SURGICAL SCOPETHE MAGAZINE FOR RCSI FELLOWS AND MEMBERS 12/2015 // EDITION/7

LOOKING AT THE FUTURE OF SURGICAL TRAINING?

MEMBERS AND FELLOWS

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3CONTENTS

4 THE PRESIDENT WRITES An update from Mr Declan J. Magee.

6 MEDICAL COUNCIL CHIEF SEEKS TO INTRODUCE FLEXIBLE FITNESS TO PRACTICE PROCESSES

Mr Bill Prasifka outlines his vision for the Medical Council and priorities for the year ahead.

8-13 MILLIN MEETING REPORT8 Transforming data into actionable information This year’s Millin Meeting, which had as its theme

“Dimensions of Change in Surgical Practice” began with a session on “Outcomes Reporting and Data-Driven Surgery.”

10 Facing up to bullying Session 2 of the Millin Meeting explored the dynamics of

training a new generation of surgeons in a high pressure environment.

12 The struggle for quality service delivery Session 3 of the Millin Meeting looked at new models for

service delivery and workforce planning.

14 LIVER TRANSPLANT PIONEER An interview with RCSI Honorary Fellowship recipient, Professor

James Garden.

16 REALITY’S NOT WHAT IT USED TO BE RCSI Virtual Reality breakthrough in surgical training.

18-21 EUROPEAN SOCIETY OF COLOPROCTOLOGY ANNUAL MEETING REPORT

18 Professor Ronan O’Connell provides an overview of the ESCP’s tenth Annual Meeting.

19 Prem Puri delivered the keynote Abraham Colles Lecture.20 Dr Andrea Coratti on robotic surgery.21 Professor Charles Knowles on SNS for bowel disorders.

22 THE 24TH CARMICHAEL LECTURE Michael O’Leary on a kinder, gentler Ryanair, the future of air

travel…and the HSE.

23 ADVANCES IN EMERGENCY MANAGEMENT OF TRACHEOSTOMY

As part of WAMM 2015, RCSI hosted two half-day tracheostomy workshops.

25 SURGEONS AND DOCTORS ON THE FRONTLINE An interview with one of the authors of Irish Doctors in the First

World War, former RCSI Council member, Joe Duignan.

28 RCSI NEWS The latest College news.

30 INTERNATIONAL EXCHANGE SCHOLARSHIP PROGRAMME

An interview with Dr Ainhoa Costas Chavarri, recipient of the American College of Surgeons and RCSI International Exchange Scholar programme.

The Royal College of Surgeons in Ireland, 123 St. Stephen’s Green, Dublin 2.Tel: + 353 1 402 2100. Email: info@rcsi.ie Web: www.rcsi.ie

Editorial Board: Niamh Walker, Eunan Friel, Louise Loughran, Professor Sean Tierney.

Editor: Niamh Walker.

Contributors:Ainhoa Costas Chavarri, Andrea Coratti, Philip Crowley, Mary Day, John Duddy, Joseph Duignan, James Garden, Colm Henry, Joe Hughes, Simon Jones, Paul Kavanagh, Frank Keane, Charles Knowles, Declan J. Magee, Bill Maher, Rosarii Mannion, Brendan McGrath, Deborah McNamara, Ronan O’Connell, Conor O’Keane, Bill Prasifka, Prem Puri, Donncha Ryan.

Senior Graphic Designer: Johanna Arajuuri.

Photographers: Lafayette, Ray Lohan.

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PUBLISHED BYIFP Media, 31 Deansgrange, Blackrock, Co. Dublin.

FOR IFP MEDIA:

Editor:Bernard Potter.

Contributors:Bernie Commins, Shauna Rahman.

Design:Barry Sheehan.

Production:Ciaran Brougham, Martin Whelan, Niall O’Brien, Michael Ryan.

RCSI can accept no responsibility for the accuracy of contributors’ articles or statements appearing in this magazine and any views or opinions expressed are not necessarily those of the organisation, save where indicated. No responsibility for loss or distress to any person acting or refraining from acting as a result of the material in this publication can be accepted by authors, contributors, editors or publishers. Readers should take specific advice when dealing with specific situations.

Surgical Scope is an official publication of the Royal College of Surgeons in Ireland, edited and published on behalf of RCSI by IFP Media. No part of this publication may be reproduced in any material form without the express written permission of the publishers. Copyright RCSI Surgical Scope 2015.

12/2015 // EDITION/7

MEMBERS AND FELLOWS

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Sign-up to Direct Debit to enjoy a vast array of benefits Payment of your annual subscription by Direct Debit will ensure that you always remain in Good Standing with RCSI – and receive the following great benefits:

› Participation in the RCSI community

› The latest news in Surgery

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› Discounted hire rates and access to College amenities

4

Mr Declan Magee.

THE PRESIDENT WRITES 5

MILLIN MEETING“Dimensions of Change in Surgical Practice” was the theme of this year’s Millin Meeting. As a profession, we have always aspired to optimal performance and best behaviour and have delivered both in the vast majority of cases. However, nowadays, we must both show evidence that this is so and take measures to minimise the occurrence and impact of situations where it is not. The opening session of this year’s meeting, “Outcomes Reporting and Data Driven Surgery’, explored the benefits and the pitfalls in health outcomes reporting, and emphasised the importance of clearly defined frameworks for quality care and careful assessment of the resulting data.The second morning session, “Supporting Doctors in Complex Training and Working Environments”, was a useful catalyst for discussion of an important and highly relevant subject in the context of both the Medical Council’s report, Your Training Counts, and the widely reported controversy in Australia, surrounding bullying and harassment within surgery. The contributions in this session outlined the complex dynamics that need to be managed in the trainer/trainee relationship, the role that good leadership plays in establishing positive environments in which to learn and work, and the need to find new, more effective methods to train new generations of surgeons.The afternoon session looked at “New Models for Service Delivery and Workforce Planning”. The speakers addressed key issues including the development of the Hospital Groups and where they go from here, the struggle to deliver planned surgery within a constrained healthcare system and the difficulties in retaining trainees in the public health service. The vigorous Q&A session that followed underlined the intensity and scale of the challenges faced in these critical areas.

MULTISOURCE FEEDBACK A working group set up by the Medical Council has developed an online MultiSource Feedback (MSF) tool and RCSI have agreed to seek volunteers to pilot the use of this tool in an Irish context. This will not be used to assess either competence or performance but as a tool to inform doctors’ reflection on their own practice. MSF is intended as a formative, practice-based activity which is conducted and owned by the doctor with the support of RCSI. In the first phase, only patient feedback will be used.The purpose of this pilot is to confirm the validity and reliability of the current draft form in the Irish context and measure doctors’ experience of the MSF process. It has been agreed with the Medical Council that participation in the pilot will be recognised for either 10 internal CPD points or as meeting the audit requirement for one year. 

SURGICAL TRAINING PATHWAYImplementation of the new surgical training pathway continues to evolve with the identification by trainers of specific challenges in a number of specialties. We are working as closely as possible with the specialties to find solutions that will enable us to modify the pathway where appropriate, while retaining the objective of making training more attractive and at all times ensuring there is no compromise in the quality of training.In a welcome development in this regard, there appears to be a recognition among the commissioners of health services that steps must be taken to ensure a career in surgery remains attractive.

GLOBAL HEALTH PARTNERSHIPS“Global Health Partnerships: Innovations in Surgery, Education and Research 2016” is the title of an international conference that will take place in RCSI on Thursday, April 21 and Friday, April 22, which will bring together researchers, practitioners and others committed to promoting health and combatting diseases of poverty, with a focus on low and middle income countries. This event will inform and complement RCSI’s ongoing collaboration with the College of Surgeons of East, Central and Southern Africa (COSECSA), a long-term partner of RCSI. The objective of the conference is to facilitate discussion and the exchange of ideas among a range of north-south educational, training and research partnerships. A strong line-up of speakers is already taking shape and topics explored will include but will not be limited to:

surgery in resource-poor settings;

retaining and strengthening the health workforce;

vaccine-preventable diseases;

communicable disease control;

mother and child health;

nutrition and food security;

water and sanitation;

the health effects of climate change; and,

other poverty-related health conditions.

IRISH HEALTHCARE AWARDSRCSI had a very successful evening at the recent 2015 Irish Healthcare Awards with a number of staff, teams and graduates picking up prizes at the ceremony, held in the Shelbourne Hotel, Dublin, on November 5. The Medical Validation Ireland (MVI) team at RCSI was commended for its submission in the ‘Best Use of IT’ category of its Assessment E-Portfolio, which it developed for the Qatar Revalidation Project.

THE PRESIDENT WRITES...AN UPDATE FROM MR DECLAN J. MAGEE.

6

MEDICAL COUNCIL CHIEF SEEKS TO INTRODUCE FLEXIBLE FTP PROCESSESMR BILL PRASIFKA COMMENCED HIS TENURE AS CHIEF EXECUTIVE OF THE MEDICAL COUNCIL IN OCTOBER. JUST OVER A MONTH INTO HIS NEW ROLE, HE SPOKE TO SURGICAL SCOPE ABOUT HIS VISION FOR THE MEDICAL COUNCIL AND HIS PRIORITIES FOR THE YEAR AHEAD.

M r Prasifka sees the remit of the Medical Council as being of critical importance: “The Council’s role is essential in creating an environment which enhances good professional practice among doctors. This work is spearheaded by two main areas

of activity, Council’s Fitness to Practise (FTP) processes and the development of Professional Competence.”“Fitness to Practise is probably the more high profile of both areas, but while it is an essential aspect of the Council’s work, it remains a relatively limited part of what we do. The enhancement of Professional Competence structures and the raising of standards of practice expected from all doctors has the potential to have the broadest, long-term impact on the standard of healthcare delivered to the public.”

FITNESS TO PRACTISELooking at Fitness to Practise issues in particular, Mr Prasifka says the Medical Council’s processes need to be more efficient and more effective: “Our aim is to streamline our processes to make them more flexible, less adversarial and more focused on finding solutions to problems. Sometimes patient complaints can be relatively straightforward – in a recent meeting with a patient, it became clear that all the patient really wanted was some information from the doctor.”More flexible and innovative processes will include approaches such as mediation, Mr Prasifka confirms. However, legislation will be necessary to provide the legal framework that will facilitate the implementation of these new processes: “The current legislation in relation to FTP is prescriptive and imposes formal mechanisms for the resolution of complaints. The experience of the General Medical Council (GMC) in the UK is that more informal approaches have enabled them to deal with a higher percentage of complaints and to manage them more effectively. We have been in discussions with the Department of Health on this and we are hopeful that the required legislation can be passed in the first quarter of 2016 (i.e., before an election).”Streamlining of the FTP processes will ultimately result, Mr Prasifka says, in only the most serious cases going through the full process, i.e., cases which raise concerns that, if proven, merit consideration of more substantial sanctions and clear-cut outcomes, either erasure or suspension.

PROFESSIONAL COMPETENCEDoctor registrations, at the time of the interview, were up 30 per cent on 2014, Mr Prasifka reports. “We are investing in our registration system with a view to increasing its efficiency and we hope to put the system fully online in 2016.”Mr Prasifka also signals a greater focus on the uptake of continuing professional development (CPD) programmes and Professional Competence schemes. “Registered professionals have a responsibility to ensure that they continue to progress their professional development. I have to say that we welcome the competence schemes that have been established by the training bodies as an extremely important contribution to professional development. However, their effectiveness is dependent on the full participation of the relevant professionals. This is an area where there is room for improvement.”Next year will see the publication of an updated version of the Medical Council’s Guide to Professional Conduct and Ethics. The purpose of this guide is to ensure that the medical profession and the public have a clear understanding of the standards of practice expected from doctors. “During each term of the Medical Council, our guidance on good professional practice is reviewed and revised. We want to ensure that the guidance we provide is inclusive, relevant and useful.

Mr Bill Prasifka, Chief Executive of the Medical Council.

7MR BILL PRASIFKA

“A consultation process in 2014 highlighted a number of topics which required in-depth review. Based on this process, a  Draft Guide to Professional Conduct and Ethics was put together and we went out to consultation on this in July of this year by seeking the views of the public, doctors and partner organisations, prior to finalisation. We will be launching the Guide to Professional Conduct and Ethics (8th edition)  early next year.”The first phase of a project that will make content as accessible as possible on the Council website, and in particular, ensure that it is developed to link the Guide to Professional Conduct and Ethics to the real-life scenarios doctors face, will also be implemented.In 2016, the Medical Council aims to deepen its engagement with all stakeholders: “We intend to work closely with our stakeholders, of whom RCSI is an important member, across a range of urgent issues next year. Issues which we intend to address in our clinical site visits

will include matters identified in Your Training Counts - such as intern feedback and bullying. Of course, in our general engagaement with stakeholders, we will also discuss other matters, such as participation of women in the workforce and the effectiveness of professional indemnity schemes.“I am aware that some view the Medical Council as somehow antagonistic to the profession or as not working in its best interests. This is a misunderstanding of our role and our work. Take, for example, the highlighting of training problems in the Your Training Counts survey (see panel). Ultimately, while these issues may be uncomfortable to confront in the short term, dealing with them decisively and effectively will be to the benefit of the profession as well as to the benefit of patients. There should not be a dichotomy of interests between patients and doctors. Working to ensure that training is of a high quality is in the interest of the profession and patients.”

Findings include:

the lowest rated aspect of learning environments by trainees this year was “feedback” on their role;

30 per cent of interns are still disagreeing, to some extent, that their previous medical education prepared them well for the intern year;

induction and orientation were again rated very poorly by trainees with slight dis-improvements in 2015;

bullying persists within the training environment in 2015 with 35 per cent reporting being bullied in post;

50 per cent of trainees reported doctors as being the main source of bullying, while 36 per cent of trainees reported nurses and midwives as being the main source of bullying they’ve experienced;

almost 7-in-10 trainees who experienced bullying in their learning environment did not report their experience to anyone in authority;

of those trainees that reported their experience of bullying to someone in authority, almost 40 per cent felt no action was taken;

nine-in-10 trainees rated the quality of care to patients as “good or better”; and,

trainees also rated “teamwork” and “peer collaboration” significantly more highly than in the previous year.

The report also has some interesting findings on trainee views with regard to learning environments. Trainees who gained their basic medical qualification outside Ireland rated learning environments significantly more highly than graduates of Irish medical schools. Trainees who entered medical school directly from second level education rated their learning environments significantly more highly than graduate entry trainees. Intern trainees rated the quality of learning environments significantly lower than all other trainees.

Mr Prasifka commented:“I am disappointed that the reported experiences of bullying by trainees is no better this year and that many seem to be receiving little or no feedback and have poor experiences of induction. These findings are worrying and need to be addressed as quickly as possible. I am fully aware that the issue of bullying cannot be dealt with overnight and that a cultural shift needs to occur in this instance. However, an improved induction programme or the simple delivery of feedback is something that can in fact be achieved quickly.

“If trainees working in a clinical environment are feeling under prepared it is a patient safety issue and that is why we have decided to do all we can do within our regulatory role. We will be working now with UCD on this new project to undertake research into doctors new to the practice of medicine in Ireland to inform what will become known as the Safe Start programme. We will continue to work with our partner organisations in the health sector to ensure that further actions are implemented and I hope that by this time next year we will begin to see more positive findings coming through.”

LATEST FINDINGS FROM YOUR TRAINING COUNTSThe Medical Council recently published its Your Training Counts 2015 report, reflecting the second year of data the Medical Council has collected from trainee doctors in order to gain a greater insight into their perceptions of the clinical learning environment. The findings are outlined here along with the Medical Council’s responses.

REGISTERED PROFESSIONALS HAVE A RESPONSIBILITY TO ENSURE THAT

THEY CONTINUE TO PROGRESS THEIR PROFESSIONAL DEVELOPMENT

S imon Jones, Research Professor in Population Health, Department of Population Health, NYU Langone Medical Center, opened the first of the morning sessions with a presentation that shared some insights based on the UK’s experience in outcomes reporting.

DATA RICH BUT INFORMATION POOR?He noted that one of the key findings from the Bristol Royal Infirmary Inquiry (2002) was that the NHS was “data rich but information poor.” For example, while there has been extensive collection of mortality data, he noted: “Mortality as a sole performance measurement is about as useful as a chocolate teapot. Mortality rates are useful as a screening tool but should not be used in isolation or as a means of ranking hospitals.” Professor Jones went on to emphasise the importance of providing a meaningful context for outcome reporting. He listed the five key pillars of the NHS outcomes framework (https://indicators.ic.nhs.uk/webview/):

1. Preventing people from dying prematurely;

2. Enhancing quality of life for people with long-term conditions;

3. Helping people to recover from episodes of ill health or following injury;

4. Ensuring that people have a positive experience of care; and,

5. Treating and caring for people in a safe environment and protecting them from avoidable harm.

In relation to individualised consultant outcome data, he suggested that a key question that has to be resolved is whether it is useful or whether it is merely confusing: “In particular, it is important to ensure that published indicators are actually relevant.”He concluded with some specific warnings to those in charge of outcome reporting:

don’t let private companies drive the outcome reporting agenda;

avoid tokenism in putting information into the public domain; and,

listen to your clinicians.

A FRAMEWORK FOR QUALITY CARE“Improving Healthcare and the Role of National Audit” was the title of the second presentation of the session, which was delivered by Dr Philip Crowley, National Director, Quality Improvement Division, HSE. In recent years, Dr Crowley says there has been a primary focus on finance and controlling staff levels, reflecting the national leadership agenda. Crisis response has predominated and clinical voices have been greatly outnumbered. “So where does this leave quality?” he asked. Dr Crowley explained that the HSE has been testing a quality framework which focuses on person-centred care and quality improvement. A range of initiatives are intended to feed into and support this framework. They include proactive leadership for quality improvement, governance for quality and safety, learning and measuring for improvement, staff support to improve care, support for person-centred care and, crucially, the delivery of safe, effective care. According to Dr Crowley: “By the end of Q2, 2016, we will have tested the framework’s effectiveness in enabling both a strategic focus and

TRANSFORMING DATA INTO ACTIONABLE INFORMATION THIS YEAR’S MILLIN MEETING, WHICH HAD AS ITS THEME “DIMENSIONS OF CHANGE IN SURGICAL PRACTICE”, BEGAN WITH A SESSION ON “OUTCOMES REPORTING AND DATA-DRIVEN SURGERY” THAT FOCUSED ON THE CHALLENGES SURROUNDING THE TRANSFORMATION OF HEALTH OUTCOME DATA INTO MEANINGFUL, ACTIONABLE INFORMATION.

8

Millin Session 1 - Professor Simon Jones, Ms Mary Day, Professor Conor O’Keane and Dr Philip Crowley.

9

action on quality at HSE central level, as well as at community health care organisation (CHO) level, hospital group (HG) level and National Ambulance Service (NAS) senior management team level. The framework will also be tested to assess its ability to provide a quality checklist that will enable the systematic consideration of key drivers for improvement when undertaking quality improvement initiatives at CHO, HG and NAS frontline team levels.”Oversight and guidance on testing at CHO and HG teams will be provided by the Improving Quality Committee. A plan for testing will be designed and developed with members of the senior management team within one CHO and one HG. Projects linked to each of the six improvement drivers will be identified and supported by the HSE’s relevant Quality Improvement Division (QID) staff. Dr Crowley identified six QID priorities:

building capacity and capability for improvement;

building clinical and collective leadership;

integrating and supporting national safety programmes;

leading a national person-centred programme;

partnering on key quality programmes; and,

the collection of information and analysis for improvement.

Dr Crowley emphasised the value of the national audits that are now in place and the efforts that have gone into their formation, he also acknowledged the frustration created by the delays in establishing the legislative framework within which the Irish Audit of Surgical Mortality can be undertaken. He did note that Heads of Bill for the relevant legislation had been published the day before the Millin meeting: “But we now have to get the Bill through its various stages.”He added that he had fully taken on board that mortality rates are “a blunt indicator” that can be completely misinterpreted, however, he said, they remain useful in the context of filling in a bigger picture. “Our whole approach to the National Office of Clinical Audit (NOCA) process is intended to be one of support, not one of policing. The aim is to work with the hospitals to analyse the data and help to respond effectively to its implications. Our emphasis is on a lot of engagement, a lot of feedback. This will ensure that, for example, we avoid issuing mortality data that is unadjusted, uncorrected, or inaccurate.”He finished with a case which, in his view, provided a specific example of the benefits of the audit process. A 90-year-old patient presented from home with multiple fractured ribs following a low fall and underlying medical conditions – COPD, diverticulitis, degenerative spinal disease and circulatory disease. He was admitted to ward after 32 hours in the Emergency Department with an injury severity score of 4, and a probability of survival of 96.1%. The patient died six days after admission to ward. The NOCA prompted a review by the Hospital Trauma Clinical Governance Committee and the resulting review highlighted the requirement to make improvements in the early detection of sepsis in the Emergency Department.

FROM BOARDROOM TO BEDSIDEThe morning session concluded with a dual contribution from Mary Day, CEO, Ireland East Hospitals Group, and Professor Conor O’Keane, Clinical Director, Quality and Safety, Mater Misericordiae University Hospital (MMUH), exploring the dynamics of engagement with quality care delivery from board level to the patient’s bedside.Ms Day, herself a member of the MMUH Board of Directors, outlined the implementation by that board of a project aimed at providing its members, individually and collectively, with a comprehensive picture and understanding of the quality of clinical care at the hospital, and a platform to act to hold the hospital accountable on the quality of clinical care delivered. A baseline was established through a review of board minutes and board meeting agendas in the six months prior to the project commencing, as well as interviews with the directors. A plan to implement 10 change ‘packages’ was put in place along with a methodology to measure the changes. The 10 changes included: selection of quality indicators, targeted reading for board members focused on understanding quality of clinical care, shared learning and a commitment to spending 25% of board meeting time focused on quality.Results of the project, Ms Day reported, included a 150% increase in time spent discussing quality of clinical care at board meetings, and monthly analysis by the board of quality of care indicators. Ms Day added: “There was an improvement in the quality of discussion and the number of recommendations made by the board in relation to quality of clinical care.Ms Day concluded her contribution by listing key lessons learned in the process, including:

data must be automated to ensure sustainability of implementation;

outcome measures must be used at board level;

interviews of board members at onset was invaluable in setting the approach for the project;

the indicator selection needs to be reviewed at regular intervals to select the most appropriate indicators that reflect the hospital strategy; and,

the focus must be on patient experiences and clinical practice audits.

Professor O’Keane followed up Ms Day’s presentation with a look at the process of turning clinical data into quality information, specifically in relation to a comparative audit of hospital mortality. He described a standardised mortality ratio (SMR) as an important stimulus for reflection: “It is a useful starting point to reflect on the quality of patient care, to assess mortality and to identify potential areas for improvement. It allows comparison to a ‘national average’ and is relatively easy to administer. And it is endorsed by QID and the Acute Hospital Division of the HSE.”

MILLIN MEETING

AS AN ISOLATED INDICATOR, MORTALITY IS ‘AS USEFUL AS A CHOCOLATE TEAPOT.’

D r Paul Kavanagh, Director of Professional Development and Practice, Medical Council, provided an overview of the trainee experience of bullying in Ireland, based on findings from the Medical Council’s Your Training Counts (YTC) survey.

Explaining why the survey addressed bullying, Dr Kavanagh said: “Consultation feedback (and anecdotal evidence) suggested it could be an issue. Research shows it is an issue for trainees both in their roles as ‘workers’ and as ‘learners’.”

HIDDEN CURRICULUMDescribing bullying as both an “informal and hidden curriculum issue”, Dr Kavanagh said it impacts on the trainee in a variety of ways including poorer wellbeing, stress, and lower work engagement with consequent staff retention implications. It also has an impact on patient care and safety. Citing research (Paice E, Smith D., Bullying of trainee doctors is a patient safety issue, The Clinical Teacher 2009) Dr Kavanagh said: “Bullying culture can lead to patients being bullied and can also result in trainees who are bullied avoiding certain (necessary) care team members/departments and showing reluctance to report patient safety concerns for fear of reprisals.”Highlighting some of the key findings in the YTC survey, Dr Kavanagh noted: “More than half of respondents (56 per cent) had witnessed someone being bullied within the previous year and more than a third of respondents reported being personally bullied.”Comparing the findings of the Irish survey to an equivalent survey by the General Medical Council in the UK indicated that there was four times

more reporting of being personally bullied here than in the UK.Looking at the personal experience of bullying, the YTC survey showed no significant variations in experience by gender or by country of qualification. However, the survey showed that GP and HST trainees were significantly less likely than other trainees to experience bullying in post. Interns were most likely to experience bullying in post (48 per cent) and were most likely to be bullied frequently (29 per cent). Trainees based in smaller hospitals were significantly more likely than others to experience bullying in post. The impact of bullying on trainees is significant, according to the survey. Dr Kavanagh commented: “Data from 2015 re-affirms the statistically significant link (from YTC 2014) between being bullied in training and having a poorer experience of learning environments (e.g. a 35 point difference in D-RECT scores between trainees who were bullied frequently and those who were not bullied). Trainees’ experience of learning environments is strongly associated with learning outcomes, he added. “Data from 2015 also re-affirms the link between being bullied in training and having a lower (self-reported) quality of life. Trainees who were bullied in post were significantly more likely than other trainees to rate their quality of life as ‘less than good’ (51 per cent v. 27 per cent).”Dr Kavanagh also said there was a statistically significant association with trainee retention intentions and experience of bullying. Trainees who were bullied in post, were significantly more likely than other trainees to say they did not intend to practise in Ireland for the foreseeable future: 26% of those bullied in post intended to leave medical practice in Ireland, and, of those who were not bullied, 17% intended to leave.

FACING UP TO BULLYING: THE TRAINEE EXPERIENCE SESSION 2 AT THE MILLIN MEETING, ENTITLED “SUPPORTING DOCTORS IN COMPLEX TRAINING AND WORKING ENVIRONMENTS”, EXPLORED THE DYNAMICS OF TRAINING A NEW GENERATION OF SURGEONS IN A HIGH-PRESSURE ENVIRONMENT WHERE BULLYING, LOW MORALE AND AN UNWELCOMING WORKPLACE ARE SIGNIFICANT FACTORS.

Ms Rosarii Mannion, National Director of HR, HSE; Ms Deborah McNamara, Council Member, RCSI and Consultant General & Colorectal Surgeon, Beaumont Hospital, Dublin; and Dr Paul Kavanagh, Director of Professional Development and Practice, Medical Council.

10

11MILLIN MEETING

Summing up, Dr Kavanagh said that bullying is endemic in medical education and training, and Ireland is no different in this regard. He concluded: “In terms of turning this around, management involvement is very important. Interventions are more likely to be credible and to succeed in the presence of strong leadership commitment. Equally, work environments that focus on people are likely to mitigate bullying and the issues associated with it.”

LEADERSHIP – GETTING IT RIGHTMs Rosarii Mannion, National Director of HR, HSE spoke about leadership at all levels in the context of human resources. Ms Mannion said that she fundamentally believes “if we get it right with our staff, we get it right for our patients.” Research shows that effective team working, effective relationships at work, good performance management and constructive challenges deliver a 33 per cent differential in terms of the patient’s experience, Ms Mannion stated.“The mission we are going to be working towards is to empower staff to perform to the best of their abilities. We can’t deny that staff have had negative experiences. A recent staff engagement survey had a low response but the messages from it still can’t be ignored and they indicated staff are not engaged to the level they should be.”The People Strategy soon to be launched aims to bridge the gap between aspiration and reality and Ms Mannion outlined the framework for it: “The key elements are leadership and culture, employee engagement, workforce optimisation, learning and development, evidence and data, performance and safer, better healthcare.”The objectives that the framework aims to accomplish include:

the delivery of safe, quality care in the right setting;

support for medical staff, including the creation of a culture of learning;

optimisation of resources;

growing the medical workforce; and,

implementing the MacCraith Reports.

TRAINING A NEW GENERATIONMs Deborah McNamara, Council Member, RCSI and Consultant General & Colorectal Surgeon, Beaumont Hospital, Dublin, addressed the meeting about the challenges faced in training a new generation of surgeons. Ms McNamara began by acknowledging that surgery is not an easy career for men or women and that every day surgeons face a range of barriers in the workplace. Ms McNamara said that 266 surgeons are due to retire within the next 10 years, 110 of whom are general surgeons. She continued: “From the HSE perspective, I’m not sure that their most serious issue is a gender problem in surgery as much as a service problem.” Highlighting some key statistics, Ms McNamara said that, at the

moment, 40 per cent of doctors in Ireland are women and just under a third of hospital consultants are women. Quoting statistics sourced from RCSI, Ms McNamara said that an increase in the number of trainees overall, accompanied by relative stability in the numbers of female trainees has seen female participation fall in percentage terms to 38%. In the largest specialty, General Surgery, there has been a slight increase in the absolute numbers of female trainees, with the percentage figure remaining stable at 40 per cent approximately. In the second largest training programme, Trauma and Orthopaedics, the traditionally low level of female participation continues.The new training pathway for surgeons is one of the areas that gives cause for hope, according to Ms McNamara, with intake numbers for 2014 and 2015 (the people who will qualify as surgeons in 2022/2023) suggesting that numbers of females qualifying in surgery should remain fairly stable.Moving on to how people choose careers, Ms McNamara said that role models are extremely important. Visible career paths are vital. Without visible examples of successful female surgeons, female trainees find it difficult to visualise a successful career path and are likely to self-select out of surgery. Furthermore, there is a significant amount of data that indicates evidence of gender-based discrimination on at least three continents in medicine and surgery. “In recent UK research, most trainees, interestingly both male and female, feel that surgery is not a career that is welcoming to women. There is some component of a hidden curriculum that trainees are perceiving.”Is this problem unique to surgery or does it have a societal component? Findings in a recent paper by Seamus McHugh, showed that male schoolchildren thinking about a career in medicine were more likely to choose surgery than their female counterparts, which Ms McHugh commented, does suggest that societal influences do play a part.A UK longitudinal study (Goldacre) of 20,700 doctors, found that 69 per cent of male surgeons and 41 per cent of female surgeons are parents by age 35. This shows that parenthood is another important factor to be taken into account in assessing the pressures that come to bear on surgical careers. So how do we find some ways forward? Ms McNamara pointed to a strategy for diversity that has been put in place in the Mayo Clinic which aims for wide inclusiveness across faiths and sexual orientation and which also carries out assessments to ensure that the strategy is being delivered. “Part-time training opportunities and supports need to be improved and we need to ensure that part-time trainees are getting good training and mentorship. Family and personal life need to be supported. There needs to be a ‘normalisation’ of parenthood and a rethinking of ‘core’ days to allow surgeons to participate in family life. There has to be a recognition that there is no ‘one-size-fits-all’ solution.”

MORE THAN A THIRD OF YTC RESPONDENTS REPORTED BEING PERSONALLY BULLIED.

I n the opening presentation of the afternoon session, Dr Colm Henry, National Clinical Advisor and Group Lead for Acute Hospitals in the HSE, discussed acute hospitals and the unique combination of pressures which they face. Dr Henry began by outlining the cost pressures. Healthcare costs are being driven ever upwards by both supply

forces (such as new medical disciplines and new more expensive therapies) and demand forces (including new infectious diseases and ageing populations).

ACUTE ANXIETIESOver the last five years, emergency admissions have grown for all age groups, especially the oldest. This is not just an Irish phenomenon. In the UK and Australia, they have found that Emergency Department (ED) admission increases are driven in the main by older patients. Also, despite extensive investment in the provision of alternatives, the public continues to prefer to use EDs. So what are the future options for acute hospital models? Dr Henry suggested three directions that acute hospitals can take in the future as envisaged in a UK study, Acute Hospitals and Integrated Care (Naylor, Alderwick and Honeyman). The first option is the notion of a hospital as an island, where a fortress mentality develops in the face of mounting financial and demographic pressures. Option two sees hospitals evolving as part of an integrated care system, working with partners to provide co-ordinated care to patients with the greatest need through vertical and horizontal integration. The final option suggests that hospitals move to a new level where they address the requirements of population health systems, where they would go beyond integrated care for patients and begin to address the wider health needs of populations.Dr Henry finished his presentation with a sobering retrospective look at the consistent failure of attempts to reform the health system in Ireland, beginning with the Hospitals Commission in 1936 which attempted to reduce the number of hospitals nationwide and establish 12 general hospitals around the country. It met with considerable opposition from local politicians, the medical profession and the Church. In 1968, the Fitzgerald Report was published against a background of 169 hospitals providing acute care around the country, including 43 in

Dublin (with two local authorities involved). This report again sought an amalgamation of hospitals but eventually became bogged down in unwieldy compromises and, by 1975, a Hospital Development Plan was still pleading that ‘efforts to reach agreement on this must be finalised with the local interests involved’. It is evident, he concluded, that it has been our political system, not our politicians per se, which has prevented the reconfiguring of our hospitals so we can deliver a more reliable and effective standard of quality care.

HOSPITAL GROUPS – WHY ARE WE WAITING? Mr Bill Maher, now Group CEO with the Bon Secours Health System, and formerly Group CEO for RCSI Hospitals Group, talked about the establishment of the Hospital Groups and the plans in place for their future development. Before he began, he echoed Dr Henry’s closing points by noting that, in Ireland, we have one TD for every 25,000 constituents, which, he says, is why the political system is so involved in hospital planning and development.Mr Maher outlined the main elements of the new Hospital Groups model:

Hospital Groups themselves;

Community Health Organisations (CHOs);

National Clinical Programmes;

National Standards – HIQA;

local accountability/empowerment;

Money follows the patient – activity based funding; and,

evolution to Trusts.

Mr Maher identified some of the external challenges to the model’s implementation. Ageing population is one of the most serious of these issues, he said: “For Hospital Groups to function properly, there is an urgent need for major investment in primary, community and continuing care services. For example, if current admission and discharge patterns continue, RCSI Hospitals Group would need another 312-bed hospital in the Group to care for older persons by 2021. We

THE STRUGGLE FOR QUALITY SERVICE DELIVERY SESSION 3 OF THE MILLIN MEETING LOOKED AT NEW MODELS FOR SERVICE DELIVERY AND WORKFORCE PLANNING.

Professor Frank Keane, Mr Bill Maher, Mr John Duddy and Dr Colm Henry.

12

13MILLIN MEETING

need to change the way we deliver services. Primary, secondary and tertiary care integration is the key to unlock the potential of the Hospital Groups.”As for internal challenges, the building blocks of governance and leadership are being put in place: “The establishment of boards is overdue but imminent. Executive management teams are being established. In terms of integrating groups and CHOs, the University of Limerick Hospitals Group is currently best placed in this regard. There has been progress but overall, it is essential now to accelerate the transition and deliver the legislation that’s required.”Putting Directorate structures in place is another fundamental aspect of establishing the Groups. “Effective implementation here includes defining the role of Clinical Director and ensuring a Clinical Lead presence at hospital level. Directorate structures need to be put in place with sufficient resources to enable them to operate effectively.”Equally important is the establishment of effective partnerships with academic partners, CHOs, private hospitals and industry. “Links with academic partners and industry can drive education and research initiatives, while collaboration with CHOs will enable the Groups to address social care problems in hospital, support earlier discharges and integrate patient pathways. In addition, it will be important to change the current mindset and develop partnership models with private hospitals including looking at opportunities for joint recruitment and joint research.”Summing up, he listed the immediate priorities that need to be addressed:

establishing the boards;

accelerating transition to a new model;

realigning CHOs;

promoting research and education;

developing partnerships;

developing legislation; and,

meeting patient needs by addressing ED challenges, meeting access targets and eliminating diagnostic waits.

UNFORTUNATE REALITIESProfessor Frank Keane, Clinical Lead of the National Clinical Programme for Surgery spoke about the realities of delivering planned surgery within a constrained system. He began by outlining what has already been delivered with the launch of the Model of Care for Elective Surgery in 2010 and the Model of Care for Acute Surgery in 2013. In terms of constraints, he pointed to the inadequate increase in Budget 2016’s allocation to health. Professor Keane added his voice to the comments of previous speakers in identifying the various factors contributing to hospital overload, including an excess influx driven by a range of factors such as increasing patient numbers, increasing patient age and inadequate access to diagnostics and a delayed efflux as a result of factors such as poor, untimely planning and inadequate community care.Professor Keane said the first step must be to recognise and address the unfortunate realities: “We do not have a clear and sustained health strategy. We have too many acute hospitals. Our strategies for the Hospital Groups and their CHO alignments are unclear. We have staff shortages and a range of staff issues, including pay and a lack of reward for good performance. Our IT resources are indifferent and our strategic

planning is prey to the vagaries of politics and the electoral cycle.”Accepting these realities, what is to be done? Professor Keane outlined a number of steps that can be taken to enhance performance, including:

putting in place sound management and clinical governance structures;

developing and implementing clear institutional strategic goals;

instilling a culture of sustainable performance management;

establishing greater oversight of internal professional and operational standards;

applying greater in-patient ward cohorting, rounding and discharge rigour;

moving towards more weekend working; and,

greater HSE drive on integration and process improvement between and within clinical groups.

In conclusion, he stated that surgical programmes have failed in their primary goals to separate acute from elective flow, to provide protected resource for efficient, planned surgical activity and to change the default mode ‘beds full = cancel planned surgery’.“Achieving these will require more than just improved surgical performance. It can only happen if all medical disciplines work better and work together.”

TRAINING AND LEAVINGThe final speaker in the afternoon session was Mr John Duddy, SpR in Neurosurgery and Surgical Lead NCHD, Beaumont Hospital, Dublin, who examined the issue of trainee retention in the public health service. Mr Duddy illustrated the difficulties in retaining staff in Ireland by citing a number of research papers including a recent study indicating that 88 per cent of 1,519 Irish medical students surveyed were either definitely leaving or contemplating leaving the country (Gauda et al., Human Resources for Health 2015). In terms of solutions, he highlighted recommendations from the Brian MacCraith report covering training, working conditions for NCHDs and Consultants, workforce planning, specific plans for public health medicine, general practice and psychiatry. Commenting on protected training time based on the agreement reached between the HSE, IMO and the Forum of Postgraduate Training Bodies, July 2014, Mr Duddy said that this has meant little change for working NCHDs and that there are low levels of awareness of the protected training times among trainees and trainers.As regards working conditions, negotiations on rates of remuneration for new entry Consultants concluded with new payscales being accepted by IMO members in January of this year, with implementation delayed until May 2015. Mr Duddy said that the impact of the new payscales remains to be seen.The personal development/work planning process should include an outline of the resources required to achieve the service and personal objectives set out in the plan. A working group to progress this issue is still to be established.Overall, Mr Duddy said, it is vital to protect training time to improve the NCHD experience and to provide surgeons with resources to do their work.

BEDS FULL = CANCEL PLANNED SURGERY

14

SURGICAL SCOPE: Who were the key influences that inspired you to become a surgeon and, in particular, what led you to specialise in hepatobiliary and pancreatic surgery?

PROFESSOR GARDEN: I was the only member of my family to follow in my father’s footsteps into medicine and when I went to Edinburgh Medical School, I had thought that I would also become an orthopaedic surgeon! I cannot say that I really shone as a medical student, but I was most influenced by my mentor, Professor Sir David Carter, whom I first came into contact with when a student in Sir Patrick Forrest’s academic unit at the Royal Infirmary, Edinburgh. However, during my student years, I witnessed amazing general surgical skills that finally convinced me that abdominal surgery was going to deliver the greater challenge for me. I followed Sir David Carter to Glasgow in 1979 and received excellent clinical training in the west of Scotland. I developed clinical and research interests in the management of portal hypertension and bleeding oesophageal varices but realised that there was a major gap in the management of liver disease. It was this that drove me to pursue a one-year fellowship in hepato-pancreato-biliary (HPB) surgery. The training in HPB surgery was outstanding and I rather stumbled across liver transplantation during my stay in Paris with Professor Henri Bismuth, immediately following RCSI’s very own Oscar Traynor! It seemed entirely appropriate to me at that time, however, that liver transplantation should be part of the HPB surgeon’s armamentarium.

Q.You have spent the last 27 years at the Royal Infirmary of Edinburgh. Could you talk about your affinity with the Infirmary and its importance to you?

A: On returning to Edinburgh in 1988 with Sir David Carter, the vision was to capitalise on my HPB training and draw on the talents in hepatology, already present in Edinburgh, to establish a specialist HPB service and liver transplant programme. I have always had a great interest in medical history and had never really thought that I would have the opportunity to return to the Infirmary where so many key figures in surgery had established their reputation.

It was a great time to practise surgery with major improvements in imaging and diagnosis, advances in cancer therapy and, of course, major transformation in surgical techniques. It is really only looking back on that time that I realise that I was very much part of the introduction of specialist abdominal surgery, laparoscopic surgery and major transplant surgery – surgical advances that hardly seemed possible when I started in medical school.

Q: Could you outline the challenges faced in establishing the Scottish Liver Transplantation Programme and how they were overcome?

A: There were many challenges. The key to our success was the tremendous support that we had across many disciplines. We looked at several models of running a transplant programme, trying to incorporate their strengths while ensuring that their weaknesses were addressed in developing our own service. Investing well in anaesthesia and critical care resources, and securing funding for our own multidisciplinary unit were pivotal.Providing an emergency operating theatre for all surgical colleagues in the Royal Infirmary ensured that the irregular transplant activity would not impact on other surgical services but rather enhance them. I would also single out Professor Paul McMaster and his Birmingham colleagues for the tremendous support and encouragement which they provided. It was an exciting time being part of a team that was tightly focused on delivering good patient outcomes.

Q: You undertook the first successful liver transplant in Scotland. How did that come about and what are your abiding memories of that time?

A: The experience was surreal in many ways. Years of planning had been required to get us to that point but it was wonderful to see how individual members of the team took great pride in delivering a good outcome. We were not allowed a ‘learning curve’ by our paymasters and did not disappoint them! It was immensely satisfying to see that academic leadership could deliver a major advance and improvement in health service care in Scotland.

TRANSPLANT PIONEERAT THE MILLIN MEETING IN NOVEMBER, RCSI AWARDED AN HONORARY FELLOWSHIP TO PROFESSOR JAMES GARDEN, REGIUS PROFESSOR OF CLINICAL SURGERY AND PAST HEAD OF THE SCHOOL OF CLINICAL SCIENCES AND COMMUNITY HEALTH AT THE UNIVERSITY OF EDINBURGH. THE OUTSTANDING ACADEMIC SURGEON AND PIONEER IN LIVER SURGERY SPOKE TO SURGICAL SCOPE ABOUT HIS LIFE AND WORK.

15RCSI HONORARY FELLOWSHIP

Q: Could you share some thoughts on your experiences in your role as Clinical Director leading the reconfiguration of general surgical services in the Lothian University Hospitals NHS trust? What were the key factors in delivering a successful reconfiguration?

A: I was fortunate enough to serve as clinical director of surgical and allied services within NHS Lothian. The provision of an emergency operating theatre when establishing the transplant programme turned out to be the catalyst in the Royal Infirmary to increasing specialisation between upper gastrointestinal (GI) and lower GI surgery. There was no need to push this through. It was consultant-driven and based upon a desire to improve patient outcomes. The surgical staff in the two major hospitals in Edinburgh supported the establishment of a single colorectal service at the Western General Hospital, with the focus for oesophago-gastric and HPB surgery at the Royal Infirmary. This had an immediate impact on the quality of surgical training in acute and elective surgery but, more importantly, ensured that patients in the Lothian area had access to a specialist surgeon in both the acute and elective setting. The change did not stop there and there was considerable political outcry when it became necessary to reorganise emergency surgery care at a third, smaller hospital in West Lothian. This all arose through feedback regarding the quality of surgical training which identified suboptimal quality of surgical care and patient risk. The incorporation of improvements and the reconfiguration of services was consultant-driven and based entirely on improving outcomes for patients.

Q: Your academic surgical unit has an outstandingly productive record and you have published extensively in your own field. With such a heavy workload, how do you maximise academic research productivity?

A: This is all about creating the right environment for those who wish to aspire to a career in academic surgery. First and foremost, the quality and quantity of clinical training has to be assured. Secondly, the research environment has to be right. We are extremely fortunate to have excellent multidisciplinary research institutes that can deliver excellent and relevant research opportunity and supervision within a virtual department of surgery. Involvement of surgery in undergraduate and postgraduate teaching is important in nurturing talent from an early stage. Finally, it is all about recognising the needs of individual members of the team and nurturing their strengths, as well as mitigating and, where possible, eliminating weaknesses.

Q: As a leader of the development of the MSc in Surgical Sciences, a collaborative initiative between your University and the Royal College of Surgeons of Edinburgh, could you provide an overview of its impact over the last six years?

A: The Edinburgh Surgical Sciences Qualification has probably been one of the most fulfilling activities in my surgical career. Uniting the professional and academic development of the surgical trainee within a distance learning masters degree programme clearly identified a real need with record recruitment from its first year. We currently have as many as 500 students in 60 different countries matriculated within our programmes at any one time, testifying to their strengths in delivering relevant education ‘anywhere, anytime, and on any device’. It has also been wonderful to see how we can philanthropically support surgical training in the more remote and disadvantaged parts of the world. Our activity in Malawi complements nicely the work that RCSI has been doing over many years.

Q: You were appointed Surgeon to the Queen in Scotland in 2004, could you outline the nature of that role and its responsibilities?

A: The role is not particularly onerous but requires principally my availability during visits to Edinburgh by Her Majesty or key members of the Royal Family. I can’t reveal too much but I get to attend some nice social events!

Q: What was your reaction to receiving the RCSI Honorary Fellowship?

A: It was a wonderful privilege for me to become an Honorary Fellow of your prestigious and historic College. I have always enjoyed good relationships with College Fellows over the years in my work, through surgical gatherings and other educational activity at home and overseas. I have always been impressed by the professionalism and business acumen of the College and am pleased that I have the opportunity and excuse to visit Dublin more frequently in the future. I can see lots of opportunity for future collaboration, particularly in the College’s outreach activity.

Q: A former rugby player, you have also run two Chicago marathons to raise funds to enable surgeons from underdeveloped countries complete the MSc in Surgical Sciences. When you manage to get a break in your hectic schedule, what’s your favourite way to spend your downtime?

A: My marathon days are probably numbered now but I was pleased to raise a small amount of money to support our overseas trainees within our educational programmes. I still try to maintain a regular exercise schedule but my preference is to swing a golf club rather than just walking. I do enjoy skiing in the winter but the stops for refreshment and lunch have become a little more prolonged now! Our two children are in Denver and Edinburgh so there will be increasing opportunity in the coming years to spend good family time with them.

Professor James Garden with RCSI President, Mr Declan J. Magee.

A s part of the RCSI VR Hospital App, RCSI has developed two modules to date, to be used as part of the surgical training curriculum, with plans to subsequently develop the remaining sections of the app, dealing with major and minor surgical procedures in the future.

IMMERSIVE LEARNING EXPERIENCEThis is the first time that Oculus-powered VR tech has been used to simulate emergency medicine and this form of immersive/experiential learning. According to Mr Ryan: “RCSI is continually looking to enhance the learning experience for students and trainees by providing them with realistic simulations of life and death situations. The RCSI VR Hospital is the next phase of simulation learning and brings ‘gamification’ even further into the learning environment.“Initially, the College will be supplying trainees with Samsung’s Oculus-powered Gear VR headsets. In the short term, the plan is to make 10 headsets available via a library-based system in much the same way as

laparoscopic take-home kits are currently made available to trainees.”Prior to the end of the year, the College will release its first Samsung Gear VR app to the general public which will be made available free on the Gear VR App Store. Mr Ryan believes RCSI will be the first College, medical or non-medical, to release a training app of this kind free to the general public on the Oculus. “The app features a pneumothorax emergency that places students in a Resus room where they take control and make life or death choices for their patient. It creates a stressful and immersive environment that simulates conditions that might be experienced by young doctors when they see trauma patients in real life.”The app immerses users in a multitude of perspectives through an intense journey; from the patient in a traumatic event, the paramedic during patient transfer and as the medical physicians making critical life and death decisions in the emergency department. It replicates real life scenarios difficult to simulate through conventional means. This stressful and immersive environment simulates conditions commonly experienced by junior doctors when they encounter trauma patients in real life.

REALITY’S NOT WHAT IT USED TO BE – RCSI VR BREAKTHROUGH IN SURGICAL TRAININGRCSI HAS LAUNCHED THE RCSI VIRTUAL REALITY (VR) HOSPITAL WHICH INTRODUCES OCULUS VR TECHNOLOGY TO SIMULATION TRAINING FOR SURGICAL TRAINEES, CREATING A UNIQUE EDUCATIONAL VR EXPERIENCE. DONNCHA RYAN, LEARNING TECHNOLOGY MANAGER, RCSI SPOKE TO SURGICAL SCOPE ABOUT THE COLLEGE’S GROUNDBREAKING VR INITIATIVE.

This is the first time that Oculus-powered VR tech has been used to simulate emergency medicine.

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17VIRTUAL REALITY TRAINING

DESIGN TEAMThe core design team that worked on the initial app are: Professor Sean Tierney, Dean of Professional Development & Practice, RCSI; Dr Cuan Harrington, Surgical Research Fellow, RCSI; Jessica Halligan, Learning and Content Developer, Dept of Surgical Affairs, RCSI; and Mr Ryan. This team partnered with Immersive VR Education, a Waterford-based tech company, which specialises in the development of educational applications for VR, to deliver the project. Next up is an in-house RCSI initiative for an expansion to the app which is scheduled to be released exclusively to trainees in March 2016. With the invaluable assistance of surgical specialists who agreed to wear head-mounted 3D cameras to record live procedures, the design team are formulating a section that will create an immersive experience of surgery from the surgeon’s perspective. “This app, which is being rolled out as a pilot, is just the beginning. Ultimately, the aim is to have a complete suite of core surgical procedures, minor and major. The objective is to create a completely immersive experience of being in the operating theatre – once the headset is on, you’re in it.”

THE FUTURE OF TRAINING?According to Mr Ryan, VR has tremendous potential as a learning tool: “The basis of education has essentially remained unchanged for the past several hundred years with students having to read text or view photos or videos. Even new technologies like iPads are still used to display information to students who then have to visualise the learning concept that the teacher is trying to impart. VR allows for total immersion that will make hard-to-visualise concepts easy to understand. VR also allows students to actively take part in real world situations that they would otherwise never get a chance to experience. “This technology has the potential to be an important component of the surgical training programme. One of the huge advantages it offers is accessibility. While, inevitably, there are restrictions in access to physical infrastructure-based training facilities such as simulation labs, ultimately, as this tech develops, any trainee who has a mobile phone will be able to access a VR surgical training experience.”Mr Ryan concludes: “VR is the first disruptive information technology since the smart phone. Learning using VR is closer to ‘remembering’ than learning, making it a game changer and the coming years will most likely see educational institutes at all levels adopting this technology.”

The app immerses users in a multitude of perspectives through an intense journey; from the patient in a traumatic event…

…to the medical physicians making critical life and death decisions in the emergency department.

…to the paramedic

during patient transfer…

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T he Dublin 2015 annual meeting has been acknowledged to be a great success, Professor O’Connell reports. He commented: “Delegates had the opportunity to share knowledge, experiences and skills and by all accounts, were delighted with the location and the friendly, warm environment.”

“The format for this year’s event included the highly rated ‘educational stream’ which was introduced in Barcelona. This year, the stream was developed further. In addition to activities targeted towards technical skills, decision-making and clinical judgement, an additional day for teaching practical technical skills was introduced, with two new pre-congress ‘hands-on’ workshops on laparoscopy and proctology.The workshops were held on Tuesday, September 22: the laparoscopic skills course was held at RCSI and the proctology skills course took place at the Mater Hospital.“Each workshop was attended by over 20 trainees. We’re very grateful for the support of Ethicon, and the assistance of RCSI and the Mater, who, together, made this valuable educational event possible.”

HIGHLIGHTSThe annual meeting was attended by over 1,600 delegates and was the largest meeting the Society has held to date, according to Professor O’Connell.“There were many highlights, including the Abraham Colles Keynote Lecture by Professor Prem Puri and a symposium on palliative care, chaired by Professor Hartwig Korner and Soren Laurberg, which provided many talking points and emphasised the importance of a holistic and patient-centred view with a particular focus on issues related to end of life care. A strong theme emerged from the symposium emphasising that the priority for the patient was not necessarily the duration of life but rather, the quality of life. “On Wednesday evening, a moving and memorable session, began with a presentation from an Irish patient, Christina O’Dwyer, who shared her experience of five stomas, the first of which took place in 1994 when she was nine years old. Her compelling presentation emphasised

ESCP’S TENTH ANNUAL MEETING IN DUBLIN ATTRACTS LARGEST ATTENDANCE TO DATETHE TENTH EUROPEAN SOCIETY OF COLOPROCTOLOGY (ESCP) ANNUAL MEETING TOOK PLACE AT THE CONVENTION CENTRE, DUBLIN FROM SEPTEMBER 23 TO SEPTEMBER 25. IN THE AFTERMATH OF THE ESCP’S MOST SUCCESSFUL CONFERENCE TO DATE, PROFESSOR RONAN O’CONNELL, PROFESSOR OF SURGERY AND CONSULTANT SURGEON AT ST VINCENT’S UNIVERSITY HOSPITAL, AND A PAST PRESIDENT OF THE ESCP, SPOKE TO SURGICAL SCOPE ABOUT SOME OF THE HIGHLIGHTS FROM THE CONFERENCE SCHEDULE.

Professor Ronan O’Connell.

THE ESCPThe ESCP was formed in 2005 from a merger of the European Association of Coloproctology and European Council of Coloproctology. Its work has three primary strands:

training, standards and accreditation, working closely with the European Union of Medical Specialists (UEMS) Division of Coloproctology;

scientific meetings; and,

member services.

The ESCP also offers a range of Fellowship Programmes:

two six-months fellowships;

four three-month fellowships;

four four-week observerships;

12 pre-congress placements; and

three reciprocal travelling fellowships with international societies ( the American, Japanese and Korean colorectal societies)

The ESCP website, www.escp.eu.com, accommodates new educational content for members such as the implementation of the UEMS European Board of Surgical Qualification (EBSQ) Coloproctology diploma.

the challenges the patient faces and drew a strong response from the delegates attending. Her talk was followed by a presentation from Andrew Butler who discussed intestinal transplantations and their outcomes, and gave specific examples of how patients coped.”

PRIZEWINNERSMilou Martens from Maastricht University Medical Centre, the Netherlands won the BJS Society Prize for the Best of the Six Best Papers with her presentation entitled “Organ-preservation for clinical complete responders after chemoradiation for rectal cancer - does timing of selection matter?” Dr Martens will travel to the American Society of Colon and Rectal Surgeons (ASCRS) meeting in Los Angeles in April 2016 to present her paper there as part of the ESCP/ASCRS reciprocal Travelling Fellow programme.Sebastian Smolarek from Morriston Hospital Swansea, in the UK, was awarded the ESCP prize for Best Lunchtime Poster. His poster was entitled: “Adhesional small bowel obstruction post open and laparoscopic colorectal surgery: a prospective longer-term study”.

19ESCP

H irschsprung’s disease (HD) is a multi-genetic disorder with complex inheritance patterns. Population risk is one in 5,000 but is reported to be increased in families of patients with HD. The ratio of male to female incidence is 4:1 and more than 90%

of those affected produce symptoms in the newborn period.Familial recurrence of HD should be discussed with families of diagnosed patients, Professor Puri stated, and genetic counselling should be offered in these families and in particular for those patients with long segment and total colonic aganglionosis.

KEY FINDINGSKey research findings highlighted by Professor Puri in his presentation include:

several patients with Hirschsprung’s Disease continue to have disturbances of bowel function many years after pull-through operation;

resected proximal margin of ganglionic bowel in Hirschsprung’s Disease displays abnormalities of nitrergic innervation, interstitial cells of Cajal (ICCs) and smooth muscle; and,

conditions that clinically resemble HD, despite the presence of ganglion cells on suction rectal biopsies, can be diagnosed by providing an adequate biopsy and employing a variety of histological techniques.

VARIANT HIRSCHSPRUNG’S DISEASEIntestinal neuronal dysplasia (IND) is a rare, but distinct clinical entity, which can be clearly proven histologically, Professor Puri said. The majority of patients with IND can be successfully managed by conservative treatment or internal sphincter myectomy. Pull-through operation is rarely indicated in the management of IND. Internal anal sphincter achalasia (IASA) is characterised by nitrergic nerve depletion, and can be diagnosed by anorectal manometry. Myectomy appears to be a more effective treatment compared to Botox intrasphinteric injection. In relation to smooth muscle disorders, Professor Puri noted that the outcome is generally fatal. The need for surgical intervention should be weighed carefully and individualised, he said, since most explorations have not been helpful and probably are not necessary.

DEVELOPMENTS IN TREATING HIRSCHSPRUNG’S DISEASEA PRESENTATION BY PREM PURI, NEWMAN CLINICAL RESEARCH PROFESSOR AT THE UCD SCHOOL OF MEDICINE AND MEDICAL SCIENCE, AND PRESIDENT OF THE NATIONAL CHILDREN’S RESEARCH CENTRE AT OUR LADY’S CHILDREN’S HOSPITAL, CRUMLIN, DUBLIN, FOCUSING ON HIRSCHSPRUNG’S DISEASE AND VARIANT, WAS THIS YEAR’S ABRAHAM COLLES KEYNOTE LECTURE, AWARDED BY RCSI, AND WAS DELIVERED AT THE ESCP SCIENTIFIC AND ANNUAL MEETING ON THURSDAY, SEPTEMBER 24.

Professor Prem Puri.

LEADING INNOVATOR IN HD TREATMENTProfessor Prem Puri is currently the President of the World Federation of Associations of Paediatric Surgeons (WOFAPS) Foundation. He is Past President of the WOFAPS, and Past President of the European Paediatric Surgeons Association (EUPSA). He is Editor-in-Chief of Paediatric Surgery International, and also sits on the editorial boards of several other journals. Professor Puri is Honorary Fellow of a number of prestigious medical and scientific societies, including the American Surgical Association (ASA), the American Paediatric Surgical Association and the Japanese Association of Paediatric Surgeons.

ABRAHAM COLLES During his 70 years, Professor Abraham Colles made significant advances in surgery and medicine, published papers on anatomy, orthopaedics and gynaecology, and revolutionised the medical world of the early 19th century. He was elected as President of RCSI in 1802 at the age of only 28 years. In 1804, he was appointed Professor of Anatomy, Physiology and Surgery at the college. Among his most famous writings is his 1814 paper, “On the Fracture of the Carpal Extremity of the Radius”; this injury continues to be known as Colles’ fracture.

20

C linical and scientific interest in robotic surgery has been intensifying in recent years with the number of publications on the topic increasing from less than 200 in 2004 to over 1,400 in 2014. The number of annual worldwide procedures has been on

the increase over the last six years, Dr Coratti noted, going from 200,000 in 2009 to over 500,000 in 2014, according to figures reported in the Intuitive Surgical 2014 Annual Report. While robotics have applications in specialties ranging from urology to ENT, in his address, Dr Coratti focused on colorectal surgery. Dr Coratti recounted a cross-section of research findings from the years 2005 to 2008, which indicated that robotic surgery is feasible and safe, although it was also found to be more time-consuming than laparoscopy. Research suggested that robotic colonic surgery could have several benefits including: dealing with enlarged lymph nodes dissection, enlarged resections for advanced tumours, and synchronous liver surgery.Looking at rectal cancer surgery specifically, Dr Coratti noted that the conventional laparoscopic approach to rectal surgery has several limitations. Research has pointed to specific concerns including the difficult technique, the associated learning curve, the high risk of non R0 resection margins (R0 classified as being where no cancerous cells are seen microscopically); and urinary and sexual dysfunctions. Therefore, great expectations have arisen around the robotic surgical system as an alternative modality in overcoming challenges of laparoscopic surgery and thus enhancing oncologic and functional outcomes.Dr Coratti discussed research (Xiong B, J Gastrointest Surg 2015 [systematic review and meta-analysis]) comparing the two modalities across eight studies, involving 1,229 patients (554 robotic and 675 laparoscopic rectal surgeries). The research found no differences in perioperative outcomes concerning:

operation time;

estimated blood loss;

post-operative morbidity and mortality; and,

time of recovery (bowel function and oral diet) and length of stay.

In addition, robotics was found to be associated with a lower conversion rate. In relation to oncological outcomes, no relevant difference was found to be present in terms of harvested lymph nodes. Robotic resections elicited lower rates of circumferential resection margin (CRM) involvement compared with laparoscopy.

ASSESSING THE BENEFITSOverall, Dr Coratti observed that robotics may improve the technical performance in minimally invasive surgery, especially in complex procedures. In the colorectal specialty, robotics demonstrates better application in rectal resection for cancer, reducing open conversion rate, improving early urogenital functions and preserving perioperative and oncological outcomes. Colonic surgery may be a good training model before approaching more complex procedures such as TME. Furthermore, he added, in selected cases, robotic surgery can have some technical benefits even in colonic surgery. He concluded that as of now, robotics cannot be considered the ‘best thing’ in colorectal surgery, but it may be a great opportunity for colorectal surgeons to approach complex cases, increasing feasibility, indications and the diffusion of minimally invasive surgery.

ROBOTIC SURGERY – HYPE OR THE NEXT BIG THING?IN THE KEYNOTE LECTURE ON THURSDAY, SEPTEMBER 24, AT THE ESCP SCIENTIFIC AND ANNUAL MEETING, ANDREA CORATTI MD, DIRECTOR OF ONCOLOGICAL AND ROBOTIC SURGERY DIVISION, DEPARTMENT OF ONCOLOGY, CAREGGI UNIVERSITY HOSPITAL, FLORENCE, LOOKED AT THE POTENTIAL APPLICATIONS OF ROBOTICS IN COLORECTAL SURGERY.

Dr Andrea Coratti.

PIONEER IN ROBOTIC SURGERYA leading and pioneering surgeon in the field of robotic surgery since its inception, Dr Coratti has participated in the development and standardisation of many novel robotic procedures. He is currently the Director of the Division of Robotic Surgery and Oncology Unit at the Careggi, Coordinator of the International School of Robotic Surgery in Grosseto, and Professor of Surgery at the School of General Surgery of the University of Florence and University of Siena. Dr Coratti has performed more than 5,000 surgical procedures, including 1,200 laparoscopic and 650 robot-assisted. His minimally invasive experience includes major hepato-pancreato-biliary, upper gastrointestinal and colorectal procedures.

21ESCP

S acral nerve stimulation, also termed sacral neuromodulation, typically involves the implantation of a programmable stimulator subcutaneously, which delivers low amplitude electrical stimulation via a lead to the sacral nerve. Professor Knowles described neuromodulation, as

an inherently non-destructive, reversible and adjustable process. In his address, Professor Knowles discussed new outcome data, new SNS techniques and new insights on mechanisms.

NEW OUTCOME DATAIn terms of observational data, Professor Knowles cited a systematic review of the clinical effectiveness of neuromodulation in the treatment of faecal incontinence (FI) (Thin, NN, British Journal of Surgery 2013) which reported median 100% implant retention in the short and medium term and median 79% implant retention in the long term. Long term outcomes for SNS for FI had a success rate of 71% after seven years, according to Altomare et al, British Journal of Surgery 2015. Discussing the collation of randomised data on SNS for FI, Professor Knowles said there is a continued deficiency in well-designed trials.

NEW TECHNIQUESMoving on to procedural optimisation, he referenced Williams, ER and Siegel, SW, International Urogynecology Journal which observes that the advent of the tined lead (leads that deliver electrical pulses produced by a neurostimulator) has revolutionised the technology, allowing for a minimally invasive outpatient procedure to be performed under intravenous sedation. With the addition of fluoroscopy to the bilateral percutaneous nerve evaluation, there has been marked improvement in the placement of temporary leads. The screening evaluation is now a better reflection of possible permanent improvement. Selection of a particular procedure should be tailored to individual patient characteristics. Subsequent implantation of the internal pulse generator (IPG) or explantation of an unsuccessful staged lead is

straightforward outpatient procedure, providing minimal additional risk for the patient. Future refinement of the procedure may involve the introduction of a rechargeable battery, eliminating the need for IPG replacement at the end of the battery life. Ultimately, Professor Knowles commented, small rechargeable IPGs may be more attractive to some patients.

MECHANISM INSIGHTSOutlining new research on a joint mechanism of action for sacral neuromodulation for bladder and bowel dysfunction, Professor Knowles pointed to commonalities between the bladder and rectum including:

both are storage organs with filling and emptying cycles;

sphincters (anal and urethral) are synchronised;

both interact with the pelvic floor; and,

both have broadly similar neural organisation.In conclusion, Professor Knowles said that the ongoing evolution in SNS for bowel disorders must be driven by a better evidence base, optimised procedures and technology, expanded indications and an optimised patient selection.

SNS FOR BOWEL DISORDERSIN THE KEYNOTE LECTURE AT THE ESCP SCIENTIFIC AND ANNUAL MEETING ON WEDNESDAY, SEPTEMBER 23, CHARLES KNOWLES, PROFESSOR OF SURGICAL RESEARCH AT QUEEN MARY UNIVERSITY OF LONDON AND CONSULTANT COLORECTAL SURGEON AT BARTS HEALTH NHS TRUST, DISCUSSED DEVELOPMENTS IN SACRAL NERVE STIMULATION (SNS) FOR BOWEL DISORDERS.

Professor Charles Knowles.

EXPANDING RESEARCH FRONTIERSCharles Knowles is Professor of Surgical Research at Queen Mary University of London and Consultant Colorectal Surgeon at Barts Health NHS Trust. He qualified from the University of Cambridge and undertook general surgical training and a PhD in London before being awarded a HEFCE clinical senior lectureship (2006-2011). Professor Knowles is Director of the NIHR Enteric Healthcare Technology Cooperative, Co-director of the National Centre for Bowel Research and Surgical Innovation and Chair of the Whitechapel Society for Gastroenterology. He is research lead to the sections of Neurogastroenterology (British Society of Gastroenterology) and Pelvic Floor (Association of Coloproctology of Great Britain and Ireland). He has authored over 120 peer reviewed publications. His main clinical interests are the surgical management of benign (degenerative and inflammatory) coloproctological conditions with a focus on the pelvic floor. His research interests include: the evaluation of new technologies for the treatment of chronic GI diseases (especially focusing on neuromodulation) and the development of advanced in-vivo and in-vitro GI diagnostics for treatment stratification.

R yanair Chief Executive Michael O’Leary admitted to a packed O’Flanagan Lecture Theatre at RCSI during the Millin Meeting, that it took him a while to accept that being nice to customers could be a profitable business model!In fact, he said he’d been the last person at Ryanair to

buy into the airline’s new customer-friendly policy. Mr O’Leary said the airline’s new approach had been driven by staff, not by management: “I was focused on driving down costs. Management were the ones telling staff to measure everybody’s bag down to the last millimetre.” The airline’s strict baggage policy, he explained was not intended to make money but was specifically conceived to discourage passengers from checking in bags at all. A policy that worked, he added, noting that the percentage of passengers checking in bags had fallen from 80 to 20 per cent. This transformed the company’s cost base, as it no longer needed to rent the same number of check-in desks or deploy staff to man them.The strategy worked but Mr O’Leary now believes that it went too far. “We overdid it. We had people concocting new rules at boarding gates. We were putting our staff at points of conflict with customers. I didn’t quite get how stressful it could be to board a Ryanair aircraft,” he said.Initially, he was resistant to the new ‘nicer’ Ryanair image but he says he is now fully behind it because the friendlier Ryanair is enhancing the bottom line. The customer friendly strategy, Always Getting Better isn’t just improving the customer experience, he says. Forward bookings and load factors are rising and traffic figures are up to 105 million customers. “Our new customer-friendly strategy is delivering for our customers, our staff and our shareholders.”

LONG-HAUL MARKETHowever, we can’t expect to see Ryanair transatlantic flights anytime soon, Mr O’Leary said. Ryanair’s low cost model isn’t transferrable to the long-haul market, he explained, as the flight times were too long.Mr O’Leary predicted there will be radical rationalisation within the airline industry within the next five years. “The three big legacy carriers in Europe – BA, Lufthansa and Air France are partnered up with three big US majors — and are fighting the three big Gulf carriers, trying to keep them out.”

Eventually, he said, these airlines will consolidate into three global superpowers, each comprising a Gulf, a European and a US carrier.“They will have enormous control and almost limitless funds to acquire better aircraft, provide better services and offer lower prices in the economy cabin on long haul.”This would not damage Ryanair’s dominance of the short-haul market in Europe, he noted, saying the company had ordered an additional 400 aircraft and planned to grow annual passenger numbers from 105 million to 180 million in the next five to six years.

NO MORE MR NASTY?THE 24TH CARMICHAEL LECTURE WAS DELIVERED BY MICHAEL O’LEARY, CHIEF EXECUTIVE, RYANAIR.

A kinder, gentler Michael O’Leary?

22

BLUE-SKY THINKINGMichael O’Leary’s views remain as colourful as ever.

ON THE HSE:“Nothing succeeds in this country, if it is run by politicians. On top of which, the HSE is held back by an ineffective management and bypassed by unions who are effectively running the show.”

ON FREE AIRLINE TICKETS: “My ultimate ambition is to drive the cost of tickets down to zero, with the company funding itself through discretionary sales of snacks, wifi or even in-flight gambling.”

ON RYANAIR’S LONG TERM PROSPECTS:“We will continue to dominate as long as we don’t screw up short haul in Europe. If we can grow from 105 million to about 180 million passengers over the next five or six years that is a far better business plan for the immediate future rather than worrying about long haul.”

T he two half-day workshops took place on November 11 at RCSI. Faculty present comprised international multidisciplinary experts from the UK, Ireland, the US and New Zealand including:

the RCSI National Tracheostomy Course Faculty;

leading international experts in front of neck access (FONA) techniques and training;

the UK National Tracheostomy Safety Project Course (NTSP) Faculty; and

the Global Tracheostomy Collaborative (GTC).

WORKSHOPSThe morning workshop, Train the Tracheostomy Trainers, was aimed at those involved in delivering small or large-scale tracheostomy-related teaching and enabled participants to learn first-hand from multidisciplinary experts who have been teaching tracheostomy care internationally for nearly 10 years. It included practical sessions from educationalists and international experts explaining how to effectively train staff using best practice.The afternoon programme, a Tracheostomy and FONA Masterclass,

was delivered in RCSI’s anatomy labs by international experts in airway access. Human cadaveric practical sessions were supported by emergency simulations, as well as small group teaching sessions on anatomy, physiology and radiology. The Tracheostomy and FONA Masterclass took participants through key steps in the patient journey, including:

where we are with FONA in 2015;

planning a tracheostomy (anaesthetic and surgical considerations);

radiology relevant to tracheostomy;

surgical tracheostomy; and,

emergency airway and tracheostomy management using simulated scenarios.

The workshops were the latest initiative in a wider effort to develop a new vision for the delivery of emergency management of tracheostomy care in Ireland.According to Mr Hughes: “Tracheostomy and laryngectomies are high-risk procedures for patients who, almost inevitably, are suffering from

EMERGENCY MANAGEMENT OF TRACHEOSTOMYAS PART OF WORLD AIRWAY MANAGEMENT MEETING (WAMM) 2015, RCSI HOSTED TWO HALF-DAY TRACHEOSTOMY WORKSHOPS. THE COURSE ORGANISERS, MR JOE HUGHES, CONSULTANT ENT SURGEON AND RCSI NATIONAL TRACHEOSTOMY COURSE LEAD, AND DR BRENDAN MCGRATH, NHS ENGLAND LEAD CLINICIAN FOR TRACHEOSTOMY AND A TREVOR MCGILL VISITING PROFESSOR AT HARVARD UNIVERSITY & BOSTON CHILDREN’S HOSPITAL, SPOKE TO SURGICAL SCOPE, OUTLINING THE CONTENT OF THE WORKSHOPS AND EMPHASISING THE IMPORTANCE OF DEVELOPING A COHESIVE FRAMEWORK FOR THE EMERGENCY MANAGEMENT OF TRACHEOSTOMY PATIENTS.

23RCSI TRACHEOSTOMY MASTERCLASS

Pictured at the RCSI Tracheostomy & Front of Neck Access Master Class and Train the Trainer Programme in RCSI are from left, Dr Brendan McGrath, Consultant in Anaesthesia & ICM, University Hospital of South Manchester and Mr Joe Hughes, Consultant ENT Surgeon, Limerick.

a complex mix of conditions. It is not always immediately evident how they should be managed in emergency situations – should a particular patient be managed by ear nose and throat specialists or by an intensive care team, or by an anaesthetist? Here in Ireland, we’re some years behind the UK in terms of tracheostomy management in an emergency context. Dr McGrath is working with us to help bridge that gap and, in the longer term, the objective is to help establish best practice in the emergency management of tracheostomy patients.”In the meantime, Mr Hughes has been working closely with Dr McGrath to adopt the principles put in place by the National Tracheotomy Safety Project (NTSP) in the UK (see panel above). “The NTSP has already put in place key guidelines that are also applicable here. The guidelines address a range of issues including lack of training, lack of immediately available equipment at bedside and infrastructure deficiencies.”These guidelines were simplified into an algorithm. The algorithm, along with videos demonstrating complicated procedures, is now available on the NTSP website.

RCSI TRACHEOSTOMY COURSEThe first tracheostomy and airway intervention course was held in RCSI in February 2014. and was led by Mr Hughes. According to Mr Hughes: “Guided by Dr McGrath’s input and the NTSP resources, we developed an interactive course in RCSI incorporating lectures, workshops and practical simulations with the aim of educating both regular and occasional carers of tracheostomy patients. “The course objective was defined as the improvement of clinical skills in the assessment and management of patients with challenging and already secured airways. A key component of the course was the bringing together of all the relevant areas of expertise, which is vital in developing an effective tracheostomy management model.”The first day of the course was targeted at primary and secondary resus responders, CNS nursing division, respiratory therapists and speech and language therapists; the second day was primarily for emergency physicians, surgeons, intensivists and critical care specialists. Mr Hughes continued: “Over the two-days the course provided targeted, practical training for all involved in any aspect of the delivery of tracheostomy and artificial airway management in acute hospitals and community settings. The airway intervention component of the course provided clinicians and healthcare specialists with an opportunity to familiarise themselves with current devices and techniques.”

THE WAY AHEADDr McGrath sees the course as an important initial step: “I’ve worked with Mr Hughes on the development of the course so I’m very familiar with all aspects of it. It’s a comprehensive introduction to all the key issues and, importantly, emphasises a multidisciplinary response. It is important that the impressive foundations put in place by Mr Hughes and RCSI are enhanced and built on. “The next phase is to develop familiarity with and knowledge of the key tracheostomy care guidelines across the spectrum of disciplines – medical, nursing, allied health staff from ICU, anaesthesia, head and neck surgery, and emergency medicine. Once that knowledge resource is in place, then more ambitious challenges, such as the establishment of exemplar tracheostomy care centres, can be confidently addressed.”

THE NATIONAL TRACHEOTOMY SAFETY PROJECT (NTSP)Dr Brendan McGrath, Consultant in Anaesthesia & Intensive Care Medicine, University Hospital of South Manchester explains the origins of the NTSP.“Dr Dougal Atkinson, Dr John Moore, Dr Cath Doherty and myself were working as intensive care doctors in Manchester and decided to look at ways to improve the management of patients with tracheostomies. We sought the help of colleagues in critical care, anaesthesia, ENT surgery and maxillofacial surgery, and formed a multi-disciplinary, multi-site working party to develop a suite of guidance resources.

“We have tested and developed our emergency guidance with high fidelity simulators using specific scenarios to ensure that nursing staff, doctors and allied health professionals can follow our algorithms. We have also tried and tested this guidance in a number of different Trusts in the northwest of England and developed the project incorporating multi-site, multi-specialty peer review and feedback. We presented this work to the UK Difficult Airway Society and the UK Intensive Care Society and we are currently engaged with these groups, the National Patient Safety Agency, ENT and MaxFax Royal Colleges and our regional Association of North Western Intensive Care Units and Association of Mersey Intensive Care Units networks to develop a national tracheostomy safety resource.”

The NTSP is part of the Global Tracheostomy Collaborative, with the aim of delivering a quality improvement project to provide better tracheostomy care everywhere. To find out more about the NTSP, go to www.tracheostomy.org.uk

WORLD AIRWAY MANAGEMENT MEETING 2015For the first time in their 20 year histories, the Difficult Airway Society (DAS) and the Society of Airway Management (SAM) combined their annual scientific meetings to produce an eclectic programme of lectures, workshops and social events for the World Airway Management Meeting 2015, which took place over three days from November 12 to November 14.

Six keynote sessions were held, including innovative lectures from Professor Alan Merry (New Zealand) on human supervisory control, Professor Martin Birchall on advanced therapeutics and the future of airway surgery, and Mr Guri Sandhu, who discussed airway reconstruction, past and present.

Workshops focused on a range of key topics including ultrasound, front of neck access, thoracic, paediatric and fibreoptic intubation, supraglottic airway devices and videolaryngoscopy.

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25IRISH DOCTORS IN WW1

T he three authors Kevin Cullen, Patrick Casey and Joseph Duignan brought complementary expertise to the writing of the book. Joe explains: “Pat has studied history, while Kevin had already authored a book about

people from Monaghan or with Monaghan connections who took part in the First World War. Adding in my medical background, it meant we had a useful mix of relevant skills and knowledge.”

RESEARCH BACKGROUNDThe research involved in compiling information for the book took three years and, according to Joe, the authors wrote the book as they were researching. Their primary sources were the Rolls of Honour of Irish Medical Schools. “The Rolls of Honour were our starting point and Pat was particularly adept in using these sources and initiating new paths for our research. From there, we broadened our scope to encompass a wide range of resources, including: the London Gazette, the oldest continuously published newspaper in the UK and one of the official journals of record of the British government; the Book of the Distinguished Service Order; the Book of the Order of the British Empire; and the medal index cards on the Ancestry website.”Other sources that the authors employed included the censuses of Ireland of 1901 and 1911 and the British Medical Journal from 1914 to 1915. They also contacted relatives, where this was possible. As the work continued, the authors built up detailed profiles tracing the war records of individual doctors, progressively filling in more and more detail, such as identifying who was commissioned, and tracking down where individual surgeons, doctors and students had been located. Kevin Cullen organised the drawing of specialist maps which were featured in the book and which clarify the proximity of medical facilities and aid posts to frontline battle positions. Joe notes: “Doctors in many instances served on the frontline as well as along the paths of evacuation from it. Sometimes regimental aid posts were set up as little as fifty yards from the front.”

INCLUSIVENESSThe authors aimed to ensure the book was as comprehensive as possible: “We tried to be as all-inclusive as we could, but, inevitably, there were some gaps and some individuals were omitted. Where doctors had gone to distant outposts of the British dominions, for instance, records often could not be traced. Ultimately, we were able to identify 3,305 individual doctors in the book. At the time of publication, we invited anyone who had additional names or information to get in touch with us and, since then, we have been able to identify 10 additional doctors who served.”From Joe’s own perspective, one of the most striking discoveries he made was the extent of involvement of Irish doctors in the war: “The sheer number of Irish doctors who served surprised me. In all, approximately 25 per cent of the entire medical workforce were Irish-trained doctors. A contributory factor was that many students came from England to study medicine here at the time.”

SURGICAL AND MEDICAL ADVANCESThe brutality and intensity of the war resulted in many significant surgical advances: “Throughout the war, there were major developments in a range of areas including treatment of abdominal injuries, chest injuries, brain injuries and fractures. An example was the Thomas Splint, introduced by the famous Welsh surgeon Hugh Owen Thomas, for the treatment of femur fractures. “Prior to its introduction, the only remedy was to tie an injured soldier’s leg to a rifle and femur fractures had a mortality rate of 80 per cent. The Thomas splint reduced the mortality rate to 15 per cent.”One of the most significant measures taken in World War One was an initiative driven by Trinity graduate Almroth Wright which resulted in mandatory typhoid vaccination for all British troops. “This meant that the incidence of typhoid, which had been a major problem in the Boer War 15 years earlier, was negligible.”The book is available in bookshops and from www.iap.ie priced at €35.

SURGEONS AND DOCTORS ON THE FRONTLINE IN WW1IRISH DOCTORS IN THE FIRST WORLD WAR, AN ACCOUNT OF THE HEROIC WARTIME EXPLOITS OF IRISH SURGEONS, DOCTORS AND STUDENTS, WAS PUBLISHED EARLIER THIS YEAR. ONE OF THE BOOK’S THREE AUTHORS, JOE DUIGNAN, A FORMER RCSI COUNCIL MEMBER AND A RETIRED SURGEON, SPOKE TO SURGICAL SCOPE, EXPLAINING HOW THE BOOK WAS WRITTEN AND SHARING SOME OF ITS COMPELLING CONTENT.

Irish Doctors in World War One by Joseph Duignan, Kevin Cullen and Patrick Casey (Irish Academic Press) was published earlier this year.

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This operating theatre had three operating tables and when busy all were in action the whole time.

The deck of the River Clyde covered with dead bodies. These are members of the Royal Munster and Royal Leinster Fusiliers who were killed at V beach at the tip of Cape Helles in Gallipoli. During this episode in the war, a young RCSI graduate, Dr Peter Burrowes Kelly, treated 750 wounded soldiers on the River Clyde over a 48-hour period even though he was wounded in the leg on the second day. For this outstanding act of valour he was awarded the Distinguished Service Order.

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The tank was used by the British in 1917 and caused great fear among the Germans initially; however, there were too few and they were too slow to have a real military impact.

There were three major battles in Ypres during the war and it was destroyed. After the war it was rebuilt brick by brick to its original condition by German prisoners of war.

Sir Thomas Myles was President of the RCSI from 1900-1902. An ardent nationalist, in 1914 he was gun running into Kilcoole in Wicklow along with Erskine Childers in Howth. In 1916, he arranged with the Viceroy to open a hospital in Dublin Castle; during the Rising he treated both the British Army officers and the rebels in the Richmond hospital where he was medical director. When the Viceroy sent him a message that he was sending detectives to arrest the rebels, they were taken out of the hospital in his chauffeur driven car and brought to Linden Convalescent home.

Sir William de Courcy Wheeler, who was later to become President of the RCSI, gave over his private hospital at 33 Fitzwilliam Street for the treatment of officers who were brought back to Ireland during the war.

IRISH DOCTORS IN WW1

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RCSI NEWSSend your professional news to: fellows@rcsi.ie

200 NEW FELLOWS, MEMBERS AND DIPLOMATES AT DECEMBER CONFERRING CEREMONYMore than 200 healthcare professionals were conferred with postgraduate awards at a conferring ceremony in the College on December 7. In surgery, these awards included Fellowships in Cardiothoracic Surgery; General Surgery; Neurosurgery; Ophthalmology; Oral and Maxillofacial; Otolaryngology; Plastic Surgery; Trauma and Orthopaedic Surgery; Urology; and Fellowships Ad Eundem and Memberships were awarded in ENT and Ophthalmology.

INTERNATIONALLY RENOWNED COLORECTAL SURGEON RECEIVES HONORARY FELLOWSHIPProfessor Neil Mortensen was awarded an Honorary Fellowship of RCSI at the postgraduate conferring ceremony in December. He was Professor of Colorectal Surgery in the University of Oxford Medical School and worked at the Oxford University Hospitals from 1987 until his recent retirement. Following his appointment to Oxford he campaigned for the recognition of colorectal surgery as a specialty in the UK and Ireland. He has an extensive research portfolio, publishing over 300 original papers and 30 book chapters, as well as editing eight books. He is currently Editor in Chief of the journal Colorectal Disease.

Mr Padhraig O’Loughlin, FRCSI (Trauma & Orthopaedic Surgery) and Mr Declan J. Magee, President, RCSI

Ms Rania Mehanna, Mr Talal Al Sindi, Professor Patrick Broe and Ms Ann O’Connor

FRCSI Conferring December 2015

‘IN CONVERSATION WITH...’ BESTSELLING AUTHOR DR SPENCER JOHNSONDr Spencer Johnson, RCSI Alumni and bestselling author of The One Minute Manager and Who Moved My Cheese?, took the stage with Irish broadcasting veteran, Pat Kenny on October 29 in RCSI for the first in a series called ‘In conversation with...’. Sharing his books’ fundamental theme of “simple and obvious ways to reduce stress”, Dr Johnson and Pat Kenny engaged in a lively discussion as they explored strategies for successfully dealing with change and how Dr Johnson turned “from a fascination with illness to a focus on life”.

Mr Declan Magee, President, RCSI and Professor Neil Mortensen, RCSI Honorary Fellowship recipient. at the RCSI Fellows, Members and Diplomates Conferring Ceremony. Mr Pat Kenny and Dr Spencer Johnson

29RCSI NEWS

Pawan Rajpal, Martin Cunningham and Peter Gillen

Vincent Keaveney, Trevor McGill, Frank D’Arcy and Alexander Blayney

Finbar Lennon, Vincent Lynch and Micheal Glynn

Professor John Hyland, Michael O’Leary and Mr Declan J. Magee

Stephen Murphy, Thomas Burke and Mike Flood

RCSI ALUMNI, FELLOWS AND MEMBERS EVENTS IN THE MIDDLE EASTMore than 120 RCSI Alumni, Fellows and Members in Doha, Dubai and Kuwait attended an RCSI guest lecture, ‘Reframing Leadership in Healthcare’ delivered by Professor Ciaran O’Boyle, Director of the RCSI Institute of Leadership in November. The lecture was followed by supper and networking for classmates, friends and colleagues in each country. In Doha, the RCSI Medal was presented by the President, Mr Declan J. Magee, to the family of the late Dr Hassan Al-Naama, RCSI graduate (Medicine, Class of 1987) and Fellow (FRCSI 1991). Dr Yousuf Almaslamani spoke about his friend Dr Hassan Al-Naama, paying tribute to his professionalism, dedication and his desire to make a difference.Commenting on these events, Ms Áine Gibbons, Director, Development & Alumni Relations, RCSI, said: “With over 2,000 Alumni and 1,800 Members and Fellows in the Middle East, the RCSI global network of health professionals is making a very significant impact on the health of the population throughout the region. These events presented an important opportunity for RCSI to reconnect with graduates and surgeons to strengthen their ties both to RCSI and each other.”

MILLIN MEETINGIn November, more than 200 surgeons attended the annual RCSI Millin Meeting to discuss changes within surgical practice in Ireland. The meeting addressed outcomes reporting and data driven surgery; supporting doctors in complex working and training environments; and new models of service delivery and workforce planning.

Ms Sarah Sharif Al Olama (Medicine, Class of 2000), Ms Buthainah Al Shunnar (Medicine, Class of 1991) and Ms Houriya Kazim (Medicine, Class of 1988 and FRCSI 1993).

Prof Cathal Kelly (FRCSI 1990) and Mr Mohamed Hassan (FRCSI 1997).

Mr Isam Al Nasf (FRCSI 2000) and Mr Amer Alfawaz (Medicine, Class of 1980).

Mr Paul Nolan, Mr Fahad Al Kulafi, Mr Yousif Al Maslamani (FRCSI 1993) and Mr Patrick Sheehan (FRCSI 1994).

Mr Mohamed Hassan (FRCSI 1997), Mr Declan J. Magee, Mr Tamam Abou Ali (FRCSI 2002) and Mr Sameh Soliman (FRCSI 2012).

“ I have been living in Rwanda since 2013 where I work for the Human Resources for Health Programme at the Rwanda Military Hospital in Kigali. During that time, I’ve had an opportunity to work with the College of Surgeons of East, Central and Southern Africa (COSECSA), and have become

increasingly aware of RCSI initiatives in the region.” Dr Costas Chavarri has been involved in the move to establish a representative group for female medical students, doctors, surgeons in training and female surgeons in the COSECSA region. “It’s important that women have visible role models and strong female mentorship and the establishment of this group, Women in Surgery Africa (WiSA) is an initiative that aims to develop an environment that will enable female role models and female mentorship to flourish. “The idea had its beginnings at a conference in Bethune Hospital in Toronto in 2013 when I met Dr Faith Muchemwa, a Plastic and Reconstructive Surgery COSECSA resident from Zimbabwe. We

thought it would be a good idea to set up a formal group that would actively seek to develop a strong network of female surgeons in Africa and her idea for WiSA grew out of that (see panel).”As a result of her involvement with COSECSA, Dr Costas Chavarri had become very interested in RCSI and wanted to find out more about the College, in particular its teaching and training activities. “The Exchange Programme has given me a great opportunity to visit the College and see its educational activities up close. I’ve seen so much while I’ve been here and it’s been hugely informative. There are several ideas which I plan to take back to Rwanda and which I hope to adapt and implement.”

HECTIC ITINERARYDr Costas Chavarri had a hectic itinerary on her Exchange Programme visit to RCSI: “Everyone has been more than generous with their time and extremely helpful. I had an opportunity to meet with Mr Eunan Friel, Managing Director of Surgical Affairs; Professor Oscar Traynor, Professor of Surgical Education; Mr Donncha Ryan, RCSI Learning Development Manager; Ms Katherine Browne of the Irish Higher Surgical Training Group and Professor Ruairi Brugha, Head of RCSI Division of Population Health Science. “I also had a chance to talk to Professor Sean Tierney and got some really useful insights about the educational potential of online tools. I’m particularly interested in exploring the possibilities of developing an e-logbook for trainees in Rwanda. This week has given me a much fuller understanding of what RCSI is doing in terms of education. “It’s been exciting to see the new technology that the College is using such as the RCSI Virtual Reality Hospital and it has been inspiring to have the opportunity to get to see the College’s leading educators in action and to talk to them.”Dr Costas Chavarri spent two days in the Surgical Skills Laboratory: “I had the opportunity to observe a Human Factors lecture, led by Ms Dara O’Keeffe, on conflict resolution and bullying which was highly enlightening. I would really like to see a human factors programme developed in Rwanda.“Prior to this visit, I had decided to focus my career on education and this Exchange Programme experience has confirmed that objective for me.”

EXCHANGE PROGRAMME RECIPIENT STUDIES EDUCATIONAL INNOVATIONSDR AINHOA COSTAS CHAVARRI, BOSTON CHILDREN’S HOSPITAL, HARVARD MEDICAL SCHOOL, WAS THE SUCCESSFUL AMERICAN COLLEGE OF SURGEONS (ACS) RECIPIENT OF THE ACS & RCSI INTERNATIONAL EXCHANGE SCHOLAR PROGRAMME FOR 2015. DURING HER EXCHANGE PROGRAMME VISIT TO THE COLLEGE, DR COSTAS CHAVARRI SPOKE TO SURGICAL SCOPE ABOUT HER REASONS FOR APPLYING FOR THE EXCHANGE PROGRAMME AND HER TIME SPENT IN RCSI.

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WOMEN IN SURGERY AFRICAWomen in Surgery Africa (WiSA), was formally launched at the COSECSA AGM on December 2 in Blantyre, Malawi. The RCSI-COSECSA Programme is providing a range of supports for WiSA, including peer review of best practice models and development of guidelines for membership, as well as organisational and financial support for the launch.In addition to increasing the mentorship base, creation of this group is intended to help promote collaborations for teaching and research between the different country chapters. WiSA aims to promote, facilitate and enable women to take up leadership roles and positions in surgery through its innate ability to understand the needs of women in surgery and the difficulties women surgeons and trainees face. It will act as a forum for discussion of pertinent issues specific to, and affecting, its members. These issues will range from the pressures on women as surgeons and surgical trainees, for example, gender-based professional discrimination and the difficulties only faced by women such as pregnancy. This Association will aim to promote professional networking and encourage multi-centre collaborations.Professor Miliard Derbew, COSECSA Vice-President and Gender Focal Person, is the current patron of WiSA.

Dr Ainhoa Costas Chavarri, Boston Children’s Hospital, Harvard Medical School was the successful American College of Surgeons (ACS) recipient of the ACS & RCSI International Exchange Scholar Programme for 2015.

For further information and to view the abstract criteria, please visit www.rcsi.ie/globalhealth2016

SAVE THE DATETHURSDAY 21ST & FRIDAY 22ND APRIL 2016RCSI, Royal College of Surgeons in Ireland, Dublin 2

GLOBAL HEALTH PARTNERSHIPSINNOVATIONS IN SURGERY, EDUCATION & RESEARCH

This international conference will bring together researchers, practitioners and others committed to promoting health and combatting diseases of poverty, with a focus on low and middle income countries. Participants will present or contribute to discussions, and learn lessons coming from a range of north-south educational, training and research partnerships.Participation from southern partners who have collaborated with Irish research institutions or NGOs is particularly welcome.

Abstracts are invited from those who wish to present research findings or lessons from best practice in Global Health. Topics will include but will not be limited to: surgery in resource poor settings, retaining and strengthening the health workforce, vaccine-preventable diseases, communicable disease control, mother and child health, nutrition and food security, water and sanitation, the health effects of climate change and other poverty-related health conditions.

THE CALL FOR ABSTRACTS IS NOW OPEN

Thursday 11th February 2016

Connolly Hospital presents the 26th Annual Videosurgery meeting.

Friday 12th February 2016

Parallel Sessions in:

Plenary Session:

Highlights will include: › The annual Johnson & Johnson Lecture › Presidential Address › 91st Abraham Colles Lecture

Saturday 13th February 2016

The Annual meeting of the Irish Higher Surgical Training Group (IHSTG) including the annual Bosco O’Mahony guest lecture.

CHARTER DAY MEETING11th – 13th February 2016

› Cardiothoracic Surgery › ENT › Neurosurgery › Oral & Maxillofacial

Surgery

› Trauma & Orthopaedic Surgery

› Emergency Medicine › General Surgery › Ophthalmic Surgery

› Plastic & Paediatric Surgery

› Urology

REGISTRATION IS NOW OPENFor further information and to register, please visit www.rcsi.ie/charterday2016

For further information and to view the abstract criteria, please visit www.rcsi.ie/globalhealth2016

SAVE THE DATETHURSDAY 21ST & FRIDAY 22ND APRIL 2016RCSI, Royal College of Surgeons in Ireland, Dublin 2

GLOBAL HEALTH PARTNERSHIPSINNOVATIONS IN SURGERY, EDUCATION & RESEARCH

This international conference will bring together researchers, practitioners and others committed to promoting health and combatting diseases of poverty, with a focus on low and middle income countries. Participants will present or contribute to discussions, and learn lessons coming from a range of north-south educational, training and research partnerships.Participation from southern partners who have collaborated with Irish research institutions or NGOs is particularly welcome.

Abstracts are invited from those who wish to present research findings or lessons from best practice in Global Health. Topics will include but will not be limited to: surgery in resource poor settings, retaining and strengthening the health workforce, vaccine-preventable diseases, communicable disease control, mother and child health, nutrition and food security, water and sanitation, the health effects of climate change and other poverty-related health conditions.

THE CALL FOR ABSTRACTS IS NOW OPEN

Thursday 11th February 2016

Connolly Hospital presents the 26th Annual Videosurgery meeting.

Friday 12th February 2016

Parallel Sessions in:

Plenary Session:

Highlights will include: › The annual Johnson & Johnson Lecture › Presidential Address › 91st Abraham Colles Lecture

Saturday 13th February 2016

The Annual meeting of the Irish Higher Surgical Training Group (IHSTG) including the annual Bosco O’Mahony guest lecture.

CHARTER DAY MEETING11th – 13th February 2016

› Cardiothoracic Surgery › ENT › Neurosurgery › Oral & Maxillofacial

Surgery

› Trauma & Orthopaedic Surgery

› Emergency Medicine › General Surgery › Ophthalmic Surgery

› Plastic & Paediatric Surgery

› Urology

REGISTRATION IS NOW OPENFor further information and to register, please visit www.rcsi.ie/charterday2016

For further information and to view the abstract criteria, please visit www.rcsi.ie/globalhealth2016

SAVE THE DATETHURSDAY 21ST & FRIDAY 22ND APRIL 2016RCSI, Royal College of Surgeons in Ireland, Dublin 2

GLOBAL HEALTH PARTNERSHIPSINNOVATIONS IN SURGERY, EDUCATION & RESEARCH

This international conference will bring together researchers, practitioners and others committed to promoting health and combatting diseases of poverty, with a focus on low and middle income countries. Participants will present or contribute to discussions, and learn lessons coming from a range of north-south educational, training and research partnerships.Participation from southern partners who have collaborated with Irish research institutions or NGOs is particularly welcome.

Abstracts are invited from those who wish to present research findings or lessons from best practice in Global Health. Topics will include but will not be limited to: surgery in resource poor settings, retaining and strengthening the health workforce, vaccine-preventable diseases, communicable disease control, mother and child health, nutrition and food security, water and sanitation, the health effects of climate change and other poverty-related health conditions.

THE CALL FOR ABSTRACTS IS NOW OPEN

Thursday 11th February 2016

Connolly Hospital presents the 26th Annual Videosurgery meeting.

Friday 12th February 2016

Parallel Sessions in:

Plenary Session:

Highlights will include: › The annual Johnson & Johnson Lecture › Presidential Address › 91st Abraham Colles Lecture

Saturday 13th February 2016

The Annual meeting of the Irish Higher Surgical Training Group (IHSTG) including the annual Bosco O’Mahony guest lecture.

CHARTER DAY MEETING11th – 13th February 2016

› Cardiothoracic Surgery › ENT › Neurosurgery › Oral & Maxillofacial

Surgery

› Trauma & Orthopaedic Surgery

› Emergency Medicine › General Surgery › Ophthalmic Surgery

› Plastic & Paediatric Surgery

› Urology

REGISTRATION IS NOW OPENFor further information and to register, please visit www.rcsi.ie/charterday2016

AD

-CRC Press A4 .indd 1 11/12/2015 11:19