Surgeonsnews
RESEARCH REVIEW
PUSHING THE BOUNDARIES
Supporting research from junior trainees to career academics
TRAINEES AND STUDENTS
ROCK AROUND THE CLOCK
Making it easier to manage Less Than Full-time Training
ANNUAL REPORT
THE COLLEGE’S YEAR EXAMINED
The verdict on 2014 from the Trustees, Chief Executive and Treasurer
Surgeonsnews September 2014
The magazine of The Royal College of Surgeons of Edinburgh
SEPTEMBER 2014 • VOLUME 13 • ISSUE 3
SURGICAL SPIRIT The programmes that are improving healthcare across the globe
PLUS
RCSEd pushes for quality over quantity in WTR and training debate www.surgeonsnews.com
surgeons_news_colour_page_out 13/11/2013 13:58 Page 2
outstanding
quality everytime first time All medical devices are CE marked in accordance with the Medical Device Directive (93/42/EEC)
For more information on the complete range of surgical blades, handles, scalpels, disposable, fine and retractable scalpels please go to our website.
The world’s leading surgeons and healthcare professionals can always rely on the consistent quality, precision and performance of surgical blades, handles and scalpels from Swann-Morton. Our extensive range includes over 70 blade shapes and a selection of 27 handles. Used in various disciplines for both general and specialist surgery, all our products are subject to the strictest quality control procedures and are guaranteed never to let you down.
Where only Swann-Morton will do. Owlerton Green, Sheffield S6 2BJ Telephone: 0114 2344231, Sales: 0114 2344223, Fax: 0114 2314966 uksales@swann-morton.com, exportsales@swann-morton.com ‘Swann-Morton’ and the ‘Ring Pattern Logo’ are the registered trade marks of Swann-Morton Limited and related companies.
www.swann-morton.com
WELCOME
FROM THE EDITOR John Duncan introduces the September edition
A
ccess to basic healthcare is taken for granted in the ‘developed’ world. We can legitimately debate the methods of organisation and funding of that care, but not its existence. For two billion of the world’s population that basic care does not exist. As surgeons, we all know the impact of basic procedures to prevent premature death or disability. Basic fracture care, the drainage of sepsis, caesarian section, the repair of a hernia or the basic management of cleft foot can all be provided at low cost and make a remarkable difference to health and prosperity in the ‘developing’ world. This edition of Surgeons’ News showcases the initiative to make the provision of essential surgery one of the World Health Organization (WHO) and United Nations’ post-2015 development goals. Just as the control of infectious disease has improved global health and life expectancy, so the provision of basic surgical care can transform lives. Alongside this, we highlight other aspects of how surgery can contribute to the humanitarian agenda. Circumcision has been shown to reduce HIV infection rates. Also in our feature section, one of our Fellows, Mr Tim Hargreave, talks to Mark Baillie about the work of the WHO to prevent 3.5 million HIV infections by carrying out 20 million adult male circumcisions in Africa.
The College has run basic surgical skills courses all over the world. Since 2010, working with, among others, the United Nations Relief and Works Agency, we have supported courses in East Jerusalem to improve surgical training in Palestine. This is another aspect of our contribution to humanitarian organisations that support improvements in surgical care. When we asked Médecins Sans Frontières for an article about their work, it was a surprise to me to find it written by a good friend. Jonathan Pye is a general surgeon from North Wales who was the Secretary of ASGBI. He writes about his time with MSF in the Central African Republic. Closer to home, the College recently voiced concern about calls to allow trainees to opt out of the European Working Time Directive. The President discusses this in his regular column and we carry a feature with responses from our Trainees’ Committee and Faculty of Surgical Trainers on page 8. Producing an annual report is an important exercise that enables us to reflect on the life of the College and to inform Members and Fellows of our activities. The report forms a significant part of the September edition of Surgeons’ News each year. Also published this month is the College Research Report documenting how we have supported our Members and Fellows in delivering high-quality surgically related research. John Duncan editor@surgeonsnews.com
This edition of Surgeons’ News showcases the initiative to make the provision of essential surgery one of the World Health Organization and United Nations’ post-2015 development goals www.rcsed.ac.uk | 1
34
Surgeonsnews
RESEARCH REVIEW
PUSHING THE BOUNDARIES
Supporting research from junior trainees to career academics
TRAINEES AND STUDENTS
ROCK AROUND THE CLOCK
Making it easier to manage Less Than Full-time Training
26
ANNUAL REPORT
THE COLLEGE’S YEAR EXAMINED
The verdict on 2014 from the Trustees, Chief Executive and Treasurer
Surgeons Surgeonsnews September 2014
The magazine of The Royal College of Surgeons of Edinburgh
SEPTEMBER 2014 • VOLUME 13 • ISSUE 3
SURGICAL SPIRIT The programmes that are improving healthcare across the globe
PLUS
RCSEd pushes for quality over quantity in WTR and training debate www.surgeonsnews.com 00 FC SN Sep14 Cover with Spine.indd 1
12/08/2014 11:54
EDITOR John Duncan DEPUTY EDITOR Robyn Webber EDITORIAL BOARD Richard McGregor Peter Lamb Peter Douglas Sarah Allen Chris Henry Dr Yvonne Hurst Aoife O’Sullivan Mark Baillie FOR ADVERTISING ENQUIRIES Tom Grant Barker Brooks Communications Tom.Grant@barkerbrooks.co.uk Tel: +44 (0)844 858 2890 PUBLISHED BY The Royal College of Surgeons of Edinburgh, Nicolson Street, Edinburgh EH8 9DW Registered Charity No. SC005317 contributions@surgeonsnews.com Tel: +44 (0)131 527 1600 For editorial enquiries contact Mark Baillie: Tel: +44 (0)131 527 3405 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, Katherine Pentney, Alistair McGown SUB EDITORS Sam Bartlett, Kirsty Fortune MEDICAL SUB EDITOR Arshad Makhdum GROUP ACCOUNT DIRECTOR John Innes john.innes@thinkpublishing.co.uk PRINTED BY Acorn Web Offset Ltd, Yorkshire, UK ISSN 1750-7995 The views expressed in Surgeons’ News are not necessarily those of the editorial team or the Royal College of Surgeons of Edinburgh. Information printed in this edition of Surgeons’ News is believed to be correct at the time of going to press.
2 | Surgeons’ News | September 2014
Contents
September 2014
04
GENDA A News and views from the College and the profession
18
THE PRESIDENT WRITES Ian Ritchie on opting out of the Working Time Directive
20
ESSENTIAL SURGERY The ICES campaign to provide universal basic surgical care
22
I NTERVIEW Mr Tim Hargreave on the HIV prevention drive in Africa
20
26
36 40
30
PENMAN FELLOWSHIP Ian Finlay’s Fellowship journey in the ‘rainbow nation’ of South Africa
42
34
MÉDECINS SANS FRONTIÈRES Jonathan Pye and his experiences in the Central African Republic
48
BASIC SURGICAL SKILLS Charting the success of the RCSEd’s BSS course in Palestine
30
DENTAL SURGERY Updates from the Faculty BRIDGE2AID Parmilan Gill on bringing dental care to ‘developing’ countries
RAINEES AND STUDENTS T Getting published; Less Than Fulltime Training; skills conference
COLLEGE INFORMATION Diploma Ceremony listings plus awards and grants
52 55
OUT OF HOURS Graham Layer tickles his tastebuds
64
NNUAL REPORT 2014 A Facts and figures on the College’s performance this year
FROM THE COLLECTIONS The Neanderthaloid Skull
International Faculty already includes: Dr Patrick Tonnard, Dr Lorne Rosenfield, Dr Patrick Trevidic, Dr Foad Nahai, Dr Alain Fogli, Prof Wolfgang Gubisch, Dr Malcom Paul, Dr Raj Acquilla, Dr Raina Adami, Dr Nick Lowe
CONTENTS
Surgical & Non-Surgical Conferences Live Demonstration Theatre Non-Surgical technology and techniques in action Injectables Masterclass in association with AoAE Demos of Fillers, Toxins and Peels Allergan Medical Institute Masterclass Free to attend Live injecting by Allergan experts NEW Surgical Training Dome Interactive, hands-on learning for trainee consultants NEW Dermatology Lab The science behind skin and skincare Great Live Debate Theatre Controversy, opinions and insights aired The Business Hub Advice to improve business outcomes CPD Accredited Verifiable Content Networking Drinks The key industry social NEW Surgeons’ VIP Lunch Surgical & Non-Surgical Technology Workshops Major Scale Event 200 exhibitors and 4,000 attendees
FROM INJECTING TO RESECTING – ONE MAJOR SCALE EVENT. CCR Expo is a major scale, multidisciplinary meeting packed with CPD accredited content for surgeons and other aesthetic medicine professionals. From scalpel to syringe, CCR Expo provides a professional platform for the exchange of ideas, the pursuit of best practice and the sharing of knowledge, insight and expertise. Visit www.ccr-expo.com/surgnews2 to discover more.
REGISTER NOW AT www.ccr-expo.com
@ccr_expo #CCR2014 www.facebook.com/ccrexpo1
www.rcsed.ac.uk | 3
Agenda The latest news from the College and profession / ANNUAL REPORT
College reports on activities in 2014
T
he Royal College of Surgeons of Edinburgh has published its Annual Report for 2014 (pages 55–63), with updates on key activities and developments from the last 12 months. Highlights of the year include announcement of Heritage Lottery funding to redevelop the College’s museum and the opening of a regional centre in Birmingham – the College’s first base in England. Writing in the Trustees’ Report, RCSEd President Mr Ian Ritchie said: “The purpose of the College is to support the maintenance
of high standards in surgical practice and in surgical training. We continue to do this by delivering a suite of courses and supporting examinations, both intercollegiate and collegiate, in this country and internationally. The College’s courses are wide ranging, from generic ones such as Training the Trainers (TtT) and a programme on the delivery of Procedure-Based Assessments (PBA), down to highly specialised courses in areas of surgical practice across the whole range of the 10 surgical disciplines.” Turn to page 55 to read the full report
Points ruling sets tough challenge for UK students
4 | Surgeons’ News | September 2014
www.rcsed.ac.uk | 55
Students will now be under more pressure to publish to gain their FP application points
/ STUDENTS
Early this year, the UK Foundation Programme Office (UKFPO) announced changes to the Educational Achievements process for entry into the 2015 Foundation Programme. In its statement, it advised that “points for educational achievements will be given for qualifications and publications only, and presentations will no longer qualify for points on the FP application”. While the UKFPO states that it is almost impossible to verify each professional event within their specified criteria, the news has been met with concern by already anxious final-year
ANNUAL REPORT 2014
medical students fiercely competing for entry into the Foundation Programme, which was oversubscribed by 293 students this year. With many medical students previously looking to national conferences run by bodies
such as The Royal College of Surgeons of Edinburgh for valuable points to count towards their FP application, more students will now be aiming to have their work published. For more on this, turn to page 42.
/ EVENTS
Notice of annual general meeting The College will hold its AGM at 12.30pm on Friday 14 November 2014, in the Main Hall, Royal College of Surgeons of Edinburgh, Nicolson Street, Edinburgh, EH8 9DW. / SURVEY
Members to air their views in 2014 survey Later this year, RCSEd Fellows, Members and Affiliates will get a chance to give the College their views on a range of issues, from the services offered by RCSEd to major professional issues in surgery. The College last carried out a major survey of its membership in 2010, following which the College has expanded its RSA network, developed its communications and opened a regional centre in Birmingham. The survey can be completed online, although paper copies will also be available. The College strives to provide an excellent service and to work to promote the highest standards in surgery and patient safety on behalf of its members. As such, RCSEd would urge all Fellows, Members and Affiliates to take the time to provide their views, which will help guide the College in its future activities. Look out for the membership survey later this year.
/ AWARDS
Hunter Doig Medal goes to ‘excellent mentor’ In July, Dr Jennifer Robson was awarded the College’s Hunter Doig Medal in recognition of her work in inspiring and motivating female undergraduates and trainees to pursue a career in surgery. Dr Robson is currently clinical lecturer at the University of Edinburgh and honorary
specialty registrar in vascular surgery at the Royal Infirmary of Edinburgh. Explaining more about her nomination to receive the College’s Hunter Doig Medal, RCSEd Council Member and regius professor of clinical surgery at the University of Edinburgh Professor James Garden said: “Dr Robson is an excellent role model and mentor to undergraduates, current trainees in surgery and, specifically, those women who wish to pursue a career in surgery. It is a pleasure to honour her achievements with the Hunter Doig Medal.” Dr Robson said: “As a trainee, it has been very interesting and a great privilege to be involved from the outset in the development of Edinburgh Surgical Sciences Qualification and the other distance-learning initiatives run by the RCSEd and the University of Edinburgh. “I feel honoured to have been awarded the Hunter Doig Medal. It is encouraging to see that the College recognises and acknowledges the contributions of its junior Members as well as its more accomplished and well-established Fellows.”
/ PROFESSIONAL OPPORTUNITIES
Recruitment drive for otolaryngology SSG The College’s Surgical Specialty Group (SSG) in otolaryngology is recruiting new members to take office in 2014. SSGs of the College provide specialty-specific conduits for advice and information between Fellows, College Council and the various specialty organisations. If you are a proactive, clinically and politically aware RCSEd Fellow, this is an excellent opportunity to serve your College and your specialty. Ideally, you should be able to commit to two meetings each year, be a good team worker and communicator, and
have a clear vision of where you think RCSEd and otolaryngology should be going in the next few years. Members are appointed to serve a threeyear term which, in some circumstances, may be extended for a further three years. To be considered for membership of the SSG in otolaryngology, please send a letter, brief CV and the names of two referees at Alice Brown, SSG Secretariat, to a.brown@rcsed. ac.uk (0131 527 1642). The closing date for applications is Friday 24 October 2014.
/ REPORT
Key medical bodies consider Greenaway’s training proposals The RCSEd, through the Academy of Royal Medical Colleges, is working with the four UK health departments, Health Education England, COPMeD, the Medical Schools Council and others to consider the implementation of the recommendations set out in the review of postgraduate medical education and training conducted by Professor David Greenaway. A series of seminars based on topics such as interaction with employers, the primary/
secondary care interface, SAS doctors, the academic pathway and credentialing have been arranged to allow detailed consideration of key issues associated with the implementation of these recommendations. The College will be represented at these events and will be working to ensure the changes being proposed for surgical training meet the needs of trainees, patients and employers. www.shapeoftraining.co.uk
Securing the future of excellent patient care Final report of the indep endent review Led by Professor David Greenaway
www.rcsed.ac.uk | 5
AGENDA
NEWS IN BRIEF Journal impact The impact factor of the College’s peer-review journal has risen again to 2.207, ranking The Surgeon at 58 out of 200 surgical titles in the Thomson Reuters index. The journal, which is published jointly with the Royal College of Surgeons in Ireland, now holds one of the highest impact factors for a general surgical membership title.
thesurgeon.net
Retirement age
Problems associated with increasing the retirement age for healthcare professionals are to be explored at a special event. ‘Aging Practice: Implications for Healthcare Professionals and Patient Safety’ takes place on 15 October 2014, and will look at solutions and develop an action plan to present to national governments. Organised by the Academy of Medical Royal Colleges and cohosted by the RCSEd and the Royal College of Physicians of Edinburgh, the symposium is relevant to medical practitioners, healthcare staff, commissioning groups and employers, who face the risks associated with age-related medical conditions and cognitive decline.
For further information, visit www.rsced.ac.uk
Surgical crises event The RCSEd is to work with the Royal Society of Medicine and Clinical Human Factors Group to deliver a one-day event on surgical crises and so-called ‘never events’. The meeting is in Edinburgh on Tuesday 21 October and aims to illustrate how and why errors occur within the surgical team and outline key strategies to avoid mistakes. The meeting will be followed on Wednesday 22 October with the annual conference of the Faculty of Surgical Trainers. Special rates are available if booking for both events.
www.rsm.ac.uk/events/ regional-programme.aspx
6 | Surgeons’ News | September 2014
Participants showed great commitment to high-quality training programmes / COURSE
Training the Trainers inspires Indonesians
I
n May, College president Ian Ritchie and senior education adviser David Pitts delivered a two-day Training the Trainers programme to surgeons in Bandung, Indonesia. The participants, training programme directors from across Indonesia, were joined by president Professor Aryono D Pusponegoro, past president Dr Sjamsuhidajat Ronokusumo and Dr Kiki Lukman, who has since been elected as the next president of the College of Surgeons of Indonesia.
The Training the Trainers course was followed by a half-day workshop on the direct assessment of complex surgical procedures, which focused on the use and development of workplace-assessment tools. The commitment shown by the local participants to the development of highquality training programmes in a challenging setting was impressive and the organisers are grateful to B. Braun for its sponsorship and administrative support of the event.
/ CONFERENCE
Prestigious line-up to tackle assessment at annual meeting The programme has been released for this year’s Faculty of Surgical Trainers Annual Meeting, which takes place at the College’s Edinburgh campus on Wednesday 22 October 2014. Open to all in the surgical community, regardless of college affiliation, this year’s topic is ‘Who Makes the Cut? Assessment in Surgical Training’. The meeting will focus on state-of-the-art assessment of trainees, with an emphasis on current workplace-based assessments. The confirmed speakers include Professor John Norcini, Dr Steven Yule, Mr William Allum, Professor Jonathan Beard, Mr Steve Hornby, Captain
Gordon Graham, Professor Moya Kelly and Mr Humphrey Scott. Surgical director of the FST, Mr Craig McIlhenny, who is also speaking at the event, said: “We are delighted that such an excellent group of speakers will be joining us for the 2014 FST conference. Together, they bring a depth of experience and range of perspectives that will make October’s event a focal point for the debate on assessment in surgical training.” Abstract submissions (up to 300 words) are open, with a closing date of Friday 12 September 2014. See page 12 for further details.
The Christie School of Oncology Surgical Education Events Programme Education Centre, Wilmslow Road, Manchester, M20 4BX
Intensive Surgical Anatomy Course for MRCS Part B OSCE (12 Sep 2014) This intensive revision course is intended to help surgical trainees prepare for the final part of the MRCS exam. This course is an intense and pertinent revision of all subject areas tested in the MRCS exam and it Fee: £175 will consolidate the candidate’s core and applied knowledge in anatomy.
Edinburgh MRCS Preparation Course (13-14 Sep 2014) To help improve candidates’ performance in the MRCS Part B examination via practice sessions with ‘mock’ MRCS OSCE stations & discussions with examiners on the pitfalls & problems commonly encountered with the exam process. Fee: £450 (£435 / £400 / £385 for RCSEd Affiliate Members)
The Christie Robotic Pelvic Oncology Symposium (17 Sep 2014) This course will provide an overview of the major aspects of robotic pelvic oncology including the cutting edge DaVinci® robotic system. The current and future status of robotic surgery in oncology will be discussed as well as the role of team work in robotic surgery. Fee: £25 (registration fee refunded)
Basic Surgical Skills (27-28 Sep 2014, 7-8 Mar 2015) Participants are introduced to the principles underpinning the various techniques with individual tuition and under the expert supervision of consultant surgeons. Participants are assessed throughout the course and issued with a certificate upon successful completion. Fees: £585 (£550 RCSEd Affiliate Members)
Manchester Melanoma Surgery Meeting (9 Oct 2014) This meeting aims to provide a common forum highlighting the surgical aspects of melanoma treatment, to discuss the multidisciplinary aspect of melanoma surgery, and to consider some research themes (molecular biology and clinical) around malignant melanoma. Fee: £75
RCSEd Key Skills for Future Surgeons (25-26 Oct 2014, 31 Jan-1 Feb 2015) This Consultant-led course is specifically aimed at providing junior doctors intending to pursue a career in surgery a structured programme of learning basic surgical skills and techniques. It will introduce to the participant the safe surgical techniques that are common to all surgical practices. Fee: £75
Intensive Revision Course for MCEM Part A (15 Nov 2014) This intensive one-day revision course will provide the candidates with an overview of essential applied clinical anatomy, basic physiological principles, and the physiology of the respiratory, cardiovascular, renal, and central nervous systems. Fee: £145
Surgical Revision Course for Final Year Medical Exam (16 Nov 2014) Taught by practicing surgeons, this course aims to consolidate the student’s surgical knowledge whilst addressing any weaknesses, provide a focused revision of pertinent surgical topics, and aid the candidate’s ability to perform in clinical examinations (OSCE). Fee: £40 FURTHER INFORMATION: www.christie.nhs.uk/school-of-oncology / education.events@christie.nhs.uk / @TheChristieSoO
COURSE DIARY
Receive 20% discount on all Surgery titles with promo code BBN11 when ordering online at http://bit.ly/CRCSurgery plus free shipping
www.crcpress.com
Advert summer.indd 1
15/05/2014 10:48:14
OCTOBER AND NOVEMBER 2014 OCTOBER 2014 1 Training the Trainers: Foundation Essentials (Preston) 1-2 Emergency Abdominal and Thoracic Surgery for the General Surgeon (Dundee) 1-3 Care of the Critically Ill Surgical Patient 2-3 Training the Trainer (Preston) 8-9 Basic Surgical Skills (Hong Kong) 10-11 Basic Surgical Skills (Hong Kong) 11 Surgical Anatomy of the Trunk (St Andrews) 11-12 Foundation of Clinical Surgery 12-13 The Edinburgh MRCS OSCE Preparation Course (Kolkata) 13-14 Basic Surgical Skills (Hong Kong) 15-16 Basic Surgical Skills (Hong Kong) 17-18 Basic Surgical Skills (Hong Kong)
22 Musculoskeletal Course for GPs/GPSTs 22 Annual Meeting of the Faculty of Surgical Trainers – Who Makes the Cut? Assessment in Surgical Training 23-24 MFDS Part 2 Revision Course 23-24 Basic Surgical Skills (Lyon) 25 Future Surgeons: Key Skills (Manchester) 25-26 Foundation of Surgical Gastroenterology (Birmingham) 25-28 Scottish Surgical Bootcamp (Inverness) 26 Future Surgeons: Key Skills (Manchester) 28 Basic Skills in Paediatric Surgery 29-31 Core Skills in Orthopaedic Surgery 30-31 Basic Surgical Skills (Nottingham) 31 The Orthopaedic Symposium NOVEMBER 2014 1 Surgical Anatomy of the Limb (St Andrews) 4-5 Basic Surgical Skills (Bali) 5 Training the Trainer: Foundation Essentials 6-7 Basic Surgical Skills 6-7 Training the Trainer 6-7 Non-Technical Skills for Surgeons 7 Future Surgeons: Key Skills (Nottingham)
7-8 Basic Surgical Skills (Bali) 8-9 Foundation of Surgical Gastroenterology 10-11 Basic Surgical Skills (Birmingham) 10-12 Advanced Trauma Life Support 12 Musculoskeletal Course for GPs/GPSTs (Birmingham) 14 Future Surgeons Critical Care 18-20 Neurosurgical Approaches to the Cranial Compartments 20 Preparation for the Diploma in Implant Dentistry (London) 24 Radiology for Surgeons 24-25 Judgement and Operative Skills in Emergency Surgery (Manchester) 25-26 Facial Aesthetic Surgery: Dissection Course for Surgeons 28 Plastering Techniques for Fracture Treatment (Kilmarnock) 28 Student Research Symposium 29 Future Surgeons: Key Skills (Merseyside) For details contact education@rcsed.ac.uk or +44 (0)131 527 1600 All events in Edinburgh unless otherwise stated
www.rcsed.ac.uk | 7
AGENDA
QUANTITY NO SUBSTITUTE FOR QUALITY IN TRAINING
I
n July, the College challenged the Department of Health suggestion that trainee doctors in the UK should ‘opt out’ of the European Working Time Directive (EWTD) of a 48-hour week to enable them to get the training they need and deliver healthcare in the UK’s trust hospitals. RCSEd warned there is a danger that trusts will put pressure on surgical trainees to opt out of the directive only for this extra time to be spent covering rota gaps and not gaining any additional useful educational experience. RCSEd president, and consultant trauma and orthopaedic surgeon, Mr Ian Ritchie, commented: “We believe that the problem does not lie with the Working Time Directive but with its implementation, which 8 | Surgeons’ News | September 2014
The College rejects the government’s suggestion that the Working Time Directive be ignored has left National Health Service trusts throughout the UK dependent on trainees for the delivery of service. It is an absolute truth that service is an integral part of training and certainly should not be separated as is being suggested. However, it should not rely on trainees to the extent it does. In addition, as the record of hours worked is based on a weekly average over six months, implementation of the directive has also been marked
‘Opting out’ of the European Working Time Directive would be bad for trainees and patients, the College asserts
extra hours to work ‘in the hope’ that they somehow independently gain more experience in between shift pressures is not using time effectively and carries no guarantee that this extra time will be effective in making them better or safer consultants.” A poll of surgeons in training at the College’s recently opened Birmingham regional centre showed that while more than half of the trainees (54%) agree that the EWTD is good for patients, 88% felt that there was an imbalance between service provision and training in their trust. Chair of the RCSEd Trainees’ Committee and Trainee Representative on Council, Richard McGregor, added: “This is a very emotive subject, and one that affects the very fabric of how many surgeons in training live their lives up and down the United Kingdom. The statement released by the DoH is a visceral reaction to a service under pressure, and in surgical training quantity is no substitute for quality. The danger of such a vague statement issued by the health secretary is that it could lead to a series of unintended consequences. Training and service provision are inextricably linked, and by fracturing the two, or worse, giving trusts the power to press surgeons in training to ‘opt out’ of the EWTD, it will create a two-tiered system of training. Moreover, it will be a disaster for retaining and recruiting junior doctors to the specialty. This announcement is not good for doctors, and it is not good for patients.” McIlhenny, who is also a consultant urological surgeon, continued to say that the profession should strive to ensure it produces consultants fit for providing excellent and safe surgical care in the NHS.
Encouraging trainees to opt out of the Working Time Directive will not improve training, but allowing the health services to become less reliant on trainees for the delivery of service will; changing rotas and shift patterns to include time for trainees to receive training and for consultants to deliver it will by noticeably long shifts and fewer opportunities for consultants and trainees to work together.” Craig McIlhenny, director of the College’s Faculty of Surgical Trainers, the only dedicated training faculty in the UK, is concerned about the opt-out plans. “High-quality surgical training is vital to the provision of excellent surgical care and high levels of patient safety, and simply increasing hours that trainees are at work will not improve either surgical training quality or the safety of care for patients,” he said. “We need to continue to move towards a system of training that means supervision by appropriate and motivated trainers working towards clearly defined competencies for surgical trainees. Giving the trainees
He added: “The artificial separation of service and training is misguided; excellent service and training should go hand in hand.” Ritchie concluded the College’s position by commenting: “Encouraging trainees to opt out of the Working Time Directive will not improve training, but allowing the health services to become less reliant on trainees for the delivery of service will; changing rotas and shift patterns to include time for trainees to receive training and for consultants to deliver it will. I would challenge the service to do these things and once they have been done the quality of training will be much better, without resorting to a working pattern that ultimately leads to higher risk to the patient and to the trainees.” www.rcsed.ac.uk | 9
AGENDA
RESEARCH FOR ALL As the latest Research Report shows, the RCSEd is continuing its support for surgical research, from those in the earliest training years to renowned career academics
T
he RCSEd has published its latest biennial Research Report, which showcases a breadth of research from clinicians at different stages in their careers. The report includes prestigious awards such as the Robertson Trust Fellowship, the Cutner Travelling Fellowship in Orthopaedics and the John Steyn Travelling Fellowship in Urology. Writing in his introduction to the Report, Professor Kenneth Fearon, chairman of the RCSEd’s Research Allocation Committee, commented: “It is a pleasure to report on the high quality of projects that have been submitted to and funded by the College. The College is keen to fund not only career academics who eventually seek a university position, but also those wishing to be exposed to the research environment and who will eventually practise within the NHS. Both destinations are valued equally.” To this end, the Committee has re-instituted the joint MRC/RCSEd three-year PhD Fellowship scheme, continues to offer one-year fellowships, such as the Maurice Wohl and Robertson Trust fellowships, and has increased the upper limit to the funding offered for individual small project grants. Professor Fearon also gave special thanks to the donors of research funds, whose generosity supports the many projects in the Research Report. The latest report marks 20 years of the College supporting research through research fellowships, travelling fellowships, small research grants and bursaries, during which time more than £7m has been awarded to support over 700 individual surgeons working in university departments and hospitals throughout the UK and abroad. Discussing the challenge of assessing the breadth of applications submitted to the College, Professor Fearon said: “The range of ‘surgical research’ is considerable,
THE RESEARCH REPORT INCLUDES STUDIES INTO: The role of heat-shock protein
90 in modulating ischaemiareperfusion injury in the kidney. An analysis of retinal digital image abnormalities seen in acute retinopathy of prematurity – is reduced oxygen therapy protective? The benefits of
10 | Surgeons’ News | September 2014
oxygen saturation targeting trial II UK retinal image digital analysis (BOOST-II UK RIDA) study. Case-control genetic association analysis of primary rhegmatogenous retinal detachment using novel highdensity exome genotyping.
Research Report
2012–2014
FROM HERE, HEALTH
More than £7m has been awarded to support over 700 individual surgeons working in university departments and hospitals worldwide from basic science in Drosophila or zebrafish to the health economics of daybed surgery. Given this broad spectrum, it is sometimes difficult to determine what is worthy of funding and what is not. Equally, it can be difficult for applicants to discern what might be attractive to a funding committee. Due to its craftbased nature, surgery – and thereby surgical research – should mostly have a strong clinical component or at least an element that may be translated into the clinical environment.” College president Mr Ian Ritchie commented on the ‘exciting possibilities’ for future fundraising efforts in pursuit of the College’s key research priorities of translational, clinical and cancer research, along with patient safety through harnessing outcome data. The 2012–2014 Research Report is available on the College’s website.
FACULTY OF SURGICAL TRAINERS ANNUAL MEETING – WHO MAKES THE CUT? ASSESSMENT IN SURGICAL TRAINING WEDNESDAY 22 OCTOBER 2014 KEYNOTE SPEAKERS: l P rofessor John Norcini, one of the world’s foremost experts on the assessment of physician performance l D r Stephen Yule, Harvard Medical School – an expert on the assessment of non-technical skills in surgeons l M r William Allum, Surgical Director of the Intercollegiate Surgical Curriculum Project and Consultant Upper GI Surgeon at the Royal Marsden NHS Foundation Trust l Professor Jonathan Beard, Professor of Surgical Education at RCSEng and Consultant Vascular Surgeon at the Sheffield Vascular Institute l Full details on fst.rcsed.ac.uk
The FST conference will be preceded on Tuesday 21 October by a joint meeting with the RSM: ‘Surgical crises and “never events” – recognise, understand, rescue and avoid’. Reduced fees will be available for those attending both events.
This year’s meeting will focus on all aspects of assessment in surgical training. The focus will be on current methods of assessing surgical trainees’ technical and non-technical skills and how trainers can optimise their use of current workplace-based assessments. We will also look
at the assessment of trainers in light of impending GMC proposals to approve all surgical trainers in the near future. The use of assessment in selection into surgical training and at the exit of surgical training will be addressed, while the current UK system of training and future developments will be covered. The meeting will present the current state of the art in assessment and its place in best practice in surgical training. It will be of relevance to all surgeons with an interest in training.
Full details on fst.rcsed.ac.uk
AGENDA
ASSESS ALL AREAS Assessment methods for surgical trainers and trainees will come under the spotlight at a major conference in October 12 | Surgeons’ News | September 2014
‘W
ho Makes the Cut? Assessment in Surgical Training’, the title of this year’s Faculty of Surgical Trainers (FST) conference, may seem dramatic to some, but with GMC accreditation for all trainers in secondary care coming in 2016, it is a theme that could become increasingly relevant over the next 12 months. Assessment – of trainers and trainees – is a broad and complex topic, and is reflected in the range of speakers at October’s event. The lineup of international experts offers a depth of experience and perspectives that include primary care, psychology and the military. Two leading figures in the field of assessment in medicine will deliver keynote lectures. First, Professor John Norcini, president and chief executive of the Foundation for Advancement of International Medical Education and Research (FAIMER) Institute will discuss formative assessment in the context of postgraduate education. The afternoon keynote address will come from Dr Steven Yule, assistant professor at Harvard Medical School and Boston’s Neil and Elise Wallace STRATUS Center for Medical Simulation, and look at non-technical skills to assess surgical performance. Other distinguished speakers will include surgical director of the ISCP Mr William Allum and Jonathan Beard, professor of surgical education at RCSEng, plus many others. FST’s director Mr Craig McIlhenny will also be speaking about the work of the faculty with a preview of the forthcoming Standards for Surgical Trainers document, which promises to improve transparency, accountability and standards. With impending accreditation on the minds of many delegates, there will be considerable interest in the contribution from Professor Moya Kelly, director of postgraduate general practice education, NHS Education for Scotland, who will discuss assessment of trainers in primary care. Commenting on the GMC accreditation of secondary care trainers, Professor Kelly believes it is a positive step: “I think it is good to formalise training. It does highlight it as something that is important
and needs appropriate time. One of the dangers is that trainers see this as another hoop to jump through, rather than part of their personal development, and some may choose not to train anymore. Having said that, I don’t think it should be assumed that every consultant should become a trainer.” Despite a rigorous approval system for both practices and individuals who apply for training responsibilities, Professor Kelly says there’s no evidence of anyone being put off training and, indeed, new practices continue to put themselves forward for training. Better remuneration for trainers is just one of the factors that ASiT pastpresident Mr Steve Hornby thinks would improve the current system. He also cites better recognition, more time for feedback and extra flexibility for training operating lists. Mr Hornby will be providing a trainee’s view of assessment at the FST conference. One of the concerns about the formalisation of training is that it will become a form-filling exercise. As an ST8 in Upper GI and Bariatrics, Mr Hornby completes 40 Workplace-Based Assessments (WBAs) a year, but believes there is too much emphasis on raw data and not enough on the quality of assessment and feedback. He feels that an increasing realisation that WBAs are a requirement has made it easier to get them completed by trainers, but engagement could be improved with better planning and formalisation of time to discuss the points of a procedure. Mr William Allum agrees that WBAs have been through an ‘evolutionary process’ and outlines further strategies to improve engagement with them, from more communication and education around their role in formative and flexible assessments to the introduction of apps for mobile devices. The role of non-technical skills in patient safety is not a new theme at RCSEd events, but the FST conference debate will focus on the teaching and assessment of such skills. Harvard’s Dr Yule says there is a range of validated tools for assessing nontechnical skills that have emerged in the last decade: “We finally have tools and vocabulary to focus on the full range of behaviour in the operating
One of the dangers is that trainers see this as another hoop to jump through rather than part of their personal development, and some may choose not to train anymore theatre that make for high-performing teams and successful surgery. And we can measure and improve these skills in surgeons and trainees using tools such as non-technical skills for surgeons (NOTSS). Assessments are becoming more objective as these skills taxonomies are refined and used more regularly.” Dr Yule believes validated tools are best used in direct observation during a real or simulated operative scenario: “Using NOTSS to observe specific behaviours in the OR, categorising them according to the four categories and then rating how well the surgeon performed in each can be very insightful. Saying that, there is a range of options available and questions to answer: how many observers, should they be surgeons or social scientists, how much training do raters require, which tool to select, and [should you] assess ‘live’ or from video?” Many listening to Dr Yule at the FST meeting in October will be asking if a trainee with great technical skills, but poor non-technical skills, should be allowed to become a consultant. He says: “I do not think that a hospital, health board, university or the College should allow someone to become a consultant if they know they have substandard non-technical skills. Doing so would reflect a wider issue of values in what makes a proficient surgeon. It may also reflect poorly on the comprehensiveness of the training programme to develop surgeons who are fit for purpose. “Taking the question to the next level, I believe surgical trainees should be assessed on their nontechnical skills as part of board examinations. This would help them in the long run because we know that assessment drives learning (and is better than repeated study in some cases for long-term retention). No future surgeon wants to be an ineffective communicator, poor leader or incapable of making effective decisions.”
Who Makes the Cut? Assessment in Surgical Training RCSEd, Wednesday 22 October 2014 For further information, contact education@ rcsed.ac.uk 0131 668 9209 or visit www. rcsed.ac.uk The full interview with Dr Steven Yule is available on the FST website: fst. rcsed.ac.uk
www.rcsed.ac.uk | 13
AGENDA
SURGICAL SAFETY UPDATE More cases from the Confidential Reporting System for Surgery
TRACHEOSTOMY MANAGEMENT
A 50-year-old, acutely unwell male underwent laparotomy and small-bowel resection for obstruction. Postoperatively he was admitted to ICU, where he remained intubated and ventilated. His progress was complicated by a spontaneous pneumothorax, which necessitated chest drainage and, because of prolonged intubation, a tracheostomy was undertaken to facilitate suction and respiratory care. The patient was improving gradually, and had been discharged to ward care, when he suddenly succumbed to a cardiorespiratory arrest in the early morning hours. Post-mortem examination revealed that the cardiorespiratory arrest had been due to obstruction of the tracheostomy by a mucous plug. Ward night staff had not been trained in tracheostomy management and failed to notice the patient’s deterioration.
CORESS comments
Expert ENT opinion was obtained: sadly, death from mucus plugging of tracheostomy tubes is an avoidable but recurring event. Tracheostomised patients may be admitted under any surgical specialty, and therefore it is
14 | Surgeons’ News | September 2014
essential that all staff dealing with such patients are aware of best practice. • All healthcare professionals dealing with tracheostomised patients must have adequate training in tracheostomy care and resuscitation needs. • Hospitals should have a standardised local policy for care and a multidisciplinary tracheostomy team where possible. • Patients should have a double-lumen tube to allow easy changes in cases of mucous plugging. • A spare inner tube, tracheal dilators, suction cannulae and a spare smaller tube must all be available at the patient’s bedside. • Cuffed tubes must have pressures checked twice daily. • The requirements of humidification and suctioning needs must be reassessed regularly. • Timely decannulation should be undertaken in conjunction with a multidisciplinary team. Although there is a paucity of detail regarding this case, it appears that poor humidification and suctioning due to lack of adequate training resulted in mucus plugging. Perhaps simply removing the inner tube might have prevented subsequent hypoxic arrest. NCEPOD has released its latest report, Tracheostomy
CORESS is grateful to the clinicians who have provided the material for these reports. The online reporting form can be found at www. coress.org.uk Published contributions will be acknowledged by a Certificate of Contribution, which may be included in the contributor’s record of continuing professional development or appraisal.
Care: On the Right Trach? (June 2014). The report can be downloaded from the website at www.ncepod.org.uk
THE SWISS CHEESE EFFECT
I was called to assist an ENT SpR undertaking a solo list while his consultant was on leave who had created a CSF fistula during elective sinus surgery. I reviewed the pre-operative CT scans before scrubbing and found that the scans showed no evidence of sinus disease. The fistula was repaired intra-operatively, and the patient made an uneventful recovery. On investigation as to how the patient had been listed for surgery in the absence of sinus disease on CT, it became apparent that a different registrar had listed the patient, whose complaint was of post-nasal drip, for surgery, on the grounds of a radiology report that stated that there was extensive disease. A radiology transcription error had occurred, which was overlooked as the CT had not been reviewed in the clinic. Furthermore, as the history did not support a diagnosis of chronic sinusitis, the CT scan should not have been requested. The patient underwent unnecessary surgery, resulting in a major complication, with no symptomatic benefit.
CORESS comments
This case represents a ‘never event’ in which a number of circumstances contributed to the adverse outcome – the so-called ‘Swiss cheese’ effect. An initial incorrect clinical diagnosis was made despite the symptoms; there was failure to follow RCR guidelines in requesting CT at the first visit when the only symptom was that of post-nasal drip; a transcription error occurred in the radiology department; the patient was listed for surgery by a surgeon who did not have final responsibility for the operative procedure, on the basis of the incorrect radiology report; the CT scan was not reviewed prior to surgery by the operating surgeon (as recommended in the WHO checklist). The importance of the operating surgeon checking all of the patient’s relevant investigations prior to anaesthetic induction cannot be overemphasised.
Frank CT Smith Programme Director on behalf of the CORESS Advisory Board www.coress.org.uk
www.rcsed.ac.uk | 15
AGENDA
The latest guidelines, papers and studies
IN BRIEF WARD SIMULATION TO IMPROVE SURGICAL-WARD ROUND PERFORMANCE: A RANDOMISED CONTROLLED TRIAL OF A SIMULATION-BASED CURRICULUM
This study aimed to investigate the effects of a simulation-based curriculum for ward-based care on ward-round (WR) performance. Twenty-nine surgical residents were randomised to a halfday educational intervention (n=14) or to standard practice (n=15). All of them conducted a standardised, simulated WR of three patients. The intervention group demonstrated better patient assessment (P=0.002), management (P=0.014), and non-technical skills (W-NOTECHS) scores (P<0.001). The authors conclude that introducing a curriculum for surgical WRs could improve patient outcomes. Pucher P, Aggarwal R, Singh P, et al. Annals of Surgery 2014; 260(2): b236
FEASIBILITY RCT OF DEFINITIVE CHEMORADIOTHERAPY OR CHEMOTHERAPY AND SURGERY FOR OESOPHAGEAL SQUAMOUS CELL CANCER
This three-centre study assessed the feasibility of an RCT comparing neoadjuvant treatment and surgery with definitive chemoradiotherapy. Of 375 patients with oesophageal SCC, only 42 (11.2%) were eligible. Reasons for eligibility varied between centres, with differing proportions of patients excluded because of tumour length (P=0.002). Analyses of recordings and patient interviews showed that recruiters had challenges articulating the trial design. Before recruiter training, no patients were randomised. After training in one centre, five of 16 eligible patients were randomised. The authors conclude that an RCT of surgical versus non-surgical treatment for SCC of the oesophagus is not feasible in the UK alone because of the low number of eligible patients. Blazeby J, Strong S, Donovan JL, et al. Br J Cancer 2014; 111(2): b234
16 | Surgeonsâ&#x20AC;&#x2122; News | September 2014
OPERATIVE VERSUS NON-OPERATIVE TREATMENT FOR CLOSED, DISPLACED, INTRA-ARTICULAR FRACTURES OF THE CALCANEUS: RANDOMISED CONTROLLED TRIAL
This UK multicentre trial randomised 151 patients with acute displaced intraarticular calcaneal fractures to operative (n=73) or non-operative (n=78) treatment. There was no significant difference in patient-reported scores for pain and function two years after injury, or in any secondary outcomes (complications; hindfoot pain and function; general health; quality of life; clinical examination; walking speed; gait symmetry). Complications and re-operations were more common in those who received operative care. The authors conclude that, based on these findings, operative treatment by open reduction and internal fixation is not recommended for these fractures. Griffin D, Parsons N, Shaw E, et al. For the UK Heel Fracture Trial (UK HeFT) Investigators. BMJ 2014; 349: b4483
SYSTEMATIC REVIEW, NETWORK META-ANALYSIS AND EXPLORATORY COST-EFFECTIVENESS MODEL OF RANDOMISED TRIALS OF MINIMALLY INVASIVE TECHNIQUES VERSUS SURGERY FOR VARICOSE VEINS
This systematic review of 31 RCTs evaluated the effectiveness of minimally invasive techniques (foam sclerotherapy [FS], endovenous laser ablation [EVLA] and radiofrequency ablation [RFA]) compared with traditional surgery in terms of recurrence of varicose veins, venous clinical severity score (VCSS), pain and quality of life. Exploratory cost-effectiveness modelling was undertaken. Differences between treatments were negligible in terms of clinical outcomes. Total FS costs were the lowest, and FS was marginally more effective than surgery. EVLA and RFA might be considered cost-effective if their
costs were similar to those for surgery. The authors conclude that there is little to choose between surgery and the minimally invasive techniques in terms of efficacy or safety, so the relative cost of the treatments becomes one of the deciding factors. Carroll C, Hummel S, Leaviss J, et al. Br J Surg 2014; 10: b1040
SYSTEMATIC REVIEW OF SKILLS TRANSFER AFTER SURGICAL SIMULATION-BASED TRAINING
This systematic review evaluated the use of surgical simulation-based training and the transferability of the acquired skills to a patient-based setting. Fourteen studies investigated laparoscopic procedures, 13 endoscopic procedures and seven other procedures. The studies provided strong evidence that those who reached proficiency in simulation-based training performed better in the patient-based setting. Simulation-based training was as effective as patient-based training for colonoscopy, and laparoscopic camera navigation. The authors conclude that this provides further support for structured simulation-based training. Dawe R, Pena GN, Windsor JA, et al. Br J Surg 2014; 10: b1063
CONSENSUS GUIDELINES FOR ENHANCED RECOVERY AFTER GASTRECTOMY
An international enhanced recovery after surgery working group has assembled an evidence-based framework for optimal perioperative care for patients undergoing gastrectomy. Recommendations are given for 25 components of care. This should facilitate future multicentre registries and randomised research. This is required to improve the strength of the recommendations and optimise perioperative care. Mortensen K, Nilsson M, Slim K, et al. Br J Surg 2014; 10: b1002
JOU RN
S•
ATION REPOR CIT T L A
2 201
2011Latest Impact Impact factor Factor 1.406! T
H
OM
RS
2.207! 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:
• • • • • • • • • •
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.thesurgeon.net
AGENDA
THE PRESIDENT WRITES Ian Ritchie provides his regular update
T
he pace of change never seems to flag even though most of the UK population have been slowed down by the spectacular summer weather. The main subjects of conversation have been seven-day consultant present care, consultant outcomes data and the European Working Times Regulations. The news that the UK Department of Health was accepting proposals that trainee doctors in the UK should opt out of the European Working Time Directive (EWTD) was met with widespread alarm from trainees and trainers alike. The proposal had come as part of the recommendations put forward by a task force who had been looking at the impact and implementation of the EWTD on the NHS and on health professionals. The task force also recommended â&#x20AC;&#x201C; and the Department of Health accepted â&#x20AC;&#x201C; that service and training should be separated; this, too, was greeted with concern. It is easy to assume that all time spent at work is good training. However, this is not the case
and all too often there is an emphasis on quantity over quality. The fact is that 48 hours per week should be enough time to train anyone as long as the quality of that training is of the right standard. It is also easy to identify the issues, but far harder to identify solutions. The task force had clearly attempted to do so, but perhaps it was simply looking in the wrong place and at the wrong root cause. The current situation is far from perfect, but in our response to the news, we were clear in our belief that the problem does not lie with the Working Time Directive, but with its implementation. National Health Service Trusts throughout the UK have always depended on trainees for the delivery of service. That service is an integral part of training and certainly should not be separated as is being suggested. However, it should not rely on trainees to the extent that it does. In addition, as trainee numbers have dropped and as the record of hours worked is based on a weekly average over six months, implementation of the directive has been marked by noticeably longer shifts and fewer opportunities for consultants and trainees to work together. However, looking at this in isolation is only looking at the tip of the iceberg. The problems of service provision
in the NHS have to be considered in the round and as consultants, we will have to think about the way we work, just as much as how our trainees work. To make the directive work, consultants must have the time to be trainers and to work together with trainees. It is, therefore, becoming increasingly apparent that the much-debated 9:1 consultant contract that focuses on service delivery alone is not an option that will deliver an innovative and dynamic consultant workforce into the future. Surgical practice remains at the vanguard of innovation in treatment for difficult and otherwise fatal conditions. That will undoubtedly continue because exploring new treatments and techniques for these conditions remains an intellectual challenge, which is enormously attractive. However, the challenge today is not only the traditional one of fighting diseases, but also that of organising the way we deliver those treatments in response to the changing environment of fewer trainees, increasing public expectation, reduced resources and changing working practices. It is easy to say that the responsibility lies with management, but as high earners in the health service, every consultant is also a manager and so part of the responsibility lies with us to tackle these difficult problems. If we do not look critically at how we deliver our services so that patients get the best deal possible and our trainees receive the best training that we can deliver, then the responsibility for the treatment that we will receive in the future as patients ourselves will lie squarely at our door. Aside from self interest, the GMC requires us to provide the best care for our patients, but also to care for our colleagues. That is something we can each do on an individual and team basis. We can examine
The fact is that 48 hours per week should be enough time to train anyone as long as the quality of that training is of the right standard whether the way we are working is in the best interests of patients and trainees. We have the capacity to influence what goes on in our departments and in our teams. So let us accept that rotas and shift patterns have to change. Let us champion proper job-planning where we can negotiate appropriate time for training as well as service delivery. Let us create a culture where less than full-time working is not just accepted, but encouraged. If we can take up those challenges, I know that the managers will be only too happy to enter into negotiation about how to facilitate any changes that we might wish to make. Encouraging trainees to opt out of the Working Time Directive will not improve training, but allowing the health services to become less reliant on trainees for the delivery of service will; changing rotas and shift patterns to include time for trainees to receive training and for consultants to deliver it will. I would challenge the service to do these things and once they have been done, the quality of training will be much better, without resorting to a working pattern that ultimately leads to higher risk to the patient and to the trainees. Ian Ritchie president@rcsed.ac.uk
www.rcsed.ac.uk | 19
GLOBAL HEALTH: ESSENTIAL SURGERY
A campaign is under way to make basic surgical care a component of universal healthcare for one-third of the world’s population
HEALING POWER
A
s it stands today, an estimated 2 billion people lack access to the most basic surgical services that prevent premature death and severe disability. As a result, easily treatable surgical conditions can lead to devastating lifelong disability, social exclusion, economic hardship and even death. This situation has remained largely unknown and unrecognised by the global health community well into the last 30 years. Even less recognition is given to viable and simple solutions available to address these neglected surgical diseases in low and moderate-income settings. Thus, ‘essential surgery’, the thesis of defining these conditions and setting practical and realistic goals in alleviating the enormous burden of disease in many low-income countries, has become the primary goal of the International Collaboration for Essential Surgery (ICES). What began in 2011 as a response to a call by Dr Michael Cotton to convene around the lack of access to essential surgery has resulted in a dynamic non-profit organisation with teams based out of the USA and the UK. Under the leadership of ICES board chair Dr Michael Cotton, ICES executive director Dr Jaymie Henry MPH, and ICES board member Dr Robert Lane ICES is changing the path and profile of essential surgery on a global level. The expertise of the team is supported by a robust board of advisers that includes Nobel Laureate Professor Muhammad Yunus, Lord Ian McColl of Dulwich and Lord Bernard Ribeiro, co-chair of the UK All Party Parliamentary Group on Global Health. ICES’s message is clear: essential surgeries are basic surgical procedures that prevent life-threatening complications and disabilities; they are simple, affordable and save lives. And, even more importantly, essential surgeries need to be a part of the continuum of local healthcare delivery. In most high-income countries, surgery and anaesthesia are integrated as part of the basic continuum of care. However, throughout much of the ‘developing’ world, surgical care remains a neglected but critically needed component of universal health coverage. This is the reality for over a third of the global population, who lack access to basic, cost-effective and life-saving surgical procedures to treat simple conditions such as obstructed labour, maternal
20 | Surgeons’ News | September 2014
REFERENCES 1. Grimes, CE et al. Costeffectiveness of surgery in low- and middleincome countries: a systematic review. World J Surg 2014; 38(1): 252-63. 2. Cotton, M et al. Value innovation: an important aspect of global surgical care. Global Health 2014; 10(1):1.
haemorrhage, congenital birth defects such as club foot and cleft lip, traumatic injuries and accidents, soft-tissue infections and hernias. These conditions don’t exist untreated in the ‘developed’ world. The poor continue to suffer because of a shortage of skilled personnel, inadequate infrastructure, and high out-of-pocket costs that invariably push the most destitute to even greater depths of poverty. One of ICES’s strategies and strengths has been to convene experts who can combine academic research with ‘boots on the ground’ expertise to focus on viable solutions. The ICES team has distilled the message about the need for essential surgery into a multisector and global rallying point by creating a specific and clear strategy that has resulted in a ‘roadmap’ for action and advocacy. ICES focuses on advocacy, data and policy, and has gained support from governments, civil society and researchers to push the issue and need for essential surgery forward in a meaningful way. There is increasing recognition of the critically important part that surgery and anaesthesia play in preventing death and alleviating disability worldwide. On 26 May 2014, the World Health Assembly (WHA) Executive Board reviewed and unanimously passed an agenda item on ‘Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage’, making it possible for a global surgery resolution to be introduced at the 68th WHA in May 2015. ICES and critical global surgery and anaesthesia organisations were a part of this effort. In April, ICES facilitated a dialogue spearheaded by the UK All-Party Parliamentary Group on Global Health and Reproductive Health to stimulate engagement with the UK government. Earlier this year, ICES hosted an official side event at the United Nations (UN) linking the need for essential surgery with the Millennium Development Goals and paving the way for essential surgery to be included in dialogues alongside HIV, TB and malaria in the post-2015 development agenda. ICES and its team have also contributed to the academic dialogue surrounding essential surgery by publishing a systematic review of the cost-effectiveness of surgical procedures in developing countries1, the value innovation2 surrounding delivery of surgical care in developing countries, and formal statements to international bodies at the UN. Finally, ICES, in collaboration with Golden Hour Films, is making sure that the need for essential surgery is front and centre in global health dialogues through the dissemination and screening of the film The Right to Heal in venues ranging from the Houses of Parliament to the UN. It is also on The Lancet website. These initiatives are housed under the 15x15 campaign: Increasing Access to Essential Surgery (see 15by15surgery. org). 15x15 aims to make 2015 the ‘Year of Surgery’ by increasing awareness around 15 essential surgical interventions that can take care of about 80% of the basic needs of a community. Through a series of efforts aimed to stimulate policy shifts at the WHO and the UN, the advocacy efforts outlined above, as well as projects to stimulate presentation of data in a compelling way, 15x15 calls on multi-sector actors to solve the problem of a lack of essential surgical care in developing countries. As awareness about the role of surgery in primary and universal healthcare grows, so does the opportunity for
15X15 AIMS TO MAKE 2015 THE ‘YEAR OF SURGERY’ BY INCREASING AWARENESS AROUND 15 ESSENTIAL SURGICAL INTERVENTIONS THAT CAN TAKE CARE OF ABOUT 80% OF THE BASIC NEEDS OF A COMMUNITY individuals and global entities to support programmes and efforts that will increase access to safe surgical care. Large-scale solutions are possible if major policy actors, national governments and health donors recognise and prioritise surgery as an essential component of universal health coverage. In this day and age, no one should suffer premature death or disability due to a lack of access to essential surgical care. As stated by Dr Kim in a recent address to The Lancet Commission on Global Surgery, we are all invited to “challenge this injustice, and to build a shared vision and strategy for global equity in essential surgical care… [making] the case that surgery is an indivisible, indispensable part of healthcare”. While ensuring universal access to essential surgical care and anaesthesia will not be easy, it is certainly possible. ICES is committed to making sure that the 2 billion people waiting on the sidelines of public health for access to essential and emergency surgery become front and centre in the global health dialogue, and are recognised and provided with access to essential surgical care. Jaymie Claire Ang Henry MD, MPH Founder/Executive Director of the International Collaboration for Essential Surgery (ICES) www.essentialsurgery.com therighttoheal.com
www.rcsed.ac.uk | 21
GLOBAL HEALTH: INTERVIEW
College Fellow Mr Tim Hargreave tells Mark Baillie about his close involvement with the world’s largest surgical public health drive – to reduce the spread of HIV in Africa by circumcising 20 million men
FIGHTING THE ODDS “T PHOTOGRAPHY: MIKE WILKINSON
his is all about numbers; I’m sort of metamorphosing from a surgeon into a public-health doctor, and the point is that if you’re doing something for public health, it has to be cost-effective. So you don’t want to have to treat thousands of people to prevent one case.” Tim Hargreave launches into our interview with a level of enthusiasm that must be a valuable trait in one of the most ambitious projects for tackling the HIV pandemic. The numbers attached to the World Health Organization (WHO) programme are impressive. Along with other key players, WHO aims to undertake 20 million male circumcisions by 2016 and prevent about 3.4 million adult HIV infections with a cost saving of US$16bn. In Namibia alone, the US President’s Emergency Programme for AIDS Relief (US PEPFAR) estimates that the programme will avert 77,000 infections between 2008 and 2025 – that’s one for every 2.4 circumcisions. Against a total cost of $52.5m is an estimated net saving of $540m from fewer infections. The first real clue of a link between lower HIV transmission rates and circumcision came from epidemiological studies in regions with high rates, which then looked for variable In trials, the factors. Countries that had protective effect was low circumcision rates had the highest HIV rates. coming out at 60%, Mr Hargreave continues: 48% and 53%… it was “In around 2002, people were saying maybe circumcision was at that stage the WHO protective, but then some groups convened an expert were disagreeing with that. There was a big discussion at that time meeting and decreed about whether a public-health that male circumcision intervention should be launched, was an effective public- but the scientists won the day by saying a randomised prospective health measure trial was needed.”
22 | Surgeons’ News | September 2014
Three trials were launched, but all were stopped early by data-safety monitoring boards when it became clear that men who were being circumcised were not getting HIV at anything like the uncircumcised rate. Mr Hargreave explains: “The protective effect was coming out at 60%, 48% and 53% in these trials, and if you looked at all the original epidemiological data and then at the randomised trial data, it showed an effect that was pretty constant, a protective effect. At that stage, the WHO convened an expert meeting and recommended that male circumcision was an additional effective public-health measure.” Regions in which the initiative has been running for longer are already seeing HIV rates falling; Mr Hargreave quotes areas such as Kisumu in Kenya, Rakai in Uganda, and Orange Farm in South Africa. “If you went to parts of Africa 15 years ago, it was an absolute disaster,” he says. “You’d go into a ward and many patients would be dying of HIV. Now, an incredible number of people are living with Aids, and widespread use of antiretroviral drugs is preventative in that it lowers the viral load so that those receiving the treatment are less infective. The difficulty, of course, in a lot of Africa is that the drug supplies are not always 100% reliable, and they’re also expensive.” Between 2003 and the end of 2013, the number of people receiving antiretroviral therapy in poor and middleincome countries went from under 1 million to 13 million. In that same period of time, HIV-related deaths and new HIV infections began to fall gradually. However, the cost implications of keeping millions of people on antiretroviral treatment for life are huge, so there is a natural interest in forms of preventative treatment. Mr Hargreave is keen to emphasise that the programme is not intended to replace other prevention methods, but is part of a comprehensive package of measures. Prior to the launch of the circumcision programme, there was the ‘ABC’ campaign – abstain, be faithful and use condoms. Although the ABC message is effective – Mr Hargreave says the rate of condom usage at first intercourse by young African men is much higher than it is in the UK – the problem is that ‘ABC’ simply is not enough to tackle the HIV epidemic.
www.rcsed.ac.uk | 23
GLOBAL HEALTH: INTERVIEW
Circumcision and transmission to women Quinn et al. NEJM 2000
Transmission (per 100py)
30
n Circumcised n Uncircumcised
25.0
25.6
20 12.6 6.9
10
0
0.0 <10,000
0.0 10,000 - 49,999
>50,000
Viral load (man) Of 47 couples in which the circumcised male partner was HIV+ and whose viral load was <50,000 particles, 0 of female partners were infected after two years versus 26 of 143 female partners of uncircumcised HIV+ men (9.6/100 py) (p = 0.02)
Although a comprehensive evidence base for the in 14 countries in sub-Saharan Africa has presented its own preventative effects of male circumcision had been challenges. In some areas, sessions were delivered using established, the WHO still faced a huge task in ‘up-scaling’ a bananas for parts of the training. “We’ve got to do all of this safe, quick and effective programme to the level that would at very low cost, with very large numbers of people, and the make a significant difference. Mr Hargreave explains: “The programme has been largely delivered by paramedics.” operation takes about 25 minutes when done by a medical The programme can’t work without close cooperation officer, and they gain competency between WHO, key global partners after about 100 procedures. Twenty such as US PEPFAR and health Twenty five minutes five minutes per procedure limits ministries in the countries in which the numbers you can do in a day and per procedure limits the programme is active. “It is all simply doesn’t work for the numbers about training and scaling up the the numbers you can we need to get through. We have, resource in the country concerned. therefore, spent the last three or So everything the WHO does is do in a day and simply four years looking at devices.” done through a ministry of health. doesn’t work for the There is a lot of interest in We can’t work other than through a the work of the programme’s ministry of health because we are a numbers we need to Technical Advisory Group, which UN body,” explains Mr Hargreave. get through. We have, Mr Hargreave co-chairs. At its next This translates into a tiered meeting in September, there will system of training for ‘master therefore, spent the be representatives from the US trainers’, who are then deployed in last three or four years PEPFAR, the Centre for Disease their respective countries to instruct Control in Atlanta, and the Bill and local practitioners. looking at devices Melinda Gates Foundation, plus Mr Hargreave has been working experts from fields ranging from in a voluntary capacity for the WHO engineering, surgery, research, nursing, programme and since 1984 and has served on various advisory groups. In policy making. 2004, he was approached about randomised trials for the PrePex has emerged as one device for delivering the HIV programme. He continues: “I was told that if the trials numbers needed at speed and through trained, but nonshow benefit, we need to hit the ground running and have medically qualified, practitioners. It is sutureless, bloodless some educational materials ready to meet a possible surge in and does not require local anaesthetic injections. Identifying, demand for safe circumcision. So, in around 2004/05, I was testing and approving the right devices is certainly one commissioned by the WHO to write a manual of technique.” key factor for the project, but so too is creating a rapid and The manual is still the main reference tool for technique quality-based training system. Rolling out such a programme for all the programmes across Africa; all of the 6 million 24 | Surgeons’ News | September 2014
Tim Hargreave was a consultant urological surgeon and renal transplant surgeon at the Western General Hospital, Edinburgh. He retired from NHS practice in 2002
men who have taken part in the programme have been circumcised using one of the techniques described in Mr Hargreave’s manual. One of the criticisms of the programme was that it would lead to risk-compensation behaviour – circumcised men having more sexual partners than before and not using condoms. Mr Hargreave is well versed in his response to
Distribution of MC and HIV in Africa Williams BG et al. PLoS Medicine 3(7): e262. 2006 Proportion (%) of men who are circumcised
No data n 0-40 n 40-75 n 75-90 n 90-100
Prevalence (%) of HIV in 2003
No data n 0-3 n 3-5 n 5-10 n 10-40
such accusations, explaining that there is little evidence that the procedures changes behaviour in the participants: “The first question is if they behave badly or change their behaviour, is it going to have a major effect on the efficacy of the programme? Well, the answer is no. The next question is do they actually change their behaviour? The studies suggest that the guys who are more promiscuous before [the circumcision] remain more promiscuous afterwards, and the guys who were less promiscuous before remain less promiscuous.” So what of the ongoing challenges? “There are particular areas that are difficult for geographical reasons. The islands in Lake Victoria, for example, are not easy because they are inhabited by nomadic fishermen. There is quite a high HIV prevalence there and it is very hard to reach them because they’re all on hundreds of little islands all over the place. It is difficult for them to take time off work and many go back working in unclean water too soon, and innovative programmes have had to be devised to prevent complications.” This, Mr Hargreave explains, is why the programme is now looking more closely at innovative ways to deliver messages about the campaign to different segments of the target groups. Although the initial target of 20 million is likely to be missed, the gap has been closing more rapidly in the last two years, and with some participant countries already reporting reduced infection rates, there seems little doubt that Tim Hargreave and his colleagues will continue to work towards that target regardless of the challenges. www.rcsed.ac.uk | 25
GLOBAL HEALTH: BSS IN PALESTINE
TEAM EFFORT The College’s Basic Surgical Skills course in East Jerusalem has attracted support from a range of stakeholders, including the UN, and now looks set to be adopted into Palestine’s training programme
W
hen faculty and delegates on the Basic Surgical Skills (BSS) course met at East Jerusalem’s Augusta Victoria Hospital on 29 April, a milestone was reached. There, for the first time, instruction and teaching on the course was conducted mainly by a local Palestinian faculty. The team behind the course has been striving to reach this point since 2010, when Robin and Magdalena Kincaid, both of the Royal Cornwall Hospital, first approached the College with their proposal. With badging and support from the RCSEd, the Kincaids contacted local non-governmental organisation (NGO) Juzoor for Health and Social Development, the United Nations Relief and Works Agency (UNRWA) and, of course, the Augusta Victoria Hospital, where the course has been held. Writing for the BMJ, Robin Kincaid explained how responsibility for training on the course had gradually been transferred to local surgeons: “Half of the practical sessions on animal tissue were led by Palestinian faculty members, who had been introduced to the four-stage teaching modules and other techniques that were covered in a ‘train the trainer’-style session led by David Sedgwick and John Anderson. It was with real pleasure that the UK faculty could observe the Palestinian faculty teaching the 20 candidates on this fourth BSS course. “This was the much-anticipated milestone in our succession planning. As the co-founder of the course, I could finally see the running of it handed over to a team of Palestinian trainers assembled from East Jerusalem, West Bank and Gaza. This had been one of our goals from the outset, to pass on the necessary skills for the
26 | Surgeons’ News | September 2014
course to be run autonomously with some oversight from an RCSEd team. This has already been successfully implemented in Europe and the Far East, but it is the first course of its kind with certification from the College in the Middle East.” Omar Abdul Shafi, head of the Augusta Victoria’s surgical department, concedes he had some reservations about how the course could be delivered: “When we were approached at the end of 2010 by Magdalena and Robin Kincaid expressing their interest in conducting the BSS course at our hospital, I was very sceptical given all the hurdles that we would have to overcome. Hitherto, surgical training took place solely on real patients. However, the RCSEd’s willingness to adopt this major undertaking has given a great momentum to the Kincaids’ project. “With the vast experience of the Scottish team, the Palestinian team was progressively initiated into the BSS routine. We started with one Palestinian observer on the first course and ended up with five Palestinian instructors from three different Palestinian cities.”
Above: Teaching on the first day of the course Top right: UK faculty instructing the PLE faculty in how to prepare course materials
The Basic Surgical Skills course has grown in importance and popularity as an increasing number of professionals, educators and health institutions recognise its value in helping to standardise surgical skills training in Palestine Dr Shafi is particularly impressed by the enthusiasm for the course expressed by younger surgeons and hopes to harness that as a way of increasing the faculty for future courses. Now, just four years after the course was first held, the Palestine Medical Council, the body in charge of training programmes and specialty certification, is looking to integrate BSS into the first year of surgical residency training. Of all the locations around the world where College BSS courses are held, East Jerusalem is unique in being the only one with support from the UN, which immediately recognised its value to healthcare in the region. Umaiyeh Khammash of the UNRWA explains: “Due to the political situation, Palestine’s health system is fragmented and isolated, which has had a negative impact on our quality of healthcare services. Palestine’s health system faces numerous challenges, including access to technology and continuous education opportunities for health professionals. UNRWA
continuously seeks opportunities for capacity building and technology transfer in order to strengthen its services and quality of care, despite the odds.” The backing of the UN helps tremendously in overcoming the many logistical difficulties, such as supplying and transporting materials and animal tissue. But the UN also plays a vital role in terms of advocacy for the benefits of the course among medical groups and NGOs. Khammash saw the BSS as an important opportunity for the UNRWA and for the country to interact with and learn from the RCSEd, which he describes as “one of the most prestigious institutions in the world”. Ultimately, though, it was an opportunity to improve the quality of services, and standardise and harmonise procedures by consultants and trainees in Palestine who come from more than 100 medical schools all over the world. Khammash says the course delivers exactly what the UNRWA needs in terms of increasing capacity within the health service and he hopes to be able to continue to offer the BSS in Palestine for several years to come. “The www.rcsed.ac.uk | 27
GLOBAL HEALTH: BSS IN PALESTINE
programme has been very successful and meaningful for our health programme, and the knowledge our staff have gained has had an immediate and lasting impact on the quality of services we provide,” he said. Another key partner, Juzoor, is well experienced in working with international partners. Since 2004, it has held an exclusive licence from the American Academy of Family Physicians to offer the Advanced Life Support in Obstetrics course, and in 2012 became the first (and, to date, only) international training centre accredited by the American Heart Association to offer basic and advanced life support courses. Juzoor’s director, Dr Salwa Najjab, explains how supporting the BSS was a natural fit with its existing activities: “One of our main strategies is continuing professional development and we seek to introduce evidence-based training models to help to improve the performance of healthcare providers. 28 | Surgeons’ News | September 2014
One of our main strategies is continuing professional development and we seek to introduce evidence-based training models to help to improve performance “The BSS has grown in importance and popularity among professionals, educators and health institutions who recognise its value in helping to standardise surgical skills training in Palestine. Being a part of the course is important to us as it is in line with our strategy to bring high-quality training and capacity building methodologies to the country. We see the value it has in improving training and we look forward to continued involvement with the Royal College in this initiative.”
Clockwise from top left: Teaching on the first day; the Palestinian faculty takes over teaching of BSS; course convener Mr David Sedgwick with Osama Bishtawi (PLE faculty), head of surgery in Nablus
Stay Updated Visit our new website - www.cuschieri.dundee.ac.uk/
Basic, Intermediate and Advanced Masterclasses General Surgery ENT Gastroenterology Orthopaedics Urology Gynaecology General Practice Anaesthetics Interventional Radiology Cadaveric courses using Thiel embalmed cadavers Cuschieri Skills Centre, University of Dundee Level 5, Ninewells Hospital, DUNDEE, DD1 9SY Phone: +44(0)1382 383400 Fax: +44(0)1382 646042 Web: www.cuschieri.dundee.ac.uk/ Email: cscbookings@dundee.ac.uk
GLOBAL HEALTH: PENMAN FELLOWSHIP
RAINBOW NATION Professor Ian G Finlay reports on his Fellowship to Cape Town, South Africa
I
Professor Ian Finlay
founded the internationally recognised department of coloproctology at Glasgow Royal Infirmary
t was both a pleasure and an honour to be invited to visit South Africa as the Penman Visiting Fellow for 2014. This was my first visit to South Africa and although I had heard a great deal about Cape Town, I was quite unprepared for the beauty of the landscape in the Cape region. The focus of my visit was to the Groote Schuur Hospital and the University of Cape Town Health Sciences Faculty, although I had the opportunity to visit several other hospitals in the course of two weeks. The Groote Schuur Hospital will be forever famous as the site where the first cardiac transplant was carried out. It is wonderful that the old hospital where the operation took place has been preserved as a museum and includes the department of surgery. As has been the case for previous Fellows, I feel I learned far more from my hosts than I was able to impart to them. Given the upheaval that we are experiencing in the UK in the provision of healthcare and the imminent radical changes that will occur in medical training, I found that there was much to learn from the current South African system.
TRAUMA SERVICES My introduction to the Groote Schuur Hospital on the first morning was to join the early morning trauma round 30 | Surgeons’ News | September 2014
led by Professor Andrew Nicol. The trauma unit in Cape Town has a well-deserved world reputation for clinical care, research and innovation based on the enormous number of trauma patients that are admitted every day. No visiting European surgeon is prepared for the extent and severity of the trauma that they will see in South Africa, arising predominantly from interpersonal violence in the township communities. Trauma surgeons in Cape Town can gain in six months the experience in managing trauma that would take a lifetime for a surgeon in the UK. The nature of the trauma also differs from that in the UK, with a large number of gunshot injuries and severe blunt trauma, especially to the head and neck, and often in women. It was especially sad to see ‘punishment’ spinal gunshot injuries leading to paralysis in a country where the capacity to provide spinal rehabilitation is limited. Professor Nicol and Professor Pradeep Navsaria have worked hard to develop an outstanding trauma centre that is supported by state-of-the-art radiology, with images available at the bedside and on tablets. I was especially interested in the structure of the unit. The trauma surgeons undertake almost all surgery in trauma patients that we would expect general surgeons, vascular surgeons and urologists to carry out in the
UK. They would only infrequently seek assistance from sub-specialists and they routinely referred only to neurosurgeons and maxillofacial surgeons. The unit has a dedicated theatre list during the working day, but competes with other specialties for use of the emergency theatres at night. I was interested that, unlike in the UK, it was the anaesthetists – not surgeons – who determine the priority of patients for the emergency theatre. On the basis of my own experience of competing for the use of the emergency theatre, this may be a model that we should consider in the UK. The unit is a world leader in producing clinical guidance for the management of trauma. In brief, the emphasis of this guidance has been to advocate an increased use of a conservative approach to management. This ranges from simple cleaning of gunshot wounds (often leaving the bullet in situ) to the conservative or minimally invasive (pericardial washout) management of gunshot wounds to the heart. It is extraordinary that in the case of cardiac gunshot wounds, Professor Nicol was able to publish a manuscript based on more than 100 patients that he collected in a very short timescale. It is clear that conservative management for trauma is safe in Cape Town. I concluded that this was because the clinicians have an enormous experience of trauma, leading to excellent clinical judgement. This in turn enables the clinicians to very accurately select those patients who require urgent surgery. I was thoughtful, however, as to how well this clinical guidance could be applied to clinicians in the UK who see relatively few trauma patients. As such, it is timely that in the UK the decision has been made to develop trauma units. As I left for South Africa, the Scottish Government announced that there would be four trauma units in Scotland. My experience in Cape Town has reinforced my view that trauma units are required in the UK. It has also caused me to ponder whether four in Scotland may be too many to deliver the clinical experience that is necessary.
THE COLORECTAL UNIT Although I was able to visit a number of clinical areas in the hospital, as a colorectal surgeon, the focus of my
No visiting European surgeon is prepared for the extent and severity of the trauma that they will see in South Africa, arising predominantly from interpersonal violence in the township communities. Trauma surgeons in Cape Town can gain in six months the experience in managing trauma that would take a lifetime in the UK
Below: The first heart transplant operation took place at Groote Schuur Hospital in 1967
visit was to the colorectal unit. Coloproctology is rather a ‘Cinderella specialty’ in South Africa, with fewer than 10 specialist surgeons across the country. This is not surprising because South Africa has many more pressing health needs related predominantly to the provision of public health measures and the management of infectious disease. Nevertheless, a specialist colorectal service is necessary and the unit in Cape Town, with three consultants, has an important national role in training other surgeons and delivering much-needed specialist care. Since most colorectal surgery in South Africa continues to be undertaken by general surgeons, the patients who are referred to the colorectal unit have very difficult clinical problems, such as advanced rectal cancer or complex intestinal fistulae requiring intravenous nutrition. All the rectal cancer patients I saw, or were discussed at the multidisciplinary team meeting, had large, fixed or tethered tumours and required preoperative long-course radiotherapy and chemotherapy. It was a pleasure to attend theatre to see two complex operations undertaken by Adam Boutall. One involved the resection of an anal squamous cancer in a man who had failed chemo-radiotherapy. The enormous resulting defect was closed using a large rectus muscle flap. It was an exemplary operation and it was a delight to see the patient recover completely and be discharged before the end of my Fellowship. The second patient had an ileal pouch operation. Operating theatres feel the same to surgeons the world over, which means the visiting surgeon soon feels at home. This was certainly the case for me in Cape Town as we discussed the nuances of surgical technique. A particular dilemma for the clinicians in South Africa is to distinguish between Crohn’s disease and tuberculosis because the presentation is so similar. I was interested to note that in Cape Town, because of the frequency of TB, all patients with suspected Crohn’s disease are treated with anti-tuberculosis drugs in the first instance. Given the large number of patients found to have both conditions, I have suggested that this could be a fruitful area for clinical research. I was interested to hear of Professor Paul Goldberg’s mobile colonoscopy suite that he takes to rural areas in the Northern Cape, mainly to screen patients known to have family polyp syndromes and who would otherwise not be able to attend for screening. It is a wonderful clinical service, as well as a research www.rcsed.ac.uk | 31
GLOBAL HEALTH: PENMAN FELLOWSHIP
resource, that I would be especially interested to see at first hand. Just as in the UK, theatre time was limited for all surgeons. The colorectal surgeons are able to operate for only three half-day sessions each per week. I have never understood why hospitals in so many countries across the world do not make better use of such an expensive resource as the trained, skilled surgeon. The visit reminded me of my own efforts to develop the colorectal unit at Glasgow Royal Infirmary almost 25 years ago. Many of the challenges are the same as I experienced. However, the Cape Town group is making excellent progress with three committed and enthusiastic consultants and a rapidly expanding workload. I wish them well.
HIV AND SURGICAL PATIENTS It is well recorded that South Africa is in the midst of an HIV epidemic. Approximately one-third of the patients admitted to the surgical wards at Groote Schuur Hospital are HIV positive, so I was somewhat surprised by the apparent nonchalance of the staff towards any risks that they may face personally. This is in contrast to the very robust anti-infection measures we would impose in the UK in similar circumstances. It transpired that almost everybody on the staff had at some time suffered a needlestick or similar injury while treating an HIV patient, but with timely retroviral treatment (which they had all received), no doctor to date has seroconverted. This is testament to the improvements that are being made in the management and treatment of patients with HIV. In reality, HIV has changed from an acute to a chronic disease in South Africa.
Almost everybody on the staff had at some time suffered a needlestick or similar injury while treating an HIV patient, but with timely retroviral treatment, no doctor to date has seroconverted
I gained the impression, however, that HIV was so common in South Africa that the surgeons have taken the view that this subject matter would not be of interest in Europe and beyond. My view, however, is that it would be extremely helpful for surgeons who see relatively few patients with HIV to have evidence-based guidance on a range of issues. For example, if a patient has a hernia and is HIV positive, and surgery necessitates that they stop taking retroviral drugs, what then happens to their HIV disease? Is it worth the risk or should the hernia be left alone? This is only one example of the useful data that could be obtained in Cape Town.
REMOTE AND RURAL SURGERY Across the UK, we are facing an increasing challenge to provide healthcare for remote and rural areas. Worldwide, there is a population-demographic shift of people of working age from rural to urban areas, and medicine is no different: young doctors prefer to work and live in or adjacent to conurbations. The challenge of providing medical care in rural areas is even greater in South Africa. The need is not for high-technology care, but for doctors who have basic general skills. This has been successfully solved by insisting that all doctors must work for one year after foundation training in a remote or rural area. Doctors have to choose from five job options. Interestingly, this work can be in any discipline and may well differ from that of their preferred career aim. The most interesting aspect of this policy for me was that none of the doctors to whom I spoke considered this to be an undesirable imposition. Quite the opposite: they all found it an enjoyable and enhancing experience. They also found it beneficial in developing their overall clinical skills, despite the fact that it may not have been in their chosen craft specialty. I found this pertinent in the context of the recent Shape of Training Review in the UK, which recommends that doctors of the future should have a more general and flexible training. Although we may not wish to mandate that all doctors in Scotland go to a remote area, perhaps more of our city rotations should include a period of time in a remote or rural hospital.
Above: New Somerset Hospital was used as a designated emergency centre for the World Cup in 2010
The Penman Fellowship The Penman Fellowship is funded due to the generosity of the family of the late Frank Penman. During a holiday to Cape Town in 1963, Frank Penman, a solicitor from Watford, became seriously ill with a ruptured aortic aneurysm and was treated at the Groote Schuur Hospital, where he underwent emergency surgery. As was common at the time, he did not survive, but his family were so impressed by his care that they set up a
32 | Surgeons’ News | September 2014
fund in his memory. The purpose of the fund is to allow trainee surgeons from South Africa to visit the UK for additional training and for UK surgeons to visit Cape Town in order to advance the practice of surgery by co-operation between the two nations. Frank Penman was a remarkable man. He graduated from the University of Cambridge and became a successful lawyer. Throughout his life he was a
pacifist who believed in the ‘brotherhood’ of nations. Despite his profound opposition to war, he served with distinction in the Friends’ Ambulance Unit in Italy during the First World War. I am sure that he would be delighted to know that a bequest in his name is helping to further medical education in the ‘Rainbow Nation’ that is South Africa today; a country with so many opportunities, yet so many challenges.
KEY TO SUCCESS My overall impression of the university is that of a dynamic surgical unit supported by enthusiastic and hard-working staff. The key to this success appeared to be the very high morale that I observed in all the staff. The emphasis of the department was clinical care and both undergraduate and postgraduate teaching. All three were delivered to the highest standards. Although I had not considered this fact before, it was apparent that each modality supports the others, creating a ‘virtuous circle of quality’. This was especially true of the high-quality postgraduate teaching that was unequivocally contributing to the high quality of patient care. The success of the unit can be largely attributed to the leadership of the head of department, Professor Del Kahn. Professor Kahn has a gentle but quietly positive personality, and is very approachable. This is emphasised by a sign that I observed on his desk that says: “The answer is yes, what is the question?” This epitomises his inclusive and supportive approach. I am especially grateful to Professor Kahn for organising the trip and for his kindness to me throughout my stay. Finally, I wish to thank the Trustees of the Penman Fellowship for choosing me to be the Penman Fellow for 2014. It has been a great honour and pleasure to undertake the Fellowship.
Surgeons outlines.indd 1
10/05/2012 12:24
www.rcsed.ac.uk | 33
GLOBAL HEALTH: MÉDECINS SANS FRONTIÈRES
Médecins Sans Frontières is known for delivering healthcare in some of the world’s most unstable regions. Retired general surgeon Jonathan Pye recently returned from working for the charity in the Central African Republic, where years of conflict have taken their toll on the country’s infrastructure
THE BRAVE AND THE BOLD
I
have never really been a fan of landing at an airport. In my opinion, it is the worst part of the journey. The feeling of your heart racing as the rubber hits the tarmac and the plane takes a few lurching bumps is dreadful. Certainly, I was not prepared for the landing that I experienced in the Central African Republic (CAR); the plane touching down was the least of my worries. As we disembarked the rather small plane and entered the airport, the sound of gunfire echoed from nearby fighting that had started prior to our arrival. The CAR is in a serious state of disrepair and war breaks out from time to time with little warning. Our team’s plans to head to the main Médecins Sans Frontières/Doctors Without Borders (MSF) site for a briefing, before being taken to our residence, had to be put on hold as we took refuge in the airport and waited for the fighting to subside. My first mission with MSF was already off to a dramatic start and I could only wait in suspense to see what the rest of my two months in the CAR would entail. The CAR is immediately north of the Democratic Republic of Congo and south of Chad. While getting my geographical bearings was important, I also knew that I had to prepare myself surgically for the upcoming mission. From my training, I knew that MSF assured its staff that they would be able to access electricity and clean water, but I was still unsure about the overall conditions of the facilities in which I would be working. 34 | Surgeons’ News | September 2014
Jonathan Pye
was Consultant General Surgeon in Wrexham and Lead Clinician for the Cross-Border Upper GI Cancer Centre for North Wales and West Cheshire. In 2005, he had his first exposure to disaster medicine, helping in Pakistan after the earthquake. After retirement, Mr Pye started work with MSF and his first mission was to the CAR.
Before leaving the UK, I had the opportunity to speak with a fellow surgeon who had been stationed in the Democratic Republic of Congo, who suggested I bring along the Primary Surgery series of books for additional assistance. These were absolutely invaluable and are something I would advise every surgeon planning to serve with MSF to add to their vital packing list! I fully believed the conditions of the hospital would be a bit outdated, and so I approached the mission in the CAR with an open mind, not expecting the surgery theatre to be of the same calibre that I was used to while practising at Wrexham Malar Hospital in Wales. However, no amount of mental preparation readied me for the conditions of the surgery department in the CAR. A surgeon in the UK has the luxury of an entire team to assist them throughout the surgical operation; this was not the case on my mission. I jokingly referred to myself as the one-man surgery machine. I was responsible for every step of the surgical process. From moving the steps to the table for the patient to climb on, to opening the pre-wrapped surgical tools and undertaking the actual operation, it was all my responsibility. Another major difference was the overall condition of the hospital. Cleanliness was of major concern, but there was nothing we could really do to resolve this issue other than to be careful with sterilisation. I had to remind myself that MSF goes to the places where others are too afraid to visit. This became my personal mantra of sorts.
Local MSF staff present Dr Pye with a tribal-print shirt as a leaving present
Dr Pye sutures a woman’s abdomen after carrying out a Caesarian section
Fortunately, I started in surgery when technology was at a low level, and so I always feel ready to use ingenuity to complete the task in hand. In part, that is what experience teaches you, as well as the generality of your training. I was able to fall back on that when things got a little tricky and to remain cool, calm and collected under difficult circumstances. It quickly became apparent that flexibility and innovation would play a prominent part in my time with MSF. During my training at St Mary’s in London, I learned the foundations for proper surgical attention. While having a solid basis of surgical procedure was important in the CAR, even more crucial was the ability to combine the foundation principles with innovative ideas. In one particular case, I had to put this into practice. What started as a typical day in the clinic quickly turned into a ‘medical adventure’. A man entered the
WHILE HAVING A SOLID BASIS OF SURGICAL PROCEDURE WAS IMPORTANT IN THE CENTRAL AFRICAN REPUBLIC, EVEN MORE CRUCIAL WAS THE ABILITY TO COMBINE THE FOUNDATION PRINCIPLES WITH INNOVATIVE IDEAS
facility with a severely fractured femur. In the UK, this type of injury would be set using metal implants. Although I would have liked to reset the leg in this typical fashion, it was not possible because the risk of infection was so severe. I had to do the next best thing and carry out a skeletal traction technique. The surgical drill in the hospital was a puny affair, with insufficient gearing to allow for proper penetration of an adult male tibia with the Steinmann pin. Almost instinctively, I went back to our base and borrowed the workshop drill. The sterile Steinmann pin was tightened into position on the drill and, after a few moments of hesitation, I went for it. The procedure worked like a dream and we were able to set the man’s leg and treat it adequately. I can only imagine what my lecturers at St Mary’s would say if I told them that I used power tools designed for construction to mend a man’s leg. Since returning home from the CAR, I have been able to collect my thoughts and properly reflect on my experiences with MSF. My time there was very rewarding and it really was a great privilege to work as a surgeon with MSF. The work we do is hard and stressful, but patients trust you to fix them using years of training and experience. In view of that, I wanted to give back in some way. I am grateful that MSF has recognised my skills and let me put them to use in a region where the help was very much needed. www.msf.org.uk
www.rcsed.ac.uk | 35
DENTAL
Richard Ibbetson announces a major initiative from the Dental Faculty
TAKE TRAINING TO A NEW LEVEL
T
he enhancement of the quality of patient care through education, training and assessment is the central pillar of the work of the Royal College of Surgeons of Edinburgh. The Faculty of Dental Surgery shares the same core aims. Over the past 10 or so years, successive examinations convenors working in conjunction with our departments of Dental Examinations and Education have transformed our examinations into the robust and validated assessments that they are today. However, there is also an increasing recognition that examinations cannot assess direct clinical skills, and for these to be fully developed high-quality education and training is required. The ultimate quality of an oral healthcare professional is determined by the individual, but is greatly influenced by those who provide the education and training. A dental trainer must possess the knowledge and a variety of skills to be effective, with the ability to review, revise and develop their approach. The College, therefore, has a role in supporting the development of trainers. In order to do this more effectively, some two years ago a successful Faculty of Surgical Trainers was established with Mr Craig McIlhenny as its first surgical director. It works to raise the profile and recognition of surgical education and training. It also promotes training in non-technical as well as traditional technical skills, and provides a framework for the training and education of surgical trainers. The Faculty of Dental Surgery shares these aims and objectives and is delighted that College Council has recently approved the establishment of a Faculty of Dental Trainers. This new faculty will be part of the Faculty of Surgical Trainers, but with its own separate and distinctive identity. By the time that this piece is published, we anticipate having appointed our first dental director. Membership of the Faculty is
36 | Surgeonsâ&#x20AC;&#x2122; News | September 2014
open to everyone with an active interest or involvement in dental training, both in the UK and internationally. Membership is available at three levels â&#x20AC;&#x201C; Associate, Member and Fellow. The criteria to be met for these different levels of membership can be found on the College website.
The ultimate quality of an oral healthcare professional is determined by the individual, but is greatly influenced by those who provide the education and training The Dental Faculty represents the breadth of dentistry, including not only hospital and specialist practice but primary-care dentistry. Applications to join the Faculty of Dental Trainers are welcome from all dentists and dental care professionals. The application requires the submission of evidence of activities as a dental trainer, and Membership or Fellowship of the Faculty will permit the use of the appropriate postnominals. Membership of the new Faculty is open not only to Members and Fellows of our Dental Faculty but also to the wider dental community, whereas for those with a College affiliation no fees are currently payable. We believe that this will support dental trainers, giving an opportunity for benchmarking and further development. This in turn will benefit those in the earlier stages of their careers and, overall, will improve the quality of care for our patients. Richard Ibbetson Dean, Faculty of Dental Surgery
ASSOCIATION EVENTS WITH EXCELLENCE AND INDIVIDUALITY We are now delighted to be working in partnership with the Festival Theatre and National Museums Scotland to offer Associations a complete package for their Conference.
• Auditorium for 1,000 delegates • 24 Break-out rooms • Exhibition Space for Sponsors • Refreshment Areas • Stunning Playfair Hall for Speakers Welcome Dinner • Gardens and Surgeons’ Hall Museums for Drinks Receptions • National Museums Scotland for a spectacular dinner for 1,000 delegates • Ten Hill Place Hotel for delegate accommodation • Exciting new event space to be opened at the Royal College of Surgeons of Edinburgh in 2014 Please tell your Association that your College can offer a great venue in the city of Edinburgh, and take care of all the arrangements. T: 0131 527 3434
E: events@surgeonshall.com
W: www.surgeonshall.com
DENTAL / FREE CPD
Vice-dean Chate in BDJ debate The Dental Faculty’s vicedean, Mr Robert Chate (pictured), has taken part in a debate in the British Dental Journal (BDJ) in response to an article he published on the potential implications of short-term cosmetic orthodontics for general dental practitioners. Dr Anoop Maini, a general dentist and president of the European Society of Aesthetic Orthodontics, wrote to the BDJ with concerns that Mr Chate’s initial opinion piece (BDJ 2013, 215: 551–553) would divide the orthodontic specialist community from general dentists, later adding that he hoped orthodontists did not
consider general dentists to be a threat. In his response, Mr Chate stressed that his original article had been endorsed by the Specialty Advisory Board and the Dental Council of the RCSEd, and that the article’s aim was to “provide ethical and cautionary guidance” for any level of practitioner undertaking orthodontic treatment with limited and potentially unstable objects. Scan the QR code above to view the full debate in the BDJ.
MPDC study group opens in Birmingham Dr Clive Gibson is running a study group to support candidates working towards the MPDC at: The Birmingham Centre The Royal College of Surgeons of Edinburgh, 85-89 Colmore Row, Birmingham B3 2BB The group meets between 6.30pm– 8.30pm on the first Wednesday evening of alternate months as follows: 3 September 2014 5 November 2014 7 January 2015 4 March 2015 6 May 2015 1 July 2015 Anyone interested in sitting the exam is welcome to attend this informal peer review study group. Please contact Clive Gibson via c.gibson@rcsed. ac.uk There is no charge to attend; each meeting is eligible for two hours’ verifiable CPD.
/ PRESENTATIONS
Award-winning Wessex trainees are all smiles
T
he Royal College of Surgeons of Edinburgh has once again proudly supported trainee presentations at the Wessex BDA Hospitals Group meeting. At the popular event, which took place in Salisbury on 20 May 2014, the College sponsored prizes in three categories: best SHO audit, best SHO case report and best specialist trainee presentation. The winner of the specialist trainee prize was Mark Bainbridge, a post-CCST orthodontic specialist trainee from Portsmouth. Mark explored anchorage concepts in orthodontics, giving an overview of how anchorage could be used to resist unwanted movements. Mark presented a case in which a mini implant had been used to supplement anchorage on one side of the mouth, whereas more conventional 38 | Surgeons’ News | September 2014
anchorage techniques had been used on the other. Mark used this case to illustrate impressively the concepts of conventional anchorage, maximum anchorage and absolute anchorage. The winner of the SHO case presentation prize was Kathryn French, maxillofacial SHO at Salisbury. She presented an unusual case of developmental facial deformity, which had been managed in conjunction with Mr T Flood, consultant maxillofacial surgeon, and Mr M Richards, lead maxillofacial technician. Her young patient presented at eight years of age complaining of nasal deformity and blockage, facial asymmetry and consequential bullying. The patient had experienced facial trauma when she was two weeks old. In her presentation, Kathryn explored some of the difficulties involved in managing facial deformity in young
patients, in particular how and when to intervene surgically. The final prize was awarded to Katy Tidbury, maxillofacial SHO at Salisbury. Katy explored changes to quality of life following cleft osteotomies. Using a Quality of Life questionnaire, she gathered information from 36 cleft patients before and six months after their osteotomy. This questionnaire evaluated the reason for the patient undergoing the treatment as well as changes to social aspects of their life, such as confidence and happiness with appearance. Katy was able to demonstrate improvements in quality of life after the surgery and she also collected valuable data on any postoperative complications experienced. Mrs Pamela Ellis, Consultant Orthodontist, Dorset County Hospital, and RCSEd Dental Regional Adviser
/ HONOURS
KEY DATES IN OCTOBER
The RCSEd Faculty of Dental Surgery is set to hold some of its most important events of the year THURSDAY 23 OCTOBER 2014 2pm: King James IV Professorship Lecture Professor Crispian Scully CBE Symposium Hall, RCSEd 3.30pm: Dental Symposium – Celebrating 60 Years of Dental Council Dr G Howard Moody Symposium Hall, RCSEd
7.30pm for 8pm Dental Triennial Dinner Signet Library, Parliament Square, High Street, Edinburgh FRIDAY 24 OCTOBER 2014 12.15pm: Annual General Meeting Symposium Hall, RCSEd For further information, contact Linda Stuart at l.stuart@rcsed. ac.uk; 0131 527 1605
Global medals open for nominations Nominations are invited for the awards of the Faculty of Dental Surgery (Home) Medal and the Faculty of Dental Surgery (International) Medal of the RCSEd. Those submitting nominations for either award should provide clear reasons why the individual should be considered for the award. Each medal may be given to dentists or others who have made a distinguished contribution to the faculty, College and dentistry. The closing date for nominations is 7 November 2014. For more information on the criteria or to nominate someone, contact Linda Stuart at l.stuart@rcsed.ac.uk
Faculty Fellow’s work recognised with MBE
T
he work of a Fellow of the Faculty of Dental Surgery has been recognised in the Queen’s birthday honours list. Anthony Griffin was appointed a Member of the Order of the British Empire for services to Dental Technology. Mr Griffin has worked for more than 30 years in a variety of management roles, starting at People’s College of Further Education in Nottingham and, later, with direct links to De Montfort University, Leicester. He now has a portfolio that includes a national quality assurance role, a healthcare support service, and Council membership and Fellowship of the Dental Technologist Association. Commenting on his award, Mr Griffin said: “I have been fortunate to have, and I am still having, a very interesting career with many opportunities to work in support of improving health in the UK and also being able to work with a wide range of educational initiatives to encourage learning. Being the recipient of an MBE was a delightful surprise.”
Anthony Griffin was delighted to be on the Queen’s honours list
/ FEES
GDC and BDA clash over plans for 64% fee hike
T
he British Dental Association (BDA) has signalled its opposition to General Dental Council (GDC) proposals to increase the Annual Retention Fee (ARF) by 64%. Under the proposal, the ARF would rise from £576 to £945 and help the GDC collect an extra £18m, which the BDA says is needed to deal with an anticipated increase in complaints and Fitness to Practise hearings. A statement on the GDC website says: “Since 2010 when we last increased the ARF, there has been a 110% increase in the number of complaints from patients and members of the public, employers, other registrants and
the police about GDC registrants. As a result, we need additional funds to investigate these complaints and where necessary to bring Fitness to Practise cases involving dentists and DCPs.” The BDA has responded by surveying its members about the proposal and their confidence in the GDC. BDA chair Dr Mick Armstrong said: “The suggestion that the profession pay more to fund a council that has been shown unable to do its job properly is astonishing. The rise would be unpalatable at the best of times but, coming now, it just looks like the profession is being asked to foot the bill for the GDC’s incompetence.” www.gmc-uk.org www.rcsed.ac.uk | 39
DENTAL
BRIDGING THE GAP Parmilan Gill profiles Bridge2Aid, the global charity bringing dental care to rural communities in developing countries
M
ost of us have suffered from toothache at some point in our lives. It can be debilitating, causing us to experience problems with communicating, eating and smiling. Those of us living in more ‘developed’ countries would make an urgent appointment to see the dentist, but 75% of the world’s population have no access to a dentist or to emergency dental treatment. Dentists are gravely needed in rural areas of ‘developing’ countries across the African continent. Traditional diets are beginning to incorporate sugarfilled foods, leading to a dramatic rise in dental decay. Lack of access to basic dental care is a serious problem and, if problems are not treated appropriately, they can lead to infection and death. Bridge2Aid attempts to address this issue by using UK-based dentists to train rural healthcare officers (RHOs) in remote communities. Since 2005, 3.1 million people in Tanzania alone have been given access to 40 | Surgeons’ News | September 2014
Parmilan Gill
works as a specialty doctor in oral and maxillofacial surgery, and in her spare time volunteers with Bridge2Aid as an assistant clinical lead
The RHOs are presented with certificates and equipment on successful completion of their training
emergency dental care thanks to Bridge2Aid’s training programmes. I am a UK-based dentist and a returning volunteer to Bridge2Aid, with my first trip being two years after qualifying. My most recent trip was in September 2013 as part of a team of eight dentists and three dental nurses. Our base was the Geita region in the north-west of Tanzania. Geita is a gold-mining hub with a population of more than 700,000. We visited two villages, which were a bumpy two-hour drive from our base. On arrival, we would often be greeted by more than 100 patients awaiting treatment. Many of them had been in pain for years, and had walked for days or even weeks to seek free treatment from Bridge2Aid. The equipment employed in training is simple as it is for use in environments where access to electricity and clean water is mostly nonexistent. Sterilisation of instruments is carried out in a pressure cooker. After setting up, the UK dentists took it in turns to run daily seminars with the RHOs. They had already done dental theory training in preparation for practical training, and it was incredible to see them develop: on day one, they barely knew how to hold a syringe, yet by the end of the training period, they were confidently extracting teeth. The elation of an RHO when they correctly extracted a tooth was priceless.
SINCE 2005, 3.1 MILLION PEOPLE IN TANZANIA HAVE BEEN GIVEN ACCESS TO EMERGENCY DENTAL CARE DUE TO BRIDGE2AID’S TRAINING PROGRAMMES A team debrief wrapped up each day with discussion on progress made during the training session, the strengths and weaknesses of the RHOs, and how to help their development. The dental nurses assessed whether the RHOs were competent in oral-health education and sterilisation protocols. The RHOs sat a written exam at the end of the practical training and it was at our discretion to decide whether they were competent in the practical aspects. Upon successful completion of the training, all five RHOs received a set of basic dental instruments and a pressure cooker. Newly trained RHOs are provided with an initial support network by Bridge2Aid until their confidence and experience grows, with the government’s local health service absorbing this responsibility at the appropriate time. Prior to my first trip with Bridge2Aid, I had many anxieties, which all proved groundless. The support and organisation from Bridge2Aid was second to none: I was fed and watered at all times, and I was never worried for our safety. And at the end of the trip, I could opt to stay for a two-day safari of the Serengeti – an option that I would highly recommend to any volunteer, as it was an unforgettable experience. My involvement with Bridge2Aid is not solely due to a sense of duty. Helping people to be free from pain is amazing and I loved every minute of the experience. I have had the pleasure of working with talented, inspirational people, many of whom have become friends for life.
An RHO discusses proposed treatment with the patient’s mother
How are the RHOs progressing? Mary Mahamba serves a community of approximately 10,000 people. Before Bridge2Aid training, she would see at least 20 people each month with dental pain and would often treat them with expensive antibiotics, which many people can’t afford. Since completing training, she has treated almost all her dental patients with extractions of problematic teeth. All patients received oral health education.
www.bridge2aid.org Thank you to Kayleigh Twist from Bridge2Aid for her assistance with this article
Simeon Mugybuso is 26 and works in a community of around 1,000 people. Following training, he has extracted numerous teeth and given his dental patients oral health education. He is confident that the learning outcomes of the Bridge2Aid training were met fully.
Patient stories An end to years of suffering Seven-year-old Mariam had been living with agonising toothache for years. Her studies were suffering and Mariam’s family was concerned about the swelling to her face. When she heard about the free treatment being offered by Bridge2Aid, Mariam’s mother, a cotton farmer, hired a bicycle for 3,000Tsh (approximately £1.05) and cycled for four hours with Mariam to Bridge2Aid at the health
centre. After four years of pain and sleepless nights, Mariam’s pain was finally relieved. Mary is 25 years old, widowed with three children. She works on a local farm. She had been suffering with toothache for more than seven years, until eventually the infection tracked out and manifested as extra oral sinuses. She had walked for
three weeks to seek free treatment from Bridge2Aid. Yasinta is 27 years old and married with two young children. She farms cotton, cassava and potatoes for a living. She had been living with dental pain for over four years, and walked for hours to reach the health centre, where the problematic teeth were removed successfully.
www.rcsed.ac.uk | 41
TRAINEES AND STUDENTS
Following the UKFPO’s decision to award points only for qualifications and publications, many students are preparing their work for submission to the competitive world of peer-review publishing. Here, we speak to one student who developed her conference abstract into a full review article and succeeded in having it accepted by a major specialty journal
POINTED IN THE RIGHT DIRECTION?
U
niversity of East Anglia undergraduate Charlotte Maplanka’s abstract ‘Is there a role for routine omentectomy in the management of gallbladder cancer?’ won Best Poster Presentation at the National Conference for Aspiring Surgeons in Bristol on 2 March 2013 and in March 2014 was published in the Journal of Gastrointestinal Cancer. Charlotte’s success story is an example of the value in presenting at such conferences. While this exercise may no longer count towards points, it still proves an invaluable experience for medical students, foundation doctors and trainees in preparation for their future careers. Praising Charlotte’s achievement, conference convener and professor of medical education at the University of Bristol, Davinder Sandhu, said: “We, the custodians of the next generation, need to do more to support young students and doctors. Encouragement comes from recognition of effort. Those that go the extra mile to present their contribution should be congratulated.” Professor Sandhu, who is also national surgical director of the College’s Regional Surgical Advisory Network, added: “If the majority push themselves for a national presentation to raise their profile and in return get an extra point for their Foundation application it should not be discouraged. We are dealing with highly intelligent and innovative students who deserve to be nurtured to become champions of the future.” Here, Charlotte tells us about her experience at the conference, her success in becoming published and her thoughts on the changes by the UKFPO.
SURGEONS CONFERENCE IN 2013 TO COUNT TOWARDS YOUR FOUNDATION PROGRAMME APPLICATION? Absolutely! Although I hadn’t specifically set out just to score points, I did think that a national conference presentation at an RCSEd event would be a positive contribution in enhancing my application for attractive foundation posts in the face of fierce competition.
HOW DID YOU FEEL WHEN YOU LEARNED THAT PRESENTATIONS AT NATIONAL CONFERENCES WERE NO LONGER BEING ACCEPTED AS EDUCATIONAL ACHIEVEMENTS BY THE UKFPO? I was a bit disappointed – not just for myself, but all other students who work just as hard to take part, and for the organisers and assessors of national conferences and competitions in general because of the time they invest in organising such fantastic events. These give students platforms for learning and networking, and although I didn’t enter the competition just to score points, gaining points towards the UKFPO for presenting at meetings arranged by verified organisations encourages learning from various platforms/formats. It also provides incentives and opportunities for independent research, to network with like-minded people, communicate with tutors and do activities that ensure we will become well-rounded doctors.
AT WHAT POINT DID YOU DECIDE TO PURSUE PUBLISHING YOUR ABSTRACT?
I look forward to applying when I am in my final year. I am currently taking a break from my studies with an aim to resume medical school in September.
During my presentation, well before I knew the outcome. The assessors asked questions that stimulated a lot of discussion; I remember exploring the difficulties faced in assessing surgical interventions for a cancer that is not very commonly encountered and at that moment I was very much inspired to research a bit more and develop my work.
DID YOU INTEND FOR YOUR POSTER PRESENTATION AT THE ASPIRING
WAS IT DIFFICULT TO CONVERT YOUR POSTER ABSTRACT INTO
WILL YOU SOON BE APPLYING TO THE FOUNDATION PROGRAMME?
42 | Surgeons’ News | September 2014
A PUBLISHABLE REVIEW ARTICLE? As I left the conference very motivated, I felt compelled to get on with the work. I could visualise what I wanted and was rather excited to do it, but the reality of writing a full article was hard work and required a lot of discipline.
Charlotte Maplanka says conferences can play a big part in student motivation
HOW DID YOU GO ABOUT GETTING PUBLISHED? I had already received useful feedback and support from my tutors in preparing the poster and the discussions with the conference assessors helped to create a clear plan to develop the work into a full article. Once the plan was set, I sent it to my surgical mentor, Mr Darren Morrow, consultant vascular surgeon, with a request for advice and guidance on how to research and present written work to surgical experts. He was very generous with his time and pointed me in the right direction. I also received helpful feedback from other specialists (surgical and non-surgical) on various aspects of my work.
WAS PRESENTING YOUR ABSTRACT AND WINNING BEST POSTER AN ADVANTAGE IN GETTING YOUR WORK PUBLISHED? Without a doubt. It was discussions with the assessors that furnished a clear plan of what to do next. I was left with some unanswered questions along with numerous points for consideration. It was those questions that inspired the review, and winning essentially became extra motivation and the propellant for completing the review.
DID YOU APPROACH MANY JOURNALS BEFORE YOUR ABSTRACT WAS ACCEPTED? I made no attempt at publishing the abstract alone. I mainly focused on completing the review first then submitting it. I imagine that this is probably not the proper way to go about it but I wanted to complete the work first. I first tried to submit a different version to a more general nonspecialist surgical journal, which gave positive feedback but highlighted that the work was not a priority. Therefore I rewrote the review and made a fresh submission to a specialist journal (Journal of Gastrointestinal Cancer) and they asked me to revise and resubmit within a month, and the manuscript was accepted within a few hours.
HOW DOES IT FEEL TO HAVE YOUR WORK PUBLISHED? It’s still very emotional. It’s such a humbling honour and I am truly grateful. A lot of work and effort went into the review; I am absolutely overwhelmed and I thank the RCSEd, the National Conference for Aspiring Surgeons and all my tutors who helped me.
DO YOU STILL THINK IT IS WORTHWHILE FOR STUDENTS TO PRESENT AT CONFERENCES SUCH AS THE ONE YOU ATTENDED, EVEN THOUGH THEY CAN NO LONGER GAIN POINTS FOR THEIR
It’s still very emotional, a humbling honour, and I thank the RCSEd, the National Conference for Aspiring Surgeons and all my tutors who helped me FOUNDATION PROGRAMME APPLICATION? Absolutely. The experience of presenting should serve one well throughout one’s surgical career. Furthermore, the feedback and discussions with the conference assessors are very helpful and remain a useful learning tool. Generally, I learnt how to present my own research work to experts, to discuss topics with specialists, consider options and how to further develop my research work for publication.
WHAT ADVICE WOULD YOU GIVE FELLOW STUDENTS WHO ARE LOOKING TO HAVE THEIR WORK PUBLISHED? Everyone has the potential to publish. I can share only what has worked for me and that is having a strong support system both in my personal life and in tutors with regards to training. I’ve found it very important and encouraging to have an approachable, supportive and positive surgical mentor in Mr Morrow, who believes in me as a student and makes me feel that anything is possible. I would add that writing a publishable article is very demanding and requires openness to honest critique. But it is all very much worth it in the end, and I suppose it makes it easier to find and work on a topic that one is truly passionate about, so go for it.
www.rcsed.ac.uk | 43
TRAINEES AND STUDENTS
How can we make it easier to implement Less Than Full-time Training in surgery?
Rhiannon Harries ASiT Webmaster and Representative for Wales and General Surgical Registrar, Wales Deanery Contributing Authors, ASiT Council: Ciara McGoldrick, Laura Derbyshire, Justice Reilly and Edward Fitzgerald
TIME FOR A RETHINK
L
ess Than Full-time Training (LTFT) is training undertaken while working a reduced number of hours, resulting in a relative lengthening in the number of years spent training. LTFT is usually no less than 50% of full-time training, but can be less (to a minimum of 20% for up to 12 months) if agreed by all interested parties. To be eligible for LTFT, there must be a ‘well-found reason’ for not being able to work full time, perhaps because of disability or ill health, or being a carer for children or an ill or disabled partner, relative or other dependant, or there are unique opportunities for personal or professional development.
44 | Surgeons’ News | September 2014
Approval for LTFT is given by the trainee’s postgraduate Local Education and Training Board (LETB) in agreement with the local hospital trust. Funding for LTFT posts is provided by the postgraduate LETB (educational component of basic pay) and the local hospital trust (on-call banding arrangement).
GROWING NEED FOR LTFT Despite increasing numbers of female doctors in the UK1 and female trainees applying to core surgical training and higher surgical training (30% and 16%, respectively, 20122), only 10% of consultant surgeons are women3.
THERE IS CONCERN OVER THE SUPPORT GIVEN TO TRAINEES DURING LTFT SURGICAL POSTS IN PROVIDING AND MAINTAINING A BALANCED TIMETABLE TO MEET THE NECESSARY COMPETENCIES OF THEIR TRAINING sharing requires two surgical trainees to work the hours of one full-time trainee. From a surgical training perspective, slot sharing has a number of problems. There may be no other trainees eligible for LTFT within the same LETB and specialty, making slot sharing impossible. There may be eligible trainees, but they have different specialty or operative needs, making slot sharing unsuitable. Surgical rotations (particularly for smaller surgical specialties) often cover larger geographical areas, making slot sharing impractical. It is considered unacceptable that higher surgical trainees in LTFT should have to share operative training sessions with another higher surgical trainee, as this has an impact on their training experience and competencies gained.
RECOMMENDATIONS
It is suggested that women choose not to continue with higher surgical training, as this is the peak age for childrearing2. As the majority of females in LTFT are women returning to work after having children, it would suggest that LTFT is vital to maintaining the inevitably increasing female surgical workforce4.
CURRENT CONCERNS The numbers of LTFT posts available in the UK are currently low, with only 151 LTFT surgical trainees in 20115, and may become inadequate with rising numbers of female surgical trainees. Concerns have been raised over the lack of information surrounding access to LTFT posts for surgical trainees, as well as a significant difference between LETBs. There is also concern over the support given to trainees during LTFT surgical posts in terms of providing and maintaining a balanced timetable to meet the necessary competencies of their training. The current system supports three ways that LTFT can be incorporated into the system. The trainee can be in a full-time slot, supernumerary or slot sharing. Although logistically easier for local hospital trusts to manage, slot
REFERENCES 1. GMC State of Medicine 2011. www.gmc-uk. org/State_of_ medicine_ Final_web.pdf_ 44213427.pdf 2. McNally S. Surgical training: still very competitive, but still very male. Bull Roy Coll Surg Engl 2012; 94(2): 53â&#x20AC;&#x201C;55. 3. NHS Hospitals and Community Health Services: Medical and Dental Staff, England 1997â&#x20AC;&#x201C; 2007. Leeds, UK: The information Centre for Health and Social Care. 2008. 4. J ones M, Montgomery J & Thomas S. Flexible training has matured. BMJ 2008. http://careers. bmj.com/ careers/advice/ view-article. html?id=3062 5. Department of Health. Workforce Census 2011.
There should be increased provision and funding for LTFT posts in surgery, in all specialities, in all postgraduate LETBs. Information, which is consistent throughout the UK and Republic of Ireland, should be readily available for all surgical trainees considering applying for LTFT. Individual LETBs should outline basic information, including eligibility criteria and the application process, as well as a point of contact for advice on their websites. On a practical basis, having a LTFT adviser within each school of surgery, in addition to within each LETB, who would have closer links with trainees and trainers on a local level, could ease ongoing challenges. Education and encouragement should be provided to junior trainees and medical students to make them aware that LTFT can be compatible with surgical training. The ARCP panel should support surgical trainees in LTFT and help to meet their individual learning needs. Higher surgical trainees in LTFT should not have to share operative training sessions with another higher surgical trainee. For those undergoing LTFT training after returning to work following childbearing, ideally the options for and availability of LTFT posts should be initiated by the LETB and the training programme director with the trainee when they inform them of their intention to take a period of maternity leave. The length of time required to approve a LTFT post varies between LETBs, and trainees should be made aware of this. Additionally, training programme directors should be transparent with trainees at this stage if there have been significant difficulties in approving LTFT slots in the past so that modifications and alternatives can be considered. The Association of Surgeons in Training has produced a position statement discussing the issues around provision of LTFT within surgical specialities, which can be found at www.asit.org/resources/articles
www.rcsed.ac.uk | 45
TRAINEES AND STUDENTS
Annual skills event delivers on quality The fourth Northern Surgical Skills Conference has taken place at the Education Centre, Sunderland Royal Hospital, in association with the RCSEd and Newcastle University
T
his year’s Northern Surgical Skills Conference was organised by Newcastle medical students under the supervision of Mr Venkat Kanakala, the convenor, and Mr Peter Small, the conference director. The conference was attended by students not only from Newcastle University, but also from Keele and Edinburgh universities. Mr Small, consultant upper GI surgeon at Sunderland Royal Hospital, and Dr Andrew Mellon, director of medical education and clinical sub-dean at Newcastle University, jointly welcomed the delegates and opened the proceedings. As before, the main focus of the conference was on practical skills. Students were given the opportunity to learn basic suturing and then undertook biopsies, abscess drainage and tendon repairs on pork belly and trotters. We are proud of the practical skills teaching on offer and this year’s meeting did not disappoint. Students had an excellent opportunity to interact and learn skills from senior faculty on a one-to-one basis. They then got a taste of keyhole surgery using state-of-the-art laparoscopic equipment.
CONFERENCE DIRECTOR Mr P K Small CONVENOR Mr V Kanakala ORGANISING COMMITTEE • Miss Hannah Hayhurst • Mr Andrew Jajja • Miss Miriam Poulsam • Miss Claire Hardie • Mr Samuel Tingle
Students had an excellent opportunity to interact and learn skills from senior faculty on a one-to-one basis
46 | Surgeons’ News | September 2014
The clinical skills prize, for which delegates competed by stacking sugar cubes laparoscopically, was won by Miss Harriet Crook. Students also had an opportunity to test their hand-to-eye co-ordination skills on a Simendo computer laparoscopic simulator. Talks were given in the morning by Mr Small, speaking on the past, present and future of surgery, and by Mr Mike Clarke, consultant vascular surgeon and regional representative of RCSEd, regarding human factors in surgery. Afternoon talks focused on career development in surgery, with information about the life of a surgeon from Mr Simon Jones, programme director of core surgical training, Northern Deanery. A stimulating talk on developing a strong surgical portfolio was given by Mr Ben Banerjee, consultant vascular surgeon, Sunderland Royal Hospital. Dr Iain Anderson, an F2 doctor in the RVI, rounded up with what to expect as a surgical F1. Abstracts submitted for presentation were assessed by a team of experienced surgeons and were of an extremely high standard. The oral presentation prize was awarded to Rebecca Webb-Mitchell for her presentation on ‘Changes in exercise capacity after paediatric heart transplantation’, and the poster prize went to Toby Hoskins for ‘The use of electronic media to deliver a preoperative exercise programme to reduce postoperative complications’. We are extremely grateful to our sponsors – the Royal College of Surgeons of Edinburgh, Karl Storz, Ethicon Endo-Surgery and Covidien – for their generous support. Thank you also to all the faculty members who gave up their time to help make the day a success. We hope that the insightful talks and unrivalled practical skills teaching will help this year’s students on their journey to becoming surgeons.
REGIONAL SURGICAL ADVISERS IN YOUR AREA
4
5
The College’s support and advice network throughout the country
3
1 Surgical Director of the Advisery Network
8
6
Davinder Sandhu, University of Bristol, Bristol, Severn 2 Associate Surgical Director of the Advisery Network Steven Backhouse, Princess of Wales Hospital, Bridgend, Wales
7
10 9
12 13
11 31
SCOTLAND
EAST OF SCOTLAND 3 Graham Cormack, Ninewells, Dundee 3 Sam Majumdar, Ninewells, Dundee
29 45
32 30 43
45
NORTH OF SCOTLAND 4 Morag Hogg, Raigmore Hospital, Inverness 4 Sean Kelly, Raigmore Hospital, Inverness 5 Aileen McKinley, Aberdeen Royal Infirmary, Aberdeen 5 Euan Munro, Aberdeen Royal Infirmary, Aberdeen
44 28 27
25
47
42
26
19
WEST OF SCOTLAND 6 Lindsey Chisholm, Royal Alexandra Hospital, Paisley 7 Jon Dearing, Ayr Hospital, Ayr 8 Martyn Flett, Royal Hospital for Sick Children, Glasgow 9 Calan Mathieson, Southern General Hospital, Glasgow 10 Chris Rodger, Forth Valley Royal Hospital, Larbert 11 Mary Shanks, Crosshouse Hospital, Kilmarnock
39
17 18
15
40
16
41
2
45
34
33
1
23 24
SOUTH EAST OF SCOTLAND 12 Farhat Din, Western General Hospital, Edinburgh 13 Anna Paisley, Royal Infirmary of Edinburgh, Edinburgh 13 Zahid Raza, Royal Infirmary of Edinburgh, Edinburgh
35
20
38 36 37
21
22
ENGLAND
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
OXFORD 33 Chris Cunningham, Churchill Hospital, Oxford 34 Richard O’Hara, Milton Keynes Hospital, Milton Keynes 33 Mike Silva, Churchill Hospital, Oxford
EAST MIDLANDS 17 David Exon, Leicester Royal Infirmary, Leicester 18 Sridhar Rathinam, Glenfield Hospital, Leicester 19 Bill Tennant, Queen’s Medical Centre, Nottingham University Hospital
SOUTH WEST PENINSULA 35 Simeon Brundell, Derriford Hospital, Plymouth 35 Ken Hosie, Derriford Hospital, Plymouth
KENT, SURREY & SUSSEX 20 Jonathan Clasper, Frimley Park Hospital, Surrey 21 Mike Lewis, Royal Sussex County Hospital, Brighton 22 Mike Williams, Eastbourne District General Hospital, Eastbourne
WESSEX 36 Anthony Evans, Portsmouth Hospital, Portsmouth 37 Dominic Hodgson, Queen Alexandra Hospital, Portsmouth 38 Vel Sakthivel, Southampton General Hospital, Southampton
LONDON 23 Robert Mason, St Thomas’ Hospital 24 Ziali Sivardeen, Homerton University Hospital
WEST MIDLANDS 39 Ishan Bhoora, Cannock Chase Hospital, Staffordshire 40 Rajiv Vohra, Queen Elizabeth Hospital Birmingham, Birmingham 41 Ling Wong, University Hospital Coventry and Warwickshire, Coventry
MERSEY 25 Azher Siddiq, St Helen’s Hospital, St Helen’s 26 Venkat Srinivasan, Arrowe Park Hospital, Wirral NORTH WESTERN 27 Stuart Clark, Manchester Royal Infirmary, Manchester 28 Jeremy Ward, Royal Preston Hospital NORTHERN 29 Mike Clarke, Freeman Hospital, Newcastle 30 Jonathan Ferguson, James Cook University Hospital, Middlesbrough 31 Paul Gallagher, Wansbeck Hospital, Northumberland 32 Ian Hawthorn, University Hospital of North Durham
YORKSHIRE & HUMBER 42 Aidan Fitzgerald, Northern General Hospital, Sheffield 43 Clare McNaught, Scarborough Hospital, Scarborough 44 David O’Regan, Leeds General Infirmary, Leeds 45 Mark Steward, Bradford City Hospital, Bradford
NORTHERN IRELAND
46 Sean Patton, Craigavon Area Hospital, Portadown
WALES
47 Vaikuntam Srinivasan, Glan Clywd Hospital, Rhyl
Surgeons News | 47
14
COLLEGE INFORMATION
DIPLOMA CEREMONIES Congratulations to all our new Fellows and Members who were presented with diplomas at the ceremony on 4 July ADMISSION TO FELLOWSHIP AD HOMINEM Professor John Birkmeyer George D Zudeima, Professor of Surgery & Director, Centre for Healthcare Outcomes and Policy, University of Michigan, presented by Professor Robert Steele, Member of Council Professor Benjamin Joseph, Retired Consultant Orthopaedic Surgeon & Professor of Orthopaedics, Kasturba Medical College, presented by Mr Alistair Gibson, Member of Council Professor Robert Madoff FACS, Chief of the Division of Colon and Rectal Surgery & Stanley M Goldberg MD, Chair in Colon and Rectal Surgery, Director, William C. Bernstein MD, Familial Cancer Registry, University of Minnesota Medical School, presented by Professor James Garden, Member of Council AWARD OF FELLOWSHIP WITHOUT EXAMINATION Dr Jaydip Biswas FICS, Director and Head, Department of Surgical and Medical Oncology, Chittaranjan National Cancer Centre AWARD OF FELLOWSHIPS IN DENTAL SURGERY WITHOUT EXAMINATION Mr Rahul Naidu MFDS RCSEd, Faculty of Medical Sciences, University of the West Indies, Trinidad & Tobago Professor Mahesh Verma, Director & Principal, Maulana Azad Institute of Dental Sciences PRESENTATION OF THE HUNTER DOIG MEDAL Jennifer Margaret Jane Robson, University of Edinburgh PRESENTATION OF DIPLOMA OF FELLOWSHIP IN THE SPECIALTY 48 | Surgeons’ News | September 2014
OF CARDIOTHORACIC SURGERY Paul Richard Vaughan, University of Sheffield PRESENTATION OF DIPLOMAS OF FELLOWSHIP IN THE SPECIALTY OF GENERAL SURGERY Gnaneswar Atturu NTR, University of Health Sciences, India Layal El-Asir, University of Jordan James Alexander Milburn, University of Aberdeen Daya Bihari Singh, University of Calcutta, India Vivek Srivastava, University of Wales PRESENTATION OF DIPLOMA OF FELLOWSHIP IN THE SPECIALTY OF OPHTHALMOLOGY Shah Md Rezaul Karim, University of Dhaka, Bangladesh PRESENTATION OF DIPLOMAS OF FELLOWSHIP IN THE SPECIALTY OF OTOLARYNGOLOGY Bethan Fon Jones, University of Wales Catherine Mary Smyth, Queen’s University, Belfast Himanshu Swami, University of Pune, India PRESENTATION OF DIPLOMA OF FELLOWSHIP IN THE SPECIALTY OF UROLOGY Ather M Abdelbaky, Cairo University, Egypt PRESENTATION OF DIPLOMAS OF FELLOWSHIP IN THE SPECIALTY OF TRAUMA & ORTHOPAEDIC SURGERY Saurabh Aggarwal, University of Rajasthan, India Sudhakar Rao Challagundla, Osmania Medical College, India Rupen Gordhandas Dattani, University of Wales Praveen Kumar Inaparthy, NTR
University of Health Sciences, India Royston Dwayne Wharton, University of the West Indies PRESENTATION OF THE McCORMACK MEDAL Malcolm Brodie Will, University of Glasgow PRESENTATION OF THE SYME MEDAL Ricky Harminder Bhogal, University of Leicester Karen Ann Eley, University of Liverpool PRESENTATION OF FELLOWSHIPS OF THE FACULTY OF SURGICAL TRAINERS Philip David Earl, University of London Davinder Pal Singh Sandhu, University of London PRESENTATION OF MEMBERSHIP OF THE FACULTY OF SURGICAL TRAINERS Andrew Richard McAndrew, University of London PRESENTATION OF DIPLOMA OF MEMBERSHIP IN OPHTHALMOLOGY Saajan Kukreja Liaquat, University of Medical & Health Sciences, Pakistan
Okwu Timothy Okwu, University of Calabar, Nigeria Justin Chong Li Ong, Queen’s University, Belfast Antunes Pereira, Charles University, Prague Arumughan Sasikumar, University of Calicut, India Chin Jin Seo, National University of Ireland Stephanie Sarah Young, University of Dundee PRESENTATION OF DIPLOMA IN IMMEDIATE MEDICAL CARE Samuel Ley, University of Glasgow PRESENTATION OF THE BASICS MEDAL Samuel Ley, University of Glasgow PRESENTATION OF DIPLOMAS OF FELLOWSHIP IN DENTAL SURGERY WITHOUT EXAMINATION (by application) Abhishek Kshetrapal, Manipal University, India Christopher Ian Lowe, Universityof Sheffield Adil Osman Mageet, Bangalore University, India PRESENTATION OF DIPLOMA OF MEMBERSHIP IN OTOLARYNGOLOGY Anusha Balasubramanian, International Medical University, Malaysia PRESENTATION OF INTERCOLLEGIATE DIPLOMAS OF MEMBERSHIP IN SURGERY IN GENERAL Rana Jahangir Alam, University of Chittagong, Bangladesh Oomen Mathew Arikupurathu, Kerala University, India G Vijay Bhargava, Osmania University, India James Peter Blackmur, University of Edinburgh Georgina Marian Bough, Newcastle University William George Britnell, University of Manchester Mariana Oliveira E Costa David James Curry, Queen’s University, Belfast John Michael Hallett, University of Edinburgh Abigail Lucy Hayward, University of Aberdeen Hannah Kranenburg, University of Cambridge Biju Murali, Kerala University, India Gulam Murtaza, Samara State Medical University, Russia Jamie Andrew Nicholson, University of Aberdeen
PRESENTATION OF THE JOHN McDONALD MEDAL Hannah Carolyne Jack, University of Otago, New Zealand PRESENTATION OF DIPLOMAS OF MEMBERSHIP IN ORTHODONTICS Mark Bainbridge, University of Sheffield Victoria Jane Beck, University of Otago, New Zealand Hannah Carolyne Jack, University of Otago, New Zealand Audrey Frances Pace, University of Malta Rachna Patel, University of London PRESENTATION OF DIPLOMA OF MEMBERSHIP IN PERIODONTICS Eugene Michael Gamble, University of Manchester
PRESENTATION OF DIPLOMAS OF MEMBERSHIP IN PAEDIATRIC DENTISTRY Yasir Othman Bin Ahmed, King Saud University, Saudi Arabia Ravinder Kaur, University of Sheffield Aida Mesbahi, Shiraz University, Iran PRESENTATION OF DIPLOMA OF MEMBERSHIP OF THE FACULTY OF DENTAL SURGERY David Drysdale, University of London PRESENTATION OF DIPLOMAS IN IMPLANT DENTISTRY Vineeth Balachandran, Rajiv Gandhi University of Health Sciences, India Wleed Ul Haq, University of Birmingham Atul Kothari, University of Glasgow Chetan Christy Mathias, Rajiv Gandhi University of Health Sciences, India Gulshan Kumar Murgai, University of Birmingham Irfan Qureshi, Baqai Medical University, Pakistan Preeti Shah, University of London PRESENTATION OF DIPLOMAS IN ORTHODONTIC THERAPY Esther Barry, University Dental Hospital of Manchester Tracy Dibden, Bristol Dental Hospital Emily Freda Gates, Bristol Dental Hospital Sharon Mary Hayes, Bristol Dental Hospital Julie Ann Hodgson, University Dental Hospital of Manchester Michelle Jones, University Dental Hospital of Manchester Brita McCartan, Bristol Dental Hospital Corrina Helen Smith, Bristol Dental Hospital Nicola Jane Southgate, Bristol Dental Hospital Gemma Tracey Swan, Bristol Dental Hospital
IN MEMORY HONORARY FELLOWS Sultan Azlan SHAH (FRCSEd Hon 1993) FELLOWS Charles James Barton ANDERSON (FRCSEd 1946) John CHAMBERLAIN (FRCSEd 1967) Hussein Ibrahim EL-AZGHAL (FRCSEd 1963) Ian Clifford FARMER (FRCSEd 1975) Rodney Philip HEWITSON (FRCSEd 1950)
Alexander Daniel HOLT-WILSON (FRCSEd 1975) Ashley John MILLER (FRCSEd 1969) Amarish Jagmohan PARIKH (FRCSEd 1962) Nilay Nimit Sunil PATEL (FRCSEd 2002) John Kenneth Percival PERERA (FRCSEd 1959) John Howard WHEELER (FRCSED 1967) Leslie Louis WILLIAMS (FRCSEd 1959)
www.rcsed.ac.uk | 49
COLLEGE INFORMATION
CONGRATULATIONS TO THE FOLLOWING AWARDS AND GRANTS RECIPIENTS UNDERGRADUATE BURSARIES C Alexander, University of Aberdeen: Visit to Nuffield Department of Surgical Sciences, University of Oxford, for “Recurrent urological stone disease: can it be predicted and what are the implications of repeated ionising radiation exposure?” S Khan, University of Manchester: Visit to ENT Department, Salford Royal Hospital, for “Regrowth of surgically treated vestibular schwannomas in neurofibromatosis type 2” P Karunakaran, University College Dublin: Visit to Temple Street Children’s University Hospital, Dublin, for “Volumetric and craniometric changes in posterior cranial vault distraction for syndromic craniosynostosis” T Roxanne, University of Glasgow: Visit to the University of Cambridge for “Inhibition of humoral alloimmunity by transfer of third-party regulatory T cells with direct allospecificity for host MHC alloantigen” M Twoon, University of Aberdeen: Visit to Plastics & Reconstructive Surgery Unit, Aberdeen Royal Infirmary/NHS Grampian, Aberdeen, for “Lateral mammoplasty instructional video” ETHICON TRAVEL GRANT S Latis, The Royal Melbourne Hospital, Australia – Surgical Head and Neck Oncology Fellowship ETHICON BURSARY C Alexander, James Buchanan Brady Urological Institute, Johns Hopkins Hospital, USA C MacLeod, Aswan Heart Centre in Egypt S Vivekanantham, Department of Neurosurgery, Christian Medical College, India R Gohil, Ophthalmology Department, Australia
50 | Surgeons’ News | September 2014
All the latest grants, fellowships and bursaries from the RCSEd
AWARDS & GRANTS
SMALL RESEARCH GRANTS (UP TO £10K)
Applications are invited from surgical trainees and recently-appointed consultants who are Fellows or Members. Grants are awarded for pump-priming projects for a period of one year only. Research project submissions should satisfy one or more of the College’s four priority areas: Surgical translational research Surgical health services research Research into surgical aspects of patient safety, simulation and non-operative technical skills Cancer research of demonstrable direct clinical relevance to the management of solid tumours. The application should also include a well-defined exit strategy (ie how the project will be taken forward).
MRCS and would want to join the RCSEd and are also eligible. Closing date for applications is Friday 24 October 2014.
ALASTAIR F JAMIESON FELLOWSHIP IN GENERAL SURGERY
This General Surgery Fellowship is dedicated to Alastair F Jamieson and signifies a donation from A Jamieson FRCSEd and Mrs Theresa Jamieson in the name of their son. Applications are invited from surgical trainees who are Members/Fellows of the Royal College of Surgeons of Edinburgh, in good standing. The successful applicant will receive an award of £50,000 to cover salary and costs only for one year.
Closing date for applications is Friday 17 October 2014.
Closing date for receipt of applications is Friday 24 October 2014.
THE ROBERTSON TRUST RESEARCH/TRAINING FELLOWSHIP
OPHTHALMOLOGY RESEARCH GRANTS
Applications for funding (£50,000) (for one year) are invited from Fellows/ Members of the College in good standing. The successful candidate must be from Scotland and working within the UK, or the Research itself must be undertaken in Scotland. Surgical trainees who are within a year of completing the
(SPONSORED BY ROYAL BLIND)
ajor project grants (up to £50,000) M Small Research Support Grants for ongoing research (up to £10,000) Applications for funding under the above categories are invited from ophthalmologists currently working in Scotland and all Fellows and Members of the College in good
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.
standing, undertaking research projects in the UK. The closing date for receipt of applications is Friday 7 November 2014.
ETHICON FOUNDATION FUND TRAVEL GRANTS
Grants are awarded towards travel overseas to gain further training or experience and are restricted to the cost of one return airfare only. Travel for the sole purpose of attending a
scientific meeting will not be supported. Requests for retrospective awards will not be considered. Closing date for applications is Friday 21 November 2014.
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 Friday 21 November 2014.
BURSARIES FOR AFFILIATE MEDICAL STUDENT ELECTIVE PLACEMENTS IN AFRICA 2015
The Royal College of Surgeons of Edinburgh is offering bursaries to Undergraduate Affiliates enrolled at UK universities who plan to carry out their elective placements in Africa. The elective need not necessarily be in a surgical unit but priority may be given to students demonstrating a special interest in surgery. Each bursary will normally be in the region of £500, which can be used towards travel and accommodation costs or other expenses involved with the placement. Closing date for applications is Friday 9 January 2015.
PROFESSIONAL EXCELLENCE GROUPS: CREATING BETTER LEADERSHIP IN SURGERY 19 SEPTEMBER 2014 ROYAL COLLEGE OF SURGEONS OF EDINBURGH THE aim of this course is to develop the skills and methodology for participation in Professional Excellence Groups (PEGs) to gain maximum benefit from them. Attendees will establish the purpose and key characteristics of PEGs, develop key skills (listening, contributing, questioning, providing feedback) and provide and review a model of a PEG experience.
CONVENOR Lorna Marson FRCSEd, Senior Lecturer in Transplant Surgery, University of Edinburgh FACULTY David Pitts, Cupar Anne Maree Wallace, Edinburgh Juliette Murray, Edinburgh Angus Watson, Inverness COURSE FEE £115 (£95 for RCSEd Fellows and Members) Book online www.rcsed.ac.uk or email education@rcsed.ac.uk / +44 (0)131 527 1600
www.rcsed.ac.uk | 51
OUT OF HOURS
Graham Layer dines out in Dublin and savours the flavours of Provence, before taking his tastebuds back to UK cities
Craicing good cuisine
O
Graham Layer is Consultant Surgeon at the Royal Surrey County Hospital and RCSEd Honorary Secretary
n my numerous visits to Dublin, I have admired the Georgian architecture, particularly that around Merrion Square. A discrete front door at the side of the Merrion Hotel leads into the cavernous Restaurant Patrick Guilbaud, the only establishment in Ireland with two Michelin stars. The main restaurant is a huge, vaulted, contemporary space decorated with bright flashes of artwork, and looks out on to the gardens of the hotel. My companions had the four-course degustation menu, which was superb, while I chose the à la carte, so we had a taste of a spectrum of the offerings. There were endless welcome amuse-bouches and double petits fours between the main offerings, but a highlight was the croquettes of suckling pig served with a fried quail’s egg, pancetta and foie gras – outrageously comforting. The others enjoyed their outstanding fresh John Dory ‘a la plancha’, while I succumbed to the glazed duck, which was served in two parts: first the main muscular bit with hibiscus and orange, and then a sort of confit as a separate course. Magnificent and somewhat oriental. The desserts were amazing: the chocolate mixtures were spectacular in all respects. I chose the Grand Marnier soufflé. My disappointment was that the soufflé was perfect, but I would have liked to have had the frisson of excitement of pouring custard into the hole that you drill with your spoon through the superficial layers, before it all wells up as a froth (reminiscent of peroxide solution on a wound). The portions were generous, service was impeccable and the bill entirely reasonable as we had been
52 | Surgeons’ News | September 2014
careful with the ethanolic accompaniments; and it was, of course, in Euros. We dined three times at Restaurant Les Bories in Gordes in Provence, a one-starred dining room attached to the delightful Les Bories Hotel near the Abbaye de Senanque run by chef Pascal Ginoux. Unusual dishes and masses of these interdigitating course things to surprise your palette. The dining room spills out onto a balmy terrace surrounded by olive trees with distant views of the Luberon. Degustation was great but just too much, so we settled for the à la carte on subsequent visits and were not disappointed. Our selections in these astonishing meals included tangy lobster and salmon carpaccio, asparagus with scallops and caviar, turbot with aubergine ravioli, pink lamb cutlets with roast vegetables, divine local goats’ cheese, tempura lobster mimicking an expensive fish finger, foie gras with little orange balls of sweetness, fillet of beef with piles of artichokes, particularly plump risotto of monkfish and sea bass, fluffy courgette flowers and some sweet fruity desserts. Another gustatory dream in Euros. While in Provence, stop at Café de l’Ormeau in the square in Loumarin and watch the world passing by in this pretty little village, having an overgenerous Caesar salad or salade Niçoise with a cool glass of dry white or rosé wine. Back in Gordes, try an oozing steak with glorious béarnaise, or another version of the Niçoise, on the terrace of the La Bastide de Gordes. The restaurant is, again, excellent with stunning views of the valley and hanging gardens, but you will pay extra for the privilege. Back down to earth and a number of UK cities. We tried
The degustation menu at Restaurant Patrick Guilbaud in Dublin is to die for Wedgwood in Edinburgh city centre serves up trendy fare with a Scottish twist
the gloomy Michael Caines establishment in the ABode Hotel, Manchester, inspired by the Gidleigh Park two-star chef. It was very late in the evening by the time the three of us arrived – not a good plan. The basement restaurant was morgue-like in atmosphere and decor. Not enticing. It was a brasserie-style menu with all the old favourites, and the food, when it came, was juicy and of high quality. This convenient city-centre establishment, in what is otherwise a culinary desert of starred restaurants, needs to be given a second chance, so I may report back. For city centres, I have enjoyed good sustenance at the Birmingham Hotel du Vin Bistro and am about to try the Edinburgh version – a boutique becoming something of a stalwart. The title says ‘bistro’, but I am never very certain how that differs from a brasserie these days. The menu is almost predictable: different steaks, fish or whatever, with a vegetarian option, but with various French-style possibilities – moules, bouillabaisse and so on. The ethic is to use the finest seasonal local organic produce available, but this should not be an excuse for unpredictable service. The problem with popular city centres is that anything goes, so finding a gem can be tricky. In Edinburgh, there is the cheap and cheerful Mother India’s Café on Infirmary Street, serving generous, quite tasty portions. But further down the hill, hidden on the Royal Mile, is Wedgwood, which is on the ascent. This is a solid find, serving quality, recognisable food with a slight Scottish twist, but with flair and clearly an eye on higher galaxies. Trendy ham hock, spicy black pudding, plentiful quails’ eggs, creamed sweetcorn, venison and leeks, venison haggis and beetroot, duck with artichokes and a duck leg croquette together with chorizo and sprouts! It boasts being local restaurant of the year and is very reasonably priced for its prime location and mouth-watering quality. Hotel bars are usually disastrous, and I would not normally mention them, but the one at the Liverpool Hilton serves its restaurant food in the bar, very promptly, and is more than adequate and good value – and, with a cool beer, was just what the surgeon ordered.
Summer of ’14 Bernard Ferrie raises a glass in memory of the fallen
Y
ears ending in 14 have not been happy ones. The toast is to absent friends and these are mostly red wines.
1314 Bannockburn Cornish Point Bannockburn 2006 (£25, Laithwaite’s) – round, voluptuous Central Otago pinot noir. Cavalry were still charging and bogging down 600 years on. 1414 Hundred Years War Hundred of Joanna 2006 (£11.84, Chacilli Wines) – full-bodied Cabernet Sauvignon/Merlot from Wrattonbully. 1514 Bang goes first historical theory. 1714 War of Spanish Succession Vina Tondonia 1998 (£22, Berry Bros and Rudd) – outstanding golden white Rioja, complex and involving, like history. To savour, especially for bourbons. 1814 Napoleonic Wars Napoleon Brandy (£10.99, Aldi) – light and fruity, a little troublemaker, related to being vertically challenged? (Second historical theory.) 1914 First World War How and why? Home for Christmas? The Willing Participant (£11.99, Waitrose) – the earliest to enlist volunteered. Pinot noir from the Yarra Valley, with a long finish, like the war. Silky juicy Il Papavero (£6.99, Laithwaite’s) – the poppy symbol of carnage on a massive scale. Dark red. Poppy seeds that lie dormant in soil for centuries like unexploded ordinance. 2014 Annexation of Crimea Putinoff Vodka (£9.49 Lidl) – as ice cold as a mountain stream in Siberia. Need something stronger with lots of hydroxymethylglutaryl flavanones? Bergamot as good as statins? So how about a nice cup of Earl Grey and Battenberg cake in the sunshine. Ashen-faced Lord Downton strides across his tank-free lawn in his cream Edwardian picnic suit clutching a telegram… Peace in our time? No chance.
www.rcsed.ac.uk | 53
A new book from an award‐winning publisher
SCHEIN'S COMMON SENSE Prevention and Management of Surgical Complications For surgeons, residents, lawyers, and even those who never have any complications
Order online and claim a 20% discount
Quote promotional code SCS13 Moshe Schein MD FACS General Surgeon, Marshfield Clinic, Ladysmith, Wisconsin, USA
Paul N. Rogers MBChB MBA MD FRCS Consultant General and Vascular Surgeon, The Western Infirmary, Glasgow, UK
Ari Leppäniemi MD Head of Trauma and Emergency Surgery, University of Helsinki, Finland
Danny Rosin MD Attending General and Advanced Laparoscopic Surgeon, Sheba Medical Center, University of Tel Aviv, Israel
The enthusiastic feedback received from readers of the international bestseller Schein's Common Sense Emergency Abdominal Surgery (now in its 3rd edition, translated to seven languages; Springer Verlag; ISBN 978‐3540748205) inspired the Editors to do a similar book dedicated to surgical complications: practical, non‐formal, internationally relevant (in all types of practice and levels of hospitals) – and definitely not politically correct: what is considered taboo by others is not taboo for us; here we discuss everything! As in the Editors’ previous book, the use of references is restricted to the absolute minimum, and citing figures and percentages is avoided as much as possible. The chapters in this book are the opinion of experts – each contributor has a vast personal knowledge and clinical experience in the field he is writing about. This book will help all surgeons (and their patients), avoid the misery of complications, and will provide advice on the management of those that are unavoidable. Complications and death are an integral component of surgery. Surgeons have to look death in the eyes, try to prevent it and vanquish it – this is what this book is all about.
Schein’s books are always terrific reads, conveying pithy observations and practical advice and doing so with wit and scholarship. This latest is surely a must for every surgeon’s bookshelf. Abraham Verghese MD, author of CUTTING FOR STONE ISBN: 978 1 903378 93 9 • Paperback 155mm x 235mm • 558pp • Retail price: GBP £60; USD $99; EUR ∈90
1 By telephone
UK/Europe/ROW +44 (0)1952 510061 USA/Canada 419 281 1802
2 By fax
UK/Europe/ROW +44 (0)1952 510192 USA/Canada 419 281 6883
FIVE EASY WAYS TO ORDER
3 Online
www.tfmpublishing.com
4 By mail
tfm publishing Ltd Castle Hill Barns Harley, Shrewsbury Shropshire, SY5 6LX, UK
5 Bookstore
Contact your local medical bookstore
ANNUAL REPORT 2014
www.rcsed.ac.uk | 55
ANNUAL REPORT
RCSEd Office Bearers & Council September 2014
COUNCIL MEMBERS
Mr Charles Auld
Mr Roger Currie
Dr Judy Evans
Professor James Garden CBE
PRESIDENT Mr Ian Ritchie
VICE-PRESIDENT Professor Jimmy Hutchison
Mr Alastair Gibson
Professor Michael Griffin OBE
Miss Elaine Griffiths
Mr Robert Jeffrey
VICE-PRESIDENT Mr Mike Lavelle-Jones
HONORARY TREASURER Mr John Duncan
Professor Peter McCollum
Mr Richard McGregor
Mr Richard Montgomery
Professor Rowan Parks
HONORARY SECRETARY Professor Graham Layer
DEAN OF THE FACULTY OF DENTAL SURGERY Professor Richard Ibbetson
Mr Simon Paterson-Brown
Mr Pala Rajesh
Ms Cate Scally
Professor Robert Steele
56 | Surgeonsâ&#x20AC;&#x2122; News | September 2014
Report from the Trustees
I
MR IAN RITCHIE
n this, my second annual report, I hope to outline the advances that have been made in the College over the past year. It is inevitable in such a report that only a light gloss can be given to the many exciting initiatives that have been started and which continue to develop within a thriving and vigorous organisation such as ours. At this point, I wish to pay tribute to the Council of the College. All major decisions are carefully considered by Council and can progress only with Council support. I am very grateful to the Council for the care they take when considering these matters of importance. I am supported ably by the College’s Office Bearers who advise on the daily running of the College, along with the senior management team. The staff of the College also provide the day-to-day support to our ever-growing membership and it is widely recognised that they are the face of the College, which is known to be friendly and supportive. I wish to record my thanks to them for their dedication.
PROFESSIONAL ADVANCEMENT AND DEVELOPMENT The purpose of the College is to support the maintenance of high standards in surgical practice and in surgical training. We continue to do this by delivering a suite of courses and supporting examinations, both intercollegiate and collegiate, in this country and internationally. The College’s courses are wide ranging, from generic ones such as Training the Trainers (TtT) and a programme on the delivery of Procedure-based Assessments (PBA), down to highly specialised courses in areas of surgical practice across the whole range of the 10 surgical disciplines. There is also the very successful Edinburgh Surgical Sciences Qualification (ESSQ), which is an online course that received the Queen’s Anniversary Prize for Higher and Further Education, widely regarded as the highest national honour in UK education and which was acknowledged at a ceremony in London attended by Professor James Garden. The examinations continue to develop, particularly internationally, with successful diets in Sri Lanka, Myanmar and Malaysia, alongside our regular
examinations in India. The Joint Surgical Fellowship Examination (JSCFE) had its first diet in October 2013. This was a success and the second diet will be held in October 2014 in Sri Lanka. There are also plans to develop examinations in trauma and orthopaedics, cardiothoracic surgery, neurosurgery and urology in the next stage of this process. The Non-Technical Skills for Surgeons (NOTSS) courses remain popular and there is increasing demand for this learning that can facilitate teamwork. NOTSS has been incorporated into the Intercollegiate Surgical Curriculum Programme (ISCP) website for the benefit of trainees in all colleges. The NOTSS course has also been delivered in an ever-growing number of international locations, including Macau and Vienna, in 2013/14. The College’s Patient Safety Board has also secured a grant of £75,000 from The Health Foundation to conduct research into using an adapted NOTSS system and structured checklist to reduce errors and improve patient safety on surgical wards. Revalidation continues to make steady progress. The Revalidation Helpdesk has not received a large number of enquiries, which suggests that the principles and processes of revalidation are working well for the majority of our Fellows and Members. The Surgeon continues to do well, with an impact factor of 2.207, and our collaboration with our sister college, the Royal College of Surgeons in Ireland, is very successful in this regard. The Surgical Skills Competition did not run this year, although this gave the Dental Faculty an opportunity to carry out a similar, very successful exercise with dental students. They plan to do the same in 2014 and we are actively examining the possibility of a further surgical skills competition for students in 2015.
FACULTY OF PRE-HOSPITAL CARE Over recent months, under the leadership of Colville Laird, the Faculty of Pre-Hospital Care (FPCH) has been rolling out a new regional faculty structure. At the time of writing, regional meetings have been held in 10 locations across the UK and two further meetings are planned. A meeting is also scheduled to provide an opportunity for the Faculty’s regional leads to come together.
The President’s Meeting this year on the subject of emergency surgery was one of the most successful we have held, with excellent speakers and a very high turnout www.rcsed.ac.uk | 57
ANNUAL REPORT
FACULTY OF SPORTS & EXERCISE MEDICINE This has been another very successful year for the Faculty, with the high profile gained by Sports and Exercise Medicine from the Olympic Games in 2012 being reinforced by the high profile of the Commonwealth Games in 2014. Closer to home, Mr Jon Dearing has represented the College on the Faculty Board and has been pivotal in developing a physical activity programme for surgeons and patients, with information sheets that will be useful for surgical patients in the pre and post-operative periods.
FACULTY OF SURGICAL TRAINERS The Faculty of Surgical Trainers continues to flourish with an increasing membership, currently sitting at 372. The Faculty is on the point of publishing standards for surgical trainers, which will prove of great value to those surgeons who wish to be accredited as trainers by the GMC from 2016 onwards. This will aid surgeons in the process and make it a relatively pain-free experience to be incorporated in annual appraisals and the revalidation cycle. The Faculty also ran an extremely successful second annual meeting in Birmingham in 2013 on the subject of simulation. The next meeting in October 2014, at the College in Edinburgh, will be on assessment.
NETWORKING AND OUTREACH The President’s meeting this year on the subject of emergency surgery was one of the most successful we have held, with excellent speakers and a very high turnout. The feedback received has been very good and we have seen a steady increase in the numbers registering for the next meeting in March 2015 on oncological surgery. In the early part of this year we held a launch meeting in the College for a planned joint conference in May 2015 with the Royal Australasian College of Surgeons in Perth, Western Australia. This will undoubtedly prove to be a very popular event, despite the distance from the UK. With an exciting programme and a beautiful location, this must be high on the list of priorities for surgeons in 2015. The College had a very successful visit to the Association of Surgeons in Training (ASiT) meeting in Belfast in April 2014. The President attended with the Vice-President, Mr Mike Lavelle-Jones, winner of the coveted ASiT Silver Scalpel Award (2014) for excellence in surgical training. Membership of the College continues to increase and the opening of our base in Birmingham is part of the College’s strategy of increasing its visibility, relevance and influence on behalf of our members in England and Wales. The staff of the centre, headed by Mr Chris Sanderson, have already been active in running courses and networking in Birmingham and beyond. While it is anticipated that it will be at least three years before we can judge the success of the Centre, early showings suggest that there will be no shortage of work and activity in the new premises at Colmore Row in the heart of Birmingham.
INTERNATIONAL The International School of Surgery continues to have a high presence on the College website, with an opportunity to signpost visitors to the Joint Surgical 58 | Surgeons’ News | September 2014
Colleges Fellowship Examinations. Alongside this, the International School of Surgery is promoting educational activities for the international community. I have visited a number of locations around the world in the past year, including the Philippines, Thailand, Sri Lanka and India. In a new venture in Indonesia, we have been supporting Basic Surgical Skills courses and we have also delivered the Training the Trainers course and a PBA course. Professor Simon Frostick, the College’s adviser on curriculum development, and Mr David Pitts have been working with Malaysia on curriculum development, which supports the process of bringing together the universities and the Ministry of Health in a common pathway for surgical training. Mr Trevor Crofts attended the Global Health Initiative Conference in Sierra Leone on behalf of the College and this represents an exciting and important part of the College’s work on the international stage in promoting safe surgery as a means of improving the health of populations in ‘developing’ countries.
GOVERNANCE Our new Council Members have settled in well and have contributed widely to the work of the College. Our thanks to Professor James Garden and Ms Cate Scally for their contribution to the work of the College, as they now demit from Council. Mr Bob Jeffrey has assumed the role of lead for Continuing Professional Development from Professor Graham Layer, and Mr Charles Auld is leading on the relationship of Professions Allied to Surgery, whose activities fit well with the surgical practice. Mr David Smith, Convenor of Education, is coming to the end of his term of office and Mr Gerry McGarry has been appointed to succeed him. I am very grateful to Mr Smith for his commitment to the education portfolio and the development of many new initiatives, not least webinars, which are proving very popular internationally. In the Examinations Department, Mr Ken Hosie is demitting office as Convenor of Exams. He is succeeded by Professor Peter McCollum. Under Mr Hosie’s leadership the international exams have been developed in several new locations, and in the UK continue to thrive in Edinburgh, Sheffield and Coventry.
TRAINEES The Trainees’ Committee has been enhanced by the election of the remaining five members. They are already proving to be a dynamic group, led by Mr Richard McGregor, the elected Trainee Member of Council, whose challenges to Council are well received. The latest topics have been on the subject of bullying and harassment. A very successful Trainees’ Committee day with Council was held on 3 July 2014. Members of the Trainees’ Committee are also interacting well with the Academy trainee doctors group and other institutions, such as ASiT and BOTA. This goes a long way to demonstrating the Royal College of Surgeons of Edinburgh’s interest in trainee matters and the importance it attaches to these.
INTERCOLLEGIATE The College continues to play its full part in intercollegiate discussions, and in the management
The College continues to provide sought-after qualifications
of intercollegiate bodies. The four presidents held a day of interviews at RCSEd in April for the very important intercollegiate roles of chairs of the Joint Committee on Surgical Training, the Joint Committee on Intercollegiate Examinations, and the Intercollegiate Basic Surgical Exams Committee. One of the topics of most importance to the immediate future of the colleges and surgeons in general is the Greenaway Report. This has been considered at the Surgical Forum of Great Britain and Ireland, and a collective view of the colleges and specialty associations has been produced by Professor John MacFie, Chair of the Forum. He has published this document and it is available for review. However, there is a lot more to be done in the detail of exactly how the principles underpinning the Greenaway Report are applied to surgical training, not only in the generality of surgery, but also in the particular areas of the subspecialty interests. The College has had a very busy year. The activity of the College is focused on providing excellent surgeons through high-quality training for the needs of patients. The vibrant activity of the College is an indication of its prominence and its relevance in these debates.
COLLEGE CAMPUS Hot on the heels of the delivery of our Birmingham Centre, our contractors have commenced work on site in Edinburgh to refurbish the Surgeons’ Hall Museums. This is a very exciting project and will enable the College’s collections to be shared with a much wider audience. There are also several other developments to the College’s Edinburgh campus in the pipeline which together will radically improve the facilities available to our membership and put the College in great shape to adapt to meet future challenges and demands.
The College is focused on providing excellent surgeons through high-quality training for the needs of patients www.rcsed.ac.uk | 59
ANNUAL REPORT
Report from the Chief Executive The fruits of our labours over the last 12 months can be seen in a number of exciting developments in 2014. In this report it is not possible to do justice to all the activity that has taken place, but only to pick out some of the highlights from a very busy year. Of particular note are the opening of the College’s new regional centre in Birmingham, the Lister project for the redevelopment of the Museums, and the launch of the International School of Surgery, all of which feature below.
MEMBERSHIP, ENGAGEMENT AND GROWTH The College’s total membership continues to grow within the UK and internationally, and now stands at circa 22,000. Within this number the Dental Faculty is flourishing and has experienced growth, particularly within its Fellowship. In autumn 2013, College Council took the decision to have a regional centre in Birmingham, the College’s first base outside Edinburgh in its 500-year history. Following an intensive period of premises negotiations, fit-out, and staff recruitment, the Birmingham Centre opened in April of this year. The opening was marked by a week of events of relevance to a broad spectrum of the membership. The Birmingham Centre will allow us to enhance the support provided to the 80% of the College’s UK membership who live and work in England and Wales. It is a venue within the heart of our membership base in which the College can run courses, meetings and events, and it is also a hub for delivery across the regions led by our network of Regional Surgical Advisers (RSAs) and Regional Dental Advisers (RDAs). The restructuring of the network to more closely align RSAs and RDAs will help facilitate this. During 2013, we continued to deliver a busy programme of outreach activity, which included a series of successful forum events that brought together students, trainees and experienced consultants. Our goal is to significantly enhance our regional delivery of College activities across the UK. The College’s Faculty of Pre-Hospital Care remains at the forefront of new developments. During 2013, the Faculty set up a UK-wide regional structure to enhance training and delivery, and established a Faculty professorship. Ongoing activity includes the development of additional diplomas, which will improve the standards of pre-hospital care and contribute to better patient outcomes. Our international membership, across more than 100 countries, represents a significant part of the College, and is continuing to grow. A key development in 2013 was the launch of the International School of Surgery (ISS). Although still in its infancy, the ISS has been well received and is supporting our membership outwith the UK through the provision of a single point of contact and information on RCSEd’s range of international activities. The 2014 President’s meeting, on the subject of emergency surgery in the 21st century, was very successful and highlights from it can be found on the College’s website. The College’s first Dental Clinical Skills Competition, 60 | Surgeons’ News | September 2014
MS ALISON ROONEY
generously sponsored by Dentsply, was held in 2013/14. All but two of the UK dental schools participated, hosting regional heats for 300 participants. The 14 finalists met in Edinburgh in March for the grand final and the winner received an all-expenses-paid trip to the Chicago Dental Society’s Midwinter meeting in February 2015. All of the above gives a flavour of our activities; keeping the membership informed is key and, during 2013, the use of social media and e-communications was greatly increased and the College’s web presence improved. Surgeons’ News has also been given a new look and The Surgeon is now ranked 58th out of 200 surgery journals with a 12% increase in impact factor, which is testament to the effort of all those involved in our partnership with the Royal College of Surgeons in Ireland.
EDUCATION, ASSESSMENT AND ADVANCEMENT
The Birmingham Centre opened in April 2014
RCSEd continues to expand its educational portfolio across all areas, including e-learning, where our webinar sessions have proved very popular. More courses are being run from the Edinburgh campus and offsite, resulting in a substantial increase in the total number of participants. This step change in activity is anticipated to continue with the opening of the Birmingham Centre. The expansion in the number of international centres offering a range of RCSEd examinations has resulted in an increase in our candidate numbers from that of 2012. Internationally, the MRCS Part A examination is now held in 23 locations. Dental and ophthalmology examinations continue to be in high demand; tri-collegiate specialty dental examinations have been introduced and new diplomas are being developed. The Faculty of Pre-Hospital Care is also expanding its suite of examinations. Overall, during 2013, more than 5,000 candidates presented for examinations and, of these, around 2,000 were based in the UK and 3,000 international. Following its formal launch in 2013, the Faculty of Surgical Trainers continues to grow in strength and numbers, and held its second annual meeting, sponsored by Johnson & Johnson, in Birmingham in October 2013 on the theme of simulation. With the introduction of revalidation for surgical trainers on the horizon, the Faculty is developing the mechanisms required to support its membership through the process. Plans are well developed for the Faculty’s 2014 meeting in Edinburgh in October on the subject of assessment. The College has been involved significantly with intercollegiate activities with its three sister colleges in the UK and Ireland, in particular through its successful running of the Joint Committee on Intercollegiate Examinations (JCIE). The Joint Surgical Colleges Fellowship Examination (JSCFE), the newly introduced international fellowship examination, is also administered under the auspices of this College and I am pleased to report that the initial diets have been undertaken successfully, with additional specialties under development.
Many other professional skills-related activities have been supported and developed throughout the year, a selection of which has been included within the Trustees’ section of this annual report. In concluding this section, I would like to highlight the College’s joint Fellowship award with the Medical Research Council, the establishment of the College’s Standards Office and our work in invited reviews around assisting overall good practice, and our work with the Dental Faculty in undertaking a comprehensive review of the Dental Regulations.
CAPITAL PROJECTS In November 2013, the College was delighted to receive £2.7m from the Heritage Lottery Fund towards our transformational Lister Project to redevelop the Surgeons’ Hall Museums and the College’s library and archives. This funding, along with the very generous donations received through the College’s Heritage Society, has allowed this project to get under way and, as I write, our contractor has started work on site. The Museums are due to re-open next summer with considerably improved physical access and exciting new exhibitions and displays. The design for the College’s multipurpose events building has been finalised and the process is under way to identify a contractor to undertake the refurbishment works. This new addition to the campus will enhance RCSEd’s facilities in Edinburgh and provide a high-quality venue suitable for examinations, courses, conferences and other events. Work on our other capital projects, including our property on Nicolson Street, the feasibility studies for the hotel expansion and the refurbishment of our major office space are ongoing – all in all, a very busy time and a significant investment in the asset base of the College.
FINANCIAL SUSTAINABILITY, INFRASTRUCTURE AND COMMERCIAL DEVELOPMENT As the Honorary Treasurer reports, the College remains on a firm financial footing with mainstream operations and the College group as a whole performing well. This is in no small part due to the contribution of the College’s commercial operation, Surgeons’ Lodge Limited (SLL), which supplements the income received from membership subscriptions and supports the delivery of the wide range of new initiatives and developments discussed within this report. Contributing to its success is the appetite for pursuing innovation and quality. Of particular note are the activities run by SLL in connection with the Edinburgh Festival, which attract growing numbers to the College each year and the achievement of the Conference Hotel of the Year Award at the Scottish Hotel Awards by our four-star Ten Hill Place Hotel. The College’s infrastructure continues to improve year on year, with the latest investments, including an up-to-date telephony system, virtual server environment and enhancement to business information hardware and software systems.
Fundraising remains important if we are to realise the College’s many ambitions and, as we complete the target needed for the Lister Project, work will continue apace in the areas of education and research.
HERITAGE The focus of our Museums and Heritage Department has been on the delivery of the Lister Project, as described earlier. While the most visible aspect of the project is the building works, the department’s staff have been busy individually packing, recording and decanting the circa 4,000 exhibits to keep them safe, and working with professional exhibition designers to develop the narratives for the new displays to be featured in the refurbished museums. Museum visitor numbers continue to exceed expectations; indeed, in the final weekend before closure for refurbishment record numbers crossed the threshold. The library and archives are also a key aspect of the Lister Project and staff have been successful in their bids for a significant sum of money to assist with archiving work.
COLLEGE STAFF – OUR KEY RESOURCE Undoubtedly, our staff are our key resource and I have quite deliberately left this aspect of my report to the end as I believe that reading through the rest of the report will give the best flavour of the huge amount of work that the College and SLL teams have undertaken, none of which would have been possible without their skill and determination. Throughout the year, we have endeavoured to keep staff engaged through all-staff briefing events, the introduction of management team development events, and the launch of a staff ‘intranet’. The numbers employed overall have increased in support of significant new activities. Six members of staff have been recruited for the Birmingham Centre, led by Chris Sanderson, the College’s newly appointed Public Affairs Manager and Head of the Birmingham Regional Centre. These staff will deliver activities related to education, examinations, outreach, public affairs and policy. In support of the College’s Lister Project and its associated, post-opening activity plan, additional posts have been created within the Museums and Heritage Department. Appointments have also been made to strengthen the College’s online activities and ESSQ programme as it expands its ChM portfolio in partnership with the University of Edinburgh.
AND FINALLY … I would like to take this opportunity to extend my sincere thanks to the many individuals whose continuing efforts allow the College to flourish. In particular, I am grateful to the President, Office Bearers, Members of Council and Fellows and Members who volunteer their time to undertake work on behalf of the College. I would also like to thank my senior management team and the College’s staff for their support. Their hard work has enabled the delivery of a heavy agenda and has put us in good shape to meet the challenges to come.
ANNUAL REPORT
T
HONORARY TREASURER
o operate effectively, a charity needs to have a secure financial base. Our College continues to be in that position. The consolidated accounts for 2013 show a turnover of £15.6m, once again with a surplus of income over expenditure. The balance sheet for 2013 shows assets for the group of £31m, up £2.8m from 2012. This year we have benefited from two substantial bequests, which are being used to further increase our charitable activity. The funding for the non-HLF proportion of the costs of the Lister Project has been given a major boost by the award of a very significant sum from a charitable foundation, subject to the College satisfying the foundation’s due diligence process. This, coupled with the contributions from Fellows, Members, other Trusts and the Heritage Lottery Fund will complete the £4.6m funding required for the project overall, without the need to draw from our College reserves. The work to renovate the building at 19 Hill Place, which is planned to be completed by early 2015, is being funded from our own resources. This building will deliver further facilities for core College activity, as well as providing space that SLL can use for external events.
Balance sheet as at 31 December 2013
31/12/2013 31/12/2012
£000 £000
Tangible fixed assets
19,150
19,514
Heritage assets
3,875
3,875
Investments
6,165 5,778
Current assets
10,876
8,202
Creditors: amounts falling due within one year
(4,194)
(3,958)
Creditors: amounts falling due after more than one year
(4,760)
(5,134)
31,112 28,277
Represented by: Unrestricted funds General fund
13,698
12,211
Designated fund
6,330
6,047
20,028 18,258
Restricted funds
11,084
10,019
Net assets
31,112
28,277
62 | Surgeons’ News | September 2014
MR JOHN DUNCAN
The number of Members and Fellows in good standing has increased by 1,500 in the past year, and our subscription income has remained strong despite once again not increasing subscriptions for Members and making only a modest increase for Fellows SLL had another strong year in 2013 with a turnover of £3.7m, generating an operating profit of £430,000. This is in addition to the income the College receives from the company through its licence to occupy 10 Hill Place Hotel and the College’s other buildings. This would not have been possible without the diligence and energy of the SLL Board, under the chairmanship of one of our Regents, Mr George Borthwick, the College’s Commercial Director and the staff of SLL. The events side of the business has had very strong first and second quarters in 2014. Due to the building work hampering primarily events activity, the income budgeted for the third and fourth quarters for SLL has been significantly reduced. Similarly, the licence to occupy fees payable by SLL have also had to be reduced. Income from the Museum will also be much reduced in 2014, reflecting it being open for only four months of the financial year. All of this will result in a combined reduction in income for the College in 2014, which was taken account of at the budget planning stage. In 2014, we took on the lease of the property in Colmore Row, Birmingham. The facility has been fitted out and six members of staff have been appointed. The renovation was carried out under budget and the salaries for the staff members and the cost of the fit-out have been budgeted for in 2014. This important development is core charitable activity to provide a better service for our Members and Fellows. The number of Members and Fellows in good standing has increased by 1,500 in the past year and our subscription income has remained strong despite once again not increasing subscriptions for Members and making only a modest increase in the subscription for Fellows. The College’s investment portfolio has performed well given the conservative investment strategy appropriate for a charity. This is my fifth and final report as Treasurer. In my first report I explained the need to make a prior year adjustment to the accounts and to include a provision against the share capital and liabilities of SLL. I am glad that in 2013 we have released all of the provision against liabilities and that in 2014 SLL has moved into a positive balance sheet. In those five years, assets on the balance sheet of the Group have risen from £19.4m in 2009 to £31.1m in 2013. The College is in a sound financial position, which will enable us to continue to pursue our charitable activities ever more vigorously.
Treasurer's statement on the summarised accounts of The Royal College of Surgeons of Edinburgh
Total incoming resources £15.6 million
Donations, bequests and gifts
7%
Subscriptions
29%
Examinations
26%
Courses
3%
Faculties
7%
Grants 1% Trading income
21%
Investment income
3%
Other
3%
Total resources expended £13.1 million Fundraising and trading costs
21%
Subscriptions
6%
Examination costs
19%
Courses
4%
Property
10%
Faculties
6%
Publications
5%
Grants
2%
Professional activities 13% Governance and support costs Other
1% 13%
The financial statements on pages 62 and 63 are not the full statutory consolidated financial statements of the Royal College of Surgeons of Edinburgh but are derived from the financial statements of the Royal College of Surgeons of Edinburgh, Hill Square Educational Trust and Surgeons’ Lodge Limited, a wholly-owned trading subsidiary of the Royal College of Surgeons of Edinburgh. The full financial statements for the year ended 31 December 2013 have been audited by Chiene & Tait, Chartered Accountants and Statutory Auditors, and received an unqualified opinion. The summarised accounts may not contain sufficient information to allow a full understanding of the financial affairs of the College. For further information, the full financial statements should be consulted. A copy of the full financial statements will be available from the Library, the Royal College of Surgeons of Edinburgh, Nicolson Street, Edinburgh. J L Duncan, Honorary Treasurer
www.rcsed.ac.uk | 63
FROM THE COLLECTIONS
Despite recent carbon dating, the unusual cranial features of the Neanderthaloid Skull continue to perplex medical experts
THE ENIGMA OF THE NEANDERTHALOID SKULL
T
he Neanderthaloid Skull was introduced to the College collection by David Middleton Greig. His notes show that the skull was given to him by “a medical friend who had inherited it without knowledge of its origin”. The history of this skull has presented a conundrum. Greig showed this skull, along with drawings and millimetre-scaled outlines, to several anatomists. Sir Arthur Keith commented: “You have a specimen which shows certain cranial features never before seen in a neanthropic man – a perfect torus supraorbitals and a perfect torus occipitalis.” Therefore, the low forehead with heavy brow ridge and protrusion at the back of the base of skull described by Keith shows that this skull differs from the modern human skull. The features are something that Keith described as “found only in the skulls of Neanderthal man”. Due to these characteristics, this specimen became known as the Neanderthaloid Skull. Greig documented that, a year later, he and Keith were still discussing the skull, this time with reference to the deficiency at the bregma, visible at the top of the skull. Keith added: “This skull of yours is an enigma: publication may bring others to light. I am sure it is a singledevelopment entity and someday the nature of the lesion will be known.” The detailed study of the skull by Greig was published in 1933 in the Edinburgh Medical Journal, and was reprinted as the bound publication A Neanderthaloid Skull, presenting features of Cleidocranial Dysostosis and other peculiarities.
64 | Surgeons’ News | September 2014
The publication contains the colour illustrations of RW Matthews, which are millimetre-scaled outlines, and X-rays. Greig’s conclusion ended with: “I fail to find in the peculiarities of this skull a single developmental entity albeit with a pathological basis and must content myself with as adequate description and drawings as I can offer.” Part of the enigma of the Neanderthaloid Skull was solved during a study in 2008 by Professor Bryan Sykes. The radiocarbon measurements taken during this research showed the skull to be modern and not Neanderthal, with a high probability of it dating from the mid-17th century. Emma Black Public Engagement and Marketing Officer, Surgeons’ Hall Museum
PRESIDENTâ&#x20AC;&#x2122;S MEETING & AUDIT SYMPOSIUM 2015 SURGICAL ONCOLOGY FRIDAY 20 MARCH 2015 Advances in surgical technique and in the organisation and delivery of care have contributed significantly to improved outcomes for patients with cancer. This meeting will provide an update on contemporary management of various malignancies, with a major focus on surgical treatments, as well as updates on oncological therapies. This meeting will include contributions from all the surgical specialty associations. KEY SPEAKERS INCLUDE: l Professor Timothy J. Eberlein (Bixby Professor and Chairman of the Department of Surgery at Washington University School of Medicine, St. Louis and Surgeon-in-Chief at Barnes-Jewish Hospital) l P rofessor Arnold Hill (Professor and Chair of Surgery and the Head of the Medical School at the Royal College of Surgeons in Ireland) l P rofessor Alastair Munro (Professor of Radiation Oncology at the University of Dundee and Honorary Consultant Oncologist NHS Tayside)
l P rofessor Graeme Poston (Consultant Hepato-biliary Surgeon at University Hospital Aintree, Liverpool, and Professor of Surgery at the University of Liverpool) l P rofessor Tom Treasure (Consultant Cardiothoracic Surgeon, Clinical Operational Research Unit, University College London Abstracts can be submitted via the Education pages of the RCSEd website. Closing date is 5pm on Monday 5 January 2015. www.rcsed.ac.uk/presidentsmeeting
Your greatest asset...
Deserves the perfect partner Custom-made to meet the highest standards of quality, comfort and performance, Evimed are delighted to offer a loupe to suit everyone’s individual needs.
Name: Essential Magnification: 2.5x Colour: Silver Frame Style: Sports Essential Frame Size: Sml / Lrg Best feature: Great value
Name: HD Magnification: 2.3x, 2.8x, 3.3x, 3.8x Colour: Titanium Grey / Red / Blue Frame Style: Sports or Cosmo Frame Size: Sml / Med / Lrg Best feature: Stylish & lightweight
Name: Kepler Kompakt Magnification: 3.5x, 4.6x, 5.7x Colour: Titanium Grey / Red Frame Style: Sports or Cosmo Deep Frame Size: Sml / Med / Lrg Best feature: Powerful & compact
Evimed also offers ExamVision™ LED lights including the Essential, Nano, Focus and XP, providing light in exactly the right place. Arrange a no-obligation consultation
Freephone 0500 211111 E: sales@evimed.uk.com W: www.evimed.uk.com
Loupes • Choice of Magnification • Sports Frames • LED Lights • Visors