James IV Traveller�s Report: or I Wish I Could Do It Again!

Dileep N Lobo, MS, DM, FRCS

ABSTRACT

Background: The James IV Association of Surgeons Inc. is a premier surgical organisation whose members include 100 outstanding surgeons form the English speaking world. Each year it bestows a Traveller�s Award on 2-4 young surgeons to enable them to travel to centres of their choice and help them develop professionally. I was fortunate to have been awarded one of the Fellowships in 2007, the 50th anniversary year of the founding of the Association.

Methods: I wrote to surgeons, some of whom are members of the James IV Association, in premier institutes in the United States of America and arranged to visit Texas Medical Centre, Houston, University of California, Irvine, Memorial Sloan Kettering Cancer Center, New York, Johns Hopkins Medical Institutes, Baltimore and Mayo Clinic, Rochester over a 6 week period. I also attended the 50th anniversary celebrations of the Association at New Orleans.

Results: The visit was probably the most enjoyable time I have had professionally since Medical School. I made professional and personal friends and broadened my outlook. Witnessing the functioning of some of the best centres in the world gave me confidence in own achievements. I received invitations to write articles, three of which have been accepted for publication. I have learnt new surgical and teaching techniques and have established research collaboration between Houston, Sapporo and Nottingham and have obtained a $40,000 grant to start work on novel nutrients.

Conclusions: I am grateful to the James IV Association of Surgeons for the honour bestowed upon me and feel that the Fellowship has helped me develop both personally and professionally.

Introduction

I am an academic surgeon working at Nottingham University Hospitals, Queen�s Medical Centre, Nottingham, UK and have been in post since 2003. My research interests are focussed on surgical nutrition and metabolism, fluid and electrolyte balance and pancreaticobiliary disease and my clinical practice centres on hepatopancreaticobiliary and emergency surgery. I have been working since 1997 with Professor Brian J Rowlands, who is a member of the James IV Association of Surgeons Inc., in the capacities of surgical trainee, research fellow and consultant colleague. It was Professor Rowlands who encouraged me to apply for the James IV Traveller�s Award and I was fortunate to have been accorded the honour in 2007.

The James IV Association of Surgeons Inc. was founded on 17 October 1957 by Sir John Bruce of Edinburgh, Prof. Ian Aird of London and Dr. William Hinton of New York with a primary aim of promoting international exchange among surgeons in the English speaking world. Sir John Bruce was elected President of the Royal College of Surgeons of Edinburgh in the same year, and he suggested that the Association should be named after King James IV of Scotland who ratified the Seal of Cause of the College on 13 October 1506 by the grant of a Royal Charter. King James IV was a great patron of learning and the arts, and the historian Erasmus wrote, �He had wonderful powers of mind, an astonishing knowledge of everything, an unconquerable magnanimity and the most abundant generosity.�

The James IV Association has 100 members at any given time and its members represent the highest achievers in surgery in the English speaking world. Each year the Association bestows 2-4 Travellers� Awards on young surgeons in the English Speaking world and I am grateful to the Association for recognising my achievements and giving me the opportunity of being one of the 50th Anniversary Travellers.

I describe my travels in this report, explain how I benefited from the award and provide some illustrations of how I have changed since my travels.

Methods

Having got over the elation of having been chosen to travel, I wrote to surgeons in the institutions I wished to visit. Many of them are members of the James IV Association and the replies were prompt and welcoming. They were all very accommodating and arranged excellent programmes for me. The visit was intended to be mutually beneficial and one of the aims was for me to be an ambassador for surgery in the United Kingdom. Ample opportunities were provided for me to have an exchange of ideas with world leaders and to deliver lectures based on my own work and personal experience. I chose to visit centres that would help me further develop my clinical and research interests. Once the itinerary was confirmed, I booked my tickets and hotel accommodation. I was fortunate that Continental Airlines flew to most of my destinations. Hotels were easy to book and recommendations from my hosts were very useful. Two of my hosts, Dr. Anil Kulkarni and Dr. Murray Brennan, even let me stay in their own homes!

Itinerary

The James IV Association recommends that the period of travel should be 6 weeks. However, clinical commitments at work make it difficult to travel for more than 3 weeks at a time. I, therefore, travelled to the United States of America in two stints of 3 weeks each with an intervening period of 2 weeks. My itinerary is summarised in Table 1 and my hosts in each institution visited are listed in Table 2.

Hosts at the local institutions

New Orleans

I was not sure what to expect in New Orleans in the aftermath of hurricane Katrina. The city had been cleaned up, but appeared desolate. I did not see any of the vibrancy that the New Orleans of old was famous for.

The American College of Surgeons Conference was very impressive. This was the first time that I attended an ACS Conference and the sheer magnitude of the meeting overshadowed that of any British or European Conference. I attended the plenary sessions and sessions on trauma, resuscitation, pancreatic surgery, incisional hernias, patient safety, critical care and nutrition. I also attended free paper and video sessions. The highlight of the meeting for me was the 50th Anniversary Celebration of the James IV Association of Surgeons. The scientific session included an excellent talk on the History of the Association by Dr. Ian Macintyre and summaries of the greatest advances in the last 50 years in Trauma/Infection/Metabolism, Transplantation, Technology/Education and Endocrine Surgery by Drs. Brian Rowlands, Ronald Busuttil and Samuel Wells respectively. The 50th Anniversary Dinner was a grand celebration with entertaining talks by Sir David Carter, Dr. John Wong, Professor James Garden and Dr. Murray Brennan, the President of the Association (Figs. 1-2). I also had the pleasure of meeting Dr. Stanley Dudrick, a person I have wanted to meet ever since I developed an interest in surgical nutrition. It was then that I realised the full impact of the honour of being a James IV Traveller and in a way it was a humbling experience.

Houston

My next stop was Houston where my host was Dr. Anil Kulkarni, Professor of Surgery at the University of Texas Medical School. Anil and his wife Sulabha very kindly let me stay at their home in Pearland. Anil had arranged an excellent programme for me which included talking at the Grand Round at Hermann Hospital. My talk was appreciated and I was asked to repeat it to the medical students on the same day!

I had one-on-one interactions with a number of surgeons in Houston and thoroughly enjoyed the experience.

Orange

I reached Orange County in the midst of the devastating fires, to which the pilot drew the passengers� attention before landing. However, the area around the hospital was safe and life continued as normal despite the smoky atmosphere. My hotel was a 10 minute walk from the hospital. Dr. David Hoyt, the Chairman of Surgery at UCI was a perfect host and had arranged an excellent programme for me (Table 5). He and Dr. Jack Connolley, a senior member of the James IV Association, made every effort to make me feel at home (Figs. 7-8). Grand rounds at UCI are usually held on a Thursday, but as I had to leave on Thursday, a special session was arranged for me to deliver my talks (Table 3) on Wednesday. I also attended the Trauma Review Meeting and found it to have a high educational value. Dr. Thang Nguyen was a great help, helping me find a fuse for my adaptor plug, driving me around the sites of Orange, introducing me to Vietnamese cuisine and dropping me off at John Wayne Airport.

Oslo

Before arranging my James IV travels, I had already committed myself to delivering a guest lecture on Perioperative Fluid Therapy to the Norwegian Surgeons� Association in Oslo. The flight from Orange to Oslo via Newark was the only flight in my six weeks of travel to be delayed. My lecture had to be postponed by an hour and I had to deliver it unshaven and dressed in jeans!

Back in the UK

I returned to the UK on 27 October 2007 and was subject to a lengthy interrogation on the James IV Association by the police at the airport! I am not sure how much of it they understood, but maybe my three day stubble made them suspect that I may have been up to no good. I planned to spend two weeks at work before returning to the USA for the second leg of my travels. I received the sad news of my mother�s sudden death in Lucknow, India on 6 November. She died of a myocardial infarction while watching a school play. The funeral had been planned for 8 November. I left for India on the night of 6 November and after a 9 hour flight to Delhi and a 13 hour taxi journey from Delhi to Lucknow, arrived in time for the funeral. I had debated postponing the second leg of my visit, but as all the arrangements had been made, I decided to go ahead. I returned to the UK late on 9 November and after repacking my bags, left for New York in the early hours of the morning of 10 November. Those had been sad and stressful days for me, but in the end I felt that I had made the right decision to proceed with my travels.

New York

Dr. Murray Brennan, the President of the James IV Association was my host in New York and very kindly let me use his apartment in Manhattan. I reached his apartment on the evening of 11 November and found a note stating that his Fellow Dr. Troy Kimsey would pick me up to attend a basketball game between the Knicks and the Miami Dolphins at Madison Square Garden! The seats were excellent and the view was terrific. I thoroughly enjoyed the evening and forgot all about my jetlag. Dr. Michael House, another Surgical Fellow met me in the lobby of Memorial Sloan Kettering Cancer Center at 0650 the next morning, and thus commenced a rich experience of one of the world�s leading cancer centres. I attended fellows� teaching conferences, surgical grand rounds, laboratory research conferences, pancreas staging conferences, radiology conferences and clinical research conferences, besides delivering three lectures, attending theatre sessions and having one-on-one interactions with the attending surgeons.

The visit to MSKCC was very busy, but I enjoyed it immensly. I learnt much from the visit, in terms of clinical care, teaching, audit and management and the insights gained have certainly enriched my own practice. The two talks I delivered (Table 3) were received well. Dr. Brennan�s choice of wine at the dinner hosted for me was interesting (Fig. 11) and led us to debate whether it was the official James IV Association wine! I did manage to do a small amount of sight seeing in New York, but did not get very close to the Statue of Liberty.

Baltimore

I had wanted to spend a week at Johns Hopkins Medical Institutes in Baltimore, but had to cut my stay down to three days because of the Thanksgiving Day weekend. Nevertheless, my hosts Drs. Richard Schulick and John Harmon did fit a lot into the three days and yet again, I thoroughly enjoyed the visit. I had discussions with a number of surgeons (Table 7), spent time with Dr. John Cameron (Fig. 13), who is a member of the James IV Association and has a personal mortality rate of 1% for over 1000 pancreatic resections, walked around the very beautiful campus (Fig. 14), visited the newly opened William Stewart Halsted Library (Fig. 15) and had dinner with Dr. Julie Freischlag, who is the Chairperson of the Department of Surgery, and other faculty members (Fig. 16). I delivered a talk at the GI Conference (Table 3), attended the Morbidity and Mortality Conference, the multidisciplinary Pancreatic Clinic, the Liver Conference and theatre sessions. I also spent some time at the Baltimore waterfront in the evenings and once again, had a very productive visit.

Rochester

The last week of my travels was spent at the Mayo Clinic at Rochester and I felt that, to some extent Dr. Mark Duncan�s words were true. I felt, without disrespect to the other centres that I visited, that the Mayo Clinic provided the best experience of my travels. If you ask me why, I can�t give you a rational answer, but maybe it is a combination of the warmth of my host, Dr. Michael Sarr (Figs. 17 and 18), the philosophy on which the institution is based (Figs. 19 and 20), the patient pathways and the investment that the management has made in the people who work there. No wonder, they brave the bleak winters to work there! Dr. Sarr picked me up at the airport, took me to dinner and made sure that I met him at the clinic at 0615 hours the following morning. The day started with the morbidity and mortality conference, was followed by an all day theatre session and ended with a talk delivered by me at the surgical grand rounds (Table 3), followed by dinner with the faculty. The following four days were spent interacting with the attendings (Table 8), giving more talks, teaching residents and attending theatre sessions. My travels ended with Dr. Sarr dropping me off at Rochester airport in the early hours of the morning of 1 December.

There was some free time, but not much of it. I spent some of the time renewing old acquaintances and friendships in New Orleans, Houston, Scarsdale, Boston and Rochester. These were colleagues who I knew during my medical studies and residency in India. I even managed to meet two of my trainers, Drs. Patrick Kamath and Manju Kalra, both of whom now work at the Mayo Clinic. I spent a few days with relatives in Birmingham and Princeton. I did not do much sightseeing, but did do some shopping and even managed to buy all the things on the lists my children had given me! I also spent some time experimenting with food.

I kept in touch with work by e-mail and performed my editorial duties for the European Journal of Clinical Nutrition and Surgery (Oxford). I reviewed papers and managed to write three of my own papers that were pending. I also wrote protocols for two future studies.

My impressions

The six weeks spent on the James IV travels were probably the most enjoyable time I have had professionally since medical school. I only fully realised the prestige associated with the award during the course of my travels and feel particularly grateful to the Association for bestowing the honour on me. I feel that the whole experience has made be a better clinician, researcher and trainer and it has been an important milestone in my personal development. So what did I learn and what did I achieve?

Summary of outcome of James IV Travels

The travels broadened my outlook and have made me a better person, surgeon, researcher and trainer.

Visiting some of the best centres in the United States has given me confidence in my own achievements and at the same time has helped me identify areas for improvement. I made friends � both professional and personal. I was impressed by the pride that the Residents have in being trained. They are proactive, hard working, well read and are ready to support their arguments with evidence. It was a real pleasure for me to interact with them and teach them. I also learnt much from them. I have admiration for the enthusiasm that the Faculty Members have for Resident Teaching and the high levels of attendance of Faculty Members at Grand Rounds, Lectures and other clinical meetings.

I learnt that radiology is as reliable/unreliable all over the world. Only the 5th pancreatic cancer that I witnessed in theatres was resectable! A �pancreatic cystic lesion� listed for laparoscopic resection turned out to be a renal cyst. The Grand Rounds and Morbidity & Mortality Meetings were educational and instructive. All discussions were evidence based and residents had to be thoroughly prepared.

Even in the best centres, multitasking in theatres can be dangerous. Enough said! There is a huge investment in research in the United States. I also felt that I have achieved much with the relatively meagre funding that I had in the UK. The Multidisciplinary Team Meetings were focussed. All cases were prepared prior to the meeting and there was no time wasted. Discussions were focussed and coherent management plans were made.

The idea of updating audit databases every week at a meeting was a great idea. It ensured accurate collection of data.

My talks were well received at all the centres and there was healthy discussion and debate at the end of the talks, which made my efforts worthwhile.

I have implemented new teaching techniques (especially the one that Dr. Coit impressed me with) on my return to Nottingham. The residents love this and look forward to the sessions every week.

I received three invitations to write articles and all three have been accepted for publication: a review of Dr. Cameron�s book on Pancreatic Surgery for the New England Journal of Medicine, an editorial on fluid balance for the Annals of Surgery and a review article on the Enhanced Recovery After Surgery Programme for the Archives of Surgery.

I have established research collaboration between Houston, Sapporo and Nottingham and have been awarded an initial grant of $40,000 grant to start work on novel nutrients in 2009.

Thank you

In conclusion, I would like to express my gratitude to the James IV Association of Surgeons Inc. for honouring me with the 2007 Traveller�s Award, to my hosts (and their secretaries) who arranged excellent programmes for me and to all the surgeons, physicians, researchers and residents with whom I interacted. I would also like to thank the University of Nottingham and Queen�s Medical Centre, Nottingham for granting me extended leave for my travels and to my wife Annie and children Deepti, Arun and Varun for letting me spend all this time away from home without complaining!