RCSEd Surgeon's News December 2022

WHICH FACTORS LEAD TO ARTHRITIS IN HUMAN JOINTS?

The world’s leading surgeons and healthcare professionals can always rely on the consistent quality, precision and performance of surgical blades, handles and scalpels from Swann-Morton. Our extensive range includes over 70 blade shapes and a selection of 27 handles. Used in various disciplines for both general and specialist surgery, all our products are subject to the strictest quality control procedures and are guaranteed never to let you down.

Where only Swann-Morton will do.

www.swann-morton.com

NEEDSOFDISADVANTAGED PATIENTSMUSTBEMET

This issue of Surgeons’ News marks my second anniversary as editor and my first in my Trust role as an Associate Medical Director. Both have provided many learning opportunities and areas for reflection over the past couple of years.

From a Health Service perspective, while we have safely managed to remobilise a significant amount of elective surgery, we are under increasing pressure from unscheduled care. This is placing significant demands on beds, with exceptionally long waits in emergency departments. Our Trust is no different to any others and, as I write this at 10am, there are nine ambulances parked outside.

It does not take much extrapolation to realise the difficulties this causes if we do not have a protected stream for scheduled care. Unscheduled admissions will overflow into elective surgical beds and cause even greater problems with our remobilisation of surgical services and the clearing of the pandemicrelated backlog.

It sits with all of us as surgeons and dental surgeons to meet the needs of patients who have been significantly disadvantaged by long treatment waits due to the interruption of normal treatment by the COVID-19 pandemic. It is clear from my own operating lists that a number of these patients have deconditioned significantly and, unsurprisingly, their clinical condition has often worsened. The operation they were listed for may no longer be appropriate and they now require some level of clinical review prior to surgical intervention. This brings yet more pressures to surgical and anaesthetist colleagues.

The College itself has had a busy few months. Many of you will have

seen the new statues that grace the College campus forecourt and are the title image of this edition. Their story is well publicised and they serve as a fitting tribute to healthcare workers worldwide.

The UK has seen significant change following the death of Her Majesty Queen Elizabeth II. Our Patron has become King Charles III, further cementing the College’s royal ties.

In this issue we report on the successful international meeting held in Chennai, India. This was diverse, welcoming and provided an opportunity for education and international networking.

A previous Surgeons’ News editor once said to me that this unique position allows an overview at the ‘changing of the guard’. This edition marks the passage of Professor Mike Griffin’s four-year tenure as President, along with Pala Rajesh as Vice-President and Alastair Gibson as Honorary Treasurer. We take note of the significant personal and professional contributions they have made to College life over many years.

Of course, we also welcome Professor Rowan Parks as President, Vice-President Tim Graham and our first female Vice-President, Clare McNaught, highlighting the inclusive thinking of the College.

Council also refreshes at this time and it is interesting to note that, of the current composition, at least eight have been Regional Surgical Advisers, showing that this College endeavour has provided pathways for colleagues to engage and work with the College.

Finally, I would like to wish all readers a healthy and happy holiday and festive period, and good wishes for 2023!

Roger Currie surgeonsnews@rcsed.ac.uk

Roger Currie on the crisis of unscheduled care and reflections on recent events at the College

Unscheduledadmissionswill overflowintoelectivesurgicalbeds andcausegreaterproblems

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 surgeonsnews@rcsed.ac.uk

DESIGN AND PRODUCTION

Think Publishing Ltd, 20 Mortimer Street, London W1T 3JW Tel: +44 (0)20 3771 7200 www.thinkpublishing.co.uk

ACCOUNT MANAGER Indira Mann

DESIGNER, Juanita Adu, Alistair

PRINTED BY

Acorn Web Offset Ltd, Yorkshire, UK

ISSN 1750-7995

The views expressed in Surgeons’Newsare not necessarily those of the editorial team or the Royal College of Surgeons of Edinburgh. Information printed in this edition of Surgeons’Newsis believed to be correct at the time of going to press. The Royal College of Surgeons of Edinburgh permits single copying of individual articles for private study or research. Multiple copying of individual articles for teaching purposes is permitted without specific permission. For copying or reproduction for any other purpose, written permission must be sought from the Royal College of Surgeons of Edinburgh. Exceptions to the above are those institutions and non-publishing organisations that have an agreement or licence with the UK Copyright Licensing Agency or the US Copyright Clearance Center. Access to the magazine is available on the College website rcsed.ac.uk

Cover: RCSEd

McGown

SUB EDITOR Kirsty Fortune

MEDICAL SUB EDITOR Dr Arshad Makhdum GROUP ACCOUNT DIRECTOR John Innes john.innes@thinkpublishing.co.uk

Agenda

The latest news from the College and profession

College unveils sculptural tribute to pandemic workers

Believed to be the first memorial to pandemic workers, ‘Your Next Breath’ was unveiled at the RCSEd on 13 October.

The artwork, which was created by renowned sculptor Kenny Hunter, pays tribute to the compassion and resilience of NHS staff during the pandemic and depicts four healthcare workers in scrubs as they experience a moment of reflection at the end of a shift on a COVID-19 ward.

During discussions with surgeons and RCSEd Council members Anna Paisley, Clare McNaught and Nirmal Kumar, Hunter captured the mix of strong emotions experienced by healthcare workers during

the challenging and exhausting period of the pandemic.

Professor Michael Griffin, the College’s Immediate Past President, said: “The unveiling of this striking piece of public art represents not only a

significant moment in history, but also offers us the opportunity to stop and reflect on all the NHS workers who lost their lives while working on the frontline during the pandemic.

“We are delighted to see this incredible piece of art come to fruition. I hope that this memorial, which is situated permanently within our College grounds, will encourage visitors for years to come to consider how much healthcare workers sacrificed and how vital they were throughout this time.

“I would like to thank Kenny, who has done such a fantastic job in bringing this sculpture to life, and all of my colleagues who served our healthcare system throughout the pandemic and to whom this sculpture is dedicated.”

MEMORIAL

We are delighted to see this piece of art come to fruition

From left, Nirmal Kumar, Clare McNaught and Mike Griffin at the artwork’s unveiling

Rowan Parks and distinguished guests at the artwork unveiling

New Vice-Presidents take up posts

We are pleased to announce the appointment of two new Vice-Presidents following an election process.

Clare McNaught and Tim Graham have taken over from Rowan Parks and Pala Rajesh, who have held the roles since November 2018. As VicePresidents, McNaught and Graham will support and implement the manifesto of Rowan Parks, our new President.

McNaught said: “I am delighted and privileged to be able to serve the College as Vice-President. This is the first time in 517 years that a woman has been elected to this office and it was notable that two

of my female colleagues also stood in this election. This is a testimony to how seriously the College is working to improve equality throughout our organisation to better reflect the diversity of our membership.”

Graham added: “I’ve been involved with the College for many years now in different roles

and this journey has been a privilege. To now be elected to Vice-President of this historic and international College is a delight as well as an honour. I look forward to working with Clare, Rowan and the rest of the team to contribute to the improvements the College continues to make to UK and international surgery.”

Honorary roles

The College is delighted to welcome Siong Liau as RCSEd Honorary Treasurer. He takes over the role from Alastair Gibson. We also welcome Robin Paton, who has taken on the role of RCSEd Honorary Secretary, replacing Clare McNaught.

Election results: meet your new members of Council and Dental Council

After a ballot of our Members and Fellows, the College is pleased to announce the following appointments to Council, who took up their positions at the Annual General Meeting on 11 November: Mike Silva, elected for a one-year term; Alistair Mountain; Sai Vittal, for a one-year term; and Katie Hurst, replacing Haroon Rehman as Trainee Representative for a two-year term.

Janet Wilson demits from Council, as does Michael Griffin as President, Pala Rajesh as Vice-President, Alastair Gibson as Honorary Treasurer and Haroon Rehman as Trainee Representative.

The Dental Council is also delighted to announce the following appointments: Grant McIntyre, Vice-Dean, who replaces Helen Craddock; Carole Boyle (re-elected) and John Scholey

ELECTION

ALISTAIR MOUNTAIN SAI VITTAL

KATIE HURST

MIKE SILVA

CAROLE BOYLE

JOHN SCHOLEY

GRANT MCINTYRE

Siong Liau

Clare McNaught Tim Graham

Professor Robin Paton

British Association of Black Surgeons hosts inaugural conference

The College was proud to be a platinum sponsor of the British Association of Black Surgeons’ (BABS) Inaugural Conference 2022, which took place on 15 November.

The conference created an opportunity for delegates to network and hear from influential speakers and participate in topical debates. It also enabled them to support BABS’ mission to widen participation in surgical leadership, foster long-term career progression and increase representation across the profession.

Sarah Itam, Consultant Urological Surgeon and Chair of BABS, said: “We appreciate the generous support of the RCSEd as the conference’s platinum sponsor. BABS looks forward to ongoing collaboration with the College in the shared goal of helping to build a more diverse, inclusive surgical landscape that better serves its patients.” FORUM

Talks on Northern Ireland’s healthcare challenges

The College was delighted to join leading surgical experts and Government representatives in Belfast on 22 August to discuss the future of Northern Ireland’s healthcare system. Health Minister Robin Swann and Chief Medical Officer Professor Sir Michael McBride, alongside the UK’s four Royal Colleges, looked at the range of challenges currently facing the surgical workforce.

Healthcare workers from a plethora of surgical roles, including trainees and surgical nurses, were invited to come along to the full-day session. Talks were given by 15 surgical professionals on a variety of topics, including elective treatment centres and attracting the next generation of surgeons.

On the day the Department of Health also presented the findings

of a number of reviews into surgical services they had facilitated in the last two years, as well as the change they hope to deliver going forward.

Professor Mike Griffin, then President of the RCSEd, said: “Significant challenges are being faced in Northern Ireland when it comes to surgical backlogs, and this event was an important opportunity to meet with healthcare workers and decisionmakers to share ideas on what steps can be taken to improve surgical care delivery.”

Professor Laura Viani, President of the Royal College of Surgeons in Ireland, said: “We were delighted to be part of this important forum and we will continue to collaborate on surgical care, training and education to benefit patients across the island of Ireland.”

Lively discussion at the Belfast forum

Surgical experts joined with Government representatives to examine the future of Northern Ireland’s healthcare system

SurgeonsQuarter spreadsitswings

Award-winning agency rolls out its travel services to College Members, staff, visitors and the public

Surgeons Quarter Travel (SQ Travel), the latest addition to the Surgeons Quarter business portfolio, has gone from strength to strength during the COVID-19 pandemic.

SQ Travel can organise flights, accommodation and transport for surgeons carrying out examination work on behalf of the College. In addition, it can arrange the travel needs of delegates attending events held across Surgeons Quarter’s four venues.

SQ Travel uses systems provided by Hays Travel Independence Group, allowing it to benefit from the group’s expertise, buying power, technology and back-office functions.

Scott Mitchell, Managing Director at Surgeons Quarter, said: “As many of our surgeons travel frequently for training and educational purposes, it made sense to coordinate all of their travel and accommodation in a more streamlined way.

“We also have tens of thousands of delegates visiting our venues each year, so providing an all-round service that includes transport to Edinburgh, accommodation and events is an added bonus.”

ALL SYSTEMS GO

Business began in earnest for SQ Travel immediately prior to the start of the pandemic. In the weeks that followed it was instrumental in arranging travel and accommodation for medics around the country during lockdown, as well as facilitating bookings at the College’s hotel, Ten Hill Place (THP).

SQ Travel was originally established to streamline travel for surgeons and Fellows of the College, but its remit has rapidly expanded to include business travel and holidays for College staff, Members and Fellows as well as the general public. Its independence is key to being able to provide impartial advice and the best offers available.

Many College employees and Members have taken advantage of SQ Travel’s expanded services. They have booked trips to unique locations, such as Everest Base Camp, while sports enthusiasts have been quick to take advantage of the superb packages to events such as Wimbledon 2022 and the Italy v Scotland Six Nations match at the Stadio Olimpico in Rome.

Justin MacKenzie, the agency’s Travel Manager, said: “I worked in the travel

and tourism industry for 12 years in Spain and have always had a passion for travel, so it’s been great to be involved in this new side to Surgeons Quarter’s business. It has also been immensely rewarding aiding surgeons with their travel arrangements, as well as helping people turn their holiday dreams into reality.”

SQ Travel is looking forward to dealing with more enquiries and bookings from the general public following its recent advertising campaign on STV.

Profits from the business go towards the College’s charitable aims meaning customers are helping improve patient outcomes worldwide while travelling the globe with SQ Travel.

To find out how SQ Travel can help with your corporate travel arrangements or next holiday email travel@surgeonsquarter.com or call 0131 527 1737

Hard-working surgeons can look forward to a well-organised holiday through SQ Travel, including special Wimbledon packages, above

Left to right: Justin MacKenzie, SQ Travel Manager; Steven McLean, SQ Travel Consultant; Lawrie King, SQ Senior Travel Consultant

Review

By Francis R Sutherland and Chad G Ball £42.99 (TFM Publishing)

Written by two expert hepato-pancreato-biliary (HPB) surgeons with a North American practice, The Wise Scalpel: Tips & Traps in Liver Gallbladder & Pancreatic Surgery is the opening book in a new series.

It uses a modern and clear style, where short paragraphs of explanation and example are used, and are summarised throughout the text by bullet-point ‘wisdoms’. These convey a wide range of lessons – some evidently hard-won by the authors –and are collated at the end of each chapter for emphasis and consolidation.

This is not a state-of-the-art description of the field, nor does it focus on the evidence base or technical aspects of modern HPB surgery. Instead it tries to explain the principles and the strategic approach of the specialty and outlines pitfalls encountered by the authors in their practice.

The opening chapters explain the present landscape of modern HPB surgery by recounting some of the historical context through which it developed. What the authors choose to describe in their opening chapters as the craft of modern HPB surgery is also understood as nontechnical skills, and their

placement of these elements of modern practice in the forefront of their book demonstrates how important they believe these concepts are to safe surgical practice. These beliefs are becoming more widely shared across all medical fields, but the emphasis is still important.

The organ- and operationspecific chapters read as though they are offering mentorship to junior colleagues with an interest in HPB surgery at all levels of experience. They describe a variety of information relating to anatomic interest, the breadth of technical challenges and the delicacy of the work, and ultimately convey some of the passion the authors have for their field.

The ‘wisdoms’ they offer come across exactly as intended, not as evidencebased statements, but as advice from experts who have gained experience from salvaging not only their own difficult situations, but also those of their colleagues. They avoid and explicitly advise against unkind judgements, advocating a more supportive approach. Aggressive simplicity is the intent and there is discouragement of heroic or high-risk manoeuvres.

The largest part of the book focuses predominantly on

elective procedures, which are solely practised by HPB subspecialists so is of most relevance to those recently qualified or intending to qualify in this field.

The topics that will generate the widest interest among general surgeons will be difficult gallstone disease and HPB trauma. The approach to gallstone disease differs globally and the obvious omission in this text is the lack of description of laparoscopic approaches to common bile duct stones, either direct or trans-cystically, which is in contrast to the careful consideration given to approaches to the difficult cholecystectomy.

The management of HPB trauma is largely absent, which seems due to the role of the ‘trauma surgeon’ as a distinct specialisation within North

American practice. This is at odds with the majority of UK and global practice, where the general surgical on-call remains part of the role of most GI surgeons, so more detail would have broadened the appeal of the book.

Nonetheless, The Wise Scalpel is a useful resource for the right surgeon. It is easy to read, and offers condensed experience and insight into the thought processes of the authors and how they approach their practice.

Some deeper understanding can also be gained on rereading and I suspect returning to the book over time will offer further benefits as the reader becomes more experienced in their field.

Douglas C Morran

Consultant Upper GI Surgeon, NHS Ayrshire and Arran

This useful overview of HRB surgery imparts passion and wisdom, writes Douglas C Morran

The Wise Scalpel: Tips & Traps in Liver, Gallbladder & Pancreatic Surgery

Theyavoidand explicitlyadvise againstunkind judgements

IN BRIEF

The latest guidance, articles and

Tranexamic acid for safer surgery: the time is now This article summarises the evidence that tranexamic acid substantially reduces the risk of surgical bleeding, and highlights the importance of this to anaesthetists, surgeons, patients and healthcare systems. It proposes that tranexamic acid use is considered in all adults having in-patient surgery and that “consideration of tranexamic acid use” is included in the Surgical Safety Checklist of all hospitals. The authors conclude that wider use of tranexamic acid will improve surgical safety, reduce unnecessary blood use and release funds for other purposes within the healthcare system.

UK Royal Colleges Tranexamic Acid in Surgery Implementation Group. Br J Surg 2022; doi.org/10.1093/bjs/znac252

Use of cold-stored whole blood is associated with improved mortality in resuscitation of major bleeding

This observational study looked at outcomes for 1,623 trauma patients whose resuscitation included whole blood (74%) compared with blood-component therapy (24%). Patients who received whole blood had a higher shock index, more comorbidities and more blunt trauma.

Whole-blood patients were 9% less likely to experience bleeding complications and were 48% less likely to die. Authors concluded that the study supports the use of whole blood in the resuscitation of trauma patients.

Hazelton JP, Ssentongo A, Oh JS et al. Ann Surg 2022; 276(4): 579-588

Short-term risk prediction after major lower limb amputation: PERCEIVE study

This multicentre study of 537 patients undergoing major lower limb amputation (MLLA) compared the accuracy of preoperative predictions of 30-day mortality, morbidity and MLLA revision

studies

by surgeons and anaesthetists with relevant risk-prediction tools. Clinicians predicted mortality and MLLA revision well, but were poor at predicting morbidity. They overpredicted the risk of all outcomes. Most short-term riskprediction tools had poorer discrimination or calibration than clinicians. The best method of predicting mortality was a statistical tool that incorporated clinician estimation.

Gwilym BL, Pallmann P, Waldron CA et al. Br J Sur; doi.org/10.1093/bjs/znac309

Timing of a major operative intervention after a positive COVID-19 test affects postoperative mortality This study sought to determine the safest time after COVID-19 for patients to undergo high-risk operations. Between January 2020 and May 2021, 938 COVID-19-positive cases were matched to 7,235 controls. Ninety-day mortality was similar if surgery was nine weeks or longer after a positive test, but higher when the operation was within seven to eight weeks, five to six weeks, three to four weeks, and one to two weeks. Within eight weeks from diagnosis, 90-day mortality was 16.6% versus 5.8% for the controls. Authors concluded patients undergoing major operations within eight weeks after a positive test have higher postoperative mortality.

Kougias P, Sharath S, Zamani, N et al. Ann Surg 2022; 276(3): 554-561

Carotid endarterectomy, stenting or best medical treatment alone for asymptomatic carotid artery stenosis

This multicentre, randomised controlled trial evaluated 513 patients with asymptomatic carotid artery stenosis (of at least 70%). Forty per cent were allocated to carotid endarterectomy (CEA) plus best medical treatment (BMT), 38% to carotid artery angioplasty with stenting (CAS) plus BMT, and 22% to BMT alone. The incidence of stroke or death from any cause within 30 days or ipsilateral ischaemic stroke within five years was 2.5% with CEA plus BMT, 4.4% with CAS plus BMT, and 3.1% with BMT alone. Authors concluded that interventional treatments were not found to be superior to BMT alone but, because of the small sample size, results should be interpreted with caution.

Reiff T, Eckstein H-H, Mansmann U et al. Lancet Neurol 2022; 21(10): 877-888

Temporal trends in comorbidity in adult elective hip and knee arthroplasty patients in England

This study from the National Joint Registry on primary elective hip (696,504) and knee (833,745) arthroplasties evaluated comorbidities between 2005 and 2018. During this period the proportion of elective patients with one or more comorbidity at the time of their operation increased (THA: 20% to 38%, KA: 22% to 41%). This was driven by increases in four conditions: COPD, diabetes, myocardial infarction and renal disease. Authors concluded that there were significant increases in the number of comorbidities and future research should explore the impact of this on preoperative and postoperative care.

Penfold CM, Judge A, Sayers A et al. Bone Joint J 2022; 104-(9): 1052–1059

Wider use of tranexamic acid can bring several important benefits, such as reduced blood use

A fond farewell

My four years as President have been wonderful and I am extremely proud of everything we have achieved as a team.

I could not have done this without the support of my two VicePresidents – Pala Rajesh and Rowan Parks – Honorary Treasurer Alastair Gibson, and Honorary Secretaries Judy Evans and Clare McNaught.

We were a tight team and we worked together to make the changes needed to grow and develop the College. We achieved a great deal, but none of it would have been possible without the hard work and resilience of the College staff.

My term has not been without its challenges. I knew we had to change to grow. In our professions there were many people I wanted to help: trainees, women in surgery, less-thanfull-time workers and SAS doctors. I wanted to support, nurture and develop all of them and give them the tools they need to excel. I wanted to rekindle the joy of looking after, caring for and curing patients.

When I was a young registrar it was a joy to come to work. We worked long hours, but we had places to meet, relax and be social. Nowadays our workforce must take rests in corridors or in the cafes where their patients’ families might be at the next table. We need to try to improve the working environment if we have any hope of retaining and

recruiting staff in our hospitals. I also realised that if you want to make it better for one group –women, for example – you would ultimately make it better for everyone. The brilliant ‘Let’s Remove It’ campaign to cut out bullying and undermining helped everyone. Encouraging support for less-than-full-time working helps everyone. So we developed a campaign that would be the main theme of my Triennial meeting – ‘Making it Better’ for everyone.

TRIENNIAL SUCCESS

Initially to be held in June 2020, for obvious reasons it finally happened two years later. We joined up with ICOSET and it was a huge success. It was wonderful to bring surgeons and dentists together to share ideas, network and enjoy social events.

We also decided to update the brand. The one that hit the mark was the combination of the castle (for Edinburgh), 1505 (the date of our Royal Charter), the sun rising over ignorance (taken from our siglium), the globe (representing our international presence) and the unicorn, Scotland’s heraldic animal, which is also known as a powerful horse of healing.

One of my key ambitions as President was to reach the younger members of our profession. Our Membership, Marketing and Communications team created an app that could deliver all the

Clockwise from top right: Mike Griffin and Craig McIlhenny, Surgical Director of FST, at ICOSET In 2019; the President in his official robes; Prince Charles visits the College; unveiling the sculpture commemorating healthcare workers during the pandemic; the President speaks at the Triennial Conference; Professor Griffin in theatre

benefits of the College in an easily digestible format. This, combined with offering free Affiliate membership to all medical and dental undergraduates, helped us to grow the early years segment of our membership pipeline and will stand us in good stead for the future.

I am also proud of our Skills Competitions, which continued during the pandemic due to the creative thinking of Angus Watson, who put the skills ‘in a box’. Each year we have increased the number of students who have taken part – this year we had 1,300 applications at the first stage.

COVID-19 RESPONSE

During the pandemic I met with the Communications and Policy teams on an almost daily basis to assess the ever-moving clinical situation and lobby for what we needed to ensure that our members were looked after. I also drove a dedicated COVID-19 strand of webinars, which ran weekly

Professor Mike Griffin reflects on the successes and challenges of his tenure as RCSEd President and welcomes the new team of Office Bearers

I wanted to rekindle the joy of looking after, caring for and curing patients

throughout the pandemic to share information and raise issues that our clinicians were facing. We also ran webinars targeted at trainees, who were feeling very isolated during this time. Given other priorities, they were worried about their career path and the lack of proper practical craft skills and training.

Our Development and Partnerships team, under the leadership of Michael Stitt, was expanded to include International and I was delighted that Mariette Naud-Betteridge, who had managed our new Kuala Lumpur office, was appointed as Head of International. Together, the team worked with then Vice-President Pala Rajesh to bring his vision to life. This culminated in the College’s first ever International Conference in Chennai this October.

In September we welcomed HRH Tuanku Muhriz ibni Almarhum Munawir and delegation to the College to bestow

the Tuanku Muhriz Travelling Fellowship on Andy Kent. Angus Watson gave a lecture on his time in Ukraine. We also presented the College International Medal 2021 to Tan Sri Dr Noor Hisham Abdullah. This was a particularly poignant visit, as it fell during the period of mourning following the death of Her Majesty Queen Elizabeth II. With our flag at half mast, the College mourned the loss of Her Majesty by stopping all activities on the day of the funeral and greying out our communications for the period of mourning. I was honoured to be invited to the memorial service in St Giles, as the President of a Royal College whose Patron is her heir, King Charles III.

STRENGTH TO STRENGTH

Our museum has been transformed over the last few years and is now one of the most important visitor venues in Edinburgh. The Library has also gone from strength to strength, increasing the number and variety of subscriptions, books and periodicals available.

Surgeons Quarter faced an extremely challenging few years due to the pandemic. However, the team, under the leadership of Scott Mitchell, quickly reacted to take advantage of the furlough scheme.

He also put our

hotel, Ten Hill Place, to good use during lockdown by offering rooms and a meal to all those working on the frontline who needed to live away from their family to protect them from the virus. Even Scotland’s National Clinical Director, Jason Leitch, made use of the offer.

A NEW ROYAL PATRON

On 29 June we welcomed HRH Prince Charles to view the prototypes of four statues we have created as a gift to honour his father and our Patron, HRH Prince Philip.

The four bronze life-size statues, entitled ‘Your Next Breath’ were created by sculptor by Kenny Hunter to commemorate the resilience and courage of healthcare workers during the pandemic.

On that day we announced that Prince Charles, now King Charles III, had become our Patron.

Surrounded by paintings and images of his father, Prince Charles made an unexpected and emotional speech about how his father loved his work with the College and how he hoped to follow in his footsteps. We are honoured to have him as our Patron.

SAFE HANDS

Despite the interruption of normal presidential activities due to the pandemic, I believe that together we have achieved a great deal.

We have positioned ourselves as the friendly College, welcoming everyone from the UK and across the world and making sure that we reach as many people as possible from the start of their career to their retirement.

It has been an honour and a pleasure to serve you for four years. There is much more to do, but with the new Office Bearers now in place, we are in extremely safe hands.

Professor Mike Griffin president@rcsed.ac.uk

I wanted to reach younger members of our profession

Investing in our people

It is with great pride that I have been elected and now installed as President of our College. It is an exciting but still challenging time to take over, and I am deeply fortunate to be inheriting a great ship, stewarded by the incredible hard work of my friend and predecessor, Professor Mike Griffin.

I am only too aware of the responsibility and the commitment that comes with this crucial role. In becoming the 176th President of the RCSEd, I am the first surgeon originally from Northern Ireland to hold this office.

In another first for the College, a father and now son have been presidents of two different Royal Colleges in the UK and Ireland, as well as also both being President of our Surgical Specialty Association, ASGBI. So I would like to pay tribute

to my father George, a Fellow of this College since 1963 (and still in good standing). He was President of our sister college, the RCSI, from 2000 to 2002 when Sir John Temple was President of the RCSEd.

It is my role to build on the great work of those who have come before me and ensure the College continues to flourish and have influence.

It is now 517 years since our College was founded, and I believe we are just as influential and crucial to UK and international surgery as we were then. Our Edinburgh campus and facilities are second to none. We have outstanding talent here – those who have the capacity to think outside of the box and innovate. We have many jewels in our crown, including our Faculties: Dental Surgery, Surgical and Dental trainers, Perioperative Care,

Pre-Hospital Care, Remote and Rural and Humanitarian Healthcare, and Sport and Exercise Medicine.

These Faculties have all grown so much in recent years and keep us at the forefront of surgery and dentistry, both in the UK and, increasingly, internationally. Our challenge is to remain ahead with these developments, not because it is in the College’s interests, but because it is in the interests of our patients and their safety, which is the reason we are here. We also need to invest in people – future Members, Fellows and College staff.

I have been fortunate to have been part of a phenomenal clinical and academic unit for almost 25 years. My colleagues at the academic HPB Surgical Unit at the Royal Infirmary of Edinburgh, under the leadership of Professor Sir David

Our new President Rowan Parks reflects on his exciting yet challenging role and vows to continue the work of his predecessors in ‘Making it Better’

Carter, Professor James Garden and now Professor Stephen Wigmore, have just been the most wonderful, dedicated, supportive and collegial colleagues I could ever have wished for. The unit has a global reputation and I am tremendously proud of that. I wish to pay tribute to the incredible support and teamwork shown by all of my clinical and academic colleagues that has permitted me to undertake many roles and responsibilities, not least my involvement in the College over the past 13 years and more.

The key to teamwork is valuing everyone in the team. We must continue to foster that teamwork among our College staff, currently led by Tony Oxford. Our College will move forward with this teamwork in mind, enabling us to innovate, educate, train and care for patients.

As you know, when Mike and I put together the programme for the Triennial Conference, the theme was ‘Making it Better’. Unfortunately, the pandemic meant the conference was delayed for two years, eventually being held in June this year. That theme, however, remains important and it is my intention to continue to use it as we transition into the next administration. We do want to make it better – better for surgeons, trainees, students, SAS doctors, for dentists and, ultimately, our patients.

NURTURING TRAINEES

Our trainees have had it very tough over the past couple of years. Their resilience has been stretched, their training has been impacted and often their working environment has been challenging. We must ensure they are valued and nurtured. I am passionate about the education and training of the next generation of surgeons and dentists, and this will be a major focus of our endeavours over the next few years.

We must ensure their training is prioritised as we recover from the impact of the pandemic, but also manage a huge backlog of elective surgical workload. We must also rekindle in them the excitement, the

satisfaction and the joy of looking after, caring for and curing patients.

During the next three years I aim to work with our Regional and International Surgical Ambassadors to engage with students, trainees and younger Fellows with a commitment to support, stimulate and encourage these future surgeons.

A major focus as we enter the next few years will be on our workforce. Together with our trainees, we also need to support our SAS doctors and our non-medical workforce, as well as our consultant colleagues.

We have an outstanding Council at present, bolstered even more by our recent elections. We have a completely new Office Bearer team. I couldn’t have asked for two better Vice-Presidents – Tim Graham and Clare McNaught – who will lead both at home and abroad. Tim’s huge experience in education, training and assessment will be vitally important as we develop and expand our education and examination portfolio. Clare, our youngest ever VP and first ever female VP, will have oversight of our international portfolio. This will be crucial as we recognise that more than 40% of our College membership are

based overseas. It is also great to have Robin Paton taking over as Honorary Secretary and Siong Liau as Honorary Treasurer.

What I can promise is that I will bring passion and enthusiasm to this role, and with such a superb team and Council behind me, I believe that the College can and will carry on the fabulous work of the last administration and truly make a difference for young doctors, surgeons and our patients.

We must rekindle in trainees the excitement and the joy of looking after, caring for and curing patients

Opposite page, Immediate Past President Professor Mike Griffin, left, and new President Rowan Parks at the Diploma Ceremonies in November

Left: Rowan Parks speaking at the Belfast Forum

Professor

Rowan Parks president@rcsed.ac.uk

SURGICAL SAFETY UPDATE

Cases from the Confidential Reporting System for Surgery (CORESS)

Air embolism in coronary artery bypass perfusion error

This case reflects a report recently submitted to CORESS. Cardiac surgery is a highly technical area in which a patient undergoing heart surgery may be placed on heart-lung bypass to ensure continued organ oxygenation while the heart is temporarily stopped. In this case, a technical error gave rise to an adverse incident when a vent tube was inadvertently placed into the perfusion circuit the wrong way round. On establishing cardiopulmonary bypass, the surgical team became aware that air had entered the heart after noting an air bubble within the cardioplegia cannula.

The visible air was cleared and the operation continued. Postoperatively, it was evident that the patient had sustained a hypoxic brain injury. The cause was identified as a significant air embolism during institution of bypass.

The patient did not regain consciousness postoperatively. Following repeated CT scanning and clinical reviews, the prognosis was felt to be extremely poor. Treatment was withdrawn and the patient died. The root causes were human error and equipment factors.

Whilst the specific clinical features of this case are not pertinent to all surgical practice, the principles of checking kit, ensuring knowledge of equipment operation prior to commencement of surgery, and of being aware of potential systems errors are relevant to all surgical practice. The Society for Cardiothoracic Surgery is aware of, and has commented on, this case.

SCPS Safety Committee findings

This was an adverse event arising out of a highly technical and niche area of surgery in which misapplication of the perfusion apparatus was involved. The equipment was checked and found to be functioning normally. Due to the design of the pumps, the risk of human error leading to an inadvertent change of flow direction to the vent pipe was real. This potential to inadvertently reverse the flow on this

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

particular pump was demonstrated to all members of the perfusion team. It was recommended that once the heart-lung machine has been set up and existing safety checks completed, it should be switched to zero revolutions rather than placed in standby mode. This should be added to the perfusionist protocol checklist. Fluid should be aspirated into the vent line prior to its insertion (wet table test). This task should be included in normal checks undertaken by the scrub nurse. Human factors contributed to this incident.

As part of the Massive Air Embolism protocol review the SCPS recommended introduction of one-way valves to the vent suction line. Other specific recommended actions included a wet table test of all suckers as standard to avoid errors. It was felt that wet testing of vents prior to insertion would further increase the safety of these devices.

Double trouble

A 76-year-old male vascular patient with atrial fibrillation and a femoro-popliteal bypass graft was inadvertently prescribed both apixaban and enoxaparin together. Although the prescriptions were on different charts, it was an intentional attempt to ‘bridge’ the patient onto a direct oral anticoagulant (DOAC).

Reporter’s comments

Pharmacy advice made it clear that concomitant prescribing of two anticoagulants is contraindicated unless it is for a patient being started on warfarin for venous thromboembolism (VTE) or for an established warfarinised patient with a subtherapeutic or unstable international normalised ratio. DOACs have a rapid onset of action –hours not days. When switching from a parenteral anticoagulant to a DOAC, the first dose should be given when the next dose of low molecular weight heparin is due or on cessation of an IV unfractionated heparin infusion. The higher initiation doses for both apixaban and rivaroxaban

are not ‘loading doses’. All DOACs have short half-lives and this is a larger dose to cover the higher period of risk, acutely after a VTE.

CORESS comments

The Advisory Board commented that electronic prescribing might have averted this issue. It was also noted that the discipline of checking all drug charts in use remains an important function of the daily ward round.

Inadvertent bladder injury at orchidopexy

An eight-year-old boy presented for bilateral second-stage orchidopexy for intra-abdominal testes. The first stage, a Fowler-Stephens procedure, whereby the testicular vessels are divided to allow hypertrophy of the accessory supply via the vas deferens (Figure 1), had been carried out several years earlier with an unusually long period between first and second stages due to COVID-19. The parents were keen for both testes to be moved to the scrotum during the same operation to avoid further anaesthetics.

The procedure was approached laparoscopically. The primary port was inserted without complication, infraumbilically, using an open technique. Insertion of two secondary ports was hampered by limited space despite using standard insufflation pressure and flows.

Both testes were seen within the abdomen. The left testis was associated with a large hernia sac and was managed through an open incision into the groin after a laparoscopic

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

The online reporting form is on our website, 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.

CORESS is an independent charity supported by AXA Health, the MDU and the WPA Benevolent Foundation.

procedure on the right side. Visualisation was challenging due to the limited space so the pressure for the pneumoperitoneum was increased to 15mmHg, although the working space was still unusually small.

The testis was mobilised and then a Veress needle and ‘step’ port sheath were passed up from the scrotum into the peritoneal cavity under vision. The needle did not immediately pass into the peritoneal cavity and required some manipulation. An 11mm step port was passed up the sheath, the testis grasped via the port and brought down into the scrotum. Postoperatively, there were no immediate concerns, but the family were anxious and the child was kept in overnight. He did not pass urine and was clearly peritonitic the next morning. Bloods and imaging were in keeping with a bladder leak, which was confirmed at exploratory surgery. The edge of the bladder had been injured by the Veress needle inserted via the scrotum and there was a clear urine leak. The patient made an uneventful recovery once the bladder had been repaired.

CORESS and reporter’s comments

The pressure required for the pneumoperitoneum was higher than normal and might have pushed the bladder out more laterally than usual. The Veress needle was brought up medial to the medial umbilical ligament and did not pass smoothly, providing a clue about possible mis-passage that was not picked up at the time. Bladder injury is a recognised complication of this procedure.

In future, the approach should be lateral rather than medial to the medial umbilical ligament. The bladder should be empty prior to the key manoeuvre, although the role of catheterisation in young males prior to surgery is controversial and should be dealt with on a case-by-case basis.

New CORESS app

The CORESS Reporting App, which makes reporting easy and convenient, is now available to download and use on your phone. Search for CORESS in the Apple or Google Play app stores to find out more.

Intra-abdominal testis following first stage Fowler-Stephens procedure with division and clipping of testicular vessels

NEW BLOOD

After the success of the inaugural ‘So you want to be a vascular surgeon?’ courses held last year, a second set of events this year offered an exciting new opportunity for top learners.

The winning medical student of the skills competition at each course centre – in Edinburgh and Birmingham – was given the opportunity to take part in a one- or two-week elective at a UK vascular unit, courtesy of an educational grant from global device company Terumo Aortic.

Rebecca Williams, a medical student from Hull York Medical School, came top at the Edinburgh course – held at the College – for the best end-to-side anastomosis.

Semhar Abraha, who attends Warwick Medical School, performed the best patch angioplasty at the Birmingham course.

Both women elected to spend their placements with Becky Sandford, Consultant Vascular Surgeon and RCSEd Vascular Specialty Board member, at St Thomas’ Hospital, London.

The ‘So you want to be a vascular surgeon?’ courses are a collaboration between the RCSEd and the Rouleaux Club, the UK vascular trainees’ association. This year’s winners both gained positive feedback from the day.

Read what the students had to say about their experiences on the course and while on their placements (right).

I took part in the course held at the RCSEd in May. It was a jam-packed day, with a variety of interactive sessions and presentations. This was one of the first events I had attended in person since the COVID-19 pandemic and it was exciting to have practical sessions scheduled.

I would highly recommend it to other medical students, especially if you haven’t had much exposure to the field or are interested in surgery as a whole. The sessions were interesting and hands-on – it was definitely worth the time spent!

The day gave me an insight into the spectrum of vascular operations, the lifestyle of a trainee and the calibre of equipment used in endovascular procedures, with the opportunity to ask questions throughout.

One of the activities on offer on the course was a consultant-led suturing workshop. Each participant received individualised feedback on their technique in an enthusiastic and nurturing environment.

Due to the pandemic I had missed out on my elective placement during medical school, so I was grateful for the placement opportunity and the chance to experience another hospital Trust. I was made to feel extremely welcome by the vascular team and was able to see a variety of aspects of the specialty during my week there. I saw a complex open abdominal aortic aneurysm repair, amputations and many endovascular procedures. In clinic I saw patients after their operations, who were pleased with the results. They were grateful for the improvement in quality of life. I could appreciate how this would be a rewarding career.

During the placement I learned that vascular is ‘the help’. All other surgical specialties call you if they run into trouble or need assistance. The vascular surgeons have the capability to manage and resolve the problems that might cause panic. They are able to save lives.

REBECCA WILLIAMS HULL YORK MEDICAL SCHOOL

Lauren Shelmerdine introduces two medical students who won the opportunity to experience life as a vascular surgeon

“I would highly recommend it to other medical students, especially if you haven’t had much exposure to the field”

Lauren Shelmerdine (right), MRCSEd and co-convenor of the courses, congratulates Edinburgh winner Rebecca Williams; inset left: Williams fully embraces her vascular placement

on my elective

The course included a suturing workshop

This course was a great experience as it gave me an insight into the variety offered by the speciality and I heard from surgeons at different levels of training. The skills workshops were well organised with great facilitation.

On the first day I started on the on-call handover meeting at 8.30am. This was a great opportunity to get an understanding of the myriad conditions managed by the vascular team as they discussed every patient’s plan.

I observed a bilateral common femoral endarterectomy with profundoplasty and iliac stenting in the ‘hybrid’ theatre. It was valuable to see the joint approach on a case between vascular surgeons and interventional radiologists.

I followed up on the patient throughout their stay until they were discharged three days later, and got an understanding of the care plan following discharge.

Over the following days I had a range of different experiences. For example, I got to scrub in on an open repair of an aortic aneurysm, which was a great opportunity to brush up on my anatomy and witness some intricate surgical skills, including graft insertion. I also learned a lot from shadowing the anaesthetist during anaesthesia induction and talking through the preoperative assessment for aortic patients.

I shadowed the registrar on call before observing another open abdominal aortic aneurysm repair. I also followed a patient suspected of aortic dissection through the assessment pathway from taking their history to management.

I spent one day at the emergency vascular clinic, which takes referrals for non-life or non-limb threatening emergencies, and shadowed the vascular nurses who triaged the newly presenting patients and the consultant while making management plans. This provided me with experience of a great array of presentations, including post-surgical seroma, lower-limb ulceration and critical-limb ischaemia.

The last day of the elective was the highlight as I got to scrub in as first assistant on a registrarled theatre list. I was fortunate to assist in different procedures, including multiple phlebectomies, a toe amputation and an above-knee amputation. I was able to use some of the basic surgical skills I learned, such as simple interrupted sutures,

subcuticular sutures and hand ties. It was a very rewarding experience with hands-on experience supported by feedback and teaching.

Overall, my time in theatre was great and gave me an introduction to surgical skills and the functioning of a surgical team. The elective was a golden opportunity to see what a career in vascular surgery entailed and I was able to tailor it to get an overview of the different aspects of the specialty. The elective with a vascular department has been the best experience I have had as a medical student.

SEMHAR ABRAHA WARWICK MEDICAL SCHOOL

Above: Semhar Abraha in action at the Birmingham course, before her work was judged to be the best on the day

Below: Both winners spent their placements with Consultant Vascular Surgeon Becky Sandford at St Thomas’ Hospital, London

Find out more about next year’s courses at bit.ly/vascular-courses

Lauren Shelmerdine Vascular SPR, North East England, Rouleaux Club Executive Committee member and representative on RCSEd Vascular Surgical Specialty Board

“The elective was a golden opportunity to see what a career in vascular surgery entails”

Walking on water

Although the blood supply of bone at rest has been well defined by Brookes and others, this was in static or postmortem tissue. Denham recognised that several times body weight was transferred across joints during activity and joint surface pressures of many atmospheres have been measured. While activity appears to be the primary function of the skeleton, the way in which activity affects perfusion under joints has received little attention.

Intraosseous pressure (IOP) has been studied in normal, avascular and steroid-treated models, but only under static conditions. IOP has been recorded in association with forage decompression for painful and osteonecrotic bone conditions. Variation in IOP with drugs and on exsanguination has been found. IOP is thought to be raised in osteonecrosis, arthritis and bone pain, but there has been difficulty in defining a normal IOP and using it effectively for clinical purposes.

It is perhaps surprising that IOP is thought to be a constant, measurable simply by needle insertion. No other solid organ has internal pressure measured that way. Although IOP recordings vary considerably, they usually exhibit wave patterns synchronous with the arterial pulse, with respiration and even with drug circulation time. IOP measurements in healthy bone are associated with a proportional pulse pressure (PP), which suggests that IOP reflects conditions at the needle tip rather than being a constant throughout the bone. Needle clearance by the traditional FiCAT

method of flushing with saline damages the local circulation and causes a prolonged drop in IOP whereas, after clearance by aspiration, recovery is rapid.

It is likely that the injection of saline into normal bone causes a fall in IOP due to blood, fat, saline, heparin and bone fragments being injected back into the delicate vascular tree. Previous work that showed a raised IOP in ischaemic bone may have been measuring a raised IOP caused by the injection itself.

Proximal arterial occlusion causes a drop in IOP and loss of the associated PP, whereas proximal venous occlusion significantly raises IOP with preservation of the PP. The difference between the IOP with a proximal venous then arterial clamp gives a measure of perfusion achievable in the cleared volume at the needle tip.

This novel biological concept does not appear to have been considered previously or applied elsewhere. In osteonecrotic or avascular bone the pressure difference is small, whereas in healthy bone the range is greater.

Michael Beverly, Orthopaedic surgeon, Botnar Research Centre michael. beverly@ btinternet.com

This principle may be applied elsewhere – for example, in compartment syndromes – by using a proximal tourniquet. Irrespective of the initial needle pressure in a compartment (where the proximal venous to arterial occlusion difference is large) there is a wide perfusion range achievable at the needle tip. If the subtraction difference is small, perfusion at the needle tip is limited and decompression is more urgently required.

Load transmission

Although researchers have suggested that bone might be hydraulically strengthened, early studies did not support this, but their methods were far from physiological. When IOP is studied with physiological loading in an animal model and in vitro, loading causes an instantaneous and proportional increase in subchondral IOP. During proximal arterial occlusion the rise in IOP is reduced, and with proximal venous occlusion there is a greater rise. With loading of one body weight the subchondral IOP is much higher than arterial pressure. In the animal model simultaneous recordings made at the femoral head, femoral condyle and proximal tibia show an IOP rise at all sites when loaded. Saline injections at those sites show that

Michael Beverly reprises his King James IV Professorship lecture to consider how human joints work and why they develop osteoarthritis

The beautifully designed delicate structures tolerate huge fluctuating pressures

Below: Volunteer walking during measurement of IOP in upper tibia

pressure is transmitted through the length of a bone, but not across the joints.

In the perfused in vitro model cyclical loading to simulate walking causes marked fluctuation in IOP against a falling background IOP. Together these studies suggest that the subchondral bone is slightly flexible and that forces applied to the joint are transferred through the subchondral region partly by hydraulic pressure within a contained environment. These pressures can be very high. It is to be expected that there might be modifications to the subchondral circulation to prevent capillary and fat cell damage.

Anatomy

Burkhardt described normal bone histology and identified features that might be related to pressure, but there are no histological studies that look for evidence of hydraulic pressure load transfer. The subchondral bone plate, capillaries and trabeculae are relatively fragile. Much of the subchondral tissue is composed of large, thin-walled adipocytes or haemopoetic tissue.

Orthopaedic surgeons are aware that bone fat is essentially oily or fluid at body temperatures. These soft tissues would be capable of transferring pressure without

suffering damage provided they are enclosed or contained and supported. The fine subchondral capillaries first described by Hunter (Hunter’s mesentery) immediately below healthy cartilage are proportional in number to the thickness of the cartilage. Below that are previously non-described axial plane-radiating vessels best seen on water-bright MRI running parallel to the articular surface.

The marks are present in all normal water-bright MRI joint scans, but are best seen in the subchondral plane of the upper tibia in axial slices. Radiological opinion is that the marks are vascular. Histologically their position and orientation matches that of the axial plane-radiating vessels. The vessels are present in the first subchondral upper tibial slice, peak at 6–10mm depth and are absent by 16–20mm depth. Where the vessels penetrate the cortex near the articular margin there are complex distortions that could, under load, act as choke valves to prevent loss of blood from the cancellous interior.

On removal of the load, circulation continues at ordinary physiological pressures. Collectively these beautifully designed delicate structures tolerate huge fluctuating pressures and pass the force by hydraulic pressure onto the larger trabeculae. They, in turn, converge onto the cortical shaft, transferring load along the shaft to the joint at the other end. There the reverse occurs, passing force from the shaft through the trabeculae, generating pressure in the subchondral region to support the joint surface.

Osteoarthritis

There is an inverse relationship between the number of MRI marks and Kellgren-Lawrence grade of osteoarthritis, both medially and laterally. While cause and effect remain to be separated, the relationship between vascular disease, osteoarthritis and osteoporosis should be of orthopaedic interest. Vasculomechanical mechanisms may

explain other orthopaedic phenomena – such as the general mutually exclusive nature of osteoporosis and osteoarthritis. It may be that the softer subchondral bone of the osteoporotic patient flexes proportionately more and is thereby better perfused than the harder sclerotic bone found in osteoarthritis.

Novel research

We present a novel understanding of joint physiology and subchondral bone circulation. At rest subchondral cancellous bone behaves as a perfused tissue with IOP being mainly due to arterial supply rather than venous back pressure or tissue turgor. A single measure of IOP is variable and meaningless, reflecting only conditions at the needle tip.

The difference in IOP with proximal venous and arterial occlusion possibly offers a better method for assessing perfusion at the needle tip in a closed organ. A substantial proportion of the load applied to a joint is transmitted through the semi-liquid fatty tissues by hydraulic pressure to the trabeculae.

Subchondral tissues and vascular structures are modified to support hydraulic forces. Vessels are lost in early osteoarthritis, suggesting that vasculo-mechanical physiology in the subchondral region may play a role in its development. Our proposition opens the door to novel means of research, diagnosis, surveillance and prognosis, and in due course potentially better treatments for osteoarthritis.

Find a full list of references at bit.ly/KingJamesLectures

King James IV Professorship

This is awarded annually to surgery or dental surgery practitioners who contribute significantly to the clinical and/or scientific basis of surgery.

Vasculo-mechanical physiology in the subchondral region may play a role in the development of OA

Letter from America

Dear Colleagues,

According to the US Department of Health and Human Services, the average pre-COVID-19 American baby born in 2019 should expect to live until 79 years of age. Perhaps incomprehensible to their sleep-deprived parents, some of these adorable little poop factories will eventually graduate from medical or dental school. They will enter the workforce as young practitioners, competing for recognition in an ocean of older, more experienced competitors. Who are the most superannuated of American surgeons? A 2009 study of 137,426 American surgeons showed urology winning the Greyest of the Grey Award with median age 52, followed closely by thoracic surgery at 51 years.

We certainly hope the doddering dotards at the end of the scale have enjoyed fulfilling careers, but the problem that this missive will attempt to address lies at the other end of surgeons’ careers. A multi-centre American study of new urogynaecology patients showed that age preferences for their surgeons followed a bell-shaped curve, with most preferring 50 to 60 years of age with more than five years of experience. This correspondent has advised his residents and Fellows that if patients and their families are given a choice, they will consistently choose a surgeon older than 40.

My advice unknowingly agreed with that of Sir William Osler, who once said: “The teacher’s life should have three periods: study until age twenty-five, investigation until forty, profession until sixty, at which age I would have him retired on a double allowance.” Research until age 40 is not an ideal way for a young surgeon to refine their surgical skills, although part-time research can be of immense value. However, in the immortal words of noted London maxillofacial surgeon John Langdon: “A young surgeon must fill his boots with blood.”

Newly minted surgeons in their 30s are competing for patient referrals with well-established and often well-known older surgeons. How does the young surgeon inspire confidence among those mature patients who have not yet self-diverted to a more senior competitor?

In the immortal words of noted London maxillofacial surgeon John Langdon: ‘A young surgeon must fill his boots with blood’

With patients preferring to be treated by older surgeons, hungry young surgeons can struggle to get the experience they need, explains Eric Dierks

Beware the hierarchical environment. As viewed through the eyes of a young American surgeon, medical institutions tend to fall into two general categories: hierarchical and non-hierarchical. Hierarchical environments are those in which patient referrals are pyramidal, with the more senior, well-established surgeons at the top getting their pick and the new, inexperienced but hungry surgeons at the bottom doing the mundane work. Young surgeons must await the decline of the dotards to ramp up their volume of challenging and career-building surgical cases. An example of this in the American system would be that of a group of private-practice surgeons of stairstep ages in which the senior surgeons do the interesting or highly remunerative cases, the midcareer surgeons get some of this good stuff and the early-career surgeons pick up the scraps.

The preferred category is the non-hierarchical environment in which the young surgeon is thrust into a busy environment with no formal or informal limitation upon their access to patients. The patients lack the option of directing their care to a more senior surgeon. The young surgeon performs interesting procedures from the beginning, along with all the rest. American examples include large teaching hospitals such as Cook County in Chicago, Parkland in Dallas and many others.

Once the young surgeon is comfortably ensconced in a stimulating practice environment, consideration may be given to the strategy of ‘Fake it ‘til you make it’ (FITYMI, pronounced ‘fitty me’). What can a young surgeon do to act and/or appear older, more seasoned and therefore wiser? The meaning of this common aphorism is well summarised by the action of one of the mentors of this correspondent when that mentor was himself a fledgling oral surgeon. When Dr Edwin Granite opened his new office in Delaware many decades ago he purposefully stubbed out a cigarette butt in the shiny new waiting room ashtray so that his first patient would have the impression that he was not the first.

In the medical context, FITYMI should never involve lying to patients, only the creation of a favourable, albeit mythical environment to enhance their experience. For example, a young surgeon’s attire can be optimised. In a large, multi-institution American study, in response to the question: “Which doctor would you prefer as your surgeon?”, the overwhelming favourite was the photo of a young surgeon wearing scrubs, followed by scrubs and white coat. A similar study performed in Switzerland produced similar results with white scrubs preferred for surgeons.

Early-career surgeons may consider the episodic use of propranolol. Scottish researcher Sir James Whyte Black received the Nobel Prize in Medicine in 1988 for, among other things, developing propranolol. Preoperative oral propranolol has been shown to be highly effective in decreasing overall anxiety as well as reducing surgical tremor among young ophthalmologists performing cataract and other ophthalmic operations. Its use as a prophylaxis for stage fright, although considered an off-label prescription in the US, has been reported and is widely advocated on popular websites such as Reddit.

For many professions, and particularly in healthcare, ‘a knack for listening’ is very important. Perhaps this is the most valuable area of improvement for a young surgeon – or, indeed, for anyone.

Kind regards

Eric Dierks FRCSEd, Affiliate Professor of Oral and Maxillofacial Surgery, Oregon Health and Science University

Newly minted surgeons in their 30s are competing for patient referrals with often well-known older surgeons

Safe team, safe patient

Anna Paisley follows up a recent Robert Shields Lecture and explores how poor wellbeing puts the physical and emotional health of staff at risk with impacts on the clinician, the system and patient safety

Human factors, which aim to design systems that mitigate risk and make it easier to perform to our best, are integral to improving patient safety. Current systems models place the individual at the centre of the entire model. It is clear that worker wellbeing has a direct influence on all other aspects of the work system and is directly correlated with patient safety and treatment outcomes. In other words, there can be no patient safety without healthcare worker safety. According to the National Academy of Medicine, healthcare worker wellbeing is “a state of personal fulfilment and engagement that leads to joy in one’s practice and connection to why one entered

Anna M Paisley RCSEd Council Member and Chair, RCSEd Patient Safety Group

healthcare in the first place”. For surgical and other teams, it involves many factors, including emotional, mental and physical health (Figure 1).

CAUSES OF POOR WELLBEING

A number of reports from UK national bodies have highlighted concerns over poor healthcare worker wellbeing and its impact on patient safety. These graphically record the challenges facing staff in the modern NHS.

In line with human factor principles, they all note that the system in which staff work has a major impact on their mental health. They all acknowledge that healthcare is a tough job, but that it is made far harder than it should be by neglecting the basics in caring for healthcare worker wellbeing.

Issues affecting staff wellbeing were highlighted in the Boorman review in 20091 Unfortunately, there has been little tangible progress since then, with more recent reports from Health Education England2, the General Medical Council3 and the British Medical Association4 reporting similar findings.

Several additional factors are considered by many to be particularly important in the current healthcare climate. Over recent years we have become more aware of the concept of moral distress. This occurs when one knows the right thing to do for a patient, but institutional constraints make it impossible to pursue that course of action. It has been reported that 73% of NHS staff feel their organisation does not have enough staff and resources to enable them to do their jobs properly. This inevitably leads to fear, feelings of loss of control and low morale.

Bullying and undermining also play a part. An RCSEd survey found that 33% of Members and Fellows had experienced bullying and undermining, with 44% feeling unable to report it. These behaviours affect the recipient and observers, as Figure 2 illustrates.

Complaints and adverse events, no matter how trivial, are powerful triggers for mental illness and substantial contributing factors to doctors’ suicides. They can have significant emotional impact on all staff, causing feelings of guilt, shame and inadequacy – the so-called second victim syndrome.

Causes that are specifically related to surgery have been comprehensively outlined in a systematic review5. Clinical factors included adverse events, medical error and malpractice claims, as well as intraoperative stress. Environmental factors included

Figure 1: Wellbeing involves many factors1

Figure 2 ( below): Bullying and undermining behaviour affect not only the victim, but witnesses and patients too

poor institutional support, poor relationships with colleagues, lack of structured mentorship programmes, pressure to succeed in research and missed educational opportunities.

Many studies highlighted difficulties coping with suffering and death, emotional exhaustion and imposter syndrome.

In The Wounded Healer, the report on the first 10 years of NHS England’s Practitioner Health Programme, Clare Gerarda postulates that the traits which often define the surgeon and the demanding high-risk surgical workplace may place surgeons at particular risk of poor wellbeing6

Furthermore, it is Gerarda’s observation that surgeons who present with mental health issues generally struggle more than other doctors to accept illness, relinquish their professional identity and see themselves as patients. Doctors, and surgeons in particular, are reluctant

to seek help for mental health issues due to the perceived personal, professional and institutional stigma associated with the diagnosis.

EFFECTS OF POOR WELLBEING

Numerous studies have shown an association between distress and a range of medical comorbidities. Strain can also lead to behavioural problems, including mood disturbance, poor concentration and impaired decision-making, along with a deterioration in memory, reaction time and the performance of different cognitive tasks.

Poor wellbeing significantly worsens compassion, professionalism, staff productivity

and work satisfaction, leading to poorer performance at work. Surgeons, specifically, may experience negative impacts to both their technical and cognitive intraoperative performance, with serious consequences to patients.

If staff are unhappy and have high levels of stress, it has repeatedly been shown that there will be increased sickness rates and poor recruitment and retention, as well as more instances of early retirement.

There is also a significant psychological impact, with increased rates of relationship breakdown, substance abuse, stress, anxiety, burnout, depression and suicide (Figure 3).

References

1. Boorman S. NHS Health and Wellbeing. Department of Health, Nov 2009.

2. NHS Staff and Learners’ Mental Wellbeing Commission. Health Education England, 2019.

3. West M, Coia D. Caring for doctors, Caring for patients. GMC, 2020.

4. Mental health and wellbeing of the medical profession. British Medical Association, Oct 2019.

5. Vitou CA et al Optimising surgeon wellbeing. Ann Surg. 2021; 1: e029.

6. The wounded healer: report of the first 10 years of the practitioner health service. NHS GP Health Service, 2018.

7. Caring for the mental health of the medical workforce. British Medical Association, 2019.

8. We are the NHS: people plan 2020/21; action for all. NHS England, Jul 2020.

9. Swensen SJ, Shanafelt TD. Mayo Clinic: Strategies to Reduce Burnout. Oxford University Press, 2020.

IMPROVING WELLBEING

Most interventions to improve wellbeing have focused on improving individual coping skills and building resilience. These include cultivating work-life balance (Figure 4), prioritising personal time, training in mindfulness, building strong support networks and stressreduction techniques.

Staff should take time to look after their physical health: eating well, ensuring they get adequate sleep, exercising regularly and making time to see their GP when needed. Reading about resilience or going to a workshop will not lead to lasting improvements. Staff need to learn to reset priorities and build changes into their everyday routines.

While it is helpful to develop personal strategies to cope with the job, this only goes part way to improving wellbeing. As Human Factor theory clearly tells us, it is essential to also target the workplace at a system-level to address organisational factors that underpin poor staff wellbeing, thereby dealing with the causes as well as the consequences.

Figure 4: Staff need to balance work and their

Strategies targeting systems factors have been highlighted in many recent guidance documents from several UK bodies, including HEE2 , GMC3, BMA7 and NHS England8 .

personal life to achieve wellbeing

ANTI-STRESS ABC

The GMC report Caring for doctors, Caring for patients3 focused on developing greater consistency of good work environments to improve the wellbeing of doctors. The report defined an ABC of doctors’ core needs to minimise workplace stress – autonomy, belonging and competence – and set out an action plan with six key recommendations linked to these core needs.

The Mayo Clinic, meanwhile, has described nine key guiding principles when thinking about systems improvements9 .

OPTIMAL CARE

The culture of surgery has in the past accorded a low priority to surgical team members’ mental health. We are ordinary people, and the stresses and strains of the healthcare environment impact on us as much as they do on other healthcare professionals. We need to check in on our colleagues and ask how they are. We all need to talk openly about our stresses and challenges, and make it OK to talk about mental health.

The wellbeing of surgical team members is central to patient safety and optimal patient care. If we don’t look after ourselves and our teams, we cannot hope to provide good quality care for our patients.

RCSEd wellbeing resources

The RCSEd recognises that staff wellbeing is also a key factor in helping to ensure safe patient care. The promotion of good mental health has been a priority over the last year, and we have developed a set of resources to improve wellbeing at individual and system levels.

Wellbeing weeks

The College Trainees’ Committee has run wellbeing weeks, which raised awareness of the importance of wellbeing. Surgical team members took part in various activities, including daily webinars, virtual workshops and sessions on cooking, mindfulness, yoga, art and how to make work fun. CPD points were given for webinar participation, underlining their importance.

Moon and Back

Last autumn the College launched the Moon and Back campaign to encourage people to take time out of their busy schedules to focus on their mental health.

Focus on bullying

The #LetsRemoveIt campaign to reduce bullying and undermining in the workplace began in 2017, and a range of resources have been developed. The College was also instrumental in forming the anti-bullying alliance with other national bodies, and has developed national guidelines, such as Improving the Working Environment for Trainees out of Hours

Working well Training resources have been developed to foster working environments in which wellbeing can flourish for surgical and dental teams. These include the NOTSS, PiNTS and DeNTS programmes, which help to develop good non-technical skills such as communication, teamworking, leadership, situation awareness and decision-making.

The College has also nurtured system culture to ensure appropriate training environments through the Faculty of Dental Trainers, and support for members of the wider perioperative team through the Faculty of Perioperative Care.

We have collaborated with Healthcare Improvement Scotland on resources to improve Team-Based Quality Reviews. We also contributed, along with other healthcare organisations in Scotland, to the GMC Scottish Wellbeing Advisory Group.

To find out more visit bit.ly/3yO2M2L

Chennai vision

The first ever International Conference of the Royal College of Surgeons of Edinburgh – Beyond COVID-19: Impact & Innovation –finally took place in Chennai, India, after an agonising wait of two years due to COVID-19 restrictions.

The idea of organising an international conference of this magnitude is mind-boggling, and the credit for this vision should go to our Immediate Past President, Michael Griffin, and chief architect of the conference, Immediate Past Vice-President Pala Rajesh.

They were supported by our new President, Professor Rowan Parks (then Vice-President), and the entire College Council. Their vision was transformed into reality by a cavalry of College staff, headed by Tony Oxford, CEO; Michael Stitt, Director of Development and Partnerships; Scott Mitchell, Managing Director of Surgeons Quarter; Jan Cutting, Director of Membership, Marketing and Communications; and the driving force behind it all, Mariette

Vittal Consultant Endocrine Surgeon, Chennai; Convener of MRCS Exams, Chennai

Naud-Betteridge, Head of International Engagement, who served as the engine for the event.

The spectrum of surgical and dental specialties was highlighted by globally renowned leaders in surgery and dentistry in this academic conclave. We couldn’t have asked for a better world-class venue and facilities than the ITC Grand Chola hotel in Chennai.

This conference provided a platform not only to showcase academic excellence and futuristic innovations, but also surgical

practice in remote and rural settings. These few days provided an ideal environment for global networking, making new friends, and reestablishing and renewing links after the pandemic.

SOMETHING FOR EVERYONE

The conference was inaugurated on 6 October by Mike Griffin with the lighting of a kuthuvilaku – a traditional Indian lamp – in the presence of Pala Rajesh, Rowan Parks and College Council members, along with the Vice-Chancellor of the Tamilnadu Dr. MGR Medical University, Professor Sudha Seshayyan.

This was followed by three days of fantastic plenary sessions and exciting parallel specialty sessions. Simultaneously, there were three days of symposia and a surgical skills course held at the premises of Tamilnadu Dr. MGR Medical University for surgical trainees.

Sai Krishna Vittal and Pala Rajesh provide a flavour of RCSEd’s much-anticipated international gathering

Sai Krishna

Pala Rajesh Immediate Past Vice-President RCSEd

These few days provided an ideal environment for global networking and renewing links

From left: Alastair Gibson, Phil Taylor, Rowan Parks, Michael Griffin, Pala Rajesh, Clare McNaught, Sudha Seshayyan, Claire Edwards, Amanda McCabe, Anna Paisley and Rekha Rajesh at the conference

Anna Paisley, Clare McNaught, Claire Edwards and Amanda McCabe don saris

On the first evening it was a privilege to witness the piano recital of world-renowned pianist Lydian Nadhaswaram with his sister, Varshini Nadhaswaram, on vocals and flute. It was an out-of-this-world experience to have been part of the audience.

It was also the first time that a College diploma ceremony was held in India – many new Members and Fellows received their diplomas on 8 October. The entire ceremony was executed to perfection by Head of Membership, Verity Hancock, and Membership Engagement Manager, Gillian Brymer, and their teams.

The diploma ceremony was followed by a gala dinner, where the President and both VicePresidents spoke and prizes were awarded to the best posters and presentations. The gastronomic delights of the dinner served us the globe on a plate and our tastebuds were in ecstasy.

The icing on the cake was music from Chennai band Roxygen, who provided a fitting finale to this exciting conference. One can only wish we had these academic extravaganzas and College engagements more often.

Hands across the water

PALA RAJESH

When I was appointed RCSEd Vice-President it was one of the proudest moments of my career. My remit was International and at the very first strategy session of my tenure I laid out my vision for the College’s international activity.

I wanted the College to reach out further and grow its membership overseas. Our office in Kuala Lumpur was in its early stages of development – my strategy was to use the office as a stepping stone to grow awareness and membership of the College across Southeast Asia.

To see the vision come to life we had to be there. The RCSEd is the most respected College in Southeast Asia. Edinburgh was the seat of medical learning for over 500 years and we have made our mark. We had to reach out and welcome our fellow surgeons and dentists overseas to our friendly College.

FOCUS ON INNOVATION

My first ambition was to hold a multi-disciplinary conference in the seat of medical education in India and my home city of Chennai. I planned it for October 2020, but COVID-19 stopped us in our tracks. We postponed more than once, but finally organised it to take place on 6–8 October 2022. We pulled our top team together, as Sai has mentioned, and we set to work.

Michael, Scott, Mariette and I sourced the venue – the Grand Chola Hotel – and met with potential sponsors and partners in the city. The subject was set: Beyond COVID-19: Impact & Innovation. Mariette ably brought together the programme and set it all in motion. The team worked with a fabulous event company in Chennai to bring our ideas to life.

It was an amazing achievement and a huge success. My aim was to provide a unique opportunity for us to reflect and develop our thinking for a very different future than the one we expected to face in early 2020.

While we grappled with how to deliver the same quality of service during the pandemic, technology and its ability to support us came into sharp focus.

For me, the conference was a way of exploring how the rise of these new technologies have changed the way we work and created a lasting impact on the provision of healthcare.

We gathered together over 100 global leaders in surgery from all over the world – Argentina, the US, the UK, Australia, Hong Kong, Singapore, Malta and many more countries – and, of course, from across India. We welcomed 700 delegates over three days and around 60 students from the

nearby Tamil Nadu University. More than 150 people presented posters and abstracts. The conference was a huge success.

The event looked spectacular with professional branding and backdrops. We even had our own media partners in Medgate and visits from The Times of India and The Hindu

DINNER, DANCING AND DIPLOMAS

We began the conference with the first ever screening of our College song and video. Each evening featured entertainment. Lydian Nadhaswaram, mentioned earlier, is a pianist who won World’s Got Talent competition some years ago. We were lucky to hear him and his sister Varshini Nadhaswaram perform.

This was made possible by my longest friend from medical school, Kalyan Subrahmanyam, and his wife, Shoba, with the help of another friend, Imthiaz Pasha.

On the last night we had our gala dinner, after which Roxygen had us dancing. It was a truly inspiring evening where we felt like a family, connected with our fellow Members in India and from around the world. After two years of not being able to travel or meet together, this was hugely important.

We also held our first ever diploma ceremony in India, welcoming over 200 attendees and 11 special guests who received their International Medal, Ad Hominem and eight Fellowships without examination. The event felt very much like the diploma ceremonies we hold in Edinburgh.

The most important aspect of the whole conference was the ability, after all these years of lockdown, to network, share ideas and welcome new friends, including 155 new Affiliate members, who were all excited to be part of the College.

The conference was a very important first step in the College reaching out to the rest of the world.

It was an amazing achievement and a huge succes

Pala Rajesh delivers a speech at the Chennai 2022 Conference

SURGEON SURGEON

Battle of the Surgeons 2022, a national skills course and competition organised by the Foundation Trainees Surgical Society (FTSS) of the West Midlands, took place in early July. The RCSEd-accredited course catered for pre-core training surgical aspirants and was taught by registrars (>ST3) and consultant surgeons from a range of specialties.

The day began by laying a foundation for surgery with demonstration lectures on common surgical instruments and sutures, as well as needle types. The trainees

Participants

then took part in a series of basic surgical skill workshops involving highly supervised kinaesthetic learning with two to three trainers for every trainee.

The practical workshops comprised hand and instrument knot tying, simple and mattress suturing, tendon repair on porcine models and anchoring porcine abdominal drain tubes with knot tying.

These exercises gave the trainees an opportunity to ‘learn by doing’, reflecting and then reattempting the task, employing Kolb’s learning cycle, where learning is said to be consolidated by reflection and

building on experiences1,2

The last item on the day’s programme was a friendly competition, where trainees were assessed on a one-to-one basis by independent assessors who measured their basic suturing skills against standardised, pre-agreed marksheets to avoid bias. The top three winners won a gift voucher to attend the Foundation Trainees Surgical Society National Conference held in Edinburgh on 23 July.

The competition was a great way to incentivise trainees throughout the day. The course reinforces “motivation to learn = expectancy of success x value of success”3,4

Informal feedback from Faculty and delegates was hugely positive, and we await collated online feedback from the College. One attendee welcomed the opportunity to practise basic suturing skills under close supervision, adding: “The element of a competition made it even more exciting.”

As a team member and course lead, I felt the event gave a taste of surgery and provided aspiring surgeons the chance to develop their skills. The competetive element inspired the trainees and gave individuals the opportunity to shine.

FRAMEWORK FOR EXCELLENCE

The RCSEd provides a supportive framework, guiding trainees in constructing courses under senior consultant supervision and getting

Nakulan Nantha Kumar Academic Foundation Doctor, University Hospitals of North Midlands, on behalf of FTSS of the West Midlands

An RCSEd-accredited course and competition provides future surgeons with essential training and the opportunity to shine, writes Nakulan Nantha Kumar

intently watch a Faculty member demonstrate a safe incision prior to suturing

The RCSEd has a long-standing reputation for offering the highest standards of surgical education and training both nationally and internationally. As part of our commitment to maintaining and improving these standards, the College offers an accreditation service, which allows an external educational activity to undergo our rigorous internal quality assurance process.

With an ever-increasing range of educational activities to choose from, the marker of RCSEd accreditation provides those seeking a course with the reassurance that a particular activity meets the same exacting quality standards as courses within the College’s educational portfolio. Course accreditation provides a number of benefits: Assurance for prospective attendees that the course meets our exacting quality standards.

Use of the RCSEd logo on marketing and certificates.

Support and feedback on course design and delivery.

Use of “accredited by the Royal College of Surgeons of Edinburgh” on course material.

Listing on RCSEd Accredited Courses on the College website.

Award of CPD points for the course (up to six CPD points per day).

Learning the principles of safe needle handling

the plan accredited. The College also provided an efficient booking system – a logistical life-saver – and, more importantly, a fabulous team of managers who offered advice along the way.

Accreditation was a key step in organising the course because it ensured the training adhered to gold standards set by RCSEd.

The process entailed designing and submitting a detailed plan of the event programme, setting learning outcomes and creating a step-by-step approach for how each would be achieved during the course.

This meticulous planning ensured that the course ran smoothly on the day and was a memorable experience for both attendees and Faculty.

By sharing our experiences from the West Midlands, we hope to

References

1. Kolb D. Experiential learning. Englewood Cliffs, NJ: Prentice-Hall; 1984.

2. Kusurkar RA, Ten Cate OT. AM last page: Education is not filling a bucket, but lighting a fire: Self-determination theory and motivation in medical students. Acad Med 2013; 88: 904.

3. Weiner B. Human motivation: metaphors, theories, and research. Newbury Park, CA: SAGE; 1992.

4. Taylor DC, Hamdy H. Adult learning theories: implications for learning and teaching in medical education: AMEE Guide No. 83. Med Teach 2013; 35: e1561–1572.

inspire future surgeons to take part in organising learning events. These help shape the future of surgery by inspiring the surgeons of tomorrow.

I would like to thank the organising committee of this event,

I felt the course gave a taste of surgery and provided an opportunity for practice for keen budding surgeons

Is your course RCSEd accredited?

A Faculty member demonstrates how to suture abdominal drains

Sriram Rajagopalan, Rebecca Lefroy, Tahir Khaleeq, Yanish Poolovadoo, Mrithula Shivakumar, Alicia Halsall, Dhanya Lakxmi, Christopher Swift and Sufia Laulloo. Without their support it would not have been possible.

An unbroken written record

The Royal College of Surgeons of Edinburgh was founded in 1505 as a craft guild when the surgeons formally united with the city’s barbers as the ‘Incorporation of Surgeons and Barbers of Edinburgh’, receiving Royal Charter in 1778.

We are very fortunate that the College archives are as old as our organisation, and we can safely lay claim to being the custodians of one of the oldest and most complete institutional medical archives in Scotland, and possibly the world.

Although the earliest manuscript in the College Archive dates to 1466, we hold an uninterrupted record of all Council meetings held from 1581 to the present day; it is possible the minutes between 1505 and 1581 were lost, destroyed or simply did not exist.

The RCSEd Minute Books are some of our most heavily accessed archives. They have unquestionably informed the greater part of our knowledge on the esteemed history of the College, and are a treasure trove for staff, Members and Fellows, as well as the huge number of academic researchers interested in our heritage and the history of medicine and surgery more broadly.

It is also due to these resources that we have a record of all the men and women who have qualified with our institution since the 16th century, enabling us to deliver a very popular genealogical enquiry service.

Taken together with our early manuscript collection, the Minute

Books offer a fascinating insight into how medical practitioners in Edinburgh organised and evolved into medical ‘professions’ hundreds of years ago, enabling historians to unravel this complex history. This has particular significance given that Edinburgh had emerged as the world-leading centre for medical teaching by the mid-18th century.

We are delighted to announce that these remarkable Minute Books – all 25 volumes covering the years 1581 to 1922 – have now been digitised and are freely available to read online.

CONTINUITY IS KEY

When considering how to best describe these precious historical records, I was initially stumped. How do you summarise five centuries of Council meetings from these hefty volumes in so few pages?

To give you an idea of the sheer breadth of subjects covered, they include business affairs and activities; litigation and disputes; financial transactions; educational and social events; exams and teaching; presentation of new Members and Fellows; disciplinary matters; reactions to wider social, economic and political change, particularly with implications on medical education; and, importantly, the development of anatomical and surgical education.

However, there is a thread that weaves through the collection of Minute Books, which has supported the aims of our original founders, ensuring our longevity into the 21st

century: continuity. Therefore, I thought I would look more closely at this theme and also illustrate the measures taken by the College when individuals have subverted the original principles of the Incorporation. Continuity can be found in so many areas of our work, most notably and obviously through education, training, examination and membership. Our original 1505 Charter, or ‘Seal of Cause’ to give its formal title, was explicit that the Incorporation should exist as a formal examining body, and one of the earliest meetings, held in 1582, registers a William Bisset who was examined and “fund qualifit” to practise.

A fascinating set of College archives charting the evolution of medical professions in the capital since the 16th century is now available online, writes Jacqueline Cahif

Above: One of the College’s Minute Books from 1581

The College achieves its ‘highest standards’ through training and supporting surgeons for the entirety of their career

Jacqueline Cahif College Archivist, RCSEd

Above: Old Surgeons’ Hall, High School Yards, Edinburgh

Left: Interior of a Surgery by Matthijs Naiveu, showing a surgeon treating a man’s arm wound in the 18th century

THE ‘HIGHEST STANDARDS’

The structure of teaching and qualification has obviously changed markedly since our inception. The decline of the Triple Qualification (TQ) examination in the 1960s, which was comparable to an undergraduate university medical degree, transformed our remit, and the College now functions as a centre of higher surgical education and examination. The current RCSEd mission statement reads:

“With our interest in professional standards, the College’s primary role – and the main concern of our Fellows and Members – is to ensure the safety of our patients… We do this by championing the highest standards of surgical and dental practice.”

The College achieves its ‘highest standards’ through the provision of training beyond initial qualification and supporting surgeons for the entirety of their career. This idea

of extended education existed in our organisation centuries ago, thus a minute from 1647 notes that, once qualified, a surgeon should “continue his examinations”.

The theme of continuity can also be seen in centuries-old customs still upheld by the College. The 16thcentury minutes disclose the regulations applied to RCSEd Office Bearers, including several that have endured. Like today, they were elected, and a minute from 1582 identifies the first recorded election of the Deacon (President), Boxmaster (Treasurer), ‘Keeper of the Kist’ (Secretary) and quartermasters. Unlike today, the election itself took place in the (outgoing) Deacon’s house.

Discussions that have taken place in meetings during turbulent and uncertain times in our history give a flavour of the practical steps taken by the College to meet challenges, such as public health emergencies. I recently came across a fascinating entry from the 17th century with particular contemporary relevance that draws a direct parallel with the recent COVID-19 pandemic, whereby the RCSEd Presidential term was extended by one year.

In order to provide a sense of stability during a particularly severe outbreak of plague in Edinburgh in 1604, the Office-Bearer elections were cancelled and the Deacon and “four maisteris, box maisteris and keipar of the key of the kist, ar continewit in thair offices for this yeir to cum [during] the continewing of the plague of pestilence”.

BREAKING THE RULES

In order to promote the highest standards of surgical practice the College requires its membership to adhere to professional codes of conduct. The RCSEd Laws from 2021 state: “Fellows and Members are expected to conduct themselves personally and professionally with integrity and honesty”.

Much of our success and prolific reputation lies in this aspect of our organisation’s overall objectives, and the College has consistently promoted professional and correct behaviour through its entire history.

Today, surgeons found to have participated in disreputable behaviour will likely have their

Above: The Anatomist Overtaken by the Watch (1773), by William Austin. Some anatomists in the 18th century turned to crime to obtain cadavers

membership rescinded. The minutes show surgeons and trainees in the past frequently engaged in rule-breaking and misconduct, and at times this was a real concern to the College. What is particularly notable, however, is the unwavering consistency in stamping out incorrect or perceived immoral behaviour.

Rule-breaking most commonly involved pre-qualification apprentice surgeons usurping the privileges of qualified ‘mastersurgeons’, or unauthorised medical practitioners who had crossed occupational boundaries. The medical marketplace of the early modern period was marked by great fluidity between different groups – many amateur – and the Incorporation took steps to suppress their activities with great regularity.

In 1585, for example, it was reported that an unqualified “simple barber” [as opposed to a licensed barber-surgeon] was punished for practising surgical procedures, being made to “hummell himself on his kneis” and beg for forgiveness in front of the full Incorporation. There are numerous similar incidents in the

minutes and these individuals were a persistent source of irritation to the surgeons.

CRIME AND PUNISHMENT

However, more serious crimes were laid out before Council meetings, some of which brought the College into serious disrepute, the most well-known concerning the practice of bodysnatching, which was particularly rampant in Edinburgh.

Unsurprisingly, whenever cases of bodysnatching came to light, public attention turned to the surgeons. This became a recurring thorn in the side of the College from the early-18th century and continued well into the 19th century as the demand for cadaveric teaching material intensified.

The minutes expose the lengths the College went to in order to dissociate themselves from this gruesome practice – in short, the surgeons had to be seen to be taking action. During a meeting in 1742 Office Bearers ordered the placement of notices on “Church Doors, City-Gates, Coffee-houses or other public places” to “show the World the sentiments of this

The College has consistently promoted professional and correct behaviour through its entire history

Society” in their opposition to “this Monstrous Crime”. Several decades later, in October 1771, a meeting was held to discuss the offer of a financial reward “to discover who took the dead body out of the Grave… some days since”.

The College minutes also record professional quarrels and on occasion disputes appear to have played out in public, seemingly when the offenders had participated in one drink too many. In 1670, for instance, two Members brought shame on the College after an altercation in the town when one threatened the other with violence and that he would “break his heid”.

A notable (and extreme) example from 1679 involved a master-surgeon who displayed violence towards his apprentice, to the extent that he beat him and drew blood “in great quantity and to the hazard of his lyfe”. The roles were reversed in 1818 when a student assaulted a College examiner, surgeon John Gairdner (later PRCSEd). A young man, the son of an Ayrshire minister, had turned up at Gairdner’s home the evening following an examination held at the College where the examiner had rejected him. As revenge, the student attacked the surgeon with a whip in order to punish him. Consequently, he was taken into custody and tried by the Sheriff under the ancient Scots law of “hamesucken” (striking a person in their home).

We also get a glimpse into some of the more turbulent meetings themselves. During one 17thcentury meeting an Office Bearer offended the Deacon with “injurious” speech. His penalty? A spell in Edinburgh’s Tollbooth Jail.

A 500-YEAR RECORD

In 1699 a Library was officially established by the Incorporation after a public appeal for “physicall, anatomicall, chururgicall & other Curious Books”. However, the preservation of the Minute Books as well as the thousands of early modern manuscripts suggests the Incorporation was assiduously collecting its business papers from the 16th century. This not only demonstrates the surgeons’ meticulous recordkeeping, but suggests that the Secretary

(‘Keeper of the Kist’) most likely acted as the Incorporation’s archivist, managing not just the College Minutes, but also what we refer to today as the ‘Chirurgians’ Business Papers’. Possibly a stretch, but I do like to think that my current position as College Archivist is the continuation of a role that stretches back 500 years.

Overall, the College Minute Books are testament to the success of the world’s oldest surgical institution remaining faithful to its original aims, while demonstrating continuity in its efforts to consistently promote the highest standards of professional integrity among its membership.

Above: Resurrectionists (1847) by Hablot Knight Browne, depicting bodysnatching in London. The crime was also rife in Edinburgh and the College was keen to distance itself from this practice

That is not to say the College has been unchanging or inflexible. The minutes leave a paper trail on how the College has adapted to transformations in surgical knowledge, education and practice – including the Anatomy Act (1832), Medical Act (1858), introduction of the NHS in 1945, or even more recently by embracing technological innovation to accommodate distance learning for its overseas membership.

Want to find out more about the history of your College or profession? Access our Minute Books from anywhere in the world on our Digital Collections website (follow the Special Collections link) at archiveandlibrary.rcsed.ac.uk

Canada calling

From May 2020 to July 2021

I undertook an overseas Fellowship in functional neurosurgery in Vancouver, Canada, supported by an Ethicon Foundation Fund travel grant. The COVID-19 pandemic presented new challenges to pursuing an overseas Fellowship, including those related to travel, relocation and overall logistics. Furthermore, tests and quarantine accommodation were required.

Having said that, I feel that there wouldn’t have been a better place to do a Fellowship during the pandemic than Vancouver. The province of British Columbia was fortunately relatively spared from the original first wave of the pandemic. And with its outdoor-centric and healthyliving population, Vancouver enjoyed relatively low levels of COVID-19 throughout.

The Fellowship was led by Professor Chris Honey and the programme has been running for more than 20 years. Functional neurosurgery involves the modulation of nervous system activity. Historically, this involved injuring (‘lesioning’) key structures involved in a specific areas of the brain. Subsequently, deep brain stimulation (DBS) evolved, which involves electrical neuromodulation to provide similar effects to these lesions, but with the advantage that the effect can be titrated and reversed.

Conditions treated by functional neurosurgery include movement disorders (Parkinson’s disease, dystonia and tremor), pain, epilepsy and psychiatric conditions. Currently more than 175,000 DBS systems have been implanted worldwide.

One of the attractions of the Fellowship was the variety of operations performed and conditions treated. Professor Honey’s practice encompasses almost the entire range of functional neurosurgery, including lesional surgery, microvascular decompression surgery, as well as neurosurgery for pain and psychiatric conditions.

In addition, he performs procedures that are dropping out of the surgical vocabulary due to their rareness and complexity, such as trigeminal nucleotractotomy and motor cortex stimulation. Naturally, the Fellowship also includes a large and efficient DBS practice, and this clinical exposure was also a priority for me. Anything broader than this in terms of surgery – for example, non-invasive approaches – would have diluted this core experience in DBS too much.

TWIN BASES

Location-wise, the Fellowship runs from two main hospitals. The team was based at Vancouver General Hospital, a large, busy teaching hospital in the centre of the city that incorporates all main surgical

Hart Senior Lecturer & Honorary Consultant Neurosurgeon, St George’s, University of London

specialties and is a major trauma centre. Our operations were done at the University of British Columbia, which encompasses a smaller, six-theatre elective hospital. This is part of the university campus in the Pacific Spirit National Park.

British Columbia has a population of around five million, conveniently similar to Scotland, where I grew up. However, the difference is in population distribution, with British Columbia’s inhabitants mostly concentrated in Vancouver and the surrounding suburbs. Outside of this metropolitan area was a province approximately the size of France and Germany combined. This brought about unique challenges relating to communication with and transport to more remote communities.

BUSINESS AS USUAL

Healthcare in Canada is similar to that of the UK in that it is almost entirely publicly funded. Overall, healthcare is well funded, with a healthcare budget of approximately $20bn CAD (approximately £12bn) per year. While it is hard to make specific comparisons as to the level of funding between the UK and Canada,

Michael Hart reflects on the highlights and challenges of undertaking an overseas Fellowship in neurosurgery during the height of the pandemic

The Fellowship offered more than what is required to become a safe and effective practitioner in functional neurosurgery

Michael

there appeared to be a much higher usage of philanthropy in Canada.

Healthcare authorities were in the seemingly conflicted position of wishing to control the COVID-19 pandemic while also reducing waiting lists. Fortunately, we were able to continue operating at record levels throughout and performed over 80 primary DBS insertions. Possible reasons for this include operating at a geographically distinct and smaller elective hospital that did not admit patients with COVID-19.

All patients were screened prior to admission and were rarely in hospital for more than 24 hours, while the elective nature of surgery meant we

Clockwise from top left: Vancouver in British Columbia looks over the Pacific Ocean; Michael Hart explores the great outdoors with Professor Chris Honey; view from the Harts’ apartment towards the University of British Columbia, one of the two hospitals where the Fellowship is located

presented no demand on intensive care facilities. These advantages held true for the other surgical specialties with which we shared the facility. Credit should also go to our patients, who often went into self-imposed isolation prior to surgery.

The Fellowship offered more than what is required to become a safe and effective practitioner in functional neurosurgery, both in terms of volume and training quality. I was essentially able to routinely lead all operative cases myself and run my own clinic. One of the striking features of the Fellowship was the high number of procedures that were performed. It readily became apparent that to do this one needs a highly efficient setup, with a great team and a low rate of complications.

HAPPY FAMILIES

From a personal perspective, my memories of Vancouver will be of the most wonderful family experiences. It was a joy seeing our children settle into school so well and make so many friends. The school emphasised the community feel of the Davie Village area (home of the LGBTQ2+ community) and charismatic West

End, where we lived. It also prioritised teaching about the local environment. We quickly became accustomed to the British Columbian ethos of exploring the great outdoors. During the winter months a highlight was the whole family learning how to snowboard on the local mountains, less than 30 minutes from downtown Vancouver, every weekend. We also enjoyed hiking, mountain biking and paddle boarding.

This Fellowship was undoubtedly the highlight of my training. I feel thoroughly well prepared to lead a busy functional neurosurgery service.

While the knowledge and skills I have learned will serve me well for the rest of my consultant career, it will be the memories of the great team I worked with and wonderful patients I helped to treat that will endure.

It was also a wonderfully fulfilling family experience, punctuated by a reinvigoration for enjoying the great outdoors and becoming part of a truly unique city. Overall, I would highly recommend not only this Fellowship, but spending any time possible in beautiful British Columbia.

Tackling the backlog

Lasitha B Samarakoon examines how SAS and locally employed doctors can help to reduce substantial waiting lists for elective surgery in the UK

space and support staff. The often-extensive experience of SAS surgeons can be very useful in a telephone setting where the doctor does not have the opportunity to physically examine patients before reaching a diagnosis, management plan and prioritisation.

WORKFORCE TRAINING

There are an estimated six million people waiting for elective surgery in the NHS1 . This represents one in 10 of the population, a figure that has increased by one third since the start of the pandemic due to the widespread disruption of NHS services.

The government has pledged to tackle this backlog with some £8bn in funding to the NHS within the next three years, boosting elective surgical capacity by 30% by 20242 .

SAS (covering specialty doctors and associate specialists) and locally employed doctors (LEDs, covering a wide range of posts, including Fellows and Trust-grade doctors) are an integral part of the NHS, comprising one third of the medical workforce. There are several ways they can help tackle the backlog.

WORKING AUTONOMOUSLY

Most senior SAS surgeons are experienced practitioners who work independently with minimal or no supervision. Many have completed

References

1. www.bma.org.uk/ advice-and-support/ nhs-delivery-andworkforce/pressures/ nhs-backlog-dataanalysis [Accessed online 25.02.2022]

2. www.england.nhs. uk/coronavirus/ wp-content/uploads/ sites/52/2022/02/ C1466-delivery-planfor-tackling-the-covid19-backlog-of-electivecare.pdf [Accessed online 25.02.2022]

a structured training programme and hold specialist accreditation outside the UK. Some Trusts have a policy to officially recognise autonomous working by SAS doctors. Enabling and encouraging SAS surgeons with the right level of competence to work autonomously brings many benefits to SAS doctors, patients and Trusts.

This means SAS surgeons can undertake theatre and endoscopy lists to help deal with the backlog of cases. The available infrastructure may limit the number of extra lists available to SAS doctors at present, but exploring additional locations such as treatment centres could increase capacity.

LEADING TRIAGE CLINICS

In many Trusts there is a bottleneck in initial outpatient appointments following GP referral to surgical services. Experienced SAS surgeons could run triage clinics to assess patients’ complaints and prioritise waiting lists accordingly.

The pandemic has seen the advent of telephone clinics that can be run without needing outpatient clinic

The pandemic has reduced the exposure of surgical trainees to appropriate surgical training cases, with potential impacts on the length and quality of current surgical training. SAS doctors are often overlooked as a training resource. Many SAS doctors make ideal trainers and mentors, often having experience in different clinical settings. Some have been trained as trainers and are members of the Faculty of Surgical Trainers.

As such, SAS doctors should be given the opportunity to share their experience, and participate in the training and mentoring of trainees. This will help to upskill the surgical workforce, making more trained surgeons available to help deal with the backlog in elective cases.

SURGICAL OUTREACH

Establishing and maintaining surgical outreach services is one important way of tackling the backlog. SAS surgeons are ideally suited to this role, because they have sufficient breadth of knowledge and experience to successfully lead and run such initiatives.

SAS surgeons and dentists can play a vital part in reducing the NHS waiting lists for elective treatment. Senior surgeons and managers should seek to allow the SAS workforce to practise to their full potential. This will enable autonomous working where appropriate, and facilitate SAS surgeons to act as trainers, mentors and leaders in establishing and running services where they are competent to do so.

Lasitha B Samarakoon Consultant in General and Emergency Surgery, University Hospitals of Leicester NHS Trust

For the love of learning

Fellowships are an extremely ill-defined and poorly understood part of a surgeon’s career. The best iteration, in my mind, is a sufficient period spent in a unit acquiring specialist skills and knowledge ahead of taking on a consultant post.

A Fellowship should not be a duplication of training. However, in an era of surgical training heavily disrupted by COVID-19, some surgeons may reasonably wish to advance their skills in index procedures.

Overseas Fellowships can provide exposure to alternative healthcare environments and an opportunity to visit a new country. A ‘good Fellowship’ will make a candidate more competitive for consultant posts, but few are formally validated and reputation is often based on word of mouth.

TRAINING NIRVANA

Throughout my training, I had always hoped to undertake a Fellowship in Australia, but this plan fell victim to the pandemic. Overseas Fellowships had become highly popular among local surgeons, who were unable to travel abroad for such training. It all worked out well for me, though, as I secured a post for one year at Wrightington Hospital in revision hip and knee arthroplasty in 2021.

Wrightington is a specialist orthopaedic hospital and surgical hub in north-west England. It was John Charnley’s unit – the English orthopaedic surgeon and pioneer of the hip-replacement operation –

and was home to the first effective hip replacement.

The unit has an extremely rich history and delivers the highest levels of care to its patients. I was supervised by Professor Peter Kay, Professor Martyn Porter, Mr George Pavlou and Mr Bodo Purbach, who are some of the finest surgeons in this profession. The volume of training opportunities available in Wrightington, even with some lingering COVID-19 and winter restrictions, wildly exceeded pre-pandemic levels in most hospitals around the country. The hospital also offers several other themed Fellowships in orthopaedic subspecialties.

I was able to perform both low- and high-complexity elective procedures. Fellows operated on complex cases together with supervising consultants; independent practice is also heavily encouraged in preparation for your consultant post.

TEACHING CULTURE

The high volume of revision and complex surgery meant these procedures were a routine part of the day, enhancing the culture of teaching and learning. The great sense of responsibility and pride taken in teaching and training means that Fellows are highly protected in this centre. Academic opportunities were available to me, although admittedly I didn’t have the time to take them on.

The Fellowship provided me with essential exposure to a wide range of

pathology as well as the opportunity to learn from highly regarded and experienced surgeons in a centre of excellence. The surgeons offered a great deal of insight into issues that affect consultants, but are generally not encountered as a trainee. There was as much to learn about the management of consultant practice as there was orthopaedics.

My own supervisors supported and encouraged professional development outwith routine scheduled activity. On many occasions they facilitated my work with the College as Council member and Chair of the Trainees’ Committee. They made highly valuable contributions during our discussions on ongoing College campaigns. Without their help and understanding of this role, I think it would have been very difficult to do it alongside the Fellowship.

It is worth noting that Fellowships can be financially challenging. Wrightington, Wigan and Leigh offer Fellows the chance to provide on-call trauma cover for an additional supplement. I didn’t take up this offer, but I did do the occasional locum shift. Not all Fellowships are the same; exposure and experience are supervisordependent. So it is important to have a clear idea of what you want from a Fellowship.

l Haroon Rehman has a special interest in service recovery, patient safety and training.

Haroon Rehman on the role of post-CCT Fellowships in the UK and his own positive experience at Wrightington Hospital in north-west England

Haroon Rehman Consultant Trauma & Orthopaedic Surgeon, Victoria Hospital, Kirkcaldy

It’simportanttohave aclearideaofwhatyou wantfromaFellowship

Engage boosters

Thomas Williams encourages fellow aspiring surgeons to make the most of the College when seeking a mentor and identifying opportunities

Finding your feet as an aspiring surgeon is both daunting and confusing. Within the high-pressure environment of the operating theatre – filled with occupied, multi-tasking clinicians – it is easy to lose your confidence, suppress your queries and allow ‘imposter syndrome’ to seep in.

For medical students it can be overwhelming trying to step into the surgical world. Regardless of your specialty, identifying suitable mentors and role models may be a challenge. Luckily, the College can act as the ideal intermediary via the Regional Surgical Ambassadors’ (RSA) network.

This initiative provides College members and affiliates with advisers in their local region, offering support and direction in our budding careers. This can manifest in many ways, from expert advice on portfolio building to expanding our horizons, and helping us identify new opportunities for research, awards and clinical experience.

I contacted the RSA network as I struggled with the same issues as many of my peers: ambition and motivation coupled with a poor understanding of how best to channel it. Sadly, such knowledge isn’t well taught in a medical school curriculum, meaning we are left to find the answers ourselves.

So I reached out with a typical overly formal and pretentious medical student email to the Surgical Ambassador for Yorkshire & Humber. In truth, I wasn’t expecting much more than some generic, recycled advice. However, I promptly received a warm and understanding response from Mark Peter offering to discuss any questions I had over the phone.

On the back of just a few interactions, I had an entire summer elective placement organised, working alongside an incredible team in surgery – not even 15 minutes from my house. Better yet,

A fun montage from Huddersfield Royal Infirmary features the consultants who Thomas worked with during his elective. From left, consultants Mark Peter, Tamir Salih, Robert Adair, Brian Dobbins, William Ainslie and Arin Saha

I was given opportunities to expand my portfolio and access to an entire department of people who had been through or were going through the same process.

Being from Huddersfield, I had unfairly assumed that my hometown was no epicentre of medical expertise. As such, I was astonished to realise the outstanding level of care being delivered and to learn it was a national exemplar site of emergency surgical care.

Alongside encouraging my interests and expanding my clinical competency, Mark and his colleagues ensured that I developed an appreciation of the ins and outs of a career in surgery, making sure not to simply provide a showcase of the glamorous aspects of being a consultant on which most of us fixate.

This became one of the more insightful aspects of my experience, providing an understanding of surgery at every level, from junior doctor to consultant – an honest blueprint of what it takes to pursue such a career, highlighting the many personal and clinical challenges we

can expect to encounter.

Having someone within your intended position to contact is an invaluable resource of knowledge and support, particularly within a field as demanding and competitive as surgery. It is an immense comfort to have individuals with such prowess having genuine interest in your career, and offering their time and insight to help you along.

Engaging with the RSA network will enable you to nurture your surgical interests, become more aware of relevant opportunities and expand your network of mentors and influence. The more you engage with such individuals and services, the more your proclivity to do so will increase. From there your confidence, competency and accomplishments will compound, and you will accrue the attributes and expertise needed to propel you into your desired career.

Alongside the RSA network, the College has a broad array of resources available for Members to benefit from. From the RCSEd app you can access library services, innovative anatomy tools, a repository of webinars led by experts, along with information on upcoming courses, exams and a wealth of other opportunities.

See facing page for more information on the RSA Network

Having someone within your intended position to contact is an invaluable resource

Thomas Williams Fourth-year medical student, Hull York Medical School

REGIONAL AMBASSADORS IN YOUR AREA

The College’s support and advice network throughout the country

Jaiganesh Manickavasagam, Ninewells Hospital, Dundee

Andrew Martindale, Ninewells Hospital, Dundee

Stephen Jones, Ninewells Hospital, Dundee

NORTH 5 Malcolm Nicol, Raigmore Hospital, Inverness 6 Pragnesh Bhatt, Aberdeen Royal Infirmary, Aberdeen 6 Manoj Kumar, Aberdeen Royal Infirmary, Aberdeen

Bhaskar Ram, Aberdeen Royal Infirmary, Aberdeen

WEST 7 William Andrew Clement, South Glasgow University Hospitals, Glasgow 7 Maria Coats, Glasgow Royal Infirmary, Glasgow

SOUTH EAST 8 Robyn Webber, Victoria Hospital, Kirkcaldy

Peter Driscoll, Victoria Hospital, Kirkcaldy 1 Andrew Tambyraja, Royal Infirmary of Edinburgh

ENGLAND

EAST OF ENGLAND

9 Anita Balakrishnan, Cambridge University Hospitals, NHS Foundation Trust, Cambridge

10 Stuart Irving, Norfolk and Norwich University Hospital, Norwich 11 Roshan Lal, James Paget University Hospital NHS Trust, Great Yarmouth

EAST MIDLANDS

12 Hazem Khout, City Hospital, Nottingham 13 Paul Lee, Grantham and District Hospital, Grantham 14 Aravind Desi Syamarao, Diana, Princess of Wales Hospital, Grimsby

KENT, SURREY AND SUSSEX

15 Mike Williams, Eastbourne District General Hospital, Eastbourne

LONDON

16 Cynthia-Michelle Borg, University Hospital, Lewisham 16 Jihene El Kafsi, Frimley Park Hospital, Wexham

16 Nagarajan Muthialu, Great Ormond Street Hospital

16 Michael Saunders, The Royal Free London (NHS Foundation Trust)

MERSEY

17 Ravi Pydisetty, St Helens and Knowsley Teaching Hospitals NHS Trust, Whiston

18 Janardhan Rao, Countess of Chester Hospital, Chester 19 John Taylor, University Hospital, Aintree

NORTH WESTERN

20 Richard Graham, North Manchester General Hospital, Manchester 20 Aiman Khunda, Salford Royal Hospital, Manchester 20 Nadeem Khwaja, Wythenshawe Hospital, Manchester 20 Emma Stapleton, Manchester Royal Infirmary and Salford Royal Hospital, Manchester 21 Jayadeep Jayachandran Saraswathy, Cumberland Infirmary, Carlisle

NORTHERN 22 Paul Gallagher, Northumbria Healthcare NHS Foundation Trust 23 Sanjay Pandanoboyana, Newcastle Freeman Hospital, Newcastle upon Tyne

Alex Phillips, Royal Victoria Infirmary, Newcastle upon Tyne

Dan Saleh, Royal Victoria Infirmary, Newcastle upon Tyne 3 Peng Wong, James Cook Hospital, Middlesbrough 3 Sarah Healy, James Cook University Hospital, Middlesbrough

OXFORD

2 Giles Bond-Smith, Oxford University Hospitals NHS Trust, Oxford 2 Stephen Boyce, Oxford University Hospitals NHS Trust, Oxford

If you are interested in applying for a Regional Adviser role please email outreach@ rcsed.ac.uk

SEVERN

SOUTH EAST

WEST PENINSULA

WEST MIDLANDS

YORKSHIRE AND HUMBER

PARALLEL LIVES

In early September the RCSEd Younger Fellows (YF) Committee hosted the second YF Residential Forum entitled ‘The Surgeon as an Athlete: Perfecting Peak Performance in your Practice’. This two-day event was held at Ashorne Hill in Leamington Spa.

The theme was chosen to parallel the career of a professional athlete given the demands of the surgical profession on our physical and mental health, and the importance of taking care of ourselves to sustain the next 30 or more years of our careers.

We were joined by delegates from regions across the UK and internationally, the forum providing an informal atmosphere for networking and interaction.

We were privileged to be joined by Professor Michael Griffin, then President of the College, who immersed himself in the activities and discussions with great enthusiasm. He was eager to hear our views and concerns, and his participation clearly demonstrated his support for the YF group.

Pala Rajesh, then Vice-President of the College, and Mark Peter, previous Chair of the YF Committee, were also at the event, and it was fantastic to have in attendance Clare McNaught, founding member of the YF Committee and now College Vice-President, who continues to guide and encourage our committee with passion and energy.

The course began with an introduction from Nathan Stephens, Chair of the YF Committee.

The icebreaker asking people to name their dream location and perfect hobby threw up surprising answers – a

COACHING AND TEAMWORK

We are grateful for the excellent speakers who kindly gave up their time to share their knowledge and expertise with us. Our first speakers were Eilidh Gunn and Emma Howie, who delivered a session on surgical coaching,

College blog may document interpretive surgical art inspired by the Himalayas in coming years!

Sarah Healy and Nathan Stephens on The Surgeon as an Athlete forum, aimed at connecting and supporting Younger Fellows

Sarah Healy Consultant ENT H&N Surgeon, James Cook University Hospital, Middlesbrough; YF Co-Chair

Nathan Stephens Consultant Upper GI and General Surgeon, the Royal Liverpool University; Hospital YF Chair

gamification and sabermetrics. They are research fellows at the University of Edinburgh, and gave us a fascinating insight into the application of data and technology to improve surgical performance.

We then braved the outdoors for our Crystal Maze challenge, which put teamworking abilities to the test. Four teams did battle using technical skill and ingenuity to win crystals and earn time in the Crystal Dome. It was great to see everyone working together and having fun.

We rounded off the first day with a talk from Professor Griffin, who highlighted the many College activities and his commitment to ‘Making it Better’ for us all.

An evening of food and drink at the venue gave everyone the opportunity to relax and explore themes from the day. It was reassuring to learn that concerns are often shared across the group, and encouraging to see people supporting each other.

PSYCHOLOGY INSIGHT

The second day began with a yoga session to reset our minds and bodies. Dr Amanda Martindale, chartered psychologist at the British Psychological Society and senior lecturer in Sport and Performance Psychology at the University of Edinburgh, was Friday’s opening speaker. She has provided support to high-level athletes, having been a member of the Scotland Team support staff at the 2006

Commonwealth Games and prepared athletes for World Championships and the Olympic Games. Her talk showed the parallels between the demands and pressures of a professional sporting event and performing a major surgical case. The resources available to prepare an elite athlete are very different to those in the NHS, but her strategies for psychological preparation and visualisation are transferable to surgical practice.

Clockwise from top left: The teams line up at the start of the Crystal Maze challenge; delegates for the second YF residential forum get down to business; the blue team do battle in the Crystal Dome; Professor Michael Griffin showing us how it’s done, supervised by Pala Rajesh

developing processes within a medical context. Razak’s expertise is multifaceted; she has a PhD in Healthcare Human Factors and Ergonomics, and a clinical background in mental healthcare.

OPTIMAL PERFORMANCE

We closed the forum with a speaker who epitomised our theme. Gary Lambert is a consultant vascular and endovascular surgeon with experience of delivering vascular trauma cover to a Level 1 major trauma centre. He is also an international highperformance sports coach. For the past four years he has coached the England Touch (rugby) Senior Women’s Squad to consecutive unbeaten European Championship gold medals and, in 2019, to the World Cup bronze medal. His talk gave insight into coaching at an elite level, with a focus on guiding the team to achieve a shared goal and the importance of supporting one another.

The pre-lunchtime talk, aptly entitled ‘Preparing for practice: nutrition and diet for the surgeon’, was delivered by Karen Ward from Meraki Nutrition. Ward is a registered nutritionist and nutritional therapist, who designs personalised health plans for professionals to suit all lifestyles.

She acknowledged some of the challenges we face in trying to get healthy food in work and out of hours, and why we reach for sugary snacks to keep us going on long shifts. She gave us some practical solutions and even some recipes for healthy snacks on the go. We then had an enlightening Q&A session to dispel some of the myths around current food trends and diet crazes.

Saydia Razak delivered a talk on working in complex systems, focusing on her research into the development of higher tactical analysis as a tool to break these systems down into manageable tasks. This illustrated a way of

Lambert’s interest in measuring performance and using data to improve outcomes was thoughtprovoking and echoed the opening talk of the conference. He is a prime example of how leadership skills, ergonomics and high-performance psychology gleaned from the world of professional sport can be applied to clinical practice to optimise our performance as surgeons.

We would like to thank the College for funding the event, and to Professor Griffin and Clare McNaught in particular for their support and participation.

We are grateful to all of the delegates for contributing and making it such a fun and successful couple of days. Finally, the event would not have been possible without the dedication and hard work of Una Curran in the College Communications department.

The next YF Residential Forum is in the planning stages for 2024. We encourage you all to get involved.

Get involved

The Younger Fellows’ Group is a support network for senior trainees and younger consultants, which also provides feedback to the College Council. More details at bit.ly/YoungerFellows

The resources available to prepare an elite athlete are very different to those in the NHS, but the strategies are transferable to surgical practice

Forging ahead

Celebrations for the 40th Anniversary of the founding of the Faculty of Dental Surgery are complete and we must now look forward to the next 40 years. The three days of dental meetings were well attended and feedback has been very positive.

The first day featured the annual meeting of the Faculty of Dental Trainers (FDT), which was a rich combination of lectures and discussions on the role of online teaching in modern pedagogy.

Speakers considered the role and efficacy of webinars in effective training and where blended learning might be a better option for some learners. The perennial question of how much you can trust online content and where you might look for reassurance of accuracy against the argument of why we should change from familiar didactic teaching approaches formed the next section of the day.

This was followed by an update on what the FDT has been doing over the last year. The afternoon was a triple header on robotics and simulation, followed by a lively debate on teaching in undergraduate hospitals.

On the second day we welcomed our Dental Ambassadors from the

UK and around the world to discuss the thorny but important and contemporaneous subject of sustainability in dentistry. After an introduction from the local team in Edinburgh we heard about how we can introduce a more sustainable way of working without compromising high-quality, cross-infection control postCOVID-19. We truly need to address this problem, as dentistry is one of the worst offenders in the use of disposables in all surgical practice.

KING JAMES IV LECTURES

At the end of each day we were treated to the inaugural lectures of our King James IV professors and, because of the delays caused by the pandemic, we had three incumbents. Professor Barry Quinn from the University of Liverpool presented his lecture, ‘Can we simulate dental surgery in virtual worlds and how real does the simulation have to be?’, which investigated how haptics can change the way we train dentists, from undergraduate to specialist level.

Professor Douglas Peterson from Connecticut gave an inspiring lecture on his work on managing orofacial pain postorofacial cancer entitled

Above and above right: Tim O’Brien and Philip Taylor visit Saveetha Dental College

Below: Dental Dean Philip Taylor

‘Dental management of the oncology patient: translating research into clinical practice and improved patient care’.

Gerry McKenna from Queen’s University Belfast completed the triple bill with an excellent demonstration of how ‘Rethinking oral care for older adults’ is so important in an increasingly ageing global population.

If all that was not enough we entertained 118 colleagues and College staff at a gala dinner in Playfair Hall, where we enjoyed the sounds of a piper and the conviviality of fellowship that only our College can provide.

The Faculty must thank Linda Wilson, Cire Grimmer, Craig Brodie and Alison Amin for their hard work in putting all this together.

CHENNAI CONFERENCE

Two weeks later the Dental Faculty was in Chennai, India, at the first RCSEd International Conference. The FDT was very much a part of the dental presence, and the two dental Faculties worked seamlessly to present a united message of dental excellence.

Presentations from our Convenor of Dental Examinations, Tim O’Brien, FDT Director Sarah Manton and myself were anchored by our two keynote

Philip Taylor reflects on the success of recent Faculty events and activities that create a pathway for the next 40 years

We were able to cement close relationships with new colleagues from two universities in Chennai

speakers, Shakeel Shahdad and Barry Quinn. The audience was most appreciative of the opportunity to meet with the Faculty and we were able to cement close relationships with new colleagues from two universities in Chennai with exciting prospects for future collaborations in India.

As ever with these conferences, the opportunity to network was as important as the programme content, and the dental team made the most of this with new opportunities in Malaysia and in Malta for exam centres.

We also visited a leading Indian dental school, Saveetha Dental College, where we were shown the fantastic clinical and research facilities on offer to students there.

We had the opportunity to meet both in India and later online at a

follow-up meeting with a recent Honorary Fellow of the Faculty, Professor Gopi Krishna, who was able to help us understand in more detail the way specialist dentistry operates in India.

BACK TO BAHRAIN

Only a week after returning to Edinburgh from Chennai – to attend College Council – the Faculty travelled to Bahrain to catch up with our colleagues there. We met officials from the Ministry of Health and private practitioners, and observed the MAGDS examination being held. We have had a long-standing cooperation

Below: The Faculty travelled to Bahrain to present its examination porfolio and meet with colleagues

with Bahrain and this visit served to cement this further.

We were able to see the facilities in both private hospitals and in government-run sites, which were very impressive. Most importantly we secured a new letter of understanding between the Ministry of Health and the College, which shows our commitment to working in Bahrain.

We discussed potential plans for holding our examinations in the country and encouraged the trainers from all sectors to consider using our accreditation system to validate their courses.

We presented the Minister of Health, Her Excellency Dr Jaleela bint Alsayed Jawad Hasan, with our portfolio of examinations, and there was considerable interest in the new suite of diploma examinations, with

We saw fantastic clinical and research facilities

a future opportunity to consider holding the specialty examinations in Bahrain.

MALTA MEET

At the time of writing I have been invited to present in Malta in mid-November at an international conference in the country. This opens up a new opportunity to work with Malta’s Minister of Health, Christopher Fearne, to discuss a new collaboration and possible examination centre. I hope to be able to report further in future editions of Surgeons’ News

EDUCATION CONVENOR

As I mentioned in the last issue, some new faces were appointed to the Dental Executive as terms of office came to an end. I am delighted to announce that Lochana Nanayakkara has been appointed to the position of Education Convenor.

Nanayakkara works at Barts and The London Dental Hospital in Restorative Dentistry and she has been the Deputy Lead for Education at Barts NHS Trust – the largest NHS Trust in the UK – for several years. She has a wide experience of training from DCT to Consultant level. Her record includes a 100% consultant (64 consultants)

buy-in for Educational Supervisor training and revalidation, which is no mean feat.

The role will be an open book for her as we look again at our education delivery from scratch in the light of post-COVID-19 requirements and detailed discussions with our partners overseas. We also hope to create a closer working relationship with our sister Faculty, the FDT.

The demitting Convenor, Richard Cure, will continue to manage the Accreditation portfolio, which is already a very popular move, with interest from all over the world. We will be looking to train new assessors for this process in the coming months so look out for the opportunity to make a difference to training the world over.

LOOKING AHEAD

As you can see the Faculty has been very busy in the last few months. Beyond all the travel, we have been negotiating with the General Dental Council (GDC) regarding mediated

entry, which has become a very sensitive subject.

If you’ve been waiting for progress in this respect, or have colleagues asking you what has happened, it is true that we have decided on behalf of the four Royal Colleges to temporarily stop the process at the level of Specialty Advisory Committee (SAC) advice.

This was for two reasons. First, if the SAC says the applicant is not suitable for admission, they can reapply. That application, surprisingly, does not go back to the SAC, but is looked at in a ‘court’ held by the GDC with no specialists in the room. This seems to be causing issues with ‘unsuitable people’ being admitted to the list.

Second, there are issues about the SAC members spending inordinate amounts of their personal time reviewing applications without being remunerated. We, as Royal Colleges, do not feel this is fair to the applicant or for the esteem of the specialty itself.

We are an integral part of the new GDC-led specialty reviews, as we will be leading on the necessary summative assessment that will link to that training. This is now very advanced and there will be more detail about the changes published in the next few months.

You can be reassured that your team is working on your behalf to ensure the RCSEd’s voice is heard across the world.

Right (from left): RCSEd Immediate Past President Mike Griffin, Susan Taylor, Immediate Past Honorary Treasurer Alistair Gibson, Dental Dean Philip Taylor and new Vice-President Clare McNaught at the gala dinner in Edinburgh

Professor Philip Taylor Dean, Faculty of Dental Surgery

Wehavebeennegotiatingwith theGDCregardingmediated entry–asensitivesubject

A toast to 40 successful years

This year the Royal College of Surgeons of Edinburgh celebrated the 40th anniversary of the founding of the Faculty of Dental Surgery with an evening event for honoured guests.

They included people from across the dental world who mingled with former Deans, College staff and Dental Council members past and present. This event was followed on 23 September by the first Dental-only diploma ceremony and diplomates’ reception. Our thanks to everyone who has been a part of our journey over the last four decades. We would also like to raise a glass to those who have worked hard all year to deliver the range of special anniversary events and activities.

As the Dental Faculty’s 40th anniversary year draws to a close we share some highlights from the celebrations in September

Clockwise from top left: Professor Rowan Parks, Professor Gopi Krishna and Professor Philip Taylor; the Dental Council; Philip with Gopi and Lakshmi Krishna; Professor Chooi Gate, right, winner of the International Medal; Fleur Stoops, Trainee Representative on Council; attendees networking; Carole Boyle and Greville Waterman; Rowan and Philip with Sarah Manton, FDT Director; the evening provided opportunities for mingling; centre, left, Chooi Gate with Rowan and Philip; right, all smiles for a very successful evening

ROOT CAUSES

King James IV of Scotland, who confirmed this College’s Seal of Cause in 1506, had an interest in all matters scientific, including medicine and surgery, and was particularly proud of his skill as a dental surgeon, adopting the unusual practice of paying patients on whom he operated.

To mark the millennium, the RCSEd, with the Faculty of Dental Surgery, proposed that lectureships be awarded annually in open competition to practitioners of surgery or dental surgery who have made a significant contribution to the clinical or scientific basis of surgery. Her Majesty Queen Elizabeth II gave permission for the College to use the title King James IV Professorship.

They are the most senior academic awards made by the College and are intended to recognise a substantial body of work by an individual not less than five years from substantive appointment as a consultant or an equivalent position. The courtesy title of Professor is given to King James IV lecturers for the duration of the College year in which their lecture is delivered.

This year’s lectures took place at the College during September and featured three thought-provoking themes. Gerry McKenna, who reprises his lecture here, discussed preventative and operative care for caries in older adults. Barry Quinn considered the rise of simulated dental practice, while the dental management of oncology patients was the subject of Douglas Peterson’s lecture.

LECTURE 1

RETHINKING ORAL CARE FOR OLDER ADULTS

Significant changes in the oral health of older adults have given rise to a partially dentate ageing population. While increasing levels of natural tooth retention is a very positive development, it now presents the challenge of managing chronic dental diseases, particularly caries, into old age. As with younger generations, caries management should follow the principles of minimal intervention in older adults, with a strong emphasis on prevention. Studies have successfully demonstrated that atraumatic restorative treatment can be successfully utilised in this patient group, including for those patients living in nursing homes1

Given patients’ dislike of removable dentures, their biological cost and high levels of non-compliance, other treatment options should be

considered when planning tooth replacement for partially dentate older patients. The use of resin-bonded bridgework to restore patients to a shortened dental arch (SDA) has been shown to significantly improve patient satisfaction.

In a randomised controlled clinical trial, patients were restored to an SDA using resin-bonded bridges. Patients reported significant improvements in oral health-related quality of life compared with those provided with removable dentures2. This study also demonstrated that provision and maintenance of an SDA for partially dentate older patients was significantly more cost-effective than partial dentures3 Patients expressed their strong preference for SDA treatment through qualitative interviews and also in their maximum recorded willingness to pay for the treatment4

Poor oral health and loss of natural teeth can impact on the quality of life

Philip Taylor introduces the King James IV Professorships, while Gerry McKenna gives an overview of his inaugural lecture

The use of resinbonded bridgework to restore patients to an SDA improves patient satisfaction

Gerry McKenna Clinical Professor and Consultant in Restorative Dentistry, Queen’s University Belfast School of Medicine, Dentistry and Biomedical Sciences

of older people, as well as their systemic health, diet and nutrition. While prosthodontic rehabilitation has been shown to improve masticatory ability in partially dentate older patients, this does not translate to improvements in nutritional status.

These findings demonstrate the need for dietary intervention alongside tooth restoration to improve nutritional status in older adults. One successful approach to changing food behaviours in the long term is that of habit formation.

In order to test this approach in partially dentate older adults, a randomised controlled clinical trial was developed. This work demonstrated that through development of automaticity, a tailored dietary intervention coupled with prosthodontic rehabilitation improved older adults’ consumption of three targeted food groups: fruit and vegetables, wholegrains and healthy proteins. These improvements were demonstrated at six weeks, four months and eight months after treatment intervention5

LECTURE 2

CAN WE SIMULATE DENTAL SURGERY IN VIRTUAL WORLDS AND HOW REAL DOES THE SIMULATION HAVE TO BE?

Modern-day dentistry requires our students to gain high levels of manual dexterity and excellent eye-to-hand control. Lord Darzi once stated: “Never first time on a patient.” Today it is essential that students are safe to practise before treating their first patients.

Barry Quinn described how simulated practice and the technology itself is rapidly moving forward, with students now being taught in immersive environments that are haptically enabled.

These developments provide the opportunity for scanning patients, haptically rendering the images for surgery rehearsal before the student operates on the real patient. This lecture reviewed the new haptically enabled simulators, but also posed the question ‘how real does the simulation have to be?’

At the University of Liverpool, Quinn leads the integrated teaching of restorative dentistry for the interprofessional education of dental and dental therapy students.

Douglas Peterson’s lecture highlighted the value of high-quality researchbased guidelines in clinical interprofessional oncology practice. He provided a summary of the process leading to creation, dissemination and utilisation by healthcare professionals, and described the impact of guidelines on clinical outcomes and the relationship with enhanced financial outcomes. He emphasised the importance of dental professionals in contributing to the guideline process when caring for oncology patients.

Peterson’s primary academic and clinical responsibilities throughout his career have been directed at oral management of the medically complex patient, with an emphasis on oral complications in oncology patients.

Lecture 1 references

1. DaMata C, McKenna G, Anweigi L, Hayes M, Cronin M, Woods N, O’Mahony D, Allen PF. An RCT of atraumatic restorative treatment for older adults: 5 year results.

J Dent 2019; 83: 95–99.

2. McKenna G, Allen PF, O’Mahony D, Cronin M, DaMata C, Woods N. The impact of rehabilitation using removable partial dentures and functionally orientated treatment on oral health-related quality of life: a randomised controlled clinical trial.

J Dent 2015; 43: 66–71.

3. McKenna G, Allen PF, Woods N, O’Mahony D, Cronin M, DaMata C, Normand C. Cost-effectiveness of tooth replacement strategies for partially dentate elderly: a randomised controlled clinical trial. Community Dent Oral Epidemiol 2014; 42: 366–374.

4. McKenna G, Tada S, Woods N, Hayes M, DaMata C, Allen PF. Tooth

replacement for partially dentate elders: a willingness-to-pay analysis.

J Dent 2016; 53: 51–56.

5. McCrum LA, Watson S, McGowan L, McGuinness B, Cardwell CR, Clarke M, Woodside JV, McKenna G. Development and feasibility of a tailored habit-based dietary intervention coupled with oral rehabilitation on the nutritional status of older patients. Pilot Feasibility Stud 2020; 24: 120.

Barry Quinn Chair in Restorative Dentistry and Dental Education, Academic Lead and Head for Restorative Dentistry, School of Dentistry, University of Liverpool

Douglas Peterson Professor, Oral Medicine, School of Dental Medicine, UConn Health, Connecticut, US

AWARDS & GRANTS

Tuanku Muhriz Fellowship in Rural Surgery

The Fellowship provides funding for travel to Malaysia to gain further experience and training in rural surgery. Applications are open to Fellows and Members of the Faculty of Dental Surgery of the College in good standing. Applicants will be one of the following: Surgeons who are higher surgical trainees who have not yet attained consultant grade. Trainee general surgeons, around the time of their appointment to a consultant post, to enable them to study in centres with particular expertise relating to rural surgery.

Surgeons making short visits to learn new surgical techniques or to work in centres developing a rural surgery service. Up to £2,000 may be awarded to cover travel costs related to the Fellowship.

The closing date for applications is Wednesday 1 February 2023

Bursaries for Affiliate Medical Student Elective Placements in Africa

The RCSEd is offering a number of bursaries for elective placements in Africa. The elective need not necessarily be in a surgical-specific unit, but

priority may be given to students demonstrating an interest in surgery. The bursary will comprise a single payment that can be used towards travel and accommodation costs, or other expenses involved with the placement such as vaccinations and visas. The bursary will be up to £500 for each award. The award is open to medical students enrolled at UK universities undertaking approved surgical electives abroad. Students must be affiliates of the RCSEd in good standing.

The closing date for applications is Thursday 12 January 2023

Fellowship in Dental Education and Clinical Experience

This Fellowship provides funding for travel to the United Kingdom from Malaysia to gain further training in dental education and clinical experience. Up to £2,000 may be awarded to cover travel costs related to the Fellowship. Applications are open to Fellows and Members of the Faculty of Dental Surgery of the College, in good standing. Applicants must be based, or have trained, in Malaysia. Applicants will be one of the following: Trainee dental surgeons, around the time of their appointment to a consultant post, to enable them to study in centres with particular expertise relating to dental education and clinical experience.

Dental surgeons making short visits to learn new techniques, or to work in centres developing a dental education and clinical experience service.

Dental surgeons who are higher surgical trainees and who have not yet attained consultant grade.

Those dentists whose specialty is linked with the specialist lists recognised by the General Dental Council of the UK.

The closing date for applications is Friday 13 January 2023

Ethicon Foundation Fund Travel

This grant provides a contribution towards international travel costs to further enhance a specialty skill or experience that is not normally available in the applicant’s own hospital for a period of between six weeks and 12 months (although visits of up to 24 months may be considered). The grant is intended to cover the cost of one economy-class return journey up to a value of £1,000.

Applications are invited from Fellows or Members of the College in good standing. Successful applicants will normally be Fellows or

Members in training-grade appointments, but more senior applications may be considered.

The closing date for applications is Wednesday 25 January 2023

RCSEd/Binks Trust Medical Student Elective Travel

The RRCSEd, in association with the Binks Trust, offers medical students an opportunity to apply for financial support towards their elective abroad in surgery. The bursary will be up to £250 for each award. The award is open to medical students in the UK and the Republic of Ireland undertaking approved surgical electives abroad. Students must be affiliates of the College in good standing.

The closing date for applications is Wednesday 25 January 2023

Bursaries for Undergraduate Elective or Vacation Studies

The College is offering bursaries to undergraduate students of medicine or dentistry to enable them to work for elective or vacation periods in universities, medical schools, NHS laboratories or research institutes in the UK. Research projects in any branch of surgery are eligible for consideration.

The bursary will be up to £150 per week for a maximum of eight weeks. Up to £300 is also available for consumables. Preference will be given to applications sponsored by a Member/

Fellow of the College, but quality of project and applicant shall be the overriding consideration. Students must be affiliates of the College.

The closing date for applications is Wednesday 15 March 2023

Saleem Khwaja Memorial Fellowship in Paediatric Surgery

Saleem Khwaja was a professor of paediatric surgery who worked in the UK, Africa and the Middle East. He contributed widely to the specialty, particularly neonatal surgery and children’s surgery in the tropics. The Fellowship was established in recognition of his commitment to teaching, research and education. The Fellowship provides funding for travel abroad to gain further education and training, or to offer charitable service to another centre in support of skills development. Up to £5,000 may be awarded to cover costs related to travel and accommodation. Applications are invited from higher surgical trainees or junior consultants who are Members or Fellows of the College in good standing.

The closing date for applications is Wednesday 22 March 2023

Cardiothoracic Surgery Medical Student Elective Travel Awards

The Royal College of Surgeons of Edinburgh is pleased to offer medical students an opportunity to apply for financial support towards their elective in cardiothoracic surgery. The award provides a contribution towards the overall costs of travel and subsistence. The bursary will be up to £500 for each award. The award is open to medical students in the UK and the Republic of Ireland undertaking approved surgical electives abroad. Students must be affiliates of the Royal College of Surgeons of Edinburgh in good standing.

The closing date for applications is Wednesday 12 April 2023

The Dundas Medal

The medal is in commemoration of Dr Charles Robert Dundas FFARCS FRCP Glasgow, a senior lecturer in the Department of Surgery (Anaesthetics in Aberdeen and honorary consultant anaesthetist from 1975 to 1995).

An annual award recognises efforts to improve the provision of palliative care for patients when they are in hospital. The award is open

to individuals or teams (medical, nursing or paramedical) working in any hospital in the United Kingdom. It is not essential that the applicant should be an FRCSEd. The term hospital applies to both acute and community hospitals. This award does not provide any funding. However, awardees are invited to a diploma ceremony where they are presented with the Dundas Medal and Dundas Medal Certificate.

The closing date for applications is Wednesday 12 April 2023

DIPLOMA LISTINGS

Congratulations to all our Fellows and Members who were presented with diplomas and awards in Edinburgh in July and September

FRIDAY 8 JULY 2022, ROYAL COLLEGE OF SURGEONS OF EDINBURGH

Admission to Fellowship ad hominem

Professor Peter Bjorn Licht, MD PhD, Clinical Professor in General Thoracic Surgery, Southern Danish University, Denmark

Dr Hadi Seikaly, MD, MA Leadership, FRCSC, Professor of Surgery and Oncology; Divisional Director Otolaryngology Head and Neck Surgery, University of Alberta, Canada

Presentation of the College Medal

Mr Simon Paterson-Brown, FRCSEd FFSTEd, Honorary Senior Lecturer, Department of Surgery, University of Edinburgh

Fellowship in Surgery (Without Examination)

Professor Bindey Kumar, Head of Department of Paediatric Surgery, All India Institute of Medical Sciences, Patna, India

Diplomas of Fellowship in the Specialty of General Surgery

Muthana Hanon Haroon, University of Baghdad, Iraq

Adithya Malolan Pathanki, Manipal University, India

Diplomas of Fellowship in the Specialty of Ophthalmology

Ahmed Mamdouh El Shafei, Cairo University, Egypt

Ghazanfar Ullah Mahmood, University of Latvia

Diploma of Fellowship in the Specialty of Oral and Maxillofacial Surgery

Juergen Schlabe, Heidelberg University, Germany

Diplomas of Fellowship in the Specialty of Plastic Surgery

Mahalakshmi Ishwar, Rajiv Gandhi University of Health Sciences, India

Lucie J Wright, University of Edinburgh

Diplomas of Fellowship in the Specialty of Urology

Rickaz Abdul Raheem, University of Sri Jayewardenepura, Sri Lanka

Rotimi David, University of Ilorin, Nigeria

Diplomas of Joint Surgical Colleges’ Fellowship in Trauma & Orthopaedic Surgery

Mohammad Omairul Haque Israr, Lalit Narayan Mithila University, India

Simret Singh Randhawa, National University of Ireland

Intercollegiate Diplomas of Membership in Ophthalmology

Alaadin Abdin, University of Damascus, Syria

Maamoun Salah Al Hariri, Cairo University, Egypt

Muhammad Zaka Ullah Khan, Bahria University, Pakistan

Haitham Abdulhafez Moued, Vinnista National Medical University, Ukraine

Lubna Salameh, University of Jordan Abhishek Sheemar, All India Institute of Medical Sciences, India

Intercollegiate Diploma of Membership in Otolaryngology

Valerie Yujin Kim, University of Dundee

Intercollegiate Diplomas of Membership in Surgery in General

Amgad Abdelhadi Elhag Abdalla, International University of Africa, Sudan

Saurabh Daga, West Bengal University of Health Sciences, India

Joseph Galea, University of Malta

Rehan Gamage, University of Colombo, Sri Lanka Rosalyn Hawkins, University of Aberdeen Ananthamoorthy Krishnamoorrhy, University of Jaffna, Sri Lanka

Anubhav Malhotra, Panjab University, India Sinthuja Naguleswaran, University of Manchester

Mohammad Zeeshan Nasser, Dow University of Health Sciences, Pakistan

Zeeshan Khan Nazim, University of Peshawar, Pakistan

Christina Shoba Rajamanickam, Monash University, Australia

Devarakonda Sreekar, Dr MGR Medical University, India

Thomas Robert William Ward, University of Liverpool

Diploma of Membership of the International Postgraduate Deanery

Ali Mohammad, Arabian Gulf University, Bahrain

The George Gray Youngson Medal 2021/22 Awarded to the highest-placed graduate for the MSc in Patient Safety and Clinical Human Factors in an academic year.

Suzanne Creed, University of Edinburgh

Diplomas of Fellowship in Dental Surgery (Without Examination – By Application)

Noorul Wahab, Liaquat University of Medical Health Sciences, Pakistan

Afeef Umar Zia, University of Health Sciences Lahore, Pakistan

Diploma of Fellowship of the Faculty of Dental Trainers

Afeef Umar Zia, University of Health Sciences, Lahore, Pakistan

Diplomas of Membership in Endodontics

Eilaf Alsaleh, Kuwait University

Mohammadreza Ranjbari, Shahid Beheshti University, Iran

Diplomas of Membership in Orthodontics

Marwa Jameel Ahmed Salman Ahmed, Ajman University, United Arab Emirates

Heba Elsayed Kamel Akl, Cairo University, Egypt

Mohamed Hasab Elrasoul Ali, National Ribat University, Sudan

Hamad Adel Alsaleh, University of Dammam Saudi Arabia

GayaththiriI Anandasayanan, University of Peradeniya, Sri Lanka

Budoor Bin Bahar, University of Sharjah, United Arab Emirates

Siddhartha Brijwani, Manipal University, India

Dalia Ahmed Fathy Abdelghani Emara, University of Sharjah, United Arab Emirates

Sven William Christian Jensen, University of Adelaide, Australia

Diploma of Membership in Paediatric Dentistry

Wei Xi Tan, Padjadjaran University, Indonesia

Diplomas of Membership in Prosthodontics

Murtadha Abdulmohsen Al Ali, University of Birmingham

Diplomas of Membership of the Faculty of Dental Surgery

Mohamed Ahmed Almoselli, Ajman University, United Arab Emirates

Sandra Wagdi Bebawi, Cairo University, Egypt

Ziad Khan, Khyber Medical University, Pakistan

Hussam Ashraf Mahmoud Okba, Misr University for Science and Technology, Egypt

Wei Xi Tan, Padjadjaran University, Indonesia

Matthew Chi Hong Yii, University of Dundee

Diplomas in Orthodontic Therapy

Julia Anne Dixon, King’s College London

Kelly Anna Grant, University of Bristol Dental School

Samantha Louise Harrison, University of Bristol Dental School

Courtney Stagg, University of Bristol Dental School

Cara Sadie Whitehouse, University of Bristol Dental School

The John McDonald Medal

Awarded to the most meritorious candidate from all international diets of the Membership in Orthodontics Examination.

2019: Heba Elsayed Kamel Akl, Cairo University, Egypt

2021: Siddhartha Brijwani, Manipal University, India

FRIDAY 2 SEPTEMBER 2022, ROYAL COLLEGE OF SURGEONS OF EDINBURGH Installation to the Court of Regents

Rt Hon Professor the Lord Kakkar, KBE, PC, FRCSEng FRCP FRCSEd FMedSci FKC, Emeritus Professor of Surgery, University College London; President of the Thrombosis Research Institute

Award of Honorary Fellowship

Professor Jacqueline Taylor, MB ChB, FRCP(Glasg) Hon FRCPI, Hon FFPHM, DSc, Hon FCSSL, Hon FRCS Eng, Consultant Physician; Associate Medical Director NHS Scotland Academy

Admission to Fellowship ad hominem

Mr Richard E Perry FRACS, Chair, Intus Group, New Zealand; Consultant Colorectal Surgeon, Intus Digestive and Colorectal Care; Visiting Colorectal Surgeon, St Georges Hospital, Christchurch; Visiting Colorectal Surgeon, Southern Cross Hospital, Christchurch, New Zealand

Professor Martin D Smith, Professor and Chair, Department of Surgery, University of the Witwatersrand, Johannesburg; Chief Surgeon and Head of the Department of Surgery, Head of HPB Unit, Chris Hani Baragwanath Hospital, University of the Witwatersrand, Johannesburg, South Africa

Award of Fellowship in Surgery (Without Examination)

George M Kushner DMD, MD, Professor and Chairman of Oral and Maxillofacial Surgery, University of Louisville, US

Mr Nikolaos Tsapralis, Consultant Plastic Surgeon, Ziekenhuis Gelderse Vallei, the Netherlands

Diplomas of Fellowship in the Specialty of General Surgery

Goran Ameer Ahmed, University of Sulaimani, Iraq

Ananthakrishnan Madhavan, University of Manchester

Diploma of Fellowship in the Specialty of Neurosurgery

Swati Jain, Duke-National University of Singapore

Diplomas of Fellowship in the Specialty of Trauma and Orthopaedic Surgery

Oisin John Francis Keenan, University of Manchester

Vijai Varun Mahabir, University of the West Indies Abubakar Mohammad Mustafa, University of Dhaka, Bangladesh

Diploma of Joint Surgical Colleges’ Fellowship in Trauma and Orthopaedic Surgery

Munzir Izzeldin Abdelraouf Abbasher Gaboura, University of Gezira, Sudan

Diploma of Joint Surgical Colleges’ Fellowship in Urology

Kalyan Gudaru, Manipal University, India

Diploma of Fellowship in the Specialty of Vascular Surgery

Olivia Margaret Boulton McBride, University of Edinburgh

Diploma of Fellowship of the Faculty of Surgical Trainers

Suddhajit Sen, University of Calcutta, India

Intercollegiate Diplomas of Membership in Ophthalmology

Hayder Sabah Jasim Al-Rubaye, University of Baghdad, Iraq

Hend Salah El-Din Amer, October 6 University, Egypt

Rohit Sanjay Laul, Maharashtra University of Health Sciences, India

Intercollegiate Diploma of Membership in Otolaryngology

Rachel Jayne Scurrah, Newcastle University

Intercollegiate Diplomas of Membership in Surgery in General

Alexander James Baldwin, University of Birmingham

Karishma Chandarana, University of East Anglia

Ha Phuong Do Le, University of Manchester

Sarah Jane Hardwick, Imperial College London

Mohammad Hasan, University of the Punjab, Pakistan

Ukoha Agwu Kalu, University of Nigeria

Ihsan Ullah Khan, Khyber Medical University, Pakistan

Deng Atwan Ater Ngoth, University of Juba, Sudan Megan Scotcher, University of Leicester

Matthew James Stone, University of Oxford

Muhammad Yasir Tarar, Services Institute of Medical Sciences, Pakistan

Postgraduate Certificate in Remote and Offshore Medicine

Jane Orrock, University of Pretoria, South Africa

Diploma of Fellowship in Dental Surgery (Without Examination – By Application)

Uzair Luqman, National University of Sciences and Technology, Pakistan

Diploma of Fellowship in the Specialty of Oral Medicine

Emma Josephine Hayes, University of Oxford

Diplomas of Membership in Orthodontics

Shatha R Abdulkader Al Khalidy, Ajman University, United Arab Emirates

Ler Chong, Asian Institute of Medical, Science and Technology, Malaysia

Lydia Suk Jing Lim, Asian Institute of Medical, Science and Technology, Malaysia

Kanwal Zulfiqar, University of Peshawar, Pakistan

Diploma of Membership in Primary Dental Care

Noor-E Tabassum Islam, University of London

Diplomas of Membership in Prosthodontics

Balqees Azzam Hamad Almomen, University of Dundee

Paul Guerino Cocozza, University of Glasgow

Deepesh Patel, University of London

Diplomas of Membership of the Faculty of Dental Surgery

Nur Afiqah Binti Abdul Rahman, MARA University of Technology, Malaysia

Nur Adlina Diyana Binti Md Ismail, Padjadjaran University, Indonesia

Lydia Suk Jing Lim, Asian Institute of Medical, Science and Technology, Malaysia

Mariham Nader Shafik Samy, October 6 University, Egypt

Gillian Claire Wardrope, University of Aberdeen Maleeha Zahoor, University of Health Sciences Lahore, Pakistan

Diploma in Implant Dentistry

Simon Anthony Clavell Bate, University of Sheffield

Diploma in Special Care Dentistry

Saifullah Khan, University of Karachi, Pakistan

Diplomas in Orthodontic Therapy

Elizabeth Temilade Ikuesan, University of Bristol Dental Hospital

Sophie Ce-Ting Loo, University of Central Lancashire

Donna Mooney, University of Central Lancashire Sushila Kumari Pun Gurung, University of Bristol Dental Hospital

FRIDAY 23 SEPTEMBER 2022, ROYAL COLLEGE OF SURGEONS OF EDINBURGH

Admission to Fellowship in Dental Surgery ad hominem

Professor Velayutham Gopikrishna, MDS, PhD, Adjunct Professor, Sri Ramachandra Dental College & Hospital, Sri Ramachandra Institute of Higher Education and Research, Chennai, India

Award of the Dental Faculty International Medal for 2022

Professor Toh Chooi Gait, BDS Hons, MSc, FDSRCPS (Glasgow), FDS RCSEd, FFDTEd, Professor of Restorative Dentistry, International Medical University, Kuala Lumpur, Malaysia

Award of the Dental Faculty Medal for 2022

Dr Sarah Lennox Manton, BDS(Edin), PhD, FDS RCSEd, FHEA, FDTFEd, Director, Faculty of Dental Trainers, RCSEd; Chair, BNF Dental Advisory Group, British Pharmaceutical Society

Diplomas of Fellowship in Dental Surgery (Without Examination – By Application)

Leena Al-Sheerawi, Cairo University, Egypt

Lochana Nanayakkara, University of London Gurdeep Singh, Baba Farid University of Health Sciences, Faridkot, India

Diploma of Fellowship in the Specialty of Orthodontics

Christopher David Donaldson, University of London

Diploma of Fellowship in the Specialty of Restorative Dentistry

Rajesh Kumar Dubal, University of London

Diplomas of Fellowship of the Faculty of Dental Trainers

Stephen James Bonsor, University of Edinburgh

Peter Vincent Fowler, University of Otago, New Zealand Toh Chooi Gait, National University of Singapore

Diplomas of Membership in Endodontics

Thomas Marc Friend, Cardiff University

Sally Brigid McCarthy, National University of Ireland

Diploma of Membership in Oral and Maxillofacial Surgery

Senthil Moorthy Murugesan, Tamil Nadu Dr. M.G.R. Medical University, India

Diplomas of Membership in Orthodontics

Nourhan Adel Mohamed Elsayed Ahmed, Alexandria University, Egypt

Mohammed Khalid Al Ahmed, University of Aleppo, Syria

Tita Chiwasuchin, Chulalongkorn University, Thailand

Ahmed Hosni Elkhadem, Cairo University, Egypt

Meeral Makwana, University of London

Chidchanok Sessirisombat, Srinakharinwirot University, Thailand

Xu Zhang, Kunming Medical University, China

Diplomas of Membership in Paediatric Dentistry

Noora Ali Aburahima, University of Sharjah, United Arab Emirates

Lubabah Samir Abd Almonim Gadi, King Abdulaziz University, Saudi Arabia

Mariam Mahmood Murad Hamouda, Ajman University of Science and Technology, United Arab Emirates

Sing Ying Lim, Vinayaka Missions University, India

Alexei Mogilevski, University of Queensland, Australia

Fatma A H Mohammed, October 6 University, Egypt

Tengku Maryam Fatimah Tengku Ab Malek, University of Adelaide, Australia

Diploma of Membership in Primary Dental Care

Olurotimi Babatunde Adesanya, University of Benin, Nigeria

Diploma of Membership in Special Care Dentistry

Jessica Hamilton, Queen’s University Belfast

Diplomas of Membership of the Faculty of Dental Surgery

Natrah Ahmad Fuad, University of Malaya, Malaysia

Zarmina Babar, Khyber Medical University, Pakistan

Charlotte Rhona Aisling Conroy, Peninsula Medical School, University of Plymouth

Rajesh Kumar Dubal, University of London

Mennat Allah Ahmed El Tohamy Ebrahim, Future University, Egypt

Lauren Margaret Catherine Fitzpatrick , University of Dundee

Heidi Kane, University of Dundee

Ramandeep Kaur, Baba Farid University of Health Sciences, Faridkot, India

Sally Brigid McCarthy, National University of Ireland

Mishaim Aamir Mian, National University of Ireland

Dimitri Mulkern, University of Birmingham

Zerlis Nawaz, Riphah International University, Pakistan

Ashwin Nathan, Sri Ramachandra University, India

Priyadharshini Palasuperamaniam, Sri Ramachandra University, India

Abigail Megan Sanders-Dutton, Queen’s University Belfast

Muhammad Aliff Ikram Bin Noor Zari, Universiti Teknologi MARA, Malaysia

Diplomas in Clinical Dental Technology

John Emejen Kolly Kooli, University of Central Lancashire

Michael Andrew Ross, University of Central Lancashire

Diplomas in Implant Dentistry

Sami James Hassan, University of London

Bhavin Patel, University of London

Diplomas in Paediatric Dentistry

Katherine Isla Fiona Brearley, University of Edinburgh

Sarah Louise Hartigan, University of Manchester School of Dentistry

Rachael Ann Taylor, University of Leeds

Diplomas in Orthodontic Therapy

Sarah Louise Adams, Bristol Dental Hospital

Claire Louise Blandford, King’s College Hospital, London

Lucia Chambi, University of Central Lancashire

Victoria Cooper, King’s College Hospital, London

Fatemeh Danaei, University of Central Lancashire

Megan Leigh Frederick, University of Central Lancashire

Kayleigh Jones, University of Manchester School of Dentistry

Megan Lund, University of Manchester School of Dentistry

Annabel Louise Moore, King’s College Hospital London

Tamara Sherean Simms, University of Central Lancashire

Victoria Smith-Birch, King’s College Hospital, London

Natasha Amy Snape, University of Manchester School of Dentistry

Bernadette Turner, King’s College Hospital, London

Katey Elizabeth Uttley, University of Manchester School of Dentistry

Hannah Jane Wood, University of Central Lancashire

HOURSIN...

BELFAST

Spend a couple of days in Northern Ireland’s capital to discover how the city that survived the Troubles is now a UNESCO City of Music, says Sarah Riches

Belfast locals have long had a dry sense of humour, a taste for beer and a love of music. As Paul Donnelly, a political mediator and DC Tours guide, explains: “At the height of the Troubles, the Harp Bar – the home of punk – had security grilles on blacked-out windows to reduce the impact of bomb blasts. That’s the length we went to for a pint.”

DAY 1

Belfast started life as a village that sprang up on the banks of the River Lagan in AD 688. It makes sense, then, to begin your tour by the water. The river is lined with artworks, including Andy Scott’s Beacon of Hope – dubbed ‘the Thing With the Ring’ – which depicts a woman holding a hoop to symbolise

thanksgiving. Amble north towards John Kindness’s sculpture, The Big Fish, then cross the river to east Belfast to see glasswork inspired by fantasy series Game of Thrones, which was filmed across Northern Ireland. By now you’ll be deep in the city’s shipbuilding quarter, so look out for SoundYard. Walking beneath its 500 rods activates sensors to make them chime, a nostalgic nod to the sound of shipbuilders’ hammers striking steel.

Above: Explore the city’s industrial past at Titanic Belfast

Right: The impressive Belfast City Hall

Over just two days in the capital you can meet residents to learn about its troubled past and enjoy its music scene.

The riverside path guides you towards Titanic Hotel – the doomed vessel was designed, built and finally launched in 1912 in Belfast. After browsing Drawing Office One’s exhibition, hop over the road to Titanic Belfast, which delves into Belfast’s former cottage industry –

linen production – shipbuilding past and the construction of the Titanic

When you’re ready for lunch, return to the hotel to dine on curried chowder in Drawing Office Two, which brims with natural light thanks to triple-height skylights. Note the bar’s Villeroy & Boch tiles, which also lined the Titanic’s pool.

After lunch, visit Crumlin Road Gaol on the city’s north-west border where children were once imprisoned alongside men and women, some of whom were banished to Australia or hanged on site. In the 1960s and 1970s it was used to incarcerate political prisoners Ian Paisley, Martin McGuinness and Bobby Sands. The jail closed in 1996 before reopening as a museum, complete with a tunnel that connects to the now-derelict courthouse opposite.

If the sky is blue, continue north to Belfast Castle or take in Cave Hill Country Park. Alternatively, check out the city’s music scene to discover why UNESCO awarded Belfast its City of Music status in 2021. You won’t have time to visit all of the capital’s 80-plus live music venues, but for a taster take the Belfast Traditional Music Trail. This begins at the Second Fiddle music venue, where you can hear Jason O’Rourke on the concertina and Cormac O’Briain on the uilleann pipes.

“There are 50,000 traditional Irish tunes, which were written down in 1792,” explains Jason. “Before that it was an oral tradition, with tunes passed down through the generations and learned by ear.”

Musicians play tunes in sets of two to five. “If someone starts a set, they decide how many tunes are played, so it’s a big no no to interrupt,” adds Jason. “When the leader wants to change tune, they’ll shout ‘hup!’ to let the others know.”

You can then move on to McHugh’s, where Ciara Cullen plays the accordion and dances a slip jig – if you’re feeling brave, you can learn the brush dance.

Stop for dinner in the pub before ending the night at The MAC, which hosts comedy and plays, or listen to a harp performance or attend a céilithe dance at Cultúrlann McAdam Ó Fiaich, an Irish cultural centre.

DAY 2

Built in 1906 to mark Belfast’s new city status, Belfast City Hall sits proudly in the centre. Its permanent exhibition explores the period from 1613 to the present day across 16 rooms. Highlights include a mayor’s robe embroidered with gold thread, traditional children’s games and a display about locals who made it big, from filmmaker Sir Kenneth Branagh and Grammy Award winner Sir Van Morrison to author CS Lewis.

Once you’ve finished you’ll be in the perfect spot to begin DC Tours’ History of Terror walking tour. Paul Donnelly begins by explaining the background to the Troubles (1968–1998) – the conflict between Protestant unionists who wanted Northern Ireland to remain part of the UK and Catholic nationalists who wanted to become part of the Republic of Ireland.

You’ll then hear the human stories behind the conflict, such as Paul’s

Top: Enjoy a gin at The Crown Liquor Saloon, with its gas lamps and Victorian tiles

Above: Just one of the 250 traders at St George’s Market

Below: The Palm House at the Botanic Gardens

friend who was blown across Castle Lane by a bomb in 1972 and still refuses to walk down the alley. That same friend was in the wrong place at the wrong time on four other occasions.

“He wasn’t even a target,” says Paul. “I tell him he’s like a cat with nine lives.”

The tour ends in time for lunch. On weekends pop into St George’s Market, which was built in the 1890s. Today its 250 traders sell everything from potato bread and Irish whiskey marmalade to antiques. Meander south through the city past Queen’s University to the Botanic Gardens, which were established in 1828. In summer the park blooms with roses, while winter sees it dusted with snow. On chilly days warm up in the Tropical Ravine and beneath the Palm House’s glass and steel dome, or spend a few hours exploring the Ulster Museum, home to a 87m-long handwoven Game of Thrones tapestry and Peter, a taxidermy polar bear.

A string of restaurants and bars line the street between the gardens and the city centre. Go for an early dinner at Molly’s Yard, a converted stable that serves dishes such as fish of the day alongside Kilmegan Irish cider.

Prefer gin? Then order a glass of mother’s ruin from The Crown Liquor Saloon. Built in the 1880s, the former gin palace features original gas lamps, stained-glass windows and beautiful Victorian tiles.

The pub is opposite the Grand Opera House, which has hosted Laurel and Hardy, Charlie Chaplin and Luciano Pavarotti since it opened in 1895. Ballet dancer and Strictly Come Dancing judge Dame Darcey Bussell has also performed there. With its illustrious history, onion-domed minarets and velvet and gilt interior, it’s grand indeed, so it is.

Move on to McHugh’s, where Ciara Cullen plays the accordion and dances a slip jig

Sarah Riches

Feast for the senses

Graham Layer crosses continents and welcomes a return to taste appreciation after succumbing to COVID-19 earlier in the year

Layer Past VicePresident, RCSEd

COVID-19 eventually caught up with me in early summer and a couple of months later I was still suffering from the weird after-effects of altered taste and smell. I have still enjoyed my food, but the secret has been in textures, not just appearances.

It is surprising how much visual inputs contribute to what you think you are eating, even though you may not necessarily taste it. Slippery pasta, crunchy granola, flaky fish, muscular meat, individual peas and beans, and so on. Those wonderful senses of the palate had nearly fully returned as I enjoyed a Cornish holiday for a week with surgical friends.

Cornwall has amazing seafood and I made a return visit to Porthmeor Beach Café, a favourite next to the Tate in St Ives. Newlyn’s Mackerel Sky Seafood Bar, an informal café with a queue, served us a fine lunch. It is tapas style so you can sample a range of delicacies. The fish, bacon and corn chowder was excellent, as was the crispy squid, but the best was battered local hake with fries, buckets of mussels and fantastic scallops cooked in Cornish dukkah (a mix of sesame, coriander and cumin) with red peppers.

The Gurnard’s Head is a pub on the north-western clifftops of Cornwall with an enviable reputation. We had a satisfying lunch prior to a coastal walk. Soup and trout were followed by tempura pollock, hake and duck leg. The latter was unusual, covered in a bizarre orange sauce and a fried duck egg, and the fish dishes were somewhat heavy. For those who could manage a further course, panacotta and sticky toffee pudding were enjoyed. All the dishes were mediocre and not up to the outstanding expectations that went before them.

No 2 Fore Street was a brilliant find on Mousehole Harbour and is aspiring to fine dining. The twice-baked parmesan and crab soufflé was ingenious with crab sauce and moules marinières. Wonderful main courses included an enormous bisected lobster with caper mayonnaise, hake saffron risotto with samphire, and lemon sole in panko

crumbs with a bucket of moreish fries and truffle aioli. Some also coped with the most delicious tarte Tatin or an oozy rich chocolate fondant. An impressive restaurant. Kota in Porthleven is very special indeed. The chef is Jude Kereama, who is half Maori, half Chinese Malay, and has an expanding local hospitality empire. This restaurant appears in The Good Food Guide and The Michelin Guide and has multiple AA rosettes. Our dinner was magnificent. The restaurant is on the inner harbour and has a great ambience. Amuse bouche of leek soup with truffle oil was accompanied by blue cheese on a biscuit, and served with bread and miso butter. This was followed by scallop with crispy onions in an Asian sauce, which melted into lobster ravioli swimming in a tomato consommé. And then chunky monkfish with a crispy coating with pollock, in a coconut lemongrass bisque with a saffron mayonnaise and greens in seaweed butter. For meat-eaters, there was tender pink lamb two ways with a pea puree. Dessert was light honey and almond cake or a white chocolate mousse with meringue and strawberries. Petits fours of chocolate and hazelnut macaroons, and a fudge of white chocolate and passion fruit (which balanced the sweetness), concluded a superb meal. This place is going far. Book now. Back in London,

Graham

Kota in Porthleven is very special indeed. This restaurant has multiple AA rosettes and our dinner was magnificent

The Jugged Hare at the Barbican is convenient for concerts, but does stop serving early. The food is meaty with jugged hare and suckling pig on the menu, but also trendy cauliflower steaks and smoked fish pie.

About Thyme in Pimlico is a colourful institution serving generous tapas-style food for sharing. We enjoyed both seafood and ham croquettes, charcuterie platter, anchovies, meatballs and goat cheese. You can’t go far wrong here and the daily choice of different dishes is wide.

I also returned to Dishoom at Kensington and Covent Garden in early post-COVID recovery – the spice was a good idea, otherwise there was no detectable flavour in the curries. Heat dominated from mouth to oesophagus to stomach, clearing the upper respiratory tract on the way through.

For the Edinburgh Festival this year I revisited The Outsider, which has great castle views. The restaurant is eclectic, but has seafood and some French-influenced dishes, rillettes and a variety of mussel preparations – but also venison and some gnocchi. A well-established place with an energetic and lively atmosphere during the

Festival! International Surgical Week was held in Vienna in glorious sunshine, and I recommend The Guest House hotel and its dining room, the Brasserie & Bakery, which spills out onto a delightful outdoor terrace opposite the opera house and Hotel Sacher. The food is contemporary, generous, beautifully presented and takes account of health more than many carbohydrate-laden menus. A classic prawn cocktail with massive crustacea, fresh oysters and an amazing steak tartare surmounted with a quail’s egg started dinner, followed by a grilled whole Dover sole for dissection, all of which were outstanding.

The oddly named ef16 is hidden down an alleyway north of St Stephen’s Cathedral and serves exquisite food as a tasting menu in an outdoor courtyard. Some ingredients are sourced and foraged locally.

We started with amazing tempura prawns on a wonderful green salad with a tasty mango sauce, fabulous ravioli, wild boar with pasta, and beef with local mushrooms and gnocchi. Well presented and to be strongly recommended.

Zum weissen Rauchfangkehrer in the inner city was enjoyable, despite being popular for eons with tourists. To the music of a live pianist, our party delved into the Austrian menu, with the inevitable Wiener schnitzel, tasty local sausage and then multiple slices of powerfully flavoured ox with mushrooms.

No trip to Vienna is complete without a coffee house visit, and I sat outside the famous Demel close to the Hofburg for iced coffee and a shared Sachertorte with fluffy cream. It is a great institution.

A trip to family on Vancouver Island, Canada, saw me at the Fairmont Empress Hotel in Victoria taking afternoon tea served on a three-layer cake stand in the Lobby Lounge. It was elegant service with various teas; savoury sandwiches; salmon blinis; scones, cream and jam; and a selection of cakes. Expensive, entertaining and worthwhile –the waiter adding to our experience with his tales from 42 years in post.

salmon blinis; scones, cream and jam; and a selection of xpensive, and worthwhile –aiter to our experience with his es from 42 years in post

The Deep Cove Chalet, north of Victoria, now has the best food and service ever. French chef owner Pierre, has been there for 50 years and is a lavish cook – fabulous cross-sectional beef Wellington and perfect fresh halibut. Many guests were impressed by rabbit and anatomical sweetbreads, and the fiery preparation of the crepes suzettes.

service ever French chef owner Pierre, has been there for 50 years and is a preparation of the crepes suzettes.

Nearby in Sidney, Beacon Landing, now called Riva, has a new chef serving Italian fare. Outstanding prawn carbonara was expertly cooked with juicy ingredients, herbs, garlic and parmesan –plenty of textures and great flavours.

Italian fare prawn edients, herbs, and parmesan –

Main

Main image: scallops with an Asian twist at Kota in Cornwall

Inset: a tempting plate of oysters served with prawn cocktail in Vienna

But for superb seafood, Sea Glass in Sidney on the edge of a marina at sunset is the place, with a terrace over the water.

We never reached the main course mega-towers, but shared a selection of over-generous starters, including battered cod tacos smothered in mango salsa, aioli and pickled red onion, and a ‘surf and turf’ with giga prawns and fillet steak. Welcome back, world of flavours.

The Hare at is convenien

MADEIRA MAGIC

Carole A Boyle DipWSET Dental Editor, Surgeons’ News

Richard Lane DipWSET Wine educator, journalist and podcaster The Wine List

What makes Madeira so different from other wines? First, it is a story of longevity – you can still buy, for a price, Madeira made from grapes grown in the 19th century. And it has been around much longer –according to legend, George, Duke of Clarence, when confronted with a death sentence in 1478, chose to be drowned in a butt of his favourite Malmsey Madeira. Madeira’s longevity arises from its unique aging process – it is ‘maderised’ (cooked) to produce deliberate oxidation that avoids the spoilage associated with most conventional wines. This method was first developed after British merchants came to the island in the 17th and 18th centuries. They observed how quality was improved after wine had spent time in the holds of ships sailing to colonies in North America and the West Indies. This led to Madeira wine being used as ballast on long trips. Such deliberate heat and oxidation is today replicated in temperature-controlled stainless-steel vessels called estufas. This rapid process results in wine being ready to consume the second year after harvest. However, the more gradual canteiro process associated with higher-quality

wines is more labour-intensive. Wines are instead matured in oak barrels in lofts where temperatures can reach 40°C and they can age for decades. These wines change colour as they mature, turning brown and developing smoky dried-fruit aromas. They accumulate high alcohol levels due to fortification with alcohol spirit after fermentation and from evaporation as the wines mature.

Even at 100 years of age, Madeira retains its distinctive nutty flavours. More recent vintages are more affordable

yet will still offer flavour complexity. But madeira is not always sweet; it can be dry, but always with high acidity and alcohol levels between 17% and 22%.

There are many styles of Madeira based on chosen grape varieties, level of sweetness, how long the wine has been aged and whether it is single vintage or from multiple years of grape harvest. The more expensive wines tend to be labelled according to specific grapes, of which there are four ‘noble’ varieties: Sercial, Verdelho, Boal (or Bual) and Malvasia (see panel, below).

These are all quality Madeira wines made from white grapes. Yet the majority of ordinary Madeira wine is made from the black grape Tinta Negra and here ageing is included in the labelling with three, five, 10 or 15 years. The older the wine the more complex the flavours. The high alcohol of Madeira wines suggests a cautious approach is advisable, with small, sherry-like glasses being the serving vessel of choice. But the good news is that once opened, a Madeira wine will retain freshness, being already oxidised, and should remain drinkable for weeks and months after opening.

Madeira is a wine of its place – a Portuguese island in the Atlantic with subtropical weather, which is generally too warm for grape growing, but an ideal destination for winter sunshine. Grapes are generally grown at altitude to slow grape ripening in the mild year-round climate, the high rainfall mitigated by good drainage in Madeira’s volcanic soils.

The story of Madeira’s wine is embedded in the history and culture of the island itself. Distinctive family names still dominate Madeira wine labels today – notably Blandy’s, Henriques & Henriques, and D’Oliveira.

No visit to Madeira would be complete without a visit to a Madeira lodge. The most accessible are located in the capital, Funchal. Blandy’s, which is the largest, offers tours of the aging lofts, a museum of wine-making equipment and a history of the company. D’Oliveiras offers tastings set in an atmospheric room surrounded by bottles.

This festive season don’t dismiss Madeira as just another fortified wine to be enjoyed at the end of a meal. Madeira makes an excellent aperitif and many can accompany food. And remember, there is no need to drink it all on the day –the rest of the bottle can be enjoyed well into the new year, and perhaps into the year after that.

THE NOBLE MADEIRA VARIETIES

• Sercial is dry or extra dry with the lightest colour and citrus and nutty aromas. It is ideal as an aperitif.

• Verdelho is medium dry with more sugar, giving notes of candied fruits. It is versatile and can accompany a meal.

• Boal is medium sweet and darker with caramelised coffee and

Left:

Inset left:

Inset right:

chocolate flavours. Perfect to pair with rich cheeses or chocolate desserts.

• Malvasia – also called Malmsey – is more full-bodied, and the sweetest and darkest in colour, but is balanced by high acidity. It works well with richer desserts and on its own at the end of a meal.

Tasting notes

notes

Madeira wines

Blandy’s Duke of Clarence Rich Madeira

Available from Waitrose (£12.49)

Deep golden brown with honey and raisins on the nose. A rich, full-bodied and soft-textured wine that is immediately appealing. An ideal entry point into the world of Madeira wine.

Henriques & Henriques 10-year-old Sercial Madeira

Available from Waitrose (50cl, £19.99) Perfect before dinner – dry with aromas of nuts and orange peel.

Henriques & Henriques Verdelho 15-year-old Madeira

Available from Waitrose (£24.99)

Full of figgy fruit and racy acidity. Well balanced by gentle sweetness.

Blandy’s 15-year-old Bual Madeira

Available from Waitrose (50cl, £24.99) Christmas in a bottle. Rich and nutty, and fantastic when paired with cheese.

Blandy’s 10-year-old Malmsey Madeira

Available from Waitrose (50cl, £18.99)

Goes well with dessert or with a cheese board. Sweet with candied fruits and a long finish.

Henriques & Henriques 10-year-old Malmsey Madeira

Available from Majestic (50cl, £22.99)

Deep brown with intense flavours of dried fruit, chocolate and coffee. Ideal to sip and for contemplation after dinner.

Even at 100 years of age, Madeira retains its distinctive nutty flavours. More recent vintages are more affordable yet will still offer flavour complexity

There are different varieties of Madeira

Tourists have the opportunity to press the grapes that will become Madeira

Blandy’s is one of the original producers of Madeira

Six of our favourite

Creative minds

From ceramics and metalworking to mosaics and printmaking, Ann Shearer lines up 12 arty opportunities to try your hand at in the new year

Looking for a new challenge in 2023 or even a last-minute Christmas gift? Many makers and designers offer workshops and classes, as well as kits and gift vouchers.

There is a huge variety of classes available, both face-to-face and online. I hope some of you will try a craft course in 2023 – you never know, it might change your life!

Edinburgh Sculpture Workshop’s courses are a great way to explore sculptural methods. There are artist-led courses in stone and woodcarving, ceramic sculpture and more. In February 2023 it will run clay portraiture online, an eight-week course where you will create a portrait sculpture working with images of a person of your choosing. Find out about courses and gift vouchers at www.edinburghsculpture.org

SilverHub Jewellery School and Studios was established in Edinburgh in 2008 by jeweller and artist Lisa Arnott. She has since been joined by Jessica Howarth and guest designers. The school delivers day and evening leisure classes, as well as a very successful foundation year in jewellery design and making. The Flourish Jewellery Project, in which SilverHub is a partner, offers everyone an opportunity to try out one-day taster sessions at the school. To find out more or book a place go to www.silverhubstudios.com

Would you like to weave your own unique wearable scarf using materials such as lambswool and Shetland wool? Well, head down to Coburg Art Studios in Leith, Edinburgh, and sign up to one of James Donald’s weekend weave workshops, or his Tuesday and Thursday 11-week evening classes. These cover many aspects of weaving and textiles. Find information and vouchers at www.pickone.co.uk

Would you like to weave your own wearable scarf materials such as lambswool and Shetland wool? head down to Art Studios in Leith, and sign up to one of weave or his and 11-week classes. These cover many aspects of and textiles Find information at

Seeing the joy of a loved one appreciate a hand-knit can often be just as fulfilling as wearing one yourself. Ysolda Teague is a Scottish knitwear designer who offers online knitting courses, free tutorials and patterns for her knitwear designs through her website, www.ysolda.com. Her latest collection, Knitworthy Six, has six accessory patterns spanning a wide range of techniques, each of which has been thoughtfully designed to both challenge adventurous beginners and satisfy experienced knitters.

Bryony Knox, an award-winning silversmith, teaches creative metalwork courses for all levels. You can make an embossed copper box in a morning, a dachshund in a day or even an Arts and Craft copper clock in a week at Knox’s studio in Leith, Edinburgh. To find out more go to www.bryonyknox.com

Edinburgh Printmakers is a creative hub for printmaking and the visual arts in the Fountainbridge area of Edinburgh. It offers weekend, evening and one-off courses for those looking to experiment with printmaking. Set against the backdrop of a remarkable heritage building, the atmosphere is creative and inspiring. Keep an eye on www.edinburghprintmakers.co.uk for the new courses and workshops in the new year or buy a gift voucher for the arty person in your life.

Glass Lab Edinburgh is a new studio founded by artist/designer team David Mola and Jeff Zimmer. They run classes in stained glass, glass fusing, glass painting and sandblasting for beginners and more experienced students. They also sell tools and materials for stained and fused glass; take on commissions; and repair stained glass for homes, churches and businesses. Classes run in the evenings (six-week terms) and on weekends (one- and two-day options). See www.glasslabedinburgh.com for details.

Sally-Ann Provan is one the UK’s top milliners and teaches a variety of hat-making workshops and short courses, either online or at her Edinburgh studio. Options include blocking felt hats, where you can make a fedora, trilby or cloche in the colour and shape of your choice; fascinator-making; beaded headpieces and hair vines; and, new for 2023, pillbox and smartie hats.

Provan is one the UK’s top milliners and teaches a of and short courses, either online or at her studio. include felt where you can make a fedora, or cloche in the colour and of your beaded and hair new for and smartie hats

Provan also offers one-to-one tuition at the studio or online. Details and dates can be found at www.sallyannprovan.co.uk

Trained

20 years’

As an experienced mosaic teacher, she runs small, creative workshops from her studio in central Edinburgh. Choose from a one-day Introduction to Mosaics workshop, a weekend class in Classical Mosaic Techniques, a private lesson or a gift voucher to cover all or part of the costs. Perfect for beginners as well as those who want to learn more about this ancient art. Classes for 2023 are now live at www.helenmilesmosaics.org

Linda Farquharson runs small linocut workshops from her studio near Dunkeld. On a day course you’ll learn the techniques of relief printing, cutting and printing your own ‘block’ to create a small edition of linocut prints. With three students on each course, you are assured lots of personal tuition. Just bring a simple sketch and lots of enthusiasm – and be prepared to go home with inky fingers! Further details and gift vouchers at www.linocut.co.uk

arquharson runs t from her io near Dunkeld On a y course learn e of relief and your own to create a linocut prints With on each course, you are tuition. Just ring a sketch d d be to go e with details and at

Provan one-to-one at or can an and educational space in that was set up in 2012 Fiona and Chris The studio offers individual courses for adults and a scheme include and taster sessions and courses four to six weeks different to ceramics such as wheel hand and surface decoration. Details and details are at

Cyan Clayworks is an artist-run ceramic studio and educational space in Edinburgh that was set up in 2012 by Fiona Thompson and Chris Donnelly. The studio offers individual tuition, regular courses for adults and a membership scheme. Options include evening and

Lucy Engels is a quilter and visual artist who creates unique quilt patterns that coax out your inner artist by allowing you to put your own personality and stamp on what you are making. Alongside quilt patterns, she has created a range of English paper-piecing kits for beginners and seasoned quilters alike. Engels runs quilting workshops online and in person in Edinburgh. Sign up to her email list at www.lucyengels.com to find out more.

in Greece, Helen Miles has more than

experience designing and making mosaics.

day taster sessions and longer courses lasting four to six weeks covering different approaches to ceramics such as wheel throwing, hand building and surface decoration. Details and booking details are available at www.cyanclayworks.co

Learningcurve

Surgeons’ Hall Museums made the headlines in September after accepting a new human tissue specimen for the first time since the 1990s. The specimen is a tension-free transvaginal tape (TVT) and attached tissue, which was surgically removed from the donor in April 2022.

In August 2021 Lisa Megginson contacted the museum to ask whether her medical device could be donated, to end what she describes as 'a horror story' on a positive note. Indeed few people learning about her physical and emotional journey since having the TVT procedure could fail to be shocked and moved.

While the museum immediately realised the importance of the device, this unusual offer of donation presented many legal and ethical considerations.

The collections are by default closed to human remains. However, as we are one of the few museums legally permitted to hold contemporary human tissue and have the expertise to conserve and curate these sensitive collections, we feel a responsibility to consider such offers on a case-by-case basis. This specimen is an excellent example of why we do just that.

As far as we are aware the museum has never received a specimen directly from a patient. In the past, collections have come from the hospital, pathologist or surgeon. We had to consider the ethical considerations, not to mention the practical issues involved.

After consulting external experts and seeking advice on informed consent for tissue donation, the museum felt confident to proceed.

We also had the generous support of the operating surgeon, Professor Hashim Hashim, and the Bristol Urological Institute, Southmead Hospital, Bristol.

The TVT was removed and transferred to the museum directly

References

1. baus.org.uk/patients/ sui_mesh_complications. aspx

2. www.birmingham prostateclinic.co.uk/ bladder/treatments

3. First Do No Harm – The report of the Independent Medicines and Medical Devices Safety Review, led by Baroness Cumberlege, 2020

The TVT procedure was introduced in the 1990s as a new, minimally invasive surgical treatment for stress urinary incontinence (SUI). The British Association of Urological Surgeons estimates that just under 24,000 surgeries took place for treatment of SUI between 2014 and 2016 in the UK1

It is estimated that around 10,000 of SUI cases between 2006 and 2016 used the TVT procedure2

The synthetic mesh, most often polypropylene, is introduced via a curved trocar and is used as a sling under the urethra to reinforce the weakened ligaments. Due to the small incisions, patients could be discharged faster compared to more traditional approaches. The limitations were limited visibility for insertion.

It is only by having a physical representation that we can tell this story. Exhibiting a surgically

removed device enables the visitor to see for themselves the impact on the patient.

Interpretation of the donated specimen will make it clear that many women have experienced no side-effects to this procedure. However, it will also highlight the significant physical complications that can occur and perhaps, more importantly, give attention to the wider issues and obstacles that faced those who had complications.

As such the device enables the museum to explore issues highlighted in the First Do No Harm report, overseen by Baroness Cumberlege3. These include concerns surrounding informed consent, patient advocacy, rapid uptake of the procedure, lack of long-term monitoring data and defensive reactions from the medical community.

As the report states: “We know there are some excellent surgeons doing their best to care for meshinjured women, but … we have also heard from women whose doctors, surgeons and GPs ignored or dismissed their concerns.”

In another first, Megginson was awake during and watched her own TVT removal surgery. This was due to a need for closure and because of a declining confidence and trust from many years of convincing an entrenched medical community of her plight.

While this chapter in women’s health may cause embarrassment to some in the medical profession, we hope that by highlighting this story and issues uncovered in the First Do No Harm report, we will only strengthen and progress women’s health, and help, as the report urges, “to build a system that listens, hears and acts with speed, compassion and proportionality”.

Louise Wilkie Curator, Surgeons’ Hall Museums

from the hospital, where it was mounted and preserved in fluid by Cat Irving, our Human Remains Conservator.

Louise Wilkie on the museums’ first human tissue donation since the 1990s and its anticipated role in strengthening women’s healthcare

Louise Wilkie (left) and Lisa Megginson with the tension-free TVT specimen