SURGICAL SCOPETHE MAGAZINE FOR RCSI FELLOWS AND MEMBERS 10/2015 // EDITION/6

THE ADVENTURERMark Pollock pushes medical boundaries

Millin Meeting 2015Friday 13th November 2015

SESSIONS WILL INCLUDE:Healthcare Outcomes ReportingChallenges in the Workplace & Training EnvironmentProvisions of New Models for Service Design and Manpower Planning

Keynote Lectures will include the 24th Carmichael Lecture and the 38th Millin Lecture.

To register online and to view the full programme visit www.rcsi.ie/millin2015

MILLINMEETING2015

RCSI DEVELOPING HEALTHCARE LEADERS WHO MAKE A DIFFERENCE WORLDWIDE

3CONTENTS

04 THE PRESIDENT WRITES… An update from Mr Declan J. Magee.

06 SURGERY – NEGLECTED STEPCHILD OF GLOBAL HEALTH Of more than 300 million surgical procedures performed worldwide

in 2012, only 6 per cent were in countries that comprise 37 per cent of the world population, writes RCSI President Mr Declan J. Magee.

07 REGIONAL MEETING, ENNISKILLEN Mr Mark Grannell, Lead Clinician at the South West Acute Hospital,

Enniskillen shares his impressions of the Regional Fellows and Members Meeting in June.

08 GLOBAL HEALTH: TOP OF RCSI’S SURGICAL CARE AGENDA

Mr James Geraghty, Consultant General Surgeon, Senior Lecturer in Surgery and Chair of RCSI’s Outreach Committee, outlines why RCSI is well positioned to address global health issues.

10 COURT OF EXAMINERS OVERSEES GROWTH OF EXAMINER COHORT

Professor John Hyland, Vice President, RCSI and Chairman of the Court of Examiners speaks about the work of the Court.

12 A DIFFERENT ADVENTURE Mark Pollock is engaged in a determined battle to fast-track a cure for

paralysis.

15 UNDERSTANDING REVALIDATION: A UK PERSPECTIVE Dr Julian Archer on how Revalidation operates in the UK and the

research work being done to understand and evaluate it.

17 NEW MODEL OF CARE FOR TRAUMA AND ORTHOPAEDIC SURGERY

Mr David Moore, Joint Clinical Lead of the National Clinical Programme for Trauma and Orthopaedic Surgery, discusses the new Model and its potential to improve the patient experience.

20 CALL OF HOME Two surgeons share their experiences of returning to Ireland.

22 FACULTY OF POSTGRADUATE SURGICAL EDUCATORS Professor Oscar Traynor, Director of the National Surgical Training

Centre, on the background to the development of the new Faculty.

23 BUILDING RESILIENCE Professor Jim Lucey on burnout and practical strategies to avoid it.

25 OPERATION SMILE Dr Bill Magee, Co-Founder and CEO, Operation Smile, discusses

the global medical charity. Professor Michael Earley reports on an Operation Smile mission in Madagascar.

28 RCSI NEWS RCSI MyHealth app. Breast Cancer Ireland Great Pink Run. World

Head and Neck Cancer Day. Postgraduate Conferring Ceremony. Honorary Fellowship awarded to Dr Alain Diméglio.

30 FREYER LECTURE 2015 The lecture was delivered by Professor Cathal Kelly, Chief Executive,

RCSI.

The Royal College of Surgeons in Ireland, 123 St. Stephen’s Green, Dublin 2.Tel: + 353 1 402 2100. Email: info@rcsi.ie Web: www.rcsi.ie

Editorial Board: Niamh Walker, Eunan Friel, Louise Loughran, Professor Sean Tierney.

Editor: Niamh Walker.

Contributors:Julian Archer, Michael Earley, James Geraghty, Mark Grannell, John Hyland, Cathal Kelly, Bill Magee, Declan J. Magee, David Moore, Tony Moloney, James Paul O’Neill, Mark Pollock, Sean Tierney, Oscar Traynor, Jim Lucey.

Senior Graphic Designer: Johanna Arajuuri.

Photographers: Ray Lohan and Declan Burke.

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PUBLISHED BYIFP Media, 31 Deansgrange, Blackrock, Co. Dublin.

FOR IFP MEDIA:

Editor:Bernard Potter.

Contributors:Bernie Commins, Shauna Rahman.

Design:Barry Sheehan.

Production:Ciaran Brougham, Martin Whelan, Niall O’Brien, Michael Ryan.

RCSI can accept no responsibility for the accuracy of contributors’ articles or statements appearing in this magazine and any views or opinions expressed are not necessarily those of the organisation, save where indicated. No responsibility for loss or distress to any person acting or refraining from acting as a result of the material in this publication can be accepted by authors, contributors, editors or publishers. Readers should take specific advice when dealing with specific situations.

Surgical Scope is an official publication of the Royal College of Surgeons in Ireland, edited and published on behalf of RCSI by IFP Media. No part of this publication may be reproduced in any material form without the express written permission of the publishers. Copyright RCSI Surgical Scope 2015.

10/2015 // EDITION/6

Millin Meeting 2015Friday 13th November 2015

SESSIONS WILL INCLUDE:Healthcare Outcomes ReportingChallenges in the Workplace & Training EnvironmentProvisions of New Models for Service Design and Manpower Planning

Keynote Lectures will include the 24th Carmichael Lecture and the 38th Millin Lecture.

To register online and to view the full programme visit www.rcsi.ie/millin2015

MILLINMEETING2015

RCSI DEVELOPING HEALTHCARE LEADERS WHO MAKE A DIFFERENCE WORLDWIDE

THE PRESIDENT WRITES...MR MAGEE REPORTS ON RANGE OF NEW DEVELOPMENTS.

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Mr Declan Magee.

THE PRESIDENT WRITES 5

TRAUMA AND ORTHOPAEDIC MODEL OF CAREThe recent launch of the National Model of Care for Trauma and Orthopaedic Surgery represents a significant advance, setting out clear parameters for an enhanced, more efficient service. It envisions a Model of Care that can make a positive difference to the patient experience and drive the development of practices in line with evolving treatment methods.Under the able stewardship of Mr David Moore and Mr Paddy Kenny, Joint Clinical Leads of the National Clinical Programme for Trauma and Orthopaedic Surgery, the Model is a testament to the determination of the HSE Clinical Strategy & Programmes Division and RCSI, in collaboration with the Irish Institute for Trauma and Orthopaedic Surgery (IITOS), to improve the safety and quality of care for all patients presenting to trauma and orthopaedic centres.This Model of Care complements the work previously completed by the National Clinical Programme for Surgery which published Models of Care for Elective and Acute Surgery in 2013. 

FACULTY OF POSTGRADUATE SURGICAL EDUCATORSThe National Surgical Training Centre, part of our new academic education building, will provide an ideal environment for the newly formed Faculty of Postgraduate Surgical Educators. The Faculty aims to increase the profile and recognition of surgical education and training, while ensuring that excellence in surgical training equates to excellence and safety in patient care. The Faculty of Postgraduate Surgical Educators will encourage new initiatives and new concepts in the delivery of excellence in surgical training. It will comprise 18 members initially who will be involved in teaching, assessments and curriculum development across surgical training in RCSI. 

SURGICAL TRAINING PATHWAYAnother landmark in the transformation of the Surgical Training Pathway was reached with the progression of trainees from ST2 to ST3 in July 2015. As anticipated, the implementation of the new Surgical Training Pathway continues to be challenging, requiring hard work and commitment from trainers and trainees alike to ensure its success.

PHYSICIAN ASSOCIATESIn an initiative intended to help mitigate the unprecedented workforce challenges the Irish health system is facing, RCSI has decided to explore the role which Physician Associates (PAs), might play and how they might resolve some of the difficulties in fully staffing a clinical service. PAs are clinicians who are academically qualified to provide medical and surgical services to patients in a range of settings under the supervision of doctors. The first four PAs to work in Ireland are all from North America and have been employed by Beaumont Hospital, in association with RCSI, as part of a two-year pilot programme to evaluate the potential value of the PA role and measure the outcomes it can deliver in the context of the Irish health system. In parallel with this, RCSI has launched the first training programme in Ireland for PAs, under the direction of Professor Arnold Hill and this will commence in January 2016.

ENGAGEMENT ACROSS IRELANDEngagement with the wider healthcare profession and, in particular, our Fellows and Members is a priority for RCSI and an important part of the Presidential calendar. As part of that commitment, RCSI

held very worthwhile Regional Meetings in Cork in January and in Enniskillen in June 2015.The Enniskillen meeting followed an academic meeting earlier in the day between the RCSI Medical School and the South West Acute Hospital. The meeting featured curriculum development presentations by Professor Arnold Hill, Dr Ann Hopkins and Professor Leonie Young. Mr Mark Grannell, Consultant Surgeon, presented updates in clinical teaching on behalf of the South West Acute Hospital. Since 2012, students from both Queen’s University Belfast and the Royal College of Surgeons in Ireland have been accessing undergraduate medical education in the Hospital, under the guidance of a dedicated team of medical consultants within the Western Trust. A plaque was unveiled in recognition of the South West Acute Hospital as a teaching hospital of RCSI and it was a pleasure for me to be back in my home county to acknowledge and celebrate this cross-border educational collaboration. The Regional Meeting, held later the same day at the Lough Erne Resort, drew a strong attendance from both north and south of the border. There was an excellent response from those who attended. One immediate outcome has been a decision to hold a Council Meeting in Belfast in May 2016, to coincide with the Association of Surgeons of Great Britain & Ireland Annual Congress.

LANDMARK FOR GLOBAL SURGERYAt the Sixty-Eighth World Health Assembly on May 22, 2015, health ministers from around the world approved the World Health Organization Resolution 68/31 on Strengthening Emergency and Essential Surgical Care and Anaesthesia. This recognises that surgery and anaesthesia are fundamental to achieving universal health coverage.  This Resolution follows consistent, long-term advocacy efforts by RCSI and the wider healthcare community.RCSI was also pleased to play its part in supporting the recent report of The Lancet Commission, which highlighted the impact of universal access to surgical and anaesthesia care, noting that, with such access, 1·5 million deaths per year could be averted. The report also concluded that essential surgical procedures rank among the most cost-effective of all health interventions. (For more on The Lancet Commission’s findings, see ‘Global Health’, page 9)Direct government funding for domestic surgical training initiatives is critical to the long-term sustainability and success of surgical training institutions in Sub-Saharan Africa, such as the College of Surgeons of East, Central and Southern Africa (COSECSA), a long-term partner of RCSI. During the Geneva event, I had the opportunity to address a large number of health ministers and First Secretaries from Sub-Saharan Africa to advocate strongly for vital resources for COSECSA.

PROFESSIONAL WELLBEINGIn light of the Royal Australasian College of Surgeons’ Expert Advisory Group’ s campaign to reveal the extent of discrimination, bullying and sexual harassment in the practice of surgery, it seems unlikely that the issues identified by the group would be unique to one system. In that context, RCSI is currently exploring the development of a formal initiative to open up discussion and debate around these issues, with a view to assessing their prevalence, establishing a support structure to support individuals and developing a framework for the enhancement of the general wellbeing of surgeons.

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SURGERY STILL ‘THE NEGLECTED STEPCHILD OF GLOBAL HEALTH’RCSI PRESIDENT DECLAN J MAGEE ON THE WORK CARRIED OUT BY RCSI TO MEET SURGICAL TRAINING NEEDS IN AFRICA.

A cross the world this year, many more people will die from lack of access to safe surgery and anaesthesia than from malaria, HIV/AIDS and tuberculosis combined. Common conditions such as appendicitis, hernia and complicated childbirth frequently result in death and

untreated bone fractures often lead to life-long disability and consequent financial ruin for whole families.While there have been remarkable gains in global health over the past 25 years, these have focused on infectious diseases and nutrition and have not addressed access to essential surgical care.In the words of Jim Yong Kim, president of the World Bank, and Dr Paul Farmer, Harvard professor and founder of Partners in Health, surgery has been ‘the neglected stepchild of global health’.Dr David Wilkinson of the World Federation of Societies of Anaesthesiologists has identified the components of the service deficit as including: a skilled workforce; basic equipment and infrastructure; essential documentation; and monitoring and evaluation.For the past eight years, RCSI, with great support from the Irish people in the form of funding from Irish Aid, has been engaged in substantial collaboration with the College of Surgeons of East, Central and Southern Africa (COSECSA) to address the surgical manpower gap and, hence, the deficit in essential surgical care.COSECSA, a “college without walls” and with scant resources, trains surgeons across the eastern half of sub-Saharan Africa and spans 10 countries with a total population of 320 million people. This vast population has fewer than 1,700 surgeons – that’s one surgeon for every 200,000 people. Compare this with high-income countries, such as Ireland, where we have a ratio of one to fewer than 10,000 people.RCSI collaboration has had considerable success in significantly increasing the capacity of COSECSA to train surgeons within the region and often at provincial level, so as to minimise internal brain drain. However, this has occurred in a context where there has been little meaningful engagement by local country governments or health ministries in addressing the overall problem. Until now, common misconceptions about surgery being expensive and unaffordable have prevailed. But two events in recent weeks hold out the prospect of changing all that.Firstly, The Lancet Commission’s landmark study, Global Surgery 2030, provides real data and suggests solutions for achieving access to “safe, affordable surgical and anaesthesia care when needed”. The commission outlines just how stark the situation really is.

ACCESS TO CAREOf the more than 300 million surgical procedures worldwide in 2012, only 6 per cent were performed in countries that comprise 37 per cent of the world’s population. Five billion (or two-thirds) of the world’s population lack access to care, despite the fact that investment in surgical and anaesthesia services is affordable, saves lives and promotes economic growth. Indeed, financial modelling identifies a benefit-cost ratio of greater than 10:1.

Provision of essential surgery will prevent 1.5 million deaths each year, or 6.5 per cent of all avertable deaths. A quarter of all people who have a surgical procedure will face financial catastrophe as a result of seeking care.These are shocking statistics but, for the first time, they provide global surgery with a strong evidence base and define a problem that demands action. Action is needed from the wider global community but, more critically, governments of low and middle-income countries must recognise surgery as an essential and affordable part of a national health service and take the strategic decisions to enable funding of surgical initiatives, including support for training the required workforce.And so to the second seminal event. On May 22, at the World Health Assembly in Geneva, ministers for health from around the globe approved the World Health Organization’s (WHO) resolution, entitled “Strengthening Emergency and Essential Surgical Care and Anaesthesia as a Component of Universal Health Coverage”.Universal health coverage, already endorsed by the WHO, envisages that all citizens of the world can obtain essential health services without suffering financial hardship when paying for them. This new resolution states that essential surgical care is an inseparable component of this.There is a large international community of surgical and anaesthetic organisations, individuals, institutions and colleges, including RCSI, which has been working towards this initiative and which now applauds and celebrates its adoption.

GAME CHANGERThis game-changing resolution represents a real opportunity for progress. It urges member states, for the first time ever, to “identify and prioritise a core set of emergency and essential surgery and anaesthesia services at the primary health care and first referral hospital level” and furthermore to “develop methods and financing systems for making quality, safe, effective and affordable emergency and essential surgical care and anaesthesia services accessible to all who need it”.Success in these and other requirements will be measured and reported to the World Health Assembly in 2017.In the meantime, it allows organisations such as COSECSA to make the case that long-term capacity development and surgical training programmes are fundamental to addressing the ambitious objectives set out under the resolution. With new authority, they can seek and obtain funding from their own ministries and approach external donors and funders, who can now see the enormous life-saving potential of such investment.It is appalling that most people have no access to basic surgery. It will not be institutions or individuals in the high-income countries that will resolve this situation, but rather it is lower and middle-income country governments who must provide the infrastructure and local institutions to train the future surgical providers. Our role is to support governments and education and training bodies to meet this challenge. This is the key to the principles of sustainable development and partnership that underpin Ireland’s aid policy, as delivered by Irish Aid, and also guides the endeavours of RCSI in sub-Saharan Africa. This is an edited version of an article first published in The Irish Times, Monday, July 13, 2015.

7REGIONAL MEETING, ENNISKILLEN

REGIONAL MEETING IN ENNISKILLENRCSI HELD A REGIONAL FELLOWS AND MEMBERS MEETING IN CO. FERMANAGH AS PART OF THE COLLEGE’S SCHEDULE OF REGIONAL MEETINGS THIS YEAR. PROVIDING A PLATFORM FOR INFORMAL DISCUSSION AND DEBATE, THE MEETING WAS A GREAT SUCCESS, ACCORDING TO MR MARK GRANNELL, LEAD CLINICIAN AT THE SOUTH WEST ACUTE HOSPITAL.

E nniskillen in Co. Fermanagh proved to be a timely destination for one of this year’s Regional Meetings, as it afforded RCSI President, Mr Declan J Magee, the opportunity to unveil a plaque at the South West Acute Hospital, marking three years of collaboration between it and RCSI.

“We had originally planned to unveil a plaque, acknowledging the educational links between RCSI and the South West Acute Hospital,” Mr Grannell explained. “Additionally, a location was also needed for the Regional Fellows andMembers Meeting - so it had a two-pronged function.”

SOUTH WEST ACUTE HOSPITALThe South West Acute Hospital opened just three years ago and is the only hospital in Northern Ireland offering consultant-led teaching with medical student placements from Northern Ireland and the Republic of Ireland. Since 2012, students from Queen’s University Belfast (QUB) and RCSI have been accessing undergraduate medical education at the hospital, under the guidance of a dedicated team of medical consultants.“From the point of view of the surgical fraternity in Northern Ireland and also within the South West Acute Hospital, it was quite a unique event and one we were quite honoured to host,” said Mr Grannell. 

SPEAKERSThe Enniskellen Regional Meeting featured a number of important speakers, including: RCSI President, Mr Declan J Magee, whose topic was ‘RCSI - where are we now?’; RCSI Managing Director, Surgical Affairs, Mr Eunan Friel gave an update on surgical training and practice; Mr Paul Nolan, Associate Director for International Programmes, Surgical Affairs, gave an introduction to and overview of the membership exam for the Court of Examiners. The speeches were followed by an open forum, offering an opportunity for RCSI Members and Fellows to speak informally about any relevant topics.“We were honoured to have had such a prestigious line-up [at the

meeting], and to acknowledge and commemorate the educational links and achievements fostered between the two institutions,” said Mr Grannell.Regional Meetings are part of RCSI’s engagement strategy with Fellows and Members, to explore ways in which RCSI can support them, and to facilitate feedback from them. The objectives of the Enniskillen Regional Meeting were multi-faceted, according to Mr Grannell.“The meeting dealt with the business of surgery; how surgical training can be developed; and how to establish links north and south of the border to help with surgical training; these were some of the key aspects of it.“It was a very progressive step to have the meeting north of the border. It reignited old relationships and will develop new ones. But it also set the steps forward for future progression and onward discussion on how to proceed.”This latter point refers to re-establishing links in surgery and other surgical areas, strengthening  cross-border collaborative links, and arranging meetings between surgical groups.For RCSI Fellows and Members, Regional Meetings are quite significant as they allow various challenges facing surgeons today to be explored and debated.One such challenge, according to Mr Grannell, centres around training, particularly since the implementation of the European Working Time Directive.“The European Working Time Directive means that surgeons have to be trained to the same degree of standard in a shorter period of time, and that is quite a difficult thing to do.”Additionally, surgery is not seen as the desirable career it might once have been, he adds.“A lot of trainees, unfortunately, do not see surgery as a sensible or a desirable career choice and that is something that all surgical colleges need to address.” There are several reasons for this, says Mr Grannell who explains that not only is surgery a very demanding specialty, but that it carries with it a lot of responsibility, part of which involves perfecting the skillful craft that is surgery.

At the South West Acute Hospital, Enniskillen, Co. Fermanagh in May: Ms Deborah McNamara,

RCSI Council Member; Mr Mark Grannell; and Professor John Hyland, RCSI Vice President..

I n 1982, Mr James Geraghty, a young surgeon, and his wife Anne, a general practitioner, travelled to Southeast Nigeria. Both newly qualified, they wanted to experience firsthand what it was like to work as medical professionals in a developing country. “Working in a 260-bed hospital with, on average, only

three other doctors, was a learning experience in itself,” says Mr Geraghty. “We quickly learned the healthcare needs of the community and developed our skillsets by addressing these needs. At that time, surgery was important but infectious diseases, maternity services, trauma and infant mortality dominated.”James retained an interest in global health and recently he availed of a new opportunity to renew his involvement in this area when he was elected to the Council of RCSI. “I was fully aware of the enormous work that RCSI was involved in regarding global health, so I decided to become involved in the College’s Outreach Committee. This Committee does what it says, it reaches out to people in need, in global health and surgery in particular, and strengthens RCSI’s role in the international global health arena.”

ROLE OF RCSI IN GLOBAL HEALTHCARE“RCSI is deeply committed to assisting surgical and anaesthetic care as part of the global healthcare agenda, through initiatives such as COST Africa, SODIS, Health Research in Africa and the RCSI-COSECSA Collaboration Programme,” says Mr Geraghty.

Given his own firsthand experience as a surgeon working in Africa, Mr Geraghty recognises the value of COSECSA and its achievements, which include:

Graduation of 146 specialist surgeons, with 335 currently in training;

Training more than 350 surgeons across 20 courses, as accredited trainers;

Development and roll out of Africa’s only surgical e-Learning platform and 26 IT laboratories;

Development of a database of every surgeon in the region;

Establishment of a Women in Surgery programme; and

COSECSA Mobile Surgical Skills Unit helping to train young surgeons, through its sophisticated technology, in hospitals across five of the 10 COSECSA countries.

Recently, both RCSI and COSECSA (separately) signed Memorandum of Understanding (MOU) documents with the Global Alliance for Surgical Obstetric, Trauma and Anaesthesia Care (the G4 Alliance). This Alliance is dedicated to building political priority for surgical care as part of the global development agenda. The success and achievements of the RCSI-COSECSA Collaboration Programme can be attributed to the College’s long-term commitment to assisting in the development of global health.“RCSI President, Mr Declan Magee has had a longstanding interest in global health, and his drive and enthusiasm has influenced us, his

GLOBAL HEALTH: TOP OF RCSI’S SURGICAL CARE AGENDA AS RCSI PREPARES TO HOST ITS INAUGURAL GLOBAL HEALTH CONFERENCE IN APRIL 2016, MR JAMES GERAGHTY, CONSULTANT GENERAL SURGEON, SENIOR LECTURER IN SURGERY AND CHAIR OF RCSI’S OUTREACH COMMITTEE, OUTLINES WHY RCSI IS WELL POSITIONED, TO ADDRESS GLOBAL HEALTH ISSUES

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Mobile Surgical Skills Unit.

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colleagues, and has really contributed to promoting the global health initiative within the College,” Mr Geraghty notes.RCSI is also involved in the education and teacher training of those in developing worlds and IT is driving this healthcare progression.“RCSI is well-positioned because of its expertise with members of the College and also with its excellent IT facilities. e-Learning is a major part of this, so we don’t necessarily have to be onsite to deliver education and training. If we look at elective surgery (cleft lip, cataracts, etc.), we can allow a longer timeframe before operating, while in emergency surgery like cancer, you need to respond immediately. Using the state-of-the-art College IT facilities means we can deliver education and teacher training electronically, as well as conducting examinations. This, in itself is contributing to the development of global health by improving the knowledge base of healthcare professionals.”

DEVELOPMENTS IN GLOBAL HEALTHThe three main developments in global health this year, according to James, are the findings reported in Global Health 2030; the approval of the Resolution on Emergency and Essential Surgical Care at the World Health Assembly (WHA); and the union of more than 100 stakeholders forming the G4 alliance with a collective aim to provide access to safe, essential surgical, obstetric, trauma and anaesthetic care.”

THE LANCET COMMISSION ON GLOBAL HEALTHIn April 2015, The Lancet published its two-year study, Global Health 2030, a comprehensive report, to which both RCSI and COSECSA contributed. The findings of this report have since been endorsed by RCSI and surgical colleges around the world including College of Surgeons of Singapore, Association of Surgeons of India and American College of Surgeons.The Lancet findings include:

Five billion people lack access to safe, affordable surgical and anaesthesia care, when needed;

143 million additional surgical procedures are needed each year to save lives and prevent disability;

33 million individuals face catastrophic health expenditure due to payment for surgery and anaesthesia each year;

Investment in surgical and anaesthesia services is affordable, saves lives and promotes economic growth; and

Surgery is a central part of, and must be treated separate from, healthcare.

WHA RESOLUTION ON SURGERYIn May 2015, ministries of health from around the world approved a resolution on Emergency and Essential Surgical Care at the 68th WHA in Geneva. This is the first time surgery has been formally recognised by the international healthcare community as a component of universal healthcare. This landmark event was attended by RCSI representatives including the RCSI President, Mr Declan Magee, who made a speech at a meeting of African Health Ministries encouraging Ministries to provide direct funding for surgical training.

G4 ALLIANCEThis is an umbrella organisation of colleges and NGOs that advocate to governments and multilateral organisations on behalf of the

neglected surgical patient. RCSI became a member in December 2014 and the organisation was formally launched at the WHA in May. GLOBAL HEALTH CONFERENCE 2016“There is now a renewed global enthusiasm and recognition of the critical role of surgery in global health. It is the first time that surgery has been formally recognised by international healthcare as a component of universal healthcare. This recognition is extremely important, as surgery is not only the most cost-effective of all health interventions, but it has the ability to improve patient outcomes across all branches of healthcare,” Mr Geraghty notes.“This leads onto Ireland taking the opportunity to put the spotlight on issues relating to global health. With this in mind, RCSI will host a Global Health Conference, which will focus on education and training, specifically new connectivity, which is available through IT. We are inviting global leaders to speak on relevant global health issues, but we also want to create awareness amongst the international healthcare community of what Ireland is doing. We have medical professionals travelling to developing countries around the world and it is important to let the community know what practical contributions Ireland is making to these issues and can make in the future. Global research and findings will also be a key component of the conference.” The commitment, Mr Geraghty concludes, which RCSI has towards promoting global health and also the commitment, the College has towards supporting our partners in global health, will continue and grow into the future.

GLOBAL HEALTH

Mr James Geraghty.

RCSI INVOLVEMENT: World Health Assembly (WHA);

The Lancet Commission on Global Health;

Global Alliance for Surgical, Obstetric, Trauma and Anaesthesia Care (G4 Alliance); and the

Global Healthcare Conference 2016.

“Surgeons are, by training and instinct, positively disposed to making a personal contribution to the education of the next generation of practitioners. To that extent, the profession has been highly receptive to the message that the Court has been communicating over the past 12 months.“Apart from the fundamental importance of examining, we have highlighted the collegiality that surrounds it. The annual Court of Examiners Meeting keeps examiners up-to-date on developments and international best practice in clinical assessment as well as providing examiners the opportunity to network with colleagues. Court

R CSI established the Court in 2014 to acknowledge the essential role examiners play in the assessment of MRCS and FRCS candidates. In the last 12 months, the Court has overseen a significant increase in the cohort of examiners alongside the development of a governance framework to

maintain and enhance standards in examining.The Court has a central role to play in RCSI’s educational mission, according to Professor Hyland. “The College’s raison d’être is the delivery of the highest standard of surgical education. Examination and assessment are core activities of our participating surgeons in the education, training and assessment of future generations of practitioners. In that context, the examiner has a pivotal role to play in ensuring a rigorous assessment of the knowledge, clinical skills, judgement, decision-making ability and professional competence of Membership and Fellowship candidates. This is crucial for the College and, ultimately, for the well-being of patients, as it ensures that candidates are safe and competent to practise as surgeons.”

ADVANCEMENT OF EXCELLENCEThe establishment of the Court of Examiners has allowed the College to enhance recognition of the contribution made by Examiners and has supported the maintenance and advancement of excellence in examining standards, Professor Hyland explains. “RCSI’s examination system has a distinctive profile consisting of a broad cohort of candidates and examiners with diverse backgrounds and diverse medical specialties. The Court has facilitated the creation of a cohesive governance framework for examining that allows us to assist examiners in their work while at the same time enabling more detailed assessment of the examination and examining processes to consolidate strengths and incorporate innovations where appropriate, while simultaneously ensuring that multiple exams across international sites are consistently and rigorously deployed.”

DEVELOPING THE FRAMEWORKThe Court of Examiners is managed by an Executive Committee which meets on a bi-monthly basis to explore day-to-day issues and formulate broader strategic plans for the development of the examination process and examining in the future. According to Professor Hyland: “The Executive Committee, and our Annual Examiners’ Meeting, provide practical fora through which examiners can voice opinions and offer feedback about the examination process in ways that can influence the future direction and shape of that process.”Since its inception last year, the Court has strongly promoted the benefits of participation in examining, Professor Hyland says.

COURT OF EXAMINERS GUIDES DEVELOPMENT OF EXAMINER COHORT PROFESSOR JOHN HYLAND, VICE PRESIDENT, RCSI, AND CHAIRMAN OF THE COURT OF EXAMINERS, SPEAKS TO SURGICAL SCOPE ABOUT THE COURT’S WORK.

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Professor John Hyland.

11COURT OF EXAMINERS

Members are recognised by RCSI for their work through Professional Competence Scheme or CME/CPD credits for both examining and attending the annual meeting.”The Court of Examiners has also emphasised recognition of examining through involvement of examiners in key College events: “We have invited examiners to participate in all relevant formal College ceremonies. The participation of examiners at postgraduate conferrings underlines the importance of their work and augments the sense of occasion surrounding the event.”The Court’s work in promoting the role of the Examiner and its benefits has had significant impact, with a trebling of numbers from 24 MRCS Examiners in June 2014 to 75 in June 2015.

FUTURE INITIATIVESBut, Professor Hyland says, this is just the beginning. The Court has several significant new developments planned for the next two to three years. Firstly, it will continue to heighten the profile of postgraduate examining at RCSI and seek to recruit more examiners. Initiatives over the next few months will include an information stand at the Millin Meeting on Friday, November 13, and participation in the Postgraduate Conferring ceremonies in December. The Court also intends to open up new opportunities for participation in RCSI’s domestic and overseas examinations.“Over the next few years, starting in 2016, new chapters of the Court will be established at overseas campuses. The Court will seek to strengthen the provisions for consistency in standards across international examination sites, while ensuring that there is no

dilution in local relevance. As a simple example, where inflammatory bowel disease (IBD) is an appropriate disease to be cited for a particular exam question in Ireland, tuberculosis (TB) may be the more appropriate disease example to be cited within the exam in another country. It is also of crucial importance that examiners are fully informed as to cultural issues across the College’s global examination process and the Court will be developing a protocol to assist in enhancing awareness of cultural nuances.”Professor Hyland adds: “Members of the RCSI Court are, in many instances, leaders in their specialties and several also participate in Courts of Examiners in London, Edinburgh and Glasgow. The knowledge and experience of our growing cohort of distinguished examiners will inform the Court’s work in ensuring that RCSI continues to be a leader in driving innovation and excellence in examining.”

GETTING INVOLVEDThere are a range of opportunities to become involved as an Examiner. These include:

Intercollegiate MRCS – Surgical Examiner in ‘Part B’ OSCE examination;

Intercollegiate DO-HNS / MRCS (ENT) – Surgical Examiner in ‘Part 2’ OSCE examination; and,

Intercollegiate FRCS / JSCFE – Surgical Examiner in ‘Section 2’ Oral and Clinical examination.

The commitment: Court Members are expected to examine once a year – or more often if an individual examiner has availability – and attend an Annual Plenary Meeting. Members will be appointed for an initial period of five years. This tenure could be extended for a further five years at the request of a Member and the discretion of the Executive Committee. After 10 years of consecutive service, Members may be entitled to apply for the position of Senior Examiner on the Court. Ultimately, a Senior Examiner, after completing a two-year term in that role, can submit for nomination to the Court’s ‘Emeritus Panel’.

BENEFITS OF PARTICIPATING: Professional Competence Scheme (PCS) credits

for examining – ‘Research and Teaching’ category;

PCS credits for undertaking training/attending Annual Plenary Meeting of the Court –‘External Activities’ category;

PCS credits for committee/sub-committee participation –‘Internal Activities’ category;

Exposure to the most up-to-date clinical assessment techniques and methodologies; and,

Opportunities for overseas experience and networking with colleagues.

EXAMINERS’ ELIGIBILITY CRITERIA:

Be a Fellow (or Fellow Ad Eundem) in good standing of the Royal College of Surgeons in Ireland or one of the three Royal Surgical Colleges of the UK or be of equivalent standing in another College of Surgeons;

hold or have held a full consultant post (not a locum post) for at least two years post-CCT or equivalent;

be clinically active at the time of appointment to the Court of Examiners;

have a track record of active support and participation in postgraduate surgical training/education/teaching;

satisfy the Court of Examiners of their standing with IMC/GMC or equivalent body;

Basic Sciences examiners should hold an equivalent basic science qualification to the satisfaction of the Court; and,

lay examiners can be appointed at the discretion of the Court of Examiners.

General queries relating to the Court of Examiner should be directed to examiners@rcsi.ie

12

A DIFFERENT ADVENTUREMARK POLLOCK BATTLES TO FAST-TRACK PARALYSIS CURE

13MARK POLLOCK

M ark Pollock, explorer, adventurer and collaboration catalyst, was awarded an Honorary Doctorate degree from RCSI at the School of Medicine conferring ceremony in June at the RDS. Subsequently, he spoke to Surgical Scope

about his involvement in the latest breakthrough in spinal cord injury treatment, his motivational work with businesses and philanthropic organisations and the competitive instincts that drive him on in the face of adversity.Dealing with the reality of his spinal cord injury was a journey into the unknown for Mark: “Like most people who suffer a spinal cord injury, initially I had no idea what it meant for me as an individual, and the sort of impact it would have on my family and my friends. In the beginning, it was about processing the enormity of what had happened. After 16 months in hospital, I became aware that some people were leaving in wheelchairs, others were recovering. I initially had to work to accept that I might not recover while, in parallel, holding on to the hope that there may be a cure, or something approaching it, to be discovered out there.”He also had to convince his medical team that he was holding that delicate equation – between a realistic acceptance of his situation and a belief that he could find a path to some form of recovery – in balance. “The professionals, understandably, worry that people aren’t accepting reality. But I was clear in my mind that there was a realistic possibility that my condition would not change, that I would have to rebuild my life as a wheelchair user. At the same time, I was determined to look beyond, to see what boundaries could be pushed back, what new solutions could be found.”Finding and connecting scientists worldwide to fast-track a cure for paralysis became Mark’s primary objective. Showing his trademark determination, in 2012, Mark travelled to California to visit Ekso Bionics, a company doing pioneering work in the field of robotic exoskeletons to augment human strength, endurance and mobility. “While there, I learned about the work they were doing and had the opportunity to use robotic legs. Later that year, I bought a set of robotic legs so that I could work with them on a more consistent basis. After a year or so working with them I knew that, to make real progress, I would need to challenge myself more, physically, and that I needed to learn more.”Through his role as an ambassador for Wings for Life, the fundraising organisation for spinal cord injury research, and his and his fiancée Simone George’s seats on the Christopher and Dana Reeve Foundation board, he began to meet leading scientists in Europe and the US. In particular, Mark had the opportunity to meet scientists in Cambridge, Harvard, Louisville and, ultimately, UCLA, where researchers led by V. Reggie Edgerton were working on spinal stimulation combined with drug interventions. Paralysed patient Mark proved to be the catalyst that brought the researchers, based in Los Angeles, together with the exoskeleton developers, based in Richmond, California. Mark worked with this alliance of innovative technology and pioneering research from February to May of 2014 in UCLA. The new approach, developed by the scientists at UCLA and the engineers at Ekso Bionics, combined a battery-powered, wearable bionic suit that enables people to move their legs in a step-like fashion with a non-invasive, spinal stimulation procedure. Mark described what he was required to do as part of the research: “The robot worked with me, dynamically powering down its motors proportionally as I did more work. As I did more, the robot did less.”

Mark made substantial progress after receiving a few weeks of physical training without spinal stimulation and then just five days of spinal stimulation training in a one-week span, for about an hour a day. “Stepping with the stimulation and having my heart rate increase, along with the awareness of my legs under me, was addictive. I wanted more. In the last few weeks of the trial, my heart rate hit 138 beats per minute,” Mark said. “This is an aerobic training zone, a rate I haven’t even come close to since being paralysed while walking in the robot alone, without these interventions. That was a very exciting, emotional moment for me, having spent my whole adult life, before breaking my back, as an athlete.”

RESULTSThe results of the research based on Mark’s involvement in 2014 were published in September 2015 by the IEEE Engineering in Medicine and Biology Society, the world’s largest society of biomedical engineers. As the published research indicates, through the combination of spinal stimulation and robot technology, Mark was able to voluntarily control his leg muscles and take thousands of steps in a robotic exoskeleton device during five days of training – and for two weeks afterward. This was the first time that a person with chronic, complete paralysis had regained enough voluntary control to actively work with a robotic device designed to enhance mobility, according to the UCLA scientists. Mark’s leg movements also resulted in other health benefits, including improved cardiovascular function and muscle tone. Mark comments: “For people suffering from catastrophic spinal cord injury, there’s every reason to believe that these types of interventions will have a major impact on our quality of life. This research offers great hope and now it needs to move rapidly from the lab to the clinic and out into the world. It will take time and investment to make the technology behind the breakthroughs more widely available. At the Mark Pollock Trust, we are focused on helping to make this a reality.”Funders of the research included the Reeve Foundation, the National Institutes of Health’s National Institute of Biomedical Imaging and Bioengineering, the F. M. Kirby Foundation, the Walkabout Foundation, the Dana and Albert R. Broccoli Foundation, Ekso Bionics, NeuroRecovery Technologies and the Mark Pollock Trust. In terms of where the research goes from here, Mark says: “I don’t think the cure for paralysis will come as one ‘fix’. I think it will be made up of multiple interventions. The scientists are continuing their work supported by some US and Russian funding to build the data and make the case for this technology. The next phase involves working with NeuroRecovery Technologies, the company which developed the device used to stimulate the spinal cord, in order to commercialise these discoveries, making them available to all paralysed people. One of the funding initiatives that will help with developments like this is the main Mark Pollock Trust fundraiser – Lifestyle Sports ‘Run in the Dark’. It takes place at 8pm on November 11 and it’s expected that 25,000 people in 50 cities around the world, from San Francisco to Sydney, will take part.”Mark now wants to attract groundbreaking research on spinal injuries and paralysis to Ireland: “I’m working to develop further research collaborations with Reggie Edgerton’s team in UCLA and Yuri Gerasimenko of the Pavlov Institute with Trinity College Dublin. We have just started funding a research fellow to continue the research combining walking in the robot with spinal electrical stimulation and a pharmacological intervention over a longer term.”

FIGHTING BACKHow does Mark explain his determination to proceed even in the face of doubts from his medical team based on the reality of the limits of what medicine can do for a spinal cord injured patient? “When you acquire a disability, it robs you of parts of your identity – significant, defining parts of that identity. I had been an adventure athlete and the disability shut me out from sport but the instincts that had driven me to compete were still there. I had a real drive to do something, to put my efforts into some type of constructive action. So when the Ekso robotic legs became available, they brought out my competitive instincts more and more. I found myself looking to push forward and achieve new personal bests.”The process also helped him restore, at least in part, that element of his identity that disability had taken from him: “In the past I was an adventure athlete, pushing at the edges of what was achievable in endurance events all over the world, having been inspired by Shackleton, Scott and Amundsen. Now I am working with modern day explorers, scientists and technologists. Where before I competed in extreme environments, now I have the opportunity to explore the outer reaches of what’s possible in medical science.”

WHEN THE RULEBOOK DOESN’T WORK…Mark’s reputation as an inspiring public speaker is now well-established and his address to RCSI accepting his Honorary Doctorate was particularly well-received. In his speeches, he revisits many traumatic experiences in his life with clarity and apparent ease. “I’ve been speaking in public now for many years. In my twenties, I began speaking at fundraising events for the sports I took part in. I found I really enjoyed it. That was before the accident, now it’s become a major part of my professional life and a way of both communicating

about dealing with paralysis and campaigning for support to find ways to overcome it.” His public speaking commitment has grown over the years and his skills as a motivational speaker are sought after by businesses and philanthropic organisations. “When I’m speaking at a company event, I’m conscious that each individual who attends should get something positive from it. I enjoy speaking and going into all kinds of different businesses. Frequently, I have one-to-one conversations with people after a talk. I end up having human, personal conversations with people having tough times.”Part of what he does he describes as “creating teams that think differently”. He recalls: “As part of a course I did in Harvard a couple of years ago, I studied crisis leadership and particular examples of it, such as Shackleton’s trip to the Antarctic when his ship, the Endurance, became trapped in ice and, in a more recent example, the Chilean mining disaster. I realised that crisis management is an area where I can make a meaningful contribution to businesses. “For the predictable challenges that organisations face, hierarchical structures usually respond well. For the unpredictable, where there is no rulebook, a flatter, co-operative approach is needed. In that context, I feel comfortable motivating teams, through talks, to respond to those kinds of situations. I see my role as acting as a catalyst to encourage new ways of thinking.”

FINDING A BALANCEFrom a practical perspective, how does he manage and organise the different aspects of his life – the work to seek a cure for paralysis, the public speaking engagements, the ambassadorial roles? “Science, working with researchers and technologists, comes first, then speaking engagements, then promotional activities. I work with a great team – Piers White, Head of the Mark Pollock Trust, and Sarah Donovan, the Trust’s Communications and Engagement Lead, and a team of over 400 volunteers. And, of course, there’s my fiancée, Simone, who has been an immense and constant support through every challenge I’ve faced. She’s a key thought leader in our work.”And how does he unwind? “Over the next few weeks, my relaxation plan is simple, to sit down and watch as many matches as I can throughout the entire Rugby World Cup campaign!”

To find out more about Mark’s motivational speaking, log on to www.markpollock.comFor more details on the work of the Trust, go to www.markpollocktrust.orgFor more information on the Run in the Dark, go to www.runinthedark.org

14

MARK POLLOCK: HIS STORY SO FARAfter losing his sight due to a detached retina in 1998 when he was 22, Mark Pollock, a committed rowerfrom County Down, was not going to let his blindness push him off course. His remarkable achievements included becoming an adventure athlete, culminating in becoming the first blind person to race to the South Pole. In 2010, four weeks before he was due to marry his financée Simone George, Mark fell from a second-storey window onto concrete and damaged his spinal cord. Left paralysed, he spent 16 months in hospital. Through the Mark Pollock Trust, he is on a mission to find and connect people around the world to fast-track a cure for paralysis. He is working with neuroscientists from UCLA; the Pavlov Institute, St Petersburg; and Trinity College Dublin; and is now the world’s principal ‘test pilot’ for Esko Robotic Legs.He has undergone four years of aggressive physical therapy, including taking 600,000 steps over a two-year period, every single one recorded by his robotic legs and sent in real time for analysis. Mark was selected by the World Economic Forum as a Young Global Leader. He is on the Board of the Christopher and Dana Reeve Foundation and is a Wings for Life ambassador. He is the subject of an acclaimed IFTA-nominated documentary, Unbreakable: The Mark Pollock Story, is a TEDx Hollywood speaker and co-Founder of the global running series ‘Run in the Dark’.

MARK’S INSPIRATIONSMark spends much of his time these days working as a motivational speaker. When in need of inspiration himself, which figures does he turn to? “There are so many, particularly all the scientists that the Trust works with. Looking to more widely-known individuals, Christopher Reeve, who did so much pioneering work as an activist on behalf of people with spinal injuries, is a particular inspiration. And of course explorer adventurers from the past like Shackleton and Tom Crean and, today, Sir Ranulph Fiennes. These people are inspiring because they’re prepared to push themselves to the edge. It’s not a safe place at the edge, you risk falling. Some people look to avoid those sorts of places but the people I admire tend to seek them out.”

15REVALIDATION

D r Archer is Director of the Collaboration for the Advancement of Medical Education Research Assessment (CAMERA), a group of researchers in the Plymouth University Peninsula Schools of Medicine and Dentistry who are interested in understanding how to

select and assess students, doctors and dentists across the UK clinical education continuum. CAMERA is also leading the UK Medical Revalidation Evaluation coLLAboration (UMbRELLA). This which brings together regulatory academics and revalidation implementers from across the UK. Other participants include Improvement Science London UCL, Manchester Business School, NHS Education for Scotland, Healthcare Improvement Scotland, Wales Deanery and Belfast NHS Trust (see panel ‘The UMbRELLA Collaboration, page 16).

Dr Archer’s research work on Revalidation grew out of his wider interest in work-based assessment. “I have led a programmatic approach to understanding Revalidation since 2009. The programme evolved into three interwoven studies, attracting funding from the Health Foundation and the National Institute for Health Research (NIHR). The trilogy of studies entitled What is Revalidation? seeks to understand Revalidation in policy, in practice and in public.”

REVALIDATION IN THE UK: AN OUTLINEAs defined by the General Medical Council, Revalidation in the UK is the process by which all licensed doctors are required to demonstrate on a regular basis that they are up to date and fit to practise in their chosen field and able to provide a good level of care. Revalidation was launched in the UK in December 2012. Under the Revalidation system, 156,000 licences – to be renewed on a five-year cycle – were issued by the end of 2012, encompassing UK doctors both within the NHS and outside it. In effect, without a licence, a doctor cannot practice in the UK. As part of the Revalidation process, each licensed doctor participates in an annual consultative appraisal process with an appraiser. The appraisal is carried out using a framework of broad areas based on Good medical practice, the GMC’s core ethical guidance for doctors, which sets out the principles and values on which good practice is founded.The appraiser can be from any clinical specialty, not necessarily that of the appraisee. In primary care, there are a number of GPs who are professional, full-time appraisers. The appraisee brings clinical governance information and additional supporting information to the consultation to demonstrate adherence to the Good medical practice framework. Within hospitals, doctors are usually appraised by colleagues from the same organisation. The next step is the submission by the appraiser of a formal report, approved by the appraisee, to a Responsible Officer (RO). In the primary care context, the RO is usually a senior GP who has experience of working in wider GP structures and who often won’t know the person who’s appraisal is being reviewed. Within the hospital system, the RO is usually a senior doctor within the appraisee’s hospital and will usually have access to a range of additional information outputs about the appraisee, as well as the appraiser’s report. In the final step in the process, the RO then makes a recommendation to the GMC.

UNDERSTANDING REVALIDATIONDr Archer says that understanding Revalidation and its objectives is a far from straightforward process. In fact, he says, it is arguable that a properly articulated definition of medical Revalidation has yet to be formulated: “In the first of the three-part study of this

UNDERSTANDING REVALIDATION A UK PERSPECTIVE DR JULIAN ARCHER HAS CARRIED OUT EXTENSIVE RESEARCH ON WORK-BASED ASSESSMENT AND REVALIDATION. HE SPEAKS TO SURGICAL SCOPE ABOUT HOW REVALIDATION OPERATES IN THE UK AND THE RESEARCH WORK BEING DONE TO UNDERSTAND AND EVALUATE IT.

Dr Julian Archer, Director of the Collaboration for the Advancement of Medical Education Research Assessment (CAMERA), a research group based in the Plymouth University Peninsula Schools of Medicine and Dentistry.

16

area, ‘Revalidation in policy’, my colleagues and I interviewed 30 policymakers who had worked on the development of Revalidation here in the UK and our interviews indicated that they themselves were not clear on what they were trying to achieve.”“The process sets out to have doctors demonstrate that they are ‘up to date and fit to practise’. These are two very different factors to measure and this dual objective in itself appears to raise more questions than it answers in relation to the process. Being ‘up to date’ suggests notions of optimum levels of performance and ease with the latest advances, while ‘fit to practise’ connotes minimum competencies and the fulfilment of regulatory requirements. These phrases have been widely used as if they are interchangeable when they are quite different and require distinct implementation processes.”

REVALIDATION IN PRACTICEThe second strand of Dr Archer’s research, focusing on Revalidation in practice, attempts to map the reality of the appraisal process, capturing, with the agreement of the participants, actual appraisals in video and/or audio formats, as well as interviewing doctors who were appraisees, appraisers or ROs. The appraisals studied were part of a pilot programme implemented in the run-up to the actual implementation of Revalidation.“The research gave real cause for concern about the impacts of Revalidation on the appraisal process. To put it in context, the Revalidation appraisal process was introduced on the back of a pre-existing NHS appraisal system which, as was widely acknowledged, had been patchily implemented. However, individuals in our study who had experienced the NHS appraisal found it more supportive and helpful than the appraisal under the Revalidation system. Doctors felt undermined by Revalidation’s regulatory process and were less open in responding to it. While the GMC describe the process as supportive, appraisees in the pilot programme studied did not report experiencing it as supportive and suggested that Revalidation was leading to a flattening standardisation of performance.”Having said that, Julian notes that appraisal rates have risen dramatically under the Revalidation system. The significance of that increase, however, he says is dependent on the value of those appraisals, which is, in turn, dependent on their accuracy and the level of engagement of doctors with the process.The third strand of the Health Foundation and NIHR-funded study, focusing on Revalidation in public, exploring what patients have to say about the effectiveness of the process, is due to be published in 2016.

For detailed information on the revalidation process, go to: www.gmc-uk.org/doctors/revalidation/9627.asp

THE UMBRELLA COLLABORATIONThe UMbRELLA collaboration has been brought together to evaluate the regulatory impact of medical Revalidation within its first cycle of implementation. Using a mixed methods approach to examine both large statistical datasets and in-depth qualitative data, it seeks to understand how Revalidation is taking shape in the UK. The UMbRELLA evaluation of the first cycle of medical Revalidation in the UK aims to gather information about Revalidation mechanisms at all levels of the process.Specifically, the research seeks to establish how consistently Revalidation is fulfilling six key regulatory aims which it is intended to meet, which are to:

bring all doctors into a governed system that evaluates their fitness to practise (FTP) on a regular basis;

require doctors to collect and reflect on evidence about their whole practice through appraisal;

focus doctors on Good medical practice to promote professionalism by increasing awareness and adoption of its values and principles;

facilitate identifying and addressing potential concerns earlier – and before they become safety issues or FTP referrals;

support ROs to fulfil their statutory function of advising the GMC about the FTP of their doctor; and,

include effective and equitable patient and public involvement in revalidation.

The mixed methods research will be delivered via seven work packages, organised by methodological activity:

1 Literature reviews2 Secondary analysis of existing data3 National and strategic surveys4 Appraisal capture5 Interviews with stakeholders6 Documentary analysis7 Root cause analysis of documentation when FTP

referral has taken place.

RCSI SURGEONSPORTFOLIOSurgeonsportfolio (www.surgeonsportfolio.org) is an online tool to assist surgeons with Revalidation in the UK and is available free to Fellow and Members of the Royal College of Surgeons in Ireland, Royal College of Physicians and Surgeons of Glasgow, Royal College of Surgeons of Edinburgh and Royal College of Surgeons of England.The portfolio has been built through intercollegiate collaboration and with the support of the surgical specialty associations. Professor Sean Tierney, Dean of Professional Development & Practice, RCSI, explains: “SurgeonsPortfolio has been developed to assist surgeons with Revalidation, providing a secure online tool for appraisal, and enabling surgeons to control the information they collect, report and manage with regard to their practice and professional life.”The portfolio is available to all Fellows and Members of RCSI working in Northern Ireland and the UK. For more information on how to avail of this service, email: pcs@rcsi.ie

17NEW MODEL OF CARE FOR T&O SURGERY

T rauma and orthopaedics is the largest and busiest surgical specialty in health services in Ireland. Mr Moore comments: “Musculoskeletal injuries account for one-third of the acute surgery workload and one-third of the bed days used in Irish hospitals annually. Trauma and orthopaedics services are

an integral part of the Irish healthcare system and the new model addresses the many challenges confronting the specialty in its ultimate objective of delivering effective patient care.”

ENSURING EQUITY OF CARE The underlying principle guiding the development of the model was that equity must apply across healthcare. Mr Moore states: “Patients who require planned surgery are entitled to access to services, as are patients who require emergency care. Both are equally important and, despite the many challenges facing healthcare teams, we have a responsibility to ensure that resources are provided for both. “The practice of cancelling planned surgery due to large volumes of emergency referrals disadvantages a large cohort of patients. Patients awaiting planned procedures are often in constant pain, and, frequently, are so significantly disabled that their condition has a serious impact on their quality of life. To ensure an equitable provision of healthcare, access for all patients to the right care at the right time is an imperative.”

DELIVERING CAREThe Trauma and Orthopaedic Services Team (TOST) delivers trauma and orthopaedic care in our hospitals but is significantly under-resourced: “It is a consultant-led service that aspires to being consultant-delivered. Consultant numbers currently make that aspiration unachievable but, if this obstacle was dealt with, it would facilitate significant improvements in the responsiveness and efficacy of care delivery.”Looking at the TOST in a wider context, the development of closer collaboration between it and other programmes of care has the potential to greatly improve the quality of the patient’s journey through primary care, secondary care and rehabilitation, according to Mr Moore: “Multi-disciplinary team interactions

NEW MODEL OF CAREMAPS ROUTE TO WORLD-CLASS T&O SERVICETHE NATIONAL MODEL OF CARE FOR TRAUMA AND ORTHOPAEDIC SURGERY WAS RECENTLY LAUNCHED IN RCSI. MR DAVID MOORE, RCSI COUNCIL MEMBER, WHO, ALONG WITH MR PADDY KENNY, IS JOINT CLINICAL LEAD OF THE NATIONAL CLINICAL PROGRAMME FOR TRAUMA AND ORTHOPAEDIC SURGERY, SPEAKS TO SURGICAL SCOPE ABOUT THE NEW MODEL, ITS POTENTIAL TO IMPROVE THE PATIENT EXPERIENCE AND HOW IT CAN PROVIDE THE BASIS FOR A WORLD-CLASS TRAUMA AND ORTHOPAEDIC SERVICE.

Mr David Moore.

have been demonstrably linked to improved patient outcomes. General practitioners (GPs), for example, are essential members of the healthcare team, and close co-operation and communication between primary and secondary care is critical to a fully integrated service. Guideline-controlled, direct access to MRI for GPs is an example of a specific development that would help drive efficiency in orthopaedic outpatient service delivery, but, again, this requires adequate resourcing.”

STREAMLINING TREATMENT PATHWAYSThere is significant scope for treating more patients within the current system by standardising treatment pathways and ensuring that appropriate facilities are available at the right time to the right patient. Not all patients require hospital treatment, Mr Moore notes, and, in order to ensure that patients are referred to the appropriate healthcare professional, the aforementioned primary and community care linkages need to be further developed and supported.

“An excellent example of how this works is the musculoskeletal physiotherapy clinic model. Developed in conjunction with the National Clinical Programme for Rheumatology, enhanced scope physiotherapists have been successfully running these clinics since 2012. Consultant leadership has been critical in ensuring the success of this model and patient satisfaction with the care received at the clinics is very high. The extension of this model to primary care, with the involvement of additional health and social care professionals, would be an excellent way to treat patients in the community. Formal referral guidelines from primary to secondary care can provide GPs with a standardised pathway for referring patients.”

CARE DELAYED, CARE DENIED?The duration of interventions taking place at an orthopaedic outpatient clinic can vary from a relatively short time requirement for fracture diagnosis and treatment to a considerable time requirement for complex cases, Mr Moore explains. In many hospitals, orthopaedic outpatient clinics have large attendance figures. Moreover, they frequently overrun the expected timeframe, thus resulting in lengthy delays for patients and inefficient service delivery. “Overcrowding at trauma and orthopaedic outpatient clinics is endemic nationally. As a result, patient safety is compromised and patients are not afforded the appropriate access to, or time with, their treating consultants. The Irish Institute of Trauma and Orthopaedic Surgery (IITOS) identified safe clinic guidelines some time ago

1818

A MEASURED STRATEGY Audit is an integral part of measuring the quality of care that is delivered and will make an important contribution to performance improvement, Mr Moore believes. Initiatives such as the Irish Hip Fracture Database (IHFD) have enabled clinicians to audit practice against international standards for a particularly vulnerable group of patients. Similarly, the Irish National Joint Registry will define the epidemiology of joint replacement surgery in Ireland and will provide timely information on the outcomes of joint replacements in addition to identifying risk factors for a poor outcome. The Trauma Audit and Research Network (TARN) is a vital component of a trauma system, as it provides a tool for auditing patient care at the individual hospital level. This includes the effectiveness of the trauma system for improving patient outcomes across the entire continuum of care from pre-hospital to rehabilitation.

ADVANCED NURSE PRACTITIONERSAdvanced Nurse Practitioners (ANPs) in trauma and orthopaedic care should be developed around a model focused on service need and based on the guidance provided by the Nursing and Midwifery Board of Ireland (NMBI). The core concepts of the ANP role include:

autonomy in clinical practice;

expert practice;

professional and clinical leadership; and

research.

Mr Moore comments: “The role of the ANP is built upon a vision whereby nursing practice can be developed beyond the current scope of practice and is supported by clinicians, nursing and other members of the multidisciplinary team.”The National Clinical Programme in Trauma and Orthopaedics recommends the development of ANP role in trauma and orthopaedics. The ANP would greatly assist in the management of patients in the appropriate place and thus, would be invaluable in reducing waiting lists.

ESTABLISHING TRAUMA NETWORKS: A FIRST STEPThe weight of international evidence supports the establishment of trauma networks as a way to reduce mortality and morbidity in trauma patients. According to Mr Moore: “The development of the hospital groups presents us with an ideal opportunity to transform trauma care in Ireland. Currently, patients with orthopaedic injuries are taken to the nearest hospital, regardless of whether or not there is an orthopaedic service on site.“This is not best practice, and a first essential step in forming a trauma network structure should be to formally agree that ambulances transporting patients with orthopaedic trauma, should bypass hospitals that do not have an orthopaedic service on site. This Model of Care strongly recommends that a national approach should be taken, in order to ensure that a system of trauma networks and major trauma centres is developed as a matter of urgency.”

19NEW MODEL OF CARE FOR T&O SURGERY

(IITOS, 2011), and national implementation of these guidelines is urgently recommended.“Waiting lists and waiting times for initial orthopaedic outpatient appointments in Ireland are too long, demonstrating a mismatch between supply and demand. Remedial action to address this imbalance is urgently required.”Mr Moore points to the Virtual Fracture Clinic concept as an example of a proven method of ensuring that only patients who require follow-up appointments at fracture clinics are given such appointments. The National Clinical Programme for Trauma and Orthopaedic Surgery is committed to working with clinicians to progress this initiative and apply its principles more widely, he adds.

BUILDING MOMENTUM A truly world-class trauma and orthopaedic service can be delivered to patients, Mr Moore says, if the recommendations in this Model of Care are implemented, and if staff with the appropriate skills and experience are retained. However, he warns that the momentum generated by the launch of the Model of Care must not be allowed to fade. In particular, he urges the implementation of two important initiatives without delay: firstly, ambulances carrying patients with orthopaedic trauma should go directly to hospitals with an orthopaedic service on site; and, secondly, the orthopaedic safe outpatient clinic guidelines should be implemented nationally. “The work to establish a system of trauma networks needs to intensify in the months ahead and, looking to the immediate future, it is vital, in the interests of the trauma and orthopaedic patient, to maintain and build on the momentum created by the launch of the Model of Care.”The National Clinical Programme for Trauma and Orthopaedic

Surgery is a joint initiative between the HSE Clinical Strategy & Programmes Division and RCSI incorporating the IITOS. Mr Moore gratefully acknowledges the work of all those who participated in, and contributed to, the development of the National Model of Care for Trauma and Orthopaedic Surgery.

BONE HEALTH AND OSTEOPOROSISConsidering the global burden of disease imposed by osteoporosis, in particular fragility fractures, the projected population demographics for Ireland and the current absence of a national approach to fracture management services, a coordinated and integrated model is required in order to deliver safe, high quality health care.Early diagnosis, fracture risk assessment and fracture prevention are important aspects of managing impaired bone health and osteoporosis. Secondary fracture prevention is of particular importance, as mortality and morbidity rates increase within the first year after sustaining an initial fracture. It is important that risk assessment measures are focused not only at the right place and right time, but also on the right people – that is those at risk of fracture (Department of Health, WA, 2011:21). Maintenance of Certification recommends a nationwide fracture liaison service.

I n 2010, Professor James Paul O’Neill left Ireland to take up a position as Fellow in head, neck and skull base surgery in Memorial Sloan Kettering Cancer Centre (MSKCC), New York. It was always an ambition of his to work with Dr Jatin Shah, one of the best known head and neck surgeons in the world, and also chief in MSKCC.

Before reaching New York, Professor O’Neill was an intern at Beaumont Hospital - where he completed his basic surgical training - and he partook in the Irish otolaryngology training programme for four years. He sat his intercollegiate exam in 2010. During his training in Ireland he also completed an MD thesis, a masters in medical education and an MBA in UCD. “Back in 2005, the day before the New York marathon, I had an appointment to meet one of the faculty members of MSKCC in New York. That was the first time that I had a discussion about how I could navigate my way to get a position on their fellowship programme. I knew I wanted to be a head and neck cancer surgeon and MSKCC had an incredible reputation.”The following five years were focused on reaching his goal. His wife Caitriona, who was doing a PhD in Trinity College Dublin at the time, applied to continue her research at MSKCC, and was accepted. July 2010 saw them relocate to New York. Professor O’Neill describes the next two-year surgical oncology clinical fellowship as ‘bootcamp’, with 5am starts, operations almost daily – including Saturdays – tumur boards and immediate research demands and expectations. It was also the most enjoyable time of his career.“There is no doubt that at the end of the two years, I had changed considerably as a person in terms of my outlook and what I wanted from my career. Things really changed in 2011 when our beautiful daughter was born, which was a fantastic experience and also marked the beginning of us looking homeward again.”

HOMEWARD BOUNDProfessional and personal motivations were behind the decision to eventually move back home to Ireland, explains Professor O’Neill.“I needed to achieve the Certificate of Completion of Specialist Training (CCST) as I was released from the ENT programme somewhat early in order to take my position in MSKCC. So I had to give one year as senior registrar to the Irish training programme.“I was also delighted to be back in Ireland and have all the benefits of having family around,” he adds. He took up the position of senior registrar in the Mater Hospital in 2012 and subsequently completed his first textbook on head and neck disease with Dr Shah and Elsevier publishers. A second book has been commissioned for 2016.In 2013 he was appointed as consultant in the Department of Otolaryngology at St James’s Hospital. But at the end of his first year, for various reasons, he was considering his options once again, as well as a potential return to North America. “Around about this time I applied for the position as Chair in Otolaryngology Head and Neck Surgery at RCSI. A week after this interview I travelled to North America for another interview and job offer.” But the desire to stay in Ireland was strong. Caitriona had completed her PhD and was being approached by potential employers. Furthermore, our daughter had been diagnosed with non-specific global developmental delay and as a child with special needs, the importance of having family around her was all the more real, not only for my daughter but also for Caitriona and myself coming to terms with her challenges.”News that Professor O’Neill had been successful in his application to RCSI was a wonderful occasion and it meant that they did not have to uproot again. “Now in Beaumont Hospital I solely work in head and neck oncology and have a significant undergraduate teaching

CALL OF HOMETRAVELLING TO AND LIVING IN VARIOUS PARTS OF THE WORLD ARE JUST A FEW OF THE MANY BENEFITS AND OPPORTUNITIES THAT A CAREER IN SURGERY AFFORDS. BUT SOMETIMES, THE LURE OF HOME CAN BE DIFFICULT TO IGNORE. SURGICAL SCOPE FINDS OUT WHAT INFLUENCES THE DECISION TO PURSUE A SURGICAL CAREER ABROAD, AND WHY SOME RELOCATE BACK TO IRELAND.

20Professor James Paul O’Neill.

21CALL OF HOME

responsibility and fantastic colleagues. I have honestly loved every minute of my time so far and greatly enjoy the fact that many of my class mates and contemporaries are also now in Beaumont.”As someone who lived abroad for a time, he feels very lucky to be home again. “Despite the thrill of Manhattan I loved returning to Dublin. A recent weekend was a classic example why I love being home. There was a rugby international on Saturday and a GAA semi-final on Sunday and that brings out what I love best about Ireland - not sitting in a bar on Third Avenue in Manhattan with a crap pint of Guinness!“I’m very excited for the future for our students and our trainees but also for our patients. Yes, there are daily limitations and frustrations, but we have set out our strategic targets and already had minor victories during the year. I want the best for Irish ENT in every aspect and I’m completely committed to that goal.”

FROM TORONTO TO LIMERICKVascular/endovascular surgeon, Mr Tony Moloney, enjoyed six very successful years in Toronto, Canada, before he and his wife, Eimear, made the decision this year to move back to Ireland with their three children aged six, five and three. The prospect of being closer to family, and in particular, giving their children the chance to spend more time with their grandparents, supported the decision to move back home in August 2015.“The main reason to come home was family. I think that anyone who has been away understands that drawback to being far away from home. For me, one of the big drivers was our kids getting to know our parents, their grandparents. Also, the opportunity to work in University Hospital Limerick came up. The pool of vascular positions in Ireland is quite small so when an opportunity comes along you need to grab it.”It was a carefully considered decision and not taken lightly, explains Mr Moloney.

A DIFFICULT JUMP“From my perspective, it was a difficult jump to make because I was established in Toronto, with an established track record. And then, to give that all up to come home and re-establish yourself is a little bit daunting. I was coming to a place where I don’t have a track record, or set referrals. I gave up something stable and predictable for something that will eventually become stable and predictable, but it is a big step.” Mr Moloney says the decision to move to Toronto was based on reviews by two medical colleagues and friends. He felt it would be a good move for him and his family back in 2009. He completed a fellowship in vascular surgery at St Michael’s Hospital and the Toronto General Hospital (TGH) from 2009 to 2010. He then completed a locum year at TGH before becoming a staff member at St Michael’s Hospital, Toronto, until 2015, essentially running his own practice within a hospital setting.  “Professionally, it was superb. I was in a big centre that allowed me to do complex work, including advanced endovascular aneurysm repair (EVAR) and trauma. It was very busy, but it was quite rewarding.“The Irish system just wouldn’t have the same volume. The catchment area in which I worked was absolutely enormous, so as a result of that, there was greater volume and greater complexity too. Because of that volume, you would see cases that you would rarely see in Ireland.” On a personal level, it worked well for family life too. “Toronto is a wonderful place to live. The only drawback would be the lack of extended family and the distance from home. Apart from that it is a great place to raise your own family. It is a massive city so it is

really geared towards providing services for families. So, everything from the zoos, the parks, the amenities, they are all really good. The weather is very good in the summer, and then in the winter, you have the winter sports.”Mr Moloney has noticed the impact of recession on Ireland since he has been away. “Dublin appears unchanged, in fact it looks more polished than it ever was. Rural Ireland has vastly changed. You drive through places like Waterford or Carlow and there are boarded-up shops - that is quite a noticeable change.”“My own family’s hardware business of 104 years closed while I was away, that just reflects how badly rural Ireland was affected by recession,” he says. But the decision to return is still the right one for Mr Moloney and his family. “I had my homework done, I had talked to a lot of people. I had looked into the implications of my family coming home, both personally, professionally and financially. So far, things couldn’t have gone better.”

Mr Tony Moloney.

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T he concept of the Faculty of Postgraduate Surgical Educators grew out of the evolution of RCSI’s surgical training model. Professor Traynor fills in the background: “A combination of reduction in the duration of training programmes (eight years instead of the previous 12 to 14 years) and a

simultaneous reduction in working hours (from 80-90 hours per week to 48 hours per week) has made the traditional model for surgical training unsustainable.  RCSI recognised the potential challenges for surgical training as far back as 2003, and began work to institute a new model.”

INTENSIFICATION OF TRAININGThe new surgical training model provided by RCSI augments workplace training with a structured, delivered education programme which includes a syllabus-based technical skills programme,  a syllabus-based non-technical skills programme (i.e Human Factors in Patient Safety) and a knowledge/judgement based online programme. This new approach is now an integral part of surgical training, particularly in the early years.With the development and implementation of the new model, the intensity of RCSI-based training has increased significantly in the past 10 years. “We now have more than 800 trainees attending our classes and the College has become a leading advocate of the role of simulation in the acquisition of both technical and non-technical skills. “The New Academic Education Building (NAEB) will provide world class educational facilities for both our postgraduate and undergraduate students in a state of the art simulation/skills centre. With the development of these exceptional physical facilities, it was recognised that it was vital to ensure that we develop our teaching faculty resources to match and the Faculty of Postgraduate Educators has been conceived and established in order to drive the delivery of the highest standards of training and education in both technical and non-technical skills and to lead the transition from our current facility to the NAEB.”

ROLE OF THE FACULTYThe Faculty will work to increase the profile and recognition of surgical education and training and to ensure that excellence in surgical training equates to excellence and safety in patient care. Professor Traynor comments: “Excellence in surgical training is the first step in the delivery of high-quality patient care in the future, and trainees themselves now demand increased accountability, quality and excellence

in their training. The Faculty of Postgraduate Surgical Educators will encourage new initiatives and new ideas in terms of how we can deliver excellence in surgical training.”The Faculty of Postgraduate Surgical Educators comprises 18 members initially who will be involved in teaching, assessments and curriculum development across surgical training in RCSI. The majority of the Faculty are surgeons in active surgical practice from a variety of different specialties and different geographical regions in Ireland.According to Professor Traynor, a key objective of the Faculty is to put a formal structure around both the people and the processes involved in surgical education within the NSTC at RCSI.Professor Traynor adds: “The Faculty is working to develop an academic career progression pathway for the Educators themselves. We aim to develop a ‘bespoke’ set of criteria, in conjunction with the Professor of Surgery in the RCSI Medical School, for Faculty to recognise and reward excellence in teaching and education, as well as in research.  A clearly defined academic promotion pathway will allow us to attract and retain the highest quality surgical educators and will act as a stimulus to promote excellence in surgical education. The Faculty aims to engage trainers in a way which gives them a sense of vocational fulfilment, while recognising and rewarding their academic input. Ultimately, the Faculty will make a key contribution to positioning RCSI as a leading provider of structured, simulation-based surgical education globally.”

RCSI LAUNCHES FACULTY OF POSTGRADUATE SURGICAL EDUCATORSIN JUNE, RCSI LAUNCHED A PIONEERING NEW FACULTY, THE FACULTY OF POSTGRADUATE SURGICAL EDUCATORS, TO MAXIMISE THE QUALITY AND VALUE OF POSTGRADUATE SURGICAL EDUCATION IN IRELAND. PROFESSOR OSCAR TRAYNOR, DIRECTOR OF THE NATIONAL SURGICAL TRAINING CENTRE (NSTC), OUTLINES THE BACKGROUND TO THE DEVELOPMENT OF THIS INITIATIVE AND THE ROLE OF THE NEW FACULTY.

Professor Oscar Traynor, Director of the National Surgical Training Centre.

23BEYOND THE OT

P rofessor Lucey began by emphasising the importance of suspending any preconceived notions about what constitutes mental health. He then posed a fundamental question that each medical professional should ask – what kind of doctor am I?

BEYOND THE STEREOTYPESThe answer to this question can be obscured by some of the traditional, stereotyped images of the doctor or surgeon. One of the most widely accepted stereotypes of the medical professional is the idea of the surgeon as a sort of Apollonian Superwoman or Superman. Another popular notion is the idea of the surgeon as Chiron, a wounded healer, whose skills are amplified by his own suffering. Yet another historical idea of the surgeon is that of the empiricist, coolly detached, an objective observer.Dr Lucey said that these ideas are simplistic and often unhelpful in mapping a realistic outline of what it means to be a medical professional in the 21st century. Today’s surgeons deal with a range of complex challenges within a demanding and stressful environment. They must adhere to a range of high-professional standards as required by the benchmarks of good professional practice (see Panel on page 24), requiring diverse abilities including collaborative and teamwork capabilities as well as management, scholarship and clinical skills. And they must meet these standards within an environment that is under-resourced in terms of people and finance, while waiting lists get longer and work pressures mount.

PREVALENCE OF BURNOUTIn assessing the pressures of medical life, most doctors will say ‘yes, it’s stressful but we can handle it’. However, for a significant proportion of medical professionals it can become too much. It is now accepted among psychologists and neuropsychologists alike that prolonged periods of work, to the point of exhaustion, diminish work performance.

Burnout occurs when there’s an ultimate disconnect between our initial motivation, the passion and drive to do something worthwhile and the external factors that we can no longer manage. Research focusing on hospital doctors in general has shown that burnout, at some stage of their careers, is a common occurrence.International statistics indicate just how prevalent burnout is among physicians. As long ago as 1996, research in The Lancet, reported on a high prevalence of psychiatric morbidity among UK consultant physicians (27%), and suggested that it was related to work overload, feeling poorly managed and poorly resourced, and having to engage directly with patients’ suffering.According to 2012 research (Archives of Internal Medicine), 45% of US physicians had at least one feature of burnout and 35.2% had full burnout, with front-line medicine showing the highest prevalence. Professor Lucey emphasised the consequences of mental illness, noting that depression should be considered a life-threatening disorder. He cited substantial findings supporting this view including research that claims patients with coronary artery disease and depression have a two-fold to three-fold increased risk of further cardiac events. Research in General Hospital Psychiatry, reported that job stress is a major factor in high rates of physician suicide. At a minimum, pushing oneself too hard brings about a deterioration in performance and deprives patients of the individual’s care skillset.While, in many cases, recovery is possible, it takes time and comes at a personal cost to the individual, as well as at an economic and resource cost to the hospital and the healthcare sector as a whole. Acknowledging that remedies are possible, he advised that prevention is the best solution.

PROMOTING WELLBEINGWhat can the surgeon or medical professional do to avoid burnout and counter depression? He quoted author, educator and management consultant Peter Drucker’s dictum “culture eats strategy for breakfast” to illustrate the difficulties in finding ways to

BEYOND THE STEREOTYPESBUILDING RESILIENCEMEDICAL DIRECTOR, ST PATRICK’S MENTAL HEALTH SERVICES, AUTHOR ON MENTAL HEALTH ISSUES AND RCSI ALUMNUS, PROFESSOR JIM LUCEY, DELIVERED A TALK AT THE RECENT ALUMNI GATHERING ON BURNOUT AND MENTAL HEALTH WITHIN THE MEDICAL PROFESSION. HERE ARE SOME HIGHLIGHTS FROM HIS PRESENTATION.

24

maintain a healthy resilience, given the range of cultural pressures the individual faces. Among these many cultural factors, there is a widespread loss of faith, whether in institutions or religions, across society and this has a practical impact on psychological well-being, he noted. Drug dependencies and addictions are increasingly prevalent, undermining physical and psychological health. Clearly, culture can undermine our strategies to achieve well-being in many ways. Nonetheless, we can build resilience to withstand these cultural pressures and deflect their influence.

MAKING A CHANGEThe successful implementation of significant change is dependent on surgeons themselves engaging in the strategic management and evolution of the profession. If that responsiblility is handed to a faceless manager, it won’t work. The impetus to find real, balanced solutions must come from surgeons themselves.Surgeons must take increasing ownership of their roles, and the shaping of those roles, in a progressive and co-operative way, Professor Lucey believes. That is essential because in the years ahead, the search for balance will encounter new challenges and it will be the responsibility of surgeons to ensure that they lead these changes in a way that maintains their integrity as practitioners at the peak of their powers and as fully rounded, human beings with satisfying and fulfilled lives.

RESILIENCEThe capacity for resilience is a product of six factors:

education;

social competencies;

positive values;

talent and interests;

friendships; and,

a secure base.

Inevitably, people find there are gaps in their resilience but, Professor Lucey noted, there are practical approaches to filling these gaps. He outlined five steps to wellness, a set of evidence-based actions which have been shown to promote people’s well-being. These activities are simple things individuals can do in their everyday lives. They are:1. connect;2. be active;3. take notice;4. keep learning; and,5. give.

In seeking to make and maintain connections, he cited the importance of making time for family life and for friendships. Balance is a key word, he believes. The surgeon’s drive to acquire skills proficiency to a high degree of competence and to continually expand the boundaries of knowledge is crucial. And its validity is underlined by research, which shows that repeated exposure to tasks, improves skills. Nonetheless, if someone defines her or himself exclusively as a surgeon, he or she is at serious risk of creating an imbalance that could be detrimental both in work and life outside work.Maintaining work/life balance is not a narcissistic endeavour, it is part of a responsibility, not just to yourself, but to those you work with.Being active, engaging in dance, singing or physical exercise has been shown to be extremely beneficial in encouraging wellbeing. Similarly mindfulness, the practice of learning to be ‘in the moment’ can be helpful. Ultimately, Dr Lucey concluded, there are a range of effective strategies for behavioural change including educational outreach, one-to-one dialogue, interactive education or multi-faceted education using a variety of strategies in a combined effort. The vital initial condition is that the surgeon/medical professional recognises the issues at stake and the importance of a holistic image of their life and work.

Panel 1. Eight domains of good professional practice.

RELATING TO PATIENTS

PATIENT SAFETY AND QUALITY OF PATIENT CARE

COLLABORATION AND TEAMWORK

MANAGEMENT (INCLUDING SELF-MANAGEMENT)

SCHOLARSHIP PROFESSIONALISM CLINICAL SKILLS

COMMUNICATION AND

INTERPERSONAL SKILLS

25OPERATION SMILE

O peration Smile— through the help of dedicated medical volunteers — has provided free surgeries to children in more than 60 countries since its inception 33 years ago. Founded by Dr Bill Magee, a leading US plastic and craniofacial surgeon,

and his wife Kathleen, the international medical charity has, to date, provided more than 250,000 surgeries for children born with cleft lip, cleft palate and other facial deformities.In 1982, as a young plastic surgeon with a medical and dental degree, Dr Magee was given the opportunity to travel to the Philippines with a group from Houston, Texas who were focused on taking care of children with cleft lip and cleft palate and other facial deformities. Their last stop was Naga City, where more than 300 patients and families visited the medical centre there, looking for help. The doctors were only equipped to operate on approximately 40 children back then, and had to turn away the rest. “There was absolutely no one in that region to take care of clefts, and we knew these families would never be treated. The final straw for us was a mother who presented us with a ripe basket of bananas, her eight-year-old daughter at her side with a big hole in her lip. She was grateful that, even though we had to turn her child away, we had tried to help,” Dr Magee says. Dr Magee believes it was at that moment Operation Smile was formed and he and his wife decided to gather a group of medical professional colleagues and return to tend to the children who had been turned away. So, the following year they returned and had to turn away another 300 children. Word spread in the international medical community and, with volunteer numbers increasing, Operation Smile began its successful journey.

TEAM DEVELOPMENTWhen the Operation Smile mission groups began in 1982, they would stay for approximately two weeks, and make a return visit one year later. According to Dr Magee, there was no continuity of care or consistency of treatment. “There were no global standards developed for safety, and research and education were not an orchestrated part of the overwhelming majority of these type of groups. Over the years we realised the importance of this and developed not only Global Standards of Care that meet or exceed the standards that we use at major hospitals in the US, but we have also incorporated safety standards as a principle within the countries that we collectively serve. We have developed instrument sets with companies like Stryker to increase the efficiency of surgical care, and we have undertaken research in educational platforms that are unique within surgical care. “In addition and as a result of seeing first-hand what the experience in 1982 did for our 13-year-old daughter who accompanied us on that trip, we developed a Student Programs Team as a critical part of the Operation Smile mission and culture. The Student Programs Team

OPERATION SMILEDR BILL MAGEE, CO-FOUNDER AND CEO, OPERATION SMILE, DISCUSSES THE GLOBAL MEDICAL CHARITY, WHICH IS HELPING TO PUT SMILES ON CHILDREN’S FACES

Dr Bill Magee, Co-Founder and CEO, Operation Smile.

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incorporates high school and middle-school students into the mission experience, helping develop sensitivity and leadership for the future at an early age. We have seen the lessons that these students learned in this environment help set their values in an unbelievably productive and positive way,” Dr Magee says.

MEDICAL SERVICE PROVIDERSTo build long-term sufficiency in resource-poor environments, Operation Smile trains doctors and local medical professionals in its partner countries so they are empowered to treat their local communities. Operation Smile also donates medical equipment, supplies and provides year-round medical treatment through its worldwide centres. By providing these services, Dr Magee says, children have access to safe surgery, good health and have the opportunity to live normal lives with confidence. “People living with cleft lip and cleft palate can’t eat or drink normally so, are often malnourished and can be ostracised because of their symptoms. Living with dignity begins with a smile.”The success of Operation Smile has surpassed Dr Magee’s expectations, with the charity now the largest, volunteer-driven, surgical organisation of its kind in the world.

“We’ve never recruited volunteers, everything just happened organically. When we first set out to address the global issue of cleft lip and cleft palate, our goal was to help whoever we could as much as we could. Now, after 33 years of taking care of families in low-and middle-resource countries, we recognise that there is a very significant difference in not only the access to surgery, but also in the infrastructure which would allow a safe surgical environment,” he says. The surgeon, according to Dr Magee, only represents about 10% of the surgical process. Effective and safe anesthesia, nursing, pre- and post-operative care, instrumentation, monitoring equipment, etc., are extremely important to provide a safe, surgical environment. Dr Magee believes the organisation has an ethical and moral responsibility to advance these surgical principles in the communities that the volunteers serve in. “We have a very unique position, because, through the child that we treat with a cleft, we gain the trust of their family and their community. There will never be enough trained medical people in the associated specialties to adequately handle the need, therefore, creative new ideas are essential. If the constituents in these countries are to have access to safe surgical care, Operation Smile involves

At the moment there are four cleft surgeons in Ireland who are all Operation Smile volunteers including: Professor Earley; Dr Davd Orr, who is a prominent figure within Operation Smile Ireland; Dr Eoin Ó Broin a consultant in Cork University Hospital; and Dr Chris Theopold, Temple Street Children’s Hospital. Their input and expertise are invaluable.

Professor Earley has completed 15 missions since joining the organisation including three in the last 12 months to the Dominican Republic, Ho Chi Minh, Vietnam, and has just returned from a major international mission in Madagascar. Operation Smile undertakes about 150 to 160 missions per year around the world, with the most frequent mission taking place every six months to any one site. The average mission, lasts about 12 days – short but effective. Post-operative follow-up is then undertaken by the in-country surgeons, who are also responsible for completing and doing all the groundwork before the volunteers arrive. Missions can vary between exclusively teaching and training missions (the most recent one in Jimma, Ethiopia), where Operation Smile volunteers educate the local surgeons in dealing with immediate patient needs, while also dealing with the extensive backlog of patients. Professor Earley’s role in the Madagascar mission was of Surgical Team Leader with a full team of 50 medical professionals including surgeons, nurses, paediatricians and anaethetists, working with him. There are 600 children per year who need operations for cleft lip and cleft palate in Madagascar, which has a population of 20

million, compared to one in 600 children born in Ireland (110 born on average per year), which is significantly higher than the European average.

During the Madagascar mission, Professor Earley and his team treated about 118 patients. “I found that there are many older patients who also need to be treated and who are too far away from the medical treatment centre to attend – some travelled for two days. One 39-year-old man came with his wife and daughter, and it was particularly poignant after the operation as he had lived with a wide cleft lip for his whole life and now he could start a new life. It is a win-win situation. You are helping people in need and you are seeing and experiencing a country and its culture in a different way than anyone could imagine,” he says.

Incidence is constant, especially in Africa, Asia and South America, in relation to cleft deformities. Every three minutes a child is born with a cleft deformity – and if anything, Professor Earley says, the demand is growing.

Looking forward to his next mission to Vietnam in April 2016, Professor Earley says one development, which he would be keen to reinstate, is the University Student Progamme where previous RCSI students would have learned onsite how to perform cleft procedures in a developing country’s medical environment. “This is an invaluable learning experience for medical students,” he notes.

“The missions are life-changing for both patients and volunteers, and I would encourage all medical professionals to consider working with Operation Smile.”

OPERATION SMILE IN ACTIONProfessor Michael Earley, Consultant Plastic Surgeon, at Our Lady’s Children’s Hospital, Crumlin, has been Chairman of the Surgical Council of Operation Smile since 2003.

not only the continued treatment of children with facial clefts, but also the understanding that these children introduce us to their community, and the needs that exist for those individuals in a wider variety of pathologies that require surgical intervention. Our goal is to initiate that care to a broader audience in a safe and effective way.”

FUTURE FOR OPERATION SMILEAs world leaders prepare to announce their 15-year agenda for global action through the United Nations Sustainable Development Goals (SDGs), Operation Smile is announcing its global strategy to address the immense need for access to surgical care as a core component of Universal Health Coverage (UHC). The SDG focus on access to safe surgery fits squarely into the vision of Operation Smile to create a world where no child suffers from lack of access to care. “We strongly support the efforts of the World Health Organization (WHO) to raise awareness of safe surgical care as an essential healthcare service that should be accessible to all,” Dr Magee says. “Operation Smile is committed to working alongside the UN, governments, the WHO and other international institutions, local authorities, the private sector, academics, civil society and everyday citizens, to ‘ensure healthy lives and promote well-being for all at all ages’.“Our goal now is to surround ourselves with like-minded individuals who have the financial assets to invest in the exciting opportunity to elevate the entire surgical environment. If we can do that, anyone who needs surgical care, whether that be from childbirth, traumatic incidents such as car accidents or falls, or cataracts will have a higher likelihood of receiving care than they had in the past.”

27OPERATION SMILE

Professor Earley with his first patient of the day.

Professor Earley in an operating theatre during his recent Madagascar mission.

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RCSI NEWSSend your professional news to: fellows@rcsi.ie

Dr Alain Diméglio and Mr Declan J. Magee, RCSI President.

RCSI MYHEALTH APP OFFERS EASY ACCESS TO CREDIBLE HEALTH INFORMATIONRCSI has launched a new health app which offers easy access for users to a credible source of health information. The RCSI MyHealth app has been developed in conjunction with 16 of Ireland’s leading charity organisations. More than 800 health conditions are listed in the app as well as information on where to seek advice and support.

This app is useful for health professionals who are looking to provide supplementary information to patients about specific health conditions as well as for people looking to take charge of their own health.

Download it today free of charge from the Apple App Store and Google Play.

BREAST CANCER IRELAND GREAT PINK RUNProfessor Arnold Hill, Chairman of the RCSI Department of Surgery and Chairman of Breast Cancer Ireland; Sonia O’Sullivan, 5000m World Champion and Olympic silver medallist; and Aisling Hurley, Breast Cancer Ireland Chief Executive; at the fifth annual Breast Cancer Ireland Great Pink Run. The run attracted over 4800 entrants and raised €125,300 in aid of Breast Cancer Ireland.

HONORARY FELLOWSHIP AWARDED TO DR ALAIN DIMÉGLIODr Alain Diméglio was awarded an Honorary Fellowship of RCSI at the postgraduate conferring ceremony. Professor at the Medical School of Montpellier since 1968, he was Chief of the Paediatric Orthopaedic Department and also held the role of President of the National Paediatric Surgery Society. He is engaged in a range of humanitarian missions in Africa and in Asia where he has trained many paediatric orthopaedic surgeons. Dr Diméglio’s numerous international publications focus on the topics of growth, clubfoot and Legg-Calvé-Perthes disease.

RCSI RESEARCH INFORMS LANDMARK LANCET REPORTTwo thirds of the world’s population lack access to safe, affordable surgical and anaesthesia care when needed, according to initial findings of a report carried out by The Lancet Commission with support from RCSI. The Lancet Commission on Global Surgery published its initial findings in a landmark study: Global Surgery 2030: evidence and solutions for achieving health, welfare and economic development. A 15-year programme to implement the proposals was launched in May. View the full report at www.thelancet.com/commissions/global-surgery

Pictured at the Breast Cancer Ireland

Great Pink Run, are Professor Arnold Hill, Sonia O’Sullivan and

Aisling Hurley.

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RCSI AND BEAUMONT MARK WORLD HEAD AND NECK CANCER DAYProfessor James Paul O’Neill, Head of the Department of Otolaryngology, RCSI, in conjunction with the International Federation of Head Neck Oncologic Societies (IFHNOS) organised a series of events to coincide with ‘World Head and Neck Cancer Day’ on July 27.

A Head and Neck Symposium was organised to raise awareness of head and neck cancer and highlight its risks, as well as to promote early detection and prevention. A free screening clinic was held at Beaumont Hospital, one of six hospitals in Ireland running similar events that aim to raise awareness of head and neck cancer.

Ireland joined the international movement of 53 countries that observed World Head and Neck Cancer Day.

SURGICAL TRAINING ON WHEELSEarlier this summer the College of Surgeons of East Central and Southern Africa (COSECSA) announced the launch of a Mobile Surgical Skills Unit, which travelled from Dublin, Ireland and arrived in Dar es Salaam, Tanzania.

The Mobile Surgical Skills Unit is the world’s first dedicated mobile surgical skills training unit. It is equipped with surgical training technology which will be used by COSECSA surgeons to train surgical trainees in COSECSA-affiliated hospitals. The initiative is part of a well-established partnership initiative between RCSI, Irish Aid and COSECSA.

Pictured at the Head and Neck Symposium, are: Professor Patrick Broe, former President of RCSI, Consultant Surgeon, Beaumont Hospital; Mr Declan Magee, RCSI President; Mr Kevin O’Malley, US Ambassador to Ireland; and, Professor James Paul O’Neill, Professor of Otolaryngology, Head and Neck Surgery, RCSI, Beaumont Hospital, Dublin.

COSECSA Council, Irish Embassy Representative and Tanzania’s Chief Medical Officer in front of the Mobile Skills Unit.

POSTGRADUATE CONFERRING CEREMONYMore than 390 healthcare professionals were conferred with postgraduate awards at a conferring ceremony on July 6. In surgery, these awards included Fellowships of RCSI in General Surgery; Otolaryngology; Plastic Surgery; Trauma & Orthopaedic Surgery; Urology; and Fellowships Ad Eundem. Memberships of RCSI were awarded including Memberships in ENT and Ophthalmology.

Pictured at the RCSI postgraduate conferring ceremony are: Ms Iseult Finn, Membership of RCSI; Professor Tom Gorey, RCSI Council Member; and Mr Aidan Manning, Fellowship of RCSI in General Surgery.

Pictured at the RCSI postgraduate conferring ceremony are: Ms Shirley Potter; and Ms Anne Collins, Fellowships of RCSI in Plastic Surgery.

THE ELEMENTS OF LEADERSHIPProfessor Kelly began by identifying what he believes are the most valuable elements of leadership. “Firstly, I believe in the importance of the team. They say that you become the average of the 12 people that you spend the most time with, which underlines the importance of choosing the right team. That team, in turn needs a clear mission or purpose, as both a statement of intent and a compass to guide it through the various challenges along the way.”Resilience is a vital quality for leaders, he said: “Sometimes you just have to tough it out and wait for the tide to turn. Leadership also needs to be ambidextrous, balancing guardianship of core principles with an openness to innovation and change.“Other crucial components of leadership are efficiency in execution and the promotion of a positive, goal-oriented culture which encourages people to perform to their optimum while finding fulfilment in what they do. Finally, there is perhaps the most difficult leadership discipline of them all, self-management.”

LEADERSHIP AT RCSIProfessor Kelly outlined his observations of these qualities as characterised by leadership at RCSI: “The College’s collective ethos, its diversity of expertise and a general willingness to challenge and discuss, and then to take unified action behind an agreed approach, stand out for me as being some of its most distinctive qualities. “Equally, I have seen the great value of our core mission, as a moral compass on an ongoing basis. The mission can guide you through the complexity of really challenging decision-making, preserving the integrity of the Institution. From the very beginning, RCSI’s mission has been very clear and while its expression has been modified with the changing times, its primary intent has never altered.”He continued: “Our mission to ‘educate, nurture and discover for the benefit of human health” guides and informs all our decision-making. But statements like this only come alive, when you are faced with difficult decisions. When the economic or political climate changes, what are your priorities, what do you save, what do you hold fast to?”

He also identified a questioning approach, which he thinks is important: “We do not take success for granted. As a self-governing institution, we cherish our independence but are also aware that, we are, in a real sense, on our own. And that means we are never complacent.”People sometimes talk about the ‘burden of history’ Professor Kelly noted, but, he said, an institution’s history is very important. “People are often surprised at the depth of history at RCSI, even our own Fellows. I think it is even more important for our internal staff, so that we never forget where we came from and that we continue to be emboldened by, and stay true to, our legacy.”

A LEGACY OF ‘FIRSTS’Balancing its respect for a unique heritage, RCSI has continually innovated. Professor Kelly commented: “Founded, in part, to establish surgery as a profession and academic specialty, the College went on to set up the first Chairs in surgery, midwifery and, in the 1960s, anaesthesia on this island. The first Chair in preventative medicine in the British Isles was established by RCSI in 1841.The postgraduate training bodies in Anaesthesia (later evolving into the College of Anaesthetists of Ireland), Radiology, Dentistry, Nursing and Sports and Exercise Medicine were all established by RCSI, in response to gaps in training in Ireland. “The College has continued to innovate in a whole range of healthcare programmes, from the first Graduate Entry Medical School, to the first Clinical Research Centre on a hospital site, to nurse prescribing, to the National Pharmacy Internship Masters programme, and most recently, the Physician Associates programme.In closing, Professor Kelly recalled when he first became Dean: “I travelled overseas to see the admission-interviews in action. I was stunned by the quality of the applicants. What energises me and my colleagues in RCSI, is the exceptional students that we get to engage with. You couldn’t fail to be moved by their energy and excitement about the future. “As an institution, we are committed to meeting their passion – be they undergraduates, PhD students, surgical trainees or consultants doing CPD – and providing them with an exceptional environment to allow them reach their potential.”

EXPLORING LEADERSHIP THIS YEAR’S FREYER LECTURE WAS DELIVERED BY PROFESSOR CATHAL KELLY, CHIEF EXECUTIVE, RCSI. HIS THEME WAS LEADERSHIP AND, IN PARTICULAR, HOW RCSI EMBRACES AND ACTUALISES ITS LEADERSHIP ROLE IN THE DEVELOPMENT AND DELIVERY OF OPTIMUM HEALTHCARE OUTCOMES.

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The Sir Peter Freyer Memorial Lecture & Surgical Symposium is hosted annually on the first weekend of September by the Department of Surgery, NUI Galway. Professor Sean O’Beirn established this conference in 1975 and was succeeded by Professor HF Given. It is currently hosted by Professor Oliver McAnena and Professor Michael Kerin. It is the largest surgical conference in Ireland and is open to all surgical disciplines both nationally and internationally.

The Sir Peter Freyer Memorial Lecture 2015 was delivered by Professor Cathal Kelly, Chief Executive, RCSI.

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