James IV 2006 Traveler

Janice L Pasieka MD FRCSC FACS

University of Calgary, Calgary Alberta CANADA

I am grateful for the honour bestowed on me by the James IV Association. I would like to thank the Association for the opportunity to embark on these travels that allowed me to meet and network with new (and old) friends in the endocrine surgical world. I had the opportunity to live aboard and explore parts of the UK and Australia. .I am very appreciative of the hospitality and effort that many individuals (including many of the administrative assistants of these individuals), put towards utilizing my time most effectively during my travels. To that end, there are a few individuals that stand out during my time away that I wish to single out.

In Order of Appearance:

James / Ken � were instrumental in making my time in Scotland a real highlight. They knew the needs of a James IV traveler and made sure they were met.
Lorna � opened her home me � I just question where the time went and why we never seemed to get around to discussing the role of women in surgery???
Professor Toth � for his insights into the future challenges facing medicine and for adding to my tie collection!
Colin and Pat � opening their home and sharing with me their great Irish hospitality
Greg and Vanessa - for rescuing me that night�
Jonathon � what a trill to present at Oxford - dinner was a highlight
Bruce and Bev � how blessed I am to have friends that care. Bruce I know was instrumental in laying the groundwork for my visit and ensuring that I was well taken care of in each city I visited in Australia
Mark � how exciting to be able to attend my former fellow�s OR and be allowed to take a little pride in his continuing success
Tom and Mary-Jo � straight talkers and good friends. Glad to see them in such good health.
Michael / Catherine � How grateful I am to have the opportunity to see where my next fellow will be working.
Peter � first class host, made my trip to Tassie a highlight.
John � Who taught me much about one convict�s genetic anomaly
Jonathan / Meei � Challenging some �surgical dogma�. Now how much fun was that!?
Ivan and Jeanette � new friends and gracious host from WA! I continue to laugh every time I watch The Chaser CD.
Peter / Rob � friends who first showed me the value in international collaboration. Who would have thought Peter that our �little� study would stand the test of time 10 years later
NC, David, Owen and Daphne � They know the role they play in my life each and every day. This time around, Owen taught me the 9 ways to get a batter out in cricket, David helped me stand on a surf-board (albeit only for 1 second), and Daphne showed me my taste in music is �too old�. As for NC � thanks for letting me join right into your Ironman training schedule and for - well you know what for�

United Kingdom

My James IV travels started one week prior then I had originally planned. I was asked to be the Visiting Professor for the University of Western Ontario Residents Research Day. UWO is my medical school alumni and I was thrilled to be able to go �back� and take part in their residency training research program. I had a busy day with the residents and presented the keynote address titled �My journey into academic surgery�. From London Ontario I flew to Stockholm to present �Microcarcinoma of the Papillary Thyroid� in the Nobel Forum at the Karolinska Institute. This was in honor of Bertil Hamberger, former mentor of mine, who was retiring. What a thrill to be part of this event and honour a great man and surgeon in the endocrine world. Then I flew back to Arizona to attend the American Association of Endocrine Surgeons Meeting. From there, a quick stop in Calgary to do laundry and within twelve hours I was back on a flight overseas to the UK.

I arrived in London on Thursday, May 3rd. I spent the day getting orientated at the Royal College Residency Neufeld Hall � my home for the next 2 1/2 weeks.

Friday, May 4th

I met with Dr. Martin Caplan at the Royal Free Hospital. Dr. Caplan is one of the leading gastroenterologist experts in neuroendocrine tumors and runs a multidisciplinary neuroendocrine clinic. I attended the morning neuroendocrine clinic, which ended up going until about 2:30-3:00 in the afternoon. It was fascinating to see many of the similarities with our own multidisciplinary neuroendocrine clinic and some of the differences. As in our NET clinic, with the patients� complexity, it ran several hours overtime. The patients patiently wait to see Dr. Caplan. We went over all of the patients coming into the clinic with the two gastroenterology Fellows first thing in the morning. Dr. Caplan then saw just those critical patients while the Fellows saw the others utilizing the guidelines that he had outlined in the morning. I also met Dr. Meyer the medical oncologist working in the clinic. Dr. Caplan and Dr. Meyer have several protocols that have shown promise and all pancreatic neuroendocrine tumors are entered into a protocol for chemotherapy. They have response rates of 20-30% in the well-differentiated tumors and in the intermediate or high-grade tumors, the response rates are 30-40%. This is a cisplatinum based regime with streptomyosin and 5-FU. It is well tolerated and something that we need to consider in our own institution since, to date, we very rarely ever treat the neuroendocrine tumors of the pancreas with chemotherapy.

This was a very positive day as the networking with Dr. Caplan will be instrumental in linking Calgary and Canada to the European neuroendocrine tumor group. He has been frustrated by the fact there has been no Canadian contact and all of his contacts are in the various centers in the United States. With the similarity in our national health system, Dr. Caplan was keen to liaison with a Canadian group. We have decided to keep in touch to consider various protocols and the utilization of their expertise in our own clinic. Dr. Caplan�s multidisciplinary clinic has seen over 100 neuroendocrine tumors in comparison to our 400. The most interesting thing was how grateful the patients were to have the opportunity to see such a world expert �free of charge�. Many of their patients are on lutecium octreotide therapy and are firm believers of radionucleotide therapy. That evening I was still quite jet lagged and I got lost wandering home which is always fortuitous as it allowed me to explore Bloomsbury and Regents Park on foot.

Saturday, May 5th

I started the day by learning the Tube system in London�s underground to get to Regents Park for a 10-kilometer race that I had signed up for prior to arriving in London. When I arrived it must have been my accent that gave me away as they immediately said �you�re the Canadian�. Following the run, I wandered and found my way back towards the hotel, stopping at the National Portrait Gallery. I decided that I needed to work in one museum or art gallery a day while in London.

Sunday, May 6th: Started out as a beautiful day and with the Mall closed on Sunday was an ideal place to go afoot. I walked to the Mall and was sitting in James Park when a police escort came screaming to a halt a couple of feet in front of me and evacuated the entire Mall, Buckingham Palace and James Park because of �an incident� for which they could not tell if there was a security risk or not. I, along with 100,000 other tourists, was then set afoot to come up with �plan B�. How different the world has become. The Londoners were not fussed as this has become a way of life for them. The security cameras were everywhere � so foreign to this Canadian. Plan B consisted of a day of walking through the other parks and discovering as much of London central as I could on foot before arriving at the National Art Institute to see the Monet exhibit.

Monday, May 7th

A bank holiday. The day started with navigating once again the Tube system and recognizing the various closures of certain stations for maintenance did mean a change in route however, I made it down to Wimbledon to do a five-mile race with the Wimbledon Runners and the Hercules Club. While running the race I spotted the Wimbledon Tennis Museum and made a mental note of it�s location. Following the race, I spent four hours at the Wimbledon Museum getting a tour of the All English Lawn Tennis Club. Once again returning the Neufeld, getting lost along the way, discovering new avenues and streets and new sites to explore.

Tuesday, May 8 and Wednesday, May 9th

Met with several members of the International Women�s Federation. This is a very strong chapter of the International Women�s Federation. Their main objective is looking at how to promote, educate and advance women onto both charitable and non-charitable boards through various seminars. They are a diverse group made up of women in the corporate world as well as the medical sector and the arts. Unfortunately the President, Lisa McDonald, who is a medical oncologist from Bart�s had to cancel at the last minute and could not make the meeting. I found their chapter approach to focusing on a goal enlighting and one that I hope to bring to the IWF Calgary chapter for consideration.

I then spent the day at Hammersmith Hospital. My gracious host was Professor Williamson. I presented Rounds in the morning to a Surgical Group. We followed this with a discussion of the similarities and dissimilarities in the teaching curriculum for Surgical Registrars and the challenges they face on the development of appropriate clinical skills with the restricted work hours mandated by the European Union. The UK also struggles with the recognition that many of their graduating Registrars are taking up Fellowship positions merely to complete their clinical training as they do not have the appropriate clinical or surgical skills to go and practice on their own. We also talked about the balance of taking General Surgical call and the need for an adequate number of surgeons to balance service needs from consultant� s needs. We then went onto the Ward where I was presented several hepatobiliary cases with various aspects related to neuroendocrine tumors.

This was followed by a long discussion with Dr. Palazzo a consultant endocrine surgeon at Hammersmith. Fausto and I discussed the development of endocrine surgical programs and the resurgence of the longstanding tradition of endocrine surgery at Hammersmith. As well, we discussed the need of centralization of the endocrine surgeons at one site and the importance of research in the programmatic development of any subspecialty. In general the surgeons feel strongly that the mix of private/public medicine has not developed in a �brain drain� from the public system, that it is not a two- tiered system and that the quality of care is equal. Fear of most Canadians is the complete opposite of this. It is the general belief that the opening up of more private health care facilities will lead to a poorer public system. However, I found it interesting that the endocrine surgical division was more interested in focusing it�s practice and downplaying the private aspect of it in the hopes of enhancing the development of surgery. They have regionalized thyroid cancer and there is a particular quota of 40 thyroid cancer patients per year in order to be a thyroid cancer center consultant. This should improve patient care and the development of a thyroid cancer unit. The unit is driven by the endocrinologists and not by the surgeons. Therefore the surgical input will have to continue to be incorporated in multidisciplinary clinics and rounds with the endocrinologist and treating physicians. Through this model, ENT and General Surgeons that share a similar interest and are devoted to the multidisciplinary clinics, research and education in thyroid cancer will be allowed to participate and be part of the thyroid cancer model. I spent a lot of time delving into the logistics of this since at my own Institution there is a large threat to move thyroid surgery to a completely different institute under the auspices of the move of ENT being moved to a community hospital. Spare time over the next couple of days was spent visiting the Imperial War Museum which is an absolute must for anyone that comes to London and daily runs in Regents Park.

Friday, May 11th

The morning was spent in the operating room with Mr. Fleming at Hammersmith Hospital. Interesting observations were the disregard of the OR suites as a closed unit compared to Canadian OR�s. You walked through the OR suites with your street clothes on to get to the change room. A straightforward parathyroidectomy from the mediastinum was the operation. None of the parathyroidectomies are done under local, for �cultural� reasons. The physicians do not believe that the majority of British patients would accept having their operation under a local anesthetic. Without any decrease in the length of stay, neither the anesthetist nor the surgeon thought the local approach was of value at this time. Despite that, intraoperative nerve monitoring was put in place and yet was never utilized during the operation. Another observation was the positioning and the prepping of the patient was not done by the surgical team but by the nursing/anesthetic support team. Patients are admitted the night before in order to be assessed by anesthesia and the surgical team. Some patients, when beds are not available, stay at the hospital hotel across the street, paid for by the health trust. Operative notes are handwritten, not dictated. Postoperative orders are written by the anesthesia team and are not the responsibility of the surgical team.

Following the OR I spent a couple of hours discussing the private versus public health care system and the advantages that surgeons in the UK felt this mixture provided. Both the Fellow and Mr. Fleming were from Australia originally and therefore we spent a great deal of time talking about the Australian exit examinations at the Royal College level. This is a very extensive five part oral exam and a two part written short answer/long answer questions. It appears to be very comprehensive and utilized as a gatekeeper to ensuring a high quality and high standard of education upon finishing one�s residency. This is in sharp contrast to the changes that are being undertaken at the Royal College of Canada with its standardization and it�s simplicity to the examination process here in Canada.

That afternoon I went over the St. Mary�s Hospital to visit with Professor Darzi. His unit, an academic surgical unit, started off in a small department with a humble beginning and has grown into a world-class surgical technology investigative centre. We talked about how their government moved to decrease waiting lists and this was achieved first by increasing capacity of the operating theatres. Secondly the strategy was to standardize the fee schedule in order to make private and public utilization of the ORs equal and therefore facilitate more efficiency in the public hospitals since there was no advantage to stockpiling patients into the private system. This meant utilization of the ORs on Saturdays and extended OR time in the public system has allowed for a decrease in the waiting lists of surgical patients. There is a move to continue to decrease the waiting list. This is in sharp contrast to Canada�s initiative in decreasing waiting lists without the initial increase in capacity of the operating theatres. Clearly without an increase in capacity the waitlist will continue to climb in our country.

I then spent the afternoon with the Research Fellows, discussing their research in surgical technology and education. The extensive computerized simulation program, which the Research Fellows were working on, was quite impressive. 3-D holographic models of patients, and simulators that had biofeedback technology were demonstrated to me. One of the resident�s projects was looking at changes in brain wave function while assessing simple surgical tasks from the novice to the experienced consultant was demonstrated. Also the work in the basic science lab included looking at molecular profiles of the bacterial stool load and how this may be predictive or influencing the development of such disease as inflammatory bowel disease or colon cancer. I was very impressed with the work being done here and will continue to look for and read with interest work produced by Sir Darzi�s group.

I presented Rounds to the St Mary�s group on Multidisciplinary Clinic �The Role of Surgery in the Palliation of Neuroendocrine Tumors�. Following that, I went to dinner with two of the senior consultants from this unit, Paul Ziprin and Barry Paraskevas both colorectal surgeons and basic scientists. Barry has an interest and was recently promoted to spearhead surgical education in both the undergraduate and early registrar level. We talked about the educational process and the struggles they are having with the recent change in the selection process for registrars. This process is now more an automated process opposed to an interviewing process. They share my concerns with the lack of clinical expertise being taught to the registers� and the change in the focus of students going into medical school, i.e. more focused on lifestyle issues than altruistic humanitarian issues. I found it interesting that it is a universal change in the perception of our profession and likely reflects societal changes in the Western World.

Friday, May 11th was spent at St. Bart�s Hospital with Professor Ashley Grossman, an endocrinologist, world known for his work in pituitary and neuroendocrine tumors. I attended their multidisciplinary rounds where they discuss patients with nuclear medicine, radiology, pathology, medical oncology and occasionally surgery. They discussed various treatment options for a variety of patients from malignant pheochromocytoma to malignant thyroid cancer. Following this we had an Endocrine Round where the medical students and registrars presented recent endocrinology cases, again with pathology being reviewed and a discussion of the diagnosis and treatment.

St. Bart�s Hospital has a longstanding history of medical intervention and Dr. Grossman took me on a tour of the old St. Bart�s Hospital including the Great Room. St. Bart�s is within walking distance of St. Paul� s Cathedral, therefore, following my time with Dr Grossman I couldn�t pass up the opportunity to wander through this magnificent church and climb to the top. On the way back, a visit to St. Bart�s Museum and a visit to the Hunter Museum close to home finished out the day.

Saturday, May 12th

Spent the day taking in more museums (returning to the Portrait gallery, the Photographic museum and the Florence Nightingale Museum and wandering the streets of London. That evening I was invited over to Pauline Hyde�s home. This is a woman from the IWF who, upon arriving at her home, I realized was a significant upper class Brit whose husband was well known in American politics. Her house was scattered with pictures of her and her husband with such leaders as Jimmy Carter, Humphrey Hubert, Ronald Reagan and Lyndon Johnson. She herself rose to fame by developing a headhunter company and then subsequently becoming an author of children�s books and at the present time has just written a novel and is in the process of writing her memoirs. This was a very interesting evening as it gave me insight into what the non-medical populus think of the British health care system. There is a perception that the public hospitals in Britain are filled with infection and for this reason people like Pauline are told not to go to a public health facility, as it is unlikely you would survive a hospital stay. Therefore, private health care and private hospitalization is perceived as the superior system to this woman, yet this is in contrast to what I had seen in the public hospitals to date.

Tuesday, May 15th

I spent the morning at the Royal Free attending the Multidisciplinary Tumor Board with the Royal Free Hospital and Middlesex College linked in by video. These are mandatory multidisciplinary conferences for the physicians. This is combined hepatobiliary and neuroendocrine attended by the hepatobiliary surgeons, including the Chair, Professor Brian Davidson, Dr. Caplan and the medical oncologist, pathologists and radiologists attend this meeting. Sixty-three patients were reviewed with their pathology, radiology and their treatment plan all being outlined. Because of the large number of patients that needed to be seen, there was very little time for discussing the pros and cons of the treatment options put forwarded by the attending. It was clear that this was a means of ensuring that the pathology and the radiology were reviewed. The physicians are under an extreme amount of pressure to meet the waiting list times for which they will be severely penalized if they do not meet these goals. Therefore the review must be done in a timely fashion in order that the patients can be brought back to clinic and then planned surgery or treatment is undertaken. The challenge was to ensure that all of the documentation, the films and pathology was there and the attendings had a chance to review it prior to the discussion. This was not always the case and that in itself made it frustrating as without that vital piece of information sometimes the treatment could not be discussed. Very few trainees attended these rounds. It could be a very valuable teaching experience. The afternoon was spent viewing the Impressionist exhibit at the National Gallery.

Thursday, May 17th

I spent the morning at the multidisciplinary clinic for endocrine tumors at the Hammersmith Hospital. In attendance were nuclear medicine, pathology, radiology, endocrine surgery and all of the endocrinologists. The tumor group have a randomized trial on low dose versus high dose I-131 therapy in low risk patients and further randomized into withdrawal versus recombinant TSH. Once again the goal is to review all of the patients. Here we went through 25 patients and there was more dialogue as to the best treatment approach. Patients with insulinomas and Conn�s tumors were also presented to the group with an open discussion of their selective venous sampling, review of their pathology with the plan to consult surgery. This was a much more interactive endocrine tumor group then I had seen to date, and the trainees I believed benefitted from the discussions. The afternoon was spent running in Regent�s Park and having to move from the College before dinner with Mr. Lynn and Mr. Williams. Mr. Lynn is a prominent, now retired, endocrine surgeon who continues to work in the private hospital system. Learned more about the politics of surgery in London that night.

May 17 � May 20th

Neuroendocrine Workshop on Endoscopic Surgery. Traveled to Vienna to participate in this workshop put on by the European Association of Endocrine Surgeons. What became apparent was the growing sentiment against the anatomical surgeons, i.e. the laparoscopic surgeons and the hepatobiliary surgeons that were removing pancreatic tumors endoscopically and the endocrine surgeons which were dealing with this disease as an endocrinopathy and how best to surgically treat it. It was clear that the endocrine surgeons need to embrace this different technique for removing these tumors and the anatomical surgeons need to understand there is more to the technical exercise of removing the tumor. It was useful to see different ways of approaching the pancreas endoscopically and to reaffirm in my own mind that endoscopic procedures on this gland are technically feasible, they just need to be developed.

Sunday, May 21st

I traveled to Edinburgh. I then tried to scope out the lay of the land and identify the important places to visit by walking the streets of the city. Monday was a day of visiting Edinburgh Castle, walking the historical Royal Mile and then climbing to the top of Arthur Seat which gave a panoramic view of the city.

Monday, May 21st

I traveled to Glasgow and met up with Ms. Doherty who is an breast/endocrine surgeon in the Beaston Oncology Unit. What was enlightening was her thoughts of women in surgery, women trainees and the fact that most Scottish surgeons do very little private work compared to London. It became apparent that the further north one travels in the UK the less private healthcare and the more public health care is provided by surgeons. There was no opportunity to meet any of the other surgeons or see the unit. I wandered around the university before returning to London on the train. I did not find that the effort to travel to Glasgow was as worthwhile as I had hoped it would be.

Tuesday, May 22nd

I spent the morning and midafternoon with Mr. Chetney in the Breast Clinic at the Royal Infirmary in Edinburgh. Mr. Chetney was one of the key and instrumental players in developing a comprehensive breast unit where the patients could come in and be evaluated clinically, radiographically and pathologically at one visit. They also have within their unit their own OR to accommodate all of their patients. Interesting the breast surgeons take no general surgery call and therefore have no patients other than breast surgical patients on their unit. I then spent an hour and a half with Dr. Bartlett, the head of the Translational Research Unit in Cancer UK who is working predominantly in breast tumors but we spent a great deal of time talking about the problems of having clinicians doing basic science research and basis researchers understanding the clinicians needs. This is a fundamental problem that is also seen in Canada.

I proceeded to the Royal Infirmary and met Ms. Lorna Marsten, a transplant/endocrine surgeon, and was involved with their multidisciplinary tumor board. There I met Dr. Toth a leading endocrinologist and presented Endocrine Rounds to the group on the �Impact of Pathological Changes seen in the Diagnosis of FVPTC�. The evening was spent, a dinner at Professor Toth�s house with the three other transplant/endocrine surgeons, Lorna, Merat Akyol and John Forsyth. This was a lovely dinner where we discussed Scottish politics, the trials and tribulations of training surgeons for rural areas versus academic physicians and the frustrations shared by all within the University to be productive academically versus the service component of health care.

Thursday, May 24th

The morning was spent in the Operating Room first with Mr. John Forsyth doing a total thyroidectomy for Graves� disease. Dr Akyol then with an attempted laparoscopic adrenalectomy for what ultimately turned out to be a renal tumor. Following this I met with the research Fellows. Each of them presented their recent research work. It is quite exciting to see the caliber of research these House Officers were presenting.

That evening along with the Research Fellows, Professor Gardner and Mr. Ken Feron hosted me at the Royal College of Edinburgh. This is a very impressive building with the original portrait of James IV and Lord Lister. This was a marvelous opportunity to talk more candidly with the young research fellows and lecturers who were just embarking on their careers. These residents had no concerns about the time commitment for doing a couple of years of research, obtaining their Masters or PhD prior to completing their surgical training. Quite different from our system where there is much resistance to stepping out of a general surgery residency program to become a surgical scientist.

Friday, May 25th

Professor Gardner and I attended ward rounds with the hepatobiliary service. The high dependency unit is where all postoperative patients that have epidural catheters go to as the regular ward does not function with the epidural catheters. Many of the patients in the high dependency unit would not meet the criteria of our high observation unit. Nursing shortage does not appear to be a problem in this institution as 2:1 nursing to patient ratio was maintained in this unit.

The afternoon was spent at the multidisciplinary clinic rounds on hepatobiliary lesions where we went through the x-rays and the rural consultations. As a tertiary care centre, rural consultants ask for a second opinion by sending in the x-rays and a brief history. An opinion is rendered whether the group at the Royal will see the patient or what investigations or treatment plan should follow. This is a highly efficient way of triaging as the clinical sister (nurse) was then able to facilitate the triage plans to the rural consultant. I then gave a lecture on the �Palliative of Surgery in Midgut Carcinoids� to the group.

That afternoon, Professor Gardner and I drove to Glen Eagles where he had some business to conduct and I wandered the grounds of this incredibly elegant hotel and golf course. This gave me the opportunity to interact with Professor Gardner on a more informal and personal level. Upon returning from a beautiful drive through the country-side we met up with Professor Feron and Ms. Marsden at the Rubiyet Restaurant that night which conclude my visit to the University of Edinburgh.

I spent the next five days travelling north to Inverness by train. I spent a few days hiking the highlands of Scotland on the Great West Highland Way around the Glencoe area. From there I went over the Belfast. Colin Russell was my host. Shamus Dolin the endocrine surgeon I was hoping to work with, was unfortunately not available. After seeing a few of the sights around Belfast, Monday was spent meeting the gastroenterologists and Dr David McCann the endocrinologist who runs the neuroendocrine clinic. We had a multidisciplinary clinic where they presented a couple of complex neuroendocrine patients and we discussed various treatment strategies. They have a very similar clinic to our own but desperately need surgical back-up and surgical expertise in a more global fashion.

The following day was spent doing ward rounds in Belfast Hospital with the colorectal team, then spent some time discussing general surgical on call schedules and the change that has been forced upon them with the European work regulations of house staff. This has evolved into a new general surgery rotor. They are looking a similar structure to providing call that we have organized in Calgary. We discussed the pros, cons and the trials and I was able to provide insight into the tribulations that we had gone through in Calgary and what we have done to maximize its potential. That night I had a lovely dinner at the Russell�s home with a James IV traveler from Ireland, George Johnston, the dedicated endocrine anesthetist and the head of the academic surgery, Mr George Campbell.

The following day I spent doing ward rounds with Professor Campbell. We then met with the postgraduate researchers in the Department of Surgery laboratory where they presented their research work to me.

May 16th

From Belfast I flew back to London and was driven to Oxford. At Oxford I spent the day in the operating room with Mr. Greg Sadler. We did a laparoscopic adrenalectomy and a very challenging insulinoma. That evening Professor Meakins hosted me at the High Table at Balliol College for a wonderful dinner where I spent time finding a little bit more about the academic versus the NH surgical service and how these two �systems� work in parallel. I was housed at Greg Sadler�s home, which provided me the opportunity to see more of the countryside around Oxford and meet his delightful family.

The last day was spent presenting Grand Rounds at Oxford. I then did ward rounds and spent some time meeting with the endocrinologists. After spending the day exploring Oxford and various Colleges, I returned to London for one more day of exploration before heading back to Calgary. The highlight of my final day in London was the 2000 nude cyclists riding through the streets of London to raise awareness for the green movement. Believe it or not but that day I failed to pack my camera, so you will just have to take my word that such a site (event) took place!

AUSTRALIA

Arrived in Sydney on Wednesday, December 5th, early in the morning and immediately went walking along the harbor front, exploring the area, before heading out for my daily run. Spent the evening at the Opera House attending the Symphony � the second best way to fight jet lag.

Thursday December 6th

I went to North Shore Hospital where I did Professorial Rounds with the Surgical Fellows in Endocrine Surgery, attended by Dr. Delbridge, Dr. Sidhu and Dr. Sywak. There was a small group in attendance. I then did a tour with the post doc working in Bruce Robinson�s lab. In going through the lab I met the technician that is responsible for much of the genetic testing on the SDHB and SDHD mutations. Since I was a co-author on this paper trying to outline the clinical pheno type of these individuals, I brought to their attention and updated on one of our unique patients. This was most helpful as they had just recently also had a patient with a paraganglioma that rose from the vagina, something that has not been reported in the SDHB mutation and it stimulated much discussion. I hope that we will then write these patients up in the hope of advancing the pheno type of this disease.

Friday, December 7th

I spent the day in the Operating Room with Dr. Sywak. This was at the private hospital which demonstrates the efficiency of having (1) a dedicated anesthetist that he works with at all times and (2) a dedicated scrub team that turned the room over in a very timely fashion. We were able to complete six cases including two total thyroidectomies, a couple of redo parathyroidectomies, two other parathyroidectomies and lateral lobe biopsy. The private hospital is quite willing to accommodate the surgical needs of the patient and the surgeon. Very little time spent in between cases as the anesthetist would work quickly to get the patients asleep for the next case. It truly illustrated, that in the right environment, efficiency is possible. The group did however point out that it is quite different when they work in the public hospital across the road. That evening I attended a Christmas dinner celebration with Leigh and his surgical team.

Saturday and Sunday were spent with the Barraclough�s. I left the hotel and moved into their home. We spent the day on their boat in the harbor fishing and having a wonderful lunch discussing various medical and non-medical topics. It was great to catch up with old friends. Dr. Barraclough wears many hats and I was fascinated to hear about his international work with the World Health Organization and his quality and safety work for the College. Bruce has been instrumental in setting up a new medical school that services the western part of Sydney, which is an underprivileged sector. This medical school is innovative; its curriculum, is based on being in the community and involves exposure early to the clinical medicine while attending concordant problem-based lectures. It is designed to take on the students from this area, educate them and have them remain in the under-serviced portions of New South Wales. Dinner conversations were most interesting. First I was hosted by Stan and Mark as we tried to solve the problems of the world of surgery. The following day I enjoyed a lovely BBQ at Bev and Bruce�s home with Tom and Mary-Jo. One learns most during these social gatherings.

Monday December 10th

returned to Sydney and was picked up by Dr. Michael Jensen who is head of Surgery at St. Vincent�s. St. Vincent�s campus is a very impressive campus with a large public and a private hospital all amalgamated together and run by the nuns and the Catholic Church. This has made it one of the most successful, not-for-profit private hospitals and a very successful public hospital. The other aspect of their health care system is that Notre Dame has recently built a satellite medical school that is attached to the hospital. They will be instituting a very unique and advanced medical school program that Dr. Jensen and Surgery will be very much involved in the development of. I then spent the afternoon with an endocrinologist, Dr. Catherine Samoia who is in charge of the research lab, the Garvin Institute. This is one of the most successful research institutes in all of Australia. This was a very worthwhile interaction as it allowed me to network with a brilliant researcher and I anticipate that this will foster collaboration of new projects in the future. I then went to dinner with the Endocrine Oncology Division from St. Vincent�s. It is made up of both Head and Neck Surgeons as well Surgical Oncologists who have done Fellowship training at either Memorial Sloane Kettering or in the UK. Once again I was quite fascinated by the mix of private versus public practice for these surgeons. They are able to do it quite successfully because of the proximity of the private hospital in the St. Vincent�s campus. Potentially a lot of research material is being put through St Vincent�s but at the present time only a few of the surgeons are actively involved in research and taping into the resources at the Garvin Institute. Hopefully this could change if my current fellow returns to St. Vincent�s.

Tuesday December 11

the morning was spent presenting Rounds to the Surgeons, Medical Oncologist, the Nuclear Medicine Physicians, Pathologists and Endocrinologists on the Follicular variant of papillary thyroid cancer. Following this a Professorial session with their residents on mid gut carcinoids. A multidisciplinary Head and Neck Clinic for which the patients actually attend and are seen by the group then followed this. From there I then caught a plane to Hobart.

Upon arriving in Hobart, I was taken to the Hobart Hospital where I met up with the Surgical Registrars and my host Professor Peter Stanton, Head of General Surgery. These Registrars are from the Melbourne system and do a six month rotation in Hobart. We then went through various cases and in Professorial Rounds. This was followed by a lovely dinner with the Registrars allowing me the opportunity to find out more about their surgical training.

Wednesday December 12th

I had the chance in the morning to explore a little bit of Hobart and go for a long run across the bridge and along the foreshores. In the afternoon, I presented �The Development of Patient Based Outcome Tool in Parathyroid Disease� to the Endocrinologists and the General Surgery Faculty. I believe there will be a big change in their practice as the data convinced many of the Endocrinologists of the necessity and benefit that parathyroidectomy has on patients with HPT. I then spent an hour and a half with John Burgess, the endocrinologist who is responsible for the MEN I patients in Hobart. This was most instructive as his knowledge on the disease and the way they follow their kindreds has been very helpful. It also brought up several ideas for us to collaborate in MEN I patients, particularly the two patient kindreds that we have that are presenting only with hyperparathyroidism as well as wanting to tap into the long term follow up of patients with gastrinoma tumors that have been treated surgically versus those that are treated much more conservatively in Hobart. The Hobart group have taken an aggressive approach to the parathyroid disease and a less aggressive approach to the pancreatic disease than we would do in Calgary or Michigan. That night Peter hosted the endocrine group and myself at his private club. Professor Stanton was a delightful host and helped make my trip to Hobart very worthwhile. Time spent with Dr Burgess was most useful as I tried to tap into his knowledge and understanding of MEN I as much as time allowed.

Thursday December 13th

I flew to Melbourne and met up with Professor Jonathan Serpell, the Head of General Surgery and the Endocrine Unit at the Mossah University. I had a tour of the facility the then presented Rounds on the �Development of an Outcome Tool on Hyperparathyroidism� to the Endocrine Surgeons and the Registrars. That evening Jonathan hosted me to a lovely dinner in Brighton with the endocrine surgical team.

I then spent the morning of the following day in the Operating Room with Jonathan Serpell and a recent endocrine surgical recruit Dr Meei Yeung. This was at the Alfred Centre, which is a surgical centre that was built for the sole purpose of decreasing the waiting lists. The Alferd Center was Melbourne�s response to the increasing need for capacity in the public system. Patients that are waiting too long on any waiting list in the city are referred to this center and are done here without the threat of being bumped or losing their priority in the queue � they just accept another surgeon doing their case. This �project� has reduced the waitlist considerably and appears to be well received by both the patients and the physicians. Following our morning in the OR, went to lunch with Meei, gaining a better understanding as the role women play in the surgical faculty. How universal the difficulties women surgeons have in surgical departments is! This is an area that needs work� My impression after spending time with the Melbourne endocrine surgeons is that they will have a significant impact on endocrine surgery in Australia, provided they continue to be involved in research in this area. Professor Serpell I believe has the vision and the ability to lead this group in this direction. The afternoon and the rest of the day were spent exploring Melbourne and it�s international recognized art scene. As always the day�s explorations were followed by a run along the river, when the temperature dropped below 28.

December 15th

After a long run in the rain (finally a break from the heat) I boarded a plane for Perth. I was picked up by Mr Ivan Thompson in Perth and got a tour of the outline of Perth itself before going for dinner with he and his wife Jeanette. Ivan had insisted that I stay with them during my visit. The next day was spent driving down to the Margaret River for lunch and some wine tasting with Ivan and Jeanette. The Thompson�s were delightful hosts and I had the opportunity to meet some of their family.

The following day (after a great run along yes another the river) I had a tour of C-Tech their computerized simulator surgical skills lab. This was opened by the Queen in 2000 and is a very impressive facility that is utilized throughout Western Australia as the centre for training paramedics, nurses, medical students, surgeons, GPs and anesthetists. I then spent the day at the Western Australian Endocrine Society Meeting which consisted of nine endocrine surgeons from Perth that meet once a year as a group and present topics to each other and share interesting cases. They delayed their meeting in order to have it coincide with my visit and therefore I gave three different talks throughout the day. In the afternoon we were joined by the pathologists, endocrinologists and the nuclear medicine physicians for a multidisciplinary discussion of a variety of cases. This local level meeting is a great idea and I believe help stimulate collaboration as well as education among this small but important group of surgeons. That evening I was hosted at the University Club dinner for which I was presented beautiful pictures from Western Australia to remember my trip. They hang proudly in my office�

The following morning I went to the Sir Charles Hospital where I was given a tour of the facility. This was followed by a multidisciplinary clinic where all of the endocrine surgeons that I met the day before presented a couple of challenging and difficult cases.

On Tuesday December 18th

I boarded a plane to head to Adelaide � a city that I have come to know well. In Adelaide, I had a dinner presentation with twelve endocrine/breast surgeons from Adelaide. The Adelaide group had contributed to the patient based outcome measurement tool for primary hyperparathyroidism and I was able to give them the ten-year follow-up. We then had a much more informal discussion about the role of endocrine surgery, its relationship with ENT surgery, the movement of privatized surgery for the sake of referrals versus academic quality. Other parts of the discussion were based on the up and coming IAES Meeting which will be hosted in Adelaide and thoughts which are contrary to the views of those in Sydney as to how to run a pre/post graduate course.

Although I was set to give Grand Rounds the following day at the Royal Adelaide Hospital there were very few people still in the City as it was close to Christmas. I had an opportunity to cycle to the highest peak in the Adelaide region, Mount Lofty, with a cycling club that day. I therefore sent an email to Professor Jamieson explaining my dilemma and his response was that �the cycling sounded better for my soul�. With that wise advice I headed off cycling with my best friend and her Triathlon club. I then spent the rest of the time in Adelaide and in a small town called Robe, cycling, running on the long beaches, watching the Cricket at the Adelaide Oval (of course the boxing day test match was seen on TV) and spending Christmas with some very dear friends before return to the snow in Calgary.

Things that I have learned

Running a 10 Km race upon arrival is the best way to fight jet-lag
The English drive on the Left � run on the Right
The Scottish drive on the Left and run on the Left
BBC News � a true global preceptive
Private and Public systems can co-exist, but it is not completely the solution
Read the �broad sheets� � if interested in the news!
The Tube � the only way to travel � mind the gap!
Black-top cabs � best in the world
Innovation and technology will drive the next major advances in surgery
The further north you go in the UK the less private health care is found
Glen Coe is not the same place as Glencoe, they are miles apart � need read the signs/map carefully when hiking
It is not what is in the bag that counts � it�s the bag itself�
A minimum of 1, a maximum of 2 museums a day�
NHS does not appear to have a nursing shortage
Leadership drives the academic productively in a department
The evolving changes in surgical training � are leading to universal problems
Sydney Symphony � The second best way to beat jet-lag
Running in the rain beats running in the HEAT
OR�s can be changed over in 15 minutes!
Most beautiful run � around Sydney Harbour
Tassies� and Newfs� are kindred spirts that exist in parallel yet opposite universes
Hospitality of the Aussies� second to none
Sydney is not in the center of Australia�
Thinking outside the box for novel solutions to the wait-list problem is the only way Canada will solve the problem
Will need to return to explore WA
Every center struggles with M&M rounds
Cycling truly is �good for the soul�
Live Cricket is a �chess game� - not appreciated when seen on the television
Best running experience @ the water�s edge on Long Beach, Robe
Surfing is HARD
Aussie�s love their exercise (at least the ones I know and love!)
Silly-mid-on

Tips for James IV Travelers

Be sure to find someone in the country or city that is very much connected with the Association. If there is a former traveller in the area � this is very advantageous. These individuals will lay the ground work for you. Outside surgical departments the role and expertise of the James IV fellow is not well known. Former travelers understand the needs and can be a great asset to making the time most productive. Without direct links, it will take longer to get to do and see the things you want to do.
The administrative assistants of your host are invaluable. They can and will make things happen for you, help arrange or recommend accommodations
Be flexible � the itinerary should be filled prior to arriving � but make room for meeting others as things present themselves once you get to meet the players.
Always leave time to explore the surrounding area, it takes some getting use to � but you will have time to do other things. Research the area before hand and use the �locals� advise as to where to good and what to see
Bring a computer with 4-5 prepared talks, a dictaphone (to record each day and observations � it will make the report easier to compose upon your return), workout gear, iPod, that book you never have time to read and the camera.
Pack light � you will need � the amount of clothing you think you will. Schedule to stay where laundry facilities are available � way through the trip.
Periodically staying in the homes of your host will only add to the experience and give you a break from living out of a hotel room.
Plan some time in the OR � very insightful experience
Insist on spending time with the residents and fellows � give Professorial rounds. They are the future and their insights into the challenges ahead can be most instructive
Leave your practise at home � try not to be too connected with the office � they can and will get by without you there � try it you will find it enlightening.

James IV Association of Surgeons

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