Surgeons' News September 2015

EXERCISE

THE EVIDENCE STACKS UP

Studies into the benefits of preoperative fitness to postoperative outcomes

SPECIALTY

PAST, PRESENT AND FUTURE

ANNUAL REPORT

Tracing the ancient roots of plastics, the last of the general surgeries

THE COLLEGE’S YEAR IN BRIEF

The Trustees, CEO and Treasurer outline the key activities of 2015

Surgeonsnews September 2015

The magazine of The Royal College of Surgeons of Edinburgh

B LL ON

The painful truth about access to surgery

www.surgeonsnews.com

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WELCOME

FROM THE EDITOR John Duncan introduces the September edition

T

he key message of the Lancet Commission on Global Surgery is that 5 billion people worldwide do not have access to basic surgical care (see our cover feature, page 22). That care need not be complex.

The basic management of fractures, wound care, Caesarean section or hernia repair do not require complicated or resourceintensive facilities. Scaling up surgical and anaesthetic care to acceptable levels is affordable and no more costly than the investment in treating infectious disease that has already been committed.

Allied to this availability of care is its cost to the individual. In ‘developed’ countries, we regard access to emergency care – financed either nationally or through an insurance system – as almost a fundamental human right. In the ‘developing’ world, the financial impact of major surgical illness to an individual and their family can be enormous. As surgeons, this is an issue to which we can relate.

The annual report (see page 55) is an important means of keeping Members and Fellows up to date with the life of the College. The reports of the President and the Chief Executive as well as the annual accounts give an overview of progress in the last year. We have also included the headline results of the membership survey and the important news of the election of Mike Lavelle-Jones as the College’s next President.

The issue of the publication of surgical outcomes related to individual surgeons is an important

one and is discussed by the Association of Surgeons in Training on page 42.

The surgical specialty we highlight in this edition is plastic surgery (page 34), discussing both its development and the wide range of surgical illnesses it treats.

The appointment of Clinical Leadership Fellows has been an important development over the last few years. On page 17, Nathan Stephens, the College’s Scottish Clinical Leadership Fellow, discusses Professional Excellence Groups and their benefits to the profession.

In the ‘developing’ world, the financial impact of major surgical illness to an individual and their family can be enormous As the Lister Project nears completion, on page 10 our Director of Heritage, Chris Henry, updates us on progress ahead of the reopening of the Museum in September.

We have covered how physical fitness affects patient outcomes in successive editions of Surgeons’ News. Malcolm West discusses the practical aspects of risk prediction and prehabilitation on page 30.

I must also mention a milestone reached by our longest-serving contributor. I am very grateful to our resident wine buff, Bernard Ferrie, who has been providing his irreverent and insightful reviews since our launch edition in 2002. This issue marks Bernard’s 50th column for Surgeons’ News. Cheers!

John Duncan editor@surgeonsnews.com

www.rcsed.ac.uk | 1

44

EXERCISE

THE EVIDENCE STACKS UP

Studies into the benefits of preoperative fitness to postoperative outcomes

SPECIALTY

PAST, PRESENT AND FUTURE

ANNUAL REPORT

Tracing the ancient roots of plastics, the last of the general surgeries

THE COLLEGE’S YEAR IN BRIEF

The Trustees, CEO and Treasurer outline the key activities of 2015

Surgeonsnews September 2015

The magazine of The Royal College of Surgeons of Edinburgh

B LL ON

34

The painful truth about access to surgery

www.surgeonsnews.com

EDITOR John Duncan DEPUTY EDITOR Robyn Webber EDITORIAL BOARD Richard McGregor Peter Lamb Peter Douglas Sarah Allen Chris Henry Dr Yvonne Hurst Aoife O’Sullivan Mark Baillie PUBLISHED BY The Royal College of Surgeons of Edinburgh, Nicolson Street, Edinburgh EH8 9DW Registered Charity No. SC005317 contributions@surgeonsnews.com Tel: +44 (0)131 527 1600 For editorial enquiries contact Mark Baillie: Tel: +44 (0)131 527 3405 DESIGN AND PRODUCTION

Think Publishing Ltd, Suite 2.3, Red Tree Business Suites, 33 Dalmarnock Road, Glasgow G40 4LA Tel: +44 (0)141 375 0504 www.thinkpublishing.co.uk ACCOUNT MANAGER Sian Campbell DESIGN Mark Davies SUB EDITOR Kirsty Fortune MEDICAL SUB EDITOR 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 2015

Contents

30

September 2015

04

AGENDA News and views from the College and the profession, including an update on the Museum restoration

08

THE PRESIDENT WRITES Ian Ritchie looks back on an eventful three years in office

12

MEMBERSHIP SURVEY Facts and figures distilled from our comprehensive membership report

22

LANCET COMMISSION Plans for better provision for five billion healthcare have-nots

26 28 30

BASIC SKILLS Teaching the BSS course in Rwanda

34

PLASTIC SURGERY Kevin Hancock traces the history of one of the oldest specialties

38

DENTAL Dental Dean on dental care professionals; regional advisers network; results of the membership survey on the Faculty and College

TRAINING THE TRAINER The course with global appeal EXERCISE Evidence grows of the benefits of fitness to postoperative outcomes

42

TRAINEES AND STUDENTS The ‘consultant outcomes publication’ debate; Rory Piper’s paediatric epilepsy elective in Boston; schools outreach

48

COLLEGE INFORMATION Diploma ceremony listings, awards and grants; obituaries

52

OUT OF HOURS From Sydney to Soho, Graham Layer shares his gastronomic delights

55

ANNUAL REPORT 2015 A word from the College’s Trustees, CEO and Honorary Treasurer

64

FROM THE COLLECTIONS A deserter’s, or drunkard’s, tattoo

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

r r r r r r r r r r

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

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

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

Agenda The latest news from the College and profession / SURVEY

/ ELECTION

Survey highlights concern over 24/7 care

Mike Lavelle-Jones

Lavelle-Jones elected President

I

n July, Mr Mike Lavelle-Jones was elected as the next President of RCSEd and will take up office following the Edinburgh College’s annual general meeting on Friday 13 November.

Currently serving as RCSEd Vice-President for external affairs, Mr Lavelle-Jones is also a consultant general surgeon with an interest in colorectal and paediatric surgery at Ninewells Hospital in Dundee.

Mr Lavelle-Jones commented: “I look forward to working with Council, our membership, College staff and all our colleagues to build on the legacy of my predecessors and lead the College as it grows and develops over the next three years.”

/ MUSEUMS

An artist’s impression of the £4.2m redevelopment

4 | Surgeons’ News | September 2015

The College’s recent membership survey has revealed that 75% of Fellows and Members do not believe 24/7 consultant-led NHS services are achievable under the current service model. Of those in training grades, a higher proportion did not think the reforms were achievable, with just 9% believing they were.

The findings are published as the Government is introducing plans to offer patients access to consultants seven days a week in England, where the RCSEd has around 11,000 Fellows and Members.

Despite the concerns, 76% of those surveyed agreed that the NHS should offer round-the-clock services, with those in general, cardiothoracic and vascular surgery showing levels of agreement of more than 80%.

The College also found that onequarter of respondents felt their employer had sufficient surgical capacity at the appropriate grade, with almost half (47%) saying there was not sufficient capacity.

See page 12 for a summary of surgical responses and page 40 for dental results

Modern home for College collections The College museums will reopen this month following a major redevelopment. The doors closed last year for a Heritage Lottery-funded £4.2m upgrade that included a new entrance and stonework conservation, as well as a new layout and redisplay for the renowned collections.

See page 10 for details.

NEWS IN BRIEF Notice of annual general meeting

Finishing touches As he enters the final months of his term of office, Ian Ritchie sits for his presidential portrait with artist Keith Breeden.

The College will hold its AGM at 12.30pm on Friday 13 November 2015 in the Main Hall, the Royal College of Surgeons of Edinburgh, Nicolson Street, Edinburgh EH8 9DW.

Report for 2015 / EVENT

Perioperative care conference

R

SCEd is running a one-day conference in conjunction with the Association for Perioperative Practice (AfPP) that will enable delegates to explore current and future challenges facing surgical care practitioners and surgical first assistants and how the College can provide support.

Professor Terence Stephenson

/ STANDARDS

GMC plans new assessment The General Medical Council (GMC) has approved a plan to develop a unified assessment for every doctor seeking to practise in the UK. The new assessment would replace the Professional and Linguistic Assessments Board test.

GMC chair Professor Terence Stephenson said: “We must have systems in place to ensure that… all doctors practising [in the UK] have been examined and evaluated to the same high level.”

‘The Perioperative Practitioner: Advancing Surgical Care – Who’s Supporting Who?’ is on 17 October 2015, at the Burlington Hotel, Birmingham.

Discussion topics will include current and prospective needs and challenges facing perioperative practitioners and the provision of support, lobbying and continuing professional development

by the College and the AfPP. Key speakers include Mr Norman Briffa, consultant cardiothoracic surgeon at Sheffield Teaching Hospitals, Mrs Tracy Coates, Safety and Learning Lead NHSLA, and Mrs Susan Hall, co-lead, Advancing Surgical Roles Group, AfPP. Contact education @rcsed.ac.uk for details

Fears over public health cuts

/ EVENT

Facial surgery expert to deliver keynote lecture

I

nternationally acclaimed facial surgeon Professor Iain Hutchison is to deliver the Dental Faculty’s Annie McNeil Lecture on 25 September.

Professor Hutchison is oral and maxillofacial consultant at St Bartholomew’s, London.

He specialises in resection of cancer of the head and neck and the reconstruction of patients with severe facial deficits. He also founded and runs the facial surgery research charity Saving Faces.

Dean of the Dental Faculty Professor Bill Saunders said: “We are privileged that Professor Hutchison will be delivering this year’s Annie

The College’s annual report is published in this edition of Surgeons’ News (pages 55–63), with updates on activities and progress over the last 12 months. Highlights include the College’s opposition to the Medical Innovation Bill and its support for clinical leadership fellowships.

Discussing another initiative – plans to launch a Faculty of Surgical Care Practitioners – College President Mr Ian Ritchie said: “The development is a recognition of the importance of other members of the surgical team in the delivery of surgery. The College’s ambition to provide better outcomes for patients worldwide is linked to our support for surgical care practitioners.”

McNeil Lecture. Iain has been a key figure in international multicentre clinical trials on oral and facial disease as well as injury prevention and treatment. He will be sharing his experiences in facial surgery, explaining how the anatomy and physiology of the face relates to its physical, emotional and societal functions.”

The lecture, ‘Voyages with my patients – a lifetime of facial surgery’, takes place at Wolfson Hall, at 11.15am on Friday 25 September, followed by the Dental Faculty’s AGM.

In July, the College questioned whether proposed £200m cuts to public health budgets in England may result in increased costs for services such as surgery. Referring to initiatives to tackle smoking, alcohol abuse and inactivity, President of the College Ian Ritchie said: “These cuts will ultimately increase the pressure on NHS resources at a time when investment is required to integrate health and social care. Prevention is always better than cure. With surgery being one of the more expensive forms of treatment, initiatives that ultimately reduce the demand for surgery should be supported.”

World conference The College is to host the 25th annual meeting and exhibition of the World Society of Cardiothoracic Surgeons on 19–22 September.

www.wscts2015.org

To register, contact outreach@rcsed.ac.uk www.rcsed.ac.uk | 5

AGENDA

NEWS IN BRIEF College opens Café 1505@surgeonshall RCSEd has opened a cafe just outside its South Gate. Operating a ‘scratch kitchen’, all food at Café 1505@surgeonshall is cooked, baked or assembled from scratch. The cafe offers main courses, salads and delifilled sandwiches along with coffees, teas and hot chocolates. Café 1505 is open daily from 7.30am.

/ TRAINING

Touch Surgery app endorsement

T

he College has teamed up with Touch Surgery, maker of a mobile cognitive simulation and rehearsal app, to deliver better training and improve global surgical practice through Touch Surgery’s library of simulations.

Touch Surgery is officially the largest community of surgeons rehearsing virtual surgery and is accessible via any smart device on both iOS and Android platforms.

RCSEd Convenor of Education Professor Gerry McGarry said: “We are committed to advancing surgical training and education, and always strive to explore new and improved approaches to enhance our membership’s learning, training and career development.

“The Touch Surgery app is an innovative learning tool that we believe can help surgeons

Surgical sims for smart devices

at all levels of their careers. The app provides an exciting platform for surgeons to share their experiences of challenging procedures and to rehearse and learn new techniques.” www.touchsurgery.com

Scottish Academy on care failings The Academy of Medical Royal Colleges and Faculties in Scotland has published recommendations to address systemic failings in NHS care in Scotland, evidenced in reports on hospital deficiencies, which it believes have been mainly caused by the failure of clinical staff and NHS management to work together to deliver improved healthcare.

Central to the recommendations in Learning from Serious Failings in Care are the need to engender more effective team working, to place quality of care ahead of targets, to ensure appropriate staffing levels and to end the culture of ‘learned helplessness’ experienced by staff when poor standards of patient care are condoned and perpetuated.

The College dinner brought in more than £15,000 / FUNDRAISING

Gala dinner for breast screening in Myanmar A College gala dinner on 4 July raised more than £15,000 for a mobile breast-cancer-screening unit in Myanmar. The President’s charity campaign aims to raise sufficient funds to source and purchase a vehicle with cubicles, examination facilities and ultrasound tools, enabling the local breast care team in Yangon to take the equipment on the road to remote locations.

www.scottishacademy.org.uk

Correction: Soldiers, surgeons and a speaker A note from the author, Wyn Beasley, of the above article (Surgeons’ News, March 2014, p32) thanked “Alistair Gaisford, a Monro descendant on his mother’s side”. This should have read: “Alastair Gaisford, a Monro descendant on his father’s side”.

6 | Surgeons’ News | September 2015

Professor James Garden CBE

/ AWARDS

ACCEA 2015 ‘competitive’ The 2015 ACCEA results are expected to be announced in early 2016, but the process is likely to be more competitive than normal.

Applications have increased by around one-third on the previous year for the same number of awards, warned Professor James Garden CBE, chair of the RCSEd Clinical Excellence Awards Committee. “For the first time, ACCEA has elected to publish the full application for both successful new and renewal applicants.

The increasing transparency is welcome, but RCSEd is concerned that the efforts of consultant surgeons in delivering excellence and improvements in patient care may go unrecognised,” he said.

THE OLD TOWN COLLECTION EDINBURGH The perfect destination for your association’s next conference

The Old Town Collection Edinburgh brings together three of the City’s most iconic buildings – the Festival Theatre, the Royal College of Surgeons of Edinburgh and the National Museum of Scotland.

All within a short walk around Edinburgh’s beautiful Old Town, the venues offer a distinctive location for your association’s next conference.

An historic setting with 21st century technology throughout, the Festival Theatre is the ideal location for your main conference sessions. Spacious foyers in this remarkable refurbished theatre lead into the beautiful 1928 auditorium with ample comfortable seating for all your delegates.

The Royal College of Surgeons of Edinburgh provides breakout, exhibition and catering space, boasting both historic and modern buildings.

The King Khalid Building, the Quincentenary Conference Centre, the Playfair Building, 12 breakout rooms and the new Prince Philip Building are superbly fitted out with all the resources you and your delegates will need.

Plus, of course, on-site accommodation is available in the four-star Ten Hill Place Hotel.

The National Museum of Scotland is a stunning destination for the key social event of your conference. The Museum has atmospheric vaulted chambers –

perfect for arrival drinks – galleries to educate and entertain your guests, and conference facilities for additional breakout space. The perfect destination for an evening reception or gala dinner, the Grand Gallery sets the scene for an end to your conference day that your guests will never forget.

Our catering partner will deliver the finest Scottish menu and Surgeons’ Hall’s dedicated events team will manage your event across all three Old Town Collection venues.

The three organisations within the Collection are registered charities, and profits from their conference businesses are used to support the education and cultural sectors in the city, and around the world.

For conferences up to around 750 delegates, The Old Town Collection should be your first choice in Scotland’s capital city.

Please tell your association about The Old Town Collection Edinburgh.

For more information about your one-stop shop for conferences in the beautiful city of Edinburgh, contact our events team today ● www.oldtowncollection.co.uk ● info@oldtowncollection.co.uk ● 0131 527 3434

AGENDA

THE PRESIDENT WRITES Ian Ritchie provides his final update as the College’s President

A

s I approach the end of my term as President of your College, I have been reflecting on this eventful period in my life. I have been privileged to meet many of you throughout the UK and around the world, and in many diverse environments. I have also established connections and maintained friendships across many professions. Throughout all these meetings, discussions and experiences the common thread has been the care of patients. It is the cause above all others which unites us.

In my three years as President, sustainable healthcare has inevitably been at the forefront of everyone’s minds, given the rate of change in the way the health service is governed in the devolved nations of the UK. In all jurisdictions, the cost of healthcare causes concern to clinicians, patients, managers and politicians. We have to steward the resources we are given wisely in order to provide the best possible healthcare for the populations that we serve. We have to accept that it is no longer sustainable to have ‘palaces of sickness’ where secondary care clinicians work in isolation from their primary care colleagues.

Apart from anything else, the pressure that this arrangement puts on beds and resources in secondary care is not sustainable. We must think differently about how we work with our primary care colleagues and it seems inevitable that at some point secondary care clinicians will have to reach out into the community more than we have done up to now. Clearly this is not possible in terms of major surgical procedures, but there are other ways in which we could work more sustainably with our colleagues. The question is whether we have the will to engage in what will be a challenging process.

The second area that concerns me is the demographic of the surgical workforce. Less than 20% of the surgical workforce are women. I wonder what it says about the profession that so few women regard surgery as a viable career. The proposition that women are in some way unsuited to a career in surgery has been discredited and we know that all surgeons, whatever their gender or circumstances, have the legitimate expectation of being able to have a proper work/life balance, a fulfilling career, and the time to look after and support their families and loved ones. We must become more attuned to this and create a professional environment that is healthy for surgeons and their families. The GMC Trainees’ Survey revealed bullying and harassment as a serious problem in surgical practice. Bullying,

We have to accept that it is no longer sustainable to have ‘palaces of sickness’ where secondary care clinicians work in isolation from their primary care colleagues 8 | Surgeons’ News | September 2015

in all its forms, is something we condemn wholeheartedly and unequivocally. To ensure that it is eliminated requires that we carry out the difficult exercise of reflecting on our personal attitudes and ways of working. Are we unconsciously doing or saying things that undermine or belittle our colleagues at any level?

The best way to deal with these problems is to focus on teams and how they will help us to cope with the changing nature of healthcare delivery. The teams we had in the past have disappeared, with a consequent breakdown in communication between managers and clinicians. This has resulted in the high-profile incidents that we have experienced in England, Scotland and Wales. Such incidents are not acceptable and as individual clinicians we have to consider how to react to these issues. At the heart of the problem lies the fact that ‘the team’ is becoming more ephemeral, with people increasingly scrutinised as individuals, rather than as part of a larger responsible group – we work in teams, but are no longer part of a team. It is in such circumstances that problems like bullying and harassment become more likely because we all feel isolated and unsupported.

Teamwork is important but the teams must be structured differently from the way we are used to. The ‘Sir Lancelot Spratt’ team is no longer tenable in the modern health service. We must be open to the possibilities and opportunities that come from acknowledging and welcoming the leadership potential from all our colleagues in all areas.

Finally, and somewhat controversially, I would like to question whether the term ‘consultant’ is appropriate in the 21st-century NHS. Many of us cherish the term because it took us so long to achieve that status, and I know our colleagues in training aspire to be consultants. However, in the modern health service, and with the prospect of seven-day services and consultant-present care, consultants no longer work as they did back in 1948.

Therefore, the term ‘consultant’ seems anachronistic and does not truly represent our role, making that role, and the role of those who are not badged ‘consultant’, unclear to our patients. An alternative approach would be to define exactly what we mean by ‘consultant’ these days.

As I move on from the immense honour of being President of this ancient institution, I remain delighted at how modern and forward-thinking it is. As Fellows and Members, you can be proud of your contribution to delivering safe, high-quality healthcare in a changing world. We have done many things over the last three years that have challenged the status quo and I know that over the next three years, under the leadership of Mike Lavelle-Jones, the College will continue to demonstrate that, although it is the oldest surgical College, it has many new ideas to take surgery forward.

Ian Ritchie

The latest guidelines, articles and studies

IN BRIEF NCEPOD: Time to get control? A review of the care received by patients who have had a severe gastrointestinal haemorrhage

This report from the National Confidential Enquiry into Patient Outcome and Death evaluates the management of patients with an acute GI bleed and provides recommendations on the organisation of services to counteract GI bleeding.

NCEPOD, July 2015, www.ncepod.org.uk

Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled trial

This trial randomised 560 patients undergoing elective abdominal surgery with midline laparotomy to receive small ‘tissue bites’ of 5mm every 5mm or large bites of 1cm every 1cm for abdominal closure. Patients in the small-bites group had a higher ratio of suture length to wound length (5·0 vs 4·3). At one year follow-up, 57 (21%) patients in the largebites group and 35 (13%) patients in the small-bites group had incisional hernia (p=0·02). Authors concluded that the small-bites suture technique is more effective for prevention of incisional hernia in midline incisions and should become the standard closure technique.

Deerenberg EB, Harlaar JJ, Steyerberg EW et al. published online in the Lancet, July 2015

Comprehensive surgical coaching enhances surgical skill in the operating room

This randomised controlled trial evaluated the impact of individualised coaching on surgical technical skill in the operating room. Twenty trainees undergoing a minimally invasive surgery rotation were randomised to conventional training (CT) or comprehensive surgical coaching (CSC), including performance analysis, debriefing, feedback and

NICE GUIDELINES Suspected cancer: recognition and referral NICE guidline NG12 offers evidencebased advice on the recognition of, and referral for, suspected cancer in children, young people and adults. The recommendations have been organised by symptoms and investigation findings, as well as by the site of suspected cancer.

Arthroscopic surgery for degenerative knees: systematic review and meta-analysis of benefits and harms

behaviour modelling. The CSC group scored higher on a procedure-specific skill scale compared with the CT group and made fewer technical errors. Authors concluded that comprehensive surgical coaching enhances surgical training and results in skill acquisition superior to that observed with conventional training.

This systematic review evaluated nine trials to determine the benefits and harms of arthroscopic knee surgery involving partial meniscectomy, debridement, or both for middle-aged or older patients with knee pain and degenerative knee disease.

Interventions including arthroscopy showed a small benefit for pain at three and six months, but not up to 24 months.

No benefit on physical function was found. Authors concluded that the small benefit seen from interventions that include arthroscopy for the degenerative knee is limited in time. Knee arthroscopy was associated with harms.

Taken together, the findings did not support the practice of arthroscopic surgery for this indication.

Bonrath EM, Dedy NJ, Gordon LE, Grantcharov TP. Ann Surg 2015; 262(2): 205–212

Thorlund JB, Juhl CB, Roos EM, Lohmander LS, BMJ 2015; 350: 2747–2755

Baseline prevalence of abdominal aortic aneurysm (AAA), peripheral arterial disease and hypertension in men aged 65–74 years from a population screening study (VIVA trial)

Gastrografin in prolonged postoperative ileus: a double-blinded randomised controlled trial

This observational study investigated combined screening for AAA, peripheral arterial disease (PAD) and hypertension (HT) in 25,083 Danish men aged 65–74 years. An AAA was diagnosed in 3.3%, PAD in 10.9% and HT in 10.5%. Lipid lowering and/or antiplatelet treatment was initiated in 34.8% of participants.

Authors concluded that preventive actions were started in one-third of attenders. The long-term effect of this strategy on morbidity and mortality is an important part of further analysis.

This trial randomised 80 patients to receive 100ml of gastrografin or flavoured distilled water (control group) administered enterally. Mean duration of PPOI did not differ, but gastrografin accelerated time to flatus or stool. There were no significant differences between groups in complications or duration of hospital stay. Authors concluded that gastrografin is not clinically useful in shortening an episode of PPOI with upper and lower gastrointestinal symptoms, but it may be of benefit in patients who display lower gastrointestinal symptoms exclusively.

Grøndal N, Søgaard R, Lindholt JS. Br J Surg 2015; 102(8): 902–906

Vather R, Josephson R, Jaung R et al.

Ann Surg 2015; 262(1): 23–30

NICE, June 2015, www.nice.org.uk

www.rcsed.ac.uk | 9

AGENDA

After years of planning, the College museum is to reopen as a major visitor attraction

A NEW CHAPTER

T

he common perception of museum curators and staff is that they exist in a cosy world in which objects are studied, evaluated and researched and, finally, displayed. While study, research and display are the important factors in a museum’s functions, we are concerned with the display element at the moment.

Since the beginning of the year, the Lister Project has focused on constructing the physical access elements – that is, the stairs and lift. A visitor entering the complex will now see a glass-fronted structure connecting the Playfair Hall to the Hill Square buildings.

The stonework was completed in partnership with Edinburgh World Heritage following a strategy to preserve the features using reversible conservation techniques rather than restoration.

The main part of our work now is concentrated on the refurbishment and redisplay of the Surgeons’ Hall Museums. For this, we have recruited Thomas Johnstone Limited, a very experienced contractor whose previous works include the National Museum of Scotland and the British Museum. In keeping with our desire to use high-quality contractors, our showcase suppliers are Goppion S.p.A, an Italian company whose contracts have included the Louvre and involved designing a case to hold The Mona Lisa.

From the outset of the project, we were very aware that a key part of the display was to interpret the collections in an engaging way that would appeal to a diverse general audience. Although most of our museum visitors don’t have a medical background, the workings of the body, what can sometimes go wrong and how this may be treated are of universal interest.

Our challenge was how to tell the story of the fascinating 500-year history of the College, and surgery more broadly, in a way that would connect to a modern audience, regardless of their background or prior knowledge. To do this, we created themes to help visitors navigate and make sense of the collections.

Visitors approach a museum visit in different ways, so we’ve used various tools and methods to ‘layer’ information, enabling visitors to choose the level of detail they want to delve into. In its simplest form, the

10 | Surgeons’ News | September 2015

A glass-fronted structure connects Playfair Hall to the Hill Square buildings

interpretation panels on the walls are designed to catch the eye with a main headline message, followed by an introductory paragraph and then the more detailed body of text. The top level of information will be enough to provide meaningful context for some visitors; others will want to read more.

In addition to graphic panels, we have worked with various companies and designers to provide what we think will be a truly exciting experience for visitors. The centrepiece of this is an introductory audio-visual show centred on the first public dissection performed at ‘old’ Surgeons’ Hall in 1702. We have built a reconstruction of an 18th-century anatomy theatre, complete with

Display cases being installed in the History of Surgery part of the museum

The centrepiece of this is an introductory audiovisual show centred on the first public dissection performed at ‘old’ Surgeons’ Hall in 1702 a cadaver on an anatomy table. As a film plays with a costumed actor narrating the events, the cadaver figure will be projected onto from underneath, highlighting the relevant anatomical details through the various stages of the dissection.

There will also be several interactive exhibits in the museum displays, including a simulator of keyhole surgery, film footage, various touchscreens (such as a College timeline), and a large anatomy exploration station where visitors can swipe, pinch, zoom and rotate their way around the body, looking at the skeleton, muscles, circulation or whichever body system they choose.

All the various devices we have employed were carefully considered to enhance and enrich the museum visit, which at its heart is still a chance to view the wonderful collections of the College.

Installation of the objects began in August and we have six weeks to repopulate the museum and tweak all the final computer installations that accompany the displays.

The museum reopens to the public on 24 September and is accompanied by one week of events related to the subject matter. We hope to see you on or after that date.

Chris Henry Director of Heritage

Visitors will be able to see a recreation of an 18th-century dissection in the anatomy theatre

Membership event The College is offering its membership a chance to explore the museum before it reopens to the public. The exclusive preview starts at 4pm, Wednesday 23 September 2015. All RCSEd Fellows, Members, Associates and Affiliates are welcome.

www.rcsed.ac.uk | 11

AGENDA

MEMBERSHIP SURVEY RESULTS

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n December 2014, the RCSEd launched its second full membership survey (the first survey having taken place in 2010). Surgical and Dental Fellows, Members, Associates, and Affiliates in the UK and internationally were given the chance to provide their views about the College, its activities and services. Responses were also sought on a wide range of professional issues, from seven-day services to less than full-time working.

Summarised here are results from the surgical survey – see page 40 for a summary of responses from our dental colleagues.

2,299

Responses were received from

75

countries, including the UK

TOP THREE RESPONSE RATES BY GRADE

responses in total were returned

57% Consultant

10% response rate – a very good uptake for a survey

36% of responses were from international Fellows, Members or Affiliates

12 | Surgeons’ News | September 2015

15% Specialty trainee

8% SAS doctor or equivalent TOP THREE RESPONSE RATES BY MEMBERSHIP CATEGORY

47% Surgical Fellow

30% Surgical Member

14% Retired Fellow

OPINIONS ON PROFESSIONAL ISSUES

The professional issues rated most important were the Shape of Training report and 24/7 consultant-led services

50%

3 out of 5 UK and international respondents would be interested in attending an RSA or ISA event

say the Shape of Training report was very important, but threequarters say it is not possible to shorten surgical training

48%

think that seven-day services are very important

76%

agree that the NHS should offer seven-day services

75%

say they do not believe sevenday services are achievable under the current service model

77%

say it is important to have the opportunity to work less than full-time, but just less than onethird thought their employer is supportive of less than full-time or part-time working (28%) *The College is seeking to address this by introducing electronic voting to make the process faster and easier

WHAT OUR MEMBERS THINK ABOUT THE COLLEGE

Only one quarter of respondents said their employer has sufficient surgical capacity at the appropriate grade; 47% said they did not

83%

50%

would recommend RCSEd membership to colleagues

joined because of the College’s reputation as being friendly

68%

63%

of Surgical Members intend to take their Fellowship with the RCSEd

believe the College offers a wide range of educational conferences and skills courses

54%

75%

never or only sometimes vote in Council elections*

agree that the College has an unrivalled reputation for its exams

www.rcsed.ac.uk | 13

ISCP UPDATE

JOINED-UP THINKING Surgeons will find it easier to document and submit records of training they provide thanks to collaboration between the College’s Faculty of Surgical Trainers and the ISCP

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Craig McIlhenny FST Surgical Director Gareth Griffiths ISCP Surgical Director Maria Bussey Head of the ICSP William Allum Chairman of JCST

nyone with surgical training responsibilities will need to be recognised as such by the General Medical Council (GMC) by 31 July 2016. This process will apply to all trainers in secondary care and is designed to bring surgeons in line with primary care, where trainers have been recognised and approved by the GMC for some time. This process will apply to those who hold a named trainer role in secondary care – that is, those who are either assigned educational supervisors or named clinical supervisors.

This process of recognition will entail demonstrating and recording what you do as a trainer. For the approval process, the GMC has chosen to use a framework originally devised by the Academy of Medical Educators (AoME) that defines what a good educational supervisor should be doing. This framework consists of seven domains in the field of education and training. These domains will be used to ensure that you are carrying out your job as a trainer effectively.

The body responsible for ensuring that you are a recognised trainer will be your educational organiser – your deanery or Local Education and Training Board (LETB). Many deaneries and LETBs are currently progressing work on a local educational portfolio that trainers can use for this recognition process. By necessity, however, these processes are going to be fairly generic and lack a surgical focus. The actual approval process will be incorporated into your current enhanced appraisal.

This means that the individual who signs you off as a surgical trainer may not be a surgeon, nor indeed a trainer. We believe these generic approaches will not be enough to enhance the quality of surgical training, and that a surgery-specific approach is needed.

The existing AoME framework that forms the backbone of this process also lacks a surgical context.

The Faculty of Surgical Trainers (FST) has, therefore, devised and published Standards for Surgical Trainers, which will enable surgical trainers to comply with the GMC approval process. Essentially, the Faculty has

14 | Surgeons’ News | September 2015

adapted the existing AoME standards and rewritten them with the surgical trainer in mind. These standards have been presented to the Joint Committee on Surgical Training (JCST), which supports them as the standard for UK surgical trainers.

While this process of recognition has the potential to help all trainers improve, there are some dangers that could derail a move towards championing a quality agenda. First and foremost, we are concerned that some good trainers will relinquish their training role because they see the process as a ‘tick-box’ exercise. The FST standards have been designed to minimise this risk by making it explicit as to what is required of a surgical trainer and make it easy for them to prove that they meet the standard required for recognition.

Second, even the most dedicated trainer may have reservations about any duplication of effort needed to maintain a separate educational portfolio. As trainers, we already input a lot of information into ISCP on behalf

of our trainees. This contains a wealth of evidence about our current practice as trainers, but at present we are unable to access this in a way that can provide meaningful evidence for this trainer recognition process.

The FST has, therefore, been working in close collaboration with both the JCST and ISCP to integrate the Standards for Trainers into the upcoming version of the ISCP (see ‘The power of ten’, page 16). Work is now progressing to embed the evidence-collecting tools that we have devised into the ISCP system. This means that evidence you already place into the ISCP will be automatically collected and assigned to the correct AoME domain for your ongoing recognition as a trainer.

As an example, all the workplace-based assessments that you complete for your trainees will be collated and mapped to the correct domains for the educational part of your appraisal. This will ensure that we minimise any duplication of effort on your part, eliminating the need for you to input this evidence into a parallel system, such as the one held by your deanery or LETB. With the addition of further tools to the trainer section of the ISCP, such as a Trainer Profile, where you describe which training opportunities you can offer trainees, we hope that the ISCP will provide you with a clear annual output on your trainer activity that you can take to your appraisal with minimal extra effort. Over the five-year revalidation cycle, this will produce a clear and unambiguous report that you meet the requirements for trainer recognition.

ROCCO BAVIERA/ALAMY

Evidence you already place into ISCP will be automatically collected and assigned to the correct AoME domain for your ongoing recognition as a trainer

www.rcsed.ac.uk | 15

ISCP UPDATE

The power of 10 The latest upgrade to the ISCP has focused on honing the system as an intuitive and useful guide to learning THE ISCP is approaching its eighth anniversary following its introduction to surgical training in 2007. Although its program code has gone through several updates, another is now necessary.

Back in 2007, the ISCP was an entirely new approach and the surgical community took time to become accustomed to it. The frequent website updates and the initial rigidity of ISCP processes led to criticism about poor functionality and a perceived ‘tick-box’ culture.1,2 Following the 2012 evaluation, we have decided to improve website navigation, enabling modifications to promote better use.3 ISCP is intended to provide the content of surgical training, to record teaching and provide structure for informal assessment and feedback. Guidance for, and recording of, everyday training is assisted by workplace-based assessments (WBAs).

Feedback will be a more prominent part of WBAs in version 10. Feedback will be the first item to complete, with options to describe strengths, development needs and recommended actions. Trainees will be encouraged to reflect on their activity, review progress and identify development needs.

Planned developments

The Learning Agreement is another area in which version 10 will use a change in format to encourage better use. This sets out key areas that the trainee and assigned educational supervisor (AES) agree should be covered during a placement and reviews progress against these objectives at an interim meeting and then

The Resource Area will be expanded for the storage of new educational tools found to be valued by users and which they wish to share with others. These will be available for optional use a final meeting at the end of the placement. Within version 10, each objective can be viewed easily alongside the area for recording the outcome of the

n Improved link between the eLogbook and the ISCP n Indication of trajectory by showing levels achieved against those expected for each topic at the key waypoints (ST4, ST6, ST8) n Updated app for specific aspects of data entry n Incorporation of the standards and trainer domains established by the Faculty of Surgical Trainers

16 | Surgeons’ News | September 2015

subsequent meetings.

We hope that this will encourage reflection on the part of the trainee and AES. To enhance feedback further, there will be future changes to the clinical and assigned educational supervisor report forms.

Performance across a range of domains will be described using free text and by choosing from descriptive prompts ranked on a five-point scale.

The Resource Area will be expanded for the storage of new educational tools found to be valued by users and which they wish to share with others.

These tools will not form part of the curriculum, but will be available for widespread optional use. Should they be found to be useful and of widespread applicability, we may consider including them in the curriculum. Examples of what might be placed in the Resource Area include model learning agreements and alternative feedback forms.

We hope that version 10 will improve the technical aspects of the web programme, as well as the more important role of ISCP as a guide to learning – listing what needs to be known, providing structure for detailed advice and recording progress.

At the time of going to press, firm plans were in place to release the live v10 site by the end of August.

Gareth Griffiths ISCP Surgical Director Maria Bussey Head of ICSP

REFERENCES 1. Eraut M. Evaluation of Phase 2 of the Intercollegiate Surgical Curriculum Project. Published on the ISCP website, 2007.

2. Watson G. Intercollegiate Surgical Curriculum Project – an evaluation.

Published on the ISCP website, 2012.

3. Allum WH. ISCP Evaluation – the next steps.

Ann R Coll Surg Engl 2014; 96(1) (Suppl): 14–16.

BEYOND THE BLADE The College is to host a discussion forum designed to promote excellence in non-technical aspects of the profession

Nathan A Stephens (Scottish Clinical Leadership Fellow at RCSEd) Richard McGregor Timothy Stansfield Anya Adair Alastair Murray Clare Rogers Bynvant Sandhu Anne Maree Wallace Lorna Marson

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he corporate and business world has long recognised the need to support and train their staff beyond the technical aspects of the job to improve engagement and allow individuals to excel. By facilitating employees to function at their best, organisations have thrived and, in turn, increased profits. Parts of the public sector, specifically healthcare, have been slow to recognise the need to maintain staff morale and support high achievers. In particular, there has been a narrowed focus on the (necessary) development of technical competencies, but at the

What is a Professional Excellence Group? l Five to 10 surgeons at different career stages l Rules of confidentiality are set by the group l Mature and open discussion l Meet every few months to reflect and comment on important issues or challenges l Insights gained from diversity of group members l Members report back to the group outcomes and any changes to practice

expense of developing abilities in leadership, management, teamwork, work–life balance, and wider career development.

RCSEd has recognised this and developed programmes such as the successful Non-technical Skills for Surgeons (NOTSS) courses. Similarly, Professional Excellence Groups (PEGs), led

by Lorna Marson (senior lecturer and honorary consultant in transplant surgery at the University of Edinburgh), were launched by RCSEd in September 2014.

The concept of PEGs is to support high-achieving surgeons at different stages of their careers.

The structure and format of the groups has been adapted from successful leadership development methodologies employed in the business and industry sectors. It is important to realise that the purpose of PEGs is neither to allow nepotism and career favouritism, nor to deal with the failing surgeon. Rather, they are designed to facilitate the flourishing of personal professional development and excellence in an individual who happens to work as a surgeon.

PEG members determine the frequency of the meetings, but they are typically held three to four times per year. Topics for discussion are varied, including planning your future career, dealing with a difficult colleague, how to prepare for taking over as clinical lead, and optimising work–life balance. The strength of the group lies with the diversity and expertise of the individual members.

The PEG meeting takes place on 18 September at the RCSEd. For further information, contact a.stevenson@rcsed.ac.uk

Life as a modern-day surgical trainee can be difficult and sometimes confusing. PEGs have provided an excellent forum to discuss and gain perspective on some of the issues and challenges I face in developing my future career www.rcsed.ac.uk | 17

CONFERENCE PREVIEW

The Faculty of Surgical Trainers meeting will offer practical advice on how to improve as a trainer

TALKING EXCELLENCE

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s surgeons, we aspire to excellence in our dealings with our patients. As trainers, we aspire to excellence in the training we deliver.

Achieving excellence in surgical training is the theme of this year’s conference. Attendees can expect a practical emphasis on what constitutes excellence as a trainer, and will be able to take away ideas and concepts to put into practice.

Teodor Grantcharov is a name synonymous with surgical training.

His drive toward improvement is attested to by a PubMed search that reveals more than 100 peerreviewed publications in this area.

As the meeting’s keynote speaker, Dr Grantcharov will give his insight into the current state of the art in surgical training and education, and we are grateful to him for travelling from St Michael’s Hospital in Toronto to join us, and for his support for the Faculty of Surgical Trainers (FST).

Perhaps the highest accolade for a surgical trainer, and a clear badge of excellence, is the Silver Scalpel Award, nominated by the Association of Surgeons in Training.

Mike Lavelle-Jones (pictured right), the College’s presidentelect, received this award last year and his insight into what it takes as a trainer to reach

Good feedback is vital to our trainees to help them to improve their performance and become independent and safe surgeons 18 | Surgeons’ News | September 201

Craig McIlhenny Surgical Director of the FST

Teodor Grantcharov will give the keynote speech

this level of excellence will be invaluable.

Another Silver Scalpel recipient, Gavin Pettigrew, will expand on what constitutes an excellent environment for providing great surgical training.

Stephen Covey’s book The 7 Habits of Highly Effective People is an international best-seller, and Chris Munsch will rework this for surgeons with the ‘Seven Habits of Successful Trainers’, which should provide a detailed map of the route to refining our performance as trainers.

The Shape of Training (SHoT) review has sparked considerable debate and controversy, but we don’t yet know how this may impact our training practice.

Ian Eardley has been involved in looking at how the report might change surgical training, and will deliver a clear view of the implications of Professor David Greenaway’s report for future training.

Good feedback is vital to our trainees to help them to improve their performance and become independent and safe surgeons.

Orthopaedic surgeon Sarah Gill is studying for a doctorate on which aspects of feedback are most effective in training, and she will share this knowledge with us.

Remaining within the orthopaedic fold, David Finlayson will challenge the meeting by asking ‘So you think you are a trainer?’ Using realworld examples, he will provide a thought-provoking and interactive session. This will be followed by a free paper session and the award of prizes for best poster and oral presentations. Abstract submission is open now for posters and oral presentations on all aspects of surgical education and training.

FACULTY OF SURGICAL TRAINERS ANNUAL MEETING 2015

ACHIEVING EXCELLENCE IN SURGICAL TRAINING 22 OCTOBER, MACDONALD BURLINGTON HOTEL, BIRMINGHAM The annual FST conference will use practical, real-life examples of excellent surgical training and explain how it can be achieved in today’s health service.

expert on surgical training; Mr Christopher Munsch, Cardiothoracic Consultant at Leeds Hospital, and Mr Mike Lavelle-Jones, 2014 Surgical Trainer of the Year and RCSEd Vice-President.

Confirmed speakers include: Dr Teodor Grantcharov, Associate Professor at the University of Toronto, Staff Surgeon at St Michael’s Hospital, and

Abstract submissions open now fst.rcsed.ac.uk

www.rcsed.ac.uk | 19

AGENDA

SURGICAL SAFETY UPDATE Recent cases from the Confidential Reporting System for Surgery Delayed management of alkali ingestion

As the on-call ENT SpR, I was referred a patient by the medical SHO on MAU. The patient had ingested a small volume of hydrogen peroxide. He rightly requested I perform a flexible nasendoscopy to assess for upper-airway oedema or burns. The patient was stable with no voice change or stridor. Examination was reassuringly unremarkable.

On review of her notes, it became clear that she had been admitted to the hospital many hours previously.

She drank the bleach at 3pm, attended A&E around 4pm, was triaged as ‘urgent’, but was seen hours later, in minors by an emergency nurse practitioner. Although it was recognised that she needed admitting, the potential seriousness of the situation was not noted. Information from Toxbase suggested QT monitoring, but no ECG was performed. The patient was referred to the medical team for admission, but no one attended A&E to review her. A doctor did not assess her until 2.30am, when she arrived on MAU, and underwent airway assessment and ECG. Thankfully, the patient remained stable, but ingestion of a toxic alkaline substance can cause acute airway compromise and patients need urgent ENT examination in A&E, not 12 hours later. She had been allowed to eat and drink before medical review, despite risk of upper GI perforation. She was discharged the next day after OGD had been performed. The A&E department was contacted to implement measures to prevent this incident recurring.

Reporter’s comments

Ingestion of alkali is a serious incident and should be treated as a priority. An appropriate member of staff should assess patients correctly triaged as ‘urgent’. Specialist review should be sought in department. Airway assessment and ECG is indicated.

CORESS comments

This case illustrates problems of communication in poor handovers, and failure of clinicians to take ownership of the patient. Button batteries are another potential cause of caustic injuries to the oesophagus caused by sodium hydroxide, produced as a result of electrical discharge from the battery. Over the last few years, a significant number of these cases have occurred, such that NHS England has issued a patient safety alert (2014): www.england.nhs.uk/ wp-content/uploads/2014/12/psa-button-batteries.pdf

Antibiotic prophylaxis in groin hernia repairs A 72-year-old patient was admitted for day-case repair of a symptomatic right inguinal hernia, under

20 | Surgeons’ News | September 2015

local anaesthetic. Medical history included total knee replacement for osteoarthritis, severe COPD and home oxygen therapy, with exercise tolerance limited to 15 yards. He had previously been advised not to have a general anaesthetic. In theatre, the patient was monitored and IV access was secured. The surgeon performed an initial ileo-inguinal block with 1% xylocaine with adrenaline, and requested that antibiotic prophylaxis be administered. Co-amoxiclav (1.2g IV) was administered by the anaesthetist. Within 60 seconds, the patient developed a cough that progressed rapidly to wheeze and then severe shortness of breath with cyanosis.

Initial treatment was undertaken with oxygen and salbutamol nebulisers, but the patient rapidly became unresponsive and required intubation and ventilation.

He was treated for presumed anaphylactic shock with adrenaline, hydrocortisone, magnesium sulfate and chlorpheniramine. Arterial blood sampling confirmed respiratory failure with an acidosis (on 100% on FiO2: pH, 7.10; pCO2, 11.1; pO2, 7.1; O2 saturation, 75%; lactate, 7.0; bicarbonate, 18.2). The operation was abandoned, and the patient was transferred to ITU, where he required an adrenalin infusion overnight. The patient was extubated at 24 hours, returned to the ward, and was discharged within 48 hours, making a full recovery.

In the outpatient clinic, at preoperative assessment and during the theatre WHO checklist, the patient denied any penicillin allergy. However, careful retrospective review of the patient’s notes and interviews with family members suggested a similar episode 12 months previously, when the patient was admitted to A&E with sudden onset of a generalised rash, facial swelling, wheeze and cough after his GP commenced him on amoxicillin for communityacquired pneumonia. Symptoms at that time had started immediately after amoxicillin administration and improved with prednisolone and salbutamol. Despite these features, the patient was not warned about the possibility of allergy and did not have allergy testing, resulting in him being ignorant of the condition. Subsequent blood-test findings included positivity for mast-cell tryptase and raised IgE post-event. The patient is now aware of his allergy status and wears an alert bracelet.

Reporter’s comments

Patients’ knowledge of their medical history can be unreliable. It is advisable to be prepared: IV access is useful if a patient is undergoing a significant interventional procedure, even under local anaesthetic. Finally, the current evidence base does not support antibiotic prophylaxis in groin hernia repairs.

CORESS comments

There was no clear evidence that it was recognised that the patient had a drug allergy. Phrasing an open question to a patient – “have you ever had any adverse reaction to a drug you’ve been given?” – may be more useful than a cursory query about drug allergies.

A recent Cochrane meta-analysis1 showed that there are insufficient data overall to demonstrate a clear advantage of antibiotic prophylaxis in hernia repair, but illustrated a classic problem in evidence-based medicine where a lack of evidence in support of an intervention may be interpreted as a reason not to implement it.

1 Sanchez-Manuel FJ, Lozano-García J, Seco-Gil JL. Antibiotic prophylaxis for hernia repair. Cochrane Database Syst Rev 2012; 2: CD003769. doi: 10.1002/14651858.CD003769.pub4.

Incident involving low-friction sheets

During routine laparoscopic appendicectomy, during which the operating table was tilted, the patient, a 70kg man, slid to the floor. Laparoscopic instruments were pulled out as the patient fell, but ports remained in situ.

The patient was transferred, with full spinal protection, back to the operating table, and the procedure completed without further event. There was no intra-abdominal injury as a result of the fall. Postoperatively, the patient underwent CT of the head and spine. There was no apparent injury. The patient made an uneventful recovery and was discharged two days later.

Reporter’s comments

Some months before, low-friction patient transfer (‘slide’) sheets had been introduced to move patients to and from the operating table. These sheets were routinely left under the patient during surgery. In this case, the slide sheet contributed to the patient’s departure from the table. We have now changed our operating procedure such that patients for surgery are placed either skin to mattress (if narrow enough to roll onto and off a transfer sheet) or onto a vacuum bean-bag device (if too wide to be rolled). Slide sheets are removed once the patient is positioned.

CORESS comments

This case highlights the importance of the operating surgeon maintaining control over patient positioning. If an operating table is tipped or inclined, adequate patient restraints in the form of straps or poles should be employed.

Inadvertent administration of a muscle relaxant through an IV line

A 45-year-old patient underwent uneventful laparoscopic cholecystectomy for biliary colic. On transfer to the ward, she developed acute respiratory arrest, after her cannula (placed in theatre) was flushed before administration of cyclizine (IV) for postoperative nausea. She became visibly cyanotic and flaccid, and required emergency ventilation with a bag-valve mask and simple airway for approximately one minute before regaining the ability to breathe. She subsequently had full recollection of the event, but reported that she was unable to move or breathe. It transpired that residual amounts of the muscle relaxant atracurium had been present in the triple-lumen IV line connector.

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

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

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

Reporter’s comments

The IV line connector was not thoroughly flushed with normal saline after use in theatre by appropriately trained anaesthetic staff. At surgical and anaesthetic governance meetings, it was concluded that use of multiple-port connectors should be limited (employing single-injection ports instead) and that cannulae and all ports of any IV device must be thoroughly flushed after use.

CORESS comments

The Advisory Board agreed with the reporter’s comments. The NRLS produced a Signal Alert regarding residual anaesthetic drugs in cannulae in 2009: www.nrls.npsa.nhs.uk/resources/?EntryId45=65333

Missed hip prosthesis

A 82-year-old diabetic patient with non-salvageable leg ischaemia was admitted to the hub hospital of a vascular network under the on-call consultant.

Her angiograms were reviewed, and care was handed over to the consultant in charge of ward care for the week. The latter arranged for her to be placed in an available slot on an elective operating list to be undertaken by a third consultant vascular surgeon.

At surgery, above-knee amputation was somewhat protracted by the discovery of the long stem of a hip prosthesis when dividing the femur. Diamondtipped power tools eventually enabled division of the femur and prosthesis, and the patient made a satisfactory recovery.

Reporter’s comments

The presence of the hip prosthesis, although noted, was not commented on by the on-call consultant upon handover to the ward consultant, who did not review the angiograms personally and failed to notice the operative scar over the hip. The operating consultant, having had the patient placed on his list by his ward-based colleague, also failed to review the films and missed the old hip-operation scar.

CORESS comments

With modern consultant-delivered teamworking, shift systems and multiple handovers, there is scope for important clinical information not to be communicated appropriately. The responsibility for ensuring patient safety lies with each clinician in the chain and, despite the advent of specialisation, the basic surgical tenets of adequate history-taking and clinical examination should not be ignored.

Although a WHO check was undertaken, the operating surgeon had not personally reviewed the films, which would have clearly shown the hip prosthesis. Moreover, a check for metalwork should be undertaken before applying a diathermy plate.

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

www.rcsed.ac.uk | 21

GLOBAL SURGERY

The Lancet Commission has reported that billions of people lack access to basic surgical care, setting ambitious targets to deal with the problem. Will the world’s health leaders rise to the challenge?

MISSION TO TACKLE CARE IMBALANCE

22 | Surgeons’ News | September 2015

T

he Lancet Commission on Global Surgery, which reported in April, demonstrated the immense disparity in the provision of surgical care across the globe. Surgery is an integral component of healthcare, yet access to surgical and anaesthetic care in low and middle-income countries (LMIC) is woefully poor. The commission, which was written by a group of 25 experts with contributions from more than 110 countries, was launched at a day-long symposium at the Royal Society of Medicine in London.

The report outlines that, of the 313 million operations done worldwide each year, just one in 20 occurs in the poorest countries, where more than one-third of the world’s population lives. New estimates produced for the Commission find that there is a global shortfall of at least 143 million surgical procedures every year, with some regions needing nearly twice as many additional operations as others.

The warning from the Commission could not be clearer, with Andy Leather, one of its lead authors and director of the King’s Centre for Global Health, saying, “The global community cannot continue to ignore this problem – millions of people are already dying unnecessarily, and the need for equitable and affordable access to surgical services is projected to increase in the coming decades, as many of the worst affected countries face rising rates of cancer, cardiovascular disease, and road accidents.”

The Commission’s key messages were that 5 billion people are unable to access safe surgery when needed and that the scaling up of surgical anaesthesia care is affordable, saves lives and promotes economic growth.

It acknowledges that although the costs of delivering the additional procedures are large, the cost of doing nothing is greater still.

The report also linked access to surgery with affordability, and found that one-quarter of people worldwide who have a surgical procedure will incur financial catastrophe – costs that they can’t afford and which drive them into poverty – as a result of seeking care. The burden of catastrophic expenditure on surgery is highest in LMIC and, within any country, lands most heavily on poor people.

The publication of the Commission was quickly followed by official recognition by the World Health Assembly of the importance of access to surgery and anaesthesia as a component of universal health coverage.

Surgical colleges from around the world – including the RCSEd – joined forces to issue a statement of support. It

Access to safe surgical procedures is something that we take for granted… so it will be shocking to many that 5 billion do not have proper access to good surgical care read: “The Colleges undertake to promote research on access to safe, affordable and timely surgery, reporting on the WHO’s and the Lancet Commission’s recommended surgical indicators. We will progress these within our region and support low- and middle-income countries with whom we partner.”

The group pledged to report on progress as early as the October 2015 American College of Surgeons Congress with further updates at the May 2016 Royal Australasian College of Surgeons Congress.

“Access to safe surgical procedures is something that we take for granted in the UK and in many countries around the world, so it will be shocking to many that 5 billion of the global population do not have proper access to good surgical care,” said RCSEd president, Mr Ian Ritchie.

There are multiple factors that prevent access to surgery, including transport, surgical capacity, safety of surgery and ability to pay. The College believes that access to safe, affordable medical care should be the cornerstone of any health system but, despite massive leaps forward in global healthcare in the last 20 years, there has not been enough attention placed on the need for access to surgery.

Mr Ritchie expressed his hope that the Lancet Commission and new sustainable development goals can begin to tackle the inequality in healthcare that exists globally, commenting: “It is clear that we desperately need more surgical professionals if we are to meet the surgical needs of the world’s population. RCSEd is keen to be at the forefront of training and supporting surgeons as part of the global health workforce.”

The College has more than 7,000 Fellows and Members in around 100 countries and, in 2012, established the RCSEd International School of Surgery (ISS), which offers educational support for surgeons and surgical professionals throughout their careers. The ISS provides access to courses, training and examinations globally, helping improve standards and set a benchmark for surgical excellence. This includes the College’s Basic Surgical Skills (BSS) course, which gives surgical trainees exposure to the skills they need to deliver surgical care (see pages 26–27). www.rcsed.ac.uk | 23

GLOBAL SURGERY

A hospital in Somalia (above) and working with street children in Kenya

Ultimately, the College’s aim is to help develop surgical capacity in countries where it is needed, promoting the continuity and dissemination of skills, all of which support the aims of the Lancet Commission. A recent example is an initiative to work with urological surgeons in Myanmar and build an improved surgical curriculum that will support and develop surgical capacity in the country.

So what has been the reaction from the wider surgical community and those who have experience of working within healthcare systems in LMIC? “The road to improving access is difficult but not impossible, as the Commission clearly shows,” says Dr Paul McMaster, of Médecins Sans Frontières. But, as McMaster points out, part of the challenge is the complex nature of diseases and conditions that require basic surgical care: “If it was a single treatable disease wreaking havoc, the world would be much more likely to act. But because the surgical burden of disease is less easy to ‘package’ as a problem, the suffering will continue, 24 | Surgeons’ News | September 2015

unless we heed and adopt the approach advocated by the Lancet Commission.”

Professor A R Sharfi, a member of the College’s International Surgical Adviser (ISA) network and head of the Department of Surgery, University of Khartoum, Sudan, gives an example of the multi-faceted challenges of providing surgical care: “As is the case in many African countries, complications from a variety of factors are an all too regular feature of surgery in North Sudan.” Professor Sharfi says one of the main reasons for this problem is that many patients present with advanced disease because they have been treated at an earlier stage by ‘native healers’ (non-medically qualified practitioners of herbal and other types of medicine).

“This puts an extra burden on medical professionals,” continues Professor Sharfi. “Besides treating patients, they must play a major part in educating patients through primary healthcare centres and the media. Therefore, I hope that one of the benefits of the Lancet Commission

Lancet Commission on Global Surgery In numbers

5bn Number of people who do not have access to surgery

143 5% 110 MILLION

UNIVERSAL IMAGES GROUP LIMITED/ALAMY

Annual global shortfall of necessary procedures

If it was a single treatable disease wreaking havoc, the world would be much more likely to act, but because the surgical burden of disease is less easy to ‘package’ as a problem, the suffering will continue unless we heed the approach advocated by the Lancet Commission on Global Surgery will be to help reduce complications, and therefore the higher costs, of surgical treatment in many African countries.”

A further complication is the fact that levels of access to

Ayurvedic medicine is popular in Mumbai

Percentage of worldwide operations that take place in the poorest countries

Number of countries that contributed to the Lancet Commission

surgery can vary considerably within single countries, as Dr P Raghu Ram, ISA in India and Padma Shri Awardee for 2015, explains: “To say there is huge variation in the surgical care across India would be an understatement.

While there are a few centres in the country that offer surgical care on a par with the best in the world, delivery of surgical care and, for that matter healthcare in India, is a lottery, with some getting excellent care and most not.”

Dr Raghu believes there is inadequate priority given to public health, with current spending on healthcare in India sitting at around 1% (which is low even compared with many ‘developing’ nations).

The Lancet Commission has succeeded in pulling together the strands of a disparate and complex global problem. The challenge now facing the worldwide surgical community is to combine expertise, influence and resources to help the 5 billion who do not have access to surgery. www.globalsurgery.info www.rcsed.ac.uk | 25

SKILLS: RWANDA Children in Mayange, Rwanda

After working with surgeons in Palestine to establish a foundation training course, the College is backing a similar scheme in Rwanda

BUILDING ON THE BASICS

“O

nce a month, everyone in the skills and trauma care, and has taught on courses in Hong country, including the president, Kong and Mumbai. He was convenor of the team of six is encouraged to take part in UK surgeons running BSS in East Jerusalem’s Augusta community rebuilding projects such Victoria Hospital over the past four years, which was as painting schools or repairing attended by Palestinian surgical trainees from Gaza, the roads. It’s part of the vision to West Bank and East Jerusalem. rebuild the country following the It was while visiting Rwanda to teach on a trauma care genocide 21 years ago,” says David course that Mr Sedgwick took the BSS proposal to Sedgwick FRCSEd, about Rwanda’s Dr Ntakiyiruta Georges, head of the Department of ‘Umuganda Day’. Similarities could Surgery at the University of Rwanda. Two previous be drawn between this approach courses had been run by Mr Robert Lane to improving the country’s FRCS and colleagues, which provided the infrastructure and his own work in foundation for the BSS courses.

Rwanda aimed at the next generation In supporting such work, the College’s aim is of surgeons. to build capacity in national healthcare systems in RWANDA Mr Sedgwick has been a basic surgical skills low- and middle-income countries. Therefore, (BSS) instructor with the College for 20 years, and the BSS courses are run with an ‘exit plan’ for for the last 14 years has been a course convenor.

RCSEd involvement to be gradually scaled He has a long-standing interest in teaching surgical back until courses are run entirely by local

26 | Surgeons’ News | September 2015

surgeons. Thereafter, the college continues to ‘badge’ the course and visit regularly to see how it has developed.

As an example, Mr Sedgwick highlights the BSS in Palestine, which was officially handed over to a local faculty last year, having launched in 2011. “The last course in East Jerusalem was taught 100% by Palestinians. And it was very exciting to witness that.

The plan is to go back there in a mentoring capacity and, eventually, maybe once a year we will go over to credential the course in the same way that we do in Hong Kong, Bali and Malaysia.”

Reaching that milestone, when a course is finally handed over to local staff, very much depends on the starting point. Mr Sedgwick explains: “When we began in Palestine, there was no course and no trainers. It’s taken us five years to get to the point where the Palestinians could ‘fly solo’.

“Now the Basic Surgical Skills Course is about to become mandatory for surgical trainees in the Palestinian Medical Council’s curriculum. That’s really important because they’re going to need to run at least three courses a year. Clearly, we can’t run three courses a year from the UK, but what we can do is visit once a year for an update on how things are progressing.”

Mr Sedgwick has made a huge personal commitment to the Rwandan venture, lobbying the Scottish Government for support and even raising funds from his local Burns and Rotary clubs. However, with the backing of the College, the course can be officially badged by a recognised professional education body with a strong reputation in the international surgical community.

The College has also provided funding via the Binks Trust – which was specifically endowed to the RCSEd for surgical training in Africa – with additional support from the College’s International School of Surgery.

Dr Georges explains the reasoning behind working with international partners such as the RCSEd: “Lack of funding and availability of local trainers can make it difficult to deliver courses, but collaboration with international faculty and partners can strengthen local capacity to do so. Of course, the added benefit is that trainees are taught by certified instructors on an already established, high-standard course.”

Rwanda has a severe shortage of surgeons: there are fewer than 60 for a population of almost 12 million. Most work at the teaching hospitals in Kigali and Huye, which can be overwhelmed by surgical emergencies, leaving little time for elective surgery.

The first College-badged BSS in Rwanda took place in October 2014, with the second course due to be held in October 2015 when 20 first-year surgical trainees will attend. However, as Dr Georges explains, the demand for basic skills courses extends beyond core surgery trainees: “Trainees in ENT, and obstetrics and gynaecology would also benefit from the course. Plus, medical officers at district hospitals perform most of the surgery – mainly Caesarean sections – which will have many unnecessary complications due to a lack of basic surgical training. Teaching BSS to GPs would increase the access to essential surgery.”

All partners involved in delivering the course are under no illusions about the scale of the challenge to improve Rwanda’s surgical capacity, but increased access to basic surgical skills represents a step in the right direction.

Course attendees learn basic surgical skills

Rwanda has a severe shortage of surgeons: there are fewer than 60 for a population of almost 12 million

Trainees watch video footage of surgical procedures

Certified instructors teach course attendees

www.rcsed.ac.uk | 27

TRAINING THE TRAINER

David Pitts explains why a College course targeted at trainers has wide-ranging appeal

INTERNATIONAL EXCHANGES David Pitts Senior Education Adviser to the College d.pitts@ rcsed.ac.uk

W

hat does Wolverhampton have in common with Bangkok, Kuala Lumpur and Malang? In 2015, together with Edinburgh, Preston and Birmingham, they were all venues for RCSEd’s Training the Trainer (TtT) programme.

PRESSURES AND DEMANDS In the UK, attendance at TtT courses became a compulsory part of the curriculum for most surgical specialties from around 2006. Very few overseas surgical programmes have ever had that requirement, but they are experiencing the same pressures on time for training as we are in the UK. Alongside those pressures in many countries come the requirement to increase the numbers of surgeons while improving the quality of the service they deliver through new technology, new techniques and increasing patient expectations. All of this leads rapidly to the conclusion that the quality of training has to be improved. To achieve that goal, trainers in surgery have to become conscious of their skills as trainers, and be able to improve those skills and adapt the ways they teach to new situations. This is a familiar story to

MORE INFORMATION If you would like more information on the work of the College overseas, please contact Catherine Thwaites, International Activities Manager, c.thwaites@rcsed.ac.uk Overseas TtT courses are usually by invitation of the local organisers only because of the extremely high demand.

However, UK courses for senior trainees and consultants and the TtT: Foundation Essentials programmes for senior medical students and foundation doctors can be found on the college website.

28 | Surgeons’ News | September 2015

anyone involved in surgical training in the UK over the last decade.

PARTNERS IN DELIVERY All of the TtT initiatives overseas result from local invitations from colleges with which Edinburgh has collaborated for many years in exams and education.

In many cases, the TtT events are conducted as part of a larger conference or congress.

In Malang, Indonesia, Professor Kiki Lukman and his colleagues from the College of Surgeons of Indonesia (with the support of B Braun) organised the course to be delivered locally by two of the UK TtT faculty.

For Jeyaram Srinivasan (Preston), it was the first time delivering the course that he had helped to develop in the UK at an overseas venue. He said: “Teaching overseas is a privilege. In the TtT course, we have a lot of interaction with participants. This gives unique insights into how they deliver care in their country, which in turn helps me to better understand my own practice. In all of this, I am grateful to my own hospital (Lancashire Teaching Hospitals Trust) for its support in this and all of my other College projects.”

In Kuala Lumpur, Malaysia, there were two oneday TtT courses held in June as part of the College of Surgeons and Academy of Medicine of Malaysia’s 2015 congress. The courses were hosted at its new Advanced Surgical Skills Centre at the Universiti Kebangsaan Malaysia Medical Centre by Professor Hanafiah Harunarashid to coincide with the facility’s official opening by Mike Lavelle-Jones, President elect.

PIONEERS IN DEVELOPMENT Good trainers need good tools and an educational delivery system that is fit for purpose. With this in mind, the Edinburgh College goes beyond the basic TtT programmes to support the development of workplace assessment tools and the surgical curricula with which they are accustomed. Two years ago, David Pitts and Ian Ritchie ran workshops in Thailand to support the Royal College of Surgeons of Thailand (RCST) in the development of procedure-based assessments (PBAs).

Links with China IN MAY, the RCSEd became the first UK Royal College to hold an examination in the People’s Republic of China. The oversubscribed diet of the MOrth RCSEd followed the signing of a memorandum of understanding between the College and the Ninth People’s Hospital, Shanghai Jiao Tong University, which is one of the leading centres for the treatment of head and neck oncology in Asia.

The agreement was reached during a visit by College President Mr Ian Ritchie, and arranged by the offices of the Dean of Stomatology,

Professor Zhang, and Professor Peter Chung from Hong Kong.

The memorandum instigated an annual scholarship to allow a UK trainee in oral and maxillofacial surgery (OMFS) to spend valuable clinical time in the Ninth People’s Hospital oncology department. The first scholarship has already taken place, with Mr Tom Handley, an OMFS trainee, spending one month in China (pictured).

Mr Tom Handley (right) spent a month in China

Training the Trainers in Malang, Indonesia

The College was invited by Dr Thanyadej Nimmanwudipong and the RCST Education group to run a curriculum-development workshop and to hold a PBA masterclass for those who have been working on the development of PBAs in Thailand following the first workshop. David Pitts was joined for these events in August by Professor Simon Frostick, the chair of the College’s Curriculum Development Group, which oversees and coordinates its work in these areas.

Teaching overseas is a privilege. In the TtT course we have a lot of interaction with participants. This gives unique insights into how they deliver care in their country, which in turn helps me to better understand my own practice Jeyaram Srinivasan

www.rcsed.ac.uk | 29

EXERCISE

EVERYTHING TO PLAY FOR With a growing number of studies into preoperative fitness and postoperative outcomes, the best results are yet to be seen, says Malcolm West

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Mr Malcolm West is a National Institute for Health Research Clinical Academic at the University of Southampton and specialist trainee in general surgery in Wessex

e live in a sedentary society in which we drive cars, sit deskbound in front of screens, and use mobile technology for most of our work and home lives.

Nevertheless, there is a large body of evidence supporting the notion that physical fitness has benefits in almost every context of health and disease and, furthermore, that physical inactivity is one of the leading public health issues we face1–3. Better outcomes for fitter or more active people have been documented in all the major chronic medical conditions that affect ‘developed’ countries, including coronary artery disease, heart failure, diabetes, chronic obstructive pulmonary disease, cancer and stroke.

PHYSICAL ACTIVITY AND ILL-HEALTH Lack of physical activity is the most recently recognised major modifiable risk factor of ill-health and premature death, along with poor nutrition, smoking and alcohol consumption3–4. More active individuals have been shown to have better outcomes in various chronic disease states.

Supervised and unsupervised exercise programmes have been shown to be beneficial in chronic obstructive pulmonary disease, stroke, heart failure and intermittent claudication. Such data raise the obvious question: if outcomes in chronic disease are linked to physical fitness, does this also apply to outcomes after surgery?

If so, can preoperative physical fitness be improved by exercise interventions in enough time to influence outcomes after surgery?

RISK PREDICTION AND SURGICAL OUTCOMES Outcomes after major surgery depend on ‘modifiable’ factors such as perioperative medical care and intraoperative technique and what were previously thought to be ‘unmodifiable’ components, such as the ability of the patient to physiologically tolerate surgical trauma. Surgeons have long recognised the importance of identifying high-risk patients and have developed novel strategies to aid preoperative risk prediction and mitigate against these risks. Preoperative risk prediction and mitigation by optimising chronic disease states, correcting 30 | Surgeons’ News | September 2015

Reduced physical fitness (objectively measured utilising CPET) has been shown to be associated with increased postoperative morbidity in various major surgical cohorts

Left and above: Physical fitness is assessed using cardiopulmonary exercise testing

nutritional deficiencies and implementing enhanced recovery programmes lead to a more efficient use of hospital resources and may improve surgical outcomes.

Although outcomes from major surgery (i.e. oncological outcomes, reduction in morbidity and mortality, and improvement in quality of life) continue to improve year on year, substantial gains may yet be achieved with accurate objective preoperative risk prediction and exercise interventions5–6.

Current approaches to risk prediction include clinical acumen, prediction scores, plasma biomarkers, measures of cardiac function and shuttle-walk tests. Although the profession has been using these for several decades, their effectiveness in predicting surgical morbidity is not well established. However, reduced physical fitness (objectively measured utilising cardiopulmonary exercise testing – CPET) has been shown to be associated with increased postoperative morbidity in various major surgical cohorts.

CPET provides an objective method of evaluating physical fitness under stress, mimicking the stress of a major surgical event. Furthermore, it allows interrogation of the causes of exercise intolerance when exercise capacity is reduced, with the exciting opportunity of intolerance modulation for therapeutic gain. The hypothesis that unfit patients are more susceptible to adverse outcomes following major surgery is intuitively appealing and implicit in many aspects of preoperative assessment.

To date, 24 cohort studies involving more than 4,000 patients have reported the relationship between preoperative CPET-derived variables (i.e. objectively www.rcsed.ac.uk | 31

EXERCISE

measured physical fitness) and postoperative outcome.

These data have been brought together in several systematic reviews. They show a remarkably consistent positive correlation between physical fitness and postoperative outcome7–9. Work by our group (the Fit-4-Surgery Consortium) has clearly demonstrated this phenomenon in patients undergoing major colorectal surgery10–11.

Neoadjuvant therapies using chemotherapy (NAC) or chemoradiotherapy (NACRT) are becoming increasingly common before major cancer surgery. The aim of this therapy is to reduce tumour bulk and treat micrometastases before surgery to increase the likelihood of complete oncological resection, thereby improving long-term outcome. Neoadjuvant therapy using NAC/ NACRT is widely used in locally advanced cancer, including oesophagogastric and rectal cancers, as well as certain breast, urological and lung cancers.

The Fit-4-Surgery group recently published two studies exploring the impact of neoadjuvant cancer treatments on physical fitness before major oncological surgery. The first study evaluated the effect of NAC on locally advanced oesophageal or gastric cancer, and found a significant reduction in fitness after NAC. Lower baseline fitness was associated with increased one-year mortality in those who completed a full course of NAC and underwent surgery12.

A subsequent study in patients undergoing NACRT before

Prehabilitation is defined as ‘the process of enhancing the functional capacity of the individual to enable him or her to withstand a stressful event’.

Exercise training before elective surgery meets this criterion locally advanced rectal cancer surgery within an enhanced recovery programme reported similar results, showing a significant deleterious effect on fitness following NACRT by approximately 25% and an association with increased inhospital morbidity13. This is novel data and has never been shown before, but the precise mechanism of this decline in fitness with neoadjuvant treatments is currently unknown.

PREHABILITATION Interventions to improve postoperative recovery have usually been targeted at the intraoperative and postoperative periods. For high-risk patients about to undergo major surgery, however, this is likely to be too late. As discussed above, poor fitness is linked to poor postoperative outcomes, so identifying interventions to optimise preoperative fitness before major surgery is a priority. The preoperative period may also be an emotionally salient time to engage patients in enhancing their physical fitness before their surgical journey.

Prehabilitation is defined as ‘the process of enhancing the functional capacity of the individual to enable him or her to withstand a stressful event’. Physical exercise training before elective surgery meets this criterion.

32 | Surgeons’ News | September 2015

Studies have shown that active individuals have better outcomes in various chronic disease states

Preoperative exercise interventions have been shown to be feasible and safe, as well as offering improvements in function and quality of life14–15.

Initial randomised controlled trials in colorectal cancer survivors showed mixed results. However, on the whole, better postoperative walking distances have been shown in exercise intervention groups16–17. Other, more recent, randomised studies on aerobic prehabilitation before colonic resection have shown marked improvements in fitness18–19. Kothmann and colleagues found that a moderate continuous exercise programme significantly improved oxygen uptake in a high-risk cohort of patients with aortic abdominal aneurysms under surveillance20.

It seems reasonable to enhance our preoperative assessments by incorporating objective preoperative physical fitness risk scoring that is easy to comprehend triaxial accelerometers) and found that our patients achieved far less than the recommended daily step count of 10,000 steps a day at baseline. We noticed an acute decline in activity with NACRT in both groups which mirrored the acute loss of fitness and an improvement in activity in both groups that was probably due to the natural resumption of activities of daily living post-NACRT. Of note, the exercise group re-attained their baseline activity levels with a significant change in fitness after the intervention period. However, the control group sustained a further decline in fitness. We believe that the dramatic changes in fitness between the groups were mediated by the exercise intervention, and that improving activity alone was not enough. We also believe that an improvement in preoperative fitness might translate into an improved surgical outcome. However, these novel findings require validation in larger randomised studies, and our group is currently conducting such a clinical trial (NIHR-funded PB-PG-0711-25093).

FUTURE DIRECTION

The Fit-4-Surgery Consortium conducted a blinded, interventional parallel-group study and showed that a six-week prehabilitation programme improved objectively measured physical fitness in patients scheduled for major rectal cancer surgery after standardised NACRT as opposed to a control group21. This finding was widely publicised by BBC Health Check as well as by Liverpool and Southampton universities because prehabilitation in a post-cancer treatment setting before major surgery had not been attempted before.

Consistent with our previous work, we validated the observation of the acute harmful effects of NACRT on physical fitness. We also measured physical activity (using

References are available at www.surgeons news.com

Substantial gains to improve surgical outcomes utilising preoperative patient optimisation are yet to be made. We know poor preoperative physical fitness (reflecting poor physiological reserves) are associated with postoperative morbidity, and that rehabilitation following acute or chronic stressors can improve fitness and quality of life.

Several opportunities are developing in perioperative medicine, including increasingly sophisticated risk prediction, collaborative decision-making, ‘personalised medicine’ and targeted exercise interventions. Therefore it seems reasonable to enhance our current preoperative assessments by incorporating objective preoperative physical fitness risk scoring that is easy to comprehend.

The idea of ‘fitness for surgery’ is a good basis for a discussion about the specific risks and benefits of a particular procedure for a particular patient. Personalised medicine involving tailored exercise interventions aimed at improving fitness may be used to guide operative interventions, postoperative care, cancer therapies (including selection of chemotherapy and timing of cancer treatments in relation to surgery), and choices of appropriate multimodal prehabilitation/ rehabilitation programmes. Mechanisms underpinning the interactions of changes in fitness with changes in tumour microenvironment, cancer therapies and exercise are largely unknown, so work in this area is urgently needed.

ACKNOWLEDGMENTS This work was funded by the Royal College of Anaesthetists BOC Fellowship awarded by the National Institute of Academic Anaesthesia and the National Institute of Health Research for the Fit-4-Surgery programme of research. www.rcsed.ac.uk | 33

PLASTIC SURGERY

RESTORE, REBUILD AND MAKE WHOLE Kevin Hancock delves into the history of one of the oldest specialties, dating as far back as 2000BC

P

lastic surgery remains unique among surgical specialties because plastic surgeons do not concentrate on a particular disease process or on just one anatomical site. This makes the specialty very wide ranging and probably the last of the general surgeries, with plastic surgeons operating from the head and neck to the lower limb and from the arm and upper limb to the breast, abdomen and perineum. We are involved in the management of congenital and acquired problems, with a major input into trauma and oncology.

The history of plastic surgery goes back as far as 2000BC when physicians in India and Egypt practised rudimentary forms of plastic surgery. In the sixth century BC the Sushruta Samhita was published in India, written by the ‘founding father of surgery’: Sushruta. This important classical Sanskrit text on medicine is considered to be one of the earliest major works detailing plastic surgery procedures – in particular, nose reconstruction using a flap of skin from the forehead.

Moving to Europe and the 16th century, Italian surgeon Gasparo Tagliacozzi is considered another pioneer of plastic and reconstructive surgery. In 1597, he published De Curtorum Chirurgia per Insitionem (On the Surgery of Mutilation by Grafting) and a quotation from this book has become synonymous with plastic surgery: “We restore, rebuild and make whole those parts which nature hath given, but which fortune has taken away. Not so much that it may delight the eye, but that it might buoy up the spirit and help the mind of the afflicted.”

Modern British plastic surgery was born during the First World War when the brutal nature of trench warfare caused terrible head and facial injuries. It was Major Harold Gillies, serving in the Royal Army Medical Corps in France, who saw the value of a dedicated reconstructive surgical discipline and who helped to

Mr Kevin Hancock Chair of the College’s Plastic Surgery Specialty Group

Clinical experience for plastic surgery The range of plastic surgery is evidenced by guidelines for clinical experience from the Joint Committee on Surgical Training

Right: Woodcut depicting 16thcentury plastic surgery on the nose. Taken from De Curtorum Chirurgia per Insitionem

One of the fundamental techniques of plastic surgery is the ability to move tissue around the body. This began with Harold Gillies’ tubed pedicles and, in the 1960s, free flaps were developed 34 | Surgeons’ News | September 2015

establish a centre devoted to facial repair at Queen Mary’s Hospital in Sidcup, Kent.

By the 1930s, there were four plastic surgeons practising in England. They were Gillies, Thomas Kilner, Archibald McIndoe and Arthur Mowlem, who became known as ‘the big four’. At the outbreak of the Second World War, several plastic surgery units were set up to treat both civilians and military patients. These units were largely sited outside the main centres of population to avoid German bombing.

Today there are approximately 450 consultant plastic surgeons working in the UK. Although some of the original units remain, most have now moved into the cities and main teaching hospitals.

The British Association of Plastic Surgeons was founded in November 1946. The first meeting was at the Royal College of Surgeons of England, when Sir Harold Gillies was elected as the first president. In December 2004 the association changed its name to the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS).

One of the fundamental techniques of plastic surgery is the ability to move tissue around the body. This began with Gillies’ tubed pedicles and, in the 1960s, free tissue transfer

l Cutaneous plastic surgery (including skin cancer) l Hand surgery l Head and neck surgery l Breast surgery l Paediatric plastic surgery l Burns l Sarcoma l Oculoplastic surgery l Aesthetic/cosmetic surgery l Lower limb trauma l Genitourinary reconstruction l Microsurgery (including revascularisation), replants and free tissue transfer

Joint Committee on Surgical Training www.jcst.org The curriculum for plastic surgery training is available at www.iscp.ac.uk

WELLCOME LIBRARY, ALAMY

WELLCOME LIBRARY, ALAMY

PLASTIC SURGERY

(‘free flaps’) were developed. In free tissue transfer, the plastic surgeon removes tissue, including skin, fat, muscle, nerves and bone, from one part of the body and moves it to the part of the body where it is needed. The arteries and veins are reattached and, in some cases, the nerves are as well. One of the most well-known types of free tissue transfer is in breast reconstruction for women who have had a mastectomy as part of their breast cancer treatment.

Traditionally, plastic surgery was a postgraduate specialty, with surgeons embarking on training in plastic surgery after completing a general Fellowship with experience in general surgery or orthopaedics. This system has now been streamlined, and recruitment into plastic surgery at ST3 level is a nationally organised process taking place twice a year. The range of plastic surgery is evidenced by the guidelines for clinical experience on the Joint Committee on Surgical Training website (see box, 36 | Surgeons’ News | September 2015

page 34). Trainees are expected to have undertaken some 2,100 logbook operative procedures during the six years of training, and operative competencies are in place with indicative numbers (e.g. 57 breast reconstructions and 80 lower-limb traumas).

Research and innovation have been paramount in the development of plastic surgery. This continues to be evidenced with a high proportion of trainees undertaking formal research, as well as publication and presentation being an essential part of training assessment.

In recent years, the public profile of plastic surgery has increased enormously, not always for the best reasons.

While awareness of the specialty has been helped by medical student attachments and presence in teaching hospitals, the trivialisation of cosmetic surgery, with television programmes such as Nip/Tuck and reality shows, combined with magazine and other media revelations,

Photographs of plastic surgery cases from the Royal Army Medical Corps Muniment Collection taken by Dr Albert Norman

ROYAL COLLEGE OF SURGEONS OF ENGLAND

Research and innovation have been paramount in the development of plastic surgery. This continues, with a high proportion of trainees undertaking formal research needs to be controlled. The international scandal that surrounded PIP breast implants illustrated how poorly cosmetic surgery was regulated, and the Cosmetic Surgery Interspecialty Committee at the Royal College of Surgeons of England is helping to address this problem.

The future for plastic surgery clearly lies with greater cooperation with our surgical colleagues. The development of oncoplastic breast surgery and orthoplastic lower-limb trauma surgery as separate subspecialities, as well as plastic surgery participation in multiple other multidisciplinary teams, shows the great value of surgical cooperation and joint operating.

For those of us who have chosen plastic surgery as our career it remains an extremely wide-ranging surgical specialty that can be hugely rewarding and enjoyable.

Portrait of a soldier with facial wounds,

by Henry Tonks, 1916–18

Shaping up nicely Aenone Ruth Harper explains what attracted her to training in plastic surgery I CHOSE to pursue surgery the moment I walked into a theatre coffee room in the second year of medical school – it felt like home. This feeling has never left me and I love coming to work for that reason.

I spent the last six months of medical school in Angers, France, on the European exchange programme ERASMUS. Here, I did a placement in the plastic surgery unit and was entranced by the surgery I witnessed.

I had never even heard of, let alone seen, a microvascular reconstruction. Even now, as I come towards the end of training, the sight of returning capillary refill to skin, signifying a successful microvascular anastomosis, does not get old. In fact, it is a considerable source of pride that I am now in possession of that skill.

To arrive at this point, I completed foundation competencies and progressed to core training, 12 months of which was themed to plastic surgery, six months in general surgery and six months in intensivecare medicine. During this, I completed all necessary courses – ATLS, Basic Surgical Skills, Core Skills in Plastic Surgery and my RCSEd Membership.

Harper trained for six months in Angers, France

I then went into a ‘locum appointment for service’ job at registrar level for nine months, during which I completed more relevant courses – microsurgical skills, free flap course, advanced skills in hand surgery, and fracture fixation. From this I obtained a standalone ‘locum appointment for training’ (LAT) job, which at the time could be employed outside of National Recruitment. I focused on honing my surgical operating logbook ready for the national selection process, and also spent time in formal research for an MSc. I secured my first national training number (NTN) in plastic surgery in 2012 and was offered the opportunity to count

my nine months as a LAT towards my training, which I did. My second NTN in plastic surgery has come about as a result of the inter-deanery selection process, which allows eligible trainees to move their training number to another region, usually for family reasons. I have worked in plastic surgery units in Manchester, Hull, Swansea, Bristol and now Merseyside, and I would not exchange that wealth of experience for anything. I have seen and experienced a wide and varied practice.

That was evident in my logbook for national selection and I performed well at interview because of the breadth of my exposure to the specialty.

Of course, mine is only one route to the end, and many current and prospective trainees may balk at the ‘patchwork’ nature of my career so far. However, I have met some wonderful trainers who have transferred their enthusiasm for the specialty to me; they clearly care for their patients and help their trainees on the journey to becoming consultants.

Aenone Ruth Harper Plastic Surgery ST6, Mersey Deanery

www.rcsed.ac.uk | 37

DENTAL

Professor Bill Saunders welcomes the further inclusion of dental care professionals into College activity

TEAM PLAYERS

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hile the majority of the work of the Dental Faculty is the assessment and education of the dental surgeon at varying levels of experience and training, there is an important role for the College in the assessment of other essential members of the dental team: the dental care professionals. Under the direction of the Advisory Board for Dental Care Professionals, a number of examinations have been introduced to match the expanding roles for this vital group. These include diplomas in dental hygiene, dental therapy, clinical dental technology and orthodontic therapy.

An important element of the practice of dentistry is teamwork, which is stressed by the General Dental Council in its most recent publication, Dental Team Learning Outcomes for Registration (2015 revised edition). Paragraph 8 of the document for dentists states: “Ensure that any team you are involved in works together to provide appropriate dental care for patients”; and Paragraph 11 states: “Recognise and respect own and others’ contribution to the dental and wider healthcare team and demonstrate effective team working, including leading and being led”. It is clear that the concept of a team to provide optimal care for patients is pivotal and the Faculty supports this wholeheartedly.

We are anxious to be inclusive and to ensure that dental care professionals have a strong voice and are integrated in the Faculty as part of this team.

Dental hygienists, therapists and clinical dental technicians require skills of a very high order and recently

It is clear that the concept of a team to provide optimal care for patients is pivotal and the Faculty supports this wholeheartedly 38 | Surgeons’ News | September 2015

were allowed to receive patients directly, without referral from a dentist. It is clear that assessment of the abilities of this group to allow them to be registered with the General Dental Council is an important role for the College.

There is increasing interest in teaching institutions wishing to affiliate with our Faculty to provide these assessments. Indeed, one institution will use our diploma in dental hygiene and therapy as an assessment for dental students as they progress to their dental surgery degree. Registered dental care professionals, including dental nurses, can now undertake enhanced training in orthodontic therapy and the Faculty has developed a suitable examination to assess this. This is the first opportunity for dental nurses to become part of our Faculty. It is always gratifying to welcome diploma recipients from the dental care professionals group to our diploma ceremonies, where the success of qualification can be shared with family and friends.

In addition, continuing professional development (CPD) for dental care professionals is mandatory and, in the first cycle of this CPD (2008–13), more than 35,000 registrants with the General Dental Council complied with the requirements.

The Faculty has a role in supporting CPD activity and a conference is held each March specifically for dental care professionals. This aims to strengthen and further develop the dental team. These meetings are fully subscribed and provide a broad base of educational experience, from core continuing professional development to contemporary and future practice.

The Faculty of Dental Surgery wishes to be a home for all the dental team and we will continue to encourage participation by dental care professionals in the furtherance of the aims of the College.

Professor Bill Saunders Dean, Faculty of Dental Surgery

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

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

1

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

2

ENGLAND

3

EAST OF ENGLAND 4 Simon Wardle, James Paget University Hospital, Great Yarmouth KENT, SURREY & SUSSEX 5 Lindsay Winchester, Queen Victoria Hospital, East Grinstead

6

20

NORTH EAST OF ENGLAND 6 Francis Nohl, Newcastle Dental Hospital NORTH WEST OF ENGLAND 7 Alex Milosevic, Liverpool University Dental Hospital 8 Mike Pemberton, University Dental Hospital of Manchester 9 Callum Youngson, School of Dentistry, Liverpool

17

19 18

7

8 9

14

NORTH LONDON 10 Phil Taylor, Barts and the London School of Medicine and Dentistry, London 4

NORTH EAST LONDON 11 Nick Lewis, UCL Eastman Dental Institute, London

13

NORTH WEST LONDON 12 Sumithra Hewage, Northwick Park Hospital, Harrow OXFORD 13 Mary McKnight, John Radcliffe Hospital, Oxford SOUTH YORKSHIRE/EAST MIDLANDS 14 Philip Benson, Charles Clifford Dental Hospital, Sheffield SOUTH WEST OF ENGLAND 11 Crispian Scully, UCL Eastman Dental Institute, London (Although based in London, he is representative for Avon) 15 Pamela Ellis, Dorset County Hospital, Dorset 16 Matthew Moore, Royal Devon & Exeter NHS Foundation Trust YORKSHIRE 17 Brian Nattress, Leeds Dental Institute, Leeds

WALES

18 Joy Hickman, Glan Clywyd Hospital, Clwyd

12

16

11 10

15

5

REPUBLIC OF IRELAND

19 Simon Wolstencroft, St James’ Hospital, Dublin

NORTHERN IRELAND

20 Gerald McKenna, Queen’s University Belfast

RDA VACANCIES

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

www.rcsed.ac.uk | 39

DENTAL

DENTAL MEMBERSHIP SURVEY RESULTS

I

n December 2014, the RCSEd launched its second full membership survey. Dental Fellows, Members, Associates, and Affiliates in the UK and internationally were asked to provide their views on the activities and services of the College and Dental Faculty. Responses were also sought on the professional issues that mattered to our membership.

417

responses in total were returned from across all categories of dental membership, a response rate of around

8.5% of the total membership

TOP FIVE GRADES OF RESPONDENTS

29% Consultant

26% Specialist dental practitioner

13% Primary dental care practitioner

10% Specialty doctor/dentist

6% Specialty trainee TOP FIVE FIELDS OF PRACTICE OF RESPONDENTS

32% Orthodontics

12% Primary dental care

36% Oral and maxillofacial surgery

29% Oral surgery

24% Paediatric dentistry International members are working in

33

40 | Surgeons’ News

countries, with Hong Kong, Malaysia, Egypt, Australia and the USA the areas with the most respondents

WHAT OUR MEMBERS THINK ABOUT THE COLLEGE AND DENTAL FACULTY

OPINIONS ON PROFESSIONAL ISSUES

63%

Around three-quarters of respondents would be interested in attending an RDA/IDA event, whereas around half said they would be interested in being involved as Faculty

of UK dental respondents say their employer provides sufficient time and resources for CPD

Nine out of 10 respondents consider it important to have the opportunity to work less than full-time

83%

45%

49%

would recommend FDS RCSEd membership to colleagues

joined because of the College’s reputation as being friendly

54%

55%

of Dental Members intend to take their Specialty Membership with the RCSEd

never or only sometimes vote in Council elections*

72%

62%

agree that the Dental Faculty has an unrivalled reputation for the running and quality assurance of exams

say they would be interested in joining the Faculty of Dental Trainers

think that their employer is supportive of less than full-time or part-time working

The professional issue rated most important was the regulation of cosmetic dentistry and implants

90%

of UK dental respondents believe there should be Specialist Lists; 4% said “no” and 6% “don’t know” When asked whether Direct Access is a positive development, UK respondents’ views are evenly split

33%

34%

said “yes”

said “no”

32% said “don’t know”

*The College is seeking to address this by introducing electronic voting to make the process faster and easier

www.rcsed.ac.uk | 41

TRAINEES AND STUDENTS

The debate on the publication of outcomes data must take into account the effect on patients and surgical training, write representatives of the Association of Surgeons in Training

DATA DANGER

C

onsultant outcomes publication (COP) was introduced in cardiothoracic surgery in 2005 in response to the Bristol Royal Infirmary Inquiry, and subsequently for all surgical specialties in England in 2013–14 following the Mid Staffordshire Inquiry. The aim is to enhance transparency and surgical quality, but while improving surgical care is paramount, COP may not be the ideal solution. COP is not without risk and may have unintended detrimental effects, particularly with regard to surgical training1–5.

The delivery of high-quality healthcare to present and future patients relies on excellence in surgical training. Furthermore, surgical training and trainee involvement in operations has been shown to have no detrimental effect on patient outcomes6–12. However, COP may reduce the operating experience of trainees as consultants could be reluctant to allow trainees to gain necessary experience, particularly as the primary operator. Giving trainees less exposure to operations may result in future generations of surgeons lacking adequate skills to provide safe surgical care. There is already evidence to show that trainee operative experience has declined following the introduction of COP within cardiothoracic surgery.

The European Working Time Directive has already reduced trainee operative experience, and the potential for COP to decrease it further by promoting defensive practice by consultants is of huge concern13, 14. COP may also lead surgeons to ‘cherry-pick’ to avoid difficult and complex cases. Surgical trainees need to be exposed to an adequately complex case mix to become competent consultants.

Patients deserve top-calibre surgical trainees and consultants, but COP could affect the recruitment and retention of high-quality candidates into surgical training. COP could have a huge impact on a surgeon’s career and reputation, and ‘naming and shaming’ of surgeons may encourage trainees to select other specialties or to seek training opportunities abroad.

This could result in a brain drain of excellent candidates from the UK or from surgery. Already, there has been a significant decline in UK graduates pursuing a career in cardiothoracic surgery in the NHS since the introduction of surgeon-specific outcomes15. In addition, psychological stress suffered by surgeons when complications arise may negatively impact patient outcomes. COP might 42 | Surgeons’ News | September 2015

ASiT has published a number of statements that are available at www.asit.org/ resources/articles

Unit-specific data are better markers of the patient journey within a hospital, allowing for real sources of potential error to be identified and corrected

accentuate this, to the detriment of patients and surgical training16. Reporting unit outcomes could be more meaningful in changing patient outcomes and more acceptable to the surgical community17.

There is little evidence to suggest that COP improves surgical outcomes18, 19. Indeed, consultant outcomes often oversimplify a highly complex process of patient care.

Particularly in an era of austerity, trust resources and infrastructure, rather than the performance of individual clinicians, may be deleterious to patient outcome. For example, failure to rescue (FTR) sick postoperative patients is a key outcome in many surgical specialties.

However, many issues that lead to FTR are not within an individual surgeon’s direct control, including levels of medical and nursing staffing and the availability of critical care support and hospital resources19, 20.

Publication of surgeon-specific rather than unit-specific data undervalues the role of the multidisciplinary team, including critical care, perioperative

medical input, nursing staff and allied healthcare professionals. Unit-specific data are better markers of the patient journey within a hospital, allowing for real sources of potential error to be identified and corrected. Publication of unit- or hospital-specific data, using adequately designed tools, would have a positive effect on surgical training by promoting less risk-averse practice and encouraging excellence within surgical units.

Any data published, whether unit or consultantspecific, must be of the highest quality. The datacollection process must be robust because poor-quality, incomplete and unadjusted data may misinform the public and unfairly damage the profession and individual surgeons. Independent systems for submitting data, which are designed for this purpose, deserve further investment.

COP may place an additional administrative burden on

Surgical trainees are important stakeholders in the process of COP … they are the future generation of consultants consultant trainers, which could dilute the time available to provide training. NHS consultants must be given adequate administrative support and a realistic timeframe to complete these important audit tools.

In addition, proper risk-adjustment must be conducted to avoid surgeons cherry-picking less-risky, lesscomplex cases.

If consultant outcomes are to continue to be published, there is a need to consider including data collection on surgical training to minimise the impact of COP on training – for example, collection of trainer-specific outcomes to monitor the number of cases performed by trainees before and after the introduction of COP. Trainees should be allocated to trainers who can demonstrate that the number of procedures trainees are performing under consultant supervision is adequate and has not been eroded following COP. Surgical trainees are important stakeholders in the process of COP because it affects their training and they are the future generation of consultant surgeons. Excellence in surgical training is critical for patient safety. To deliver high-quality surgical care, tomorrow’s surgeons must receive excellent training today. The impact of COP on surgical training must be carefully considered and monitored. Publication of unit-specific data may be a more positive metric to change patient outcomes and improve surgical training for future generations.

References are available at www.surgeonsnews.com

Helen Mohan, Vimal J Gokani, Rhiannon L Harries on behalf of ASiT Council www.asit.org @ASiTofficial www.rcsed.ac.uk | 43

TRAINEES AND STUDENTS

Rory Piper looks back on his medical elective with specialists in paediatric epilepsy at Boston Children’s Hospital, USA

NEW FRONTIERS IN NEUROSURGERY

E

Rory Piper Academic Foundation Doctor, University of Cambridge

pilepsy surgery is a neurosurgical discipline that centres around the care of patients who have epilepsy that does not respond to drugs. In selected candidates, epilepsy surgery is a highly effective treatment option, aiming for, and often achieving, complete freedom from seizures.

The provision of this service relies on a true multidisciplinary approach, including psychologists and social workers in addition to the core medical team. Furthermore, epilepsy surgery draws on cutting-edge advances in medicine and technology to maximise the clinical outcome and avoid detrimental postoperative deficits.

Although Scotland has an epilepsy surgery service, the volume of patients is relatively small and opportunities for students to engage are few. Therefore, I selected Boston Children’s Hospital (BCH)/Harvard Medical School, USA, as the destination for my medical school elective. In 2014, BCH was named as the best-ranking US children’s hospital for neurosurgery and has a dedicated, high-volume, cutting-edge epilepsy service. Moreover, BCH is at the frontier of research for epilepsy surgery, particularly in using novel neuroimaging methods to enhance surgical planning, performance and outcome.

I set three aims for my elective. First, I wanted greater exposure to paediatric neurosurgery, epilepsy surgery in particular. Second, I hoped for greater understanding of

44 | Surgeons’ News | September 2015

how cutting-edge technology and neuroimaging is applied to enhance the planning, performance and outcomes of neurosurgery. Finally, I wanted to contribute to the research pursuit of improving patient care by applying advanced neuroimaging to enhance epilepsy surgery.

As well as activity on the neurosurgical ward and in clinics, I had the opportunity to spend time in the neurosurgical operating room. On these days, I was exposed to complex and often full-day epilepsy cases.

These included resection procedures (anterior temporal lobectomy, removal of cortical dysplasia, removal of cerebral tumours); disconnection procedures (functional hemispherectomy, corpus callosotomy); laser ablation and vagal nerve stimulation. I also gained experience in other paediatric cases, such as surgery for spinal dysraphism and craniosynostosis.

LASER THERMAL ABLATION I was determined to learn about advanced epilepsy surgeries that employ novel neuroimaging techniques.

An excellent example from my time at BCH is the use of thermal laser ablation in the treatment of lesional epilepsy (e.g. hypothalamic hamartoma and mesial temporal sclerosis). This is a minimally invasive neurosurgical technique that aims to ablate deep lesional targets in the brain.

Patients are operated on in an intraoperative MRI suite.

After the first MRI, the surgeon plans a safe trajectory from skin to lesion. The laser is driven down a guidewire using a stereotactic technique. Next, from the MRI control room, the ablation is remote-controlled and is watched in real time using thermal measurement from MRI thermal imaging. Although this technique is under evaluation and is available only in the USA, it shows great potential and may be adopted in UK practice in the near future.

Above: An MRI scan Below: Boston Children’s Hospital is leading the way in epilepsy surgery research

AVOIDING VISUAL FIELD DEFECTS As a medical student, I have developed a keen interest in academic medicine. Through combining an interest in epilepsy surgery with previous academic experience in neuroimaging, I have undertaken two literature-based projects that focus on using diffusion magnetic resonance imaging and tractography to spare vital white matter tracts in the brain during epilepsy surgery. These techniques are not used in Edinburgh, so visiting a centre that used these methods routinely was very exciting.

Furthermore, during my time at BCH, I conducted an original research project at the Harvard Medical School Computational Radiology Laboratory. I wanted to improve tractography of optic radiation (white matter tract carrying visual information from the thalamus to the occipital lobe) to improve preoperative planning in epilepsy surgery, and to help prevent postoperative visual field deficits. The completed project has been presented at an international conference and holds potential for publication in a peerreviewed journal, which will further foster a clinical career in neurosurgery and an academic pathway.

CAREER MILESTONE My elective was a significant step forward in my career progression. I received extensive exposure to paediatric and epilepsy surgery, which gave me a far greater understanding of the clinical neurosciences and affirmed my desire to pursue a career in neurosurgery. It also enabled me to witness and learn about advanced neuroimaging and neurosurgical techniques not employed in Scotland. Finally, the experience of striking a healthy balance between clinical and research activities has cemented my desire to include academic training as a component of my future career. In addition to further academic training, the potential for adding to the literature may be beneficial for the surgical care of patients worldwide.

In conclusion, integration of my clinical and research interests as well as the resources and expertise held

by BCH delivered an elective that has heightened my competency as a medical student and which will be a vital milestone in my pursuit of a career in academic neurosurgery.

ACKNOWLEDGMENTS I would like to thank Ethicon and the Royal College of Surgeons of Edinburgh for their most generous financial support.

Boston Children’s Hospital was named as the best-ranking US children’s hospital for neurosurgery and has a dedicated, high-volume, cutting-edge epilepsy service www.rcsed.ac.uk | 45

TRAINEES AND STUDENTS

HEAD START FOR NEXT GENERATION Information day gives senior pupils insight into the application process for medical school

W

hile history and tradition remain important to the RSCEd, we must also look to the future and remain relevant in the evolving field of medicine. A key factor in doing this is inspiring the next generation of surgeons.

On 25 July, the College’s outreach team decided to do just that, and for the first time invited S4–S6 pupils from schools in and around Edinburgh to visit the College for an information day to advise them about getting into medical school.

With approximately 21,000 applications for around 8,000 places, the medical admissions process is highly competitive.

Mr Zahid Raza, one of RCSEd’s Regional Surgical Advisers and convenor of the event as well as a selector for Edinburgh University’s Medical School, has experienced first-hand how demanding the process can be and came up with the idea as a means to ensure potential applicants are as prepared as possible.

S4–S6 pupils visit the College for careers advice

46 | Surgeons’ News | September 2015

Mr Raza explains: “Getting into medical school is tough, compounded by applicants competing with a cohort of very academically gifted and bright students. I was delighted when the College agreed with my idea of running a one-day symposium aimed at enabling enable students to find out how to maximise their chances of gaining entry into medical school and to network with experts. This provides a unique situation where the oldest surgical college in the world is providing a stepping stone for the youth who will be the doctors – and surgeons – of the future.”

In the middle of their summer break, 64 pupils representing 33 schools arrived at the College’s Symposium Hall for a packed programme of talks by representatives from four of the five Scottish medical schools.

There were also speakers at all stages of their medical careers – from students through to a military surgeon – who gave the students an honest insight into the application process.

Lizzy Tan, a fifth-year medical student at the University of Edinburgh, explains:

“Applying for medicine is a daunting process because there are so many hurdles to cross.

This event discussed each of these hurdles in turn, making the application process seem more manageable. With medical students and doctors on hand all day to answer any burning questions, it made applying for medicine seem less intimidating. I wish there had been such an event when I was applying to medical school.”

The wide range of speakers, some of whom did not take the conventional route into medicine or were unsuccessful on their first attempt, ensured that students took away valuable information that they may not necessarily have come across through the ‘official’ channels. The common theme was that there is far more to studying medicine than outstanding grades, and students were encouraged to think about the soft skills that are required to make a great doctor.

We extend our thanks to Mr Raza for convening the event and to all speakers and students who contributed to making the day a success. We look forward to running similar events in the future.

With approximately 21,000 applications for around 8,000 places, the medical admissions process is highly competitive

REGIONAL SURGICAL ADVISERS IN YOUR AREA

2

3

The College’s support and advice network throughout the country

10 9 4

1 Director of the Advisory Network

Steven Backhouse, Princess of Wales Hospital, Bridgend, Wales

SCOTLAND

NORTH OF SCOTLAND 2 Morag Hogg, Raigmore Hospital, Inverness 2 Sean Kelly, Raigmore Hospital, Inverness 3 Aileen McKinley, Aberdeen Royal Infirmary, Aberdeen 3 Euan Munro, Aberdeen Royal Infirmary, Aberdeen

5

47

29

48

28 42

46

MERSEY 22 Janardhan Rao, Countess of Chester Hospital, Chester 23 Azher Siddiq, St Helen’s Hospital, St Helen’s 24 Venkat Srinivasan, Arrowe Park Hospital, Wirral NORTH WESTERN 25 Stuart Clark, Manchester Royal Infirmary, Manchester 26 Jeremy Ward, Royal Preston Hospital, Preston 26 Mike Woodruff, Royal Preston Hospital, Preston NORTHERN 27 Paul Gallagher, Wansbeck Hospital, Northumberland 28 Ian Hawthorn, University Hospital of North Durham 29 Lynn Stevenson, Cumberland Infirmary, Carlisle OXFORD 30 Chris Cunningham, Churchill Hospital, Oxford

16

17 37 38 39 45 1

15

30

13

12

40

14

31

44 20 21

33

ENGLAND

LONDON 20 Cynthia-Michelle Borg, University Hospital Lewisham 21 Ziali Sivardeen, Homerton University Hospital

25

23 24 22

EAST OF SCOTLAND 10 Graham Cormack, Ninewells Hospital, Dundee 10 Musheer Hussain, Ninewells Hospital, Dundee

KENT, SURREY & SUSSEX 18 Mike Lewis, Royal Sussex County Hospital, Brighton 19 Mike Williams, Eastbourne District General Hospital, Eastbourne

43 41

26

SOUTH EAST OF SCOTLAND 8 Farhat Din, Western General Hospital, Edinburgh 9 Robyn Webber, Victoria Hospital, Kirkcaldy

EAST MIDLANDS 15 Sridhar Rathinam, Glenfield Hospital, Leicester 16 Vel Sakthivel, Lincoln County Hospital, Lincoln 17 Bill Tennant, Queen’s Medical Centre, Nottingham University Hospital

6 27

WEST OF SCOTLAND 4 Lindsey Chisholm, Royal Alexandra Hospital, Paisley 5 Jon Dearing, Ayr Hospital, Ayr 6 Simon Gibson, Crosshouse Hospital, Kilmarnock 7 Calan Mathieson, Southern General Hospital, Glasgow 4 Andrew Renwick, Royal Alexandra Hospital, Paisley 6 Mary Shanks, Crosshouse Hospital, Kilmarnock

EAST OF ENGLAND 11 Vivek Chitre, James Paget University Hospital, Great Yarmouth 12 Andrew Gibbons, Peterborough City Hospital, Peterborough 13 Milind Kulkarni, Norfolk and Norwich University Hospital, Norwich 14 Vijayaranjan Santhanam, Addenbrooke’s Hospital, Cambridge

7

8

32

36 34 35

18

19

31 Richard O’Hara, Milton Keynes Hospital, Milton Keynes 30 Mike Silva, Churchill Hospital, Oxford

SOUTH WEST PENINSULA 32 Simeon Brundell, Derriford Hospital, Plymouth 33 Neil Smart, Royal Devon & Exeter Foundation Trust, Exeter WESSEX 34 Anthony Evans, Portsmouth Hospital, Portsmouth 35 Dominic Hodgson, Queen Alexandra Hospital, Portsmouth 36 Arjun Takhar, University Hospital of Southampton NHS Trust WEST MIDLANDS 37 Ishan Bhoora, Cannock Chase Hospital, Staffordshire 38 Pradeep Kumar, Queens Hospital, Staffordshire 39 Ramanan Vadivelu, Royal Wolverhampton Hospital NHS Trust 40 Ling Wong, University Hospital Coventry and Warwickshire, Coventry YORKSHIRE & HUMBER 41 David O’Regan, Leeds General Infirmary, Leeds 42 Mark Peter, Scarborough General Hospital, Scarborough 43 Mark Steward, Bradford City Hospital, Bradford

WALES

44 Sanjeev Agarwal, University Hospital Wales, Cardiff 45 Raymond Delicata, Nevill Hall Hospital, Abergavenny 46 Vaikuntam Srinivasan, Glan Clywd Hospital, Rhyl

NORTHERN IRELAND 47 Catherine Scally, Antrim Hospital 48 Colin Weir, Craigavon Area Hospital

www.rcsed.ac.uk | 47

11

COLLEGE INFORMATION

Congratulations to all our new Fellows and Members who were presented with diplomas at the ceremony in July 2015

DIPLOMA CEREMONIES Admission to Fellowship Ad Hominem Professor Julietta Patnick CBE, Deputy Director, Cancer Screening, Public Health England, Director, NHS Cancer Screening Programmes and Visiting Professor in Cancer Screening, Cancer Epidemiology Unit, University of Oxford Professor Shekhar M Kumta, Professor, Department of Orthopaedics and Traumatology, Faculty of Medicine, Chinese University of Hong Kong Professor Anthony A Meyer FRCSEng, Colin G Thomas Jr MD Distinguished Professor of Surgery and Chairman, Department of Surgery, School of Medicine, University of North Carolina Award of Fellowships Without Examination Mr Kareem Marwan FRACS, Consultant General Surgeon, Eastern Health Hospitals and Consultant General and Colorectal Surgeon, Knox Private Hospital, Melbourne, Australia Diplomas of Fellowship in the Specialty of Cardiothoracic Surgery Mohammad Mohammad Mohammad El Diasty, Mansoura University, Egypt Diplomas of Fellowship in the Specialty of General Surgery Noel Cassar, University of Malta Sridhar Dharmavaram, Andhra Pradesh University of Health Sciences, India Andrew James Healey, University of Edinburgh 48 | Surgeons’ News | September 2015

Lona Jalini, Newcastle University Michael David Kipling, University of London Samuel Oluseyi Ogunbiyi, University of Ilorin, Nigeria Andrew Ian Sutherland, University of Edinburgh John David Terrace, University of Edinburgh Richard Wismayer, University of Malta Diploma of Fellowship in the Specialty of Neurosurgery Rahul Dubey, Kanpur University, India James Sam Walkden, University of Manchester Diplomas of Fellowship in the Specialty of Paediatric Surgery Anand Vishwanath Upasani, University of Mumbai, India Diplomas of Fellowship in the Specialty of Trauma and Orthopaedic Surgery Peter Domos, University of PĂŠcs, Hungary Amit Kumar, University of London Intercollegiate Diplomas of Membership in Surgery in General Sarav Preet Ahluwalia, Manipal University, India Mohammed Jassim T Aldiwani, University of Manchester Alison Ursula Bing, University of Aberdeen Thomas F E Clarke, University of Leeds Peter Samuel Edward Davies, University of Liverpool Marina May Diament, University of Edinburgh

Graham Finlayson, University of Manchester Surya Sai Teja Gandham, University of Liverpool Muhammad Haroon, Quaid-i-Azam University, Pakistan Thomas Arthur Howard, University of Manchester K M Saiful Islam, University of Dhaka, Bangladesh Sebastian Leuschner, Newcastle University Kenneth Russell Mackenzie, University of Dundee Janice Miller, University of Aberdeen Kyaw Myint, University of Mandalay, Myanmar Harikrishnan S Nair, University of Edinburgh Cho Ee Ng, University of Edinburgh Pankaj, University of Delhi, India Matilda Francis Rachel Powell-Bowns, University of Dundee Mohan Harshanath Samarasinghe, University of Colombo, Sri Lanka Michiel Robert Simons, University of Aberdeen Shen Hwa Vun, University of Edinburgh

IN MEMORY SURGICAL FELLOWS Mohamed Aly Mohamed ARAFA (FRCSEdOrth 1982) William Herbert BAIN (FRCSEd 1955) Herbert Livingston DUTHIE (FRCSEd 1956) John Charles FOSTER (FRCSEd 1953) Howard Fuller GODFREY (FRCSEd 1967) Norman Alan GREEN (FRCSEd 1990) Ronald Lawrie HUCKSTEP (FRCSEd 1957) David Rodd JAMES (FRCSEd 1985) Martin McArthur LEES (FRCSEd 1985) Keith James McGONIGAL (FRCSEd 1966) Vincent James MARMION (FRCSEd 1962) Joseph Mohamed RAJACK (FRCSEd 1975) Christopher RAND (FRCSEd Orth 1982) Devindar Paul SANAN (FRCSEd 1960) Donald John SCOBIE (FRCSEd 1979) William SERIGHT (FRCSEd 1952) Sant Prakash SINGH (FRCSEd 1964) John Wasley SMITH (FRCSEd 1960) Andrew Philip SPROWSON (FRCSEd Tr & Orth 2010) Kenneth WOOD (FRCSEd 1957) DENTAL FELLOWS Robin Morris DAVIES (FDS RCSEd 1994) Brian HOLMES (FDS RCSEd 1967) Gordon David Craig KENNEDY (FDS RCSEd 1964) Alexander Macdonald WESTWATER (LDS RCSEd 1947, FDS RCSEd 1969)

Diplomas of Membership in Ophthalmology Omar Ahmed Hassan Barrada, Cairo University, Egypt Marco Makram Samaan Isac, Assiut University, Egypt

Franky Lucien Steenbrugge, Ghent University, Belgium

Diploma of Membership in Otolaryngology Chun Seng Ooi, University of Dundee

Diploma in Remote and Offshore Medicine Carolyn Lewis, University of Cape Town, South Africa

Diplomas of Fellowship in Immediate Medical Care Without Examination Frederick John Hall, University of Birmingham Syed Masud, University of London

Diploma of Membership in Prosthodontics Bardia Valizadeh, Mashhad University of Medical Sciences, Iran

Fellowships of the Faculty of Surgical Trainers Khin Tun, University of Rangoon, Myanmar Ling Sen Wong, University of Glasgow Memberships of the Faculty of Surgical Trainers Leela Cecile Biant, University of London Swe Yin Khin Htun, University of Yangon, Myanmar

The Lister Medal Chee Siong Wong, University of Dublin

Diplomas of Membership of the Faculty of Dental Surgery Jasmine Chopra, Baba Farid University of Health Sciences, India Elizabeth Gonzalez Malaga, University of Madrid, Spain Kanika Gupta, Himachal Pradesh University, India Hussameldien Abdelmunaim Noureldien Hussien, National Ribat University, Sudan Darshayani Meyyappan, Sri Ramachandra University, India

Ranjita Rao, Dr MGR Medical University, India Arindam Sinha, Rajiv Gandhi University of Health Sciences, India Bardia Valizadeh, Mashhad University of Medical Sciences, Iran Elizabeth Emma Willasey, Newcastle University Diploma in Implant Dentistry Deepam Patel, University of London Diplomas in Orthodontic Therapy Dawn Karen Brown, Manchester Dental School Siobhan Ann Byrne, Manchester Dental School Cheryl Louise Derbyshire, Manchester Dental School Victoria Emma Jane Harrison, Manchester Dental School Carol Jane King, Manchester Dental School Sarah Victoria Lindley, Manchester Dental School Kristian Livingston Hammond Loughins, Manchester Dental School Alicja Pietkiewicz, Manchester Dental School Lisa Jayne Roberts, Manchester Dental School www.rcsed.ac.uk | 49

COLLEGE INFORMATION

All the latest grants, fellowships and bursaries from the RCSEd

AWARDS & GRANTS

Ethicon Foundation Fund Travel Grants

Grants are awarded towards travel overseas to gain further training or experience, and are restricted to the cost of one return air fare 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 27 November 2015.

Ethicon 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 27 November 2015.

Small Research Pump Priming Grant

The Royal College of Surgeons of Edinburgh Research Strategy highlights the following areas of research as priorities for the College to support: Surgical/dental translational research Surgical/dental health services research Research into surgical/dental aspects of patient safety, simulation and nonoperative technical skills Cancer research of demonstrable direct clinical relevance to the management of solid tumours.

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

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

Please note that requests for running costs 50 | Surgeons’ News | September 2015

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

Research project submissions should satisfy one or more of the College’s four priority areas for research, as listed above.

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

who are within a year of completing the MRCS and would want to join the RCSEd are also eligible. The Fellowship is for a period of one year.

The funding allocated for this Fellowship is currently £50,000 per annum and this provides the salary, National Insurance and superannuation costs only. No funding will be allocated for running costs, purchase of equipment, acquisition of computing facilities or travel.

Closing date for applications is Friday 6 November 2015.

Closing date for applications is Friday 13 November 2015.

Quincentenary Fellowship 1505-2005 Joint RCSEd/Cutner Research Fellowship In Orthopaedics

The Maurice Wohl Research Fellowship in Surgery/Dental Surgery (£50,000)

The College is pleased to announce the establishment of the Joint RCSEd/Cutner Research Fellowship in Orthopaedics to celebrate the Quincentenary of the College.

This has been made possible due to the funds donated by the Cutner family to help and support education and training in orthopaedics, including research.

Applications are invited from suitably qualified and experienced young surgeons in the field of orthopaedics. Applicants must be a Member or Fellow of the College and in good standing. Surgical trainees

Applications are invited from suitably qualified and experienced young surgical trainees who are Fellows or Members of the College. Surgical trainees who are within one year of completing the MRCS, and would wish to join RCSEd, are also eligible.

The funding attached to this Fellowship provides salary, National Insurance and superannuation costs only for one year, and research must be undertaken in the UK. Research project submissions should satisfy one or more of the College’s four priority areas for research, as listed below: Surgical translational research Surgical health services research

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.

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.

of Surgeons of Edinburgh. Applications are invited from all trainee doctors who wish to spend a period of time researching into disorders of a rheumatic, arthritic or inflammatory nature. Studies concerned with systemic/disseminated lupus erythematosus, vasculitis and Raynaud’s disease, or other diseases of a vascular and inflammatory nature, will be particularly appropriate.

The primary aim of the Fellowship is to support trainees wishing to undertake research either as part of their professional training or with a view to an academic career.

Applicants are advised to consider carefully the goals they wish to achieve and to identify specific educational objectives in their application.

Applications can be made for a period of one year and the Trust will provide a sum of up to £50,000 to fund salary and research costs.

Closing date for applications is Friday 13 November 2015.

Closing date for applications is Friday 4 December 2015.

Lorna Smith Charitable Trust Research Fellowship

Ophthalmology Research Grants (sponsored by Royal Blind)

Administered by the Royal College

Major project grants (up to £50,000)

Small research support grants for ongoing research (up to £10,000).

Applications for funding under the above categories are invited from ophthalmologists currently working in Scotland and all Fellows/Members of the College in good standing, undertaking research projects in the UK. Closing date for applications is Friday 30 October 2015.

Bursaries for Affiliate Medical Student Elective Placements in Africa 2016

The RCSEd is offering a number of 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 that are involved with the placement.

Closing date for applications is Friday 8 January 2016.

CONGRATULATIONS TO THE FOLLOWING AWARDS AND GRANTS RECIPIENTS ROBERTSON TRUST RESEARCH FELLOWSHIP Mr Peter Young, Specialty Trainee Orthopaedics, University of Glasgow.

The effect of nanoscale surface topography on osteoclast differentiation and activity in orthopaedic materials.

ALASTAIR F JAMIESON FELLOWSHIP IN GENERAL SURGERY Dr Amir Awwad, Clinical Radiology Specialist Registrar, University of Nottingham.

Haemodynamic 4D flowsensitive MR imaging of abdominal aortic aneurysms.

SMALL RESEARCH PUMP PRIMING GRANTS Mr Adam Frampton, Honorary Clinical Lecturer in General Surgery, Imperial College London.

MicroRNA markers in bile for detecting and stratifying pancreatic cancer.

Mr Gurdeep Mannu, Academic Clinical Fellow, University of Oxford.

A case-control study to investigate the lifestyle and biological risk factors for developing ductal carcinoma in situ (DCIS) of the breast and its progression to invasive breast cancer in women.

Mr Iain Murray, ECAT Clinical Lecturer, ST3, University of Edinburgh.

Therapeutic targeting of myofibroblasts in skeletal muscle fibrosis.

Miss Emma Scott, Clinical Research Fellow, University of Edinburgh.

Contrast-enhanced magnetic resonance imaging as a diagnostic tool for chronic allograft damage following renal transplantation.

Mr Andrew Sutherland, Specialist Registrar, University of Edinburgh.

Improving graft function in transplantation with

normothermic regional perfusion: a pilot study to investigate the underlying mechanism.

UNDERGRADUATE BURSARIES Mr Matthew Arnold, University of Aberdeen.

The effect of varying amounts of decalcification and de-collagenisation on bone strength and toughness at the Department of Orthopaedics, Edinburgh Royal Infirmary.

Miss Mollika Chakravorty, University of Sheffield.

An economic and clinical comparison of the outcomes following robotic versus laparoscopic nephrectomy at Guy’s and St Thomas’ NHS Foundation Trust.

Mr Thomas Drake, University of Sheffield.

The role of store-operated calcium signalling in colorectal cancer metastasis at the Multidisciplinary

Cardiovascular Research Centre, University of Leeds.

Mr Shaun Evans, University of Birmingham.

Principal component analysis of the serum microRNA response to traumatic brain injury at the NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham.

Mr Haseeb Moiz, King’s College London.

Assessing the accuracy of low-cost fused deposition modelling in 3D printing of maxillofacial prosthetics at the Academic Centre for reconstructive Science, King’s College London.

Mr David Williams, Newcastle University Medical School.

Investigation into NucB and the prevention of microbial biofilm formation in orthopaedic ankle fracture fixation at the School of Marine Science and Technology, Newcastle University.

www.rcsed.ac.uk | 51

GREG POWERS

OUT OF HOURS

Graham Layer spices up his life on a gastronomic tour of the world

Global delights

A

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

nother few months of travelling brought me to a realistic Vietnamese experience in Darlinghurst, Sydney, at the Red Lantern.

This is the establishment run by TV chef and author of The Food of Vietnam Luke Nguyen.

It’s worth a diversion to experience real Vietnam in a quiet back street of the Sydney inner suburbs.

It serves a veritable feast on a realistic colonial stage set, with all the smells, flavours, textures and peculiar subtlety of Vietnamese cooking. The banana prawn rolls and pork neck rolls were light and tangy, the five-spiced quail was excellent, bánh xèo (prawns and pork in a rice flour pancake) were delicious, and spatchcock with sesame and ginger was particularly wonderful, as was beef in oyster sauce with sesame. The salmon was unusual in a peppery caramel sauce, but it worked well.

On the other side of the Australian continent, RCSEd held a joint congress with the Royal Australasian College of Surgeons in Perth – a mammoth event and hugely well attended and produced. There was little time for independent gustatory pleasures, but I enjoyed the food and views at Matilda Bay on the shores of the Swan River en route to the amazing CTEC Simulation Centre, just to the south west of the ever-growing modern city centre.

My guests enjoyed fresh prawns in an Italian crust, fabulous tasty barramundi and sirloin on a giant bone, all with innovative salads. I would return for the barramundi alone, which was outstanding.

Very close to the conference centre itself was Balthazar, nothing to do with the New York or London brasseries, but a darkly lit contemporary haven for unusual food served to an exceedingly high standard. We avoided the kangaroo despite its mushroom ketchup. Oysters and crab with watermelon were exceptional, followed by duck breast with ginger and prunes, and pork fillet with a bacon croquette with roast vegetables dripped with delicious spicy sauces. Chocolate

52 | Surgeons’ News | September 2015

Fiola Mare is renowned for its seafood dishes

truffles, a passion-fruit concoction and peach with goat’s cheese made up the somewhat unusual desserts.

I did not make Margaret River and its famous wineries on this visit, but I did enjoy amazing barbecued fish platters at Fish on Parkyn in Mooloolaba on the Queensland coast, and splendid French–Australian food sourced locally at The Maple Tree in Lorne on the Great Ocean Road, both courtesy of Australian surgeons well versed in Surgeons’ News back pages. The fresh fish platter was an anatomical sight to behold and full of the freshest flavours imaginable, with the restaurant just on the quayside close to where the fishing fleet moored. All of this followed a starter platter that had, among other local delights, superb oysters fried and coated in parmesan.

My most expensive fish outing recently was Fiola Mare on the shores of the Potomac in Washington DC. Astonishing quality at sky-high prices, not forgetting the suggested and calculated 18–22% gratuities. An amazing multilayered pyramid of crustacea with a rainbow array of sauces, followed by halibut, monkfish and the best lobster ravioli I have ever sampled, perhaps due to its cholesterol content. More down to earth in DC is the ever-popular smart, contemporary Indian restaurant Bombay Club, with its classic western-style Indian menu served in an atmosphere reminiscent of an updated Raj. The spices are definitely adjusted to the safe end of the scale, so the formula here keeps this place throbbing. Compare this with the bizarre experience that the Honorary Treasurer and I enjoyed at Moksh in Mermaid Quay, Cardiff, recently. An Indian restaurant like no other I have ever experienced, it offers a mixture of a ‘tasting menu’, Heston Blumenthal and the old Indian favourites with unusual twists and all extremely delicious. With the multiple small courses being somewhat filling, we surrendered at the dessert before the strange little sweets arrived covered in edible gold and silver, which the Treasurer could not resist. The

A meat feast at Matilda Bay

Second helpings Bernard Ferrie revisits Aldi and Lidl for more bargain buys

Moksh-style desserts

advertisement from chef Stephen Gomes says ‘envisage a voyage of exploration’, and that is certainly true. It was an evening full of surprises and I liked the dry ice tricks and the bottled hickory smoke, which also contained four different meaty tikkas. The amuse-bouche was poppadoms with mint and tamarind chutney, followed by a soup with ginger ice cream and lemon caviar. Prawns followed, dipped in Bloody Mary and coriander foam. After the smoke in a jar came two different straightforward curries of butter chicken and lamb, then samosas. It was all very entertaining and the chef was hospitable and clearly passionate about his exploration of the classic Indian dishes and his magical way of turning them into the flavours of the moment.

Back to London and the Dean Street Townhouse, not to be missed. It’s one of the current hot spots and where you need to be seen in Soho. A great Sunday brunch, with a wide-ranging menu from potted shrimps through to roast beef, all served in an atmospheric space very efficiently and with style. The twice-baked haddock soufflé was light and fluffy and full of flavour, and the salad with chicken, bacon and avocado was good. The crab and prawn salad was somewhat light on the crab and prawn, and too heavy on dandelions. The main courses were satisfactory, without much deviation from the classic fare of rib-eye, lamb chops, salmon and chicken, but my guest was delighted with his version of a ‘cheeseburger’. Everything was cooked to order perfectly and the atmosphere was a real buzz, with excellent people-spotting opportunities. We were not rushed out and spent a leisurely time enjoying being part of the vibrant London Soho scene.

L

ike it says on the tin, lip-smackingly tasty Exquisite Collection Picpoul de Pinet (£5.99, Aldi) has vibrant lemon acacia flower aromas from Jean-Claude Mas in Languedoc. Bring on the shellfish for your ‘see food’ diet. Cremant du Jura (£7.29, Aldi) is a crisp, dry chardonnay, one of the nicest cremants available, and the bottle looks like Krug to impress your friends. Value double plus.

Nice bottle of Chablis, squire? (£8.99, Lidl). Hint of gooseberry and lovely with poached salmon, prawns and home-grown salad. Or Muscadet Sèvre et Maine (£4.99, Lidl), which is crisp, clear and astonishing value.

Slightly less sharp than the Chablis. Salt ‘n’ vinegar, mate? Dash of lemon?

Ruby-red Fortezza dei Colli Chianti Classico Riserva 2009 (£8.99, Lidl). Nicely balanced and mature, ready for drinking – a good example of this popular Italian.

Or you might prefer Saint-Emilion Grand Cru 2012 (£9.99, Lidl) with beef or hard cheese.

Oh Canada: Trius Vidal Icewine 2013 (£24.99, halfbottle, Aldi), succulent, rich honey, apricot and spice.

What a bargain for a dessert wine but you may need to search around a few branches. Nectar from Niagara with time, temperature and date of harvesting recorded.

Clinical record keeping was never so enjoyable.

While browsing, look out for salted caramel truffles, rich Christmas pud, amaretto biscuits and venison steaks. Oh, and frozen crab, lobster and goose. Eating in is the new dining out.

www.rcsed.ac.uk | 53

HOST YOUR EVENTS AT THE STUNNING PRINCE PHILIP BUILDING

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

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

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

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

Scott Mitchell, commercial director, says:

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

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

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

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

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

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

Annual Report

2015

ANNUAL REPORT

RCSEd Office Bearers & Council September 2015

COUNCIL MEMBERS

Mr Charles Auld

Mr Roger Currie

Dr Judy Evans

Mr John Duncan

PRESIDENT Mr Ian Ritchie

VICE-PRESIDENT Professor Jimmy Hutchison

Professor Simon Fostick

Mr Alastair Gibson

Miss Elaine Griffiths

Mr Robert Jeffrey

VICE-PRESIDENT Mr Mike Lavelle-Jones

HONORARY TREASURER Mr Richard Montgomery

Mr Sunil Kumar

Professor Peter McCollum

Mr Richard McGregor

Ms Clare McNaught

HONORARY SECRETARY Professor Graham Layer

DEAN OF THE FACULTY OF DENTAL SURGERY Professor William Saunders

Professor Rowan Parks

Mr Simon Paterson-Brown

Mr Pala Rajesh

Professor Robert Steele

56 | Surgeons’ News | September 2015

Report from the Trustees MR IAN RITCHIE

T

he Council of the Royal College of Surgeons of Edinburgh recently agreed the College’s vision as being to ‘achieve the best possible outcomes for patients worldwide’. They also defined our mission as ‘the pursuit of excellence and advancement in surgical and dental practice through leadership, innovation, setting standards, education, training and CPD’. This clearly and appropriately puts patients at the heart of all that we do. In pursuing the best outcomes for patients, it is the College’s ambition to provide support for surgeons, and those associated with the practice of surgery, to deliver the best possible care.

This is traditionally achieved through examinations and, to this day, we continue to deliver the MRCS as a collegiate enterprise across the UK and internationally. We pride ourselves on the high standard that is delivered in these examinations and our new Convener of Examinations, Professor Peter McCollum, has been active in ensuring that the quality of the examination, the process of its delivery and the support for our examiners is second to none. Working with our sister colleges, we have been instrumental in developing and delivering the Joint Surgical Colleges Fellowship Examination, which has had two successful initial diets in General Surgery. The next diet will be held in Kuala Lumpur and is eagerly anticipated by the international community. The standard of this examination is a ‘day-one consultant’ in the United Kingdom. This is the international benchmark that we seek to support.

Alongside our examinations, we also deliver courses.

Our previous Convener of Education, Mr David Smith, and new Convener, Professor Gerry McGarry, are tireless in ensuring that we have an impressive suite of courses for all needs, which are delivered in Birmingham, Edinburgh and internationally. It is a great pleasure to see the new ideas that come from our Conveners of Examinations and Education to support our Fellows and Members in their different needs for education and standards.

The Dental Faculty has introduced a Convener of Dental Education to complement the work of the Surgical

It is the College’s ambition to provide support for surgeons and those associated with the practice of surgery to deliver the best possible care

The president and CEO of the Foundation for Advancement of International Medical Education and Research, Professor John Norcini, gives the keynote lectures at the Faculty of Surgical Trainers’ conference

Convener and the existing role of the Dental Examinations Convener. This role will undoubtedly further enhance the high standing of the Dental Faculty in dental practice across the UK and we are already seeing the benefits of this addition.

FACULTY OF SURGICAL TRAINERS The Faculty of Surgical Trainers (FST) goes from strength to strength. It has developed a Faculty of Dental Trainers (FDT) to support and recognise dental training in the UK along similar lines to the FST. Publication of the Standards for Surgical Trainers has also been an important development and one that has been widely supported by the surgical community across the UK and internationally.

On a more pastoral note, I was privileged to visit our surgical colleagues in Staffordshire for a second time last year. The surgical community in Staffordshire has faced significant challenges in the recent past and our follow-up visit recognises the major changes that have happened in the organisation of surgical delivery in that region. It was a privilege to see the response of our Fellows to the difficult times that they are facing in delivering surgical care for their patients. I was impressed by their resilience and their adaptability to change. As a College, we have the honour of supporting our Fellows and Members as they work through these difficulties. This applies across the country and the world. I have been approached by surgeons going through difficult times and it has been my privilege to point them www.rcsed.ac.uk | 57

ANNUAL REPORT

in the direction of support from fellow surgeons and professionals who are able to help them gain perspective on their situation.

REFURBISHMENT WORKS The College campus in Edinburgh continues to develop with major building works; these are described in more detail in the Chief Executive’s report. The museum refurbishment is well under way and we have been privileged to receive significant funding from the Wohl Foundation to assist us in providing a world-class surgical museum facility. The refurbishment and introduction of other buildings into the workings of the College continues apace. The College requires the additional space for the delivery of courses, holding meetings and other activities related to surgical practice as we continue to expand and develop in service of our fellowship. None of this is possible without the commitment of College staff, and I pay tribute to all staff, both in Edinburgh and Birmingham, for their commitment to the College’s ethos. It is they who make sure our reputation for being the ‘friendly College’ is continued into the future.

The Chief Executive and senior management team deserve a special mention for the way in which all the projects have been delivered to a tight timetable. The work involved is considerable and I commend the leadership of the Chief Executive and her team in delivering all these projects. Without their hard work on our behalf, the College’s core activities would suffer.

The Office Bearers, along with the Chief Executive, is the group that help me and the Council to deliver the strategic priorities of the College. I pay tribute to the Vice-Presidents, Honorary Treasurer, Honorary Secretary and the Dental Dean for the work that they have achieved over the last year. In particular, I am pleased to mention that Mr John Duncan, former Honorary Treasurer and now a Member of Council, received an OBE in the Queen’s Birthday Honours, which is an appropriate recognition of his commitment to healthcare in Inverness and to the ideals of this College.

PRESIDENT’S MEETING The President’s Meeting on 20 March this year was a great success. The subject was the surgery of oncology and this provided the opportunity for surgeons to consider the latest advances in their specialties. It is as always a tribute to the organisers that the meeting was so successful, and it is with great pleasure that I recognise the efforts of Professors Bob Steele and Rowan Parks in delivering yet another excellent meeting.

The work of the College is wide and is delivered in many geographical locations. In Scotland, we continue to work with the Academy of Medical Royal Colleges and Faculties in Scotland in a variety of areas, including a call to the Scottish Government to consider how to deliver sustainable healthcare in the 21st century by working collaboratively with all healthcare professions in Scotland; and encouraging an increase in physical activity in surgical patients, as well as in surgeons, with a view to improving outcomes for patients.

A short-life working group of the Scottish Academy has produced a document entitled 58 | Surgeons’ News | September 2015

Our Birmingham facility is busy delivering courses in support of Fellows and Members nearer to where most of them live and work The Birmingham centre (above) has hosted keynote lectures by such luminaries as Lord Winston (below)

Learning from serious failings in care, which looked at a number of critical reports across the United Kingdom and made recommendations. The lessons are there for us to consider in the areas of leadership, culture and professional engagement, staffing, quality of care, and patient experience and external review. While it is easy to assume that many of these subjects are not within our individual control, I commend the report and some reflection on how we can individually make a difference in all these areas.

Across the UK, the College continues to interact with our sister Colleges through the Joint Surgical Colleges Meeting, the Joint Committee on Intercollegiate Examinations and the Intercollegiate Committee on Basic Surgical Examinations. These activities are part of our core business in setting standards.

The Surgical Forum has been ably chaired by Professor John MacFie over the past two years.

The Forum is a vital opportunity for the Colleges and the Specialty Associations to collectively provide authoritative advice to governments, the surgical community and our other medical colleagues on matters of universal concern to do

with surgery. We are also active with other Colleges in the Academy of Medical Royal Colleges in the UK, addressing concerns that affect the delivery of healthcare across the whole of the medical spectrum.

BIRMINGHAM SUCCESS The College’s base in Birmingham has completed its first full year of activity. The report from the staff at the Birmingham centre indicates that our profile in terms of political engagement at Westminster has increased.

We seek to promote the distinctive voice of the Royal College of Surgeons of Edinburgh and represent the views of our Fellowship at the highest level. In pursuit of this, we have led the opposition to Lord Saatchi’s Medical Innovation Bill with support from other Colleges. Our Birmingham base is active in supporting our Regional Surgical Advisers network in England and Wales, and the facility is busy delivering courses in support of Fellows and Members nearer to where most of them live and work. The Birmingham centre has also hosted keynote lectures by commentators such as Lord Winston and Sir Bruce Keogh.

One of the key innovations introduced into the College is the shared funding of Clinical Leadership Fellows in Northern Ireland, Scotland and Wales. Our first Clinical Leadership Fellow, Nathan Stephens, is coming to the end of his year. The insights he has gained into the delivery of government policy and the workings of NHS Education for Scotland will no doubt enhance his ability to deliver as a surgeon and trainer. Within the College, Nathan’s activities have brought a new insight into some of our actions, notably, the development of the Faculty of Surgical Care Practitioners. This Faculty development, led by Mr Charles Auld, and supported by Nathan, is a recognition of the importance of other members of the surgical team in the delivery of surgery. The College’s ambition to provide better outcomes for patients worldwide is linked to our support for Surgical Care Practitioners.

Outside Scotland, we have developed links with the governments in Northern Ireland and Wales, where we will fund half the salary of Clinical Leadership Fellows. We

believe that widening surgeons’ horizons beyond the need to provide first-class surgery for patients to also consider the context in which that service is provided is important for the future delivery of healthcare.

Professor Sir Bruce Keogh, who spoke to RCSEd Fellows in October

The College’s international activities continue to grow

INTERNATIONAL PRESENCE Our international activities continue, and we look forward to celebrating the 25th anniversary of the College of Surgeons of Hong Kong in September 2015. Our associations with surgeons in Hong Kong and Singapore continue to develop and it is a pleasure to see the institutions in these countries maturing. Our partnership with these international organisations is one that continues to develop through the International School for Surgery.

We have other international partnerships, notably in India, Indonesia, Malaysia, Myanmar, the Philippines and Thailand, and with the College of Surgeons of Eastern, Central and Southern Africa. The nature of our partnership with each of these countries and organisations varies according to the requirements of each location, but as well as setting examinations, our activities help with curriculum development and support for trainers. A key element is our partnership with the Tropical Health and Education Trust (THET) in delivering urology training in Myanmar and assisting with the development of a curriculum tailored to local needs. This pilot has attracted funding from THET and it is our ambition to expand this to other branches of surgery and other countries.

One of the highlights of the last year was the Joint Meeting with the Royal Australasian College of Surgeons in Perth, Western Australia. The contribution from Fellows of the College to that meeting was considerable and was very well received. These links are important to the life and vigour of our College as we seek to deliver our mission of the best possible outcomes for patients worldwide.

It is inevitable that an annual report will not cover the full range of the College’s activities, but I hope this gives you an understanding of the range and depth of activities of this College supporting surgeons across the UK and around the world.

www.rcsed.ac.uk | 59

ANNUAL REPORT

Report from the Chief Executive

O

MS ALISON ROONEY

ne of the most exciting and ‘consistent’ features of the College is that it is constantly evolving and adapting to better serve the needs of you, our membership, and hence your patients. The opening of the College’s Birmingham Regional Centre in 2014 was a milestone for the College as it is the first-ever base outside Edinburgh in its 500-year history. This, coupled with many other developments that I have included in my report, is enabling RCSEd to remain relevant and meet the challenges we face now and in the future. As ever, space is too limited to allow for an exhaustive listing of all that has happened, but I hope the following report highlights some of the key achievements of the last year.

of investments in staffing over the last year that will stand us in good stead moving forward. A key appointment has been our new Head of Development, whose fundraising experience will assist the College to deliver enhanced services and benefits that would otherwise lie beyond the scope of our core income streams.

A number of appointments were made in relation to the staffing of the Birmingham office, including the College’s first dedicated public affairs and policy roles, and staff to operate the centre and support the outreach and educational activities run from that office. Investment was also made in new posts to strengthen the same activities run from Edinburgh.

PUBLIC AFFAIRS AND OUTREACH HUB

The College’s campus in Edinburgh has undergone much change in the last year and I am grateful to everyone who has endured the disruption caused by our capital projects.

We are now beginning to see the benefits of this investment, with the College’s new multipurpose events space, the Prince Philip Building, taking its first bookings.

The College’s Heritage Lottery-Funded Lister Project has presented us with many challenges as it has progressed throughout the year. At the time of writing this report, the stonework repairs to the façade of the Playfair Building and the redevelopment of the College’s archives are almost complete. The project has also recently reached an exciting milestone in its development with the commencement of the museums’ exhibition fit-out works. This will be one of the final elements of the project ahead of the planned opening at the end of September.

A particular highlight of this project during the year was the discovery of a 105-year-old time capsule hidden within the Playfair Building. The capsule contained newspapers dated March 1909, two postcards and a list of names of the joiners who had been working on the building in 1909.

A further capital project is the creation of Café 1505 @ Surgeons’ Hall in the College’s retail property on Nicolson Street, adjacent to the College’s main entrance.

Operated by Surgeons Lodge Limited, it opened in July and is ideally placed to service members of the public and visitors to the museums.

The next chapter in the campus development will be the creation of new office space within the College’s existing Edinburgh campus, thereby freeing up the Adamson Building, possibly as an extension to our thriving hotel, so providing strengthened financial sustainability.

The Birmingham Regional Centre has already made a significant impact, especially as a hub for the College’s public affairs activity through enabling an increase in lobbying activity, participation in key stakeholder meetings, collaborative working with partners across the UK, development of policy statements, and responses to consultations, particularly relating to issues affecting our circa 10,000 membership in England and Wales.

The centre has been a hive of activity, used by the College and its Faculties for examinations, seminars, webinars and courses, as well as by several related organisations such as Specialty Associations and by external organisations for commercial bookings. Two very well-received ‘expert sessions’ for our members, given by Lord Winston and Sir Bruce Keogh, were also initiated at the centre and more are planned for the future.

A key rationale for the centre was to enable more outreach activity in England and Wales. To this end, the Birmingham team has supported careers fairs, MRCS lectures, trainee events and research symposia. It has also worked with the College’s team of Regional Surgical Advisers to help support our membership on a more personal, local basis. All of this has contributed greatly to the College’s visibility and influence on behalf of our growing membership base.

Looking ahead, a number of other developments have been set in motion, and these will support the College in driving forward its strategic aims in relation to setting and maintaining the highest standards of surgical care for patients. These include work to provide support and recognition for surgical care practitioners and surgical care assistants, the development of an Institute of Remote Healthcare within the College and the development of a Faculty of Dental Trainers to build on the success of the College’s Faculty of Surgical Trainers.

STAFF: OUR KEY RESOURCE It is a tribute to our hard-working staff that we are able to deliver the new developments described in this report, as well as maintaining the day-to-day operations of the College. I am deeply grateful for their continued enthusiasm and commitment to the College. We have made a number 60 | Surgeons’ News | September 2015

CAPITAL PROJECTS

MEMBERSHIP, ENGAGEMENT AND GROWTH The College is a membership organisation, so it is important to us that we continue to check that we are meeting the expectations of our worldwide membership. To this end, a membership survey was launched at the end of 2014. The results of this survey have just been collated and we were pleased with the level of response from RCSEd Members across the globe. We are busy interrogating that information to ensure we continue to provide and develop services that meet the expectations and desires of our membership. We

will also be undertaking a range of follow-up activities with the circa 1,000 individuals who indicated that they would like to engage with the College in various areas. This work will help us get behind the headline figures in the survey and gain a much deeper understanding of the results.

One clear message from the survey was the high value placed on the examinations, training and other educational activities, such as e-learning and influencing curriculum development, undertaken by RCSEd and, as such, this will remain a key area of focus for us going forward.

I am also pleased to note that our membership numbers continue to remain healthy at more than 22,500 Fellows, Members and Affiliates.

EDUCATION, ASSESSMENT AND ADVANCEMENT The College continues to expand its educational portfolio across all areas, including e-learning, where the webinar sessions have grown in popularity. More courses are being run overall, in both the Edinburgh campus and Birmingham Centre, and in offsite locations throughout the UK and beyond. Overall, there has been a substantial increase in the number of participants for the College’s educational activities, with more than 4,000 delegates attending courses in 2014. Moving forward, the College will capitalise on the opportunities available through a blended learning approach of face-to-face and online learning.

RCSEd was also able to secure grant funding for various professional activities that otherwise would not have been able to go ahead. These include a grant from the Health Foundation for work relating to the use of Non-Technical Skills for Surgeons (NOTSS) and a ward-round-based structured checklist to reduce errors and improve safety on surgical wards; and a grant from the Tropical Health and Education Trust for a two-year partnership project to improve surgical training in Myanmar.

Future plans in education include developing a catalogue of services for the international market and supporting the revision of the College’s overseas inspection programme.

There has been a small increase in the number of candidates sitting examinations since 2013. Quality assurance of the examination process continues to be of major importance to ensure that the College maintains its reputation for high standards. The College is also continuing to increase the number of examination centres at home and internationally.

The 2013–14 Dental Skills Competition, sponsored by Dentsply, was extremely successful with all but one dental school taking part. The final was held in Edinburgh in March 2014, and the winner was awarded an expensespaid trip to the USA to attend the Chicago Dental Society’s Midwinter meeting in 2015. The competition was the first of its kind and provided the next generation of dental surgeons with an opportunity to showcase their dental knowledge and skills. Following this success, the 2015–16 competition has been launched and will run in dental schools across the UK this autumn/winter.

The Faculty of Surgical Trainers continues to grow in strength and numbers, with its annual meeting, sponsored

by Johnson & Johnson, very well attended once again. The theme for the meeting was assessment, and the Faculty was delighted to welcome keynote speaker Professor John Norcini, the President and CEO of the Foundation for Advancement of International Medical Education and Research, one of the world’s leading experts in workplacebased assessment.

A new initiative, piloted in 2014, was RCSEd’s Communication Skills Video Competition. This challenged entrants to ‘get creative’ and develop a three-minute video highlighting one of the three elements of good communication skills examined in the MRCS OSCE. The winning entry will now feature on the website as an aid for trainees preparing for the examination.

FINANCIAL SUSTAINABILITY AND COMMERCIAL DEVELOPMENT The College continues to be in good financial health, with the core activities of RCSEd and the wider group all doing well. It is this continued performance, particularly of the commercial activities, that enables the College to invest in the range of new projects and initiatives described above.

Surgeons Lodge Limited, the entity that manages most of the College’s commercial activity, continues to go from strength to strength. Particular highlights have been the overall successful performance for 2014, linkages with the Edinburgh Festival, and the award of ‘Conference Hotel of the Year’ to Ten Hill Place at the Scottish Hotel Awards. The Hotel has also been awarded an AA Rosette.

HERITAGE I have already mentioned the building and fit-out works associated with the Lister Project. However, these are only part of the work in relation to this ambitious project. Behind the scenes, our Heritage Department has been working to develop the content for the new displays and to maintain the many artefacts that will be on show in the redeveloped museums. This work is very labour intensive and involves both the creation of new written and digital content, and also the identification from the College’s collections and archives of relevant film footage, photographs, paintings, images and archive documents that will be presented to visitors once the transformed museums open their doors.

A project archivist has also been employed to assist the Heritage Department in preparing and cataloguing the RCSEd archives ahead of their return to their now muchimproved storage facility.

The College is indebted to the many individuals whose continuing efforts allow it to flourish. I am particularly 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, whose hard work has enabled the delivery of a heavy agenda and has put us in a good shape to meet the challenges to come. www.rcsed.ac.uk | 61

ANNUAL REPORT

T

HONORARY TREASURER

MR RICHARD J MONTGOMERY

his is my first report as your Honorary Treasurer since I took over from John Duncan in November 2014. John ran a steady ship for five years through a period of economic uncertainty, while initiating and supporting many of our present exciting developments.

I think we can all be grateful to him for this.

The College is going through a period of ambitious development of our faculties, courses and examinations, as well as our campus. All these developments are carefully planned and closely scrutinised by the various College financial committees, which include members of the legal, financial and banking professions. We are grateful for the time and the expertise that these distinguished individuals devote to our charity.

Naturally, the pace of change at the College must be underpinned by a financial performance to match our aspirations. The group unrestricted income for 2014 was £14.9m, with a surplus of income over expenditure. The balance sheet shows assets for the group of £33.1m, up £2m from 2013.

The Lister Project is progressing towards an autumn completion, although it was held up slightly by the sort of unexpected findings that inevitably delay work on historic buildings. The College takes the preservation of its heritage very seriously, so this work is done to a high standard and, where possible, returns the building to its original specification. We have made provision for cost overruns on certain aspects within the separate budget allocated for this project. The project is supported by the generosity of our Fellows, Members, Foundations, Trusts and the Heritage Lottery Fund, without the need to draw on our reserves.

The event space project has now been signed off, and has been put to good use already for both social and professional functions. Members and Fellows who are planning professional events or medium-sized social functions would be well advised to take a look at this splendid facility overlooking the College Green, and opposite the Ten Hill Place Hotel. Listing of the building during the construction phase caused a change of plan and inevitably a modest overspend.

Surgeons Lodge Limited (SLL) is a College-owned company that runs the College’s business ventures in accommodation and catering, principally the Ten Hill Place Hotel. SLL had another good year, with a turnover of £3.9m, generating a profit of £600K, despite the temporary closure of the museums. The expertise of the SSL board, under the Chairmanship of George Borthwick, together with Commercial Director Scott Mitchell and his team, continues to drive the business forward for us.

The College Regional Centre at Colmore Row, Birmingham, is fully up and running, providing a local facility for many of our Members and Fellows. Naturally,

The College is a three-legged stool: subscriptions and examinations together provide over half of our income, although trading income is catching up 62 | Surgeons’ News | September 2015

Balance sheet as at 31 December 2014 31/12/2014 31/12/2013 £000

£000

20,594

19,150

Heritage assets

3,875

3,875

Investments

6,175

6,165

11,846

10,876

Creditors: amounts falling due within one year

(5,002)

(4,194)

Creditors: amounts falling due after more than one year

(4,387)

(4,760)

33,101

31,112

14,988

13,698

6,166

6,330

21,154

20,028

11,947

11,084

33,101

31,112

Tangible fixed assets

Current assets

Represented by: Unrestricted funds General fund Designated fund

Restricted funds Net assets

the staff at Colmore Row now show in the accounts as an increase in salary costs. Council views this as an efficient way of providing local facilities and services to our circa 10,000 Fellows and Members in England and Wales.

The College’s investment portfolio is managed prudently by our investment managers, Cornelian, and in 2014 achieved 3–4% gross income yield. The Investment Committee considers this to be acceptable in the current circumstances for a low- to medium-risk portfolio.

The College does not invest in companies associated with tobacco or arms manufacture. Consideration was also given to divestment from companies involved in fossil fuels.

To divest now, when the oil price is low, would crystallise a substantial loss and potentially threaten the College’s ability to fulfil its charitable aims, which we have a legal duty to protect. In practical terms, almost all third-party funds contain some form of fossil-fuel exposure; many other companies use fossil fuels in their core activities, making divestment difficult. The College considers fossil-fuel divestment to be a reasonable aspiration for the future, and is already invested in renewable energy projects, but decided against it at present.

The number of Members and Fellows in good standing is now at 21,803, an increase over last year of 811. The College has endeavoured to keep subscription increases to a minimum, and believes its subscriptions to be lower than those of many other Royal Colleges. Subscriptions and examinations together provide over half of our income,

Donations, bequests and gifts

Total incoming resources

ÂŁ16.2 million

Subscriptions

29%

Examinations

27%

Courses

4%

Faculties

6%

Grants

6%

Trading income

3%

Other

2%

Subscriptions Examination costs

ÂŁ14.3 million

22%

Investment income

Fundraising and trading costs

Total resources expended

1%

20% 6% 21%

Courses

4%

Property

9%

Faculties

6%

Publications

5%

Grants

3%

Professional activities 14% Governance and support costs Other

although trading income is catching up. Ultimately, we foresee that trading income could allow us to become even more competitive with our subscription levels.

However, at the moment the College operates in a sector where inflation is higher than in the general economy.

1% 11%

This means that to maintain sound finances, we will have to consider a modest subscription increase in 2015.

Thanks to the efforts of our Fellows and Members, our staff, and the input from our supporters and Regents, our College remains in sound financial health.

Treasurer's statement on the summarised accounts of the Royal College of Surgeons of Edinburgh 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 2014 have been audited

by Chiene & Tait LLP, 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.

R J Montgomery Honorary Treasurer

www.rcsed.ac.uk | 63

FROM THE COLLECTIONS

The Museum’s permanent reminder of 19th-century penal punishments

THE DESERTER’S TATTOO

P

erhaps a piece of tattooed skin is not something you would expect to find in a museum of surgery. However, when considering the history of displaying living humans and human tissue in the public arenas of surgical colleges, public medical museums and so-called ‘freak’ or side shows, this object’s place in the collection, although considerably uncomfortable, is not surprising.

Penal tattoos left an indelible and humiliating mark of not only punishment, but ownership. Once marked, a person was identified as a troublemaker, and future perceived breaches of rules could result in more severe punishment or death Without context, it is difficult to know why individual tattoos were taken by surgeons. Some suggest artistic merit or individual design, others relate to personal sentiments of love, cultural symbolism and religion. However, the penal military tattoos within our museums can often reveal links to the lives of those we sometimes forget exist within our collections.

Penal tattoos left an indelible and humiliating mark of not only punishment, but ownership.

Once marked, a person was identified as a troublemaker, and future perceived breaches of rules could result in more severe 64 | Surgeons’ News | September 2015

punishment or death. The Persians were among the earliest societies to use punitive tattooing. When the Greeks adopted the practice, they used a delta (for doulous – slave) to mark their slaves.1 The ‘D’ tattoo in the collections of Surgeons’ Hall Museums is thought to stand for ‘deserter’, although it could have been used to label a soldier as a ‘drunkard’. The record for this object shows that the skin was taken from the left infraaxillary area of an adult male. No other details of the person who was branded have been recorded.

A branding tool was sometimes used to mark deserting soldiers.

One such contemporary implement, produced by Savigny & Co,2 which was known for making surgical instruments, shows a similar style of character to the tattoo in our collections. The practice of tattooing those viewed as criminals ended in the late 19th century and this tattoo was probably inked on the soldier before 1875. At this time, other initials used for punitive military tattoos included ‘BC’ for ‘bad character’, ‘V’ for ‘vagabond’ and ‘F’ for ‘fraymaker’.

Emma Black Public Engagement Officer, Surgeons’ Hall Museum

Above: This tattoo was removed from the infraaxillary area of an adult male

REFERENCES 1. DeMello M. Inked: Tattoos and Body Art around the World 2. http://www. sciencemuseum. org.uk/ broughttolife/ objects/display. aspx?id=92953

COURSE CALENDAR SEPT 2015 — DEC 2015 02 - 04 Sep 03 Sep 07 Sep 09 Sep 10 Sep 16 - 18 Sep 17 Sep 18 Sep 21 - 24 Sep 24 -25 Sep 28 Sep 29 Sep 30 Sep

20th Dundee Advanced Rhinoplasty Course NEW Lower GI Polypectomy Skills NEW Advanced in Stroke Interventions Temporal Bone Course Temporal Bone Course Basic Skills in Upper Gastrointestinal (UGI) Endoscopy 1st Scottish FESS 4 Orbital and Lacrimal Surgery Course 2nd Scottish Advanced Frontal Sinus Surgery Course (FESS 3) EAES Laparoscopic Upper GI Surgery Course NEW Thiel Cadaveric Advanced Laryngeal & Pharyngeal Surgery Workshop Rhinoplasty and Septoplasty Skills Aesthetic Facial Surgery Exercises by Cadaver Dissection Facial Plastic Surgery Flap Reconstruction Dissection Course

01 - 02 Oct 06 Oct 19 - 20 Oct 23 Oct 24 Oct 26 Oct 27 - 29 Oct 28 - 29 Oct

Interventional Radiology – The Basics NEW Principles of Forefoot Surgery NEW Progressive Skills in Veterinary Laparoscopy & Thoracoscopy Course Advanced Cosmetic Course Botox and Dermal Fillers Course Managing Surgical Crisis: Non-technical skills Advanced Temporal Bone Surgery Course Human Cadaveric Flexible Ureterorenoscopy Masterclass

02 - 03 Nov 02 Nov 03 Nov 04 Nov 04 - 06 Nov 05 Nov 05 - 06 Nov 09 - 12 Nov 13 Nov 17 - 19 Nov 24 Nov 27 Nov

Core Skills in Laparoscopic Surgery Course Emergency Safe Neck Surgery by Cadaver Dissection Endoscopic Sinus Surgery by Cadaver Dissection (FESS1) Advanced and Open Sinus Surgery by Cadaver Dissection Basic Skills in Colonoscopy Training Course Ultrasound for Novice Trainees Advanced Laparoscopic Renal Resection Course EAES laparoscopic Lower GI course Temporal Bone Course NEW Thiel Cadaver Free Flap Reconstruction Course Percutaneous Tracheostomy on a Cadaveric Porcine Model under Endo Control Minor Surgery in General Practice

01 - 03 Dec 01 Dec 04 Dec 07-09 Dec 14 - 16 Dec

Essentials & Intermediate Laparoscopic Skills for Gynaecological Trainees Surgical Management of Thyroid Cancer Hysteroscopy and Endometrial Ablation Course Intermediate Skills Course for Laparoscopic Surgeons Basic Skills in Upper Gastrointestinal (UGI) Endoscopy

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

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Castle Hill Barns,E:Harley, Shrewsbury, Shropshire, SY5 6LX, UK Suite Suite2B, CheviotHouse, House,4141Bath BathRoad, Road,Swindon, Swindon,Wilts Wil T: +44 (0)1952 510061 F: +44 (0)1952 510192 info@tfmpublishing.com W: www.tfmpublishing.com Company no 3301765.

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