No.27, Sept 09 (File size 8.5MB) - Association of Surgeons of Great

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Association of Surgeons of Great Britain and Ireland
EDITORIAL
Welcome to the September edition of the Newsletter. Since
the July issue, we have experienced quite a ‘Summer of
Surgical Challenge’. EWTR has come and gone, although
the predicted results on training and service provision are
still to filter through; the country is in a financial
meltdown; national debt is rising; and there are threats for
cuts of £15 billion in NHS real-term funding in the five
years from 2011 (ref: Steve Barnett, NHS Confederation).
What effect will this have on surgical service provision and
training? Well, major I would anticipate. Plans for
revalidation and recertification are well advanced, yet too
expensive. Although recertification is here to stay (see
John Primrose, Editorial, March 2009), the GMC have
recently informed us that ‘the process’ is to be simplified
to such an extent that is likely to merely involve surgical
licensing and the widespread uptake of those current
appraisal practices which are already well represented
amongst our surgical specialties. Arrangements for
recertification of surgeons are already well advanced when
compared to those of most other specialties and I suspect
that any changes in our current ‘arrangements for
appraisal’ will be minimal when announced for reaccreditation. Watch this space and I will keep you
informed as further information becomes available.
The financial squeeze will also implicate on training.
Hospital trusts will be required to maintain service
commitment at all costs and I do fear that surgical training
will be one of the casualties. Already we are seeing SpR
rotas propped up by the appointment of “trust doctors” and
there is significant current evidence of reduction in training
opportunities as our trainees are diverted to maintaining
service within our hard pressed NHS hospitals. I have no
doubt that, when the full effects of EWTD are realized,
alongside cuts to NHS budget, there will be certain
hospitals who decide not to train, but to concentrate on the
provision of patient care by ‘trained doctors’. Who are
these trained doctors? Well not consultants I suspect; they
are too expensive and unattractive at times of financial
stress. The sub-consultant grade (for this is the reality) is
gradually being introduced into many of our UK hospitals
and will need to be carefully monitored, maybe through the
SACs, but certainly via our local training committees. The
impact this will have to surgical training and career
progression for our present day and future surgical trainees
is indeed significant. Are trainees in your hospital suffering
as a result of EWTD or financial restraint? Please let me
know at [email protected] and I will publish your
concerns in the December Newsletter.
Returning to recertification: this will be administered by
the GMC and based on the four GMC domains of “Skills,
Knowledge and Performance; Safety and Quality;
Communication, Partnership and Teamwork; and
Maintaining Trust”. Nevertheless, the GMC is not held in
high regard by many of our surgical colleagues and appears
to have lost much of it’s credibility over the last 10 years.
Number 27, September 2009
Please read John MacFie’s excellent leader published in
this edition of the Newsletter and entitled “GMC: Is it fit
for purpose?” It challenges the very role of the GMC as
our regulatory body, particularly with respect to its role in
“dealing firmly and fairly with doctors whose fitness of
practice is in doubt”. This is very much a personal view,
but I defy all of you to disagree with many of his thoughts.
Several commentaries have been commissioned and are
also published along with a response from the GMC. Have
you fallen foul to GMC disciplinary practice? Do you feel
changes to the regulation of doctors are required? Please
write to me with your experiences at [email protected]
and I will publish your letters in the December Newsletter;
names and addresses can be withheld on request. To set the
ball rolling, one of my colleagues on the ASGBI executive
writes, and I quote:
“Dear John, my opinion of the GMC mirrors yours. I have
no proof, but all I have heard gives me this deep seated
feeling that they are the enemy. I do fear them. I do
practice in such a way as to avoid any contact with them. I
do not think that any contact with them would be fair, just
or have my interest at heart. They frighten me and I resent
having to pay for them. I too hope to get to retirement
without meeting them. Publish.”
(Name and address withheld)
Despite the above, we would all agree that patient safety
remains paramount to our practice of surgery. The GMC is
responsible for overseeing safety and quality, yet there are
many aspects to patient safety which need careful attention
in our everyday surgical practice. For this reason, ASGBI is
organising a one day patient safety conference entitled
“Avoidable Adverse Events in the Surgical Patient”. This
will be held in London, at the Royal Institute of British
Architects, on Friday 23rd October 2009 and details of the
programme can be found at: www.asgbi.org.uk/patientsafety-conference An excellent panel of speakers has been
drawn from the Protection Societies, the Medicines and
Healthcare Products Regulatory Agency, hospital trust
management, CORESS, aviation, and of course many of
your colleagues. Please register for this event and join us
on 23rd October. We will be publishing a statement
following the conference and would welcome your
participation and comments on this important subject.
Finally, a further date for your diaries. The next ASGBI
International Surgical Congress entitled “The Challenges
of Surgery” is being held at the “BT Convention Centre in
Liverpool from 14th to 16th April 2010. The venue is
surrounded by excellent affordable hotels, restaurants and
bars and I would encourage you all to bring your
colleagues, junior staff, nurses and technical staff to this
superb venue. We very much look forward to meeting
with you and your ‘teams’ and can assure you of a
memorable event.
Mike Wyatt
Honorary Editorial Secretary
GMC: IS IT FIT FOR PURPOSE?
John MacFie
2
Despite the fact that the GMC is held in high
esteem, both within and without the medical
profession, with regards to the first three of these
objectives, recent years have seen the organisation
come under increasing criticism for the manner in
which it conducts disciplinary proceedings.
Indeed, few issues so unite the medical profession.
Ask any doctor their opinion of the GMC, and the
overwhelming majority will express the view that
the GMC is no longer fit for purpose.
NEWSLETTER
The GMC was established under the Medical Act
of 1858. The purpose of the GMC is to protect,
promote and maintain the health and safety of the
public by ensuring proper standards in the practice
of medicine. The GMC has four main functions as
defined in the Medical Act 1983: keeping up-todate registers of qualified doctors; fostering good
medical practice; promoting high standards of
medical education and dealing firmly and fairly
with doctors whose fitness to practise is in doubt[1].
The purpose of this short review is to examine
those factors which have lead to such a dramatic
change in the medical professions’ opinion of its’
own regulatory body.
Fear
Prior to the 1990s, most doctors only ever thought
about the GMC at the time they paid their annual
subscription. It was largely regarded as a benign,
paternalistic, professional organisation. The last
two decades have seen a sea change in attitude.
Dissatisfaction with the GMC is now
commonplace. Indeed, there is probably no parallel
in modern society whereby a professional body is
held in such low regard by its own members. A
major factor behind this change in attitude is fear.
Few now would disagree that fear of referral to
the GMC, or of litigation, accounts for much overinvestigation and over-treatment. It is tempting to
blame the compensation culture and the legal
profession for this and, whilst I have no doubt that
they have made a major contribution to fuelling
patient dissatisfaction, there is also no doubt that
the GMC as the doctors’ regulatory authority has
failed the profession. The GMC is funded by the
medical profession and disciplines the medical
profession. It is poacher and gamekeeper rolled
into one. In 1983 the GMC’s ‘Blue Book’ stated
that the GMC was not “ordinarily concerned with
errors in diagnosis or treatment or with the kind
of matters which give rise to action in the civil
court for negligence”. This statement infers that
the GMC was not then, or for its previous 125
years, concerned about medical negligence. Over
the last 20 years this has changed. The GMC now
has fitness to practise (FTP) panels sitting on
most days in both Manchester and London. The
majority of cases do not relate to drug abuse,
drunkenness, failure to answer calls or
inappropriate liaisons with either patients or
members of staff but to medical negligence. This
is compounded by the willingness of doctors to
find fault with their colleagues for financial gain.
Unsurprisingly, surgeons and other consultants
now have an obsessive fear of missing organic
disease and are unable to cope with diagnostic
uncertainty. Patients are given mixed messages
about their symptoms. It is easier to pursue
investigation or instigate invasive therapies on the
basis of equivocal findings because this alleviates
doctors’ anxieties and mitigates against possible
litigation. No one is advocating, on the basis of
prospective randomised trials - or on historical
evidence and precedent - that surgeons might
adopt a ‘wait and see’ policy. The idea that the
surgeon might sit by the patient’s bed, hold their
hand, meet their relatives, and understand their
particular anxieties is overwhelmed by a desire to
investigate or treat.
The change with respect to standard of proof in
fitness to practise panels from the current criminal
standard (beyond reasonable doubt) to the current
civil standard of proof (the balance of
probabilities) is a mistake, both for the medical
profession and our patients. It will result in
doctors adopting defensive practise. Under these
circumstances, no doctor would easily justify the
maxim ‘let nature takes her course’ or let’s ‘wait
and see’. Surgeons now work in a climate of fear;
fear that not to investigate will be seen
subsequently as negligent when, in fact, it might
have been a deliberate act of care and compassion.
The media delights in medical misdemeanour. The
public remain convinced that failure to investigate
can alter the natural history of disease. No test
ever altered the natural history of disease!
This fear is justified!! In 1990 the GMC received
about 900 complaints. By 1995 this had increased
to 1,503, by 2000, 4,470 and by 2005 just over
5,000 [2]. It has been estimated that approximately
one in four doctors will, at some point in their
career, receive a letter from the GMC concerning
their practise. Anxiety about the GMC is
compounded by the fact that, increasingly, the
veiled threat of GMC referral is heard from Trust
executives, medical directors, representatives of R
and D committees and innumerable patient
interest groups who use the threat of referral as a
weapon against the profession. Doctors do all they
can to avoid such a referral knowing that,
whatever the outcome, the process is long, time
consuming and, in the interim, detrimental to their
professional standing.
The presumption of guilt
When reported to the GMC, doctors no longer
receive what used to be termed ‘the dear guilty
bastard letter’ nor are their names immediately
removed from the website before any deliberations
are made. The tone of letters received by the
accused doctor is intimidating and, unquestionably,
the presumption is of guilt. All institutions of
employment must be informed. The doctor has no
recourse to confidentiality despite the fact that no
guilt has been proved. Instantly a doctor’s career is
threatened and there is a slight on their professional
and personal reputation which remains, even if
completely exonerated.
It is now routine practice to have to declare on any
application for a new post or ACCEA form any ongoing GMC enquiry. Inevitably, this influences
outcomes to the detriment of applicants despite the
fact that no guilt has been established. Some GMC
investigations may take up to two years from
There are a number of concerns about this
process. First, it is lengthy, notwithstanding the
stated aims of the GMC to conclude matters
expeditiously. Secondly, there is no recognised
consistency within the UK of accredited expert
witnesses. Inevitably, the GMC case examiners
will be influenced by “expert witness” opinion
received. Whilst not a criticism of the GMC per
se, this illustrates a potential unfairness. The
GMC acts (at present) as both investigator and
adjudicator. The accused doctor is at the mercy of
GMC decisions. Whilst the GMC makes it clear in
its current guidance[3] that doctors are given the
opportunity to comment on issues at an early
stage, this was not always the case, and is
sometimes not advised by defence organisations.
In the past, when a doctor first received
notification from the GMC that a complaint had
been received, they would blank out all reference
to a patient’s name or institution. Hardly
transparent! I am informed this practice has
ceased. Consequently, the perception of doctors is
that they are powerless to influence decisions
about investigation or progression to a full FTP
hearing. During this interregnum, no recognition
Costs
There are 230,000 doctors in the UK all paying
£410 a year to the GMC. A large proportion of
these costs goes on disciplinary procedures.
Doctors pay their subscriptions for the dubious
privilege of funding an organisation which has the
powers to strip them of their livelihood. The
infrastructure involved in dealing with complaints
is colossal. Assessors, both lay and medical, legal
representation for both the GMC and the accused
doctor, costs of panel members and expert
witnesses run into many tens of thousands of
pounds per case. Less well known are the
financial costs to individual doctors. These don’t
occur as a consequence of time removed from the
workplace. Should a doctor not be a member of a
medical protection society, the legal costs of
representation at FTP hearings comes from their
own pocket. Crown indemnity does not cover this.
Locums be warned! Further, if the doctor is
unfortunate enough to have to attend a FTP
hearing, he or she will have to meet all their travel
and accommodation costs in London or
Manchester for the duration of the hearing. The
consequence is that individual doctors, even if
completely exonerated, may have had to part with
many thousands of pounds to clear their
professional reputation. In contrast, every
complainant, whether justified or not, has full
travel and accommodation costs met by the GMC.
Hardly a level playing field! Considering that the
GMC is fully funded by doctors’ subscriptions it
seems somewhat unfair that acquitted doctors are
not entitled to their costs and that unproven or
even vexatious complainants will receive all of
their expenses.
3
Stream 1 cases are allocated a medical and a lay
case examiner. The GMC may seek “expert”
witness opinion to support their case. Case
examiners may decide to progress to a FTP
hearing, make undertakings, issue a warning, offer
advice or conclude with no action.
The proof of the pudding, however, is in the
eating! There were over 5,142 complaints to the
GMC in 2008. Of these, 2,022 (39%) did not
progress, 1,465 (28%) were investigated as “stream
1” and 1,655 (32%) as “stream 2”[4]. Of the 1,465
“stream 1” cases, a decision was reached by case
examiners in 1,297 cases (I assume the other 165
doctors are still waiting). No less than 359 (25%)
cases were referred for fitness to practise hearings
and 333 (26%) were concluded with no further
action. In 2008 there were 204 FTP hearings
concluded and erasure or suspension was the
outcome for 117 (56%). No impairment was found
in 28 (14%). So the case examiners got it wrong
on 361 occasions. This represents almost a quarter
of all doctors the GMC decided to investigate with
case examiners as “stream 1”! Our justice system
would collapse if the criminal prosecution service
were so wide of the mark.
NEWSLETTER
Disciplinary procedures are opaque and poorly
understood
One reason most medical practitioners find GMC
procedures difficult to understand is simply that
they keep changing! For the interested, compare
and contrast descriptions of GMC procedures in
2004[2] and those of today[3]. At present, receipt by
the GMC of what they euphemistically term an
enquiry results in “triage”. The primary purpose of
triage is to determine whether or not the
information received raises a question about the
doctor’s fitness to practise. If the information raises
serious allegations which, in themselves, would call
into question the doctor’s fitness to practise, a full
investigation is instigated. This type of investigation
is currently described as ‘Stream 1’ and involves
the use of case examiners. If the information
received is deemed less serious, and potentially
something which would more appropriately be
dealt with locally, then enquiries with the doctor’s
employers or contractors are made to establish if
they have any wider concerns about their practise.
Once this information has been obtained, a second
assessment is performed to decide whether further
investigation is required or not. This process is
described as ‘Stream 2’ and - for reasons of space will not be discussed further here.
is given to the pastoral care of accused doctors.
Finally, there is a perception that case examiners
are unduly influenced by public opinion. This
stems from the observation that prior to 2000 less
than 10% of complaints progressed to a FTP.
However, following a well known case (GMC v
Toft) Justice Lightman argued that public
confidence in the GMC and in the medical
profession required that complainants had a
legitimate expectation of ‘public investigation’.
The proportion that progress to a FTP is now
almost 25%. One fears that the default position is
now to allow a complaint to progress.
receipt to resolution (the GMC’s own target for
concluding fitness to practice cases is 15 months).
This is a long time for a doctor’s career progression
to be impaired, particularly if the original complaint
was vexatious. I recognise that the GMC has the
power to conclude “vexatious” complaints at initial
assessment, but the fact of the matter is that
opinions differ as to what constitutes vexatious and
the GMC is likely to default to investigation as
their statutory duty is to the public not the doctor.
NEWSLETTER
Fitness to Practise hearings
FTP hearings are conducted like any other court
of law. They are necessarily adversarial. The
proceedings are conducted with impartiality. The
GMC, acting as the prosecution, and represented
by a barrister, calls witnesses and takes expert
opinion attempting to establish impairment to
fitness to practise. This is followed by the
defence. The accused doctor, also represented by a
barrister, also calls witnesses and takes expert
evidence. On completion, panel members may
seek clarification on certain issues and then they
retire in private to deliberate and reach a verdict.
There is no strict definition of fitness to
practise[5]. It relies upon an interpretation of the
GMC’s Good Medical Practice Guidelines. This
introduces an interesting legal conundrum. It is a
little known fact, outside the legal profession, that
there is no statutory definition of ‘serious
professional misconduct’. The attitude of the
courts has always been that it was a matter for the
profession to decide. Prior to the Medical Act of
1969 the term used was ‘infamous conduct in a
professional respect’ which clearly related to the
mores of doctors not their competence. In the
absence of a definition, it becomes a matter of
interpretation for each individual FTP hearing.
Their discussions are not public, hence the lack of
transparency, and arguably they are unduly
influenced by public opinion. Certainly, there is a
widespread view within the profession that the
ultimate sanction of a doctor being struck from
the register has been inappropriately used in
certain well-known high-profile cases.
From the professions viewpoint, there is also the
perception that injustices might occur as a
consequence of non-representative panels and as a
result of inappropriate expert witness testimony.
In the 1990s, the FTP panel comprised nine
members, the majority medical with a medical
chairman. Since 2003, the normal panel has
comprised 5 members with the recommendation
that at least one must be medical, one lay, and that
they should be constituted in such a way that they
are diverse in terms of ethnicity and gender. In
reality, these recommendations are often not
achieved. Frequently, panels sit with a minimum
quorum of three. Notwithstanding the fact that
GMC panellists are trained and advised by a legal
assessor, the fact remains that doctors may be
judged by individuals with no insight or experience
into their own speciality. Not surprising, therefore,
many doctors feel they are being judged, not by
their peers, but by professional committee members.
As regards expert witness testimony, it has to be
recognised that the GMC is limited to those
individuals who agree to give evidence. It is not
uncommon for expert witness statements to be
obtained from doctors not in the same subspecialty area of the accused doctor or from those
already retired. Further, it is a well recognised fact
that the incentive for many doctors to act as expert
is driven by financial, rather than professional,
considerations. This is unacceptable.
4
The extraordinarily rapid advances in surgery in
recent years will undoubtedly continue apace.
Surely, if a doctor is accused of malpractice, the
very least he/she can expect is that he will be
judged by a colleague who is in active practise in
the same sub-speciality?
I am informed that, following FTP procedures, the
GMC conducts a 360 degree assessment of
performance of expert testimony. This is laudable.
It is regrettable that the results of this exercise
have never been made public or made available
for the profession’s scrutiny.
The Future
In 2006, the Chief Medical Officer, Professor Sir
Liam Donaldson, produced a report entitled Good
Doctors, Safer Patients which formed the basis of
a Government White paper published in February
2007 entitled Trust, Assurance and Safety: The
Regulation of Health Professionals in the 21st
Century. This paper marked the start of a process
for implementing new legislation that included
amendments to the Medical Act of 1983 through a
Health and Social Care Bill. This Bill received
Royal Assent in July 2008 becoming the Health
and Social Care Act 2008. The major changes
introduced include the establishment of an
independent adjudicator, the creation of GMC
affiliates and the replacement the current criminal
standard (beyond reasonable doubt) to the civil
standard of proof (balance of probabilities). Time
will tell if these changes reverse the profession’s
negative feelings about the GMC.
In recent years, it has been argued, the GMC has
become the puppy of politicians, self- righteous
medical managers and shroud-waving judges all
acting in the declared common good of the
patient. This is manifest in the GMC’s logo
“regulating doctors, ensuring good medical
practice”. The reality is that the failure of the
GMC to support the profession has resulted in a
culture of fear and recrimination which,
inevitably, will damage patient care. The
utterances of certain prominent figures in both the
legal and medical establishments may all have a
resonance with the popular press, but they need to
appreciate that the long-term damage they have
inflicted on the overall care of patients is
immeasurable. They need to bear in mind that
medical perfection is an impossible dream.
In conclusion, I believe that the GMC is not “fit
for purpose” with regards to its role in
disciplining doctors. A powerful case can be made
for this aspect of GMC work being funded from
public funds not from doctors’ pockets.
REFERENCES
[1] http://www.gmc-uk.org/about/role/index.asp
[2] O’Rourke, M
Regulating Health Care Professions
In: Principles of Medical Law, 2nd Edition
Eds Andrew Grubb and Judith Lang
[3] http://www.gmcuk.org/concerns/doctors_under_investigation/a_gui
de_for_referred_doctors.asp
[4] http://www.gmcuk.org/about/council/papers/2009
/may/6b%20-%20Annex%20A%20%20Fitness%20
to%20Practise%20Annual%20Statistics%20for%
202008.pdf
[5] http://www.gmcuk.org/concerns/the_investigation
_process/the_meaning_of_fitness_to_practise.pdf
The reality is that, each year, we receive around
5,000 complaints or enquiries, a small number when
you consider that there are 232,000 doctors on the
medical register, who deal with tens of millions of
patients annually. Around a third of these cases are
closed very quickly as they are not relevant to the
doctor’s fitness to practise. Another third are referred
by the GMC to local complaints procedures. This is
important – most complaints can, and should, be
dealt with and resolved locally. The final third are,
on the face of it, serious allegations that require
further investigation by the GMC.
No one who has their professional conduct or
competence questioned will find it a pleasant
experience. Doctors must, however, be assured
that the process will be conducted fairly and
transparently by trained staff who operate within
clear rules and guidelines. Our fitness to practise
procedures are not developed in isolation. They
have been extensively consulted on with the
profession, medical defence organisations and
medical Royal Colleges. They are available for all
to see on the GMC website.
But we have to be clear. The allegations we
investigate are very serious: doctors with
convictions for child pornography and sexual
assault; doctors whose incompetence, and lack of
insight, puts patients at serious risk; and those
who abuse their position of trust with patients
GMC: IS IT FIT FOR
PURPOSE?
COMMENTARY ON THE ARTICLE
BY JOHN MACFIE
COMMENTARY: ONE
To paraphrase Winston Churchill, self regulation is
a very poor form of regulation except all those
other forms that have been tried from time to time.
In his thoughtful, provocative and informative
piece reflecting on the GMC, John MacFie seems
to be arguing for external regulation rather than
self regulation. While many of us would agree
with many of John’s assertions I, for one, would be
extremely concerned if we, as a profession,
abandoned any attempt to regulate ourselves.
The concept that we over-investigate and over-treat
patients because of concern about referral to the
The leading article suggests that, on many
occasions, the GMC’s Case Examiners ‘got it
wrong’ when, after a thorough investigation, both a
medical and a lay case examiner have agreed that
the case should not be referred to a public hearing.
In reality, this is a demonstration that the GMC is
doing its job effectively by determining that only
the most serious cases should be referred to a full
public hearing. The same logic applies to the
decisions by Fitness to Practise panels. If every
doctor who went before a panel had their name
removed from the register then one could argue that
the process was biased and unfair, when the reality
is that every panel makes its own independent
decision on the facts of the case based on the
evidence it hears, including that provided by expert
witnesses from both the GMC and the doctor.
It is important that doctors recognise the important
role the GMC plays in supporting public
confidence in the medical profession. Patients and
the public trust doctors in part because regulation
of the profession is independent of government
and independent of dominance by any one group.
This means that the GMC must balance the
interests of the profession and the public and not
be seen to favour one group or another.
We are committed to listening to and
understanding the views of the profession. All of
our guidance, from the standards against which
doctors are judged, to the rules and processes we
operate, are always open to consultation with the
profession and their representative bodies. We take
more steps each year to try and make it as easy as
possible for doctors to share their views with the
GMC and to influence the way we operate. We
welcome the views of individual members of the
profession and constructive debate.
Una Lane
Assistant Director
Fitness to Practise
General Medical Council
GMC bears some considerable scrutiny. Is it not
rather that we are concerned about litigation in
general in a world where patient expectation has
changed dramatically over one clinician’s working
lifetime? Occasionally patients say that we should
“do whatever you think is best”. That happens much
less frequently than it did. Patients and their relatives
now expect a much fuller explanation of clinical
situations and, as professionals, we simply have to
respond to that. Concern about being referred to the
GMC is, surely, not the primary cause for the
increasing complication and sophistication of
modern medicine. Nor should we use concern about
the litigious culture of the day be an excuse for not
undertaking compassionate and holistic care.
The increased referral rate to the GMC surely
reflects societal change and is not something that
we can fairly put at the door of the regulatory
body. Rather, we should acknowledge that it
presents the regulatory body with a problem in
5
The vast majority of doctors are good doctors
working in often difficult circumstances. Every day
in the UK thousands of patients are treated by
highly competent and caring individuals who, in
many cases, have devoted their lives to patient care
and the advancement of medical knowledge. There
can be no one in the medical profession who would
wish colleagues who are not fit to practise to
continue to do so. But equally, it is in no one’s
interest if there is a perception that their regulator is
not fit to investigate serious concerns about doctors.
NEWSLETTER
RESPONSE FROM THE GENERAL
MEDICAL COUNCIL
when they are most vulnerable. In such serious
cases, can there be any doubt that there should an
investigation and that action should be taken,
when some members of the medical profession albeit a very few - are not fit to practise?
GMC: IS IT FIT FOR
PURPOSE?
I would absolutely agree with the concept that there
should be presumption of innocence. There should
also be a level playing field in terms of expenses
and costs for the doctor who is acquitted. Similarly,
6
COMMENTARY: TWO
NEWSLETTER
sorting the wheat from the chaff. The fact that
5,000 referrals end up with 45 findings against a
doctor must show that they are getting something
right. I would not want, for a moment, to belittle
the trauma which any doctor would feel when they
are referred to the GMC. The fact that only 2% of
those referrals end up with a fitness to practise
hearing, with a 50% acquittal rate, should allow
us to see things in perspective. It would be
interesting to know, however, how many doctors
retired and removed themselves from the Register
before a fitness to practise hearing could take
place. We know that the last five years of practice
have a much higher chance of referral to the GMC
than the mid portion of one’s career.
I agree with much of what Professor McFie has
said about the current role of the GMC. The GMC
is now clearly a regulatory body and its origins as
a professional body have long since passed. It has
recently changed its strap line to “Regulating
Doctors, Ensuring Good Medical Practice” and
while the first is now true, the second phrase is
still aspirational.
The GMC has become the regulatory arm of
government, in the same way that the Postgraduate
Medical Education and Training Board (PMETB)
has become the regulator of postgraduate medical
education, thus withdrawing this remit from the
profession. As John McFie says, the GMC has
become a body feared by individual doctors and
the profession in general. He also alludes to a lack
of confidence in the processes of the GMC by the
profession, and I agree completely that this is so.
The GMC exists now to reassure the public that
the profession is regulated, whether or not this is
actually so. In order to ensure good and fair
regulation, the GMC needs to review its current
formula and needs to augment the influence of the
profession within the GMC. Clinicians currently
practising in a specialised area must be involved
in assessing the work of doctors within a
specialty. They will be more accepted by the
accused and also know better where to unearth
problems within clinical practice in a way that lay
members and non-specialist doctors never can. We
need committed specialists involved in this work
who have the best interests of patients and the
profession at heart. People like Professor McFie!
Where I disagree with him, however, is in the
effect that regulation has had upon our practise.
There is no doubt that standards of care have
improved, partly as a consequence of increased
scrutiny and regulation of clinical practise. There
is no impediment to good quality care
encompassing a conservative approach, providing
that it is transparent, there is good communication
and documentation, and there is multi-disciplinary
input into contentious decision making, for the
protection of both doctors and patients. The
slightly patriarchal approach he describes is
somewhat anachronistic.
I would wholeheartedly agree that an appropriate
judgement can only be obtained when the decision
is reached by assessors in active practice, from the
same or a closely related specialty. Expert
witnesses should also come from that background.
Given that the vast majority of clinicians are
employed by the NHS, it should be possible to
reimburse the NHS for their time, so removing any
concern about the motives of the expert witness.
The erosion of professional and public confidence
in the Council, presumably led to the White Paper
and the Health and Social Care Bill. I think that
the changes which have already been made have
improved the standing of the Council within the
profession and, while there is further room for
improvement, I would not agree that the GMC is
“not fit for purpose” in disciplining doctors.
John Duncan
I am, however, critical of the GMC in other aspects
of its work, over and above its Fitness to Practise
structures and its heavy-handed regulatory posture.
In particular, it has failed to extract the key
learning points and respond appropriately to
several of the recent major high profile cases,
including the Bristol and Shipman enquiries.
The first message that should have come from the
Bristol enquiry was that there needs to be careerlong training and personal development for
consultants. This is particularly so when they are
learning new procedures and practices.
Consultants adopting new techniques need
practical training and accreditation in order to
avoid the apparent adverse effects of the “learning
curve”. This will, of course, be expensive and
slow the rate of change and adoption of new
techniques, but is essential in order to prevent
doctors putting themselves and patients at risk.
The second missed message from Bristol was that
the issues only became apparent because of good
independent data collection. NHS Trusts are
currently only vaguely aware of whether their
clinical staff are good, bad or indifferent at the
core purpose of safely treating patients. We are
dependent upon consultants collecting their own
personal outcome data, which is invariably subject
to individual bias, for this most important of
information. In some areas of medicine it is
completely absent.
The GMC, as regulator, should insist on
institutional data collection of the outcomes of the
treatment, both interventional and conservative,
that we provide to patients. If clinical governance
is to mean anything to NHS Trusts, their boards
and managers, then this is an essential.
Similarly, the most important points from the
Shipman tragedy have not been acted on. Shipman
started killing patients through avarice and the
same forces are potentially still at work. General
Practitioners can still accept gifts and legacies
from patients. The Death and Cremation
Certification systems that are currently in place
serve little purpose other than to allow the disposal
of bodies with the least scrutiny possible as to the
cause of death, and pay the doctors involved such
that it is in their interest to acquiesce to this sad
COMMENTARY: THREE
At a time when the General Medical Council is
undergoing enormous change and we are moving to
re-licensing, together with PMETB merging with
the GMC, it is right that we review its purpose and
take the opportunity to engage with the process of
reform in a constructive and helpful way.
It is important not to confuse the functions of the
GMC with litigation or local disciplinary actions.
Litigation is the process whereby patients can
pursue doctors, usually for financial compensation,
with regard to the standards of care that they have
received. Any patient can pursue litigation through
the legal framework, entirely at their own will and
requiring the doctor to defend his or her position or
admit liability. Compensation may be paid to the
patient, usually through an indemnity organisation.
Litigation, though I am sure unpleasant, has no
impact on the doctors licence to practise and will
often involve the Trust as an employing
organisation as a co-litigant when NHS patients are
involved. Litigation does not prevent the doctor
from falling below standard again and potentially
harming other parties, though I am sure it will
make the doctor reflect on his or her actions.
The GMC, by contrast, is concerned only with the
doctor’s fitness to practise in the round and
whether or not that is impaired. Sanctions are not
in the form of monetary compensation, but range
from undertakings, to conditions, suspension or
ultimately erasure. These restrictions on a doctor’s
ability to practice can prevent further harm to
patients. Complaints to the GMC can be initiated
by patients, employing organisations or colleagues
and great pains have been taken in recent years to
limit those concerns which come to the attention
of the GMC to those which are the most serious
and bring into question the doctors licence to
practise. As mentioned in John McFie’s article,
5,000 complaints in 2006 resulted in only 90
progressing to a Fitness to Practise panel and in
only half of those 90 cases were restrictions placed
on the doctor. This is a set of statistics which, if
correct, hardly suggests an aggressive organisation
that is out to shackle members of the profession
and demonstrate regulatory muscle to the public.
Colin Ferguson
True, we all pay a fee to be on the medical register
and that fee funds all the activity of the GMC. In
the same way, we all pay tax to the Government on
our income which pays for the police service and
the country’s courts which regulate us. I fail to see
the distinction between the two, but I agree with
John that, in the past, the bias on GMC panels in
favour of medical members did make it very much
look as though we were both poacher and
gamekeeper. Nevertheless, in recent times, as
pointed out in John’s article, panels now have a
more even balance between lay and medical
members and appropriate ethnic and diversity
issues are taken into account when panels are
constituted. I fundamentally disagree with John’s
allegation that the majority of cases coming before
the GMC are to do with medical negligence. They
simply are not and litigation and GMC sanctions
should not be confused.
There are a wide range of issues which come
before panels, those relating to clinical
competence only are considered if it is felt that
there is a serious enough impairment to question
the doctors ability to continue to practise
medicine. In reaching that decision and selecting
those cases that go forward, John rightly describes
case examiners who sift through the case, examine
the details of the complaint and ask for the
doctor’s comments on it before reaching a final
decision. The doctor has an opportunity at that
point very clearly to put his or her own views
forward together with the help from, if required,
legal advisors. For those doctors who are not
members of a defence organisation, or who cannot
afford to engage with a defence lawyer, there are
organisations which will provide completely free
legal advice and representation if needed (this is
available through the Bar Council and the Pro
bono units). The standards which doctors are
expected to follow are very clearly laid out in
Good Medical Practice (GMP) and these are the
standards against which we will be judged if it is
deemed that we have lapsed in some way.
Other supporting guidance is published by the
GMC providing more detail on how to comply with
the principles in GMP.[http://www.gmcuk.org/guidance/index.asp]. If you haven’t read
7
The record of the GMC as a regulator has not,
hitherto, been good, and left unaided, it is
unlikely to improve. We must accept that the
GMC is on the other side of a regulatory divide
from the profession. Where then do we look for a
professional body that will carry authority to
express the views of the profession, and insist on
NEWSLETTER
This all went undetected because of the low level
of Clinical Governance that then existed within
Primary Care, and little has changed since. We
still have large numbers of General Practitioners
working in isolation and in small groups in which
the relationship between the doctors is primarily
financial, not clinical.
it’s voice being heard? I believe this is a role that
the Royal Colleges should adopt and develop.
The Royal College of Surgeons of England has
taken leadership in this regard with the
introduction of its new policy of devolving
functions to the regions and attempting to
develop networks of influence through its
Directors of Professional Affairs and Regional
Specialty Professional Advisors. This new policy,
which aims to support surgeons in the workplace
and seeks an influence in service configuration,
is very welcome and other Royal Colleges should
consider a similar approach. It will facilitate the
profession to be heard more clearly by the GMC
and the public and, perhaps, allow us to
demonstrate that it is engaged in reforming our
practices in the interests of patients.
state of affairs. Dame Janet Smith pointed all this
out in her third report but little has changed and
the recent legislative changes to Cremation
Certification will make no difference.
8
NEWSLETTER
GMP recently, you should. The concept of “serious
professional misconduct” went out a long time ago
and is now replaced with impairment. Are there
bench marks for impairment? Well, as well as
GMP, there are competency tests and assessment
tests which doctors can be asked to go through and
their performance is compared against a peer group
in, for example, simulated surgeries, multiple
choice questions and other tests of competence.
Following this, a funnel plot is generated and the
individual under question can clearly be identified
as being either within the group norm or more than
two standard deviations outside it.
This objective way of assessing a doctors ability
compliments the expert witness views which are
also often sought, either prior to making a decision
on whether to progress with the complaint, or
during a fitness to practise hearing. The worries
expressed by John that you might be judged by
individuals who have no day-to-day knowledge of
your specialty may seem valid, and clearly not
every surgeon can have a surgeon on his or her
panel, nor every psychiatrist the same or every GP
the same. This concern has been challenged in the
High Court and dismissed [the Dzikowski
judgement]. The issues being considered are often
not so much specialised but generic and can be
clearly understood by lay and medical members of
the panel. Where doubt exists, external experts can
be called in to give a view, though they take no part
in reaching the final decision of the panel. The
change in the standard of proof brought about a lot
of concerns and, at first glance, seems to be a
potential injustice for doctors. However, I think it is
important to understand the civil standard of proof.
The civil standard of proof applies only at the fact
finding stage where the facts are in dispute. It
means that, when deciding whether a disputed fact
has or has not been found proved, the panel does so
on the balance of probabilities. In some cases,
evidence amounts to opposing statements by the
patient and the doctor – no witnesses or photos.
Who do you believe in such circumstances?
I don’t think doctors should change their practice
to take account either of the risks of litigation or
of being found to have impaired fitness to practise
but, for sure, what they do need to do is to
improve their documentation in justifying the
decisions that they take. John mentions a number
of scenarios relating to “letting nature take its
course” and adopting a “wait and see” policy and
these are very reasonable and very important
options for doctors and patients alike.
Nevertheless, it is important to document your
decisions very carefully and to engage with the
patient and, where relevant, their families about
these decisions. If that is done, my belief is that
no one will be subject to either complaint,
litigation or restrictions of their licence.
I agree that the letters that come to doctors when a
decision is made to investigate their practice are
unpleasant to receive. They certainly could be
considered threatening or intimidating, and no one
would want to open one on a Saturday morning at
the beginning of a weekend whilst eating breakfast.
Nevertheless, I find again comparison with other
regulatory organisations helpful. If any readers have
been subject to an investigation by Her Majesty’s
Custom and Revenue, they will recognise also (as
happened to me) that the letter informing you that
your tax affairs are going to be investigated
retrospectively for the past six years leaves a pit in
your stomach and feeling extremely concerned and
vulnerable, even when you know that you have done
nothing wrong. Likewise, such a letter will be
expensive and time consuming to defend. In my
own case, it cost me over £1,000 in accountancy
fees to summate six years of taxation papers simply
as a result of being randomly picked to have such an
investigation carried out. I spent a long time
wondering whether there could have been one small
lecture fee or some interest on a current account
which I had forgotten to or failed to declare in the
past six years, and the weeks of silence whilst the
paperwork was ground through by some faceless
individual chewed away at me even though I was
absolutely certain that no gross errors had
happened. When the letter confirming that
everything was in order came through, it was brief.
There was no apology for the expense and
disruption that I had had to go through, nor were
there any thanks for complying promptly and
efficiently with the investigation. If you have ever
been searched on returning from an overseas
holiday by the customs as part of a random
selection, similar feelings occur. I don’t think,
therefore, that the letter that you get informing you
that the GMC is looking into your fitness to practise
is any different, and I personally don’t think there is
any easy way to inform someone that that
unpleasant action is going to happen, be it by the
GMC, the tax officials, your Trust or patient lawyer.
John makes the point that the GMC seems to be
both investigator and adjudicator. These functions
have largely been separated in recent years with
the formation of panellists who are trained and
appointed by the GMC purely to serve as such
and have no formal relationship with the GMC.
Panellists are appointed in open competition and
against agreed competencies to ensure they have
the skills necessary to undertake the task.
The GMC legal team will present the case to the
panel, the doctor and or his representatives will
have an opportunity to respond, and the panel can
question both the GMC and the doctor before
withdrawing to make their independent decision.
As far as sanctions are concerned, these are not
random but there is a book of indicative sanctions
which advise what would be appropriate in a given
circumstance. The guidance aims to ensure
consistency in decision making but, as each case is
considered on its merits, there is flexibility for the
panel to take account of particular mitigating or
aggravating circumstances in the case under
consideration. Some things, like sexual relations
with patients, child pornography, criminal
convictions and acts of dishonesty, will tend to
attract higher sanctions. Where there may be
remedial opportunities for the doctor’s clinical
practice, conditions can be put in place which will
ask the doctor to retrain or restrict his practice until
he or she has demonstrated that it is not impaired.
Public confidence in the profession is important.
Without that, none of us can do our work and, if it
is perceived that there are doctors in the system
who are not up to standard in all aspects of their
behaviour and practice, then this damages the
standing of the profession. One very important
thing to understand is that the reputation of the
Tom Lennard
Professor of Surgery, Newcastle University
President British Association of Endocrine and
Thyroid Surgeons
The plan to have responsible officers in localities
dealing with some of the so called lesser issues is
interesting because it transgresses one of the
fundamental rules of panels which have been in
EDITOR’S NOTE
COMMENTARY: FOUR
over a complaint, sometime vexatious, from the
public. These complaints may have been usually
investigated locally, thoroughly and competently
and found to have no substance, yet the GMC
seems to take little account of this. Some clinicians
also find themselves subject to police investigation
but will say that with the police it is completely
transparent, there is due process and it is clear
what is being said and by whom. This is in marked
contrast to the GMC process which has been
described as “Kafkaesque”. The flip side of this, of
course, is that there are a few difficult,
dysfunctional and frankly dangerous individuals in
the systems and Trusts get little or no help in
removing such individuals from the workforce. In
this one respect, I disagree with Professor MacFie.
A criminal standard of proof is not appropriate in
dealing with HR issues, and any competent
regulatory body also must have flexibility.
However, the thought of the GMC as presently
configured having this flexibility is worrying.
So what is the solution? So-called self regulation
is not serving us well and should be abandoned. A
competent body funded by public monies should
be set up. Being forced to pay the GMC to be
persecuted, as some would see it, is fundamentally
wrong. It might be argued that this would put
doctors in a worse position. I would argue not.
Any new body would have to be set up with a
competently transparent process and be subject to
scrutiny and challenge. The prevailing economic
climate would encourage pragmatism and
efficiency. The principle means of dealing with a
complaint should be local and the Trust or other
employing or responsible body should be held to
account for such a process. Only the most serious
complaints would be referred on and, in this
circumstance, matters should be dealt with
Professor MacFie makes a personal and vigorous
attack on a famous medical institution, the
General Medical Council. Is his vitriol justified?
In general terms I believe it is, and his article
should stimulate much needed debate on the role
of the GMC and the supposed self regulation of
the medical profession.
First, it is important to acknowledge, as John
MacFie does, the fact that in some areas, such as
undergraduate education, the GMC has done a
good job. Indeed, when it was suggested that
PMETB, an organisation held in even less esteem
than the GMC, should take over responsibility for
undergraduate education then there was universal
opposition. But it has to be accepted that in
respect of its disciplinary activities, finding a
doctor who supports it would be similar to the
frequency of encountering a snowflake in Hell.
So how has the situation come to rise that the
profession’s regulatory body is now held in such
low esteem by the profession? It stems from the
holy grail of self regulation, an outdated and
effete concept whereby, as John MacFie says, the
GMC is both “poacher and gamekeeper”. In
bending over backward to deal with every matter
raised by the public, however ridiculous, it has
lost the profession’s respect. It apparently also has
no ability, or no wish, to recognise that a
complaint by the public, or by another doctor or
health care professional, may be vexatious.
So the problems are jointly those of process and
competence. Trust Medical Directors and Chief
Executives complain regularly that it is often their
most competent, caring and clinically excellent
clinicians that are subjected to years of torment
Professor Lennard has been a panellist with the GMC
since 2001. The views expressed above are his alone
and do not represent the views of the GMC in any way.
9
The future will bring important changes. There
will be a complete separation from investigation
and adjudication. It will be for the OHPA to
decide on the composition of panels once the
GMCs adjudication function transfers to it. The
GMC will continue to carry out the investigation.
In effect, this already happens as I have
mentioned above, but the separation will be much
more transparent under the proposed new systems.
I think the changes that are going to happen
demonstrate that the GMC itself has realised that
it needs to move with the times and the world has
moved on. Credit must be given for this, and we
should engage with the process, understand it and
help to improve it in whatever way we can, not
just scream from the sidelines that it is a load of
old rubbish.
NEWSLETTER
Every panellist who sits on a panel is subjected to
a 360 degree assessment for each case on which
they have sat. This is anonymous and, in addition,
every panel member undergoes annual training
and updating for a minimum of one day per year.
Any panellist who falls below the standards
expected will be dropped from future panels.
place to date, namely, that no panellist must sit on
a panel regarding a doctor who they have worked
with professionally or trained. This is designed to
minimise bias, although admittedly with some of
the high profile cases it is very hard not to know
the doctor concerned. Nevertheless, the move to
locality responsible officers means that you will
very much be known b y the person who is making
a decision about whether to progress your case or
not. Will everyone be happy with that? What if you
have crossed swords with the individual before?
Great care needs to be taken, therefore, in
selecting these responsible officers and in training
them to ensure such biases cannot happen.
profession as a whole and the potential damage to
that done by an individual doctor will tend to
carry greater weight than the individual fortunes
of the doctor concerned. It is a privilege to be a
doctor in any society but particularly in the United
Kingdom, and with that privilege come
responsibilities that are different to other
professions and other walks of life. It’s part of the
job that we have to take those responsibilities on.
efficiently by the competent body. Unlike the
situation with the GMC, a complaint made
directly would be not considered but sent for a
competent local investigation first. This avoids the
duplicate, or even triplicate processes, which
cause so much disquiet.
So what of the GMC? It should continue to do
what it does well. This includes overseeing the
quality of undergraduate education, maintaining
COMMENTARY: FIVE
NEWSLETTER
I was delighted to be asked to write a commentary
on Professor MacFie’s short review, particularly as
I found myself in complete agreement with his
conclusion.
One cannot help but wonder how we have
managed to let ourselves get into this dreadful
position. The original guiding principle in 1858 of
promoting the welfare and education of doctors
conveyed the impression of a caring organisation
looking out for us. How things have changed!
Under the 1983 Medical Act, the GMC was given
four main functions:
• Keeping an up-to-date register of qualified doctors.
• Fostering good medical practice.
• Promoting high standards of medical education.
• Dealing firmly and fairly with doctors whose
fitness to practice is in doubt.
The use of the word” firmly” along with “protecting
patients” in the new logo, gives the public an
impression that they need to be safeguarded from a
substandard profession. It has also led to
unnecessary fear and anxiety amongst doctors.
The words fear and anxiety are justified. Ask
anyone unfortunate enough to have been before a
GMC Fitness to Practise panel. There has to be
something wrong with a system that causes so
COMMENTARY: SIX
John MacFie’s article encapsulates the thoughts
concerning the GMC of many doctors. To the
majority, the GMC implies a complaint and all the
associated repercussions; its role in undergraduate
education, subsuming the activities of PMETB,
are scarcely recognised. The power of the GMC
over our daily lives will, however, increase with
the advent of licensing.
The FTP committees have an unenviable task. As
John MacFie points out, a full FTP enquiry is
adversarial and both sides are given a fair hearing.
The Fitness to Practise panels are supposedly
independent from the GMC executive, but it is
inconceivable that panel members are not subject
to the untraceable telephone call or ‘soundings’ in
quiet corridors from those on high. John alludes
to the quality of expert witnesses used by the FTP
panels: the same criticism applies to the civil
courts where expert witnesses are often drawn
from the retired or ‘professional experts’.
10
We must be unique in permitting the continuation
of a system whereby the profession foots the
entire costs of a plaintiff. It would be entirely fair
that each plaintiff was wealth or means tested (as
the medical register and dealing with
recertification, if economics ever allow this
process to be meaningfully established. As
suggested by the Tooke Review it should also take
over the remit for postgraduate medical education
from PMETB. The GMC would do this well and
this would be an overwhelmingly popular move.
John Primrose
much unnecessary stress in even the most
competent members of the profession.
While no one should play down the significance
of poor medical practice, we must keep things in
proportion. The GMC’s own figures show that
there are very few bad apples in the barrel. In
2006, only 45 doctors had restrictions placed on
their fitness to practise. Out of the 230,000
doctors registered with the GMC, this represents
only 0.02%. Can any other professional group
come anywhere close to this figure? I doubt it.
Despite this, the Government/GMC continues to
work hard to make it easier to register complaints
about us. Why have they felt it necessary to do
this and reduce the standard of proof needed to
find against us in fitness to practise panels? Why
have they developed a process which has
undermined the confidence of the entire medical
profession?
Regardless of the apparent crusade against us by
the Government/GMC, the medical profession
continues to be held in the highest regard by the
public. Is it jealousy of our position that has
driven this process? Whatever the reason for us
being in this position, I must agree with the
conclusion that the GMC is “not fit for purpose”
with regard to its role in disciplining doctors.
John Moorehead
occurs for job-seekers allowance and legal aid
applicants), that all should pay a non-refundable
deposit scaled to wealth, and that defendants costs
are repaid in full if the latter is ‘acquitted’. This
may reduce some of the vexatious complaints.
John MacFie attests to the fact that the GMC is not
held in high (if any) esteem by the rank and file in
the profession. Its most senior officers are
autocratic and dodge difficult and probing
questions (viz ASGBI Annual Congress). The
consequences of its utterances and actions result in
a climate of fear of using clinical judgement, fear
of innovation and fear of taking the infrequent but
necessary risk which would be in the patient’s
benefit as may occur in emergency surgery.
As surgeons, we are particularly vulnerable owing to
the immediacy of our results. Whilst the GMC may
not listen to individuals, it might if representative
associations such as ASGBI and the Royal Colleges
forced the issue by conjoint action. A concerted
effort is required to make our regulators get in tune
with the rank and file of the profession. John
MacFie is to be applauded for his incisive and
thought provoking paper; many would not have had
the courage to write (or publish) the same.
Tom Dehn
Purpose
The purpose of revalidation is:
1. To confirm that licensed doctors practise in
accordance with the GMC’s standards.
2. To confirm that doctors on the GMC’s
specialist register continue to meet the
standards appropriate for their specialty.
3. To identify for investigation, and remediation,
poor practice where local systems are not
robust enough to do this or do not exist.
Elements
The elements of revalidation are:
1. Relicensing.
2. Recertification.
3. Multi-source feedback.
4. Appraisal.
5. Responsible Officer.
Relicensing
Relicensing will occur every five years and will
include evidence on appraisal, audit, CPD , and
patient and colleague feedback. It is the Royal
Colleges of Surgeons and the Specialty
Associations that will set the standards and
describe the evidence that will be required for
recertification.
Standards
Surgeons from across the surgical specialties have
been working on standards for the recertification
of surgeons and have produced a standards
framework which is available on the English
College Website: http://www.rcseng.ac.uk/
standards/revalidation/standards In this work,
outcome data have been identified as a key source
of evidence for recertification but it is
acknowledged that each specialty is at a different
stage of development. The Colleges and Specialty
Associations are working together to see what
outcome measures might be ready for the start of
recertification and there has been an ongoing
consultation in this process.
Whatever is decided as a result of this
consultation process, it seems clear that there will
be a requirement for surgeons to present evidence
of outcomes, and the discussion below represents
my views of how national databases might be
used for this purpose.
Administrative Datasets
Hospital Episode Statistics (HES) data in England,
and similar administrative datasets in Wales and
Scotland (from here on I will use HES as a
generic term for all these), provide data on
Local, Regional, and National Audit
I would expect that all surgeons now contribute to
local audit. In many centres this remains largely
an exercise in collecting and discussing local
morbidity and mortality data. This has benefit and
much can be learned from discussing
complications with colleagues in a non-hostile
environment at a local level. However, it lacks an
element of external review, it is often incomplete
and it provides only a local view without a
national comparison. Regional audit can be a
useful tool which widens the comparison to
multiple hospitals in a whole region and there are
examples where this works well, an example
within vascular surgery is the North West Vascular
Group audit.
National audit has the advantage of providing a
picture of activity and outcomes on a large scale
throughout the UK. Whilst, inevitably, there will
be local and regional variations, the data available
in a national audit provide the ability to set
standards based on large volumes of data and to
examine and understand these local and regional
variations. What is important with national audit
is that this complements, and does not impede,
local audit systems.
National Databases
There are many examples of existing national
databases within both medicine and surgery which
provide useful outcome data. These include audits
of cancer, cardiac surgery, myocardial ischaemia,
stroke, and the national joint registry. Within
vascular surgery we have the National Vascular
Database, and I will use this to illustrate the
discussion below.
With the advent of the internet, most of these
databases have moved to a web-based system of
data collection and, therefore, contribution to
11
From 16th November 2009, all doctors will need a
licence in order to practise medicine in the UK.
Current information from the GMC indicates that
revalidation will be built largely on local,
workplace-based, systems of clinical governance
including a strengthened form of appraisal. The
following from the GMC website summarises
revalidation and recertification.
NEWSLETTER
Tim Lees
numbers of procedures along with some basic
clinical and outcome data. The advantage of these
systems is that they produce a large volume of
data and cover all hospitals and so they provide a
national picture, and there is a structure already in
place in hospitals to collect this data. Historically,
however, they have tended to be very inaccurate
and clinicians have had little faith in their ability
to paint a true picture of activity. Nevertheless, the
accuracy of these datasets is improving,
particularly as payment by results drives the need
to improve local coding, and they are already in
use by institutions such as Dr Foster and CHKS
who analyse the data for hospitals. If they are to
be used in the future for personal audit, however,
they will need to become much more accurate in
relation to consultant allocation of cases and there
will be a need to collect more clinical data than is
currently collected. In addition to this, there needs
to be a recognition that, with the ever increasing
demands for clinical excellence, coupled with the
reduction of the availability of senior trainees,
consultants are increasingly working in teams
both in patient management and in performing
operations. Thought will need to be given as to
how to report in these circumstances. My view is
that reporting on teams, rather than individual
surgeons, is the way forward for HES, but it is not
clear how that could fit into individual
revalidation.
NATIONAL DATABASES AND
REVALIDATION
12
NEWSLETTER
these national systems has become much easier.
For the Vascular Society, having purchased the
initial system, the user can access the system
without charge and so there is no longer a
financial barrier to contributing data, which has
been an issue for many centres in the past.
Outcome Data
For the purposes of recertification it will be
necessary to produce data at an individual level
along with comparison with national figures.
There are several ways this might be done, and in
the VS we currently use funnel plots for this
purpose. An example of this is shown below. The
illustration is a mortality funnel plot which
includes all vascular index operations, whether
emergency or elective, and each dot on the plot
represents a centre. This is clearly too generic to
be useful, but similar plots can be produced for
specific procedures, e.g. aortic aneurysm repair by
open surgery in elective patients. The data then
becomes much more meaningful and centres can
log in and see where they lie in relation to
national statistics at any time. In itself this
provides a useful feedback tool and should
stimulate centres who approach the upper
confidence limits to look closely at their data and,
if necessary, their practice. For the purposes of
recertification and revalidation, the VSGBI will
be producing this data for surgeons at an
individual surgeon level. This will provide
surgeons with a readily available means for
reporting their individual outcomes against
national figures for the main index procedures,
and this should be ideal for the requirements of
recertification.
It should be stressed that this is only one small
part of the function of a national database, but is
nevertheless an important one.
Time and Commitment
We all know that our estimate of what we do and
how we do it can be quite inaccurate when the
actual data is examined, and so collecting accurate
data is essential. This must be done prospectively
because retrospective collection of data by
trawling through case notes is laborious, more
time consuming, and probably less accurate. It is
now essential for us as surgeons to demonstrate
that we are doing a good job, in addition to
actually doing a good job. This cannot be achieved
without effort, and time must be dedicated to the
collection and recording of data and this must be
recognised as a significant workload in the
consultant timetable. I firmly believe that
consultants themselves should be involved in data
collection, and interpretation. There is no reason
that surgeons should not train other individuals to
assist them with this, but I suspect most Trusts
view requests for this sort of assistance as a very
low priority. There needs to be further investment
in the collection of good quality audit data, and
each hospital needs an infrastructure to assist
surgeons in this task.
Advantages and Disadvantages of Data
Collected by Surgeons
There are both advantages and disadvantages of
using a national database, such as described
above, for the purposes of national audit and
recertification. These are listed below:
Advantages
• Surgeon confidence in the data.
• More accurate data collection.
• Less prone to administrative uncertainty or lack
of medical training in data field completion.
• Single web based system ensures conformity
with respect to data field definition and
responses.
• Consultant allocation understood better by
clinicians than administrative staff.
• Clinical data richer.
• Real time reporting with no delay in the
amalgamation and analysis of data.
• Ability to risk adjust data.
Disadvantages
• May be less comprehensive than administrative
datasets unless compulsory submission.
• Selective reporting is possible.
• May be bias as surgeons are collecting their
own outcome data.
Perhaps the main criticism of national databases is
that unless all surgeons contribute it is possible to
be part of a poor performing centre and remain
hidden from the outside world. Therefore, 100%
contribution is required and, in my opinion, this
should be driven by the surgeons themselves
rather than any outside body. The benefits of
using national databases for recertification far
outweigh the benefits of relying on administrative
datasets and, therefore, this will be a significant
driver to contribution in the future. The other
criticism of national databases relates to the issue
of selective reporting. Whenever I am involved in
a discussion about this it seems to be suggested
that surgeons may hide their results to produce a
favourable report on outcomes. I don’t believe this
to be true, but I think it is possible that
complicated patients get “lost in the system” and,
therefore, may not be reported on. For example, a
patient who has multiple complications, and has a
long post-operative stay, may get transferred
between hospitals and between medical teams,
and there are plenty of opportunities for the
medical records to be somewhere other than with
the operating surgical team and, therefore, for the
complications not to be recorded.
There is a simple answer to this and that is periodic
external validation. It would be relatively easy to
visit a centre chosen at random periodically to
check two things; first that all the cases that should
be included in the data are being submitted and;
secondly to check that the outcomes for the
submitted cases are correct and serious
complications are being recorded. Although this
would have some financial implication it would be
relatively easy to set up and I believe it could be
Douglas R Donaldson
SW Thames Elected Regional Representative
on ASGBI Council (2005 to 2009)
South-West Thames is one of four Thames
Regions and the implied juxtaposition to the River
Thames is slightly confusing as the Region
extends from the Thames all the way down to the
English Channel. The Region covers four counties
- Surrey, Middlesex and parts of Sussex and
Hampshire - and serves a population of
approximately 4.5 million. It is almost triangular
in shape, with the apex of the triangle (rather
appropriately) being St George’s Hospital/Medical
School and the Royal Marsden Cancer Hospitals.
Further south, geographically, on the outskirts of
London, lie Kingston Hospital, Mayday Hospital,
Croydon and St Helier’s Hospital, Carshalton. Five
DGHs, namely East Surrey Hospital, Epsom
Hospital, Royal Surrey County Hospital,
Guildford, Frimley Park Hospital and Ashford/St
Peter’s Hospitals, lie above the North Downs.
Progressing South over the South Downs to the
coast lie the remaining Hospitals in our region –
St Richard’s Hospital, Chichester and Worthing
Hospital. Therefore, the Region covers the
spectrum of the urban conurbations of South
London , the Stock-broker areas of the Southern
Home-counties, the rural countryside and the
coastal seaside. Hence, our trainees are exposed to
the full range of environments both to commute
to, and to work in, during their five years of
training. This contrast does, I’m sure, help them to
make up their minds as to where they would
ideally (!!) like to be appointed as a Consultant
Surgeon.
Our Region has a total of four trusts created by
the merger of two neighbouring Hospitals. In
1998 East Surrey Hospital, Redhill merged with
Crawley Hospital and, in the same year, Ashford
Hospital, Middlesex merged with St Peter’s
Hospital, Chertsey. The following year, Epsom
and St Helier’s Hospitals merged and this Trust
became a University Hospital in 2003 in
recognition of its partnership with St George’s
Hospital Medical School. This year Worthing and
St Richard’s, Chichester merged. These mergers,
and the reconfiguration that is necessary, as
anyone who has been involved in one will know,
do involve numerous and almost constant
meetings away from one’s clinical and teaching
time to achieve the managerial and financial
benefits of bringing two Hospitals together. Once
the ‘New order’ is established, and the teething
problems are ironed out, a bigger department does
confer certain advantages and allows Clinicians to
sub-specialise within their chosen field.
The 18th green at Sunningdale Golf Club
South West Thames has been popular with
trainees, with large numbers of applications for
each of the Registrar posts that become available.
Peter Leopold is the current Programme Director
of the Registrar rotation and he feels the rotation
is in a healthy position, but there are certain
problems some of which are probably common to
other Regions. The National Training Numbers for
Registrars in our Region has remained constant,
but there is pressure to reduce these numbers
because of workforce planning. There will not be
13
GENERAL SURGERY IN THE
SOUTH-WEST THAMES
REGION
NEWSLETTER
Risk Adjustment
For those of us in clinical practice, it is quite clear
that two patients undergoing exactly the same
operation can present very different risks in terms
of the post operative outcome. With increasing
scrutiny of outcomes, the natural inclination is to
resist taking on high risk cases, but failure to do
this may disadvantage our patients. Risk
adjustment of cases is, therefore, important in
outcome reporting. Accurate risk modelling is not
easy, but I believe that national clinical databases
rich with clinical data will be the best tools for
this purpose.
Summary
The role of National Databases in recertification
is yet to be fully defined, and there is currently
ample opportunity to take part in the discussion
process taking place. I have a very clear view that
the use of national databases is considerably
preferable to the use of administrative datasets
such as HES for accurate reporting of our
outcomes following surgery. Unless the profession
takes a very active role in insisting on this, and
fully embraces outcome reporting, our outcomes
will be reported for us, using a system not
necessarily of our choosing. Some of the
Specialty Associations have already seen the light
and are very advanced in their outcome reporting,
but others have a long way to go.
run by the Specialty Associations, or a more
independent body if required.
14
NEWSLETTER
enough Consultants posts into which these
Registrars can progress. There is difficulty in
accommodating super sub-specialisation within
the Region and there are limited numbers of
training opportunities in, for example Upper-GI
cancer (oesophago-gastric and hepatopancreatico-biliary) within the Region. Peter feels
that linking with neighbouring Regions would
allow for flexibility and broaden the opportunities
for training as there will never be a constant
number of trainees, at any one time, wishing to
undertake each individual sub-speciality. 35% of
the Registrars are female with a sizeable
proportion opting for a flexible training scheme.
Ideal as this scheme is, there are often great
difficulties in funding this type of post as Trusts,
who pay 40% of the registrars’ salary, wish to
have a full-time registrar. The situation is often
resolved by two flexible trainees sharing one fulltime post within a Trust.
Because of different boundaries, our Region is
served by two Deaneries; the London Deanery
and the Kent, Surrey and Sussex Deanery. The
boundary is the M25. Trainees, during their
training, will, therefore, pass back and forth from
one Deanery to another with the inevitable
difficulties this creates. Despite these drawbacks,
the Deaneries have developed and enhanced their
Educational Departments and there is now
rigorous quality management of Trainees, Trainers
and the Hospitals in which they all work. There is
no doubt that these measures are now bearing fruit
with focussed, supervised and standardised
training across our Region.
The Region’s main Teaching Hospital, and only
Medical School, is at St George’s Hospital,
Tooting. It has recently linked with Royal
Holloway College, Egham, but medical students
will still graduate from London University. Many
of the other surgical specialities, namely
Cardiothoracic, Neurosurgery, Plastics and
Paediatrics, have centralised on to the St George’s
site in recent years with the resultant competition
for space and operating time. Hence the
ubiquitous cranes and building works whenever
one visits the St George’s campus. I’d suggest
taking some sandwiches with you when you go to
park your car as a visitor to St George’s!! Plans
have been agreed for St George’s to become a
Trauma Centre, but the development is still in the
A view across the South Downs
“embryo-stage” – there is no helipad yet! Matt
Thompson, Professor of Surgery, has brought
innovation and dynamism to the vascular surgical
department and energised research within his unit.
There are excellent colonoscopic training courses
in the purpose-built endoscopic unit, created and
run by Roger Leicester, and St George’s is the
only hospital in the region undertaking
Transplantation surgery (mostly renal).
The surgery for upper GI cancer (oesophagogastric and hepato-pancreatico-biliary) throughout
the Region has now been resolved and is based in
the two Cancer Centres within the Region; Royal
Marsden and Guildford. The only exception is the
O-G cancers at Chichester, which currently go to
Portsmouth. In large part these new arrangements
are working well, especially from the patient’s
point of view. Having discussed various issues
with colleagues working in the units, the main
problem is for the “in-reach” consultants, ie. those
not primarily based at the Cancer Centre with
their main contract being held by another Trust.
These consultants perform their emergency
general surgery duties at this other Trust, but are
also on-call for their cancer sub- speciality at the
Cancer Centre. Providing post-operative
supervision of their elective cancer cases is also
difficult; a long round-trip before or after a tiring
day at their base hospital(s). These problems are,
I’m sure, experienced elsewhere in the UK and
they will need to be addressed before frustration
supervenes and conflict develops. One of the two
post-CCT Fellowships awarded to the region is
based at the upper GI unit at Guildford. All Trusts
in the Region undertake benign upper GI work.
Vascular Surgery, as a separate sub-speciality,
within the Region is well established and no NonVascular surgeon undertakes emergency vascular
surgery unless in exceptional circumstances.
Vascular Emergencies within the Region are dealt
with in two main areas, namely the SW London
Group and the Surrey Vascular Group. Outwith
these groups, Chichester shares a vascular rota
with Portsmouth, and Worthing a rota with
Brighton. Martin Thomas at St Peter’s, Chertsey,
instigated the first cross-site vascular cover in the
country back in 1996. St Peter’s, Ashford,
Middlesex and Epsom were in a rota with the
surgeon travelling to the patient at whichever
hospital they had presented. This scheme was
successful and set an example for other Regions
to follow. The “hub” of the SW London group is
St George’s and the “spokes” are Mayday, Epsom,
East Surrey and Kingston, with the patients being
moved to St George’s after stabilisation. Paul
Thomas and the locum vascular surgeon provide
vascular cover for St Helier’s when available. If
they are not available, then the patient is moved to
St George’s. The Surrey vascular group is
comprised of Ashford/St Peter’s, Frimley,
Guildford and Basingstoke. Endovascular stenting
is undertaken within the two main vascular groups
and some centres are now undertaking stenting for
thoraco-abdominal aneurysms. The ultrasound
screening for aortic aneurysms is now underway
and the centres performing the screening will
operate on the screen-detected aneurysms. This
process may provide additional impetus to the
centralisation of elective vascular surgery.
Most surgeons throughout the UK are likely to
attend their annual sub-speciality meeting, be it
BASO, ACPGBI, AUGIS, Vascular Society, etc as
well as the Annual Congress of ASGBI. SW
Thames does not have General Surgical meetings,
as such, and this is not just apathy on our part.
Surgeons in SW Thames have ready access to the
meetings of the Royal Society of Medicine and
there are 6 or 7 meetings per year of both the
Section of Surgery and Section of Coloproctology.
Shift work is the norm for the Juniors throughout
the Region with Chichester being the only
exception with a full-time rota system for their
registrars. CEPOD lists are now present in all
Trusts and mostly run all day. The CEPOD list at
St George’s is used by many different specialities
with resultant delay for minor general surgical
cases. Success in the exit FRCS examination has
been achieved by all trainees so far, although some
have had to re-sit the multiple-choice paper. The
clinical examinations have been less problematic,
as many of the Consultants in the Region are
willing “mock-examiners” and the trainees greatly
appreciate this extra and informal tuition.
From a personal point of view I have very much
enjoyed my four years as Elected Regional
Representative for this Region. Attending ASGBI
Council meetings allows one to hear the latest
developments in the current, and often
controversial, issues affecting our Speciality being
discussed. As an Ordinary member one will often
hear little or nothing about these issues. In these
days of paperless communication, would it be
possible that not just the Regional Representatives
and Link Surgeons receive the minutes of Council
meetings but every member of ASGBI? This is
likely to foster more involvement and
participation in ASGBI. In the mid 1990’s, when
the Speciality Associations had become
established, I, and many others I knew, felt that
this development might weaken the position of
ASGBI. On the contrary, as it has become obvious
that an individual Association can’t ‘go-it alone’,
the strength of the ASGBI has very much
increased. I sincerely hope that ASGBI will
become the “Voice of Surgery” as it is truly
impartial and is one organisation which represents
the General Surgeons from the whole of Great
Britain and Ireland.
15
The Darzi report has not fully rolled- out yet and,
as such, little, so far, has changed. Some
centralisation has already occurred; upper GI
cancer to the Royal Marsden and Vascular surgery
to St George’s. Discussions are underway in the
London area of our Region to develop links and
so produce the Network approach which is one of
the cornerstones of this report. The development
of a trauma Centre at St George’s will benefit not
only South London but a large part of our Region
too. Some of the smaller hospitals on the outskirts
of London are being ear-marked as potential
Polyclinics; this will be in addition to their role in
providing out-patients and Day-surgery facilities.
The “Local Hospital” model will threaten some
existing Trusts (supposedly 2/3rds of all DGHs in
London). One predicts that, whatever political
motivation and financial encouragement is given,
any change will take longer than expected.
The River Thames at Hampton Court Bridge
NEWSLETTER
Breast Surgery is performed in all hospitals except
Epsom/St Helier’s where patients are treated at the
Royal Marsden. Onco-plastic techniques are
widely practised and, due to the excellence of
several of the Departments within the Region, one
suspects one or more will join the nine Oncoplastic training Centres, at present, in the UK.
Bariatric Surgery is undertaken in three Centres; St
George’s, Ashford/St Peter’s and Chichester. In the
latter unit the service is provided by an
Independent facility. This is the closest the Region
comes to having an Independent Treatment Centre
in General Surgery. The need for surgery in these
challenging patients (a recent patient at Chichester
had a BMI of 106) seems to be ever increasing and
one suspects more and more hospitals will offer
this service “in house”.
These meetings are well attended. The SW
Thames surgeons do meet once per year to discuss
the Registrars and this is an opportunity to learn
what is going on in our region. SW Thames is
lucky to have some wonderful golf courses and
Dominic Coull (ex-SpR and now Consultant
Surgeon in Reading) organised a couple of
golfing days for SW Thames surgeons which were
very successful and enjoyable (despite my
putting!!).
There are busy colorectal units in each of the
General Surgical departments within the Region.
Laparoscopic colorectal surgery is undertaken in
each hospital and some are more established than
others. The MATTU (Minimal Access Therapy
Training Unit) in Guildford was developed by
Professor Michael Bailey and is linked to the
Royal College of Surgeons of England. This unit
has a National/International reputation for training
in Minimal Access surgery. The Colorectal
department at Frimley (led by Mark Gudgeon) has
been awarded a laparoscopic colorectal post-CCT
Fellowship (linked with Basingstoke) in
recognition of the excellence of its training. With
the number of colorectal consultants throughout
this Region and the country as a whole, as in
upper GI work, is super sub-specialisation within
Colorectal Surgery (eg. Cancer, IBD, functional
disorders, etc) inevitable in the foreseeable future?
Anyway the “Robots” are coming and are
installed, or about to be installed , in at least four
Trusts throughout the Region!
• Mr George Hanna’s talk was entitled
‘Laparoscopic compliance mapping for
prediction of tissue pathology’ and resulted
from his project ‘Development of a real time
endoscopic compliance mapping system’ that
won the Bupa Foundation’s 2003 surgical
innovations competition.
NEWSLETTER
In May 2009, the Bupa Foundation, the
independent medical research charity, was
delighted to participate in the Association of
Surgeons of Great Britain and Ireland’s
International Surgical Congress ‘Delivering a
Modern Surgical Service’. The Bupa Foundation
Symposium, ‘From tactile sensation to teams,
ways to diminish stress in the surgeon’ was
chaired by Professor John MacFie, who is a Bupa
Foundation governor. The symposium featured
three Bupa Foundation-funded surgical projects:-
• Mr Peter McCulloch, University of Oxford,
spoke on ‘Teamwork training in operating
theatres: what can be achieved?’ (a medical
research grant supported between 2006 and
2007).
• Dr Sonal Arora presented on behalf of Dr R
Kneebone, Imperial College London, on
‘Reducing stress in surgeons: developing an
interventional tool’ (a medical research grant
supported between 2005 and 2007).
In recent years, the number of applications for
funding of projects on surgery has been overtaken
by some of our newer areas of interest such as
communication and health for older people. We
hope that this article will assist in raising awareness
of the Bupa Foundation among the wider surgical
community and we would welcome more high
quality applications for projects in surgery, as we
appreciate this is an area which would greatly
benefit from an additional source of funding.
The charity
Since 1979, the Bupa Foundation has awarded
grants totalling around £25 million to medical
research and healthcare initiatives across a broad
range of disciplines. We aim to produce long-term
benefits that have an impact on the health of
individuals across the UK and internationally.
The Bupa Foundation
donates approximately
£2.6 million per year
through its grants and
awards, funding the
work of medical
research teams in
NHS hospitals and
UK medical colleges.
16
The Board
The Bupa Foundation
is run by a Board,
which meets quarterly.
Dame Deirdre Hine, Chair of the
Bupa Foundation
Dame Deirdre Hine became chairman of the Bupa
Foundation in 2004.
• Dr Judy Evans, Consultant Plastic Surgeon, the
Nuffield Hospital, Plymouth.
• Professor Stephen Duffy, Professor of Cancer
Screening, Wolfson Institute of Preventive
Medicine, London.
• Mr Chris Hasluck, Principal Research Fellow,
Institute for Employment Research, University
of Warwick.
• Professor Hugh Montgomery, University
College London.
• Professor Tony Kendrick, Professor of Primary
Medical Care and Director of Community Clinical
Sciences Division, Aldermoor Health Centre.
• Professor Parveen Kumar, Professor of Clinical
Medical Education, Queen Mary College, Barts
and the London School of Medicine and
Dentistry.
• Professor David Oliver, Consultant Physician
and Clinical Director at the Royal Berkshire
NHS Foundation Trust, Reading.
• Professor Jennie Popay, Professor of Sociology
and Public Health, Institute for Health
Research, University of Lancaster.
• Professor Mary Watkins, Deputy Vice
Chancellor, University of Plymouth.
• Professor John MacFie, Professor of Surgery,
Postgraduate Medical Institute, University of Hull.
The following three governors are employed by
Bupa and sit on the Board because of their
expertise in the Bupa Foundation’s areas of focus.
They are:
• Dr Andrew Vallance-Owen, Deputy Chairman
of the Bupa Foundation and the Bupa Group
Medical Director.
• Dr Virginia Warren, Consultant in Public Health
Medicine and the Bupa Group Assistant
Medical Director.
• Mr Steve John, Bupa’s Group Communications
Director
The Grants
Grant rounds open to all clinical researchers are
held every year, two for medical research grants,
one for specialist grants and two for the Philip
Poole-Wilson Seed Corn Fund.
Medical research grants are made to UK
researchers for clinical studies on five topics: • Surgery: projects ranging from development of
surgical practices to evaluating outcomes and
identifying/teaching new techniques.
• Preventive medicine including epidemiology.
• Information and communication between
medical professionals and the public/patients.
• Mental health in older people.
• Health at work.
The specialist grants programme began in 2001
when the Bupa Foundation committed £600,000
to fund medical research aimed at reducing
adverse events in patient care. Since then the
amount offered each year has been increased to a
total of £750,000 for one or more projects in the
chosen area.
For information on recent themes and grant
winners, please refer to the specialist grants
awarded page of the Bupa Foundation website:
www.bupafoundation.co.uk
Surgical innovation was chosen for the specialist
scheme in 2003 and was won by Mr George
Hanna for ‘Development of a real time
endoscopic compliance mapping system’. The
diminished tactile feedback in minimal access
surgery degrades the surgeon’s ability to identify
the nature of tissue and may lead to tissue
damage. His study aimed to:
Design and develop an endoscopic high
precision clinical real time compliance
mapping system.
ii) Compare its tissue discriminatory power with
that of surgeons’ hands.
iii) Report the mechanical properties of in-vivo
intra-abdominal human tissue.
iv) Establish the prediction power of the system.
i)
The clinically useable, high precision, objective
real time compliance mapping system that Mr
Hanna developed is three folds more sensitive and
10% less specific than the surgeon’s hand.
Compliance of living human intra-abdominal
normal and cancer tissue has been reported with
very high discriminatory power between normal
and cancer tissue. This is potentially useful for the
development of more realistic surgical simulators.
Surgery will feature as a topic for the specialist
grant again before long, but, in the meantime, is a
permanent area of interest for the medical
research grants, as above.
The Philip Poole-Wilson Seed Corn Fund
The late Bupa Foundation governor Professor
Philip Poole-Wilson was highly committed to
setting up this stream of funding. Introduced this
year, the Seed Corn Fund aims to deal with one of
the obstacles to successful grant applications;
establishing proof of principle through feasibility
studies.
In order to encourage new research ideas, the
‘seed-corn’ fund of £200,000 a year, with
individual allocations of up to £20,000, is
•
•
•
•
•
•
•
Research.
Communication.
Epidemiology.
Health at work.
Clinical excellence.
Care for the elderly.
Patient safety.
Surgery
Naturally, members of the Association of
Surgeons of Great Britain and Ireland would be
most interested in the Bupa Foundation funding
for surgical research.
The Bupa Foundation funds a great variety of
projects on surgery. These have previously
included training in minimal access surgical
techniques, trials of the Da Vinci system for
robotic surgery, applying the black box approach
used in aviation to reducing errors in operating
theatres and a project looking at musculoskeletal
problems in orthopaedic surgeons.
Some of the more recent projects supported under
the surgical theme include:
Dr J Stephens, University of Wales, Swansea,
£96,163 over three years for ‘Incretin hormones,
obesity and impaired glucose homeostasis:
Bariatric surgery as a tool to study the role of
incretin hormones in obesity and associated
metabolic dysfunction’.
Dr Winter, Papworth Hospital Cambridge,
£176,102 over a four year period plus a further
£84,050 for a randomised controlled trial of
video-assisted Thoraloscopic Cytoreductive
Pleurectomy compared to Talc Pleurodesis in
patients with suspected or proven mesothelioma.
Mr P Ahrens, Royal Free Hospital Hampstead
NHS Trust, £49,110 over three years for
‘Randomised controlled multicentre study of
conservative management vs open reduction and
internal fixation of mid-term clavicle fractures.’
Mr K Moorthy, Imperial College London,
£170,082 for ‘Improving the quality of care of
emergency surgical patients’.
Miss Zoe Winters, Bristol, £107,002 for ‘The
QUEST Feasibility Study – an evaluation of the
feasibility of the QUEST Study, a multi-centre
17
Each year a call for submissions on a specified
topic in one of the Bupa Foundation focus areas is
made. The focus areas are chosen in turn on an
annual basis.
Awards
In addition to
grants, each year
the Bupa
Foundation presents
£15,000 awards in
recognition of
Professor Philip Poole-Wilson
excellence in
medical research
and healthcare in seven categories:
NEWSLETTER
Specialist grants have been devised as a proactive
stream of funding. Themes are within the main
focus areas for the Foundation, but represent a
move towards a commissioning approach.
intended to nurture
small studies with
the hope that some
can then be
progressed to
bigger research
studies.
The Foundation also identifies a theme each year
for the specialist grants scheme and is open to a
number of different countries. In 2008 the Bupa
Foundation donated a total of £2,204,382 to
medical and health research.
randomised trial to assess the impact of the type
and timing of breast reconstruction on quality of
life following mastectomy.’
Mr J Poloniecki, St Georges’, University of
London, £179,400 for ‘Differences between
hospital death rates following elective repair of
abdominal aortic aneurysm (ERA) with allowance
for risk factors’.
Dr B Wright, Selby & York PCT, £56,042 for
‘Would some genetically vulnerable surgical
patients benefit from prophylactic serotonergic
reuptake inhibitors to prevent poor postoperative
psychological recovery? Phase 1: Serotonin
transporter gene polymorphisms as predictors for
recovery after laproscopic cholecystectomy’.
Miss Alison Halliday, University of Oxford,
£405,484 over three years for ‘Asymptomatic
carotid surgery trial (ACST-2): an international
randomised trial to compare endarterectomy with
carotid artery stenting to prevent stroke’.
NEWSLETTER
Miss J Dawson, Oxford, £142,513 for
‘Prospective assessment of outcomes and
satisfaction with foot and ankle surgery, and
evaluation of the new MOXFQ patient-reported
outcome measure in relation to surgery on
different regions of the foot and ankle.’
Professor N Maffuli, Keele University/University
Hospital of North Staffordshire, £7,000, for a pilot
study ‘Comparison of Sub-vastus and standard
medial parapatellar approach for a total knee
replacement: eight year outcomes following a
randomised controlled trial’.
Projects funded by the Bupa Foundation under
other research categories may also have interest
for surgeons. Amongst the many successful
Foundation funded projects likely to have
worldwide implications is one that demonstrates a
creative ‘cross-fertilisation’ of ideas in applying a
technique from surgery to another field of
medicine. This pilot study successfully
demonstrated the feasibility of a new technique
for minimising blood loss in patients following
major injury. The study was led by Professor Ian
Roberts, London School of Hygiene and Tropical
Medicine, who was awarded £219,707 over two
years by the Bupa Foundation for the CRASH 2
pilot study (clinical randomisation of Tranexamic
acid, an antifibrinolytic in significant
haemorrhage). This agent has been widely used in
major surgery but had not previously been tested
in trauma.
On the basis of this successful pilot, the UK
National Institutes of Health Research Heath
Technology Assessment Programme later awarded
funding for a full scale trial to the researchers at
the London School of Hygiene and Tropical
Medicine. This clinical trial will involve 20,000
patients across the globe;13,000 had already been
recruited worldwide by January 2009. The trial is
scheduled to end in September 2010.
HOW TO APPLY FOR FUNDING
18
Annual awards
The details of eligibility, award categories and
judging criteria for the Bupa Foundation Awards
2009 will be announced early in the New Year and
posted on the charity’s website at:
Winners are announced at the annual prize-giving
dinner held in November each year.
Medical research grants
Health professionals working for public or private
organisations may apply for medical research
grants for UK-based projects. The Bupa
Foundation Board considers applications twice a
year. Anyone wishing to apply for a Bupa
Foundation medical research grant should use the
on-line eligibility test on the website to confirm
whether their project qualifies.
Specialist grants
The Bupa Foundation gives specialist grants to
recognise innovative approaches to delivering
healthcare. The theme for specialist grants for 2009
was ‘The social determinants of health’. Please
visit the Bupa Foundation website in autumn 2009
for the 2010 entry details. In contrast to the
medical research grant stream, this competition is
open to researchers in specified countries
internationally, as well as those in the UK.
Philip Poole-Wilson Seed Corn Fund
The Bupa Foundation allocates £200,000 annually
to this funding stream. If you are a health care
professional involved in research, or university
based researcher with an interest in health or
social care, with a great idea for new research in
one of these areas, you can apply for a grant to
help you develop your ideas. This could be to
support pilot work, for example, or to bring
together a team of people to work on a proposal.
The maximum award is £20,000 and it is expected
that activities funded would be completed within a
year. High priority will be given to applications
from young and/or new researchers who have not
previously been funded.
Making an application
You can apply online for any of our grant streams
at our website, as below. In addition, one original
signed copy of the application form must be
posted to the Bupa Foundation:
The Registrar
The Bupa Foundation
Bupa House
15 - 19 Bloomsbury Way
London
WC1A 2BA
Fax: 020 7656 2708
At present, Bupa Foundation Awards have a
different process. Please refer to the ‘Awards’
section on our website for details of how to enter
for these prizes.
For full information on the Bupa Foundation or
any of the projects featured, visit us at
www.bupafoundation.co.uk. If you have any
queries you are welcome to contact the Registrar
Lee Saunders or Assistant Registrar Teresa
Morris. We look forward to hearing from you.
Email: [email protected] or
[email protected]
Tel: 0207 656 2591 or 0207 656 2536
post-nominal letters, you will also be able to include
a telephone number, website and email address.
BRAND NEW ASGBI
MEMBERSHIP BENEFIT:
PERSONALISED PATIENT
INFORMATION LEAFLETS
Read on ...
I am sure we would all agree that good
communication is key in establishing trust in the
doctor-patient relationship. Without the patient having
a good understanding of what is involved in a
treatment, their signature on a consent form has little
medico-legal validity. Written information goes a long
way to helping the patient remember what was
discussed in the consultation, and also helps to protect
you by acting as evidence of what was communicated.
NEWSLETTER
Do you find yourself repeating the same information
over and over again to patients requiring surgery? Do
you struggle to find the correct information leaflet to
give to patients in your busy clinic? ASGBI and EIDO
have come up with a solution we think you will like.
A breakdown in communication is at the core of over
half of hospital complaints - just ask your complaints
manager! With NHS negligence premiums costing
£369m in 2008/2009 and tipped to nearly double to
£713m over the 2009/2010 financial year [1], better
patient information and informed consent are back at
the top of the agenda.
EIDO Healthcare is all
about providing top
quality patient
information to inform the
patient, protect the
clinician and reduce
claims against the
hospital. Our patient
information leaflets follow a rigourous development
process that includes full referencing to published
evidence bases. Our commitment to the accuracy and
relevance of our leaflets is an ongoing process. The
clinical content is regularly reviewed by our own
team of Consultants, as well as the various Royal
Colleges and Associations that endorse our leaflets.
In 2006, the ASGBI showed that it shared our
commitment in this vital area, appointing experts to
provide editorial input to ensure that the content is
accurate and relevant to your practice.
To maintain a strong patient focus, the leaflets are
reviewed by our team of non-medical editors and proofreaders, the Plain English Campaign and patients
themselves. This ensures that the leaflets are clear and
understandable - in fact, our leaflets are rated as “more
readable than the Sun Newspaper”.
The end result is a library of leaflets that are not
only in keeping with the latest guidelines, and
supported by a large evidence base, but that are easy
to understand.
20
How do I access the personalised leaflets?
This key benefit will become available to you as part
of the renewal of your ASGBI membership in
January 2010. You will be able to choose between 1
to 10, or 11 to 20 personalised, ASGBI-endorsed,
leaflets. All you need to do is tick the relevant box on
your renewal form and you will then be given access
to your own personalised leaflets through EIDO’s
web download centre. As well as your name, title and
LATEST NEWS FROM EIDO
Translations
One of the most frequently asked questions is “Are the
documents available in other languages?”. Although
we have always offered a service to translate leaflets
on an on-demand basis, we’re pleased to announce the
launch of our Translation Service, a ready-to-go
library of the most frequently used leaflets translated
into six foreign languages. These foreign-language
leaflets are also updated annually and come with a
professional indemnity guarantee.
The EIDO Translation Service initially includes 20
leaflets translated into Mandarin, Polish, Turkish,
Bengali, Portuguese and Arabic.
e-Learning courses
EIDO’s expertise extends beyond producing patient
information leaflets. Our innovative e-learning courses
provide information for health professionals on the
medico-legal principles of informed consent (be
INFOrMED) and clinical negligence (be CAREful).
In response to demand from our NHS customers, we
have revamped the functionality behind these web
resources to allow hospitals to take a more active
role in monitoring usage and issuing a ‘certificate of
completion’.
Both be INFOrMED and be CAREful have been
developed in collaboration with medico-legal experts
and are in use in hundreds of hospitals in the UK
and Australia.
• be INFOrMED examines current case law
surrounding consent and demonstrates the
consequences of not obtaining consent. Recent
additions to the course deal with the Mental
Capacity Act and guidance from the GMC and
PMETB for trainees about delegated consent.
• be CAREful is designed to reduce the risk of
litigation by promoting best practice in the area
of clinical governance. Clinical negligence
litigation is increasing and the legal rules are
constantly evolving. The Government is tackling
practical difficulties raised by litigation and it is
important for all healthcare managers and
practitioners to be aware of the significant impact
their approach to dealing with these difficulties
has on clinical practice.
EIDO offers a comprehensive service in the area
of consent to treatment. EIDO is your partner,
giving you peace of mind in this crucial area of
your professional practice.
Matthew Ravenscroft and Ben Standeven
National Account Managers
[1] http://www.hsj.co.uk/conservatives-highlightnhs-litigation-cost-increase/1984984.article
This slogan was coined by
the then Prime Minister of
Malaysia, Dr Mahathir, in
the 1980’s. It translates as ‘Malaysia can’ and has
become a well used ‘battlecry’ particularly at
sporting events. Six years in Malaysia has taught
me that Malaysia not only ‘can’ but actually ‘does’!
The independent state of Malaysia came into
existence in 1957, when the British formerly
handed over government of the country. Most of
you probably think of Malaysia as ‘Malaya’ with
memories of the fierce World War II fighting
through hostile jungle. Now it is a vibrant,
economically successful, country with very few
traces of the ‘third world’ left behind. The wealth is
based on large natural resources, once rubber and
tin, now palm oil, off-shore oil and successful hightech industries all backed by a stable government.
Although predominantly Muslim, the country is a
genuine ethnic mix of Malay, Indian and Chinese
who pretend to feud but really live alongside each
other - their religions, laws, ethics and food as can
only happen in a country which has been a
cultural mix for ever.
Penang, ‘Pearl of the Orient’ founded by the
British explorer Francis Light in 1786, is an island
of some 292 square kilometres [the size of the Isle
of Man] lying off the north west coast of mainland
Malaysia. It is joined to the mainland by a 13.5
kilometre bridge and has a population of 800,000,
most of who live in the capital Georgetown. The
Island is made up of Chinese shophouses, ethnic
enclaves, temples, white beaches and towering
high-rises - like Hong Kong with villages
[kampongs], tropical island, and lovely hotels all
mixed into one with diverse cultures and the best
food in Asia.
So how did I come to call Penang my home?
I had long ago decided to retire at 60; not because
I was disenchanted with the Health Service, but
because I wanted to finish while I was still
capable of being a good surgeon. What I had in
mind was playing a bit more golf, seeing some of
the places I had never seen and spending a little
time in the Royal Standard Inn. Looking back
now, it was the best decision I have ever made but,
perhaps more interestingly, from afar, I realise I
enjoyed almost every minute of my 30 odd years
in the NHS - we really had the best of everything;
freedom to practice high standard medicine in the
public sector without the constraints of our
patients money being involved and the ability to
As background I think it would help you to know
a little of the history of Medical Schools in
Malaysia and in particular that of PMC. Malaysia
had four - now five - University medical schools:
University of Malaya [UM], University
Kebangsaan, Malaysia [UKM], University Putra
Malaysia [UPM] and University Sains Malaysia
[USM]. The output of doctors was insufficient for
the developing medical needs and requirements
of the country and the government encouraged
the foundation of private medical schools –first
the International Medical School in KL [IMU]
and then, in 1996, Penang Medical College, a
joint venture between RCSI, University College
Dublin and the Penang Development Corporation
[an arm of the Penang State Government]. The
students, mostly Malaysian, but with a smattering
of Indonesians, Sri Lankans and Australians
spend their first two and a half years in Dublin –
at either UCD or RCSI. During this time they
carry out their basic sciences and early clinical
training and then come back to Penang to
undertake another two and a half years of clinical
training. A unique and much valued tenet is that
their final degree is an Irish one MB.BCh.BAO
[National University of Ireland]. The students,
who are part scholarship sponsored and part
privately funded, benefit enormously from their
time in Dublin – not only academically but also
from maturity, experience and not least in their
command of the English language.
When I came to Penang in 2003, we had just 40
students per year. The academic staff of the
College was mainly made up of Irish doctors who
had held senior academic positions in Dublin. The
College is situated in the heart of Georgetown,
opposite the old British Polo Ground some 400
yards from the Penang General Hospital [the
second or third largest government hospital in
Malaysia] to which we have exclusive access for
student teaching. The premises are delightful part old colonial and part modern but
architecturally old, surrounded by trees and a
quiet colonnaded academic atmosphere. During
21
“Malaysia: Boleh!”
NEWSLETTER
Peter Lee
make a little extra in private practice without
doing things others would be better at and without
prejudicing the huge practical experience we had
acquired and continued to acquire in our NHS
work. The Academic Unit in Hull had a strong
Irish connection; it was through this that, in late
2002, I was approached by David Bouchier-Hayes
and asked if I would like to be Professor of
Surgery at Penang Medical College [PMC] in
succession to Tom Hennessy, the well known
oesophageal surgeon and formerly Professor at
Trinity College, Dublin. I met Michael Horgan the
hugely impressive and entrepreneurial CEO of the
Royal College of Surgeons in Ireland, who treated
me as though I might have something worthwhile
to offer [in stark contrast to most of the
administrators of the NHS I had become used to].
By August 2003, after an exploratory visit, I was
installed as the head of the Department of Surgery
at PMC. Who knows why we take these
decisions? Did not Brutus say something like:
“There is a tide in the affairs of men, which taken
at the flood leads on to better things”?
A LETTER FROM MALAYSIA
Penang Medical College
NEWSLETTER
the six years I have been there I have seen the
yearly intake grow to 120 - not without its
problems both in terms of space and teaching staff
– but always backed by the enormous academic
educational facilities and experience of UCD and
RCSI and under the watchful eye of not only the
Malaysian Qualification Authority, the Medical
Council of Malaysia but also the Irish Medical
Council and the National University of Ireland.
So far, this dialogue is probably a cross between a
Conde Naste travel article and an advert for PMC
- in case you want to send your son or daughter
there – well why not? Without any question of
doubt, the ASGBI Honorary Editorial Secretary
[three times external examiner to PMC and lover
of all things Far Eastern especially Tom Yum
Soup and Penang Laksa] had more in mind than
this when he asked me to write the article,
probably: what is it like to undergo a major career
change from full-time surgeon to medical
educationalist at the age of 60 and, in doing so, to
translocate to the other side of the world?
Probably he hoped I would write about the
surgical setup in Malaysia –third world or
otherwise; almost certainly he would hope that I
would give my views in hindsight of the NHS,
the recent developments in British Surgical
Training - all with dispassionate interest from the
safety of 10,000 kilometres away.
PMC Graduation 2009
Well, why don’t I say what I think? After all I’m
an old fogie now, ready to fall off the perch and
about to be devalidated by that body we have all
come to know and trust – the General Medical
Council (when will their performance be
examined and revalidated I ask myself?). How
nice of them to let me know I can still call myself
a doctor, I thought my degrees had been awarded
to me by the University of Edinburgh!
22
So lets deal with the positive things first; what
about the move to Penang? I had taught surgery
for most of my working life, albeit mainly
postgraduate, but when I arrived in Asia I really
knew nothing about undergraduate medical
education. First I had to sit down and relearn all
my general surgery. I knew a lot about
hemorrhoids, but little about renal colic or liver
abscesses. Gardens textbook ‘Clinical Surgery’
became my companion - now I’m pretty good on
anything from head injuries to bladder tumours.
Then I had to learn about curriculum
development, examinations [or should I say
assessments], standard setting and all the other
nuances of teaching including the ability to speak
the language created by the Medical
Educationalists. Sometimes I wonder just to
secure their own environment? So the world of
CbD’s and TOSCE’s, Bloom’s Taxonomy of
learning and mini-CEXes became my own.
What have I learned? Well, Medical
Educationalists [of which I am now one] are like
curates eggs – some of what they produce is
excellent, some is untried and untested – so don’t
believe it all and don’t let them take over the
world!
Give me some examples you say. Well 10 years
ago we were told that if you did not practice
Problem Based Learning you were cannon fodder.
Now it’s become structured self-learning or
directed self-learning or case based learning
because hardly any medical schools could cope
with the practical problems of PBL – no matter
how good it appeared.
Or OSCE’s – they told me I must give up short
cases in our final exams because they were old
fashioned and unfair – I watch with amusement
now as the OSCE’s go back to ‘global assessment’
[just like short cases!] Sometimes I wonder how
much the changes in the ‘assessments’ are dictated
by increasing numbers of students and
practicalities of marking rather than by true worth.
Who says a 200, one best option, MCQ is the
most discriminatory surgical exam? Where is the
proof? Certainly not in my experience.
Then to Evidence Based Medicine – the ‘golden
globe’ of modern day medicine - we have made
great strides in introducing and demanding this
from our students – but, again, do not fall for it
hook, line and sinker. Evidence based medicine
is only as good as the trials and the research
workers who do them. Every edition of the BJS
now contains a meta-analysis or two; how
reliable are these? [As a sceptic I think the
trainees now see it as an easier way of knocking
off a publication or two without the problems
and time constraints of setting up a decent bit of
research work.]
But I digress. Becoming a full-time educationalist
has given me a new lease of life. At a time when I
was tired and probably a little burned out, I found a
new interest, enjoyed reading and teaching with no
time constraints and I learned about things I had
never understood such as fluid balance and sepsis.
I watched as I was able to pass this knowledge on
to our students, many of whom I got to know well
rather than just as a passing face.
Finally, what about surgery and surgical training
developments in the UK in the six years since I left?
I watch, from afar, with concern as the influence
of the government through PMETB and the
EWTD continues to disempower the medical
profession and turns it into a cohort of shift
workers. Do not worry too much. Maybe this will
work; after all, the nurses have done it for years.
The real problem to me is the acceptance of
‘shared responsibility’ by a generation of surgeons
not used to it - we will just have to learn to have
structured hand overs and to look after other
surgeons patients as well as we would have looked
after our ‘own’. Time alone will tell if the
outcomes are better or worse, but one thing is for
certain, the next generation of surgeons will never
have known anything different!
So there we are then, a few thoughts from
Malaysia; some good and some bad. Do I let the
latter get me down? No way. I sit out on the
balcony in the sunshine, listen to the waves, crack
open a frosted Tiger beer and light up my fifth
duty free Villiger of the day-and, when the
telephone rings, never again does my wife come
and say “It’s the hospital wants you”!
“Jumpa Lagi” [see you soon], as we Bahasa
speakers say. ‘Malaysia Boleh’, and does.
EDITOR’S NOTE
Peter Lee is Professor of Surgery at Penang Medical
College, Malaysia. He was formerly a Consultant
Surgeon at Hull and East Yorkshire Hospitals and is a
Past-President of the Association of Coloproctology of
Great Britain and Ireland. The opinions expressed in
this article are the authors personal views and do not
represent those of the Institutions mentioned. Finally,
thanks go to the Penang Tourism for kind permission to
reproduce several of the illustrations.
23
My only real criticism would be that the training
period is too long - maybe 12 years or more
before trainees achieve consultant status. In times
gone by, Malaysian registrars would look to the
UK for experience and training. The attitude of
the British government, the GMC and the
Colleges has put a stop to that - the young doctors
of Malaysia, Sri Lanka, India and Pakistan feel let
down by this and have lost faith in their former
mentors. The situation is made worse when they
hear tales of poorly qualified European common
market doctors walking into jobs they had
previously valued, and who can blame them?
Perhaps I could end with a couple of personal
grouses? The Surgeon/Apprentice relationship
appears to have been discredited for no particular
good reason [it worked for most of us], and yet we
now favour 4 to 6 monthly rotations which are
next to useless for acquiring sustainable practical
skills – both from the trainer and trainee point of
view. Why not spend a decent length of time with
one or two surgeons? Lastly, what about the
Intercollegiate Exit Exam? How long can the
training continue to end in an exam which really
means nothing in terms of sub-specialty training
or recognition? We need Board Exams, CME and
revalidation for the specialties and need to look no
further than America for our models.
NEWSLETTER
And what about Malaysian surgery? If you think it
is third world, forget it. Many of the patients turn
first to private hospitals if they can afford it or, at
least, until their money runs out. The facilities and
care are excellent and up to date. It is not
possible, at present, to combine private and public
hospital practice. To make money the surgeons
may tend to go full-time private a little too early,
tending to do cases they may not be the best to do
and, because of case numbers, risk deskilling
themselves in operations and techniques they had
hard earned in their training. The public hospitals
are busy, full of ‘old style’ general surgery and
excellent for training. The standard is good. The
junior surgeon training is based on the Malaysian
MS course and is very reminiscent of the old style
British training and FRCS - excellent and makes
me wonder why we ever changed it. Sub-specialty
training is somewhat behind the UK, but the Subspecialty Associations are now becoming well
established and making their mark.
I watched horrified and powerless as my own son
was caught up in the farce of the MMC and
MTAS specialty training interview system untried and untested. I grimace as the government
attempted to whitewash the problem by
implementing an independent enquiry. I listened
with interest as a senior UK surgeon described
the new Intercollegiate Surgical Curriculum to a
Malaysian audience in Langkawi. Very politically
and medical educationally correct - maybe even a
bit over the top?? Just like the undergraduate
curriculum, the training will be competency
based; there is nothing wrong with this, provided
the WBA’s, CbD’s, DOPS and mini-CEXe’s
[which were carried out before but on a more
informal basis] prove to be practical and reliable
[is there evidence already available for this?] and
provided that there is time available for an
interested and educated cohort of trainers to carry
them out. What troubles me more is that the new
curriculum is hiding the basic truth that with
specialised units, the EWTD and administrative
service demands, the opportunities for training
the young surgeons in the basics of operative
surgery are limited. Maybe part of the answer is
to institute training lists using patients sources
from all of the hospital [eg. hernias, VV’s, haems,
etc] carried out by older or newly retired
surgeons who are already proven ‘good ‘teachers.
We tried this in Hull and the trainee surgeons
loved it.
And all of this in a stimulating environment
surrounded by the new smells , tastes and sounds
of the Orient. All of this and an opportunity to
make new friends, learn new ways, broaden my
horizons, visit new counties and play some of the
best [and cheapest] golf courses in the world, and
be paid for it! What more could you ask? It
seems to me that the newly retired surgeon is a
largely untapped source of skilled and motivated
teachers for undergraduates. RCSI have
recognised this, I think very successfully, why not
others? If you have thought about it, do it - it
does not need to be across the world, but is
mighty exciting if it is!!
A detailed history written by our Archivist, Dr
James Douglas, is available on the Society website
at www.bts.org.uk for those who are interested.
Alongside this, is the need to maximize long-term
graft and patient survival, and the involvement of
clinicians and scientists working together will be
key to help deliver this.
What do the readers of this Newsletter think of
transplantation? A number of surgical colleagues
would argue that transplantation is one operation
involving three anastomoses and can be
undertaken by any competent general surgeon!
So what attracts surgeons into transplantation?
It’s certainly not the hours of work or the
prospect of private practice. A previous survey of
general surgical trainees showed that long hours
and the lack of private practice are a major
disincentive. So what is special about
transplantation? For many it is the opportunity to
see the transformation a successful transplant
can bring to a patient, but also to be involved
with that patient over many years. It is the
opportunity to work within a team of likeminded professionals across a range of
disciplines and there are always new clinical,
scientific and ethical challenges to work through
together.
The British Transplantation Society (BTS) - not
the British Transplant Society, as we are often
called - was founded in 1971 and initially
comprised mainly immunologists with a few
surgeons. It has subsequently grown and now has
nearly 800 members. The aim of the Society has
always been:
The BTS is different from all of the other
surgical specialty societies in that its
membership is not predominantly surgical,
although there are some non-surgical members
of the Society who think that it is! The
membership is diverse both across the
professions and across the organ types; but
united by the theme of transplantation. The wide
range of professional groups include surgeons,
physicians, pathologists, basic scientists, clinical
scientists (working in Histocompatibility &
Immunogenetics), transplant nurses, donor
coordinators, ethicists and pharmacists. The
organ types represented are predominantly
kidney, liver, pancreas, small bowel, heart and
lung; but with some representation from aspects
of tissue transplantation. This diversity provides
a tremendous opportunity for networking and
collaboration, but also the challenge of ensuring
all the constituent parts of the Society feel
sufficiently represented and that their needs are
met. Many members of the BTS will also be
members of their own professional Societies
such as the BSI (British Society of
Immunology), BSHI (British Society of
Histocompatibility & Immunogenetics), Renal
Association, BASL (British Association for the
Study of the Liver), ITNS (International
Transplant Nurses Society), the International
Society for Heart and Lung Transplantation
(ISHLT) and, of course, the ASGBI! Membership
of multiple Societies of course competes for
study leave and funding and is one of the
challenges we have been trying to deal with.
The day-to-day working of the Society is
undertaken by the Executive and Council with the
support of KSAM who provide our Association
Management. There are also a number of subcommittees of Council which fulfil specific
functions – Ethics, Transplant Training and
Education (TTEC), Standards, Clinical Trials
Steering Group, Conference Organizing
Committee, Nominations Committee and
Communications Committee. In addition, the BTS
is represented on a wide range of external
organisations including the ASGBI Council, its
Education and Training Board and CORESS. The
full Council meets three times a year, with the
Executive meeting on a more regular basis. Over
the last few years it has been increasingly
recognized that the Society must be representative
of all constituencies of its membership and, as
such, Council has been restructured to allow that.
The Executive and Council are elected by the
membership in a ballot administered by the
Electoral Reform Society. The elected members of
25
Transplantation is a
relatively new
specialty, that has
only become
routine clinical
practice over the
last 50 years, and is
supported by a
strong research and
ethical background.
The demand for
organs outstrips the
supply and
currently over 8000
Keith Rigg, BTS President
people are waiting
for a transplant with 3500 transplants being
performed last year. However, 1000 people per
year die whilst waiting for a transplant or are
removed from the list because they are no longer
fit. The Organ Donation Taskforce published 14
recommendations in January 2008 with the
ambition of increasing the number of organ
donors by 50% within five years and this would
result in 1700 more transplants per year. More
details are available at:
www.dh.gov.uk/en/Healthcare/Secondarycare/Tran
splantation/index.htm
NEWSLETTER
‘to advance the study of the biological and
clinical problems of tissue and organ
transplantation, to facilitate contact between
persons interested in transplantation, and to make
new knowledge available to any person for the
general good of the community. The Society may
also concern itself with the social implications of
transplantation.’
BRITISH TRANSPLANTATION
SOCIETY: WHO ARE WE?
26
NEWSLETTER
Council are the four members of the Executive
(President, Vice-President, Secretary and
Treasurer); three Councillors without portfolio;
eight Councillors representing the constituencies
of transplant surgery, transplant nephrology, liver
transplantation, cardiothoracic transplantation,
basic science, histocompatibility, donor transplant
coordination and recipient coordination and
nursing; and the chairs of the Ethics and the
Transplant Training and Education Committee.
Other members of Council are the chair of the
Carrel Club, Standards Committee and Clinical
Trials Steering Group; the Society archivist and
the web-manager.
The sub-committees of Council perform some
important functions and have had some
significant achievements. The Standards
Committee have produced some important, well
respected, evidence-based guidelines covering
such areas as transplantation in general, live
donor transplantation, non heart beating donation.
They have also worked with other groups to cover
cross-discipline guidelines. The full range are
available to download on the website. The Ethics
Committee have been able to consider carefully
many of the ethical issues facing transplantation
today, and regularly produce position statements
that subsequently can be quoted as the Society
position. They organize a popular session within
the Annual Congress as well as a yearly
symposium and it is important that our ethical
viewpoint can be proactive rather than reactive
whenever possible. The Transplant Training and
Education Committee were responsible for
putting together the content for the transplant
section of the ISCP curriculum and website.
Historically it has tended to deal with issues of
training of intra-abdominal transplant surgeons,
as training of others is generally covered by other
groups – although physicians are co-opted if
there are relevant things to discuss. The Clinical
Trials Steering Group have endeavoured to
coordinate clinical research across centres to
ensure that this research is clinically driven rather
than by industry alone. This is an area that will
become increasingly important.
the best paper – and a medal is awarded for both
the best clinical and laboratory presentation. This
year’s award winners were Simon Knight and
Ross Francis. The programme planning is a
particular challenge to ensure the meeting is
relevant to all parts of the clinical, scientific and
nursing communities.
Historically, the BTS Annual Congress has been
held around the UK with local transplant units
bidding to host it and in the spirit of competition
to make it the best meeting ever from both the
scientific and social perspective. Attendances
have steadily increased and now over 500 will
attend over the course of the three day meeting.
This means we have outgrown many of the
smaller venues and have the potential to rattle
around in the larger more expensive venues, and
this has meant running the meeting at a loss.
Council have discussed and debated this long and
hard over the last few years and have established
a number of important principles: meetings
should be attractive and accessible to all members
of the Society; conference venues should meet
agreed standards; a full range of accommodation
should be available nearby and meetings should
be financially neutral. We recognize that we must
rely less on the financial support of our
Corporate Partners and, at the same time, keep
registration fees as low as possible, and
particularly for those with low incomes, to
encourage attendance from the diversity of the
membership. As, increasingly, consultants also
have to pay their own way to attend, then
meetings must be both scientifically and
financially attractive. We have, therefore, taken
the decision that from 2011 to 2016 we will
alternate between Bournemouth and Glasgow and
have been able to negotiate some very favourable
deals as a result. Our challenge will be to make
those meetings sufficiently different to encourage
good attendance.
Whilst we would like the whole transplant
community to make the BTS Annual Congress the
main meeting they attend, we recognize that there
are competing meetings. The Society is keen to
promote an increasing number of joint meetings
with partner organizations within the context of
the Annual Congress. This years Annual Congress
was held jointly with the Renal Association in
Liverpool (and we can recommend the venue to
the ASGBI) and within the Congress there were
joint full day or half day meetings with BASL,
BSHI and ITNS. We will look to build on this in
The main focus of the BTS for many members is
the Annual Congress which is held in early
Spring. This has always been a tremendous
opportunity to network with colleagues as well to
be updated in the clinical, scientific and ethical
aspects of transplantation. The transplant
community is a relatively
small community and the
scientific and social
interaction between the
different professions and
disciplines is much valued.
The meeting is held over
three days and is the usual
mix of plenary sessions,
invited speakers and free
communications. One of the
highlights of the meeting is
the Medawar Medal which is
awarded to the young
scientist/doctor who presents This year’s award winners were Simon Knight and Ross Francis
Transplantation is always a very popular topic in
the media and, thankfully, much of the media
attention focuses on positive stories, although
there always have been negative stories which
have to be handled carefully and sensitively, and
which have the potential to cause harm to organ
donation and transplantation. Media enquiries
come from a wide range of sources from the
extremes of Woman’s Weekly and Saga Magazine
to Al-Jazeera and Mexican TV; however the
majority come from local and national print and
broadcast media. The Society does not employ a
press officer and, therefore, endeavours to
respond to media enquiries within house; which
is usually one of the executive members unless
specific expertise is required from elsewhere
within the Society. We have recently developed a
Media Centre on the website and produced some
guidelines for media enquiries. The Society has
always taken a positive approach to the media and
have endeavoured to engage wherever possible.
The Society’s new look website
The Society has also taken the opportunity over
the last year to redesign its website and logo to
update its image and to be fit for purpose. The
BTS wants to position itself as the professional
voice of transplantation in the UK. There are two
sections to the website; one is the password
protected Members Area and the other the Public
Engagement section which is aimed at the public,
non-transplant professionals and the media. The
BTS would like the website to increasingly
become the primary means of communication
with the membership and sends a monthly Ebulletin to them. The Members Area has separate
pages for all the constituent groups with
discussion forum, a jobs and opportunities page
and a searchable membership database. This is all
work in progress and the challenge is to ensure
the website remains fresh and relevant. Have a
look at www.bts.org.uk and see what you think.
I’d like to finish on a personal note and ask if you
are registered on the Organ Donor Register. If
not, have you taken the opportunity to discuss
with your family what your wishes are about
what you want to happen to your organs after
death? You can join the Organ Donor Register
either by ringing 0300 123 23 23 or going online
at www.organdonation.nhs.uk Please do think
seriously about this.
Keith Rigg
President, BTS
[email protected]
27
The Carrel Club is the group for surgical trainees
within the BTS and was initially established
around 20 years ago and I was in fact the
founding secretary of the group! It has waxed and
waned a bit over the years, but has been
reinvigorated over the last 5 years or so. It
currently has a very healthy membership with a
good number of trainees interested in a career in
transplantation. They have active representation
on BTS Council, the Transplant Training and
Education Committee, the Transplant Surgeons
Chapter committee and ASiT council. The key
issues for members of the Carrel Club are those
common to the majority of surgical trainees –
EWTD, training, sub-specialty recognition and
sufficient good quality consultant jobs.
NEWSLETTER
So what about the surgeons in the Society? There
are two groups for transplant surgeons; the
Transplant Surgeons Chapter, open to all surgical
members of the Society, and the Carrel Club,
open to surgical trainees. The Transplant
Surgeons Chapter was set up several years ago
when it was apparent that many surgical members
of the BTS felt that their issues, views and
concerns needed a specific forum. It was also felt
that such a forum would facilitate the integration
of all surgical transplant specialities in the BTS.
There was a debate about whether these
professional surgical issues would be best met
within a surgical body such as the ASGBI or as a
specific group with the BTS. There was a strong
desire for this to remain within the BTS where
the natural sub-specialty affinities lay and where
abdominal and cardiothoracic surgeons sat
comfortably. The Chapter meets a couple of times
a year including once within the Congress; the
meetings are always lively with an excellent
attendance and it is the only real opportunity for
transplant surgeons to meet. Topics include those
of both an educational and professional nature.
Within the latter category, and many of these will
be familiar to ASGBI members, have been
training, EWTD, job planning, ISCP curriculum
and multi-organ retrieval teams.
We are always keen to promote the value of organ
donation, the importance of transplantation and
new developments in the field; and there are
many opportunities for this. The perennial
chestnuts that the media want to discuss on a
regular basis are the controversial subjects of
payment for organs and the ‘opting-out debate.
As the voice of transplantation in the UK, the
BTS needs to become more political and lobby
where appropriate. We have given evidence to the
House of Lords Sub-Committee looking at Organ
Donation and Transplantation, we want to ensure
the recommendations of the Organ Donation
Taskforce are realised, make our views known
about the proposed EU Organ Directive and
ensure research is not unduly hindered by
legislation and regulation. This is an important
time for transplantation nationally with strong
government and Department of Health backing in
light of the recommendations of the Organ
Donation Taskforce. It is important that the BTS
and its members remain actively involved.
subsequent years and already a joint meeting with
the ISHLT is planned for next year’s Annual
Congress which is being held in London.
Selection for surgical training posts has become
increasingly competitive and is likely to be
exacerbated by plans to reduce the current excess
in core training posts. Equally, Programme
Directors are experiencing continuing difficulty
distinguishing between eligible candidates.
Aptitude testing has been implicated as a potential
mechanism to aid selection. To critically assess the
future role of aptitude testing in surgical selection,
it is important to attain comprehensive
understanding of testing goals, current
occupational usage in other fields and the evidence
basis for this. Additionally, assessment of surgical
speciality selection and its criticisms is necessary
to assess the scope for future developments.
What is aptitude testing?
Aptitude tests, also referred to as psychometric
tests, are a structured exam technique, used to
assess an individual. Traditionally, multiple-choice
questions progress in difficulty and are negatively
marked. Performance relies on speed, accuracy
and dynamic learning. Primarily, aptitude tests
measure a person’s ability to acquire new
knowledge or skill, with particular emphasis on
logical and analytical abilities.[1] The term
aptitude can also encompass assessment of
personality qualities.[2] Critical thinking is a
particularly valuable disposition, reflecting both
cognitive and non-cognitive abilities, rooting from
interplay between innate reasoning and
personality traits.[3,4] Increasingly, the link
between critical thinking ability, exam success and
career progression is being reinforced. [5,6]
History of aptitude testing
Aptitude testing for selection was originally
developed by the British military with the aim to
provide the Royal Air Force (RAF) with a filtered
cohort of trainees, ensuring the lowest possible
training costs.[7] The success of the programme
perpetuated the development of skill-specific tests
to assess innate qualities. A ‘Domain Centred
Framework’ was applied, involving identification
of occupation-specific ability requirements,
followed by development of tests to assess these
domains.[8] Currently the RAF identifies
attentional capacity, psychomotor, verbal
reasoning, numerical reasoning, spatial and work
rate as crucial domains for aircrew.[9]
The development of aptitude testing in selection is
most appealing in professions governed by
lengthy, high-cost training programmes.[15] The
nature of surgical training, involving a huge
vocational commitment, accompanied by
significant financial implications for the
individual and the tax payer, places speciality
training firmly in this bracket.
Development of the surgical selection process
The role of aptitude testing in surgery was first
proposed by Schueneman [16] as a mechanism to
facilitate surgical selection. With strong influence
from successful application in aviation,[7,9,17]
members of the Royal Colleges of Surgeons saw
parallels between the advantages of testing.
Traditionally, trainee selection was a poorly defined
process, allowing a high degree of assessor
autonomy.[18] Lack of selection criteria created huge
scope for bias, manifesting in phenomena such as
the halo effect (tendency to assess an individual
positively on a single attribute).[19,20] The
maturation away from individualism, to a more
centralised selection process, has helped to
nationally standardise candidate selection.[18]
Currently, selection for interview is based on
successful completion of an application form
encompassing academic qualifications, clinical
research, competencies, personality skills,
professional integrity and assessed commitment to
chosen speciality.[21] References and letters of
recommendation are also taken into account. At the
next stage, interviews are performed on a semistructured basis in order to evaluate professionalism,
clinical competence, personal qualities, critical
thinking and communication.[22] However, increases
in the volume of adequately qualified candidates
competing for a limited number of specialist
training posts is a prevalent issue.
Despite modifications to the selection format,
inconsistencies in candidate rating [23] and
inaccuracy of unstructured interview
techniques,[24] causes concern. The consistency of
more objective methods, such as aptitude testing,
is in demand.
Roles of aptitude testing in surgical selection
Changes in surgical training, as a consequence of
MMC and the EWTD, have resulted in a
significant reduction in potential training hours for
junior surgeons, from 30,000 to only 6000.[25]
29
Introduction
Surgery as a profession is changing, in terms of
trainee selection, career progression and the
development of novel operative techniques,
creating a shifting focus of skills. Advances in the
accessibility, and proficiency, of scopic surgery has
had significant effect on operative technique and
training. New legislation, namely, Modernising
Medical Careers (MMC) and inclusion of surgical
trainees to the European Working Time Directive
(EWTD), has led to compulsory reform. Radical
changes, enforced by the implementation of these
national directives, has had greatest impact on
specialty training programmes.
NEWSLETTER
Natasha Wielogorska
Globally, aptitude testing is well established in
military selection, [8 – 11] and has accumulated
growing popularity in other fields. Development of
psychometric testing could become an
accomplished screening tool for many types of
recruitment. Major advances in selection to Higher
Education has led to the development of admission
tests such as the Biomedical Admissions Test
(BMAT), the Thinking Skills Assessment (TSA,
Cambridge) and the National Admissions Test for
Law, among others. Particular focus on Bachelor
of Medicine programmes sees applications
increasingly accompanied by aptitude
assessment.[12] These advances have developed in
response to inconsistent evidence on the link
between academic achievement and success in
further education,[1,13,14] leading to uncertain
integrity of these methods.
APTITUDE TESTING AND ITS
ROLE IN SELECTION FOR
SURGICAL TRAINING
NEWSLETTER
30
Plus, with training costs at an all time high and
surgical outcomes under increasing scrutiny,
trainee selection must be reliable and rigorous.
Reductions in available training time calls for
better selection of candidates. Additionally, the
expense occurred in the training of surgeons is
immense. One study has estimated the annual cost
of speciality training in the US at more than
$47,970 per trainee.[26] Furthermore, disparity
between availability of surgical specialist training
posts (500 nationally) [22] and the number of
approved foundation posts (5,900 for 2008) [27]
puts huge emphasis on scrupulous selection.
Surgical disciplines, in comparison to other
branches of specialist training, generally displayed
the highest competition ratios, with applications
per post as high as 53.8:1 (Cardiothoracic Surgery)
and 22.5:1 (Trauma and Orthopaedics).[22]
Clearly there is a need for more reliable candidate
distinction. Appropriate aptitude testing as a valid
assessment of required skill would be beneficial
in refining applications. Ideally, achievement on
psychometric testing should correlate with figures
for successful completion of training, high levels
of surgical skill and positive operative outcomes.
The suggestion that aptitude testing could be used
to identify superior surgical abilities, aid selection
and impact upon service improvement is colossal.
Consequently, extensive investigation into
required skill and appropriate testing is necessary.
Evidence basis of aptitude testing in surgical
selection
Schueneman et al investigated the role of three
psychometric components; complex visuo-spacial
organisation, stress tolerance and psychomotor
abilities, to operative skill in surgical residents.
Academic records were also analysed. Results
showed a positive correlation between all three
aptitude scores and surgical ratings. Conversely,
there was no relationship between academia and
operative ability. This study offers convincing
support for the role of aptitude testing in surgical
selection.[16] Previously, however, poor links were
shown between cognitive testing and clinical
performance.[28] Inconclusive analysis has
prompted further research in an attempt to
establish concrete links between elements of
aptitude and measurable trainee ability.
To identify the worth of different psychometric
skills in assessing surgical ability, a validated
assessment of five aptitude tests was performed
on 100 surgeons. The following domains were
tested; spatial, diagrammatic, verbal and
numerical reasoning, plus dexterity. Results
showed no correlation between numerical
reasoning or diagrammatic reasoning and
individual skill. Positive correlations to technical
competence were shown with spatial reasoning,
verbal reasoning and dexterity. More specifically,
spatial reasoning was identified as the most useful
single predictor of performance.[29]
Dashfield et al, used computerised psychometric
tests, similar to those used in military selection, to
assess perceptual motor abilities in surgical
trainees. A surgical task was performed and rated.
Following a period of self-directed practice,
trainees reattempted the task and were scored
again. A correlation was established, showing more
limited performance improvement in trainees with
a favourable aptitude result.[30] This supports the
idea that innate ability has impact on inherent skill,
and promotes aptitude testing as a means to
selection. Conversely, skill practice decreased the
innately determined variation between candidates.
The application of these findings suggests that,
although aptitude testing may identify naturally
gifted candidates, the benefits of selection may be
abolished by skill practice, therefore extensive
development of an aptitude testing selection
scheme may not be cost efficient when compared
to increased training for selected candidates.
Increasingly, virtual simulated programmes are
being researched to develop, monitor and assess
surgical technique.[31] Some of these studies show
positive correlation between simulator training and
surgical proficiency.[32-34] It would be interesting
to investigate whether modern enhanced training
techniques utilising simulators would further
reduce innate variation between candidates.
In a skills comparison study between medical
students and master surgeons, Francis et al found
no correlation between spatial skills and surgical
performance, whereas both dexterity and handeye co-ordination were more proficient in the
surgical group.[35] In contrast, Steel et al found
no basis for dexterity in assessed work quality.[36]
A comparison, looking at a variety of
psychometric skills within a number of medical
professionals, found no difference between
dexterity, hand-eye coordination or spatial ability
between personnel.[37]
McClusky et al also found innate ability to have
an effect on skill acquisition. Subjects with higher
scores in perceptual and psychomotor aptitude
attained performance goals with less trail
attempts. Interestingly, there was no correlation
with spatial reasoning.[38] Other work suggests
that skill acquisition may be influenced by age
and gender.[39]
Preliminary work by Gilligan et al, further supports
the role of aptitude testing in trainee assessment [40]
and the recent decision by the Royal College of
Surgeons in Ireland (RCSI) to incorporate aptitude
measures within selection is encouraging. [41] Initial
research into the success of this selection protocol
shows positive outcomes in reliability and
discrimination between candidates. However, due to
the scientific uncertainty of psychometric testing as
a tool for surgical selection, the aptitude scores in
this validation study were not included.
Consequently, support for this selection process
omits aptitude testing and, therefore, counts against
their value in selection.[42]
Further work has fractionated aptitude research, in
order to investigate the implication of a specific
domain. Spatial awareness has attracted particular
focus. Early studies support a link between
surgical proficiency and spatial awareness.[16, 43]
Recently, data supporting the role of spatial ability
is more variable. Steel et al found visuo-spatial
skills to be of far greater merit in assessment of a
trainee’s capabilities than dexterity. [36] In another
study, scores for spatial ability and numeracy
ranked higher in the proportion of candidates
selected for interview in surgical selection.[40]
However, a number of studies dispute positive
Inconsistencies identified in the current selection
technique could be having an immeasurable effect
on trainee cohorts. In my opinion, changes to the
selection process should aim to target these
foremost. In terms of aptitude testing, further
research needs to be done into its benefit and role
in selection. Prior to any implementation,
extensive research is essential. Developments
should identify appropriate tests which
statistically correlate to objective elements such as
surgical skill. Adoption of a ‘Domain Centred
Framework’ would be beneficial, with an
emphasis on validation. Successful development
of appropriate aptitude testing, addressing these
critical view points, could lead to the development
of an effective selection battery for the future.
However, in review of current research, there is
large scope for improvement.
Table 1: The five skill criteria for surgeons
identified by Van de Loo [43]
References
Full references are available, on request, via:
[email protected]
Although this work emphasises the importance of
certain personality factors and supports the role of
interviewing in the surgical selection process,
some studies show conflicting results.[44] Using a
EDITOR’S NOTE:
This medical student essay won the Sutton Prize
at Southampton
31
In other fields of medicine, there is strong
evidence between certain aptitudes and
professional ability. Study of radiological trainees
identified clear correlation between ability and
performance of three-dimensional spatial
aptitudes.[47] More recent studies continue to
support this link. Waywell et al, have shown
junior radiologists to have heightened spatial
awareness compared to the equivalent aged
general population.[48] Similar visual special skills
have also been implicated in histopathology.[15]
As mentioned previously, personality qualities can
be assessed by psychometric testing and further
contribute to surgical competency. In one study,
Greenburg devised a list of personality traits and
presented them to 115 surgeons and trainees for
necessity rating within their profession. On
assessment, nine characteristics were identified of
particular perceived importance. These were
decisiveness; fairness; good team participation;
flexibility; admitting to errors; discipline;
considering all the facts; motivation; and an
ability to listen.[49] In a separate study, a tool
developed for assessing the predicted performance
of surgical trainees in the Netherlands included
personality factors within the criteria. Each of the
five sections were given equal weighting in
assessing suitability.[41] (Table 1)
Conclusion
A review of the method of selection for surgical
training is necessary for cost and patient safety.
Aptitude testing is a positive step towards
achieving the right candidate for the limited
number of training positions. However, evidence
basis for the use of aptitude testing in surgical
selection is poor and it may be that enhanced
modern training techniques such as simulators
would reduce the initial variation in assessed
candidate’s aptitude. Research lacks consistency
and is often small scale. Reported links between
psychometric testing and surgical ability are
conflicting and may be based on trend.
Conversely, the validated benefit of aptitude
testing within the military services has
considerable weighting. The decision of the RCSI
to include aptitude testing in their selection
criteria is surprising in the absence of good
evidence. However, I believe that aptitude testing
could be incorporated into the selection criteria
alongside other techniques such as a structured
application and interview process. There needs to
be more research into achieving the correct
question format to ascertain which components
correlate to the best surgical candidates.
Additionally, advances in minimally invasive
surgery have led to an increase in the range of
endoscopic and laparoscopic procedures available,
putting different demands on professionals. The
altered perception of televised images and the
experience of the fulcrum effect, (disparity
between hand movement and operative action)
may represent an area for aptitude testing in the
future.[51]
NEWSLETTER
Dexterity is another perceptively valued skill.
Degrees of required dexterity vary with speciality
demands. For example, open trauma surgery
requires far less operative dexterity than
ophthalmic surgery.[46]
Revised NEO Personality Inventory, similar
personality traits were commonly identified
among both male and female surgeons.[50] This
promotes the identification of a generic surgical
personality, despite attempts to move away from a
surgical prototype.[43] Deary’s study found no
correlation between personality and surgical
abilities in trainees.[44]
aptitude weighting. Deary et al found
measurement of three aptitude components,
(intelligence, visuo-spatial ability, personality)
showed no statistical significance with
professional skill. Contrary to other work, there
was no link between spatial skills and ability.
Identified trends suggested, instead, that more
successful candidates were of conscientious nature
and had better stereoscopic depth perception.[44] A
comparison between medical students and
surgeons showed surprisingly lower spatial skills
in surgeons but higher manual dexterity.[35]
Similarly, Gallagher et al, found levels of spatial
awareness among Urologists to be equivocal to the
general public.[45]
COMMUNICATING
SURGICAL EXCELLENCE: AN
EDITOR’S PERSPECTIVE
Communication is central to surgical excellence.
For the past seven years as Editor in Chief, and
for a similar period before that as an Associate
Editor, I have been privileged to help develop the
EJSO, formerly the European Journal of
Surgical Oncology and now colloquially The
Journal of Cancer Surgery from a regional to a
worldwide Journal. The EJSO is jointly owned by
BASO- The Association for Cancer Surgery, many
of whose members have strong links with the
ASGBI; and by ESSO, The European Society for
Surgical Oncology.
NEWSLETTER
David Rew
In a decade or so, building on reforms initiated by
my predecessor and mentor, Professor Irving
Taylor, and in partnership with our publishers,
Elsevier Science, the editorial team has doubled
the publication frequency, the manuscript flow and
the Impact Factor. We have also broadened the
coverage in depth of all of the surgical cancer
subspecialities, including those within the remit of
neurosurgeons, gynaecologists and urologists.
Through the wonders of technology, the contents
of a print journal of reference, which once
languished parochially on less than 2,000
bookshelves, are now read worldwide. In the past
year we have distributed more than 200,000 full
article downloads across the world wide web.
More importantly and less tangibly, we have
undertaken a series of initiatives to support our
authors and to drive up the quality of presentation
and content to make all papers as readable and as
educationally rewarding as possible.
Over this period, I have been privileged to have
first sight of the raw material of surgical science,
both in its publishable form and in the 70% or so
of submissions that fail to make the grade for
publication for whatever reason. An international
specialist journal editor’s desk is a barometer of
educational, writing and research standards in
many units and countries, and of trends in quality
and content.
For many years, UK academic surgical units were
pacesetters in formulating and presenting clinical
scientific endeavour, driven by trainees hungry for
academic recognition and preferment, and by such
as the SRS, now SARS. Surgical editors such as
John Farndon at the BJS were rigorous and
vigorous in the pursuit of precision and written
excellence. In other countries, surgical units are
now much more academically active, and our
Dutch surgical colleagues in particular are highly
productive of good quality work.
32
If UK Surgery plc is to regain or maintain its preeminence as a powerhouse for innovation,
academic enquiry and clinical excellence, then the
high quality published manuscript is central to its
future, and the search for writing and editorial
talent capable of driving that quality ever upwards
continues. For these reasons, I would like to share
with you the processes by which we have driven
the EJSO from regional to world wide recognition
as a UK-led, specialist peer reviewed journal of
quality, and what it takes to secure publication
against what is now world wide rather than
parochial professional competition.
We start with the point that Queen’s English (in
competition with verbose and bloated
Ameringlish) is now de facto the worldwide
language of professional communication and
record, with a rich, precisely defined and broad
vocabulary. For those brought up with the skills of
précis, it is also capable of clarity with simplicity
and conciseness, an observation often lost in
turgid documents which appear to mistake
wordiness for intelligence and volume for gravity.
The human attention span is strictly limited in the
face of an avalanche of words, imagery and
content facing us in every day life. Manuscripts
which are to capture the interest of the reader and
his or her attention, for even a few seconds, must
stand out for their preciseness and clarity.
In publishing, as in much that is of true value in
life, “Less is More”, an observation well
illustrated by Watson and Crick’s seminal paper
on the structure of DNA in Nature in 1953, which
extended to an overwhelming two pages. We have
thus set a strict limit of 3,000 words for all papers,
which is more than adequate for the
communication of a clinical research message. We
have also sought to eradicate wordiness and
duplication of meaning (“at this moment in time”
becomes “now” and so on), journalese, linguistic
efflorescence and flamboyant imprecision.
This inflation applies as much to data as to words,
where authors often seem to be under the
impression that large volumes of tabulated data
and computer generated statistical analysis add
gravitas rather than fog. Good data invariably
speaks for itself, and we oblige authors to
rationalise and present only the key data and
statistical procedures. We place limits on table
size and upon numbers of tables and figures.
With clarity of language and presentation comes
clarity of thought. A title posing a vaguely phrased
question is no substitute for a clear statement of
factual content and observation. An aim or
hypothesis must be capable of clear expression.
Regrettably, and far too often in cancer “research”,
studies are submitted (and rejected by us) of
archival material using a combination of the
plethora of immunochemical and molecular
biological markers and trawled correlations,
without any credible hypothesis, understanding or
critical appraisal of selection, heterogeneity and
sources or error. Similarly, large clinical data sets
are trawled with stats packages and any deviation
for “non-significant” used as the centre piece of
the message, regardless of a lack of credible
hypothesis. Too often, conclusions are reported
which reflect not the evidence to hand but wishful
thinking or self justification on the part of the
authors. For these reasons, we oblige subtitles and
headings in the Discussion section to focus
thinking, and absolute rigour in the Conclusions
based upon the information presented.
A key element in the success of the EJSO has been
in the application of modern technology to the
editorial process, allowing efficient, seamless and
paperless submission and review; and of the use of
the Internet for a commercially viable and income
generating distribution system. To survive, a
journal must be profitable. Licenses are purchased
by academic and other institutions to make content
free and instantly available to the individual end
user anywhere in the world. We look very carefully
at new models of publication, and particularly at
the on-line journals and repositories. As yet, we are
not persuaded that the rigorous production
processes of a printed, peer reviewed journal can be
substituted at a sufficient level of quality by newer
models, but this view may, of course, change with
time, technology and experience. Moreover, the
process of electronic access is continually evolving
greater functionality, and editors also have at their
disposal some powerful search tools for cross
checking and tracking new manuscripts against the
published literature.
Less than a decade ago, we formulated a
programme to make the EJSO the first choice of
the regional journals for the deposition of papers on
the generality of cancer surgery, and thereafter to
position it favourably and accessibly in comparison
with its major international (primarily US based)
competitors. Now that these objectives have been
achieved, the gauntlet is down to find the next
generation of editorial talent to carry forward both
the EJSO and other UK-led surgical journals as
core elements of an informal national surgical
strategy for pre-eminence. The EJSO demonstrates
what can be achieved with focus, a clear plan and
leadership under Specialist society ownership.
Discussions continue as to how best to reposition
and re-invigorate BASO-ACS, The Association for
Cancer Surgery, as a national cross-disciplinary
representative body for the professional interests of
all cancer surgeons, many of whom, like myself,
are also members of the ASGBI and proponents of
“UK Surgery plc” in the international community
of surgeons, to whom we have much to offer. I
very much hope that in advertising the success of
the EJSO on behalf of my editorial colleagues, I
will encourage those of you with academic and
publication intent across the cancer sub-specialities
to consider the EJSO as a worthy vehicle and
partner for your future work.
For correspondence on EJSO matters, please
contact: [email protected]
33
In order to help our authors adjust to the demands
of our publication and editorial policy, which is
often at variance in detail with that of other
journals, and for many of whom English is not
their first language, we have been very proactive
in providing tools for support. We have published
a series of guidelines for writing in the EJSO, and
set out clearly the expectations. Weaker
manuscripts are often “pre-processed” with
guidance for rewriting before review, and reasons
for rejection or amendment are given as fully as
possible. Some manuscripts go through several
cycles of revision and requests of the authors, but
the end results in published papers are usually
well worth the extra effort by editors and authors
alike, with positive feedback to the journal.
Conversely, we intend that no paper is rejected
without good reason or effort at improvement.
Journals cannot merely be vessels for the
deposition of published work, or else they will fill
with endlessly repetitive “me to” work,
advertising the clinical output of one unit or
another. The surgical literature has been under
continuous evolution for more than a century,
through anecdotal observation and case reports, to
statistical and ethical rigour and prospective
controlled trials. Much work reporting the output
of individual surgical units is nevertheless
predictably repetitive, with authors seeking out
minimal variation on a common theme to justify
publication, without adding to the sum on insight
or knowledge of the subject. While single-unit
case series can still influence the literature, the
interconnectivity of the Internet, and advances in
database and software design now facilitate much
larger collaborative studies and the posing of
more sophisticated questions based on large data
set analysis. My own view is that regional,
national and international collaboration should be
the direction of travel for the foreseeable future,
as projects such as the UK’s national cardiac
surgical data initiative have shown how patient
care can be improved through such global studies.
NEWSLETTER
Case reports have also been largely eliminated
from the high level literature. Few are truly
original, and the fact that a mass is the largest or
most oddly sited variant of a metastasis or other
pathology rarely tells us anything useful in the
management of the underlying condition. Those
cases which do have a valuable underlying
message are selected in the class of “Lesson of the
Month”. Technical “How I do it” articles are also
rejection fodder for rigorous editors, unless they
provide sufficient data and follow up to
demonstrate that the technique is clinically and
meaningfully advantageous.
This brings us on to one of the less appetising
aspects of editorial responsibility, which is the
professional obligation to police the world
literature for fraud and to take appropriate action.
Publication misconduct ranges from the trivial and
unintentional to systematic and deliberate fraud,
such as the republication of the work of others
under a new title and authorship, of which we
have identified a number of examples in recent
years, and for which the continual vigilance of
readers and reviewers is particularly important.
Review articles are the stock in trade of a
journal’s Impact Factor, and an editor chasing the
impact factor alone would reject all other articles.
However, this is not a realistic strategy for a peer
reviewed journal of record. Indeed, subject
reviews would not be possible were it not for the
output of original work and manuscripts to review.
We have, nevertheless, been both selective and
demanding of the quality and sourcing of review
articles, as far too many are a simple churning of
the literature, aided by search engines and abstract
indices, leading to “cut and paste jobs” and a
“meta-literature” which add no new insight and
knowledge to the subject area selected.
THE SECRET LIFE OF...
Andrew McIrvine: Commodore of the Royal
Ocean Racing Club
boats and the sea – having been brought up in
London and Oxford. I badgered my parent into
buying me an International Cadet dinghy, which I
think cost them £12. I lavished much care, paint
stripper and scraping, bringing her from a yellow
and green monstrosity to respectable dark blue
paint and varnished desks. That has just made me
think why I must have chosen blue for most of my
boats ever since. This boat also infected me with
the racing bug; I still have not grown out of it.
This article is designed to explain how I ended up
in my current position, although it surprises me as
I never sought or expected it; here goes with my
sailing CV
I was first introduced to sailing when I was about
8. My family went to the New Forest every
summer and had old friends living down there
whose son was a keen sailor – and later became a
senior naval officer. I became instantly attracted to
House jobs put paid to that. My first job was 1 in 1
orthopaedics at St Thomas’s, so no weekends for
sailing. My luck improved when I went to Kingston
where I met a wonderful physician, Bevan Hollings,
who wanted to race his 34 footer and needed crew.
We had a great few years until 1979 when a small
inheritance allowed me to launch out with my first
keelboat. I bought one of the first J24s built over
here (now an International Class with 5000
worldwide) shared with my wife and a great friend,
Dr David Shepherd, also ex St Thomas’s and a
radiologist in Bournemouth. That partnership went
on for 10 years – unusual in boats - and mainly
because of David’s extreme tolerance and good
nature. The partnership with my wife is ongoing!
I ended up on the committee of the J24 class, an
introduction to the politics of sailing and class
rule writing.
35
I am currently (since December last year) the
Commodore of the Royal Ocean Racing Club
(RORC) – probably the most prestigious club in the
world associated with offshore racing. We started
this sport in 1926 with the Fastnet race. This year is
the 30th anniversary of the severe 1979 Fastnet race
storm in which 15 lost their lives. Although this
freak storm obviously generated maximum press
interest, offshore racing has an impressive safety
record, compared with other extreme sports.
NEWSLETTER
My friend the Association’s Honorary Editorial
Secretary asked me to pen this piece as we were
floating about during the recent NHS Regatta. He
has known about my passion for sailing for some
years, but now I seem to have landed up in a sailing
‘top job’ he thought you all might like to know
more, (and it makes a change from him copying
pieces of my political rants from Private Eye).
Medical school in London was probably a rather
more relaxed affair than nowadays as I seem to
remember a lot of sailing and not much study. I
sailed for St Thomas’s and United Hospitals
teams. There were masses of opportunities for
team racing including a University league run on
Wednesday evenings on the Welsh Harp in North
London. We would team race the cars up there as
well before we raced the Fireflies! I understand
university team racing is having a resurgence now
– but sadly not much at the medical schools. It
was while I was treasurer of United Hospitals
Sailing Club that we planned and bought an old
barge to convert into accommodation for the Club
in Burnham. During one of the fundraising parties
– to which we invited everyone in sailing – I met
the then Commodore of RORC, David Edwards.
From that crucial meeting I went on to crew on
his boats, and then other offshore boats on the
South Coast during the heyday of the One Ton
Cup and Admiral’s Cup in the early ‘70s.
Later I progressed through two International
Moths and, if I have one regret in sailing, it is that
I am too old and unfit to sail the modern versions
of these which fly through the air balanced on
foils doing outrageous speeds.
I had two years abroad during the ‘log-jam’ years
when there were no SR jobs. The first in Boston
allowed me to do a lot of J24 sailing, including
championships in Key West and on the Great
Lakes. Regular sailing was in Marblehead with
great trips to local regattas in Martha’s Vineyard
and Newport. Sailing a J 24 through the
navigational hazards of Wood’s Hole at night with
none of the modern navigational aids was sporting
at best, (after we had bounced off a rock my wife
has rather avoided sailing – especially at night).
Shortly after my consultant appointment, I
decided to take the plunge and buy an X99. This
was a fairly extreme 9.9 metre boat designed for
high downwind speed and theoretical offshore
capability – though more for the Baltic where she
was designed than bashing up and down the
English Channel and beyond. I remember Bill
Heald looking at the boat with some incredulity
that anyone would go offshore in anything with
such a flimsy looking mast – and so it proved. We,
like many other owners, lost a couple of rigs over
the next few years.
This boat gave me the chance to get more into
international competition and we went to
championships in France, Ireland, the
Netherlands, Germany and Sweden, all good
experience rather than filled with success. I again
got involved in running the class and ended up as
UK and then International class secretary.
NEWSLETTER
During the winter, while by day I attempted to
understand surgical immunology research, at night
I went to classes to learn astro-navigation; sadly I
remember very little of it now as I have never had
to use it in anger.
Back to unemployment in the UK, I carried on
with the J24 and occasional trips on bigger boats
giving me the taste to return to longer distance
racing again.
The class was great for one-design racing but
carried a big rating penalty on handicap, which
eventually killed the class in the UK, so it was
time to move on again; this time to a moderately
crazy and expensive project but which was great
fun.
On to Cape Town where, again, my luck was in.
During a party given in our honour in our first
week there I was introduced to Jerry Whitehead.
He was one of the senior members of the Royal
Cape Yacht Club, still avidly racing in his 70s and
was another great sailing mentor for me. He was a
brilliant, naturally gifted, navigator – a breed
killed off by modern GPS. He had cruised and
charted the Falklands. We would set off on races
around isolated rocks off the Western Cape which
he would find at night, I know not how. I ended
up helming his boat for the year on both inshore
and offshore races. Sailing off the Cape of Good
Hope was my only experience of the amazing
Southern Ocean swells.
I had read about a new extreme boat being
planned by the US company J Boats. They had
started with the J24 but this had been so
successful that they had carried on designing all
sizes of boat – and still do. They had tended
towards cruiser racers - but this was to be an all
out racing boat built of carbon with a carbon rig –
and almost zero home comforts. It was 12.5
metres long, J boats had run out of numbers for
boats designed in feet so she was designated a
J125. Three friends went to the Southampton Boat
show to talk about it – and ended up deciding to
go with the project. We were buying the prototype
named ‘Wings of the Wind’ on a special deal.
Delivery involved collecting the boat in Fort
Lauderdale, racing offshore down to Key West,
doing the Race Week there and then shipping her
home. Amazingly, this all worked pretty well. The
offshore race was exciting as the course tracks
alongside the last live coral reef in the USA. If
you hit it, fines run to $100,000. So, when the
tropical squall hit in the middle of the night, and
we were trying to get the kite down on an
unfamiliar boat in the dark while heading towards
said reef at 18 knots, it was possibly too exciting.
We got her home but then really struggled to get
any good results. She was heavily optimised for
downwind sailing but most of our cross-Channel
races are upwind. This was a boat that could
sustain 20 knots plus on a reach but up wind was
very ordinary. The handicappers rated her as if she
was going downwind all the time. Only once did it
all come right, on the classic race to Dinard/St
Malo which for the first time in the 30 plus times
that I have done it was downhill all the way and
Wings won overall.
36
We had lots more fun with that boat culminating
in a trip to the Med where we did the famous
In February I was invited by the past Commodore
David Aisher to sail on his boat Yeoman XXXII,
in the inaugural Caribbean 600 race. There are
lots of day race weeks in the Caribbean but this is
the first time there has been a non-stop distance
race. This was a huge success and generated
masses of good publicity for the club – and we
won our class.
During this period I had been a main committee
member of RORC but had reached the end of my
term. I decided it was time for a change and go
back to smaller boats, one-design racing but at
two extremes. First the Daring Class in which I
took a share in a boat. These are an adaptation of
a 5.5 metre boat used in the Olympics in the 60s.
They only exist in Cowes and are the largest class
regularly racing there. They are beautiful looking
but incredibly wet. The racing is fun but a bit
limited trundling round the central Solent.
Most recently I have been on a whistlestop
weekend to New England where first I was able to
use the opportunity to have had dinner with my
old chief, John Mannick from Harvard & the
Brigham. The next morning I met the new head of
the Volvo Round-the World Race and watched the
restart in Boston –then on to Newport, Rhode
Island for the grand opening of the New York YC
‘country branch’.
For more fun I also took a share in a sportboat –
the Cork 1720. This is really a planing dinghy
with a keel, but so over-powered you need 5 or 6
crew to sail them. This boat we have taken to
Cork Week, Largs in Scotland and even the
renowned Lake Garda where we were nearly sunk
by another boat in a spectacular collision. The big
advantage, compared with my other boats, is that
she gets places fast - on a trailer.
As a further ill-advised sailing project, I joined
with a friend in restoring a 1926 6-metre which by
chance he found rotting gently in a scrapyard in
Derbyshire. She is back afloat and almost back in
racing trim. Yet another ‘hole in the ocean’ into
which to pour money.
So, having given up offshore sailing, how did I
end up with my present position?
Further meetings the next morning with movers
and shakers of US sailing and then home.
I got a call out of the blue from the then General
Manager of the RORC. One of the RearCommodores was going to have to work abroad
and wished to resign – would I take his place and
just fill in for a year? Then a year later would I
like to be Vice-Commodore? Two years further
on, here I am supposedly in charge.
In between trips abroad and frequent meetings in
London and Cowes I write a monthly column for
‘Seahorse’, the international sailing magazine –
oh yes, I do find some time for some surgical
work in Dartford and at King’s. I should mention
in these sensitive times that I do NOT claim
expenses!
So, back to offshore racing, so far mainly on other
people’s boats, but as usual planning my next one.
I am now six months into the job – 21/2 years yet
to go!
37
My greatest good fortune was a call from Peter
Rutter last year. Like me he is a vascular and
general surgeon with a busy practice, but he was
RORC Commodore three before me. He said you
will find it very difficult to do it all and run a
boat – why not come in with me on my new boat,
Quokka - a Corby 36 - for the offshore races next
year – so I accepted only too gratefully. So far it
could not be better – we have won Class 1 in the
first two RORC races of the season.
NEWSLETTER
Since December life has become increasingly
hectic. Within four days of election I was in the
USA joining in meetings with commodores and
officials of all the major clubs over there
discussing implementation of our international
handicap rule – IRC. A few weeks later to Madrid
for the International Sailing Federation AGM;
then to Paris to meet with our equivalent club in
France, the UNCL.
Middle Sea race. This is a classic which starts and
ends in Malta but includes a circumnavigation of
Sicily and other islands, making a distance of 630
miles. It includes fantastic scenery, warm sea, and
close observation of the volcanoes of Etna and
Stromboli – too close observation because the
snag with the Med is the wind. There is either far
too little, as in the year we did it – or far too
much, as in the next year. With no wind you can
be left stuck behind an island wind shadow for
ages. The whole race took six6 days and nights.
THE DISASTER THAT IS
CURRENT BRITISH MEDICAL
TRAINING: A PERSONAL VIEW
David Skidmore
38
“When I qualified from medical school it was
from a new-look course based on ‘problembased learning’ at an established medical
school that had a long and illustrious history,
Barts and The London. Despite that, I was
convinced on leaving that I was completely
unprepared for the real world of being a
doctor. My particular feelings of dread came
at the idea of not being technically competent
at doing basic practical tasks.”
A young trainee in Plastic Surgery supports this
view:
MEDICAL STUDENT MATTERS
The stimulus to pen this article comes first from
the statement of a young doctor in a recent
newsletter from the General Medical Council
about the problems inherent in the “modernising
medical careers” policy. Johann Malawana, Junior
doctor at the Royal London Hospital says:
“Consultant surgeons feel that the standard of
knowledge and skills is drastically lower in
medical students and surgical trainees than
ten years ago and that further ‘dumbing down’
of the curricula would be a disaster for future
British medical standards. One of the
consequences of oversimplified undergraduate
training is inadequate postgraduate
knowledge, which can lead to misdiagnosis
and even malpractice.”
The second problem we face is a further
reduction in training hours from August 2009 as a
consequence of new regulations from Brussels on
the European Working Time Directive (EWTD). I
instituted discussion on this topic in the
Financial Times in January [1] which was
followed up by letters from Professors Horrocks,
MacFie and Rowland on behalf of the
Association [2].
So the question has to be asked – how is it that we
are spending £250,000, over 5/6 years, training
doctors who are not fit for purpose on
qualification?
It is universally acknowledged that there are 168
hours in the week. It is also acknowledged that
people get sick outwith normal business hours
(i.e. 9.00am to 5.00pm, Monday to Friday) and
sometimes have the temerity to be sick, or to want
to have a baby, at nights, at weekends, and during
Bank and public holidays. This means hospital
services have to be available around the clock in
Accident and Emergency Services, General
Medicine, General Surgery, Obstetrics,
Gynaecology, Anaesthetics, Paediatrics and
Orthopaedics.
Internationally, the medical profession recognises
that continuity of care, headed by a Consultant
figure with a team of variably experienced
trainees working under his/her direct control, is
the best way of ensuring/optimising patient care.
What then has gone wrong?
Traditional Training
The apogee of meticulous British general and
specialist medical practice occurred after the
Second World War and lasted for some forty
years. Why was this?
In the aftermath of the Second World War a
National Health Service was instituted. The senior
specialist doctors had been reserve officers who
worked alongside a small cadre of service doctors
during the war. The war produced major clinical
advances, antibiotics, blood transfusion and the
beginnings of arterial and chest surgery.
Physicians and surgeons who had served all over
the world came back to the UK with a “can do”
philosophy about what was going to be achieved
for the civilian population. Tuberculosis, with its
pulmonary and orthopaedic manifestations, was
quickly conquered. In the 1950s cancer, cardiac
and brain surgery became an accepted part of the
clinical armamentarium.
The chiefs, now in their fifties, inculcated a
discipline of high standards of care and clinical
research. Medical students, of whom only 15%
nationally were female, recognised that they were
entering a tough profession with round-the-clock
responsibilities. This was offset by the
camaraderie of an excellent resident’s mess in the
major hospitals akin to a service mess. The life
portrayed in Richard Gordon’s “Doctor in the
House” film of the 1950s was not a gross overexaggeration of the environment of our major
hospitals. During precious time-off good quality
sporting activity was common. To students and
postgraduate trainees, the Consultants were
certainly paternalistic, encouraging friendship
across the years and showing us, in every detail,
what a medical career would mean. Salaries, until
your mid thirties, were risible and job contracts
were in sequence six months, then a year, then
two years and perhaps four years as a Senior
Registrar. If you were minded to aspire to a
Consultant career in the major disciplines, family
life certainly had to take second place and there
was the ever present need to pass examinations
like the FRCS where, in the 1960s and 70s, the
pass rate was approximately 40% of the
candidates taking the test.
Medical students during their three clinical years
were expected to be resident for varying times
during each particular module of work. For
obstetrics we lived-in for three months and this
meant that, even as a student, you were part of the
mess and benefited from informal teaching from
doctors 3-10 years older than yourself at every
occasion.
By the time I qualified in 1964, I had “scrubbed
in” as an assistant on more than 200 major
operations including 50 cardiac bypass cases. I
had delivered 40 babies under supervision and
carried out 26 post-mortems under the watchful
eye of the Professor of Pathology. Medical
students, again under supervision, took blood,
inserted catheters, stitched up wounds in Casualty,
performed lumbar punctures and assisted trained
nurses in every aspect of ward work including
caring for the dying. Little wonder that, after three
Subsequently, my personal career involved three
years of full-time research and six years as a
Senior Registrar, first in cardiac surgery and then
in general and cancer surgery, before being
appointed as a Consultant Surgeon at the age of
39. From then on, in a normal week I would see
70 new patients in clinic and personally perform
about 40 operations, the while supervising my
team in their clinics and operating work.
The Modern Dilemma
The contrast with “modern” training could not be
more striking. At pre-clinical level, medical
school admissions data across the UK shows that
there is a wide ethnic mix, some British born and
others coming to the UK for the first time as
university students.
In an article in The Times (24th February 2009),
Ed Hussain author of The Islamist highlights
problems of education, gender, language, safety
and leadership in the immigrant population which
might require attention. Further, 55% of our
medical school students are female. This
feminisation of the workforce must inevitably
impact on workforce planning in the future.
The teaching of anatomy – the language of the
human body when it comes to clinical care – is in
gross disarray, partly because of the shortage of
good anatomists and second because of
competition from other “exciting” topics such as
psychology, communication and ethics in the
A word is in order here about the previous preeminent role of senior nurses in the training of
doctors. The twin pillars of clinical excellence in
the health service must be the combination of the
parallel, but different, skills of senior nurses and
medical staff. Until 25 years ago, a clinical ward of
28 beds was under the overall charge of the Ward
Sister. The standards of nursing care, cleanliness,
laundry supply, feeding of patients and supervising
relatives and junior doctors was the acknowledged
role of the Ward Sister who had a responsibility for
what went on in her territory around the clock.
When she was not personally there in charge, the
Staff Nurses reported to her about overnight events
when she came back on duty. She supervised
students in all of the necessary disciplines needed
for the efficient running of the unit, analogous to a
senior NCO in any service unit. A busy acute
hospital cannot function without people who
exercise this type of continuing responsibility and
thereby control standards.
In the last two decades, this care and
responsibility has been dissipated, contract
cleaning managers, not Ward Sisters, apparently
supervise hotel services, catering companies
provide the food and PFI companies employ the
porters. Neither doctors nor nurses can, therefore,
change observed and continuing deficiencies in
these realms with consequent observed increase in
hospital acquired infections and poor nutrition of
patients. Furthermore, we have the alarming
consequences of relatives bringing in “takeaway”
food for patients and generally behaving in a most
undisciplined way when in the hospital to the
obvious detriment of their relative and all the
other patients in a particular ward.
The medical student, a supernumerary observer,
sees all this undisciplined mayhem around them.
The ward, which used to be the preserve of two or
three Consultants and a Ward Sister, now has
constantly rotating shifts of doctors and nurses
shuffling paper, reading notes and trying to
assimilate what the previous team has done (or
not done) for any particularly patient. Sadly, now
no one, except perhaps the Consultant, exhibits
39
During this time, in addition to operating with my
chiefs, I carried out some 1,300 operations on my
own and was responsible for the administration of
the hospital in terms of junior staff rotas and ward
management such as winter emergency
restrictions on elective admissions. Thus, at the
age of 30, as with the men who had trained me, I
was able to run a hospital from the administrative
standpoint as well as carry out a wide range of
surgical procedures. This was standard experience
for aspiring surgeons of my generation. In effect,
within these two years, I had already completed
5,000 hours of training which the EWTD now
suggests is the majority of training necessary for
Consultant appointment.
My contemporaries, after three years of
theoretical training, were itching to get involved in
hands-on clinical care. Nowadays, students are not
allowed to be involved. They are supernumerary
observers rather than an integral part of a clinical
team. Patients can state that they do not wish to be
examined by medical students, even when
admitted to a teaching hospital whose raison
d’etre is obvious from the name.
After an intensive year as “Houseman” intending
surgeons like myself would teach anatomy to preclinical students, before working as a Casualty
Officer and a Senior House Officer in one’s
planned speciality. Having gained an FRCS at the
age of 28, I became the Resident Surgeon at the
very busy Barnet General Hospital. For two years,
under the supervision of two Consultants both of
whom had been highly decorated for their military
service during the war, I lived in the hospital 133
hours one week and 88 hours the next. I went
home on Monday, Wednesday and Friday evenings
one week and had Tuesday and Thursday evenings
and the weekend at home on the second week.
curriculum. Anyone in doubt about this should
read an editorial written by Calvert and
Freemantle from Queens Medical School,
Birmingham where I studied in the 1960s [3]. 47%
of students lack confidence in their anatomical
skills. A recent survey of Consultant Surgeons
showed that 72% felt that the anatomical skills of
recently qualified surgical trainees was below
average. This against the background of clear
evidence that medical schools continue to attract
some of the brightest and initially most motivated
18 year olds in the UK.
years of what I have described elsewhere as “total
immersion” in clinical apprenticeship, passing the
final MB examination was something of an
anticlimax. We knew that we were capable of
being Pre-Registration House Officers; we had
understudied these roles for two years
Conclusion
Last year, a 24 year old RAF helicopter pilot,
Flight Lieutenant Michelle Goodman, was the
first woman to be awarded a Distinguished Flying
Cross for bravery in Iraq [4]. Yet we deny any
competence for responsibility to our medical
graduates. Sixty five years ago Guy Gibson, VC
aged 24, was a Wing Commander when he led
133 men on the Dam Busters raid. Eight aircraft
and 53 men failed to return [5, 6].
40
continuity of care and knows all the details of the
patient’s predicament. The letters from Mr Benson
and Jim Clarke in the March 2009 edition
(Number 25, page 14) of this Newsletter
exemplify this failure. Like Chinese whispers,
however meticulous the handover, critical detail
about management inevitably gets omitted
whether about drug allergy of a patient or very
personal issues such as marital disharmony which
can have a bearing on all aspects of patient
management. Patients are no longer allotted to
medical students who, in times gone by, became
the friend, supporter and advocate of the patient
throughout his or her time in the hospital.
The author with Flight Lieutenant Goodman, DFC
To the dilemma about student training, we now add
the frightening prospect of the enhanced European
Working Time Directive being implemented in
August 2009 to the inevitable detriment of adequate
medical coverage of acute services. It has been
estimated that traditional postgraduate training of
specialists, such as I have described, involved
25,000 to 30,000 hours of study and practice.
The present European working regulations
involve 8,000 hours and this will be cut to 6,000
hours. Just because Southern European
politicians think this is adequate for their
expectations of a Consultant
it is not, in my judgement,
any reason for us to accept
this politically motivated
opinion. A past President of
the Royal College of
Surgeons commented
recently that the new
document on medical
training produced by the
General Medical Council
Wing Commander Guy
“needs completely rewriting”.
Gibson, VC
We have to remember that, over the last 25 years,
there has been a revolution in the techniques and
drugs available for treatment, we are looking after
a rapidly ageing population with greater comorbidity, and crowded hospitals. The general
population’s expectation of results of therapy all
add to the professional demands on specialists.
This cannot be the time to further downgrade the
work commitment of staff in our hospitals.
The Association of Surgeons of Great Britain and
Ireland has been trying to get government to
realise the implications of the folly for years
without effect. There is, however, a conspiracy of
silence in the Department of Health on these
issues. The fact that the staff of the Department of
Health in Whitehall work a 40 hour week may be
relevant. However, certain careers, such as that of
a junior military officer, a civilian pilot, or
mariner cannot be time limited, are intensely
practical and demand an apprenticeship style of
training. This is certainly the case in practical
acute medicine and surgery. In recent evidence to
an American Congress committee, Captain
Sullenberger the pilot of the plane that
successfully ditched into the Hudson River in
New York stated “the current experience and skills
of our country’s professional airline pilots come
from investments made years ago”. This is equally
true of surgical training, as I have demonstrated in
this article.
The contrast between the legal and medical
professions is stark. Lawyers control themselves
via the Law Society and the Bar Council. Medical
Royal Colleges have been sidelined by
Government. Non-medical managers control the
profession at hospital level to the detriment of
patients and a once proud profession. Unless there
is a radical change in policy as determined by
Government, the General Medical Council and the
universities charged with undergraduate medical
training will continue to sleepwalk into an
uncertain future with deskilled “soft science”
doctors attempting unsuccessfully to meet the
clinical needs of an ageing or injured population.
It is five minutes to midnight and maximal
pressure now has to be exerted in an attempt to
prevent the total collapse of “out of hours” acute
care in the nation’s hospitals.
REFERENCES
[1] F D Skidmore
Standards of British Medicine under attack
Financial Times, 5th January 2009
[2] M Horrocks, J MacFie and B J Rowlands
Restraints have compromised patient safety
Financial Times, Jan 9 2009
[3] M J Calvert and N Freemantle, N, 2009.
Cost effective undergraduate medical education?
Journal of The Royal Society of Medicine, 2009,
102, 46-48.
[4] www.raf.mod.uk/news/archive (07.03.2008)
[5] Guy Gibson
Enemy Coast Ahead
Michael Joseph Ltd (1946).
[6] Paul Brickhill
The Dambusters
Whitefriars Press (1951)
EWTD: SUPPORTING YOUR
TRAINEES
Ed Fitzgerald
President, Association of Surgeons in Training
The coming weeks and months will doubtless
prove to be a difficult time for many surgical
trainees as new rotas and working patterns are
adopted, set against a backdrop of insufficient staff
with which to fill these increasingly thin rotas.
TRAINEE FOCUS
“If you can keep your head when all about you
are losing theirs, it’s just possible you haven’t
grasped the situation.”
This article aims to provide a simplified, practical
guide specific for surgeons, in particular
concentrating on practical advice Consultants can
give their trainees. However, given the 48-hour
week applies to Consultants and trainees equally,
we hope that the information contained will be
helpful to all. The full version of this abridged
guide can be downloaded from the ASiT website
(www.asit.org). Please do pass on these details to
your team and encourage your trainees to read it.
In preparing this guide, we have brought together
the latest advice from a range of organisations,
including the surgical Royal Colleges, the British
Medical Association and NHS Employers. The
bottom-line is that trainees need to be pro-active
to protect their training while, at the same time,
remaining professional and ensuring patient
safety. We hope that Consultants will do
everything within their power to support them, in
particular protecting training time and supporting
suitable rotas that allow this.
We hope this guide provides clarity on the key
issues surrounding EWTD and enables surgical
trainees to remain, as always, one step ahead of
the game.
Background to the EWTD
“We got into this mess because a group of
professional people, surgeons, have had their
hours of work defined for them by others
with little or no knowledge of the work
concerned” John Black, August 2009
August saw the implementation of the final stage
of the European Working Time Directive, ending
the exemption for junior doctors that was
originally established in 1993. This controversial
piece of European legislation was aimed at
protecting the health and safety of the worker. It
initially excluded a number of defined groups,
including doctors in training. Since this exemption
was over-tuned in 2000, we have seen the
introduction of an average 58-hour working week
from 1 August 2004, 56-hours from August 2007
and now 48-hours.
The reduction in surgical training opportunities
associated with EWTD implementation, thus far,
is real and has been well documented, with
numerous academic papers detailing the decline in
operative exposure.
42
Surgical trainees remain opposed to this restriction
of working hours for several reasons. As a craft
speciality, surgery is particularly vulnerable to the
inevitable reduction in training opportunities and
experience that accompanies this. Patient safety
will be jeopardised in the short-term through
reduced rota cover, multiple handovers, and a lack
of continuity in patient care. In the longer term,
the reduction in training opportunities and
inevitable focus on service will clearly impact on
the clinical and operative experience of surgical
trainees with an eventual deleterious effect on
service delivery and patient outcomes.
Finally, we believe the assertion that EWTD is
essential health and safety legislation is
disingenuous given that the resulting shift work
will result in more irregular hours and longer
periods of on-call. This scenario is unlikely to
result in well-rested doctors or the healthier worklife balance that some have sought to promote.
It is true to say that the NHS and the medical
profession have had many years to prepare for
this. Surgical trainees have watched the
Department of Health’s implementation schedule
closely during this time. ASiT first published a
specific position statement outlining EWTDrelated concerns in 2006. Since then, and despite
numerous further warnings, we have seen no
significant change in the provision of surgical
training within the NHS in order to address these
concerns; nor is there any evidence the NHS is
planning to address these in the future.
Given that the introduction of any compensatory
changes in training will now inevitably take
several years to establish, we continue to call for
the current legislation to be repealed in order that
the patients of today, and tomorrow, get the firstclass care they deserve.
In the meantime we need to remain constructive
and work around current legislation to ensure
training time is protected, while at the same time
developing and promoting new training initiatives
across the country.
EWTD and New Deal Rules
There is frequent confusion over the rules
governing junior doctor’s working hours. There
are two relevant areas of legislation:
1. Working Time Regulations (the UK
implementation of the EWTD).
2. New Deal Contract (the junior doctor contract).
The current legislation limiting working hours,
together with mandatory breaks and rest periods,
are now formed by a combination of these.
Whilst the New Deal only applies to junior
medical staff, the EWTD rules apply to all
workers (including Consultants) across all sectors.
The New Deal Contract included the following
key points:
• Working time should not exceed 56-hours of
work per week.
• Actual duty hours depend on working pattern
implemented (e.g. full, partial, etc).
• Eight consecutive hours rest between full shifts.
• Natural breaks of 30-minutes per four-hours
worked.
• Minimum of 24-hours rest every 7-days, or 48hours rest every 14-days.
•
•
•
Remuneration for Opting-Out
Any additional work undertaken after opting-out
of EWTD limits should be remunerated by your
employing organisation. How you are paid is open
to local negotiation with your NHS Trust.
However, it is important to note that your pay
banding will not necessarily change should you
choose to opt out.
Direct.gov: What counts as EWTD work?
As well as carrying out your normal duties, your
working week includes:
• Job-related training.
• Job-related travelling time.
• Paid and some unpaid overtime.
• Time spent ‘on-call’ (note: non-resident on-call
doctors only count the hours actually spent
working as ‘work’).
Remuneration can be through paid hourly locum
rates at least equal to the nationally agreed locum
scale, or through the conventional banding
system. The latter approach would require formal
monitoring in order to establish appropriate
remuneration, and is best suited to regular
additional work as opposed to ad hoc shifts.
Current nationally agreed locum rates are detailed
in the pay circulars listed in the reference section
of this document.
If you work two jobs you could either:
EWTD and Medical Indemnity
Trainees have rightly raised serious concerns
regarding their medical indemnity for work
undertaken over and above their 48-hour compliant
rota. Given the propensity of hospital management
to distance themselves from any adverse outcomes,
trainees are right to be cautious and question what
support, if any, the NHS will offer.
• Consider signing an opt-out agreement with
your employers if your total time worked is over
48 hours or reduce your hours to meet the 48hour limit.
Direct.gov: What does not count as EWTD work?
Your working week does not include:
• Breaks when no work is done, such as lunch breaks.
• Normal travel to and from work.
• Time when you are ‘on call’ away from the
workplace and not working (i.e. non-resident
on-call).
• Travelling outside of normal working hours.
• Unpaid overtime that you have volunteered for,
for example staying late to finish something off.
• Paid or unpaid holiday
EWTD and Personal ‘Opt-Outs’
If you wish to, anyone may apply to opt-out of the
EWTD working time limits. However, it is
important to note:
• You cannot opt out of the EWTD or New Deal
rest requirements.
• Opting out does not exempt you from the 56hour New Deal working time limit.
For trainees, opting out does not necessarily
result in extra training time. You may find the
extra hours worked are taken up by further
service commitments. You will need to weigh up
carefully whether these will further your clinical
experience and training. If you sign an opt-out
you are free to cancel this agreement at any time
by giving between one week and three months’
notice to the Director of HR (the notice period
depending on the wording of the opt-out
agreement you have signed up to). It is important
that any opt-out you choose to pursue is of your
own volition:
• Your employer cannot ask or pressurise you to
opt out from EWTD limits.
• Opting out of EWTD limits must not be a
requirement for your employment.
There is currently no nationally agreed system for
opting out of EWTD working time limits in the
Two specific scenarios have been identified:
1. Where clinical workload necessitates staying
beyond your allotted hours.
2. Where you attend for training in your own time
outside your allotted hours.
The first scenario is likely to be indemnified.
However, if this is a recurring scenario then it may
be more appropriate for the employer to
acknowledge this, re-design the rota, and re-band
your post as appropriate.
The second scenario is less clear-cut. While, in
theory, NHS indemnity should still apply, the
caveat may be whether the employing organisation
knows this ‘work’ is occurring, and whether the
supervising Consultant is prepared to take clinical
responsibility for this.
The NHS Litigation Authority has previously been
asked to clarify this issue and released the
following statement:
“Any activity carried out by clinicians, which
would be the subject of an indemnity if carried
out during ‘allotted’ hours, will be treated no
differently under our schemes because that
work was being done outside these hours”.
Stephen Walker, Chief Executive
NHS Litigation Authority, November 2007
We asked the Medical Defence Union for their
opinion and received the following response:
“…we would need to know in what capacity
the surgeons in training are attending cases
‘for their own education outside of the EWTD
working hours’. If they are merely observing
such cases and are not in any way providing
clinical care but are just an observer, the
question of indemnity would not arise. If,
43
•
averaged over 26-week period.
Eleven consecutive hours of rest per 24-hour
period.
Minimum of 24-hours rest every 7-days, or 48hours rest every 14-days.
Twenty minutes break per 6-consecutive hours
worked.
Four weeks paid annual leave.
TRAINEE FOCUS
• Working time not exceeding 48-hours per week,
NHS. Opting out must be agreed with your
employer in writing. A sample opt-out letter is
available from ASGBI (see references at end of
this document).
EWTD regulations include the following key
points:
however, they are attending cases as part of
the medical team providing care or treatment,
we would expect that they are doing so as part
of their employment and in that case they will
be covered by NHS indemnity and there would
be no need to inform the MDU. In the first
instance we would advise any doctor who was
working outside the EWTD hours to check
with the NHS employer for whom he or she is
contracted to work these additional hours what
the indemnity arrangements are.”
TRAINEE FOCUS
We asked the Medical Protection Society for their
opinion and received the following response:
“Clarification has been sought which confirms
that the NHSLA (National Health Service
Litigation Authority) has reassured Doctors
treating NHS patients beyond the limits of their
contractual duties that they would be indemnified
for claims by the NHSLA. However, it would be
wise to discuss the views and options locally if
working beyond contracted hours is not for
service provision, but for educational purposes.
Claims which arise from patients receiving NHS
hospital care should, therefore, be covered by
Trust indemnity. MPS would assist in matters
which arise from clinical work undertaken outside
of core contractual hours for non claims matters,
such as GMC or disciplinary investigation.
From a risk management perspective, junior
doctors should consider the appropriateness of
volunteering for extra work if they are tired,
despite there being a good training
opportunity. They must obviously ensure their
own and the patients welfare as a priority.
Ultimately, trainees are accountable for the
decisions which they make, and they will be
expected to always put the interest of the
patient first.”
It is, therefore, clear that in the event of any adverse
clinical incident occurring, a surgical trainee would
be expected to have shown a professional regard for
their rest periods, and not put a patient at risk as a
result of their own tiredness. Regardless of
indemnity, in the second scenario a trainee may still
find themselves in breach of their employment
contract by undertaking these additional hours (see
next section).
EWTD Non-Compliance
It is just as important that those wishing to adhere
to a 48-hour compliant rota are able to do so.
Trainees concerned that their EWTD rota is, in
fact, not 48-hour compliant over the reference
period of 26-weeks should raise this issue with the
Director of their Human Resources department and
clinical leads. If this concern is valid, the employer
has a duty to then reduce working hours through
rota amendments such that compliance is met.
A number of sanctions and penalties are available
for NHS Trusts that fail to implement or
knowingly run non-compliant rotas (excluding
those for which derogation has been applied).
44
These include:
• An improvement notice.
• Prohibition notice.
• Fine (£5,000 per employee per week).
• Imprisonment of the responsible authority.
EWTD and Employment Contracts
Trainees may find themselves in breach of their
employment contract and/or terms and conditions
of service by undertaking additional hours over
and above those included in their EWTDcompliant rota. This is dependent on the definition
of ‘work’ as applied to surgical training and this
(as far as we are aware) has not yet been legally
defined in this scenario. It will also depend on the
exact wording of your contract, which may differ
widely from hospital to hospital.
It is, therefore, vital that trainees wishing to
undertake either paid locum work, or additional
training beyond their contracted hours, are aware
of the specific wording of their contract.
Typical contractual statements preventing such
work may be worded as follows:
“You agree not to undertake locum medical or
dental work for this or any other employer
where such work would cause your contractual
hours (or actual hours of work) to breach the
controls set out in paragraph 20 of the Terms
and Conditions of Service.”
“Your hours and duties are as defined in the
attached job description [for rotations, the job
description may differ for each individual
post/placement]. You will be available for duty
hours which in total will not exceed the duty
hours set out for your working pattern in
Paragraph 20 of the Terms and Conditions of
Service.”
In a worst-case-scenario, breach of these
contractual obligations may be considered
grounds for dismissal. At the very least, it is likely
your NHS Trust will seek to use this in their
defence should any adverse incident occur during
hours worked over-and-above your contractual
obligations. We are aware of some NHS Trusts
who, despite including these clauses in their
employment contracts, are then asking medical
staff to work additional hours to fill rota-gaps.
Such incongruities should be highlighted to the
employing NHS Trust.
REFERENCES
EWTD for surgical trainees
http://www.asit.org/resources/articles/
ewtd_for_surgical_trainees
ASiT EWTD Position Statement - January 2009
http://www.asit.org/assets/documents/
ASiT_EWTD_Position_Statement.pdf
ASGBI: Opting out of the 48-hour working week
http://asgbi.org.uk/download.cfm?docid=
D37CD92E-0877-4389-BD56AC60590EF438
ASGBI: The Impact of EWTD on Delivery of
Surgical Services: A Consensus Statement
http://asgbi.org.uk/download.cfm?docid=
F3FAB184-01E1-414A-BA7C0CE07BBEDD7F
The Royal College of Surgeons of England / Royal
College of Anaesthetists Working Time Directive
2009 Project report: WTD - Implications and
Practical Solutions to Achieve Compliance
http://www.rcseng.ac.uk/service_delivery/
working-time-directive/docs/RCSRCoA%20WTD
%20Project%20Report.pdf
Cavendish
Medical
THE FIRST CUT IS THE
DEEPEST?
With the skill of a central London
estate agent marketing a shoe box as a
bijou pied a terre, the Prime Minister
has stopped proselytising on the perils
of abandoning his beloved Keynesian
spending policies in favour of a
“prudent programme of austerity
measures”, or cuts, to “non-essential”
government services.
Quite what is “non-essential” in
relation to the NHS is not yet clear,
although it seems that a drastic
reduction in the front line head count
is less imminent with the Minister of
Health, Mike O’Brien, recently denying
that recommendations from a report
prepared by the management
consultancy McKinsey were being
seriously considered.
What is clear is that hospital
consultants, and in particular Surgeons,
will be asked to do more than their fair
share in helping to reduce the
projected £180 billion deficit in the
nation’s finances. Unlike a hedge fund
manager, it is less easy for a surgeon
to amend his modus operandi and
relocate to Switzerland at short notice
when the taxation environment
becomes less favourable.
A cursory examination of the 2009
Budget reveals more pain to come for
“high earners”. This tax year, everyone
is entitled to earn their first £6,475
free of income tax, known as the
“personal allowance”. As of April 2010,
the allowance will be given up by those
earning £100,000 per annum or above,
resulting in a punitive marginal rate of
tax of 60% on earnings between
£100,000 and £114,000 (not including
national insurance contributions)!
The headline income tax rate for those
earning over £150,000 has been well
advertised as increasing from 40% to
50%. Perhaps less well known, is the
significance of the new restriction of
higher rate tax relief on pension
contributions. Those who have made a
lump sum pension contribution since
the 22nd April 2009 may well have
fallen foul of special transitional rules
and should contact their financial
adviser.
More alarming is the continued interest
of various commentators in the “drag
on the economy” of unfunded public
sector pension liabilities, variously
estimated at between £30 and £40
billion per annum. Last year, personal
contributions of higher earning
members of Superannuation were
increased from 6% to 8.5% per annum
to help plug the gap. This move, as
well as an increased retirement age of
65 for new joiners to Superannuation,
was supposed to have deferred the
decision over major surgery to the NHS
pension to a future government.
However, as long as it is politically
expedient to highlight the “iniquity” of
guaranteed, inflation proofed, final
salary pensions in relation to the
apparently riskier investment backed
schemes found in the private sector,
the NHS pension may not be safe from
further reform.
Although most vitriol is usually
reserved for those in “management
positions”, stories of recent senior
retirees from the police force taking
home tax-free lump sums in excess of
£450,000 have not been well received
in the current climate.
Perhaps it’s time to revise that
retirement date?
Prepared by Simon Bruce on behalf
of Cavendish Medical Ltd
[email protected]
Tel: 0207 636 7006
This article is not and should not be treated as
financial or investment advice. Cavendish Medical is
an independent financial planning practice and a
Professional Partner of the ASGBI. Cavendish Medical
Ltd is registered in England and is authorised by the
FSA, registration number 05448773
experience the difference
HONORARY SECRETARY
Mr Jonathan Pye demits office as the Association’s Honorary Secretary, at the completion
of his term, at the 2010 AGM in Liverpool, and his successor is now sought.
The post is for a maximum term of office of five years, and the Honorary Secretary is a
member of the Association’s Executive Board, Council and other ASGBI committees.
The Honorary Secretary is also a Trustee of the Association’s Surgical Foundation.
A Job Description is available, via the ASGBI website, at:
www.asgbi.org.uk/appointments
CONTRIBUTE TO THE LEADERSHIP OF YOUR ASSOCIATION
Appointment to this post will be by competitive interview. Applications, in the form of a
covering letter and a brief CV, should be received by the closing date of
midnight on Monday 2nd November 2009.
Interviews will be held on the morning of Wednesday 16th December 2009.
Applications should be emailed, in confidence, to:
[email protected]
MESENTERIC METASTASES
FROM A RECURRENT
PHAEOCHROMOCYTOMA
CAUSING SMALL BOWEL
OBSTRUCTION
48
CASE STUDIES
Shakeeb Khan, Shahab Siddiqi, James Gunn
and John MacFie.
Scarborough Hospital and Castle Hill Hospital,
Cottingham.
Case presentation
An 83 year old male, who had undergone a left
adrenalectomy for an apparently benign
phaeochromocytoma 14 years previously,
presented with symptoms of vomiting,
constipation and central abdominal pain. He was
haemodynamically stable and his abdomen was
mildly tender on examination. Blood investigations
revealed a raised white cell count of 16.1 x 109/l,
an elevated C-reactive protein of 207mg/l and a
normal amylase. Arterial blood gas analysis
showed respiratory alkalosis with normal base
excess and lactate. CT scan of his abdomen
showed two segments of thick walled small bowel
with a small amount of free air, suggesting a
localised perforation and several mesenteric
nodules some with necrotic centres (Figures 1 and
2). In view of the clinical and radiological
findings, an emergency operation was undertaken.
Figure 1
Figure 2
Figure 1: Top arrow shows free air and bottom
arrow shows thickened small bowel
Figure 2: Arrow shows one of the mesenteric
nodules
On laparotomy, two distinct areas of small bowel
were noted to be inflamed and oedematous. These
were adherent to three nodules on the small bowel
mesentery. One of the nodules appeared to be the
site of small bowel obstruction with proximally
dilated and distally collapsed bowel. The small
bowel mesenteric nodules were black in colour, 13cm from the bowel edge and varied in size from
5-20 mm. The nodules were resected and sent for
histological analysis. Careful inspection of the
entire bowel did not reveal any perforation or
ischaemia. It was deemed by the operating
surgeon that the small bowel perforation had
healed spontaneously. The post-operative course
was uneventful with no labile blood pressure.
Histological examination of the mesenteric
nodules confirmed metastatic
phaeochromocytoma (Figure 3). They were
strongly positive for synaptophysin, chromogranin
and CD56 and negative for cytokeratin and
melanoma markers. Urine catecholamines were
analysed postoperatively and were not elevated.
Figure 3: Histological appearance of the resected
nodules
What are phaeochromocytomas?
Phaeochromocytomas are tumours arising from
the adrenal medulla with an incidence of less than
5 per million per year [1] and are defined by the
World Health Organisation as tumours of adrenal
medullary chromaffin cells. They may be benign
or malignant, and the distinction between the two
is often difficult [2]. Usual sites of metastasis and
recurrences are bone, liver and lymph nodes [1].
How are phaeochromocytomas diagnosed?
Plasma and urinary catecholamines and
metanephrines measurements are the initial
investigations. Raised plasma metanephrines
provide a sensitivity of 98% and specificity of 92%
[3]. If these are found to be raised, the diagnosis can
be confirmed and the tumour localised with
imaging modalities such as computerised
tomography or magnetic resonance imaging.
What are the signs and symptoms of
phaeochromocytomas?
Phaeochromocytomas produce and secrete
catecholamines causing the classical symptoms of
sympathetic hyperactivity such as labile blood
pressure, tachycardia, headache, sweating and
tremor [3, 4]. However, presentation can be atypical
or patients may remain asymptomatic for extended
periods, all leading to delayed diagnosis [5, 6]. It has
been suggested that half of all phaeochromocytomas
remain undetected during life [7] and up to 40% of
cases are diagnosed incidentally [8]. An Australian
study found phaeochromocytomas in 0.05% of
coronial autopsies [9].
How can phaeochromocytomas remain
clinically dormant for prolonged durations?
Phaeochromocytomas can have a wide spectrum
of presentation and may remain dormant for
prolonged periods [10]. They do so if the
catecholamines produced by the tumour are
inactivated by the enzyme catechol-O-methyl
transferase [11].
How can phaeochromocytomas present as an
acute abdomen?
Rarely phaeochromocytomas can present as an
acute abdomen. The elevated levels of
catecholamines produced by tumour cells can cause
arterial vasoconstriction and segmental intestinal
ischaemia [12, 13]. Secondly, raised catecholamine
levels can stimulate alpha-adrenergic receptors in
the gut resulting in inhibition of bowel motility and
pseudo-obstruction [14]. Both these mechanisms can
result in further complications such as intestinal
perforation [15, 16].
[9]
[10] Grossman E, Knecht A, Holtzman E, Nussinovich N,
Rosenthal T. Uncommon presentation of
pheochromocytoma: case studies. Angiology 1985;
36(10):759-765.
[11] Eisenhofer G, Keiser H, Friberg P, Mezey E, Huynh T T,
Hiremagalur B et al. Plasma metanephrines are markers
of pheochromocytoma produced by catechol-Omethyltransferase within tumors. J Clin Endocrinol
Metab 1998; 83(6):2175-2185.
[12] Salehi A, Legome E L, Eichhorn K, Jacobs R S.
Pheochromocytoma and bowel ischemia. J Emerg Med
1997; 15(1):35-38.
[13] Sohn C I, Kim J J, Lim Y H, Rhee P L, Koh K C, Paik S
W et al. A case of ischemic colitis associated with
pheochromocytoma. Am J Gastroenterol 1998;
93(1):124-126.
[14] Turner C E. Gastrointestinal pseudo-obstruction due to
pheochromocytoma. Am J Gastroenterol 1983;
78(4):214-217.
[15] Karri V, Khan S L, Wilson Y. Bowel perforation as a
presenting feature of pheochromocytoma: case report and
literature review. Endocr Pract 2005; 11(6):385-388.
[16] Mazaki T, Hara J, Watanabe Y, Suzuki S, Kohno T, Eguchi
T et al. Pheochromocytoma presenting as an abdominal
emergency: association with perforation of the colon.
Digestion 2002; 65(1):61-66.
[17] Moirangthem G S, Singh N S, Singh L D, Singh T D,
Debnath K. Phaeochromocytoma at the root of the
mesentery. Int Surg 2000; 85(2):113-115.
[18] Vazquez-Quintana E, Vargas R, Perez M, Porro R,
Gomez D C, Tellado M et al. Pheocromocytoma and
gastrointestinal bleeding. Am Surg 1995; 61(11):937-939.
[19] Wan W H, Tan K Y, Ng C, Tay K H, Mancer K, Tay M H
et al. Metastatic malignant phaeochromocytoma: A rare
entity that underlies a therapeutic quandary. Asian J Surg
2006; 29(4):294-302.
[20] Eisenhofer G, Bornstein S R, Brouwers F M, Cheung N
K, Dahia P L, de Krijger R R et al. Malignant
pheochromocytoma: current status and initiatives for
future progress. Endocr Relat Cancer 2004; 11(3):423436.
Figure 4: Gross appearance of a phaeochromocytoma
arising from the adrenal gland
(Taken from: www.healcentral.org)
REFERENCES
[1]
[2]
[3]
[4]
[5]
[6]
Stenstrom G, Svardsudd K. Pheochromocytoma in
Sweden 1958-1981. An analysis of the National Cancer
Registry Data. Acta Med Scand 1986; 220(3):225-232.
DeLellis R A, Lloyd R V, Heitz P U, Eng C. Pathology
and Genetics of Tumours of Endocrine Organs. Lyon,
France: IARC Press, 2004.
Eisenhofer G, Siegert G, Kotzerke J, Bornstein S R,
Pacak K. Current progress and future challenges in the
biochemical diagnosis and treatment of
pheochromocytomas and paragangliomas. Horm Metab
Res 2008; 40(5):329-337.
Stein P P, Black H R. A simplified diagnostic approach
to pheochromocytoma. A review of the literature and
report of one institution’s experience. Medicine
(Baltimore) 1991; 70(1):46-66.
Goh Y S, Tong K L. Phaeochromocytoma the great
mimicker: a case report. Ann Acad Med Singapore 2008;
37(1):79-81.
Lo C Y, Lam K Y, Wat M S, Lam K S. Adrenal
pheochromocytoma remains a frequently overlooked
diagnosis. Am J Surg 2000; 179(3):212-215.
[21] Kocak S, Aydintug S, Ozbas S, Ceyhan K, Eraslan S. The
importance of lifelong follow-up for patients with
pheochromocytoma: report of a case. Surg Today 1996;
26(10):839-841.
[22] Sparagana M. Late recurrence of benign
pheochromocytomas: the necessity for long-term followup. J Surg Oncol 1988; 37(2):140-146.
[23] Goldstein R E, O’Neill J A, Jr., Holcomb G W, III, Morgan
W M, III, Neblett WW, III, Oates J A et al. Clinical
experience over 48 years with pheochromocytoma. Ann
Surg 1999; 229(6):755-764.
[24] Plouin P F, Chatellier G, Fofol I, Corvol P. Tumor
recurrence and hypertension persistence after successful
pheochromocytoma operation. Hypertension 1997;
29(5):1133-1139.
[25] Mercuri S, Gazzeri R, Galarza M, Esposito S, Giordano
M. Primary meningeal pheochromocytoma: case report. J
Neurooncol 2005; 73(2):169-172.
[26] Schlumberger M, Gicquel C, Lumbroso J, Tenenbaum F,
Comoy E, Bosq J et al. Malignant pheochromocytoma:
clinical, biological, histologic and therapeutic data in a
series of 20 patients with distant metastases. J Endocrinol
Invest 1992; 15(9):631-642.
[27] Favia G, Lumachi F, Polistina F, D’Amico D F.
Pheochromocytoma, a rare cause of hypertension: longterm follow-up of 55 surgically treated patients. World J
Surg 1998; 22(7):689-693.
49
After how long can apparently benign
phaeochromocytomas recur?
Apparently benign phaeochromocytomas have
been reported to recur many years after initial
presentation [21]. The longest interval between
surgery and recurrence detection have been
reported as 14 [22], 15 [23], 16 [24], 26 [25] and 28
years [26]. Favia et al. proposed that such patients
should be followed up life-long using annual 24hour urinary catecholamine levels and regular
blood pressure measurements [27].
[8]
Benowitz N L. Pheochromocytoma. Adv Intern Med
1990; 35:195-219.
Solorzano C C, Lew J I, Wilhelm S M, Sumner W,
Huang W, Wu W et al. Outcomes of pheochromocytoma
management in the laparoscopic era. Ann Surg Oncol
2007; 14(10):3004-3010.
McNeil A R, Blok B H, Koelmeyer T D, Burke M P,
Hilton J M. Phaeochromocytomas discovered during
coronial autopsies in Sydney, Melbourne and Auckland.
Aust N Z J Med 2000; 30(6):648-652.
CASE STUDIES
How can benign and malignant forms of
phaeochromocytoma be differentiated?
Distinction between benign and malignant forms
of phaeochromocytoma can be difficult. Even
histology may not be predictive [19] and the only
reliable criterion is the presence of chromaffin
tissue at sites where it is normally not present [20].
[7]
What was the cause of acute abdominal
symptoms in this case?
Neither pseudo-obstruction nor bowel ischaemia
was the cause of the symptoms in the presented
case. Instead, they were a consequence of
mechanical intestinal obstruction. The obstruction
was produced by adherence of loops of small
bowel to the mesenteric metastatic nodules. The
localised perforation suspected on CT most likely
sealed spontaneously. We could identify only two
previous instances of malignant
phaeochromocytoma involving the mesentery.
However, both were retroperitoneal masses
present at the base of the small bowel mesentery
and were noted at the initial presentation [17, 18].
PEDAL
THROMBOEMBOLECTOMY
FOR ACUTE ISCHAEMIC LIMB
CASE STUDIES
C G Davies, D J May, C P Shearman.
Southampton
Case presentation
A 53 year old woman, known to have small cell
carcinoma of the lung with nodal disease,
presented with an acutely painful right foot that
had been troubling her for three days getting
progressively more painful. On presenting to
hospital, the foot was cool with paraesthesia and
movement of the digits was still present although
reduced. The patient was normotensive, not
diabetic, had been a smoker of twenty cigarettes
per day for twenty years, had no previous history
of peripheral vascular disease and was treated for
dyslipidaemia with simvastatin. On clinical
examination she had a pulse of eighty beats per
minute in sinus rhythm. There was no palpable
abdominal aortic aneurysm; femoral pulses were
felt on both sides. There was no palpable
popliteal, dorsalis pedis or posterior tibial pulse
present on the right side, pulses were normal on
the left.
Question
What imaging modalities could be used to
investigate this further? What are the advantages
and disadvantages of each?
Answer
Ultrasound duplex, CT angiography and MR
angiography are all non-invasive imaging
modalities that can be used. Ultrasound duplex
requires a vascular trained sonographer to give
detailed information on nature of disease, MR
angiography takes longer to acquire images and is
less frequently available out of hours, it can also
not be used on all patients depending on presence
of metal clips etc, CT angiography does have a
significant radiation exposure attached to it with
the potential risk of contrast induced nephropathy.
In this case, a CT angiogram was performed since
the patient presented out of hours with no
available vascular
sonographer but
with the availability
of CT angiography
(Figures 1 and 2).
Question
Where are the
likely points for
emboli to lodge?
Figure 2: CT Angio 2
Answer
Arterial emboli typically lodge at branch points in
the arterial circulation where the caliber of the
arterial lumen diminishes. In this case, the CT
angiogram showed large amounts of mural
thrombus occupying in excess of 75% of the
vessel lumen just above the bifurcation of the
aorta. Thrombus extended into the right common
iliac artery. The right superficial femoral artery
occluded shortly after its origin with distal
reconstitution. Popliteal artery was patent
throughout. The anterior tibial, posterior tibial and
peroneal arteries were all occluded.
Question
What should be done next?
Answer
A surgical thrombectomy. Georges Labey
performed the first embolectomy in 1911 on a 38
year old man with mitral valve stenosis, the
embolus being removed from the bifurcation of
the left common femoral artery. Two other options
are available, namely thrombolysis and catheter
aspiration. In this case, thrombolysis was
contraindicated due to the lung cancer also, in this
type of pattern of thrombus which is often platelet
rich rarely respond to thrombolytic agents. In this
case, the patient was taken to theatre for a
thromboembolectomy. Exposure of both right and
left common femoral arteries, profunda and
superficial femoral arteries was obtained. This
allowed the left leg to be protected by clamping
the superficial femoral artery when trying to
improve inflow to the right given the large volume
of thrombus seen in the aorta and common iliac
on the CT angiogram. A moderate amount of
thrombus was obtained from the superficial
femoral artery with good back bleeding from the
profunda and good inflow. There was no
improvement in the foot.
Question
Which vessels does the embolectomy catheter
normally pass down? What should be done next?
50
Figure 1: Aortic Thrombus
Answer
In eighty five percent of cases, an embolectomy
catheter passed down from the femoral artery will
pass into the peroneal artery. It has been shown
that, by bending the tip of an embolectomy
catheter through thirty degrees and repeating the
embolectomy, the posterior tibial artery can be
accessed in seventy five percent of cases [1]. If
there is no improvement with
thromboembolectomy via a femoral approach,
then exposure of the popliteal artery to the point
where it branches and embolectomy down each of
the branches as far as the catheter would pass
easily should be performed as described by
Fogarty [2] (Figure 3).
discharge was mobile, pain free with normal
sensation in the foot.
Question
Is cancer a risk factor?
Question
Could this be avoided?
Figure 3: Popliteal trifurcation
In this case, a large volume of clot was removed
from the anterior and posterior tibial arteries and
from the peroneal artery. The arteriotomy was
closed with a vein patch and 6/0 prolene to
prevent stenosis at the arteriotomy site. Following
this the foot did not improve despite there now
being a posterior tibial pulse being present. Since
the foot had not improved, an approach to the
posterior tibial artery was made at the ankle. A
2Fr Fogarty embolectomy catheter was passed into
the posterior tibial artery into the foot, passing
around the pedal arch. Again, a good volume of
clot was removed. The arteriotomy was closed
with a vein patch using 8/0 prolene. Following the
pedal embolectomy the patient had a warm pink
foot with easily palpable pulses.
Thromboembolectomy of arteries exposed at the
ankle has previously been shown to re-establish
patency in 83% and result in limb salvage in 79%
[3]. Indications for the procedure include
incomplete extraction of thrombus via the popliteal
trifurcation, incomplete transfemoral extraction of
thrombus with restoration of a popliteal pulse, and
thromboembolus initially confined to the
infrapopliteal arteries. It is important to assess the
success of any thrombo-embolectomy. If the
clinical response is poor then further imaging
should be undertaken and, if necessary, more distal
access for thromboembolectomy achieved. Our
patient was anticoagulated post operatively and on
Answer
In a multicentre placebo-controlled clinical
outcome based trial to evaluate the efficacy of
nadroparin (a low molecular weight heparin) for
the prevention of thromboembolic events in
cancer patients receiving chemotherapy
(PROTECHT trial), there was a significant
reduction of thromboembolic events in patients
with lung cancer 8.8% thromboembolic events
in the control group vs 4.0% in those on
nadroparin [5].
REFERENCES
[1] Gwynn BR, Shearman CP, Simms MH. Eur J Vasc
Surg 1987 Apr; 1(2) 129-32.
[2] Fogarty TJ, Daily PO, Shumway NE, Krippaehne W.
Experience with balloon catheter technique for
arterial embolectomy. Am J Surg 1971
Aug;122(2)231-7.
[3] Youkey JR, Clagett GP, Cabellon S Jr, Eddleman
WL, Salander JM, Rich NM.Thromboembolectomy
of arteries explored at the ankle. Ann Surg. 1984
Mar;199(3):367-71
[4] Korana AA, Francis CW, Culakova E, Fisher RI.
Thromboembolism in hospitalized neutopenic
cancer patients. J Clin Oncol 2006 Jan 20;24(3)
484-90.
[5] Agnelli G, Gussoni G,Bianchini C,Verso M,Tonato
M. A Randomized Double-Blind PlaceboControlled Study on Nadroparin for Prophylaxis of
Thromboembolic Events in Cancer Patients
Receiving Chemotherapy: The PROTECHT Study.
Blood (ASH Annual Meeting Abstracts) 2008 112:
Abstract 6 © 2008 American Society of
Hematology
51
Answer
Thromboembolic events have been shown to occur
in 7.98% of patients who are hospitalised
receiving chemotherapy in the presence of
neutropenia. Arterial thromboembolism occurred
in 2.8% of those with lung cancer [4].
CASE STUDIES
Question
Is chemotherapy a risk factor for thromboembolic
disease?
Answer
A hypercoaguable state exists in cancer patients
due to interaction between the cancer cells and the
haemostatic system. Clotting activation occurs as
tumour cells have a procoagulant action on
monocytes, thrombocytes and on the endothelial
cells. Mural thrombus is sometimes seen as
patients will often have imaging after
chemotherapy to assess the tumour response.
CONFIDENTIAL REPORTING SYSTEM IN SURGERY
52
This edition of Feedback includes various cases which, respectively, highlight necessity for a competent designated
lead clinician in cases of complex trauma, which emphasise, (once again), the importance of full examination of injured
patients and lastly, which provide a reminder of principles of vascular control.
As ever, we are grateful to the clinicians who have provided the material for these reports. The on-line reporting form is
on our website www.coress.org.uk which also includes all previous Feedback Reports. Published contributions will be
acknowledged by a “Certificate of Contribution” which may be included in the contributor’s record of continuing
professional development.
CARDIAC STABBING (Too many cooks, no Chef de Cuisine...)
I was the on-call registrar for general surgery when I was
summoned urgently to the Emergency Department at
23.00 hrs, to see a 38 year old male, who had received a
single penetrating knife injury to the left side of his sternum.
I attended the resuscitation bay. On arrival, I found the
patient conscious and talking to a nurse. In attendance
was the Emergency Department (ED) consultant, two
anaesthetic SpRs, an anaesthetic SHO, an operating
department assistant, an ED SpR, the locum general
surgical SHO and two ED nurses.
Initially, on arrival, the patient had been haemodynamically
stable. However, he had since become tachycardic and
systolic BP had dropped to 60mmHg. This prompted the
trauma call. The ED SpR had undertaken urgent
ultrasound of the heart and was concerned that there
appeared to be fluid in the pericardial sac.
I assessed the patient’s airway, breathing and
circulation. Airway was clear, breath sounds equal with
no added noises and oxygen saturation was adequate.
GCS was 15 and the patient was talking freely. Two
large bore intravenous cannulae were sited and
crystalloid infusions running. The anaesthetic team was
preparing equipment should intubation be required.
Examination revealed a 1.5 cm vertical stab wound at
the left sternal edge, between 4th and 5th ribs.
I asked the ED consultant for his assessment of the
situation, suggesting that we prepare the emergency
thoracotomy kit and that the patient should be transferred
pre-emptively to the emergency operating theatre as soon
as possible, for possible thoracotomy. The ED consultant
told me that he was currently trying to contact the
cardiothoracic SpR by phone and that thoracotomy
equipment was close by in the resuscitation bay.
I returned to the patient, (who had initially responded to
a fluid challenge), and observed a second drop in
systolic blood pressure to 50mmHg. The ED SpR
confirmed that the patient had been cross-matched but
that we could not expect blood for 40 minutes. I agreed
that it was appropriate to order O-negative blood and
asked him to do this immediately. He handed me an
arterial blood gas report, demonstrating significant
metabolic acidosis. Resuscitation by the other members
of the team was ongoing.
The ED consultant told me that the cardiothoracic SpR
would not be attending (reason unclear), but that he
would contact the cardiothoracic consultant on-call. I
told the ED consultant that I would also contact my
consultant. I provided my consultant with a succinct
history, his immediate concern being that the patient
was suffering from cardiac tamponade. He asked that
the patient be transferred to the operating theatre
immediately. He told me that he would attend the
hospital directly.
As I returned to the patient, the ED consultant stated
that the cardiothoracic consultant had requested that the
patient be transferred to the cardiothoracic surgery
department at the other hospital in the city, where that
(Ref: 69)
consultant was based. (There are two hospitals in the
city; one has an emergency department and takes the
majority of medical and surgical emergencies and all
trauma, the second hospital has reduced emergency
services but is the site at which the cardiothoracic
surgery department is located. Time taken to travel
between the two centres is a minimum of 20 minutes).
I explained that I felt that transfer constituted
unacceptable risk for the patient. The ED consultant
said that the cardiothoracic consultant was not happy
to operate away from his department because he was
unsure that correct equipment would be available. I
asked that the cardiothoracic consultant attend the
patient to assess him. At this time I felt it necessary to
contact my consultant for a second time as I was
concerned that the patient might be transferred
against my judgement. My consultant agreed that the
patient should not be transferred and should, instead,
be moved immediately to the operating room. The ED
consultant contacted the cardiothoracic consultant for
a second time, explaining that we were not happy to
transfer the patient because he remained unstable.
They agreed to keep the patient in the ED until the
cardiothoracic consultant arrived to assess the patient.
I explained that my consultant and I disagreed with this
decision, believing that any assessment could be
undertaken in theatre, where we would be optimally
located to undertake resuscitative thoracotomy if
required. I asked the anaesthetic team to get ready to
transfer the patient to theatre, contacted the theatre
coordinator and asked theatres to prepare for a patient
who may require thoracotomy and cell salvage. At this
point a further discussion began between myself, the ED
consultant and one of the anaesthetic SpRs, who was of
the opinion that the patient did not have cardiac
tamponade and should instead be transferred for CT
scan. Again, I disagreed, stating that the patient had a
significant injury and had remained unstable since
admission.
At this point my consultant arrived and ordered the
patient’s transfer to the operating room. In the
anaesthetic room a second ultrasound scan was
performed, demonstrating fluid within the pericardial sac.
The patient was consented for surgery and my
consultant waited for the cardiothoracic consultant, who
was on his way. On arrival, the cardiothoracic consultant
indicated concern about available resources but
eventually agreed to operate and ultimately I assisted
him in performing a sternotomy. We found a significant
amount of blood clot within the pericardium and,
following removal of the clot, identified a 1.5cm stab
wound perforating the left ventricle, which was bleeding
profusely. My consultant, who had remained in theatre,
assisted in controlling the bleeding and suturing the
wound. Post-operatively the patient was transferred to
the Intensive Care Unit and remained for 24hrs.
Ultimately the patient made a full recovery and was
discharged from hospital.
CORESS Comments:
This case stimulated considerable discussion by the
Advisory Committee. Issues illustrated by the case
concern leadership, timing and responses to trauma
calls and provision of designated trauma teams.
In complex trauma it is essential that a nominated,
experienced and competent clinician assumes responsibility
for directing patient management. In this case, the Advisory
Committee felt that, whilst in the emergency department, the
patient should have been managed by the ED consultant
and general surgical registrar until the consultant general
surgeon arrived. Once the patient had been assessed by a
cardiothoracic surgeon then, if he/she decided to transfer
the patient, this was his/her responsibility.
The outcome in this scenario was favourable, but there
are issues that should be addressed:
• Early assessment by the consultant general surgeon is
important in the management of such patients. The
cardiothoracic surgeon may not be instantly available and
it is important that another senior surgeon is present.
• Local agreements and transfer protocols should be
clearly established concerning responsibility for such
patients. Surgeons should not be arguing amongst
themselves about whether a patient should, or should
not, be transferred.
• If the cardiothoracic surgeon has seen the patient and
wishes the patient to be transferred, then he should
take responsibility for the outcome of that decision.
An experienced cardiothoracic surgeon should be
allowed to make such a decision.
The Society for Cardiothoracic Surgery in Great Britain
and Ireland made the following additional comments:
• The doctors involved in this case were put in an
invidious position by the fact that cardiothoracic
surgical unit and emergency departments were in
different hospitals.
• A cardiothoracic unit will be covering other hospitals
for similar trauma within the region.
• Such cases are managed optimally in a cardiothoracic
theatre where appropriate equipment and in particular,
cardiac bypass facilities are available. If there is penetrating
injury to a coronary artery, bypass may be required.
• There will be patients with chest trauma who are
stable for transfer to a cardiothoracic unit and others
who are not. Many stab wounds seen in an
emergency department do not penetrate deeply and
injured patients remain haemodynamically stable.
DISTRACTING FRACTURES
A lady aged 48 fell and sustained a fracture of proximal
humerus and distal radius. Both were treated
conservatively and progress was satisfactory. However,
after two months, it was noted that her elbow was stiff with
a reduced range of movement in both flexion and
extension. Follow-up radiographs revealed a Mason 2
fracture of the radial head with a displaced fragment which
was causing reduced range of movement of the elbow.
Reporter’s Comments:
It is often said that the second fracture is the one most easily
missed. Beware the third fracture! The radial head fracture
was missed because attention was distracted by the two
(Ref: 74)
most painful injuries. Careful initial assessment of the patient
and clinical examination at follow-up is essential. This is
especially the case in busy fracture clinics, where there is a
high chance that a patient may see several surgeons.
CORESS Comments:
The lesson here is to undertake comprehensive
examination. X-rays of all joints proximal and distal to
fractures will be useful and, here, should have included
the elbow. However, these will not be undertaken in all
cases. This case further illustrates a problem previously
emphasised in CORESS Feedback Report 61;
December 2008.
LIFE-THREATENING HAEMORRHAGE DURING
ELECTIVE NEPHRECTOMY
A right nephrectomy was undertaken through a
subcostal extraperitoneal approach. The right renal artery
was clamped close to the aorta and the kidney removed.
Access was difficult as the renal artery was approached
behind the vena cava. After oversewing the origin of the
right renal vein on the IVC, control of the renal artery
stump was lost, either because the clamp slipped or the
artery was avulsed from the aorta. Immediate attempts to
stop the bleeding included the blind application of
vascular clamps across the aorta transversely. While this
stopped the aortic bleeding, torrential haemorrhage
ensued, which was extremely difficult to control. It is
likely that the bleeding arose from a lumbar vein. Finally,
control was achieved by packing, after several hours and
transfusion of many units of blood. However, packs were
removed after an hour and further haemorrhage ensued.
The patient survived but suffered a life-threatening
haemorrhage that was potentially avoidable or could
have been better controlled, resulting in permanent
damage to the remaining kidney.
Blind application of clamps to control haemorrhage is
dangerous. Application of direct pressure with a finger
should be the first response, while calling for assistance,
obtaining extra suction and cross matching blood.
A trauma call should have been put out as soon as the
patient arrived in the ED (or before, if forewarned of the
patient’s arrival). ATLS principles for the management of
trauma should be adhered to. The ED consultant should
have assumed leadership responsibility rather than
relying on the cardiothoracic consultant, who had not
seen the patient. Transfer of unstable trauma patients
between hospitals should not be undertaken - it is better
that the surgeon travel to the patient rather than risk
transfer of a haemodynamically unstable patient.
Patients with penetrating trauma have cardiac injury until
proven otherwise. Unstable trauma patients should not
be transferred for a CT scan.
(Ref: 80)
Adequate exposure and lighting are essential. If control
cannot be obtained, the area should be packed and packs
left in-situ for 48 hours before removal. Clamps passing
transversely across the aorta run the risk of damaging
lumbar veins passing in an antero-posterior direction
alongside the left edge of the aorta on the left side of the
patient, and into the inferior vena cava on the right side.
CORESS Comments:
Principles of arterial and venous vascular control need
to be borne in mind when undertaking dissection
around blood vessels. A useful mnemonic summarising
necessary conditions for adequate control of bleeding is
LAMPPS (Light; Access; Manpower; Position; Pressure;
Suction). Whilst arterial inflow may be reduced by
clamping the aorta, bleeding from the vena cava and
iliac veins can sometimes be controlled by gentle
pressure with rolled swabs mounted on sponge holders,
applied to either side of the region of venous damage.
Surgeons should be aware of the anatomy of the lumbar
veins and of the risk of damage to these delicate
structures during retroperitoneal mobilisation of the
kidneys. Damaged lumbar veins can be difficult to
control. Application of liga clips – if the vein can be
visualised – may be helpful in this situation, but should
not be attempted blindly.
53
FURTHER REACTION TO PATENT BLUE V DYE
A further case of anaphylaxis in response to use of Patent V blue dye, to localise nodes during mastectomy, has been
reported to CORESS. The latter submission was made following a previously reported case of anaphylaxis (CORESS
Feedback Case 57; September 2008). Whilst these cases may represent isolated occurrences, clinicians should be
aware of this specific risk, should have appropriate safeguards in place and be prepared to react in a timely fashion.
FINALLY...
54
The Medicines and Healthcare Products Regulatory Agency (MHRA) is an executive agency of the Department of
Health whose functions include responsibility for the regulation of medical devices. All medical devices and equipment
can fail, but an increasing number of incidents, resulting in significant morbidity, arise out of user device / interface
problems or lack of understanding of the mechanisms of action and potential problems that can arise in relationship
to the device in question.
MHRA continues to receive reports of problems associated with a number of devices in particular, and has produced
a series of educational modules to address the issues associated with use of these devices, which may be of value to
surgeons. To date, three modules are available covering:
• Electrosurgery (diathermy) • Anaesthetic machines • Operating tables.
These modules are available on the website: www.mhra.gov.uk/conferenceslearningcentre/index.htmModules are
password protected because they are intended for professional educational purposes but there are simple
instructions on the website as to how to obtain, by return, the necessary password for access.
ODD SIGNS: or just urban myths?
In an office canteen:
AFTER TEA BREAK, STAFF SHOULD
EMPTY THE TEAPOT AND STAND
UPSIDE DOWN ON THE DRAINING
BOARD
In a safari park:
ELEPHANTS
PLEASE STAY IN YOUR CAR
At a conference:
FOR ANYONE WHO HAS CHILDREN
AND DOESN’T KNOW IT, THERE IS A
DAY CARE CENTRE ON THE
SECOND FLOOR
THE BACK PAGE
In a multi-storey car park:
TOILET OUT OF ORDER, PLEASE
USE FLOOR BELOW
In an optician’s window:
IF YOU CAN’T SEE WHAT YOU’RE
LOOKING FOR, YOU’VE COME TO
THE RIGHT PLACE
Outside a cafe:
DON’T STAND THERE HUNGRY,
COME IN AND BE FED UP
Taped to a Vet’s window:
POPPED OUT, BACK IN 5 MINS.
SIT! STAY!
In a launderette:
AUTOMATIC WASHING MACHINES,
PLEASE REMOVE ALL YOUR
CLOTHES WHEN THE LIGHT GOES
OUT
In a second-hand shop’s window:
WE EXCHANGE ANYTHING,
BICYCLES, WHITE GOODS,
FURNITURE.
WHY NOT BRING ALONG YOUR
WIFE AND GET A WONDERFUL
BARGAIN?
In a jewellers:
EARS PIERCED WHILE YOU WAIT
SEPTEMBER QUIZ
The “Fedora” and the “Homburg” are types of what?
Courtesy of T M Lewin, Commercial Partners of the Association, the first two
readers to email the correct answer, together with their ASGBI membership
number, to [email protected] will receive a free shirt of their choice from any
branch of T M Lewin, or their on-line store at: www.tmlewin.co.uk As usual,
members of the Association’s staff, Executive Committee or their families
are prohibited from entering.
Fellows of the Association can also obtain the best possible
prices by simply entering the promotional code “ASGBI” when
shopping on-line at the Lewin’s website: www.tmlewin.co.uk
35-43 Lincoln’s Inn Fields, London, WC2A 3PE
Tel: 020 7973 0300 Fax: 020 7430 9235
www.asgbi.org.uk
A Company limited by guarantee, registered in England 06783090
Printed on
recycled paper
56
The opinions expressed in this Newsletter are those of the individual authors,
and do not necessarily reflect the policy of the Association of Surgeons of Great Britain and Ireland

No.27, Sept 09 (File size 8.5MB) - Association of Surgeons of Great

Transcription

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