Surgeons Scope Magazine - December 2022

THE MAGAZINE EXCLUSIVELY FOR RCSI FELLOWS AND MEMBERS ISSUE 2 2022

WORKING IN MISSOURI

Dr Majella Doyle in St Louis ON THE FRONTLINE Dr Vivian McAlister A Career in the Military NO TIME TO EAT Sustenance for Surgeons

+ SPOTLIGHT ON VASCULAR SURGERY BREAKING BAD NEWS MENOPAUSE SUPPORTS

''It is proving to be 30-40% faster and I believe it is already saving the HSE and taxpayers money. In some cases, where I predicted a patient may have needed two operations to have the procedure done, this laser has done it in one.’'

Derek Hennessey, Consultant Urologist, Mercy University Hospital regarding the SOLTIVE™ system

Find out more about the SOLTIVE™ system here:

› Letter

A Letter from the President, RCSI PROFESSOR LAURA VIANI

Dear RCSI Fellows and Members, As the festive season approaches, I marvel at how quickly the first six months of my Presidency have passed and how busy the world has become now that we are travelling again and meeting in person. It has been a huge honour to represent RCSI on your behalf. Since June, I have had the opportunity to meet many Fellows and Members in person and virtually during our Conferrings in July, at our North American Chapter of Fellows reception during the ACS Clinical Congress in San Diego in October, in Waterford for our Doing the Rounds Roadshow, and online for our Surgical Matters webinar series. I look forward to meeting many of you at the Doing the Rounds Roadshow in Tullamore in April and in Cork in June and at the many events we are planning for 2023.

I was proud and pleased that for the second time this year one of our Irish surgical trainees, Danielle McLaughlin received the British Association of Paediatric Surgeons (BAPS) medal, awarded by the Intercollegiate Board in Paediatric Surgery for outstanding performance at the Intercollegiate Specialty Examination in Paediatric Surgery. At our July Conferrings, I had the honour of presenting this medal to Brendan Rory O’Connor, for the Examination held in Edinburgh in 2021. A wonderful achievement and testament to the excellent quality of RCSI training and the calibre of surgeons we produce.

Charter Meeting 2023 takes place Saturday, 28 January 2023 – Friday 3 February 2023. The theme is ‘Shaping the Future’ and the programme includes symposia on ‘The Future of Surgery’ and ‘Technology for Surgeons and the Patient’, the 30th Carmichael Lecture, the 98th Abraham Colles Lecture and the 45th Millin Lecture. See page 7 for the full Charter Meeting programme; registration is now open at rcsi.com/ charterweek.

As a regular part of Charter Meeting, the ‘Becoming a Standout Surgeon’ session will be held on Friday, 3 February as part of the Parallel Group III. This has been designed with our Affiliate Members in mind, including surgical trainees, medical students, foundation doctors, interns, NCHDs and anyone interested in a career in surgery. Professor David Healy will lead this inspirational, informative and practical panel discussion offering guidance on becoming a standout surgical trainee candidate, focusing on the CST intake data from RCSI and the profiles of successful candidates. It will also cover career development advice, planning a surgical career, a surgical trainee’s perspective on how to successfully apply for CST and HST, and the exciting opportunities available to support future surgeons to achieve their aspirations, objectives and ambitions. This session is close to my heart and certainly something I could have done with as I started my surgical career.

RCSI President, Professor Laura Viani

Charter Meeting 2023 takes place Saturday, 28 January 2023 – Friday, 3 February 2023. The theme is ‘Shaping the Future’

SURGEONS SCOPE / 1

› Letter

RCSI President, Professor Laura Viani

There is evidence that certain procedures deliver better patient outcomes when the procedure is conducted using robotic platforms. This workshop marks the beginning of robotic surgical training at RCSI.

Recently, surgical teams – including nurses and theatre staff – took part in RCSI’s fi rst ever Robot-Assisted Surgery (RAS) training programmes, run in collaboration with Intuitive at the National Surgical and Clinical Skills Centre at RCSI. Th ere is evidence that certain procedures deliver better patient outcomes when the procedure is conducted using robotic platforms. Th is workshop marks the beginning of robotic surgical training at RCSI. In July, we published the fi rst issue of Surgeons Scope of 2022. It featured diverse topics including the inspiring journey of Ms Tafadzwa Mandiwanza, Paediatric Neurosurgeon, the impact of Schwartz Rounds on the wellbeing of surgeons and surgical teams, and Professor Eilis McGovern’s refl ection on her outstanding career journey. If you missed the July issue, please email the Fellows and Members offi ce at fellows @ rcsi.com. Next year, as an alternative to the print version, we look forward to off ering readers the option to access Surgeons Scope in digital form.

Th is edition of Surgeons Scope is similarly engaging with inputs from a diverse group of Fellows and Members of the College. Our regular A Surgeon In feature (page 8) catches up with Professor Majella Doyle who refl ects on her impressive career as a liver transplant surgeon and explains how, as “a home bird at heart”, she ended up in St Louis, Missouri. RCSI Fellow Dr Vivian McAlister goes Back to the Beginning (page 30), refl ecting on his personal and professional journey, his role as a Lieutenant Colonel in the Canadian Forces Health Services and his experience of deployment to Afghanistan.

Th e topic of eff ective communications and the importance of empathy when delivering bad news to patients is covered in Breaking Bad News (page 12). Neurosurgeon Henry Marsh’s refl ection on facing terminal illness (page 16) is wonderful. Th is account is an extract from his recent bestseller, And Finally, and has inspired me to buy the book. A First for Africa (page 24) features Dr Fridah Bosire, the first African woman to be awarded the Gerald O’Sullivan medal for her outstanding COSECSA exam results. Fridah provides insights into her life as a surgeon in Kenya.

Finally, I would like to take this opportunity to wish you and your loved ones a very happy holiday and I hope that 2023 brings you health and happiness.

Best wishes

Laura Viani President, RCSI 2

SURGEONS

THE MAGAZINE EXCLUSIVELY FOR RCSI FELLOWS AND MEMBERS

Contents 04

08

24

ON OUR COVER

Dr Maria B. Majella Doyle.

Photograph by Tim Parker Photography, Washington University, St Louis.

22

04

Scope News

22

Pause for Thought

07

Charter Programme 2023

24

A First For Africa

08

A Surgeon in ... St Louis

27

Scope Diary

28

Colles Q&A

30

Back to the Beginning

RCSI roadshows, robotic surgery training and ACS honours

A highlight of the RCSI calendar

St Louis, Missouri is home to liver transplant surgeon, Dr Maria B. Majella Doyle

10

No Time to Eat

12

Breaking Bad News

16

And Finally

20

Specialty Spotlight

Why surgeons need to look after number one

How good communication skills enhance the clinician-patient relationship

A new survey finds that female doctors need to be supported during menopause

Dr Fridah Bosire is awarded the Gerald O’Sullivan Medal at RCSI

Book now for upcoming Fellows and Members events

Professor Carmel Malone on life, work and running a marathon

RCSI Fellow Dr Vivian McAlister on his career as a military surgeon

Neurosurgeon and bestselling author Henry Marsh on facing terminal illness

Vascular Surgery: Ms Mary Barry on the opportunities and challenges

RCSI SURGEONS SCOPE MAGAZINE is published bi-annually by RCSI for its surgical Fellows and Members.

Issues are available online at www.rcsi.com.

Your comments, ideas, updates and letters are welcome.

Please contact Catherine Jordan, Managing Editor, in the Fellows & Members Office, 111 St Stephen’s Green, Dublin 2; telephone: +353 (0) 1 402 2116; email: catherinejordan@rcsi.com.

RCSI Surgeons Scope is posted bi-annually to our Fellows and Members in Good Standing. To ensure you continue to receive your copy, please send your current contact details to fellows@ rcsi.com. RCSI Surgeons Scope is produced by Gloss Publications Ltd, The Courtyard, 40 Main Street, Blackrock, Co Dublin.

Copyright Gloss Publications.

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OUR HERITAGE RCSI’s mission is to educate, nurture and discover for the benefit of human health. Founded in 1784 with surgery at our core, we are an independent, not-for-profit, world leading international health sciences education and research institution, with a deep professional responsibility to enhance human health.

SURGEONS SCOPE / 3

› News

Scope News ACS HONOURS FOR RCSI, ROBOTIC SURGERY TRAINING, NEW EDUCATION PLATFORM

RCSI PRESIDENT AWARDED HONORARY FELLOWSHIP OF AMERICAN COLLEGE OF SURGEONS

RCSI President, Professor Laura Viani and Consultant Otolaryngologist and Neuro-Otologist at Beaumont Hospital and Temple Street University Children’s Hospital, has been made an Honorary Fellow of the ACS, in recognition of her contribution to surgery and her role in the establishment of the first cochlear implant centre in Ireland.

Mr Kieran Ryan, Managing Director for Surgical Affairs, RCSI, said: “Professor Viani has singularly transformed the lives of thousands of profoundly deaf children and adults. She provides an outstanding example to surgical trainees and medical students of excellence in patient-centred care. We are proud that she has been awarded the highest recognition by the American College of Surgeons, an award that is richly deserved.”

RCSI ‘DOING THE ROUNDS’ ROADSHOWS In October, the RCSI President, Fellows and Members team and the Department of Surgical Affairs travelled to the RCSI Education facility in Waterford for what turned out to be a very productive South East Roadshow, an opportunity to listen and learn about the local concerns in the South East of the country.

In attendance were 45 surgical Fellows and Members, trainees and NCHDs from University Hospital Waterford, Wexford General Hospital, South Tipperary General Hospital and St Luke’s General Hospital, Kilkenny.

Presentations from Professor Simon Cross, Mr Morgan McMonagle, and Professor Fiachra J. Cooke, and from regional representatives, Dr Osama Elfaedy, St Luke’s General Hospital in Kilkenny, Mr Ivan Ivanovski, Wexford General Hospital, and Professor Peter Murchan of Tipperary University Hospital, provided food for thought.

There were robust discussions covering training, regional services, support for teaching, and limits on clinical capacity. We look forward to working in collaboration with our colleagues in the South East to bring support in these areas.

BEAUMONT RCSI CANCER CENTRE RECEIVES FULL OECI ACCREDITATION The Beaumont RCSI Cancer Centre – an innovative collaboration between Beaumont Hospital, RCSI University of Medicine and Health Sciences and St Luke’s Radiation Oncology Network – has received official accreditation for the quality and standards of cancer care and research by the OECI, a European organisation that sets comprehensive standards for cancer centres and networks.

In January 2021, Beaumont RCSI Cancer Centre elected to participate in the OECI Accreditation and Designation Programme, a quality assessment

programme focused on multidisciplinary integrated cancer care and research.

The Cancer Centre was independently evaluated by a team of experts from centres across Europe in October 2021 and assessed across a number of domains including governance, research, multidisciplinary working, patient involvement and empowerment, organisational quality and prevention, diagnosis and treatment of cancer.

The Cancer Centre was recognised as a ‘patient centred organisation’ with ‘wellcoordinated research structures’ and ‘a dynamic education system’ by the OECI.

Ian Carter, CEO of Beaumont Hospital; Professor Leonie Young, Scientific Director, Beaumont RCSI Cancer Centre; Professor Arnold Hill, Head of School of Medicine, RCSI; and Professor Patrick Morris, Medical Director, Beaumont RCSI Cancer Centre.

Becoming A Standout Surgeon

Professor Sean Tierney, Professor Simon Cross, RCSI President, Professor Laura Viani and Professor Fiachra J. Cooke

4

Medical students, NCHDs, surgical trainees, Affiliate Members and those interested in a career in surgery should note an important date: On Friday 3 February 2023, Professor David Healy, RCSI, Council Member, will host an inspirational, informative and practical panel discussion offering guidance on becoming a standout surgical trainee candidate. The discussion will focus on the CST intake data from RCSI and the profiles of successful candidates; a surgical trainee’s perspective on how to successfully apply for CST and HST, and what they did to stand out; discussions on what the role of a surgeon might look like in ten years; and guidance from a Career Development Advisor on how to prepare for applications and create a CV. The session will also include advice on making strategic career decisions including how to plan for a career in surgery, and the exciting opportunities available to support future surgeons to achieve their aspirations, objectives and ambitions. For more information, contact the Fellows and Members office at fellows@rcsi.ie. Registration now open.

› News

ROBOTIC SURGERY TRAINING BEGINS AT RCSI

Surgical teams have taken part in RCSI’s first-ever robotassisted surgery (RAS) training programmes, run in collaboration with Intuitive.

The programmes took place at the National Surgical and Clinical Skills Centre at RCSI and saw attendees, including nurses and theatre teams, experience hands-on training on the da Vinci Xi surgical system, provided by Intuitive, the

pioneer of robot-assisted surgery.

The inclusion of robotic training is among several innovative initiatives being introduced within RCSI’s surgical training programme, aiming to enhance the surgical skills and competency training delivered for surgical trainees.

The training programme gave attendees the opportunity to better understand the handling, care and integration of Intuitive systems, instruments, accessories and technology.

Professor Oscar Traynor

Professor Oscar Traynor inducted into American College of Surgeons Academy of Master Surgeon Educators Professor Oscar Traynor, Professor of Postgraduate Surgical Education, RCSI has been inducted into the American College of Surgeons Academy of Master Surgeons. This honorary distinction recognises surgeon educators who have devoted their careers to surgical education and are considered leaders in their fields. Our congratulations to Professor Traynor on this achievement.

Robot-assisted surgical training.

BECOME AN MRCS EXAMINER

Conferrings, July 2022

CONFERRINGS

RCSI President, Professor Laura Viani and the Fellows and Members Team were delighted to welcome 144 surgical Fellows and Members to the College in July 2022 to celebrate their achievement at our Summer Fellows, Members and Diplomates Conferring in RCSI Dublin and welcomed 139 new surgical Fellows and Members to our Winter Fellows, Members and Diplomates Conferring on Monday, 5 December 2022. We look forward to supporting our new Fellows and Members through each stage of their careers.

OPERATION CHILDLIFE CLINICAL TRAVEL FELLOWSHIP

Through the Operation Childlife Clinical Travel Fellowship, RCSI and Operation ChildLife are working together to support surgical trainees and medical professionals gain additional expertise by participating in paediatric healthcare missions, led

by Irish hospital consultants, doctors and nurses who plan and deliver two-week programmes of care, with Operation Childlife in Vietnam,

Tanzania, Mongolia and Jordan. More information is available from Caroline McGuinness: cmcguinness@rcsi.com

RCSI is currently recruiting for new clinical examiners in Ireland, Bahrain, Malaysia and UAE to examine in upcoming MRCS Part B examinations.

MRCS examiners play a vital role in ensuring that all surgical trainees have the skills and knowledge to provide excellent patient care, and this is only possible with involvement from current surgical experts working in the health system.

As an examiner, you will become a member of the RCSI Court of Examiners, whereby the objective is to increase the profile of postgraduate surgical examining at RCSI and to make such examining activity more relevant and attractive to the College’s surgical community in Ireland and overseas.

Eligibility criteria for clinical examiners: 1. Fellow (including Fellow ad eundem) of one of the four Royal Surgical Colleges.

2. Hold or have held full consultant status (not a locum post) for at least two years post CCT or equivalent.

3. Able to complete one term of office before retirement i.e. one full term (six years including a probationary year). Two further terms of five years may be approved.

4. Engaged in active clinical/ academic practice (licence to practise with the GMC).

Prospective examiners looking to apply will need to complete the relevant application form and send it to courtofexaminers@rcsi.ie.

SURGEONS SCOPE / 5

› News

HSE National Policy and Procedure for Safe Surgery launched at RCSI

RCSI LAUNCHES NEW EDUCATION PLATFORM FOR NCHDS WITH 110 COURSES

A new CPD Hub education platform, developed to meet the challenges faced by NCHDs in modern day healthcare, includes over 110 faceto-face and online courses, focusing on both clinical and non-clinical skills. The platform will support the professional development of NCHDs in surgery, emergency medicine, and other medical specialties. For more information, contact cpdss@rcsi.ie.

RCSI and partners to develop UN Global Surgery Learning Hub The global surgical care crisis requires action at all levels, from changes in health policymaking to the provision of infrastructure and equipment, to the expansion and the upskilling of the frontline surgical care workforce.

To date, there is no single definitive source for global surgery materials to support the training and education for surgeons, anaesthesia providers, obstetricians and gynaecologists and perioperative 6

L-R: Dr Michael Dockery, Clinical Lead for NCP in Anaesthesia; Aileen O’Brien, Nurse Lead in NCP Anaesthesia; Mr Kenneth Mealy, Co-Lead for NCPS and Past President of RCSI; and Dr Orla Healy, National Clinical Director, Quality and Patient Safety, HSE.

nurses practicing in underserved communities.

In response, the RCSI Institute of Global Surgery is partnering with the Global Surgery Foundation (GSF) and United Nations Institute for Training and Research (UNITAR) to develop an open-access UN hosted Global Surgery Learning Hub that gathers and allows easy access to a wide range of trusted, quality global surgery educational resources.

Find out more from Dr Ines Peric at inesperic@rcsi.com or Eric O’Flynn at ericoflynn@rcsi. com from the RCSI Institute of Global Surgery.

The HSE has launched its National Policy and Procedure for Safe Surgery.

The policy endorses the principles of the World Health Organisation (WHO) Surgical Safety Checklist (2008) and the HSE’s Patient Safety Strategy (20192024) to ensure that all patients undergoing surgical procedures do so safely. The Policy applies to all patients undergoing surgery in Irish hospital settings and to all healthcare staff involved in the surgical patient pathway.

ACS Clinical Congress

The RCSI North American Chapter of Fellows Reception at the ACS Clinical Congress in San Diego, on Monday, 17 October, was a wonderful networking event with more than 50 RCSI Fellows and Members attending the Congress from Ireland and internationally. RCSI President, Professor Viani presented a beautiful sculpture to Dr Julie A. Freischlag President of the ACS, in celebration of the centenary of the original collaboration between the ACS and RCSI.

RCSI President, Professor Laura Viani with ACS President, Dr Julie A. Freischlag

TWO-IN-A-ROW – IRISH TRAINEES COMING OUT ON TOP

For two years in a row, Irish surgical trainees received the British Association of Paediatric Surgeons (BAPS) medal, by the Intercollegiate Board in Paediatric Surgery for their outstanding performance at the Intercollegiate Specialty Examination in Paediatric Surgery.

This year, Danielle McLaughlin was awarded the Medal for the Examination held in Edinburgh on 9/10 March 2022. We look forward to making this medal presentation at the Fellows, Members and Diplomates Conferring ceremony this month.

In 2021, Brendan Rory O’Connor was awarded the Medal for the Examination held in Edinburgh on 22/23 September 2021. RCSI President, Professor Laura Viani presented the Medal to Brendan at the Fellows, Members and Diplomats Conferring on Monday, 4 July 2022 at RCSI Dublin. Congratulations to both recipients of this award.

Brendan Rory O’Connor and Danielle McLaughlin

› Calendar

Charter Meeting 2023 ‘SHAPING THE FUTURE’

Saturday 28 January – Friday 3 February 2023 PROGRAMME OVERVIEW SATURDAY 28 JANUARY 2023 • Annual Meeting of the Irish Surgical Training Group (ISTG) TUESDAY 31 JANUARY 2023

• Awards and Presentations • President’s Invitational Lecture • 45th Millin Lecture

• National Office of Clinical Audit (NOCA) Annual Conference • Honorary Fellowship Conferring • 17th Annual Intercollegiate Case Presentations FRIDAY 3 FEBRUARY 2023 WEDNESDAY 1 FEBRUARY 2023 • Annual Health Service Quality Improvement and Innovations Conference (Hosted by RCSI National Clinical Programmes) • RCSI National Clinical Programmes Parallel Sessions: - National Clinical Programme in Surgery Session - National Clinical Programme In T&O Session - National Clinical Programme in Emergency Medicine Session • Faculty of Surgical Trainers’ Programme • Parallel Group I -

Faculty of Dentistry Faculty of Sports and Exercise Medicine Faculty of Nursing and Midwifery Irish Institute of Pharmacy (IIOP)

• 33rd Annual Videosurgery Meeting THURSDAY 2 FEBRUARY 2023 • Symposium I – The Future of Surgery and Technology for Surgeons and the Patient • Parallel Group II -

Breast Surgery Colorectal Surgery ENT / Otolaryngology Head and Neck Surgery HPB Surgery Upper GI Surgery Urology LUNCH: Sponsors exhibition: industry perspectives

• Johnson and Johnson Lecture • Symposium II – How Do We Train for the Future?

• Symposium III – Future Perspectives on Registries and Clinical Audit • 30th Carmichael Lecture • Symposium IV – New Cancer Initiatives, New Cancer Centres Developments and what is happening in our new cancer centres • Parallel Group III -

Affiliate Members Programme ‘Becoming a Standout Surgeon’ Cardiothoracic Surgery Neurosurgery Oral and Maxillofacial Surgery Trauma and Orthopaedic Surgery Vascular Surgery

• 98th Abraham Colles Lecture • Symposium V – Future of Surgery in Ireland • Parallel Group IV -

Emergency Medicine Endocrine Surgery Ophthalmic Surgery Paediatric Surgery Plastic and Reconstructive Surgery

PROGRAMME, REGISTRATION & QUERIES

Charter Meeting 2023 will be a fully in-person event, taking place at RCSI, St Stephen’s Green, Dublin 2.

Online registration is essential.

Registration and the draft programme will be available at www.rcsi.com/charterday CPD will be available for all sessions.

For queries, please contact charter@rcsi.ie.

SURGEONS SCOPE / 7

› A Surgeon in…

A Surgeon in…St Louis THE SECOND LARGEST CITY IN MISSOURI IS HOME TO HIGHLY REGARDED LIVER TRANSPLANT SURGEON AND RCSI ALUMNA (CLASS OF 1996), PROFESSOR MARIA B. MAJELLA DOYLE Earlier this year, Maria B. Majella Doyle, MD, MBA, FACS, FRCSI Professor of Surgery, was named the Mid-America Transplant and Department of Surgery Distinguished Endowed Chair in Abdominal Transplantion at Washington University School of Medicine in St Louis. She is Director of the HPB Fellowship Program, Director of Liver Transplant in the Division of General Surgery, Section of Abdominal Transplantation, and Vice-Chair of Clinical Affairs for the Department of Surgery at Washington University School of Medicine, as well as Director of the Paediatric Liver Transplant Program at St Louis Children’s Hospital.

Her surgical interests at the university are focused on adult and paediatric hepatobiliary and pancreatic surgery as well as liver and kidney transplant. ajella Doyle was born in Cork and lived there until the age of five when her family moved to Dublin because of her father Ted’s career. Then, when she was ten, they moved again, this time to a property with stables and fields in Wicklow, so that she and her older brother, Howard, who were both keen showjumpers, could keep ponies. Majella’s mother, Marie, worked as a primary teacher while her father was involved in the hotel industry. Majella’s parents still live near Enniskerry.

“We used to go to horse shows every weekend,” says Majella. “I was very lucky, it was an amazing childhood.”

After secondary school, Majella studied for a degree in physiology at Trinity.

“I had a wonderful time there,” she remembers. “I made great friends and lived in rooms on Front Square. When the Trinity Ball was on there were always people trying to hide in our cupboards.”

Soon after completing her science degree at Trinity, Majella contracted meningitis, and it was while she was in hospital recovering that she first gave serious consideration to studying medicine.

“I wasn’t really sure what I was going to do after my science degree and the doctor who was taking care of me said, ‘Why don’t you do medicine?’ There was no history of medicine in our family and I didn’t really know how to go about it, but I applied to RCSI and they offered me an interview. I got in and started the upcoming September.

“I’d had a lot of fun at Trinity, but I really flourished academically at RCSI, and I won a few medals in anatomy, pharmacy and surgery during my time there. I made lifelong friends and always catch up with them whenever I come home. Our class was very close – we have an amazing WhatsApp group, so we are up to date with what people are doing – and it was great to meet up with everyone at our reunion last year.”

Majella initially thought she was interested in pursuing a career as an obstetrician or gynaecologist but changed her mind after rotations in surgery in Beaumont and Drogheda in her final medical year.

“We got to scrub in a lot and I was hooked,” she remembers.

8

Professor Maria B. Majella Doyle, FRCSI (2006)

After her intern year in Beaumont, vascular surgeon Professor Sean Tierney, FRCSI (1991) encouraged her to apply for the surgical training scheme, and Majella secured a spot at the Mater Misericordiae University Hospital.

“I was working with Professor P. Ronan O’Connell, FRCSI (1983) and Mr Gerry McEntee, FRCSI (1982) in GI surgery and on the vascular team with Professor O’Malley. I was also exposed for the first time to Hepato-PancreaticoBiliary (HPB) surgery, which I really enjoyed. Mr McEntee was also a transplant surgeon, but he did his transplants in St Vincent’s University Hospital, so I wasn’t really exposed to transplant at that time. He was a tough taskmaster but an amazing surgeon so I learnt a lot.”

Majella went on to do a Research Fellowship in the Department of Academic Surgery at Cork University with Professor H. Paul Redmond.

“That was a great experience,” says Majella. “It was nice to go back to Cork, to the motherland where I was born, and they accepted me back even though I had left, which is not like Cork people!”

Accepted onto the higher surgical training scheme, Majella then spent what she describes as a ‘great’ year working with Mr Bosco O’Mahony (deceased) and Professor Ken Mealy, FRCSI (1985) at Wexford General Hospital, after which she returned to the Mater. A fortuitous encounter at the IHPBA meeting in Washington DC was to set her career on a path she could not have anticipated.

› A Surgeon in…

St Louis, Missouri

Dr Maria B. Majella Doyle

“I was in my fourth year of training,” Majella remembers, “and I was attending a meeting of the IHPBA Association. Gerry McEntee bumped into Professor Will Chapman; they had trained together in liver surgery, at King’s College London.

Will had just moved to Washington University, and they were looking for a fellow, and I was looking for a fellowship. It’s so random the way things happen sometimes! I didn’t know anything about St Louis, and the only thing I knew about WashU was the manual I and everybody else used to carry in our pockets when we were trainees.”

Majella completed her surgical training at Tallaght University Hospital and embarked on a Clinical Fellowship in Abdominal Organ Transplant and HPB surgery at Washington University School of Medicine in St Louis, Missouri, in 2005.

“I only planned to come for a year to do some training in transplant, as this training gives you a lot of skills that you don’t necessarily get from doing just HPB,” she explains. “I intended to go back to Kings College in London and then return to Ireland. But there were no jobs in Ireland at the time and I was getting on well, so I stayed for a second year to complete the transplant fellowship. And then Professor Tim Eberlein, the Chair of Surgery at Washington University, Will Chapman and another surgeon, David Linehan, recruited me to join the department as a member of the Abdominal Organ Transplant and Hepatobiliary Surgery team. It’s been incredible; I’ve been so lucky.”

Majella started as an assistant professor and has since progressed to full professorship. She started out performing adult liver, kidney, and pancreas transplants along with liver and pancreas cancer resections before undertaking paediatric liver transplants. Subsequently, she became the Surgical Director of the Paediatric Liver Transplant Programme at St Louis Children’s Hospital in 2015.

Somewhere along the way, she also found time to do an MBA. “I decided that if I was going to stay in the US, I needed a better understanding of the business side of healthcare,” says Majella. “And so I completed an MBA at Washington University in 2012. It took 20 months and was a big commitment.

Some of the responsibilities given to me in the department such as the role of Vice Chair for Clinical Affairs are as a result of this experience.”

Majella focuses her clinical research interests on clinical outcomes, hepatocellular carcinoma, liver transplantation, and donor management. She is proud to be the current president of the Americas Hepato-Pancreato-Biliary Association and Councilor of the American Society of Transplant Surgeons.

“A typical week includes elective surgeries on Mondays and Fridays and a clinic on Wednesdays,” she says, “and then sometimes I do surgeries on Tuesdays and Thursdays for living donors. But when you’re on call you just don’t know what’s going to happen. So you live a life of uncertainty. I came back from a holiday on

“St Louis is nice and small, with a population of 2.8 million. There are big parks, great museums and a wonderful zoo.” two occasions to transplant sick babies … it’s sort of a crazy life really.”

Surgery call for adult liver, kidney, and pancreas transplants is shared between a team of six, but the paediatric transplant call is shared between just two.

“Dr Khan and I do all the paediatric liver transplants. This year already [early November] we have transplanted 21 livers, which may not seem like a lot when there are 52 weeks in the year, but each one is a big time commitment. We do at least ten days of call a month between kidneys, donors and transplants.”

When Majella arrived in St Louis first, she lived in an apartment in the Central West End, a vibrant area close to the hospital, which she describes as being “a little bit rundown, but sort of up and coming” at the time. She stayed there until she met her now husband, Bob Roth, (‘he’s amazing!,’” she says) who works in biotech, and they moved to the suburbs when they married in 2014.

“Now we live in a house with a garden and a swimming pool,” she says. “When I first arrived in St Louis it was 105 degrees. Being Irish, I didn’t even know how I was going to be able to breathe! So the pool is great in summer. The winters are cold – not Boston or Chicago cold with big snowdrifts, but we do get a few ice storms – and we get four proper seasons, and spring and autumn are beautiful.”

Majella says St Louis is a very liveable city.

“St Louis is nice and small, with a population of 2.8 million. It’s easy to get around. My commute is only 20 minutes in traffic and ten minutes if there’s no traffic. There are big parks and it’s very geared towards families, with great museums and a wonderful zoo.”

Majella and Bob’s son, Rory, is six – “he keeps us all entertained” – while Bob’s two older children, Ryan and Amanda, are both away at college. Ryan, on an athletic scholarship as an ice hockey player, is completing his business degree, and Amanda is interested in attending medical school after completing her undergraduate studies. The entire family loves to ski and goes to Colorado as often as they can get away together; Rory has already decided he wants to be an Olympic skier. “Either that or an artist,” says Majella.

When she can, she gets out on the golf course, but claims not to be very good.

“My husband is a much better golfer than I am,” she says. “So he’s always giving me tips.”

And she rides a friend’s horses when she gets the chance, having initially tried to learn polo. “That’s what they do here,” she says, “but that proved to be quite difficult, so now I just go for a ride.”

Majella makes the trip back to Ireland several times a year to visit her parents, who still live in Wicklow and her sister, Sarah, who is also a doctor and lives in Greystones. Her brother lives in France.

“I’m very much a home bird so I love going back to Ireland,” she says. “We don’t really take vacations anywhere else, other than to ski.” ■ SURGEONS SCOPE / 9

› Wellbeing

No Time to Eat IT HAS BEEN SAID THAT HEALTHCARE PROFESSIONALS DO NOT EAT AT WORK, THEY FORAGE. BUT EVIDENCE SHOWS THAT ESTABLISHING A POSITIVE FOOD CULTURE IS VITAL NOURISHMENT FOR BODY AND SOUL f the consequences of surgeons and other healthcare professionals neglecting their own diet and nutritional wellbeing weren’t so potentially serious, their poor eating habits might be seen as laughable.

But as a factor contributing to burnout – the topic on everyone’s minds – it’s something to which more attention needs to be paid.

Of course, not all surgeons conform to the stereotype, reliant on coffee, energy bars and high sugar drinks to keep them going. Dr Jamal Saleh FRCSI (1989) is a Consultant Orthopaedic Surgeon and Chairman of the Board of Directors at Alsalam Specialist Hospital, Bahrain. As well as his clinical work, Dr Saleh undertakes committee work for The National Health Regulatory Authority, is Governor of the Bahrain Chapter of the American College of Surgeons, President of Bahrain Sports Medicine and Sports Science Society, and chairs the Bahrain Mountain Biking committee. He directs and teaches Advanced Trauma Life Support and recently completed a masters degree in Healthcare Law and Ethics at RCSI. He says a disciplined approach to diet and lifestyle enables him to stay on top of this heavy workload.

“To stay healthy, I wake up early every day, even on weekends,” he says. “I alternate between going to the gym for resistance exercises and cycling as a cardio sport. I find this combination suitable for my age and well being. At the age of 63, I weigh 73 kg, which is right for my height of 179 cm. I keep my weight down by weighing myself daily. My diet is healthy; I take fruit and water rather than a high-protein, high-fibre breakfast before morning exercise. Other meals are low-fat and rich in white proteins and greens. I don’t rely on coffee to keep me stimulated, as I have an abundance of self-motivation and a busy schedule to keep me alert.”

Dr Saleh is blessed with excellent health and professional fulfilment, but believes his healthy lifestyle coupled with diverse professional and extracurricular interests have protected him from burnout.

Professor Peter Brennan FRCSI (1997) is a consultant maxillofacial surgeon at the Queen Alexandra Hospital in Portsmouth specialising in head and neck cancers. He is an expert on how human factors such as fatigue, stress and emotions as well as nutrition and hydration, impact on patient safety and says there is an increased likelihood of human error if medical professionals are not properly fed and hydrated.

“It’s easy to forget to look after ourselves at work,” according to Professor Brennan. “We know that taking breaks and eating and drinking regularly 10

is a critical component of being ‘optimised’, helping to sustain our energy, concentration, and performance, and reduce the risk of human error. Yet … the realities of working in busy, modern hospitals get in the way.’

“Medicine is a demanding profession, with days often starting early and finishing late, and many fall into the habit of forgetting to take regular breaks, not drinking enough fluids, or missing meals. If we want to improve staff wellbeing and reduce the risk of errors, we need to change this.”

Professor Brennan says poor nutrition and dehydration significantly impact on performance in a demanding operating room setting, with even modest levels of dehydration shown to impair cognitive function and performance.

Meals containing protein, carbohydrates and fats such as those derived from olive oil, fish and avocado as well as certain nuts have been shown to provide optimal nutrition, while simple sugars (such as chocolate bars) and processed food do not support long-term concentration and endurance.

Professor Brennan recommends taking a short break of 10–15 minutes every 2–3 hours when at work, especially if performing complex tasks or surgery.

The procedure can continue if there is suitable expertise within the team, but each team member should plan to take a regular break, which can be staggered.

› Wellbeing

“Human factors including nutrition and rest are a critical part of how other safety-critical industries structure their workload.”

Dr Jamal Saleh, FRCSI (1989)

Mr Niall Downey, FRCSI (1997)

Taking regular breaks in a long case leads to improved outcomes and shortens overall operating time.

“Even a short time spent away from operating can help provide a fresh outlook, improve morale, and enable a toilet and food/water break,” writes Professor Brennan. “Recovery is aided through regular sleep, which is positively linked to healthy eating and drinking.”

Mr Niall Downey was a Cardio-Thoracic Surgery trainee in Belfast and Dublin during the 1990s, receiving his FRCSI in 1997. In 1999, faced with a shortage of SpR Training Posts he “reluctantly jumped ship” and retrained as an airline pilot with Aer Lingus. He is currently a captain on the A320 and A321 fleet flying on the airline’s European and Trans-Atlantic routes.

Downey set up Framework Health to share the aviation industry’s successful Safety Management System modified specifically for healthcare.

“Human factors including nutrition and rest are a critical part of how other safety-critical industries structure their workload, an approach noticeably absent in healthcare,” he explains.

“Adverse Events are usually caused by systemic faults but often blamed on the last individual to have touched the ball. We encourage healthcare to adopt a Just Culture, and embed a systemic Human Factors approach.”

For Downey, a useful acronym is HALT: “If I’m hungry, angry, late or tired I’m significantly more likely to make an error.”

“Hunger has been shown to contribute to reduced concentration and poor decision making as does dehydration,” he explains. “As little as a 2% drop in hydration has a significant effect on performance, but is quickly reversed once fluids are drunk. Seventeen hours without sleep causes impairment equivalent to a Blood Alcohol Concentration (BAC) of 0.05%, the drink-drive limit in Ireland, while 24 hours without sleep doubles this to 0.1%. All of this can be easily addressed by treating staff as the valuable resource they are, not as the cost they are sometimes perceived.”

As a pilot, Downey’s hours are limited to reduce risk, with a maximum of 15 hours on duty when there are two pilots. He also has access to regular food and drinks, and an approved hotel on the far side.

“My job often involves getting up at 3am or earlier to drive to work several days in a row or arriving home at that time,” he says. “Disneyland it isn’t but it’s a vast improvement on conditions in my previous life as a surgeon!

Another issue is that anger is a side effect of all of the above and, unchecked can lead to bullying and incivility in the workplace.”

Elizabeth Bleed MD MA and Catherine Humikowski MD of the Critical Care Department at the Ann and Robert H Lurie Children’s Hospital of Chicago note in their article ‘Lunchtime Revolution’, published in the

Professor Peter Brennan, FRCSI (1997)

Journal of the American Medical Association in August 2022, that many doctors “ … have a pitiful relationship with food. Healthcare professionals do not eat at work, they forage. The act of eating is typically quick, efficient and solitary. Emails and patient charts dominate lunchtime … It is strange … that a profession devoted to preserving life holds the act of eating in such low regard.”

Bleed and Humikowski set up a weekly lunchroom in a conference room adjacent to the PICU in which they work, and invited their colleagues to join them. There was no agenda for the gathering other than the simple act of eating together on Thursdays at noon.

The pair did not track “the benefits of [their] wellness intervention”, but they hope that the initiative “becomes part of a broader culture shift among physicians around how we treat our bodies and each other. We hope students and trainees take note: eating is not a shameful act of self-indulgence. It is a biological, social and spiritual necessity. For a profession that lectures patients and families about nutrition … medicine is shockingly bad at nourishing itself. If basic human needs are not met, all other efforts to mitigate burnout, compassion fatigue and attrition will fail. Like building a house with no foundation, expensive structural investment in workforce integrity will collapse if everyone is hungry.”

There’s plenty of evidence to support Bleed and Humikowski’s belief that the act of eating is as nourishing as the food itself. They cite a cross-sectional study of firefighters showing that communal eating correlated with improved performance; a survey of adults in the UK which found that participants who shared mealtimes reported increased happiness, life satisfaction, and community engagement; and research showing that strangers who eat the same food score higher on the measures of trust, conflict resolution and cooperative behaviour.

“Add these benefits to increased efficiency and job satisfaction associated with lunch breaks at work,” they write, “and it almost seems like medicine is flunking on purpose … [perhaps] the low-hanging fruit in the fight against burnout might be actual fruit. Establishing a food culture in medicine … requires a collective respect for the benefits of shared meals and an acceptance that food is necessary for life and community is necessary for living.”

Bleed and Humikowksi conclude by exhorting clinicians, if their clinical practice is truly incompatible with a midday meal, to “revolt by eating lunch and expecting those around you to do the same”.

This may be easier said than done. As Niall Downey says, “without buy-in from government and senior management we may have a long road ahead of us.” ■ S U R G E O N S S C O P E / 11

› Communication

Breaking Bad News LEARNING HOW TO COMMUNICATE BAD NEWS IS ONE OF THE SKILLS TAUGHT IN THE HUMAN FACTORS IN PATIENT SAFETY PROGRAMMES AT RCSI

here is emerging evidence that the quality of the relationship between the clinician and the patient predicts objective improvements to the patient’s outcome.

It has been known since the 1960s that a supportive conversation with an anaesthesiologist directly prior to a surgical procedure results in a reduced requirement for pre-operative sedation and post-operative prescriptive pain relief. Other patient outcomes include, improvements in control of blood pressure, pain (including 12

headache), weight and blood sugars, improved adherence to treatment recommendations, shorter time spent in hospital, and reductions in return visits to the out-patient clinic.

This is the evidence which guides the training delivered to surgeons and healthcare professionals as part of the Human Factors in Patient Safety programmes at RCSI. The programmes are led by Professor Eva Doherty, Director of Human Factors in Patient Safety and faculty in the Department of Surgical Affairs, and are delivered to the surgical, emergency medicine

› Communication

Allowing a patient to speak uninterrupted permits an assessment of the patient’s problem and expectations. and ophthalmology trainees, the scholars on the online interprofessional Postgraduate Diploma/MSc and participants on the Continuous Professional Development Support Scheme.

A central component of all of these courses is communication skills training and in particular training in the skills to help manage difficult conversations which include the breaking of bad news. Communication skills, which are frequently considered to be counter-intuitive, are the focus as there is evidence that they enhance the quality of the clinician-patient relationship, save time and lead to higher levels of patient satisfaction and lower rates of complaints and litigation. Difficult conversations such as bad news telling requires using these same skills with more emphasis compared to less difficult conversations.

COUNTER-INTUITIVE SKILLS OF EFFECTIVE COMMUNICATION Seventy-five different healthcare communication skills have been identified, each with a body of evidence to support their use in healthcare conversations.

The principal skills are described here.

The beginning of the interaction is important. Patients expect clinicians to have prepared for the conversation they are about to have. The initial greeting with an introduction is the clinician’s opportunity to make a connection.

Evidence from social psychology literature has shown that human beings assess each other’s personality traits within the first few milliseconds. The #hellomynameis campaign refers to an awareness campaign initiated by Dr Kate Granger who was a physician in the UK with a rare, terminal sarcoma.

Kate was surprised by how few healthcare professionals introduced themselves to her while administering care, and she initiated the #hellomynameis campaign to highlight the importance of introductions. The campaign has since been adopted by the national health services in both Ireland and the United Kingdom. Introductions should be conducted giving the clinician’s full name and subsequently first names may be used.

The patient’s expectations and agenda should be identified at this stage using open questions in comparison to closed questions that result in brief or yes/ no responses. Open questions and screening questions (“What else?”) should continue to be used until a complete account of the patient’s concerns has been reached. Evidence indicates that clinicians interrupt patients after the first 11-18 seconds following the patient’s response to the first open question.

These interruptions are often motivated by a concern that the patient will speak for too long whereas the evidence is that patients will stop talking after approximately 90 seconds. Allowing a patient to speak uninterrupted permits an assessment of the patient’s problem and expectations. This prevents misunderstandings and allows for any unrealistic expectations to be handled in a sensitive manner before they become problematic.

Periodic summarising is a process skill that is not routinely used by many clinicians but is an effective method of checking, understanding and also communicating to the patient that the clinician is listening attentively and that they understand. At an early point in most conversations, patients will

WHAT PATIENT-CENTRED STEPS CAN YOU TAKE WHEN YOU NEED TO DELIVER UNWELCOME NEWS? Anne Jordan, End-of-Life-Care Coordinator in an acute Level 4 Hospital, Dublin, offers some practical techniques that you can use.

Build a relationship Building a rapport based on trust when you are first treating a patient, establishes a good foundation for difficult conversations later on.

Anne Jordan, BSc Occupational Psychology, MsC Loss and Bereavement

Establish some understanding of their needs before you break bad news Gain some understanding of their and their family’s situation, their religion, culture, home situation, so you can use your judgement as to how to approach communicating the medical position.

Find the appropriate physical setting It’s important to plan to communicate bad news as privately as possible, and to establish the patient’s wishes – do they want to know everything, do they want a family member to be present, their choice is important.

There should be no interruptions.

Demonstrate empathy You will not feel the way the recipient of bad news feels or truly understand their emotions, but you can comfort and support them.

Understand the patient’s perspective Be aware of the patient’s, rather than your grasp of a specific situation, the patient’s concept of ‘worse’ may not be the same. Encourage the patient to describe what they already know and understand.

Speak in plain language Use conversational language, minimise medical terms.

Schedule enough time for your news and their questions Patients must be given a clear opportunity to ask questions.

Remain available for more interaction After bad news is delivered, the patient’s ability to absorb subsequent information is often impaired. As the news sinks in and realities surface, the patient often wants and needs further discussion.

Optimise the next visit You can, for example, ask patients if they would like to bring a friend or relative on a follow-up visit, when matters will be addressed in more depth. Beyond helping your patient remember what was said during the visit, this additional person could potentially act as your advocate, helping you get your message across. (But make sure this third party doesn’t hijack the consent process).

Allow for hope Even a glimmer of hope is better than none at all.

Anne Jordan delivers ‘Dealing with Bad News’, a communications workshop for hospital staff, devised by The Irish Hospice Foundation and Hospice Friendly Hospitals.

S U R G E O N S S C O P E / 13

› Communication

give cues about the emotional impact of what is being described and this should be acknowledged as early as possible. Contrary to what is commonly believed, this will result in shorter consultations and more satisfied patients.

Clinicians will need to convey a diagnosis or an opinion that may not be expected by the patient and can be experienced as bad news. While a terminal diagnosis is obviously bad news, other revelations such as Professor Eva Doherty, laboratory/imaging results or treatment Director of Human Factors in delays, etc. may also constitute bad Patient Safety, RCSI news. Signposting this news using a warning shot is an effective method of directing the patient’s attention to what is important and preparing the patient to hear something unexpected. Signposting in general is an effective skill to use to explain why clinicians are asking certain questions or why certain examinations/tests/treatments are being recommended and is an efficient method of including the patient. For example: “I have something you might not be expecting to discuss today”. The use of this specific skill has been shown to be associated with a reduced likelihood of a malpractice claim.

Silences in conversations allows for patients to have time to express their emotions and ask questions. “What questions do you have?” rather than “Have you any questions?” is more likely to encourage patients to ask questions, particularly patients who may not wish to delay a busy clinician.

During the conversation, it may be necessary to offer different options to patients. Shared decision-making (SDM) is most beneficial when there is equipoise, in other words when there is more than one option available which is of equal benefit. If this is the case, then the patient can be encouraged to describe their preferences in accordance with their beliefs, lifestyle, age, and cultural background. This decision-making process should be supported by the clinician to guide the correct choice. Many patients may need to consider lifestyle changes to improve their own health and their motivation for such change can be assessed using motivational interviewing (MI) techniques.

These techniques include asking the patient to quantify how much difference such changes would make to them and then how able they feel to make these changes. Patients who offer low evaluations will need further discussion over a longer period of time. Adherence to treatment recommendations is low among many patient groups and can be enhanced through the expert use of communication and MI skills. Choosing Wisely is a campaign that originated in the United States in 2012. The aim of the campaign is to equip clinicians and patients with the communication skills to make optimal healthcare decisions which will ultimately prevent the use of unnecessary tests and treatments.

‘Teach-back’ is a phrase used to describe a skill which the clinician should use towards the end of the conversation and promotes patient adherence. It requires the clinician to check the patient’s understanding of what has been discussed so far. There are different ways this can be achieved. For example, by saying “I want to check that I have done a good job explaining all this to you. Can you tell me what you understand about it all so far?” or “I expect 14

The skill of empathy does not come naturally and needs to be learned.

Clinicians who see themselves as highly empathic are likely to offer solutions and advice rather than empathy ...

you will go home and tell your wife/husband/son/daughter/family member what we have discussed, what will you tell them?” The clinician can try out different ways of checking a patient’s understanding to discover the best way for themselves.

Care should be taken to present information using language that is matched to the patient’s information needs. The clinician may have to accommodate to the patient’s age, cultural background and to the presence of any disabilities such as deafness, eyesight problems or intellectual disabilities. A significant proportion of patients have health literacy issues and so may not be able to read patient information leaflets. Many patients are reluctant to disclose these issues and this will require sensitive awareness. Getting to the end of the conversation requires the specific identification of the future plan and remaining issues and questions. Safety netting is a concept which describes the management of uncertainty and is used to draw attention to what the patient should do if the plan goes wrong or if recovery does not progress as expected.

Patients who are experiencing strong emotions require containment in the form of empathy, genuine concern and effective use of silences. Skilled empathic responses for as long as it takes, place psychological limits around the patient and facilitate the development of security and psychological processing of the emotions. Empathy is not the same as sympathy. Sympathy is an emotional response whereby an individual feels an emotion in response to witnessing the emotions of another. It is possible to demonstrate empathy while not feeling that exact emotion. For example, it is possible to demonstrate that one can see/hear the patient’s fear and worry while not actually feeling afraid or worried. Empathy is therefore both an intellectual and an emotional skill. It should be expressed with sensitivity and genuineness which requires an emotionally intelligent capacity and the ability to regulate one’s own emotions.

The skill of empathy does not come naturally and needs to be learned.

Clinicians who see themselves as highly empathic are likely to offer solutions and advice rather than empathy when a patient is distressed. Counter to what might be expected, clinicians can save time if they take the earliest opportunity to demonstrate empathy.

Clinicians do not learn these important communication process skills if they have not been taught them. These counter-intuitive skills can be used with increased emphasis when breaking bad news. The evidence is that training in these skills not only leads to more satisfying conversations for all but also leads to reductions in clinician stress and burnout. ■

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If a member receives a patient complaint, we can help form a response and make the whole experience less stressful.

Comfort in protection that’s right for you:

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BECOME AN MRCS EXAMINER OF THE ROYAL COLLEGE OF SURGEONS IN IRELAND PLAY YOUR ROLE The Royal College of Surgeons is currently recruiting for clinical, basic, and lay examiners in Ireland, Bahrain, Malaysia, and the United Arab Emirates to examine in upcoming MRCS B OSCE examinations.

Members of the RCSI Court of Examiners are kept informed of developments and international best practice in clinical assessment at the Annual Court of Examiners Meeting and are awarded Professional Competence Scheme (PCS) credits for examining and attending our annual meeting. Members also receive a complimentary member’s pack with RCSI Court of Examiners merchandise.

If you’re interested in becoming an MRCS examiner with RCSI, please visit rcsi.com/coe, register your interest by scanning the QR Code or email courtofexaminers@rcsi.ie.

REGISTER YOUR INTEREST TODAY

› Specialty Spotlight

Specialty Spotlight Vascular Surgery STATISTICS ON THE SPECIALTY How many consultants? Currently there are 33 Consultant Vascular Surgeons in practice in Ireland. How many trainees? 23 Vascular Surgery Trainees.

How many fellowships available in Ireland? There are a small number of

fellowships available in Ireland at St James’s Hospital, Beaumont Hospital and University Hospital, Galway. Is there a gap between the number of Consultants in the specialty and the number required? Yes. How many

Consultant posts do you think are likely to become vacant over the coming years? There will be a significant number of Consultant posts

available over the coming years as retiring consultants are replaced and more importantly as new posts are created. Current recommendations from the Vascular Society advise that there should be one vascular surgeon per 100,000 population which with a current population in the Republic of Ireland of just over five million equates to 50 vascular surgeons.

WHAT ARE THE STRATEGIC INITIATIVES FOR THE SPECIALTY?

Vascular Surgery is a relatively new specialty having gained independent specialty status from the Irish Medical Council in 2014. We aim to ensure that all patients requiring access to vascular surgical care receive the highest quality treatment in a timely, accessible and equitable fashion. We aim to continue to recruit and train highly skilled vascular surgeons in Ireland.

A comprehensive Vascular Surgical Curriculum and Vascular Surgical Training Scheme has been implemented since 2014, supported by very committed vascular surgical trainers. By July 2023, four of our vascular surgical trainees will have completed training and achieved CCST, a huge achievement for a new specialty and a tribute to our dedicated Training Programme Directors over the past eight years.

WHAT ARE YOUR KEY OBJECTIVES WHILE IN OFFICE? Ms Mary Barry FRCSI (1987), Chair of the Irish Vascular Society.

Mary Barry (FRSCI, MB BCh BAO LRCPI&SI) was appointed Chair of the Irish Vascular Society in January 2022 for a two-year term. She was awarded MCh in Surgery in 1996 and MD in Surgery in 2004. After completing Basic and Higher Surgical Training in Ireland, she did further training in London’s Hammersmith, Charing Cross and Ealing hospitals and completed a Fellowship in Complex Aortic Surgery at Erasmus University Hospital, Rotterdam, The Netherlands. In 2002, she was appointed Consultant in Vascular Surgery, St Vincent’s University Hospital and UCD Clinical Associate Professor. Her research interests include outcomes from aortic surgery, quality improvement for diabetic foot disease and the biology of carotid artery disease. She has been published extensively in peer-reviewed journals in all of these areas.

20

• To complete the Model of Care Document for Vascular Surgery by the end of 2022. This will outline how vascular surgical services are to be provided in Ireland over the next five to ten years.

• To maintain the current high standard of training through promotion of in-person training, remote teaching and practical masterclasses throughout the year.

• To promote closer collaboration with the European Society of Vascular Surgery and the Vascular Society of Great Britain and Ireland. This would provide for international training opportunities in Europe and the UK. These could be in the form of short or longer term fellowships with the option of fellowship exchange programmes. For those consultant vascular surgeons in practice it could also provide opportunities to undertake shortterm sabbaticals to learn new techniques.

• To promote more international research collaboration through co-operation with national and international registries.

› Specialty Spotlight

WHICH PARTICULAR CHALLENGES ARE FACED BY THIS SPECIALTY IN IRELAND AT PRESENT?

Like all surgical specialties the recent pandemic has resulted in significant increases in waiting lists for in-patient and out-patient vascular surgical treatment. Patients are presenting with more advanced disease requiring more complex multi-disciplinary care.

As the incidence of diabetes in Ireland continues to increase, the management of diabetic foot complications is a huge challenge and is projected to become an even bigger problem in the coming years. This population now makes up a significant proportion of patients requiring revascularisation.

• Staffing shortages – we will need to recruit more Consultant Vascular Surgeons. More nurses trained in the care of vascular surgery patients, particularly at Clinical Nurse Specialist and Advanced Nurse Practitioner level will be required. Vascular Physiologists are urgently needed to staff vascular laboratories and Clinical Podiatrists will be required in increasing numbers in the hospitals and community services.

ARE THERE ANY SUB-SPECIALTY AREAS THAT YOU SEE PARTICULAR NEEDS IN, AND HOW CAN THEY BE ADDRESSED? Diabetic foot management – this requires urgent development of

pathways of care so that this population of patients is seen quickly and treatment commenced as quickly as possible to reduce the risk of lower limb amputation. Development of rapid access multi-disciplinary Diabetic Foot Clinics is a priority. Peripheral Arterial Disease – the majority of patients with PAD can be managed with best medical therapy and exercise programmes. The provision of supervised exercise programmes nationwide would be of huge benefit to this population of patients and greatly enhance their quality of life. Venous Disease – there are now very long waiting lists for patients with varicose veins and venous ulcers. This can be addressed through more efficient and expeditious assessment of these patients using defined referral pathways. Expansion of more ambulatory facilities to treat these patients by endovenous methods under local anaesthesia would remove the need for access to major theatre facilities and greatly improve efficiency and the patient experience. Closer liaison with Medicine for the Elderly Services – for in-patient vascular surgery patients with dedicated sessions provided by Medicine for the Elderly Consultants should be a priority.

This collaboration has been shown internationally to reduce peri-operative complications, reduce length of stay and improve outcomes in this frail elderly population.

WHAT WOULD YOU SAY TO SURGICAL TRAINEES CONSIDERING A CAREER IN THIS SPECIALTY?

Vascular Surgery is a very exciting specialty with an enormous variety of disease presentations. It is constantly evolving with new techniques being developed every year.

It requires a surgeon to be trained to a very high level of surgical technical skill and precision in both open surgical and endovascular procedures.

The vascular surgical trainee must now acquire skills not only in surgery but also in endovascular techniques such as peripheral arterial angioplasty, endovenous ablation for varicose veins and endovascular management of abdominal and thoracic aortic aneurysms. The current training scheme provides opportunities not only in learning surgical skills but also to become proficient in vascular ultrasound, fluoroscopy and advanced wire skills.

The vascular surgical trainee must now acquire skills not only in surgery but also in endovascular techniques such as peripheral arterial angioplasty, endovenous ablation for varicose veins and endovascular management of abdominal and thoracic aortic aneurysms.

For those trainees who seek academic advancement with well-established MCh and MD programmes available within Ireland, opportunities are provided.

There are also long-established links with international centres providing excellent opportunities to undertake post-CCST specialist fellowship training in Canada, North America, Europe, the United Kingdom and Australia.

Training as a vascular surgeon requires significant commitment and a lot of hard work. However, it is a most rewarding specialty and has the benefit of allowing the surgeon to work with a wide variety of specialties within the hospital.

DATES AND KEY UPCOMING EVENTS TO NOTE

2023 will be very exciting and significant for Irish Vascular Surgery with the two major international vascular surgical meetings being held on the island of Ireland.

3 February 2023: Charter Day Meeting, RCSI – Vascular Session: Artificial Intelligence in Complex Aortic Surgery and Vascular Radiology. Model of Care for Lymphoedema. 26-29 September 2023: European Society of Vascular Surgery Annual Meeting 2023 – Belfast. 22-24 November 2023: The Vascular Society for Great Britain and Ireland Annual Meeting 2023, Convention Centre, Dublin. 2023: New Guideline Publications from European Society of Vascular Surgery (Anti-thrombotic Therapy for Vascular Surgery; Management of Descending Aortic Diseases; Management of Peripheral Artery Disease). May 2024: Joint Irish Vascular Society/Northern Ireland Vascular Society (IVS/NIVASC Meeting) – date to be confirmed.

A SPECIAL MENTION

I would like to take the opportunity to send the congratulations of all members of the Irish Vascular Society to Mr Prakash Madhavan, Consultant Vascular and Endovascular Surgeon in St James’s University Hospital who has been awarded a Lifetime Achievement Award at the recent Vascular Society of Britain and Ireland in Brighton in November 2022. Prakash is the first Irish Vascular Surgeon in the history of the Vascular Society to win this award. It is richly deserved and a testament to Prakash’s unstinting hard work as not only a vascular surgeon but also as an educator, surgical trainer and most of all as a surgical innovator. ■ S U R G E O N S S C O P E / 21

› Menopause

Pause for Thought FEMALE DOCTORS REQUIRE MORE SUPPORT DURING MENOPAUSE TO REDUCE THE RISK OF EXODUS FROM THE WORKFORCE, ACCORDING TO A NEW SURVEY

Um acidem dereculicid

emale doctors must be well supported through the menopause to reduce the risk of a potential exodus of passionate and skilled clinicians from the workforce, according to the Medical Protection Society (MPS).

Around 18% of Medical Council female registrants are aged between 46-55, when menopause is likely to occur. Many could be impacted by symptoms such as anxiety, depression, poor concentration, brain fog, dizziness and insomnia while doing their best to care for patients in challenging and complex environments.

MPS said it fears many of these doctors may leave medicine early without better mental wellbeing support, greater awareness from leaders and workplace adjustments – all of which will help these doctors to continue to perform at their best and stay in the workforce for longer.

A survey of female doctors in Ireland who have experienced menopause supports the concerns. The research, conducted by MPS, revealed that only 5% feel supported by their employer/workplace and less than 1% feel supported by their line manager, while 60% feel supported by family and friends.

Over a quarter (27%) feel supported by colleagues but 8% say colleagues have been dismissive of their menopause symptoms.

60% do not know where to seek support for their menopause symptoms at 22

their workplace, and almost one in five (18%) say they have considered early retirement due to menopause symptoms and the impact on their wellbeing.

Gozie Offiah, Senior Lecturer, Undergraduate Medical Programme, RCSI and the National Clinical Lead for Intern Training for the Medical Intern Unit, HSE, said: “It is striking that while most doctors report feeling confident in supporting and managing patients who are impacted by menopause symptoms, so many female doctors do not feel well supported at work when they are affected by these symptoms themselves.

“I recognise menopause and the associated symptoms vary widely; however, clearly there are a significant number of female doctors who are suffering in silence and require more support during this phase of their life. Brain fog, forgetfulness, poor concentration and insomnia can make any job difficult, but particularly so in a challenging and complex environment like healthcare.

“Many female doctors tell us they are concerned about their symptoms impacting on their performance, or resulting in medicolegal issues. This causes additional stress. One doctor summed up her experience in our survey, saying menopause is like ‘falling off a cliff ’.

“Leaders and managers in the HSE and in private healthcare settings must be trained on the menopause and how the symptoms can impact on the wellbeing of some individuals and their teams. Those suffering with symptoms

› Menopause

Dr Gozie Offiah, Senior Lecturer, RCSI

“Many female doctors tell us they are concerned about their symptoms impacting on their performance, or resulting in medicolegal issues.”

should feel comfortable to discuss workplace adjustments and seek mental wellbeing support. If there is a menopause workplace policy this should also be well communicated.

“Making improvements in this area is not only right and fair, it is also essential.

If we do not destigmatise menopause, we may lose many skilled and passionate doctors during a time when the profession can ill afford it. A supportive culture will alleviate additional stress, enable these doctors to continue to perform at their best for patients, and thrive in their careers for longer.”

A paper, Supporting Doctors through the Menopause, produced by MPS, sets out some recommendations: • All healthcare organisations should introduce flexible working arrangements for individual clinicians struggling with menopause, with policies and procedures to ensure they can seek support – such as making reasonable workplace adjustments, taking breaks or taking time off when needed – without fear of adverse impacts on their career or professional reputation.

Professor Paul Ridgway FRCSI • Managers and senior leaders in the HSE and in private healthcare settings must be trained in the topic of the menopause, including the impact the symptoms can have on working females and their teams. Anyone who is suffering with menopause symptoms needs to be supported by their managers, to discuss any necessary changes to working arrangements.

• Occupational health teams should be involved in a proactive way in planning and supporting clinicians going through the menopause in a proactive way to avoid them leaving the profession. This should include support for mental health and wellbeing.

• Primary care providers should consider staff with menopause expertise, when hiring new team members, as this will benefit patients, clinicians and practice staff.

• Healthcare professionals working in the HSE or in private practice who are struggling with menopause symptoms themselves should seek support and professional advice on potential treatments and lifestyle measures. MPS also has a role to play – we listen to and care for members, including offering support with their wellbeing and we have made our 24/7 confidential counselling service available for those struggling with the menopause. ■ The Medical Protection Society Limited (“MPS”) is the world’s leading protection organisation for doctors, dentists and healthcare professionals. Established to protect and support the professional interests of more than 300,000 members around the world, membership provides access to expert advice and support and can also provide, depending on the type of membership required, the right to request indemnity for any complaints or claims arising from professional practice.

QUOTES (ANONYMOUS) FROM DOCTORS IN IRELAND WHO TOOK PART IN THE MPS SURVEY:

“

Menopause is life changing, many women including me will describe it like ‘falling off a cliff ’. Vasomotor symptoms are tortuous but cognitive decline even with HRT is worrying. There is always a concern that I will have to stop practicing medicine due to symptoms of menopause.

”

“

I was clueless about my own symptoms and now realise how dismissive I was about others. The more we educate and mobilise knowledge the better. I thought I was going mad.

”

fortunate that there are two members of staff trained “I am very in this area who advise regarding menopause. ” e need to cover a 24-hour rota and a lack of locum cover means no one “canThtake time off unless a first degree relative dies … Lack of sleep two years ago really impacted me at work in the mornings, but I still turned up. ” I am a menopause specialist so I don’t have any issues with managing “patients or dealing with colleagues suffering through menopause. There is a substantial need for programmes to manage menopause in the workplace and training managerial staff, and public awareness campaigns in dealing with this very important issue.

”

“

Menopause isn’t a huge issue for me, but it would be helpful to have more flexibility in work and the ability to reduce hours would allow the time to address health needs.

”

like to reduce my hours but we do not have the resources.

“MyI would own GP is understaffed and I have been reluctant to make an appointment because I know that she is under pressure too. ” impacts on efficiency at work and particularly “The lack of sleepimpacts on doing on-call. ” and its complications were not taught well at third level “ofMenopause GP training. As a female GP, I have actively sought out further education on this issue. ” embarrassed discussing with male “I would feel incredibly colleagues or managers. ” personal experience has helped immensely in understanding “andMytreating menopause symptoms but I have never come across someone reducing or changing their work due to the symptoms.

Occasionally, they may take a couple of days due to sleep disturbance or mood problems but it is rare.

”

S U R G E O N S S C O P E / 23

› COSECSA

A First for Africa DR FRIDAH BOSIRE, A KENYAN GENERAL SURGEON, IS THE FIRST WOMAN TO BE AWARDED THE GERALD O’SULLIVAN MEDAL, NAMED AFTER THE LATE PRESIDENT OF RCSI WHO INITIATED THE COLLABORATION WITH COCECSA

Dr Fridah Bosire, Mr James Geraghty, RCSI Council Member and Mrs Breda O’Sullivan.

Dr Fridah Bosire

ach year, the candidate who achieves the highest results in the COSECSA (College of Surgeons of East, Central and Southern Africa) exams, across all countries and specialties, is awarded the Gerald O’Sullivan Medal. The medal was first awarded in 2012 and is named after the late President of RCSI who initiated the collaboration with COSECSA. In 2020, Dr Fridah Bosire, a general surgeon based in Nairobi, Kenya, became the first woman to win the prize. Dr Bosire came to Ireland in February 2022 and gave a presentation entitled Global Surgery: Enhancing Safe Quality Evidence-based Surgery in LMICs (low to middle income countries) at the Millin Meeting, after which she was formally presented with the medal by Breda O’Sullivan, widow of Gerald O’Sullivan.

Fridah Bosire was born on the morning of 27 July 1988, at a small dispensary in Kisii, rural Kenya. Her father, Joseph Bosire, is Professor of Curriculum and Instruction as well as the Deputy Vice Chancellor Academic Affairs at the Jaramogi Oginga Odinga University of Science and Technology in Bondo, 24

Kenya. Her mother, Dr Mary Bosire, is a lecturer in the department of Accounting, Finance and Management Science at the Faculty of Commerce, Egerton University in Njoro, Kenya.

“I am told that I made my debut into the world exactly 15 minutes after my mother checked into the dispensary,” she says, via Zoom from her home in Nairobi. She is one of a family of five girls, in a majorly patriarchal society.

“There is a preference for male children in the traditional African community, and so it is a huge stigma for a family to have only daughters. However, my father has always been my greatest supporter. Our parents empowered us by ensuring we got a good education, overlooking the stigma. My father fought all the cultural challenges, encouraged us to study hard, follow in his footsteps and reach great heights. I understood from a very early age that as a female in Africa, I had to break through glass doors and cultural barriers so as to excel in life, and be a good example to all the young girls in my community. I owe everything to him,” she says.

Fridah says she knew from an early age that she wanted to make a career in medicine. “I developed an interest gradually while in primary and high school, thanks to a wonderful science teacher, Mr Japheth Bett.”

At the tender age of 13, Fridah enrolled at Mount Saint Mary’s Catholic boarding school, where she says she learned the value of hard work. She excelled in her primary level exams and went on to join Moi Girls High School, Eldoret, a prestigious high-performing National School. Her favourite subject was, of course, biology. “I was taught from an early age to have discipline, integrity, and consistency. Our school motto was ‘honour, courage and industry’. I always knew I wanted to work in the health sector, as I was fascinated by the idea of nurturing patients back to good health.”

After high school, Fridah went on to do her medical undergraduate degree at Kenyatta University in Nairobi. “Surgery became an area of interest whilst in my undergraduate years, as I greatly enjoyed my surgical rotation during my senior clerkship years.” This interest was further heightened during her internship year at Tenwek Mission Hospital in Bomet, Kenya, a high-level Surgery and Trauma Centre. “I interacted with various surgeons, adept in their expertise. We had immense support in training from visiting missionary surgeons from abroad, through the PAACS (Pan-African Academy of Christian Surgeons) programme pioneered by Professor Russ White, clinical Professor of Surgery at Brown

› COSECSA

University School of Medicine, Cardio-Thoracic Surgeon and Dr Carol Spears, General Surgeon, Diplomate of the American Board of General Surgery.”

After completing her intern year at Tenwek, Fridah got a brief administrative role at a county hospital where she worked as the Sub County Medical Officer in Charge of Health in the whole county. “I learned a lot about health systems, policies and governance during this period. The role involved improving standards of practice and policy making, as well as driving public health initiatives to improve health care accessibility and affordability. However, my passion was still in surgery.” She went on to apply for the Tenwek COSECSA/ PAACS general surgery programme in 2016 and was delighted to be admitted into the programme after an extremely competitive interview. PAACS has a longstanding partnership with COSECSA that allows trainees from PAACS accredited institutions to participate in the COSECSA training programme.

“I had the privilege of working with and having great female surgeons as mentors, including Dr Agneta Odera, Dr Carol Spears and Dr Andrea Parker,” says Fridah.

The training programme was intense. “But I love what I do. I am ecstatic in the operating theatre and elated when I see a patient do well. I find joy in teaching and mentoring my junior colleagues and seeing them excel. I have a strong desire to bring about change in the number of females who enrol for surgical training in my country. Being a competent female surgeon is a great privilege, and very rewarding. I consider my strongest points to be enthusiasm, stamina, resilience and tenacity.” She won the best MCS candidate award during the 2017 COSECSA exam in Maputo, Mozambique, when nursing her two-month-old baby.

Fridah explains the challenge facing pregnant female surgeons. “It was really tough. During my cardio-thoracic rotation I was often in the operating theatre for nine or ten hours, sometimes more. I also did an Orthopaedics rotation, which was very physically demanding, during my third trimester. I did my written MCS COSECSA second year exam when I was 38 weeks pregnant, and the oral exam just two months post-partum. Looking back, I must have studied really hard!” She says she spent her days learning in the operating theatre, her nights studying Schwartz’s Principles of Surgery.

Fridah had her daughter, Yvette Ayira, who is now five, in 2017. Due to prolonged labour, she was delivered via Caesarean section by an Irish urogynaecologist, Dr Jonathan (Johnny) Shaw, who was visiting Tenwek from the US to help patients with obstetric fistula. She says if her baby had been a boy, he definitely would have been named after him!

Dr Fridah Bosire

“There is a preference for male children in the traditional African community, and so it is a huge stigma for a family to have only daughters.”

When Fridah completed her residency in 2021, she moved to Nairobi to take up a position at St Mary’s Mission Hospital, which looks after the population of Kibera, the largest slum in the city. The 300-bed hospital has just two general surgeons, and outsources the other specialist surgeons.

“We are trained to give back to society,” she says, “to go to a place where there is a surgical need. We deal with lack of equipment, infrastructure, poor resources, and financial shortcomings on a daily basis. Our biggest challenge is that we do not have an ICU, so I am trying to set one up at the moment so that we can provide critical care services to our patients who are in dire need. “ After just a year at St Mary’s, Fridah was appointed medical director of the hospital and she now heads up the hospital’s clinical services. As there are only two surgeons, she is on a one-in-two call rota. “The administrative role is challenging but rewarding at the same time. I use the responsibility accorded to me to advocate for the provision of quality healthcare services for patients, and I am excited to say that we are now in the construction phase of our ICU/ HDU/Renal Unit, Oncology Unit as well as Dialysis Centre.

“We see a lot of cancer cases – oesophageal, breast, cervical/ovarian and colon. Patients come in really advanced stages, and it breaks my heart. They cannot access the service because they do not have the money, so they present at an advanced stage of disease. It is a Catch 22 situation, in that they lack the resources to come, and we lack the proper resources to help them. At the moment we have to move patients to another hospital if they need ICU care. The healthcare system in Kenya is complex, and treatment is not free, so patients have to be able to afford a deposit or down payment to the referral facility. In the mission hospital the cost to the patient is less, and we do not turn them away, but we are very stretched.” It is a constant struggle but clearly rewarding when the team sees patients do well. “I am excited for the next phase, where we actually get to make these services available to our patients.”

Fridah’s intention when she arrived at St Mary’s was to stay short-term and then go abroad on fellowship and train in a sub-specialty.

“My initial interest was in breast oncoplastic surgery, but due to the need, I

St Mary’s Mission Hospital, Nairobi.

S U R G E O N S S C O P E / 25

› COSECSA

“The healthcare system in Kenya is complex, and treatment is not free, so patients have to be able to afford a deposit or down payment to the referral facility. ” am inclining towards Trauma and Critical Care,” she explains. “Having patients under my care makes it very difficult for me to move. I get a lot of satisfaction from my work now.”

When Fridah visited Ireland in February she had the opportunity to undertake an observership with Mr James Geraghty at SVUH, where she witnessed robotic surgery for the first time. “I was able to observe his breast care clinic as well, and it gave me the idea to start a breast clinic here at St Mary’s. Since I returned from Ireland we have already seen more than 300 patients, and the idea is to screen more, as early diagnosis saves lives.”

Fridah sat her final written COSECSA exams in December 2020, and the oral exam in January 2021. “I had great tutorship from all my PAACS faculty at Tenwek, and indeed I owe the award to the effort they put in my training. I was equipped to face the exam with confidence.”

Fridah says she was elated to achieve the best score in Africa in the final COSECSA exams, and to be the first woman to achieve this. An invitation by the College to come to Ireland on a fully sponsored trip to be presented with the Gerry O’Sullivan medal, was her first time out of the continent.

“I fell in love with Ireland on that trip,” she says. “And it made me very happy that my hard work and effort was recognised. My family was immensely proud.”

During her trip to Ireland, Fridah had the opportunity to spend time at RCSI. “I got to see the RCSI heritage collections of the fathers of surgery, the people we read about in surgical books – William Dease, Abraham Colles and others. The RCSI tour by head porter Mr Frank Donegan included a viewing of the medical instruments used for surgery in the past. We came to this cabinet where there was a 19th-century amputation hand saw and he explained that this is what they used to do amputations way back. I replied, ‘This is what I have available to do amputations now’, which he found quite amusing. My favourite part of the tour was the Women on Walls portraits, which recognise the pioneering achievements of extraordinary women. I drew great inspiration reading about these phenomenal women.”

Fridah plans to stay in Kenya in the short to medium-term, but due to the limited opportunities that exist in her country still hopes to go abroad on fellowship. “I want to seek further opportunities for education, so that I can bring new skills back to help our patients. During my visit to RCSI, I had the honour of meeting and getting wise counsel from Professor Ronan O’ Connell, as well as Professor Mike Griffin (President of RCSEd) and Professor Mike McKirdy (President of the Royal College of Physicians and Surgeons Glasgow).”

Since receiving the Gerald O’Sullivan award, Fridah says she has read everything she can about the man after whom it is named. “I draw inspiration in my current practice from him, hence my choice to stay and work to serve the needy at a small mission hospital. I think he was an exemplary member of the surgical profession. I feel I am his protege by getting this award, and I hope to achieve for my patients in Kenya as much as he did for patients worldwide.” ■ 26

Dr Fridah Bosire at RCSI.

THE RCSI/COSECSA COLLABORATION PROGRAMME The partnership between RCSI and COSECSA has been running since 2007. It was initiated by the late President Professor Gerald (Gerry) O’Sullivan of RCSI and Professor Erzingatsian, Honorary Fellow, RCSI, FRCSI (1976), the then President of COSECSA. The men had been classmates at RCSI in the 1960s and 1970s.

The partnership now encompasses anaesthesiologists, ob/gyn, and perioperative nurses, and involves eight colleges working together. It has been funded by Irish Aid since its inception.

Professor Erzingatsian died this summer at his home in Zambia.

2022 COSECSA EXAMS, WINDHOEK, NAMIBIA The annual COSECSA Fellowship exams took place in Namibia from 5-6 December. 170 candidates who have trained with COSECSA in over 20 countries in sub-Saharan Africa travelled there to undergo clinical and viva exams.

COSECSA invited examiners from surgical colleges around the world to serve in these exams. Eight RCSI Fellows including President Professor Laura Viani and Past President Ronan O’Connell agreed to serve on an honorary basis. The exams were followed directly by the graduation ceremony on 7 December. Her Excellency Ms. Bronagh Carr, Ambassador of Ireland to Zambia and Mr. Brian Caden, First Secretary, attended the ceremony reflecting Irish Aid’s longstanding support to the RCSI/ COSECSA Collaboration Programme.

Dr Fridah Bosire would like to thank Professor Ronan O’Connell, Professor Laura Viani, Mr James Geraghty, Mr Eric O’Flynn, Miss Ines Peric, and Miss Deirdre Mangaoang for making her trip to Ireland possible.

She would also like to extend immense gratitude to her PAACS faculty/ family. Ms Susan Koshy (CEO, PAACS), Dr Keir Therlander, Dr Bruce Steffes, Professor Russ White, Dr Carol Spears, Dr Heath Many, Dr Agneta Odera, Dr Liz Mwachiro, Dr Mike Mwachiro, Dr Bob Parker and Andrea Parker, Dr Kiprono Koech, Dr Mike Ganey, Dr Will Copeland, Dr Arega Fekadu, Dr Jens Vaylann.

› Scope Diary

Scope Diary

SPRING/SUMMER 2023

FELLOWS AND MEMBERS EVENTS PROGRAMME

Fellows, Members and Affiliate Members of RCSI are warmly invited to register for the upcoming events and to save the dates CHARTER MEETING 2023 Saturday, 28 January – Friday, 3 February 2023 RCSI Dublin SHAPING THE FUTURE Becoming a Standout Surgeon (Part of RCSI Charter Week Affiliate Member programme – Registration now open) Friday, 3 February, 11.30am to 1.00pm RCSI Dublin

SURGICAL MATTERS WEBINAR The Emotional Impact of Working in Healthcare Wednesday, 22 February, 6.00pm Online Webinar

SYLVESTER O’HALLORAN PERIOPERATIVE SYMPOSIUM Thursday, 2 March - Saturday, 4 March 2 March: CERC (Clinical Education and Research Centre) Building at University Hospital Limerick 3 & 4 March: School of Medicine, Faculty of Education & Health Sciences, University of Limerick

SURGICAL MATTERS WEBINAR A Surgical Training Perspective Wednesday, 22 March, 6.00pm Online Webinar DOING THE ROUNDS ROADSHOW MIDLANDS (TULLAMORE) Wednesday, 19 April, 4.30pm Midland Regional Hospital Tullamore SURGICAL MATTERS WEBINAR The Future of Scheduled and Unscheduled Care Wednesday, 17 May, 6.00pm Online Webinar DOING THE ROUNDS ROADSHOW, CORK Thursday, 22 June, 4.30pm Cork University Hospital REGISTRATION & QUERIES: fellows@rcsi.ie.

Online registration is essential.

Registration is now open.

CPD will be available for all sessions.

For queries, please contact fellows@rcsi.ie.

S U R G E O N S S C O P E / 27

› Q&A

The Colles

Q&A

Professor Carmel Malone CONSULTANT GENERAL AND BREAST SURGEON, PROFESSOR CARMEL MALONE HAS ALWAYS DEMONSTRATED STRONG LEADERSHIP

Professor Carmel Malone, FRCSI (2005)

A graduate of UCD in 1995, Professor Malone was appointed Consultant Academic General and Breast Surgeon in Galway University Hospitals and University of Galway in 2006 and was appointed Head of School of Medicine in 2016. During her fiveyear term she led the modernisation of the undergraduate curriculum focusing on preparedness for practice and development of improved infrastructure including a highfidelity simulation centre in on the University Hospital Galway site. From 28

2019-2021, Professor Malone chaired the Irish Medical Schools Council, working with Ireland’s medical schools and healthcare partners during the COVID crisis to ensure continuity of training for undergraduate students.

She led the School of Medicine to an Athena Swan Bronze Award in 2018; previously the School had the lowest level of female leadership in the British Isles. The University of Galway was the first school of medicine in Ireland to achieve this award. In her clinical and academic practice, Professor Malone

has a particular interest in breast cancer molecular oncology and breast reconstructive techniques. She has published widely in these areas and her current research interest explores the use of CAR-T cells in breast cancer patients. Professor Malone is past president of the Society of Irish Breast Surgeons (2015-2018) and remains a consultant trainer and member of the RCSI General Surgery postgraduate training committee as well as providing preceptorship in reconstructive techniques to consultant colleagues.

When and where are you happiest? With family, around the table, lots of conversation, banter and laughter.

What is your ideal evening?

Friday evening pizza with my children in Dough Bros, sitting on benches, chatting about our week.

If you could research and write a book on any subject, what would it be? A travelogue. Driving the Pan American highway, from Colombia to Ushuaia, Argentina.

I’ve never visited South America and it’s definitely one for the bucket list.

However, I think the reality would be far less intrepid – more Francis Brennan than Jack Kerouac – as road trips go.

What relaxes you most?

Running, or more specifically, finishing a long run.

What is your greatest fear?

Small planes. I don’t want to fly in anything where I can see the pilot. Many years ago I travelled to Honduras with my colleague Professor Ray McLaughlin, FRCSI (1988) and the Irish army on a medical relief mission. I can still hear the pilot beeping the horn of the plane to move the goats from the improvised runway. When we landed, we saw an identical small plane crashed in a trench nearby. I only take the ferry now when visiting the Aran Islands.

When did you decide you wanted to become a surgeon?

A surgical research project as a medical student in the Mater led to

› Q&A

an elective in Johns Hopkins with John Cameron and that set me on the road to a career in academic surgery, assisted by a number of wonderful mentors along the way.

Would you have any advice for your younger self? Take your time. The fastest route to a consultant post is not the goal. I see it as a very positive development that young doctors take opportunities throughout (and sometimes outside) their training to broaden their experience both in medicine and life.

It’s important to remember too that a consultant post is really only the start of your career and there are many more potential roles ahead.

How do you have fun? I’m not sure if fun is the correct term but I started running about ten years ago and last week finished my 21st marathon. I’ve run all the World Major series as well as marathons in Madrid, Paris and Amsterdam.

Marathons are a great way to see a city but nothing beats the support in Dublin. The excitement and camaraderie at the start line is only eclipsed by the relief and sense of achievement at the finish line. It’s almost enough to make you forget miles 22 to 24.

Where would you be if you decided not to become a surgeon? I initially applied to study Fine Art in NCAD. Sadly, I lack even a modicum of the necessary creativity to become the next Mary Swanzy or Eileen Gray, but reconstructive surgery provides a far better outlet for any artistic ambitions I harboured.

In what way do surgeons struggle/what issues do surgeons today face? Trying to deliver ever-increasing expectations with ever-decreasing resources.

Who have you learned the most from in your life? Personal My parents and their unwavering devotion to their family. Professional I have been fortunate to have a number of excellent mentors during

my training. Professor David George’s empathy and understanding when communicating with patients is something I try to replicate daily, and observing Mrs Eva Weiler-Mithoff ’s technical mastery and careful patient selection has taught me invaluable lessons in my own reconstructive practice.

How does a surgeon in 2022 cope with pressure? It is critical for all surgeons to have the confidence and competence that a high-quality training programme delivers. Supportive colleagues, not just fellow surgeons but across multiple disciplines, and effective teamworking allow us deliver the results our patients deserve.

What is the best thing about the system of training young doctors in Ireland? There is a deep-rooted ethos of teaching embedded across all areas of clinical practice in this country. As Head of School of Medicine in University of Galway, it was humbling to see the commitment of busy full-time clinicians teaching both medical students and trainees.

What is your greatest extravagance? Fancy running shoes. The delusional hope that some new carbon plate technology will overcome my very limited athletic ability and make me run like Kipchoge!

Do you have a mantra to live by? Surgical practice teaches us that even the most complex and daunting challenges can be broken down into a series of small steps, you just have to make a start.

What do you consider your greatest achievement? My two children, I’m enormously proud of them.

In your profession, a historical figure you admire? Revered in Johns Hopkins, it would be hard to identify any individual who has contributed more to surgical practice than William Halsted. From local

“Surgical practice teaches us that even the most complex and daunting challenges can be broken down into a series of small steps, you just have to make a start.”

Duciptil iciamquem n

Professor Carmel Malone Oscar Wilde

anaesthesia, concepts of cancer spread and most importantly the introduction of surgical residency training, Halsted left a substantial legacy across research, training and technical practice despite battling his own personal demons along the way.

What is your favourite memory? My mother died last year after a long illness and some of my strongest memories are of hours spent with her window-shopping and chatting whilst my father waited patiently for us. It reminds me that the greatest gift you can give, especially to your children, is time.

Name your favourite writer(s).

Hilary Mantel, Haruki Murakami, any historical biography.

If you could invite any historical figure to dinner, who would it be? Oscar Wilde. Who doesn’t want to be entertained over dinner?

Which talent would you most like to have? I wish I were a

Haruki Murakami

polyglot. Italian, Spanish, Chinese top the list if I ever find the time.

What is the wisest thing you have ever said? “Can I ask your advice…?”

Name one virtue all surgeons ought to have. Compassion.

Name one vice no surgeon should have. Apathy. ■ S U R G E O N S S C O P E / 29

› Back to the Beginning

Back to the Beginning AS HE REFLECTS ON A LONG CAREER IN SURGERY IN IRELAND AND CANADA, AND AS A MEMBER OF THE CANADIAN FORCES HEALTH SERVICES DEPLOYED TO AFGHANISTAN, IRAQ AND HAITI, DR VIVIAN C MCALISTER, FRCSI (1987) SAYS LUCK HAS PLAYED A HUGE PART IN HIS LIFE AND CAREER. HE IS CURRENTLY PROFESSOR EMERITUS IN THE DEPARTMENT OF HISTORY AT THE UNIVERSITY OF WESTERN ONTARIO

Dr McAlister has been honoured with the Order of Canada for ‘his seminal contributions to and leadership in the military and civilian surgical communities, as a medical practitioner, researcher and educator’.

rowing up in Terenure, Vivian McAlister attended Loreto on the Green and St Mary’s College in Rathmines before completing his secondary school education as a boarder at Castleknock College. His grandfather Patrick O’Dowd was a doctor, who graduated early in the 20th century from University College Dublin. His father John McAlister was a dentist, so there was medicine in the family.

“I can’t remember ever making the decision to become a physician,” says Vivian, via Zoom from his home in Canada, “but I applied to medical school and Trinity offered me a place in March of my final year of school, prior to completing the Leaving Certificate. I started in September 1973, having just turned 17. Professor Ronan O’Connell [former President, RCSI] was one of 30

my classmates. I would cycle from Terenure into Trinity for lectures with Paul Burke FRCSI (1983) who was a year ahead of us.

“What was unique about Trinity at that time was that after your first two years of basic science education, you were assigned to one of Dublin’s many small hospitals for the rest of your training. I went to Sir Patrick Dun’s where I was part of a very small community of physicians, trainees and students, all of whom virtually lived in the hospital on Grand Canal Street. It was like being part of a family and echoed the experience I had in boarding school, where I lived with the boys for five years. I am still friends with my classmates from Castleknock and with my fellow students from Sir Patrick Dun’s and Trinity.”

After graduating in 1979, Vivian completed an intern year, with six months of surgery followed by six of medicine. During that period he considered a career in surgery, but a shortage of surgical training places saw him taking up a series of short house-officer jobs including one in Harcourt Street Children’s Hospital and another in St Vincent’s Hospital.

“Jobs were very, very scarce in Ireland at that time,” he recalls. “I thought perhaps I’d be a general practitioner, and I think if I had been offered a job I probably would have taken it and stayed in Ireland as a family doctor. But instead I left Ireland and went to the far north of Canada to practise as a general practitioner.”

At the age of 25, Vivian was already married to Christiane and had three young daughters, the youngest of whom was born just a few weeks before they left Ireland.

“I don’t remember being nervous at all,” says Vivian. “I was excited, looking forward to the opportunities. And we were extraordinarily well prepared as Irish-trained physicians – we were equipped to deal with just about anything.”

Vivian and Christiane initially planned to be in Canada for just a year.

“Once I started travelling, though, I got hooked. Medicine was extremely flexible. You could be what you might call a travelling physician, you could work your way around the world, doing short-term jobs. At first I worked in a place that was dependent on a mine and when the mine shut down, they didn’t need me any more. Then we moved to the southern part of Saskatchewan, on the prairie, where I was a general practitioner for almost four years. Among my patients were Indigenous Canadians, who reminded me of patients from rural Ireland. When we had our Canadian citizenship, we decided to come back to Ireland so I could do some surgical training. I intended to go back to Canada as what we call a community surgeon – a non-specialist surgeon, or general surgeon working in a smaller hospital.”

From 1985 to 1990, Vivian worked as a surgical registrar in Ireland, in various hospitals including, for a time, in Enniskillen during the Troubles, an

› Back to the Beginning

A surgical station to support a casualty collection point in Iraq in 2017.

“Surgeons have a very privileged role in society, and with that privilege comes the responsibility to pay back...”

Major McAlister, as part of the NATO Training Mission - Afghanistan, at a meeting with physicians in Kabul in 2012.

experience for which he is grateful. During this period he sat for the primary and the fellowship exams at the same sitting.

“I studied for both at the same time. The College said to me: ‘Look, you’re not getting your fees back if you fail the primary!’ I did a course in the College for the primary. We all worked in hospitals at the same time and we’d come into College in the evenings and at weekends. That was another very strong group, which included Professor Cathal Kelly FRCSI (1990) [now Registrar of the College]. Again, I felt I was part of a ‘family’ team in which we supported one another to do well.”

Vivian passed both exams at the first attempt and became a Fellow in 1987.

“I wasn’t part of the surgical training scheme and I let it be known that I was going to go back to Canada,” he explains. “And as a consequence of that, I found that doors opened for me. The senior registrar programme was very structured, but I was able to design my own training the way I wanted. I was doing vascular surgery with Vincent Keveney and Denis Mehigan FRCSI (1981) in St Vincent’s, when Niall O’Higgins FRCSI (1970) asked me if I would be interested in doing a job with him. He was developing cancer surgery and liver transplantation, but also as professor he was involved in teaching. So I

was to be the surgical tutor, and registrar. That was a brilliant job. I did it for 18 months, and it really set me off on my path and I decided to become a specialist surgeon, rather than a community general surgeon as I had originally intended.

Niall helped me get a job in London, Ontario, where I did a clinical fellowship with Bill Wall in liver surgery and transplantation from 1990 to 1992. That both helped my surgical training and gave me the entrée back into the Canadian scene that I wanted.”

On completing the Canadian fellowship exams, Vivian took a job as a liver transplant and general surgeon in Halifax, Nova Scotia.

“By my good fortune again I was part of an excellent team of surgeons and we provided care for the Atlantic provinces, covering Newfoundland, New Brunswick, Prince Edward Island and Nova Scotia,” explains Vivian. “That gave us a very important role within the whole Canadian context of liver transplantation. We would travel anywhere in those areas for organ donors but generally the patients came to us. I did quite a bit of telephone care in co-operation with their local physicians. So we were one of the very early programmes doing remote care that has become more popular in recent years.

We were three surgeons looking after liver transplant patients, and we worked with our two physician colleagues. The five of us were pretty tightly knit, and we were able to look after these patients to the highest standard. We were also part of the kidney-pancreas transplantation programme.”

Vivian stayed in Halifax until 2001, when he was recruited back to London, Ontario, to work on the multi-organ transplant team. In addition, he carried out liver surgery, ERCP and general surgery.

“In Halifax, I had been a teacher for several military surgeons,” he recalls.

“And there were military surgeons in Halifax who were my colleagues. So I knew the system very well. And in my own background, my grandfather Charles McAlister was a soldier. I was conscious of it, but I never thought I’d act upon it. After 9/11, I was asked to give a talk on the history of surgery at a national meeting. I reviewed our role as military surgeons of the various conflicts. And I made a comment that our war in Afghanistan might be forgotten in the future, a bit like the Boer War now. Somebody in the audience made a cutting comment saying: ‘Well, you’ve got to remember, it is a war.’

S U R G E O N S S C O P E / 31

› Back to the Beginning

Dr McAlister in the field.

Vivian was deployed seven times in total – five times to Afghanistan, and once each to Iraq and Haiti – with each deployment lasting between two and four months.

And I remember being stung by it, and I went home and I thought about what he had said and about how Canada had been extremely good to me in terms of the opportunities it had given me. Surgeons throughout the world have a very privileged role in society, and with that privilege comes the responsibility to pay back and so, if the country is at war, and the soldiers are at risk, surgeons have to be available for them. I knew there was a shortage of surgeons in Afghanistan, and so I volunteered.”

Vivian made his first trip to Afghanistan as a civilian in 2007, after which he decided to join the Canadian Forces. He commenced six weeks of basic training in 2008 at the age of 52.

“It was terrible,” Vivian recalls, “but I managed. There was another gentleman there who was a little older than me and he was very fit. We stuck together. He’s one of these guys who’s a runner, and I’m not at all, I hate running. So he said to me: ‘We will be first and second every time we train.’

“Then there was medical officer training. You could break that one up and I did it in bits and pieces, because every time I was scheduled to train, they’d send me overseas instead. The peculiarity of that one was not only that I was older, but for part of it, I was teaching part of the course while for another part I was a student.”

Vivian says his family were supportive of his decision, even though they must have been very worried about him.

“My family was very generous. They thought it was crazy, I suppose, at the beginning, but they understood my rationale, because I’ve always been serious about our commitment to citizenship in Canada. With hindsight, I think it caused a lot of distress. But the Canadian Forces provided as much support to ameliorate that as possible, so I was able to communicate while I was overseas.

At times I had to be careful not to communicate too much, because if I was constantly on the phone to them, they might miss a call one day and think something had happened to me.”

Vivian was commissioned as a major in 2008. As the Canadian Forces had closed their military hospitals, he was seconded to the hospital he was already 32

working at in London, Ontario and was able to keep his existing job. He continued to make academic contributions to transplantation but now also focused on combat surgery. He described the pattern of injuries caused by the anti-personnel improvised explosive device and he designed a vehicle for “farforward surgery”.

“Externally, you would not know I was in the military at all as we didn’t attend the hospital in uniform,” he explains. “The only difference was that I was available to the armed forces for training others, and for exercises or deployment.

Occasionally, I had to tell my colleagues: ‘I have to go and do this.’ I was part of a magnificent team who covered me for all of those deployments, sometimes at very short notice. I was on four ‘on call’ lists at the same time – liver transplant, kidney transplant, general surgery, ERCP. And I’d just send a quick email or phone and say: ‘I have to go, can you manage?’ And they’d all say yes immediately.”

Vivian was deployed seven times in total – five times to Afghanistan, and once each to Iraq and Haiti – with each deployment lasting between two and four months. While he says he never regretted the decision to sign up, he did dread the deployments.

“I didn’t consider the consequences too much,” he says, “although I knew there was a bit of luck involved. Once or twice, I got worried that maybe the luck was going to run out. But once you’re there, you just do the job, and once I was home, I was delighted.”

When Vivian signed up, the age of retirement had been 55, but that was extended year by year and he ended up staying until the age of 63, leaving with the rank of Lieutenant Colonel. At one stage, he was the oldest person in the Canadian military.

When he turned 66 earlier this year, he retired from clinical practice.

“It was the right time,” he says. “I worked hard all my life and the types of things I did are all critical types of surgery – high stakes, for the patient, surgery.

I was also involved in teaching, and I trained a good cadre of replacements for myself; some went elsewhere, but several stayed and took over my job. So my job was well cared for and I was superfluous to their needs. I wanted to get out before I made an error.”

Now Vivian is a Professor Emeritus at the University of Western Ontario, also known as Western University. Now attached to the Department of History, he is undertaking research and writing on the history of medicine.

Of his three daughters, Chloe is a general surgeon in Toronto, Chryssa is an ophthalmologist in Kitchener and Chioni is a civil servant in Ottawa. He and Christiane have eleven grandchildren, which he says takes up quite a bit of time.

“We don’t remember paying as much attention to our own children as these grandchildren,” he laughs. “I have family in Dublin and we come back once a year and they visit us here too. So we’re very lucky that communication is so good between Canada and Ireland. It’s almost like living in different provinces of Canada.”

In 2019, Vivian was honoured with the John McCrae Memorial Award, presented to current or former clinical health services personnel of the Canadian Armed Forces for exemplary service, and with a lifetime achievement award from the Canadian Society of Transplantation. In 2020, he was made an officer in the Order of Canada.

“I’m very grateful and touched,” he says. “I don’t know if it’s the same for everybody but at my age I find I get emotional so easily. These things don’t come out of the blue. No matter what you do, how good you are, it’s up to your colleagues to nominate you and to go through those tedious processes of getting supporters and things like that. So that’s what they’ve done for me. If these were awards for teams, I’d be much happier.” ■

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