Surgeons' News March 2016

SPECIALTY

THE STORY OF NEUROSURGERY

From humble beginnings to today’s technologically advanced clinical field

INTERVIEW

A MAN OF CHARACTER

David Lang, the artist behind college calligraphy since 1968

TRAINEES & STUDENTS

SOUTH AFRICAN ADVENTURE

An elective placement in Johannesburg proves to be a voyage of discovery

Surgeonsnews March 2016

The magazine of The Royal College of Surgeons of Edinburgh

Remote possibilities How to retain talent and maintain standards in out-of-the-way places

www.surgeonsnews.com

surgeons_news_colour_page_march 03/02/2016 11:59 Page 2

outstanding

quality everytime first time EMS 633531

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

FM 73368

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

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

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

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

Where only Swann-Morton will do.

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

www.swann-morton.com

WELCOME

FROM THE EDITOR John Duncan introduces the spring issue

A

s individuals we all need to know that we have access to healthcare when we require it.

That access may be for an acute or chronic healthcare need, each of which come with differing time pressures and expectations. Those living or working in remote communities share that expectation, though most understand the difficulties involved in providing such care.

Technology can facilitate that care, but the training and experience of the healthcare worker on the spot will be vital to achieve highquality outcomes. In this edition we examine this subject from a number of different angles.

The College is working to assimilate the Institute of Remote Healthcare to sit alongside the Faculty of Pre-Hospital Care. A meeting in May – Rethinking Remote – will examine this subject. Roger Strasser, Dean of Northern Ontario School of Medicine, is an international authority on medical education for remote communities and Alistair Fraser, Shell’s Vice President for Health, has an intimate knowledge of the problems

Technology can facilitate remote care, but the training and experience of the healthcare worker on the spot will be vital to achieve high-quality outcomes

of providing healthcare for the oil and gas industry. They both have interesting and enlightening things to say on this important subject in our cover features.

The issues of standards and access to care are similar for a stable island population or for transient groups of workers in a desert or an arctic environment. The disease processes are, after all, exactly the same. The College is publishing a report on the provision of surgical care for rural and remote communities and the lead author, Gordon McFarlane, has written a summary of the important conclusions on pages 26–28.

COSECSA, the College of Surgeons of East, Central and Southern Africa, has done much to support the provision of surgical education in Africa. Our sister college in Ireland has supported COSECSA over many years and in December our College again contributed, when George Youngson, Ian Ritchie, Trevor Crofts and others went to Malawi to teach and assess trainees.

When David Lang wrote my name on my Fellowship diploma in 1981 he had already been inscribing the names and dates on every diploma for 13 years. He continues to do so – a remarkable contribution to the life of the College (see page 38).

There were certainly Duncans on the Jacobite side at the Battle of Culloden in 1746, the last full-scale battle on British soil. Such was the nature of that conflict, there were almost certainly Duncans on the Hanoverian side as well. The College is working with the National Trust for Scotland to make a replica of the only human remains from the battlefield – a skull complete with musket wound on display in the Museums – for the Trust’s 270th anniversary exhibition (see page 64).

John Duncan editor@surgeonsnews.com

www.rcsed.ac.uk | 1

22

SPECIALTY

THE STORY OF NEUROSURGERY

From humble beginnings to today’s technologically advanced clinical field

INTERVIEW

A MAN OF CHARACTER

David Lang, the artist behind college calligraphy since 1968

40

TRAINEES & STUDENTS

SOUTH AFRICAN ADVENTURE

An elective placement in Johannesburg proves to be a voyage of discovery

Surgeonsnews March 2016

The magazine of The Royal College of Surgeons of Edinburgh

Remote possibilities How to retain talent and maintain standards in out-of-the-way places

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 PUBLISHED BY The Royal College of Surgeons of Edinburgh, Nicolson Street, Edinburgh EH8 9DW Registered Charity No. SC005317 contributions@surgeonsnews.com Tel: +44 (0)131 527 1600 For editorial enquiries contact Mark Baillie: Tel: +44 (0)131 527 3405

Contents

March 2016

04

AGENDA News and views from the College and the profession

08

THE PRESIDENT WRITES Michael Lavelle-Jones provides his first update as the College’s President

14 18

MICROSURGICAL SKILLS One-day course covers the basics

DESIGN AND PRODUCTION

Think Publishing Ltd, Suite 2.3, Red Tree Business Suites, 33 Dalmarnock Road, Glasgow G40 4LA Tel: +44 (0)141 375 0504 www.thinkpublishing.co.uk ACCOUNT MANAGER Sian Campbell DESIGN Mark Davies SUB EDITOR Kirsty Fortune MEDICAL SUB EDITOR Dr Arshad Makhdum ACCOUNT DIRECTOR Helen Cassidy helen.cassidy@thinkpublishing.co.uk 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.

Cover illustration: Jimmy Turrell

2 | Surgeons’ News | March 2016

22

38

FLEXIBLE WORKING The merits of less-than-full-time hours for employer and employee REMOTE HEALTHCARE Roger Strasser reports ahead of the Rethinking Remote conference; Alistair Fraser gives an oil industry perspective; Gordon McFarlane summarises College guidelines

30 34

COUNTRY PROFILE COSECSA’s conference in Malawi

38

INTERVIEW Calligrapher David Lang looks back on his career with the College

40

FACIAL RECONSTRUCTION The groundbreaking work in Ethiopia of charity Facing Africa

SPECIALTY Technological advances in the art of neurosurgery

43 45

SAS GRADE How to use the ISCP’s website DENTAL The latest from the Faculty’s Dean; and prize presentations

48

TRAINEES AND STUDENTS Winning researchers; placements in Johannesburg and Middlesbrough; ASiT’s recommendations

56 62 64

COLLEGE INFORMATION Diploma listings, awards and grants OUT OF HOURS Restaurant and wine reviews FROM THE COLLECTIONS A skull recovered from Culloden

JOU RN

S•

ATION REPOR CIT T L A

OM

CONTENTS

RS

T

H

2 201

Latest 2011 Impact Impact factor Factor 1.406!

2.175!

SON REU

TE

Get 10 extra journals when you opt for online only access RCSEd and RCSI Fellows and Members can sign up to read The Surgeon online only and receive unlimited access to 10 additional titles at no extra cost:

r r r r r r r r r r

Surgery International Journal of Cardiology Surgical Oncology Clinical Neurology and Neurosurgery Injury Journal of Dentistry International Journal of Surgery Best Practice and Research Clinical Gastroenterology Current Anaesthesia and Critical Care Seminars in Fetal and Neonatal Medicine

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.

Don’t forget, you can sign up separately with Elsevier to receive e-table of contents by email each time a new edition of The Surgeon is published: www.rcsed.ac.uk | 3 www.thesurgeon.net

Agenda The latest news from the College and profession / STANDARDS

College publishes guidance on care in rural settings

T

he number of unfilled hospital consultant posts in Scotland has more than doubled since 2013, the College has reported.

During 2013 there were 170 vacant consultant jobs across all medical specialties in Scotland.

This has now risen to 385 posts, with the problem being most acute in remote and rural areas.

The RCSEd has published its report on the delivery of surgical services in rural areas to improve support for consultants and trainees based

in some of Scotland’s most remote hospitals.

Written by a working group of surgeons with extensive experience in rural practice, the College’s report highlights the best ways to maintain standards through collaborative working between bigger city centre hospitals and smaller rural general hospitals.

RCSEd President Michael Lavelle-Jones said he hoped the report would start a debate about the best configuration for rural communities.

He said: “It is quite clear that ‘one size does not fit all’

when it comes to service delivery in these challenging environments and that the needs and provision will vary depending upon the surgical specialty and the region.

“Reducing risks to as low as possible while balancing the desire for patients to be cared for close to home is the logical aim. The standards proposed are applicable well beyond this geographic boundary and are relevant to wherever surgical care needs to be delivered in a rural setting.”

More on pages 22–28

/ COLLABORATION

Joined-up thinking on research future

Experts share ideas on strategies

4 | Surgeons’ News | March 2016

In October, the College co-hosted Frontiers in Surgery – Research Collaboratives with the West Midlands Research Collaborative.

Planned by Trainees’ Committee member Stephen O’Neill, the day consisted of interactive presentations from leading experts on the future of collaborative research. Attendees were from a diverse range of backgrounds and included medical students, surgical trainees, surgical consultants, dentists and anaesthetists.

The first session was on expanding the reach of collaborative research and

included talks from Ewen Harrison and Aneel Bhangu (co-founders of the GlobalSurg Collaborative), Tom Pinkney (West Midlands Research Collaborative) and Andrew Beggs (clinician scientist).

This was followed by a session on publication strategy and designing clinical trials with talks from Iain Spray (Newmed Publishing), Dmitri Nepogodiev (STARSurg Collaborative), Joyce Yeung (West Midlands Trainee Research in Anaesthesia and Intensive Care Network) and Jane Blazeby (Bristol Surgical Trials Centre).

/ EVENT

Graduates celebrate ESSQ success In November, the Edinburgh Surgical Sciences Programme held its graduation ceremony, welcoming students from around the world as well as from within the UK. The ESSQ suite of surgical science MSc qualifications is run jointly by the College and the University of Edinburgh and is a recipient of the Queen’s Anniversary Prize for Higher and Further Education.

Students graduated in the ChM programmes in general surgery, trauma and orthopaedics, vascular and endovascular surgery.

James Donaldson was awarded the Henry Wade Medal for the top-performing student in the urology programme.

/ LEGISLATION

Victory for patient safety

T

he College has achieved a significant victory for patient safety and robust science following a vigorous lobbying campaign that has led to UK Government MPs voting against plans that could have exposed patients to unethical, experimental treatments.

The Access to Medical Treatments (Innovation) Bill seeks to increase the speed and scope of medical innovation in England and Wales. However, the proposed methods to achieve this have been based on the suggestion that litigation, or the fear of litigation, was deterring medical professionals from trying new drugs and treatments – an idea not supported by evidence or practice.

Measures within the Bill

Parliament reassesses Medical Bill after College highlights safety concerns

would have allowed doctors to “depart from the existing range of accepted medical treatments as long as they obtained the view of another doctor”. This would have loosened significantly the current checks and balances on untested and unproven

treatments that protect both patients and practitioners.

RCSEd worked extensively with MPs to raise concerns over the potential effects on patient safety, and coordinated activity with medical charities and other royal colleges to ensure these

concerns were raised as loudly as possible.

Thanks to this extensive lobbying, MP Chris HeatonHarris, who introduced the Bill to Parliament, has now asked for the sections of the Bill that would have undermined the current robust system to be removed.

Michael Lavelle Jones, RCSEd President, said: “I am delighted that Mr Heaton-Harris and other MPs have listened to our concerns and dropped these unwanted and unnecessary clauses. There remains precious little evidence that litigation deters clinicians from trying new treatments. The existing legal and ethical framework provides clear guidance to clinicians, and undermining this framework would have presented a significant threat to patient safety.” www.rcsed.ac.uk | 5

AGENDA / INTERNATIONAL EVENT

President presents diplomas at ceremony in Myanmar

T

he College held a ceremony for the presentation of diplomas in Yangon, Myanmar, on 13 January.

The event took place at the University of Medicine, with the President and Office Bearers there to welcome more than 80 diplomates into the College.

The majority of diplomates had passed the Intercollegiate Diploma of Membership in Surgery in General, while others collected the Diploma of Membership in Ophthalmology.

The University of Yangon’s Aye Chan won the Muthusamy Medal for achieving the highest mark in the FRCSEd Ophthalmology examination.

College President Michael Lavelle-Jones spoke to delegates and guests about the College’s partnership work in Myanmar for a training programme in urology. He said: “Partnerships have always been an underpinning principle of our College’s international activities and none of what I have described could have been achieved without the help and support of our colleagues and friends working here in Myanmar.”

Michael Lavelle-Jones congratulates recipients of diplomas in general surgery and ophthalmology

/ INTERNATIONAL

Exam workshop in India

/ OUTREACH

Careers roadshow reaches St Andrews

O

Council Member Alistair Gibson talks to students

n 2 February the College held the latest leg of its Surgical Careers Roadshow in conjunction with St Andrews University Surgical Society.

More than 50 first-tothird-year students at the University of St Andrews School of Medicine attended the careers evening to listen to talks by Robyn Webber and David Sinclair on the College’s Wade anatomy programme and had access to the specialty

6 | Surgeons’ News | March 2016

stands. The Regional Surgical Advisers (RSAs) and Fellows brought surgical kit for the students to handle and there were also opportunities for students to practise knot-tying and laparoscopic skills with guidance from the faculty.

The Surgical Careers Roadshow is a UKwide initiative that enables the Outreach Team to work with student surgical societies, local RSAs and local RCSEd Fellows and Members to give students access to information and advice from surgeons who have already navigated the surgical career pathway.

Late last year the College worked with India’s National Board of Examinations (NBE) to deliver the third Faculty Development Workshop in Surgical Disciplines.

Held in Hyderabad from 29 November to 1 December, the purpose was to promote awareness of surgical specialties and develop the skills, attitudes and practices of a competent teacher. The initiative was developed by Bipin Batra, NBE’s Executive Director and College Fellow.

The NBE has run postgraduate courses in India for more than 40 years, establishing uniformly high standards on a pan-Indian basis.

/ CONFERENCE

Support for flexible working In the most recent membership survey, the College found that 77% of its membership said they considered it important to have the opportunity to work less-than-full-time, although only one-third thought their employer or the profession were supportive of it.

To address concerns and queries on this issue, the College is pleased to be hosting a

Flexible Working in Surgery Conference on 25 April.

This conference will consist of a series of lectures, and delegates will have the opportunity to talk about their experiences working less-than-full-time in a surgical career and issues that affect them, such as time management, maternity/paternity factors, rota organisation and flexible working near retirement.

General surgery textbook now in its fourth incarnation

Schein’s Common.

Sense Emergency.

Abdominal Surgery.

Moshe Schein, Paul Rogers, Ari Leppäniemi, Danny Rosin and Jonathan Efron TFM Publishing ISBN 978-1910079119 £60.00

More on pages 18–20

/ AWARDS

Hunter Doig Medal for Edinburgh excellence

I

n November, Farhat Din was awarded the College’s prestigious Hunter Doig Medal in recognition of her contributions to excellence in surgery.

A colorectal surgeon from Western General Hospital in Edinburgh, Din was awarded a Cancer Research UK Clinician Scientist fellowship in 2010. She integrates her clinical practice as a colorectal consultant with her translational research programme at the University of Edinburgh investigating the effects of energy and metabolism signalling in colorectal cancer.

Din commented: “It is absolutely fantastic to be recognised by the Royal College of Surgeons of Edinburgh as having made a contribution to surgery, science and training at this early stage in my career.”

The first Hunter Doig Medal was

Reviews

Pictured left to right: Caroline Doig, Farhat Din and Michael Lavelle-Jones

awarded by the College in 2007, to recognise excellence within the College’s female membership.

The medal is named after two of the College’s most notable female surgeons: Caroline May Doig, a paediatric surgeon, who was the first woman to be elected to the Council in 1984, and Alice Headwards-Hunter, the first woman to sit and pass an RCSEd examination.

/ TRAINEE EVENT

Audit Symposium 2016 The College’s annual audit symposium takes place on 15 April. This oneday event gives trainees and junior doctors the opportunity to present their audit work and outcomes through abstracts and posters, with the Surgeon-in-Training Medal given for the best presentation.

This is the fourth edition of this book, first published in 2000, and draws from a range of international contributors, edited by general surgeons from the US, UK, Finland and Israel.

It is aimed at the on-call general surgical trainee and covers a comprehensive range of commonly encountered emergency gastrointestinal surgical conditions, together with chapters on trauma, paediatric, urological and gynaecological emergencies.

It highlights the general philosophical approach to managing such patients and takes the reader through all aspects of care, from preoperative work up to postoperative recovery and management of common surgical complications.

The book is well structured and formatted with short, easy-to-digest chapters, albeit liberally interspersed with cartoons and quotes.

Content is based on the personal opinions of a group of experienced emergency general surgeons, and describes a direct, pragmatic approach to management. However, some of the approaches described would not be consistent with the protocols followed in many institutions. Indeed, no evidence is provided in support of the management pathways described and the entire book is virtually devoid of references. In the editors’ own words this book is “written in a practical, colloquial and direct in-your-face style”. While this makes for easy reading the tone is flippant, and in my opinion rather inappropriate, often verging on the offensive.

Reviewed by Anna Paisley

For details, contact education@rcsed.ac.uk or 0131 527 1600 www.rcsed.ac.uk | 7

AGENDA

THE PRESIDENT WRITES Michael Lavelle-Jones provides his first update as the College’s President

W

hat a difference a day makes.

I think it is true to say that my life has not been the same since I received the call telling me the outcome of the ballot for the presidency. This election differed from those held in previous years in that candidates were subject to a hustings and had the opportunity to present their manifesto for the next three years. This was followed by a fairly robust Q&A session. At times it was challenging to be on the receiving end of the questions, but I would like to think it helped our Council towards an informed decision. I have no doubt that, in some form or another, a hustings will be part of the electoral process for presidents of the future.

For me, it has, of course, been an advantage stepping up to the plate from the position of Vice-President, and before that Honorary Secretary and Convenor of Examinations – all roles providing considerable insight and that vital institutional memory that I hope will smooth the transition to a new administration.

As I took over the reins on Friday 13 November, I reflected afterwards, at the diploma dinner, that while such a date was inauspicious for some – including myself – others were being catapulted into frontline surgical trauma practice in the aftermath of the tragic events in Paris and elsewhere in the world that evening. It serves as a reminder that we as surgeons and we as a College must always be prepared for the unexpected. Our current work around urgent care and disaster management should stand us in good stead.

What was more predictable was the outcome of the junior doctors’ ballot on strike action. I would like to think that such a clear mandate for industrial action has played its part in persuading all concerned to step back from the precipice and seek every means possible to find a suitable resolution. By the time this piece is in print, we may know the outcome of the next few weeks’ pivotal discussions. I am old enough (unfortunately) to remember the impact of the 1976 junior doctors’ strike when I was a final-year medical student in Liverpool.

The impact was far-reaching and the temporary fix of persuading final-year medical students to fill the gap would clearly be no solution in 2016.

However, all has not been doom and gloom. I have had the opportunity to take part in the MRCS examinations in Hyderabad, India, where enthusiasm and support for our College knows no bounds. I also attended the Philippines College of Surgeons 71st Surgical Conference in Manila, which provided a first-hand opportunity to engage with my fellow presidents and colleagues from the region, and to explore ways in which we as a College can build partnerships and share expertise. It also served as a stark reminder of how our beleaguered NHS in the UK continues to be regarded elsewhere as an icon of good healthcare delivery. It all depends on your terms of reference. It also tells me that all of us who practise in the devolved nations have a duty to support and protect what I believe is one of our nation’s greatest assets – the NHS. To return to the manifesto for the next three years, with our campuses in Edinburgh and Birmingham now truly fit for purpose, we are well placed to serve our membership in Scotland and the rest of the UK, where 80% of our domestic members are based. With that in mind, we shall build up our profile and portfolio of activities based at RCSEd Birmingham.

In addition, in

All of us who practise in the devolved nations have a duty to support and protect what I believe is one of our nation’s greatest assets – the NHS 8 | Surgeons’ News | March 2016

The NHS has a good reputation worldwide for its healthcare delivery

response to your feedback from the membership survey, we shall provide an enhanced outreach programme working alongside our Regional Surgical Advisers network. This is our opportunity to direct the intellectual and administrative capacity of our organisation to the development of our core business in education, training and assessment directly and through the mechanism of political influence.

Finally, and of equal importance, is our international community. I hope that over the next three years, I will succeed in making you feel even more a part of our College with increasing engagement through our new international Fellowship training scheme, enhanced distance and face-to-face learning programmes and, where appropriate, our Membership and Fellowship examinations. I hope our College activities over the next three years will accurately reflect your professional needs wherever you live and work.

To achieve these aims, I am fortunate to be supported by an extremely strong and experienced office-bearer team, with John Duncan and Graham Layer as VicePresidents alongside our Dental Dean, Bill Saunders.

Richard Montgomery provides financial continuity as Honorary Treasurer and Judy Evans completes our team, taking on the role of Honorary Secretary. This team provides a good geographic and specialty spread from across the UK and is a reminder that, as a College, we have the interests of all surgical specialties at heart, as well as those represented by our faculties of Dentistry,

Pre-hospital Care, and Sport and Exercise Medicine.

The professional business governance and leadership of our organisation continues in the capable hands of our Chief Executive, Alison Rooney, supported by her departmental heads.

As well as appointing new office bearers, at the annual general meeting in November 2015 we welcomed some new members to Council, namely Tim Graham, Mike Griffin, Sanjay Gupta, Anna Paisley, Ahmed Nassef, Steve Wigmore and our new trainee representative, Alice Hartley. For the first time, there is a specific seat on Council for SAS doctors, who will be represented

by Victoria Dobie.

We also said goodbye to several long-serving members of Council, notably Robert Steele, Robert Jeffrey, Peter McCollum, Sunil Kumar and Richard McGregor, who steps down on completion of his two-year appointment as our trainee representative. Peter McCollum will continue to share his invaluable experience in his capacity as Convenor of Examinations for the next two years.

I am confident that our new Council will provide wise counsel over the coming years for the benefit of our membership.

Wherever you are, I look forward to working with and for you.

Michael Lavelle-Jones president@rcsed.ac.uk www.rcsed.ac.uk | 9

AGENDA

SURGICAL SAFETY UPDATE More cases from the Confidential Reporting System for Surgery Explosive gastrotomy

I was called by the gynaecologist, who had taken a patient back to theatre with a burst abdomen five days after caesarean section. On the day of the burst abdomen, she had eaten a large meal at midday. The abdomen became distended, and about five hours later, the abdominal wound had burst. The gynaecologist was worried as he was not sure of the cause of the distension. I found that the mid-small bowel was moderately distended, but with no obvious cause of obstruction. Extending the midline incision superiorly, I found the stomach to be massively distended despite the presence of an 18G nasogastric (NG) tube. I asked for the NG tube to be aspirated, but without success. I requested the NG tube to be replaced with a larger one. No larger NG tubes were available, so a further 18G tube was inserted. Again, it was not possible to aspirate the tube. The tube was removed and found to be blocked by grains of rice. I therefore decided to decompress the stomach via gastrotomy.

I placed a purse-string on the antrum of the stomach and opened the stomach using diathermy. On gaining access to the stomach lumen, there was a loud explosion and the operative field and staff were covered with grains of rice. The distal half of the stomach had a large anterior rent and the rest of the wall was contused with a number of shorter, fullthickness lacerations. I undertook a partial gastrectomy with a Bilroth-1 reconstruction. The patient made a good recovery.

10 | Surgeons’ News | March 2016

Reporter’s comments

A combination of rice and gastric acid led to fermentation.

As a trainee, I had been taught not to use diathermy to open dilated bowel because of the risk of gaseous explosion, but had never encountered this previously. I performed the gastrotomy with diathermy, without relating the gross gastric dilatation to risk of production of explosive gases. Explosive gases are produced in the stomach and can occur even without bowel obstruction.

CORESS comments

CORESS was grateful for this reporter’s interesting and honest contribution, and further comments are shown below: I would like to use this event to help my colleagues and I to develop a more open and educational system for reporting and learning from adverse events. I am head of surgery at a major government hospital in a developing country. I have previously worked in the UK. Currently we do not have a system for reporting or educating staff in preventing or dealing with adverse events and near misses.

Most adverse events are not reported.

I see this case as an excellent opportunity to show staff that being open and discussing problems can lead to improvements in care and can be dealt with in a blamefree manner.

Second appendicectomy?

A 32-year-old man with pain in the right iliac fossa was admitted with suspected appendicitis. He had a similar presentation 10 years earlier, when he had undergone diagnostic laparoscopy. He was kept under observation.

Blood tests and abdominal ultrasound were normal (the appendix was not visualised). The pain persisted unchanged and remained severe. On the third day of admission, he was listed for diagnostic laparoscopy by the responsible consultant. However, the consultant wasn’t available to supervise the on-call SpR, who was not able to perform the laparoscopic procedure independently. The on-call consultant didn’t agree with the plan and wasn’t happy to support any operation. The responsible consultant requested the operation be changed to an open appendicectomy, which could be undertaken by the on-call SpR. Open surgery revealed the patient had undergone laparoscopic appendicectomy at his previous admission, and that the history concerning previous simple diagnostic laparoscopy was incorrect. The patient made an uncomplicated recovery from an unnecessary operation.

Reporter’s comments

Patients often forget procedural details and may unintentionally provide incorrect information. Simply referring to his GP summary of past medical problems would almost certainly have avoided this unnecessary operation.

CORESS comments

Patient history and accurate medical records are both important in obtaining a correct diagnosis, but this case flags up other important areas of problems in communication.

The operation was delegated to a trainee and a compromise was made in terms of procedure performed, which was not in the patient’s best interests. There does not appear to have been any direct communication between the responsible consultant and the on-call consultant, and there was no collegiate approach to patient management. Formal consultant-to-consultant handover and good communication are vital components of a safe surgical service.

A matter of consent

A female patient, admitted as a day case for repair of a paraumbilical hernia, was taken to theatre and given a general anaesthetic before I had seen her. It is my practice to see all my patients preoperatively, mark the surgical site, and sign and date confirmation of consent. However, it is also normal practice at my institution for a senior ward nurse to document patient consent. In this case, the theatre staff noted that the consent form had been signed by the ward nurse and assumed that I had also seen the patient. The patient was taken to theatre and given a general anaesthetic without me being informed. Luckily, the hernial defect was still palpable after anaesthesia, so I repaired it. The patient had an uncomplicated recovery.

Reporter’s comments

This was a problem with a system that allowed consent to be undertaken by someone other than a member of the surgical team in order to increase speed and efficiency. In

We are grateful to those who have provided the material for these reports.

The online reporting form is on our website www.coress. org.uk, which also includes previous Feedback Reports.

Published cases will be acknowledged by a Certificate of Contribution, which may be included in the contributor’s record of continuing professional development.

the event, it did not achieve the latter. There was failure of communication. All patients admitted for a procedure under GA or regional anaesthesia should be seen by the operating surgeon preoperatively to ensure that the procedure is appropriate, the surgical site is marked correctly, and informed consent is obtained.

CORESS comments

Good Surgical Practice (Royal College of Surgeons of England) and Consent: patients and doctors making decisions together (GMC) both set out principles of consent. An observation from the Advisory Board was that “the road to litigation is paved with assumptions”.

The law says you should not be driving

A 75-year-old woman presented to the eye clinic four months after being referred by her GP, following incidental finding of left hemianopia by her optician. By the time the patient arrived in clinic, her visual field loss had worsened and the patient admitted that she couldn’t “see a rabbit running across the road until it’s too late”.

She also told me that her car had been written off after she had collided with a stationary car at the side of the road because she hadn’t seen it.

The patient lived in a village. She said she still had good distance vision, so she would be careful, drive slowly and only in the daylight. The patient was emphatically informed that the law is clear that she should not be driving. The patient’s GP was informed and the patient was asked to contact the DVLA immediately.

Reporter’s comments

This case highlights that doctors, opticians and patients are not aware of visual factors that limit the right to drive.

The outcome was exacerbated by delay in the primary referral. Although no harm was done (except to the parked car), this report raises an important safety issue.

The situation should have been dealt with much earlier and the patient asked to contact the DVLA. Awareness of visual driving standards should be raised among all involved parties, including GPs, opticians and patients.

There is a misconception that if you can see well in the distance, you can drive. Double vision and visual field loss pose serious risks for driving.

CORESS comments

Surgical conditions that place restrictions on driving include cardiac and vascular conditions such as aortic aneurysms and carotid stenosis with TIAs, hand surgery, and some malignancies. Surgeons need to understand their responsibilities and should familiarise themselves with the conditions common to their specialty, so that they can provide patients with appropriate advice.

DVLA advice with respect to specific surgical conditions can be found at www.gov.uk/health-conditions-and-driving

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

www.rcsed.ac.uk | 11

AGENDA

The latest guidelines, articles and studies

IN BRIEF NCEPOD sepsis study

This report from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) set out to explore avoidable factors in the care for patients with suspected sepsis. Reviewers considered that there was a delay in identifying sepsis in 36% of cases, severe sepsis in 51% and septic shock in 32%.

The report recommended that all hospitals should have a formal protocol for early identification and management of sepsis. It concluded that early recognition, better documentation and prompt treatment of sepsis would lead to improved care for patients. Further recommendations were that all acutely ill patients should be reviewed by a consultant within national timeframes, there should be formal arrangements for handover, and that hospitals with criticalcare facilities should provide a criticalcare outreach service 24 hours a day.

NCEPOD, November 2015

Meta-analysis of colloids versus crystalloids in critically ill, trauma and surgical patients

This meta-analysis evaluated 59 clinical trials involving 16,889 patients that compared crystalloids with colloids as volume replacement in patients with traumatic injuries, those undergoing surgery and in critically ill patients.

Colloid administration did not lead to increased mortality (OR 0.99), but did increase the risk of developing acute kidney injury necessitating renal replacement therapy (OR 1.35). Subgroup analyses showed increased mortality and renal replacement therapy were associated with use of pentastarch, and increased risk of renal replacement therapy with use of tetrastarch. The risks of mortality and renal injury attributable

12 | Surgeons’ News | March 2016

to colloids were observed only in critically ill patients with sepsis.

Authors concluded that current general restrictions on the use of colloid solutions are not supported by evidence.

Qureshi SH, Rizvi SI, Patel NN, Murphy GJ. Br J Surg 2015; 103(1): 14–26

Randomised multicenter trial comparing glue fixation, selfgripping mesh and suture fixation of mesh in Lichtenstein hernia repair (FinnMesh Study)

This randomised trial compared three mesh-fixation techniques for open inguinal hernioplasty with regard to chronic pain. Lichtenstein hernioplasty was performed under local anaesthesia in 625 patients with a cyanoacrylate glue (Histoacryl, n = 216), self-gripping mesh (Parietex ProGrip, n = 202), or conventional non-absorbable sutures (Prolene 2-0, n = 207) for mesh fixation. There were no significant differences postoperatively in pain or need for analgesics between the study groups at one year. Authors concluded that mesh fixation without suture is feasible without compromising postoperative outcome.

Rönkä K, Vironen J, Kössi J et al.

Annals of Surgery 2015; 262(5): 742–8

Meta-analysis of the association between preoperative anaemia and mortality after surgery This meta-analysis of 24 studies involving 949,445 patients evaluated the association between preoperative anaemia and postoperative outcomes.

Some 371,594 patients (39.1%) were anaemic and this was associated with increased mortality (OR 2.90), acute kidney injury (OR 3.75) and infection (OR 1.93). Anaemia was also associated

with an increased incidence of red cell transfusion (OR 5.04). Similar findings were seen in cardiac and non-cardiac subgroups. Authors concluded that preoperative anaemia is associated with poor outcomes after surgery, although it remains unclear whether anaemia is an independent risk factor or simply a marker of underlying chronic disease.

Fowler AJ, Ahmad T, Phull MK et al.

Br J Surg 2015; 102(11): 1314–24

Mortality of emergency general surgical patients and associations with hospital structures and processes

This study evaluated 294,602 emergency admissions in 156 NHS trusts from Hospital Episode Statistics between April 2005 and March 2010 to investigate differences in mortality among patients admitted for emergency colorectal laparotomy, peptic ulcer surgery, appendicectomy, hernia repair and pancreatitis.

The overall 30-day mortality was 4.2%, with trust-level mortality rates from 1.6% to 8.0%. The lowest mortality rates were observed in trusts with higher levels of medical and nursing staffing, and a greater number of operating theatres and critical-care beds relative to provider size. Higher mortality rates were seen in patients admitted to hospital at weekends (OR 1.11), in trusts with fewer general surgical doctors (1.07) and with lower nursing staff ratios (1.07).

Authors concluded associations with staffing and other infrastructure resources suggest that potentially modifiable factors exist that relate to patient outcomes.

Ozdemir BA, Sinha S, Karthikesalingam A, et al. Br J Anaes 2015; 116(1): 54–62

O All T n e OP An w i T h ST i n e inTergiCAl Sur ing TrAin

Save the date!

Save the date! edinburgh 21 October 2016

The Faculty of Surgical Trainers Annual Meeting 2016 Training by numbers: Competence, Time and Money in Surgical Training Speakers already confirmed: • Anthony gallagher, Professor of Technology Enhanced Learning, University College Cork • nick Sevdalis, Professor of Implementation Science and Patient Safety, KCL, and Editor-in-Chief, BMJ Simulation and Technology Enhanced Learning More speakers to be announced

new this year workshops on giving e ec ve feedback, simula on in training, and be er use of iSCP

MICROSURGICAL TRAINING

Delegates from across the UK and overseas travelled to the College in October for the inaugural Basic Microsurgical Skills course

BIG STEPS INTO MICRO-SKILLS

T

he medical students, core trainees and specialist registrars on the Basic Microsurgical Skills course were introduced to skills in microsurgery and its applications, including practical techniques in basic microsurgery and arterial and venous anastomosis.

The one-day course was made possible by a collaboration between the RCSEd and the Department of Hand and Reconstructive Microsurgery at Singapore’s National University Hospital. The training was delivered

by Wee Lam, Camilla Jay Stewart and Dan Widdowson,

14 | Surgeons’ News | March 2016

Delegates practise microsurgery using the Digital Surgicals Microtrainer Platform

part of the plastic and reconstructive surgery team at St John’s Hospital, Livingston.

A Digital Surgicals (DS) Microtrainer Platform, an innovation by the National University Hospital in Singapore, facilitated assessment of each individual’s technical performance to produce a learning curve of improvement throughout the day.

Consultant hand surgeon Amitabha Lahiri from Singapore gave delegates an excellent introduction to the microscope, microsurgical technique and the DS Microtrainer Platform. The morning sessions then

Delegates gain confidence in various microsurgical techniques

moved on to suturing using the Microtrainer, followed by arterial anastomosis and delegates practising end-to-end repair of chicken vessels.

In the afternoon, Ben Chew (consultant plastic surgeon from Glasgow) delivered a demonstration of venous anastomosis, and delegates had further practice in end-to-end repair of chicken vessels.

The day concluded with a competitive assessment of microsuturing using the DS Microtrainer Platform, which was won by FY doctor Rosalind Marshall.

Delegates praised the exposure to handson practice and the high student-to-faculty ratio, and many said they left the event feeling more confident with microsurgical techniques and principles.

With a great team of faculty, including Jen Reid, Siti Zahari, Suzanne Thompson, Bernard Robertson, Nikolas Arkoulis, Megan Anderson and Li Yong from plastic surgery units in Edinburgh and Glasgow, the course proved to be a fantastic success, and a rewarding and exciting learning opportunity for all involved. We look forward to organising next year’s event.

A DS Microtrainer Platform facilitated assessment of individual technical performance to produce a learning curve of improvement

www.rcsed.ac.uk | 15

LIFE AFFIRMING PALLIATIVE CARE

Dorin Ziyaie charts the rise of palliative care from a gloomy end-of-life affair to a specialty geared up to help patients with chronic benign diseases too

I

n my career as a surgeon I have seen technological advances revolutionise the art of surgery and, at the same time, witnessed new specialties such as palliative care provide better, more comprehensive patient care.

I have witnessed efforts to establish such services and get them recognised and understood – and the subsequent services become overwhelmed with referrals.

When I graduated, I knew little of palliative care. In time, I saw clinicians of my own age group shifting from general medicine or general practice into palliative care training schemes, and hospital-based beds and wards made available.

Dr Dorin Ziyaie FRCSEd Consultant Colorectal Surgeon, Honorary Senior Lecturer and Teaching Lead at Ninewells Hospital, Dundee

Initially, it was all about the dying patient and usually this was a patient with terminal cancer. Death was perceived to be imminent, to take place in the hospital and always on the parent ward in a side room. For patients and relatives it was a morbid and gloomy endof-life affair. My perception as a surgeon was that it was about a syringe driver to keep the patient comfortable till the end arrived.

Then the pattern of referrals changed. Patients who were referred had cancer that conventional surgery could not cure but for whom death was not imminent.

The news for patient and family was morbid but there was hope for quality of the remaining life, not in a drowsy ‘comfortable’ state, but in an awake, fully comprehending state, talking, eating, and even walking. Soon we referred to the palliative care team earlier and we saw some patients comfortable enough to be discharged home to die. However, we still saw it as only related to cancer, and it was always about a dying patient.

As time moved on, our awareness increased. Patients didn’t need to have cancer but were suffering from

PATCH

How a new charity is putting end-of-life care in hospitals on the agenda In October 2015, the RCSEd hosted the launch of the first charity in Scotland to support and identify ways to deliver 24/7 palliative care for hospital patients. The inspiration for Palliation and the Caring Hospital (PATCH) began in 2009 with the Acute Palliative Care Unit (APCU) in Ninewells Hospital in Dundee, an innovative model of intensive palliative care established in an acute surgical ward through charitable funding and now funded by the NHS. Despite the success of the APCU model in Tayside, PATCH’s aim is to support staff who have a plan to improve

16 | Surgeons’ News | March 2016

The board of directors of PATCH, including Chairman Sir Michael Nairn (fourth from left) and Medical Director Pamela Levack (second from right)

palliative care relevant to their own hospital. The charity has funded surgical nurses to complete an MSc and certificates in palliative care; a joint research project (primary care, palliative care and oncology) examining why patients with advanced cancer are admitted out of hours with pain; and a communications course for FY1 doctors on speaking

to relatives about very ill patients. PATCH will be funding a project with St Columba’s Hospice in Edinburgh to run a course for Scottish nurses working in the acute setting.

Several reports have shown the unmet needs of patients with regard to palliative care in hospital. While hospice palliative care is of the highest quality, only 4% of us will die

in one. Fifty-five per cent (a total of 2.5 million people in Scotland) will die in hospital.

Despite the widespread belief that patients should die at home, this is not always ideal for either patient or carer. Many patients do not wish to leave the familiar hospital environment, with the consultant they know and access to specialist investigation or treatment.

There is also an increasing number of patients with complex needs for whom ‘active’ treatment such as surgery can be combined with palliative measures such as control of pain and nausea.

The Scottish Partnership for Palliative Care supports initiatives to raise the profile of palliative care in hospital, while acknowledging the difficulties of providing it in a busy hospital setting. patchscotland.com

Palliative care is no longer restricted to patients with terminal cancer

chronic debilitating illness. Examples from my line of practice include patients with chronic inflammatory fistulating disease or those without an established route to their digestive tract.

Patients could be referred for symptom control so that they were fit and strong enough to face the next step of treatment. Some of the many examples are down-staging with radiotherapy/chemotherapy in malignancy or in benign complex inflammatory bowel disease, multipleoperative approaches, and immunosuppression with powerful drugs.

I recently witnessed four new patient referrals – terminal cancer, leaking abdominal aortic aneurysm (AAA) not fit for surgery, severe dementia and abdominal pain of no specific origin, and metastatic disease

It is about improving the quality of every hour a patient lives with an illness, and trying to keep one step ahead of the game when conventional treatments no longer work

with minimal symptoms – introduced to the team for symptom control.

The specialty is no longer confined to inpatient care. Patients are discharged to receive high-quality care in their own surroundings. A 32-year-old patient with inoperable abdominal carcinomatosis causing small bowel obstruction was discharged home with an nasogastric tube in situ and spent six weeks with her family, supported by community palliative care. Later I received a letter from her parents. Their daughter had sat in the garden every day spending time with her young family. They were not bitter; they valued how peaceful and content their daughter was and, most importantly, how well supported they felt.

I can see that the specialty is no longer a referral pathway for imminently dying patients. It is no longer just for those terminally ill with cancer. Patients with chronic benign disease can benefit too. The word dying does not have much to do with it. It is about improving the quality of every hour a patient lives with an illness, and trying to keep one step ahead of the game when conventional treatments no longer work. Patients can go home from hospital with community palliative care. Palliative care no longer has the old stigma attached to it. It is recognised, appreciated and welcomed for all patients. www.rcsed.ac.uk | 17

FLEXIBLE WORKING

MOVING WITH THE TIMES

18 | Surgeons’ News | March 2016

© IMAGEZOO / ALAMY STOCK PHOTO

Alice Hartley, Rachel Thomas and Lorna Marson discuss the merits of less-than-full-time hours for all surgeons

S

urgical culture and practice are changing.

The number of female applicants to core surgical training (CST) and the female consultant surgeon population is slowly increasing to better reflect society. The European Working Time Directive has altered day-to-day surgical working, with a move towards teambased working and, most importantly, the term ‘work–life balance’ is no longer synonymous with weakness or a lack of professional commitment.

Traditionally, less-than-full-time (LTFT) working was considered applicable only to mothers of small children.

However, doctors with sporting ambitions or academic careers also have the right to apply for LTFT contracts, and recent modification of parental-leave legislation gives fathers equal rights to childcare. However, despite these changes, the percentage of LTFT workers in surgery remains lower than that in other specialties.

In contrast to a decade ago, surgery today is an unpopular career choice. In 2013 and 2014, there were CST places unfilled1–2. The annual GMC trainee survey shows that surgical trainees consistently have the lowest satisfaction of all trainees and the most commonly cited reason is the inability to achieve an adequate work–life balance.3 Pressures of working in the NHS are also felt by senior doctors. A survey conducted by the Hospital Consultants and Specialist Association (HCSA) found that 83% of consultants would consider taking early retirement due to stress.4 With the retirement age now set at 68 years, it is not surprising that the current workforce can’t see how their current job plans will be viable at retirement. To lose the most experienced members of our team to early retirement would be a colossal waste of expertise. Equally, though, failure to address the needs of surgeons in their early careers could cause irreparable damage. Perhaps flexible working is the key to recruiting and retaining surgeons.

The latest RCSEd membership survey revealed that more than 75% of all Fellows and Members would like to work flexibly at some point in their career. Unfortunately, only 31% felt that the profession was accepting of this due to the stigma, either real or presumed, that is associated with LTFT working. The RCSEd hopes to lead the surgical community in changing attitudes and perceptions of LTFT training and working, and has set up a short-life working group to provide information and facilitate flexible working.

WHAT WE ARE DOING: Holding a networking and information event in April 2016 for those working or interested in LTFT working Creating a peer-support network to put people in touch with others with similar experiences Creating a College website section with links to this network and the relevant policy documents from organisations like AoMRC and ASiT, covering aspects such as parental leave and returning to work following time out in academia or on maternity leave The Honorary Treasurer has granted discounted membership fees to LTFT workers and those on maternity/paternity leave Alice Hartley, Rachel Thomas and Lorna Marson

Less-than-full-time working can improve work–life balance

Theory in practice REFERENCES 1. Eardley I, Scott, H, Wilkinson D. Why a career in surgery is no longer the golden ticket. BMJ Careers 2015; August.

2. Peters K, Ryan M. Machismo in surgery is harming the specialty. BMJ Careers 2014; February.

3. GMC. National Training Survey.

2014.

4. HCSA. Who cares for the carers? HCSA hospital doctors’ stress survey reveals shocking results. 2015.

Available from hcsa.com 5. Colbert SD, Scott J, Dale T, Brennan PA. Performing to a world-class standard under pressure: can we learn lessons from the Olympians?

British Journal of Oral & Maxillofacial Surgery 2012; 50(4): 291–7.

Professor John MacFie, Chairman of the Federation of Surgical Specialty Associations (FSSA) of the UK and Ireland

Professor MacFie is Consultant Colorectal Surgeon at York Foundation Teaching Hospital Trust, based in Scarborough. He feels strongly that surgeons should be able to modify their job plans throughout their career to reflect changing priorities. These include changes in clinical practice, increasing specialisation, teaching, research, and managerial and college roles.

While he recognises the logistical implications of reducing how often surgeons are on call, particularly in smaller hospitals, he is of the view that no surgeon should be on call after the age of 55 years. Failure to do this will encourage experienced surgeons to retire early and this will add to the burden on the next generation.

As they approach their late 50s or early 60s, many surgeons are advised to retire or work parttime for financial reasons. Professor MacFie feels that it’s a shame many CEOs decline requests for surgeons to work part-time, as this results in premature loss of valuable experience.

Part-time working for surgeons, whether at the beginning of their career or at the end, necessitates full support and collaboration from colleagues. Professor MacFie currently works a six PA contract, which he enjoys, as it permits ongoing contact with his hospital colleagues while allowing him to pursue research and fulfil his role as president of a national association. This would not be possible without the support of his colleagues.

Professor MacFie’s advice to others considering part-time work would be to discuss their intentions informally with colleagues and senior management at the earliest opportunity, and to record their aims and aspirations in the appraisal process. He feels that surgeons could make some tangible offers to the trust and department, such as extra elective work or waiting-list initiatives, so that flexible working is not just a one-way process in favour of the surgeon.

www.rcsed.ac.uk | 19

FLEXIBLE WORKING

Paths to work–life balance SPORTING OPPORTUNITIES

Serryth Colbert, Consultant Maxillofacial Surgeon, Bath In 2001, already a successful amateur rower, the 26-year-old combined flexible working with sporting achievement and devoted five years to training and competing with the Great Britain rowing team. As a member of the Leander Club in Henley, where he rowed with Sir Matthew Pinsent, Colbert won a gold medal in the Commonwealth Rowing Championships.

Colbert’s memories of this time are positive and he has no regrets. Now a father of two who also contributes his surgical skills to the Future Faces cleft charity in India, he feels that his unconventional early career path has given him a balance in his life that may otherwise have been lacking in his demanding specialty.

During training interviews he had mixed reactions from senior members of his profession. While most of them appreciated the sacrifice and achievements, others responded with negative comments about his commitment.

Although flexible working is rare in oral and maxillofacial surgery, Colbert encourages LTFT working, as he finds that flexible trainees are usually highly efficient and exhibit good timemanagement skills.

After being told by Sir Steve Redgrave that the key to success is hard work and determination, Colbert has demonstrated that surgeons and successful athletes are not so different after all.5

FLEXIBLE TRAINING

Lorna Marson, Associate Dean (Surgery) for South-East Scotland Marson had her two children, now teenagers, while she was training in surgery and she was one of the first to train flexibly in Scotland. As a consequence of her own experiences, Marson actively promotes surgery as a career for women and was awarded the College’s Hunter Doig Medal for her significant contributions to surgery.

As an academic surgeon, Marson splits her time between the NHS and the University of Edinburgh. She also supports LTFT training and the importance of mentoring in her

role as Associate Dean (Surgery) for South-East Scotland.

CHILDCARE

Rachel Thomas, STR5 General Surgery, West of Scotland Thomas started LTFT training after her second child was born in 2013. With a dual career, marriage and no family in Scotland, Thomas relies on paid childcare and believes that LTFT training offers a better work–life balance and the opportunity to create a more peaceful home life.

Thomas loves her job and the challenges it brings, but surgery is an intense vocation, which can be overwhelming.

Doctors have the privilege of spending time with patients at the end of their lives and many reflect and regret time away from families due to demanding careers.

For Thomas, 80% training means a fixed day off per week, with either 5/7 night shifts or 6/7 long day shifts. LTFT training does present challenges and success is dependent on a good supervisor relationship and identifying training opportunities early. Handover must be robust, but this is standard practice for current trainees used to shift work.

IF YOU HAVE SUGGESTIONS AS TO HOW THE COLLEGE CAN SUPPORT FLEXIBLE WORKING IN SURGERY, OR ARE INTERESTED IN BECOMING INVOLVED WITH THE PEER-SUPPORT NETWORK, PLEASE CONTACT ALICE.HARTLEY@RCSED.NET

FLEXIBLE WORKING IN SURGERY 25 April 2016, The Royal College of Surgeons of Edinburgh A day of talks and informal networking sessions where delegates will have the opportunity to discuss experiences and issues around working less-than-full-time in a surgical career.

To book, contact outreach@rcsed.ac.uk call 0131 668 9213 visit rcsed.ac.uk

20 | Surgeons’ News | March 2016

DID YOU KNOW?

The College this year enhanced support for Fellows and Members on maternity and paternity leave, and now offers everyone on maternity or paternity leave a pro-rata reduction on their subscription for leave lasting from one month up to a maximum of 12 months.

For details, please contact our membership team who will be able to help you further: membership@rcsed.ac.uk 0131 527 1654

Events at Surgeons’ Hall Museums Join us in 2016 when we will be hosting events in partnership with the Science Festival and Museums at Night.

See our website for more info: www.museum.rcsed.ac.uk

Open 7 days 10am–5pm Free RCSEd Fellows and Members (please sign in at the museum reception) £6 Adults £3.50 Concessions

REMOTE HEALTHCARE

Ahead of a visit to the UK, Canada’s Professor Roger Strasser discusses his work on education for remote rural healthcare

BROADENING OUR HORIZONS

S

Roger Strasser Professor of Rural Health, Dean and CEO, Northern Ontario School of Medicine, Lakehead and Laurentian Universities, Canada

ome 20 years ago, I did a series of studies on the health service needs of people in remote rural communities. From this research, I came to realise that people everywhere have a security need. They need to know that if they are unlucky enough to be seriously ill or injured, the ‘system’ is there for them.

This focus on the safety net is reflected often in the advocacy by small communities for local hospital and medical services.1 In urban areas, hospitals with emergency departments and ambulance services are never far away, whereas access to care in remote rural settings can’t be taken for granted. In a nutshell, access is the rural health issue.2 This is true whether you live in these communities or are visiting for work or leisure.

Consequently, there is a need for health service models in remote rural communities that are designed in these settings to respond to the health needs of the people in these communities. In this context, surgical services are of particular importance, not only in acute situations, but also for managing common health problems and maintaining maternity care.3 Attempts to take urban-designed service delivery models and implement them in remote rural settings have, in general, proved unsatisfactory.

It is important to recognise that the healthcare providers in these communities are the frontline

22 | Surgeons’ News | March 2016

providers of care. As a general statement, rural practitioners, when compared with their metropolitan counterparts, may be described as ‘extended generalists’.

Rural practitioners provide a wider range of services, have a heavier workload and carry a higher level of clinical responsibility in relative professional isolation.

These characteristics hold true for all rural practitioners, whether they are doctors, nurses, pharmacists or other health professionals.4 Since the mid-1980s, research evidence describing the specific range of knowledge and skills required by rural practitioners has been accumulating. This has led to the inclusion of specific curriculum content on rural health and rural practice in undergraduate medical courses and in rural-based vocational training programmes initially for general practice and more recently other specialties. In the southern hemisphere, the Australian College of Rural and Remote Medicine has achieved recognition of rural and remote medicine as a specialty with specific training.5 This includes advanced rural skills training in surgery developed

It is important to recognise that the healthcare providers in these communities are the frontline suppliers of care

Conference call

On 23–24 May 2016, I hope you will join me at the Rethinking Remote: Innovative Solutions in Remote Health Care Conference in Inverness.

This conference aims to address the following questions: How have diverse remote communities solved healthcare challenges?

What role might technology have in providing solutions to healthcare in remote locations or communities?

In what innovative ways can healthcare workers or first responders be supported to provide better care in remote locations?

Can innovation in education and training make a difference to remote healthcare?

through collaboration with the Royal Australasian College of Surgeons.

In the northern hemisphere, Scotland is a leader in recognising the importance of well-trained and broadly skilled rural surgeons. Following the NHS Scotland report Delivering for Remote and Rural Healthcare in 2007, the Remote and Rural Training Pathways Project proposed a curriculum for remote rural surgical practice that includes the knowledge base and necessary competencies required of a surgeon working in relative isolation.6 This training involves rotations in designated rural general hospitals where graduates of the programme are expected to practise. This is consistent with the rural training pathway approach, which is gaining recognition for success in recruitment in different parts of the world.7 In Canada, Northern Ontario is geographically vast, has a chronic shortage of doctors and has culturally diverse populations with worse health status than Ontario province as a whole. The Northern Ontario School of Medicine (NOSM) was established in 2005 with a social accountability mandate to contribute to improving the health of the people and communities

of Northern Ontario. NOSM recruits students from Northern Ontario and similar remote rural and cultural backgrounds, and provides learning in context through Distributed Community Engaged Learning (DCEL), NOSM’s distinctive model of medical education and health research.

DCEL involves teaching and learning at more than 90 sites connected through electronic communications and supported by active community engagement. The NOSM digital library service and curriculum delivery ensures that learners and academic staff wherever they are have access to educational resources and information as if they were in a major city teaching hospital. At the postgraduate level, NOSM provides training in general practice and eight other general specialties, including general surgery.8 Ninety-two per cent of NOSM medical students come from Northern Ontario with the remaining 8% from remote rural parts of the rest of Canada. Sixtytwo per cent of NOSM graduates have chosen general practice (predominantly rural) training with almost all the others (33%) training in other general specialties.

Ninety-four per cent of the doctors who completed undergraduate and postgraduate education with NOSM are practising in Northern Ontario, including 33% in remote rural communities.

In this second decade of the 21st century, there are opportunities for service delivery and education/ training models that may not have been there in the past. Communications and transportation technologies have reduced the degree of isolation and opened exciting possibilities for education and care. These include telehealth care ranging from consultant advice to patients and health professionals, to supervising remote interventions by video, to remote robotic procedures, as well as electronic access to educational resources and information for remote healthcare providers.

Professor Strasser will be the key speaker at Rethinking Remote: Innovative Solutions in Remote Health Care Conference, 23–24 May 2016, Eden Court, Inverness isrh2016.org

REFERENCES 1. Strasser RP, Harvey DHP, Burley M. The health service needs of small communities.

Aust J Rural Health 1994; 2: 7–13.

2. Strasser R. Rural health around the world: challenges and solutions. Fam Pract 2003; 20: 457–463.

3. Iglesias S. Evidence for enhanced surgical services provided by generalists.

Second World Summit on Rural Generalist Medicine.

Montreal, May 2015. https://vimeo. com/124610867 4. Strasser R. Education for rural practice in rural practice. Educ Prim Care, 2015.

In press.

5. www.acrrm.org.au/ training-towardsfellowship/ overview-oftraining-with-thecollege 6. Sim AJW, Grant F, Ingram AK. Surgery in remote and rural Scotland.

Surg Clin N Am 2009; 89: 1335–1347.

7. Cairns Consensus Statement on rural generalist medicine, Australian College of Rural and Remote Medicine, Nov 2013. Available from www.acrrm. org.au/docs/ default-source/ documents/ about-the-college/ cairns-consensusstatement-final3-nov-2014. pdf?sfvrsn=4 8. Strasser R, et al.

Transforming health professional education through social accountability: Canada’s Northern Ontario School of Medicine. Med Teach 2013; 35: 490–496.

www.rcsed.ac.uk | 23

REMOTE HEALTHCARE

Shell’s Dr Alistair Fraser provides an industry perspective on innovation in remote healthcare

DISTANCE NO OBJECT

D

elivering medical care remotely has been possible for decades and remote healthcare (RHC) is now a ubiquitous term.

Easier data connectivity, improved nearpatient tests and increased acceptance of social media for human interaction make RHC more relevant and an opportunity to improve care quality. RHC technologies and competencies will become routine in general healthcare, particularly in rural areas. Within this context, I want to give an overview of RHC within Royal Dutch Shell.

Shell is a global group of energy and petrochemical companies operating in more than 70 countries with around 94,000 employees. Health accountabilities and activities are specified in a corporate control framework, and place requirements on the global health team, businesses, management, contractors and employees.

We mandate that operations must be able to access a medical-emergency professional in one hour and a local hospital within four. When these times can’t be met, mandatory risk assessment increasingly points to RHC as risk mitigation.

RHC can be defined as the diagnosis and medical treatment of people working in locations geographically or chronologically distant from medical care. In the UK, an example is the care provided by medics offshore in the UK continental shelf.

In Shell, enhanced RHC was implemented where we were unable to meet our timeframe standards for hospital access, such as in Baffin Bay, west Greenland.

However, the more medical definition of RHC is now superseded and we take a broader, integrated systems view of what is required (see box). With growing experience, we now use risk-differentiated implementations of RHC in less remote locations and routine operations, with some examples given below.

SEISMIC, SAIL AND DRILL Oil production is a result of a sequence of activities over years that include seismic surveys, coring and test wells.

This sequence involves extremes of activity, often in very remote areas with tight schedules. Noble Globetrotter II sails worldwide and drills wells, and helicopter support used to be the norm. Implementing RHC on vessels now enables us to provide better medical care than is 24 | Surgeons’ News | March 2016

VSee telemedicine kit, which enables remote practitioners to liaise with onshore doctors

available locally and, where safe, removes the need for (and risk of ) helicopters. RHC allows patients with minor cases to continue to work and those with major cases to be evacuated directly to an air-ambulance and taken immediately to an international centre of excellence.

Recently, we were able to x-ray a lower-limb fracture, get orthopaedic confirmation that it was stable (and therefore considered minor) so that we could deliver conservative treatment on board the vessel. Prior to RHC, the patient would have been medevaced internationally for diagnosis of the fracture, incurring risk and cost, with no additional benefit to the outcome.

Laboratory equipment allows a broad range of analyses and is frequently used. RHC provides reassurance for both medic and patient, particularly in non-specific

Shell’s integrated system for RHC People and profession Competence, experience, leadership, worker welfare and mindset Enabling technology Inter-vessel transfer, helicopter, bandwidth, reliability Medical equipment and supplies (including near-patient diagnostics such as radiography, ultrasound, laboratories) Planning procedures and protocols Emergency response systems Fitness-to-work assessment Health-risk assessment, food hygiene and outbreak management Research Competence, protocols, outcomes, best practice Training competence and accreditation Need for global standards, wide scope, leadership skills, project planning Networks Topside medical cover with access to experienced specialists

diagnoses. Overall, the medevac rates in these maritime operations have reduced by 40–90%.

NIGERIA Operations in Nigeria involve multiple remote onshore locations and two offshore assets. Bonga is in the Gulf of Guinea, 147 miles from Lagos, with a flight time of 70 minutes. While not considered extremely remote, medevacs are complex and involve risks to people.

In 2013, Shell introduced VSee telemedicine kits that include video, stethoscope and ECG, enabling improved interaction with onshore doctors.

There is inevitability about resistance to change that requires intervention. Shell used telemedicine to enable a community of practice to deliver continuing professional development, and our medics use it to communicate with

The remote location of oil workers makes delivering healthcare a challenge

Shell has introduced VSee telemedicine kits that include video, stethoscope and ECG, allowing improved interaction with onshore doctors

their families, increasing their familiarity with the technology. Telemedicine consultations doubled from 201 in 2014, and medevacs fell from 47 to 12.

Patients talk directly to the distant doctor, leading to high satisfaction scores.

The telemedicine technology is used at the Shellsupported Obio Cottage Hospital in Port Harcourt. The hospital focuses on mother and child interventions, and RHC has contributed to reducing mortality towards levels seen in Europe.

LOOKING FORWARD We are only scratching the surface of learning from RHC. The Institute of Remote Healthcare offers a vehicle to research and develop standards of practice, drive education and competence globally, and provide the basis to move to a professional career path. The opportunities then extend well beyond industry and extreme remote areas into rural care and NGO work in the developing world.

Other options that might be considered include reassessment of how we train and support individuals who rarely use their skills, and who do so only under pressure. Virtual, over-the-shoulder coaching in real time may prove more effective than traditional training for first-aiders, defibrillator users and for medics’ critical psychomotor skills.

Perhaps we can combine smartphone apps with an iPhone stethoscope and dermal sensors to provide a new kind of first-aid kit. The opportunities and speed of change are tremendous.

Dr Alistair Fraser Vice-President, Health, Royal Dutch Shell www.rcsed.ac.uk | 25

REMOTE HEALTHCARE

SPREADING STANDARDS FAR AND WIDE

A report from the College has set out guidelines for maintaining standards in rural surgery. Lead author Gordon McFarlane summarises its findings

T

he remote Highlands and Islands of Scotland are served by six rural general hospitals (RGHs) providing emergency and elective medical and surgical care for the small communities in the region. Catchment populations average 25,000, with three of the hospitals situated on islands and the other units at least 65 miles from the nearest district general hospital. General surgeons working in these units do elective general surgery, urology, endoscopy services and minor orthopaedics. In addition to emergency general surgery, they cover urological, gynaecological, obstetric, neurosurgical, eye and ENT emergencies, and are responsible for all non-medical presentations to the emergency department.

In urban areas, advances in surgery have led to increasing subspecialisation and centralisation of services.

Constraints on time spent in training and concern over litigation have further narrowed the breadth of practice of newly qualified consultants.

26 | Surgeons’ News | March 2016

Gordon McFarlane Consultant Surgeon, Gilbert Bain Hospital, Shetland

In 2014, the College set up a working group to examine the standards that should inform delivery of surgical care in a rural setting. Rural general surgeons and surgeons involved in postgraduate training met with specialists practising in urology, orthopaedics and otolaryngology. The immediate context of the subsequent report is the RGHs within Scotland, but many of the principles may be extended to the rest of the UK and beyond. The guidelines are summarised below.

STANDARD OF CARE The standard of care in surgical units in RGHs must be the same as that provided elsewhere in the country.

Maintaining standards across the surgical specialties and subspecialties requires a team-based approach, with consultant surgeons working closely together and liaising with anaesthetists, junior doctors, specialist nurses, physiotherapists, radiographers and pharmacists.

Monthly morbidity and mortality meetings must take place in which each team member is free to contribute.

A CCT in general surgery with a ‘mainstream’ subspecialty interest (colorectal or upper GI) would be the essential basic component for training in remote and rural surgery is less clear. The literature concentrates on the volume of cases without taking into account the presence or absence of regional MDT support. Analyses of individual surgeons’ results within large units reveal considerable variation, and it is well established that anaesthetic and oncology services play a major part in overall outcome from cancer surgery. There is emerging evidence that abdominal emergencies may have better outcomes when treated in Scottish rural units compared with district general or teaching hospitals.1

TRAINING

Full use must be made of weekly multidisciplinary meetings, where rural surgeons can link into the regional cancer network to discuss relevant cases. National guidelines (SIGN in Scotland) must be followed and quality performance indicators for each cancer must be measured locally and reviewed through regional networks.

Surgeons may provide some or all of the local endoscopy services and these units must adhere to nationally audited performance and safety standards (JAG/GRS), particularly for bowel screening. The surgical unit must participate in other national audit programmes such as cancer referral waiting times, DVT prophylaxis and treatment of sepsis.

Professional organisations such as surgical colleges and the Association of Surgeons of Great Britain and Ireland produce statements on professional practice relevant to emergency general surgery and general paediatric surgery.

These documents, on the whole, are aimed at surgical practice in larger units and their recommendations should not be applied thoughtlessly to the rural situation. Patientcentred care involves providing appropriate services locally, bearing in mind that transfer to a major trauma centre, specialist vascular unit or neurosurgical service may lead to significant delays, particularly for island RGHs in adverse weather conditions.

There is an expanding body of literature advocating centralisation of surgical services in large-volume subspecialist units. The case is unambiguous for some general surgical operations such as oesphagectomy, but in other areas, such as colorectal surgery, the evidence

Surgeons working in rural areas, such as the Isle of Skye, face a unique set of challenges

REFERENCE 1. Fergusson SJ, Paterson-Brown S, Harrison EM. Is Small Beautiful?

Emergency Laparotomy Outcomes in Scottish Rural Versus NonRural Hospitals: a 10 Year Retrospective National Cohort Study. BJS 2015: 102s7; 87.

A CCT in general surgery with a ‘mainstream’ subspecialty interest (colorectal or upper GI) would be the essential basic component for training in remote and rural surgery.

A trainee who expresses an early interest in remote and rural surgery could usefully spend part of their core training in emergency medicine, trauma and orthopaedics, urology or cardiothoracics. During ST years 3–6, time spent in breast, vascular and paediatric surgery would be helpful. Post-CCT, the surgeon would spend between one and two years in a remote and rural training fellowship in the north of Scotland, where further interests could be developed by six-month attachments in specialties such as urology and trauma and orthopaedics, and shorter attachments to gain experience in emergency obstetrics and gynaecology, otolaryngology, ophthalmology and neurosurgery. An attachment to one or more of the rural surgical units would also be of benefit.

It is recognised that a post-CCT general surgeon who wished to do basic training in urology or orthopaedic trauma management would have to spend at least six months in the specialty. Considerable dedication would be required on the part of the trainee, who would effectively become a junior trainee in that specialty. A substantial knowledge base would have to be gained rapidly, while manual skills would be easier to transfer, allowing the trainee to pick up basic operations quickly. The trainer would also have to show significant commitment, directing study and credentialing agreed procedures.

In compiling the discussion paper, advice was sought from consultants in other specialties involved in relevant postgraduate training at national level. These included training committee members in obstetrics and gynaecology, otolaryngology, ophthalmology and neurosurgery. While high-quality care would be best undertaken by the appropriate specialist, the challenges posed by remote geographical locations were recognised.

It was suggested that a period of one or two months in each of these specialties would allow a trainee at or near the end of general surgical training to complete a syllabus www.rcsed.ac.uk | 27

REMOTE HEALTHCARE

for a selected number of emergency procedures tailored to the individual requirements of a trainee or appointee.

Close liaison with local personnel, such as midwives or GPs with special interest, coupled with telephone advice from the referral unit, were considered essential because the individual would have insufficient time to attain full decision-making skills.

As the rural surgeon may be responsible for only occasional trauma cases presenting to the emergency department, ATLS training to the level of instructor was recommended.

The Greenaway Report suggests more broad-based training for all doctors, with the avoidance of early subspecialisation. This could be of considerable advantage to a rural surgical trainee and allow some cross-specialty competencies to be gained at an earlier stage, although one subspecialty interest would still be desirable. There was concern that criteria for credentialing procedures have not yet been established.

REPORT SUMMARY This is a summary of Standards Informing Delivery of Care in Rural Surgery, a report from the short-life working group of the Royal College of Surgeons of Edinburgh, published in February 2016.

The full report is available at rcsed.ac.uk

MAINTAINING SKILLS AND PROVIDING SUPPORT The now-established yearly appraisal system for all doctors can help the rural surgeon identify areas of practice where knowledge or skills require updating. Maintenance of skills can be enhanced by: working closely with fellow consultants joint operating with local and visiting consultants travelling to the referral unit to assist when a particular procedure can’t be carried out locally undertaking lists in the referral unit attending appropriate courses and conferences across the surgical specialties occasionally spending longer periods of time at the referral unit.

It is recognised that a newly qualified consultant appointed to a remote and rural post will face additional challenges related to the wide variety of skills required and relatively low numbers of specific cases. A local senior colleague and a senior consultant from the referring unit should be designated mentors at appointment.

In order to provide a comprehensive elective as well as an emergency service, there must be safe and appropriate transfer arrangements for seriously ill patients. Scotland is now fortunate in having a consultant-led retrieval service for both adults and children, although it is essential that local medical staff (usually consultant anaesthetists) maintain transfer skills themselves.

Allied health professionals, including nurses, midwives, pharmacists and physiotherapists, are enjoying an expanded role in the diagnosis and treatment of many conditions and make a significant contribution to

A newly qualified consultant appointed to a remote and rural post will face challenges related to the wide variety of skills required and low numbers of specific cases 28 | Surgeons’ News | March 2016

specialist areas such as the emergency department and palliative care. Patients and staff benefit when the surgeon works closely with these other professionals, not least the surgeon.

Radiological services remain a vital support for elective and emergency surgery and the development of a national digital imaging service (PACS) in Scotland with easy access 24/7 has been of considerable benefit to rural units as well as larger hospitals. A local CT scanner has become essential and reporting of all images can now be done remotely. Basic laboratory services may be adequately provided by biomedical scientists.

The national PACS system has enhanced communication between clinicians considerably, not least in orthopaedic trauma. Rural units have also benefited greatly from linking into MDT meetings for many of the major cancer types. Increasing numbers of patients are having follow-up consultations by videolink, particularly in oncology and orthopaedics, while one unit runs a hoarseness clinic using a video laryngoscope so that the images are seen in real time by an otolaryngologist in the referral unit.

Use of technology in other areas has been less successful. A high-quality image via PACS and a telephone has been much more successful than a videolink for trauma cases, and a pilot study of remote paediatric consultation by videolink was found to be unhelpful for RGHs.

CONCLUSION

Gilbert Bain Hospital in Shetland

Rural populations will always be present in Scotland and indeed throughout the world. A career in rural surgery offers lifestyle advantages, particularly for the outdoor enthusiast. Keen support from subspecialist general surgeons and other surgical specialists in referral centres, coupled with passion, adaptability and a degree of humility on the part of the trainee will allow the UK to continue to train remote and rural surgeons, despite the rising tide of super-specialism. Advances in communications and technology can be helpful to the rural surgeon but must be trialled before being adapted into widespread use. Maximising the delivery of elective services locally, by personnel in rural areas, will ensure maintenance of a safe and appropriate service for timecritical surgical emergencies.

Photo © Emily Brown

Photo © Martin Boersema

Photo © Jamie Goodhart

RETHINKING REMOTE Innovative Solutions in Remote Health Care Conference Eden Court, Inverness 23rd – 24th May 2016

In May 2016 Rethinking Remote will highlight innovative solutions in remote healthcare by considering:

Be part of the discussion.

How have diverse remote communities solved healthcare challenges?

Come share your

What role might technology play in providing solutions to healthcare in remote locations or communities?

experiences, research

In what innovative ways can healthcare workers or first responders be supported to provide better care in remote locations?

Can innovation in education and training make a difference to remote healthcare?

and ideas, together we can build innovative solutions to our common challenges.

Speakers will include: Professor Roger Stasser, Northern Ontario School of Medicine, Canada Professor George Crooks OBE, Medical Director, NHS 24 and Director of the Scottish Centre for Tele-health and Telecare, UK

Keep up to date with

Professor Rhona Flin, University of Aberdeen, UK

the latest conference

Dr Alistair Fraser, Vice President (Health), Royal Dutch Shell

information via the

Brigadier Tim Hodgetts CBE, Medical Director, Defence Medical Services Abstracts will be invited for oral and poster presentations.

conference website www.isrh2016.org

PARTNERS:

www.rcsed.ac.uk | 29

COSECSA CONFERENCE

Spirits and standards were high at COSECSA’s annual conference in Malawi. The College reports on its involvement with training in the area

MEETING OF MINDS 30 | Surgeons’ News | March 2016

T

he rains were late in Malawi and the land and people needed water. In Blantyre, the temperature was a blistering 37oC, electricity was intermittent and tap water was rationed, with supply to different parts of the city turned off throughout the day.

Despite this, spirits were high at the annual College of Surgeons of East, Central and Southern Africa (COSECSA) conference, held in December 2015 in Blantyre, and a heartening sense of optimism and empowerment surrounded proceedings.

COSECSA is the successor to the Association of Surgeons of East Africa, and was set up in December 2007. It is an independent body that fosters postgraduate education in surgery and provides surgical training throughout east, central and southern Africa. COSECSA operates in 10 countries in the sub-Saharan region: Burundi, Ethiopia, Kenya, Malawi, Mozambique, Rwanda, Tanzania, Uganda, Zambia and Zimbabwe. It bestows a membership (MCS) and specialty

The Council of COSECSA welcomes new Fellows

George Youngson with delegates from Tanzania and Zambia

Mastering NOTSS One-day course covers the use of non-technical skills to improve performance and whether NOTSS needs adjustment for use in Africa

George Youngson CBE Course Convener

Fellowship (FCS) in all specialties except cardiothoracic surgery. These examinations precede COSECSA’s annual general meeting and scientific congress.

The RCSEd helps to deliver training and examinations held as part of the conference. The meeting was attended by Immediate Past President of RCSEd Ian Ritchie, James Campbell (who ran examiner training), Fanus Dreyer (Consultant General Surgeon, Dumfries), who was elected to the Fellowship of COSECSA, and Ewen Harrison (representing the Edinburgh Surgical Sciences academic programme). Trevor Croft provided the pièce de résistance with his Rahima Dawood Foundation lecture entitled Globalisation of Medicine: Reality or Rhetoric?

Pre-conference courses are usually run for examiners and trainees and this year was no exception, with a team from the British Association of Paediatric Surgeons providing a neonatal surgical skills course, another course run on internal fixation of fractures and a one-day masterclass in non-technical skills for surgeons, ‘NOTSS in Africa’.

Course delegates were mostly trainees from Malawi, but Tanzania and Zambia were also represented.

While some delegates attended purely out of curiosity, most already had an understanding of the taxonomy of NOTSS and wished to learn how to use it to improve their own performance or to assess their trainees.

The suitability of the current version of the NOTSS taxonomy (1.2) for use in low-income situations has been questioned and Steven Yule, one of the originators of parts of it and now Director at Harvard University’s STRATUS Center for Medical Simulation, is doing a two-year study in Kigali, Rwanda, to ascertain whether NOTSS needs to be modified for that type of healthcare environment.

However, a universal response from all the candidates on this course is that intraoperative performance is key to outcome, particularly given the restrictions on ‘rescue’ from postoperative complications in Africa with such limited resources available.

Delegates watched videos of surgical performance and were able to anonymously rate what they saw and discuss the cognitive and social skills on display.

The heat of discussion added to the heat of the day, placing another pin on the map of global delivery of the College’s NOTSS programme.

www.rcsed.ac.uk | 31

COSECSA CONFERENCE

International collaboration

The principles behind GlobalSurg, the need for funding and why empowerment starts with education I was speaking at the COSECSA conference about the GlobalSurg Collaborative, a project in which patient-level data are prospectively collected internationally. It uses a crowdsourcing strategy whereby the traditional model of research is inverted by directly appealing to junior clinicians, often through social media. The first study examined emergency abdominal surgery and suggests that patient-safety factors may have an important role in reducing mortality in low- and middleincome countries.

Building capacity for research and audit is essential for quality improvement everywhere.

The University of Edinburgh/ RCSEd distance-learning courses provide a means by which surgical trainees can work towards a postgraduate qualification

Ewen Harrison representing the Edinburgh Surgical Sciences academic programme

Tea plantation

(MSc or ChM) while continuing to work in surgery in their own country. The popularity of this approach was made clear at the meeting. Seven trainees from COSECSA countries have already graduated with an MSc, 17 are currently studying for an MSc and a further five are on the higher-level ChM courses.

Funding students from lowincome countries to complete these courses is essential. Students have already received funding from RCSEd, Johnson & Johnson, and Physicians for Peace. The success of the programmes shows how important these investments are, but demand for places still far outstrips what current funders can support.

Examiner training The UK’s experience of the move to OSCE-style examinations strikes a chord with delegates James Campbell MRCS Examiner, Trainer and Locum Consultant Surgeon in the Highland and Western Isles, Scotland

Following an expression of interest from COSECSA in adopting the objective structured clinical examination (OSCE) style of examination, RCSEd delegates shared their UK experience of OSCE with the assembled examiners.

The UK team were there simply to explain how the transition to OSCE was achieved in the UK, and the change in mindset required from the examiners.

We struck a chord with enthusiasts, the warily interested and

32 | Surgeons’ News | March 2016

sceptics alike. It was very apparent that COSECSA examiners want exam content to be relevant to their practice, but were open to the OSCE style of delivery.

After examiner training, the RCSEd team took part in COSECSA’s demanding MCS and FCS exams, which boasted an astonishing range of cases. Professor Youngson and I were assessors for the MCS examination, and Immediate Past President of RCSEd Ian Ritchie took his turn as an examiner. All three of

The much-needed rain arrived on the last day of the conference and the tea plantations at the base of Mount Mulanje turned visibly greener. I left the conference buoyed by the enthusiasm and commitment I had encountered.

For progress to be made in quality improvement, front-line individuals in low- and middle-income countries must become directly involved in clinical research. Those providing the clinical care want to be at the heart of the clinical research. Empowerment starts with education, and distancelearning programmes are an ideal foundation for this.

For details of GlobalSurg, visit globalsurg.org

us examined in the FCS specialty examinations, and put several highquality candidates through their paces. On completion, the number of qualified surgeons in Malawi had been virtually doubled.

We were warmly hosted by the exceptionally broad range of surgeons from COSECSA, fellow surgeons from Africa, Europe, North America and the Antipodes.

On completion [of the exams], the number of qualified surgeons in Malawi had been virtually doubled

CORE SKILLS IN VASCULAR SURGERY Friday 15 April 2016, RCSEd Edinburgh campus This one-day course will prepare participants for assessment of vascular emergencies, interpretation of vascular investigations and basic vascular suturing skills (anastomosis) and embolectomy.

Convener Mr Dev Mittapalli, Ninewells Hospital & Medical School Fee £215 (£195 for RCSEd Affiliate Members) To book, visit www.rcsed.ac.uk or email education@rcsed.ac.uk

SURGICAL APPROACHES TO THE SPINE

Tuesday 24 – Thursday 26 May 2016, RCSEd Edinburgh campus This three-day event offers an introduction to anatomy and surgical approaches by lectures, followed by cadaver dissection and demonstration in the RCSEd skills laboratory.

Convener Mr Likhith Alakandy, Consultant Neurosurgeon, Glasgow Fee £695 (£665 for RCSEd Members/Fellows and £670 for FST Members)

To book, visit www.rcsed.ac.uk or email education@rcsed.ac.uk

www.rcsed.ac.uk | 33

SPECIALTY: NEUROSURGERY

THE HEAD MASTERS

Roger Strachan on the development of neurosurgery, from its ancient origins through to today’s technologically advanced specialty

34 | Surgeons’ News | March 2016

N

eurological surgery, or neurosurgery, has been a separate surgical specialty for around 100 years. Access to the cranial cavity is an ancient art, with trepanation of the skull dating back thousands of years.

Many skulls have been discovered in the 18th and 19th centuries that show evidence of surgical holes and defects created in the skull, the reasons for which have been hotly debated.

The evolution of neurosurgery as a separate surgical specialty is largely attributed to Sir Victor Horsley (1857–1916) working in London, Sir William Macewen (1848–1924) in Glasgow, and Harvey Cushing (1869–1939) in Boston. Horsley was the first to remove a spinal tumour in 1887, and by 1900, working as the first ever appointed ‘brain surgeon’ at the National Hospital in Queen’s Square, reported on a series of 44 operations for glioma and the earliest procedures for the pituitary gland. This was before Cushing had even announced his intentions to become a neurosurgeon, completing his surgical training at Johns Hopkins University in 1900. Macewen was attributed with the first successful clinical localisation and removal of a meningioma presenting with epilepsy in a young girl.

Cushing did not get on well with Horsley and did not approve of his surgical techniques. Both were craftsmen.

Although technically quick, Horsley was less interested in precise haemostasis than his fellow surgeon; Cushing was slower than Horsley but perhaps more meticulous.

We should remember these differences when we reflect on the abilities of our individual trainees.

Over the last century, the development and organisation of neurological surgery in the UK has largely been attributed to three giants of the specialty: Sir Hugh Cairns (1896–1952), born an Australian but who worked in London and Oxford; Sir Geoffrey Jefferson (1886–1961), a student and surgeon in Manchester who set up a specialised neurosurgical service at the Manchester Royal Infirmary; and Sir Norman Dott (1897–1961), born in Edinburgh, the son of an art dealer and initially trained as an engineer.

As a result of a hospital admission, Dott became fascinated with medicine and, after graduating in 1919, was instrumental in establishing Scotland’s first dedicated neurosurgical ward at the Royal Infirmary of Edinburgh in 1938. He also set up a brain injuries unit at Bangour General Hospital during World War II. The Norman Dott

One of the original CT scanners developed in the 1970s, initially used for scanning the head alone

The results can bring enormous satisfaction and you can end your career knowing that you have improved the quality of life for thousands of patients immeasurably

A 3D CT angiogram demonstrating bilateral cerebral aneurysms on the Circle of Willis

Medal is now awarded for the best performance in the Neurosurgical Speciality Fellowship examination.

A new era of neurosurgery has emerged over the last 30 years. There have been rapid advances in the specialty, and just as advances in antisepsis and anaesthetics in the 19th century enabled huge leaps in surgical practice, enormous strides in microprocessor power, computational ability and material science have seen a revolution in the application of science to surgery.

This rapid progress in computer power has driven neurosurgical advancement and perhaps is one reason why it is such an attractive and challenging specialty: we can do so much more now with a higher degree of safety than we could even 20 years ago.

Imaging has progressed from the CT head scanners developed in the 1970s to third-generation spiral CT scanners that can create three-dimensional reformatted images and angiographic pictures with remarkable detail in minutes. MRI, also originally developed to image the brain, is now producing incredibly detailed pictures using 3-Tesla magnets and powerful computers. From this has developed functional MRI, advancing our understanding of brain physiology and neurosciences research enormously. Echo-planar MRI, rapid-acquisition MRI (HASTE), positron emission tomography (PET) and single-photon emission computerised tomography (SPECT) have also made a huge contribution to research. Computers and stereotaxy have enabled the introduction of neuronavigation: we can now target areas deep within the brain no bigger than a couple of millimetres. www.rcsed.ac.uk | 35

SPECIALTY: NEUROSURGERY

The time for training has been relentlessly reduced over the years and has had to become a lot more focused and intensive Endovascular treatments have revolutionised the treatment of cerebral aneurysms and other vascular malformations. Although these techniques are the realm of interventional radiologists, there are now many centres in the world where neurosurgeons are being dual trained in surgery and endovascular treatments for aneurysms. Focused radiotherapy with the introduction of the Gamma Knife and other methods of stereotactic radiosurgery have not only allowed the better treatment of malignant brain tumours, but even benign lesions such as acoustic neuroma and meningioma, and arteriovenous malformations.

Functional neurosurgery (such as surgery for epilepsy) and neuromodulation (using techniques to stimulate or modify electrical activity in all areas of the central and peripheral nervous systems), although not new techniques, have become far more effective in the last three decades because of technological advances. Deep brain stimulation for movement disorders, particularly Parkinson’s disease, and spinal-cord stimulation for chronic neuropathic pain have improved the quality of life of many patients immeasurably.

Meanwhile, advances in optics have enabled better microscopes and a resurgence in intracranial endoscopic techniques, expanding the options for treatment of many diseases, with lower risks and better outcomes than ever before. Spinal instrumentation and prosthetic developments, using new alloys and better design, have revolutionised the armamentarium that spinal surgeons have at their disposal.

Of course, it goes without saying that all this technological advancement does not lessen the importance of traditional surgical training and development of surgical skills. What is important is the application of that technology in a responsible and effective way, which requires judgement and careful scrutiny.

Neurosurgery remains a fascinating and demanding specialty. Even after almost 30 years in the specialty, every day I see new diseases and new challenges that need the application of long-acquired methods in different ways. The risks remain high and the smallest of errors can lead to a dismal outcome. However, the results can bring enormous satisfaction and you can end your career knowing you have improved the quality of life for thousands of patients immeasurably.

Training in neurosurgery has evolved almost as rapidly as the clinical revolution. I have lived through Calman training (1995), Modernising Medical Careers (2005), the introduction of MTAS and the creation of run-through training (2007), National Selection in Neurosurgery (2008) and now the Shape of Training (Greenaway, 2013). Reduction in hours (EWTD) and the fixed periods of time imposed by run-through training 36 | Surgeons’ News | March 2016

Frame-based stereotactic insertion of deep-brain electrodes for neurostimulation in Parkinson’s disease

have made it a challenging time for both trainers and trainees.

Given the risks that neurosurgery can involve, perhaps more than many other surgical specialties, training has become more difficult as the time for training has been relentlessly reduced over the years and has had to become a lot more focused and intensive. No longer can the next generation of neurosurgeons learn by apprenticeship alone – they need to manage their training in a more directed way to achieve the same ends.

The current generation of surgeons have to learn their craft just as well as their predecessors did, yet are faced with managing a practice that is more regulated and scrutinised than ever before. Further, they are practising in a society that is much better informed, whose expectations are higher, and whose tolerance for error is lower than it was 25 years ago. Now, they must specialise early, undertake Fellowships to hone their knowledge and skills, and learn the art of cooperative working, not only within their own specialty, but also with other surgical specialties. And they must be prepared for

transparency, to have their practice scrutinised through regulation and publication, both within the specialty and in the wider social arena.

Sometimes, I mourn the passing of the eccentrics and mavericks who I trained under and who gave me the skills and judgement to deliver safe and effective care. Surgical training and the delivery of care is now preordained and driven by criteria and rules. This may give the public the reassurance they seek, but I am not sure it produces better surgeons. I was a little pessimistic when run-through training was introduced, but several years later, I see a new generation of highly motivated and talented trainees who I am confident can acquire the necessary surgical skills. My concern is that the relentless regulation and de-professionalisation of all doctors, and particularly surgeons, will demoralise them and damage their enthusiasm and drive. However, I am confident that neurosurgery and the new generation of surgeons can overcome these challenges and gain as much reward out of the specialty that I have enjoyed for more than 25 years. Despite the constraints of modern training, we must continue to instil in our trainees the old values of good judgement, integrity and compassion, as well as the practical skills they need to undertake surgery as safely and responsibly as possible.

Roger Strachan Neurosurgeon, South Tees NHS Trust since 1995, and Training Programme Director, Northern Deanery, 2010–2015 Neuronavigation images reconstructed from imaging data allowing precise targeting within the brain

Full of surprises Ian Coulter explains what keeps him motivated as an ST5 in neurosurgery There’s never a dull day in neurosurgery. When asked “what’s it like working in neurosurgery?” Forrest Gump’s box of chocolates analogy often springs to mind – you never know what you’re going to get each day. You could come to work expecting to do a ward round and end up scrubbed for an emergency craniotomy.

Most medics pass through medical school and foundation training without any clinical exposure to neurosurgery.

Interested students are encouraged to gain an insight into the specialty by undertaking undergraduate placements, including electives in neurosurgery. Some may have the chance to work in neurosurgery as a foundation doctor, although these posts are relatively rare.

Following foundation training, those enthused enough to pursue neurosurgery as a career may apply for run-through training, which lasts eight years in the UK. Appointment to these posts remains fiercely competitive and involves negotiating the national selection process. Successful applicants are allocated to a deanery and commence training in one of the 30 units in the UK. The ST1–3 years may include rotations in specialties relevant to neurosurgical practice such as neurology, emergency medicine and intensive care. Higher training usually begins at the ST3–4 level, and as a registrar you work closely with a consultant for six-month periods to develop experience in different aspects of the specialty. On-call emergency work is variable. I’m writing this on my fourth night shift having operated on three stroke patients in the last couple of nights.

More commonly, we manage patients of all ages with cranial

and spinal trauma, subarachnoid haemorrhage, cauda-equina compression and shunt malfunction. We are typically focused on building our operative numbers and attaining the target of 1,200 required for CCT. Towards the end of training, most trainees have developed a subspecialty interest and aim to undertake a Fellowship in the UK or abroad. Some take time out of training to do research, but this is not obligatory and Fellowship training is perhaps deemed more important when applying for consultant posts. As a consultant, you may specialise in one or more of the following

Areas of neurosurgery are positively evolving in line with technological advancement areas: vascular, oncology, spine, functional, paediatrics, skull base and trauma, although spinal surgery forms approximately 50% of the work for most.

Although opportunities to clip cerebral aneurysms are now uncommon due to the development of endovascular treatments, other areas of neurosurgery, such as spinal and functional surgery, are evolving in accordance with technological advancement, thereby ensuring a bright future for the specialty.

Motivated individuals seeking a challenging but rewarding clinical career should consider neurosurgery. I’m always looking forward to the next case and I’ve never looked back.

Ian Coulter, ST5 Northern Deanery

www.rcsed.ac.uk | 37

INTERVIEW

Mr Lang has been hand-writing RCSEd diplomas since 1968

38 | Surgeons’ News | March 2016

Calligrapher David Lang looks back on decades of inscribing the College’s diploma certificates and presentation scrolls

PHOTOGRAPHY: MIKE WILKINSON; HEADLINE: DAVID LANG

Y

ou may never have heard of David Lang, but if you are a College Fellow or Member, the chances are that he has literally had a hand in one of the most important stages of your life and career. As the College’s calligrapher, Mr Lang has hand-written the name of each and every Fellow and Member on diploma certificates since 1968.

This amounts to tens of thousands of names, each expertly penned

by Mr Lang. Most people would agree that this is a remarkable achievement, There’s all sorts of intricate but Mr Lang has never given much thought to his longevity or the exact number of certificates he has written. detail, like tiny scalpels and However, he does remember the details of his very first commission from the other surgical instruments College, which came via a call from the RCSEd to Edinburgh College of Art. He recalls: “It was about 60 or 70 diplomas, which needed to have names, dates and around the shield subjects added, depending on the type of diploma.

“Over the years, the number of certificates in each batch has grown considerably, and especially in the last couple of years there seems to have been an is little margin for error, as Mr Lang explains: “I would always produce a draft explosion of requirements for diplomas. So it gets a for approval before going ahead with the final version – and after that be extra bit hectic sometimes, but it’s enjoyable.” careful to avoid spelling mistakes!”

The process has changed reassuringly little in the Perhaps one of the most important – and recognisable – parts of such work is intervening time: Mr Lang receives a call from the the College’s armorial bearings. Mr Lang must be more familiar with them than College when a new batch of certificates is needed, almost anyone else, having sketched, illustrated and painted the coat of arms on he collects the certificates and delivers the completed many occasions, sometimes spending up to a week on a single illustration. versions a few weeks later.

Every detail of the crest is set out in a written description (in Old Scots) by After leaving art college, Mr Lang embarked on a the Office of the Lord Lyon in Scotland, and any artistic interpretation must be graphic design career working with, among others, careful to get all the elements exactly right. “There’s all sorts of intricate detail, the medical publisher E & S Livingstone, where he like tiny scalpels and other surgical instruments around the shield,” Mr Lang came into contact with many of the leading surgeons explains. “The detail is incredible; it’s almost over-complicated compared with of the day. Alongside designing book covers and other coats of arms that I’ve studied.” producing medical illustrations, Mr Lang found time Was it daunting taking on such a task, working to the same brief followed to keep his calligraphy skills honed by producing by other artists over centuries? “Well, I obviously referred to the written diplomas for the College. description from the Lord Lyon, but also looked at the previous versions. As long Working with one of the world’s most prestigious as all the elements are included, there is some leeway to adapt the style of the medical organisations, Mr Lang has also been called illustration, which I have tried to do. One full-colour version I was asked to paint on many times to produce presentation scrolls for took a full week, so a lot of patience and care is required.” the College to gift to other institutions. These were Of course, as well as patience and care, the work demands attention to detail often one-off certificates marking an anniversary or a and a steady hand. Mr Lang has worked for other professional membership special visit. Illustrated on vellum, a parchment made bodies, but you can’t help thinking his spiritual home is the Royal College of from calf skin, and at around £100 per sheet, there Surgeons of Edinburgh. www.rcsed.ac.uk | 39

FACIAL RECONSTRUCTION

Oral and Maxillofacial Consultant Kelvin Mizen was called upon to provide a groundbreaking procedure in Ethiopia after a young boy was attacked by a hyena

NEW FACES

I

became aware of surgical mission work in Africa for facial reconstruction dealing with the ravages of noma (formerly known as cancrum oris) when I was an oral and maxillofacial trainee in early 2000.

Noma is an infective process that causes necrosis of the facial tissues, leaving severe facial defects, usually involving the lips and cheeks. It is often unilateral, but can involve the nose, eyes and mandible with associated trismus. Most sufferers are young children, of whom approximately 90% die from sepsis.

Survivors are left with terrible facial defects.

It is associated with poverty, malnutrition, dehydration, measles, poor oral hygiene and immunosuppression and is prevalent in subSaharan Africa.

In 2007, a colleague told me about a planned mission to Ethiopia to treat noma, under the auspices of the charity Facing Africa. I have now completed my eighth surgical mission. Ethiopia has a population of 94 million and more than 80% live in rural communities.

Three years ago, the country had a per capita health expenditure of approximately £12. It is believed there are currently only four MRI and six CT scanners.

Our team comprises surgeons, anaesthetists and nurses from all over the UK, plus volunteers from many countries worldwide. Facing Africa has been working in Addis Ababa since 2007 to combat the effects of noma.

During the missions, many patients suffering from other diseases are brought to us with myriad head and neck conditions, including animal bites.

The case of Abel Mesfin was different. Abel is a young boy from rural Ethiopia who sustained serious facial injuries after being attacked by a hyena near his village. He was playing with friends, wandered outside his compound and was savaged by a female hyena looking for food for her cubs. The hyena clamped her

The aims of reconstruction would be functional: to enable Abel to be able to speak and swallow again. However, the final decision could not be taken until we examined him in person 40 | Surgeons’ News | March 2016

Abel with his Facing Africa team of doctors and nurses

jaws around his head and started to drag him 400m to her den. Abel’s mother was called and, giving chase, she somehow managed to free him. Abel was bleeding heavily and the hyena had removed his mandible, upper and lower lips, right ear and both cheeks. He also had a fractured skull. Despite these terrible injuries, he was alive. The hyena didn’t give up and came back for a second attempt only to be confronted by the villagers, who managed to scare the animal off.

After some difficulty in arranging transfer for treatment, Abel was moved to a hospital in Addis Ababa. Local staff cleaned his wounds and placed a rudimentary mandibular plate. This is where Facing Africa came in. Chris Lawrence, CEO of the charity, was contacted for advice. We were sent photographs of Abel’s injuries and gave instructions on how to keep him alive until our team could get to Ethiopia. It also appeared that part of Abel’s anterior tongue had been severed.

All the evidence indicated that the surgical treatment had to be planned carefully.

Various email and phone conversations took place between all team members and it was agreed that he was likely to succumb without an intervention. The aims of reconstruction would be functional: to enable him to speak and swallow again. However, the final decision could not be taken until we had examined him in person.

We funded CT scans of his head, neck and fibulae.

These were sent by post and uploaded to Materialise in Belgium for computer-assisted planning. Unfortunately, when they arrived the fibulae scans were missing. There

Abel pictured in December 2015, at home with his mother

www.rcsed.ac.uk | 41

FACIAL RECONSTRUCTION

I am lucky to be involved with a charity that believes in holistic patient care.

I am proud that we have a complication rate comparable with our work in the West. I have met and worked with many extraordinary people

The Facing Africa team and patients at the rehabilitation unit

was no time to waste, so I got around this by gaining photographs of clinical measurements of Abel’s own leg and using a generic image of an adult fibula that was then scaled down to fit. I had no idea if this would work.

Facial bony reconstruction is planned accurately with 3D images. This enabled us to reposition Abel’s mandibular remnants precisely, then virtually osteotomise his fibula to create a neo-mandible. We then printed cutting guides and milled a bespoke reconstruction plate to secure the fragments. A huge advantage of modern techniques is that the fibula can remain vascularised on the leg while being fashioned into a mandible, whereas before it would be non-vital for over an hour before anastomosis. The whole kit was kindly donated by Synthes and Johnson & Johnson. The other innovation used was implantable dopplers from Cook Medical. These are placed on the anastomosed vessels to continuously monitor the inflow and outflow of the flap in real time. As far as we know, this type of procedure has never been performed before in Africa, let alone Ethiopia.

On arrival at the Facing Africa rehabilitation facility, we finally met Abel and his hopeful parents.

We were invited to use a brand-new operating suite in the Myungsung MCM Korean Hospital. It was a 42 | Surgeons’ News | March 2016

More than 80% of Ethiopians live in rural communities

long procedure of more than 11 hours during which there were many obstacles. Luckily, the neo-mandible fitted perfectly. Thanks to the highly skilled team, we eventually transferred Abel to the rudimentary ITU without a tracheostomy. The major advantage was that he did have a tongue, which I managed to mobilise and attach to his new jaw. He made remarkable progress and was soon transferred back to our ward to be cared for by our excellent team of experienced nurses.

After a week, he was transferred back to the charity’s rehabilitation facility to be cared for by our team of doctors and nurses. Even after we had returned to the UK, Abel continued to receive care, as did all other patients operated on during the mission. I am sent regular updates on his recovery via email, photographs or video clips. I can advise on any question or challenges there may still be.

Abel is now running around like any other five-yearold boy. He is growing, speaking and the NG tube has been removed. We achieved our initial treatment aims.

He still has a long way to go, but I hope we can go on to reconstruct his upper lip and cheeks if he should desire it.

I am planning to return in March 2016 on a non-surgical mission to see him and many other patients on whom we have operated over the last eight years. The aim of this is to get a deeper understanding of the values and beliefs of the people we treat.

I fell in love with Ethiopia many years ago and I am lucky to be involved with a charity that believes in holistic patient care. I am proud that we have a complication rate comparable with our work in the West.

Through my work with Facing Africa, I have met and worked with many extraordinary people. Without them and the patients, we could not progress. Working abroad certainly enhances my skills and I believe it benefits patients in the UK. I would like to thank Facing Africa, Hiroshi Nishikawa, Le Roux Fourie, David Ball, Bill Hamlin, Einar Eriksen and, last but not least, the nursing and theatre staff who have made these missions a success.

Kelvin Mizen is Oral and Maxillofacial Consultant, Diana, Princess of Wales Hospital, Grimsby www.facingafrica.org

Any questions? Victoria Dobie finds out what SAS grades in all surgical specialties need to know about using the ISCP web-based resource to create a portfolio of evidence of competence Why SAS surgeons should use the ISCP website The Intercollegiate Surgical Curriculum Programme (ISCP) is a web-based resource that all surgical trainees must use to

create a portfolio of evidence during their training. SAS surgeons and surgeons in non-standard service posts are also entitled to use this website.

The ISCP website carries the definitive

information on the surgical curricula for each of the specialties, with clear standards and levels of progression.

The web platform enables a surgeon to build a portfolio of training and www.rcsed.ac.uk | 43

Š ELLY WALTON/IKON IMAGES

GETTING STARTED

SAS GRADE

experience through the validation and recording of learning experiences.

The information on the ISCP website and portfolio stored there can be used by a surgeon who is not in a training programme to guide career development and progression. This includes support for appraisal, application for Certificate of Eligibility for Specialist Registration (CESR) and future job applications.

SAS grades must create a user profile on the ISCP website

Background to the ISCP The need for formal curricula in postgraduate training arose from the Modernising Medical Careers (MMC) report and became a requirement of each specialty in 2007. On behalf of the four Royal Surgical Colleges of the UK and Ireland, the Joint Committee on Surgical Training decided to develop one of the world’s first dedicated web-based surgical curriculum programmes – the ISCP – to house the curricula for each surgical specialty and to provide surgeons with an interactive portfolio to be used to collect evidence of experience and competence. The ISCP has kept evolving since. A new version is due out in 2016, and the website can now be used to support professional development for those not in training posts.

The ISCP website holds information on the curricula for each surgical specialty

Selecting a user profile There are two main types of user of the ISCP: l Those who want to use it to build a portfolio of evidence of experience and competence. This is for trainees and all other surgeons who want to build a portfolio and incurs a fee l Those who will use it to assess others, but not to build a portfolio of experience and competence. This is free of charge for consultants and other surgeons who will carry out assessments only.

Within the first of these options, there are two further choices: trainee (includes core and specialty) and Non-NTN doctor using the ISCP. SAS surgeons and surgeons in non-standard service posts who want to build a portfolio should select the first option above and then ‘Non-NTN doctor’.

The second option above registers the surgeon as an assessor for those undertaking learning experiences on the ISCP. All SAS-grade surgeons, and those in service posts with more than two years’ experience, may register for the ISCP in the role of assessor. Any surgeon taking on an assessor role should have completed the necessary training in the assessment processes and be sufficiently experienced to perform the assessment.

Information you need to provide The ISCP was designed to match the training system that requires each trainee to have a clinical supervisor (CS), an assigned educational supervisor (AES) and a training programme director (TPD) to provide educational evaluation.

SAS surgeons and those in non-standard service posts who want to create a portfolio will need to identify a senior surgeon to act as their supervisor within ISCP. This single person should be named as both CS and AES (a TPD is not required) and will 44 | Surgeons’ News | March 2016

provide the necessary supervisory reports. The senior surgeon acting as supervisor would be undertaking the role voluntarily, at the request of the SAS surgeon, and should preferably already be a recognised trainer in surgery, as they will need a fuller understanding of the working of the ISCP. There are plans to amend these requirements on the web-based system, but in the meantime these arrangements are necessary.

For help with getting registered The ISCP website is still in the process of developing its access for SAS surgeons and those in non-standard service posts, and obviously giving the name of an agreed supervisor for the roles of CS and AES is a workaround.

Any SAS surgeon and those in non-standard service posts having difficulty in registering with the ISCP should phone or email the ISCP helpdesk on 020 7869 6299 or helpdesk@iscp.ac.uk, respectively.

Victoria Dobie is the SAS representative on Council and Chair of the SAS and Locum Consultant Committee

For the Dental Faculty, 2016 promises to be a year of international developments, says Professor Bill Saunders

GLOBAL LINKS

T

he Dental Faculty would struggle to survive without its international activities.

The efforts of both UK and overseas examiners to quality assure candidates to ensure the highest level of attainment is, of course, paramount to the Faculty’s continuing prominence.

Our reputation for fairness, friendliness and contemporary practice in assessment and our vast experience makes us a popular choice as partner for overseas institutions. However, it is vital that those organisations know the standard required so candidates are not disadvantaged by lack of understanding of the curriculum and the standard of English required.

In recent years, the Faculty has been asked to accredit institutions for specialty training, but this has never been formalised. We have a number of memoranda of understanding for several major institutions internationally, but these mostly deal only with arrangements to conduct examinations in overseas institutions and the responsibilities of each party.

We are developing a comprehensive document to enable us to assist organisations overseas to conduct speciality training to the requisite level. This will include everything from in-course formative assessment methodologies to the recording of clinical activity during training. The General Dental Council’s publication Standards for Specialty Education has helped inform the document. We hope to begin a formal longitudinal accreditation system this year to help organisations begin or enhance their specialty training programmes.

I mentioned in a previous article the difficulty our UK-based examiners have in taking time off from their regular employment to examine for the College. This is even more difficult when examining overseas, and many of our examiners make the exceptional sacrifice of taking annual personal leave to fulfil these duties. It is

clear we need to encourage more of our colleagues in the international centres to become examiners for us.

In large centres, training can be arranged locally and examiners from smaller institutions can be included in our regular training days in Edinburgh. We are desperate for all examiners to write questions, and no examiner should feel inhibited in this important duty. Many of us find it difficult to write questions that satisfy the high levels of Bloom’s Taxonomy, where we need candidates to analyse, evaluate and create. To achieve these aims, it is often easier when writing questions to use the verbs that apply to these categories: ‘appraise’, ‘criticise’, ‘categorise’, ‘compare and contrast’, ‘validate’ and ‘interpret’. Many exams are moving to a ‘single best answer’ format, which brings its own difficulties, but we encourage all our examiners to engage with the College to ensure that our examinations are fit for purpose.

We have established strong links with the Hamdan bin Mohammed College of Dental Medicine in Dubai. We also have a long-term relationship with colleagues in Egypt and are now able to return to conduct exams in Cairo. We await the granting of a licence by the government authorities for the Bahrain Postgraduate Dental Centre with which we have agreement for us to provide quality assurance for their speciality programmes and for our Members and Fellows to teach there. The extraordinary efforts made by the local specialists under Hamad bin Shams and, in Edinburgh, by Howard Moody will bear fruit soon hopefully. We have other opportunities in the region, including in Iraq and Sudan.

We very much appreciate the strong relationships we have with the Hong Kong College of Dental Surgeons, the Royal Australasian College of Dental Surgeons, University Dental Schools in Malaysia and the National University of Singapore.

We hope our endeavours in China and India will continue and I value the efforts made by Specialty Advisory and Advisory Board chairs to foster these links.

Interest in the activities of our Faculty from international institutions continues to grow and I hope we can match that enthusiasm and provide a responsible and high-level service to our colleagues overseas. I trust 2016 will be a successful year for us all.

Professor Bill Saunders Dean, Faculty of Dental Surgery

Interest in the activities of our Faculty from international institutions continues to grow and I hope we can match that enthusiasm www.rcsed.ac.uk | 45

DENTAL

Trainees and dental care professionals have been showcasing their presentation skills at a College-sponsored event in Wessex

Prize presentations

T

he College was proud to sponsor the trainee presentations at the Wessex BDA Hospitals Group Meeting on Tuesday 1 December 2015 at Salisbury Hospital. There were strong presentations from trainees and dental care professionals across the region.

The dental care professionals prize was awarded to Amy Houston and Jo Frost, who are nurses at Great Western Hospital, Swindon. Their audit on the use of personal protective equipment (PPE) measured what PPE staff within the maxillofacial department deemed appropriate. It then measured compliance with using appropriate PPE against hospital guidelines. Although compliance was good overall, there were a few areas for improvement. Houston and Frost are planning education sessions for staff and will re-audit this year.

The dental core trainee prize was awarded to Jessica Scott from Salisbury District Hospital. Her case presentation demonstrated the value of thorough surgical planning in wisdom tooth extraction when the inferior dental nerve is closely associated with the roots of the third molar. The patient presented with swelling associated with a deeply impacted wisdom tooth. As well as a periapical radiolucency suggestive of a dentigerous cyst, the tooth showed close

46 | Surgeons’ News | March 2016

The audit demonstrated that patients are receiving appropriate anaesthesia for their treatment in line with IOSN

Pictured from left to right: Supriya Ghurye, Jessica Scott, Amy Houston, Jo Frost, and Karen Bennett (Chair of Wessex BDA Hospital Group), who presented the certificates

association with the inferior dental nerve. CT imaging allowed a stereolithographic model to be made of the mandible and facilitated planning for surgical removal of the tooth.

An acrylic guide was then manufactured to direct the safe removal of bone and eventual extraction of the tooth without nerve damage.

The specialist trainee prize was awarded to Supriya Ghurye, an oral surgery StR in Wessex (Isle of Wight). Ghurye audited the use of the Index of Sedation Need (IOSN) for adult patients attending oral surgery.

The aim of the audit was to assess whether patients are receiving anxiety control/ anaesthesia for their treatment that is appropriate for their need as demonstrated by their IOSN rank score, rather than their demand. All patients with an IOSN score of four or below should only be receiving treatment under local anaesthesia and all patients with an IOSN score of four or more may be considered for sedation or general anaesthesia.

The audit showed that patients are receiving appropriate anaesthesia for their treatment in accordance with IOSN. Ghurye concluded that IOSN is a useful tool for guiding decision-making and justifying use of sedation/general anaesthesia to commissioners.

Pamela Ellis Regional Dental Adviser

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

NORTH EAST OF SCOTLAND 1 Martin Donachie, Aberdeen Royal Infirmary SOUTH EAST OF SCOTLAND 2 Donald Thomson, Dundee Dental School (Based in Dundee, acts as adviser for South East Scotland)

1

TAYSIDE 2 Brendan Scott, Dundee Dental School

2

WEST OF SCOTLAND 3 Kurt Busuttil-Naudi, Glasgow Dental Hospital and School

3

ENGLAND

EAST OF ENGLAND 4 Simon Wardle, James Paget University Hospital, Great Yarmouth 18

KENT, SURREY & SUSSEX 5 Lindsay Winchester, Queen Victoria Hospital, East Grinstead NORTH WEST OF ENGLAND 6 Alex Milosevic, Liverpool University Dental Hospital 7 Mike Pemberton, University Dental Hospital of Manchester 8 Callum Youngson, School of Dentistry, Liverpool

15

17 16

6

7 8

13

NORTH LONDON 9 Phil Taylor, Barts and the London School of Medicine and Dentistry, London 4

NORTH EAST LONDON 10 Nick Lewis, UCL Eastman Dental Institute, London

12

NORTH WEST LONDON 11 Sumithra Hewage, Northwick Park Hospital, Harrow OXFORD 12 Mary McKnight, John Radcliffe Hospital, Oxford SOUTH YORKSHIRE/EAST MIDLANDS 13 Philip Benson, Charles Clifford Dental Hospital, Sheffield SOUTH WEST OF ENGLAND 10 Crispian Scully, UCL Eastman Dental Institute, London (Based in London, acts as adviser for Avon) 14 Pamela Ellis, Dorset County Hospital, Dorset YORKSHIRE 15 Brian Nattress, Leeds Dental Institute, Leeds

WALES

16 Joy Hickman, Glan Clywyd Hospital, Clwyd

11

10 9

14

5

REPUBLIC OF IRELAND

17 Simon Wolstencroft, St James’ Hospital, Dublin

NORTHERN IRELAND

18 Gerald McKenna, Queen’s University Belfast

RDA VACANCIES

North East of England South West of England South Wales For details, contact: outreach@rcsed.ac.uk

www.rcsed.ac.uk | 47

TRAINEES AND STUDENTS

Delegates and poster presenters with CUSS President Natalie Lewis (second from right)

STUDENT RESEARCH STEALS THE SHOW Michael LavelleJones presents David Evans with the Student Oral award

Undergraduates in Wales impressed judges at the annual research competition

I

n October 2015, an audience of more than 100 consultants, trainees and students from a variety of surgical specialties were treated to eight oral presentations and more than 40 posters at the sixth annual RCSEd All Wales Medical and Dental Student Surgical Research Symposium. The beautiful and historic site of Margam Park in South Wales played host to the conference, which rewards academic and research excellence at student level.

From its humble beginnings in a small function room in 2010, the symposium has had stellar success, and is now firmly embedded in the Cardiff and Swansea medical and dental student academic (and social) calendar.

The afternoon commenced with an inspiring address from the College’s President, Michael Lavelle-Jones. The breadth and depth of research presented was compelling.

The prize winners SCHOOL ESSAY COMPETITION

Scot Hawtin, winner Luke Johannson-Brown, runner-up

DFT/DCT POSTER COMPETITION

Nina Williams, winner Manal Mohammed, runner-up Aoife Natasha Swain, commended DTR Medical’s Innovation and Design Trophy was won by Emerald Storey

RCSED STUDENT ORAL COMPETITION

David Evans, winner Shaswath Ganapathi, runner-up

RCSED STUDENT POSTER COMPETITION

The symposium has enjoyed stellar success and is now firmly embedded in the Cardiff and Swansea medical and dental student academic and social calendar

IMAGES: STEVE ATHERTON AND JESSICA MERRELL, MEDICAL ILLUSTRATION, ABMUHB

Aoife Natasha Swain, commended (right)

Manal Mohammed, runner-up (right)

In particular, work developing target markers in acute kidney injury and a project designing a precision photon-beam device to assess range of joint movement had an impact on the gathered delegates.

Medic David Evans was the overall winner of the oral presentations for his work on targeted electrical stimulation of leg muscles to prevent venous stasis.

He shared success with Emerald Storey for her poster presentation on the use of an offloading knee brace in osteoarthritis. Both received an all-expensespaid ‘Golden Ticket’ to present their work at the National Audit Symposium in Edinburgh in December.

Nina Williams receives her award for winning the DFT/ DCT Poster competition

Emerald Storey, winner. She also won the DTR Medical – Innovation and Design Trophy Laura Bremner, runner-up

SMTL (WALES) GOOD SCIENCE TROPHY

Llywela Wyn Davies, winner

Emerald Storey, winner (right)

Other prizes awarded included the sixth-form students’ school essay prize, the Student Surgical Skills competition, the SMTL good science trophy and the DTR – Medical Innovation and Design Trophy.

Symposium host and organiser Steven Backhouse said: “The symposium has gone from strength to strength because of support from our sponsors, the commitment of the surgical and dental network in Wales and the enthusiasm of students to share their research with their peers.”

For video footage of the event, visit youtu.be/ K2UEqQwgz1s Dan Leopard, ENT ST3, Wrexham

www.rcsed.ac.uk | 49

TRAINEES AND STUDENTS

OUT OF AFRICA Charles Badu-Boateng reports on his elective placement at Chris Hani Baragwanath Academic Hospital in Johannesburg, South Africa

Soweto has high rates of poverty and mortality

A Charles Badu-Boateng is a finalyear medical student at King’s College London

lthough South Africa has one of the continent’s strongest economies, the average life expectancy is relatively low, at 57 years for males and 60 for females in 2011 (WHO, 2013). This has been largely attributed to the high burden of communicable diseases, especially HIV and AIDS (11% prevalence), tuberculosis (incidence of 970 per 100,000 population) and malaria. Violence and injuries from road-traffic accidents also contribute to the high mortality in the country.

I did my elective placement in emergency medicine/ trauma at Chris Hani Baragwanath Academic Hospital in Johannesburg from 24 August to 19 September 2015.

Baragwanath Hospital is on the edge of Soweto, where the prevalence of HIV is believed to be higher than the national prevalence – as high as 29.4% – with the most vulnerable age group being 18–35-year-olds, though reliable data are difficult to obtain (Soweto Research Project, 2013). HIV levels have mainly been attributed to the higher poverty rates, larger proportion of youths and the number of informal settlements in the region.

The clinical exposure in the emergency department on this placement was second to none. From the first week, I was fully immersed in clinical work, clerking

50 | Surgeons’ News | March 2016

Charles BaduBoateng sutures a wound during his elective placement

and managing numerous patients. Having overcome my initial apprehension and finding the appropriate senior guidance, I was able to build confidence in making safe clinical decisions, especially learning to escalate patient care and becoming comfortable with managing patients with common conditions such as diabetes and heart failure complicated by AIDS. This has undoubtedly given me the confidence that I can be a safe, competent and caring doctor, and motivates me to be the best I can be, regardless of circumstances and resources available.

The weekend trauma placements gave me the most challenging clinical experience to date. Having to work 28-hour shifts during busy weekends stretched me both physically and mentally, especially with many patients coming in with multiple stab injuries and gunshot wounds also being a frequent presentation.

However, the supervision was adequate enough to ensure I was never out of my depth. The prize fund also enabled me to attend an advanced trauma life support course as an observer. I was involved in all the stations, including suturing, performing chest drains, intubation and reinforcing safe and systematic assessment of patients. I also volunteered to be a patient for the assessment, and this provided an incredible insight into the patient journey, especially since several of the candidates on the course also worked at Chris Hani Baragwanath Hospital.

Orlando Towers, Soweto, Johannesburg

Finally, I was able to put the training into practice by suturing many wounds, inserting a chest drain, intubating a patient under direct supervision of senior clinicians, and assisting in exploratory laparotomies.

I certainly feel that this placement has allowed me to improve on my skill set for both the patient-centred and practical aspects of medicine.

As an award winner of the 2015 RCSEd Africa Travel Bursary, I would like to express my heartfelt gratitude to the College. The funds from the award significantly lightened the burden of undertaking my medical electives in Johannesburg. I’d also like to thank my host institution, the University of the Witwatersrand, Johannesburg, and my supervisors, Dr Patricia Saffy (head of the emergency department) and Dr Martin Mauser (specialist general surgeon).

The hospital’s busy resuscitation department

Having to work 28-hour shifts during busy weekends stretched me both physically and mentally, especially with many patients coming in with stab injuries and gunshot wounds www.rcsed.ac.uk | 51

TRAINEES AND STUDENTS

ASiT has set out plans to ensure surgery remains an attractive career option for high-quality candidates

IN GOOD SHAPE?

F

ollowing publication of the Shape of Training Steering Group (STSG) recommendations, two workstreams have been focusing on areas for possible implementation. The Academy of Medical Royal Colleges (AoMRC) and General Medical Council (GMC) have worked in conjunction on the Shape of Training Mapping Exercise, which took place in late 2015. In addition, Health Education England (HEE) has commissioned the Royal College of Surgeons of England to identify and recommend improvements to the quality of surgical training and lead a feasibility study and cost-benefit analyses of these options.

ASiT has long maintained that, in order to provide the best-quality care to patients in the UK and Ireland, it is critical that surgeons are trained to the highest standards. It is also imperative that surgery remains an attractive career choice, with opportunities for career progression and job satisfaction, to attract and retain the best candidates. Here, we discuss some of our recommendations to achieve this.

FINAL PRODUCT The final product of training in any proposed reforms should not be inferior to the current CCT holder in terms of competency, technical ability, professionalism and employability. At the end of training, an individual should be competent to practise independently as a consultant surgeon within their specialty. A shift 52 | Surgeons’ News | March 2016

away from specialisation and towards generalism is a retrograde step. While patients need surgeons competent in emergency surgery, the evidence clearly shows that specialist surgeons in high-volume centres achieve better outcomes. Training should be augmented to ensure that specialists also have sufficient general and emergency skills.

DURATION OF TRAINING If a reduction in duration of postgraduate training is to be considered, such a major change would require successfully piloted training programmes, including the shift of workload toward more dedicated training alongside a lesser commitment to service provision, or supernumerary training posts.

CORE SURGICAL TRAINING The indicative minimum time for core surgical training should be no less than two years. High-quality training experiences in critical care, anaesthetics or emergency medicine can be of benefit to core surgical trainees, when defined learning outcomes relevant to surgical practice are in place. However, time on non-surgical specialties should not exceed six months in total.

RUN-THROUGH TRAINING There are recognised advantages to run-through training, including a fixed training location and a cost saving by holding only one national selection process. However, the

Rhiannon Harries ASiT President James Glasbey ASiT Publicity Officer On behalf of the ASiT Council

It is likely that a ‘one-sizefits-all’ approach to selection and training progress will not be acceptable to all WIDER SURGICAL TEAM

benefit of an uncoupled training pathway is in providing a second ‘gateway’, thus ensuring competitiveness and allowing trainees sufficient exposure to a broader range of specialties to enable them to make more informed career choices. It is likely that a ‘one-size-fits-all’ approach to selection and training progress will not be acceptable to all.

MODULAR-BASED TRAINING There may be a benefit to the introduction of modular-based training experiences encompassing clinical activities related to subspecialty themes.

There may be scope for a dedicated block to accelerate learning in interventional procedures such as with endoscopic or radiological skills, where traditionally time allocation has been limited and indicative numbers for competency may be difficult to achieve. However, we recognise the importance of complementary exposure of outpatient clinics, elective operating and perioperative ward care in the management of elective patients. As such, we would not support the introduction of separate placement blocks of these activities.

COMPETENCY-BASED TRAINING With regards to the issue of competency-based training progression in specialty training, patients can be confident that the consultant treating them has achieved competence, rather than arriving at competence simply through serving enough time.

However, there may be potential difficulties in delivering true competency-based training programmes. Wholesale ‘buy-in’ would be required from trainers and bespoke progression may introduce difficulties in rota filling and workforce planning, particularly in light of modules still being time-based.

Allied healthcare professionals (AHPs), including, but not limited to, surgical care practitioners, advanced nurse practitioners and physicians associates, are certainly a valuable workforce in the NHS and have potential to enhance training. However, concerns remain regarding their defined role, their regulation, and if there is a costbenefit for their role within the NHS. It is essential that AHPs complement but not replace junior doctors and do not negatively impact on surgeons’ training. There is, however, a great need to increase the number of phlebotomists, pharmacy assistants and administrative staff in order to reduce the service-provision demands on foundation doctors and core trainees.

EDUCATIONAL SUPERVISORS Job plans for educational supervisors should place value on their role as trainers and allow dedicated, protected time for training purposes. Trainers should meet with their trainees on a regular basis to discuss their progress.

SIMULATION Simulation can facilitate the acquisition of technical and non-technical skills. However, the introduction of compulsory simulation training should occur only when there is evidence that it can be delivered nationally, in all surgical specialties, without regional deficits. Any provision of simulation-based training should be at no additional cost to the trainee.

POST-CCT FELLOWSHIPS AND CREDENTIALS Post-CCT fellowships should remain as additional training experience for advanced techniques or areas of practice confined to a niche subspecialist interest, and not for curriculum areas or levels of competency that are currently achieved within a surgical training programme. Credentials should not overlap with any skill or competency accredited in the existing curricula for award of a CCT. ASiT’s full recommendations are available at www.asit.org Follow us on Twitter @ASiTofficial www.rcsed.ac.uk | 53

TRAINEES AND STUDENTS

As part of the College’s student opportunities, we look at cardiothoracic placements for undergraduates at the James Cook Hospital, Middlesbrough The James Cook University Hospital is one of Europe’s most modern hospitals

OPPORTUNITY KNOCKS

C

ardiothoracic surgery is one of the smallest surgical specialties, but provides some of the most exciting and varied opportunities for surgeons. The Cardiothoracic Surgery Department at James Cook Hospital, with support from the RCSEd, gives final-year medical students at UK universities the chance to work under the supervision of Consultant Surgeon and former RCSEd Regional Surgical Adviser Jonathan Ferguson. On their placement, students spend supervised time in theatre and shadow trainees, consultants, clinicians and other professionals as they go about their day-to-day activities.

Placement Convener Jonathan Ferguson started this series of assignments to help students make career decisions. He says: “The programme has been set up to allow students interested in a career in cardiothoracic surgery to spend dedicated time immersed in the specialty. Students can qualify without significant exposure to the smaller surgical specialties. I hope this pilot programme will benefit students making major career choices in the early part of their training. If this initiative is successful, other small surgical specialties may adopt a similar approach.”

I have gained a valuable insight into the career of a cardiothoracic surgeon while improving my surgical skills and knowledge Andrew Bridgeman

54 | Surgeons’ News | March 2016

Previous students have found the time spent at James Cook Hospital immensely beneficial. Final-year medical student Shi Sum Poon from the University of Liverpool said the placement far exceeded expectations for handson experience.

He says: “From harvesting of saphenous veins to median sternotomy and thoracotomy, I was able to enhance my interpretation skills for coronary angiography, CT and radiography of the chest for cardiac and thoracic cases during preoperative assessment, and clinically oriented anatomy and physiology of the heart and lungs intraoperatively.”

Andrew Bridgeman, a final-year student at the University of Bristol, observed complex cases on a daily basis and found everyone enthusiastic to teach.

He says: “I have gained a valuable insight into the career of a cardiothoracic surgeon while improving my surgical skills and knowledge of many of the procedures they perform.”

University College London final-year medical student Ernest Chew aimed to gain theatre exposure and assist in as many operations as possible, which Mr Ferguson was glad to support.

Chew says: “Even though the learning curve was steep for the first few days, it did not quell the excitement when I walked into theatre every morning to see what was on the list. The most enjoyable moment was observing a VATS lobectomy, which I had never seen before. I was in awe at the complexity of the surgery and the intricate anatomy of the thorax.”

For more information and to apply visit www.rcsed.ac.uk or email outreach@rcsed.ac.uk

REGIONAL SURGICAL ADVISERS IN YOUR AREA

5

6

The College’s support and advice network throughout the country

13 12 7

Council Member with Responsibility for Regional Surgical Advisers 1 Roger Currie, Crosshouse Hospital, Ayrshire Director of the Advisory Network 2 Steven Backhouse, Princess of Wales Hospital, Bridgend, Wales

10

11

9 1 8

25

45

28

46

27 26

Advisory Network Group Members 3 Stuart Clark, Manchester Royal Infirmary 4 David Exon, Leicester Royal Infirmary 5 Sean Kelly, Raigmore Hospital, Inverness

40

3

SCOTLAND

44

23 22

NORTH OF SCOTLAND 5 Morag Hogg, Raigmore Hospital, Inverness 6 Aileen McKinley, Aberdeen Royal Infirmary, Aberdeen 6 Euan Munro, Aberdeen Royal Infirmary, Aberdeen

18

35 36 37

WEST OF SCOTLAND 7 Lindsey Chisholm, Royal Alexandra Hospital, Paisley 8 Jon Dearing, Ayr Hospital, Ayr 9 Simon Gibson, Crosshouse Hospital, Kilmarnock 10 Calan Mathieson, Southern General Hospital, Glasgow 9 Mary Shanks, Crosshouse Hospital, Kilmarnock

43 2

30

ENGLAND

EAST MIDLANDS 18 Sridhar Rathinam, Glenfield Hospital, Leicester KENT, SURREY & SUSSEX 19 Mike Williams, Eastbourne District General Hospital, Eastbourne LONDON 20 Cynthia-Michelle Borg, University Hospital Lewisham 21 Ziali Sivardeen, Homerton University Hospital

16

15

38

17

29

42

32

EAST OF ENGLAND 14 Vivek Chitre, James Paget University Hospital, Great Yarmouth 15 Andrew Gibbons, Peterborough City Hospital, Peterborough 16 Milind Kulkarni, Norfolk and Norwich University Hospital, Norwich 17 Vijayaranjan Santhanam, Addenbrooke’s Hospital, Cambridge

4 18

20 21

SOUTH EAST OF SCOTLAND 11 Farhat Din, Western General Hospital, Edinburgh 12 Robyn Webber, Victoria Hospital, Kirkcaldy EAST OF SCOTLAND 13 Musheer Hussain, Ninewells Hospital, Dundee

41 39

24

31

34 33

19

OXFORD 29 Richard O’Hara, Milton Keynes Hospital, Milton Keynes 30 Mike Silva, Churchill Hospital, Oxford SOUTH WEST PENINSULA 31 Simeon Brundell, Derriford Hospital, Plymouth 32 Neil Smart, Royal Devon & Exeter Foundation Trust, Exeter WESSEX 33 Anthony Evans, Portsmouth Hospital, Portsmouth 34 Arjun Takhar, University Hospital of Southampton NHS Trust WEST MIDLANDS 35 Ishan Bhoora, Cannock Chase Hospital, Staffordshire 36 Pradeep Kumar, Queens Hospital, Staffordshire 37 Ramanan Vadivelu, Royal Wolverhampton Hospital NHS Trust 38 Ling Wong, University Hospital Coventry and Warwickshire, Coventry

MERSEY 22 Janardhan Rao, Countess of Chester Hospital, Chester 23 John Taylor, University Hospital Aintree, Liverpool

YORKSHIRE & HUMBER 39 David O’Regan, Leeds General Infirmary, Leeds 40 Mark Peter, Scarborough General Hospital, Scarborough 41 Mark Steward, Bradford City Hospital, Bradford

NORTH WESTERN 24 Jeremy Ward, Royal Preston Hospital, Preston 24 Mike Woodruff, Royal Preston Hospital, Preston

WALES

NORTHERN 25 Paul Gallagher, Wansbeck Hospital, Northumberland 26 Barney Green, James Cook University Hospital, Middlesbrough 27 Ian Hawthorn, University Hospital of North Durham 28 Lynn Stevenson, Cumberland Infirmary, Carlisle

NORTHERN IRELAND

42 Sanjeev Agarwal, University Hospital Wales, Cardiff 43 Raymond Delicata, Nevill Hall Hospital, Abergavenny 44 Vaikuntam Srinivasan, Glan Clywd Hospital, Rhyl

45 Catherine Scally, Antrim Hospital 46 Colin Weir, Craigavon Area Hospital

www.rcsed.ac.uk | 55

14

COLLEGE INFORMATION

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

DIPLOMA CEREMONIES FRIDAY, 13 NOVEMBER 2015 EDINBURGH Honorary Fellowship Professor Terence Stephenson FRCP, London, FRCPCH, FRACP(Hon), FRCPI(Hon), FHKAP, FRCSEng(Hon), FRCGP(Hon), FRCA(Hon), FCAI(Hon), Chairman, General Medical Council Fellowship Ad Hominem Professor Andrew V Biankin FRACS FRCSGlasg, Regius Professor of Surgery and Director of the Wolfson Wohl Cancer Research Centre, University of Glasgow Professor Allan Gross FRCS(C), Professor, Division of Orthopaedic Surgery, Mount Sinai Hospital, University of Toronto and Orthopaedic Surgeon to the Toronto Blue Jays Baseball Club Dr J Colville Laird FIMC RCSEd FRCGP, Medical Director, BASICS Scotland, Chairman of the Faculty of Pre-Hospital Care, RCSEd Fellowship Without Examination Mr Ashraf H Abouharb, Consultant Neurosurgeon, Department of Neurosurgery, Royal Victoria Hospital, Belfast The Hunter Doig Medal Miss Farhat Vanessa Nasim Din, University of Manchester Diplomas of Fellowship in the Specialty of General Surgery Kirstie Ann Laughlan, University of Leicester John David Terrace, University of Edinburgh Diplomas of Fellowship in the Specialty of Neurosurgery Paul Martin Brennan, University of Cambridge Christopher James Andrew Cowie, Newcastle University Sadaquate Khan, University of Sheffield Diploma of Fellowship in the Specialty of Otolaryngology Emma Jane Stapleton, University of Edinburgh Diplomas of Fellowship in the Specialty of Trauma and Orthopaedic Surgery Sarfraz Ahmad, University of Aberdeen Mohammed-Shoaib Arshad, University of Manchester

56 | Surgeons’ News | March 2016

Kenan Dehne, University of Damascus, Syria Nirad Joshi, Shivaji University, India Basalingappa C Navadgi, Gulbarga University, India Emma Kate Reay, Newcastle University Numan Ali Shah, University of Manchester Rajkumar Thangaraj, Dr MGR Medical University, India Craig Gordon Tinning, University of Glasgow Shashidharan Viswanathan, Bangalore University, India

Fellowships of the Faculty of Surgical Trainers James Douglas Hutchison, University of Dundee Anna Mary Paisley, University of Oxford

Diploma of Membership in Ophthalmology Dina Ahmad Deyaa El-Din Mohamad El-Anwar Mohamad, Zagazig University, Egypt

Diploma of Fellowship in Dental Surgery in the Specialty of Dental Public Health Fiona Irene Catherine Margaret Watson, University of Dundee

Diploma of Membership in Otolaryngology Aaron Stephen James Ferguson, Queen’s University Belfast Intercollegiate Diplomas of Membership in Surgery in General Quratul Ain, University of the Punjab, Pakistan Robert Thomas Brady, National University of Ireland Kevin Michael Gallagher, University of Edinburgh Peter Douglas Hutchison, University of Manchester Nada Esam Yagoub Ibrahim, University of Khartoum, Sudan Razaz Mohamed Osman Karamalla, University of Khartoum, Sudan Vishal Kumar, Chhatrapati Shahu Ji Maharaj University, India Andrew Christopher Manning, University of the West Indies Christopher McDonald, University of Dundee Masood Rehman Moghul, University of London Kai Nie, University of Oxford Charlene Plumpton, University of Malta Stephen Eric Reaney, Queen’s University Belfast Siddharth Ramesh Shah, Maharashtra University of Health Sciences, India Claire Alyss Spolton-Dean, University of Hull and University of York Francesca Chun Sau Th’ng, University of Edinburgh Lucie J Wright, University of Edinburgh

Fellowship in Immediate Medical Care Gareth Huw Meirion Roberts, University of Birmingham Diploma in Immediate Medical Care Christopher Abbott, University of London

Diploma of Membership in Oral and Maxillofacial Surgery Albraa Badr A Alolayan, King Abdulaziz University, Saudi Arabia Diploma of Membership in Orthodontics Amr Abd El-Latif Ibrahim, Cairo University, Egypt Ahmed Solyman Ibrahim Solyman, Cairo University, Egypt Diploma of Membership in Paediatric Dentistry Yang See Chau, University of Sheffield Diplomas of Membership of the Faculty of Dental Surgery Hamzah Ahmed, University of Glasgow Jackie Erin Allen, University of Sheffield Mohamad Termizi Bin Bakar, Universiti Kebangsaan, Malaysia Kieran Francis Doyle, Queen’s University Belfast Heidi Lilian Kate Foster, University of Leeds Anitha Logeswari Gnanavel, Dr MGR Medical University, India Edward Robert Hook, University of Bristol Lucy Kate Horsfall, University of Sheffield Rachel Mary Jameson, Newcastle University Neha Kapur, University of Birmingham Anusha Koobair, University of the Witwatersrand, South Africa Lakshay Kumar, Maharashtra University of Health Sciences, India

Grace Mary Leek, University of Leeds Nicholas Neil Longridge, University of Liverpool Yomna Alaa Eldin Hassan Mahmoud, Alexandria University, Egypt Fatima Saira Sarfraz, University of Liverpool Itra Imran Sarwar, University of Health Sciences Lahore, Pakistan Yasmin Shakarchy, University of Birmingham Sarah-Jane Spiller, University of Liverpool Ruben Alexander van der Valk, University of London Lucy Ann Woodside, University of Liverpool The John Mcdonald Medal Amr Abd El-Latif Ibrahim, Cairo University, Egypt Diplomas in Orthodontic Therapy Kirsty Marie Allen, DCP School, Bristol Dental Hospital Paula Jane Brown, Central Manchester School of Dental Care Professionals Pauline Reed Brown, Edinburgh Dental Education Centre Joanne Emma Castle, DCP School, Bristol Dental Hospital Nicola May Clements, DCP School, Bristol Dental Hospital Kayleigh Ferguson, Institute of Postgraduate Dental Education, University of Central Lancashire Corrine Naomi Handford, Central Manchester School of Dental Care Professionals

Louise House, DCP School, Bristol Dental Hospital Anna Ivanova, Institute of Postgraduate Dental Education, University of Central Lancashire Jenna Alexandra Lewis, Central Manchester School of Dental Care Professionals Laura Jayne McDonnell, DCP School, Bristol Dental Hospital Donna Bridget McEvoy, Institute of Postgraduate Dental Education, University of Central Lancashire Autumn Emily Tapper, Institute of Postgraduate Dental Education, University of Central Lancashire Sarah Jane Twist, Central Manchester School of Dental Care Professionals Melanie Anne Watson, Central Manchester School of Dental Care Professionals WEDNESDAY, 13 JANUARY 2016, MYANMAR The Muthusamy Medal Aye Chan, University of Yangon, Myanmar Diploma of Membership in Ophthalmology Shwe Wah Aye, University of Yangon, Myanmar Nyein Su Aye, University of Yangon, Myanmar Aye Chan, University of Yangon, Myanmar Ni Ni Hlaing, University of Yangon, Myanmar Hline Hline, University of Yangon, Myanmar Toe Naing Htat, University of Yangon, Myanmar Aung Aung Soe Htike, University of Yangon, Myanmar Thet Zaw Htun, University of Yangon, Myanmar Arkar Kyaw, University of Yangon, Myanmar

IN MEMORY HONORARY FELLOW Robert KILPATRICK (Lord Kilpatrick of Kincraig) (FRCSEd Hon 1996) SURGICAL FELLOWS Subhabrata Roy CHOUDHURY (FRCSEd 1966) Aaron Isaac GOODMAN (FRCSEd 1947) William Moncrieff HAINING (FRCSEd 1962) Robert James Terry JARVIS (FRCSEd 2001) John Phillimore MITCHELL (FRCSEd 1948 CBE) DENTAL FELLOW John Chambers SOUTHAM (FDS RCSEd 1981)

Moe Aye Latt, University of Yangon, Myanmar Naing Lin, University of Mandalay, Myanmar Khin Than Mu, University of Mandalay, Myanmar Si Si Myat, University of Yangon, Myanmar Zin Mar Myint, University of Yangon, Myanmar Kyawt Kyawt Naing, University of Yangon, Myanmar

www.rcsed.ac.uk | 57

COLLEGE INFORMATION

Hla Myat New, University of Mandalay, Myanmar Khine Nweni, University of Yangon, Myanmar Saw Sandar Nyunt, University of Yangon, Myanmar Nay Lin Oo, University of Yangon, Myanmar Yin Kyi Oo, University of Yangon, Myanmar Hlaing May Than, University of Yangon, Myanmar Su Myat Thaw, University of Yangon, Myanmar Yu Yu Thein, University of Yangon, Myanmar Thi Thi Tin, University of Mandalay, Myanmar Pwint Phyu Win, University of Yangon, Myanmar Soe Soe Win, University of Yangon, Myanmar Theingi Win, University of Yangon, Myanmar Wai Nwe Win, University of Yangon, Myanmar Soe Wai Yan, University of Yangon, Myanmar Diplomas of Membership in Surgery in General Nay Myo Aung, University of Yangon, Myanmar Nyi Htet Aung, University of Yangon, Myanmar Theingi Aung, University of Mandalay, Myanmar Yan Myo Aung, Defence Services Medical Academy, Myanmar Zay Yar Aung, University of Yangon, Myanmar Zwe Mon Aung, University of Yangon, Myanmar Thida Hlaing, University of Mandalay, Myanmar Moe Thein Htike, University of Yangon, Myanmar Kyaw Htook, Defence Services Medical Academy, Myanmar Thurein Htun, Defence Services Medical Academy, Myanmar Linn Htut, University of Yangon, Myanmar Yin Yin Htwe, University of Yangon, Myanmar Thazin Khaing, University of Yangon, Myanmar Aung Khant, University of Yangon, Myanmar Phoo Pwint Khine, University of Yangon, Myanmar La Min Ko Ko, University of Mandalay, Myanmar Ei Ei Kyaw, University of Yangon, Myanmar Pyae Pa Pa Kyaw, University of Yangon, Myanmar Shwe Pyi Kyaw, University of Yangon, Myanmar Thein Soe Lin, University of Mandalay, Myanmar Htin Zan Linn, University of Yangon, Myanmar Hnin Ei Maung, University of Yangon, Myanmar Lei Yu Mon, University of Yangon, Myanmar Thet Su Mon, University of Yangon, Myanmar Kaung Myat, Defence Services Medical Academy, Myanmar Zaw Myint, University of Yangon, Myanmar Hla Myo, University of Yangon, Myanmar Aung Myo, University of Mandalay, Myanmar Ye Naing, University of Yangon, Myanmar Thein Naing, University of Mandalay, Myanmar Nang Khin Lay Naung, University of Medicine Magway, Myanmar Maung Maung Nyein Tun, University of Mandalay, Myanmar Min Lwin Oo, University of Yangon, Myanmar Nay Lin Oo, University of Mandalay, Myanmar Aung Thet Oo, University of Mandalay, Myanmar

58 | Surgeons’ News | March 2016

DIARY

The latest surgical and dental events, seminars and courses

FEBRUARY 2016 25 26 26–27 27

NOTSS (Non-Technical Skills for Surgeons) Surgical Simulation: Finding the way forward in Scotland Foundation of Surgical Gastroenterology Course (Birmingham) Surgical Anatomy of the Trunk Course (St Andrews)

MARCH 2016 1 3–4 7&8 7&9 11 12 16 16–18 17–18 19 19–20 19–22 21–23 13 March–1 April

Preparation for Diploma in Implant Dentistry (Dubai) Higher Surgical Skills Course Basic Surgical Skills Course (Birmingham) Advanced Trauma & Life Support (ATLS) Future Surgeons: Key Skills 20th Annual Conference for Dental Care Professionals Training the Trainers: Future Essentials (Wolverhampton) Care of the Critically Ill Surgical Patient (CCrISP) Training the Trainers (Wolverhampton) Surgical Anatomy of the Limbs: One-day Practical Review (St Andrews) Basic Surgical Skills Course (Manchester) Scottish Surgical Bootcamp (Inverness) The Edinburgh Hand Course Basic Surgical Skills Course

APRIL 2016 2&3 6 7&8 9 & 10 15 14–16 15 17 & 18 18–19 20 & 21 25 & 26 29

The Edinburgh MRCS OSCE Preparation Course (Manchester) Basic Surgical Skills Course (Manchester) Anatomy for MRCS OSCE The Edinburgh MRCS OSCE Preparation Course RCSEd Audit Symposium 2016 A Preparation Course for the FRCS EXIT Examination Course in General Surgery (Chennai) Core Skills in Vascular Surgery Mock MRCS OSCE Exam Course (Aberdeen) Advanced Techniques in Endoscopic Nasal and Sinus Surgery The Edinburgh MRCS OSCE Preparation Course (Delhi) Complete Ear Surgery Course Plastering Techniques for Fracture Treatment

MAY 2016 4–6 9 12 & 13 14 15 24–26 25 & 26

Core Skills in Orthopaedic Surgery Basic Skills in Paediatric Surgery Basic Surgical Skills Course Future Surgeons: Key Skills (Manchester) Future Surgeons: Key Skills (Manchester) Surgical Approaches to the Spine Critical Appraisal for ISFE

For further information, please email education@rcsed.ac.uk or telephone +44 (0)131 527 1600. All events are in Edinburgh unless otherwise stated.

Kyaing Htun Oo, University of Yangon, Myanmar Win Min Paing, University of Yangon, Myanmar Phyo Win Pe, University of Yangon, Myanmar Aye Min San, University of Yangon, Myanmar K Khaing Saw Lwin, University of Yangon, Myanmar Thiri Khine Sint, University of Yangon, Myanmar May Myat Soe, University of Yangon, Myanmar

Yi Yi Cho Thein, University of Yangon, Myanmar Cho Naing Tun, University of Yangon, Myanmar Aung Kyaw Wai, University of Yangon, Myanmar Yan Naing Win, University of Yangon, Myanmar Myitzu Win, University of Yangon, Myanmar Nandar Win, University of Mandalay, Myanmar Khin Pyae Won, University of Yangon, Myanmar Tin Myo Zaw, University of Yangon, Myanmar

HOST YOUR EVENTS AT THE STUNNING PRINCE PHILIP BUILDING

For further information, please contact our events team on events@surgeonshall.com or 0131 527 3434 www.surgeonshall.com

The College’s commercial enterprises team specialises in making the most of the institution’s impressive buildings, with all the profits being invested back into running the organisation.

The College is best known for its magnificent Playfair Building, which dates back to 1832. Other venues include the modern Quincentenary Hall and the neighbouring King Khalid Building.

Now open for business is the Prince Philip Building, the College’s £1.5 million revamp of a former Edinburgh University Language School building, which transformed it into three floors of event space for hosting everything from birthday parties and weddings to medical conferences.

Scott Mitchell, commercial director, says:

“The Prince Philip Building, tucked away on a quiet side street, has been transformed.

While the frontage on Hill Place has been enhanced, the real changes are on the inside, and we expect this to become one of the best-known venues in Edinburgh.

“The new event space is accessed from our famous pillared entrance opposite the Festival Theatre, through our private gardens into a lobby area with cloakroom.

“Inside, we have three floors of purpose-built space to suit everything from exhibitions and ceilidhs to small-scale boardroom meetings or a theatre-style auditorium for up to 160 people.

“It is a hugely versatile space and sits perfectly between our other venues – the historic grandeur of the Playfair Hall and the glass and chrome modernism of our Quincentenary conference hall.”

This is your new event space, so please consider the Prince Philip Building for any events you are planning..

COLLEGE INFORMATION

All the latest grants, fellowships and bursaries from the RCSEd

AWARDS & GRANTS 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 research institutes in the UK and Ireland. Proposals for work on research projects in any branch of surgery are eligible for consideration.

Closing date for applications is Wednesday 23 March 2016.

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 Wednesday 27 April 2016.

Small Research Grant

The College’s Research Strategy highlights the following areas of research as priorities for the College to support.

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.

Applications for grants of up to £10,000 are invited from surgical trainees and recently appointed consultants who are Fellows/Members of the College in good standing.

Grants are awarded for pump priming projects for a period of one year only.

Please note that requests for running costs to support established projects will be less favourably reviewed than those for pilot work that has the potential to facilitate applications for more substantial funding in the future.

Research project submissions should satisfy one or more of the College’s

four priority areas for research, as listed above. The application should also include a well-defined exit strategy (i.e. how the project will be taken forward).

Closing date for receipt of applications is Wednesday 15 June 2016.

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. Applicants must be Fellows/Members of the College in good standing.

The closing date for applications is Wednesday 15 June 2016.

Travelling Fellowships

The Cutner Travelling Fellowship in Orthopaedics The John Steyn Travelling Fellowship in Urology

Medical Student Elective Travel Bursaries

The 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 Ireland who are affiliates of RCSEd and who are undertaking approved surgical electives overseas.

Closing date for applications is Wednesday 27 April 2016.

60 | Surgeons’ News | March 2016

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.

Sir James Fraser Travelling Fellowship in General Surgery.

The closing date for receipt of applications is Wednesday 15 June 2016.

Syme Medal

The Syme Medal is a prestigious mark of excellence awarded by the College to a Fellow or Member of the College in good standing, on the basis of a recently submitted thesis (MD or PhD), published body of research or educational development. Research should have been published in high-quality peer-reviewed journals. Consideration will be given to the impact of work on future research or clinical practice.

The Syme Medal is to be awarded to surgeons in training or recently appointed consultants and is distinct from the King James IV Professorship.

With their written application, candidates must submit a curriculum vitae (no more than two pages) along with a discourse, of up to 1,500 words (excluding references, prior publications and papers in press), summarising their recent research or educational development. The essay must refer to and contain findings emanating 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 publication in the Journal of the Royal College of Surgeons of Edinburgh and Ireland. Depending on the nature of the work and the topic, the successful candidate may be invited to present a lecture at the College.

Closing date for applications is Wednesday 15 June 2016.

Joint RCSEd/SOMS/Shanghai Head & Neck Fellowship 2015

Applications are invited from Members/Fellows of the RSCEd and the Scottish Oral and Maxillofacial Society (SOMS) for a four- to six-week Fellowship in the Head and Neck Oncology Training Centre in the Department of Oral and Maxillofacial – Head and Neck Oncology, Ninth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine.

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

Application is by letter and CV (no more than four pages), along with two current references, which should be

sent to Mrs Cathy McCartney at c.mccartney@rcsed.ac.uk. Applicants for the Fellowship may be invited to interview if required. Further information can be obtained from Mr Roger Currie at r.currie@rcsed.ac.uk Closing date for applications is Wednesday 29 June 2016.

Wong Choon Hee Medical Student Elective Travel Bursary

The RCSEd, in association with Meducatus (www.meducatus.com), is pleased to offer medical students an opportunity to apply for financial support towards their elective in surgery.

This award is open to medical students in the UK and the Republic of Ireland undertaking approved surgical electives abroad.

This award is advertised and awarded annually in September. It provides the successful applicant with a contribution towards the overall costs of travel and subsistence.

For further information, please contact Mrs Cathy McCartney, or download the guidance notes and application from the Awards and Grants page at www.rcsed.ac.uk.

Closing date for applications is Wednesday 6 July 2016.

www.rcsed.ac.uk | 61

OUT OF HOURS

Culinary ramblings Graham Layer’s guide to gourmet delights, from Ho Chi Minh City to Chicago

T

he Colony is a new opening in London’s Mayfair within the Beaumont Hotel. Essentially an oldfashioned classic club room, rather too dark for comfort, with effortless formality from smartly dressed waiters serving high-end comfort food mainly emanating from the British 20th century with a tinge of Western Europe and the US. Curious aromas of leather and brass mixed with crustacea, eggs Benedict, rib of beef and pasta stimulate the olfactory senses. Four of us took Sunday brunch. The omelette Arnold Bennett was fluffy, rich and delicious, but possibly overwhelming as a first course. Duck egg corned beef hash was full of flavour, but could have done with more of the corned and less of the hash. Steak tartare perfect. Main courses included a good lobster roll, excellent creamed sweetcorn to accompany, and a lobster Caesar. For dessert, diners can choose the make-up of their ice cream sundae, and the trifle and banana split scored well. The atmosphere was comfortable, but the overall bill was not inexpensive.

Ho Chi Minh City, Vietnam, is a world away, although the Park Hyatt Hotel very much tries not to be. It is an oasis in the busy city and its restaurants are impressive.

The Vietnamese food served in Square One is authentic (as you would expect), but each plate comes buried in a bush 62 | Surgeons’ News | March 2016

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

of indigestible mint leaves, which I for one can do without.

The Temple Club quite close by is a first-floor classic. Very Old Vietnam with a contemporary twist. Then Eon, the Heli Bar on the 51st floor of the new Bitexco Financial Tower, which serves great tempura prawns and spring rolls with a cool beer. Somewhere in between is Xu, serving pared-down Vietnamese dishes with lemongrass appearing everywhere.

Dessert with dry ice was a novelty I could have lived without.

Chicago is a perennial favourite, made all the more enticing by RL Restaurant, which produced fabulous veal chops and steak Diane flambéed in classic fashion.

The service was wonderful once the table was eventually available an hour or so late, but they courteously offered complimentary bellinis and wine as recompense without even being asked. Impressive. The Park Hyatt Hotel has a fabulous bar that serves the most wonderful dissolving wagyu burgers and sweet potato fries. A great fish lunch can be had in Chicago at Joe’s, hiding behind the Nordstrom store on the Magnificent Mile. Melt-in-the-mouth shrimp stuffed with crab, tempura and even fish in Mexican-style nachos after very good clam chowder and a good choice of wines. When in Chicago, you must eat pizza. The place to have pizza is Gino’s East. For $34 for four, you get a deep-pan pizza of immense proportions. The Meaty Legend

PEDELECS

Sample the famous Wiener Schnitzel at Berlin’s ancient Lutter & Wegner

contains sausage, bacon, ham, pepperoni and some other muscular morsels embedded in cheese on a base that took nearly an hour to prepare. It was worth the wait.

Dan Ryan’s Chicago Grill is a mid-range steak and burger establishment in Hong Kong – very good value, but a little chaotic. Beggars’ chicken served in the Peking Garden nearby is a sight to behold: a whole bird in lotus leaves cooked for hours within a foil and terracotta casing and then smashed open Peking style with a brass hammer. All very different but entertaining experiences.

Berlin before Christmas is magical. Close to Friedrichstrasse is Lutter & Wegner, which serves the famous Wiener Schnitzel with fried potatoes and onions.

Delicious but too large and too dry, so I recommend taking it with a Caesar salad topped off with chargrilled prawns for a sumptuous lunch. By contrast, an Advent Champagne Sunday Brunch at the Hotel Adlon’s Restaurant Quarré, just to the west of this Gendarmenmarkt area, with a view of the Brandenburg Gate, hosts a magnificent and luxurious buffet banquet. It commences with multicoloured caviar, oysters and cold half lobsters, let alone the charcuterie, other cold fish, salads and soup. All washed down with limitless Moet champagne served from gold magnums. Roast beef fillet and sirloin or duck followed. Booking in advance is essential and, although expensive, it is superb value. At the other end of the spectrum, but still in the old city, is a small French restaurant, Nord Sud, which is extraordinarily good value at less than 10 for three courses with three set menus. And it is very French, quirky and distinctive.

Back to Scotland. In Edinburgh’s Old Town, I tried out Divino Enoteca, a perfectly respectable although unexciting classic Italian institution. I must again mention Wedgwood, which I booked for the multi-course tasting menu for an evening before the Military Tattoo. Each course good, but not excellent, and the whole performance of so many courses takes forever. The Outsider on George IV Bridge (above Divino) has come up in my expectations: the chef is ex-Wedgwood and the straightforward mid-market European food entirely reasonable – this time made very special by having the upstairs window table overlooking the Castle Esplanade and the fabulous fireworks. Do not forget Café 1505 at the entrance to the College campus on Nicolson Street. Salads and hot lunches, coffees and desserts – a really good stop for a light meal and charming staff serving delicious food with a healthy angle.

Golden wines Bernard Ferrie uncorks some tantalising tipples

A

s we pass 50 wine columns, special bottles savoured and noted over the years. Beware Manchester wine bars and the silver-tongued David Tolley! However, still no Blue Nun or Mateus Rose.

Talking of Portugal – Luis Pato Vinha Pan 2005 (£33.99, Worth Bros) dark, inky and rich; nicely aged. Dense, dark red currants. 100% Baga grape… a special one with pepper, spice, mocha coffee, raisin, mulberry, etc.

Viña Tondonia Reserva 1998 (£30, BBR) – a truly goldenwhite Rioja. Complex, juicy, full-flavoured, 90% Viura and 10% Malvasia. Try cod poached in olive oil or a La Riojana to accompany this outstanding bottle.

Eon offers good food and fine views of Ho Chi Minh City

Bollinger Special Cuvée Brut (£40, widely available), a full-bodied prince among Champagnes. Bolly slips easily off and over the tongue, whether it’s Patsy or 007 ordering.

Biscuity, bubbly class.

English sparkling wine? Renishaw Hall Seyval Blanc 2012 (£22.99, Waitrose) from the former Derbyshire home of the Sitwells. One of the most northerly bottles ever sampled. Bubbling, bottled poetry.

New Zealand – a constant source of fine wines. One for the road? Two actually. Felton Road Bannockburn Chardonnay 2013 (£30, BBR), another one to convert the ABCs. Pinot Noir 2013 (£30, BBR ) from some of the most southerly vineyards on the planet. Stylish, absorbing, exuberant when young; savoury and earthy on the palate. Should open up further in the next few years.

Habitual sticky end. Elysium – abode of the blessed – drink this and you will feel blessed and at home. Elysium California Black Muscat Quady 2013 (£11.50 half bottle, Connolly’s). Rose and lychee aromas. Paradise.

www.rcsed.ac.uk | 63

FROM THE COLLECTIONS

THE REMAINS OF BATTLE

A skull recovered from Culloden gives a fascinating insight into the pivotal conflict

“E

ven at this distance of time it may be seen that the ball entered in front and came out behind.

This skull was found on that part of the field of Culloden, when the Highlanders, wrapping their Plaids about their left arms, and stooping low, made their attack on the King’s Troops.”

The above text is taken from the original catalogue as written by Charles Bell himself, and refers to a remarkable specimen on display in the museum. It is the skull of a Highlander killed at the Battle of Culloden, by a Hanoverian musket ball. The clearly defined entry and exit holes show just how fast the musket ball was travelling, probably fired from a range of about 45 metres.

The Battle of Culloden took place on 16 April 1746.

Despite lasting for less than an hour, the conflict changed the course of Scottish history as it signified the end of Bonnie Prince Charlie’s bid for the British crown and the demise of clan culture. It was also the last large-scale battle to take place on British soil.

I was contacted in December by Derek Alexander, Head of Archaeological Services for National Trust for Scotland (NTS), with a view to making a 3D plastic model of the said skull to use in the Trust’s 270 year commemorative exhibition at its fantastic visitor centre in April.

Although it was not news to us that the skull was from Culloden, Derek excitedly informed us that it is the only known human remains ever recovered from the battlefield. Burial sites have remained undisturbed out of respect for the dead.

Using just a digital SLR, Stefan Sagrott took more than 140 photographs of the skull from all angles.

These images will be processed by computer software to create a highly detailed 3D model and then output on a 3D printer to produce an exact replica of the skull.

We plan to print our own copy, too, for handling sessions so that visitors to the Museums can see this unique specimen close up, and get some sense of this short but pivotal conflict.

Rohan Almond Assistant Curator, Surgeons’ Hall Museums

64 | Surgeons’ News | March 2016

The National Trust for Scotland is using a series of photographs to create a 3D model of the skull

The clearly defined entry and exit holes on the skull show just how fast the musket ball was travelling, probably fired from a range of about 45 metres

POSTGRADUATE TRAINING COURSES

Open since 1992, the Cuschieri Skills Centre continues to deliver high quality, relevant procedure-based skills courses to local, national and international medical personnel of all levels.

An enhanced, custom-built facility including interventional human anatomy, virtual reality simulations, microsurgery and a state of the art simulated operating environment combine to form one of the most innovative research and training facilities in Europe.

STAY UPDATED Visit our new website – www.cuschieri.dundee.ac.uk

Course programme includes: • GENERAL SURGERY

• GENERAL PRACTICE

• ORTHOPAEDICS

• ANAESTHESTICS

• ENT

• UROLOGY

• GYNAECOLOGY

• INTERVENTIONAL RADIOLOGY

• GASTROENTEROLOGY

• THIEL EMBALMED CADAVERS

Visit our website for course information and to register for courses – www.cuschieri.dundee.ac.uk To stay up to date with the latest course developments and news follow us on Twitter @CuschieriSkills and join us on Facebook

Cuschieri Skills Centre

Cuschieri Skills Centre, University of Dundee Level 5, Ninewells Hospital, DUNDEE, DD1 9SY Phone: +44(0)1382 383400 Fax: +44(0)1382 646042 Email: cscbookings@dundee.ac.uk Web: www.cuschieri.dundee.ac.uk

Special offer For the readers of Surgeons’ News and SN Global...

20% discount on ALL tfm’s medical books Order online at www.tfmpublishing.com and enter promotional code SOSN15

New release... ISBN: 978 1 910079 11 9 • Softback 772pp • GBP £60; USD $99; EUR ∈90

Schein’s Common Sense Emergency Abdominal Surgery, 4th ed M Schein MD FACS, PN Rogers MBChB MBA MD FRCS, A Leppäniemi MD, D Rosin MD, Jonathan E. Efron MD FACS FASCRS

This new edition builds on the reputation of the three previous editions. Already a worldwide benchmark, translated into half a dozen languages, this book guides surgeons logically through the minefields of assessment and management of acute surgical abdominal conditions. General surgery as a concept may have been overtaken in many parts of the world by the development of niche specialties, but the need for a cohort of generalists able to deal competently with common surgical emergencies has not gone away. Young surgeons and experienced practitioners alike will benefit from the distilled wisdom contained in these pages. The direct, no‐nonsense writing style gives clear guidance while at the same time providing amusing insights into our collective surgical psyche. Some new editors and authors enhance the new edition. Almost all chapters have been revised to take account of new concepts and modern developments. New chapters have been added and some completely rewritten often with a new emphasis on the importance of a laparoscopic approach. This is NOT a standard textbook. Read it! You’ll not regret it.

Since Mondor’s times in the forties of the last century there was no other book in surgery to be written so easy and witty…

Boris D. Savchuk, World Journal of Surgery

In the same series... ISBN: 978 1 903378 93 9 • Softback 558pp • GBP £60; USD $99; EUR ∈90

Schein’s Common Sense Prevention and Management of Surgical Complications M Schein MD FACS, PN Rogers MBChB MBA MD FRCS, A Leppäniemi MD, D Rosin MD The enthusiastic feedback received from readers of the international bestseller, Schein's Common Sense Emergency Abdominal Surgery, 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

A perfect gift… ISBN: 978 1 910079 34 8 • Softback 160pp • GBP £12.99; USD $19.99; EUR ∈17.99

The Little Book of Surgical Cartoons EE Perelygin MD, M Schein MD FACS Evgeniy Perelygin — a surgeon who is known to his friends as Perya — has managed to capture the funny, the amusing, and the ridiculous aspects of what surgeons do and think. Yes, surgeons take their profession very seriously and their patients even more so. But, what is true in any aspect of human life is also true for surgery — there is always something to laugh about, or even ridicule. And this includes, above all, surgeons themselves! In each of these cartoons lurks the kernel of a basic surgical truth. This truth has been blown up, distorted, and exaggerated, but remains at the heart of the picture. Each picture has a legend describing the situation, which is followed by an aphorism, quote, or comment. This book is essentially for surgical eyes — they are all cutting edge, and will have the reader in stitches.

So stop taking yourself so seriously, do not be afraid to laugh or make others laugh. If anyone does not appreciate your humor, he/she can kiss your ass! A life without a sense of humor has no sense at all. Moshe Schein Kindly note the following postage charges: UK & N. Ireland — free P&P for orders of £60 or more (before discount) Rest of the World — a 20% postage charge applies to all orders Castle Hill Barns, Harley, Shrewsbury, Shropshire, SY5 6LX, UK T: +44 (0)1952 510061 F: +44 (0)1952 510192 E: info@tfmpublishing.com W: www.tfmpublishing.com Company no 3301765. Vat Registration no 664 4998 78. Registered address: Suite 2B, Cheviot House, 41 Bath Road, Swindon, Wiltshire, SN1 4AS, UK