Perspectives
developed. Yet the registry will achieve immediate benefits to sur-
geons through facilitating compliance with audit for the continuing
professional development programs and professional registration,
and for patients by providing surgeons with regular feedback
regarding their individual outcomes.
The burden associated with spinal disease and its variation in
management to the Australian community and healthcare system is
significant, and its importance has been recognized in recent
national reports. Now, similar to many other countries, Australia is
piloting a national spine registry. Its aims – to improve individual
patient care, and to better define optimal management of spinal
disease – are ambitious, but are critical to making an impact to the
management of this significant source of disability in the Australian
population.
References
1. Hoy D, March L, Brooks P et al. The global burden of low back pain:
estimates from the Global Burden of Disease 2010 study. Ann. Rheum.
Dis. 2014; 73: 968–74.
2. Australian Institutee of Health and Welfare. Impacts of Chronic Back
Problems. Bulletin 137. Cat. no. AUS 204. Canberra: AIHW, 2016.
3. Australian Commission on Safety and Quality in Health Care and
Australian Institute of Health and Welfare. Sydney: The Australian
Atlas of Healthcare Variation, 2015. Chapter 3.3.
4. Australian Commission on Safety and Quality in Health Care and
Australian Institute of Health and Welfare. Sydney: The Second
Australian Atlas of Healthcare Variation, 2017. Chapters 4.2
and 4.3.
5. Australian Commission on Safety and Quality in Health Care. Priori-
tised List of Clinical Domains for Clinical Quality Registry Develop-
ment: Final Report. Sydney: ACSQHC, 2016.
Is modern perioperative care too complicated for surgeons?
The dawn of modern perioperative care in colorectal surgery was
1995, described by Kehlet as fast-track in Copenhagen.1 Elderly
patients undergoing colectomy were given epidurals, operated on
laparoscopically, given limited intravenous fluids, fed early and
mobilized early. The programme was rigid and worked. Patients
went home on day 2 after surgery. Later work demonstrated that
this programme also worked in open surgery, in different countries
and for different surgical procedures.
Modern enhanced recovery after surgery (ERAS) has made
things much more complicated and very few units have achieved
results similar to Kehlet.2 We know that compliance with ERAS
elements predicts outcomes and therefore it may be that increasing
the complexity of ERAS programmes is counterproductive.3 Is
there a relationship between this increasing complexity and failure
to match the results of the original simple programme?
To the elements mentioned above have been added glucocorti-
coids, pre-operative carbohydrate loading, the oesophageal Doppler
© 2018 Royal Australasian College of Surgeons
951
6. McGirt MJ, Parker SL, Asher AL, Norvell D, Sherry N, Devin CJ. Role
of prospective registries in defining the value and effectiveness of spine
care. Spine 2014; 39(22 Suppl. 1): S117–28.
7. van Hooff ML, Jacobs WCH, Willems PC et al. Evidence and practice
in spine registries. Acta Orthop. 2015; 86: 534–44.
8. International Consortium for Health Outcomes Measurement (ICHOM).
Low Back Pain Data Collection Reference Guide Version 2.0. Cam-
bridge, MA: ICHOM, 2015.
9. Breakwell LM, Cole AA, Birch N, Heywood C. Should we all go to the
PROM? The first two years of the British Spine Registry. Bone Joint J.
2015; 97-B: 871–4.
10. Copay AG, Glassman SD, Subach BR, Berven S, Schuler TC,
Carreon LY. Minimum clinically important difference in lumbar spine
surgery patients: a choice of methods using the Oswestry Disability
Index, Medical Outcomes Study questionnaire Short Form 36, and pain
scales. Spine J. 2008; 8: 968–74.
11. Lee MJ, Cizik AM, Hamilton D, Chapman JR. Predicting medical com-
plications after spine surgery: a validated model using a prospective sur-
gical registry. Spine J. 2014; 14: 291–9.
Susannah Ahern,* PhD, FRACMA
Esther Apos,* BSc (Hons), PhD
John J. McNeil,* PhD, FRACP
John Cunningham,†‡ MClinEpi, FRACS
Michael Johnson,† MBBS, FRACS
*Department of Epidemiology and Preventive Medicine, Monash
University, Melbourne, Victoria, Australia, †Neurosciences
Institute, Epworth Richmond, Melbourne, Victoria, Australia and
‡Department of Orthopaedics, Melbourne Health, Melbourne,
Victoria, Australia
doi: 10.1111/ans.14562
and prehabilitation to name but a few. Most programmes now have
15–20 elements.2 Keeping track of all of these requires complex
and expensive audit systems and constant education of junior staff
and nurses.
Some of these elements are useful and relatively easy to imple-
ment but others are less convincing. Glucocorticoids, on their own,
are associated with a one-day decrease in day-stay without obvious
side effects.4 Pre-operative carbohydrates make patients feel better
before surgery but probably have no clinical benefits beyond this.2
The oesophageal Doppler, described by my anaesthetist as the
devil’s spawn, has no additional benefit in an ERAS context.5 Pre-
habilitation is a great idea but has a very limited evidence base and
probably has no role to play in the malignant patient as more than a
week or two are required to make any realistic difference.6
Making it complicated has coincided with the intrusion of the
perioperative physician (read anaesthetist) who’s desire to monitor
everything and optimize everything in everybody, so useful and
952
appropriate in the operating theatre, may simply get in the way of a
normal post-operative recovery in most patients. As demonstrated
by Kehlet’s work, most patients will get better with or without us
and in fact we may be standing in the way of a normal recovery
and increasing physiological stress by meddling.
A recent perioperative medicine textbook, authored by Anaesthe-
tists, makes no mention of ERAS or fast-track and the fourth chap-
ter, describing the post-operative ward round, is written without
surgical input suggesting that there is a perceived abrogation of
perioperative care interest by surgeons.7
Surgeons need to watch this space very carefully. A very simple
protocol for perioperative care was introduced over 20 years ago. I
would argue that no significant advances have been made in this
space since and that recent additions to fast-track have simply made
these programmes harder to implement and have been compro-
mised by the intrusion of other clinicians into the perioperative care
environment. Surgeons need to take perioperative care back and
keep it simple.
References
1. Bardram L, Funch-Jensen P, Jensen P, Kehlet H, Crawford ME. Recov-
ery after laparoscopic colonic surgery with epidural analgesia, and early
oral nutrition and mobilisation. Lancet 1995; 345: 763–4.
Progress towards a sustainable clinical academic training pathway
Clinical academics are clinician leaders who, through training and
experience, have chosen to make research and/or education a signif-
icant part of their professional career1 and as defined by the Royal
Australasian College of Surgeons (RACS). A major concern is that
overall the numbers of medical graduates who are choosing an aca-
demic career is declining.1,2 The most recent Australian Institute of
Health and Welfare aggregated data (of teachers/educators and
researchers registered as medical practitioners) indicate a decline
from 2.70% in 2013 to 2.63% in 2015.3 While only a small propor-
tion of the medical workforce, they nevertheless make a dispropor-
tionately large contribution to research and training that is vital to
the progress and provision of healthcare. Therefore, it is baffling
that there is no clear, mile marked, standardized and structured
route for an aspiring clinician wishing to pursue this career path.
Our UK colleagues recognized and addressed this anomaly a
decade ago by implementing the UK Integrated Academic Training
Pathway programme which reversed their similarly troubling
trend.4
A Working Party, consisting of members from the Royal Aus-
tralasian College of Surgeons, Medical Deans ANZ, Royal Austral-
asian College of Physicians, Australian Medical Association,
Australian Academy of Health and Medical Sciences and the
Australian Medical Council, was established in 2015 to continue to
build consensus, and review and develop models that would
increase recruitment and retention of clinician researchers.
Perspectives
2. Gustafsson UO, Scott MJ, Schwenk W et al. Guidelines for perioperative
care in elective colonic surgery: enhanced recovery after surgery (ERAS)
society recommendations. World J. Surg. 2013; 37: 259–84.
3. Currie A, Burch J, Jenkins JT et al. The impact of enhanced recovery
protocol compliance on elective colorectal cancer resection: results from
an international registry. Ann. Surg. 2015; 261: 1153–9.
4. Srinivasa S, Kahokehr AA, Yu T et al. Preoperative glucocorticoid use
in major abdominal surgery: systematic review and meta-analysis of ran-
domised trials. Ann. Surg. 2011; 254: 183–91.
5. Srinivasa S, Taylor MHG, Singh PP, Yu TC, Soop M, Hill AG. Rando-
mised clinical trial of goal-directed fluid therapy within an enhanced
recovery protocol for elective colectomy. Br. J. Surg. 2013; 100: 66–74.
6. Lemanu DP, Singh PP, MacCormick AD et al. Effect of preoperative
exercise on cardio-respiratory function and recovery after surgery: a sys-
tematic review. World J. Surg. 2013; 37: 711–20.
7. Symons J, Myles P, Mehra R et al. Perioperative Medicine. Oxford, UK:
John Wiley & Sons, 2015.
Andrew G. Hill, MD, FRACS
Department of Surgery, Middlemore Hospital, The University of
Auckland, Auckland, New Zealand
doi: 10.1111/ans.14704
It identified a number of specific challenges to growing and
maintaining a critical mass of clinical academics. These included an
absence of clear and flexible training pathways, insufficient clinical
academic posts upon completion of training and inadequate finan-
cial remuneration of clinical academics.2,5
An extensive literature review highlighted a paucity of studies
documenting the contribution of clinical academics even though
there were positive correlations between organizations, which fos-
tered a research culture and improved patient outcomes. Further-
more, the Working Party surveyed 156 teaching hospitals, tertiary
and medical research institutes but only 30% responded (47/156),
of which 34% (16/47) stated that within their current operations
were provisions for a defined training pathway for clinical aca-
demics.6,7 RACS has proactively promoted its flagship ‘Developing
a Career in Academic Surgery (DCAS)’ course that offers a sub-
stantial curriculum for early career doctors as well as more estab-
lished clinicians. Furthermore, RACS continues to support its
clinical academic fraternity through the Foundation for Surgery,
which provides research scholarships and Fellowships to worthy
recipients.
Both medical schools and Specialist Colleges play vital roles in
providing the leadership necessary to establish a defined and flexi-
ble pathway that integrates clinical and research training. The Uni-
versity of Auckland, Monash Partners Academic Health Science
Centre, Western Sydney University and the University of Sydney
© 2018 Royal Australasian College of Surgeons