Surgicalthe royaL A ustralasian News College of Surgeons May 2013

Vol: 12 No:10 The Golden Nov/Dec Scalpel games 2011 - a test of surgical skill

Value of the Audit Improving patient outcomes

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10 Alcohol-fuelled violence Why we need to talk about it 16 Global Burden of Surgical Disease How surgeons can advance the agenda 18 A test of skill Medics compete in surgical battle of skills 22 Medico-Legal The ongoing saga of Jayant Patel 12 6 Relationships & Advocacy 22 Your Practice Card 8 Surgical Snips A new web facility for 14 Poison’d Chalice members 17 Dr BB G-loved 28 PD Workshops 25 International 33 Case Note Review Development 37 Curmudgeon’s Corner Continuing a vision in the 46 Book Club Pacific 26 Successful Scholar Ajay Iyengar’s research UpToDate® with heart To learn more or to 32 Morbidity Audit and Logbook Tool subscribe risk-free, visit This key tool continues learn.uptodate.com/UTD improvement for Fellows Or call +1-781-392-2000. Patients don’t just expect you to have all the right answers. 18 34 They expect you to have them right now. Fortunately, there’s

SurgicalTHE ROYAL AUSTRALASIAN News COLLEGE OF SURGEONS MAY 2013

Vol: 12 No:10 UpToDate, the only reliable clinical resource that anticipates your The Golden Nov/Dec Correspondence to Surgical News should be sent to: Scalpel games 2011 - a test of surgical skill questions, then helps you find accurate answers quickly – often in [email protected] Letters to the Editor should be sent to: [email protected] the time it takes to go from one patient to another. Over 700,000 Or The Editor, Surgical News, Royal Australasian College of Surgeons, clinicians worldwide rely on UpToDate for FAST clinical answers College of Surgeons Gardens. 250-290 Spring Street, East Melbourne, Victoria 3002 T: +61 3 9249 1200 F: +61 9249 1219 W: www.surgeons.org Value of the Audit they trust. Shouldn’t you? Join your colleagues and subscribe to ISSN1443-9603 (Print) ISSN 1443-9565 (Online) Improving patient outcomes

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RACS_Print_Ad.indd 1 4/4/13 8:31 AM RESULTS OF 2013 ELECTIONS TO COUNCIL

their approach is a different level of interaction, a The results of the 2013 elections to Council President’s different level of sophisticated advocacy that our Perspective were tabled at the Annual General Meeting College is now putting its mind to. in Auckland on 9 May 2012. What is our record to date, and where do we go to from here? Congratulations to all successful candidates I remain incredibly proud of the contribution and sincere thanks to all candidates who that our College has made to emerging countries nominated. like the Pacific Island Nations, Papua New Guinea, The pro bono contribution of Fellows has Timor Leste, and Myanmar. Between 1995 and been, and continues to be the College’s 2012, the Pacific Island Program delivered more most valuable asset and resource. We are than 60,000 consultations, and 16,000 operations Global burden of surgical disease grateful for their commitment. were performed. More importantly we have built s an active clinician, I can conceptualise the needs of the capacity in the local health systems as we have next patient, deliver a surgical service within a hospital undertaken these activities. In short, we have tried Fellowship Elected Aand I have a good understanding of surgical service to leave a lasting footprint. Councillors requirements nationally. I have introduced trauma courses to All enormously good work. It gives us credibility There were ten Fellowship Elected SE Asia and the Pacific and have, I think, a good understanding and a platform of solid contribution to take Councillor positions to be filled. of differing needs in different countries. However, when it our advocacy to the higher levels of bringing comes to the issue of the global burden of surgical disease, it the surgical burden of disease more fully to Re-elected to Council are is an entirely different level of interaction. College Fellows as the attention of groups like the World Health practising surgeons should at least try to understand the issue Organization. This in itself is challenging; trying John Charles Batten, Orthopaedic, TAS and to do so will need to think ‘outside’ their usual focus of to interest national governments in what they may Ian Craig Bennett, General, QLD providing high quality care to the next patient. perceive as a self serving agenda is tough. This is Graeme John Campbell, General, VIC A few figures that were highlighted at our recent not a short term initiative. It is a most important Catherine Mary Ferguson, Otolaryngology, symposium: of 7 billion people on the planet, piece of work which our College needs to progress Head & Neck, NZ 2 billion do not have access to surgical care. There are over the years ahead. Barry Stephen O’Loughlin, General, QLD 1.2 million deaths a year from road traffic accidents – the We have already made some headway. We Julian Anderson Smith, Cardiothoracic, VIC population of Adelaide; 50 million are injured – twice the have hosted two recent meetings on the Global Marianne Vonau, Neurosurgery, QLD population of Australia and New Zealand. There are Burden of Surgical Disease. These meetings have David Allan Watters, General, VIC 2,000 childhood deaths a DAY from road accidents. There had representatives from across the globe and are enormous numbers of congenital anomalies with across medical specialities. Working together Simon Alan Williams, Orthopaedic, VIC 200,000 children having club feet that would warrant we have prepared a draft poster on the care of surgical correction. contaminated wounds at the request of surgeons Newly elected to Council is While Australia and New Zealand focus discussions on What has now been demonstrated is that in public health in Indonesia. formerly co-opted Councillor the rights of home births and the professional profile of terms, the best value for money spent within the surgical At a recent meeting held in the College chaired Sean Guy Hamilton, Plastic and midwives and obstetricians, around the world there are arena is from the following four areas: by David Watters and Russell Gruen, we decided Reconstructive, WA 1,600 obstetric deaths per day. In South Sudan, the world’s 1. Timely, good quality surgical management of trauma to progress a simple statement: “Access to Safe newest nation, every third woman delivering a child dies. For 2. Abdominal and other surgical emergencies Surgery and Anaesthesia when needed” every woman who dies in childbirth, there are 20 times that 3. Comprehensive emergency obstetric and neonatal care (an article detailing this event can be found on Specialty Elected number who have complications. As an example, there are 4. Elective conditions that have a distinct impact on the page 12). and New Zealand College Councillors about 2 million cases of obstetric fistulae each year. quality of life, such as cataracts, talipes, hernias. of Anaesthetists has indicated it is keen to work Re-elected to Council is So the numbers are enormous. And where does surgical with us to progress this aim. Michael John Grigg, Vascular Surgery, Victoria care actually occur? It is no surprise that the wealthiest The challenge for this College and for surgery around We have consensus that WHO’s metrics to assess 30 per cent of the world’s population receives 74 per cent the world, is to ensure the profile for the surgical burden peri-operative mortality should be collected to Newly elected to Council is of the surgical procedures. The poorest one third receives of disease is properly understood. We may understand it, provide data on need and we should use that data Roger Stewart Paterson, Orthopaedic Surgery, only 3.5 per cent of the surgical procedures. Some countries and our surgical colleagues internationally also do, but to to advocate strongly with Australia’s representative have multiple millions within their population who would achieve action over time with the capacity for sustainable on WHO to progress this issue. There is a lot more South Australia benefit from surgical care. The Global Burden of Disease is impact, means that we must convince groups like the World I could say about progressing advocacy in this measured in terms of disability adjusted life years (DALYs) Health Organization that this is of vital importance. WHO area, as it is more sophisticated and complex than Thank you to the scrutineers David Scott and and this shows that approximately 15 per cent of the total has 193 member states and with their substantial ‘reach’ can some of the work we have done thus far. Andrew Roberts. health requirement in the Western Pacific and 12 per cent in ensure that change does occur through government and Mike Hollands South East Asia relates to surgical conditions. their appropriate departments of health. However, impacting President

Page 4 / Surgical News May 2013 Surgical News May 2013 / Page 5 Relationships & Advocacy of 2011 business excellenceWinner award

information gathered from existing sources, principally the National Minimum Dataset (NMDS) and As a surgical profession Value of the audit National Mortality Collection (NMC), I think we should be administered by the Ministry of Health. “ justifiably proud … that we What can we learn from New Zealand’s The POMRC’s stated aim is to are prepared to analyse test the robustness of this “whole of Perioperative Mortality Review system? what we do Cover system” view, using existing data, before Story planning new data collection systems as ” a foundation for peer review of selected cases. It is felt that “whole of system” suggests closer review of the role of acute analysis is feasible with New Zealand’s cholecystectomy may be warranted, given the Rooms With Style offers 3 core services higher mortality rate. population of 4.4 million. exclusively for Surgeons One limitation is that not all private Overall, pulmonary embolus death rates hospitals submit data to the NMDS; all are low (0.019 per cent of all procedures, > Medical Fitouts public hospitals do and public funded 0.05 per cent of acute admissions, and > Practice Management Consulting procedures in private hospitals are also 0.008 per cent for elective admissions). As captured. The audit covers all deaths expected, mortality rises with increasing > Recruitment within 30 days of procedures (including ASA status, increasing age, acute procedures (especially femoral and hip fractures) and cardiology and gastroenterology interventions) and anaesthesia (general lower limb surgery in general. Focusing on Call today and regional), not just deaths under the thromboprophylaxis may reduce deaths due to find out how we can care of surgeons. to this postoperative complication. tailor our services to suit Patients with an ASA score of 1 or 2 have a As is evident from this description, your practice. POMRC reports differ significantly low rate of mortality after elective procedures from the Australia and New Zealand (30 day mortality 0.07 per cent), but this rate Audit of Surgical Mortality (ANZASM) rises with increasing age after the age of 50 that is supported by the College. years – 0.6 per cent mortality in the 80 – 84 1300 073 239 Indeed, no New Zealand Fellow can year old age group and 1.4 per cent if greater [email protected] than 90 years of age. Even fit, elderly patients tick the “participation in ANZASM” www.roomswithstyle.com.au box on their CPD returns – ANZASM undergoing minor procedures may face remains a goal for the future. Just as significant mortality risk. the ANZASM gained strength with the Emergency procedures also carry a addition of each State and Territory, significantly greater risk, possibly magnified adding comparable data from New by age. Acute procedures in octogenarians are Medical Consultation Rooms for Rent Zealand would add further strength associated with a mortality rate of 9 per cent; Consulting Rooms, Sessions elective procedures have a mortality rate of 1.2 when this becomes possible. Located in Darlinghurst moments from the St Vincent’s Hospital Every year, 4,000 to 5,000 patients die per cent. campus, the Garvan Research Institute and directly opposite the Victor after procedures in New Zealand. In It is clear that while the New Zealand Chang Cardiac Centre on Liverpool Street are modern and beautifully many cases, the procedure was only one POMRC is not yet linked to the ANZASM, appointed consulting rooms. Rooms are competitively priced - includes reception service whilst car parking space is available. part of a complex episode of care, often it can still provide valuable insights into involving elderly patients. However, deaths linked to procedures in an Australasian Contact Toni on 0433 019 524 or email [email protected] with any audit the challenge is to resist system. The full report (and last year’s report) rationalisation and attempt to uncover is available on the NZ Health Quality and valuable lessons. There are always going Safety Commission website at http://www. urgeons have been at the forefront what we do and proud that we are willing to be instances when care could have hqsc.govt.nz/our-programmes/mrc/pomrc/ of championing the value of clinical to learn from what we do in order to been better. publications-and-resources/publication/813/ For Lease Saudit. It is a line that I have been improve. Virtually every surgical specialty A brief look at the cholestectomy data using, and re-using, for many years to has identified audit as a key professional shows an overall mortality rate of 0.4 AMA HOUSE, ST LEONARDS, SYDNEY audiences that have included health activity and a “raison d’etre”. per cent; 1.0 per cent in acute cases, 0.16 3 x Specialist consulting rooms available ministers, hospital administrators, I was therefore interested that the per cent following elective procedures. Modern spacious medical suites with a large patient waiting room journalists and others. New Zealand Perioperative Mortality These rates are similar to those found Ample parking adjacent to rooms As a surgical profession I think we Review Committee (POMRC) released in published North American series. Contact (02) 9438 2271 or 0411 430 509 (ah) should be justifiably proud of what we its second report in late March covering Death was infrequent in ASA1-2 Michael Grigg do, proud that we are prepared to analyse the period 2006-2010. The report uses cases, regardless of acuity. POMRC Vice President

Page 6 / Surgical News May 2013 Surgical News May 2013 / Page 7 Surgical Snips Surgical Snips

Life changing surgery A young woman has had life-changing surgery to insert electrodes in her brain to control the impulses that are a result of Tourette’s syndrome. Fellow Terry Coyne was part of the team with neurologist Peter Silburn to undertake the procedure that will stimulate areas of the brain. The patient, Chloe Mann said: “I’m hoping this will give me some sort of normality in life so I can go out more places and not feel anxious or judged.” SA Medical School concern Courier Mail, April 6. Senior University of Adelaide figures have expressed concern at the lack of direction from State Government regarding the Royal Adelaide Surgery risky for ailing elderly Hospital Medical School. While the New Zealand’s Perioperative Mortality Review Committee’s government have decided to build second report has found that one in five unwell elderly die a new hospital, there has been undergoing surgery, though Kiwis who are fit and healthy are no indication of the shifting of the least likely to have complications. state’s lead medical school. The Time heals However, Chair of the New Zealand National Board of the College released a statement saying Eighteen years after surgery as a four-year-old, Perth woman Jasmine College Scott Stevenson has said that the findings are an it was “dismayed over the ongoing Teakle is thankful to then up and coming surgeon Fiona Wood (pictured) important reminder of the risks of surgery. uncertainty around the future of the for believing she could reduce the birthmark which covered the right side He also said the report is reassurance that the health system state’s hospital services”, along with of her face. Dr Wood advised that Jasmine have injections and skin grafts undergoes processes for continual improvements. holding “grave reservations” the new made from skin taken from her hip and grown in a lab. The scars are now “The data suggests that care in our health system is as good as hospital would deliver all the current barely visible. “Without the surgery and skin graft [the birthmark] would have any first-world health system,” Mr Stevenson said. services needed. affected me so much more,” Ms Teakle said. Stuff.co.nz, March 29. Adelaide Advertiser, March 20. Weekend West, March 30.

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Page 8 / Surgical News May 2013 Surgical News May 2013 / Page 9 Relationships and Advocacy

to Australia of alcohol misuse at $14.3 including mortality rates, crime and alcohol would likely be met with a fierce, billion with total costs, including indirect traffic accidents. professional and well-funded campaign costs, at $36 billion each year. “However, there has not yet been the by the increasingly well organised liquor “That is a horrifying number when you political will to introduce this change industry. consider that a massive national project even though it was a recommendation of He also said it was crucial for any like the NBN roll-out is expected to cost the Henry Tax Review.” surgeon entering the debate to know who $37 billion or that the National Disability Professor Carson is also calling for was funding research and interest groups. Insurance Scheme will begin at $16 the College to ratify partnerships with “The liquor industry is very rich and billion per annum. the National Alliance for Action on very powerful and increasingly organised “In New Zealand the problem is similar. Alcohol and other reputable independent around the world and is actively seeking Half of serious crimes and a third of groups and to lobby national and state to increase consumption very much like police apprehensions involve the misuse governments as part of regular meetings Big Tobacco,” he said. of alcohol with estimated costs including with government representatives in “It has its tentacles in many groups and health care and child interventions at $16 support of the initiatives. a lot of research has been contaminated billion.” by industry backing which can only ever Now Professor Carson has put a Evidence-based advocacy represent a conflict of interest so surgeons proposal forward. The proposal to go before the College need to look very closely at where any Council will also call for the College to research has come from before offering In particular, he is asking the support the collection of data pertaining any support or endorsement.” College to support: to concomitant consumption of alcohol • The application in Australia and in patients presenting with injury as Important position New Zealand of a stepped a mandated data field requirement on the frontline volumetric tax on alcohol; in Trauma Service Verification and Professor Carson said surgeons were Emergency Department interventions. also in a position of offering personal • State and Territory efforts aimed at “As surgeons we are dramatically interventions at the time of hospital reducing the availability of alcohol confronted with the effects of alcohol treatment, particularly to young patients through the reduction of outlet misuse when we attend patients with injured through binge drinking. density and trading hours; and injuries resulting from road traffic trauma, “Studies have shown that people are • The reduction of the overall interpersonal violence and personal at their most open to changing their volume of alcohol advertising accidents along with the more direct behaviours such as smoking when they and promotions through effects such as liver failure, GI bleeding, first come to hospital to be treated for the independent regulation, upper GI and oropharyngeal cancer consequences and there is no reason to limitations on times and and infections related to malnutrition,” believe the same wouldn’t be true of binge placement of promotions or Professor Carson said. drinking,” he said. Alcohol-fuelled violence the requirement for health “The proportion of our patients “Surgeons have a certain authority and An important issue for our advocacy agenda advertising counter measures. so affected will vary with specialty if we take the time to stress the dangers and location, but overall contribute a of alcohol misuse to our patients before Professor Carson said that studies now significant proportion of the surgical discharge, we might save a life.” ollege Councillor and NT Council, building on the work of the situation and that’s how we feel in a showed that each week, on average, 60 workload putting us in a position which Professor Carson stressed that he and General Surgeon Associate College’s Trauma Committee, to lobby controlled environment. Australians die and a further 1,500 were I believe requires us, as a profession, to the Trauma Committee were not pursuing CProfessor Phillip Carson for a change in public attitudes towards “Yet the police, ambulance personnel hospitalised as a direct result of excessive fight for change. abstinence, but a policy of moderation described walking into the Intensive Care drinking through a campaign similar to and accident and emergency staff have alcohol consumption, consumption levels “There is a substantial body of work and harm minimisation. Unit (ICU) at the Royal Darwin Hospital the ground-breaking work conducted by it even worse when trying to deal with that could be reduced through taxation. emanating from public health researchers “All of these changes will require on a Monday morning as akin to walking the College to reduce road deaths and people who are screaming and fighting “Taxation of alcohol should be based which provides evidence for cost effective government action which may cause into a war zone. injury in the 1970s. and bleeding and vomiting, most of on the principle that alcohol is no interventions to minimise harmful political pain so we need strong and There are the young men comatose “I think in Australia and New Zealand whom will have very little memory of ordinary commodity, but a product that drinking and the RACS can enhance the conviction-led leadership to bring in ICU with head injuries, there are the we have a blind spot when it comes to their behaviour when sober. is responsible for major harms in our advocacy strength of this broad coalition community opinion with us,” he said. women suffering severe facial wounds drinking alcohol because it is such a “As a society it seems we have become community,” he said. by supporting and confirming evidence- “I believe the College is in a perfect and there are the road trauma and central part of our society and socialising, desensitised to the harm caused by “International scientific evidence based policies and by providing dramatic position to help lead this social change accident victims; broken bones, broken but the situation has now become alcohol abuse even while that harm consistently shows that alcohol and arresting examples of the health both within general society and the hearts and ruined lives, patients and completely out of control,” Professor continues to escalate leading to bashings, consumption and harm are influenced effects of alcohol misuse as part of the political community because surgeons are families filling the wards and corridors Carson said. stabbings, domestic violence and by price which means that taxing alcohol public discourse.” now seeing the trauma and misery caused solely because of excessive alcohol “I feel angry some Monday mornings traumatised children. on the basis of alcohol content is one of Professor Carson said it was important by alcohol misuse almost every day – consumption. walking into the hospital and, like most “Various reputable reports have now the most effective policy interventions to for surgeons to understand that any particularly on Mondays.” Now he has taken a proposal to the of my colleagues, think this is a crazy conservatively estimated the direct costs reduce the level of alcohol-related harm push to limit the sale and availability of With Karen Murphy

Page 10 / Surgical News May 2013 Surgical News May 2013 / Page 11 International Development

Advancing the Agenda on the Global Burden of Surgical Disease – we need to measure the “Access to safe surgery and anaesthesia when needed” Perioperative Mortality Rate (POMR)

access to safe surgery and anaesthesia, It is agnostic of whether surgery and to follow patients up consistently after further significant reductions in maternal anaesthesia are delivered by specialists or discharge for 30 days. mortality will only be achieved by also not, but highlights the right of patients to Risk stratification is desirable to clini- addressing the up to 25 per cent of safe delivery of each. cally interpret perioperative mortality. pregnancies that require a procedure and/ The meeting agreed that perioperative Not every country would be able to col- or anaesthetic to avoid injury, deformity mortality rate (POMR) is an indicator of lect these and the burden of recording is or death of the mother and/or child. both safety and access. greater, but they are to be recommended Safe surgery and anaesthesia are Though it might be perceived as and will be required for clinicians (sur- not unaffordable luxuries only for primarily an indicator of safety, it is also geons, anaesthetists and public health rich countries. They should be seen a measure of access since the number of physicians) to be convinced. as a basic human right, and their lack procedures performed must be known The risk stratification data recommend- represents a significant cost in terms of to calculate it. Lack of access resulting in ed are simple to collect and do not require life and disability to the communities delayed presentations will lead to higher any laboratory tests to assess: age, urgency that cannot access them. An increasing mortality as well as fewer procedures. (elective or emergency), procedure and number of studies suggest that surgery Thus POMR reflects the system’s ASA status. ASA status was discussed and and anaesthesia can be delivered in Low responsiveness to primary and secondary considered to be simple, accepted for over and Middle-Income Countries (LMIC) care issues – its capacity to deliver. 50 years and quite applicable to LMICs as effectively and inexpensively, often at There was consensus that WHO’s well as to G20 nations. Anaesthesia provid- a similar cost ($11-35 per Disability- existing metrics on perioperative ers everywhere can be taught to use ASA. Adjusted Life Year [DALY] averted) mortality should be used. These are: A procedure should ideally be counted to measles vaccination, vitamin A Death on the day of a procedure (within as the first procedure that a patient supplementation or bed nets to prevent 24 hours/same day as procedure), receives during an episode of care. A malaria. The surgical management and; Death after commencement of a procedure should only count towards of injuries, infection, obstetric and procedure and before discharge from a death once, rather than twice or more abdominal emergencies and many hospital if less than 30 days. where a patient dies after an unplanned deformities is, therefore, cost-effective A procedure was defined as a procedure reoperation. Ideally it should only be the and potentially deliverable for all. performed within an operating facility first procedure that is counted. which requires the administration of sedation or anaesthesia whether local, Consensus Reached regional or general. Next steps The meeting also agreed that the Perioperative mortality rate requires The workshop then turned its one-liner “Access to safe surgery and the number of deaths and the number attention to the task ahead. This will meeting was held in the RACS Background active adults aged 15-44 years, an anaesthesia when needed” embodied of procedures to be counted. In practical be a sustained campaign of advocacy, Council room in March to reach The unmet burden of surgical disease age group that carries heavy family our message to the profession, to the terms most operating rooms count the persuading governments, ministries of A consensus on whether and how is substantial. Currently two billion responsibilities. There is also a pandemic public, to governments and ministries. number of procedures, at least with an health, hospitals and clinicians of the to measure perioperative mortality. The of the world’s population does not of non-communicable diseases affecting It was originally recommended by the operation registry. It will require some value of POMR as a tool to improve participants included Councillors of the have access to emergency and essential older patients, with cardiovascular and organising committee of the Global form of follow up of patient progress in patient outcomes and ensure the most Royal Australasian College of Surgeons surgical care. Each year this results cerebrovascular disease, diabetes and Burden of Surgical Disease Symposium the wards to identify which patients die appropriate allocation of resources. (RACS), Australian and New Zealand in an estimated 70,000 unnecessary cancer constituting the leading conditions, held at the RACS September 27-28 2012, before discharge. One of our immediate aims is to put College of Anaesthetists (ANZCA), and maternal deaths (25 per cent of 280,000 and increasing numbers likely to require under the auspices of RACS, ASA, The Although there are other measures the global burden of surgical disease and Australasian Society of Anaesthetists per annum), 175,000 excess deaths surgery at some stage as their condition Alliance for Surgery and Anaesthesia of mortality such as death within 48 the value of POMR firmly on the agenda (ASA) together with representation from from road traffic accidents (25 per cent progresses. Presence (ASAP), the Harvard hours of a procedure and anaesthetic, of the World Health Assembly. the World Federation of Anaesthetists of 750,000 per annum), and 35,000 Considerable improvements in Humanitarian Institute (HHI) and the death within 30 days, and death under Those in positions of authority across (WFSA), Tonga, the Cook Islands and avoidable anaesthetic deaths (1:500 in maternal mortality and other maternal International Surgical Society (ISS). the bedcard of a surgeon, these are the world must be repeatedly reminded of Physicians active in public health. 35 million operations). health outcomes have been achieved The one liner’s advantages are it avoids more difficult to collect and would be the fact that timely access to safe surgery The meeting recommended that all Trauma and non-communicable through better access to skilled birth being a slogan, is inclusive of surgery challenging to collect in many LMICs. and anaesthesia will save millions of lives countries report Perioperative Mortality diseases (NCDs) comprise the major attendants and attention to the fifth and anaesthesia, and covers the concepts These metrics should be regarded as and avert much disability. Rates for death on the day of surgery and causes of death globally. Accidents and Millenium Development Goal (MDG5). of essential and emergency surgery optional extras for countries with the David Watters death before discharge from hospital if injuries represent the leading cause of However, as suggested by the estimated with ‘when needed’, though this idea capacity and desire to collect, analyse Chair, Professional Development less than 30 days postoperative. death and disability in economically 70,000 deaths related to lack of maternal might sometimes require explanation. and report them. LMICs will not be able and Standards

Page 12 / Surgical News May 2013 Surgical News May 2013 / Page 13 Surgical Services ADVANCED ALLERGY PROTECTION & SENSITIVITY

Poison’d Chalice “True is it that we have seen better days”

bought a new car. This is a very a car that can learn from observing you. If a present on one’s birthday and then unusual experience for me. I tend to only I had Trainees like that! asking the giver if they could take it back Ibuy a car, usually second hand, and But maybe the problem was not with and exchange it for something else! then drive it until it begins to fall apart. their learning, but with my ability to I loved my old car – a Mercedes with teach. In the past I have been a popular New tricks many hundreds of thousands of miles lecturer and tutor – plenty of lists Perceived ingratitude does not lead to a on the clock, big comfortable seats, but interspersed with witticisms. The current cohesive environment, nor a productive with an unpleasant plume of greenhouse generation (what is the current generation working relationship. I continue to get gas emissions emanating from its rear. I – we have had “Y”, are we now up to flashbacks of awkward encounters that decided that I had better get it serviced – “Z”?) learn in a different way. It seems could be best described from ‘Taming of it had been about a decade after all. they must learn by experience, even if the Shrew’ (Induction, Scene 1), “I’ll not The mechanic was kind – “I can give the experience is artificial – role-playing budge an inch”. Maybe tact should have you $500 for it but not a cent more!” for example. No doubt this is the result been part of my position description. For “But I want to get it repaired” I said. of increasing intelligence colliding with a long time I thought “tact” was in some ® “No you don’t” he said. “It is going to educational deprivation through cost way dishonest involving a sacrifice or at ANSELL’S SENSOPRENE LATEX-FREE be at least $10,000 to get it roadworthy”, minimalisation strategies. Whatever, I am least a disguising of principle. I have come AND ACCELERATOR-FREE FORMULATION muttering words like carburettor, diff determined to make them think, not just to realise that tact is much more about etc. “and then I expect something else rely on checklists, electronic reminders appreciating other people’s positions and DELIVERS ADVANCED ALLERGY PROTECTION will go wrong.” Was he heartless or and so on. points of view. AND IS UP TO 30% THINNER THAN STANDARD just realistic? I began to realise that my But it is not just me that I need worry As I drive my new, learning-car home SURGICAL GLOVES FOR UNPRECEDENTED car had the equivalent of inoperable about. I have a whole department from the showroom I reflect on a couple cholangiocarcinoma with intractable of surgical teachers that participate of things. Firstly, will the car become SENSITIVITY AND COMFORT. jaundice. As the Bard did write: “True in undergraduate and postgraduate confused or even dysfunctional when my is it that we have seen better days” (‘As educational programs, mostly with no, wife insists on driving it? How does a car You Like It’, Act 2, Scene 4). It would be a or at best, minimal remuneration. One learn from two (very) different drivers? kindness to consider its misery. of the more difficult challenges for a Secondly, next week’s M + M meeting; For more information, or to request a sample My new car is somewhat sterile in surgical director is to get people, surgeons maybe the Trainees can explain how contact us on 1800 337 041 or visit comparison, but the salesman said it in particular, to do things differently, they can learn from two very different would “learn” as I drove it. It would get to especially when the thing that they are surgeons? Now, there is a thought… WWW.MEDICAL.ANSELL.COM.AU know my driving patterns. Imagine that – doing is basically a gift. It is like receiving Professor U.R. Kidding Ansell, ® and ™ are trademarks owned by Ansell Limited or one of its affiliates. © 2012 Ansell Limited. All rights reserved. Page 14 / Surgical News May 2013 Rural surgery Surgeon Health

more likely to be overweight, took less exercise and felt less confident about their health (5.3 V 5.8), but without a difference in Clinical Director for Rural Coach Project rates of smoking or drinking alcohol. Mar- riage did not affect tendency to burnout, Sally returned to Lismore as a but the results favoured no burnout for Consultant in 2008 and has been there for those having more than one child. the past five years. The support from all Let’s hope surgeons in Australia, her colleagues in all areas of medicine in New Zealand and the Pacific have more the area has been the best part of working enthusiasm, less cynicism and a greater in a rural area and one of the reasons she sense of achievement than their North decided to move to Lismore. The delightful American counterparts. Those of you surroundings and usually lovely weather Burnt out or burned up? who might want to use a standard were also a definite attraction. Sally has Look after yourself instrument to assess your degree of a great life outside of working including burnout might consider the Maslach hockey, mosaics, the theatre and the arts, Burnout Inventory General Survey or the and lots of fine dining. Burnout Clinical Subtype Questionnaire. I would urge any Trainees to contact But be careful what you look for – you Dr Sally Butchers on sallybutchers@ he other day C Nical consulted and a low sense of personal accomplishment might not like what you find. bigpond.com. She is keen to be of me. I didn’t know him that (inefficacy).1 The clinical subtypes of C Nical was given the same advice assistance to any Trainee considering Twell, in fact hadn’t seen him for burnout were classified as frenetic (involved, as I gave Down-N-Dumped last year. working in a rural environment and three years. I asked him how life was ambitious, overloaded), underchallenged First take a holiday, get away from work. will be attending the PSA conference in going – this set off a long tirade about (indifferent, bored, with lack of personal Next drop some commitments, certainly Queenstown NZ this year. his Surgical Directorate (not Prof U R development) and worn-out (neglectful, those that stretch your capacity to cope In 2012, General Surgeons of Australia Kidding), cuts to operating lists, nursing unacknowledged, with little control).3 – perhaps that list in the far off hospital (GSA) generously gave a Rural Surgery staff too often insisting the last case on The specialists were asked on a scale (unless that gets you away from it all). Grant to nine Trainees who applied a list was cancelled before 4.30pm just of 1-7 whether it was mild (1) or so Reduce your private patient load. Make to attend the Provincial Surgeons of because “we might run over”. bad that they were considering leaving time for regular exercise; don’t drink Australia Conference in Mt Gambier. The hospital wasn’t providing a good medicine (7). All specialties ended up with alcohol because you are stressed, certainly These Trainees were most grateful for the service, the waiting lists are blowing out Likert scores of between 3 and 4 – i.e. not more than 1-2 drinks per evening. financial assistance to cover the cost of and managers are clipboard carrying middling – and they already undergo re- But I also suggested being positive, not their conference registration and found unmentionables. So what’s new I thought? certification every five years! to dwell on the negative, on what’s wrong the opportunities for networking very Hasn’t it always been like this? But what did “severe” mean? Feedback with the system. Stop complaining, and A new face is on board worthwhile. The diagnosis was clear within a few identified too many bureaucratic tasks give up the whinging. That might be GSA has generously offered to sentences of his frustrated complaining. (5.4), too many hours working, financial difficult for C Nical, but when you are to move the Rural provide a Rural Surgery Grant C Nical was in burnout. He’d had enough issues (4.6), feeling like a cog in a wheel nice to people, they might even smile at Coach project forward again in 2013 for any Trainee to and needed a break. Burnout is common (4.2). Difficult colleagues, compassion you from behind their masks – and we all attend the Provincial Surgeons amongst doctors, and at least in the fatigue, or a difficult employer were wear masks to work, some of which are of Australia (PSA) conference US seems relatively common among the lowest rated (2-3). There was no best left where they are. Dr BB G-Loved ince 2011, the Rural Coach Project Sally is a to be held 25 – 27 July 2013, in surgeons. significant gender difference and it was (RCP) has identified and supported General Surgeon Queenstown NZ. Applications In the US they work longer hours, those aged 46-55 who were most at risk. 40 Trainees interested in a rural in Lismore for the Rural Surgery Registration carry more medical school educational When burnout surgeons were References S 1. Peckham C. General Surgeon Lifestyles surgical career. This may have been by NSW who has a Grant are available from the RCP debt, and have too few holidays (only compared with those not suffering - Linking to Burnout: Medscape Survey, way of ongoing mentoring, advocacy special interest Project Officer. 13 days a year) if comparison with the burnout they were less happy at work, March 28th 2013. http://www.medscape. and the opportunity to build their in Younger I would be most interested to rest of the world is anything to measure but only slightly less happy outside work, com/features/slideshow/lifestyle/2013/ rural connections by offering financial Fellows, Women hear of any Trainees who wish to by. Although surgeons aren’t the worst and not much difference with regards to general-surgery?nlid=29829_983&src=wnl_ assistance to Trainees who attend the in Surgery and be involved with the Rural Coach specialists affected – top of the medical popular favourite pastimes – spending edit_medp_surg&spon=14#1 Provincial Surgeons of Australia (PSA) Rural Surgery Project. The project does not offer burnout charts at over 60 per cent time with the family (84 per cent both 2. Shanafelt TD, Boone S, Tan L, et al. conference. and is keen to make links with the training courses, but rather offers support belongs to emergency medicine, which groups), exercise (67 and 70 per cent), Burnout and satisfaction with work-life balance among US physicians relative A/Prof Frank Miller, a General Surgeon Trainees. She has an interest in teaching, for Trainees interested in a rural surgical doesn’t surprise me, with urologists, travel (64 and 68 per cent) and reading to the general US population. Arch from Wangaratta, has been the Clinical is an EMST instructor and is starting to career. general and neurosurgeons hovering (60 per cent both groups). Intern Med. 2012;172:1377-1385. http:// Director of the Rural Coach Project since instruct on the MOSES courses. Any Trainee who is working in a rural around the 40-42 per cent mark while Golf, hunting and fishing fell in the 20 archinte.jamanetwork.com/article. 2011. He has thoroughly enjoyed the role Sally started her training at Prince area and would be interested in writing otolaryngologists and orthopaedic per cent range without much difference aspx?articleid=1351351 Accessed February getting to know the Trainees who have of Wales Hospital in Sydney. She was a short article on their experiences surgeons are 48 per cent.1 Anaesthetists between those burning and those not. 7, 2 013. sought his guidance. Due to his many seconded to Lismore as an Intern and as for publication, please contact Trish ranked in the high 40s also. Forty-four per cent of burned out 3. Montero-Marin J et al. Understanding extra roles within the College, he has a Registrar. She also worked in NSW at Meldrum, RCP Project Officer RACS Medscape recently reported a study of surgeons took less than two weeks leave a burnout according to individual differences: ongoing explanatory power evaluation of stepped aside as Clinical Director, Rural Coffs Harbour and Bega. Sally gained her [email protected] burnout in general surgeons.2 Burnout year compared with 27 per cent of those two models for measuring burnout types. Coach Project (RCP) to be replaced by Dr Fellowship in 2005 and then spent two Tom Bowles was defined as loss of enthusiasm for work without symptoms of burn out. BMC Public Health 2012;12:922 Sally Butchers. years working in the UK. Chair, Rural Surgery Section (exhaustion), feelings of cynicism (cynicism), Burned out general surgeons were slightly

Page 16 / Surgical News May 2013 Surgical News May 2013 / Page 17 Fellows in the News

station 3: anatomy station 3: imaging

A test of skill station 5: trauma station 2: suturing

Fellow Emily Granger thought it time to put some skills to the surgical test Surgeons and nurses assessed the work The five games stations were: conducted at each station, marked tasks, esigned to test the knowledge, On October 20 last year, surgeons, “A great deal of surgical education Station 1: Bowel Anastomosis at which each team member provided immediate feedback and sent skills and nerves of junior junior doctors, surgical Trainees, is carried out at separate sites and attempted a hand-sutured bowel anastomosis, being judged on scores to an electronic scoreboard which Ddoctors across New South Wales, nurses and HETI volunteers gave up a I thought it might be fun for them, selection of suturing material and suturing technique; showed cumulative totals throughout the the inaugural Golden Scalpel Games were Saturday to let the games begin, with and interesting for us, to bring them Station 2: Suturing Skills in which teams were offered five competition. held in October last year at St Vincent’s teams competing for the Golden Scalpel together and see what they could do,” suturing tasks including subcuticular suturing, excision of a Dr Granger said the competition had been Clinic in Sydney. Perpetual Trophy and a $2000 prize to go Dr Granger said. subcutaneous lesion, insertion and securing of a chest drain, designed to enhance teamwork, test skills in The brain-child of cardiothoracic toward surgical training equipment. “Even quite junior doctors have very end-to-end vascular anastomosis and a laparotomy closure; a less formal environment than required at heart-lung transplant surgeon Dr Each network was represented by good skill levels and are very capable Station 3: Laparoscopic Skills at which team members exams and provide informal tutoring as the Emily Granger, the contest involved a team of five surgical skills Trainees and we wanted to demonstrate that rotated through a range of tasks including the application of teams progressed through the stations. teams from each of the six surgical from interns to senior resident medical capacity and create a fun environment endoclips and endoloops, cutting technique, placing a suture in She said that such was the enthusiasm networks in NSW completing tasks at officers with each team rotating through in which they could test themselves. an artificial bowel and tying an intracorporeal knot; of participants, network teams arrived in five training stations under the watchful five 20-minute training stations each “At this stage of their surgical training Station 4: Anatomy and Imaging where teams worked team colours with mentors and supporters eyes of assessors. presenting a different challenge. they have had no formal assessment of together to answer anatomical questions relating to the eye, cheering on their endeavours. Dr Granger, who was the then Director Dr Granger, a conjoint lecturer at the their skills and many junior doctors larynx, tongue, heart, muscles of the foot and abdomen; “There was really strong enthusiasm for of the Eastern and Greater Southern University of NSW, said she envisioned are keen to receive feedback before they Station 5: Trauma Scenario where teams role-played the event from all the Health Networks in Surgical Skills Network, won the support the games as a way of bringing the state’s make decisions about further specialist the simulated initial assessment of a man severely injured NSW with some senior surgeons working of both the Health Education and surgical Trainees together to both review or surgical training so we thought the in an explosion who required immediate resuscitation and hard with their junior doctors to get them Training Institute (HETI), which supports the knowledge gained over the previous Games offered a way to both provide simultaneous identification and management of life threatening ready,” she said. and promotes health education across the year and to showcase their skills before that feedback while allowing them to injuries. “We provided details before the day of what state, and the hospital to host the games. peers, the public and senior consultants. measure themselves against each other.” the stations would be, but not the tasks and u

Page 18 / Surgical News May 2013 Surgical News May 2013 / Page 19 Fellows in the News

some consultant surgeons provided extra station 5: trauma tutoring before the event as a wonderful show of support to the junior doctors.” Dr Granger said that after more than four hours of incising, suturing, laparotomy simulation, anatomy identification and trauma teamwork there were fewer than 30 points separating all six teams out of a theoretical maximum score of 250. She said the anatomy station had been particularly included to test the knowledge of junior doctors in an era of increasing concern regarding anatomy teaching and said all judges were delighted with the results achieved by the network teams. “The results in anatomy were extremely good and the identification was quite challenging,” she said. “They used models, radiological images, CT Scans and specimens and were very good at identifying nerves and (vic asm) muscles that would pose a challenge to many clinicians. “Surgical Practice and Training - confronting and tackling the regional issues” “The trauma station was another 55th Victorian Annual Surgeons Meeting highlight in terms of seeing the junior teams work together, follow EMST FRIDAY 18 - SUNDAY 20 OCTOBER 2013 PRIZES principals and in some cases deal with Novotel Forest Resort, Creswick / Friday 18 October There are prizes for the following categories: their first emergency cricothyroidotomy. Welcome Dinner and Show - Sovereign Hill (Families are encouraged to attend) 2013 DR Leslie Prize – Best clinical registrar paper “I have long been a believer in making 2013 RC Bennett Prize – Best laboratory based surgical education more broadly Saturday 19 October; Meeting Dinner - Novotel Forest Resort, Creswick research paper presented available to junior doctors and so to see them embrace this opportunity so CALL FOR ABSTRACTS DCAS Scholarship – Best presentation enthusiastically was wonderful. appropriate to academic surgery. “Some of the participants of the Games Medical Student Prize – Best presentation by will decide not to pursue a career in The winners, based at the Royal North Please indicate that your abstract is for VIC ASM 2013 and which area you a Medical Student surgery in favour of becoming a physician Shore Hospital in Sydney, were presented with To make the Games a reality Submissionswish your topic to be submitted Are under. Now All successful Open abstracts will be printed Audio visual instructions will be sent to all a gold-plated scalpel encased in a trophy box required the assistance of or an anaesthetist, but they still need to be in the Final Program & online. successful authors. proficient, in my opinion, in these basic along with the $2000 prize money. HETI, St Vincent’s Hospital Please note that single case reports will not be Dr Granger thanked the volunteer surgeons, (which hosted the Games at St surgical skills. Submissions must include: accepted for presentation or poster “All doctors should know how to insert nurses and Games supporters including HETI, Vincent’s Clinic), and sponsors – A title and secure a chest drain, stitch up cuts, St Vincent’s Hospital, Investic, the Medical Investec Bank, MIGA, Laerdal, – An abstract of 250 words or less MEETING ORGANISER Insurance Group, Leardal and Johnson & Covidien and Johnson & clean out dirty wounds and tie knots that – A short presenter bio (50 words) to facilitate the Chairperson’s introduction Denice Spence, Victorian Regional Manager will stay tied.” Johnson Medical and key event organiser Mr Johnson. training network – Authors (Presenter in CAPS and UNDERLINED, i.e. J.L.M Peterson, Royal Australasian College of Surgeons And so, at last, to the winners of the Andrew Kemp, the Education Support Officer contributed staff, judges and inaugural 2012 Golden Scalpel Games. for the Eastern and Greater Southern Health equipment to create and A.K.MATTHEWS, A. Thomas, N. Bravo) College of Surgeons Gardens Unable to resist, it must be reported network. manage the stations. Without – Address and Contact Details 250 - 290 Spring Street, East Melbourne that the Northern Surgical Skills Network The Hunter New England Surgical Skills our judges, officials and HETI – Conflict of Interest Declaration VIC 3002 Australia won by a knife-edge with 202.19 points Network has now volunteered to host the volunteers, this day would not T: +61 3 9249 1254 F: +61 3 9249 1256 Games later this year. have been possible. over the Hunter New England Network Email abstract submissions by Friday 16 August to: [email protected] E: [email protected] team at 201.97. With Karen Murphy

Page 20 / Surgical News May 2013 Surgical News May 2013 / Page 21 Medico Legal

manslaughter. Dr Patel’s defence team successfully argued consistency. Registered medical professionals now have that he had an ‘honest and reasonable belief’ that the a positive legal obligation to report to the relevant removal of the patient’s colon, in an attempt to address national board any health practitioner whom they rectal bleeding, was a necessary course of action. believe to be placing patients at risk.3 Failure to report in some circumstances may be considered to constitute The political inquiries professional misconduct (“mandatory reporting”). The Queensland Government commissioned four inquiries regarding the Patel circumstances. The Where are we now – The law “ Hospital Commission of Inquiry” (“The Although the High Court overturned Dr Patel’s Morris Inquiry”) was led by Anthony Morris QC, conviction, it did extend the circumstances in which and recommended that charges be brought against Dr doctors may be charged or convicted for manslaughter The ongoing saga of Patel and that changes should be made to the Medical arising out of negligent medical treatment. The High Practitioners Registration Act 2001 (Qld). The Morris Court extended the concept of “surgical treatment”, Inquiry only produced an interim report and ended ultimately giving surgeons a wider duty for all of Dr Jayant Patel before any final report was produced, because lawyers the actions, conduct and advice connected with the for two government bureaucrats successfully argued treatment itself and, importantly, this now includes that the Commission of Inquiry was contaminated with post-operative care. In its judgement, the Court said, ostensible bias in respect of matters arising under the “Surgical treatment refers to all that is involved, from Inquiry’s terms of reference.2 a recommendation that surgery should be performed, Following the Morris inquiry, the “Queensland Public to its performance and the post-operative care which Hospitals Commission of Inquiry” (widely known as is necessary to be given or supervised by the person the “Davies Inquiry”) also recommended that charges be who conducted the surgery.”4 This is still good law brought against Dr Patel, but also discussed how former today even after the recent decision of the ministers should be apportioned with some of Supreme Court to acquit Dr Patel. In terms of the Dr Patel found not guilty the blame. A further “Foster Inquiry” examined the relevant standard to be applied, it is still accepted in administrative structure of Queensland Health and what Australian law that, for a successful prosecution, the administrative procedures could be put in place to ensure question to be asked is whether a competent surgeon that the events that took place at Bundaberg Hospital could have decided to operate and recommend surgery, n Wednesday March 13, a Queensland Supreme investigating after further complaints from Toni Hoffman would not occur again. and second, whether the decision to operate was so Court jury found the former Bundaberg and a patient, Ian Fleming. Shortly following the great a departure from reasonable skill and professional Osurgeon Jayant Patel not guilty of the commencement of Queensland Health’s investigation, Lessons to be learnt expectation as to warrant criminal liability. manslaughter of a former patient. This case marks the Dr Patel resigned from his position and was flown back to The Davies Inquiry and to a lesser degree, the Foster The Court acknowledges that there must still be a second time Dr Patel has stood trial on the charge of the . Inquiry, uncovered problems within the structure of physical act of surgery, and a recommendation not to manslaughter relating to the death of the patient, with the There were a total of four inquiries, with multiple Queensland Health, specifically, in respect of how it proceed with surgery would not necessarily give rise to High Court previously quashing his earlier convictions recommendations to charge Dr Patel with various crimes, allowed Dr Patel to continue performing operations criminal liability. However, a recommendation to proceed i n 2012. including manslaughter and causing grievous bodily at Bundaberg Hospital after complaints were made with surgery, which advice or opinion is formed in This decision does not end the Dr Patel saga; with harm. Dr Patel was subsequently arrested in 2008 and against him. Such a failure on the part of Queensland circumstances where the advice is grossly negligent, can prosecutor Michael Byrne SC saying that he intends to extradited to Australia from the United States. In 2010, Health highlights the importance of a thorough, certainly give rise to criminal culpability. pursue all outstanding charges against Dr Patel including in the Queensland Supreme Court, Dr Patel was found detailed, transparent and adequate complaint system. Such factors as the likely success of the surgery, likely several charges, two charges of causing grievous guilty of three counts of manslaughter and one count Furthermore, recruitment agencies and hospitals need impact on the life of the patient, co-morbidities affecting bodily harm and two other manslaughter charges. Dr of unlawfully causing grievously bodily harm. Dr Patel to ensure adequate due diligence on all potential the outcome of the surgery and the potential for serious Patel’s defence lawyers have said they will make an appealed that decision to the employees; given that it became clear that, had such due complications post surgery might all be relevant to the application to have all future charges dropped. This on the grounds that there had been a miscarriage of diligence been done in the case of Dr Patel, it would have decision as to whether surgery is recommended or not. recent update marks a dramatic turn in the Dr Patel saga justice based on the conduct of the trial and that he found that Dr Patel had previously been banned from The Court has also suggested, with that final decision, and potentially closes the curtain on the long running had been convicted on the wrong basis. The High performing surgery in New York and Oregon before his that criminal accountability could apply where a surgeon medical malpractice story that has attracted worldwide Court unanimously upheld the appeal, saying that a arrival in Australia – the information being available on a recommends and undertakes surgery “which he knew, attention. “miscarriage of justice had occurred”1 with all convictions “Google” search. or should have known, to be beyond his powers”. That is, being quashed and a new trial was ordered. On a larger scale, subsequent changes to the health not simply that the surgeon may be inexperienced, but The timeline – what happened? A subsequent trial was commenced against Dr Patel on regulatory system, such as the introduction of the Health that the surgeon recklessly carries out a procedure which, Dr Patel first began working at the Bundaberg Base the charge of manslaughter in relation to the death of one Practitioner Regulation National Law (National Law), on an objective basis, is clearly beyond the scope of the Hospital in southern Queensland in 2003. Shortly after of his former patients. After a 23-day trial, a Queensland provides for national registration and accreditation of surgeon’s experience and expertise. commencing his employment, Toni Hoffman, a senior Supreme Court jury found Dr Patel not guilty of health practitioners, resulting in a more efficient system nurse at the Bundaberg Hospital, raised concerns about manslaughter, with the jury concluding that Dr Patel’s to check qualifications of applicants, especially in Is it over? Dr Patel’s surgical conduct. However, it was some two decision to operate on the patient did not constitute relation to overseas qualified practitioners. The National The Patel saga raised concerns about recruitment

years later in 2005 before Queensland Health began criminal for the purposes of a charge of Law imposes national regulations allowing for greater processes and the competency of overseas medical u

Page 22 / Surgical News May 2013 Surgical News May 2013 / Page 23 Medico Legal Fellowship Services

This decision does not end the Dr Patel saga; with prosecutor Michael Web facility promotes your practice “Byrne SC saying that he intends to pursue all outstanding charges ” Another tool for Fellows practitioners. Furthermore whistle blowers were being ignored officials lost their jobs, reputations were tarnished and lives were would like to introduce a new facility and internal governance procedures in hospitals failed to prevent lost. Moving forward, one can only hope that the changes made within the website to promote your foreseeable risks to patients. Since the first investigation in 2005, go a long way to preventing such circumstances occurring again, practice. It’s called ‘Practice Card’; much has been done both on a legislative level and management and help maintain the high standards of medical practice in I it’s free, it’s controlled by Fellows and we level within healthcare facilities in an attempt to ensure that Australia. hope you use it. Practice Card will be of such a situation will never happen again. New national laws and With Richard Laufer particular benefit to Fellows establishing registration procedures will make health practitioner registration their practice and those who don’t have more rigorous and ultimately make health departments more an existing web presence promoting their accountable for their actions. Michael Gorton, practice. Since being found not guilty, it has been reported that College Solicitor As the name suggests, Practice Card Queensland prosecutors will continue with 12 other charges is like a business card. Practice Card against Dr Patel, including two other counts of manslaughter. References provides basic information from the Although Dr Patel’s defence team have been reported as saying 1. Patel v The Queen [2012] HCA 29 at [130], [260]. College website that might be of interest they will make a formal submission to the Director of Public 2. v Morris & Ors; Leck v Morris & Ors [2005] QSC 243, [158-164]. to prospective patients or referring Prosecutions to drop any new charges, there does not appear to 3. See for example National Practitioner Regulation Nation Law clinicians and encourages contact be an immediate end in sight. There were, and are many lessons Act 2009 (Qld). 05398-Medical Personnel (90x130mm) Advt_Layout 1 1/08/12 12:08 PM Page 1 with your practice. When a patient or to be learnt from the Patel saga. Politicians and health department 4. Above n1 at 26. clinician searches for a surgeon within Find a Surgeon, if there is a practice card associated with your listing, they can go to the Practice Card and learn more about you, your practice, your practice location and contact details. To establish your Practice Card, log in to the College website, go to My Practice Card on the left hand menu of your ‘My Page’ and follow the instructions. your name, specialty, area of practice and can be deactivated and reactivated as it practice address details (which can’t be suits you. different from the Find a Surgeon listing We hope you will take advantage of this and membership database records), but facility and we welcome your feedback. you can add extra practice addresses We will be promoting the Practice Card and associate a map with your preferred facility at the Annual Scientific Congress, practice address. and specialty society annual scientific On this point it is important that meetings. Make sure to visit the College the primary contact information held stand if you want a demonstration of this within the membership database is terrific new facility – you could win an correct. Practice Card isn’t a substitute or iPAD as well. alternative to the membership records. To learn how to opt in to Find a Specialist Consultants in permanent You can change your membership record Surgeon, see the video at http://www. and temporary medical staff placements. by logging in to the website, going to My surgeons.org/member-services/college- Contact Carol Sheehan Account (left hand menu of the My Page), resources/website/find-a-surgeon/ selecting ‘access your account details’, and To learn more about Practice Card go Telephone 03 9429 6363 then the option ‘Personal’. You can then to http://www.surgeons.org/my-page/my- Facsimile 03 9596 4336 update your personal information and practice-card After hours 03 9596 4341 opt in to Find a Surgeon. Alternatively the Email [email protected] You can choose from different web page annual College transcript facility allows Website www.csmedical.com.au themes, describe your practice and detail you to update your membership record. Address 22 Erin St Richmond 3121 your professional associations, load your The contact options can be controlled Cathy Ferguson picture and practice logo. The Practice for times when your practice may be Chair, Fellowship Card facility will automatically load unattended and the entire Practice Card Services Committee

Page 24 / Surgical News May 2013 Surgical News May 2013 / Page 25 International Development

Dr John Kearney (right) observing Dr Padwick Gallen undertake a procedure

(L-R) Dr John Kearney, Dr Padwick Gallen, Ms Naomi Mullin with a scrub nurse at Pohnpei State Hospital Photos courtesy of Naomi Mullin

Continuing a vision Dr Padwick Gallen & Dr John Kearney treating a patient Dr Padwick Gallen pictured Dr John Kearney continues his support for the development of ophthalmology services in the Pacific

ith diabetic eye disease Eye Clinic, has been providing surgical of help from Alcon, Designs for Vision, Yap three years ago, he not only identified Hospital, thanked Dr Kearney and his country full-time ophthalmologist looming as a social eye care to the people of the Pacific, Optimed and my mother.” and recruited a surgical resident to team for helping equip the hospital of with yearly supervisory visits then Wcatastrophe in many including Papua New Guinea and East Dr Kearney and a four-member team undertake a Diploma of Ophthalmology Pohnpei to serve the needs of its people. made to supplement training, Pacific Island nations, the discovery Timor, for almost 20 years. visited the two Micronesian states of at the Pacific Eye Institute at Suva, but Dr Kearney said that his team has also provide mentorship and to maintain by an Australian eye team of a disused To support the delivery of eye Pohnpei and Kosrae for two weeks in paid for it. identified nurses at the hospital who may standards. purpose-built optometry/ophthalmology services to people in the region, Dr January 2013, organised by the College as After completing his Post-Graduate benefit from further studies at the Pacific He particularly wished to thank consulting room at the Pohnpei State Kearney is determined to restore the part of its AusAID-funded Pacific Islands Diploma in Ophthalmology in 2012, Dr Eye Institute so that when Dr Gallen the staff of the College’s International Hospital in Micronesia was a surprise existing optometry/ophthalmology Program. Kearney and his team were pleased to returns as a qualified eye specialist, there Development department for highlight of the trip taken in consulting suite at Pohnpei State With optometrist Mr Michael Hare, formally present Dr Padwick Gallen with will be personnel available to help him their skills, assistance and expert January 2012. Hospital and have the equipment to Dr Kearney and his team conducted 21 the Mrs Alison Kearney scholarship on provide services that Pohnpei has not management of such teams. With both a functioning slip lamp and treat those in need. surgeries in Kosrae and 25 in Pohnpei. their most recent visit to Micronesia. The previously been able to offer. “[College] staff undertaking refractor head, the room has become the “There had been a Micronesian During the visit, the team were able to scholarship, a foundation established by While the incidence of diabetic the necessary and effective focus of a campaign by team member ophthalmologist, but he died a few service medical equipment that Pohnpei Dr Kearney’s mother and after whom retinopathy was significant and consistent administration of these programs and Queensland ophthalmologist Dr years ago and was not replaced which State Hospital already owned, but that the scholarship is named, will enable with the very high incidence of diabetes allows me and my team to get John Kearney to source the equipment to in turn meant that the consulting suite had fallen into disrepair. Dr Kearney was Dr Gallen to undertake his Masters of in the general population, most severe into these countries of need and enable the suite to again become fully- [in Pohnpei] was no longer in use,” pleased with the quality of the equipment Medicine in Ophthalmology at the Pacific vision loss was directly related to cataract get straight to work and that is of operational. Dr Kearney said. that the hospital now has on hand. Eye Institute in 2013. and to a lesser extent pteryiums. inestimable value,” he said. Dr Kearney, an Associate Professor of “We are working to re-equip the clinic So committed is Dr Kearney to the Governor John Ehsa, Governor of Dr Kearney said he believed that Dr Kearney also praised members Ophthalmology at Bond University and and I have been begging companies for people of the region, that during an Pohnpei, who attended the scholarship Micronesia required regular team visits of the local eye teams for their skills senior eye surgeon at the Gold Coast equipment and so far we have had offers earlier visit to the Micronesian state of presentation ceremony at Pohnpei State each year until they have their own in- and enthusiasm.

Page 26 / Surgical News May 2013 Surgical News May 2013 / Page 27 Regional News 2013 Workshops & Activities NSW Professional development supports life-long learning. College activities 15 July Sydney are tailored to the needs of surgeons and enable you to acquire Writing Medicolegal Reports, 13 August, Sydney new skills and knowledge while providing an opportunity for reflection Supervisors and Trainers for SET about how to apply them in today’s dynamic world. (SAT SET)

AMA Impairment Guidelines well-structured and comprehensive reports that QLD communicate effectively to the reader. This activity is 18 June, 5th Edition: Difficult Cases proudly supported by Avant and mlcoa. Supervisors and Trainers for SET 29 May, Brisbane; 27 November, (SAT SET) Melbourne Finance for Surgeons 31 July, Brisbane Keeping Trainees on Track (KToT) The American Medical Association (AMA) 19 July, Melbourne Impairment Guidelines inform medico-legal This whole day course establishes a basic practitioners as to the level of impairment suffered understanding of how to assess a company’s SA by patients and assist with their decision as to the performance using a range of analytical methods and 18 June, Adelaide suitability of a patient’s return to work. This activity Keeping Trainees on Track (KToT) financial and non-financial indicators. It reviews the is proudly supported by Avant (29 May and 27 three key parts of a financial statement; balance sheet, 29 - 31 August, Adelaide November) and mlcoa (27 November). Surgical Teachers Course income (profit and loss) and cash flow. Participants 12 September, Adelaide Talking points in Tassie learn how these statements are used to monitor Polishing Presentation Skills Three critical issues are coinciding this year Keeping Trainees on Track financial performance. (KToT) 18 June, Adelaide; 31 July, Brisbane Process Communication TAS 20 September, Hobart This 3 hour workshop focuses on how to manage Model hree areas of significant concern commission to undertake the detailed Thirdly, the initiative for training Non-Technical Skills for Surgeons trainees by setting clear goals, giving effective feedback 2 - 4 August, Melbourne (NOTSS) have arisen that will have assessment. more specialist doctors in Tasmania, and discussing expected levels of performance. You PCM is one tool that you can use to detect early significant impact on surgical Secondly the National Partnership which is designed to support the can also find out more about encouraging self- T signs of miscommunication and turn ineffective services in Tasmania. These are the Agreement on Improving Public training and retention of specialist directed learning at the start of term meeting. VIC communication into effective communication. This Commission on Delivery of Health Hospital Services (NPA-IPHS) Schedule doctors in the Tasmanian public 19 July, Melbourne workshop can also help to detect stress in yourself Finance for Surgeons Services in Tasmania; the Commonwealth A: National Elective Surgery Target health system. The funding available Supervisors and Trainers for and others, as well as providing you with a means to 2 - 4 August, Melbourne Funding for Elective Surgery; and the (NEST) is about to enter its second year. is $39.613 million over three years. SET (SAT SET) reconnect with individuals you may be struggling to Process Communication Model Commonwealth Funding for Education The proposals from the three major The emphasis is on consultant 18 June, Brisbane; 13 August, Sydney understand and reach. 24 - 25 August,Melbourne and Training Positions. hospitals have been submitted to the time for training registrars in Preparation for Practice Firstly it is of concern to me as Chair DHHS who have been negotiating with addition to employing Fellows to This course assists supervisors and trainers to effectively fulfil the responsibilities of their very Preparation for Practice 18 September, Melbourne that there has been no consultation with the Commonwealth. Final sign off for an give them additional experience from Keeping Trainees on Track (KToT) important roles. You can learn to use workplace 24 - 25 August, Melbourne the Tasmanian Regional Committee of additional $8.3 million for the 2013/14 when they gain their qualification assessment tools such as the Mini Clinical the College regarding our opinion on the financial year is almost achieved. This will enabling them to undertake a This two day workshop is a great opportunity to Examination (Mini CEX) and Directly Observed learn about all the essentials for setting up private delivery of Elective Surgical Services in mean additional funding to address 623 broader practice in rural areas. Procedural Skills (DOPS) that have been introduced practice. The focus is on practicality and experiences Contact the Tasmania. extreme long wait patients. The other focus of the program as part of SET. You can also explore strategies to help provided by fellow surgeons and consultant speakers. Professional The Commission on Delivery of The positive thing for this negotiation is for additional registrars in sub you to support trainees at the mid-term meeting. This Participants will also have the chance to speak to Development Health Service in Tasmania released their is that for the first time as Chair of the specialty areas where we have trouble workshop is also available as an eLearning activity by Fellows who have experience in starting up private Department on preliminary report on February 25, 2013, Tasmanian Statewide Surgical Services recruiting specialists in the state. The logging into the RACS website. practice and get tips and advice. This activity is +61 3 9249 1106, identifying elective surgery as a key area Committee (TSSSC), I have been intention is to finalise a proposal proudly supported by The Bongiorno National of Tasmania’s health system that they actively involved in the Commonwealth and associated contracts between Writing Medicolegal Reports Network and mlcoa. by email believe would benefit from clinical and negotiations. This is the first time that THOs/DHHS, specialist Colleges 15 July, Sydney; 28 October, PDactivities@ system redesign. The commission noted a practicing surgeon has been included and the Commonwealth by July, 2013, Melbourne Polishing Presentation Skills surgeons.org or visit www.surgeons.org in their report that further analysis of in such negotiations as previously it in order to allow for new positions This 3 hour evening workshop helps you to gain 12 September, Adelaide the system is necessary to determine was undertaken by bureaucrats from starting in 2014 to be established and greater insight into the issues relating to providing The full-day curriculum demonstrates a step-by- - select Fellows the redesign options that would most the DHHS. The important thing is accredited, if not already in place. expert opinion and translates the understanding step approach to planning a presentation and tips then click on appropriately fit the Tasmanian system for surgeons to be included in the Brian Kirkby into the preparation of high quality reports. It also for delivering your message effectively in a range of Professional to the maximum benefit of patients. negotiations as in the past the clinician’s Chair, Tasmanian Regional explores the lawyer/expert relationship and the role of settings, from information and teaching sessions in Development. A project team is proposed by the perspective has not been considered. Committee an advocate. You can learn how to produce objective, hospitals, to conferences and meetings.

Page 28 / Surgical News May 2013 Successful Scholar

profile “These children, however, are at the worst end of the congenital Highlights heart disease spectrum, and many have already undergone multiple surgeries before having the Fontan Procedure which is 2013: RACS Foundation for Surgery Eric Bishop Scholarship now usually offered at around four to five years of age. “We now also have a subset of patients with hypoplastic left 2013: NHMRC Grant “Detection of Liver heart syndrome, children who have only begun to survive since and Renal Function Abnormalities in the the development of a very large and complex operation known as Australian & New Zealand Population the Norwood Procedure in the last decade. of Fontan Patients” “Long-term outcomes for all Fontan patients have significantly 2012: RACS Foundation for Surgery improved; however, the increase in the proportion of patients Catherine Marie Enright Kelly with hypoplastic left-heart syndrome has led to high rates of Scholarship re-intervention and long-term failure and we need to understand 2011: RACS First Part Surgical this so that we can offer the best possible advice to the parents of Examinations (Basic Surgical Sciences/ such very sick babies.” Cardiothoracic Specialty-Specific/ Dr Iyengar is conducting his PhD research through the Clinical Examination) Figure 1 University of Melbourne, the Department of Cardiac Surgery RACS Clinical Examination Committee The Fontan procedure. Three modifications of the Fontan procedure at the Royal Children’s Hospital and the Heart Research Group, have been performed in Australia and New Zealand since 1975. Prize Murdoch Children’s Research Institute. His work is being supervised by Associate Professor Yves Co-Investigator and National 2007: multi-centre, bi-national registry established in 2008, the world’s d’Udekem, Department of Cardiac Surgery at the Royal Heart Foundation Summer Scholar: first such Fontan registry. Children’s Hospital and Heart Research Group at the Murdoch “The Australia and New Zealand Heart In particular, Dr Iyengar is seeking to analyse early patient Children’s Research Institute, Professor David S Celermajer, Research Group Fontan Database: An outcomes following the surgery, the long-term rate of failure, Department of Cardiology at Royal Prince Alfred Hospital and international, multicentric experience” death, transplantation, arrhythmia and thromboembolic events the Sydney Heart Research Institute, University of Sydney, and and to examine the effects of warfarin and aspirin, the two main Professor John Hutson, Department of General Surgery, Royal anticoagulation regimes given to Fontan patients. Children’s Hospital and Surgical Research at the Murdoch rants provided by the College, “Fontan patients obviously undergo a significant physiological Children’s Research Institute. the NHMRC and the National change and now that the population is growing steadily 1000 GHeart Foundation have allowed (Figure 2) and aging, we are in a better position to understand A helping hand Melbourne cardiothoracic Trainee Dr the long-term 900effects of that change,” Dr Iyengar said. The College has supported Dr Iyengar through the Foundation Ajay Iyengar to analyse the outcomes, “For instance,800 we know their veins are under much higher for Surgery Catherine Marie Enright Kelly Scholarship for 2012 failure rates and risk factors facing pressure, that the blood passing through the lungs isn’t pulsatile and the Eric Bishop Scholarship in 2013, with monies provided to 700 children in Australia and New Zealand and that cardiac output is fixed even during strenuous exercise. top up funding provided through external funding agencies. who have undergone the Fontan “There is also600 enormous inter-centre variation in the practices Procedure to treat complex congenital of anticoagulation and fenestration and we need to know if there 1000 500 non-HLHS heart malformations. is a significant difference between regimes to determine optimal 900 long-term treatment.400 HLHS Only offered in New Zealand since 800 1975 and Australia since 1980, the “We are also300 now seeking to determine the incidence of 700 Fontan Procedure is used to treat subclinical chronic200 liver and renal disease amongst Fontan children born with only one ventricle patients, long-term complications that are only now emerging.” 600 Dr Iyengar, 100who helped establish the Fontan Registry as a and involves connecting the caval veins 500 directly to the pulmonary arteries medical student0 and intern, said information was gathered from non-HLHS allowing blood to pass passively the six centres conducting the surgery and the further six centres 400 HLHS 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 through the lungs without going following up adults with congenital heart disease in Australia and 300 through the heart (Figure 1). New Zealand. 200 Dr Iyengar said, however, that as the He said that approximately 65 Fontan procedures were Fontan population aged, long-term risk conducted in Australia and New Zealand per annum and said 100 factors and physiological effects now the information collected via the registry was invaluable given the 0 needed to be analysed and understood. heterogeneous nature of the Fontan cohort. Research with heart He is now conducting that “Some of these children are missing the left ventricle and 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 Trainee Dr Ajay Iyengar hopes to improve population-based analysis of Australian some the right, and while we do not know the exact cause of Figure 2 these defects, the usual risk factors for congenital heart disease long-term outcomes from childhood surgery and New Zealand Fontan patients using Steady growth of the Fontan population in Australia and New Zealand, data generated through the Australia including genetic and chromosomal abnormalities and parental with a recent exponential growth of the proportion with hypoplastic left and New Zealand Fontan Registry, a exposure to environmental factors have been implicated,” he said. heart syndrome (HLHS). Source: Australia and New Zealand Fontan Registry.

Page 30 / Surgical News May 2013 Surgical News May 2013 / Page 31 Successful Scholar Audits of Surgical Mortality

Dr Iyengar hopes to complete his thesis by the “This stream of my research will show which regime is better end of the year and believes it will be the first such and even if we find no difference that will be a powerful result Case Note Review population-based study of a general Fontan population because aspirin is easier and safer for patients to take and we published in the world. hope the information gathered will lead to an alignment of the Mirizzi Syndrome – acute renal failure and sepsis He said Fontan patients were such a new cohort treatment regime across Australia and New Zealand. within general society, most of whom have only “Overall, I hope my work will allow clinicians to inform This can be found as a blog discussion on the website, go to: http://www.surgeons.org/my-page/racs-knowledge/blogs/ survived because of complex surgery, that surgeons patients and their families about the likely long-term outcomes all-blogs/anzasm-case-note-reviews/2013/anzasm-case-note-review-may-2013/ and cardiologists felt a special duty of care toward their following the Fontan Procedure and allow clinicians to make long-term well-being. more informed decisions about whether surgery is in the best “These are an amazing group of patients to work interests of such sick kids as those with hypoplastic left heart n elderly patient was admitted but this could not be performed at the and 130 to 250. The patient required with and it has been extraordinary developing an syndrome.” as an emergency with biliary admitting hospital and was subsequently intubation, inotropic support and understanding of a group of people that you could say Dr Iyengar, who plans to recommence his cardiac surgery Aobstruction. The patient had done at the private hospital in the same subsequently started haemofiltration just didn’t exist before,” he said. training next year as a SET 3 Trainee, said he was honoured multiple comorbidities, including town. because of anuria. “The life expectancy of the Fontan population is by the support provided through the RACS, particularly the ischaemic heart disease and asthma, and Several days went by with no procedure A few days later inotropes were still not the same as the general public because of the opportunity given to him to expand his skills in epidemiology developed painless obstructive jaundice. being done while the patient’s jaundice required and the bilirubin remained changes made to their physiology and given that and bio-statistics. An ultrasound confirmed the presence gradually elevated. The plan to proceed at five times normal. The decision was the procedure has now been conducted for 40 years Since beginning his PhD, he has also been selected to take of gallstones and the possibility of to surgery was thwarted because of taken to operate to relieve the biliary in Australia and New Zealand, we are also seeing the Graduate Certificate of Advanced Learning and Leadership Mirizzi Syndrome was considered and the lack of an anaesthetist; eventually obstruction because it was appreciated emerging evidence of increased incidences of liver offered by the University of Melbourne. subsequently confirmed on the Magnetic an ERCP was performed confirming that the biliary stent was not working. disease and kidney failure and it’s vital that we find “I was already working on this research and wanted the time resonance cholangiopancreatography. Mirizzi Syndrome and a plastic stent A subtotal cholecystectomy was out why. to concentrate on it full time so it was wonderful to receive the Admission bilirubin was 143, renal was placed in the bile duct. The patient performed and the obstructing stone “We also want to understand the differences in support of the College,” he said. function was normal and the patient was became sweaty and weak afterwards removed. The patient’s postoperative anticoagulation regimes that are offered through “I see my future role as a surgeon and academic very broadly, not anaemic. requiring intensive care and it was noted course was stormy, with increasing different centres and by different clinicians. as someone who facilitates change, leads research and lobbies on An attempt was made to that the patient’s bilirubin was elevated inotropic requirements, ongoing “The rate of thrombotic complications is low, but behalf of patients and there is no better group of patients to work organise endoscopic retrograde after ERCP and that the patient’s lipase anuria and finally torrential melaena there is no way yet of knowing if that is based on one with and for, in my opinion, than the Fontan population.” cholangiopancreatography (ERCP) and was 1400. There had been a doubling possibly related to disseminated anticoagulation regime over another. With Karen Murphy stenting pending definitive treatment, in creatinine levels from between 100 intravascular coagulation with bleeding from the patient’s previous ERCP sphincterotomy. After a family conference the decision was taken to WESTERN HEALTH withdraw therapy and the patient died later that day. Upper GI & HPB Surgery Fellow (UGIG Unit) Comment Melbourne’s West is one of the fastest growing and most culturally diverse areas in Aus- Obstructive jaundice due to Mirizzi’s tralia. Western Health is investing now to meet the demands of this growing population and improve the quality of care and access to services for people in the West. Syndrome in an elderly patient is a FOR SALE very serious situation. While these Vacancy Reference Number: 12271 patients often appear deceptively well, Full Time / Fixed Term Contract: 3rd February 2014 until 1st February 2015 Suite 9 & 10 they are prone to developing severe Level 4, 517 St Kilda Road Corner Commercial Road The Upper GI / HPB unit at Western Health consists of 8 Surgeons who work across complications of biliary obstruction, all three (3) campuses - Footscray, Sunshine and Williamstown. The major cases are namely acute renal failure and sepsis. all completed at the Footscray Campus. Modern, Well Presented Rooms Timely relief of biliary obstruction is of The Fellow is expected to be involved in the receiving roster with the Consultants back up. paramount importance. • Opposite Alfred Hospital The Upper GI / HPB Fellow is also expected to be involved in non-clinical duties such as Due to problems with accessing • Four large consulting rooms education and training of Junior Medical Staff as well as representing JMS interests by anaesthetic support and accessing acting as a representative on one or more committees such as the JMS Operations • Reception/waiting area ERCP services, it was not possible to • Staff amenities Management Committee, the JMS Post Graduate Medical Education Committee, proceed with this patient’s definitive Adverse Outcomes Committee and other relevant working parties. • Partitioned and carpeted throughout treatment sufficiently quickly. Had The successful applicant must hold a FRACS qualification or equivalent to be eligible • Area: 141m2* biliary drainage happened sooner, it is for this position and have obtained your General Registration with the National • Includes 2 on site car spaces *Approx. more likely that the patient may have Medical Registration Board - AHPRA. survived this illness. Lack of resources Applications close Monday 7th June 2013. prevented the surgical team from being able to offer the treatment that was Further Information needed. Enquiries: Associate Professor Val Usatoff 03 8345 6666 [email protected] Tim Atkin 0488 559 225 For more information on these and other exciting employment opportunities at Western Health, Suite 4, 1632 High Street, Glen Iris, Vic, 3146 please visit www.westernhealth.org.au Guy Maddern 9811 5111 www.healthcarerealestate.com.au Chair, ANZASM

Page 32 / Surgical News May 2013 Surgical News May 2013 / Page 33 Morbidity Audits

MALT is currently being configured to One-click supervisor the specific requirements of the training approval boards for SETs in Otolaryngology Head Training boards will have the and Neck Surgery, Paediatric Surgery and option to utilise a ‘third workflow’ Urological Surgery, and for IMGs of every whereby the only supervisor specialty. involvement in MALT is to view procedure totals in the Logbook MALT rollout to Fellows Summary Report and click once MALT is already being used by to approve the whole rotation. Fellows who are Supervisors in This is useful when there is no Cardiothoracic Surgery, General requirement for Supervisors to Surgery, Neurosurgery and review logbooks at the case level. Orthopaedics (NZ), as they need access to view/approve SET cases. Better tracking of While the current focus is on rolling procedure totals out the system to SETs and IMGs, MALT SETs - does your Supervisor only is ready for use by Fellows as a personal approve your cases at the end of the log and/or audit tool and preparations rotation? Need to know your totals are underway to activate Fellows accounts more often so you can track your and launch it to all Fellows for this progress? The Logbook Summary purpose during 2013. Report will be able to be generated 5. The College can add a small number of showing all cases, not only those MALT is a free tool designed for Fellows procedure-specific fields on request (i.e. approved. to use in several ways: TNM for cancer procedures) Morbidity Audit and Logbook Tool • Personal log of cases Enhancements • Self-audit MALT is to include a bundle of small Ongoing improvements for your logbook • Fellows from a hospital surgical unit could New features improvements suggested by SETs and use MALT to audit their department coming in 2013 Supervisors, such as: • A specialty society could audit a new t is going to be another big year for • Preparations are underway to launch • A Dashboard shows the status of • UR number field being renamed to procedure, tracking its uptake over time Custom-reporting tool the Morbidity Audit and Logbook MALT to Fellows as a personal log and your cases in one glance UR/NHI Tool (MALT)! Since the Web Logbook audit tool • Edit your hospital list and supervisor • Fellows could audit their private Want to be able to easily design your I own reports? Want to extract tables • Prophylaxis and Admission Type practice was replaced in September 2012 with the • A suite of new enhancements are being list will be multi-pick MALT system, usage by Surgical Education prepared • Audit-level data can be optionally and graphs into presentations? Training Boards may wish to extract Trainee • Ability to still add complications Training programs (SETs) has increased entered including diagnoses linked MALT is designed to be ‘ready to go’ - after case approved and rotation steadily. With the full rollout of MALT with SNOMED Fellows simply record data against the procedure totals into Excel for uploading What’s it all about? into other systems? The MALT system period closed happening in 2013 the future is bright! standard dataset automatically assigned • Additional filters for the Journal • Already this year, in February, a MALT Mobile MALT rollout to SETs to them, noting that: will be able to do all this via a ‘custom- reporting tool’. View smartphone-friendly version was • Designed for any smartphone – iPhone, and IMGs 1. The dataset is that recommended by • ‘Today’ button in date field launched. MALT Mobile allows data Android, Windows etc MALT is very flexible. Training boards the College for effective surgical audit Import tool Ian Bennett entry on-the-go • Login directly from your smartphone can customise many of the settings in (from the Surgical Audit and Peer Chair, Logbooks and Clinical Have you years of personal case data in an • The MALT system was showcased internet browser at malt.surgeons.org. MALT so it works the way they need it Review Guide). Audit Oversight Committee on the College stand at the ASC in • No additional account setup to. For example: 2. Additional procedures can be added Excel spreadsheet? Do you contribute to Auckland required – if you have an active • Whether supervisors need to use for Fellows if required. The standard another database in a hospital or rooms? • MALT is being configured to the MALT account you can use MALT MALT to approve cases or not procedure list is that provided for SETs. MALT will be able to import this data To know more about specific requirements of the training Mobile now. • The procedure list 3. The system provides five basic audit for you. MALT please contact the boards for SETs in Otolaryngology • Linked to the main MALT system so • How many supervision levels and reports and a data extraction tool. MALT team: Head and Neck Surgery, Paediatric the data automatically synchronises. what they are called 4. To enable aggregate data analyses, Apps www.surgeons.org/malt Surgery and Urological Surgery Need to enter data on-the-go from your • The dates of the rotation periods users can extract their own data P: +61 8 8219 0900 • MALT is being configured to the spe- As with the main MALT system: and when the logbook is to be closed into MS Excel and provide it to the smartphone where there is no network in E: [email protected] cific requirements of all International • Records can be referred to the (usually the submission deadline) group conducting the audit (i.e. the range (i.e. some large hospitals)? Apps are Medical Graduates (IMGs) supervisor in bulk • What fields should be mandatory department of surgery). being built for iPhone and Android.

Page 34 / Surgical News May 2013 Surgical News May 2013 / Page 35 Education Curmudgeon’s Corner

Trainees in Difficulty A new online resource

urgeons have always expressed supervisors’ expressed concerns about the concerns about some of their difficulty of dealing with this issue, the In Memoriam STrainees. Surgeons have tried to TiD resource has identified this as one of support Trainees and positively assist the six fundamental topic areas. them, while maintaining the quality of Our condolences to patient care. Being a good supervisor in Easy access to, and use of, this situation is difficult. More so as the resources the family, friends and approaches around training, probation, In order to make the resource useful colleagues of the and dismissal have become more tightly across all specialties, the templates and following Fellows whose regulated due to the involvement of legal processes include both generic and death has been notified and/or employment considerations. specialty specific materials. Where All surgical specialty training boards specialty training boards have developed over the past month: have encountered one or more Trainees their own documentation these have who experienced difficulties during been included. If a specialty does not George Stirling, their training program. Some of these have material for any of the topic areas, Victorian Fellow difficulties have been resolved and the for example ‘diagnosing difficulties’ or Trainees continued (or are continuing) ‘gathering information’ then generic What’s right on the big day? Edward Beckenham, to successfully complete their training documents can be used. New South Wales developments, by a wide range of research, Let’s even the playing field program, while other Trainees had a Crucial to the successful management from a variety of medical teaching Fellow number of terms on probation before of Trainees in Difficulty is maintenance environments. Secondly, to bring together being dismissed from the program. of an up-to-date and complete file of Charles Swanston, as many resources as possible, both generic Probation, dismissal and subsequent documentation. This of course also here is one thing that fashioned or jealous of the and specialty specific, and to make them New Zealand appeals are very frustrating and time describes the intervention that attempts to really annoys me and that modern young lifestyle, but readily accessible from the same site. Fellow consuming for all involved. Specialty address the difficulty. Tis double standards and this seems to me to be double- training boards have invested a Previous experience across a number of in particular people who display standards. considerable amount of time in ensuring International research the specialty training boards has shown double standards. I went to a The other thing that struck that their documentation and processes Early identification and response to that the most effective way to do this is wedding recently. As is the modern me at the wedding was that for probation are transparent, clear and potential problems has been identified in for a training board administrator to be way the groom and bride had been the guests asked to see the We would like to notify readers that it is not the practice of stand up to scrutiny. There is need for international research as an important key involved in the process from the earliest living together for three years and bride’s ring, but not the resources as there are concerns expressed decided to get married. I overheard groom’s. Being a romantic Surgical News to publish obituar- to assisting Trainees (or IMGs) who may point, and to have the responsibility for ies. When provided they are about the processes. be experiencing difficulty. Unfortunately, keeping records of meetings and all of the one guest saying (in jest, I suspect, couple they had actually published along with the names In response to those concerns the supervisors have demonstrated some relevant information. or at least I hope) that the groom chosen the same rings (but of deceased Fellows under In College Education Development and reluctance to talk to Trainees when a This has been found to be effective was making “an honest woman” of different sizes). So there is an Memoriam on the College web- site www.surgeons.org go to the Research Department has developed an problem first arises. because it relieves the Supervisor of the bride. example of double standards online resource for all members of the Does this mean that an in the opposite direction. Fellows page and This attitude is not unique to surgical those tasks and reduces the risk of lost click on In Memoriam. College: supervisors, trainers, IMGs, and supervisors. Steinert identified six information. In many situations, it will unmarried couple living together is Curmudgeons do not read the social } Trainees. The Trainees in Difficulty (TiD) common responses including: denial, composed of a dishonest woman and a pages of the papers, but I believe that describe the intervention that proves to Informing the College resource contains an extensive collation of avoidance, anger/ frustration, and be successful. This approach has been man about whom no comment is made? there are often detailed descriptions If you wish to notify the College advice, templates and processes and is set acceptance; only the last one of these incorporated into the TiD approach. This set me thinking – one never hears of the dress of the bride – “Strapless, 1 of the death of a Fellow, please up so that information relating to six key leading to a productive intervention. To access the Trainees in Difficulty of a bride making the groom an honest A-line gown with sweetheart neckline topics can be accessed according to need. As you can see from the above listing resource, College members need to be man. He may be made a happy man, but and corset closure. The airy shimmer contact the Manager in your The topics are: of topics, the first three topics in the logged in to the College website. he apparently does not need to be made of Brescia Organza lends itself to softly Regional Office. They are • Diagnosis of difficulties Trainees in Difficulty resource have ‘honest’. billowing waves that gracefully move Once a member is logged in, ‘My Page’ ACT: [email protected] • Gathering of evidence been deliberately designed to provide will open and in the left menu ‘RACS One also hears of young men who across the A-line skirt. An embellished NSW: [email protected] • Teaching and monitoring information and support documents Knowledge’ will take you to ‘eLearning’, “sow their wild oats”. This is usually lace motif adds a stunning element to the • Implementation of probation to encourage and facilitate early which will take you to ‘Courses’. accompanied by a “nudge, nudge, wink, asymmetrical dropped bodice.” The poor NZ: [email protected] • Analysis of insight intervention. Stephen Tobin wink” as if it is to be expected and groom – “He wore a grey suit,” seems the QLD: [email protected] • Move to dismissal Lack of insight has been identified as a Dean of Education permitted. Do young women sow wild average description. SA: [email protected] significant underlying issue in identifying oats? If so, I have never heard of it. Such Yes, you have probably already guessed TAS: [email protected] There are two elements that were very particular kinds of problems which a Reference behaviour in young women is often seen that the wedding that I attended was my VIC: [email protected] important in the way this online resource Trainee (or IMG) may experience. Lack of 1. Steinert Y. The ‘problem learner: Whose as not acceptable. “She was a bit of a girl own. We curmudgeons do find a Mrs has been developed and presented. insight can require a different approach problem is it? AMEE Guide No 76. Medical in her younger days.” Curmudgeon from time to time. Please WA: Angela.D’[email protected] Firstly, to be informed about current to both identify and manage. Because of Teacher, 2013, e1-e11 early Online Perhaps we curmudgeons are old- ask me to show you my ring. NT: [email protected]

Page 36 / Surgical News May 2013 Surgical News May 2013 / Page 37 Professional Development

2012 Definitive Surgical Trauma Care (DSTC) and Definitive Perioperative educational tool to support the education and training of Trauma Nursing Care The changing face of the others are encouraged to attend free of charge. The program is being tailored for a surgical educator Courses audience and will involve two online core components – Academy of Surgical Educators ‘Simulation based education: contemporary issues for the health professionals’ and ‘Being a simulation educator’; and Re-focusing activities for the Academy of Surgical Educators a one day workshop on ‘Simulated patient methodology’ and ‘Patient focussed simulations’. The workshop will be DSTC Australasia in association with IATSIC facilitated by Professor Debra Nestel, Monash University in the competency era?’ Both are in Melbourne for the ANZAHPE (International Association for Trauma Surgery and will be held at the College. Further details, dates and conference from June 24 to 26. and Intensive Care) brings you courses for 2013 times will be announced on the College website. In Brisbane in September we have invited Dr Sonal Arora, As part of the Academy’s advocacy work, a number Clinical Lecturer in General Surgery Department of Surgery and of representatives will deliver educational sessions and Cancer, Royal Imperial College to speak on ‘Simulation and its 2013 COURSES: discuss the needs of the faculty members. Presentations role in educating our educators’. Dr Arora will be in Brisbane Sydney (Military Module): 23 July about the Academy developments have been incorporated for SIM Health from September 16 to 20. Final dates, times and into the Victorian, Queensland and Northern Territory/ Sydney: 24 – 25 July venues will be announced on the College website. South Australia/Western Australia regional Annual One of the key functions of the Academy this year is to develop Auckland: 29 – 31 July Scientific Meetings; the specialist society meetings of a generic surgical educator program which all faculty members Perth: The Australian and New Zealand Society of Cardiac 7 – 8 November and surgical educators can participate in irrespective of what and Thoracic Surgeons and General Surgeons Australia; Melbourne: 11-12 or 22-23 Nov educational role they occupy in the College. A recent gap analysis Provincial Surgeons of Australia and a presentation to the and surgical educator curriculum report by Assoc Prof Robert (to be confirmed) Paediatric and Urological Surgical Boards. Depending on O’Brien (Director of Medical Education at St. Vincent’s Hospital) The DSTC course is an exhilarating educational time commitments as well as the choice of other specialities, will inform this. The report has been reviewed within and outside opportunity focusing on there may be further opportunities in 2013. The Dean would surgical decision-making in complex scenarios the College. This educator program will be developed during • welcome consideration for involvement in state and regional 2013, and be available in 2014. • operative technique in critically ill trauma patients meetings, as well as specialty society meetings in 2014. • hands-on practical experience with experienced instructors (national and international) he Academy of Surgical Educators (ASE) was established Working together At the ASC • insight into difficult trauma situations with learned to support, enhance and recognise surgical educators The third successful Royal Australasian College of Surgeons, For the recent Auckland ASC, convenor Mr Richard techniques of haemorrhage control and the ability to handle within the College. In order to do this we need to identify Royal Australasian College of Physicians and Royal College of T Perry established an impressive line-up in the Surgical major thoracic, cardiac and abdominal injuries the changing needs of members and address those needs through Physicians and Surgeons of Canada, Conjoint Medical Education Education stream. A major plenary session on Tuesday, the professional development activities offered. The Academy Seminar was held again at the Sofitel Sydney Wentworth on May 7, was chaired by the previous Dean of Education, The DSTC course is recommended by the Royal Australasian also has new developments and research in the field of surgical Friday, March 8, 2013. The theme was ‘Serving the Community: Prof Bruce Barraclough. College of Surgeons for all consultant surgeons and final year education as important priorities. Training Generalists and Extending Specialists’. As the Academy develops, we wish to have an Academy Trainees who participate in care of the injured. It is considered The ASE now boasts a membership base of 320 individuals, Presenters were from the three host Colleges and boasted meeting, which could include presentation and invited essential for surgeons involved in the management of major comprised of supervisors from the Surgical Education Training eminent speakers such as Mr Andrew Connolly, Dr Jason Frank, speakers as well as a forum regarding current and future trauma and those working in remote, regional and rural areas. (SET) program, educators from the Skills and Professional Mrs Anne Kolbe, Mr James Birch, Dr Bryce Taylor, Dr Kevin surgical educator needs. Rather than simply foist another The Definitive Perioperative Nurses Trauma Care Course Development programs and other surgeons and external Imrie, Prof Michael Cox, Dr John Gommans, Prof Richard meeting with associated travel onto our busy membership, (DPNTC) is held in conjunction with many DSTC courses. It educators with a proficiency and passion for medical education. Murray, Prof Linda Snell and Prof Trish Davidson. Participants we would plan that such a meeting could be based out is aimed at registered nurses with experience in perioperative The Academy offers a comprehensive suite of educational activities included senior health educators, policy makers and advisors, of Melbourne and make use of webcasting. We would be nursing and allows them to develop these skills in a similar for its members. These include both online and face to face courses regulators and others working in the area of specialist education setting. interested to hear from members of the Academy and other such as Supervisors and Trainers for SET, SET Selection Interviewer and training. surgeons about such a meeting. The Military Module is an optional third day for interested Training, Keeping Trainees on Track, the Surgical Teachers Course The joint Graduate Programs in Surgical Education offered Membership of the Academy is open to all Fellows surgeons and Australian Defence Force personnel (this course is as well as faculty training programs for all of the Professional by the University of Melbourne in partnership with the College only offered in Sydney). and Trainees committed to the role of Teacher / Scholar. Development and Skills courses. enrolled 14 surgeons this semester. This suite of programs External members who have strong educational interests During June, the Academy will be hosting a number of addresses the specialised needs of teaching and learning in a and expertise are also welcome to join. For more Educator Studio Sessions at the College’s Melbourne office modern surgical environment. DSTC is recommended by The Royal information refer to: http://www.surgeons.org/for-health- and simultaneously broadcasting to its members via a web The program is a modular one, with graduates exiting Australasian College of Surgeons for all professionals/academy-of-surgical-educators/ conferencing platform. with a Graduate Certificate, Graduate Diploma or Masters of Consultant Surgeons and final year trainees. or contact Kyleigh Smith on +61 3 9249 1212 or email Victorian surgeons may wish to attend or take the webcast. Each Surgical Education. These graduating Fellows will be integral [email protected] presentation will be followed by a Q and A style session with a to enhancing the knowledge and educational leadership of the networking opportunity following. Guest speakers will include Academy. Julian Smith Please register early to ensure a place! Dr Ian Curran, Dean of Educational Excellence and Head of In June, the Academy members will be invited to participate Chair, Professional Development Innovation, London Deanery, on ‘Trainees in Difficulty’. Professor in NHET Sim, Australia’s first National Simulation Health Chair, Academy of Surgical Educators Contact Sonia Gagliardi on +61 2 8738 3928 Tim Dornan, Professor of Medical Education at Maastricht Educator training program, funded by Health Workforce Australia. Stephen Tobin or email: [email protected] University will be speaking on ‘Where does apprenticeship stand Educators who currently use or intend to use simulation as an Dean of Education

Page 38 / Surgical News May 2013 Surgical News May 2013 / Page 39 SAAPM Audits of surgical Mortality

Australian studies that can be used as a bench-mark. Boufous From the SAAPM Annual Report et al.1 reported on fractured NOF in NSW and noted a death rate of Seven years of fractured neck of femur cases in South Australia, 2005–06 to 2011–12 4.7 per cent to 5.1 per cent over a 10 year period. The SA figures are slightly higher. Allaf et al.2 reported that annual ach year, the audits of surgical fractured NOF death rates from 70 mortality publish an annual eight NHS Trusts varied greatly, report. As time goes by and E 60 ranging from 3.9 per cent to 17.7 more cases are accumulated, there per cent. The purpose of their is a developing database that allows 50 paper was to assess whether a five analysis of some aspect of surgical year average is a better indicator mortality. 40 of the true situation. The paper In each annual report, the South reported presents five years of raw data Australian Audit of Surgical Mortality 30 for one of the Trusts, the South

(SAAPM) has tried to look at one Deaths 20 Manchester University Healthcare aspect of the audit and see if further Trust, which indicates an average information can be obtained. This year, 10 annual mortality rate of 7.7 per cent the topic of interest has been deaths between 1997 and 2001, slightly Your Audit online from fractured neck of femur (NOF) 0 higher than the SA figures. and comparing them with international Audits improve with your feedback standards. Conclusion The data collected by SAAPM Financial year Surgical diagnosis would support the view that, in would like to thank you for access to data is limited to their own of fracture of neck South Australia, the quality of care Figure 1 your ongoing commitment to operational needs. All communication of femur for patients with fractured neck Ithe mortality audit process. The is encrypted using current industry Over the first seven years of the audit, of femur is similar to elsewhere Australian and New Zealand Audit of security standards (HTTPS). there have been 615 notifications of Deficiencies of care not complete (9 per cent of death in Australia and overseas. As the Surgical Mortality (ANZASM) program All you will require is an internet orthopaedic deaths. Of this group, associated with fractured notifications did not have their case data collection continues, the data has been operational for more than 10 connection and preferably Internet 562 (91 per cent) have undergone the neck of femur forms filled out), but only a severe held by the audits in the various years beginning in Western Australia. Explorer 7 or above, Safari 4 or skewing of the data would alter the audit process of a completed surgical From 1 July 2005 to 30 June 2012, there regions will provide a valuable It is now operating nationally, with all Mozilla Fire Fox 3.6. Directly entering conclusion. case form and an appropriate first – or were six cases (2 per cent), out of a source of information. States and Territories contributing since data saves time; it can be completed second-line assessment, including total of 303 deaths with the surgical Glenn McCulloch 2010. at different times thus progressively 303 cases in which the diagnosis was diagnosis ‘Fracture of Neck of Femur’, for Overall mortality SAAPM Clinical Director I would like to make you aware of the completing all of the case information. fractured neck of femur. which clinical events (areas of concern, It is all very well to be pleased that ‘Fellows Interface’, an extension to the The system has been in use for three Figure 1 (right) shows the number of consideration or adverse events) were no serious incidents have occurred, References existing in-house Web-based Mortality years now and the feedback I have surgical case forms received with the identified by the reporting surgeon, the but the question that also demands 1. Boufous, S., Finch, C. F., & Lord, S. Audit IT system. Currently project staff received during this time has been R. (2004). Incidence of hip fracture surgical diagnosis ‘Fracture of NOF’ first-line assessor or the second-line an answer is whether the mortality enter audit information into the system encouraging. This initiative provides in New South Wales: are our efforts for the period 2005/2006 to 2011/2012. rate of patients with fractured NOF is to facilitate the assessment process. users with a dynamic, user-friendly assessor. All of these cases were critically having an effect? Medical Journal of The number of cases with this surgical However, the Fellows Interface tool to enter Surgical Case Forms reviewed; the clinical events that were comparable to other units and world Australia, 180, 623-626. diagnosis has been increasing in identified were either matters relating standards. As SAAPM looks only at 2. Allaf, N., & Lovell, M. (2004). enables Fellows with the means to enter and complete First-line Assessments recent years, reflecting an increase to hospital events (e.g. falls, delay in death as an outcome, one must turn Annual review of fractured neck of information directly into an electronic online. Completing audit forms has in the number of hospitals that are operating theatre access) or events that to other sources of data to see how femur mortality rates: is this a true template of the Surgical Case Form, as been made more convenient. The involved in the audit and, therefore, could not be prevented (e.g. sudden many patients have a procedure for picture? Annals of the Royal College well as for first-line assessments. This process is more streamlined with less the number of orthopaedic surgical neurological events). There have been a fractured NOF and do not die. SA of Surgeons of England, 86(5), system has been configured for both PC paperwork. deaths reported. It should be noted no events where there was a surgical or Health maintains such records. Their 347-348. and Mac users. Nationally over 35 per I am hoping that more users will that surgical diagnosis data is only treatment error. database suggests that, in the year Note: Some of this data and cent of surgeons are using this interface try the Fellows Interface system and captured through surgical case forms Considering that this population 2010/2011, there were 824 patients discussion will be in the 2012 as a means of submitting their forms. feedback comment, both positive SAAPM Annual Report which is (not notifications of death), so this is group has many serious co-morbidities, with a diagnosis of various forms and negative. Staff are available soon to be published. The article likely to be a slight underestimate as 9 of fractured NOF. Using this figure to assist you. Please contact your and their management is often complex was prepared by Sasha Stewart, Secure connection regional Audit office for a user ID and per cent of these forms have not been and involves multiple specialties, it is as the denominator, the 53 deaths Project Manager, and Glenn The web-based Audit and Fellows returned. a remarkable achievement that so few recorded by SAAPM equates to a McCulloch, Clinical Director, Interface system ensure data security. password. Figure 1: Number of deaths with surgical deficiencies of care have been identified. death rate of 6.4 per cent. The question SAAPM. All access to the system is controlled by Professor Guy Maddern diagnosis ‘Fracture of NOF’ (total 303) One could argue that the data is arises whether there are any similar username and password. Each user’s Chair, ANZASM Steering Committee

Page 40 / Surgical News May 2013 Surgical News May 2013 / Page 41 Foundation for Surgery

Thank you Yes,for Idonating would like to d toonat e to our Foundation for Surgery

the FoundationAll donations for are tax deductible Surgery

Name: New South Wales VictoriaAddress: New Zealand TThailandelephone: Professor Peter McKeown Mr Harry Tsigaras Mr Ian Stewart Mr Juggrich Srisurakrai

Mr Keri Prabhakar Professor Email: Stephen O’Leary Mr Julian WhiteSpeciality: Dr Elizabeth Tompsett Mr Sumitra Wickramasinghe Mr Gary Stone Enclosed is my cheque or bank draft (payable to Foundation for Surgery) for $ USA . Mr Michael Farrell Mr Iain McLean Mr Nicholas Finnis, Mr Gregory Brick Mr Peter Brown AM Please debit my credit card account Mrfor $ Peter Raudkivi. Mr Jeffrey Robinson Western Mastercard Australia Visa AMEX Diners Club NZ Bankcard Western Samoa Mr Gavin Wilton ONZM Queensland Mr William Roberts Mr Toga Potoi My Timor Heart Dr Paul Millican Mr JohnCredit Teasdale Card No: Expiry / Written by Ellen Whinnett and Ellen Smith Mr David Lynch Mr Peter Graham AM Ireland Using striking photographs and volunteers’ stories My Timor Heart Your passion. Card Holder’s Name - block letters Mr Michael SugrueCard Holder’s Signature Date illustrates the profound positive impact of the College’s Timor Leste South Australia Dr Brian Mehigan Your skill. I would like my donation to help support: program. Written by Ellen Whinnett, a Walkley award winning journalist Mr Nicholas Marshall General Foundation Programs International DevelopmentTotal: Programs and the Head of News at the Herald Sun newspaper. All proceeds from the Mr John JoseY our legacy. Singapore Scholarship and Fellowship Programs Indigenous Health Programs sales of My Timor Heart go directly to Foundation for Surgery to fund the Mr Wei Chang Timor Leste Program.. I have a potential contribution to the Cultural Gifts Program $41,400 Your I do not give permission for acknowledgement of my gift in any College publication Please send your donation to: Order Form Foundation. AUSTRALIA & OTHER COUNTRIES NEW ZEALAND Name: ...... Foundation for Surgery Foundation for Surgery 250 - 290 Spring Street PO Box 7451 Address: ...... East Melbourne , VIC 3002 Newtown, 6242 Wellington Yes, I wouldAustralia like to donNewat Zealande Telephone: ...... to our Foundation for Surgery Email: ...... Please find enclosed my payment for: $...... All donations are tax deductible $60 AUD + P&H ($10 AUD in Australia for first copy then AUD $5 for each additional copy) (incl. GST) Name: *Please contact us for Postage & Handling costs outside Australia. Address: Telephone: Cheque: Money Order: Email: Speciality: Credit Card: Card Type: Mastercard / Visa / American Express Enclosed is my cheque or bank draft (payable to Foundation for Surgery) for $ .

Card No: Please debit my credit card account for $ .

Expiry Date: ...... Mastercard Visa AMEX Diners Club NZ Bankcard

Signature: ...... Credit Card No: Expiry / Please send this form to: The College has produced a book, Timor Leste Program Your passion. Card Holder’s Name - block letters Card Holder’s Signature Date called My Timor Heart, to celebrate College of Surgeons’ Gardens Your skill. our achievements in Timor Leste. Royal Australasian College of Surgeons I would like my donation to help support: My Timor Heart will recognise the 250-290 Spring Street, Your legacy. General Foundation Programs International Development Programs extraordinary efforts of the medical East Melbourne. VIC 3002 Scholarship and Fellowship Programs Indigenous Health Programs AUSTRALIA I have a potential contribution to the Cultural Gifts Program volunteers in Timor Leste, and the I do not give permission for acknowledgement of my gift in any College publication life-changing impact their work has Email: [email protected], I would like to donate Your on people living in a country that Phone: +61 3 9249 to o u1230r Foundation for Surgery Please send your donation to: Fax: +61 3 9249All donations 1236 are tax deductible Foundation. AUSTRALIA & OTHER COUNTRIES NEW ZEALAND continues to struggle with the legacy Foundation for Surgery Foundation for Surgery

of years of civil war and violence. Name: 250 - 290 Spring Street PO Box 7451 The RoyalAddress: Australasian College of Surgeons takes the issue ofTelephone: security and privacy East Melbourne , VIC 3002 Newtown, 6242 Wellington Email: Speciality: Australia New Zealand seriously. Information contained in this form will not be used for any other purposes Enclosed is my cheque or bank draft (payable to Foundation for Surgery) for $ .

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Page 42 / Surgical News May 2013 Mastercard Visa AMEX Diners Club NZ Bankcard Surgical News May 2013 / Page 43

Credit Card No: Expiry /

Your passion. Card Holder’s Name - block letters Card Holder’s Signature Date

Your skill. I would like my donation to help support: Your legacy. General Foundation Programs International Development Programs Scholarship and Fellowship Programs Indigenous Health Programs I have a potential contribution to the Cultural Gifts Program Your I do not give permission for acknowledgement of my gift in any College publication Please send your donation to: Foundation. AUSTRALIA & OTHER COUNTRIES NEW ZEALAND Foundation for Surgery Foundation for Surgery 250 - 290 Spring Street PO Box 7451 East Melbourne , VIC 3002 Newtown, 6242 Wellington Australia New Zealand Specialist Without Borders

Not only was there satisfaction with the“ style of teaching and presentation of material, but a great camaraderie developed between SWB team members and local doctors and students.” Mr Anderson said that in another first for SWB, an educationalist, Mr Don Bramwell from Flinders University, had accompanied last year’s teams to oversee teaching, provide independent analysis and feedback and to help the organisation deliver the highest quality and most appropriate medical and surgical education. “We want to provide the very best education we can by streamlining our teaching modules for qualified specialists, Trainees, interns and medical students and we believe Mr Bramwell will help us achieve that,” he said. “We have therefore invited him onto the SWB executive and are now in the process of raising additional funds to allow him to travel with us on future team visits.” Support for the future Mr Anderson also said a recent Australia Taxation Office decision to grant SWB full gift deductibility was also a milestone in the organisation’s development, allowing SWB supporters to claim a full tax rebate on their donations. “The costs of running SWB are amongst the lowest of any not-for-profit in Australia given that our dedicated specialists pay their own travel costs GI and vascular, we were also able to present and accommodation while we pay for teaching modules around intensive care, radiology, oncology, materials and local seminar venues,” he said. obstetrics, paediatrics and psychiatry,” he said. “This decision will hopefully have a huge impact “Malawi had requested a teaching visit as part on us because it could mean that we attract not of the preparation for their surgical residents who only more personal donations, but the support of Support were preparing for a Master’s Degree in surgery so the medical industry,” he said. we had the curriculum sent to us before the visit “The more funding we attract, the more work we and established an association with the can do on curriculum development and the more growing supervisory body in East Africa for surgical countries we can visit. residents to ensure our teaching was relevant to “In September of this year we will be going their needs. to Malawi again and to Zimbabwe, but ideally “The Malawian seminar was then constructed to we would love to undertake four trips a year, assist those surgical residents by providing not only two to Africa and two to our Asian and Pacific updated information, but also exam techniques neighbours.” This group is spreading its teaching further over a number of days including a mixture of Mr Anderson said SWB was now actively seeking didactic lectures and simulated teaching modules. the participation and support, in particular, of pecialists Without Borders (SWB), established He said support had grown to such a degree that last All the residents who attended the course passed urologists and plastic surgeons, but all surgeons by SA Upper GI and Hepatobiliary surgeon Mr year SWB was able to offer for the first time fully mixed their final exams, which was a great compliment to and specialists with an interest in teaching are SPaul Anderson in 2005 as a teaching organisation surgical/medical seminars over two weeks in Malawi and the teachers and the organisation. welcome. designed to increase the skills of doctors working in Rwanda. “The second week of the trip was spent in “To be able to deliver a seminar on burns, developing countries, has now attracted the support of In September last year, Mr Anderson led an SWB Rwanda with the medical/surgical seminar held maxillofacial and plastics, while having renal more than 400 specialists from around the world. visit comprising 20 Australasian medical and surgical in Kigali attracting 100 doctors, medical students, physicians conducting some training, would be Mr Anderson said that while there were 300 members consultants as well as eight medical students to the two nurses and midwives. wonderful in these countries.” from Australia and New Zealand, other medical and African nations. “Not only was there satisfaction with the style surgical specialists from Canada, the UK, South Africa, “While the surgical component in the seminars was of teaching and presentation of material, but a For more information visit the website at the US and Africa had now signed on to give of their time dominant , consisting of the various surgical specialties great camaraderie developed between SWB team www.specialistswithoutborders.org.au to teach in those countries that request an SWB team visit. including orthopaedics, ENT, neurosurgery, upper members and local doctors and students.”

Page 44 / Surgical News May 2013 Surgical News May 2013 / Page 45 advertisement All Books now Welcome to the Surgeons’ Bookclub 25% discount

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Page 46 / Surgical News May 2013 Surgical News May 2013 / Page 47 Graham Coupland Lecture 2012

Silence can be helpful as it Was Graham Coupland is “an invitation for the patient to talk, as well as being ahead of his time? important therapeutically ” The second part of a lecture presented at the NSW Regional Committee End of Year Dinner, 14 December 2012

s surgeons, our concern is the and the welfare of others, psychological patient’s suffering goes hand in hand with or how they’ve coped. When a patient person, suffering from illness, involving depression and anxiety, and finding out about it. By being receptive tells us their story, and we listen correctly, Awho is likely to be lost in the more nebulous, existential concerns to do to the person and connecting with them it has a healing effect on us as well as on strange world of their own illness and the with loss of dignity, loss of control and we give them the clear message that we the patient. In this way the stories, theirs hospital or institution in which they find spiritual crises. are there for them, sharing their suffering. and ours, get interwoven. That’s what themselves. To find out about this aspect of our Just “being there” tells them that they our memorable patients give us and it’s a The elements of suffering, varying in patients’ suffering is difficult. I suspect are not alone. As they tell their stories, wonderful gift. intensity and proportion in any single that a blunt question: “Are you suffering?” patients can redefine their meaning and Surgeons who excel also make us a gift, situation, are loss, isolation, helplessness would be met with denial as patients by doing so, transcend their suffering. As an example to follow, a standard to aspire and hopelessness. Looking at these four, would hesitate to lay bare their innermost I just mentioned, silence can be valuable to. Graham was such a person and it is for one can immediately see that we can do fears in the same way that they would as it gives the patient the message that that reason that we honour his life in this something to alleviate three of the four; tell us about their appetite or their bowel we are physically present in their time of oration. we can offer hope, we can offer help, and habits. To know about their suffering we suffering, that they are not alone on their To finish, let me try to answer the we can minimise isolation, but doing this must listen to their story for this gives us journey. Sackett, one of the founders of question in the title: ‘Was he ahead of his is not easy. the information but, more importantly, Evidence Based Medicine, said “the most time?’ I believe the answer is both “yes” A patient’s suffering becomes part of goes a long way to relieving their suffering powerful therapeutic tool you’ll ever have and “no”. their story. All of us have a story. We are – but more about that in a moment. is your own personality.5” “Yes,” because his professional and our story. Indeed, it has been said that a To enable a patient to tell their story So what are the dangers of this personal life encompassed the attributes human being is nothing, but a story with we must first make it clear to them that approach? Both parties can be damaged. If that we now codify as our nine skin around it.3 Our story defines who we we want to listen, and to listen we must you are not aware at the critical moment competencies and all aspire to well before are. As we go through life our experiences empty our own minds of the day to when the patient is ready to tell his or her anybody thought of writing them down. get interpreted then redefined and day preoccupations that tend to clutter story you may increase or prolong their “No,” because he was a surgeon and a reinforced by recollection and retelling, so our heads – is this patient’s mild fever suffering. To have an untold or rejected healer, as so many have been before him, becoming our story. When we suffer, this significant? How am I going to get last story of suffering is the worst of agony. probably intuitively using the methods becomes part of our story. How, then, are night’s urgent case into theatre? I must How many times have you, as the “second I’ve briefly described. we surgeons to deal with this aspect of remember to tell the registrar to get opinion” surgeon, heard a patient say, Our challenge is to resist the forces that our patients? started on time tomorrow as I’m going to “they didn’t listen to me”? mitigate against us practising in this way Like all medical encounters we must be late – and so on. I found doing rounds As far as the clinician is concerned, we and to follow him in becoming surgeon start with diagnosis. There is no blood in the evening, slowly, and without junior may get too close and so be overwhelmed healers, as well as teaching the next test or imaging that will give us this. staff a good way to start the process. by the patient’s pain and loneliness, or generation to be surgeon healers. Indeed, patients are often mute about Silence can be helpful as it is an invitation we may expose our own vulnerabilities. Hugh Martin, their true suffering, tending to express for the patient to talk, as well as being I think it is this risk that is behind the NSW Fellow only some definable concerns such as important therapeutically. tradition that doctors shouldn’t engage pain, malaise, weakness, nausea or loss Some of you may feel that this aspect emotionally with their patients, a view References of appetite. This is not to say that these of patient care is being addressed by that I thoroughly reject. A middle course 3. Havig A. Fred Allen’s Radio Comedy. Temple are unimportant – in a recent study students being taught communication of engaging, listening and being there University Press, Philadelphia. 1991 Wilson found these physical symptoms skills, but without true underlying benefits both parties: it benefits the 4. Wilson KG, Chochinov HM, McPherson played a major role in patients’ suffering.4 compassion and a receptive, empty mind patient in the way I’ve described, and it CJ, LeMay K, Allard P, Chary S, et al. The same study found that there were open to the patient’s story, patients will benefits the clinician. Suffering with Advanced Cancer. J Clin Oncol. non-physical causes of suffering in quickly perceive that these techniques are Yes, it benefits us. I’m sure we all 2007;25:1691-1697 different domains such as social in superficial and thus demeaning. remember some of our chronic or 5. Smith: Thoughts for new medical students which were concerns about isolation The good news is that alleviation of the terminally ill patients: what they’ve said at a new medical school. BMJ 2003;327:143

Page 48 / Surgical News May 2013 Surgical News May 2013 / Page 49 College Awards The Royal Australasian College of Surgeons Member Advantage Benefit Program

Congratulations on your achievements This presentation took place at the USANZ ASM on 13 April 2013 International money transfers He has made 456 presentations to He has been a supportive educator learned societies, written 160 original and mentor to many of our Trainees papers in peer-reviewed journals, 60 book who have worked with him in at better rates than the banks! chapters and authored 10 books. London. Among them, I include our He has had 36 visiting professorships, current President Michael Hollands. presented 192 invited lectures, and 87 His first visit was to Annual Do you need to pay an international invoice, purchase times travelled as visiting surgeon in Scientific Meeting of the Urological Europe, America, South Africa, South Society of Australia and New Zealand a property or send money to family members overseas? East Asia and New Zealand. in 1986. Since then he has been Our partnership with OzForex allows you to transfer He holds a personal chair as the an invited guest at many further Professor of Urology in the University of scientific meetings. He has delivered money worldwide at significantly lower rates than banks. London at the Institute of Urology, Royal many papers, chaired sessions and Free and University College London given honest and candid opinions award winner School of Medicine. on many topics. He has encouraged Benefits of using OzForex include: He is also the Director of the Institute rigor in scientific presentations and Anthony Richard of Urology at that institution. helped improved the standard of £ Free transfers for RACS Fellows and Trainees Mundy MS FRCP FRCS He is also a Visiting Consultant presentations at scientific meetings Honorary Fellowship Urologist, St Luke’s Hospital, Malta and as a visiting Professor undertaken $ No receiving bank fees in most countries and an Honorary Civilian Consultant surgical teaching sessions particularly ¤ Phone access 24-hours a day, 5 days a week Urologist to the Royal Navy in New Zealand. He has conducted nthony Richard Mundy has He is a Member of Council, Royal workshops, demonstrated his ¢ Online access 24/7 an international reputation in College of Surgeons of England 2000 and surgical technique in complicated ¥ Competitive foreign exchange rates Asurgery in the field of urology. He a Past President of the British Association reconstructive operations and taught is particularly well known to urological of Urological Surgeons. a local contingent his skills. He has across 52 currencies surgeons of Australia and New Zealand. He is an Honorary Member, Urological made a valuable contribution to He was born in London, educated as a Society of Australia and New Zealand. urological surgery in Australia and classics scholar and trained in surgery and Professor Mundy has made a great New Zealand over the past 25 years Register online today to save on transfers, or urology at St Guy’s hospital in London. contribution to urological surgery and this honorary Fellowship is speak to OzForex’s accredited dealers for more His work in reconstructive urological in Australia and New Zealand both granted to acknowledge this. surgery has made a great contribution to through generous support to Fellows in information about the service. this particular field and distinguished him London and through visits to both our Citation kindly provided by in urological surgery. countries. Andrew Brooks

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