Surgeons' News March 2015

ETHICS

RIGHT VS WRONG

Professor Robert Winston on the history of moral dilemmas in healthcare

REGULATION

MEDICAL INNOVATION BILL

What you need to know about the controversial legislation proposals

UROLOGY

SPECIALTY PROFILE

Technology, training and Nobel Prizes in one of the oldest disciplines

Surgeonsnews Surgeons March 2015

The magazine of The Royal College of Surgeons of Edinburgh

COURAGE AND CONVICTION We proudly present our new Fellow, Daw Aung San Suu Kyi

PLUS

The benefits of increasing physical activity www.surgeonsnews.com

surgeons_news_colour_page_out 13/11/2013 13:58 Page 2

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WELCOME

FROM THE EDITOR John Duncan introduces the spring edition

I

n 2004, College Council decided to give Daw Aung San Suu Kyi the highest honour the College can bestow, an Honorary Fellowship. Another decade passed before an opportunity arose to make the award. In January, RCSEd President Mr Ian Ritchie and members of an MRCS examining team travelled from Yangon to Naypyidaw, the capital of Myanmar to do so (see page 18).

While most Honorary Fellowships have been for clinical and academic excellence, her “nonviolent struggle for democracy and human rights” has resulted in numerous international awards, including the Nobel Peace Prize.

Myanmar is a fascinating and hospitable country and its people deserve our support.

After several years of absence, we resumed MRCS examinations in Yangon in 2013, and there is much more we can do to aid the development of training and assessment, as well as clinical care. The College has also facilitated a significant number of trainees to come to the UK as observers. The huge financial sacrifice made by them and their families is humbling.

Meanwhile, the College’s Birmingham Regional Centre continues to develop its role. One of the main aims for the office was to improve our national visibility and relevance. The work that the President, the policy group and the Birmingham team have done in lobbying about the Medical Innovation Bill has done much to demonstrate that relevance to Parliament. Lord Saatchi introduced the bill, which aims to remove the risk of actions for negligence when administering ‘innovative’ treatments.

We think the bill, as originally stated, represents a threat to patient safety (see page 36).

Following representation from us and other organisations, a number of amendments have been tabled to improve the bill.

Lord Winston commented on our helpful contribution when he spoke against the bill in the House of Lords, as recorded in Hansard.

It will have had its second reading in the Commons by the time you receive this edition. If it passes, it

will be a better bill following our efforts; if it does not pass, the College will have had some part in that.

As I write, a large area of the College’s campus is a building site as the Lister Project progresses apace. The steel work for the link building has been erected and the builders are creating the new entrance from the garden to the events building. The museum and its associated works are on schedule to open in September.

Time capsules can provide a fascinating historical insight into the community that left them behind. The capsule left by the men carrying out the restoration of the Playfair

A number of amendments have been tabled to improve the Medical Innovation bill… if it passes, it will be a better bill following our efforts; if it does not pass, the College will have had some part in that Building in 1908 demonstrates what was in their minds and what was important to them (see page 8). If we were to leave a time capsule in the present renovation, what should we put in it?

What objects will reflect what is in our minds and what is important to us? Your suggestions would be appreciated by this magazine and the museum team.

Physical activity is important to us, both as individuals and as clinicians. A study showing the importance of a pre-operative exercise programme in reducing morbidity following aortic aneurysm surgery came across my desk this month, emphasising to me that making our patients fitter before elective surgery is of benefit. See page 22 for more on this; and in the summer edition we will feature a round-table discussion of this important development.

John Duncan editor@surgeonsnews.com www.rcsed.ac.uk | 1

24

Surgeonsnews

ETHICS

RIGHT VS WRONG

Professor Robert Winston on the history of moral dilemmas in healthcare

REGULATION

42

UROLOGY

MEDICAL INNOVATION BILL

SPECIALTY PROFILE

What you need to know about the controversial legislation proposals

Technology, training and Nobel Prizes in one of the oldest disciplines

Surgeonsnews Surgeons March 2015

The magazine of The Royal College of Surgeons of Edinburgh

MARCH 2015 • VOLUME 14 • ISSUE 1

COURAGE AND CONVICTION We proudly present our new Fellow, Daw Aung San Suu Kyi

32

PLUS

The benefits of increasing physical activity www.surgeonsnews.com

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

Think Publishing Ltd, Suite 2.3, Red Tree Business Suites, 33 Dalmarnock Road, Glasgow G40 4LA Tel: +44 (0)141 375 0504 www.thinkpublishing.co.uk ACCOUNT MANAGER Sian Campbell DESIGN Mark Davies, Alistair McGown SUB EDITORS Sam Bartlett, Kirsty Fortune MEDICAL SUB EDITOR Arshad Makhdum GROUP ACCOUNT DIRECTOR John Innes john.innes@thinkpublishing.co.uk PRINTED BY Acorn Web Offset Ltd, Yorkshire, UK ISSN 1750-7995 The views expressed in Surgeons’ News are not necessarily those of the editorial team or the Royal College of Surgeons of Edinburgh.

Information printed in this edition of Surgeons’ News is believed to be correct at the time of going to press.

2 | Surgeons’ News | March 2015

Contents

March 2015

04

AGENDA News and views from the College and the profession, including awards, events and Museum updates

17

THE PRESIDENT WRITES Ian Ritchie on meeting the needs of patients around the world

18

HONORARY FELLOWSHIP Myanmar’s opposition leader Daw Aung San Suu Kyi receives her award for services to healthcare

22

PHYSICAL ACTIVITY Jon Dearing presents the evidence for increasing activity levels

24

COUNTRY PROFILE How, despite challenging terrain and periods of political instability, Nepal is making great strides in healthcare

28

37

DENTAL The Faculty’s influence; career pathways; Wessex prizes; dental regional advisers in your area

42

TRAINEES AND STUDENTS Oxford hands-on skills symposium; the work of the Trainees’ Committee

SPECIALTY: UROLOGY The ancient discipline is now a leader in technological innovation

46

COLLEGE INFORMATION Diploma ceremony listings, courses, awards and grants

32

ETHICS Highlights from Professor Lord Robert Winston’s Fellowship lecture

OUT OF HOURS Graham Layer’s gourmet delights

36

MEDICAL INNOVATION BILL Why the College is fiercely opposed to the controversial legislation

52 56

FROM THE COLLECTIONS Facial cast of an adult with acquired syphilis, prevalent among soldiers in the American Civil War

PRESIDENT’S MEETING & AUDIT SYMPOSIUM 2015 SURGICAL ONCOLOGY FRIDAY 20 MARCH 2015 Advances in surgical techniques and in the organisation and delivery of care have contributed significantly to improved outcomes for patients with cancer. This meeting will provide an update on contemporary management of various malignancies, with a major focus on surgical treatments, as well as updates on oncological therapies.

This meeting will include contributions from all the surgical specialty associations.

KEY SPEAKERS INCLUDE: ● Professor Timothy J. Eberlein (Bixby Professor and Chairman of the Department of Surgery at Washington University School of Medicine, St. Louis, and Surgeon-in-Chief at Barnes-Jewish Hospital) ● Professor Arnold Hill (Professor and Chair of Surgery and the Head of the Medical School at the Royal College of Surgeons in Ireland) ● Professor Alastair Munro (Professor of Radiation Oncology at the University of Dundee and Honorary Consultant Oncologist NHS Tayside)

● Professor Graeme Poston (Consultant Hepato-biliary Surgeon at University Hospital Aintree, Liverpool, and Professor of Surgery at the University of Liverpool) ● Professor Tom Treasure (Consultant Cardiothoracic Surgeon, Clinical Operational Research Unit, University College London) www.rcsed.ac.uk/presidentsmeeting

Agenda The latest news from the College and profession / AWARD

Honorary Fellowship for Daw Aung San Suu Kyi

N

obel Peace Prize winner and Myanmar pro-democracy politician Daw Aung San Suu Kyi has joined the RCSEd as an Honorary Fellow.

4 | Surgeons’ News | March 2015

Daw Aung San Suu Kyi (centre, back) with the College delegation and her colleagues

College representatives met with Daw Suu in Naypyidaw on 16 January to present her award and discuss the development of the country’s healthcare system.

RCSEd president Mr Ian Ritchie said: “It was a great privilege to

award an Honorary Fellowship to such a distinguished recipient, whose standing as a globally recognised figurehead for freedom and democracy is unparalleled.”

Turn to page 18

/ EVENT

John Hutton Memorial Lecture

The FST Annual Conference will use practical examples of inspiring training

/ CONFERENCE

FST 2015 forges path to training excellence

The British Society of Dental and Maxillofacial Radiology and the College will host the John Hutton Memorial Lecture on 23 April 2015. This year, the prestigious lecture will be delivered by Mr P G J Rout (pictured), consultant oral and maxillofacial radiologist at Birmingham Dental Hospital, under the title ‘Working in the Dark’.

Mr Rout said: “Radiologists spend much of their time working in the dark. This lecture will cover why this is important, aspects of radiological interpretation, and how dental and maxillofacial radiology is emerging to illuminate clinical diagnostic problems.”

The Memorial Lecture for 2015 is accredited for one CPD hour and is free of charge. To register, please contact Dr Bethan Thomas, Honorary Secretary (BSDMFR Bethan.thomas @kcl.ac.uk). Please ensure you provide your GDC/GMC number to obtain your CPD Certificate.

Professor Chung-Mau Lo

Professor O James Garden CBE

E

xperts will discuss how to achieve excellence in training at the 2015 Faculty of Surgical Trainers Annual Conference, which will take place at the Macdonald Burlington Hotel, Birmingham, on 22 October.

The event will use practical, real-life examples of excellent surgical training and explain how this can be achieved in today’s health service.

Confirmed speakers include Dr Teodor Grantcharov, associate professor at the University of Toronto, staff surgeon at St Michael’s Hospital and expert on surgical training; Mr Christopher Munsch, cardiothoracic consultant at Leeds; and Mr Mike Lavelle-Jones, 2014 Surgical Trainer of the Year and RCSEd vice-president.

To book or for more information, visit fst.rcsed.ac.uk

/ AWARD

RACS Medal for Dr Gordon Low The College congratulates Dr Gordon Low FRCSEd, of Victoria, Australia, who was awarded the International Medal of the Royal Australasian College of Surgeons at its 2014 Annual Scientific Congress. The medal was also awarded to his wife, Rosie, in recognition of her contributions to their work in the past 25 years in facilitating surgical exchanges between Australia, New Zealand and China through their self-funded programme, Project China.

Dr Gordon Low (left) and his wife Rosie receive their medals

/ AWARDS

ACS honours two Fellows In October 2014, the American College of Surgeons (ACS) awarded its Honorary Fellowship to past Council Member Professor O James Garden CBE and College Fellow Professor Chung-Mau Lo. The ACS Clinical Congress took place on 26–30 October in San Francisco, and is one of the largest surgical meetings in the world.

www.rcsed.ac.uk | 5

AGENDA

NEWS IN BRIEF Dubai hosts MFDS Part 2 preparation The first MFDS Part 2 revision course to be held outside the UK took place in Dubai on 23 and 24 January.

Three MFDS examiners travelled from the UK and were joined by two Dubai-based examiners for the intensive two-day course. Following lectures and small-group teaching sessions, a full day of mock OSCEs gave participants the opportunity to experience conditions similar to the examination, with feedback provided afterwards from examiners and other participants.

Course convener Mr Donald Thomson said: “After the recent Part 1 MFDS courses in Dubai, it was nice to see many familiar faces returning for the first Part 2 course to be held overseas. With participants from Hong Kong, Singapore and Ireland, as well as the Gulf States, it was a truly international course.”

International Surgical Adviser selected for Padma Shri Dr P Raghu Ram (left), Member of the RCSEd International Surgical Adviser network and consultant oncoplastic breast surgeon, is to receive one of India’s highest honours, the Padma Shri.

The Padma awards are given to Indian citizens in recognition of their distinguished contributions to society. Dr Raghu Ram has been instrumental in raising awareness in India about the importance of early detection of breast cancer, while bringing about considerable improvements to breast healthcare in India.

Dr Ram said: “I dedicate this award to my mother, Dr Ushalakshmi, who has conquered breast cancer, and indeed to all the women in this country who have fought breast cancer with courage and determination.”

6 | Surgeons’ News | March 2015

Lord Winston gives an exclusive lecture on medical ethics

/ REGIONAL OFFICE

Birmingham centre marks first birthday

T

he College’s regional office in Birmingham will soon be celebrating its first 12 months as the RCSEd’s first ever base outside Edinburgh. The centre was opened in spring 2014 to cater for the 80% of the College’s UK membership who live and work in England and Wales, with the prestigious address also providing a base for the College’s policy and outreach departments.

Head of the Birmingham Regional Centre and RCSEd policy manager Chris

Sanderson said: “We’ve had a great first year at Colmore Row, with lots of events to improve engagement with members and enhance the services provided by the College.

Highlights from the Birmingham centre have included exclusive Fellowship lectures from Professors Sir Bruce Keogh and Lord Robert Winston on topics ranging from NHS services to medical ethics.”

Turn to page 32 for more on Lord Winston’s lecture

/ AWARDS

Nominations open for 2015/ 2016 Hunter Doig Medal

T

he RCSEd is inviting nominations for the Hunter Doig Medal to be awarded in 2015/2016.

The Hunter Doig Medal is awarded every second year to a female Fellow or Member of the Royal College of Surgeons of Edinburgh who, in the opinion of Council, demonstrates career potential and ambition, as well as the following achievements: ● High standards of practice

in terms of ‘good surgical practice’ ● Clinical excellence ● Ongoing contribution to education and training ● Clinically based research and audit ● Laboratory research of direct clinical relevance.

Applicants for the Hunter Doig Medal may self-nominate or be proposed by a colleague, board, committee or other body recognised by the College. Applications must be accompanied by a full CV and supported by three referees,

two of which will be surgeons and one of which will not be a surgeon. Written references should be submitted at the time of the application.

Nominations in the first instance should be submitted by Friday 5 June 2015 to Mrs Irene MacDonald, PA to the Chief Executive, Royal College of Surgeons of Edinburgh, Nicolson Street, Edinburgh, EH8 9DW, or by email to i.macdonald@rcsed.ac.uk

/ TRAINING

/ POLICY

RCSEd voices its support for plain cigarette packaging In January, the RCSEd welcomed news that the Government intended to call a vote on plain cigarette packaging before the General Election in May. RCSEd President Mr Ian Ritchie said: “We are increasingly aware of the direct impact smoking has on the likelihood that a patient will experience complications during surgery. Smoking also increases recovery times and results in unnecessarily long stays in hospital following surgery. The instances of patients being denied surgical options because their history of smoking makes the procedure too risky are all too common. This is why the Royal College of Surgeons of Edinburgh supports any action that will reduce the number of people who smoke.”

College concerned over training versus service delivery

F

ollowing issues raised by the BMA about the impact on patients of a reduction in the time taken to train doctors, the RCSEd has warned that more consideration needs to be given to the way doctors are trained.

RCSEd president Mr Ian Ritchie is urging the Department of Health to recognise that the time taken to train medical professionals is, in many ways, a secondary issue, and the real problem is the reliance placed on trainees by the NHS to deliver services.

Mr Ritchie stated: “We support the Shape of Training Review and want an NHS that offers patients consultant-led care 24 hours a day, seven days a week. However, we are not convinced that trainees will be able to develop their full range of competencies within a muchreduced training period if they continue to form the backbone of service delivery.

“While we recognise training and service provision are inextricably linked and should not necessarily be completely separated, we maintain there is a distinction and this should be recognised and addressed.”

Flight discounts available from Qatar Airways

www.rcsed.ac.uk | 7

AGENDA

TIME CAPSULE FOUND AT MUSEUM Builders unearth ‘snuff tin’ of artefacts buried a century ago by workers renovating the Playfair Building

A

team of builders currently working on the redevelopment of the College’s Surgeons’ Hall Museum got a surprise when they discovered a 105-year-old time capsule buried under the iconic Playfair Building.

Scheduled to reopen in autumn 2015, the museum had not been radically altered since 1908 and it would seem that the Edwardian construction workers charged with transforming this architecturally renowned building all those years ago, decided to leave something for those who would follow them.

On 28 November 2014, the builders, from John Dennis Ltd, unearthed the time capsule, found behind a hoarding in the Jules Thorn hall. Stored within a snuff tin were two newspapers from 19 March 1909, two postcards and a list of names dated 26 March 1909.

Commenting on the discovery, RCSEd director of heritage Chris Henry said: “We were aware from historical records that an ‘official’ time capsule from 1830 is buried in the College’s grounds, but this one must have been placed by the construction workers during the 1909 extension work, without the knowledge of the College. Considering the tin has been underground for more than 100 years, it is in surprisingly good condition, as are the contents.”

The snuff tin ‘capsule’ would have originally contained Kendal Brown Scented Snuff, manufactured in the Lake District town of the same name by Samuel Gawith. Given that a regular tin held 10g of powdered tobacco, the time capsule tin would have contained a considerable amount of snuff, perhaps shared by the men during their working day. The snuff brand is still in production today, using much of the original machinery from the inception of the company in 1793.

The first newspaper discovered in the snuff tin, The Labour Leader: A Weekly Journal of Socialism, Trade Unionism and Politics, was set up by Scottish socialist Keir Hardie MP. Hardie is regarded as one of the pioneers of the Independent Labour Party and

8 | Surgeons’ News | March 2015

The capsule must have been placed by the construction workers during the 1909 extension work, without the knowledge of the College Labour Party, which grew out of the trade union and socialist movements of the 19th century. The newspaper carries a number of articles on socialist movements throughout Europe, and stories on the Paris Strike, ‘The Liberal Betrayal’, ‘Welsh Notes’ on the threatened coal strike and the Russian revolutionary ‘Azef Affair’.

The second newspaper, The Illustrated Carpenter and Builder, was a weekly journal published by John Dicks and established in 1877. The newspaper includes all manner of building-related articles, discussions, floor plans and scale drawings. This week’s cover story concerns the designs for a suburban house “near London”, to cost £500. This equates to approximately £52,500 today.

It gives us an insight into the lives of those who were part of the process of building the College’s physical identity

Postcards and newspapers shed light on the life and work of Edwardian builders

Also included within the capsule were two postcards depicting the Scottish National Exhibition of 1908, which took place to the west of the city in the grounds of the Saughton Hall Estate. It featured a Senegalese village, a water chute, helter-skelter and a figure-eight railway. More than 3.5 million people visited the exhibition over six months, with entrants being charged 6d.

Finally, there was the piece of paper listing all the joiners from Scott Morton & Co who carried out interior design work during the 1909 construction. Scott Morton and his brother John set up business in 1870 and, through a number of permutations, the company continued until 1966. It was then taken over by Whytock & Reid, the company who actually made most of the furniture for the 1909 renovations, including all 97 Playfair Hall chairs, which are still in use.

Henry concludes: “This fascinating piece of College history will become an important part of our redisplay as it gives us an insight into the lives of those who were part of the process of building the College’s physical identity as we see it today.”

RCSEd is the UK’s oldest surgical Royal College and its museum – originally developed as a teaching museum

for students of medicine – has been open to the general public since 1832, making it Scotland’s oldest medical museum.

It hosts a large, historic collection of surgical pathology artefacts, including anatomical specimens, surgical instruments and a pocket book made from the skin of the infamous murderer, William Burke. Its archive also holds a letter from Sir Arthur Conan Doyle crediting RCSEd Fellow Dr Joseph Bell as the main inspiration for the character of Sherlock Holmes.

The redevelopment project to transform the museum will include the creation of displays and galleries, doubling the number of items on view to the public, and showcasing innovative audio-visual and interactive elements. The Playfair-designed building will also be conserved and transformed with contemporary additions such as a glass atrium, providing the public with easier access. The enhanced museum will also boast a 17th-century dissecting theatre, while a new, dedicated education suite will increase opportunities for learning for schools, families and special interest groups. www.rcsed.ac.uk | 9

AGENDA

BOX OF DELIGHTS Museum collections officer Rohan Almond reveals how Roman oculist stamps made a big impression on museum staff

M

useums are in a constant state of flux: exhibitions come and go, displays develop, stores are moved and staff change. Sometimes, an item’s story can be forgotten, sitting on a shelf waiting to

be rediscovered.

This is precisely what happened at Surgeons’ Hall last year. While working in the Quincentenary Hall store with a group of volunteers, we came across a small cardboard box that contained what looked like red wax seals.

Referencing the accession number, they were simply described as ‘Impressions from a Roman Oculist Medicine Stamp’. The seals were mounted on a piece of card with the above words. The card also said that the seal had come from the Antiquarian Society Museum. The writing looked familiar, but there was no further information on the record. Some hours of research later, Sir James Young Simpson (1811–1870) came up as a possible match, and comparing a letter from him reinforced this theory. Suddenly, the rediscovery of the seals took on a new weight and significance.

While he has come to be best known for the discovery of chloroform as an anaesthetic and for his work in obstetrics, Simpson was not just a medical man. Throughout his life, he maintained a passion for archaeology and antiquarianism, and in his latter years became honorary professor of antiquities to the Royal Scottish Academy. Despite a frenetic schedule at his practice and home at 52 Queen Street, he continued to pursue this interest and published a number of key papers and articles, including a number on Roman medical stamps.

Simpson wrote about these particular stamps in The Monthly Journal of Medical Science, Volume 12, 1851. The stamps were found in the early 19th century at Tranent, East Lothian, not far from the Roman settlement at Inveresk. It is possible that these impressions were made by Simpson himself as part of his archaeological

10 | Surgeons’ News | March 2015

The original stamps would have been used to mark blocks of eye ointment or the seals on jars

Rohan Almond

The stamp was found in the early 19th century at Tranent, East Lothian, near the Roman settlement at Inveresk. It is possible this impression was made by Simpson himself as part of his archaeological research research, having been to see them in person at the Scottish Antiquities Society Museum.

Oculists were specialised eye doctors who treated eye diseases, and the original stamps would have been used to mark either semi-solid blocks of eye ointment before they became hard or the seals on jars.

Without the work of museum volunteers, this unassuming box might have lain undisturbed for years, almost an extension of the way the original was buried in the ground (although, I would hope, not for as long).

In the meantime, the stamps will take pride of place in our display when we reopen after the Heritage Lotteryfunded Lister Project is completed. Come and see them from this September.

With more than 30,000 users and 28 million procedures recorded, the eLogbook is more than just a trainee resource

SOMETHING FOR EVERYONE

T

he intercollegiate eLogbook was set up as an RCSEd initiative in 2003. It has been one of the most outstanding achievements of the College and, having started as a purely orthopaedic logbook, it now encompasses all the surgical subspecialties, with more than 30,000 users and 28 million procedures logged. Although there are other web-based logbooks available, the eLogbook is the biggest.

Despite this undoubted success, and although some consultants who used the logbook in training continue to use it as consultants, the logbook is still seen primarily as a tool for trainees. This may change, however, with the appraisal cycle of revalidation requiring consultants to discuss with their appraisers the scope of their practice.

Theatre management systems may provide independent validated logs of activity, but many are based on the OPCS4 coding system and, consequently, provide reports that give a limited view of the breadth and specialisation of a surgical practice. They are also often hospital site-specific. Hence, a complete picture of a person’s practice can require several reports.

Furthermore, data entry is frequently done by nursing staff who may have no real interest in who is doing an operation and who is assisting. Therefore, data about levels of trainee supervision in surgery may be less than accurate; something that will be relevant TOTAL USERS AND OPERATIONS BY SPECIALTY Total users

Total operations

Trauma and orthopaedic

11,726

10,687,811

Urology

2,464

2,349,670

Neurosurgery

1,687

761,501

General surgery

17,705

6,450,644

Cardiothoracic

1,075

340,619

Otolaryngology

2,691

2,069,600

Paediatric

869

504,603

Plastic surgery

2,208

2,663,145

Oral and maxillofacial

3,166

1,373,959

Ophthalmology

249

24,275

Vascular

427

85,095

USER UPLOADS BY GRADE Consultant

513,307

SAS

308,911

Clinical Fellow

212,589

StR

849,544

SpR

333,497

FTSTA

204,520

for those maintaining a portfolio to be recognised as a trainer.

The reports provided by the eLogbook cover the whole of one’s practice and have been refined over the years such that the operation group report now provides a first-class consolidation of the breadth and depth of a surgical practice. At the same time, it gives a detailed and accurate picture of the training taking place.

The operation group report is, therefore, an excellent document for supporting your appraisal and revalidation.

What makes this option for record-keeping even more attractive, is that most consultants can build nearly all of this log of their practice ‘on the fly’ as part of their normal work with trainees. The only operations the consultant will need to add are those done without a trainee present or those done privately. By building their logbook in collaboration with trainees it also increases the validity of trainee logbooks.

How does this work? All trainees require their logbooks to be validated. If this is done electronically, rather than on paper, then the validated procedures can be added to the consultant’s logbook as part of the process with no further data entry.

If you want to start building your logbook in this way, log in to the site, and click on the link ‘There are operations to validate’ just below the eLogbook logo.

There is a link on the next page to instructions on how to use the process. If you have forgotten your password to the logbook website, please do not hesitate to contact the helpdesk. helpdesk@elogbook.org www.elogbook.org David Large RCSEd eLogbook Surgical Lead

www.rcsed.ac.uk | 11

AGENDA

COUNCIL GIVES SAS A VOICE Plans to elect an SAS Member to Council will help make the College’s governing body more representative of today’s workforce, writes Victoria Dobie

T

he RCSED Council has created a Council seat for a Staff, Associate Specialist and Specialty Doctor (SAS) representative. The College has taken the lead among the Royal Colleges in acknowledging that doctors and surgeons in this grade are increasing in number and have needs specific to their role. All SAS grade Members and Fellows will have the opportunity to vote for their representative on Council, but they must be registered with the College as holding an SAS post.

By creating an SAS representative on Council, the College is demonstrating its commitment to this group of surgeons The need for service provision in hospitals by a doctor who is familiar with their department and appropriately trained for their duties, but is not necessarily a consultant, has been increasing throughout the UK. At present, 25% of the hospital doctors who are not trainees are SAS grades.

However, surgeons in the SAS grade are a diverse group: a surgeon may be appointed to a specialty doctor post with just two years of post-foundation experience in their specialty, whereas some SAS surgeons have more than 40 years’ experience in their specialty.

While SAS posts are created solely to provide service cover, SAS surgeons can develop their role according to their own aptitudes and the needs of the service.

Many SAS surgeons take on management, teaching and leadership duties in the same way as consultants do, so need the same support. However, SAS surgeons will also require further training to enable them to increase their contribution to the service.

The College Council understands that for these reasons SAS surgeons differ from consultants and trainees and should be considered as a separate group.

By creating an SAS representative on Council, the College is demonstrating its commitment to this group of surgeons.

Nomination details for the SAS representative on Council will be circulated in the spring.

Victoria Dobie Associate Specialist in Orthopaedic Surgery, Borders General Hospital

ARE YOU AN SAS OR LOCUM? LET US KNOW! There are already opportunities for SAS grade Fellows and Members to participate in the running of the College. At present, the College has a Staff Grade, Associate Specialist and Specialty Doctor and Locum Consultant (SASLC) Committee that meets three

12 | Surgeons’ News | March 2015

or four times a year, and manages matters that concern this group of Fellows and Members. There is also a seat for SAS Fellows and Members on all the Surgical Speciality Groups.

Regarding education, SAS surgeons are eligible to apply for all the educational courses

organised by the College. In 2014, the first educational meeting specifically for SAS surgeons was held as part of the inaugural week for the new Centre of Operations that the College has opened in Birmingham. The College is planning further SAS educational meetings for 2015.

All Fellows and Members of the College who are in SAS-grade posts should check their registration details with the College. To do so, log on to the College website at www.rcsed.ac.uk, follow My Profile, then Professional Details, and in the Post field enter ‘SAS’.

The latest guidelines, articles and studies

IN BRIEF Randomised clinical trial of the impact of surgical ward care checklists on post-operative care in a simulated environment

Surgical trainees conducted baseline ward rounds of three patients with common post-operative complications in a simulated ward environment. Subjects were randomised to intervention or control groups, and final ward rounds were conducted with or without the aid of checklists for management of postoperative complications.

Twenty trainees completed 120 patient assessments. All intervention-group subjects used the checklists, resulting in fewer critical errors compared with controls. The intervention group showed improved patient management and non–technical skills, whereas controls did not. Authors concluded that checklist use can improve management of postoperative complications, and the quality of ward rounds.

Pucher PH, Aggarwal R, Qurashi M, Singh P, Darzi A. Br J Surg 2014; b1666

Contralateral prophylactic mastectomy after unilateral breast cancer: a systematic review and meta-analysis

This review included 14 studies in a metaanalysis. Compared with non-recipients, contralateral prophylactic mastectomy (CPM) recipients had higher rates of overall survival and lower rates of breast cancer–specific complications, but saw no absolute reduction in risk of metachronous contralateral breast cancer (MCBC). Among patients with elevated familial/genetic risk (FGR) both relative and absolute risks of MCBC were significantly decreased

among CPM recipients, but there was no improvement in survival.

Authors concluded that the superior outcomes observed when comparing CPM recipients with non-recipients in the general population are probably not attributable to a CPM-derived decrease in MCBC incidence. They recommended that unilateral-breast-cancer patients without FGR should not be advised to undergo CPM. Fayanju OM, Stoll C, Fowler S et al.

Ann Surg 2014; 260: b1000 Supplemental author material

Early versus on-demand nasoenteric tube feeding in acute pancreatitis

This trial randomised 208 patients to

NICE GUIDELINES Gallstone disease

This guideline offers evidencebased advice on the diagnosis and management of gallstone disease in adults.

NICE, October 2014 www.nice.org.uk/guidance/CG188

Head injuries

This quality standard covers assessment, early management and rehabilitation after head injury in children, young people and adults.

NICE, January 2014 www.nice.org.uk/guidance/CG176

either early feeding with a nasoenteric tube or an oral diet 72 hours after presentation with acute pancreatitis.

There were no significant differences between the early group and the ondemand group in the rate of major infection (25% and 26%) or death (11% and 7%). In the on-demand group, 72 patients (69%) tolerated an oral diet and did not require tube feeding.

Bakker OJ, van Brunschot S, van Santvoort HC et al for the Dutch Pancreatitis Study Group.

N Engl J Med 2014; 371: b1983

Tonsillectomy or adenotonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis

This review assessed the effectiveness of tonsillectomy (with and without adenoidectomy) in children and adults with chronic/recurrent acute tonsillitis in reducing the number and severity of episodes of sore throat. It includes seven trials: five in children (987 participants) and two in adults (156 participants).

Authors concluded that surgery leads to a reduction in the number of episodes of sore throat in children in the first year after surgery. Children who were more severely affected were more likely to benefit. Insufficient information is available on the effectiveness of surgery in adults. The impact of surgery is modest and must be weighed against the risks of the procedure.

Burton MJ, Glasziou PP, Chong LY, Venekamp RP. The Cochrane Collaboration 2014

www.rcsed.ac.uk | 13

AGENDA

SURGICAL SAFETY UPDATE More cases from the Confidential Reporting System for Surgery RETAINED FOREIGN OBJECTS IN OPHTHALMIC SURGERY

A 68-year-old patient underwent trabeculectomy, under local anaesthesia, done by an experienced glaucoma surgeon. Sponges soaked in antimetabolite were placed under the conjunctival flap (into the space between Ténon’s capsule and the sclera), for three minutes, as per standard practice. At the end of this period, two of the five pieces of sponge could not be retrieved. It was assumed they had migrated backwards between Ténon’s capsule and the sclera. Repeated attempts at removal resulted in significant orbital haemorrhage. The sponges were eventually removed by an orbital surgeon under general anaesthesia: one was found behind the macula, and the other had migrated to the tendon sheath of one of the rectus muscles. Thankfully, no harm came to the patient’s vision.

Reporter’s and CORESS comments

The capsule of Ténon (bulbar sheath) is a thin membrane that envelops the eyeball from the optic nerve to the limbus, separating it from the orbital fat. Local anaesthetic may be administered into the space between Tenon’s capsule and the sclera. A sponge or other item inserted into this space can potentially migrate within the space to any location beneath the membrane. Standard practice was to insert sponges into the sub-Ténon’s space, with no failsafe method of retrieving them.

Attempted retrieval (with forceps, say) may inadvertently push the sponges deeper.

This problem can be prevented by threading sponges onto a suture (6/0 or 5/0 nylon) beforehand, tying it in a loop, analogous to a necklace. This makes surgery quicker as well as safer. Sponges can still potentially come off the necklace, so they must be counted in and out of the eye.

Reconciliation of a swab count is essential in all surgical fields to reduce risk of patient harm.

LACK OF VAC

A complex patient, with a chronic perineal wound being treated with negative-pressure dressings, was placed on the emergency list for dressing change because the patient could not tolerate dressing changes on the ward.

Higher-priority emergencies and reluctance by staff (surgical as well as anaesthetic) to undertake “non-lifesaving or non-limb-saving surgery” in the middle of the night resulted in the patient being deferred for more than two days. It had not been appreciated by the teams involved that a sponge dressing was in situ without

14 | Surgeons’ News | March 2015

negative pressure being applied, nor had the significance of this been realised. By the time the patient was brought to theatre, there had been deterioration with formation of a large amount of pus. The wound cavity was much more friable and haemorrhagic than previously (whereas it had been slowly improving). This set back the patient’s progress significantly.

Reporter’s comments

There was failure to recognise that a negative-pressure dressing should not be left without suction for any significant time (let alone two days). Use of the emergency list for patients requiring regular dressing changes may not be appropriate, but is commonplace. There is a need for an alternative to the emergency list for complex patients requiring predictable, regular returns to theatre.

CORESS comments

Vacuum dressings are useful in the management of open wounds that produce large quantities of fluid, but they may require specialised management and equipment. Some complex cases may need dressing changes in theatre, particularly if debridement or sedation is necessary.

When undertaken in theatre, these cases should be included in an elective schedule rather than as ad hoc cases on an emergency list. Team-working practices in which space is left on elective lists for urgent ward-based cases may facilitate this strategy. Good communication at handover between shifts should ensure that a patient’s clinical priorities are recognised by the incoming team.

COMMUNICATION FAILURE COMPOUNDING INAPPROPRIATE DEVICE USE

A 77-year-old male underwent open repair of a 6.5cm infrarenal aortic aneurysm. The inferior mesenteric artery was oversewn at the aneurysm sac and a Dacron® bifurcated graft was inlaid to the iliac-artery bifurcation on each side. On completion of surgery, the bowel appeared pink and the patient was transferred to the ITU. Seventy-two hours after surgery, the patient was unwell with elevated CRP and WCC. No other source of sepsis could be identified and a flexible sigmoidoscopy suggested distal colonic ischaemia. The patient returned to theatre for laparotomy, where it was found that the distal descending and sigmoid colon had infarcted.

A Hartmann’s procedure was undertaken, resecting the ischaemic bowel, stapling the rectal stump and bringing out the proximal descending colon as an end-colostomy in the left iliac fossa. The patient returned to the ITU.

CORESS is grateful to the clinicians who have provided the material for these reports.

The online reporting form can be found at www. coress.org.uk Published contributions will be acknowledged by a Certificate of Contribution, which may be included in the contributor’s record of continuing professional development or appraisal.

Despite resuscitation, the patient continued to deteriorate and abdominal ultrasound suggested the presence of a pelvic abscess. The patient returned to theatre for a third time, where it was noted that ITU staff had inappropriately employed a faecal management system consisting of a large-bore catheter with a sealing 45ml balloon inserted into the rectal stump. A formal protocol for use of this device had not been consulted.

Product literature indicated that the device should be used only for bedridden or immobilised, incontinent patients with liquid or semi-liquid stools to: divert faecal matter; protect wounds from faecal contamination; reduce the risk of skin breakdown and spread of infection.

The rectal stump had been disrupted and was communicating with the abscess, which was drained.

The small bowel required extensive mobilisation and there was now apparent ischaemia of the end-colostomy.

Hence, the remaining colon was resected, an endileostomy fashioned and the rectal stump debrided and re-closed with sutures. The patient returned to the ITU where he made a prolonged and stormy recovery.

Reporter’s comments

Left colonic ischaemia is a recognised complication of repair of aortic aneurysms in which the inferior mesenteric artery is usually oversewn. This may occur where the marginal communicating branch of the left colic artery, ‘the wandering artery of Drummond’ (which forms an anastomosis between the superior and inferior mesenteric arteries) is inadequate or diseased. If ischaemia of the left colon is recognised at the time of surgery, the origin of the inferior mesenteric artery may be inlaid into the aortic graft. Frequently, however, the colon appears normal on

completion of surgery. Failure of a patient to thrive postoperatively should always give rise to concern over the possibility of colonic ischaemia.

Inappropriate use of the faecal management system and balloon promoted further ischaemia and disruption of the rectal stump. ITU staff did not liaise with the surgical team and appeared unaware of the nature of the second surgical procedure. No protocol or guidelines were in existence concerning use of the catheter-based system.

Product guidelines specifically advised against use in cases of rectal injury. Excessive faeculent discharge would not be expected from a rectal stump. Use of similar systems should only take place in accordance with product instructions and recognising potential complications arising from use.

CORESS comments

The Advisory Committee agreed with the reporter’s comments. Use of the balloon system was clearly inappropriate in this case. The responsibility for who looks after the patient admitted to ITU must be clearly established. No matter which clinician holds overriding responsibility, it is vital that there is adequate communication between all teams involved so that the implications of any management strategy are fully understood. Good communication might have prevented the secondary iatrogenic consequences of this known complication of aneurysm repair.

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

www.rcsed.ac.uk | 15

FACULTY OF SURGICAL TRAINERS ANNUAL MEETING 2015

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

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

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

Abstract submissions open now fst.rcsed.ac.uk

AGENDA

THE PRESIDENT WRITES

I

Ian Ritchie provides his regular update on College activities n an interview in The Guardian published in January, the NHS’s medical director Sir Bruce Keogh stated that the NHS’s future is in danger because its model of care cannot meet the growing demand for treatment from the UK’s ageing population. He said that this, coupled with the lack of local services, was the core reason for the extreme pressure now being placed on the NHS. However, he denied that the NHS was, as some have claimed, in ‘crisis’ saying the word itself was provocative and implied that the situation couldn’t be dealt with. He also echoed the sentiments he expressed when he spoke at our Birmingham Centre last year, that these pressures can be mitigated, though it will take radical action, and, as UK healthcare professionals, we have the privilege of working in the finest healthcare system in the world.

As President I have the equal privilege of meeting our Fellows and Members, and their colleagues, working in healthcare systems around the world. Each system has challenges and strengths from which we can all learn. Understanding the challenges and strengths of our home system enables us to recognise opportunities to improve them. Healthcare professionals must be at the heart of any changes to the systems in which we work, and take the lead in developing the teams that will effect those changes.

As a College it is our role to support our Fellows and Members to do just that and, earlier this year, it was a true honour to be able to discuss with one of our newest Honorary Fellows just how the College could help do so in her own country, Myanmar (see p18). Daw Aung San Suu Kyi is a truly inspirational person and her commitment to reinvigorating the healthcare system in Myanmar is absolute. We hope that the College and others in the medical community will be able to provide expertise and support in rebuilding the system and

As professionals, as leaders and as practitioners we must work as part of a team across all healthcare specialties and disciplines in the best interests of the patient

establishing a surgical centre of excellence in Myanmar.

That work has started and we will continue to work with our Fellows and Members there to provide resources and training for future generations of surgeons.

One of the things that struck me most about Suu Kyi was her natural inclusiveness, a quality which I believe is essential for leadership. She is, of course, renowned as a strong leader who wins the respect of those she works with and those who, like me, come into contact with her as a result of that work. Her leadership is not loud and self-proclaiming but quiet and strong. She has put herself on the line for her beliefs and, as such, represents leadership with sacrifice.

As practitioners, we can learn a lot from people such as Suu Kyi. It is important to remember we are one part of a wider team and that, ultimately, our role as leaders is not to enhance our own standing but to lead for the benefit of people we serve: for Suu Kyi these are the people she represents politically; for us, it is our patients.

As a College we have a role in supporting our membership and colleagues to acquire the skills they need to become good leaders. To this end I am very proud of the success we have already had in instituting a programme of Clinical Leadership Fellows. Our first Fellowship is now up and running in Scotland and we are in the process of establishing two more in England and Wales.

I share Sir Bruce’s opinion that the NHS must change radically if it is to meet the needs of its patients in the future. I also believe that Suu Kyi’s conviction that the medical community must come together to enable the healthcare system in Myanmar to not only recover, but thrive, holds true in all nations and certainly in the UK. As professionals, as leaders and as practitioners we must work as part of a team across all healthcare specialties and disciplines in the best interests of the patient. This is true whether that work relates to the treatment of an individual, or to effecting instrumental change in our healthcare system to safeguard it for future generations.

Ian Ritchie president@rcsed.ac.uk www.rcsed.ac.uk | 17

HONORARY FELLOWSHIP

Daw Suu expressed her hope that the College would return to provide its expertise to the doctors who will care for future generations in Myanmar

18 | Surgeons’ News | March 2015

COLLEGE AWARDS FELLOWSHIP TO AUNG SAN SUU KYI Pro-democracy leader receives highest RCSEd honour for her contribution to healthcare

T

he RCSEd’s long and illustrious Fellows’ roll now holds the signature of one of the world’s leading proponents of democratic freedom. On 16 January, Myanmar’s opposition leader and Nobel Prize winner Daw Aung San Suu Kyi met the College’s President and his delegation to be gowned and sworn in as an Honorary Fellow.

On receiving the award, Daw Suu commented that this was the first time she had received a Fellowship in her

office in the Myanmar capital of Naypyidaw, and she thanked the delegation for travelling a long way to meet her.

During an informal meeting afterward, Daw Suu called upon the RCSEd and the country’s other friends in the international medical community to support the reinvigoration of a health system that has suffered from many decades of underinvestment. She expressed her hope that the College would return to provide its expertise to the doctors who will care for future generations in Myanmar.

The College’s representatives explained their plans to work with local teams on various projects, particularly in joining an international effort to establish a centre of surgical excellence in a redeveloped Rangoon General Hospital.

Myanmar and the RCSEd THE COLLEGE has 230 Members and Fellows in Myanmar who benefit from College membership, including access to resources and training. The College visits Myanmar annually to conduct the MRCS, with around 90 candidates presenting for each examination diet.

In 2013, a capacity-building project was launched to develop the highest standards of surgical practice in Myanmar through education, training and examination. Funded by the Tropical Health and Education Trust, the work was carried out

by RCSEd and the Department of Medical Science at the Myanmar Ministry of Health. This led to a Memorandum of Understanding between the College and the Ministry of Health agreeing cooperation in the areas of patient safety, infection control,

Immediate past president Mr David Tolley (right) is leading a bid for a pilot surgical training project in urology

post-operative care, advanced surgical skills and non-technical skills for surgeons.

Immediate past president Mr David Tolley is also leading a bid for a pilot surgical training project in urology which, if successful, will deliver an intensive surgical training programme in Myanmar over the coming two years, as well

as study visits to the UK for up to six Myanmar surgical trainees.

The project is being supported by the RCSEd’s International School of Surgery and is an excellent fit with the College’s international strategy, which emphasises the need to work with international partners to build local capacity.

www.rcsed.ac.uk | 19

HONORARY FELLOWSHIP Aung San Suu Kyi receives the College’s highest honour

RCSEd President Mr Ian Ritchie said: “It was a great privilege to award an Honorary Fellowship to such a distinguished recipient, whose standing as a globally recognised figurehead for freedom and democracy is unparalleled. In discussion after the ceremony we spoke of the struggle for change in politics and in many other areas of life. We agreed that one of the greatest challenges is changing culture and mindset, which is a slow process with no fixed timetable.

“Aung San Suu Kyi spoke of the poverty in the country and how the people of Myanmar deserve to be more prosperous. To highlight this, she told the story of her assistant’s two brothers who are from a rural area and were amazed by the sight of buses in the streets of Rangoon, having never seen them elsewhere before.”

Our new Honorary Fellow received her first degree from the University of Delhi and then studied for an MA in philosophy, politics and economics at St Hugh’s College, Oxford. Before becoming leader of the then Burmese pro-democracy movement, she held roles at the United Nations, the School of Oriental and African Studies at the University of London and the Union of Burma. Her long personal fight for democracy, her sacrifice and her commitment to freedom have been recognised all over the world. She has been awarded the Sakharov Prize, the Nobel Peace Prize, the Congressional Medal of the USA and the Companion of Australia by Queen Elizabeth – among many others.

20 | Surgeons’ News | March 2015

Our reason for awarding Fellowship is because of Daw Aung San Suu Kyi’s contribution to healthcare for the people of her country. [Her] efforts are in complete harmony with the continuing commitment of our College to support excellence in surgical training Reading the citation, RCSEd Council Member Dr Judy Evans said: “The award of our highest honour is only very exceptionally given to non-surgeons. Our reason for awarding Fellowship is because of Daw Aung San Suu Kyi’s contribution to healthcare for the people of her country. We know her Nobel Prize money and many other donations have been used to fund healthcare projects and everyday improvements for the people of Myanmar. We are also aware that her personal energy is now leading others in such projects as the regeneration of Rangoon General Hospital, and the establishment of an international-standard centre of excellence for medicine and surgery. Daw Aung San Suu Kyi’s efforts are in complete harmony with the continuing commitment of our College to support excellence in surgical training and assessment in Myanmar and beyond.”

ASSOCIATION EVENTS WITH EXCELLENCE AND INDIVIDUALITY We are now delighted to be working in partnership with the Festival Theatre and National Museums Scotland to offer Associations a complete package for their Conference.

ASSOCIATION EVENTS • Auditorium for 1,000 delegates WITH EXCELLENCE • 24 Break-out rooms AND INDIVIDUALITY

• Exhibition Space for Sponsors lighted to be working in partnership with the Festival Theatre and • Refreshment Areas s Scotland to offer Associations a complete package for their Conference.

• Stunning Playfair Hall for Speakers Welcome Dinner • Gardens and Surgeons’ Hall Museums for Drinks Receptions • National Museums Scotland for a spectacular dinner for 1,000 delegates • Ten Hill Place Hotel for delegate accommodation • Exciting new event space to be opened at the Royal College of Surgeons • Auditorium for 1,000 delegates of Edinburgh in 2015 2014 • 24 Break-out rooms Please tell your Association that your College can offer a great venue in the city of Edinburgh, and take care of all the arrangements.

• Exhibition Space for Sponsors • Refreshment Areas T: 0131 527 3434 E: events@surgeonshall.com

W: www.surgeonshall.com

PHYSICAL ACTIVITY

From gardening to housework, some regular activity can make all the difference to surgical outcomes. Jon Dearing looks at the evidence

MOVING TARGETS

I

n 2007 the World Health Organization declared that lack of physical activity is the fourth largest cause of preventable death in the world. It is important to make a distinction between physical activity – bodily movement caused by skeletal muscles that uses energy – and exercise. Physical activity involves day-to-day activities such as walking, housework and gardening performed such that the subject becomes a little short of breath. No special equipment is required and there is no competitive element.

The lack of physical activity is felt particularly keenly in Scotland, where life expectancy is now the lowest in Europe. There is also a marked difference based broadly on social class whereby the life expectancy of the richest quintile in society is improving in line with that of the rest of Europe whereas the life expectancy of the poorest quintile is rising very slowly, such that it lowers the mean.

In Scotland the recommendations of the Toronto protocol from 2007 are being implemented (Table 1).

In essence this involves multi-agency working so that policies on health, transport, planning and education are aligned to encourage a healthy lifestyle in the broadest sense. The aim of this is to improve and increase life expectancy in Scotland by five years and reduce mortality by 4% a year in adults.

A significant driver for physical activity as a ‘medicine’ was provided by Steven Blair in his seminal paper in 20091. In that study, 4,000 diabetic men were exercised on a treadmill to work out their cardiorespiratory fitness, and their body mass index was noted (Figure 1). Their mortality over the next decade was recorded and the key finding was that low cardiorespiratory fitness was the greatest risk factor for mortality. That is, patients with low cardiovascular fitness but normal body weight were at greater risk of cardiovascular mortality than somebody who was obese with high cardiorespiratory fitness.

A further large-cohort study involving 40,000 patients looked at the percentage of cardiovascular deaths attributable directly to lack of cardiorespiratory fitness.

The study found that lack of cardiorespiratory fitness was the major significant factor in up to 17% of cardiovascular deaths (Figure 2), this being greater than obesity, smoking, diabetes and hypercholesterolemia combined. When 22 | Surgeons’ News | March 2015

TABLE 1: SEVEN INVESTMENTS THAT WORK 1. ‘Whole of school’ programmes

All school day geared towards physical activity, including regular physical activity classes, cycling to school and after-school activities

2. Transport policies that prioritise walking, cycling and public transport

Improves air quality, reduces private car use and increases physical activity by the general public

3. Urban design and infrastructure promote safe access for recreational physical activity, walking and cycling across the whole life course

Place schools and houses close to green aresas, develop cycling and walking networks

4. Physical activity and prevention of non-communicable diseases integrated into primary healthcare systems

Healthcare workers to promote physical activity and preventative medicine

5. Public education to raise awareness and change social norms on physical activity

Use mass media and social media to promote the advantages of physical activity

6. Community-wide programmes involving multiple agencies and settings that integrate community engagement and resources

Involve communities in physical activity programmes and use local resources as a focal point

7. Promote sport for all ages

Allow involvement regardless of gender and age. Engage with sports clubs to deliver physical activity

10 9 8 7 6 5 4 3 2 1 0

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p

Reference

Risk of death from cardiovascular disease

FIGURE 1: CALCULATING CARDIORESPIRATORY FITNESS OF 4,000 DIABETIC MEN

nd re rt fo

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02 .0 <0

h h w te w w te e/ Lo era Hig Lo era Hig Lo erat h g d d d o o hi o M M M BMI 30.0–35.0 BMI 18.5–25.0 BMI 25.0–30.0 Levels of physical activity

Attributable fractions (%)

FIGURE 2: LACK OF CARDIORESPIRATORY FITNESS WAS THE MAJOR SIGNIFICANT FACTOR IN UP TO 17% OF CARDIOVASCULAR DEATHS

one considers the investment by governments across the world to deal with these factors, the savings will be readily appreciated. Lack of physical activity is costing healthcare systems in the UK £8.3bn per year, according to the most recent estimate.

WHERE DO SURGEONS COME IN? Improving cardiorespiratory fitness should be a laudable goal for any healthcare professional. However, we each have our own subspecialty interests and, even though we might be keen to improve the general health of the population, if faced with a patient with a specific disease we tend to focus on that disease rather on further prevention. It is important to realise that physical activity works to prevent surgical disease and improves outcomes. Breast cancer, colorectal cancer, prostate cancer and bladder cancer have all been shown to have reduced incidence in patients with high levels of physical activity. Physical activity also improves post-operative medium-term survival from colorectal cancer and reduces the side effects of chemotherapy.

Patient-orientated outcomes following surgery for arthritis, colorectal cancer, incontinence, breast cancer, bladder cancer, prostate cancer, and bowel cancer are all improved by physical activity. In a healthcare system in which hospital trusts and surgeons are ranked according to patient outcomes, this is surely an easy way of improving patient outcomes with minimal effort or expenditure.

Surgeons should ask all patients in clinic or who are admitted under their care a simple screening question:

18

Men Women

16 14 12 10 8 6 4 2 0

w Lo

REFERENCES 1. Blair SN. Physical inactivity: The biggest public health problem of the 21st Century.

Br J Sports Med 2009; 43: 1-2.

F CR

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g in ok Sm

“Do you do 30 minutes of physical activity five days a week?” If the answer is no, the surgeon needs to know how to assist and direct the patient. The NHS Choices website in England has advice whereas in Scotland all local councils run physical-activity programmes, with details provided on their websites.

The Royal College of Surgeons website has advice for patients and surgeons as well as helpful links. The College is working with the other Royal Colleges in Scotland to produce a consensus statement on physical activity to aid clinicians in secondary care in delivering the physical activity message.

The video ‘23 and a half hours’ is available to play on televisions in waiting areas in outpatient departments, and is an excellent information source to stimulate patient involvement. Remember, too, that the message is for surgeons as well as patients. Do you do 30 minutes of physical activity five days a week? If not, then think how you could fit it into your daily schedule and make the change. For good.

Mr Jon Dearing Consultant Orthopaedic Surgeon and Physical Activity Lead for the RCSEd

www.rcsed.ac.uk | 23

COUNTRY PROFILE

Despite numerous healthcare challenges, medical training in Nepal is going from strength to strength

PEAK PRACTICE Kamal Aryal

Jeremy Ward

Mike Lavelle-Jones

N

epal is a land-locked country located various areas in the last 15 years, with an improvement between India to the south and China in the human development index and per capita income, and a decrease in maternal and infant mortality. in the north, and is home to eight of the Another area of development has been the increase tallest peaks in the world, including Mount in the number of places to train undergraduates and Everest. Since it opened its borders to the postgraduates in medicine and other healthcare outside world in the 1950s, it has received professions. Until the early 1990s, there was only one tremendous contributions from other countries towards medical school, which took up to 30 students. Now its development and well-being. there are five medical schools. Four of them train With a population of approximately 30 million, 20% of undergraduates and postgraduates, whereas the oldest whom live in the capital, Kathmandu, there are several institution, Bir Hospital â&#x20AC;&#x201C; now known as the National constraints to the delivery of healthcare in Nepal. Much Academy of Medical Sciences â&#x20AC;&#x201C; trains only postgraduates. of the country is rural, located in hilly or mountainous Altogether, there are 18 medical colleges producing more regions. Many places can only be reached on foot, so than 1,500 medical graduates each year. access to healthcare is difficult and often delayed.

Most of these medical colleges also train postgraduate Political instability has resulted in a lack of long-term surgical trainees and the number of training posts is healthcare planning by the government. Most people increasing at most institutions each year. After one year are extremely poor, with more than 60% below the of internship, medical graduates are eligible to apply for poverty line. The per capita income is approximately $600 and the overall Master of Surgery (MS) programmes. After completing a literacy rate is just 65%. There three-year MS course, many trainees apply for a Master is a lack of sanitation and clean of Chirurgie (MCh) subspecialty degree. drinking water in most parts of Unfortunately, there is little consistency between the country, and maternal and different training programmes. There is Nepal infant mortality rates are among clearly a need for high-quality the highest in the world. Nevertheless, training for these the country has made significant progress in graduates to achieve the

24 | Surgeonsâ&#x20AC;&#x2122; News | March 2015

Kathmandu is home to 20% of the Nepalese population

Fellow profile Mr C P Maskey is service commission chairman at Patan Academy of Health Sciences, Kathmandu WHERE DID YOU TRAIN? To fulfill the requirements of the FRCS exam, I worked for six months as an SHO and six months in the A&E department at Maidstone General Hospital in Kent. I moved to a two-year registrar

post in Basingstoke, rotating between orthopaedics and thoracic surgery.

Before returning to Nepal, the Nepalese Government nominated me to spend a further three years training in the UK.

WHY DID YOU AFFILIATE WITH THE RCSED? I was so impressed with the teachers on the Primary FRCS course that I decided I would focus on becoming a Fellow of the RCSEd. WHAT IS THE MOST ENJOYABLE PART OF YOUR POSITION? I really enjoy clinical teaching, and I have trained hundreds

of doctors in various countries, including Bhutan, Bangladesh and India.

WHAT IS THE MOST CHALLENGING ASPECT OF YOUR JOB? On my return to Nepal, I was posted in regional hospitals where there were no radiograph or laboratory facilities, and where I was the only surgeon and had to treat a wide range of conditions.

www.rcsed.ac.uk | 25

COUNTRY PROFILE

Member focus Dhiresh Maharjan is a lecturer in colorectal surgery at the Kathmandu Medical College Teaching Hospital, and consultant in colorectal surgery at the Grande International Hospital

Although RCSEd activities in Nepal slowed down following the massacre of the Nepalese royal family in 2001, it still holds MRCS MCQ and EMI there competencies required to deliver surgical care to needy patients in this country.

Until 2000, the Royal College of Surgeons of Edinburgh held FRCS part A, B and C examinations and FRCS courses in Nepal, which improved training and education in the country, with better training units and accreditation of some courses by the College.

Although RCSEd activities in Nepal slowed down following the massacre of the Nepalese royal family in 2001, the College still holds MRCS MCQ and EMI there, and MRCS objective-structured clinical examinations are held in various cities in India.

Dhiresh Maharjan (second from left) and his team

WHERE DID YOU TRAIN AND IN WHICH SPECIALTY? I completed my MRCSEd (general surgery) in 2006 and completed my FCPS (general surgery) in 2013, followed by a fellowship in colorectal surgery at Ghent University Hospital, Belgium.

WHY DID YOU AFFILIATE WITH THE RCSED? After completing medical school at Kathmandu’s Manipal College of Medical Sciences, I did my house clerkship for one year in different hospitals around Kathmandu. However, my last posting was to the surgery department at the National Academy of Medical Sciences, which inspired me to become a surgeon and so the choice of surgical college was crucial. In Nepal, the RCSEd was the established institution from where the country’s first renowned surgeons, such as Professors D N Gongal and Anjani Kumar Sharma, became

Fellows. I flew to Edinburgh to study for and sit my final exam, which was one of the most memorable experiences of my training.

WHAT DO YOU ENJOY ABOUT YOUR WORK? I enjoy working in a team with Dr Prabin Bikram Thapa, who has been an immense support to me.

We started offering advanced laparoscopic surgery in 2008 and have run training courses for residents and juniors. Major achievements in recent years have included starting singleport laparoscopic surgery and changing the traditional practice of nil by mouth to early feeding after major GI surgery.

A NEW ERA In November 2013, the College supported a laparoscopic surgery course at Dhulikhel Hospital, near Kathmandu, held in association with Health Exchange Nepal (UK).

In November 2014, RCSEd vice-president for external affairs Mr Mike Lavelle-Jones led a delegation that visited teaching hospitals, including the National Academy of Medical Sciences, Tribhuvan University Teaching Hospital and Patan Academy of Health Sciences, before running a three-day laparoscopic surgery course.

The delegation also hosted a regional forum in Kathmandu on 6 November 2014, attended by 35 surgeons of various grades from all over the country. Discussion topics included non-operative technical skills for surgeons, simulation in surgery and the College’s International Medical Graduate scheme. Nepalese Fellows Professors D N Gongal and Upendra Devkota also spoke to attendees about the role of the RCSEd in Nepal.

WHAT DO YOU FIND CHALLENGING? The limited resources of a developing country such as Nepal are a challenge.

Nevertheless, we have improved our service for malignancy follow-up over the last 10 years.

In Nepal, the RCSEd was the established institution from where the country’s first renowned surgeons became Fellows Healthcare delivery is problematic in hard-to-reach rural areas

26 | Surgeons’ News | March 2015

Charity links UK medical professionals are joining forces with their Nepalese counterparts via the Health Exchange Nepal UK charity, which aims to support healthcare development in Nepal HEALTH EXCHANGE Health Exchange Nepal UK (HexN UK) is a Lancashirebased charity started in 2008 by Professor Satyan Rajbhandari, consultant endocrinologist at Lancashire Teaching Hospitals and the charityâ&#x20AC;&#x2122;s secretary. Dr Jeremy Ward, College regional adviser in North West England, is chairman of HexN UK. The charity was established to develop and foster links between health professionals in Nepal and the UK, and to support the development of healthcare in Nepal. Since its inception, HexN UK has set up and funded visits to the UK by doctors and nurses from Nepal to gain experience in treating diabetes, medicine and surgery.

One of the first projects HexN UK supported in Nepal was the development of a

patient-centred diabetes film, which greatly helped manage this condition. HexN holds an annual multidisciplinary diabetes conference, coordinated by practitioners in Nepal, with visiting speakers from the UK. It also provides funding for rural village healthcare appointments and eye-screening programmes in schools. Medical support to an orphanage has been provided in Kathmandu, as well as to the Nepal Ambulance Service.

Strengthening of links with hospitals around Kathmandu enabled the first three-day laparoscopic surgery skills

course to be run at Dhulikhel Hospital near Kathmandu in November 2013. This was facilitated by chairman Dr Jeremy Ward, an upper GI and laparoscopic surgeon, and Mr Kamal Aryal, consultant colorectal surgeon in Great Yarmouth. Mr Shyam Matanhelia, consultant laparoscopic urologist at Lancashire Teaching Hospitals, who designed and produced the i-Surgicals laparoscopic simulator, also attended and provided great support.

Over three days, 16 delegates took part in lectures and seminars, gained significant

Over the last two years HexN UK and i-Surgicals have been proud to donate four simulators to Dhulikhel Hospital

simulator experience, and observed numerous general surgical and urological procedures in theatre. Over the last two years, HexN UK and i-Surgicals have been proud to donate four simulators to Dhulikhel Hospital.

The second laparoscopic course was run in November 2014 and HexN UK was delighted to go to Nepal with RCSEd vice-president Mr Mike Lavelle-Jones on a College visit to re-establish links with medical institutions. LavelleJones played an important part in the laparoscopic course in delivering lectures and in theatre. This co-operation will enhance links to the advantage of all parties, and the charity looks forward to building on this relationship. www.hexn.org

www.rcsed.ac.uk | 27

UROLOGY

LIGHTING THE WAY Justine Royale explains how one of the oldest specialties uses technology to provide enormous advances in urological treatment

U

Justine Royale Consultant Urological Surgeon, Aberdeen Royal Infirmary, and Training Programme Director for the East of Scotland Urology Rotation

rology dates back centures, yet is dynamic enough to be keeping up with the space programme in terms of its development. It attracts people who are interested in this diversity but have to be capable of keeping up with its constantly changing outlook.

Bladder and ureteric stones have been found dating back more than 7,000 years, and we know from Egyptian recordings that stones and circumcisions were dealt with then. The following thousands of years are littered with references to lithotomies and how potentially dangerous “cutting for stone” can be.

Urologists in the 1800s would have been fascinated by the new techniques of endoscopy, but light was an issue until Max Nitze, in the 1870s, managed to use a system of lenses and platinum-electrified filaments to illuminate the interior of the bladder to a successful degree. Nitze also developed irrigating and operating cystoscopes, and the first major steps towards modern endoscopic urology were taken. The resectoscope has undergone multiple improvements since then, most notably in the 1930s with the ability to resect endoscopically, courtesy of Hugh Hampton Young. Today, we have high-definition images of the bladder interior, as well as diagnostic development such as narrow-band imaging and photodynamic diagnosis.

Urologists have also been leading lights in the development of laparoscopic and robotic surgery.

Laparoscopy was again initially limited by the ability to get sufficient light and good optics for an adequate view inside a dark abdomen or extra-peritoneal space. However, once these factors were overcome, the ability of urologists to operate on all intra-abdominal organs took off. This was aided from the late 20th century by master–slave robots.

They enabled minimally invasive surgery to be undertaken in 3D with wristed instruments. This strategy enables the surgeon to do increasingly complex procedures.

Urologists are not just surgeons. We are one of the few specialties to receive two Nobel Prizes for outstanding developments. The first was awarded in 1966 to Charles Brenton Huggins, who realised that castration improved the prognosis in prostate cancer markedly and hence understood that it was a hormonally dependent tumour.

The second was awarded in 1977 to Andrew Schally and Roger Guillemin for the breakthrough that would lead to

28 | Surgeons’ News | March 2015

WELLCOME LIBRARY, LONDON

Urology has been around for centuries, as this 16thcentury sculpture by Timan Riemenschneider shows.

It depicts St Benedict removing a bladder stone from Emperor St Henry II

www.rcsed.ac.uk | 29

WELLCOME

UROLOGY

the creation of a drug (goserelin) that did the same job as physical castration. In the last few years, we have had multiple new drugs, including abiraterone acetate and enzalutamide, that prolong the life of men with prostate cancer and could revolutionise treatment.

As with other specialties, we need diversity in the urology workforce. We see increasing numbers of women attracted to the specialty; some parts of it are very well suited to part-time employment and we have multiple part-time trainees. We work well across the board with our colleagues in oncology and interventional radiology, as well as with a growing cohort of urology nurse specialists.

While International, American and European societies of urology were forming in the late 1800s and early 1900s, the British Urology Society didn’t split away from the main body of surgeons until 1945 with the formation of the British Association of Urological Surgeons. We have been debating how many urologists the UK needs ever since.

At that time, there were still many general surgeons in the UK who were doing a bit of urology and few sub-specialists; this has changed over the years. Initially, most people trained as general surgeons and changed direction later. However, it was recognised that urologists need not be exposed to that much general surgery. Hence, cross-cover at night for higher trainees was dropped. In the last decade, most urology trainees have been exposed to very little general surgery.

The shortening of training with the European Working Time Directive and Modernising Medical Careers has meant that urologists who qualify with a certificate of completion of training (CCT) have a very different skill set now to what they had 20 years ago.

For the CCT in urology, there are indicative numbers of procedures and core competency levels that need to be achieved in a variety of procedures (see Table 1), but level 4 competency (the ability to perform a procedure independently and deal with the complications) is not expected in all areas.

Lithotomy instrument set used for the removal of kidney and bladder stones in the 1800s

We are not just surgeons. We are one of the few specialties to receive two Nobel Prizes for outstanding developments 30 | Surgeons’ News | March 2015

Table 1: Procedures and core competencies for the CCT in urology Procedure

Total number

Flexible cystoscopy

200

Urodynamics

50

TRUS and biopsy

50

TURP

150

TURBT

150

Inguinoscrotal

50

Ureteroscopy

50

PCNL

10

ESWL

20

Nephrectomy and other retroperitoneal

30

Radical prostatectomy

20

Cystectomy

15

TVT, TOT, sling, colposuspension

25

Andrology (Nesbit, priapism, amputation)

20

Paediatric groin surgery

25

Clearly, this means that training will produce good core urologists who will be able to deal with endoscopic resection and easier stone work, but not to deliver major complex surgery in sub-specialty areas. This means that most people who want to perform major complex work seek training in these areas as fellowships, either just before or just after their CCT. At the moment, these are all self-selecting and a lot are self-financed. However, it is envisaged that, over time, post-CCT jobs will be developed and that these will be appointed competitively.

Currently the training structure in urology is such that a medical graduate would be expected to do two foundation years, two years of core training and, after appointment at national selection, two years as a specialty trainee prior to getting their CCT and taking up a consultant post. You can improve your chances at national selection by doing the right courses, having all your exams and extra qualifications, as well as doing research and having other outside interests.

Recruitment to urology is likely to increase in coming years due to an ageing population and the declining mortality rate from prostate cancer, though the Government may attempt to deal with these phenomena in different ways.

With the Government’s demands for more generalists, are we likely to see longer training in the core or intermediate years to accommodate this or will we see an early diversion and a fast track to CCT for a small group? Either way, we need to continue to encourage diversity in urology – not just in recruitment, but in entry points as well. Every urologist knows that ‘one size does not fit all’, and this applies just as much to prostate cancer as it does in our workforce. Without the heterogeneity that we encourage in our workforce, the specialty will become stale and nonprogressive, which nobody needs or wants.

LASER-SHARP FOCUS ON TRAINING

UROLOGY IS a fast-changing, diverse surgical specialty.

Technologically, it is at the cutting edge, having been instrumental in the development of robot-assisted surgery, laser technology and naturalorifice surgery. It encompasses operations ranging from local anaesthetic diagnostic procedures all the way up to major open reconstructive surgery. There is huge scope for subspecialisation, including stone surgery and major pelvic oncology.

Students often have little real exposure to urology during medical school. Those interested in the specialty will typically get their first real taste of it as an FY2. While foundation programme experience of urology is not necessary, all budding urologists are required to pass the MRCS exams and achieve their core surgical competencies, typically in a two-year training post where they will need to spend at least six months attached to a urology firm. During core training, the main focus should be to gain

In core training, the main focus should be to gain competence in the basics of endourology and inguinoscrotal surgery, as well as clinical skills in diagnosing and treating common benign diseases competence in the basics of endourology and inguinoscrotal surgery, as well as clinical skills in diagnosing and treating common benign diseases.

Like most higher surgical specialties, entry at ST3 is fiercely competitive. You need to have a strong, diverse logbook of

The da Vinci Robotic Prostatectomy system enables the surgeon to perform laparoscopic surgery with enhanced vision, precision, dexterity and control

Mr William Gietzmann

ST3 Urology, Aberdeen Royal Infirmary

procedures, a good background in audit, and â&#x20AC;&#x201C; for the more competitive deaneries â&#x20AC;&#x201C; experience of research and to have done at least one or two peer-reviewed publications.

ST3 intake occurs once a year in the spring. All candidates are interviewed together over two days in a setup more akin to the MRCS part-B exam than a traditional interview. The process involves one portfolio station followed by four other stations designed to test your diagnostic, practical and communication skills.

Specialist training typically involves between three and four years developing skills in core urology. The fifth and final year is normally spent pursuing a subspecialty interest. Increasingly, people are choosing to continue their training with a one- or twoyear fellowship before seeking a consultant post.

As with all surgical specialties, training is hard work. The need to gain enough experience within an European Working Time Directive-compatible rota remains a challenge for trainers and trainees alike. A great deal of dedication is needed to excel not just in theatre but also in research and publications.

Fitting all this around busy 24-hour on-calls can seem like quite a challenge but, as is recognised by nearly all, the urology community is one of the friendliest and supportive of the surgical specialties, and there will always be a colleague or boss there to help.

For anyone considering a career in urology, I could not recommend it more, and the best way to find out if it is right for you is to do as many urological foundation and core training jobs as you can.

PHOTOGRAPHY: DR P. MARAZZI/SCIENCE PHOTO LIBRARY

Junior doctors who enter training programmes in urology will find themselves in a demanding yet rewarding and supportive specialty, writes Mr William Gietzmann

www.rcsed.ac.uk | 31

ETHICS

In his Fellowship lecture, Professor Robert Winston looks at the history of medical ethics and the issues surrounding reproductive medicine, from IVF to eugenics

THE MORAL MAZE

ILLUSTRATION: WELLCOME LIBRARY, LONDON; PHOTOGRAPH: JANE WILLIAMS

T

he frontispiece to Nicolaas Hartsoeker’s book, Essai de Dioptrique, published in Geneva in 1694, depicts a human sperm with a homunculus in the head (pictured right). This was based on what Hartsoeker thought he had seen when he looked at his own seminal fluid under a microscope, giving himself such a fright that he did not look down a microscope for the next two years.

Gottfried von Leibniz, writing to the Royal Society at about this time, said of Hartsoeker that it was amazing to consider that he could see little people down a microscope with all their limbs completely formed, with fingers and toes. He presumed half of them would be male, and if so they would have little testicles with sperm containing little males who, in turn, would also have little testicles containing sperm, and so on, back to creation.

About 80 years later Rabbi Elisha ben Meir raised the ethical principle when, referring to Hartsoeker’s work, he wrote that it had been seen through a microscope that a drop of semen carries little people inside it, therefore to destroy the seed is like murder.

Even to this day there are religious groups, for example the Catholic Church, which are reluctant to accept in vitro fertilisation as a treatment. Indeed, it still condemns it because it sees the human embryo as a person. This is an interesting point because it seems to me that our ethics can only be as good as our understanding of nature.

This is rather well shown by Professor Tomohiro Kono’s experiment in Japan to produce parthenogenetic mice that could develop to adulthood. Because these mice grew without fertilisation from a sperm, are they really mice?

Of course, any mouse born as a result of this process will be female because Y chromosomes are not involved.

But it is an interesting example of why it is very difficult to understand how the Church can say life begins at conception when there is no definition, and I think that is an important issue in the debate on ethics.

32 | Surgeons’ News | March 2015

In humans, you can make a parthenogenetic embryo by pricking it or immersing it in an acid solution and you get up to a certain stage of development, not usually beyond blastocyst.

The interesting thing is if you could suppress genes such as H19 whether or not you would end up with an immaculate conception.

The other ethical issue in reproductive medicine is eugenics. We should start by considering Francis Galton (see ‘Survival of the fittest’, p35). He believed very much in the theory of evolution and that we should encourage only the fittest in our society to reproduce. His work led to the formation of the Eugenics Society, which held its first international congress at my own university of Imperial College London in 1912.

Here, people came from all over the world to promote the idea of trying to improve society. Perhaps the most famous result of that was what happened in America where there were laws against miscegenation and marriage between blacks and whites. In Virginia this was enacted in 1924 in the case of Carrie Buck, a young woman whose mother abandoned her. Carrie was raped at the age of 15 while in care, became pregnant and had a daughter. And so there were three generations of young women who had been in care and living in difficult circumstances.

While an inmate of the Virginia State Colony for Epileptics and Feebleminded, Carrie Buck was approached by the surgeon Dr John H Bell. He wanted to sterilise her and in fact he applied to the Court in America and eventually ventured to the Supreme Court, which at that time was chaired by Oliver Wendell Holmes.

In his judgement, Wendell Holmes said: “It is better for all the world, if instead of waiting to execute degenerate offspring for crime, or to let them starve for their imbecility, society can prevent those who are manifestly unfit from continuing their kind. The principle that sustains compulsory vaccination is broad enough to cover cutting the Fallopian tubes.... Three generations of imbeciles are enough.” The court gave Bell permission to sterilise Carrie in 1927, but she was never told she had been sterilised.

Instead, she was told that her appendix had been removed.

What is fascinating about the judgement, which is on the statute book, is that in 1945 this was quoted by the doctors at the Nuremberg trials in their defence.

PHOTOGRAPHY BY JANE WILLIAMS

One of the reasons I oppose the Medical Innovation Bill is because I believe it interferes with effective medical research, which is a moral obligation for us

www.rcsed.ac.uk | 33

ETHICS

Moving forward to recent years, pre-implantation genetic diagnosis is a method we can use to biopsy the embryo and produce a baby that is free of a gene defect.

In the case of the first babies born following this type of screening, their mother had approached my unit for help.

Over five years we refined PCR, which was then done by hand, and we also made sure that embryo biopsy was safe and the result was twins who were free of the genetic defect that had killed an elder sibling.

However, the question arises: is this practice eugenic? I wonder if the ability to do this changes attitudes towards children born with special-need conditions, and perhaps this remains an unsolved ethical issue.

In the early 1970s I was very interested in devising methods of reversing sterilisation. Eventually, using microsurgery, we were able to get a success rate of 90% or higher, providing the tubes had not been severely damaged. I saw hundreds of patients from all over the UK who came requesting reversal of sterilisation.

I eventually published a paper on the first 100 patients I saw. Shockingly, the biggest single proportion of those women had been sterilised at the time of their pregnancy.

In most cases they had applied legally under the Abortion Act of 1967 for a termination and the surgeon had agreed on condition that they were sterilised at the same time.

These women felt completely wretched afterwards and typically were having relationship problems, or felt depressed, and were still grieving for the lost pregnancy.

34 | Surgeonsâ&#x20AC;&#x2122; News | March 2015

I raise this point because we have to accept that in a very stressed society in which there is conflict, in which there is a shortage of resources, in which there are going to be changes in healthcare internationally, you could see how issues such as eugenics could again rear their head.

Therefore, doctors are to some extent at the forefront of the ethics issue with an onus to behave ethically.

Beauchamp and Childressâ&#x20AC;&#x2122; Ethical Principles are respect for autonomy; the notion that you try not to do harm (maleficence); that you try to do good (beneficence); and that you do justice. The most difficult aspect of these principles is probably justice because of the pressures of the health service forcing us to decide how we apportion what care we are able to deliver. The great problem in eugenics was the autonomy principle. Advocates of eugenics probably believed they were being altruistic; they were trying to improve society but forgetting that the autonomy of the individual is sacrosanct.

I wonder if [pre-implantation genetic diagnosis] changes attitudes towards children born with special-need conditions, and perhaps this remains an unsolved ethical issue

Lord Winston takes questions from the Collegeâ&#x20AC;&#x2122;s Fellows

Advocates of eugenics probably believed they were being altruistic; they were trying to improve society but forgetting that the autonomy of the individual is sacrosanct

Survival of the fittest Francis Galton worked at a rather obscure university in Bloomsbury where he became professor of genetics. Galton was undoubtedly a genius. By the age of five he could read Latin and Greek. By the age of seven or eight he was reading Virgil in the original.

Galton was a friend of Karl Pearson and a cousin to Charles Darwin. He believed very much in the theory of evolution and survival of the fittest. Hence he arrived at the idea that we should encourage only the fittest in our society to reproduce.

The thinking at the time was that some families could be classed as having

‘defective inheritance’ and should be encouraged not to reproduce.

The ‘defective’ classification could come from family members being ‘simpleminded’, supported by rate-payers, out of work, or suffering from tuberculosis.

In this example, Galton was thinking of the ethics of his society as being important to promote and improve the quality of society. He went on to try to prove that genius and intelligence is hereditary in a book on the subject. As an example of this, he used Judges of England from 1660 to 1865 because they were all related to one another.

with her, I believed IVF was justified. When I discussed it with my team, they were not prepared to treat her. They felt there was a risk of causing HIV in the child and it took six months to change their minds. At the time we were being filmed by the BBC so I found myself in the very uncomfortable situation of being on screen when my team turned me down very firmly. However, the fact that the team were able to do that so openly was very positive from an ethical point of view.

When we looked at the data for mothers passing on HIV to their babies there was a risk of around 10%, but it was certainly no worse than Mendelian inheritance of a serious genetic disease where no doctor would refuse treatment to the patient.

Eventually the team agreed that we would treat this woman and she went on to have a baby that was not infected and the woman is still alive because, of course, HIV is no longer a death sentence and she has been receiving appropriate treatment.

Looking back to the early stages of that case, one can’t help feeling that there was a kind of punitive element to how we were thinking. It took me over the course of three consultations to make up my mind; it really took a while for the decision to mature.

Francis Galton: leading proponent of eugenics

WELLCOME LIBRARY, LONDON

Today there are different issues related to autonomy.

A doctor may be approached by a patient requesting a procedure that they don’t feel comfortable with. The question is where does the doctor’s autonomy come into play and how does that relate to the autonomy of the patient? I suppose one has to find a way of suggesting to that patient that they go to another doctor who can independently advise on the procedure in question. I think that is an important issue in a democracy.

One of the most interesting ethical issues is effective medical research. One of the reasons I oppose the Medical Innovation Bill is because I believe it interferes with effective medical research, which is a moral obligation for us. Medical research is very different from simple innovation. The latter is not recorded in patients’ notes, and there is no appropriate way to determine what happened and where the doctor has not gone through a peer-review process.

Raanan Gillon, former professor of ethics at Imperial College, also adds in scope to the issue of justice by asking, if you are making a decision about a procedure, what does society think? A classic example in my field is family balancing. I think there is very little wrong with selecting an embryo of a certain sex based on the wishes of the parents, but society is quite clearly opposed to that kind of approach. So we have agreed that we will not alter or try to influence the sex of a child in our society.

A major ethical question for my own unit arose when we were approached by a woman who was HIV-positive. She was asymptomatic but had severely damaged tubes and her only chance of a pregnancy was IVF. This was in the early days of HIV when it was seen as a death sentence. Having had at least three consultations

www.rcsed.ac.uk | 35

LEGISLATION

The Medical Innovation Bill is one of the most controversial pieces of healthcare legislation of recent years, facing strong opposition from the RCSEd and much of the medical community

TOO MUCH TO RISK

T

he Medical Innovation Bill is designed to codify existing best practice in relation to decisions by medical practitioners to depart from standard practice and to administer innovative treatment. It allows the test of whether innovation is negligent to be applied at the time when the doctor is deciding whether to innovate, as opposed to the existing common-law test which is applied following a claim of negligence. The bill states that it is not negligent for a doctor to depart from standard practice where he or she does so by applying an accountable and transparent procedure that allows full consideration of all relevant matters.

The bill was brought forward by Lord Maurice Saatchi and was influenced by his personal experience of the healthcare system. Lord Saatchi has argued that doctors are prevented from innovating because of the threat of litigation and that a significant number of cancer deaths are ‘wasted deaths’ because nothing is learned as a result.

36 | Surgeons’ News | March 2015

Public consultations showed that more than 18,000 people agreed that doctors should not have to fear litigation, but there was strong objection amongst the healthcare community and concerns raised that the legislation would weaken patient safeguards.

Since submitting its response to the formal consultation, the RCSEd has lobbied members of the House of Lords at every stage of the bill’s passage through the House.

This included outlining our fundamental objections, but also suggesting amendments that would help to reduce the risk to patients.

In a letter to Members of the House of Lords, the College cited anecdotal evidence from Fellows and Members suggesting that the threat of litigation does not deter innovation, with current case law, GMC regulations and ethical guidelines, as well as individual judgement, all providing a clear and patient-centred framework for innovation.

RCSEd President Ian Ritchie wrote: “Offering medical professionals the option to ignore prevailing medical opinion will

undermine medical fact based on scientific research and the outcomes of rigorous trials.

There will always be pressure from patients who are awaiting the conclusion of a trial, but the current system is the fairest way to ensure drugs and treatments are safely available as soon as possible. Undermining this process would be particularly risky given that current, randomised clinical trials would still represent the fairest chance of receiving new treatments.”

The College has argued that it is impossible for a patient to give ‘informed consent’ to an experimental treatment when all the short and long-term consequences are not fully known, not even to the medical professional. For an already overstretched NHS, there could be consequences from being required to fund experimental treatments. There is an additional danger that patients seeking experimental treatments privately could harm the chances of that treatment becoming more widely available following a successful clinical trial.

Professor Bill Saunders discusses the wider influence of the Dental Faculty

SPEAKING UP FOR QUALITY

T

he Interim Memorandum of Understanding (MoU) between the Royal Colleges and the General Dental Council creates an important role in the development and management of postgraduate training and assessment in the UK. The high standards set by the Faculty gives us the opportunity and honour to quality-assure programmes of training in the UK and overseas. It is a privilege to know that trainers and trainees in many countries have such high regard for our assessment and educational standards.

However, is this our only role?

There is no doubt that the opening of our office in Birmingham to more closely integrate our Members and Fellows in England has already reaped rewards in other aspects of the Faculty’s role – those of political commentator and adviser. The work of the College’s public affairs manager Chris Sanderson and policy officer Andrew Mullinex, both based in Birmingham, in monitoring relevant activity at all levels of the political spectrum gives us an incredible opportunity to both comment and hopefully influence dental policies in the UK. The recent article in The Sunday Times and The Herald is testament to this important role. Mr Rob Chate, Council Member and immediate-past vice-dean, has worked tirelessly to bring problems associated with short-term orthodontic treatment to the attention of the profession and the public. Professor Trevor Burke and Mr Martin Kelleher, two of our Fellows, have campaigned for many years about the overtreatment and hence unnecessary damage

A strictly enforced 9:1 contract may improve the turnover of patients in hospital, but it can be counterproductive for many aspects of training and assessment

that may occur if some types of cosmetic dentistry are undertaken. This has generated heated debate that can only result in higher standards of care for patients.

At the end of 2014, I had the privilege of meeting with Sir Paul Beresford MP, a practising dentist, at the House of Commons. The team in Birmingham brokered this meeting and I attended with the College president Ian Ritchie and Andrew Mullinex. We were able to explain the role of the College and general issues affecting surgeons and dentists. This was a useful engagement and Sir Paul was sympathetic to our concerns, including the increase in the ARF of the General Dental Council and the contracts of hospital consultants. We can’t thrive, or maybe even survive, without the goodwill of our examiners, many of whom are NHS consultants. A strictly enforced 9:1 contract may improve the turnover of patients in hospital, but it can be counterproductive for many aspects of training and assessment. Government needs to understand that without the latter, the quality of the workforce of the future will be greatly diminished.

The Dental Faculty also has the opportunity to respond to consultations by various organisations, including the General Dental Council. Your elected Dental Council consists of many experienced individuals who are highly regarded by the profession. All have contributed to these consultations, which are then collated by the staff in the Birmingham office. This enables us to provide reasoned input into the development of many aspects of dentistry.

This fortunate position can’t be maintained in isolation and the Council is very keen to seek the views of its Members and Fellows on important issues pertaining to dentistry. If you feel that the College can contribute to political debate, then do not hesitate to contact us at the College.

We will be pleased to hear from you.

Professor Bill Saunders Dean, Faculty of Dental Surgery www.rcsed.ac.uk | 37

DENTAL

/ CAREERS

Foundation trainees explore future pathways

M

More than 80 foundation dentists benefited from career advice from the Dental Faculty of the Royal College of Surgeons of Edinburgh at the South West Dental Foundation Conference at Longleat on 2 December 2014.

Pamela Ellis, dental regional adviser, and Nathan Brown, adviser for the South West Dental Deanery, explored career pathways with newly qualified dentists.

This included the jobs and examinations necessary to

become a specialist or an academic as well as the options for further education for a dentist choosing to remain in general practice.

The sessions encouraged trainees to consider life beyond dental foundation training and how they might achieve their career goals. There was particular interest in the membership of the Faculty of Dental Surgery (MFDS) exam and the trainees gained a greater understanding of the syllabus and exam structure.

The winners of the Collegeâ&#x20AC;&#x2122;s book draw were Catherine Law from the Sherborne Dental Practice and Emily Douglas from the Axminster Dental Practice. More than 50 trainees signed up to the Collegeâ&#x20AC;&#x2122;s mailing list.

The Dental Faculty would like to thank conference organiser Mike Attenborough for inviting the College to the event.

/ PRESENTATIONS

College sponsors Wessex prizes

T

he College was proud to support the trainee presentations at the Wessex BDA Hospitals Group meeting. At a well-attended event in Salisbury on 4 December 2014, the College sponsored

Wessex winners Matthew Langford and Kelly Hughes

prizes in three categories: best specialist trainee presentation, best dental core trainee presentation, and best dental care professional presentation.

The winner of the specialist trainee prize was Andrea Lewis, StR in oral and maxillofacial surgery at Salisbury NHS Foundation Trust. Lewis did a clinical study into the knowledge and confidence levels of staff from the emergency department and minor injury unit in the management of dental infection. She found that knowledge and confidence levels improved after an education session on managing infections and she will now explore a longer term teaching programme in southwest England.

The winner of the dental core trainee prize was Matthew Langford, FY2 at the University Hospital Southampton, with his audit of the quality of admission

clerking in maxillofacial surgery. This audit measured the completeness of clerking of maxillofacial patients before and after the introduction of a pro forma. Introduction of the pro forma led to improvements in the quality of clerking and will now be used for all maxillofacial admissions.

The final prize was awarded to Kelly Hughes, a dental nurse at Winchester Hospital. Hughes audited the reasons why patients who had undergone local or general anaesthetic maxillofacial procedures at the Royal Hampshire County Hospital returned postoperatively. She highlighted the need to provide relevant care-information leaflets, taking time to give patients an overview of what to expect and how to care for themselves at home.

Mrs Pamela Ellis Consultant Orthodontist, Dorset County Hospital and Dental Regional Adviser

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www.rcsed.ac.uk | 39

DENTAL

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

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

1

ENGLAND

EAST OF ENGLAND 3 Simon Wardle, James Paget University Hospital, Great Yarmouth

2

KENT, SURREY & SUSSEX 4 Lindsay Winchester, Queen Victoria Hospital, East Grinstead NORTH EAST OF ENGLAND 5 Francis Nohl, Newcastle Dental Hospital, Newcastle upon Tyne

5

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

16

19 17

6

7 8

13

NORTH LONDON 9 Phil Taylor, Barts and the London School of Medicine and Dentistry, London NORTH EAST LONDON 10 Nick Lewis, UCL Eastman Dental Institute, London

3

18

10 Crispian Scully, UCL Eastman Dental Institute, London

12 11

NORTH WEST LONDON 11 Sumithra Hewage, Northwick Park Hospital, Harrow

15

10 9

14

4

OXFORD 12 Mary McKnight, John Radcliffe Hospital, Oxford SOUTH YORKSHIRE/EAST MIDLANDS 13 Philip Benson, Charles Clifford Dental Hospital, Sheffield SOUTH WEST OF ENGLAND 14 Pamela Ellis, Dorset County Hospital, Dorset 15 Matthew Moore, Royal Devon & Exeter NHS Foundation Trust, Exeter YORKSHIRE 16 Brian Nattress, Leeds Dental Institute, Leeds

40 | Surgeons’ News | March 2015

WALES

17 Joy Hickman, Glan Clywyd Hospital, Clwyd

18 Alan Gilmour, Cardiff University

REPUBLIC OF IRELAND

19 Simon Wolstencroft, St James’ Hospital, Dublin

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2011Latest Impact Impact factor Factor 1.406!

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

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

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

Donâ&#x20AC;&#x2122;t forget, you can sign up separately with Elsevier to receive e-table of contents by email each time a new edition of The Surgeon is published: Surgeons News | 41 www.thesurgeon.net

TRAINEES AND STUDENTS

Students learn basic suturing and knot-tying techniques and practise on porcine tissue

Delegates gain skills and insight into practical surgery and available career options in Oxford lectures and workshops

HANDS-ON SKILLS AT SYMPOSIUM 42 | Surgeonsâ&#x20AC;&#x2122; News | March 2015

After an introduction to the principles of electrocautery, students were able to practise basic diathermy techniques

I

Following a demonstration of an open inguinal hernia repair, each delegate was provided with a hernia model and mesh

n October, the RCSEd, along with the Hugh Cairns Surgical Society (HCSS) and Oxford Foundation Surgical Society (OFSS), held the first Oxford Surgical Skills Symposium, with places for the event selling out in less than 24 hours.

The symposium aimed to introduce 75 senior medical students and foundation trainees to a variety of surgical aspects not routinely covered in current surgical curricula. The course provided â&#x20AC;&#x2DC;hands-onâ&#x20AC;&#x2122; experience in basic surgical skills and instructor-led surgical teaching.

Individual groups were presented with introductory lectures to three of six surgical topics: suture material and needles; anatomy of hernias and principles of repair; surgical haemostasis and electrocautery; introduction to laparoscopy; bowel anastomosis; and introduction to the management of fractures.

The lectures were followed by three consecutive workstations covering the same topics with delegates given access to state-of-the art equipment. Each workshop was manned by consultant surgeons and senior surgical trainees acting as instructors. Delegates were given approximately one hour to familiarise themselves with the equipment and practise a set of skills. Throughout the day instructors provided one-toone support. Covidien representatives, with specialist training in each designated area, also assisted in each of the workshops. At the laparoscopic skills station, students could test their skills in a competition. The prize went to Tim Fowler, a Foundation Year-one doctor.

The symposium provided the opportunity for delegates to meet faculty from a range of surgical specialties, as well as creating an environment to learn from senior expertise. A key objective was to provide an insight into aspects of practical surgery with a view to promoting career choices in the surgical field.

The course was organised by regional surgical adviser for Oxfordshire and consultant hepatobiliary and pancreatic surgeon Michael Silva. The organising

Delegates were given one hour to familiarise themselves and practise a set of skills. Throughout the day instructors provided one-to-one support committee included the incumbent and immediate past president of HCSS, Abhishek Trehan and Sameer Ganatra, respectively, and president of the OFSS, Katherine Hurst, who played a vital part in the organisation and running of the event. The event was mainly sponsored by Covidien, with the trauma workstation also sponsored by DePuy Synthes.

The symposium would not have been possible without the participation of the faculty who gave up part of their weekend for the event and the generous efforts of the Covidien team, which resulted in a set of workshops that ran like clockwork.

A further event is planned for later this year.

Trainees tried a range of laparoscopic skills and performed a simulated appendicectomy

TRAINEES AND STUDENTS

Michael Moran and Alice Hartley reflect on the work of the Trainees’ Committee, which was formed in 2012 to represent trainees at the RCSEd

DEDICATED TO TRAINING NEEDS

F

ar from being a committee that meets for the sake of meeting, the RCSEd Trainees’ Committee (TC) has established itself as a crucial part of the College network. Run by and on behalf of trainees, the work of the committee ensures that surgical trainee matters remain high on the agenda of the College. Its efforts in 2013, headed by former chair Mr Issaq Ahmed, led to legislative change that saw HMRC allow all mandatory fees payable by medical trainees to become tax deductible.

WORKING WITHIN THE RCSED At an early stage in the TC’s existence, its members were allocated different liaison roles across the RCSEd where trainee input was important. The education department meets regularly with TC members to discuss areas of unmet educational need, the relevance and applicability of current courses and to generally benchmark College educational programmes with the requirements and

TC MEMBERS

Mr Richard McGregor (chair), General Surgery, SE Scotland Mr Alex Aarvold, Orthopaedics, Wessex Mr Peter Coyne, General Surgery, Northern England Miss Alice Hartley, Urology, Northern England Mr Mike Kipling, General Surgery, Northern England Mr Iain McCallum, General Surgery, Northern England Mr Michael Moran, ENT, Northern Ireland Mr Stephen O’Neil, General Surgery, SE Scotland Miss Emma Reay, Orthopaedics, Northern England Mr Junaid Sultan, Vascular Surgery, Yorkshire

44 | Surgeons’ News | March 2015

priorities of surgical trainees. Similarly, the College’s outreach department works with the TC, and asks that there is representation at events hosted by the College across the UK and beyond. This has been a great way for the TC to engage with the membership and has enabled prospective College Members to meet with current Members to hear first-hand about membership benefits, the affiliate network and engagement activities.

In the area of communications, the TC works to spread messages and news from the College across social media and various other channels. In addition, the committee acts as a pilot group for new initiatives, and its opinions are sought before surveys or publications are released in order to

ensure that the expectations and needs of the trainee membership will be met.

The chairman of the TC, Mr Richard McGregor, is also an elected member of the RCSEd Council, which provides the TC and those it represents with direct access to the highest level of College governance.

This provides essential two-way communication, ensuring that trainee voices are heard and that College priorities are disseminated to the trainee audience. This model has translated to working groups convened by the College, all of which now have TC representation.

Topics that have become priorities include whistleblowing, bullying and harassment, and less than full-time (LTFT) training. The TC has also prepared formal responses to crucial medical policy documents that would have significant implications for Members, such as the European Working Time Directive and the Shape of Training Review.

WORKING EXTERNALLY TO REPRESENT OUR MEMBERS The TC is now well known among the wider medical community, and its members have been invited to represent the College trainee membership on various external committees. There is representation of the TC at the Academy of Medical Royal Colleges Junior Doctors’ Group, the Academy of Medical Royal Colleges and Faculties in Scotland and the

COMMITMENT TO MEMBERS “Since becoming involved with the TC, I have become very aware of just how important the College Members are to the President, Council members and other staff of the College.

It really is a College that lives and breathes for its Members, and wants to represent their needs responsibly.”

Michael Moran, TC Member “I have been really encouraged by the support and recognition that the TC is given by the President, College Council and other departments within the College.

They take our concerns seriously and several issues that we have identified, such as undermining

and bullying, and LTFT training, have become priorities for the College.”

Alice Hartley, TC Member “The College seeks to support and represent its membership at every level. The Trainees’ Committee is an essential part of that work.

The Council depends on the Trainees’ Committee for advice and comment on matters that affect the future consultant workforce of the NHS. I am greatly encouraged by the dedication of the members of the TC to the work of the College on so many fronts.

It gives me faith that we will continue to be forward looking and innovative in the face of ever-present change.”

Ian Ritchie, RCSEd President

Scottish Surgical Simulation Collaborative. In addition, the TC maintains links with a variety of other trainee organisations, such as the Association of Surgeons in Training, the British Orthopaedic Trainees Association and the Association of Otorhinolaryngologists in Training. With good geographical representation across the UK, the TC members also maintain links with their local deaneries and schools of surgery.

ON THE AGENDA As all members of the TC are trainees themselves, there is always a keen eye on emerging opportunities in and potential threats to surgical training. Currently, the TC is designing and organising free educational events at the RCSEd centre in Birmingham to serve the many Members who live within one hour’s drive of the city.

Work is also ongoing on the use of simulation in surgical training, and the TC is closely involved in safeguarding LTFT training for all trainees who may choose or require this form of training.

TC members are committed to maintaining relevance in an ever-changing surgical training environment, and are dedicated to acting as advocates for high-quality surgical training and excellence in patient care. You can contact members of the TC if you have any concerns about surgical training or ideas for future activity.

To contact the Trainees’ Committee, email: michael.moran@rsced.net or alice.hartley@rcsed.net

www.rcsed.ac.uk | 45

COLLEGE INFORMATION

All the latest grants, fellowships and bursaries from the RCSEd

AWARDS & GRANTS Undergraduate Student Bursaries The RCSEd is offering bursaries to enable medicine or dentistry undergraduates to work for elective or vacation periods in universities, medical schools, NHS laboratories or research institutes in the UK and Ireland. Proposals for work on research projects in any branch of surgery are eligible.

Closing date for applications is Wednesday 25 March 2015.

Ethicon Foundation Fund Travel Grants

Grants are awarded towards travel overseas to gain further training or experience and are restricted to the cost of one return airfare only. Travel for the sole purpose of attending a scientific meeting will not be supported. Requests for retrospective awards will not be considered.

Closing date for applications is Friday 1 May 2015.

Medical Student Elective Travel Bursaries

The RCSEd, in association with Ethicon, is

DIARY

offering students an opportunity to apply for a travel bursary towards their elective in surgery. The bursaries to the value of £250 are open to medical students in the UK and Ireland who are affiliates of RCSEd and who are undertaking approved surgical electives overseas.

Closing date for applications is Friday 1 May 2015.

Small Research Grant

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

The College is offering Small Research Grants up to £10,000. Applications are invited from surgical trainees and recently appointed consultants who are Fellows/Members of the College in good standing. Grants are awarded for pump priming projects for one year

only. Requests for running costs to support established projects will be less favourably reviewed than those for pilot work that could facilitate applications for more substantial funding in the future.

Research project submissions should satisfy one or more of the College’s four priority areas for research, as listed above. The application should also include a well-defined exit strategy (i.e. how the project will be taken forward).

Closing date for applications is Friday 12 June 2015.

King James IV Professorships

Applications are invited from surgery or dental surgery practitioners who have made a significant contribution to the clinical and/or scientific basis of surgery. The courtesy title of professor will be accorded to the individuals for the duration of the College year in which their lectures are delivered. Applicants must be Fellows/Members of the College in good standing.

Closing date for applications is Friday 12 June 2015.

The latest surgical and dental events, seminars and courses

MARCH 2015 3 How to Improve Your Surgical Skills at Home: A Refreshing Way to Look at the Acquisition Skills and Practice of Surgery 7 19th Annual Conference for Dental Care Professionals 7–8 Basic Surgical Skills Course (Manchester) 14 Surgical Anatomy of the Limbs (St Andrews) 20 President’s Meeting and Audit Symposium 21 Future Surgeons: Key Skills (Merseyside) 23–25 Edinburgh Hand Course 25 Training the Trainers: Foundation Essentials Course (Wolverhampton) 26–27 Training the Trainers (Wolverhampton) 26–27 Endovascular Aneurysm Repair (EVAR) Planning Deployment for Endovascular Surgeons 27 Professionalism and Excellence in Scottish Healthcare: Our Future 28–29 Edinburgh MRCS OSCE Preparation Course (Manchester)

9–10

APRIL 2015 1–2 Edinburgh MRCS OSCE Preparation Course (Delhi)

For further information, please email education@rcsed.ac.uk or telephone +44 (0)131 527 1600.

All events in Edinburgh unless otherwise stated.

46 | Surgeons’ News | March 2015

Anatomy for MRCS OSCEs (Wade Programme in Surgical Anatomy) 11–12 Edinburgh MRCS OSCE Preparation Course 12–14 Mock MRCS OSCE Exam Course 20–21 Advanced Techniques in Endoscopic Nasal and Sinus Surgery 24 Plastering Techniques for Fracture Treatment 29 – 1 May Core Skills in Orthopaedic Surgery MAY 2015 6–8 12 14–15 15 20–21 20 26

Advanced Trauma Life Support Preparation for Diploma in Implant Dentistry (Edinburgh) Basic Surgical Skills (Edinburgh) Non-Technical Skills for Surgeons (Inverness) Critical Appraisal for ISFE Musculoskeletal Course for GPs/GPSTs Basic Skills in Paediatric Surgery

Travelling Fellowships

Cutner Travelling Fellowship in Orthopaedics John Steyn Travelling Fellowship in Urology Sir James Fraser Travelling Fellowship in General Surgery

Closing date for applications is Friday 12 June 2015.

Syme Medal

The Syme Medal is a prestigious mark of excellence awarded by the College to a Fellow or Member of the College in good standing on the basis of a recently submitted thesis (MD or PhD), published body of research, or educational development. Research should have been published in high-quality peerreviewed journals. Consideration will be given to the impact of work on future research or clinical practice. The Medal is to be awarded to surgeons in training or recently appointed consultants and is distinct from the King James IV Professorship.

With their written application, candidates must submit a curriculum vitae (no more than two pages) along with a discourse, of up to 1,500 words (excluding references, prior publications and papers in press), summarising their recent research or educational development. The essay must refer to and contain findings emanating from the candidate’s own work. A list of any prior publications and papers currently in press should be included. The names of any supervisors and collaborative workers must be acknowledged as well as the name of the institution(s) where the work was carried out.

FOR MORE INFORMATION ABOUT THE COLLEGE’S AWARDS AND GRANTS CONTACT: Cathy McCartney, Awards and Grants Administrator The Royal College of Surgeons of Edinburgh Nicolson Street, Edinburgh EH8 9DW Tel: +44 (0)131 527 1618 Email: c.mccartney@rcsed.ac.uk Only Fellows, Members and Affiliates in good standing are eligible to apply.

The RCSEd collects personal data from you during the application process for awards and grants. We will not share this information with any third parties, and your data will be used solely for the purpose of processing and administrating applications.

Appointments to the Syme Medal are made on the understanding that those elected submit a manuscript for publication in the Journal of the Royal College of Surgeons of Edinburgh and Ireland. Depending on the nature of the work and the topic, the successful candidate may be invited to present a lecture at the College.

Closing date for applications is Friday 19 June 2015.

Joint RCSEd/SOMS/Shanghai Head & Neck Fellowship 2015

Applications are invited from Members and Fellows of the RCSEd and the Scottish Oral and Maxillofacial Society (SOMS) for a four-to-six week Fellowship in the Head and Neck Oncology Training Centre in the Department of Oral and Maxillofacial – Head and Neck Oncology, Ninth People’s Hospital Affiliated to Shanghai Jiaotong University School of Medicine. The funding for this Fellowship is up to £3,000 to cover costs.

Application is by letter and CV (no more

than four pages) along with two current references. Applicants may be invited to interview if required. Further information can be obtained from Mr Roger Currie at r.currie@rcsed.ac.uk Closing date for applications is Friday 26 June 2015.

Wong Choon Hee Medical Student Elective Travel Bursaries The RCSEd, in association with Meducatus, is pleased to offer medical students an opportunity to apply for financial support towards their elective in surgery. This award is open to medical students in the UK and Ireland undertaking approved surgical electives abroad.

These awards are advertised and awarded annually in September.

The bursaries provide a contribution towards the overall costs of travel and subsistence.

Closing date for applications is Wednesday 8 July 2015. www.rcsed.ac.uk | 47

COLLEGE INFORMATION

Congratulations to all our new Fellows and Members who were presented with diplomas at the ceremony in November 2014

DIPLOMA CEREMONIES Admission to Fellowship Ad Hominem Professor Cornelis Hubertus Carolus Dejong, Consultant Surgeon, Department of Surgery, University Hospital Maastricht Dr Neil Gordon Dewhurst FRCPEd FRCPLond FRCPSGlasg FACP(Hon), Immediate Past President, Royal College of Physicians of Edinburgh; Consultant Cardiologist and General Physician, NHS Tayside; Honorary Senior Lecturer in Medicine, Dundee University Award of Fellowships Without Examination Mr Stuart Douglas Anderson, Affiliate, Greenville Orthopaedic Associates, Pennsylvania, USA; Attending Orthopaedic Surgeon, Edgewood Surgical Hospital, Sharon Regional Hospital, Grove City Medical Centre, UPMC Horizon, Pennsylvania Mr Mark Adrian Potter FRCSEng(Gen.Surg), Consultant Colorectal Surgeon and Honorary Clinical Senior Lecturer, Western General Hospital, Edinburgh Mr Saeed Monir Ali Rakha FRCSIrel FACS, Consultant General and Trauma Surgeon, Department of Surgery, Prince Mohammed Bin Abdulaziz Hospital, National Guard Health Affairs, Al Madinah Al Munawarah, Saudi Arabia Professor Ismail Sagap, Consultant General and Colorectal Surgeon and Senior Lecturer, UKM Medical Centre, Malaysia Presentation of the President’s Gold Medal Mr John Laing Duncan FRCSEd, Consultant General and Vascular Surgeon, Raigmore Hospital, Inverness 48 | Surgeons’ News | March 2015

Presentation of the Dental Faculty Medal Dr Ann Catherine Shearer FDS RCSEd, Associate Postgraduate Dental Dean, NHS Education for Scotland Presentation of Diploma of Fellowship in the Specialty of Orthodontics Andrea Maas, Heinrich-HeineUniversity Düsseldorf, Germany

Presentation of the Dean’s Medal Clare Holly Porter, University of Bristol Presentation of the John Smith Medal Rachael Jablonski, University of Sheffield Presentation of Diplomas of Membership of the Faculty of Dental Surgery Emilie Marie Abraham, University of Sheffield Afifah Ali, University of Manchester Katherine May Archer-Smith, University of Leeds Eleni Besi, Aristotle University of Thessaloniki, Greece Shanthi Bilvamangal, Dr MGR Medical University, India Jennifer Ruth Burdett, Newcastle University Catherine Siobhan Caswell, University of Liverpool Bella Dave, University of London Alison Michelle Elizabeth Du Plessis, University of Dundee Jacobus Christoffel Du Plessis, University of Dundee Alice Elizabeth Catherine Dyke, University of Liverpool Fauzia Farrukh, Manipal University, India Anne Green, University of Bristol

Charlotte Hallos, University of London Thomas Edward Howe, University of Sheffield Alexander James Howell, University of Manchester Rachael Jablonski, University of Sheffield Poonam Jagatiya, University of London Hardeep Kaur Kooner, University of Dundee Tiffany Sinyan Li, University of Sheffield Sarah Margaret Millen, University of Dundee Freya Milner, University of Sheffield Emily Claire Moul, University of Sheffield Sabah-Un Nasar, University of London Pooja Pandey, Rajiv Gandhi University of Health Sciences, India Clare Holly Porter, University of Bristol Sooda Rehman, University of Peshawar, Pakistan Yuliya Sharkouskaya, University of Bristol Divya Sudeep, University of Calicut, India Katy Louise Tidbury, University of Bristol Benjamin Veale, University of Sheffield Claire Grace Warner, University of Sheffield Benjamin Williamson, University of London

IN MEMORY

Prudence BARRON (FRCSEd 1945) Mark Benjamin BLOCH (FIMC RCSEd 2010) George Roderick Cooper McLEOD (FRCSEd 1963) Anjani Kumar SHARMA (FRCSEd 1961) Don Bandula WIJETUNGE (FRCSEd 1976)

Presentation of Diploma in Implant Dentistry Eimear Mary Oâ&#x20AC;&#x2122;Connell, University of Edinburgh Presentation of the Council Medal David Charles Morcom, Senior College Officer, RCSEd Presentation of Diplomas of Fellowship in the Specialty of General Surgery Rajiv Peravali, University of Birmingham Timothy James Stansfield, University of Aberdeen Andrea Marie Warwick, University of Sheffield Presentation of Diploma of Fellowship in the Specialty of Otolaryngology Shayan Shahid Ansari, Punjab University, Pakistan Presentation of Diplomas of Fellowship in the Specialty of Trauma and Orthopaedic Surgery Stuart Andrew Aitken, University of Glasgow Nikolai Briffa, University of Malta Jerome Andrew Davidson, University of London David Oliver Ferguson, University of Leeds Nicholas Mackenzie Frew, University of Leeds Kiran Kumar Singisetti, Berhampur University, India

James Kenneth John Tyler, University of Manchester Nijil Lal Vasukutty, University of Kerala, India Caroline Jane Witney-Lagen, University of London Alexander MacDonald Wood, University of Manchester Presentation of Diploma of Fellowship in the Specialty of Urology Richard James Glendinning, University of Liverpool Presentation of the Thomas Annandale Medal Michael David Kipling, University of London Presentation of the Harold Stiles Medal Abdulla Jawed, Kasturba Medical College, India Presentation of Diploma of Membership in Surgery in General Jingye Wu, Peking University, China Presentation of Intercollegiate Diplomas of Membership in Surgery in General Glenn Paul Abela, University of Malta Marija Agius, University of Malta Khalid Ghassan Al-Hourani, University of Edinburgh Khaled Al-Tarrah, University of Aberdeen

Ibrahim Alrishan Alzouebi, University of Damascus, Syria Edward Caruana, University of Malta Steven Dixon, Newcastle University Kamran Asim Gaba, University of Edinburgh Liang Chye Goh, Manipal University, India Muthana Hanon Haroon, University of Baghdad, Iraq Suganth Jayaraman V M, Dr MGR Medical University, India Lepa Lazarova, University of Sheffield Edward Arthur Anson Mains, University of Edinburgh Catherine Joyce Ridd, University of Sheffield Fatema Sayeed, University of Dacca, Bangladesh La Min Soe, University of Yangon, Myanmar Wunna Soe, University of Yangon, Myanmar Francesca Theuma, University of Malta Kyaw Sein Tun, University of Mandalay, Myanmar Vishnukumar Venkatesan, Sri Ramachandra University, India William Thomas Wilson, University of Glasgow Martina Wismayer, University of Malta Christopher John Wooton, University of Dundee Presentation of Fellowship of the Faculty of Surgical Trainers Christopher William Oliver, University of London Presentation of Membership of the Faculty of Surgical Trainers Michael James Woodruff, University of Sheffield Presentation of Diplomas in Immediate Medical Care David Percival, Liverpool John Moores University ZoĂś Smeed, University of Aberdeen Presentation of Diploma in Remote and Offshore Medicine Campbell Mackenzie, University of Cambridge www.rcsed.ac.uk | 49

FARQUHARSON AWARD 2015

Nominations are requested for the 2015 Farquharson Award. This award is in memory of Eric Farquharson, surgeon and Fellow of the College, who was author of Farquharsonâ&#x20AC;&#x2122;s Textbook of Operative Surgery and previous Vice-President of the College. This award is offered on a biannual basis.

In keeping with the original bequest, the Farquharson Award is offered to anyone who has made significant contributions to surgical teaching or surgical anatomy at undergraduate or postgraduate level.

Although this award was traditionally reserved for those who taught at the bedside, in theatre, in the dissecting room, or through lectures or textbooks, the award has broadened to incorporate new methods of teaching through simulators, wet laboratories, operative videos and distance-learning programmes.

As well as being open to junior and senior surgeons, the award is available to those in allied professions who have contributed to surgical and anatomy teaching. Recipients do not have to be Fellows or Members of the Edinburgh College, neither do they have to be medically qualified.

The closing date for the 2015 Farquharson Award is Friday 5 June 2015. A proforma for the citation can be obtained from Mrs Irene MacDonald (i.macdonald@rcsed.ac.uk)

REGIONAL SURGICAL ADVISERS IN YOUR AREA

3

4

The College’s support and advice network throughout the country 1 Director of the Advisery Network

5

Davinder Sandhu, University of Bristol, Bristol, Severn 2 Deputy Director of the Advisery Network Steven Backhouse, Princess of Wales Hospital, Bridgend, Wales

6

9

7

8

11 12

10 31

SCOTLAND

29

NORTH OF SCOTLAND 3 Morag Hogg, Raigmore Hospital, Inverness 3 Sean Kelly, Raigmore Hospital, Inverness 4 Aileen McKinley, Aberdeen Royal Infirmary, Aberdeen 4 Euan Munro, Aberdeen Royal Infirmary, Aberdeen

32 30 42

44 43 28

WEST OF SCOTLAND 5 Lindsey Chisholm, Royal Alexandra Hospital, Paisley 6 Jon Dearing, Ayr Hospital, Ayr 7 Martyn Flett, Royal Hospital for Sick Children, Glasgow 8 Calan Mathieson, Southern General Hospital, Glasgow 9 Chris Rodger, Forth Valley Royal Hospital, Larbert 10 Mary Shanks, Crosshouse Hospital, Kilmarnock

27

25

46

42

26

19

20 38

17 18 40

SOUTH EAST OF SCOTLAND 11 Farhat Din, Western General Hospital, Edinburgh 12 Anna Paisley, Royal Infirmary of Edinburgh, Edinburgh 12 Zahid Raza, Royal Infirmary of Edinburgh, Edinburgh

2

35

EAST OF ENGLAND 13 Vivek Chitre, James Paget University Hospital, Great Yarmouth 14 Andrew Gibbons, Peterborough City Hospital, Peterborough 15 Milind Kulkarni, Norfolk and Norwich University Hospital, Norwich 16 Vijayaranjan Santhanam, Addenbrooke’s Hospital, Cambridge

KENT, SURREY & SUSSEX 21 Jonathan Clasper, Frimley Park Hospital, Surrey 22 Mike Lewis, Royal Sussex County Hospital, Brighton 23 Mike Williams, Eastbourne District General Hospital, Eastbourne LONDON 24 Ziali Sivardeen, Homerton University Hospital MERSEY 25 Azher Siddiq, St Helen’s Hospital, St Helen’s 26 Venkat Srinivasan, Arrowe Park Hospital, Wirral NORTH WESTERN 27 Stuart Clark, Manchester Royal Infirmary, Manchester 28 Jeremy Ward, Royal Preston Hospital NORTHERN 29 Mike Clarke, Freeman Hospital, Newcastle 30 Jonathan Ferguson, James Cook University Hospital, Middlesbrough 31 Paul Gallagher, Wansbeck Hospital, Northumberland 32 Ian Hawthorn, University Hospital of North Durham

16

34

24

ENGLAND

EAST MIDLANDS 17 David Exon, Leicester Royal Infirmary, Leicester 18 Sridhar Rathinam, Glenfield Hospital, Leicester 19 Vel Sakthivel, Lincoln County Hospital, Lincoln 20 Bill Tennant, Queen’s Medical Centre, Nottingham University Hospital

45

33

1

15

14

39

21

38 36 37

22

23

OXFORD 33 Chris Cunningham, Churchill Hospital, Oxford 34 Richard O’Hara, Milton Keynes Hospital, Milton Keynes 33 Mike Silva, Churchill Hospital, Oxford SOUTH WEST PENINSULA 35 Simeon Brundell, Derriford Hospital, Plymouth 35 Ken Hosie, Derriford Hospital, Plymouth WESSEX 36 Anthony Evans, Portsmouth Hospital, Portsmouth 37 Dominic Hodgson, Queen Alexandra Hospital, Portsmouth WEST MIDLANDS 38 Ishan Bhoora, Cannock Chase Hospital, Staffordshire 39 Rajiv Vohra, Queen Elizabeth Hospital Birmingham, Birmingham 40 Ling Wong, University Hospital Coventry and Warwickshire, Coventry YORKSHIRE & HUMBER 41 Aidan Fitzgerald, Northern General Hospital, Sheffield 42 Clare McNaught, Scarborough Hospital, Scarborough 43 David O’Regan, Leeds General Infirmary, Leeds 44 Mark Steward, Bradford City Hospital, Bradford

WALES

45 Sanjeev Agarwal, University Hospital Wales, Cardiff

46 Vaikuntam Srinivasan, Glan Clywd Hospital, Rhyl

www.rcsed.ac.uk | 51

13

OUT OF HOURS

Keller’s clean winner Graham Layer takes his palate on a tour of tasting menus, highlighting The French Laundry in northern California

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

T

he Slanted Door at the Ferry Building on the Embarcadero, San Francisco, cannot be missed – a vast, contemporary Vietnamese restaurant with the most delectable combination of dishes made really for sharing and tasting, and with that clean but rich Indochinese flavour mixture which is a fascination to my palate and combines the best of western-style Chinese with real south-east Asian cuisine. At lunch it is heaving with satisfied diners.

My recommendations would be shrimp and pork rolls with peanut sauce, crab and sesame cellophane noodles, “grass-fed estancia shaking beef”, caramelised shrimp, spicy squid, and pork spareribs doused in hoisin sauce – more than enough for two. So familiar, enticing and very reasonably priced, with a bay view.

Then out into the “countryside” to the Napa Valley in

52 | Surgeons’ News | March 2015

northern California and The French Laundry, Yountville.

“The Laundry” is the inner sanctum, the holy of holies in the international temple of gastronomy. My visit to this three-star legend of Thomas Keller’s was planned months in advance, taking five people on the phone and internet to secure a table for four, upstairs – a little more reverent and quieter than the buzz on the ground floor, giving a feeling of being inside a laminar flow tent.

Due to commence at 5.45pm, the evening was nearly ruined when the puncture warning light came on, on the way there. Flustered and intimidated we arrived late, having parked by the restaurant’s extensive open vegetable gardens, and were rapidly shown to our table, glimpsing the quiet army of chefs in the theatre kitchen under bright lights behind expansive windows. The front-ofhouse staff were dressed formally but the majority of the

Spring cruise Bernard Ferrie takes to the high seas and samples some fine grapes en route

T

ough winter; the old medico suggests taking the sea air so 3,800 nautical miles round the Iberian peninsula to get through 8,500 bottles of wine – well, that’s between you and your fellow passengers. Here are just six.

All aboard the creaky SS Politician and the first port is Falmouth – delicious and refreshing Camel Valley Cornwall Brut (£24.95, Camel Valley) as the sun sinks over the yardarm. It’s possibly the best British fizz of the lot. Force 9 in the Bay of Biscay so no chance of mooring in Bordeaux or Gascony. Make it shaken, rattled and rolled to Corunna to enjoy Sainsbury’s Taste the Difference Albarino (£8) – zesty lime, peach and apple – then hurry to Santiago de Compostela.

clientele were almost “bare below the elbows”, reflecting the hallowed sterility of the set-up perhaps? Everyone was taking discreet photographs of the food but the restaurant provides each diner with a pack containing a laundry label inscribed with your bill, your individual menu and masses of information, together with an iconic clothes peg, a tin of shortbreads and a box of chocolate truffles. So there are plenty of souvenirs, and all included, as is service, in the $295 nine-course tasting menu. Wine extra. Royal Ossetra caviar $75 extra. Shaved white truffles $175 extra.

The theatrical list of courses multiplied with morsels in between to keep us occupied and commenced with the famous mini ice-cream cone filled with a tartare of salmon, before we reached the fabulous oysters bathed in tapioca and white sturgeon caviar. We proceeded to a mixed salad of artichokes, olives and spinach garnished with other delights fresh from the garden, rather than splashing out on the brown butter risotto with truffles. Fish followed and was a Japanese delicacy of Pacific medai (barrelfish),

Gentler seas take us down the Portuguese coast – port is not just for Christmas: Krohn LBV 2009 (£14.95, Chatsworth Estates) – good depth of fruit and whiff of spices, but may throw a hint of sediment, a bit like those enormous cruise liners as they dock. Krohn Colheita 2001 (£19.95, Chatsworth Estates) is smooth, complex and nutty after 14 years in wood captivity.

The three Michelin-starred French Laundry in Yountville, in the Napa Valley

Gibraltar next – avoid the Barbary macaques – then cross the border to Jerez for 12-year-old Lustau Dry Amontillado (£8, Sainsbury’s) – raisins, salted almonds – lightly chilled with tapas.

Halfway point is Mallorca to banish the cobwebs with Macia Batle Tinto 2013 (£9.95, M&S), one of the few Mallorcan wines available here – aromatic, herby and brambley. Start return leg 1kg heavier. How did that happen? Was it the 250kg butter added to the six tonnes of veg? Splice the mainbrace.

www.rcsed.ac.uk | 53

PHOTO BY MATT LLOYD/REX

OUT OF HOURS

a glorious white fish with a crunchy frizzled surface and a collection of beautiful vegetables and fruits. A whole lobster tail followed – served with walnuts, red onion and beetroot – with a frothy soubise sauce (like an oniony béchamel).

Then a difficult decision, either roasted wild Scottish grouse with oats and Guinness or “ris de veau” with cepes, i.e. retroperitoneal bits with fungus. The team was split, which allowed us to biopsy each others’ offerings. This was followed by charcoal-grilled beef, the “cap of the ribeye” we were told, which was a large portion of the tenderest honed muscle imaginable, served with corned beef tongue. Sounds bizarre but delicious. Being French, then on to cheese, which was a hard Tomme de Savoie coated in a broccoli crust and served with an almond sponge and an apricot pâté. This led into desserts, when our table was thinking of surrendering, and these were endless… First a sort of layer cake, superbly executed as a precise mille-feuille with apple and a darker fruit – plum perhaps? Then some puffy meringue with a fabulous ice-cream, both with unusual ingredients, to be followed by the best chocolate dish I have ever seen and eaten: a ganache resting on a chocolate doughnut which was floating in olive oil surrounded by a concentric ring of firm chocolate. Extraordinary, but it works, followed by a multitude of mini-spherical doughnuts with coffee, macaroons and chocolate macadamia nuts, then a whole wooden box of homemade truffles, most of which we took home – together with our tins of shortbreads and other prizes. So an expensive meal, but well worth the cost, not just in volume alone but in sheer perfection, artistry, ingenious dishes, stimulating flavours, delicious combinations and supreme professional service.

Would I go again? Definitely, and would probably enjoy it the more for knowing how it all works.

Now, my theme is tasting menus and I was invited to a birthday party at Trinity in Old Clapham, south London.

Relaxed but smart tables in a slightly cold outpatients waiting room-like atmosphere, with magnificent and innovative food. This contemporary restaurant run by Adam Byatt has been building up a very big name and rightly so, and is a very good deal. The tasting menu of a 54 | Surgeons’ News | March 2015

Exquisite fare at the French Laundry, above, and restaurant owner Thomas Keller, right

similar number of courses to “The Laundry” is £65 and the quality is stunning, with entertaining and effective service, even for a large party as we were. Battle commenced with a lovely, smooth, yellow pumpkin soup swamping some curds and whey accompanied by an attractive biscuit-like bread with olives and a dip, followed by a croquette of crispy pig’s trotter with crackling and other accessories, or I could have taken the chestnut and artichoke salad with truffled duck egg – memories of the Napa Valley? Fish was excellent sea bass with a frothy oyster “emulsion” and this was followed by a stupendous venison Wellington with figs and root vegetables. As if in France, on to the cheese, which was truffled Brie on toast (essentially), then the single dessert of clementine panna cotta served with a bubbly homemade chocolate, reminiscent of the Aero bar. This establishment warrants a Michelin star and has three AA rosettes – only a few restaurants have four and two have five.

Still in London, a lunch visit to Cut, where an evening dinner had not been anything like as good as its sister in Beverly Hills (about which I have previously waxed lyrical). This time we had a super American-style meal, sharing a state-of-the-art cobb salad as a starter – superbly presented in parallel lines of multiple tiny cubes of blue cheese, bacon, avocado, olives, lettuce, beans, egg and so on and prepared with excellent ingredients highlighting cold chunky lobster. The wagyu “burger” with every conceivable optional extra and sauce was outstanding, as was a bloody ribeye steak. The fries I understand were some of the best my lunch partner had eaten and were more than plentiful. A very enjoyable venue with friendly, super-efficient staff – the combination now is just right.

WSCTS2015 25TH WSCTS ANNUAL MEETING AND EXHIBITION 2015 19â&#x20AC;&#x201C;22 SEPTEMBER 2015, EDINBURGH, SCOTLAND Join us in Edinburgh at the Royal College of Surgeons of Edinburgh Registration will open soon!

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FROM THE COLLECTIONS

‘EMBARRASSING ILLNESS’ IN CAST FROM THE PAST Facial impression of an adult with acquired syphilis (GC2631), just one of the diseases prevalent among soldiers in the American Civil War

T

his wax cast of the upper part of the face shows bilateral cicatricial ectropion of the eyelids due to acquired syphilis. Although all Museum objects are currently off display, an image of this cast features in the museum’s touring exhibition Words and Deeds, Weapons and Wounding.

The touring exhibition focuses on the impact of warfare, from the Napoleonic era to World War Two, examining the roles of caregivers and patients. Due to the period of time covered, the exhibition illustrates the extent of fatalities caused by infection and illness in warfare before the introduction of antiseptics and preventative medicine. The exhibition also explores added complications relating to the spread of infection

Syphilis can be treated effectively if caught in the first stages. As shown by the recent rise in cases of syphilis in areas of Scotland, the disease is not always on the decline that were caused by unsanitary operating conditions.

Featured in the touring exhibition’s section on the American Civil War, this cast is used to remind us that disease seen in civilian life could also affect those involved in battle. Diarrhoea, dysentery, typhoid fever, smallpox and malaria were prevalent, and could be fatal, among the troops. Venereal diseases were common, and reported cases of syphilis and gonorrhoea peaked at the beginning and end of the American Civil War. Because syphilis could not be treated effectively at this time, those who suffered from it were left with a progressive illness and the risk of spreading infection to their partners and children.

56 | Surgeons’ News | March 2015

In the American Civil War era there was no effective treatment for syphilis

REFERENCES 1. www.hps.scot. nhs.uk/documents/ ewr/pdf2013/ 1350.pdf

Today syphilis can be detected and treated effectively if caught in the first stages. However, as shown by the recent rise in cases of syphilis in areas of Scotland1, this does not mean the disease is always on the decline.

Consequently, the Museum’s historical collections have an important part to play in raising modern discussions on preventative healthcare in the community and highlighting the importance of seeking medical care for ‘embarrassing illnesses’.

Emma Black Public Engagement Officer, Surgeons’ Hall Museum

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