Surgeons' News December 2016

REPORTS

MEETINGS OF MINDS

Round-up of the FST and Perioperative Care conferences

SPECIALTY

ONWARDS AND UPWARDS

Prospects for trainees considering a career in Upper GI surgery

IN CONVERSATION

STRESS AND THE SURGEON

With burnout on the increase, what can be done to prevent it?

Surgeonsnews December 2016

The magazine of The Royal College of Surgeons of Edinburgh

Getting It Right First Time Initiative maps out the best route to quality care

www.rcsed.ac.uk

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WELCOME

FROM THE EDITOR Clare McNaught introduces her first issue as Surgeons’ News editor

A

number of clinical commissioning groups (CCGs) in England have introduced a policy of restricting access to elective surgery for patients who smoke or have a BMI over 30. This decision is thinly veiled as a public health intervention to encourage patients to adopt more positive lifestyle practices before operations. On the surface, this seems a laudable objective, but undoubtedly the main driver behind this rationing of services is the requirement of the CCGs to reduce their financial deficit.

Once again, non-urgent surgical care has become the first casualty in the battle to balance the books. Smoking and obesity are more prevalent in deprived populations and punitively punishing this group by delaying access to surgery will not help us achieve a sustainable NHS. There is no doubt that the time has come to have an honest and open non-political debate about the future funding of our NHS, perhaps through the route of a Royal Commission. In the meantime, strategies such as Getting It Right First Time (GIRFT), as described by Professor Tim Briggs (on page 30), may help us to critically evaluate our clinical practice, reduce variation and optimise the use of our scarce financial resources.

Symptoms of occupational stress, or ‘burnout’, are endemic among people in all walks of life, but particularly in those who work in the healthcare profession. Our Younger Fellows have been running events throughout the UK to highlight this problem and, on page 36, offer us an insight into the effects of burnout on professional and personal lives.

The provision of acute surgical care remains a challenge across the globe. The recent proposed Shape of Training pilot in general surgery to produce surgeons with broadbased acute skills has been met with anxiety, particularly from our junior doctors. Iain Anderson tells us (on page 26) that we have much to learn from our colleagues in Groote Schuur Hospital, Cape Town, where trainees are supported to take clinical responsibility at an earlier stage of their career, and where generalists and specialists work in ‘symbiosis’ to respond to the demands of the emergency surgical patient. The key to their success seems to be a positive learning environment and a strong firm structure.

On a more positive note, the Edinburgh Medical Missionary Society, co-founded by our Fellow Dr Peter Handyside, celebrates its 175th anniversary. Our College has a long and proud tradition of charitable activity. At present, a considerable amount of work outside the UK is aimed at building surgical capacity in countries where it is needed.

I am delighted to have this opportunity of being editor of Surgeons’ News, and am grateful to my predecessor, John Duncan, for his wise counsel and help during the production of this edition. As we rapidly approach the festive season may I, on behalf all of the team here at Surgeons’ News, wish you a safe, happy and successful 2017.

Clare McNaught editor@surgeonsnews.com

There is no doubt that the time has come to have an honest and open non-political debate about the future funding of our NHS, perhaps through the route of a Royal Commission

22

Surgeonsnews

REPORTS

MEETINGS OF MINDS

Round-up of the FST and Perioperative Care conferences

SPECIALTY

ONWARDS AND UPWARDS

Prospects for trainees considering a career in Upper GI surgery

IN CONVERSATION

STRESS AND THE SURGEON

With burnout on the increase, what can be done to prevent it?

Surgeonsnews December 2016

The magazine of The Royal College of Surgeons of Edinburgh

DECEMBER 2016 • VOLUME 15 • ISSUE 4

Getting It Right First Time Initiative maps out the best route to quality care

36 www.rcsed.ac.uk

EDITOR Clare McNaught 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 EDITORIAL ASSISTANTS Jonathan McIntosh and Emma Wilson 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 | December 2016

Contents

December 2016

04

AGENDA News and views from the profession, including improving rural services; the effects of Brexit; reports from FST and Perioperative Care conferences

08 22

THE PRESIDENT WRITES Regular update on College activities

24

HISTORY The life of Dr Peter Handyside, a man on a medical mission

26

VISITING PROFESSORSHIP South Africa's pioneering hospitals give Iain Anderson food for thought

30

GIRFT PROGRAMME Tim Briggs examines the progress of the orthopaedics initiative now helping other specialties navigate the best route to quality care

34

EXAMINATION ADVICE Tips and techniques on how to pass the FRCS in General Surgery

36

STRESS AT WORK With burnout affecting half of all surgeons, our panel discuss its causes and measures to mitigate it

MUSEUMS The remarkable tales of Mabel Fitzgerald and Ines Pfister told through items in the collections

30

42

SPECIALTY The development of oesophagogastric surgery and pathways for trainees

45

DENTAL Dean's report; skills competition; experts on the map

49

TRAINEES AND STUDENTS Outreach activities; ASiT on support from a non-medical workforce

55 62 64

COLLEGE INFORMATION Awards and grants; diploma listings OUT OF HOURS Visual delights and taste sensations FROM THE COLLECTIONS 'Barbers' make the cut in Golf Cup

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Latest 2011 Impact Impact factor Factor 1.406!

2.046!

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

r r r r r r r r r r

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

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

Don’t forget, you can sign up separately with Elsevier to receive e-table of contents by email each time a new edition of The Surgeon is published: www.thesurgeon.net

AGENDA

Agenda The latest news from the College and profession / REMOTE SURGERY

MSPs join call for better support for rural services

M

SPs have backed a call from the RCSEd for better protection of surgical services for rural communities.

MSPs met with representatives from the College at the Scottish Parliament on 28 September 2016 to discuss the findings of an RCSEd report about standards for rural surgery. The report highlighted problems with recruitment and retention of consultants in remote and rural areas. The group agreed that a key factor in protecting services was to review the way medical professionals are recruited, trained

and encouraged to develop their careers in rural and remote areas.

Kate Forbes, MSP for Skye, Lochaber and Badenoch, said: “With increasingly specialist subsets within individual hospitals, it has become increasingly challenging to replicate this level of expertise rurally.”

College President Michael Lavelle-Jones said: “The RCSEd has produced a comprehensive set of recommendations, but chief among these is significant improvement in the support larger urban hospitals provide to smaller rural hospitals, to keep services as local Kate as possible. With Forbes the engagement of MSP

this group of MSPs, I hope the issue can now be taken forward within the Scottish Parliament.”

Other recommendations include enrolling more students from rural communities, and the creation of specific rural surgery training placements and Fellowships.

Read more on page 6

/ OBITUARY

The College is deeply saddened by the death of Professor Kenneth Fearon, Chair of its Research Committee from 2006 to 2014.

Professor Fearon was elected to the RCSEd Fellowship without Examination in 1998 and joined the Research Committee in 1999.

Professor Stephen Wigmore, current Chair of the RCSEd Research Committee, said: “Ken made an immense contribution to the College, with responsibility for the 4 | Surgeons’ News | December 2016

allocation of funds from 10 different categories of Fellowships, grants, bursaries and awards. He was an excellent Committee Chair with a passion for promoting research.”

Professor Fearon was also Chair of the College’s Ophthalmology subcommittee and the Lorna Smith Charitable Trust Committee. Away from the RCSEd,

Ken Fearon was Professor of Surgical Oncology at the University of Edinburgh, through which he established an international reputation in research in cancer cachexia, and had many successful MD and PhD students. He was a key driver of Enhanced Recovery After Surgery (ERAS) and a founding member of the ERAS Society.

KEN JACK/ALAMY STOCK PHOTO

Professor Kenneth Fearon FRCSEd

/ AWARDS

Applications open for three awards

T

he College is inviting nominations for the Hunter Doig Medal 2017, the Farquharson Award 2017 and the Faculty of Dental Surgery Medals, Home and International.

The Hunter Doig Medal is awarded every other year to a female Fellow or Member of the College who demonstrates career potential and ambition, along with high standards of good surgical practice, clinical excellence, an ongoing contribution to education and training, clinically based research and audit, and laboratory research of direct clinical relevance.

The biannual Farquharson Award is in memory of Eric Farquharson, Surgeon, Fellow and previous Vice-President of the College, as well as author of Farquharson’s Textbook of Operative General Surgery.

The award is open to surgeons and those in allied professions who have made significant contributions to surgical teaching or surgical anatomy, at either undergraduate or postgraduate level.

Traditionally reserved for those who taught at the bedside, in theatre, in the dissecting room or through

lectures or textbooks, the award now incorporates new methods of teaching through simulators, wet laboratories, operative videos and distance-learning programmes. Recipients do not have to be Fellows or Members of RCSEd or be medically qualified.

Nominations are also invited for the awards of the Faculty of Dental Surgery (Home) Medal and the Faculty of Dental Surgery (International) Medal of the RCSEd. Each medal may be awarded to dentists or others who have made a distinguished contribution to the Faculty, College and dentistry.

Applications for the Hunter Doig and Farquharson awards should be submitted to Irene MacDonald at i.macdonald@ rcsed.ac.uk by 26 May 2017.

Nominations for the dental awards should go to Linda Stuart at l.stuart@ rcsed.ac.uk by 23 January 2017.

Farhat Din (right) receives the Hunter Doig Medal 2016 from Caroline Doig

Mother Teresa receives Fellowship

/ HONOURS

Honorary Fellow declared a saint The RCSEd can list a saint as one of its Fellows now that the Catholic Church has canonised Mother Teresa. In 1985, the College’s Indian Chapter was instrumental in persuading Mother Teresa to come to Delhi during its sixth Overseas Meeting to accept an Honorary Fellowship, the highest honour the RCSEd could bestow at the time. / SCHEME

Log unsafe products at Yellow Card site All adverse incidents related to medical devices (performance concerns for diagnostics, defective medicines and counterfeit products) are now reportable online to the Yellow Card Scheme in addition to traditional reporting of suspected adverse drug reactions. You can do this at mhra.gov.uk/yellowcard or using the free Yellow Card app. You can create a watch list of medications to receive news on them and see previous Yellow Cards you have submitted.

/ MEMORANDUM OF UNDERSTANDING

RCSEd renews links with Sri Lanka College Mr LavelleJones (front right) with members of the College of Surgeons of Sri Lanka

College President Michael Lavelle-Jones travelled with delegates to Sri Lanka in August for the 45th Annual Academic Sessions of the College of Surgeons of Sri Lanka held in Colombo on 17–20 August 2016.

While there, Mr Lavelle-Jones re-signed a Memorandum of Understanding, which was last signed by RCSEd Past President David Tolley five years ago, to allow the two organisations to continue to work together in participating in international joint meetings, as well as agreeing to offer support and engagement within the areas of education, training and examination/assessment in Sri Lanka.

rcsed.ac.uk | 5

AGENDA

JOINED-UP THINKING

I

The College has been making the case for better support for consultants and trainees in rural areas across the UK

n March of this year, the College published its report on the delivery of surgical services in rural areas. This came following rapid changes in the provision of general surgery in rural hospitals over recent years, which have been driven by surgical services becoming increasingly centralised and specialised. The report included a number of recommendations to improve support for consultants and trainees.

Since publication the College has been working to influence governments and NHS structures across the UK to implement the recommended changes.

This work has advanced furthest in Scotland and Wales, where the issues of recruitment, retention and service delivery are most acute.

In Scotland, the College hosted its first ever event at Holyrood, with Kate Forbes MSP (SNP, Skye, Lochaber and Badenoch), to discuss these issues with key decision makers. The event – attended by representatives of all political parties, health boards from across the country, NES (NHS Education for Scotland) and NHS Scotland – helped to demonstrate the breadth of support for this agenda. The agreed recommendations have now been sent to the Scottish Government to seek its backing.

Shortly after, a joint meeting was held in Aberystwyth in partnership with the

MSP Kate Forbes highlights the aign College’s camp at Holyrood

6 | Surgeons’ News | December 2016

The rural surgery event in Wales. L–R: Stephen Cannon, Junior VP of RCSEng; Michael Lavelle-Jones, RCSEd President; Susan Hill, RCSEng Council Member; Tim Havard, RCSEng Director for Professional Affairs for Wales; John Duncan, RCSEd Vice-President; Gordon McFarlane, Consultant Surgeon, Gilbert Bain Hospital, Shetland

Royal College of Surgeons of England.

Surgeons and other clinicians came from across Wales to learn from the experiences of their colleagues in Scotland. The event concluded with a productive debate about practical steps that will help tackle the specific challenges the Welsh healthcare system faces. These recommendations will be sent to the health secretary.

In both countries, all potential solutions will need full buy-in from government and from both rural and urban health boards if they are to be successful. RCSEd will be working to ensure that all of the positive words from recent events will be followed up by decisive action. The College will also

We will be looking at the steps we can take to make rural working more attractive to surgeons of the future be looking at the practical steps we can take to make rural working more attractive to surgeons of the future.

For more information on this work, contact Andrew Mullinex at a.mullinex@rcsed.ac.uk

The Faculty of Dental Trainers A new faculty designed to recognise and support all members of the dental team in their roles as trainers and educators The first of its kind in the UK, the Faculty of Dental Trainers (FDT) is open to anyone - both in the UK and internationally, regardless of Royal College affiliation - who can provide evidence of appropriate involvement in dental training and education.

The FDT offers a broad membership structure for dental trainers at different career stages and in different areas of practice, allowing those who join to demonstrate their commitment to dental training and education.

Open to: Dentists, dental nurses, hygienists, therapists, orthodontic therapists, technicians and clinical dental technicians.

The FDT will: Reward interest, engagement and achievement in dental training.

Establish a Faculty home for recognised dental trainers.

Provide support and guidance for career development in dental training.

Promote standards in training.

Membership is available by application at three levels: Associate, Member and Fellow. Members and Fellows of the Faculty will be awarded the post-nominals MFDTEd and FFDTEd.

Further information: Visit fdt.rcsed.ac.uk or email fdt@rcsed.ac.uk

Nicolson Street Edinburgh EH8 9DW

85-89 Colmore Row Birmingham B3 2BB

T: +44 (0) 131 527 1600 F: +44 (0) 131 557 6406 E: mail@rcsed.ac.uk

T +44 (0) 121 647 1560

REGISTERED CHARITY NO. SC005317

www.rcsed.ac.uk | 7

PRESIDENT

Michael Lavelle-Jones looks back on an eventful 2016 and assesses the prospects for the year ahead

THE PRESIDENT WRITES

O

ver the next few months, I will be leading a series of events around the UK that will enable representatives of the College to meet with our Fellows, Members and affiliates, as well as all those engaged in healthcare delivery, to discuss the issues affecting our professions. The opportunity to meet with our Members face to face and listen to their views on the challenges and opportunities across surgery is one of the highlights of being President of the College.

Our first event, held in Newcastle on 2 November, focused on the future of the NHS. Many of the discussion topics were reflective of current pressures and constraints on the NHS, with all voicing concerns on issues such as the junior doctors’ contract, bullying and undermining in the workplace, and patient safety.

I look forward to our next event in Belfast in the new year.

The Newcastle forum took place just a few weeks after the GMC published its annual report, which warned that poor morale among doctors could put patients at risk. None of the issues cited in the report will be a surprise to those who work in the NHS: the loss of the traditional ‘surgical firm’, shrinking numbers of specialty trainees, rota gaps and burnout are all familiar to surgical departments across the UK. As such, they are issues that concern us as a surgical college and I am asked

8 | Surgeons’ News | December 2016

frequently what the College can do to support Members faced with these challenges.

One solution is to provide a platform for clinicians to share their experiences and concerns. In October, the College hosted a panel discussion on the issue of burnout, led by Council Member, Chair of our Younger Fellows Network (and our new editor of Surgeons’ News), Clare McNaught. The session brought together surgeons of different career stages, specialties and grades for an open and frank discussion about work-related fatigue and stress (see page 36). Undoubtedly, this will be the first of many similar discussions.

Another example of support for Members is our campaign over the course of this year to address the challenges faced by surgeons and trainees in rural and remote communities. This began in March with the publication of our report, Standards Informing Delivery of Care in Rural Surgery, which included recommendations to tackle problems surrounding recruitment and retention. The release of the report, and the coverage it received, provided the foundation for a programme of lobbying and political engagement. So far, we have focused our efforts on the governments of Scotland and Wales, where rural surgical services have been in steady decline over many years. In recent weeks, we brought the issue to the top of the agenda with a cross-party meeting held at the Scottish Parliament engaging NHS managers and parliamentarians in Scotland, as well as a very successful event in Aberystwyth, Wales, held in conjunction with the English College. It is clear that issues affecting remote and rural practice do not have national boundaries and we have much to learn from each other. No doubt there are areas of

It is your continued membership and support of the College that puts us in the privileged position of leading and representing the surgical and dental professions The College is committed to addressing the challenges faced by surgeons and trainees who serve remote communities, such as Lochalsh in the Highlands of Scotland

England and Northern Ireland with similar problems, and we intend to address the issue across the whole of the UK. Ultimately, activity such as this can help us influence the rules, regulations and financial structures under which we all work for the benefit of our profession and patients. However, I am keenly aware that our ability to shape the actions of governments and regulators would not be what it is without the weight of 24,000 Members behind our reports, consultation responses and meetings. So, it is your continued membership and support of the College that puts us in the privileged position of leading and representing the surgical and dental professions.

With one of the largest and most widespread global memberships of any surgical college, staging such events outside the UK can be more challenging. Nevertheless, these are highly valuable and enjoyable activities and provide me with the opportunity to meet as many of our international Members as possible. It was a great pleasure to host a reception in Washington DC in October – our first such event in the US, and timed to coincide with the Annual Congress of the American College of Surgeons. Our event attracted around 60 US Fellows and, with some 400 Members across the US, this was an impressive turnout, particularly given the size of the country. A similar international event is planned for Malta in February next year and, no doubt, there will be further opportunities to meet Members around the world as 2017 progresses.

During a period of constraints on the health service, it is timely to remember that some tests and procedures do not always equate to better treatment or outcomes when reviewing options with patients. In October, the Academy of Medical Royal Colleges launched its Choose Wisely campaign, which listed 40 treatments,

procedures and tests shown to be of minimal benefit to patients. This initiative, which we shall consider in detail in a future edition of Surgeons’ News, resonates with Realistic Medicine, the theme of the Chief Medical Officer’s 2015 report in Scotland and the earlier launch of Prudent Practice in Wales. Of course, campaigns such as this are about more than simply making efficient use of resources during times of financial pressure.

Choosing Wisely encourages cultural change towards transparent and shared decision-making, in which both patient and practitioner take decisions together based on full and frank conversations about all aspects of care.

In recent weeks, I have been privileged to attend three undergraduate/early years training events: the Oxford Surgical Skills Symposium, the STARSurg 5th National Meeting in Edinburgh and, most recently, the All Wales Student Research Surgical Symposium. A huge sense of enthusiasm, engagement and optimism shone through each event. It must be our mandate to ensure that this energy does not get lost in the face of the extreme pressures of healthcare delivery during the early years of training in the NHS. Finally, as this is the last edition of Surgeons’ News this year, I would like to thank you for your continued support of the College and wish you well for the year ahead. This has been another productive year for us, with the continued introduction of more examinations, courses and faculties that affirm our position as the professional home for surgery and dentistry. I hope you have time for rest, recuperation and relaxation over the festive season. On behalf of everyone at the College, I look forward to working with you and continuing to represent you in the year ahead.

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

AGENDA

SURGICAL SAFETY UPDATE More cases from the Confidential Reporting System for Surgery

Too many guns

During a reversal of Hartmann’s procedure, the rectum and sigmoid colon were found to be very narrow.

Intra-operatively, both 25mm and 29mm circular stapler guns were opened and checked to see where they would reach the rectal stump. Further dissection allowed a 29mm gun (the preferred option) to reach near enough to the stump. A 29mm anvil was placed in the descending colon and an anastomosis was attempted. The gun was placed rectally, and the spike extended through the rectal stump and docked with the anvil. The gun tightened as expected, but didn’t fire correctly. It then became apparent that the 25mm gun had been used to try to connect to the 29mm anvil. A further attempt with the correct gun was successful.

Reporter’s comments

A size mismatch between staple gun and anvil occurred when the wrong gun was used in error. Beware – the design of the gun for this device allows a size mismatch to occur. Ideally, only one size of staple gun should be open and available at the operating table at any one time. A visual and verbal check should be done to ensure components match before the staple gun is fired to form an anastomosis.

CORESS comments

This report suggests a system error in which it was possible to unite two mismatched components. CORESS would like to know if this situation has also happened to you. If it is a common occurrence, representation will be made through MHRA to alter the manufacturing process.

Colour coding of device components for individual sizes is

10 | Surgeons’ News | December 2016

used for some devices, although even this may not prevent similar occurrences. As per the reporter’s comments, only one gun and its specific components should be available in the operative field.

Retained wound protector

A self-retaining wound protector was used to hold a wound open during a colorectal operation. The surgeon made the incision slightly bigger and put his hand through the protector to perform a hand-assisted anastomosis. When the patient became unwell a few days later, it was found that the wound protector had been retained in the abdomen. A second operation was required to remove it.

Reporter’s comments

Wound protectors and other surgical items, such as ports and gallbladder retrieval bags, are often not included in the surgical count. When an incision is enlarged, the wound protector should be changed for a larger size. It is assumed that the protector slipped into the wound when the incision was enlarged and was retained under the abdominal wall when the surgeon removed his hand. All disposables should be included in the count. Do not make assumptions about what can and can’t be retained.

CORESS comments

All disposable items used in the operative field should be counted in and out. Do you know what the policy is in your theatre and is it enforced? Always check that the equipment being removed from the wound is intact, and that components have not been left in situ.

Mini-tracheostomy complications

An elderly female patient had an uneventful right upper lobectomy for lung cancer. Five days after the operation, she began to develop respiratory failure, secondary to retained secretions that she was unable to expectorate. It was decided to insert a mini-tracheostomy tube under local anaesthetic to facilitate pulmonary toilet. The patient was in the intensive care unit (un-intubated) and an anaesthetist administered midazolam. During the insertion procedure, the guidewire became misplaced outside the airway and, on insertion of the mini-tracheostomy tube and dilator, a significant arterial injury occurred. When the dilator was withdrawn, there was massive haemorrhage up the mini-tracheostomy tube that could not be controlled. The patient lost in excess of 1,700ml of blood extremely rapidly and, although she was transferred immediately to an operating theatre where local control was achieved by emergency sternotomy, resuscitation was unsuccessful.

Reporter’s comments

Poor technique was involved. The guidewire was not in the trachea before dilation began. The procedure was not done in or near an operating theatre in case of haemorrhage, although this complication is rare.

National guidelines on indications for mini-tracheostomy usage and insertion are lacking. As a consequence of this incident, it is now our practice to introduce minitracheostomy tubes only in an anaesthetic room or

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.

an operating theatre. The procedure is performed under general anaesthesia and commences with a rigid bronchoscopy for bronchial toilet. The rigid bronchoscope is then withdrawn to just below the level of the cords. The mini-tracheostomy tube is introduced into the airway with direct visualisation through the rigid bronchoscope to ensure correct placement of the tube.

CORESS comments

Mini-tracheostomy should be undertaken in a well-lit operating theatre or anaesthetic room, with facilities and available personnel with expertise to intubate at hand. In many cases, general anaesthesia may not be feasible initially (sedation is usually contraindicated) and the procedure can be carried out under local anaesthesia by experienced staff. A key step in the procedure is to ensure that the Tuohy needle is in the trachea, with free aspiration of air, prior to insertion of the guidewire. The National Safety Standards for Invasive Procedures should be enforced for these procedures.

If the patient is severely hypoxic and non-cooperative, it may be a wise alternative to intubate, ventilate and opt for early tracheostomy.

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 Retrospective analysis of 30-day mortality for emergency general surgery admissions evaluating the weekend effect

This study evaluated data for emergency general surgical admissions to NHS hospitals in the Northern Deanery in England between 2000 and 2014. The 30-day mortality rate fell from 5.4% (2000–2004) to 2.9% (2010–2014). There was no significant difference in mortality for patients admitted at the weekend, but there was a higher mortality for operations undertaken at the weekend (HR 1.15 for Saturday and 1.40 for Sunday).

The increased mortality had reduced by 2010–2014 when the risk was not significant (HR 1.18 for Saturday and 1.12 for Sunday). Authors concluded that there has been a weekend effect in patients undergoing emergency general surgery based on the day of the operation, but not for the day of admission. The mortality for emergency general surgery has improved, and in the past five years the increased risk of mortality for weekend surgery has decreased.

McCallum I, McLean R, Dixon S, O’Loughlin P. Br J Surg 2016; 103(11): 1557–65

Transcatheter versus surgical aortic valve replacement in patients with severe aortic stenosis

This systematic review and metaanalysis evaluated four trials with 3,179 patients comparing transcatheter aortic valve implantation (TAVI) versus surgical replacement (SAVR) in patients with severe aortic stenosis at low and intermediate risk of perioperative death.

Transfemoral TAVI was associated with reduced mortality, stroke and acute kidney injury, but increased short-term

12 | Surgeons’ News | December 2016

valve reintervention and heart failure.

Compared with SAVR, transapical TAVI was associated with higher mortality.

Authors concluded that many patients who have a shorter life expectancy or place a lower value on the risk of longterm valve degeneration are likely to perceive net benefit with transfemoral TAVI versus SAVR. Siemieniuk RA, Agoritsas T, Manja V et al.

BMJ 2016; 354: i5130

Postoperative 30-day readmission: time to focus on what happens outside the hospital

This study evaluated National Veterans Affairs Surgical QIP data for 237,441 surgeries: 43% orthopaedic, 39% general and 18% vascular. Overall, the 30-day unplanned readmission rate was 11.1%, differing by surgical specialty (vascular 15.4%, general 12.9% and orthopaedic 7.6%). Most common readmission reasons were wound complications (30.7%), gastrointestinal (16.1%), bleeding (4.9%) and fluid/electrolyte (7.5%) complications. Authors evaluated predictive models and concluded that postoperative readmissions are difficult to predict at the time of discharge but, of information available at that time, preoperative patient-level factors are the most important.

Morris M, Graham L, Richman J et al. Ann Surg 2016; 264(4): 621–31

Comparison of the National Early Warning Score in non-elective medical and surgical patients The National Early Warning Score (NEWS) is used to identify deteriorating patients in hospital. This study evaluated the ability of NEWS to discriminate

cardiac arrest, death and unanticipated ICU admission in patients admitted to surgical specialties, and compared this with medical specialties. For death within 24 hours, the area under the receiver operating characteristic curve (AUROC) for surgical admissions was 0.914, compared with 0.902 for medical admissions. For combined outcomes, the AUROC was 0.874 for surgical admissions and 0.874 for medical admissions.

Authors concluded that NEWS performed equally well, or better, for surgical as for medical patients.

Kovacs C, Jarvis SW, Prytherch DR et al.

Br J Surg 2016; 103(10): 1385–93

Early, goal-directed mobilisation in the surgical intensive care unit: a randomised controlled trial This multicentre trial randomised 200 patients who had been mechanically ventilated to standard of care or early, goal-directed mobilisation using an inter-professional approach. The intervention improved the mobilisation level, decreased SICU duration of stay (mean seven days vs 10 days), and improved functional mobility at hospital discharge. More adverse events were reported in the intervention group (2.8%) than in the control group (0.8%); no serious adverse events were observed. Three months after hospital discharge, 36 patients had died (21 in the intervention group, 15 in the control group). Authors concluded that early, goal-directed mobilisation improved mobilisation, shortened duration of stay and improved patients’ mobility at hospital discharge.

Schaller SJ, Anstey M, Blobner M et al.

Lancet 2016; 388(10052): 1377–88

RCSEd 16th Annual Audit Symposium Friday 24 March 2017 Trainees at all levels have the opportunity to attend and present their audit work.

Convenor Mr David M Smith, Consultant Surgeon, Ninewells Hospital and Medical School Fee £110 (£95 RCSEd/ASiT/BOTA member, £50 medical student) To book visit www.rcsed.ac.uk or email education@rcsed.ac.uk

Post-Bariatric Surgical Complications for the General Surgeon Friday 31 March 2017 Delegates will learn how to recognise and manage a variety of early and late surgical complications related to bariatric surgery.

Convenor Mr Andrew de Beaux, Consultant General and Upper GI Surgeon, Royal Infirmary of Edinburgh Fee £120 (£95 RCSEd Member/Fellow) To book visit www.rcsed.ac.uk or email education@rcsed.ac.uk

www.rcsed.ac.uk | 13

FST CONFERENCE

A FRESH APPROACH This year’s Faculty of Surgical Trainers Conference explored national and international research into competency-based training, focusing on assessment not assumption of capability

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ensions between training and service provision and lack of funding and time support were on the agenda at the fifth annual Faculty of Surgical Trainers (FST) Conference, where an international group of surgeons and healthcare professionals shared knowledge on the metrics used and progression pathways available in a competency-based training model. The conference looked at the progress made since Professor Richard Reznick’s lecture at the FST’s inaugural meeting in 2012 on training orthopaedic trainees in Canada using a skills-demonstrated rather than time-based model. This year’s attendees also considered future applications of the system.

Keynote speaker Professor Mary Klingensmith, President of the Association for Surgical Education, shared the new pathways trainers were developing in the US after the American Board of Surgery unified its commitment to moving towards this training method in 2015. She tackled issues of having two separate bodies that set certification standards and another that oversees the training process, and difficulties incentivising additional faculty training without funding, relying on surgeons becoming trainers for the opportunity to broaden their knowledge and gain challenging, yet rewarding, experience.

Attendees discussed current issues affecting workplacebased assessment, including lack of standards, differences between assessor marking metrics and unreliable outcomes due to the inability to reproduce results. The psychology behind marking strategies was also taken into account, with examples of trainers marking trainees well for hard work rather than on their suitability for unsupervised practice.

Professor Olle ten Cate (the originator of Entrustable Professional Activities (EPAs)

Attendees discussed current issues affecting workplace-based assessment, including lack of standards 14 | Surgeons’ News | December 2016

Keynote speaker Mary Klingensmith

rcsed.ac.uk | 15

ILLUSTRATION: STUART KINLOUGH/IKON IMAGES

FST CONFERENCE

ABSTRACTS

This year’s oral and poster presentations

ORAL PRESENTATIONS

l Implementation of a formative annual otolaryngological Objective Structured Clinical Examination (OSCE) for higher surgical trainees in the north west region: assessment of reliability and validity.

By Nicola Stobbs l What is known about the attributes of a surgical trainer? A systematic review.

By Benjamin Dean l Factors influencing the effectiveness of the operating theatre as a learning environment in a medical student population. By Lauren Wells l Trainee microsurgeons do not adversely affect free flap outcome. By Jennifer Kean l Simulated surgical MDT: Can we learn from undergraduate teaching?

By Jennifer Pollard l Filling the void: an educational quality improvement project to increase foundation doctors’ confidence in basic surgical skills. By Daniel Doherty

POSTER PRESENTATIONS

l Virtual reality simulation in thoracic surgery neither here nor there, so

where? By Alan Dawson l Acquisition of cardiac surgery anastomosis skills outside the operating room. A pilot study on the role of low-fidelity simulation and deliberate practice. By Sotiris Papaspyros l Integrated academic surgical training in the UK: a cross-sectional survey.

By Natalie Blencowe l The cost of surgical training.

By Rhiannon Harris l Simulated surgical emergency training – where are we? By Khurram Khan l Feedback in surgical education.

By Michael El Boghdady l Pioneering boot camp training for UK cardiothoracic trainees: objective assessment of the transfer of skill from simulator to theatre. By Louise Kenny l Evaluation of an undergraduate surgical skills course: a course for the future undergraduate surgical curriculum.

By Matthew Hillen l Does surgeon grade impact on the outcome of dynamic hip screw insertion?

By George Augustithis l A stepwise approach to urology training

tools to measure trainee competence) discussed his assessment system, which has been implemented successfully in residencies around the world. During his speech, he outlined a seven-item EPA framework, which included limitations, required experience and expiration date to incorporate revalidation and skills maintenance.

As the Netherlands is leading in EPA training, the country’s experiences and knowledge are being shared globally, with the American Board of Surgery meeting Dutch experts in 2017.

Professor Ian Curran tackled the regulators’ view of competency-based training, while Mr Craig McIlhenny, Surgical Director of the FST, chaired a panel discussion on whether the UK was ready for this training method.

He said: “If we are to move to a competency-based system, we will need robust training programmes, with good metrics and clear way-points for progression.”

Professor Nick Sevdalis has been investigating team-based care delivery, studying skills and ways to improve them in perioperative settings through simulation-based training and debriefing techniques.

He delivered a lecture on evaluating training interventions. His talk was on how long it takes to translate research findings into routine practice, the average duration being 17 years, and how research can be a form of advocacy for patients.

Workshops included a tour of ISCP version 10; improving feedback in ISCP (which was run by Gareth 16 | Surgeons’ News | December 2016

l

l

l l l

l

l l

of an International Surgical Training Programme (ISTP) trainee in a district general hospital. By Carnjini Yogeswaran Thambaiya How we did it: setting up a national formative ST3 boot camp for otolaryngology higher surgical training.

By Rajesh Anmolsingh Can we delegate prostate biopsies to trainees or nurse urologists and how much training do they require?

By James Donaldson A quick and easy makeshift suture pad.

By George Rahmani Use of non-technical skills in laparoscopic surgery. By Katy Emslie Implications of PLICS costing data on time in surgical training.

By Raghvinder Gambhir Endoscopic sphenopalatine artery ligation: general applicability in a teaching unit. By Shiying Hey Ethical considerations in surgical teaching: an Asian perspective. By Tze Lin Wee ASiT 40-4-40: a celebration of 40 years of the Association of Surgeons in Training. By James Glasbey

Griffiths and Maria Bussey); giving better feedback; and an introduction to simulation-based education with the advancement of virtual reality technology.

The session closed with awards given for best oral and poster presentations. Lauren Wells won the Medtronic Prize for Best Oral Presentation for her talk, ‘Factors influencing the effectiveness of the operating theatre as a learning environment in a medical student population’.

Carnjini Yogeswaran Thambaiya won the Ethicon Prize for Best Poster Presentation for ‘A stepwise approach to urology training of an International Surgical Training Programme (ISTP) trainee in a district general hospital’.

Next year’s FST Conference will be held on 4 October 2017 in Birmingham. This is open to all with an interest in surgical training.

If we are to move to a competencybased system, we will need robust training programmes, with good metrics and clear waypoints for progression

Craig McIlhenny

Professor Simon Frostick on the implications of Brexit for UK medical research

THE GREAT UNKNOWN

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Simon Frostick is Professor of Orthopaedics at the University of Liverpool and Honorary Consultant at Royal Liverpool and Broadgreen University Hospitals NHS Trust

he outcome of the EU referendum has resulted in the UK entering a period of uncertainty in many walks of life. For those of us who voted to remain in the EU, it is not easy to believe that anything other than disaster is looming.

For those who voted to leave, a new era of freedom from the tyranny of Brussels is forecast. Vague reassurances from Westminster do little to allay fear of what might come, not least in the area of medical research.

Applying for research funds is not a fun activity. Recent data from the Medical Research Council (MRC) show an overall success rate of only 22% – a one-in-five chance of obtaining funding. For those UK institutions in the top 50 of global rankings, less than one-third of applications were rated as internationally competitive by the MRC. UK medical research funding comes from the Research Councils (predominantly the MRC and Biotechnology and Biological Sciences Research Council (BBSRC)), large charities such as Wellcome Trust, Cancer Research UK, Arthritis Research UK, the British Heart Foundation and numerous small charities, and the National Institute for Health Research (NIHR). NIHR contributes just over £1bn to UK medical research each year, with about onequarter of that sum funding research programmes.

In its 2014 report, the Department for Business, Innovation and Skills (now the Department for Business, Energy and Industrial Strategy) allocated £4.7bn for UK research. The MRC was given £580m with the BBSRC receiving £350m for the 2015–2016 funding year.

Between 2007 and 2013, the UK received €8.8bn from the EU and contributed €5.4bn for all areas of research. The UK was given the second largest amount of funds next to Germany. According to a publication from the Royal Society, the Framework Programme 7 (FP7) contributed 3% of the total UK research and development budget compared with 11% from Research Councils UK. The biggest contributor to R&D in the UK is ‘business’, providing 45%.

UK universities received 71% of the FP7 funding. About 10% per annum of the total funding pot for UK research comes from the EU. The Horizon 2020 programme is a huge investment in research from the EU: €75bn until 2020. The Francis Crick Institute could lose £10m out of a research budget of £130m following Brexit.

It has been reported that some UK collaborators have already been excluded from new applications Funding is only one part of EU-based research.

Research is collaborative. Medical research is increasingly expected to have impact on the understanding and treatment of diseases – that is, it should be translational.

Many collaborations are based around personal contact.

However, the ability to develop consortia throughout Europe as a result of the EU funding opportunities has opened up new channels of research. It remains to be seen how our exit from the EU will affect this. It has certainly been reported that some UK collaborators have already been excluded from new applications.

Most institutions where research is undertaken depend on a significant number of non-UK EU scientists to provide expertise. These scientists are essential to the continued success of UK research. Within the UK, we have a skills gap that cannot be filled from our own population. UK research (as well as many other major UK institutions, including the NHS) will be unable to deliver high-quality output if our colleagues from the EU are either subjected to visa restrictions or leave because of continuing uncertainty about their future or, indeed, are not allowed to stay because of UK migration policies.

The crystal ball remains very cloudy. The Government has promised some back-filling of possible loss of EU research funding but it seems unlikely that this will be a longterm solution.

Whether you take an optimistic or pessimistic view of the situation, significant change in the research environment will occur. My view is that it will be to the detriment of UK research.

rcsed.ac.uk | 17

AGENDA

SETTING STANDARDS This year’s Faculty of Perioperative Care conference held discussions on CPD opportunities, development of standards and better recognition of perioperative practitioner roles

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n 29 October, perioperative practitioners and surgeons from across the UK gathered in Birmingham for the second joint meeting between the RCSEd and the Association for Perioperative Practice (AfPP).

At the meeting, College representatives announced the opening of further membership categories for the Faculty of Perioperative Care, which was launched in March.

Delegates at last year’s event had expressed an interest in greater educational opportunities to help with continuing professional development (CPD), support for

Mr Nathan Stephens, Specialty Registrar, Glasgow Royal Infirmary

defined standards of care and more recognition of the perioperative practitioner role. This feedback led to the theme for this year: the setting of standards – an opportunity or requirement?

The varied programme addressed topics, including CPD requirements for perioperative practitioners, realising the benefits of revalidation, and current issues in professional regulation. The panel discussion, chaired

by AfPP Vice-President Adrian Jones, focused on support for Non-Medical Surgical Assistants (NMSAs) practising in extended surgical teams. During the discussion Cherry Lee, a first-year student Surgical Care Practitioner, shared some of the highs and lows of her practice development, and reflected on whether the standard of care given to her had been appropriate, timely and effective.

Jones, who is a seasoned role advocate, reviewed current challenges and proposed how sustainability could be achieved. Just how do we all ensure NMSAs’ professional leadership, education support and continuing practice development?

He said: “The recruitment and early-years academic education of those welcomed into new NMSA roles, although now well established, can still be a daunting prospect for individual practitioners, their clinical supervisors and line managers. These concerns remain one of the main contact points for our association’s professional advice service.”

As NMSAs’ practice (Surgical First Assistants/Surgical Care Practitioners) continues to develop locally, what of our relationships with each other, our professional leads and clinical supervisors?

Dawn Stott, Chief Executive of the AfPP and Co-Convener of the conference, said: “The collaboration between the two organisations has provided a great platform for learning and ongoing personal development for advanced practitioners. The day has allowed relevant information to be given to all the delegates, no matter where they are in their career pathway, and offered an environment for like-minded practitioners to share knowledge and best practice across this specialty group.

How do we ensure NMSAs’ professional leadership, education support and practice development?

Funding for education for this group of practitioners has been a problem for a while. Now that the Health Select Committee has raised concerns about the ability to adequately train and supply NHS staff within current budgets, it is a great opportunity for two organisations to recognise this and support the wider surgical team to ensure better outcomes for patients.”

Charles Auld, RCSEd Council Lead for Perioperative Care and Conference Co-Convener, said the event was an excellent opportunity to bring leaders of the medical and nursing professions together who can influence government policy. He commented: “These are exciting times for this relatively new workforce in the NHS. As a College, we will work closely with the Faculty of Physician Associates at RCP in London as well as HEE, but we consider the partnership with AfPP as extremely important as we move forwards in providing support for members of the extended surgical team.”

RCSEd Council Member Robert Jeffrey spoke about the College’s commitment to providing CPD opportunities through the Faculty of Perioperative Care. “We are establishing high-quality, appropriate courses to offer accredited CPD and to help fulfil the requirements for promotion to membership of the Faculty. Current available courses include anatomy delivered by David Sinclair, a Perioperative Care Practitioner Intraoperative Non-Technical Skills course with George

Above: Delegates question the panel Below, from left to right: RCSEd VicePresident John Duncan, President Michael LavelleJones and AfPP Chief Executive Dawn Stott

Youngson, and leadership and development with Juliette Murray. These courses will be modified depending on feedback and will be tailored to the requirements of the wider membership. In addition, the joint annual meeting with AfPP highlights various aspects of perioperative care with invited expert speakers.”

For more information on the Faculty of Perioperative Care, including new membership categories and upcoming events, visit fpc.rcsed.ac.uk

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AGENDA

SUCCESS STORIES Catherine Shaw looks at how research outputs highlight the added value of ESSQ programmes

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ext year will mark the 10th anniversary of the launch of the Edinburgh Surgical Sciences Qualification (ESSQ). It has been generally recognised that this part-time, online, distance-learning Master’s degree programme was groundbreaking and innovative in its approach to surgical education.

Students have the advantage of combining flexible study with clinical commitments. The programme also enables those based in low- and middle-income countries to remain in their home country while benefiting from world-class education.

Over the past decade, the programme has gone from strength to strength. Student numbers have continued to increase and in 2013 the MSc in Surgical Sciences programme was awarded The Queen’s Anniversary Prize for Higher and Further Education, which seeks to promote world-class excellence and achievement.

Since the launch of the MSc in Surgical Sciences, the programme of surgical education offered by the University of Edinburgh in partnership with the RCSEd has continued to expand. In addition to the original MSc programme, which was aligned to the early years of surgical training, there is now a Master of Surgery (ChM) available for end-of-training and Fellowship-level candidates in five surgical subspecialties.

It is well known that the programmes offer rigorous clinical and academic surgical training. Our early experience published in a 2013 Annals of Surgery paper demonstrated that MSc graduates have improved success rates when undertaking the Intercollegiate College Membership professional exam (MRCS), but there was also added value to the students and graduates in the research arena.

After undertaking research methods taught in earlier modules, students enrolled on both the MSc and ChM degree programmes do an individual, independent research dissertation, which enables them to develop their research skills. Such skills, once seen as the preserve of the ‘academic surgeon’, are essential to practising evidence-based surgery in which decisions relating to the management of individual patients often require up-to-date knowledge and critical judgement of multiple complex fields.

20 | Surgeons’ News | December 2016

On completion of their degree programme, many ESSQ graduates go on to present their research project at national and international conferences, and publish their studies in peer-reviewed journals

Dr Catherine Shaw Research Manager, Department of Clinical Surgery, University of Edinburgh

On completion of their degree programme, many ESSQ graduates go on to present their research project at national and international conferences, and publish their studies in peer-reviewed journals. Perhaps equally important is the relationships formed between dissertation supervisor and student, which often leads to informal mentorship and can be the start of a long-term and prolific research career for individual trainees.

When I joined the Department of Clinical Surgery at the University of Edinburgh as Research Manager just over one year ago, we conducted an audit of the research outputs generated by MSc and ChM alumni graduating between 2010 and 2014. This time frame covers just over 300 graduating MSc and ChM students who have completed a research dissertation. From this cohort of students, 95 full research papers, wholly or partly based on MSc or ChM research dissertations, have been published in peer-reviewed journals. More than 100 conference papers have been presented at international conferences and approximately 60 have subsequently been published as conference proceedings.

This presents a fantastic personal achievement for those students irrespective of whether their work has led to a research publication. Such achievements add strength and variety to an individual’s personal record, and highlight the additional, tangible benefits to trainees undertaking an ESSQ qualification as they navigate surgical training pathways and develop their career.

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!

www.essqchm.rcsed.ac.uk

MUSEUMS

TRAIL BLAZERS Items from the College collections illustrate the remarkable stories of Mabel Fitzgerald and Ines Pfister, both active in science and medicine in 1920s Edinburgh

22 | Surgeons’ News | December 2016

KEYSTONE PICTURES USA / ALAMY STOCK PHOTO

Mabel Purefoy Fitzgerald receives her degree from the University of Oxford at 100 years old.

Below: a board of management memo recording Fitzgerald’s attendance

I

n recent years the College’s Museum has been part of a significant effort to recover the stories of women in science and medicine – those who were never recognised in their time, and those who were but have since been largely forgotten.

In 1972, physiologist and clinical pathologist Mabel Purefoy Fitzgerald (1872-1973) belatedly became a University of Oxford graduate at 100 years old. Eighty years earlier, Fitzgerald had unofficially studied science and medicine in collusion with some of the most distinguished Oxford scientists, so impressing neurophysiologist Francis Gotch that he later had the regulations concerning female students altered.

Gender prohibited Fitzgerald from studying for a qualification in Oxford when she moved there in the 1890s. Yet, by the early 1900s she had launched a career in laboratory medical science and would produce groundbreaking research on the role of oxygen in breathing. This included Royal Society publications, written jointly with the well-known physiologist John Scott Haldane in 1905, and also on her own in 1913 and 1914.

In addition, Fitzgerald joined the Extramural School of Medicine at the College in 1920 as a lecturer in bacteriology, after some five years working as a clinical pathologist at the Royal Infirmary of Edinburgh.

By the time Fitzgerald took up these positions women, for the most part, remained isolated from the mainstream.

Moreover, few teaching posts were open to women at the turn of the century; Jex-Blake’s Medical School for Women closed in 1898 and the Elsie Inglis’ Edinburgh Medical College for Women merged with the Extramural School of Medicine. In the school’s calendar for session 1916, only one woman out of 53 “present lecturers” was recorded, that being Inglis. By the 1928 session, two women out of 43 present lecturers are recorded, one of those being Mabel Fitzgerald. There existed a distinct hostility to medical women well into the 20th century, and it would be wrong to suggest that the presence of a few female lecturers signifies any kind of meaningful acceptance of women as teachers of science and medicine.

Nevertheless, what seems especially remarkable about Mabel Fitzgerald’s role is that she sat on the board of management for the duration of her time at the school; a seemingly respected member who regularly attended meetings throughout the 1920s. She does not appear to have been a “shrinking violet” by any means, and was assertive in her role on the board of management, often requesting funds for apparatus and teaching assistants.

Several months before her death at the age of 101, Fitzgerald was presented with the examination paper

The survivors spent the night aboard, with Pfister leading the singing of popular songs to keep spirits up

taken that day by candidates in the Oxford Final Honour School of Physiological Sciences. In this paper, for an examination Fitzgerald herself was barred from taking officially, students were asked to comment on a quotation from one of her published papers on respiration. A fitting tribute.

One woman who possibly studied under Fitzgerald at the university was Hilta Ines Christina Pfister (1898–1944).

Recently, archive materials (including her birth certificate, graduation papers, medal awards and doctoral thesis) were kindly donated to the College by her son, Tom Morley, from Australia.

Pfister was a woman of many talents. She first graduated from the University of Western Australia in 1920, Bachelor of Arts with first-class honours in French and German. She then went on study at the University of Edinburgh, achieving a Bachelor of Medicine and Bachelor of Surgery, first class with honours, in 1925. At the graduation ceremony Pfister received three awards, winning every single prize available to a female student at the time: The Scottish Association for Medical Education of Women Prize (awarded to the most distinguished woman M.B., Ch.B. graduate of the year); M’Cosh Graduates and Medical Bursaries; and The Dorothy Gilfillan Memorial Prize (awarded to the woman student most distinguished in the final M.B., Ch.B. examination).

In 1927 she completed a PhD at Birmingham University on the distribution of elastic tissue in blood vessels in birds.

It would be remiss not to include her passing, the details of which are heroic. In June 1944 she was with her husband, Lieutenant-Commander Morley, on board the SS Columbine, a South African merchant steamship off the coast of Cape Columbine, when it was hit by a torpedo from U-boat U-1981. In heavy swells, their lifeboat capsized but was eventually righted. The survivors spent the night aboard, with Pfister leading the singing of popular songs to keep spirits up (despite suffering from acute rheumatism).

By noon the next day 14 had died from exposure. Without enough life jackets to go round the couple decided to give theirs to other survivors: “They then jumped overboard, waved farewells and disappeared. The others were too weak to attempt rescue.”2 It is an honour to be able to highlight such a selfless act of bravery and sacrifice.

Jacqueline Cahif RCSEd Archivist Rohan Almond Assistant Curator, Surgeons’ Hall Museums

Ines Pfister (inset left) has arts and medical degrees. Her son has donated archive materials, including her graduation papers and medals, to the College

REFERENCES 1. http://uboat.net/ allies/merchants/ ships/3266.html 2. University of Edinburgh roll of honour 1939– 1945, page 24 (compiled by the University of Edinburgh Graduates’ Association, December 2014)

www.rcsed.ac.uk | 23

HISTORY

MAN ON A MISSION

Patricia Baxter looks at the life and career of Dr Peter Handyside, who helped set up the Edinburgh Medical Missionary Society 175 years ago

HOME MEDICAL MISSION WORK On 30 October 1848, Handyside received a request for medical assistance from Reverend McMenamy, a missionary among the Irish community in Edinburgh.

An excellent teacher of anatomy and clinical surgery with an exceptional reputation as a surgeon, Handyside’s valuable writings together with his contribution to anatomical studies are well documented 24 | Surgeons’ News | December 2016

At this time, he was appointed Medical Officer to the Edinburgh City Mission (founded 1832). Initially, Handyside visited patients in their homes with the missionary, but on 25 November 1853 he opened a dispensary at Main Point, the head of West Port and Lauriston. Here, he initiated a home medical mission named the Missionary Dispensary for the Irish (or Missionary Dispensary and Hospital for the Irish Poor).

This idea was later taken up in other cities and towns in the country: Liverpool (1866), Glasgow (1868), Aberdeen (1869) and Manchester (1870), among others.

The Livingstone Memorial Training Institution and Dispensary, which Handyside helped to found

FURTHER DEVELOPMENT With an increasing number of patients, Handyside required larger premises. In 1858 he took a lease on a whisky shop adjacent to the Magdalen Chapel in Edinburgh’s Cowgate and the new premises were named the Medical Missionary Dispensary of Edinburgh. A superintendent, Dr William Burns Thomson, was appointed in 1859 with EMMS directors Dr John Coldstream and Dr Benjamin Bell. The work continued to grow and in 1861 the EMMS assumed the responsibility of the now-named Edinburgh Medical Missionary Dispensary and Training Institution at the suggestion of the medical missionary students. At this time, Handyside took a less active role at the Cowgate dispensary while continuing to administer a dispensary at High Riggs with the Edinburgh City Mission, retiring as Medical Officer in 1863 after 15 years.

After a period of poor health, he returned to teaching anatomy at the RCSEd and his work at the Royal Infirmary. Handyside also formed a new teaching museum of anatomy. He was an active supporter of the EMMS throughout his remaining years and participated in founding the Livingstone Memorial Training Institution and Dispensary, which opened on 25 January 1878. Handyside continued to lecture until within a few weeks of his death, and died at his home in Edinburgh on 21 February 1881.

An excellent teacher of anatomy and clinical surgery with an exceptional reputation as a surgeon, Handyside’s valuable writings and his contribution to anatomical studies are well documented by various authors, including Dr John D Comrie and Professor Matthew H Kaufman.

Patricia A Baxter Honorary Archivist for EMMS International

COURTESY OF EMMS INTERNATIONAL

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t a public meeting at the Royal Hotel, Edinburgh, on 30 November 1841, the Edinburgh Association for Sending Medical Aid to Foreign Countries was formed. Although not one of the founders of the society, Dr Peter David Handyside (1808–1881) was an office bearer, and an active supporter throughout his life. Two years later, the society became the Edinburgh Medical Missionary Society (EMMS). Last month, the society, now known as EMMS International, celebrated its 175th anniversary.

Handyside has the accolade of being the founder of home medical mission work in Great Britain. Born in Edinburgh on 25 October 1808, the son of William Handyside, a Writer to the Signet, he went on to study medicine at Edinburgh University. In 1827, he received the Harveian Society Medal for an experimental essay describing the effects of lactucarium (‘lettuce opium’), on domestic animals. The following year, Handyside was made Senior President of the Royal Medical Society. He graduated with an MD degree in 1831 with his thesis De Vasis Absorbentibus. Handyside served his apprenticeship with Dr James Syme before studying in Paris and Heidelberg. He obtained a Fellowship of the RCSEd in 1833 and he commenced teaching anatomy in the Extramural School in 1834. In 1840, he was appointed surgeon at Edinburgh Royal Infirmary and in 1846 ceased lecturing to concentrate on his practice at Queen Street, Edinburgh.

Portrait from the College collections of Dr Peter Handyside In 2014, the College acquired the portrait of Dr Peter Handyside from EMMS International.

The artist was unknown at the time of the acquisition, but recent research reveals that the portrait was painted by Colvin Smith (1795–1875) in 1858 and bequeathed to the Medical Missionary Institute in Edinburgh. Colvin Smith was born in Brechin, studied at the RA Schools in London and spent time in Italy. He established a practice in Henry Raeburn’s former studio in 1827.

rcsed.ac.uk | 25

FRANK PENMAN MEMORIAL VISITING PROFESSORSHIP

CAPE CRUSADER

A pioneer of groundbreaking procedures, South Africa’s Groote Schuur has much to teach UK doctors, says Penman Professor Iain Anderson 26 | Surgeons’ News | December 2016

Adam Boutall (second from left) leads the Groote Schuur IFU team and hopes to roll out the accumulating expertise to other teams and hospitals

The teaching professorship was hosted locally by Professor Delawir Kahn. During my two-week visit, I spent about 60% of my time at Groote Schuur Hospital and visited the major departments associated with general surgery, taking part in ward rounds, clinics, theatre lists, departmental clinical meetings, teaching rounds and teaching sessions with junior doctors and students, and giving lectures.

I spent the rest of my time visiting other hospitals, including district or regional hospitals at Mitchells Plain and Victoria, as well as Red Cross War Memorial Children’s Hospital and Tygerberg (a teaching hospital of Stellenbosch University).

I saw very high levels of medical care, and this is particularly noteworthy given the considerable resource challenges and complex clinical conditions requiring treatment.

Areas of specialist practice abounded, but the relationships between specialist and generalist were positively symbiotic – something from which UK surgery could learn.

Contrasting clinical patterns

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ape Town is home to Groote Schuur Hospital, famous for its pioneering heart transplants, trauma services and its role for many years as the only teaching hospital for thousands of miles in

any direction. The opportunity to visit the University of Cape Town Department of Surgery as the Penman Professor in February 2016 was an exciting prospect indeed and an opportunity for which I am very grateful to the Penman Trust and my many South African hosts.

Average life expectancy in South Africa is substantially shorter than that in the UK. Tuberculosis and HIV remain endemic and are often interlinked, and the impact of lack of high-quality housing on health – most notably in the informal settlements – is self-evident. Taken with limited resource availability, there are inevitable differences in patterns of diseases and expectations from treatment.

I saw many advanced cases that would challenge doctors in any health system, and offered a remarkable and concentrated clinical experience for the student or senior trainee. The spectrum of cases seen in even a short period would be educational for any UK-trained doctor or senior medical student: tuberculosis, HIV, Echinococcus, gunshot wounds, to pick but a few, as well as serious diabetic complications and advanced presentations of many conditions (elective and emergency) found in Western countries.

Trauma surgery in Cape Town is justifiably renowned. Its consultantled service continues to train surgeons from around the globe and a Fellowship there would be a www.rcsed.ac.uk | 27

FRANK PENMAN MEMORIAL VISITING PROFESSORSHIP

huge plus for any future surgeon in a UK trauma centre. With better organisation of trauma services in the UK, secondments to this unit from the UK would be all the more worthwhile and appropriate.

A new service in acute care surgery (ACS) in Cape Town is also showing early success. ACS is a hot topic in the UK as well, but more of that later.

Training and team structure The UK could also learn from the teaching and training of junior surgeons and students in Cape Town.

Junior surgical staff gain clinical exposure and responsibility more quickly than their UK counterparts, but the successes probably stem more from the culture of learning, teamwork, institutional pride and leadership. The senior staff actively foster these and the resulting team spirit surpasses anything I have seen elsewhere, probably reflecting the time devoted by senior staff to hands-on practice and active clinical teaching. The local model of care allows greater consultant presence than our NHS system often does. Time and priority given to attendance at integrative functions such as grand rounds and clinical team meetings is high. Contrast that with the NHS, where short-term pressures (now in their 17th year) and other time restrictions have been factors in decimating these important developmental activities.

The staffing model features senior and junior consultants (or Fellows) supported by registrars, medical officers and house officers. Following house jobs and a compulsory attachment in a rural hospital, aspiring surgeons spend two or more years in the grade of medical officer.

They gain substantial hands-on clinical experience, much more so than doctors at that level in the UK, before applying for surgical training.

Candidates for surgical training may have undertaken more than 100 laparotomies (our exit level).

Surgical registrar training lasts four years. Knowledge levels equate to middle years of UK surgical training, but the clinical experience of the South African trainees seemed more advanced. I was particularly impressed by their ability to present succinct management plans on 28 | Surgeons’ News | December 2016

ward rounds – their knowledge of their patients was good, as was their preparedness to assume clinical responsibility. In addition to their hard work, it seemed to me that this was due to strong role-modelling and belonging to a department with a strong team ethos and identity. Of course, the existence of team meetings and teaching ward rounds are prerequisites for this strategy, and these components have disappeared from many UK services.

Each of the teams at Groote Schuur I visited seemed to function similarly. Professor Kahn and his senior colleagues must take credit for this strategy because the pattern seemed to underpin the success of the department’s relationships. They each had clear consultant clinical leadership in theatre, clinic and ward rounds, they each had a well-attended weekly clinical

meeting in which interesting cases (with some literature review) were presented, and each team made time for coffee and team bonding at that and other weekly meetings. There was a strong teaching-oriented discussion around complex cases for juniors and students – much more so than in the UK. The Fellow and junior consultant system works well, and deserves replication elsewhere. It enables competent surgical trainees to expand their skills and responsibility within a supportive framework.

During this time (one to two years),

Groote Schuur offers excellent care, good teaching and model systems

There would be merit in our UK trainees going to Groote Schuur hospitals for experience in ACS as well as trauma

The successes probably stem more from the culture of learning, teamwork, institutional pride and leadership surgeons develop sub-specialist skills. The UK has lost this grade in many units and should redevelop it.

There is advanced specialisation of surgical practice in Groote Schuur and there are aspects of specialist care from which we could learn – from organisation, resource management, complex diagnoses and advanced disease to having a live MDT clinic that gives patients with rectal cancer a multidisciplinary plan from a single day at hospital.

These issues and the cases seen would make for a valuable fellowship for any GI surgeon. During my brief time there, tuberculous anal fistulae (plus Pott’s fracture), prophylactic colectomy before liver transplantation for sclerosing cholangitis, complex gastrocolic fistulae and hydatid disease all came up, as did more conventional tertiary problems.

These are complex cases for which the expertise matches in depth that in specialist teaching hospitals in the UK and probably exceeds it in breadth.

Of course, Groote Schuur will always be famed for its pioneering work in cardiac transplantation. The theatre used is now preserved as a fascinating museum that lays out the build-up to the first transplant and the subsequent plaudits and

Penman Professor Iain Anderson: “There is so much to learn” from Cape Town’s hospitals

criticisms from around the world.

That programme was partly based on access to research on large animals, something that is extremely limited in the UK. Future developments in research and skills teaching could utilise that differential access.

Students Senior medical students were well taught, enthusiastic and highly motivated. They prepared and conducted cases for presentation in advance of teaching sessions, and did this well. Some surgical students had made teaching videos of simple procedures during their project time using models and volunteers, and these are now used to teach non-medical support staff in small, local clinics. I enjoyed meeting the thriving student surgical society, which has been set up and fostered

by Professor Kahn. More than 100 students attended the lecture and proved to be a lively and questioning bunch: good news for the future of surgery in the Cape.

The Cape Town environment remains one that would make for a superb student elective: the diversity of health and care, the teaching ward rounds, the can-do approach and the history would all add to the spectrum of disease that pertains.

Acute Care Surgery ACS is a talking point in many countries as surgical teams seek to care better for acute admissions while avoiding the periodic disruption that unselected emergencies can have on elective care. Groote Schuur has developed a model drawn from practice in the US and UK, but considers its local health inequalities may be more like that of the US. The trauma service is separate, but otherwise the case profile is similar to that in the UK. Notably, biliary colic seldom gets beyond the emergency department and a larger proportion of cases on the ward had presented with late sepsis (DU, appendix and so on) than would do so now in the UK. There would be merit in our UK trainees

going to Groote Schuur hospitals for experience in ACS as well as trauma.

Much of the surgery carried out in the district and regional hospitals under the Groote Schuur umbrella falls within the remit of ACS and trauma. The Victoria and Mitchells Plain hospitals are two district facilities within the referral catchment of Groote Schuur. In these smaller hospitals, CT remains limited or unavailable. A handful of young consultants manage the acute care, trauma and general surgery workload supported by visiting staff and permanent medical officers.

During the vibrant teaching round, discussions ranged across emergency surgery, settling one time on choice of operation for peptic stricture of the duodenum and another on extended right hemicolectomy versus segmental colonic resection for obstructing carcinoma splenic flexure with local nephric and diaphragmatic invasion.

On another occasion, the issues of care, both ethical and practical, for prisoners were discussed on the ward and in the following coffee break.

Intestinal Failure Unit Visiting the department’s Intestinal Failure Unit ranked highly for me, as I work in the older of the two national units in the UK. Professor Goldberg and Mr Boutall have developed a sixbed unit where this specialised care can be developed and from where the skills can be disseminated.

As in the UK, the patient load included trauma, Crohn’s disease and postoperative fistulae. However, at Groote Schuur, the inability to give antiretroviral drugs intravenously and TB are real considerations, as is the relative inability to deliver home intravenous feeding. There may be scope to develop or maximise outpatient TPN or supplemented enteral nutrition, and these techniques could be useful in many other healthcare systems.

Why not visit?

When surgeons dream of their ‘ideal’ practice, many think of one that combines the high-quality specialist and the broad generalist, is built around a strong surgical team and includes interested students. Visit Cape Town if you get the chance – there is so much to learn there. www.rcsed.ac.uk | 29

GIRFT PROGRAMME

GETTING IT RIGHT FIRST TIME

BRAIN LIGHT / ALAMY STOCK PHOTO

In an era of financial constraint and rising volume, grassroots support and engagement have been key in helping one initiative find the best route to quality care.

Professor Tim Briggs explains

30 | Surgeons’ News | December 2016

T Professor Tim Briggs is National Director for Clinical Quality and Efficiency for NHS England

he original Getting It Right First Time (GIRFT) pilot in elective orthopaedics was funded by the medical directorate of the Department of Health and NHS England, and was undertaken by my team, based at the Royal National Orthopaedic Hospital in conjunction with the British Orthopaedic Association (BOA).

It marked an important landmark for the NHS, and the orthopaedic specialty in particular, in that it was a clinically led, professionally supported, centrally funded project run from a provider-based team.

My team are clinical and managerial insiders, all ‘at the coal face’, who understand the current problems facing the NHS – rising demand and financial constraints – and who want to find appropriate solutions. We have found variations in quality and efficiency, and talked our colleagues through the data and heard the stories of what is happening and why.

This is leading to change in professional and managerial practice built on an evidence-based approach and understanding of the complexities of delivering change in long-term embedded clinical practice and culture.

The approach is successful, as it is owned and driven by leading clinicians to ensure that high-quality outcomes and patient safety are at the forefront of change. The process and methodology is working: we are seeing a reduction in variation, and savings are now being realised. Indeed, our first survey of providers one year post-pilot (71 trusts to date) indicates direct savings of between £20m and £30m from the first tranche of respondents with an additional £15m to £20m of savings forecast in 2015/16 – an excellent return on the initial £200,000 investment in the pilot.

Extrapolating this to 142 trusts would potentially see savings to date in the region of £40m to £60m and a further £30m to £40m over the next 12 months. These data have been used in the Pilot GIRFT Orthopaedic Dashboard, published in April 2016, with a further review of progress underway.

The GIRFT team has visited almost every trust in England as part of the pilot (more than 140 trusts, including over 200 hospital sites) and has spoken to members of every orthopaedic and management team. From this, it is clear that we need to look beyond tariff reduction or rationing and work to identify the many ‘fixable’ variations we have identified.

It is the incremental effect of a mass of improvements that typifies the GIRFT approach, and we truly believe that the task is so huge that providers and clinicians need this external, but ultimately sympathetic, approach to help them identify what can and must be done to tackle unwanted variations in outcomes and needless variations in cost.

The current expanded programme has been going since March 2015 and has been rolled out to a further 11 specialties. We have also appointed national clinical leads

We are already seeing evidence of reduced variation and impressive levels of buy-in from clinicians and managers

IMPACT TO DATE

The emerging evidence of change in NHS provision of orthopaedic surgery with clear quantitative impact: l A step change in the method of fixation for primary hip replacement in the over-65 cohort with a jump from just under 45% of activity to over 55% using cemented fixation in 2012/13 and 2013/14, reversing a longterm trend. This is a change in practice that begins to align care to National Joint Registry-advised best practice and is also worth an estimated £4.4m per year, as cemented fixation generally offers both a better clinical and financial option. l The initial 71 trusts that have responded to a Department of Health (DoH) survey indicate direct savings of between £20m and £30m with an additional £15m to £20m of savings in 2015/16 – an excellent return on the initial £200,000 investment in the orthopaedic pilot.

Trust responses to the DoH survey also provide qualitative information on changes in service provision encouraged by the GIRFT programme: l A move towards ring-fenced elective orthopaedic beds. l Greater scrutiny of the charges applied for loan kit. l Early evidence of greater price awareness and sensitivity among surgeons. l Of the Trusts that have replied, 75% report renegotiation and rationalisation of their implant stock. l Moves to address appropriate surgeon-level minimum volumes. l Networks are forming to concentrate complex case-mixes in the right environment for best outcomes.

to replicate the process and the peer-to-peer review role I delivered in the pilot.

We are already seeing evidence of reduced variation and impressive levels of buy-in from clinicians and managers and, although each specialty has its own unique ‘footprint’ in terms of variation and opportunity, the common themes are very much that we can provide clear sight of what is happening and what can be done to improve care and efficiency. Early output from the new work streams indicate that they will reveal fresh ways in which this work will help us to enhance the quality of outcome and experience for patients, while helping the NHS to become more fit for purpose as demand grows.

National Director of Clinical Productivity Professor Tim Evans and myself (in my role as National Director of Clinical Quality and Efficiency) have met with all the www.rcsed.ac.uk | 31

GIRFT PROGRAMME

Royal Colleges and professional associations and have gained their commitment to the GIRFT programme. All of them are enthusiastic about participating in this clinically led improvement programme. Furthermore, we recently convened a meeting of all medical directors in England to discuss the programme, and attendance was almost 100% from trusts with palpable levels of engagement.

The idiosyncratic forces that operate in healthcare economies mean that marginal gains can be reversed if we do not maintain control and improve

ATTRIBUTION The GIRFT programme cannot claim that all positive change in any metric is solely due to its influence, as there are many national and local efforts that have an impact on total efficiency and quality in hospitals, health sectors, orthopaedic surgery and within individual trusts. Untangling all the factors for change is impossible. However, there is evidence of changing clinical behaviour where GIRFT has had conversations with individual clinicians.

GIRFT AS A HEALTH ECONOMICS PROGRAMME The challenge for commissioners and providers is to provide the highest standards of care based on current best evidence in accordance with clinical ethical responsibilities, while maintaining cost-effectiveness through resource allocation.

To meet the aim of Pareto-efficient resource allocation, a marginal gains approach is required for both quality and efficiency. GIRFT has proven to be successful in attaining marginal quality gains via the promotion of best practice standards in orthopaedic decision-making. GIRFT has also been successful in delivering effective marginal efficiency gains through procurement rationalisation, bed-day consumption through reduced length of stay and reductions in costly readmissions.

From the health economics viewpoint, GIRFT improves the efficiency of available resources, reduces average costs and improves quality outcomes. As evidenced, the programme delivers efficiency gains for healthcare economies and utility gains for patients. GIRFT was developed to address unwarranted variations in the quality of clinical outcomes. However, we have arrived at a de facto health economic solution as well. The idiosyncratic forces that operate in healthcare economies mean that marginal gains can be reversed if we do not maintain control and improve. The way to ensure this progress continues is to improve the quality of data collection, analysis and

THE GIRFT CHARTER

The programme has created its own charter for addressing inequalities it has identified. It aims to: l Improve the quality of patient outcomes l Improve patient experience l Enhance safety l Address unacceptable variation in practice and outcome l Challenge unacceptable and wasteful practice l Identify and disseminate best practice l Provide hands-on clinical consultancy and intervention to effect rapid change

32 | Surgeons’ News | December 2016

distribution so that GIRFT carries on providing detailed intelligence of increasing value to hospital trusts.

To achieve the aims of our charter (see below), GIRFT must be supported by increasing the reliability and consistency of NHS data with enhanced dashboards. We now have three years of hospital data to work with, but we will be improving metrics and data-collection processes to produce an increasingly accurate information source.

We also want to influence behaviours towards best practice and to support trusts with further site visits.

General, spinal, vascular and urology surgery and neurosurgery and the second round of orthopaedic visits are in progress, and the remaining specialties are being scheduled. The visit schedule allows the GIRFT team to discuss local practice with trust provider staff, informed by their data and national comparative data, and then to build relationships that actively promote engagement through empowerment. This is a vital step in the process, and it has allowed GIRFT to become a consultancy/ improvement/coaching project, rather than simply a query and analysis of data. After all, we cannot change a single thing without engagement.

Supporting the improvements of clinical coding is also an important goal – reviewing and assessing clinical coding quality to ensure that what is recorded as activity increasingly matches what has happened in practice. This will feed into better data and metrics that have improved accuracy and are met with increasing trust. GIRFT wants to change behaviour but people will not change what they do if they do not believe the numbers.

There is also a need to create novel data collections to populate desired metrics, such as those necessary to understand and monitor wound infection, ring-fenced bed models and many more.

It is also important to take control and improve the efficiency of NHS procurement by rationalising implant choice and inventory. After the analysis of the preliminary GIRFT data sets, I wrote to all orthopaedic providers on behalf of the BOA to demonstrate how reducing variation in selection of implant types for certain joint replacements to those that have the highest standards of post-prosthetic longevity, and the best evidence for patient outcomes, can significantly rationalise NHS procurement for this type of prosthesis. This shift to a standardised procedure should decrease average purchase cost, decrease stockholding requirements, reduce waste and improve quality standards (all marginal efficiency gains). This strategy can be shared by the GIRFT team as best practice, so rationalising procurement is a particularly transferable GIRFT improvement.

WHAT NEXT? So far, the programme’s success has been partly owing to both bringing the right data and right people together on an increasingly large scale.

IMPORTANT VARIATIONS FROM BEST PRACTICE UNCOVERED BY THE GIRFT PROCESS VARIATION FOUND

EXAMPLE

FINDINGS

Access to orthopaedic services

Variable standardised rates of hip replacement per 100,000 population

Range for CCGs is 55 to 208 Lower quintile: 115 Upper quintile: 160

Access to timely care

Waiting lists

More than 50% of providers cannot achieve the 18-week standard

Access to musculoskeletal services

Access to physiotherapy and rehabilitation services

Less than 50% of patients have rehabilitation following hip fracture

Clinical criteria

Level of comorbidity accepted

Charlson score (comorbidity) for orthopaedic and spinal surgery: 0.41 to 0.56

Guidelines

Guidelines for hip replacement

Multiple overlapping guidelines that are often difficult to implement effectively, and occasionally containing contradictory guidance, and based on a wide variety of research

Choice of procedure

Type of primary hip replacement in patients over 65 years old

Cemented: 5% to 95% Uncemented: 5% to 100% Hybrid: 0% to 75%

Choice of prosthesis

Type of Orthopaedic Data Evaluation Panel (ODEP) 10A-rated implants

From 0% to 100% for acetabular implants

Cost of implants

Different type of hip prosthesis

£761 to £3,669 per hip

Cost of equipment

Trust spend on low volume ‘loan kits’

£50,000 to £750,000 pa

Procurement variation

Different prices paid for the same implants

Implant costs range from less than £595 to more than £854 for the same procedure type

Low volumes of surgery

% surgeons undertaking fewer than five procedures per year

Primary hip: 16.0% of all surgeons Hip revision: 45.9% of all surgeons

Implementation of a clinical pathway

Duration of stay (replacement)

Hip: 5.3 days to 7.1 days, Knee: 5.0 days to 6.8 days

Postoperative complications

Infection rate

Estimated at 0.4% to 3.5%

Postoperative complications

Emergency readmission rate

Within 28 days of primary hip replacement: 3.8% to 9.8%

Long-term clinical effectiveness

Rate of revision of hip replacement

0.4% to 1.4% at one year 6% to 3.4% at five years

Clinical outcomes

Health gain

Hip (Oxford score): 18.7 to 21.6 EQ-5D (Index score) for primary hip replacement procedures ranges from 0.3 to 0.6 (2.4-fold variation)

Staff costs

Hours of care per patient per day

6.33 hours to 15.48 hours on all wards

Staff wellbeing and morale

Sickness and absence rates

From 2.7% to 5.8% all staff

The next steps of the GIRFT project are to continue to refine the methodology in orthopaedics and progress the roll-out to a wider audience, which will enable improvements in the quality of care and efficiency savings to be scaled up dramatically.

There are powerful data items, such as NHS litigation costs, which exist, but the GIRFT team has gained extended access to these only recently. There are further data that would be useful, but are not currently collected,

such as an agreed definition of a wound infection. Efforts to address this are being initiated.

Within its new home in NHS Improvement, the GIRFT team is looking to roll out its proven methodology across all medical and surgical specialties, dentistry and – potentially – community and primary care in the future.

This will be founded on comprehensive, robust and transparently accessible data to inform discussion, generate understanding and lead to change. www.rcsed.ac.uk | 33

FRCS INTERCOLLEGIATE EXAM

34 | Surgeons’ News | December 2016

Winner of ASGBI and GB Ong medals, Nikola Henderson provides her tips on how to pass the FRCS in General Surgery

PASSING ON THE KNOWLEDGE

T

he FRCS Intercollegiate Exam is a daunting and expensive hurdle that you must overcome for the award of CCT. There is extensive guidance on the application process on the Joint Committee on Intercollegiate Examinations website ( jcie.org.uk). You should consult this early; prepare your funds and application well before the deadline.

SECTION 1 Focus your time and effort on knowledge and technique. The latter is extremely important so it’s worth practising answering precise and specific questions that are similar to those you will encounter on the day. The best way of doing this is to use the excellent online resources.

The Companion Series is basic essential reading, as is a standard surgical textbook and an up-to-date ATLS manual. Read reviews on Amazon and ask colleagues what they recommend. There are excellent resources and publications on the College website and those of subspecialty organisations. I found webinars particularly useful and varying the media can make studying less monotonous.

Download and print the curriculum and go through it point by point to ensure that you’ve covered everything, scoring off each item as you go.

SECTION 2 You are going to meet the guardians of the profession, who will challenge and push you over two rigorous days. You need to prove that you are suitable to join them as a consultant and have the knowledge and experience to begin your career as a specialty surgeon. If reading the previous sentence has made your blood run cold, if you doubt that you are ready, then you have some work to do. I altered the way I prepared for the viva and clinical quite significantly from section 1 and began to talk rather than read. Many people find a course helpful.

Your answers should begin with “my approach is…” rather than the more vague “well, you could...” Practise saying: “I would open the chest”, “I would perform a midline laparotomy”, “I would arrange an MRI”. The examiners want to know what you would do.

Nikola Henderson ST8 General Surgery

Bedtime reading should be replaced with the British Journal of Surgery, stretching back over the last 18 months. You should read and dissect every general surgical paper until criticising and reviewing a paper feels easy and you have a system for doing so.

Practise with some experienced colleagues – ideally an examiner and in front of an audience of peri-exam peers.

Get over performance anxiety well before the exam and make sure you become slick and practised at talking sense under pressure.

A subspecialty textbook aimed at consultants will stand you in good stead for many years. Selectively read your main subspecialty journal from the preceding two years and every ‘game changer’ paper. Know the guidelines relevant to your practice.

Understand the politics behind developments in your area and know who the expert surgeons and centres are. A peri-FRCS trainee should really already know most of this, so if you do not, get talking to your senior colleagues, reading editorials and asking lots more questions.

THE CLINICAL This part should feel comfortable as it is what you do every day. Try to attend clinics in all general surgical specialties. In the exam, treat patients as you would normally and relax. If a clinical problem is really difficult – for example, an obese abdomen has been opened several times and is covered in stomas, hernias and scars – and looks like a daunting undertaking, then say so. Be very polite, to both the patient and the examiners.

There is no single book or website that can give you the secret of success. As a general rule, start early, stay focused, make a plan and work hard. See the exam as a rite of passage and have faith in your ability to negotiate this final hurdle prior to independent practice.

Bedtime reading should be replaced with the British Journal of Surgery, stretching back over the last 18 months www.rcsed.ac.uk | 35

IN CONVERSATION: BURNOUT

SUPPORT SURGEONS UNDER STRESS

2

With half of surgeons reported to be showing signs of burnout, what can be done to prevent and alleviate it? Our panel discuss the issues HOW WOULD YOU DEFINE BURNOUT?

VICTORIA DOBIE (VD): It’s people reaching the end of their tether and not being able to cope, with signs and symptoms along the way, with the result that they function poorly at work.

STEPHEN BENNETT (SB): It’s where you run out of the energy reserves required to do the job.

ALICE HARTLEY (AH): It’s not just work that is affected.

Family and personal life are often the first to suffer, because we’re trying to keep up the persona that we can manage at work. People at home will probably be more supportive of us and, therefore, might recognise it sooner.

VICTORIA WEBBER (VW): It’s probably exhaustion and dissatisfaction at work, but could also be more serious in the form of depression and anxiety.

CHAIR – CLARE McNAUGHT (CM): The definition in much of the literature is that it is a ‘syndrome of emotional exhaustion and depersonalisation caused by work-related stress’. I’m sure we’ve all experienced it because recent studies suggest at least 50% of the surgical workforce is showing significant symptoms of burnout.

WHAT IMPACT DOES BURNOUT HAVE ON FRIENDS AND FAMILY?

VD: Compassion fatigue is one of the most distressing aspects of burnout; when people reach a point where they don’t care. And those who care the most and push themselves the hardest can be most susceptible to burnout.

CM: I think we often see that in our colleagues who are really struggling – they tend to start to isolate themselves.

They stop participating in governance issues, stop coming to meetings and become almost uncontactable.

VW: Is that perhaps because of fear of criticism from colleagues?

36 | Surgeons’ News | December 2016

1

When you’ve got a family and work life, there can be a feeling of guilt that runs the whole time, in everything you’re doing.

You can’t put 100% into both sides SB: There’s a perception that we’re supposed to be able to manage. Yes, it’s a difficult job, but we’re doctors, and we will get on. So if you’re not coping, it’s quite difficult to admit that to anyone because you don’t want to be perceived as weak.

CM: We’re in the most incredible career where we’re often saving patients’ lives. We never think about it like that, but it’s true. Yet sometimes you have this huge self-doubt and

THE PANEL 5

VICTORIA DOBIE SAS Representative on RCSEd Council and Associate Specialist in Orthopaedic Surgery

1

STEPHEN BENNETT Clinical Lead, Consultant General and Laparoscopic Surgeon

2

CLARE McNAUGHT Editor of Surgeons’ News, RCSEd Council Member and Consultant General and Colorectal Surgeon

3

ALICE HARTLEY Trainee Member of Council and an ST5 in Urology

3

4 5

VICTORIA WEBBER StR in General Surgery

you think, “What am I doing?” You have this terrible lack of perspective on your life because you’re so focused on everything that you can’t do. You get overwhelmed.

AH: If you’re not coping, or you feel like you need to stay late at work or do your emails or extra work at home, it then encroaches on family time. And not just evenings, but also at weekends. I’ve certainly taken work on holiday before.

SB: Often you don’t have the capacity to be the partner that you ideally want to be because you feel the pressure at work. For most of us, work is a high priority in our lives.

Family should be higher, but it doesn’t always display itself that way. That can cause issues.

VW: When you’ve got a family and work life, there can be a feeling of guilt that runs the whole time, in everything you’re doing. You can’t put 100% into both sides.

HOW DOES BURNOUT AFFECT PATIENTS?

VW: They are probably the last group to be affected because doctors are putting everything into patient care. The individual doctor, family and work colleagues probably all suffer before the patients.

VD: It can be dangerous for patients when burnout is unrecognised. The doctor may continue to take on clinical work, but other aspects of patient care, such as paperwork, may not be completed. This has an impact on the ability of the rest of the team to deliver safe patient care.

SB: If you’re not on top form, you can’t provide the best service. Your operative skills may not be as good as they could be.

CM: Confidence and judgement calls are probably not as good. When I’ve been overtired, I can’t make decisions as clearly as I would usually.

PHOTOGRAPHY: PETER SANDGROUND

4

www.rcsed.ac.uk | 37

IN CONVERSATION: BURNOUT

WHAT ARE THE MAIN CAUSES OF BURNOUT?

VD: Not being able to say no, but it’s very important to know when you can’t take on extra tasks.

AH: Personality comes into it. As surgeons, we strive to be perfectionists.

CM: A recent study of urological consultants and trainees cited increasing administrative work and bureaucracy as the most significant trigger for feelings of burnout.

SB: With new consultants, expectations of what the job is going to entail often don’t marry up with the reality.

More established consultants can take on more and more responsibilities that take them away from patient care.

As surgeons, we want to focus on operating and on patients who we can help, whereas there are lots of other things that go with patient care that we maybe don’t recognise as being so important, but that still have to be done.

WHAT EFFECT DOES BURNOUT HAVE ON JUNIOR SURGEONS?

VD: Teams used to sit down and have coffee together, but that doesn’t happen anymore. So you don’t get the older surgeons talking to the younger ones. We’ve lost a lot of the protective mechanisms that were there.

AH: Juniors move around a lot. They might be a long way from friends and family. Plus, they can be revising for exams at the same time. All of that can cause stress.

SB: When I became a consultant, it was probably the loneliest I have been in my life. I was in a department where there wasn’t very much teamworking. It’s a big transition to go into that from being a trainee in the company of lots of other trainees. You can quickly feel isolated.

CM: Juniors are susceptible to burnout, too. They often start calling in sick for on-calls, stop engaging with workbased assessments and stop participating in team social events. They are often difficult to find on the wards and avoid interactions with seniors.

38 | Surgeons’ News | December 2016

A recent study of urological consultants and trainees cited increasing administrative work and bureaucracy as the most significant trigger for feelings of burnout WHAT CAN WE DO TO PREVENT BURNOUT?

AH: Take regular breaks, leave work on time, take regular holidays – all of these are advocated, but in reality I don’t know how feasible they are in the NHS. SB: There are some straightforward measures that I’ve found make a big difference when I’m feeling stressed. One of them is recognising that you can’t do everything and acknowledging that you need to switch off from time to time. However, that can happen only if you have colleagues you can trust to look after your patients.

AH: The culture of a department is a key factor: if the clinical director is happy with that style of working, it’s fine, but there can be a different culture where you are expected to answer emails at 9.30 at night and it can be difficult to resist that.

VW: There are simple things the individual can control, such as eating and sleeping properly. That’s obvious, but if I haven’t slept very well, I feel dreadful. These are easy steps that can make you feel more capable of taking on a big day.

CM: At the opposite extreme, there are destructive habits, too. Unfortunately, the literature shows a lot of people will turn to alcohol and drugs to help them cope.

AH: There’s also the issue of gaining weight, which can happen from always grabbing food on the go – and there’s never healthy food in vending machines.

SB: Another problem is doctors not allowing themselves enough time to recover from minor illnesses or ailments.

If you’re burnt out, the virus is going to floor you much more and you’re not going to allow yourself time to get over it.

CM: Doctors may turn up when they aren’t fit for work because they have so much to do and they are worried about it creating extra work for someone else. So this could be caused by there being no slack or flexibility in the system.

VD: If someone is absent a lot, it may be a sign of burnout; being off work doesn’t necessarily mean a person is recovering. It can be a warning sign.

WHAT CAN ORGANISATIONS DO TO PREVENT BURNOUT?

SB: There are always going to be external pressures on getting more out of the workforce. Consultants often feel those pressures quite strongly because they are expected to see and operate on more patients than they might think is safe. However, there can also be a lack of appreciation of what’s a sensible workload by the management. If that could change to a recognition of what’s healthy and sustainable, it would make a big difference.

CM: Should we expect our employers to allow us to have counselling sessions or to receive coaching in mindfulness techniques? It would be nice to feel valued by your organisation. When something goes wrong, you are inundated with reports to complete and every aspect of your care is scrutinised, often by non-medical managers who do not fully understand the situation.

When was the last time someone said “thank you” when it all went well?

VD: Maybe management should see it as a good investment in time and in the service to provide some kind of service to help with counselling or unwinding and make it accessible, but it would be difficult to organise.

AH: I certainly think when you’re talking to patients, and breaking bad news, it can have a massive impact on your own personal wellbeing. If you’re doing that on a repeated basis with no real support network, it can leave you feeling awful.

SB: That should get picked up in the appraisal process, but that happens only once a year. Although I’m not sure an appraisal is the right place for it, at least it can be a place to explore these issues.

VD: The health part of the appraisal is rarely explored adequately, but it is an important aspect.

CM: Let’s be honest, appraisals can be tick-box exercises. Particularly in struggling organisations

Take regular breaks, leave work on time, take regular holidays – all of these are advocated, but in reality I don’t know how feasible they are in the NHS

where the people who are doing the appraisals haven’t been given adequate time and you have not had enough time to prepare, it becomes a less meaningful process.

SB: There is a reasonable amount of support within the Deanery process for trainees. As a supervisor, I’ve referred trainees in difficulty to the appropriate Associate Dean, who then has access to professional support for people who are struggling.

CAN MORE BE DONE TO NORMALISE TALKING ABOUT STRESS AND BURNOUT?

VD: Yes, but openness about the coping mechanisms is just as important. Occupational health gives very good advice, but the problem is early recognition of the issue and being prepared to do something about it.

SB: Can it be a negative experience to be referred to occupational health?

CM: Yes. At the moment there is stigma associated with it.

In countries such as the United States, there seems to be a more open culture about receiving counselling or therapy.

VD: There’s a lot to be gained from being open about mental health issues and sharing stories of how to cope with them or recover from them.

AS SURGEONS, HOW DO WE RESPOND TO COLLEAGUES WHO ARE STRUGGLING?

VW: The trouble probably comes before burnout is recognised. Problems can occur over months or years, with signs like someone struggling but not asking for help, or upsetting colleagues – they can actually become disliked because of how they act before burnout is acknowledged.

SB: There can be a perception that someone who is struggling is not supported, but the people around them do want to help because they want the whole department to be functioning well. You should want the best for colleagues.

CM: Unfortunately, people who are suffering from stress can be difficult to work with: they can be easily irritated and colleagues may start to avoid them. Should we be asking for mentor schemes in hospitals to make sure everyone has support?

SB: It is more common now, when you start as a consultant, to have a more www.rcsed.ac.uk | 39

IN CONVERSATION: BURNOUT

senior colleague nominated as your support person, but it’s very much optional whether the new consultant makes use of it.

VD: SAS doctors start without a mentor and they don’t get the induction that trainees get. They just go in at the deep end and get on with it. So a lot of the structures that we’re talking about for trainees and consultants aren’t there for SAS doctors.

Hospitals could publicise the issue more, with signs or notices promoting awareness of the issue, and signs and symptoms to look out for, and offer solutions such as occupational health or getting support from colleagues.

IF YOU HAD ONE TIP TO GIVE SOMEONE WHO FEELS BURNT OUT, WHAT WOULD THAT BE?

AH: I would say cut back on all the extra things you think you need to do. They can wait. That’s the extra audits and papers you’re trying to write. If you need time just to consolidate and get well, then just stop doing all of the extra activity and concentrate on yourself.

VW: I’d recommend focusing on enjoyment outside of work. It could be exercise, sport, a musical instrument or another hobby, but it should be something that’s important.

SB: My one thing would be find someone you can trust and talk to openly. It could be a partner at home, a mentor at work or a therapist, but it should be someone who can listen and challenge you when you are not looking after yourself.

VD: Go for a weekend away with peace and quiet. It’s important to be able to 40 | Surgeons’ News | December 2016

I’d recommend focusing on enjoyment outside of work. It could be exercise, sport, a musical instrument or another hobby, but it should be something that’s important take a step back and think about life, maybe with someone you can talk to.

CM: Mine would be get a dog. When I see my two dogs running towards me in the garden, it brings my stress levels right down. They always love you. They make you go outside and get fresh air.

CHAIR’S CONCLUSIONS We all know burnout is common. We recognise the symptoms because we’ve either had some of them ourselves or we’ve seen it in our colleagues. We admit that it has an effect on our personal lives and not just our work lives. There seems to be enough evidence to conclude that there is a huge need to start taking better care of mental health. Particularly in the current health service – the pressures are so great I think everyone struggles to cope at some point.

Normalising the issue and being open about it with our colleagues is something that can be done at an individual level and would be a very positive step.

It’s also very important for employers to take steps to monitor staff stress levels, to put in place structures for staff to come forward if they are struggling and to provide appropriate support in those cases.

DATES FOR YOUR DIARY The latest surgical and dental events, seminars and courses DECEMBER 2016 1–2 2 2–3 7–9 8–9 9 9 10–11 12 15–16

Basic Surgical Skills Student Research Symposium Training the Trainers (Chennai) Care of the Critically Ill Surgical Patient The Edinburgh MRCS OSCE Preparation Course (Chennai) Plastering Techniques for Fracture Treatment (Leeds) Non-Technical Skills for Surgeons (NOTSS) (Newcastle) Foundation of Surgical Gastroenterology Basic Microsurgical Skills Core Skills in Ureteroscopy (Bothwell)

JANUARY 2017 6 12–13 14 14–15 20–21 22–24 23 25 25–27 26–27 27 28–29 31 Jan –1 Feb

Core Skills in Vascular Surgery Anatomy MRCS OSCE Preparation Course Prep for Diploma in Special Care Dentistry (Birmingham) The Edinburgh MRCS OSCE Preparation Course MFDS Part 2 (Dubai) Mock MRCS OSCE Exam Course (Aberdeen) Basic Surgical Skills (Eindhoven) Prep for Diploma in Implant Dentistry (London) Advanced Trauma Life Support Vocational Dental Practitioners’ Conference Urology Training Day Basic Surgical Skills (Manchester) Basic Surgical Skills

FEBRUARY 2017 3 6 7 8 9 16–17 17–18 20 20–21 22–24 24–25 26 28

Future Surgeons: Key Skills Surgical Anatomy Study Day for Perioperative Practitioners Neuroradiology Workshop for Neurosurgeons RCSEd Cadaveric Intermediate Open Abdominal Surgery RCSEd Major Open Abdominal Surgery Endovascular Aneurysm Repair (EVAR) Planning and Deployment for Endovascular Surgeons Art of Surgery Diploma in Implant Dentistry (Sydney) The Edinburgh Head & Neck Course, Module I The Edinburgh Head & Neck Course, Module II Dental Implantology (Glasgow/Edinburgh) Diploma in Implant Dentistry (Dubai) Simulation-based Education for Surgeons

For further information, please email e ucation rcse ac u or telephone +44 (0)131 527 1600.

All events are in Edinburgh unless otherwise stated.

SPECIALTY: OESOPHAGOGASTRIC SURGERY

Graeme Couper looks at the development of oesophagogastric surgery and how surgical trainees can gain the most from this specialty

MOMENTOUS PROGRESS

42 | Surgeons’ News | December 2016

Graeme Couper Consultant Oesophagogastric Surgeon, Royal Infirmary of Edinburgh

JACOPIN/BSIP/SCIENCE PHOTO LIBRARY

A

n oesophagogastric (OG) surgeon transported from an operating theatre in 1986 to the modern day would barely recognise the operations listed and the techniques used. While the discoveries and changes that have occurred have undoubtedly been of huge benefit to patients, they have also had a dramatic effect on the training opportunities available to trainees.

The first of these is one of the most significant discoveries in the last 100 years of medicine.

Understanding the role of Helicobacter pylori in the development of peptic ulceration has saved countless lives and avoided life-changing surgery for many more.

From the first report by Marshall and Warren,1 it took almost a decade for its full role to be confirmed and the appropriate treatment regimens finalised. The knock-on effect for the surgical community has been significant, with the almost complete disappearance of operations such as vagotomy and pyloroplasty, highly selective vagotomy, and Billroth I and Billroth II gastrectomies for peptic ulcer disease.

The number of publications on peptic ulcer surgery over the last six decades (figure 1) is an accurate reflection of the changing times. Operations that were the bread-and-butter training procedures for an OG trainee have almost disappeared. Alongside this is a marked change in patients with peptic ulcer disease requiring surgery in an emergency setting. A review of emergency peptic ulcer surgery by Robson et al2 reported an average rate of 20 operations for bleeding and 44 for perforation per year in 2002–2005 in Lothian. An updated review of figures from 2010–2015 shows that, while the operative rate for perforation has remained unchanged at approximately 40 per year, the number of patients with bleeding ulcers now requiring surgery has more than halved in the last decade, with an average of nine cases per annum compared with the previously reported 20 per year.

This is undoubtedly due to improved endoscopic and radiological techniques, but again represents a reduction in training opportunities.

OG cancer services have similarly seen a huge change in the last 30 years, with a move towards

FIGURE 1. NUMBER OF PUBLICATIONS RELATING TO PEPTIC ULCER SURGERY IN 1955–2015 800

600

400

200

0 0 96 –1 5 5 19

REFERENCES 1. Marshall BJ, Warren JR. Unidentified curved bacilli in the stomach of patients with gastritis and peptic ulceration.

Lancet 1984; 1(8390): 1311–15 2. Robson AJ, Richards JM, Ohly N, Nixon SJ, PatersonBrown S. The effect of surgical subspecialisation on outcomes in peptic ulcer disease complicated by perforation and bleeding. World J Surg. 2008; 32(7): 1456–1461 3. www.isdscotland. org/Health.../201502-17-UpperGI-QPIReport.pdf?

65 19 1– 6 19

0 97 –1 5 6 19

75 19 1– 7 19

0 98 –1 6 7 19

85 19 1– 8 19

0 99 –1 6 8 19

centralisation of surgical services. Within Scotland there are approximately 900 new oesophageal and 500 new gastric cancer diagnoses per year (figures obtained from Scottish Cancer Network National Audit3). Resection rates are low, with 15% of oesophageal cancer patients undergoing surgery and 25% of gastric patients. This amounts to 135 oesophagectomies and 125 gastric resections per year on average. Currently there are seven centres within Scotland performing resections for OG cancer.

If the available cancer resections were divided equally between the seven centres, this would still only amount to 37 cases per unit per year.

Accepting that there are currently large differences in volume between centres it is difficult to see how a trainee, in some regions, wishing to pursue a career in OG cancer surgery can achieve adequate exposure during the training years to be equipped to be a standalone consultant. How do we solve the problem?

One solution would be to follow the example of the vascular, paediatric and cardiothoracic surgeons and have a national training scheme with selected trainees rotating through the different centres. This model has also been adopted in Australia for specialty training, but does have a significant impact on family life. We are then left with the non-cancer surgeons who are still expected to deal with OG emergencies and have a further reduction in exposure to gastric and oesophageal surgery.

There needs to be a more structured training programme to ensure that all those who embark on this path are exposed to the maximum number of cases possible during their training

95 19 1– 9 19

0 00 –2 6 9 19

5 00 –2 1 0 20

0 01 –2 6 0 20

15 20 1– 1 20

There are two areas of upper GI surgery that have particularly seen expansion in the last 30 years: laparoscopic anti-reflux surgery and bariatric surgery.

The first of these comprises a group of historical operations made more acceptable to patients and surgeons by the development of laparoscopic techniques and improved equipment. Patient satisfaction rates are high for the laparoscopic techniques and are comparable to those reported during the era of open surgery.

Bariatric surgery is different in that the operations and operative techniques have changed. From its infancy when open vertical banded gastroplasty was the operation of choice, laparoscopic techniques are now the routine procedure and, although there was an initial surge of insertion of laparoscopic adjustable bands, it is now more common for patients to undergo a laparoscopic sleeve gastrectomy or laparoscopic bypass. Within this area of surgery has come a need for a multidisciplinary approach to these patients similar to that required for patients with cancer. Due to the specialised nature of the surgery, it is performed only in larger centres, with exposure to the surgery limited to a handful of trainees.

So, would I recommend OG surgery to a surgical trainee undecided on which specialty to choose? Yes, I would, but there needs to be a more structured training programme to ensure that all those who embark on this path are exposed to the maximum possible number of cases during their training. This may require a limit on the number of trainees entering OG training. How do we increase surgical trainees’ exposure to operating in the upper abdomen and familiarise themselves with the anatomy? When discussing the topic of this article with me, a senior OG trainee and a senior OG consultant both, independently and within one week of each other, expressed that the most useful operation for training in OG surgery was during organ retrieval when employed in the national transplant unit. rcsed.ac.uk | 43

SPECIALTY: OESOPHAGOGASTRIC SURGERY

Stuart McKechnie discusses challenges faced by an UGI trainee

Training pathway

C Stuart McKechnie Post-CCT Trainee in Benign UGI and Military Surgery

hanges in organisation have made it more important than ever to maximise return from all aspects of the registrar training pathway. This is particularly true for upper gastrointestinal (UGI) surgery. Centralisation and pure operative numbers mean diligent trainees need to use other aspects of surgical training to create the surgical skillset required for life as UGI consultants. They also need to strategically assess future job availability and location in taking the decision to pursue this specialty. I have finished this pathway and, while I do not want to risk overpersonalisation, there are some aspects that I believe are important to consider.

Most trainees have become more comfortable with the laparoscopic approach than their seniors were at the same stage. This has created its own problems, with the converted open procedure providing more of a challenge.

The advanced techniques needed for gastric mobilisation, thoracoscopic resections, fundoplication and bariatrics can be learned efficiently only if a robust technique has been developed through core procedures such as appendicectomy and cholecystectomy. Specific steps can also be rehearsed with laparoscopic trainers and, while they can’t replace operative experience, they can increase confidence to utilise training opportunities.

Then there’s multi-person operating. There are many facets to most operations that multiple

44 | Surgeons’ News | December 2016

Laparoscopic gall bladder surgery

I have found multi-organ retrieval to be the most useful aspect of training surgical trainees can use to fulfil their own learning objectives. Taking an Ivor Lewis oesophagectomy as an example, trainees can achieve their aims by performing abdominal mobilisation (open and laparoscopic) while oesophagogastric trainees may wish to concentrate on dissection in the chest and subsequent anastomosis. Chest drain insertion, feeding jejunostomy and pyloroplasty can all be utilised according to learning needs.

Lastly, I have found multi-organ retrieval to be the most useful aspect of training. The procedural steps available to learn from one operation, including visceral rotation, rapid control and cannulation of great vessels, thoracotomy and dissection of the porta and nephrectomy, have meant my surgical confidence took a leap at the ideal time of ST6, with the skills learnt applicable in so many areas of elective and emergency general surgery. In no other area of training do you have the opportunity to perform major surgery independently, in an unfamiliar environment. This is especially relevant to my role as a military surgeon.

My time in retrieval was during a year of Transplant and HPB, but participation in the retrieval team could also take place as an on-call component during other general surgical placements.

Professor Bill Saunders provides an update on the latest developments from the College’s Faculty of Dental Surgery

ABOVE AND BEYOND

I

n my last column I mentioned the inauguration of the Faculty of Dental Trainers (FDT) and on 1 September we opened the website. Applications are already coming in thick and fast. The work put in by the College’s communications and marketing department to ensure a smooth launch is not to be underestimated and the Faculty is grateful for all their efforts. I would urge Members and Fellows to promote membership of the new Faculty; your colleagues do not need to be affiliated with our College to join. I am very excited about the FDT and how it will enable us to engage with trainers and educators across the dental profession.

Training dentists at every level is becoming, thankfully, less ‘apprentice based’ and more formal and professional, with both technical and non-technical skills being taught. Surgeons have a fantastic course in the training of non-technical skills, the so-called NOTSS course. The College website describes it as “a behaviour rating system based on a skills taxonomy that allows valid and reliable observation and assessment of four categories of surgeons’ nontechnical skill: situation awareness, decision making, communication and teamwork, and leadership”. We hope to introduce this type of training into the portfolio of courses we can offer the FDT. We are determined to recognise the trainers in our profession for the high quality of training they give to the candidates who choose us for their summative assessments at every level.

The Dental Faculty offered to take part in a pilot submission to the General Dental Council (GDC) regarding Standards for Specialty Education. Clearly, not all the standards as outlined by the GDC are pertinent to us, but we undertook the exercise in good faith and have received the pilot report from the organisation. We look forward to discussing our role in specialty training and assessment with the regulatory authority and I am confident we can fulfil all the requirements that will be set for us.

While our role in specialty training continues to evolve, we remain

Our Faculty of Examiners show a great deal of dedication to the College by way of time spent not just examining, but writing scenarios and questions, and undertaking training determined to deliver the highest standards and most contemporary assessment methodology to ultimately ensure and enhance patient safety.

The Faculty has an enviable reputation for its activities overseas and the efforts of the specialty advisory boards and advisory boards to strengthen ties internationally are much appreciated. My ‘retired’ status means I am privileged to attend most of the meetings of these boards. I am always immensely encouraged by the enthusiasm and dedication of the board members. It is their efforts that make the College as strong and well respected as it is.

In addition, our Faculty of Examiners show a great deal of dedication to the College by way of time spent not just examining, but writing scenarios and questions, and undertaking appropriate training. Many often have to take personal leave to attend these activities.

This commitment is fantastic and the issue of taking such leave to undertake these vital duties shows a complete lack of foresight and engagement by many health boards and trusts.

Without the extraordinary commitment of our advisory board members and examiners from where is the next generation of specialists and consultants to come? The College has pressed employing NHS authorities to recognise this commitment to training and assessment, but it is proving a hard slog to gain recognition of the importance of this work.

Professor Bill Saunders Dean, Faculty of Dental Surgery www.rcsed.ac.uk | 45

DENTAL

Aspiring dentists have been taking part in the heats of the Dental Faculty’s annual skills competition

RISING TO THE CHALLENGE

I

n the Faculty’s Dental Skills Competition, which is the first of its kind in the UK and is sponsored by Dentsply Sirona, final-year dental students from across the UK demonstrate their skills in a series of challenges.

The competition runs from September to December, with 16 rounds, one at each UK dental school. Students must undertake complex dental work on a mouth mould, which is then submitted anonymously to the assessors, who later announce the winner.

The first heat took place at the University of Birmingham and the winner was Edward Newton. The 23-yearold was delighted to win the Birmingham round, commenting: “I am thrilled to be going to Edinburgh to compete in the Grand Final, and it’s also nice to be noticed for something I enjoy and take pride in. We are told dentistry is becoming more and more competitive, so I hope this will help me stand out from the crowd. I also particularly enjoy restorative dentistry and, with manual dexterity an important part of it, hopefully this will provide some recognition for this skillset and help me pursue a career once I qualify.”

Along with a certificate and trophy, Newton received a travel and accommodation package to compete in the Grand Final in Edinburgh on 30 March 2017, at which the top 16 finalists from across the UK will undertake a broad range of clinical procedures to determine who will be crowned the overall winner.

“The Dental Skills Competition really captures the students’ enthusiasm and drive, and challenges them on a range of key clinical skills. Competing against the best students in the country is a significant challenge,” said Brian Nattress, a member of the Dental Council at the College and a consultant restorative dentist in Leeds.

“One of the major aims of the College’s Dental Faculty is to set and quality-assure the highest standards for the dental 46 | Surgeons’ News | December 2016

Above: a student performs complex dental work on a mouth mould Left: the competition offers great networking opportunities

profession, and recognise that with the awards of Membership and Fellowship,” said Professor Bill Saunders, Dean of the Dental Faculty. “This competition is a shining example of ensuring that those standards are constantly challenged and updated, with students benefiting from the networking opportunities it brings.

“The RCSEd is very 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 Sirona for its collaboration to make this competition possible.”

The winner of the first heat, Edward Newton, receives his trophy

I am thrilled to be going to Edinburgh to compete in the Grand Final, and it’s also nice to be noticed for something I enjoy and take pride in

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BEST OF

BOTH

DENTAL

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

1

TAYSIDE 2 Pauline Maillou, 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 KENT, SURREY & SUSSEX 5 Lindsay Winchester, Queen Victoria Hospital, East Grinstead

16

NORTH WEST OF ENGLAND 6 Nick Grey, Manchester Dental School 7 Callum Youngson, School of Dentistry, Liverpool

15 6 7

NORTH LONDON 8 Phil Taylor, Barts and the London School of Medicine and Dentistry, London

12

NORTH EAST LONDON 9 Nick Lewis, UCL Eastman Dental Institute, London 4

NORTH WEST LONDON 10 Sumithra Hewage, Northwick Park Hospital, Harrow

11 10

OXFORD 11 Mary McKnight, John Radcliffe Hospital, Oxford SOUTH YORKSHIRE/EAST MIDLANDS 12 Philip Benson, Charles Clifford Dental Hospital, Sheffield

13 14

SOUTH WEST OF ENGLAND 13 Pamela Ellis, Dorset County Hospital, Dorset PENINSULA 14 Ewen McColl, Peninsula Dental School, Plymouth YORKSHIRE 15 Brian Nattress, Leeds Dental Institute, Leeds

NORTHERN IRELAND

16 Gerald McKenna, Queen’s University Belfast

48 | Surgeons’ News | December 2016

RDA VACANCIES

North of England South West England (Devon/Exeter) South East Scotland North Wales Avon Cardiff Republic of Ireland For details, contact: outreach@rcsed.ac.uk

9 8 5

TRAINEES AND STUDENTS

From symposia to workshops and competitions, the College runs a broad range of events to improve skills across the UK

OUTREACH ACTIVITIES

THE THIRD OXFORD SURGICAL SKILLS SYMPOSIUM

T

he College has collaborated with the Hugh Cairns Surgical Society and Oxford Foundation Surgical Society (OFSS) to deliver the third Oxford Surgical Skills symposium.

Held on 8 October, the aim was to introduce 72 senior medical students and foundation trainees to a variety of skills not routinely covered in current surgical curricula. The course provided handson experience of basic surgical skills with instructor-led surgical teaching. College President Mr Michael LavelleJones gave a talk at the symposium, and also offered encouragement and advice to participants.

This day-long event was comprised of six workstations that accommodated 12 participants at a time. The workstations were: an introduction to laparoscopic skills; bowel anastomosis; thoracic trauma; introduction to the management of fractures; a hernia repair station; and electrocautery/surgical haemostasis. A consultant surgeon and senior surgical trainee at each station provided one-to-one attention to participants. The day was split into two sessions in which participants rotated through three workstations, preceded by short lectures that covered each station.

The day concluded with an awards ceremony where the winners of the laparoscopic skills competition and the most promising surgeon received prizes.

The symposium was organised by the Regional Adviser for Oxfordshire and Consultant Hepatobiliary and

A delegate learns new skills at one of the six workstations

Dundee tests skills The College, in collaboration with Medtronic, ran the first heat of the RCSEd National Student Surgical Skills Competition at Ninewells Hospital for Dundee medical students on Saturday 17 September. Aspiring fourth- and fifth-year surgeons took part in the competition, which covered a range of tests on basic surgical skills, including suturing and laparoscopy. Alex North won the competition, followed closely by Alison Lim. There was a great atmosphere during the competition, and it was an opportunity for students to learn new skills in a relaxed and fun environment.

Alex North (left) wins the first regional heat, held in Dundee

This was the first of 19 regional heats taking place across the UK. As well as a certificate and trophy, Mr North won a travel and accommodation package to compete in the Grand Final in Edinburgh on 18 February 2017 in which the 19 finalists from the heats will complete a range of tests to determine the overall winner.

rcsed.ac.uk | 49

Trauma Consultant Xavier Griffin talks attendees through a procedure at the Oxford symposium

Pancreatic Surgeon Michael Silva, supported by Katherine Hurst, past-President of OFSS. Medtronic was the main sponsor, with the trauma workstation sponsored by DePuy Synthes. Registration for the symposium was via the College website for a nominal fee of £10 each.

WADE PROGRAMME IN SURGICAL ANATOMY

O

n 26 September, the Wade Programme in Surgical Anatomy visited Oxford. The Anatomy Suite at Oxford University was the venue for the surgical anatomy workshop, convened by the College’s Professor of Anatomy, David Sinclair, and Regional Surgical Adviser for Oxfordshire, Michael Silva.

The workshop catered for senior medical students with the aim of increasing awareness of the important links between anatomy and surgical practice. The evening kicked off with an inspirational talk from Professor Sinclair entitled ‘Surgery and Anatomy – Partners in Time and Space’. Professor Sinclair outlined a concept for the study of surgical anatomy as a blend of anatomical knowledge and its applications in surgical practice, all of which is ultimately aimed at benefiting patients. Participants were encouraged to develop a three-dimensional, internally visualised model of the anatomy of the body, rather than merely memorising verbal descriptions.

This was followed by three practical sessions using cadaveric specimens on the surgical anatomy of the head and neck, trunk and limbs. Each practical session used three clinical scenarios to take participants through the surgically relevant anatomy using prosections as visual and tactile cues. Professor Sinclair discussed the head and neck, Mr Silva detailed the anatomy of the trunk, and Director of Anatomy of Oxford University, Mr Thomas

50 | Surgeons’ News | December 2016

Wade feedback “It was excellent to have such good demonstrators talk through cases and anatomy in such small groups.”

“This was one of the most enjoyable surgical workshops that I’ve ever attended. The quality of the teaching was superb and the learning derived from it greater than I expected.”

“It’s been a very good refresher of first-year anatomy and the compartment syndrome explanation was very valuable in terms of learning surgically relevant anatomy. I wish all surgeons did this.”

Faculty and delegates at the Wade Surgical Anatomy Workshop

Cosker, discussed the limbs. Students were able to interact with the Faculty in a way that stimulated questions and a deeper recognition of the link between anatomy and surgery. The overriding sentiment expressed by the participants was: “Could we have more, please?”

The event was made possible by the interactions of the regional network and Mr Cosker.

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rcsed.ac.uk | 51

TRAINEES AND STUDENTS

With trainees facing increasing challenges, support from a non-medical workforce could be the solution

TEAM EFFORT

D A PeckhamCooper, D Bunting, V Gokani, J Glasbey, H Mohan, R Harries, A Williams

emands on the surgical workforce are increasing as a consequence of rapid changes to healthcare policy, reducing trainee numbers, working time directives and an ageing patient demographic. The NHS has looked to alternative healthcare professionals focused on delivery of high-quality service in the wake of poor retention of the medical workforce, individual specialty imbalances and regional variability in recruitment.

In the past decade, surgical training in the UK has undergone a radical overhaul and there is a continued drive for this to further evolve and change in line with the implementation of the Shape of Training and the Improving Surgical Training reports.1,2 Despite this, there continues to be broad failings in UK surgical training.3 Trainee satisfaction scores published from the GMC’s National Training Survey 2014 showed that surgical trainees were the least satisfied doctors of any specialty, with particular issues identified in the early years of training.4 These include: the conflict between training and service provision, which is especially acute at core level; rota gaps; variable shift patterns; and limited trainer/trainee exposure combined with significant reductions in daylight elective training opportunities.

These challenges are acknowledged in Improving Surgical Training, which identifies “a need to reduce service commitment and address the conflict between training and service, whilst acknowledging the increasing workload resulting from a changing population and patient demographic”. The resulting recommendation proposes a strategy to redress this service-training imbalance by suggesting that “a non-medical workforce (NMW) should be developed to deliver surgical care by

52 | Surgeons’ News | December 2016

The recommendation proposes a strategy to redress this servicetraining imbalance by suggesting that ‘an NMW should be developed to deliver surgical care by supporting junior surgeons’

REFERENCES 1. Greenaway D, editor.

Securing the future of excellent patient care. www. shapeoftraining.co.uk/static/ documents/content/Shape_ of_training_FINAL_Report. pdf_53977887.pdf 2. Royal College of Surgeons (Eng). Improving Surgical Training. Proposal for a pilot surgical training programme (2015). www. bota.org.uk/wp-content/ uploads/2015/11/RCS-EngIST-Recommendations.pdf 3. Fitzgerald E, Giddings C, Khera G, Marron C. Improving the future of surgical training and education: consensus recommendations from the Association of Surgeons in Training. Int J Surg 2012; 10(8): 389–392 4. General Medical Council.

National training survey 2014. www.gmc-uk.org/NTS_2014__ KFR_A4.pdf_56706809.pdf 5. Lamont P on behalf of Royal College of Surgeons (Eng). The Curriculum Framework for the Surgical Care Practitioner (2014). www.rcseng.ac.uk/surgeons/ training/docs/surgical-carepractitioner-curriculum

PW ILLUSTRATION / IKON IMAGES

6. Bird J, Decker D on behalf of the College of Emergency Medicine (2015). NonMedical Practitioners in the Emergency Department

supporting junior surgeons and in some cases by sharing on-call responsibilities”.5 The term NMW encompasses several groups of allied health professionals with no pan-specialty consensus on terminology. The surgical care practitioner (SCP) is defined in the Curriculum Framework for the Surgical Care Practitioner (2014) as: “A registered non-medical practitioner who has completed a Royal College of Surgeons accredited programme (or other previously recognised course), working in clinical practice as a member of the extended surgical team, who performs surgical intervention, preoperative care and postoperative care under the direction and supervision of a consultant surgeon.”6 However, this definition fails to differentiate between a broad variety of roles and professionals. The College of Emergency Medicine identifies nurse practitioners, advanced nurse practitioners, advanced clinical practitioners and physician associates as separate entities based on clinical background, training, qualifications,

7. Williams L, Ritsema T. Satisfaction of doctors with the role of physician associates. Clin Med (Lond) 2014; 14(2): 113–116 8. Eardley I for Royal College of Surgeons (Eng).

A proposal to undertake a pilot to improve training in general surgery (2016). www. rcseng.ac.uk/surgeons/ training/docs/positionstatement-future-of-surgicaltraining-2016 9. Assocation of Surgeons in Training and British Orthopaedic Trainees Association (2015). Evidence submitted to the Royal College of Surgeons of England ‘Improving Surgical Training’ Consultation. A statement from ASiT and BOTA

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TRAINEES AND STUDENTS

Data suggest that surgical care practitioners enhance patient care, maintain surgical services and can act to support surgical training. At consultant level, surgeons seem broadly supportive experience, prescribing rights and scope of practice.

Different clinical roles and responsibilities are identified within these job titles.7 It is clear there is confusion among trainees regarding the scope of practice of the NMW, and patient expectations of the NMW must also be considered. There is a danger that patients may feel misled regarding the role of various professionals.

Indeed, despite the close affiliation of the RCSEng with patient representative groups during the development of the 2014 National Curriculum framework, both parties acknowledge a potential for ambiguity.6 The role of the broadly termed ‘surgical care practitioner (SCP)’, however, is now well established within healthcare organisations and, while evidence is scarce, data suggest that they enhance patient care, maintain surgical services and can act to support surgical training. At consultant level, surgeons seem broadly supportive and pleased with the impact on their teams.8 One of the premises for expansion of the NMW role is to provide a continuous, highly skilled and stable workforce unaffected by training hospital rotations.

Investment in training and the slightly higher cost per head than a junior medical trainee is, therefore, justifiable by the continuity of employment and by in part offsetting the potential cost of locums.9 It is too early to assess the longevity of individuals’ service in these roles and their job progression in a broader context, but the NMW adopting this enhanced career path are likely to be ambitious and driven. The long-term cost savings may not be as significant as hoped, as some individuals have completed their master’s training and simply used this as a vehicle to alternative career enhancement, whether that be into nursing management, clinical education or entering medical school.

There is continued caution and apprehension among surgical trainees with regard to SCPs with many considering them a ‘mixed blessing’. Trainees understand the need to address service provision challenges and can see the benefits a suitably trained and skilled SCP would have within the surgical team. However, despite the curriculum framework explicitly stating “that surgical training will not be compromised”, anecdotal evidence and comment suggest that in many cases SCPs are preferentially being granted training opportunities ahead of trainees. In addition, there are issues regarding governance and supervision of SCPs. There are concerns regarding the use of SCPs on the on-call rota, as it may result in higher surgical trainees supervising a practitioner whose training and level of skill they are less familiar with than that of a core trainee. This may lead to difficulties in safe delegation and may require the higher surgical trainee to be more involved in direct delivery of 54 | Surgeons’ News | December 2016

routine patient assessment to a level normally done by a core trainee. This effectively reduces the call tier by one and increases pressure on higher surgical trainees, leaving less time to concentrate on the sickest patient or the operating theatre, to the detriment of training and patient safety.

ASiT recognises that the NMW are valuable to the NHS and may serve to improve patient care and enhance training. However, little work has been done with respect to the cost–benefit analysis of their role. In evidence submitted to the Royal College of Surgeons’ Improving Surgical Training consultation, ASiT has raised concerns regarding “their defined role, their regulation, and the use of the term ‘Physicians Associate’ that may be misleading or confusing for patients”.

ASiT strongly believes that prior to any proposals for the widespread implementation of the NMW, a rigorous investigation into these concerns should be sought, alongside exploration of patient-reported outcomes and safety. Similarly, concerns that the potential utilisation of the NMW in a clinical role may impede or dilute training must be addressed, and it is imperative that the NMW should complement but not replace junior doctors and/or negatively impact on a surgeon’s training.

COLLEGE INFORMATION

DIPLOMA CEREMONIES

Congratulations to all our new Fellows and Members who were presented with diplomas at ceremonies in Edinburgh and Hong Kong DIPLOMA CEREMONY THE ROYAL COLLEGE OF SURGEONS OF EDINBURGH FRIDAY, 2 SEPTEMBER 2016 Conferment of Companionship Professor Patricia Peattie OBE, FRSA, Retired Assistant Principal of Edinburgh Napier University, Chairman of Trustees for the Scottish Colleges Foundation and Lay Assessor of Examiners, Royal Colleges of Surgeons Exit Examinations Admission to Fellowship Ad Hominem Professor James Anthony McCaul FRCPSGlasg(OMFS) FDS RCPSGlasg, Professor and Consultant Maxillofacial/Head and Neck Surgeon, Royal Marsden NHS Foundation Trust and Consultant Maxillofacial/Head and Neck Surgeon, Northwest London Hospitals NHS Trust Fellowship Without Examination Professor Changqing Gao, Vice-President, Chairman and Professor, Department of Cardiovascular Surgery, PLA General Hospital, Beijing, China Dr Mark Ranjan Jesudason, Professor of Surgery, Christian Medical College, Vellore, India Fellowship in Dental Surgery Without Examination Dr K Sadashiva Shetty, Principal, Professor and Head of the Department of Orthodontics, Bapuji Dental College and Hospital, India Fellowship in the Specialty of Cardiothoracic Surgery Keng-Leong Ang, University of Dublin, Ireland Espeed Khoshbin, University of Aberdeen Diplomas of Fellowship in the Specialty of General Surgery Haytham El-Hadi Abudeeb, Al-Fateh University, Libya Muhammad Amir Zaheer, University of Health Sciences (Lahore), Pakistan Diplomas of Fellowship in the Specialty of Neurosurgery Samira Akmal, University of Nairobi, Kenya

Diplomas of Fellowship in the Specialty of Trauma and Orthopaedic Surgery Yuvraj Agrawal, B P Koirala Institute of Health Sciences, Nepal Arun Bhaskaran, University of Calicut, India Mohamed Zubair Farook, Tamil Nadu Dr MGR Medical University, India Aiman Khunda, University of Baghdad, Iraq Kyle McDonald, Queen's University Belfast

Fellowship of the Faculty of Surgical Trainers Selwyn Michael Griffin OBE, Newcastle University

Diplomas of Fellowship in the Specialty of Urology Alvaro Enrique Bazo Morales, University of La Laguna, Spain Aza Ali Mohammed, University of Baghdad, Iraq

Diplomas of Membership in Ophthalmology Ahmed Mohamed Tawfik Mohamed Ibraheem, Ain Shams University, Egypt Mohammed Mohammed Mahdy Tawfeek, Zagazig University, Egypt

Diploma of the Joint Surgical Colleges’ Fellowship in General Surgery Zhiyan Yan, University of London

Diplomas of Membership in Otolaryngology Nisha Neelambaran, Kannur University, India Darren Jia Xiong Yap, University of Dundee

Diploma of Fellowship in Ophthalmology Jeannine Claire Nelson-Imoru, Carlos J Finlay Institute of Medical Sciences, Cuba

Intercollegiate Diplomas of Membership in Surgery in General Omer Abdalla Abdelwahab Abdalla, University of Juba, South Sudan Esubalew Alemu, University of Manchester Joseph Anthony Attard, University of Malta Rathinavelu Barani, Pondicherry University, India Kurt Carabott, University of Malta Baseem Choudhry, University of London Chi Kit Chuen, University of Dundee Syed Ali Mohsin Ehsanullah, Baqai Medical University, Pakistan Alastair Charles Faulkner, University of Edinburgh Samuel Anthony Galea, University of Malta Giorgio Gioffre, University of Trieste, Italy Javeria Iqbal, University of Peshawar, Pakistan Raveen Lasantha Jayasuriya, University of Sheffield Adil Jehangir Khan, Khyber Medical University, Pakistan Khurram Shahzad Khan, Baqai Medical University, Pakistan Rebecca Lewis, University of Edinburgh Mohamed Aseef Mohamed Yehiyan, University of Peradeniya, Sri Lanka Abu Bakar Md Mostafa, University of Dhaka, Bangladesh Aamir Nawaz, King Edward Medical University, Pakistan Maria Loredana Popescu, Victor Babes Medical University, Timisoara, Romania

IN MEMORY

SURGICAL FELLOWS Roger ABBEY-SMITH (FRCSEd 1943) Michael John ALDRIDGE (FRCSEd 1973) Roshini Marcelle ALLES (FRCSEd 1985) Gordon James Aitken CLUNIE (FRCSEd 1961) Clive Phillip COLE (FRCSEd 1973) Reginald Bruce CONYNGHAM (FRCSEd 1961) Geoffrey L Driscoll (FRCSEd 1979) Kenneth Christopher Howard FEARON (FRCSEd (without Examination) 1998) William John GARRETT (FRCSEd 1957) John Douglas Arnold HENSHAW (FRCSEd 1960) Kenneth Thomas HESKETH (FRCSEd 1959) Ramendra Nath SETH (FRCSEd 1969) Douglas Paviour SHORT (FRCSEd 1952) Michael Joseph SIMCOCK (FRCSEd 1967) Douglas Stormouth THOMSON (FRCSEd 1953) Appasamy VIJAYAN (FRCSEd 1997) Mohammed YUSUF (FRCSEd 1976)

The Sir Walter Mercer Medal Kyle McDonald, Queen's University Belfast The Syme Medal Rachel Victoria Guest, University of London

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COLLEGE INFORMATION

Saad Rehman, University of Health Sciences (Lahore), Pakistan Hanna Chinenye Uwakwe, Abia State University, Nigeria Ahmed Waqas, Quaid-i-Azam University, Pakistan Ram Zar War, University of Yangon, Myanmar Neil Ranjan Liyanagae Wickramasinghe, University of Edinburgh Darren Jia XiongYap, University of Dundee Hafsa Younus, University of Health Sciences (Lahore), Pakistan Membership of the Faculty of Surgical Trainers Khurram Shahzad Khan, Baqai Medical University, Pakistan Diploma in Otolaryngology – Head and Neck Surgery Darren Jia Xiong Yap, University of Dundee Diploma of Fellowship in Dental Surgery in the Specialty of Paediatric Dentistry Christine Marion Park, University of Glasgow Diploma of Fellowship in Dental Surgery Without Examination (by application) Mirghani Awad Yousif, University of Khartoum, Sudan Diplomas of Membership in Orthodontics Anil Abdul Kaphoor, University of Mysore, India Nasser Alamiri, University of Manchester Asma Abdulla Al-Mulla, University of Dundee Fawaz Lafi Nasser Almutairi, Kuwait University Ikmal Binti Mohamad Jaafar, University of Glasgow Diploma of Membership in Paediatric Dentistry Batool Ghaith, University of Dublin, Ireland Diploma of Membership in Periodontics Faizan Zaheer, National University of Ireland, Ireland Diplomas of Membership of the Faculty of Dental Surgery Mohamed Hassan Aboel Fotoh, Tanta University, Egypt Mariam Bahi Eldin Aly Gawdat, Misr University for Science and Technology, Egypt Charles Arthur Henry, Newcastle University Susan Johnstone, Newcastle University Nikhil Bharat Kanani, University of London Naeem Rashid, University of Manchester Ahmed Mohamed Sobhy Aly Saleh Abo Shanab, Misr University for Science and Technology, Egypt

56 | Surgeons’ News | December 2016

Hurjoht Singh Virdee, University of Birmingham Nitika Virmani, Ambedkar University, India Diploma in Orthodontic Therapy Suzanne Bouic, King's Health Partners, London Adina Iuliana Dima, King's Health Partners, London Ariane Alana Hart Diplexcito, Edinburgh Dental Education Centre Nicola Jane Ganly, DCP School, Bristol Dental Hospital Abigail Hussey, King's Health Partners, London Sarah Jean Sands, King's Health Partners, London

CONJOINT DIPLOMA CONFERMENT CEREMONY THE ROYAL COLLEGE OF SURGEONS OF EDINBURGH AND THE COLLEGE OF SURGEONS OF HONG KONG SATURDAY, 17 SEPTEMBER 2016 Fellowship Ad Hominem Professor WEI Fu Chan FACS Fellowship Without Examination Mr LIU Ta Li Fellowship in Dental Surgery Without Examination Dr CHAI Wen Lin Diplomas of Fellowship in the Specialty of Dental Surgery Without Examination (by application) LEE Kit Yee, The University of Hong Kong LI Qian Feng, Xi’an Jiaotong University LUK Ka Chun, The University of Hong Kong Mang Chek WEY, University of Malaya Diplomas of Joint Fellowship in the Specialty of Cardiothoracic Surgery CHAN Hoi Ming Herman, The Chinese University of Hong Kong LAU Wing Hung, The Chinese University of Hong Kong LEE Oswald Joseph On Jing, The University of Hong Kong Diplomas of Joint Fellowship in the Specialty of General Surgery CHAN Chung Yan Justin, The Chinese University of Hong Kong CHAN Ka Man Fiona, The University of Hong Kong CHAN Kar Vin, The University of Hong Kong CHAN Wai Hong, The Chinese University of Hong Kong

CHAN Ying Wing Jessie, The Chinese University of Hong Kong CHEUNG Chung Yeung, The University of Hong Kong FUNG Tak Lit Derek, The University of Hong Kong KONG Wai Chung Angela, The Chinese University of Hong Kong LAM Shek Ming Sherman, The University of Hong Kong LAM Shi, The University of Hong Kong LEE Suet Ying, The University of Hong Kong LEUNG Yu Wing, The University of Hong Kong LOK Hon Ting, The Chinese University of Hong Kong MAN Chun Hin Tommy, The University of Hong Kong WONG Kwok Kei, The University of Hong Kong WONG Lai Yin Claudia, The Chinese University of Hong Kong WONG Wui Bun, The University of Hong Kong Diplomas of Joint Fellowship in the Specialty of Neurosurgery CHAN Kit Ying, The Chinese University of Hong Kong CHU Sai Lok, The Chinese University of Hong Kong Diploma of Joint Fellowship in the Specialty of Paediatric Surgery LEUNG Ling, The University of Hong Kong

Diplomas of Joint Fellowship in the Specialty of Urology CHAN Hoi Chak Wilson, The Chinese University of Hong Kong KAN Wai Man, The University of Hong Kong LAI Chun Ting Terence, The University of Hong Kong LI Trevor Churk Fai, The University of Hong Kong NG Chi Man, The University of Hong Kong NGO Chang Chung, The University of Hong Kong TEOH Yuen Chun Jeremy, The University of Hong Kong TSANG Chiu Fung, The University of Hong Kong WONG Ka Wing, The Chinese University of Hong Kong Diplomas of Membership of the Faculty of Dental Surgery FONG Sze Ting, The University of Hong Kong LAU Man Chung, The University of Hong Kong LAW Kai Sun, The University of Hong Kong YUEN Ha Ching, The University of Hong Kong YUNG Ka Chun, The University of Hong Kong Diplomas of Membership in Oral and Maxillofacial Surgery AU Ho Yeung, The University of Hong Kong HUI Sheung Yu Bosco, The University of Hong Kong KUNG Yue Hin Alvin, The University of Hong Kong LAI Kar Yan Karen, The University of Hong Kong SUEN Ka Shing, The University of Hong Kong

Diplomas of Membership in Orthodontics CHAN Yi Lee Eliza, The University of Hong Kong Yang Rafidah Binti HASSAN, University of Malaya, Malaysia Woei Li KOAY, Universiti Kebangsaan, Malaysia LEUNG Man Yee, The University of Hong Kong SHAO Sheng, Nanjing University, China Diploma of Membership in Paediatric Dentistry YEUNG Patricia Melody, The University of Hong Kong Membership in Prosthodontics HO Ching Man Brian, The University of Hong Kong PONG Sze Ming, The University of Hong Kong Diploma of International Membership in Special Care Dentistry LEE Pui Ho Antonio, University of Sydney, Australia Diploma in Implant Dentistry LUK Ka Chun, The University of Hong Kong Diplomas of Membership in Surgery in General and Intercollegiate Membership in Surgery in General CHAN Chuen, The Chinese University of Hong Kong CHAN Nok Lun, The University of Hong Kong CHAN Shing Kit, The University of Hong Kong

CHAN Yin On, The Chinese University of Hong Kong CHENG Ka Yan Catherine, The University of Hong Kong CHIA Chi Fung, The University of Hong Kong CHOW Chi Woo Samuel, The University of Hong Kong HO Nga Sze, The Chinese University of Hong Kong Viswanath JAYASANKAR, Manipal University KWOK Sin Man, The Chinese University of Hong Kong LAM Wing Chung Wilson, The Chinese University of Hong Kong LAU Jerome, The University of Hong Kong LAU Sau Ning Sarah, University of Cambridge LI Ronald, The Chinese University of Hong Kong LI Yu Yin, The University of Hong Kong LO Tsoon Wuan Samuel, The University of Hong Kong LUM Tak Wai, The Chinese University of Hong Kong MAK Ka Lun, The University of Hong Kong Sudhakaran MANICKAM, Tamil Nadu Dr MGR Medical University, India NG Chi Yuen, The University of Hong Kong NG Tam Man, The Chinese University of Hong Kong Adrien ORTIZ-CARLE, Aix-Marseille Université, France SHUM Jone-King, The Chinese University of Hong Kong SIU Pui Wai, The University of Hong Kong TANG Yeuk Lam Michelle, The Chinese University of Hong Kong WAN Raymond Chung Wai, The Chinese University of Hong Kong WONG Chun Him Francis, The University of Hong Kong WONG Kwun Hung Max, The University of Hong Kong WONG Lai Shan, The Chinese University of Hong Kong YAU Wai Ming, The University of Hong Kong YU Ting On, The University of Hong Kong Conjoint MRD RCSEd/FCDSHK (Int) Medal Dr HO Ching Man Brian (2015) Conjoint MORTH RCSEd/FCDSHK (Int) Medal Dr CHEE Deborah (2013) Dr CHAN Yi Lee Eliza (2015) GB Ong Medal Dr NG Sheung Hey Andrew (2015) The Muthusamy Medal Dr LOK Ka Hing (2014) China Medal Dr NG Sheung Hey Andrew (2016) Li Shields’ Medal Dr NG Sheung Hey Andrew (2015)

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COLLEGE INFORMATION

All the latest grants, Fellowships and bursaries from the RCSEd

AWARDS & GRANTS Bursaries for Affiliate Medical Student Elective Placements in Africa 2017

Bursaries are available to undergraduate affiliates of the RCSEd enrolled at UK universities who plan to carry out their elective placements in Africa. The elective does not necessarily need to be in a surgical unit, but priority may be given to students demonstrating a special interest in surgery.

Usually, each bursary is in the region of £500, which can be used towards travel and accommodation costs, or other expenses involved with the placement.

Closing date for applications is Wednesday 4 January 2017.

Ethicon Foundation Fund Travel Grants

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

Requests for retrospective awards will not be considered.

Closing date for applications is Wednesday 15 February 2017.

Medical Student Elective Travel Bursaries

The RCSEd, in association with Ethicon, is pleased to offer medical students an

58 | Surgeons’ News | December 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.

opportunity to apply for a travel bursary towards their elective in surgery.

The bursaries to the value of £250 are open to medical students in the UK and Ireland who are affiliates of RCSEd and who are undertaking approved surgical electives overseas.

Closing date for applications is Wednesday 15 February 2017.

Undergraduate Student Bursaries

The RCSEd is offering bursaries to undergraduate students of medicine or dentistry to enable them to work for elective or vacation periods in universities, medical schools, NHS laboratories or research institutes in the UK and Ireland.

Proposals for work on research

projects in any branch of surgery are eligible for consideration.

Closing date for applications is Wednesday 22 March 2017.

Faculty of Surgical Trainers/ASME Educational Research Grant

Applications for the joint Faculty of Surgical Trainers (FST)/ASME small educational research grant(s) are invited from surgical trainees and consultants who are members of FST and/or ASME. Grants are awarded for projects for a period of one year only and funding will be for grant applications up to £3,000.

For full details and to apply, download the guidance notes and application form from the FST website (https://fst.rcsed. ac.uk/grants.aspx).

CONGRATULATIONS TO THE FOLLOWING AWARDS AND GRANTS RECIPIENTS Ethicon Travel Grant

Simon Graham, Specialist Training Registrar, Mersey Deanery, Orthopaedic and Trauma. Visiting Groote Schuur Hospital, University of Cape Town, South Africa.

Orthopaedic Trauma Fellowship.

Robert Choa, Specialist Registrar, Burns and Plastic Surgery, University Hospital Birmingham. Visiting Fiona Stanley Hospital, Perth, Australia.

Microsurgery, Burns and Skin Oncology Fellowship.

Ethicon Bursary

Email or post applications to Cathy McCartney, see left.

Closing date for applications is Wednesday 17 May 2017.

Joint RCSEd/SOMS/Shanghai Head & Neck Fellowship 2017

Applications are invited from Members/ Fellows (MRCS/FRCS) of the RCSEd and the Scottish Oral and Maxillofacial Society (SOMS) for a four- to six-week Fellowship in head and neck oncology in Shanghai at the department of Cranio-Maxillofacial Science, School of Stomatology, Ninth People’s Hospital, Shanghai Jiao Tong University.

The funding is up to £3,000 to cover costs.

The level of operative experience required to benefit most from the time is equivalent to a final-year post FRCS (Intercollegiate) trainee. Other applicants will be considered on merit, but this level of operative experience should be seen as a benchmark.

Application is by letter and CV (no more than four pages) along with two references, which should be sent to Mrs Cathy McCartney at c.mccartney@ rcsed.ac.uk. Further information can be obtained from Mr Roger Currie at r.currie@rcsed.ac.uk Closing date for applications is Wednesday 21 June 2017. Applicants may be invited to interview.

Raheej Khan, Imperial College London. Visiting Sindh Institute of Urology and Transplantation, Pakistan.

Paul McLean, University of Dundee.

Department of Head and Neck Surgery. Visiting Memorial Sloan Kettering Cancer Center, US. Patrick Hickland, Queen’s University Belfast. Visiting Vancouver General Hospital and British Columbia Children’s Hospital, Canada.

FST/ASME Grant

Paul Sutton, Specialist Registrar and Honorary Senior Lecturer, University of Liverpool. Exploring clinical decision making amongst surgical trainees in a simulated environment.

Sotiris Papaspyros, ST7 Cardiothoracic Trainee, Royal Infirmary, Edinburgh. Reliability of low-fidelity simulation models in acquisition of basic surgical skills outside the operating room. The role of deliberate practice.

Bursaries for Undergraduate Elective or Vacation Awards

Heather Leather, Centre for Global Health, King’s College London. A systematic review of community health workers’ role in surgical assessment within low- and middleincome settings.

Marc Walton, Centre for Integrative Physiology, University of Edinburgh.

Implanted silicon systems for monitoring and targeted drug delivery

in glioblastoma multiforme: assessing the bio-compatibility for candidate flexible electronic substrates.

Ellhia Sudan, University of Edinburgh. Characterisation of the microenvironment of hepatocellular carcinoma (HCC) in non-alcoholic fatty liver disease (NAFLD) with or without cirrhosis.

Savva Pronin, Department of Clinical Neuroscience, Western General Hospital, Edinburgh. Audit of management of cauda equine syndrome and MRI scan-negative cauda equine syndrome in NHS Lothian.

Sonia Soopen, School of Dentistry, University of Birmingham. An in vitro study of the ability of a tricalcium silicate-based endodontic sealer to produce an effective threedimensional seal using the single cone obturation technique.

Ananyo Bagchi, the Walton Centre NHS Foundation Trust, Liverpool.

Incidence of postoperative epilepsy in seizure-naïve patients undergoing craniotomy for surgical resection of meningioma.

Joint RCSEd/SOMS/Shanghai Head & Neck Fellowship

Owais Khattak, ST6 Oral and Maxillofacial Surgery, Royal Blackburn Hospital, Blackburn. Fellowship in Head and Neck Oncology in Shanghai at the Department of CranioMaxillofacial Science, School of Stomatology, Ninth People’s Hospital, Shanghai Jiao Tong University.

Wong Choon Hee Bursary

Luke Chan, University of Edinburgh.

Visiting the urology and trauma units, Royal Melbourne Hospital, Australia.

Paul McLean, University of Dundee.

Visiting the Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, US. Susanne Flach, University of Oxford.

Visiting the Department of ENT, Head and Neck Surgery, Bern, Switzerland, and Department of Orthopaedics, Wester Regional Hospital, Nepal.

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COLLEGE INFORMATION

REGIONAL SURGICAL ADVISERS IN YOUR AREA

6

7

The College’s support and advice network throughout the country

11 10 8

9

1

Council Member with Responsibility for Regional Surgical Advisers 1 Roger Currie, Crosshouse Hospital, Kilmarnock Director of the Advisory Network 2 Steven Backhouse, Princess of Wales Hospital, Bridgend, Wales

22 39 40 23 34

Advisory Network Group Members 3 Stuart Clark, Manchester Royal Infirmary 4 David Exon, Leicester Royal Infirmary 5 Vijay Santhanam, Addenbrooke’s Hospital, Cambridge 6 Sean Kelly, Raigmore Hospital, Inverness

35 33

21 3 38

20 19

SCOTLAND

NORTH OF SCOTLAND 6 Morag Hogg, Raigmore Hospital, Inverness 7 Lynn Stevenson, Aberdeen Royal Infirmary, Aberdeen

29 4 14

30 31 37

WEST OF SCOTLAND 8 Lindsey Chisholm, Royal Alexandra Hospital, Paisley 1 Simon Gibson, Crosshouse Hospital, Kilmarnock

2

13

12 32 24

15 5

23

36 17 18

SOUTH EAST OF SCOTLAND 9 Farhat Din, Western General Hospital, Edinburgh 10 Robyn Webber, Victoria Hospital, Kirkcaldy

26 25

28 27

16

EAST OF SCOTLAND 11 Musheer Hussain, Ninewells Hospital, Dundee

ENGLAND

EAST OF ENGLAND 12 Andrew Gibbons, Peterborough City Hospital, Peterborough 13 Stuart Irving, Norfolk and Norwich University Hospital, Norwich EAST MIDLANDS 14 Sridhar Rathinam, Glenfield Hospital, Leicester 15 Roshan Lal, James Paget University Hospital, Great Yarmouth KENT, SURREY & SUSSEX 16 Mike Williams, Eastbourne District General Hospital, Eastbourne LONDON 17 Cynthia-Michelle Borg, University Hospital Lewisham 18 Ziali Sivardeen, Homerton University Hospital MERSEY 19 Janardhan Rao, Countess of Chester Hospital, Chester 20 John Taylor, University Hospital Aintree, Liverpool NORTH WESTERN 21 Jeremy Ward, Royal Preston Hospital, Preston 21 Mike Woodruff, Royal Preston Hospital, Preston NORTHERN 22 Paul Gallagher, Wansbeck Hospital, Northumberland 23 Barney Green, James Cook University Hospital, Middlesbrough OXFORD 24 Mike Silva, Churchill Hospital, Oxford

60 | Surgeons’ News | December 2016

SOUTH WEST PENINSULA 25 Simeon Brundell, Derriford Hospital, Plymouth 26 Neil Smart, Royal Devon & Exeter Foundation Trust, Exeter WESSEX 27 Anthony Evans, Portsmouth Hospital, Portsmouth 28 Arjun Takhar, University Hospital of Southampton NHS Trust WEST MIDLANDS 29 Ishan Bhoora, Cannock Chase Hospital, Staffordshire 30 Pradeep Kumar, Queens Hospital, Staffordshire 31 Ramanan Vadivelu, Royal Wolverhampton Hospital NHS Trust 32 Ling Wong, University Hospital Coventry and Warwickshire, Coventry 32 Giles Pattison, University Hospital of Coventry and Warwickshire, Coventry YORKSHIRE & HUMBER 33 David O’Regan, Leeds General Infirmary, Leeds 34 Mark Peter, Scarborough General Hospital, Scarborough 35 Mark Steward, Bradford City Hospital, Bradford

WALES

36 Sanjeev Agarwal, University Hospital Wales, Cardiff 37 Raymond Delicata, Nevill Hall Hospital, Abergavenny

38 Vaikuntam Srinivasan, Glan Clywd Hospital, Rhyl

NORTHERN IRELAND 39 Catherine Scally, Antrim Hospital 40 Colin Weir, Craigavon Area Hospital

Faculty of Perioperative Care Membership Categories The FPC now has three membership categories that recognise the different career statuses of applicants.

Membership benefits include: › Recognition of your commitment to perioperative practice and, for Full Members, use of the postnominals MFPCEd › Access to Acland Anatomy, library facilities, Surgeons’ News and discounted accommodation at RCSEd’s Ten Hill Place Hotel › Access to a range of courses and events tailored to the needs of perioperative practitioners › Affiliation with an internationally respected College with an international membership of over 23,000 Website: fpc.rcsed.ac.uk Email: fpc@rcsed.ac.uk Phone: 0131 527 1642

Charity number: SC005317

New membersh ip categories !

AFFILIATE MEMBER Open to all perioperative practitioners, including Surgical Care Practitioners (SCPs) and Surgical First Assistants (SFAs), and those with similar roles, eg Advanced Scrub Practitioners, Physician Assistants and Physician Associates. This level is also open to trainees who meet the entry requirements.

ASSOCIATE MEMBER Primarily aimed at Surgical First Assistants (SFAs), but also open to all perioperative practitioners in the UK who can satisfy the evidence requirements for entry.

FULL MEMBER Primarily aimed at Surgical Care Practitioners (SCPs), but is also open to other perioperative practitioners who can satisfy the evidence requirements for entry.

If you have a postgraduate diploma (such as a MSc in Surgical Care Practice or the RCSEd Cardiothoracic Diploma) or you are an established perioperative practitioner, you may be eligible for the new membership categories of membership of the Faculty of Perioperative Care (FPC).

OUT OF HOURS

Graham Layer crosses continents in search of visual delights and taste sensations

In the line of beauty

I

admire the cosmetic artistry that goes into serving food these days and how that makes the dishes so much more enticing. I thought it would be interesting to compare a few places in 51-year-old Singapore with similar restaurants in the old UK. To start is an astonishing rustic omelette with tarragon, reminiscent theme with The Gardener’s Cottage of omelette Arnold Bennett. This was in Edinburgh and the Open Farm followed by a creamy risotto with peas, Caesar salad, Community restaurant near Singapore cuttlefish, chorizo and Serrano ham – Open Farm Community Botanic Gardens. The Edinburgh institution mouth-watering and made very attractive is difficult to find if you have not been there with the use of saffron. There was a significant before, and it looks like a small stone cottage with a barramundi dish, with all the crushed potatoes and front vegetable garden and an almost open-air kitchen bok choy hiding underneath a generous fillet of fish bathed in the back garden, set up away from the pavement. in coconut laksa, and a pappardelle with mushrooms, A helpful slate with the menu inscribed in chalk is propped presented perfectly. Caramelised mango came next, and up nearby. There are a couple of rooms inside, with large pumpkin cake with butternut ice cream. bench tables and seats, and a menu that changes daily On the seafood front, in the UK we have Ben’s Cornish of excellent and unusual cuisine. Its own vegetables Kitchen in Marazion and Rick Stein, Porthleven, versus dominate the various courses. The experience is homely Jumbo Seafood on the east coast of Singapore. Ben’s is a and comforting. We were four and chose a variety of terraced cottage on the coast with views of St Michael’s main courses. I enjoyed a delicious lobster, fortunately Mount, which serves seafood based on local catches. This half-extricated from its exoskeleton, served with trendy time, my chicken Caesar salad looked like two Scotch eggs kohlrabi. Fish dominated the party, but otherwise on a bed of lettuce, the crouton–breadcrumb spherical pappardelle followed flavoured with pig’s head mounds of minced chicken draped nonchalantly with in a wonderful sauce. Dessert was a raspberry anchovy fillets. Hake was served perfectly, and a catch cheesecake – very satisfying, but deconstructed in of the day appeared with asparagus and pesto. such a way as to be unrecognisable.

Rick Stein does a lobster-styled lunch on a The Open Farm Community has innovative Saturday, with wonderful lobster ravioli, and is in a and attractive food, and is an oasis of green in the much grander glass-and-steel affair on the harbour smart suburban area around Singapore’s botanics and at Porthleven. It is charming inside and the staff National Orchid Garden. I was entertaining an are well rehearsed. A menu derived from expat local who named this as her favourite the Padstow flagship is served and is restaurant in Singapore, and I can see why. reliable and enjoyable. The lobster Head chef The chef, Ryan Clift, is originally from and fish pie was more disappointing of Ben’s Devizes and serves an eclectic menu and dominated by other fish not Cornish of wonderful flavours and design. The resembling a crustacean, so I Kitchen, Ben Prior food was contemporary and alive: would have been happier with two ‘Hail Caesar’ was a deconstructed portions of the ravioli. Desserts Caesar salad, with chicken at both restaurants were fruitbreast adorned by a Parma ham based and felt healthy. The equivalent, with giant croutons panna cotta was excellent. and parmesan crisps plus halved Jumbo Seafood, meanwhile, is soft-boiled eggs, anchovies, a Singaporean institution and the cos lettuce and a spicy sauce. banquet choices are based around An alternative was a gigantic enormous chilli or black pepper baked smoked haddock crabs. Dissection of these beasts is

62 | Surgeons’ News | December 2016

HARD ROCK CAFE

Graham Layer RCSEd VicePresident

a challenge: a full scrub kit might be more appropriate than Ben’s Cornish Kitchen looks the offered paper bib. They were delicious nonetheless and out on to St followed masses of previous courses in true Chinese style, Michael’s Mount including the inevitable large garoupa fish smiling from its plate, ready for its cheeks to be carved out. These banquets just keep on coming, with more and more extraordinary and delicious dishes. A totally different experience to peaceful Cornwall.

Next up are the terrace at Pollen – a Jason Atherton restaurant in the Flower Dome at the Gardens by the Bay in Singapore – and The Gateway Restaurant. Pollen terrace serves an all-day, bistro-style menu, afternoon tea and cocktails in a Mediterranean garden setting. Linguine puttanesca was a classic – plentiful, flavourful and the sauce not too sticky. Bruschetta-type platters were offered with interesting choices of avocado and smoked eggs – all in all, a light, comforting lunch.

The Gateway in Royal Botanic Garden Edinburgh offers a simple, delicious lunch at a very reasonable price and the three of us chose great fish dishes accompanied by a chilled glass of very dry white wine. No pretence. Perfect.

My final duo are Singapore’s Hard Rock Café and Henry’s Grill in Esher, Surrey, both with live music. The first is the Singapore version of the classic burger joints and our enormous party almost all chose the legendary hamburger. Australasians would call this the lot and add a few more layers – beetroot, egg, mushrooms, cheese, onions and bacon, all supine upon the plump beefburger beneath. The second is an eco-friendly, organic, Mexicanthemed restaurant perfect for parties tucking into enchiladas and other Mexican delicacies, which they do really well.

Sir Stamford Raffles of colonial Singapore fame had a “forward view” which might have been applied to the local cuisine: “Our object is not territory but trade: a great commercial emporium…” and, as we have tasted, our chefs of today are continuing this creative trade to ensure their success in tropical Singapore and the temperate UK. Hard Rock classic

England sparkles again Bernard Ferrie samples some fizz from south of the border

T

he year’s big success is English bubbly. To start, Henners Brut Vintage 2010 from Herstmonceux East Sussex (£28, Worths). Toasty blanc de noirs from a single vineyard, wonderful with turkey.

Buzzard’s Valley Sparkling Baby Blush Medium 2012 (£15, vineyard) pinot noir and seyval blanc. Had this with the 2015 turkey as well – subtle and delicate, slightly pink. So was the wine – a big turkey and thirsty work in the kitchen.

Balfour 1503 Brut (£29.99, Majestic) from Hush Heath Winery in Kent – apple citrus fruit shades of thyme and peppers. Not so hush hush.

Chapel Down Vintage Reserve Brut (£24.99, Majestic) from Tenterden, Kent. Red apple, lemongrass, fresh bread nose.

Citrus quince, strawberry brioche on the finish.

Denbies Broadwood Folly (£14.99, Lidl). The folly commemorates Waterloo, but follies need no excuse. Citrus and brioche Brut – corking from Dorking. Pick of the mix.

Ridgeview Marksman Rose 2013 (£23, M&S) – subtle, palest pink and full-bodied – powerful bubbles as our sommelier and his dry cleaner will attest. A fitting choice for our ruby anniversary cruise.

Harvey Nichols English Sparkling Brut (£27.50) – grapes from Hampshire and Sussex. Apple, peach, creamy biscuit – but actually underwhelming.

Eton Mess and hot Belgian waffle may be off the menu since June but Chapel Down Nectar 2014 (£14.50 for 50cl, Thind Sevenoaks) roses and honeysuckle from the garden of England is delicious on its own.

rcsed.ac.uk | 63

FROM THE COLLECTIONS

THE BARBERS AND THE LEECHES Golf Cup shows notable wins for the Surgeons in the annual handicap event

T

he Battle of the Barbers and the Leeches was a friendly rivalry between the Physicians and the Surgeons of Edinburgh for the annual Handicap event played by the Royal Colleges Golf Club. The inaugural match teed off in 1890 and continues to be held every May at Luffness New Golf Club. It was founded and first captained

by Douglas Moray Cooper Argyll Robertson (1837–1909), President of the RCSEd 1885–1887. Argyll Robertson was an ophthalmic surgeon of great repute, one recognition of this being his appointment as Surgeon Oculist to Queen Victoria and King Edward VII. Outside his profession he was just as enthusiastic. His interest in art resulted in his election as one of the judges for the Royal Scottish Academy, and he excelled in a range of sports, including golf. He won the Gold Medal of the Royal and Ancient Golf Club in 1865, 1870, 1871 and 1872.1 His portrait hangs in the College’s Birmingham office.

The Golf Cup, pictured, was donated to the College in 1898 by John Chiene (1843–1923) during his Presidency of 1897–1899, and was presented to the winners each year, to be kept at the respective College until the next meeting. It was made in Edinburgh by Marshall & Sons in 1890, the silver trophy alone weighing 115oz. On one side is the coat of arms of the Surgeons and on the other that of the Physicians.

On top of the lid stands the god of medicine, Asclepius.

Around the mahogany base hang 56 silver shields engraved with the names of the participants and the results of each match. The shield from 1897, for example, includes a host of notable names on the Surgeons’ side. No fewer than seven Presidents are on the team: Sir David Wallace (RCSEd President 1921–1923); John Duncan (1889–1891); John Chiene (1897–1899); George Mackay (1919–1921); Sir James Hodsdon (1914–1917); Sir George Berry (1910–1912); and Joseph Cotterill (1907–1909).

The combined achievements of this distinguished group of men is remarkable – perhaps there is a link between surgical skill and golfing prowess?

Recently conserved by Harry Beale Collins, the Golf Cup will be displayed in the main College reception until it is fought over once again next May. Historically, the Surgeons dominated the competition from its inception through to 1980, winning 64 of the 77 matches played.

Victory has been relatively shared of late and 2016 saw a draw. Hopefully, the Surgeons will regain the trophy with John Orr (PRCSEd 2006–2009) as current captain of the Royal Colleges Club.

Rohan Almond Assistant Curator, Surgeons’ Hall Museums 64 | Surgeons’ News | December 2016

The Golf Cup will be displayed in the main College reception

REFERENCE 1. Savin JA. The Royal Colleges Golf Club, 1890–1990. BMJ 1990; 301(6766): 1462–3

Douglas Moray Cooper Argyll Robertson c.1900,

by Sir George Reid (1841–1913)

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