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ASSOCIATION OF SURGEONS IN TRAINING YEARBOOK 2013

Published by THE ROWAN GROUP Boundary House, Boston Road, London W7 2QE Tel: 020 8434 3424 on behalf of THE ASSOCIATION OF SURGEONS IN TRAINING at the Royal College of Surgeons 35/43 Lincoln’s Inn Fields, London WC2A 3PE Tel: 020 7973 0300 www.asit.org

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Contents
ASiT Executive and Council
Yearbook Editor’s Foreword - Henry Ferguson President’s Report - Steve Hornby Vice-Presidents’ Reports - Jonathan Wild and Joseph Shalhoub Treasurer’s Report - Pauline Buxton Honorary Secretary and Sponsorship Co-ordinator’s Report - Andrew Beamish Immediate Past President’s Report - Goldie Khera Director of Education’s Report - Piriyah Sinclair Publicity Officer’s Report - Justice Reilly ASiT Council and Past ASiT Office Bearers Reports from the Regions and Subspecialty Groups 5 6 8 11 12 13 14 16 17 20

ASiT-Supported Bursaries:
ASiT/BJS Training Bursary Winners: Annabelle Williams and Ashok Kar 80 ASiT Travelling Bursary Winners 2012/13: ASiT/Covidien Travelling Fellowship 2012 Report: St Francis Hospital, Katete, Zambia - Geoffrey Roberts 82 Mai-Tais, Trauma Surgery and Spam! - Ross Davenport 84 ASiT/Operation Hernia Shorland Hosking Travelling Fellowship to Takoradi, Ghana - David Messenger 86 International Consensus Meeting, New York Veeru Kasivisvanathan 90 Endovascular Surgery in Malmo, Sweden Matthew Metcalfe 91 Society of American Gastrointestinal Endoscopic Surgeons Meeting, San Diego - Matthew Leeman 92 European Tissue Repair Society Meeting, Athens Stephen Goldie 93 Prince of Wales Hospital, Sydney - Tjun Tang 94 ASiT Regional Meeting Grant Winners 2012/13: All Wales Surgical Careers Conference - Em Qattan 94 Welsh Barbers Research Group Launch Evening Andrew Beamish 95 Foundation Surgical Skills in Surgery Course: Delivering Standardised, Affordable Surgical Skills Training for Foundation Doctors and Medical Students Edward Dyson 96 Northern Surgical Skills Conference - Fay Riley 98 East Kent Surgical Meeting - Kapil Rajwani 99 Leicester SCRUBS National Undergraduate Course Zahir Mughal, John Isherwood and Justin Yeung 100 UK Endovascular Trainees Inaugural Meeting Craig Nesbitt 103 Glasgow University Surgical Society (GUSS) Undergraduate Conference - Michael McDermott 103 ASIT Statistics for Surgeons Course - Amy Godden 104

Political Portfolio
Non-Consultant Grade Specialists in the UK Surgical Workforce: Results of a National Trainee Survey on the Future of Post-CCT ‘Sub-consultants’ from the Association of Surgeons in Training Provision of Emergency Cross-Cover Between Surgical Specialities: A Statement from The Association of Surgeons in Training ASiT Statement in Response to the Challenges for Future Surgical Training Document ASiT Statement in Response to the Announced Training Fee Increases from 2013-15 ASiT Statement in Response to Seven Day Consultant Present Care Executive Summary ASiT Statement in Response to Increase in WBA numbers by the London Deanery

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41 47 47 48 49

ASiT Conference 2012
Conference Report: Cardiff - Ed Fitzgerald International Attendees at the ASiT Conference: Philip Wau Yan Chiu, Hong Kong Ninos Oussi, Sweden Jessica Montori, Italy Pre-conference FSS Course Report Sayinthen Vivekanantham 50 56 57 58 59

Scientific Section
Implant Based Breast Reconstruction - Where Are We? Steven Thrush State of the Art: Advances in Intraoperative Imaging and Guidance in Cranial and Spinal Neurosurgery Adam Williams, Nicholas Haden and Peter Whitfield History and Advances in Lower Limb Angioplasty Gary Lambert and Alok Tiwari The Use of Endoscopic Simulation in Surgical Training James Ansell and Jared Torkington 105

Training and Careers Section
Understanding Surgical Training in Light of The Health and Social Care Act Anna Moore, Graham Sleat and Professor Sir Bruce Keogh Training a Viking Surgeon in the 21st Century Gordon McFarlane Silver Scalpel Award Winner 2012: What is a Good Surgical Trainer? Humphrey Scott Trainee-led Research Collaboratives: Pioneers in the New Research Landscape - Tom Pinkney Making the Most out of the Foundation Programme; Encouraging the Next Generation Pranav Patel and Rajesh Aggarwal How to Stay Out of Jail - Gareth Gillespie 60 64

108 112 118

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Students’ Section
Surgery as a Graduate Entry Medic - James Dunn 124 Student Elective Prize Winners’ Reports 2012/13: Trauma and Orthopaedics in Tanzania - Adam Ali 125 General Surgery in Vietnam - Elleanor Zimmerman 127

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All rights reserved. No part of this publication may be produced, stored in a retrieval system, or transmitted in any form or by any means without prior permission from the Publisher. While every care is taken to ensure that the information published in this yearbook is accurate, the Publisher cannot accept responsibility for any omissions or inaccuracies. The views and opinions expressed in this yearbook are not necessarily those of the Association.

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Yearbook Editor’s Foreword
Henry Ferguson

It is my pleasure to welcome you to the 2013 edition of the Yearbook of the Association of Surgeons in Training, and for those of you receiving this in your Conference delegate bag - welcome to Manchester! As always, the Yearbook aims to be informative, interesting and motivating. At the same time it seeks to give a flavour of the work the Association has been pursuing over the last 12 turbulent months. Professor Sir Bruce Keogh outlines the changes associated with the implementation of the Health and Social Care Bill, and explains how this will affect the surgical trainees of the future. This can be read alongside ASiT position statements on the shape of surgical training, the potential of a sub-consultant grade, and on cross-cover between surgical specialties while on-call, among other important subjects. For those of you approaching exams, I am delighted to present updates on the use of Acellular Dermal Matrices in Breast reconstruction, the use of simulation in endoscopy training, and percutaneous intervention for peripheral vascular disease.

I hope you enjoy the read!

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Last year’s conference in Cardiff was our largest ever, and had a true international feel. The experience of our international attendees is summarised alongside the official report of Cardiff 2012. The outstanding success of the Medical Student and Foundation Doctors sessions has inspired an article by Rajesh Aggarwal on Making the most of Foundation Training, and we of course include reports from our many regional, national and international Bursary winners. Many thanks must again go to all of the authors who have contributed to this publication and to the sponsors who have made it possible. In addition to this, a special thank you goes to our publisher Anne Rowe of The Rowan Group, whose many years of experience helps guide us year on year. My personal thanks must also go to Steve and the Executive for their support during this year.

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President’s Report
Steve Hornby

It has most certainly been an interesting year to be the President of the Association of Surgeons in Training. In my time in office, we have seen the introduction of revalidation and the establishment of commissioned healthcare, changes which represent some of the biggest shake ups in the the way medicine is practised in recent decades. In July of 2012 I was asked to give evidence of the impact of EWTD in surgical training and the provision of healthcare. The select committee called by Charlotte Leslie MP and Lord Kakkar heard not only how the EWTD but also how the SIMAP and Jaeger rulings have had particular impact on craft specialities such as surgery. The committee was informed that in order to maintain quality in surgical training and the safety of patient care it was essential that the rulings be relaxed for surgical trainees. For the first time in my memory there is now a real political will to look at these rules and to come to a compromise that is acceptable to both surgeons in training and is safe for the general public. With revalidation launched at the end of last year and with the GMC paper ‘Recognition and Approval of Trainers’, we have a unique opportunity to define exactly what good training is, who is capable of delivering it and what facilities must be in place for it to occur. For over a year ASiT has been feeding into The Faculty of Surgical Trainers, an initiative set up by the Royal College of Surgeons of Edinburgh. This aims to provide practical help and support to individuals who want to highlight and develop their skills as surgical trainers. 6

I have also been lucky enough to feed back council’s views in the development of the JCST Strategy Document, the five year evaluation of the ISCP and an Intercollegiate forum looking at the future of surgical training and provision of service. ASiT has led the way in areas such as Surgical Simulation with our often quoted recommendations appearing as an Editorial in The International Journal of Surgery. We hope to carry on this vein as we launch the Pilot of a National Mentorship Scheme aiming to link senior and junior trainees together for advice and guidance on both professional and personal matters. Watch out for details of this at the Conference. We have produced position statements on matters such as cross-covering surgical specialties and our opposition to the sub-consultant grade. We hope to have a new statement on the challenges faced by those individuals in less than full time training, out later in the year. We have continued to steadfastly oppose initiatives that we feel will negatively impact patients and trainees alike, such as the sub-consultant grade and I can pledge that we will continue to do so. The annual ASiT Conference continues to go from strength to strength. We have more pre-conference courses than ever before covering a wide ranging series of topics. The programme will no doubt prove to be enlightening clinically, academically and politically and the social events, as always, will be much fun. I would like to sign off this statement by saying what an absolute pleasure and privilege it has been working with the Council this year. I don’t think that I have

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met a more talented and motivated group of individuals. Their ingenuity, energy and enthusiasm are inspiring. I would wholeheartedly recommend getting involved with ASiT, whether that be at a local regional level, as faculty or delegates on our many courses or even as a member of council. Working with the Association is rewarding and informative and allows you to develop friends and relationships that will last for a career. I wish our entire membership the very best of luck in the coming year and beyond. We face stern challenges to healthcare and surgical training in these times but with the talented individuals I get to work with everyday still choosing surgery as a career, I have no doubt that these can be overcome. All the very best.

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Joint Vice-President and South Yorkshire Representative
Jonathan Wild

I have thoroughly enjoyed my third year on the ASiT Executive and it remains a privilege to be involved with a group of enthusiastic trainees on Council who strive to improve the standard and delivery of surgical training. While we await the impact of the Health and Social Care Act 2012, which will come into force this year with potentially far reaching alterations to the surgical training landscape, surgical training remains in a state of flux with many ongoing issues still to be addressed. Increasingly, there will be more training opportunities available in the independent sector as private providers have a greater role in delivering healthcare for the NHS. Whether independent sector providers will fully commit to their training obligations and how trainees will be relieved from the traditional NHS service requirements in order to access such training opportunities also remains to be seen. ASiT remains committed in trying to ensure that any loss of training opportunities in the independent sector is minimised. The most recent hike in the JCST fee is disproportionate, especially given that trainees already pay for around one-third their postgraduate training costs. In my opinion £255 per year to administer training does not offer good value for money for trainees. The critical issue is, however, that the DoH and the GMC no longer provide any funding to support the JCST. The GMC remain adamant that it is the trainees and colleges that are the only beneficiaries of surgical training. Surely members of the public also 8

benefit from excellence in surgical training and the administration that this requires? The GMC seem to ignore this and refuse to offer financial support despite the JCST carrying out work on the GMC’s behalf. Despite ASiT strongly opposing the fee rise, and supporting the suggestion that the burden of the JCST fee could be spread across all college members and fellows, rather than just trainees, it was also disappointing that, despite the support of this move by one college council, an intercollegiate agreement could not be made. I look forward to this year’s ASiT debate - on the use of WPAs in surgical training. The last 12 months has seen the continued abuse of WPAs, used inappropriately for summative and trainer assessment, by the London Deanery. It seems peculiar to me as to why trainees in London need to complete double the number of WPAs as trainees in the rest of the country, especially given that this goes against the national guidance laid down by the JCST. There is of course on a background of scepticism over the value and validity of WPAs in general. While trainees outside of London are concerned that their own Deanery may adopt a similar requirement of 80 WPAs a year, of more immediate concerns are those of London trainees who face the prospect of failing their ARCP for not meeting the 80 target, despite completing more WPAs than a comparable trainee outside of London. On behalf of those concerned trainees, ASiT have written to the GMC to ask for clarification on this matter.

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The previous year has seen ASiT expand its portfolio of education events. A survey run at the ASiT Conference in Cardiff in 2012 identified disparities in training in medical law and ethics amongst surgical trainees. Despite 90% of trainees surveyed agreeing that training in medical law and ethics is essential, only just over half reported receiving any postgraduate training in medical law and ethics so far in their training, with only 49% agreeing that training received as an undergraduate, and 26% as a postgraduate, was adequate. In addition only 16% of those trainees who have been required to provide a statement for the coroner felt adequately prepared for the experience. As a result of these findings, ASiT teamed up with the Medical Protection Society (MPS) to create a one day medico-legal training conference aimed for surgical trainees. The inaugural “Getting to Grips with Medical Law and Ethics” conference, held in September 2012 at RCSEng, was attended by 120 trainees and was extremely well received. Plans are well underway to run this event again in September 2013, and we are aiming to hold this at a venue outside London this time. ASiT have also collaborated with the René Remie Surgical Skills Centre (RRSSC) in Almere, just outside Amsterdam, to create 5-day intensive in vivo microsurgery courses for ASiT members - the ASiT Dutch Microsurgery Course. With industry support these high quality courses, delivered by a Professor of Microsurgery who has over 35 years of experience as a microsurgery instructor, offer a significant discount on the registration fee when compared with other microsurgery courses available. I have visited the RRSSC myself - it is a great place, fantastic course with high quality teaching and I highly recommend it to any trainees who require microsurgery skills. Whilst on the subject of live anaesthetised animals for surgical training, as ASiT/trainee rep on the Association of Laparoscopic Surgeons (ALS) Council, I am pleased to report that the ALS Advanced Laparoscopic Training Day in Cork, as part of the 2012 ALS conference was a major success. Taking advantage of less restrictive EU law on the use of anaesthetised animals for surgical training, delegates were able to perform advanced laparoscopic skills and utilise the live models to practice various haemostatic techniques, supervised by an unrivalled consultant faculty. As an association the ALS is certainly supportive of trainees. In addition to heavily discounted conference registrations for presenting trainees, facilitated by the ALS ‘sponsor a trainee’ initiative, the training day was free of charge to trainees. ASiT are also grateful to the ALS Council for providing expert faculty to the ASiT Northwick Park Laparoscopic Course in September, and for this year’s pre-conference ASiT Intermediate Laparoscopic Skills course.

SCIENTIFIC

I also represent ASiT on the RCSEng Patient Liaison Group (PLG). ASiT has had a longstanding relationship with the PLG and we are grateful for their ongoing support of ASiT initiatives, including the Foundation doctor essay competition, the Silver Scalpel Award and for their recent help with the ASiT Emergency Cross Cover position statement. We also greatly appreciate the PLG’s involvement with the ASiT conference, in particular by providing the patients’ perspective to the ASiT debate and supporting the ASiT PLG Patient Safety Prize, to be awarded for the first time at the 2013 conference. In my role as ASiT representative for South Yorkshire, I ran the successful ASiT Foundation Skills Course at the Northern General Hospital, attended by thirty foundation doctors and medical students, back in September, and in February I oversaw a DIY surgical skills workshop at the RCSEd National Surgical Conference of Foundation and Student Doctors, hosted by Sheffield Medical School. I have also help set-up a 2-day ASiT Practical and Operative Skills in ENT course, supported by Olympus, to be run for the first time, on 6th-7th June 2013, at the Northern General Hospital, Sheffield. I fully support the use of simulated surgical skills training for core surgical trainees, in order to reduce the learning curve and prepare CSTs for actual practice, and it is therefore encouraging to see the considerable investment that has been made by the Deanery into simulation facilities in South Yorkshire. I have been involved with the predominantly trainee-led delivery of the South Yorkshire CST Procedural Skills Programme over the last 18 months. Based on this experience, and a survey conducted all consultant and HSTs, it is clear that the main challenge to successful integration of simulation into the surgical curriculum is engagement and availability of consultant trainers. In a recent survey of surgeons in South Yorkshire, of the 48% consultants who have SPA time for training and education only 26% were aware of how to access simulation facilities with 62% unaware of the existing CST skills programme. 81% of consultants with SPAs, and 69% of HSTS, rarely or never teach simulated skills, however the majority would like dedicated time available to so do. To justify the investments made so far into infrastructure and equipment, ensuring that interested trainers are available to teach in the skills lab must be addressed, as at present simulation facilities remain underused.

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Joint Vice-President and North West Thames Regional Representative
Joseph Shalhoub

I have thoroughly enjoyed my second year as part of the ASiT Executive and working with Steve, the other Exec members and Council. Continuing where the previous year ended, benefits to ASiT members have continued to expand. Nine £300 ASiT Clinical and Academic Travelling Bursaries and twelve £100 ASiT Regional Meeting Grants were awarded in 2012 to deserving applicants. The reports relating to some of these awards can be read in the Yearbook. To add to these popular benefits, we have added the ASiT Surgical Training Research Grants; the first recipients of these £500 bursaries for research in surgical education and training will be announced in February 2013. If you are interested in applying to these and other ASiT initiatives, they are advertised regularly by email, the ASiT eNewsletter or can be found on the ASiT website (www.asit.org/resources/awards). The Foundation Skills in Surgery course is establishing itself regionally and has become a regular fixture among the pre-Conference course list (Manchester being no exception). Priding itself on a high candidate to instructor ratio, each course has received excellent feedback. In North West Thames, these are being consistently run twice a year in association with the Imperial College Surgical Society. ASiT Regional Representatives are attending the Foundation Skills in Surgery course at Imperial in preparation for running additional courses in their own Deaneries.

Regionally, pan-London skills teaching, based at St Mary’s Hospital, continues to be well-received, as does lecture-based registrar teaching at University College London for North West Thames and North East Thames trainees. Furthermore, these sessions gives the opportunity for trainees to congregate and discuss training experiences. The Imperial College Surgical Society continues to go from strength to strength, with it’s annual inaugural lecture delivered by Professor Harold Ellis who inspired medical students with his story of how the NHS has changed since its conception. Maintaining its reputation as the UK’s largest trauma conference for medical students and junior doctors, the 7th annual ‘Trauma’ conference welcomed around 200 delegates from all over Europe. The second conference to be hosted by the Imperial College Surgical Society was the 2nd ‘Global Health and the Surgeon’ conference, which aimed to expose students to the realities of the global burden of disease and the role of surgery in the humanitarian response. The conference hosted talks from speakers from the World Health Organisation, Operation Hernia, Mercy Shipsand Medsin. In December 2012, the Society also hosted an exciting consortium of world experts in reconstructive surgery. The ‘Transplanting Faces and Hands’ evening was a sell-out event, bringing together the UK Face Transplant Team and the

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Reconstructive Transplantation Unit from Massachusetts General Hospital, Harvard Medical School. This year, in addition to my role as Regional Representative, I have been involved in examining the need for and helping to plan implementation of the ASiT Mentoring Scheme. I have helped develop ASiT’s position statement in relation to non-Consultant specialist grades within the surgical workforce. I have represented ASiT on the Academy of Medical Royal Colleges Trainee Doctors’ Group, the Royal College of Surgeons of England Academic and Research Board, the editorial board of the journal ‘Surgery’, and the Surgery Section of the Royal Society of Medicine. ASiT had a presence at the BMJ Careers Fair at the beginning of October 2012 and our stand received a lot of interest from those wishing to pursue a career in surgery. Following the success of the Cardiff Conference in 2012, Manchester 2013 promises to be an excellent clinical, academic and social event for surgical trainees. We are now looking ahead to the ASiT Conference for 2014!

Treasurer’s Report
Pauline Buxton

I would first like to thank Mr Robert Davies for his diligent care of ASiT finances during his 2 year tenure as ASiT Treasurer and for persuading me to follow in his footsteps (after a few well timed glasses of red wine!). ASiT as an organization continues to expand financially due to an increasing membership, a successful conference in Cardiff and ongoing corporate sponsorships. This has enabled ASiT to be able to give more back to our members in charitable grants most notably with new initiatives such as the regional meeting sponsorship and travelling fellowships. ASiT-run courses also benefit as we are able to offer consistently low attendance fees, which we feel is important to members as we recognize that study budgets are unfortunately not what they once were. We are as always, immensely grateful to our sponsors in the medical industry for there continued support even in this tough economic climate and hope that we are able to continue our relationship for many years to come. In the coming year the aim is to continue to keep ASiT on a sound financial footing so that we can continue to support our members. Look forward to seeing you in Manchester 2013.

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Honorary Secretary and Sponsorship Coordinator Report
Andrew Beamish

This past year has taught me that with drive and determination an individual can successfully put his or her hand to almost anything. On several occasions I have reminded myself that my specialist interests lie within a general surgical field. In a ‘Jack of all trades’ role as Honorary Secretary, Sponsorship Coordinator and Webmaster, much of my work for ASiT has had little in direct relation to the act of performing surgery. Rather it has been administration, website management and industry schmoozing for money to support trainees in their training. Although the politics of a medical career can easily drive us to contemplate a life where the grass is greener, the rewards of a surgical career keep most of us on the straight and narrow. This year has been incredibly rewarding and I have learnt many new skills, from rudimentary graphic design to advanced negotiation (AKA begging for cash). I look forward to the second year of my role and to taking these new skills into my future training and post-training years. It reminds me that where action to achieve change and improvement is outside our comfort zone, we can grapple with the bull’s horns and learn how to achieve it. I would wholeheartedly encourage any interested, enthusiastic trainee to become involved with ASiT; the earlier the better. Any hard work invested is more than compensated for by the personal, social and CV benefits that can result. Who else has the opportunity to interview some of the best surgical trainers in the country for the Silver Scalpel Award and find out what really makes them tick? An incredibly humbling and truly 12

inspirational experience for an aspiring young trainee. It takes an enormous effort from a small number of individuals to make the flagship ASiT event, our annual conference, happen. The fact that many of you have received this yearbook at the Manchester Conference confirms that we have raised an inordinate amount of money, ensuring not only that the conference goes ahead, but that it is affordable to trainees and medical students who are increasingly being asked to finance the very training that will equip them with skills to serve the NHS for an entire career. Thank you to all who have submitted abstracts and attended the conference. Without enthused and engaged trainees and students, this international conference would be entirely redundant. I offer my thanks to the industry sponsors who really do make such an impressive event possible. Without their ongoing support, ASiT would simply not be able to afford to provide the conference’s impressive educational programme and the opportunity to boost CVs, meet other trainees, get up-to-date with training issues and attend inexpensive pre-conference training courses. I would also particularly like to thank my predecessor and current ASiT Vice-President, Mr Jonny Wild, for his hard work and talent in negotiation. The industry relationships that he founded prior to my appointment have made sponsor recruitment infinitely more achievable, to the benefit of every one of our members. I hope you thoroughly enjoy the Conference and Gala Dinner and do feel free to say hello or ask any questions in person or by email.

ASiT - the pursuit of excellence in training

Immediate Past President’s Report
Goldie Khera

Firstly can I say what an absolute pleasure and deepest honour it was to humbly represent you as your President in 2011-2012. It was a truly positively life changing and unforgettable experience for me! The fascination of surgery is that it is constantly evolving and there is always so much to learn and discover. We all aspire to be safe and skilled surgeons who serve patients in a professional and caring manner. This can only be achieved through world class education and training. Recently however, it seems to be despite the system rather than because of the system. For example, if the eminent very vocal proponents of plans to introduce sub-consultant grades spent their considerable time, talent and effort in actually improving training, lobbying lawmakers, utilising new technology and new assessment techniques then we would be able to utilise this era of change in our favour rather than creating yet another disaster. The largest reorganisation in the history of the NHS, combined with a requirement to make £15-20 billion of austerity savings, risks critically destabilising patient care and undermining excellence in training beyond reparation if left unchecked and unfought for.

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I see this time of political uncertainty as a unique period of opportunity to effect real change to make progress and achieve new gold standards - it is not a time to be quiet or afraid. ASiT gives us a collective identity to negotiate on your behalf and a voice to be heard at a National and International stage to genuinely make a change for the better for surgical trainees. Last year saw numerous new initiatives and plans to cascade benefits to members locally. I have been delighted that ASiT Regional Meeting Grants for members to hold meetings in their training regions have continued from strength to strength. With grants awarded to hold local trainee meetings or contribute to the start-up costs for new courses for those currently in surgical training, up to the value of £100. Members are encouraged to apply via their ASiT regional representative, the details for which are available on the ASiT website: http://www.asit.org/about/ regional there is no deadline for applications. In another new venture; the ASiT Travelling Bursaries to support clinical and/or academic training activities have also flourished. Each bursary of up to £300 is available to contribute towards travel to clinical or academic centres either in the UK or abroad. Up to 10 bursaries have been awarded per year - 5 with a February application deadline and 5 with an August application deadline. The reports pertaining to some of these success stories can be read further on in this yearbook. Whilst writing this in January 2013, I am currently enjoying life as a locum Consultant General Surgeon in Brighton. This follows on from my weekly commute from Liverpool to Newcastle during my Presidential year as a post CCT Bariatric fellow. To my wife Su and Talula our 41/2 year old in Liverpool, my humblest apologies for not being around again once more this year - I have missed you and promise to make it up to you!

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Director of Education’s Report
Piriyah Sinclair

It has been an absolute pleasure and honour to have had the opportunity to represent the Association of Surgeons in Training as Director of Education for the past 10 months and it was a baptism of fire to the ASiT Executive. The mere volume of emails received per day necessitated clearing my doctors.net account back to 2007 and eventually relenting to a gmail account. One of the Director of Education’s main roles is to represent surgical trainees on various committees and at various meetings. These have included: the Intercollegiate Committee of Basic Surgical Examinations (ICBSE), Internal Quality Assurance (IQA) for ICBSE, JCST Simulation Working Group, ISCP Management Committee, RCS Education Board and deputising on other committees, such as the OSCE Subgroup and Faculty of Surgical Trainers. This has given me a unique insight into many of the important changes taking place in surgical training. Sitting on ICBSE and IQA has been a real eye opener. Like many surgical trainees, I used to be of the opinion that the MRCS OSCE was a ‘dumbed down’ version of the old exam. However, a lot of time and effort goes into making this a reliable and equitable exam with a high level of quality assurance - such that the exam has 14

come on leaps and bounds over the past few years. The recent changes to the OSCE that will go through in February 2013, will further ensure a more rigorous examination and fairer distribution of marks. Work is ongoing at the OSCE Subgroup to create new stations that test the breadth of the curriculum. Simulation is another big training issue at the moment. As I write this, simulation syllabuses have been written for neurosurgery, paediatric surgery, urology, maxillofacial surgery and ENT surgery. These have been submitted to the GMC and are awaiting approval. The other surgical speciality simulation curriculums are still in progress. The ASiT Simulation Statement, which has now been published as an Editorial in the IJS, has been referenced many times during discussions and accessibility to simulation facilities continues to be a major concern. We are planning to add questions to our annual ‘Are you being trained survey’ to assess whether surgical trainees are getting adequate access to simulation training. This is particularly important, given that simulated assessments will become increasingly part of ISCP in the future and there are some schools that wish to make simulated assessments compulsory prior to starting operating on patients.

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The Faculty of Surgical Trainers, an initiative of RCS Edinburgh, had their inaugural meeting in November 2012. There were some very interesting talks, including one by the keynote speaker Professor Richard Reznick. He presented the simulation training programme that they have started with orthopaedic trainees in Toronto. Trainees are expected to do certain routine operations repeatedly in a simulated environment: ‘they do hemiarthroplasties until they are sick of the sight of them.’ They are then assessed on these procedures, prior to operating on patients. This simulated ‘bootcamp’ lasts 2-3 months and has been shown to reduce the learning curve, errors and improve technical ability when trainees do start to operate on patients. In the UK, cardiothoracics have adopted a ‘boot camp’ style training programme to a lesser extent, with a 2 week simulated training boot camp for core trainees prior to starting their surgical rotations. ASiT will continue to be involved in the evolution of the Faculty of Surgical Trainers and look forward to seeing how it develops and grows. We also presented a poster on our National Mentoring Scheme Pilot, the background to which will be published in Surgeon’s News this year. Much time and effort has gone into creating initially the mentoring survey, to investigate both what already exists and what surgical trainees want from a mentoring scheme, as well as developing the pilot, which is to be launched at the Manchester conference in April 2013. I organised a mentoring taster session for the ASiT Council and the feedback was unanimously positive. It may be ‘touchy feely,’ but there is no doubt that mentoring training can help build leadership skills and maximise every trainee’s potential, as can having a surgical mentor. Mentoring is underutilised in surgical training and is a rewarding activity that we will promote actively over the coming years. We are running a mentoring workshop, as one of the preconference courses at the Manchester conference and hope that this will be taken up with enthusiasm. We have also spent a lot of time this year increasing our portfolio of courses and making strong links with Industry Partners to be able to offer these courses free or at minimal cost to members. In September we ran the ASiT Higher Surgical Laparoscopic Skills Course at the Northwick Park Institute for Medical Research. This involved simulated training of various upper and lower GI operations on porcine cadavers, with excellent feedback. If we can get adequate levels of sponsorship, we will continue to run this annually.

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We have also run a medicolegal course in conjunction with MPS, preparing for a career in surgery and many more. We have many new courses being developed, including a two day ENT course to be run in Sheffield. We have been very ambitious this year with preconference courses for the ASiT conference in Manchester 2013 and have attempted to cover as many surgical specialties as possible. New courses include US for surgeons, core neurosurgical skills, core cardiothoracic skills, intermediate laparoscopic skills, mentoring and coaching and much more. If the new courses prove to be popular, we will try and run these outside of the conference. On a completely different note and a very exciting one at that, I am about to become a mother. This will bring its own challenges and rewards. My baby is due in late March and there is a chance that I will not make the conference this year. However, I will be there in spirit if not in person!! The role of Director of Education is a busy one. Many sacrifices are made, particularly in terms of one’s annual leave, but ultimately it is incredibly rewarding. I have learnt an enormous amount, from building my confidence and contributing actively to College meetings to organising aspects of a national conference. I am very grateful to have been elected to this role and look forward to doing it to the best of my abilities over the coming year.

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Publicity Officer’s Report
Justice Reilly

Now in my third year on Council, I am currently in the process of CST applications and have greatly appreciated first hand the help ASiT offers to a junior CV. Through ASiT, I have been able to keep abreast of not only updates at my level of training, but am aware of the future outlook. My role was new for 2011/2 and originally was management of, and promotion via our social network pages. With so many member-only incentives, this has grown into a somewhat larger task than first anticipated. 2012/3 saw the innovation of several new ASiT courses, including the ASiT Mentorship and Coaching Course, Statistics, Medical Ethics and several specialty courses. As my role as Publicity Officer I have been able to include reviews of these as articles in the RCSEd to further ASiT’s reach. Through promotion of the Global Surgical Fronteirs course, I was able to establish an annual ASiT GSF prize.

Our Twitter account which was launched shortly before the 2012 conference now has several hundred followers and we continue to promote our events, bursaries and deadlines via Facebook. This has also been a useful medium to engage with Medical student Surgical Societies. Our new-look bimonthly newsletter keeps members abreast of upcoming deadlines and courses. I am constantly impressed by the drive and ingenuity of my fellow Council members and I would encourage anyone to join the ASiT Council. Keep in touch! @ASiTofficial #ASiT2013 #ASiTConference Association of Surgeons in Training

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ASiT Council
Office Name Email
mrstevehornby@gmail.com goldiekhera@yahoo.com cebgiddings@gmail.com shalhoub.joseph@gmail.com jonnywild@doctors.org.uk drbeamish@doctors.org.uk p.buxton@doctors.org.uk piriyah.s@gmail.com fergusonh@doctors.org.uk edwardfitzgerald@doctors.org.uk justicereilly@yahoo.com President Steve Hornby Immediate Past President Goldie Khera Past President Charlie Giddings

Vice President/ London NW Thames Joseph Shalhoub Vice President/ Yorkshire - South/ALS Jonny Wild Secretary/Sponsorship Coordinator/Webmaster/Wales Treasurer Director of Education/ISCP Yearbook Editor/ West Midlands Conference Organiser Publicity Officer Andrew Beamish Pauline Buxton Piriyah Sinclair Henry Ferguson Edward Fitzgerald Justice Reilly

Specialty Associations
ALS AOT AUGISt BNTA Cardiothoracic Duke’s Club Foundation Year Rep ISCP Mammary Fold Medical School Liaison Group Medical Student Rep Military Jonny Wild (Exec) Peter Radford Trish Duncan Andrew Robertson Vincent Yip Andrew Alalade/ Adam Williams Mick Murphy David McCormack Catherine Boereboom Daniel Stevens Piriyah Sinclair (Exec) Seni Mylvaganam Laura Derbyshire Eleanor Zimmerman Chris Lamb seni@doctors.org.uk lfderbyshire@doctors.org.uk radders12345@gmail.com doctdunc2@hotmail.com andrewgnrobertson@hotmail.com vincentskyip@gmail.com afalalade@hotmail.co.uk apwilliams13@gmail.com moamurphy@mac.com djmccormack@doctors.org.uk catboereboom@doctors.org.uk stevensd1987@gmail.com

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eleanor.zimmermann@students.pms.ac.uk

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Office NIHR/SARS OMFS

Name Vimal Gokani Kishore Shekar

Email vimal.gokani@gmail.com kishore_shekar@hotmail.com basil.bekdash@gmail.com stewart.cleeve@bartsandthelondon.nhs.uk dan_saleh@hotmail.com garylambert@doctors.org.uk drrajnair@hotmail.com

Paeds Basil Bekdash/ Stewart Cleeve PLASTA Rouleaux Club SURG Eastern East Midlands - North (Trent) East Midlands South (Leicestershire) Daniel Saleh Gary Lambert Raj Nair

Regional Representatives
Piriyah Sinclair (Exec) Catherine Boereboom Thomas Hall Syed Ahmed Heman Joshi Joe Shalhoub (Exec) Kate Stenson Andrew Beggs Chris Battersby Sudip Sanyal kstenson@doctors.org.uk andrew@andrewbeggs.org clfbattersby@yahoo.co.uk sudipsanyal2004@yahoo.co.uk dodd_benjamin@yahoo.com.au fatima.aloraifi@gmail.com drbriankelly@hotmail.com ocallaghan.john@gmail.com fmcdermott@doctors.net.uk drdev@doctors.org.uk jamesamilburn@gmail.com andrew.robson@ed.ac.uk alexvesey@gmail.com davemess@doctors.org.uk Rhiannon.Harries@doctors.org.uk dwood@doctors.org.uk fergusonh@doctors.org.uk paulmalone@doctors.org.uk Tch2@doctors.org.uk syedahmed@doctors.org.uk hemanjoshi@doctors.org.uk

London - Kent, Sussex & Surrey London - NE Thames London - NW Thames London - SE Thames London - SW Thames Mersey Northern North West

Northern Ireland Ben Dodd Republic of Ireland Fatima Al Oraifi/ Brian Kelly Oxford John O’Callaghan Peninsula Frank McDermott Scotland - East Scotland - North Scotland - South East Scotland - West Severn Dev Mittapalli James Milburn Andrew Robson Alex Vesey David Messenger

Wales Rhiannon Harries/ Andrew Beamish (Exec) Wessex West Midlands Yorkshire - North David Wood Henry Ferguson Paul Malone

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Peter Tom Tom Michael Michael Michael lona 96-97 lona 97-98 lona Gareth ASiT - the pursuit of excellence in training 98-99 Rowan 99-00 Rowan

Yearbook Editor
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Cox Holme Holme Rhodes Bradburn Bradburn* Reid* Reid Reid* Griffiths* Parks Parks*

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Joe Sasha Conor Simon Sarah Sarah Ben Alex Ed Charles Roddy Simon Goldie Joseph James Jonathan Joseph

Huang Burn Marron* Shaw* Mills Mills* Cresswell* von Roon* Fitzgerald* Giddings* O’Kane* Gibson Khera Shalhoub* Milburn* Wild* Shalhoub*

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Anthony John John John Brian Eric George Terry AR Greg Tim Keith Linda John Barry John Richard Malcolm Jane Mc Tim Mick Dermot Gareth Ged David David Bryony Bryony Carrie Carrie Simon Simon Joe Leith Conor Ewen Ben Ed Charles Goldie Steve

Giddings Black Smith Logie Rees Taylor Foster Hall Hearn McClatchie Archer Vellacot de Cossart Templeton Taylor Taylor Cobb Reed Cue Brown Corlett O’Riordan Griffiths Byrne* O’Regan* O’Regan * Lovett* Lovett* Rodd* Rodd* Cole* Cole Huang Williams Marron Harrison Cresswell Fitzgerald Giddings Khera Hornby

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Ben Alex Ed Charles Roddy Simon Goldie Joseph James Jonathan Joseph

Cresswell* von Roon* Fitzgerald* Giddings* O’Kane* Gibson Khera Shalhoub* Milburn* Wild* Shalhoub*

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Brian John Karl Roddy Peter Simon Andrew Barney Bob Anne Nick Ged Carrie Simon Caroline Dominic Alex Will Conor David Jonny Andrew

Shorey Fielding Fortes-Mayer Nash Moore Ambrose Mclrvine Harrison Baigrie Stebbing Shaper Byrne Rodd Cole Burt Slade Kovalic Hawkins Marron Cruttenden Wood Wild Beamish

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Tony John Karl Roddy Peter Simon Andrew Paul Peter Mark Grant Joe Mohamed John Conor Tom Robert Pauline

Griffith Fielding Fortes-Mayer Nash Moore Ambrose Mclrvine Sauven Dawson Hartley Kane Huang Baguneid Bolton Marron Edwards Davies Buxton

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Yearbook Editor
85-91 90-92 91-93 93-94 94-95 95-96 96-97 97-98 98-99 99-00 00-01 01-02 02-03 03-04 04-05 05-06 06-07 07-08 08-09 09-10 10-11 11-12 12-13 89-90 90-91 91-95 95-96 96-13

Peter Tom Tom Michael Michael Michael lona lona lona Gareth Rowan Rowan Michael Finlay Finlay Michael Mohamed Mohamed Michael Suhail Elizabeth Andrew Mohamed Lucy Paul Jonathan Dimitri Jonathan Emma Jitesh Jonathan Bruce Ishtiaq Ishtiaq Jessica Jessica Henry Henry John Tom Michelle Julie ASGBI Jason Chris Ewen Ishtiaq Omair Andrew

Cox Holme Holme Rhodes Bradburn Bradburn* Reid* Reid Reid* Griffiths* Parks Parks* Lamparelli* Curran* Curran Lamparelli* Baguneid* Baguneid* Lamparelli* Anwar* Shah* Renwick* Baguneid* Wales* Glen* Ghosh* Raptis* Ghosh* Cheasty* Palmar* Ghosh Levy* Ahmed* Ahmed Johnston Johnston* Ferguson* Ferguson Templeton Holme Lucarotti Dunn

Regional Reports
East of England
It has been a pleasure to represent the East of England Region over the past year and to have also been elected as Director of Education for ASiT last year. It has certainly been rewarding and the past year has seen many new initiatives within the region. The East of England trainee research collaborative EESuRG (East of England Surgical Research Group) has grown, both in size and in accomplishments. We now have some projects off the ground, with support from our patron Professor Bradley - a Consultant Transplant Surgeon from Addenbrooke’s Hospital with a significant academic interest. The first annual AGM was held in December 2012 and a new committee was elected. We are grateful to have Prof Bradley on board and look forward to further developments over the coming years. Simulation was big on my agenda last year and I am glad to say that this area is coming on leaps and bounds. The ASiT Cambridge Foundation Skills in Surgery Course was run in April 2012 and was a resounding success, with excellent participant feedback. Due to its popularity, it will become a regular feature and we are planning to run it again in June 2013. Anyone wanting to be course faculty, please get in touch. Several laparoscopic workshops have been held at Addenbrooke’s Hospital and the core trainees have a new and improved training programme, including a 2 day anatomy course. Adverts have also been placed for two trainee Simulation Fellows, to help develop simulation facilities within the East of England region. There have also been further leadership initiatives within the region in the form of Quality Improvement Fellows (QIFs). Trusts have been requested to appoint QIFs from trainees who are ST2 and above. Each QIF is attached to the Medical Director for the duration of their appointment and continues in speciality training 50% during the twelve months, the other 50% being dedicated to their QIF role and considered as out of programme training. The focus of the QIF is to be service quality improvement. The trainee will be identifying a service quality improvement issue in conjunction with the host medical director and to develop a project in improving outcomes in the identified area in conjunction with a multi-professional team. As part of the Royal College of Surgeon’s Surgical Safety Week, the East of England Surgical Safety Conference was held in Ipswich on 5th October 2012. This was well attended by Consultants, but there were few trainees in the audience. This is likely to be due to the timing (2 days after rotating jobs). Many

Membership Secretary

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Smith Macklin Harrison Ahmed Shariq Beamish

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Piriyah Sinclair

East Midlands - North
Surgical training in ‘Trent’ has been enthusiastically overseen in the last year by Mr James Catton, upper GI consultant at Nottingham City Hospital and our new Training Programme Director. He has taken some of the uncertainty out of tasks required for progression in training in the region by giving clear objectives at the start of the academic year. He has been an advocate for the Regional Moodle (on line learning environment). Along with Mr Ayan Banerjea, colorectal consultant at Queens Medical Centre, he has promoted the tradition of robust monthly registrar teaching sessions. These take place across the region and contain useful teaching from a variety of medical and surgical specialities. The annual mock viva teaching day held at the Royal Derby Hospital is valuable practice for all trainees and an eye opener for the unprepared! We have a cadaveric dissection teaching day planned for the new year aimed at core and higher surgical trainees. Simulation training in the region has been highlighted as an essential method of gaining technical skills in an hours reduced training program, availability of simulation equipment has been circulated to all trainees. The region has also sponsored 4 places for local trainees on the Definitive Surgical Trauma Skills course at RCSEng in November 2012, these skills will be invaluable as the East Midlands Major Trauma Centre at Queens Medical Centre, Nottingham, gets ever more busy. There have been big changes to vascular surgery training nationwide which is now being run as a separate training subspeciality, Trent trainees in vascular surgery now complete one year of general surgery training and a further year of general surgery on call before working on a solely vascular rota.

Henry Ferguson

Kent, Surrey and Sussex
The Kent, Surrey & Sussex region is geographically vast. I am, however, delighted to be working as the representative of this region. I have attended a couple of regional surgical meetings promoting ASiT. We currently have several different surgical workshops which I’m hoping will take off locally in 2013. It is become increasingly likely that we in the KSS region are following the London deaneries requirements of 80 Work Based Assessments in the year. This is twice the recommended amount of the Joint committee of Surgical Training. I strongly believe that it should be a matter of quality and not quantity of assessments performed in the year. The ASiT council has written to the JCST and the GMC to pursue this issue further. I would be more than happy to hear what trainees in the region have to say with regards to this and any issues you may face. 21

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political and safety issues were discussed. Dan Poulter, a GP by training and current health minister fielded various questions and engaged well with the audience. ASiT was thanked for including some questions on Consultant mentoring in the mentoring survey and hopefully the Royal College will move forward with Junior Consultant mentoring in a positive and encouraging way. The regional website is still under construction. If any core trainees or higher surgical trainees have a keen interest in IT and wish to help to get this off the ground, again please do get in contact. We still hope to include an ‘ASIT news’ section to ensure that all trainees are kept up to date with current training developments, courses etc once this is up and running. If anyone has any suggestions for regional courses or wishes to apply for an ASiT regional meeting grant please do contact me (piriyah.s@gmail.com).

Reduction in surgical training numbers at a national level and limits on the availability of LAT posts pose difficulties for those wishing to take an Out Of Programme Experience but otherwise surgical training in Trent is a good place to be. Catherine Boereboom

West Midlands Deanery
As one of the largest Deaneries in the UK, the West Midlands offers outstanding opportunities for training in all 10 surgical specialties, including the newly created dedicated Vascular training programme, due to recruit in 2013. The central geographical position of the region makes it a fantastic choice for those needing to commute for family or professional reasons, and the variation in community make-up gives opportunities for exposure to both rural surgery in areas such as Herefordshire, to inner-city trauma in Birmingham. The Centre for Defence Medicine at the Queen Elizabeth Hospital adds to the region’s portfolio with complex military cases cared for alongside a world-renowned hepatic surgery unit. Alongside this clinical excellence, opportunities for both Laboratory-based and clinical research are widespread with access to the University of Birmingham, the Birmingham Clinical Trials Unit and the West Midlands Research Collaborative. These factors, combined with the relatively large number of available training numbers per year makes the West Midlands an ideal training region, and I can thoroughly recommend applying, whatever your level or specialty intentions.

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My term commenced with 2012 conference around the corner and I was fascinated with the turn out and the amount of work the executive committee put into its organisation. It was truly a conference for trainees run by trainees… I am sure that the 2013 ASiT Conference will be bigger and better! Syed Ahmed

North-West
It has been a privilege to represent the North-West of England during this term and has allowed me to put forward the concerns of surgical trainees in the region and apprise them of changes taking place in what has been a tumultuous year for the NHS and surgeons and trainees alike. Traditionally, ASiT in the north-west has been associated with General Surgery and during this term, I have endeavored to expand the scope of trainees from other surgical specialties to enable them to contribute their views to the ongoing process of change involving training and service delivery; this was demonstrated by the active response to the ASiT training needs survey by trainees across the region. The response of trainees to the ASiT crosscover statement also showed how much this has been a concern for trainees. There have also been understandable apprehensions about the future of the surgical workforce with talk about the surgical sub-consultant grade and the lack of detail on the process involved in making these decisions, and I have continued to try to answer these questions within the remit of ASiTs involvement in these issues. ASiT has resolutely been against the introduction of the sub-consultant grade in any form and have steadfastly maintained this position. Part of my work as a representative of ASiT has been to encourage and provide realistic advice to medical students wanting to do surgery and foundation trainees exploring their options in the face of changes to the surgical curriculum and structure of training. I have been involved in the mentoring of trainees as well as discussing the scope of surgical training with both these groups during meetings in Manchester. Given the intense interest in these issues, I am keen to continue to develop the links ASiT has with the Manchester Medical School and their active student society with a view to planning a Careers evening later this year. In addition, we are in the process of rolling out a Foundation Surgical Skills (FSS) Course this February in collaboration with core trainees in Blackpool, to encourage more medical students and Foundation trainees to experience hands on what being a surgeon is like. The FSS course has been rolled out through centres across deaneries and has received praise for the interactive and hands-on experience 22

it provides in addition to allowing students and Foundation doctors alike to discuss issues and opportunities with higher surgical trainees and research fellows. I have always been motivated by listening to the experiences of surgeons who have worked in different and often difficult environments and the sense of camaraderie in being part of a special group of doctors. This has been enhanced by the participating in meetings with the surgical branch of the Manchester Medical Society and plan to engage and recruit surgeons both active and retired from the society, with their wonderful stories and their experiences, to talk to future surgeons and students and enhance the strong bond that surgeons within the North-West share. In view of the increasing demands on the surgical training time, there is a demand for the use of simulation in surgical training to provide a safe and realistic environment for the acquisition of skills that are increasing difficult to acquire. The Manchester Surgical Skills and Simulation centre was launched in September 2012 and provides surgeons in the North West with a superb training facility, with state of the art operating theatre work-stations, cadaveric material and simulated specimens available for training. The centre is available for the organization of courses and teaching programs with links provided to the operating theatres at the MRI. And finally, 2013 is the year that the annual ASiT conference comes to Manchester. A lot of effort and work has gone into the organization of the conference particularly by Ed Fitzgerald and the executive and this conference promises to offer trainees the widest variety of courses, events and prizes. On behalf of the trainees in Manchester and the ASiT council Welcome to Manchester!! Sudip Sanyal

Oxford Deanery
The Oxford Deanery covers the counties of Oxfordshire, Berkshire and Buckinghamshire. Being a relatively small deanery in geographical terms, all training hospitals are within driving distance of Oxford. The Core Surgery training scheme in the Oxford Deanery is a two year programme consisting of four six-month posts in a variety of surgical specialties. However, each rotation is themed to one or more specialties. The region has over 65 approved training posts for core surgical trainees, but takes only 20 trainees, which does allow a good deal of flexibility to accommodate individual training needs. The region includes a good mix of smaller, secondary referral centres, as well as the larger, and more specialised tertiary referral centres that permit unparalleled experience in cutting-edge surgery and

ASiT - the pursuit of excellence in training

research. Oxford University Hospitals provides a wide range of clinical services, medical education and training. OUH is also involved in a wide variety of research programmes, in collaboration with the University of Oxford and many other research bodies. OUH consists of four hospitals - the John Radcliffe Hospital, Churchill Hospital and the Nuffield Orthopaedic Centre, all located in Oxford and the Horton General Hospital in the north of Oxfordshire. The JR is Oxfordshire’s main A and E site. The JR has surgical trainee placements in paediatric surgery, cardiothoracics, neurosurgery, plastic surgery, ENT and general surgery. The Churchill is a centre for, amongst other specialties, cancer services, transplantation surgery, and urology. The NOC is an elective orthopaedic hospital, providing specialist orthopaedic and rheumatology services. Buckinghamshire Healthcare Trust includes three acute hospital sites. Specialist services include, amongst others, skin cancer, burns care and the plastics subregional centre, cardiac services and the National Spinal Injuries Centre. Royal Berkshire NHS Foundation Trust, provides acute medical and surgical services to Reading, Wokingham and West Berkshire and specialist services to a wider population. Heatherwood and Wexham Park NHS Foundation Trust provides, amongst other services, general surgery, urology, orthopaedics, ENT, oral surgery and plastic surgery. Central teaching for core trainees involves a monthly half day session of lectures, mock exams and specialty based teaching targeted at the MRCS. There are excellent opportunities to teach medical students on the wards as well as in the anatomy lab. John O’Callaghan

Severn
I was honoured to be appointed the Severn Deanery ASiT representative in September 2012 and I hope to continue the great work that Izzy Dash has done on behalf of the surgical trainees and medical students in our region. The past year has witnessed a surge in the number of educational opportunities available to trainees within the Severn Deanery. It is pleasing to see that many of our trainees have been proactive in developing new courses, with a particular mention going to Mr James Coulston for his organisation of the Trauma Surgery Skills Day, aimed at CT2-ST5 trainees, and to Mr Simon Monkhouse for developing the ‘LIGHT’ course for senior general surgical trainees with an interest in laparoscopic hernia repair. Miss Jessamy Bagenal and Miss Rebecca Llewellyn-Bennett must also be congratulated for setting up the Severn Surgery Journal Club specifically aimed at improving the critical appraisal skills of core trainees.

David Messenger

South West Peninsula
This was my first full year as the regional representative for Peninsula region. We still maintain close ties with Severn region and Izzy Dash organised a very successful foundation skills in surgery course in Bath in July 2012 which I taught on. 23

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SPARCS, our regional research collaboration with Peninsula, continues to go from strength to strength with a multicentre laparoscopic incisional hernia audit being selected as a poster of distinction at ASGBI 2012. The multicentre appendicectomy audit has recently been completed and two randomised controlled trials looking at the impact of dressings and impregnated sutures on wound infections are due to commence in the near future. The Severn Deanery provides its core trainees with a high quality teaching programme that incorporates basic sciences, surgical skills and human factors training. Mr Rob Longman, Miss Caroline Rodd and Miss Ilana Langdon all deserve special thanks for their tireless efforts in organising the programme, in addition to the higher surgical trainees who have been actively involved in delivering teaching throughout the various hospitals in the region. It is no coincidence that the Severn Deanery boasts the highest MRCS pass rate in the UK. Yet again, our annual Audit and Research day served to highlight the quality of work undertaken by trainees in our region. Prizes were awarded by Professor Norman Williams later that evening at the ever popular School of Surgery Dinner. Those enjoying success included Mr Sean Strong, Mr Ishtiaq Rahman and one of the Bristol medical students, Elle Farelleh. Mr Philip Clamp won the surgical trainee of the year award with Mr William Carlino and Miss Rebecca Llewellyn-Bennett joint winners of the core trainee of the year award. The efforts of our trainers were not forgotten with Mr Andrew Stewart being awarded the trainer of the year. Congratulations must also go out to our senior general surgical trainees who achieved a 100% pass rate for the FRCS exam in 2012! Despite the many successes in our region, few core trainees were able to make the direct transition into higher surgical training this year. It is a particular aim of mine to ensure that our ‘conversion rate’ improves, which I hope to achieve through my involvement with the ST3 interview course that has recently been developed by Mr David Sinclair. I look forward to being able to advance the cause of surgical trainees in Severn and welcome any contributions that can be of benefit. I hope to see a large Severn contingent at the ASiT conference in Manchester next April.

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As part of my role in ASiT I am our representative on the ASGBI International Development Committee. I have been on missions with Operation Hernia to Mongolia and Ghana and have found these experiences invaluable as a trainee. I would like to promote global health and engagement of this with trainees as an excellent learning and teaching experience. It is extremely rewarding and reinvigorates your NHS practice. From my point of view trainees should be allowed to use part of their study leave allocation to work in low or middle income countries as long as they can demonstrate the educational benefit. I was fortunate in this regard with two of the hospitals I have worked in. I helped run the ASiT stand at the recent BMJ careers fair which was a good opportunity to meet some our current members and speak to prospective surgical trainees to give advice. I have organised ASiT’s first ‘Statistics for Surgeons’ course that was held December 2012 in Exeter. This course sold out very quickly and received very positive feedback, we plan to run it again this summer. I hope to see some of you at the pre-conference core skills in laparoscopy course that I have organised and enjoy the conference! Frank McDermott

Thames - North West
This report will be found within the Vice President’s report by Joe Shalhoub.

Yorkshire North
This report will be found within the Vice President’s report by Johnny Wild.

South

One of the main things occurring in my time on ASiT Council 2012-13 and previously, has been progression in the development of simulation training facilities, which I have helped ASiT to remain a key player in. See our recent publication on simulation published in the IJS. Some of our work on simulation has also been communicated through to Edinburgh’s RCS’s Faculty of Surgical Trainers, which we should welcome as a much needed development demonstrating that the Colleges are finally willing to address many of the deficiencies of surgical training that the Association of Surgeons in Training has been highlighting for over a decade! We welcome RCSEd’s active engagement with us in this faculty. Unfortunately however on the flip side, RCSEd still declines our requests to have a seat for ASiT reinstated on their council, hence my own (and others’)

continued resignation from membership of them as a surgical college, in the view that it has taken a backwards step in how they represent and consult with trainees. To replace ASiT’s seat with that of an individual who, although elected by the RCS membership, does not benefit from the raft of support of a Council constituting representatives from every specialty & every region of the UK (ie. ASiT), is unfortunate. RCSEd certainly sees it as desirable to have a trainee upon their council with whom they can state that they have consulted prior to passing certain changes through. However, it must be recognized that one individual standing alone without a similar network to ASiT’s of other trainees behind them, could not be expected to be as well equipped to appreciate the widespread ramifications of any such changes. This highlights the need for us more than ever to remain vigilant and alert to potentially detrimental moves, which may impact upon our training. We continue to exert pressure for ASiT’s reinstatement to RCSEd’s Council. Separately I have also been representing ASiT on the BADS Council (British Association of Daycase Surgery), as their first trainee representative. We must recognise that Daycase Surgery is rapidly becoming the norm and is highly desirable amongst our patients, hence we must ensure we are actively engaged in an effort to ensure training only benefits from the move towards more daycase operating. This is an opportunity to better our training experience, yet without our involvement and monitoring on this transition there is a real risk that we may instead suffer. We are requesting specific information on this in our current annual ASiT survey being sent out to all of our members and we will welcome and encourage your responses, comments and thoughts on how we should continue to proceed. I would also wholeheartedly encourage you to submit abstracts for training in daycase surgery in particular to BADS’ annual conference held this June in Southport. We shall present and discuss our survey findings to the audience gathered there. As you read this report, I will have rescinded my position as Yorkshire Representative to ASiT Council, indeed ending my last 6 years of active ASiT Council work (representing NW England previously) and we will be looking for my replacement. I would encourage anyone with an active interest in bettering surgical training to step forward without delay. I would support and anticipate more regional courses forthcoming in Yorkshire for 2013 onwards. In particular I hope that the incoming representative could also attempt to address some of the regional deficiencies that I have simply been unable to deal with, and work hard to maintain a balanced understanding of current views and opinions of our coalface surgeons in training, to take forward as ASiT’s voice on other committees! Paul Malone

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Scotland East
It has been an honour for me to be elected to represent East of Scotland deanery, the smallest in the UK. I made every effort to strengthen ASiT in the region and more trainees are actively involved with ASiT than ever. Personally, it has been a pleasure to be part of the Faculty of Foundation Skills in Surgery course for the third time and getting involved with ASiT annual conference and attending ICBSE (Intercollegiate Committee for Basic Surgical Examinations) meetings were great learning experiences. It has been a hectic year in the deanery with shortage of registrars and EWTD causing Rota issues and GMC survey highlighting some areas of concern. However, recent appointment of LATs addressed Rota issues. Formal teaching has been a longstanding problem in the deanery but with recent amalgamation of teaching with North of Scotland, even though in its early stages, seems to have resolved this. Despite the problems with formal teaching we had excellent results in the exit exams partly due to peer support and partly due to the hard work of some dedicated consultants helping candidates with their preparation. Restructuring of acute admissions unit with two registrars being on-call has been a major change in the deanery which seems to give better operative experience for trainees without compromising patients safety due to availability of second registrar to cover the ward. However, we have to wait and see for the long-term efficacy of this new change. Furthermore, ASiT representatives from all regions of Scotland have been instrumental in the development of trainees led research group - Scottish Surgical Research Group (SSRG) which is slowly gaining popularity and hopefully by the time this report is published SSRG would have been well established and its website up running! Dev Mittapalli

James Milburn

South East

South East Scotland continues to enjoy a high standard of training across the surgical specialties, with high rates of trainee satisfaction and satisfying career advancement as they progress through their programmes. Many of the ASiT courses that are offered in other regions are currently provided locally in Edinburgh by the RCSEd. However, we are in the process of establishing an ASiT medical student foundation surgical skills course and a financial advisory day for trainees. Representation of ASiT views at local meetings and dissemination of information to regional trainees has continued through the year, together with continuing the links with local training committees. In Scotland, a research collaborative network has recently been set up - the Scottish Surgical Research Group (www.scottishsurgeons.com). This is a network of trainees throughout all four training regions in Scotland, together with senior academic support. We hope to report our early publications soon. Do get in touch with ideas or to discuss matters further! Andrew Robson

West

North-East

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The continuing changes in the organisation, regulation and delivery of quality surgical training have caused concern to trainees in the last 12 months. However, despite some uncertainty locally most trainees seem satisfied with their posts and there have been many quality initiatives undertaken across the specialities. Links between current surgical trainees and the Ogston society (the local undergraduate surgical group) continue to grow. The quality of facilities especially in simulation at the Suttie centre in Aberdeen and the Centre for Health Sciences in Raigmore continue to provide great opportunities in simulation. Congratulations to all local trainees who have passed membership and

It has been a pleasure for me to continue to represent the UK’s very best trainees - those of the West of Scotland. It has been a busy year. Since ASiT’s successful Cardiff Conference I have continued to regularly attend Council to represent your interests. Regionally, I have delivered careers lectures to Glasgow University medical students and have also given a lecture to foundation trainees on how to arrange and fund a year abroad. I have continued to attend and form a part of the Glasgow College’s Trainee’s Committee and in conjunction with this group, arranged a very well received Surgical Careers Evening. Many excellent speakers gave highly informative and entertaining talks. This will be an on going event, so I would urge any medical students and foundation trainees considering a surgical career to attend - please spread the word. Core surgical trainees should consider future attendance as practically mandatory; this meeting will represent

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fellowship exams in the last year. I have been the regional representative for the last 3 years and have truly enjoyed every minute of my time on the ASiT council. However, it is time for me to depart and I wish my successor and the whole ASiT council best wishes for the future. The surgical landscape continues to evolve and I know ASiT will remain the best advocate for trainees in this turbulent period.

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the best opportunity for you meet and chat to important surgeons working in your future specialty of choice they will be there to speak to you. Please also keep an eye out for forthcoming ‘Surgical Update’ evenings that we are planning - more to follow. I would like to offer congratulations again to Fiona Leitch et al for putting on yet another successful Foundation Skills in Surgery course at the college. Feedback was splendid and I would urge all trainees to recommend this course to their junior colleagues. The Glasgow University Surgical Society Committee is also to be commended for hosting a highly successful 4th Undergraduate Surgical Conference (see their report for details). Amongst other well-earned sponsorship they were awarded an ASiT Regional Meeting Grant. Probably the main focus of my work for ASiT this year has stemmed directly from a question asked by a local trainee about data governance with respect to the eLogbook. Concerns have since been brought up by a variety of people. A report that I have authored about this will have already been published by the time this Yearbook is in press - ASiT will circulate a copy to all its membership separately. Since looking into this area, I now find myself representing you, and trainees nationally on an Intercollegiate Group reviewing the risks, challenges and obligations that contemporary legislation on data governance present to us as surgeons. This will be my last yearbook report as your representative as my two-year term will come to an end this summer. I will arrange an election. If you are thinking about applying please contact me nearer the time for details of what the job entails. I strongly suggest that that all who have the slightest interest in the issues that face us as surgical trainees apply - I have had a fascinating and informative stint in the job and have been frankly amazed at the short distance that there actually is between us, the grassroots, and the policy makers in their dim and distant towers! If you choose to get involved, I’m not exaggerating when I say that you can have a real influence. If you didn’t make it to Cardiff last year, I strongly suggest you join me at Conference in Manchester in 2013: it promises to be great. Remember to submit your research - all accepted abstracts will be published and there are a lot of prizes on offer to bolster your CV. I am, as ever available to listen to your gripes and comments, and to try to answer your questions either by telephone (07795634522) or email (alexvesey@gmail.com) Alex Vesey

Ireland
It has been an honour to represent the trainees in the Republic of Ireland in the past year. Ireland has never had representation in ASiT before this year. Although Ireland has a completely different training scheme than that of the UK including our colleagues in the North of Ireland, it’s interesting to see that despite our close proximity there are core differences/similarities in our training. The National Basic Surgical Training (BST) program in Ireland involves 2 years of 6-monthly rotations in surgical subspecialties followed by entry to the competitive 5-6 year higher surgical training (HST) program. Most of our trainees are concerned about the gap in between BST and HST, opting for either research or non-training SHO/registrar posts to be competitive for HST. There has been mixed emotions about the recent introduction of an additional year of basic specialty training (BSPT) following BST as a senior house officer or junior registrar in a specialty of choice, therefore having structured mentorship programs by seniors would be of great benefit. This year I have been keen to promote ASiT’s profile in Ireland. We lack surgical trainee representation here in Ireland and having a strong well-rounded trainee representation like ASiT with successful efforts to surgical excellence is inspiring. I look forward to the coming years of ASiT, and for those keen to stepping up to this role I highly recommend it. Fatima Aloraifi

Wales
It has been hugely rewarding for myself and Andi to represent Wales as ASiT representatives for 2012, especially with our capital city, Cardiff, playing host to the ASiT conference in March. Congratulations to the Executive for making this such a terrific success. It was amazing to see so many Welsh Trainees in attendance, in particular 66 poster presentations coming from Welsh Units (out of a total of 575)! Also a big thank you to the volunteers from Cardiff University Surgical Society for their invaluable help at the conference. March 23 marked an important day for the Welsh Institute of Minimal Access Therapy (WIMAT) based in Cardiff, gaining accreditation status from the RCSEng for postgraduate surgical training. Professor Norman Williams unveiled a shiny placard for the centre to honour the occasion. This was all thanks to the hard work of Dr Neil Warren and the team at WIMAT. Welsh trainees have always praised training at WIMAT, in particular the Welsh Laparoscopic Colorectal Training Scheme and the Welsh Endoscopic Training Network. Let’s hope their success continues in 2013.

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Rhiannon Harries & Andi Beamish

Robert Nash

AUGIS
The Association of Upper Gastrointestinal Surgeons Trainee group represents hepatobiliary, pancreatic, oesophagogastric and bariatric trainees from across the UK and Ireland. The trainee section of AUGIS is a rapidly developing part of the society, with over 200 trainee members. We continue to develop new educational opportunities for our members and to represent the views of trainees at this time of upheaval in training. The trainee committee is made up of trainees from around the UK and Ireland and across the specialities. We welcome Vincent Yip (England & Wales) and Jawad Ahmad (Ireland) to the now fully elected committee. ASiT - the pursuit of excellence in training 27
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Swansea played host to the 1st All Wales Surgical Careers Conference in June. This saw a huge turn out of medical students, foundation doctors and core surgical trainees from Wales and beyond. With a wide range of presentations from a variety of speakers and involvement from both RCSEng and RCSEd, there was something for all surgical enthusiasts. Congratulations to Emman Qattan, president of the Swansea Surgical Society for organizing a hugely successful day. Both myself and Andi were happy to be involved with the event and look forward to the 2nd All Wales Surgical Careers Conference in 2013. The latest within the Wales Deanery is the much rumoured reconfiguration that is to take place in the near future, with potentially several hospitals set to lose there acute services, therefore leading to concerns as to the impact on surgical training within the deanery. Changes to training post locations at all levels are likely to result in the near future. Watch this space! The Welsh Barbers Research Collaborative continues to go from strength to strength, with the development of the HART (Hughes Abdominal Repair Trial) RCT, and their ongoing links with other research collaboratives. Once again congratulations to all those trainees who were successful at ST3 recruitment, passed their FRCS and those who have been appointed to Consultant posts!

Subspecialty Reports
Association of Laparoscopic Surgeons (ALS)
This report will be found within the Vice President’s report by Johnny Wild.

AOT
The AOT represents ENT trainees - from registrars getting CCTs, through to core trainees, and even the occasional foundation doctor who has set their heart on a career in the specialty (and who can blame them?). Things are going to be tough for the NHS over the next few years, and for ENT this will be no different. Yet entry into the specialty remains very competitive, for a number of reasons. Firstly, the variety the specialty provides, ranging from putting microscopic implant electrodes into a cochlea, to removing huge thyroids and neck dissections. Secondly, the specialty’s mixture of routine elective surgery and the occasional urgent and life-saving airway intervention. And lastly, the research in the area, ranging from tissue engineered transplants, robots to treat obstructive sleep apnoea, and viral vectors for head and neck cancer. Issues affecting ENT trainees this year will look similar to past years. How will the bosses select the new ST3s at national selection? Will there still be LATs appointed? Will consultant appointments look the same in five years as they do today? The AOT meets each year in the summer for an annual conference, held in Leeds in 2012, in which issues for training in the specialty are discussed, contacts and friends are made, and a glass of wine is shared over dinner. We are looking forward to heading to the south coast later this year.

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The 2012 AUGISt training day was the highlight of our year and took place in June at Digestive Diseases Federation in Liverpool. The format was adapted to combine with the British Society of Gastroenterology trainees for a series for evidence-based discussions, before breaking for more practical surgical skills and decision making sessions. We would like to thank the local organisers Robert Jones and Declan Dunn and the local faculty for putting together an excellent day. A report can be found on the AUGISt website, which continues to develop its educational content for Upper GI trainees preparing for the intercollegiate examination (www.augist.org). The 2013 Training day will take place prior to the AUGIS conference in Gateshead on 18th September 2013. The British Obesity and Metabolic Surgery Society delivered their first national training day in January 2012 in Bristol. A full report is available on their trainees’ webpage (www.bomss.org.uk). This will become an annual event and in January 2013 will be used to launch the new Bariatric National Research Collaboration in Glasgow. The inaugural Great Britain and Ireland Heapato Pancreatico Biliary Association (GBIHPBA) meeting also took place at the Belfry in September 2012. This two day conference made up of state-of-the art lectures from the leaders in liver and pancreatic surgery was a great success and an excellent addition to the trainee calendar. Congratulations must go out to Mohan Singh of Heartlands Hospital, Birmingham, won the 2012 ASiT-AUGIS Trainees prize. We hope to see the number of upper GI abstracts submitted to the ASiT conference to continue to grow. Sadly, John Hammond’s term as President is coming to an end but we congratulate Robert Jones on his election as the new President. Over the past two years John has led the development of the trainee group that provided new educational opportunities and highlighted challenges in training. It still remains an exciting time for trainees in upper GI surgery. We are sure AUGISt will continue to go from strength to strength under its new President and we look forward to AUGIS 2013 in Gateshead. Andrew Robertson, Vincent Yip and Rob Jones

The other is for those in training posts at ST3 level and above, and provides a forum for discussion of courses, issues and concerns trainees have. It is also a forum where conferences and training opportunities are plugged, and feedback from BAOMS/STC committee meetings disseminated. Recruitment to the speciality is currently through a national process which takes place twice a year. So far, this has yielded jobs for all those eligible to be appointed, but this profile may change in the next few years as the graduates from dental schools with shortened courses kicks in. However, the job situation for those completing training, unlike other surgical specialities, remains positive. The annual conference takes place in June in Dublin this year and will provide a beautiful venue for the annual meet-up. For further information, go to www.baoms.org.uk Nabeela Ahmed nabeela.omfs@me.com

British Neurosurgical Trainees Association (BNTA)
“If you act like you know what you’re doing, you can do anything you want - except neurosurgery” - Sharon Stone The British Neurosurgical Trainee Association (BNTA) represents the Neurosurgical trainees in the United Kingdom and Ireland. Membership is free and open to all trainees (SpRs, STRs, LATs and FTSTAs) in Neurosurgery, and we currently have about 300 members. The current president is Chris Cowie, a Specialist Registrar in Newcastle, and the executive committee has two representatives (Andrew Alalade and Adam Williams) who sit on the ASIT council. Members from all the 35 neurosurgical units in the UK meet biennially during the Society of British Neurosurgeons (SBNS) conference. In the last 12 months we have had two successful SBNS meetings in Aberdeen and Leeds.The next SBNS meeting scheduled for 22-24 May 2013 will be hosted by the Royal Hallamshire Hospital in Sheffield. The British Neurosurgical Trainee Course has continued to grow from strength to strength, with positive feedback from participants. The course modules run over two and a half years, and are held at 6-monthly intervals to cover the entire syllabus. The BNTA has an informative website www.e1v1m1.co.uk with the latest updates on courses, fellowships, neurosurgical classification systems, the FRCS (SN) examination and clinical trials - all the typical things that will interest any neurosurgical trainee.

British Association of Maxillofacial Surgeons
The British Association of Maxillofacial Surgeons (BAOMS) has two trainee groups with web-based forums. One is applicable to those who are juniors in the speciality and have returned to study their second degree (JTG BAOMS on Facebook) or who are considering the speciality whilst in SHO posts. 28

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National selection interviews occur annually via the Yorkshire and Humber Deanery, and successful candidates are appointed to ST1 posts (with a few to ST2 and ST3 posts). The ST1-3 years include rotations in neurosurgery, neurology and other allied specialties like ENT, A&E and Orthopaedics; while the ST4-8 years are purely spent in neurosurgical rotations. The issues facing Neurosurgical trainees are very much the same with those of the whole surgical community. The BNTA continues to support the pan-surgical stances taken by ASiT in its pursuit for excellence in training eg JCST issues, feedback from the use of ISCP etc. There is a Codman BNTA/ASIT prize for the best poster at the annual ASIT conference and the 2012 winner was Mr Mark Wilkes from the Western General Hospital, Edinburgh - “Management of Cerebrospinal Fluid Diversion Device-Associated Infections in Adults: A Retrospective Evaluation of the Role of Intraventricular Antimicrobial Therapy”. The BNTA continues to work in partnership with ASIT on issues for the benefit of trainees. Andrew Alalade

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As we reflect back on 2012, we see a time of great change in our speciality. The trainee’s session at the annual meeting had a great turnout and we discussed some interesting and topical issues related to getting trained in Cardiothoracic Surgery. The curry afterwards was well received and should become a fixture. The annual meeting continues to go from strength to strength, particularly with the recent addition of the University. Once again there were over 20 appointments to the speciality at national selection with many high calibre individuals added to the trainee group. This is a far cry form the moratorium of appointments to the speciality between 2004-2007. The high standard of appointees was particularly obvious during the hugely successful boot camp in October, designed to prepare the newly appointees of the basic skills required of them as new registrars. We must give a huge thanks to Sorin for their unwavering support of Cardiothoracic Trainees, including generously supporting and hosting the boot camp. Funding has been secured and this will become a yearly fixture. Going forward it looks clear that cardiothoracic will join Neurosurgery as a speciality that will recruit out of foundation programmes, similar to the integrated programmes of some European and North American Centres. What proportion of candidates will joint our speciality at ST1 level each year is to be decided but it is certainly a radical change form the past when often extremely experienced existing registrars were appointed as first year registrars.

Michael Murphy and David McCormack

Dukes Club
The Dukes’ Club is a trainees group representing colorectal registrars nationwide. We sit on the Association of Coloproctology, Great Britain and Ireland (ACP) council, ASiT council, ACP audit and research, clinical services and education committees and JAG training group. A Scottish representative is a new addition to the Dukes committee ensuring training issues North of the boarder are heard. The two major events on the Dukes’ Club calendar are the trainees’ sessions at the ACPGBI conference and the annual Dukes’ Club educational weekend held every Spring. At the ACPGBI Conference in Dublin this July the Dukes’ Club hosted a lively, entertaining and wellvoiced debate entitled “The future of colorectal surgery lies in super specialisation”. ACPGBI President-Elect

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The SAC continues to work hard to make sure the standards of surgical training are maintained at a high level. Information being logged each day by trainees about the operations and clinical situations they are involved in and the level of involvement promises to provide valuable information individual centres training capacity. We expect that this information will allow the SAC to place trainees in units appropriate to their needs. The SAC has also been keen to gauge the views of the Cardiothoracic Surgery committee, both trainees and consultants, on the place of operative requirements for CCT. The survey we sent out has provoked a high rate of completion and some interesting data. It will be interesting to see if operative requirements do become a requirement for CCT as they are in most UK specialities and in most international cardiothoracic training programs and if they do become a requirement whether that will have a positive effect on the standard of UK trainees. The exit exam continues to test the trainees towards the end of their training to create a standard by which our national trainees can be judged and continues to attract many Cardiothoracic Trainees outside the national system, both from the UK and abroad, who are keen to add the FRCS CTh to their CVs as a standard bearer of their training. The centres at Southampton and Hull can be proud of their efforts in hosting the part 2 this year. It is great news that Ethicon will continue to support the SCTS scholarships for Senior trainees to improve their operative experience towards the end of their training with another four, six month stipends. We look forward to seeing you all at the 2013 trainees meeting in Brighton.

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Karen Nugent spoke for the motion, and was narrowly defeated by Mr John Hartley speaking against. We look forward to the trainees’ session on the Tuesday evening of the 2013 conference in Liverpool. This year’s educational weekend, again supported by an educational grant from Ethicon Endo-surgery, was held at Chesford Grange Hotel in Kenilworth in February 2012. The program included sessions on laparoscopic colorectal training and how to get it (Mr Mark Coleman, Prof Puthucode Haray), emergency colorectal surgery (Mr Jim Hill, Dr Alistair Glossop), IBD and intestinal failure (Mr Marcel Gatt, Mr Janindra Warusavitarne), organ preservation in rectal cancer (Mr Simon Bach, Dr Ian Geh and Dr Gina Brown), as well as Professor Dion Morton and ACPGBI President Mr Graham Williams. We are grateful to all speakers who gave up their time to make the weekend such a success, and are currently planning the next educational weekend for 9 and 10 March 2013. Save the date! This year the Dukes Club have published an up to date database of colorectal research jobs, the database will be regularly reviewed to give trainees access to many new research opportunities. The ACPGBI/Dukes’ Club Colorectal Travelling Fellowship scheme is an exciting new opportunity for colorectal trainees. Fellowships of up to £2,500 are available to enable senior colorectal trainees to visit an internationally renowned colorectal unit in order to expand and enhance their training and increase exposure within their subspecialist area of interest. The research job database, travelling fellowship scheme details, along with all Dukes Club information can be found at www.thedukesclub.org.uk Catherine Boereboom

Mammary Fold
The Mammary Fold is a national trainee group representing the voice and interests of breast surgical trainees in the UK. We have representation on the Association of Breast Surgery (ABS) and ASiT council ensuring the interests of over 200 members are heard and understood. It has been another strong year for us as we continue to face uncertain times as breast trainees. A founding principle of the mammary fold is to provide trainees with resources to master the science and skills of breast and oncoplastic surgery. A mainstay of delivery of this commitment is our website which has fast become the most relevant source of training information for trainees. The website provides members with access to keynote conference lectures, surgical videos, journal articles and important documents and guidelines. The site also brings trainees 30

the latest news with regards to courses, conferences and jobs. We have maintained our links with the publishers Oxford University Press, Elsevier and Hodder Arnold to continue to provide significant book discounts to our members (details of which can also be found on our website). Another popular section to the website is the members discussion forum providing a tool for trainees to exchange ideas, collaborate and seek peer advice. We are pleased to state that we are continuing our partnership with Lifecell and Mentor who have agreed to share their educational resources on the website and also provide us with places on their courses such as breast reconstruction cadaveric courses and international meetings on Strattice based reconstruction. This past year has also seen our most successful pre-ABS educational meeting to date covering topics including lipomodelling and the use of acellular dermal matrices. We also had a very successful mammary fold plenary session at the ABS meeting ensuring that the educational needs of trainees were also met by conference. The session included a mock Breast-Oncoplastic MDT and an expert tutorial on how to mark up patients for oncoplastic breast operations. This coming year will also see the return of our Spring meeting to be held this time in Wales. This will provide trainees the opportunity to enjoy a retreat with an expert Consultant faculty to undertake a robust educational programme catering for junior and senior trainees as well as let their hair down a little. This year has also seen the launch of the mammary fold mentoring scheme pairing trainees of all levels with more senior trainees and consultants to provide, educational, career guidance and pastoral support as dictated by you in our mentoring survey. The programme will be evaluated and extended following the experience of the first year of this initiative. The JCST (joint committee on specialist training) has now set out guidance for the competencies required for a trainee to apply for CCT and it is clear that general and emergency surgery is the cornerstone of this. No oncoplastic competencies are listed for the breast surgery subspecialist, which is certain to impact training opportunities and training priorities for the trainee breast surgeon. This year mammary fold will make it a priority to work with ABS to ensure breast trainees are aware of the need to obtain general/emergency surgery competencies but also that oncoplastic training is more formally recognised and opportunities to receive oncoplastic training are optimised for all breast trainees. As we all know breast is best so please take a look at our website and join us - www.themammaryfold.com Seni Mylvaganam

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Paediatric Surgery
Historically, the small size of our training body has led to more informal trainee representation. Over the last few years, there has been an expansion in numbers with approximately 120 numbered training posts, and a similar number interested in or working at the same level. There are two national trainee representatives with overlapping two year tenures: currently these are myself and Basil Bekdash. We are in the process of implementing a better structure for representing trainees in our subspecialty and for two-way communication between trainees and their representatives. We currently attend meetings of our Specialist Advisory Committee (SAC) and the executive of the British Association of Paediatric Surgeons. We are also members of ASiT council representing ASiT members with an interest in paediatric surgery. As a large organisation, ASiT is in a position to more effectively represent the interests of paediatric surgery trainees that are shared with other subspecialties. Paediatric surgery can also bring insights and experience from a niche but important and broad area of practice that has relevance not just for surgeons treating children. There are continuing concerns regarding workforce planning in particular in small sub specialties such as paediatric surgery and we hope to contribute to better data and planning through an improved trainee network. As we enter a period of predicted excess trainees completing the training program, we will continue to offer support and advice to trainees. James Andrews and Basil Bekdash

cosmetic surgery legislation and subsequent cosmetic training pathways. Without the support of ASiT the small community of current and aspiring plastic surgery trainees would not have a platform for collaboration, without which much of our work would not exist. Last year the conference saw good plastic surgery attendance, which we hope only increases in coming years. Finally 2013 has seen the prospect of composite allotransplantation become reality in the UK and PLASTA are proud of our colleagues who once again brought cutting edge innovation to our ranks. The new PLASTA website will be up and running later this year and the new PLASTA newsletter for members has been a great success. Finally I look forward to meeting many of your at conference this year and am happy to help in any way I can. Dan Saleh

Rouleaux Club
2012 has been a truly memorable year for Vascular Surgery and the Rouleaux Club (RC). March 16 2012 saw the creation of the tenth surgical specialty in the UK. The creation of the new specialty brings with it many new challenges, not least for trainees. Recent years have seen strategic changes in the organisation and delivery of vascular surgery. The creation of centralisation has increased the throughput of centres, concentrating emergency and elective workload in centres. This is being followed by the implementation of the national screening programme for abdominal aortic aneurysms. The new specialty brings with it new challenges, a new Specialty Advisory Committee (SAC) is overseeing the process of curriculum development and implementation. Naturally there are uncertainties in the immediate and near future for trainees and the RC has been intimately involved in the advisement and development of the forthcoming implementation of the curriculum through its representatives on the Vascular Society Council (VSC) and SAC. The SAC and VSC must be commended from a trainee’s perspective on their insistence on the involvement of the trainees in the process. Throughout the process the RC has been asked for its input and contributions. This culminated in the RC’s own symposium session at this year’s Vascular Society AGM. The symposium gave the RC the opportunity to present to the entire Vascular Society membership, raising concerns of trainees ahead of the implementation of the new curriculum. Talks centred on quality assurance and the current mis-match in trainees’ experiences, the development of simulation based training programmes, out of hours on-call commitments and the need to concentrate on ensuring a fair training process for those trainees remaining within General Surgery training. This 31

PLASTA
The previous year has been good for plastic surgery trainees. An increased presence at the ASiT annual conference and a re-establishment of links between our PLASTA members and new executive holds promise for 2013. In an increasingly competitive job market PLASTA and ASiT have exchanged ideas on how best to tackle the impending workforce surplus without resorting to service grade specialists. We are also fortunate BAPRAS are very pro-trainee and training and will not tolerate anything short of excellence at consultant level. PLASTA have also strived to bring transparency to the arduous process of national selection for higher training posts. 2013 will focus on supporting trainees through the impending introduction of sub-specialty curriculums for ST7/8 and helping trainees maximize interface fellowship opportunities. PLASTA are also involved as stakeholders in the potential emergence of

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was followed by a lengthy and animated debate from all areas of the membership and a very positive approach on behalf of trainees. Furthermore, pledges to create structured centralised inductive training for each new intake, to react to trainees’ needs and to move forward together in the interests of the new specialty and our patients as a whole. The RC has sought throughout to represent and protect the interests of the trainees both current and future as the new curriculum comes into force. We have endeavoured to foster a closer relationship with ASiT this year to ensure we have the support of the wider surgical trainee community. We are mindful of our ties with General Surgery and these will remain for the years to come, as there is sharing of initial curricula, leading to a need for quality assurance of posts for both groups of trainees. The work and emphasis of the RC must and will change and adapt to best represent the interests of its trainees. As we approach the application process for the first admissions to ST3 in Vascular Surgery in 2013, we are seeking to ensure the process is fair and that there is provision to reduce impact on those unsuccessful, or who have entered training in General Surgery but developed specialist interest in Vascular Surgery. The next five years will see most trainees in General Surgery with a subspecialty interest in Vascular Surgery completing their training and ensuring they are competitive with those subsequently completing the new Vascular Curriculum remains a priority not just for the RC, but for the VSC and SAC alike. Whilst quality assurance of training has always been the prime role of the RC, it is now becoming apparent we must extend this to include a publicity role, extending the gospel of vascular surgery to vascular trainees of the future, encouraging greater competition for higher training places to raise the profile of vascular surgery amongst our surgeons of the future. An expansion to the committee of the RC was voted in at the recent AGM, and this expansion will enable us to reach out to extend our traditional membership of higher trainees and target trainees at foundation and CT level. We are also embracing the role of collaborative research and the election of a new Academic Representative will be the first step in this process. We have also directed our attention to taking a lead on training provision. With reducing numbers of higher trainees (20 per year) we will be able to focus on providing National Training Days, and we will be laying on our first National Training Day prior to the BSET summer meeting, seeking at the same time to invite Interventional Radiology trainees to attend, extending the hand of friendship to our colleagues to help dispel concerns over training collision in the future. The help and support that the RC has received from 32

ASiT has been crucial, the ability to keep abreast of the simultaneous changes in the General Surgery Curricula, exams and ideas at the college and SAC level has enabled us to monitor and feedback potential concerns from not just our trainees but those of interlinked specialties. As we move forward, with a relatively small number of higher trainees to represent, it will become increasingly important to maintain and foster our relationship with ASiT to help protect the trainees of the future. Finally, the advent of the new surgical specialty was accompanied by a re-branding of the Vascular Society, and along with it, the RC was invited to re-brand too, giving us the opportunity to move forwards into the future with a new emblem and new identity, which has also seen the production of RC ties, the proceeds of which go to the Circulation Foundation, the Vascular Research Charity which is increasingly able to fund research and targets most of this at trainees. So, as we move forward into 2013, we will see the first ST3 selection round for the new Vascular CCT. Those already in general surgical with vascular subspecialty interest will continue through to completion of their CCT as originally planned. There is to be a joint SAC working group between General Surgery and Vascular Surgery to help shape and manage this transitional group of trainees. The future is very bright indeed for all vascular trainees. We have the support from our SAC, Council, ASiT and our colleagues. The coming years are set to be very influential for the RC and we are all looking forward to them greatly. Gary Lambert

Military Surgery
A new addition to the military surgical trainees’ calendar within the last 12 months is the non-clinical training day, held for the first time in December 2011. The aim of the day, held at the Institute of Naval Medicine in Gosport, is to provide information to registrars about non-clinical issues that may affect your career. Informative briefs on pensions, the consultant appointment process and an operational update were well received and trainees are reminded that attendance is mandatory. The day also represents an opportunity to meet face to face with single service and defence consultant advisors for any guidance that may be necessary and allows members of all three services to take their fitness tests! Thanks to Maj Anna Sharrock for organising the 2012 meeting. Military surgical registrars of grade ST5 and upwards are continuing for now to deploy to Camp Bastion for 6 weeks at a time. Deployments are still recognised as time in training by JCST but if you are due to

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As well as providing support for trainees undertaking out-of-program research, ADMST provides input to the part-time MSc in military and trauma surgery run by the University of Swansea. Any trainees in orthopaedic, plastic, maxillofacial or general surgical specialities with an interest in trauma are encouraged to apply. My two year tenure as the military representative to the ASiT council is due to end towards the end of 2013. If any military trainees are interested in taking over the role, or if you have any questions or issues regarding surgical training within either the regular military or the reserve forces then please do not hesitate to contact me. Sqn Ldr Chris Lamb chris.lamb@cantab.net

Vimal Gokan

The Association of British University Surgical Societies (ABUSS)
The Association of British University Surgical Societies (ABUSS) enables medical students all over the UK to share their views, ideas, experiences and surgically related events with a large population of medical students, who also share an interest in surgery and wish to pursue a career in a surgical speciality. Supported by the RCSEng, surgical society Presidents or nominated representatives are invited from every medical school in the UK to present their societies’ activities and raise any concerns about undergraduate surgical education to the MSLC. Prior to the MSLC meeting, society representatives and the ABUSS executive committee discuss current

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deploy you must notify them well in advance if you want the time to count towards your CCST. DPMD should be able to provide further guidance regarding the processes surrounding this. Bastion has been an invaluable destination for surgical trainees over the last decade, and the impending draw-down of Op Herrick and the return of the UK armed forces to contingency will present a new set of challenges to trainees keen to gain trauma experience. It remains to be seen how this operational ‘training gap’ will be filled but a number of possibilities, including overseas training fellowships, are being looked at for the future. The ASGBI have recently announced the formation of a new sub-speciality association, The Association of Trauma and Military Surgery (ATMS). The ATMS will be holding it’s first academic conference as a sub-section of the main ASGBI meeting in Glasgow on 01 May 2013. This new sub-speciality association meeting will replace the Military Surgical Conference which co-located successfully with ASGBI over the last 2 years. All military surgeons are encouraged to join the new association, submit work to the academic programme and attend the meeting. Please remember that all academic work must be cleared using the appropriate form through the JMC medical director’s office prior to submission. From an academic point of view, all military trainees undertaking a post-graduate degree should be working under the auspices of the Academic Department of Military Surgery and Trauma (ADMST). ADMST is based in Birmingham and headed by the Defence Professor of Military Surgery (Surg Capt Mark Midwinter) and the Defence Professor of Trauma and Orthopaedics (Col Jon Clasper). It covers all military surgical specialities.

SARS
We enjoy a great relationship with the Society for Academic & Research Surgeons (SARS). This is a Society which represents Academic Surgeons, and trainee Academic Surgeons. SARS holds an annual conference at various medical schools around the country, usually on the first Wednesday and Thursday in January. This conference provides the opportunity for the main advantage of SARS membership: Trainee presentations from all surgical specialties take place, with a large number of prizes available. These are great for the CV, and there is usually a financial incentive too. Medical students also feature in the meeting, with their own session and prize. It has been known that the most prestigious SARS prize, the Patey prize, is won by a medical student, so remember, you have to be in it to win it! Another advantage of membership is a very reduced BJS subscription rate for trainees, of only £37 per year. As ASiT representative to the Society of Academic & Research Surgeons, I meet with the SARS Council at their quarterly meetings. This means I am involved in helping to arrange parts of the ASiT Annual Conference, and also the SARS Annual General Meeting. We have a session at the SARS Meeting which hosts talks or debates relevant to current issues in training. At the ASiT Conference we hold a ASiT/SARS/BJS pre-conference course on Research Skills; SARS also kindly sponsors a prize at the ASiT meeting, for which we are very grateful. All those interested in research should seriously consider joining SARS, from junior medical students to those with established careers. Networking opportunities are fantastic. You never know, you might be able to set up your PhD by meeting the big-wigs at the meeting!

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activities and issues they feel affect their members and are yet to be addressed. Societies discuss how they have been able to benefit their members by enhancing surgical skills and career progression, and share ideas regarding events and advice on gaining sponsorship and material supplies. Recent discussions have led to the proposal of producing a standardised surgical curriculum for members so that students interested in surgery regardless of the medical school that they attend have equal opportunity to develop their knowledge, CVs and skills. ABUSS has also committed to increase communication between surgical societies and the entire medical student population. This is to help maximise surgical opportunities such as events, awards and prizes run by societies, the RCSEng, ASiT, and OiS that they may not otherwise have been made aware of. As part of this initiative, the executive committee now produce bimonthly newsletters - of which two editions have already been published and distributed. It contains event listings, publicises surgical awards that are relevant to undergraduate students, and facilitates societies in organising large scale events through free advertising while ensuring there are no clashes with other events. The newsletter allows those students interested in surgery to make the most out of all the opportunities available to them, as well as offering students an opportunity to write articles related to surgery and have their work published and distributed. If there is anything you feel that ABUSS should be addressing or that you would like to speak to us about, please do not hesitate to contact us at rcsabuss@gmail. com. Similarly, if anyone would like to advertise an event or award, or write an article for publication in our newsletter, please get in touch. Kriti Singhania, President and Jos Selwyn-Gotha, Publicity Officer

the local student reps and our regional and specialty representatives to hold regular Foundation Skills in Surgery Courses around the UK. Having heard from the Medical Student Liaison Committee (MSLC) members together with Laura Derybshire, our MSLC rep, I have targeted the minimal opportunities available to students to prove their aptitude in practical and surgical skills on their CV. In response to this important point, I received council approval to initiate a brand new surgical skills competition, which we hope to roll out at the 2013 International ASiT conference, and you will be hearing from us about this exciting event very soon. I am currently working closely with our new Foundation Rep, Dan, to finalise the targeted parallel session at the ASiT Conference this year, and we will be working hard to match the fantastic schedule that past medical student rep Reema Chawla and past Foundation Year rep Will Muirhead put together last year in Cardiff. Last but not least, the annual ASiT/Elsevier Elective Prize will be accepting applications soon, and I am very much looking forward to reading the entries in the new year. Eleanor Zimmermann

Medical Student Liaison Committee (MSLC)
The MSLC meeting brings together student representatives of surgical societies from throughout the United Kingdom (UK), the Royal College of Surgeons England (RCSEng) and ASiT. The current Chair is Professor Gus McGrouther, supported by College representatives from Opportunities in Surgery (OiS) and Education departments. ASiT representation on the MSLC and support for student surgical societies has been long-standing. The MSLC provides a vital link between ASiT and medical students, allowing both regular communication with students about educational events and issues related to training, plus support at a national level for students society led events. Recently, the UK surgical societies formalised into the Association of British University Surgical Societies (ABUSS). Through this new organisation, the societies are working together to improve local activities and influence national agenda. Here, Kriti Singhania (President) and Jos Selwyn-Gotha (Publicity Officer) provide insight into the excellent work ABUSS have been doing over the past 12 months. Miss Laura Derbyshire, ASiT MSLC Rep 2012-13 & Eleanor Zimmermann, ASiT National Medical Student Rep 2012-13

Medical Student Representative
This year I have had the wonderful privilege of taking over from Reema Chawla and continuing her and previous medical student reps hard work to bridge the gap between students and postgraduate training and opportunities, while representing medical students views within ASiT council. Any issue which arises in debate on surgical training will directly influence our future careers and holding this position has been an enlightening experience, allowing to witness ASiT’s vital role in implementing changes and protecting our future interests. Since taking up this position in April, I have endeavoured to maintain ASiT representation within each surgical society, and aim to continue to work together with 34

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Non-Consultant Grade Specialists in the UK Surgical Workforce: Results of a National Trainee Survey on the Future of Post-CCT “Sub-consultants” from the Association of Surgeons in Training
Authors: J Shalhoub, G Khera, S Hornby, HJM Ferguson, CEB Giddings and JEF Fitzgerald on behalf of the Association of Surgeons in Training Correspondence Mr Edward Fitzgerald
Executive Summary
The structure of the surgical workforce has been much debated historically; in particular, whether there should there be a recognised role for those successfully completing training employed as non-Consultant grade specialists. This role has been termed the ‘sub-consultant’ grade. We report the results of a national surgical trainee survey that examined this issue. All junior doctors in surgical training (i.e. pre-CCT) in the UK were invited to participate in an electronic, 38-item, self-administered national training survey through regional and national mailing lists, including the Association of Surgeons in Training, speciality associations and Royal Surgical Colleges. Of 1,710 questionnaires submitted, 1,365 were appropriately completed by current surgical training grade junior doctors and included in the analysis. Regarding the question ‘Do you feel that there is a role in the surgical workforce for a post-CCT non-consultant specialist (“sub-consultant”) grade in surgery?’, 56.0% felt there was no role, 31.1% felt there was a role and 12.8% were uncertain. Only 12.6% of respondents would consider applying for such a post, while 72.4% would not and 15.0% were uncertain. Paediatric (23.3%), general (15.7%) and neurosurgery (11.6%) were the specialties with the highest proportions of trainees prepared to consider applying for such a role. Of note, for both questions, there was a significant difference in the responses by gender (p < 0.0001, Chi-square test) with female trainees more likely to consider applying for such a post. Overall 50.8% of respondents felt that the introduction of a post-CCT non-consultant specialist grade would impact positively upon service provision, however, only 21.6% felt it would have positive impact on patient care, 13.9% a positive impact on surgical training, 11.1% a positive impact on the surgical profession and just 7.9% a positive impact on their surgical career. It is clear from this survey that the proposed sub-consultant grade is unpopular, and it is not felt that it would enhance patient care or safety.

Introduction to ASiT
The Association of Surgeons in Training (ASiT) is a professional body and registered charity working to promote excellence in surgical training for the benefit of patients. With a membership of over 2,000 surgical trainees from all 10 surgical specialities, the association provides support at both regional and national levels throughout the United Kingdom and Republic of Ireland. Originally founded in 1976, ASiT is independent of the National Health Service (NHS), Surgical Royal Colleges, and specialty associations. Governed by an elected Executive and Council, the association is run by trainees for trainees.

Background to Non-Consultant Grade Specialists in the Surgical Workforce
In the United Kingdom the conclusion of formal post-graduate medical training is recognised by the award of the Certificate of Completion of Training (CCT), granted under the auspices of the Royal Colleges and General Medical Council (GMC). The various pathways and the current detail of surgical training has previously been described elsewhere1. Possession of a CCT allows entry onto the Specialist Register held by the General Medical Council, and the certificate holder may apply directly for Consultant posts. It was previously also possible for a CCT holder to apply for Staff Grade and Associate Specialist Doctor posts for service provision outside of the Consultant career structure. These grades are now closed to new entrants. ASiT - the pursuit of excellence in training 35

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The structure of the surgical workforce has been much debated historically; in particular, whether there should be a recognised role for CCT holders employed as non-Consultant grade specialists. This role has been termed the ‘sub-consultant’ grade. This was revisited by NHS Employers in their 2008 briefing document stating that ‘the future NHS will not require all doctors to progress to the current role of consultant’2. The paper proposed a rationale for non-consultant specialists, referring to workforce planning, changes in training necessitated by Modernising Medical Careers (MMC) and the European Working Time Regulation (EWTR), 2 and a perceived lack of experience of CCT holders for what was described as a “traditional consultant post” . 3 4 This has been the subject of a previous position statement by ASiT and responses by other groups reflecting trainees’ views on the future surgical workforce. Alternative workforce structures are by no means new and have been discussed since the inception of the NHS in 1948, when the Spens Committee report suggested that service would be mainly consultant provided5. Over a decade later the Senior Hospital Medical Officer (SHMO) grade was discussed, initially included in the staffing plans for the NHS as a way of dealing with a perceived excess of doctors in training6. The plan at the outset for that grade was seemingly a familiar one - that it would be a period of independent practice, but of lesser complexity and responsibility than that of a consultant. The expectation was that an SHMO post would lead to appointment as a hospital consultant. It soon became clear that there was very little chance of progression. In 1961, the Platt Committee concluded that the work of an SHMO and that of a consultant were essentially identical, and recommended that the SHMO grade be abandoned7, a recommendation which was implemented shortly thereafter in 1964. The Report of the Royal Commission on Medical Education, led by Lord Todd and published in 1968, also proposed generating the grade of ‘junior specialist’8. More recently, the idea of seamless progress through 9,10 11 ‘higher specialist training was outlined by a report in 1986 and the ‘senior registrar’ grade was abolished with 11 the introduction of ‘Calman’ training , which preceded the current era of MMC. One of the drivers of ‘Calmanisation’ was to ensure that training was no longer “protracted by unnecessarily prolonged spells in repetitive posts of limited educational value or by an inappropriate and time-consuming process of competition each time a new post or entry to a new grade is required”12. This historical background is important to appreciate. It serves to highlight that it has never previously been deemed acceptable or workable to have a grade whereby the overlap in duties and responsibilities makes roles difficult to distinguish, or whereby despite undertaking similar duties (e.g. operations) one is deemed to be of lower responsibility or requiring less skill13. This remains as valid for today’s surgical workforce as it has done in the past. This paper from the Association of Surgeons in Training reports the results of a national trainee survey regarding such ‘sub-consultant’ posts and discusses the arguments currently surrounding these.

National Surgical Trainee Survey Results
In order to assess surgical trainees’ opinions regarding ‘sub-consultant’ posts in the workforce, specific questions were included in an electronic, 38-item, self-administered national training survey. All junior doctors in surgical training (i.e. pre-CCT) in the UK were invited to participate in this anonymous, non-mandatory survey through surgical mailing lists and websites by ASiT and specialty associations. Responses were collected through the SurveyMonkey web-survey portal (SurveyMonkey.com, LLC, Palo Alto, California, USA). Data was analysed with Prism (version 5.0, GraphPad Software, California). Of 1,710 questionnaires submitted, 1,581 were appropriately completed and sufficient for further analysis. From these, only current surgical training grade junior doctors (SHO/Core Trainee and Registrar responses were included, leaving 1,365 individuals in the following analysis. Responses were received from all 19 postgraduate medical training Deaneries covering the geographical training regions in England, Northern Ireland, Scotland and Wales, plus military trainees in the Defence Deanery. Responses were received from all surgical specialties. Overall, 906 of the 1,365 respondents were male (66.4%) and the mean age was 32.5-years old. Regarding the question ‘Do you feel that there is a role in the surgical workforce for a post-CCT non-consultant specialist (“sub-consultant”) grade in surgery?’, 56.0% felt there was no role, 31.1% felt there was a role and 12.8% were uncertain. A breakdown of the responses to ‘Would you consider applying for a post-CCT non-consultant specialist (“sub-consultant”) post?’ can be seen in Table 1. Only 12.6% of respondents would consider applying for such a post, while 72.4% would not and 15.0% were uncertain. Of note, for both these questions, there was a significant difference in the responses by gender (p < 0.0001, Chi-square test) with female trainees more likely to consider applying for such a post.

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Table 1: Would you consider applying for a post-CCT non-consultant specialist (“sub-consultant”) post?

Answer Options Positive Positive Neutral Neutral Negative Negative Grand Total (%) (n) (%) (n) (%) (n) (n) Service provision? 50.8% 691 25.1% 342 24.1% 328 1361 Patient care? 21.6% 294 37.7% 514 40.8% 556 1364 Surgical training? 13.9% 189 20.1% 274 66.0% 900 1363 The surgical profession? 11.1% 151 18.7% 255 70.2% 957 1363 Your career? 7.9% 108 18.9% 258 73.1% 997 1363
Table 2: How do you feel that the introduction of a post-CCT non-consultant specialist (“sub-consultant”) grade would impact upon

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Category Yes Yes No No Uncertain Uncertain Grand Total (%) (n) (%) (n) (%) (n) (n) Gender Female 19.0% 87 61.2% 281 19.8% 91 459 9.4% 85 78.0% 707 12.6% 114 906 Male Surgical Specialty OMFS 0.0% 0 100.0% 12 0.0% 0 12 Unspecified 0.0% 0 66.7% 4 33.3% 2 6 6.0% 5 76.2% 64 17.9% 15 84 Plastic Surgery Urology 7.4% 6 79.0% 64 13.6% 11 81 ENT 7.9% 9 75.4% 86 16.7% 19 114 8.6% 3 77.1% 27 14.3% 5 35 Cardiothoracic Trauma & Orthopaedics 10.1% 24 75.5% 179 14.3% 34 237 11.6% 10 75.6% 65 12.8% 11 86 Neurosurgery General Surgery 15.7% 105 68.5% 457 15.7% 105 667 Paediatric Surgery 23.3% 10 69.8% 30 7.0% 3 43 Grade of Trainee ST1 / CT1 18.9% 25 59.8% 79 21.2% 28 132 15.4% 27 61.1% 107 23.4% 41 175 ST2 / CT2 Research Fellow 13.5% 18 68.4% 91 18.0% 24 133 SpR 1-2 / StR 3-4 9.1% 30 78.0% 256 12.8% 42 328 14.2% 48 72.6% 246 13.3% 45 339 SpR 3-4 / StR 5-6 SpR 5-6 / StR 7-8 9.3% 24 81.0% 209 9.7% 25 258 Country of Qualification United Kingdom 12.4% 138 72.7% 811 15.0% 167 1116 9.4% 6 78.1% 50 12.5% 8 64 European Union excluding UK Rest of the World 15.1% 28 68.6% 127 16.2% 30 185 Overall 12.6% 172 72.4% 988 15.0% 205 1365

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50.8% of respondents felt that the introduction of a post-CCT non-consultant specialist (“sub-consultant”) grade would impact positively upon service provision, however, only 21.6% felt it would have positive impact on patient care, 13.9% a positive impact on surgical training, 11.1% a positive impact on the surgical profession and just 7.9% a positive impact on their surgical career (Table 2).

Discussion
This comprehensive online survey has shown a clear weight of opinion among trainees across all 10 surgical specialties and all levels of training against the introduction of a sub-consultant grade. This opinion is particularly strong in terms of this proposal’s potential negative impact on surgical professionalism, surgical training and, most worryingly, on patient care. The findings of this survey corroborate those of a previous survey of medical registrars by the Royal College of Physicians, which indicated only 15% would consider a sub-consultant role14.

• Potential reduction in autonomy • Additional need for established lines of clinical authority • Need to establish lines of legal responsibility and accountability • Decreased career incentive for trainees • Need for additional new pathways for career progression • Potentially conflicting interests of those who are existing ‘Consultants’ • Effectively re-creating the previously disbanded ‘Senior Registrar’ grade • Retrograde step moving emphasis away from excellence onto basic competence • Sub-consultants would not be trainers under current regulations • Lack of parity amongst other post-CCT medical professionals • Lack of clarity for patients regarding additional new job titles
Table 3: Quick reference table summarising the arguments against the introduction of a post-CCT non-consultant specialist (“sub-consultant”) grade

Table 3 summarises the arguments against the introduction of a post-CCT non-consultant specialist (“subconsultant”) grade. ASiT supports the principle that all patients are entitled to consultant-delivered care and this view is mirrored by other trainee groups. The rationale for this premise is supported by a recent report by the Academy of Medical Royal Colleges (AoMRC) entitled ‘The Benefits of Consultant-Delivered Care’15. The report examined the evidence base for the consultant-delivered care model focusing on quality, outcomes and productivity rather than pay or working conditions. Part of the evidence was taken from an externally commissioned independent review of the literature. The report concluded that the benefits of consultant delivered care were: • Rapid and appropriate decision making • Improved outcomes (in both normal and exceptional circumstances), with particular reference to acute surgery16 • More efficient use of resources • General practitioners’ access to the opinion of a fully trained doctor • Patient expectation of access to appropriate and skilled clinicians and information • Benefits for the training of junior doctors In an era of Teaching Assistants and Community Support Officers this independent review of the literature demonstrated that in medicine, if you invest in a high quality workforce there will be the expected benefits of innovation and efficiency. Accepting the benefits of consultant-delivered care, it is no surprise that patients and their relatives desire high-quality care and relate this to the concept of a ‘consultant’ being the senior clinician in the team. The consultant role has an accepted “kite-mark” within the UK and it is becoming increasingly expected by patients to request and receive consultant-delivered care. This ‘gold-standard’ should not be diluted by introducing post-CCT non-consultant positions in an attempt to restrict salaries.

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Workforce planning is notoriously difficult, especially in surgery given that the duration of craft specialty training is, at its fastest, more than a decade. Politically driven changes to post-graduate medical education, 11 first with the Calman reforms and latterly with MMC, aimed to speed production of the workforce. In combination with the “Hutton bulge” (which relaxed the restriction on creating National Training Numbers [NTNs] between 2003 and 2005 with implementation of the first stage of EWTR) increasing recruitment into training, this has led to a surplus of fully-trained surgeons. It is therefore to be expected that there is the potential for a 60% increase in trained post-CCT doctors by 2020, as stated by the Centre for Workforce Intelligence (CfWI)17, although the validity of the data used as the basis for this report is disputed18. If viewed solely through a financial lens this represents a significant challenge to the NHS, employers and the public purse. There would, however, be clear opportunities for the public with the wealth of trained surgeons currently in the UK. As recommended in the Temple Report “Time for Training”, commissioned by the Secretary of State for Health, a reconfiguration of the services would yield significant benefits with a consultant-delivered service19. Consistent access to senior doctors was also identified in the 2011 Doctor Foster report “Inside your Hospital” 20 as influencing mortality rates . Despite the growing evidence of benefit from, and recommendations for, a consultant-delivered service, it has not been seized on. A strong and tenacious political direction will be required to realise this opportunity. Where surplus CCT holders exist, the number of trainees in that speciality should be reduced through appropriate awarding of NTNs. NHS service requirements will still remain, so any reduction in NTNs should be balanced with the creation of non-training posts to address this. This ASiT survey indicates that while the idea is unpopular, 50% of those questioned feel that a sub-consultant grade would improve service provision. ASiT does not believe a CCT-holder should be required to take up such non-consultant posts, as these are different roles requiring different skills to a consultant position. An economic argument for the introduction of a sub-consultant grade is also difficult to support. A sub-consultant would need to be overseen by a named consultant, both electively and when providing out-of-hours care, thereby creating an extra level of cover and cost. Without close supervision this may increase the likelihood of inappropriate investigations, admissions and potential litigation costs. Equally, consultants may require additional remuneration for providing overall responsibility for the care of patients admitted under a sub-consultant. Their introduction is therefore likely to increase, rather than decrease, the costs to NHS trusts whilst not providing equivalent patient safety or patient satisfaction. It is also counter intuitive to train doctors to the standard of high quality independent practice only to recruit at a lesser role. Foundation Trusts (FTs) may have the ability to set new terms and conditions for staff and are thereby creating a sub-consultant grade21. University Hospitals Birmingham NHS Trust created 40 new roles for doctors in 2009 alongside the training grades. The most senior post had a new title of ‘specialist consultant’ and had terms and conditions based on the 2003 consultant contract. These posts allow post-CCT doctors positions of equivalent responsibility as a consultant, but without the protection of nationally agreed terms and conditions of service. As more Trusts aim for Foundation status, this is likely to become much more widespread, and the value of the name ‘consultant’ is at risk. ASiT is concerned that it may represent the start of a race to the bottom to find the lowest cost available “trained doctor” at the expense of quality. If a sub-consultant grade is required because of the reduced length of training, or the reduced working hours available since the introduction of the 48-hour EWTR-compliant week, then it is the criteria for the award of a CCT that should be addressed22. The suggestion that those completing specialist training are inexperienced, or unable to fulfil the roles of a consultant, should not lead to the notion that they should therefore have their own patients and deliver unsupervised service as a sub-consultant - this is completely illogical. If training needs to match service requirements are identified, then hospital employers should support, arrange or provide this to a consultant once they are appointed to a substantive post. The recent review of compensation levels, incentives and the Clinical Excellence and Distinction Award schemes for NHS consultants suggested the need “ … to recognise different stages in a consultant career by introducing a break point in the pay scale and a new principal consultant grade that would cover up to 10 per cent of the consultant workforce at any one time.”23 It has been proposed that this principal consultant grade would be one “ … to which experienced, high-performing consultants, who are undertaking larger roles in terms of service delivery, expertise or leadership could be 24 promoted.” The significant public investment in surgical training will not be returned should there be significant workforce migration. A medical degree is an internationally recognised qualification and recruitment drives by overseas healthcare systems will prove attractive to UK trained surgeons without perceived home-grown opportunities. Given current healthcare reforms, working outside the NHS is also likely to be easier in the future. Surgeons in training have also

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heavily invested in their careers both financially and personally, and the creation of a sub-consultant grade will devalue their aspirations; this is no surprise, given the competitive nature of surgery and the significant training time. The creation of a demotivated non-compliant workforce would only be likely to have a negative effect on innovation and efficiency.

Conclusions
Surgery is a rewarding career with traditionally high levels of job satisfaction and interesting and diverse opportunities to progress. It is a popular career despite the high stakes career structure, significant clinical and professional responsibilities and frequent antisocial working conditions. Changes to the career structure must be made in the interests of patient safety and quality, and not just cost. It is clear from this survey that the proposed sub-consultant grade is unpopular, and it is not felt that it would enhance patient care or safety. Neither the creation of a named “sub-consultant” grade nor the effective creation of such a grade by the alteration of terms and conditions, working patterns and/or responsibilities is welcome. Such a sub-consultant grade has been considered and discarded in the past, and it represents no better an idea now than it did 65 years ago. What is true now, and has always been true in the NHS, is that patients deserve the best - and the best is a consultant, not a sub-consultant.

References

1. Fitzgerald, JE, Giddings, CE, Khera, G,Marron, CD, Improving the future of surgical training and education: Consensus recommendations from the Association of Surgeons in Training. International journal of surgery, 2012. 10(8): p. 389-92. 2. Employers, N, Briefing 52: Medical Training and careers – the employers’ vision, 2008. 3. Fitzgerald, JEF, Post-CCT Non-Consultant Grade. Position Statement by The Association of Surgeons in Training, 2008, Association of Surgeons in Training. 4. Physicians, TCotRCo, Patients, Training, Clinical Leadership and a ‘Subconsultant’ Grade, 2008: London. 5. Spens, W, Report of the Inter-Departmental Committee on the Remuneration of Consultants and Specialists, 1948. 6. Stevens, R, Medical practice in modern England : the impact of specialization and state medicine2003, New Brunswick, N.J. ; London: Transaction. 7. Great Britain. Ministry of, H, Report of the Joint Working Party on the Medical Staffing Structure in the Hospital Service1961, [S.l.]: ASiT - the pursuit H.M.S.O. 8. Todd, AR, Report of the Royal Commission on Medical Education, 1965-68, 1968: London. 9. Security, TDoHaS, Hospital medical staffing. Achieving a balance, 1986, The Department of Health and Social Security. 10. “Hospital medical staffing: achieving a balance”. British medical journal, 1986. 293(6539): p. 147-51. 11. Health, TDo, Hospital doctors. Training for the future; the Report of the Working Group on Specialist Medical Training., 1993, The Department of Health. 12. Calman, KC,Temple, JG, Naysmith, R, Cairncross, RG,Bennett, SJ, Reforming higher specialist training in the United Kingdom-a step along the continuum of medical education. Medical education, 1999. 33(1): p. 28-33. 13. Doran, FS, A subconsultant grade in surgery. British medical journal, 1978. 1(6109): p. 385-6. 14. Goddard, AF, Evans, T,Phillips, C, Medical registrars in 2010: experience and expectations of the future consultant physicians of the UK. Clinical medicine, 2011. 11(6): p. 532-5. 15. Colleges, AoMR, The Benefits of Consultant-Delivered Care, 2012. 16. Death, NCEiPOa, Death in acute hospitals: Caring to the end? A review of patients who died within four days of admission, 2009. 17. Intelligence, CfW, Shape of the medical workforce - starting the debate on the future consultant workforce, 2012. 18. Edinburgh, RCoPo, Response to: “Shape of the medical workforce - starting the debate on the future consultant workforce”, 2012. 19. Temple, J, Time for Training: A Review of the impact of the European Working Time Directive on the quality of training, 2010, Medical Education England. 20. Foster, D, Inside your hospital: Dr Foster Hospital Guide 2001-2011, 2011. 21. Broad, M. Trust under fire for sub-consultant grade. 2009; Available from: http://www.hospitaldr.co.uk/blogs/our-news/birmingham-trust under-fire-for-introducing-sub-consultant-grade 22. Fitzgerald, JE,Caesar, BC, The European Working Time Directive: a practical review for surgical trainees. International journal of surgery, 2012. 10(8): p. 399-403. 23. Hunt, J, Written Ministerial Statement: Review of Awards for NHS Consultants and publications of NHS Employers report on junior doctor’s contracts, 2012, Department of HEalth. 24. Amy, R, Review Body on Doctors’ and Dentists’ Remuneration. Review of compensation levels, incentives and the Clinical Excellence and Distinction Award schemes for NHS consultants, 2012, The Stationary Office.

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Provision of Emergency Cross-Cover Between Surgical Specialities A Statement from The Association of Surgeons in Training January 2013
Authors: Mr Gary Lambert (ASiT Rouleaux Club Representative), Mr Jonathan Wild (Vice-President), Mr Steve Hornby (President) and Mr Ed Fitzgerald (Past-President) Acknowledgements: Mr Basil Beckdash (Paediatric Surgical Trainees representative) and Mr Peter Radford (ASiT representative for the Association of Otolaryngologists in Training) Written on behalf of the ASiT Executive and Council
Foreword
Patients are concerned that they receive appropriate treatment, delivered by doctors trained and experienced in dealing with the management of their condition. The Patient Liaison group at the Royal College of Surgeons England would like patients to receive safe and high quality care delivered in a timely manner so as to achieve the best possible clinical outcome and that these services are provided by appropriately trained and competent doctors. ASiT have highlighted in this report the concerns in service delivery and training that need to be addressed in order to maximise good patient clinical outcomes. RCS (Eng) Patient Liaison Group (PLG) - December 2012

Executive Summary
• ECC can be defined as the provision of emergency care by a doctor trained or training in a different specialty to that which they are requested to assess or manage. • Most commonly surgical ECC is referred to in respect of the out-of-hours assessment and management of acute surgical emergencies within a given specialty, be they new admissions or ward patients. • The sole principle on which to base ECC must be the provision of safe, appropriate and timely patient care when needed. • The problems surrounding emergency cross cover primarily relate to: • Potential variability in patient care and resource use by those providing care outside of their usual surgical specialty area. • Trainee’s competence, experience, and confidence in dealing with surgical problems outside their own specialty. • The paucity of specific training opportunities (local, regional and national) for trainees required to assess and/or manage surgical problems in different specialties. • Variable access to senior support in the specialty being cross-covered, together with the willingness to provide this. • Medico-legal implications of providing such cover outside a surgical trainee’s normal area of practice, particularly without previous experience or means for regular skills practice and up-dating. • In this document ASiT set out a number of proposals to address these matters. Key points include: • JCST and SAC guidance on curriculum content is required to ensure robust guidance on training provision for those undertaking ECC. • Curriculum alignment between specialties providing cross-cover to ensure trainees demonstrate similar competencies at similar grades. • Improved provision of local, regional and national training opportunities for those trainees required to provide cross cover between specialties. • Where used, ECC should be utilised to ensure timely early emergency assessment and management only. • Improved senior support for those trainees delivering cross cover.

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About ASiT

The Association of Surgeons in Training (ASiT) is a professional body and registered charity working to promote excellence in surgical training for the benefit of junior doctors and patients alike. With a membership of over 2000 surgical trainees from all 10 surgical specialities, the association provides support at both regional and national levels throughout the United Kingdom and Republic of Ireland. Originally founded in 1976, ASiT is independent of the National Health Service (NHS), Surgical Royal Colleges, and specialty associations. Governed by an elected Executive and Council, the association is run by trainees for trainees. 1 1.1 1.2 1.3 1.4 1.5 2 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 Introduction This statement discusses the issues and provision of emergency cross-cover (ECC) between surgical specialties. ECC is a concept that has been present between specialties for many years in order to utilise trainees to fulfil on-call service requirements. However the progressive changes within surgery have caused increasing difficulties in its provision, which need addressing. Questions have been raised at both the consultant and trainee level with respect to the appropriateness and also manner in which ECC is provided between specialties. The review conducted as part of this document was initially in response to concerns relating to general surgical and urology cross-cover, however proposals should be considered appropriate to any surgical specialties providing or receiving cross-cover. We hope this document will inform in regards to the trainee’s position and help guide discussions with respect to the provision of cross-cover amongst the surgical specialties. Emergency Cross-Cover ECC can be defined as provision of emergency care by a doctor trained or training in a different specialty to that which they are required to assess or manage. Most commonly surgical ECC is referred to in respect of the out-of-hours assessment and management of acute surgical emergencies within a given specialty, be they new admissions or ward patients. Since the implementation of the European Working Time Directive (EWTD), New Deal (ND) and Modernising Medical Careers (MMC), surgical specialties have been exploring new ways of working. The increased use of ECC between specialties is a result of numerous factors including changes to rota patterns in an attempt to maintain EWTD rota compliance and a reduction in training posts. . Cross-cover relationships commonly exist between general surgery and urology, ENT and maxillofacial surgery, as well as orthopaedics and plastic surgery. The implementation of MMC and EWTD has resulted in a reduction in the training hours and exposure of junior trainees being appointed to ST3 and beyond.1-5 There has been a radical overhaul and restructuring of surgical training in the UK6, and current junior trainees may not have undertaken 6-months Emergency Department posts, nor rotated through as many surgical specialty SHO posts as in previous years (particularly Foundation Year doctors filling posts previously staffed by surgical SHOs). Subsequently, their experience and ability in managing surgical emergencies across other specialties has reduced as curricula have been streamlined to meet the training requirements within their own specialty. Evidence demonstrates that the care provided by trainees in cross-covering specialties differs from that of those trainees within that specialty.7 Such variation in practice needs to be addressed.

Principles of Safe Emergency Cross-Cover 3 3.1 The sole principle on which to base ECC must be the provision of safe, appropriate and timely patient care when needed. 3.2 Prompt and definitive decision making is critical in the outcome of patient care with delays in the correct diagnostic or therapeutic decisions carrying associated increase in both morbidity and mortality. 3.3 The suitability of a trainee to provide ECC can be assessed by applying guidance issued by the GMC and standards expected by the courts. 3.4 GMC guidance upon Good Medical Practice paragraph 3 states that: “In providing care, you must recognise and work within the limits of your competence”8 3.5 Doctors are required to act to the required standard of care expected of them by law. The Bolam test9 requires a doctor to act in accordance with the accepted practice of a responsible body of medical opinion. Inexperience cannot be used as a defence in the event of a trainee acting without obtaining guidance from a senior.10 The law therefore expects a trainee to seek advice from experienced colleagues when appropriate. 42 ASiT - the pursuit of excellence in training

Conversely a consultant would be found negligent were he to delegate responsibility to a trainee in the knowledge that the junior was incapable of performing the duty.11 Given that the actions of medical professionals are being placed under increased scrutiny by the courts, following decisions such as in Bolitho,12 medical professionals therefore carry greater responsibility to their level of expertise. 3.6 Both professional and legal guidance upon the provision of care centers around the competence of a doctor to provide the care required of them. Competence is of paramount importance when assessing suitability to provide ECC for a specialty in which the doctor is not training and thus may have limited exposure and experience. The GMC’s guidelines and the law both defend the basic principles of patient safety and care. 3.7 Recent recommendations from the Royal College of Surgeons of England, have stated that surgical care should be consultant led and, where necessary, consultant delivered.13 It is the consultant’s duty to ensure that those trainees to whom they are delegating care and management of their patients are appropriately experienced and trained.13,14 3.8 Implementation of adequate training and induction programmes has the potential to inform and educate incumbent trainees not only on their responsibilities, but also to provide them with necessary skills and knowledge.15

“Whether consultants are supportive or not, the skills learnt in the modern era are not as generic as they used to be, and the juniors not as skilled in their own specialty, let alone another one”. “The situation in our trust is very much that the Urology service is propped up by the General Surgical SpRs with no assessment of training or competence. I feel it is entirely wrong that we are just expected to provide this cover which is outside our speciality”. “Clarity from ASiT and the SAC would be very helpful in this matter as at present I feel General Surgical Trainees are left exposed to criticism and possibly worse such as legal action, and discussion of this now will assist in the future with further separation issues in other specialities”. “Yes, frequently [experience problems] and I feel very under-qualified and under-trained to be providing a urology service”. “Giving an opinion about a torsion will result in a scrotal exploration 100% of the time in my practice since I do not feel confident or qualified to make the decision not to explore anyone”. “I perform approx 2 emergency scrotal procedures per month, never have any training or senior support and have not been involved in an elective scrotal procedure for 8 years”. “My concern is that occasionally we are required to perform emergency procedures such as suprapubic catheter or scrotal exploration for torsion with no urology consultant cover. The only training I have had in these is on a “see one do one” basis as I have never worked in a urology job. While this is ok most of the time, I don’t feel I have the experience or knowledge to deal with unexpected findings”. “From my personal point of view, as a senior general surgical trainee I could manage the patients adequately, but as I had never done a urology post and was post-CCT [Certificate of Completion of Training], there was always an uneasiness about doing this from a medico-legal point of view”. “I have often found it difficult and at times impossible to contact the on-call urology consultant for advice or assistance. When contactable they are extremely unsupportive and resentful of the disturbance. I have been pressurised to undertake scrotal exploration when it did not appear to be clinically indicated and also to undertake it with no prior experience/ expertise in emergency exploration/orchidopexy. My other concern is that the majority of scrotal explorations are undertaken in the under 18 if not under 16 age group i.e paediatric and this has further implications medico-legally”. “I do not feel that general surgical registrars should be the ‘catheter service’ for the whole hospital”.
Table 1: Representative quotes from a recent snapshot survey of ASiT members which asked for opinions on the provision of emergency cross-cover for urology by general surgery trainees

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4. 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 4.10 4.11

Current Concerns A recent ASiT snapshot survey demonstrates many widespread variations in the experiences amongst general surgical trainees providing ECC for urology. Representative quotes from this survey can be found in table 1. Evidence demonstrates that there is variation between the management of the acute scrotum when general and urological trainees are compared.7 There appears to be a wide variation in the degree of confidence and competence in assessing and managing the acute scrotum in the emergency setting. Such variation is likely to occur between trainees of other specialties with other comparable conditions unless they have been subject to the same training, exposure and assessment of such cross-covered conditions. The degree of senior supervision, support and coverage that is available and provided by specialties requiring ECC is variable between institutions. In the case of urological cross cover by general surgery registrars, trainees are expected to perform assessment and sometimes operative management of the acute scrotum with little or no experience or formal training. Regarding trainees who deem themselves competent and confident in the assessment and management acute scrotal emergencies, there is often little or no exposure to elective lists to maintain on-going competence within the specialty. At present early care of urological emergencies form part of the curriculum for core trainees in general surgery. Therefore exposure to urological emergencies through ECC, with appropriate supervision from seniors, can provide core trainees with learning opportunities needed to fulfil their curriculum requirements.16 From ST3 onwards, the management of the acute scrotum in paediatric patients is included in the general surgery curriculum. However there is no mention of the management of the acute scrotum, or in fact any specific mention urological emergencies, such as urinary retention, in adult patients in the intermediate or final stages of the general surgical curriculum.16 The historical reliance upon the training of general surgeons in particular gave rise to the expected ability to assess and manage a broad range of conditions. This is no longer the case with the continuing subspecialisation seen in surgery. The breadth of training has reduced along with the relative experience in these fields. There is often overlap between surgical specialties, both in terms of training and procedures and conditions managed (e.g. groin, hernia and vasectomy surgery in the case of general surgery and urology). Such overlap forms the historical basis of the use of cross-cover and therefore the requirement for general surgical trainees to maintain competence in the management of the scrotum.

Other Surgical Specialties Issues of ECC are certainly not restricted to general surgery trainees covering urology, with head and neck services often requiring ECC between maxillofacial surgery, ENT and sometimes plastic surgery. ASiT are increasingly concerned of reports regarding non-medically qualified dentists providing emergency care out of hours for patients in specialities such as plastic surgery as a result of amalgamation of on-call rotas. An out of hours telephone survey of ENT units in the UK has also raised concerns regarding inexperienced non-ENT trainees expected to provide emergency resident ENT cover. This study demonstrated a lack of training of doctors from other specialties covering ENT. Two-thirds of respondents were cross-covering other specialties in addition to ENT, with 19% of doctors covering four or more surgical specialities whilst on-call.17 These concerns echo those from a previous study of junior doctors covering ENT which showed that of those cross-covering from other specialties only 35% had received any training on how to manage common ENT emergencies.18 4.12 Cross-cover of children by primarily adult sub-specialities has also raised issues regarding the assessment and management of children presenting with possible testicular torsion and acute abdominal pain. The relationship of secondary general and urological surgery with tertiary paediatric surgery also warrants comment. 4.13 Initial assessment and management of a child with acute abdominal pain, for example acute appendicitis, can be made at a secondary-care level by either general surgery and or general paediatrics. In the majority of cases, the initial observation period can be safely undertaken locally avoiding potentially unnecessary transfers to tertiary centres, often out-of-hours. A decision to operate locally is determined by provision of adequate resources and expertise, as outlined by the Children’s Surgery Forum.19 4.14 Issues relating to children presenting with possible testicular torsion echo those highlighted between general surgery and urology with regards the acute scrotum in the adult services. The technical aspects of scrotal exploration are similar in children (particularly post-puberty) and thus within the competency of the surgical team providing the service to adults in the local unit. Delay in definitive treatment caused by transfer 44 ASiT - the pursuit of excellence in training

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5. Recommendations 5. 1 In response to the issues identified with regards to ECC, ASiT suggests the following proposals as appropriate for all specialties providing ECC out of hours. Summary advice for trainees can be found in table 2. 5. 2 Where there is potential for ECC between specialties, such as in general surgery and urology, further JCST and SAC guidance on curriculum content is required to ensure robust guidance on training provision for those undertaking ECC. 5. 3 Trainees should not be expected to perform ECC for any specialty or condition which is not included within their curriculum, and thus no formal requirement or provision for training. 5. 4 In those areas where there is clinical knowledge and skills overlap between specialities providing cross cover, curriculum alignment must take place between those specialties to ensure trainees demonstrate similar competencies at similar grades. 5. 5 In departments where a surgical specialty is cross-covered by another, there is a duty upon consultants in both specialties to ensure there are adequate training opportunities and provision for trainees to gain the required level of competence to conduct their duties of ECC. 5. 6 Trainees who have not received adequate training experience or competence to provide ECC must bring this to the attention of the on-call specialty consultant in question and their educational supervisor. 5. 7 Trainees providing ECC who do not feel competent to do so must inform the consultant for whom they are cross-covering and should utilise the resultant opportunity to gain experience and competency. 5. 8 In centres where cross-cover is provided for a specialty, consultants will provide immediate appropriate support for those trainees providing ECC when asked to do so. 5. 9 Wherever possible, care of patients should be provided by those doctors trained or training within the specialty in question, thus avoiding the need for cross-cover provision. 5. 10 Where ECC provision is necessary, it should be to provide timely appropriate emergency care only, and should not include the out of hours (e.g. weekend daytime) management of ward patients including routine ward rounds. 5. 11 Once admitted, all patients should be assessed by their appropriate specialty consultant on a post-take round, and not solely by the registrar providing cross-cover.

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4.15 4.17 4.18 4.19 4.20 4.21

to tertiary care is inappropriate and safe practice may appropriately require greater surgical and anaesthetic consultant input. Although curricula for general surgery, urology and general paediatrics include the assessment of surgical conditions of childhood, recent closure of secondary care level inpatient paediatric units threatens to divert significant numbers of children with common emergency presentations away from local services and towards tertiary care. As a result the critical mass necessary to sustain local paediatric surgical services may be lost with few learning opportunities available for trainees working in secondary care to fulfil curricula requirements and maintain competence. Prior to adoption of MMC the Gold Guide to training concluded that trainees should not cross-cover other specialties once they had entered higher training. It is noticeable that this is no longer the case in current editions of the Gold Guide, though it does allude to the GMC guidance on acting within one’s competence.20 There are particular challenges in the provision of ECC for surgical specialties where emergency cases are infrequent. In such instances there is greater likelihood that they will operate non-resident rotas, leaving other specialties to manage cases that there is little chance to gain any experience, even for trainees within that particular specialty. It is important to ensure that a specialty’s need for ECC due to rota provision does not impact unnecessarily upon the workload, training and delivery of patient care of another specialty’s trainees. Specialties such as general surgery most frequently operate a resident system for on-call cover and as such can be seen as an easy target for the provision of ECC. The requirement for a resident on-call service is usually driven by the volume and extent of the workload within the specialty in question, and as such, resident teams are often already busy prior to the addition of cross-cover responsibilities. The recent separation of vascular surgery from general surgery, and with it a separate vascular training programme and curriculum, adds further complexity to the issues surrounding ECC. Vascular surgery now represents an additional speciality that will require trainees from other surgical specialities to crosscover in order to support consultant vascular surgeons in service delivery. How the new speciality status of vascular surgery impacts on the training of non-vascular trainees and their on-call responsibilities remains to be seen.

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5. 12 Further research into the required frequency and outcomes of ECC between specialties will better identify whether or not such cross-cover provisions are in fact necessary, or whether such emergencies should be managed by the specialty themselves. 5. 13 Consideration should be given at local, regional and national levels to provide specific courses addressing the training needs of those expected to provide surgical cross-cover for different specialities whilst on-call, in order to ensure trainees are emergency safe and provide consistent, up-to-date patient care. • You should always work within the limits of your competence as per GMC guidance. • Prior to commencing a training post find out in advance if you will be expected to provide ECC. • If you have not received adequate training or do not feel competent to provide the ECC then bringing this to the attention of your educational supervisor and/or training programme director, ideally in advance of starting the post. • Your supervisors should help with the early identification of training opportunities in order for you to gain the required level of competence to conduct ECC duties. • If you find yourself providing any element of ECC that you do not feel competent to do so then you have a duty to inform the consultant on-call for the speciality and document having done so. • You should then utilise any resultant opportunities to gain experience and training under consultant supervision. • If you have any concerns about patient safety then you are obliged to raise these concerns. GMC advice on raising concerns about patient safety can be accessed on www.gmc-uk.org/guidance/ethical_guidance/raising_ concerns.asp
Table 2: Summary of advice for trainees who are asked to provide ECC

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1. Marron C SJ, Mole D, Slade D. European Working Time Directive, a Position by the Association of Surgeons in Training. London; 2006. 2. Fitzgerald JEF, Caesar BC. The European Working Time Directive: A practical review for surgical trainees. Int Surg 2012; 10:399-403. 3. RCSEng. Surgical training seriously compromised by European Working Time Directive. London: RCS; 2005. 4. Lowrychair J CJ. Results of the online EWTD trainee survey. Ann R Coll Surg Engl (Suppl) 2005;87: 86-87. 5. Wraighte PJ FD, Manning P. The Impact of the European Working Time Regulations on Orthopaedic Trainee Operative Experience. Ann R Coll Surg Engl (Suppl) 2012;94: 156-158. 6. Fitzgerald JEF, Giddings CEB, Khera G, Marron CD. Improving the Future of Surgical Training and Education: Consensus Recommen dations from the Association of Surgeons in Training. Int J Surg 2012; 10:389-392. 7. Tydeman C, Davenport K, Glancy D. Suspected testicular torsion - urological or general surgical emergency? Ann R Coll Surg Engl 2010;92(8): 710-712. 8. The General Medical Council. Good Medical Practice. GMC; 2006. Bolam v Friern Hospital Management Committee [1957] 1 WLR 582. 9. 10. Wilsher v Essex Area Health Authority [1987] QB 730. In. 11. Mason J LG. Mason McCall Smith’s Medical Law and Ethics (7th edn). OUP: Oxford, 2006. 12. Bolitho v City & Hackney Health Authority [1998] AC 232, [1997] 4 All ER 13. RCSEng. The Royal College of Surgeons of England. Standards for Unscheduled Surgical Care. London: RCS; 2011. RCSEng. The Higher Risk General Surgery Patient; towards improved care for a forgotten group. London: RCS & DOH; 2011. 14. 15. Cheng L TP. Out of hours cross-cover between oral and maxillofacial surgery and ear, nose and throat surgery. Ann R Coll Surg Engl(Suppl) 1997;79: 9-11. 16. ISCP General Surgery Curriculum. http://www.gmc-uk.org/General_Surgery_curriculum_2010.pdf_32485335.pdf 17. The disinfection of flexible fibre-optic nasendoscopes out-of hours: confidential telephone survey of ENT units in England - 10 years on. Radford P, Unadkat S, Rollin M, Tolley N. Conference proceedings of BACO 2014, Glasgow. 18. Sharpe D, Farboud A, Trinidade A. ‘Is that the ENT SHO?’: concerns over training and experience of juniors expected to cross-cover ENT at night. Clin Otolaryngol 2009; 34:275 19. RCSEng. Surgery for Children: Delivering a first class service. London: RCS; 2000 (updated 2007) 20. The Gold Guide: A Reference Guide for Postgraduate Specialty Training in the UK: available at http://www.mmc.nhs.uk/pdf/Gold%20 Guide%202010%20Fourth%20Edition%20v08.pdf. 7.1 7.2

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ASiT has published a number of statements which are available at http://www.asit.org/resources/articles These include our position statements: • Simulation in Surgical Training (November 2011) • Cost of surgical training (April 2011) • Future of Surgical Training (August 2010) • EWTD for Surgical Trainees (August 2009)

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ASiT Statement in Response to the Challenges for Future Surgical Training Document January 2013
The ASiT Council once again welcome the opportunity to respond to this document, which we appreciate has been hotly debated and seen several iterations. We are pleased that the document is emphatic in its dismissal of the sub-consultant grade as this move has long been opposed by ASiT as a backwards step in the development of surgical services in the United Kingdom. We additional welcome the recognition that surgical trainees are often talented individuals who have will have already undergone many years of training. ASiT holds the view that trainees have a lot to offer the NHS, especially in the areas of enhance patient safety and quality service improvement. We agree that not all consultants are equal but we feel that it is important the different remuneration be based not solely on chronicity but also by amount of involvement in peripheral activities i.e. teaching, research and administration. The prospect of structured career development is also a welcome step. The ASiT council agrees that all new CCT holders must be skilled in the management of emergency surgery cases but we have grave concerns about that being the bulk of those individuals work as we feel that these posts will prove ultimately very unattractive to newly qualified consultants. ASiT appreciate the papers assertions that we must produce surgeons with the skills that the general public requires. Creating a demotivated and demoralised workforce, however will not result in the levels of innovation and development that has been at the heart of British surgery in the past. Providing what the public must be balanced against pushing the boundaries of what is possible to offer. The main concern with the document is that whilst it openly discourages the sub-consultant grade, several of its recommendations risk causing it, albeit not in name. Mr Steve Hornby ASiT President on behalf of the Association of Surgeons in Training

January 2013
Whilst ASiT are mindful of the costs involved in the administration of specialty trainees we remain disappointed that this cost is being levelled squarely at the feet of the trainees themselves. As ASiT have already demonstrated in our statement ‘The Cost of Surgical Training’2 trainees already pay a staggering amount of their own money in order to complete their training. This original document was published before the advent of £9000/year tuitions fees at medical schools, so any figures included are now a gross underestimate. The GMC feels that the beneficiary of surgical training should pay for its administration. ASiT does not dispute this but takes issue with the GMC’s insistence that the trainee is the only beneficiary. It is surely unarguable that the public at large gain great benefit from excellence in surgical training and its careful administration. We are also disappointed that cost could not have been spread across the entire college member/fellowship. As Members and future Fellows of the 4 Colleges the ASiT Council viewed this as an equitable solution that would have cemented the colleges’ commitment to its trainees. At this stage ASiT would once again like to request consideration for the fee to either be incorporated into college membership fees or for greater clarity over the matter of tax deductibility.

References

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1. http://www.jcst.org/traineefee/trainee_fee2012 2. http://www.asit.org/assets/documents/ASiT_Cost_of_Surgical_Training_final.pdf

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ASiT Statement in Response to the Announced Training Fee Increases from 2013-20151

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ASiT Statement in Response to Seven Day Consultant Present Care Executive Summary January 2013
The ASIT Council welcomes the opportunity to respond to the document on seven-day consultant present care. Surgery has long provided a consultant delivered seven-day emergency service. We accept however that daily consultant review of all inpatients is something that is lacking across several specialties in the surgical domain and in certain centres across the country. Certainly we acknowledge that poor discharge management at the weekend has a knock-on effect for the next week, the elective work that we are able to perform and ultimately the capacity to admit and manage new emergency cases. The ASIT Council agrees all three standards as they are set out in the document. These standards must be met by an investment in the expansion of the consultant workforce. They should not be met by simply overburdening the current consultant body. Equally it is unacceptable to compromise quality through the introduction of new tiers of service such as the sub-consultant grade. This is distinction is crucial and the ASiT Council feel it should be made clear in the document. The current summary has the statement ‘The Academy intends the term ‘consultant’ to include all doctors on the specialist register’. ASiT feels that this is two ambiguous.The term ‘consultant’ should simply mean an individual employed by the trust as a consultant. Deviation from this could pave the way for the compromises suggested above. As stated in the summary document this investment must be matched in the primary care sector by facilities that will allow patients to be discharged when they no longer require an acute hospital bed and can be managed in the community. Mr Steve Hornby ASiT President on behalf of the ASiT Council

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ASiT Statement in Response to Increase in WBA Numbers by the London Deanery 7 April 2013

Re: Requirement for 80 WBAs/year by London Deanery I am writing to you regarding an issue that is causing many of our members considerable concern. This pertains to the requirement from the London Deanery for Surgical Trainees to complete 80 workplace based assessments per year. This is double the recommended number quoted by the Joint Committee for Surgical Training and the decision to do this has been made unilaterally. As I am sure you aware there remains great controversy regarding the WBAs, with many surgical trainees sceptical toward their validity and educational value in training. The following examples from the literature give some impression of the depth of feeling. 1. Pereira EAC, Dean BJF. British surgeons’ experiences of mandatory online workplace-based assessment. Journal of the Royal Society of Medicine. 2009 Jul;102(7):287-93. 2. Bindal T, Wall D, Goodyear HM. Trainee doctors’ views on workplace-based assessments: Are they just a tick box exercise? Medical teacher. 2011 Jan;33(11):919-27. 3. Pentlow A. Workplace-based assessments in surgery: Are we heading in the wrong direction? Medical teacher. 2013 Jan;35(1):102. Despite reservations, trainees have engaged with the process. From the outset of the announcement for the London Deanery to require 80 WBA/year ASiT have had grave concerns. We raised the matter with JCST who indicated they did not have a mandate to dictate to individual deaneries what their requirement should be but simply to issue guidance. Moreover, we wrote directly to Professor Standfield, Head of School of Surgery for the Deanery expressing our concerns on the issue. A copy of this is attached. We have yet to receive any reply. The plans have moved ahead and ASiT is now hearing from London trainees who are deeply concerned that they are going to fail their ARCP due to a lack of WBAs, often when the numbers they have completed would be more than satisfactory in a different region. We have again brought the matter to the attention of the JCST but they regretfully maintain that they cannot act to alter the requirements for the London Deanery. The ASiT Council would be very interested to hear what the GMC’s view would be if a trainee were to face the situation outlined above. Yours sincerely, Mr Steve Hornby President of the Association of Surgeons in Training cc Dr Andy Heeps, Chair, Academy of Medical Royal Colleges Trainee Doctors Group Dr Ben Molyneux, Chair of the BMA JDC Mr Ian Eardley, Chair of the JCST

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Dear Dr Osgood,

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ASiT Conference Report: Cardiff 2012
Ed Fitzgerald edwardfitzgerald@doctors.org.uk
As the only pan-specialty national conference for surgical trainees in the UK and Ireland, the Association of Surgeons in Training (ASIT) annual meeting offers a unique opportunity for clinical up-dates, training courses, research presentations and careers talks specifically aimed at surgical trainees. Combined with numerous prizes, a Charity Gala Dinner and the opportunity to socialise with colleagues from across the country, the weekend has become an essential date in the diary for all surgical trainees. Following on from the success of 2011’s meeting 1 in Sheffield , the 2012 Cardiff City Hall played host to nearly 700 delegates from the UK and overseas. With a record number of 1,168 abstract submissions, the conference offered an excellent forum for presenting trainee audit and research work. The trends over recent years, together with the abstract submission categories are detailed in Table 1. Following a rigorous peer-review process, the highest scoring abstracts were accepted for poster presentations, with the best selected for Abstract Submission Category Basic science including anatomy Breast surgery Cardiothoracic surgery Case reports Coloproctology Endocrine surgery ENT surgery Hepatopancreatobiliary Maxillofacial surgery Miscellaneous surgery Neurosurgery Orthopaedics Paediatric surgery Plastic surgery Surgical training and education Transplant surgery Trauma / Emergency surgery Upper-gastrointestinal surgery Urology Vascular / Endovascular surgery Total abstracts submitted

Cardiff City Hall proved a an excellent setting for the 2012 ASiT Conference

presentation in one of the four oral prize presentation sessions. In total, over £3,500 in prizes, grants and bursaries were available for the best conference trainee and medical student presentations. Numerous surgical associations, charities and companies have joined together with ASiT and other surgical specialty trainee associations to sponsor these, and all offer a prestigious addition to a surgeon’s curriculum vitae. Details of these awards are provided in Table 2.

Hull 2010 Sheffield 2011 Cardiff 2012 14 18 21 30 43 60 21 11 26 87 109 121 59 76 87 5 13 12 43 73 76 21 20 26 8 11 7 55 71 110 5 13 18 85 99 141 7 15 11 28 31 52 80 111 160 3 6 8 29 44 62 29 40 40 40 37 69 55 89 61 704 930 1,168

Note: Abstracts undergo anonymous peer review by a minimum of three reviewers, with only the highest marked (under 50%) accepted for presentation
Table 1 - Trends in abstract submission to the ASiT Conference

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Pan-Specialty Oral Presentation Prizes • Ansell ASiT Medal • SARS ASIT Academic & Research Surgery Prize • ASGBI ASiT Short Paper Prize • Ethicon ASiT Surgical Education Prize • Elsevier ASiT Medical Student Prize Pan-Specialty Poster Presentation Prizes • RCSEng/ASiT Poster Presentation Prize • International Journal of Surgery Case Report Prizes Surgical Specialty Trainee Prizes • Orthopaedic Research UK Prize • BASO-The Association of Cancer Surgery Prize • AUGIS Trainee Prize • ALSGBI Trainee Prize Specialty Trainee Group Prizes • ASiT-Rouleaux Club Prize • ASiT-AOT Prize • ASiT-SURG Prize • ASiT-PLASTA Prize • ASiT-Dukes’ Club/ACPGBI Prize • ASiT-Mammary Fold Prize • ASiT-BNTA Prize
Note: Prize winners are highlighted in the published abstracts section of this supplement
Table 2 - ASiT Conference Surgical Trainee Research & Audit Prizes

ASiT/BOTA Foundation Skills in Surgery Course Course convenor: Mr Joe Shaloub ASiT/SARS/BJS Research Skills Course Course convenor: Mr Vimal Gokani ASiT/Covidien Core Laparoscopic Skills Course Course convenor: Mr Steve Hornby Masterclass in Journal Club/FRCS Academic viva course Course convenors: Mr Ajay Sharma and Mr Saba Balasubramanian ASiT GI Surgical Stapling and Energised Dissection Course Course convenors: Mr Thomas Hall and Mr Dhya Al-Leswas ASiT Surgical Art Workshop Course convenor: Mr Paul Malone

Table 3 - Educational pre-conference courses

Pre-conference courses started the meeting on Friday, in advance of the main plenary sessions on Saturday and Sunday. As ever, these popular courses offered great value-for-money and covered a broad range of topics useful for trainees at all levels. We are grateful to the work of the course convenors in organising these, who are listed in Table 3. The pre-conference course day finished with a Welcome Reception in the grand setting of the Marble Hall at Cardiff City Hall. All Royal College of Surgeons Presidents were invited to attend and address delegates informally, and we were delighted that Professor Norman Williams from the Royal College of Surgeons of England (RCSEng) accepted.
Delegates had the opportunity to participate in numerous educational pre-conference courses

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Professor Norman Williams, President of the Royal College of Surgeons of England, chats informally with conference delegates at the welcome drinks reception

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A light-hearted welcome speech was followed by drinks and canapés, and a string-quartet provided a suitably grand accompaniment to the occasion.

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Following a warm welcome from Mr Goldie Khera (Surgical Registrar and ASiT President 2011/2012), Saturday morning saw the start of the main conference, and programme highlights are listed in Table 4.

• Cutting Edge: The science behind your surgical training • Future focus: Robotics and endoluminal surgery • Specialty update: Remote and rural surgery • ASiT Lecture: Surgical Research Collaboratives - the reality • Question Time with Surgical Royal College Presidents • Safe surgical practice: How to keep out of jail! • Applying for surgical training: What factors are important? • Career focus: the surgical trainee at war • ASiT Debate: How can we measure the quality of surgical training? • International Surgical Trainees: The Italian and Swedish experience • Medical Student and Foundation Doctors Parallel Session
Table 4 - Key programmes highlights

title ‘Consultant Surgeon’ by non-medically qualified podiatrists, the European Working Time Directive, and some horizon-gazing regarding future problems in surgical training. The Swann-Morton Silver Scalpel Award session hosted last year’s winner, Mr Gavin Pettigrew (Consultant Transplant Surgeon, Addenbrooke’s Hospital, Cambridge) in a key-note address on his vision of excellence in surgical training. From training, surgical practice then took centre stage with two cutting-edge up-dates. Professor Philip Wai Yan Chiu from the Chinese University of Hong Kong provided an excellent review of advancements in robotics and endoluminal surgery, while Mr Gordon McFarlane from Lerwick in the Shetland Islands discussed the unique practice of the remote and rural surgeon.

Dr Stephanie Brown (Director of Policy, Communications and Marketing at the Medical Protection Society) began with an entertaining and informative talk discussing her experience of representing surgeons involved in complaints and litigation. Details of these cases concentrated the mind and some useful tips were provided. The second talk of the opening session was provided by Alison Cook (Director of Policy and Communications at the Royal College of Surgeons of England) who provided a fascinating insight into the modern world of managing the media and politicians in order to better represent surgery and surgeons. Question time with the Presidents of the Royal Surgical Colleges provided one of the most interactive and inflammatory conference sessions of 2012. Mr David Tolley, the President of the Royal College of Surgeons of Edinburgh, was unfortunately unable to attend and was represented by his Vice-President, leading to some joking from his Fellow President, Mr Ian Anderson from the Glasgow College, as to whether he was brave enough to attend what many would consider to be a lion’s den! Each Royal College representative was invited to start the session with a brief presentation describing their College’s activities, particularly for trainees. There followed a question-and-answer session covering a diverse range of hot topics including the use of the

Professor Philip Wai Yan Chiu from the Chinese University of Hong Kong addressed the conference on recent advancements in robotics and endoluminal surgery

Following lunch and poster presentation judging, the afternoon sessions commenced with two inspirational and motivational speakers. Tori James became the first ever Welsh woman to climb Mount Everest at the age of 25 and starred in the BBC documentary “On Top of the World”. She presented the eye-opening story of her journey, overcoming the obstacles of sponsorship and mother-nature to achieve her goals. An equally enthralling talk from former ASiT Council member Surgeon Lieutenant Commander Catherine Doran (Royal Navy), who provided a detailed account of surgery on the front line in Afghanistan together with the difficulties of providing this in such a challenging environment. The Ansell ASiT Medal oral prize presentation session hosted the highest scoring abstract submissions of the conference, with some excellent reports of high-impact surgical research. Following this, the winner of the 2011 Covidien ASiT Fellowships and the Elsevier Medical Student Elective prize presented their experiences. The afternoon concluded with the ASiT Debate: “How can we measure the quality of surgical training?” Mr Ian Eardley (Chair of the JCST), Mr Raj Aggarwal

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Mr Alan Horgan Consultant Laproscopic Surgeon, Freeman Hospital, Newcastle Mr Bernard Lee Consultant Vascular Surgeon, Belfast City Hospital Mr Sunil Ohri Consultant Adult Cardiac Surgeon, Southampton General Hospital Mr Paul Renwick Consultant Vascular Surgeon, Hull Royal Infirmary Mr Humphrey Scott (2012 winner) Colorectal Surgeon, Ashford and Peter’s NHS Foundation Trust, Chertsey
Table 5 - ASiT Swann-Morton Silver Scalpel Award nominees

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The 2012 prize winner was Mr Humphrey Scott and Dame Hine also presented the ASiT Outstanding Contribution Award to Mr David O’Regan, Consultant Cardiothoracic surgeon in Leeds, founder of the Silver Scalpel Award and Past ASiT President. A memorable evening concluded with a live DJ and dancing into the early hours.

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Mr Andrew Guy Consultant Vascular and General Surgeon, Leighton Hospital, Crewe

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(National Institute of Health Research Clinician Scientist, Imperial College London), Sue Woodward (Chair, Patient Liaison Group, RCSEng) and Mr Ed Fitzgerald (Surgical Registrar and ASiT Past-President) spoke in turn, with an interesting debate following. Saturday evening saw the social highlight of the weekend, with over 200 delegates and guests attending the Charity Gala Dinner Party at the stunning new Royal Welsh College of Music and Drama. The 2012 dinner was held in aid of the Royal Medical Benevolent Fund (RMBF) and their President, Dame Deirdre Hine, was guest of honour. The Charity Gala Dinner raffle raised £1,000 for the RMBF in their 175th anniversary year. Following a drinks reception with magicians and a string quartet, a wonderful Welsh-themed four course dinner with wines was served in the new architect-designed atrium. All nominees for the Swann-Morton Silver Scalpel Award attended as guests and were presented with certificates to recognise their contributions to surgical training; their details are provided in Table 5.

The Royal Welsh College of Music and Drama was a stunning venue for the Charity Gala Dinner Party in aid of the Royal Medical Benevolent Fund

On Sunday morning the Medical Student and Foundation Doctor parallel session continued to draw a crowd of keen junior attendees. This year’s talks covered preparing for a career in surgery, how to write an abstract, and a new surgical careers fair where delegates were able to informally chat with Registrars from all the main surgical specialties who could answer their questions directly. In the main hall Ms Carol Makin, Past-President of the Royal Society of Medicine Section of Coloproctology gave an insightful talk on serendipity in surgery. Other talks addressed the business of healthcare and the science of surgical training, with the ASGBI ASiT Short Paper Session and the SARS ASiT Academic and Research Surgery session seeing the remaining highestscoring abstract authors present their work. This year’s ASiT Lecture was delivered by Professor Dion Morton (School of Cancer Sciences, University of Birmingham) who discussed trainee-led surgical research collaboratives and the future of surgical research. Afternoon sessions continued with an international trainee perspective from the Italian surgical trainee association President, Jessica Montori, and the Swedish trainee association President, Ninos Oussi, followed by UK-specific talks addressing the role of the Joint Committee for Surgical Training (JCST) and the application process for surgical training, with detailed statistics provided by Dr Alison Carr (Senior Clinical Advisor to the Medical Education and Training Programme of the Department of Health). The day concluded with the Elsevier Medical Student Prize oral presentations session, and the announcement of the award winners from the conference weekend. As ever, the Association is indebted to our corporate partners who recognise the importance of supporting the ASiT Conference and investing in a future generation of surgeons. This year saw a considerably larger exhibition with 27 organisations attending. From international charities to multinational companies,

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we were pleased to introduce them to our delegates and thank them for their continued support. The names of sponsors and exhibitors are provided in Table 6. Platinum Corporate Sponsor • Ethicon Gold Corporate Sponsors • Covidien • Medical Protection Society • Ansell Healthcare Europe Silver Corporate Sponsors • Royal College of Surgeons of England • Wesleyan Medical Sickness Other Exhibitors and Sponsors • Africa Health Placements • AOUK • Army Medical Services • BJS Society • BMJ OnExamination • Cochrane Collaboration • Doctors Support Network • Elsevier Publishing • Hodder/Examdoctor • LaproSurge • Laprotrain • Operation Hernia • PasTest • Royal College of Physicians and Surgeons of Glasgow • Royal College of Surgeons of Edinburgh • Royal Medical Benevolent Fund • Royal Society of Medicine • RRSSC Microsurgery • Swann-Morton Ltd • Wesleyan • Wetlab
Table 6 - ASiT Corporate Sponsors and Exhibitors

Feedback from delegates was strongly supportive, with further details and comments provided in Table 7. As a conference organised by trainee surgeons for trainee surgeons, understanding what our colleagues want and need from our conference is vital is meeting their educational needs. Written Feedback “The pre course conferences were excellent and are a key integral reason that I attend. Keep up the good work!” “Overall I think the conference was good and well organised” “I attended the critical skills appraisal course which was excellent. I think the whole conference was run extremely well and will want to attend again” “Very Good. Great for trainees” Laparoscopic skills course: “Great teaching in lectures and good input and feedback during the practicals” “Brilliant course. Interactive. Practical Sessions. Very pleased to have done it.” Foundation Skills in Surgery Course: “I registered for the conference primarily for this course. My goodness it was worth every penny. All the tutors were really helpful, friendly, enthusiastic and objective towards all types of ‘silly’ questions I asked. Thank you so much” Feedback Survey Data Would you recommend an ASiT Conference to a colleague? Yes = 92.7% Would you attend an ASiT Conference in the future? Yes = 88.8% Do you think the ASiT Conference offered good value for money? Yes = 82.8%
Table 7 - ASiT Conference feedback from delegates

Delegates had the opportunity to visit over 27 exhibitors at the conference

Behind the scenes, 12-months of preparation and hard work goes into ensuring the smooth running of such a major event. We are grateful for the administrative support provided by Laura Andrews, Kristina Gloufchev and Harriet Innes over the conference weekend. We also thank the Council of the Association of Surgeons in Training, Cardiff University Medical School student helpers, and all our faculty and speakers for their time and assistance.

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The Council of the Association of Surgeons in Training 2011/2012

The promotional poster for the 2012 ASiT Conference in Cardiff

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ASiT Executive 2011/12 Left to Right - Back row: Jess Johnston, Omair Shariq, Steve Hornby, Jonny Wild, Henry Ferguson, Justice Reilly. Front Row: Rob Davies, Joe Shalhoub, Goldie Khera, James Milburn, Ed Fitzgerald.

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Plans are already well advanced for next conference in April 2013, and we will be announcing details over the summer. Abstract submission and delegate registration will open in the autumn. To be kept up-to-date please subscribe to our email updates via our website www.asit.org, follow us on Twitter @ASiTofficial, and join us on Facebook.

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International Attendees at The ASiT Conference:
1) Philip Wau Yan Chiu, Director of CUHK Jockey Club Minimally Invasive Surgical Skills Center and Professor, Dept of Surgery, The Chinese University of Hong Kong
It is my honor to be invited as faculty to the annual conference of the Association of Surgeons in Training. It was held at the historic city hall of Cardiff. This is my first time to visit Cardiff, and I found that it is a very nice city with a mixture of both urban and historical buildings. In front of my hotel lies the Cardiff castle, an historic castle having originally been built in Roman times. I am amazed by the beautiful architecture of the City Hall of Cardiff where the conference was held.

During the conference, I met numerous energetic and enthusiastic surgical trainees from United Kingdom. I enjoyed speaking to them, especially to answer their questions after I made a presentation on “Robotic and Endoluminal Surgery - the future of surgery”. Indeed I found that surgical trainees from United Kingdom and Hong Kong shared very similar enthusiasm towards training and new development in surgery. I am fascinated especially by the ability of organization from the core members of the Association of Surgeons in Training. I believe without their marvelous effort and ample time of preparation, the conference will not be as successful as it is, with more than 700 delegates attending the major event. I wholeheartedly congratulate the organizing committee for their success, especially to Mr Goldie Khera the president of ASiT 2012 for inviting me to participate in this conference.

Cardiff City Hall

Professor Chiu with the President of ASiT 2011/12 Goldie Khera

Professor Chiu with other members of the faculty of the pre-conference core skills in laparoscopic surgery course

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2) Surgical Training of Tomorrow Requires Global Thinking
Ninos S Oussi, Former President of KIRUB, Stockholm, Sweden

The Swedish Surgical Society (SKF) with its association Swedish Society of Young Surgeons (KIRUB) work for enhancing international relations. One of the goals is to increase exchange with other Surgical Societies such as RCS and ASiT. Increasing possibilities for interacting, exchanging knowledge and maybe also surgeons. With new meetings, exchanging ideas and knowledge we could improve surgical education and provide a better and safer management of patients. Surgeons should play a larger role on the international arena. During the last ASiT Conference in Cardiff, in March 2012, as former president of KIRUB I represented Sweden and had the privilege of giving my view of the future surgical education in Sweden and Europe.

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The ASiT Organizing Committee put a lot of effort and worked immensely to gather several interesting lecturers. Both new and old ideas were discussed during the conference; the EWTD-discussions stole most of the attention. It was also interesting to experience the differences in education within the UK, not so much from lecturers as from speaking with several of the participants from different parts of the country. To conduct a common education in Sweden with a population of approximately 9 million and a total of 7 medical universities should obviously be easier to administer. What reality shows us is of course open for debate. I took the audience via Sweden, to the heart of Africa in Malawi, to Taizhou in East-China and back to Cardiff, Wales. Throughout the lecture I spoke about surgical education; shortening the learning curve and the importance of going from time-based to competencybased education. By utilizing new techniques we can avoid injuring patients during training and in general, during management of surgical patients. With a well-structured, quality-based and controlled education we may offer patients what we call patient-safety management. In addition to traditional education we should utilize new technique, for example 3D and 4D simulator training devices. Limitations are only in our imagination. Or, as Eleanor Roosevelt put it, “The future belongs to those who believe in the beauty of their dreams”. We are, as influential people and doctors, obliged to serve, take part in the general debate and act for the greater good. At the end of the day let us not forget it is people we are dealing with. The process of globalization generates room for progress.

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3) Jessica Montori, Italian Multispecialistic Society of Young Surgeons
Being invited to participate to the ASIT national meeting was a privilege and a honor. In September 2011 at the Surgicon meeting in Goteborg I represented the Italian Multispecialistic Society of Young Surgeons. A session was formed by Mr Goldie Khera that explained the surgical training in the UK; Mr Ninos Oussi bringing the Swedish experience and myself. At the time we were contacted, we were asked by Dr Margareta Berg - the organizer of the congress - to create our own session working together. We spent the summer having meetings on Skype, phone calls and endless emails… but in the end our teamwork was fruitful and the session was very interesting. We worked in harmony and this cooperation brought us something more: friendship and the feeling that we are a part of a larger group and that although we come from different countries and very different systems, we can have similar experiences, problems and goals. When I was invited to be a part of ASIT in Cardiff, bringing the Italian experience in surgical training - I was extremely excited. Being half welsh I was particularly thrilled to participate. The organization was professional and precise. Arriving in Cardiff I was greeted by a splendid sunny weather which is always a pleasure, the lovely hotel was right in the center of the town. That evening a reception was held in an elegant, young and merry atmosphere. The enthusiasm was contagious and I noticed how everyone was participating and enjoying the entertainmentand each other’s company. What better way to begin and get charged for the work ahead?! The town hall was a delightful location, it was great to see how, even if everyone was working hard, there was the extravagant touch of having the statues wearing surgical masks!... this simple but catching idea put us all in a good mood! The subjects treated in the sessions were so interesting, covering the broad aspects of surgery and life as surgeons, attracting a great number of participants. What struck me the most was the interest and curiosity of the colleagues I spoke with: Everyone made me feel comfortable and the sparkle in their eyes gave me faith in our future.

I reckon that exchanging experiences and information and building relationships is at the basis of a successful meeting and I can underline how this was evident at the Cardiff meeting, where I could feel part of the surgical community. ASIT is a steady point for young surgeons in the UK and a model to follow for many other countries. We are all working for a common goal. For me cooperation among different countries is the key to the future; knowing what is working and what isn’t and how things are done in other places can only enrich us. Trying to get the best of different systems can lead us to train the surgeons of tomorrow in a successful and competitive manner not only in our countries but all over the world. On my account I wish to thank everyone involved in the ASIT Cardiff meeting as they made it a memorable experience for me and I hope the relations between our societies can go on for a long time.

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Teaching the Foundations to a Surgical Career: ASIT/BOTA Foundation Skills in Surgery Course
Sayinthen Vivekanantham, Medical Student, Imperial College London
Having stood multiple times at the back of an operating theatre, struggling to see what is going on, an opportunity to further my suturing skills and gain an insight into the practical aspects of surgery would be very worthwhile. The ASiT/BOTA Foundation Skills in Surgery Course was a pre-conference course for the 2012 ASiT Conference based in Cardiff. This course was aimed at medical students and foundation year doctors, intending to give them a solid grounding into basic suturing that will help them both in examinations and in giving them a running start into their clinical practice. The course is now in its fourth year, and has been very popular with students and doctors when run as both pre-conference courses or as part of ASiT’s initiative to run courses and workshops locally across the country. I attended the course on the 23rd March 2012, alongside 20 other medical students and junior doctors from all corners of the UK. The entire day was very structured and began with two lectures from senior doctors. The first lecture highlighted the importance of keeping good medical records, using interactive clinical based discussions. The second focused on equipping us with the appropriate knowledge about different surgical instruments, sutures and drains, and the importance of their practical use within surgery. Following this, the delegates were divided into two groups for practical sessions on generic and orthopaedic surgical skills, allowing us to put techniques into practise with senior doctor mentoring us on a one-to-one basis. The orthopaedic session focused on teaching us how to apply a backslab on patients with a Colles’ fracture, and tips from experts on how to achieve the perfect cast. This session then moved onto demonstrating the principles of internal and external fracture fixation. These procedures, which are rarely seen by medical students, were demonstrated on saw bone models and were explained clearly and in detail; I will keep elements of this teaching with me for time to come. Following lunch, the generic surgical skills session focused on core skills a medical student or junior doctor should have prior to attending theatre or the emergency department procedure room. This included

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initially learning gowning and gloving followed by suturing and knot tying. Having been shown these techniques carefully, we were then given the chance to practise on animal tissue, giving us a realistic feel of what it would be like to suture in a clinical setting. As we became more comfortable with the basic stiches shown, we advanced onto tendon repairs using pigs’ trotters. Despite all these great features of the course, the best feature of this practical session was the near one-toone demonstrator to attendee ratio. Having a tutor individually guide us through the skills allowed us to obtain real-time feedback and have our questions answered as they emerged. Through having a senior surgical trainee guide you through the whole session, they were also able to explore the clinical relevance of different techniques and the rationale behind the different approaches. By the close of the day, everyone was able to participate in both sessions, whilst also having made new friends and gained an insight into a clinical career as a surgeon. The day ended with a lecture about careers in surgery and tips for submitting a competitive application into surgery. Throughout the whole course, it was evident that the demonstrators were all very dedicated, approachable and encouraging. Having decided to pursue a career in surgery, I am confident this course has given me a solid foundation that I am now able to build on further as I progress through my education.

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Understanding Surgical Training in Light of the Health and Social Care Act 2012
Anna Moore, Kate Drysdale, Graham Sleat and Professor Sir Bruce Keogh
1. Introduction
The NHS was founded in 1948 and was designed to deliver the clinical care that was needed free at the point of delivery. However, by the early 21st century, the NHS is not in a good place. Having been iconic, it had not kept up with public expectation. Waiting lists were sometimes longer than 18 months for joint replacements or psychological intervention, rationing was common and by international comparisons the NHS was falling behind other health systems. Clinical and scientific advances, increased specialisation, different professional working patterns and inadequate funding resulted in a health service that was designed in 1948 was no longer fit for purpose. This was brought in to sharp relief by a series of high profile clinical incidents in the 1990s including ranging from excess paediatric cardiac surgical deaths in Bristol to deaths on long waiting lists. In response the Government focussed on doubling the NHS budget over 10 years, reducing waiting lists, building more hospitals and establishing a process for defining good clinical practice through a series of national service frameworks and establishing NICE, ensuring that organisations took clinical quality seriously through embedded clinical governance and introducing a quality regulator, now the Care quality Commission. So by the time Lord Darzi conducted his review for the 60th birthday of the NHS people no longer worried about when they would be treated and the focus shifted towards the quality of treatment. His review concluded that quality should be made the organising principle of the NHS, that there should be a greater focus on clinical leadership and innovation and that patients should be given more say on how their care should be delivered. Importantly, he embedded a definition of ‘quality’ to be used across the entire health system. This had three key elements: health care should be clinically effective, patients and their carers should have a good experience of the care they receive and finally no harm should be done as a result of treatment. This definition was enshrined in law in the Health and Social Care Act 2012 (the Act).

The global economic situation has put a strain on the UK economy meaning that we are no longer able to spend more on the health service each year. The cost of providing healthcare is also rising from increased demand, increased cost of interventions and waste in the system. In order to continue to provide improvements in health care quality, we need to provide the best value care. Value in this context can be described as the relationship between costs and outcomes.

2. Aims of the Act
The government’s response to these challenges was the white paper ‘Liberating the NHS’ and the subsequent Health and Social Care Act 2012. The Act is designed to revolutionise and modernise the way that care is provided, achieving continuously improving health outcomes but without the associated increase in cost that has been characteristic of previous health reforms. In essence, there are 3 key components of the act that will enable it to be brought about:

a) An outcomes focused NHS The paradigm shift
The Act will bring about a paradigm shift away from process targets to measuring the success of the NHS by the outcomes it achieves. This will allow outcomes to become the currency of the NHS. Early attempts to monitor the performance of NHS services led to the development of sets of measures and associated targets. Most of these were measures aimed at performance managing the NHS, using indicators constructed to measure the processes of care, such as the number of interventions conducted or the way services are delivered. There can be unintended consequences when process measures are used and efforts are focused on achieving the target rather than necessarily improving outcomes. The A&E 4 hour wait is an example of this. This target has cut waiting times for many patients in A&E. However unintended consequences have included some patients being ‘unnecessarily’ admitted in order to avoid them ‘breaching’, and patients choosing to go to A&E rather than a GP out of hours service because they know they will be seen promptly.

NHS Outcomes Framework
The NHS Outcomes Framework means that the NHS will now be judged on the outcomes it achieves for patients. These have been developed in the three elements of quality: clinical effectiveness (in the areas of acute, long term conditions and recovery), the patient’s experience of care and, clinical safety. Quality improvement will be supported by Quality Standards, developed by NICE1.

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b) Increased power and responsibility for clinicians
The advent of clinical commissioning with senior clinical roles in each commissioning group and supporting structures such as AHSNs, Senates and Networks gives unprecedented positional authority and accountability to clinical professionals. GPs have been placed at the heart of the new commissioning system and are now responsible for the appropriate spending of £60million of the taxpayers money.

b) NHS Commissioning Board
A new, politically independent NHS Commissioning Board (NHSCB) was launched in October 2012. It will take on many of the responsibilities historically located in the Department of Health. This reduces the negative effect on NHS planning of the short term view created by a party system of government with a limited term of office. The Secretary of State for Health maintains responsibility for the NHS, but he or she will no longer have the power to give directions to the NHS. A document called the Mandate will set goals based on the NHS Outcomes framework for the quality of the service to be provided. The NHSCB will support CCGs to commission care that is tailored to the needs of their local populations. The NHSCB will also be responsible for commissioning primary care, renegotiating the GP contract, setting tariff structures and for specialist commissioning.

c) Meaningful patient involvement
Patients will be supported and encouraged to be more involved in their care and the development of NHS services. Developments in self management and shared decision making will mean patients will become equal partners in the decisions about the nature of the care they receive. Patients will also have the opportunity to exercise choice about where they are cared for. A renewed focus on patients’ experiences will ensure that dignity and respect are at the heart of all care.

4. Impacts on Surgical Training
The changes created by the Act will affect all doctors in the UK. Surgical trainees will see changes in the cases they see, the environments in which they train and the way that quality is assessed.

3. Structural Changes to the NHS
The NHS is not being privatized. There will be no change from access to services being based on need and free at the point of delivery. The improvement to the NHS will be achieved through structural changes to the organisations that commission, regulate and support the health system. The Act makes these changes, which reduce ‘top-down’ management and increase local determination, statutory and irreversible.

a) Involvement in quality measurement
Doctors will be expected to be involved in measurement and quality assessment of the services they work in. It will be important that not only institutions are able to demonstrate that they can improve patient outcomes, but that the doctors in their hospitals understand how their own performance relates to the outcomes the hospitals achieve. This approach has been shown to vastly improve the outcomes for patients through the work done in cardiothoracics and as a result of this success, will be implemented across other specialties2. Other examples where measurement has been demonstrated to lead to improvement are the stroke pathway in London and also the deteriorating patient network; in both the routine measurement of quality, linked to individual teams, has demonstrated reductions in mortality and improved outcomes3. The competition to win contracts to provide care on behalf of a CCG means that hospitals will need to demonstrate they can provide the best quality care, driving the requirement to collect and demonstrate the quality of the services they provide as well as provide an environment which patients find appealing. This increased choice will require fundamental changes to the way that information is made available both to commissioners and patients.

a) Clinical Commissioning Groups (CCGs)
CCGs are made up of groups of GP practices and other professionals, who will be responsible for buying (commissioning) care on behalf of their local communities. Clinicians have an intimate understanding of their patients’ needs and the front line workings of the system. With the right information and support, this places them in the best position to make complex decisions about the provision of health care.

What is commissioning?
This involves an assessment of a population’s health needs, spanning both health and social care. It takes into account social inequalities and the particular needs of the population. Services that will meet these needs are purchased from appropriate providers. Commissioners monitor the quality of the services that are provided. Commissioning was previously done by Primary Care Trusts (PCTs), and although GPs and clinicians were involved, it was usually run by managers.

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b) Changes in case mix
It is likely that patients will be cared for in different settings in the future. All hospitals will not provide all procedures and patients may choose to have care in different place, such as the community and independent sector. While no CCG will be allowed to provide anything less than a comprehensive service, it is probable that the cases most attractive to independent providers will those of a lower complexity and baseline risk. As such it is possible that the traditional setting for surgical training may need to extend to settings outside the traditional NHS providers. It is likely that in order to get the range of clinical and surgical skills, a trainee will be trained in a wider variety of settings.

1. h t t p : / / w w w. n i c e . o r g . u k / a b o u t n i c e / q u a l i t y s t a n d a rd s / qualitystandards.jsp 2. (Everybody Counts: Planning for Patients 2013-14 - http://www. commissioningboard.nhs.uk/files/2012/12/everyonecounts planning.pdf) 3. http://www.rcplondon.ac.uk/projects/stroke-improvement national-audit-programme-sinap 4. http://www.hee.nhs.uk/ 5. www.fmlm.ac.uk 6. http://www.fmlm.ac.uk/clinical-fellow-scheme

References

c) Management of training
Health Education England (HEE) will provide national oversight for workforce planning, education and training4. It will take over the functions of Medical Education England (which covered medicine, dentistry, pharmacy and healthcare science), the allied health professional advisory board and the nursing and midwifery professional advisory board. HEE’s purpose will be to ensure the health workforce has the right skills and is available in the right numbers. HEE is accountable to the Secretary of State. Local Education Training Boards (LETBs) will be regional outposts of HEE. They will be responsible for the local training and education of professionals. NHS employers, education providers and health professionals will work together to plan and commission local education and training. This will enable professional training to be designed and commissioned to meet the needs of institutions and help design and shape a workforce that is able to meet the needs of the evolving NHS.

5. Conclusion
The evolving landscape of new NHS structures provides many opportunities for surgical trainees. The focus on outcomes which will be endemic in the new system is a powerful driver for continuous improvement of patient care. Trainees will need to develop a suite of additional skills as clinical leaders and become familiar with measuring, assessing and explaining outcomes. Through this surgeons can continue to both advocate for, and provide the best care to the populations they serve. Organisations such as the FMLM5 will support clinical leaders and facilitate their skill development. Schemes such as the NHS Medical Director’s Clinical Fellows scheme6 give trainees with an interest in leadership an opportunity to gain experience of how regional or national organisations impact on healthcare.

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Training a Viking Surgeon in the 21st Century Remote and Rural Surgery
Gordon McFarlane ChM FRCS, Consultant Surgeon, Gilbert Bain Hospital, Shetland Islands
Despite increasing urbanisation worldwide, a significant proportion of the world’s population can still be defined as rural. This includes 20% of Canadians, 30% of Australians, and 57% of the population of China; yet rural general surgery remains a largely unrecognised specialty. There are some encouraging signs: the Royal Australasian College of Surgeons has a Rural Surgery section which actively promotes training for rural surgeons; the Association of Rural Surgeons of India meets annually and is in its 18th year; and in Scotland, the first meeting of the Viking Surgeons Club took place in Stornoway in 1974. This latter group was originally set up for mutual support and education of single handed surgeons in the “Viking territories” and included surgeons from Iceland to Penzance, but since then many small units in the UK have closed and none are singlehanded. There are now 6 Rural General Hospitals in Scotland, most with 3 local surgeons. The hospitals are located in Wick, Fort William, and Oban on the Scottish mainland while Lerwick Kirkwall and Stornoway are island based. Gilbert Bain Hospital, Lerwick, Shetland is the northernmost hospital in UK, located 200 miles north of Aberdeen. Transfer by air ambulance (based at Glasgow and Aberdeen) is a minimum of a 4 hour turnaround time and may be much longer depending on weather conditions. There are three local general surgeons, three anaesthetists and three physicians.
Gilbert Bain Hospital, Lerwick, Shetland Islands

Radiology and laboratory services are provided by radiographers and technicians respectively; consultant support is from Aberdeen. A CT scanner was installed five years ago and images are transmitted to Aberdeen for reporting. As well as general surgical emergencies, the surgical unit commonly deals with breast, colorectal and general paediatric surgery urology orthopaedic trauma, upper and lower GI endoscopy, emergency obstetrics and gynaecology and “surgical” A & E including minor ENT and eye trauma. The overall theatre activity for 2010 shared among the three general surgeons is shown in Table 1. Visiting eye, ENT, maxillofacial and paediatric surgeons undertake additional lists. A selection of procedures for the same year from one surgeon’s logbook is given in Table 2. Some of the procedures, such as an anterior resection, may be shared between more than one consultant. In addition, the author undertook two laparoscopic nephrectomies supervised by a visiting urologist from Aberdeen. The obstetric unit is looked after by midwives and general practitioners with advice from Aberdeen; when a patient needs to go to theatre for a caesarean section, retained placenta or post partum haemorrhage, the surgeons is called to undertake the procedure. For the last year, we have also been undertaking elective sections. There have been two emergency craniotomies in the last 8 years. Major Major + TOTAL

General Orthopaedics Urology Obs. & Gynae. Endoscopy Other TOTAL

Minor*

Intermediate

217 13 107 8 392 4 741

115 99 16 447 71 19 0 103 13 21 2 143 3 16 0 27 237 0 0 629 10 1 0 15 449 156 18 1364

Table 1 - Operations by local surgeons in Gilbert Bain Hospital 2010 *Classification based on CIGNA Health Insurance Schedule 2004

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Table 2 - Sample procedures from author’s logbook 2010

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Increasing subspecialisation and centralisation of services into larger units continues to threaten the viability of rural surgical units. But in a white paper from the Scottish Government in 2005, the health service was challenged to provide care that was “local, safe and sustainable”1. The Remote and Rural Workstream report was subsequently published in 2008, emphasising the need for a minimum of three surgeons at each centre; the importance of the whole team to be able to demonstrate appropriate competencies; and the 2 value of networking with larger centres . Major changes in the pattern of service delivery, or further closures, were not options. Peer review, adherence to national standards, and local audit are all important to demonstrate continuing competence. A retrospective study of colorectal cancer cases from Fort William was published in the Scottish Medical Journal in 20113 demonstrating respectable mortality and outcomes. A series of TURP’s from Shetland was presented to the Scottish Urological Society in 2010. Upper and lower GI endoscopies are all undertaken by the surgeons in Shetland with regular audit undertaken and presented locally to fulfil JAG requirements. Since 2006, the Surgical Profiles project in Scotland4 has been using national data such as mortality and length of hospital stay to identify possible problems in outlying units. Earlier reports prompted some audit and changes within the unit and there were no areas of concern for Shetland in the most recent report. Breast and Colorectal cancer performance indicators have been collected for several years now within the North of Scotland Cancer network; Shetland has maintained a timely throughput of cases and satisfactory outcomes. Working within a

Managed Clinical Network, with excellent support from colleagues in Aberdeen, has been essential to achieve this. Cancer cases are discussed by video link to Colorectal, Breast, and Urology MDT’s in Aberdeen, and occasionally to the Upper GI MDT. Neoadjuvant chemoradiotherapy is given to rectal cancer patients in Aberdeen for example, and then the patient returns to Shetland for surgery. Maintaining knowledge and practical skills can be a challenge. Joint operating with a fellow consultant is helpful to share skills and experience. Occasionally a surgeon from Aberdeen may visit to assist with a laparoscopic bowel resection or nephrectomy. The rural surgeon may travel to the referral unit or other hospitals to maintain or upgrade skills; this can be helpful in some areas but in others is of limited use, especially where the surgeon is competing with local trainees! The present author found a two week spell in a theatre in Africa of great value for honing operating skills across most of the surgical subspecialties including subtotal thyroidectomies, burr holes and a craniotomy, caesarean sections, hysterectomies, oesophageal dilatations and intubations for cancer and a lung decortication. With the present regulations and constraints on surgical training, how can an individual train to be a rural general surgeon? Ideally, the career choice should be made fairly early on, so as the final four years as an StR can encompass a year each in breast, upper GI, lower GI and vascular surgery. This latter specialty may now be more difficult to achieve in programme as vascular surgery has now achieved independent status; time in paediatric surgery, thoracic surgery and endocrine surgery may be of value instead.

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Mastectomy & Axillary sample/clearance 6 Division adhesions/small bowel obstruction 4 Hartmann’s Procedure 2 10 Hemicolectomy/Anterior resection Laparoscopic Cholecystectomy 17 11 Hemiarthroplasty hip/DHS Herniorrhaphy (irreducible, child) 1 ORIF (plate and screws ankle, etc) 9 14 Transurethral Resection of Prostate (TURP) Emergency Caesarean section 5 1 Salpingectomy for ectopic (laparoscopic) Evacuation for Retained Products of Conception 1 Colonoscopy 154 89 Upper GI endoscopy Therapeutic OGD (dilatation, PEG tube insertion, bolus obstruction oesophagus) 5

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The North of Scotland Deanery offers a two year post CST programme to widen skills and experience 5 further; competencies have been proposed . A typical programme might involve 6 months urology, 6 months orthopaedic trauma, several months at two different rural surgical units, and time spent in gynaecology, obstetrics, A & E, including minor ENT and eye emergencies, neurosurgery and plastic surgery. A proleptic appointment to a rural consultant post at this stage would facilitate targeted training as not all rural units need such a broad range of skills. Practicing 6 as a general surgeon in UK is still an option . Living in a beautiful part of the world is an added bonus.

References

1. The Scottish Government.Delivering for Health.http://www.scotland. gov.uk/Publications/2005/11/02102635/26356; 2005 2. Remote and Rural Steering Group. Delivering for Remote and Rural Healthcare: The Final Report of the Remote and Rural Workstream. http://www.scotland.gov.uk/Publications/2008/05/ 06084423/0; 2008 3. Grant AJ, Sedgwick DM. Small can be beautiful: 10 years managing colorectal cancer in a rural general hospital. Scott Med J 2011 Feb; 56(1): 26-9 4. Health Improvement Scotland. The Surgical Profiles Project. http://www.indicators.scot.nhs.uk/Surgical_Profiles_2011/Index.htm; 2011 5. Remote and rural training Pathways Group. Remote and Rural Surgical Training. Final Report. http://www.scotland.gov.uk/Resource/ Doc/924/0060540.pdf; 2007. p57-105 6. Grant AJ, Prince S, Walker KG, McKinlay AJ, Sedgwick DM. Rural Surgery: a new specialty? BMJ Careers 2011 Aug 12; 343: d4761

3rd Conference of International Federation of Rural Surgeons combined with the 17th Annual Conference of the Association of Rural Surgeons of India, Rajasthan, 2009

Viking Surgeons Club annual dinner Iceland 2009

Quendale Bay, Shetland

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Silver Scalpel Award Winner 2012: What is a Good Surgical Trainer?
Humphrey Scott Consultant Colorectal Surgeon Ashford & St Peter’s NHS Foundation Trust Chertsey
Introduction
We all recognise that it is incumbent on all surgical trainees to maximise their training opportunities. I have been interested for a long time in the attributes of good surgical trainers, what makes them “good”, what drives them and where their motivation has come from. This article looks at these issues from core and higher trainees’ perspectives, trainers’ perspectives and summarises the attributes of a good surgical trainer. The article also mentions the motivating factors behind a good surgical trainer.

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Over the last decade a transformation in the structure of postgraduate training in surgery has occurred. Deficiencies in training and career progression experienced at the Senior House Officer grade were identified in the Chief Medical Officer’s report, ‘Unfinished Business’1. This report became a key driver for change and in response Health Ministers proposed a radical overhaul of speciality training embodied in 2 the Modernising Medical Careers (MMC) agenda . Implemented in 2007, MMC adopted a philosophy of a transparent and efficient career pathway for junior doctors in speciality training, to produce consultants fit for ascribed national service priorities. An emphasis was placed on high quality, time limited training programmes with structured progression and competency based assessment. In surgical specialities, new unified curricula were developed by the Intercollegiate Surgical Curriculum Project (ISCP) which also housed trainees’ e-portfolios and new tools for assessment. For surgical trainees, the ISCP underpins the values of MMC and offers a comparable design across differing surgical specialities3. Following the systematic failure of the recruitment process to new run through training programmes which were originally endorsed by MMC, the Tooke report was commissioned4. Tooke’s recommendation for a return to core and speciality training programmes in surgery has been adopted, with the ethos of MMC and its accompanying educational tools seemingly embedded in surgical training programmes across Britain.

Perspectives from Core Trainees on Trainer Attributes, MMC and EWTD
We found that the 5 highest scoring trainer attributes for this group were: • enthusiasm • giving feedback • a willingness to set targets for trainees • completing online assessments with trainees • inspirational trainers that motivate trainees Some phrases that illustrate the expectations held by core trainees are: ‘trainers should give positive and constructive criticism without destroying your confidence’. Trainers should be ‘committed and understand the training requirements of ISCP’. Trainers should ‘observe trainees to find out their weaknesses and strengths’. I found it interesting that there was no evidence that Core Trainees felt that EWTD or the changes of MMC had adversely impacted on their training. These Core Trainees recognised that they had performed far fewer cases than their SHO counterparts had, but felt it was the 4 hour wait target, rather than EWTD that was limiting their time in theatre.

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Background

I think the big challenge faced by surgical trainers and trainees in meeting the standards laid out at national level by ISCP, comes in the form of the European Working Time Directive (EWTD). The restrictions currently imposed on useful training hours, which have reduced by approximately 40% of what was available to Calman trainees5 has undoubtedly impacted on the continuity of service delivery and trainee experience, as voiced in virtually every corner of the profession6-9. In this environment trainees have to be sufficiently motivated and able to use online tools and attend courses. While intensive modernisation of the curricula and training framework has occurred, little has been done to provide additional support or resources at the point of delivery. The burden of providing high quality training in the craft of surgery is ultimately devolved to individual Consultant trainers in individual hospitals. In this established modern training landscape, the pivotal role of consultant surgeon is accentuated. I conducted a study with a colleague to identify the expectations that current trainees at different levels of seniority have of their trainers in surgery10. It was interesting to analyse the different perspectives from varying grades of trainee, as well as consultant trainers. This was a qualitative, collaborative inquiry process to identify the expectations of trainees and trainers. We looked at what core and higher trainees wanted from their trainers and what the trainers thought were important attributes for their trainees. I have described the different perspectives and attributes below.

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Perspectives from Higher Speciality Trainees on trainer attributes, MMC and EWTD
The 5 highest scoring trainer attributes identified by speciality trainees were different from the Core Trainees and were: • inspires & motivates trainee • behaves as a role model • leads in difficult situations • patience • ensures trainee performs cases Some key phrases to illustrate the attitudes of specialty trainees are: ‘trainers should provide time and space for someone to develop’. Trainers should ‘be competent to cope with unforeseen events… when something goes wrong’ and ‘have the patience to take you through a case’. Trainers should ‘allow you the freedom to get on with it, but back you up if you need it’. EWTD was mentioned as adversely affecting patient care and on call systems. However the reduction in operative experience encountered by the Higher Speciality Trainees was said to be due to a shift towards consultant-led service delivery rather than EWTD. Time pressure on lists was also cited as affecting Higher Speciality Trainees’ logbooks. The Higher Speciality Trainees acknowledged that improvements in curricula and assessment had been made by the Royal surgical colleges.

Discussion
It is clear that since the introduction of the MMC agenda and the efforts of the Royal Colleges and Deaneries to introduce a structured curriculum, there have been definite improvements in the framework of surgical training. Indirectly trainees have also benefited from the increased practice of outcomes audit to monitor performance in surgical units. As outcomes were scrutinised by patient bodies and national agencies, the importance of consultant led healthcare was highlighted and the need for consultant supervision of operating lists. However EWTD has led to a large decline in training hours and concerns that the current generation of surgeons will not be able to manage complex conditions. In addition the four hour accident and emergency wait target and the need for efficient use of theatre time to meet waiting list targets have potentially reduced theatre exposure for junior trainees and the number of cases that trainees are permitted to undertake. From the discussions I had with the Core Trainees, it was apparent that they appreciated trainers who were role models and certain trainers had already been influential in deciding a career pathway in surgery. Good trainer attributes identified by Core Trainees centred on the themes of communication, leadership and commitment. The Core Trainees wanted trainers that were enthusiastic, communicated effectively and preserved the trainees’ confidence while giving feedback to them. They also gave greater importance to the completion of online assessments than the Higher Speciality Trainees or consultants. In discussions with Core Trainees it was evident that electronic learning and curricula were felt to be integral to modern surgical training. The Higher Speciality Trainees had different priorities on the attributes that trainers should possess. Largely their aims were centred on learning the craft of surgery and thus operative exposure. These more highly trained trainees appeared much more focussed on learning operative skills and thought that good trainers were those who delegated operative cases. It was recognised by this group that patient safety was important and that a good trainer should be in control of the operation at all times. The trainers themselves should have a good rapport, be approachable and appear motivated to train. They should be proficient and accomplished surgeons with good technical transferable skills. They appreciated trainers who were patient enough to take them through cases in theatre and were experienced enough to take control should unforeseen events arise. Hence the overriding theme for the Higher Speciality Trainees was leadership and organisation so that adequate theatre opportunities were created and preserved for them to learn.

Views from Hospital Consultants on ‘What Makes a Good Surgical Trainer?’
Consultant surgical trainers found that the 5 highest scoring attributes identified by consultants were: • the need to engage other trainers • being aware of individual trainee needs • ensuring trainees perform cases • discussing difficult problems sympathetically • patience Some key phrases identified from the interview to illustrate these views are: a good trainer is ‘experienced and confident enough to allow others to do the procedure’ and a good trainer should ‘be able to give continuous and encouraging, honest feedback’. A good trainer should ‘inspire trainees and be available at all times to train’ and a good trainer should be ‘supportive in adverse situations and maintain the trust of the trainee’.

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• the importance of role models to the trainees • the need of their own life-long learning for professional satisfaction • they had altruistic feelings towards the trainees • the need to improve on the experiences which they had experienced in their own training • they recognised the importance of communication skills • they recognised the importance of personal and professional support • they appreciated their lack of need for financial payment or peer recognition • they enjoyed teaching As the Schools of Surgery continue to develop and with the devolvement of education down to Trusts and the implementation of Health Education England and the Local Education Training Boards, I suggest there will be a requirement for particular individual surgeons to dedicate more time and effort to surgical education. I know that it is incumbent on both trainees and trainers to maximise learning opportunities to overcome these difficulties and continue to preserve the strong tradition of teaching in the craft of surgery, so that

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The consultant trainers thought that being committed, approachable and organised was important for trainees. These factors along with good time management skills may reflect the fact that the consultants were aware of time needed to be put aside for all aspects of training, which not only include operative and patient management skills, but also includes time sitting with trainees, deciding goals and completing assessments. I find it interesting that trainees of different levels and trainers have different beliefs and priorities on the attributes a good surgical trainer should possess. Trainers should therefore be flexible and be prepared to adapt to the requirements of the trainee. I would expect the trainees to be wholly committed to the learning process. We have identified national workplace initiatives that appear to be compromising the delivery of training to trainees. EWTD, the change in culture towards service delivery and the 4 hour accident and emergency wait were stated as adversely impacting on trainees’ operative exposure. I have always, since the start of my surgical training, been interested in why certain surgeons appear more engaged in education than others. Indeed, as a consultant, I am aware that there is always the same crowd of surgeons who put their hands up and volunteer when asked to be involved in training exercises. In my MA in clinical education11 I studied a group of these consultants, whom I termed “the usual suspects”. In a grounded, qualitative study I found that the factors that motivated these consultants included:

the future generation of surgeons is as skilled as the current. With greater understanding of the perceptions held by consultants on their role as trainers and trainer attributes sought by trainees, this may be better served. This will enable the surgical profession to continue its pursuit of excellence and through training, the continual improvement of patient care.

References

1. Donaldson L. Unfinished business: proposal for reform of the senior house officer grade. 2002 2. The four UK Health Departments. Modernising Medical Careers: the next steps. 2004 3. UK Joint Committee on Surgical Training. Intercollegiate Surgical Curriculum Programme. 2008 4. Tooke P. Aspiring to excellence: final report of the independent inquiry into modernising medical careers. 2008 5. Galasko CS. Hunter’s legacy and surgical training and competence in the 21st century. Ann R Coll Surg Engl 2005 May; 87(3): W7-24 6. Garvin JT, McLaughlin R, Kerin MJ. A pilot project of European Working Time Directive compliant rosters in a university teaching hospital. Surgeon 2008 Apr; 6(2): 88-93 7. Benes V. The European Working Time Directive and the effects on training of surgical specialists (doctors in training): a position paper of the surgical disciplines of the countries of the EU. Acta Neurochir (Wien) 2006 Nov; 148(11): 1227-1233 8. Mestres CA, Revuelta JM, Yankah AC. The European Working Time Directive: quo vadis? A well-planned and organized assassination of surgery. Eur J Cardiothorac Surg 2006 Oct; 30(4): 571-573 9. Black J. EWTD update and the party conferences. Annals of the Royal College of Surgeons of England (Supplement) 2009 10. PJ Nisar & HJ Scott. Key Attributes of a Modern Surgical Trainer: Perspectives from Consultants and Trainees in the United Kingdom. Journal of Surgical Education 2011: 6; 202-208 11. HJ Scott. Calling the usual suspects; the reasons surgeons become involved in postgraduate education. University of Brighton, 2009

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Trainee-led Research Collaboratives: Pioneers in the New Research Landscape
Original article published by the BMJ group 2012 BMJ Careers 09/08/2012 DC Bartlett, TD Pinkney, K Futaba, L Whisker and G Dowswell on behalf of West Midlands Research Collaborative (WMRC) Adapted with permission by Marriott PJ on behalf of WMRC
With the continuing growth of evidence based medicine, there is a pressing need for surgeons to engage with research. For Specialist Registrars (SpRs) this was institutionalised over the last decade and a half by the need to report experience in research as part of the annual Record In Training Assessment (RITA). Similarly, newer core and speciality trainees’ Annual Review of Competence Progression (ARCP) includes evidence of research activity as a core annual requirement for progression. The extensive literature on training junior doctors is unanimous in relation to the importance of gaining first hand research experience. However, this same literature is often silent on the best means to achieve this. Historically, doctors in training have worked independently on small and often unpublished ad hoc projects. Most surgical trainees experience considerable anxiety, frustration and wasted efforts in relation to research, partly because of the need to rotate every four, six or twelve months. To conduct a high quality study in these short time periods is challenging, particularly if funding and ethical approval are required and especially while delivering patient care and fulfilling clinical training objectives. So are training rotations incompatible with the time needed to complete high quality studies? Is there another way? There has been a growing literature on the ‘science of science’, which has described and explored the ways in which successful projects are delivered. Teamwork is becoming increasingly important not only for research but also for clinical practice. In England, several National Institute for Health Research (NIHR) funding streams have arisen from the longstanding

observation that research needs to be relevant, appropriate and of sufficient quality. At a national Research and Development (R&D) level, the recipe appears to be strongly in favour of engaging clinicians, academics and public/patient involvement in order to ensure the necessary combination of rigour and relevance. The NIHR Research for Patient Benefit (RfPB) programme is a good example of this approach. From a quality perspective, the Medical Research Council has increasingly recognised the need for bigger studies, meaning that teamwork/collaboration is not an option but a necessity to conduct a practice-changing study. To address the difficulty in obtaining high quality research experience and a lack of adequate time in individual posts there has been a recent rapid growth of trainee led research collaboratives. The majority of these have been set up and run by surgical trainees although other specialities are now getting involved. These collaboratives are already proving highly successful and this article will describe what they are, how you can benefit from getting involved and why you need to think hard about joining the party.

How Do Research Collaboratives Work?
At the simplest level, they are networks of interested people who can see the benefits of working together to get research done. Rotating doesn’t hinder but strengthens the model, as once you move to work at another trust you can continue projects already started. The groups act as a filtering mechanism, identifying studies which are likely to be attractive, relevant and deliverable. They also act as a ‘dating agency’ - matching trainees with similar interests with those who have gained greater experience of research and putting both groups in touch with academic support. Research collaboratives quickly build links with local trials units and methodology experts. This is really important for trainees because all Randomised Controlled Trials (RCTs) are run in association with a registered clinical trials unit. These are based in the most research active universities and they are keen to develop strong links with the next generation of researchers, so you are pushing at an open door. There may be more than one trials unit in any locality - for example, in Birmingham, there is a cancer trials unit, a clinical trials unit and a primary care clinical research and trials unit. Each have slightly different expertise and interests, but all have staff who frequently help research collaboratives. Other organisations like the NIHR funded Research Design Service or Protocol Development Services will also help with funding applications.

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What Are You Likely to Gain? (see Figure 1)

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The reality is that even in a collaborative, there is still a lot of blood, sweat and tears which are needed to successfully complete a research project. However, the benefits of working together and the sense of achievement more than make up for this. The English and Welsh research landscape has seen several research collaboratives appear in a very short time period. This means that you may be able to find one in your geographical area.

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Figure 1 - What have you got to lose? Figure  1

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Research can be lonely - you get an instant network of people to work with. You may be able to join an existing study if it is of interest to you and the senior clinicians wherever you are working at the time. Research collaboratives save everyone time - you don’t have to engage with every part of the research process yourself, unless you are the lead researcher. This means that someone else will have designed the case report forms, got ethics approval, or R&D clearance, or found a local PI, or written the statistical analysis plan. Research collaboratives also act as a strong motivation to get things done - if you are working on your own project, you might put things off for a week or two, but if 30 people are waiting for you to do whatever you promised, this means you all get more done, and more quickly. Working with others gives you a ‘collective momentum’. This will lead you to gaining faster and better publications for your portfolio and CV. Anyone who identifies, recruits or consents trial participants, or gathers data for a study can be added to the list of study co-authors. This means that studies can be published ‘on behalf of the collaborative’ and all contributors will be PubMed searchable as members of that study group. You can put it on your CV and people can see precisely what you have contributed to the study. Team work and management experience in a research setting is a big plus on the CV for trainees.

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Examples of Research Collaboratives
See http://www.asit.org/resources/collaboratives for further details West Midlands Research Collaborative www.wmresearch.org.uk Mersey Research Group for General Surgery www.merseysurgery.com London Surgical Research Group www.lsrg.co.uk South Peninsular Audit and Research Collaborative for Surgeons www.sparcs.org.uk Welsh Barbers Research Group www.welshbarbers.org East Midlands Surgical Academic Network www.emsan.org.uk

DREAMS Trial - The second trainee-led multicentre RCT from the WMRC in association with the Birmingham Clinical Trials Unit is investigating the effect of preoperative single dose intravenous dexamethasone on postoperative nausea and vomiting in patients undergoing GI surgery. We have so far opened 23 sites and recruited 361patients on our way to a total of 950 (to date 172 patients ahead of schedule).

National Multicentre appendicectomy cohort study - This exciting National Collaborative
venture has been completed and involved all of the surgical research collaboratives across the UK. A concurrent prospective audit of appendicectomy operations over a set two-month period was undertaken. The final dataset included over 3300 patients from 95 centres, 89 of which were from the UK and the remainder from abroad (including New Zealand and Hong Kong). The data shows wide variation in practice and the need for further high quality trials to guide clinical practice.

How to Get Involved
Most research collaboratives meet regularly. Contact the secretary via the research collaborative websites and ask for details of the next meeting (agenda, minutes, time and place) or view the meeting details on the website directly. When you attend, get there a little early and begin the process of meeting other interested trainees. It’s probably best not to rush in and propose new ideas or projects until you have found out what is currently happening and what is going well or running into difficulties. Find out from the web, members or officers of the research collaborative what trials or epidemiological studies are currently proposed, recruiting or in need of completion. Think hard about how you can contribute to the existing portfolio of the research collaborative before coming up with anything new. Three studies currently being managed by the West Midlands Research Collaborative (WMRC) to illustrate what can be achieved:

Conclusions
Collaboratives provide a framework for support but still have to attract motivated individuals who buy into shared enterprise and collective learning. Collaboratives have to tap into local support and expertise in order to function properly. High quality publications from large scale multi-centre trials, cohort studies and database mining exercises can be delivered while building research capacity and giving members a taste of research success. Involvement in collaboratives also teaches collaboration, peer review, accountability, responsibility and teamwork. Success leads to success - there is big potential for regional, national and international ventures based on this model. Stay out of collaboratives at your peril you will be left behind by people taking the collective way to research success.

ROSSINI Trial - This was the first trainee-led
multicentre RCT to be run by the WMRC. A total of 769 patients undergoing a laparotomy were randomised to either use of a wound-edge protection device (WEPD) or standard care (no WEPD). Twenty-one hospitals participated and recruitment was completed over 2 months early in January 2012. The paper has been submitted to The Lancet.

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Making the Most out of the Foundation Programme; Encouraging the Next Generation
Pranav H Patel, ST3 General Surgical Registrar, East Midlands South Deanery and Rajesh Aggarwal, NIHR Clinician Scientist, Department of Surgery, Imperial College London; Instructor in Gastrointestinal Surgery, Department of Surgery, University of Pennsylvania
Introduction
The popularity of surgery amongst undergraduates is historically high. There has been a conformational change in the format of surgical training over the past 10 years. In order to secure a training post in such a competitive discipline, an individual must constantly maximise all opportunities throughout their early training.

Type of Validation
Medical Expert

Undergraduate Training Contact basic science tutors - undertake projects

Foundation Training Observe surgical discipline, practice surgical techniques in skills lab Build strong relationships with educational and clinical supervisors. Undertake projects/audits Create, co-ordinate and conduct teaching programmes for peers or undergraduates at local and regional level Remain up to date with current surgical research and practice, subscribe to journal, i.e. BJS Note fallacies in local clinical practice, suggest improvement by novel pathways or audits

Core Surgical Training Decide on final sub-speciality of interest. Undertake relevant course, ie ATLS, CCrISP, BSS, AO Develop strategies for good team management, include juniors in projects. Observe good professional qualities in senior role models Apply as deanery training advocate Collaborate with regional and national trainees on projects and training surveys Focus academic work on scientific and review articles rather than case reports Become involved with local/national management panels to outline novel protocols or pathways

Professional and Manager

Attend surgical ward rounds, clinics, theatre sessions. Observe Master-apprentice model Engage with surgical trainees to gain first hand experiences of what career entails Undertake Audits Complete a intercalated BSc, undertake a clinical or laboratory project Explore conversion of BSc to MSc or PhD

Scholar

Health Advocate

Figure 1 - CanMEDS framework produced and approved in 1996 by the Royal College of Physicians and Surgeons of Canada

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The structure of surgical trainee appointment has changed on three occasions following the introduction of the Modernising Medical Careers (MMC) programme1. An aspiring surgeon must not only remain up-to-date with the processes, but constantly evolve their clinical and academic profile to remain competitive. The modern trainee must aim to decide on sub-speciality interest during undergraduate training in order to structure their development from the earliest point. There are various frameworks that describe methods for developing oneself in medicine. The CanMEDS physician competency framework was established by the Royal College of Physicians and Surgeons of Canada2. It outlines the knowledge, skills and abilities a physician requires for better patient outcomes. The framework is based on seven roles that all physicians need to have, to be better doctors: Medical Expert, Communicator, Collaborator, Manager, Health Advocate, Scholar and Professional (Figure 1). These roles describe a template that can be used to excel throughout undergraduate, foundation and core surgical training. Simulation-based medical education and clinical training has gained increasing prominence over recent years. It is of importance to any trainee in medical education, therefore it must always be a focus in ones development and training. It enables knowledge, skills and attitudes to be acquired in a safe and structured educational format. Procedure based skills, communication, leadership and team working can be learnt, be measured and used as a mode of certification to become an independent practitioner3.

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Undergraduate Training
United Kingdom medical undergraduate training has traditionally been divided into a pre-clinical and clinical phases. It is vital to optimise both aspects to develop the basic knowledge to build ones medical expertise. The pre-clinical phase involves didactic basic science teaching, supplemented by clinical tutorials and lab experiments. The latter clinical phase consists of long and short duration speciality placements in medicine, surgery and designated specialities such as paediatrics or obstetrics and gynaecology. The majority of UK medical schools will provide a ranking process to select clinical placements in undergraduate training.

Communicator
Within the clinical phase of undergraduate training, the constant interaction with junior and senior trainees in surgery provides a further opportunity to become involved with clinical based academic pursuits. It is feasible to enquire and become involved in audit and basic research projects, which may flourish into presentable or published work. Furthermore, an early encounter of clinical audit will develop ones professionalism by showing a commitment to improving patient care.

Scholar
A majority of undergraduate University medical degrees intercalate a Bachelor of Science (BSc) degree. In some cases, it is optional or not offered unless requested. The CanMEDS model places emphasis on one role of a doctor as being a scholar. As scholars, a physician must demonstrate a lifelong commitment to reflection, dissemination, application and translation of medical knowledge. Therefore, it is incumbent on a trainee to undertake a formalised research project within the BSc arena. This will further develop basic understanding of laboratory based or clinical medical and ideally surgical research.

Medical Expert
The exposure to clinical medicine is limited; however the interaction with clinical medical professionals remains consistent. This part of training is a good opportunity to meet and discuss potential specialities of interest like surgery. Through questioning surgeons about the clinical application of basic science, you may assimilate whether a surgical career is suited to your personality. Undergraduates are commonly assigned to basic science tutors, who will have research projects in allied fields to medicine. It is important to explore and understand the significance of laboratory based research at an early stage, as it may be translated into clinical practice during training.

Health Advocate
During BSc research projects a number of universities provide the option of conversion to MSc or PhD degrees at an undergraduate level. These projects may provide access to major research projects or collaborations, which impact on clinical application of surgery. If such higher degrees are offered, serious consideration must be made if the project appeals to ones speciality interest.

Professional and Manager
Undergraduate clinical training provides an excellent opportunity to sample preferred specialities as well as explore those not immediately to mind. These years enable a medical student to experience the varied aspects of the surgical discipline, including ward rounds, theatre, out-patients clinics and management including audit. The exposure to the traditional ‘masterapprenticeship’ model described by Halsted remains commonplace in surgery4. It is vital to observe and understand this model as a universal teaching tool used by the majority of surgeons to train juniors.

Simulation Training
Undergraduate training lends itself to simulated patient encounters, current UK medical school curricula incorporate early training for students in history taking and physical examination. It is crucial to take full advantage of simulated experiences for the development of one’s knowledge and personal style. Patient based simulations are now a major part of end of year assessments. The standard format is the Objective Structured Clinical Examination (OSCE) with the use of lay individuals simulating medical conditions5. The modern undergraduate must become proficient at this mode of assessment as it becomes widespread in professional examinations such as the Membership of the Royal College of Surgeons (MRCS). Undergraduate medical training remains a fantastic opportunity to expand horizons and develop close relationships with surgical clinicians, it must not be wasted.

Collaborator
The format of surgical training, as well as appointment, has changed from a ‘pull-up’ to a ‘push-through’ system. It is becoming increasingly important to collaborate with clinicians in surgery to decide on the speciality of interest as early as possible. Therefore, it is highly advantageous to have committed to a surgical career by the completion of undergraduate training. In fact, if an individual is motivated and organised during the clinical phase of medical training they can tailor their placements to explore and determine a chosen speciality or shortlist.

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Limbs & Things learning online

M AST ER T H E SKILLS O F KNO T T YING AND SUT URING
Course Editor and Contributing Author

SutureTutor Plus
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Foundation Training
Foundation Training is divided into Year 1 and 2 (FY1 and FY2), with a competency-based training curriculum. This format has replaced the traditional pre-registration House Officer and Senior House Officer roles although the latter title is still in common usage. The application for core surgical training is completed and secured during FY2. It is important to be vigilant of the application timetable in order to have a robust clinical and academic profile.

Supervisor, with a Clinical Supervisor for each placement in FY1. It is important to consider the number of consultant supervisors available to provide development opportunities. In a typical FY1 year, three four-month placements are completed with potentially one educational and 3 clinical supervisors. Developing a habit for regular review and appraisal is an important part of clinical training, it also enables an individual to meet supervisors and discuss opportunities for advancing clinical and academic profiles.

Medical Expert
Surgical skills opportunities in theatre may be limited at foundation level as a result of major cases and seniority of other trainees. Learning in theatre is generally observational, a junior trainee must attend all available theatre sessions to not only observe the steps for a given procedure but also management strategies for surgical patients. The majority of hospitals will have a surgical skills lab provision. This may be easily accessed for a foundation doctor with a surgical interest. Making early contact with the surgical skills tutor will enable regular sessions and progressive skills acquisition.

Collaborator and Communicator
Learning is a major part of medical development, imparting learning on others progresses communication and collaboration skills. There are many opportunities to formulate teaching programmes for undergraduates and peers in other specialities. Collaboration is the key to developing a successful teaching programme. Co-ordinating with a local hospital medical education centre by focussing the surgical requirement of an undergraduate curriculum will make teaching current and interesting for students. Teaching has multiple modalities including didactic lecture-based, problembased, bedside clinical and practical skills. Consider incorporation of a variety of these modalities to make a programme novel and current.

Professional and Manager
FY1 is completed under the auspices of a supervising consultant, known as the assigned Educational

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Scholar
During foundation training it is vital to research the surgical discipline as well as remain up to date with current practice. Reading research articles and papers in major surgical journals is good practice for all clinical professionals. Examples include the British Journal of Surgery and the Annals of the Royal College of Surgeons of England. The majority of UK hospital libraries will backlist major journals for professional access.

Medical Expert
The major advancement of surgical knowledge begins at CST. The first years focus is to determine the subspeciality of interest between General Surgery, Trauma and Orthopaedics, Ear Nose and Throat (ENT) and Urology. Once decided, it is vital to develop expertise in the discipline of choice. The focus is development knowledge, clinical acumen and surgical skills.The ability to manage an acutely unwell surgical patient takes precedence. This may be an acute admission, a trauma patient or a patient deteriorating post-operatively. This is best accomplished by omnipresence on the surgical wards and emergency admission departments. Knowledge is supplemented practically by undertaking the ATLS and Care of the Critically Ill Surgical Patient (CCrISP) courses. These courses are now mandatory at CST level and a pre-requisite for entering Year 2 of training. They are nationally over-subscribed, therefore undertake early, preferably in FY2. The development of excellent basic surgical skills is of utmost importance to every surgeons training. The Royal College BSS course is mandatory and teaches basic techniques. A surgical trainee must apply these gold standard techniques to all operative work. It is crucial to master simple techniques such as knot tying and wound closure before progressing to other areas.

Health Advocate
Clinical audit projects will be easily available at Foundation level, offer to undertake departmental audits and aim to complete the audit cycle to gain most benefit for oneself and patients. By remaining vigilant in daily clinical practice, it is possible to outline areas for improvement at clinical and management level. Suggesting audit projects to seniors and supervisors shows a willingness to improve service and enhance patient experience.

Simulation
The foundation curriculum incorporates simulation training as part of year 1 and 2. There is direct exposure to a high fidelity simulated patient model. Typical models are ‘SimMan,’ which react to interventions according to pre-programmed algorithms. Scenarios are run with supervising clinicians to assess response to common medical emergencies. Simulation scenarios are commonly incorporated within surgical courses such as Advanced Trauma Life Support (ATLS). Clinical skills simulation on animal models is the mainstay of Basic Surgical Skills (BSS) courses. Practicing surgical techniques on simulated tissues allows a trainee to practice skills such as ‘suturing’ prior to use on patients. Undertaking such courses show an early commitment to speciality and interest to develop oneself in modern surgical training.

Professional and Manager
There are a wealth of responsibilities attributed to the CST level; clinical training is both patient and team management.There is pastoral care required to develop a good surgical team. Involvement of juniors with projects such as audit or data collection engenders greater teamwork. Consider how patient care and experience can be improved, suggest change to protocols and then commence audits. It is important to note what makes a good surgical professional, observe both consultants and senior trainees to incorporate demonstrable qualities such as leadership, balancing patient expectation and decisiveness into your professional development.

Core Surgical Training
Core Surgical Training (CST) is composed of a further two years of basic speciality training. There is an established structure consisting of Year 1 with 3 subspeciality placements of 4 months or 2 placements of 6 months and a Year 2 with 2 placements of 6 months. This is the first competitive appointment stage in the process of surgical training. The curriculum for surgical training is set by the Joint Committee for Surgical Training (JCST) and implemented with an online portfolio known as the Intercollegiate Surgical Curriculum Programme (ISCP)6. Pre-existing knowledge of this structure is crucial for surgical trainees preparing for speciality surgical training at registrar or ST3 level.

Collaborator and Communicator
It is important to secure a surgical mentor during CST, a trusted a senior will provide consistent, reliable feedback on progress and outline future direction required. There are a pool of CST trainees in all deaneries, collaborate on projects regarding training and practical issues across hospitals. Such projects may be presented and published at deanery prize sessions or conferences. Each deanery has a trainee advisor, usually a current CST, who is responsible for training needs. Securing such a post would expose a trainee to the Dean and directors of training, improving ones stature.

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Scholar
Continuing academic work and projects is vital at CST stage. Focus on writing research articles such as scientific papers and review articles rather than case reports. The former are more reputed at ST3 application. Inform seniors of interest in academia; submit audits as abstracts to relevant surgical conferences. It takes practice to write a good paper or abstract, do not falter at rejection.

Health Advocate
Changing health strategies involves input at management level. Apply and offer observer status on local management panels. Offer to undertake local projects or audits on current protocols and patient pathways in surgery Suggest areas for change and once experienced, apply for a position on the panel. Further bolstering of management skills may be achieved by undertaking local or national courses.

Simulation
As an established core surgical trainee, it is imperative to make simulation a major aspect of personal and clinical development. This phase of training lends itself well to technical development, it is important to undertake courses such as Basic Laparoscopic Skills early in training. These taught skills may be further developed on laparoscopic simulators to develop competencies according to the ISCP curricula. A number of randomised trials have demonstrated that simulation based training leads to a more effective performance in laparoscopic skills7,8. Modern trainees must use clinical simulators regularly to advance basic skills and transcend their learning curves from novice to early intermediate in a controlled pre-patient arena.

Let us help you prepare for your MRCS and FRCS exams with our peer reviewed, exam format questions that are pitched to mirror the level of difficulty you will encounter in the actual exam. Choose how you want to revise, including: Group Learning – Quiz format revision tool AdaptForMeTM – Questions pitched to improve your learning faster Work Smart – Work by curriculum area to focus your efforts New - Revison App – Download it now for free at iTunes or Google Play and revise with or without an internet connection MRCS Part A Papers 1 and 2: 1900 SBAs, 1,750 EMQs & 200 MCQs FRCS General Surgery - ISB Section 1 Exam: over 1,000 SBA and EMQ Questions FRCS Trauma & Orthopaedic Surgery - ISB Section 1 Exam: 100’s of EMI & SBA Questions Try our FREE sample questions online today.

Conclusion
This article highlights the areas of focus to successfully develop a surgical portfolio. The CanMEDS framework provides the basic template for this. However, this structure may be applied to all aspects of medical life; by focussing on the examples outlined above an individual can tailor their development to be the best candidate for higher training.

References

1. Modernising Medical Careers - Medically - and dentally-qualified academic staff: Recommendations for training the researchers and educators of the future training: http://www.nihrtcc.nhs.uk/intetacatrain/copy_of_Medically_ and_Dentally-qualified_Academic_Staff_Report 2. Frank JR, Jabbour M, et al. CanMEDS 2005 framework. Eds. Report of the CanMEDS Phase IV. Working Groups. Ottawa: The Royal College of Physicians and Surgeons of Canada. March, 2005

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3. Aggarwal R, Mytton OT, Derbrew M, et al. Training and simulation for patient safety. Qual Saf Health Care 2010; 19: i34-i43 doi: 10.1136/qshc.2009.038562 4. Halsted WS. The training of the surgeon. Bull Johns Hopkins Hosp 1904;15: 267e75 5. Harden RM, Gleeson FA. Assessment of clinical competence using an objective structured clinical examination (OSCE). Med Educ 1979; 13: 41e54 6. Joint Committee of Surgical Training Surgical Curriculum 2001: http://www.jcst.org/publications/Curriculum/pdfs/general_ surgery_curriculum.pdf 7. Aggarwal R, Ward J, Balasundaram I, et al. Proving the effectiveness of virtual reality simulation for training in laparoscopic surgery. Ann Surg 2007 Nov; 246(5): 771-9 8. Seymour NE, Gallagher AG, Roman SA, et al. Virtual reality training improves operating room performance: results of a randomised, double-blinded study. Ann Surg 2002 Oct; 236(4): 458-63

How to Stay Out of Jail
Gareth Gillespie, Publications Manager, Medical Protection Society
As a doctor, the level of scrutiny laid against your practice has never been higher. Years ago, if something went wrong in clinical practice you could face a complaint; there was the less likely chance of receiving a clinical negligence claim; and then there was the very remote possibility of a GMC investigation. These days all of the above are on the rise: doctors are facing multiple jeopardy. Clinical negligence claims in NHS hospitals are rising year on year, and surgery is the most common specialty giving rise to such claims. The main causes of claims are incorrect treatment, and a failure to diagnose or delay in diagnosis - these have occurred in nearly 30% of cases, according to most recent figures. Complaints to the GMC, meanwhile, are also increasing each year. New figures released in The State of Medical Education and Practice in the UK Report: 2012 showed that surgeons were the subject of 11% of all complaints received in 2011. This was the second most commonlyrepresented specialty in the figures, behind GPs. The new figures released by the GMC also show that one in 64 doctors on the medical register are under investigation - with such causes including investigations and treatment, probity, lack of respect for patients and poor communication skills. So what can be done? At MPS, a large part of our risk management work centres on helping doctors to help themselves. This principally focuses on communication skills - particularly as a well-referenced study by Beckman found that 70% of litigation is related to poor communication following an adverse event1. Patients are more likely to sue if they feel deserted, that they have not been treated with respect, or that they have not been given the right type, quality or quantity of information. MPS’s decision to focus on issues relating to communication is somewhat justified by the figures in The State of Medical Education and Practice in the UK Report: 2012, which showed that in 2011 there was an increase of 69% in the number of allegations investigated about effective communication. Allegations about respect for patients rose 45%. The GMC put these increases down to higher patient expectations and the changing dynamic of the doctor-patient relationship - that greater equality in today’s society has led to patients feeling they can demand more from all professionals.

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Malcolm Gladwell’s book Blink, which used research from psychology and behavioural economics to focus on the adaptive unconscious, looked in part at medical malpractice in the US and suggested why patients sued some doctors: “It’s how they were treated, on a personal level, by their doctor. What comes up again and again in malpractice cases is that patients say they were rushed or ignored or treated poorly. ‘People just don’t sue doctors they like,’ is how Alice Burkin, a leading medical malpractice lawyer, puts it. ‘In all the years I’ve been in this business, I’ve never had a potential client walk in and say, ‘I really like this doctor, and I feel terrible about doing it, but I want to sue him’.” 2 All this ties in with MPS’s own experience. Of the cases where we assist our members with a complaint, communication with patients and the attitudes of staff are in the top four causes. Patients are generally not clinically competent and so their only reliable means of establishing an opinion of their doctor is by way of their interpersonal skills. If they feel that these skills are poor, they will infer that a doctor’s clinical skills are poor too. Adverse events happen in the best of hands. High quality patient-centred communication has a serious impact on a patient’s decision to complain or claim against you. A big part of improving communication with patients is being open following an adverse event: offering an apology and a full, detailed explanation of what went wrong is often all a patient wants - to understand what happened and why. This was harrowingly illustrated by the high-profile case of Bethany Bowen, which involved a surgeon using surgical equipment he was not adequately trained to operate. Bethany was five when she underwent a procedure to remove her spleen. The operation was performed using a morcellator, which was for the hospital a new piece of equipment - but the decision to use it was taken without the knowledge or consent of Bethany’s parents. The procedure went wrong and Bethany died. Bethany’s mother Clare has spoken publicly about her desire to see the tragedy used to educate doctors. Aside from the obvious shortcomings in the consent process and the competency of the surgeon involved, the case was marked by Mrs Bowen’s struggle to find out the truth of what went wrong. She has described the battle to get an explanation, and her discovery that key materials from the surgery had been disposed of, making it difficult to properly investigate the incident. In addition, the documentation surrounding the events was scanty. Mrs Bowen said that all she required what she had been fighting for all along - was information and an apology.

Remembering the human factor following an adverse event can be viewed as a method of avoiding being sued, but it is much more than that - it is morally and ethically the right thing to do.The GMC’s Good Medical Practice says, in paragraphs 30 and 31: “You should offer an apology and explain fully and promptly to the patient what has happened, and the likely short-term and long-term effects. Patients who complain about the care or treatment they have received have a right to expect a prompt, open, constructive and honest response including an explanation and, if appropriate, an apology.” Too often this does not happen, due to fear of recrimination. When, in fact, being honest and open may just be the thing that keeps you out of jail - and, more importantly, helps to restore patients’ trust in those responsible for their care.

1. Beckman HB, et al. The doctor-patient relationship and malpractice: Lessons from plaintiff depositions. Arch Int Med 1994; 154:1365-70 2. Gladwell M. Blink. Penguin (2006)

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ASiT/British Journal of Surgery Training Bursary Winners 2012/13:
1) Annabelle Williams, Core Trainee Year 2, London Deanery
In January 2012, after writing an application with a letter of support from my educational supervisor, I was awarded an ASiT/BJS training bursary. This helped me fund a place on the Royal College of Surgeon’s Specialist Registrar Skills in General Surgery course. Since I am avidly perusing a career in general surgery, with a view to sub specialising in Upper GI or Colorectal surgery, I felt this course would be a valuable educational experience. I was conscious of a need to consolidate the operative knowledge and skills I had gained so far in my Core Surgical Training prior to taking on the role of the surgical registrar. It seemed the next logical step in my career development and progression, building on a foundation of my clinical experience and knowledge from previous courses such as Basic Surgical Skills. Pre-course material includes an informative booklet and DVD, which allows for candidate preparation. The course content is divided up over 4 days. The first two days concentrate on bowel anastomosis - end to end, Bilroth I gastrectomy, oesophago-Roux Loops at depth, stapled side to side to name a few. The third day focused on vascular suturing techniques, and anastomoses - end to side and inlay reconstructions with dacron grafts for example. Finally, the fourth day focused on developing core laparoscopic skills and practicing them while performing a laparoscopic cholecystectomy. All the days followed the format of watching a video demonstration of a particular technique and then having the opportunity to practice the skill in pairs. The course is very hands-on and the faculty are available to help, advise and critique performances in an educational way on an individual basis as the faculty to candidate ratio is very small. There was also opportunity for discussions of alternative techniques and useful ‘handy hints’ during the practicals as well as during the breaks. By the end of the first day each candidate had completed 5 hand sewn anastomoses. This pace continued for the entirety of the course which made for an intensive but very rewarding four days.

The course is run at a number of hospitals nationwide as well as at the Royal College itself. I attended the course at Walsall Manor Hospital which provided an instructive and supportive environment in which to practice and hone essential operating skills under the experienced eye of expert tutelage in a well resourced wet skills laboratory. Excellent catering and an enjoyable course dinner were very pleasant added bonuses. It is an expensive course to attend but one that is very worthwhile and good value for money. This course provided the opportunity to learn, develop and practice the most commonly required skills needed by a general surgical registrar. It provides an excellent basis in bowel anastomosis, vascular anastomosis and the essential principles and skills needed for laparoscopic surgery. I can highly recommended this course for those in the latter stages of Core Surgical Training in order to aid the preparation required before assuming the increased responsibility a general surgical registrar role entails.

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2) Ashok Kar, Core Surgical Trainee, London Postgraduate School of Surgery
I used my award to attend the Royal College of Surgeons, England, “Bypass, Balloon Pumps and Circulatory Support” course on 20th June 2012, at the end of my CT1 year. This was part of my ongoing professional development during core training, with a desire to build on longstanding interests in cardiothoracic surgery. Specifically as one of the key operative steps to most cardiac surgical operations involves utilising a cardiopulmonary bypass (CPB) circuit, I felt it imperative to consolidate my learning on this technically challenging procedure. The course itself is run annually at the college. It had very clear, achievable objectives and the faculty were all approachable throughout the day and keen to impart their knowledge. The mix of small group practical workshops alongside formal lectures worked |well, and we were provided with a useful course booklet for reference. I particularly enjoyed the interactive computer based scenarios, led by a faculty member in small groups. These were designed to take us through common trouble-shooting procedures that must be considered when there are difficulties in establishing CPB, and help develop our judgement and decision-making skills. Learning how to communicate with the perfusionists was also invaluable and has made it easier for me to follow the constant dialogue in the operating theatre between surgeon, anaesthetist and perfusionist, often at crucial times during a procedure. An important point to note is that the course does not take participants through the specific technical aspects of setting a patient up on CPB e.g. how to place pursue strings for aortic cannulation, but rather the principles of what must be thought through at each stage. Indeed, since attending the course, I have gained confidence in both assisting put patients onto CPB and also when coming off because of the opportunity to reinforce my theoretical knowledge during the course. Now in my CT2 rotation, I am able to concentrate more on learning the demanding technical skills necessary to place a patient on CPB, while still following the discussions taking place around me to ensure that the procedure goes on smoothly.

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I should mention the course also had an interesting session after lunch going through the various different circulatory support devices available such as Ventricular assist devices and Extracorporeal Membrane Oxygenation systems. It was great to be shown actual models and given the time to appreciate of how these complex machines had evolved from earlier attempts to the intricate total artificial hearts available today. Finally I also enjoyed the skills station at the end of the day where we able to practice insertion and maintenance of intra-aortic balloon pumps. Overall I believe that this is an excellent course to attend for SHOs interested in cardiac surgery and certainly has enhanced my understanding of the steps involved in establishing CPB along with other support measures available in the intensive care setting. I feel it has complemented my learning in the operating theatre and made me more comfortable with this challenging subject area as I prepare to move towards higher surgical training.

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ASiT Tavelling Bursary Winners 2012/13:
1) ASiT/Covidien Travelling Fellowship 2012 Report Geoffrey Roberts, St Francis Hospital, Katete, Zambia
Introduction
My wife and I arrived in Katete, Zambia, late on a Friday evening in August, to be met by a message from the senior surgeon to meet him for rounds at 0730 the next day and the mess steward who had no idea we were coming. This very much set the tone for the adventure of the following six months!

despite being classified as a district hospital, receives referrals from all over the province. Patients self-refer from all over the country, travelling up to 500km or more. The hospital has 350 beds, but frequently more in-patients, admits between 20 and 40 patients per day and performs more than 100 operations per week.

Work
The surgical department consists of two wards, each with between 40 and 50 inpatients. The team varies, at the quietest being only the Prof and me, but sometimes with several licentiates and a Zambian trainee. Elective operating is on Mondays, Wednesdays and Fridays, with two theatres and a total of twenty cases per day. Clinics are on Tuesdays and Thursdays and emergencies are admitted by the clinical officers 24 hours a day. The patient mix is best described as anything that could not be referred (the main hospital in Lusaka is an expensive 8 hour bus journey away). At any one time, we could be caring for several abdominal catastrophes at various stages of recovery, a number of open fractures, several burns, several limb amputations, one or two paediatric cases (abdominal tumours, hernias or congenital malformations) and any number patients with fractures, complex wounds, urinary obstruction or major head injuries. Rarer pathologies include advanced soft tissue tumours, skin cancers, necrotising infections and peripheral vascular disease. The day starts with rounds at 0730, then clinic or surgery until 1700 and an evening round of sick patients and acute admissions, then any emergency surgery. In an average week I operate on 40 patients, see 60 or 70 in clinic and perform a round on at least six days. The work is unrelenting and exhausting but largely rewarding. The opportunity to operate and be trained on varied and complex cases has been fantastic.

Background
I had just finished core surgical training, with some experience in general and plastic surgery, burns, urology and A&E, and an extra year as a junior fellow in general surgery between foundation and core training. The advice I had been given when planning the trip was that I would need to be able to get in and out of an abdomen safely, repair a hernia and manipulate a fracture. For the rest, I would be working with a retired Professor of Surgery from Holland. My wife is a strategy consultant in the City and would be employed in various non-clinical roles by the hospital, including stores, pharmacy and medical records.

Cases
I perform about 100 operations per month, with excellent experience spanning laparotomies, hernia repairs, skin grafting, local flaps, a full range of orthopaedics and everything in between. Some cases are however more exotic than others:

Animal bites
We admit a snake bite every week. These are the ones who have survived the envenoming and present with massive necrosis of the subcutaneous tissues, normally of the hand or foot. Management is serial debridement then reconstruction with skin graft or local flap, although the tendons are often destroyed. I have just discharged a seven year old who survived a crocodile attack with “only” a comminuted open fracture of his radius and ulna. External fixation and skin grafting has given a reasonable result.

Saint Francis Hospital
I am working at a rural mission hospital, with a long tradition of having a senior European surgeon and visiting British doctors. Because of this, Saint Francis’ has an excellent reputation throughout Zambia and, 82

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Abdominal catastrophes
Opening an abdomen and finding an inflamed appendix or perforated gastric ulcer is a welcome relief! Often patients present with a history of symptoms for over a week and are found to have advanced peritonitis, necrotic bowel or widespread cancer. The abdomens are invariably hostile and I have encountered some weird and wonderful cases - a compound volvulus with necrotic small bowel and sigmoid, a transverse colon volvulus near perforation, with the spleen caught in the pedicle of the volvulus, several typhoid perforations and a toddler with a week old intussusception and two bowel perforations amongst others.

Challenges
We work without many of the simple things that are taken for granted in the UK. Essential drugs (IV fluids, anaesthetic agents, antibiotics, insulin) have all been out of stock for periods in the last three months. I have drained a tension pneumothorax using a section of suction tubing and used a water bottle in the absence of chest drains. We do have access to ultrasound, but the reports often don’t match operative findings. The lab provides a reasonable blood transfusion service but does not test electrolytes, so the management of fluids in patients with bowel obstruction or paralytic ileus is guess work at best. As already hinted, patients present late, unresuscitated and critically ill. They are often malnourished and have coexistent malaria, HIV or TB and so a poor physiological reserve. Their management would be difficult in a modern intensive care unit - our ITU is simply the beds near the nurses’ station where observations are performed more than once a day. There is no access to ventilators, inotropes or parenteral nutrition. Although the equipment and drug shortages are a big challenge, by far the toughest aspect of working here is the culture difference. Things are done particular ways because that is how they have always been done. Antibiotics are prescribed for everything, from burns to bowel obstruction. Post operative care is similar to that practised in the UK thirty years ago. As would be the case everywhere, visiting doctors are viewed with some caution until they have earned a degree of respect. Although people have always listened to my opinion, it has at times proved difficult to reconcile local practice to modern surgical training.

Trauma
Around half of our inpatient work is trauma related. The common causes are traffic incidents, football, ox cart crashes and falling from mango trees. Major head injuries are common and treated conservatively. Open fractures are treated with external fixation and flaps or skin grafts. Abdominal trauma is rare, but I have performed one splenectomy (a daunting prospect here, they are all huge due to malaria and often fixed to the diaphragm). Children falling from mango trees (at least two a day at this time of year) commonly have horrific supracondylar fractures of the humerus.

Traditional Healers
Many people will consult the local healer before us. They have a “mankwala” (medicine) for everything, often just multiple small cuts at the site of the problem. While the scars are useful for localising pain, the culture of there being a medicine for everything has led to more than one dissatisfied patient demanding the mankwala for his lipoma, hernia or urinary retention and refusing surgery or catheter!

Burns
Cooking and heating is with open fires. Children commonly present with major scalds from knocking cooking pots over, adults with flame burns as the flickering fires trigger fits in photosensitive epileptics who then fall into the fire. They rarely receive first aid and no one in the hospital or our referring clinics adequately understands the role of fluid resuscitation. A 20% injury normally results in death.

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I work 7 days most weeks, often up to 20.00. When I do however get time off, watching the sunset with a G&T has become a favourite past time. The hospital is also only 200km from one of Africa’s foremost national parks, and weekends away on safari provide an essential break. In terms of local resources, food is plentiful, but the water and electricity supplies are hit and miss at best and sudden blackouts (including in theatre) can be quite irritating.

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Lessons
The intense and sometimes confrontational nature of this placement has vastly expanded my experience and skill in many non-clinical ares, including teamwork, leadership, conflict management, communication and education. My logbook serves as evidence of the abundant operative training I have received, but equally the need to manage difficult patients with nearly no investigations has forced me to develop my skills in clinical assessment and management. I doubt I will ever look at a CT scanner in the same way again!

2) Mai-Tais, Trauma Surgery and Spam! Ross Davenport, Specialist Registrar General, Trauma & Vascular Surgery & Clinical Lecturer, Centre for Trauma Sciences, Queen Mary University of London (QMUL)
Thanks to an ASiT travelling bursary I was able to travel to the 2012 annual meeting of the American Association of Surgery for Trauma… in Hawaii! As conference venues go, the Grand Hyatt on the ‘Garden Isle’ of Kauai certainly takes some beating. The meeting this year was of particular interest to me as nearly half of the 73 oral scientific presentations were on the topic of my PhD thesis and current research interests - trauma haemorrhage, coagulopathy and massive transfusion. As the big names in trauma took to the podium in shorts and Hawaiian shirts one could be forgiven for thinking the AAST is a relaxed meeting but looks can be deceiving. The AAST is THE global trauma meeting with consultants and attendings from all over the world often presenting research papers themselves such is the prestige of the meeting. Each presentation was followed by an address from an invited discussant who had previously reviewed the manuscript ensuring a rigorous and probing discussion. The Centre for Trauma Sciences (QMUL) had two abstracts accepted for the meeting and of note, Elaine Cole one of our senior trauma nurses currently undertaking a PhD, presented outcome data associated with prolonged activation of the fibrinolytic pathway and infections following major trauma. This year without the pressure of presenting I was grateful for the opportunity to provide moral support and immerse myself in the presentations, educational seminarsand networking sessions as well as take in a few of the sights of Hawaii in the extended trip. The AAST is a leader in global trauma care and the conference provided a unique environment for education in all aspects of managing the severely injured patient. The quality of scientific presentations, educational forums and interactive sessions with clinical directors of high volume trauma centres such as David Feliciano (Atlanta), Ron Maier (Seattle) and Kenji Inaba (LA County) were not only highly informative but a great inspiration to surgical trainees. I attended two lunchtime sessions - “Challenging Penetrating Chest Trauma Cases” and “A Trauma Night on Call ” the format of both were interactive case discussion with top tips and ‘get out of jail’ techniques, for the trauma patient in extremis, provided by the wealth of experience from the expert panel. The breakout sessions and social events

Would I Do it Again?
Yes. We have had a great time, learned a lot and are glad to have come. Working in Africa is a great opportunity to explore the world, experience surgery in a different light and develop clinical skills.

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deep water and failing to make it past the breaking surf it soon became apparent Quiksilver and O’Neill were probably not going to be chasing us down the beach for sponsorships deals. The centre of Kauai is one of the wettest places on earth with average annual waterfall of 460 inches but makes for lush scenery and the spectacular Waimea Canyon is rightfully known as - Pali ‘the Grand Canyon of Pacific’. The cliffs of the Na coast were stunning and it was obviously why Steven Spielberg chose to film parts of Jurassic Park on the island interior. No trip to Hawaii would be complete with a visit to the poignant memorial of the USS Arizona at Pearl Harbour and the fascinating museum. We took the opportunity to tour the USS Missouri which has served in all major conflicts from World War II to the Gulf War. It may be the largest battleship ever built but the medical facilities were cramped to say the least! The US Navy has provided an important concept in modern trauma management - ‘damage control’. The stated objectives of shipboard damage control are: 1) Take all practicable preliminary measures to prevent damage 2) Minimize and localize damage as it occurs 3) Accomplish emergency repairs as quickly as possible, restore equipment to operation, and care for the injured personnel These objectives and the overriding principle of performing the minimum repairs necessary to maintain ship worthiness have been adapted to the care of severely injured patients. The most pervasive concept in trauma care over the last three decades has been the adoption of damage control principles in both surgery and resuscitation. As for sampling the islands delicacies I am pleased to say we managed to avoid ‘Hawaiian steak’ or Spam as the rest of the world knows it despite Hawaii being the largest consumer per capita of the tinned luncheon meat. We opted to stick to a staple diet of Mai-Tais, Blue Hawaiians and coconut M&Ms!

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importantly provided an opportunity to develop new collaborations with academic surgeons, haematologists and transfusion specialists who share similar research interests in trauma haemorrhage and coagulopathy. The International Network for Trauma Research of which the Queen Mary’s is a founding member has now established links with four US Level 1 trauma centres in Boston, Pittsburgh, San Francisco and St Louis as well as the US Department of Defense as well as five centres across Europe. Aside from the conference, Hawaii is a fabulous holiday destination once you have got over the jet lag of the London-LA trip and 5 hour onward flight to the islands. I made the most of the sleepless nights with early morning runs to watch the amazing sunrise from the beach. As is compulsory in Hawaii we tried our hand at surfing, but after consistently being wiped out in knee

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3) The ASiT/Operation Hernia Shorland Hosking Travelling Fellowship to Takoradi, Ghana David Messenger, ST6 in General Surgery, Severn Deanery
Introduction
In March 2012, I was fortunate enough to be awarded one of the first ASiT/Operation Hernia travelling fellowships. The funding for my fellowship was donated largely by Howard Eggleston, a former patient of Professor Andrew Kingsnorth’s, and was named in honour of Shorland Hosking, a consultant surgeon from Poole, who died tragically in an air accident shortly after returning from an Operation Hernia mission to Nigeria. Operation Hernia is an independent, not-for-profit organisation, whose mission statement is ‘to provide high quality surgery at minimal costs to patients that otherwise would not receive it’. It was initiated in 2005 from Derriford Hospital, Plymouth, via the city’s cultural links with Takoradi, Ghana. Operation Hernia has since expanded and to date has repaired over 6000 hernias, at 18 locations in 11 different countries with teams originating from 22 countries. I have had a long-standing interest in hernia surgery and have never failed to appreciate the impact that an effective hernia repair can have on the quality of life of the patient. It was this opportunity to undertake a humanitarian mission where my surgical skills would be of maximal benefit to a community where healthcare resources are limited that prompted me to apply for the fellowship. I chose the mission to Ghana, as this was my first experience of humanitarian surgery and I wanted this to be in a well established setting. The prevalence of inguinal hernia in Ghana is as high as 7.7% of the population1. However, less than 40% are actually repaired, resulting in many patients developing long-standing inguinoscrotal hernias that are associated with a high incidence of morbidity and mortality2. Presentation is often delayed and approximately two-thirds of cases are repaired as emergencies. Sekondi-Takoradi is located in the Western Region of Ghana with a population of almost 450,000 (Figure 1). Its principal industries are timber, ship-building and crude oil. The discovery of the latter has led to a dramatic expansion of the metropolitan area in recent years. Most of the adult workforce is engaged in physically demanding jobs where the effects of an

untreated hernia can be debilitating. The stark reality is that if you are unable to work, then there is little means to support both yourself and your family. The value of the mission could not be clearer.

Figure 1 - Map of Ghana indicating relative location of Takoradi to other

major cities. of www.worldatlas.com/webimage/countrys/ Figure 1 - Image Map courtesy of Ghana indicating relative location of Takoradi africa/gh.htm www.worldatlas.com/webimage/countrys/africa/gh.htm

[PHOTO AWAITED] Preparation

Figure 2 - Members of the October 2012 mission to Takoradi. From left

The co-ordination of the mission was masterminded by Mr Chris Oppong, a consultant surgeon from Derriford and Director of Operations for Ghana. It soon became apparent that an anaesthetist was required and I duly offered the services of my wife (!), Dr Natasha Joshi, an ST7 anaesthetic trainee, who was supported by a travelling grant from the Association of Anaesthetists of Great Britain and Ireland. Our preparations included undergoing an extensive vaccination programme, obtaining visas from the Ghanaian High Commission in London, arranging flights and gathering together an array of gloves, gowns, sutures, laryngeal mask airways and portable pulse oximeters! We are grateful to the Spire Hospital, Bristol, and those colleagues who were kind enough to donate equipment for the mission. Operation Hernia has pioneered the use of polyester mosquito net meshes as a cost-effective means of hernia repair and these were pre-sterilised at the Derriford and Royal Gwent hospitals prior to our journey. Figure 3 - Ghanaian style tilapia fish served with jollof rice and fried After arriving in the capital, Accra, the team assembled Siddiqui) at a local guest house, before travelling on to Takoradi by road the next day. In addition to Natasha and me, our team consisted of two consultant surgeons from Dewsbury: Mr Shina Fawole, team leader and a veteran of three previous Operation Hernia missions, and his

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colleague Mr Harjeet Narula. They were accompanied by Melanie Precious, a Senior Operating Department Practitioner, also from Dewsbury, proving the old adage that a surgeon cannot operate without at least one member of their regular theatre team! In fact, Melanie’s scrub and anaesthetic experience were to prove invaluable throughout the course of the mission. The final members of the team included Mr Rafay Siddiqui, an ST4 general surgical trainee from the London Deanery, and Mr Roger Watkins, a recently retired consultant surgeon from Derriford, who joined us for the final two days of our mission after conducting a separate mission to the Cape Coast (Figure 2).

performing a spinal anaesthetic

Figure 2 - Members of the October 2012 mission to Takoradi. From left to right: Mr Shina Fawole, Mr Rafay Siddiqui and myself with members of the nursing team at the Hernia Centre, Takoradi Hospital

The Mission
On arrival in Takoradi, we were met by Dr Bernard Boateng-Duah, Chief Medical Officer of the Ghana Ports and Harbour waslocation in charge of Figure 1 - MapAuthority of Ghana Hospital, indicating who relative of Takoradi to other major cities. Image courtesy of the logistical arrangements of our stay. We had the Figure 4b - The operating theatre on the ground floor at Takoradi Hospital www.worldatlas.com/webimage/countrys/africa/gh.htm Figure 4b - The operating theatre on the ground floor at Takoradi Hospital exclusive use of a Ghana Ministry of Health Villa, which [PHOTO AWAITED] provided a welcome respite at the end of a long Figure day’s 4b - The operating theatre on the ground floor at Takoradi Hospital Figure 2 - Members of the October 2012 mission to Takoradi. From left to right: operating (occasional disruption to the hot water and electricity supplies not withstanding!). The culinary skills of the catering team were superb who ensured that we had the opportunity to enjoy variety of Ghanaian dishes (Figure 3).

Figure 4c. The operating theatre at Dixcove Hospital. The table height could not be altered and was per Figure 4c The theatre for at Dixcove Hospital. The height could tilted to the left asoperating a default position caesarean sections. Wetable performed the paediatric herniotomi down straining our backs! not to beavoid altered and was permanently tilted to the left as a default position for

Figure - Ghanaian tilapia fish served with jollof rice and fried plantain (photo kindly supplied by Mr Rafay (photo 3 kindly supplied bystyle Mr Rafay Siddiqui) Siddiqui)

Figure 3 - Ghanaian style tilapia fish served with jollof rice and fried plantain

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caesarean sections. We performed the paediatric herniotomies sitting down to avoid straining our backs!

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4a - The operating theatre at Ghana Ports Harbour Authority Ho Figure Figure 4a - The theatre at Ghana Ports and and Harbour Authority Hos Figure 4a - operating The operating theatre at anaesthetist, Ghana Ports and Harbour Authority supervising Peace, thenurse local nurse who is performing a spinal anaesthe supervising Peace, the local anaesthetist, who is performing a spinal anaestheti Hospital. Natasha is supervising Peace, the local nurse anaesthetist, who is

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Bernard had already co-ordinated the not insignificant task of selecting patients for our mission. Recruitment had largely occurred through radio announcements, clinic visits and perhaps most pleasingly through word of mouth. A prime example of this was the patient who told me he had waited all year for his hernia to be repaired just so the British surgeons could perform his surgery! We operated at three sites during the week: Ghana Ports and Harbour Authority Hospital, Takoradi Hospital and Dixcove Hospital, located a one hour drive from Takoradi (Figures 4 a, b and c). At Takoradi Hospital a disused wing had been refurbished in 2006, with funding from the British High Commission, to create the Hernia Treatment Centre that incorporated an operating theatre and day-case ward. On the morning of surgery, patients were pre-assessed and a decision made with regards suitability for repair under local, spinal or general anaesthesia. As a general rule, inguinal hernias that were manually reducible were repaired under local anaesthesia, with irreducible hernias or those with a substantial inguinoscrotal component being performed under spinal anaesthesia. General anaesthesia was reserved for incisional hernias and paediatric herniotomies. Over the course of the five-day mission, our team performed a total of 94 procedures in 87 patients (Table 1). Operation Primary inguinal hernia repair 65 Recurrent inguinal hernia repair 7 Paediatric inguinal herniotomy 7 Incisional hernia repair 4 Hydrocoelectomy 3 Epigastric hernia repair 2 Paraumbilical hernia repair 2 Recurrent paraumbilical hernia repair 1 Orchidopexy 1 Mesh excision 1 Lipoma excision 1 94 procedures in 87 patients
Table 1 - Log of procedures undertaken by the team

mesh. There were no post-operative complications and all adult hernia repairs were discharged on the day of surgery. Only one patient who had undergone repair of a large incisional hernia stayed overnight. H1 H2 H3 H4 Groin only, reduces spontaneously on lying down Groin only, reduces completely with gentle manual pressure Inguinoscrotal, reducible with manual manipulation Irreducible inguinoscrotal 11 (15.5%) 15 (21.1%) 26 (36.7%) 19 (26.7%)

Table 2 - Kingsnorth classification system applied to inguinal hernias repaired by the team

Initially, repair of the inguinal hernias proved to something of a technical challenge, owing to the anatomical differences between those encountered in Ghana compared to in the UK. Most inguinoscrotal hernias were due to a longstanding patent processus vaginalis that commonly required transection of the sac to facilitate reduction. Furthermore, these hernias were embedded within a well developed cremasteric muscle and tended to encircle the cord structures, which made dissection of the sac more troublesome. In many instances, partial excision of the cremaster was required in order to effect sound mesh repair around the deep ring.

Personal Experience
I can honestly say that the experience of operating solidly for 12 hours each day, in an environment subject to power cuts, poor lighting, a lack of running water and frequently defective equipment has been the most rewarding of my career to date! I was especially proud of Natasha, who as the sole anaesthetist dealt effectively with a number of challenging anaesthetic situations, mainly related to leaking circuits and a limited oxygen supply. During the week I performed a total of 32 procedures: 21 inguinal hernia repairs (three recurrent), six paediatric inguinal herniotomies, two incisional hernia repairs, two hydrocoelectomies and one epigastric hernia repair. Eleven of these procedures were performed independently with the consultant operating in another theatre. Many patients had travelled long distances for their surgery and I was humbled by the gratitude that they showed our team. I was amazed at how well the patients tolerated their procedures and it was often quite difficult to get them to admit that they were in any pain. In the UK, I could never imagine performing a sizeable inguinal hernia under local anaesthetic in a 30 year old male without any form of sedation. The local nursing staff at all three centres worked tirelessly and were extremely welcoming. There was no need to rely on iTunes for entertainment in theatre, as

Inguinal hernia repairs accounted for 71 cases (including 6 recurrent), of which 39 (55%) were performed under local anaesthesia. The majority of inguinal hernias were inguinoscrotal, or H3/H4 according to the Kingsnorth classification system (Table 2)3. Polyester mosquito net meshes were used for repair in 37 inguinal hernias with the remainder being repaired using brand mesh left over from previous missions. The handling of the mosquito net meshes was broadly comparable to that of brand mesh, although we found that bigger bites with each suture were required to adequately secure the 88

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Figure 6 - Patient with a giant inguinoscrotal hernia at Dixcove Hospital (photo kindly supplied by Mr Rafay Siddiqui)

Social Aspects

Figure 7 - Kwame Nkrumah Memorial Park, Accra
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Ghana was the first African nation to gain independence from the British in 1957 and is proud of its status as a stable parliamentary democracy in a politically volatile region. It is a majority Christian country, with a sizeable Muslim minority, and is compromised of over 100 ethnic groups. It is the relative and interFigure 6 - Patient with ainter-religious giant inguinoscrotal hernia ethnic tolerance that has seen Ghana avoid the civil Siddiqui) wars that have afflicted neighbouring states. Whilst in Accra, we visited the Kwame Nkrumah Memorial Park where we able to learn more about the birth of Ghana as a modern nation and the concept of pan-Africanism Figure 5 - Sister Marion, lead nurse at the Hernia Centre, Takoradi Hospital (Figure 7). This also proved to be a popular setting for newlyweds to pose for their wedding photographs! They were ably led by Sister Marion who had previously It is perhaps the following quote from Nkrumah that undertaken a one month elective placement at Derriford best sums up Ghana’s drive to achieve middle-income hospital (Figure 5).The only reluctance we encountered country status by 2015: from the nursing staff occurred at Dixcove when we embarked on our final case of the day at 7.00pm. ‘We have the blessing of the wealth of our vast resources, We later learned that the staff preferred to leave in the power of our talents and the potentialities of our people. daylight hours to avoid the snakes that would appear at 6 - Let us with grasp now the opportunities before Hospital us and(photo meet the supplied by Mr Figure Patient a giant inguinoscrotal hernia at Dixcove kindly Siddiqui) night on their walk home! challenge to our survival.’ It was at Dixcove that we encountered patients with the largest hernias (Figure 6). The community at Dixcove is less 5 affluent than Marion, Takoradi with onenurse doctor at serving Figure - Sister lead the Hernia Centre, Takoradi Hospital the needs of over 20,000 patients. Consequently, these hernias were longstanding and in one instance emergency repair of a hernia that had become obstructed was required. The reality of everyday life in this community was illustrated by the case of a 6 year old boy with an inguinal hernia who only weighed 13kg. We decided not to proceed with surgery as he had a right basal pneumonia and instead admitted him for intravenous antibiotics. Despite also having recently recovered from malaria, his mother was still desperate for him to undergo surgery as his hernia was limiting the physical contribution he could make to domestic Figure 7 - Kwame Nkrumah Memorial Park, Accra tasks. Figure 7 - Kwame Nkrumah Memorial Park, Accra
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we were often serenaded with gospel singing throughout the cases! Anaesthetic cover was provided by nurse anaesthetists who for the most part were highly skilled and keen to learn from Natasha. I was particularly Figure 4c. by The at Dixcove Hospital. The table height could not be altere impressed the operating nurses at the theatre Hernia Centre who wereto actively improving their practice and tilted the engaged left asina default position for caesarean sections. We performed the paedia had implemented the use of pre-assessment proformas, down to avoid straining our backs! antibiotic protocols and a handwashing policy.

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Summary
This was a thoroughly worthwhile mission for all those involved. Despite having never met each other before, I thought that the team gelled together well. Shina was an inspiring team leader, navigating us through several tricky situations (often related to Ghanaian taxi journeys!). Harjeet and Roger provided sound advice and were both excellent trainers. The contribution from Natasha and Melanie was immense who managed to instigate a change in practice with regards to the administration of spinal anaesthesia - tilt the patient head down, rather than perform a second injection of local anaesthetic if the spinal does not act immediately. I found Rafay to be a supportive and well-rounded colleague who like me benefitted tremendously from this experience. It was not until I returned to work in the UK that I realised that this mission has matured me both as a surgeon and as a person. It has taught me to be adaptable, more understanding of the limitations within the NHS and perhaps most importantly has given me a much needed perspective on life. I would recommend, therefore, that any trainee looking to broaden their surgical horizons should become involved with a humanitarian mission.

4) Veeru Kasivisvanathan, NIHR Academic Clinical Fellow, London School of Surgery
I would like to thank ASiT for their generous travelling bursary, which helped cover some travel and accommodation costs for an International Consensus Meeting held in New York in October 2012 on reporting standards of MRI-targeted prostate biopsy. The existing standard practice for prostatic biopsy is trans-rectal ultrasound guided prostate biopsy. However this technique is prone to error and ways of improving the prostate biopsy strategy are being sought. One way that is attracting a lot of interest is MRI-targeted prostate biopsy. The limitation with introducing an alternative biopsy technique into clinical practice is that one must be able to evaluate its outcomes. A recent systematic review identified that it is difficult to fully evaluate its outcomes of this technique, as there is a lot of variation in reporting standards. The purpose of the meeting was to come to a consensus on reporting standards for MRI-guided prostate biopsy and devise an international multicentre trial for MRI-guided prostate biopsy. I helped to organize the consensus meeting along with a group of other researchers affiliated with University College London. The attendees of the meeting were 23 leading experts in MRI-targeted biopsy of the prostate. They included Urologists, radiologists, histopathologists and methodologists. From the meeting we devised a checklist containing reporting recommendations for studies of MRItargeted biopsy, which will hopefully allow us to better evaluate this technique in the future. In addition we raised the possibility of a multi-centre trial, which is currently in further discussion. Some of our findings have been accepted for presentation at the European Association of Urology 2013 Conference and American Urology Association 2013 Conference. A paper detailing our findings is being completed and will soon be in submission. The support from ASiT has aided me in achieving my academic goals as part of my specialist training in Surgery. I hope to continue this work over the coming years and spend some full time in research in this area.

Recommendations
I have listed below two simple but achievable aims that would improve the quality of care received by the patients in Takoradi (1) Routine adoption of the WHO pre-operative checklist at all hospitals (2) The purchase of portable pulse oximeters for patient monitoring both peri-and post-operatively. We donated our own to Dixcove hospital. This may be best achieved through Lifebox, a not-for profit organisation, that aims to put a pulse oximeter in every operating theatre throughout the developing world (www.lifebox.org)

Acknowledgments
I am grateful to ASiT, Operation Hernia and Howard Eggleston for providing financial support. Thanks must also go to Mr Chris Oppong, Dr Bernard Boateng-Duah and Mr Eddie Prah for ensuring such a memorable and well organised mission.

1. 2. 3.

References

DL Sander, Porter CS, Mitchell KC, Kingsnorth AN. Operation Hernia: humanitarian hernia repairs in Ghana. Hernia 2008;12: 527-529 Clarke MG, Oppong C, Simmermacher R, Park K, Kurzer M, Vanotoo L, Kingsnorth AN. The use of sterilised mosquito net for inguinal hernia repair in Ghana. Hernia 2009;13: 155-159 Kingsnorth AN. A clinical classification for patients with inguinal hernia. Hernia 2004; 8: 282-284

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5) Endovascular Surgery in Malmo, Sweden Matthew Metcalfe, SpR Vascular Surgery, North West Deanery
Following a UK endovascular fellowship and having worked in most of the London teaching hospitals during my vascular training, I took the advice of Peter Taylor... “Go abroad and learn something completely different prior to starting your consultant post; you will not get this opportunity for another 10 years”. I visited Skåne University Hospital in Malmo, Sweden. This hospital has an excellent track record and is one of the world’s leading centres in endovascular technology. After a short flight to Copenhagen, the efficient Scandinavian railway system took me directly to Malmo within half and hour. The city has a population of around 300,000 but the vascular services cover the southern half of Sweden with a hub and spoke set up. The city used to be a major fishing port, but redevelopment has made it a major business centre with its excellent links to Denmark via the Oresund Bridge.

and fistuloplasties. In addition I witnessed Palmaz stent deployments, aortic aneurysm sac pressure measurements and renal artery stenting. In particular I learnt about fascial closure techniques, complex aortic stenting and fistuloplasty with stenting.

Endovascular Theatre

Malmo Hospital

Turning Torso Tower

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Martin Malina, Tim Resch, Bjorn Sonneson, Nuno Dias and Katarina Bjorsas lead the department. Each day begins with a 0800hrs board meeting where all admissions and inpatients are discussed in Swedish (although it was not difficult to translate into English). The staff regularly spoke in English for my benefit when needed and involved me in the patients’ management plans during this meeting. Following this, there were 2 interventional rooms and either 1 or 2 endovascular theatres running all day. I was free to scrub up for any case I wished and I took the opportunity by assisting in 2 branched EVARs (one ruptured), 2 fenestrated EVARs, infrarenal EVARs, carotid, femoral and popliteal open procedures along with numerous angioplasties

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What struck me most was their determination to complete the procedure using endovascular techniques, whereas an open conversion would have taken place sooner in the UK. With their vast equipment armoury at their disposal they would use different sheaths, catheters and wires etc until eventually successful. They were all skilled at both open and endovascular surgery and indeed their backgrounds were a mix of interventional radiology and surgery. I have had excellent endovascular training in London, where radiologists and surgeons work close together but with different roles. In Malmo, I witnessed the work of the possible ‘future vascular specialist’ that hopefully we shall see in the UK as a result of the new specialty status of Vascular Surgery.

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their current work, attend postgraduate education sessions and debate areas of controversy. The meeting features: Cine-clinics, featuring looping video presentations, where popcorn was provided; a learning centre where small group discussions, new technology demonstrations and practical skills tuition were held and their92 own SAGES souvenir shop! ASiT - the pursuit of excellence in training The San Diego Convention Center is located in Downtown San Diego, and backs onto a large marina, with one of the largest US naval bases across the bay on Coronado Island. The capacity for the entire convention

bay on Coronado Island. The capacity for the entire convention centre is over 125000 people in a total area of 57200 square meters - the joint SAGES and IPEG meeting occupied less than a third of this capacity. The meeting featured a very useful app, which included the entire schedule, maps and a twitter feed. It was possible for the audience to tweet their questions electronically to the panels during each session, which lead to a more interactive feel to the meeting. The meeting had a strong and varied program, with educational, intriguing and thought provoking sessions. The video session “Best of NOTES from around the world” was presented by several world leaders in the field and covered advances in transgastric and transoesophageal access, solid and hollow organ surgery and introduced TOVAT - Trans-Oral Video Assisted Thyroidectomy - performed entirely through incisions created within the oral cavity. 6) Matthew Fraser Leeman, Hiru Inoue from Japan featured prominently in the program, presenting and teaching Per-Oral Endoscopic ST8 General Surgery, Esophageal Myotomy (POEMS), a new alternative South East Scotland treatment for achalasia, which has developed as an I was awarded an ASiT travelling bursary to attend extension of the endoscopic submucosal dissection the Society of American Gastrointestinal techniques employed for early oesophagogastric cancers. Endoscopic Surgeons (SAGES) 2012 Scientific The video session entitled “Oops - now what?!” was Session & Postgraduate Courses, which was the most provocative session. A packed auditorium held in San Diego, California on March 7-10th. This is watched presentations of anonymously donated an annual meeting where some of SAGES 6000 members footage of a variety of complications including access meet to present their current work, attend postgraduate injuries, solid and hollow organ injuries, stapler misfires education sessions and debate areas of controversy. and stapling across NG tubes. Of particular interest The meeting features: Cine-clinics, featuring looping was a series of spine-tingling as-they-happened bile video presentations, where popcorn was provided; duct injuries that brought gasps and groans from the a learning centre where small group discussions, new audience! There was also a session where the “Top 21 technology demonstrations and practical skills tuition videos” was introduced - a series of step-by-step videos for the most commonly performed minimally invasive were held and their own SAGES souvenir shop! procedures that will be useful for the general surgeon with particular interest in minimally invasive surgery and contains detailed descriptions of the set-up, equipment and steps involved. As might be expected at an American meeting, Bariatric surgery featured strongly in the program. There were basic science symposia, covering the latest research into appetite and weight regulation and the pathogenesis of type 2 diabetes. A session entitled “Innovations in obesity and metabolic surgery” focused more on the recent technical advances within the field of bariatric surgery. These included laparoscopic gastric plication as a primary procedure, endoscopic procedures for primary weight loss and weight loss failure after previous bariatric surgery. There was a joint symposium between the International Paediatric Endosurgery Group (IPEG) and SAGES where paediatric bariatric surgery discussed. The discussion of which procedure to The San Diego Convention Center is located in I was awarded an ASiT travelling bursary to attend the Society was of American Gastrointestinal Endoscopic perform at what (if any) minimum age, was particularly Downtown San 2012 Diego, and backs onto a marina, Courses, which was held in San Diego, Surgeons (SAGES) Scientific Session & large Postgraduate th . This is an annual meeting where some of SAGES 6000 members meet to present California on March 7-10 with one of the largest US naval bases across the keenly debated.

I was impressed with the variety and volume of vascular surgery that I witnessed in such a short time period. Even a week’s visit would be beneficial to a vascular trainee. Malmo is well connected with its railway services and small enough that one can walk between the town centre and the hospital campus with ease and in safety. Malmo itself, based at the South West tip of Sweden, has a dark history with enough tourist attractions to keep you busy on the weekend. The picturesque town of Lund is nearby as is Copenhagen, and the trains will get you to other areas with ease (Stockholm, Gothenburg). I would like to thank all the staff at Skåne for making me feel so welcome and for making my visit so worthwhile. In particular, I thank them for giving me the opportunity to scrub up and form part of the operating team on such a regular basis.

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Thanks to the financial support of the ASIT Academic Travel Bursary, I was able to attend and present at the 22nd European Tissue Repair Society Meeting, held on 4th & 5th October 2012, in Athens, Greece. The meeting was held in the opulent surroundings of the Royal Olympic Hotel, located in the centre of Athens with views over the Acropolis. These plush surroundings masked the current policy of austerity in the country. The conference hotel was located very close to the Greek Parliament; the backdrop for many of the recent protests, demonstrations and riots. By good fortune, the police vehicles mounted with water cannons parked in the side streets, miraculously remained dormant during the days of the meeting, before violence then erupted again shortly after the meeting was concluded. The congress was open to scientists interested in all aspects of tissue repair and regeneration, with particular emphasis been given to recent advances in molecular biology and biotechnology. The meeting attracted large

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7) Stephen Goldie, Plastic Surgery Trainee, St John’s Hospital, Livingston and Royal Hospital for Sick Children, Edinburgh

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There were hernia sessions and another provocatively titled session “Inguinal Hernia: Treating the other Guy’s Complications” covered recurrence and chronic pain, including management strategies such as a laparoscopic retroperitoneal approach to neurectomy. The program also contained sessions on social media, robotic surgery and surgery in space. Many of the videos can be watched via the SAGES website (www.sages.org/videos). SAGES 2013 is scheduled to take place April 17-20th in Baltimore, Maryland. I had 2 posters accepted for presentation (“MetaAnalysis of Staging Laparoscopy Versus Computed Tomography in Oesophagogastric Cancer” and “The Diagnostic Accuracy of Multi-Detector CT Versus Staging Laparoscopy in Oesophagogastric Cancer Peritoneal Metastases”) during the meeting. I also sat and passed the Fundamentals of Laparoscopic Surgery (FLS) exam during the conference. FLS is a curriculum comprising knowledge, problem solving and practical skills, necessary for safe laparoscopic surgery. The FLS exam provides objective evidence of having achieved these competencies and comprises a cognitive multiplechoice exam and a practical skills component, containing 5 laparoscopic tasks. I am very grateful to ASiT for awarding me a travelling bursary, which made the trip possible.

numbers of clinicians, in particular Plastic Surgeons, who seem to have realised the potential benefits of utilising regenerative medicine within their speciality. Notably, there was a strong presence from scientists and plastic surgeons from Manchester, UK, where there seems to be a critical mass of clinicians, scientists and funding amassed allowing a rapid burgeoning of projects relating to regenerative medicine. Interacting with the basic scientists at this meeting in Greece allowed in depth discussions to aid understanding of the pathophysiological mechanisms of human disease and the potential clinical applications of the technologies presented. In several sessions, prominent, as well as younger scientists and clinicians presented their recent work on various topics, such as: chronic wounds, inflammation, fibrosis, extracellular matrices, angiogenesis, biomaterials, stem cells and cancer. My own presentation was of work carried out in Cambridge, at the Labs of Cancer Research UK Laboratory on the Addenbrooke’s Hospital Campus. I presented a novel method of inducing ‘long-term transgene expression in skin using a non-viral vector to model and treat human disease’. Using a transposon delivery system we were able to introduce DNA to murine skin by first encasing it in ‘microbubbles’ which were injected intradermally. We then used a noninvasive sonoporation device to ‘smash’ the bubbles, ‘shotgunning’ the DNA into cells just like shrapnel from an exploding shotgun cartridge. The system also included the integration of a dual fluorescent/bioluminescent marker allowing tracking of any labelled cells. We used a Xenogen In-Vitro Imaging System (IVIS) in order to monitor and track integration of DNA in the model. My hope is that this gene expression system could be used to help model human diseases of the skin like epidermolysis bullosa (EB) or squamous cell carcinoma (SCC), and then in the future potentially treat human skin conditions with known genetic mutations. Many speakers alluded to Greece being an appropriate location for a meeting on tissue regeneration due to the Ancient Greek myth regarding Prometheus. In Greek mythology, Prometheus is credited with the creation of man from clay and then the theft of fire for the use of humans. As punishment for this theft, Zeus, King of the Gods, sentenced Prometheus to eternal torment, whereby he would be bound to a rock and each day an eagle would devour his liver, only for it to regrow each day then be eaten again. Some think the myth indicates that the ancient Greeks knew of the livers remarkable capacity for self repair. The Greek word for liver, hepar, is derived from the verb hepaomai, meaning to ‘mend’, or ‘repair’. However, I think my favourite learning experience from my short visit to Athens was that iced coffees, ‘freddo’ or ‘frappé’ style, originate from Greece and taste superb when the temperature is over 30°C.

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8) ASiT Travelling Bursary 2013
Tjun Tang SpR Eastern Deanery
Now a Newly Appointed Consultant Vascular Surgeon, Changi General Hospital, Singapore
I shall be doing a post-CCT vascular and endovascular fellowship at the Prince of Wales Hospital in Sydney, Australia for 1 year. The Prince of Wales Hospital in Sydney is one of the top hospitals in Australia and is approved by the Australian Board of Vascular Surgery for both vascular and endovascular training. The hospital is famous for its integration of clinical care and education with the University of New South Wales and in recent years has consistently attracted senior international vascular fellows. The vascular department is very busy and research orientated and has recently custom built one of the world’s most advanced hybrid operating rooms. The aims of the fellowship are to learn endovascular treatment of below the knee occlusive disease, gain some experience of renal transplantation (vascular trainees do not usually learn this during HST in the UK where this is the norm in Australia) and gain some experience in carotid stenting. This is very hard to get in the UK now as there are really only 2-3 centres in the country which do this procedure regularly. Overall this fellowship will broaden my horizons in a different healthcare system and improve my independent operating experience and surgical maturity.

ASiT Regional Meeting Grant Winners 2012/13:
1) Em Qattan, Medical Student & President of Swansea University Surgical Society
On the 16th June 2012 the first All Wales Surgical Careers Conference was held in the Taliesin Arts Centre at Swansea University. With support from ASiT and both the Royal College of Surgeons of Edinburgh and England, the Swansea Surgical Society welcomed delegates to this year’s event. The conference aimed to provide medical students and junior trainees with up to date information about a career in surgery. The morning consisted of talks on a number of different specialties by consultant surgeons, as well as some highly interactive Q&A sessions. Poster sessions were held at lunchtime and delegates mixed with speakers allowing further informal networking. The afternoon session began with the presentation of five abstracts and then focused on providing delegates with practical information regarding portfolios, research and ‘how to get your training number’. Prizes this year were sponsored by WIMAT and Ansell and we received a number of high quality abstracts and posters for consideration. The presentations and posters shortlisted were judged by an expert panel on the day. This year’s WIMAT AWSCC prize for best oral presentation was won by Samera Dean, a Swansea Graduate Entry medical student, and the Ansell AWSCC poster prize was awarded to Junior Doctor Abi Kanthabalan. There were a number of key sponsors that helped to make the day possible and informative for delegates. In addition to our partners, we would like to say a special thank Swann-Morton, the BMA, Wesleyan, the MDU and all our volunteers who helped to make the day such a success. We hope to welcome you all again next year, to the 2nd AWSCC which will be held in Cardiff in 2013 and hosted by Cardiff University Surgical Society.

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2) Welsh Barbers Research Group Launch Evening, Miskin Manor, South Wales, 8th March 2012
Andrew Beamish, ST3 Wales Deanery www.welshbarbers.org
What is Welsh Barbers?
The Welsh Barbers Society was founded by surgical trainees in the Wales Deanery and is open to any surgical trainee or medical student in Wales with an interest in surgery. Its aim is to inform, support and guide on all aspects of working life as a junior surgeon, providing support on anything from exams and decisions on training, to where to go out around your local hospital. The Welsh Barbers Research Group (WBRG) is an arm of the Welsh Barbers Society, set up in 2010 and now with more than 100 members. Inspired by the success of the West Midlands Research Collaborative (WMRC), the WBRG was initiated by Julie Cornish, a higher surgical trainee in the Wales Deanery. A number of such trainee research collaboratives have sprouted across the UK in recent years, including the London Surgical Research Group (LSRG) and the South Peninsula Audit and Research Collaborative for Surgeons (SPARCS). With an enthusiastic committee of founder members, the WBRG has developed an impressive portfolio of audit and research projects, including a major multi-centre randomised control trial - the Hughes Abdominal Repair Trial (HART). This trainee-led, collaborative approach to surgical research comes in an era of great expansion in surgical research. Support for such initiatives is forthcoming from influential bodies such as the Association of Surgeons in Training, the Surgical Royal Colleges and a most valuable hands-on approach from influential academic surgeons such as Professor Dion Morton. The WBRG was delighted to hold a highly successful launch evening on Thursday 8th March to celebrate its official launch as a trainee-led surgical research collaboration. The WBRG is thankful to ASiT for its support in the form of a regional meeting award. The launch evening included inspirational talks from Mr Martyn Coomer, Secretary of the RCSEng Research Department and Professor Ian Russell of the Clinical Trials Unit in Swansea. Further encouragement came from updates on the impressive work being undertaken by other trainee collaboratives from the West Midlands and London groups.

Why be Involved in the Welsh Barbers Research Group?
Today’s surgical trainees are encouraged to enter formal training earlier than in previous years and clear incentives exist in modern UK application systems, with penalties applying to trainees taking longer to enter specialty training. As a result, many higher trainees have little or no formal research background. The WBRG seeks to address the impact of this by enabling: i) increased research activity among surgical trainees ii) the sharing of experience in setting up and running trials among registrars who have varying levels of research experience iii) audit and research projects to transcend 4 or 6 month placements - as it often takes a long time to get projects going and momentum can be lost when people change jobs iv) trainee leadership to overcome difficulties in time input from Consultants iv) sharing of the increasing administrative burden in ethics/research projects A range of projects running at a variety of phases leads to a productive research portfolio. This portfolio should not necessarily be ‘top heavy’ with randomised controlled trials - all levels of project are welcome. See where your idea fits in. More important is that projects are deliverable. Involvement with the collaborative is encouraged for trainees of all grades and it is intended that trainees will learn and refine audit and research skills, including: • • • • • • Project development Chairing meetings Leading groups/working within project teams Communicating with research agencies Ethics applications Grant and funding applications

How Can you be Involved?
If you wish to register to be part of the research group,please complete the online registration form at www.welshbarbers.org

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3) Foundation Skills in Surgery Course: Delivering Standardised, Affordable Surgical Skills Training for Foundation Doctors and Medical Students
Edward Dyson, Academic FY2, Neurosciences Critical Care Unit, Cambridge University Hospitals NHS Foundation Trust ewd21@wbic.cam.ac.uk
Background
Since 2011, ASiT has run the Foundation Skills in Surgery course for foundation year 1 & 2 doctors, and more recently for final year medical students. The course offers those with little or no surgical experience a chance to learn the basic skills required to assist in the operating theatre and to demonstrate to their senior colleagues that they have been proactive in seeking training opportunities in surgery outside of the normal working day. For those with previous experience, it offers an opportunity to practice their skills on real animal tissue and ask questions in an informal environment to an experienced faculty. The course is accredited by the Royal College of Physicians & Surgeons of Glasgow. It is mapped to the Intercollegiate Surgical Curriculum Programme (ISCP)1 for Core Surgical Training, in particular the Basic Surgical Skills and Professional Behaviour & Leadership modules, making it an ideal starting point prior to completing the Intercollegiate Basic Surgical Skills Course. At a time of heavy competition for surgical training posts, it provides good portfolio evidence of extra-curricular acquisition of skills, and as such is very useful for gaining entry to surgical training posts. We hosted a course for 28 delegates in April 2012 at the University of Cambridge Clinical Skills Unit, Addenbrooke’s Hospital. The course was completely free of charge to ASiT members, making the annual subscription fee worthwhile in one day alone - a stark contrast to many other courses on offer. At a time when junior doctors’ salaries are increasingly spent on their post-graduate education2, ASiT is comitted to actively seeking out ways to minimise course set-up costs, and needless to say to offer teaching for no financial gain.

The Course
We began with interactive presentations on surgical record keeping (including the writing of operation notes), types of sutures and drains, and the principles of safe tissue and instrument handling. The delegates subsequently split into two groups, one learning general surgical techniques and the others learning orthopaedic skills. In general surgery, delegates were initially taught gloving, gowning, sterile field preparation and draping. A further practical followed on instrument handling and local anaesthetic infiltration. Each delegate was then given their own section of pig abdominal wall as well as a pig’s trotter. Exercises included excision of skin lumps (pig nipples) and simulated sebaceous cysts, and drainage of abscesses, before practising interrupted, continuous, mattress and subcuticular sutures to close the skin. The students were subsequently taught tendon repair on the pig trotter where they had further opportunities to practise skin closure and knot tying.

The excellent tutor to student ratio was particularly highlighted by delgates

In orthopaedics, students were taught the principles of fracture management, both in the initial stages and the definitive fixation. This included a workshop with interactive clinical case scenarios followed by a practical demonstration of fracture reduction and the application of different types of splints and Plaster of Paris backslabs. At the end of the day the faculty (all of whom were ST3+ registrars in general or orthopaedic surgery) gave advice on gaining entry to Core Surgery Training and how to prepare early for the competitive application process. Advice included ideas for audits and research projects and how to get work published.

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A tutor volunteers in the fracture reduction simulation

We would like to thank the University of Cambridge Clinical Skills Unit and the Addenbrooke’s PostGraduate Medical Centre for their generosity, without which we would not have been able to offer this course free of charge to ASiT members. We would also like to thank Suffolk Meat Traders Ltd of Bury St Edmunds who kindly donated the pig trotters. Finally, ASiT were instrumental in providing guidance to set up the course, tutors to deliver the course and funds in the form of a Regional Meeting Grant to pay for the remaining meat products. We are looking forward to running this course again in June 2013 - details to be released nearer the time. In the meantime we welcome enquiries from anyone thinking of setting up a course like this one in their own region.

References
The feedback we received was overwhelmingly positive. The highest scoring elements in the course feedback were the relevance of the practical sessions, the tutors’ knowledge of the subject matter, and the tutors’ ability to respond to feedback and explain things that the students were having difficulty with. Specific comments highlighted further the excellent tutor to student ratio (1:2) and the enthusiasm and confidence that came across from the tutors about their subject matter.

1. Intercollegiate Surgical Curriculum Programme Syllabuses, https://www.iscp.ac.uk/surgical/syllabus.aspx (accessed on 16/10/2012) 2. Harrison E. The Cost of Surgical Training: Who should pay for post-graduate education? ASGBI Newsletter 2006: 4-6

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Call us today for further details on Freephone 0800 521251

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4) The Northern Surgical Skills Conference 2012
The Northern Surgical Skills Committee 2012
www.northernsurgicalskillsconference.co.uk

Organising Committee Tom Ankers Jessie Hill Christophe Thomas Fay Riley
On May 19th 2012 the second annual Northern Surgical Skills Conference took place in association with the Northumbrian Upper Gastro Intestinal Team of Surgeons (NUGITS). Fifty medical students attended the conference at the Northern Skills Institute, Hexham General Hospital. This included a considerable contingent from medical schools other than Newcastle - from Dundee in the North to Brighton in the South. The students were given a warm welcome by Dr Richard Thomson, Clinical Sub-dean at the University of Newcastle upon Tyne, who opened the proceedings. At the Northern Surgical Skills Conference we are proud of the practical skills teaching on offer and this year’s meeting did not disappoint. Karl Storz very kindly provided laparoscopy stacks again to give students a taste of laparoscopic surgery. New for 2012 was the suturing workshop sponsored by The Royal College of Surgeons Edinburgh. In addition to teaching on basic suturing and knot tying techniques, delegates were given the chance to test their suturing skills on pig trotters. The SimMan station gave students practice in managing emergency scenarios not often covered in the undergraduate curriculum. Fourth year Newcastle student Joshua Howells impressed the surgeons throughout the day and was awarded the coveted Golden Scalpel Award for the best practical skills. This year’s enthusiastic speakers were a highlight of the day. Talks included a new and deeply moving presentation on Human Factors in Surgery by Mr Clarke, Consultant Vascular Surgeon and Regional Representative of the Royal College Surgeons Edinburgh. Mr Horgan from NUGITS gave an inspiring talk on surgery in the developing world which included a live web chat with Mr Kondo Chilonga, Head of Surgery at the Kilimanjaro Christian medical Centre in Tanzania. Other talks included ‘The Future of Surgery’ by Mr Sean Woodcock, Consultant General Surgeon, and ‘Surgical Careers

and Portfolio Advice’ by Mr Iain McCallum, Specialist Registrar. All of the talks were extremely well received by the students. The quality of abstracts submitted was extremely high. Fourteen abstracts from plethora of surgical specialties were chosen to be presented as posters at the conference. Three expert judges: Mr Horgan, Mr Bawa and Mr Clarke assessed the posters and four entrants were selected to present their work. Of these, Kishan Moosai’s ‘Beyond the basin: The development of a multimedia teaching package on pelvic anatomy for future Pelvic Surgeons’ was judged to be the best. Prizes for the finalists were kindly donated by PasTest and Oxford University Press. The conference received extremely positive feedback scoring ‘excellent’ on overall experience. There was particular praise for the high surgeon to student ratio, engaging talks and the good value for money! We must not forget that the conference would not be possible without the generous support of our sponsors. We would like to give special thanks to the Association of Surgeons in Training, the Royal College of Surgeons Edinburgh, the British Medical Association, the Royal College of Surgeons England, Karl Storz and Ethicon Endosurgery. Thank you also to Mr Venkatesh Kanakalaka and all the other faculty members who gave up their time to help make the day a big success.

The 2012 Faculty and Organising Committee
We hope that the insightful talks and unrivalled practical skills teaching will help this year’s students on their journey to becoming the surgeons of the future.

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5) East Kent Surgical Meeting 2012
Kapil Rajwani, Foundation Year 1 Trainee, KSS Deanery
A trust wide surgical meeting was organised for junior doctors at the East Kent Hospitals University NHS Foundation Trust on June 29th 2012. The meeting was held at the Education centre at Kent and Canterbury Hospital and was sponsored by KCH, QEQM and WHH charities, GlaxoSmithKline (GSK) and the Association of Surgeons in Training (ASiT). Foundation and Core Surgical trainees from across the trust were invited to submit abstracts relating to surgical research, audit, clinical case report or quality improvement. Thirty two abstracts were submitted by twenty trainees. These abstracts were reviewed by consultants and selected for oral or poster presentations. The purpose of the meeting was to provide a platform for junior trainees to showcase their hard work, gain experience in presenting and encourage surgical discussion and debate. It was also meant to give trainees the opportunity for discussion with consultant surgeons about a career in surgery.

Prize Winners
Prizes were awarded for best poster and best oral presentations in the FY1, FY2 and Core Surgery category: Best oral presentation in the FY1 category: Dr Charlotte Ashton and Dr Kavitha Vimalesvaran Best oral presentation in the FY2 category: Dr Richard Smith Best oral presentation in the Core Surgery category: Mr Arash Aframian Best poster presentation: Dr Charlene Twum-Barima

Feedback
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The feedback from the meeting has been positive. The vast majority of participants thought the event was well organised and presentations were of a high quality. More than 80% of participants said they would definitely like more such events, would come back again next year and recommend it to others.

Future Meetings
Following the success of the East Kent Surgical Meeting 2012, the organising team is keen on running an annual scientific meeting for junior doctors in the trust. We have taken the feedback on board and planning has begun for the East Kent Academic and Research Meeting 2013. Watch this space.

June 29th 2012
The East Kent Surgical Meeting 2012 was a great success and the Kent and Canterbury education centre proved to be an excellent venue. The day was split into two sessions - morning and afternoon. The morning session consisted of ten fascinating presentations on a wide range of surgical topics. The chair of the meeting, Mr Edward Streeter, consultant urologist, was one of the judges, accompanied by six other consultant surgeons and senior registrars and the trust’s education advisor, Ms Susan Kennedy. Each presentation was followed by questions, answers and stimulating discussion. Following a break for lunch, the afternoon began with a 45 minute poster presentation session. Posters were of a high quality and during the session delegates engaged in dialogue and informal discussions about their work. Posters were judged on appearance and a short presentation. Six further oral presentations followed the poster session. The afternoon oral presentation session was chaired by Mr Jawaharlal Senaratne, consultant vascular and general surgeon. The guest speakers for the event, Miss Elizabeth Sharp and Mr Syed Ahmed, were invited to talk to the delegates about careers in surgery and getting onto the training programme. Mr Ahmed also discussed the role of ASiT in improving surgical training and the opportunities offered to trainees involved with the organisation.

Special Thanks Guest speakers
Miss Elizabeth Sharp, consultant breast and general surgeon, core surgery training director for KSS deanery and member of the core surgery national recruitment advisory committee Mr Syed Ahmed, ASiT council member for KSS deanery, currently a CT2 surgical trainee in KSS deanery and has recently acquired a national training number in trauma & orthopaedics.

Chairs
Mr Edward Streeter, consultant urologist Mr Jawaharlal Senaratne, consultant vascular and general surgeon

Special Mention
Mr Nitin Shrotri, consultant urologist and lead clinician

Sponsors
KCH, QEQM and WHH charities GlaxoSmithKline (GSK) Association of Surgeons in Training (ASiT) Thank you for all your support and encouragement!

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6) Leicester SCRUBS National Undergraduate Course
‘Recognising and Managing the Acutely Unwell Surgical Patient’ Saturday 29th September 2012 Zahir Mughal, Final Year Medical Student, University of Leicester, John Isherwood, Clinical Research Fellow and Justin Yeung, Consultant Colorectal Surgeon, University Hospitals of Leicester Mzm3@student.le.ac.uk
Leicester SCRUBS ran the Recognising and managing the acutely unwell surgical patient course for Leicester Medical Students in September 2010 and 2011 at the Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary. The course was developed by 4th and 5th year Leicester Medical Students and Core Surgical Trainees. In 2012 we sought to further improve on the quality of the course and expand it onto a national scale by inviting students from other medical schools.

Lectures in the Robert Kilpatrick Clinical Sciences Building (RKCSB) Lecture Theatre

• Assessment of the acute surgical patient • Common surgical emergencies • Shock and sepsis • Post-operative complications • How to give an effective handover A live demonstration of a simulation was performed by surgical trainees to reinforce lecture content and provided students with an idea of what will be required during the afternoon simulated scenarios. The intensive lectures in the morning session were well received and student feedback was very positive, students reported that the lectures were very relevant and aided them in the afternoon simulations.

Aim
To provide medical students with knowledge, skills and practice at recognising and managing the acutely unwell surgical patient on graduation.

Delegates
This course was aimed at medical students in their 4th/5th year. Although the course revolved around surgical patients, the skills and knowledge base covered were applicable in the management of any acute patient. The course was quickly oversubscribed. Seventy delegates attended representing six UK medical students. Delegates were given travel information, free on-site parking, an event programme, and career progression material provided by the sponsors. Students were asked to complete a quiz and feedback form pre and post workshop.

A-E assessment demonstration Simulations

Lectures
The one day course was separated in two with various lectures in the newly refurbished lecture theatre in Robert Kilpatrick Clinical Sciences Building, followed by simulations in the Ian Lauder Clinical Skills Unit. The lectures were delivered by surgical registrars:

The afternoon consisted of four 1-hour long clinical simulation scenarios that were based on real clinical situations encountered by surgical demonstrators and covered acute surgical presentations and common surgical complications. Each group consisted of between 10-12 students in two separate groups. Each scenario was divided into part A and B, allowing all students full interactive participation during a scenario. All simulations were led by two to three trainers at core surgical trainee or specialist

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trainee level. Student groups rotated between all four simulations like an OSCE, with lunch and coffee breaks in between. The trainers were given a detailed briefing of their scenario by our Couse Consultant. The students carried out full A-E assessments, reviewed the charts and notes, established differential diagnoses, requested investigations, initiated treatment and performed handovers. Each patient had accompanying Early Warning Scores and drug charts, chest X ray, ECG, blood results etc. and students had the opportunity to cannulate, take blood, complete investigation request forms and prescribe drugs.

Workshops All student groups participated in a one hour workshop on “preparing patients for surgery”. The station aimed at developing an understanding of the tasks and investigations undertaken to ensure safe preparation of a patient for emergency or elective surgery. This involved interactive case studies, presentations and small group tasks facilitated by a General Surgical registrar. An hour long interactive basic surgical skills workshop included an introduction to sutures and needles, followed by a tutorial on how to use the surgical instruments. Practical skills covered included tying reef knots, surgical knots, interrupted, vertical and horizontal mattress sutures.

Simulations in the Ian Lauder Clinical Skills Unit, Leicester Royal Infirmary

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Budget
The total costs of hiring the clinical skills unit, equipment, portering, unit staff, printing, lunch, refreshments and sutures was in excess of £2000. Our sponsors kindly provided £850, and the remainder of the cost was covered by delegate fee of £10 and Leicester SCRUBS.

Conclusion
The event was extremely successful and received excellent feedback. The trainers felt the groups were rather large and perhaps numbers will need to be capped at 10 in future in order to maximise student participation and learning experience. There was general consensus amongst students and trainers that the £10 fee to attend was quite small. Indeed the course was priced to be student friendly but in light of the expenditure, high quality of the course and student satisfaction, the course fee may well be increased next year. Further analysis of quiz results and feedback will be undertaken to further explore the use of simulation teaching in undergraduate medical education.

Prize Winners
The following students were recognised for outstanding performance in the following stations as judged by the trainers. They received certificates and books as prizes. • The trauma patient: Krupa Somani (Leicester) • Post-operative dyspnoea: Sara Al-Ansari (Leicester) • Post abdominal surgery complication: Sara Al-Ansari (Leicester) • Acute Abdomen: Nicola Rose (Leicester) • Basic surgical skills: Stefen Klimach (Brighton and Sussex)

Sponsors
Leicester SCRUBS would like to offer our gratitude to our sponsors for their support and financial contribution: Association of Surgeons in Training (ASiT), RCSEng, RCSEdin, RCPSG, MDU, MPS, Wesleyan and Oxford University Press. In particular the Royal College of Surgeons of England for their generous contribution to the delegate bags. A special thank you to ASiT for their support throughout the planning of the event, assistance in recruiting trainers/lecturers and help on the day of the event. We would also like to extend our gratitude to all the trainers who gave up the time to teach for us, in particular Mr John Isherwood for writing the clinical scenarios.

Organisers
Preparing patients for surgery

Course Director: Zahir Mughal (Final year Leicester Medical Student, Leicester SCRUBS President) Course Chairman: Mr Justin Yeung (Consultant Colorectal Surgeon) Course Consultant: Mr John Isherwood (Clinical Research Fellow)

Basic surgical skills workshop

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7) The UK Endovascular Trainees Inaugural Meeting, The Freeman Hospital, Newcastle Upon Tyne, August 20th 2012
Craig Nesbitt ST3 General Surgery, Northern Deanery
The UK Endovascular Trainees (UKETS) is a new and innovative training initiative which has been established by three trainees from the Northern Deanery; Craig Nesbitt (Vascular Surgical Research Fellow), James McCaslin (Vascular surgical ST7) and Sebastian Mafeld (Radiology ST1). As a group, we recognised the value of virtual reality simulation training in order to improve patient safety, yet harboured concerns that despite clear evidence to support its efficacy, dedicated simulation based endovascular skills training has not been widely established in the UK. Our manifesto is to promote “safe access, safe navigation and safe closure” through hands-on, expert led, simulation training. We feel strongly that these core training principles underpin safe endovascular practice in all procedural specialties, and so we set forth to develop a training meeting where vascular surgeons, interventional radiologists and interventional cardiologists could hone these basic skills. The inaugural meeting was a huge success; with overwhelming enthusiasm from trainees, and an expert faculty including consultants from all three parent specialties. The UKETS meeting promoted an environment where trainees could learn and share ideas together; practicing the basic endovascular skills that are fundamentally important no matter what your chosen specialty. We are extremely grateful to ASiT for the generous grant, and encourage any trainee interested in endovascular intervention to check out our website and watch for news of upcoming training events (www.ukets.org)

8) The Glasgow University Surgical Society (GUSS) Undergraduate Conference 2012
Michael McDermott (on behalf of the GUSS Committee), Treasurer
In its 4th inauguration, the Glasgow University Surgical Society (GUSS) held their annual undergraduate conference at the Royal College of Physicians and Surgeons of Glasgow on the 3rd of November 2012. The conference encompassed medical students at all stages and from across the United Kingdom all with an enthusiasm for surgery. The conference began with an address from Professor Paul Horgan (Honorary President of GUSS) who delivered an excellent and highly informative talk on the current pathways a trainee typically takes, within the UK, to become a consultant surgeon. This was followed by a talk, delivered by Dr Stuart McDonald, a senior and revered lecturer in Clinical Anatomy at the University of Glasgow. Dr McDonald used a number of interactive clinical cases to highlight the importance of anatomy in the clinical setting to identify pathology and facilitate a final diagnosis. Following from this, Mr Angus MacDonald, Consultant Colorectal Surgeon from Monklands Hospital spoke on ‘Colorectal Cancer Surgery - pursuing excellence and reporting disappointment’. Mr MacDonald delivered a talk that was informative, thought-provoking and provided many points for discussion - without a doubt, one of the highlights of the day. Following a short interval, Miss Juliette Murray took to the podium to deliver another fantastic talk on ‘Breast Disease and a Career in Breast Surgery’. Miss Murray spoke about common clinical presentations to the breast clinic and the current strategies utilised in the management of breast disease. In addition, she kindly shared her personal experiences and provided invaluable insight on how to obtain the elusive worklife balance whilst having four young children and a successful surgical career. The fifth speaker was Mr Colin MacIver, a consultant Maxillofacial/Head and Neck surgeon from the Southern General Hospital in Glasgow. Mr MacIver delivered one of the most exciting talks of the day, on the innovative and fascinating subject of facial transplantation.

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Sticking with the world of Maxillofacial Surgery, the next talk was given courtesy of Mr Mark Devlin, again from the Southern General Hospital in Glasgow. Mr Devlin spoke on ‘Cleft Care: from cradle to grave’. The talk focused on the importance of the holistic management of cleft patients and highlighted the roles of the various members of the multi-disciplinary team which are required to facilitate the normal development of a child born with a cleft lip and/or palate. The final talk of the day was given by Miss Catherine Sharp a consultant General and Upper GI Surgeon from Crosshouse, Kilmarnock. Miss Sharp gave a fascinating talk, on new and innovative surgical approaches to put type 2 diabetes mellitus into remission. With diabetes in remission and blood sugars coming down, it was definitely lunch time. This offered the delegates a chance to refuel and wander around the Royal College and stop by the sponsor stalls and look at the poster presentations. In all, the talks were fantastic and covered a wide array of clinical specialties. The afternoon adopted a more hands on and practical approach to surgery. Delegates were divided into smaller groups and with thanks to a number of surgical trainees and foundation year doctors we were able to offer a crash course in basic surgical skills. The skills that were on offer included; suturing skills (introductory and advanced), knot tying, introduction to laparoscopy, plastering and fracture fixation. The delegates rotated around all stations. The feedback received from the practical sessions was extremely positive and many commented that the GUSS undergraduate conference offered an opportunity to learn skills that no other undergraduate society currently offer, particularly the fracture fixation station. Shortly after the surgical skills session our poster prize winners, as chosen by Professor Horgan, and winners of the raffle (for our selected charity, Medics against Violence) were announced. This was followed by a wine and refreshment reception. The day was finally rounded off with the first GUSS annual dinner, were delegates and speakers were invited to join the GUSS committee for dinner and drinks within the Royal College. The whole day went exceptionally well and we, as a committee, are delighted that the delegates who attended our conference felt that it was beneficial and good value for money. Based on feedback provided, 95% of delegates felt that the conference offered excellent educational value and 90% would highly recommend the GUSS conference to their peers. The committee would like to make special thanks to all our speakers and skills tutors who kindly gave up time to help make the conference a success. Additionally, the conference would not have been possible without the generosity of our sponsors. Thank you all! 104

9) ASIT Statistics for Surgeons Course
19th-20th December 2013 St Luke’s Campus, University of Exeter Convener: Dr Roy Powell Organiser: Mr Frank McDermott (Peninsula Regional Representative) Amy Godden, CT1 General Surgery, Torbay Hospital
The subject of statistics is, for most, bewildering; however, the quiet confidence of Dr Powell who so clearly has such depth of understanding and passion for his subject, demystified the basic principles of statistics. The course comprised several short lectures interspersed with relevant practical workshops using the statistical package ‘SPSS’ to put theory into practice. The participants comprised doctors from FY2 to senior registrars. It was interesting to observe the commonalities with regard to areas of uncertainty from the vast ranging experience within the group. The course started with basic definitions and principles of statistics and once these building blocks were laid, without conscious effort we were advanced into some more complicated areas of statistics that would have bamboozled us all at the outset! The method used by Dr Powell to relate statistical principles to everyday situations not only aided comprehension, but also served as an aide memoir when trying to recall the information for use in practical situations. The participant’s reaction within the lectures could be likened to a crowd at a fireworks display with the numerous “oohs” and “aahs” prompted by lightbulb moments when the penny dropped on so many previously unfathomable principles. A thoroughly worthwhile course for any doctor at any level.

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Implant Based Breast Reconstruction Where Are We?
Steven Thrush, Oncoplastic Breast Surgeon, Worcester Royal Hospital Society
Increasing patient expectations, improved oncoplastic training and subsequent increased availability has led to increasing numbers of immediate and delayed breast reconstructions being performed in the UK. The most significant development in breast reconstruction in the last decade has come in techniques using implants to recreate the breast volume in the immediate setting (at the same time as a “skin-sparing” mastectomy). Previously an expandable implant would be placed under pectoralis major following a mastectomy and slowly expanded over a period of months until a comparable size with the contralateral breast was achieved. The expander would then be removed and replaced with an anatomically shaped silicon implant to hopefully achieve symmetry. This technique could give excellent results in some individuals’ hands; in the majority it was felt to have its limitations. It also meant two operations, multiple visits to out-patients for inflation (which can be an uncomfortable experience) and potential migration of the implant supero-laterally. (Picture 1)

• Grade I: Mild ptosis - The nipple is at the level of the infra-mammary fold and above most of the lower breast tissue. • Grade II: Moderate ptosis - The nipple is located below the infra-mammary fold but higher than most of the breast tissue hangs.

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• Grade III: Advanced ptosis - The nipple is below the inframammary fold and at the level of Two new techniques have become increasingly popular breast projection. maximum Myo-dermal sling technique provides a natural shape but requires a symmetrisation procedure to the other and add to our immediate reconstruction portfolio. breast. Both release the inferior and medial fibres of pectoralis • Grade IV: Severe ptosis - The nipple is far below major to allow the muscle flap to provide coverage the inframammary fold and points toward of the upper aspect of an implant. This technique the floor. has developed from experience with the submuscular placement of implants in breast augmentation (the Box 1
Picture 2

Picture 1 - Demonstrates the problem of migration with the sub pectoral implant technique

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“dual-plane” technique). This ensures a natural slope to the upper part of the breast and hides the implant edges.The inferior aspect of the implant is then covered by either a de-epithelised dermal sling (created from the excess skin from the inferior aspect of the breast) or a sheet of natural prosthetic materials (NPMs). The commonest form of these natural materials currently used is the acellular dermal matrix (ADM). The market leader is porcine in origin (Strattice® Lifecell) but the early data from the United States (US) used human cadaveric dermis (Alloderm® Lifecell). ADM’s are created using a process that removes cells and significantly reduces the key component in the graft that appears important in the xenogenic rejection response. ADM’s provide a scaffold consisting of collagens, elastins, vascular channels and proteins that support native revascularisation, cell repopulation and tissue. These materials have been used for several years in uro-gynaecological procedures and in complex hernia repairs. Either a sheet of this material or the dermal flap allows the formation a sling between the lower border of pectoralis major and the inframammary fold, allowing an implant to lie completely covered. It is analogous to an internal bra and because the muscle fibres are released, avoiding inflation of an implant against a muscle, it also has been described as the tension free implant based reconstruction. Its main benefit has been the potential of performing a one stage procedure. The other potential advantages of these techniques over the submuscular technique includes improved lower pole expansion (a more natural shape), reduction in postoperative pain and decreased operative time. They also produce predictable results in experienced units. It is important to note that these two techniques are not suitable for the same breast shape and volumes. The myo-dermal sling technique needs sufficient ptosis (Grade 2 or >) (box 1) to provide the dermal flap

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Myo-dermal sling technique provides a natural shape but requires a s breast.

Box 1

Fig 1. Classification of Skin Sparring Mastectomy

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∑ ∑ ∑ ∑

and is greater in the generous volume breast while a NPM assisted technique is better in the non-ptotic, smaller breast. In the myo-dermal technique a skinreducing mastectomy is performed (type 4 of Carlson’s Classification - figure 1) while, in a NPM assisted procedure a type 1 skin sparing mastectomy is usually performed. The myo-dermal sling technique would be offered to those women who would otherwise need a large volume of native tissue to reconstruct their breast volume (eg DIEP flap - tummy) while patients suitable for the NPM technique may also be suitable for a smaller myo-cutaneous flap (eg autologous Latissimus dorsi). The myo-dermal technique does uplift the Box 1 breast (mastopexy), which means that the contra lateral breast requires an uplift to achieve symmetry. As this is Picture 2 - Myo-dermal sling technique provides a natural shape but native “stretchable” tissue, it does produce some ptosis. requires a symmetrisation procedure to the other breast (Picture 2). The NPM technique will occasionally needPicture 3 contralateral symmetrisation but even though the ADMThis woman has had a previous right latissimus dorsi reconstruction a is colonised by native cells it does not stretch to allowassisted implant reconstruction. Fig 1. Classification of Skin Sparring Mastectomy the same degree of ptosis. (Picture 3)

Picture 3

There are several potential advantages of implant based reconstructions compared to the pedicled and free flap techniques. There is obviously no donor site morbidity and recovery is much quicker - because of this and the reduced initial costs, in the US the vast majority of reconstructions are now implant based. This raises some important questions: Fig 1. Classification of Skin Sparring Mastectomy Grade I: Mild ptosis - The nipple is at the level of the infrawe be worried about this shift in reconstruction • Should ∑ Grade I: Mild ptosis - The nipple is at the level of the inframammary fold and above most of the lower breast tissue. practice? mammary fold and above most of the lower breast tissue.
Box 1
Grade II: Moderate ptosis - The nipple is located below the inframammary fold but higher than most of the breast tissue hangs. Grade III: Advanced ptosis - The nipple is below the mammary fold but higher than inframammary fold and at the level of maximum breast projection. Grade IV: Severe ptosis - The nipple is far below the ∑ Grade III: Advanced inframammary fold and points toward the floor.
Figure 1 - Classification of skin sparing mastectomy

Grade II: Moderate ptosis -

• Should we be worried about the use of a biologic material? The nipple is located below the infra term data on re-operation rate, aesthetics or patient satisfaction? The nipple is below the

most of we thebe breast tissue hangs. • Should using techniques that have limited long-

ptosis Whatof is maximum worrying is breast that these techniques are now inframammary fold and at the level projection.

mainstream with mainly case series to back up the claims of over existing techniques. Introduction, Grade IV: Severe ptosis - The nipple isbenefit far below the enthusiasm and finally understanding of where a new inframammary fold and points toward the floor. surgical technique fits into managing a condition is a recognisable phenomenon but the days of “having a go” have gone. The NPM assisted technique has been ASiT - the pursuit of excellence in training

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Where Are We Now?
Clinical governance and revalidation dictates that we should know our own data, our implant loss in reconstructions, our recurrence rates etc. The National Mastectomy and Breast Reconstruction Audit (NMBRA) showed that there is a significant risk of implant loss (9%) in IBR but this data was collected before the expansion in use of these two techniques. A significant lesson that should be learnt from the PIP implant fiasco is that introducing a foreign material can have significant consequences. If we did discover a problem with ADMs - identifying individuals that may have had this procedure would be extremely difficult because there is no specific OPCS code for the procedure. Multiple codes have been used by different Trusts with marked variation in tariff. To address these concerns the Association of Breast Surgeons and British Association of Plastic and Reconstructive Surgeons have produced guidelines for ADM specific reconstructions as well as publishing guidelines for Oncoplastic Breast Surgery. The NMBRA was an extremely important audit because the results have been used to provide quality criteria for Oncoplastic surgery and should be seen as an example for other specialities. It does require the goodwill of the surgical fraternity and the financial support to ensure independent collection and interpretation. Patient Related outcome measures (PROMs) are an integral part of such an audit. Long-term, large volume data does not currently exist on either of the techniques that have been described and there are reports of concerns, especially about the NPM technique. To address the lack of data, a prospective audit of these techniques should be starting this year. This hopes to get nationwide explantation rates, re-operation rates and identify factors that may influence success of the procedure. This would allow specific quality criteria for these techniques to be introduced.

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actively marketed and supplemented/marketed with dedicated cadaveric training sessions. We are also in the era of the internet savvy patient who will have seen patients enthusing on this technique and the skills of named experts. This seems to be only about the NPM assisted and not the commoner myo-dermal sling technique. It would be sceptical to say that this is due to the promotion of the companies providing these products (which are not cheap). The significant cost of the NPM has reduced the uptake of the technique because of the reluctance of commissioners to pay extra for the material without evidence of benefit.

References

Carlson GW, Bostwick J, Styblo TM, et al. Skin-sparing mastectomy: oncologic and reconstructive considerations, Annals of Surgery 1997; 225, no. 5: 570–578 Ho G, Nguyen TJ, Shahabi A, Hwang BH, Chan LS Wong AK. A systematic review and meta-analysis of complications associated with acellular dermal matrix-assisted breast reconstruction. Ann Plast Surg Apr 2012; 68(4): 346-56 National mastectomy and breast reconstruction audit, Fourth Annual Report, 2011 http://www.ic.nhs.uk/webfiles/Services/NCASP/audits%20and%20 reports/NHS%20IC%20MBR%202011%20Final%20Interactive%20 16-03-11.pdf Salzberg CA, et al. An 8-Year Experience of Direct-to-Implant Immediate Breast Reconstruction Using Human Acellular Dermal Matrix (AlloDerm) Plast Reconstr Surg 2011; 127: 1 Nair A, Jaleel S, Abbott N, Buxton P, Matey P. Skin-reducing mastectomy with immediate implant reconstruction as an indispensable tool in the provision of oncoplastic breast services. Ann Surg Oncol 2010 Sep; 17(9): 2480-5. doi: 10.1245/s10434-0101058-4 Nava MB, Cortinovis U, Ottolenghi J, Riggio E, Pennati A, Catanuto G, Greco M, Rovere GQ. Skin-reducing mastectomy. Plast Reconstr Surg 2006 Sep;118(3):603-10; discussion 611-3. Oncoplastic Breast Reconstruction. Guidelines for best practice. http://www.associationofbreastsurgery.org.uk/media/23851/final_ oncoplastic_guidelines_for_use.pdf Acellular dermal matrix (ADM) assisted breast reconstruction procedures. http://www.associationofbreastsurgery.org.uk/media/23851/final_ oncoplastic_guidelines_for_use.pdf

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State of the Art: Advances in Intraoperative Imaging and Guidance in Cranial and Spinal Neurosurgery
Adam Williams, Specialist Registrar in Neurosurgery, Nicholas Haden, Consultant Neurosurgeon and Complex Spine Surgeon and Peter Whitfield, Consultant Neurosurgeon and Associate Professor of Neurosurgery, Department of Neurosurgery, South West Neurosciences Centre, Derriford, Plymouth
Introduction

significantly less accurate. Similar problems affect spinal surgeons: the mobile spinal column cannot be easily held intra-operatively (often in the prone position) in the same position the patient was imaged in preoperatively (often supine). In an effort to overcome these limitations, there has been the development of ever more elegant methods of intra-operative imaging acquisition and navigation including CT, MRI and USS, to better guide both cranial and spinal neurosurgeons.

History of Intra-operative Imaging
Intraoperative imaging in Neurosurgery has made great progress since Dandy’s evolution of pneumoencephalography in the early 1900s1. The 1980s saw the 2 introduction of intraoperative imaging with CT , but the clear benefits of MR, including the lack of hazardous radiation and better parenchymal imaging, drove a group incorporating General Electric Medical Systems (Milwaukee, WI), neurosurgeons, radiologists and otolaryngologists, at Brigham and Women’s Hospital (BWH) in Boston to develop intraoperative MRI (ioMRI3. At the time, the closed configuration of MRI imaging precluded access to the patient and so a fundamental shift in MRI magnet and coil technology was required to allow intraoperative access to the patient.

All forms of surgery are improved by more accurate preoperative imaging and intraoperative localisation of pathology. However, the brain and spinal cord have a particular distaste for surgeons that venture off course and an area of particular interest over the turn of the century has been the development of more advanced intraoperative imaging and neuronavigational equipment to aid the modern neurosurgeon. Neuronavigational equipment is well established in British cranial neurosurgery. In essence, ‘frameless’ systems rely on the virtual fusion of 3D preoperative CT or MRI imaging to the patient’s anatomy. The patient’s head is positioned preoperatively and is held firmly in place with a Mayfield clamp. Registration of the position of the patient’s head ‘in space’ is achieved using a two-camera infrared optical, or electromagnetic, localiser and this data is coupled with the preoperative Figure 1 imaging establishing a spatial relationship between Figure 1 the preoperative imaging data and the corresponding Eventually SIGNA, a 0.5 Tesla “double donut” of intraoperative anatomy. Navigational systems can then vertically orientated bi-planar superconducting magnet track the movement of surgical instruments using coils (figure 1) was developed, allowing the surgeon infrared reflectors, and using defined mathematical to operate between the two coils ensuring adequate algorithms, a specific point in the imaging dataset can access and reasonable freedom of movement. However, be “matched” to its corresponding point in the surgical along with the challenges in MR design, the immobility field. The surgeon can therefore work in the math of the system required concurrent challenges with ematical space of the brain image that corresponds to development of MRI-compatible surgical instruments, such as the non-ferromagnetic drill (Midas Rex the physical space. Unfortunately, current systems are flawed. Once: a Corporation, Medtronic, Minneapolis, Minnesota and craniotomy has been turned, brain retractors placed, the intraoperative visual displays. Thus, the major cisternal or ventricular CSF has been drained, changes difficulty with the static “double donut” solution in PaCO2 occur or a tumour is partially resected, the proposed above was the need to completely remodel intracranial contents move (“brain shift”). This makes the both the operating theatre in which it was housed, preoperative images that are used for neuronavigation and the surgical equipment.

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Alternative methods were developed to overcome these limitations whereby the MRI magnets could be rapidly moved into and out of the surgical field. In 2001 Hadani4 developed the PoleStar® N-10 (Medtronic Navigation, Louisville, Colorado), a moveable openconfiguration low-field 0.12T system with two parallel magnets attached to a C-arm that could be moved into position easily, and the BWH group developed the IMRIS system, a moveable ceilingmounted closed- configuration high-field (1.5T) scanner allowing rapid delivery of the scanner to the patient and thereafter its removal, bypassing the need for complex MRI-compatible surgical equipment5.

While some modern low-field systems still use a side-loading positioning of the patient however, the most popular low-field design is that of the PoleStar® N30 surgical imaging system (Medtronic Navigation, Louisville, Colorado, figure 3). While the image detail of these systems is not comparable to those of the high-field equipment, this system reduces overall cost and complexity in a number of ways. For example, it reduces the need for radio frequency shielding, it eliminates the need for complex operating department reconstruction and it avoids potentially risky patient transfer into and out of the scanner. It also allows for surgery to continue while the scanner is either in place, or stowed underneath the operating table.

Modern Intraoperative Cranial Imaging
Both low and high field principles have been developed into modern systems. However, the demand for imaging that approaches diagnostic MRI quality (1.5-3.0T) has driven a movement towards the high-field closed-bore systems that require either patient or scanner movement, but come with much higher field strength. Thus, more efficient ways of intraoperative transfer of patients into and out of MRI scanners have been developed. An example of this includes the Brainsuite® iMRI (Brainlab AG, Feldkirchen, Germany, figure 2), that is installed in over 60 sites worldwide, that focuses on customised high-field installations of 1.5-3.0T MRI scanners from Phillips, GE or Siemens, with efficient patient-flow using dedicated operating tables and transfer systems, to and from the MRI scanner. The neuronavigation systems, capable of preoperative and intraoperative imaging fusion, are usually either ceiling mounted (Brainsuite® iMRI) with slave screens on the theatre walls, or portable units (Brainlab curve). In addition, high field systems allow for hybrid systems, incorporating advanced MRI modalities including; functional MRI (fMRI), diffusion-weighted MRI (DW-MRI), MR-spectroscopy (MRS), MR-angiography (MRA), and MR-venography (MRV).
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Advances in Spinal Neuronavigation and Intraoperative Imaging
Spinal surgery continues to make rapid technological advancements, and while plain radiographs and fluoroscopy have been used for guiding skin incision placement, ensuring surgery at the correct level and as an adjunct to anatomical knowledge in implant placement, it is a poor solution for the last of these. Simple fluoroscopy is bi-planar (anterio-posterior and lateral) and cannot provide the axial views that are most useful in ensuring accurate placement of implants. Consequently, better image-guidance techniques are emerging. These techniques include the fusion of pre-operative CT images to intraoperative anatomy. A fine-cut CT scan of the spine is performed pre-operatively and once the spinous processes of the appropriate levels have been exposed operatively, a dynamic reference array (DRA) is clamped to an appropriate spinous process. The CT data is then registered to the patient with reference to this array, either with ‘surfacematching’ or by using a number of specific predefined anatomical landmarks that are localised intraoperatively with a registration probe. While the ability to fuse pre-operative CT imaging with intraoperative

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anatomy and imaging is beneficial, it is not without limitations: pre-operative preparation is lengthy requiring specific CT sequences, registration can be problematic and the spine is a dynamic structure, and the pre-operative CT does not demonstrate the inter-segmental relationship is it is in the operating position. Thus, two further techniques of particular interest which include intra-operative CT image acquisition and intraoperative 3d C-arm fluoroscopy. In the first of these, once an adequate operative exposure is undertaken, reference fiducials are attached to rigid bone landmarks and an intraoperative CT is performed. The fiducials are then registered in relation to a DRA attached to a spinal process. Such imaging and navigation techniques have made significant improvements to patient safety. A group in Pittsburgh6, using an intra-operative 64-slice multidetector CT scanner, have been able to demonstrate only a 1.2% incidence of imperfect placement. Conversely, is evidence the up to 30% of pedicle screws can be poorly placed using simple fluoroscopy and anatomical knowledge, even in the hands of experienced surgeons7.

instrumentation has provided encouraging results8. There is strong data that pedicle screw placement is more accurate using image navigation over conventional fluoroscopy9 and may contribute to cost-saving by allowing immediate screw revision in the event of malplacement and thus negating the need for early revision surgery10.

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Figure Figure 4 4
3D Fluoroscopy systems, such as the Siemens ARCADIS® Orbic 3D C-arm (figure 4), whilst using similar imaging technology to a standard intraoperative fluroscope, automatically rotate around the patient in an isocentric fashion and use software manipulation to create a 3D image of the bone. It thus functions in a similar fashion to CT. During the image acquisition, a DRA is clamped to the relevant spinous process and the C-arm is also fitted with a calibration marker, and thus the camera, DRA and bony anatomy can all be localised in space. While the image quality is less accurate than that obtained with pre- and intraoperative CT, its navigational accuracy is good and it comes without the significant cost of the gold-standard intraoperative CT scanner. Packages such as the Brainlab Spinal Navigation Application (figure 5) allows surgeons to use images data from either modality to augment their anatomical understanding. Application of this technology Figure to spinal 110

The Future of Intraoperative Imaging The future is likely to hold greater integration of diagnostic-grade imaging and modalities to the intraoperative setting. The Advanced Multi-modality Imaging Guided Operating (AMIGO) suite in the BWH (figure 6) incorporates 3.0T MRI, positron emission tomographic and CT, ultrasound, radiographic fluoroscopy, and microscopy to update preoperative plans. This unification of multiple intraoperative imaging modalities promises the delivery of superior care for a wide range of neurosurgical problems. Further advancements are also likely to be made into the use of ioMRI-compatible robotics to enhance the surgeons ability to perform surgery within closed-field ioMRI environments.

Figure 6 6.

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However, it will be necessary to overcome the limitations affecting current imaging, including: the electrical environment in the operating environment, magnetic field instability, artifact and contrast extravasation due to disruption of the blood brain barrier. More than this, however, will be reductions in the considerable financial implications in the acquisition of such technology, and its economic justification will be critical to ensure its future in standard neurosurgical practice. There is emerging evidence that ioMRI reduces length of hospital stay and that hospital charges and costs11, but that will need to balanced with the initial outlay and disruption to current service provision.

References

1. Dandy WE. Roentgenography of the brain after the injection of air into the spinal canal. Ann Surg 70: 397-403, 1919 2. Lunsford LD. A dedicated CT system for the stereotactic operating room. Appl Neurophysiol 1982. 45: 374-378 3. Mislow JMK, Golby AJ, Black P. Origins of intraoperative MRI. Neurosurg Clin N Am 2009 April; 20(2): 137-146 4. Hadani M, Spiegelman R, Feldman Z, et al. Novel, compact, intraoperative magnetic resonance imaging-guided system for conventional neurosurgical operating rooms. Neurosurgery 2001; 48(4): 799-807. discussion: 9

ASiT Clinical and Academic Travelling Bursaries Application deadline 4th August 2013 ASiT is offering our members travelling bursaries to support clinical and/or academic training activities. Each bursary will be for up to £300 to contribute towards travel to clinical or academic centres either in the UK or abroad. Up to 5 bursaries will be awarded in the current round. To apply for an ASiT Travelling Bursary, you need to be a current ASiT member and email info@asit.org with the following: 1. A summary outlining the specifics of the visit or course and why you should receive a travelling bursary (400 words maximum) - please include your ASiT membership number 3. A 1-page summary of your CV Successful applicants will be required to write a report for the ASiT Yearbook. Further details can be found at: http://www.asit.org/resources/awards/travelling-bursaries We look forward to receiving your application. www.asit.org Registered Charity: 274841

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5. Sutherland GR, Kaibara T, Louw D, Saunders J. A mobile high-field magnetic resonance imaging system for neurosurgery. Neurosurg Focus 6(3): Article 6, 1999 6. Tormenti MJ, Kostov DB, Gardner PA, et al. Intraoperative computed tomography image-guided navigation for posterior thoracolumbar spinal instrumentation in spinal deformity surgery. Neurosurg Focus 2010. 28 (3): E11 7. Weinstein JN, Spratt KF, Spengler D, et al. Spinal pedicle fixation: reliability and validity of roentgenogram-based assessment and surgical factors on successful screw placement. Spine 13: 1012-1018 8. Nottmeier EW, Seemer W, Young PM. Placement of thoracolumbar pedicle screws using three-dimensional image guidance: experience in a large patient cohort. J Neurosurg Spine 2009. 10: 33-39 9. Amiot LP, Louis-Phillipe, Lang, et al. Comparative Results Between Conventional and Computer-Assisted Pedicle Screw Installation in the Thoracic, Lumbar, and Sacral Spine. Spine 2000; 25: 606-14 10. Hüfner T, Stübig T, Göstling T, Kendoff D, Geerling J, Krettek C. Cost-benefit analysis of intraoperative 3D imaging. Unfallchirurg 2007; 110: 14-21 [German] 11. Hall WA, Kowalik K, Liu H, et al. Costs and benefits of intraoperative MR-guided brain tumor resection. Acta Neurochir Suppl 2003; 85: 137-142

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History and Advances in Lower Limb Angioplasty
Gary Lambert, Vascular Research Registrar and Alok Tiwari, Consultant Vascular Surgeon, University Hospital, Birmingham
Introduction
Peripheral Arterial Occlusive Disease results from atherosclerosis of the arteries. Its links to smoking, hypertension, diabetes and hypercholesterolaemia are well documented and universally accepted. The infra-inguinal patterns of disease have historically been the main limiting factor to the use and long term outcome of percutaneous angioplasty. Such factors include relative length of diseased segments, complete and flush occlusion, multifocal segmental involvement with associated poor runoff and chronic obstruction. Coronary heart disease remains the major cause of death in people with PAD and the mortality rate, mainly from coronary and cerebrovascular events, is three to four times greater than age-sex matched controls without claudication1. The risk is similarly increased in those who have asymptomatic disease as well as those with intermittent claudication. Patients presenting with intermittent claudication have been shown to develop significant morbidity and mortality of the following five years. Symptomatically; 50% will improve, 25% will stabilise and 25% will worsen. Of those who worsen, 20% (5% of total) will need intervention and 8% (2% of total) will need a major limb amputation2. Furthermore, 5-10% will have a non-fatal cardiovascular event, 30% will die: cardiac 16%, cerebral 4%, other vascular 3%, non-vascular 7% and only 55-60% will survive with no cardiovascular event. Their prognosis following amputation is poor. Two years following a below-knee amputation, 30% are dead, 15% have an above-knee amputation, 15% have a contralateral amputation, and only 40% have full mobility3. The comorbidity and mortality rates associated with the presence of peripheral vascular disease have been a driving force behind the attempt to develop less invasive and less risky interventions for peripheral arterial disease, with an aim to increase limb salvage rates at the same time.

The BASIL Trial (Bypass versus Angioplasty in severe Ischaemia of the Leg) sought to identify whether patients with severe limb ischaemia due to PAD were best treated with a surgical or endovascular approach. 452 patients with severe limb ischaemia due to infrainguinal disease were randomized to angioplasty or infrainguinal bypass. The primary endpoint was amputation-free survival. Secondary endpoints included all-cause mortality, morbidity, reintervention, quality of life, and hospital costs. Its results demonstrated that both overall survival and amputation free survival was almost identical between the surgical intervention group and the endovascular intervention groups4. Surgery was associated with a higher morbidity (57% vs 41%), mainly due to myocardial infarction and wound infection, though the 30-day mortality was similar (5% for surgery and 3% for angioplasty). Surgery was more expensive during the first year, due to the longer hospital stay, although 6-month amputation-free survival remained similar. Patients undergoing angioplasty had higher failure rates (20% vs 3% at 1 year) and subsequently, higher reintervention rates (27% vs 17%). Subsequently, the rates of endovascular procedures for lower limb ischaemia have risen, with concurrent advances in both angioplasty and stent technology and techniques. TASC The publication of the TASC guidelines in 2000 was intended to provide a more standardised method and process for the investigation and management of PAD. The subsequent update in 2007 of the TASC II guidelines demonstrated the progress in endovascular interventions for lower limb PAD within a short period of time. This progress has continued further and work is progressing on the TASC IIb guidelines which will include tibial vessel classification and also look in greater detail at open surgical options and severe lesions5,6. Progress in device and therapeutic modalities since the original TASC and even TASC II guidelines has seen the advent of the self expanding nitinol stents and more recently the use of Drug Eluting Balloons (DEBs). These have further increased the potential reach and use of endovascular techniques in the lower limb. During the decade since the original TASC guidelines were published, the use of endovascular modalities has extended beyond the TASC A and B lesions to include C and now even D lesions previously treatable by open surgical bypass only. One limiting factor in the endovascular management of the lower limb, particularly of the SFA and popliteal artery has been the incidence of re-stenosis due to calcification, elastic recoil or neointimal hyperplasia coupled with diffuse disease. The rates of SFA restenosis at six months following PTA is 30-70%7,8, which compares poorly against that of arterial disease

BASIL; Angioplasty vs Bypass?
Prior to the BASIL trial, there was increasing debate over the relative roles and outcomes for surgery and endovascular intervention in the management of lower limbs with PAD present4.

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TASC II classification of lower limb occlusive disease

Balloon Angioplasty
The first peripheral balloon angioplasty conducted was performed by Charles Dotter in 1964. He performed balloon angioplasty of the Superficial Femoral Artery of an 82 year old lady with critical limb ischaemia9. Standard balloon angioplasty utilises a balloon catheter passed over a wire through the arterial stenosis and dilating the stenosis or occlusion under pressure from the balloon.

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elsewhere in the body, carotids 2-5%, coronaries 20-35% or renal arteries 15-20%5. It is such limitations that have resulted in the progression of technologies in the aim of reducing restenosis and improving outcomes.

Standard angioplasty has technical limitations however. The ability to traverse long occlusions, or successfully treat diffuse multisegment disease is limited. Flush occlusions of an arterial bifurcation also limit the ability and extent to which standard balloon plasty can be performed successfully. Balloon angioplasty is further limited by a number of conditions including restenosis from intimal hyperplasia, acute elastic recoil causing early failure and dissection. In order to counter these conditions, a number of balloon technologies have been developed.

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Left leg SFA subintimal angioplasty using an Outback Ltd catheter (Cordis), with the L shaped guides to assist luminal re-entry visible Left proximal SFA balloon angioplasty of a short stenosis

It can be further supported by the use of stenting if necessary in the presence of restenosis or recoil from the lesion. SIA has been shown to have an 80-90% one year limb salvage rate12. However one year patency rates are inferior to those of both vein graft bypass and even PTFE graft bypass of femoral and femoro-popliteal segments. The major limiting factors to the use of SIA is not the length of the lesion, but the status of the vessel wall and lumen above and below the lesion to be treated.

Drug-eluting Stents and Balloons
Angioplasty is associated with re-stenosis of segments. The combination of elastic recoil and cellular proliferation leads to the target lesion re-stenosing. The use of stents to try and maintain the luminal diameter post plasty is limited by the risk of in stent thrombosis, late vessel remodelling, neointimal hyperplasia and the risk of stent deformity if it spans a joint. Whilst the risk of stent deformity is discussed elsewhere in this article, stent failure due to elastic recoil, neointimal hyperplasia and late vessel remodelling remains an important cause of occlusion post endovascular intervention.

Subintimal Angioplasty
The first Subintimal Angioplasty (SIA) was performed in 1987 by Amman Bolia10,11. The deliberate creation of an intimal dissection by passing the guidewire out of the lumen, through the intima, beyond the diseased segment before re-entering the arterial lumen distally has allowed greater use of endovascular intervention for infra-inguinal disease. The procedure outcome is user and centre dependant, with variations reported between centres.

Initial right SFA/Popliteal subintimal angioplasty with inadequate outcome

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Early experiences utilised standard catheters, sheaths and guidewires to perform the dissection and return to the distal lumen. More recently, advances in catheter design have led to specific catheters such as the Outback Catheter by Cordis, which are designed to assist in the guided direction of the wire through the intima, beyond the lesion and re-entry to the lumen distally. Subintimal angioplasty has been demonstrated to assist in managing previously difficult lesions. Flush occlusions of the SFA, and even long TASC D lesions can now be considered using this method to revascularise the limb. 114

Further treatment following figure above using a Zilver Ptx (Cook) drug eluting stent to improve the flow past the lesion and maintain patency

The use of the chemotherapeutic drugs in association with both stents and balloon angioplasty was originally pioneered in coronary angioplasty13. The drug of choice initially was Sirolimus, though more recently Paclitaxel

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In stent re-stenosis treated with Advance 18PTX (Cook) drug eluting balloon

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Cutting Balloon Angioplasty Cutting balloons were first designed to treat restenosis of coronary artery stents due to neo-intimal hyperplasia. The balloon has a number of microsurgical blades mounted on it longitudinally. As the balloon is inflated, the blades incise into the intima, disrupting the ringlike structure that results in elastic recoil, permitting a more controlled and tension free dilatation of the vessel. A number of studies have demonstrated the potential efficacy of cutting balloons in the management of short recurrent stenoses and most importantly in the stenosis of graft anastomoses following lower limb bypass17. Cutting balloons are limited primarily in the length of stenosis that can be treated and the current move towards investigating drug eluting technology may

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has become more widespread. It has the benefit of being rapidly taken up by tissues in contact with it, making it of use in Drug Eluting Balloons (DEB). The SIROCCO study initially studied the outcome in Bare SMART stents with Sirolimus coated stents. This demonstrated a 0% six month restenosis rate in the drug eluting stent arm versus 23% in the bare stent arm, although the rate of restenosis in the bare stent arm was lower than previously expected14. The Sirolimus has two distinct mechanisms of action, being both anti-inflammatory and cytostatic in its actions. More recently, drug eluting balloons have been developed that utilise Paclitaxel instead of Sirolimus. Tepe et al demonstrated that use of such drug coated balloons reduced reintervention rates from 37% to only 4% (p<0.001) versus non drug eluting balloons at six months15. A number of subsequent studies have demonstrated the reduction in restentosis rates that are associated with drug eluting balloons, though the absolute indications and uses remain unclear16. One benefit that the balloons carry is the lack of stent insertion needed, thus reducing the possible associated complications of stent insertion, or fracture. Long term data is still absent due to the novelty of the technique, though it is hoped that DEBs will show positive long term benefits.

overtake their use which has yet to become widespread in peripheral arterial disease.

Cryoplasty
The use of nitrous oxide within the angioplasty balloon results in cooling of the balloon to -10 degrees centigrade. This cooling effect is believed to cause an acute phase response and apoptosis in the vessel’s smooth muscle. This method of cold induced apoptosis is believed to reduce the elastic recoil and development of neointimal hyperplasia. Although licensed in the USA and Europe in 2002 and 2005 respectively, this procedure has failed to gain widespread use. Clinical data is limited and the numbers within studies is too small from which to draw adequate conclusions. Cost is significantly increased by the process with procedures costing $1700 more per procedure18 resulting in its clinical use being limited as a result and a failure to gain widespread acceptance.

Bare Stents

The limitations of standard balloon angioplasty include calcification, elastic recoil and re-stenosis. The stent is used as a structural scaffold to maintain the luminal diameter following angioplasty. Early stents were stainless steel, balloon mounted stents that were expanded under pressure from the balloon within the stent lumen. Balloon expandable stents are inherently stiff and therefore can only be used to treat short lesions, causing their use in the lower limb, and particularly femoro popliteal region to be limited19,20. The femoropopliteal segment is further complicated by the differing complex mechanical forces that the artery is subjected to. The artery is subjected to considerable forces simultaneously with every movement of the leg, and this leads to the risk of stent fracture or occlusion. Modern stents have been developed to counteract the original limitations of stainless steel stents. Originally, balloon expandable stents were very rigid with little flexibility and were thus prone to kinking when subjected to radial or torsional forces. Newer materials such as Nickel Titanium Alloy (Nitinol) have enabled development of more complex helical stent frameworks. These frameworks permit greater flexibility and radial resistance to forces. They have developed further to create stents that will expand under their own intrinsic memory without the need for balloon expansion and also reduce the need for temporary occlusion of the lumen. Modern stent materials have also sought to reduce the risk of stent occlusion by taking into account the electrical charge properties of the stent material to help reduce the potential for thrombosis and neointimal hyperplasia. There is now evidence that the use of primary nitinol stents in the femoro-popliteal segments carry a 20-30% reduction in restenosis over angioplasty alone at two years, and is of increasing consideration as a primary intervention as a result21,22.

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The longest standing follow up of nitinol stent data comes from the SIROCCO I and II studies14,23. The studies compared bare nitinol SMART stents with Sirolimus eluting nitinol stents, which demonstrated a 6 month restenosis rate of 11.6% and maintenance of ABPI and symptom improvement beyond 24 months. Further studies into more modern nitinol stents within the SFA have also demonstrated significant improvement in the restenosis rates when nitinol stenting of SFA lesions is compared to that of balloon angioplasty alone. This data and the progressive improvement in design and delivery of the stents has seen an increase in the use of stenting of the SFA and the combination of nitinol stents with subintimal angioplasty to treat lesions previously considered treatable by surgical bypass only.

Left SFA luminal angioplasty with placement of a Viabahn (Gore) covered stent

Developing Technologies
There is increasing attention returning to the use of Laser assisted angioplasty. This technology was previously explored with limited success and therefore stopped due to the heat generated and dissipated through tissues as a result of the hot tip lasers in use at the time25. However, the development of Laser Excimer technology has resulted in further research into its use in angioplasty and recanalisation. The use of ultraviolet laser reduces the tissue temperature created, limiting collateral damage. It also has a greater ability to not only ablate thrombus but also inhibit platelet aggregation following its use26. The LAIRD trial demonstrated a 6 month limb salvage rate of 93% in patients undergoing Laser Excimer Angioplasty for critical limb ischaemia and deemed unfit for surgical intervention27. Mechanical atherectomy has yet to gain widespread use or acceptance. Research and evidence for the techniques of excisional and rotational atherectomy remains mixed and sparse. Techniques for crossing or passing through chronic lesions are still yet to be proven. The development of micro-dissection tipped catheters and high frequency vibration catheters to aide the luminal crossing of lesionshave yet to demonstrate effectiveness, though development and research is ongoing.

Left SFA stenosis initially balloon angioplastied, with inadequate outcome leading to insertion of a Lifestent (Bard) bare nitinol stent

Covered Stents
Covered stents have been developed in both self expanding and balloon expandable types. The clear difference with bare stents is the use of graft material to provide coverage and seal of the stent and vessel wall. The use of such stent grafts is of benefit in the management of pseudo-aneurysms and also in arterial trauma too. The use of stent grafts in PAD is less clear and the relatively new stents are yet to demonstrate adequate long term data on patency rates. The Viabahn (Gore) ePTFE covered nitinol stent has been demonstrated to have equivalent one year patency to synthetic femoro-popliteal bypass24. Aside from the benefit of traumatic wall coverage, the stent grafts also carry the ability to cover plaque that is otherwise friable or at risk of rupture if stented, reducing the risk of in stent or distal thrombosis. The VIBRANT study has completed recruitment and is investigating the outcomes in bare vs covered stents.

Conclusions
The morbidity and mortality rates associated with both peripheral arterial disease and its subsequent surgical management have been challenged over the past decade by the development of new and increasing technology with respect to endovascular therapy. The results of the BASIL trial challenged the long held philosophy that surgery was superior in all aspects to endovascular therapy. In the time since the results were published, the techniques available in endovascular management have expanded and developed rapidly, with many

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demonstrating equivalent patency and limb salvage rates in comparison to open surgical bypass. The long term success of these techniques depend upon the ability to cope with complex forces, multifocal disease, long segment disease, elastic recoil and neointimal hyperplasia following therapy. As with many therapies, the future answers will probably lie within the combination of multiple modalities to better identify and treat target lesions using the most appropriate method. Ongoing research will enable identification and further re-classification of which lesions should be best treated with different modalities. With the developments that have occurred since the original publication of BASIL, there is certainly an opportunity to look again at the indications and outcomes for open vs endovascular management of lower limb occlusive disease.

1. Kannel WB, McGee DL. Update on some epidemiologic features of intermittent claudication: the Framingham Study. J Am Geriatr Soc1985; 33: 13-18 2. Burns P, Gough S, Bradbury AW. Management of peripheral arterial disease in primary care. BMJ. 2003; 326(7389): 584-8 3. European Society of Cardiology. Diagnosis and Treatment of Peripheral Artery Diseases. European Heart Journal 2011; 32: 2851-2906 4. Adam DJ, Beard JD, Cleveland T, Bell J, Bradbury AW, Forbes JF, Fowkes FG, Gillepsie I, Ruckley CV, Raab G, Storkey H; BASIL trial participants. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial. Lancet 2005 Dec 3; 366(9501): 1925-34 5. TASC. Management of peripheral arterial disease (PAD). TransAtlantic Inter-Society Consensus (TASC). Eur J Vasc Endovasc Surg 2000;19 Suppl A: Sixxviii, S1-S250 6. Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg 2007; 33 (Suppl 1): S1-75 7. Duda SH, Poerner TC, Wiesinger B, et al. Drug Eluting stents: potential applications for peripheral arterial occlusive disease. J Vasc Interv Radiol 2003; 14: 291-301 8. Duda SH, Bosiers M, Lammer J, et al. Sirolimus-eluting versus bare nitinol stent for obstructive superficial femoral artery disease: the SIROCCO II trial. J Vasc Interv Radiol 2005; 16: 331-338 9. Dotter CT and MP. Judkins Transluminal treatment of arterio sclerotic obstruction. Circulation 1964; 30: 654-670 10. Bolia A, Brennan J, Bell PR. Recanalization of femoropopliteal occlusions: improving success rate by subintimal recanalization. Clin Radiol 1989; 40: 325 11. Bolia A, Miles KA, Brennan J, Bell PRF. Percutaneous transluminal angioplasty of occlusions of the SFA by subintimal dissection. Cardiovasc Intervent Radiol 1990; 13: 357-363 12. Met R, Van Lienden KP, Koelemay MJW, Bipat S, Legemate DA, Reekers JA. Subintimal Angioplasty for Peripheral Arterial Occlusive Disease: A Systematic Review. Cardiovasc Intervent Radiol. 2008 July; 31(4): 687-697 Serryus PW, Regar E, Carter AJ, Rapamycin eluting stent: 13. the onset of a new era in interventional cardiology. Heart 2002; 346:1773-80

References

14. Duda SH, Pusich B, Richter G, Landwehr P, Oliva VL, Tielbeek A, Wiesinger B, Hak JB, Tielemans H, Ziemer G, Cristea E, Lansky A, Beregi JP. Sirolimus-eluting stents for the treatment of obstructive superficial femoral artery disease: Six-months results. Circ 2002;106:1505-1509 15. Tepe G, Zeller T, Albrecht T, Heller S, Schwarzwälder U, Beregi JP, Claussen CD, Oldenburg A, Scheller B, Speck U. Local delivery of paclitaxel to inhibit restenosis during angioplasty of the leg. N Engl J Med. 2008 Feb 14; 358(7): 689-99 16. Minar E, Schillinger M. Innovative technologies for SFA occlusions: drug coated balloons in SFA lesions. J Cardiovasc Surg (Torino). 2012 Aug; 53(4): 481-6 17. Vikram R, Ross RA, Bhat R, Griffiths GD, Stonebridge PA, Houston JG, Chakraverty S. Cutting balloon angioplasty versus standard balloon angioplasty for failing infra-inguinal vein grafts: comparative study of short- and mid-term primary patency rates. Cardiovasc Intervent Radiol 2007; 30: 607-610 18. Samson RH, Showalter D, Lepore M, Nair DG, Merigliano K. CryoPlasty therapy of the superficial femoral and popliteal arteries: A reappraisal after 44 months’ experience. Journal of Vascular Surgery Sept 2008; 48(3): 634-637 Sabetti S, Schillinger M, Amighi J, Sherrif C, Mlekusch W, 19. Ahmadi R, Minar E. Primary patency of femoropopliteal arteries treated with nitinol versus stainless steel self expanding stents: propensity score-adjusted analysis. Radiology 2004; 232(2): 516-521 20. Grimm J, Mueller-Huelsbeck S, Jahnke T, Hilbert C, Brossman J, Heller M. Randomized study to compare PTA alone versus PTA with Palmaz stenting for femoropopliteal lesions. J Vasc Interv Radiol 2001;12: 935-942 21. Schillinger M, Sabeti S, Dick P, Amighi J, Mlekusch W, Schlager O, Loewe C, Cejna M, Lammer J, Minar E. Sustained benefit at 2 years of primary femoropopliteal stenting compared with balloon angioplasty with optional stenting. Circulation 2007; 115: 2745-2749 22. Dick P,Wallner H, Sabeti S, Loewe C, Mlekusch W, Lammer J, Koppensteiner R, Minar E, Schillinger M. Balloon angioplasty versus stenting with nitinol stents in intermediate length superficial femoral artery lesions. Catheter Cardiovasc Interv 2009; 74: 1090-1095 23. Duda SH, Bosiers M, Lammar J, Scheinert D, Zeller T, Olivia V, Tielbeck A, Anderson J, Wiesinger B, Tepe G, Lansky A, Jaff MR, Mudde C, Tielmans H, Beregi JP. Drug-eluting and bare nitinol stents for the treatment of atherosclerotic lesions in the superficial femoral artery: long-term results from the SIROCCO trial. J Endovasc Ther. 2006;13(6): 701-710 24. Kedora J, Hohmann S, Garrett W, Munschaur C, Theune B, Gable D. Randomized comparison of percutaneous Viabahn stent grafts vs prosthetic femoral-popliteal bypass in the treatment of superficial femoral arterial occlusive disease. J Vasc Surg 2007; 45(1): 10-6 25. Tepe G, Zeller T, Albrecht T, et al. Local delivery of paclitaxel to inhibit restenosis during angioplasty of the leg. N Engl J Med 2008; 358: 689-699 26. Wollenek G, Laufer G. Comparative study of different laser systems with special regard to angioplasty. Thorac Cardiovasc Surg 1988; 36(suppl 2): 126-132 27. Laird JR, Zeller T, Gray BH, Scheinert D, Vranic M, Reiser C, Biamino G. Limb salvage following laser-assisted angioplasty for critical limb ischemia: results of the LACI multicenter trial. J Endovasc Ther 2006; 13: 1-11

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The Use of Endoscopic Simulation in Surgical Training
James Ansell, Royal College of Surgeons of England Research Fellow in Simulation, Welsh Institute for Minimal Access Therapy (WIMAT), Cardiff Medicentre and Jared Torkington, Consultant Colorectal Surgeon, University Hospital of Wales, Cardiff
Introduction

mechanical simulators were constructed from plastic8. The Erlangen Plastic Mannequin for upper endoscopic management was the earliest to be reported9. Mechanical models have lacked realism because of poor simulation of tissue properties8. These simulators have largely been replaced by more realistic and adaptable alternatives but may still be useful for the novice during the early stages of learning8. Ex-vivo Animal Tissue Simulators: These models are made from plastic parts with explanted animal organs and have overcome some of the practical and ethical limitations of live animal simulation8. The Erlangen Active Simulator for Interventional Endoscopy (EASIE) was one of the first models of this type to be developed for endoscopic training10. This consists of a plastic head and torso mounted on a tilting device8. Porcine upper gastrointestinal organs are inserted into the simulated abdomen. An arterial perfusion system feeds synthetic coloured fluid via an electric pump incorporated into the frame to simulate arterial bleeding8. This model has also been developed into a lighter, more portable design known as the compactEASIE11. There are fewer ex-vivo models available for lower GI endoscopy. The Endo X Trainer (Medical Innovations International, Rochester, Minn) is a bovine simulator for use in diagnostic colonoscopy training and the WIMAT colonoscopy suitcase is a porcine colonic polypectomy model12,13 (Figure 1).

Current surgical trainees have fewer hours to reach 1 competency in endoscopy . A new approach is needed if streamlining of training is to be effective. Simulating surgical procedures is one way to enhance training and assessment. In 2011, the Association of Surgeons in Training (ASiT) concluded that simulation should be integrated into the curriculum to supplement clinical training but not to replace it2. Improved accessibility, awareness and high standards of local facilities will allow trainees and trainers to fully utilise simulation2. The Joint Committee on Surgical Training (JCST) has started to incorporate simulation into the Intercollegiate Surgical Curriculum Project (ISCP) as part of skills assessment3. Simulation is particularly attractive in the field of endoscopy because it avoids the use of patients for skills practice and ensures that trainees have had some exposure before undertaking real-life procedures4. Endoscopic skills have a long learning curve with 200 procedures being suggested as the minimum number needed to reach technical competence in diagnostic colonoscopy5. Simulator training results in higher rates of caecal intubation and a reduction in patient discomfort6. Endoscopic training in the United Kingdom (UK) is governed by the Joint Advisory Group on Gastrointestinal Endoscopy (JAG) and administered through the JAG Endoscopy Training System (JETS)7. Mandatory JAG Figure 1 - The WIMAT Colonoscopy suitcase for simulated colonic polypectomy training courses for accreditation utilise simulation techniques Figure 1 WIMAT - The WIMAT Colonoscopy suitcase for simulated colonic polypectomy trai Figure 1 - The Colonoscopy suitcase for simulated colonic polypectomy training as an adjunct to real-life training. This article provides Virtual Reality Simulators : Virtual reality computer simulators are a w Ex-vivo animal simulators are adaptable and can be used an overview of endoscopic simulation, outlines the Virtual Reality Simulators : Virtual reality (VR)(VR) computer simulators 16 are a way o 16 . These utilis an opportunity to practice skills in a risk-free environment . These utilise c an opportunity to practice skills in a risk-free environment to simulate a range of endoscopic procedures including key features of simulator validation and the different with varying degrees of difficulty. This enables the trainee to perform mul with varying degrees of difficulty. This enables the trainee Mucosal to perform multipl Gastroscopy, Colonoscopy, Endoscopic ways of optimising training opportunities. results to monitor their progress. There are currently several VR endosco results to monitor their progress. There are currently several VR endoscopic recent Cochrane Collaboration Review demonstrated that VR training Polypectomy, Retrograde recent Resection Cochrane (EMR), Collaboration Review Endoscopic demonstrated that VR 21 training im . The majo surgical training and is at least as effective as video training 21 Cholangiopancreatography (ERCP), Endoscopic Simulators surgical training and is at least as effective as and videoPercutaneous training . The major lim the financial expense, with the average cost of a VR trainer exceeding £1 8 the financial expense, with the average cost of and a VR trainer exceeding £100 Endoscopic Gastrostomy (PEG) tube insertion . These Mechanical Simulators: Over the past decade, there has are too simplistic for advanced trainees the assessment parame 12 are too simplistic for advanced trainees and the assessment parameters are a financially viable option for been an explosion in the development and utilisation of irrelevant . training large numbers as a marker of expertise 12 irrelevant as a marker of expertise . simulators for endoscopic training (Table 1). The first of participants with varying levels of experience. 118 ASiT - the

The Requirements of an Endoscopic Simulator The Requirements ofthe an Endoscopic Validation: With development Simulator of any new simulator, validation of it Validation : With the development of any new validation ofinstrum its e process. Validation is the determination of simulator, the extent to which an 8 determination of the extent to which an instrumen process. Validation is the pursuit ofdesigned excellence in training . The first step in any validation process is establishi to measure 8 The training first step in 23 any validation process is establishing designed to measure examined by a .new tool . The specific relationship to be pr 23 23 examined by a new training tool . The specific relationship to be prove . A robust “construct” should clarify whether the simulator is b “construct” 23

Simulator
1. Mechanical

Examples - Adam Rouilly simulator - Koken model I-B - Chamberlain Group LLC

Description Silicone rubber model for basic procedures. Plastic colon, mounted in rigid foam. Has the ability to be fitted with replaceable colonic stricture and polyps. Portable plastic tray system, can lay animal tissues within the tray and can perform a variety of procedures without or without simulated bleeding Portable colonoscopy trainer which can simulate removal of sessile and pedunculated polyps with/ without the capacity for bleeding and diathermy Ex-vivo platforms to allow OGD, ERCP, EUS with potential for haemostasis tuition Trolley-mounted, computerized device with a flat-screen display on a movable arm. Several modules are available range of endoscopic procedures and pathology. It simulates patient vital signs and responses to administration of sedation and to pain Contains library with over 120 tasks (51). Can measure end points. Has modules for degrees of difficulties and dealing with pathology. For training and assessment of colonoscopy skills. Simulates multiple matrices including; shaft looping, tip contact, variable shaft stiffness, application of abdominal pressure and movement of patient A realistic platform with haptic feedback identical to human tissue. These are expensive with ethical concerns and can demonstrate anatomical variation

Strengths 1. Teaching basic skills 2. Ready on demand

Weaknesses 1. Unable to teach intermediate advance skills 2. Lack of realism

2. Ex-vivo animal

- Endo X trainerTM (Medical Innovations)

1. Advanced therapeutics skills 2. Low cost 3. Uses actual endoscopic equipment 4. Some assessment abilities

1. Dedicated facilities 2. Preparation required 3. Pre-ordering of organs before use

- Colonoscopy suitcase (WIMAT)

EASIE-R (Endosim)

3. Virtual reality

- Accutouch HT (CAE Previously Immersion Medical)

1. Teaching basic skills 2. Ready on demand

1. Cost 2. Assessment abilities limited 3. Limited teaching beyond basic navigation skills

- GI mentor II (Simbionix)

- Endo TS1 (2nd Gen) (Olympus)

4. Live animal models

- Porcine model

1. Most realistic model 2. Advanced skills 3. Research with new devices

4. Dedicated facilities 5. Cost

Table 1 - Summary of endoscopic simulators for performing diagnostic and therapeutic colonoscopy (adapted from 27 and 31)

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To Advance Clinical Performance

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Disadvantages include a technically demanding set-up process and difficulties with re-using animal tissue. Live Animal Simulators: Porcine models have been adopted as the live animal model of choice for endoscopic simulation14. The haptic feedback is identical to human tissue, although the thickness and orientation of various 8 organs can be different . In the United Kingdom (UK), the Cruelty to Animals Act (1876) prevents their use15. Rigid adherence to the requirements of the Animal Welfare and Ethics Committee is essential in the centres that allow this training to take place. Virtual Reality Simulators: Virtual reality (VR) computer simulators are a way of providing trainees with an opportunity to practice skills in a risk-free environment16. These utilise computer based modules with varying degrees of difficulty. This enables the trainee to perform multiple simulations and record results to monitor their progress. There are currently several VR endoscopic trainers available17-20. A recent Cochrane Collaboration Review demonstrated that VR training improves upon standard surgical training and is at least as effective as video training21. The major limitation ofVR training is the financial expense, with the average cost of a VR trainer exceeding £100,00022. Most VR trainers are too simplistic for advanced trainees and the assessment parameters that they use may be irrelevant as a marker of expertise12. 120

The Requirements of an Endoscopic Simulator
Validation: With the development of any new simulator, validation of its effectiveness is a critical process. Validation is the determination of the extent to which an instrument measures what it was designed to measure8. The first step in any validation process is establishing what exactly needs to be examined by a new training tool23. The specific relationship to be proven is referred to as the “construct”23. A robust “construct” should clarify whether the simulator is being validated to assess, or to teach its users23. Once this is established, the process of validation should provide evidence to support each facet (Table 2). The more aspects of validity proved, the stronger the overall argument23. It is vital that skills developed on a simulator should be transferable to the real-life clinical setting. Reliability: Reliability is the aptitude of an instrument to consistently discriminate between performance across evaluators or over time24. It is measured on a scale of 0 to 1, with 0 being totally unreliable and 1 being completely reliable24. It is generally agreed that an appropriate reliability score for a test is ≥0.824. There are several types of reliability including: inter-rater or inter-observer reliability refers to the degree to which different raters/ observers provide the same assessment25. Test-retest reliability refers to the consistency of a measure from

ASiT - the pursuit of excellence in training

Type of Validation
Face

Definition The rational expectation that an association between two things exists The extent to which a measure reflects the trait or domain it purports to measure

Method of examination Questionnaire to non-expert users

Content

For assessment tool: review by experts of the skill domains being tested Construct/Contrast An agreement between a theoretical concept and a specific tool or procedure (Experienced surgeons should score higher on its assessment parameters than juniors) Criterion (Predictive or Concurrent) Predictive validity: The ability of a tool to predict future performance Concurrent validity: The correlation between assessment tool and the “gold standard” Correlation between test score and future performance ratings Measuring relevant parameters for defined groups of variable expertise

Table 2 - Summary of validity types25,32

Adam,Rouilly is pleased to be able to offer the new HI-ELITE Phantom (Endoscopic Laparoscopic Interdisciplinary Training Equipment) trainer manufactured by CLA in Germany in co-operation with Prof Dr H Feussner, Munich Technical University for training in NOTES (Natural Orifice Transluminal Endoscopic Surgery) techniques. The ELITE phantom can be used for teaching conventional laparoscopic and endoscopic skills and for performing hybrid interventions. Procedures which can be practised include: cholecystectomy, appendectomy, intestinal segmental resection, intra-abdominal manipulation and NOTES interventions via the vagina and the urethra.

Adam,Rouilly Limited, Castle Road, Eurolink Business Park, Sittingbourne, Kent, ME10 3AG

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one time point to another25. Internal consistency or inter-station reliability refers to the ability of different items within an assessment tool or examination to measure the same characteristic or skill25.

Optimising the Simulation Experience
Endoscopic simulation training is most effective when delivered in a structured way, tailored to the expertise of the user. However, taking a trainee away from the clinical environment may diminish or remove the linkage between technical learning and other important

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Comparison with patient based data

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Questionnaire to expert users

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interpersonal skills such as communication and leadership. This has been overcome in surgery by the use of Simulated Operating Theatres. This approach is also useful in endoscopic training where Virtual Endoscopy Suites have been used to assess lower GI endoscopy skills using tools such as the Imperial College Assessment of Skills in Endoscopy (ICASE) global scoring method26.

Conclusion
There are several forms of simulation available for training in endoscopy. All simulators should be reliable and valid for use before widespread implementation. Simulator training is most efficient when delivered in a structured format in a real-life simulated environment. If simulators are to be used for assessment, more objective measures need to be developed to increase reliability. Future work should be directed at using simulators to teach complex therapeutic endoscopic procedures and creating new simulation alongside developments in novel clinical procedures.

Future of Endoscopic Simulation
Further research and development are needed to improve the complexity of VR simulation cases27. There also remains a deficiency of reliable therapeutic endoscopic simulators that allow complications to be managed. It is likely that simulators will need to be modified and developed according to changing techniques and novel procedures. Natural Orifice Transluminal Endoscopic Surgery (NOTES) is growing in popularity and several groups are working towards established simulator training for this technique. The ELITE (endoscopiclaparoscopic interdisciplinary training entity) system is one example28. This is an ex vivo surgical training model for laparoscopic surgery, combined endoluminal/ endocavitary procedures (“hybrid surgery”) and NOTES28. The ELITE system is a full-size replica of a human female torso including a gas-tight abdominal wall and offering various access points to the abdomen28. Cholecystectomy and appendicectomy can be simulated realistically with this new training system. Evaluation of the model showed that 97% of the subjects considered the ELITE to be a useful simulator for NOTES28. Robotic endoscopy is a further area in development. The use of the Master and Slave Transluminal Endoscopic Robot (MASTER) has been validated for procedures including gastric endoscopic submucosal dissection (ESD)29. This form of robotic-enhanced endosurgery applies robotic technology, separating control of instrumental motion from that of endoscopic movements29. It is vital that as technology progresses, simulation is kept up-to-date in order to allow training to progress alongside. Objective methods of training and assessment are currently undergoing development. In 2011, Obstein reported the use of a kinematic based system using sensors on a flexible endoscope to give an overall score as a quantitative measure of skill30. Validated novel parameters for performance included path length, flex, velocity, acceleration, jerk, tip angulation, rotation and curvature of the endoscope. This is similar to extensive work which has been conducted on motion analysis in laparoscopic surgery and could be used for simulated endoscopic training on two levels. Firstly, in the development of a quantitative index to define varying levels of experience, toward which trainees can work. Secondly, serving as evidence of professional development that is assessed at annual progress reviews.

References

1. Morris-Stiff GJ, Sarasin S, Edwards P, Lewis WG, Lewis MH. The European Working Time Directive: One for all and all for one? Surgery 2005; 137(3): 293-7 2. Association of Surgeons in Training (ASiT) (2011) Simulation in Surgical Training. Available at: http://www.asit.org/assets/ documents/Simulation_in_Surgical_Training_ASiT_Statement. pdf [Accessed 03 December 2012] 3. Shingler G, Ansell J, Goddard S, Warren N, Torkington J. Piloting the ISCP surgical skills assessment: The Wales Deanery Experience. Accepted for publication in Ann R College Surg Engl 2012; (suppl) 4. Issenberg SB, McGaghie WC, Hart IR, Mayer JW, Felner JM, Petrusa ER, Waugh RA, Brown DD, Safford RR, Gessner IH, Gordon DL, Ewy GA. Simulation technology for health care professional skills training and assessment. JAMA: the Journal of the American Medical Association 1999; 282: 861-866 5. Jae Il Chun, Kim N, Um MS, Kang KP, Lee D, Na JC, Lee ES, Chung YM, Won JY, Lee KH, Nam TM, Lee JH, Choi HC, Lee SH, Park YS, Hwang JH, Kim JW, Jeong SH, Lee DH. Learning Curves for Colonoscopy: A Prospective Evaluation of Gastroenterology Fellows at a Single Center Gut Liver. 2010; 4(1): 31-35 6. Wang KK, Ott B, Geller A. Endoscopic Education: what is the cost of training (abstract) Gastrointest Endosco 1995; 41: 332 7. JAG. (2012). Joint Advisory Group on Gastrointestinal Endoscopy [Online]. Available at: http://www.thejag.org.uk/ TrainingforEndoscopists.aspx [Accessed: 1/8/12] 8. Desilets DJ, Banerjee S, Barth BA, Kaul V, Kethu SR, Pedrosa MC, Pfau PR, Tokar JL, Varadarajulu S, Wang A, Wong Kee Song LM, Rodriguez SA; ASGE Technology Committee. Endoscopic simulators. Gastrointestinal endoscopy 2011; 73: 861-867 9. Classen M, Ruppin H. Practical Endoscopy Training Using a New Gastrointestinal Phantom. Endoscopy 1974; 6:127-131 10. Hochberger J, Neumann M, Hohenberger W, Hahn EG. EASIE Erlangen Education Simulation Model for Interventional Endoscopy - a new bio-training model for surgical endoscopy. Biomedizinische Technik. Biomedical engineering 1997; 42 Suppl: 334 11. Hochberger J, Matthes K, Maiss J, Koebnick C, Hahn EG, Cohen J. Training with the compact EASIE biologic endoscopy simulator significantly improves hemostatic technical skill of gastro enterology fellows: a randomized controlled comparison with clinical endoscopy training alone. Gastrointestinal endoscopy 2005; 61: 204-215 12. Sedlack RE, Baron TH, Downing SM, Schwartz AJ. Validation of a colonoscopy simulation model for skills assessment.TheAmerican journal of gastroenterology 2007; 102: 64-74 13. Ansell J, Arnaoutakis K, Goddard S, Hawkes N, Leicester R, Dolwani S, Torkington J, Warren N. The WIMAT Colonoscopy suitcase model: A novel porcine polypectomy trainer. Colorectal Disease 2012; Jun 2. [Epub ahead of print]

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14. Nelson, DB, Bosco JJ, Curtis WD, Faigel DO, Kelsey PB, Leung JW, Mills MR, Smith P, Tarnasky PR, VanDam J, Wang KK, Wassef WY. Technology status evaluation report: endoscopy simulators: May 1999. Gastrointest Endosc. 2000 Jun; 51(6): 790-2 15. Act, C. t. A. (2012). Cruelty to Animals Act (1876) [Online]. Available at: http://www.ncbi.nlm nih.gov/pmc/articles/PMC1872363/ [Accessed: 31/7/2012] 16. Walsh CM, Sherlock ME, Ling SC, Carnahan H. Virtual reality simulation training for health professions trainees in gastrointestinal endoscopy. Cochrane database of systematic reviews. John Wiley & Sons, Ltd. 2012 17. Kim WS, Woo HS, Ahn W, Lee K, Cho JH, Lee DY, Yi SY (2007). Non-clinical evaluation of the KAIST-Ewha Colonoscopy Simulator II. Studies in health technology and informatics 125: 214-216 18. Long V, Kalloo AN. AccuTouch Endoscopy Simulator: development, applications and early experience. Gastrointestinal endoscopy clinics of North America 2006; 16: 479-487 19. Olympus. (2012). Olympus Colonoscopy Simulator Community [Online]. Available at: http://www.colonoscopy-simulator.com/ community/index.php [Accessed: 01/08/2012] 20. Simbionix. (2012). GI mentor [Online]. Available at: http:// simbionix.com/simulators/gi-bronch-gi-mentor/[Accessed: 01/08/2012] 21. Gurusamy K, Aggarwal R, Palanivelu L, Davidson BR. Systematic review of randomized controlled trials on the effectiveness of virtual reality training for laparoscopic surgery. Br J Surg 2008; 95(9): 1088-97 22. Sutherland LM, Middleton PF, Anthony A, Hamdorf J, Cregan P, Scott D, Maddern GJ. Surgical simulation: a systematic review. Ann Surg 2006; 243(3): 291-300 23. Sedlack RE.Training to competency in colonoscopy: assessing and defining competency standards. Gastrointestinal endoscopy 2011; 74: 355-366 e351-352 24. Meeker WQ, Escobar, LA. Statistical methods for reliability data. New York: Wiley, 1998 25. American College of Surgeons education division (2011)Technical skills education surgery. Available at: http://www.facs.org/ education/technicalskills/faqs/faqs.html 2011;Accessed 25/08/2011 26. Moorthy K, Munz Y, Orchard TR, Gould S, Rockall T, Darzi A. An innovative method for the assessment of skills in lower gastrointestinal endoscopy. Surg Endosc 2004 Nov; 18(11): 1613-9 27. Sedlack RE. The State of Simulation in Endoscopy Education: Continuing to Advance Toward Our Goals. Gastroenterology 2012 Nov 10 [Epub ahead of print] 28. Fiolka A, Gillen S, Meining A, Feussner H. ELITE-the ex vivo training unit for NOTES: development and validation. Minim Invasive Ther Allied Technol 2010; 19(5): 281-6 Ho KY, Phee SJ, Shabbir A, Low SC, Huynh VA, Kencana AP, 29. Yang K, Lomanto D, So BY, Wong YY, Chung SC. Endoscopic submucosal dissection of gastric lesions by using a Master and Slave Transluminal Endoscopic Robot (MASTER). Gastrointest Endosc 2010 Sep; 72(3): 593-9 30. Obstein KL, Patil VD, Jayender J, San José Estépar R, Spofford IS, Lengyel BI, Vosburgh KG, Thompson CC. Evaluation of colonoscopy technical skill levels by use of an objective kinematic based system. Gastrointest Endosc 2011; 73 (2): 315-21, 321 31. Ansell J, Mason J, Warren N, Donnelly P, Hawkes N, Dolwani S, Torkington J. Systematic review of validity testing in colonoscopy simulation. Surg Endosc 2012; 26(11): 3040-52 32. Sedlack RE. Validation process for new endoscopy teaching tools. Techniques in Gastrointestinal Endoscopy 2001; 13: 151-4 The authors declare no conflicts of interest.

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Surgery as a Graduate Entry Medic
James Dunn

The portfolio of reasons why one student or junior doctor is drawn to surgery whilst another is to acute medicine and yet another to general practice is clearly hugely individual. What is clear is that those individuals who chose to pursue an acute hospital specialty have a training journey that is going to be unpredictable, stressful, long and competitive. As a junior urology registrar I find that my peers from medical school who choose to pursue general practice have finished their training, many of them have obtained partnerships in local practices and are working four long days a week for a salary that is just a little under double mine... Presented with that comparison I have wondered at times if I’ve made the right choices. In fact, this is where post grad students are ahead, we’ve already faced this dilemma once. When we returned to read medicine we must all have thought about the prospect of further years of student life and the accumulation of further debt. Have you not considered where you might have got to in life if you hadn’t chosen to go back to the beginning. I guess the older you were when you started the harder you thought about it. But we did choose to go back. In that decision we elected to make the journey as important as the destination. I don’t mean that to sound Zen, trust me I am as un “alternative” as people come but the bottom line is that time has to pass anyway... When you decided to go back to medical school, you accepted that sure as eggs are eggs, in four years time you would be four years older and at the stage you would either be four years along a road that you wanted to travel (with its ups and downs) or you could still be wondering if you should take the plunge and try... only it’s four years harder now... 124

So looking back now, there are bits of advice I’d give to anyone at the start of training... 1) Make sure your “notable other” is really fully truly aware of what is coming and supports you... you are going to have to move house, twice probably and if you have children and are planning full time training then you will do less than half of your share of the work... 2) If you are a woman with or wanting children then choose your specialty carefully. I think most people would agree part time training and maternity demands are well understood in Obs and Gynae and Urology, other specialties are starting to follow... 3) Don’t lose time. When you’re an F1 download the CT1 applications and fill it in... find the gaps and plug them... No one is expecting you to get papers written and published in your own right but if you make the right noises people will help you and whether it is a case report or a poster abstract with a pub-med citation it all helps. Do the same at the start of the CT years for your ST3 jobs... 4) Engage fully with the NHS eportfolio/ISCP portfolio. Get something entered onto it every single week. Not only will it form the basis for your ARCPs, but it will also provide the foundation for revalidation. 5) Understand that your study budget is not going to cover things... applications are a competitive process and if Joe Blogs has done 3 courses then you need to have done them too... set up a professional fees account and start saving for courses with your first pay check (£100/month should cover it). If that makes you feel a little overwhelmed... don’t be. As I said, the time has to pass anyway and in four years’ time I’ll be looking for a consultant job and you’ll be on your way and being asked to write an article for ASiT about post graduate students doing surgery. Do what you want to do and do it well.

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The basic structure of the working day was familiar, starting at 7.30 with a departmental ‘morning report’ where the on-call team from the previous day would present new admissions and discharges, the operating list for the day would be reviewed, and the medical students were kept attentive by frequent interrogation. The team would then divide into three groups: those attending the ward round, clinic and theatre. At any one time there were 70 to 80 patients on the ward, many there for several weeks with their fractured limb(s) held in traction to maintain alignment until a slot became available in theatre. Every space was utilised, from the entrance area to the corridors, and during visiting hours the atmosphere was vibrant to say the least. In addition to the staggering number of road traffic accident victims, there was a wide aetiological mix of cases, from children who had sustained fractures from falling out of mango trees to men who had tendon

The facilities for investigating patents were basic. There was no MRI scanner, and for 3 weeks of my visit the CT scanner was broken, more of a problem in neurosurgery where patients with suspected intracranial haematomas were subjected to exploratory burr holes to locate the source of the lesion. The machine for measuring electrolytes was broken, and the hospital often ran short of antibiotics. To compound the problem, patients often presented to KCMC at a late and complicated stage in their illness, when they felt that it was sufficiently severe to justify the 50-60 dollar hospital fee. Young children with bone tumours or osteomyelitis, for example, presented months into the disease process having been taken to local hospitals (where the treatment available is extremely limited) or traditional healers: by the time they arrived at KCMC they often required aggressive surgery or amputation. There was one orthopaedic theatre with 3 lists per week and also a dedicated theatre for septic cases. Whilst facilities were available for full sterile preparation, the surgeons often had to make do with the equipment available for fracture fixation: for example, if locking intramedullary nails were not available for a femoral fracture then a K-nail would be used instead. I was able to assist on many occasions which was an exceptional learning experience: in particular, I enjoyed helping in the

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lacerations following machete attacks. A particularly interesting case was of a pregnant woman who had sustained a severe open fracture of the tibia and fibula after being bitten by a crocodile, only escaping its jaws after she managed to poke it in the eye: her wounds 1) Trauma and Orthopaedics were not only extensive but grew some unusual organisms that proved resistant to a range of antibiotics. in Tanzania There were also some deeply disturbing cases, including a young boy who required an amputation following Adam Ali, Oxford University compartment syndrome when a plaster cast had As with trauma anywhere in the world, it was frustrating to see so many cases that could easily have applied been prevented. However, I felt this frustration more in Tanzania than anywhere else been I have been as too tightly at a district hospital and his the healthcare system is Christian already under so much pressure. main highway the way to the Kilimanjaro Medical Centre The (KCMC) is a on complaints of pain ignored. hospital was littered with the remains of road traffic accidents, and I could not help but feel that tertiary referral hospital for a population of 11 million investing time and money in public health initiatives such as improvements in road safety is a greater priority even than investing in hospitals. people in Northern Tanzania. In February-March 2012, I thoroughly enjoyed my time at KCMC and the opportunity to see the magnificent country of I spent 6 weeks in the department of orthopaedic Tanzania. I was not only able to develop my own practical skills and assist the local team, but have gained an appreciation of someobserving of the immense challenges facing healthcare workers in the surgery at KCMC, and assisting local doctors developing world and how their ingenuity can go a long way to compensate for a lack of resources. who faced the daunting task of treating a high volume I would like to thank ASiT for the generous grant that helped fund the cost of my elective of severe trauma with the limited resources available to a hospital in the developing world.

ASiT Student Elective Prize Winners’ Reports 2012/2013:

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emergency cases where extensive wound debridement surgery was often required. Almost all orthopaedic surgery performed was for trauma: arthroplasty, for example, was simply too expensive, and if analgesics and local steroid injection failed to alleviate pain then arthrodesis was performed. The limitations in treatments available in Tanzania was also reflected in the medical student curriculum, with great emphasis being placed on achieving competency in basic practical skills such as plaster casting and the insertion of traction pins, with comparatively little on pathologies which would require elective orthopaedic treatment. After leaving medical school, many of the students go on to work in district hospitals where the support available is limited indeed, and thus graduating with a robust set of practical skills in different specialities is not simply desirable but a necessity.

As with trauma anywhere in the world, it was frustrating to see so many cases that could easily have been prevented. However, I felt this frustration more in Tanzania than anywhere else I have been as the healthcare system is already under so much pressure. The main highway on the way to the hospital was littered with the remains of road traffic accidents, and I could not help but feel that investing time and money in public health initiatives such as improvements in road safety is a greater priority even than investing in hospitals. I thoroughly enjoyed my time at KCMC and the opportunity to see the magnificent country of Tanzania. I was not only able to develop my own practical skills and assist the local team, but have gained an appreciation of some of the immense challenges facing healthcare workers in the developing world and how their ingenuity can go a long way to compensate for a lack of resources. I would like to thank ASiT for the generous grant that helped fund the cost of my elective

Clinics took place twice per week, with each having over 200 patients attending. KCMC made good use of its Assistant Medical Officers (non-medically qualified clinical staff) in dealing with the large volume of patients, the AMOs assisting doctors in many practical procedures. Coupled to KCMC was the Tanzania Training Centre for Orthopaedic Technologists (TATCOT), the only centre of its kind in central and east Africa, where dedicated technicians would construct prosthetic limbs for patients following amputations as well as a range of other orthotic devices, in some cases as an effective means of compensating for the lack of availability of elective surgery. I was also extremely impressed by the ingenuity used for orthopaedic rehabilitation: devices to develop dexterity and strength following injury were built from scratch and tailor made according to the patients’ needs. Despite the limited resources available, the orthopaedic service at KCMC is thus able to restore a remarkable level of functionality to patients with devastating injuries.

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2) General Surgery in Vietnam
Eleanor Zimmermann, Medical Student, Peninsula Medical School
Cho Ray Hospital in Ho Chi Minh City is one of the largest tertiary referral hospitals in Vietnam. I spent eight weeks with the general surgery department aiming to increase my clinical experience of common presentations, improve my practical surgical skills under supervision, and gain a better understanding of global healthcare. The majority of my time with the department was shared between assisting in theatre and attending postoperative ward rounds, whilst I collected prospective data for an audit on postoperative complications. The first few moments when I was guided to the doctors room at the back of the surgical ward are a bit of a haze of dishevelled bodies with anxious and expectant faces. The very sick waiting crouched on the floor of the corridors, their family beside them unpacking lunch onto the rolled out canvas they had brought with them. Although the general surgery department has a 52 bed capacity, many patients are forced to share due to high demand. With no monitors, the doctors and nurses rely heavily on each other’s clinical assessment and immediate triage skills, and one mistake could be easily missed. I soon found out that although Cho Ray hospital is a state hospital, the costs of specialist care are only in part contributed to (the patient pays approximately 80% of overall cost). The financial implications of a hospital admission for the family combined with limited health education means late stage advanced malignancy is the most common elective presentation, and sadly preoperative and postoperative patient care is largely guided by the cost, not availability, of resources.

Preoperative clinic assessments were a completely separate entity. Although all communication was in Vietnamese, often a keen medical youth would come and translate snippets of information for me, and I soon become accustomed to reading the body language of the chief as he prodded patient after patient in four quadrants of the abdomen, or the whole team peered at a patients behind as he bent over to display his troublesome haemorrhoids. Yes, initially I was so shocked I was mortified for the patient, had to refrain from jumping up to cover them up, or to hold the hand of the young lady who looked petrified as she listened to the loud decision of the surgeon as he gestured to her abdomen and explained that she would have a colostomy in place by next afternoon. The required efficiency of the department however, was crucial to these patients having any chance at all at continuing with some form of normal quality of life. Patients presented when their symptoms became unbearable, and often would have scraped together family funds to pay for an operation. With up to 20 patients presenting to this one hour morning meeting for a diagnosis and management plan, no one can deny that these surgeons are doing their utmost best to offer every single patient a chance.

Training in the department is heavily weighted on practical skills: Here I am being taught how to close a laparotomy

One of the postoperative wards. Patients are often forced to share a bed due to limited space

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My audit focused on postoperative complications observed in elective, urgent and emergency operations that I observed or assisted in during a three week period. At follow-up of three weeks, of 26 included operations, a total of 6 complications were confirmed giving an overall complication rate of 23%: 2 surgical site infections (SSI) and 4 immediate anatomical injuries. The results admittedly were surprising, with 2 SSIs (8%) being better than our published rate in the NHS for clean-contaminated procedures, even though handwashing does not appear the custom (I was laughed at even by patients when I insisted on using my self-bought alcohol gel before and after patient contact) and prophylactic antibiotics are rarely used. Although heparin is not readily prescribed, no clinical suspicion

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of deep vein thrombosis was reached, and none of the patients reached a Wells score above 2 points throughout their postoperative care. The most common complication was intra-operative anatomical injury with 4/26 (15%); these ranged from bladder perforation during surgical incision of the abdominal wall in an anterior resection for rectal cancer, to a haemothorax from an emergency laparotomy for traumatic liver injury. This high rate can be attributed to (although not excused by) the complex pathology of some of these cases, the higher risk factors in these particular patients, and also the surgeons themselves; trainees are overworked, under continuous time pressures and often left with minimal supervision and support. In Vietnam, you are a surgeon the day you walk into the surgical ward as a fresh graduate having decided to become a surgeon. The rate at which you improve your clinical and practical skills is exponential and the lack of enforced written membership exams leads to a promotion system dependant on the judgement of your direct superiors. Inevitably however, often trainees have become deskilled - particularly early - in other fields of medicine, further complicating the management of a patient with complex comorbidities. This elective allowed an invaluable insight into the challenges of effective healthcare provision, created a fascinating debate on surgical training as well as providing an outstanding hands-on experience. I would thoroughly recommend Cho Ray Hospital to any student with an interest in general surgery and I would like to thank the Association of Surgeons in Training for their extremely generous support through the elective prize.

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