Surgeons' News June 2015

HISTORY

GENERATION X

Margaret Farquharson on the launch of the 10th edition of her father’s classic textbook

ROUNDTABLE

THE RIGHT MOVE

A panel of experts discuss promoting the benefits of pre-operative physical activity

INTERVIEW

BOXING CLEVER

Dr Teodor Grantcharov on the value of simulation in the various training systems around the world

Surgeonsnews June 2015

The magazine of The Royal College of Surgeons of Edinburgh

Advances in cancer care Developments across the specialties to improve oncology outcomes

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 summer edition

I

f you were born after 1960, you have a 50% chance of suffering from cancer in your lifetime. The President’s Meeting this year had surgical oncology as its theme and we carry several articles by speakers at the meeting.

For me, the most striking part of the meeting was the debate on the motion that surgical resection of colorectal metastases is of proven benefit. Before the speakers gave their presentations, the delegates were strongly in favour of the motion. Having heard the evidence, or rather the lack of evidence to support what many of us thought had already been demonstrated, there was a significant change in the view of the meeting and a reversal of the motion. If I required such a resection, I would probably have the procedure, but that would be now knowing that my decision was based on a balance of probability rather than proof. My faith in evidence-based medicine was renewed.

Many of us used particular textbooks in our early training. Over the years and through subsequent editions, these have developed into multiauthor books published both digitally and in print. A book that continues into its 10th edition, after 61 years, must still have a market. Farquharson’s Textbook of Operative Surgery is exactly that. On page 22 we celebrate the remarkable achievement of Eric Farquharson and his family, who have overseen its production through three generations.

Winston Churchill’s view of exercise – never stand when you can sit and never sit when you can lie – is not only economical with the truth, it is frankly wrong.

The issue of how the profession can influence our patients and the wider population regarding

the benefits of exercise was the subject of our Surgeons’ News roundtable. We publish the output of that discussion on page 38.

It is easy for organisations such as Royal Colleges to appear out of touch given the age group from which most members of their councils are drawn. Having an elected member of Council representing trainees has helped this college, but our new Younger Fellows’ group should improve our visibility and relevance for this important group within the College’s membership (see page 8).

Tom Scotland made a significant contribution to patients in the north-east of Scotland as an orthopaedic surgeon, but his impact as a medical historian has been remarkable. His knowledge of the development of military surgery and particularly his encyclopaedic knowledge of the First World War, combined with his ability to communicate that knowledge, has impressed many across the UK and worldwide. He was a major keynote speaker at the joint meeting of the College with the Royal Australasian College in May and he has once again contributed to Surgeons’ News with an article about the improvements Henry Gray made to wound management in World War I (see page 30).

John Duncan editor@surgeonsnews.com

Winston Churchill’s view of exercise – never stand when you can sit and never sit when you can lie – is not only economical with the truth, it is frankly wrong www.rcsed.ac.uk | 1

50

HISTORY

GENERATION X

Margaret Farquharson on the launch of the 10th edition of her father’s classic textbook

ROUNDTABLE

THE RIGHT MOVE

A panel of experts discuss promoting the benefits of pre-operative physical activity

INTERVIEW

BOXING CLEVER

Dr Teodor Grantcharov on the value of simulation in the various training systems around the world

Surgeonsnews June 2015

The magazine of The Royal College of Surgeons of Edinburgh

Advances in cancer care

22

Developments across the specialties to improve oncology outcomes

www.surgeonsnews.com

EDITOR John Duncan DEPUTY EDITOR Robyn Webber

Contents June 2015

EDITORIAL BOARD Richard McGregor Peter Lamb Peter Douglas Sarah Allen Chris Henry Dr Yvonne Hurst Aoife O’Sullivan Mark Baillie

04

AGENDA News and views from the College and the profession

10

THE PRESIDENT WRITES Why international training standards are key to the NHS’s future

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

14

THE PRESIDENT’S MEETING A summary of the lectures, debate and symposia on ‘surgical oncology’

22

HISTORY Three generations, one classic text: we salute Farquharson’s Textbook of Operative General Surgery

26

INTERVIEW Dr Teodor Grantcharov reveals his passion for surgical simulation

30

HISTORY Tom Scotland on how Henry Gray reshaped WWI wound management

34

DESIGN AND PRODUCTION

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

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

2 | Surgeons’ News | June 2015

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44

DENTAL Examinations and training; regional advisers; skills champion report

50

TRAINEES AND STUDENTS Undergraduate elective in Sierra Leone; Northern Ireland Cancer Research Consumer Forum

INTERNATIONAL PROFILE RACS draws up a framework to help at every stage in a surgical career

56

COLLEGE INFORMATION Diploma ceremony listings, courses, awards and grants

38

ROUNDTABLE Experts discuss how to promote the health benefits of physical activity

62

OUT OF HOURS Graham Layer takes his tastebuds on a culinary tour of three cities

42

POLICY GROUP An outline of the work of the College’s Policy Group

64

FROM THE COLLECTIONS Dr Ponfick’s topographic atlas of medico-surgical diagnosis

SURGEONS’ NEWS READER SURVEY

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From in-depth interviews and features to the latest College news, we hope Surgeons’ News is of interest to every member of the College, regardless of country, specialty or grade. To continue doing this, we need your input.

We want to hear what you think about the College’s membership magazine to make sure we are producing content you enjoy reading.

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Agenda The latest news from the College and profession

/ ONLINE

Representatives of the royal surgical colleges and specialty associations

E-voting rolled out for Council elections Surgical Fellows are to be invited to vote for Members of Council using a new e-voting system. Nominations closed on 29 May for five Council vacancies, which will arise at the AGM in November.

The new system will provide an easier method of electing Council Members, allowing Fellows to engage in the election processes of the College in a more convenient and accessible way.

In July, a link to a secure, online voting form will be emailed to those eligible.

Paper forms will still be supplied for Fellows who wish to send a postal vote. / SURVEY

Surgeons’ News survey Give us your views about Surgeons’ News and you could win an Apple Watch.

From in-depth interviews and features to the latest College news, we hope Surgeons’ News is of interest to every member of the College, regardless of country, specialty or grade. We would like to hear what you think about the College’s membership magazine to make sure we are producing content you enjoy reading.

The survey will take less than 10 minutes, all responses will be treated in confidence and your contact details will not be passed on to any third parties.

Go to www.surveymonkey. com/s/RCSEd_SN15 4 | Surgeons’ News | June 2015

/ EVENT

Forum addresses performance issues The College hosted a meeting of the Surgical Forum of Great Britain and Ireland on 12 March 2015.

Representatives from the royal surgical colleges and the specialty associations were in Edinburgh to discuss identifying surgeons with performance issues and how best to handle them.

/ COURSES

Learn to lead with PEGs

P

rofessional Excellence Groups, or PEGs, offer individuals the opportunity to establish constructive relationships within a safe environment for sharing personal challenges and concerns.

The Professional Excellence Groups: Creating Better Surgeons workshop offers the opportunity to experience what it is

like to be part of a Professional Excellence Group. It also enables attendees to develop essential skills and abilities in identifying and providing mentorship throughout their careers. The course is on 18 September in Edinburgh.

To book, contact a.stevenson@rcsed.ac.uk or call 0131 668 9237

/ EVENT

FSSA meeting

The Council and SSG chaired a meeting with Specialty Association presidents on 13 March. Topics discussed included the place of anatomy teaching in the undergraduate curriculum, the Medical Innovation Bill and use of energy devices in theatre.

of Securing the future e car t ien pat nt excelle w independent revie Final report of the Greenaway Led by Professor David

/ PEOPLE

College Chaplain retires after 40 years’ service

/ SHOT REVIEW

FSSA: Training must fulfil society’s needs The Federation of Surgical Specialty Associations (FSSA) has released a statement outlining why training cuts implemented under the Shape of Training review could harm doctors.

The FSSA said focusing on training times alone, with the only endpoint being appointment to a consultant post, may no longer be appropriate, citing that the UK and Ireland are the only countries that have appointment to a consultant post as the only outcome of training.

The statement said: “The priority must be to train surgeons to fulfil the needs of society: in other words there is no justification to train more and more specialists when demand for such posts is few [sic]. Society needs surgeons who can deal with emergencies as these constitute the largest cohort of patients being admitted to UK hospitals each year.”

fssa.org.uk

Pictured from left: Sarah Jane Macmillan, Maureen Macmillan, Gilleasbuig Macmillan and Ian Ritchie

I

n February, RCSEd president Ian Ritchie hosted a dinner to celebrate Gilleasbuig Macmillan’s contribution to the life of the College. At the end of 2014, Gilleasbuig retired as minister of St Giles’ Cathedral and as College Chaplain.

He took up the position of chaplain in 1973 when Sir Donald Douglas was president. During those 41 years, he has served the College through 15 presidencies.

This remarkable constancy in the life of the College is unsurpassed in modern times. He has been a presence at countless diploma ceremonies, adding significantly to the sense of occasion.

Many of those attending diploma ceremonies are not from a Christian background. Gilleasbuig has always been welcoming to those of all faiths and of none.

In his life outside the College, as well as his charge of St Giles’ Cathedral, he has been Chaplain to the Queen in Scotland since 1979 and Dean of the Order of the Thistle for 25 years.

The dinner in February was attended by many past presidents, office bearers, Council Members and Fellows who had worked with him over these decades. The College wishes him well in what we hope will be a long and happy retirement. www.rcsed.ac.uk | 5

AGENDA / TRAINING

Plans for more structured simulation training In November, the College will host the Scottish Surgical Simulation Collaborative (SSSC) for a consensus meeting on the future of simulation training in Scotland.

The SSSC was established in 2012 as a bicollegiate group of the RCSEd and Royal College of

Physicians and Surgeons of Glasgow, with ties to NHS Education Scotland. Its task is to provide strategic recommendations for better integration of simulation.

The SSSC Core Surgical Training recommendations were implemented in August 2014 to include three courses,

a gradually overhauled monthly teaching programme and webinars, and an incentivised laparoscopy practice project involving take-home simulators and target competences.

The SSSC is now working with urology, paediatric surgery, general and vascular surgery, as well as campaigning for funding and constructing a faculty development course.

/ EVENT

Aspiring Surgeons conference The College hosted the fifth annual National Conference for Aspiring Surgeons in Bristol in February, calling on undergraduates and foundation doctors from around the UK to present ideas and share their passion on innovation, safety and quality in surgery.

The event was held in association with the University of Bristol Surgical Society (SCRUBS), and included educational workshops on presentation

/ EVENT

T

Plastering practice

skills, research and audit, and technical skills such as suturing, knot-tying and plastering techniques.

The event’s convenor, Professor Davinder Sandhu, director of the College’s Regional Surgical Advisory network, said: “This event plays a key role in inspiring tomorrow’s surgeons. Those who attended gained valuable insight into our rewarding but competitive career, and it was a great opportunity for bright minds to share innovation and ideas.”

Symposium celebrates excellence he College co-hosted the Professionalism and Excellence in Scottish Healthcare symposium on 27 March. Held jointly with the Scottish Academy of Medical Royal Colleges Trainees’ Committee, the event showcased pioneering quality improvement projects by trainees from various specialties, alongside the importance of promoting

non-technical skills across the NHS to improve patient safety.

Richard McGregor, RCSEd trainee representative on Council (pictured left), co-chaired the event. He said: “The event was an excellent opportunity to engage with colleagues across a range of specialties to discuss the challenges faced in training and across the wider NHS. A personal highlight was to hear about the immensely successful work of the Scottish Clinical Leadership Fellows.”

NEWS IN BRIEF RCSEd/CSHK Conjoint Scientific Congress 2015 The College of Surgeons of Hong Kong (CSHK)’s Silver Jubilee Congress, Surgery for Tomorrow’s Asia, will be held on 11–13 September 2015 at the Hong Kong Convention and Exhibition Centre, 1 Expo Drive, Wan Chai, Hong Kong.

It will present a diversified and interactive programme, including various symposia.

A statement from the CSHK said: “The Silver Jubilee not only marks a milestone in the College history, but also the thriving and robust history of surgical development over the past 25 years in Hong Kong.

Generation after generation, our predecessors, Fellows and Members have unified in bringing our College to a leading role in surgical training.”

cshk.org/csc2015

Elections for first SAS Member Voting papers will be issued in August for Fellows and Members of the College in SAS grades to vote for a dedicated representative on Council. With the election results expected in October, the new SAS Member of Council will formally join the College’s governing body at the AGM in November.

Applications open for ESSQ intake Delivered jointly by the College and Edinburgh University, the ESSQ is a suite of online distance learning programmes designed to support learning for the MRCS and FRCS examinations. The closing date for applications for the 2015/16 cohort is Friday 21 August 2015.

essqchm.rcsed.ac.uk

/ APPOINTMENT

Professor James (Barry) Cullen / PEOPLE

Fellow retires aged 87 RCSEd Fellow Professor James (Barry) Cullen has retired from the Singapore National Eye Centre, at the age of 87.

Colleagues Professors Sharon Tow and Christopher Beng-Ti Ang said: “Professor Cullen is a highly respected and muchloved senior colleague. He spent the last 20 years developing and raising the standard of neuro-ophthalmology in Singapore. In doing so, he has trained a multitude of ophthalmologists who are leading figures in Singapore today.”

Past Dental Dean takes director post at Aberdeen Uni

I

mmediate Past Dean of the College’s Dental Faculty, Professor Richard Ibbetson, is to take up a new role as director of dentistry at the University of Aberdeen.

Professor Ibbetson said: “I am delighted to have been appointed and I am looking forward to taking up my post in early July. On my visits to Aberdeen, I have been impressed by the commitment of colleagues within the dental school itself, the School of Medicine and Dentistry and

the wider College of Life Sciences and Medicine.

This, together with the strong support of colleagues within the wider NHS, will enable us to provide high-quality dental education and develop the research base. In so doing, we will be a valuable ongoing resource for the population of north-east Scotland and beyond.”

Professor Ibbetson

JUDGEMENT AND OPERATIVE SKILLS IN EMERGENCY SURGERY (JOSES) 9–10 November 2015, Quincentenary Building The Royal College of Surgeons of Edinburgh The aim of the two-day course is to: l Identify areas of uncertainty and vulnerability as a consultant in the treatment of emergency general surgical patients. l Improve judgement and decision-making in situations where a clinician may have limited experience. l Enable a clinician to develop a mechanism and strategy for dealing with difficult operative situations and pathology. l Improve critical thinking and strategies in relation to FRCS examination For further information and to book please visit www.rcsed.ac.uk/education

www.rcsed.ac.uk | 7

YOUNGER FELLOWS’ GROUP

JOIN THE CLUB The College has launched an initiative to increase engagement with Fellows in the early years of consultancy, writes Clare McNaught

T

he Royal College of Surgeons of Edinburgh has a proud history, educating surgeons and setting standards for the profession for more than 500 years. Life as a consultant has changed dramatically over this time, but perhaps most noticeably over the last decade. We now live in an environment of raised public expectation, increased scrutiny with the individual reporting of surgical outcomes and escalated workload due to changes enforced by the European Working 8 | Surgeons’ News | June 2015

Time Directive. In recognition of these new pressures, the College has embarked on a programme of activities to assist our younger consultants, such as the Professional Excellence Groups, which provide mentorship and support to surgeons. One further initiative is the Younger Fellows’ Group.

A Younger Fellow (YF) is defined as any surgeon who has obtained Fellowship within the last 10 years.

This may seem a rather arbitrary cut-off, but the aim of the group is to facilitate younger surgeons of all disciplines and from all locations in the UK to socialise, get involved in College life and feed back their opinions on professional issues to Council.

To start things off, a small committee of YFs has been appointed to organise the inaugural meetings. By now, you will have seen the adverts for ‘Curry at the College’, with the invitation to ‘spice up’ your surgical career. These nights are being held in our Edinburgh and Birmingham properties, so that we can attract YFs from both sides of the border. In addition to the heaps of curry

Clare McNaught, Council Member and Consultant General and Colorectal Surgeon, Scarborough Hospital

We live in an environment of raised public expectation, increased scrutiny with the individual reporting of surgical outcomes and escalated workload due to changes enforced by the EWTD and drinks, the meetings will introduce the Younger Fellows’ Group, give information on how to get involved with College activities and also provide an outlet to vent our frustrations or share our success stories with new friends and like-minded colleagues.

Similar societies have been established by a few of our sister colleges across the globe, providing an avenue to promote international collaboration and

exchange. Over the last 20 years, the Australasian Younger Fellows’ Group has run a three-day residential course for 20 local surgeons and four international delegates from the UK, US and Asia.

I attended this event last year, held at the Hard Rock Hotel on Sentosa Island, Singapore. There was a hectic mix of workshops, lectures, team-building exercises and heated debates about topical surgical issues. There was also time for socialising, fine wine and dining. This was truly a life-changing experience for me and I left the meeting feeling reinvigorated and passionate about replicating this experience for YFs in the UK. YFs are the future of the College. The past success of our organisation has been due to the willingness of volunteers to sacrifice some of their precious free time to promote the career of surgery and perform the work of the College in terms of examination and education activity. So, YFs, ask not what your College can do for you, but what you can do for your College.

The Younger Fellows’ Group will advise YFs on how to get more involved with College activities

www.rcsed.ac.uk | 9

AGENDA

THE PRESIDENT WRITES Ian Ritchie considers the importance of open and honest debate over the future of the NHS

A

s the UK general election draws near, every day brings a new report issuing warnings about the bleak future of the NHS. At the time of writing, the election is still some weeks off, but by the time you read this, the results will be known and, whatever the outcome, the fact will remain that change is needed in the NHS. I have spoken often about the need to change the way we work in the NHS, and that this will require honest and open discussion between those who deliver the service, those who manage it, and those who influence and affect it politically. Such conversations must be without prejudice and we must have the freedom to consider all options and ideas, and ensure that the patient remains at the heart of our considerations. I believe absolutely that we must have similar conversations with those who use the service, our patients.

Through all the recent reports in the press, it is clear the general public has a great desire to preserve the NHS but also believes the service is sometimes used inappropriately. This comes through in an acknowledgement recently

We need to ensure the standards of training throughout the UK and in the international community are at a similar high level that there should be a charge for missed appointments when there is still an overwhelming desire by the public for free GP appointments. I welcome this opening of a debate with NHS users. We need rational and honest dialogue about how the health service is used and how the costs are recognised.

It is important to remember that the NHS is still considered the best in the world and is recognised as such by colleagues across the globe.

As I travel internationally, many surgeons ask about placements in the UK for their trainees. Our 10 | Surgeons’ News | June 2015

International Medical Graduate Sponsorship Scheme is hugely successful, currently supporting more than 60 international surgeons a year into placements in the UK. I have been speaking to our Fellows about extra capacity that may exist to support even more individuals, and about their willingness to train international surgeons.

The response was heartening and we are now working hard to determine how the College could further support and develop this activity.

This work has reinforced our belief that, as a profession, we need to ensure the standards of training throughout the UK and in the international community are at a similar high level. This highlights the pivotal importance of the Faculty of Surgical Trainers and the Standards for Surgical Trainers, the first such standards developed anywhere in the world.

They are truly groundbreaking and allow us to look optimistically toward a future where trainers in the UK would be properly recognised for the important job they do, and where surgeons in the international community, who adhered to those same standards, could prove that they were at a level that would allow UK trainees to have the GMC recognise training received in international locations as part of their training for a CCT. This potential for recognition by the GMC of experience abroad is incredibly exciting.

For surgeons, to travel to international destinations – where the type of surgery and the systems of surgical practice are different from those in the NHS – is a life-enhancing opportunity, giving a different perspective on life, healthcare and the practice of surgery. This would be good for the NHS. It would encourage us to reflect on how we work and how we deliver our service with the immense privileges and resources that we have in the NHS. If we show ourselves able to consider different ways of working and to learn from our colleagues around the world, then surely we can expect the same from our patients when it comes to their use of the NHS. So we come full circle. The NHS is an institution that is recognised across the world and we all value it. Clinicians and patients must have a serious debate about its future if it is to survive.

Ian Ritchie president@rcsed.ac.uk

The latest guidelines, articles and studies

IN BRIEF Effect of the World Health Organization Checklist on patient outcomes: a stepped wedge cluster randomised controlled trial

This cluster randomised controlled trial examined effects on in-hospital complications of implementing the WHO Surgical Safety Checklist (SSC). A total of 2,212 control procedures were compared with 2,263 SCC procedures.

The complication rates decreased from 19.9% to 11.5% (P < 0.001). Mean length of stay decreased by 0.8 days with SCC utilisation. Authors concluded that implementation of the WHO SSC was associated with a reduction in morbidity and length of in-hospital stay.

Haugen AS, Søfteland E, Almeland et al. Annals of Surgery 2015; 261: b821â&#x20AC;&#x201C;b828

Randomised doubleblind trial comparing the cosmetic outcome of cutting diathermy versus scalpel for skin incisions

This double-blind trial randomised 66 patients to cutting diathermy or scalpel for skin incision in patients undergoing bowel resection. Scar cosmesis was assessed at six months by a plastic surgeon using the Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scale (POSAS). There was no significant difference between the diathermy and scalpel groups. Pain scores on postoperative day one were significantly lower in the diathermy group. The authors concluded that cutting diathermy is a cosmetically acceptable technique for abdominal skin incisions.

Aird LNF, Bristol SG, Phang PT et al.

Br J Surg 2015: b489

A randomised trial of laparoscopic versus open surgery for rectal cancer

This international trial randomised 1,044 patients with rectal cancer to undergo either laparoscopic or open surgery in a 2:1 ratio. At three years, the loco-regional recurrence rate was 5.0% in the two groups.

Disease-free survival rates were 74.8% in the laparoscopic group and 70.8% in the open group. Overall survival rates were 86.7% in the laparoscopic group and 83.6% in the open group. The authors concluded that laparoscopic and open surgery was associated with similar survival rates.

Jaap H, Deijen CL, Abis GA et al for the COLOR II Study Group.

N Engl J Med 2015; 372: b1324

UK guidelines for the management of variceal haemorrhage in cirrhotic patients These updated guidelines on the management of variceal haemorrhage deal specifically with the management in patients with cirrhosis under the following subheadings: (1) primary prophylaxis; (2) acute variceal haemorrhage; (3) secondary prophylaxis of variceal haemorrhage; and (4) gastric varices. They provide recommendations for clinical practice.

British Society of Gastroenterology 2015 (www.bsg.org.uk)

Prospective observational study of abdominal injury management in contemporary military operations: damage control laparotomy (DCL) is associated with high survivability and low rates of faecal diversion

This study evaluated abdominal trauma managed over five months at the Joint Force Combat Support Hospital, Camp Bastion, Afghanistan. Ninety-four of 636 trauma patients (15%) underwent laparotomy. Military injury mechanisms dominated [44 gunshot wounds (47%), 44 blast (47%), and six blunt trauma (6%)]. Seventy-two patients underwent DCL. Seventy of 94 (74%) sustained hollow visceral injury (HVI); 44 of 70 (63%) had colonic injury. Repair or resection with anastomosis was performed in 59 of 67 managed HVI patients (88%). Six patients were managed with faecal diversion.

Anastomotic leaks occurred in four of 56 patients (7%) with known outcomes.

Overall mortality was 15 of 94 (16%).

Authors concluded that in a wellpractised combat support hospital, damage control is associated with low mortality and infrequent faecal diversion.

Smith IM, Beech ZK, Lundy M, Bowley J, Douglas M. Ann Surg.

2015; 261: b765.

NICE GUIDELINES Bladder cancer: diagnosis and management

This NICE guideline provides recommendations on information and support for people with bladder cancer, diagnosing and staging bladder cancer, treating and follow-up of non-muscle-invasive bladder cancer, and treating muscle-invasive bladder cancer.

NICE guidelines 2015

www.rcsed.ac.uk | 11

AGENDA

SURGICAL SAFETY UPDATE Recent cases from the Confidential Reporting System for Surgery Retained foreign objects in ophthalmic surgery

I undertook a gastric bypass on a type-II diabetic patient with morbid obesity and BMI of 45kg/m2.

The patient had hypertension and was a smoker.

During laparoscopic bypass, the patient was noted to have a paraumbilical hernia measuring approximately 5cm at the neck and containing a plug of omentum.

As part of the procedure, the omental plug was reduced to facilitate access to the duodenojejunal flexure. The gastric bypass was performed uneventfully.

A decision was made not to repair the hernia at the time of surgery because of the risks of recurrence and because the open-lumen bowel surgery would have increased the risk of mesh infection.

On the fourth postoperative day, the patient was admitted with bowel obstruction secondary to small bowel incarceration in the paraumbilical hernia. This had caused local perforation of the bowel and faecal peritonitis. Despite laparotomy and washout, the patient became critically ill and developed a cascade of complications that required repeated bowel resections

12 | Surgeons’ News | June 2015

and laparostomy. The patient died two months later from multiple-organ failure.

Reporter’s comments

The patient’s risks of complications arising from paraumbilical hernia repair were increased due to obesity and comorbidities. Hernia repair was, therefore, deferred.

In the event, the patient developed incarceration, leading to bowel perforation and peritonitis. In the future, I would be more likely to perform sleeve gastrectomy than gastric bypass on a patient with a controlled ventral wall hernia because the latter procedure does not require mobilisation and dissection of the omentum.

CORESS comments

The Advisory Board accepted the reporter’s decision not to fix the hernia and also noted that it might have been difficult to detect the hernia on examination preoperatively because of the patient’s obesity. An option, however, was to obliterate the potential space laparoscopically with an omental plug. Use of biological meshes may reduce the risk of mesh infections.

Wrong eye drops administered

As the ophthalmic surgeon on call, I was treating a patient who presented with angle-closure glaucoma.

I had to go to the ophthalmic ward to obtain pilocarpine and put the minim packet into my pocket. Earlier, I had also collected atropine. When I came back to instil this medication to the patient, I administered atropine by mistake. I realised my error straightaway. I washed the eye with saline and then administered pilocarpine.

I explained to the patient what had happened and then, with senior support, peripheral iridotomies were performed on the patient. The patient did not come to any harm.

Reporter’s comments

I was distracted by having to leave the patient to get the pilocarpine. The packaging of the atropine and pilocarpine were similar and I failed to check the medication before I administered it.

CORESS comments

This case illustrates several sources of potential risk.

Systems errors occurred in that the drugs required to treat the patient were not available in the patient’s location, and were contained in similar packaging. Moreover, the reporter was carrying two types of drug, thereby increasing the potential for confusion. CORESS has published details of several similar cases in different clinical situations. The bottom line, in all of these cases, is that it is always the duty of the treating clinician to ensure that they have physically checked the drug before administering it to the patient.

Handover blues

A patient was kept in hospital for pain control after a difficult elective laparoscopic cholecystectomy.

On the following morning, a Friday, the patient had an unusual amount of pain, but normal observations and a tender (but non-peritonitic) abdomen. Blood tests revealed a high inflammatory response and supportive therapy was organised, with repeat assessment planned over the weekend. The patient was handed over to the night on-call team for review.

On Saturday morning, the night registrar noted the patient wasn’t on the list for ward review (in our hospital, inpatients are placed on a different list from post-take patients, and are reviewed by a separate surgical team).

The FY1 was informed and asked to place the patient’s name on the review list. For whatever reason, the patient’s name was not included on this list and, subsequently, the locum registrar covering the wards that day did not review the patient. Ward nurses responsible for the patient did not alert the surgical team.

On Sunday morning, the night on-call registrar, who knew the patient, coincidentally reviewed the blood test results from Saturday and noted a soaring inflammatory response. The on-call team reviewed the patient and found him septic, with peritonitis. The patient underwent urgent laparotomy, and a sub-hepatic collection of old blood, bile and fibrin was washed out.

The patient eventually made a satisfactory recovery.

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.

Reporter’s comments

There was a lack of a robust system of handover that could pick up missed referrals from individuals feeding information to the lists. No communication took place between senior doctors about a potentially sick patient.

There was also a lack of communication between nurses and doctors. The handover system relied exclusively on information typed in by the most junior member of each team, and there was no provision to cross-check information on the handover list with the electronic patient records our hospital uses.

CORESS comments

With the move towards increasing teamwork and shifts systems, there is a real risk of loss of patient ‘ownership’ and diminished responsibility by individual clinicians for patient care. Previous CORESS cases have already illustrated similar problems in communication, particularly during handovers.

Inadvertent injection of chlorhexidine during angiography

A serious untoward incident, involving inadvertent injection of an alcoholic solution of 2% chlorhexidine, occurred during lower-limb angiography. The fluid was drawn up from an unlabelled gallipot that was adjacent to the intended X-ray contrast media for injection. The procedure was performed under low lighting. Tissue necrosis developed and amputation of the leg was eventually necessary.

Search of the NRLS database revealed four incidents during the last three years involving inadvertent intravenous injection of chlorhexidine instead of X-ray contrast media. Two caused severe harm, and another resulted in cardiac arrest during pacemaker insertion procedure. One near-miss occurred where there was potential for the syringe intended for intravenous contrast media to have been refilled from an unlabelled open container filled with chlorhexidine. In another incident, a patient’s arterial line was flushed with chlorhexidine from a gallipot instead of the intended saline solution.

The National Patient Safety Agency (NPSA) has previously drawn attention to similar problems in Signal: Injectable medicines in theatres (www.nrls.npsa. nhs.uk/signals/?entryid45=66753).

CORESS/SSPSEG comments

This incident was discussed in detail at the Surgical Services Patient Safety Expert Group, which concluded that all skin-cleansing agents should be removed from the interventional field before commencement of the intended procedure.

As a corollary, agents to be injected should be drawn up from labelled sterile containers and must be checked before administration.

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

www.rcsed.ac.uk | 13

THE PRESIDENT’S MEETING 2015

Surgical oncology The President’s Meeting heard from specialists about numerous aspects of oncology care, including new possibilities in individually tailored treatments that could bring a dramatic shift in the battle against cancer. In the following pages, we provide a snapshot of the lectures, symposia and debate at the event

John Duncan Editor

INDEX 15 The patient’s point of view 16 Debate: Surgical resection of colorectal metastases is of proven benefit 18 McKeown lecture 20 Symposia

H

alf of the population born after 1960 will be diagnosed with cancer during their lifetime.

Cancer prevention and cancer treatment are, therefore, important to us as individuals as well as professionals. Surgeons have been talking about modern cancer care for centuries. Joseph Lister and William Halsted, performing radical mastectomy 150 years ago, were providing modern cancer care for that time. During my training, controversy surrounded the use of conservation surgery in breast cancer that now would be regarded as standard care. In modern practice, the issues relate to the individualisation of treatment for patients, and the possibility of using genomics or tailored immunotherapy to radically improve cancer outcomes. Determining the optimal size for cancer treatment units to enable both access to care and optimal outcomes for patients remains an issue. The President’s Meeting programme addressed these subjects.

As a surgeon who treats very few patients with malignancy, adjuvant chemotherapy has represented a difficult issue. If I were the patient, knowing what I know, would I expose myself to the considerable morbidity of treatment, given that my chance of benefiting, while statistically significant, was actually quite small?

Depending on the circumstances, the answer would probably be yes, but I would understand the downsides as well as the opportunity costs. No-one would argue that populations of patients benefit from adjuvant therapy, but having some way of determining who among them will benefit and who will not would change cancer care completely. Genomics holds out that possibility. The

14 | Surgeons’ News | June 2015

ability to look at the differences between the genotype of a patient’s normal and tumour cells and predict from those differences who will benefit and who won’t from particular treatments is predicted to revolutionise cancer care.

Immunotherapy also stands at the edge of widespread applicability. The use of immunotherapy in metastatic melanoma has yielded remarkable results. Initially providing excellent palliation for many patients, it has now been shown to produce what appears to be a cure for 20% of these patients. The production of a virtual vaccine against individual patients’ tumour antigens seems less science fiction and more a realistic possibility, and could change the whole landscape of cancer care.

These changes spell a more optimistic future for many patients, but it leaves the profession and the community with issues to address. How do we organise and fund this care? These decisions come on the back of the continued dilemma of balancing access to care and the volume– outcome relationship for the more common cancers. The difficulty is finding equipoise in the relationship. Many have the scars on their backs from attempts to rationalise surgical care. My observation would be that while change may take time and diplomacy, for clinical and economic reasons, it is inevitable that change will be achieved.

The production of a ‘virtual vaccine’ against a patient’s tumour antigens could change the landscape of cancer care

After 40 years serving in the NHS, Mr Rami Seth gained a deeper understanding of healthcare when he received devastating news

Patient perspective

I

was enjoying my retirement in 2004 when I had painless hematuria, which ended up with my right kidney and ureter being taken out. Unfortunately, a year later I had metastases in my liver in four places, and the inferior vena cava was also invaded through the caudate lobe. I knew it was inoperable, and my colleagues and a second opinion confirmed this. I had a course of interferon, which fortunately worked and my tumours shrank. A surgeon at St James’s Hospital in Leeds also removed part of my liver and explored my inferior vena cava. Then, in 2008, I had metastases in my right lung, which was removed. In 2009, I had a tumour in my other lung, which turned out to be a primary carcinoid. I have now been free of cancer for more than five years and it’s wonderful to be alive every day.

Most patients can’t remember exactly what the doctor or surgeon told them when giving them bad news, but all of them recall the way it was disclosed. So always introduce yourself to a patient and ask them how they would like to be addressed.

Patients have a right to participate in decision-making about their treatment options. This should be done during protected time with the patient. Close the door, turn off your pager and divert your phone. Ask the

Always be an ally to the patient rather than just a care provider patient if they want anyone else to be present at the consultation. That patient or their companion may wish to take notes – patients are not always able to absorb the information given during consultations.

On learning they have cancer, some patients fear they will become a burden on their families – some fear they will be abandoned. Others fear a loss of dignity and control over their own lives. There can also be ambiguity in a patient’s decisions at this time. They may want to know, yet not want to know, and this ambiguity can vary as the disease progresses. You should have a clear understanding of their needs and discuss how much information they would like as the disease progresses.

Individual patient needs vary. Some may like to meet other patients with the same illness; older patients can find decision-making more burdensome; some patients do their own research and want to discuss treatment options; while others may want to know about genetic factors and about clinical trials that are going on. You should be aware of this and adapt to their needs.

Finally, you should remember mistakes do happen.

Most patients understand that you are human and

humans make mistakes, and if you explain to them what went wrong and you have fixed it, usually they will understand and that will be the end of the matter.

Always be an ally to the patient rather than just a care provider. A hand on the shoulder is kindness to another human. And always remember that it’s a huge privilege to be a physician or a surgeon, to be placed in a situation where you have the opportunity to help a fellow human in pain or distress.

Mr Rami Seth’s first-hand experience of being a cancer patient has given him great insight into how to communicate with patients

www.rcsed.ac.uk | 15

THE PRESIDENT’S MEETING 2015

Debate: Surgical resection of colorectal metastases is of proven benefit

S

urgeons should only recommend procedures that meet the accepted standards of evidence. By these standards, metastasectomy is not proven because the only evidence is from observational data – there are no randomised controlled trials (RCTs). The selected patients had characteristics associated with better survival: few metastases, long disease-free interval and response to chemotherapy.

This is not a single assessment, but is made over months.

Progression excludes further patients, so inherent likelihood of survival is itself a confounding factor in survival analysis.

Many surgical interventions – for example, tension pneumothorax, cataract and hip surgery – are based on observational evidence alone, but should meet the following criteria: a plausible mechanistic effect, a close time relationship between intervention and outcome, and a striking and sustained benefit. Metastasectomy fails these tests. That all metastases can consistently be found and removed is implausible. Not having died yet can’t reliably be attributed to liver surgery. In most cases, the disease recurs. In three randomised trials, a policy of intensive surveillance to find operable metastases has been associated with higher death rates.

So why do surgeons believe in liver metastasectomy?

Cancer survival curves include a tail of longer survivors.

The 2.7% featured in the Morris analysis are not a random sample, but are drawn from this tail. Their survival more plausibly reflects selection than surgery.

PulMiCC demonstrates that an RCT is possible, but uncertainty must be acknowledged before unproven surgery is proposed. The trial design allows for prior belief to be respected and could be replicated for liver metastasectomy.

AGAINST: Tom Treasure Professor of Cardiothoracic Surgery, University College London

By accepted standards of evidence, metastasectomy is not proven because the only evidence is from observational data – there are no randomised trials 16 | Surgeons’ News | June 2015

FOR: Graeme Poston

Professor of Surgery, University of Liverpool, and Consultant Hepatobiliary Surgeon, Aintree University Hospital, Liverpool

N

o one has challenged the practice of lymphadenectomy when resecting primary colorectal cancer, nor proposed a trial of simple excision of the primary tumour without lymphadenectomy versus radical excision with lymphadenectomy, yet lymph node metastases are metastatic disease.

Population-based observational studies confirm that resection of technically resectable colorectal liver metastases is associated with similar five-year survival to that seen after resection of stage-3 disease.1 Furthermore, prospectively collected international registry data2 and single-institution studies3 demonstrate 10-year survival after liver resection of 25–30%.3 Data from the randomised Phase 2 EORTC CLOCC trial4 of ablation of colorectal liver metastases plus chemotherapy (60 patients) versus chemotherapy alone (59 patients), shortly to be presented at the American Society of Clinical Oncology (ASCO)5, confirm significant long-term survival benefit for ablation over chemotherapy alone. [At median follow-up of 9.7 years, 92 deaths reported, 53/59 in the CT arm and 39/60 in the RFA+CT arm. Significant difference in OS in favour of the RFA+CT arm (HR=0.58, 95% CI: 0.38–0.88, p=0.01).

Observed median OS 45.6 months (95% CI: 30.3–67.8) for RFA+CT vs. 40.5 months (95% CI: 27.5–47.7) CT arm].

THE VERDICT AUDIENCE MEMBERS were asked, before and after the debate, to vote on whether resection of colorectal metastases is of proven benefit. A striking swing in opinion at the end of the session was noted.

Population-based observational studies confirm that resection of technically resectable colorectal liver metastases is associated with similar five-year survival to that seen after resection of stage-3 disease It was not possible to present these data in the debate because they were under ASCO embargo at the time.

Lastly, the CEA trial referred to by Tom Treasure was conducted in the late 1970s. Patients with a rising CEA were randomised following apparently curative surgery for primary colorectal cancer to observation or a secondlook laparotomy at a time when there was no effective treatment for metastatic colorectal cancer. Therefore, it isn’t surprising that the second-look laparotomy intervention conferred no survival benefit.

References are available at: www.surgeonsnews.com

Votes before the debate:

For 72% | 28% Against After the debate:

For 42% | 58% Against www.rcsed.ac.uk | 17

THE PRESIDENT’S MEETING 2015

Integrating cutting-edge approaches to everyday treatment will maintain our specialty in its leading position in the care of cancer patients

18 | Surgeons’ News | June 2015

Redefining cancer care A summary of Professor Timothy J Eberlein’s McKeown Lecture on delivering high-quality oncology treatments in 2015

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hese are challenging times for cancer research, with declining cancer funding and fewer cancer specialists per capita. However, we are on the cusp of redefining the way we think of cancer care and research. This is due to the explosive growth of technology in the field of genomics.

Through multidisciplinary teams, we are beginning to see the application of genomic information in the treatment of patients with breast cancer, lung cancer, leukaemia and other tumours. Without doubt, this signifies a move towards a more ‘personalised medicine’.

Similarly, in immunology, we are starting to unlock the secrets to utilising immune therapies as an additional approach to the treatment of cancer. Vaccine therapies are being designed that use genomic sequencing. With this technology, we are able to identify mutations from individual patients, develop a vaccine to these unique tumour antigens and make vaccine therapy more effective and definitely more personal.

Meanwhile, in the field of imaging, there are new opportunities through technology development that will be used by surgeons. Photoacoustic imaging and an intraoperative goggle system are two such examples. The former has been miniaturised for endoscopic evaluation of gastroesophageal pre-malignant lesions and could easily be adapted for evaluation of the tracheal bronchial tree. The latter is an exciting real-time visualisation of the operative field that enables the surgeon to identify satellites and better define margins. These goggles may also be ideal for remote teaching of less-experienced surgeons.

Finally, prevention and access to care will have a greater impact in population health. Developing educational outreach, communications and screening programmes, and emphasising the importance of change to lifestyle, will result in lower rates of cancer in patients.

As surgeons, what can we do? First, we can practise multidisciplinary care that is patient-centred, more efficient and emphasises the continuum of care. Second, I would suggest that surgeons participate in clinical trials, especially therapeutic clinical trials. This is because surgeons have a unique vantage point. They are often the primary contact with a newly diagnosed solid tumour, which means they have the ability to accrue patients to therapeutic trials. Finally, there is an opportunity to utilise risk-adjusted data to improve quality outcomes and patient safety.

Professor Timothy J Eberlein

is Bixby Professor and Chairman of the Department of Surgery at Washington University School of Medicine in St Louis and Surgeon-in-Chief at Barnes-Jewish Hospital

Dr Julie Margenthaler did the first study on fluorescence goggles during lumpectomy surgery

We are on the cusp of redefining how we think about cancer. Integrating these cutting-edge approaches to everyday cancer care will maintain our specialty at the leadership of cancer patient care.

INNOVATIONS IN THE MANAGEMENT OF BREAST CANCER Surgical management of breast cancer has focused on the clinical parameters surrounding conservative breast surgery and breast reconstruction. Today, there are exciting innovations around imaging, such as those mentioned earlier. Photoacoustic imaging is capable of identifying sentinel lymph nodes, and by using this technology in early breast cancer, one may avoid an open surgical procedure in the axilla.

With fluorescence goggles, an invention of Dr Sam Achilefu, one of our oncologic imaging researchers, an NIR contrast agent has been developed that is selectively retained in tumours. After injection of this agent, the system excites the contrast agent. The NIR fluorescence and colour reflectance images are captured and processed to generate a superimposed image in which fluorescence is highlighted in a false colour on the normal view. This superimposed image is seen in the head-mounted display in real time by the surgeon, which allows visualisation of the tumour boundary, thus providing image guidance for cancer surgery.

The goggle system is currently being used on human patients with breast cancer or melanoma. The first study was done with Dr Julie Margenthaler in February 2015 on a patient undergoing lumpectomy. Images seen by Dr Margenthaler of the sentinel lymph nodes were replicated on a laptop screen for Dr Achilefu to see. Imaging parameters such as colour thresholds and exposure time can be changed via the laptop without interrupting the surgeon. The surgeon has the option of seeing the colour channel, or the fluorescence channel of the superimposed colour-fluorescence channel. Indocyanine green (ICG) dye was used instead of LS301 because we have not received FDA approval for using LS301 in humans. ICG is not a tumour imaging agent but it has similar spectral properties as LS301, thereby serving as a surrogate dye pending FDA approval of LS301.

Genomic analyses of breast cancers are identifying pathways in luminal breast cancer and treatment strategies in other types of breast cancer. Impressive advances in the definition of breast cancer antigens using tumour sequencing and characterisation of tumour microenvironments make immune therapies such as vaccines a reality in the future management of breast cancer.

Images seen by Dr Margenthaler of the sentinel lymph notes were replicated on a laptop screen for others to see the surgeon’s view

www.rcsed.ac.uk | 19

THE PRESIDENT’S MEETING 2015

Specialty association Symposium One

BOA, SCTS and Vascular Society

B

Chaired by Mr Alastair Gibson and Mr Robert R Jeffrey elfast-based vascular surgeon Mr Bernard Lee presented interesting data regarding the treatment of retroperitoneal sarcoma on behalf of the Vascular Society. He emphasised the importance of complete tumour excision, stating reported five-year survival of less than 30%. He said it was rare for radiological characteristics to lead to a specific tissue diagnosis. Clinical outcomes from treatment strongly correlated with both the quality of surgical excision and whether treatment was undertaken at a specialist centre. Indeed, 30-day mortality at a low-volume centre was reported as being twice that at a high-volume centre. He emphasised the importance of a tissue-based network organisation.

SCTS’s Mr Michael Shackcloth from Liverpool Heart and Chest Hospital discussed outcomes in thoracic malignancies with particular consideration of the

treatment of lung cancer. Although the resection rate of primary tumours had doubled in the last seven years (to approximately 6,500 cases currently), the wide variation in national and regional rates was noted. He reported that 1,807 extra patients would be cured each year if all units in England had the same resection rate as that of the highest units. The reduction in morbidity with minimally invasive surgery was clearly demonstrated without compromising overall survival.

Finally, BOA’s Professor Timothy Briggs drew on his experience at the Royal National Orthopaedic Hospital to provide data with respect to the management of bone sarcomas. It was salutary to learn that even in 2015 clinical diagnosis was often delayed and early radiological findings misinterpreted. However, once referred to a specialist centre with access to multi-

Mr Michael Shackcloth emphasised the importance of resection rates

modal imaging, chemotherapy and surgery could be planned for optimal outcome. The audience had a fascinating insight into limb salvage after tumour resection, particularly in light of recent ‘growing’ prostheses lengthened via electromagnetism.

Symposium Two

ABS, BAPS, BAPRAS and BAUS

B

Chaired by Dr Judy Evans and Professor Graham T Layer

Professor Barry Powell described advances in melanoma treatment

20 | Surgeons’ News | June 2015

AUS president Mark Speakman explained changes in the management of prostate cancer, discussing issues around treating a tumour that does not always kill and the concept of ‘active surveillance’.

Barry Powell, professor of plastic and reconstructive surgery in London, spoke for BAPRAS on the modern management of melanoma and described an era of hope in its treatment, representing significant advances in the last five years. The description of the keystone flap was memorable, as was the discussion of the role of sentinel lymph node biopsy in primary malignant melanoma.

ABS president Professor Kieran Horgan from St James’s University Hospital in Leeds provided an update on the main contentious topics that are currently

occupying breast specialists’ agenda. These included management of familial disease and changing times in management of the axilla.

He highlighted the changing concept of the importance of axillary metastatic disease and its burden. He also described new operative techniques and issued a warning about the unknown long-term consequences of the use of acellular dermal matrices.

The final speaker, BAPS’s Mr Suren Arul, consultant paediatric surgeon at Birmingham Children’s Hospital, who has extensive experience of trauma in military service, gave a fascinating insight into the generalisation of paediatric surgery and the skills required by paediatric surgeons, ranging from laparoscopic techniques to radical de-bulking procedures for cancer. The question of the education and training of future paediatric surgeons was a major discussion point.

symposia

Four specialty sessions covered treatment for a range of cancers from vascular oncology to bone sarcomas

Symposium Three

ACP, ASGBI and AUGIS

T

Chaired by Mr Charles Auld and Professor Michael Griffin

he first paper was delivered by ASGBI’s Professor John Primrose from the University of Southampton and was based on a multi-centre follow-up after colorectal cancer surgery (FACS) trial, which analysed the common practice of intensive follow-up after curative surgery. To summarise, the results appeared to show no benefit in the additive effect of CT and CEA compared with one or other of these investigations. Other observations included similar survival of patients with singlesite recurrence irrespective of site.

ACP’s Mr Brendan Moran, Mr Brendan Moran consultant general and colorectal explained how surgeon in Basingstoke, gave an preoperative excellent overview of recent imaging is key advances in surgical management to treatment of rectal cancer of rectal cancer with particular

reference to the importance of preoperative imaging, refinements in surgical technique and the value of adjuvant therapies. The accuracy of MRI appeared fundamental in the choice of treatment strategy and he alluded to the importance of the Swedish and Dutch trials.

He also discussed the move from transabdominal to micro-transanal surgery for early disease, as well as the evolution of robotic surgery in minimal-access techniques AUGIS’s Mr Nick Maynard of Oxford University Hospital provided a superb update on the staging algorithm for oesophageal cancer.

He drew on his significant experience with PET–CT in Oxford and highlighted that PET provided not just valuable staging information, but had a major role in prognosis. The presence of FDG avid lymph nodes, but not SUVmax or FDG avid tumour length, was an independent adverse prognostic factor. Future work may allow oncologists to select patients most likely to respond to neoadjuvant therapy.

Symposium Four

BAOMS, ENT UK and SBNS

T

Chaired by Mr Roger Currie and Mr Mike Lavelle-Jones he first talk on behalf of ENT UK was by Professor Hisham Mehanna from the University of Birmingham. His presentation focused on improvements in the care of patients with recurrent head and neck carcinoma.

Professor Mehanna has delivered a very robust evidence base to support the improvements that have been made.

Professor James McCaul from the Royal Marsden gave a fascinating talk Professor Hisham on the LIHNCS trial and Mehanna spoke of glimpses of the hard work the improvements required for it to have in treating head and neck cancer been the fastest recruiting

head and neck trial in the UK. Professor McCaul is leading research for BAOMS and highlighted his desire to make research more clinically relevant in the lives of ordinary consultants.

Mr Paul Grundy, consultant neurosurgeon at Wessex Neurological Centre, gave the final talk on behalf of the SBNS and delivered a state-of-the-art presentation on the developments in neuro-oncology, including functional imaging and the increasing use of awake craniotomy for resection. He clearly showed the benefits of subspecialisation and high-volume operating in this challenging environment. www.rcsed.ac.uk | 21

HISTORY

We celebrate 60 years of a classic surgery text, involving three generations of one family with College connections

IT’S A FAMILY AFFAIR

I

n 1954, Edinburgh surgeon Eric Farquharson wrote a new book on operative general surgery as a guide for trainees. Sixty-one years later, the 10th edition of Farquharson’s Textbook of Operative General Surgery has just been published: two of the editors are his elder daughter, Margaret, and his grandson, James Hollingshead.

In Eric’s obituary published in the British Medical Journal in 1970, the book was described as his ‘memorial’, and its legacy continues to this day. For a surgical textbook to remain in publication for 60 years and through 10 editions is remarkable, given the advances in knowledge and practice. Margaret grew up around the book and has been its co-editor for the last two editions. Why does she think the book has endured for so many decades?

“This book has always managed to discuss more about what the options were as one went through an operation, rather than just describing each stage,” comments Margaret. “Forbes Rintoul [past editor of the title] described it well when he said it gave the reader the anatomy, the operation’s objectives and then encouraged you to get on with it, while explaining where the pitfalls might be along with intraoperative decisions.”

The book is woven into Margaret’s memories of growing up in her Edinburgh home: “I remember my father writing it in his study from 6am and in the evenings. Photographs for illustrations were taken in the conservatory using an old camera with a leather lens cap and no shutter; the glass plates were developed in the linen cupboard and fixed in the bath. My mother proofread and, when I was a medical student, he tried out new pieces of writing on me as well as on my mother. If we could not understand them, he would always decide the explanations were not clear enough.”

Margaret qualified from St Andrews in 1969 and her surgical training was in Edinburgh, Great Ormond Street and Basingstoke. She spent a year working in Nepal

Order the latest edition of Farquharson’s Textbook of Operative General Surgery direct from CRC Press and get 20% off the regular price, plus free shipping worldwide.

Order online to claim your discount http://bit.ly/ Farquharson CRC

The textbook gave the reader the anatomy, the operation’s objectives and then encouraged you to get on with it, while explaining where the pitfalls might be 22 | Surgeons’ News | June 2015

Recipients of the Farquharson Award The College grants the biennial award for significant contributions to teaching at undergraduate or postgraduate level in the subjects of surgery or anatomy in their widest sense.

Professor Robert Walmsley, 1974 Professor D E C Mekie OBE, 1976 Professor Harold Edwards CBE, 1978 Professor G J Romanes CBE, 1980 Dr Phyllis Knocker, 1982 Dr D W Lamb, 1984 Mr James A Ross MBE, 1986 Professor E W Walls, 1988 Professor Hugh Dudley CBE, 1990 Professor Harold Ellis CBE, 1992 Mr Iain F MacLaren, 1994 Mr A A Gunn, 1996 Professor R J Heald, 1998 Professor Chummy S Sinnatamby, 2002 Mr David Sinclair, 2004 Mr Pradip Datta, 2007 Dr Malcolm Wright, 2009 Dr Catherine Hamlin, 2011 Mr Robert Whitaker, 2013

Margaret Farquharson with an earlier edition of her father’s textbook

but for most of her career practised as a part-time surgeon in Basingstoke.

The book developed from its beginning as an authored text – written single-handedly – to become a multicontributor work with input from numerous experts. Each edition has been published under the watchful eye of Eric’s widow, Elizabeth (now aged 99), who has meticulously read through proofs before approving the pages for press.

Eric became unwell during preparation of the fifth edition and handed editorship to Forbes Rintoul, his senior registrar. Forbes carried the fifth edition to completion and remained with the title through a further three editions.

However, prior to Margaret taking over as editor, there were signs that the title may have run its course. Forbes was about to retire and the publishers at the time were inclined to discontinue the book. Margaret brought copyright back into the Farquharson family and, working with a colleague from North Hampshire Hospital, set about finding a new publisher.

Margaret continues: “My colleague Brendan Moran had worked for two years as a surgeon in a mission hospital in West Africa and believed the book was of considerable value to an isolated surgeon who had to cover a wide range of surgical challenges.”

When it came to the ninth edition, Margaret and Brendan decided that operations within the present definition of general surgery had to be expanded, including discussion of the more advanced operations.

She explains, “Any procedure that was outside what’s now general surgery had to be taken back to what a www.rcsed.ac.uk | 23

HISTORY

Eric Farquharson 1905-1970 ERIC FARQUHARSON was educated at Edinburgh Academy and at Edinburgh University, from which he graduated MB ChB in 1928. He obtained the Fellowship of the College in 1931 and one year later gained his Doctorate of Medicine (MD) with commendation.

In 1959 he was appointed surgeon in charge of his own wards. Over the next 11 years he directed what came to be regarded as one of the best clinical teaching units in Edinburgh.

His celebrated magnum opus the Textbook of Operative General Surgery was an instant success and soon achieved what was virtually the status of holy writ with candidates for the Fellowship examinations of all the Royal Surgical Colleges. It owed its popularity to the clarity of its descriptive prose, to its lucid presentation of the anatomy relevant to each operative procedure and to its simple, almost conversational style, which made it a pleasure to read. It also had excellent

illustrations, including many examples of the author’s considerable expertise as a clinical photographer.

He gained further widespread fame through his energetic advocacy of outpatient surgery under local anaesthesia for inguinal hernia. At that time this was

general surgeon might have to do if they were working in Shetland or somewhere in rural West Africa.”

Under new publisher Hodder Arnold, the changes introduced for the ninth edition proved successful. More than 11,000 copies were sold in India alone, and it was translated into Modern Greek and Spanish. During the preparation of the current edition, the publisher changed once more when Hodder’s medical books were acquired

by CRC Press, part of Taylor & Francis. The new edition of Farquharson has taken its place as a flagship title among CRC’s surgery books.

Despite the growing specialisation and subspecialisation of surgery, Margaret has upheld her father’s original vision for the book: “My father believed strongly in single authorship to give a continuity of style and balance. We have tried to keep this philosophy by writing, or adapting, much of the text ourselves while relying heavily on other specialists for advice. In some chapters, four or more specialists have been involved.”

Sixty years after an eight-year-old Margaret visited the Edinburgh printing works and book binders to see the first edition typeset and bound, the 10th edition has been published with a fully interactive e-book to complement the printed version. Each print copy contains a unique claim code that readers can use to download an electronic edition with searchable text, PubMed-linked references and downloadable artwork.

Joining Margaret and Brendan for the 10th edition was Eric’s grandson, James Hollingshead, who happens to be at the same stage of his surgical training as Eric was when the idea for the first edition was conceived.

24 | Surgeons’ News | June 2015

The three editors of the 10th edition Farquharson’s Textbook of Operative General Surgery (from left to right): James Hollingshead, Margaret Farquharson and Brendan Moran

a revolutionary departure from surgical orthodoxy which aroused adverse comments and even censure from many quarters. However, the excellent results which he obtained in a series of more than 400 patients silenced his critics and, 55 years on, day-case hernia repair has become standard practice.

Eric Farquharson gave long and devoted service to the College as an examiner, as a member of Council, and as vicepresident from 1967 until his death. He was a member of the Court of Examiners of the Royal College of Surgeons of England from 1951 to 1957 and in 1966 he was elected to the Council of the English College. This gave him the distinction of being the only surgeon to have served concurrently on the Councils of the Edinburgh and English Colleges.

Excerpt from Surgeons’ Lives: An Anthology of College Fellows Over 500 Years, published in 2005 by RCSEd

To define the aims and scope of the 10th edition, it is hard to beat the description provided by Eric in the preface to the first edition: “[The book is] designed to present, as far as possible, the whole subject of operative surgery in balanced perspective from the viewpoint of the general surgeon […] I have endeavoured to describe, in detail and with adequate illustrations, all the operations which the junior is likely to undertake himself, and also the more commonly performed operations in which he may have to assist. In the specialised fields of surgery I have described in the same manner such operations as the general surgeon may at times be required to undertake when more expert help is not available.”

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

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

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

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

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

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

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

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

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

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INTERVIEW

AHEAD OF THE CURVE

Surgeons’ News speaks to Dr Teodor Grantcharov , holder of professorships in Toronto and Copenhagen and leading authority on simulation and assessment Surgeons’ News: How did you become interested in surgical education as a special field?

Teodor Grantcharov: I started working on this just before 2000 when I was a resident in Copenhagen.

I chose surgery because I enjoyed operating, but I noticed that there was a lot of meaningless feedback from my cases. After operating, people I worked with just said, “That was a good job” or “You did very well”.

At first, I was flattered and enjoyed it, but I was aware that with that type of feedback, I would never get better. So I started filming my procedures. I would get positive feedback at the time, but when I went home and reviewed the footage, I could clearly see aspects that could have been done better. I started thinking that we needed to improve the way we evaluate each other, and the way we assess performance and share feedback in a more structured way. I’m still trying things that I can do 26 | Surgeons’ News | June 2015

better when I review my performance, even though I’ve been practising for more than 15 years.

SN: Surgical training can be split into two sides: those who provide the training and those who receive it. Is there one side that you’re more interested in?

TG: This is something that runs very deep in our culture.

Once we graduate, we feel that we are on the other side, but we are not – we are still very much trainees. We need to learn new procedures or use new technology, as surgery is always changing. If we feel that we know everything and we never make mistakes, we will never be good teachers.

SN: One of the reasons the College’s Faculty of Surgical Trainers was established was to improve the recognition given to consultants

We need to eliminate learning curves in the operating room and shift them to the simulated environment

Above: Dr Teodor Grantcharov (centre) believes simulation is a vital component of surgical training

who provide surgical training in the UK. In your own country, is there a distinction between surgeons who provide training and those who don’t?

TG: The training system in Canada is slightly different to the one in the UK, but the problem is the same. We graduate from being trainees and are then expected to be trainers. To some extent, consultant surgeons have taken this responsibility for granted and the system has left it to individuals to determine how they are going to teach and how much time they will invest in it.

There are no standards or formal education for the trainer. That’s why I think it’s so important that the College’s Faculty of Surgical Trainers has produced the pioneering Standards for Surgical Trainers. Ensuring that trainers are qualified, have the necessary tools, and know how to deliver are critical points in the quality assurance of education.

SN: How does your role as professor of surgical simulation in Copenhagen fit around your responsibilities in Canada?

TG: I live and practise in Canada, but I trained in Copenhagen and I have maintained a relationship with the university through supervising students at PhD and master’s level. As such, my appointment as professor of surgical simulation in December 2013 was a natural progression.

My surgical-simulation role helps to facilitate the exchange of students and practices. There is no perfect health system in the world: there are good and bad practices in every system, and we should learn from each other to adopt the positive aspects and eliminate the bad elements.

SN: Is there a growing recognition that simulation is an important aspect of surgical training and education?

TG: When I first went into practice, there had been very few developments in virtual reality for training and assessment. Only a handful of individuals were working in this area and I think I got one of the first doctorates related to it. Yes, a lot of people questioned simulation’s value at that point – around 1999–2000 – but I’m pretty confident that nobody questions its importance now.

SN: What type of simulation does your department offer?

TG: At Toronto University we are focusing on moving the learning curve from the real environment – that is, from the patient – to the simulated environment. And there are so many different ways of doing it. There are expensive high-tech devices; there are simple, good-old box trainers; there are full-body mannequins. There is a lot of focus on which is better and I have always said that I don’t think this is a useful debate.

The best solutions may depend on the local environment. For example, in Canada, surgeons do not receive salaries, but are paid based on cases. So getting time from surgical trainers is the most challenging thing.

In this situation, if some of the trainers’ time could be replaced with time practising on high-tech automated devices, it would help to alleviate pressure in the system.

Even though such simulators are an expensive one-time investment, they would have multiple benefits for the local healthcare environment. In other countries, there may be better access to trainers, but more difficulty in funding simulation equipment, so a different model would be needed. It doesn’t matter which model we use as long as we deliver on the curriculum, with clearly www.rcsed.ac.uk | 27

INTERVIEW

stated standards. The main point is that we need to eliminate learning curves in the operating room and shift them to the simulated environment.

SN: In the UK, some trainees borrow their department’s box trainers to work on their skills at home, as there may not be time to do so during working hours. Is this a common issue in Canada?

TG: The quality of training shouldn’t be the responsibility of any individual. It should be the responsibility of the system. If you reach a point where people have to invent their own quality in their own time, I think the system has failed. Doctors learning independently will always lead to huge variance and mistakes. A good system should retain responsibility for any initiatives that improve quality, reduce adverse events, improve outcomes and reduce costs.

SN: Are there differences between the use of simulation for training in skills improvement and simulation for assessment? Are they distinct areas or do they overlap?

TG: There is no training without assessment; the two can’t be separated. Sometimes there is too much focus on training without formal assessment and standards.

If you reach a point where people have to invent their own quality in their own time, I think the system has failed One without the other will not be successful. I feel very strongly that modern training must include assessment.

SN: Has simulation established the position it deserves or has it got more potential to support training?

TG: I think that development and improvement will never stop. We will never get to the point where we feel we ‘made it’. The next issue to focus on is the consequences of our assessments. How can we use assessments in highstakes scenarios? What will happen with those who fail?

Are we going to remediate them? Is this the result of lack of abilities that are changeable or not changeable?

It’s established that simulation is effective and there are different models that work, so the next issue is how to ensure that trainees and trainers meet certain standards.

Until then, we can continue to build evidence. But I really hope that one day we will see a curriculum with built-in assessment systems that will be ready to take the consequence of those assessments.

Dr Teodor Grantcharov is Associate Professor at the University of Toronto, Professor in Surgical Simulation at Copenhagen University and holds a Canada Research Chair in Simulation and Surgical Safety.

He is the keynote speaker at the 2015 Faculty of Surgical Trainers Annual Conference, taking place on Thursday 22 October 2015 at the Macdonald Burlington Hotel, Birmingham fst.rcsed.ac.uk

28 | Surgeons’ News | June 2015

HOST YOUR EVENTS AT THE STUNNING PRINCE PHILIP BUILDING The College’s commercial enterprises team specialises in making the most of the institution’s impressive buildings, with all the profits being invested back into running the organisation.

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

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

Scott Mitchell, commercial director, says: “The Prince Philip Building, tucked away on a quiet side street, has been transformed.

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

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

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

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

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

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

HISTORY

THE WAR ON WOUNDS Tom Scotland assesses the contribution of Aberdeen surgeon Henry Gray to wound management and orthopaedic surgery during World War I

W

ounds sustained during the First World War in France and Flanders were filthy. They were associated with soft tissue destruction and contaminated by fragments of shell casing, shrapnel balls, bullets, clothing and soil from the richly manured fields. Many men died from overwhelming infection. Scottish surgeon Henry Gray pioneered wound excision. As a result of his innovative treatment many limbs and lives were saved.

During World War I, the British Expeditionary Force (BEF) in France and Flanders sustained almost 2.7 million battle casualties. Of these, 26.1% (more than 701,000) never reached the medical services. These were men who had been killed, were missing or were prisoners of war. Of all the casualties, 1,988,969 (73.9%) were seen and treated, of whom 7.6% died.1 Contaminated wounds caused by fragments of shell casing or shrapnel balls were responsible for most wounds.

In a single day on 20 September 1917 in the Battle of the Menin Road, during the Third Battle of Ypres, there were 10,789 casualties, with 35.8% wounded by high explosives, 19.9% by shrapnel and 27.2% by bullets. Other wounding agents included hand grenades, bayonets and gas.1 Each battalion of fewer than 1,000 men had a regimental medical officer and 16 stretcher bearers, increased to 32 during a major attack. The stretcher bearers brought the wounded from no manâ&#x20AC;&#x2122;s land to the regimental aid post close to the front line, where they were assessed by the regimental medical officer.

Stretcher bearers from a field ambulance transported the wounded to an advanced dressing station (ADS) or main 30 | Surgeonsâ&#x20AC;&#x2122; News | June 2015

Tom Scotland Retired Consultant Orthopaedic Surgeon, NHS Grampian, and Honorary Senior Lecturer, University of Aberdeen

dressing station (MDS), the treatment facilities provided by the ambulance. The ADS was usually about two miles behind the front line and the MDS the same again to the rear. Each ambulance served a brigade of 4,000 men and three field ambulances were allocated to an infantry division of 12,000 men.

The wounded were next taken to clearing hospitals, renamed casualty clearing stations (CCSs) in 1915, which were usually out of range of enemy artillery, at a minimum of 10,000 yards from the front line. They could be reached relatively quickly by motor ambulance wagon convoys from ADSs. Their purpose in 1914 was to clear casualties by hospital train to base hospitals near the French coast for definitive surgery, but it took too long to get there. Patients developed overwhelming pyogenic wound infections and organisms causing gas gangrene had an opportunity to grow. Many limbs and lives were lost because of this delay.

WOUND MANAGEMENT During the first five or six months of the war, both in field ambulances and clearing hospitals, wounds were superficially disinfected and sutured – hopelessly inadequate treatment. More effective surgical intervention at base hospitals was frequently delayed for several days and results were appalling. A quote from the Official Australian Medical History of the Great War sums this up: “During the first six months of the conflict the mortality and morbidity from ‘septic’ infection dealt to the surgical profession in every nation concerned a staggering blow, from which it recovered only through tedious and painful apprenticeship.”

Soldiers with limb- and life-threatening wounds needed early definitive surgical intervention to reduce the incidence of severe pyogenic infections and gas gangrene. The latter could become widely spread within 24 hours. It was necessary to operate definitively on high-risk patients before they were sent by train to the base. CCSs assumed this role and were performing 30% of all surgical procedures by 1917. By then, two to four CCSs were grouped together, each with accommodation for approximately 1,200 wounded and often admitting 150–300 patients before passing ‘on call’ to the adjacent clearing station. CCSs responsible for treating abdominal wounds, chest wounds and compound fractures of the femur were positioned closer to the front line because soldiers with these wounds were in most need of surgical intervention.

Wound excision is a procedure to remove all dead tissue and foreign material from a wound, leaving only healthy, bleeding tissue. It is a fundamental principle of war surgery. In 1915, the first accounts of wound excision were published independently by Gray, and by ETC Milligan, an Australian graduate of Melbourne University who joined the Royal Army Medical Corps (RAMC) at the outbreak of the war. Gray was consulting surgeon to a group of base hospitals in Rouen, while Milligan was working in a CCS. Gray went further and proposed excision and primary closure of selected wounds, a technique he had started to employ in November 1914. To be successful, surgery had to be done early, before wounds displayed signs of infection. Primary closure allowed healing by first intention, which saved a great deal of time. Wounds treated this way required much less nursing attention and fewer dressings, and reduced pain and complications associated with a septic wound. It was essential to remove all devitalised

Above: Evacuation pathway, with thanks to Gordon Stables, Department of Medical Illustration, University of Aberdeen Left: Rifle Splint, from RAMC Handbook, 1911

tissue, otherwise wound closure over residual dead or contaminated tissue would have disastrous consequences for the patient. Where there were fractures, loose pieces of bone without normal soft-tissue attachments were removed, and bone ends and soft tissues thoroughly cleaned by irrigation. Gray noted that apparently minor-looking missile wounds might be grossly contaminated from the filth of the battlefield carried into the depths of the wound.

Surgery had to be performed by a sufficiently experienced surgeon exercising sound clinical www.rcsed.ac.uk | 31

HISTORY

The Thomas splint was much more effective than the rifle splint at reducing movement

judgement. If there was doubt about completeness of the procedure, Gray’s practice was to put a salt pack into the wound and inspect it a couple of days later when delayed primary closure was usually possible.

During particularly busy periods, wound excision was carried out at a CCS and the patient transferred by hospital train to a base hospital where delayed primary closure was performed. It was in large part due to Gray’s pioneering work that definitive surgery was performed at CCSs closer to the front.

In the early months of the war, medical teams relied on antiseptics to deal with filthy, contaminated wounds.

Gray’s view was clear. Their use was no substitute for adequate surgery. In The Early Treatment of War Wounds2, a book published in 1919, he wrote: “It cannot be emphasised too urgently that the use of antiseptics will not make up for inadequate operative treatment. It can safely also be said that the stronger the antiseptic, the worse the result. … On the other hand, provided the operation is adequate, one kind of rational after-treatment does not seem to influence the patient’s chance of life or limb more than another.”

32 | Surgeons’ News | June 2015

REFERENCES 1. Mitchell, T J & Smith, G M. History of the Great War Medical Services Casualties and Medical Statistics. London: His Majesty’s Stationery Office; 1931; 108, 168.

2. Gray, H M W. The Early Treatment of War Wounds. London: Henry Frowde and Hodder & Stoughton; 1919; 59–60, 107.

FEMORAL FRACTURES Compound fractures of the femur were responsible for one in 50 admissions to CCSs. Gray documented a mortality rate of 80% in 1914 and 1915, when splints employed to immobilise fractures were ineffective and when there was significant delay in performing definitive surgery. The only splint mentioned for dealing with fractures of the femur in The Royal Army Medical Corps Handbook of 1911 was the rifle splint, which was not fit for purpose. Patients usually arrived at CCSs in hypovolaemic shock and quite unfit to withstand the wound excision necessary to save their limbs and lives.

By 1917, Gray was consulting surgeon to the British Third Army under the command of General Allenby.

His friend and colleague Robert Jones had introduced the Thomas splint to immobilise femoral fractures of soldiers wounded on the Western Front and Gray ensured its universal application at the Battle of Arras in April/May of that year. The Thomas splint was much more effective in restricting movement at the fracture site. Most patients reached CCSs in good clinical condition and fit for surgery.

Gray documented 1,009 cases of compound fracture of the femur during the Battle of Arras. Previously, employing inadequate splints, the majority of patients reached CCSs in hypovolaemic shock. The mortality in CCSs was 50% and many died before they reached there.

At Arras, using the Thomas splint, only 5% reached the CCSs in shock and unfit for surgery. The mortality was 15.6% with an amputation rate of 17.2%.

HEAD TO TOE As a result of his experience dealing with the haemodynamic sequelae of compound fractures of the femur, Gray was appointed by the Medical Research Committee (renamed Council on 1 April 1920) to sit on its Shock Investigative Committee, set up in 1917 to examine the effects of shock, which were poorly understood at the time. At his instigation, a shock centre was established at Third Army CCS 3 at Gezaincourt in 1918, and run by Captain Kenneth Walker. This became a much-visited facility by medical officers from his and other units.

Gray improved the treatment of penetrating wounds of the knee joint. Their outcome in the early months of the war was disastrous, and were frequently associated with loss of limb or life.

Early wound excision was vital and primary closure of the wound was essential to save the joint and retain movement.

If infection became established, it resulted in disintegration of the articular cartilage and breakdown of the patient’s general resistance, so that amputation was the only way to save the patient’s life. Even if the skin could not be closed completely, provided the synovial lining of the joint was sutured, thus excluding the joint from the “outside world”, a satisfactory outcome could be anticipated. X-ray localisation of foreign bodies helped in planning the procedure. Patients whose wounds were associated with major fractures or vessel damage were best treated by immediate amputation.

For others, complete wound excision and primary closure usually brought good results.

Gray published on infected gunshot wounds of the head, where the principle of early excision of devitalised tissue was the same and primary closure of the wound over the brain was essential. He held strong views about prevention and treatment of gas gangrene. If all devitalised tissue was radically removed, then the patient would not develop gangrene. If the patient had gangrene, then he could be saved only by excision of all involved tissue.

All surgeons would do well to remember Gray’s firmly held belief that the early opening up and cleansing of severe wounds are necessary preliminaries to any other form of treatment.

Henry Gray acknowledged by others BY 1916, Gray was widely regarded as an expert in the management of compound fractures. Lieutenant Colonel A D Carberry, who wrote The New Zealand Medical Services in the Great War 1914–1918, in 1924, wrote: “Surgery, especially that of the front line, was a specialty of the Third Army whose Consulting Surgeon, Colonel H. M. W. Gray, was noted since 1916 for his work in the treatment of compound gunshot fractures. His memoranda, issued by the Third Army in 1917, formed the basis of the front line surgical practice of this and other armies. His well-known book, The Early Treatment of War Wounds, published at the end of 1918, epitomised the advancing knowledge of that period.”

REFERRING TO wound excision, A G Butler, in the Official History of the Australian Army Medical Services, 1914–1918, Volume II: The Western Front, wrote: “Sir Henry M W Gray, to whom war surgery owes so much, was carrying out the treatment independently at the Base in France, and soon afterwards advocated it energetically at the front.”

GRAY WAS mentioned in dispatches on five occasions and was the recipient of many honours for his services to war surgery, including a knighthood and an honorary LLD

Henry Gray, courtesy of Mrs Ann Boyer, his great-niece

from the University of Aberdeen.

He earned the great respect of young surgeons working under his guidance. For his part, Gray felt very privileged to have worked with so many brilliant young men. On 12 April 1919, a dinner was held in his honour at the Criterion Restaurant in London, given by many of the young surgeons with whom Gray had worked during the war. He was presented with a large silver bowl at the end of the dinner as a token of the admiration felt by those present.

COLONEL MIKE Stewart RAMC, a fellow of this College and formerly defence medical services consultant adviser in trauma and orthopaedics to the surgeon general, wrote a foreword in a previous publication co-edited by the author of this article.

He said of Gray: “His outstanding results with the British Third Army in the casualty clearing stations of the Western Front in the latter half of the war laid the foundations of the principles and practice of modern day war surgery.”

www.rcsed.ac.uk | 33

INTERNATIONAL PROFILE

The Royal Australasian College of Surgeons is developing a framework to support its membership throughout their careers, from training to retirement

CAREER STEPPING STONES

A

surgeon may experience several phases of transition throughout their career, each representing a significant period of change.

For surgeons practising in their home country, transitional stages may result from a new role, new team, geographical move, changing scope of practice, response to technical and scientific discoveries, family needs, community needs, adverse health issues, business opportunities or re-entry after a period of leave. For those who have moved to a foreign country to practise, there may be additional complexities, including language and cultural barriers, differing methods of disease management, diverse patient expectations and working within a different healthcare system. While these changes may be exciting, they may also be associated with increased stress, anxiety and vulnerability, which can affect the surgeon’s mental health, competence and performance.

Awareness of the challenges that surgeons face during transitional periods is important to ensure appropriate support mechanisms are in place. This benefits their own health and wellbeing, and also the care they provide to their patients and community. The transitional experiences of international medical graduates demonstrate that formal and informal schemes can help, including programmes for education, mentoring and orientation, as well as assistance with forward planning, help from supportive colleagues, the benefits of accumulated experience, codified protocols

Awareness of the challenges that surgeons face during transitional periods is important to ensure appropriate support mechanisms are in place 34 | Surgeons’ News | June 2015

Professor Julian Smith chairs the RACS Academy of Surgical Educators and Professional Development Committee

Associate Professor Stephen Tobin is RACS Dean of Education

and care pathways, and networking with other individuals who have made the transition.

The Royal Australasian College of Surgeons (RACS) recognises the importance of providing support in this area and is developing a ‘career spanning’ framework that is progressively staged from when the medical graduate enters pre-vocational training to when the surgeon retires.

Broadly, the stages in a surgeon’s career are: l Pre-vocational training l Surgical training l The first 10 years of practice as a ‘Younger Fellow’ l The mid-career stage as an established surgeon l The senior surgeon phase or the final 10 years of practice.

In addressing each unique phase of a surgeon’s career, the framework will act to mark career progression, encourage vertical escalation and provide targets to guide learning and assessment. Furthermore, the framework will enable surgeons to focus their learning activities more effectively, point to learning activities they can engage with, and enable colleagues and assessors to know when a learner has achieved a given stage and is ready to move to the next one.

RACS already has a comprehensive professional development programme that each year delivers more than 80 activities in a range of modalities to support the development of non-technical competencies in surgeons.

The framework will align professional development activities to each career stage, including existing programmes run by the RACS Professional Development

The JDocs competency framework describes the tasks, skills and behaviours that should be achieved during the first three postgraduate years

Department, and identify areas to develop further, as well as external schemes, partnerships and resources that may be applicable.

STAGE 1: PRE-VOCATIONAL TRAINING Standards relating to the clinical learning environment for junior doctors vary, particularly in what needs to be achieved during the early phase of their medical career.

Many doctors work in service positions, some without a vocational focus. Recognising the need to address this gap, the College prioritised engagement with pre-vocational junior doctors in 2013. The outcome is the JDocs competency framework, which describes the tasks, skills and behaviours that should be achieved during the first three postgraduate years, as well as subsequent years. This should ensure that those selected into the RACS Surgical Education and Training programme are well prepared.

The framework, supported by a suite of learning and assessment resources, aims to guide the motivated selfdirected doctor, with individual choice of which activities or resources to access. This includes the development of an online logbook tool that will enable junior doctors to capture their achievements and procedural experiences, documenting progression during the early years of their career trajectory. An e-portfolio is also in development and will enable the junior doctor to upload work-based assessments, such as key clinical tasks and outcomes of professional learning. Workplace-based assessment tasks will help indicate progress and readiness for selection into procedural specialty programmes (including surgery).

The surgical training phase is exciting but can be stressful

STAGE 2: SURGICAL TRAINING Most surgical trainees are in their late-20s to mid-30s, which is a time of personal and professional evolution as they build their families, deal with financial obligations, adhere to safe working hours, develop their surgical portfolio of cases and complete the intense surgical training programme. Juggling multiple and, at times, competing priorities can be stressful for trainees. This is exacerbated by the programme structure because five of the nine surgical specialties require annual relocation to another training post in order to broaden traineesâ&#x20AC;&#x2122; exposure to surgical cases. Each new post represents a new employer, so trainees may lose their leave entitlements, including sick leave, long service and maternity leave.

In addition, they also have to deal with the logistics of relocating, new teams, different policies and procedures, and broadening their scope of practice.

Aware of the stress that this prolonged period of training places on trainees and their families, the College offers flexible training for most of its specialties.

This is particularly to support trainees returning to work after childbirth.

While the training programme is by necessity a challenging and rigorous one, RACS is keen to provide avenues where trainees can engage with senior Fellows to influence policy and training standards. Trainees are represented at all levels of RACS governance, including their own association, the Royal Australasian College of Surgeons Traineesâ&#x20AC;&#x2122; Association. A peer-elected trainee representative for each specialty sits on each of the nine www.rcsed.ac.uk | 35

INTERNATIONAL PROFILE

specialty training boards. A representative also sits on the Board of Surgical Education and Training, Education Board and is a voting member of Council. This gives the trainees a voice within RACS.

STAGE 3: YOUNGER FELLOW A ‘Younger Fellow’ is defined as a surgeon in the first 10 years of practice. Challenges at this stage in their career include securing sub-specialty fellowship training, joining a hospital department, establishing a private practice, family considerations, increased accountability, making and being responsible for decisions concerning patient management, and engaging with professional development.

The Younger Fellows Committee, comprising regionally elected Fellows in the first 10 years of practice, governs all education and support programmes associated with the 1,500 surgeons in this stage.

STAGE 4: ESTABLISHED SURGEON The longest phase of a surgeon’s career is as an established surgeon. This is often where surgeons will refine their scope of practice, move into management or leadership roles, build and maintain their private practice, adopt an educational role, contribute to their College or community in a pro bono capacity, and deal with the challenges of ageing parents and growing families.

RACS has a comprehensive professional development programme that primarily addresses this stage of the surgical career and all of the competencies required of a practising surgeon. There are 36 individual educational activities that are repeated around Australia and New Zealand, resulting in around 80 being delivered annually.

The Younger Fellows Committee, comprising Fellows in the first 10 years of practice, governs all education and support programmes associated with this stage

STAGE 5: SENIOR SURGEON A ‘senior surgeon’ is defined as being within 10 years of retirement and is typically transitioning away from a busy clinical practice. These Fellows may start to relinquish roles of responsibility, adjust their public and private case mix, take on outside consultancy work, make more time for other pursuits, move into medico-legal work, and take on a more active education role with medical schools, specialty boards and the RACS. Challenges include succession planning, paucity of part-time positions, and professional and personal identity conflicts. For some, there will also be health issues and deteriorating technical and mental capacity.

Building Towards Retirement is a one-day course conducted annually by the RACS Senior Surgeons Section, which addresses planning for retirement, the

Implant dentistry diploma

The College’s dental faculty is delivering a diploma in implant dentistry in Australia and New Zealand with help from the Royal Australasian College of Dental Surgeons (RACDS). To help promote the exam, RACDS is a strong 36 | Surgeons’ News | June 2015

regional partner, with local knowledge and access to an experienced examination and administration team.

The first diet of the exam was held in Auckland in October 2014, where RACDS nominated three regional

psychosocial factors of retiring, financial and legal advice, superannuation opportunities and tax requirements.

The Section also coordinates an educational stream at the RACS Annual Scientific Congress, bringing together retired Fellows and those seeking to wind down from active practice. With regards to pursuing a more active role in education, RACS offers a range of professional development that supports the competency of scholarship and teaching. The programme covers foundation skills in educational principles, teaching for diverse audiences in varied clinical settings, performance management, delivering feedback, workplace-based assessment tools and their use, evaluating educational research, supervision and training and standard setting.

Formats range from one-hour webinars to three-year master’s degrees.

The development of the surgical career framework will articulate a clear progression to levels of competence, and identify the resources and support available for each level. In doing so, it is envisaged that Fellows will have a better appreciation of the challenges they may encounter as they transition throughout their career and ensure greater awareness of the programmes available to support them through these phases. It is hoped that through the development and delivery of this new framework, the process will be a unifying and transformational experience for the College, its members and associated stakeholders.

examiners to attend the first diet as observers. RCSEd organised examiner training for the RACDS delegates and also trained them in running future preparatory courses.

Convener of dental examinations Professor Fraser McDonald commented: “As far as I am aware, there is no

other diploma in Australia and New Zealand that offers the degree of implant dentistry by assessment only.

Anyone who fulfils the criteria can apply for the examination – there are no obligations to attend the course, which we hope offers flexibility and cost-effectiveness.”

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!

22.5 CPD Points www.wscts2015.org For all enquiries please email: info@wscts2015.org or vipin.zamvar@wscts2015.org

Congress venue

PHYSICAL ACTIVITY

GREAT STRIDES As part of the College’s campaign on exercise and surgery, we invited a panel of experts to debate the promotion of physical activity as a healthcare benefit

P

hysical activity is increasingly recognised by policy makers, healthcare professionals and patients as being important to health and wellbeing. So, in April, the college organised a roundtable event to discuss different experiences of promoting it.

Chairing the discussion was Mr Jon Dearing, RCSEd Lead for Physical Activity, who asked how the roundtable panellists had experienced promoting physical activity in the workplace and what they felt they could learn from each another.

Dr Andrew Murray, Royal College of Physicians and Surgeons of Glasgow Lead for Physical Activity, has been very active and high profile over the last few years in promoting the physical activity message.

He said: “Getting more people more active more often has been established as a compelling aim – it’s just a question of by what method we achieve that.”

As well as for public health, physical activity is important in getting patients fitter before surgical procedures, noted Mr John Duncan, RCSEd Council Member, because it reduces complication rates and speeds up recovery. “From my own point of view,” he said, “the question is how we get this message into undergraduate teaching and how we inculcate that from an early stage in clinical careers.”

So are there barriers to understanding the message in terms of population and personnel?

Dr Stephen Boyce, A&E Specialist and Sport and Exercise Medicine Consultant, said: “I think healthcare professionals are aware, but in the east end of Glasgow, there are people who don’t even live to pension age. So which segment of the demographics do we target with that message? Can we change the habits of a lifetime in 38 | Surgeons’ News | June 2015

CHAIR

Mr Jon Dearing RCSEd Lead for Physical Activity

PANELLISTS

Dr Niall Elliott Head of Sports Medicine, sportscotland Institute of Sport

Dr Aileen Keel CBE Deputy Chief Medical Officer

Mr Ian Ritchie RCSEd President

older age groups? Should we focus on the younger group even though it may take 30 or 40 years for the benefits to come through?

“The only access for the promotion of physical activity in an A&E department is probably through its minor injuries area, where staff may have a bit more time and the pressure isn’t as intense.”

Mr Ian Ritchie, RCSEd President, said that hospital staff talking about being healthy and physical activity was much more effective if they were physically active themselves. He added: “That’s why I’m particularly interested in what Ann Gates has been doing to stimulate interest in an undergraduate medical curriculum in physical activity that goes along with the GMC standards for medical education.”

Ann Gates, founder and Director of Exercise Works!, talked about ‘teachable moments’, the opportunities during the consultation, which may just be 30 seconds, in which a doctor gives patients supportive advice about physical activity. She said: “In some instances, orthopaedic surgeons have been able to advise their patients that they’d done so well in a pre-operative exercise training course that they no longer needed the surgery. When you consider that a doctor may well see half a million patients in their career, that has enormous potential for advocacy and promotion of physical activity.”

Deputy Chief Medical Officer Dr Aileen Keel added: “The point I make whenever I get the opportunity is that

When you consider that a doctor may well see half a million patients in their career, that has enormous potential for advocacy and promotion of physical activity Ann Gates

PANELLISTS

Mr John Duncan

RCSEd Council Member and Director of Undergraduate Teaching (Inverness), University of Aberdeen

Dr Andrew Murray

RCPSG lead on physical activity

Dr Stephen Boyce

A&E specialist and SEM consultant

no doctor would record a 20-cigarettes-a-day habit on a patient’s notes without asking the patient if they had ever thought of giving up. Equally, if you ask about physical activity, you should be advising that person on how to get more active, and it only takes a few seconds.”

However, she felt that A&E wasn’t the most fruitful environment in which to talk about physical activity, but that “in routine history taking, every doctor should be asking about physical activity”.

Mr Duncan said that there was still much to be done to give medical students a deeper knowledge of the benefits and when and how to make that kind of intervention. “If the old analogy ‘if you don’t examine it, it’s not important’ is the case, then I’m not aware of us having an OSCE question that involves taking an exercise history from a patient,” he commented.

Ann Gates said: “Patient stories are very, very powerful as part of the multimedia learning component and we’re pleased we can aim to incorporate some of those things into our health professional curriculum now.”

Beth Cameron, PR and Communications Officer at the Faculty of Sport and Exercise Medicine, pointed to the availability of educational resources, such as the Faculty’s medical student exercise prescription booklet.

However, she added: “Funding is one of the big problems for smaller organisations that are trying to make a difference and trying to persuade universities to adopt this subject into curricula.”

Mr Ian Ritchie felt that leadership rather than money was what was needed. He said: “It’s therefore a matter of the desire on the part of leaders in medical schools to make this happen. And you have to ask ‘why wouldn’t

Ann Gates

Founder and Director of Exercise Works!

Beth Cameron

PR & Communications, Faculty of Sport and Exercise Medicine

www.rcsed.ac.uk | 39

PHYSICAL ACTIVITY

they?’ because it’s obviously a no-brainer. For example, in orthopaedics, physical activity can reduce the need for a hip or knee replacement; more active patients can avoid surgery entirely, which is obviously a great prospect. So, for all sorts of reasons, it’s a good idea to have physical activity as part of the undergraduate curriculum.”

Dr Niall Elliott, Head of Sports Medicine at sportscotland Institute of Sport, said undergraduates learned habits from what they saw on ward rounds. “If students witness patients being asking about physical activity during pre-operative assessments, then they’ll adopt it into their own practice and it will become the norm,” he commented.

Dr Keel was concerned about the level of awareness among healthcare professionals and agreed the issue of physical activity should be embedded in the historytaking procedures at undergraduate level, along with teaching students why they’re asking questions about physical activity.

She said: “In the same way that students are taught to always ask about smoking or alcohol intake, they should know to always offer information about the benefits of physical activity. That’s the way to get it into the DNA of the healthcare workforce.”

The message we need to give to young people is that they could transform patients’ lives if they ask the question about physical activity and signpost the patient to more information Dr Aileen Keel

40 | Surgeons’ News | June 2015

Mr Duncan asked for thoughts on general practice, where around 90% of all interactions with patients take place. He said: “We wouldn’t want to embed awareness at undergraduate level, but to then lose it in foundation and general-practice training.”

Dr Murray noted that he had taken part in a lot of training for general-practice nurses and health visitors, “who are really making this a part of what they’re doing and looking to cascade resources through primary care”.

The preoperative assessment clinic is one particular opportunity surgeons have that other specialties don’t, according to Dr Boyce. “Surgeons can target the groups they wish to – the right advice for 40- or 50-year-olds in an orthopaedic clinic could mean those patients don’t return with further problems in 10 years’ time,” he said.

Mr Duncan said: “As perhaps the only person here who’s been able to prescribe exercise as a vascular surgeon for 20 years – that is, physio-directed exercise for claudicants – I would say it worked so well that it could eliminate the need to operate.”

Dr Keel commented that she had always been an advocate for being physically active, but had not realised the impact that physical inactivity has in generating and worsening diseases. “So the message we need to give to young people is that they really could transform patients’ lives if they just ask the question about physical activity and, if necessary, signpost the patient to more information,” she said.

Dr Murray said he hadn’t known anything about the healthcare benefits of physical activity until he was to be examined on it. However, he felt there was now much more understanding of the subject.

“There has been a series of powerful advocates and now awareness of it is much more likely in terms of the cabinet secretary, chief medical officers, key people within health boards, presidents of medical colleges and so on,” he said.

As perhaps the only person here who’s been able to prescribe exercise as a vascular surgeon, I would say it worked so well that it could eliminate the need to operate Mr John Duncan

Top-down approaches don’t necessarily work, according to Mr Ritchie, in his experience as a consultant in the NHS. He admitted that his attitude was ‘just wait and see what happens’ and quite often nothing happened. “I’m much more impressed with grassroots initiatives such as walking routes within hospitals,” he said. “That’s where change comes from and that’s where people are going to make the biggest gains.”

We have to make exercise more appealing, argued Dr Murray: “Nathan Stephens [Scottish Clinical Leadership Fellow] has done a great job of liaising with Ramblers Scotland, specific hospitals, keen clinicians and managers to work out how we can make walking more attractive.”

Mr Dearing has been championing physical activity from within the health service for a long time. So does he think that he is still a lone voice or are other consultants getting the message?

“They are,” said Mr Dearing, “but the people who put up barriers at the start continue to put up barriers. And often those who aren’t receptive are very ingrained in their ways. In the beginning, those who were keen on promoting this message were generally branded as sports enthusiasts, and that was a barrier to getting the message through that just going for a walk or taking the stairs rather than the lift could make a difference. But the more the message is repeated, the more people think about changing their ways.”

Beth Cameron added: “Because sport and exercise medicine is a relatively new specialty, I think there’s a perception that we are here to serve professional and elite sport. However, the specialty has an enormous application for the NHS in encouraging both staff and patients to lead healthier lives.”

Doctors should also take care to look after their own health, according to Dr Boyce: “Any surgeon standing at an operating table doing a five-hour procedure will find that tiring and may not be physically active enough as a result. All doctors should consider if they actually meet their profession’s own recommendations for physical activity.”

At the end of the session, Mr Dearing thanked everyone for their contributions to this important debate.

In closing, he commented: “We started off talking about promoting physical activity to patients and finished off with promoting that same message to healthcare staff.

We have covered undergraduate training, postgraduate training, involvement of the third sector, and keeping hospital staff fit. However, the overarching issue seems to be leadership – not necessarily top-down leadership, but thought leadership and leading by example, and taking the initiative to drive change. Hopefully, we have shown today that anyone who has a clinical involvement with patients can play a role in that.” www.rcsed.ac.uk | 41

POLICY The College has been quoted in Hansard, demonstrating its influence in Westminster

Professor Graham Layer profiles the work of the College’s Policy Group

OPERATING IN THE POLITICAL ARENA

Graham T Layer Honorary Secretary, RCSEd and Chair, Policy Group

W

hile the College has been working to promote the highest standards of surgical practice and training for 510 years, there is only a limited amount that any Royal College can achieve to ensure that its voice is heard. This interaction with the world outside is vital for the success of the College’s functions and indeed for its purpose.

Our work is increasingly determined by external organisations. Bodies as diverse as the GMC, GDC, NICE, SIGN, Monitor, HEE and the Health Ombudsman all directly and indirectly impact on all aspects of work and the future of our profession. Therefore, it is essential that

A recent example of this work is the Medical Innovation Bill, the demise of which was clearly influenced by the objections from the medical profession and the Royal Colleges, none more so than RCSEd the College works with all health organisations on behalf of its membership and for the continued improvement in clinical standards and patient care.

The College’s Policy Group is responsible for this activity and advises Council on such matters. Comprising practising surgeons and dentists from throughout the UK, it helps raise the College’s visibility, influence and relevance through stringent consideration of matters concerning health policy and strategy. This has helped RCSEd develop positions to inform the proactive engagements the College now enacts and which its membership has demanded.

42 | Surgeons’ News | June 2015

These positions are often presented in the form of consultation responses, 62 of which have been submitted in the last calendar year. Through these, we are in constant dialogue with a wide range of organisations across the UK, and our recommendations are often taken on board.

When such responses fail to secure the desired result on a key issue, we work to ensure that the president is provided with all he needs to engage parliamentarians and senior figures. The College has now been quoted in Hansard on several occasions, showing that the opinions of the surgical profession represented by your College are worth quoting in Parliament. A recent example of this work is the Medical Innovation Bill, the demise of which was influenced by the objections from the medical profession and the Royal Colleges, none more so than RCSEd. The Policy Group also takes a proactive role in the current health delivery, configuration and economic debates. Our Public Affairs department, based in Birmingham, links closely with the Group and has been responsible for organising a number of events, such as the lectures by Lord Robert Winston and Sir Bruce Keogh. It is responsible for the meetings of the president and office bearers with stakeholders such as senior civil servants, ministers and politicians across the UK. The president has had profitable talks with the King’s Fund, Cancer Research UK, HEE, the Chair of the Health Select Committee and various All-Party Parliamentary Groups, all of which impinge on the mission of the College.

I am pleased to note that the Policy Group has now reached adulthood and is measurably effective in the political arena. I am indebted to the various members of the Group whose hard work has helped achieve this.

For more information about the work of the Policy Group, please contact policy officer Andrew Mullinex at a.mullinex@rcsed.ac.uk

The College is using the knowledge and enthusiasm of Fellows around the world to deliver a range of activities through its advisory network

TALENT ON TAP

I

n late 2008 the College appointed its first five Regional Surgical Advisers (RSAs). Based in Cambridge, Dundee, Edinburgh, Glasgow and Preston, they were charged with providing a local conduit to the College for our membership.

Six and a half years later, there are now 52 RSAs active across the UK, 10 International Surgical Advisers, 22 UK Regional Dental Advisers and 25 International Dental Advisers.

The adviser network enables the College to provide onthe-ground information and support to our membership and also delivers a wide range of events and activities designed to support and develop the current surgical and dental workforce, and inspire and inform the next generation of professionals. Collectively with the Outreach team, the adviser network is developing and delivering a wide range of new and innovative activities, including: l Supporting the cardiothoracic specialty to actively promote itself as a career option by offering final year medical students the opportunity of work placement under the supervision of a consultant surgeon. l Improving access to medicine for school pupils across the state and private school sectors, through events and workshops which aim to equip pupils with the information and insight needed to embark on the path to a career in medicine. l Surgical anatomy workshops for undergraduates. l The promotion and support of student involvement in research through events such as the All Wales Medical Student Surgical Research Symposium and the Bristol Aspiring Surgeons Symposium. l Hosting the Collegeâ&#x20AC;&#x2122;s regional forums which bring together local Fellows, Members and Affiliates from all specialties and grades.

These meetings enable them to discuss and debate the issues that

affect them professionally, and in which the College has a role to play representing the views and concerns of the membership and influencing governments, politicians, healthcare managers and those who shape our healthcare systems. l Championing the role and activities of the College internationally and supporting the College to develop and deliver courses and events that meet the needs of the local population.

Through the newly established Advisory Network Group, under the direction of the Network Director and the leadership of Council member Roger Currie, the role of the Collegeâ&#x20AC;&#x2122;s advisers continues to grow and develop. Advisers subsequently take up other roles within the College as UK and international Membership and Fellowship examiners; course conveners; committee members and chairs; and as elected Council members.

Additionally, our advisers are increasingly called on to work in their local area with the President, Dean and other office bearers attending meetings with senior figures in all areas of healthcare.

RSA vacancies

We are currently recruiting for RSAs in Birmingham, Edinburgh, Liverpool, London, Manchester, Newcastle, Nottingham and Sheffield.

If you are interested in applying for any of these posts please contact the Outreach Team on outreach@ rcsed.ac.uk 0131 668 9202

The adviser network enables the College to provide on-the-ground information and support to our membership www.rcsed.ac.uk | 43

DENTAL / EXAMINATIONS

Membership goes global The Dental Faculty continues to be proactive in strengthening its profiles for examining and providing highquality educational events in the UK and overseas

The first diet of the International Membership in Special Care Dentistry examination: (from left to right) examiners Dr Ken Hui, Dr Lesley Longman and Dr Sarah Manton, with successful candidate Dr Antonio Lee

Vice-Dean Dr Sarah Manton explains how the College’s dental exams are developing to meet the needs of the profession around the world

T

he Dental Faculty is expanding its overseas portfolio with the introduction of new examining centres and by holding its first international membership examination.

The Membership of the Faculty of Dental Surgery examination has moved to Dubai and Kuala Lumpur. Both of these centres are proving very popular and are attracting candidates from across the Middle East and Asia. The diets held in March were ‘sold out’, with 65 candidates registering to sit. The September diets for both centres are already fully subscribed.

The highly respected Membership in Orthodontics has reached mainland China, with a first diet in Shanghai attracting 14 candidates. The Membership has also been 44 | Surgeons’ News | June 2015

taken to Alabama this year, the first time that a request has been received for the examination from the US. In addition, it is being introduced to Sri Lanka in 2015, with some 10 candidates sitting.

The Faculty has also taken the TriCollegiate Membership in Paediatric Dentistry to Hong Kong, the first Royal College to take this examination abroad.

A further diet will be taking place in Dubai in September.

At home, the Membership in General Dental Surgery has been redesigned to become the Membership in Primary Dental Care, and the first diet of Part 1 has been held at the College hub in Birmingham.

An exciting new addition to the Dental Faculty portfolio is the International Membership in Special Care Dentistry.

This examination has been tailored for overseas candidates. It is intended for those who have been trained outside the UK and who are ineligible for the Tri-Collegiate Membership in Special Care Dentistry, because of differences in the training and clinical requirements in different countries.

When the International Membership is taken to overseas centres, a combination of UK and local College examiners will set the questions and conduct the examination, so that protocols, guidance, legislation and the clinical practice relevant to that country are examined at Membership level.

The first diet of the International Membership has been held in Hong Kong, where it is hoped that the specialty of Special Care Dentistry will soon be established. The field of Special Care is expanding in Asia, with new clinical units being built and training programmes becoming established. Kuala Lumpur has expressed interest in using the new International Membership as the exit examination for its training programme.

The Dental Faculty continues to be proactive in strengthening its profiles for examining and providing high-quality educational events in the UK and overseas.

The Specialty Advisory Boards work hard to develop initiatives and expand into new areas. With the help of the College examinations staff, as well as our resident educationalist and psychometrician, the Faculty strives to make the tests we offer fair and fit for purpose. The value that is placed on gaining a qualification from the College in Edinburgh is endorsed by the number of candidates coming forward and by the demand from our centres.

T

/ EXAMINATIONS

he College’s Faculty of Dental Surgery is introducing the diploma in Special Care Dentistry (Dip SCD), with the first diet being held in December 2015.

The examination is intended to test a candidate’s ability at the level expected of a dental practitioner with a particular interest in SCD; it is not intended to test to the level of a specialist in SCD. Vice-Dean of the Dental Faculty Dr Sarah Manton said: “We are delighted to announce this new examination, which is aimed at dentists who wish to demonstrate enhanced skills in special care dentistry, those who are seeking to improve their application for specialist training, those who may already be in training and dentists working in primary care situations who wish their skills to be validated for enhancement in the workplace.”

The Dip SCD examination includes applied sciences relevant to special care dentistry and the principles related to the practice of SCD, including clinical reasoning.

The aims of the examination are to allow candidates to demonstrate: l Core knowledge of SCD as defined by the learning outcomes l A level of competence in the management of patients who have additional needs commensurate with a general practitioner who has a special interest in SCD l Clinical reasoning skills relevant to the practice of SCD l Knowledge of relevant referral pathways in primary and secondary care, as well as appropriate involvement and liaison with multidisciplinary teams and care agencies.

Candidates planning to apply must have an acceptable primary dental qualification and have been working as a qualified dentist for at least two years, including a minimum of 12 months’ full-time (or equivalent) postgraduate experience in SCD. Candidates will also be required to submit a logbook record of clinical experience in SCD. The purpose of the logbook is to indicate to the examiners the candidate’s breadth of experience in SCD, including evidence of dental skills.

The Dental Faculty is launching a new diploma to benefit dentists at different career stages

Special Care pathways

The examination is aimed at dentists who wish to demonstrate enhanced skills in SCD, those seeking to improve their application for specialist training, those already in training and dentists working in primary care www.rcsed.ac.uk | 45

DENTAL

The Faculty of Dental Trainers is aiming to win greater recognition for the work of those who teach and train new generations of the dental team

T

Trainers on target

he Faculty of Dental Trainers (FDT) is being established to raise awareness and help support and develop dental educators in their role as trainers of the dental team and also to recognise excellence and high quality. This exciting development is the first of its kind and will give clinicians the opportunity to gain recognition for delivering high-quality education. As clinicians, we have adopted and evolved into the educator/ trainer role with very little formal induction or guidance into the demands of this position.

As the delivery of safe and effective patient care has become the focus of what we do, the role of the dental educator in establishing this standard has become ever more important.

The Faculty will develop markers using the newly published Standards for Dental Educators by the Committee of Postgraduate

Dental Deans and Directors for recognising dental educators who deliver high-quality training. We will also work closely with the Faculty of Surgical Trainers (FST) to establish a means of recognising excellence in the delivery of training in dentistry using the FST’s established quality standards to safeguard patients.

The key aims of the FDT are to:

l Promote, recognise, and reward excellence

in dental education and training l Provide guidance for career development

and progression for those who wish to lead in dental education l Define and establish standards for education aiming to improve the standard of care for the benefit of patients.

This development will offer the opportunity to raise the profile and improve recognition of dental education and training

to promote excellence in patient care, but will also champion and promote training in non-technical skills, as well as traditional technical skills, to enhance patient safety.

The steering group of the Faculty will establish the different levels of membership at which trainers can join, with the aim of being inclusive to all trainers. Its shortterm goal is the development of the quality markers.

Poet, orator and priest George Herbert once said: “Skill and confidence are an unconquered army” – our trainers are the unconquered army and the FDT will provide a means of capturing these trainers and recognising their skills in educational delivery to enhance safe patient care.

Ulpee Darbar Director of the Faculty of Dental Trainers

This exciting development will offer the opportunity to raise the profile of dental education and training… but will also champion and promote training in non-technical skills to enhance patient safety 46 | Surgeons’ News | June 2015

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 2 Brendan Scott, Dundee Dental School

1

ENGLAND

2

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

20

NORTH WEST OF ENGLAND 6 Alex Milosevic, Liverpool University Dental Hospital 7 Mike Pemberton, University Dental Hospital

16

19

of Manchester 8 Callum Youngson, School of Dentistry, Liverpool

17

6

7 8

13

NORTH LONDON 9 Phil Taylor, Barts and the London School of Medicine and Dentistry, London 3

NORTH EAST LONDON 10 Nick Lewis, UCL Eastman Dental Institute, London

18

12 11

10 Crispian Scully, UCL Eastman Dental Institute, London

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

WALES

17 Joy Hickman, Glan Clywyd Hospital, Clwyd

18 Alan Gilmour, Cardiff University

REPUBLIC OF IRELAND

19 Simon Wolstencroft, St James’ Hospital, Dublin

NORTHERN IRELAND 20 Gerald McKenna, Queen’s University Belfast

www.rcsed.ac.uk | 47

DENTAL / CONFERENCE REPORT

Skills champion celebrates in Chicago Hannah Crane, winner of the Dental Clinical Skills competition, reports on her trip to a world-renowned dental conference in the USA

N

early a year after winning the Dental Clinical Skills competition, I was excitedly packing my bags to attend the Chicago Dental Society Midwinter Meeting.

Since winning the skills competition, I had graduated from dental school and I was enjoying working as a dental foundation trainee in practice. I was really looking forward to the experience, as the Chicago Midwinter Meeting is a highly regarded dental scientific conference, and I was certain I would pick up advice and skills that would help me in practice.

In beautiful, snowy Chicago, the size of the conference was incredible, and the programme had so many excellent courses to choose from that I was spoilt for choice.

I attended courses on a range of topics, including endodontics, oral medicine, gerodontology and fixed prosthodontics.

These lectures were all given by leading specialists and it was very inspiring to hear their advice. I learned about recent advances in dentistry, both innovative clinical techniques and state-of-the-art materials. I gained great insight into new techniques and the challenges we face treating an ageing population who are

Hannah Crane

I gained great insight into new techniques and the challenges we face treating an ageing population who are keeping their teeth for longer and have more complex medical and dental needs

THE RCSED DENTSPLY DENTAL SKILLS COMPETITION THE College is delighted to announce that the Dental Clinical Skills competition will be taking place again this year, with regional heats beginning in the autumn.

Sponsored once again by DENTSPLY, the competition will give students across the UK the opportunity to showcase their skills.

Winners from each heat will take part in the Grand Final in Edinburgh on 10 March 2016.

48 | Surgeonsâ&#x20AC;&#x2122; News | June 2015

keeping their teeth for longer and have more complex medical and dental needs.

In the exhibition hall, it seemed that almost every type of dental product was present, from articulating paper to implants.

I watched a Sirona CEREC CAD/CAM machine being used to make an all-ceramic crown from start to finish â&#x20AC;&#x201C; it was fascinating to see a crown develop from a simple block of ceramic. I also had the chance to look at some of the materials and equipment that I had learned about during courses.

I flew home with a renewed excitement for the advances in dentistry, which I hope to use in the future.

The competition was a fantastic experience, which I am certain will benefit me in my future career. I would like to thank the Faculty of Dental Surgery at the Royal College of Surgeons of Edinburgh for making it possible for me to attend this fantastic conference, along with DENTSPLY and everyone else involved in organising the competition.

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www.rcsed.ac.uk | 49

TRAINEES AND STUDENTS

John Evans (left) and his elective partner, Douglas Burke

John Evans shares his experience of visiting Sierra Leone for an undergraduate elective as the first Ebola cases were being reported in West Africa

CALM BEFORE THE STORM

S

hortly before departure to Sierra Leone – one of the world’s poorest countries – for my medical elective, an Ebola outbreak was reported in Guinea and Liberia. My placement at a rural healthcare facility situated near the border with Guinea was promptly switched to Bo Government Hospital, safely ensconced in the country’s interior. The small handful of doctors there were supported by community medical officers, and the atmosphere was of relaxed informality. Dr George (a general surgeon) and Dr Jalloh (a paediatrician) warmly welcomed my elective partner, Douglas Burke, and me.

Alongside a man selling kola nuts, the hospital’s entrance was marked by a large poster with a price list for treatments and investigations – an anti-corruption strategy. Healthcare is not free in Sierra Leone, although a bold policy from a progressive government to provide

50 | Surgeons’ News | June 2015

free care to pregnant women, lactating mothers and children under five years of age has proven popular.

Bo Government Hospital lacks running water, and the hydro-electricity is only meaningfully available during the rainy season. In spite of the extreme resource limitations, the hospital accommodates a wide range of medical and surgical specialties, and some particular cases stick in my memory. A young girl with multiple intestinal perforations secondary to typhoid fever needed a laparotomy, and the surgeon brought his diesel generator from home to provide the electricity; ordinarily battery-powered head torches sufficed. The lack of air conditioning led to such profuse sweating during a Caesarian section that the obstetrician joked that his sweat was sterile.

The bulk of my elective was spent in the Connaught Hospital in the country’s capital city, Freetown. It is a tertiary referral centre, and has 80 in-patient medical

A young girl with multiple intestinal perforations secondary to typhoid fever needed a laparotomy, and the surgeon brought his diesel generator from home to provide the electricity beds and a large surgical service. Facilities were better at the Connaught Hospital than in Bo. The country’s only medical school is based there and most of the 30 or so doctors graduating each year work there. Dr Oliver Johnson of the King’s Sierra Leone Partnership (KSLP) was invaluable in organising my elective. The dean of medicine, Dr Deen, and a general surgeon, Dr Dumbuya, were my supportive mentors for daily clinical activities, which involved the intensive care unit, the regular wards, the operating theatre and the newly reorganised emergency department.

The first ever laboratory-proven case of Ebola in Sierra Leone occurred during my time in the country.

Knowing that the outbreak could spill over from neighbouring countries, preparedness activities were already well under way, and I was involved in helping to prepare the isolation ward: simple measures such as hanging plastic sheeting between beds, and diluting vats of bleach to disinfect surfaces. At that time, although there were many suspected cases that required isolation, these patients thankfully tested negative for the virus.

The situation later deteriorated and the outbreak has dealt a devastating blow to the country.

KSLP has been based at the Connaught Hospital for a number of years, working successfully towards sustainable improvements in medical training, financial management, and an increasing spectrum of other aspects of healthcare provision. I was involved in two improvement projects.

The first evaluated demand on laboratory services, comparing in-house testing with the use of private laboratories that can be found surrounding the hospital. In

Above: Conditions for surgery in Bo are challenging

Below: The price list for treatments sits at the entrance to Bo Government Hospital

the second project, I collected an array of data concerning medical inpatients – demographics, duration of stay, clinical outcomes and common diagnoses. There were some unexpected findings that will be used to better plan services. Perhaps most rewardingly, these projects involved significant collaboration with local members of staff – laboratory scientists, nurses and administrative staff in the records office, among others.

My medical activities continued outside the hospital.

UK-based charity Street Child organised a fundraising marathon and I contributed to the first-aid effort under the auspices of Exile Medics, headed by British orthopaedic surgeon Brett Rocos, and in concert with the Sierra Leonean Red Cross. It was based in Makeni – the president’s home town – and I spent a day enjoying village life in my outpost near the halfway point. Gallons of rehydration solution were prepared but, despite the extraordinary temperatures, ailments were restricted to cramps and blisters – ideal for my first taste of marathon medicine.

Sierra Leone is a remarkable country. Everyday encounters regularly gave me much pause for thought. Alas, Sierra Leone – ‘Salone’ to her friends – is known for all the wrong reasons. A fair account would tell of the energy of the citizens and their welcome, of the remarkable religious tolerance, the relative safety and the incredible natural beauty. This was an extraordinary elective on so many levels, and this short article can’t hope to do it justice. I am grateful to the RCSed for generously awarding this bursary, as well as to all the people and patients who welcomed me into their country, hospitals and lives. Additional financial support was provided by the Nichol-Young Foundation and the Association of Commonwealth Universities.

John Evans Studied at Imperial College London www.rcsed.ac.uk | 51

TRAINEES AND STUDENTS

TACKLING CANCER FROM ALL SIDES The Northern Ireland Cancer Research Consumer Forum allows patients and doctors to work together to improve treatment. We speak to Michael Moran Snr and, overleaf, to Michael Moran Jnr about their involvement

around 20 individuals who are or have been cancer patients or have cared for cancer patients. The group is supported by Cancer Research UK senior research nurse Ruth Boyd, who works at the Northern Ireland Cancer Centre, and is chaired by Mrs Margaret Grayson.

The group was set up in 2011 to represent the public and patient viewpoint in cancer research.

Among members, there is a fairly wide range of cancer experiences, including prostate, breast, colorectal and skin cancers.

We organise public information sessions once or twice a year at which research clinicians present news on the latest advances and plans in cancer research and treatment. Furthermore, we attend meetings of the clinical research division of the Northern Ireland Cancer Centre, where we can discuss research plans with clinicians.

HOW DID YOU GET INVOLVED WITH THE CRCF? MM Snr: I am a survivor of malignant melanoma, which was treated by surgery. And so when my son,

My contributions are mainly driven by my experiences as a patient and my realisation that, with accurate diagnosis and prompt action, good outcomes are much more common than many people realise 52 | Surgeons’ News | June 2015

Michael, was at a national cancer conference in 2011, he met Ruth and Margaret and ‘volunteered’ my services.

Not that this was a problem for me: I was glad to be involved as a way of demonstrating my gratitude.

WHAT DOES YOUR ROLE ENTAIL? MM Snr: Members of the forum review the patient information sheets (PIS) generated as part of the approval process for cancer clinical trials. When these trials are under consideration, I make written submissions on issues of informed consent, on whether risks are fully explained and presented in a balanced manner, and on whether the PIS is couched in understandable language. I then attend meetings where trials are discussed. I also attend publicity and political lobbying events with other forum members.

Michael Moran Snr is a biologist, a survivor of malignant melanoma and a volunteer with CRCF

WHAT HAVE YOU BEEN ABLE TO BRING TO THE FORUM AS A RESULT OF YOUR OWN EXPERIENCES AS A PATIENT? MM Snr: As it happens, I am a biologist, but our members come from various backgrounds. My contributions are informed somewhat by my scientific knowledge, but are mainly driven by my experiences as a patient and my realisation that, with accurate diagnosis and prompt action, good outcomes are much more common than many people realise.

ARE SIMILAR PROGRAMMES OPERATING ANYWHERE ELSE? MM Snr: Groups such as ours are widespread throughout the UK in relation to cancer and other conditions, and in our field are connected to, and coordinated by, the National Cancer Information Network. The volume of such work is growing all the time and researchers now readily recognise its importance.

DAVID CAVAN

WHAT IS THE NI CANCER RESEARCH CONSUMER FORUM (CRCF)?

Michael Moran Snr: The forum is a group of

The Moran son and father duo are helping the NICRCF tackle cancer

www.rcsed.ac.uk | 53

TRAINEES AND STUDENTS

MICHAEL JUNIOR, HOW HAS THE CRCF HELPED YOUR OWN CLINICAL RESEARCH? Michael Moran Jnr: Having recently completed a doctorate investigating genetic and protein markers of head and neck cancer, the NICRCF has been very important in underscoring the importance of highquality, tissue-based research.

The CRCF is available for consultation on grant applications, development of patient information and feedback on research outcomes, and there are now great links in Belfast between the cancer clinical care environment, the research laboratories and the patient/ carer forum.

With an excellent understanding of the importance of clinical research, the NICRCF has been fantastic in its role as an advocate for increasing recruitment to clinical trials, which helps the work of clinical researchers considerably.

WHAT ARE THE KEY BENEFITS OF INVOLVING PATIENTS IN SURGICAL RESEARCH? MM Jnr: I wouldn’t have been able to complete my PhD without input from patients. Having used tumour tissue from pathology archives, I was able to work within a team of translational researchers to develop an invaluable resource that will inform our understanding of head and neck cancer biology.

In addition to the biology, the study of disease risk factors and lifestyle contribute to our understanding of cancer, and as researchers we have so much to learn from the patients who are in clinics every day in our local area.

I was really surprised at how supportive of this research the NICRCF was, and there is sincere willingness to engage with tissue-based research so that care can be improved for patients in the future. There is an understanding that it is better for tumours to be 54 | Surgeons’ News | June 2015

There is an understanding that it is better for tumours to be studied in a lab, rather than gathering dust on a shelf studied in a lab, rather than gathering dust on a shelf.

It is our duty as researchers to gain as much valuable information from these precious resources.

HOW MUCH DIRECT INTERACTION IS THERE BETWEEN PATIENT REPRESENTATIVES AND CLINICIANS? MM Jnr: There is no limit to the frequency of contact between the consumer forum and the translational cancer researchers in Belfast. From meeting one another for coffee or stopping to say ‘hello’ along the road to seminars, meetings or clinical trial boards, there is both formal and informal contact.

WHAT ARE THE CHALLENGES OF ATTRACTING PATIENT INVOLVEMENT? MM Jnr:The biggest challenge is time. In a cashstrapped NHS, we do not always have as long as we may like with a patient to be able to explain things fully. In addition, on the day when a patient has been told that they have cancer, a request to participate in a clinical trial or donate part of his/her tumour for research is not appropriate, and time is then needed on another day.

Although patients are very supportive of the research, time is required to build up meaningful relationships.

Even with these constraints, the support of patients for research that would benefit others is so admirable, and the CRCF has become an invaluable part of the research network in Northern Ireland.

Michael Moran Jnr is a member of the RCSEd Trainees’ Committee and an ST5 in ENT/Head and Neck Surgery

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

COLLEGE INFORMATION

All the latest grants, fellowships and bursaries from the RCSEd

AWARDS & GRANTS Small Research Pump Priming Grant

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

The College is now pleased to announce the following Small Research Pump Priming Grants of 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 a period of one year only.

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

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

Closing date for applications is Friday 12 June 2015.

Syme Medal

James Syme (1799–1870) was a leading surgeon of his day and an enthusiastic teacher and surgical innovator. He was also the mentor of Joseph Lister. The Syme Medal is a prestigious mark of excellence awarded by the College to a Fellow or Member on the basis of a recently submitted thesis (MD or PhD), published body of research, or educational development.

56 | Surgeons’ News | June 2015

Research should have been published in high-quality peer-reviewed 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 CV (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.

Appointments to the Medal are made on the understanding that those elected submit a manuscript for publication to The Surgeon: Journal of the Royal College of Surgeons of Edinburgh and Ireland. The successful candidate may also be invited to present a lecture at the College.

Closing date for applications is Friday 19 June 2015.

King James IV Professorships

Applications are invited from practitioners of surgery or dental surgery 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 receipt of applications is Friday 12 June 2015.

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.

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.

Joint RCSEd/SOMS/Shanghai Head & Neck Fellowship 2015

Applications are invited from Fellows and Members 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 offering financial support for electives in surgery. This award is open to medical students in the UK and Ireland undertaking approved surgical electives abroad. These awards will be advertised and awarded annually in September. The award provides a contribution towards the overall costs of travel and subsistence.

Closing date for applications is Wednesday 8 July 2015.

Lorna Smith Charitable Trust Research Fellowship

Administered by RCSEd. Applications are invited from all trainee doctors who wish to spend a period of time researching into disorders of a rheumatic, arthritic or inflammatory nature. Applications can be made for a period of one year and the Trust will provide a sum of up to £50k to fund salary and research costs.

Closing date for applications is Friday 4 December 2015.

DIARY

The latest surgical and dental events, seminars and courses JUNE 2015 1 Non-technical Skills for Surgeons (NOTSS) (Penang, KL) 11-12 Basic Surgical Skills Course 20-21 Basic Surgical Skills Course (Manchester) JULY 2015 1 Training the Trainer: Foundation Essentials (Birmingham) 2-3 Training the Trainer (Birmingham) 2-3 Basic Surgical Skills Course 18-19 Basic Surgical Skills (Manchester) AUGUST 2015 8-9 The Edinburgh MRCS OSCE Preparation Course (Kuala Lumpar) 20-23 MFDS Part 1 Revision Course (Dubai) 22-23 The Edinburgh MRCS OSCE Preparation Course (Kerala) For further information, please email education@rcsed.ac.uk or telephone +44 (0)131 527 1600. All events are in Edinburgh unless otherwise stated.

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COLLEGE INFORMATION

RCSEd & MRC Joint Clinical Research Training Fellowship

The Medical Research Council (MRC) is now inviting applications for the next round of the jointly funded Clinical Research Training Fellowship (CRTF). The MRC provides opportunities for additional clinical research training fellowships through collaborations with the Royal Colleges and charity funders. Any jointly funded fellowships will be offered under standard MRC terms and conditions, and at the same funding level as any other MRC clinical research training fellowship.

RCSEd Clinical Research Training Fellowship

Currently one joint clinical research training fellowship is available, open

to RCSEd Fellows and Members who meet the eligibility criteria set out by the Medical Research Council (MRC). Areas to be considered for support are surgical/dental translational research, surgical/dental health services research, research into surgical/dental aspects of patient safety, simulation and non-operative technical skills, and cancer research of direct clinical relevance to the management of solid tumours.

Applications open on Wednesday 29 July 2015. The deadline for submissions is 4pm on Wednesday 9 September 2015, with shortlisting taking place in February 2016. Interviews will be held on 2–3 March 2016 and take-up dates will be from April to September 2016.

For more details, please contact c.mccartney@rcsed.ac.uk. To apply, visit the MRC website at mrc.ac.uk

Ophthalmology Research Grants (sponsored by Royal Blind) Major project grants of up to £50,000 Small Research Support Grants for ongoing research of up to £10,000.

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

CONGRATULATIONS TO THE FOLLOWING AWARDS AND GRANTS RECIPIENTS AFRICA BURSARY Mr Alexander Hollis, University of Birmingham.

Visit to Kilimanjaro Christian Medical Centre, Tanzania.

Mr Don Koh, Imperial College London. Visit to Charlotte Maxeke Johannesburg Academic Hospital, South Africa.

Mr Matthew Little, Queen’s University Belfast. Visit to Mseleni Hospital and Groote Schuur Hospital, South Africa.

Mr Toby Hoskins, Newcastle University. Visit to St Francis Hospital, Zambia.

Mr Charles Badu-Boateng, King’s College London.

Visit to Chris Hani Baragwanath Academic Hospital, South Africa.

OPHTHALMOLOGY John Forrester, School of Medicine and Dentistry, University of Aberdeen.

In-depth studies of innate and adaptive immunity in in vitro analyses of crosslinked recombinant human collagen hydrogels and dendritic cells in corneal regeneration for pre-clinical applications.

Umiya Agraval, Tennents Institute of Ophthalmology, Gartnavel General Hospital,

58 | Surgeons’ News | June 2015

Glasgow. Patient-reported outcomes (PROs): are we performing cataract surgery too early?

Andrew Tatham, Princess Alexandra Eye Pavilion, NHS Lothian. Functional impairment in glaucoma study: risk of roadtraffic accidents and the development of new visual standards for driving.

Robert MacLaren, Nuffield Laboratory of Ophthalmology (NLO), University of Oxford.

Optimising gene therapy treatments for dominant retinitis pigmentosa.

Mandeep Sagoo, UCL Institute of Ophthalmology.

Identification of new mechanisms and targets in retinoblastoma.

Parwez Hossain, Academic Unit of Clinical Experimental Sciences, Faculty of Medicine, University of Southampton. Resolving the mechanisms of host inflammasome activation in microbial keratitis.

ETHICON TRAVEL GRANTS Jonathan Simpson, Surgical Registrar (ST7), Peter MacCallum Cancer Centre, Melbourne, Australia.

Fellowship in surgical oncology with a specific focus on cytoreductive surgery to treat pseudomyxoma, and pelvic exenterations as a treatment strategy for recurrent rectal cancer. In addition, further development of laparoscopic and robotic surgical skill sets.

Shafic Al-Nammari, Senior Fellow, Mercy Medical Center, Baltimore, Maryland, US. Fellowship in complex foot and ankle surgery with an emphasis on revision reconstructive procedures and ankle arthroplasty.

Rehan Saif, Specialty Registrar, Department of HPB Surgery and Liver Transplantation, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.

Visiting international fellowship for further training in liver surgery and transplantation.

Issaq Ahmedk, Senior Fellow, North Sydney Orthopaedic and Sports Medicine Centre, Mater Clinic, Sydney. To undertake a specialist sports injuries and arthroplasty fellowship.

Andrew Sutherland, Specialist Registrar,

Erasmus MC, Rotterdam.

To gain further training in laparoscopic living-donor nephrectomies.

ETHICON BURSARIES Chetan Khatri, Imperial College London. Visit to Liverpool Hospital, University of New South Wales, Australia.

Daniel Klotz, University of Oxford. Visit to the Department of Surgery, University of Hong Kong.

Chantelle Rizan, Cardiff University. Visit to the Department of Surgery, Victoria Hospital, St Lucia, and Trauma and Expedition Medicine Base Camp, Belize.

Nigel Ng, University of Aberdeen. Visit to the Johns Hopkins University Burn Center, USA. Alexander Hollis, University of Birmingham. Visit to the Kilimanjaro Christian Medical Centre, Tanzania.

Daniel Blyth, University of Leicester. Visit to the Orthopaedic Department, Ngwelezana Hospital, South Africa.

Helen Culley, University of Warwick. Visit to St Martha’s Hospital, Bangalore, Karnataka, India.

DIPLOMA CEREMONIES

Congratulations to all our new Fellows and Members who were presented with diplomas at ceremonies in March and April 13 MARCH 2015 Admission to Fellowship Ad Hominem Mr Iain David Anderson MBE FRCSEng FRCPSGlasg FRACS Consultant Surgeon, Salford Royal Hospital NHS Foundation Trust; Honorary Senior Lecturer in Surgery, University of Manchester School of Medicine Professor Gordon Sydney Findlater Head of Anatomy, University of Edinburgh Medical School Professor Jason Andrew Leitch FDS RCSEd FDS RCSEng FDS RCPS Glas National Clinical Director, Healthcare Strategy and Quality Unit, Scottish Government; Honorary Consultant in Oral Surgery, University of Dundee

Award of Fellowships Without Examination Dr Adnan Mustapha Salloum Consultant Paediatric Surgeon and Paediatric Urologist, Royal Aberdeen Childrenâ&#x20AC;&#x2122;s Hospital Diplomas of Fellowship in the Specialty of Cardiothoracic Surgery Neil Cartwright, University of London Robert David Slight, University of Aberdeen Diploma of Fellowship in the Specialty of Neurosurgery Alireza Shoakazemi, Islamic Azad University of Mashhad, Iran Diploma of Fellowship in the Specialty of Otolaryngology Mohammed Sufian Miah, University of Dundee

Diplomas of Fellowship in the Specialty of General Surgery Subodh Seth, University of Delhi, India Adam Stannard, University of Aberdeen Diplomas of Fellowship in the Specialty of Paediatric Surgery Ravindar Anbarasan, Dr MGR Medical University, India Madhavi Girish Kakade, University of Pune, India Jonathan Michael Wells, University of Edinburgh Diplomas of Fellowship in the Specialty of Trauma and Orthopaedic Surgery Zeeshan Khan, University of Peshawar, Pakistan Iain Walter William McGraw, University of Aberdeen

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COLLEGE INFORMATION

Diplomas of Fellowship in the Specialty of Plastic Surgery Muhammad Asim Bashir, University of Dundee Muhammad Faheem Khadim, Quaid-e-Azam Medical College, Bahawalpur, Pakistan Jason Kin Fai Wong, University of Aberdeen Diplomas of Fellowship in the Specialty of Urology Mohammed Badri Mohammed Al Sheikh, Al-Mustansirya University, Iraq Vishwanath Shivaling Hanchanale, Karnatak University, India The McCormack Medal Neil Cartwright, University of London

William Martin Oliver, Newcastle University Anokha Oomman, University of London Louise Amy Robiati, University of Aberdeen Gabrielle Scicluna, University of Malta Khuan Teck Matthew Seah, University of Edinburgh Robert Keith Silverwood, University of Aberdeen Aseel Najeeb Sleiwah, Al-Mustansirya University, Iraq Umar Sufian Tarar, University of Health Sciences, Pakistan Alexander Michael Whittam, University of Leeds Angeline Anning Yong, National University of Singapore

The Syme Medal Nathan Andrew Stephens, University of Edinburgh

Diploma in Immediate Medical Care David Steven Murray, University of Wolverhampton

Diploma of Membership in Ophthalmology Khin Oo May, University of Yangon, Myanmar

Diploma of Fellowship in the Specialty of Dental Public Health Timothy Brendan Elmer, University of Sheffield

Intercollegiate Diplomas of Membership in Surgery in General Faisal Ameer, Lala Lajpat Rai Memorial Medical College, India Ibrahim Azam, Charles University, Czech Republic Abdul Aziz, University of Aberdeen Shenbana Bagirathan, University of Nottingham Jonathan Anthony Barrow, University of Leeds Timothy John Batten, Peninsula College of Medicine and Dentistry Chetan Mulralidhara Rao Dojode, Rajiv Gandhi University of Health Sciences, India Firas Abdul Rahim El-Hanafi, University of Khartoum, Sudan Karan Goswami, University of London Charlotte Katharine Gunner, University of Edinburgh Lin Aung Han, University of Mandalay, Myanmar Daniel Hipps, Newcastle University Hafiz Muhammad Ijaz Ul Haq, Rawalpindi Medical College, Pakistan Kyi Thar Kyaw, University of Mandalay, Myanmar Abdalla Enayet Abdelhameed Mohamed, University of Khartoum, Sudan Rory John McGillivray Morrison, University of Leeds Sohail Nisar, Newcastle University

Diplomas of Fellowship in Dental Surgery Without Examination (by application) Jayesh Shrikant Rahalkar, University of Bombay, India James Sunny Pazhayattil, Manipal University, India

60 | Surgeons’ News | June 2015

Diploma of Fellowship in the Specialty of Orthodontics Peter William Germain, Newcastle University Diplomas of Membership in Orthodontics Sarah Germain, Newcastle University Alaa M A S Mohammd, Kuwait University Sherif Mohamed Shaarawy, Cairo University, Egypt Diplomas of Membership of the Faculty of Dental Surgery Mays Al-Ajeel, Charles University, Czech Republic Fahd Aleem, Gandhara University, Pakistan Joo Ming Cheong, University of Malaya, Malaysia Nicholas Clifford, University of London Auzar Sheroi Irani, Maharashtra University of Health Sciences, India Rajan Bhasker Mehta, University of Wales David Rhys Owens, University of Bristol

IN MEMORY

DENTAL HONORARY FELLOWS Vincent George KOKICH (FDS RCSEd Hon 2007) SURGICAL FELLOWS AD HOMINEM Stephen Andrew COPELAND (FRCSEd ad hom 2000) SURGICAL FELLOWS Frank Howard BEDDOW (FRCSEd 1956) Robert Maurice Andre GIRAUD (FRCSEd 1962) John Wilson KYLE (FRCSEd 1962) Khushru Mancherji MEHTA (FRCSEd 1948) Alexander Alan ROBERTSON (FRCSEd 1957) John William DOWDELL (FRCSEd 1980) Maurice Avrom FELDMAN (FRCSEd 1963) Robert Cornelius MARKS (FRCSEd 1983) John Dow Booth MILLER (FRCSEd 1974) Wyn MORRIS-JONES (FRCSEd 1966) SURGICAL MEMBERS Juliet Leigh ALLETSON (MRCSEd 2002)

Amir Abbas Rezvani, University of Leeds Diplomas in Orthodontic Therapy Rohima Begum, University of Central Lancashire Fiona Fortune, University of Central Lancashire Radhika Kapri, King’s Health Partners Hedieh Motahari, King’s Health Partners Ivana Sovadinova, King’s Health Partners Michelle Walters, King’s Health Partners 24 APRIL 2015 Admission to Honorary Fellowship Associate Professor Michael J Hollands FRACS FACS FRCSEng Clinical Associate Professor, Western Clinical School, Sydney University & Senior Staff Specialist, Westmead Hospital, Sydney, Australia Admission to Fellowship Ad Hominem Associate Professor Andrew A C Heggie FFDRCSIrel, FRACDS(OMS) Head, Oral and Maxillofacial Surgery, Royal Children’s Hospital of Melbourne, Australia Presentation of the College International Medal Professor Malcolm Underwood FRCSEd(C-Th) FCSHK Chief, Division of Cardiothoracic Surgery, Chinese University of Hong Kong

Award of Fellowship Without Examination Associate Professor Theodoros Kofidis Head of Division of Adult Cardiac Surgery, National University Heart Centre, Singapore, and Senior Consultant Cardiothoracic Surgeon Diplomas of Fellowship in the Specialty of General Surgery Yogesh Kumar, Pondicherry University, India Blossom Eve Jean Oppen Lake, University of Birmingham Duncan Michael Light, Newcastle University Iftikhar Mehmood, University of Punjab, Pakistan Syed Muhammad Ali Naqvi, Quaid-i-Azam University, Pakistan Brendan Paul Wooler, Newcastle University Diploma of Joint Specialty Fellowship in General Surgery Guiqin Germaine Agnes Xu, National University of Singapore Diploma of Fellowship in the Specialty of Otolaryngology Baskaran Ranganathan, Bangalore University, India Diploma of Fellowship in the Specialty of Paediatric Surgery Fiona Jane Murphy, University of Leicester Diplomas of Fellowship in the Specialty of Trauma & Orthopaedic Surgery Francis Michael Brooks, University of Dundee Vasanthakumar Ramsingh, Dr MGR Medical University, India Sridhar Rao Sampalli, Kakatiya University, India Suddhajit Sen, University of Calcutta, India Gautam Jugal Kishor Tawari, University of Mumbai, India Diploma of Fellowship in the Specialty of Urology Kingsley Chinedu Ekwueme, University of Ibadan, Nigeria The Syme Medal Aman Chandra, University of London The Henry Wade Medal Edward Calleja, University of Malta Diploma of Membership in Otolaryngology Ali A Salamat, University of Aberdeen

Intercollegiate Diplomas of Membership in Surgery in General Oroog Ali, National University of Sciences & Technology, Pakistan Kashif Raza Alvi, Ziauddin University, Pakistan Fiona Lamont Ashton, University of Edinburgh Myo Thet Aung, University of Yangon, Myanmar Rahul Bamal, Lucknow University, India Alexander Steven Dearden, University of Glasgow Susanna Kate Green, University of Leeds Wunna Htun, University of Mandalay, Myanmar Yashavanth Kumar V, Rajiv Gandhi University, India Mudasir Malik, University of Kashmir, India Robert Stuart McCormick, Newcastle University Molola Oyewole, University of London Corinna Slawinski, University of London Nay Win Than, University of Yangon, Myanmar Umar Bin Javed Yousuf, University of Bristol Diploma of Fellowship in Immediate Medical Care Monojit Choudhury, University of Calcutta, India Memberships of the Faculty of Surgical Trainers Richard Mark Graham, University of Dundee Vikram Kate, Nagpur University, India Chitta Ranjan Chowdhury, University of Dacca, Bangladesh Diploma in Remote and Offshore Medicine Muhannad Malik Kamuna, University of Baghdad, Iraq Diplomas of Fellowship in Dental Surgery of Examination (by application) Paul Chetcuti Caruana, University of Malta The John Mcdonald Medal Adriana Bartolo, University of Malta Diploma of Membership in Oral Surgery Edmund Paul Bailey, University of Liverpool Diplomas of Membership in Orthodontics Ahmed Abdullah, University of Damascus, Syria

Adriana Bartolo, University of Malta Katrina Gardovska, University of Latvia Iveta Indriksone, University of Latvia Karen Elizabeth Shaw, University of Dundee Peteris Sosars, University of Latvia Joanna Thomson, University of Glasgow Julie Caroline Williams, University of Birmingham Diplomas of Membership in Primary Dental Care Salma Mohamed Majdi Ali Sayed Ahmed, Ain Shams University, Egypt Amani Abdulaziz Salman Ali, University of Damascus, Syria Fatima Hasan Alsulaiti, Ajman University of Science & Technology, United Arab Emirates Diplomas of Membership in Prosthodontics Parvez Robin Amanullah, University of London Derk Hendrik Jan Jager, University of Groningen, Netherlands Sneha Subhash Kubal, Maharashtra University of Health Sciences, India Salah Naser Riyal, University of Jordan Safa Somi, University of Tabriz, Iran Diplomas of Membership of the Faculty of Dental Surgery Vipin Allen, Chaudhary Charan Singh University, India Syed Naseer Askari, University of Karachi, Pakistan William David Blundell, University of London George Anthony Cortvriend, Newcastle University Rabia Farhan, National University of Sciences & Technology, Pakistan Rizwana Sabreen Hossain, University of Dacca, Bangladesh Ehtesham Khan, Khyber Medical University, Pakistan Neil Marley McFetridge, University of Glasgow Fariya Mohammed, Rajiv Gandhi University, India Umair Abbas Mohammed, University of Dundee The Orthodontic Therapy Medal Sophie Gannon, University of Central Lancashire Diplomas in Orthodontic Therapy Lisa Marie Brown, University of Central Lancashire Rachel Gibson, University of Central Lancashire Deborah Elizabeth Hildrow, University of Central Lancashire Samantha Anne Smith, University of Central Lancashire

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OUT OF HOURS

Graham Layer takes a culinary tour of the capitals of three home nations

A tale of three cities

62 | Surgeons’ News | June 2015

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

MISSIONPHOTOGRAPHIC.COM

I

continue to travel between the UK capital cities, and so here are mouth-watering experiences from three of them. Castle Terrace restaurant in Edinburgh is in a beautiful building and serves glorious food cooked by chef patron Dominic Jack (pictured below). He is inspired by my current favourite Edinburgh chef, Tom Kitchin, with whom he co-owns the establishment, which holds a Michelin star. I was convinced by the maître d’hôtel that I would enjoy the first day of the harvest of sea kale, a Scottish delicacy, but my English palate was somewhat too delicate for it. Served like asparagus with poached eggs and a fabulous hollandaise, it is a bitter seaweed, more like cabbage than asparagus, but shaped like celery. It was tender and visually appealing and there was a plentiful supply, but I remain uncertain as to its pedigree. I much preferred what followed: monkfish fillets wrapped in a skin of ham with tangy red pepper marmalade. The rest of the menu was fascinating with, predictably, venison and other game, and unusual amuse-bouches. Everything was impeccably presented.

I was in Cardiff recently and booked Sunday lunch at Park House near the city centre. The lunch did not live up to all the amazing recommendations, not helped by appalling weather. I also dined at The Social, the in-house restaurant of the Parc Hotel. Dinner in the hotel was, well, dinner in the hotel. Pier 64 at Penarth Marina, however, did not disappoint. It is a contemporary place with great views over the water from huge windows, and offers a vast menu of everything that is popular today and is served in large, good-quality portions. Clearly popular, it is good value and what you see and expect is what you get.

Now twice to London’s Covent Garden. Clos Maggiore is a well-established French restaurant despite its Italian suffix and was labelled the most romantic restaurant in London by a well-known guide, so I booked it for lunch with my wife on her birthday. The restaurant has a small, unassuming frontage revealing inside a complex network of foliage-clad synaptic rooms. It certainly lived up to expectations on the gastronomic front.

Lunch was less than £30 for two courses with multiple offerings between, including stunning cheesy bread, then a charming solitary birthday candle surrounded by truffles. We commenced with two quenelles of white crab meat on smoked salmon with beetroot and green leaves – fabulous.

I proceeded to venison loin from Windsor coupled with a venison shepherd’s pie and vegetables, which was wonderful. My wife shared her magnificent chunky

Castle Terrace in Edinburgh is well deserving of its Michelin star

Clarke’s features interesting décor and fabulous seasonal food

CAROL SACHS

Clos Maggiore is a hidden gem in London’s Covent Garden

white-fish steak with samphire, purple carrots, triplecooked chips and a little fritter – remarkable value and terrific flavours.

The Ivy Market Grill opened earlier this year in Covent Garden, on the opposite side from Clos Maggiore, and is already a huge success. Its pub-style dining room serves some of The Ivy’s classics from the other end of Longacre, as well as a whole brasserie-style menu of meat and fish and its own version of a hamburger with cheese. Great fun and of a similar style to the popular Grand Cafés currently pervading most capitals of Europe, Australia and the US. I recommend the classic Ivy starter – warm crispy duck meat in a five-spice dressing, served on pak choi and beansprouts with a ginger dressing, giving the flavours of Peking duck in pancakes with the feel-good factor of eating it with salad rather than fatty duck skin. The scallops were excellent and the star of the show was crispy courgette fries with a lemon and mint yoghurt to share in the middle of the table. These are outrageous and you can’t get enough of them. Main courses consist of a satisfactory hamburger, good Argentinean and Uruguayan steak, daily specials and lighter options such as grilled chicken salad with avocado and a spicy ginger dressing, with quinoa providing the bed for the tasty bits.

Clarke’s has been on Kensington Church Street for more than 30 years. This is an outstanding restaurant, with a contemporary and slightly distressed interior with masses of space between tables, charming staff and a fabulous seasonal menu. Dinner was superb and wonderful value, but parking was challenging, so take the tube or a taxi. The wall décor features enormous chrome cutlery, including a knife and fork which I dreamt was a scalpel and pair of forceps within this theatre of food. I succumbed to the crab in mayonnaise with rye bread, purple cress and peashoots sitting on the juiciest smoked salmon flesh. This was followed by Angus rib of beef, a signature cooked to perfection, oozing blood and juices to mix with horseradish cream and rocket with homemade potato crisps.

Exceptional. A sort of fruit brioche followed, which was as light and tasty as I have ever experienced. The charismatic chef patron, Sally Clarke, was there cooking and chatting to us as we enjoyed a fantastic evening.

Zum Wohl!

Germany comes out on top in Bernard Ferrie’s selection of value wines

T

his is not about German wine – I find that subject unapproachable and many of the wines sickly. This selection are all value-formoney wines from Aldi and Lidl.

First on the list is Exquisite Collection Clare Valley Riesling 2014 from Australia (£6.99, Aldi), with steely green apple grapefruit and lime and, at 12%, is stronger than most German Rieslings. Seafood Thai or Chinese go well.

I can’t resist Freeman’s Bay New Zealand Sparkling Sauvignon Blanc (£9.99, Aldi), with lime, gooseberry and passion fruit. If you don’t fancy the bubbles, then Exquisite Collection Marlborough Sauvignon Blanc is very good value, at £2 less and typical of the grape type and region.

Lidl for the red pair – good, reliable Spanish red Cepa de Lebrel, which has terrific intense flavour, is great value at £5.99 and is available all year round. A good, solid everyday drinking Rioja if you have daily wine these days. Great with venison or lamb to match the red fruit and spice.

Roll out the Barolo (£9.99). Red, luxurious, smooth and powerful – sounds like a Maserati – best finished at one sitting as its balance and road-holding had deteriorated by the next day. T-bone steak with crisp lollo rosso lettuce, surely.

Need emergency bubbly late in the day on a motoring holiday? Bissinger champagne (£13.99, Lidl) – widely available throughout Europe. Not thin and sharp, but a steady and reliable taste.

Look out for interesting biscuits for your next wine tasting, but try to resist the dark continental chocolates.

Mrs Merkel’s boys must be very happy.

www.rcsed.ac.uk | 63

FROM THE COLLECTIONS

Illustration from Dr Emil Ponfick’s Topographic Atlas of Medico-Surgical Diagnosis

ANATOMY ON A PLATE

F

rom 1900–1905, Dr Emil Ponfick, then director of the Pathological Institute, University of Breslau, worked with lithographer K Wesser to create 30 colour ‘topographic plates’. Technically brilliant, yet also accessible to the non-medic, Ponfick’s work has become a favourite at public engagement activities. Ponfick asserted that there was an over-emphasis on pathology in medical illustration at this time, and to fully understand disease, pathology and anatomy should be combined in illustration. In his call for a method of joint diagnosis, he argued against presenting “the diseased organ alone and without regard to its influence upon other parts of the body”.

Ponfick observed that physicians encountering disease needed to have topographical records which would provide recognisable anatomical structures, but also “concrete form the exceptions to the memorised rules recording normal positions”. Without aiming for the completeness of Cruveilhier’s Atlas, Ponfick intended to picture the sum of topographical deviations, following in the tradition of Pirogoff’s Atlas.

Ponfick describes the difficulties in producing these 30 plates, and a number of years were required to “obtain 64 | Surgeons’ News | June 2015

useful sections”. Ponfick’s work was “confined to a very short period of time”. Access to artificial methods to lower room temperature were not available to him, so he dissected during colder months.

Despite difficulties, Ponfick aimed for perfection, often replacing primary sections several times. When the “acceptable section” was taken from the frozen body, the surface was covered with a plate of milk-glass. The circumference and important outlines of organs were traced, then smaller cavities were drawn on the glass.

The drawings were transferred to transparent paper, then re-measured by Ponfick and Wesser. Ponfick aided the artist with extra detail and explanation “very materially by drawing an exact sketch of each cut surface on a large blackboard”. As well as wonderfully coloured plates of horizontal and vertical sections, Ponfick produced detailed patient notes, including patient history, present condition, clinical and anatomical diagnosis and postmortem examinations.

Emma Black Public Engagement Officer, Surgeons’ Hall Museum

Above: Horizontal section through the superior abdominal regions of a man, 35 years old, who died of cancer of the stomach and all epigastric retro-peritoneal glands

POSTGRADUATE TRAINING COURSES

Open since 1992, the Cuschieri Skills Centre continues to deliver high quality, relevant procedure-based skills courses to local, national and international medical personnel of all levels.

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Course programme includes: • GENERAL SURGERY

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

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