Liane S Feldman MD FRCSC FACS
I would like first to express my appreciation and gratitude to the James IV Association for the significant honour and privilege of the fellowship for 2010. I traveled in two blocks, the first in Europe in May-June 2010 and the second in Australia and New Zealand in July-August 2010. The fellowship allowed for a unique opportunity to meet and spend time with surgeons, researchers, educators and trainees in England, France, The Netherlands, Australia and New Zealand. Some of my goals were to understand how different countries and institutions approach technological innovations in surgery. How are new technologies in digestive surgery introduced into practice and why? How do trainees and surgeons in practice acquire the skills to ensure safe introduction of worthwhile innovations and how are these skills assessed? How are innovations evaluated and why are some countries or institutions more successful at performing high-level trials in surgery? I also wanted to observe clinical activities in minimally invasive and upper GI surgery in these various countries. I established or strengthened professional collaborations for research and also created lasting family memories in Australia where I travelled with my husband and three children aged 12, 10 and 7. I am grateful for the hospitality of Prof Ara Darzi, Prof Jacques Marescaux, Prof Jaap Bonjer, Prof Guy Maddern, and Prof John Windsor and their colleagues and trainees, who all took time out of their busy schedules to meet and share ideas formally and informally. Their assistants were also invaluable for coordination and scheduling.
Part A – Europe (May 20-June 3 2010)
Department of Biosurgery and Surgical Technology Imperial College, London, UK (Host: Professor Lord Ara Darzi)
Day 1:
I spent a stimulating afternoon in the Academic Surgical Unit at St Mary's Hospital where I met with a number of “clinical fellows” (surgical trainees pursuing advanced degrees in the department), researchers and educators. The breadth and quality of research in the department is impressive, as are the facilities. Prof Darzi explained that his underlying philosophy is to bring clinicians and researchers together in a collaborative way, working at the same site. These researchers include educators, economists, computer engineers and psychologists at the Queen Mary Hospital site, and robotic engineers at the Hamlyn Robotics Centre at Imperial College in South Kensington. This was an impressive group: bright, passionate, engaged. I was exposed to some completely inspiring new ideas but also had the chance to find areas for collaboration.
I first met with Danilo Miskovic and Susannah Myles. They are both pursuing PhDs in education, supervised by Prof George Hanna. Danilo is a Swiss surgeon who completed his training in Switzerland while Susannah is the middle of her training. I had seen Danilo present a paper at SAGES on a project to train UK surgeons in laparoscopic colorectal surgery and was now able to get more details about this impressive effort. It was decided to create a number of training centres throughout the country that would agree to give courses and mentor other surgeons in their region; in return, these centers often got upgrades in equipment. Over 130 surgeons are enrolled in the program, and agree to be assessed by the mentors after each case using a novel performance measure created by Danilo and his group. The results are entered through a website. The assessment tool is similar in many ways to the assessment tools we created, and so we had much to discuss. Danilo has been able to look at performance for this large number of surgeons in practice. When I marveled at the way this effort was rolled out across the country, Danilo felt that the fact that there was little central involvement in the actual process of mentoring, and it unfolded in various ways depending on the center and proctor contributed to its success. We hope to embark on a collaboration to help validate his tool in a multicenter effort as well as other tools for other procedures. One of Susannah's interests is in developing a tool to assess teaching performance of the mentors in the program.
I met Professor Darzi for lunch in his office. I learned about how he started in academic surgery and the relationship between clinical and academic surgeons in the UK. When he began at Imperial College about 15 years ago, there was little tradition of academic surgery in the department, and he has built a world-class program in that short time. The main research interests include future technologies, education, skills assessment/simulation/training, patient safety, and policy. The policy aspect arose from his experiences as minister of health for a two-year period, during which he continued to operate. This commitment to clinical care informs his vision as an academic surgical leader.
After lunch, I learned about “choice architecture” from another research fellow, the idea that decisions are influenced by how choices are presented. The idea is to redesign environments- a simple example is for hand washing, the simple design of having a hand pump outside of each patient room increases the likelihood of the MD actually washing his hands much more than nagging them to wash their hands. They are building a model patient ward and working with artists and designers to improve safety. These concepts made me think about how difficult it has been to get evidence into clinical practice, and how our work with the creation and implementation of clinical care pathways in the Department of Surgery is a kind of choice architecture manipulation– care pathways help clinicians make the “right” choice in common clinical scenarios and hopefully will then decrease unwanted variability and improve safety/quality. Later during the trip, I picked up “Nudge” by Sunstein and Thaler where many of these ideas originated.
Next, I met with Vish Patel, a clinical fellow working on an education project using “Second Health”, a virtual hospital based on Second Life, an immersive 3D virtual world where people interact with each other through avatars. The virtual hospital includes operating rooms and patient areas, as well as equipment, nurses, etc. Vish is working to create scenarios for learning and patient safety. One of the scenarios he showed me was of a nurse asking him (through his avatar) to check on a patient whose IV infusion was not working. The avatar needs to wash his hands, ask the patient questions, check the label on the IV, etc. The idea is to use these scenarios to train junior residents and students in common problems. Stress levels were reduced in medical students who trained in this virtual OR compared to those who simply got a lecture or just went to the OR without any preparation. This is an exciting use for this technology that has the potential to engage trainees in a new way. Another application is in teaching patients what to expect about their upcoming hospital care. There is of interest to me with my involvement with patient education as part of our enhanced recovery projects.
I then met with a series of groups or individuals involved in simulation training. I met with a group of computer engineers involved in creating simulations for interventional radiology (which included quite realistic haptics), ultrasound-guided liver biopsy, and 3 dimensional anatomic models. Next, I met with a psychologist who showed me the Imperial College Virtual OR (a perfect replica of a Storz OR 1 endosuite) complete with monitors, simulators and mannequins. They use this to study team interactions in the OR. In one study, they looked at the effect of preop mental rehearsal on surgeon stress and teamwork in the OR under control and stressful conditions (anesthesia instability, missing equipment, unreliable assistant, chit-chat, music, etc). Teamwork is evaluated with a variety of measures and using multiple assessors. All the images are recorded for future analysis.
I then toured the laparoscopic simulation room. A variety of simulators including MIST-VR, LapMentor and a new Olympus colonscopy simulator are being assessed. One project is to assess the effects of sleep deprivation on performance, and we discussed a completed study on the effects of a medication used to treat narcolepsy on reversing some of the effects of sleep deprivation in trainees. Not sure how that would go over at the residency training committee!
Finally, I toured the skills laboratory across the street in another pavilion from the main hospital. The educational activities for the trainees are coordinated on a wide scale through The London Deanery. Skills training is mandatory, and the skills center coordinates training for 170 trainees from as far as 3 hours away. All attend one half-day session each month with the curriculum spanning 30 different simulations, mostly using “limbs and things” models or ex vivo animal tissue. Procedures from simple staped anastomosis to pouch formation and hepaticojejunostomy are simulated. There are two full-time staff just for these sessions.
While I learned about projects, I also asked the clinical fellows about some general training issues. The training program is quite different in the UK of course, and considerably longer than in North America. It begins with a three-year core surgery period, after which one applies for a five-year senior training period in a more specialized area, which is competitive. After this, many trainees will pursue additional fellowship training. The clinical fellows at Imperial College are mainly pursuing PhDs between the core and senior training periods. It is very competitive to be accepted in the program, and Prof Darzi encourages them to obtain a PhD rather than a Masters in order to remain in Academics. They are general paid through grants, often through one of the private insurers, which requires them to work one in six days as a house officer at a private hospital for their salary. This was not a cause for complaint though. We discussed how the 48-hour work week works – they do 8-hour shifts.
Finally, I gave a talk entitled “Safer introduction of innovations into practice: understanding the learning curve for surgical performance”. The audience included about 40 researchers, clinical fellows, trainees and surgeons. There was about 20 minutes of discussion with many insightful comments and questions.That evening, we had a delightful dinner with Professor Darzi and invited speakers for the next day's robotics symposium at the Athenaeum club. Also attending was Lady Hamlyn, the supporter of the Hamlyn Centre for Robotic Surgery at Imperial College.
Day 2:
I attended the 3rd Hamlyn symposium for Medical Robotics at the Royal Society. This was a peer-reviewed meeting with attendees mainly from Western Europe. There were about 100 participants. The focus was to explore new challenges and opportunities for medical robotics in Engineering, Medicine and the Natural Sciences. Most papers described emerging multi specialty applications for robotic technologies, surgical navigation and augmented reality, medical imaging computing and some clinical applications. There were posters and oral presentations of very high quality, as well as a debate moderated by Professor Darzi entitled “Robotic surgery: science or bubble? I learned about technologies on the horizon such as articulated laparoscopes, robotic single port manipulators, and swimming micro robots. The presenters were primarily engineers, and the collaboration between the clinicians and engineers at Imperial College reminded me of how Dr Thomas Krummel described the centre for innovation at Stanford.
Day 3:
I attended cases in the operating theatre at St Mary's hospital. I began by observing a laparoscopic cholecystectomy. A few differences about the OR were immediately obvious- one may walk through the OR in street clothes; one does not need to wear a mask; the room had windows; anesthesia was induced in an antechamber room attached to each OR, and the nurses table was prepared in another connected room. A few similarities: They were using the WHO checklist; the equipment was all Storz, HD, and they used 10mm 30 degree scope and all disposable ports. The case was straightforward. The surgeon was Mr Manos Zacharakis, and Raj Aggarwal was the senior registrar; a senior house officer was holding the fundus of the GB. I later had a chance to chat with Manos in the coffee room- he is an upper GI surgeon, so we discussed foregut cases mainly. I next observed a laparoscopic right hemicolectomy by Mr Paul Ziprin, a colorectal surgeon, assisted by a senior registrar. This was in an endosuite, with the equipment on ceiling booms. They used the ligasure for the dissection, and a medial to lateral dissection approach. The registrar did much of the dissection under direction.
Between these cases, I had the opportunity to meet with professor George Hanna. Prof Hanna is an upper GI surgeon whose clinical practice is mainly gastric and esophageal malignancy. He has broad academic and research interests in technology, metabolic surgery and education. He supervises several PhD students who sit at desks in a room just outside his office. He has used human reliability assessment to define errors as a measure of proficiency in a variety of open and laparoscopic procedures. This may be applicable for a study we are doing in predicting recurrent paraesophageal hernia from recorded cases - can these types of “errors” predict recurrence? This also interested me as a possible outcome for simulation-based studies looking at skill transfer to the operating room. I also met with one of his students who has developed a rat model of gastric bypass to study metabolic surgery, and has some excellent results.
I returned to theater to observe a final case, a young lady with a mediastinal abscess and right pleural effusion 2 weeks following drainage of a peritonsillar abscess. She had a drain paced in the effusion under ultrasound guidance but had some signs of persistent sepsis. She was referred from another hospital to Prof Hanna as a GI surgeon with the possibility that this represented an esophageal perforation. A thoracoscopic approach with the patient in prone position was attempted. Unfortunately, the degree of inflammation and adhesions precluded this, and the patient was repositioned for a thoracotomy.
I greatly enjoyed my time at Imperial College and was inspired by exposure to many new ideas and possibilities for collaboration.
Day 1:
My goal at IRCAD was to visit one of the premier surgical technology training centres in the world. As the creators of Websurg, IRCAD has developed a multimedia empire highly valued for its educational content with our trainees. Dr Jacques Marescaux invited me to audit a course on NOTES. I arrived Thursday evening from London and walked for about 15 minutes from the hotel to the city center, a charming old Europe mass of cobblestone pedestrian streets in the shadow of a grand cathedral. I had dinner at a typical Alsacian restaurant, Chez Yvonne, with the faculty who will be teaching the NOTES course. This included many of the well-known surgeons at IRCAD (Bernard Dallemagne, Didier Mutter) and their American counterparts in surgery (Lee Swanstrom, Brian Dunkin) and gastroenterology (PJ Pasricha). Device development and innovation in general were discussed and the situation in the United States was compared with the situation in Europe. Silvana Perretta discussed her progress in a porcine model with intraluminal therapies for achalasia.
Day 2:
I attended the NOTES course at IRCAD. The facility is excellent and impressive. The didactic teaching was very current. After this, we watched live porcine surgery including transvaginal retroperitoneal nephrectomy, a NOTES sigmoid resection using magnets for retraction, transgastric cholecystectomy and the intraluminal myotomy.
The live surgery was in the 3rd floor lab, with 13 pig stations. The images were excellent, each station had a technician, and picture in picture capability for the endoscopic and laparoscopic images. There were 2 trainees at each station with a teacher. All the teachers were very experienced. The goals for the day were transmitted in a loop on a monitor at each station for reference. The goals were to achieve transgastric access using a needle knife and balloon dilatation- this was definitely teachable and reproducible. The trainees struggled though with the usual problems- the instability of the flexible platform, the movement of the scope, the need to move the scope and the effectors, disorientation, poor quality of equipment meant for endoscopy not surgery. The gastroenterologists progressed technically more quickly, and did not seem to mind the upside-down views, but did not know the surgical anatomy, so had their struggles there.
Day 3:
A second pig lab was held, this time to rehearse transvaginal access, both to the retroperitoneum and peritoneal cavities. It was relatively easy to get into the retroperitoneum, then the CO2 insufflation and scope were used to dissect the space in order to find the kidney and adrenal. After this, a cholecystectomy was attempted. The afternoon was a series of excellent lectures and discussion. Many new platforms and devices were presented. Common features included the need to fix the scope in position, the need to separate the working ports from the image (triangulation), the need to develop better instruments, and the way robotics and advanced imaging are needed to improve on things. Suturing devices for endoscopy were also discussed, several are coming to market and seem promising. Clearly, GI surgeons will need to develop and maintain their endoscopy skills. Accredited skills centers will play an increasingly vital role for surgeons retooling their skills. Several previously common surgical procedures have been replaced with endoscopic procedures (eg., gastrostomy by PEG, esophagectomy by ablation, choledochoenteric anastomosis by stents), and how the goal is to substitute complex invasive procedures by simpler, less invasive ones, this is true technologic disruption. Essentially it comes down to whether the philosophy is to perform complex invasive procedures by a different approach (eg open->lap->NOTES) or if the goal is to actually replace a procedure with a new, simpler one via the intraluminal approach (eg open OR laparoscopic gastrostomyPEG). Seems to me that the latter is more likely to happen.
Finally, clinical results of NOTES were discussed. Most use a hybrid procedure, with a single port in the umbilicus (usually 5mm) for exposure and clipping. At IRCAD they have done around 20 cholecystectomies, highly selected patients, and say that the patients really have no pain. However, they also showed a video of an easy GB where they dissected out the CBD and hepatic artery completely. It was recognized prior to clipping or division after using traditional laparoscopic visualization. Other data were reviewed. There have been some issues with nausea and throat pain from the long endoscopic procedures. Clearly, NOTES is very difficult technically, and the equipment is not there yet. The stated goals are to decrease pain and improve recovery after GI surgery, yet these outcomes are measured superficially or not at all. Robotics will facilitate these complex endoscopic procedures, but it is unclear if there will be a favorable cost-benefit to their effectiveness. It will be hard to show advantages for NOTES or single port compared to traditional laparoscopy, especially with miniaturized instruments, and it is unclear if industry and payers will see a market to justify development outside of academic engineering and surgical experiments.
Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands (Host: Professor Jaap Bonjer)
Day 1:
I was picked up at the hotel Monday morning by Dr Bonjer. I attended the morning report along with the residents, students and attendings in the department of surgery (GI surgery, oncology, vascular, traumatology and thoracic). The junior resident on call that morning proceeded to review all the cases operated on during the weekend using a concise powerpoint presentation summarizing the clinical presentation, imaging, what was done and the outcome. Cases that were to be done that day were reviewed. A few questions about management were asked by the attendings. One interesting difference is that the “trauma surgeons” repair the fractures. There is usually an abdominal surgeon, vascular surgeon and trauma surgeon on call each day. The resident training has been very much challenged by the institution of a 46 hour work week about 15 years ago. The residents work 8 hour shifts and the schedule is difficult to organize. Because of this, there are very few residents present during the day for scheduled cases. Another complaint is the need to work every day for 3 weeks (including weekends), although the 4th week is completely free. This was a recurrent theme of discussion during my visit, of interest as Quebec seems to be headed toward a similar regime.
I met with several attendings and PhD students. Although the population is one-half that of Canada's, The Netherlands has a tradition of extremely high quality multicenter RCTs in surgery, including the COLOR trial (lap vs open colon resection for cancer led by Dr Bonjer). I was interested in understanding the factors that contribute to this success. Through meetings with several researchers and surgeons, some factors seem to be “cultural” – that the surgeons are willing to randomize their patients, even if they personally prefer one or the other approaches; that patients wish to contribute to advancing knowledge; that the medical community is proud of this tradition and wants to uphold it; the fact that the 8 academic medical centers are in relative close proximity facilitates multicenter trials; whether funding was easy or hard to obtain from peer-reviewed granting was debated. I heard the term “evidence-based” repeatedly from attendings and trainees, many are actively involved in ongoing complex trails of surgical procedures.
I met with JD Blankensteijn, a vascular surgeon involved in the DREAM trial of endovascular vs open AAA repair, the long-term results of which were published in the NEJM last week. He explained his involvement in developing a technical skills assessment for the European vascular credentialing exam. We discussed validation testing, including the strengths and weaknesses of various approaches to measuring performance like global rating scales and motion analysis. We also discussed how we can assess outcomes in surgical trials, he explained how in the DREAM trial, QOL in the two groups was identical at 3 months, and that the psychological impact of having a big operation like open AAA repair may affect perceptions of QOL.
I met with the coordinator of the COLOR II trial (lap vs open resection for rectal cancer). He explained the trial and that enrollment is now closed. Short-term results should be available this summer. In Holland it is very common for students who wish to enter a surgical residency to first do a PhD after medical school in a surgical department. While only about 10% of students enter residency directly from medical school, having a PhD improves your chances to one in three. It is essentially unheard of to do research during training, unlike in the UK and North America. Having a PhD is pretty much required to get an academic position.
I met with Dr WJ Meijerink who explained the structure of the residency, which beings with a 2 years “common trunk” for all trainees at the academic center. Year 3-4 is spent in a regional hospital affiliated with the academic center, then year 5-6 are specialty years. Many then do 1-2 year fellowships supported by the government. It seems that there is no credentialing exam requirement for licensing. Dr Meijerink's clinical focus is colorectal, and he has been involved in setting up a Dutch registry for colon surgery that is now mandatory - all procedures need to be entered, which takes about 30-45 minutes per patient. Risk adjusted outcomes are then fed back to clinicians. Last year, even before it was mandatory, fully 66% of colorectal resections were entered into the registry! Dr Meijerink also has been involved in training practicing surgeons in laparoscopic approaches, directly mentoring two dozen surgeons, and in technical skills training for residents.
Day 2:
After the morning report I met with the previous chairman who was also the program director, as per tradition. He explained the evaluation for residents used across the country. Each resident has a portfolio that is web-based. This includes OSATs-like evaluations for a minimum of 20 procedures per year covering domain from preoperative care, set-up of the patient, knowledge of steps of the operation and technical skills. Each specialty has a list of procedures and benchmarks for competency for each 2-year block from A to D (can do independently) and E (can teach). In comparison with the list of >100 procedures American PDs think graduating residents should be competent in (according to Dick Bell's Annals paper), this seems more realistic. There are other evaluations included in the portfolio as well. Compliance for trainers and trainees is fed back using a “Smiley” face system – according to Thaler and Sunstein in their book Nudge about helping people do the right thing like fill out feedback assessment on students, there is evidence that this smiley face system works well. There is also more money available for resident skills training, and a country-wide schedule is set up each year with the available courses (eg ATLS, basic laparoscopic skills, advanced laparoscopy at Covidien for example), and residents are required to attend as appropriate for their level. There is also a yearly resident review course attended by all Dutch residents. This is all supported by the government, who contributes ~150000 Euro per resident. The hospital (or University?) then pays the residents salary from this ~60000 Euro, and keeps the rest except for 4500 Euro per resident that is used for academic activities. For example, each resident attends a conference every year through this fund.
I then went to the operating room with Dr WJ Meijerink who performed two single port cholecystectomies. We first saw the first patient in the day surgery admitting area. All the operating rooms are brand new after a fire 2 years ago. He used the single port from Olympus and the curved instruments from Storz for the first time. He had done about 20 lap choles with single port and was doing these prior to beginning colon surgery. There was no resident scrubbed, his assistant was the referring surgeon, a trauma surgeon. Dr Meijerink demonstrated his technique using a straight needle in the RUQ after some mobilization of adhesions to the fundus. He was able to achieve proper exposure, but it was clearly more difficult that a multi port lap chole. The next case was easier as the gallbladder had no inflammation. The flexible tip Olympus camera was used, which did help somewhat with the exposure. I was impressed with the incision as the new port was placed through a 1.5 cm incision through the umbilicus and this looked excellent at the end. I then observed Dr Bonjer and one of his colleagues, a vascular surgeon, perform a laparoscopic right adrenalectomy for pheochromocytoma. The case went routinely except the patient was very hypertensive, requiring that the pneumoperitoneum be released several times. Dr Bonjer attributes this to the lack of phenoxybenzamine in Holland. His port position was somewhat different than I use, and he had excellent exposure by adding a 5th port for additional traction.
That afternoon I gave a talk to the department on “Challenges in laparoscopic incisional hernia repair” There was a lot of discussion about indications for repair, mesh choices, component separation. One of the 3rd year residents was designing a large trial of lap vs open incisional hernia. I rounded with Dr Bonjer and the pheo patient was doing well in the medium care unit. We discussed our experience with adrenalectomy in general, some difficulty we had with patients with metastatic disease to the adrenal and previous radiation.
Dinner was with Dr Meijerink and two residents. The residents are not happy with the work hour restrictions. They are also concerned that there is a lack of suitable positions once they graduate. One resident is involved in trying a new schedule to decrease the problem of lack of residents during the day time hours, and gave me a copy of this, as we are moving in the same direction in Quebec. She also said that the peripheral hospitals do not always fully comply, and the residents are there for 2 or 3 years with high operative volumes. I was told by the attendings though that audits occurred and the hospitals could be fined >100000 euros, but the feeling was that the peripheral hospitals were not audited as often. The residents felt that the rules were too restrictive, and that many residents come in on their off weeks to participate in interesting cases. But they also have more time to spend on their research activities.
Day 3:
I went to the OR after the morning report. I watched a 5th year resident take a 2nd year resident through a lap appe. Dr Bonjer has mandated that all operations be supervised, this is a change in culture. The case was straightforward, the senior resident was very patient and helpful, the skills of the 2nd year resident was similar to what I would see at home. I next observed Dr Miguel Cuesta perform a minimally invasive esophagectomy. The thoracic mobilization was done in the prone position which afforded excellent exposure without single lung ventilation. The patient was then turned for the laparoscopic portion. He does not do a pyloroplasty. An incision was made for the resection and creation of the conduit with 100cm GIAs. The anastamosis was done in the neck by the fellow. A feeding jejunostomy is also routine. Dr Cuesta has done about 40-50 cases in this way and was doing a RCT of MIS vs open esophagectomy which is at the mid way point. He also does colorectal surgery, including rectal cancer, which he said was a bit unusual, usually surgeons will focus on upper GI or colorectal.
I gave a talk entitled “Simulation for Training and Assessment in Laparoscopic Surgery”. There was a good discussion about FLS, and interest in including FLS in the Netherlands. This was followed by dinner with Dr Bonjer, Dr Cuesta, the GI surgery fellow and Donald van der Peet, another GI surgeon who I had met at SAGES and was the new program director. Donald and I discussed paraesophageal hernia repair, the use of mesh for repair, and the relative lack of evidence in this area- of course, he is designing a trial!
We also discussed the 46 hour work week. One significant issue is the lack of access to being around in the day when having to work evening and night shifts. Of note, the only time I saw residents involved in any cases during my visit was the appe. The fellow was there for the esophagectomy also. There are not enough senior residents around during the day shift to take full advantage of the cases. Two staff often scrub on more complex cases, that was a routine I observed for the adrenal, a hepatectomy today, and was supposed to be the case for the esophagectomy.
Part B – Australia and New Zealand (July 30-Aug 18 2010)
University of Adelaide (Host: Professor Guy Maddern)
We were graciously hosted by Professor Guy Maddern and stayed in his beach house. Prof Maddern is a previous James IV traveler who I met at the Baliol colloquia in Oxford in 2008 and 2009.
Day 1:
Prof Maddern picked me up at 6:45 and we headed over to the Queen Elizabeth Hospital. We began with ward rounds attended by all the consultant surgeons, fellows, residents and students on the upper GI surgery service. The group handles mainly upper GI and general surgery, including liver and pancreas surgery, esophageal and stomach surgery, but also staff an out-patient clinic where they see patients referred for all kinds of problems, including vasectomies. We visited all the in-patients and rounded at the bedside. A student would present the case and some discussion ensued with the group or the patient. We discussed the management of idiopathic pancreatitis, acalculous cholecystitis and the role of percutaneous cholecystostomy, the need for prophylactic antibiotics for patients post splenectomy, the use of aspirin for a patient with postsplenectomy thrombocytosis, management of multiple common bile duct stones. We then proceeded to multidisciplinary rounds attended also by two radiologists, a gastroenterologist and an oncologist. Cases were reviewed and discussed with the group. These included mostly cases for liver resection, some gastric cancer cases, and a case of abdominal pain and inflammation nyd. I then went to the outpatient clinic with one of the upper GI surgeons who does mainly esophagus and gastric surgery, as well as general surgery. Day surgery cases that are seen in the clinic are then distributed among any of the staff – this includes vasectomy, hernia, etc.. The Royal College has educational brochures created for common procedures that are given to the patients – I got some copies, very well done- similar to what we are developing at the MGH as educational material for the fast track care pathways, but theirs are country wide and standardized.
I then met with the graduate students doing research with Prof Maddern. A PhD student, 6 months into his research, was beginning a project on portosystemic shunts and liver metastasis. Another surgical trainee was doing a masters on prevention of adhesions, another was doing masters on addition of electrolysis to RFA for liver lesions, and a PhD scientist who works in the department explained his work. We had an interesting discussion about a rodent model of Barretts and the role of bile reflux in promotion of adenocarcinoma. I learned about the training program, which begins with a 1-2 year internship after 6 years of medical school. Many do advanced degrees to improve their admission chances. Then 5 years of general surgery followed by 2 years of fellowship in either upper GI, colorectal, breast/endocrine (they do the adrenals too but not pancreas). Within upper GI, people tend to do either HPB or esophagus/stomach. Everyone still does general surgery too, although this seems to be changing (eg not all breast surgeons do gallbladders).
I gave a talk on simulation for skills training in laparoscopic surgery. Prof Maddern is involved in a countrywide, multimillion dollar project researching and implementing simulation, including a van that goes around with simulators to the various programs. We discussed who pays for simulation, including FLS, study design, distributed vs massed practice, proficiency goals and how high they should be. The talk was attended by a group of educators and researchers working on a variety of projects in skills training for the past 3 years. Many similar interests and challenges were discussed.
I attended a teleconference to a rural community (Mount Gambier)- this is multidisciplinary and attended by oncologists, nurses and surgeons at the 2 sites. Several patients who were operated in Adelaide but live remotely were discussed.
I was picked up by my family and we later brought the children to Prof Maddern's beautiful house in Adelaide, where we met some of his children. His daughter Georgina baby-sat while we went to dinner with the UGI unit consultant surgeons, researchers and their spouses. Among other topics, we discussed many aspects of surgical training (assessment, dealing with the struggling trainee, curricula, work hour restrictions).
Day 2:
I was picked up and taken to the Royal Adelaide Hospital where I met Prof P Devitt and Dr Sarah Thompson of the upper GI unit. Dr Jamieson is away working for a week in a remote community. The surgeons all staff one week at a time in several remote communities where they do cases and pick up referrals for more complex cases that are done in Adelaide.
We went to ward rounds attended by all students, interns, residents and fellows on the service at conducted at the bedside. Dr Thompson is Canadian, trained in Calgary and then with John Hunter, who then came here a few years ago to do further training in foregut surgery, particularly for malignant disease. She is now a consultant and finishing her PhD. The ward cases were mainly general surgery (eg, pancreas, biliary, jaundice). We discussed management of recurrent dysphagia after heller myotomy, use of mesh for paraesophageal hernia repair (they are involved in a multicenter RCT with 3 arms- control, surgisis and timesh), and the role of partial wraps for reflux disease. I asked about why they have continued to have such a high volume of antireflux surgery when our volumes have plummeted, and this is because the gastroenterologists still refer patients early on. I also discussed adrenalectomy with Dr Thompson, in Australia it is the breast/endocrine surgeons who do these in many places, but Dr Thompson learned adrenals in her fellowship and has continued to do them at the RAH.
I learned more about the health care system from Prof Devitt, it includes public and private hospitals. Surgeons can work in either or both. Academic hospitals are in the public system but private patients can be cared for in the public hospitals also. Surgeons have about ½ day per week in the public system, and Prof Devitt also operates 1 day/week in a private hospital. Complex cases like esophagectomy can be done in private hospitals. In the private system, one concern is that students and trainees are not integrated there, even fellows may not be encouraged to participate in cases depending on the hospital, and lots of cases are “wasted” from the training point of view. In the private hospitals, an advantage is that there is more incentive to do more cases though. The patient can essentially decide where to have something done – faster in the private system, but “free” in the public and not seen as worse quality. Now even some research trained surgeons end up in the private system, which is a concern. The discussion highlighted for me some of the difficulties in the system and what we may expect as perhaps more privatization comes in Canada.
I then met with the researchers in the department. This is a world-famous unit studying esophageal disease, benign and malignant. There are 2 PhD scientists in the department interested in Barretts, studying DNA methylation as a potential marker for mucosa at risk for transformation to adenocarcinoma, and the role of antireflux surgery in changing DNA methylation. The ultimate goal of course is to be able to predict patients at risk for malignancy. They were very interested in the Barrett's database being set up at McGill. I met with a medical student doing a project using the huge database (>2000) of antireflux procedures, follow-up is as long as 18 years. Her main question is whether long-term dysphagia is related to whether a complete or partial wrap was done on the context of the preop manometry findings. We discussed some of the potential confounders. I met with a nutritionist leading a randomized trial looking at the role of immune modulating nutritional formula for esophagectomy. We have similar interest in using this formula in the context of the new prehabilitation trial for colorectal surgery. I also met with Sarah Thompson to discuss her research focused on sentinal node mapping in esophageal cancer.
We then attended combined gastroenterology-surgery rounds at noon. A radiologist was also present and many cases were discussed. These ranged from a case of obstructive jaundice, to abdominal pain nyd, to rectocele to esophageal motility disorder. This was a good opportunity to hear from both the GI and surgery perspectives. A case was then presented of severe c difficile colitis. They have very little experience with severe c difficile, and were very interested in the Quebec perspective, having presented the data from the Quebec outbreak in the mid 2000's.
I gave a talk to the unit about pheochromocytoma. There was lots of discussion and debate about approaches to alpha blockade and whether management is changed for tumours secreting adrenaline vs noradrenaline. We also reviewed approaches to incidentaloma and contraindications for laparoscopic adrenalectomy.
Hillel and I went out to dinner with the UGI group and their spouses at The Sauce- very good “Mod Oz” food, including fantastic local oysters and Riesling. We heard their perspectives on Australian politics (there is an election campaign going on), travel, Australian wine, food and Australian Rules Football.
University of Auckland, NZ (Host: Professor John Windsor)
Day 1:
I was met at Auckland City Hospital by Lois Blackwell, Professor Windsor's assistant, who was very helpful in arranging the trip. The hospital is quite new, attached to the older hospital. It is bright and well designed. The medical school is in the hospital. I met with six surgical research fellows in the Department of Surgery. There was a mixture of clinical and basic science research and the projects were discussed. An issue in a trial of the impact of warm humidified insufflation gas on pain and recovery after appendectomy in children led to an interesting discussion about measuring recovery, one of my primary research interests, and the difficulties particularly in the pediatric population. The basic science projects involved hepatic steatosis in liver transplant, and severe pancreatitis, a major interest of Prof Windsor's. Another project was in colon cancer and the use of molecular markers for screening and prognosis. I had a lengthy discussion with a fellow whose research was in enhanced recovery after colon surgery, another interest of mine. He was performing a trial of esophageal doppler vs fluid restriction for intraoperative fluid management in the context of a fast track surgery program under Prof Hill's guidance. Prof Hill has an international reputation in this area and in the measurement of fatigue, so we had a lot of common interests to discuss. This was a bright, engaged and committed group of trainees and the discussion was lively.
Following this, I met with Mattias Soop and Anthony Phillips, as well as other members of their surgical metabolism group. Anthony Phillips is a PhD scientist in the department with a long track record in surgical research. Dr Soop is a new recruit, in his second year of colorectal practice after training in Sweden, the UK and Mayo Clinic. I was acquainted with his work as part of the ERAS (Enhanced Recovery after Surgery) group in Europe. The main topic for discussion was the prehabilitation trial we just published in BJS. I presented the trial and a good discussion ensued about prehabilitation, measurement of recovery, and the importance of mobilization post op as part of fast track surgery. There is a good opportunity for collaboration in that project. We discussed possible outcomes of the project, including grip strength, walking tests, fatigue, and others.
I then met Prof Windsor and he took me to the Mercy Ascot hospital to tour the Advanced Clinical Skills Center. Prof Windsor established this skills center several years ago and has a strong interest in surgical education. I toured the center then gave two talks: Laparoscopic Splenectomy for Splenomegaly and Debates in Paraesophageal Hernia Repair, attended by surgeons from both the university and private sectors, trainees and fellows. The session was interactive and there were good discussions about surgical techniques, such as mesh hiatoplasty. I presented our study on portal-splenic vein thrombosis after splenectomy.
I had dinner with Prof Windsor and other members of the group. I learned about the health care system in New Zealand, the tensions between the public and private sectors, and they were very interested in how the Canadian system worked. I continued my discussion with Mattias Soop about where we are in establishing care pathways at McGill and his experiences in establishing the program at his hospital. There were wide ranging discussions with the group about topics such as transplantation, the introduction of laparoscopic donor nephrectomy, and mentoring surgical trainees. It was clear that they have a well functioning, productive and collegial group with a high quality research culture.
Day 2:
I observed Prof Windsor, his fellow and a medical student perform a subtotal gastrectomy and D2 lymphadenectomy for an obstructing pyloric cancer. Prof Windsor's clinical practice includes upper GI and pancreas primarily. The case went very smoothly. Prof Windsor uses mostly hand-sewn anastomoses, and reconstruction with a roux-en-y, and we had the chance to discuss some of these issues. He pointed out the importance of stripping the peritoneum in the lesser sac, and some of the tricks to do this. I had the chance to hear about their work hour restrictions which are 70 hours/week and 16 hour maximum shift- this is dealt with by doing a week of nights per month. The next case was a laparoscopic bilateral inguinal hernia; this was done by the fellow.
Prof Windsor and I also had the chance to further discuss issues around surgical simulation. He described his concerns with simulation for procedural learning, although sees the role for basic skills training. He has committed a lot of energy to a multimedia curriculum including 3D anatomy for procedural training, including metrics. There is also an interest in the potential for virtual worlds for training (like second life), which I also heard about at Imperial College.
Conclusions
The James IV Fellowship was a fantastic opportunity to reach farther afield and devote time to discussion and learning from other groups in five other countries. I was inspired by new concepts I encountered to deal with our common problems in surgical training, innovation, quality improvement, and enhanced recovery. These included ideas such as virtual worlds, robotics, and choice architecture. I gained a deeper understanding of technologies on the horizon for GI surgery (robotics and transluminal surgery, and the critical difference between adapting an open procedure to be done endoscopically versus creating a whole new procedure). I learned from programs that have worked with shift-hour limitations for decades, their challenges and solutions. I learned about how successful academic programs create a culture for surgical research. I strengthened collaborations with renowned upper GI surgeons in Europe, Australia and New Zealand. Last, but certainly not least, I greatly enjoyed the opportunity to travel with my family in Australia, creating lasting memories.
I would like to again express my gratitude to the James IV Association for the great honour of representing the society and their faith that I could do so. I very much appreciated the time and effort of my hosts and their colleagues who shared their knowledge, enthusiasm and time freely. Their assistants as well were invaluable in planning the trip and making local arrangements. I am grateful to my colleagues at the Montreal General Hospital and feel so lucky to be in a working environment that supports and encourages our individual growth. Finally, my husband Hillel and our children Zachary, Ariel and Jonah deserve my thanks as always for participating in my adventure every day.