RAD1331 NL22 JUL08asgbidocuments.surgicalmembershipportal.co.uk/jonoural/no.22_july... · Dr Daniel...

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EDITORIAL It is with great trepidation that I take over from John MacFie as Honorary Editorial Secretary of ASGBI. I think you will all agree that he has been an excellent servant and has stimulated considerable discussion with his carefully worded, often controversial but always topical, viewpoints on the developments which have driven surgical practice over the last three years. John has steered us through the genesis of MTAS, MMC and EWTD, and we are now having to deal with the consequences of these fundamental changes to surgical training and practice. There exists a considerable threat to surgical training in the UK, and it is imperative that the ASGBI, Specialty Associations and Societies, Royal Colleges, SAC’s and ASiT speak with one voice; if not, the surgeons of tomorrow will merely to be employed as “worker bees” (Ursula Ward, CEO Portsmouth Hospitals) within NHS surgical factories, adherent to policies driven by 18 week targets and rewarded according to procedural numbers rather than results. Indeed, this week I was intrigued to hear the Department of Health (Lord Darzi, 30 th June 2008) announce that future NHS policy will be driven by “the quality of care that patients receiveand not by targets; maybe someone is listening … or more likely there are votes to be won! We must not be complacent! We must listen to our surgical colleagues who provide a first class service on the shop floor, as well as to our trainees, if we are to maintain our professional status and our practice within our NHS hospitals amidst all of this change. Indeed, in this Newsletter you can read Ben Cresswell’s (President, ASiT) article on Adapting Surgical Training in an Evolving NHS and Protecting Excellence for the Future”. These are important views and we must involve our trainees actively in the decision making that will mould our practices in the 21 st century. To this end, ASiT have been invited to write regular articles for the Newsletter and we look forward to their thoughts and challenges to the development of General Surgery in the UK. General Surgery is also changing and there is no better example than that of the Vascular Surgeons who are likely to break away and form their own sub-speciality involving the interventional radiologists and a separate training programme for the “Vascular Specialists” of tomorrow. Read Mike Gough’s, (President, VS) excellent summary entitled Vascular and General Surgery:The End of a Love Affair” and compare this with Marcus Brooks 2007 Moynihan Travelling Fellowship report entitled “Vascular Surgeon or Vascular Specialist? Experiences gained in Australia and Sweden”. The move to sub- specialisation is inevitable, and it extremely important for ASGBI to recognise and embrace such change; if we do not, we will fragment and lose considerable power and influence at the high table. The same is happening for many of the Surgical Specialities and it is for his reason that a Federation of Surgeons of Great Britain and Ireland was proposed at the AGM in Bournemouth this May. Watch this space for more details in the next edition of the Newsletter. At the time of writing, the main threat to the practice of UK Surgery is not sub-specialisation, but the political drive to develop the non consultant or sub-consultant specialist grade. At the recent International Surgical Congress of the Association of Surgeons of Great Britain and Ireland 2008, the “Hot Topic Session” entitled “Is the sub-consultant grade inevitable?” stimulated considerable debate. The podium speakers were John MacFie, Professor of Surgery Scarborough, Ben Cresswell, President of ASiT, Mohib Khan, Co-Chairman of the BMA's Staff and Associate Specialist Committee and Ursula Ward, Chief Executive of the Portsmouth Hospitals NHS Trust. The debate indicated that there is clearly major concern from present day surgical trainees that the “Consultants Post” they have all been aspiring to achieve may not actually exist at the end of their training. Instead, they will become “worker bees” for the NHS in a sub-consultants post with poor remuneration and uncertain career progression. The drivers for this are myriad. There has been a significant increase in training posts over the last few years, but this has not been matched by expansion in consultant numbers. In addition, training has been challenged not only by EWTD, MMC and MTAS, but also by the abolition of the Associate Specialist grade, increasing numbers of UK medical graduates, the highly skilled migrant programme and the increased number of European Economic Area (EEA) applications. This has resulted in considerable strain to UK surgical training programmes and significant uncertainty regarding the future of the end product of these programmes, the post CCT SPR. It is clear that, without significant expansion in consultant numbers over the next 5 years, many current SPR’s will either face unemployment of be forced to accept poorly paid “specialist” or “sub-consultant posts”. What are the solutions? Well ideally consultant expansion will be required, but this is expensive and currently politically unattractive. To Government (and many Trust Chief Executives), consultants are viewed as over privileged, over paid and underperforming luxuries. The “New Consultant Contract” was supposed to extract more work from each consultant, in return for more pay. What actually happened was that consultants pay increased, but with little improvement in productivity. There was clearly significant lack of appreciation as to how hard most NHS consultants were working under the old scheme. There is a strong belief that Government cannot, or will not, fund the required consultant expansion. Instead, it is envisaged that most hospitals will be run by “post CCT Specialists”, who will not need to be paid on recently negotiated consultant pay scales. There is fear from the trainees that these are the only jobs which will be open to them post CCT and that only a few will then be eligible for further specialist training and the attainment of consultant status. As an Association of Surgeons, we must be united in our response to these initiatives. It has always been our belief that following the award of CCT, “the Consultant Post” must be the “bare minimum” to which our trainees should aspire. Patients understand the term “Consultant”, what he/she does and what he/she stands for. Most consultants work extremely hard to provide a professional service and it is this professionalism which is under serious attack. If you have views on this subject, we invite you to let us know by replying to [email protected] The web debate will be entitled “Is the sub-consultant grade inevitable”. All letters will be published on the ASGBI website and we can use your opinions to inform further debate and discussion on this subject. Finally, I must mention the European Working Time Directive. All hospitals will need to be compliant by August 2009, yet few have made any plans for the introduction of the 48 hour week. ASGBI recently held a Consensus Conference entitled “The impact of EWTD on Delivery of Surgical Services”. A Consensus Statement is in preparation and will be available for comment shortly. Again, we would welcome your views on EWTD. Please send your letters to [email protected] and we will publish these on the website. I will keep you posted as to the trials, tribulations and solutions that might emerge with the moulding of surgical training and practice over the next three years. Welcome to the post MMC, MTAS, EWTD NHS. We are in for a bumpy ride! Mike Wyatt Honorary Editorial Secretary In this issue... 2008 Prize Winners.............................................................2 The Making of a Surgeon 2008 ..........................................3 ASGBI website ...................................................................5 Berkley, Lord Moynihan .....................................................6 Tales from our Corporate Patrons ......................................9 Colin Morgan, OBE..........................................................11 Lifetime cash-flow modelling ..........................................12 Vascular and General Surgery ..........................................14 Navigating the mortgage maze .........................................16 2009 International Surgical Congress ..............................17 Moynihan Travelling Fellowship Report ..........................18 Leadership; can it be taught?............................................22 Adapting surgical training in an evolving NHS ...............26 CORESS ...........................................................................30 The Back Page ..................................................................32 Association of Surgeons of Great Britain and Ireland Number 22, July 2008

Transcript of RAD1331 NL22 JUL08asgbidocuments.surgicalmembershipportal.co.uk/jonoural/no.22_july... · Dr Daniel...

EDITORIALIt is with great trepidation that I take over from John MacFie as HonoraryEditorial Secretary of ASGBI. I think you will all agree that he has beenan excellent servant and has stimulated considerable discussion with hiscarefully worded, often controversial but always topical, viewpoints on thedevelopments which have driven surgical practice over the last three years.John has steered us through the genesis of MTAS, MMC and EWTD, andwe are now having to deal with the consequences of these fundamentalchanges to surgical training and practice.

There exists a considerable threat to surgical training in the UK, and it isimperative that the ASGBI, Specialty Associations and Societies, RoyalColleges, SAC’s and ASiT speak with one voice; if not, the surgeons oftomorrow will merely to be employed as “worker bees” (Ursula Ward,CEO Portsmouth Hospitals) within NHS surgical factories, adherent topolicies driven by 18 week targets and rewarded according to proceduralnumbers rather than results. Indeed, this week I was intrigued to hear theDepartment of Health (Lord Darzi, 30th June 2008) announce that futureNHS policy will be driven by “the quality of care that patients receive”and not by targets; maybe someone is listening … or more likely thereare votes to be won!

We must not be complacent! We must listen to our surgical colleagueswho provide a first class service on the shop floor, as well as to ourtrainees, if we are to maintain our professional status and our practicewithin our NHS hospitals amidst all of this change. Indeed, in thisNewsletter you can read Ben Cresswell’s (President, ASiT) article on“Adapting Surgical Training in an Evolving NHS and ProtectingExcellence for the Future”. These are important views and we mustinvolve our trainees actively in the decision making that will mould ourpractices in the 21st century. To this end, ASiT have been invited to writeregular articles for the Newsletter and we look forward to their thoughtsand challenges to the development of General Surgery in the UK.

General Surgery is also changing and there is no better example than thatof the Vascular Surgeons who are likely to break away and form theirown sub-speciality involving the interventional radiologists and aseparate training programme for the “Vascular Specialists” of tomorrow.Read Mike Gough’s, (President, VS) excellent summary entitled“Vascular and General Surgery: The End of a Love Affair” andcompare this with Marcus Brooks 2007 Moynihan Travelling Fellowshipreport entitled “Vascular Surgeon or Vascular Specialist?Experiences gained in Australia and Sweden”. The move to sub-specialisation is inevitable, and it extremely important for ASGBI torecognise and embrace such change; if we do not, we will fragment andlose considerable power and influence at the high table. The same ishappening for many of the Surgical Specialities and it is for his reasonthat a Federation of Surgeons of Great Britain and Ireland was proposedat the AGM in Bournemouth this May. Watch this space for more detailsin the next edition of the Newsletter.

At the time of writing, the main threat to the practice of UK Surgery isnot sub-specialisation, but the political drive to develop the nonconsultant or sub-consultant specialist grade. At the recent InternationalSurgical Congress of the Association of Surgeons of Great Britain andIreland 2008, the “Hot Topic Session” entitled “Is the sub-consultantgrade inevitable?” stimulated considerable debate. The podiumspeakers were John MacFie, Professor of Surgery Scarborough, BenCresswell, President of ASiT, Mohib Khan, Co-Chairman of the BMA'sStaff and Associate Specialist Committee and Ursula Ward, ChiefExecutive of the Portsmouth Hospitals NHS Trust.

The debate indicated that there is clearly major concern from present daysurgical trainees that the “Consultants Post” they have all been aspiringto achieve may not actually exist at the end of their training. Instead,they will become “worker bees” for the NHS in a sub-consultants postwith poor remuneration and uncertain career progression. The driversfor this are myriad. There has been a significant increase in trainingposts over the last few years, but this has not been matched by expansionin consultant numbers. In addition, training has been challenged notonly by EWTD, MMC and MTAS, but also by the abolition of theAssociate Specialist grade, increasing numbers of UK medical graduates,the highly skilled migrant programme and the increased number of

European Economic Area (EEA) applications. This has resulted inconsiderable strain to UK surgical training programmes and significantuncertainty regarding the future of the end product of these programmes,the post CCT SPR. It is clear that, without significant expansion inconsultant numbers over the next 5 years, many current SPR’s will eitherface unemployment of be forced to accept poorly paid “specialist” or“sub-consultant posts”.

What are the solutions? Well ideally consultant expansion will berequired, but this is expensive and currently politically unattractive. ToGovernment (and many Trust Chief Executives), consultants are viewedas over privileged, over paid and underperforming luxuries. The “NewConsultant Contract” was supposed to extract more work from eachconsultant, in return for more pay. What actually happened was thatconsultants pay increased, but with little improvement in productivity.There was clearly significant lack of appreciation as to how hard mostNHS consultants were working under the old scheme. There is a strongbelief that Government cannot, or will not, fund the required consultantexpansion. Instead, it is envisaged that most hospitals will be run by“post CCT Specialists”, who will not need to be paid on recentlynegotiated consultant pay scales. There is fear from the trainees thatthese are the only jobs which will be open to them post CCT and thatonly a few will then be eligible for further specialist training and theattainment of consultant status.

As an Association of Surgeons, we must be united in our response tothese initiatives. It has always been our belief that following the award ofCCT, “the Consultant Post” must be the “bare minimum” to which ourtrainees should aspire. Patients understand the term “Consultant”, whathe/she does and what he/she stands for. Most consultants work extremelyhard to provide a professional service and it is this professionalism whichis under serious attack. If you have views on this subject, we invite you tolet us know by replying to [email protected] The web debate will beentitled “Is the sub-consultant grade inevitable”. All letters will bepublished on the ASGBI website and we can use your opinions to informfurther debate and discussion on this subject.

Finally, I must mention the European Working Time Directive. Allhospitals will need to be compliant by August 2009, yet few have madeany plans for the introduction of the 48 hour week. ASGBI recently helda Consensus Conference entitled “The impact of EWTD on Delivery ofSurgical Services”. A Consensus Statement is in preparation and willbe available for comment shortly. Again, we would welcome your viewson EWTD. Please send your letters to [email protected] and we willpublish these on the website. I will keep you posted as to the trials,tribulations and solutions that might emerge with the moulding ofsurgical training and practice over the next three years. Welcome to thepost MMC, MTAS, EWTD NHS. We are in for a bumpy ride!

Mike WyattHonorary Editorial Secretary

In this issue...2008 Prize Winners.............................................................2The Making of a Surgeon 2008..........................................3ASGBI website ...................................................................5Berkley, Lord Moynihan.....................................................6Tales from our Corporate Patrons ......................................9Colin Morgan, OBE..........................................................11Lifetime cash-flow modelling ..........................................12Vascular and General Surgery ..........................................14Navigating the mortgage maze.........................................162009 International Surgical Congress ..............................17Moynihan Travelling Fellowship Report ..........................18Leadership; can it be taught?............................................22Adapting surgical training in an evolving NHS ...............26CORESS ...........................................................................30The Back Page..................................................................32

Association of Surgeons of Great Britain and Ireland Number 22, July 2008

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MOYNIHAN PRIZEDYSFUNCTION OF THE PIK3CA-AKTPATHWAY IN ANAL CANCERH. Patel, J. Northover, T. Gunther andA. Silver(London)

2nd PRIZE SHORT PAPERSINADEQUATE INNATE IMMUNERESPONSE TO COLORECTALTUMOURS MAY FACILITATEMETASTASISS. Pugh, M. A. Hilal, N. Pearce,S. Khakoo and J. Primrose(Southampton)

3rd PRIZE SHORT PAPERSPROTEOMIC ANALYSIS OF BREASTCANCER-DERIVED EXOSOMESS. Down and F. Berditchevski(Birmingham)

JOHN FARNDON PRIZE 2007RANDOMIZED CLINICAL TRIAL OFPERIOPERATIVE SYSTEMICWARMING IN MAJOR ELECTIVEABDOMINAL SURGERYP. F. Wong, S. Kumar, A. Bohra,D. Whetter and D. J. Leaper

JOHN WILEY & SONSAUDIO-VISUAL PRIZE

1st PrizeLAPAROSCOPIC AORTIC SURGERYR. A. Bulbulia, F. J. A Slim,L. G. Emerson and K. R. Poskitt(Cheltenham)

2nd PrizeLAPAROSCOPIC RADICALANTEGRADEPANCREATOSPLENECTOMYI. S. Tait, F. M. Polignano andG. D. Adamson(Dundee)

3rd PrizeLAPAROSCOPIC EXPLORATION OFCOMMON BILE DUCT A. M. Harris(Huntingdon)

E-POSTER PRIZESTHE PROGNOSIS OF SURGICALLYRESECTED OESOPHAGEAL CANCERIS DEPENDENT ON THE NUMBER OFLYMPH NODES EXAMINEDC. P. Twine*, W. G. Lewis, A. Casbard,J. D. Barry, G. Blackshaw,G. W. B. Clark, T. J. Havard,T. D. L. Crosby, S. A. Roberts andG. T. Williams(Cardiff)

CLOSTRIDIUM DIFFICILE RIBOTYPE027 COLITIS - LESSONS LEARNTFROM ANALYSIS OF SEVERE CASESS. Zeidan*, N. Beck, R. House,P. Nichols, K. Nugent, J. Smallwood,H. Steer and A. Mirnezami(Southampton)

SURVIVAL POST EMERGENCYSURGERY IN PATIENTS AGED OVER90 YEARS OLDM. Nadeem*, K. Bowen and T. Farooq(Yeovil)

INTERNATIONAL BURSARYWINNERSDr Daniel Makawa (Zambia)Dr Alema Onira Nelson (Uganda)

PHOTOGRAPHIC COMPETITIONMs Mary Slingo (Southampton)

GOLF COMPETITION St Andrews QuaichMr Michael Lampareli (Dorchester)

Presidents PutterMr James Gossage(Maidstone)

International Surgical Congress14th to 16th May 2008, Bournemouth International Centre

PRIZE WINNERS

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SUCCESS IN THE MAKING

‘The Making of a Surgeon’14th to 16th May 2008,Bournemouth InternationalCentre (BIC)The Association’s Annual Scientific Meeting thisyear became the inaugural ‘International SurgicalCongress of the Association of Surgeons of GreatBritain and Ireland.’ This reflected the closerInternational and European links that havedeveloped through the Association’s DesignatedSocieties and Strategic Partners and theincreasing pan-surgical nature of the meeting,with the 2008 Congress comprising of over 30Specialty Associations. Around 1,600 peoplewere on site over the three days, of which 1,077were medical delegates, and 1,070 abstracts weresubmitted in total.

The theme of the meeting was ‘The Making of aSurgeon’ and the main symposia, lectures andworkshops discussed numerous themes ineducation, training and professional developmentand the ‘cradle to grave’ issues confrontingsurgeons in the workplace throughout theirsurgical lifetime.

Lord Ara Darzi, Minister of State for Health and aFellow of ASGBI, officially opened the Congressand the scientific programme opened with anInternational Perspective on education andtraining from the UK, USA, Ireland andAustralasia presented by Sir David Carter(Edinburgh), Dr Timothy Flynn (Gainesville,Florida), Professor Frank Keane (Vice-President,RCS Ireland) and Professor John Collins(Melbourne) respectively. This was followed byDr John Daly (Philadelphia) providing a patient’sperspective and recounting his experiences of liverfailure and transplantation entitled ‘To give and toreceive: thoughts of a recipient’ and amotivational session returning to Everest, inwhich Professor Monty Mythen and Dr MichaelGrocott discussed the challenges of altituderesearch and its benefits for critically ill patients.

Symposia focused on pan-surgical, multi-disciplinary themes rather than specialist contentand demonstrated a rich variety of interest,including Cancer Reform Strategies, EvidenceBased Surgery, Surgical Simulation, HerniaManagement, A Bad Day On-Call and Leadership.Several non-general surgical associations usedtheir sessions to update delegates on what generalsurgeons need to know from their specialist areasand lively discussion was stimulated in sessionson Service Redesign, General Paediatric Surgeryand the ‘Hot Topic’, which asked ‘Is the Sub-Consultant Grade Inevitable?’

Further discussion was provoked by a number ofMedico-Legal sessions on the last day of theCongress, with barrister Ms Mary O’Rourke andDr Stephanie Bown (The Medical ProtectionSociety) examining a selection of medico-legalcases and Sir Graham Catto (President, GeneralMedical Council) proclaiming ‘The GMC;Honestly, I’m a Friend’ in an examination of ‘TheGMC and the Surgeon; Friend or Foe?’

In addition to a varied programme of taughtcourses and workshops, Bournemouth saw thelaunch of a number of interactive advice sessions,starting with ‘All you need to know about...YourFinancial Affairs’ with Cavendish Medical and ‘Allyou need about...Leadership’ with LeedsMetropolitan University and My Peak Potential.These sessions were complimentary but ticketedand proved a successful addition to the programme.

In all, 598 short papers were presented at themeeting in both oral and poster format and thisyear saw the introduction of E-posters for thoseposters marked Posters of Distinction. E-posterswere presented orally and on plasma screensaround the trade exhibition and an E-posterlounge was provided where delegates could viewand search posters at their convenience throughoutthe meeting.

The meeting was widely judged a success, with astimulating mix of scientific and political sessions,a new professional advisory service, a varied tradeexhibition and a number of innovative featuresincluding E-Posters, interactive advice sessions, aConcierge Desk and of course the sticks of rockand an ice cream man! A Drinks Reception hostedby the Association’s Corporate Patrons and theAssociation’s Annual Dinner at the BournemouthPavilion provided the ideal opportunity for friendsand colleagues to meet and renew acquaintances.Bournemouth proved an attractive location for theconference and Clive Tyers, Head of Conferences,Exhibitions and Events at the BournemouthInternational Centre reflected “It is the first timethe ASGBI have selected the BIC for thisinternational event and we were delighted to beable to play a part in its success.”

Images and recorded highlights of the meeting areavailable to view and download fromwww.asgbi.org.uk/bournemouth along with fulldetails of the Association’s 2009 InternationalSurgical Congress, ‘Delivering a ModernSurgical Service’, to be held in Glasgow from13th to 15th May 2009.

At the 2008 International Surgical Congress MrAl Windsor presented on ‘AbdominalCatastrophe and V.A.C. Therapy’ in the‘Management of the Difficult Wound’ sessionon Thursday 15th May 2008. This was extremelywell received and for those who were unable toattend, KCI Medical have added details of‘Management of the Open Abdomen with V.A.C.Therapy’, including an application of V.A.C.Therapy animation, to their website atwww.kci-medical.com

For further information please contact JoannaOstrowska at [email protected]

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AN INTERNATIONALPERSPECTIVEIn 2008, ASGBI, in partnership with the BritishJournal of Surgery Society and the Association’sOverseas Surgical Fellowship Group, provided twoinaugural International Bursaries for surgicaltrainees from poorly resourced countries who wishto attend the International Surgical Congress.

The winners of the 2008 Bursaries were Dr DanielMakawa from Zambia and Dr Alema Nelson fromUganda. In addition to attending the InternationalSurgical Congress, the recipients were also hostedby local surgeons at the Royal BournemouthHospital and Poole Hospital prior to the Congress.

Dr Alema Nelson recounts the experience in thefollowing report:

“It was a great pleasure for me to be awarded abursary to attend the International Congress ofthe Association of Surgeons of Great Britain andIreland (ASGBI) in Bournemouth. This is anachievement in my life.

I had the opportunity to be hosted in the RoyalBournemouth General Hospital and Poole Hospitalby Mr Basil Fozard and Mr Shorland Hoskingrespectively. I was extremely impressed with theholistic patient management, computerized patientrecord keeping and the general cleanliness in thesetwo hospitals. My knowledge was broadened by thefantastic technology of Laparoscopic surgery whichI witnessed from these hospitals. Frankly speaking,this was my first time to see LaparoscopicCholecystectomy and Laparoscopic Mesh Herniarepair.

The best way of transforming a trainee into aSurgeon is through surgical education, trainingand professional development. This was perfectlyachieved by this congress.

All sessions I attended were innovative, wellarticulated and presented. Just to mention a fewamong others; A Bad Day On-Call; HerniaManagement; Trauma; Peri-operative OrganDysfunction and the Hot Topic, ‘Is the sub-consultant grade inevitable?’The PresidentialAddress by Professor Brian Rowlandsdemonstrated the ASGBI’s support to mentoringsurgical trainees.

It was not only about Surgery. What about theAnnual Dinner? It was fantastic, with verydelicious meals, variety of wines, excellentreception and a very good, entertaining, liveband.

My humble requests to ASBGI are;

To continue awarding bursaries to overseastrainees to attend the International SurgicalCongress in order to broaden their surgicalknowledge.

To provide training opportunities to overseastrainees.

To make the International Bursary winnersambassadors to surgical trainees in thedeveloping world.

Lastly I take this opportunity to thank theAssociation of Surgeons of Great Britain andIreland and the BJS Society for awarding me theInternational Bursary to attend the InternationalSurgical Conference in Bournemouth.”

Dr Alema Onira Nelson MD, MCS (ECSA)

Details of how to apply for anInternational Bursary to attend the2009 Congress in Glasgow will beavailable at www.asgbi.org.uk/glasgowfrom 1st August 2008.

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A GENTLE GIANT:BERKELEY LORD MOYNIHANMichael Crumplin, Honorary Archivist“I have gathered a posie (sic) of other men’sflowers and nothing but the threads that bind themis mine own”On September 18th 1855, Sergeant Andrew Moynihanof the 96th Regiment of Foot was one of the stormingparty that assaulted the Great Redan at Sevastapol, atough redoubt, held by the Russians during theCrimean War. A previous attempt by the British forceon June 18th had failed. He rescued two officersunder fire and, in so doing, was bayoneted twice andreceived ten other wounds. He, and indeed GreatBritain, was fortunate in his not being fatally injuredon that terrible day. Instead, he was one of the firstrecipients of the Victoria Cross and subsequentlyattained an unusual accolade of obtaining acommission from the ranks. He was not the firstMoynihan to hail from a military background. Apartfrom Lord Berkeley’s paternal grandfather Malachi,who was a soldier, five other Moynihans had fallen,fighting for Marlborough and Britain, at the Battle ofMalplaquet in 1709. His name bespeaks of his Irishdescent and the family hailed from Templemore inTipperary.

Berkeley Moynihan was born on the 2nd October1865, in Malta – the same year in which Lord Listerpublished his first paper on the use of antisepticmethods on a small series of young patients withcompound fractures.

How proud young Berkeley must have been of hisillustrious father, Andrew, who was to become acaptain and musketry instructor in Malta.

It was his mother, Ellen Anne, who gave the youngMoynihan not only much affection but also, hesubsequently felt, his great opportunities in life. ForAndrew died of Brucellosis, leaving Ellen Moynihan aforlorn widow and nearly destitute on the island. WhenAndrew’s company lined up to bid farewell to thewidow and her three children, the young Berkeley waspassed from hand to hand by every man, before beingbid adieu from the island. With great courage, Ellenstruggled to cope and provide. A letter, written to thesecond Lord Moynihan by Berkeley in 1929, revealedthe depth of feeling and gratitude to his mother;

“ …. she was the gentlest, sweetest, most considerateof people. I never heard her say an uncharitable thingof anyone; she never did an unkind act; and atimmense sacrifice she gave me my chance. She wasterribly poor, and my education was more than shecould afford; but she denied herself everything for me.And she showered love on me and helped me so gentlyand tenderly in every possible way. It was her

influence that made me want to work and succeed formy son, as she had laboured and sacrificed for me, soyou see, my son, it is to her that I owe everything. Forthough it is forty years since she died, I could not talkabout her without breaking down.”

The impoverished family, a mother, two daughters anda son, stayed with relatives a while in Liverpool, thenon to Leeds. At his kindergarten and at Christ’sHospital, where he was unhappy, he achieved nothingof note and then, at fifteen he moved to the RoyalNaval School, New Cross, where he showed prowess atswimming and football. He had always wished to be asoldier, much to his mother’s distress. When he oneday learnt of her sadness over this issue, he decided onmedicine as his career. What may have influenced thematter was that his mother and father had witnessedmuch disease and death – in Scutari from disease andin India from cholera. Some relatives helped Ellen getBerkeley to medical school. Poverty dictated rigorousstudy at the Medical School of Yorkshire College,Leeds. There was little time or money for pastimes andfrolics. The six-foot tall student then studied at theLeeds General Infirmary and accepted the challenge ofthe London MB and Primary fellowship in 1887 – theyear of Victoria’s Golden Jubilee. He passed. Hisintensely studious efforts were rewarded by manyprizes and distinctions except in surgery! He hadimmense mental and physical stamina and could studyfor sixteen hours a day.

He was appointed house surgeon to Mayo Robson andlater had an opportunity to slip away to Germany towitness surgical practice where, he felt, there was nobetter surgery than that performed in much of the UK.Controlling admissions beds and emergencies, he wasappointed RSO at the Leeds General Infirmary in1890, the year he passed the final FRCS. Atlunchtimes, this cheerful, reliable and dedicatedtrainee sometimes found time to cavort with the littlepatients for half an hour on the children’s ward.His chief, Richard Jessop, had a daughter, Isabel, whoBerkeley later married in 1895. He set up privatepractice and obtained his MS in 1893 and a year later,was disappointed not to be appointed to the staff ofthe LGI. In 1896, he gained an assistant surgeoncy tothe hospital. Between 1896 and 1914, was his periodof scientific and surgical effervescence. He became asurgeon of international repute. His width of surgicalability astonished many. He wrote on the appendix,TB of the skin, hernia, excision of the scapula forsarcoma and chronic peptic ulcer. He wrote masterlytomes on gallstones, pancreatic disorders, peptic ulcerand of course his masterpiece, Abdominal Operations.Mocked by some, he was dubbed the “pyloric pierrot”for wearing a white gown, cap, shoes and rubbergloves (the first British surgeon to do so) to operate.His mastery at the table was exposed by his gentletouch and “caressing” of the tissues. Not watching the

Figure 2: Leeds General Infirmary, now theThackray Medical Museum.

Figure 1: The Moynihan residence in Malta

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clock, he was punctilious over haemostasis and usinga variety of appropriate instruments, he changedattitudes to the craft. He was the first surgeon inBritain to perform a total gastrectomy, remove apancreatic calculus and re-operate for anastomoticulceration after gastro-enterostomy. His internationalaudience grew.

Meanwhile Isabel had produced a son and twodaughters, so mimicking his own mother. Berkeley’sprivate practice was beginning to grow – as were hisfees, but one person noted that a third of his privatepatients did not pay, since they couldn’t afford it.

He was an avid teacher and would sit on a ward tablewith one leg swinging free, captivating his audiencewith his charm and skills. In 1909, his surgery skills,research, fine oratory style and writing brought himthe Chair of Surgery at Leeds University. Three yearslater he was elected to the English College Counciland was knighted.

In 1912, he took a major role with Hey Groves in thefoundation of the British Journal of Surgery, whichwas to serve as a valuable written bond betweensurgeons. There was initial lukewarm reception, butafter its first edition in 1913, opinions changed andmany leading surgeons gave their support to thisuniquely new British surgical publication.

He had been impressed by meetings of provincialsurgeons in the USA and decided to emulate thisassociation in Britain. He had also been struck by thelack of cohesion among members of his profession,“Surgeons in one town knew little or nothing ofsurgeons elsewhere. A surgeon from Manchester hadnever, so far as I could hear, visited an operatingtheatre in Leeds, nor had one ever been asked inconsultation.” As an interim arrangement, he formeda Chirurgical Club with 30 members, who wouldrotate visits to each surgeon’s place of work. The firstmeeting was held in Leeds in 1909. In 1929, the clubtook the name the Moynihan Chirurgical Club.

In 1914, he had written to Sir Rickman Godlee, anephew of Lister, to encourage a national Associationof Surgeons;

“You may remember that I have once or twicementioned to you the need for a representativeSurgical Association in Great Britain and Ireland.Every country that is counted amongst the “first classpowers” has such an association with the exception ofEngland. In spite of the work done at the RoyalSociety of Medicine in the Surgical Section, and at themeetings of the British Medical Association, andelsewhere, it is I believe true to say that no reallyadequate occasion is ever offered in England for afully representative and first class debate on surgicaltopics, nor is there any opportunity for the generalmeeting of surgeons for the free intimate discussions,perhaps more valuable than public debate, whichresult when a large body of men working in one fieldmeet together.”

A tepid reception was given to this proposal andBerkeley’s dream was not to materialise until after theWar.

In 1914, the family moved into a grand stone housebefitting the great surgeon – Carr Manor.

The year before, Lord “Bobs” Roberts had urgedpreparation for a war with the German Empire. Hewas labelled a scaremonger, but he was the man tocorrectly predict Britain’s unprepared state. Robertscame to Moynihan for help and support for a systemof medical military training.

In November 1914, Moynihan was given a temporaryrank of Colonel in the RAMC. He was based at Rouenand driven by his much-cherished Private Tupper, hetoured various military hospitals in a large red Daimler.He helped restructure the medical organisation inFrance, took a special interest in thoracic wounds andmet many eminent surgeons - Dr Crile was one such.

In March 1915, hereturned to hispractice in Leeds,but did make somefurther trips to thefront. He was givencommand of the 2ndNorthern GeneralHospital and waseventually promotedto Major Generaland, in 1917, wasmade a Companionof the Bath.

The autumn of 1917took Moynihan tothe United States toadvise on wartimesurgery and talkabout the conflict ingeneral. Surgically,he lectured abouttimely evacuation ofwounded men, disinfectant wound care and woundsof the body cavities – also the control of infectiousdiseases in the army. He spoke to large audiences ofup to 3,000 guests, of surgical issues, liberty, tyrannyand warfare. This he did with masterly oratory,vigour and success and he was rapturously receivedwherever he spoke. Finally he was entertained byPresident Wilson at the White House. After beingmade KCMG in the summer of 1918, he resigned hiscommission in 1919.

Despite the initial lack of enthusiasm, before theGreat War, for his forming a coalition of surgeons, hepersuaded the then President of the English College tosupport and to give patronage to the formation of anAssociation. That President, Sir Rickman Godleeeventually gave this support and invited the twelveleading surgeons to a dinner in his house in WimpoleStreet. Moynihan’s ideas were there cordially receivedand he was asked to draw up a constitution. The GreatWar had interrupted much progress, but after this, onthe 8th January 1920, the inaugural meeting of theAssociation took place. Sir John Bland Sutton was thefirst President of the meeting, which was held inLondon. It took a good while for the somewhatcarefully guarded status of membership and its malepreponderance to change!

Figure 3: Carr Manor, near Leeds

Figure 4: Berkeley Moynihanwith Dr Crile

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After the war, busier years were to follow. For a start,there was a post-war boon in civilian surgery, longsuppressed by the conflict. Berkeley’s reputation led toa worldwide practice, which would subsequentlynecessitate a base in London. The local pressspeculated on the great surgeon’s every move.Unusually for those days, his practice attracted a flowof private patients away from the metropolis to theprovinces - a commonplace event for Moynihan. Hewas simply flooded with work and so he raised hisfees again and again – inevitably inciting criticism. Ofcourse the great man was frequently extremelycharitable with his charges. When one Lancashirebusinessman refused a cholecystectomy by Moynihan,as the charge was 100 guineas, Moynihan negotiated alower fee! With greying hair and a figure somewhatfilling out, he always had an air of cleanliness abouthim – as if he had just been in a bath. Abstemious inhis habits, he enjoyed fruit and fish, usually takenwith a single glass of wine. He rose between six andseven and took breakfast in his dressing gown, thenworked at his desk until eight o’clock. After work, hemight play tennis, golf or swim, although there waslittle time for his family and leisure pursuits. Isabeland he were infrequent but generous entertainers.Berkeley’s entertaining conversation was kindly,dogmatic and resistant to gossip. An avid theatre-goerand book-lover, he retired to bed at ten where he didmost of his reading.

His attitude to staff and patients was firm, kindly andrarely did he find fault, working his team like galleyslaves, he always gave acknowledgement and thanksto all, whether he was operating on the kitchen tableby oil lamp on the moors, in his nursing home atHyde Terrace or in a hospital theatre in Leeds.

In 1922, he decided against a migration of his practiceto London for many and obvious reasons, principallyagainst any rivalry and unwelcome competition. So onsome days of the week, when not in Leeds, he took asuite of rooms at Jules hotel (later hiring rooms inPortland Place) and consulted from there! He operatedat a private nursing home near Portland Place, ownedby Lady Carnarvon.

Moynihan was deeply involved in many public affairsand for such philanthropy and his work in the war, hewas made a Baronet in 1922. In 1926 he became aFreeman of the City of Leeds.

His two great surgical heroes were John Hunter andLord Lister. Of the latter, with hyperbole, Moynihansaid that, “he has been the greatest material benefactorof all mankind … his work has saved more lives thanall the wars of all the ages have thrown away.”

A sincere affection for his Alma Mater, the RoyalCollege of Surgeons of England, ran deep and he hadwide ambitions for it – surgical training, research andthe promotions of surgical ideals. The CollegePresidency had never fallen on the shoulders of aprovincial surgeon, but in 1926, it did, with almostuniversal approval. Great honour had come to Leeds.On his return from the election, he was met by twentycarloads of white-coated medical students and carriedshoulder-high to the car, where Lady Moynihanawaited him. He sadly retired from the Leeds GeneralInfirmary in the same year and now devoted his timeto College affairs.

Under his direction, research laboratories were built inthe College and, with Sir Arthur Keith, he negotiatedvia a generous benefactor – a surgeon, Sir BuckstonBrowne, the purchase of Darwin’s old dwelling,Downe House in Kent, which became a hive ofsurgical research.

In 1929, he became ill. After vomiting and ahaematemesis and thinking he had gastric cancer, heironically was found to be suffering from a duodenalulcer. Reticent not only about his own illnesses butalso his religion, Berkeley brushed with the Church,being a proponent of euthanasia.

By the end, Moynihan had almost every honourconceived thrust upon his broad shoulders – far toomany to enumerate. One singular reward did not cometo him – to his immense disappointment – that ofbeing elected Fellow of the Royal Society. Heconsidered himself eligible, for his research andcontributions to the knowledge and management ofpeptic ulcer. Sometimes critical of the Society andactively seeking advancement, he did little to aid hiscause. There is no doubt that this business and notbeing appointed to the Royal Household were deepdisappointments for him.

Difficulties in later life began to assail the great man.He lost many possessions in a fire that consumed hisconsulting rooms in Leeds in 1931. He also suffered,but found hard to accept, significant hypertension.

Cerebral deterioration was sadly to leave its mark onhis personality – aloofness, vanity, boastfulness andexaggeration left him open to ridicule. His oratory inthe Lords lacked the lustre of his performance informer years. The year of 1936 was as busy as any forBerkeley. Occasional day trips to London, Wimbledonand golf, were one day interrupted by Isabel’s death.He wrote a moving private eulogy to her, endingwistfully, “She was a small yet great and lovely ladyworthy of all honour and remembrance.”

After a tragic performance at his loved one’s funeral,he now dwindled away, hour-by-hour, unable totolerate the loss of his life partner. He was, less than aweek later, discovered unconscious on the floor of hisstudy and six days after Isabel’s passing, he died.Interred in Lawnswood cemetery in his own city, wecan recall some words he had written six weeks beforehe died, “it has all been great fun and I wouldwillingly have it over again.”

Figure 5: Berkeley Lord Moynihan in 1931, fiveyears before he died.

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TALES FROM OURCORPORATEPATRONS:WHAT DO OURINDUSTRYPARTNERS NEEDFROM US?Keith Rowlands, Cook Medical

Cook Medical is a Corporate Patron of ASGBI.Although this represents a significant financialcommitment, we feel we have an excellentrelationship with the Association, and deriveconsiderable benefit from the enhanced profile andfacilities extended to us. We have influence with theExecutive Committee, meeting together several timesa year. We have no complaints.

Other societies may not be so visionary as to considerindustry as true partners. Of course, on a simplytransactional level, we wish to promote our productsand services to your members, and congress organisersneed revenue from the exhibition. It is important forboth parties to get value from the partnership, and it ispossible to offend. Personally, my pet hate is beingcalled “trade”, which suggests an inequitablerelationship and encourages a short-term transactionalapproach. And it would upset my mother.

A common mistake is to organise a ramblingexhibition with little incentive for delegates toventure out into the remotest parts to discover thepoor unfortunate representatives who have waited allmorning for coffee break. It is soul destroying towatch all the delegates file out, chat amongstthemselves, and disappear back into the sessionswithout conversing with any representatives. It iseven worse if you are so far away from the coffeepoint that you don’t see them at all. Sometimes itfeels like there is a force field around the stands,with surgeons actively avoiding the stands as theyare repelled by our magnetic personalities.

It can be amusing to watch as the promotional itemsare more tantalising than the products and peoplesneak up to grab them before retreating. CookMedical has had some very popularballpoint/highlighter pens for many years. Theserequire a simple twist to operate, although it is asource of constant amusement for us to watch thembeing pushed, pulled and finally yanked apart. Thereis a helpline printed on the barrel, and instructions foruse in 14 languages on our website.

Professional marketing is not just sales promotion. Itis about identifying and anticipating customer needsand developing products or services to meet theseneeds. Sometimes wants are more aspirational thanneeds, otherwise everyone would drive the most basiccar. On the other hand, occasionally we underestimate

our needs. Twenty years ago, when we were allhappily listening to vinyl, who would have thought weneeded an iPod?

Cook Medical believes that the best way to treat ahernia is to achieve a permanent repair without apermanent foreign body. Synthetic meshes requireskin cover, are prone to infection, and cannot be usedin a contaminated environment. Most surgeons agreethat the ideal material must be resistant to infection,provide a barrier to adhesions and allow tissueincorporation for a strong, lasting repair without thescarring and encapsulation problems seen with manyof today’s prostheses. Yet many surgeons want aninexpensive permanent mesh, relying onpolypropylene and scar tissue to reinforce the defectrather than repair it. So before we can satisfy the need,we have to raise awareness of the limitations ofsynthetic mesh. It is a sine qua non that a biologicmust be totally reliable, with as few recurrences assynthetics. We must provide evidence of safety,efficacy and cost effectiveness.

Representatives should communicate the advantagesof the product and support you with information.They must build trust and a relationship with you, thecompany and the product, so that you can be sure thatyou are treating your patients with a reliable device.

Marketers describe the buying process as a continuumfrom unawareness to regular use - and ultimateadvocacy. Initially, of course, we are all unaware ofthe existence of a product. Advertising, exhibitions,public relations and word of mouth lead to awarenessand, perhaps, comprehension. Realistically, this isprobably the optimum outcome of a discussion at anexhibition stand: you to know about and understandthe products. Whether you go on to purchase thedevice will depend on how suitable it is for yourneeds. Value for money is essential, with the cheapestnot necessarily being the best value. We would hopeyou will take time to review the literature andconsider whether there is a place in your practice forour material. If so, we are available to help you toplace it, supporting you in theatre or in discussionswith the hospital administration. Once you have usedit, it is important that you remain satisfied andcontinue to order it, perhaps even become an advocateat future congresses.

The medical device industry is highly regulated, andno reputable company seeks deliberately to mislead.The company’s reputation is at stake. The CE mark isyour guarantee of the safety of a device, as this is noteasy to obtain, particularly for Class III devices.Companies do not invest in the launch of productswhich would compromise the well-being of yourpatients. It is for you to weigh up the relative merits ofcompeting products and their cost/benefit. Sometimesthese will depend on the situation. For example,biologic materials for hernia repair are the first choicefor complex and potentially contaminated cases,where a synthetic mesh would lead to infection andother complications. There is no doubt that routinehernia procedures would also benefit from a naturalrepair, without encapsulation or scarring and with lesspain and discomfort, but there is a greater need for abusiness case in these settings.

The North American market for biologic soft tissuerepair is more developed than that in Europe. In theUS, around 10% of ventral hernias are managed witha biologic, including human dermal products whichare not available here. Porcine dermal products arealso available, and are usually cross-linked. This givesthem strength and renders them resistant to

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collagenase,but also

makesthem

inert and unableto remodel. The rapid

uptake of naturalbiomaterials on the other side of

the Atlantic is partially due to thecompetitive healthcare system which encourages

the adoption of new technology. In Europe, costcontainment and evidence based medicine encouragea much more cautious reception for novel devices.This conservative approach reduces risk, but can alsodelay the adoption of the latest technologies, whichcan be detrimental to patient care. To those of us inindustry who believe we have something exciting andrevolutionary to offer, it can be highly frustrating. Inan environment where surgeons expect five year databefore they will entertain something fundamentallynew, and where industry is expected to fund most ofthe trials, the obstacles are huge for a small companywith a new idea but few resources. In fact, thisenvironment stifles innovation. Increasingly, only thelarge multinationals have the resources to developsomething significantly novel and to wait for the long-term results before seeing a return on investment.

As previously stated, Surgisis Biodesign achieves apermanent repair without a permanent foreign body.Many people believe that collagen simply absorbsover time unless it is cross-linked. If this were so,100% of defects would recur. Surgisis Biodesign isdesigned to be equivalent in terms of recurrence rates

to synthetic mesh, but betterfor pain, discomfort, erosionand infection. Thetechnology is not simplycollagen. Naturallyoccurring growth factorssignal the body and causeangiogenesis and fibroblastproliferation. White bloodcells are attracted to thematrix leading to resistanceto infection (although thematerial will not be effective

in grossly contaminated settings). The fibroblastsdifferentiate into muscle cells, nerves, capillaries etc,leading to complete remodelling of native tissue,indistinguishable from the surrounding area. Overtime, more tissue is laid down, leading to long-termstrength. Finally, just as in normal connective tissue,the extracellular matrix is completely replaced by hosttissue. Recent studies have demonstrated that therepair with Surgisis Biodesign is significantly strongerat 60 days than cross-linked porcine dermis. Evidenceof strength over time comes from animal studies,particularly where Surgisis Biodesign was implantedinto dogs that were sacrificed at given intervals andthe strength of the repair tested using a ball push-through test. Proof of concept has been demonstratedby over 100 clinical publications, including five yearfollow-up of contaminated and potentiallycontaminated ventral hernia. After two years, the newtissue is four times stronger than the original implant,which already exceeded the strength of normalabdominal wall.

The 2008 International Surgical Congress of theAssociation of Surgeons featured a session entitled“Embracing New Technology”. The new biomaterialsand meshes for ventral hernia repair were discussed infront of around 100 people. It is clear from this interest

as well as increased activity from industry, thatbiologics are starting to find their place in soft tissuerepair. Often biologics are reserved for the mostcomplex cases, for example replacement of infectedmesh or use in potentially contaminated settings.Although the results are good, they are even better inclean cases. Here, the benefits of a natural, flexiblerepair without scarring, encapsulation and shrinkagewill be enjoyed by the patients and experienced withless pain and discomfort or sensation of a foreign body.

The European Hernia Society has decided to start theEHS Registry for Biological Prostheses. ERBP is thefirst registry in Europe for biologic meshes. It is aprospective registry on the use of collagen meshes inabdominal wall surgery. From June 2008 to December2010, the central registry will monitor all patientsreceiving a collagen based mesh, but especially incase of (potentially) contaminated environment,parastomal hernia treatment (or prevention) andtreatment of paraoesophageal hernia. Data will becollected on preoperative condition of the patient,indication, surgical procedure and outcomes at 1month and 1 year postoperatively. ERBP is aninitiative of the European Hernia Society with thesupport of the industry. More information is availablefrom www.herniaweb.org

A more formal prospectivecomparative trial is alsounder way in Europe. TheLapsis study compares openversus laparoscopic repair inventral primary andincisional hernias and theuse of this new collagenprosthesis (SurgisisBiodesign) vs a permanentprosthesis in both groups.The major complication rateat three yearspostoperatively is theprimary endpoint of thestudy. The study is co-ordinated by Professor Neugebauer from Cologne,and led by Professor Marc Miserez from Leuven,Belgium. Fourteen centres in Europe are active, fromPortugal to Croatia to Denmark, but there are no UKcentres at the moment. More information can beobtained from [email protected]

A symbiotic relationship, we hope. Industry will aimto provide products which meet the needs of surgeonsat a fair price. We will add value where we can byencouraging studies and the presentation of scientificevidence and cost effectiveness data. Ourrepresentatives will support you, perhaps educate you,and of course seek to persuade you. We will sponsoryour scientific congresses and other initiatives whichcontribute to our shared aims. We understand yourcaution in the adoption of new technologies, but hopeyou will not be sceptical or cynical. Please considerour messages, then decide for yourselves whether thetechnology is right for you and your patients.

Exhibitors generally review a congress and decidewhether to support it again in future. The traffic in theexhibition and the level of interest in the technologydetermine whether the meeting is recommended forthe following year. The efforts ofthe conference organisers tomaintain these relationships aremuch appreciated, but the realguarantee of future collaborationis in the hands of the delegates.

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COLIN MORGAN, OBEWe are delighted toreport that ColinMorgan, an HonoraryFellow of theAssociation, wasappointed an Officer ofthe Most Excellent Orderof the British Empire inthe 2008 Queen’sBirthday Honours.

Colin Morgan has 32years experience in theMedical Device industryand is the ManagingDirector of ETHICON

UK, a division of Johnson & Johnson MedicalLimited and a Corporate Patron of ASGBI.Throughout his career, Colin has made a significantcontribution to the development of the UK MedicalDevice industry through his commitment andparticipation in a number of advisory and influentialgroups, including: UK Government Health IndustryTask Force (2003-2007), Member - UK MinisterialMedical Technology Strategy Group (2008), PastChair (1999-2002) Association of British HealthcareIndustries, Board member of Scottish HealthInnovations Limited (SHIL).

In the Healthcare Industries Task Force (HITF),Colin co-chaired the UK Market Access Group,investigating improved Procurement methodsdesigned to generate faster adoption of new andexisting medical technologies and procedures intothe NHS and ensured that the Scottish industryperspective was reflected within the UK review.

Colin’s work has been previously recognised withHonorary Fellowships of the Royal College ofPhysicians & Surgeons of Glasgow, the RoyalCollege of Surgeons of Edinburgh and theAssociation of Surgeons of Great Britain andIreland. Colin is a member of the Court of Patrons ofthe Royal College of Surgeons of England.

Colin joined ETHICON in 1976 and held a varietyof sales, marketing and general management roleswith increasing responsibility, both within UK andInternational markets including Asia, Eastern Europeand Africa. In 1992, Colin was appointed GeneralManager, Johnson & Johnson Portugal, based inLisbon. Colin returned to the UK in 1995 and wasappointed Managing Director, ETHICON UK.

Colin Morgan comments, “I am honoured to receivethis recognition and award which acknowledgesmany individuals who work in the Medical Deviceindustry in the UK and whose products every daymake a real difference in the quality of outcomes andlife for patients undergoing surgery. I would alsothank and acknowledge the unstinting support I havereceived from family, and colleagues within Johnson& Johnson and the wider medical device industrywho share this common ideal, and I remaincommitted to the development of this key sector forthe UK economy”.

Professor William David George, CBEWe are also delighted to report that ProfessorGeorge, lately Regius Professor of Surgery, WesternInfirmary, Glasgow and a Fellow of the Association,was appointed a Commander of the Most ExcellentOrder of the British Empire in the 2008 BirthdayHonours list.

The GMC has developed assessment procedures for investigating allegedly poorlyperforming doctors in all areas of medical practice. These procedures involve astructured peer review workplace assessment and a test of competence, tailored tothe doctor’s actual practice. The assessment instruments for this process, whichwere first developed in 1997 in conjunction with the Royal Medical Colleges andspecialty Associations, are under constant review to ensure that they are pertinentand up to date.

The Academic Centre for Medical Education, (ACME), at University College London,which is carrying out this work with the GMC, undertakes an on-going validation ofthe test of competence assessment instruments, which include a written test and aset of clinical skills tests in an OSCE (Objective Structured Clinical Examination)format. It needs practising doctors of good standing to assist in the validationprocess, both as assessors and as validators.

The results of these tests are anonymised and presented as ranges of achievementfor grades of specialists. Those who wish can receive feedback about their ownperformance in the tests relative to their peers. In the unlikely event of a volunteerhaving scores that indicate a serious impairment of their fitness to practice, ACMEis required to take appropriate action.

ACME are now recruiting volunteers for the next validation days for surgery on 8th

and 9th October 2008. For participating in one day volunteers will receive a fee of£350, plus travel expenses (but not accommodation). CPD credits will be given. Thevenue will be the General Medical Council offices on Euston Road in London.

Becoming involved in piloting theGMC’s assessment tools for surgery

AN OPPORTUNITY TO HELP MAINTAIN GOOD PRACTICE

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LIFETIME CASH-FLOWMODELLING: A PROGNOSISFOR YOUR HARD-EARNEDPENNIES

“Doctor, tell me straight - how long have Igot?” the stereotypical patient asks, and yougive a straight answer. It might be reassuring,might not be - but it’s the truth in yourprofessional opinion.

But what about your money? How long will itlast? What will your retirement allow you todo? Will you run out of money before you runout of life? Most doctors haven’t much of anidea about that, and there’s no doubt that this isthe one truly concerning question for themajority of people.

Let’s face it, retirement for most people isn’t afew years before the inevitable happens, but canrun into decades. And whilst NHS employeesare fortunate in having a Government fundedfinal salary pension, that’s only part of thestory.

Financial planning is concerned with just theseissues – constructing a robust lifetime cash-flow model that tells the client how theirfinancial life looks in the future. Whether theylike the results or not, it is difficult to arguewith the facts.

If the report shows that they are likely to runout of money, recommendations can be made torectify the situation and the model can be re-runto show the effects of the recommendations.

If it looks as if they will die happily in their bedwith a pound in their pocket and theundertaker’s bill unpaid, what more reassurancewould anyone want?

If they have more than enough money and willend up with an enormous inheritance taxliability, they can effectively plan their giftingand perhaps even their philanthropic strategiesin order to mitigate it.

The problem has been that until recently such aplan has been virtually impossible to create,given its complexity. That is, until the launch ofthe ‘Truth’ software, which has beenenthusiastically received by a number ofleading financial planning firms.

‘Truth’ initially enables us to constructstraightforward items such asincome/expenditure and asset/liability reports.Although this sounds simple, it is often the firsttime that clients have seen their finances laid

out in such a revelatory way. It can oftenidentify areas in which there might be certainamount of overspending going on (so honesty isessential!). This deals with the current situationand is by far the most labour-intensive part ofthe process.

But then, taking into account mutually agreedassumptions about inflation, investmentgrowth, interest rates and even longevity,‘Truth’ projects all of the data forward to anagreed ‘date of death’. You can specify thelifestyle you would like to lead once retiredand find out whether it will be possible. Onecan drop into the equation likely events suchas inheritances, and of course the system canbe updated each year to reflect actual changesin circumstances or assumptions. Any numberof ‘what-if ’ scenarios can be investigated.Perhaps the effect on your finances of one orboth of you going into care in later life, orselling up and moving abroad.

Although the data input is highly detailed, theresults are straightforward and highly visual.A series of graphs show how income andoutgoings interact and how capital grows ordwindles over time. From this top level yourplanner can then ‘drill down’ into the data inorder to help you make any adjustments thatmight be of benefit.

Whilst the thought of such a long-termprognosis might be a little daunting for someto contemplate, there is no doubt that this‘new science’ of cash-flow modelling can beof enormous benefit, either as a reassuranceor as a call to action.

Dr Mark Martin

Managing Director, Cavendish Medical1st Floor, Devon House, 171-177 GreatPortland Street, London W1W 5PQTelephone: 0207 636 7006Fax: 0207 631 4174Email: [email protected]

www.cavendishmedical.com

Cavendish Medical is a paid subscriber to the‘Truth’ financial planning software and is nototherwise associated with or remunerated byPrestwood Software (the developer of ‘Truth’)or any of its associated companies.

This article has been sponsored by ASGBILtd, a wholly owned subsidiary of theAssociation of Surgeons of Great Britain andIreland

Cavendis

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NATIONAL ASSOCIATION OF LINksMEMBERS

Patient and Public Involvement in Health and Social CarePress Release: April 2nd 2008

National body of health-activists launched The National Association of LINks Members says that:• PPI must lead to genuine, sustained improvements in NHS and social care• LINks’ members must have real power and influence• LINks must actively include communities usually ignored by the NHS and socialcare• LINks’ members must have effective training opportunities• Ministers must guarantee expenses and indemnity for LINks’ members• LINks must be sustainable organisations–not subject to abolition in a couple ofyears

Malcolm Alexander, Chair of the National Association said:“For the second time in five years, the Department of Health has abolished publicinvolvement organisations across the country and disrupted the monitoring of health careby local people. The new, poorly-funded LINks organisations could take years to establishthemselves and recruit effective membership.

NALM has been established by the most active Patients’ Forum members across Englandto limit the damage caused by abolition and to support local people rapidly to build strong,effective and independent organisations to monitor health and social care. We are buildingregional and national structures to ensure that grass-roots activists can influence healthauthorities and the government on all major health and social care issues.

NALM will initially focus on the safely and quality of social care, the effectiveness ofambulance services and the quality of cancer services, mental health services and ofpaediatrics.”

Notes: 1. The Association was set up following a national ballot of Patients’ Forum members organized by the

Electoral Reform Society. A Steering Group of 18 was elected (2 from each Region) followed byrecruitment amongst the membership of Patients’ Forums. The Association is wholly member-led andindependent. Its role is informing, advising, disseminating information and acting as a source of expertadvice, regionally and nationally for its members and key stakeholders including the Department ofHealth, MPs, House of Lords, Healthcare Commission, National Centre for Involvement, LocalGovernment Association, Strategic Health Authorities and local government.

2. The Chair of NALM is Malcolm Alexander. Malcolm is Chair of the Patients’ Forum for the LondonAmbulance Service and lectures in public involvement and community development at WestminsterUniversity.

The Vice Chair of NALM is Ruth Marsden. Ruth Marsden was Chair of the Patient and Public InvolvementForum for Hull and East Yorkshire Hospitals Trust.

She is Chair of the Clinical Radiology PLG for Hull and East Yorkshire Hospitals Trust, and Chair of theSpecialist Trusts of Yorkshire, Humberside and Teesside. She has an engineering background, with aparticular interest in military technology.

3. LINks will ask what local people think about their health and social care services and campaign toimprove these. They will investigate issues of specific concern to the community and use powers tohold service-providers to account. LINks will have rights of access to information within a specifiedtime and will carry out spot-checks and visits to health and social care services to assess whetherservices are safe and effective. They will make reports and recommendations and if necessary refermatters to the to the local ‘Overview and Scrutiny Committee’

4. The legislation recognises that LINks will want to form national and regional bodies and Health MinisterAnn Keen MP has confirmed this.

“The arrangements may (in particular) make provision as respects co-operation between a localinvolvement network and any English network or English networks.” (Local Government and PI inHealth Act “222. (5))

The National Association of LINks Members(NALM) was launched on April 1st 2008 tocoincide with the establishment by theGovernment of Local InvolvementNetworks. These bodies will monitor healthand social care across England and replacePatients’ Forums.

NALM is national, member-led organisationwhich will campaign for effective patientand public involvement (PPI) and greater

democracy in health and social careservices. It seeks directly to influenceMinisters in the Department of Health andDepartment of Communities and LocalGovernment, on a wide range of health andsocial care issues. NALM will participate inmajor policy debates on quality, access andprovision of services.

The abolition of Patients’ Forums will leavea long gap during which neither health care

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14

VASCULAR AND GENERALSURGERY: THE END OF ALOVE AFFAIR?

Michael GoughPresident, The Vascular Society

Well probably! Although this is not the case in Europeand North America, vascular surgery remains one ofthe components of “general surgery” in the UK. Moresenior members of the Association will have observedthe demise of the general surgeon over the last 20years. No longer will you find an operating listcomprising total gastrectomy for carcinoma in thegastric remnant following a previous Polyagastrectomy, an aortic aneurysm repair and amastectomy all of which featured on my first list as aconsultant general surgeon in 1986! None of them hada CVP line and they all went back to the ward fromtheatre.

Certainly there have been many changes since thenwith sub-specialisation arguably being the most farreaching. Already we have both breast and vascularsurgeons who do not participate in the generalsurgical on-call rota, although the latter more thanmake up for it by providing 24/7 vascular cover.Conversely many “general” surgical trainees obtain aCCT without the joys of the instant gratificationexperienced by successful revascularisation of acritically ischaemic leg or the disappointment ofproceeding to amputation the following day.

Many factors have contributed to sub-specialisationincluding patient expectation, health servicerequirements, technical developments and reducedjunior doctor training hours. Whilst providing anefficient and safe clinical service is clearly a laudableachievement, not everything about this exercise isnecessarily beneficial. In particular, it sometimes feelsas though the creation of sub-specialties withingeneral surgery has made simple procedures morecomplex and has created a self perpetuating need forspecialists. This concern is also exemplified by thehuge importance that multi-disciplinary teammeetings have assumed. Is it really necessary todiscuss every angiogram or CT scan performed thatweek? There must be many patients in all sub-specialties of general surgery where the treatmentoptions are obvious and perhaps we should spendmore time in active clinical work and training.

These views will be considered heretical by many and,of course, sub-specialisation is of great benefit to ourpatients, as identified some years ago when a CEPODreport showed that the best results from surgery forruptured aortic aneurysm were obtained by vascularsurgeons. In retrospect, this was probably animportant driver to the ultimate demise of a globalgeneral surgical on-call rota. Similarly, acutelyischaemic legs can rarely be salvaged byembolectomy since rheumatic heart diseasedisappeared. It is no longer acceptable to attemptembolectomy and follow this by amputation as wasthe case when I was a “basic surgical trainee”. Insteadthese emergencies may now be treated byendovascular techniques or require intra-operativethrombolysis and femoro-distal bypass. Thecomplexity of these procedures clearly means thatsub-specialisation is here to stay. As vascular surgeonswe have even made varicose veins more complex withthe introduction of ultrasound guided sclerotherapy,endovenous laser therapy and radiofrequency ablation,

so even these patients cannot be treated by atraditional general surgeon!

Thus, it is no longer possible to be a “Jack of AllTrades” and sub-specialisation is inevitable - but notas much fun!

Sub-specialisation: Impact on Training andRevalidation

Sub-specialisation raises important questions abouttraining and assessment. For the latter, will I have torevise everything I used to know, and some things thatI didn’t, about pancreatitis, hyperparathyroidism,inflammatory bowel disease, hormonal manipulationof breast cancer, etc before sitting an exam to allowme to continue to practice as a vascular surgeon? Theanswer to this appears to be yes, just as our traineesare examined in all these areas of general surgery inthe Intercollegiate FRCS examination. Of course,there may also be a good market for a short text-bookof “Vascular Surgery for Colorectal, Endocrine,Breast and Upper GI surgeons”?

Clearly, if we are going to create sub-specialties ofgeneral surgery then training andrecertification/revalidation must reflect this. For atrainee committed to vascular surgery it is clearlymore valuable to be able to perform a carotidultrasound than a flexible sigmoidoscopy, or to deployan iliac stent rather than a haemorrhoidectomy. Inother words, training must be fit for purpose. Not onlywill this meet the requirements of a modern NHS, butalso go some way to compensate for the mandatoryreduction in training opportunities for junior doctors.In the time available it simply isn’t possible fortrainees to become competent in the broad range ofgeneral surgery and thus sub-specialisation isinevitable. Focussed, curriculum driven training willproduce surgeons who in whom we can haveconfidence for each of the components of generalsurgery.

Although we all recognise the inevitability of this wehave been remarkably slow in accepting it and indeveloping appropriate training programmes. Thereare several reasons for this, although the failure ofsome of the agencies that oversee training to acceptthis is a major factor. The response should be: “Doesit really matter if general surgery no longer exists -what’s in a name?” The surgeons are still out thereplying their trade.

The Vascular Society has been “ahead of the game” ina number of activities over the years includingcreating guidelines for the provision of vascularservices within Trusts/Strategic Health authorities,developing clinical networks to facilitate 24/7availability of emergency vascular surgery in the UKand in developing an audit and governance framework(National Vascular Database), to identify potentialweaknesses in the provision of care. We are alsoleading the way in redesigning training to meet theneeds of the 21st century!

A few years ago cynics believed that vascular surgerywas dead - patients would disappear into the hands ofthe interventional radiologists or vascular diseasewould disappear because of the widespread use ofsecondary prevention (statins, antiplatelet medicationand smoking cessation), or a magic bullet would cureatherosclerosis. However, interventional radiology is arelatively unattractive area of radiology leading todifficulties in recruitment. We also have an agingpopulation and government initiatives for populationscreening for aortic aneurysm and a programme forimproved management of TIA and stroke. Thus, the

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requirement for vascular therapy has not diminishedand a new strategy is required for dealing with thisworkload.

The aging population

The prevalence of symptomatic (intermittentclaudication, critical ischaemia) peripheral vasculardisease increases dramatically with age. This, and theincreasing number of diabetic patients in thecommunity, means that lower limb interventions arestill required. Further, rather than straightforwardabove-knee femoro-popliteal bypass (as forclaudicants) these patients often require morecomplex time consuming combinations ofendarterectomy, intra-operative angioplasty andreconstruction.

Impact of AAA screening

The Department of Health announced a nationalscreening programme for abdominal aortic aneurysmearlier this year to be rolled out over the next fiveyears. This will clearly increase the requirement forelective aneurysm surgery over the coming years.

Stroke and TIA initiative

Following a transient ischaemic attack secondary to acritical internal carotid artery stenosis, carotidendarterectomy has been proven to reduce thesubsequent risk of stroke. Whilst the majority ofstrokes occur within two weeks of a TIA, previousaudits show that patients are rarely seen andinvestigated during this time frame, let alone undergoappropriate intervention.

Following a Department of Health review of strokeservices, to which the Vascular Society contributed,this process is to be streamlined with presentation andreferral for appropriate assessment recommendedwithin 24 hours of the index event. Interventionshould be performed within two weeks and this willsignificantly increase the volume of carotid surgeryperformed in the UK.

Interventional Radiology and Vascular Surgery:the Single Vascular Specialist?

Enthusiasts have suggested that, in the future, we willtrain pluripotential vascular specialists capable ofundertaking all interventional and surgical treatments.Although this is not currently on the horizon, and maybe difficult given the reduction in the duration oftraining, there are innovative changes in the pipelinefor our specialty.

For some time a joint working group of the RoyalColleges of Surgeons and Radiologists, together withthe Vascular Society, have been discussing a newtraining curriculum which will provide trainees ineither specialty with complementary skills in theother. Thus, for radiologists, they are likely to becomecompetent in minor surgical skills (vessel exposure,closure of arteriotomies) and in undertaking clinics,instigating investigations and supervising in-patientcare for patients admitted for a radiologicalintervention. Similarly, surgical trainees will betrained in vascular ultrasound, interpretation of cross-sectional imaging and performing angiography andstraightforward interventional procedures.

Acquiring these skills will facilitate 24/7 access toinvestigation and treatment, and the performance ofincreasing numbers of adjuvant radiologicalinterventions during the course of a surgicalrevascularisation as highlighted earlier. A furtheradvantage of “surgeons” achieving thesecompetencies could be in emergency care where

continuous “radiology” cover may not be available(e.g. EVAR for ruptured AAA).

Before we get too excited about these developments,there remain a number of hurdles to cross. This isclearly a significant departure from the current generalsurgical training curriculum and goes beyond the 2-3years subspecialty training that is currently available.In particular, such a major change will require theapproval of the General Surgical SAC, the RoyalColleges and PMETB. All of these agencies are awareof these proposals and, to a greater or lesser extent, arereasonably happy with them. From a regulatorystandpoint our aims can probably be best achieved byvascular surgery becoming a formally recognised sub-specialty of general surgery approved by PMETB.

Nevertheless the sub-specialty will still be within theGeneral Surgical SAC, which will recommend theaward of a CCT to trainees who have completed theirtraining. The difficulty posed by this is that SACagreement on the amount of “general” or abdominalsurgery that trainees should undertake beforeembarking upon their sub-specialty modular trainingthe programme content is required. It would seemlogical that this might be two years (ST3 & 4) duringwhich the ICSP curriculum suggests that the corecompetencies in general surgery should be achieved.An alternative view, given that these new sub-specialists are extremely unlikely to contribute to thegeneral surgical emergency rota, is that one yearwould suffice. Hopefully this issue will be resolvedin the next couple of months and an application forrecognition of the sub-specialty can be submitted toPMETB together with a complimentary submissionfrom the Royal College of Radiologists (RCR) for asimilar sub-specialty of radiology.

A draft of the programme that has been designed isshown in Figure 1. The modular componentsundertaken during ST5-8 have already been devisedby the education committees of the Vascular Society,RCR and British Society of Interventional Radiology(BSIR). They encompass the whole spectrum ofvascular surgery and non-oncological (solid organ)intervention and the modules that each traineecompletes will depend on whether they are primarilysurgical or radiology trainees. A full range ofassessment tools have also been developed for trainingand the new post-CCT fellowships will allow us topilot these.

Figure 1: Potential programme for training invascular intervention (surgery and radiology)

Post-CCT FellowshipsIn advance of the joint curriculum, which we hopenew trainees will be entering from 2009, the post-CCT fellowships, recently introduced by theDepartment of Health, will allow exposure to this typeof training for surgeons and radiologists who have

ST1/Core training Basic surgery (3x 4 months)

ST2/Core training 6 months vascular surgery6 months radiology

Competitive entry to ST3

ST3 Core competencies in general surgeryST4 Core competencies in general surgery ST5 Modular training, new curriculumST6 Modular training, new curriculumST7 Modular training, new curriculumST8 Modular training, new curriculum

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16

Over recent months, newspaper headlines havepainted a rather gloomy picture for UKhomeowners. Many commentators havespeculated about the future of house prices, whileothers have reported the rising costs of mortgages.

It is true to say that the mortgage market haschanged over the past year. Back in 2006,borrowers were enjoying low mortgage rates,many even lower than the Bank of England baserate, and there was an abundance of mortgageproviders fighting for business. Today theenvironment looks different – there are fewerlenders actively competing in the market and thecost of funding mortgages has risen steadily. As aresult, consumers have seen mortgage ratesincrease and many are facing increased paymentswhen they come to remortgage from their existingdeals.

After a decade of rapid house growth and cheapermortgage costs, many homeowners are facing aslowing housing market for the first time. It willbe no surprise to learn that these changingeconomic conditions have caused manyconsumers to take a more cautious approach,resulting in a new breed of ‘wait and see’homeowners, who are eager to see what happensto the economy before they make any decisions.

Many homeowners blame a lack of economicknowledge for this reluctance to take action.Almost half (49%) questioned by Lloyds TSBbelieved they had insufficient economic know-how to make decisions in the current climate, withmore than two-thirds of respondents describingtheir economic awareness as basic or below.

But doing nothing can be a false economy andcould end up costing homeowners more in thelong run. For example, if you don’t arrange a newmortgage deal before your current one expires youwill automatically be moved onto the standardvariable rate (SVR), which could be moreexpensive than your existing deal.

So whether you are looking to remortgage, movehome or buy your first house, here is a step-by-step guide to taking control of your mortgage.

Take charge of your mortgage

1. The most important thing is to start shoppingaround early. Start speaking to lenders wellbefore your existing deal expires and don’tleave it until the last minute. Despite thenegative headlines, there are still good mortgagedeals out there for consumers, so do go andseek advice. If you find a good rate now, butyour current deal does not expire for a fewmonths, most lenders will let you book the ratein advance. It may incur a charge, but somehomeowners will think this is worth it, if theybelieve mortgage rates will continue to rise.

2. Most existing homeowners will have builtequity in their property over time but, if youare a first-time buyer, start saving towards adeposit. Having a deposit will enable you tobenefit from the best rates - the depositrequired is typically around 10% of theproperty’s value.

3. If you are remortgaging, the environment willlook quite different from the last time you tookout a deal, so be prepared for your payments toincrease. But lenders are aware of thesechanges and, as a result, they have beendeveloping products to help homeowners adaptto this new rate environment.

4. Your mortgage payments are a substantial partof your monthly outgoings, so it’s important towork out your priorities. Some consumers mayprefer the security of a fixed-rate product,which allows them to set a budget over thelong term. Other homeowners may want tobenefit from potential rate drops, so would bebetter suited to a tracker product.

5. Make sure you take into account all theelements of a mortgage offer and not just therate. Look at the package as a whole – thatincludes the fees, the length of tie-in and theopportunity to earn rewards such asAIRMILES or cash back.

This article has been sponsored by ASGBI Ltd,a wholly owned subsidiary of the Association ofSurgeons of Great Britain and Ireland

recently, or are about to obtain their CCT. Followingthe applications submitted in the spring there will beseven “surgical” posts providing interventionalexperience and four “radiology” posts providingsurgical training. Given that existing trainees will notcomplete the new sub-specialty training until 2012-2014, it is important that this initiative is continued,although agreement on this has not yet been reached.

These are clearly times of change for VascularSurgery - we’re not dead but we may not be quite thesame in the future!

And finally, on a slightly less serious note, theSocieties comprising ASGBI must not forget that “I”represents Ireland. The Vascular Society had not helda meeting in the Republic for some 20 years untilFebruary this year when a very successful meeting oncarotid disease was organised by Prakash Madaven inDublin. It was particularly successful for the

President who, being a long time Wales supporter,enjoyed watching Wales beat Ireland in the 6-Nationsand relieved the Secretary (Jonothan Earnshaw, anhonorary Irishman for the day) of 10 Euros. Thephotograph above records this historic event!

NAVIGATING THE MORTGAGE MAZE

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2007 MOYNIHANTRAVELLING FELLOWSHIPREPORT

Vascular Surgeon or VascularSpecialist? Experiences gained inAustralia and Sweden

Marcus J Brooks

IntroductionThe development of endovascular aortic surgery hasbeen rapid; eleven years separate Juan Parodi firstintroduction to Palmaz’s balloon expandable metalstent (1987) and John Anderson performing afenestrated endovascular repair of a juxta-renal aorticaneurysm (1998). This revolution in the managementof aortic disease has only been made possible byparallel developments in vascular imaging (CT andMR) and endovascular technologies. In my SpecialistRegistrar training I observed the trend towardendovascular intervention replacing much of openvascular surgery; endovascular aneurysm repair(EVAR) may be an obvious example, but angioplastyhas virtually replaced the aorto-femoral bypass andabove knee fem-pop bypass and in much of the worldcarotid artery stenting (CAS) is taking over from openendarterectomy.

I have a particular interest in the management ofpatients with disease of the thoracic and thoraco-abdominal aorta having written my MD thesis atImperial College on the inflammatory response toopen thoraco-abdominal aortic aneurysm repair. It isin the thoracic and thoraco-abdominal aorta that aorticstenting has perhaps had the greatest impact in themanagement of complex aneurysms and aorticdissection. The 2007 ASGBI Moynihan TravellingFellowship provided me with the opportunity to travelto three centres in the world that have pioneered theendovascular management of complex aortic diseaseand are now at the forefront of developments ofbranched and fenestrated endografts; The VascularUnit at the Royal Prince Alfred Hospital in Sydney,Dr John Anderson at the Ashford Medical Centre inAdelaide and The Endovascular Centre in Malmö,South Sweden.

Royal Prince Alfred Hospital, Sydney, AustraliaThe Royal Prince Alfred Hospital in Sydney (RPA) isone of the oldest and largest teaching hospitals inSydney. It was built by public subscription followingthe attempted assassination of Queen Victoria’s sonPrince Alfred in 1868. Professor Geoffrey White andProfessor Jim May were early proponents of EVAR.The White-Yu graft was one of the first endografts forwhich clinical follow up data was published.1 Thevascular unit at RPA coined the term endoleak in1996 to differentiate failure to exclude the aneurysmsac fully (endoleak) from haemorrhage outside of thesac (aortic rupture).2 Professor White is nowrecognised as a leading expert on the complications ofendovascular stent grafting.

The follow up of patients following EVAR and theneed for re-interventions is the cause of part of theexcess cost as compared to open repair. At RPA theyhave moved from CT follow up to Duplex and plainabdominal x-ray; Duplex is used to measure the sacdiameter and detect endoleaks while the plainabdominal x-ray will reveal graft migration or stentfracture. Recent as yet unpublished work from RPAscanning patients following EVAR in more that one

position shows that endoleaks can be missed on CTperformed only with patients supine.

One technical challenge for EVAR is patients withcommon iliac artery aneurysms. One approach is toembolise the internal iliac arteries and landing thedistal stent graft into the external iliac artery. The riskwith this approach is that it may result in disablingbuttock claudication and occasional colon ischaemia.An alternative is to use a branched endograft or IBD(Iliac Branch Device). The latest IBDs come preloadedwith a catheter through the side branch to facilitatecannulation of the internal iliac artery (Figure 1). TheIDB is seen sitting in a right common iliac arteryaneurysm on the left image and on the right thecompletion angiogram shows the aneurysm excludedfrom the circulation with internal iliac flow preserved.

At the RPA I was also able to attend the weeklyvascular unit surgical and radiology multi-disciplinarymeeting, which was similar to those that I hadattended in the UK. I also observed a number of openand endovascular arterial procedures, includinganeurysm repair and lower limb bypass. Professor

White was keen to emphasise theimportance of good imaging forsuccess in endovascularprocedures. The quality of CTimaging available was clear froma 3D reconstruction performedwhen the top metal tines of aninfra-renal aortic stent graftfailed to open fully during oneprocedure (Figure 2).

Professor White performs a weekly half-day list ofdiagnostic and peripheral endovascular procedures ina cardiac catheter laboratory. Most of the diagnosticprocedures were to plan aortic interventions. He alsoperforms angioplasties to the iliac and superficialfemoral arteries. The RPA maintains the traditionalsplit between interventional radiologists and vascularsurgeons and the majority of peripheral vascularinterventions are performed in Radiology. Unlike myexperience in the UK, EVAR and IBDs wereperformed in theatre using a mobile C-arm withoutinput from interventional radiology. It was, therefore,necessary for the surgeon performing the procedure tohave the necessary wire skills to place the guide wiresand cannulate the graft limbs.

I am grateful for everyone at RPA who made me feelwelcome. My particularly thanks must go to ProfessorWhite (on the right in Figure 3), and Ravi Gurgol,then senior Vascular Fellow and now ConsultantVascular Surgeon in Melbourne.

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Ashford Medical Centre, Adelaide, AustraliaThe contrast between RPA and Ashford MedicalCentre could not be greater. Ashford Hospital is aprivate medical centre in Adelaide specialising in themanagement of cardiac disease. This was my firstexperience of the private healthcare system inAustralia. Unlike the United Kingdom where 10% ofthe population take out private health insurance, inAustralia 50% of the population are insured. Privatehospitals often have an Emergency Department (ED)and treat acute as well as elective patients. Manysurgical consultants, including Professor White andProfessor May in Sydney, work in the private systemand maintain their public role as a Visiting MedicalOfficer (VMO). John Anderson now has an entirelyprivate practice jointly with Glen Benveniste, who co-incidentally was research fellow to my predecessor,Roger Baird, at the Bristol Royal Infirmary.

Dr Anderson was an early proponent of endovasculartherapies. He has personally performed the greatestnumber of fenestrated and branched endovascularrepairs in the world including the first Cook ZenithTM

fenestrated and branched grafts.3 Dr Anderson’spractice is predominantly endovascular and he worksindependent of interventional radiology; hisendovascular cases, including fenestrated aortic grafts,are performed in a cardiac catheter laboratory. Thefollowing four patients give an example of a typicaloperating list.

First patient was recovering from a stroke secondary toa tight left internal carotid artery stenosis. The patienthad a bovine arch (common origin of the innominateand left common carotid arteries) which madecannulation of the common carotid artery difficult.Eventually the carotid stenosis was crossed and a stentdeployed using a distal embolic protection device.

Second patient had recurrence of right leg shortdistance intermittent claudication four years after aSFA stent. A stent was deployed to re-expand thenarrow area of the stent.

Third patient had presented as an emergency withright leg acute on chronic ischaemia. Antegradeangiography revealed occlusion of all three cruralvessels. As a wire passed easily down the anteriortibial artery Dr Anderson opted to thrombolyse thisvessel using a pulse spray catheter. The next morningthe patient had a palpable dorsalis paedis pulse andrepeat angiogram revealed the anterior tibial artery tobe patent to the foot.

Final patient had recently suffered a TIA and had atight left internal carotid artery stenosis.Endovascular access was difficult due to iliac andcommon carotid artery tortuosity. Despite advancinga ‘buddy’ wire in the external carotid artery aprotection device would not advance into the internalcarotid artery. Dr Anderson decided to abandon thisprocedure and rescheduled the patient for a carotidendarterectomy, this was performed uneventfully thefollowing day.

Dr Anderson performed acustom made fenestratedstent graft for a patient witha six centimetre juxta-renalabdominal aortic aneurysmwith an anomalous lowright renal artery artery(Figure 4). This procedurewas performed jointly withMichael Berce and JasonCheun, two other vascularsurgeons. A standard

ZenithTM stent graft (Cook Medical, Perth, Australia)had been customised with a scallop for the SuperiorMesenteric Artery (SMA), left renal arteryfenestration, up-pointing side branch low down theright side of the graft body to allow access to theanomalous right renal artery origin and diameterreducing ties. The graft was inserted via a rightcommon femoral artery cutdown and threepercutaneous punctures were made through the leftcommon femoral to allow catheter access to the SMAand renal arteries. The graft was successfullypositioned, the target vessels cannulated and the stentgraft and branches deployed. The aneurysm wassuccessfully excluded, but, no flow was seen in theSMA. Dr Anderson used a combination of pulse spraythrombolysis and stenting to re-establish SMA flow(Figure 5). The patient experienced 48 hours of post-operative abdominal pain but subsequently made afull and uneventful recovery. The potential risks ofthese procedures and the high level of endovascularskills needed to achieve good results and avoidconversion to open repair were obvious.

I am grateful to everyone I met at the AshfordMedical Centre, specifically Dr Anderson and DrCheung (Figure 6).

Endovascular Centre, Malmö University Hospital,Malmö, SwedenMalmö is the third largest city in Sweden and lies inthe Southern county of Scandia. The opening in 2000of the Oresund Bridge connecting Malmö to Denmarkhas led to a economic upturn for the city. TheEndovascular Centre is headed by Professor KrassiIvancev, an interventional radiologist who believes indisseminating interventional radiology skills tovascular surgeons. In the Endovascular Centre thereare two other interventional radiologists, MichaelAkesson and Mathias Lindh. Endovascular proceduresare performed either by them on by one of thevascular surgeons Dr Ivancev has trained; Dr MartinMalina, Dr Bjorn Sonnerson and Dr Timothy Resch.When I visited all three trainees were from surgicalbackgrounds; Tilo Kobel (Germany), Teng Lee (USA)and Rob Hinchcliffe (UK). I learnt that RoyGreenberg and Tim Chuter, the two leading exponentsof fenestrated stent grafts in the USA, both learnt theirendovascular skills from Professor Ivancev.4, 5

Dr Ivancev has the largest experience in Europe ofbranched and fenestrated endografts.6 The Malmö unitwere also early to report on the changing aneurysm

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morphology following EVAR.7

The facilities for endovascularinterventions are impressivewith two dedicated angiographysuites and a dedicated operatingtheatre with a floor mountedflouroscope. There is also alarge reporting room with threePACS work stations and a

Terrarecon (Terrarecon, San Mareo, CA) 3Dworkstation. All vascular cases are planned at theseworkstations. It was noticeable that the workstationswere used as frequently by the surgeons as theradiologists. The working day started with a meetingat 7.30 attended by all the surgical and radiologicalconsultants and the trainees. The emergencyadmissions from the previous twenty-four hours andelective cases for the day were discussed. The films ofthe previous day’s cases are then reviewed. Thismeeting took place in Swedish but as everyone spokegood English it was easy to get someone to translatewhen necessary.

I observed another Iliac Branch Device (IBD); a rightinternal iliac branch and left internal iliac arteryembolisation were performed in an 81 year old manwith an aorto-bi-iliac aneurysm. This case wasperformed jointly by Professor Ivancev and DrSonnerson. A sixty nine year old male presented witha tender aneurysm. Urgent CT scan revealed a tencentimetre juxta-renal aneurysm. This was repairedthe next day using an in-house modified ZenithTM

endograft with a scallop to incorporate the superiormesenteric artery and bilateral renal fenestrations(Figure 7).

The Endovascular Centre has anactive program for carotid arterystenting. One interesting casewas for restenosis following anopen carotid endarterectomywith patch twelve months earlier.A tortuous distal internal carotidartery meant that a protectiondevice could not be used (Figure8). Another difficult case was a

patient with ‘tandem’ symptomatic stenoses of the leftcommon and internal carotid arteries. The technicalchallenge was to stabilise a sheath in the proximalcommon carotid. This was achieved using a techniquepioneered in Malmö; a ‘through-and-through’ guidewire was advanced retrograde through the leftsuperficial temporal artery and snared from below inthe thoracic aorta (Figure 9).8

I also observed a number of infra-renal EVARs andperipheral vascular interventions includingfistuloplasty, thrombolysis, suction embolectomy,subintimal angioplasty, iliac stenting, renal stentingand iliac venous recanalisation. In one patient,translumbar aneurysm sac pressure measurementswere made to investigate for sac expansion in theabsence of a demonstrated endoleak. In keeping withDr Ivancev’s belief that vascular surgeons who want to

develop endovascular skills must learn to perform allvascular interventions, I also observed mesentericangiography and embolisation for GI haemorrhage,TIPS procedures and IVC filter insertion. Dr Ivancevfeels that not only are these good trainingopportunities but they are also necessary skills ifvascular surgeons are to join interventionalradiologists on an emergency rota.

I would like to thank Krassi Ivancev (Figure 10), andeveryone at Malmö for making me so welcome andmy short stay so informative. Rob and Teng inparticularly made my stay much more enjoyable witha couple of excellent nights out in Malmö.

SummaryIt is striking that in Australia (population 20 million)around 500 fenestrated aortic grafts have beenimplanted, yet in my training in the UK (population 60million) I was involved in just two cases. I had assistedor performed over seventy EVARs by completion ofmy UK training which is equivalent to the numbersperformed by the Australian and Swedish trainees thatI met. Where my endovascular experience wasdeficient was in peripheral interventions. The UnitedKingdom has been slow in equipping vascular traineeswith the necessary skills to perform the full range ofendovascular procedures. This is hopefully nowchanging with recognised endovascular fellowshipsagreed between the Vascular Society and the BritishSociety of Interventional Radiology.

The Malmö Endovascular Centre provides a positivemodel for the future with vascular surgeonsperforming endovascular procedures alongsideinterventional radiologists. Each has clinical andtechnical expertise to bring to the management ofthese complex patients. For this approach to besuccessful it is essential that the same high level oftraining is available to ‘surgical’ and ‘radiological’trainees in terms of interpreting pre-operativeimaging, planning procedures and the technicalendovascular skills necessary for theirimplementation. The quality of imaging, number ofpublications, and success in attracting referrals of theMalmö Endovascular Centre and subsequent careersof it’s trainees are testament to the benefit of acollaborate approach, and offer a stark contrast tounit’s fighting a turf war over whether surgeons,radiologist or cardiologists, should be performingendovascular procedures.

Dr Anderson is completely familiar with the cathetersand the wires that he uses, something he hasdeveloped from his large endovascular practice. It isunlikely, if not impossible, that all vascular surgeonswill attain this level of technical skill. Many surgeonswill prefer to collaborate with an interventionalradiologist. It is important to recognise that having theskills and resources to manage complications is just asimportant for endovascular interventions as it is foropen surgery: Just as most vascular surgeons wouldnot want to perform complex open aortic surgerywithout a cell salvage device and back up from a

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blood transfusion laboratory, complex endovascularprocedures should not be performed without the skillsand devices for distal embolic protection, vesselembolisation, thrombolysis and suctionthrombectomy.

The equally important aspect of a TravellingFellowship is that of making new friends and catchingup with old ones. I am particularly grateful to Andrewand Charlotte Lennox, who I first met when Andrewwas a Visiting Fellow at St Mary’s Hospital inLondon, for making me so welcome at their homeduring my stay in Sydney. I met a number ofAustralian vascular surgeons and trainees during mytime in Australia and Sweden. A number of thetrainees are interested in visiting Vascular Units in theUK and I look forward to welcoming them to Bristolwhen they do. I have already been back to visitMalmö and am looking forward to an opportunity togo back out to Australia (Figure 11).

I am extremely grateful to the Association ofSurgeons of Great Britain and Ireland for the award ofthe 2007 Moynihan Travelling Fellowship. TheFellowship provided me with a unique opportunity toexperience first hand the very forefront ofendovascular therapy and meet the doctors who hadpioneered many of the techniques in routine use today.I cannot thank Professor White, Dr Anderson and DrIvancev enough for their time and willingness to sharetheir experience with me. The same can be said foreveryone I met in both Australia and Sweden.

As a result of this Fellowship I have a far greaterunderstanding of how to develop my ownendovascular skills and how to develop anendovascular service. Since my appointment to aConsultant post at the Bristol Royal Infirmary thatexperience has proved invaluable. In developing theendovascular programme I am working withcolleagues in vascular surgery, interventionalradiology, cardiology, paediatric cardiology andcardiac surgery. We have recently held a successfuljoint regional meeting on the multi-disciplinarymanagement of aortic pathology and look forward tothe opening of a hybrid endovascular theatre withinthe new Bristol Heart Institute next year. I made somegreat new friends around the world and re-establishedold friendships. I look forward to maintaining thesefriendships in the future.

As to the question ‘Vascular Surgeon or VascularSpecialist’ the short answer is both; open surgeryremains fundamental to the management of patientswith vascular disease, but it is a specialist whounderstands the natural history of the patientscondition and is able to offer a full range of treatmentoptions, be they conservative, pharmacological,endovascular, or as yet undiscovered, who can treatthe greatest number of patients with the bestoutcomes. Nowhere is this truer than in themanagement of complex aortic disease where thedecision on whether to treat is often a difficult oneand where open surgery and endovascular stent graftseach have their own risks and complications.

Figure 1. (a) Iliac Branch Device (IBD) sitting withina right Common Iliac Artery aneurysm (b)Completion angiogram showing exclusion of theaneurysm from the circulation.

Figure 2. CT Reconstruction of the uncovered metaltines of a stent graft showing how they had overlappedduring packing and failed to fully deploy.

Figure 3. From left to right (front row) Professor NickCheshire (invited speaker), myself, Dr Irwin Mohan(Consultant Vascular Surgeon, Sydney) and ProfessorGeoffrey White and (back row) Australasian vasculartrainees at an Industry sponsored thoracic stentmeeting, Queensland, Australia.

Figure 4. CT reconstruction of a juxta-renalabdominal aortic aneurysm with anomalous low rightrenal artery treated by Dr Anderson using a custommade fenestrated endograft.

Figure 5. (a) Selective cannulation of the SuperiorMesenteric Artery at completion of fenestratedendograft showing proximal dissection with no distalflow (b) SMA flow re-established using thrombolysisand stents.

Figure 6. Seated with Dr John Anderson (left) and DrJason Cheung (right) in the Ashford Medical Centrecoffee room.

Figure 7. In-house modified fenestrated aortic stentgraft for urgent treatment of a tender 10cm juxta-renalabdominal aortic aneurysm.

Figure 8. CT reconstruction of a re-stenosis followingcarotid endarterectomy showing tortuosity of thedistal internal carotid artery.

Figure 9. (a) CT reconstructions showing tandem leftcommon and internal carotid artery stenoses – yellowarrows (b) ‘Through and through’ guidewire from leftsuperficial temoral artery to common femoral artery(c) Completion angiogram.

Figure 10. At dinner in Malmö with Dr Ivancev.

Figure 11. The Vascular 2007 dinner in Melbournewith from left to right John Wolfe (St Mary’s Hospital,London), myself, Sam Melick (Retired VascularSurgeon, Brisbane, Queensland) and Andrew Lennox(Vascular Surgeon, Prince of Wales Hospital, Sydney).

References1. White, G.H., et al., Three-year experience with the White-

Yu Endovascular GAD Graft for transluminal repair ofaortic and iliac aneurysms. J Endovasc Surg, 1997. 4(2): p.124-36.

2. White, G.H., W. Yu, and J. May, Endoleak—a proposed newterminology to describe incomplete aneurysm exclusion byan endoluminal graft. J Endovasc Surg, 1996. 3(1): p. 124-5.

3. Anderson, J.L., M. Berce, and D.E. Hartley, Endoluminalaortic grafting with renal and superior mesenteric arteryincorporation by graft fenestration. J Endovasc Ther, 2001.8(1): p. 3-15.

4. Greenberg, R.K., et al., Beyond the aortic bifurcation:branched endovascular grafts for thoracoabdominal andaortoiliac aneurysms. J Vasc Surg, 2006. 43(5): p. 879-86;discussion 886-7.

5. Chuter, T.A., Fenestrated and branched stent-grafts forthoracoabdominal, pararenal and juxtarenal aorticaneurysm repair. Semin Vasc Surg, 2007. 20(2): p. 90-6.

6. Hinchliffe, R.J. and K. Ivancev, Endovascular aneurysmrepair: current and future status. Cardiovasc InterventRadiol, 2008. 31(3): p. 451-9.

7. Malina, M., et al., Changing aneurysmal morphology afterendovascular grafting: relation to leakage or persistentperfusion. J Endovasc Surg, 1997. 4(1): p. 23-30.

8. Ivancev, K., T. Resch, and M. Malina, Novel accesstechnique facilitating carotid artery stenting. Vascular,2006. 14(4): p. 219-22.

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Steve Jackson

There are many definitions of leadership. My currentpreference is that ‘Leadership is the ability to achieveyour pre-determined goals, whilst recognising therights of others’. My own leadership education beganwhen I left school in 1970 and started work a mileunderground with the haulage team on number 48Face at Thoresby Colliery in Nottinghamshire. Igraduated to the role of ‘scraper driver’ on number 50Face, driving the colossal machine that moved freshlyhewn coal from under the ‘ripping lip’ to the conveyorbelt that would transport it to the surface. ‘Big Brian’was the district Deputy and my line manager. His styleof leadership did not lack for brevity, clarity, orrobustness but recognised that he had a duty to keepme from harm and from harming others in what was avery dangerous environment.

In 1973, I developed wanderlust, joined the RoyalNavy, and had a career that spanned 34 years andincluded a wide range of demanding appointments atsea, ashore and abroad. I managed to rise from therank of Ordinary Seaman, with relatively fewresponsibilities, to that of Captain, on the staff of theSurgeon General in Whitehall and authorship of the‘Defence Health Strategy’. I developed an interest inand understanding of leadership and peopleperformance and spent my latter years in the RoyalNavy being responsible for the personal andprofessional development of others.

I enjoyed this aspect of my work so much that in 2006,along with three like-minded colleagues, we formedMyPeakPotential Ltd, a company that specialises inpeople performance, learning, communication, andchange. Between us we have significant leadership andmanagement experience in demanding jobs, onoperational duty and in the outdoors. We have facedconsiderable complexity, ambiguity, and uncertainty –key elements of the new leadership terrain. Operatingsuccessfully in extreme conditions has given our teama unique ability to transfer these hard earned skills to amanagement context which we use to improve people'sability to tackle workplace challenges with renewedconfidence, motivation and a positive mental attitude.

Steve Jackson you have heard about. John Doyle is ahighly experienced, versatile, and inspirationaloutdoor teacher, who has an impressive list ofachievements in the outdoors and a passion forpassing on his deep knowledge of leadership,teamwork, and the outdoors to others. Dave Buntinghas many years experience as a Chief Instructor withresponsibility for the syllabus, programmes, deliveryof training and general management of a number ofoutdoor development centres around the globe for adiverse range of about 6,000 students a year. LeighWoodhouse is a serving Army helicopter pilot andflying instructor who contributes to our programmesas circumstances allow. The leadership achievementsof three of the Directors have resulted in the awardof the MBE and the fourth by competitive promotionto high rank in the Royal Navy.

All four have been involved in leading challenging andsuccessful mountaineering expeditions to the hardestroutes on the world’s highest mountains – includingGasherbrum I (11th highest peak), Makalu (5th

highest), Kangchenjunga (3rd highest), and Everest. In2006, we led the expedition that attempted to make thefirst British ascent of Everest via the notorious WestRidge, which was the subject of a TV Documentaryseries ‘Everest: Man V Mountain’. In 2004, LeedsMetropolitan University joined that project andcontributed a tremendous amount of support andresearch throughout all stages of the expedition. In2007, Dave Bunting gave a presentation that focusedon the leadership and team-building aspects of thatexpedition at the ASGBI AnnualScientific Meeting inManchester.

At around this time, ASGBIrecognised that surgeons neededa way to develop themselves asleaders and looked for ways tomeet that need. They decided todevelop a postgraduateleadership programme for theirmembers and did so inconjunction withMyPeakPotential and Leeds Metropolitan University,who by now were partners - combining the establishedtrack record of Leeds Metropolitan University forinnovation in post-graduate education, with theexpertise and flair of MyPeakPotential. The newmodular masters award1 that emerged is designed tomeet the needs of surgeons and incorporatesPostgraduate Certificate and Diploma as target awards.It takes a multidisciplinary approach to utilise the bestlessons of psychology, philosophy, education, andmanagement to encourage fast, effective, long-termlearning through experience of real-life and real-timeoutdoor challenges. The Postgraduate Certificate andDiploma awards of the programme follow a similarpattern of study, combining three weekends of study inthe UK and a week-long residential, experiential,module in Bavaria for each award. The Certificatefocuses on the development of intrapersonal aspects ofleadership (leading one’s self); with the Diploma

moving on to an interpersonal focus (leading others).Independent study is supported through the Virtual

LEADERSHIP; CAN IT BE TAUGHT OR DOES IT HAVE TO BE LEARNT?

The four founders of MyPeakPotential

(L-R) Dave Bunting, Steve Jackson and John Doyle with the West Ridgeof Everest in the background.

Dave Bunting presentingon leadership to LeedsMet University studentsand staff

The Carnegie Alpenrose in Gunzesried-Säge, Bavaria

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Learning Environment of Leeds MetropolitanUniversity.

The two, week-long, residential modules are deliveredfrom the MyPeakPotential base (the CarnegieAlpenrose), an extensively renovated former alpine hotelin Gunzesried-Säge, a small hamlet in the OberAllgäuregion of Bavaria. Access from the UK couldn't beeasier as it is about an hour's drive from Friedrichshafenairport, itself only a short, cheap flight from London.With its magnificent scenery, clean air, crystal clearwater and diversity of cultural resources, this part ofBavaria has the perfect environment for outdooractivities that promote personal development. TheCarnegie Alpenrose is extremely comfortable, with en-suite bedrooms, Wi-Fi throughout, excellent food and anexclusive private lounge and bar with satellite TV.

The new leadership programme has a particular focuson the development of emotional intelligence (Ei) asleadership is, fundamentally, about understanding andmanaging your own emotions and those of others.There has been a growing recognition in recent yearsthat Ei influences behaviour in a wide range ofdomains including education, society, and theworkplace2. Ei is said to relate to academicachievement, performance at work, the ability tocommunicate effectively, solve everyday problems,build meaningful relationships and even the ability tomake moral decisions. Ei has the potential to increaseour understanding of how individuals behave and adaptto their social environment and is, therefore, animportant topic for study in the context of leadership.

It is of interest that recently the Academy of MedicalRoyal Colleges and the NHS Institute for Innovationand Improvement jointly developed the MedicalLeadership Competency Framework. The Frameworkdescribes the leadership competences doctors need tobecome more actively involved in the planning,delivery and transformation of health services. TheEnhancing Engagement in Medical Leadership team isworking with the General Medical Council (GMC) andthe Postgraduate Medical Education and TrainingBoard (PMETB) to integrate the Framework intoundergraduate and postgraduate curricula. Acomparison of the ASGBI programme with theFramework demonstrates a very good fit and that theASGBI programme addresses all of the competenceshighlighted in the Framework.

For the MSc and the other programmes that we run inBavaria we make the assumption that the people whocome to us have the necessary technical knowledgeand skills required to do their job. Our programmes areunderpinned by an explanation of the four factors thatwill prevent people from performing well and howthese can be addressed. The four factors are a lack ofconfidence, lack of motivation, the inability to dealwith stress and a negative mental attitude. In order toovercome these four factors we aim to help:

• Development of self-awareness, self-confidence, self-regulation, motivation, empathy, and social skills.

• Improvement of the more generic work related skillssuch as planning, organising, and delegating.

• Improvement of the more specific skills of workingin and leading a team.

We tailor the outdoor activities to match individual’sneeds in terms of leadership development and physicalchallenge, providing a range of appropriate activitiesfor the least to the most active student. Whilst theoutdoor environment in Bavaria provides an idealsetting away from the participant’s professionalcontext, there is no requirement for previous outdoorexperience and only a moderate level of fitness isrequired. There are wide variations in the demands thatcourses place on participants and they can progressfrom short, simple exercises to longer, moredemanding ones. The aim is to challenge theparticipants’ team working and leadership abilities andto achieve the learning outcomes - not to prove levelsof fitness! To achieve this we need to create anatmosphere of challenge and apparent risk to facilitatethe learning.

Our programmes have three stages:

• Stage one - allows participants to gain knowledgeand understanding from theoretical sessions.

• Stage two - gives them the opportunity to apply andevaluate that new knowledge in the outdoors.

• Stage three - through facilitated review sessions,draw out the learning experiences, and constructparallels with work to integrate learning back intothe work place.

We use outdoor activities as vehicles to learn andpractice leadership and team working abilities in anovel and challenging environment. The activities caninclude mountain walking, abseiling, mountain biking,rock climbing, open boating, kayaking, high ropescourse and rafting. In winter, activities include skiing,ski-touring, snow-holing and snow-shoe trekking. Ourresidential programmes are highly flexible and we willdesign them to meet client specific requirements interms of content and length.

This might be a useful time to consider how outdooractivities that appear unrelated to work activities canimprove performance at work. Effective learning takesplace when an individual puts an idea into practice.That practical experience tests the original idea, theindividual can reflect upon the results achieved -modify the idea as necessary - and try again. Theoutdoors is a superb environment in which to do thisbecause it is closer to reality than most forms oftraining as participants behave normally and cannotrole-play due to the unfamiliarity of the setting. Formost people it takes them out of their comfort zone,which is necessary to develop and learn. Learningoccurs when we move briefly into stretch, try newGraduates on a recent team-building course

Learning about team work through mountain biking

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things, and return to comfort to reflect upon theexperience and assess what we have learned. Soonwhat was in stretch becomes comfortable, our comfortzone expands, and we become more capable. Ourexperience of controlling people’s exposure to risk in

the outdoors ensures that our participants do not spendtime in their panic zone as that causes stress andsignificantly hinders performance and learning. This isshown in the Yerkes-Dodson model (Figure 3) whichdemonstrates that performance is linked to the arousalof the individual.

Not only does the outdoors provide a novel, non-contextual environment for learning but also becausetasks are unrelated to work activities and are relativelysimple they expose the processes by which individualsperform and achieve. Outdoor activities offer anemotional dimension that parallels real life andpresents a full learning experience. The physical,emotional, and cognitive nature of the activities helpsby breaking down psychological barriers that caninhibit participation and learning. The immediacy and

nature of the tasksinvolving these threedomains requires fullparticipation, the taking ofdecisive action, andheightens the experience.So gaining greatercommitment from theparticipants andencouraging longerretention of the learningoutcomes.

The safety of our participants is our highest priority andalthough outdoor activities have apparent danger, inreality the danger is minimised and mitigated. Theoutcome of our outdoor programmes is invariably oneof the individual experiencing strong emotions in a safeenvironment. This is important because it uncovers theunderpinning processes (the behaviour patterns andinterpersonal skills of participants) of how people relateto others. In taking what they perceive as risk, whilstbeing challenged and supported, participants canexplore and understand their own limitations, how theyreact to others and how that affects their behaviour.Limitations can then be placed in context and practicalsteps planned to overcome them.

To summarise about outdoor activities, by combiningcerebral, physical, and emotional dimensions, they

offer the opportunity to discover the behaviourpatterns and interpersonal skills of how peoplebehave, interact, and achieve, regardless of whetherthey are abseiling or undertaking a work role. This isthe key to the effective use of the outdoors, firstdesigning a course that is strong in isomorphs - thesimilarity between behaviours at work and in theoutdoors – and then enabling participants to discoverthis relevance and transfer their learning back to theworkplace. This has been described as isomorphictransfer – the gaining of knowledge and skills in oneenvironment that can be transferred to another.Going back to the title of this article, there are thosewho will be of the view that leaders are born notmade. Our view is that, whilst some people may havea natural talent to lead, we do not believe thatanybody is born with innate leadership skills. Welearned in our previous careers that leadership is avital skill and not a black art; it can be learned,practiced, and polished by anyone who is prepared tomake the effort. It is no different to other professionalattributes, to get better at it you have to dedicate timeto it. ‘Surgery has always depended on exceptionalleadership, effective management, and team workingand surgeons should receive leadership and teammanagement training’. They are not my words, butare extracted from a paper by Tony Giddings andCraig Williamson3, which should be required readingfor all involved in the leadership and management ofsurgical teams (and a much wider audience in myview). They concluded that ‘Effective team working isinextricably linked to good leadership. Both are skillsrequiring training and development. It is essentialthat the NHS invests in that training and developmentfor all members of multi-professional and inter-disciplinary teams. It is also essential that allsurgeons recognise their duty to act both as effectiveleaders and as contributing team members. Both arenecessary to achieve optimal outcomes for patientsand trainees and to minimise risk of harm’.

MyPeakPotential can help you, your teams and yourTrusts to improve team working and leadership in asafe, enjoyable, environment in which you will learnabout yourself and how you relate to others. We candesign tailored team building, team bonding and teamdevelopment courses that meet your specific needs.Visit our website www.my-peakpotential.com orgive us a ring to enquire about availability, dates andprices. Email us at: [email protected] ortelephone us on +49 (0)8321 788 4854.

For further information, an application form, or toexpress your interest in enrolling on the PostgraduateCertificate, Postgraduate Diploma or Masters Awardin Leadership please contact the course leader:Adrian Schonfeld, Carnegie Faculty of Sport &Education, Fairfax Hall, Headingley Campus, LeedsMetropolitan University, Leeds, LS6 3QS or Tel:+44(0)113 812 4606. [email protected]

References1 MSc Leadership: Personal & ProfessionalDevelopment www.leedsmet.ac.uk/carnegie/pgstudy2 Consortium for Research on Emotional Intelligencein Organizations www.eiconsortium.com3 Teigen KH., 1994. Yerkes-Dodson: A Law for allSeasons. University of Tromso, Norway. SagePublications.4 Giddings A., Williamson C, 2007. The Leadershipand Management of Surgical Teams – A position paperprepared for the Council of the Royal College ofSurgeons of England.

Figure 3:Yerkes-Dodson model

Emotional, physical, and cognitivechallenges being met by a groupof recent graduates

Students experiencing moving out of their comfort zone

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08The Association of Surgeons of Great Britain and Ireland, in partnership with theBritish Journal of Surgery Society Ltd, are offering Fellowships to sponsorsurgeons wishing to work in a developing country, primarily in the Third World,on a short-term basis.

The purpose of the Fellowships is to provide training and support for overseasmedical schools in the development of their postgraduate training programmesand, thereby, establishing links with these centres.

A full CV should be submitted giving details of past and current appointmentsincluding any related work in developing countries. A detailed account of theproposed programme, including full itinerary, costs involved and objectives tobe achieved, together with supporting correspondence, is required. Pleaseinclude details of any other applications for funding your project overseas. Theclosing date for applications is Monday 6th October 2008.

Applications should be submitted to:-

Miss Bhavnita BorkhatriaOverseas Surgical Fellowships (2008)

2008 OVERSEAS SURGICAL FELLOWSHIPS

2008 MOYNIHAN TRAVELLING FELLOWSHIPThe Association’s prestigious Moynihan Travelling Fellowship, up to the value of£5,000, is available annually by open competition to Specialist Registrarstowards the end of higher surgical training or Consultants within five years ofappointment at the closing date for this application. The Fellowship is intended toenable the successful candidate to broaden their education and to present anddiscuss their contribution to British and Irish surgery overseas. It is notappropriate, however, that the award be used as part-funding for an off-serviceyear of training.

Candidates must be residents of the United Kingdom or the Republic of Ireland butneed not be either Fellows or Affiliate Fellows of the Association; however theyshould be engaged in general surgery or in one of its specialties. A full CurriculumVitae should be submitted giving details of all past and present appointments andpublications, together with a detailed account of the proposed programme oftravel, costs involved and objectives to be achieved during the Fellowship.

Short-listed candidates will be invited to attend for interview by the Association’sScientific Committee on Tuesday 11th November 2008. The Committee will payparticular attention to originality, scope and feasibility of the proposed itinerary.The successful candidate will be expected to act as an ambassador for British andIrish Surgery and should be fully acquainted with the aims and objectives of theAssociation of Surgeons of Great Britain and Ireland and its role in surgery.

After the Fellowship, the successful candidate will be required to provide awritten report of their Fellowship for inclusion in the Association’s Newsletter,and to address the ASGBI International Surgical Congress, 14th to 16th April2010. A critical appraisal of the Centres visited, together with an assessment of

Association of Surgeons of Great Britain and Ireland

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ADAPTING SURGICALTRAINING IN AN EVOLVINGNHS: PROTECTINGEXCELLENCE FOR THEFUTURE?

Ben Cresswell, President ASiT

The NHS in general, and the provision ofsurgical services in particular, is changing andthe evolution is likely to produce a noveloutcome. Surgery is a craft speciality, in that itinvolves not only the acquisition of knowledge,but also practical and technical skills. Thismakes it distinct from many other medicalspecialities and produces unique demands interms of training requirements. To preserveexcellence for the future, it is clear that trainingwill also need to evolve.

There is certainly scope for self-directed learningand learning outside of the workplace and thismay well expand with the increased use ofsimulators in training. Despite these advances,however, many aspects of the craft require directpatient contact and skilled supervision. In thisrespect, the time surgeons are able to spend inthe operating theatre, outpatient clinic andendoscopy suite is essential to successfuldevelopment and acquisition of the skillsrequired for safe independent practice. Thetraditional approach to training has been anapprenticeship model. However changes inaspects of medical training and service delivery,coupled with the requirement from 2009, of a 48hour working week, mean that a trueapprenticeship system cannot continue.

Clearly there is an obligation to both patients andsurgical trainees to develop and protect the mosteffective training programme possible. We mayneed, however, to look at some major changes inthe ways in which training can be delivered inorder to achieve this.

The European Working Time Directive (EWTD)currently limits doctors in training to an averageworking week of 58 hours and the New Dealrequirements to a maximum of 56 hours. Thishas resulted in a theoretical reduction inavailable training hours from 32000 to 21000. Inmany units however, the impact has been muchgreater, as managers have seen an economicadvantage to reducing hours even further in orderto reduce payment bandings and hence salarycosts. In 2009, the fully implemented EWTDwill further reduce maximum hours to 48 perweek and we will be left with a total of 18000training hours.

The negative implication of hours reduction ontraining is indisputable and has been shown toimpact severely on operative experience. In2005, Tom Bates published a review of theAssociation of Surgeons of Great Britain andIreland (ASGBI) logbook data. At the time theASGBI logbook was used almost exclusively byUK higher trainees in General Surgery and thestudy considered a total of 46000 pairedoperations. The effect of hours restriction wasan overall reduction of 15.5% in recorded

operations. Specifically, the key indexprocedures of inguinal hernia repair andvaricose vein surgery were reduced by 27% and44% respectively.

Further studies have confirmed the deleteriouseffects of reducing hours with the current modelof training, at all levels of seniority. Perhaps themost striking was published by Littlewood et alin 2006 who showed that an SHO employed on atypical full-shift, 1 in 8 rota for a 6 monthattachment, could expect to be present fordaytime duties for only 15 of a possible 26weeks, and this is before taking into account theimpact of Consultant leave.

Even highly motivated units who have strived tomaximise training exposure have facedproblems. In 2005, Marron et al published theresults of the implementation of carefullydesigned modular SHO rota which maximisedexposure to in-patient surgery, outpatient dutiesand day surgery / endoscopy lists. Despitehaving a rota designed expressly for themaximisation of training, outpatient experienceand operative / endoscopy exposure were bothsignificantly reduced due to the restriction ofworking hours.

In the “craft based specialities” there are a finitenumber of elective operative cases per week,which should provide a unique opportunity forthe acquisition of training cases. However, asmentioned above, the move to shift-based rotashas seen the number of hours spent providing“out of hours cover” increase, as a proportion oftotal hours, and it is no longer acceptable thatthese hours be “lost training opportunities” as,with the current challenges, literally everyoperation will count.

In addition to the reduced time available fortraining, moves are afoot which willsubstantially alter the way in which surgicalservices are delivered. The shift of somestraightforward elective procedures (the idealtraining cases) to the independent sector, movesto provide “care closer to home” with increasesin primary care surgery and the use of non-medically qualified practitioners, all have thepotential to reduce the finite number of trainingcases available.

Attempts to improve the efficiency of the NHSand to “trim wastage” may result in somesignificant changes in the arrangements for thedelivery of care. Increasingly, elective andemergency services are being separated andLord Darzi clearly has a wish to further divideinstitutions into elective centres and acutehospitals with the role of the independent sectorin the care of NHS patients likely to increasebased on the ability to provide a “good deal” toboth patients and commissioners alike.

Surgical staffing for the various evolvingsecondary care locations may be very differentand the training opportunities afforded by eachwill similarly vary. When considering how bestto develop the delivery of training in this newarena for service delivery, one of the mostimportant hurdles to overcome is the eliminationof the current “slack” in the training system.

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That is, “wasted” training hours cannot betolerated and we need to think about how best tocondense the available training opportunities intothe time that trainees will have available. Thismeans that the delivery of training will need tobecome more efficient in order to produce highquality surgeons within the new time frames andworking patterns. Appropriate placement oftrainees best able to exploit the trainingopportunities at each facility will be paramountand some form of a modular system would seemto be desirable.

Davey et al in 2005, have shown that, despitereductions in working hours, doctors would stillspend more time training in training than bothNASA Astronauts and long-haul airline pilots(Figure 1). The obvious difference being that thetraining of both these groups is far morestructured and focussed without time lost toservice provision. Clearly Surgeons of the futureare being prepared to deliver a service andstriking the right balance in their preparation forthis is therefore essential.

Figure 1

Previous systems have attempted to reconcile therequirements of trainees at various levels withthe opportunities available at individual units, ata fairly crude level. In some circumstances it isrelatively easy to match more senior traineeswith specific specialist interests, to unitsproviding appropriate tertiary services, but itbecomes much more difficult at a more basiclevel to achieve parity of experiences for alltrainees and specifically to assess and meet thedemands of the trainee who is struggling withthe acquisition of key skills. An important steptowards the creation of a modular trainingsystem in General Surgery has been thedevelopment of the Intercollegiate SurgicalCurriculum Project (ISCP), which has set out thekey skills and procedures required at each levelof training for the individual sub-specialities.Movement towards a modular system canprogress on several levels from the introductionof fairly minor local changes to large scaleNational shifts which would require substantial

changes in workforce planning and serviceprovision.

At the most basic of levels a modulararrangement could be applied locally, whereseveral trainees have been allocated to a givenunit. Within the conventional system of a traineeworking with a single trainer, there is inevitablysome “wastage” of training opportunities eitherbecause the trainee has not reached the levelrequired to perform all, or even part, of theprocedure or that the trainee has advancedbeyond that level. It is highly likely that, withinany given unit, there will be trainees who wouldbenefit from every case operated and a moreflexible approach in the allocation of caseswould be of benefit to all.

Currently, in the majority of units, exposure toemergency surgery remains the least efficientaspect of surgical training as the number ofadmissions and operations performed out ofhours is reduced when compared to daytimeactivities. With the move to full shiftsnecessitated by working time restrictions, theproblem is compounded by a greater overallproportion of a trainee’s time being spent in theout of hours setting.

If emergency services were indeed regionalised(and the number of acute units reduced) then thenumber of admissions to the new emergencyunits would obviously increase. In such acontext, a modular approach with a formalseparation of elective and emergency exposuremay become increasingly more appropriate.(Figure 2)

Modules of emergency surgery could beprovided within a two-tier on-call system withFoundation (F) year 2 and ST 1&2 doctorsproviding a 1st on-call service, supported by a2nd tier of ST 3 – 5 “higher” trainees. Eachtraining year could be split so that a third of thetrainee’s time is spent on the high-intensityemergency surgery service and the remainder inelective blocks, concentrating on the acquisitionof appropriate technical skills, knowledge andattitudes. During the elective blocks, the juniortier of trainees may be required to remain on ashift-type rota to provide medical cover for theelective inpatient populations, but beyond ST3,the elective on-call would be of the low-intensitynon-resident variety, which would minimise thedisruption to daytime elective work patterns.

Figure 2

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There should be some recognition that moresenior trainees would benefit from betterpreparation for the challenges that will be facedin being on-call in independent Consultantpractice, and both ST 6 & 7 trainees and existingConsultants alike would benefit from thesesenior trainees taking a more independent role inspecialist out of hours cover, with appropriatesupervision. The final year of the trainingscheme should be very much focussed on theindividual trainee’s final specialty interest and, ifthe ST8 year is planned carefully, there shouldbe very little requirement for any further post-CCT fellowship scheme, with the possibleexception of a very few and highly specialistniche skills that would only be necessary for anabsolute minority of new Consultants.

Suitably managed and implemented, suchreforms will represent an opportunity to increaseresources for training, as trainees need not belimited to NHS secondary care establishmentsand may be able to take advantage ofopportunities arising in these new settings. Suchchanges come at a price – the relationshipbetween trainer and trainee may be lost and asyet, the quality of training within these settingsis yet to be established. Careful appraisal oftrainers would therefore become essential.

It has long been the case that trainingopportunities vary, both between units, but alsobetween individual trainers. Some Consultantsare outstanding clinicians and operators, but justnot great educators. In the future, it is quitepossible that a number of surgeons may not havetrained within the NHS and may have no

experience of UK training. It is clear, therefore,that some form of accreditation for surgicaltrainers will be required, along with properincentivisation of both individuals and units toensure high standards. With such accreditationshould go the recognition that good trainingrequires adequate resources, both in terms oftime and facilities.

In conclusion, the apprenticeship model ofsurgical training is no longer workable, and willbecome even less so with future developments inthe medical workforce. A move to a differentmodel of training in the craft specialities isrequired and a modular system would seem to sitwell with current developments.

Reduction in available hours, the MMCprogramme, reconfiguration of surgical servicesand changes in the quality and quantity of trainershave all placed unique and individual demands onthe way in which surgical training can, andshould, be delivered. High quality training for thefuture will rely on far more than just contact withtrainers and requires formal processes to beadopted at the outset. Accreditation of trainers,especially outside of the NHS secondary caresetting, is essential and changes in the wayindividual providers are remunerated for theprovision of training, along with the developmentof training quotas will be essential.

The current changes in medical education offer aunique opportunity for improvement. However,stringent independent audit and appropriatefinancing and resourcing are essential for thepromotion of excellence in training.

Violence, The Surgeon and The Modern WorldA one day conference exploring the experiences and roles

of surgeons in war, civil disturbances and criminal violence

Friday 31st October 2008 at The Royal Society of MedicineAll surgical sub-specialties involve the management of trauma. Surgeons meet trauma in

many guises, mostly as accidents involving vehicles or falls. They also meet the trauma ofviolence. Surgeons, perhaps more than any other profession, or group of doctors, deal with

the immediate physical effects of violence and then witness its ongoing, long-term effects onthe well-being and function of its victims. Trauma is an important part of both surgical

training and surgical practice, and as surgeons we are involved in the initial triage,assessment, resuscitation, repair and then rehabilitation of injuries from violence. This

meeting is about whether surgeons have a further role in dealing with violence, namely thatof helping to prevent the traumas of violence from occurring in the first place.

For further details please contact Miss Bhavnita Borkhatria on:[email protected]

Joint meeting of the Association of Surgeons ofGreat Britain and Ireland’s

Overseas Surgical Fellowship Groupand the Royal Society of Medicine’sCatastrophes and Conflicts Forum

CONFIDENTIALREPORTINGSYSTEMINSURGERY

Mr Adam Lewis demitted office as Programme Director for CORESS at the end of May 2008.Adam has overseen the instigation and development of the CORESS process and has beeninstrumental in increasing awareness of CORESS and in the preparation and distribution ofFeedback reports. The Board of Directors and the Advisory Committee would like to recordtheir gratitude to Adam for all his hard work during the last three years and to wish himwell in his other endeavours.

Mr Frank Smith, Consultant Surgeon at Bristol Royal Infirmary, has been appointed asCORESS Programme Director with effect from 1st June 2008.

This edition of CORESS Feedback includes two cases which vividly illustrate the extent ofConsultants’ responsibility for effective administration of their practice, both within theNHS and in independent practice. As ever, we are most grateful to the surgeons who allowedus to publish these reports for the benefit of their colleagues. The value of CORESS to us allis dependent on the surgeons who are prepared to support the programme by sending such

AN OPEN MOUTH (Ref: 51)

ALL MY FAULT (Ref: 52)

When my long-standing secretary retiredshe was replaced by a locum who was,perhaps, under some pressure as she wasin the process of moving house. Like manyof us, I am very dependent on mysecretary to work without a great deal ofsupervision. When a permanent appointmentwas made, it was then found that reportshad not been filed and even signed lettershad not been posted. Although a review ofall relevant notes showed that no harm hadoccurred to patients and, in particular, allpositive reports had been acted upon, I wasrequired to attend an inquiry where mymanagement skills were criticised.

Reporter’s Comments:

It seems that Consultants are responsiblefor the work of secretaries even thoughthey have no direct control over them. If

there is a mistake then the consultant maybe disciplined by local management andthis can affect his / her career.

CORESS Comments:

The Consultant is responsible for ensuringthat adequate administrative processes arein place so that continuity of care is notjeopardised by failure to review results,arrange follow up, communicate with GPs,refer to another specialist, etc. Efficientadministration is an integral part of goodclinical care as this case demonstrates. Evenif there was a different line managementstructure for secretarial staff, it remainsthe Consultant's responsibility to take actionif patient care is threatened by inadequateor ineffective support. Cases like this canlead to all sorts of legal consequencesincluding clinical negligence claims, internal

As part of a “waiting list initiative”, Irecently removed a small facial lesion froman NHS patient in a private clinic. Thepatient, who was well known locally, hadvery poor oral hygiene. At the end of the daythe nurse, employed by me, went to a nearbycoffee bar and discussed this in considerableand uncomplimentary detail with herboyfriend. Unfortunately, a close friend ofthe patient was sitting nearby and overheardthe discussion, realised who the two weretalking about and reported the conversationback to the patient. I became aware of thesituation when I received a letter from thepatient's solicitor saying that legal actionwas to be commenced against me on the basisthat I was responsible for the actions of mystaff.

Reporter’s Comments:

Although I fully accept that the behaviourdescribed is indefensible, I was under the

impression that the NHS bore someresponsibility for legal action arising out oftreatment of NHS patients. I now learn that asan independent contractor I am responsiblefor the actions of my staff, even when theyare not on hospital or practice premises. It isessential that staff members are properlywarned about the need for confidentiality.

CORESS Comments:

The Consultant is vicariously liable for hisemployee. He should have ensured that sheunderstood the duty of confidentiality, butas the employer he was always going to beanswerable for her acts or omissions evenif he had provided her with a comprehensiveinduction course. In some ways he mightthink himself lucky as a complaint mighteasily have gone to the GMC who would havetaken a very dim view. If this had been aclinical negligence case, due to some erroron the nurse's part, the NHS patient may

URGENT INACTION (Ref: 53)

A technically difficult restorativeproctectomy on a very obese patient tooknearly 5 hours. Before leaving theatre Imassaged the patient’s calves which feltrather indurated although a good dorsalispulse was palpable. After the post-theatreward round I returned to the recovery areato review the patient and examined the calvesagain, finding them more obviously induratedbut not swollen. I thought the most probableexplanation was a compartment syndrome andspoke to the locum orthopaedic consultantwho was on duty and who agreed to check thediagnosis with a pressure transducer. I askedhim to do a fasciotomy if he agreed. When Igot home I telephoned the hospital and wastold that as there were good foot pulses itwas not necessary to intervene. Iimmediately returned to the hospital, and dida bilateral fasciotomy. The calf muscles werevery oedematous and immediately bulged outof the wounds. Later the plastic surgeonsneeded to graft the wounds and it was manymonths before the patient was walkingproperly. Fortunately she accepted myexplanation and apology for the delay and didnot take things further.

Reporter’s Comments:

The presence or absence of distal pulses isirrelevant to the diagnosis of compartmentsyndrome. Operation is needed urgently onclinical grounds and the decision should notbe delegated to a junior colleague.

CORESS Comments:

Although reliable data is lacking, theAdvisory Committee think that thiscomplication is becoming more common,presumably associated with increasingobesity in the general population. Colorectalsurgeons, in particular, might be welladvised to review the literature oncompartment syndrome after proceduressuch as this. Preventative measures suchas avoidance of stirrups and lowering thelegs below the horizontal during the courseof a prolonged operation may be useful.Certainly the legs should be checked and thepresence of palpable pulses does not excludethe diagnosis. Although it would now beunreasonable to expect a colorectal surgeonto do a fasciotomy, the Committee suggeststhat it is unwise to leave the hospital, in

PILLAR TO POST

An elderly patient of mine, with a pasthistory of carcinoma of the colon, wasadmitted with abdominal pain by the on-callsurgical team. A CT and colonoscopy onemonth before had been clear. Two days afteradmission he was referred back to me. When Isaw him he was grossly dehydrated but notseptic. His abdomen was moderately distendedbut non-tender. Instructions were given forappropriate resuscitation, prior to surgery,which was to be undertaken by the duty teamwhen the patient was adequately prepared.These instructions were passed on to the nightteam. Over the weekend, the patient was seenby a speciality registrar who was on dutyuntil midday on Saturday and Sunday; the daysurgical registrar and finally the nightsurgical registrar. Each noted that thepatient's condition was not improving despiteapparently adequate fluid resuscitation.However, none seemed to appreciate thesignificance of this, nor did they inform theresponsible consultant. On Monday morning, Ifound the patient septic with a peritonitic,rigid abdomen. At operation I found aperforated sigmoid diverticulum but thepatient arrested on the table and could not berevived.

Reporter’s Comments:

There was a failure of timely resuscitationand referral back to my team after acuteadmission and lack of effective communicationbetween on call registrars who did notappreciate the severity of the patient'sillness. The duty Consultant did not appreciatethe inexperience of the junior surgical staff oncall. The clinical abilities of junior surgicalstaff should not be relied upon unless one isfamiliar with their clinical skills. TheConsultant has to adopt a more hands-onapproach which may mean more work but isthe only way to avoid future disasters.Lastly, the rota system being used at ourinstitution is unsatisfactory and lends itself tothese sorts of situations as there is nocontinuity of care.

CORESS Comments:

The Advisory Committee make no apology forpublishing yet another example of thepotentially disastrous consequences ofdysfunctional organisation and the failure of aConsultant to appreciate the current need forclose supervision of trainees. The Committeeare grateful to the Reporter for sending thiscase and can add little to the comments made.Personal handover of seriously ill patients toa Consultant colleague, in writing, is alwayswise before a Consultant goes off duty. Such

(Ref: 54)

FINALLY...MRHA has received reports of tracheostomytubes falling out due to failure of the securingtabs on the tracheostomy tube holder. Thesecuring tabs had been excessively trimmed bythe user, resulting in the stitching falling apart.Care must be taken when trimming any excessmaterial from the securing tabs of the tubeholder.

Reprinted from “One Liners” (Issue 55, January2008) with the kind permission of the Medical

and Healthcare Products Regulatory Agency.

As Feedback goes to press, MRHA has alsoinformed us that it has received a substantialnumber of reports concerning failure of surgicalstaples, leading to serious sequelae such asperitonitis, bleeding and acute respiratory failure(when used in the chest). The automatic reactionwhen staples do not work correctly is to throwthe faulty cartridge away. MHRA would like toencourage surgeons to report such instances and

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SOME INTERESTING FACTS?

‘Stewardesses’ is the longest word typedwith only the left hand...

...and ‘lollipop’ is the longest word typedwith your right hand.

No word in the English language rhymeswith month, orange, silver, or purple.

‘Dreamt’ is the only English word that endsin the letters ‘mt’.

Our eyes are always the same size frombirth, but our nose and ears never stopgrowing.

The sentence: “The quick brown fox jumpsover the lazy dog” uses every letter of thealphabet.

The words ‘racecar’, ‘kayak’ and ‘level’ arethe same whether they are read left to rightor right to left (palindromes).

There are only four words in the Englishlanguage which end in ‘dous’: tremendous,horrendous, stupendous, and hazardous.

There are two words in the Englishlanguage that have all five vowels in order:‘abstemious’ and ‘facetious’.

TYPEWRITER is the longest word thatcan be made using the letters only on onerow of the keyboard.

A cat has 32 muscles in each ear.

A goldfish has a memory span of threeseconds.

A “jiffy” is an actual unit of time for1/100th of a second.

A shark is the only fish that can blink withboth eyes.

A snail can sleep for three years.

Almonds are a member of the peachfamily.

An ostrich’s eye is bigger than its brain.

Babies are born without kneecaps. Theydon’t appear until the child reaches 2 to 6years of age.

February 1865 is the only month inrecorded history not to have a full moon.

In the last 4,000 years, no new animalshave been domesticated.

If the population of China walked past you,eight abreast, the line would never endbecause of the rate of reproduction.

Leonardo Da Vinci invented the scissors.

Peanuts are one of the ingredients ofdynamite.

Rubber bands last longer when refrigerated.

The average person’s left hand does 56% ofthe typing.

The cruise liner QEII moves only sixinches for each gallon of diesel that itburns.

The microwave was invented after aresearcher walked by a radar tube and achocolate bar melted in his pocket.

The winter of 1932 was so cold thatNiagara Falls froze completely solid.

There are more chickens than people inthe world.

Women blink nearly twice as much asmen.