which change or influence patient management or fall under medical device directives” downloaded fewer than 500 times and the majority came without medical guidance. One study that evaluated popular melanoma detection apps found that three out of four classified more than 30% of melanomas as ‘not a concern’. Another evaluated 23 apps which provide dose equivalencies for opioid conversion. Here, more than half were developed with no medical involvement and a large variation was discovered in the suggested dose for the same drug conversion. It is, therefore, advisable for surgeons to exercise appropriate caution before uninhibited use of medical apps in clinical practice. In response, some private companies and public agencies have established separate curated medical app repositories. These list apps which have 26 | Surgeons’ News | March 2014

been peer reviewed after submission by a developer, such as Happtique in the USA, and NHS England’s Health Apps Library. For medical app developers, one of the most interesting prospects is app production for wearable devices, such as Google Glass. This device is a set of glasses with a built-in display screen, microphone, voice recognition and a camera. Users can take video or pictures, surf the internet or interact with others (call, text, or message), simply by speaking to the device and looking at the screen. Real-time access to medical records, face-recognition technology, teleconsultation, and live recording of any clinical scenario are just a few of the potential applications. Despite cautions, apps can undoubtedly provide many exciting tools to assist surgical training and practice, but this field has consistently defied prediction. By using, designing, engaging with and building apps, surgeons have already been involved in creating some of the most high-profile, useful and cutting-edge advances in this field and perhaps the only future certainty regarding surgical apps is that such innovation will continue. Richard RW Brady Specialty Registrar in Colorectal Surgery, Western General Hospital, NHS Lothian

conflict of interest

Richard Brady is the owner of social media and medical app consultancy ResearchActive. com Ltd and has been an investigator in a number of the studies referred to in this article.

Farr Institute training

l Summer schools, to run alongside the Farr Institute conferences, that will provide PhD students, new staff members and other clinicians and researchers with a short introduction to key methods and tools used in the analysis of routine health data.

Professor Frank Sullivan explains how the rising use of linked healthcare information is leading to surgical advances

New data from old

e may not have reached the point where the database is mightier than the scalpel, but that day could be coming closer. Use of data from series of patients in Scotland has long illuminated many clinical issues in surgery that were unclear from the study of individual cases of head injury, haematemesis and other conditions. It is the increasing ability to make more sophisticated use of linked information, however, that promises to transform clinical practice. Scotland has made a major contribution to this emergent science as a result of the use of the Community Health Index in a gradually increasing number of healthcare episodes over the past four decades. In future, this will involve all European counties and researchers in North America. Surgeons who have the insight and desire to use linked data will find the Farr Institute provides the infrastructure and training to make the best of worldleading opportunities. Below are two examples of how this works.

Lower-limb amputations Vascular surgeons are one group who have seen a reduction in their caseload of limb amputation, assisted by Scotland’s ability to ensure the registration, recall and regular review of people with diabetes. The rate of lower-limb amputation dropped by 30% between 2004 and 2008, with a particularly large reduction of 40% for major amputation. Improved care is made possible by linking hospital, GP and laboratory data in SCI-DC to enable more effective care of patients. Similar techniques are being employed for observational studies and quasi-

experimental designs to improve patient care, for example, in reducing wound infection through linked data in Scotland’s infection intelligence platform.

Study subjects For interventional studies, Scotland now has a register of people who are willing for their records to be searched securely and confidentially to determine whether they may be eligible for a specific research project. This

“The rate of lower-limb amputation dropped by 30% between 2004 and 2008, with a particularly large reduction of 40% for major amputation” research tool will be one of the databases available within the local and national safe havens throughout Scotland as part of the Farr Institute infrastructure. These use state-of-the-art methods to acquire, link and make available data for a range of purposes, including research. Trainees or consultants who want to understand some of the phenomena they see every day have the opportunity to train in the use of linked health-service data or work with world-leading research teams in each Scottish medical school. They also have educational opportunities at local, national and UK level.

l A one-week course to provide basic training for clinicians and researchers wanting to use routinely collected data. l Create an international, cohort-based programme for mid-career clinicians and researchers to identify and develop them as new leaders of informatics research. l Host and maintain a central repository of education offerings to ensure a co-ordinated approach to delivery and comprehensive coverage of required skills. www.farr institute.org

Frank Sullivan with Dr Emily Jefferson University of Toronto www.rcsed.ac.uk | 27

surgeons’ debate

Open and shut case EVAR is the treatment of choice for 65-year-old men with screen-detected AAA, but can it beat open surgical repair for long-term life expectancy? Leading specialists make their arguments for and against this modern approach

bdominal aortic aneurysm (AAA) repair, in the context of a population screening programme, is a prophylactic operation. Its aim is to remove the risk of early death due to aortic aneurysm rupture. There are no certainties of benefit for individual patients. There are two aspects to the risk–benefit equation: procedural risk (30-day perioperative mortality and morbidity) and long-term survival. There are two methods of intervention – open surgical repair (OR) and endovascular aneurysm repair (EVAR). EVAR has undoubtedly given us another valuable tool in the treatment of AAA. It offers a lower perioperative risk, shorter hospital stay and faster return to normal function. These are all very desirable characteristics and it would seem a ‘no-brainer’ that it should be the preferred option whenever possible. However, everything may not be as clear cut as it seems. There is a range of perioperative outcomes in the four reported RCTs. The oldest studies (2005) show the greatest separation in terms of mortality to EVAR v OR (2.1% v 6.2% and 1.2% v 4.6%). This represents a 4.1% and 3.4% perioperative mortality advantage to EVAR. In more recent studies (2009 and 2011), however, this is smaller and in the most recent the difference is not even statistically significant (2.5% and 0.7%). The aneurysms in the RCTs had been picked up as an incidental finding, usually through the investigation of other conditions or symptoms. This is an older, higherrisk population compared with a screened population. It could be reasonably anticipated that the screened population, younger and perhaps fitter, will also have more favourable aneurysm anatomy and state of immediately adjacent arteries than seen in the RCTs. Indeed, the mortality rate of a screened population for open repair has been reported to be one-third that of when the aneurysm is found incidentally. It is, therefore, not wildly unreasonable to suppose that the perioperative

28 | Surgeons’ News | March 2014

Against:

Peter Stonebridge

Professor of Vascular Surgery, Ninewells Hospital, Dundee

Wesley Stuart Consultant Vascular Surgeon, NHS Greater Glasgow & Clyde

mortality difference in favour of EVAR will be minimal at best and may be very difficult to prove statistically. That would potentially leave a faster return to normal function as the only significant advantage of EVAR over OR in a screened population undergoing aneurysm repair. If all other issues were absolutely equal, this alone might be seen as enough of an advantage. There is also, as it has been put, ‘a sting in the tail’ of EVAR. Meta-analysis shows that the advantage of EVAR in terms of the incidentally identified aneurysm repair procedural mortality is lost by around four to five years later. Survival following EVAR was, in fact, marginally worse than OR at this point. Given that patient populations in randomised trials should be similar, where is this ‘excess’ post-procedural mortality coming from? All patient-related factors should be the same save for one group having a fabric graft sewn in and the second group having an endovascular metal/fabric graft delivered. Secondary ruptures, which are essentially absent in OR, are the most likely explanation for the loss of EVAR’s early survival advantage. Furthermore, close, often contrast, CT follow-up (not required in OR) can, even with evidence of aneurysm sac regression, fail to warn of impending post-EVAR rupture or device limb occlusion. There is a known risk of device limb occlusion of about 5% which translates to an amputation

rate of 2%, and a late rupture rate of 4% in the 10 years following EVAR. Additionally, the reintervention rate and complication rate of EVAR is higher than for OR and, though it falls off, it does not disappear, having been reported up to eight years following implantation. Newer devices, though easier to place, have not yet shown an improvement in terms of longevity. EVAR, therefore, could be seen as carrying a significantly poorer long-term guarantee. If the longer-term, mortality ‘catch-up’ of EVAR over OR is independent of the patient and, as seems to be the case, is device or procedure-based, then one might expect this to be unaltered in the screened population. This, in turn, would suggest that if there is any advantage that EVAR might have had in this population it will be lost well before the four-year analysis point. If this risk continues to apply over the many years the screened population group would normally expect to live, it would appear the EVAR population carries an undefined but potentially significant increased long-term risk. Furthermore, as life expectancy grows, the potentially

Left: The NHS invites men for AAA screening when they turn 65 Right: EVAR is one way to treat AAA

“EVAR represents an undefined long-term risk that we would personally be unwilling to take as a patient”

negative impact of this will not be fully realised for the next 20–30 years. So, you are in your mid-to-late 60s, you attended screening and after a variable follow-up you now face an aneurysm repair. You, like many people of this age nowadays, are fit and well, you do not smoke, you have not had any cardiac symptoms. You reasonably expect to reach at least 85 years of age. You have a choice. EVAR gives you a short hospital stay of two or three days, faster return to normal function, possibly marginally better perioperative survival. However, you are more likely to require follow-up and reintervention, more likely to still die of the condition you are being treated for, and you will have no real guarantee, and no idea what will happen in the next 10–20 years. After five years you would almost certainly have been better off with an OR. Or you could have an OR, your post-operative stay might be about one week, you will take a couple of months to get back to your previous level of fitness, then you can forget you ever had the operation. EVAR represents an undefined long-term risk that we would personally be unwilling to take as a patient, because we would invest in the long term and not the short term. As clinicians, we should know we are doing the patient some good, not just hoping we are. Unfortunately, in the case of EVAR in a screened population, it would be doing the latter not the former. www.rcsed.ac.uk | 29

surgeons’ debate

FOR:

Michael G Wyatt

images courtesy of the NHS AAA Screening programmeProgramme

Consultant and Reader in Vascular Surgery, Freeman Hospital, Newcastle upon Tyne and Newcastle University

he MASS trial shows that the mortality benefit of screening men aged 65–74 for AAA is maintained up to 10 years and cost effectiveness becomes more favourable over time. To maximise the benefit from a screening programme, emphasis should be placed on achieving a high initial rate of attendance and good adherence to clinical follow-up, preventing delays in undertaking surgery, and maintaining a low operative mortality after elective surgery. The results of the MASS trial are primarily driven by open repair and reported before the widespread use of EVAR. Historically, therefore, open repair has been advocated for young patients with screen-detected AAA. However, times have changed, and with the continued development of safe and effective EVAR devices, it is right to question this ‘open first policy’ for the repair of these screen-detected AAA. The Vascular Society of Great Britain and Ireland published an AAA Quality Improvement Programme in March 2012 which showed a significant reduction in elective AAA mortality across the UK, but this decrease was primarily related to EVAR, with high-volume ‘EVAR centres’ reporting the best results (a 30-day mortality of 0.8%). Therefore, if we are to minimise elective AAA mortality for screen-detected AAA, it would seem highly appropriate to offer patients the choice between open repair and EVAR. Patient choice is important and they need to know that there is no evidence to suggest that open repair is better than EVAR (even at 10 years), despite EVAR patients requiring secondary interventions to maintain stent graft integrity. There is, however, evidence that the frequency of early complications following open repair is higher than for EVAR and, consistently, more patients die in the first 30 days. We know that this survival advantage is maintained for up to three years. Patients with screen-detected AAA are frightened; their world has been turned upside down; they need time to think, time to plan and time to reorganise their domestic and business affairs in case of death. These men need a quick, simple and effective treatment, with a high chance of success and a low mortality rate (<1%). Can open repair offer those odds in many institutions? No. Can EVAR? Yes. With the continued development of high-quality EVAR devices, and the realisation that much follow-up can be CT/radiation-free, it would seem illogical to withhold this excellent treatment from the majority of patients with EVAR-friendly screen-detected aneurysms. Yes, there are medium-term problems associated with EVAR, but if patients are alive post-procedure (and more will be after EVAR), then these stent graftrelated problems can be readily fixed. Gone are the days of major mortality associated with endograft revision/ replacement. Most modern vascular centres now have excellent follow-up programmes and we have learnt how to treat stent graft problems effectively with minimal morbidity/mortality. What about open repair? How many centres still have a significant programme of open repair? As the number of patients undergoing open repair continues to decline, so do the skills of the surgeon, and training becomes a major

30 | Surgeons’ News | March 2014

With EVAR treatment, the stent graft is released from a catheter and the catheter is then slowly pulled back

A conventional graft after open repair

problem. Result: increased open mortality. If we are not offering open surgery to most patients, why should we offer a major invasive procedure to a few patients with screen-detected AAA? Cost is less of an issue as stent grafts become more affordable and follow-up less invasive. Quality of life is significantly improved in the early post-operative phase, and for those 65-year-olds required to continue in employment until they are over 70, this is possible with EVAR, but often not following open repair. This increased patient productivity may also help reduce the overall economic impact of EVAR when compared with open repair. In addition, AAA may well be a marker of systemic atherosclerosis in otherwise fit young men. Such patients would have a reduced life expectancy when compared with an AAA-free age and sex-matched population. EVAR longevity may not, therefore, be of such importance as non-AAA-related death becomes of greater relevance prior to stent graft failure. In this instance, we should treat these 65-year-olds as 70 to 75-year-olds, and not decline them the opportunity of EVAR with all of its associated advantages. The EVAR trials randomised patients over 60 years of age. There is little evidence to suggest that this was wrong. Why then disadvantage 65-year-old men with screen-detected AAA? The modern treatment of choice for these patients is EVAR. Open surgery should be reserved only for those outwith the IFUs (instructions for use) for endovascular treatment. Only in this way will we progress in our management of this potentially fatal disease, preserve life for as long as possible, minimise complications (including erectile dysfunction, renal impairment and cardiorespiratory compromise) and allow these fine gentlemen an opportunity to watch their grandchildren grow up in the certain knowledge that open repair has not curtailed their lifespans or their lifestyles.

the monro dynasty

Sir David Monro (1813–77), son of Tertius

Charles John Monro with his brother Alex, around the time of Charles’ return from Britain in 1870

Army surgeon David Carmichael Monro (1886–1960) was made Honorary Surgeon to the King

Charles John Monro (1851– 1933), ‘the father of rugby’ in New Zealand

32 | Surgeons’ News | March 2014

In the second part of our series on the Monro dynasty, Wyn Beasley follows the family into the 19th century

Soldiers, surgeons and a speaker

he saga of the anatomist Monros took an one of his more controversial decisions was to use his imperial turn in the first half of the 19th century. casting vote to defeat Fox’s first ministry in 1862. On David Monro (1813–77) son of Tertius, graduated Monro’s retirement Fox failed to move a vote of thanks to in medicine from Edinburgh, but then migrated him. Feeling slighted, Monro re-entered the House, long in 1841 in the ship Tasmania, stopped off in enough to move the vote that unseated the Fox ministry Australia where his brother Henry (aka Harold) once more. had preceded him, before continuing in the Ariel to New Monro and his wife Dinah had their home, named Zealand, where he settled in the Nelson area. Whether Bearcroft – after the title of Sir Alexander, the Stirling his father was an embarrassment, even in retirement, is Commissioner – at Waimea West, in the estuary upriver uncertain; but we recall that Frederick Knox, younger of Nelson. They had four sons and two daughters, and the brother of Robert Knox the anatomist, had emigrated a elder daughter Maria Georgiana married James Hector couple of years earlier, arguably when his family name (1834–1907), another Edinburgh medical graduate who became a subject for scorn and derision after the Burke and would become the doyen of New Zealand science. Hare scandal. Reunited collections Monro soon abandoned medicine to “Relations with This is a convenient time to mention the become involved in colonial politics, William Fox were Monro collection. Tertius, who died in 1859, and in 1849 was briefly a member of the New Munster legislative council; in always strained, left his collection of medical texts and MSS to son David, and these ultimately reached 1854 he became member for Waimea and one of David New Zealand in 1871. Possibly it was not in the first colonial parliament. He until Sir David resigned as Speaker in 1870 was evidently prosperous: at one stage Monro’s more that he was able to deal with the bequest. Emma Amelia, the daughter of the Rev controversial He in turn bequeathed the collection to Decimus Dollimore (the first Baptist clergyman in New Zealand) came as decisions was to his son-in-law James Hector, and when Sir James died his widow had the collection governess to the Monro children. From use his casting lodged in the General Assembly Library there she became schoolmistress in a in Wellington. But their son, Charles neighbouring Marlborough valley, where vote to defeat Monro Hector, who went on from Otago she was courted by William Bell, one of Fox’s first to Edinburgh, graduating MB CM in the pioneer farmers in the district; their son Francis Gordon Bell (known as Gordie, ministry in 1862” 1895, and indeed worked for some time in Dunedin, arranged for the collection to and another Edinburgh graduate) would be transferred in 1929 to Dunedin. Donald Kerr, the special become the second professor of surgery in the collections librarian at the University of Otago, told me that Dunedin Medical School, and PRACS 1948–50. the General Assembly Library has just unearthed an MS list David Monro’s political career continued: in 1861 he of the items, compiled by Lady Hector, and this is being sent followed Sir Charles Clifford as Speaker, going on to hold south to join the rest of the collection. the post through six changes of government in that decade. It is a substantial collection of books and MSS. The From 1863 he devoted himself to redrafting standing spreadsheet lists about 400 items – works by Albinus, orders on the model of the House of Commons; his by various Bells, Cheselden, Galen, in a 1565 edition; draft was adopted with only minor amendments. He was Albrecht von Haller, the father of physiology, both Hunters, knighted in 1866. Throughout his political career he was Malpighi and of course the three Alexander Monros – an ally of Edward Stafford, who had travelled out to mainly primus and secundus as you would expect; and the Australia with him when they were young, but his Fabrica of Vesalius. relations with William Fox were always strained, and www.rcsed.ac.uk | 33

the monro dynasty

Education in New Zealand To revert to the family of Sir David Monro, his son Charles John (1851–1933) began his secondary schooling at Nelson College (1863–65), where one of the houses at the college today is named Monro. He was then sent over to Britain and to Christ’s College in Finchley, North London. Established as an Anglican foundation in 1857, its building – designed by Edward Roberts (with a 120ft tower that must have owed something to the Holstentor in Lübeck) – opened three years later. A number of alumni of the period played significant roles in the establishment of rugby round the Empire: Monro, 1867– 69; Shepstone Giddy (1871–74) was one of those who introduced the game to South Africa, where he became Solicitor-General of Cape Colony; and W P Carpmael (1876–83) founded the Barbarians Football Club which plays matches against touring teams to this day. And the use of the scrum cap originated in this school. Returning in 1870, Charles brought back with him this game of rugby football, which he proceeded to promote in New Zealand. It took root first in Nelson and Wellington, and indeed Charles Monro played for Nelson until 1875, by which time the game had spread to Wanganui and Hamilton, and an Auckland team had made the first rugby tour of the country. The sport soon became popular, especially at schoolboy level. In 1876 two matches were played between Nelson College and Wellington College. Nelson, captained by a pupil-teacher Joseph Firth, won the second of these – and Firth, after a period on the staff in Wellington, went to Canterbury University College where he obtained his BA, before returning in 1892 to become the legendary headmaster of Wellington College for an unequalled 30 years. Charles Monro married in 1885; he and his wife Helena undertook a twoyear world tour by way of honeymoon before settling in the Manawatu. In 1890 the family moved into the homestead ‘Craiglockhart’ (named after Tertius’s country estate at Colinton in Edinburgh) that they had built on the hill overlooking Palmerston North. The house is still there; sold by Mrs Monro in 1944, a decade after her husband’s death, it is a student hall of residence these days, and part of the Massey University campus with the agricultural research facilities, that were the making of Massey, in the foreground

“David Carmichael Monro was schooled at Wellington College before going to Edinburgh for his medical course, where he was embarrassed by being introduced to the class as a member of the dynasty” 34 | Surgeons’ News | March 2014

of its view. During their time in Craiglockhart the Monros became prominent in Manawatu society, and Charles active in various sporting and cultural activities. He was to prosper in trading land and property, and in the flax industry which was then an important element in the Manawatu. Just as the 2011 Rugby World Cup was getting under way, a statue of him was Helena married Charles John Monro unveiled by the governor-general, Sir Jerry Mateparae, outside the Rugby in 1885; for their honeymoon they Museum in Monro’s adopted city, toured the world for Palmerston North. This reminded two years Kiwis of just how much they owe to our Charles Monro, but he was not the only Charles Monro of his generation.

Military Monros

His cousin Charles Carmichael Monro (1860–1929), nine years younger, was the son of Henry/Harold, who returned with his family from Australia some while after David moved on – though this Charles was born at sea, on 15 June 1860 in the ship Maid of Judah. He was educated at Sherborne, the setting for Goodbye, Mr Chips, and at Sandhurst, becoming a career soldier like his 17th-century ancestor. He would in time save many Antipodean lives by his boldness of decision. He was commissioned into the 2nd Regiment of Foot – a precursor of the Royal West Surrey – in 1879. Monro served in South Africa and was present at the battle of Paardeberg in 1900, when Kitchener surrounded but did not utterly defeat Cronje, though the Boer commander later surrendered. He worked steadily up the ladder, commanding a brigade in Dublin in 1907, and in 1912 the 2nd London Division, which he took to France in 1914, and which was prominent in the first battle of Ypres. By December he was a corps commander and in July 1915 he took command of the Third Army. In October 1915 he was posted to Gallipoli to succeed Sir Ian Hamilton, who had got nowhere John ‘Jack’ Stuart against the Turks – the question Monro, elder of withdrawing from the peninsula brother of David having arisen by this time. Many Carmichael Monro people contributed to the debate, and Monro had no shortage of conflicting advice, including even a visit from the War Minister, Kitchener. (If Kitchener had launched the land campaign at Gallipoli more smartly and skilfully in the early part of 1915, it might have succeeded.) In spite of all these distractions, Monro ended up driving the evacuation – which was accomplished, not with the

30–35% casualties he had originally budgeted for, but totally without loss. The only successful part of the campaign was the one which confirmed its failure. Monro briefly commanded the British First Army in France in 1916, before becoming Hector ‘Peter’ commander-in-chief in India, where MacDonald Monro, he built up the country’s military younger brother of capabilities during the remainder of David Carmichael the war, and capably handled a period Monro of post-war unrest. In 1920 he was made a baronet, taking the title ‘of Bearcrofts’ which so plainly refers back to his military ancestor. He also became Bath King of Arms, a ceremonial role, and in 1923 he was made governor of Gibraltar. He died in 1929, full of honours if not quite of years. He reached the top, Knight Grand Cross or equivalent in three orders – of the Bath as a soldier, of the Star of India as a subcontinentalist, and of St Michael & St George as a proconsul – and might have been excused had he echoed the words of Lord Curzon, who referred to “the series of Grand Crosses with which the Sovereign has recognised my distinguished services”. Although he made his career outwith Scotland, his grave in Brompton cemetery is surmounted by a Celtic cross. Unlike Sir Alexander of Bearcrofts, though, he did not found a dynasty.

End of the dynasty Charles John Monro’s eldest son, born in Switzerland during that long honeymoon, was named David (after his grandfather) and Carmichael (after Tertius’s first wife, a Carmichael-Smythe). Perhaps because of the Firth connection, David Carmichael Monro (1886–1960) was schooled at Wellington College before going to Edinburgh for his medical course, where he was embarrassed by being introduced to the class as a member of the dynasty. Because of the Carmichael factor, perhaps, he became an army doctor after graduating in 1911. He went to France in 1914, being mentioned in despatches after one of the Ypres battles. His service is recorded on one of the marble tablets at his old school. These lined the walls of a dignified memorial hall, opened in 1928, its centrepiece being a memorial window honouring those who died. Forty years later, the hall was demolished as an earthquake risk – taking the wrecker’s ball four months to beat into submission. Fortunately, both the window and the marble tablets have survived.

David Carmichael Monro had two postings to India after the Kaiser’s war: the first more humbly overlapped Charles Carmichael and from the second he returned in 1931. He was at Millbank for a time, then Edinburgh Castle (which had him on the spot to become FRCSEd in 1934); after which he went to the Royal Army Medical College, becoming assistant professor in 1938 and full professor two years later. He was made Honorary Surgeon to the King, prompting a congratulatory telegram from the Craiglockhart family back in Palmerston North which ended: “God save the King”. In 1941 he became consultant surgeon to the Middle East Forces, and in North Africa he ran into old friends. He found that his New Zealand counterpart as consultant surgeon was Duncan Stout, who had been one year senior to him at Wellington College (in 1901 they had both been awarded Turnbull Scholarships); and, of course, 2 NZ Division was commanded by the man who had been ‘Freyberg iv’ in the terminology of the school, three years junior to Monro, before launching his own illustrious career. Monro’s ideas appealed to the New Zealanders: good surgery well forward, quality transfusion services, and the Tobruk splint, which the Kiwis refined and enjoyed. A full colonel on arrival, he became major-general, was mentioned in dispatches again, and made CBE. He became CB later; the Norwegians gave him the Cross of Liberty, the USA the Legion of Merit. In Alexandria he married Kathleen Noon; their marriage was childless, but they adopted a daughter who is today a custodian of family memorabilia. In retirement David Monro lived in Roehampton out of London; he died in 1960. David Carmichael had two brothers, all three becoming doctors; the younger of these, Hector MacDonald Monro – universally known as Peter – was a New Zealand graduate (MB ChB 1920) but FRCSEd in 1924. I remember him as a senior and respected country doctor in nearby Feilding when I was a registrar in Palmerston North, where his elder brother John Stuart Monro – known as Jack and, like David, an Edinburgh graduate (MB ChB 1912); and in 1922 DOMS (London) – was an ENT surgeon. Peter’s son Paul Alexander Monro (1928–2013), who graduated in New Zealand in 1957, followed him in Feilding but in a separate practice, then lived in retirement at Taupo, where he died four days before his 85th birthday. It has been reported to me that, living alone after his wife (who died a month after him) went into care, he poured himself an after-dinner whisky, and went into the kitchen for water. The housekeeper found him there next morning. It was the first and only time, my informant claimed, that Paul had left his whisky in the glass unfinished. The last of the line: With his passing the Monro Paul Alexander medical line, which its Antipodean Monro (1928–2013), members did so much to maintain, is son of Hector extinguished. ‘Peter’ Monro

A GUIDING HAND IN THE MONRO MAZE

“Readers with a capacious memory may recall Gordon Bell, Duncan Stout, James Hector and Bernard Freyberg, who have appeared in earlier essays of this series. “I should acknowledge the assistance of Alistair Gaisford, a Monro descendant on his mother’s side whose working life has been in Australia, but who has guided me through the Antipodean labyrinth of the Monros. “He tells me also of plans to inaugurate a perpetual trophy in CJM’s honour, for Rugby tests [men and women] between Scotland and New Zealand.” Wyn Beasley

www.rcsed.ac.uk | 35

ENT surgery

Exploring the senses

In the first of a new series of specialty features, we look at the development and current status of ENT surgery. Cate Scally begins by charting the history of the discipline, starting as far back as c.1500BC

he specialty of ENT is, in historical terms, a fairly recent grouping. We are extremely fortunate to have in our number the retired ENT surgeon Neil Weir, who has dedicated a significant part of his life to gathering information and publishing an extensive history of our specialty, and it is his work I draw on here. Mr Weir has kindly let us use his knowledge in the expanded section on ENT that will feature in the redevelopment of the RCSEd Museum in 2015. ENT surgery featured in the Egyptian papyruses (c.1500BC), which described in detail the management of a fractured nose using packs of linen soaked in grease and honey. The ‘father’ of plastic surgery of the nose, however, was from the Indian subcontinent. Sushruta (c.1000BC) described the forehead flap to restore the noses of warriors injured in battle. The knowledge was brought to the West by an English surgeon resident in Madras who witnessed the practice in 1794. Hippocrates (c.480BC) described the removal of nasal polyps by

“The Egyptian papyruses (c.1500BC) … described in detail the management of a fractured nose using packs of linen soaked in grease and honey” 36 | Surgeons’ News | March 2014

Below: Part of Hieronymus Fabricius ab Aquapendente’s otology drawing, published in 1600 in Venice

drawing sponges down through the nasal cavity and out the oropharynx. Galen (c.131AD), a physician educated in Alexandria but practising in Rome, laid the basis of experimental physiology and animal dissection. He demonstrated the basic anatomy of the ear and the function of the recurrent laryngeal nerves. Much knowledge was gained in the Graeco–Roman collaboration, but it was the Byzantine compilers in Constantinople who kept the teachings alive. Care of the sick was one of the first principles of Christianity, so most monasteries had herb gardens. Arabic medicine of the time contributed greatly to pharmacological development and Albucasis (936–1013AD) developed a form of ‘tonsil guillotine’. With the Renaissance came increased understanding of anatomy and detailed drawings such as those by Leonardo da Vinci. The microscope became a regular research tool in the 1660s, with increasing benefit as a tool for illumination developed over the years. The Scottish military surgeon Archibald Clement (1700–71) developed a candle-powered illuminator for inspecting the tympanic membrane. The French promoted otology as a separate specialty to General Surgery, with Jean Marie Itard (1774–1838) presenting a clinical summary of knowledge to date. He also contributed to the development of sign

Wellcome Library, ALAMy

The GENERATE project This national research priority-setting exercise for ENT surgery, hearing and balance services was developed following a horizonscanning exercise undertaken for ENT UK. Its aim was to identify barriers to commissioning services while developing national commissioning guidance. GENERATE is a collaboration between ENT UK, the British Academy of Audiology (BAA) and the British Society of Audiology (BSA), using the expertise of evidENT (the UCL Centre for Evidencebased ENT) for academic quality assurance and project coordination. The project will bring together all the groups involved in developing, implementing and using evidence in ENT, hearing and balance. These groups will be consulted and work in partnership to deliver an agreed research agenda that is relevant to clinical practice and service delivery, with outcomes that are meaningful to patients. If you would like more details or are interested in being involved, please contact generate@ entuk.org

www.rcsed.ac.uk | 37

ent surgery

language in deaf mutes. Interestingly, the Edinburghborn Alexander Graham Bell started life as a teacher of deaf people and it was with Hermann von Helmholtz, looking at vibrational research focusing on the tympanic membrane, that he developed the Diaphragm Magneto Telephone in 1877. Many great names such as Toynbee, Yearsley, Wilde (Sir William, father of Oscar) and Hinton rescued the profession from the quackery that had developed in the 19th century, expanding knowledge of the ear and surgery of the mastoid bone. It was in the 1930s that the binocular operating microscope came into common use and that, combined with antibiotics, asepsis and reliable anaesthesia, heralded the modern era of otological microsurgery. Tracheostomy was described in 2AD but not commonly practised until the 16th century. It became a treatment of laryngeal diphtheria with the first British tracheostomy performed by George Martine of St. Andrews (1702–43). It is also the first recorded case of a double cannula with an inner tube to allow cleaning. Tonsillectomy had been performed by drawing it out and placing a ligature around the base with eventual sloughing. By the 19th century the use of the guillotine had been popularised with modifications by Morell Mackenzie. Laryngeal polyps or papillomata required removal by laryngofissure until the development of the laryngoscope. Manuel Garcia, a Spaniard and

Wellcome Library

“The greatest advances of the 20th century were due to the development of binocular microscopes, portable artificial light sources and powerdriven instruments” Professor of Singing at the Paris Conservatoire, developed a system of mirrors using a dental mirror and reflected light to view his own larynx. Laryngoscopy was developed using artificial light and many forceps were designed to instrument the larynx. The first total laryngectomy for cancer was performed by the general surgeon Professor Theodor Billroth in 1873. That patient died of recurrent disease seven months later but the practice developed from there. During this time in the development of management of ear and throat disease, little progress was made regarding nasal conditions. Indeed, the erectile tissue of the turbinates became of interest mainly to those such as Sigmund Freud and his friend, the German otolaryngologist Wilhelm Fliess, in regard to ‘nasal reflex neuroses’ where turbinectomy was 38 | Surgeons’ News | March 2014

Top: Thomas Buchanan’s 1825 designs for acoustic surgery and, left, his auroscope Above: John Lizars’ diagrams of nasal operations (1847)

used as a treatment for pre-menstrual depression by disrupting the ‘naso–genital reflex’. Nasal polyps were identified as being linked to asthma and nasal speculae were developed. Septoplasty preserving the mucosa was developed in the 1880s. The introduction of general anaesthesia allowed the development of rhinoplasty techniques, which were well established by the end of the 19th century and refined further by Jacques Joseph of Berlin in 1898, with the introduction of intranasal rather than external incisions. The greatest advances of the 20th century were due to the development of binocular microscopes, portable artificial light sources and power-driven instruments. These developments allowed exploration of the sinuses and endoscopic refinement of surgical techniques. Sinus surgery became not only possible but minimally invasive and this trend continues today. Ms Cate Scally RCSEd Council Member and Consultant ENT Surgeon in Antrim Hospital, Northern Ireland

ENT Webinar Series In association with ENT UK, the Royal College of Surgeons of Edinburgh is pleased to offer its membership access to a series of live and archive webinars on ENT surgery.

Forthcoming Acoustic neuroma: diagnosis and treatment

Date: Wednesday 9 April 2014 Time: 20:00 GMT Guest Speaker: Tristram Lesser Target Audience: ST3 - ST5 ENT trainees. CPD: 1 approved Fee: Free

Endoscopic DCR

Date: May 2014 (Date to be confirmed) Time: 20:00 GMT Guest Speaker: Paul Harkness Target Audience: ST3 - ST5 ENT trainees. CPD: 1 approved Fee: Free

Globus sensation: A holistic approach

(topic to be confirmed) Date: Thursday 19 June 2014 Time: 20:00 GMT Guest Speaker: Janet Wilson Target Audience: ST3 - ST5 ENT trainees. CPD: 1 approved Fee: Free

This is an RCSEd membership benefit resource for all RCSEd Fellows, Members and Affiliate Members. To find out more about our ENT webinar series, please log in to the Education pages of our website www.rcsed.ac.uk or contact elearning@rcsed.ac.uk

Vestibular compensation

Date:Â Wednesday 9 July 2014 Time: 20:00 GMT Guest Speaker: Simon Browning MA(Ed), MPhil, FRSC(ORL), MB BCh Consultant ENT Surgeon, Abertawe Bro Morgannwg University NHS Trust Target Audience: ST3 - ST5 ENT trainees. CPD: 1 approved Fee: Free

ent training

Heading in the right direction Michael Moran outlines the training pathway for a career in ENT, a diverse and stimulating surgical area with numerous interesting subspecialties

NT is a surgical specialty that is traditionally shoehorned into a busy undergraduate medical curriculum. As a result, many students graduate without gaining an appreciation of the variety of subspecialties within ENT, or how stimulating and diverse a specialty it really is. Otolaryngologists in training are often, therefore, individuals who rotated through an ENT job at an early point in surgical training, and decided they wanted to stay in ENT. Similar to other surgical specialties, the ENT career is likely to begin in the foundation years of training, perhaps with a four-month placement in ENT during FY2. Following this, a budding ENT surgeon would be expected to enter core surgical training for the next two to three years, during which time the MRCS examination should be taken. ENT trainees are

Avenues of research The diversity of ENT and its subspecialties means there are many research domains available to prospective and current trainees

40 | Surgeonsâ&#x20AC;&#x2122; News | March 2014

expected to also take the Intercollegiate Diploma in Otolaryngology â&#x20AC;&#x201C; Head and Neck Surgery (DOHNS), and a unique aspect of ENT training at this level is that trainees can opt to take part two of this examination, combined with part A of the Intercollegiate MRCS, in order to obtain the MRCS(ENT) qualification. Prior to 2011, ENT core trainees would have been expected to obtain both DOHNS and MRCS as separate qualifications, and this is still a safer option for the trainee surgeon who may not be successful in obtaining a

There are many centres in the UK investigating different clinical and scientific aspects of ENT diseases. Current forms of research include basic science research, translational research and multicentre randomised controlled trials. In 2011, ENT Health Services research was supported by the awarding of a National Institute of Health Research professorship to

Professor Anne Schilder (pictured below left), who is working to improve evidence-based management of ENT conditions through clinical trials. Although research is well spread across the country, there are organisations such as the Otorhinolaryngological Research Society and the British Society of Academics in Otolaryngology, which are working

“In an ideal situation, a trainee working towards a career in ENT would have an ENT theme for their core training phase, with incorporation of other relevant specialties” specialty training number in ENT, and who has another specialty interest he/she can pursue instead. In an ideal situation, a trainee working towards a career in ENT would have an ENT theme for his/her core training phase, with incorporation of other relevant specialties such as plastic surgery or upper gastrointestinal surgery. Selection at ST3 level, as with many surgical specialties, is highly competitive, and a trainee would be expected to demonstrate a portfolio of audits, relevant courses and perhaps research involvement to be competitive alongside peers. From ST3 there are currently six years of higher specialist training, and during this period the trainee will be exposed to, and gain competency in, the

many facets of an ENT career. These include otology, rhinology, head and neck surgery, skull base surgery/ neurotology, thyroid and parathyroid surgery, facial plastic surgery, paediatrics and laryngology. The training period must be spent in at least three hospital units, and trainees must also demonstrate evidence of either 300 nights on call, or having managed 1,000 ENT emergencies. A trainee at the end of the training pathway should be able to provide evidence of at least 2,000 operations (as principal or main assisting surgeon), and must complete a minimum of seven specific operations that are most relevant to emergency on-call work. In addition to this core ENT training programme, trainees are encouraged to take part in a clinical fellowship, either in the UK or abroad, with the aim of gaining a specialist skill and area of expertise. For those with a research interest, it is also possible to take time out of the programme for research, and currently a national network of ENT trainees who are, or have been, part of the Academic Clinical Training pathway is developing. Although challenging, the variety provided by a career in ENT makes the training well worthwhile, with opportunities to suit those wanting a general ENT practice or a subspecialty interest with an academic position, and everything in between! For more information on a career in ENT, visit www.entuk.org and www.aotent.com

to integrate research and develop collaboration among institutions. With regard to head and neck cancer surgery, ENT surgeons are working with colleagues in maxillofacial surgery and clinical oncology to develop and promote the National Cancer Research Institute (NCRI) Head and Neck Clinical Studies Group portfolio, and the number of clinical trials generated by this group is increasing at an

impressive rate. ENT surgeons as a specialty group were also represented by Professor Terry Jones (pictured left) and Professor Hisham Mehanna (pictured right) on a recent NCRI report entitled ‘Challenges and opportunities in surgical cancer research in the UK’, which acknowledges the growing strength of head and neck cancer research nationally.

The current cohort of academic clinical fellows, clinical research fellows and academic clinical lecturers represent a broad spectrum of research interests across the whole specialty. This should ensure that ENT maintains a strong foothold in the arena of medical research when research funding is ever more difficult to obtain. www.ors.uk.net

www.rcsed.ac.uk | 41

dental

Time to even the score? Richard Ibbetson reports on the latest news from the College’s Dental Faculty

risis after crisis, complaint after complaint, concern after concern. Is it really the case that healthcare in the UK is more notable for its problems than its successes? Sometimes it does feel that way. One element of improving a service for patients is top-quality training. This is essential to develop younger colleagues and support the continuing development of all healthcare professionals to enable high-quality care to be provided. Training in postgraduate dentistry in the UK has become more formal and regulated. The ARCP process has provided more objectivity in the monitoring of a trainee’s progress and trainers are better prepared for their role with a variety of courses available to develop skills in mentoring, appraisal and assessment. However, having these elements in place doesn’t guarantee that all will be well – highquality teaching and training take time as well as skill. Many of us have experienced trying to observe a trainee or postgraduate carrying out a clinical procedure whilst supervising five or six other trainees, running a busy referral clinic or treating a patient of our own. In this respect, the 9:1 consultant contract, instituted to reduce waiting times and improve access to care, when strictly applied, may have damaged our ability to teach and train.

“If 9:1 were the half-time score in a football match, it would be considered one-sided. Can the same be said of many consultant contracts?” 42 | Surgeons’ News | March 2014

Reflecting on my own training, there was much less structure and certainly less formal monitoring. In no way should we return to the training methods of 30 years ago, but clinical practice and teaching are much more pressured than they used to be. I believe that there has been a reduction in the effectiveness of the specialist or consultant-led team in terms of training. Looking for the causes, lack of time and working practices may be significant. The current dental consultant contract is itself a counting exercise and measures clinical effectiveness most frequently in terms of the number of patients seen. It is hard to see how it can be done any other way because we have so few markers of clinical effectiveness or quality outcomes in dentistry. ‘Shared care’ between the specialist and the general dental practitioner reduces the opportunities for long-term review of treatment provided for patients. The consequence is less understanding among trainees of maintenance, deterioration and failure, with rich teaching and learning opportunities being lost. The aspiration is to deliver the highest quality care even in the most demanding circumstances. Trainees can learn to do this only if their training is structured, they are supported and taught to aspire to the highest standards – and they are clear on what these are. All of this is simply not possible without giving trainees time and, in return, trainees giving of the same. If 9:1 were the half-time score in a football match, it would be considered one-sided. Can the same be said of many consultant contracts? Richard Ibbetson Dean, Faculty of Dental Surgery

section xxxxxxxx

Dental students exhibit their skills during one of the heats last year

Wide open: the final will take place on 6 March / Clinical Skills

Grand finalists await skills competition Fourteen students from dental schools across the UK have been shortlisted for the grand final of the Dental Faculty’s Clinical Skills Competition on 6 March. Sponsored by DENTSPLY, the competition is the first of its kind in the UK and 260 dental students competed in the heats, which took place in 14 dental schools from October to December last year. In an interview with the BBC, finalist Imogen Bexfield from the School of Dentistry at the University of Leeds said: “RCSEd has a world-class reputation and I feel very honoured to be affiliated with them, especially at such an early stage in my career. I am hugely excited to go to Edinburgh and to get to know even more about the organisation and the people behind it. I can’t even imagine how brilliant it would be to win the final and go to the conference in Chicago. I will just have to hope that my clinical skills prevail on the day.” The top prize is an expenses-paid trip to the Chicago Dental Society’s Midwinter Meeting in February 2015, courtesy of the RCSEd’s Faculty of Dental Surgery. All participants in the competition will receive a certificate of participation and a year’s affiliation with RCSEd.

/ appointments

Professor William Saunders elected dean of College faculty

new dean has been elected to lead the RCSEd’s Faculty of Dental Surgery. Professor William Saunders (pictured), a long-standing member of the College’s Dental Council and the UK’s first professor of endodontology, will take over from the current dean, Professor Richard Ibbetson, in October 2014. Commenting on his appointment, Prof Saunders said it would be a privilege

to work with such a strong professional body: “I am absolutely delighted to have been elected dean of the Dental Faculty; it is such an honour to represent the College in this capacity. The Dental Faculty is a thriving institution within the College and I hope to continue the good work undertaken by my predecessors. Dental Council and SAB chairs are motivated and committed to the values of the College and it will be a huge privilege to work with this excellent organisation.”

Appointed in 1981 to a lectureship in conservative dentistry at Dundee’s School of Dentistry, Prof Saunders completed higher training in restorative dentistry and a PhD. He then spent 13 years at the University of Glasgow Dental School, where he served as senior lecturer and professor of clinical practice, and became the first professor of endodontology in the UK in 1995. He returned to Dundee in 2000 and served as dean for 11 years. He has also been chair of the UK’s Dental Schools Council. www.rcsed.ac.uk | 43

dental / trainee events

Dental Foundation trainees explore career pathways

or the second year running the College’s Dental Faculty has provided career advice to Dental Foundation trainees in the south-west of England. The South West Deanery Dental Foundation Conference took place at Longleat in Wiltshire on Tuesday 3 December Speaking to more than 80 trainees, Pamela Ellis, College

regional dental adviser, and Nathan Brown, adviser for the South West Postgraduate Dental Deanery, explored different career pathways in dentistry. Trainees were able to learn more about careers in general dental practice as well as in specialist areas. Interest was expressed in the structure and syllabus of the Membership of the Faculty of Dental Surgery (MFDS) exam and the importance of

gaining this qualification for career progression. The session was well received and made many of the delegates think more about where they saw their future career and how they might achieve their goals. The Faculty is grateful to the conference organiser, Mike Attenborough, for inviting the College and for his superb organisation of the event.

Pamela Ellis

Nathan Brown

/ trainee PRIZEs

Best in SHO: Wessex regional presentations Another successful Wessex BDA Hospitals Group meeting took place on Thursday 5 December, where the RCSEd sponsored prizes in three categories: best SHO audit, best SHO case report and best specialist trainee presentation. Winner of the specialist trainee prize was Ella Mitchell, maxillofacial StR from Southampton, who presented a rare case where IgG4-related disease, which was diagnosed in a patient presenting to the maxillofacial team with a three-month history of an enlarged lymph node. After multiple investigations, IgG4-related disease was diagnosed. In her presentation, Ella gave an overview of the disease and highlighted the importance of early recognition and appropriate management of this condition. Jennifer Burdett, SHO from Salisbury, picked up the prize for best SHO case report. Her presentation of the oral and maxillofacial surgery management of a patient involved in a major road traffic accident in 2008 included acute and long-term management over a fiveyear period. Jennifer was able to report to the group on the final outcome for the patient. The final prize was awarded to Ian Blewitt, SHO from Swindon. Ian presented the results of an audit into compliance with assessment of patients with suspected oral cancer within two weeks. He was able to demonstrate 100% compliance with this target by the oral and maxillofacial team at Swindon.

44 | Surgeons’ News | March 2014

/ INTERNATIONAL

Faculty announces Bahrain initiative The Faculty of Dental Surgery is working with College Fellows in the Kingdom of Bahrain to support the development of a Bahrain postgraduate dental centre. Dental Dean, Richard Ibbetson, visited Regional Advisers in Bahrain in December (pictured) to confirm College support for the project and had the pleasure of meeting the Minister of Health, Mr Sadiq AbdulKarim Al Shehabi, and the chief executive officer of the Bahrain National Health Regulatory Authority, Dr Bahaa Eldin Fateha. The project was initiated by two Regional Advisers, Dr Hamad Shams and Dr Hassan Selim, and past Dental Faculty Vice-Dean, Howard Moody. The centre is due to open for its first intake of postgraduates in January 2015.

surgeons_news_colour_page_out 13/11/2013 13:58 Page 2

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trainees and students

WE’re Taking on the bullies

In December, a GMC survey found that surgical trainees had one of the highest reporting rates for bullying and undermining of all medical specialties. In response, RCSEd invited representatives from across the profession to discuss the extent of the problem and examine possible solutions What is undermining and bullying?

DR NEIL DEWHURST (ND): One person’s bullying is another

person’s stiff talking-to, is another person’s constructive criticism. So I think it’s an individual perception. DR RACHEL THOMAS (RT): I think a situation can be

interpreted differently depending on the individual as to whether you think something constitutes bullying or whether that’s just what you’d expect in stressful surgical situations. MR RICHARD MCGREGOR (RM): The Oxford English

Mr Ian Ritchie

President RCSEd

Dictionary says a bully is a person who uses strength or influence to harm or intimidate those who are weaker. Having read that definition, it’s certainly something I have witnessed. The 2012 NHS staff survey said 33% of doctors and nurses reported instances of being bullied within their lifetime; this was not looking at a snapshot of a year, but within their lifetime working, which is a large figure and quite worrying. DR DUNCAN HENDERSON (DH): It’s interesting that the

2013 GMC trainee survey found that individuals who report being bullied sits [at] around 13% whereas a witness rate is about 20%, which suggests perception certainly is a factor.

Dr Neil Dewhurst

President RCPE

MISS LORNA MARSON (LM): It’s also a matter of people

feeling safe enough to speak up about it and I think there is a real challenge around the treatment of those who do speak up about bullying. The definition of bullying is really interesting because it demonstrates the power gradient between individuals of differing grade. DH: There’s always a gradient, I don’t think I’ve ever seen

bullying between peers. 46 | Surgeons’ News | March 2014

Mr Richard McGregor

Trainee Member of Council, RCSEd

Dr Duncan Henderson

Anaesthetist at St John’s Hospital and Associate Postgraduate Dean for the Foundation Programme in South-East Scotland RM: Psychological studies have staged mock scenarios in public where an individual is overtly bullied and passers-by typically failed to intervene. The reasons they give for this phenomenon is they’re worried that if they then interject they themselves may be on the receiving end. ND: The medical profession has a history of being male

dominated and it’s in a far better place now for getting the gender balance right. I would be interested to look at instances of male-to-female bullying and female-to-female bullying to see the differences and the age variance.

Dr Rachel Thomas

Member of BMA’s Scottish Junior Doctors Committee

What effect can bullying by a trainer have on a trainee? MR IAN RITCHIE (IR): As clinicians, we tend to have a parent/child approach with trainees when, in fact, it would probably be healthier if we regarded them as equal adults, albeit with less clinical experience. Perhaps that would lend itself to rational discussion between two adults rather than situations that could be viewed as bullying. As a trainee, I grew up with a situation where I felt I had to look up to ‘the boss’. LM: The parent/child concept is interesting because

children tend to learn the patterns of behaviour from the parent. So young consultants may continue with these patterns of behaviour. Indeed, they may be more likely to display these early on, when they lack confidence in their new consultant role. RT: If you are working 12-hour shifts and you hand over to the same person every day on the same rota for six months and this person is bullying you, it can make you feel very lonely. If you have a mentor, you’ve got somebody else you can talk to and give you a second opinion on whether you are being bullied.

Miss Lorna Marson

Senior Lecturer and Honorary Consultant Transplant Surgeon, Edinburgh Royal Infirmary, and Associate Postgraduate Dean for Surgery, SouthEast Scotland

“I think there is a real challenge around the treatment of those who do speak up about bullying” Lorna Marson

www.rcsed.ac.uk | 47

trainees and students

“It’s really important for trainees not to feel that they will be fingered by speaking out; that they should respond honestly to any surveys because it’ll get back through the system and remediation will take place” Ian Ritchie ND: Today’s workplace is even more pressured, particularly

in specialties such as emergency medicine. But it’s important to be able to say, ‘can we go and sit down and have a cup of tea’. Unfortunately, it’s difficult to find the time for that any more. IR: That also points out the fact that we no longer have long-term teams because that kind of behaviour is less likely to happen with somebody you don’t know very well. The point about not having the time is you don’t invest the time for somebody that you know you’re not going to see again. If we were going to contribute anything to this debate we would want clinicians to return to delivering a team-based approach to care. It’s really important for trainees not to feel that they will be fingered by speaking out; that they should respond honestly to any surveys because it’ll get back through the system and remediation will take place. LM: But that is a difficult concept to get across to trainees

because too many of them have had their fingers burnt and they have seen the way individuals who’ve expressed concern have been treated. The danger is that if the person who’s being bullied speaks out they are the person who is labelled as unable to cope or the ‘troublemaker’. So the key person to protect is the person who either is saying that somebody else is being bullied or is being bullied themselves. We 48 | Surgeons’ News | March 2014

have to try to work with such trainers to alter their patterns of behaviour. RM: I fully agree that people should be able to vocalise concerns and not be fingered. But, as trainees, do we not have the right to know if a unit has got a bully in it in the first place? IR: It seems that periods of stress on the whole healthcare system are inevitably the times when reports of bullying come up. Maybe we need to encourage clinicians at all levels to think about different ways of delivering the service which will reduce stress. We should acknowledge that, at the same time as bullying is a problem, if somebody feels that a situation is not working out for them, there is a potential for that person to falsely claim that they are being bullied. So it’s important to ensure equity and fairness all around because to be accused of bullying must be devastating.

“We should make it clear that bullying is unacceptable and the victims need to speak out about it” Rachel Thomas LM: There is a link to the pressures on the service but

there’s also a link to culture. In surgery, there can be a culture of criticism that’s part of training. It is easy to be critical of a trainee without taking the time to emphasise their positive attributes. As assessment of training becomes more formalised using web-based assessment tools, such as the Intercollegiate Surgical Curriculum programme, and includes multisource feedback assessments, this may change.

Is there a link between the ‘surgical personality’ and the bully? LM: It’s important to focus on a team approach as it

may lead to less of a hierarchical approach. It provides an opportunity for informal discussion ‘over a coffee’, which should allow more positive interaction between the trainer and trainee, and an opportunity to discuss specific, challenging issues. IR: But it’s also the case that if you do the surgical pause

and the surgical briefing properly then the hierarchy suddenly becomes flatter. This can create an atmosphere in theatre where the consultant will feel less like they are working as an individual, but working as part of a team. If you get the situation where somebody is being a bit brusque the other members of the team will rally round and correct that behaviour. DH: There are departments where there are no specific bullies but they are dysfunctional and trainees don’t like going there because the consultants don’t get along. Trying to fix that is very difficult, but it makes a huge difference to the working lives of everybody in the department. RM: One of the main findings of the Francis report was that a culture of bullying in Mid Staffs undermined clinical care. Although that is a particular case, it raises the question of whether patients have a right to know about bullying and undermining within a department where they are receiving treatment.

What could the royal colleges do to tackle bullying? RT: What would be helpful is information for trainees to outline what constitutes bullying and highlighting that something can be done about it. I think a lot of people think it’s just part of the banter in surgery. So we should make it clear that bullying is unacceptable and the victims need to speak out about it. LM: Mentoring is another possible avenue. The real

attraction is that it’s a step away from the working

environment and it’s a safe place to explore some of these experiences. Equally, you could argue that the people who are doing the undermining or bullying also need that sort of safe place. IR: And I would reflect that, because of reduced trainee numbers and the introduction of rota patterns, such a network of support is not possible at the moment. DH: What’s even worse is that it can take place on social

media, which can be a disaster. So I agree entirely – sitting down with somebody in an environment where you can just get it off your chest is hugely beneficial.

Closing remarks from Mr Ian Ritchie Today’s discussion has looked at many aspects of bullying, its effect on training and perceptions around training and surgery as a career. It seems that pressure upon the health service as a whole is a significant factor. In addition, stressful situations can arise during surgical procedures, which may lead to heated exchanges and subsequent accusations of bullying. It has also been pointed out that there is less time available for trainers to speak with trainees on a one-to-one, informal basis, which can be important in establishing understanding and trust. We have identified particular aspects of surgery that may explain the results of the GMC survey, but we have also looked at a number of ways to tackle the problem. We’ve discussed the importance of less hierarchical, teambased approaches, the value of mentor programmes and spending time with colleagues away from the stresses of a clinical setting. It is important for bodies such as the RCSEd to point out the good things about training, as well as addressing the problems, and start turning perceptions around. Today’s discussion will hopefully mark the start of that process. www.rcsed.ac.uk | 49

trainees and students

Measuring up trainees’ needs Contrary to the findings of the Greenaway Report, more flexibility is required for future doctors to gain the skills necessary for consultant careers – so argues the Association of Surgeons in Training

Scan the QR code above to view the full ASiT Shape of Training Review Response document

he final report of the independent review led by Professor David Greenaway made recommendations regarding the structure and delivery of medical and surgical postgraduate training for the next 30 years. The changes proposed within its 19 recommendations are far-reaching and have implications for current and future trainees in the UK. The broad goal of delivering trained doctors who match the needs of the local population is laudable. However, patient expectations for their care continue to rise. At the same time, the complexities of surgical care together with the focus on outcomes are driving the profession towards ever more specialist care. In parallel to this, factors previously discussed by ASiT are conspiring to substantially reduce the operative experience of current surgical trainees. ASiT therefore finds it difficult to see how the generalist model proposed in this review can be reconciled with these pressures and be of benefit to patients and trainees. We have specific concerns regarding the potential product of the proposed training system in surgery. While it is commendable that the review acknowledges that there is no appetite for a subconsultant grade, this is the reality of what the reforms would lead to in all but name. Future holders of the Certificate of Specialty Training (CST) will lack the depth of knowledge and operative experience of current

trainees due to the shortened and broadened training structure and, while the review intends these trained surgeons to provide the majority of generalised care, it is clear that they will be working at a lower level to that of the current consultant. This is not in the best interests of future patient care. With regards to post-CST training, ASiT cannot support subspecialty credentialing. The migration of subspecialty credentialing beyond formal postgraduate training raises significant financial and organisational questions, which appear not to have been given consideration. It is our opinion that a ‘one-sizefits-all’ approach to postgraduate training is inappropriate. Greater flexibility must be given for craft specialities to achieve the technical, professional and knowledge-based skills that their future consultant careers will necessitate. There should be significant clarification of a large number of the recommendations within this review and significant thought given to the alteration of others before any movement towards changing surgical training is considered. We look forward to engaging with the profession to discuss this further. Mr Henry Ferguson ASiT Vice President. Written on behalf of the ASiT Executive and Council

“It is our opinion that a ‘one-size-fits-all’ approach to postgraduate training is inappropriate” 50 | Surgeons’ News | March 2014

/ conference

Sheffield hails event success

Oral presentation winner Clare Brown with host Steven Backhouse / symposium

Welsh student research showcase

his annual event provided students with an opportunity to showcase audit and research to fellow students and the 35 invited faculty and judges, drawn from RCSEd surgical Fellows in Wales and Welsh academic, commercial and governmental fields. An impressive nine oral and 62 poster presentations reflected the breadth and quality of student research in Wales. Judges provided valuable debate and feedback on each presented work. Research opportunities within Welsh healthcarerelated companies and enterprises were outlined by MediWales and Health Research Wales. The winners of the oral and poster presentations were announced as Clare Brown and Christopher Wilcox, respectively. They received a ‘Golden Ticket’ all-expenses paid invite to present at the RCSEd National Student Research Symposium in Edinburgh. The nine finalists of the surgical essay competition were also in attendance to collect their awards. The financial support of main sponsors MEDEL, Reckitt Benckiser, DTR Medical as well as BMJ, BMA and Wesleyan was gratefully acknowledged. The DTR Medical Innovation Trophy and SMTL (Wales) Basic Science Trophy emphasised our sponsors’ keenness to recognise and reward student research in Wales. We look forward to this year’s Poster winner Chris Wilcox with judge Ali Al-Hussaini Symposium in October 2014.

Over 100 students from Cardiff and Swansea Medical Schools came together on 18 October 2013 for the College’s fourth All Wales Medical Student Surgical Research Symposium. Manon Jenkins reports

On 15 February, the College was proud to collaborate with the Sheffield Surgical Society to hold the second National Surgical Conference for Foundation and Student Doctors at the University of Sheffield Medical School. Delegates from across the UK and from as far as the Ukraine came for inspiring talks from expert consultants, student oral and poster presentations, and skills workshops. Charlotte Holmes, the Sheffield SurgSoc President, said, “We were delighted to host this event again and privileged to collaborate with the College to generate even more interest from the medical student community. It is important to provide opportunity for those interested in a career in surgery to hear such inspirational talks, learn about student research and practice surgical skills.”

/ careers

Roadshows reach Inverness and St Andrews On 22 November 2013, RCSEd hosted the Inverness Surgical Careers Roadshow. Open to fourth- and fifth-year medical students and foundation doctors, the evening gave attendees the opportunity to speak with representatives from each surgical specialty. St Andrews was the next destination for the roadshow, held on 4 February 2014 in association with the University’s Surgical Society. St Andrews medical students gained advice on portfolio development, career progression and training. Surgical Society President Michael Helley commented, “Events such as these are invaluable to our students, and I am sure it will have enthused those contemplating a career in surgery to pursue their interests and encouraged others to consider becoming a surgeon. I would like to thank the College for their support and the surgeons for their very valuable advice.”

www.rcsed.ac.uk | 51

trainees and students

Two heads are better than one Research collaboratives are becoming increasingly popular as a way of fulfilling CCT requirements for surgical trainees

he Greenaway Report on the Shape of Training highlighted the importance of trainees accessing research opportunities. All surgical specialties cite research as an area of competence in the relevant JCST guidelines that must be fulfilled in order to attain the certificate of completion of training (CCT) in their specialty. The requirements vary between the specialties and within individual training schemes, but the JCST states trainees must provide “evidence of an understanding of, and participation in, research as defined by the specialty”. Research collaboratives within and across surgical specialties have evolved in the last decade throughout the UK. Collectively, a realisation that highquality, large-volume, multicentre research is increasingly relevant and sought after by clinicians, academics and funders has led to collaboration which is individually and mutually beneficial to the surgical community. A research collaborative usually consists of a trainee body within a specialty with the support and guidance of a senior trainee or consultant with a research interest, or an academic surgical unit. The idea is to carry out large bodies of research utilising the geographical spread of trainees regionally and/or nationally to provide access to data from a multitude of centres. This gives the benefit of producing high-quality research data that are multicentre and involve larger numbers than would be possible from single-centre studies, or from single trainees working in a time frame limited by six- or 52 | Surgeons’ News | March 2014

12-month placements. This methodological approach gives trainees the opportunity to contribute to many projects within a region simply by taking on a role in data collection (local/clinical investigator) from their centre, or to take forward and coordinate their own project (principal investigator), as well as gaining skills in study design, grant-application writing, paper writing and the delivery of presentations. All of this can be achieved while the trainee remains in full-time clinical training because the research workload is split throughout the collaborative. There are many UK research collaboratives making significant contributions within their fields. While some are well-established academic units producing high-quality, randomised, controlled trials supported by prestigious and generous grants, others are in their infancy. The goal these initiatives have in common is a united, researchorientated body of trainees within a specialty who can collaborate on and optimise underinvestigated areas of research. There are also opportunities to unite collaboratives and produce large, relevant, UK-wide studies. In an era when high-quality research is a necessary foundation for evidence-based medicine, but when funding is ever more difficult to secure to support long-term clinical fellowships, the model of surgical research collaboratives provides an excellent framework. In addition, these collaboratives enable meaningful engagement for surgical trainees in the required research methodology. Diane Hildebrand and Michael Moran are members of the RCSEd Trainees’ Committee For further information, visit: www.surgeonsnews.com

JOU RN

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ATION REpOR CIT T L A

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Fellows and Members can sign up for this by contacting: RCSEd: membership@rcsed.ac.uk / +44 (0) 131 527 1654 RCSI: fellows@rcsi.ie / +353 1 40 2235 Please quote your College reference number in all correspondence.

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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/dental aspects of patient safety, simulation and nonoperative 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 (i.e., how the project will be taken forward). Closing date for applications is Friday 27 June 2014.

King James IV Professorships

Applications are invited from practitioners of surgery or dental surgery who have made a significant contribution to the clinical and/or scientific basis of surgery. The courtesy title of Professor will be accorded to the individuals for the duration of the College year in which their lectures are delivered. Closing date for applications is Friday 27 June 2014.

Travelling Fellowships

The Cutner Travelling Fellowship in Orthopaedics The John Steyn Travelling Fellowship in Urology Sir James Fraser Travelling Fellowship

Closing date for applications is Friday 27 June 2014.

The Syme Medal

Applicants must submit a CV (maximum of two pages) along with a discourse (up to 1500 words, excluding references,

54 | Surgeons’ News | March 2014

prior publications and papers in press, summarising their recent research or educational development). The essay must refer to and contain findings from the candidate’s own work. A list of any prior publications and papers currently in press should be included. The names of any supervisors and collaborative workers must be acknowledged as well as the name of the institution(s) where the work was carried out. Appointments to the Syme Medal are made on the understanding that those elected submit a manuscript for consideration to the Journal of the Royal College of Surgeons of Edinburgh and Ireland. The successful applicant may be invited to present a lecture at the College. Closing date for applications is Friday 20 June 2014. Please send three copies of each application.

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 25 April 2014.

Medical Student Elective Travel Bursaries

The Royal College of Surgeons of Edinburgh (RCSEd), in association with Ethicon, 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 the Republic of Ireland who are affiliates of RCSEd and undertaking approved surgical electives abroad. Closing date for applications is Friday 25 April 2014.

undergraduate student bursaries

The RCSEd is offering bursaries to undergraduate students of medicine or dentistry to enable them to work for elective or vacation periods in universities, medical schools, NHS laboratories or UK research institutes. Proposals for work on research projects in any branch of surgery are eligible for consideration. Closing date for applications is Wednesday 26 March 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

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.

DIARY

The latest surgical and dental events, seminars and courses

March 2014 Higher Surgical Skills Course 6-7 8 18th Annual Conference for Dental Care Professionals 8-9 Basic Surgical Skills Course (Manchester) 14 Future Surgeons: Key Skills 17-19 The Edinburgh Hand Course 19-20 Emergency Abdominal and Thoracic Surgery for the General Surgeon 20 The Role of Human Factors in Healthcare and Their Influence on Surgical Performance: An Evening Symposium 20 Guiding Hands: Mentoring Skills for Surgeons 21 President’s Meeting and Audit Symposium 2014 – “Emergency Surgery in the 21st Century” 25 Future Surgeons: Principles of Anatomy (Wade Programme in Surgical Anatomy) 27-28 Anatomy for MRCS OSCEs (Wade Programme in Surgical Anatomy) 27-28 Training the Trainers (Wolverhampton) 29 Future Surgeons: Key Skills (Manchester) 29-30 The Edinburgh MRCS OSCE Preparation Course 30 Future Surgeons: Key Skills (Manchester) 31 Training the Trainers: Foundation Essentials April 2014 2-4 Advanced Trauma Life Support

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

Congratulations to the following awards and grants recipients Small Research Grants Mr Neil Johns, University of Edinburgh: “Clinical classification of cancer cachexia phenotypic correlates in human skeletal muscle” Mr Alistair Brydone, University of Glasgow: “Osseointegration of oxygen plasmatreated 3D nanopatterned PEEK polymer implants in a rabbit intramedullary model” Mr Rhys Clement, University of Edinburgh: “Elucidating the causes of chondrocyte death in Staphylococcus aureus septic arthritis” Mr Michael Hughes, Royal Infirmary of Edinburgh: “Energy expenditure and regeneration following liver resection” Dr Campbell Roxburgh, University of Glasgow: “Establishing crosstalk between

9-10 Edinburgh MRCS OSCE Preparation Course (Delhi) 12-13 Edinburgh MRCS OSCE Preparation Course (Manchester) 6-8 Mock MRCS OSCE Exam Course (Aberdeen) 9-11 Core Skills in Orthopaedic Surgery 12-13 The Edinburgh MRCS OSCE Preparation Course (Manchester) 14-15 Advanced Techniques in Endoscopic Nasal and Sinus Surgery 14-15 JOSES Course (Manchester) 17-18 Basic Surgical Skills Course (Dundee) May 2014 1-2 Basic Surgical Skills Course 21-22 Critical Appraisal for ISFE (Birmingham) 31 Future Surgeons: Key Skills (Manchester) June 2014 1 Future Surgeons: Key Skills (Manchester) 4 Training the Trainer: Foundation Essentials (Birmingham) 4-6 Care of the Critically Ill Surgical Patient (CCrISP) 5-6 Training the Trainer (Birmingham) 12 Decision Making in Restorative Dentistry 12-13 Basic Surgical Skills Course For further information please email education@rcsed.ac.uk or telephone +44 (0)131 527 1600 All events in Edinburgh unless otherwise stated.

local and systemic inflammatory reactions in colorectal cancer” The Cutner Travelling Fellowship in Orthopaedics Mr Graham Dall, ST7 Ortho SE Scotland, Edinburgh: Clinical Fellowship to the Mercury Institute for Foot & Ankle Reconstruction, Baltimore, USA Mr James Beazley, SpR Trauma & Orthopaedics, Coventry: Orthopaedic Deformity Correction Furlong Fellowship to Beit CURE International Hospital, Blantyre, Malawi Mr Sammy Hanna, SpR in Trauma & Orthopaedics, Hertfordshire: Adult Reconstruction Fellowship (Hip & Knee) to the London Health Sciences Centre, University of Western Ontario, London, Canada The King James IV Professorship Professor Hamish Simpson, Professor of Orthopaedics & Trauma, Department of Orthopaedic Surgery, University of Edinburgh: “Understanding and preventing fracture non-unions” Professor Crispian Scully, Emeritus Professor, University College London: “Emerging infections in health, disease and oral healthcare”

Professor Peter Anderson, Consultant Cranio-maxillofacial Surgeon, Australia: “Developing adjuvant therapy for craniosynostosis” The Syme Medal Mr Ernest Azzopardi, Clinical Academic Lecturer, Cardiff University: “Polymer therapeutics: a novel paradigm in the treatment of infection (PhD work)” Miss Karen Eley, Craniofacial Fellow, Oxford University Hospitals NHS Trust: “Imaging the craniofacial skeleton: Is MRI a viable alternative to ionising radiation? And improving the perioperative management of patients undergoing free tissue transfer for head and neck malignancy” Mr Nathan Stephen, Surgical Registrar, Higher Surgical Training Rotation, West of Scotland: “Molecular biomarker discovery and physiological assessment of skeletal muscle in cancer cachexia” Mr Ricky Bhogal, SpR, in HepatoPancreatico-Biliary Surgery/Liver Transplantation, Birmingham: “The role of oxidative stress and CD154-mediated reactive oxygen species in regulating hepatocyte cell death during hypoxia and hypoxia–reoxygenation”

www.rcsed.ac.uk | 55

college information

Diploma ceremonies Congratulations to all our new Fellows and Members who were presented with diplomas on Friday 15 November 2013 ADMISSION TO HONORARY FELLOWSHIP Professor Carlos A Pellegrini FACS FRCSIrel (Hon), President of the American College of Surgeons & Henry H Harkins Professor & Chairman, Department of Surgery, University of Washington, Seattle ADMISSION TO FELLOWSHIP AD HOMINEM Professor Austin Leahy FRCSIrel FRCSEng, Professor of Health Science & Management, Royal College of Surgeons in Ireland & Consultant General & Vascular Surgeon, Department of Surgery, Beaumont Hospital, Dublin Professor John V Reynolds FRCSIrel, Professor of Surgery and Head of Department, Trinity College Dublin, National Lead for Oesophageal and Gastric Cancer, Cancer Lead, St James’ Hospital and Trinity College School of Medicine, Scientific Director, Regional Cancer Clinical Trials Programme & Principal Investigator, Trinity Translational Medicine Institute Professor Douglas E Wood FACS, Professor & Chief of the Division of Cardiothoracic Surgery, Vice-Chair of the Department of Surgery, Endowed Chair in Lung Cancer Research, University of Washington, Seattle

56 | Surgeons’ News | March 2014

AWARD OF FELLOWSHIP WITHOUT EXAMINATION Mrs Sacha M P Koch, Consultant General Surgeon, NHS Tayside, Dundee & Perth Mr Colin MacIver FRCSGlasg (OMFS), Consultant Maxillofacial Surgeon, Southern General Hospital, Glasgow, & Royal Army Medical Corps AWARD OF FELLOWSHIP IN DENTAL SURGERY WITHOUT EXAMINATION Professor Lal Pushpangadan Madathil FDS RCSEng FDS RCPSGlasg, Professor, Kerala University of Health Sciences & Consultant, Mangalore Institute of Oncology, India PRESENTATION OF DIPLOMAS OF FELLOWSHIP IN THE SPECIALTY OF CARDIOTHORACIC SURGERY Arben Kojqiqi, University of Cluj Napoca, Romania Pankaj Kumar Mishra, Patna University, India PRESENTATION OF DIPLOMAS OF FELLOWSHIP IN THE SPECIALTY OF GENERAL SURGERY Veerabhadram Garimella, Andhra Pradesh University of Health Sciences, India

Paul Owen Hendry, University of Glasgow Russell William Jamieson, University of Cambridge Thomaskutty Kuriackose Kallachil, Mahatma Gandhi University, India Rajnish Mankotia, Goa University, India Julia Caroline Massey, Newcastle University Samuel Shunan Zhou, Xi’an Jiaotong University, China PRESENTATION OF DIPLOMA OF FELLOWSHIP IN THE SPECIALTY OF NEUROSURGERY Shrijit Janardana Panikkar, Mahatma Gandhi University, India PRESENTATION OF DIPLOMAS OF FELLOWSHIP IN THE SPECIALTY OF OTOLARYNGOLOGY Debabrata Biswas, University of Calcutta, India Vikranth Visvanathan, Annamalai University, India

PRESENTATION OF DIPLOMA OF FELLOWSHIP IN THE SPECIALTY OF PAEDIATRIC SURGERY Boma Adikibi, University of London PRESENTATION OF DIPLOMAS OF FELLOWSHIP IN THE SPECIALTY OF PLASTIC SURGERY Anna Rowan Barnard, University of Oxford Alex Paul Jones, University of Leeds Kirsty Janet Georgina Munro, University of London PRESENTATION OF DIPLOMAS OF FELLOWSHIP IN THE SPECIALTY OF TRAUMA & ORTHOPAEDIC SURGERY Awaiz Ahmed, Dr MGR Medical University, India Rajavelu Chinnusamy, Dr MGR Medical University, India Giles Thomas Foley, University of Leeds Hafiz Javaid Iqbal,

University of the Punjab, Pakistan Peter John Kenyon, University of Liverpool Aniruddha Dilip Pendse, Maharaja Sayajirao University of Baroda, India Pragnesh Kishorsingh Raj, Maharaja Sayajirao University of Baroda, India Manghattil Bhaskaran Rajesh, University of Madras, India David Reuben Selvan, University of Liverpool Findlay Alexander Welsh, University of Aberdeen Edward Walter Yates, University of Aberdeen PRESENTATION OF DIPLOMAS OF FELLOWSHIP IN THE SPECIALTY OF UROLOGY Richard John Bryant, University of Sheffield Richard Christian Rowan Nayar, University of Manchester

PRESENTATION OF THE LISTER MEDAL IN GENERAL SURGERY Matthew Cassar PRESENTATION OF DIPLOMAS OF MEMBERSHIP IN OPHTHALMOLOGY Yin Min Han, University of Yangon, Myanmar Thein Than Htaike, University of Yangon, Myanmar PRESENTATION OF DIPLOMA OF MEMBERSHIP IN OTOLARYNGOLOGY Htut Maung Maung, University of Mandalay, Myanmar PRESENTATION OF INTERCOLLEGIATE DIPLOMAS OF MEMBERSHIP IN SURGERY IN GENERAL Syed Al-Nahian, University of Dhaka, Bangladesh

www.rcsed.ac.uk | 57

College information

Waqas Tariq Butt, King Edward Medical University William John Calvert, University of London Gabriele Di Benedetto, University of Palermo, Italy Imran Zaheer Inam, University of Aberdeen Nauman Saeed, Punjab Medical College, Pakistan Christopher Alexander Schnieke-Kind, University of Edinburgh Anthony Neville Wiggins, Newcastle University Aung Khine Zan, University of Yangon, Myanmar PRESENTATION OF DIPLOMAS OF FELLOWSHIP IN DENTAL SURGERY WITHOUT EXAMINATION (by application) Ian Stephen Hollingum, University of London Jonathan Edward Kallow, University of Glasgow Khushee Ramona Sharma, University of Detroit Mercy, USA PRESENTATION OF DIPLOMA OF MEMBERSHIP IN ORTHODONTICS Amr Khaled Ahmed El Refaei, Alexandria University, Egypt Mohamed Ossama El-Koussy, Ain Shams University, Egypt Leila Khamashta Ledezma, University of London Mohit Mittal, Dr B R Ambedkar Open University, India Philippa Louise Rudge, University of Bristol Mahmoud Attia Abd El-Aziz Zalat, Cairo University, Egypt PRESENTATION OF DIPLOMAS OF MEMBERSHIP OF THE FACULTY OF DENTAL SURGERY Lyudmyla Allibone, Ivan Franko National University of Lviv, Ukraine Hannah Isobel Barnes, University of Sheffield Amraj Dhillon, University of London Hannah Gargani, University of Manchester

58 | Surgeonsâ&#x20AC;&#x2122; News | March 2014

In memory Fellows Without Examination John Bryan MCFARLAND (FRCSEd 1983) Fellows Maithriya Ananda AMARASINGHE (FRCSEd 1985) Peffers Watson BROWN (FRCSEd 1964) Henry Ievan LE BRUN (FRCSEd 1948) Stewart Desmond CLARKE (FRCSEd 1960) Puthukudiyil Mathai GEORGE (FRCSEd 1978)

Laurence Grandy, University of Manchester Lauren Hunter, Newcastle University Vipul Jindal, Rajiv Gandhi University of Health Sciences, India Azeem Yar Khan, Charles University, Czech Republic Mazlina Mohd Noor, Universiti Sains Malaysia Sarah-Ann Alexandra Pitaluga, University of Sheffield Sophie Anna Helen Saunders, University of Bristol Grace Tom-Lawyer, University of Benin, Nigeria Katharine Elizabeth Wenham, University of Sheffield PRESENTATION OF THE JOHN SMITH MEDAL Lisa Durning

David Ross Hinds LEWIS (FRCSEd 1969) Shinmen LIU (FRCSEd 1962) Hector MACLEAN (FRCSEd 1962) Michael Joseph MCERLAIN (FRCSEd 1999) John Egan MOULTON (FRCSEd 1959) Bernard NOLAN (FRCSEd 1955) Graham Erskine VENN (FRCSEd 1981) Izak Frederick WESSELS (FRCSEd 1983) Daniel Greer YOUNG (FRCSEd 1962)

PRESENTATION OF DIPLOMAS IN CLINICAL DENTAL TECHNOLOGY Thomas Paul Holmes, Edinburgh Postgraduate Dental Institute Cheryl Colina McCuaig, Edinburgh Postgraduate Dental Institute Ian Stuart Mackay, Edinburgh Postgraduate Dental Institute PRESENTATION OF DIPLOMAS IN ORTHODONTIC THERAPY Victoria Winifred McPolin, School of Postgraduate Medical & Dental Education, University of Central Lancashire Jana Schrehartova, Central Manchester School of Dental Care Professionals Agata Karolina Surga, Central Manchester School of Dental Care Professionals Medical Sciences & Technology, Sudan

A new book from an award‐winning publisher

SCHEIN'S COMMON SENSE Prevention and Management of Surgical Complications For surgeons, residents, lawyers, and even those who never have any complications

Order online and claim a 20% discount

Quote promotional code SCS13 Moshe Schein MD FACS General Surgeon, Marshfield Clinic, Ladysmith, Wisconsin, USA

Paul N. Rogers MBChB MBA MD FRCS Consultant General and Vascular Surgeon, The Western Infirmary, Glasgow, UK

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Danny Rosin MD Attending General and Advanced Laparoscopic Surgeon, Sheba Medical Center, University of Tel Aviv, Israel

The enthusiastic feedback received from readers of the international bestseller Schein's Common Sense Emergency Abdominal Surgery (now in its 3rd edition, translated to seven languages; Springer Verlag; ISBN 978‐3540748205) inspired the Editors to do a similar book dedicated to surgical complications: practical, non‐formal, internationally relevant (in all types of practice and levels of hospitals) – and definitely not politically correct: what is considered taboo by others is not taboo for us; here we discuss everything! As in the Editors’ previous book, the use of references is restricted to the absolute minimum, and citing figures and percentages is avoided as much as possible. The chapters in this book are the opinion of experts – each contributor has a vast personal knowledge and clinical experience in the field he is writing about. This book will help all surgeons (and their patients), avoid the misery of complications, and will provide advice on the management of those that are unavoidable. Complications and death are an integral component of surgery. Surgeons have to look death in the eyes, try to prevent it and vanquish it – this is what this book is all about.

Schein’s books are always terrific reads, conveying pithy observations and practical advice and doing so with wit and scholarship. This latest is surely a must for every surgeon’s bookshelf. Abraham Verghese MD, author of CUTTING FOR STONE ISBN: 978 1 903378 93 9 • Paperback 155mm x 235mm • 558pp • Retail price: GBP £60; USD $99; EUR ∈90

1 By telephone

UK/Europe/ROW +44 (0)1952 510061 USA/Canada 419 281 1802

2 By fax

UK/Europe/ROW +44 (0)1952 510192 USA/Canada 419 281 6883

FIVE EASY WAYS TO ORDER

3 Online

www.tfmpublishing.com

4 By mail

tfm publishing Ltd Castle Hill Barns Harley, Shrewsbury Shropshire, SY5 6LX, UK

5 Bookstore

Contact your local medical bookstore

college information

Regional Surgical Advisers in your area

The College’s support and advice network throughout the country

1 8

Scotland

East of Scotland 1 Graham Cormack, Ninewells, Dundee 1 Sam Majumdar, Ninewells, Dundee North of Scotland 2 Aileen McKinley, Aberdeen Royal Infirmary, Aberdeen 2 Euan Munro, Aberdeen Royal Infirmary, Aberdeen 3 Angus Watson, Raigmore Hospital, Inverness

4 5

26 42

28 27 41

West of Scotland 4 Lindsey Chisholm, Royal Alexandra Hospital, Paisley 5 Jon Dearing, Ayr Hospital, Ayr 6 Martyn Flett, Royal Hospital for Sick Children, Glasgow 7 Calan Mathieson, Southern General Hospital, Glasgow 8 Chris Rodger, Forth Valley Royal Hospital, Larbert 9 Mary Shanks, Crosshouse Hospital, Kilmarnock

14 16

Mersey 21 Azher Siddiq, St Helen’s Hospital, St Helen’s 22 Venkat Srinivasan, Arrowe Park Hospital, Wirral North Western 23 Stuart Clark, Manchester Royal Infirmary, Manchester 24 Chelliah Selvasekar, Christie NHS Foundation Trust Hospital, Manchester 25 Jeremy Ward, Royal Preston Hospital Northern 26 Mike Clarke, Freeman Hospital, Newcastle 27 Jonathan Ferguson, James Cook University Hospital, Middlesbrough 28 Ian Hawthorn, University Hospital of North Durham Oxford 29 Chris Cunningham, Churchill Hospital, Oxford 29 Mike Silva, Churchill Hospital, Oxford 30 Richard O’Hara, Milton Keynes Hospital, Milton Keynes

60 | Surgeons’ News | March 2014

england

London 20 Robert Mason, St Thomas’ Hospital

East of England 11 Vivek Chitre, James Paget University Hospital, Great Yarmouth 12 Andrew Gibbons, Peterborough City Hospital, Peterborough 13 Milind Kulkarni, Norfolk and Norwich University Hospital, Norwich

Kent, Surrey & Sussex 17 Jonathan Clasper, Frimley Park Hospital, Surrey 18 Mike Lewis, Royal Sussex County Hospital, Brighton 19 Mike Williams, Eastbourne District General Hospital, Eastbourne

23 24

South East of Scotland 10 Anna Paisley, Royal Infirmary of Edinburgh, Edinburgh 10 Zahid Raza, Royal Infirmary of Edinburgh, Edinburgh

East Midlands 14 David Exon, Leicester Royal Infirmary, Leicester 15 Bill Tennant, Queen’s Medical Centre, Nottingham University Hospital 16 Sridhar Rathinam, Glenfield Hospital, Leicester

40 42

20 17

35 32

33 34

Severn 31 Davinder Sandhu, University of Bristol, Bristol (Surgical Director of the Advisory Network) South West Peninsula 32 Ken Hosie, Derriford Hospital, Plymouth 32 Simeon Brundell, Derriford Hospital, Plymouth Wessex 33 Anthony Evans, Portsmouth Hospital, Portsmouth 34 Dominic Hodgson, Queen Alexandra Hospital, Portsmouth 35 Vel Sakthivel, Southampton General Hospital, Southampton West Midlands 36 Rajiv Vohra, Queen Elizabeth Hospital Birmingham, Birmingham 37 Ling Wong, University Hospital Coventry and Warwickshire, Coventry Yorkshire & Humber 38 Aidan Fitzgerald, Northern General Hospital, Sheffield 39 Clare McNaught, Scarborough Hospital, Scarborough 40 Mark Steward, Bradford City Hospital, Bradford 41 David O’Regan, Leeds General Infirmary, Leeds

northern ireland

42 Sean Patton, Craigavon Area Hospital, Portadown

wales

43 Steven Backhouse, Princess of Wales Hospital, Bridgend (Associate Surgical Director of the Advisory Network) 44 Angus Robertson, University Hospital of Wales, Cardiff 45 Vaikuntam Srinivasan, Glan Clywd Hospital, Rhyl

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

out of hours

A cut above the rest

Hix at Tramshed in Shoreditch, London, with its Damien Hirst installation

Graham Layer provides his latest selection of restaurants

ntertaining a distinguished Australian surgeon in London for lunch required some thought. Good tucker, plenty of wine and an outback of space around about. And not too many fussing, interrupting waiters. I can recommend the perfect answer: the Michelin-starred Galvin at Windows, atop the Hilton Hotel, Park Lane, giving a 28thfloor, bird’s-eye view of London without impending nausea. This was lunch for less than £30 and included a glass of champagne. Fabulous food and a view of Buckingham Palace were inspirational. There were salads and fishy things to start, beautifully presented with sauces and the main course included delights such as pork with harissa potato puree and sea bream with shrimp and almonds. Desserts were not sweet, with an impressive selection of cheese. International relations and appetites were well satisfied. A different view but also from a starred restaurant, Hugos atop the InterContinental Hotel in West Berlin, looking east to the Brandenburg Gate. A much more complicated meal from Thomas Kammeier, with a string of courses and disappointing only in the mixed-up service and lack of atmosphere in the section of the restaurant in which we were placed (the handle of the axe-shaped room). However, the fish-tasting menu was far from disappointing. After various and later intertwined amusebouches came fried mackerel (extraordinarily tasty) or marinated scallop (bland), followed by char with leek, horseradish and caviar (fabulous), then langoustine with chestnuts (amazing) and turbot with mussels. All rounded off with quince terrine and petits fours, and the terrific view.

“Suspended above the diners is a Damien Hirst installation … I suppose not very different to the Edinburgh College serving dinner in the Museum surrounded by formalin-filled pots” 62 | Surgeons’ News | March 2014

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

Hugos restaurant atop the InterContinental Hotel with its views over West Berlin

No view as such at Marco Muller’s Rutz-Restaurant in East Berlin – similar story to the other two, with the lone Michelin star and an array of delicacies served metachronously, but a view on life which was very different – relaxed and informal, lubricated by wines from a different bottle at each of the eight (or was it 13?) courses. Served by a massively bearded fellow in a darkened room with not much out of the window but a tram track dug up for repair and miserable grey office blocks; something out of the Cold War. An unlikely venue for a tasting menu beyond belief with more flavours than Hugos’, with endless intercourse nibbles. The “experiences” were mainly an outstanding yellow tomato soup with scallop and ewe’s milk (stunning and beautiful). Crispy langoustine with pig’s ear was similarly spectacular, and then sea trout with hazelnuts,

Galvin at Windows, part of the Hilton Hotel in Park Lane, London

and ceps risotto (I took the alternative fjord shrimp in goat yoghurt). Halfway and we proceeded to mackerel, then a generous biopsy of Wagyu beef, before an odd carrot–ginger concoction, then apple cake and curry leaves. Extraordinary. Just room now in my amputated column for quick recommendations. Back in the UK, Sweet Melindas is great for lunch. This time in Marchmont, Edinburgh. Fresh fish at its best from a somewhat oriental-looking fishmonger next door. Scallops with black pudding and Thai basil, cod with chorizo and gnocchi, and tuna all so very tasty. We finished with trendy panna cotta. This is a wonderful little restaurant and excellent value. Hix at Tramshed is beef (huge supine steaks attached to bones) and chicken (whole perpendicular birds with feet high in the air). Very trendy in Shoreditch, London; very informal with service to match. Suspended above the diners is a Damien Hirst installation – a preserved, undissected Hereford cow and a cockerel in a massive glass tank. I suppose not very different to the Edinburgh College serving dinner in the Museum (a terrific venue) surrounded by formalin-filled pots. Starters are for sharing – an interesting Yorkshire pudding with chicken liver and pollock croquettes were memorable. We had a vast joint of beef between three with an array of vegetables, which was adequate, but unusually a pudding was ordered called ‘credit crunch ice cream’ – no sign of that, though, in Shoreditch. Chop Shop is a new American opening in the Haymarket, London, and is incredibly noisy. Do not go there to do business, have a romantic evening or chat to friends. Odd place; immediately popular, with wooden tables and rather squashed with a bizarre brasserie-style menu which was neither one thing nor another: “jars, crocks and planks”. Not to be repeated, and the beef I understand from my guests was uninspiring. My crab cocktail was waiting to be introduced to a crab. The crispy hot wings were too hot to handle and caused gustatory sweating. The scotch egg with salsa verde was a mismatch. Mashed potatoes and cheesy leeks were delicious but why put rosemary on chips? We didn’t dare progress to the desserts. Go there to tell everyone you have been; I suspect it will improve with evolution – it’s survival of the fittest, even in this ideal location.

Hard to swallow Bernard Ferrie looks ahead to April for wine-tasting inspiration

n effort to support the smaller independents and more obscure suppliers. Don’t worry if you can’t locate some of them. It can be chilly this time of the year so start with a dram – Auld Balonie, a rare malt (£18.29, Burke and Hare), should you have a fit of coughin’ while digging – appreciate its pungent smoky aromas. Fixed-price menu now to accompany this Aussie pairing with pressed tongue ’n cheek, ’umble pie and raspberry fool. Recipes from Delia, Nigella or poor Mrs Beeton, who died of sepsis before that book was written. Keystone and Copp offer The Taser; a stunning wine enjoyed by the boys in blue. Might stop you in your tracks. Zingy and full-flavoured inky black. Sells or cells at £9.99. Arch rivals Blotto and Spillit do Ned Kelly (£18.89) – daylight robbery at this price? Hands up those who don’t like a bargain. Dense and toasty with an aftertaste of ashes. Rustic French fare to drool over – poisson d’Avril, Marie Celeste sauce and your favourite tarte go well with the following. Dent de Chien Alsatian wine with some bite – a promise of spicy Gewurztraminer pepper but pale, thin and overwhelmed by seafood. (£19.30, Hulot 2CV Wines). Well, a lot of folk have two CVs. Chevalier du Maurice (£19.30, Jacques Tati Wines) dark, plummy, vibrant purple colour. Beware beeg girls, this is grown-ups’ wine. Think ‘even mouth-caressingly smooth’. Sad Maquis (£17.69, S&M Wines) available in bars everywhere if strapped for cash. Satin smooth smoky and sweet tobacco. Warning: these suggestions need a tall glass and a big pinch of salt.

www.rcsed.ac.uk | 63

from the collections

stone of history A calculus cut from a urinary bladder “by Jer. Callot from Thomas Murray at Paris 8th May, 1676”

he brief notes for this object detail that the calculus measures 69mm in diameter at the widest point and is made of uric acid. A buildup in uric acid can be caused by a diet high in purines, which are found in high amounts in animal protein, especially red meat. The appearance of the calculus shows it to be smooth, oval and mounted in a leather case. This is one of several calculi from the collections, which include a bladder calculus weighing 6.25kg, alleged to have come from an elephant. The RCSEd holds no records for this patient. However, the surgeon’s name, Callot, could be a variation in spelling of Collot. The Collots (or Colots) were a Parisian family famous for holding a monopoly over lithotomy for eight generations, which was eventually challenged during their time at Hôtel-Dieu de Paris during the 17th century. The Collots adopted apparatus major, later described by Jean Civiale as “one of the most terrible (operations) in surgery” (1827). Apparatus major – or the Marian Method – replaced apparatus minor and used a greater number of

“The Collots adopted apparatus major, later described by Jean Civiale as ‘one of the most terrible (operations) in surgery’” 64 | Surgeons’ News | March 2014

instruments than the earlier technique, which used only a knife and a hook. The later technique was developed c.1520 by Joannes de Romanis of Cremona and published by his student Marianus Sanctus Barolitanus in 1522. The Collots were unwilling to relinquish their medical and financial domination owed to their techniques. With growing controversy, their operating methods were concealed and journeymen surgeons were forbidden from entering the theatre of Hôtel-Dieu. However, the hospital board eventually acquired the services of other surgeons who were knowledgable of the techniques, and the Collots lost their control over lithotomy towards the end of the 17th century. Emma Black Public Engagement and Marketing Officer, Surgeons’ Hall Museum

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

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Name: HD Magnification: 2.3x, 2.8x, 3.3x, 3.8x Colour: Titanium Grey / Red / Blue Frame Style: Sports or Cosmo Frame Size: Sml / Med / Lrg Best feature: Stylish & lightweight

Name: Kepler Kompakt Magnification: 3.5x, 4.6x, 5.7x Colour: Titanium Grey / Red Frame Style: Sports or Cosmo Deep Frame Size: Sml / Med / Lrg Best feature: Powerful & compact

Evimed also offers 2 NEW ExamVision™ lights, Essential and XP nano. These join the Focus and XP in providing light in exactly the right place and are each compatible with the NEW Essential and existing Premium batteries. Arrange a no-obligation consultation

Freephone 0500 211111 E: sales@evimed.uk.com W: www.evimed.uk.com

Loupes • Choice of Magnification • Sports Frames • LED Lights • Visors