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2024 – Liana Tsikitis

Written by Julia Miranda on . Posted in US Latest, US Travellers.

Vassiliki Liana Tsikitis MD MCR MBA 2022 James IV Travelling Fellow

I am deeply grateful for the privilege of being selected as the James IV Surgical Association Traveling Fellow from the United States for 2022. I want to particularly thank Dr. John Hunter for his sponsorship and support for this unique opportunity. Due to the COVID pandemic I delayed my travel experience to the spring of 2023 and summer of 2024.

My travels took me across the United Kingdom in the summer of 2023, visiting cities including London, Manchester Leeds, and Edinburgh. In the spring of 2024, I embarked on the second leg of my fellowship, traveling to Australia (Melbourne and Sydney) and New Zealand (Auckland). This schedule allowed me to align part of my trips with my family’s time off, which added to the experience as I made lifelong connections not only with colleagues but also with their families.

My primary goal as a James IV Traveling Fellow was to observe how surgeons in different countries, with varying healthcare systems and cultural and political challenges, assess the quality of surgical care and promote the highest patient care standards. As a colorectal surgeon, I also aimed to learn how the ever-evolving paradigms of colorectal cancer are practiced around the globe and how other providers and healthcare systems have safely implemented modern technologies. What I gained from the experience far exceeded these expectations. I had the opportunity to meet and learn from a wide array of professionals including colorectal surgeons, health care administrators and basic science researchers, attend the annual meeting of the Association of Coloproctology of Great Britain & Ireland. I was fortunate that my family was able to join me for significant portions of the trip and listened as I enthusiastically retold highlights from the morning while sightseeing in the afternoons and evenings. Sharing these experiences with my family made the journey truly unforgettable. The people I met and the insights I gained are impossible to fully capture in a few pages, but I will describe the highlights of my learnings.

 

 

UK Trip (London, Manchester, Leeds, and Edinburgh)

My choice to go to the UK was multifaceted. Serving as the head of a large multi-sectioned general surgery division, I have encountered the challenges of the current healthcare landscape in the United States. Nursing turnover and premium labor costs were the reality pre-COVID and became exacerbated to the point of near collapse by the COVID pandemic. We also know that high healthcare spending does not translate to best patient care. I

 

wanted to gain exposure to the practice of surgery in a universal health care system and

identified the UK’s National Health Service system as an excellent case study.

When I arrived in London, all the hospitals I had pre-arranged to visit were facing a strike threat from the house staff workforce. Although in 2019 the long-term plan of the NHS seemed to want to address the workforce problems, emphasizing “that the performance of any health care system ultimately depends on its people”, it failed to recognize that investment on their workforce incentivization, productivity, culture and advancement was instrumental. The trainees that I spoke to when I visited were failing to see the return on their investment with meager compensation that led to their difficulties “making ends meet”. During my second day in London, while visiting with Professor Ara Darzi, I attended the Hamlyn Symposium on Medical Robotics. The keynote speaker was Dr. Tim Ferris, the National Director of Transformation NHS England, and NHS Improvement. He discussed the government’s increased funding for the NHS to 3.4% from the previous 2.2 % and presented the updated NHS Five Year Forward View. He discussed how increasing the supply to meet the demand is not adequate to address workforce shortages. He discussed a multipronged approach to address the current workforce pressures including the expansion of clinical placements, establishing new routes into nursing and other disciplines, international recruitment, a set of incentives for hard-to-recruit geographies, and importantly “flexible rostering” and funding for continuing professional development to support current staff.

The idea of bringing agency and directing funding to local areas provoked my thinking about the possibility of state health care systems and reconfiguring the healthcare system according to the needs of the community as strategies to alleviate health inequalities.

Although the Forward View sought to separate patient care between family doctors and hospitals, between physical and mental health, and between health and social care, I witnessed a system with overwhelmed GPs each addressing hundreds of patients, unable to attend to them in a timely manner unless their patient was facing a significant health threat.

During my week in London my generous hosts in the city of London included Drs. Jamie Murphy, Ara Darzi, Amyn Haji and Simon Buczacki. I spent the first day observing cases with Dr. Murphy and his partner Dr. Chet Bhan. The opportunity to spend time together led to a fruitful collaboration and the three of us jointly organized sessions for the surgical meetings of the Society of Surgeons of the Alimentary Tract in Washington DC and the International Society for Digestive Surgery in Kuala Lumpur. The second day, I met with Professor Darzi and attended the Hamlyn Symposium of Robotics where innovative robotic platforms were introduced and discussed. Intuitive dominates the market in the US and the

 

opportunity for me to be exposed to other robotic platforms was encouraging for what the future may hold in the US. The third day I visited with Dr. Amyn Haji, who is the clinical lead for colorectal surgery and endoscopy at King’s College Hospital. I was impressed with the teaching facility and the curriculum he has developed on advanced endoscopic procedures. His trainees were gastroenterology fellows from all over the UK and Australia. I was able to spend the day observing, and later attending a state-of-the-art surgical endoscopy course that he organized during the ACPGBI meeting that took place the following week in Manchester.

I was impressed by the collaborative spirit between gastroenterology and colorectal surgery units. Based on the introduction and person-to-person time made possible by my James IV fellowship, I was privileged to invite Dr. Haji to be a speaker at the combined clinical symposium during Digestive Disease Week 2024 in Washington DC, where they spoke on the management of malignant colorectal polyps and the role of endoscopic submucosal dissection. I consider myself fortunate to have established long-lasting collaborations with Drs. Murphy, Bhan and Haji and I am excited for the next projects we will work on together.

The next couple of days I spent in Cambridge visiting a research colleague with whom I had previously collaborated, Dr. Sarah Bohndiek, based at Corpus Christi College. Together we obtained a CRUK grant on the role of hyperspectral endoscopy (HySE) system and its ability to differentiate malignant versus benign polyps of the colon and rectum. It was a wonderful visit that coincided with the college’s graduation; it was a special treat to attend the graduation ceremony.

The next day I visited Oxford and met with Professor Simon Buczacki and the colorectal surgery team including Ms. Kat Baker, Mr. Bruce George, Mr. David James, and Mr. Nicholas Symon. We had a round table discussion on total neoadjuvant treatment for locally advanced rectal cancer and I attended their monthly mortality and morbidity conference. I was impressed with Dr. Buczacki’ s basic science research on genetic and non-genetic clonal diversity in colorectal cancer; the role of copy number variations that give rise to intratumoral heterogeneity that may partly explain how targeted chemotherapy agents for certain mutations, effective initially against the disease, lose their effectiveness overtime. This was the conclusion of my first week in the UK, focusing on London and the surrounding areas.

The next week was split between Manchester and Leeds. In Manchester I attended the ACPGBI (The Association of Coloproctology of Great Britain and Ireland) conference, where

 

I re-connected with several people I met in London, and had my initial meeting with my next hosts, Professor Peter Sagar, and Dr. Jim Tiernan with St James Hospital in Leeds.

My visit at Leeds’s internationally famous St James Hospital, where I spent three days observing complex pelvic exenteration and resection of advanced rectal and anal squamous cancers, in my mind was the epitome of where the NHS system showed how it can be an efficient and equitable health care system, providing cost effective, coordinated, and patient-centered care.

Professor Sagar has built a remarkable colorectal unit, where referrals for all advanced pelvic cancers within Great Britain and Ireland are sent, and patients receive timely multidisciplinary care. There is a colorectal management unit composed of administrative staff that process hundreds of referrals according to acuity and direct them to the right provider teams. Patients are presented in a weekly multidisciplinary board where steps of care are decided, and nurse navigators assist patients through the sequence of the treatment arms deemed necessary. What I witnessed in Leeds is a center of excellence supported by the NHS where all healthcare providers, including surgeons, physicians, and support staff with extensive experience and specialized training, all follow the latest evidence-based guidelines to provide the best possible care.

In the States we have multiple discussions during our national meetings and with our political representatives regarding the need for Centers of Excellence, though we still struggle with designation of those centers. Challenges to adopting such a model in the United States include geography, where distance between the patient’s home and hospital can be significant, and insurance provider agreements, which dictate where care can and will be received.

On a personal note, as my last stop in England, my visit to Leeds was a highlight. My family had joined me in Manchester and traveled with me on the train to Leeds. When we arrived, we discovered we happened to be staying at the hotel where the Australian national cricket team was staying while competing in The Ashes. My ten-year-old son was excited each morning when various players would ride in the elevator with him to the breakfast room.

Though unfamiliar with cricket, he was inspired to follow the scores and the matches that took place at the Headingley Cricket Grounds in Leeds.

Our next stop was Edinburgh, where I met with Professor Rowan Parks, who is currently the president of the Royal College of Surgeons. He was a wonderful host that showed my family and I around the Surgeon’s Hall Museum and shared the story of how the James the IV Travelling Fellowship started. The hospitality of Professors James Garden and Rowan Parks was unparalleled. I felt that I was among great old friends. There was a dinner for my family

 

with faculty from the University of Edinburgh, where I met Professor Malcom Dunlop, who is

an inspiring surgeon and researcher in the field of colorectal surgery.

The next day was filled with multiple research presentations from Professor Dunlop’s lab and a tour of the Western General Hospital. The colorectal unit at Western hospital is highly regarded for its academic rigor and its excellent patient-centered care and I witnessed both. During my visit I met Drs. Farhat Din, Doug Speake and Sarah Goodbrand, as well as connected with another Mayo Clinic alumnae, Dr. Danielle Collins.

The next day I visited the Royal Infirmary and Professor Garden gave me a Quaich, which is a special two-handed drinking cup that symbolizes friendship and partnership. In my short travels in Scotland, I learned how the Scottish system differs from England’s NHS. I sensed that the public and the physicians thought that the healthcare delivery was good and equitable. Although private insurance exists, the sentiment was that the NHS Scotland adequately attends to its population’s health needs.

During my Scottish week, my family and I had an opportunity to explore the cities of Edinburgh (where we enjoyed a concert by The Who at Edinburgh Castle), St. Andrews (where I scored a hole in one on The Himalayas) and Glasgow (where we toured Celtic Park and had tea and biscuits at Mckintosh’s famous Willow Tea Room), as well as enjoy a scenic drive to the north and around Loch Ness.

 

 

Australia (Melbourne, Sydney) & New Zealand (Auckland)

The second arm of my trip took me to Australia and New Zealand in March of 2024. I chose to visit this region because of family and colleagues who have moved to that part of the world, commenting on the exceptional quality of life and the health care they receive. In addition, Professor Michael Solomon’s clinical research program is world renowned, and I wanted to visit the people behind the Surgical Outcomes Research Centre (SOuRCe).

Arriving to Australia through Melbourne, I spent the first two days in the Peter MacCallum Cancer Centre hospital where I attended their multidisciplinary tumor board conferences and observed a few operations. My hosts in Melbourne were Drs. Joseph Kong, Alexander Heriot, Peter Carne and Jamie Keck, all well-known colorectal surgeons who were welcoming and generous with their time. During my week in Melbourne, I visited The Alfred, Cabrini Malvern, and St. Vincent’s hospitals. I attended their multidisciplinary GI tumor board and IBD conferences and I presented my research on the role of the gut microbiome in early colorectal neoplasia.

 

I was fascinated by the Australian Health System as well as the education of surgical trainees. One of the key characteristics is that both the public and private sectors play a key role in the funding and the provision of care under a common national framework. I was fascinated to learn that each hospital had slightly different funding stream from the federal and state government. During my discussions with Dr. Heriot from Peter Mac, I learned that each year the funding of his surgical oncology unit (encompassing all oncologic surgical specialties) is based on the past budget needs and factors in the quality of care as measured by patient outcomes. It made me think about value-based care and how CMS is currently trying to implement reimbursement with certain diagnoses and CPT codes.

In Australia they do not have national programs such as the National Surgical Quality Improvement Program (NSQIP) or the Commission on Cancer (CoC). Instead, quality is measured by patient experience surveys and clinical quality registries (most provided and run by each individual hospital). In Australia there are government-funded quality tracking agencies including the Aged Care Quality and Safety Commission that measures aged care across hospitals. I think the United States may benefit from such an entity, as a potential way to curtail the ever-rising healthcare costs of our aged population.

Through my conversations with local providers, I learned that this capitated system does not allow for potential market growth by the hospitals that are funded through the government. As an example, Dr. Heriot explained that if he received $115 million to cover the fiscal year, he could not support any additional oncologic procedures for patients with public insurance when that funding is exhausted – even if that is several months prior to the end of the budget year. I found, in this system, that the right balance was met when it comes to the reimbursement of consultants between public and private funding. Most surgical consultants in governmental funded hospitals (they are known as Visting Medical Officers VMOs) would have a limited FTE and the rest of their practice would be based on the private sector – where most of their personal funding would come.

As a cost containment strategy, the government has supported the position that citizens should have a supplementary private health insurance to control Australian Medicare costs (which have sharply risen over that past decade) and to continue providing good elective care with reasonable waiting times. Impressively, more than 50% of the population has followed this recommendation. Overall, I found that the quality of health care in Australia is high for complex cancer care and that for less acute elective care the private sector has stepped in to assure timely response. Though I find the multiple separate funding streams to the public hospitals complex, it does allow them to offer good and timely patient care.

 

The training of the surgical trainees is also significantly different from the US experience. Finishing medical school and working as a general surgical officer without having entered a formal surgical training program is the norm. The system absorbs the medical school graduates as an equivalent to a categorical US surgical resident and it may take multiple years to achieve their formal placement in a training program.

During my second week in Australia, I moved to Sydney where I spent several days at the Royal Prince Alfred (RPA) Hospital where my hosts were Professor Michael Solomon and Dr. Cherry Koh. I met a young trainee in her third year at RPA, applying for surgical residency while acting on the service in a manner consistent with a highly functional midlevel US surgical resident rounding on the wards and scrubbing in the cases. She was hopeful that she would enter the RPA surgical training program the following year as an intern.

At RPA, I had the pleasure of meeting with the Surgical Outcomes Research Centre (SOuRCe) leaders including Drs. Solomon, Koh and Steffens. The Center, where a large research team including statisticians, medical students, PhD students, and surgeons work together, is impressive and currently more than 200 research projects are underway in parallel. They have implemented an impressive prehabilitation program for their frail patients undergoing complex surgical cancer care.

On a personal note, my family joined me in Sydney for this portion of the fellowship experience. We were able to explore several charming neighborhoods, tour the famous Opera House, stroll through the Royal Botanic Gardens, and see the Socceroo’s take on Lebanon in a World Cup Qualifier match when I was not in the hospital and clinics.

Together, we traveled onto Auckland, New Zealand for the final leg of my travels, where my host was Maree Weston and the colorectal surgeons at Middlemore hospital. She and her family were delightful hosts.

 

 

In Auckland, I had the opportunity to attend and participate in the quarterly city-wide colorectal surgical journal club, where we discussed the new paradigm of locally advanced rectal cancer care with the advent of total neoadjuvant treatment. It was a group of about twenty colorectal surgeons that brought many complex patient cases that were discussed in a lovely downtown Auckland restaurant. It was a fun evening among colleagues in which I was warmly received. During this discussion, I learned that many colorectal surgeons in Australia and New Zealand perform all aspects of an exenteration, including the cystectomy with the ileal conduit and the closure of large perineal defect with flaps.

Additionally, I was informed that the Australasian colorectal fellowship training is longer than it is in the United States, with two clinical fellowship years in either Australia and /or

 

New Zealand and one year spent abroad- usually in the States. The number of trainees entering and graduating from the fellowship is tightly controlled. This longer training allows exposure and training related to operations such cystectomies and reconstruction that in the US are not included in the formal colorectal residency training.

The following day was spent at Middlemore Hospital, where I presented at Grand Rounds and had the opportunity to speak with physicians that are the current CMO and CEO of the hospital. We discussed funding streams and overall state of healthcare in New Zealand.

New Zealand has a free public health care system and every public hospital, like Middlemore, receives capped support from the government based on prior years’ budgets. Middlemore is the hospital that serves a high percentage of the indigenous (Māori) population and has strived to diversify its workforce to meet the needs of the population. Social determinants of health are not currently a factor in determining the allocation of public funds to hospital budgets. This is routinely brought up by many physician leaders and there is advocacy to bring this change to the system. After Grand Rounds, I was touched when the Middlemore surgical faculty presented me with a beautiful pounamu stone to protect me and bring me prosperity.

While in New Zealand, my family and I had the opportunity to take a whale/dolphin- watching excursion, experience the hot springs in Rotorua and the Geothermal Valley, walk on the white sand of Waipu Beach, and hike around the beautiful Whangarei Falls. Before our departure, when plans to attend a rugby match were upended, Dr Weston’s family invited us to observe a private practice of the “Blues” (one of Auckland’s premier rugby teams) – including the opportunity for my son to throw and kick with some very generous players.

There is no perfect health care system. My travels emphasized that the challenges we are facing in healthcare are global and no one policy nor one government or private sector provider will solve our challenges. However, it also taught me that there is a lot to learn from each other. I am eternally grateful for this remarkable opportunity; it has been one of the highlights of my surgical career to date. I want to thank my partners who took care of my patients while I was gone, as well as my chair Ken Azarow and colleague John Hunter for their continued sponsorship.

 

Family picture with Professor Rowan Parks

Family picture at St Andrews golf course

James the IV portrait

At Arthur’s seat at Edinburgh

With Farhat Din & Danielle Collins at Western Hospital

2024 – Colin Martin

Written by Julia Miranda on . Posted in US Latest, US Travellers.

It is an honor and privilege to have received the James IV Travelling Fellowship award. Because of the COVID-19 Pandemic, I had to delay travel until July of 2022. I used the funds to travel to visit Great Ormand Street Children’s Hospital in London England. Next, I attended Birmingham, UK and participated in the 2022 British Association of Pediatric Surgery (BAPS) meeting from July 13th-15th 2022. The final stop of the trip was to visit Edinburgh Scotland hosted by Professor Steve Wigmore.

Visit to Great Ormand Street Hospital (GOSH). I had an opportunity to visit one of the most iconic and historic Children’s Hospital in the world. Since its formation in 1852, the hospital has been dedicated to children’s healthcare. GOSH receives 242,694 outpatient visits and 42,112 inpatient visits every year. My visit was hosted by Paolo De Coppi. Dr. De Coppi is a Consultant Pediatric Surgeon at GOSH, Head of Stem Cells and Regenerative Medicine at the UCL Institute of Child Health in London. I had a chance to tour the clinical wards in the hospital. It was very interesting to tour and visit the neonatal intensive care unit. It was large with several babies with necrotizing enterocolitis and intestinal failure. I have clinical expertise with both of these conditions which lead to very nice bi-directional exchange on the differences in surgical care between our two countries. Finally I had a chance to give a scientific talk to the entire Department of Surgery on my research and clinical interests. The talk was titled “Environmental Stress and Intestinal Development.” It was well received.

 

British Association of Pediatric Surgery (BAPS) Program Highlights: BAPS was established in 1953 with a mission to raise standards in pediatric surgery through education and research. The meeting in Birmingham, UK was the 68th meeting. It was a fantastic to attend. It was similar to other US and international meetings that I have attended in the past. There was a robust scientific program with invited lectures, as well as ample opportunities for social networking. One difference with this program were the snacks and refreshments after each session. By the end of the meeting, I developed an affinity for tea with milk! The program started with a welcome and opening remarks by the BAPS President Munther Haddad. This was then followed by the Prize Session. This is analogous to a plenary session with long talks given by the top abstracts submitted to the program. There was a mix of basic science and clinical topics. There were 10 talks in the session and my favorite was titled: Common Dendritic Progenitors are Responsible for Tolerance Induction Following in Utero Transplantation. This talk was given by Joseph Davidson with mentorship from Great Ormand Street Children’s Hospital and the Children’s Hospital of Philadelphia. The basic science was presented concisely with tangible clinical relevance. There was also a session dedicated to Urology. In the UK many of the pediatric surgeons have extensive urology training and incorporate this into their practice. This is quite unique in the United States and I learned a lot from this session. There was also a research breakout session that focused on conducting qualitative and quantitative research. The topics and speakers were: Dr Beth Deja (University of Liverpool) – Qualitative research – What? Why? and How? Professor Kerry Woolfell (University of Liverpool) – Using qualitative research to determine the feasibility of clinical trials Dr Lisa Hinton (University of Cambridge) – Using parent experience as a tool for education, service improvement and understanding outcomes. This was an amazing session. I am starting to do qualitative research and from this session I got a

 

basic understanding of the tools needed to conduct research in this space. The final highlight of the meeting was the Journal of Pediatric Surgery Lecturer Dr. Marc Levit. Dr. Levitt is a Pediatric Surgeon and the Head of Colorectal Surgery at Children’s National Medical Center in the United States. His talk was titled: Patient Driven Change; Is collaborative care the future of medicine? (Lessons learned from the care of children with colorectal problems). Dr. Levitt gave a compelling talk on his internationally renowned colorectal program. Dr. Levitt was one of my mentors during residency at the University of Cincinnati. I had a chance to reconnect and have lunch with him. It was great to catch up and he gave me good mentoring advice.

 

Visit of Birmingham Children’s Hospital. I had a chance to visit Birmingham Children’s Hospital in the UK. The tour was given by Dr. Suren Arul who is the Division Chief of Pediatric Surgery and Urology. He spoke about the history of the hospital as well as gave us a tour of the hospital including the many new renovations and state of the art equipment. Birmingham Children’s is also the national referral center for liver transplantation. Hearing about the program and clinical volume was very impressive. We also toured the operating rooms and the neonatal and pediatric intensive care units.

 

Edinburgh Scotland. The final stop on our trip was a visit to Edinburgh hosted by Professor Steve Wigmore who is the head of the Hepatobiliary-Pancreatic Surgical Services and Edinburgh Transplant Unit Royal Infirmary of Edinburgh. The Royal Infirmary of Edinburgh and Professor Wigmore have hosted several James IV visit which added an additional value to the visit. I spent 3 days visiting this hospital, round with the team, and observing a few operative cases. Finally I had a chance to visit the surgeons Museum. Surgeons’ Hall Museums is an award winning Museum that is home to one of the largest and most historic pathology collections in the United Kingdom. The Museums are currently home to an extensive collection of pathology, anatomy and medical memorabilia. There was an extensive display surgical history and artifacts dating back hundreds of years. It was quite fascinating.

Again, thank you for this opportunity. It was certainly the highlight of my career! Best,

Colin A. Martin, MD

Brad and Barbara Warner Endowed Professor of Surgery Division Chief, Pediatric Surgery

Washington University in Saint Louis

Surgeon-in-Chief, St. Louis Children’s Hospital

Dr. Marc Levitt at the BAPS meeting


Hospital Chapel
Children’s Hospital in Birmingham


Tour of the Operating Room by Dr. Arul Children’s Hospital in Birmingham


Stained glass window from the Children’s Hospital in Birmingham


Great Ormand Street Hospital Entrance


Hospital Entrance Children’s Hospital in Birmingham


Surgeons Hall Museum Scotland


With Professor Wigmore at Dinner


Edenborough Scotland

2022-2023 – Dung Nguyen

Written by Julia Miranda on . Posted in US Travellers.

James IV traveling fellowship 2022-23

Dung Nguyen

April 2022

CANADA

Mcmaster university & hamilton health sciences

The COVID19 pandemic has affected all our lives across the globe. It seemed so long ago that I had travelled abroad. My travel plans for James IV were delayed for 2 years due to the pandemic. Needless to say, I was excited to resume global travels. I am a plastic and reconstructive microsurgeon. The goal of my fellowship was to learn how breast reconstruction and lymphedema are being managed across the world and to establish opportunities for collaboration.

My first visit was to McMaster University in Hamilton, Ontario. I landed in Toronto at 3pm and was picked up by the limousine service to take me to where I would be staying at The Barracks Inn. Immediately, I was taken in by the Inn’s timeless, understated elegant décor and warm Ancaster hospitality. Shortly after, I was greeted by my host, Dr. Susan Reid, Professor of Surgery and Immediate-Past Chair of the Department of Surgery at McMaster University. We went to dinner at Ancaster Mill, a creekside restaurant overlooking the falls! The delicious food was a perfect complement to the beautiful scenery and wonderful company. Dr. Reid gave me an overview of Hamilton and the itinerary for the week. I was excited for the busy week ahead. I was back at the Inn at 9pm. By then, I was struggling to stay awake and was ready for good sleep.

The following morning, I was taken to the Juravinski Hospital & Cancer Center where I observed Drs. Chris Coroneos and Ronen Avram performed a delayed-immediate tissue expander to free DIEP flap reconstruction. I saw an effective way to dissect a perforator flap using a monopolar bovie! I had an animated discussion with the surgeons on the differences between the US and Canadian healthcare. Canadians have quicker access to emergency care and do not have to pay for copays and deductibles, but they pay much higher taxes and have limited access and longer wait times to see specialists. In fact, lymphedema surgery is currently not an approved covered benefit. One of the plastic surgeons is trained in lymphatic surgery but has not been able to offer treatment to the patients. This became an area of interest of mine to better understand the barriers and ways that our institutions can collaborate to advocate for better access to healthcare.

That evening, I had another stimulating discussion at dinner with Dr. Reid and two other fantastic women surgeons, Dr. Lua Eiriksson and Dr. Clare Reade, who are trailblazers for changes within their institution to improve work-life balance conditions for women physicians. It was such a wonderful evening and we truly enjoyed ourselves. The conversations were motivating, inspiring, and uplifting. The food at Victoria’s Restaurant was delicious and the atmosphere so relaxing. It was incredible to talk about ideas for research, advances in patient care, international work, leadership and mentorship, the challenges and sacrifices of being a surgeon and raising a family and so on. It was a perfect way to end the first day!

I spent the second day with the residents at McMaster University. I gave a lecture to the residents on breast reconstruction and then went over case discussions. I was impressed by the thoughtful questions from the residents! Dr. Reid then gave me a tour of the University and history of the medical school and the world-famous problem-based learning model. I was impressed by the rich history and beautiful architecture. This was followed by a walk along the Hamilton Waterfront Trail where one overlook Lake Ontario and can see the old steel plant in the distance. In the afternoon, I had the opportunity to visit Synaptive Medical in Toronto. I met with the CEO and got to tour their manufacturing plant and played with their latest version of the 3D exoscope! We had dinner at a fantastic Italian restaurant in downtown before I headed back to Hamilton.

The highlight my third day was giving Grand Rounds to the Division of Plastic & Reconstructive Surgery on “Surgical Advances in Lymphedema Prevention and Treatment”. Lymphedema treatment and prevention is currently not offered in Hamilton, there was interests from within the Plastics Division as well as from vascular surgeons and oncologists to know more about current research and advancement in the field. After Grand Rounds, I returned to the OR at Juravinski Hospital to observe a combined oncoplastic reduction case and additional breast cases. I had an engaging discussion with the breast surgeon, Dr. Nicole Hodgson, on her approaches to nipple sparing mastectomy and axillary lymph node dissection. The day concluded with a nice dinner with the Plastic Surgery faculty and residents.

The next two days was partly spent in the operating room and meeting key administrators. I had the opportunity to meet with Neil Johnson, Vice President, Oncology & Regional VP of Ontario Health for HNHBB Regional Cancer Program. It was great to share our personal journeys and shared pharmacy heritage. He gave me an overview of the Ontario cancer system. We recognized that despite the differences in healthcare systems, we share a lot of similar health constraints and access issues across the border. We concluded our exchange with an invitation to keep in touch and a desire to build future research and education collaboration. I also met Dr. Jonathan Sussman, professor of oncology and Chair of the Department of Oncology at McMaster University. I gained new perspectives on the application of radiation therapy in the treatment of breast cancer. He was interested to know about my experience with lymphaticovenous bypass for prevention of lymphedema after ALND. I find these conversations very stimulating and refreshing!

On my last day, Dr. Reid took me to see Niagra Falls and gave me a car-ride tour of Niagara-on-the-Lake. Niagra Falls is as impressive and majestic as what I have read. Niagara-on-the-Lake is such a lovely town in Southern Ontario with lush wineries that rival Napa Valley, streets that are tree-lined and flower-filled and has the charms of an old town with historical buildings and fine foods. We ended the evening at dinner with the breast and plastics colleagues. I had a wonderful time in during this trip! The inspiring conversations and the friendships I have established are invaluable!

SEPTEMBER 2022

LONDON

IMPERIAL COLLEGE LONDON

My next stop was at the Imperial College London. My sponsor was Professor Ara Darzi, Baron Darzi of Denham, and the Paul Hamlyn Chair of Surgery at the Imperial College London, the Royal Marsden Hospital, and the Institute of Cancer Research. My host was breast surgical oncologist, Daniel Leff. It was such an honor for me to meet Professor Darzi and learned about his inspiring medical and political career and his passion in global health and innovation. I was grateful for his invaluable advice on career growth and development.

Upon arrival at the Charing Cross Hospital, Dr. Leff introduced me to his breast colleague, Dr. Michael Boland, and the plastic surgery team, including Drs. Simon Wood, Frank Henry, and Georgina Williams. On my first day, I observed a HoloLens-Assisted DIEP flap for breast reconstruction. Dr. Henry introduced me to the HoloLens which is a holographic augmented reality imaging technology to map out the perforators for DIEP flap harvest. At our institution, we use 3D models of the perforators to plan our flap dissection, so it was very interesting for me to see another way of using 3D technology to guide surgical dissection. I also saw an oncoplastic surgery by the breast team and had an engaging discussion about the timing of radiation therapy and shared our experience and thoughts about the pros and cons of radiation therapy before or after mastectomy on oncologic and aesthetic outcomes.

During my visit, I saw many great cases, including nipple sparing mastectomy and immediate direct-to-implant reconstruction with mesh by Dr. Hogben. I was impressed by how proficient the breast surgical oncologists are at performing oncoplastic surgery, including local perforator flap for lumpectomy reconstruction.

For my Grand Rounds, I gave a talk on our novel technique of breast reconstruction using the omentum fat-augmented free flap which generated a lot of great discussion and interests. I also learned that we share a common interest in lymphedema prevention surgery. Dr. Paul Thiruchelvam shared their preliminary data on the LYMPHA procedure, and we saw an opportunity to collaborate!

A major attraction during my visit was the tour of the Hamlyn Center and Institute of Global Health Innovation. The center is an impressive facility that focuses on technological innovation in imaging, sensing, and robotics with a strong emphasis on clinical translation to address global health challenges. I had the privilege of meeting the staff of the Hamlyn center and learning about the exciting projects that are underway including Mammobot and imaging technology to visualize cancer intraoperatively. The integrated and comprehensive research laboratories and teaching facilities were just amazing to see! It was great to end my visit on such a high note!

LONDON breast meeting 2022

Before leaving London, I attended the London Breast Meeting where I spoke on lymphedema and breast reconstruction panels and met up with colleagues from around the world. I also witnessed the historical moment when the country learned about the passing of Queen Elizabeth II. Within hours, the entire country was in mourning. Some of us took a break from the conference to pay our respects to the Queen at Buckingham Palace.

Austria

whitlinger lymphedema clinic

Before returning to the States, I visited the Wittlinger Lymphedema Clinic in Austria. The clinic has been in existence for more than 50 years and is internationally known as Europe’s center for excellence in holistic lymphedema management. It is a facility that offers comprehensive conservative lymphedema management where patients check in for 2-3 weeks at a time and receive complete medical workup, daily physiotherapy, aquatic exercise, nutrition consultation, garment fitting, and skin/nail treatments. It is also the founding site of the famous Vodder technique of manual lymphatic drainage. I got to experience the treatments as a patient for 3 days and saw the effectiveness of good conservative therapy. Inspired by what I saw, we are adopting some of their treatment approaches in a program that is tailored for patients undergoing surgery to maximize volume reduction after surgery.

March 2023

Malaysia

university of malaya kuala lumpur

My last destination was Asia where I visited Professor April Camilla Roslani, Dean of the Faculty of Medicine, and the Department of Surgery at the University of Malaya. I was excited to meet Dr. Roslani, a woman leader and pioneer who is leading the largest colorectal cancer treatment center in the country and who has paved the way to improve working conditions for women in medicine and advancing surgical standards within her country. It was enlightening to get her perspective and advice on mentorship and leadership development.

At the hospital, I saw complex breast and lower extremity reconstruction with free tissue transfer by plastic surgeons using loupe microsurgery. Just as in London, the breast surgeons are very proficient at doing implant-based reconstruction and pedicled flaps, including TRAM flap.

Dr. Hoong gave me a tour of the Breast Cancer Resource Center. She shared her vision of developing an integrated Breast Oncoplastic Curriculum Module to train future breast surgeons in providing basic reconstructive procedures to increase patients’ access to breast reconstruction.

I attended radiology rounds and breast and plastic clinics during my visit. I learned that access to lymphedema treatment is still limited in Malaysia. For Grand Rounds, I gave a lecture on lymphedema management to the residents and faculty. We discussed about our lymphedema prevention clinical trial at Stanford and had discussions on how to offer a similar service to breast cancer patients there.

Lecture on Lymphedema Management

During my visit, I also learned about the Silent Mentor Program, a voluntary body donation program for medication education, training, and research. I was fascinated to learn about the origin of the program in Taiwan and how it was adopted in Malaysia. It is a very interesting program that merges professional medical training with humanistic appreciation in a way that teaches students to respect and show gratitude to the body donor who becomes their silent mentor.

Of course, one cannot leave Malaysia without appreciating its delicious cuisine! Malaysian food, as I learned, is a melting pot of different ethnic foods. It is highly varied in flavors with unique blend of Chinese, Indian, Thai, and even a hint of European influence!

VIETNAM

medical mission trip in hue

Finally, from Malaysia I flew to Hue, Vietnam where I wrapped up the year of traveling with a medical mission trip with ReSurge International to teach and provide breast reconstruction and lymphedema surgeries. There, I also had the opportunity to share my travel experience with local surgeons.

Overall, my James IV travelling fellowship has been extremely rewarding, educational and eye-opening. I appreciate seeing how breast reconstruction and lymphedema are being managed across the globe. I have made many new colleagues and friends and am excited to continue to cultivate these relationships and nurture opportunities for collaboration.

2018 – Dr. Muriel Brackstone

Written by Brad Roberts on . Posted in Canada Latest, Canada Travellers, Uncategorized.

I would like to thank Dr. Chris Schlacta, Dr. Vivian McAllister, James IV Association Canadian Secretary, and Dr. Ken Leslie, my Division of General Surgery chair/chief, for having nominated me for this travel award. I have felt an incredible honour in being able to represent this association and have benefitted tremendously from the experience and resultant contacts and collaborations. I selected centers to visit during my travels that would provide me with a broad view of how breast cancer is treated surgically (similarities and differences) across countries, as well as purposing to meet highly productive clinician researchers in the field of breast clinical trials in order to further collaborative research opportunities.

Read Full Report

2017 – Kjetil Søreide

Written by Brad Roberts on . Posted in BI & ROW Latest, BI & ROW Travellers, Traveller Reports.

Kjetil Søreide, Stavanger, Norway
Stavanger University Hospital and University of Bergen
Travel period: Spring 2017 and Fall 2018
Cities visited: Hong Kong, Shenzhen, Edinburgh, Toronto and Boston

I should like to start out with thanking those who nominated me for this prestigious travel award as I am truly humbled and flattered from having been given this opportunity. Also knowing that it is a rare feat to have travellers from Norway (the last Norwegian traveller being prof. Frank Bergan in 1966) among the past travellers of the BI & ROW, I am truly grateful for the gracious opportunity to visit other parts of the world to learn, engage and interact. The hosts have truly been outstanding and presented a day-to-day program at each site that went over and beyond what I could expect or even anticipate. A truly grateful thanks goes out to all who so generously hosted me during my travels. I can but echo the testimony given by previous travellers to the great value this opportunity gives to interact with other colleagues in other institutions around the globe.

READ TRAVELLER REPORT (pdf)

2016 – Ewen Harrison

Written by Brad Roberts on . Posted in BI & ROW Latest, BI & ROW Travellers, Traveller Reports.

Ewen Harrison: James IV Travelling Fellowship 2016/17
University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
Countries visited

  • South Africa
  • Nigeria
  • Kenya
  • Malawi
  • US

Over the last three years I have been lucky enough to be involved in the establishment of the GlobalSurg Collaborative. This is a grassroots organisation which encourages training surgeons around the world to get involved in surgical research. The collaborative is expanding and is forming an international surgical trials network with particular support for surgeons in low- and middleincome countries.

From small beginnings, we have now gathered data on 27,000 patients in more than 70 countries focusing first on emergency abdominal surgery and subsequently on surgical site infection. The aim for my James IV Travelling Fellowship was to strengthen relationships with surgical leaders in Africa and the US and explore how we can expand our efforts in global surgical research and training.

South Africa

Cape Town
Groote Schuur Hospital

“May your choices reflect you hopes, not your fears” – Nelson Mandela.

This was the quote written on the blackboard above the sink in my AirBnB apartment in Cape Town. I am greatly indebted to Richard Spence who did an amazing job coordinating my visit to Cape Town. Richard is a forward thinking academic surgeon with a PhD in surgical outcomes research, so our interests align. South Africa has been one of the strongest GlobalSurg contributors and the team have published their own analysis of the local data.

Cape Town feels European with luminous light, a glittering ocean, and Table Mountain guarding its back. Its turbulent past is palpable. Gallowshill has a prominent memorial to the slaves hanged there for minor misdemeanours and Breakwater, now a sprawling waterfront complex of shops and restaurants, was built by slaves in forced labour camps.

Groote Schuur sits high looking out over Cape Town. It means “Big Barn” from the Afrikaans but no one ever calls it that. I was made very welcome by Ed Jonas who is the Head of the HPB unit. With the festive period just coming to an end, there had been less elective operating going on. We spoke about Ed’s career in Sweden,his recent return to South Africa and his extensive experience in HPB surgery. We discussed some interesting patients with advanced disease he had been coaxed into operating upon in Kenya. Our conversation on hepatocellular carcinoma in Sub Saharan Africa was particularly useful for me and an area of future research collaboration.

Richard Spence (right) and myself at Green Point. 
Richard Spence (right) and myself at Green Point.

Professor Elmi Muller, Head of Department and Transplant Surgeon, is well known internationally for her work developing kidney transplantation for HIV positive patients using HIV positive donors. We had previously met at the European Surgical Association in Edinburgh, where I had wielded a blade for “Address to a Haggis”, the poem recited before eating the famous Scottish delicacy. The transplant programme in Cape Town continues to expand and I was pleased to meet David Thomson and Tinus Du Toit to learn more. We discussed the evolving understanding of the selection criteria for donation after circulatory death donors, something we have also been exploring in Edinburgh.

Groote Schuur is of course a world leader in trauma surgery. I spent a day with Professor Pradeep Navsaria and Sorin Edu who showed me round the busy department. By UK standards the numbers are vast: 12000 patients assessed in the unit each year, 400 with abdominal trauma, the majority of which is penetrating (85%; one third of which is gunshot injuries). The volume of trauma puts understandable strain on systems and the hospital as a whole. Data collection and analysis is a primary research interest of mine. As such, I was particularly interested in the development of the Trauma database in Groote Schuur (Nicol, JAMA Surgery, 2014) and the challenges faced in ensuring on-going, high-quality, prospective data collection. This is an area of potential collaboration.

Groote Schuur was founded in 1938 and is famous as the site of the first human heart transplant by Christian Barnard in December 1967 – of great interest even to a liver transplant surgeon. The museum at Groote Schuur describes the endeavour and contains many interesting artefacts. Tragically the 54-year-old recipient Louis Washkansky died 18 days after surgery when a pneumonia was thought to be rejection and the immunosuppression was increased. The original consent form (below) is a little light on detail by modern standards and not signed by the operating surgeon.

Consent form (left) and operation note (right) for first human heart transplant.
Consent form (left) and operation note (right) for first human heart transplant.

Sandie Thomson is a fellow Scot and Professor of Gastroenterology. We had a wide-ranging conversation about many issues in medicine and his great work in endoscopy training and education. We also spoke about the “Rhodes Must Fall” movement, initially directed against a statue of Cecil Rhodes at the University of Cape Town. Student and staff protests were successful in persuading university authorities to remove the Rhodes statue from the campus. The worldwide protests had the broader goal of highlighting what has been described as the perceived lack of racial transformation in many educational institutions. An issue which my own institution has renewed its commitment to address this year: www.ed.ac.uk/equality–diversity/about/strategy–action–plan

Victoria Hospital | New Somerset Hospital

I was pleased to be able to visit two of the smaller hospitals in Cape Town. Mark Hampton is Head of Surgery at the Victoria Hospital in Wynberg. It was established in 1890 with 14 beds, became a General Hospital in 1923, and now sees 330 outpatients a day and 3000 emergency patients a month. Mark does an amazing job as a true general surgeon and I spent an enjoyable day going around the wards with him. The New Somerset Hospital is another smaller hospital in the Western Cape and Heather Bougard (Head of Clinical Unit) and Fazlin Noor (Consultant General Surgeon) took me round the general surgery wards. The deprivation in the catchment area of these hospitals was clear and as in all cities, in stark contrast to wealthy areas I had visited on the waterfront.

Cape Town from Table Mountain.

It is true that Cape Town is a dazzling jewel set on the ocean. It felt safe and catered well for visitors. AirBnB was good for accommodation and Uber for transportation.

Yet profound deprivation is close at hand. I had a wonderful experience and was impressed by the dedication of the clinicians in the face of limited resources. I was heading to Nigeria, but would return to South Africa on my final stop in Johannesburg.

Nigeria

Lagos
Lagos University Teaching Hospital (LUTH)

“A man does not wander far from where his corn is roasting” – Nigerian proverb.

I arrived tired after an overnight flight to Lagos, Nigeria’s former capital and the largest city in Africa.

Its growth is rapid and I was surprised to discover it is now the fourth largest city in the world with 21M in the metropolitan area (after Shanghai, Beijing and Delhi). Lagos is a sprawling wealth of humanity where I was made to feel very welcome. I am deeply in debt to Soji Ademuyiwa (Chief,

Paediatric Surgery Unit and Associate Professor) who went to great personal efforts to host my visit. Soji is a key member of the GlobalSurg Steering Committee and led the team in publishing the GlobalSurg paediatric dataset.

Soji Ademuyiwa picking me up at the airport (left). Soji Ademuyiwa, Justina Seyi-Olajide,and Felix Alakoloko at a local art gallery (right).

Lagos University Teaching Hospital was established in 1962 and is a tertiary hospital affiliated with the University of Lagos (UNILAG). I was honoured to meet Professor Chis Bode (Chief Medical Director) who well-known internationally for his work in paediatric surgery. He now leads the hospital but stays in close contact with clinicians. Professor Bode is a great advocate of surgery in Nigeria and is particularly keen to increase the capacity to deliver laparoscopic surgery. We spoke about this in detail and he was particularly interested in our work showing the benefit of laparoscopic appendicectomy in low- and middle-income countries (Surgical Endoscopy in press).

I was pleased to be asked to speak about liver surgery to the group and had a good conversation with Professor Sulieman Giwa (Head of Department) about the challenges of delivering HPB surgery.

It was also good to meet and speak with Prof Joseph Adeyemi (Dean Faculty of Clinical Sciences), Professor Fasanmade (Chariman Medical Advisory Council) and Professor Daramola (Deputy CMAC).

Soji is very progressive and is supporting the establishment of the REDCap data collection tool in Lagos (projectredcap.org/about). We have used this tool extensively and I was able to discuss some of the details of the proposal at the University. Soji has gone on to successfully run a community study of paediatric surgical disease (SOSAS Nigeria) using REDCap.

I was overwhelmed by the hospitality shown to me by the team during my visit. I am particularly grateful to Justina Seyi-Olajide, Felix Alakoloko, Seun Lapido-Ajayi, and Olumide Elebute for the kindness and they showed me. And in particular for introducing me to Nollywood, Nigeria’s popular film industry. I can highly recommend “The Wedding Party” which we watched at one of the local cinemas. I was pleased to meet Soji’s wife Iyabo Ademuyiwa, who also has an impressive research career.

I had interesting discussions about international perceptions of Nigeria and its portrayal in the media. Certainly, the UK coverage focusses on Boka Haram, described as an “Islamic extremist terrorist group based in northeastern Nigeria”. The consequence of the Boka Haram campaign is catastrophic, with at least 20,000 people murdered and millions homeless.

(www.cfr.org/nigeria/nigeria–security–tracker/p29483).

Yet many I spoke with were saddened that Nigeria was branded a “terrorist country” as a result, discouraging inward investment and travel. “What about most of the country not affected by Boka Haram?”, I was asked. “Should the UK be branded a terrorist country due to the actions of the IRA or Islamic terrorists?” My own perceptions have undoubtedly been coloured by the media but only by visiting the country did this become obvious to me.

Nigeria is the most populous country in Africa yet ranks 152 of 188 in the United Nations Development Programme human development index (HDI) of countries. Another common misconception relates to Nigeria’s oil industry. If Nigeria has such oil wealth, it is said, its people should be rich and its requirement for international development aid low. Yet for many years Nigeria’s oil industry has been plagued by corruption and mismanagement. The World Bank has estimated 80% of the energy revenues in the country benefit only 1% of the population (globalcitizen.org/en/content/oil–in–nigeria–a–cure–or–curse). Most of the produced oil is directly exported limiting the economic benefits to the local population.

Soji Ademuyiwa, Justina Seyi-Olajide, Chris Bode, Seun Lapido-Ajayi (with daughter), Myself, Iyabo Ademuyiwa, Suleiman Giwa, Felix Alakoloko, Charles Ememonu, Seyi Olajide (left). Statistical support always available at LUTH (right).

Lagos State University Teaching Hospital (LASUTH)

LASUTH is the teaching hospital close by and is operated by Lagos State and affiliated with Lagos State University. Although I did not visit the hospital directly, I was able to meet up with Mobolaji Oludara (Consultant General / Laparoscopic Surgeon) who had previously visited me in Edinburgh. LASUTH also contributed to the GlobalSurg project and Mobolaji is keen to develop more HPB capacity in Lagos.

Daniel K. Ojuka, University of Nairobi (left). Prof Fred Were, Dean of School of Medicine, University of Nairobi (right).
Soji Ademuyiwa showing me the operating department(left). Presenting to the residents about the importance high quality data in the delivery of surgery (centre). Meeting Professor Chris Bode and colleagues in Lagos (right).

I very much enjoyed my time in Nigeria and the hospitality was second-to-none. Lagos is a large busy city which is difficult to navigate and I was glad that my hosts (and in particular Felix) provided all the necessary transportation.

It is a country with immense drive and the clinicians I met are talented and passionate in equal measure. I look forward to great success in our future collaborations.

Kenya

Nairobi
Kenyatta National Hospital / University of Nairobi

“Sticks in a bundle are unbreakable” – Kenyan proverb.

I landed in Nairobi at dusk and it was pleasantly warm. The taxi driver smelled of an aftershave from my youth and we chatted pleasantly as he took me to my accommodation, an apartment block named “Habitat” and reminiscent of a 1960s sci-fi movie.

My visit to Nairobi was perhaps the most unusual of the trip. Unusual because the hospitals I visited contained virtually no patients. A long running dispute between doctors’ leaders and the government regarding pay and conditions resulted in a strike lasting 100 days.

I was hosted by Pankaj Jani, Vice President of the College of Surgeons, East Central and Southern Africa (COSECSA) and Vice Chair of the Executive Committee of the G4 Alliance. Through the University of Edinburgh, we run a successful surgical distance learning programme led by James Garden. With 500 students on courses at any one time, 140 students in total have been from SubSaharan countries. I had many good discussions with Pankaj about how we could expand this. There is a clear opportunity to work together with COSECSA to build surgical distance learning as an effective means of increasing the skills of young surgeons in the region. I was pleased after my trip to report back that we had been successful in an application to the Commonwealth Commission for Scholarships to support training surgeons in the COSECSA region.

Daniel Ojuka looked after me well during my visit. He showed my round an almost empty Kenyatta National Hospital, Nairobi. I could imagine the large Emergency Department full of patients and noise. But it was almost silent, with only 3 lying on trolleys in the middle of a large empty space. “Where are all the patients going?”, I asked Daniel. “Who knows”, he replied.

On the wards, patients who could walk had long since done so. Nursing staff were looking after those who could not leave, many of whom had not seen a doctor in weeks. Medical students were also absent – “why would they come if there are no patients and no one to teach them”, Daniel said.

The doctors have been forced to work in intolerable conditions, on call at all times and receiving a salary of $400-$850 a month (www.bbc.co.uk/news/world–africa–39271850; www.aljazeera.com/news/2017/03/kenya–doctors–strike–deal–government–

170314084246054.html). The Department of Health reneged on a new contract (the 2013 “collective-bargaining agreement”) which would have increased salaries, as well as committing to the employment of thousands of new doctors and addressing drug and equipment shortages. There was intimidation of doctors and threats of mass firings as the government sought to force clinicians back to work. Following my trip, doctors returned en masse after a new deal was signed. It remains to be seen whether conditions for doctors and patients will improve as a result of this.

Nairobi Surgical Skills Centre

I was greatly interested to learn about the unique challenges facing surgery and training in Kenya.

Despite these difficulties, I was impressed by the Nairobi Surgical Skills unit which is supported by Johnston and Johnston. This has surgical simulation facilities equal to anything I have seen elsewhere.

I spent an enjoyable morning being shown round the suberb facilities at the Nairobi Surgical Skills Centre by Edwin Bore and Danson Muchiri.

Mombasa

COSECSA Annual Conference

The College of Surgeons of East Central and Southern Africa has become an important organisation in the delivery and assessment of surgical training in the region. The Annual Conference combines college exams and graduation with a scientific meeting and grows in size and stature each year.

I was grateful to Denis Robson (J&J) for the invitation to speak about data and Measurement and Evaluation at the specially convened NGO Workshop. This sought to bring together NGOs, clinicians, advocacy groups and policy makers to generate ideas that could be translated to tangible projects.

I was pleased to meet Miliard Derbew (COSECSA President) together with Declan Magee (Royal College of Surgeons of Ireland). The RCSI together with Irish Aid have contributed significant resources COSECSA. The meeting is a great opportunity to network with the many dynamic individuals working in the region. In particular I was pleased to catch-up with Professor Eric Borgstein (Professor of Paediatric Surgery, University of Malawi), who I would be visiting next.

It was an excellent opportunity for the Edinburgh team to meet up with current students and graduates from our surgical distance learning programmes. We were able to receive valuable faceto-face feedback and make plans to expand our scholarship support for the students.

James Garden, Denis Robson, Ian Walker, Vicky Young, and myself with the University of Edinburgh surgical distance learning students at COSESCSA.

As I left for Malawi, I thought a lot about the doctors’ strike. Many patients had died who should not have. It is sobering to reflect on scale of the difficulties delivering high quality healthcare in Africa, compared to the day-to-day troubles we face in our own jobs. Which sounds a little trite when written here. Still, what is the purpose of a Travelling Fellowship, but to allow us to reflect on our own practice. And yes, to realise how good we’ve got it.

Malawi

Blantyre
Queen Elizabeth Central Hospital

“You cannot pick up a pebble with one finger” – Malawian proverb.

The sun was bright and the air cooler when I landed in Malawi. My wife had previously worked for a year in Queen’s so this was my fifth visit. I was looked after fantastically well by Professor Eric Borgstein and his wife Sophie at their house.

As I left the airport, my driver spoke at length about the worsening political and economic situation in Malawi. Maize is the main staple and the price had risen significantly in recent months. It would go on to rise in part due to the “armyworm” plague affecting Southern Africa. This new threat is common in South America where Brazil spends $600 million each year in control measures. It has tragically been recently introduced to Southern Africa where it is threatening food security. Eric’s own maize was treated on the day I arrived by sprinkling ash down the maize stems to suffocate the worms.

Malawi has been a keen GlobalSurg partner, though we have struggled with obtaining ethical approval for projects. It has been well supported by Eric Borgstein, Emma Thomson (Consultant Paediatric Surgeon) and Patrick Noah (Consultant General Surgeon), as well as Professor Nyengo Mkandawire (Professor of Orthopaedic Surgery and Head of Surgery).

One of the most exciting projects going on in Blantyre was the building of the Mercy James Institute for Pediatric Surgery and Intensive Care at the Queen Central Hospital. Otherwise known as the “Madonna Unit”, it went on to be opened in July 2017 and was funded by the singer Madonna’s charity “Raising Malawi”. This beautiful new building sits amongst the existing hospital and is a vision of how care can be delivered when the funding and drive is there.

Professor George Youngson, Joe Mackie, and David Tipping were there from the Archie Foundation. A charity based in the northeast of Scotland, they have expanded to support the establishment of paediatric operating theatres in Africa, with a new unit in Uganda, and support for the Mercy James Institute in Malawi.

It was good to speak about GlobalSurg and data to the doctors in Queen’s at their morning meeting. There is real enthusiasm to get involved in collaborative international projects. I spoke to the to the residents about data collection and common HPB conditions and learned a lot about their local practice in return.

Eric and Sophie were perfect hosts and had me making guacamole, gathering up escapee turkeys, and learning which end of a croquet mallet was which.

Professor Eric Borgstein, Joe Mackie and David Tipping (Archie Foundation). Coffee beans growing in Eric’s garden.

Johannesburg

Charlotte Maxeke Johannesburg Academic Hospital (Jo’burg General)

“Abundance does not spread; famine does” – Zulu proverb.

I left Malawi to return to South Africa on my circular trip. The fields on the outskirts of Jo’burg are completely round and looked like crop circles from the airplane, something I had never seen before. I was subsequently told this was “centre-pivot irrigation” and was quite common – crop irrigation in which equipment rotates around a pivot and crops are watered with sprinklers. Well now I know.

I was made incredibly welcome by Sarah Rayne (Academic Surgeon, University of Witwatersrand) who has been a fantastic member of the GlobalSurg team. Sarah is a passionate advocate for equity of access to surgical care across geographical regions and socially disparate groups. Sarah and I were able to discuss future collaborative research plans in surgical site infection and cancer surgery.

Professor Martin Smith is well-known in Global Surgery and has put South Africa at the forefront of advocacy in surgery for low- and middle-income countries. He is well-recognised for his expertise in cancer surgery and as a leader in many local and international surgical organisations. I was pleased to be able to speak at the surgical meeting in Wits about liver surgery and GlobalSurg.

Centre-pivot irrigation, Gauteng, South Africa (Getty Images)

I enjoyed being shown the lab research unit in Wits and discussing opportunities for further collaborations. I spent an enjoyable morning being shown the department by Prof Damon Bizos (Head of Surgical Gastroenterology) and Leanne Prodehl (Consultant Surgeon). Prof Bizos has contributed extensively to surgical training models and research, and I was interested to discuss this in detail.

Chris Hani Baragwanath Hospital (BARA)

The Chris Hani Baragwanath Hospital is the 3rd largest in South Africa with 3200 beds. Jones Omoshoro-Jones and John Devar were impeccable hosts taking a great deal of time to show me the facilities. Seventy percent of the 150 000 admissions each year are emergencies, with 160 gunshot wounds per month. This staggering figure reflects the violence of Soweto and the extensive expertise in the surgical management of trauma in ‘Bara’ reflects this.

Given my interest in technology and data I was pleased to meet Mike Klipin, who is leading the establishment of a new electronic patient record. Irma Mare and the software developers showed took me through their work. I was inspired by the progress this small team had made and impressed with the vision in establishing this. Irma and I will continue to collaborate on data projects though the REDCap consortium.

Research department at Wits (left). Prof Damon Bizos, Head of Surgical Gastroenterology, Wits (right).

I had not expected Johannesburg to be such a green city and had not previously heard of the concept of an urban forest

(edition.cnn.com/2010/WORLD/africa/11/18/johannesburg.urban.forest/index.html). Perhaps it was all the trees that made it seem friendlier than I had been expecting. The Gautrain from the airport is fast and efficient and I was grateful to my hosts for helping with all my transport.

This was the last stop on my Africa leg, before making my way to Los Angeles. I left feeling very positive given all the inspiring people I had met. While there is much to be optimistic about, the extent of the deprivation and lack of healthcare facilities sometimes felt hopeless. In the absence of stable corruption-free government, how can sustained improvements be made?

My focus will be to support the expansion of healthcare infrastructure through research programmes. Randomised controlled trials are not a particular priority for Africa. However, the grant funding for well-designed clinical research addressing local priorities, can perhaps help capacitybuild while answering important research questions. This is the philosophy of the NIHR Global Surgery Unit, which has arisen from the GlobalSurg project. It will establish 5 autonomous Clinical Trial Hubs in low- and middle-income countries with an aim for these to become independent during the lifetime of the initial grant. The UK government and others are keen to channel international aid monies through well-established networks such as ours, in an effort to ensure support gets directly to where it can be put to best use. Our first Hub is due to open in Johannesburg later in 2017.

US

Las Vegas
Society of University Surgeons (SUS) / Association of Academic Surgery (AAS) Academic Surgical Congress (ASC)

“If you aim to leave Las Vegas with a small fortune, go there with a large one” – Anonymous.

I had only twenty-four hours in the UK before I was flying to the US. I was astounded to have complementary continuous wifi on the Irish airline, Aer Lingus, on my flight across the Atlantic. Ireland were playing Scotland at rugby which most of the cabin were streaming with enthusiasm. I had to keep my partisan support muted for fear of causing an international incident.

I was honoured to be invited by Rebecca Minter (SUS President) to the ASC to deliver the BJS Lecture, “Crowdsourcing Surgical Data”.

The meeting has a great atmosphere and an emphasis on high quality, relevant plenary sessions. It was a great opportunity to meet new colleagues and catch-up with old friends. Rebecca and I are Editors on HPB and I thoroughly enjoyed her great Presidential address, “Passion, Integrity, Resilience”.

Caprice Greenberg has had a fantastic year as President of the AAS, culminating in her address “Sticky Floors and Glass Ceilings”. Caprice has recently visited Edinburgh as a James IV Travelling Fellow.  It is with sadness that I think about being out for dinner during her visit together with Professor Ken Fearon, who died earlier this year with a great loss to us all in Edinburgh and beyond.

I was also hosted by Taylor Riall (President-elect SUS), who I knew from her work on patientcentered outcomes – an area I have also been working in over the last five years.

I attended the SUS Global Academic Surgery Committee meeting chaired by Ben Nwomeh. Ben and I know each other from Twitter (!) and have both been supporting Soji Ademuyiwa’s paediatric surgery project in Nigeria. The committee is enthusiastic and promote excellence in surgical education, research, clinical care, and collaboration.

Tom Weiser (Associate Professor of Surgery, Stanford) is a great supporter of GlobalSurg and is coming to Edinburgh as a Visiting Professor for one year from August 2017. His research focuses on the role of surgical care in the delivery of health services in low- and middle-income countries. Tom has worked as part of the World Health Organization’s Safe Surgery Saves Lives program during which he performed seminal work in quantifying the global volume of surgery. He was instrumental in the creation and implementation of the WHO Surgical Safety Checklist which most of us use in the operating theatre today. Tom and I have a number of opportunities for collaboration, particularly relating to surgical infections. It was great to discuss these and get things moving forward.

Steven Yule (Assistant Professor, Harvard Medical School) is another Scot and an academic psychologist now at Harvard. Steven’s interest is in the impact of behavioural skills on team performance and patient safety, particularly in the operating theatre. Steven developed the NonTechnical Skills for Surgeons system while in Scotland which is now the gold standard tool in this area. We spoke about opportunities to gather data on non-technical skills using our crowdsourcing approach. We have good quality data on use of the WHO Surgical Safety Checklist and looking at non-technical skills would be a useful additional element to the data.

It’s a great meeting with a particularly positive atmosphere. Of course, the Strip on Las Vegas could not be more far removed from Blantyre Market, Malawi – it is like the capital city of an alien civilisation in comparison. Yet there was one prominent common theme: healthcare inequality. I had many conversations about the future of Obama’s Affordable Care Act and what may follow. The Trump presidency had only begun a couple of months earlier and while no one was very sure what would happen, many were worried. Looking down from my hotel room to the Strip, it was difficult to believe that capitalism is having an existential crisis (time.com/4327419/american–capitalisms–greatcrisis). Yet it seems that a commonality between the UK, US, and Sub-Saharan Africa is a profound lack of confidence in the best and most equitable way in which to fund healthcare provision for the societies we live in.

Susanne Warner (Assistant Clinical Professor, City of Hope Hospital, Duarte) (left). Gala dinner at AAC (right).

Los Angeles

City of Hope

“Health care is a big deal” – Barak Obama.

I drove to Los Angeles through Joshua Tree National Park, which really is like an alien landscape. The final leg of my fellowship was to City of Hope Hospital in Duarte. Yuman Fong (Chair and Professor, Department of Surgery) is an HPB luminary and James IV Traveller (1999). Yuman and Nicole were the perfect hosts at their house in Los Angeles and gave so much of their time to take me out and show me aspects of LA I had not seen before.

City of Hope is a Comprehensive Cancer Center with a strong research pedigree. It originally opened in 1914 as a TB sanatorium consisting only of two tents, one for patients and one for staff. Given the poor prognosis of TB in the pre-antibiotic era, it was called “the city of hope”.

Yuman Fong is an inspiration. He lives life at 100 miles per hour and has as many ideas in that time. We have common research interests in HPB but particularly in wearable technologies for diagnosis and follow-up in surgery. I hope we can bring some of our transatlantic patient follow-up ideas to life.

I spent an enjoyable day with Gagandeep (Gaugs) Singh (Chief, Division of Surgical Oncology, Head, Hepatobiliary and Pancreatic Surgery) watching a tricky open distal pancreatectomy then discussing parenchymal-sparing hepatectomy. He is an advocate and had some good examples of colorectal liver metastases involving hepatic veins where a resection could be performed preserving the vein.

I met Susanne Warner (Assistant Clinical Professor, Division of Hepatobiliary Surgery) at the ASC and so it was great to watch her do a difficult left hepatectomy for cholangiocarcinoma, down to but not involving the confluence. Susanne and her husband also have an interest in humanitarian work and I hope we can work together in the future.

I was particularly keen learn more about how the team viewed the indications and use of the robot in HPB. Yanghee Woo (Associate Professor, Division of Surgical Oncology) has tremendous skills with the device and I was interested to discuss it with her.

I am so grateful to Yuman and Nicole for their hospitality. From making gluten-free muffins in the kitchen (a family business bensmuffins.com), to the La Brea Tar pits and Hancock Park, the Huntington Botanical Gardens, and the LA Philharmonic, I had an amazing fantastic time.

Conclusion

The James IV traveling fellowship has been an extraordinary experience and I am immensely grateful to the James IV Surgical Society. It has been great privilege to have the opportunity to visit and speak with surgeons working in environments different to one’s own. This is particularly the case given the challenges faced in many countries delivering safe, timely and effective surgical care. Despite the differences, the world is becoming smaller and there are many similarities, with great opportunities for shared learning.

The ethos of the GlobalSurg Collaborative is one of global community, that “we are all in this together”. I am left feeling this is definitely the case and that the community of surgeons working across the globe to improve the lot of the surgical patient is real.

The process of establishing GlobalSurg Trials Hubs around the world continues apace a worldwide RCT examining simple interventions to reduce surgical site infection in place. The GlobalSurg team plan to return to Johannesburg as part of the launch of this later in 2017.

Finally, there is great opportunity in expanding surgical distance learning programmes, which in themselves, contribute to a global surgical community. Our successful efforts in expanding scholarship opportunities for training surgeons in Sub-Saharan Africa should act as a springboard for further an expansion of funding in these areas.

Callan, number one son, exicited to be riding an ostrich in South Africa (far left). Finn, number two son, happy despite the prospect of a long flight (centre left). Reading “The Gruffalo” (cenre right). Liv, Callan and Finn on Table Mountain, Cape Town (far right).

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