Surgeons' News June 2016

HISTORY

NEUROSURGERY IN THE 1800s

The pioneering work of Thomas Annandale on acoustic neuromas

INTERVIEW

MILITARY MANOEUVRES

Brigadier Tim Hodgetts on remote healthcare in the armed forces

MUSEUMS

THE STORY OF THE MEDICINE MEN

Shrunken heads and sealskin kayaks go on show in a temporary exhibition

Surgeonsnews June 2016

The magazine of The Royal College of Surgeons of Edinburgh

The test of time

Will the Greenaway guidelines improve training across the specialties?

www.surgeonsnews.com

surgeons_news_colour_page_march 03/02/2016 11:59 Page 2

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WELCOME

FROM THE EDITOR John Duncan discusses the impact of training reviews in surgery

R

eports on the future direction of medical training come along with a frequency that seems to relate to how effective the previous one was. My generation thought we knew what we were training for and there was no change to the structure of training until after we were consultants. Since then, the Calman reforms and Modernising Medical Careers have changed the geography significantly. There can be little doubt that both seismic shifts in the structure of training have had some beneficial effects but produced unintended problems.

The Shape of Training report by Professor Greenaway’s committee seeks to improve training across the specialties to ensure we have a workforce that is able to provide care for our patient population, the nature of which is anticipated to change significantly in years to come. Since the publication of the report with much fanfare, the issues it addresses have had considerably less visibility. There have been political issues that have delayed progress, but if this isn’t to be another report filed away with no action, we need to find some way to move forward.

There is much in the broad approach that we should all be able to support.

Although the detail of the scope of change in each specialty is not defined, the report gives us the chance to develop aspects of surgical training.

General surgery seems prepared to use the opportunity to improve the structure of its programme, while trauma/orthopaedics feel that their programme already has the correct shape for the future and needs little alteration. Perhaps both are correct.

Whatever detailed proposals are produced, the important concept of piloting change and learning from that activity is vital. We have yet to understand all the consequences of run-through versus core training, as well as the full impact of national recruitment. Trainees have the right to know what the structure of their training will be and the nature of its end point before embarking on

There have been political issues that have delayed progress, but if this isn’t to be another report filed away with no action, we need to find some way to move forward decisions that will influence the rest of their lives.

We owe it to them to get this right.

This year, ‘named trainers’ have to be appraised and then revalidated against their training role. In this issue, the Director of the Faculty of Surgical Trainers (FST), Craig McIlhenny, outlines the process. We also interview the keynote speaker at the annual FST meeting in October, Dr Mary Klingensmith, to talk about the concept of competency-based training, which is a major pillar of the Shape of Training report.

The College has supported Touch Surgery, a mobile surgery simulator, since early in its evolution. With the business now a success, we talk to Andre Chow, its co-founder, about the development of the app and its impact.

Our public affairs team based in Birmingham has done an enormous amount to develop the voice of the College in political terms. Andrew Mullinex, our Senior Public Affairs Officer, writes about our efforts in Westminster to improve patient safety.

I know how much the historical articles in Surgeons’ News are appreciated. This edition includes two very interesting pieces about the heritage of our College.

Finally, my colleague Graham Layer, RCSEd Vice-President and our restaurant critic, will from now on be better known in culinary circles as Jack’s uncle, with his nephew getting to the final of Masterchef. Graham includes a special mention of this in his regular restaurant review on page 62–63.

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

26

HISTORY

NEUROSURGERY IN THE 1800s

The pioneering work

by Thomas Annandale on acoustic neuromas

INTERVIEW

MILITARY MANOEUVRES

Brigadier Tim Hodgetts on remote healthcare in the armed forces

48

MUSEUMS

THE STORY OF THE MEDICINE MEN

Shrunken heads and sealskin kayaks go on show in a temporary exhibition

Surgeonsnews June 2016

The magazine of The Royal College of Surgeons of Edinburgh

The test of time

Will the Greenaway guidelines improve training across the specialties?

www.surgeonsnews.com

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

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

Cover illustration: Jimmy Turrell

2 | Surgeons’ News | June 2016

Contents June 2016

04 08 18

AGENDA News and views from the profession THE PRESIDENT WRITES Regular update on College activities NEUROSURGERY The story of Thomas Annandale and the first acoustic neuroma removal

22 24

TRAVELLING FELLOWSHIP Antipodean orthopaedic adventures

26

STANDARDS Mary Klingensmith MD talks competency-based training

28

ACCREDITATION The deadline looms for named trainers to be recognised by the GMC

30

MILITARY MEDICINE The challenges for the armed forces in providing care in remote places

34

MUSEUMS EXHIBITION 'Medicine Men' artefacts chart the adventures of science explorers

38

SPECIALTY The Vascular Society's quest for the best patient outcomes

SIMULATION Andre Chow explains how the Touch Surgery app is enhancing training

18

42

SHAPE OF TRAINING Where are we three years on from the Greenaway guidelines?

47

DENTAL Faculty news; the Dean's update; and Skills Competition winners

52

TRAINEES AND STUDENTS ASiT turns 40; College announces next student challenge

56 62 64

COLLEGE INFORMATION Diploma listings; awards and grants OUT OF HOURS Restaurant and wine reviews FROM THE COLLECTIONS Sir William Fergusson exhibits

CONTENTS

Christmas at your College Are you entertaining the family this year at Christmas?

Would you like to invite them along to your College on Christmas Day for a Champagne Reception with canapes and a sumptuous four-course banquet in the magnificent PlayfairHall?

For the first time in 500 years the College is opening its doors on Christmas Day for a five-star experience.

FOR FURTHER INFORMATION CONTACT THE EVENTS TEAM: events@surgeonshall.com

|

0131 527 3434

|

www.surgeonshall.com

www.rcsed.ac.uk | 3

Agenda The latest news from the College and profession / POLITICS

Talks resume in dispute over contracts for junior doctors

A

Junior doctors and their supporters protest in London against the government’s plans to change the contracts of NHS junior doctors

t the time of going to press, a five-day pause had been agreed between the government and junior doctors to allow further talks to take place. The Academy of Medical Royal Colleges helped to broker the deal and urged both sides to resume talks as early as possible.

The development came following a letter to Prime Minister David Cameron from the royal colleges (including RCSEd) calling on him to intervene in the dispute.

The letter said: “In our view, as leaders of the medical profession, the ongoing impasse in the dispute between government and junior doctors poses a significant threat to our whole healthcare system by demoralising a group of staff on whom the future of the NHS depends.”

In his response, Cameron said: “During my tenure as Prime Minister, we have engaged in a process lasting over three years, holding over 75 meetings and recently making many concessions to try to broker a deal. On the outstanding issue of Saturday pay, the government made three concessions over several months, while the BMA has made no attempt to compromise.”

/ AWARD

Malaysian ruler accepts highest honour The College has presented its highest award to His Royal Highness Tuanku Muhriz ibni Almarhum Tuanku Munawir, ruler of the State of Negeri Sembilan, one of the 16 states and federal territories that make up Malaysia.

His Royal Highness visited Edinburgh on 22 April to receive the College’s Honorary Fellowship. He is also a member of the Council of Rulers of Malaysia and Chancellor of the National University of Malaysia (UKM).

Presenting the award, the College’s President, Michael Lavelle-Jones, said: “We are hugely honoured to present His Royal Highness Tuanku Muhriz with the highest award the Royal College of Surgeons of Edinburgh can bestow.

“The College is delighted to welcome His Royal Highness as an Honorary Fellow in recognition of his dedicated support for the 4 | Surgeons’ News | June 2016

advancement of surgery. Tuanku Muhriz has raised immense donations to fund healthcare projects at the UKM and in the wider communities of Malaysia.

Currently, he is leading projects to establish a centre of excellence for both medicine and surgery as part of a ‘medical city’ in the vicinity of UKM.” In becoming an Honorary Fellow of the 511-year-old RCSEd, Tuanku Muhriz joins other notable international figures, including Myanmar’s pro-democracy leader Aung San Suu Kyi, and former Secretary General of the United Nations Kofi Annan.

HRH Tuanku Muhriz receives his Honorary Fellowship on 22 April while visiting the College

/ AWARD

Fellowship for California professor Julie Freischlag, Professor of Surgery, Dean of the School of Medicine and Vice-Chancellor for Human Health Sciences at the University of California, Davis, received the Honorary Fellowship of the College on 22 April.

Presenting the award, the College’s Vice-President, Professor John Duncan, said: “It is a huge pleasure to welcome Professor Freischlag to our College, which prides itself on

From left: RCSEd President Michael Lavelle-Jones, Julie Freischlag and College Vice-President John Duncan

its global reputation for excellence in surgical practice. In preparing to grant this Honorary Fellowship, perhaps the area of Professor Freischlag’s work that stood out among her many professional achievements was the immense appreciation of those she has trained for her support and mentorship.

Professor Freischlag has been a mentor and role model for countless students, residents and colleagues.”

Dr Catherine Calderwood / EVENT

RCSEd hosts future clinical leaders’ summit

O

n 7–8 April, the College hosted an event for doctors taking part in a UK-wide Fellowship programme to develop clinical leadership in the NHS. The UK

Clinical Leadership Fellows event brought together, for the first time, Fellows from all four UK nations to learn about the Scottish health and social care system, and harness the power of collective leadership and collaboration across boundaries.

The RCSEd’s current Clinical Leadership

Fellow is Dr Gemma Sullivan, an ST7 in neonatal medicine. Dr Sullivan said: “The event provides an insightful introduction to the Scottish health and social care system with representation from Scotland’s senior medical leaders, including Chief Medical Officer Dr Catherine Calderwood.

“The Fellowship offers a unique opportunity for experiential learning within strategic healthcare partnership organisations, enabling the development of the necessary knowledge, skills and networks to be an effective leader for the future NHS in Scotland.”

Welcoming Fellows and speakers to the event, which was held at the College’s Edinburgh campus, the College’s VicePresident, Professor John Duncan, said: “The Leadership Fellow programme is an important component in futureproofing the clinical leadership of the NHS. Many of my generation wish that we had had the opportunity to learn how the service works and how to go about facilitating change at an earlier stage of our careers.”

The RCSEd supports half of the funding for three clinical leadership Fellows, each based in Scotland, England and Wales.

The one-year posts are an important part of the strategy to develop professionalism and excellence across medicine and dentistry in the NHS. The programme aims to develop doctors with enhanced leadership capabilities. rcsed.ac.uk | 5

AGENDA

NEWS IN BRIEF SHINE toolkit

Undergraduates and junior doctors gather for the National Conference for Aspiring Surgeons / EVENT

Aspiring surgeons enjoy conference competition

T

he National Conference for Aspiring Surgeons was held in Bristol this year, in conjunction with the Bristol Medical School Surgical Society, ‘Scrubs’, attracting 45 undergraduates and junior doctors from around the country.

The judges had a difficult job in choosing the winner and runner-up presentations out of several outstanding projects presented by

Winners: Oral Presentations – Medical Students First: Gita Lingam Runner-up: Edward Christopher Oral Presentation – Foundation Doctors First: James Oliver Runner-up: Khaleel Hamdulay Poster Presentations – Medical Students First: Basil Moss Runner-up: Conor Jones

medical students and foundation doctors.

Workshops included ATLS taster sessions, suturing and the use of laparoscopes. Samir Pathak (ST6 General Surgery, Severn Deanery) gave a talk on how the Edinburgh Surgical Science Qualification helped him with core surgical training and its subsequent positive impact on his career.

Finally, senior members of the College team were available to talk about what the RCSEd can offer throughout a surgical career.

/ COLLEGE

College launches new perioperative faculty In March, the College opened a new faculty to recognise the important part played by members of the wider surgical team. The RCSEd Faculty of Perioperative Care (FPC) has opened its doors to all perioperative practitioners, who can now become Affiliate Members and benefit from access to tailored training, continuing professional development and support. The FPC aims to attract surgical care practitioners, surgical first assistants, and healthcare staff with similar roles.

The faculty has been established in response to changes to the structure of surgical teams and the increasing number of perioperative staff. It is 6 | Surgeons’ News | June 2016

now widely acknowledged that more integrated working and communication across the whole surgical team can lead to better patient outcomes.

College President Michael Lavelle-Jones said: “The RCSEd is very proud to be the first surgical College to formally recognise the importance of our many colleagues working in perioperative care through the creation of a dedicated faculty.

Perioperative practitioners are a core part of the surgical team and the College is pleased to be launching this faculty to support them.”

More on page 15

The College has launched a Surgical Ward Round Toolkit aimed at reducing errors and improving safety on surgical wards. It was a joint undertaking between the College’s Patient Safety Board and the Royal Infirmary of Edinburgh, and was supported by a grant from the Health Foundation’s SHINE 2014 initiative.

The project was developed using an adapted non-technical skills for surgeons (NOTSS) system and a ward round-based structured checklist. It is available along with an introductory video on the College’s website.

rcsed.ac.uk

Briefing tackles surgery on smokers The College has collaborated with Action on Smoking and Health, the Royal College of Anaesthetists and the Faculty of Public Health to produce a briefing designed for health professionals and commissioners to provide clear advice and examples of good practice in relation to smoking and surgery.

Smoking is the single biggest cause of premature and preventable death in the UK. It is responsible for almost 100,000 deaths every year across the country. In addition to the general health risks associated with smoking, research has shown that smokers are more likely to suffer a range of complications before, during and after surgery.

ash.org.uk

Scully receives oral surgery prize Dental Faculty Council member Professor Crispian Scully CBE has been awarded the International Prize of the Spanish Society of Oral Surgery.

Professor Scully has long-standing links with colleagues in the Ibero– American world, having received the Award of the Spanish Society for Oral Medicine, the University of Granada Gold Medal, the University of Santiago de Compostela Dental Award for Clinical Research and a doctorate from the University of Granada.

l TO Al OPeN h AN w i T ST i N e N i TergiCAl r Su iNg TrAiN

Save the date! edinburgh 21 October 2016

The Faculty of Surgical Trainers Annual Conference 2016 Training by numbers: Competency vs Time in Surgical Training Abstract submission now open - we accept abstracts on all aspects of surgical education and training, with prizes for best oral and poster presentations.

New this year: Workshops on giving effectice feedback, simulation in training, and better use of ISCP

To book: email education@rcsed.ac.uk call 0131 527 1600 visit www.rcsed.ac.uk

Speakers already confirmed: Mary Klingensmith MD President of the association for Surgical education, distinguished Professor of Surgery and Vice Chair for education at Washington University School of Medicine in St Louis Anthony gallagher Professor of technology enhanced Learning, University College Cork Nick Sevdalis Professor of Implementation Science and Patient Safety, KCL, and editor-in-Chief, BMJ Simulation and technology enhanced Learning Olle Ten Cate Professor of Medical education and director of the Center for Research and development of education, University Medical Center Utrecht ian Curran gMC assistant director of education and Professional Standards and Professor of Innovation and excellence in healthcare education at Queen Mary University of London

RegISteRed ChaRIty No. SC005317

XXXXXXXXXXXXX AGENDA

THE PRESIDENT WRITES

O

Michael Lavelle-Jones provides his regular update on College activities ur College never seems to stand still.

On 3 March, we launched the Faculty of Perioperative Care, the culmination of 18 months’ hard work under the careful stewardship of Council Member and Faculty lead Charles Auld. The new Faculty, with its focus on surgical care practitioners, surgical first assistants and all healthcare staff with similar roles, builds on the success of our joint meeting with the Association for Perioperative Practice, held in Birmingham last October. This collaborative event identified the need for educational and professional support for perioperative practitioners, who have a pivotal role in the surgical team. Establishing this Faculty provides clear recognition that we, as surgeons, cannot deliver the service alone.

8 | Surgeons’ News | June 2016

The Faculty will stand alongside our existing four Faculties – Dental Surgery, Pre-hospital Care, Sports and Exercise Medicine, and Surgical Trainers – and is a reminder of the inclusive nature of our College, embracing all aspects of surgical and dental care. I would urge you to help spread the word by telling your wider surgical team about our new Faculty. More information is available at fpc.rcsed.ac.uk March also saw publication of the College report on standards of care in rural surgery. I hope this document will be a catalyst for debate in this vital and frequently overlooked area of practice. So often, the needs of metropolitan surgical practice take precedence and it is important that our College takes a lead in this important aspect of surgical care.

Continuing the theme of inclusivity, rural practice in

The College is focusing on standards of care in rural communities

the UK is not unique to the Highlands and Islands region of Scotland, but also impacts on the delivery of healthcare in parts of North and Mid Wales, and in England in Devon and Cornwall, for example. In recent weeks, I had the opportunity to meet with the Minister for Health and Social Services in Wales, Mark Drakeford, and the issue of delivering healthcare in the rural community in Wales was high on his agenda. As a College, we look forward to supporting this agenda across the UK in the coming months. By the time this column appears in print, the first of this year’s regional visits will have taken place beginning at Ysbyty Gwynedd in North Wales and coinciding with the Welsh Surgical Society. This event, organised by our local Regional Surgical Adviser, Vaikuntam Srinivasan, will provide a good opportunity to network and will provide further insight into ways the College can assist our surgical membership working in Wales.

The aftermath and aftershock of the imposition of the junior doctors’ contract continues to be felt throughout the UK despite the implementation being limited to our trainees working in England.

It has left behind a bitter taste for many and is likely to be the catalyst for many unforeseen consequences aside from escalating industrial action that has the potential to affect us all – not least our patients. I would recommend careful scrutiny of the NHS England New Contract Document published in February and for you to form your own opinion – at least there is some mention of statutory training and education agreements alongside service commitment, unlike the current New Deal. It will take a lot more than a government-commissioned review of long-standing junior doctors’ concerns to heal these wounds and that was the clear message I received from our trainees at this year’s Association of Surgeons in Training conference in Liverpool.

Choosing Wisely and Global Surgery are two emerging themes in world surgery. The Choosing Wisely initiative emerged in the US as a campaign led by the American Board of Internal Medicine. Its simple aim was to address the problem of patients receiving unnecessary investigations and treatment, reasoning that this might lead to poor outcomes and waste in any cash-strapped health system.

The Choosing Wisely concept rapidly gained

It will take a lot more than a government-commissioned review of long-standing junior doctors’ concerns to heal these wounds; that was the clear message from trainees at this year’s ASiT conference momentum across the US and in Canada, and was predicated on the need for specialty surgical organisations to make five recommendations to prevent overuse of various treatments in their field. Central to this philosophy is the need to improve patient–doctor communications, and to develop a shared understanding of management plans and options.

In the UK, Choosing Wisely has emerged directly and under the banner of ‘prudent practice’ in Wales and in the Scottish ‘realistic medicine’ proposal outlined in Chief Medical Officer Catherine Calderwood’s annual report for 2016. Choosing Wisely was thoroughly debated at the Surgical Forum meeting held under the chairmanship of John MacFie this January, and brought together the views of the UK and Irish Surgical Colleges and the Federation of Surgical Specialty Associations, all of which were represented and in good voice. The consensus view that emerged was that the UK had already moved beyond the concept of ‘top five lists’ of inappropriate treatments and that we would be better served working together to reduce variation in practice across the UK, and that the Colleges and the Specialty Associations should work together to make this a reality.

Finally, in this issue of Surgeons’ News, we revisit Shape of Training (SHoT), taking account of the views of several specialties on the practicalities of implementing this programme. Little seems to have been heard of SHoT in recent months – perhaps a reflection of the pressing issues of junior doctors’ contracts – but I have no doubt that over the coming months, SHoT, mentoring and credentialing will all re-emerge as key topics and I anticipate that our College will play a pivotal part in the debate.

Michael Lavelle-Jones president@rcsed.ac.uk rcsed.ac.uk | 9

AGENDA

SURGICAL SAFETY UPDATE More cases from the Confidential Reporting System for Surgery More perils of pooled lists: carotid confusion

To meet guidelines with respect to urgent carotid surgery, I was asked by a colleague to undertake a right carotid endarterectomy on a 75-year-old female. I met the patient on the morning of surgery. On review of the notes, there was confusion as to which side her neurological symptoms had occurred.

Notes written by different doctors variably documented left- or right-sided symptoms, and the overriding reason for listing for surgery had been documentation of a ‘free-floating thrombus’ in the right internal carotid artery on CT angiography. A conflicting ward-based duplex scan of only the right carotid artery had been obtained, on which no thrombus was noted, but a plaque causing a ‘50–69% stenosis’ was seen at the origin of the internal carotid artery.

The notes also documented a junior doctor’s concern that the patient seemed too confused to provide informed consent. On undertaking a careful history from the patient, it emerged that she was fully lucid, but had a significant residual expressive dysphasia (interpreted by the junior doctor as confusion) from a previous lefthemispheric CVA, which made obtaining an accurate

10 | Surgeons’ News | June 2016

history convoluted. On the morning of her supposed recent symptoms, her blind partner had thought that her speech was a little worse and had dutifully examined her, believing that, on palpation, she seemed to have a weakness on one side of her face. This resulted in her referral to hospital and the prompt for CT angiography.

The patient herself denied any new symptoms.

Rather than proceed to surgery, a further duplex scan of both carotid arteries was undertaken in the vascular laboratory, at which time both carotids were noted to be free of thrombus and with less than 50% ICA stenoses. The patient was relieved to be discharged from hospital without an unnecessary operation, on best medical therapy, and with a routine follow-up outpatient appointment.

Reporter’s comments

This case illustrates the risks of pooled lists. A series of factors contributed to inappropriate listing for surgery.

The history was not straightforward and was compounded by the patient’s expressive dysphasia. Existence of clear symptomatology was not established and there were discrepancies between investigations. Weight was placed on the blind partner’s assessment of the patient for facial weakness.

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

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

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

CORESS comments

When undertaking pooled operation lists or surgery on a patient previously unknown to the surgeon, it is the duty of the operating surgeon to ensure they are satisfied that the patient will undergo the correct procedure.

This involves obtaining an adequate history, examining the patient and reviewing relevant investigations. Good communication at handover is essential. The operating surgeon remains responsible (and liable) for surgery and must reassure himself/herself that the appropriate procedure is performed for the correct indications.

Omental extrusion

A 25-year-old patient underwent an emergency laparoscopic appendicectomy. During the procedure, it was noted that the appendix was perforated and there was purulent fluid in the pelvis. A 24F Robinson drain was inserted and placed through the suprapubic port into the right iliac fossa. The patient recovered well and the drain was removed on the ward two days postoperatively.

When the drain was retrieved, a large part of the omentum extruded from the wound with the drain.

The patient was returned to theatre for omentectomy and re-laparoscopy. On inspection, the omentum had been pulled out of the abdominal cavity because 4cm of the omentum was stuck firmly in the lumen of the distal drain.

After discharge from hospital, the patient was readmitted with hospital-acquired pneumonia that necessitated CT PA and CT abdomen and pelvis.

Necessity for a second general anaesthetic may well have contributed to this further complication, re-admission and radiation exposure.

Reporter’s comments

A smaller drain might have prevented the omentum from becoming stuck in the lumen, although this problem is recognised with all suction drains. When a drain is placed during laparoscopic surgery, if a clip is not applied to the end, the positive-pressure pneumoperitoneum will vent out of the drain, potentially entrapping the omentum or even the bowel in the drain lumen. Over a period of several days, this tissue becomes oedematous, complicating drain removal, as shown above.

An appropriately sized drain should be selected for each case. When inserting a drain in the presence of a pneumoperitoneum, care must be taken to prevent entraining of intra-abdominal contents into the lumen by clipping the end of the drain to prevent venting.

CORESS comments

Use of drains for abdominal surgery remains a matter for debate. Ensuring that all gas is adequately vented at the end of laparoscopic surgery should reduce the risk of forcible entrapment of peritoneal contents within a drain. The drain should be the smallest required to do the job effectively. Use of suction drains should be avoided in the abdomen.

Delayed healing due to retained GranuFoam in negative-pressure (VAC) therapy

A 72-year-old diabetic male with a BMI of 39 kg/ m2 underwent laparotomy and bowel resection for perforated diverticulitis. On the seventh day postoperatively, the cephalic section of his abdominal wound started to discharge purulent fluid and a superficial wound infection was diagnosed. He was started on antibiotics, but the wound broke down.

A cavity of approximately 10cm developed and negative pressure (VAC) therapy was employed to manage exudation, encourage granulation and expedite healing.

GranuFoamTM was used with the VAC system and, after several dressing changes, the patient was discharged home for his wound to be managed with VAC by the district nursing team.

The wound reduced in depth and developed granulation tissue. After six weeks, VAC was discontinued, a surface dressing was applied to encourage epithelialisation and the patient was discharged to primary care.

He was referred back to the tissue viability nursing team nine months later with a chronic abdominal sinus.

The surgeon responsible for the original procedure reviewed the patient and re-explored the wound. At re-operation, a 2cm piece of foam dressing was found incorporated within the granulation tissue, which had prevented the wound from healing fully.

Reporter’s comments

It became apparent that it was not common practice to document the number of foam pieces packed into a cavity during negative-pressure wound changes. It was also uncommon to count them out again. Dressing changes were rarely performed by the same clinician. To prevent this incident from occurring again, foam dressings that are cut to shape and do not dissolve should be documented in the clinical records to prevent retention of a foreign object that will cause infection. This may require changes in routine practice.

The wound subsequently healed completely, nearly one year after the original emergency surgery.

CORESS comments

This case raises awareness that foreign objects can prevent wound healing. Foam dressings should be designed to function with the appropriate VAC system, and all foreign materials should be removed to aid healing in such circumstances. Wounds should be carefully inspected to ensure that this has taken place.

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

rcsed.ac.uk | 11

AGENDA

The latest guidelines, articles and studies

IN BRIEF Meta-analysis of negativepressure wound therapy for closed surgical incisions

This systematic review evaluated 10 studies including 1,089 patients comparing negative-pressure wound therapy (NPWT) with standard postoperative dressings on closed surgical incisions. NPWT was associated with a significant reduction in wound infection (relative risk (RR) 0.54) and seroma formation (RR 0.48) compared with standard care. There was heterogeneity between the included studies. Authors concluded that NPWT reduced the rate of wound infection and seroma when applied to closed surgical wounds.

Hyldig N, Birke-Sorensen H, Kruse M et al. Br J Surg 2016; 103: 477–486

Mortality from trauma haemorrhage and opportunities for improvement in transfusion practice

This prospective observational study from 22 UK hospitals evaluated patterns of blood use and outcomes of major haemorrhage in trauma. A total of 442 patients were identified who received at least four units of packed red blood cells (PRBCs) in the first 24 hours of admission.

The national incidence of trauma haemorrhage was estimated to be 83 per million. At 24 hours, 79 patients (17.9%) had died. Patients who received a ratio of fresh frozen plasma to PRBCs of at least 1:2 had lower rates of death. Delays in the administration of blood were identified.

Authors concluded that research is required to understand the reasons for death after trauma and barriers to timely transfusion support.

Stanworth SJ, Davenport R, Curry N et al.

Br J Surg 2016; 103: 357–365

12 | Surgeons’ News | June 2016

Randomised trial of stent versus surgery for asymptomatic carotid stenosis

This trial randomised 1,453 asymptomatic patients with severe carotid stenosis who were not considered high risk for surgery to carotid-artery stenting with embolic protection or carotid endarterectomy. Stenting was noninferior to endarterectomy with regard to the primary composite end point (death, stroke or myocardial infarction within 30 days, or ipsilateral stroke within one year).

The cumulative five-year rate of strokefree survival was 93.1% in the stenting group and 94.7% in the endarterectomy group. Authors concluded that stenting was noninferior to endarterectomy in this patient group.

Rosenfield K, Matsumura JS, Chaturvedi S et al.; ACT I Investigators. N Engl J Med 2016; 374: 1011–1020

Prevention of incisional hernias by prophylactic meshaugmented reinforcement of midline laparotomies for abdominal aortic aneurysm treatment

This multicentre trial randomised 120 patients undergoing elective repair of an abdominal aortic aneurysm through a midline laparotomy to retromuscular mesh-

Guidance for adrenal surgery in the UK This combined practice guidance provides recommendations for the multidisciplinary assessment and care of patients undergoing adrenal surgery in the UK. British Association of Endocrine & Thyroid Surgeons 2016

augmented reinforcement or standard closure. The incidence of incisional hernias at two-year follow-up after conventional closure was 28% versus 0% after meshaugmented reinforcement (P < 0.0001).

No adverse effect related to mesh reinforcement was observed, apart from an increased time to close the abdominal wall of 16 minutes.

Authors concluded that prophylactic retromuscular mesh-augmented reinforcement of a midline laparotomy in patients with an abdominal aortic aneurysm is safe and effectively prevents the development of incisional hernia during two years.

Muysoms F, Detry O, Vierendeels T et al.

Ann Surg 2016; 263: 638–645

Return to work and functional outcomes after major trauma: who recovers, when, and how well?

Adult major trauma survivors injured between July 2007 and June 2012 in Victoria, Australia, were followed up at six, 12 and 24 months after injury to measure function (Glasgow Outcome Scale – Extended) and return to work/ study. Of the 8,844 survivors, 23% had achieved a good functional recovery, and 70% had returned to work/study at 24 months. The adjusted odds of reporting better function at 12 months was 27% higher compared with six months. The adjusted relative risk of returning to work was 14% higher at 12 months compared with six months.

Authors concluded that although there was improvement in outcomes over the study period, ongoing disability was common at 24 months, providing valuable information for prognostication and service planning.

Gabbe BJ, Simpson PM, Harrison JE et al.

Ann Surg 2016; 263: 623–632.

AGENDA

TAKING PATIENT CARE TO PARLIAMENT

“Amendment One agreed to” – four words that speak volumes about the increasing influence of the College at Westminster. Andrew Mullinex explains

W

Andrew Mullinex Senior Policy and Public Affairs Officer, the Royal College of Surgeons of Edinburgh

hile Westminster is noted for its grand oratory and debates, the prosaic reality is that most of parliament’s work relies on the somewhat unglamorous and drawn-out process of legislative amendments and parliamentary procedures. So you could be forgiven for underestimating the significance of the Deputy Speaker’s announcement to the House of Commons on 29 January “that Amendment One (had been) agreed to”. However, this simple phrase marked a significant victory for the College’s campaign to protect patient safety.

During the previous two years, the RCSEd led a broad coalition of medical research organisations, patient safety groups and Royal Colleges in opposing what we identified as the potentially dangerous Medical Innovation Bill and subsequent Access to Medical Treatments [Innovation] Bill.

Both bills were based on the false assertion that litigation, or fear of it, has deterred doctors from innovation or straying from standard medical practice.

Thanks in no small part to a highly effective PR campaign, a large number of peers and MPs accepted this fundamental misconception as truth. Having identified problems at a very early stage, the College began articulating the problems with the bills and convincing others to work with us in a coordinated campaign.

After surveying our membership, we found little or no evidence that medical professionals were being

While it will have gone widely unnoticed, the defeat of these provisions was a major victory in the interests of patient safety

deterred from innovating. Therefore, we argued that the current framework for medical innovation, especially the safeguards provided in case law, were clear, widely understood and would be undermined if either bill was passed.

We contacted a range of parliamentarians expressing our concerns and providing them with briefings.

Critically, we also managed the work of a number of relevant organisations, convincing them to join us and ensuring our efforts had the largest possible impact.

The result was the vetoing of the Medical Innovation Bill by the Liberal Democrats as part of the coalition government, with our reservations cited as reasons why the bill was unnecessary.

However, as the bill returned in an amended form in the guise of Chris Heaton-Harris’ Access to Medical Treatments [Innovation] Bill, which had tacit government support, we redoubled our efforts. We worked particularly closely with the Royal College of Pathologists, the Royal College of Paediatrics and Children’s Health, the Medical Protection Society, the BMA and the Patients Association. We also built relationships with backbench MPs from all parties who became advocates for our position.

It was sustained pressure from this group, but in particular the small number of Royal Colleges, that helped ensure that the provisions were dropped once and for all. Indeed, our opposition was cited as the reason for the U-turn.

While it will have gone widely unnoticed, the defeat of these provisions was a major victory in the interests of patient safety. It was also a significant milestone for the College as we look to increase our influence at Westminster. It is easy to underestimate the regard that Westminster has for the Royal Colleges and the recommendations we make. However, we will continue our work in Westminster on behalf of our membership and their patients. rcsed.ac.uk | 13

AGENDA

Krishna Sethia gives feedback during a training workshop

The College is working with stakeholders on an ambitious project to improve training and patient care in Myanmar

DEDICATED TO DEVELOPMENT Professor Krishna Sethia Member of the College’s Myanmar THET project team

I

n November last year, while Myanmar prepared for its first democratic elections in almost 50 years, members of the College’s Myanmar project were returning from a two-week visit to Yangon. Using urology as a pilot specialty, they had started a project designed to assess the feasibility of a new surgical curriculum in Myanmar, and give local surgeons the skills to embed new methods for training and assessment into everyday practice.

The visit began with discussions about the detail of a new curriculum that has been enthusiastically embraced by government, universities and senior consultants. This curriculum will form the basis of a new master’s degree, which will equip trainees to manage the full range of clinical urology with special emphasis on common local diseases. The College’s team was encouraged by local trainers to create a structure for clinical teaching and to include the teaching of non-technical surgical skills throughout the three years of specialist training.

The highlights were a two-day trainer development workshop and meetings with all of Myanmar’s urological trainees. Given the huge workload of the very small number of consultant urologists, there was understandable concern about finding time to deliver

With most of Myanmar’s population having limited or no access to medical care and a population-to-consultant ratio of more than 50 times that of the UK, the challenges for medicine in Myanmar are gargantuan 14 | Surgeons’ News | June 2016

Project leaders Kyaw Zaw Hlaing (Myanmar) and David Tolley (RCSEd) with Win Myaing (President of the Myanmar Nephrourology Society)

improved education and assessment. However, the consultants soon realised the potential advantages of formalising educational activities, most of which were already being performed.

At the end of the visit, all of the centres committed to designate educational supervisors and undertake workplace-based assessments. They also acknowledged the value of individual units holding regular mortality and morbidity meetings. The trainee sessions concentrated on introducing the e-logbook and portfolio and workplacebased assessments. They were supported by members of the team who stayed on for the second week to conduct trial assessments and ensure there was a good understanding of how to develop individual portfolios.

It was obvious that others would be interested in similar training, and the subsequent College visit in February 2016 included general surgeons in the training workshops. Further exposure of trainees to qualityimprovement activities will take place when six of them pay an eight-week visit to urology departments in the UK later this year.

With most of Myanmar’s population having limited or no access to medical care and the population-toconsultant ratio of more than 50 times that of the UK, the challenges for medicine in Myanmar are gargantuan.

However, the doctors we met displayed not only a strong desire to improve training and standards of care, but also endless cheerfulness and optimism.

Their hospitality was overwhelming. The College team left Myanmar feeling truly optimistic that real change is just around the corner.

The College’s curriculum development project is being supported by a grant from the Tropical Healthcare Education Trust (thet.org)

TEAM PLAYERS The College has launched the Faculty of Perioperative Care in recognition of the vital role of the wider surgical workforce

T

he College has a record of being at the forefront when it comes to recognising the role of the whole surgical team and the importance of maintaining surgical standards to improve patient safety. The latest development in this area came in March with the launch of our Faculty of Perioperative Care (FPC) to provide recognition and support for perioperative practitioners through high-quality education, training and standards setting.

The term perioperative practitioner refers to all nonmedical members of the wider surgical team. However, non-medical surgical assistance can now be provided by surgical care practitioners, who carry out supervised, delegated surgical interventions, and the surgical first assistant, who assists under direct supervision.

An important milestone on the road to the launch of the FPC was the Collegeâ&#x20AC;&#x2122;s joint conference with the Association for Perioperative Practice (AfPP) in October 2015. At the event, 95% of delegates (both surgeons and non-medical surgical assistants) gave their backing for the launch of a faculty that could deliver the educational requirements, training and standards for these practitioners.

Our wider partnership with the AfPP has helped us to identify and understand the professional requirements of perioperative team members, and thereâ&#x20AC;&#x2122;s a further joint conference planned for this October to address

Charles Auld FPC Lead and RCSEd Council member

The first courses from the FPC are running in May and June fpc.rcsed. ac.uk

standards for perioperative practice. Although continuing professional development and revalidation are compulsory, a survey showed that 43% of nurses have to make a financial contribution to their attendance at courses, with 10% paying the full fee.

Although the College is developing its own database, there is no official database of surgical care practitioners working within the UK. The situation is complicated by a variety of job titles being assigned to this group who can perform surgical interventions. A further concern is the lack of statutory regulation of these practitioners.

Over the coming months and years, as our new faculty develops, we hope to help remedy some of these issues by bespoke education and training, setting robust professional standards, and continuing to work with our partners.

Although CPD and revalidation are compulsory, a survey showed that 43% of nurses have to make a financial contribution to their attendance at courses, with 10% paying the full fee

Perioperative perspective Dawn Stott on working with the College to develop the new faculty

Dawn Stott CEO of the AfPP

As many clinical professionals will be aware, it is now well established that the traditional surgical workforce has changed.

Non-medical practitioners are an integral part of the surgical team in many of the specialties and the importance of their roles should be recognised.

The RCSEd and AfPP worked collaboratively to research the need for a Faculty of Perioperative

Care (FPC), which the RCSEd was able to launch in March.

The AfPP continues to work in partnership with the College on the development of the faculty. The ethos of the faculty is to develop and promote standards for these

practitioners for the benefit of patients.

While AfPP provides a great support mechanism for all perioperative practitioners, the FPC will offer tailored courses for non-medical surgical assistants working within the wider surgical team. These courses, developed by surgeons with perioperative practitioners in mind, will support the ongoing team approach.

rcsed.ac.uk | 15

AGENDA

DELIVER FROM A DISTANCE Ewen Harrison argues that all surgeons require serious academic skills and that distancelearning programmes deliver these and more

I Ewen Harrison Clinical Senior Lecturer and Honorary Consultant Surgeon at the University of Edinburgh

t wasn’t long ago that a postgraduate research degree was considered a de facto requirement for progression to higher surgical training programmes.

There existed a well-trodden route for the aspiring surgeon: basic training for two years, a postgraduate research degree for two more, then a bit of anxious treading of water until that long-desired appointment to higher surgical training and a big sigh of relief. The research was a welcome pause in the action for some and a painful rite of passage for others. Painful because for those not on the road to an academic appointment, research was often seen as an unnecessary distraction from the business of becoming a surgeon.

A higher degree is no longer a requirement for recruitment to higher surgical training (if it ever was), yet the selection process for ST3 appointments rightly weights traditional academic achievement: portfolio 20%, teaching 15%, academic 10% and audit station 5%.

I say rightly because whether one is directly involved in research or not, the skills traditionally associated with ‘academia’ are now required by all surgeons in the care of patients with complex problems. Trainees recognise this. More are taking voluntary time out of specialty training for research, and many are enrolling in distance-learning higher-degree programmes such as those offered jointly by the University of Edinburgh and the RCSEd.

Perhaps one proficiency that surpasses all others is the capacity to determine how evidence applies to one’s own practice and how it can be implemented 16 | Surgeons’ News | June 2016

The ‘academic toolbox’ of skills needed to practise evidence-based surgery requires development as a trainee so its use becomes instinctive. Take an example from my own specialty of liver surgery. Determining the best course of action for a patient with colorectal liver metastases requires a subtle understanding of the interplay between cancer biology, patient co-morbidity, liver regeneration and the effects of chemotherapy before any technical considerations of whether the lumps can be cut out or not.

Management decisions such as these are common to all surgical specialties and require a sophisticated appreciation of concepts from basic science, critical appraisal, study design, meta-analysis, statistics, surgical outcomes, implementation science and so on. Perhaps one proficiency that surpasses all others is the capacity to determine how evidence applies to one’s own practice and how it can be implemented.

A basic science research degree is not required to develop these skills. In any case, other disciplines have come to the fore – clinical and outcomes research, education, global health, and quality improvement/ implementation. These disciplines are important because of their day-to-day relevance to patient care.

The vacuum in training left by the departure of the research-MD-for-all is being filled in part by the phenomenally successful Masters in Surgery (ChM) online distance-learning programmes. These deliver Fellowship-level clinical components in specialty areas supplemented by core and specialist academic skills,

2007 Launch of

MSc Surgical Sciences

2011 Launch of

Global reach 2007

2015

Since 2007, the distancelearning programmes have spread around the world

ChM General Surgery

2012 Launch of

ChM Trauma & Orthopaedics

2013

Launch of ChM Vascular and Endovascular

2014

brought together with a clinically relevant dissertation research project.

These higher-level degrees are to be distinguished from the MSc programmes taken at the MRCS stage.

Since the programmes began, almost 300 students have registered across five specialty areas: general surgery, trauma and orthopaedics, urology, vascular/endovascular, and clinical ophthalmology. Online discussion boards emulate the day-to-day professional deliberations between consultants and can fit around clinical jobs.

Geography is not a barrier, with ChM programmes including students from more than 40 countries. The Royal Australasian College of Surgeons accredited both the MSc and ChM (General Surgery) courses and Australasian surgical trainees are now prominent on both. Competencies beyond those of the curriculum are emphasised – for instance, non-technical skills and the importance of cultivating a reflective practice.

Students like this form of learning. It has been described as ‘intense, competitive and comprehensive’, requiring ‘consultant-level critical thinking and judgement’ and ‘encouraging concise articulation of patient evaluation,

management and operative techniques’. The academic skills that are developed in these programmes are put into practice. Many students have taken up the opportunity to become involved in meaningful international research through the GlobalSurg collaborative projects (globalsurg.org). This worldwide surgical research movement encourages junior clinicians to get stuck in and collect data from the patients being treated in their own surgical departments.

The practical distinction of academic surgery is now less relevant. We need to equip individuals with the skills a practising surgeon needs to understand and generate the evidence required for everyday surgical practice.

I describe nothing less than the democratisation of surgical research in which each individual’s contribution is meaningful. Distance-learning programmes are a vehicle by which we can deliver the required clinical knowledge while nurturing a culture of evidence-based surgery by teaching the transferable academic skills required by all surgeons.

Launch of MSc in Primary Care Ophthalmology

2015 Launch of

ChM in Clinical Ophthalmology

60 countries to date in total

essq.rcsed.ac.uk rcsed.ac.uk | 17

HISTORY OF NEUROSURGERY

‘A MOST SATISFACTORY RESULT’ Richard Ramsden details the first time an acoustic neuroma was removed, by Thomas Annandale, and hailed as a rare surgical success

Thomas Annandale: Regius Professor from 1877

18 | Surgeons’ News | June 2016

Watercolour of the brain from a later manuscript copy of Sir Charles Bell’s The Anatomy of the Brain

A WELLCOME LIBRARY, LONDON

Richard Ramsden MBE Professor of Otolaryn– gology in Manchester, 1977–2014

coustic neuromas (vestibular schwannomas) are benign tumours.

They arise from the myelin sheath of the vestibular part of the eighth cranial nerve as it courses through the internal auditory meatus from the inner ear to the brainstem.

Deafness, tinnitus and some degree of imbalance are the usual first symptoms. They cause widening of the meatus and, untreated, grow in a medial direction into the cerebellopontine angle, eventually involving other cranial nerves, most commonly the facial and trigeminal, and ultimately the brainstem.

Raised intracranial pressure and death may ensue if the tumour is not removed. The intracranial component is usually spherical with the ‘tail’ of the tumour in the internal meatus. They are encapsulated in a layer of arachnoid and have no dural attachment. Gelatinous in texture, they often have an associated cystic component.

They occur in one in 80,000 of the population per year, meaning they are uncommon, but not rare. These days, acoustic neuromas are removed routinely in dedicated units by teams comprising a neurosurgeon and a neurootologist. The perioperative mortality is less than 1% and serious morbidity is of the same order. However, this was not always the case.

Towards the end of the 19th century, advances in neuroanatomy and pathology enabled surgeons to make

Towards the end of the 19th century, surgeons could estimate the location of an intracranial lesion a reasonably accurate estimate of the location of an intracranial lesion. One of the greatest contributors to this knowledge was Sir Charles Bell, who created detailed clinical pictures and subsequent postmortem drawings of a patient with an acoustic neuroma.

Encouraged by these advances, surgeons in Europe and North America were able to diagnose lesions of the posterior fossa with increasing accuracy and were emboldened to attempt to remove these tumours. The patients all died either on the table or in the immediate postoperative period. The cause of death was usually vascular – catastrophic haemorrhage from the anterior inferior cerebellar artery or brainstem infarction from damage to that and other vessels. Harvey Cushing was later to compare the cerebellopontine angle to the ‘bloody angle’ at the Battle of Gettysburg. It was after World War II that the importance of the blood supply to the brainstem was fully realised.

For more than a century, neurosurgical and otological literature has universally given credit for the first rcsed.ac.uk | 19

HISTORY OF NEUROSURGERY

successful removal of an acoustic neuroma to Sir Charles Ballance in 1894. Ballance, founder of the Society of British Neurological Surgeons, worked in London at St Thomas’s Hospital and at Queen Square. Specialising in both otology and neurosurgery, he made immense contributions in both fields. It was Harvey Cushing, in his monograph, who drew the conclusion Ballance’s case was a meningioma because it was broad-based and attached to the posterior surface of the petrous bone. Ballance’s original paper included his hand-drawn operative sketch, which

Thomas Annandale studied in Edinburgh. Like all general surgeons of the day, he could turn his hand to anything

shows the tumour to be broad-based and attached to the posterior surface of the petrous bone. The internal meatus is not widened and does not contain a tumour.

Ballance describes it as “a solid tumour found attached to dura over inner part of posterior surface of petrous – somewhat firmly fixed”. Despite having read extensively around this subject over the years, I have never seen this sketch reproduced in any publication. In Cushing’s view, the accolade of first removal of an acoustic neuroma should go to Edinburgh surgeon Thomas Annandale in 1895.

Annandale, from Newcastle upon Tyne, studied medicine in Edinburgh, where he eventually succeeded Joseph Lister as Regius Professor in 1877. Like all general surgeons of the day, he could turn his hand to anything, although most of his practice seems to have been orthopaedic. His famous case, described by G A Gibson (1896, Assistant Physician at Edinburgh Royal Infirmary) and Dr J Purves Stewart (1895, Resident Physician), was

FURTHER READING Ballance C. Some points in the surgery of the brain and its membranes.

London, Macmillan & Company; 1907; 276–282 Bell C. The nervous system of the human body.

Embracing the papers delivered to the Royal Society on the subject of nerves. Longman Rees Orme Brown and Green, London; 1830; 112–114 Cushing H. Tumours of the Nervus Acousticus and the Syndrome of the Cerebellopontile Angle. Haffner Publishing Company New York; 1917 (reprinted in 1963) Gibson GA. Remarks on the results of surgical measures in a series of cerebral cases. Ed Med J 1896; 41: 689–692 Stewart JP. A contribution to the localization of cerebellar lesions.

Edinburgh Hospital Report 1895; 3: 447–453

Ballance’s sketch of a case showing features typical of a petrous meningioma. The tumour has a broad-based attachment to the petrous bone, and the internal meatus is not widened and is free of tumour

20 | Surgeons’ News | June 2016

9 Tay Square, Dundee.

18 November 1895 My dear Dr Gibson, I have just received your kind note about Mrs K. I delivered her of a healthy girl about 3 weeks ago after a perfectly easy and normal labour.

She made an excellent recovery and is now very well. Had it not been for this she would have been across to report herself and no doubt will do so when she can.

She walks quite well now, speaks as she used to, and has no headache or giddiness. There is still a little nystagmus and over the site of the operation a painless fluctuating swelling still remains.

In all respects it has been a most satisfactory result.

With kind regards, believe me, very sincerely yours, James H.W. Laing

A letter from Isabella’s GP. Gibson’s response was far from complacent. He felt that if the operation had been carried out sooner “we might have even got rid of the slight nystagmus still present”

of Isabella K. Aged 25 and four-months pregnant, she was referred by her general practitioner, Dr Laing of 9 Tay Square, Dundee, with a 10-month history of frontal headache, giddiness and difficulty in walking. She was unable to hear the ticking of a watch in her right ear or a tuning fork placed on the vertex. Examination of the eyes revealed optic neuritis (papilloedema) and both horizontal and vertical nystagmus. There was dilation of the left (contralateral) pupil, palatal weakness with regurgitation of fluids through the nose and changes in her voice. She had exaggerated tendon reflexes on both sides and ankle clonus. Her gait was broad-based and she had a tendency to fall to the right side especially if standing with her feet together and her eyes closed.

From the clinical description of the case, the mass Annandale removed was most certainly a vestibular schwannoma This strong clinical evidence of a large lesion of the posterior fossa led Dr Purves Stewart to observe “the labyrinthine deafness would be consistent with a lesion either of an auditory pathway in the cerebellum, or in the auditory nucleus or nerve itself”. She was admitted to Ward 25 under Dr Purves Stewart. The differential diagnosis was tumour, gumma or tuberculoma. Treatment was commenced with the antisyphilitic potassium iodide (her husband was a sailor absent for protracted periods in distant parts of the world) and inunction of the head with blue ointment over the right cerebellar hemisphere and the left frontal region. When this proved ineffective and Isabella began vomiting with increasing frequency, she was referred to Professor Annandale “with a view to surgical interference”.

On 3 May 1895, Annandale trephined the skull over the right lobe of the cerebellum and removed a tumour the size of a pigeon’s egg from “the lateral lobe of the cerebellum”. On opening into the mass, a drachm of clear serous fluid escaped. Within the cyst was found a solid tumour apparently encapsulated.

The mass was removed completely in pieces. Microscopic investigation showed it to be of the nature of a fibrosarcoma (at the time a rather imprecise term used widely to describe any benign cellular tumour) but from the clinical description of the case it was a vestibular schwannoma.

Postoperatively, progress was “eminently satisfactory”.

Her headache was immediately better, her sickness ceased and her nystagmus settled almost completely.

Swallowing became functional, even for fluids. Her gait improved and her optic neuritis almost disappeared.

Surprisingly, there is no mention in the clinical record of the postoperative function of the facial nerve. It is hard to imagine that it remained intact and it may just be that in 1895 a facial paralysis was not regarded as much of a price to pay for successful removal of an intracranial tumour.

Subsequent surgical series from both sides of the Atlantic in the early years of the 20th century reported apocalyptic perioperative mortality rates of over 80%. The author could find no reference in the literature to any further sorties into the cerebellopontine angle by Annandale. rcsed.ac.uk | 21

ETHICON FELLOWSHIP

Graeme Carlile reports on his travelling paediatric orthopaedic Fellowships at the Starship in New Zealand and Westmead in Australia

ANTIPODEAN ADVENTURES

I

nternational Fellowships in any specialty give surgeons a unique opportunity to experience different healthcare settings, patient presentations and pathologies, as well as to exchange ideas and learn from colleagues in other regions. For trainees, Fellowships can be seen as a stepping stone towards consultant practice – a ‘surgical finishing school’. Professionally, Fellowships enable individuals to expand their networks; personally, they are an unforgettable adventure.

Starship Children’s Hospital is located in central Auckland as a standalone facility from the neighbouring Auckland City Hospital. ‘The Starship’, as it is referred to, is a quaternary referral centre and treats children with complex medical and surgical needs from across New Zealand and the neighbouring Pacific Islands. It is a culturally diverse ‘super city’, with one of the largest populations of people from Polynesian descent outside of the islands themselves. There is a much higher incidence of osteomyelitis, septic arthritis, discitis, severe club foot and slipped capital femoral epiphysis than in the UK. In addition, given paediatric fractures are directly proportional to daylight hours, a growing problem of childhood obesity in New Zealand and the general Kiwi philosophy of ‘100% or nothing’ (even in kids), Starship also sees its fair share of high-energy paediatric trauma.

Especially to the elbow!

General orthopaedic trainees in the UK can expect to treat, on average, 12 supracondylars throughout their five years of training (based on e-logbook statistics). In my first month at Starship, I took 12 supracondylar fractures to theatre for closed/open reduction and K-wiring. Of those 12, my first supracondylar on Fellowship was open and 10 were offended (Gartland) grade threes. For any surgeon, these are difficult cases. By the end of my six-month Fellowship, I had operated on more than 50 paediatric elbow fractures, which apparently is the average number a Fellow can expect to perform.

By the end of my six-month Fellowship, I had operated on more than 50 paediatric elbow fractures 22 | Surgeons’ News | June 2016

The Fellowship provides comprehensive exposure to paediatric trauma, infection and general orthopaedics.

There are typically two general Fellows from around the world, plus a spine Fellow. The general Fellows are seen as ‘junior consultants’ and so are expected to manage trauma at consultant level from the beginning of the Fellowship with supervision ‘as required’. Electively, lists are conducted in the presence of a consultant scrubbed in theatre. At no time did we ever feel unsupported. The balance between supervised and unsupervised operating was appropriate for that stage in training – that is, preparing to become a consultant. On a day-to-day basis, the Fellows led the team in reviewing the previous day’s admissions prior to consultant rounds, constructing management plans, arranging departmental junior cover, emergency theatre lists and operating.

Starship sees an unparalleled array of disease. During my six months, I worked directly for two consultants who, in addition to general paediatric orthopaedics, had a specialist practice comprising the paediatric upper limb and sports medicine, respectively. The upper-limb work was of particular interest, dealing with everything from obstetric brachial plexus palsy to the arthrogrypotic elbow, contractures in cerebral palsy, congenital forearm deformities and paediatric hand injuries. There are few Fellowships that offer this level of exposure to the paediatric upper limb. I recorded 362 procedures in six months (187 trauma cases and 175 elective).

Starship is an excellent unit and provides Fellows with comprehensive exposure to all aspects of paediatric orthopaedic surgery. It also has a strong academic teaching programme consisting of MDTs and tutorials.

AND SO TO WESTMEAD Moving on to Sydney, we chose to live 30 minutes outside of Darling Harbour at the Olympic Park, which is a 20-minute drive from the hospital. This was also partly because of the on-call commitment at Westmead Children’s Hospital. The Fellows are typically on call starting on Friday and finishing on Monday (at 5pm), one in eight weekends. There is also no SHO/CT, so the on-call doctor covers the emergency department and theatres as well as doing the daily morning ward round. Other hospitals around Sydney will take some paediatric trauma cases, but

Graeme Carlile at Starship Children’s Hospital

Westmead remains the largest children’s tertiary centre.

Add to this the possibility of also being on call for paediatric spines and hands, and it can get very busy, very quickly.

Westmead’s setup is very different to Starship’s. Rather than generalists with a specialist interest, electively the consultants have their own dedicated specialist areas. As such, Westmead handles an array of complex specialist work. Again, the two international general Fellows are expected to run the department’s day-to-day activities, including coordinating trauma cases and ensuring there is enough cover for the numerous clinics. It is not unusual for the daily fracture clinics to hit 70 patients and have a clinic of 40 children with complex hip problems. In addition, there is a strong daily academic programme and research emphasis headed by Professor David Little.

The paediatric hip clinic offers unparalleled exposure to DDH, Perthes and slipped capital femoral epiphysis, something for which the unit has become a leading world centre. Together with Dr Oliver Birke, Professor Little has performed more than 100 surgical hip dislocations for patients presenting with acute and chronic slips. This is a technically demanding and high-stakes procedure for which they have developed techniques to improve patient safety by monitoring perfusion of the femoral head. As evidenced by their published outcomes, they have achieved enviable results. In addition, Professor Little, a world expert in the basic science and clinical management of Perthes disease, has introduced both innovative nonsurgical and operative strategies for this challenging condition, including bisphosphonates, steroids and developing reconstructive options around the hip.

Professor Little is one of the hardest-working clinical and academic surgeons I have met. He did his PhD as a fulltime clinician and now heads his own laboratory. He has a brilliant mind and takes on a complex workload, which also includes limb reconstruction using frames and revision surgery for OI. He has an excellent sense of humour.

I was also fortunate to spend time working for Dr Michael Bellemore. He has been a consultant for more than 30 years and was previously Robert Salter’s Fellow. He is also good friends with Dror Paley and John Herzenberg, who he has visited frequently to learn the latest advances in limb lengthening. Dr Bellemore’s practice consists largely of general paediatric, limb reconstruction and DDH. He is an excellent trainer in terms of his vast knowledge and experience, and also in theatre taking trainees through operative cases. He has the busiest clinical caseload in terms of DDH of all consultants and, as such, I was fortunate to gain hands-on experience, particularly with open reductions and pelvic osteotomies.

In some ways, the Fellowship at Westmead has so much on offer it can be difficult to cram it all in. I was operating on a daily basis, logging 686 cases in a year: 410 elective and 276 trauma. The workload is heavy and the Fellow is expected to take on a leadership/management role in addition to clinical duties, but it is well worth it to experience the Aussie way of life and live in a fantastic city.

Graeme Carlile Consultant Paediatric Orthopaedic Surgeon, Norfolk & Norwich NHS FT and Ipswich Hospital Trust rcsed.ac.uk | 23

INTERVIEW

FST speaks to Touch Surgery’s Andre Chow about what the groundbreaking app means for both trainees and trainers

MOBILE THEATRE

WHAT IS TOUCH SURGERY?

Essentially, it’s a completely mobile-based platform that empowers and connects the global surgical community, enabling surgeons to learn and rehearse steps of an operation before picking up a scalpel. Because it’s on a mobile platform, it’s very scalable: it has the potential to reach every surgical trainee on the planet and they can carry it with them. Our ultimate aim is to improve the delivery of surgical care around the world.

WHEN AND HOW DID TOUCH SURGERY COME INTO BEING? My co-founder, Jean Nehme, and I were both surgical trainees in London and we started Touch Surgery about five years ago to address a need we experienced every day. There are so many things getting in the way of surgical training, be it the increasing need for service provision, working time directives and so on. Essentially, however, surgical trainees worry that they’re not getting into the operating room enough.

When they do get access, they often find it difficult to make the most of the experience because there’s not been enough preparation, formal training or assessment before that point.

What we planned to do with Touch Surgery was build a platform that could help ready surgeons for the operating room, and therefore help to improve patient safety and care. Looking through the literature, we found there was a separation of surgical skill into technical and cognitive skills. Jean had just finished an MSc in surgical simulation and we realised that most training tools focus on the technical aspects of surgery. This meant there wasn’t a tool that concentrated on making sure surgeons understood steps and procedures or complications.

WHO IS IT AIMED AT? Over the last decade, new areas of surgery have developed and consultants continue to improve their techniques and learn from their colleagues. Even experienced surgeons need to keep learning and improving to be the best for their patients. Depending on what content we put on it, our platform can be applicable to the entire spectrum of surgeons.

WHAT WERE THE MAIN CHALLENGES IN STARTING UP? There were many technical challenges associated with two surgeons doing the initial coding. Then there was the hurdle of growing a team. From a personal point of view, the decision to leave clinical training and pursue this on a full-time basis was a big challenge.

24 | Surgeons’ News | June 2016

WAS THERE MUCH COMPETITION WHEN TOUCH SURGERY LAUNCHED?

There are a lot of surgical training tools and some of them are very good, but there aren’t any major competitors that do exactly what we do. That’s partly because it’s actually quite difficult to do. Building a product for the medical community takes a lot of medical input, and sometimes it takes people from within the profession to come out to build this sort of technology.

HOW HAS THE TEAM DEVELOPED? We like to call it our own multi-disciplinary team. We knew that the visual effects and the 3D models were very important so we recruited people who had worked at places such as Pixar in California and major movie houses such as Framestore and Double Negative. They had worked on films such as Gravity, Avatar, Dark Knight and the Harry Potter series. We realised we needed experts in gaming and interactions, so we hired game developers, designers and graphic engineers.

HOW DO YOU FIRST BUILD AWARENESS OF THE PRODUCT? Initially we didn’t spend anything on marketing – we just built a product, put it out there and let it spread by word of mouth. A few peer-reviewed articles have been published that validate the platform from an academic perspective. More and more institutions, such as the RCSEd, have taken an interest and endorsed the platform. For example, a number of residency programmes in the US, including at Harvard and Johns Hopkins, are using our platform as part of their formalised training programmes.

WILL SIMULATION REMAIN SOMETHING THAT PEOPLE DO IN THEIR OWN TIME? There are institutions with brilliant facilities, but they are often only available to staff. Then there are hospitals that would like to have a sim centre, but cost is a barrier.

Very-low-fidelity simulators still cost thousands of pounds, and really expensive haptic feedback simulators cost hundreds of thousands of pounds. On top of that, a physical space is needed and staff to support that service.

On visits to the US we found that facilities are often underutilised because people are expected to use them in their own time. Those who want to use the laboratory after they finish work might find it’s closed in the evening. We wanted to provide a platform that people can use wherever they are.

Because it’s on the mobile platform, it doesn’t limit who can access it, so if you’re at Harvard, if you’re at Imperial, if you’re training in India or in China, you could

Andre Chow General surgical trainee from London who co-founded Touch Surgery with colleague Jean Nehme

Touch Surgery helps trainees learn procedures wherever they are

What we planned to do with Touch Surgery was build a platform that could help ready surgeons for the operating room and, therefore, help to improve patient safety

commonly go wrong, and so on. It represents a new wave of data and can be a revelation to them.

HOW DO TRAINEES FEEL ABOUT BEING MONITORED IN THAT WAY?

still access the programme. One of the aims of Touch Surgery is to connect that global surgical community around better training and education. We could have an impact on training in developing countries. For example, we’re currently working with Harvard’s Global Surgery Department on a digital training programme in Rwanda.

With each of our simulations, you can practise as many times as you want, you can fail as many times as you want. But the idea is that you’ll get to a point where you have reached sufficient cognitive understanding of a procedure and then at that point your programme director will sign you off as being competent for that particular training milestone. It’s not about being Big Brother, it’s just about proving competence and learning.

WHAT HAPPENS IF A USER PERFORMS A PROCEDURE INCORRECTLY ON THE APP?

IS THERE MORE YOU’D LIKE TO DO TO DEVELOP THE PRODUCT?

One of the beauties of mobile technology is that we collect a huge amount of data. Our system gathers all of the interactions and decisions that users make while rehearsing a simulation. Those data can be fed back to the training directors. For example, at Harvard, the training programme director has access to a data dashboard that tracks the training progress of all their residents.

The director has an overview of how much people are practising, which simulations they’re doing, their scores, learning curves, points of the procedure where they most

The current public-facing product represents only about 5–10% of what we think we can achieve. People who visit our laboratory see some of the technologies we’re developing, but there’s a huge amount we can do in terms of not only our mobile platform, but virtual and augmented reality. We believe we can take our technology back into the operating room and help surgeons at the point of care. touchsurgery.com rcsed.ac.uk | 25

INTERVIEW

Surgeons’ News talks to Mary Klingensmith MD, keynote speaker at the Faculty of Surgical Trainers conference and President of the Association for Surgical Education

FLYING THE FLAG FOR STANDARDS THE TITLE FOR THIS YEAR’S FST CONFERENCE IS TIME VS COMPETENCY IN SURGICAL TRAINING. HOW WOULD YOU DEFINE COMPETENCY-BASED TRAINING? To me, competency-based training means that we have a defined, measurable target to which we are training a person. I don’t mean necessarily globally, but we have dissected it down into individual units. For example, it’s perhaps an ability to assess a patient who comes to triage with an acute abdomen and we can effectively validate that patient and know what to do next based on what we find.

In the US, we are still far from having that sense of all the discrete units of learning and measurable understanding of work, but it’s a measure of competency that we really do need. We’ve started moving towards competency-based education, but it’s going to be a very long road and we’re just getting started on it.

WHEN DID THE CONCEPT BEGIN TO GAIN TRACTION IN THE US? In January 2015, the American Board of Surgery made a unified commitment that we want to move in this direction. The US training system differs from other countries’ systems in that we have a board that sets certification standards, but doesn’t actually oversee the training process – that’s done by a separate body.

26 | Surgeons’ News | June 2016

Dr Klingensmith says there is pressure from trainees in the US to make training shorter

This means we’re having to deal with the political battles of getting those who oversee training to form an agreement. For the most part, we have conceptual agreement, but it’s been a matter of sharing ideas and it’s been a rather ponderous and deliberate process to this point.

ARE THOSE THE ONLY BLOCKS TO PROGRESSING COMPETENCY-BASED TRAINING? In the US, the trainee workforce truly is a workforce that serves a manpower need for the care of patients in academic centres. So it’s sometimes very difficult to separate the actual work from education; that’s one barrier.

The other issue is that, as we have delved deeper into competency-based education, it’s clear that it requires much more faculty training and time, for which there is no current payment method. Clinicians are paid based on the number of patients cared for, not for providing education.

So we don’t yet have a clear idea of how we’re going to be able to incentivise our faculty to do this additional work.

IS THE DEBATE OVER THE LENGTH OF TRAINING AS CONTENTIOUS IN THE US AS IT IS IN THE UK? In the US, the pressure is coming from trainees

Although providing training is a passion for many doctors, we’re not necessarily trained to do it and we rarely get feedback on how well we do it should be a formal feedback process, but I think the steps we would need to take to operationalise that in a systematic way are unknown.

IS THERE A CULTURE IN SURGERY WHERE IT IS ASSUMED A CONSULTANT WILL BE A GOOD TRAINER? Historically and culturally in medicine, those who stayed in academic centres had an interest in teaching and so they say the system worked. However, there’s so much more we know about sound educational principles now and we owe it to ourselves to understand that science and apply it. But it’s also true that we’re in a much more complex environment now than we ever were. For example, there’s been an explosion in simulation technology.

There have been a lot of changes that have eroded the prior system and I don’t think we’ve done a good job of acknowledging and responding to change and making certain that we are providing the best possible education for our trainees.

WHAT ROLES OR FUNCTIONS DOES THE ASSOCIATION FOR SURGICAL EDUCATION (ASE) HAVE IN SUPPORTING SURGICAL TRAINERS? to make their training shorter, mainly in the form of greater efficiencies. We’ve already had a decrease in our working hours, but there’s a feeling that we need to gain further efficiencies and have fewer years on the task of training. Many trainers are not convinced, but the trainees would like it if they could be finished in fewer years.

DO ‘ENTRUSTABLE PROFESSIONAL ACTIVITIES’ (EPAS) HAVE ANYTHING NEW TO OFFER IN SURGICAL TRAINING? There are some specialties in the US that are beginning to use EPAs successfully in residency, so there is a lot of interest in using them as models for competency-based education. The Netherlands seems to be furthest ahead in using EPAs, so the American Board of Surgery is to hold a meeting with Dutch experts later in the year.

SHOULD TRAINERS BE ASSESSED USING THE SAME SYSTEMS AS TRAINEES? We should be aspiring to that, although it’s complicated.

We would need to devise systems in which to do that, but I think we owe it to our trainees to demonstrate that we as trainers are competent at what we do.

Although providing training is a passion for many doctors, we’re not necessarily trained to do it and we rarely get feedback on how well we do it. There really

Mary Klingensmith MD President of the Association for Surgical Education, Distinguished Professor of Surgery and Vice-Chair for Education at Washington University School of Medicine, St Louis, US fst.rcsed. ac.uk

The ASE was formed in 1980 as a professional organisation for surgical trainers. I undertook an ASE-sponsored surgical education research Fellowship about 15 years ago, which resulted in a publication. After that, I became gradually more involved in ASE activity.

It’s a place where there are opportunities for training development or faculty development, where individuals can learn the techniques of educational scholarships.

We have an annual meeting where we present and share our educational scholarships and we also have a grant programme where we fund educational research projects.

IS THERE ANYTHING LIKE THE FST’S STANDARDS FOR SURGICAL TRAINERS IN THE US? There are no set standards as yet. The ASE runs a voluntary system called the Academy of Clerkship Directors for doctors who oversee undergraduate training. There’s a set of standards that must be met before doctors can join.

In graduate medical education, there is an expectation, but not a requirement, for those in supervisory roles to attend training programmes. There is a short course offered for surgery through the Association of Programme Directors of Surgery. It’s undoubtedly helpful and practical; many trainers take advantage of it because it does make their subsequent work easier, but it’s optional and does little to further one’s understanding of educational principles. rcsed.ac.uk | 27

The Faculty of Surgical Trainers’ Craig McIlhenny looks at the imminent GMC accreditation of all those in trainer roles in secondary care

ARE YOU READY?

A

re you a surgical trainer? Are you prepared for this July? As of July, all trainers in secondary care will need to be recognised by the GMC. This process applies to those who hold a ‘named trainer’ role, which at present are those who are designated as assigned educational supervisors or clinical supervisors.

To achieve recognition as a trainer, you need to prove to the GMC’s satisfaction that you have been properly trained for the role and that you have an ongoing engagement in training.

The process will be run by your deanery or Local Education Training Board (LETB), and you will probably have had communication from them regarding trainer recognition if you hold one of these two roles (if not, you may want to contact your deanery/LETB or your local director of medical education). Your deanery is responsible for identifying those who have a named training role and for informing the GMC of those who hold recognition for that role.

As a named trainer, you will need to satisfy the conditions for trainer recognition. All deaneries and LETBs have set up slightly different systems for this, but all have a degree of commonality. In general, there will be a number of statutory requirements, such as being up to date with equality and diversity training. You will also need to have formal time identified in your job plan for your role, and in most cases have evidence of having completed some form of ‘induction’ training, such as the training the trainer or educational supervisor courses.

For initial recognition there are essentially three paths.

First, you can have a recognised qualification in medical education, such as a postgraduate certificate or Master’s degree. Second, you can be a member of an educational organisation such as the Academy of Medical Educators (AoME) or a Fellow of the Higher Education Academy.

Third, you can submit a portfolio of your teaching and training practice.

Whichever route you take for initial recognition, for ongoing recognition for your role you will need to provide evidence of ongoing professional development as a trainer.

This will be mapped against

28 | Surgeons’ News | June 2016

domains produced by the AoME. Most LETBs/ deaneries now have some sort of online system for logging this activity.

This evidence will be examined at your annual appraisal by your normal appraiser and a judgement will be reached as to whether you have produced enough evidence to continue to be recognised as a trainer. You will be expected to produce some evidence every year, but your trainer recognition will run over a five-year cycle in tandem with your re-accreditation. Over this five-year cycle, you will usually be expected to produce some form of evidence for every domain.

The Faculty of Surgical Trainers supports the introduction of a scheme in which trainers are recognised for the work they do. We also support the concept of trainers needing to be trained and accredited.

However, we must ensure that any such system really will enhance the quality of training for our trainees. It needs to enhance and empower the surgical trainer to provide excellent training within our current healthcare system. We must ensure that trainer recognition does not alienate any engaged trainers, that any additional administrative burden is minimised and that the process is not reduced to a tick-box exercise.

The AoME standards that

the GMC recommends for evidence collection are by necessity broad, but this makes them vague and unsuitable for evaluating surgical trainers. The FST recognised this three years ago and began developing its own set of Standards for Surgical Trainers. These map to the original AoME domains, but are specific to surgery. The standards have been well received, have been quoted as an example of good practice by the GMC and have now been adopted by the Joint Committee on Surgical Training as the standard for surgical trainers in the UK. To minimise additional administration and maximise the time you can spend training, the FST has been working with the Intercollegiate Surgical Curriculum Programme (ISCP) to integrate these standards into a portfolio within the website. When the project goes live later this year, you will be able to access your own â&#x20AC;&#x2DC;Trainerâ&#x20AC;&#x2122;s Journalâ&#x20AC;&#x2122;, a portfolio of evidence of your ongoing engagement and development as a trainer.

Full integration into the ISCP means that all the data you already spend time inputting on the website, such as filling in learning agreements or workplacebased assessments, will automatically populate the relevant domains in your portfolio. With some additional information that you will add into your Trainer Profile detailing what procedures you normally train in, you will have a continuously updated record of your training practice. The output from this will be a simple PDF file mapped to the domains that you can take to your appraisal to show that you meet the criteria for trainer recognition.

We believe that development of these standards (and subsequent development of the ISCP integrated tools) will improve training, minimise paperwork and repetition on your part, and avoid a box-ticking culture.

Our process will ensure you have time to train, rather than fill in forms

We must ensure that trainer recognition does not alienate any engaged trainers and that any additional administrative burden is minimised rcsed.ac.uk | 29

PHOTOGRAPHY: JANE WILLIAMS

MILITARY SURGERY

30 | Surgeons’ News | June 2016

Tim Hodgetts outlines the challenges faced by the military in delivering major trauma care in remote environments

IN THE LINE OF FIRE

HOW DOES REMOTE HEALTHCARE FOR THE MILITARY DIFFER FROM OTHER FIELDS WHERE INDIVIDUALS WORK IN REMOTE LOCATIONS? My own definition is that remote healthcare exists on a spectrum, from simple to complex settings. Simple would be what we refer to as a ‘semi-permissive’ environment – remote healthcare is never going to be in a completely permissive environment because the very fact that you are isolated adds a certain amount of risk and threat. However, there can still be reliable communications, reach-back decision support, established medical evacuation (medevac) and acceptable clinical timelines – and all of these make it a relatively simple situation to manage.

However, remote healthcare becomes most complex when the environment is ‘non-permissive’: here, there is a higher threat level with unreliable communications, no reach-back advice, and medevac may be done at risk or may not be possible at all. In this setting, prolonged field care is the expectation.

To put this in perspective, in Camp Bastion at the end of the Afghanistan campaign, we faced relatively low hostility, we were relatively safe within the camp and we were electronically well connected. We’d had 10 years to establish this connectivity and we were very well resourced to diagnose and treat major trauma. Indeed, our field hospital was probably better resourced than many major trauma centres in the UK for dealing with critical injuries. When we are deployed quickly to a new operation, though, it can be expected we will encounter high physical threat, geographic isolation, a relatively austere clinical environment, and finite resources where the resupply chain may be disrupted.

WHAT ARE THE CONTINGENCIES FOR WHEN A MEDIC CAN’T PHYSICALLY BE WITH AN ILL OR INJURED PATIENT? We design operational healthcare to ensure the best possible clinical outcomes within the environmental constraints. We may accept more or less risk depending on the specific mission, but we will position our medical facilities and staff to make sure that care is available when needed. If necessary, we’ll embed individual medical staff far forward within the team on the mission in order to meet our timelines for life-saving intervention.

It may be that environmental factors disrupt the planned medevac chain and lead to higher risk, but the system is organised to mitigate risk as best as possible through the intelligent positioning of health assets. That’s a very different approach to an adventure holiday, where individuals have voluntarily accepted the risk and there isn’t the same explicit organisational responsibility to look after those at risk.

For example, when we went to Sierra Leone in 2014, the task was to provide an Ebola virus treatment unit in a remote area, but we had to make sure that we also supplied comprehensive healthcare support for our own personnel. This could be for ‘medical’ or ‘trauma’ emergencies. We, therefore, deployed RFA Argus, the hospital ship, as well as an additional surgical facility on land. If anybody had suffered a road-traffic accident (which were very common in Sierra Leone) and was significantly injured, then they would have been able to access our own military healthcare system, within an acceptable timeline, through a helicopter-based team on board the ship delivering the casualty either to the land facility or back to the ship. We take our corporate responsibility very seriously to look after our own people in any remote environment.

HOW DO CONSIDERATIONS FOR PROVIDING CARE FOR RURAL AND URBAN POPULATIONS DIFFER WHEN PLANNING DISASTER RELIEF? Natural disasters can be classified as compensated or uncompensated. A compensated disaster is one where medical teams can get the resources they need. An uncompensated disaster is where the resources simply aren’t available, through either the scale of the incident – that is, the overwhelming number of casualties – or because the lines of transportation to and from the scene are disrupted. In these situations, teams must make difficult decisions about who to treat and whether the limited resources should be restricted to those who can realistically be saved. So it’s important to know and accept in a disaster that the team will be compromising on the best standards of care.

We’ll embed individual medical staff far forward within the team on the mission in order to meet our timelines for life-saving intervention rcsed.ac.uk | 31

MILITARY SURGERY

In a natural disaster in a remote environment, prolonged field care is going to be an expectation.

Medevac assets will be limited. There will be many patients to treat who can’t easily be moved to hospital.

When you’re stuck with people at the scene, you will inevitably need to do interventions that would preferably be done in hospital, such as rapid induction of anaesthesia, administration of blood products and even occasional surgical procedures to facilitate extrication, including limb amputation.

HOW MUCH DOES THE MILITARY EXPERIENCE INFLUENCE DECISIONS ON CONFIGURATION OF TRAUMA SERVICES IN CIVILIAN AREAS? I think there’s an enormous amount to learn from contemporary military experience and this is borne out by history: medicine advances in war and conflict, and the benefits are transferred to peacetime practice.

In 2009, the Healthcare Commission annual report described our operational trauma care as ‘exemplary’, and they had never used that descriptor before.

NHS hospitals have to configure for every eventuality and major trauma is a relatively small burden on most.

Unless a new hospital is being built with the management of major trauma in mind as a main effort, then it probably hasn’t been ideally configured to be a major trauma centre. For example, the emergency department may be dislocated from the CT scanner and the operating theatre. The blood bank could be a 10-minute run for a porter.

In a tented field hospital, major trauma is invariably our core business (with notable exceptions such as our response to the Ebola virus) and we have a strategic cluster of capability at the front end designed to look after serious injury. As a patient is brought into the emergency department, we have already decided, on the ‘MIST’ message received in advance, if they are going into resuscitation bay one or if they are going directly to the adjacent operating theatre.

The most critically injured will go straight on to the operating theatre table and we will draw the emergency department team into theatre to start the resuscitation while the surgeons are scrubbing. We will also draw in the consultant radiologist to do the FAST (focused assessment with sonography for trauma) scan and any x-rays with our portable digital kit. So we’ve got a critical care cluster around the patient and this speeds up the transfer of a patient from one department to another at a time of great vulnerability, and substantially reduces the time to their life-saving surgery.

In some cases, we are comparing apples with oranges, as the majority of combat trauma is from blast or ballistics – including bullets, shrapnel and environmental debris. The surgical decisions are perhaps more binary with military trauma, because it can be obvious whether someone needs an operation immediately. If your legs have been blown off by an improvised explosive device, you need immediate surgery. If you have holes in you with internal bleeding, you need immediate surgery. In civilian trauma, with a predominantly blunt mechanism, imaging has a more prominent role in the initial decisions for surgery.

This does not trivialise the value of imaging in the remote 32 | Surgeons’ News | June 2016

Wounded military personnel have fast access to life-saving treatment

military setting, particularly for a general surgeon in deciding whether to operate far forward on a head injury, to expeditiously evacuate to specialist care, or to accept that the injury is unsurvivable.

ARE MILITARY SURGEONS CALLED UPON TO ADVISE ON CONFIGURATION OF TRAUMA SERVICES FOR CIVILIANS? The Defence Medical Services did actively participate in the national working groups as major trauma centres were stood up in England following the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report, Trauma: Who Cares?, in 2007. Furthermore, our clusters of military medical staff embedded in the NHS are very much focused on these major trauma centres. In some of the centres, you will find that the military is providing the leadership, which is both building on the experience from contemporary operations and exploiting the personal drive to continually improve the standard of trauma care.

In a more formal capacity, we are increasingly supporting the NHS in a number of ways, particularly on the development of clinical leadership, and we have been transferring military tools for solving complex problems, change management and driving innovation at pace through bespoke training to senior NHS executives.

In parallel, I have deconstructed the process of innovation within defence medicine to understand what we do well and what we can do better. This has generated an integrated model that describes the external and internal factors for driving innovation; why and how we have become early and effective innovation adopters; the conditions that are supporting translation of innovation to the wider healthcare sector (NHS, third-sector charities, and our military allies); the conditions for exploiting an internal idea through to a fielded capability; and the predictable obstructions to innovation.

While our evidence tells us that we have had serial improvement in our clinical outcomes during contemporary campaigns, we have not explained how the organisation has achieved this, and therefore the conditions that have to be replicated to accelerate future change: this model captures how an organisation can innovate at pace.

DO MILITARY SURGEONS HAVE TIME TO TRAIN IN HUMAN FACTORS AWARENESS?

The surgical decisions are perhaps more binary with military trauma. If your legs are blown off by an IED, you need immediate surgery HOW MUCH ONUS IS THERE ON INNOVATION, OR IS IT MORE A CASE OF REFINING AN ESTABLISHED PROCESS? Innovation is central to everything I do as medical director. My mantra is that while military medicine advances in war, historically it has stagnated or even regressed in peace. We can’t allow this to happen and should we disinvest, then we will accrue an intellectual deficit that is repaid in the lives of service personnel at the start of the next major campaign. We have a ‘roadmap for innovation’ and a comprehensive strategy for research, both of which are externally published in the Journal of the Royal Army Medical Corps.

And we are actively engaged in wide collaboration with UK and international academic institutes, and with industry, to ensure we leverage all opportunities to reach our research goals.

We take human factors extraordinarily seriously and we do an enormous amount of training before we deploy a field hospital. In our specialised training courses the whole team trains together in a simulated environment with realistic scenarios, which we can amend at short notice to adapt to any changing injury mechanism or pattern.

As well as rehearsing the team dynamics – be it the trauma team, the operating theatre team or the blood bank team managing a massive transfusion – we rehearse the whole hospital concurrently, where the hospital is configured, in a hangar in York, exactly as when it’s deployed. This rehearsal uses a blend of simulation techniques, including individual skills training models, sophisticated mannequins and live actors. Our research is additionally developing virtual and augmented training options that replicate the human factors within a team, as well as demand critical decision making.

For the surgical team, the flagship Military Operational Surgical Training (MOST) course includes interventional training on cadavers in tandem with simulation mannequins, with the team rehearsing their roles in real time. Beyond this, the highest level of team-based preparation has been evaluated in the last year, where emergency and operating teams have been deployed to major trauma centres in London to build cohesion while assessing and treating the seriously injured.

This training and exercising within formed teams provides a very sophisticated assurance model and by the time the hospital goes out the door, the commander will know if there are any residual risks to be monitored.

But in most situations, we would expect that each field hospital is robustly validated, with strong reassurance to the chain of command that the hospital will function from day one for the very first casualty to the highest possible standard.

Brigadier Tim Hodgetts CBE Medical Director at Defence Medical Services and Honorary Professor of emergency medicine at the University of Birmingham rcsed.ac.uk | 33

MUSEUMS

INTERNATIONAL OPERATORS A temporary exhibition at the Surgeons’ Hall Museums highlights the worldwide adventures of medical personalities. Rohan Almond and Thomas Elliott give a taste of these fascinating expeditions 34 | Surgeons’ News | June 2016

Goodsir was to conduct scientific research as part of an expedition to find the Northwest Passage. However, it was a journey from which none of the 129 men would return

M

edicine Men, a temporary exhibition at the Museums, highlights a more unusual aspect of the collection. It tells the stories of a few medical personalities with connections to the College who travelled the world in search of knowledge and adventure, and what they brought back with them. It brings together a number of fascinating specimens and objects, many of which have not been on display for some time, if at all.

HARRY GOODSIR AND THE FRANKLIN EXPEDITION Henry Duncan Spens â&#x20AC;&#x2DC;Harryâ&#x20AC;&#x2122; Goodsir became a Licentiate of the RCSEd in 1840 and took over as Conservator of the Museum from his brother John, a famous anatomist, in

Above left: HMS Terror and HMS Erebus setting sail Above right: Reward poster for evidence of the Franklin expedition

1843. Less than two years later, Goodsir took leave of the post after being asked to become Acting Assistant Surgeon and Naturalist on board HMS Erebus. He was to conduct scientific research as part of an expedition led by Sir John Franklin to find the Northwest Passage, a potential route through the Arctic Ocean linking the Pacific and Atlantic oceans, which would transform world trade routes.

However, it was a journey from which none of the 129 men would return.

HMS Erebus and HMS Terror set out from England on 19 May 1845. They were well equipped with enough supplies to last for three years. Goodsir sent letters to his family until July of that year, describing with enthusiasm his activities on board, including observations on the flora and fauna. The ships were last seen in Baffin Bay in late July and nothing was heard of them again1. The Admiralty and rcsed.ac.uk | 35

MUSEUMS

Franklin’s wife Jane both offered rewards for sightings of the group. Despite many search parties scouring the area, in 1854 all men were recorded as lost.

As a surgeon, Goodsir would have had to deal with the effects of various conditions, including scurvy, starvation and lead poisoning from the sealant of the cans of tinned food2. Lack of nourishment and extreme cold would have made the men much more vulnerable to illness, while living together in a confined space with poor hygiene made the perfect conditions for tuberculosis to flourish. All of these factors probably contributed to the deaths of the men.

Some of the bodies of the Franklin expedition subsequently found by search parties have been exhumed and autopsied. Recent use of osteological techniques and isotope geochemistry suggest a skeleton found in 1869, originally thought to be Henry Le Vesconte, is possibly that of Harry Goodsir. Scientists created a forensic facial reconstruction that shows a stark likeness to the surgeon3.

THE SEARCH FOR FRANKLIN

A recent discovery In September 2014, HMS Erebus was discovered under 11 metres of water just off King William Island. Using a combination of Inuit oral testimony and modern mapping techniques, sonar located the ship and divers found it in virtually one piece and in remarkable condition. Parks Canada and its partners continue to excavate HMS Erebus and are still searching for HMS Terror6.

AN ARCTIC ADVENTURE

Purves’s journal and map of the Newfoundland coast

36 | Surgeons’ News | June 2016

William Laidlaw Purves was born in Hill Place, part of the current campus of the Royal College of Surgeons of Edinburgh. In 1862, aged 19, he joined one of the first steam-powered seal and whaling boats to leave Scotland as Ship’s Surgeon. He later qualified as Licentiate of both Edinburgh medical colleges, graduating from Edinburgh University, and went on to specialise in ophthalmic and aural surgery.

As Purves wrote in his journal he “thought he might combine pleasure and practice by joining some ship about to make a lengthy voyage from Britain”. He set off from Dundee on board the SS Polynia “for a ten month cruise in the North Atlantic and off the coast of Labrador and Greenland for the purpose of prosecuting the seal and whaling fishing”.

Wages were dependent on the amount of skins and oil collected. The ship returned to Scotland in October 1862 with a cargo of 15 whales, seven narwhals, six or seven bear skins and several tons of whalebone. Purves was presented with a narwhal tusk by the crew in recognition of his care and attention.

We have a number of interesting items on display related to Purves’s expedition. His journal (left) records

© THIERRY BOYER/ PARKS CANADA

After becoming an RCSEd Licentiate in 1833, John Rae joined the Hudson’s Bay Company, a fur-trading business, as a surgeon. During numerous expeditions in northern Canada, he mapped large areas of uncharted Arctic territory. Known by the Inuit as Aglooka, “he who takes long strides”,4 Rae learned from local Inuit people and lived off the land rather than attempting to carry in all his supplies.

Rae went on a number of trips in search of the Franklin men, mapping as he went. In 1851, he found evidence in the form of part of a flagstaff and a piece of wood. Three years later, Inuit told him they had found the remains of 40–50 men who had starved to death. In his report, Rae wrote: “From the mutilated state of many of the bodies and the contents of the kettles, it is evident that our wretched countrymen had been driven to the last dread alternative as a means of sustaining life.”5 The suggestion that such heroes had resorted to cannibalism horrified Victorian Britain. As a result, despite being awarded the £10,000 offered by the Admiralty for finding proof of the expedition, Rae was never properly recognised for either his efforts in the search for Franklin or for discovering the Northwest Passage in the process.

Shrunken heads collected by Ferguson

many observations, from the freezing conditions on board ship to the bloody processes of killing seals. Of the Inuit, he writes about the small and crowded snow huts, their struggle for food, and skill in hunting seals and polar bears in the winter.

The ship traded with locals throughout the expedition for supplies. A kayak displayed in the exhibition is an exact replica of one the Inuit of that area would have used. It has a seal-skin hull, stretched over a wooden frame with reindeer-bone toggles. There is also a reindeer-bone knife and fork, which were probably carved by a member of the crew. Not only is the carving rather basic, but also the Inuit would not have used this style of implement for eating.

INTO THE AMAZON Dr Wilburn Henry Ferguson was an American doctor who spent much of his life travelling to various parts of the Amazon rainforest to research potential drugs derived from plants found there.

In 1931, Ferguson set out on his first trip to Peru, with his wife and six-month-old child. Over the next few decades, he returned to South America many times, convinced that the plants of the rainforest held great potential in the discovery of new drugs for incurable diseases.

In particular, Ferguson was fascinated by the custom of head shrinking, as practised by the Jivaro people who lived in remote jungle areas bordering Peru and Ecuador.

For most Jivaro tribes, the ritual of headhunting and shrinking is strongly linked to religion and ceremonial procedures. They believe that all disasters in life are the direct result of shamanistic influences, with no such thing as an accidental death. Therefore, if a family member dies, the brujo (medicine man and priest) performs an elaborate ceremony involving all the adult men to determine who was responsible for the death of their loved one. A hunting party is then sent to kill the men of the family deemed guilty, with women and children becoming members of the victor’s family.

After many years befriending the Jivaro, Ferguson was eventually initiated as a chief medicine man, the only known westerner to be honoured in this way. As part of this process, he was taught the complex procedure and secret ingredients needed to make the ceremonial head-shrinking solution. Ferguson did not want to kill a man and so used the head of a red monkey.7 Once the skull is removed, the head is placed into a mixture of nearly 30 plant juices, barks and roots, and simmered over hot coals for several days. It is then very slowly reduced in size using hot stones and hot sand.

Special attention is paid to conserving facial expression and character by carefully moulding the skin with the fingers.

Ferguson speculated that the highly toxic, and highly secret, herbal solution used could be extracted and used to shrink tumours in cases of cancer. He spent years researching and extracting individual ingredients, eventually producing a plant-derived anticancer formula he called Amitosin. Although Ferguson reported that he used the drug successfully to treat terminally ill cancer patients, the drug never received US government approval.

During the course of his time in the Amazon, Ferguson gathered various items depicting the daily life of the Jivaro people, which he intended to use as a way of promoting interest in his drug research. Having

REFERENCES 1. Kaufman MH. Harry Goodsir and the last Franklin Expedition, of 1845.

J Med Biogr 2004; 12(2): 82–9 2. Bayliss R. Sir John Franklin’s last Arctic expedition: a medical disaster.

J R Soc Med 2002; 95(3): 151–153 3. Mays S et al.

New light on the personal identification of a skeleton of a member of Sir John Franklin’s last expedition to the Arctic, 1845. J Archaeol Sci 2011; 38(7): 1571–1582 4. www.orkneyjar. com/history/ historical figures/ johnrae 5. Wilson M. Edinburgh surgeons in search of the Northwest Passage: part 2. Surgeons’ News; April 2004; Vol 3 Issue 2 6. www.pc.gc.ca/ eng/culture/ franklin/ index.aspx 7. Gilmore KO, Simons H. Secrets of the headhunters. Saturday Evening Post, 22 November 1958

The head is placed into a mixture of nearly 30 plant juices, barks and roots, and simmered over hot coals.

Special attention is paid to conserving facial expression lectured in the UK about his work, in 1948 he donated his collection to the RCSEd. Of particular note are seven shrunken heads prepared by a brujo. Four of them are individuals who were killed in raids. The lips are sewn together with palm fibre, from which they can be hung from the belts of young men during initiation rituals. The three heads that have been decorated with feathers and beads are those of children who were accidentally killed in one of the raids. They have been shrunk for a different purpose as an appeasement to their spirits.

Also donated were a whole host of Jivaro drugs, some with familiar constituents including: cascarilla, the bark of which contains quinine; coca leaf, containing cocaine; curare, a neuromuscular blocking agent; and barbasco, a plant that, when crushed, produces Rotone, an ingredient in some pesticides and weedkillers.

QUESTS FOR KNOWLEDGE From finding potential cures for cancer in the depths of the Amazon rainforest to exploring the icy landscapes of the Arctic, these men shared a thirst for knowledge that often placed them in extremely hazardous environments, all in the quest for scientific advancement. In many cases, the men were keen to actively engage with, and learn from, the local indigenous people as part of their journey.

The RCSEd continues to have a truly international outlook, with more than half its 22,000 Fellows working in over 100 countries throughout the world.

The Medicine Men exhibition runs until March 2017.

Rohan Almond Assistant Curator Thomas Elliott Head of Museum Learning and Interpretation rcsed.ac.uk | 37

SPECIALTY: VASCULAR

From publishing guidance documents to investigating treatment delays, the Vascular Society is leading by example in the quest for better patient outcomes

FINGER ON THE PULSE

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ince 16 March 2013, vascular surgery has been a separate specialty, rather than a subspecialty of general surgery. The Vascular Society of Great Britain and Ireland recognises that all current and new vascular consultants will need to change the way they work to accommodate new technologies and service reconfiguration. We have published widely on the provision of services to patients with vascular disease and last year updated our guidance on the issue.

The Society is aware that not all patients with vascular disease have aortic aneurysms and our updated document, The Provision of Services For Patients with Vascular Disease 2015, addresses the pathways required to treat patients with diabetes, peripheral vascular and non-arterial disease using a network of arterial and nonarterial hospitals. We have published recommendations that all arterial operations are performed on largevolume arterial sites, with adequate provision for repatriation and review at non-arterial hubs. We are fully engaged with 24/7 provision of service to both our elective and emergency patients, yet the way in which we provide these services is changing and is supported by service reviews provided by the Society and the Colleges through invited review mechanisms.

Interventional services are of particular importance to our patients. It is imperative that these often complex and costly interventions are provided by teams of surgeons and radiologists working together in large-volume arterial hospitals. As such, the Society is working closely with the British Society of Interventional Radiology

38 | Surgeonsâ&#x20AC;&#x2122; News | June 2016

Scan of an aortic aneurysm

The new document recognises that not all patients with vascular disease have aortic aneurysms

The Society is fully engaged with the publication of outcome data, although it believes this should involve institutional rather than personal data

available for this and applications should be sent to the Society for Vascular Technology (SVT) via tracey.gall@ivs-online.co.uk Preparations continue for the exit exam in vascular surgery, FRCS(Vasc), and Julian Scott is keen to encourage members to volunteer as examiners.

Preparations are also under way for visits to all vascular units in England, which will be completed under the auspices of the Getting It Right First Time programme, successfully piloted in orthopaedic surgery by Tim Briggs. For vascular, Mike Horrocks has been appointed to lead the process with visits planned later this year.

On a lighter note, we are delighted that two of the keynote speakers at last year’s annual conference in Bournemouth, Alasdair Walker and David Nott, have received honours. David Nott won the Robert Burns Humanitarian Award, an outstanding achievement and much deserved as evidenced by what we witnessed during last year’s Kinmonth Lecture. In a long list of honours, Admiral Walker has been promoted to the post of Surgeon Commander, the Senior Medical Officer of the British Armed Forces. We congratulate both.

Finally, this year’s meeting to celebrate the 50th anniversary of the Society will be held in Manchester. from Wednesday 30 November to Friday 2 December. We are delighted that Cliff Shearman has agreed to deliver the highly prestigious Kinmonth Lecture and that Matt Thompson has been recommended as the 2016 British Journal of Surgery lecturer. With the successful integration of the SVT and Society for Vascular Nurses meetings last year, it is a good opportunity to encourage your wider teams to register for this year and help celebrate the Golden Anniversary.

© BSIP SA / ALAMY STOCK PHOTO

(BSIR), the Surgical Colleges and the Royal College of Radiologists (RCR) to define curricula for training in each discipline and to ensure that the highest standards are met in the treatment of patients with vascular disease in the UK. We have formed a VS/RCR/BSIR liaison group to assist with the safe and effective delivery of these services and to address any ‘turf wars’ that may develop occasionally.

The Society is fully engaged with the publication of outcome data, although it believes this should involve institutional rather than personal data. This year, however, NHS England still requires individual reporting and the deadline for data entry for publication was 24 March. Data was then returned for verification with a deadline of 5 June for corrections prior to a likely publication date on the Vascular Services Quality Improvement Programme (VSQIP) in late July.

There are some useful reporting tools now available, guidance for which can be found on the VSQIP website at vsqip.org.uk.

A pilot snapshot audit started in April to investigate potential delays in treatment of patients with aortic aneurysms. We are keen to explore reasons behind delays in treatment and are running this for three months for conventional infra-renal aneurysms and one year for custom stents.

Meanwhile, there have been significant changes in the Vascular Society office. After an excellent performance in running the last two annual meetings, Fitwise has been appointed to run the office. The new website is taking shape and will be a huge improvement on the previous one. The Circulation Foundation has also invested in a new website with a more patient-focused appeal. A strong contingent from the Society ran the London Marathon, and there is a Vascular Awareness Week in September. At Council, we were also made aware of funding targeted for vascular scientists to undertake research.

There is £10,000

Mike Wyatt President Mike Jenkins Director of Communications Kevin Varty Honorary Secretary vascularsociety.org.uk rcsed.ac.uk | 39

SPECIALTY: VASCULAR

The Rouleaux Club: a voice for trainees Modern training in vascular surgery is exciting, diverse and rewarding, but presents a unique set of challenges for junior doctors, write representatives of the Rouleaux Club

40 | Surgeons’ News | June 2016

Coloured angiogram of the neck of a patient who has undergone an endarterectomy

to all areas of vascular practice, as evidenced by procedural numbers, with multiple-sourced documentation of competence and supporting evidence.

The emergence of vascular surgery as a unique specialty, no longer merely a subspecialty under general surgery, has benefited trainees, who have increased exposure to endovascular procedures and guaranteed training in this area.

However, it can lead to challenges gaining open surgical skills. This means the new NTNs can work as part of a trauma team, but not independently like the current general/vascular trainees and, if desired, would need to undertake specific training in trauma units or targeted fellowships.

The finite six-year training period culminates in successful completion of the exit examination. Time-consuming workplace-based assessments, self-

directed study, exam revision and a desire for enhanced on-call exposure (requisite for a specialty with a 50% emergency workload) can constrain an optimal work–life balance.

Geographical variations in practice can limit exposure to specific training opportunities, in addition to the longstanding service versus training experienced in all specialties. There are concerns that if the new junior doctors’ contract is imposed in England, it will exacerbate the situation by spreading the workforce over seven days, negatively impacting trainee morale.

The development of ‘boot camps’ for the vascular NTNs and the organisation of courses by the Vascular Society is an ongoing attempt to reduce the financial burden on trainees, as study budgets frequently fail to cover the costs of a single, often mandatory, training course.

This, combined with travel expenses and professional fees, adds financial penalties to specialty training.

The Rouleaux Club is an elected group of dedicated vascular trainees who seek to optimise the educational, clinical and academic opportunities for vascular trainees. It does this through close ties and collaboration with the VSGBI, SAC and Royal Colleges in the development of pragmatic, equitable solutions to the challenges faced by the workforce of vascular junior doctors, thereby continuing to attract exceptional candidates to train within the specialty.

Rachel Barnes

Affiliate Representative Shiva Dindyal

President

Steve Goodyear

Past Affiliate Representative @RouleauxClub

SOVEREIGN, ISM/SCIENCE PHOTO LIBRARY

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rterial disease affects every organ system, leading to truly multidisciplinary vascular practice, with individually tailored treatment strategies delivered in conjunction with specialists from almost every discipline of acute medicine and surgery. Although formerly the exclusive domain of interventional radiologists, numerous endovascular treatment techniques have been integrated into modern vascular practice. This has led to close ties with this specialty and a teambased approach to aortic, peripheral and mesenteric vascular disease. Such multispecialty collaborations are vital to diagnose and effectively manage complex surgical disease within an ageing, co-morbid population.

Vascular registrars must develop firstclass open surgical skills, endovascular ‘wire’ skills, a proficiency in diagnostic vascular ultrasound and detailed angiological knowledge. The range of procedures is endless, from delicate femoro-distal bypass anastomoses, carotid endarterectomy and dialysis access, to macroscopic, open surgery for ruptured abdominal aortic aneurysms or vascular trauma and their endovascular equivalents.

With the broad range of treatments available and rapid technological advances within the field, a knowledge of the best evidence, devices and clinical guidance is essential. This leads many vascular trainees to conduct a period of research, expanding their knowledge base and skill set, while hopefully driving innovation and improved practice within the NHS. Vascular trainees will continue to face challenges in their careers. The didactic CCT requirements include exposure

Surgical eLearning Opportunities in partnership with the Royal College of Surgeons of Edinburgh

PART-TIME ONLINE MASTERS PROGRAMMES FOR SURGICAL TRAINEES The Royal College of Surgeons of Edinburgh and the University of Edinburgh offer a range of part-time, online Masters programmes to support the junior and advanced surgical trainee. All of our programmes are taught by distance e-learning designed to run alongside clinical training and complement in-the-workplace assessment.

As a student, all you require is: • A computer • Broadband • 10-15 hours per week of study The MSc in Surgical Sciences (Edinburgh Surgical Sciences Qualification, ESSQ) is based on the MRCS curriculum and taught components are delivered through case scenarios of common surgical diseases, formative MCQs, and discussion forums.

The MSc Primary Care Ophthalmology provides optometrists, GPs, medical and surgical ophthalmology trainees and other eye health professionals with the opportunity to advance their understanding of primary care ophthalmology, in particular, Glaucoma, Macular Disease, Acute Eye Disease and Vision Loss.

The ChM programmes are based on the UK Intercollegiate Surgical Curriculum: ChM in General Surgery ChM in Trauma and Orthopaedics ChM in Urology ChM in Vascular and Endovascular Surgery All of our ChMs support learning for the Fellowship of the Royal College of Surgeons (FRCS) examinations, and offer an alternative to clinical/ laboratory research training for those students who do not wish to take time out of training. The MSc in Primary Care Ophthalmology and ChM in Clinical Ophthalmology programmes follow the Royal College of Ophthalmologists (RCOphth) curriculum, supporting junior and advanced ophthalmic trainees, respectively.

Contact us: MSc in Surgical Sciences MSc in Primary Care Ophthalmology email: essqinfo@rcsed.ac.uk ChM in General Surgery ChM in Trauma and Orthopaedics ChM in Urology ChM in Vascular and Endovascular ChM in Clinical Ophthalmology email: chminfo@rcsed.ac.uk

Apply now for September 2016

www.essqchm.rcsed.ac.uk

rcsed.ac.uk | 41

SHOT PROGRESS REPORT

TAKING THE NEXT STEPS

Two years after its publication, debate continues on how best to implement the Shape of Training recommendations.

Rowan Parks starts with an overview and, in the following pages, other professionals assess how to move forward

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he report of the independent Shape of Training (SHoT) Review, led by Professor Sir David Greenaway, was published in October 2013. The review was established to look at potential reforms to the structure of postgraduate medical education and training across the UK. It followed the independent inquiry into Modernising Medical Careers in 2007, led by Sir John Tooke, which also made a number of recommendations about postgraduate medical education and training in the UK. The Tooke report called for a more flexible and broad-based approach, integrating both training and service objectives into workforce planning.

Other inquiries have also highlighted the need to develop the structure of postgraduate medical training so it continues to provide consistent, high-quality training for UK doctors.

All these publications have pointed to the need for more flexibility in training to equip doctors to respond better to the changing needs of patients and the service.

The SHoT report outlined 19 recommendations to the UK government and suggested a framework for how the structure of medical training should evolve to ensure the future delivery of high-quality clinical care. These recommendations were based on evidence that healthcare is being driven by a growing number of patients with multiple comorbidities, an ageing population with many long-term medical conditions, health inequalities and

42 | Surgeons’ News | June 2016

increasing patient expectations. The SHoT report acknowledged that strategic policy commitments were focused towards more integrated care models and, therefore, one of the fundamental recommendations was that, at a global level, patients and the public needed more doctors capable of providing general care in broad specialty areas across a range of different care services and environments.

However, the report also stated that there would still be a requirement for doctors trained in more specialised areas to meet local and workforce needs. The high-level framework proposed by Greenaway was that postgraduate training needed to adapt to more adequately prepare medical graduates to deliver safe and effective general care, and to provide doctors with the ability to change or evolve their roles throughout their career.

The final recommendation of the report was that a UK delivery group should be established to take forward the recommendations and to identify which organisations should lead on specific actions. Subsequently, UK health ministers asked officials to consider the recommendations and make policy proposals, where possible, on the basis of a fournation consensus. A SHoT Steering Group (STSG) was convened for this purpose and, in 2014, it organised six UK-wide stakeholder workshops to explore how the report’s recommendations might work in practice. This led to publication of an STSG position statement in February 2015 that endorsed the following proposals:

Those aspects of the current training system that have been shown to work well and are fit for purpose should remain.

Any significant changes to medical training should be consistent with the key principles outlined within the Greenaway report, and taken forward in a measured and incremental way to avoid service and training disruption.

Any significant changes to medical training such as alternatives to curricula must reflect the UK basis of medical training and be approved by the GMC. Groups should be developed in each country with appropriate stakeholder representation, with the remit to develop proposals as agreed by ministers through the STSG, taking into account the different strategic priorities and requirements in each country.

The STSG wanted further work to describe how doctors’ training could be more generic to better meet the needs of patients. This would include

Professor Rowan Parks Deputy Medical Director of NHS Education for Scotland and Consultant HPB Surgeon

a mapping exercise led by the Academy of Medical Royal Colleges (AoMRC) and supported by the GMC to look at the extent to which colleges have or can develop the generic components of their curricula. The STSG hoped for the scoping of measures, based on evidence from pilots, on how to further develop the careers of doctors who were outside formal postgraduate training and who were not consultants, such as SAS doctors. The group also wanted consideration given to how to better prepare doctors to work across the interface between primary care, secondary care and the community, with more flexibility in training between the sectors.

Finally, the STSG signalled that it would support the GMC as it developed and piloted credentialing, working with all stakeholders with an interest in this aspect of SHoT. The STSG also stated that patients, service users and healthcare professionals were to be assured that proposed changes to training would be properly considered, modelled, costed and consulted on

In some areas, doctors are losing the ability to provide generalist care. Many specialists now say this is why they cannot contribute to emergency on-call rotas before any changes were made, but that patientsâ&#x20AC;&#x2122; interests had to be at the heart of any proposals.

Since then, various organisations, including STSG, AoMRC, Health Education England, NHS Education for Scotland, and individual royal colleges and faculties have critiqued and evaluated options for potential developments and changes. From a surgical perspective, some of this detailed thinking and evaluation has been undertaken by the Joint Committee for Surgical Training, the surgical Specialty Advisory Committees and a working group from the Royal College of Surgeons of England.

Although no material changes have been effected since publication of the SHoT report, there is no doubt that it has stimulated significant debate, thinking and evaluation.

On the whole, there continues to be broad support for many of the SHoT principles, recognising that this should be a process of evolution rather than revolution. In the future, it will be essential that any changes to training curricula and programmes align with service need, but recognise that there are various opportunities and flexibilities already present within existing training programmes. It is also recognised that doctors need to be confident and able to provide safe emergency or acute care in their defined specialty area by the end of their postgraduate training.

Over the past two decades, hospital doctors have become increasingly specialised and, in some areas, are losing the ability or commitment to provide generalist care. Many specialists now say this is why they cannot contribute to emergency on-call rotas. Since 50% of all hospital admissions are unscheduled, staffing sustainable on-call rotas has become a major challenge for service providers.

The question as to whether training in the surgical disciplines can be shortened has been much debated, with concerns raised by trainee organisations and others regarding the experience and confidence of surgeons at the time of award of a Certificate of Completion of Training if training is shortened, given the known impact of reduced hours of training due to the European Working Time Directive. What has emerged, however, is a general acceptance that it is important to deliver mentoring or more formalised professional support for new consultants in their first few years of practice.

Surgical education and training in the UK is highly regarded internationally, yet it must continue to adapt to ensure it meets future patient and service needs. The SHoT report has stimulated a fruitful debate about how this should be taken forward. Educational bodies and organisations have a responsibility to lead any required developments and modifications that will ensure highquality scheduled and unscheduled surgical care continues to be delivered by appropriately trained clinicians. rcsed.ac.uk | 43

SHOT PROGRESS REPORT

‘NO SHORTENING, NO DUMBING DOWN’

Jon Lund explains how a modular approach to general surgery training could allow the specialty to develop and meet the SHoT recommendations

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here have been several reviews of postgraduate training over the decades, with varying degrees of implementation of their recommendations. Each has been an opportunity to look at the surgical curriculum and make changes if required.

While still largely fit for purpose, there are areas of the excellent 2013 general surgery curriculum that could be adapted.

However, there is anxiety that training in general surgery will be shortened and ‘dumbed down’. Greenaway writes: “The exit point of postgraduate training will be the Certificate of Specialty Training.

It marks the point at which doctors are able to practise in their identified scope of practice, with no clinical supervision, while working in multi-professional teams.” For the scope of practice of a general surgeon, this means no change is needed to the level of knowledge, skills and attributes required

to be a consultant in our specialty: so, no shortening, no dumbing down.

Broadening the base of training was one of Greenaway’s key recommendations.

Certainly, early years of training in surgery may need an overhaul and protection to avoid a slow slide into de facto FY3 and FY4 posts, with little training in surgery. The 2013 curriculum is already modular, but the expression of this is tacit from day to day.

If a modular approach is taken across specialties, there could be a common stem to training in similar surgical specialty groups. Modules could include intensive care medicine, A&E medicine and vascular surgery, alongside emergency general, elective general and day-case surgery.

Dedicated blocks in emergency general surgery would allow rapid development of skills and experience. A few months in the day-case unit would put trainees where most of the operations suitable for training are performed. Ring-fenced time learning

Core years of training in surgery may need protection to avoid a slow slide into de facto FY3 and FY4 posts, with little training in surgery 44 | Surgeons’ News | June 2016

the technical craft of surgery would be enjoyable and could address concerns about low morale among core trainees.

The modular curriculum would continue into higher surgical training. It is suggested that there would be generic general surgery training in the first four years of higher training, exposing trainees to modules in emergency general surgery, gastrointestinal surgery and perhaps an optional module.

The last two years of higher training would focus on developing skills in a special interest and becoming a skilled emergency surgeon. However, not everyone needs skills in emergency general surgery. Release from it after ST4 for those developing a special interest in breast surgery, say, might allow time for skills now in the TIG Fellowship to be gained by all. CCT/CST would remain at the same level, with graduates from training being competent in at least 90% of the scope of their specialty.

Surgical curricula need to evolve with patients’ needs. Reports such as SHoT enable us to assess what we do and keep moving forward.

Professor Jonathan Lund Chair of the SAC in General Surgery

IN A GOOD POSITION

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Trauma and orthopaedics’ long-term focus on training across the breadth of the specialty means it is well placed to respond to the Greenaway report

he trauma and orthopaedic (T&O) curriculum has always focused on training across the breadth of the specialty, with its stated aims being to produce CCT holders who can definitively care for most of the patients needing emergency care, and to be able to recognise and refer patients for more specialised definitive management.

Therefore, with respect to SHoT’s key themes, T&O has started in a very good place and as a specialty we do not foresee the need to make any major changes in the overall end product of our training.

While T&O itself may not need to change, looking at surgery as a whole, the current review of the core surgery curriculum should ensure that the structure and function of core training delivers an appropriate breadth of experience along with transferable skills, as recommended in the report. It is also particularly in core training where we need to meet another of the report’s recommendations, which is that training should be delivered in units providing high-quality training and supervision.

We recognise that currently many of these posts focus too much on service at the expense of training.

Moving away from the report’s broad themes, and considering several of its more detailed recommendations, there are, again, areas where T&O is well placed. The current curriculum includes a section on professional behaviour and leadership skills that incorporates a number of the themes in the GMC’s proposed general professional capabilities framework, which followed on from one of the SHoT recommendations. So although some work will be required to adapt the curriculum to incorporate the new framework, many of the elements are

already in place and this will not be a major change for T&O. T&O is also in a good position to meet the recommendation that processes and assessments should be in place to allow doctors to progress at an appropriate pace through training. The waypoint assessments that have been happening for the last two years provide just that sort of check by enforcing a consistency in approach to ARCP. It would be wrong to assume that the SHoT report did not pose any challenges for T&O. We are a broad specialty, encompassing a number of subspecialty areas. In order to deliver this breadth with appropriate competence at the point of CCT, current programmes are frequently organised into six-monthly rotations. We will have to carefully consider how to reconcile the requirement for numerous placements in order to deliver breadth with the recommendation for longer placements to improve team working and deliver apprenticeship-style training.

One final challenge for T&O to consider will be the role for credentialing of some subspecialty areas or procedures. This is not felt to be necessary at present, but will need to be kept under review as subspecialties develop and new procedures emerge.

David Large Chairman SAC T&O and Honorary Clinical Associate Professor, University of Glasgow

T&O is also in a good position to meet the recommendation that processes and assessments should be in place to allow doctors to progress at an appropriate pace through training www.rcsed.ac.uk rcsed.ac.uk || 45 45

SHOT PROGRESS REPORT

Ian Eardley examines a working group’s proposals to solve long-standing issues within surgical training

REDRESSING THE BALANCE

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or some time, there has been growing dissatisfaction with aspects of surgical training, particularly the early years, and SHoT provided a platform to discuss these problems with Health Education England (HEE). As a consequence, HEE commissioned the Royal College of Surgeons of England to explore these issues and suggest solutions. The working group included representatives of the Joint Committee for Surgical Training, Intercollegiate Surgical Curriculum Programme, the Specialty Advisory Committees, specialty associations, schools of surgery and trainee organisations with the report ‘Improving Surgical Training’ submitted to HEE in September 2015.

The report identified a number of problems with surgical training. Most importantly, it concluded that the balance between service and training had tipped too far towards service delivery at the expense of training, especially in the early years of training. Not only was the service component excessive, but it was often inappropriate, with increasing administration and ward work replacing more valuable training opportunities in the operating theatre or outpatient clinic.

The group proposed a number of changes. The first was to reduce the service commitment of trainees. While some service commitment is valuable, too much is counter-productive. In the early years of training, shift systems, the need to cover acute take at the expense of everything else and increasing problems with rota gaps have all diminished available training time.

Potential solutions included merging tiers of rotas, where feasible, radically

46 | Surgeons’ News | June 2016

The report concluded that the balance between service and training had tipped too far towards service delivery at the expense of training altering rota design with a minimum of 10 people in a full-shift on-call rota, and use of a non-medical workforce to supplement or replace junior surgical trainees.

Another area in need of improvement, according to the group, is training quality.

Specific proposals included trainers being required to demonstrate aptitude and training for the role and being given adequate time in their job plan to deliver high-quality training. The group also proposed that trainees should be allocated to high-quality training units.

The third area for change was in the process of training. It is perhaps strange that we have a time-based curriculum in which all trainees are deemed to progress at the same speed.

We know that is not true. Accordingly, the group recommended a move towards competency-based progression, with defined and explicit targets combined with robust assessment of whether trainees had achieved those targets and enhanced use of simulation to accelerate

progression. For competence-based progression to succeed, a run-through structure would have advantages in that trainees could progress at different speeds.

If run-through is to succeed, then the ARCP process needs enhancement to be able to speed up, or slow down, the trainee as appropriate.

Content of training was the final area the group identified for improvement.

General surgery was the main focus of discussion, with the recognised service need for specialists who can provide general, elective and emergency care for patients with abdominal problems.

Increasingly, subspecialist areas of surgical practice, such as hepatic resection, oesophago-gastric resection for cancer and low rectal resections were not the province of every general surgeon and might more usefully be delivered by post-CCT training. Similarly, breast surgery has developed to such an extent that many breast surgeons, on achieving CCT, immediately leave the general surgery acute rota.

Following the report’s submission, the response from HEE was positive and a business case has been submitted outlining a potential pilot programme in general surgery. The response to the business case is awaited, but it is interesting to note that the Vascular Society and Vascular Surgery SAC, having seen the original document, are keen to pursue a similar pilot in vascular surgery and they have written to HEE in relation to this.

Ian Eardley Consultant Urologist, Leeds Teaching Hospital Trust, and Vice-President, Royal College of Surgeons of England

The battle against dental caries in children has come a long way, but much more remains to be done to combat this national scandal, writes Professor Bill Saunders

SUGAR, SUGAR

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ental Council and our Fellows and Members comprise some of the pivotal and influential opinion leaders of the profession and help drive a fundamental agenda to improve the health of our patients. This is central to the ethos of the College. In the past, Council has been criticised for not contributing sufficiently to the political debate regarding health matters. In the last few years, we have tried to address this perceived weakness and the staff in our Birmingham office, with their experience in political lobbying, have provided outstanding advice and kept us up to speed with consultations from a wide range of organisations, including the government, that are relevant to us.

The Vice Dean, Dr Sarah Manton, is responsible for this aspect of the Dental Council’s activity. She collates responses to consultations provided by appropriate experts on Council and sends them to Birmingham, where they are reviewed and passed to the relevant authorities. This is combined with engagement with relevant individuals and organisations.

Most recently, the Chancellor of the Exchequer’s introduction of a sugar tax has been widely welcomed by the medical and dental professions. Although it might be argued that the dental aspects of the damage created by excessive sugar consumption have been subsumed by the general health issues, the problems we face in dentistry related to sugar consumption continue.

I can remember children’s general anaesthetic sessions at the Royal Dental Hospital of London when I was a student in the late 1960s. The anaesthetist whose unenviable job was to anaesthetise these children was a charismatic and skilful man, who never panicked even when the patient went into laryngeal spasm during our attempts at inhalation general anaesthesia.

Rumour had it he had anaesthetised royalty. We, as naïve young students, found the sessions stressful and upsetting, as children, some as young as five, had many, if not all, their teeth extracted with all the associated postoperative distress of pain and bleeding. This was in the days before fluoride toothpaste was widely available.

Despite improved oral health measures, it is very sobering to read a guest editorial by Professor Chris Deery in Dental Update in which the number of general anaesthetics for dental caries in children was described as a ‘national disgrace’1. It is difficult to imagine that, in these purportedly enlightened times, 66,859 anaesthetics were given to children and young adults in the UK in 2013–14 for dental caries. This is a scandal and more effort must be made to prevent this most preventable of diseases.

Of course, huge efforts have been made by the profession to support government initiatives. The Childsmile scheme in Scotland is an example where national measures are reaping rewards by providing fluoride applications and supervised toothbrushing for young children2,3. It is clear more needs to be done.

Whether the sugar tax will help this aspect of health remains to be seen, but it is our responsibility to continue to educate the population and support any projects that will encourage dental and systemic health. Your Dental Council will continue to lobby the UK government agencies to ensure our knowledgeable and experienced voice will influence health matters in a reasoned and articulate way.

REFERENCES 1. Deery C, Owen J, Welbury R, Chadwick B. Dental caries in children and the level of repeat general anaesthetics for dental extractions.

A national disgrace. Dental Update, May 2015 2. Macpherson LMD, Anopa Y, Conway DI, McMahon A D. National supervised toothbrushing program and dental decay in Scotland. J Dent Res 2013; 92(2): 109–13 3. Macpherson LM, Ball GE, King P, Chalmers K, Gnich W. Childsmile: The child oral health improvement programme in Scotland. Prim Dent J 2015; 4(4): 33–37

Professor Bill Saunders Dean, Faculty of Dental Surgery

Whether the sugar tax will help this aspect of health remains to be seen, but it is our responsibility to continue to educate the population and support any projects that will encourage dental health rcsed.ac.uk | 47

DENTAL

The top three, from left: third place, Cara Turner, University of Bristol, School of Oral and Dental Sciences; winner, James McParlane, University of Central Lancashire School of Dentistry; second, Alice Hamilton University of Aberdeen School of Medicine and Dentistry

Skills competition winner crowned In March, the Dental Skills Competition to discover the UK’s best undergraduate dentist reached its climax at the Grand Final in Edinburgh

R

Competitors’ handeye coordination was tested with a bead-threading challenge using a lap simulator

48 | Surgeons’ News | June 2016

un by the College and DENTSPLY, the Dental Skills Competition, now in its second year, is designed to showcase the great talent of undergraduate dentists from the UK’s 16 dental schools and help to develop the very best skills and support for our future dental surgeons. Winners from the first round go through to the Grand Final where they are put through a gruelling series of tests designed to push their skills to the limit.

This year’s Grand Final winner was 25-year-old James McParlane from the University of Central Lancashire.

“The importance of winning this amazing competition hasn’t really sunk in yet,” he said. “I would definitely

recommend that my colleagues join the competition next year, as it really challenges you to strive for perfection.”

McParlane continued: “Arguably one of the most important aspects of dental care is to demonstrate technical and communication skills. This competition focuses on those skills and the delivery of excellent dental treatment.”

Skills tested in this year’s competition ranged from suturing (stitching) and fracture restoration to communicating with patients and tooth-shade matching.

“The competition really captures the students’ enthusiasm and drive, challenging a range of key clinical dental skills – it’s the dental schools’ equivalent of The Great British Bake Off!” said Brian Nattress, a member of Dental Council at the College and a Consultant Restorative Dentist in Leeds. “There was a real sense of excitement in the final and a great atmosphere. I felt honoured to see the students in action and witness again the great sense of camaraderie as they competed alongside colleagues from other dental schools in the Grand Final.”

McParlane earned an all-expenses-paid trip to one of DENTSPLY’s Endodontic Academy “A–Z of Endo” events in Ballaigues, Switzerland.

“It has been our absolute pleasure and honour to co-host the Dental Skills Competition with the Royal College of Surgeons of Edinburgh,” said Olivier Collet, Vice-President and General Manager at DENTSPLY UK. “Through delivering clinical education as well as quality and innovative solutions for better healthcare, DENTSPLY recognises the importance of supporting and encouraging some of the very best students in our industry who will go on to be the very best in their profession. The standard of clinical skills we have witnessed over the course of this exciting competition reinforces DENTSPLY’s commitment to delivering happiness, health and wellbeing.”

More than 300 students competed for this year’s title from approximately 2,000 final-year undergraduates.

“One of the major aims of the Dental Faculty of the RCSEd is to set and quality-assure the highest standards for the dental profession, and recognise that with the award of Membership and Fellowship,” said William Saunders, Dean

The finalists had to complete a range of challenging tests

This year’s contestants outside the College

The clinical skills competition really captures the students’ enthusiasm and drive – it’s the dental schools’ equivalent of The Great British Bake Off! of the Dental Faculty at the RCSEd. “This competition is a shining example of ensuring that those standards are constantly being challenged and updated, with students benefiting from the networking opportunities it brings.

RCSEd is keen to interact with the undergraduate dental schools in the UK, and this competition provides an excellent way for dental students to become engaged with us. We are most grateful to DENTSPLY for its collaboration to make this competition possible.”

rcsed.ac.uk | 49

DENTAL

/ OUTREACH

MFDS lectures spread the word

O

ver the past eight months, the Dental Faculty has reached out to almost 600 students through a series of lectures about the MFDS exam and a career in dentistry.

It is the sixth year running that the Dental Faculty has worked with local Fellows around the country to deliver informative MFDS lectures to final-year dental students.

OUR THANKS GOES TO THE FOLLOWING GUEST LECTURERS: Glasgow Dental School, Dr Sarah Manton Aberdeen Dental School, Mr Martin Donachie Barts, Phil Taylor Belfast, Dr Gerry Mckenna Birmingham, Dr David Attrill Bristol, Professor Jonathan Sandy Cardiff, Mr Will McLaughlin Dundee, Dr Brendan Scott Leeds, Dr Brian Nattress Liverpool, Professor Callum Youngson Manchester, Professor Nick Grey Newcastle, Mr Francis Nohl Peninsula, Mr Matthew Moore

/ REPORT

Mouthguard call to arms The Faculty of Sport and Exercise Medicine (FSEM) has published ‘Mouthguard Use in Sport’ on its website for the SEM community, GPs and allied health professionals to encourage the regular use of mouthguards where dental trauma may occur.

The statement, created in collaboration with the Faculty of Dental Surgery (FDS) at the Royal College of Surgeons of England, includes a handy guide to the different levels of mouthguard protection available, with the recommended option being a custom-fitted model.

The FSEM and the FDS recommend that all schoolage children participating in sport wear a mouthguard to prevent traumatic dental injuries resulting in extensive restorative treatment.

50 | Surgeons’ News | June 2016

/ TOOTH DECAY

College tackles poor oral health

T

he College’s Dental Faculty is calling on the government to do more to combat tooth decay, with hospitals spending £35m on ‘rotting teeth’ in children.

Responding to a report by the Local Government Association (LGA) that shows an increase in the number of children having to undergo surgery to remove rotten teeth, Dental Dean Professor Bill Saunders said: “The increase in the number of children having this painful and often traumatic form of surgery is nothing short of shameful, and the LGA’s findings should be an important wake-up call for government.

“Dental decay is the top cause of hospital admission for children aged between five and nine, and this is a perfectly avoidable epidemic caused by excessive use of sugar in food and drink, confusing labelling, uneven access to fluoridised water and a lack of coherent public health interventions.

“Around 40% of 11- to 15-yearolds have a sugary drink at least once a day, so the introduction of a sugar tax is a welcome first step.

However, we call on governments throughout the UK to urgently devise and implement a national obesity strategy that contains measures to reduce sugar content in a wide range of food and drinks, as well as a national oral strategy to deal with this specific issue.”

Regional Dental Adviser vacancies The Dental Faculty welcomes expressions of interest from enthusiastic individuals to become Regional Dental Advisers or International Dental Advisers in the following areas: UK & Ireland: North East of Scotland; Tayside; West of Scotland; East of England; Kent, Surrey and Sussex; North West of England; North London; North East London; North West London; Oxford; East Midlands; South West of England; Yorkshire; Wales; and Republic of Ireland International: Dubai; Hong Kong; Baltic States; Brunei Application forms and further details may be obtained from outreach@rcsed.ac.uk. The closing date for applications is 30 June 2016.

Upcoming events

2 September: BDA Scottish Scientific Conference and Exhibition 11 November: Leeds Dental Roadshow 13 December: MFDS Lecture, Glasgow

For more information, contact outreach@rcsed.ac.uk

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

NORTH EAST OF SCOTLAND 1 Martin Donachie, Aberdeen Royal Infirmary SOUTH EAST OF SCOTLAND 2 Donald Thomson, Dundee Dental School (Based in Dundee, acts as adviser for South East Scotland)

1

TAYSIDE 2 Brendan Scott, Dundee Dental School

2

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

3

ENGLAND

EAST OF ENGLAND 4 Simon Wardle, James Paget University Hospital, Great Yarmouth 18

KENT, SURREY & SUSSEX 5 Lindsay Winchester, Queen Victoria Hospital, East Grinstead NORTH WEST OF ENGLAND 6 Alex Milosevic, Liverpool University Dental Hospital 7 Mike Pemberton, University Dental Hospital of Manchester 8 Callum Youngson, School of Dentistry, Liverpool

15

17 16

6

7 8

13

NORTH LONDON 9 Phil Taylor, Barts and the London School of Medicine and Dentistry, London 4

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

12

NORTH WEST LONDON 11 Sumithra Hewage, Northwick Park Hospital, Harrow OXFORD 12 Mary McKnight, John Radcliffe Hospital, Oxford SOUTH YORKSHIRE/EAST MIDLANDS 13 Philip Benson, Charles Clifford Dental Hospital, Sheffield SOUTH WEST OF ENGLAND 10 Crispian Scully, UCL Eastman Dental Institute, London (Based in London, acts as adviser for Avon) 14 Pamela Ellis, Dorset County Hospital, Dorset YORKSHIRE 15 Brian Nattress, Leeds Dental Institute, Leeds

WALES

16 Joy Hickman, Glan Clywyd Hospital, Clwyd

11

10 9

14

5

REPUBLIC OF IRELAND

17 Simon Wolstencroft, St James’ Hospital, Dublin

NORTHERN IRELAND

18 Gerald McKenna, Queen’s University Belfast

RDA VACANCIES

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

rcsed.ac.uk | 51

TRAINEES AND STUDENTS

For its 40th anniversary, ASiT hosted a packed conference to provide inspiration, hands-on training and advice to UK trainees

ASiT IS 40!

L

iverpool was the host of #ASiT2016, the 40th anniversary celebration of the Association of Surgeons in Training (ASiT). In a weekend, the conference packed in updates in surgical training, education, festivities, reminiscence and thoughts on the future.

The weekend began with ASiT’s pre-conference courses: low-cost, high-yield environments enabling trainees to practise the skills necessary for a career in surgery, from laparoscopic training to research skills. We held 12 this year, all of which received excellent feedback and were highly recommended by delegates.

More than 1,200 abstracts were submitted, with 500 accepted as oral and poster presentations, enabling trainees to showcase their research. Attended by 700 delegates, the conference was trending on Twitter within two hours of opening.

The ASiT Charity Gala Dinner was held in aid of BFIRST, a charity that trains reconstructive surgeons in low- and middle-income countries. It took place in Liverpool Metropolitan Cathedral’s magnificent Crypt Hall.

Professor Sir Bruce Keogh, Medical Director for NHS England, gave an inspirational opening talk, telling trainees: “You are our best agents for change and promoting quality across the NHS.” He reminded us that even when people are spread around the country, working together towards common goals produces much better results.

The Silver Scalpel Award, which is kindly sponsored by Swann Morton, is the UK’s premier surgical training award, with an illustrious list of past winners, including the current President of the RCSEd, Michael Lavelle-Jones (2014).

David O’Regan, an ASiT Past President, who conceived the award in 2000, detailed the rigorous interview and selection process, with the winner selected by Professor Sir Bruce Keogh. O’Regan also outlined seven habits that help make a great trainer (see right).

The 2015 Silver Scalpel Award winner and ‘virtual surgeon’, Shafi Ahmed, took to the stage on a Segway. He discussed ‘Virtual Strikes’ in his prestigious Silver Scalpel Lecture. He took no prisoners and gave some strong advice to the delegation: “If you see a problem, present

Vimal Gokani Adam Williams James Glasbey Rhiannon Harries

Liz O’Riordan, a breast surgeon who is fighting breast cancer, moved the audience to tears in her heart-rending talk on what it is like to be a patient 52 | Surgeons’ News | June 2016

it with a solution.” The 2016 winner of the Silver Scalpel Award was revealed to be ISCP Director and Dundee vascular surgeon Gareth Griffiths.

ASiT was honoured to have the leaders of UK surgical training take part in a panel discussion. Speakers were asked to justify the College Membership and JCST fees, remind us of the College roles in training and education, and raise spirits in a time of low morale. Lavelle-Jones ended the session with the words “…don’t forget that it’s a truly great job”. We couldn’t agree more.

John Black, Past ASiT President and Past President of the RCSEng, gave a candid lecture about learning from the past. He summarised it rather well, too: “Don’t make the same mistakes again.”

Left: Presidents’ Question Time (from left): Rhiannon Harries (ASiT President 2015–16); Adam Williams (ASiT President 2016–17); Michael LavelleJones (PRCSEd); Declan Magee (PRCSI); David Galloway (PRCPSG); Ian Eardley (VP RCSEng) Right: Courses under way

Seven habits of highly effective trainers

Give time generously Be adaptable Clarify expectations Give constructive and timely feedback Know when to direct, teach, coach or mentor Confront problems Seek continual improvement and professional development

Above: The Silver Scalpel was awarded to Gareth Griffiths (second from right), ISCP Director

Liz O’Riordan, a breast surgeon who is fighting breast cancer, moved the audience to tears in her heart-rending talk on what it is like to be a patient. Have you ever appreciated how it feels to be in a waiting room, waiting to see a cancer specialist?

In parallel consensus sessions on training opportunities in global surgery and research training requirements in surgical training, thoughts were collated and transcribed into position statements. Watch out for these in a journal near you. Each collaborator will be cited as a searchable author, just like our consensus statement from #ASiT2015.

Johann Malawana updated trainees on the progress of the much-discussed imposition of junior doctor contracts, Stephen Cannon spoke about credentialing for cosmetic surgery, Stephen Westaby talked about the negatives of surgeon-specific outcomes, and Danny Kennan discussed the importance of high-quality data in reporting surgeonspecific outcomes.

Sunday saw the session ‘It’s a Man’s World... Or Is it?’, opened by the UK’s first female professor of surgery, Averil Mansfield. Cardiothoracic surgeon Farah Bhatti prepared a video talk with Heather Logghe, the Californian surgeon who started #ILookLikeASurgeon to break gender stereotypes. Consultant breast surgeon Clare Murphy told us how we can successfully train less-than-full-time, a pathway that ASiT fully supports.

In the Conflict and Catastrophes session, delegates heard from Lt Col Niall Martin about working in a war zone, Janso Padickakudi about tackling the Ebola virus in Sierra Leone, and Chris Oppong about how to get involved in Operation Hernia.

In the session on preparing for life as a consultant, Des Winter spoke about spotting the early signs of a deteriorating patient, Past ASiT President Goldie Khera explained how to ace the consultant interview, and Ewen Harrison (also an ASiT Past President) told us about academic surgery. Tim Archer gave advice on managing the managers and Geoffrey Glazer enlightened the audience about private practice.

The conference would not have been possible without the sponsors, in particular our Diamond Sponsors Medtronic, who help to make the event affordable for trainees. #ASiT2017 will be in Bournemouth, 31 March– 2 April 2017, organised by the 2016–17 President, Adam Williams. He will be representing us on the JCST (among other committees), so if you have any concerns about your training, please get in touch: info@asit.org, @ASiTofficial rcsed.ac.uk | 53

TRAINEES AND STUDENTS

SURGICAL SKILLS COMPETITION 2016–17 The College joins with Medtronic to give final-year students the opportunity to gain valuable experience and compete with students across the country

T

he RCSEd is delighted to announce that this year sees the return of the College’s National Student Surgical Skills Competition, a collaboration between Medtronic and the College to deliver opportunities for final-year medical students at UK universities to develop their basic surgical skills and compete against their peers at regional and national level.

The competition will be delivered by our fantastic network of Regional Surgical Advisers and with the support of the Faculty of Surgical Trainers.

Heats will run in autumn/winter 2016 in 19 regions and the Grand Final in Edinburgh will be in February 2017.

Check the College website for more information

54 | Surgeons’ News | June 2016

Winner of the 2012–2013 competition: Jamie Clements (Queen’s University Belfast)

“The experience and training I will obtain from such an opportunity is inestimable and an experience that not many people get. In terms of my future career and building up my portfolio and CV, I’m certainly heading in the right direction.

I’m quite overcome by the amount of opportunities that are now available to me through this competition and affiliating with RCSEd.”

Winner of the 2011–2012 competition: Mark Mobley (University of Warwick)

“I found the final of the competition challenging and learned a lot from it. I really enjoyed practising on the laparoscopic station, as I’d never used such state-of-the-art equipment before. It was also my first opportunity to carry out tendon repair – I’d witnessed it being done hundreds of times, but to actually be able to do it myself and do it well was a really rewarding experience and a great achievement for me. Winning this competition has now given me a steer in my career ambitions.”

INNOVATING WITH PATIENTS AND HEALTHCARE PROFESSIONALS IN MIND

Helping patients get healthy, feel better, live longer is all in a day’s work at Medtronic. Helping healthcare systems be more efficient is, too.

Learn about how we’re taking healthcare Further, Together by visiting Medtronic.com.

UC201602145j EN © 2016 Medtronic All Rights Reserved

COLLEGE INFORMATION

All the latest grants, fellowships and bursaries from the RCSEd

AWARDS & GRANTS Small Research Grant

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

Applications for grants of up to £10,000 are invited from surgical trainees

DIARY

JUNE 2016 3

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

The latest surgical and dental events, seminars and courses

11–12 14 23–24 27–28 29 29 30 June–1 July 30

Perioperative care practitioners’ Intraoperative Non-Technical Skills course (PINTS) Basic Surgical Skills Course (Manchester) Leadership and Development for Perioperative Care Practitioners Basic Surgical Skills Course Basic Surgical Skills Course (Birmingham) Tendon Transfers in Foot and Ankle Surgery Training the Trainers Foundation Essentials (Birmingham) Training the Trainers (Birmingham) Evening Symposium

JULY 2016 5 7–8 16–17

Preparation for the Diploma in Implant Dentistry Course (London) Basic Surgical Skills Course Basic Surgical Skills Course (Manchester)

AUGUST 2016 3–5 Trans-anal Endoscopic Microsurgery Course (TEMS) 25–28 MFDS Part 1 Revision Course (Dubai)

For further information, please email education@rcsed.ac.uk or telephone +44 (0)131 527 1600. All events are in Edinburgh unless otherwise stated.

56 | Surgeons’ News | June 2016

include a well-defined exit strategy (i.e. how the project will be taken forward).

Closing date for receipt of applications is Wednesday 15 June 2016.

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.

The closing date for applications is Wednesday 15 June 2016.

Travelling Fellowships

The Cutner Travelling Fellowship in Orthopaedics The John Steyn Travelling Fellowship in Urology Sir James Fraser Travelling Fellowship in General Surgery The Alban Barros D’Sa Memorial Travelling Fellowship in General Surgery

The closing date for receipt of applications is Wednesday 15 June 2016.

Syme Medal

The Syme Medal is a prestigious mark of excellence awarded by the College to a Fellow or Member of the College in good standing, on the basis of a recently submitted thesis (MD or PhD), published body of research or educational development. Research should have been published in high-quality peer-reviewed

journals. Consideration will be given to the impact of work on future research or clinical practice. The Syme Medal is to be awarded to surgeons in training or recently appointed consultants and is distinct from the King James IV Professorship.

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

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

Closing date for applications is Wednesday 15 June 2016.

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.

Joint RCSEd/SOMS/Shanghai Head & Neck Fellowship

Applications are invited from Members/ Fellows of the RSCEd 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 Jiao Tong 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, which should be sent to Mrs Cathy McCartney at c.mccartney@rcsed.ac.uk. Applicants

for the Fellowship 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 Wednesday 29 June 2016.

Wong Choon Hee Medical Student Elective Travel Bursary

The RCSEd, in association with Meducatus (www.meducatus.com), is pleased to offer medical students an opportunity to apply for financial support towards their elective in surgery.

This award is open to medical students in the UK and the Republic of Ireland undertaking approved surgical

rcsed.ac.uk | 57

COLLEGE INFORMATION

electives abroad. This award is advertised and awarded annually in September. It provides the successful applicant with a contribution towards the overall costs of travel and subsistence.

For further information, please contact Mrs Cathy McCartney, or download the guidance notes and application from the Awards and Grants page at www.rcsed.ac.uk.

Closing date for applications is Wednesday 6 July 2016.

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.

Currently one joint clinical research training Fellowship is available, open to RCSEd Fellows and Members who meet the eligibility criteria set out by the MRC under guidance for applicants.

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.

The deadline for submissions for this round is 4pm on 8 September 2016, with shortlisting taking place in February 2017.

Interviews will be held on 1–2 March 2017 and take-up dates will be between April to September 2017.

For more details, please contact c.mccartney@rcsed.ac.uk or to apply visit the MRC website.

Applications open on 29 July 2016.

CONGRATULATIONS TO THE FOLLOWING AWARDS AND GRANTS RECIPIENTS Africa Bursary

D Barkwill, University of East Anglia. Visiting Chidamoyo Hospital, Zimbabwe.

S Tingle, Newcastle University.

Visiting Haydom Lutheran Hospital, Tanzania.

P Chauhan, University of Birmingham. Visiting the Department of General Surgery, Kilimanjaro Christian Medical Centre, Tanzania.

V Naruka, University of Cambridge. Visiting Somerset Hospital, Cape Town, South Africa.

Ethicon Travel Grant

Saheel Mukhtar, visiting the Sindh Institute of Urology and Transplantation, Pakistan. To gain further experience in urological stone disease.

Paul Sutton, visiting the Division of Endoscopy Submucosal Dissection, Japan, Richard Wolf Centre and Städtisches Klinikum Karlsruhe Hospital, Germany.

Endoscopic submucosal dissection in Japan and Transanal endoscopic microsurgery in Germany.

Louisa Ferguson, visiting the Otolaryngology Department at the Royal Children’s

58 | Surgeons’ News | June 2016

Hospital, Melbourne, Australia. Paediatric Otolaryngology Fellowship.

Ethicon Bursary

Yasser Al Omran, Barts and the London School of Medicine and Dentistry.

Visiting Plastic Surgery, New York Presbyterian Hospital.

John Allen, Imperial College London. Visiting the Department of Otolaryngology – Head and Neck Surgery at the Johns Hopkins Hospital, USA. Ryan Preece, Cardiff University.

Visiting the Department of Surgery, Karapitiya Teaching Hospital, Sri Lanka.

Zaamin Hussain, University of Cambridge. Visiting the Orthopaedic Clinic, Vail, Colorado, USA. Catherine Lovegrove, King’s College London. Visiting the Urology Department, Roswell Park Cancer Institute, New York and Johns Hopkins Hospital, USA.

Small Research Grants

Mr Adam Frampton, Honorary Clinical Lecturer in General Surgery, Imperial College London.

The microRNA processing endoribonuclease dicer has altered expression in pancreatic ductal adenocarcinoma and prognostic implications.

Mr Jason Wong, Academic Consultant Plastic Surgeon, University of Manchester.

In vivo reprogramming of transplantable tissue using the mouse AV loop.

Mr Carlo Ceresa, Clinical Research Fellow in Transplantation, University of Oxford.

The effects of normothermic machine perfusion on human steatotic livers utilised for transplantation.

Dr Rachel Guest, Clinical Lecturer and Honorary Specialty Registrar in General Surgery, University of Edinburgh.

An unbiased screen for novel molecular biomarkers of the progression of primary sclerosing cholangitis to cholangiocarcinoma.

Mr Iestyn Shapey, Specialist Trainee in General and Transplantation Surgery, University of Manchester.

Circulating unmethylated DNA and beta-cell death

as a biomarker of graft dysfunction in pancreas and islet transplantation.

Dr Nick Kalson, NIHR Academic Clinical Fellow in Orthopaedics, Newcastle University.

Investigation of signalling pathways driving tissue fibrosis after total knee replacement.

The Joint RCSEd/ Cutner Fellowship in Orthopaedics

Mr Shao-Ting Tsang, Specialty Registrar in Trauma & Orthopaedics, University of Edinburgh.

An Investigation into the effect physical modalities have on antibiotic efficacy in an in-vitro Staphylococcus aureus biofilm model.

The Maurice Wohl Research Fellowship in Surgery/Dental Surgery Mr Iestyn Shapey, Specialty Trainee in General and Transplantation Surgery, University of Manchester.

Circulating unmethylated DNA and beta-cell death as a biomarker of graft dysfunction in pancreas and islet transplantation.

DIPLOMA CEREMONIES Congratulations to all our new Fellows and Members who were presented with diplomas at ceremonies in Edinburgh and Myanmar FRIDAY 18 MARCH 2016 Honorary Fellowship Professor J David Richardson FACS, President of the American College of Surgeons and Professor of Surgery, University of Louisville School of Medicine, Kentucky, US Fellowship Ad Hominem Professor Bipin Batra, Executive Director, National Board of Examination, Ministry of Health and Family Welfare, Government of India Professor Kevin C P Conlon FRCSIrel FACS FRCPSGlasg, Professor of Surgery, University of Dublin, Trinity College and Consultant Surgeon, St Vincent’s University Hospital and Tallaght Hospital Rhona Flin FBPsS, FRSE, FRAeS, Emeritus Professor of Applied Psychology, King’s College, University of Aberdeen Dr Thandalam Sundararajan Surendran, ViceChairman and Director, Department of Paediatric Ophthalmology, Sankara Nethralaya, India Fellowship Without Examination Mr Kapil Kumar FRCPSGlasg(Tr&Orth), Consultant Orthopaedic Surgeon, NHS Grampian, Aberdeen Award of Fellowship in Dental Surgery Without Examination Dr Alfred P F So FDS RCPSGlasg, Dental Surgeon, Hong Kong The Syme Medal Grant Duncan Stewart, University of Edinburgh The G B Ong Medal Nikola Alexandra Henderson, University of Dundee Diplomas of Fellowship in the Specialty of General Surgery Nikola Alexandra Henderson, University of Dundee Peter Stuart Mckechnie, University of Glasgow Chetan Dalpatbhai Parmar, Maharaja Sayajirao University of Baroda, India Rachel Emma Soulsby, University of London Laura Whittaker, University of Leeds Diploma of Fellowship in the Specialty of Neurosurgery Haider Ramadhan Kareem, University of Basrah, Iraq

Diplomas of Fellowship in the Specialty of Oral and Maxillofacial Surgery Andrew Nicholas Brown, University of Leeds George Andrew William Gardner, University of Dundee Jiten Devendra Parmar, University of Manchester Diploma of Fellowship in the Specialty of Otolaryngology Priya Achar, University of Mumbai, India Diploma of Fellowship in the Specialty of Paediatric Surgery Prabhu Sekaran, University of Edinburgh Diplomas of Fellowship in the Specialty of Trauma and Orthopaedic Surgery Ravindra Vijay Badge, University of Mumbai, India Manish Kiran, Dr MGR Medical University, India Paul Yuh Feng Lee, University of Wales Sally-Anne Phillips, University of London Ciara Marie Stevenson, Queen's University Belfast Deepak Vasudev Sree, University of Kerala, India Ashish Vijayan, Bangalore University, India Diploma of Fellowship in the Specialty of Urology Sheikh Nissar Ahmad, University of Kashmir, India Diploma of Membership in Otolaryngology Kristina Ming Kit Lee, University of Edinburgh Intercollegiate Diplomas of Membership in Surgery in General Syed Hussain Abbas, University of Southampton Megan Catherine Anderson, University of Manchester Zay Yar Aung, University of Yangon, Myanmar Tiffany Selina Berrington, University of Manchester Sarvajit Biligere Priyadarshi, Rajiv Gandhi University of Health Sciences, India Jessica Borg, University of Malta Alexander-William Carachi, University of Malta Ramandeep Singh Chalokia, Panjab University, India Samantha Chambers, University of Warwick Anne Sheila Ewing, University of Edinburgh Simon Patrick Goldie, University of Aberdeen Constantine Halkias, University of Ioannina, Greece Jacob Richard Hatt, University of Dundee Thusitha Sampath Hettiarachchi, University of Sri Jayewardenepura, Sri Lanka Matthew Daniel Hillen, University of Dundee

IN MEMORY

HONORARY FELLOWS John Earle CONNOLLY (FRCSEd Hon 1989) Robert Currie CUMMING (FRCSEd Hon 1980) Lloyd D MacLEAN (FRCSEd Hon 1988) Roderick Norman McIver MacSWEEN (Sir) (FRCSEd Hon 2000)

SURGICAL FELLOWS Robert Dyke ACLAND (FRCSEd 1989) John Brian ANCHEN (FRCSEd 1959) Alexander John Milne BIRNIE (FRCSEd 1968) Iain Mackay BRECKENRIDGE (FRCSEd 1964) Peter Lance BRUNNEN (FRCSEd 1948) Alexander Denis CAMPBELL (FRCSEd 1967) Robert Clark CAMPBELL (FRCSEd 1963) Rajesh Kumar CHOUDHARY (FRCSEd 1998) David Julius COHEN (FRCSEd 1963) George Allen DALTON (FRCSEd 1956) William Arthur Roy DAVIES (FRCSEd 1977) Reginald DIXON (FRCSEd 1974) Roshan Lall GUPTA (FRCSEd 1955) Geoffrey HASENOHR (FRCSEd 1966) Peter Colin JEFFERY (FRCSEd 1975) Krishan KAUSHAL (FRCSEd 1968) Peter Francis KING (FRCSEd 1947) Anthony Douglas NOBLE (FRCSEd 1966) Anthony Howard OSBORNE (FRCSEd 1976, FRCSEd(Orth) 1980) Soham Shankerbhai PATEL (FRCSEd 1969) Bruce William Haig SCOTT (FRCSEd 1976) Umesh Chandra SHARMA (FRCSEd 1967) Max Leonard SLOTOVER (FRCSEd 1939) Evan Richard SOICHER (FRCSEd(Ophth) 1996) John Herbert SOWRAY (FRCSEd (without Examination) 1986) Alistair Andrew SPENCE (CBE) (FRCSEd (ad hom) 1991) Cyril TOKER (FRCSEd 1957) David Hedley WILSON (FRCSEd 1964) DENTAL FELLOWS William James Mackenzie BARRIE (FDS RCSEd 1972) Rudolph SPRINZ (FDS RCSEd (without Examination) 1968)

rcsed.ac.uk | 59

COLLEGE INFORMATION

Woon Yang Ho, National University of Singapore Swati Jain, Duke, National University of Singapore Kamilla Mahkamova, Newcastle University Ross Cameron McLean, University of Glasgow Nikheel Vasant Pansare, Maharashtra University of Health Sciences, India Iain Alexander Rankin, University of Glasgow Fahmi Sabr Raza, University of Sulaimani, Iraq Kasra Razi, University of London Abhishek Kumar Reekhaye, Newcastle University Camilla Jay Stewart, University of Edinburgh Kirsten Elizabeth Stewart, University of Dundee Sentilnathan Subramaniam, Manipal University, India Poonam Valand, Universities of Exeter and Plymouth Ahmed Waqas, Quaid-i-Azam University, Pakistan Diploma in Otolaryngology â&#x20AC;&#x201C; Head and Neck Surgery Simon Patrick Goldie, University of Aberdeen Fellowship of the Faculty of Surgical Trainers Jonathan Robert Anderson, University of Birmingham Diploma in Remote and Offshore Medicine Mhairi Ross, University of Wales Diploma of Fellowship in Dental Surgery in the Specialty of Restorative Dentistry Christopher Stewart Millen, University of Glasgow Diploma of Fellowship in Dental Surgery Without Examination (by application) Sherif Ahmed Ahmed El Shazly, Cairo University, Egypt Diploma of Membership in Orthodontics Fahad Alharbi, King Saud University, Saudi Arabia Diplomas of Membership of the Faculty of Dental Surgery Rehan Asmat Alam, University of Health Sciences Lahore, Pakistan Gul-E-Lala Azhar, Riphah International University, Pakistan Nehal Mohamed Aly Fathi Balbaa, Alexandria University, Egypt Zannatul Ferdous, University of Chittagong, Bangladesh Anu Mahajan, Baba Farid University of Health Sciences, India Eva Renuka Pathmananthan, University of London Mir Mohiuddin Sami, Rajiv Gandhi University of Health Sciences, India Asma Sami, Rajiv Gandhi University of Health Sciences, India Ghada Adel Mahmoud Tahoun, Cairo University, Egypt Hajira Tanveer, University of Sindh, Pakistan Diploma in Orthodontic Therapy Jade Hunter, Edinburgh Dental Education Centre

60 | Surgeonsâ&#x20AC;&#x2122; News | June 2016

FRIDAY 22 APRIL 2016 Honorary Fellowship HRH Tuanku Muhriz ibni Almarhum Tuanku Munawir, Sultan of the State of Negeri Sembilan, Malaysia and Chancellor, National University of Malaysia Dr Julie A Freischlag FACS, Professor of Surgery, Davis School of Medicine, Sacramento, Vice-Chancellor, Human Health Sciences and Dean, School of Medicine, University of California Fellowship Ad Hominem Professor Aryono Djuned Pusponegoro FInaCS, Professor Emeritus of Surgery, University of Indonesia Professor James G Wright FRCSC, Professor of Orthopaedic Surgery, University of Oxford Fellowship Without Examination Dr Rajiv Agarwal FRCSEng FACS, Chief of Plastic Surgery, Department of Plastic Surgery and Burns, Sanjay Gandhi PGIMS, India

Dr Arani R Raghuram, Joint Director and Senior Consultant Cardiothoracic Surgeon, SRM Institute of Medical Sciences, Chennai, India The G B Ong Medal Julia Caroline Massey, Newcastle University Diplomas of Fellowship in the Specialty of General Surgery Fayyaz Akbar, University of the Punjab, Pakistan Paul Jose, Bangalore University, India Ben (Jang-Pin) Liu, University of Oxford Diploma of Fellowship in the Specialty of Plastic Surgery Mahalakshmi Nagarajan, Dr MGR Medical University, India Diplomas of Fellowship in the Specialty of Trauma and Orthopaedic Surgery Vijay Tryambakrao Deore, University of Pune, India Krishnaiah Katam, Dr NTR University of Health Sciences, India

Diploma of Fellowship in Dental Surgery Without Examination (by application) Abdulhakim Ahmad Q A Almandaey, University of Damascus, Syria Diploma of Membership in Endodontics Khalid Zuhair K Alghalayini, October 6 University, Egypt Diplomas of Membership in Orthodontics Padraig O'Fearraigh, University of Dublin Jian Zhou, Shanghai Second Medical University, People's Republic of China Diploma of Membership in Paediatric Dental Surgery Andrew Robert McKay, University of Sheffield Diplomas of Membership in Primary Dental Care Wafa Mohammed Ali Abdullatif, Cairo University, Egypt Eman A Jalil Al Hamdan, University of Jordan

Robbie Indrajit Ray, University of Glasgow Suresh Srinivasan, University of Delhi, India Diploma of Fellowship in the Specialty of Urology Ismail Mostafa Ismail El-Mokadem, Ain Shams University, Egypt Diploma of the Joint Surgical Collegesâ&#x20AC;&#x2122; Fellowship in General Surgery Aditya Ajit Manke, Maharashtra University of Health Sciences, India Muwaffaq Mezeil Telfah Telfah, University of Mosul, Iraq The Syme Medal John Robert O'Neill, University of Edinburgh Intercollegiate Diplomas of Membership in Surgery in General A H Ashwin Kumar, Dr NTR University of Health Sciences, India Sanjeet Singh Avtaar Singh, University of Edinburgh

Nicholas Edward Boxall, University of Manchester Faisal Farooq Butt, University of Peshawar, Pakistan Aileen Dobbs, University of Manchester John Fitzpatrick, University of Glasgow Molly Jakeman, University of Manchester Oisin John Francis Keenan, University of Manchester Robert James Lambert, Newcastle University Mark Daniel McMullan, Queen's University Belfast Nisarg Jaysheel Mehta, University of Liverpool Timothy Michael Noblet, University of Leeds Lara Sammut, University of Malta Nishant Singh, Maharashtra University of Health Sciences, India Syed Jeffrey Syed Ahmad Kabeer, University of Glasgow Samir Magzoub Talha Mohamed Talha, University of Medical Sciences & Technology, Sudan Jennifer Jayne Wilson, University of Leeds Bushra Binte Zia, University of Dacca, Bangladesh

Diplomas of Membership of the Faculty of Dental Surgery Mohd Dell Taufik Bin Abd Murat, National University of Malaysia Alison Betts, Newcastle University Suzannah Marietta Boulos, University of Birmingham Priya Vasant Chandarana, University of Birmingham Harpal Singh Flora, University of Leeds Conor Gordon, University of Dublin Siti Salwa Binti Idris, Universiti Kebangsaan, Malaysia Krishani Kalyan, Dr MGR Medical University, India Anita Kaminska, Katowice University, Poland Sreenesh Kandian, Rajiv Gandhi University, India Avni Laijawala, Gujarat University, India Michael Myint, University of London Kiruthika Natarajan, Dr MGR Medical University, India Haafsa Arshad Sahibzada, National University of Sciences & Technology, Pakistan April Sloan, University of Glasgow Uma Syed Rafiq, Dr MGR Medical University, India Patrick Colin Watson, University of Glasgow Heather Wilkes, University of Glasgow Diploma in Implant Dentistry Stuart Aherne, University of Wales Nikunj Patel, University of Wales Graham George Robertson, University of Edinburgh Diploma in Orthodontic Therapy Benjamin Parker Blum, Institute of Postgraduate Dental Education, University of Central Lancashire Alexandra Leigh Bowler, King's Health Partners, London Tanya Eleanor Clarke, Institute of Postgraduate Dental Education, University of Central Lancashire Ceri Leigh Davies, Institute of Postgraduate Dental Education, University of Central Lancashire Rosy Gurung, King's Health Partners, London Louise Hannah Harty, Institute of Postgraduate Dental Education, University of Central Lancashire Hayley Jane Miller, Institute of Postgraduate Dental Education, University of Central Lancashire

rcsed.ac.uk | 61

OUT OF HOURS

Wonders of the world Graham Layer’s culinary capers across continents from the US to Wales via Myanmar

T Graham Layer Consultant Surgeon at the Royal Surrey County Hospital and RCSEd VicePresident

he top-rated restaurant in Washington DC is Fiola on Pennsylvania Avenue, the parent of Fiola Mare, much acclaimed by myself in a previous column. Fiola was significantly more affordable because four of us dined at lunchtime rather than in the evening, and we chose our wine carefully as it’s expensive. The food is divine and essentially Italian, attractive and served perfectly by charming staff. The beautifully decorated contemporary space lacks emotional warmth – not much better than a new outpatients’ department in a PFI hospital – but is almost within earshot of the buzz at the Capitol. The menu is tricky to get your head around, with its zones of sea and land, pasta, antipasti, grilled or ‘winter flora’. You have to pick a starter and a main from the same collection, which is unusual. The titles of the dishes are unhelpful, as the presentation and content is innovative and unexpected.

For instance, the pasta carbonara is like no other I have ever seen: pasta, with a deconstructed carbonara – chunks of ham, parmesan, and all finished with an egg astride the ingredients. It was phenomenal. However, the classic lobster ravioli was a disappointing, solitary package of air with a gorgeous flavour but a feeling that you had been ripped off looking for the lobster. Veal Milanese was brilliant – a whole veal chop complete with skeletal elements, flattened out and coated in a wonderful cheesy crumb. Plain fish with vegetables was very plain, calamari too lifelike in the way it had been dissected, and scallops gigantic, but oysters miniscule. Overall, a glorious exploratory experience, but overrated and not as enjoyable as Fiola Mare on the river.

Contrast this capital city Italian with one in the village of Gullane, East Lothian, just off the famous golf course at the end of the high street. It is not unexpectedly called The Main Course. A cold evening was spent warming up in the delightfully semi-formal surroundings of this popular restaurant with willing staff and effective service and a slightly rustic décor. This time, a classic pasta

62 | Surgeons’ News | June 2016

Yangon is home to numerous delightful restaurants, several near the Shwedagon Pagoda

carbonara that did exactly what you expect for tasty comfort food and looked the business. The other dishes enjoyed by our foursome were equally comforting and great value: grilled salmon, seafood pasta brimming with seafood, risotto and so on. All substantial, absolutely fresh and steaming hot.

Then abroad to colonial Rangoon and the restaurants in Yangon, Myanmar, a selection of which I have been fortunate to try, thus avoiding the extraordinary street food of tripe and chopped-up colon on cocktail sticks. Shan Yoe Yar, a northern Burmese restaurant, said to be fine dining and spicy, had been recommended and it is central and in an old, converted traditional house. I tried it twice: an intimate evening when the offerings were stir-fried pork nerves, hot and sour pork nerves or grilled beef organs. We went for the ribs. This was an unfortunate choice, too, as the bones had been chopped into multiple mouthfuls and consisted of rib with no muscular or neurovascular appendages. The bubbly

Culinary passion in the family I am hugely proud to highlight in this issue that my nephew, Jack Layer, was a finalist in this year’s Masterchef. Like me, Jack has always been passionate about food and visiting great restaurants – it has been an enormous pleasure to introduce Jack to some fine establishments at home and abroad over the years. I’m sure Jack will build on his extraordinary Masterchef success and I look forward to seeing his culinary interests continue to flourish and excite the palates of those lucky enough to taste his fabulous and innovative recipes. @jack_layer; jack-layer.com

James Sommerin, chef at the eponymous restaurant in Wales

Shan-style spicy soup was reminiscent of a hot volcanic lake with surfacing vegetables and drowned noodles. Another attempt at fine dining here was more successful when spicy, fried potato cakes were served with a tomato relish as the starting and sharing course – a sort of chips and tomato ketchup, ideal for hungry diners. Nondescript grey fish was not filleted and bland, but chicken was good as was a banana leaf and sesame concoction. Great atmosphere and dimly lit, but packed out. House of Memories is another old house nearer the Shwedagon Pagoda and is the converted home of General Aung San, whose reconstructed office is open to visit. We dined outside on a mixture of hot stew-like curries, which were uninspiring and all brown by candlelight, although others in our group liked the mixed flavours. A safer option is White Rice, lakeside in a modern, circular pavilion, which serves essentially Chinese food and is more than adequate. Similar Chinese can be found at the Shangri-La Hotel. This hotel also serves a superb juicy hamburger with all the trimmings. But if you really want a Wagyu version, you should try the offering for US$42 at The Governor’s Residence, a hopelessly precious and overpriced colonial-style hotel, much loved by UK bespoke tour operators, but the taxi driver will have fun finding it hidden between diplomatic residences.

Back to Earth and stormy Penarth, on the esplanade again, to an unexpected find, Restaurant James Sommerin – the Scottish Michelin-starred chef of the year moved south to Wales. It is an odd location and a vast space with a frosty maître d’hôtel, but for Sunday lunch he offers a five-course (Traeth) or seven-course (Clogwyn) tasting menu. We went for the seven courses, all of which were small, but the choice of flavours was a huge success: two amuse bouches followed by pea soup, and then a great pork belly strip with octopus and peanuts. Iberico ham followed with a little salad, and then a very large fresh scallop with Jerusalem artichoke, which was disappointingly dominated by fennel. The main course was a more generous helping of tender duck with dates, swede and chard, which was unusual, but worked well. This was followed by British cheeses at extra cost, and a strange dessert called kalamansi (Chinese orange) with sesame and orange blossoms, which I did not enjoy. The final offering was the chef’s own take on tiramisu: a large, white-chocolate sphere, filled with classic tiramisu ingredients, which was a devil to manipulate on the plate with standard instruments and place in the mouth. All in all, a delicious lunch at a very reasonable price – in fact, less than a couple of Wagyu burgers in Myanmar.

Treasures from the East Bernard Ferrie savours a range of wines from the Orient

C

hinese, Indian, Japanese or Thai? And their wines? From Sauvignon to Shiraz, Vidal to Muscat, the region has a surprising amount to offer.

China first: From Ningxia region, Chateau Changyu 2010 Moser Family Cabernet Sauvignon (£19.95, BBR). Not in Mao’s little red book or next to your noodles at Wing Yip – 12.5% pleasant red fruit, smooth as silk. A cultural revolution indeed.

India next: Soul Tree Cabernet Sauvignon 2015 (£8.80, Connolly’s) with mild vegetable curry (£1.75 a tin, M&S); rich plummy berry liquorice and some spice. Soul Tree Rosé is strawberry pepper and spice. Soul Tree Shiraz – black fruit, coffee, chocolate and mint – with seafood curry.

Jewel of Nasik Sauvignon Blanc 2014 (£7, M&S) – lychee, green mango, sweet basil – with chicken tikka masala or curried fish with tangy tomato or tamarind. Lemon and green melon flavours. Great value. So is Jewel of Nasik Tempranillo Syrah (£7, M&S) – dark medium-bodied, cherry, blackberry, smoky – to stand up to rogan josh.

Japan: Sol Lucet Koshu 2013 (£13, M&S). Best-selling grape in Japan. Exotic kabosu, yuzu and lemongrass flavours.

Serve chilled with sushi. Delicate and subtle – Toyota Prius rather than Mitsubishi Evo. Pricey but nice.

Stickies: Changyu Golden Valley Icewine Vidal 2009 from Liaoning (£19 half bottle, BBR). Citrus fruits, blossom and honey with a sharp but pleasant aftertaste. With mango and pineapple fruit salad. Or have any creamy warm pud with Thai Monsoon Valley Muscat 2011 (£13.49 half bottle, Ye Olde Toll House). Scented cherry, lychee, tropical paradise – a rare find.

rcsed.ac.uk | 63

FROM THE COLLECTIONS

‘THE GREATEST MASTER OF THE ART’ Exhibits in tribute to Sir William Fergusson, skilled surgeon and doctor to David Livingstone

I

n this issue, we look at one of the latest acquisitions to the collection, generously donated by Viscountess Monckton of Brenchley. This oil portrait of William Fergusson (1808–1877) was painted by Phoebus Levin in 1853. Levin was a German artist working in London in the mid- to late-19th century. The painting was displayed at the New Gallery, London, from 1891 to 1892 as part of The Victorian Exhibition: Illustrating 50 years of Her Majesty’s reign, 1837–1887. It was exhibited there because of Fergusson’s close ties with the royal family, having been appointed Surgeon in Ordinary to Prince Albert in 1849 and Sergeant Surgeon to Queen Victoria in 1867, a year after being made a baronet.

The document shown alongside the painting is a letters patent issued by Queen Victoria officially granting Fergusson his title of Sergeant Surgeon, and the large beeswax seal bears a beautiful rendition of the monarch herself seated upon the throne.

One specimen in the collection related to Fergusson of particular interest is that of a plaster cast of David Livingstone’s left humerus (GC.2433).

Livingstone, the famous traveller of Africa, had been attacked by a lion as a young man and suffered a fracture to the left humerus, which the explorer had set (badly) himself and which had not united. Having been absent from Britain for many years, when his body was returned (his heart being supposedly, and poetically, buried in Africa), Fergusson was called upon to identify the body, as he had been consulted by Livingstone on the injury when last in London. He stated in the British Medical Journal of 18 April 1874: “The first glance at the left arm set my mind at rest, and that, with the further examination, made me as positive as to the identity of these remains as that there has been among us in modern times one of the greatest men of the human race – David Livingstone.”

William Fergusson’s skill and dexterity were recognised early in his career. By the age of 20, he was dissection demonstrator for Robert Knox during the pre-Burke and Hare period in which Knox lectured at the Anatomy School to hundreds of pupils a number of times a day. Later, as a surgeon of excellent reputation and

[Fergusson] was an early proponent of ‘conservative surgery’, especially for joints 64 | Surgeons’ News | June 2016

Above: Phoebus Levin’s oil portrait of Fergusson with letters patent from Queen Victoria. Left: Cast of David Livingstone’s humerus

experience, he was one of Scottish surgery’s greatest talents. He was an early proponent of ‘conservative surgery’, an approach that revolved around specific excision within an affected area rather than its full removal, especially concerning joints.

Among many appointments and honours, he was appointed Fellow of the RCSEd in 1829 and went on to be President of the RCSEng in 1870.

As Sir James Paget wrote in his 1901 Memoirs and Letters of Sir James Paget, Fergusson was “the greatest master of the art, the greatest practical surgeon of our time”.

Rohan Almond Assistant Curator, Surgeons’ Hall Museums

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