How Cardiothoracic Surgery started in Leeds p38

National ACCEA Awards for NHS Consultants p16

Thoracic Forum 2017 - “Multum in Parvo” p24

Cardiothoracic Surgery, One Year On: A Medical Student’s Perspective p30

Issue 02August 2017

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5 From the Editor Vipin Zamvar 7 From the President Graham Cooper

8 The Operating Consultant Surgeon and Post Operative Cardiac Surgical Complications - Do they need to be called? Simon Kendall

10 UK National Survey: Out-of-hours consultant surgeon cover for post-operative cardiac surgical complications Izaneen Mydeen

12 The Nursing and Allied Health Professional Cardiothoracic Forum at the SCTS Annual Meeting Helen Munday

15 The SCTS 81st annual meeting and SCTS Ionescu University Clinton Lloyd

16 National ACCEA Awards for NHS Consultants Richard Page

18 SCTS Nursing and AHP Education Portfolio Helen Munday

20 SAC Report Rajesh Shah

22 Thoracic Audit Update: Where Next? Doug West

23 Thoracic Surgery research collaborative Babu Naidu

24 Thoracic Forum 2017 “Multum in Parvo” Nilanjan Chaudhuri

26 SCTS Education Report - July 2017 Sri Rathinam, Narain Moorjani

28 The National Cardiothoracic Surgery Research Meeting - 28th October 2017 Gavin J Murphy

In this issue...

30 Cardiothoracic Surgery, One Year On: a Medical Student’s Perspective Ann Cheng

31 SCTS 2017 – Student Session Jimmy Toh

34 Sheffield team show steel in organising SCTS careers conference Harvey George

35 Cardiff Robotic Thoracic Surgery Live Masterclass: bringing the robot closer Ana Lopez-Marco

35 Sheffield Basic Undergraduate Surgery Course Michael Gooseman

36 SCTS Ethicon Fellowship 2016/17: Lions, Hobbits and Earthquakes – A Compelling Journey to Middle Earth David J McCormack

37 New Consultant Appointments

38 How Cardiothoracic Surgery started in Leeds Philip Kay

43 Quality David J. O’Regan

44 We’re on the move! The Royal College of Surgeons Rebuild Isabelle Ferner

45 Aortic Dissection Awareness Day – Today is a good day Christina Bannister, Dan Burgess

46 Heart Valve Voice cycle to Paris Helen Munday

48 A new educational tool in Cardiothoracic Surgery: Web-based seminars Alan G. Dawson, Sridhar Rathinam

50 Exploring Robotic Thoracic Surgery: Nottingham visits Alabama Dr Matt Daunt, Mohammad Hawari

52 “Publish and be damned” -Writing, reviewing and publishing; an editorial perspective Anthony Walker

53 Upcoming Courses - Trainees

54 Scripts and Scriptures: Evolving From Personality-Based Practice to Evidence Based Practice Hisham Sherif

56-57 Obituaries

58 Crossword

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August 2017 3

T he SCTS Annual Meeting is the highlight of the UK academic calendar, and it continues to grow

from strength to strength. Clinton Lloyd (page 15) lays out his plans for another academic feast, this time in Glasgow. (March 18 to 20, 2018). There are many things you can learn from this Bulletin, which would not be available elsewhere. Simon Kendall (page 8) recounts the experience of the Middlesbrough unit with the policy of the On-call surgeon doing all the re-explorations (rather than the operating surgeon). I am sure the vast majority of us would dismiss this idea, at first, as not workable. But having read through Simon’s article, to me it all makes sense. (Lateral thinking at its best). I am going to propose to my colleagues if we could start this in Edinburgh. With recent changes in our team, camaraderie could not be better, and perhaps this

may be the time to introduce this policy (experiment) in our unit. Richard Page (page 16) has advice on those considering applying for Merit Awards. What a shame, Scotland continues to not have these. They were stopped a number of

years ago, and the current political climate is such that there is no chance of them coming back anytime soon. Cardiothoracic Surgery continues to be attractive to a small but significant minority of medical students. A number of articles by medical students in this Bulletin discuss their engagement with our speciality. Ann Cheng

(an Edinburgh University Undergraduate student) (page 30) describes her experience with the speciality, and the reasons why she has chosen this as her future career. It is very heartening to read about such enthusiasm from the newer generation.

This Bulletin continues to be very popular, and this time we had to turn down more than a third of the submitted articles. The main reason was that they were felt to be academic articles, and were more suited to an Academic journal. On another note, this will be my last Bulletin as Editor. I would like to thank Sunil Ohri who was the Editor before me, for easing

me into this role. He had done all the hard work, and prepared all the groundwork for the Bulletin in its then format. I joined as Publishing Secretary in 2010, and seven years have gone by so quickly. There have been many changes to the Bulletin in these seven years. We moved from a paper version to an electronic version (due to financial pressures). Then, due to the generous support from Marian Ionescu, we were able to revive the paper version again. Last year we moved to Open Box Media & Communications, who also publish the Bulletin of the Royal College of Surgeons of England. I hope you have enjoyed reading the Bulletin; I have thoroughly enjoyed bringing it together. Now, it is time for a new pair of hands to move it forward. If you are interested in this role, please contact Simon Kendall, or Richard Page, or me (zamvarv@hotmail.com). And last of all, a big Thank you to Isabelle Ferner, who has been responsible for piecing together this Bulletin. I wish you all a very happy and relaxing Summer. n

From the Editor

Vipin Zamvar, Publishing Secretary

Welcome to this latest edition of the Bulletin. As before, office bearers of the Society update you with the various activities of our Society through the pages of this Bulletin.

“This will be my last Bulletin as Editor. I would like to thank Sunil Ohri who was the Editor before me, for easing me into this role.”

Philip Kay (page 38) looks at how Cardiothoracic Surgery started in Leeds

August 2017 5

There was some nervousness about holding the meeting in Belfast this year, a concern that the Irish

Sea may deter attendance. In the event the nervousness was unfounded and, the Irish Sea, if it had had any part to play, acted as a conduit. We had, again, a record attendance. As well as the good weather, the venue was superb, the atmosphere positive and overall it was a very successful meeting. Some patients and relatives from Aortic Dissection Awareness attended and were very complimentary, not only about the standard of the meeting, which I think we all take for granted these days, but also

about how welcome they were made to feel and how so many delegates engaged with them. See page 45 for information about Aortic Awareness Day.

Belfast was Enoch Akowuah’s last meeting as Meeting Secretary and it is a pleasure to be able to acknowledge all the

hard work he and the team put in to make the meeting such a success. At the Annual Meeting Marjan Jahangiri and Andrew Chukwuemeka finished their terms as elected trustees and I am grateful to them for their hard work and contribution over the last 3 years. John Dunning and Stephen Clark join the Executive as the new elected trustees. The election for 2 elected trustees from March 2018 and President-Elect will take place in November.

A year ago I described how the way we present clinical outcomes data on our website does not meet patients’ needs. As a consequence, we commissioned a report from Picker to better

understand what information patients wanted and how they would like it presented. We have now received the report ‘Exploring patients and families’ information needs and views of The Society for Cardiothoracic Surgery website’ and this has been accepted by the Executive. The full report is available for you to read in the resources section of our

website. The key findings are that generally participants in the focus groups could see the benefit of the information presented but that what we might think important is not necessarily that important to patients and they were put off by the information being too technical and overwhelming. Accordingly, we have engaged a charity called Sense About Science to work with us to enable us to present this data in a format that is more relevant and useful to patients. In this Bulletin, Philip Kay has written a piece on the history of cardiothoracic surgery in Leeds. I very much hope that this will stimulate you to write a similar piece on the history of cardiothoracic surgery in the unit that you work in. Please send any contribution, up to 1000 words, with pictures if possible, to Isabelle. We then hope to publish a series of these articles in subsequent Bulletins. I hope that by the time you read this the weather has improved and you have enjoyed or are about to enjoy a well deserved summer break. n

From the President

Graham Cooper

I suppose it is only coincidence but it was raining when I wrote my piece for last summer’s Bulletin and it is raining now. In fact the weather was better back in March at our Annual Meeting.

“Belfast was Enoch Akowuah’s last meeting as Meeting Secretary and it is a pleasure to be able to acknowledge all the hard work he and the team put in to make the meeting such a success.”

August 2017 7

It shows the large majority of surgeons who have done the operation are called for their opinion and action.

Not surprisingly it would appear the operating surgeon is not always available as the units have a policy of then calling the on call surgeon. This latter scenario occurs more frequently on Friday evenings and even more so at the weekends.

In my surgical training it was a ‘given’ that the operating surgeon took responsibility for their patients post operatively. This made a lot of sense as it was this surgeon who would know the intricacies of the complex cases and therefore was best placed to advise and action any problems. This ethos probably stemmed from the

In this issue we share the findings from our survey of all the cardiac surgical units in the UK, showing when the operating surgeon is called for post operative surgical problems, as opposed to the on call surgeon.

Simon Kendall, Honorary Secretary

first and second generation of cardiac surgeons (1960’s onwards) and they would usually have a full team of junior surgical staff in the unit supporting them. Indeed it was the chief resident or senior registrar that would be responsible for the reopening and rarely would the ‘boss’ come in out of hours.

Not only does this commitment give the patient assurance and continuity of care but it also adds to our sense of importance in our role. It makes us ‘vital’ in our patient’s care which gives us increased personal satisfaction.

As a younger surgeon/consultant I certainly supported these views and attitudes.

Our families take it for granted that on the evenings of our operating days we have a commitment to our patients. Social commitments are politely turned down and when the phone rings there is that ‘heart sink’ that its bad news from the ITU. So much so in our house that we had a separate number / ring tone for the hospital to call, so I and the family knew immediately if it was a welcome social call or bad news from the hospital (you never get good news about your patients from the hospital!).

Most of our units are in urban areas and the volume of traffic around them has intensified over the years. Gone are the days when you might justify going through amber lights, breaking speed limits because

The Operating Consultant Surgeon and Post Operative Cardiac Surgical Complications - Do they need to be called?

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‘my patient needs me’: the traffic is just too busy. Nowadays the on call registrar will have varied experience and competencies and will not necessarily be safe to perform a reopening, especially as they may not have a competent assistant.

I suspect we are all very similar - we hate it when our patients are struggling or suffering complications. Part of that is that we take our responsibility very seriously and their struggle may be due to our actions. The extreme example of this is when a post operative patient arrests. First of all you find out who the patient is and whether they are under your care - and when you find out it is indeed your patient your brain rapidly tries to think of the reasons for the arrest and what solutions may be possible. It is a sickening feeling.

In my early consultant years a patient following CABG was bleeding on the unit. I was called from home being told that the patient was unstable, was having cardiac massage and was about to be reopened.

I couldn’t get to the hospital quick enough.

I drove too fast. I pushed my way to the front of the traffic lights. I might have even carefully gone through a red light.

I rushed up to the unit.

The registrar was doing internal cardiac massage and informed me that he had inadvertently ripped the IMA graft off the LAD.

A few weeks later I related this story to my ‘mentor’ Joe McGoldrick, surgeon at Leeds. He stopped me exactly at this point of the story and asked ’So what do you do next?’

I replied - ‘control the bleeding, call the perfusionist, establish bypass’ (this was before off pump surgery was established)

Joe said ‘No, none of that! The first thing you do is pretend its your colleague’s patient’.

I laughed because I knew he was right. When you reopen a colleague’s patient you lose most of the emotion and you become more objective, but you still do an equally professional job.

Thankfully the patient went home well a few days later with all grafts intact, having established bypass on the ICU.

So fast forward to 2012 and we had a divisional away day at the Boro’s ground (they weren’t playing) - the surgeons had a break out meeting and we thought of our future plans:

Out of the blue Steve Hunter suggested that we should consider whether the on-call surgeon should be responsible for all the reopenings.

We hadn’t really considered this before, but we agreed it was certainly worth trying. Fundamentally we trusted each other to look after each others patients and the basic agreement was that the on-call surgeon

should always come in for the reopening and not let the registrar be unsupported. In retrospect this decision was helped in that we had similar practice portfolios and an existing working harmony to build on.

We had some anxieties... would we be less meticulous closing the patients if we thought a colleague would be reopening it?

Would our colleagues let our patients bleed too much before reopening the patient or...

Would our colleagues have too low a threshold for reopening the patients and make our quality markers look worse?

May I add that as a unit at this time we were not performing well on our reopening rate and our anaesthetists and theatre team were unimpressed by the number of call outs.

Five years on and its fair to say that this model of care has been a great success.

First of all, there is even more pressure to make sure the patient is dry at the end of a case as you don’t want your colleague to be disturbed. There is nothing worse to start than the morning text saying that they had to reopen your patient in the night.Secondly, when you go home after an operating day you can truly relax. You know your colleague will do a great job if there are any issues with your patient.Thirdly, and most importantly, this change of culture in association with audit / reflection, has brought a very significant reduction in our reopening rate and also our mortality and length of stay.

Another unexpected consequence was that it brought the team further together. No longer was it ‘my patient’ or ‘my results’ but it was more about the overall performance of the unit and the benefit to our patients.

In this national survey there are three other units that have adopted this practice. As yet we have not explored the reasons why they perform this way nor whether it works for them and their patients.

This model may not suit all units and time will tell if this is a temporary variance from established practice or whether it sets the scene for other units to try. n

“In my surgical training it was a ‘given’ that the operating surgeon took responsibility for their patients post operatively. This made a lot of sense as it was this surgeon who would know the intricacies of the complex cases and therefore was best placed to advise and action any problems.”

August 2017 9

In our unit, James Cook University Hospital, the on-call surgeon rather than the operating surgeon is called first for

any post-operative surgical complications such as tamponade, bleeding and graft failure. We were interested to find out what the current practice is across the different units in the United Kingdom (UK) in terms of out of hours consultant cover for surgical complications. We therefore set out to perform a national survey on all 35 cardiac surgical units in the UK.

SurveyA survey template was created on www.surveymonkey.co.uk and the link was emailed to randomly selected representatives of all the 35 units in the UK.

Six questions were formulated. These were: 1. For the purpose of this survey, can you confirm the unit you work in? (Free text answer)

2. During the weekdays (Monday-Thursday), if a patient requires a consultant surgeon out of hours (1800 to 0800 hours) for post-operative complications (e.g. bleeding, tamponade), who is called in?a. The operating surgeonb. The on-call surgeon

Cardiac surgical units have differing arrangements to cover surgical complications following cardiac surgery. We have performed a survey of all the adult surgical units the UK and we present the results.

UK National Survey: Out-of-hours consultant surgeon cover for post-operative cardiac surgical complications

Izaneen Mydeen, NTN Northern Rotation

c. The operating surgeon is called first, then, if unavailable, the on-call surgeon d. Pre-arranged cover between consultants

3. During Friday evenings, if a patient requires a consultant surgeon out of hours (1800 to 0800 hours) for post-operative complications (e.g. bleeding, tamponade), who is called in?a. The operating surgeonb. The on-call surgeonc. The operating surgeon is called first, then, if unavailable, the on-call surgeon d. Pre-arranged cover between consultants

4. During the weekends (Saturday/Sunday), if a patient requires a consultant

surgeon out of hours (1800 to 0800 hours) for post-operative complications (e.g. bleeding, tamponade), who is called in?a. The operating surgeonb. The on-call surgeonc. The operating surgeon is called first, then, if unavailable, the on-call surgeon d. Pre-arranged cover between consultants

5. Do all the surgeons in your unit adopt the same principles out of hours? a. Yesb. No

6. If the answer to question 5 is ‘No’, give a brief description of the arrangements (Free text answer)

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ResultsQuestion 1: All 35 units responded (100%)

Question 2: During the weekdays (Monday-Thursday), 51.43% said the operating surgeon is called first then the on-call surgeon.

Question 3: During Friday evenings, 54.29% said the operating surgeon is called first then the on-call surgeon.

Question 4: During the weekends (Saturday/Sunday), 42.86% said the operating surgeon is called first then the on-call surgeon.

Question 5: 27 people said Yes, all surgeons in their unit adopt the same principles out of hours. 8 people said No.

Question 6 (Free text answer):

l Some surgeons only want to be contacted if they are on-call

l Some surgeons like to be called over the weekend if there is an issue with one of their patients, even when not on-call

l Most of us provide cover for our own cases Monday-Friday evenings and would inform the on-call registrar if we were unavailable and if the on-call consultant should be called instead. Weekend complications are rarer and usually dealt with by the on-call surgeon, although the operating consultant is usually informed. My senior colleagues would usually leave these issues to the on-call consultant (and would have a much higher threshold for e.g. re-opening for bleeding)

l The operating surgeon is always notified and he will make himself available if possible. However if a real emergency arises, the on-call surgeon is probably rang first as he is expected to be available ASAP. Some colleagues regularly ask to involve the on-call surgeon but they will still be notified this is happening

l Some surgeons are more available that others for their patients but the system covers all eventualities

l Very rarely, the operating surgeon might be going away in the evening, and in that case, he will let the on-call surgeon know about his plans. We are paid 1 PA to cover our patients on the day of the operation. So if I do a case on Monday, I am contractually obliged to cover that patient if he bleeds on Monday night, even if I am not on-call. If he requires reopening on Tuesday evening, and if I am not on-call on Tuesday, I am not contractually obliged to cover the re-exploration. In reality, such cases are rare, and the operating surgeon will usually cover the re-exploration, but if for any reason he is not available, the on-call surgeon will cover it.

Unsurprisingly, during the weekdays, in 18/35 units (51.4%), the operating surgeon is called first to deal with complications. The on-call surgeon is then called if the operating surgeon is unavailable. In 13/35 units, (37.1%) the operating surgeon is called first. Therefore the initial person contacted first will be the operating surgeon in 31/35 units (88.5%). The on-call surgeon is only called first in 4/35 units (11.4%).

These numbers are similar during Friday evenings, where in 19/35 units (54.3%) the operating surgeon is called first, then on-call surgeon if the former was unavailable. In 11/35 units (31.4%), the operating surgeon is called first. However, the on-call surgeon is only called in only 5/35 units (14.3%). This is similar to the weekday figures where the operating surgeon is called first in 30/35 units (85.6%).

This figure drops to 21/35 units (60%) during the weekends - with the on-call surgeon contacted first in only 13/35 units (37.1%). In 1 unit, pre-arranged cover between consultants is usually organised for the weekend.

The response to question 5 is quite interesting as it reveals that 8 out of 35 units (14%) have inter-surgeon variability in adopting similar principles in out of hours cover. Additionally, there is at least 1 unit where the operating surgeon is given an additional PA to cover for out-of-hours post-operative complications on their own operating days. n

a (13) b (4) c (18) d (0)

a (11) b (5) c (19) d (0)

a (6) b (13) c (15) d (1)

a (27) b (8)

August 2017 11

The Nursing and Allied Health Professional Cardiothoracic Forum at the SCTS Annual Meeting The CT Forum took place at the Waterfront Conference Centre in Belfast in March 2017 and ran over a full three days commencing on the Sunday with a nursing and allied health professional stream at the SCTS University.

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T his is the third year that the CT Forum has run a day such as this and it continues to go from strength

to strength, with highly rated feedback. The University day takes a similar, albeit condensed, format to that of the Heartlands Advanced Cardiothoracic Course, and consists of a half day cardiac and half day thoracic to enable participants the flexibility of joining either the full day, or half day, thus allowing the opportunity to join other delegates in parallel university streams. I would like to thank the entire surgical faculty who took time to teach participants, and also the company representatives from Covidien, Maquet, Karl Storz, Cardio Soultions and Kevin Austin at Wetlabs for their support, teaching and participation in Belfast in 2017. We very much look forward to their participation once again in Glasgow next year and I would urge all nurses and AHPs who are planning to attend the annual meeting in 2018, to consider attending this highly practical and enjoyable day. You will not be disappointed!

We continue to see a year on year rise in the number of abstracts submitted for presentation at the Forum which allow us to put together a varied programme suitable for all nurses and allied health professionals caring for cardiothoracic patients. Topics included clinical care, advancing practice, research presentations, and professional issues from a national and international perspective.

We were delighted to welcome eminent and highly regarded plenary speakers - Ms

Cecilia Anim – current RCN President who delivered the opening remarks with a topical Nursing UK perspective, alluding to the potential impact of leaving the European Union and Andrea Spyropoulos, past president of the RCN and Sarah Murray, SCTS Lay Representative who presented on nursing issues related to the law and specifically record keeping. Jo-anne Fowles, Lead ECMO nurse from Papworth Hospital delivered an entertaining and stimulating account of treating a patient requiring ECMO which led to staff from Papworth Hospital being invited to Kensington Palace to meet HRH Prince Harry.

On an international perspective Jill Ley, Nurse Specialist in Cardiac Surgery at the California Pacific Medical Centre, San Francisco, USA & Fellow of the American Association of Nursing participated in the CT Forum. Jill also joined the University session and chaired sessions within the Forum. Richard van Valen, Advanced Nurse Practitioner

from Rotterdam and lead for Nursing & AHP education for EACTS, also attended and taught at the University day. Both their perspectives of nursing from an international level were incredibly valuable to participants and prompted interesting discussion.

In addition to the CT Forum programme, there is also a full programme targeted more towards our medical colleagues but frequently includes sessions from which nurses and AHPs benefit. I could name several from this year, but one session that really stood out for me was that in relation to consent. The law around consent changed significantly after the Montgomery v Lanakshire Health Board case and this was discussed and debated with a highly credible faculty of clinicians and lawyers. It is a subject that we all need to be familiar with, both for the safety and protection of our patients, and for each other.

The meeting programme is designed to enable the Forum to join with the main meeting for a plenary session on the Monday morning. Throughout this session, there were presentations about current research trials, the Graham Venn Lecture and the SCTS Lifetime Achievement Award. Feedback from the Forum delegates highlighted this plenary session did not fully recognise the inclusion of nurses and AHPs and so this has been communicated to the meeting organisers committee and will certainly be considered more carefully in the planning of the programme for next year.

Helen Munday, SCTS Nursing and AHP Representative

“In addition to the CT Forum programme, there is also a full programme targeted more towards our medical colleagues but frequently includes sessions from which nurses and AHPs benefit.”

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August 2017 13

SCTS Ionescu Nursing and AHP Fellowships 2017After a disappointing response to the advert for the Nursing and AHP Fellowship awards at the beginning of the year, it was decided to further promote the opportunity at the annual meeting, and extend the submission deadline. As a result, 12 good quality applications were submitted from which six were shortlisted. The telephone interviews were conducted in June and after much thought and deliberation amongst the interview panel, the following candidates were successful:-

Louise Best, Emma McIntosh & Roy Pittendriegh (Royal Sussex and County Hospital, Brighton) – awarded £2,500- the team are planning to visit several UK hospitals as well as attending the New Orleans Conference in the USA to learn about innovations and best practice in the US and combining this with a visit to the Mayo Clinic, Minnesota.

Rachel Brown (The Mater Misericordiae University Hospital, Dublin) – awarded £1,500- Rachel will be visiting several hospital in the UK to look specifically at enhanced recovery programmes after thoracic surgery, particularly in respect of lung volume reduction surgery and pectus programmes which are areas of development in her organisation.

Noirin Kearney (Royal Victoria Hospital, Belfast) – awarded £1,000-the purpose of Noirin’s placement is to observe advanced nurse practitioner (ANP) practice at Liverpool Heart and Chest Hospital and Blackpool to enable her to further develop the role of the ANP role within her own unit.

We will hear about these experiences and the impact that it has had on practice from the candidates in their presentations at next years meeting in Glasgow.

The standard of applications was very high and selecting those to be awarded was not an easy decision, so my congratulations to the successful candidates and my commiserations to the rest, but please do not be deterred from reapplying next year. We are optimistic about continuing with the Fellowship awards so please consider this next year and spread the word in your organisations about this opportunity.

SCTS Nursing & Allied Health Professional Working GroupAt the end of the SCTS Annual Meeting in Belfast, March 2017, Christina Bannister stood down as Nursing & Allied Health Professional Representative. I would like to take this opportunity to personally thank Christina for her massive contribution to the SCTS Cardiothoracic Forum and especially for her guidance over the last year. I am delighted that Christina has agreed to remain closely involved with the SCTS, and in particular, focusing on enhancing patient involvement within the Society and improving the cardiothoracic surgical information they receive.

Following discussions with the surgical leads for the SCTS it was decided last year to create a Nursing and Allied Health Professional working group to promote Nursing and AHP working within all aspects of the speciality. In addition to the current, and past, Nursing and AHP representatives for the SCTS, the group are Bhuvana Krishnamoorthy (UHSM), Amanda Walthew (LHCH), Heather Wyman (Harefield), Julie Sanders (Barts Health), Julie Quigley (Papworth) and Melissa Rochon (Royal Brompton). Currently there is a vacancy for the congenital sub-committee and interviews are expected to take place in July.

If anybody is keen to be more involved with the SCTS within your own organisations, please do not hesitate to contact me – hmunday@nhs.net. n

“Topics at the CT forum included clinical care,

advancing practice, research presentations, and professional issues.”

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The venue was a brand-new build and we were only the second major conference to be held there but

as with the previous year, there were over 1000 delegates supporting both the Ionescu University day on the Sunday and the main meeting on the Monday and Tuesday. The popularity of the meeting grows year on year in terms of registered attendees and in terms of the support we received from industry.

Part of the increasing success of the meeting has been the growing popularity of the CT Forum (nursing and allied health professionals), the surgical trainees and the medical student sessions. The growth in number of abstracts submitted to the Pat Magee prize is testament to the excellent work of Aman Coonar and the student team in fostering and developing an interest in the speciality with young undergraduates.

The feedback from the Ionescu University and meeting sessions was extremely positive and our international speakers were impressed not only with the content of the meeting, but also with the excellent meeting dinner held at the Titanic centre – complete with

Irish dancing. The lifetime achievement award honoured Prof. Ken Taylor and was graciously accepted with a touching speech by his daughter Kirstin. Congratulations to the meeting secretary - Enoch Akowuah who delivered a well organised and highly successful meeting ably assisted by the ‘titanic’ effort of Isabelle Ferner and Tilly Mitchell who work tirelessly to keep the meeting on track throughout the year. The meeting team would also like to thank Chrissie Bannister who, after 5 years, has stepped down from leading the CT Forum. She has worked tirelessly to build the profile of the CT Forum and is replaced by Helen Munday form Papworth Hospital and we look forward to collaborating with Helen in future years.

The 82nd meeting, 18th - 20th March 2018 will again be held in a new city – Glasgow. The Scottish Exhibition Centre promises to provide another excellent venue and meeting. The SEC team are committed to helping us brand Glasgow as the Cardiothoracic Conference city during the meeting and again we hope to showcase the best Glasgow has to offer. The respected Lonely Planet guide recently said of the city: “Glasgow is regenerating and evolving at a dizzying pace. Its Victorian architectural legacy is now swamped with cutting-edge style bars and world-class venues to tickle your taste buds”.

The main theme of the meeting will encompass team dynamics and the evolution of the modern workforce within the current NHS. Abstract submission opens on the 1st September with early bird online registration opening 1st December 2017. We look forward to seeing you there.

As in previous years Isabelle Ferner, the lead Conference Organiser, and Tilly Mitchell, the Exhibition Organiser, can be contacted by email or directly at the SCTS offices with any questions or concerns. (Contact details on www.scts.org). n

The SCTS 81st annual meeting and Ionescu University was held in March 2017 at the Waterfront Conference Centre, Belfast. Our previous Irish meeting was in Dublin 2006 and therefore this was our first time in Belfast and what a success it was.

The SCTS 81st annual meeting and Ionescu University

Clinton Lloyd (on behalf of the meeting team)

August 2017 15

When a consultant received a reward it was almost always carried forward indefinitely, and

there was no need for reapplication. A big factor in consultants’ motivation to apply for the awards, especially as they reached the latter stages of their careers is the fact that the salary enhancement which follows an award is included in the calculation of the pension to be received by the individual on retirement.

The NHS revised the system when the 2003 consultant contract was introduced, especially for those working in England and Wales. It became linked more closely to local clinical excellence awards (previously

Since its inception the NHS has provided National Awards for consultants. Originally called “merit awards” with A+, A, B and C categories the system provided a significant incentive for consultants to enhance their salaries, as a reward for service over-and-above the usual duties expected.

Richard Page, SCTS President-Elect, Chairman SCTS committee for ACCEA

called discretionary points) and the financial differentials between the awards were changed and renamed as Bronze, Silver, Gold and Platinum. The most significant changes were the necessity for consultants to have to apply for the awards themselves (as opposed to being nominated for an award by an organisation), the publication on-line of the applicants’ personal statements, the ability of the consultant’s employing Trust to award the equivalence of a Bronze award (as an alternative to a national Bronze award), and the need for consultants to reapply for their award every five years. On the whole the changes were well-received by consultants, and were felt to be a significant

improvement on the pre-2003 system, which was seen as secretive and had the potential for being discriminatory and unfair.

With the economic crisis of 2008 and the freezing of public-sector salaries which followed, the Department of Health has targeted National Awards in the austerity drive. For Scotland and Northern Ireland there have been no new awards at all over this period. In England and Wales there was an immediate halving of the number of total awards available, from a total of 601 in 2009 to 300 for 2010 and for every year since to the present day. This is against a backdrop of many more NHS consultants being appointed over the last decade.

National ACCEA Awards for NHS Consultants

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Applications to renew awards have to be at the same standard as those receiving new awards, so more consultants than before are loosing their awards, or having their awards renewed at a lower category (e.g. Gold to Silver, Silver to Bronze etc). Consultants who have received a National Award rescind their local clinical excellence points so a lost National Award can lead to a return to base salary, with the loss of many thousands of pounds.

The SCTS (along with the Royal Colleges, Universities and many other recognised organisations) provides support and citations for its members who are applying for a National Award. The number of consultant members within a specialist society calculates the numbers of individuals that the organisation can support; for the SCTS the numbers are 6 Bronze awards, 3 Silvers and 2 Golds. Platinum awards are considered separately, by a national committee but citations can be provided by the SCTS for as many Platinum award applicants as required.

Application for a National Award is now entirely electronic, via the ACCEA (Advisory Committee on Clinical Excellence Awards) website (www.gov.uk/government/organisations/advisory-committee-on-clinical-excellence-awards). With a little familiarisation the latter comes across as being well-structured and there are a number of helpful documents on the website which provide many of the details and FAQs surrounding the process. Support from the consultant’s employing Trust Chief Executive is a requirement for the application to be processed by the ACCEA, emphasising that what consultants do for their own hospital, either directly or indirectly, is more important than other duties.

Fourteen Regional ACCEA Committees in England, and the single committee for Wales then consider and score the applications. The Regional Committees function independently from each other and can approve the same number of awards per year.

In 2016 for England and Wales there were exactly 1200 applications for new awards. This equates to around a 25% success rate in applications for an award, a figure which is consistent through all four

categories (Bronze, Silver etc). Interestingly the number of applications for awards has steadily fallen over the last decade.

With respect to renewal of awards, in 2016 there were 416 applications in all categories, of which 82 were unsuccessful. Thus the likelihood of a consultant loosing their award currently stands at 19.7%. If this happens then they can reapply as a new award applicant the following year.

Tips for a successful application are as follows:-

l Start filling in your application form well ahead of the increasingly tight deadlines. The interval from the announcement by the ACCEA of the award timetable to the closing date for applications is getting shorter every year, presumably due to the influence of the Department of Health on the process

l Avoid too much jargon. The committees considering your application are unlikely to have cardiothoracic surgeons in their membership and there are increasing numbers of lay representatives

l Keep it brief. As for CVs and job applications bullet points are easier to read than large paragraphs of prose

“The SCTS (along with the Royal Colleges, Universities and many other recognised organisations) provides support and citations for its members who are applying for a National Award.”

l Very busy job plans (paid or unpaid) only get credit by the ACCEA if this leads to excellence in terms of improvements in quality, innovation etc. A lot of operative activity without evidence of quality doesn’t count for as much

l On the same theme having lots of differing roles is only helpful if you can provide evidence of your achievements within those roles

l Only include evidence of your achievements in the 5 years preceding your application

l Avoid repetition in different parts of the forms. Only use the additional forms which are available (teaching and training, management etc) if these can provide extra space for evidence which can’t be accommodated on the base form

l Ask a colleague (perhaps someone other than a cardiothoracic surgeon) who has been successful in receiving an award to advise you about your application prior to submission

l There is no problem with applying to renew your award and applying for an enhanced award (e.g. a Bronze renewal and a new Silver application) at the same time, as the applications are considered and scored separately,

Within the ACCEA there is uncertainty as to whether the National Award scheme will continue in its present form. The new consultant contract is still being negotiated and National Awards within this are likely to be part of the discussions.

Despite this uncertainty, over the years consultant cardiothoracic surgeons have always been pioneers in pushing forward quality of patient care, innovation, and maintaining high standards for service and training – all of which have ticked the boxes of the ACCEA committees and led to a high proportion of National Awards for our speciality, despite its small size when compared to others. My reading of the current situation is that there is very likely to be another National Awards round commencing at the start of 2018, in much the same form as it was this year. So start thinking about it now, and all the best for a successful application. n

August 2017 17

We are delighted to have formalised sponsorship from Cardio Solutions and Abbott for the allied health

education stream. The support will underpin all future AHP education. The new Abbott facility in Stratford should be finished to host future courses in the autumn, dates for which will be confirmed following a visit to the facility.

The current portfolio includes:

SCPs Master Classes in Conduit Surgery for CABG and Thoracic Surgery courses planned for later this year, date to be confirmed on the SCTS website.

SCP Revision course; course will coincide with the joint RCS Edinburgh & SCTS examination

Royal College of Surgeons of Edinburgh, the SCP exit exam. The examination will run in the autumn for existing candidates with the new iteration examination to be conducted in June 2018 (date to be confirmed). The 2016 examination highest achieving candidate who was awarded the Silver scalpel award (with support from Swann Morton) went to Rebecca Finn, SCP Queen Elizabeth Hospital, B’ham.

Advanced Cardiothoracic Course 2017.Date to be confirmed for autumn 2017 on the SCTS website. This established course offers interactive teaching sessions with lectures, workshops and wetlabs over the two days.

SCTS Band 5 & 6 nursing training course and competencies. Regional courses are run over three and half days. Cost £10. The next confirmed course will run on 27th to 30th October 2017 at the Audrey Emerton Building, Royal Sussex County Hospital, Brighton. Other courses are planned to run at James Cook Hospital, Teesside September

SCTS Nursing and AHP Education PortfolioHelen Munday, SCTS Nursing and AHP Representative

Nursing and AHP Forum research strategy. It is anticipated that this will include:

l Developing research priorities based on those highlighted by the respondents

l Highlighting existing funding sources for MSc and explore options for providing future cardiothoracic/SCTS funding sources

l Highlighting existing funding sources for PhD studentships and explore options for increasing access of existing funding opportunities, not currently open to nursing and AHPs

l Establishing an SCTS Cardiothoracic Research Network – using the expertise of those indicated from the questionnaire where they would be willing to support others

l Providing research support to members: research networking opportunities, teaching on research-related subjects, research newsletter, signposting to relevant research resources, and email alerts/bulletins of research funding opportunities, MSc/PhD supervision support

And finally, if you are not already a member of the SCTS, please do consider joining. The annual rate for nurses and AHPs is £30 per year (with a one-off joining fee of £30). Compared to many professional memberships, this represents extremely good value for money given the reduction for Associate Members in the annual meeting registration – put simply, it pays for itself. Associate membership allows access to many of the educational opportunities offered through the SCTS and access to areas on the SCTS website that are restricted for non-members.

Please do not hesitate to contact me if you have any questions - hmunday@nhs.net. n

2017 and Papworth Hospital, Cambridgeshire. Dates to be confirmed on the SCTS website.

Setting up an Allied Health Practitioner Programme. Abbott facility, Stratford. Date to be confirmed on the SCTS website.

Theatre nurses’ surgical anatomy course at the St Jude Medical Head Office in Stratford; a joint venture between the SCTS, Abbotts and Cardio Solutions. To be held at the Abbott facility, Stratford. Date to be confirmed on the SCTS website.

Future courses currently being compiled will be:1. Non-medical prescribing (NMP) course update. 2. The continuous professional development (CPD) course for the surgical care practitioners who are currently performing and who want to learn to perform the ultrasound sonasite leg scanning for the saphenous vein. This course will be accredited by the SCTS education and will also provide CPD points.

Once we have finalised content and programmes these two courses will be added to the portfolio and dates for delivery confirmed in 2018 on the SCTS website.

The postgraduate nurses’ & AHP day at EACTS. The 2017 EACTS meeting is to be held in Vienna 7th to 11th October with the Nurses and Allied Health professional postgraduate meeting to be held on the Sunday 8th October.

SCTS Nursing and AHP Forum Research Questionnaire 2017. Findings from a recent questionnaire undertaken by Julie Sanders following the annual meeting, have demonstrated an appetite for research related teaching and networking events to increase research awareness and capability to undertake research. The next steps are to use the information collated from the questionnaire to develop the SCTS

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At the outset I appreciate, recognize and value the support of all trainers/members of SCTS for

their contribution to deliver training and their continued support in the years to come. Below is the summary of current issues:

SAC Vision / Strategy / Implementation plan and measuring success: At this first meeting we discussed our vision which was to facilitate every trainee, at every level, in every region, gets high quality training there by improving patient outcomes. The strategy is to improve National selection, have a robust / consistent ARCP process and ambitious but achievable CCT completion guidelines. We would adopt the principle of utilizing data to improve quality by focusing on GMC, JCST surveys, SAC liaison reports and data from ISCP. The SAC liaison members will be working very closely with the programme directors to facilitate, advice, and support them in improving quality of training within their programmes. We will deliver this in collaboration and partnership with major organisations such as JCST, GMC, HEE, SCTS Executive, SCTS Education, JCIE and the trainee leads. We have defined measures of success which would include improvement in the GMC / JCST survey, SAC liaison report, Exam pass rate, NTN’s getting consultant post, suspension rate in initial years of consultant post and exploring the concept of “Better Training Results in Better Care”.

GMC / JCST survey: The 2016 GMC trainee survey results are available on the GMC website and also from your own deanery / school. The response rate from the GMC survey is around 98 % and from

the JCST survey is just over 75%. Whilst the response rate from the JCST survey is good, there is room for improvement and trainees should be encouraged to engage with this. The survey results gives important information regarding individual programmes and also individual training trusts which can be useful in improving the quality of the programme. The JCST survey has confirmed 93% of the trainees were satisfied with their training in Cardio thoracic surgery. The survey also confirms only 62% of NTN’s get access to theatre for 2 or more days a week which is the area for improvement which the SAC will focus.

Curriculum: SAC is applying to GMC for curriculum change to align training to the service / patient needs of the UK. In future, trainees will be required to make a choice between cardiac or thoracic surgery at the end of ST4. Broadly the future surgeons will be trained so that they have the knowledge and clinical skills of all aspects of our specialty,

but have the technical skills of the respective subspecialty i.e. cardiac or thoracic surgery. Sion Barnard / Andrew Goodwin will be leading on behalf of the SAC. The changes have been reviewed by the cardiac, thoracic, congenital and transplant subgroups of the SAC and finalised. The various subgroup leads are Sion Barnard (Thoracic), Andrew Goodwin (Cardiac), Tim Jones (Congenital), Steve Clarke (Transplant). All members of the SAC have contributed to the review of the curriculum. The timelines are as below:

2017Mid-July – deadline for final version to SAC for approvalMid-August – final version to ISCP13 September – final version to normal external stakeholders13 October – submission to the GMC14-15 December – GMC’s Curriculum Advisory Group consider changes

201815 January – expect the decisionJan - August – upload and go live

National Selection: A successful National selection was run by Wessex deanery with leadership from Jonathan Hyde, Steve Rooney with support from Sion Barnard. Programme directors, SAC members and various SCTS members contributed to the success of the National selection, which is appreciated, recognised and valued by the SAC. There were 60 applications for 10 ST1 posts and 45 applications for 8 ST3 posts. The following appointments have been made - 8 NTN, 1 LAT, 1 ACF at ST3 and 8NTN, 1ACF at ST1 level.

I took over as Chair of SAC in December 2016 from Sion Barnard to continue building on the excellent work done by him in the last few years. I am honored and privileged to have an excellent team of SAC members and programme directors with support from the SCTS executive to continue improve training, which will improve patient outcomes.

SAC Report

Rajesh Shah, SAC Chair Cardiothoracic Surgery

“SAC is applying to GMC for curriculum change to align training to the service / patient needs of the UK.”

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SAC Congenital Training Programme Success Report: David Barron prepared the congenital training programme report, which demonstrated the success of the programme. Since 1997, 17 trainees have been through the congenital training programme, 100% have achieved CCT and 94% have been successful in getting a consultant post. This is clearly a reflection of excellent training programme delivered by congenital trainers. SAC appreciates and recognises the value of excellence in training and congratulates all involved in its delivery.

SAC Quality assurance of Peri CCT Transplant fellowship:Steve Clarke has developed a proposal for quality assurance of peri CCT transplant fellowship, which outlines the knowledge, clinical and technical skills to be delivered through the fellowship. There is a standardised learning agreement and support of £4000 per fellow (subject to annual confirmation by corporate sponsors) for CPD during the fellowship. There is agreement from all transplant directors on the learning agreement. SAC is keen to develop similar quality assurance proposal for other fellowships in subspecialist areas of cardiac and thoracic surgery and would encourage colleagues to consider a similar framework. SAC Congratules Steve Clarke and the other transplant directors including Steve Tsui and Venkat Chandrasekaran for their valued input / support in delivering a successful fellowship programme. The fellowship has resulted in 10 out of 11 successful transplant consultant appointments in UK.

Review of ST1 pilot: ST1 pilot was commenced in 2013. GMC has requested comprehensive review of the ST1 pilot programme, which has been led by Prof Jahangiri. The review confirms, the pilot has been successful on the basis of which the SAC will recommend to the GMC to implement on a substantive basis. Entry through ST3 selection will continue as well.

Trainees Issues: Ahmed and Jacob are the SAC trainee leads who are working on the following issues:1. Log book update2. Trainee surveys3. National CT trainee committee

SAC leads: The following appointments to lead on various work streams have been made:Curriculum lead: Andrew GoodwinNational selections leads: Jonathan Hyde/Steve RooneyQuality Improvement lead: David BarronVice Chair / ST1 pilot lead: Prof JahangiriManpower lead: Prakash Punjabi n

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August 2017 21

In recent years the Society has focussed its thoracic audit efforts on the Lung Cancer Clinical Outcomes Project

(LLCOP) in England. The Society is fully supportive of this NHS England project, but has always argued that the whole of thoracic surgical activity should be publicly reported in national audit. In the Society returns, lung resection for primary lung cancer only accounts for around a quarter of thoracic operations, and a third of all inpatient deaths.

This article covers three areas where the Society feels that thoracic audit needs to expand; non-lung cancer surgery, the devolved nations and Eire, and activity in non-NHS hospitals.

Reporting Benign Surgery: Pilot Study with the Clinical Evaluation UnitHQIP (the Healthcare Quality Improvement Partnership, who commission national clinical audits in England) are facing funding reductions. It has been made clear during our discussions with them that they are unlikely to expand thoracic audit for the foreseeable future. How can professional societies continue to develop clinical audits in the current funding environment?

Last year the Society commissioned Prof David Cromwell at the Clinical Evaluation Unit (www.rcseng.ac.uk/standards-and-research/research/clinical-effectiveness-unit) to produce a pilot study, asking if routinely collected HES data (the Hospital Episode Statistics or coding data) could be used to produce valid outcomes reporting at unit level. There is a precedent for this approach in upper GI surgery with the SWORD project (www.augis.org/sword). We looked at two areas where we thought that OPCS codes were relatively reliable, pneumothorax and pleural sepsis surgery.

The early results have been encouraging. We have been able to produce outcomes including 30-day mortality, readmission and re-intervention rates at one year. Some comorbidity data (although not including Thoracoscore, ASA grade and some other common scores) is available within HES for case mix adjustment. In addition, the structure of the database allows linking to recent admissions, meaning that we could for example report how many admissions with pneumothorax a patient had before they received definitive surgery. Several new quality markers could become available using this approach, without any need for busy clinicians to submit extra data.

We are currently comparing the outputs from the pilot to other data sources to judge its accuracy. We already know from the LCCOP project that identification of individual consultants is poor in HES, but otherwise the results appear broadly reliable. HES based approaches hold promise as a means of providing quite complex risk-adjusted outcomes data at unit level, without time consuming extra data collection. Such a project could be used to trigger local targeted audits in outlier units.

In the devolved nations, many members are keen to see better quality audit in thoracic surgery. We want to encourage devolved health authorities to develop their surgical audit activities, as joining NHS England programmes will be complex. There are significant legal hurdles to overcome to move individual patient data across borders, but with government support there

Thoracic Audit Update: Where Next?Doug West, Thoracic Audit Lead

is no reason why robust audit could not be developed in the devolved nations. The lessons from LCCOP are that access to NHS data and adequate resources will be essential. SCTS cannot act as an audit provider (and we no longer do this in England either), but our membership do have a wealth of clinical and quality improvement experience that we can offer to support projects.

Non-NHS work is not currently included in LCCOP, although some other COP projects, for example NICOR in adult cardiac surgery, do include independent provider work. The Society now encourages submissions to the thoracic registry from independent providers, and indeed we have been receiving data from Spire Cambridge for a couple of years now. It makes little sense to limit our reporting to patients funded through the NHS. For LCCOP, practical issues (the data for LCCOP is NHS data, and many privately funded patients are not included), and the remit of the current HQIP contract limit the current project to patients operated upon in English NHS hospitals.

The SCTS has consistently advocated for the expansion of outcomes reporting and high quality analysis across our specialty in Britain and Ireland.

As always, thanks to all members, audit leads and others who give their time and effort to make thoracic audit a success. n

Lung cancer resections in the UK and Ireland 1980-2015: an illustration from the forthcoming Thoracic Third Blue Book

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People with Thoracic surgery conditions, their families, carers or members of the general public

can influence research carried out on this topic. The purpose of the group is to help make research more relevant and acceptable to people with thoracic conditions, clinicians and researchers. Resolve had its 1st annual meeting last year in Birmingham, at the SCTS conference, where patients and clinicians met to establish the aims of the patient and public involvement group.

In November 2016 RESOLVE organised a Training workshop for members of the National Thoracic patient and Public Involvement Group ‘Resolve’. This half day’s training consisted of research professionals presenting on the history of clinical trials, research funding, Governance and an introduction of GCP.

A focus group was also held with an experienced qualitative researcher who is also a patient representative. The direction of the discussion concentrated on ‘A patient’s experience of Thoracic Surgery’. Interesting views and feedback about the patient’s surgery journey and a wealth of related themes were presented.

Evaluations of the day were positive and patients commented that they felt informed and their knowledge of research had increased. They found the group helpful for networking and enjoyed speaking to other patients that had been through the same experience.

The focus group highlighted areas of care that needed more attention. The patients felt that it would be helpful to speak to someone after they had a diagnosis so they could ask further questions to reassure them. Also discussed were their experiences of being discharged from hospital after surgery. They advised that they weren’t issued with any specific information from the ward on discharge to transition back at home and wanted reassurance of what they could and couldn’t do. This session proved to be invaluable and gave us pointers of where we can improve our care for the future.

RESOLVE produces a quarterly newsletter to send out to every member of the group, to update them on thoracic research news and opportunities that arise within the group, such as attending conferences or receiving

feedback from research projects. The newsletter encourages members to feel part of a group and gain a better understanding of what we do as a research team.

At this year’s annual RESOLVE meeting held at SCTS Belfast, a medical doctor talked about conducting randomised controlled trial regarding Pneumothorax, a representative from Ethicon, part of the Johnson & Johnson company who talked about smoking cessation prior to curative surgery and Nicola, our own research fellow collecting opinions regarding the value of various quality of life questionnaires. The meeting has resulted in protocols being adjusted with the feedback from the patients and cares and patient representatives for steering group committees.

If you have a research project and you would like some patient and public involvement such as help with lay summary, patient information, informed consent or even a patient representative on the trial oversight committee, please contact the group and we can send information to our members or if you would like to present an idea of new research to our group, please get in touch. We are actively raising money to assist with members training, resources and expenses. In addition to this, some ambassadors will be asked to assist with promoting the RESOLVE group nationally; our aim is to broaden the group to gain more national members. If there are any patients that you may know that would like to join the group please call us on 0121 424 1396. n

The UK Thoracic surgery research collaborative patient and public involvement (RESOLVE) was set up in 2016 by the Thoracic research team, based at Heartlands Hospital, to provide patient and public involvement, to support the research activity nationally.

Thoracic Surgery research collaborative

Babu Naidu, Consultant Thoracic Surgeon, Birmingham Heartlands Hospital

“The patients felt that it would be helpful to speak to someone after they had a diagnosis so they could ask further questions to reassure them.”

August 2017 23

Subsequently, our Honorary Secretary Simon Kendall and President Elect Richard Page requested that I write a

short brief to go with the photographs to be published in the Bulletin. I put this aside for a while. I had helped organise the meeting and to me this seemed a bit like beating my own drum. In the end, not wishing to incur the wrath of our elders, I decided that I had better pen a few words.

To me organising the Thoracic Forum in our neck of the woods was something quite

The Thoracic Forum took place in early February within the splendid surroundings of Rudding Park in Harrogate. On the day of the meeting, the fickle spring sun decided to shine during one of the breaks. We thus had the opportunity for a couple of group photographs.

Nilanjan Chaudhuri, Consultant Thoracic Surgeon, St. James’ Hospital, Leeds

personal. I have grown up with it over the years. I have found lifelong mentors within the group. I have shared the joys as well as the trials and tribulations of friends, as a trainee and further on down the line as a consultant.

It is a unique group. There are no paid up members. Anybody can attend this paying a nominal registration fee, which includes food and accommodation.

What is also unusual about the meeting is the fun bit takes place the evening before the meeting – the dinner usually into the wee hours. The discussions at and after dinner can range from the use of pepper spray on oneself while training with the police to political intrigues and serious catching up on gossip about colleagues. This networking opportunity is invaluable to thoracic trainees nearing the end of their training.

Having started as a splinter meeting to further the interests of General Thoracic Surgeons in GB&I the group has come a full circle. It is only a mature society that can debate its own future existence. That is exactly what happened this year. The topic was, “The Battle has been Won - The Thoracic Forum

Thoracic Forum 2017 “Multum in Parvo”

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is surplus to requirement”. The motion was defeated unanimously. Having reflected on the origins of the Forum and the important milestones achieved it was felt that we still had a long way to go in championing our patients especially those with Lung Cancer. There was a strong sense of continued partnership with allied specialities such as Cardiac Surgery and Respiratory Medicine. It was felt that members should play an active role in surgical training, commissioning services and SCTS in general.

Despite those nursing a heavy head we started on time in the morning with serious business including reports on Thoracic Education, Lung Cancer Outcomes 2016 (increasing number of resections and improving 90 day survival) and the SCTS Thoracic subcommittee report.

Andrew Thorpe, a veteran of Thoracic Surgery who has personally helped me through many a difficult moment (not just with surgery) as a newbie consultant, took us on a trip down memory lane filled with many an entertaining anecdote of

how Thoracic Surgery developed in the north of England. Joel Dunning followed on by giving us a whirlwind taster of how we can innovate as surgeons in the age of social media. Pala Rajesh elaborated on how the Royal Colleges International Fellowship Scheme can help us meet the potential challenges posed by Brexit.

Thoracic Forum members will be pleased to know that their finances are in a healthy state. However, despite the informality, to continue with sponsorship of future meetings it seems we shall have to assume a minimum requirement of formal legality. Those present however wanted to maintain the “unique” informal nature of the group as much as possible.

I would personally like to thank two people who are the unsung heroes of every Thoracic Forum I have had the pleasure of attending including this one – Lorraine Richardson and Richard Steyn. Special thanks to all those friends who came to Harrogate from far and near and made this a fun meeting for everyone.

Finally, as the Pirãha tribe in the deepest darkest Amazon say Good Bye (... well actually Good Night) - “Don’t Sleep There are Snakes” - till we meet again next year in Leicester. n

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August 2017 25

The main challenge has been to obtain long-term sustainability of the the crown jewel of SCTS Education

the NTN portfolio of curriculum aligned courses. The second main piece of work was the curriculum change which has been driven by the SAC with SCTS support. The third aspect was to showcase how we are the leading specialty association in spearheading the Structured Surgical Simulation Courses.

Committee StructureAs Education Co Chairs we lead the committee with support from the SCTS Executive and Trustee Mr Prakash Punjabi. We have appraised and reorganised the committee to have section leads to all aspects of our specialty:

Consultant Education Lead – Donald Whitaker

NTN Education Leads (Tutors) – Sunil Bhudia, Carol Tan

Non-NTN Education Leads – Maninder Kalkat, Uday Dandekar

Medical Student Education Lead – Aman Coonar

AHP Education Lead – Helen Munday

Trainee Representatives – Jacob Chacko, Ahmed Al-Adhami

Communication Lead – John Butler

Accreditation and Standards Lead – Mahmoud Loubani

SCTS Fellowships We had a strong field of candidates who applied for various SCTS fellowships and awards were offered after a rigorous selection process. Interviews were conducted for the Ethicon Fellowships and AHP fellowships.

Further to Mr Ionescu’s benevolent gesture to support SCTS Educational activities for Consultant Development, a second Consultant fellowship was offered to Amit Modi.

l SCTS Education Ethicon Fellowship:Tara Ni Dhonnchu, Ramesh Kutty, Ishtiaq Rahman, Bao Nguyen

SCTS Education Report -July 2017

Sri Rathinam, SCTS Education Secretary Narain Moorjani, SCTS Education Secretary

It has been an exciting 6 months in our new role as Education Secretaries. Since the last bulletin report we have been in a constant evolving status with new developments and challenges.

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l SCTS Education Ionescu Non-NTN Fellowship:Cristiano Spadaccio, Lakshmi Srinivasan

l SCTS Education Marian and Christina Ionescu Travelling Scholarship for Consultants:Keng Ang, Amit Modi

l SCTS Education Ionescu Medical Student Fellowship:Cindy Rodrigues Cleto, David Tang, Devan Limbachia, Eyal Ben-David, Martyn Eckersley, Shruti Jayakumar

l SCTS Education Ionescu Nursing & AHP Fellowship:Team Brighton (Louise Best, Emma McIntosh & Roy Pittendriegh), Rachel Brown and Noirin Kearney.

SCTS CoursesNTN PortfolioUnder the new stewardship of the tutors Sunil Bhudia and Carol Tan, the courses are progressing well with the 2017 regulations of Ethicon in place. The recent ST3B in Hamburg and Core Thoracic Course (ST4B) were a great success. We still have the lingering problem of non-responding trainees and non-members but these are being addressed, including via notification to the Training Programme Directors.

We are developing new tools to assess the impact of the training both at trainee level in the course and at work place level. This includes objective MCQ assessment before and after sessions and OSATS on specific procedures before and after course with local educational supervisors.

Publications and PresentationsAfter four years of hard work we are now analysing the impact of the SCTS Education in terms of delivery and impact in the work place. Louise Kenny demonstrated the impact of the simulation courses by comparing testing educational supervisor assessment before and after the course. This demonstrated an objective improvement in the skill of the trainee. This work was presented at the AATS Annual Meeting in Boston, USA in May 2017, with an accompanying manuscript submitted to the JTCVS. In addition,

the manuscript detailing the programme of structured, curriculum-aligned cardiothoracic surgery training courses has provisionally been accepted by JTCVS.

Non-NTN portfolioThe non-NTN courses continue their current structure, with the aim to introduce a wet-labs component to complement the current two courses in 2017. We are collecting the non-NTN numbers through the SCTS Board of Representatives – currently only 33% of units responded. We will urge all members to feed back to Isabelle with their workforce data through SCTS unit representatives.

Introduction and Essential Skills coursesThe Introduction to Cardiothoracic Surgery has been finalised to be held in Coventry and the Essential Skills in Cardiothoracic Surgery should follow suit. Both these courses are aimed at FYs and CTs interested in cardiothoracic careers. We urge you to disseminate this to your juniors.

Medical studentsThe medical student engagement programme has been very successful with yet another great event in Belfast. There were a significant number of bids from units across the countries to host the next student engagement event. After vigorous scrutiny of strong bids, the next SCTS student engagement event heads to Sheffield.

AHPThe AHP portfolio is going from strength to strength with various courses mapped already.

Courses are all planned with infrastructure in place. Negotiations are in place both for funding as well as using industry facility to reduce cost. We are planning to use industry facilities to reduce costs.

Royal College of Surgeons of Edinburgh /SCTS WebinarsIn partnership with the RCS Edinburgh, SCTS is offering webinars on various cardiothoracic topics. The webinars were launched in Feb 2017 with the 4 webcasted receiving good feedback. Registration is free for anyone but archives are available for RCS Ed members only.

Consultant EducationWe will contact the consultant faculty to add more to consultant education both on clinical and professional development to complement the well-established SCTS Ionescu University. Mr Whittaker will contact the consultant body. Please respond and let us know your needs which will determine the nature of this venture.

Rewarding facultyAll the educational events and achievements of SCTS would not be possible without the time, effort and support of our consultant faculty. Currently we are considering various options to reward and recognise consultants’ commitment by a letter from the President to their Medical directors with more to follow.

We once again thank our industry partners for making this educational project possible for offering logistics and financial support. n

“After four years of hard work we are now analysing the impact of the SCTS Education in terms of delivery and impact in the work place. Louise Kenny demonstrated the impact of the simulation courses by comparing testing educational supervisor assessment before and after the course.”

August 2017 27

Academic Cardiothoracic Surgery in the United KingdomThe United Kingdom is currently the world leader in terms of high quality science, and produces 15% of all top rated scientific outputs with only 7% of the world’s researchers. Cardiothoracic surgery is no exception and the United Kingdom has a strong history of world leading research in our specialty. Many of the innovations that we now take for granted in our day to day practice were pioneered or introduced into routine practice in the UK. This has been reinforced by the development of high quality research infrastructure by the National Institute for Health Research (NIHR) over the last 10 years. The NIHR has an annual budget of £1Bn and has supported many of the most important clinical trials in cardiothoracic surgery in recent years including ERICCA, TITRE2, UK-TAVI, UK-Mini Mitral, and VIOLET. The surgeons who lead/ have led these trials are either substantive University appointees (Professors, Readers, Senior Lecturers), or, more commonly NHS Consultants with honorary university appointments. The 2015 Cardiothoracic Surgery UK Workforce Report identified 9 substantive and 15 honorary professors. However, this report also identified a shortage of young academic surgeons and this has important implications for the critical mass of academic cardiothoracic surgery going forward. A more recent report from the Nursing and Allied Health Professionals Research Network has also demonstrated an unmet need for cardiothoracic research in these disciplines. In response, the Society for Cardiothoracic Surgery, the Specialty Advisory Committee for Cardiothoracic Surgery, and the British Heart Foundation are developing initiatives to increases the opportunities for those wishing to develop an academic career in cardiothoracic surgery. The development of the National Cardiothoracic Research Meeting is part of this initiative.

The National Cardiothoracic Research Meeting, Glenfield Hospital Leicester, October 28th 2017The aim of the meeting is to showcase the best cardiothoracic research in the UK, and to provide opportunities for talented researchers to present their work. It is also an opportunity for juniors and senior academic colleagues to network and identify opportunities for collaboration. The meeting is modelled on the Cardiac Research Club that existed over a decade ago, with which many established consultants will be familiar. The new national meeting will however be expanded to include research from all the major subspecialties, allied specialties, and allied health professionals. The day will have three research sessions, with one session each for thoracic and adult cardiac and a third session shared by Transplant/VAD and Congenital. The best research presentation at each session will be awarded an annual prize that will include free registration at the SCTS Annual meeting in the Spring. Each session will also include a state of the art lecture from an invited speaker on a subspecialty related research topic. The keynote speakers are Professor Stephan Schueler, Freeman Hospital, Newcastle, Professor Sir Nilesh Samani, Medical Director of the British Heart Foundation and Mr Eric Lim, of the Royal Brompton and Harefield NHS Foundation Trust. The fourth and final session of the day is dedicated to careers in surgical research, whether as a University based or honorary academic. The plenary lecture will be given by Professor Dion Morton, Director of Research at the Royal College of Surgeons of England, with additional How-to-Do-it presentations from academic

Gavin J Murphy, British Heart Foundation Chair of Cardiac Surgery, University of Leicester Chair, Academic and Research Committee, Society for Cardiothoracic Surgery

The National Cardiothoracic Surgery Research Meeting -28th October 2017

clinical fellows, lecturers, and senior lecturers. A question and answer session will provide opportunities for open discussion.

The Cardiothoracic Trainee Research Collaborative and the Nursing and Allied Healthcare Practitioners Research Network will have breakout sessions during the day, and lunch will be provided. Delegates will meet in the city centre after the meeting for a curry.

Abstract submission has now closedAbstracts selected for and posters and oral presentations will be notified by return email no later than the 31st August.

How can I register?The meeting has been kindly supported by Vascutek and is free to attend. To assist with organising the event all those wishing to attend should notify the organisers at scts@leicester.ac.uk. All accepted presenters will be expected to attend. Prizes for the best oral and poster presentations will be awarded on the day.

What are the benefits of attending?As with surgical training, developing academic skills requires support, mentorship and opportunity. The aim of the meeting is to showcase to young academics the research opportunities that are available, to identify young talent to research leaders, and to promote the importance of high quality research to patients and the specialty as a whole. The meeting will attract 4 CPD points.

For further information please contact: Professor Gavin Murphy at gjm19@le.ac.uk or via his secretary Mrs Sue Page at sp504@le.ac.uk. n

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S ure, I had identified medical specialties I enjoyed, but much of medical school seemed like a big process of

elimination, envisaging whether I can or cannot do the jobs of doctors in different specialties. That was, at least, until I found myself in an eight-week-long attachment at two of the biggest cardiothoracic units in the nation. Through a series of events, and certainly with a dash of luck, I spent five weeks at the Royal Infirmary of Edinburgh under the supervision of Mr Vipin Zamvar, and three weeks at the James Cook University Hospital, a placement made possible through the Royal College of Surgeons of Edinburgh.

I met Mr Zamvar by chance on a scheduled thoracic theatre session while on my respiratory module, and his enthusiasm to impart knowledge and skills was contagious. By the end of the day, I had already assisted him in a pleurodesis and was tested on my ability to tie surgical knots. He welcomed me with open arms when I asked if I could return to the unit over the summer holiday, and looking back now, I am incredibly lucky to have met an inspiring mentor that day. In those five weeks, I observed countless cardiac and thoracic procedures, having the opportunities to scrub in for all cases. From lobectomies and lung resections, to

AVR and CABG, every case represented a worthy lesson, be it anatomy, physiology, or pathology. However, I wasn’t without my doubts. With each case I observed, and sometimes even assisted in, I became more and more aware of the complexity and challenge cardiothoracic surgeons face on a daily basis. Sure, the technical aspect of surgery is attractive, but the risks are high and days long, so why does someone choose to become a cardiothoracic surgeon in the first place? I found my answer rather shortly in clinic one day: the incredible joy from telling patients they are officially cancer-free, or the immense gratification from thankful

patients saying how much better they feel after their heart bypass surgery, are feelings that cannot be traded for anything else in the world. My doubts vanished instantly then.

I didn’t walk away with just an appreciation for cardiothoracic surgery. With the instruction and guidance from registrars,

SCPs, and Mr Zamvar himself, I was taught how to handle instruments properly and suture well, the fundamental techniques all surgeons possess. Having minimal experience in suturing prior to this, I was very grateful for the ample opportunities in theatre. I was able to pick up tips and tricks from teachers with years of experience, and their patience and willingness to teach culminated in my steady improvement. By the end of my five weeks, I could confidently do a running subcuticular suture. Imagine my own sense of surprise and accomplishment when I closed the skin layer from a saphenous vein harvest by myself,

under supervision of course, when I barely knew how to load a needle holder properly just five weeks prior!

The placement at James Cook University Hospital in Middlesbrough expanded my horizon even further. Mr Ferguson who oversees the placement designed it as an opportunity for

students to evaluate realistically a career in cardiothoracic surgery, which was perfectly timed for me just as I was starting to contemplate seriously the specialty as a career choice. The application process was straight-forward through RCSEd; however, with a capacity of just six students a year, it is a competitive programme for which

In the summer of 2016, I made the monumental decision to pursue a career in cardiothoracic surgery. Unlike most medical students I know who are gung-ho about surgery and knew they wanted to be a surgeon before they were born, I was never blessed with such obvious conviction to begin with, let alone in the niche field of cardiothoracic.

Cardiothoracic Surgery, One Year On: a Medical Student’s Perspective

Ann Cheng, Medical Student

“Watching Mr Dunning at work on the da Vinci robot was like a dream. The fluidity! The precision! The swiftness! It was beyond what a laparoscopic surgery can offer, and certainly more than what a medical student could truly comprehend.”

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I was honoured to be selected. Reading prior students’ reports, I was excited by the prospect of hands-on training that my predecessor seemed to have received, but the actual experience exceeded all my wildest expectations.

On the very first day of meeting Mr Ferguson, he told me the “minimum” that all students do on this placement are sternotomies, thoracotomies, saphenous vein harvests and skin closures, and that I could freely choose and attend the cases between any of the two cardiac and one thoracic theatres. I could go to clinics, go on ward rounds, go assess patients in cardiac ICU, whichever my preference would be to make the most out of my time there and have a better understanding of the specialty. I had much to learn, and three weeks did not seem like enough time.

It wasn’t, but I certainly had an incredible time. I experienced the “minimum” offered by the placement, and wow, was that exhilarating! I had always found the technical aspects of cardiothoracic surgery to be mesmerising, with its incredible fine attention to detail, but to be able to experience some of that, especially at the medical student level, was an extraordinary opportunity. As most students would agree, one of the many highlights, if not the highlight, is doing a sternotomy. I can only hope my face mask hid the excitement

but also anxiety well enough when I was handed the bone saw within my first week! It was in these moments when I truly understood the great responsibilities surgeons carry. The smallest thing that could go wrong in surgery may have grave consequences on the patient. An extremely powerful saw is definitely no exception. Thankfully, all the sternotomies went smoothly, and I did eventually remember to breathe again. The technical challenges on this placement provided a taster of the specialty which left me wanting for more.

Beyond these thrilling experiences, there was undeniably a fair share of fascinating cases. I learned that gossypiboma is not a medical myth (it was a foreign patient, just to clarify). I saw a case of atrial myxoma that medical students only read about in textbooks. But the most remarkable of all, I observed a case of robotic diaphragm plication. One of the biggest differences in practice between Edinburgh and Middlesbrough is the availability of robot-assisted thoracic surgery, and it was simply beautiful. Watching Mr Dunning at work on the da Vinci robot was like a dream. The fluidity! The precision! The swiftness! It was beyond what a laparoscopic surgery can offer, and certainly more than what a medical student could truly comprehend. The fact that I had the opportunity to “practice” on the simulator of the million-dollar machine only made me more excited about what my future could be.

Eight weeks went by in a whirlwind. I could very well say my experience was absolutely phenomenal and inspired me to become a cardiothoracic surgeon in the future, but I think the eight weeks had much more profound implications than that. I slowly came to grips with the complexity of these patients, and am amazed time and time again at the transformation surgery offers. I have endless admiration and respect for surgeons, their technical expertise and vast knowledge, but most importantly, their ability to make decisions that could be the difference between life and death. It was by being so deeply involved that I bore witness to the blood, sweat, and tears of the specialty. Just as I will never forget that one particular follow-up patient in clinic who very enthusiastically declared his surgeon as “the man!” who gave him a second chance at life, I will also never forget that moment when my own heart, metaphorically speaking, shattered into a thousand pieces when an emergency patient could not be salvaged. It was my first time seeing death up close from the medical perspective. It felt so relative yet absolute in this specialty, out of anyone’s control, but cardiothoracic surgeons are at the unique position where they can at least try.

For the first time in medical school, I knew with clarity that I want to be that person trying. I want to be a cardiothoracic surgeon. n

at the meeting to share with medical students were Jonathan Hyde, Betsy Evans, Kostas Papagiannopoulos, Daniel Robb, as well as

trainees Yousuf Salmasi and Rory Beattie. Students also gathered for an evening social after the event. Special thanks to Farah Bhatti as co-chair of the student engagement session and faculty members Samer Nashef and Jonny Ferguson. n

SCTS 2017 – Student SessionJimmy Toh, medical student Belfast and local event lead, Aman Coonar SCTS student engagement lead

A s a continuous effort to engage medical students in the specialty, a student engagement session took

place in conjunction with the SCTS annual meeting in Belfast on the 13th of March. The session was both very well attended and received by medical students. Students came from across the

country, and are mostly participants of the Pat Magee prize competition which gathered tremendous interest this year with over 40 excellent poster entrees and 8 oral presentations.

Students benefited from engaging sessions led by members of the faculty on national recruitment, career experience, work-life balance, overseas training, and so on. Present

August 2017 31

Sheffield team show steel in organising SCTS careers conference

To date, we have made considerable progress. Our collective efforts have resulted in the completion of the

event website and the programme. Venues have been confirmed at the Northern General Hospital, home of the South Yorkshire Cardiothoracic Centre. We are delighted to confirm our cooperation with the Sheffield Outreach and Access to

Medicine Scheme (SOAMS). This ensures we are able to reach out to local schools, particularly those in deprived areas, in order to encourage sixth form students to consider medicine and cardiothoracic surgery as a real career possibility.

Through a team effort, we have successfully negotiated considerable sponsorship from Ethicon; furthermore Wetlab will be

providing animal tissue and services allowing students’ to practice aortic anastomosis, lung stapling and insertion of a chest drain under the supervision of consultants. Attendees will take away an experience they could not get anywhere else at this stage in their education. We can cater for more than 100

students, some 62 tickets have already been sold. More information and booking is available at www.cardiothoraciccareers.co.uk or on Facebook @cardiothoracicsurgerycareersday

In closing, I can say with certainty, that all involved in organising this year’s event are extremely honoured and proud to be afforded the opportunity to host, in Sheffield.

Students: Eleanor Lee, Amanda Lee Yu Fang, Andrew Refalo, Callum Prosser, Jacob Holt, Joni Tan, Joseph Sealy, Timothy Sargeant, Valerie BJ Yii, William J Hunt

Supervision: Mr Norman Briffa - Consultant Cardiac Surgeon, Mr Michael Gooseman - Cardiothoracic trainee, Mr Aman Coonar - Consultant Thoracic Surgeon Book now! SCTS 4th International cardiothoracic surgery student engagement event 28.10.2017

Following successful conferences in Bristol, Cambridge and London it has been an immense privilege to take on the student leadership role for this conference under the supervision of Mr Norman Briffa and Mr Aman Coonar.

Harvey George, Sheffield MBChB and BMedSci Student

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Cardiff Robotic Thoracic Surgery Live Masterclass: bringing the robot closerAna Lopez-Marco, ST6 Cardiothoracic Surgery, Wales Deanery

On the 5th of May, the Thoracic Surgery Department at University Hospital of Wales, with the support

of WIMAT (Welsh Institute of Minimally Invasive Technology) and Cardiff University hosted the Robotic Thoracic Surgery Live Masterclass in Cardiff.

Evolution in thoracic surgery is constant. With the VATS technique well established now in the UK, there are now several units that have started a robotic surgery program. The aim of this masterclass was to provide a unique opportunity to gain experience of thoracic robotic surgery, offering a mentorship session with one the experts in the field performing live surgery with the 4-arm Da Vinci Surgical System robot.

We had the pleasure of having the expertise of Professor Robert Cerfolio, well-know worldwide as an expert in Robotic thoracic surgery, having performed over 3000 cases of robotic lung resections alone.

But this time, we did not bring the expert all the way to Cardiff; instead, we ‘virtually’ travelled to his operating theatre to observe several cases of robotic thoracic surgery. With a live link to his operating theatre at the University of Alabama Birmingham Medical Center, we were able to watch him performing a lung segmentectomy, a lobectomy and a sympathectomy.

The session was highly interactive, with Cerfolio, explaining not only all the operative details step by step but also giving us practical

tips and tricks on positioning the patient, port access and technical aspects of each operation. The video link was of extremely good quality, making us feel as almost being in that theatre.

The session ran successfully, counting with the presence of all the members of the Thoracic surgical team at University Hospital of Wales, and one of the Consultants from Morriston Hospital in Swansea. We also linked by teleconference with The West Midlands Hospital in Birmingham and Glenfield Hospital in Leicester, giving them the opportunity to enjoy the masterclass without travelling to Cardiff.

With the current available technologies, we demonstrated that there is not always the need to travel to the other side of the world to observe a particular technique. Live link surgery brings you the opportunity of observing the technique and also the possibility of interacting with the expert as if you were there with him. n

This course is based in Sheffield and first ran in 2014 with a number of

successful courses running since. It was the result of an idea to give students exposure to clinical cardiac surgery whilst improving their knowledge of basic science including anatomy and physiology and to start to develop their basic surgical skills in a safe and supportive environment.

The University of Sheffield has generously supported the event since its inception and has hosted it in its state of the art clinical skills facility at the Northern General Hospital. Mr Norman Briffa has provided strong and

Sheffield Basic Undergraduate Surgery CourseMichael Gooseman

supportive leadership with numerous students electing to undertake further placements under his supervision. Other key support has been provided by Kevin Austin and the outstanding Wetlab with support from industry.

Students from across the UK have attended the course with feedback extremely positive. Many students have said it has triggered an interested in cardiothoracic surgery and actively sought out further opportunities to get clinical experience. We feel that courses like this provided valuable opportunities for students to experience our specialty when

we know that it has very little or no place in a standard undergraduate curriculum.

For further information please visit www.sheffield.ac.uk/medicine/current/undergraduates/sheffield-basic-cardiac-surgery or contact me personally. n

August 2017 35

Iwas fortunate to be one of the recipients of the 2016/17 SCTS Ethicon Fellowship. With my CCT

in hand, my aim was to supplement the London Deanery based training in cardiothoracic surgery with an advanced fellowship in aortic and minimally invasive surgery. I was keen to go to a skilled unit with a strongly positive attitude toward training. In Waikato Cardiothoracic Unit (New Zealand), I found just that. The unit is headed by Prof Adam El Gamel, who was trained in the UK (Manchester) and worked as a consultant in London for the best part of a decade. Another familiar face and SCTS member practicing there is Nick Odom.

Fellowship Application and LogisticsWaikato Cardiothoracic Unit is based in the central north island of New Zealand. Surrounded on either side by beaches, Waikato is an hour’s drive from Hobbiton! The unit welcomes one international advanced fellow each year. The role includes a mix of independent practice (operating lists, on-call and clinics) and supervised opportunities to further minimally invasive and endovascular skills (see a typical week below). Application was very simple. A short application form, CV submission and a competitive interview. Those interested in spending some time in the southern hemisphere should be aware that the process of gaining medical registration and visas is easy enough but time consuming (3-6 months).

Experience and VisitorsI am deeply indebted to the SCTS and Ethicon for affording me the chance at this truly life-changing experience. The training ethos in Waikato is excellent with a comprehensive educational programme including weekly lectures, journal clubs and monthly WetLabs. One of the junior trainees,

Oliver Pumphrey, secured a UK CT Surgery run through numbers during his rotation. International expert visitors are frequent. Harefield’s Vladimir Anikin is due to visit in July. Waikato has just been granted the role as NZ Centre of Excellence for CALS with Adrian Levine due to visit in October. The Waikato Aortic Forum in August will have Roberto Di Bartolomeo, Malcolm Underwood and George Matalanis as guest faculty. Both Hans-Joachim Schäfers and Diego Gonzalez Rivas will visit Waikato to proctor in 2018. It is a great place to further surgical skills and progress clinically.

Earthquakes and Progress During my first week at Waikato, I felt the ground move beneath my feet whilst performing an operation. Naively, I quipped that there must be an earthquake or something. Indeed, there was! However, with the hospital built upon a specialised rubber base – everyone just got on with business as usual! I have relished the opportunity to consolidate my existing skills and advance my practice. Although my fellowship was cardiac focussed, previous fellowships have been thoracic/VATs orientated. The case mix in Waikato is demanding. Isolated coronary surgery makes up just 30% of the cardiac workload. Training in London was excellent and provided me a great platform to tackle the advanced rheumatic multivalvular disease and aortopathy prevalent in

Waikato. The team of consultant staff are friendly and cooperative. They provided the perfect balance of space and mentorship for finishing school. I was surprised and unaccustomed to the level of support afforded by the managerial and administrative staff. It was refreshing to have others on the team working to help the surgeons provide optimal patient care.

Future Plans I highly recommend Waikato Cardiothoracic Unit for post CCT trainees that are aiming to consolidate skills and progress. The mentality of the unit is immensely supportive and the case mix is challenging. In June, Nishith Patel joined the team from Papworth and is progressing well. I have been so impressed with the unit that I have decided to stay. My delight in securing a substantive consultant post in Waikato is mixed with sadness in leaving friends and colleagues in the UK. I look forward to meeting up and sharing stories in Glasgow. n

SCTS Ethicon Fellowship 2016/17: Lions, Hobbits and Earthquakes – A Compelling Journey to Middle EarthDavid J McCormack, Consultant Cardiac Surgeon - Waikato Hospital, NZ

Average Week in Waikato

Waikato Cardiothoracic Unit

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Name Hospital Specialty Starting DateJakub Kadlec Norfolk and Norwich University Hospital Thoracic August 2016

Carmelo Di Salvo St Bartholomews Hospital Cardiac October 2016

Felice Granato Wythenshawe Hospital Thoracic February 2017

Balakrishnan Mahesh Harefield Hospital Adult Transplantation/Cardiac

February 2017

Dimitrios Pousios Liverpool Heart and Chest Hospital Cardiac February 2017

Ulrich Stock Harefield Hospital Adult Transplantation/Cardiac

February 2017

Ioannis Dimarakis Wythenshawe Hospital Cardiac/Transplant March 2017

Sara Tenconi Northern General Hospital Thoracic April 2017

Sunil Bhudia Harefield Hospital Adult Cardiac April 2017

Hazem Fallouh Birmingham Heartlands Hospital Cardiothoracic September 2017

Karen Booth Freeman Hospital Cardiac August 2017

Kasra Shaikhrezai Golden Jubilee National Hospital Cardiac August 2017

Bil Kirmani Liverpool Heart and Chest Hospital Cardiac September 2017

David Waller St Bartholomews Hospital Thoracic

Henrietta Wilson St Bartholomews Hospital Thoracic

Aung Oo St Bartholomews Hospital Cardiac

Andreas Hoschtitzky Royal Brompton Hospital Congenital

Nnamdi Nwaejike Wythenshawe Hospital Cardiac/Transplant September 2017

Ikenne Omeje Glenfield Hospital Congenital Cardiac

• OTHER APPOINTMENTS

• NEW CONSULTANT APPOINTMENTS: FEBRUARY - AUGUST 2017

Name Hospital Appointment Starting DateAhmed Ashoub Queen Elizabeth Hospital, Birmingham Locum Consultant February 2017

Omar Nawaytou Liverpool Heart and Chest Hospital Locum Aortic/ Cardiac Consultant

March 2017

David Rose Lancashire Cardiac Centre Locum Cardiac Consultant April 2017

Pankaj Mishra Lancashire Cardiac Centre Locum Cardiac Consultant April 2017

Carmello Raimondo Lancashire Cardiac Centre Locum Cardiac Consultant April 2017

Sofina Begum Royal Brompton Hospital Locum Consultant May 2017

Mohammed Fiyaz Chowdhry

Glenfield Hospital Locum Thoracic Consultant

May 2017

Antonio Corno Glenfield Hospital Professor of Paediatric Cardiac Surgery

Shantanu Sinha University Hospital of Wales Locum Cardiac Consultant May 2017

Ian Wilson Liverpool Heart and Chest Hospital Locum Cardiac Consultant

August 2017 37

How Cardiothoracic Surgery started in Leeds

Marian Ionescu, Leeds General Infirmary

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The President, Mr. Graham Cooper has asked me to write this article as a stimulus to other Units

producing their own histories. I believe that this is an important project as with the passing of Senior Fellows we are in danger of losing this valuable archive. Much of the information in this article has been gleaned from obituaries and conversations with Consultants who had retired before I took up my post thirty years ago.

The General Infirmary at LeedsThe General Infirmary at Leeds stands proudly in the centre of the City. The original Victorian building was designed by Gilbert Scott in 1863 and holds a Grade 1 listing. The staircase at the end of the marble entrance hall is dominated by a statue of Lord Moynihan (1865-1936).

Thoracic SurgeryBerkeley George Andrew Moynihan joined the staff of LGI in 1896. He worked mainly as an abdominal surgeon “cutting for stone” (renal and biliary). In addition he made a notable contribution to the surgery of chest wounds during the First World War. He was the first President of the Royal College of Surgeons from outside London. In his Hunterian Lecture (1919) “The Surgery of the Chest in relation to retained projectiles” he dispelled the fear of open pneumothorax, which he had seen on a dozen cases following removal of the twelfth rib. He performed 48 thoracotomies for retained foreign body. However, as these were fit young patients and no lung tissue was removed, the fear of open thoracotomy remained and was generally avoided in the twenties.

In 1941 Leeds Infirmary appointed its first Thoracic Surgeon. Philip Allison (1907-74) was a local boy, born in Selby and educated at Leeds Medical School. He gained his FRCS at 25 and was appointed to the Staff of Leeds Infirmary four years later in 1936. In 1946 he was credited with

the first intrapericardial dissection of the pulmonary vessels for pneumonectomy. However, his main field was research into the pathophysiology of reflux and its complications. He established himself as a leading oesophageal surgeon and a world authority on hiatus hernia. Technically he was outstanding with a meticulous attention to detail. He was a flamboyant character both in dress and behaviour. When performing an oesophageal resection he would retire to the Surgeon’s room at “half time” and refresh himself with half a dozen oysters and a glass of champagne before embarking on the anastomosis!

In 1953 he was proposed as Professor of Surgery in Leeds. However, because of a lack of investment in the facilities (and possibly preclusion from Private Practice) he accepted the Nuffield Chair of Surgery at Oxford.

When Allison moved to Oxford in 1953 he was succeeded by his Registrar, John Aylwin

(1917-68), another Leeds graduate. He performed valuable work in both oesophageal and pulmonary surgery, postulating that early division of the pulmonary veins reduced tumour embolism. Unfortunately, his career was cut short by a cerebral haemorrhage.

Philip Kay, Retired Surgeon

“The Victorian building was designed by Gilbert Scott in 1863 and holds a Grade 1 listing. The staircase at the end of the marble entrance hall is dominated by a statue of Lord Moynihan (1865-1936).”

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Bust of Lord Moynihan at Leeds General Infirmary

Philip Allison (1907-74)

August 2017 39

Outside Leeds the Thoracic Service was supported by Edmond Lecutier (1918-97), a Leeds man born of French parents. He worked at Bradford Royal Infirmary and Wharfedale Hospital.

Zbigniew Rozycki (1916-78) moved from his native Poland to Leeds after the Second World War. He joined the Leeds Thoracic Surgical Service at Pinderfields Hospital, Wakefield. He was closely involved with the development of pulmonary and oesophageal surgery in West Yorkshire and moved to Killingbeck Hospital in Leeds when the Cardiothoracic Unit was opened by Philip Allison on 19 October 1961.

Cardiac SurgeryGeoffrey Wooler (1911-2010) was another local boy, educated at Leeds Grammar School. Initially he went to Cambridge to study Law, but after two terms switched to Medicine and

subsequently completed his clinical studies at the London Hospital. He served with the RAMC in North Africa and Italy rising to the rank of Lieutenant Colonel. He was mentioned in despatches after the Battle of Monte Cassino. In 1946 Philip Allison invited Geoffrey to join him in Leeds. Geoffrey was delighted to return to the city of his birth.

Geoffrey Wooler’s clinical acumen and surgical skills first came to National attention when he successfully drained a sub phrenic abscess on Lord Woolton who had collapsed at the Conservative Party Conference in Scarborough. Geoffrey was recommended for a knighthood, but this was not supported by the College who considered him too young.

In 1956 Wooler visited Dr. Dennis Melrose at the Hammersmith Hospital. Melrose was building a prototype heart-lung machine,

the first to be designed and built in Britain. The Nuffield Foundation agreed to pay for the construction of three machines. The first went to Bill Cleland at the Hammersmith Hospital, the second to Russia, and Geoffrey brought the third to Leeds.

In February 1957, using this machine, Wooler successfully repaired a leaking mitral valve in a 41 year old woman. The Wooler repair consisted of placing deep sutures through the annulus at both commissures. Initially, a single layer annuloplasty was performed but this evolved into a double layer technique. The Wooler repair soon became accepted worldwide and attracted many cardiac surgeons to visit Leeds. Importantly, it introduced the concept of repairing rather than replacing diseased mitral valves in selected patients. With various refinements this procedure remains a major tool in the surgical armoury for the treatment of mitral valve disease.

The operation was featured in the BBC TV programme “Your Life in their Hands” broadcast in 1957. I have seen this many times at Wooler’s house when he hosted parties for visiting cardiac surgeons.

Initially, it was thought that Wooler had achieved the first successful repair of a mitral valve in Leeds. However, it later emerged that K. Alvin Merendino had performed a similar procedure three months earlier (31 October 1956) in Seattle, USA. Again, this was a simple technique with four parallel sutures to the postero-lateral commissure.

The Wooler repair and general improvements in open heart surgery allowed Cardiac Surgery to flourish in Leeds during the 1960s. However, Geoffrey developed a large swelling on the right side of his chest. This proved to be a tuberculous abscess and he was advised to give up cardiac surgery. He did, however, continue some surgical activity albeit at a reduced pace.

Geoffrey retired in 1974 and continued to lead an active and interesting life. One of his many ventures was a restaurant in Headingley. Another, his autobiography “A Pig in a Suitcase” is full of amusing stories. He died in 2010 in his 99th year. Marian Ionescu described Geoffrey Wooler as “a very talented surgeon and a true, great Gentleman who had a clear vision for the future of cardiac surgery and a big and noble heart to encourage and help younger surgeons”.

Leeds General Infirmary, 1972

Leeds General Infirmary, 2017

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Marian Ionescu (b 1929) was a gifted young surgeon who had received a solid training in cardiac surgery in the United States. Returning to his native Romania he was faced with a continuous struggle against the oppressive Communist regime. In 1965 he and his wife Christina, a cardiologist, executed a carefully planned and daring escape. They obtained permission to visit friends in Yugoslavia who lived close to the Italian border. Their friends distracted the Yugoslav guards whilst Marian and Christina took advantage of a moonless night to push their Fiat 600 silently across the border to Italy and safety. They continued their journey to Paris where they worked in a hospital while awaiting immigration visas for the United States.

In 1966 Geoffrey Wooler learned of their escape and came to Paris to invite the Ionescus to join his Unit in Leeds. Marian occupied a position of Research Fellow and Surgical Assistant until 1971 when he was appointed as Consultant to both Leeds General Infirmary and Killingbeck Hospital and also Reader in Surgery at Leeds University. This provided a stable platform for Marian to follow his lifelong ambition of creating an artificial heart valve that could be used without anticoagulation.

In 1967 Marian was the first to create a porcine aortic valve mounted on a Dacron stent. This was implanted in the

mitral position in a series of patients. In 1969 he developed a stented autologous fascia lata valve which he implanted in all cardiac positions. Following these early successful experiences Marian progressed to using stented valves created from bovine pericardium treated with glutaraldehyde. The clinical implants began in April 1971. Initially the valves were prepared by his wife Christina at a laboratory in Leeds Infirmary. The project was taken over by Shiley Laboratories, Irvine, California in 1976. The Ionescu-Shiley Pericardial Xenograft was born. Marian described the valve as “The embodiment of the concept of man made devices. It lends itself to an infinite number of changes in shape and physiochemical interventions in order to improve its function without altering its essential characteristics: exceptional haemodynamic performance and reduced risk of embolism”. In 1987 Pfizer, the parent company of Shiley Laboratories, stopped all manufacturing activity at Shiley following repeated sudden failures of the Bjork-Shiley mechanical valve. Subsequently other international companies began to manufacture bovine pericardial valves. Marian Ionescu created this concept and must be regarded as the “father” of the bovine pericardial valve. This valve continues in general use five decades later.

Though his clinical and research life concentrated on tissue valves, Marian made other pioneering steps including the first surgical repair of parachute mitral valves, the first successful correction of a single ventricle circulation, and reconstruction of the right ventricle to pulmonary artery connection using a pericardial valved conduit.

During his 21 years in Leeds Marian wrote and published three books on cardiac surgery, edited seven more books and published a large number of scientific articles. In keeping with his great contribution to medical science he became a member of 23 Scientific Societies, holds six fellowships and obtained eleven Awards and Honorary titles, the latest being the SCTS Lifetime Achievement Award for Cardiac Surgery (March 2015).

Marian felt that “ the relationship, cooperation, and friendship with Geoffrey Wooler was deep, complete, sincere and very fruitful for the Department of Cardiothoracic Surgery at Leeds Infirmary”. Their very significant achievements in the fields of mitral valve repair and the development and implantation of the pericardial valve attracted a large number of visitors from around the world, particularly during the 1960’s and 1970’s when Leeds became a leading centre in the world of cardiac surgery.

In 1987 Marian felt “the call of the mountains” and retired from clinical practice. Since then he has climbed most of the 4000 metre high peaks between the Mont Blanc massif and the Penine Alps around the Matterhorn, with additional forays in the Himalayas and Alaska.

Killingbeck HospitalKillingbeck Hospital was founded in 1904 on the eastern side of the city. In 1912 it was converted into a sanatorium for tuberculosis where patients underwent bed rest in south facing rooms. At this time TB accounted for 1 in 6 adult deaths. In 1939 it became a hospital for infectious diseases. An operating theatre was installed in 1950.

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Marian Ionescu & Geoffrey Wooler, Leeds General Infirmary

Geoffrey Wooler (1911-2010)

August 2017 41

The Cardiothoracic Unit was opened in 1961 with David Watson (b 1923) as Consultant Surgeon and Director of Cardiac Research. On 21 May 1962 David performed the first open heart procedure at the Unit on a 12 year old girl. Initially, the Drew technique was used. This combined a heat exchanger to produce profound hypothermia with two extracorporeal circuits perfusing the lungs and systemic circulations. At 15°C the aorta and cavae were occluded providing a still bloodless field for one hour to complete the intracardiac repair. Later a Melrose oxygenator was incorporated into the heart-lung circuit.

In 1967 David Watson founded Heart Research UK. New research laboratories were opened in 1973. It was here that the Killingbeck valve, a modified porcine xenograft was developed. This is currently manufactured as the Aspire valve by Vascutek at Swillington in south east Leeds.

Heart Research UK has funded over £17m of research projects including six of the first heart transplants at Papworth.

David Watson was awarded an MBE in 2017.

In 1966 Dr. Olive Scott was appointed as the first designated Paediatric Cardiologist in the UK. Four years later Philip Deverall was appointed as a Paediatric Cardiac Surgeon and an intense programme of paediatric cardiac surgery began.

Philip Deverall moved to Guy’s Hospital in 1978 and was replaced by Duncan Walker who became “Yorkshire Man of the Decade” in 1990.

Killingbeck was a high profile institution. Prince Charles visited in 1975. Lord Louis Mountbatten opened the non-invasive Paediatric Unit in 1977. Prince Phillip visited in 1984 and the Duchess of York opened the Paediatric Intensive Care Unit in 1990.

Bradford Royal InfirmaryTo the west of Leeds there was a thriving programme in Bradford. In 1967 Mr James Davidson performed the first closure of ASDs in twins who are alive today. Thoracic surgery was lead by Alan Mearns (1940-2008), supported by Sabaratnam Sabanathan (1949-1997) and Vladimir Anikin.

The Next Generation in LeedsThe early pioneers of Thoracic and Cardiac surgery established Leeds on the world stage and laid a solid platform for the next generation who established a programme of high volume cardiac surgery.

In 1985 Nigel Saunders (d1998) joined the staff of Killingbeck Hospital as a Cardiothoracic Surgeon. Both David Watson and Marian Ionescu retired in 1987. Philip Kay was appointed to the LGI in 1987 and was joined by Andrew Murday the following year. Unni Nair also commenced at Killingbeck in 1988. Together Andrew and Unni developed a programme of cardiac transplantation. However, this was to be short lived. In 1991 Andrew left to follow his transplant dream and was replaced by Chris Munsch and Joe McGoldrick. Meanwhile Kevin Watterson had joined the Paediatric programme in 1989.

The Yorkshire Heart CentreIn 1997 the cardiac units amalgamated in a new centre at Leeds Infirmary. The Unit was strengthened by the appointment of three locum Consultants; Pankaj Kaul, V Chandrasekeran and Anvay Mulay enabling the Unit to perform 1600 cardiac operations per annum. The latter two surgeons left. Pankaj Kaul obtained a substantive post along with David O’Regan.

On the Paediatric side Duncan Walker left. Kevin Watterson was joined by Ms Carin van Doorn. She left to pursue her career at Great Ormond Street and Aarhus before returning to Leeds.

The Thoracic Units at Bradford and Killingbeck were closed and thoracic surgery concentrated at St James University Hospital under the leadership of Andrew Thorpe.

The pioneering days were a celebration of glorious invention and innovation. n

David Watson

Marian Ionescu and team, 1972 Killingbeck Hospital

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Well, that was until I heard our then divisional manager talk about QUIPP as a mechanism for cutting

the number of theatres and saving money. I felt that this was putting the cart before the horse. Indeed that may be a conclusion after addressing all the aspects of QUIPP, but QUALITY comes first. That means getting it right first time and every time. The literature is unequivocal; quality drives a reduction in costs.

We are all guilty of jargon and it is widespread in the vernacular of all the professionals in the NHS. FBC (full blood count), U&E’s (urea and electrolytes) and CXR (chest X-ray) roll off the tongues of the clinical staff just as easily as FCE (finished consultant episode), HRG (Healthcare resource groups) and SPELLS (total continuous stay of a patient in a hospital bed) drip from the mouths of the managers. I sat in self learning group on a leadership program and it appeared to me my colleagues revelled in the NHS management dialect and loved to ‘SHMI’ (summary hospital-level mortality index) their way through conversations with these acronyms. Now FCE, HRG and SPELLS are the currency terms for the income generation of a hospital but when I surveyed 173 consultant staff, not one of them could accurately define all the acronyms used by the NHS to realise income and define quality. It strikes me as very strange that the end users and prescribers of health care and technology are totally removed from the decision making and excluded by the language used to define our business. Why can’t clinicians and managers share the same language of quality and waste? It should be very easy to examine the time intervals in the

patient pathway and record the consumables. I could look at the top ten drugs spend of the unit and the use of antibiotics does correlate with a cluster of wound infections. The clinical and operational elements of health care do go hand in hand.

I was excited by QUIPP and quality first because I believe that doctors, managers and patients would have no problem defining and agreeing what good quality looks and feels like. Indeed, we are all customers in our everyday lives and we all experience service. There is no hesitation by many walking away from an encounter and complaining, often on social media, but how often do we take time to feedback the good and bad of that encounter – it is not really English? The only way to improve quality in a service encounter is to ask for feedback and act on it! We are, in general, very poor at this in healthcare. Patients are too grateful and often feel disempowered.

People who are intent on improving their service only score the 5/5 encounters that are defined by an exceptional experience and a highly likely recommendation and return. I was briefly hesitant to ask my own patients in my own satisfaction questionnaires that are handed out by the outpatient clerks – ‘Mr O’Regan treated me with dignity and respect’ and ‘Mr O’Regan listened to my concerns’. I am pleased to record a >95% 5/5 satisfaction but I can tell you it does make you think about your encounter with the patient in each and every clinic. We are there to attend to our patient needs in the best and most efficient manner possible – your own discomfort and distress is of no concern to the patient.

The other altruism of good service is that you never get a second chance to make a first impression. The outcomes of health care are defined by what we say as individuals and do as a team. Many service organisations offer training and scripts to ensure that the first encounter with the customer is good. This is not obvious in the NHS and teams are often not valued for their identity nor are they given discretion to design their own services.

There is a problem. I am disappointed to have to point my finger at the consultants. The vast majority of consultants deliver a high quality, personalised and effective service but that is just it. They have many years of experience but practice an individual art. The science of quality demands that teams adhere to Standards Operating Protocols (SOPs) and they are audited and refreshed according to best evidence and practice. Unfortunately, this is often construed as an affront to well earnt professional autonomy. Institutions like Intermountain Health Care expect everyone to adhere to all SOPs but do not necessarily compliance. Clinical acumen can override a SOP but it has to be documented. I have yet to see a scientific approach to QUALITY applied by any team or hospital in the UK. Unfortunately, it really is like herding cats. MY hope and observations lead me to think that this is a generational thing. I enjoy the insight and enthusiasm of the medical students. Perhaps we should teach the science of quality in the undergraduate curriculum. n

David J. O’ReganMBA (Distinction) MD BM FRCSEd (C-Th) FFSTEdThesis –‘Why can’t Dinosaurs Boogie?’

QUIPP (Quality Innovation Productivity and Prevention) was the buzz acronym in 2012. Personally, I was very excited because I felt for the first time in my career in the NHS that doctors and managers alike would put QUALITY before anything else. I thought this would be the first time we would be sharing the same language and singing from the same hymn sheet.

Quality

David J. O’Regan, Consultant Cardiac Surgeon, Leeds Teaching Hospitals NHS Trust

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The main aim of the project is to retain the culture and history of the current building but bring it into the 21st Century with more

flexible teaching spaces and better public access to collections. Of course it is not possible to make an omelette without breaking eggs and this means the need to move all 400 College and Association staff out of the current building to temporary space next door in the Nuffield Building for approximately three years. As the project’s name suggests, if all goes according to plan, we will be moving back to the College some time in 2020.

By the time you read this piece, we should have decanted and be settled in our temporary office and very much hope that there will be as little disruption to the service we provide for you as possible and it will be business as usual throughout the process. Whilst we are endeavouring to secure the best deal within the interests of the Society, whilst accepting the limitations of our size and clout, we still have some way to go before confirming whether or not we will enjoy our own self-contained office or be part of the Associations mass in a large open planned space upon our return to the College in 2020. I will keep you informed of any significant updates and of course you will all be welcome to come and view the new facilities when complete. n

The Society for Cardiothoracic Surgery has had its home in the Royal College of Surgeons since 2000 along with many specialty and sub-specialty associations. For those of you who haven’t had the opportunity to visit, the College stands as an impressive portico structure on the edge of leafy Lincoln’s Inn Fields in the centre of London. After nearly 220 years, it has been decided that the building in its current design is no longer fit for purpose. And so was born Project 2020.

We’re on the move! The Royal College of Surgeons Rebuild

Isabelle Ferner, Society Administrator & Conference Organiser

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S eptember 19 Aortic Dissection Awareness Day, is a day where many Countries Worldwide join together, hold

hands and create a wave of awareness for AD.

Twenty one Countries are now involved and active in the campaign which include New Zealand, Australia, Malaysia, USA, Canada, Bangladesh, along with many Countries across Europe, with Sweden being the main hub of activity. Thousands of posters have been designed, with 44 countries being written in their own language. Over 14 thousand flyers were also designed and printed in ten languages. 500 T-shirts have been made and sent out worldwide also, and much more. An enormous effort AND ALL FOR FREE! even down to worldwide postage and packaging. All that was asked, was a commitment to raise the awareness of aortic dissection by the recipients. Aortic Dissection Awareness UK (ADAD UK) was founded in the spring of 2015 and is very much an integral part of the global awareness drive, we also have a network of Aortic Dissection Survivors and family members within the UK and Ireland touched by this disease who are committed to highlighting the difficulties that AD patients encounter in all aspects, ranging from diagnostics at first phase, through to pushing for written materials on discharge from hospital. Offering emotional support once home is a major factor for survivors and our support group prides itself in giving just that.

Aortic Dissection UK Buddies group consists of over 150 members with new members finding the group each week. Perhaps you have patients attending your clinic who would benefit in finding other survivors of AD. Almost every new member conveys the feeling of being alone until they find us. Aortic Dissection UK Buddies Group can be found on Facebook.

ADAD UK have been extremely busy since our last September 19 Awareness Day, having had the main event take place at the Royal Brompton Hospital, London with a presentation given by Professor John Pepper, warmly received, along with support from Heart Research UK. This year took off in great style, with an invite extended to us from SCTS to man an awareness stand at their annual meeting, which took place in Belfast. The weekend was a great success and an invite to the next SCTS, Glasgow has been offered and accepted.

Christina Bannister/ Dan Burgess (Founder of Aortic Dissection Awareness UK)

Aortic Dissection Awareness Day- Today is a good day

Following on from Belfast we had a few smaller events within the UK at local Hospitals, also an invitation was readily accepted from Professor Christoph Nienaber to promote aortic dissection Awareness Day September 19 at the AMC 2017, which took place in June at Imperial College, London. A presentation was also given at Ipswich hospital from ‘a survivors perspective’ forming part of their ground round lecture, Management of acute aortic dissection. One of the ways some Surgeons lend a hand is to help their patients with AD connect with ADAD UK, this is such an easy thing to achieve. If you could ask the patients you have to attend an informal meeting, perhaps just a coffee within the Hospital where you practice, one of our members could attend and the connection between the survivors and the self help group will naturally develop. This years main event, taking place on Tuesday September 19, Aortic Dissection Awareness Day 2017, will be held at The Liverpool Heart and Chest Hospital. If you are interested in finding out more on this event and maybe getting involved you can do so by contacting us at aortic_dissection_awareness@outlook.com The slogan adopted by Aortic Dissection Awareness Day consists of just five words,Today is a good day and is mouthed time and time again. It is not necessarily about having a good day, it is more in tune with knowing it could be a lot worse! Having a bad day, check your pulse and think again! n

August 2017 45

Heart Valve Voicecycle to ParisOn the 15 May I set off on a three day adventure with the charity Heart Valve Voice cycling across the UK and France with a group of dedicated, like-minded people. Our goal - to cycle from Guy’s & St Thomas’ Hospital in London to the EuroPCR conference in Paris. Our aim - to raise awareness of heart valve disease, the symptoms and the need for earlier diagnosis and treatment.

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Our team of eleven came from all over the UK including cardiac doctors, cardiothoracic nurses, the

CEO of Heart Valve Voice, Wil Woan, patient advocates and former heart patient Pat Khan who was a constant source of inspiration.

Heart Valve Voice is a UK charity dedicated to raising awareness about the importance of early diagnosis of heart valve disease. Heart valve disease affects over 1.5 million people over the age of 65 in the UK, according to a 2016 Heart Valve Disease Survey and yet awareness is low with an average of 94% of people over the age of 60 being unaware of what aortic stenosis is. Working with clinicians, patients and ambassadors throughout the UK, Heart Valve Voice has become a charity that reflects the genuine concerns and opinions of patients.

I first met Wil at the SCTS annual meeting in Belfast earlier this year. When he told me about the cycle ride, I did not hesitate to volunteer and take part. However, as the day grew nearer, I started to wonder if I was really going to manage this challenge. I knew I could do the distance but wasn’t sure if I’d cope with the pace – three days did not seem very long to get to Paris on a bike! As it turned out, I need not have worried, my fellow cyclists and the wonderful support crew from Bicycle Buddy ensured that nobody was left behind and we (and our bikes) were always road ready.

While there were a few ups and downs (and not just hills!) there were many brilliant highlights from the trip. We shared a lot of laughs, particularly when four of us got lost on the first evening, which led to us cycling through a field in the dark with only one front light and one rear light between us. This was certainly not part of the planned route but what made this moment particularly memorable was the confidence our group leader Adrian Carrol had in his navigational skills. How he managed to lead us through that field and those hidden pathways only to find our way safely to our destination, I will never know!

One of the most memorable moments for me was riding up the last hill as we approached the Arc de Triomphe. It was an amazing feeling seeing the penultimate destination and knowing we had made it all the way to Paris! Actually, cycling into the traffic on the roundabout required a leap of faith as it is bad enough in a car, but on a bike, I suddenly felt very vulnerable! That part was pretty hairy and I am just relieved my mother did not have to witness it!

When we arrived at the Euro PCR conference we were met with an emotional welcome onto the stage where Wil presented the work of Heart Valve Voice. At this point we were so relieved that we finally made it and for the first time we were able to look forward to not getting on our bikes the next day!

While there were many highlights and memorable moments from the cycle ride, meeting Pat, Heart Valve Voice’s patient ambassador and hearing her story was without doubt, one of the most meaningful things

I will take away from this experience. Pat is a wonderful example of how a patient’s quality of life can be significantly improved following treatment for valve disease. Pat went from being breathless on her walk home and struggling to make it up the stairs to participating in a cycle ride from London to Paris in a relatively short time. After her surgery, Pat was determined to enjoy her new lease of life and that is exactly what she is doing. Her boundless energy and passion for raising awareness about a disease that is so personal to her is truly inspirational.

The cycle ride was a wonderful adventure and there are many things that I will take away from this journey. The memories, the laughs, the adventure, the accomplishments and the friends. The Heart Valve Voice team has mentioned they are thinking about doing it all again next year - I can’t wait to get signed up.

More information about Heart Valve Voice and Pat Khan’s story can be found at www.heartvalvevoice.com. n

Helen Munday, SCTS Nursing and AHP Representative

Images courtesy of Michelle Richards

Photography

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There are a variety of tools used in surgical education. In Cardiothoracic Surgery, we have

the luxury of the SCTS education portfolio, which affords face to face interactive educational experience; there is access to numerous wet-lab or cadaveric courses both nationally and in local deaneries; and there is an annual local educational programme within each deanery. SCTS University offers a contemporaneous overview of cardiothoracic practice for continuous professional development.

Webinars are one of many new technologies which are available for CPD which allows the delegate to engage with the programme with a remote speaker at their own site. The Royal College of Surgeons of Edinburgh (RCSEd) have used this technology, which has been rolled out in various specialties including: colorectal, endocrine and ear, nose and throat surgery. Webinars offer the opportunity to interact with leading experts without the speaker travelling and saving costs. In the era of information technology, this offers a great opportunity to disseminate knowledge as well as acquire it.

SCTS Education works in close co-operation with the RCSEd Education department offering external quality assurance and educational advice where required. A recent addition to Cardiothoracic Surgical education is the development of Cardiothoracic webinars offered in conjunction with the RCSEd.

The webinars are listed on the RCSEd website where a participant can register which is open to all not only Edinburgh fellows and members. An e-mail is also sent out by the RCSEd to all Cardiothoracic trainees highlighting that an upcoming webinar is scheduled and a link to the registration page is provided. One topic per webinar is selected

and delivered by a Consultant Cardiothoracic Surgeon using a Webex platform. The Webex application software is offered as free to install for the webinar. The webinars are scheduled to run for one hour of which the presentation is for 45 minutes with 15 minutes for questions.

The webinars offer the slides of the presenter on the device of the recipient with their voice only. The delegates can interact with the presenter through the chair person on the chat box. Throughout the webinar there is a free text box that allows the participants to submit questions to the chair who asks the speaker at

the end of the webinar on behalf of the delegates. Depending on the time available, as many questions are asked as possible. Following the event, the participants are asked to complete a

feedback form on the individual session. This is collated by the RCSEd. Since February 2017, there have been four webinars and future webinars are planned until the end of the year and these are depicted in Table 1.

A new educational tool in Cardiothoracic Surgery: Web-based seminarsAlan G. Dawson, Trainee, Aberdeen Royal InfirmarySridhar Rathinam, Consultant Thoracic Surgeon, Glenfield Hospital, Leicester

“Webinars offer the opportunity to interact with leading experts without the speaker travelling and saving costs.”

Webinar title Date TutorCardiothoracic Trauma 09 February 2017 Mr Timothy GrahamSurgery of the Thymus 06 March 2017 Mr Pala RajeshFrozen Elephant Trunk (FET) Technique in Aortic Arch Surgery

25 April 2017 Mr Geoff Tsang

Heart Transplantation 03 July 2017 Mr Rajamiyer VenkateswaranLung Cancer Surgery 24 July 2017 Mr Richard PageValve-sparing aortic root replacement 28 August 2017 Professor Tirone DavidSurgery of the Chest wall 5 September 2017 Mr Maninder Singh KalkatMinimally invasive valve surgery 2 October 2017 Mr Joe Zacharias

Mesothelioma 6 Nov 2017 Mr Apostolos NakasSurgery for Atrial Fibrillation 11 Dec 2017 Mr Michael LewisSurgery for Stage III Lung cancer 9 Jan 2018 (TBC) Professor Keith Naunheim

Table 1: Webinars in Cardiothoracic Surgery

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As the RCSEd has an international representation and in an attempt to popularise SCTS and UK Cardiothoracic surgeons, the webinars are offered at two separate time points which has not been offered in any other specialty before. One is at 20:00 GMT with the other one scheduled at 08:30. This allows all the Cardiothoracic community to have equal access to this training opportunity. The webinars are recorded and uploaded onto the RCSEd website so that all participants can re-review it or view it if unable to attend any of the scheduled webinars (members only).

The programme is led by Mr S. Rathinam with the cardiac programme collated and co-ordinated by Mr L. Balacumaraswami from University Hospitals of North Midlands. The leads have succeeded in inviting international speakers like Professor Tirone David and Professor Keith Naunheim for the wider benefit of the fraternity.

Although in its infant stages, the webinars have had a very positive response. In the first three webinars where analysis have been performed, a total of 138 delegates participated. The attendance in the United Kingdom webcast at 20:00 had more attendees than the morning webcast. The spread of delegates, although predominantly from the United Kingdom, are widely spread from Malaysia to the United States of America (Table 2). Similarly the spread of the experience level varied between medical students to established Consultant Surgeons (Figure 1). The feedback was very good with the overall rating of 4.02 out of 5. It is interesting to see that delegates access the webinars on different forms of media (Figure 2).

The cardiothoracic webinars are a new addition to surgical education in our specialty. The feedback has been very positive and the internet-based platform together with the variety of timings allows a large number of trainees to participate from any location in the world. The delegates can register for next cardiothoracic webinar at: www.rcsed.ac.uk/professional-support-development-resources/learning-resources/webinars. n

Country PercentageUnited Kingdom 44Saudi Arabia 7India 6Italy 5Greece 4United States of America 4Malaysia 3Australia 2

Germany 2Nigeria 2

Table 2: Percentage of attendees accessing the Cardiothoracic webinar by country

Figure 1: Attendees of the Cardiothoracic webinar series as per training grade

Figure 2: Type of medium used to access the Cardiothoracic webinar

August 2017 49

University of Alabama in Birmingham (UAB) is the leading thoracic robotic centre

worldwide and they kindly invited our team to see how this can be delivered. They have developed a service which has gone from undertaking small numbers of thoracic surgical procedures per annum, to one that currently manages over 1000, under the leadership of chief surgeon, Dr Robert Cerfolio. This provided an ideal opportunity for us to review how such a fantastic improvement in patient care and efficiency can be delivered and the contributory factors required from all the different members of the team.

Nottingham University Hospitals NHS Trust is a tertiary referral centre serving a population of approximately 2.5 million, and is one of the large thoracic surgical centres in the UK. Our team, in keeping with the Trust’s aspiration to be a leading national centre, has the desire and the dedication to continually strive for excellence in all aspects of the service we provide for our patients. With this in mind we started exploring robotic assisted thoracic surgery (RATS).

Dr Matt Daunt, Consultant Thoracic Anaesthetist, Nottingham City Hospital Mohammad Hawari, Consultant Thoracic Surgeon, Nottingham City Hospital

Our visiting team was made up of a thoracic surgeon, 2 thoracic anaesthetists and 2 scrub nurses. Our trip was kindly fully sponsored by Nottingham Hospitals Charity. During our visit, we observed a wide range of thoracic robotic surgical procedures including a completely robotic assisted oesophagectomy, several lobectomies, oesophageal hernia repair as well as several VATS and interventional airway cases.

The robot allowed the surgeon to do a wide variety of operations, some significantly more complex than others, some of which most likely would have needed open procedures if it wasn’t for the robot which facilitated

the degree of manoeuvrability inside the patient’s chest. Cutting, stitching, anastomosis all became an easy reproducible technique. The application of this surgery especially in sleeve lung resections and oesophagectomy is definitely of great value.

The surgical training we witnessed was very impressive. Having two consoles controlling the robot, allowed the trainer to be in full control of the training process as he or she can see all aspects of the procedure all the time, so they can guide their trainee and can take over whenever it is felt necessary. This allowed proper directed training even in complex cases.

Exploring Robotic Thoracic Surgery:Nottingham visits Alabama

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A main area in which anaesthesia differed from our current practice was the use of invasive monitoring. Currently, we routinely use invasive arterial blood pressure monitoring for all patients undergoing major lung resections and those with significant comorbidity, both intra-operatively and for the first day post-operatively, necessitating a higher level of post-op care to be available. We found that apart from one patient (who had a degree of aortic valve disease and was undergoing RATS oesophagectomy) invasive arterial monitoring was not used. The reasoning behind this was that they did not believe it would add any significant benefit to the management of the patients, but exposed them to a measurable complication rate and added time to the process. Having seen this system being on the whole successfully employed, we will review our practice and are likely to be able to reduce our use of arterial lines and its inherent complications, costs and time.

Probably the most significant variation we saw, was the analgesic protocol. Our practice involves the use of thoracic epidural analgesia or paravertebral catheter with systemic opiate analgesia for the majority of patients. This approach has been abandoned for all thoracic procedures at UAB in favour of pre-operative gabapentin, intra-operative intercostal nerve blocks, local anaesthesia ‘field blocks’, and post-operative local anaesthetic patches and opiate analgesia as required. Considering the increased morbidity that we would

expect with poor analgesia and sedation from systemic opiates, we would not have expected this approach to have any realistic chance of success, especially with major lung resections and oesophagectomy. It was enlightening to see this approach working so well, and to be able to review the patients up to 2 days post-surgery with excellent results in terms of mobility, cough and patient satisfaction. Other factors such as patient motivation, management of their expectations and pro-active and supporting nursing care would contribute to the successful employment of this technique, but it is certainly something that we would want to replicate in our unit.

Theatre efficiency was an area of significant interest when planning our visit to UAB. Operating times in UAB are from 0700hrs-1500hrs. This is mostly due to Dr Cerfolio’s passionate belief that human beings are more productive earlier in the day due to cortisol level changes. It allows his team to spend the afternoons as their free time, and seems to be effective. The theatre system that they employ is quite different to our own, as they have a suite of 3 or 4 theatres being utilised by one surgical team. This allowed the surgeon to finish one case and almost immediately begin the next by moving to the next theatre where the patient had already been anaesthetised and prepared. It is unlikely that we could deploy theatres in the same way, but we use a similar approach by utilising the anaesthetic room attached to our theatres to prepare the next patient and minimize turnaround time.

It was clear that to produce such outstanding results in terms of clinical outcomes as well as theatre efficiency, the whole team working in UAB thoracic theatres worked together with complete understanding of their shared goals and protocols. It was very pleasing to

“Our visiting team was made up of a thoracic surgeon, 2 thoracic anaesthetists and 2 scrub nurses. Our trip was kindly fully sponsored by Nottingham Hospitals Charity.”

find that all members of the team were extremely accommodating; more than happy to answer questions and often going out of their way to help us.

Having seen the robotic assisted thoracic surgery in action, and following the patients through their hospital journey, we strongly believe that this is the future for our patients. The shortened length of stays and improved pain management will not only improve our patient outcomes, but also drive efficiency within the cash-strapped NHS. The experience of visiting UAB has shown us what aspects we can bring to our practice, and also reinforced the areas where we believe we are performing well. n

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The importance of the power of the published word to surgery, surgical science and care is without

doubt. As a member of faculty for the Royal College of Surgeons course, “How to write a surgical paper” I have asked participants for their experiences of scientific publication. “Difficult”, “time consuming”, “editorial staff are never satisfied”, are among the damning responses given. So why in the face of such adversity do we insist on exposing ourselves to the rigours of scientific writing? Why is writing and publication seen as an important skill for the surgeon to have?

Publishing scientific work allows ideas to be shared and collaborations to be established. An archive is created which in turn promotes future work and, hopefully, prevents meaningless repetition of that which is already known. Writing is one part of the bigger scientific endeavours and it is hard, time-consuming work that rarely comes naturally and (except on the excellent course mentioned above) never taught. Publication therefore serves to “credit” the

author with the appropriate recognition for their toils. In the case of new scientific or surgical method and technique this is of particular importance as provision of an initial reference on which others can build and further develop or evolve. Alongside such noble and erudite reasons, publishing scientific work also serves to provide lines on CVs and much valued points against shortlisting criteria.

In the book, “How to get your paper published”, Jyoti Shah (Consultant Urologist and commissioning editor for the Annals) recognises there to be over 28000 peer-reviewed journals (more on them later) publishing approaching 2 million articles per annum. These are staggering numbers that have increased consistently since journals came into being. The competition

for acceptance is evident and hopefully too the importance of picking the most relevant journal (or more importantly, the most relevant “readership”) for the message of your work. The Annals of the Royal College of Surgeons has a very broad readership, being available to all fellows and members of the college irrespective of speciality. Whilst it may not therefore be appropriate to publish works exploring the intricacies of our speciality it

may appeal for those wishing to publish works with broader learning points. I’m of the opinion we have lots to offer the surgical community and would like to encourage my colleagues to consider the Annals, particularly if the broader learning points of your work can be highlighted.

Cardiac and Thoracic surgery both have scientific surgical histories to be proud of. Coronary artery bypass surgery is among one of the most commonly performed and studied major surgical procedures in the world today. A very crude Pubmed search for “Coronary artery bypass” yields over 64,000 results, compared to just over 32,000 for “hip replacement” (I recognise “science”

In December 1824 the Duke of Wellingtons response, when facing salacious blackmail threats illustrates the power of the many facets of publishing and published material. They did publish and they were damned; dying in obscurity within a few years.

“Publish and be damned” -Writing, reviewing and publishing; an editorial perspective

Antony Walker, Consultant Cardiac Surgeon, Blackpool Teaching Hospitals NHS FT

“The digital explosion has undoubtedly facilitated publication. We can now perform literature searches and garner references through handheld devices (rather than hours spent leafing through index medicus – google it if you’re too old to remember).”

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of this calibre is not worthy of publication). Surely in all those manuscripts there is learning that might be of relevance to our orthopaedic colleagues? Surely in all our combined surgical experience there are learning points to share with the wider surgical community? Team-working, the WHO surgical safety checklist, surgeon specific outcomes, teaching and training are all areas that cardiothoracic surgeons have valuable experience of; areas that can be studied and then published. The Annals welcomes work exploring these areas of combined, collaborative interest.

The digital explosion has undoubtedly facilitated publication. We can now perform literature searches and garner references through handheld devices (rather than hours spent leafing through index medicus – google it if you’re too old to remember). Instructions for authors (just as important to follow as choosing the right journal in the first-place) and manuscript submission are on-line. Similarly manuscripts are sent to reviewers and collation of their comments done

electronically. All these developments have greatly enhanced the turn-around time for manuscripts and feedback from editors to authors; though probably for the same reasons the attention span of all involved will continue to decrease and times need to constantly be driven down further. Such e-developments have also seen an increase in less scrupulous journals. Predatory journals offer guaranteed publication for a fee, often lacking peer review or informed editorial input and therefore no guarantee or assurance of the scientific credibility of the work being accepted. Such behaviours have been exposed by authors in increasingly inventive ways; www.scs.stanford.edu/~dm/home/papers/remove.pdf, being accepted for publication pending receipt of $150 publication fee. Randy Newman wasn’t kidding when she sang, “It’s a jungle out there” but “Bealls list of predatory journals and publishers” is available to help identify the most dangerous beasts.

Peer review is not without its faults. It is tried, tested, interesting and like publishing, a good way to earn valuable appraisal

points. If you’ve been on the receiving end of bad reviews and don’t like the system, then perhaps the best way to instrument change or improve the quality of the process, is from within. I have no doubt of the breadth of experience and expertise of my colleagues and the hours and hours of free time you all have during the working week. Hours that could be put to good use reviewing manuscripts for the cardiothoracic section of the Annals of the Royal College of Surgeons!

Mark Twain knew a thing or two about writing and publishing and said “the secret of getting ahead is getting started”; I look forward to receiving your manuscripts, notices of interest in working as a reviewer and general criticism of what you’ve just laboured through (assuming you got this far)!

So pick up your pens, tap at your keyboards and don’t worry about being damned, Tony Walker (speciality editor for the Annals of the Royal College of Surgeons). n

Antony.Walker@bfwhospitals.nhs.uk

Upcoming Courses - Trainees 27th-28th Sept 2017 Professional Development Course (ST8B) J&J Pinewood Campus, Wokingham

Course Directors: Stephen Rooney / Mike Lewis

27th-30th Oct 2017 SCTS band 5/6 Core skills course Audrey Emerton Education Royal Sussex County hospital, Brighton

Course Director: Tara Bartley

13th-15th Nov 2017 Introduction to Specialty Training in Cardiothoracic Surgery Course (ST3A) J&J Pinewood Campus, Wokingham

Course Directors: Ravi De Silva / John Pilling

28th-30th Nov 2017 Core Cardiac Surgery Course (ST4A) J&J Pinewood Campus, Wokingham

Course Directors: Joseph Zacharias / Ishtiaq Ahmed

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The earliest example of medical education can be seen in the Edwin Smith medical papyrus

from ancient Egypt, in which the master physician makes a clear distinction about diseases and conditions “he will treat” versus those he considers to be “hopeless”. This tradition of basing the management plan on the expected prognosis- according to the clinical findings- continued during the early ages of medical education; through the medical schools of Alexandria, Salerno, Isfahan and Cordoba at the hands of such giants as Hippocrates, Galen, Avicenna and Rhazes. These efforts were the foundation for medical practice based on well-defined scientific teaching and training. Because of the exclusivity of education and training, physicians were highly regarded and their decisions and orders were indisputable.

In Medieval times, however, the bright lights of scientific research dimmed, with only church-sanctioned practices allowed.

In other words, ‘scripts’ (prescriptions) were limited to and derived from the Scriptures. As such, “doctor’s orders” acquired an added air of sanctity and infallibility. During these Dark Ages, however, there was a plethora of self-proclaimed healers, barbers, herbalists and others were offering their services, albeit without any license. This chaotic “medical marketplace” had no standardized training, no measure of competency and no process for accountability.

The first substantial efforts to regulate the practice of medicine, with an objective of protecting the citizenry and promoting the safety of the public, were the formation of professional Guilds and companies. In the following two centuries, professional organisations (i.e., Colleges, Societies, etc.) were further

developed. Among their objectives are to: (a) Define the requirements in education, training and skills needed to practice medicine; and (b) Develop clear, scientific, evidence-based guidelines for the Standard-of-Care for safe practice.

Despite these efforts, the education and practice of medicine remained a Master-Apprentice model, well into modern times. As medical knowledge rapidly

expanded and many new areas and specialties emerged, it became very common for the early-career physicians and surgeons to travel halfway around the world to learn from a Master Surgeon; as in case of Dr DeBakey visiting France

to learn from Dr Leriche, or Dr Cooley learning from Sir Brock in England. This tradition of defining the specifics of medical or surgical practice along the lines of individual personal practice persists today to a certain degree. The “How I Do It” section in some cardiothoracic surgical publications, individual surgeons’

“Medicine is a science of uncertainty and an art of probability” - Sir William Osler

“Doctors always think anybody doing something they aren’t is a quack”- Flannery O’Connor

Scripts and Scriptures: Evolving From Personality-Based Practice to Evidence Based Practice

Hisham Sherif, Christiana Hospital, Delaware USA

“The first substantial efforts to regulate the practice of medicine, with an objective of protecting the citizenry and promoting the safety of the public, were the formation of professional Guilds and companies.”

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“preference cards” and the cardioplegia administration protocols are examples of such clinician-specific guidelines.

While organisational efforts to promote evidence-based practice continue and are much appreciated, individual or institutional bias has almost become the norm in areas such as cardiothoracic surgical critical care. In a six-surgeon group, it is not unusual to have as many management preferences within the same intensive care unit, which can be frustrating and interrupting to other clinicians who strive to do what Dr X “likes”.

Reasons for this bias for personal preferences as opposed to evidence-based practice recommendations are many and include the surgeon’s stature as a senior professor (“eminence-based practice”), administrative status (“position-based practice”), the institutional policies already in place (“province-based practice”), anecdotal and personal experience (“My-Way-or-the-Highway practice”), litigations (“defense-based practice”) or an incomplete or outdated understanding of the mechanisms of action of therapies (“voodoo-based practice”).

All kidding aside, more realistic reasons for the lack of adherence to clinical practice guidelines include:

l Awareness issues: Especially relevant for physicians in small towns and rural areas who are not in constant contact with the recent updates and changes in management recommendations.

l Authority issues: Frequently, high-level recommendations (such as Level I) are based on intermediate or low-level scientific evidence (Level C or Expert Opinion). In addition, as was the case of the well-publicised “sugar window” experience, strict guidelines including financial penalties were forced on the cardiothoracic surgical community, despite being based on a single measurement of blood sugar level during the first 18-24 hours postoperatively.

l Extrapolation issues: In today’s global medical community, practitioners in Africa or South America may consider research conducted in Europe or the Far East less representative or impactful to their patient population.

l Specificity issues: Recommendations are often generalised, assuming enough similarity between different groups of diseases. Guidelines for thoracic aortic disease lumps Turner syndrome patients with Marfan’s syndrome patients, for instance.

l Reproducibility issues: A recent article in Nature lists over 70 of published scientific research could not be reproduced by other researchers using the same methodology. Subsequently, practitioners may consider these findings unreliable.

These issues provide a list of actionable items, where strategies to improve adherence can be developed. In addition, improving the guidelines themselves is instrumental to improving practitioners’ trust and adherence. Expanding the scientific body of evidence to rely more on randomized controlled trials and other high-quality evidence is essential to avoid the low-level evidence of “consensus of expert opinions”. Besides, a true transdisciplinary approach that incorporates experimental evidence from other disciplines is timely and much indicated. Importantly, drafting of guidelines should be restricted to healthcare professionals and never to administrators or legislators. This will improved the engagement and contribution of practitioners, plus alleviate some of the administrative barriers to adoption including the financial and reimbursement issues.By restoring healthcare decision making to its rightful owners - the practitioners; who are actively engaged in developing realistic guidelines through rigorous, high-quality scientific evidence, our professional integrity and status can be preserved; and “Doctor’s Orders” will regain their due weight. n

“As medical knowledge rapidly expanded and many new areas and specialties emerged, it became very common for the early-career physicians and surgeons to travel halfway around the world to learn from a Master Surgeon; as in case of Dr DeBakey visiting France to learn from Dr Leriche, or Dr Cooley learning from Sir Brock in England.”

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RAM (Bob) Lawson was born in a farmhouse in Ardross, a tiny village in a rural area in the

Highland region of Scotland. His parents had settled in, the then, Ceylon after marriage but returned home to Scotland for the birth of their first child. Returning after 8 weeks to the subcontinent, the family continued a happy life in Colombo till the imminent threat of a Japanese invasion of the island forced the evacuation of British women and children to South Africa for a couple of years. On return to Colombo, Bob’s father became ill and died as the result of Lung cancer on New Year’s Day 1945.

With no financial support abroad, the family returned to the safety and comfort of the family farm, in Ardross. There Bob went to the local primary school where he excelled, mainly, he would say, because there were only three in his class. From there he went to George Watson’s College in Edinburgh where he boarded for six years. Bob was “forever indebted to the Scottish Educational System for this and for the following six years at the Edinburgh University Medical School”.

After four years in general surgery at Bangour General Hospital, a career move to cardio-thoracic surgery saw him move south of the Border to Shotley Bridge Hospital in Co Durham. He spent 1972&1973 working as a registrar at the

Brompton Hospital. This was followed by 2 years Fellowship with Professor Albert Starr in Portland Oregon after which he returned to the UK to complete the last two years of his senior registrar training on the London Chest/ Brompton/National Heart circuit. He was appointed consultant at Wythenshawe Hospital in South Manchester and at Pendlebury Children’s Hospital, Manchester in 1977.

Bob was a caring, compassionate, committed and conscientious clinician; He saw his patients twice a day and at weekends throughout the year without fail. In addition to his work at WH, he shouldered a significant paediatric surgical workload at Pendlebury. An onerous undertaking considering the emergency component of that type of surgery and the travel involved.Bob was available 24/7 for his patients. When the WL became unmanageable, he operated on WL patients on Saturdays and Sundays free of charge.

He was an excellent clinician, skilful operator and a gifted teacher who contributed greatly to developing cardiac surgical services in Manchester. He was highly regarded and universally respected by his Fellow consultants, nursing colleagues, trainees and patients alike. Many of his patients became life-long friends. He retired from Wythenshawe in 1998, but continued at Pendlebury for three more years.

On retirement, the Lawson’s moved to Blackburn where Bob was able to indulge his passion walking the Hills of Pendle. His enjoyment of hill walking was severely curtailed in recent years with the onset of a spinal disorder. He loved reading poetry, watching Scotland play Rugby. For a number of years he had a love affair with low slung sports cars. Despite bilateral hip replacements at the tender age of 45 or thereabouts. He could get in and out of his TVR and Lotus Elan with amazing agility and grace. When he could no longer manage the graceful entry and exit he settled for the excellent Skoda Superb. He travelled a great deal over the years with Liz and sometimes with his large family. Europe-wise he loved Greece the best. Bob was a true Scot; proud to be so and loving everything Scottish, particularly the Highlands and the North West.

His death came unexpectedly two weeks after admission to Blackburn Royal Infirmary on Christmas Day with an acute pneumonia. Bob was a loyal friend and an exemplary colleague of unimpeachable integrity; throughout the 40 years I have known him he displayed malice towards none with charity for all.

He will be greatly missed and lovingly remembered by all those whose lives he touched none more so than his loving wife Liz, children; Becky, Kate, Libby, Tom and Hannah and his 9 grandchildren. n

MB ChB Ed.1961; FRCS Ed. 1966; FRCS Lon. 1970.

Consultant Cardiothoracic Surgeon: Wythenshawe and Pendlebury Children Hospitals, Manchester.

Obituary: Robert Alexander Murdoch Lawson 11/2/1938 – 10/1/2017

A Deiraniya, Retired Surgeon

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It is with great sadness that I am writing this obituary about my dear and lost friend, Gus, for the benefit of

our members.

A native of ‘The Colony’, he completed his studies at boarding school in Kent and went to Medical School in Nottingham where he also completed his Doctorate of Medicine.

Following specialist training in Southampton and a one-year long fellowship in Toronto, he was competitively appointed as Consultant in Blackpool in 2004, where we first met.

He and I could not have been more different in many respects, yet we became good friends and colleagues. Our surgical cooperation drew even closer when we both helped develop the TAVI programme at the Lancashire Cardiac Centre.

He was a talented surgeon and a gifted trainer who was held in extremely high regard and with great affection by his trainees. He was regarded as an exceptionally knowledgeable clinician. He was also a very pleasant person to work with, who never lost his manners even in challenging circumstances both in theatre and ITU. Gus also became the Research and Development Lead for Cardiothoracic Surgery, and was instrumental in the development and expansion of the R & D programme. He was Secretary to the Medical Staff Committee and became a key member of the LNC.

In addition, he was very well-liked and respected by his many non-surgical colleagues throughout the hospital.

His constant dignity and professionalism shone through during some of the most difficult and stressful experiences of his career; unfortunately, for the last five years of his life he was subjected to sustained attacks on his professional and personal credibility. Throughout this challenging period he conducted himself with characteristic good grace, dignity, and humour. He was repeatedly acquitted by internal and external reviews. Characteristically, he carried on working and performing often highly complex

surgery to the highest of standards – indeed in the last few months of his life, he was commended for this by an external review.

However, by this stage, he knew that he only had a few months to live; late in September 2016 Gus was diagnosed with inoperable cholangiocarcinoma and after careful consideration he chose to make the very brave decision to let nature take its course, rather than prolong his agony. He bore his illness with considerable grace and good humour. He remained a true gentleman to the very end.

Gus died peacefully on 30/01/2017, and leaves behind his family, friends and loving partner.

I know he is in Heaven and will watch over the shoulders of his surgeon friends for many operations to come. n

FRCS

Consultant Cardiac Surgeon

Obituary: Augustine (Gus) Tang 13/09/1966 (Hong Kong) – 30/01/2017 (Blackpool)

Franco Sogliani, Consultant Cardiac Surgeon

“Gus was a talented surgeon and a gifted trainer who was held in extremely high regard and with great affection by his trainees. He was regarded as an exceptionally knowledgeable clinician.”

Pictured right: Gus Tang 1966-2017

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Across 1 Philosopher out of hospital (6) 4 Follow as an alternative (6) 7/32 Where plants are in terrible danger (6) 9 Join about 1 (7) 10 Cut, said lord (6) 12 March in formation (4,3) 15 Feature of hippo or mandrill (4,3) 17 Encourage a person serving cocktails outside (9) 19 Fit, he may be (5) 20 Drunk table whine (5) 21 Line out gently, start out gently (9) 22 Blue alumnus with a view (7) 25 News: it’s back, with a lot of noise and empty gestures (7) 27 US bum to speak easy where Francis came from (6) 29 Drive out previous beat (7) 32 See 7 Across 33 Sausage in the car (6) 34 See 24 Down

Down 1 Stunner took test again on the way up (5) 2 Love the longest river (almost) (3) 3 Some believe in this priest (3) 5 Is compiler having to leave friend? (5) 6/28 See nose put out of joint and relax (6) 7 Nan, 50, has a fit (5,3) 8 At first, respond so very politely (4) 11 Poles get doubtful and arrogant (6) 13 The sound of seals and birds (7) 14 Madame Antoinette’s intended... (5) 16 ...to get wet and naughtily sit on me (7) 17 Degree has benefit for primate (6) 18 At heart, Enid knew item went next (8) 19 The fashion of a secret rendezvous (5) 23 In the river, the Italian deportee (5) 24/34 Writer in debt, only to be restructured (4,6) 26 Strict violinist’s bow? The other end! (5) 28 See 6 Down 30/31 Everyone’s favourite outside platform (3,3)

Crossword

Please send your solutions to: Isabelle Ferner, SCTS, 35-43, Lincoln’s Inn Fields, London WC2A 3PE

The first solution pulled out of the hat after 1st October will receive either a bottle of champagne or fine olive oil.

Winner of the January 2017 Bulletin crossword competition: Congratulations to Alan Bailey who received a bottle of champagne.

Nizar Yonan - Wythenshase Hospital - 2017

Russell Millner - Blackpool Victoria Hospital - March 2017

Geoff Berg - Golden Jubilee Hospital - April 2017

Pala Rajesh - Birmingham Heartlands Hospital - April 2017

Mark Jones - Wythenshawe Hospital - July 2017

John Dark - Freeman Hospital - August 2017

Rex Stanbridge - Hammersmith Hospital - August 2017

Recent Retirements The society would like congratulate our new officers:

New Officers

Stephen ClarkElected trustee (2016)

John DunningElected trustee (2016)

Clinton Lloyd Meeting Secretary

Maninder KalkatDeputy Meeting Secretary

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