Number 38, THE FUTURE OF ASGBI: December 2012 A PERSONAL VIEW My term as President comes to an end this month. It has been a their trainees should not be obliged to do as much “general surgery” in privilege to serve the ASGBI and, usually, a pleasure. The single issue their training on the basis that they will not use it on consultant that has caused most discussion has been the future of general surgery. appointment. Whilst I have sympathy with this view, it has to be Like many of you, I have strong views on this topic. I do not adhere to recognised that a consequence of evolving different training programmes the Luddite school of surgery, which argues that nothing must change. within the umbrella of the general surgical CCT would be inappropriate. Neither do I agree with the view that General Surgery is dead, and that It would be wrong for someone to be awarded a general surgical CCT the time has come for it to be supplanted by a loose grouping of who was not competent in the management of the EGS take. smaller craft specialities. I share the aspirations of breast surgeons and others who argue that My opinions are not, I assure you, based upon any preconceived they should be recognised as distinct specialities in their own right. But notions or prejudice. They have evolved after careful consideration of a this cannot happen without GMC approval. ASGBI, therefore, has a number of factors, which will inevitably influence the provision of all responsibility to collaborate with its constituent parts. There must be surgical services in forthcoming years. These include manpower issues no “competition” with the craft sub-specialities, as these have their (the number of trainees is falling, consultant expansion has stopped own clearly defined roles. This concept of the ASGBI as ‘federation’ is and, in many specialities, there is a surfeit of CCT holders without how I see the future of this Association. My vision for the ASGBI is jobs); EWTR (apprentice style training has gone, we now have shifts based on this, and can be summarised into three salient points. and CCT holders will not be as experienced in the future as they were 1. The Annual International Surgical Congress will continue to expand and in the past); life style issues (not just the feminisation of the workforce, be comprised of a number of parallel, co-located, meetings. I favour the but a recognition that no-one - male or female - wants to work development of a “surgical week”. We have to recognise that study ridiculous hours, and why should you not have a life outside surgery); leave allowance, both in terms of time off and expenses, is becoming an increasing acceptance that much surgery does not require super- increasingly difficult for both consultants and trainees. We, as a surgical specialist skills; and lastly, but arguably most importantly, an increasing profession, would make everyone’s lives much easier if we reduced the realisation that outcomes for emergency surgery are inconsistent ludicrous number of surgical meetings in the UK each year. around the country, and are often poor. All these issues are discussed in detail in a document entitled Training Surgeons for Future Service 2. ASGBI is a not-for-profit membership company. It is not constrained Requirements. This paper is available to all who want a copy from our by Charity Law as are most surgical associations and Colleges. As website. It has been discussed at all four Surgical Royal Colleges, the such, we can unashamedly act in our members interests (charities FSSA and the Surgical Forum. It has generated heated debate, but must act exclusively in the public interest). The ASGBI is the only there is now a growing consensus that the primary principle espoused Surgical Association that can legitimately comment on terms and in this paper is correct; this is that we, as a profession, have a conditions of service, facilitate member benefits which may be responsibility to train surgeons for the needs of society. Therefore, material (like the new ASGBI Surgical Indemnity Scheme) and training requirements and the need - or otherwise - for specialists must represent surgeons from any part of the UK and Ireland. In time, be determined not by what surgeons want, but by what society needs. the ASGBI should evolve into the surgical equivalent of the BMA. Society needs emergency surgeons. The single most frequent reason Professions are only permitted a single representative Trade Union. for admission to either a UK or Irish hospital is emergency general In my view, the BMA does not represent the views and aspirations surgery (closely followed by trauma). of the surgical fraternity. I think this is the future of the ASGBI. The issue is not, as many would have it, a question of jobbing general 3. ASGBI has demonstrated, to all who care to look, that it is surgeons dabbling in the management of breast, oesophageal, hepatic extremely effective in looking after other, sister, associations. For or rectal cancer. These comments merely serve to obfuscate matters. example ASGBI organises subscription collection and membership There is no debate over the fact that uncommon complex conditions databases for around a dozen other societies, administers offices require specialist provision. But, we need to recognise that the skills and facilities and, as already mentioned above, has a proven track required to look after such complex conditions will not be attained by record as a professional conference organiser.I think that ASGBI CCT, will almost certainly need post CCT training, and will not be should expand these activities on behalf of other surgical disciplines. needed in every hospital up and down the land. We have already been approached by some of the smaller SAC- defined specialities, and I feel we should encourage these potential So, in my view, General Surgery is not dead. It is alive and well and partnerships. As such, ASGBI will increasingly represent a federation represented by the needs of the emergency general surgical take. Some of surgical specialities in which none lose their separate identities, might argue that this is, in fact, an emergency abdominal or visceral but all function together for the benefit of British and Irish Surgery. surgeon, and I have no problem with this except to point out that this is This might necessitate, as suggested by some, finding a new home. not what is, at present, defined in the curriculum for the award of a general surgical CCT. The curriculum for the CCT in General Surgery has Let me conclude by welcoming John Primrose as your next President. I recently been re-written to take account of changes now that vascular am delighted to be leaving the ASGBI is such capable hands. I have no surgery is a recognised independent speciality. This revised curriculum has doubt that he will continue to take the Association forward for the been submitted to the GMC, who, whether we like it or not, are the benefit of all members irrespective of College or speciality affiliation. arbiters of recognition of speciality status. The whole issue of speciality Merry Christmas and a Happy New Year! status and future surgical training is now the subject of the Greenaway review, which will not report for at least another year.I know that many John MacFie breast surgeons, and some in other craft specialities, feel strongly that President, 2011 to 2012

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www.asgbi.org.uk Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 2 GUIDANCE FOR CONTRIBUTORS Material submittedto the World AssociationofMedicalEditors (W by theCommitteeonPublication Ethics(COPE)and various formsofpublicationmalpractice, assetout of PublicationEthicsandtheelimination wholeheartedly tothehigheststandardsinrespect reviewed academicpublication,wesubscribe and toseekany amendmentswhicharedeemed right tosubmit anymanuscripttopeerreview original totheauthor(s).The editorsreservethe This listisnotexclusive. Great BritainandIreland(JASGBI) Although Publication standards JASGBI The Aims Association toawiderprofessionalaudience. advance thereputationandfunctionsof of theAssociation,whichwillpromoteand material oftopicalorgeneralinteresttomembers Personal experiences,parallelcareers,hobbies, • Historicalarticlesofinterest andrelevanceto • Articlesoninternational surgicalpractice,as • NewsfromtheRegions, andfromaffiliated • Articlesoftopicaldebate. • • range ofsubjectmatterwhichmayinclude: academic papers.We neverthelesswelcomeawide and isnotintendedasavehicleforconventional new andoriginalmaterial. professional writingandtoactasavehiclefor encourage andhelpdevelopstandardsin previously named quarterly publicationwhichhasevolvedfromthe ‘ ordinary, orwhichwouldfitourpopular activities andachievementswhichareoutofthe surgeons. their travels,attachmentsandsecondments. observed bymembersoftheAssociationon Speciality AssociationsandSocieties. they bearuponsurgicalandprofessionalpractice. development, andissuesinnationalpolitics,as relation tosurgicaltraining,teaching,career Articles ofnationalandstrategicrelevancein Secret Lives JOURNAL OFTHEASSOCIATION OFSURGEONSGREAT Journal oftheAssociationSurgeons is notapeerreviewed,academicpublication BRITAIN ANDIRELAND:CONTRIBUTORGUIDANCE JASGBI and asksthatpotentialcontributorstakethefollowingguidelinesintoconsideration. ’ is notaconventional,peer series. Newsletter The AssociationwelcomesandencouragescontributionsfromFellows, JASGBI JASGBI . should thusbe It aimstopublish is keento is a (As atNovember2012) AME). article tomeetthestandardsandstyleof to improvethepresentationorcontentof font directly tothe Copy shouldbesubmittedelectronically and references. terms, wewillpublishnomore thantenrelevant references intheVancouver style.Ingeneral neither encouragenorsupport longlistsof presentation andshouldbeavoided. P images and/orfigures.Ingeneralterms, be of2,000wordsorless,withuptofouroriginal are flexibleastocontent,articlesshouldusually around 750wordswithasmallpicture.Whilewe Please submitarticlesin Article length JASGBI References JASGBI agreement ofallauthorstothepublication. to anarticle,pleasesubmitwrittenauthorityand material. Wheremultipleauthorshavecontributed Y submitted inJPGformatifpossible. (minimum resolution640X480pixels)and single files.Ensureimagesarehighresolution the text.Pleasesendimagesseparatelyandas appropriate figuretitleinthecorrectlocation the article.Numberimagesandstate source requiresattributing,pleaseincludethisin from thepersonwhoholdscopyright.If or havethewrittenpermissiontoreproduce submit picturesforwhichyouownthecopyright, We supportfullcolourpictures.Pleaseonly Images andCopyright be publishedalongsideyourarticle. email addresswithanyarticlesubmitted.Thiswill correspondence’ Authors mustprovidea‘for website, tosecurethewidestpossiblereadership. electronic means,asthroughtheAssociation hard copyintheprintedjournalandbyother Association, andtodistributesuchmaterialbothin material intheadvancementofinterests Jessica P ou retainthecopyrightofyourpublished owerP . Each pageof oint graphicsdetractfromthequalityof reserves therighttousepublished is notajournalofreferenceandwecan te,at ether, JASGBI [email protected] JASGBI Production Manager, Miss point size12,Calibri can accomodate JASGBI ’s . .

support tochallenge poorperformance and medical directors lackthewillor them asanintellectualgame. Too many of thevalueappraisalsand, atbest,treat Too manydoctorshavenotbeenconvinced organisations goingthrough themotions. there arealsotoomanycases of transparent systemsacrossthecountry, there areexamplesofrobustand not consideredawidespreadsuccess.While The currentclinicalgovernanceprocessis framework whichwill“host”revalidation. The loudestmoodmusicemanatesfromthe required tomakeitasuccess. revalidation willjustifythetimeandeffort remains considerablescepticismthat demands onitsefficiency. However, there but alsoforasystemfacingunprecedented patients wantingtoreceivethebestcare, technologies”. Thisisimportantnotonlyfor with thelatesttreatmentsand should ensuredoctorsare“uptospeed Mr Hunthasdeclaredthatrevalidation systems andwillhopefullyevolveovertime. trusts’ establishedclinicalgovernance tenacity. Third,revalidationshouldbuildon Council shouldbecongratulatedforits step forwardandtheGeneralMedical good. Second,revalidationisanunarguable quality ofUKmedicalpracticeisusually explaining whythisisthecase.First, It isimportanttostatethreethingsbefore the qualityofdoctorsisinbettershape. most optimisticcanclaimeffortstotackle local mischief-making.However, onlythe political interference,poorconsultationand conflicting clinical“evidence”,thinlyveiled reconfiguration isstilloftenastickymessof Despite someprogress,service both issueseversince. centres. TheNHShasbeenwrestlingwith the debateovercreationofspecialist variability ofmedicalperformanceandfed Royal Infirmary inquiryhighlightedthe It ismorethanadecadesincetheBristol heart surgery. Reconfiguration Panel toreviewchildren’s decision toasktheIndependent withindaysofhis for medicalrevalidation Jeremy Huntannouncedthefinalgo-ahead Editor oftheHealthServiceJournal Alastair McLellan LEFT TOGMCALONE REVALIDATION CANNOTBE reproduced with theirkindpermission. network. club, colouroronewhoisoutsidethe leaders topunishsomeonefromthewrong revalidation maygivetheopportunityforsome all [too]commoninsometrustsand remarked: “ But asonecommentatoronhsj.co.uk on this. involvement andseekstogatherfeedback importance ofteamworkandpatient ago. Revalidation rightlystressesthe Mid StaffordshireFoundationTrust sixyears cultural problemspresent,forexample,at will notsolvethekindofdeep-seated behaviour. Theintroductionofrevalidation gmcalone/5051041.article dation-cannot-be-left-to ( October 2012 Health ServiceJournalwebsite on24 This articleoriginallyappeared onthe “ who championsrevalidation-warned: Another commentator-amedicaldirector address this?Idoubtitverymuch. Isrevalidationgoingto just ‘havingabadday’. frowned upon,butasit’saconsultant,heis and askedthem‘areyoustupid?’thiswouldbe junior staffmembertheyweretalking‘crap’ enhances effectiveness. boards canensureitsaveslivesand care. Strongandconsistentengagementby resented forthetimeittakesfrompatient increasingly irrelevantbox-tickingexercise, and revalidationwillslideintoan professional regulation,clinicalgovernance Isolated asastraightforwardmatterof in medialperformance. is helpingdeliveraconsistentimprovement primary care,needtoconvincethemselves those chargedwithimprovingthequalityof clinicians. Itissomethingtrustboards,and one addressingthequalityofindividual system andorganisationalissue,aswell governance processinwhichitsits,isa Revalidation, and-cruciallytheclinical But theseproblemsarenotinsurmountable. poorly performingdoctor desperately longtimetowaitdealwitha revalidation takesplaceeveryfiveyears,a doctor appears todolittletestexpertiseina bar hasbeenset.Revalidation, atpresent, Then thereisthequestionofhowhigh http://www Sadly clubcultureandoldboys’networksare ’s chosenspecialism.Finally ” If oneofmyteamsaidtoavery .hsj.co.uk/opinion/leader/revali . - ) and hasbeen ” , th

Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 3 REVALIDATION Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 4 REVALIDATION tackle thequalityofdoctorsisinbettershape” 5. Thepublicneedmaximal confidence indoctors 4. Underperformingdoctorsneedidentifying 3. Badpracticeshouldberootedout. 2. 1. there aresomeindisputablefacts: W will ultimatelyprovetobefruitless. most faitsaccomplis,kickingagainstthepricks as agreatdealofapathyandresentment,butlike There aregoingtoberealteethingissues,aswell of whichwillbelikelyoverflowinginabundance. depends onengagementandenthusiasm,neither I Director ofInformaticsatASGBI Nicholas Markham the GMCAlone Revalidation CannotbeLeftto COMMENTARY TWO: that concerns ofmanyintheprofession.To suggest this paperwilldonothingtoassuagethe process. However, someofthecommentsin doctors remainunconvincedabouttheappraisal the wholeissueofrevalidationandthatmany suggesting thatconsiderabledoubtsexistaround The authorofthisarticleisquitecorrectin Secretary atASGBI Director ofOperationsandCompany John Moorehead the GMCAlone Revalidation CannotbeLeftto COMMENTARY ONE: throw awayremarksareonapartothoseof adequate atweedingthemout.Theauthor’s but existingmechanismshavealreadyproved always betheveryoccasionalpoorperformer, medical practiceintheUK?Yes, therewill is therethatasignificantproblemwith a professional training, andsoonuptheladder to training; from medical schoolintobasic from schoolintoundergraduate medical trust accumulateincrementally, inthepassage based uponaccumulatedtrust. Creditsforthat A Director ofCommunications atASGBI David R the GMCAlone Revalidation Cannot beLeftto COMMENTARY THREE: think McLellanhasgotitaboutright.Success remark withlittlefoundation.Whatevidence e license tosurgicalprofessional practiceis become staleovertime. Doctors’ skills,interestsandperformancecan and thewaymedicalservicesareprovided. and thence,ifpossible,retraining. medicalpractice. in W know thisthatlegislationiscoming,and “only theoptimisticcanclaimeffortsto e want toseethebestpossiblestandards ew is P administrators, family ward, theatreandoutpatient staff, or sheisundercontinualscrutiny bypatients, responsibility forhisorher everyaction.He surgeon carriesasubstantial burdenof balances, ifanything,intensify. Theindividual At consultantlevel,thesechecks and which validatethattrust. competence, integrity, behaviourandsafety, there arechecksandbalancesonanindividual’s consultant status.Atallstagesduringtraining, jump beforeI’mpushed? successful surgeon,butanutterfraud.ShouldI what Ireallyam;notanapparentlyminimally having afearthattheprocesswillrevealmefor suspectIsufferfrom‘ImposterSyndrome’- I Perhaps thegreatestpersonalworryIhaveisthat difference. sceptical; maybeitreallywillmakeasignificant contend withthesedays.Imusttrynottobeso call itwhatyouwill–withwhichwehaveto So, yetanotherpieceofregulation/legislation– the mostobvious. complaints andsomemultisourcefeedback,are morbidity/mortality, costeffectiveness,recordsof specialty to–forsurgeons,their The evidenceneededtoinformwillvaryfrom revalidation cannotbeallowedtoinheritthistrait. invariably littlemorethanatick-boxexercise,and considerably beefingupas,atpresent,itis robustness oftheannualappraisalwillneed consistently identified,andthenremediated.The and allowpoorperformerstobereliably almost aslongfortheprocesstohaverealteeth, The processwilltakeyearstomature.It we alreadydo. practice. Revalidation willadd nothingtowhat either tolerateorcondonepoorclinical very quickly. Iknowofnosurgeonswhowould have thepotentialtoflagupperformanceissues meetings. These,alongwithweeklyMDTs, familiar withhaveregularandrobustaudit utter nonsense.AllthesurgicalunitsthatIam before poorperformancecanbeidentifiedis wait forthefive-yearlyrevalidationprocess would havehim.To suggestthatwehaveto shoulders, irritatedbythefactthatno“club” well-balancedmanagerwithachiponboth a strikemeasthoseof quoted “medicaldirector” was everthoughtof. Thecommentsofthe existed longbeforetheconceptofrevalidation aware thatteamworkandpatientinvolvement forward? Ithinknot.Theauthorshouldalsobe amount oftimeandmoney. Anunarguablestep anything otherthanwasteaconsiderable struggling toseehowrevalidationwilldo average. Ithinkthatmostdoctorsare highlight that50%ofdoctorsarebelow junior healthofficialwhorecentlywantedto erhaps themost potentformofscrutiny is , friends andothers.

with thecomplaints culture,andfearsof the and emotional energyexpendedindealing distractions fromclinicalwork. Throwintime Health andSafety),allofwhich aresignificant and StatMandtraining (50Shadesof local andenhancedappraisal, reflectivewriting requirements toengagein annual jobplanning, administrative pressureatpresent,with Consultants feelunderconsiderable five years. allegedly nothadsuchanappraisalinthepast consultants inmyowninstitutionhave surprise tomethatsome20%ofthe400+ appraisal process,itisamatterofsome importance nowattachedtotheannual life intoafolderonanannualbasis.Giventhe collate documentationonone’sprofessional in asupportiveenvironment,andanexcuseto opportunity forregularreflectiononpractice organisations andappraisees.Theyprovidean Formal appraisalsystemshavemuchtooffer their late60s. consultants areentitledbylawtoworkinto face thanoncewasthecase;andwheresenior significantly lessclinicalexperienceatthecoal consultants arebeingappointedwith are regularlyintroduced;whereyounger where newproceduresandmethodologies careers, inatechnicallycomplexsystem employ 500consultantsatallstagesintheir networks begintobreakdownwhenyou clubbable contactsandinformalinformation place intermsofriskcontainment.Cosy large modernhospitalcanbeafrightening senior managementandtheDoHhierarchy, a Of course,seenfromtheperspectivesof with littleovertdisturbance. actions areexercisedeffectively, quietlyand “course corrections”andlocaldisciplinary is thesensitivityaroundtheseissuesthatmany to thereputationofhospital.Indeed,such they escalateintoseriousharmtopatientsor anticipate andaddressmanyissuesbefore informal linesofcommunicationwillhelp between clinicalandadministrativecolleagues, there isgoodcommunicationandtrust malpractice. Inawellrunhospital,where evidence oftheirownincompetenceor imperiously andcontemptuouslyinthefaceof managements andconcerns,ortoact consultants hadtheauthoritytooverride hospital. Thedayshavelonggonewhen refined ineveryNHSandindependent that underwritethem,havebeenprogressively risk andcomplaintssystems,thepolicies Over thepastdecade,reporting,appraisal, consultant surgeon’s practice. emerge aboutaspectsofanindividual professional community, orforconcernsto undermined bywordofmouthinany reputation tobecomeestablishedor peer observation.Itdoesnottakelongfora , the Autumnof 2013. reflective writing withmyReporting Officer in look forwardtodiscussing this pieceof inconsistencies whichitislikely togenerate.I additional bureaucracyand ofthe or whetheritwillcollapse under theweightof secure theaimswhichhave beensetwithit, directed revalidationinitspresentformwill another. ItremainstobeseenwhetherGMC- appraisal fitforpurposeinoneformor helping maketheconceptofenhanced helping makeitworkasintended,andin engaging withtherevalidationprocess,in Clearly, surgeonsshouldtaketheleadin autocracies. studied historyandtheworkingof as fundamentallyilliberalbythosewhohave prejudice inasystemwhichmaybeperceived be hugescopefordeliberateorinadvertent therewill the processwithabsoluteintegrity, While thebestreportingofficerswillapproach command structureofthehealthsystem. their ownrevalidationandthroughtheinnate also directlyanswerabletotheGMCthrough employees theyarerevalidating.They (generally) employeesoftheNHSTrust whose independence, inthattheyareboth double indemnity. Theylack true Unfortunately, Reporting Officers carrya who theyarerevalidating. must carrytheconfidenceandtrustofthose pressures, whichareultimatelypolitical.They Officers areseentobeindependentofGMC revalidation, itisessentialthatR felt bymanymembersoftheprofessionabout directors ofNHSTrusts. Giventheanxieties Officers, whowillgenerallybemedical enormous powersinvestedintheReporting tested inthecourts.Itrelatesto believe willultimatelyandrightlycometobe haveafurtherconcernonmatterwhichI I at source. a local reportingandappraisalsystemswouldgo strengthening andenforcementofthecurrent for thiscalluponpreciousresources,when wonder whatpracticalreturnwillbesecured the healthservices.Onecannothelpbut may yetobligesubstantialcutsinfundingfor and wherethestateofnation’s finances which isalreadyunderconsiderablepressure, massive timecostsandpenaltiesforasystem appraisers andappraisees,whichwillcarry substantial increaseinworkload,bothfor already clearthatthiswillproduceavery revalidation.Itis And sotoGMC-directed entirely. voluntary participationintheappraisalprocess some colleaguesfoldorwithdrawfrom waiting room,anditissmallwonderthat GMC elephantlurkingintheprofessional long waytoteasingoutpotentialproblems eporting

Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 5 REVALIDATION

Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 6 SURGICAL RESEARCH Research Fund (nowCancerResearch UK). establish whatbecametheImperialCancer joint cancerresearchcommitteewassetupto £100,000 tobeusedforresearchintocancer. A the CollegeandRoyal CollegeofPhysicians Morris, aurologistandCouncilmember roads intosurgicalresearch.In1902,SirHenry W close associationswithLister, Paget, Spencer- Throughout the19thCentury, theCollegehad thousand visitorseachyear development in2008,andreceivesseveral museum isthrivingtoday, followingitsre- specimens weredestroyed.However 1941, wheretwothirdsoftheHunterian glory untiltheLuftwaffescoredadirecthitin dominated thesiteandremainedinitsextensive Collection ofmuseumspecimens,the accepted thecustodianshipofHunterian its foundationasaRoyal College,whenit College ofPhysicians,whodeclined.Eversince collection wasinitiallyofferedtotheRoyal significant amountofmoniestoachievethis.The Company ofSurgeonsin1799,anddonateda when theGovernmententrustedittoThe Collection, built primarilytohouseJohnHunter’s College ofSurgeonsinLincoln’s InnFieldswas centuries. ThecurrenthomeofRoyal which stemfromresearch,overseveral significant changesinsurgicalpractice,manyof been involveddirectlyorindirectlywith The Royal CollegeofSurgeonsEnglandhas College ofSurgeonsEngland Secretary totheResearch Board,Royal Martin Coomer ROLE INSURGICALRESEARCH SURGEONS OFENGLAND’S THE ROYAL COLLEGEOF Ward round:Paul Moxey theperipheralpulse palpating ofapatient. ells, Treves, Owen,allofwhommadehugein- . , the , gave Pharmacology. Otherchairsdevelopedin followed byspaceforPhysiologyand animal housewerecompleted,subsequently Ophthalmology, DentalScience,Pathology andan programme, laboratoriesforAnatomy, foundation and,afteranextensiverebuilding Sciences strengthenedtheCollege’sscientific Jones. Afterthewar occupied byRupert WillisandFrederick Wood were endowedinpathologyandanatomy, During theSecondWorld War, professorialchairs which healsopurchased. laboratories atDowne,alongsideDarwin’s home Browne, awealthyurologist,builtsurgical through thegenerosityofGeorgeBuckston College asamajorplayerinsurgicalresearchand, in 1936.Hewasdeterminedtoestablishthe committee fromitsinceptionin1913untilhedied Surgery, wherehewaschairmanoftheeditorial Great BritainandIrelandtheBritishJournalof six years,foundedtheAssociationofSurgeons the College.HewaselectedPresident in1926for Lord Moynihanwasatruepioneerofresearchfor Bastion inAfghanistan. practice continuestoday, forexampleatCamp field hospitals,savingthousandsoflives,andthis transformed casualtyclearingstationsintolarge too longandallowedfatalinfectionstosetin.He evacuating woundedbacktobasehospitalstook the Front, contrarytoofficialpolicy, where Service, insistedsurgeryshouldbeundertakenat Bowlby, asDirectorGeneraloftheArmyMedical in World War I-forexample,SirAnthony Surgical Research Report. Thiswasalsoprevalent Research FellowsaccountsinthecurrentRCS today, asexemplifiedbytheCollege’sMilitary been takeninsurgicaltreatment.Thisisevident few centuriesistheenormousstridesthathave the manywarsthathavehappenedoverlast One ofthefewpositiveoutcomestocomefrom , the InstituteofBasic

Armed Forces. tradition ofthe Collegeinitscloselinkswith the research fellowships,continuing withthe appointed asignificantnumber ofmilitary Scholars intheUSA.Recently, wehave also currently havetwotraineeswho areFulbright approached bytheFulbright Programme and Lately Cancer Research UKandArthritisResearch UK. National JointR and otherprestigiousbodies,suchasthe fellowships withsurgicalspecialistassociations undertake partnerships),andvariousjoint benefactors, othercharities(someofwhom College’s ownendowments,individual for theschemecomefromseveralsources: are highlysoughtafterbyitsmembers.Thefunds Scheme isnowwidelyknownandthefellowships around £60,000each.TheResearch Fellowship over 600researchfellowshipswhichtodaycost Nearly twentyyearson,theCollegehasawarded Peter Morristobethefirstchairmanin1993. Research FellowshipSchemeandappointedSir Browse, convincedtheCounciltoestablisha medical schools.ThethenPresident, SirNorman the departmentstoclinicalenvironmentsof recommended thattheCouncilrelocatesomeof review ledbySirMichaelPeckham independent researchinstitute,anexternal of Londonandthedifficultysustainingan cessation ofsupportingfundsfromtheUniversity running theBasicSciencedepartmentsfollowing In theearly1990s,withincreasingcostsof winner Fellows oftheRoyal SocietyandaNobelP which wasparticularlysuccessful,fosteringthree Biochemistry, BiophysicsandinPharmacology, about hisailments. Siobhan McKay listeningtoanelderlypatienttalk we , , Sir JohnV have beenthefirstRoyal Collegeto be egistry, ane. Medical Research Council, rize surgical andmethodological expertise. continuity and abilitytoprovidetherequired number ofstafftoprovidethe necessary has resultedintheCollegeunderwriting acore School ofHygieneandTropical Medicine).This collaboration withanacademic partner(London to formtheClinicalEffectiveness Unitin surgical audit.Theupshotof Doll’sreviewwas review ontheCollege’sfuturepolicytowards Professor SirRichardDolltochairastrategic ‘interference’ and,in1995,Councilasked number oftheCollegeFellowstothis was significantoppositionatthetimefroma more, savefortheirprematuredeaths.There achieved muchandbothwouldhave could bemischievousinhisways.However, he part withtheir‘personal’dataandBrendan an easyjourneytoinitiallypersuadesurgeons Epidemiology andAuditUnitin1990.Itwasnot field, withtheCollege,toformSurgical and DavidDunn(comparativeaudit)ledinthis Thus, whilstnotanewconcept,BrendanDevlin help todesignstudiesusingstatisticians’advice. disciplines; expertsinhealthservicesresearch surgical auditusesmethodsfromother such practicewasnotuniversal.Today, modern outcomes, andsharedresultswithcolleagues, operative monitoringbyrecordingsuch though Hunterpioneeredroutinepost- operations arecollectedandanalysed.Even the wayinwhichoutcomesofsurgeons’ 1993, therehasalmostbeenaparadigmshiftin Since theResearch Boardwasestablishedin project intheDevelopingWorld. elective grantsiftheyareundertakingasurgical fruitful. Medicalstudentsmayalsoapplyfor surgically relatedprojectwhichareparticularly students undertakingIntercalatedBScsina College awardstengrantsof£5,000tomedical academic zest.Attheotherendofscale, P have successfullycompetedforthesePump that anumberofformerCollegeresearchfellows for aprogrammegrant.Itisencouragingtosee corn moniesto‘getthemgoing’beforeapplying lecturers andconsultants,whoneedsomeseed ambitious anddeterminednewlyappointedsenior for equipmentandtechnicalsupporttokick-start these aregrantsofupto£10,000.Themoniespay namely PumpPriming grantsforyoungconsultants; other researchgrantsareawardedbytheCollege, In additiontotheResearch Fellowship Scheme, of prizesawardedatscientificmeetings. of theirpublicationsisalsohigh,asthenumber to beontheincrease.Theaverageimpactfactor research fellowsaregainingPhDsandthisappears College Research Fellowship. Aboutathirdof alternative supportonthestrengthofgaininga at duration, 98%oftheresearchfellowsundertake Although mostFellowshipsareofaoneyear in working alongsidestatisticiansandepidemiologists are ineducationalprojectsandothersaudit, schools throughouttheUK,someresearchfellows laboratory-based inUniversities andmedical all ofthesurgicalspecialties,andwhilstmostare The CollegeawardsResearch Fellowshipsacross riming grantsasamarkeroftheircontinued the ClinicalEffectivenessUnitofCollege. least twoyearsworthofresearch,finding

Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 7 SURGICAL RESEARCH

Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 8 SURGICAL RESEARCH in atimelyfashion. EachSurgicalSpecialtyLead is surgical investigators anddelivertheclinical trials the centrestodevelopclinical networks,trainthe of undertake thisrole,alongwith theappointment Several centreshavealready been selectedto significant financialsupportto fuelthisinitiative. extremely activeandsuccessful ingaining development ofsurgicalclinicaltrials.Hehasbeen clinical researchcentresthatwillfocusonthe whose mainroleistodriveastrategysupport Director ofResearch, Professor DionMorton, Last year, theCollegeappointeditsfirstClinical years ago–theCET’selectroniclibraryisfirst! specialist/subspecialist librariesofRCTs some30 named, predictedtheneedfor Cochrane, afterwhomtheCochranelibraryis of randomisedcontrolledtrialsinEurope.Archie emphasis onhelpingwiththedesignandreporting knowledge centreforESOT, withaspecial collaboration andtheCEThasbecome Organ Transplantation (ESOT)haveanactive Of late,theCETandEuropeanSocietyof evidence availableinsolidorgantransplantation. established in2005toevaluatethequalityof Evidence inTransplantation (CET).Thiswas Also embeddedwithintheCEUisCentrefor to read,analyseandcriticisescientificpapers. increasingly importantdataandwillenablethem trainees haveanopportunitytolearnaboutsuch Curriculum Project. Thiswillensurethatall methods moduleintheIntercollegiateSurgical the ClinicalDirector, toin-buildaresearch and itplans,incollaborationwithDionMorton, research methodsandevidence-basedsurgery courses forsurgeonsonstatistics,clinical Each year, thestaffofCEUrunanumber of the valueofHESinarangeclinicalareas. has beenchallenged,theCEUdemonstrated Although thequalityofavailableinformation pathway ofpatientscanbefollowedovertime. provide anationalpictureandthetreatment major advantagesofthesedatabasesarethatthey information forallNHSadmissionsintheUK.The contain recordsofdiagnosticandprocedure databases inScotland,Wales andNorthernIreland, statistics (HES)database,andtheequivalent and researchprojects.Thehospitalepisodes increasingly usedadministrativedataforitsaudit outcomes. Duringthelastdecade,CEUhas undergoing similartreatmentshavedifferent problems aretreateddifferentlyandwhypatients questions: whypatientswithsimilarhealth In essence,theCEUaimstoanswertwogeneric to namebutafew. Network andUKIntrathoracicTransplant Audit Reconstruction Audit,CraniofacialAnomalies R outset inanalysingdatafromtheNationalJoint its PROMSworkandwasinstrumentalatthe Oesophogogastric Cancer).Itwaspioneeringin specialist associations(e.g.NationalAuditof running largeaudits,ofteninpartnershipwith The CEUhasbeenparticularlysuccessfulin external fundingfromawiderangeofsources. robust scientificmethodshavebroughtin The staffoftheCEUhasmushroomed,asits egistry andNationalMastectomyBreast Surgical SpecialtyLeads,who willworkwith , better practiceandoutcomesforourpatients. surgeons, andplayanimportantroleinstrivingfor continue tosupportsuchambitiousanddiligent surgeon ontogreaterthingsandhopefullywill The Collegecanlayclaimtohelpingthisyoung of patientsworldwidewithend-stageliverdisease. led totherestorationofnormallifeforthousands farm. Stemmingfromthiswork,theresearchhas supported hisresearchattheBuckstonBrowne professor ofphysiologyattheCollege,who work ontransplantationwasunderDavidSlome, development oflivertransplantation.Calne’searly DeBakey ClinicalMedicalResearch Award forthe awarded thehighlyprestigious2012Lasker– who, withThomasStarzi,hasrecentlybeen congratulate SirRoy Calne, past VicePresident I meet theneedsofpatient. effective meanstochangesurgicalpracticeand conducted, large,multi-centretrialsarethemost programme. TheCollegebelievesthatwell- Steering Committee)-tooverseethisambitious committee -CRISC(ClinicalResearch Initiative has beenappointedtochairtheindependent The CollegeisdelightedthatSirMichaelRawlins clinical trialsportfoliooverthenextfiveyears. infrastructure todevelopandexpandthesurgical should developanationwideresearch This Collegeinitiativeisexcitingandworthy within thatspecialtywillbeacoreobjective. developing otherclinicianstoleadfuturestudies trial, itisexpectedthatencouragingand Specialty Leadislikelytoheadupatleastone appropriate fundingbodies.WhiletheSurgical proposals thatcanbeprocessedthrough clinicians andprovideaforumfordiscussionsof are taskedtoactasaconduitforinterested and clinicalnetworks.TheSurgicalSpecialtyLeads whom theywillworktodeveloptheclinicaltrials affiliated toSurgicalSpecialistAssociation,with behaviour infracturehealing. James Chaninvestigatingtheregulationofstemcell cannot resistusingthisopportunityto

Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 10 UPDATE ON ASGBI Programme Vice President andDirectoroftheScientific Congress has remainedconsistent. Association’s Congressforthepastthreeyears away fromtheirTrusts, attendanceatthe to reductionsinstudyleavebudgetsandtime that bothConsultantsandTrainees faceinrelation ongoing worldwiderecessionandthechallenges conferences intheworld.Thus,despite that theCongressisamongstbestmedical the highqualityofassociatedpublicationsensure programme, theprofessionalismofdeliveryand outstanding success.Thequalityofthescientific (from anAnnualScientificMeeting)hasbeen Association’s InternationalSurgicalCongress The evolution,overthepastfouryears,of A review oftheirareafromthelast12months. Board membershaveeachproducedashort ourExecutive what ishappeningwithinASGBI, As ameansofkeepingourFellowsuptodatewith EXECUTIVE NEWS Hepato and Training (ICOSET)andtheEuropean-African International Conferenceon Surgical Education arrangements havebeenmade withthe direction oftravelhasbeenextended further, and Trauma andMilitarySurgery (ATMS). This in Primary andtheAssociationof Care(ASPC) Association (UKMSA),theofSurgeons (BIF included theBritishIntestinalFailureAlliance thesehave conferences paralleltoASGBI’s; other AssociationsandSocietieswhoholdtheir hassuccessfullymanaged toengagewith ASGBI As wellasdeliveringahighqualityCongress, to attendtheCongressbytheircolleaguesorpeers. around athirdofdelegateshadbeenrecommended programme contentasverygoodorabove,andthat majority ofdelegatesratedthequality Congressshowedthatthe years oftheASGBI Additionally Congressinalternateyears. attended theASGBI year. Theremaining35%ofdelegatesoften Congressthefollowing registered fortheASGBI showed thataminimumof65%delegatesre- A ‘on-site’ registrationsontheFriday. NOTE: In2010,avolcanicashcloudresultedinno numbers significantly. 2014 and2015, whichwillincreasedelegate in to havetheirconferencesin parallel toASGBI’s recent analysisconductedbytheAssociation report onthe A), theUnitedKingdomMedicalStudents’ -P ancreato-Biliary Association(E-AHPBA)ancreato-Biliary from Professor JohnPrimrose , delegate feedbackfromthelastthree International Surgical colleagues are onboardandthefirstmeeting of Practice Committee.OurSpeciality Association decided toreactivateourdormant P response tothesenewproblems, wehave surgeon oftheirchoiceorthat oftheirGP. In it difficultforsomepatients to bereferreda In additiontothesecuts,this providerhasmade aware ofthedramaticcutsin feesfromBUPA. Those ofyouwithaprivatepracticewillbe disadvantages. Askforaquotation.It’sfree! some otherinsuranceproviders,thereareno offer. Contrarytowhathasbeensuggestedby you alltolookatthepotentialbenefitsSIShas this covermaybediscretionary. Iwould urge problems while,withotherindemnityschemes, guarantees coverwhendealingwithGMC their annualsubscriptions.Inaddition,SIS switched toSIShaveseensignificantsavingsin the benefitsSIShastooffer. Thosewhohave encouraging ourmembershiptolookcloselyat probably provedtobethemosteffectivewayof communication fromthe“converted”has the profileofSIS.Nevertheless,wordmouth These, alongwithadvertising,havehelpedraise inform ourmembersofthisnewcompany Some smallroadshowshavetakenplaceto indemnity providerstothenewSISscheme. our memberstoswitchfromtheirlongstanding expected itwouldbeaslowprocesspersuading change theirestablishedpractices,sowe creatures whoaresometimesreluctantto attract members.Surgeonsareconservative up, werealisedthatitwouldtakesometimeto Aregularblogfor • within theconferenceindustry: Surgical Congressthroughthefollowingactivities International profile andvisibilityoftheASGBI Executive, hasbeensuccessfulinraisingthe Finally, NickGair, theAssociation’s Chief subvention hasbeenobtainedfromhostcities. secured till2020,andasignificantamountof Contracts forfutureCongressvenueshavebeen Deliveringakey-note speechforthe • A Scheme (SIS),anewcompanyownedandrunby TheSurgicalIndemnity Secretary ofASGBI. with asDirectorofOperationsandCompany few issuesthatIhavepersonallybeeninvolved During thisshortreport,Iwantedtofocusona Secretary ofASGBI Director ofOperationsandCompany A Afeaturein • Invitationtodeliveraplenarylectureatthe • DeliveringaworkshopforConventionand • Two Leadership’podcastsfor global‘Thought • SGBI, hasstartedtogrow Conference Organisers International AssociationofProfessional Incentive Travel magazine. magazine. Association International CongressandConvention Association MeetingsInternational magazine. report fromMrJohnMoorehead . Meetings andIncentiveTravel Association EventPlanner congress in2013. . When wesetthis rivate magazine. .

latest documents. app wherethey canimmediatelydownload the By tappingthemessage,users opentheASGBI edition of October, to advise membersthatthenew The firstpushmessagewas sent inearly important eventsandother relevant information. of keepingmembersinformed ofkeydates, messaging providesafaster, lessobtrusiveway hours orevendaysforrecipientstoread.Push few seconds,whereasemailscantakemany that pushnotificationsarereadinamatterof that appearoniPhonesandiPads. Studiesshow notifications’, whicharesimilartotextmessages, tosendmembers ‘push ability forASGBI addition, themostrecentupdateincluded either theiremailorTwitter accounts.In and userscaneasilyreadshareTweets via Twitterinclude ASGBI’s feedon thehomepage, In September2012,theappwasupdatedto review alltheAssociation’s keyinformation. International SurgicalCongress publications forofflinereading,viewthe events andtrainingcourses,candownload members haveinstantaccesstoupcoming user video, text,imagesandsocialmedia,allonthe digital platformthatiscapableofdisplaying information fromtheAssociationintoasingle Surgical Congress.Theappcombineskey officially launchedattheMay2012International appwas Bournemouth in2011,andtheASGBI ‘Congress app’hadbeenlaunchedin launch ofa‘year-round’ ‘app’.A ASGBI the pastyearhasbeendevelopmentand Association’s website,themajorachievementin In tandemwiththecontinuedevolutionof Director ofInformatics A ourbenefit. to we shouldcontinuetoengage,asitwillonlybe developments willbeslowbut,overall,Ithink future developmentsinsurgery. Clearly, civil servantsinBrussels,settheagendafor make surethatwe,andnotsomeunaccountable problems aswedoand,likeus,areeagerto in Europehaveexactlythesamesortof discovered thatwearenotalone;ourcolleagues be ausefulgrouptomemberof. I being alittlescepticalbeforehand,Ifounditto last Septemberand,Imustadmitthat,while at themostrecentmeetingofUEMSinZurich from theCollege.IrepresentedAssociation continue ourmembershipwithoutanyinput discussion withinourExecutivewedecidedto and urgedustoremainonboard.After withdrew, ourcolleaguesinEuropemetwithus costs anduncertaintyoverbenefits.Whenwe decidedtowithdrawfromUEMSbecauseof we When theCollegebackedoutofthisagreement, UEMS (UnionofEuropeanMedicalSpecialists). having arepresentativeonthesurgicalsectionof havesharedthecostsof England andASGBI For sometime,theRoyal College ofSurgeons will keepyoupostedondevelopments. this committeewillbeheldintheNewYear. We report fromMrNicholasMarkham ’s mobiledevice.Throughtheapp, JASGBI was availablefordownload. P rogramme and integrated platform. Thenextupdatewillincludean Systems tocontinueenhanceandgrowthis A Surgical Foundation, Orthopaedic Association. other SpecialtySocieties,suchastheBritish demonstrated thatithasnowbeenadoptedby appissoclearly The successoftheASGBI • • Investment Evaluation • Financial InformationandAnalysis • ManagementAccounts • AnnualAudit • current yearfallintofourmain categories: The progressandimprovements madeinthe Accomplishments in2012 while theexistingcharity, whichwasrenamed separate entity, withitsownBoardofDirectors, The membershipcompanywascreatedasa established asatradingcompanyfouryearsago. Ltdwasfirst transformation whenASGBI viewed againstabackdropofbusiness The progressmadeinthecurrentyearneedstobe Background Director ofFinance A • can beseenfromthefollowingstatistics: members abreastofcurrentinformation.This postage costsandthelagtimeinkeeping sponsorship, whilstalsoreducingprintingcosts, increased participationineventsandcorporate opportunity togeneraterevenuethrough fantastic engagementtoolwhichpresentsthe sponsorship oftheAssociation.Theappisa advertising sectionswhichcanattractfurther In addition,SanGenisincorporatingin-app display anewsfeedfromtheSchoolofSurgery. • • 2011, athirdcompany, registeredasthe then essentiallyrequiredentirelydistinctaudits.In maintaining twoseparatebooksofaccounts,which This effectivelyresultedinthefinancedepartment membership. Additionally to providesurgicalindemnityinsurancethe recovered throughacomplexsystemofrecharges. organisations. Theseservicesarethencostedand office relatedservicestoothersmaller mentioned earlier maintaining financialrecordsforthreecompanies in effect,thefinancefunctionisnotonly several othersurgicalassociationsandsocieties.So, number ofservices(book-keeping,payroll,etc)to Indemnity Scheme SGBI isworkinginpartnershipwithSanGen 79% returningvisitors,21%newvisitors 16.09 minutesaveragevisitduration 4,672 visits in thepublicationisnotcounted). just visitingthe‘Publications’page;eachpage (This doesnotincludeindividualdocuments, + app onboththeiriPad andiPhone). different devices,i.e.userswhoaccessthe (This doesnotcountdownloadsusedon 953 downloads eotfo rHoshang.Ghadially report fromMr 31,000 pageviews Surgical News , but providesaccountingand (SIS) Limited,wasestablished retained itsoriginalidentity. , finance providesa section, whichwill Surgical The

Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 11 UPDATE ON ASGBI Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 12 UPDATE ON ASGBI Executive Boardduring2012. decision-making supporttothe Association’s exceptionally wellandprovided considerable In conclusion,Financehasperformed improve profitabilityinthemediumterm. simplifying internalprocessescouldpotentially is suggestedthatadditionaluseoftechnologyand invited to join the ASGBI Executive Boardduring invited tojointhe ASGBI It isagreatpleasure andprivilegetohavebeen Director ofCommunications A such astheiPhone‘app’, incurred costsofover£100konnewinitiatives noted that,duringthelastthreeyears,ASGBI income earned.However, inmitigationitmustbe represents afairlylowmarginaspercentageof two yearshasfallenbelow£20kineachyear. This While thisiscommendable,profitabilityinthelast 2011) hasresultedinacumulativereserveof£94k. operating surplusforthelastthreeyears(2009to Theoverallpre-tax profitability ofASGBI. An issuethatneedsfurtherconsiderationisthe Issue -Reserves andProfitability subsequently approvedbytheExecutiveBoard. over athreeyearperiod.Theproposalwas it wouldgenerateapositivediscountedcashflow concluded thattheinvestmentshouldproceed,as contract quotation,fromafinancialperspectiveand personnel reviewedtheproposal,andsubsequent used forrecordingmembershipdata.Finance proposal waspresentedtoreplacethesoftware With theaimofreducingcurrentcostbase,a Investment Evaluation improve efficiencyandreducespending. expenditure againstoperationalactivitiesto as ameasurementofperformance,andtracking generation, comparingactualdataagainstforecast was analysedandpresentedontopicssuchascash PowerPoint presentations.Financialinformation conveyed totheExecutiveBoardthrough Consequently, in2012,financialinformationwas business andsupportthedecision-makingprocess. The needforinformationisvitaltomanagea Financial InformationandAnalysis segment andtakedecisiveactionwherenecessary. tools, theBoardisabletodrilldowneachcost accomplished in2012and,withavailableanalytical discussion atExecutiveBoardlevel.Thishasbeen quarterly managementaccountsbeproducedfor As partofbestpractice,itisimperativethat Management Accounts months. undertaken andthiswascompletedwithinfour of canbeseen,anefforttocomplete theaudit As time periods,ashighlightedbythetablebelow: than originallyanticipatedandduringunsuitable auditwasbeingconductedmuchlater The ASGBI Annual Audit considerable expansionofthequarterly report fromMrDavidRew the 2011accountsinatimelymannerwas News Scanner Journal and . It Officer and Pether, ourrecentlyappointed Communications experts. Particular recognitionmustgotoJessica possible, includingourprinters,publishersandIT andbeyondwhomakeourefforts at ASGBI Finally, Imustthankallofthe“backoffice”team articles, ortosuggestsubjectsforfutureIIPPs. up thechallengetoeditorotherwisecontribute hear fromanymemberswhowouldliketotake as the interest of I are morethanenoughalternatives. academic, peer-reviewed journal,forwhichthere intend, atthisstage,tomoveoveran with broadandinclusiveappeal.We donot informative andoccasionallychallengingissues their strategyofproducingentertaining,readable, Wyatt’s visionaryEditorships. Ihopetomaintain development underJohnMacFieandMike our strategyfollowingthesuccessofits communication strategyinthecomingyear. enthusiasm injournalismtodevelopour look forwardtoharnessingherexpertiseand The quarterly you whenwearenototherwiseFacebooking. and wearenowconsideringhowbesttoTweet app, are delightedwiththeprogressofASGBI media strategy, whichiscontinuouslyevolving.We portfolio includesthewebsiteandourelectronic ourcommunication what wedoatASGBI; Association. Communicationisattheheartof to 2012, andtohavebeenaffordedtheopportunity publication oftheDecember the groundrunningtoensuretimely at theAssociationcommunications.Jesshashit from nowonwillbethecentralpointofcontact years. Nowothers arejoininginandchange is suggestions for bettermentrepeatedlyover the hasvoicedconcernsand some time,andASGBI around EmergencyGeneralSurgery (EGS)for clinical importance,riskandrelative neglect variety offronts.We haveallbeenaware ofthe momentum aroundemergency surgeryona The lastyearhasseenasteady increaseinthe Director ofEmergencyGeneralSurgery A Guest Editorialcontrol.W will beakintoevidencebasedguidelines,under Issues, undertheimprintofJournal.These academic andauthoritativestrategyforthese intend thatwewillmovetoasomewhatmore significance andimportancetosurgicalpractice.I booklets, onarangeofmatterscontemporary In parallelwiththe in submittingtheirworktothe established surgicalwriterstoseeadditionalvalue we will enhanceourprofessionalstreetcred.Inturn, will begintodevelopthecitationmetricswhich which wearenowconsidering,hopethat one orotherofanumberpublicationmodels progressively availabletothisaudience,through extremely wideaudience.Bymakingourcontent to publish have longheldtheviewthatqualityand report fromMrIainAnderson contribute tothefurtherdevelopmentof hope thatthiswillencouragebuddingand Journal ofASGBI Issues inProfessional P Journal Journal Newsletter ’s contentholdsappealtoan Journal Production Manager, who , remains atthecentreof , e , now affordedgravitas would bedelightedto we willalsocontinue Journal Journal ractice , and we .

problems andsocietalneeds,therehasbeena tension. Inrecognitionofthecurrentprofessional generalism iscleartoallandremainsapersisting between electivespecialismandemergency and workingcloselywiththeSAC. Thedilemma surgeons looking athowbesttotraintomorrow’s hasbeen As theEGSservicechanges,ASGBI considerable variationincare recently publishedand,again,describe a This willcomeonlinein2013to2014.Results of national emergencylaparotomyaudit(NELA). contributing activelytotheorganisationofa is With ouranaestheticcolleagues,ASGBI outcomes andprobablyservicerationalisationtoo. grow. Inturn,thiswillfocusattentionfurtheron to outcomes,anditseemsthistrendcanonly funding pressureisbeingexertedtorelatefunding capacity. Now, however, commissioner–led toincreaseemergencytheatre re-organised other commitments,anumberhavesuccessfully While almostallnowhaveconsultantsfreefrom else theymightbestandreasonablyproceed. changes theyhavemadeandforadviceabouthow teams havebeengettingintouch,bothaboutthe Professional Practice onEmergencySurgery, Issuesin Since thepublicationofASGBI’s specialisation (tonamebutafew). money, publicawareness,trainingandsub- including risk,cost,variableoutcomes,lackof inevitable, giventhecombinationoffactors preliminary andselectivevoluntaryauditwere The Associationisgratefulforthe generoussupport In 2014 the ASGBI Congress,inpartnershipwiththeInternationalConferenceon In 2014theASGBI The 2015Congresswillbeheldin Harrogate Association ofSurgeonsGreatBritainandIreland The nextInternationalSurgicalCongresswillbeheldattheSECCin Glasgow We Friday 24thApril2015 Surgical EducationandTraining (ICOSET)willbeheldin of thefollowingCorporateP DATES FORYOUR DIARY! from look forwardtoseeingyouthere! from Wednesday 30thApril [1] . Wednesday 1st Manchester in partnershipwith two yearsofspecialtytraining. commitment, andtointerestedtraineesinthelast consultant careergradeswithasubstantialEGS Membership isopentoallCCTholdersandnon- electronic mediaandphoneconferences. Congress, inadditiontodiscussiongroupsvia International and willmeetannuallyattheASGBI membersandFellows free tojoinforallASGBI help buildtheprofileofEGS.Thegroupwillbe about futuretrainingandcareerstructure, in thefield,contributetodebatesanddecisions surgery, forthosewhowishtogetmoreinvolved establishing aninterestgroupinemergency is interest. Inrecognitionofthis,ASGBI now describeemergencysurgeryastheirspecial over 100consultantgeneralsurgeonsintheUK some colleaguesweresurprisedtoseethatwell appointments inEmergencyGeneralSurgery, Finally, whilewehaveallbeenawareofnew in EGSamongnewCCTs andtheircolleagues. and hopefully, inturn,thiswillincreaseconfidence which iscurrentlybeingreviewedbytheGMC will bereflectedintheproposednewcurriculum surgery withintheCCTtrainingprogramme.This move toincreaseformaltraininginemergency 1 IssuesinProfessional Practice: Emergency [1] Reference to Friday 3rdMay2013 http://www Ireland (2012) Association ofSurgeonsGreatBritainand issues_in_professional_practice.cfm General Surgery to from Friday 2ndMay2014 .asgbi.org.uk/en/publications/ Wednesday 22nd atrons EAHPBA. . to .

Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 13 UPDATE ON ASGBI Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 14 SURGICAL GREATS while selectivelyexcisinglymphnodegroups early proponentofoperatingforgastriccarcinoma from variouscausesin650patients.Hewasan management ofmassivegastroduodenalbleeding rates. Heencounteredanddevelopedthe below 1.5%,lowmorbidityandexcellentcure gastric andstomalulcerswithanoverallmortality outcome of1,275proceduresforduodenal, operative care.Hewasabletoreportthe registrar, heandhistheatresistersharedthe post- his dailyoperatinglistswereastonishing.Withno ulceration duringtheSecondWorld War, where Tanner workedthroughanepidemicofpeptic which wassuccessful. not disclosethathehadjustsubmittedhisthesis, lacking anMDbut,withtypicalhumility, hedid the seniorphysicianadmonishedTanner for Charing CrossHospital,London.Attheinterview, £600. In1953,hewasinvitedtojointhestaffof Consultant in1945,atafulltimeannualsalaryof the armedservices,buthewaspromotedto and hisdeafnessprecludedhimfromservicein Balham. Heneverachievedaformalregistrarship as SeniorResident Surgeon to StJamesHospitalin Council (LCC)hospitals,beingappointedin1939 subsequently workedinseveralLondonCounty Bristol, qualifiedthereand Norman Tanner, bornin general surgery? of surgeon, becomethedoyen lowest possiblestatus”asa described tomeas“the appointed towhatheonce antithesis ofself-promoter, How doesaquietman,the (1906 –1982) NORMAN CECILTANNER British andinternational statement ofMichaelPolanyi that theyworked.Theyexemplifiedthe comparing results,hewasusingthemandproving recognised astheonlysatisfactorywayof standardised techniqueswereelsewhere only averagecompetence.Longbefore acquired andsafelyperformedbysurgeonsof Tanner’s elegant,gentletechniquecouldbe Clifford Dukestolargebowelcarcinomas. based onthesameprinciplesasthoseappliedby explicitly knowntothemasterhimself.” the rulesofart,includingthosewhicharenot his example,theapprenticeunconsciouslypicksup master andemulatinghiseffortsinthepresenceof 1 Polanyi M [1] Reference others willrecogniseourprovenance. “I’m aTanner trainee”,andweareconfident that him feellikeabandofbrothers,proudtodeclare, Those ofuswhohadtheprivilegeworkingwith into Tanner’s make-shiftoperatingtheatre. technique; thegiantsofadvancedcountriescrowded ‘scrub up’toassistandlearnthefinepointsof They wouldturnupunannouncedandbeinvitedto performed bythesurgeonswhodevelopedthem. watched newandhighly-effective operationsbeing World War, surgeonsvisitedeachotherand In therelaxedatmospherefollowingSecond LCC surgeonasanexemplar. registrars werereluctanttorisklistingamere trainees fromtheCommonwealth,asBritish applicants tobehisassistants.Thesewereinitially committee butbythelengthyqueueofhopeful recognition asamasterwasnotbestowedby Philosophy R P ersonal Knowledge:Towards aP outledge andKeegan Paul, London(1973) [1] : ost-critical “By watchingthe Tanner’s who hadwon.Hereplied:“ in Dublin,whereLadyTyrconnell askedhim popularity, at StGermain-en-Laye nearParis. T legitimate kingwhilehelived atLouis’expense not secure.Jamescontinued toclaimbethe a William andMaryfoundtheir newdominionsin your majestyhaswontherace ran away [1] and hadcontinuedwhenJames IIbecameking without botheringtoomuchaboutparliament, XIV, subventions totheEnglishcrownfromLouis The endoftheStuartmonarchyalsoended Figure 1:StatueofJamesII the battleofBoynehearrived, James IItoFrance. Afterdesertinghisarmyat Scotland, resultingintherapiddepartureof England, Irelandand Mary tothethronesof William (ofOrange)and Revolution’ brought In Financial Trouble University ofLimerick Entry MedicalSchool, Science, Graduate Professor ofSurgical Pierce A.Grace (AN ALLTOOFAMILIAR TALE) TROUBLE INTHESOUTHSEAS parlous financialstateandtheir positionwas . 1688, the‘Glorious The warbetweenthekings was costly which hadallowedCharlesIItorule ”, towhichsheresponded:“ William andMary abolishedthe My cowardlyIrish ”. o poste haste boost their Then Isee . , Each investor’s sharecouldbetraded atpar,Each investor’s their moneywas safewiththegovernment. who wouldhavethesecurity ofknowingthat government andpay4.5% to theinvestors, would make8%onthemoney loanedtothe tonnage ofships.Thejoint stock company could easilybecollectedfrom newtaxesonthe on favourableconditions;the £100,000interest would beassuredofasteadysourcefinance The schemewasingenious;thegovernment in anyamountatanytime. annum, andtheycouldwithdrawtheirmoney which wouldpaytheminterestat4.5%per £10,000 weretoformajointstockcompany subscribers whoinvestedamountsfrom£25to interest of£100,000,or8%.The1520 lend themoneytogovernmentforayearly was toraise£1.2mfrominvestorswhowould which wascontinuedwarwiththeFrench This wastotallyinadequateforthetaskinhand, over £1mwenttopayforthearmyandnavy. them with£1.7mtorunthecountryandofthat, £200,000 perannuminthe1690s.Thatleft disliked chimneytaxof2s,whichwasyielding (1658-1719). hour, e.g. 99years for aslongtheylived,orafixedterm, interest waspaidtothenomineeasanincome of annuities–again,theloanwasnotrepaidbut ‘Million Adventure’lottery(1694)andthesale tontine untilthelastmemberdied.Also,a (10%) wasdividedamongthemembersof relatively highannualinterestontheloan the governmentwasneverrepaid,buta included atontine(1693),inwhichtheloanto which togetherbroughtin£1,408,100.These revenue generatingschemeswereintroduced, have beenenoughforthecontinuedwar. Novel taxes theycollected,theamountwouldnot the corrupttaxgatherershadremittedall 6s andthecommonbachelor, 1s annum, DoctorsofDivinity, LaworPhysic,£1 depended onstatus;Dukespaid£211sper on bachelors(1695).Thebachelortaxrate marriages andburials(1695)and,surprisingly, (1697); Hackneycoaches(1694);births, window tax(1694);alandtax;taxesonpedlars taxes: apolltax(1693);stamp William andMaryintroducedaplethoraofnew New Taxes English exchequer£32.5m (1689-97). Thiswouldultimatelycostthe continue theWar oftheLeagueAugsburg government withthemoneytheyneededto establish asystemthatwouldprovidethe Darien inPanama. In1694,hisschemewasto disastrous onetoestablishaScottishcolonyat P ‘projector spent mostofhislifeasamerchantand William Paterson wasborninScotland.He The BankofEngland £1m intheestimatesfor1694 4s inthe£,butstillgovernmentwasshort aterson hadmany‘projects’,includinga cometh theman’; enterWilliamP ’, particularlyintheNetherlands. [3] . The landtaxwasdoubledto [2] Paterson . [4] . [2] ‘Cometh the . But, evenif ’s plan aterson [2] . ,

Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 15 INVITED ARTICLE Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 16 INVITED ARTICLE 1689 ittransported 100,000slavesfromAfrica very profitable slavetrade.Between1672 and founded in1660,hadthemonopoly overthe privileges £1.2m at6%,inreturnforexclusive trading made apermanentloantothe governmentof Merchants ofEnglandTrading to theEastIndies 1857. In1708,theUnitedCompany of an independentstateinIndiauntilthemutiny Company, whicheventuallygrewtobevirtually since itsfoundationin1600wastheEastIndia Another jointstockcompanythathadprospered Joint StockCompanies suspended very unreliable;in1672,CharlesIIsimply King whoowedthemoneyandkingswere was anewdepartureas,previously, itwasThe owed bythegovernmenttoinvestors.This annuities) becametheNationalDebti.e.debt other, long-termborrowings(especially Bank ofEngland,togetherwithsomethe The moneyowedbythegovernmentto The NationalDebt Figure 2:TheBankofEngland but theBankofEnglandprospered Scotland withtheDarienscheme(1698-1700), as adirectorofthebankandwentofftoruin to subscribers.Afterayear, Paterson resigned that generatedthemoneytopayinterest Tunnageunofficially ‘The Bank’,afterthetax Company oftheBankEngland’,and Governorand (1694) wasofficiallycalled‘The the companywassecure.Thenew repayment oftheirmoneyatthesametime, as allthesubscribersdidnotdemand debtsexceededitscapital.Solong company’s subscribers wouldbepersonallyliableifthe value ofthecapitalsubscribed,but company couldalsoissuepapernotestothe where theymetinthecoffeehouses.Thenew ‘Exchange Alleymen’, aftertheLondonstreet in shareswerecalled‘stock-jobbers’,or below ifitdidbadly. Thepeoplewhotraded or aboveparifthecompanydidwell, had risento£21mby1697 debtof£664,000ontheiraccession,butthis a goldsmiths unpaid.WilliamandMaryinherited for ayear, leavingadebtof£1.3mtothe looks uponashisnestegg’ manbuthasashare,whichhe any money’d described as‘thesurestestateinwhichscare was highlyregardedandin1708,it [7, 8] all . payments fromtheexchequer The Royal AfricanCompany, [4] [6] . . The newbank [5] . the stockcompaniescametoitsaid of QueenAnneneededmoneyforthewarand Scottish Parliaments, £50.5m.TheGovernment created in1707bytheunionofEnglishand traded withNorthAmerica Succession, whichlastedfrom1702to1713 Spain died,sparkingofftheWar oftheSpanish Royal Mint,fromwhencethename provided goldfromWest Africa(Guinea)tothe and madetheirinvestorsveryrich.Italso which hadthemonopolyontradewithRussia even olderMuscovy(Russia) Company(1553), and castlelogoofRoyal AfricanCompany Figure 3:JamesIIGoldcoinshowingelephant [10] Royal AfricanCompany elephant andcastle,whichwasthelogoof comes. Theearlycoinswerestampedwithan Americas and the ‘Asiento’, orcontract tosupply the righttosend oneshipayeartotheSpanish T Spanish controlledtheSouth Seas.However, was aratherriskyproposition atthetime,as monopoly ontradewithSouth America.This perpetual annuityat6%and enjoyprofitsfroma South SeaCompanywouldhave cashflowfroma the SouthSeasi.e.America.Thus, which wasalsograntedamonopolyoftradingin interest at6%onthedebttocompany In return,thegovernmentguaranteedtopay money duetothearmyandnavytotalling£9.5m. The SouthSeaCompanyundertooktoprovide into apermanentdebtatfixedinterestof6%. war debt,whichwasbeingrepaidat6%to9%, converting someofthegovernment’sshort-term the SouthSeaCompany, withtheobjectof In 1711,Robert Harley, EarlofOxford,founded South SeaCompany [12] debts down. Thegovernmentpaidoff£5mofits tax revenuesroseandinterestratescame India companiessoared;harvestsweregood, shares oftheBankEnglandandEast ships wereunmolestedbytheenemy. The Ryswick (1697).Trade prosperedasmerchant Times weregoodinEnglandafterthePeace of A reaty ofUtrecht(1713)granted thecompany New W . and aHudson’s BayCompany(1670),which This warwouldcost‘Britain’, anewentity [5] . Then, inNovember1700,thekingof ar [9] . There wasalsoan [11] . guinea [2] . , the

law on7April1720andthefunstarted signed theenablinglegislation(6GeoI,c.4)into more thantwicetheoriginaloffer. GeorgeI bought thedebtfromgovernmentfor£7.5m, the Postmaster General,theSouthSeaCompany who founded Guy’s hospital, made£180,000 who founded Guy’s of Malborough, madeafortune.Thomas Guy sold quicklydidwell.Sarah Churchill, Duchess T politicians, includingtheFirstLordof the debt.Byjudicioususeofbriberykey expand itsshareandoffered£5mforcontrolof government debt,thebankwasanxiousto the scheme;asoneofmainholders £3.5m. TheBankofEnglandobjectedstronglyto Company proposedtopaythegovernment T money wastobemadebyinvestors. increasing SouthAmericantradewherethe appreciation ofthesharevaluebasedon until 1727,and4%thereafter, butitwasthe an annualinterestof5%fromtheTreasury government lifetime ofinterestpaymentsfromthe than heorshecouldeverhopetogetfroma stock wouldmakethepersonmoremoney stock forcash.Appreciationofthevalue company stock.People couldalsobuycompany to theSouthSeaCompanyinexchangefor year, wouldbeencouraged tosurrenderthem interest waspaidbythegovernmentevery stock (£16m)andannuities(£15m),onwhich securities, suchasredeemablegovernment £31m in1719.Theholdersofgovernment greater partoftheNationalDebtestimatedat bankrupt France in1720),wastotakeoverthe Mississippischeme(whichwould Law’s and influencedbytheearlysuccessofJohn Their idea,mastermindedbySirJohnBlount 100% profit them aweeklaterat£120, you made£10or would buyyou£100ofshares andifyousold most wereboughton10% margin i.e.£10 However, everyonewantedtobuysharesand £164m, buttheyonlyhadassetsof£107m. 1720, thesharevalueofcompanywas price ofthesharesup.Ominously markets, minesandhiddentreasurekeptthe 50% profitandstoriesofnewlucrative made abaronetforhisservices.Promises of were amind-boggling£1,050,andBlountwas sent thesharesto£890.ByJune1720,they that thecompanyhadacquiredterritoryinP the Actwaspassed,theywere£310.R £100 sharesroseto£126in1719.Bythetime National Debtsentitssharepricerocketing; Company wastotakeovertwothirdsofthe The meresuggestionthattheSouthSea Shares Soar of theSouthSeaCompanyhadinmind However, meretrade wasnotwhatthedirectors and warbrokeoutagainwithSpainin1718. was madein1717,onlymarginallyprofitable colonies, for30years.Thefirstvoyage,which an unlimitednumberofslavestotheSpanish reasury o obtain controlofthedebt,SouthSea , the ChancellorofExchequer, [5] [6] . . The companywasguaranteed Those whoboughtearlyand , in August [2, 7] [2, 7] umours and . . eru way tothethrone. catastrophe andtheaccusationswentall began forsomeonetoblamethis Londonderry wasdown£50,000.Thehunt Hamilton, lost£80,000,whileLord ruined. TheKing’sphysician,SirDavid thousands ofpeoplelosttheirmoneyandwere Thestockplungedand £170 bymidOctober. early September and SouthSeasharesweredownto£700in realise theirgainsinhardcash.Thecrashbegan fear andinvestorsbegantoselltheirshares company sharesbegantofall.Uneasinessled Shareholders becameuneasyasthe‘illegal’ was toleadtheirdownfall. revolution inwarfarewithsquarecannonballs £40,000. ‘Puckles’MachineCompanyoffereda Company fromwhichhemadeaprofitof agreed tobegovernorofaWelsh Copper due timeberevealed’.ThePrince ofWales undertaking ofgreatadvantage,whichshallin hospitals forbastardchildren’, carryingonan ‘for large jack-assesfromSpain’, building ‘for of thediscovery sound butsomewereabsurd:‘for mistresses alsomadeakilling KingGeorgeI’s‘thin’ German and‘fat’ and Journal let thembeeversogreator somany death thosewhohavebrought thisruinuponus, don’t carewhatitis!’ G—’s sakeletusbutsubscribetosomething,we “ Ross reported totheHouseofCommons: “ parliament toenquireintothe matter. General A Sir Robert Walpole. result Lustreing andWelsh Copperplummetedasa shares ofEnglishCopper, York Buildings,Royal companies tradingwithoutaroyallicense.The directors quicklyappliedforwritsagainstfour Wishing toenforcetheirmonopoly, the companies withoutaroyalchartertotrade. June1720,makingitillegalfor c. 18)on24 government topassthe‘Bubble’Act(6GeoI, Sea Companydirectorsencouragedthe Alarmed atthenumberofnewrivals,South The BubbleAct out ofthemadhouseatonce. nothing somuchasifallthelunaticshadescaped A ia poet’ n1 June1720,the rival ‘projects’.On11 poured theirmoneyintoallmannerofother andpeople to akindofmania(‘distemper’) The successoftheSouthSeaCompanygaverise committee has discoveredatrainofthedeepest consumed andpricesrosewithdemand horses bought.Thefinestfoodanddrinkwere Estates werepurchasedandart,furniture jewels andservantsmadetheirappearance. though theywererich.SouthSeacarriages, great manypeopleandtheybegantospendas share pricesproducedimaginedwealthfora Let uspursuetodisgrace,destructionandeven Dutch visitortoLondonobserved:“ Committee ofSecrecywas set upby perpetual motion’, importinganumberof ‘for [13] wrote: “ . The actionoftheSouthSeadirectors , The generalcryhasbeen‘For £290 laterinthemonthand Cato’s Letters ” Many oftheprojectswere ” [13] [12] The artificial . thundered: London It islike ” [2] [14] . The . [2] !

Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 17 INVITED ARTICLE

Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 18 INVITED ARTICLE for over20years serving Prime Minister, apositionhemaintained Walpole wasBritain’s firstandlongestever a power thananyministereverhadand,in1732, the scandal.AgratefulCrowngavehimmore and protectedtheHanovarianmonarchyfrom survived. Walpole defendedthegovernment Company was strippedofmostitspower until itwaswound upin1850s.TheEast India 1760s andmanagedpartof the NationalDebt Sea Companycontinuedto trade untilthe Bubble Actwasrepealedin 1825.TheSouth companies remainedillegal in Britainuntilthe to hisestateinYorkshire to theTower ofLondon.Heeventuallyretired corrupt ChancelloroftheExchequer, wassent expelled fromParliament. JohnAislabie,the seized. FivedirectorswhowereMPs were chief cashier, had hisentireestateof£239,000 £183,000, whileRobert Knight,thecompany’s allowed £1,000toliveonoutofanestate seized tocompensatethelosses.Blountwas company weretargetedandtheirestates through Parliament. Thedirectorsofthe given inbribestogettheSouthSeascheme count outinthesesmallcoins promptly re-depositedit.Asittookforeverto own employeesinshillingsandsixpenceswho the rundown,bankpaidoutmoneytoits wake ofthegeneralfinancialcollapse;toslow There wasa‘ Sea Companyandreadjustingtheshareprice. writing offthe£7.5mowedtoitbySouth government itselfhadtorestorestabilityby the EastIndiaCompany, butintheend, of SouthSeastocktotheBankEnglandand worked outaschemetotransferlargeblocks and theywereforeverinhisdebt.Walpole nation villainy andfraudthathadevercontrivedtoruina really didnot ignorant thoughtthattheyunderstoodwhat the finances,thatwhilehewasspeakingmost stating themostintricatematters,especiallyin Earl ofChesterfieldsaidhewas“ he wasgenialandcouldexplainthingswell.The W amount oftheNationalDebt. T while thousandsofpeoplehadlostmoney, the of theExchequer. Heastutelyrealisedthat land: FirstLordoftheTreasury andChancellor assumed thetwomostpowerfulofficesin impeached buthedidresign.Walpole now Thanks toWalpole, Sunderlandwasnot Earl ofSunderland,FirstLordtheTreasury. stage. Hedefendedhisarchrivalthe(Tory) he hadinvestedinit)nowmovedcentre had opposedtheSouthSeascheme(although Sir Robert Walpole, aprominentWhigwho House ofLords. stroke whiledefendingthegovernmentin of StatefortheSouthernDepartmenthada General committedsuicidewhiletheSecretary reasury hadriditselfofaconsiderable London house,No10DowningStreet. alpole wasanoasisofcalmandconfidence; ” [2] . It foundthat£540,000hadbeen ”. Heprotectedmanyoftheguilty run’ [15] on theBankofEnglandin . Unlicensed jointstock [13] . The Postmaster [2] , so clearin the bank £1,105.8 billioninDecember2011 with usasistheNationalDebt,whichwas dissolved in1874.TheBankofEnglandisstill after theIndianMutiny(1857)andwasfinally 8 SmithO’Brien [8] MunroJ [7] [6] DaviesN [5] MurphyA [4] DaleR [3] AndreasA [2] Robert HGeorge [1] References [16] [15] [14] [13] [12] [11] [10] [9] 02/01/2012) 02/01/2011) W F http://www Available at: Oxford UniversityPress 2006 http://www Available at: Oxford UniversityPress 2006 01/01/2012) ea%20Bubble.ppt www Available at: Financial CrisesPast andPresent National MonetaryCommission,Washington 1910 The CreditofNations Macmillian, London1999 The Isles J Investment intheEarlyEnglishNationalDebt Dealing withUncertainty:ManagingPersonal Princeton UniversityPress, Princeton, 2004 The First Crash PS King&Son,London1924 History oftheBankEngland(2 J The Financial RelationsofLouis XIVandJamesII The-Public-Sector 2011/art—-public-sector measures- http://www Available at: National Statistics Public SectorFinancesNovember 2011,Officefor (accessed 02/01/2012) Oxford DictionaryofNationalBiography Robert Walpole T (accessed 02/01/2012) Oxford DictionaryofNationalBiography P Speck WA,KilburnM Princeton UniversityPress, Princeton, 2004 The First Crash Dale R BBC Worldwide Ltd,London2001 A Scharma S http://www Hudson BayCo. http://www Russia Company http://www Company(“Guinea English RoyalAfrica JM Richardson,London1830 Charter –India Company’s Considerations relativetotherenewalofEast 02/01/2011) romoters oftheSouthSeaBubble(act1720) aylor S Mod Hist. Hist Ass History ofBritain,TheBritishWars 1603-1776 Hirst .economics.utoronto.ca/munro5/South%20S of-public-sector 2006; 91:200-217 .ons.gov .oxforddnb.com/public/index.html .oxforddnb.com/public/index.html .hbc.com/en/history .history .pepysdiary 1931; 3:392-413 -Net-Debt .ac.uk/gh/russia.htm (accessed 01/01/2012) .uk/ons/rel/psa/wider .com/p/7105.php -balance-sheet.html#tab- -debt/december (accessed .html nd Edition) [16] (accessed (accessed . (accessed - - , , ”)

Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 20 COST-EFFECTIVE & SUSTAINABLE SURGERY Another is because “thedinosaurswerealsoextinct”. forthcoming environmentalcatastrophejust exemplified bytheviewthatsomewouldaccepta operative time,andseemstobelesscostly” comparable, butthelatterhasasignificantlyshorter and small-incisioncholecystectomiesseemtobe that there’snothingwecandobutwaitfor“ to thesetwoproceduresconcludedthat“ Cochrane reviewofover2,000patientsrandomised through asmallabdominalincision.Arecent expensive andtimeconsumingthatcholecystectomy autoregulation” risk ofcommonbileductinjury Laparoscopic cholecystectomyincreasesfive-foldthe its successisassociatedwithasignificantdownside. However, acloserlookatthisprocedurerevealsthat to bethegoldstandardforcholecystectomy. thousands allovertheworldeveryday. Itisclaimed cholecystectomy, aprocedureperformed by consequences. Take, forexample,laparoscopic innovations, buttheseoftenhaveunforeseen Surgery ismoreanddrivenbytechnological innovation The purposeandlimitsoftechnological technocrats One ideologicalbarrieris Ideological barriers material exhaustion shortage, massivewasteproductionandraw position toreflectonchemicalpollution,water operating theatre.Surgeonsareinaunique its societalrolebeyondthestrictlimitsof precious resources.Ourprofessionmustreflecton should haveaspecialresponsibilitytocarefor surgeons belongtoasocialeliteand,assuch, travelling andworkinghabits.Allovertheworld, W all challengeourlifechoicesandpoliticalpriorities. the economyanddegradationofbiosphere world’s demographicexplosion,theglobalisationof The westernwayoflifeisatacrossroads.The Mar, Barcelona Head, DepartmentofSurgery, Hospitaldel Antonio Sitges-Serra SUSTAINABILITY INNOVATION, ETHICSAND and going“green” inoursurgicalhabits. innovations, andbyredefiningourethicalvalues assessing thegoalsandcost/benefitsoftechnical introduce high-techprocedures trained abroadarepushinghard(andpushed)to western societies,surgeonswhohaveoftenbeen much moreeconomicconstraintsthanourrich Despite this,evenindevelopingcountrieswith for thetimebeing.Finally, thereare the and thewaywepracticesurgery. concerning thewaywelive,consume, open ourmindstonewconceptsandmanners These beliefsareblockingthedoorthatshould addressed byfurthertechnologicalinnovation. that thereisnotasingleproblemcannotbe certain specific procedures, suchasadrenalectomy, surgical waste. On theotherhand,itsadvantages for requires longlearningcurvesand producestonsof advantage inmanyinstances.It isexpensive,it postoperative stay, itoffersno,oronlymarginal, the physiologicalimpactofsurgery andshortening laparoscopy hasbroughtgreat advancesinreducing e must allmakeanefforttore-thinkourliving, passive pessimists (or better, technolatrics)whobelieve and enjoylifeasmuchwecan [1] . This mustbedonebyre- scientific cynicism. , who wouldargue [2] [4] and ismore . Although laparoscopic [3] . This is Gaia’s examples frommyhospital: procedures” areontherise.Here areafewrecent to mesincesurgicalcomplicationsarisingfrom“new reasonable? Theissueappearsparticularlyrelevant further exampleofanabusetechnology. benefits. Therecentshipwreckofthe common passengersandprobablyhadlimitedcost that hadlostallcontactwiththerealneedsof Concorde signifiedanendtoatechnologicaljewel aeronautical catastrophesever. Thetragedyof the saddest reflects oneof eponym which Concordia Case 1: curve ofhundredsprocedures or laparoscopicherniarepair)mayrequirealearning innovative operations(suchasradicalprostatectomy have evenconsideredit“normal”thatsome right colectomythroughasingleport.Someauthors spend fourhoursintheoperatingroomdoinga remove apieceofbowelthroughthevaginaor the marketforyears,butanysurgeonisallowedto run atrialcomparingtwodrugsthathavebeenon fill inlotsofformstoapplyandgetpermission so scarceandoutdated.Currently concerning theinnovationofsurgicalproceduresis surgical innovation.Itisastonishingthatlegislation P Ethics ofinnovation answer totherealneedsofpatients industrial andmedicallobby, ratherthanasound are largelyaproductoftheincreasinglypowerful surgery throughnaturalorificesorroboticsurgery, most recentproposalsofsingleportsurgery, for thesesimple,everydayprocedures.Finally, the brought longeroperativetimesandincreasedcosts inguinal herniarepairisnotevidence-based,andhas endoscopic proceduresforappendectomyor surgery arestilluncertain.Theintroductionof colectomy), forwhichthebenefitsofendoscopic procedures (pancreatectomy, hepatectomy, dangerously extrapolated“off-label”toothermajor morbid obesityorhiatushernia,havebeen syndrome demands for ‘scarless surgery’ demands for‘scarlesssurgery’ papers), institutionalpropagandaorincreasing patients, earningmoremoney, publishingmore industrial pressures,thesurgeons’ego(gettingmore prominence asaconsequenceofmarketingand Technological innovationsarealsobroughtinto achievement ofreasonableclinicalgoals. ratherthanthe andauto-promotion, at “feasibility” that technologyisbecomingmoreandaimed the been termed by whathas are exemplified These factors learning curvesandbadcost/benefitratios. waste production,unnecessaryanddangerous results indisproportionateenergyconsumption, never-ending technologicalspiral,whichinevitably across thealternativeviewwhichchallenges there appearstobeinsufficientsurgeonsputting department withaperforated duodenal ulcer liver cirrhosispresentsintheemergency and suturesthe vein,thenreintroducesthe damages theumbilical vein.Heopenstheabdomen surgeon introducesaHassontrochar which rofessional ethicshasbecomeamajorissuein Concorde A an ; (curious coincidenceofnames!)isa 42-year-old malewithapast historyof reaching atechnologicalimpasse? The CostaConcordiashipwreck:Arewe [7] . [8] , Unfortunately, you areforcedto . [5, 6] Is allthis Costa . It appears . The

drained percutaneously. Thehospitalstaywas14days. fever andondaynine,anintrabdominalcollectionis amounts to3kg¤2,220.Ondaysix,thepatienthasa The anaesthesiatimeissixhours.Waste production She issubmittedtolaparoscopicleftbisegmentectomy. biliary ductcystinvolvingliversegmentstwoandthree. cancer outcomesaresimilar extended surgeryandchemotherapy. Oesophageal expenses inresearch,preoperativework-up, this occursallovertheworld,despitemassive the expenseofcontinuouslyrisingcosts. progress attheexpenseofpatients’safety, norat surgery shouldprogress,itcertainlynot when patients“diedforthebenefitofmankind”.If Langenbeck, oreventhoseofLlileheiStarzl, be. We arenomoreintheyearsofBillrothand century isnot(andshouldbe)whatitusedto that barelyimproveoutcomes.Progress inthe21st for complicationsbecauseofinnovativeprocedures see noreasonwhatsoevertoputpatientsatrisk amsuremanyreadersknowofsimilarcases.I I transfused andfivehoursintheatre. performed. Finalresult:Two unitsofblood reconversion tostandardlaparoscopyis aborted duetobleedingandtechnicaldifficulties.A plans atransvaginalprocedure.Thevaginalrouteis surgeon thinkssheisagoodcaseforNOTESand refractory thrombocytopenicpurpura.The “laparoscopist” surgeonforasplenectomydueto than inthe70s( has thesame(<5%)five-yearsurvivalratetoday experienced centres.IntheUK,pancreaticcancer reasonable lifeexpectancyandperformedin for cancermustbelimitedtopatientswitha by policymakersandopinionleaders.Heroicsurgery Independent, unbiasedexpertsneedtobeconsulted than everbecauseofuniversaleconomicrestraints. practice shouldnowbeundermoreclosescrutiny environmental care.Thecost/benefitofsurgical of professionalresponsibility:costcontainmentand safety, theyextendatleasttotwo othermainareas Professional ethicstodaynotonlydealwithpatients’ Green issuesinsurgery Case 4: Case 3: Case 2: Five dayslater, thesutureleaksandpatientdies. endoscopic instrumentsandrepairstheperforation. recycling andreprocessing carbon footprint oftheirproductsandfavouring adopt environmentalfriendlypolicies byreducingthe Device producingcompaniesshould bepushedto instruments shouldbeusedasmuch aspossible. When endoscopicsurgeryisthe bestoption,reusable best cost/time/benefitformany surgicalprocedures. track critical issue.Open,goodqualitysurgery, plusfast- theatre availabilitymakedurationoftheproceduresa and stagnantordecliningeconomies.Restrictions in a also includestime.Operatingtheatretimeisbecoming The costofhealthcarenotonlyimpliesmoneybut care unit,arealivethreeyearslater patients over65yearsold,admittedtoanintensive peritoneal small-graincarcinomatosisisfound. onsixweekslaterandmassivediffuse re-operated comes backas‘appendicealadenocarcinoma’.Heis apendectomy (twohours).Thepathologyreport appendicitis andsubmittedforalaparoscopic major issueincountrieswithapublichealthsystem or enhancedrecoveryprotocols, mayaffordthe A A A 60-year-old femaleisdiagnosedwitha 31-year-old maleisdiagnosedwithacute 26-year-old womenissenttoa http://info.cancerresearchuk.org [11] [9] . . Only halfthe [10] . ) and NHS carefacilities( consumption, wasteproductionandrelatedissuesin agency toresearchandadviceonenergy patient perday. TheUKhasstartedadesignated production intheNHSamountsto5.5kgper proportions. Ithasbeencalculatedthatwaste W considering thecost/benefitofnewtechnologies. and ecologicaluseofantibioticsseriously of making soundpurchasingchoices,limitingthewaste the carbonfootprint:avoidingunnecessarysurgery, several waysinwhichsurgeonscanhelptominimise [2] Sitges-SerraA [1] References clinically beneficialandenvironmentallyfriendly. should onlybeadoptedwhenprovento possible, techniques,instrumentsandinnovations craft cognisantofourcarbonfootprint.Where have aresponsibilitytopracticeanddevelopour degradation oftheenvironment.Assurgeons,we industrial lobbying,economicglobalisationand relevant inanentourageoffinancialconstraints, environmental issuesarebecomingparticularly Innovation policies,professionalethicsand Conclusion 1]K [10] EspallarguesM,AlmazánC,Tebé Pons C,PlaR, [9] [8] BucherP, PuginF, OstermannS,RisF, Chilcott [7] AlloriAC,LeitmanIM,Heitman E [6] MaJ,CasseraMA,Spaun GO, HammillCW, [5] [4] [3] aste productioninourhospitalsisreachinghuge water andbrusheswhenscrubbing,appropriate Balliol Collaboration laparoscopic cholecystectomy Risk managementobservationsfromlitigationinvolving Br JSurg Ecosurgery life-years amongcritically illelderlypatients Long-term survival,qualityoflife,and quality-adjusted Rev EspEnfermDig multicenter cohortstudy digestive cancersurgery:designand initialresultsofa ONCOrisc StudyGroup.Management andoutcomesin Lancet Challenges inevaluatingsurgicalinnovation Surg Endosc trauma: apleaforscarlesssurgery? Population perceptionofsurgicalsafetyandbodyimage W technologies cholecystectomy: implicationsfordevelopingsurgical Delayed assessmentandeageradoptionoflaparoscopic Ann Surg cholecystectomy laparoscopic cholecystectomyandfour-port laparoscopic Randomised controlledtrialcomparingsingle-port Surg Endosc developing countries.Clinicalresultsandlessonslearned Successfully establishinglaparoscopicsurgeryprogramsin Cochrane DatabaseSystRev Group reviews overview ofCochraneHepato-Biliary for patientswithsymptomaticcholecystolithiasis.An Open, small-incision,orlaparoscopiccholecystectomy Arch Surg Thomas R J Clavien PA,Reeves BC, SeilerCM Ergina PL,CookJA,BlazebyM,BoutronI, M, MorelP Hansen PD,Aliabadi-Wahle S Asbun K (1):CD008318 M, SánchezE,MiasAlomar S,BorrásJM aarlola A,Tallgren M,Pettilä V eus F orld JGastroenterol , H 2009; 374:1097-101 Gooszen HG,vanLaarhovenCJ J, Berguer R, Altamirano R, CastellanosH AltamiranoR, J,Berguer R, 2002; 89:387-8 2011; 254:22-7 2006; 141:643-648 , McLean JD 2011; 25:408-15. 1996;10:1000-3 www 2009; 101:680-96 .sdu.nhs.uk 2010; 16:4115-22 2010 Jan20; ). Thereare for the

Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 21 COST-EFFECTIVE & SUSTAINABLE SURGERY

Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 22 CHRISTMAS PAST... Sister home underpainofexcoriationbytheHome support. Doctorswerebarredfromthenurses’ compensated byawonderfulfeelingofmutual resident. Thelowpayandlonghourswere Junior doctors,predominantlymale,werealso pressed uponvisitors. lubricate thevarioustastynibbleswhichwere Miraculously, abundantdrinkswereonhandto throughout theyear, givenbygratefulpatients. bought withmoneysquirreledawaybysisters by theLeaguesofFriends, localdignitariesor wrapped giftsforthepatientsandstaff, donated with ornamentsandlights.Arounditsbaselay A change ofclothingandaChristmasdinner. sisters toadmitlocal‘downandouts’forabath, reduced, butitwastraditionalforthecasualty with presentdaypressures,andadmissionswere The rateofpatientturnoverwasslowcompared to year, allcompetingforthehighestadmiration. preserved theappropriatedecorationsfromyear referred toonlybythenameofward) suffer lackofencouragement.Ward sisters(often routines ofwork,whereonemustmake-doand enthusiasm, seenasabreakfromthepunishing But Christmaswasalwayscelebratedwith Home Sisters. The nurses’homewasguardedlikeFortKnoxby rectal temperaturebeinggaugedusingadaffodil. Hattie Jacques,withherarchlookonobservinga heard thatonecouplewasdiscovered between nursingandmedical residences;we and iteludedtheusuallyimpregnablewalls provoked desireintheyoungdoctorsandnurses predicted byWilliamShakespeare,alcohol the youngdoctorsbygratefulpatients.As rules wererelaxedbyalcoholicdrinksgivento delicto instantly sacked. the genderprejudice atthetime,nurse was congratulatory slapontheshoulder but,suchwas performance earnedtheyoung mana of thefallacyabouttakingaway fromthe in thefilm a It istruethat,asintherestofsociety, therewere hospital lifeforwhichnooneelsefeltresponsible. themselves todealingwitheveryaspectof nuns fromwhomtheyhadlearnt,devoted These dedicatedandunderpaidwomen,likethe automatically forcedtoresigniftheymarried. Nurses ofallrankswerestillunmarriedand slowly beingimplemented. Declaration ofUniversalHumanRightswere be formalisedinthe1948UnitedNations overnight. Necessarysocialchangesthatwould reorganisations couldnotbeintroduced inaugurated in1946buttheintended lifestyle. TheNationalHealthServicewas were anxioustoreturnthefamiliarpre-war When theSecondWorld War ended,mostpeople A THE MID-1950s A few witches–many‘characters’liketheMatron fir tree,toppedwithaVirginMary, wasdraped trip downmemorylanewithJerryKirk HOSPITAL CHRISTMASIN . It wasnotalwayseffective,especiallywhen on anoperatingtable!Theirdemonstration Doctor intheHouse , portrayed by in flagrante ready hat,likeaknight gowned butwearingachef’s fortification withadrink,beforeemergingfully officefor consultant todisappearintoSister’s The clatteroffoodtrolleyswasasignalforthe still inflatedretentionbag! de-catheterized theapprehensivepatient,with Daddy –red!”Ijustmanagedtograbitbeforeshe seized thejarandrantowardsmecalling“Look bloodstained effluxthroughhisFoleycatheter. She spotted theWinchesterjarintowhichdrained recovering fromanopenprostatectomyasshehad bent downatthebedsideofapatientwhowas learning thevariousnamesofcolours.Shesuddenly new toys.Ononeoccasion,myelderdaughterwas desperately anxioustogethomeplaywiththeir although thechildrenusuallystoodawkwardly, Sister fortheoutstandingwarddecorations, snacks, exchangedpresents,notforgettingtopraise patients. Everyonecirculated,sippeddrinks,nibbled the rounds”,consultantschattingto Ugly Sister)andtheirchildren,allwould“do wives (someplayingtheLadyBountiful,others consultants wouldarrivemidmorningwiththeir acted asaChristmasmorningstartergun.The oompah’ ofaSalvationArmybrassband,often Carols, sometimesaccompaniedbythe‘oompah in theRoyal Navy! of theexpletivesIhadlearnedduringwarservice bachelor lives.’Onhearingthis,Iavoidedusingany relent bysuggestingthathewouldinsistwe‘lead sack us–buttheDeanhadprevailedonhimto of Governorshad,heinformedus,toldhimto creating a‘precedent’.TheChairmanoftheBoard for neglectingtodeclareourintentionand we werehauledbeforetheDean,reprimanded returned tocelebrateourfirstChristmastogether, a rules appliedinthedoctors’residences.Imarried Universal humanrightshadnotyetpercolatedthe regardless ofaffiliations. a communal celebrationanymore, butitstilloffers like nuns.Christmastimemay notbesucha others; nursesnolongertolerate beingtoldtolive everyone livinguptoabehaviour decidedby expense ofthemanyanditwas conditionalon The goodtimesforafewwere oftenatthe regret aboutthe“goodtimespast”areuseless. As Ilookback,believethatprotestationsof nurse. Needlesstosay, weallrefusedthe invitation. a nosedness stillemergedandonce,Matronforbade their wiveswereincluded.Pre-war toffee- us wereex-servicemenandsomemarried,so sisters, oftenjointlywiththejuniordoctors.Mostof There wasusuallyaChristmasdinnerforthe broadcast; itwasnotteleviseduntil1957. family ChristmasdinnerandtheQueen’s radio and theirfamilieswouldthendepartfor helping distributetheheapedplates.Consultants children beingcajoledoreventhreatenedinto suit thepatientswithnursesandconsultants’ and leg.Sisterwouldapportiontheamountsto of totsimbibed,wouldcarveproportionsbreast competence inverselyproportiontothenumber roast turkeywithacarvingknifeand, wife fromattendingbecauseshewasonlyastaff- fellow studentand,whenmynewwifeandI welcome break inroutine,applicabletoall, -shriven forbattle.Hewouldconfrontthe

Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 24 EDUCATION & TRAINING Training Boards Act responsibility system: There aretwocentralplankstothenew present toApril2013 F . The passageinthe of Surgeons Midlands, Regional Team, Royal College Regional CoordinatorfortheEast Toni Foers APRIL 2013 IN ENGLAND,FROM EDUCATION ANDTRAINING OF HEALTHCARE GOVERNANCE STRUCTURES THE MANAGEMENT AND and whichwill,on1 to currentorganisations(SHAs,Deaneries) currently operatinginshadowform,parallel and qualityassuranceorganisationwhichis 2012 From DesigntoDelivery–DH, 10January Developing theHealthcareWorkforce – The publicationof being thesubjectofsecondarylegislation. and trainingofthehealthcareworkforce,this include anyarrangementsfortheeducation provision ofhealthcareinEngland,didnot commissioning arrangementsforthe in June2012.The created asaSpecialHealthAuthority(SpHA) which isamulti-professionalbody, was authority for 2013/14, arrangingfunctions for willtake ondelegated shadow LETBs and the DHhasbeenrevised, and HEE for implementingallthenew structuresby development forsocialcare. Thetimeline responsibility forworkforce planningand and locallevel,mustassume the HEE. BothHEEandtheLETBs,atnational Department ofHealth,andmanagedby authorisation processagreedbythe form andbeingsubjectedtothe multi-professional, arecurrentlyinshadow igure 1:Structureandfundingflows , which dealswiththestructuresand outlined themanagement,governance Health EducationEngland . (LETBs), whoaresimilarly Local Educationand ieaigtheNHS: Liberating Health andSocialCare st April 2013,assumefull (HEE), specialist skills. smaller professionsandcommissioning particular professionalgroups,suchasthe take onspecificleadershiprolesfor and newmodelsofservice.LETBsmayalso can adaptquicklytonewwaysofworking and priorities,sothateducationtraining into thedevelopmentofnationalstrategies public healthproviderswillhavestronginput organisations. ThroughHEE,healthand public. LETBsarealsomulti-professional needs ofserviceproviders,patientsandthe and trainingoutcomes,sothattheymeetthe HEE, toimprovethequalityofeducation providers andprofessionalstoworkwith The LETBswillbethelocalvehiclefor The roleoftheLETBs medical deaneries. operational costsofthepostgraduate latter includestheorganisationaland and dentaleducationlevy(MADEL).The increment forteaching(SIFT)andmedical education andtraining(NMET),service budget, whichincludesnon-medical professional educationandtraining(MPET) training resources;thatistheentiremulti- workforce, andallocateeducation development ofthehealthandpublic oversight onstrategicplanningand HEE willprovidenationalleadershipand The roleofHEE the lackofexternality intheprocess. meeting is,in fact,aninternalreview, could bearguedthatthe‘Board toBoard’ all bedirectlyemployedby HEE.Therefore,it first yearoperation,LETBs andtheirstaffwill Board’ meeting.Itshouldbe notedthatinthe submitted evidenceand,finally, a‘Boardto initial application,a‘desktop’reviewofthe The authorisationprocessconsistsofthe indicators andevidencerequirements. domains isunderpinnedbyasetofdefined authorisation areshowninfigure3.Each The overarchingdomainsforLETB Figure 2 from 31October2012. workforce planning,educationandtraining given the language ofGovernmentandthe constituted. Again, ithastobesaidthat deaneries astheyarecurrently much rhetoricaroundthe importanceof included inthatnumber. Therehasbeen and anydeanerystaffwill needtobe which weunderstandis87 wteperLETB, number ofstaffeachLETBmayemploy, LETB (HEE).Thereisa‘cap’onthe contracts, willbedirectlyemployedbythe either onSHAoruniversityemployment staff currentlyemployedbydeaneries, any casebeabsorbedintotheLETB,and Deaneries, astheycurrentlyexist,willin security ofthepostgraduatedeaneries. There arecompetingviewsastothe presence atthislevelisslim. specialty. individual couldbefromanymedical LETB governingbodyandpotentially be onlyasinglemedicalpresenceonthe professional LETBslocally. Thereislikelyto andthemulti- allocated byHEEnationally, doctors intraining,willbemanagedand Surgery, togetherwithsalarycostsfor associated withtheoperationofSchools MPET funding,whichincludesallthecosts It shouldbeclearlyunderstoodthatthe The roleofthePostgraduate Deaneries F that LETB’s functions. temporary arrangementsforthedischargeof support and/ortomakealternative would betoputinspecificmanagement there areseveraloptions,oneofwhich itexercisesthem.Inthelattercase, how place restrictionsontheLETB’s functionsor In thecaseofsecondoutcome,HEEmay authorisation process: There willbethreepossibleoutcomesofthe igure 3 3. Notauthorised 2. Authorisedwithsupport/conditions 1. Authorised The likelihoodofarobustsurgical , that an examplefromtheEastMidlands. applied byHEE.Thediagrambelowshows currently subjecttoalevelofconsistency The governingbodiesoftheLETBsare environment Workforce planning intheproviderled Figure 5 planning andcommissioningcycle. regulators. Thediagrambelowdetailsthe needs, andcomplywiththerequirementsof analysis ofthelocalpopulation’s healthcare of servicesupplyanddemand,basedon entire workforce.Theywillalsotakeaccount quality ofeducationandtrainingforthe that theyhaveaprocesswhichaddresses workforce plans,andwillneedtoassureHEE interrogate educationandserviceproviders’ The LETBwillbetheauthoritywhich Figure 4 essential functionsandtheirdelivery. pressures, howtheLETBsaddressdeanery seen, inanenvironmentofincreasingcost maintenance ofdeaneries.Itremainstobe instances isbeinginterpretedas ‘essential functions’,whichinsome to therequirementmaintaindeanery Department ofHealthconsistentlyrefers

Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 25 EDUCATION & TRAINING

de laLegiond’Honneur Professional toreceivea Professor BaileyisthefirstBritishHealthcare Paris on28 Sarkozy ataceremonytheÉlyséePalace in of thehighesthonoursinFrance byPresident more than30years,hasbeenpresentedwithone Professor ofSurgeryandConsultantSurgeonfor with theRoyal SurreyCountyHospitalas P PRESIDENT SARKOZY D’HONNEUR FROM PIONEER RECEIVESLEGION ROYAL SURREYSURGICAL “ Commenting onhisaward,Professor Baileysaid: for laparoscopicsurgery largest andmostadvancedcentre ofexcellence from acrosstheworld.MATTU isnowtheUK’s for teachinglaparoscopicsurgerytosurgeons which hasanationalandinternationalreputation Professor BaileyisstillPresident oftheUnit, and hiscolleagueProfessor ChrisSutton. Surgeons, wasestablishedbyProfessor Bailey MATTU, whichislinked totheRoyal Collegeof establish akey-hole surgeryteachingcentreand UK tobeawardedgovernmentfunding The Royal Surreywasoneofthreecentresinthe Access TherapyTraining Unit(MATTU) in1995. achievements istheestablishmentofMinimal The mostnotableofProfessor Bailey’s work in,thefieldoflaparoscopicsurgery. recognised forhisservicesto,andpioneering have myworkrecognised byFrance. Ihave spent Chevalier del’Ordre delaLegiond’Honneur and to am I rofessor MichaelBailey, whohasworkedatand immensely proudtohavebeen awardedthe th March 2012. . Chevalier del’Ordre and hasbeen advancing laparoscopicsurgery. Bailey andhisteamaimtocontinuallyfocuson use this3Dsystemforoperations,andP based MATTU isthefirstcentreinworldto procedures evenmoreefficient.TheSurrey- system foroperations,aimedatmaking Postgraduate MedicalSchooltodevelop a3D research fellowsfromSurreyUniversity’s His mostrecentfocushasbeenonworkingwith Michael-Bailey (http://www 28 on Royal SurreyCounty Hospital’swebsiteon Foundation andthis articleoriginallyappeared Michael BaileyisaTrustee ofTheSurgical permission. has beenreproduced withtheirkind “ Surrey added: Hepatobiliary andPancreatic SurgeryattheR Professor NarimanKaranjia, Professor of Guildford Hospital. and alsopracticedattheNuffieldHealth consultant surgeonatRoyal Surreyfor30years Postgraduate MedicalSchool.Hewasa Surrey’s P honorary contractwiththeTrust. Heisalsoa Surrey in2008,butcontinuestoholdan retired asafull-timeconsultantattheRoyal Telesurgery inStrasbourg.Professor Bailey teaching facultyattheEuropeanInstituteof early 90sandiscurrentlyamemberofthe He hasworkedwithFrench surgeonssincethe about laparoscopicsurgeryoverthelast20years. played inteachingthousandsofFrench doctors d’Honneur fromFrance for therolehehas P nthesameday on undergone majorabdominalsurgerycangohome times. Duetotheadvances,patientswhohave less invasivesurgeryandmuchfasterrecovery and millionsofpeoplehavebenefittedfrommuch transformed thewayweoperateonpatientstoday around theworld.Laparoscopicsurgeryhas teaching andtraininghundredsofsurgeonsfrom surgical techniquesandlaparoscopicsurgery, and more than30yearsdevelopingandadvancingnew award ofLegiond’honneur. for hisphenomenalcontributionoverseas,withthe to surgicaltraining.Hehasfinallybeenrecognised patients, tohisprofessionandontheworldstage has contributedhugelyinhisowncountryto with anunparalleledcapacityforhardwork,he Great BritainandIreland,twice.Asurgicalgiant, the highestawardofAssociationSurgeons the accoladeofhavingwonMoynihanPrize, Surgeons ofGreatBritainandIreland.Heholds and President oftheAssociationLaparoscopic Section ofSurgerytheRoyalSocietyMedicine consultant surgeon,hehasbeenPresident ofthe career spanningmorethan30yearsasa the firstinUKtoembracethis.Inaglittering benefits ofminimalaccesssurgeryandwasone hequicklyrecognisedthe and technicalinnovator, world. Abrilliantuppergastrointestinalsurgeon put Surreyonthemapininternationalmedical W rofessor ofSurgeryatTheUniversity rofessor BaileyhasreceivedtheLegion th ithout adoubt,Professor MichaelBaileyhas March 2012 .royalsurrey -Legion-d%27Honneur .” .nhs.uk/P ” rofessor- rofessor ) and oyal

Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 27 THE SURGICAL FOUNDATION Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 28 A LETTER FROM... Archives at Akrotiri,courtesy ofTPMH Hospital Figure 2:The1956RAFTemporary the EasternMediterranean. for militarypersonnelandtheirdependantsin mandated anewmedicalandsurgicalfacility expansion ofthemilitarypresenceinCyprus, responsibilities EastofSuez,andthe 1960s, whenthecontractionofImperial Taxpayer sinceitsconstructionintheearly appointed hospitalsintheportfolioofUK most spectacularlylocatedandbeautifully existence. TPMHAkrotirihasbeenoneofthe Military Hospitaloverseas,after50yearsof in Cyprus,thelastremainingpeacetimeBritish Hospital atRAFAkrotiri The Princess Mary’s 1st November2012markedtheclosureof Hospital: bykindpermissionoftheartist Orthopaedic Surgeon,Peterborough Commander GoraPathak RAF, Consultant F Colonel, DefenceMedicalServices(V) Visiting ConsultantGeneralSurgeon David ARew Hospital, RAFAkrotiri Clinical Director, ThePrincess Mary’s David Vassallo OUTPOST OFEMPIRE THE LASTSURGICAL igure 1:Painting ofTPMHbyWing RAF Akrotiriinthemid1950s( A a based service (withtheonlyjuniorstaff being byapurelyconsultant- inpatients eachyear, was handling20,000outpatients and5,000 activity atthebeginningof the 1970s,TPMH Cyprus overtheyears.At peakofits civilian patientsandcasualties passingthrough diverse transitpopulationofmilitaryand 30,000 personnelinthepeakyears,andbya service populationwithdependantsofupto emergency workloadgeneratedbyalocal have supportedthewiderangeofelectiveand The 155bedsandtwooperatingtheatres in 1963 the hospitalatopeningceremony Figure 3:Princess Maryinspectsamodelof significant damage. earth tremoronitstectonicfaultlinewithno foundations haveseenitthroughatleastone nuclear bombresistant)structureand tranquillity. Theearthquake-proof (and Carp pool,providesahavenofescapeand the centralgardencourtyard,withitsKoi modernist architectureoftheperiod,while reminiscent ofthebestinnovative ceilings, todissipatethesummerheat,are from allaspects.Thetiledfloorsandhigh offers unsurpassedviewsofthecoastandsea training dutiesandintransittoAfghanistan.It which remaininusefortroopsongeneral north bytheopenexpanseofAkrotiriranges, cliffs andtheMediterraneanSea,to Cyprus, surroundedonthreesidesbylow Akrotiri peninsulaonthesoutherncoastof isolation onCapeZevgariattheendof concrete. Thehospitalsitsinsplendid ward andadministrativeblocks,facedinwhite two,threeandfourstorey series oflow-rise Crisis. Themodernbuildingcomprisesa still runninghighfollowingtheCubanMissile 1963, atatimewhenColdWar tensionswere commenced in1961andwascompleted Construction ofthecurrenthospital ascenttopower.Egypt afterColonelNasser’s support thelargemovementoftroopsout surgical registrar, untilthatpost was temporary militaryhospitalwasfirstbuiltat Figure 2 ), to service personnel Turkish CypriotlocalnationalsratherthanUK thattime,themajorityofwhomwere at casualties ofgunshot,missileandbombblast BJS. 119operationswerecarriedouton41 invasion ofNorthernCyprusin1974the with casualtiesofeventsaroundtheTurkish reported thehospital’sexperienceindealing elsewhere in Asia andAfricaarenowflown on casualties ofconflict inIraq,Afghanistan and East operationshasnotbeen realised,asUK transitcarecentre forcasualtiesofMiddle a as hospital completelyin2012. Itspotentialutility economically unarguabledecision toclosethe forcing anemotionallydifficult but proportion tothedecliningclinicalactivity, staffing thehospitalhavegrownsignificantlyin has shrunk,sothecostsofmaintainingand Sadly, butinevitably, astheservicepopulation specialists. visiting civilian,tri-serviceandReserve residents, andanitinerantpopulationof locallyengagedworkforceofCypriot a with Armystaff. Ithadadditional supportfrom Dhekelia in1978resultedreinforcement the closureofArmyhospitalBMH Mary medical officersandmembersofthePrincess life. IthadbeenstaffedprimarilybyRAF remained underRAFcommandthroughoutits of amajorRAFbase,thehospitalhas As reflectsitspresencewithintheboundaries Akrotiri, priortoclosure Hospital Figure 4:ThePrincess Mary’s of conflict there havebeensurgesofactivityduringtimes as aUKDistrictGeneralHospital,although The hospitalhasneverbeensurgicallyasbusy the TPMHmaternitywards. British citizenshavetakentheirfirstbreathin abolished inrecentyears).Some14,000 the workingofsuchhospitalsin2008 contemporary governanceissuessurrounding Hospital Gibraltarrespectively)discussedthe Veen (fromTPMHandtheRoyal Naval ’s Royal AirForceNursingService,until [1] . CP MalpassandJSWinter [2] . Tom DayandHarald [3] . within itssunlitwalls. time, andtobeablerecorditspassingfrom on theTPMHoperatingtheatresforlast consultant generalsurgeonstoclosethedoors privileged tohavebeenpresentasthe uniqueclinicalOutpostof Empire,weare a years. Inmarkingthepassingofaneraand recuperation ofmindandbodyforthepast50 Mediterranean haveacceleratedthe the island,andwhereviewsover where theseabreezesmitigateheatof TPMH intheconduciveclimateofAkrotiri, will havehappymemoriesoftheirtimeat Many surgicalteams,clinicalandnursingstaff any case,besubstantial. option, asthecostsofmaintenancewould,in contingencies isreportedlynotarealistic Mothballing thebuildingsagainstfuture the foundationforatopclasshotel. conversion intoresidentialapartments,oras multinational expatriatecivilianpopulation,for for acivilianmedicalfacilitytoservethelarge the world,itwouldprovideamagnificentsite sealed itsfate.Inanyothercoastallocationin hospital onanactivemilitarybasewhichhas paradoxically thesplendidisolationof fruitful occupancyforclinicalteams,itis out thepotentialofmanymoreyears While theTPMHbuildingsthemselveshold TPMH inrecentyears. between UKandlocalCypriotcliniciansat natural extensionofthegrowinglinks facilities attheYgiaPolyclinic inLimassol,asa internationally accreditedlocalsecondarycare the impressivelywell-staffedand workload inCyprusisbeingreferredonto hospitals. From nowon,theacuteclinical critical caredirectlyfromthewarzonetoUK well equippedstrategicairframeswithin-flight www www otiri.cfm www www Useful websites [4] DayTK,Veen H [3] MalpassCP, WinterJS [2] [1] References V R J peripheralunit a Getting thebestofbothworlds:clinicalexcellenceat Brit JSurg A Force Akrotiri1963-2013 A as aniBook.) Hants. Amorecomprehensiveversionisavailable Museum, Keogh Barracks,Aldershot Camberley (Available fromtheArmyMedicalServices November 2012 .rafakrotiri.co.uk/ .rafacyprus.co.uk/ .raf .qaranc.co.uk/theprincessmaryshospital.php assallo DJ report onmissileinjuriesinCyprus1974 Hospital,RoyalAir History ofThePrincess Mary’s Army MedCorps .mod.uk/PMRAFNS/history/rafhospitalakr 1976; 63:482-487 2008; 154(1):41-46 . Charitable Publication;

Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 29 A LETTER FROM... Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 30 THE SECRET LIFE OF... that Ihadnot fallenoff, collidedwithany solid meant thathe couldbereasonablyreassured within twominutes,apparently unscathed, standing. Presumably, thefactthat Ireturned the blockandreturntowhere hewas examiner (whowasonfoot) toridearound which consistedofbeingasked byan in averyquaint10minute‘examination street legalinduecourse,andpassedmytest the coolestthingsIhadeverdone.became afternoon andthinkingthatthiswasoneof whistling throughmyhaironanautumn say, ahelmet,tax orinsurance)withthewind Blackfriars Bridge(without,Iamashamedto motorcycles –Irememberridingover As astudent,Ihadbriefflirtationswith The EarlyYears adventure. Moreofthatanon. in regardstomyloveoftwowheeled just howfar-reaching theirinfluencehasbeen Trust, andemployer, whomaynotappreciate included inthislistshouldbemylocalNHS comfort fornearly30years.However, course, whohasbeenarockandall-embracing no otherscould.AndthereisMrsM,of in waysthatbroughtitaliveandrelevantlike John StottandDickLucasexpoundedscripture Amadeus M,whosemusicistrulysublime; voice sendsshiversdownmyspine;W equalling; AlisonKrauss,whosesilkensinging have alwaysaspired,butnevercomecloseto technique anddexteritywerethingstowhichI Everett (WGEverett)wasasurgeonwhose influenced mylifeinvariousdifferentways.Bill There aremanypeoplewhohavepositively Director ofInformatics,ASGBI Nick Markham THE SECRETLIFEOF... LIFE ONABIKE: olfgang ’, whilst myhome isinavalleyatthebottom of The hospitalis situatedonthetopofahill, Cycling wasthefirstobvious consideration. think ofalternatives. affected themoodofday. Itwastimeto much thedreadofdaily parkingfiasco almost impossible,andIwas astonishedhow leaving afterlunchtogoanddoone,became morning afterdoingaperipheralclinic,or awarded, needlesstosay).Arrivinglate would wintheprizeofday(rarely those whogotawayun-scrapedanddent-free would beataskofherculeanproportionsand would eventuallyneedtogetoutagain.This quickly disappearasyourealisedthat and feltslightlysmug,anyeuphoriawould here, thereandeverywhere.Ifyougotaspace Bedlam ensued,withcarsbecomingwedgedin markings orbaysmerelyaddedtothechaos. parking areawascompletelydevoidofany energy.the day’s Thefactthatthedesignated vehicle consumedasubstantialproportionof anywhere (literallyanywhere)toabandonthe stress asafrantic,andoftenuseless,searchfor that toriskarrivinglatewouldcreateuntold escape myattention.People verysoonlearnt time beforethestartoftheirshiftdidnot sitting intheircarshavingbreakfasttokill though, thatthefrequentsightofearly possibly increaseproductivity. Ihavetosay, staff toarriveearlyforworkandthereby Trust toprovidesuchapotentstimulus for indeed. Ioftenmusedhowcleveritwasofthe whatever reasonandlifebecameverydifficult straightforward, butanylaterthan9amfor did) meantthatfindingaplacewaspretty Arriving atworkbefore8am(asIinvariably guaranteed nothingintermsofaspace). more fraught(payingamonthlyparkingfee places inpermittedparkingareasbecameever cause ofegalitarianism.Themadscramblefor hospital whereIworkwerewithdrawninthe The seniorstaffcarparkfacilitiesatthe Car Parking Games And thenthingschanged. ones heldlessappealthanconvertiblecars. far toomuchlikehardwork,whilstpowered virtually allforms-thepedalledvarietywere For thenext30years,Iavoidedtwowheelsin more. sit atopthemonsterbikesof1,600ccand and haveachievedacertainageareallowedto who candemonstrateconsiderableskilllevels things arealotbetternow, andonlythose could haveexperiencedwasa250.Thankfully, those days)whereashithertothebiggestI (probably thebiggestmachinesaroundin myself suddenlyallowedon750ccbikes been assessedIamnotsure,butfound any otheraspectsofroadskillscouldhave objects andknewhowtosteer. Quitehow -arrivers

domestic balance towhathadotherwise been image ofthemodern manandbrought feeling thatbikingwascompatible withthe as longIcanremember, cementedthe from London–whohasbeen anavidbikerfor A cancelled theassociateddirect debit. month, Ihandedinmycar-park passand more intenseaseachweekpassed.Aftera as Isailedpastthestrugglingmotoristsgot challenges oftheday. AndthesmugnessIfelt relatively uncrumpledsuit,readytomeetthe with rain,Icouldarrivedryanda more relaxedpersona.Evenwhenitpoured freedomsandamuch acquired new-found regardless, contentintheknowledgeIhad But, deeplywoundedasIwas,carriedon distort thefacefromitsclassicgoodlooks. cheeks togetherinsuchawayastohideously bulky suitandahelmetwhichsquashedthe aged bikersqueezedintoasomewhatill-fitting, fielddayastheymockedthesightof a The femalesinthehouseholddidhaveabitof a and otherbikers,wouldleavetheirvehiclesin made mywaytoasmallsecureshedwhereI, passed thestrugglingwould-beparkersand avoid thefeelingsofextremesmugnessasI arrived atthehospital,itwouldbehardto due tosheepthanothervehicles.AndwhenI roads wherehold-upswouldbemorelikely cautious sobrietyonashortjourneyminor TT race.Inreality, Iwouldbethemodelof fuelled teenagerabouttoentertheIsleofMan – aside anddismissedastypicalfemalehysterics Senior Partner andtwodaughterswerecast purchased. Extremeoppositionfromthe trauma protectioncouldbesimplyandcheaply more ‘green’, andeffectivewet-weather years previously?Itwouldbelessexpensive, the knowledgeandskillsacquiredover30 had immediateappeal.Icouldsurelyresurrect colleague thatIbuyhisson’s motorscooter Which iswhythesuggestionbyananaesthetic And So,To Two Wheels… not flying,somuchaslandingtoofast). considered, asIamscaredofflying(perhaps a sounded tooadventurousandthepossibilityof question. Roller bladesandskateboards unacceptable wayandwalkingwasoutofthe Taxis wouldstretchthewalletinaquite impossible foramaninmyposition,Ifelt. for whichNorthDevonisfamous?Utterly combination ofheavyperspirationandtherain clothing andnotwringingwetfroma whilst arrivingforworkinappropriate date, supposedtonegotiatesuchobstacles, How wasaportlygent,wellpasthissell-by an equallysteepone(overfivemilesaway). private helicoptercouldonlybrieflybe dry, purpose-builthaven.Ano-brainer. they madeitsoundlikeIwasatestosterone- visit frommybestman–an ophthalmologist should beable tobespottedlikeabeacon powerful High-Density lampsmeantthat I luminous patchestotheclothing, aswell bike, afluorescentjacketand helmet,day application ofreflectivedecals andtapetothe Seeing andbeingseenisvital, soliberal planning beganinearnest. permission wasreluctantlygrantedand in fact,no-appeal.Notwithstanding, me, cladinleather fondly toherbeloved.Theappealofjoining refused tocontemplateridingpillion,clinging might, myownpersonalladettesteadfastly seconds toagree.Sadly, however, tryasI join them,Imusthavetakenalloftwo tour oftheItalianAlpsandwouldIliketo respective ladetteswereplanninga10-day Man rangtosayhistouringgroupandtheir confidence built.Oneevening,whentheBest lanes wereverycautiousaffairs,butgradually all? ThefirstfewtripsoutontotheDevon apprehension –hadthegirlsbeenrightafter such ahugebeastthatIfeltsuddenwavesof spattering ofchromeandblack,itlooked 1,200 machine.Gleamingwhite,witha Within amonthIhadmyownsecond-hand truly hooked. such magnifiedfacialdistortion.Iwaswelland even biggerhadnotthetighthelmetrestricted perpetual smileonmyfacewouldhavebeen properly appreciated.Itwashugefunandthe some ofthebreath-takingviewscouldnotbe albeit concentratingsohardontechniquethat riding throughthebeautifulBreconroads, manoeuvres andbraking,weprogressedto exercises inbalance,control,slowspeed Starting ontheparadegroundforsomebasic first dayandthen1,200onthesecond. quite ashocktofindmyselfon650ccthe bigger than175ccinmylifebefore,itwas weekend! Neverhavingsatastrideabike one winterweekendlastNovember. Whata tuition andheadedofffortheBreconBeacons for thefairersex.Ichosesomeone-to-one advanced, pillion,offroaderandevenonesjust courses forthenovice,intermediate, machine. BMWrunawholehostofdifferent prerequisite beforesittingastrideabig training wasanabsolutelyessential What wasveryevidentthatproper Try BeforeYou Buy he the threescepticalfemalesinthehousehold, very one-sideddiscussionsathome.Sadly, for indulge mysecretleatherfetish. In addition,Inowhadtheperfectexcuseto clothing, helmetsandopportunitiesfortouring. sussing outthechoicesforabiggerbike, I for apersonalupgradewassewn.Beforelong, touring withbigbikesinScotlandandtheseed was pouringover‘Bike’and‘Ride’magazines, also regaleduswithtalesofexperiences , appeared tohavelittle– -glow

Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 31 THE SECRET LIFE OF... Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 32 THE SECRET LIFE OF... feeling ofsafety andreassuranceinnumbers seven bikeshad metupattheEurotunnel, a what layahead.However life, butitstillonlyrepresented afractionof furthest Ihadevertravelled onabikeinmy cross- The journeytoLondonthe nightbeforeour Il GrandTour kind thought,nonetheless. dangerous fashion.Judywasdeflated.Whata would distractmyattentioninaquite declining totakeherwithmeforfearshe expected toperform,Ineverdiscovered, seat. Quitewhatotherfunctionsshewas finery andplacedinvitinglyonthepassenger A company, andsokindlyarrangedasubstitute. mates’, travellingwithoutapilliontokeepme would beatabigdisadvantageas‘Billy-no- Some neighboursandthefamilyfeltthatI concerned. could eathisheartoutasfarIwas vaunted round-the-worldmotorbiketours) McGregor (heofthetelevisedandmuch used asaSatNavdevicewasinstalled.Ewan Smartphone tobehandlebarmountedand carry alltheessentials.Wiringtoenablemy Side panniersandatank-boxwerefittedto see mywaythroughthedarkestofalleyways. from milesaway, andallowmetobeable voluptuous ‘Judy’ wasdressedinappropriate voluptuous ‘Judy’ Channel departurewas,in truth,the , once thepartyof were concerned. no Damascusroadconversion asfarthey as badtheyhadfeared,buttherewas,sadly, group offemalesathomethatthingsweren’t perhaps wentsomewaytoconvincingawary A enjoyment –Iwastrulyhooked. been sweptawayinawaveofundiluted Any doubtsthatmighthaveexistedbeforehad picturesque valleys. mountain, orthroughthe snow-capped were simplymagnificent,betheyfromatopa Confidence grewwitheachmile.Theviews the legs(thinkwhatyoumissed,Judy). power ofthemagnificentmachinebetween opening outonthestraitsandfeeling hairpins, judgingthespeedofcorners, the thrillandjoyofweavingthrough most ofeverything.Itisdifficulttodescribe duration, soitseemedbestjusttomakethe wasted emotioninalifetimeofuncertain without theSeniorPartner, butguiltissucha sense ofguiltatenjoyingsuchopulence circling backintoItalyagain.Ifeltahuge riding intoFrance andSwitzerlandbefore sumptuous quality. We didagrandcircuit, between overnightstaysatidyllichotelsof about fourtofivehoursofridingaday, then followedagloriousweekoftotal train toAlessandriainnorthernItaly. There The Netherlands,wherewecaughtanight- north throughBelgiumandintothemiddleof travelled solo.Theconvoymadeitsway Four ofthebikeshadpillions,whilstthree took over, andtheadventuretrulybegan. scooter remained indailyuse-asdidthe facial machine was somewhat impractical,sothe I The Aftermath still feltthatarrivingatwork onamonster safe returnwithnountowardevents was possessed ofenviableskill,sowhen I was instructor and showtherestofclass that I rear-wheel lock.Iwaskeentodowellforthe stop whilstcontrollingtheskid inducedby rear brakewiththefootpedal andcomingtoa reached about30mphand jamming onthe was controlledskidding–accelerating untilwe fine clutchandthrottlecontrol.Afterthis,it coned-corners atveryslowspeed,learning manoeuvres –slowspeeddrivingaroundtight a training toalargepatchofroughgroundnear after asafetybriefing,wesetoffforthe own preciousmachines.Havingassembledand be nofearsaboutinadvertentdamagetoour that wererunningthecourse,sotherewould supplied bytheextremelyprofessionaloutfit conditions. Thebikesweweretouseall to controlmotorcyclesinadverseground morning intheWelsh countrysidetolearnhow and theEUgatheredonesunnyautumn No lessthan26studentsfromallovertheUK Brecon BeaconsinOctober. Italian jobandIplannedareturntriptothe and sosomeoftheheroessummer get intoaspin.Theargumentseemedsensible, if theyeverareunfortunateenoughtostalland that theskillslearnttherecanbeputintoplay where supportive PA likensthistothesituation sadly, notinfrequentlyencountered.Myever translated totheroad,wheresuchthingsare, slippery andunevengroundcouldbereadily the skillslearntwhenridingoverrough, that Iwantedtobecomeanoff-roadrider, but an ‘off-road’coursewasthewayforward.Not the skillsandperceivedwisdomwasthat spaces topark.Thenextstepwasrefine grin asIdrovepastthosestrugglingtofind disused Welsh mine.We beganwithbasic pilots oftendocoursesinacrobatics,so this bloomin’ sling… soul”. Nowif Icouldjustgetmyarmout of wheels movethebody understand themeaningof thephrase“Four adventures andallowedme toreally parking hasledmeintonew andexciting grateful tomyemployerswhose chaoticcar and Irememberitwell.amstillextremely as possible.Afterall,you'reonlyyoungonce, the saddleandmakegooderrorassoon it’s true,butadeterminationtogetbackin wheels? Notabitofit.Hugeembarrassment, adventure andIshouldhavestucktofour that thewholebusinesswasamisguided So, doestheretrospectoscopedetermine Final Conclusion few weeks. morning grinasIpassthecarparkfornext await areturntoaction–Ishallmissthat wire thejointtogetheragain,Inoweagerly After averyslickoperationtoarthroscopically wait awhile,Iguess. way throughthecourse–are-dowillhaveto joint formytroubles.AndIwasonly1/4ofthe broken ribsandasprungacromio-clavicular principal actorinthescene.Acoupleof from theaudienceaswellgroans machine andIpartedcompany. Lotsofgasps up togreetthepointofmyleftshoulder, the wheel lockedandthegroundinexplicablyrose front braketoo.Bigmistake.Asthe pedal aswellsubconsciouslyjammingonthe brake, Idoubledmypressureeffortsonthe expectation. Whenitcametoapplyingthe quickly, Iwasdeterminedtosurpassevery pressure onthebackpedaltostopmore told todoonemorerun,butuseevengreater T , wo wheelsmovethe

Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 33 THE SECRET LIFE OF...

(Professor Freddie Hamdy, Oxford)andskin Nottingham), lowriskprostatecancer London), AINIII(Professor JohnScholefield, of thebreast(Prof SarahPinder, KingsCollege DCIS/pleomorphic LCIS Hospital), low-grade (Professor HughBarr, GloucestershireRoyal the managementofBarrett's oesophagus areas ofclinicaluncertainty revolved aroundunansweredquestionsinfive Hence, oneofthemajorplenarysessions hopes willaddresstheunansweredquestions. uncertainty thatleadstoclinicaltrials,whichone confusing orcounterintuitive.Itisthis scanty, are conditions,forwhichevidencemaybe address uncertaintyandtomanagerisk.There Every day, cliniciansandpatientsneedto reviewed ontheACS website. scientific sessions,thecontentofwhichcanbe of plenarylecturesandmultidisciplinary offered awide-rangingandstimulatingmenu disciplines. The2012conferenceonceagain wide rangeofcancer-related subject broad churchforsurgeonsspecialisingina offersa 19th and20th2012.BASO-ACS conference, whichwasheldonNovember the themeunderpinningthisyear’s and furtherafield.UncertaintyRiskwas speakers, ofthehighestquality, fromLondon provides anattractivevenuefordelegatesand academic calendareveryautumn.TheCollege the Royal CollegeofSurgeonsEngland's Cancer Surgery, continues tobeahighlightof Conference ofBASO, theAssociationfor The AnnualNationalMeetingandScientific Founding MemberofSOTA Meetings Secretary, BASO~ACS and Cheltenham GeneralHospital Consultant GeneralSurgeon, Charlie Chan UNCERTAINTY ANDRISK CONFERENCE 2012: ANNUAL SCIENTIFIC BASO~ACS and otherswheretheevidencemaybe . These included ( and tohelpusdealwithourownuncertainty career toimprovingourunderstandingofrisk, at CambridgeUniversity, has dedicatedhis P P headlines. journalists, intheirsearchformemorable exploited regularlybythemediaand risk poorly. Thislackofunderstandingis mathematics ofrisk.Laypeopleunderstand intelligent doctorscanmisinterpretthesimple perform onadailybasis.Yet, even highly treatment isanexercisethatdoctorsneedto challenging. Balancingtherisksandbenefitsof when theresultsareuncertain,isevenmore Explaining therisksorbenefitsoftreatment, patients canbedifficultandconfusing. Understanding andcommunicatingriskto from unnecessarytreatment. complex surgery, whilstsavingthemultitude oesophagus) whomightbenefitfromrisky, (low riskprostatecancerandBarrett's individuals withbiologicallysignificantdisease breast) toourinabilityidentifythefew DCISofthe history ofthedisease(low-grade range fromalackofknowledgethenatural fundamental problemsthatweface.These This sessionhighlightedmanyofthe (Professor JohnThompson,Sydney). lesions ofunknownmalignantpotential with patients is afundamentalpartof treatment decisions. Shareddecision-making issue duringhistalkonuncertainties in the UKCochraneCentre, addressed thisvery uncertainties. MartinBurton, theDirectorof Such anapproachwillhelp explain be usedinroutineclinicalpractice. however, risks ofbreastscreening.Thereisnoreason, information forwomenaboutthebenefitsand communications, suchastherevised increasingly usedinkeypublichealth These importantprinciplesarenow better communication. to onlypartoftheaxis)alsohelpinproviding portraying thefullaxisonagraph,asopposed denominator) andaccurateframing(e.g. relationship (i.e.thenumeratorand or odds(1in3).Showingthepart-whole 100 withadisease)thanpercentages(33%) representation ofrisk(e.g.33womenout More peopleunderstandfrequency this aim. arrays ( numbers, aswellnovelpictographsoricon benefits forpatients.Betteruseofwordsand comprehensible representationofrisksand doctors toprovidetransparent, keynote talkfocussedontheethicalneedfor www rofessor forthePublicUnderstandingofRisk theWinton rofessor DavidSpiegelhalter, .understandinguncertainty.org). His www.iconarray.com why theseprinciplesshouldnotnow ) is fundamentalto -based

Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 35 SPECIALTY ASSOCIATION REPORT

Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 36 SPECIALTY ASSOCIATION REPORT Valerie Beralspoke aboutthecausesof prevention will becrucial.Professor Dame understanding ofcancerdevelopment and for radicalsurgery, thenimprovementsinour If wearetoreducefurther therequirement during hisStanfordCadeLecture. Professor MeirionThomasalludedtothis be viewedwithscepticismintheUK. many partsoftheworld,butitcontinuesto biopsy inmelanomaarewidelyaccepted of today of radicalsurgerytomoreminimalist gradual regressionawayfromtheHalstedera on thesurgeryofmelanomaexplained the MelanomaInstituteAustralia.Hislecture P diseases. TheEJSOLecturewasgivenby Such controversycontinuestoexistinmany chemotherapy wasbeneficialinthisgroup. contributing trialistsrefusedtobelievethat ER positivewomenwithbreastcancer;several over thebenefitsofadjuvantchemotherapyin experienced bytheEBCTCG tenyearsago This wasmirroredbythedifficulties caused, inthemain,byscientificscepticism. in the1980swasdelayedbyoverayear, breastconservationtrial pivotal NSABPB-06 of medicaldogma.Thepublicationthe peers, assomeoftheirworkflewintheface Both ofthemfacedcontroversyfromtheir the last30years,aswellfuture. the advancesinbreastcancertreatmentover Richard Peto (EBCTCG) bothspokeabout gave theBJSLecture,andProfessor Sir Professor NormanWolmark (NSABP),who Breast CancerTrialists’ CollaborativeGroup). www.nasbp.pitt.edu Adjuvant BreastandBowelProject, have beentheNSABP(NationalSurgical the mostimportantclinicaltrialsinitiatives Over thelastthreetofourdecades,twoof the HTA andMRC. regarded bythemajorfundingbodies,suchas its keyprioritiesforresearcharehighly situations. TheJLAisfundedbytheNIHRand unanswered questions"formanydisease patients indeterminingthe“topten which isanon-profitorganisationinvolving James LindAlliance(www.lindalliance.org), Martin Burtonhasalsoworkedwiththe important prioritysettingforclinicalresearch. Embracing patientsinsuchawaycanleadto between thedoctorsandpatients. this canleadtoadifferenceofopinion in thedecision-makingprocess.Sometimes uncertainty, thenpatientswillengagewillingly share knowledgeoftherisks/benefitsand informed consent.Whendoctorsareableto rofessor JohnThompson,theDirectorof . The benefitsofthesentinelnode and ) the EBCTCG (Early there onthe4thand5thNovember2013. and challenging.Ilookforwardtoseeingyou am certainthatitwillbethought-provoking uncertain aboutwhatthiswillbe.However, I theme. Atthetimeofwriting,Istillremain Next year, wewilladdressanotherimportant answer to“life,theuniverse,andeverything". remain apersistentthemeuntilwehavethe and theirpatients.Addressinguncertaintywill This alsocreatesuncertaintyamongstdoctors patterns ofingrainedteachinganddogma. Unexpected findingscausecontroversyamid unheralded bythemedia. contraceptive pillisunexpectedand cancer. Thislatteraspectoftheoral reduction inriskofovarianandendometrial provide apersistent,significant,lifelong However, prolongeduseofthepillcanalso cancer duetotheoralcontraceptivepill. a cancer inwomen.Themediahavehighlighted TRAINING FOR CANCERSURGEONSIN (SOTA) -ANEWINITIATIVE TRAINEES ASSOCIATION SURGICAL ONCOLOGY educational material. planning research/training abroad,andonline provide anonlineforum,resources for with surgery from anyspecialtythattreats cancerpatients open tosurgicaltrainees(both CTandST) attracted nearly200members. Membershipis association. Inlessthanayear, SOTA has have allbeeninvolvedinsettingupthisnew SCTS, BAHNO, BNTA, RCOGandBAOMS PLASTA, theMammaryFold,AUGIS, SURG, Representatives fromASiT, Duke’sClub, backing ofmanySurgicalTrainee Associations. hasthe in thecancerspecialities.SOTA multidisciplinary focusforsurgeonsintraining Surgery, withtheaimsofdevelopinga support ofBASO, theAssociationforCancer (SOT The SurgicalOncologyTrainees Association of theirparticularspecialty. are lessknowledgeableaboutmattersoutside and surgicaltrainingnowmeansthatspecialists paradoxically, thedirection ofmodernmedical from differentspecialists.However, some difficultcasesrequirejointsurgicalcare advances incomplexsurgeryhasmeantthat combination ofincreasingspecialisationand characterised intheoldfashionedtraining.The breadth ofknowledgeandexperience,whichis has meantthatmoderntraininglacksthe The earlydifferentiationintospecialtycareers modest, reversibleincreasedriskofbreast A) waslaunchedearlierthisyearwiththe . In duecourse,SOT A will

main nationalconferenceon19 Sadly chemotherapy. development ofmoderncombination the cellcycle,providesbasisfor modes ofaction,andthedrugtargetswithin chemotherapy gave anintroductiononcytotoxic Oncologist attheBristolOncologyCentre, Jeremy Braybrooke,aConsultantMedical radiotherapy werealsocovered. radiotherapy (e.g.Cyberknife)andproton (IMRT), tomoradiotherapy, roboticallydelivered radiotherapy, intensitymodulatedradiotherapy risk. Thenewtechniquesofconformal quadratic equation,fractionationandorgansat strand DNAdamage,theFiveRs,linear principles ofradiotherapy, suchasdouble- rectum. Hewentontodiscusssomeofthekey discussed includingbreast,lung,prostateand specialties, manydifferentdiseasesiteswere In the pitfallsofradiotherapyincancerpatients. does radiotherapyfail?”,inalectureexplaining at CheltenhamGeneralHospital,asked“Why Peter Jenkins,aConsultantClinicalOncologist related tosurgicaloncology. participated inavariedprogrammeoftopics November. Anenthusiasticaudience Sunday 18 the Royal CollegeofSurgeonsEnglandon The inauguralSOTA Conferencewasheldat medical witnesses,bothfactualandexpert,were cancer surgery, wherethe responsibilities of Rew aspectsof talkedonthemedico-legal commonly taughttosurgeonsintraining.David legal awarenessandteachingisnotatopicthat complaints andmalpracticesuits,butmedico- keeping withtheaimtobeinclusiveofall , to help. detached advice.Ifyouleave ituntilyouarealreadyintrouble,theywillbeunable arrives. Theywillstandbyyouandgiveinformed, expert,supportivebut Emeritus ConsultantColorectal Surgeon,Leicester Michael Kelly MChirFRCS MRCP(UK) Professional Body: Difficult orworryingoperations: they nevertellyou”byNickMarkham( I Dear Editor The is somuchlessandtheresultsusuallysuperior. most doctorswilleventuallyface enjoyed readingthearticle“HowtosurviveasaConsultant Surgeon–Things th two additionalthingsIwouldtellanewlyappointed consultantsurgeonare: November 2012,inadvanceofthe . Understanding thedifferent Join theHCSAorBMAbeforeyourfirstnastycomplaint th to 20 th Do thesewithafellowconsultant.Thestress JASGBI programmed bytheSOT topics relatedtocancertreatment,andwillbe Conference. Thiswillcoverafurthersetof Sunday 3 The nextSOTA Conferencewillbeheldon European fertilisationofideas. oncoplastic breastsurgery, aswellcross- disease sitesnominatedbythecandidate)and examinations insurgicaloncology(atleastthree oncology curriculum,postspecialist training, witharevisedspecificsurgical provided newinitiativesinsurgicaloncology European SocietyofSurgicalOncology)has oncology traininginEurope.ESSO(the ESSO, spokeabouttheadvancesinsurgical Goteborg inSweden,andrecentlyPresident of Finally, Peter Naredi,Professor ofSurgeryat proved “beyondallreasonabledoubt”. the criminalcourts,wherecasemustbe very uncommonfordoctorstofacetrialwithin when consideringsanctionsagainstdoctors.Itis the sameburdenofproofascivilcourts Practitioners Tribunal ServiceattheGMCadopts (i.e. >50%).ThequasijudiciaryMedical burden ofproofisthe“balanceprobability” brought withinthecivilcourts,where casesare explained indetail.Mostmedico-legal complimentary electronicsubscriptiontothe Membership ofSOT meeting. there willbeafreeconferencedinnerafterthe Committee. Registration willagainbefree,and to theBA EJSO Journal form.aspx http://www.baso.org/sota/membership- SOTA/BASO~ACS website, online registration,throughthe Number 37,September2012). rd SO~A . November 2013,immediatelyprior . New memberscanapplyby CS AnnualScientific A is free,andcomeswitha A National

Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 37 CORRESPONDENCE Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 38 INVITED ARTICLE into theintricacies ofcountycricket.Mysix year time hadcome toinitiateuswithariteofpassage secondary education,ourfather decidedthatthe the startofnewschoolterm andanewlifein trades ofthe18 memories ofthecopper, coal,ironandslate generation whoweresparedthetoilsand appease thepost-industrialsensibilitiesofa now delicatelyrenamedtheMaritimeQuarterto Hall, theCityitselfandDocks.Thelatterare terraces aroundBrynmill,theBrangwynConcert the UniversityofSwanseatothesteepresidential West Cross,TheMayals,SingletonHospitaland Mumbles LifeboatstationandOystermouth,past grand sweepofSwanseaBaystretchesfromthe City ofSwanseaisthegatewaytoGower. The splendours oftheGoodLord’screations.The and wellpreparedLaverbreadareamongthetrue The GowerPeninsula, theWelsh BaritoneVoice University Hospitals Consultant Surgeon,Southampton David ARew SWANSEA A On Saturday31 the 1950s Figure 1:AfirstclasscricketmatchatStHelen’s in the highwaysandbywaysofGower. or Cheshire,Iwouldwalkformanymilesaround from thenearabroad,beitNottingham,Newcastle throughout ourchildhoodforannualvacation make theannualsummertrekbacktoSwansea maternity service,withitinerantparentswhowould As a1957graduateoftheSwanseaHospital’s the summer. Club foroccasionalcountyhomematchesduring the itineranthomeofGlamorganCountyCricket doubles asarugbyclubgroundinthewinter the shapeofatruncatedovalorlightbulb,which and BrynRoad totheNorth.Itisahybridsitein PubtotheEast Gorse Lane,withtheCricketer’s hill, behindtheMumblesRoad andenclosed by Ground nestledinBrynmillatthefootofasteep Cricket andFootballClub,ortheStHelen sports groundsofthehomenations.Swansea which wouldchugpastoneofthemorecurious Bay wasownedbythesteamtrainandtram, Until themid1960s,seafrontageofSwansea enlivened myparents’childhoodinthetown. explosive ordnanceoftheLuftwaffe,which GRAND DAY OUTIN st th August 1968,afewdaysbefore and 19 th centuries, andthe ’s , and County gamewasformalisedinthe19 Australia, before1800,andtoSouthAfrica.The including NorthAmerica,theWest Indiesand 1744, andthegamespreadtocolonies, county levelsport.Thelawswerecodifiedin covered inthefreepressduring1700sasa seventeenth century, ifnotbefore,andwas The historyofcricketdatesbacktothe was onthebeachoranywherebutStHelens. sun wasshininggloriously, andmostofSouthWales day ofathreematchagainstGlamorgan.The Nottinghamshire werethevisitingclub,forfirst pub. below thewindowsofCricketer’s ourselves forthedayatfootofEaststand, St old brotherChristopherandIwerepackedoffto spectacle assix followedsix;36runsinsix balls! behind informed usofthesignificance the ropes.Knowledgeableold soaksintherows increasingly animated,willing thenextballover stand. Astheoverprogressed, thecrowdbecame four ofthemoverourheads and overtheEast cricket legend.Ballafterball soared upwards,and one GarfieldStAuburnSobers, hasbecomea from thePavilion EndbyoneMalcolmNash to 2008, Cardiff).Oneoverinparticular, bowled centuries before31 matches playedaroundtheworldoverthree Lloyd’s book, or soarerecordedinexquisitedetailGraeme 365 notout.Theeventsofthenext60minutes decade, includingthethenhighestTest scoreof achievements inTest cricket overthepast pavilion. Soberswasalreadyalegendfromhis Sobers downthelongflightofstepsfrom languid, lopingWest IndianallrounderGary The fallofthefifthwicketbelatedlybrought of thefivewicketstofall. the GlamorganbowlerMalcolmNashtakingfour ground, Nottshadamassedover300runs,with runs. Bytea,astheshadowsbegantocross opening partnerR.A.Whitescoredafurther73 sixes overthecourseofhisinnings,and cricketer J.B.Bolusscored140runs,strikingsix and anexcellentwicket.TheformerEngland up therunsonagroundwithshortboundary Nottinghamshire battedatabriskpaceandpiled scoring 36runs. strikes onsixconsecutivedeliveriesinoneover, No batsmanhadeverclearedtheboundarywith overseas playerthatdayagainstNottinghamshire. twist offate,hewasfieldingforGlamorganasthe Khan hadhit34runsinasixballover wonderfully entertainingPakistani batsmanMajid had neverbeenrecorded.In1967,the Cricket match,oneparticularbattingachievement on whichwewatchedourfirsteverCounty In alloffirstclasscrickethistorybeforetheday as isthenumberofoversbowledinthattime. cricket inthe20 match in1864.Onlywarhaltedthemarchof in 1877.W.G. Graceplayedhisinauguralfirstclass inaugural Test MatcheswithAustraliawereplayed English professionalstotheUSAin1859.The tours developedfollowingthevisitofateam with Sussexbeingfoundedin1839,andinternal Helen’s withoursandwichlunches,tooccupy Six oftheBest th century. Thenumberofcricket st August 1968isincalculable, (Celluloid Limited , th and bya Century,

Figure 2:GarySobershitssixsixes on31stAugust1968. Pictures courtesyBBCWales. black andwhiteimagesfromhighabovethe many occasions.Asthecamerashootsitsblurred late WilfWooller’s astonishedcommentaryon watched thegrainycoverageofthatoverto BBC Wales werefilmingthatafternoon.Ihavere- of cricketinghistory. boys becamewitnessestoanextraordinarypiece where atleastonesmallpairofblessedyoung Arms andthepatchilyoccupiedstandsbelow, Mumbles Road end,itpansover theCricketer’s

Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 39 INVITED ARTICLE Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 40 MEDICO-LEGAL BRIEFING ignorance, an changing ablade.Butthatis it. To addresssuch copy oftheCivilProcedure Rules. more experience,ortodownloadandreada adapt acourtreportshownbycolleaguewith report thatmightbewrittentoacolleague,or a beforehand. Theinitialresponsetoarequestfor practice maynotappeartodemandtraining human body never drawnblood,letalonepeeredinsidea has beennegligent,itistobenotedthatIhave cases inwhichmybriefistoprovethatasurgeon through mylegalpractice,includingcountless After manyyearsofinvolvementwithmedicine plunge) What doesthewaterfeellike?(Thefirst Such anincrementalbeginningtoamedico a busy consultantorothercolleague–becauseof a someone asksthemtowriteareport–lawyer, most surgeons,mayfirstbecomeinvolvedbecause ‘get intothemedicalreportbusiness’,others,and a marketofinjuryclaims,thereisoften medico-legal work.Whereas,inthevolume in medico-legal and supportingthehealthservice,becomeinvolved generally mindingtheirownbusiness,savinglives There isnoconsistentpatternastohowclinicians, Putting atoeinthewater(Gettinginvolved) together onacommonoutcome. see, closeup,theworkofotherandto workgivesustheopportunityto Medico-legal our professionandskillstohelpothers. education, andperhapsalsoinourdesiretouse some similaritiesinourbackgroundsand discipline.Wethe intricaciesofother’s share colleagues andenjoytryingtounderstandsomeof medicine forlawyers.We seemtoworkwellas medics, andabout the lawfor attractive about something undoubtedly There is for medics) attraction oflaw the pool(The Sitting beside London 9 Barrister, Giles Eyre BARRISTER’S PERSPECTIVE PRACTICE: A MEDICO-LEGAL A safety razor and replaceditwithanapproved socialistnon- communal bathroominanIronCurtaincountry cuts andonce,havinglostmysafetyrazorina and notamedic, inpart,toavoidjustthat. taking up–after all,Idecidedtobecomea lawyer offer that,withoutdeclining, I havebeenslowin to havemeinhisoperatingtheatre foraday, an professional contacttheyhavemade. conscious decisiononthepartofclinicianto medico Gough Square, TOE INTHEWATER OF -legal reportmaybetoadaptthekindof , . sliced throughseveraldigitswhen ASGBI Actually, Ihavesufferedafewpaper member didrecentlyoffer -legal with toomuchofthedetailprocess. consumer, inwhichtheconsumerisnottroubled unequal relationshipoflegalservicesproviderand experience willprobablyhavebeenofthe experience ofthelitigationprocess.Anysuch the lawandlegalprocedurelimited,ifany, relation tothelaw. Heorshehasnotrainingin practice isalmostalwaysinasimilarposition A needed todrivesafely. sceptical examinerthattheyhadthecoreskills trained professionalandtheyhadtoprovea they receivedhoursofexpensivetuitionfroma however, theydohaveonedefiniteadvantage; expert, comparison withthenewmedico-legal passengers andotherroaduserssafe?In not learnttodowell?Arethey, their and dotheyunderstandwhatitishavestill drivers, dotheyrecognisetheirweaknesses, further confidenceandexperienceas‘qualified’ my carontheirownjaunt.Whiletheygain set off, untutoredbutencouragedbyfriends,in Code, theypassedtheirtestsandexpectedto worry beganwhen,havingreadtheHighway Marble ArchandtheNorthCircular confidence todriveaslearners,master Having spenttimegivingmysonsthe waving ordrowning? Beware thesplashingswimmer–ishe expertsmustsurelyfollow.medico-legal achieved. Entriesindirectoriesofexperienced responding toit.Respect and credibilityhasbeen (eventually), andcolleagueswritereports legal’ ratherthanjust‘medical’.Lawyerspayforit report isproducedwhichdefinitelylooks‘medico- surgeon, accountant,engineerormetallurgist,a kind isexpectedtodoandbe,whethertheybe getting sometrainingonwhatanexpertofany CPR andthePractice Direction,andperhapsby report, bytakingheedofwhatiswritteninthe copying acolleague’swell-triedformulain expertfindsthat,by The newmedico-legal as expected) That firstplungeintothewater(Notasbad shown tohave gotitwrong,ormerelyfailed to hopelessly wrong becausetheirmedicalexpert is case) considerablypoorer, whenlitigationgoes still feelprettybitter not toexpectsympathyfrom anyone,theycan participants inthelitigation. While lawyersknow they canbeveryprofoundfor theother medical expertevidenceare rarely discussedbut consequences of‘gettingitwrong’inproviding any reasonablycompetentclinician.The as fallingbelowthestandardtobeexpectedof fellow clinicianwhoseconductyouhavemarked future, ordestroytheconfidencecareerofa treatment andsupporttoliveadecentlifeinthe person’s opportunitytoreceivethefunding, duties. You might,however, destroythe injured anyone ifyouarenotfullyawareofyourroleand clinician, asanexpertwitnessyouwon’t kill orindeedunlikea Of course,unlikeadriver, expert)status ofaneffectivemedico-legal Effective splash-freecrawl(Achievingthe medical expertcommencingmedico-legal , and (ifona‘nowin,nofee’ , the real

the mostbasic understandingofmedicine. How understood by aprofessionalpersonwithonly reasons foritsconclusions,must bewrittento education. Thereport,andthe the lawyer’s medical report,canovercome thatgreatfailingin and howthebodyworks.Only you,inyour and incompleteknowledgeof humananatomy strange vocabulary became amedicandneverlearnedallthat Remember wherewebegan;thelawyernever thelawyer cannot beanalysedby, answers arenotreadilycomprehensibleto,and the answersandreasoningbehind the reportisofverylimiteduseifmedicine, questions may, onfirstsight,appeareffective. But who canprovideanswerstotheappropriatelegal report writing,and background tomedico-legal expert whobringsanexcellentmedical to theswimmingteamwaslimited.Themedical make afastturnattheendofpool.Myuse in astraightline,butIcouldn’t workouthowto When Iwasyoung,couldswimveryeffectively The perfectturn Whatdifferencehastheallegedclinical • How, inaclinicalnegligenceclaim,doesthe • The‘balanceofprobabilities’asanexpression • consider someexamples: must applyingivingtheirevidence.Let’s experts, includingthevariouslegalteststhatthey all thatisexpectedofthemasmedico-legal process, notjustwhattheCPRprovidesfor, but fully understandtheirroleinthelitigation expert witnesseswillwanttoensurethatthey Therefore, allconscientiousandprofessional ‘useful experts’. lawyer willdeletethepersonfromlistof suffered asaresultoftheexpert’snegligence, medical expertcannowbesuedforanyloss case. Comfortedbytheknowledgethata opinion, orthedifficultiesthatmightexistina communicate fullytheexpert’sreasoningor is, butalsoasitislikelytobeinthefuture. outcome, withnotonlythesituationasitnow basis, andthengoontocomparethat certainly intheabsenceofasolidscientific have been‘butfor wouldtheprobableoutcome question: “What must provideananswertothehypothetical negligence madetotheoutcome?Theexpert claimant istobejudged? reasonable conductthetreatmentof competent expertsis,againstwhose expert ascertainwhatthatbodyofreasonably reported? epidemiological researchyetwrittenor addressed directlybyanyresearchpaperor is crucialtoaclaim,butwhichnot but atleast51%probabilityonanissuewhich question, whichseeksnotscientificprobability, knowledge andexperience,answeralawyer’s does theexpert,usinghisorhermedical opinion isfarfromoneofcertainty?How practice, inadifficultcase,wheretheexpert’s is nothardtouse,butwhatdoesitmeanin , and hasonlyanintermittent ’ the negligence?”,almost . Civil Claims–anessentialguide court? Whilemetaphors( resulted inthedisagreementbeingfoughtout therespectivereasoning processeswhichhave in of theissues,andstrengthsweaknesses student, withoutbeinggivenafullunderstanding to thestatusofanunconvincingfirst-year of theotherside’smedicalexpert,reducinghim can alawyerexecutebrilliantcross-examination valuable partofthelitigationprocess. can betransformedintoareallyeffectiveand understanding andrelativelylittleeffort,areport medico medical expertsfindmostdifficultwithintheir and Isharedourexperienceofwhatitisthat In producing addressed inlitigation. to thelegalteststhatlawrequiresbe knowledge andexpertisetothelegalprocess contain, buthowtoapplytheirmedical P must understandnotonlywhattheCivil a a taught aboutmanyofthelawsapplicabletobeing and invariableweatherconditions.Theywere road withotherusers,multiplesigns, is controlledbuthowthecarcanbedrivenona driving tests,mysonslearntnotsimplyhowacar working intheirfield.Beforepassing addresses theparticularneedsofcourtexperts attend focussedtraining;thatistrainingwhich There isagoodreasonformedicalexpertsto and seminarsand,morerecently, inprint. medical expertsforcivillitigationinworkshops successfully. Formanyyears,Ihavebeentraining acquire tocarryouttheroleeffectivelyand expertmust that thesuccessfulmedico-legal Civil Procedure Rules liesalargebodyofskills understandable tome.Beyondthewordsof medical reportsusefultothelitigationandreadily direction ofsuchtrainingifitfailstomakethe their reports,Imustquestionthefocusor training theyhavereceivedbut,asaconsumerof expertsrefer,Many medico-legal intheirCV, to The future issues, and is co-author of‘ issues, andisco-author writing, givingevidenceandother medico-legal report for medicalexpertsinmedico-legal Giles frequentlygivesseminarsandworkshops injury Giles Eyreisabarristerspecialisinginpersonal About theAuthor guide Legal Reports in CivilClaims-anessential good plainEnglish. effectively withyouraudience,asalsotheuseof much morewillassistincommunicating overdone, explanations,pictures,diagramsand Recorder in2004. Solve LeadMediators Panel. He was appointeda Giles isamediatorandmember oftheCEDR rocedure Rules sayanexpertreportmust roadworthy condition. Medico-legal experts roadworthy condition.Medico-legal driver, andhowtocheckthattheirvehicle isin , ’ disease andclinicalnegligenceclaims. (2011) ( -legal reports,andhow Writing Reports Medico-Legal in www .prosols.uk.com vide Writing Medico- , this article)canbe with greater myco-author , )

Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 41 MEDICO-LEGAL BRIEFING

Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 42 INVITED ARTICLE subsequently in 1843.Lawes waseducatedatEtonand Experiment withthehelpofJoseph HenryGilbert John BennetLawesstartedthe BroadbalkWheat John BennetLawes experiments: theBroadbalkWheat Experiment. longest runningandmostproductive scientific soil science,thereevolvedone oftheworld’s background oflimitedunderstandingplantand on somelandremainedlow. Againstthis with manureaddition,itwaswellknownthatyields the problemiscompoundedbyfactthat,even This organicsystemisultimatelyself-limitingand livestock resultsinlesslandforcropproduction. have tograzeandsotherefore,inevitably, increased animals. Butthiscameatasubstantialcost;animals to increasemanureproductionnecessitatedmore produce manure,oneneededlivestockand,clearly, productively, buttherewasacost.Inorderto manure madeplantsgrowbetterandmore fact. Forexample,itwaswellknownthatfarmyard based uponexperienceratherthanprovenscientific plant growth”.But,inreality, mostpracticewas Many hypothesisedaboutthesocalled“elixirof science stilldidnotknowwhatmadeplantsgrow! that, in1830,Faradaywasproducingelectricity enough. Starvationwascommon.Despitethefact desperate tofeedthenation.Butstillitwasnot as anagriculturalfervourandpassiongrippedBritain, better breedsofanimalsbred,newcropsintroduced new machineswereinvented,paperspublished, lakes andwetlandsdrained,enclosuresploughed, environmental Armageddon.Woods werecleared, society,today’s wouldbeconsideredaveritable year periodstartingabout1750,bymethodsthat,in that whatweseetodaywasmainlycreatedinthe100 for itsgreatbeauty. Perhaps lesswellappreciatedis T ice agethatfrozetheThames. worse, thecountrywassufferinginfamousmini agricultural powerhousesand,justtomakematters and Australiawereyearsawayfrombecoming best, difficultandgenerallynon-existent.America 1841. ImportsfromawartornEuropewere,at Wales rosedramatically, reaching16millionby Despite thewar, thepopulationofEnglandand The storystartsfollowingtheNapoleonicwars. assessed eachyear. performed onwheatwithasinglevarietybeing optimise theiryield.Themajorityofstudieswere the nutritionalrequirementsofplantsandto original purposeofthisexperimentwastodiscover clinical experimentationandstatisticalanalysis.The many importantlessonstoallwhoareinvolvedin Experiment. Thisstudy, whilstagricultural,has prospective trials,theBroadbalkWheat is One hundredandsixtysixyearscounting!This Scarborough Farmer andConsultant,West Ayton, Robert Pigg EXPERIMENT OLDEST CONTINUOUS STORY OFTHEWORLD’S FATHER OFSTATISTICS: THE EXPERIMENTS ANDTHE THE MOTHEROFALL oday the storyofoneworld’slongestrunning , the Britishcountrysideislaudedandadmired , Brasenose College, Oxford,whichhe , protect thewholestructure. associated withplantheath,affectstheroof in asmallerhouse.Andfinally, potassium,whichis storeys. Inthisanalogy, lownitrogenwouldresult foundations; nitrogenstimulatesgreenmaterial,the and aroof. Phosphorousaffectsplantsroots, orthe houses havefoundations,wallsmakingupstoreys their role,ananalogyhelps.Considerahouse.All Lawes wouldfindout,interactive.To understand and potassium.Theirrolesaredifferentand,as three “majornutrients”:nitrogen,phosphorous plants havethegreatestneedandresponseto picture ofplantnutrition.T complete worth havingtheluxuryoftoday’s To explainthesignificanceofthisdiscovery, itis form theoriginsofartificialfertiliserindustry. subsequently makeLaweshisfortune,andwould deficient intheirnaturalstate.Thisdiscoverywould many soilswhicharenotoriouslyphosphate compound, andthusapotentiallyexcellenttonicfor Orthophosphate isawatersolublephosphate produced asubstancecalledorthophosphate. treating animalboneswithsulphuricacid,he breakthrough inthe1840s;hediscoveredthatby flourish atlowPH. Lawesmadeanimportant acidic soilsarenotfertileasmostplantsdo happens tobeveryacidic.Sadly, however, most it onsoil,haslittleifanyimpactunlessthesoil so, takingaphosphatesourcelikebonesandputting Phosphate compoundsarenotoriouslyinsolubleand this compoundisknownasSuperphosphate. compound availableasareadynutrienttocrops; when hesucceededinsynthesisingaphosphate great breakthroughcameattheendof1830s, growing cropsinpotswithvarioustreatments.His great experimenter. Hebegantoexperiment Lawes greatstrengthandsecretwasthathea see, wouldbeofparticularimportance. many greatchemistsandonesuchvisit,aswewill bedrooms intoalaboratory. Hewasknowntovisit horror,mother’s heconvertedoneofthe alchemy. AttheManor House,muchtohis science ofChemistry, whichwasrapidlyreplacing country squire.Laweswasobsessedwiththenew Baronet ofRothamsted Manorandbecomea had beenexpectedtotakeuphisroleasthe left withoutcompletinghisdegreeinClassics.He Experimental Pioneer Sir JohnBennetLawes rising star the UniversityofGiessenandwas consideredatrue London. HetookhisPhDunder Professor Liebigat chemistry, firstatGlasgow, thenatUniversityCollege Joseph HenryGilbertwasborn inHull.Hestudied Joseph HenryGilbert pupil. In1843,Lawes, whobythenwasawealthy most eminentchemists, metGilbert,Thomson’s star meet Professor Thomson,thenoneofthecountry . Lawes, whilevisitingUniversity Collegeto oday Scientist Par Excellence Sir JosephHenryGilbert , we knowthat , to ’s experiment was evidenttowardstheendof An exampleof the successofBroadbalk sodium andothermineralswas alsorecorded. potassium. Additionalinformation onmagnesium, the criticalplantnutrients,nitrogen, phosphorusand information aboutthenatureand quantityofeach applied. Slowly, theexperimentsproducedimportant improved ifeitherfarmyardmanure orfertiliserare and inorganic fertiliser typeoptimum applied yearly;andaLawes-Gilbert (exhaustion plots–un-manured);farmyardmanure a represent winterwheatgrowncontinuouslywithout The threesolidlinesaretakenfromBroadbalk,and The resultssoonvindicatedtheirapproach: a Lawes andGilberthad,betweenthem,established and arenowknownastheclassicalexperiments. farms. Manyoftheseexperimentsarestillrunning, as oneoftheworld’spre-eminentexperimental Rothamsted ExperimentalStation,nowrecognised few years,thebaronet’sseathadbecome many othervarietiesofgrassfollowed,andwithina Rothamsted; aflurryofothertrialsonbarleyand controlled trial.Broadbalkwasnottheonlytrialat seasons. Insummary, alongterm,prospectiveand approach wastodesignthetrialrunovermany TheLawes- experiment istheweather. Of various permutations,butatfixedrates. remaining plots,theyappliedinorganicfertilisersin an annualdoseof35tonnesperhectare.Onthe farmyard manure(mimickinghighyield)wereapplied; yield) andlandtowhichverylargeamountsof no additionalnutrientswereapplied(tomimiclow and sodium.Forcontrolplots,theyusedlandinwhich phosphates, potassium,nitrogenaswellmagnesium pun intended).Theyassessedtheeffectsof Lawes/Gilbert approachwastrulyground-breaking(no fertility levelsevenacrossasinglefield.The It waswellknown,eventhen,thatsoilsvaryintheir plots receivingnothingactedascontrols. magnesium; someallfive.Farmyardmanureand nitrogen, otherspotassiumandsodium,some different treatment;somephosphate,others winter wheat.Eachofthesubdivisionsreceiveda Rothamsted. Itwasthensubdividedandsownwith Broadbalk, a12acrefieldontheLawesestateat In 1843,itisrecordedthatoxenploughed Broadbalk lost inthemistsofobscurity. greatest chemistofhisage,althoughtalentisnow genius; Gilbertwouldemergeas,arguably, oneofthe he head-huntedGilbert.Thiswasanactofpure but recognisinghisownshortcomingsinChemistry, entrepreneur, hadanideaforexperimentalfarm, break, withthreedifferenttreatments:Nofertiliser new branchofscience:soilscience. course, theothervariableinanyagricultural nitrogen. Itcanbeseenthatyieldsaresignificantly , comprising phosphate,potassium Gilbert experimental farm hadover60years’worthof was thatofdata analysis.Bythisstage,theRothamsted Paradoxically, this producedanotherproblem,which continued tobeproducedlong after theirdeaths. established, however later byGilbertin1901.TheTrust theyhad Knighthoods. Lawesdiedin1900, followedayear elected totheRoyal Society, andreceiving accolades fortheirachievements,notleastbeing perpetuity. LawesandGilbertreceivedmany financial backingfortheRothamsted experimentsin of moneytoestablishatrustwhichwouldprovide his fertiliserempireandinvestedsubstantialamounts Lawes’ responsewas,again,visionary farmers, andalmostbecameanendangeredactivity. Wheat growingrapidlybecamelessattractivetoUK imports fromtheUS.UKwheatpricestumbled. amount ofwheatproducedintheUKwasequalledby would becomethePrairies. Bythemid1860s, headed westandsoon,vastareasofwildgrassland Broadbalk startedintheUSA,firstwagontrain But theWorld waschanging.Intheyearthat experiment intheworld! Broadbalk thanfromanyotheragricultural that theAmericanshadlearntmorefrom extremely effective.OneUSvisitorcommented together withthepracticalLawes,proved combination ofGilbert’shighscientificapproach, Gilbert andLaweswereaformidableteam.The generation, issadlynowforgotten. chemist andbotanist,theequalofanyinhis from theplotsatRothamsted. Gilbert,atrue work followedfromGilbert’sobservationsanddata carbohydrates coulduseittoproducefat.Allthis was uniqueinitsday, wasthatanimalsfedon Another interestingcommentfromGilbert,which applied nitrogen,whetherorganicorinorganic. and inparticularcereals(andgrasses),respondedto true ofonlyplants,suchaslegumes,butmost incorrect byGilbertandLawes.Theyfoundittobe promotedbyLiebig,wasshowntobe theory”, assimilated fromtheair. “minerals Thisso-called supplied mineralstoplants,withnitrogenbeing 19th Century. Ithad longbeenheldthatonlysoils 130 yearsagobyhand. This evocativelyshowsworkersharvestingtheplots brown stripssummerfallow. lighter areasshowingvariousnutrientdeficiencies, Broadbalk (centreofpicture)fromtheair: , ensured thatexperimentaldata In . 1889, hesold

Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 43 INVITED ARTICLE Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 44 INVITED ARTICLE Workers data confirmed thatthiswaswrong!Tall plants shade andtherefore didnotprosper. Rothamsted wheat, astheseensuredthat weeds wereinthe been consideredanassettogrow tallvarietiesof tall toweringplants.From medieval timesithad weresown.These as “squareheadmaster”, Traditionally, inBroad balk,varietiesofwheat,such to significantincreasedyields. addition, researchconductedintowheatvarietiesled Experiments 1935, thisbookwasfollowedby reference workforscientistsinmanydisciplines.In translations inlateryears,anditbecamethestandard hormonal weedkillerstermed Rothamsted producedoneofthefirstmodern time researchunderJudaHirschQuastelat bring neglectedsoilsbackintofullproduction.War however, providedimportantinformationonhowto imported. TheRothamsted experimentaldata, fertiliser, usually sourcedfromoverseas,couldnotbe This wasaformidablechallengeattimewhen need toincreasehome-grownwheatproduction. there wasarapidrealisationthatanurgent 1939. Importsofwheatweredrasticallyreducedand This changeddramaticallywiththeadventofwarin and importedgrownfoodwasrelativelyinexpensive. reflection ofthefactthatpopulationwaswellfed waned duringthe1920sand30s,primarilyasa General interestintheRothamsted experiments The impactofwar the generaltitle experiment. Thisresultedinaseriesofreportsunder recorded overmanyyears,includingtheBroadbalk a Whilst atRothamsted (from1919to1933),hestarted equation. exacttestandFisher’s variance), Fisher’s These includeddevelopmentofANOVA (analysisof Fisher. Hiscontributionstostatisticswereenormous. involved withresearch,willbefamiliarthename Most doctors,andcertainlyallwhohavebeen R development ofanotherscientificdiscipline:statistics. This dataprovedanimportantcatalysttothe information obtainedfromnumerousdifferentplots. influence ondetail. second dipwasaresultoftheabsenceLawes’ in fewerboysbeingavailableforweeding!The consequence ofthe1870schoolact,whichresulted to poorweedcontrol.The1880sdipoccurredasa and thenext,40yearslater years. Therearetwoobviousdips,oneinthe1880s first book, In 1925,thisworkresultedinthepublicationofhis analysing datafromhisbalancedexperimentaldesigns. methods. Hedevelopedcomputationalalgorithmsfor springboard forthedevelopmentofnewstatistical systematic approachoftheanalysisrealdataas Perhaps evenmoreimportantly, hebegana furthered hisstudiesofthestatisticssmallsamples. and elaboratedhisstudiesofanalysisvariance.He pioneered theprinciplesofdesignexperiments 1 illustrated inaninterestinghistoricalvignette. to agriculturalscience,buttheseareperhaps contributions It isimpossibletosummariseFisher’s foundations ofmodernstatisticalscience. been widelycreditedforsingle-handedlycreatingthe onald Fisher major studyoftheextensivecollectionsdata shows yieldsunderdifferentconditionsovermany . This bookwentthroughmanyeditionsand Statistical MethodsforResearch , which wasalsowidelyused.Hehas Studies inCropVariation . Fisher attributedthese 2, 4-D The Designof and, in . He Figure a weeds actuallyclimbedupthewheat.Thereisalso easily fallover, therebyreducingyields,andsome different weedkillersandfertilisers. only newvarietiesofwheatbutalsotheeffects further researchatRothamsted intostudyingnot dwarf EuropeanwheatsintotheUKstimulated even biggeryields.Theintroductionofthesenew efficiently withoutfallingover, whichresultedin dwarf plantscouldusenitrogenousfertilisermore could supportmuchbiggerheads.Further, these then shorterstemshadrealadvantagesasthey weeds werecontrolledwithchemicalweedkillers, dwarf genewithenthusiasm.Theyreasonedthat,if years. Europeanplantbreedersembracedthe from beingawheatimportertoexporterinfew head. Borlaug’sworkresultedinMexicogoing drought sensitiveandcapableofcarryingabigger Mexican Wheat”)resultedinaplantthatwasless growth heightgeneintowheatplants(“Dwarf Borlaug, demonstratedthatintroducingashorter Mexico, workonplantgeneticsbyNorman requirements areevenhigher modern techniquesthatoptimisegrowth,plant it canbeseenthatwithcroprotationandallthe or fertiliserwaseffectivelybeingwasted.Conversely, the wheatyields.Withoutthesetechniques,manure fertiliser to thefigurealsoshowsthatsamemanureor Most notableistheeffectofcroprotation.Reference fungicides andlimingareallclearlydemonstrated. the last169years.Theimpactofdifferentvarieties, experiment remarkableforitslongevity. manure orfertiliserfor169years,evidenceofan could youfindapieceofgroundthathasreceivedno weed killers,mayprovevaluable.Further, whereelse repository ofunmutatedseeds,untouchedbymodern its 169yearhistory grain andevenweedseedsgoingbacktheentiretyof Rothamsted hassamplesofsoil,differentvarieties of evaluate moderntechniques.Thearchiveat proving anexemplarystandardagainstwhichto pollution impacts,modernfarmingtechniquesanditis taken onasecondlife,addressingsustainabilityissues, experimental worldisstillyieldinginformation.Ithas So, after169years,thisgracefuloldladyofthe levels offertiliserapplication. treatments inthegreenandorangelinesofhigher Figure 2 Wheat productionin21stCentury written byMargaret GlendiningofRothampstead. The Ronald Fischer paragraphinthisarticle was always gratefullyreceived. basis, andsupportfortheclassical experimentsis experiments areopentothe public onalimited help inproducingthisarticle. The classical The authorisindebtedtoRothamsted fortheir Acknowledgement limit tohowbiga“head”tallplantcancarry. In , applied withmoderntechniques,doubled summarises someoftheBroadbalkdatafor . No - one knowswhenthis , hence different

SOME INTERESTING SIGNS... CHRISTMAS CRACKERS Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012

46 Association of Surgeons of Great Britain and Ireland CONTRIBUTE TO THE LEADERSHIP OF YOUR ASSOCIATION!

The Association wishes to make the following appointments to help lead ASGBI through the next phase of evolution, and to meet the objectives set out in the rolling Strategic Plan.

DIRECTOR OF PROFESSIONAL PRACTICE The Director of Professional Practice is a member of the Association’s Executive Board and Council. The post is for a maximum term of office of four consecutive years. The post holder will assume responsibility for the Association’s input into the Revalidation agenda and for engaging with the membership across Great Britain and Ireland through the Elected Regional Representatives on Council and the Link-Surgeons network. The successful applicant will engage, on behalf of the Association, with the Royal College of Surgeons of Edinburgh’s Regional Specialty Advisor programme, the Royal College of Surgeons of England’s Professional Affairs and ‘Supporting Surgeons in the Workplace’ initiative and other similar systems operated by the Glasgow or Irish Colleges. The post holder will also represent the Association on a number of external committees and bodies concerned with professional issues.

DIRECTOR OF THE SCIENTIFIC PROGRAMME The Director of The Scientific Programme is a member of the Association’s Executive Board and Council, and Chairs the ASGBI Scientific Committee. The post is for a maximum term of office of four consecutive years. The post holder will assume responsibility for the scientific programme for the Association’s annual International Surgical Congress and for engaging with the specialty associations and societies and Surgical Royal Colleges which contribute to the congress. The post holder will also represent the Association on a number of external committees and bodies concerned with scientific and surgical research issues. Job Descriptions for the above two posts are available, via the ASGBI website, at: www.asgbi.org.uk/appointments

INDIVIDUAL MEMBERS OF THE SCIENTIFIC COMMITTEE The Association seeks to appoint up to FIVE individual members of the ASGBI Scientific Committee with a mix of surgical specialty interests and at varying stages of their career (from senior trainees, to senior consultants). These posts will be for a maximum term of office of four consecutive years. The successful applicants will assist with the development of the scientific programme for the Association’s annual International Surgical Congress and for contributing to the evolution and growth of the Congress over the coming years.

Appointment to all the above posts will be by application (CV and covering letter) and competitive interview. However, initial expressions of interest in the position advertised should be made, in confidence, to: [email protected]

The closing date for application to all the above posts is 5.00pm on Friday 4th January 2013 During his career, Professor Schwab has spent nine years in active service in the U.S. Navy, and since has been a commander in the naval reserves. As a young physician in the early 1970s, he was involved in Issue 2, December 2012 the care of combat casualties from ANNUAL CONFERENCE 2013 Vietnam and, after that experience, Plans are now well in place for the has risen to become one of the Association of Trauma & Military USA’s top experts in trauma care. Surgery meeting, taking place on We are delighted that he has agreed Wednesday 1 May 2013, on the first to come and share his experience day of the ASGBI annual International and insights into trauma care with Surgical Congress. ATMS is looking us and acknowledge the kind forward to enjoying a first-rate support of the Royal British Legion conference at the superb facility of the in facilitating his visit. Scottish Exhibition and Conference Abstract submission for the meeting Centre in Glasgow (SECC). has been unprecedented this year and We are delighted to confirm that the deadline for submission of your Professor C. William Schwab will be work is midnight on Friday 4 January our distinguished trauma surgical 2013. Submission for the ATMS visitor and will deliver the annual meeting is via the ASGBI Congress Guthrie Lecture. Professor Schwab is microsite, which can be found here: Chief of Traumatology, Surgical Critical http://www.asgbi.org.uk/glasgow2013/a Care and Emergency Surgery at the bstracts.htm. Hospital of the University of rauma & Military Surgery Pennsylvania in Philadelphia. CONFERENCE DINNER In addition to a vigorous academic programme, ATMS is delighted to announce there will be a conference NEWSLETTER dinner on Wednesday 1 May at The National Piping Centre [30-34 Association of T McPhater Street, Glasgow]. This is an opportunity to relax and enjoy a delicious meal with like-minded colleagues and friends. After dinner, Glasgow’s own Kilter Ceilidh Band will have the more energetic of the delegates dancing all night long! Tickets can be purchased when registering for the conference by selecting the social programme section of the website. Professor C. William Schwab will be Delegates are advised to book delivering the annual Guthrie tickets early to avoid Lecture in Glasgow disappointment.

48 understanding between different members of the trauma team. Don’t forget that delegates to the ATMS meeting are eligible to apply for the annual Ian Jenkins Travelling Fellowship, a £1,500 award to enable trainees in trauma care to attend an event in order to enhance their training The National Piping Centre, venue for or understanding of trauma care. Apply the 2013 annual conference dinner via the www.atms.org.uk website. TRAUMA TRAINEES SOCIETY BECOME A MEMBER OF ATMS The Trauma Trainees Society works Founded in 2012, the Association of alongside the Association of Trauma & Trauma & Military Surgery aims to Military Surgery to promote trauma represent trauma care providers care to trainees from all specialities. nationally and helps drive policy The aim of the society is to support through its relations with Royal trainees and promote excellence in Colleges, other related professional trauma care. Societies and the Department of The first event organised by this new Health. With the development of society was an academic meeting held trauma networks, and the in Nottingham, with the support of the commissioning of 22 Major Trauma Nottingham University Hospitals Trust. Centres around England, trauma This meeting gathered together surgery needs to be represented at the trainees from across the country to highest level within our professional talk about aspects of modern trauma surgical bodies. care, including damage control ATMS will help top set standards, define resuscitation, damage control surgery rauma & Military Surgery training needs and represent those and quality improvement programmes. surgeons actively involved in trauma There were also talks on higher care. In addition to these worthy aims, degrees in trauma science, overseas membership of ATMS also enables fellowships, and a question and answer delegates to access discounted rates to NEWSLETTER session on developing careers in attend the annual ATMS scientific trauma surgery.

Meeting. We urge you to become a Association of T The meeting was supported by a number founder member of ATMS by visiting us of industry representatives and was here: www.atms.org.uk. attended by twenty five trainees, ranging from ST1 to senior registrars. The meeting was very well received, receiving strong feedback, and proved to be an excellent starting point for the group. Future plans for the Trauma Trainees Society within ATMS include web- based learning sources, links with overseas societies and clinical courses in trauma care, trauma radiology and team-based trauma scenario training, SECC is the venue for ATMS aimed at helping a better conference 1st May 2013

49

a) suggests fouraspectstothedefinition: final aspect,“ delivering maximumbenefitto thetrainee.The interactions followaguidedpathway aimedat successfully ensuredthatteaching andassessment continual improvementandrefinement, has Curriculum Programme (ISCP),which,by by theintroductionofIntercollegiateSurgical trainee andknowledge.Thisisbestexemplified over theprocessofinteractionsbetweentrainer, and assessed.Muchdevelopmenthastakenplace trained andhowthetrainingshouldbedelivered debate astowhattypeofconsultantshouldbe over whichpreciselevelsshouldbeattained.The frequently referredtoandcausesmuchdebate be learnedandskillstogained,iswhatmost syllabus, thatdetailed,hierarchicallistoftopicsto base thedesignofatrainingprogramme.The does provideausefulframeworkonwhichto distant fromthepracticalityofsurgicaltraining,it Although thistheoreticalapproachmayseem d) c) b) productive approach format wasdefinedinthe20 was introducedinAncientGreeceanditsmodern concept ofhavingacurriculumtoguidelearning different peopleincircumstances.The The term“curriculum”meansdifferentthingsto What isacurriculum? August 2013. required totransferthisnewcurriculumfrom in theirfinal18monthsoftraining,willbe anticipated thatallcurrenttrainees,exceptthose considered provisional.Subjecttoapproval,itis GMC, allthedetaildiscussedshouldbe required changeshavebeenapprovedbythe the proposalsbut,untilthecurriculumandany considering theproposals.Thisarticleisbasedon been madetotheGMCwhoarecurrently A Chairman, SAC inGeneralSurgery Gareth Griffiths CURRICULUM THE GENERALSURGERY number ofworkers provides alinking threadalongthepathway from less subtleskills requiredtobeaconsultant, and new generalsurgerycurriculumsubmissionhas set ofbehavioursandvaluesrequired. essentially referstotheacquisitionoffull understand andisthemostabstract,but This isthemostdifficultdefinitionto “Praxis” product isproduced. describes theactualmeansbywhich This isamoreconceptualdefinitionwhich teachers, studentsandknowledge The processofinteractionbetween product hasbeenproduced. produce theproductandthentestthat general surgeon),planthetrainingneededto type ofproductisrequired(aconsultant This iskeytocurrentthinking–definewhat product The meansofcreatingtherequired is themostfamiliardefinition. This isthedetailedsyllabus,alistoftopics,and A body ofknowledgetobelearned praxis ”, referstoallthesubtleand [1] . Educational theory has similarlycausedmuch th century bya 2001 exemplified inthegeneralsurgerycurriculumfrom “body ofknowledge”stillpersistedthough,as became moredefined.Theconceptoflearningthe the “newstyle”IntercollegiateFRCS,curriculum the “newstyle”MRCS,andwithintroductionof set. Asthe“oldstyle”FRCScametobereplacedby for monitoringtrainingagainstthestandardsthey Colleges inthe1980s.TheSACs wereresponsible Committees, wereintroducedbythefourRoyal and itssub-committees,theSpecialtyAdvisory The JointCommitteeonHigherSurgicalTraining contents ofstandardtextsonthesubject. curriculum cametobedescribedintermsofthe medical advances,increasedindepth.The Surgery reducedinbreadthbut,keepingwith today, thebodyofknowledgeremaininginGeneral surgery evolvedintothespecialtiesweknow to thebodyofsurgicalknowledgethatexisted.As surgical training,thecurriculumessentiallyequated formal curricula, meetingthestrictcriteria laid Project (laterProgramme) andthroughthis established theIntercollegiate SurgicalCurriculum be guidedbyclearcurricula. The Royal Colleges was thatallpostgraduatemedical trainingshould response tothisreportandone oftheprovisions introduced ModernisingMedical Careersin Registrars. Thefour UKDepartmentsofHealth senior registrargradeandintroducedSpecialty curriculum consider thehistoryofgeneralsurgery Against thisbackground,itisusefultobriefly Curriculum The HistoryoftheGeneralSurgery the revalidationprocessnowbeingintroduced. apprenticeship andmentoringtoautonomy formal teachingthroughtraining,guidance, Calman reportin1993 to takeforwardthechangesintroducedafter The UnfinishedBusinessreportin2002 surgery included moredetailoneachcomponentofgeneral bypass.The‘Sub-Specialist’ syllabus femoro-popliteal anterior resection,aorticaneurysmrepairand mastectomy, gastrectomy, orchidopexy, Ramstedt’s, including thyroidectomy being undefined)inawiderangeofprocedures area. The‘Core’syllabusrequiredskills(thelevel but notrestricted,tothosewithaninterestinthat required byalltraineesandthelaterbeingrelevant, withtheformerbeing ‘Core’ and‘Sub-Specialty’, syllabus ofthe2001curriculum.Thisisdividedinto of knowledge”conceptismostevidentinthe new 2013proposalattemptstoaddress.The“body lasting andhascontributedtosomeoftheissues years. Thelegacyofthisrequirementhasbeenlong and sub-specialtyemergencyexperiencefortwo emergency experienceforaminimumoffouryears consultant. Thiscurriculumrequiredgeneralsurgery be abletomovebetweensub-specialtiesasa specialties withingeneralsurgery;andwhowould trained toanadvancedlevelinoneormoresub- of independentpracticeingeneralsurgery;whowas could manageanemergencytake;whowascapable the conceptofageneralsurgeonasbeingonewho and theroleofacademictraining.Itthenintroduced it wentontobrieflydescribetrainingprogrammes after describingtheconstitutionandroleofSA [3] . . This documentwas12pageslongand, [2] . For mostofthe500yearsformal , [5] salivary glandexcision, had abolishedtheold [4] sought C,

Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 51 CURRICULUM

Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 52 CURRICULUM surgery fromgeneral reasons, andbecauseoftheseparationvascular surgery orwithinaspecialinterest.Forthese be abletodevelopfurtherwithinemergency curriculum theytraintoshouldpreparethem these surgeonsisyettobedetermined,butthe revised curriculumfor2013shouldbeprepared. )Train surgeons tobeablefunctionatan b) a) therefore to: The aimsforthe2013curriculumwere Aims forthe2013Curriculum sub-specialty areas advanced requirementsofthecurriculumin necessary, fortraineestoachievesomeofthe surgery andsecondly, itwasneitherpossible,nor curriculum’s requirementsforemergencygeneral firstly, beenadriftawayfrommeetingthe or two,itbecameincreasinglyclearthattherehad, the ISCPandwithlogbookdataoverlastyear However, byexaminingcurriculumdeliverythrough Why anotherchange? change incurriculumdesignandpresentation subsequent 2010refinement,resultedinasea- The publicationofthe2007curriculum,and training in2007. for thefirstcohortofMMCtraineeswhostarted down bythethenPMTEB,werewrittenintime general surgery primary roleonappointmentwillbeinemergency some servicerequirementforgeneralsurgeonswhose mentorship aspartofteamworking.Thereisalso experienced seniorcolleagueswhocanprovidegood formal fellowshipsorbyworkingwithmore advanced skillswillbeattainedpostCCT, eitherin an experiencedsub-specialistbyCCT. Thesemore not possible)totrainnewconsultantsthelevelof is notnecessary(andlogbookanalysisshowsit with aspecial/sub-specialtyinterest.Inthismodel,it who areabletoworkwithinateamofsurgeons surgeons whocanmanageanemergencytakeand Service requirementsareprimarilyforgeneral and possiblefutureconfigurationoftheNHS. definition; theproductrequired,givencurrent turned tothesecondaspectofcurriculum each ofthecomponentsgeneralsurgery. greater clarityandincludedjustonecurriculumfor had becomeapparentinthe2007version,gave the durationoftraining,itfilledinsomegapsthat highlighted progressiveacquisitionofskillsthrough professionalism (“praxis”)wereincluded.It on processofhowtotrainthem.Judgementand consultant itwasaimingtotrain(theproduct)and 2010 versionaddedmoredetailonthetypeof aspects ofasub-specialtytodevelopskillsin.The were givensomeflexibilitytochoosewhich limited toonearea.Inthe2007version,trainees although itwasnowrecognisedthatthiswouldbe trainees wasretained,assub-specialtytraining, need forfullemergencycompetenciesall requirements werenowpreciselydefined.The Knowledge andclinicaltechnicalskills regulations. practicalities of trainingwithinworkingtime special interest,commensurate withthe effective levelasaconsultant inateamwith be fullytrainedinemergency generalsurgery. Emphasise theneedforallgeneral surgeonsto F . uture careerdevelopmentfor [7] . Consideration, therefore, , it wasagreedthata [6] . )Rationalise thevascularsurgerycomponent. d) Moreclearlydefinetheendpointsoftraining, c) The breadthofgeneralsurgery emergency experiencefromtheoperativelogbook. P requirements forCaseBasedDiscussions, process andFRCSexamination,withdefined be confirmedasatpresent,throughtheARCP treatment. Competenceinemergencysurgerywill competent toreferthepatientonfordefinitive specialised emergencies,thedutysurgeonwillbe initiating treatmentforthelesscommon,more treatment forallthecommonconditions.After patients andwillbeabletocompleteoperative diagnose andinitiatetreatmentforallthesediverse trauma. Thedutysurgeonwillbeabletosafely conditions fromallthespecialinterestsaswell therefore, beenexpandedtoincludeemergency cover. Theemergencysectionofthesyllabus has, hospitals withoutreadyaccesstospecialinterest all ofthese.Thisisparticularlythecaseinsmaller the dutysurgeonhastobecompetentmanage conditions fromanyareawithingeneralsurgeryand emphasised. Patients willpresentwithemergency especially foremergencies,andtheseskillsare making areofparamountimportanceinallsurgery the emergencyunit).Judgementanddecision trainees couldspendeighthoursadayworkingon achieved (e.g.overafivedayworkingweek, is hopedthatthisimportantrequirementcanbe shift patternsandrotasmayimpingeonthis,butit and signsdevelopwithtime.Itisrecognisedthat patient careandtoseehowpathology, symptoms trainees tolearn,andbeinvolvedin,continuityof of timelastingnolessthanoneweekinorderfor training. Thisexperienceshouldbegainedinblocks unselected takeforthefullsixyearsoftheir requires alltraineestoberegularlyinvolvedinan The emergencygeneralsurgerycomponent Emergency GeneralSurgery The generalfeaturesofthe2013curriculum for ST8intheir choseninterest.Again,the levels ofknowledge, clinicalandtechnicalskill set transplant. Trainees willberequiredtogainthe hepatopancreatobiliary), colorectal, breastor and GI (includesoesophago-gastric interest, withthemainareasof choicebeingupper Trainees canalsochoosetodevelopaspecial general surgeryarecommon to alltrainees. The emergencyandelectiveskillsinthebreadthof ensure agoodbreadthofability T Special Interest vascular surgery. set forST4inbreast,transplant,endocrineand ensured byrequiringalltraineestoachievethelevels ST8. Breadthofknowledgeandabilityisfurther gain thehigherlevelsoftechnicalskillrequiredby with aspecialinterestintheseareaswillgoonto are atlowerlevels,recognisingthatonlytrainees level. Technical skillsforelectiveconditionsatST6 these areasforST6aresetatadeliberatelyhigh colorectal surgery and technicalskillsdefinedforST6inupperGI required toachievethelevelsofknowledge,clinical o rocedure BasedAssessmentsandbreadthof breadth ofexperience. not onlyintermsofcompetencybutalso assist inobtainingtheseemergencyskillsandto . Knowledge andclinicalskillsin , all traineesare ,

presentations are includedintheemergency definitive) management ofacutevascular Assessment, diagnosisandinitial (butnot creation ofvascularsurgeryas anewspecialty. the vascularsurgerycomponent, followingthe The finalaimofthiscurriculum wastorationalise V Defined attendanceatnationalorinternational i) Courseattendanceintheirspecialinterestand h) g) Definedteachingexperience. f) Definedaudit/serviceimprovement e) Research experiencedemonstratedbydefined d) Procedure numbersfromthelogbookto c) b) DefinednumbersofCaseBasedDiscussions a) been publishedbut,insummary, include: CCT intothecurriculum.Thesehavealready achieved byincorporatingtheJCSTGuidelinesfor Defining theendpointsoftraininghasbeen End points–GuidanceforCCT throughout thesixyearsforalltrainees. work. Emergencygeneralsurgerycontinues surgery, includingsometransplantemergency year inGIsurgeryandthreeyearstransplant with aninterestintransplantationwillspenda surgery andthreeyearsinbreast with abreastinterestwillspendyearinGI those withacolorectalspecialinterest.Trainees surgery, withtheoppositebeingcasefor three yearsinupperGIandoneyearcolorectal choosing upperGIasaspecialinterestwillspend surgery. Duringthefinalfouryears,trainees months ineitherGIsurgery, breastortransplant six monthsinvascularsurgeryandafurther ST3 andST4yearsincludeayearinGIsurgery, excessive timebeingspentinanyonearea.The and traineesinrotationdesigntoprevent surgery, inordertoguideProgramme Directors placements inthevariouscomponentsofgeneral The curriculumincludesindicativedurationsfor Indicative planforplacements alongside oneofthemainspecialinterests. trainees takingoneoftheseoptionswilldoso remote andruralsurgery. Itisenvisagedthat surgery ofchildhood,advancedtraumaor a Trainees mayalsobegiventheoptionofdeveloping in not necessaryorpossibletoachievecompetence the 2010curriculum,inordertorecognisethatitis while thetechnicalskillshavebeenadjustedfrom knowledge andclinicalskillsaresetathighlevels, ascular Surgery special interestinendocrinesurgery, thegeneral complex oruncommonproceduresbyCCT. educational meetings. ATLS accreditation. Defined managementexperience. experience. presentations andpublications. emergency surgeryandinaspecialinterest. demonstrate breadthofexperiencein special interest. Assessments inemergencysurgeryanda Defined numbersofProcedure Based across thefullbreadthofgeneralsurgery. T . rainees on impact isexpectedfromtheforthcomingreport and servicedeliverywilldevelopamajor this versionwillbenoexception.Issuesintraining All curricularequirechangeastimepasses,and emergency generalsurgery. emergency vascularwork,alongsidetheir surgery andthreeyearsinvascularwith final fouryears,theywillspendoneyearinGI vascular sectionofthe2010curriculum.Intheir follow thegeneralsurgerycurriculumand develop aspecialinterestinvascularsurgerywill vascular unit.Currenttraineeswhowantto required andinthesixmonthattachmenttoa be achievablethroughtheemergencyexposure and controlarealsoincluded,thisshouldall component. Thegenericskillsofvesselexposure [8] [7] AllumWH [6] CalmanK [5] DonaldsonL [4] [3] AllumWH [2] SmithMK [1] References their helpfulcommentsonthedraftofthisarticle. I Acknowledgements that thishasbeenachieved. the rolesrequiredofthemanddemonstrating the NHSbytrainingsurgeonscapableoffulfilling hoped thatthiscurriculumaddressestheneedsof that itmapsappropriatelytothecurriculum.Itis Intercollegiate FRCSexamandtomodifythisso started, istolookatthedesignof curriculum, thenextstep,whichhasalready endure remainstobeseen.Havingdefinedthe described inthisarticle.Whethermodelwill being trainedinemergencygeneralsurgeryas continue withingeneralsurgery, withtraineesalso oncoplastic skills.Forthepresent,thiswill training inbreastsurgeryandtheassociated Greenaway am gratefultoMrWAllumandDrRMcKee for The ShapeofTraining Griffiths GD FitzgeraldE,HornbyS,KheraG, Allum WH, http://www.shapeoftraining.co.uk/ The ShapeofTraining review England Annals oftheRoyal CollegeofSurgeons General surgerylogbooksurvey Great BritainandIreland Newsletter oftheAssociationSurgeons Is thegeneralsurgeryCCTfitforpurpose? Health PublicationsUnit,1993 Medical T The Report oftheWorking GrouponSpecialist Hospital Doctors:Training fortheFuture senior houseofficergrade Unfinished business–proposalsforreformofthe pdfs/general_surgery_curriculum.pdf http://www.jcst.org/publications/Curriculum/ JCST 2001GeneralSurgeryCurriculum Great BritainandIreland Newsletter oftheAssociationSurgeons The IntercollegiateSurgicalCurriculumProgramme (www.infed.org/biblio/b-curric.htm The encyclopaediaofinformaleducation Curriculum theoryandpractice Business.pdf http://217.154.121.42/doh/Docs/Unfinished- [8] , in press . raining One outstandingissueisthatof (2002) by Professor (2010) ;32:2-4 (2009); 26:2-6 )

Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 53 CURRICULUM Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 54 COMMERCIAL PARTNERS for anymoderndaysurgeon! Surgeon’s Shirtwoulddoubtlessfeel abittooformal hospitals,theLewin become compulsoryintoday’s sleeves. Whileashort,practicalsleevelengthhas the innovativeSurgeon’s Shirt,withdetachable half- Another popularmailorderitembackin1905was have changed,butthesentimentremainssame. T.M.Lewin Guarantee.Thewording may No-Quibble all theproductssoldbothinstoreandonline: Today, T.M.Lewin appliesasimilarqualityassuranceto assuring hiscustomersthat flannel, T.M.Lewin offeredaqualityguarantee, So confidentwasheofthesupremequality among thefashionconsciousmenoftime. street, includingarangeofflannelshirts,sopopular high items you’dbelesslikelytofindontoday’s through theLewincollectionof1905revealsother shirt stillwornallovertheworldtoday. Abrowse pioneering, theyaretheprototypeofmodern front. Mr. Lewin’s ‘coat-shirts’werenotonly 100 yearsago,shirtsdidn’t havebuttonsdownthe Lewin’s collectionof‘ready madeshirts’. of 1905remainindemandtoday, amongthemMr. gentleman. Unsurprisingly, manyofthemenswearstaples interesting insightintothesartorialhabitsofVictorian T.M.Lewin staffandcustomersalike,providingan little bookhasbecomeasourceofgreatinterestto T.M.Lewin catalogue,printedin1905.Thisfascinating Here, amongthefadeddocuments,wasanoriginal flagshipJermynStreetstore. basement ofthecompany’s Quinn, discoveredadustyboxhiddenawayinthe It wasjustover25yearsagothatT.M.Lewin CEO, Geoff originalinnovators. Lewin amongtheindustry’s hub fortheworld’sfinesttailors-MrThomasMayes the bustlingLondonStreetwhichwastobecome The firstT.M.Lewin openedonJermynStreetin1898, quality shirts,suitsandaccessoriesforoveracentury. style andelegance,T.M.Lewin hasbeenmaking A happen toshrink.” it] willbereplaced,ifbysomequeerchance,itshould brand that’ssynonymouswithtraditionalBritish “…any garmentmade[of and pinksilk! natural wool white cotton, available in a - Artillery Officers Cavalry and item popularwith Suspensory –an ‘Stowaway’ Bridget Jones.The immortalised by of ‘shapewear’ modern generation predecessor tothe too, thisfigure-huggingundergarmentwasa provide notonlywarmthbut‘supporttotheabdomen’ purchase hisown‘KnittedBodyBelt’.Designedto cotton boxersandsocks,the1905gentlemancould collectionisrestrictedto portfolio too.Whiletoday’s Underwear featuresprominentlyinthe1905Lewin for menandwomen. premium qualitybusinessshirts,suitsandaccessories world’s leadingmanufacturersandretailersof T.M.Lewin isnowfirmlyestablishedasoneofthe UK, andmoreopeningincountriesacrosstheworld, consistently competitive.Andwith100storesinthe that hasmadeusfamous,atapriceis T.M.Lewin brand.We areproudtoofferthequality to customersarestilladrivingforcebehindthe 1905, butexcellentcraftsmanshipandcommitment There islittledoubtthatfashionshavechangedsince was essentially jock strap,

Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 56 CHARITY PARTNERS Trustee David JInnes a As Dear Sir, AN OPENLETTERTOJASGBI Yours faithfully (07957 585 898). Kerry www.sparkeshome.co.uk For moreinformationabout volunteeringwiththeSparkesHome,pleasevisitourwebsite that manyofyourConsultantFellows haveuniversity-agedchildrenwiththe‘travel-bug’! I community is,Iamsure,ofrealbenefittoanywhovisit. accommodation availableinalocalvillage.Thechancetoreallycontribute females and,althoughmalevolunteersarenotpermittedtostayattheHome,thereis importantly two volunteersatatimeworkbestandaregreatlywelcomedbythetrusteesand,more difference thatthesevisitsfromEnglishspeakingvolunteerscanmake.We findthatvisitsby Having beencloselyinvolvedwiththeSparkesHomesince2005,Iamonlytooawareof have beenagreatsuccesssofar, andofgreatbenefittobothourgirlsthevolunteers. during theirtimeatuniversity, butwehavehadvolunteersofallagesinthepast.Thesevisits ormaybeaspartofaholiday Many ofourpreviousvolunteershavehelpedusduringa‘gapyear’, The SparkesHomewouldliketoinvitevolunteersaged18+comeandvisitusinSriLanka. encourage tovisitthehomehelpgirlswiththeirEnglishandotherstudies. help ofasmallstaff, butwhatIwouldliketotellyouabouthereisthevolunteerswe wifemanagestheHome,with can behoused,clothedandfed.TheMethodistMinister’s dependent onsponsorshipanddonations;foraslittleONEUKPOUNDperday, onechild the Home,weprovideextra English,MathsandSciencetuition.TheSparkesHomeisfully atotalof30childrens’homesinSriLanka.Thegirlsattendlocalschoolsand, supervises The HomeisadministeredbyUKtrusteesandlocallytheMethodistChurch,which recent civilwar, ortheyarefromfamilieswhotoopoortocareforthem. denominations. Thegirls,aged6to18years,areallvictimsofthe2004tsunamiand land donatedbyalocalMethodistChurch,withaccommodationfor40girlsfromall girls ontheeastcoastofSriLanka.TheHomewasopenedinFebruary 2007andisbuilton do hopethislettermaycatchtheeyeofsomeyourreaders,especiallyasIwouldguess trustee ofthe , by thegirlswhoresidethere.Boardandlodgingcanbeprovidedonsitefor Sparkes Home or contact Claire(07831553047),Juliet(07778778103)or I , am writing to introduce you to this very specialhomefor am writingtointroduceyouthisvery mucosa condition mayresultfromischaemic injurytothe mellitus, fromwhichithasbeen inferredthatthe cardiovascular disease,hypertension anddiabetes diseasemay coexistwith Dieulafoy’s 1 oesophagus including thesmallintestine,colonand(rarely) can ariseanywhereinthegastrointestinaltract, stomach atthefundusoronlessercurve,but haemorrhage. Itusuallyoccursintheproximal [5] mucosa withoutmucosalulceration arteriole whicherodesthroughtheoverlying lesionisanabnormalsubmucosal The Dieulafoy’s Discussion junction( just abovetheoesophago-gastric diseasewasvisible arteriole typicalofDiuelafoy’s (which wasotherwisenormal),asolitary the secondandthirdparts.Inoesophagus duodenum werenormalasfarthejunctionof gastrointestinal tract.Thestomachand At endoscopy, therewasnobloodintheupper underwent emergencygastroscopy. revealed anabdominalaorticaneurysm.He dropped to95/45.Re-examination ofhisabdomen further haematemesesandhisbloodpressure g/100ml. Duringthenextfivehours,hehadtwo left chestleads.Hishaemoglobinlevelwas7.3 His ECGshowedsomeischaemicchangesinthe examinations wererecordedasotherwisenormal. Cardiovascular, respiratoryandabdominal 110 bpmbutanormalbloodpressureof135/70. well. Onadmission,hehadasinustachycardiaof he wasstartedonoralaspirin.Heotherwise ischaemic attacktwoyearspreviously, afterwhich mild hypertensionandhadexperiencedatransient with haematemesisandmelaena.Hesufferedfrom A Hospital Department ofSurgery, LincolnCounty P ANEURYSM ABDOMINAL AORTIC PATIENT WITHAN DIEULAFOY’S DISEASEINA OF OESOPHAGEAL ENDOSCOPIC MANAGEMENT for thistoberepairedelectively. fistula.Arrangementsweremade aorto-enteric aortic aneurysmwithnoevidenceofleakageor CT scanconfirmeda7.2cminfrarenalabdominal was dischargedhome12dayslater transfusion andfurtherimaginginvestigations,he and hisconditionstabilised.Afterablood biopsy forceps.Therewasnofurtherbleeding arteriole wasdiathermycoagulatedwithhot around thevisiblelesionin10aliquots,and 1/10,000 adrenalinewereinjectedsubmucosally between Dieulafoy’s diseaseofthe oesophagus between Dieulafoy’s present case,byacombination ofmethods by endoscopy, itcanusuallybecontrolledat thissite gastrointestinal bleeding.Ifcorrectlydiagnosedat disease usuallypresentsasmajorupper ). Thiswasnotcurrentlybleeding.10mlof rofessor PReasbeck , 78 yearoldmanwasadmittedasanemergency clipping the injectionofadrenaline [1] . [3] Associations have alsobeenreported [2] banding , . In theoesophagus,Dieulafoy’s [4] , diathermy coagulation [2] or, asinthe . [1] An abdominal , causing F [1] igure . abdominal aorticaneurysm two casesinpatientswithapre-existing diseasehasbeenreportedin Although Dieulafoy’s the presentcase. mechanism whichcouldhavebeenoperativein inhibit constrictionandpromotebleeding–a inflammatory changesintheinvolvedarterymay disease expectation ofsuccess. endoscopic techniqueswithareasonable aneurysm canbemanagedbystandard diseaseinapatientwithanaortic Dieulafoy’s fistula, evidence tosuggestanaorto-enteric demonstrates that,intheabsenceofadditional lesion.Thepresentcased apparent Dieulafoy’s acutely withbothanabdominalaneurysmand uncertainty mayarisewhenapatientpresents [10] LeeOJ,KimSH [9] Yeoh K,Kang J [8] Yamaguchi Yetal [7] UsuiJetal [6] NjeruMetal [5] MakiBetal [4] ElHajjII,MalikS,McGrathKM [3] JaspersonDetal [2] [1] References injection ofadrenaline. lesionafter Figure 1:OesophagealDieulafoy’s and Takayasu’s arteritis disease the endoscopicappearancesofDieulafoy’s oesophageal oraortoduodenalfistulamaymimic not beendescribedbefore.Becauseanaorto- atherosclerotic abdominalaorticaneurysm,has lesion, coexistingwithapreviouslyundiagnosed gastrointestinal bleedingfromatrueDieulafoy’s Brueck Metal Classen M,Tytgat G NJ,LightdaleC Internist (Berlin) 2008; 49:1259-63 J Gastrointestinal Endoscopy Gastrointestinal Endoscopy2003 Rheumatol J Southern MedJ Gastroenterol Endoscopy2005;47:190-194 Digestive andLiverDisease2010;42:155-156 Dig DisSci 2002, p545 Gastroenterological Endoscopy. Thieme,NewYork, Korean MedSci [9, 10] [4] . In somecases,scleroticor , diagnostic andtherapeutic 1994; 39:2558-60 1999; 26:454-6 2009; 102:336-337 2002; 17:266-9 [6] , as wellBehcet’s [7, 8] 1996; major , ; 43: 614-616 57: 653-656

Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 57 CASE REPORT Bank of England’s ‘money printing” QE Cavendish (quantitative easing) programme, Medical particularly in relation to the wellbeing of the UK’s savers and pensioners. Dr Ros Altmann, director-general of Saga, WHY DO WE HAVE has said: “With annuity rates falling by TO THINK ABOUT about 25 per cent over the last four years as a result of QE, more than a INFLATION? million pensioners will be permanently poorer for the rest of their lives, as they Most people underestimate how much have bought an annuity at rates that money they will need to save while have been artificially depressed by the working in order to provide a solid Bank of England.” capital base with which to draw a sustainable income in later life. Over the Where as a 65-year-old man with last 20 years, the cost of living has £100,000 in his pension pot could have rocketed by 163 per cent, while average bought an annuity income of £7,855 in salaries have increased by a more July 2008, someone in the same modest 100 per cent. The effect of situation this year might only receive an inflation on savings means that £10K income of £5,923, a drop of just under placed on deposit five years ago, 25 per cent. Moreover, the NHS pension allowing for average interest and only

Medical scheme has historically used the RPI basic rate tax at 20 per cent, would (retail prices index) rate to set pension have the spending power of just over increases. In 2011, the government

h £9K today. switched to using the CPI (consumer s prices index) rate, which is generally Even with inflation at a relatively low lower, putting less money in the pockets level, the value of your retirement capital will still be eroded over the of public sector pensioners. course of your life. At 2.5 per cent, inflation will halve the value of a fixed But what does this mean in reality for income over 28 years. In addition, we those contemplating stepping back from are living longer and might need to clinical practice or planning to do so in sustain our lifestyle for up to 30 years. the future? The first step to achieving According to the Office for National an acceptable savings pot is to think Cavendi Statistics, men reaching age 65 can look about how much you will need to fund forward to another 21 years of life on your lifestyle when work has ceased. average, and women a further 24. Add Most have no realistic idea of how much in contributing to the care of elderly this is and it can come as a surprise, parents or helping the children and the particularly if you have left it to others scenario becomes even more to manage the household and book the challenging. holidays! A good rule of thumb in the majority of cases is to aim for around Much has been said publicly about the two-thirds of your normal NHS annual apparently damaging side effects of the income.

58 Taking a basic example, a surgeon on our target retirement fund. Containing around £140,000 gross pay, not our emotional reaction to events, including his or her private practice, particularly where there is uncertainty or would need to secure circa £100,000 pervasive bad news, is difficult. We per year in their retirement. Depending might believe that events in the future on the length of your service, the level will mirror the recent past. Pessimism of NHS tax-free lump sum withdrawn makes it hard to look past the short- at retirement, and your state pension term and can result in overly cautious (when eventually received), perhaps 60 decisions and corresponding sub optimal per cent could be secured. This is a results. solid base which will at least keep pace with the CPI and cover day-to-day The converse exists where we are living. And don’t forget to consider tempted by good news stories. Return your partner; there may be historical without risk bank products, unregulated pensions or savings pots lost in the fine wine investment funds, overseas system. property clubs and too-good-to-be-true tax avoidance schemes are but a few of The difficulty is that the basket of the areas where even the sharpest goods and services that you are likely financial minds have been undone to wish to consume in retirement through temporary over-exuberance. In contains items that have well exceeded a world where inflation is persistent, it is key to address early the occasional ‘normal’ inflation on an annual basis Medical (e.g. luxury travel, private school fees misalignment of expectations, existing for grandchildren etc). This then leaves plans, funding and human nature. approximately £40,000 annual income h to be funded from elsewhere. For Cavendish Medical is a fee-based s most, this means expecting to draw independent financial practice helping from any combination of your NHS medical practitioners in private practice pension tax-free lump sum, cash on and the NHS. To discuss your financial deposit, NS&I, investment property, plans, call Cavendish on 020 7636 7006. private pensions, cash and investment Simon Bruce ISAs, offshore bonds or inheritances. Managing Director of Cavendish Medical Ltd For and on behalf of Cavendish Medical Ltd Depending on the tax efficiency of your planning to date, you are likely www.cavendishmedical.com to need around £50K on an annual Cavendi This article is not, and should not be treated as, basis if you want to keep pace after financial or investment advice. Draft legislation taxes and inflation. This is a big figure can be subject to revision, and this can affect your own retirement plans. Cavendish Medical but is not out of reach by any means. Ltd. is an independent financial planning It will, however, require some thought practice that is authorised and regulated by the in advance. Financial Services Authority (FSA). The firm is also a Professional Partner of the Association of Surgeons of Great Britain and Ireland. Yet we can often make poor choices along the way because of routine human biases that detract from reaching experience the difference 59 The GMC has been in the news a fair amount Complaints to the GMC in 2011 recently. Firstly, Jeremy Hunt, the Health Secretary, announced that revalidation of doctors in the UK will commence from 3rd December 2012. And secondly, much news coverage emerged following their report on an increasing number of complaints about doctors from patients, their relatives or people acting in a public capacity.

Figures for 2011 show that complaints about doctors are at an all time high, with one in 64 A major report from the GMC, The state of doctors now being the subject of some medical education and practice in the UK expression of dissatisfaction every year. 2011 [1], published last year, analysed the Surgeons, psychiatrists and GPs are the most GMC’s data to examine trends in the GMC’s likely to be complained about. The total fitness to practise statistics. It concluded, number of complaints received by the GMC predictably, that there was a significant increased from 7,153 in 2010, to 8,781 in variation in the quality of medical practice in 2011, and figures for the first half of 2012 the UK, which they hope the introduction of show that this rise is a continuing trend. revalidation will help to improve across all areas of medical practice. But it is important to get these figures in perspective. In 2011, there were 245,903 However, the GMC also pointed out that the doctors on the register and of the 8,781 rise in complaints and investigations does not complaints received by the GMC, just 212 mean that standards of medical practice are resulted in hearings before Fitness to Practise falling; rather that the threshold for doctors and panels, compared with 326 in 2010. Following their employers to raise concerns about their investigation, just 65 doctors had their names medical colleagues is now lower. erased from the register, down from a record 92 in the previous year, and 93 had their The detailed data for 2010 outlined the number of complaints received about doctors and how registration suspended, again down from 106 those complaints are dealt with at each stage of the year before.

SIS BULLETIN the fitness to practise procedures. It also broke Although the number of complaints is high, down the results by ethnicity, gender, place of the proportion resulting in erasure or primary medical qualification, time since the suspension is relatively low. The complaints primary medical qualification and area of more likely to result in hearings and sanctions practice. The same report identified some important demographic information. against doctors are those made by ‘persons acting in a public capacity’, which boils down The GMC receives, and is more likely to to medical or other directors and the police. investigate, complaints about male doctors, who account for just over 58% of registered So, what do the GMC do with all these medical practitioners, but accounted for 75% complaints? Just 2,330 (26.5%) met the of complaints in 2010. Older doctors are also criteria for investigation by the GMC; in 1,537 more likely to be the subject of a complaint, (17.5%) cases, the GMC referred the matter which is followed up by the GMC. back to an NHS organisation for local Furthermore, at panel hearings during 2010, investigation and 4,914 (56.1%) were not Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 the older the doctor, the more likely, on pursued by the GMC. This may have been average, they would be erased from the because the complaint failed to identify a register. The report also revealed differences in specific doctor, or was not about a matter the numbers of complaints between specialties: which the GMC can investigate. So 25% of all registered doctors are GPs, but approximately three quarters of all complaints nearly 50% of complaints received in 2010 fall at the first hurdle. were about GPs.

60 Complaints from public bodies were, and still [2] in 2006, which ran to 218 pages and made are, regarded as much more serious by the 44 recommendations. GMC, mainly because of the greater level and quality of evidence supplied and the gravity of The ball was now back in the Government’s the matters complained about. court and in 2007, a White Paper, Trust, Assurance and Safety [3] was published, The introduction of revalidation is unlikely to announcing the Government’s intention to have any immediate impact on the increasing make a number of changes to the GMC, numbers of complaints, nor will it prevent including the introduction of revalidation and another Ledward, Shipman or Neale. setting the standard of proof for deciding However, in the words of the Department of fitness to practise cases as the ‘balance of Health, revalidation “represents a step forward probabilities’, rather than the criminal standard in both the effective regulation of doctors and of proof ‘beyond reasonable doubt’. In the five the creation in law of further measures to years since Trust, Assurance and Safety, improve quality and safety of care across the progress with designing the process and entire health sector.” piloting has been slow. but now it is to go live, The GMC will be responsible for revalidation, with medical leaders first, followed by all which will be based on evidence of a doctor’s doctors. continuing fitness to practise compiled over five years. This will include the relevant annual Although revalidation will become a five yearly appraisals and multi-source feedback. Your process, the aim is to revalidate all doctors, responsible officer will then make a who wish to retain a licence to practice, within recommendation to the GMC. Doctors who three years. Retired doctors, or those whose fail to revalidate will lose their licence to jobs do not require them to hold a licence to practice. practice, can stay on the register at a reduced retention fee without revalidating, but as all Revalidation has been a long time coming; the your money will buy is your name on the idea was first proposed in the late 1990s, with register and being accountable to the GMC, more formal proposals published in 2000. Its most doctors are likely to come off the register origins lie in the reaction to public concern when they retire. over Bristol Royal Infirmary paediatric cardiac surgery babies and the other “scandals” of the Dr Gerard Panting 1990s. These led the GMC, under Sir Donald SIS Medico-legal Advisor Irvine’s presidency, to propose periodic revalidation for doctors. Patients could then be References assured that their doctors were confirmed as fit [1] The state of medical education and practice in the to practise every five years and not just on the UK 2011 day they passed their finals. General Medical Council 2011 Whilst there has always been broad support for [2] Good Doctors, Safer patients Department of Health, 2006 the idea of revalidation, sorting out the detail has been problematic. After years of debate, [3] Trust, Assurance and Safety – the Regulation of st the Health Secretary, Jeremy Hunt, has decided Health professionals in the 21 Century Department of Health, February 2007

that it is important to get the system up and SIS BULLETIN running and sort out problems later. Sir Bruce Keogh, the NHS medical director, has said that the system “would not be immediately perfect”, holding that it is better to start now than wait for perfection. It was the fifth Shipman Inquiry report, published in 2005, that created a major delay in Surgical Indemnity Scheme the introduction of revalidation. Sir Graeme • Professional Indemnity exclusively for Catto described revalidation to the Inquiry general surgeons Chair, Dame Janet Smith, as “an MOT for doctors”, but she responded that there was no • Owned and run by ASGBI for members testing involved and that the proposals would • Contractual not discretionary benefits not ensure that failing and bad doctors were picked up, so they had to be reworked. • 24/7 expert medico-legal help line • Good practice rewarded Journal of the Association of Surgeons of Great Britain and Ireland. Number 38, December 2012 In response to her criticisms of the revalidation proposals in particular, and the GMC in general, Tel: 0845 094 3915 the government commissioned the Chief Email: [email protected] Medical Officer, Sir Liam Donaldson, to review the GMC in its entirety. This culminated in the Web: www.surgicalindemnityscheme.co.uk publication of Good Doctors, Safer Patients

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CONFIDENTIAL REPORTING SYSTEM IN SURGERY Programme Director, AdvisoryBoard onbehalfoftheCORESS Frank CTSmith which maybeincludedinthecontributor’srecordofcontinuingprofessionaldevelopment. Feedback Reports Three ofthecasesinthisissue this case,therisk ofbleedingwasgreaterthanthe risk the rightoption. Carefulassessmentisimportant. In and appropriately. Awatch andwaitapproachisnot In acutebleeding,careneedsto beescalatedquickly Comments: CORESS patient onthevergeofcollapse. going bleeding,andstafffailedto recogniseanacutelyill There wasfailuretoescalatecare inapatientwithon- Reporter’s Comments: ITU forsupport.Subsequently output wasrestoredandthepatienttransferredto commenced. Afterthreecyclesofresuscitation,cardiac resuscitation teamwerecalledandCPRwas toilet andcollapsedwithacardiacarrest.The not calledtotheward.Atsomepoint,hewent However and sedated. call psychiatristwascalled.Thepatientsectioned and increasinglydifficulttomanage,suchthattheon- himself. Subsequently, hebecameevenmoredistressed became verydisruptive,attemptingtodischarge agitated, pulledouthispacksandbledprofusely day,second post-operative thepatientbecamevery warfarin wasrestartedasheatriskofDVT. Onthe nasal packing.Inthemorning,hewasstableand On thenightfollowingsurgery, hebledandunderwent operative period.Surgerywasuneventful. covered withlowmolecularweightheparinintheperi- been stoppedsixdayspriortosurgery. Hewas DVTs inthepast,andregularwarfarintherapyhad underwent routineseptorhinoplasty from traumasustainedmanyyearspreviously, A reporting formcanbefoundonourwebsite, We aregratefultotheclinicians whohaveprovidedthematerialforthesereports.Theonline and thetimeoutcannotbeoverestimatedinfacilitatingsafesurgery. treatment, isparamount.Thefinalcaseillustrates,onceagain,thattheroleofWHOchecklist the generalpractitioner(andpatient)withacomprehensivewrittendischargesummary, describing information. Agoodclinicalhistoryunderpinsmanagementdecisions,andemphasisonproviding WITHDRAWAL INBLEEDINGPATIENT FAILURE TORECOGNISEALCOHOL likely tohavebeendueacutealcoholwithdrawal. confusionwas the causeofpatient’spost-operative careful history, obtainedfromthefamily, revealedthat demonstrated acutehypoxicbraininjury. Abelated, 52 yearoldman,whohadsufferedanasaldeformity , bleeding continuedandsurgicalstaffwere . Published contributionswillbeacknowledgedbya Published a , CT scan . He haddeveloped Feedback . He www.coress.org.uk relate tothefailureofeithertakingorgiving www To findoutmore,goto: in theirbestinterests. of providingconsentcanbetreated ifthattreatmentis Lastly, undercommonlaw, patientswhoareincapable themselves. consent onbehalfofpatientswho cannotconsentfor possible forattorneystobeappointed toprovide or theAdultswithIncapacityActinScotland,itis Under theMentalCapacityActinEnglandandW Under differentlegislation: that basis. legislation, andwhethertreatmentcanbeprovidedon from amentaldisorder case bybasisonwhetherthepatientissuffering consequences. However, adviceshouldbetakenona for thatmentaldisorderanditsphysical relevant mentalhealthlegislation,assessedandtreated themselves orothers,maybedetainedunderthe andwhopresentadangerto mental healthdisorder, Northern Ireland.Patients whoaresufferingfroma some respectsbetweenEngland,Wales, Scotlandand incompetent togiveconsent,iscomplex,anddiffersin disorder andwhorefuseconsent,orare for themselves,orwhosufferfromacutemental The lawontreatmentofpatientswhocannotconsent stated thefollowing: Specialist adviceobtainedfromtheAdvisoryBoard bleeding. potentially moreseriousproblemofcontinued have distractedmedicalandnursingstafffromthe management. Thepatient’sdisruptiveconditionmay been recognisedearlier, allowingappropriate assessment, riskofacutealcoholwithdrawalmighthave comprehensive historybeenobtainedatpre- in conjunctionwithfurthersurgicalexploration.Hada of DVT, andanticoagulationcouldhavebeencorrected .surgicalindemnityscheme/xyz , which alsoincludesallprevious , Certificate ofContribution as definedwithinthe (Ref: 123) operative ales, without incident. His procedurewas performedlaterthatmorning, mistakenly administered localanaesthetictowear off. the endofoperatinglistto allow timeforthe anaesthetist, andwedecidedto placethepatientat had occurred,discussedthecase withthe drapes. Iimmediatelyexplained tothepatientwhat side ofoperationhadbeencovered bythesurgical operate onthewrongside.The penmarkdenoting were doingandpointedoutthat wewereaboutto theatre healthcareassistantaskedustostopwhatwe name anddateofbirth.Itwasduringthischeckthata the patientevencontributedtothisbyconfirminghis check. Beingawake, paused forourWHOtime-out block wascomplete,wedrapedthepatientand administered localanaesthetic.Oncetheregional We talkedabouthisfamilyandbusinesswhilstI dose ofsedationbutremainedrelaxedandorientated. repair underlocalanaesthesia.Hewasgivenasmall The firstpatientwasbroughtintotheatreforhernia with allthetheatreandanaestheticstaff. abdomen. Onarrivingintheatre,Iledateambriefing deliberately markedthesideofoperationhigheron marked apatientclosetotheincisionsite,sothistime marked. Thepreviousweek,Ihadinadvertently ward, consentedandtheproposedsideofsurgerywas onthe two left.Allpatientswereseenpre-operatively inguinal herniasunderlocalanaesthetic,onerightand I applied ifthereisahistoryof, orsignsof, peripheral Antithrombotic compressionstockingsshouldNOTbe Reporter’s Comments: legs wasdocumentedintheadmissionnotes. admission forsurgery distance intermittentclaudicationfortwoyearspriorto she gaveahistoryofprogressivedebilitatingshort required partialamputation.Onfurtherquestioning, syndrome. Theforefootremainedischaemicand required emergencycalffasciotomiesforcompartment was successfullytreatedbyangioplasty, butthepatient presence ofasuperficialfemoralarteryocclusion.This magnetic resonanceangiography, whichconfirmedthe ischaemic leg.Theon-callvascularsurgeonarrangedfor embolic stockings,shewasfoundtohaveacritically pain inherleftlegandfoot.Onremovalofanti- disease. Threedayspostoperatively, shecomplainedof Hartmann’s procedureforcomplicateddiverticular A knowledge ofthepreviousappendicectomy. Thispatient the base.Post-operatively, thepatientdeniedall appendix hadbeen,therewasrowofstaplesacross or thesmalllargebowel.However, wherethe appendicitis. Noabnormalitywasrevealedinthepelvis, elevated CRP, laparoscopywasundertakenforprobable With persistingrightiliacfossapain,raisedWBC,and although assessmentofbowelloopswasdifficult. CT scanwasundertakenwhichreportedasnormal, USS undertakensixdayspreviouslyhadbeennormal.A gave nohistoryofgynaecologicalorurinaryproblems.A was stilltender, withreboundpainoncoughing.She months previously. Onthemorningafteradmission,she gynaecological reasonsatanotherinstitutionseveral history ofanorexia,bulimiaandlaparoscopyfor right iliacfossapainandvomiting.Shehadamedical 32 A SURGICAL MARKINGUNSEEN STOCKINGSCOMPOUNDLEGISCHAEMIA ANTI-EMBOLIC APPENDIX ABSENT was operatingonamorninglistwiththreeprimary 75 yearoldwomanunderwentanemergency year oldfemalepresentedasanemergencywith . No vascularexaminationofthe regularly inthepostoperativeperiod. embolic stockings,thelegsshouldbeexamined antithrombotic precaution.Inapatientwearinganti- heparin couldhavebeenemployedasanalternative been conducted,andperioperativesubcutaneous been appropriate.AVTEassessmentshouldhave wouldhave measurement ofABPIspre-operatively and inapatientwithhistoryofclaudication, patients witharterialdiseasearewelldocumented, undertaken. Risksofcompressionstockingsin appropriate examinationshouldhavebeen revealed symptomsofperipheralarterialdisease,and A Comments: CORESS appendicectomy wouldhaveshownupontheCTscan. was notunreasonable.Itislikelythatstaplesfroman undertaken andwhy. Inthiscase,diagnosticlaparoscopy discharge letterthatexplainswhatprocedurewas It isgoodpracticetogivepatientsacopyofthe procedure hasbeenperformedforavarietyofreasons. Patients maynotremember, orfullyunderstand,what This problemisnotuniquetolaparoscopicsurgery. Comments: CORESS procedures thathavebeenundertakenlaparoscopically. following theprocedureandpreferablyinwriting,ofany scars ofalaparoscopy, patientsshouldbeinformed, gridiron orLanzsurgicalincisionscar, tothegeneric With themoveawayfromopensurgeryinvolvinga Reporter’s Comments: marking combined withincisionsarenotwellfounded. draped. Concerns overrisksoftattooingfromsurgical mark shouldbe visible, evenwhenthepatientis communication isevidentinthis report.Thesurgical checkinenhancingtheatreteam value ofthetime-out checks, ratherthanusingthemas aneffectivetool.The overfamiliarity andmerelypaying lipservicetothe with anychecklisthowever, thereisadangerof wrong sidesurgery. Itsuseisstronglyadvocated. As to reducetheincidenceofadverse eventssuchas The WHOchecklistiseffectiveandhasbeendesigned Comments: CORESS speak up,thatreallysavedtheday. of anenvironmentwhereeveryonefeltcomfortableto believe itwasthebriefbeforelist,andfostering check wasreallyemphasisedtomeonthisday, butI check hasoccurred.Theimportanceofthetime-out they arenolongersedatedbeforeafinaltime-out marked inconspicuoussitesonthesideofsurgeryand My practicehaschangedsothatthepatientsarenow the wrongsidelulledmeintoafalsesenseofsecurity. and didn’t objecttolocalanaestheticbeinginjectedinto chemically disinhibited.Thefactthathewasconscious checkandwhilstalert,was sedated beforethetime-out administer localanaesthetic.Secondly, thepatientwas field, wasnotvisiblewhenIhadexposedthepatientto had made,whilstdeliberatelyhightoavoidthesurgical Two circumstancesledtothiserror;themarkthatI Reporter’s Comments: in stirrupsandlegoedema. have includedperioperativehypotension,legselevated Other factorscontributingtoischaemiainthiscasemay should beassessedbeforeprescribingTEDstockings. vascular diseaseofthelowerlimbs.Peripheral pulses potentially unnecessaryprocedurewasundertaken. was unawareshehadanappendicectomy, anda comprehensive medicalhistorywouldhave (Ref: 127) (Ref: 119) (Ref: 128) 63 CONFIDENTIAL REPORTING SYSTEM IN SURGERY Christmas Crossword Puzzle

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