THE ROYAL AUSTRALASIAN COLLEGE OF SURGEONS
SURGICAL NEWS
Vol:8 No:8 September 2007
Gillian Dunlop combines her love of art and surgery,
pages 18 – 19
ALSO THIS MONTH:
PAGES 19 – 20: LAW REPORT
“Medical practitioners have always been subject to an array of professional, ethical and legal obligations.”
PAGES 24 – 25: RACS INTERNATIONAL MEDAL
“Awarded in recognition of outstanding international service to surgery and education.”
RACS – The College of Surgeons in Australia and New Zealand
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7/09/2007 10:34:03 AM
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7/09/2007 10:40:16 AM
PRESIDENT’S
SECTION
REPORT
STRAP
Crisis in surgical services
There is a crisis and we need to be actively involved in the solution
Andrew Sutherland,
President
WHEN GOVERNMENTS, STATE and Federal of all political persuasions, avoid serious
policy discussions and respond to health issues
by symbolic 15-second sound grabs or one-off
funding decisions the significant and systemic
problems in the health system and in particular surgical services continue to be avoided.
The disconnection between State and Federal Government funding merely compounds
the matter. As the Federal election looms in
Australia and as the next round of the Australian Health Care Agreements commence it is
important to understand the problems before
us. The community does indeed have both a
health crisis and a surgical service crisis. However the most significant questions are:
1.Do the politicians recognise that there
is a crisis?
2. Will they do the things that are required
to fix it?
This is not referring to the usual tinkering
at the edges that occupies the political cut and
thrust, but the earnest responses for how we
provide sustainable surgical services into the
future.
Workforce Crises –
now and very soon
Much has been written about the health
workforce shortages. Due to the ill-advised
Commonwealth Government policy of the
1980s when medical schools were held static
or at the best with minimal increases, the
shortage of medical practitioners has acutely
worsened over the past ten years. It is safe to
say that there is a shortage of general practitioners and all other specialties in absolute
numbers. Further worsening will occur with
the ageing of both the current workforce
and the population. However these shortages
relate to the entire health workforce. None
of us would be without stories of inadequate
numbers of trained intensive care or operating
theatre nurses, physiotherapists, occupational
therapists or radiographers. There are many
days when the “surgical team” is depleted
by the inability of the health sector to recruit
and retain competent and committed staff – of
all types.
The Commonwealth Government is now
opening a number of medical schools across
Australia and the numbers of medical school
graduates will more than double from 2004 to
2015. This tidal wave of medical graduates is
occurring without the appropriate increase in
vocational training positions. Although some
of the disciplines of surgery, such as cardiothoracic, do not need a substantial increase
in Fellows there are others where steady
increases should be identified. The College
acknowledges and indeed has helped establish
the need to address surgical workforce numbers in the face of changing demographics;
principally the ageing population and surgical
work force. However, we should not accept
that an ill-considered increase in the numbers
of surgeons at the expense of other areas of the
medical workforce will solve the problems in
a sick public sector and mal-distribution of the
surgical workforce. These must be dealt with
by solutions other than a simple increase in
the surgical workforce.
The College, in cooperation with the specialty societies, has been responsibly increasing the output of our training programs.
From 1997 to 2006 there has been a 53 per
cent increase in advanced training positions.
To continue to increase these numbers is a
challenge even where they are needed. Forty
per cent of all surgery is now day stay surgery.
In 2003-2004 private hospitals accounted for
approximately 39 per cent of total hospital
separations and of all procedures 43 per cent
were performed in the private sector. In most
areas the availability of good quality training
positions in the public sector are now effectively capped due to the limit on surgical
activities of our public hospital systems. This
is due to the College’s reluctance to accredit
positions where they match our requirements
for accreditation, namely sufficient caseload
and resources for high quality surgical education and training.
Does the Public Sector Want a
Surgical Service?
Although personally committed to the public
sector I continue to struggle with a system that
appears so anti-surgical. If the various Ministers of Health wanted a vibrant surgical service
policy, infrastructure and even senior executive performance appraisals would be focused
on this. Some of the broad policy parameters
would need to cover the following:
Do you have committed surgical lists
that will not be cancelled due to lack of
bed availability, ICU beds or other resource
allocation? If addressing waiting list issues was
important then surgeons would have operating
sessions that could extend until the cases on the
list were finished. Is it reasonable to be cancelling the last half of an operating list rather than
understanding that our patients have arranged
their private lives and commitments to ensure
they can attend the hospital for a procedure?
How many will suffer from ill-health due to
the postponement of the operation?
Are you able to access operating
theatre times to do emergencies without
having to wait until the late evening and
only then having been “bumped” at least
once or twice? It is becoming clear that
emergency cases should be done in “routine”
hours when the staff are able to do it at their
best – not wait until late night hours to suit
hospital convenience.
Do you have your surgical team when
you operate? Teamwork is being stressed
more and more. Is there really a purpose
to rotating staff through all theatres so they
know little about the preferences for the surgical team, the surgeon or the procedure? Not
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PRESIDENT’S
REPORT
Andrew Sutherland,
President
everything is done by a template and there is a
distinct purpose in teams being well practiced
and familiar with their work.
The next time you pick up a pair of
scissors – will they be sharp? The routine
maintenance of operating theatres and equipment is critical. However, it is often one of
the first things to be “skimped” when budgets
and respect for the clinical teams is lacking. It
is often said that removing morning tea from
the operating theatres suite is one of the best
ways to disenfranchise staff. This holds even
more fully for incomplete instrument settings
of poorly maintained equipment.
In each State there are dedicated surgeons in
the public sector who are working hard - some
with and some without the cooperation of their
jurisdictions - to improve this situation and have
had some remarkable success but generally the
results have been disappointing.
Who is setting the surgical
agenda in the Public Sector?
Mayne Health believed they could re-define
the principal customers of the private hospitals but failed to understand the pivotal
role of the surgeons who worked in their
hospitals. Whilst the safety and comfort of
our patients is paramount, a key differentiator will always be the hospital that understands the demands of a modern-day surgical
practice and facilitates the interactions that
are required. Surgeons have choices. In the
private sector there is usually the possibility
of having operating sessions at other private
hospitals. In the public sector the surgeon’s
only choice is to leave and provide their
entire practice through the private sector.
The crisis in surgery is with us today as an
entire generation of surgeons are now considering a career without involvement in the
public sector and the demands that are integral to this. It is at this stage that one understands the importance of the questions:
SURGICAL NEWS P4
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• Do the politicians know they have a
crisis with surgical services?
• Are they prepared to undertake the substantial changes required to restore or
develop these surgical services?
Soon they will have lost the opportunity and
perhaps a generation of surgeons who are
willing and able to support the system.
What is required?
It is often written that there is a workforce
crisis but less frequently written that there
is an efficiency crisis in the public hospital
sector. Although I do not wish to enter the
management debate around the most effective
ways of ensuring organisational outcomes,
the Chief Executive of your hospital needs
to be directly accountable for your surgical
service. Is there a surgeon who works in a
public hospital where the CEO is directly
rewarded or penalised on the amount of surgery undertaken? The key changes required
are, of necessity, diverse.
Access to Operating Theatres
and Full length lists
The entire emphasis on operating lists should
be on “what else can be done today?” and not
“we must cancel your last cases”. In many
public hospitals the last 30 minutes of the list
is left vacant in case there is an over-run. Surgery on public lists will always be slower than
those in private practice due to the teaching
element. Even allowing for this it would be
interesting to examine the efficiency of the
public sector in getting the maximal work
done in the time available.
Special Provisions for Acute
and Emergency Surgery
The provision of emergency surgery is a looming problem not only because of increasing
sub-specialisation but also because of substantial recruitment and retention issues for sur-
geons involved in this area. It is not appropriate for the majority of emergency work to be
the province of Trainees. Appropriate structures, systems and remuneration are required
to ensure that acute and emergency surgery
can be done by the most appropriately experienced and trained surgeon as soon as possible
after presentation and within the safer hours
of daytime lists. Endlessly delaying cases until
closer to midnight or the next operating list is
neither appropriate nor safe for the patient or
the surgeon.
Stop Hiding Waiting Lists
More posturing occurs with waiting lists
in Australia and New Zealand than any
other measure of health sector activity. Due
to undisclosed waiting lists for outpatient
appointments, “bottom drawer waiting lists”
or waiting lists that can only last for six months,
the entire concept is now shameful. Transparency and objectivity is required politically
and managerially so when waiting lists are
discussed there is definite comparability.
Critical Mass
As they say, modern surgery is a team effort.
The future of surgical practice is by more
cooperation between surgeons and specialties
than has traditionally been the case in Australia and New Zealand. Groups within metropolitan areas and teams within hospitals will
provide diversity of skills and on-call capacity. There is also a critical mass of surgeons
required to enable any surgical service to be
formed. Although on occasions there may be
situations where a “single surgeon” hospital is
required, there is increasing momentum for
appropriate on-call rosters to balance worklife issues. The survey of all Fellows and separate work by the Divisional Group of Rural
Surgeons confirmed that at least a one-in-four
roster was deemed the most appropriate. With
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the average ratio of general surgeons to population being one to 20,000 then a regional
centre requires a population of 80,000 to
keep a general surgical service viable. Obviously the numbers are different but very relevant for orthopaedics and other specialties. It
is critical that these estimates are understood
by the health planning and political process.
The days are now long gone when surgeons
without the appropriate infrastructure or professional support can provide safe, high quality
surgical services to a community.
So What About Regional
Distribution?
Australia and to a lesser degree New Zealand
must re-think its approach to regional distribution. If the politicians earnestly believe that
the regions need to be supported, they need to
take an “all-of-community” approach. Many
health and non-health professional groups
including surgeons do not go to regional
centres because of the lack of infrastructure,
educational opportunities, and job opportunities for partner and children or community
support. The mal-distribution of surgeons and
other health professionals speaks to the inability of our politicians to think outside the
major metropolitan centres in any sense of
planning for our two countries. If the politi-
cians really believe they have a problem they
must address this with comprehensive and allof-community responses. Increases in remuneration or overall numbers of surgeons alone
will not be sufficient.
“The crisis in surgery
is with us today, as
an entire generation
of surgeons are now
considering a career
without involvement in
the public sector and
the demands that are
integral to this”
Saving the Training in
Our Public System
In the next edition of Surgical News I will
address possible initiatives to improve access
to training outside the public hospital sector.
However, within the public hospital sector the
College must now push strongly for dedicated
time for supervisors and providers of training
as well as the infrastructure to support, nurture
and monitor a quality service. The expectation is that we provide a professional training
program with formal in-training assessment,
mentoring and counselling as well as our clinical commitments. This takes time from a busy
work schedule that needs to be recognised and
remunerated, an infrastructure to undertake
audit and managerial support at the surgical
service level to ensure it all happens. Again, if
the politicians are serious that they want a surgical service that is at a teaching standard then
it must be resourced appropriately.
Is there a crisis?
The answer is yes. Our young surgical talent increasingly does not see a future in the
public sector surgical services. They see it
in the private sector. The College must
ensure that both are embraced. However
if the politicians truly believe they want a
vibrant surgical service in the public sector they need to understand, appreciate and
respond. There is a crisis but at this stage
we need the politicians to at least identify
the answers, respond and include surgeons
in the solutions.
Notice to Retired Fellows of the College
The College maintains a small reserve of academic gowns for use by Convocating Fellows and at graduation ceremonies at the College.
If you have an academic gown taking up space in your wardrobe and it is superfluous to your requirements, the College would be pleased
to receive it to add to our reserve.
We will acknowledge your donation and place your name on the gown, if you approve.
If you would like to donate your gown to the College, please contact Jennifer Hannan on +61 3 9249 1248.
Alternatively, you could mail the gown to Jennifer C/o the Conferences & Events Department, Royal Australasian College of Surgeons,
College of Surgeons’ Gardens, 240 Spring Street, Melbourne 3000.
GOWN DONATION – THANK YOU
The College would like to acknowledge the late Mr Ian A. Shumack FRACS on the generous donation of his academic gown.
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TRAINEES
ASSOCIATION
Trainee News
Hello everyone. Congratulations to those of you accepted to the
Surgical Education and Training (SET) program for 2008
John Corboy,
Chair RACSTA
COMMISERATIONS TO THOSE who will
need to try again next year – don’t give up if
surgery is what you really want to do.
To help you start planning:
SET survey
Airline costs
By now the Basic Surgical Trainees (BSTs)
who applied for SET will have received the
RACSTA SET survey. Thank you for your
responses. Chien-Wen Liew, RACSTA
Communications Officer and SA BST representative developed it with assistance from his
team in SA. Results are to be posted on the
website. In addition, the information derived
will be passed up to the Education Board.
This is a great way of getting information
to improve SET. I would like to acknowledge the hard work your SET representatives
Mitchell Nash and Simon Quinn have done
this year on SET, through the College’s SET
working party.
Moving for work in 2008?
The relocation package offered by Grace may
come in handy for you if you need to move
for training – please take advantage of this
package negotiated by RACSTA relocation
representative Matthew Peters. The feedback
to date from Trainees who have used it has
been very positive.
CASC Hong Kong 2008
The Combined Annual Scientific Congress in
Hong Kong looks very exciting – it’s an amazing chance to learn about developments at the
forefront of surgery. It runs from the evening
of Tuesday 12 May to Friday 16 May 2008.
Campbell Miles has an excellent article in
the July 2007 Surgical News and the website
address is: www.surgeons.org/casc2008.
Nastasha Polites, Ear, Nose & Throat/
Otolaryngology Specialist Surgical Trainee
(STT) is the RACSTA Rep for the
conference.
Note passport and visa requirements.
SURGICAL NEWS P6
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Meeting registration fee
Not available
(2007 ASC Trainee fee NZ$1015)
Booking now Sydney-HK
AU$1200-$1400, Auckland-HK NZ$1900
Accomodation costs
AU$170-$600/night
Travel/medical/personal insurance
Essential
Shopping money
Essential
Working parties
SET as per above. The latest update on Elogbooks is that they are coming “later in
the year”. No new news from safe-working
hours, though we are interested on your feedback on your runs. RACSTA welcome packs
are being adapted for 2008.
Flexible training
If you have been involved in flexible training,
part-time training, interrupted training – we
are putting together examples of “how it was
done” for the website as an information source
for Trainees. Please email RACSTA.Chair@
surgeons.org with an example you would be
happy for us to place on the website.
RACSTA recommendation –
End-of-run reviews
At the March 2007 RACSTA meeting, a
discussion was held about assessment of run
quality. Orthopaedics and Vascular were
noted to have strong emphasis on this, using
interviews/surveys and interviews respectively. RACSTA made a formal recommendation to the Education Board in April:
“That specialties that do not have end-ofrun reviews with Trainees investigate the
possibility of instituting these to improve
run quality.”
RACSTA recommendations are passed up to
the Education Board for consideration. Initially,
this was discussed at a teleconference. Further
information was sought and provided to the June
Education Board meeting. The recommendation
was approved and has now been passed to the
board of Specialist Surgical Training for discussion at that level. RACSTA is preparing more
information for this setting.
As an insight into how RACSTA can
develop training, I hope this is interesting to
you. It has been a learning process for me.
Hopefully we can get a useful outcome for
Trainees across all specialties.
Education Board and Council Meetings
June 2007. Attended by Damian Amato
RACSTA Co-Chair and Neurosurgery SST
Representative. Full report in the RACSTA
webpages of the surgeons.org website.
Items of interest for Trainees
from Education Board:
• RACSTA End-of-run
review recommendation.
• From SATSET (Surgeons as Trainers SET): development of Mini-clinical
exams (Mini-CEX) and Direct Observation of Procedures (DOPS ) and Trainees
being responsible for getting these done,
documented, checked by supervisors and
then submitted to the College.
• October 2008 sees the introduction
of the Specialty-aligned Basic
Science Exam.
• From 751 BSTs, 599 applied for SET.
Items of interest for Trainees
from Council
• The Safe Working Hours Draft Policy
and responses to it.
• E-logbooks – due in late 2007.
• 2007 ASC Christchurch – highest registration of Trainees for an ASC to date.
I hope your year is going well and I will update
you on RACSTA activities next month.
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PROFESSIONAL
STANDARDS
Emergency Surgery Working Party
Invaluable contributions from Fellows
Ian Dickinson, Chair,
Emergency Surgery
Working Party
THE PROFESSIONAL STANDARDS and
Development Board has established an Emergency Surgery Working Party in response
to growing concerns about the provision of
emergency surgical care, including trauma
care. Some issues include the process of subspecialisation or super-specialisation and/ or
the deskilling of the broader range of skills in
the major specialty groups. The first meeting
of the working party was held in August 2007
and the working party will meet regularly to
develop a comprehensive position statement
on the provision of emergency surgical services.
The working party consists of members
specialising in Neurosurgery, General surgery
and Orthopaedics, Fellows involved in trauma
surgery, military surgery and rural-based Fellows. In addition, the working party has representation from the Australasian College of
Emergency Medicine and Australia and New
Zealand College of Anaesthetists. Members
have a vast range of experience in acute care
services in metropolitan and regional Australia
and New Zealand. In the future the membership will expand to include other specialities
concerned with acute care services. Issues to
be considered by the working party include:
• Adequacy of acute care education
and training
• Acute care service models nationally
and internationally
• Career structures, including
remuneration and other
employment conditions
• Culture of surgery in public
hospitals, particularly for trainees
and younger surgeons
• Facilitating access to emergency surgical care
• The effect of subspecialisation of Fellows
• Differences between requirements for
delivery of emergency surgical services in
metropolitan and rural settings
The Emergency Surgery Working Party
received many responses from Fellows when
the establishment of the working party was
advertised in Council Highlights June 2007.
Fellows’ contributions to date have been
invaluable and have shaped the agenda of the
working party
I invite Fellows to continue to write
to the working party about issues
and concerns regarding acute care
services. Please address all correspondence
to the secretariat Ms Sylvia Daravong at
email: [email protected].
Last chance to register for
Skull Base Dissection Master Class
11 - 13 October 2007
Take advantage of this rare oppor tunity to gain hands-on
training in advanced neurosurgical techniques with worldrenowned exper t Professor Alber t L. Rhoton and Raine Visiting
Professor Stephen B. Lewis.
The course includes a unique presentation of neuroanatomy,
live demonstrations, radiology of skull base lesions and surgical
dissection using cadavers.
Registration forms are available online or via 08 6488 8044
and [email protected]
Perth,
Perth,
Western
Western
Australia
Australia www.ctec.uwa.edu.au
www.ctec.uwa.edu.au
SURGICAL NEWS P7
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CLINICAL
STUDIES
Stop the Clot
Integrating Venous Thromboembolism (VTE) prevention
guideline recommendations into routine hospital care
National Institute of
Clinical Studies
VTE CONTINUES TO be a major cause of
preventable morbidity and mortality among
hospitalised patients, who have a 100-times
greater risk of developing VTE than those
in the community. Eighty per cent of VTE
cases are attributable to surgical and medical
hospital admissions.
The evidence base surrounding VTE
prevention is clear, yet simple prophylactic
STEP 3
Form a team
Leadership from senior managers and senior clinicians (doctors, nurses, pharmacists and allied
health professionals) is essential for changes in
clinical practice to be accepted and used longterm1,2. Find the people who are passionate about
the need to improve practice in this area and
invite them onto the team.
Typically, one or more clinical champions
and an executive sponsor work together as leaders of the implementation team, taking advantage
of their complementary professional roles and
skills. They should be supported by another person who coordinates the changes on a day-to-day
basis3.
A clinical champion or local opinion leader
is usually someone who can speak with authority
on clinical matters, is able to motivate others to
recognise that they need to make certain changes,
and has the ability to achieve consensus when
there are different opinions on whether and how
changes need to be made4. Ideally your team
should include clinical champions from both surgical and medical units if you plan to improve
practice across both divisions.
An executive sponsor is typically someone
who has a sufficient level of influence and authority within the organisation to garner the necessary resources to make changes happen. They also
need to be able to provide support and resolve
conflicts about responsibilities that may arise.
The team coordinator has a pivotal role
SURGICAL NEWS P8
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measures that are known to dramatically
reduce the risk of VTE remain underused
within many Australian hospitals.
Since late 2005, the NHMRC’s National
Institute of Clinical Studies (NICS) has run a
national VTE Prevention Program, working
with 40 hospitals across Australia to improve
the use of VTE prophylaxis within hospital
settings.
to play. He or she is the person responsible
for overseeing, guiding and carrying out the
changes on a day-to-day basis. This person
might be a future leader who could benefit
from the mentoring opportunities and skills
that come from this experience. The team
coordinator must have the “hands-on” capacity to do the work required and to schedule
meetings when needed. A realistic allocation
of time and resources needs to be provided;
the tasks involved in implementing change
can’t normally be done as an “add-on” to a
full-time clinician’s role without leading to
burn out. Local circumstances will dictate
who else can help you.
Helpful tips …
• Include a hospital pharmacist, nurse unit
managers from relevant clinical units
and a person with quality improvement
experience, such as a quality and safety
or risk manager. Involve front-line staff
as much as possible or at least keep them
in the loop.
• Maybe ask people from high risk clinical
units or units with compliance issues to
join the team. Include people who are
passionate about change. Recognise that
there are often very strong views on issues
concerning VTE prophylaxis.
• An effective team should not be limited
to two or three people, but be careful
not to involve more than eight as your
The NICS publication, Stop the Clot:
Integrating VTE prevention recommendations
into routine hospital care, provides practical
step-by-step guidance for health professionals to ensure that best practice is being followed in this important clinical area.
This month we publish the fourth instalment in the series.
meetings may become unmanageable.
• Remember you can always set up additional working parties to help with specific tasks, such as auditing, education,
awareness raising or pilot testing new
procedures.
Facts and figures …
You might wish to cite some of the following
facts and figures when giving reasons to your
hospital’s executive on why VTE prophylaxis
is a priority quality and safety issue.
The incidence of VTE has been found to
be over 100-fold greater among hospitalised
patients compared to people of the same age
living in the community5. The incidence of
DVT in air travellers, by comparison, is only
4 times greater.
Each year, around 30,000 people are hospitalised in Australia because of VTE, with an estimated 2,000 dying as a result, and yet many of
these deaths are preventable with cost-effective
antithrombotic drugs and mechanical measures,
such as graduated compression stockings6.
VTE is very costly. Patients with VTE
require diagnostic tests, treatment with
anticoagulants, a longer hospital stay if an
inpatient and subsequent lifelong tests and
treatment7.
The National Institute of Clinical Studies
commissioned a study that used the unique
capacity of the Western Australian Data Linkage System to analyse the current magnitude
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7/09/2007 10:47:10 AM
of the problem of VTE in hospital practice.
The study found that only 20 per cent of
VTE cases in acute hospitals were unrelated
to hospitalisation. Most cases were equally
attributable to medical (40 per cent) or surgical admissions (40 per cent), and yet most
hospitals focus on VTE prevention primarily
in surgical patients8.
The incidence of VTE as a complication
of hospital admission is commonly underestimated. The Western Australian study was
able to demonstrate that over half of secondary cases occur up to three months after
hospitalisation8.
There is good evidence that VTE prophylaxis measures continue to be underutilised or
used sub-optimally. The WA study found that
the rate of VTE cases in acute hospitals has
continued to increase over the last ten years9.
The need to improve patient safety in this area
has been identified as a high priority not just
in Australia6, but also in the UK10 and USA11.
Next month Surgical News will publish
Step 4: Develop a hospital-wide policy.
A full text version of the Stop the Clot guide and
associated electronic resources can be downloaded
from www.nhmrc.gov.au/nics.
1. Ham C. Improving the performance of health systems:
the role of clinical leadership. Lancet 2003; 361 (9373):
1978-80.
5. Heit JA, Melton LJ, Lohse et al. Incidence of venous
thromboembo lism in hospitalised patients vs. community residents. Mayo Clin Proc 2001; 76(11): 1102-10.
Melbourne: NICS; 2005. Available at www.nhmrc.gov.
au/nicsAccessed 17 Apr 2007
2. Reinertsen JL. Physicians as leaders in the improvement
of health care systems. Annals of Internal Med 1998;
128(10): 833-38.
6. Preventing venous thromboembolism in hospitalised
patients. In: National Institute of Clinical Studies.
Evidence-Practice Gaps Report, Volume 1. Melbourne:
NICS; 2003 Available at www.nhmrc.gov.au/nics
Accessed 17 Apr 2007
3. Nicholas W, Farley DO, Vaiana ME, et al. Putting
Practice Guidelines to Work in the Department of Defense Medical System. A Guide
for Action. Santa Monica CA: RAND; 2001.
Available
at
www.rand.org/publications/MR/
MR1267/ Accessed 17 Apr 2007
4. Knowledge Translation Program. Tools. Opinion
Leader. Available at www.ktp.utoronto.ca/whatisktp/
tools/index.htm Accessed 17 Apr 2007
7. Bullano MF, Willey V, Hauch O et al. Longitudinal
evaluation of health plan cost per venous thromboembolism or bleed event in patients with a prior venous
thromboembolism event during hospitalization. J ManagCare Pharm 2005; 11(8): 663-73.
8. The incidence and risk factors for venous thromboembolism in hospitals in Western Australia 1999-2001.
9. Trends in Venous Thromboembolism in Western Australia
1989-2001. Melbourne: NICS; 2005. Available at www.
nhmrc.gov.au/nics Accessed 17 Apr 2007
10. The House of Commons: Health Select Committee. The
Prevention of Venous Thromboembolism in Hospitalised
Patients. London: House of Commons, 2005 Available at
www.publications.parliament.uk/pa/cm200405/cmselect/
cmhealth/9/9902.htm Accessed 17 Apr 2007
11. Agency for Healthcare Research and Quality. Making
health care safer. A critical analysis of patient safety practices: Summary. AHRQ Publication no. 01-E057. Rockville MD: AHRQ; 2001 Available at www.ahrq.gov/
clinic/ptsafety/summary.htm Accessed 17 Apr 2007
Central Gippsland Health Service, Sale, Victoria
General Surgeon
• VMO appointment with assured hospital income or salaried position with capacity to generate additional private
practice income
• One in three on-call roster
• Superb lifestyle – close to lakes, mountains, snow and beaches
One of Sale’s three General Surgeons will retire in the near future. As part of succession planning Central Gippsland Health Service is seeking a
suitably qualified and experienced Surgeon to join its specialist medical staff.
Supported by two Registrars and an Intern, the three General Surgeons provide specialist care to more than 40,000 people in Central Gippsland and
parts of South Gippsland. Other resident specialists include an Anaesthetist supported by four GP Anaesthetists, four Physicians, two Paediatricians
and three Obstetricians & Gynaecologists.
The Service is affiliated with Monash University for the teaching of medical students. Diagnostic services are excellent and include pathology and
medical imaging (including CT and nuclear medicine). There are two operating theatres and an endoscopy suite, and a six-bed critical care unit.
Your primary medical qualification should be registrable with the Medical Practitioners Board of Victoria. Your specialist background should include
Fellowship of the Royal Australasian College of Surgeons (or postgraduate clinical training, qualifications and experience assessed by the College as
suitable for appointment to this position under Area of Need provisions) and appropriate specialist experience.
Sale is a charming, prosperous rural city just over two hours drive from Melbourne. It has excellent shopping, sporting, cultural and education facilities
– including a private co-education grammar school. Combining city comforts with country living, Sale offers an ideal environment to raise a family and
build a rewarding career.
L11465
Additional information may be found on www.cghs.com.au Enquiries and applications should be directed in the first instance to Les McBride at:
Health Recruitment
Email: [email protected]
Tel: +613 9486 0500 Fax: +613 9486 0200
Suite 4, Level 4, 372 Albert Street, East Melbourne, Victoria 3002, AUSTRALIA
SURGICAL NEWS P9
P08-11 SEPT SN.indd 9
/ Vol:8 No: 8 September 2007
7/09/2007 10:47:21 AM
PSA 2007
Urological Society of
Whyalla, South Australia
Rural Surgical Education
14 - 17 November 2007
Venue:
Middleback Theatre
Nicolson Avenue, Whyalla
Australia and New Zealand
MEETING
ANNOUNCEMENT
Victorian State Meeting
Mantra Erskin Beach Resort, Lorne
19 - 21 October 2007
Principal Speaker
Christopher Kane
Chief Urologist, University of California
Convener
Organising Committee:
Mike Damp - Convener
Rosemary Hepworth
Penny Damp
y
Conference Organiser:
Kymberley Walta
Conferences & Events Management
Royal Australasian College of Surgeons
College of Surgeons Gardens
Spring Street
Melbourne, Victoria, 3000
Australia
P: +61 3 9276 7406
F: +61 3 9276 7431
E: [email protected]
Michael Chamberlain
Further information
c/- Conferences & Events Management
Royal Australasian College of Surgeons
[email protected]
College Conferences and Events Management
Contact Lindy Moffat / [email protected] / +61 3 9249 1224
The 2007 ASC photos taken by John Henderson are available for viewing by members of the College on the website.
y
Under the Auspices of the Royal Australasian College of Surgeons
INTERNATIONAL CONFERENCE ON
SURGICAL EDUCATION AND
TRAINING
5 MARCH 2008
ROYAL AUSTRALASIAN COLLEGE OF SURGEONS
MELBOURNE, VICTORIA, AUSTRALIA
Convener: John P Collins, Dean of Education, RACS
• Selection of Trainees - Reaching an
international consensus
• Workplace-based assessment - Use of new
tools and their feasibility
• Managing the underperforming trainee
• Simulation - What is its role?
Join a panel of International and Local Experts
to discuss these important and difficult
questions and reach a consensus, a summary
of which will be published in the Australian
and New Zealand Journal of Surgery.
Further information: [email protected]
Information for the 13th Ottawa International Conference on Clinical Competence
can be found at www.ozzawa13.com
Hosted by Monash University and The University of Melbourne
P08-11 SEPT SN.indd 10
7/09/2007 10:47:22 AM
CASC 2008
Conjoint Annual Scientific Congress
Vincent Cousins,
Convener
Michael Leung,
Scientific Convener
ON BEHALF OF our co-conveners, Samuel
Kwok and Andrew Yip at the College of Surgeons of Hong Kong (CSHK), and the members of the Executives, we look forward to
welcoming you to the CASC in Hong Kong,
12-16 May, 2008. The CASC of your College is a world class, regional conference and
the invited faculty numbers in excess of 50
speakers.
The two convening committees, working
on behalf of each College, have applied themselves to designing a program that has appeal
to all the Fellows and Trainees of both Colleges. This means content beyond the traditional surgical specialties and includes the very
many programs designed to be of educational
value at a “supra-specialty” level. This is
above the specialty in which we practice but
includes areas in which we are expected to
offer leadership and informed opinion. This
includes areas such as medico-legal, surgical
education, surgical oncology, trauma and pain
medicine. So whether you are a rural surgeon
or an orthopaedic surgeon we are sure you
will find content in the Congress relevant to
your daily practice.
Plenary Program
The Plenary program will be held during the first
session of each morning of the Congress. The
topics address important and potentially divisive
issues that confront us as surgeons but the topics
also confront our Colleges and our leaders. The
topics have been chosen to address contentious
aspects of each topic:
Tuesday: Doing more with less: improving bed
utilisation – without compromising standards
Wednesday: Minimally invasive surgery –
the future for all surgeons.
Thursday: Credentialling for new technology
Friday: Identifying and assisting the underperforming surgeon
Surgical Oncology
In the case of surgical oncology, the convener,
Bruce Mann is working closely with Professor Peter Choong, Head of Orthopaedics at St
Vincent’s Hospital (Melbourne) in designing
a session on bone sarcoma. This program will
benefit greatly from the participation of Dr
Franklin Sim, a leading American orthopaedic
surgeon who will receive an Honorary Fellowship from our College at the Award and
Diploma ceremony.
Another award recipient who will contribute to the program is Dr Albert Shun
who will receive an ESR Hughes award for
Surgery. Dr Shun has had a distinguished
career in paediatric transplant surgery and he
will present a keynote lecture during a combined Transplant/Paediatric surgery program titled ‘Paediatric liver transplantation –
a personal perspective’.
Surgical Education
The Surgical education program is being convened by David Birks (RACS) and Joseph Lau
(CSHK) on behalf of the ‘Surgeons as Educators’ group within the College. The distinguished
guests to the program are Dr Jeffery Huang, Vice
Minister in the Ministry of Health, Beijing and
Dr Carol-anne Moulton. Dr Huang originally
trained in Transplantation surgery and part of his
training was in Sydney. Whilst Dr Huang is a
Visitor in Surgical Education, he will also speak in
the International Forum, the Transplant program
and the Medico-legal program. Dr Moulton is a
Fellow of our College, and at present she is studying at the University of Toronto in the Centre for
Research in Education. In addition to the Surgical Education program, Dr Moulton will speak in
the Plenary program.
Colorectal program
The Colorectal surgery program is being co-
convened by Ian Hayes (RACS) and Dr Cliff
Chung (CSHK). Ian is a colorectal surgeon at
the Royal Melbourne Hospital and a member
of the Executive of the Section of Colorectal
surgery; Dr Cliff Cheung is President of the
Hong Kong Coloproctology Society.
The conveners are very pleased that Professor Michael Solomon has accepted their
invitation to be the RACS Visitor for the
colorectal surgery program. Professor Solomon is from the Royal Prince Alfred Hospital
(Sydney). Michael combined post-fellowship
surgical training with a Masters degree in clinical epidemiology and he has built on those
experiences in evidence-based medicine. He
is a past President of the Colorectal Surgical Society of Australia and New Zealand
and is currently Head of the Training Board
in Colorectal surgery and has been a major
advocate for well-constructed clinical trials in
colorectal surgery.
The Colorectal program will run over
Wednesday, Thursday and Friday and the
program will feature sessions addressing controversies in the treatment of :
• Rectal cancer
• Fistula-in-ano
• Faecal incontinence
• Management strategies for emergency
abdominal surgery
• Setting up of clinical trials
There will be two research paper sessions
with some of the papers competing for the
Mark Killingback prize. There will be a Masterclass on Friday morning discussing ‘How or
if, high quality TME surgery for rectal cancer
can be achieved using laparoscopic techniques’.
Everywhere you look in the program
we are sure you will find interesting, timely
and controversial topics. Conference website
www.surgeons.org/casc2008
SURGICAL NEWS P11
P08-11 SEPT SN.indd 11
/ Vol:8 No:8 September 2007
7/09/2007 10:48:20 AM
PROFESSIONAL
DEVELOPMENT
Fellowship Survey:
Making your College work for you
Ian Dickinson,
Chair, Professional
Development &
Standards Board
THE MAY 2007 edition of Surgical News
featured an article outlining the results of the
2006 Fellowship Survey. The response rate
to the survey was surprisingly high, with 59
per cent of Fellows responding. Importantly,
participants comprised a representative sample of the broader Fellowship in terms of specialty, regions, age and gender. These two
/3
factors give considerable power to the analysis
of the survey results.
The aim of the survey was to identify strengths
and areas for improvement for the College.
In order to add value to the survey results, in
February of this year Council requested further detailed analysis of the results by specialty
and region.
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SURGICAL NEWS P12
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It is important to note that the analysis has
revealed there to be no major differences
between specialty and regional responses
for the topics surveyed. However, we have
reported the results from a few topics where
differences between specialties and/or regions
might have been expected, and where there is
very slight variation.
Figure 1 provides a breakdown of responses by
region. Response rate by region: Figure 1
Figure 2 provides a summary of responses by
specialty Response rate by specialty: Figure 2
Contact with College Staff
Distribution of contact
The Fellowship Survey invited Fellows to comment on their contact with College staff. Fellows
were asked whether their interaction with College staff and/or offices is mostly on a regional
level, mostly with head office or equally split
between head office and the regional offices.
Of those who responded to this question, half
reported that their contact was mostly with head
office. The result was slightly lower for New
Zealand and the Australian Capital Territory
(ACT), with Tasmania recording the least contact with head office alone. The Northern Territory and Victoria recorded the highest levels of
primarily head office contact.
Quality of contact –
Regional responses
Fellows were asked to describe their experience in interacting with College staff, and
were given a list of possible descriptors. One
of the most common responses was that staff
were ‘helpful,’ with three quarters of respondents describing College staff in this manner.
There were no major differences between
regions.
The survey asked Fellows to comment
on the ease of locating and making contact
with the appropriate person at the Col-
/ Vol:8 No:8 September 2007
7/09/2007 10:51:39 AM
lege to assist with their enquiries. Of those
who responded to this question, 84 per cent
reported that it was always or mostly easy to
find the right person.
Fellows from Tasmania, the Northern Territory and overseas tended to report finding it
easier to make contact with the appropriate
College staff member (however the number
of responses in these areas was relatively low
– see Figure 1). Fellows in Western Australia
and South Australia registered the lowest
result; nevertheless the outcome is still positive, with well over three quarters finding it
easy to contact the required staff member.
Quality of Contact –
Specialty responses
When analysed across all specialties, the results
showed an even spread with no major differences between the specialties
The College will continue to ensure that
systems are in place in all College offices that
make it easy for Fellows to access the staff and
information that they require.
Professional Development
The majority of the technically specific professional development programs are delivered by the
Specialty Societies. However, the College offers a
range of professional development opportunities
in the non-technical areas of surgical competence.
Fellows were asked to indicate their preferred
delivery options for professional development, to
assist with planning.
Site
Sixty per cent of respondents indicated a preference for capital cities, whereas 44 per cent
preferred their local area. Western Australian
and Tasmanian Fellows reported a stronger
preference for professional development
activities in their local area, while South Australian and Northern Territory Fellows were
the least interested in attending activities in
their local area, preferring a capital city.
Timing
When considering timing preferences for professional development, the Fellowship Survey
results reveal that almost half of all Fellows
would prefer weekend workshops and just
under a third would prefer evenings. Based
upon a regional analysis, results indicate that
New South Wales, Queensland and Victoria
have a stronger preference for weekends, and
the ACT, Northern Territory and Tasmania
prefer evening workshops.
Course development
The feedback regarding the delivery and timing of professional development activities will be
incorporated into planning for next year’s workshop program, which is currently being finalised.
Where to from here?
It is important that the views of our Fellows
are regularly gauged to ensure that College
services and activities meet needs, and that
these services and activities represent not
only value for money, but also the changing needs of our Fellows across all specialties
and regions. The Fellowship Survey results
ensure that the wider Fellowship has an
opportunity to directly influence the College’s future direction and decisions.
Many might have expected that the survey would demonstrate regional and specialty differences. However, it is pleasing
to note that the responses were extremely
similar across all regions and specialties, and
in general met the high expectations of Fellows.
Under the chairmanship of John Graham, Chair of Fellowship Services, the Fellowship Services Committee will consider
the 2006 survey results in detail over the
coming months. This will ensure that College decision making is well informed in
terms of monitoring and meeting Fellows’
needs regarding the range of services and
activities offered by the College.
To view the detailed 2006 Fellowship
Survey report, please visit
www.surgeons.org/Fellowship
and Standards/Fellowship Survey
Helping you choose the right Medicare claiming option
Knowing that all practices have different needs, Medicare Australia is delivering a wider range of claiming choice.
The latest is Medicare Easyclaim, an EFTPOS-based system that can process bulk bill and patient paid claims on the
spot. Medicare Australia is encouraging practices to learn more about the new system, and find out what electronic
claiming options (internet or EFTPOS) suit them best.
Visit www.medicareaustralia.gov.au or call 1800 700 199.
SURGICAL NEWS P13
P12-17 SEPT SN.indd 13
/ Vol:8 No:8 September 2007
7/09/2007 10:51:52 AM
SKIN CANCER
‘Hot Issues’ Study No.2 Melanoma
Reproduced with kind permission:
Medical Defence Outlook, issue 14 – June 2007
Avant Mutual
Group Limited
Key Messages
General Practitioners and
Dermatologists
• Never ignore a history of a change in a skin
lesion.
• Ensure adequate recall and follow-up systems exist to track both pathology specimens
and patients.
• Red flag clinically suspicious lesions.
• Communicate a clear history to the pathologist.
Pathologists
• Report difficulties with equivocal histology.
• Request more information from referring
practitioner when required.
Surgeons
• Do not rely on verbal reports.
• Communicate clearly the patient follow-up
plan.
MDAV has experienced high numbers of claims
relating to cancer diagnoses. Missed and delayed
diagnoses of melanoma represent a significant
percentage of these claims and appear to show an
increasing trend. Identifying possible reasons why
melanoma is misdiagnosed and the development
of practical risk management measures is anticiSURGICAL NEWS P14
P12-17 SEPT SN.indd 14
Figure 1. Incident Year of Missed Delayed Diagnosis of Melanoma Cases
No. of Cases
IMPORTANT NOTE: AS of July 1, 2007 the
Medical Defence Association of Victoria (MDAV)
has merged with UNITED Medical Protection to
form the Avant Mutual Group Limited. The following article was published by MDAV in June
2007 and is reprinted with permission.
The melanoma case review is the second
study in the ‘Hot Issues’ series. MDAV commissioned the ‘Hot Issues’ project in line with the
strategic intent to minimise claims and associated
costs through raising awareness of emerging areas
of claims risk. By means of targeted risk management strategies and focused education, it is hoped
that there will be a reduction in human and economic costs.
Year incident occurred
Case Study: Missed and Delayed Diagnosis of Melanoma
pated to decrease the frequency of misdiagnosis
claims in the future.
with the aim to improve patient safety.
Claim File Review
Background
Australia and New Zealand have the highest
rates of melanoma in the world, with an annual
rate of 55.2 cases per 100,000 Australians . The
Cancer Council of Victoria’s figures indicate that
almost 2000 Victorians a year are diagnosed with
a new melanoma. In Victoria, melanoma incidence starts in teenage years, rises steeply to about
50 and then levels off. The rates of melanoma
remain on the increase and more cases are found
among men. The majority of melanomas can be
attributed to sun exposure in fair-skinned populations. Melanoma is an aggressive skin cancer and
although it accounts for only 4 per cent of all skin
cancers, it is responsible for 80 per cent of skin
cancer deaths.
The Cancer Council’s “Slip! Slop! Slap!” campaign has, since its inception in 1981, increased
public awareness of the risk of sunburn. There
has been an impressive change in attitudes and
behaviour during this time with a notable increase
in public awareness regarding the relationship
between excessive sun exposure and skin cancers.
Heightened public knowledge concerning
the importance of the early diagnosis of melanoma
has the potential to raise the profile of incidents
or claims relating to missed or delayed diagnosis
of melanoma. MDAV has been committed to
risk management; through claims analysis, practical risk management initiatives can be developed
Cases arising from missed and delayed diagnosis of
melanoma were identified from MDAV’s database and 65 met the inclusion criteria. The earliest
case of missed/delayed diagnosis of melanoma in
the database was found from 1985 and the incident rate fluctuated thereafter, as shown in
Figure 1. The high incidence of cases arising
in 2005 suggests missed and delayed diagnosis of
melanoma remains an issue for patients and medical practitioners. The files examined include open
(still active) and closed (settled or discontinued)
claims as well as “incidents likely” - incidents that
have been notified by members that are reasonably
expected to proceed to a claim. “Incidents likely”
incur a cost to the indemnity provider since cost
provisions must be made against reinsurance.
An amount is estimated for each such case
according to the nature and likely severity of an
incident and is reviewed periodically until the statute of limitations period expires.
Of the cases identified, 54 were closed and
11 were active at the time of the review. Fifteen
had proceeded to litigation, and 50 had not. Nine
claims were settled for a total sum in excess of
$1.3 million, four claims incurred legal costs only,
which totaled over $275,000 and two claims
remained open. Of the unlitigated incidents, 41
were closed and the nine remaining active cases
have incurred costs totalling almost $1.6 million.
In 40 per cent of the cases the members
/ Vol:8 No:8 September 2007
7/09/2007 10:51:53 AM
Case Study:
Missed and Delayed Diagnosis of Melanoma
Nature of Claim/Incident
The patient alleged the member was negligent in
that he failed to diagnose malignant melanoma. As
a result of the misdiagnosis the patient experienced
a six year delay in the diagnosis of her disease.
Medical Commentary
The patient saw her GP about a lesion on the
lateral chest wall. Clinically this appeared benign,
and the GP excised it. Three days later the GP
received a pathology report from the member
that stated that the lesion was benign and excision
was complete. The GP informed the patient of
the pathology result. Five years later the patient
attended with a small axillary swelling. The GP
referred the patient to a local surgeon, concerned
about possible breast pathology. Mammography
was negative and the swelling appeared to have
decreased in size, so the surgeon planned a three
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month review. The patient did not receive an
appointment, and another nine months went by
before she saw her GP with an obviously enlarged
lymph node. The surgeon excised this and metastatic melanoma was diagnosed. Liver metastases
were subsequently identified.
Legal Commentary
The original slides were re-reviewed and with the
benefit of hindsight features of malignancy were
identified. It became evident that the member
who reported the original specimen had experienced a degree of uncertainty making a diagnosis.
He requested two colleagues to examine the specimen and they collectively concluded that it was a
benign naevus. The member did not provide any
details in his report of the difficulties encountered
regarding the final diagnosis. The claim was settled at mediation for $110,000, shared between
the MDAV and another defence organisation
(representing the surgeon because of the administrative error of the appointment failure). The
cost to MDAV of instructing lawyers to act on
the member’s behalf and manage this claim was
$11,985.
Clinical Risk Management
Commentary
If the GP had been aware of the diagnostic difficulty at the time of the initial excision, a surgical referral for wider excision could have been
considered or at least discussed with the patient
as a precautionary option. Furthermore, if the
GP and surgeon had been aware of the uncertainty regarding the pathological diagnosis they
would probably have considered the possibility
of a melanoma in the differential diagnosis when
the patient presented with the axillary swelling.
At the very least, it is reasonable to expect that
a biopsy would have been initiated at an earlier
stage, which would have diagnosed the metastasis. To ensure that risk of a similar occurrence
is minimised, MDAV would recommend that
pathologists record all details of difficult or uncertain diagnosis in their final report. Any doubt surrounding a diagnosis should be communicated to
the referring practitioner detailing the uncertainties and offering guidelines for future management
where possible.
Contributory Factors
In 80 percent of the cases there was evidence to
suggest that a possible adverse event in healthcare management had occurred. Table 1 shows
the distribution of ‘preventability scores’ based on
evidence in the files. On retrospective review, it
was considered likely that there was a greater than
50 per cent chance of preventing the incident or
claim in 62 per cent of the cases. The majority of
cases where the member was a pathologist or a
GP were considered to be preventable. It is also
important to note that some cases were considered highly unlikely to have been preventable.
The most common factor identified in leading to a delay in diagnosis was a histology report
indicating a benign diagnosis (34 per cent), followed by inadequate history and examination of
the patient (25 per cent). Other issues included
failures in follow-up arrangements, systems issues
with obtaining histology results, results not reachSURGICAL NEWS P15
P12-17 SEPT SN.indd 15
involved were GPs and 32 per cent of the incidents concerned pathologist members. Dermatologists were involved in fewer than 10 per cent
of cases, and the remainder were general or plastic
surgeons and cosmetic practitioners. Patient age
ranged from 17 to 91 years old and 63 per cent of
the patients were female.
Figure 2 shows the pattern of adverse
events by age, superimposed on the incidence
of melanoma in Victoria in 2004. Early onset of
melanoma (developing under the age of 20) is
now a well-recognised risk, while over 15 years
ago it was considered very rare. It would appear
that the claims data is over-represented for patients
of 15 to 54 years of age. This finding may suggest
that melanoma is not always considered as a diagnosis in younger patients.
The geographical distribution of doctors and
patients involved in the cases was analysed. Nearly
90 per cent of the doctors practised in Victoria
and 80 per cent of patients lived in metropolitan
areas. Over 90 per cent of patients lived in areas
highly accessible to medical services. This correlates closely to the distribution of the MDAV
membership.
Figure 3 shows the sites of the primary lesions
which correspond with the recognised pattern
of an increased prevalence of melanomas on the
legs of women and on the head, neck or trunk
of men. This is likely to be related to areas more
prone to sunburn in the two sexes.
The recorded delay in making the diagnosis
ranged from three months to eight years, although
nearly 40 per cent of definitive diagnoses were
made within one year.
/ Vol:8 No:8 September 2007
7/09/2007 10:51:59 AM
SKIN CANCER
Avant Mutual
Group Limited
Risk Management Observations
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4RUNK
Body Site
ing the patient and patient co-operation factors.
Insufficient communication between doctors and
between doctors and patients; issues relating to
coming to a diagnosis, and management problems
also played a role in leading to a delayed diagnosis
in some cases. In a Canadian survey of similar size
in 1997, Jackson noted that errors in the original
histological diagnosis were a factor in 24 per cent
of the files reviewed.
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A number of risk management issues were identified from the case series.
General and plastic surgeons
Several adverse events arose from surgeons acting
on verbal histology reports and the final report
either not reaching the surgeon at all, or arriving
following treatment. Risk management issues for
general and plastic surgeons also indicate the benefit of considering sending the patient a copy of
the letter sent to the referring GP, especially outlining a follow-up plan. In the alternative, some
surgeons will write to the patient copying the letter to the GP.
Dermatologists
Considering the cases reviewed, the same recommendations apply regarding keeping the patient
informed in writing of the specialist’s assessment
and plan. Of the cases reviewed, systems errors
included inadequate arrangements to alert the
dermatologist to the failure of a patient to attend
follow-up and a failure of a nurse to follow a protocol ensuring a further appointment was booked.
In patients with multiple skin lesions, an atypical
melanoma may be difficult to identify.
General Practitioners
The case files revealed a number of risk management system issues relating to general
practice, in particular inadequate communication, failure to follow up adequately and
lack of detailed record keeping.
Inadequate handling of pathology specimens
SURGICAL NEWS P16
P12-17 SEPT SN.indd 16
and results also contributed to the occurrence of
an adverse event. Examples included excised tissue being discarded as benign without being sent
for histological examination and inadequate tracking of results.
The strongest clue, where the diagnosis of a
melanoma was missed or delayed, seemed to be a
history of change in a lesion. Despite examination
appearing normal (even with a dermatoscope),
the history of a change as conveyed by the patient
should not be ignored.
Pathology
Pathologists’ reports feature as a major component
of this study. Several of the specimens in the study
that were reported as benign had actually been
reviewed by at least one other pathologist before
the report was issued. However, this information
was only apparent retrospectively, when a diagnosis of a recurrent or metastatic melanoma had been
made. There was also evidence that misdiagnosis
was associated with pathologists working under
pressure and feeling professionally unsupported.
Adverse events in medicine are very often multifactorial, so all areas that may contribute to error
need to be addressed.
Future Work
A workshop is planned for October 17, 2007 to
present the outcome of the study to clinicians and
other parties involved in the management
of melanoma. The aim of the workshop is
to stimulate discussion and development of
appropriate clinical risk modification guidelines to reduce the human and economic cost
of failures in treatment of melanoma. After
an initial presentation in Melbourne, further
presentations interstate will follow.
Acknowledgements
The authors would like to thank Dr Sarah Swain,
Professor John Dowling, Professor John Kelly, Dr
Morton Rawlin, Dr Liz Mullins, Dr Paul Nisselle
and Dr John Arranga for their helpful discussion
and advice.
Dr John Williamson*
Technical Advisor (Claims)
Dr Suzanne Graham*
Clinical Claims Analyst
Dr Richard Clark
Clinical Epidemiologist
*Both authors contributed equally to this work.
Further information
To obtain further information on this study or to
express interest in attending the upcoming ‘Hot
Issues’ Melanoma workshop please contact the
Avant Clinical Risk Management Department
E: [email protected]
/ Vol:8 No:8 September 2007
7/09/2007 10:52:00 AM
BEST PAPER
The Anatomy of Complications
in the Upper Limb
Prize at the Annual Scientific Congress
Daniel Luo,
Plastic Surgery Registrar
THIS PRIZE IS awarded for the best paper
of the Surgical Education stream of the
College’s ASC.
The award is open to all Fellows and Trainees who present papers as part of the Surgical
Education section of the ASC. It has been a cash
prize of $1,000.
This year the award went to Dr Daniel Luo,
plastic surgery registrar, who presented his paper
at the Christchurch ASC in May.
Complications in clinical medicine and
surgery may arise from an inadequate knowledge of topographical anatomy. Consequently,
a thorough understanding and knowledge of
topographical anatomy is one of the major
pillars in the training of many surgical and
medical disciplines.
In Western Australia, we have found that
even simple procedures done on the ward by
junior medical staff can result in a complication due to a lack of understanding of anatomy
and its variations. Anatomical complications
include superficial radial nerve injuries and
neuromas following intravenous cannulation
at the wrist. Complications arising from anatomical variantions include such things as cannulating a dominant radial artery when inserting arterial lines or accidental cannulation of
the ulnar or radial artery at the cubital fossa
when attempting an intravenous cannulation
due to an early division of the brachial artery.
The authors, with the support of The
Office of Safety and Quality in the Department
of Health, have put together a multimedia
DVD that aims to increase awareness on the
applied anatomy of the upper limb, with
an emphasis on procedures involving the
peripheral vascular system. The DVD describes
vascular and related topographical anatomical
features prior to introducing the viewers to
procedures such as intravenous cannulation,
arterial lines, peripherally-inserted central
cannulas and central venous lines. Possible
complications that may arise from these
procedures and which can be avoided from
understanding the anatomy are emphasised.
The importance of ensuring adequate aseptic
technique in avoiding complications is also
an important theme in the demonstrations of
the procedures. Thus this teaching aid stresses
and demonstrates how to apply good aseptic
techniques in different clinical scenarios.
The amount of topographical anatomy
taught in medical school has been reduced
compared with 30 to 50 years ago. This has
been necessary to accommodate the increase
in knowledge in scientific and clinical sciences
such as genetics, immunology, epidemiology,
communication skills and radiology, some
of which were in their infancy when many
of today’s doctors qualified. This DVD is a
timely reminder of the importance of a sound
knowledge of anatomy for those practitioners
required to perform invasive procedures. It
will be trialled in Western Australia as part of
the clinical education for junior doctors and
medical students with the goal of increasing
the practitioner’s confidence and anatomical understanding of procedures, in order to
produce better patient outcomes in the longer
term. We hope that this will be a prototype
for further teaching material produced in
collaboration with the Department of Health
and The University of Western Australia.
I would like to acknowledge the Office
of Quality and Safety from the Department
of Health for their support as well as my coauthors in producing this DVD. Co-authors:
• Dr Eric Tai, Anaesthetic Registrar
• Dr Tao Shan Lim, Orthopaedic
Registrar
• Professor Bryant Stokes, Chairman of
the WA Council for Safety and Quality
in Healthcare
• Professor Paul McMenamin, School
of Anatomy and Human Biology, The
University of Western Australia
Barwon Health is the largest Regional Health Service provider in Victoria. It offers an extensive range of general & specialist hospital, rehabilitation, residential & community services
to over 93% of the Geelong community & an increasing number of residents across the Barwon South-Western region. Barwon Health has a total of 921 beds, a budget in excess of $320
million and a workforce of around 5,000.
The Geelong Hospital is a 406-bed general medical & surgical teaching hospital affiliated with The University of Melbourne with obstetric, paediatric and psychiatric beds.
There are Professorial Departments of Medicine, Surgery & Psychiatry. The Hospital positions are accredited for basic & many advanced training programs.
DIVISION OF SURGERY RURAL SURGICAL FELLOW
Barwon Health – The Geelong Hospital is seeking a suitably qualified Medical Practitioner for the above post. Applicants who have substantial post graduate experience and who are
eligible for full general registration with the Medical Practitioners Board of Victoria, are invited to apply.
Salary and conditions will be in accordance with the AMA HMO Certified Agreement 2002 (or any subsequent agreement), classification range PN20.
The position is of one year’s duration commencing 4/2/08 to 2/2/09 and offers a broad experience in general surgery. The position offers experience in gastrointestinal endoscopy, colorectal
(including laparoscopic) and endocrine surgery. The University Department of Surgery has research interests in safety and quality, surgical audit, electronic health and cancer epidemiology.
It is ideally suited to someone planning a general surgical career in a rural or regional centre. The candidate should already have passed the FRACS examination (or equivalent). Candidates
planning to sit in 2008 may also be considered.
Enquiries: Further information may be obtained by contacting the Department of Surgery on (03) 5226 7899. Closing date: Friday 19 October 2007 Alternatively,
please forward your application quoting position title, reference number and include a current curriculum vitae listing three recent professional referees to:
Mr Glenn Guest, Senior Lecturer in Surgery, Department of Surgery, Barwon Health, PO Box 281, Geelong 3220. Ph: (03) 5226 7899 Fax: (03) 5226 7019
SURGICAL NEWS P17
P12-17 SEPT SN.indd 17
/ Vol:8 No:8 September 2007
7/09/2007 10:52:05 AM
ART IN
SURGERY
A passion for surgery and art
Artisitc and professional skills are a good match
THERE HAS BEEN a long, albeit hazy, link
between surgery and art down through the
centuries.
Some of the old masters risked imprisonment in order to dissect cadavers to find what
lies beneath while later, other artists studied
medical text books or visited morgues for
much the same purpose. There have even
been recent suggestions that British artist Walter Sickert may have been Jack the Ripper, a
killer who was believed at the time to have
had some knowledge of surgery, or butchery
at the very least.
But in contemporary Australia we now
have an artist who wields her brush with the
same aplomb as her scalpel under the glare of
both theatre lights and public scrutiny.
Dr Gillian Dunlop, a Sydney Ear, Nose
and Throat (ENT) Surgeon, combines her
love of interesting surgery with a passion for
portrait painting. Her work reached the finals
of the prestigious Archibald Prize in 2004,
was the Salon Des Refuses People’s Choice
winner in 2006, was a finalist in the Portia
Geach Prize also in 2006 and was a finalist in
the Blake Prize for Religious Art in 2003.
Her current work, a commissioned portrait of Queensland Governor Quentin Bryce,
delightfully illustrates the occasional conjoining of her disparate professional interests.
“I was asked to take this commission
through representatives of the Women’s College at Sydney University. That came about
after one of the professors was eating lunch
too quickly and got a pea up his nose,” she
said. While she laughed as she related the
story she won’t name names.
“I had to administer a local anaesthetic and
while waiting for that to take effect we talked
about art and later, university representatives
got back in touch and asked me to take on this
commission. So it is a story of the professor,
the pea and the portrait.”
But there are other links between the two
SURGICAL NEWS P18
P18-23 SEPT SN.indd 2
professional parts of her life. She
has painted the portraits of several
eminent professors and surgeons
including Dr Ted Beckenham
and the President of the ENT
Society, Mr Rob Black.
When travelling, she uses
all available spare time at international conferences to wander
the halls of local galleries. With
an interest in 17th century portraiture, Dr Dunlop spends hours
gazing at the faces in the frames
but then refocuses to close-up for
her surgery.
“I can spend hours in portrait
galleries just looking at the corners of mouths, how they were
done, how they are used to illustrate something of the character of
the sitter. I know the anatomy of
the eye, that there is most commonly a five millimetre differential
between the height of the inner
and outer aspect or canthus. And I
love working on noses, both as an
artist and a surgeon.
“In medical school we were
taught all the ratios for rhinoplasty but Dr Ted Beckenham
I do it by observation, by understandBut I don’t think I fully appreciated his advice
ing the aesthetics of the entire face.”
until a few years ago. Now I can do both and I
Dr Dunlop said she had always had a pasenjoy them both,” Dr Dunlop said.
sion for art but that her father, a practical man,
“Medicine allows me to travel around the
suggested she get professional qualifications.
world to visit amazing galleries. I can afford
So with five brothers and sisters all in medi- to keep going to art school and continue to
cal school, she followed the well-worn path learn, and I get to do surgery which I really
working, after medical school, at the Eye and enjoy. When I entered the profession there
Ear Hospital in Melbourne and then travelling were no women role models and I simply
to London. In the evenings she indulged her didn’t think that women did surgery.
artistic bent, first studying at the Melbourne
“I began working in palliative care, then
School of Art and then, abroad, at the Chelsea emergency medicine then switched to surgery
School of Art.
which was the best thing I ever did. As an ENT
“I understood that painting was a bit like act- surgeon I now go to work to do my art.”
Dr Dunlop continues her art studies at the
ing so I understood what my father was saying .
/ Vol:8 No:8 September 2007
7/09/2007 10:54:14 AM
LAW REPORT
Privacy laws for doctors
National Privacy Principles impose
additional obligations
Michael Gorton,
College Solicitor
Patrick McSwiney & Vegas
National Art School at Darlinghurst and has
just taken up sculpture while working full
time at the Sydney Adventist Hospital and
the Hunters Hill Private Hospital. She said
her techniques, based on centuries old practices, mean up to a week between each layer
of paint, with some portraits taking more
than 200 hours of work. This painstaking
approach is also applied in her day job.
“I think the skills work from art to surgery rather than the reverse,” Dr Dunlop
said. “Because my painting takes so long I
get used to being patient, pedantic and exact
while operating.
“Even if I didn’t have to work as a surgeon and could devote all my time to art, I
wouldn’t. It is the combination that is most
pleasing. I take three weeks off at Christmas and get a lot of painting done but I like
going back to work because I miss the operating theatre.
“Painting can be a solitary business
whereas surgery is a team effort with great
friendship and camaraderie in theatre.”
Being quite private about her artistic
work, Dr Dunlop does not believe it should
be considered unusual for a surgeon to have
an interest in artistic endeavours. In fact she
thinks it makes perfect sense.
“There are many surgeons in different
artistic fields, many musicians for instance,
and I think it is about precision, about
patience and about dexterity,” she said.
MEDICAL
PRACTITIONERS
HAVE
always been subject to an array of professional, ethical and legal requirements. Federal and State privacy laws now impose
additional obligations.
The federal laws introduce a set of 10
National Privacy Principles, or “NPPs”,
which establish minimum standards for the
handling of personal information. These
laws apply to doctors, in relation to the
health information they hold. Also applicable are separate legislation in some states
and territories eg. Health Records Act 2001
(Vic), Health Records (Privacy and Access) Act
1997 (ACT).
Health records legislation is particularly
relevant to medical practitioners as it establishes a separate regulatory regime for the
handling of health information and applies
with particular vigour to doctors.
It is imperative that doctors take the time
to become familiar with the Privacy Principles, as they set down the rules which prescribe how health information (and other
personal information) is to be collected.
The Privacy Principles can
be summarised under the
following headings:
loss, unauthorised access and modification.
A medical practitioner will generally
be prohibited from destroying or deleting health information about an individual
until at least seven years have passed since
the individual’s last attendance.
Transparency
A medical practitioner must document
clearly expressed policies on its management of health information and make this
statement available upon request.
Access and Correction
A medical practitioner is required to provide access to health information and to
allow individuals to make corrections to
the information where this is necessary to
maintain the integrity of the record.
A medical practitioner must, upon
request by an individual, make health information relating to the individual available
to another health service provider.
Identifiers and Anonymity
A medical practitioner may only assign an
identifier to an individual if the assignment
is reasonably necessary to enable the organisation to carry out any of its functions efficiently. A medical practitioner must allow
individuals the option of entering transactions anonymously wherever this is lawful
and practicable.
Collection & Use of Health Information
Trans-border Data Flows
A medical practitioner can only collect health
information where this is necessary for the
performance of an activity or function.
A medical practitioner can only use or
disclose the health information for the purpose for which it was collected unless the
individual’s consent has been obtained.
A medical practitioner can only transfer
health information if the recipient is subject to laws which are substantially similar
to the Privacy Principles.
Data Quality and Security
A medical practitioner must take reasonable
steps to ensure that the health information
it holds is accurate, complete, up-to-date
and relevant to its functions. It must also
safeguard the information against misuse,
Transfer or Closure of the Practice
of a Doctor
Before the business of a medical practitioner
is transferred or closed down, the medical
practitioner must give notice of the proposed transfer or closure to patients and
former patients to allow those individuals to
apply for their health information before the
change takes effect.
SURGICAL NEWS P19
P18-23 SEPT SN.indd 3
/ Vol:8 No:8 September 2007
7/09/2007 10:54:45 AM
LAW REPORT
Michael Gorton,
College Solicitor
What this means for you?
These laws will not prevent you from continuing to collect and use health information.
However, you will need to have specific
measures to ensure that information handling
practices comprehensively address the requirements outlined in the Privacy Principles.
This will involve examining your current
information handling practices to identify
areas in need of reform.
As a starting point you should consider
the impact of the collection principle which
provides that health information can only be
collected for a “primary purpose” or series
of single “primary purposes” (ie, the health
care of the patient). In those circumstances,
it would not be incompatible with the spirit
of the legislation to take down a full medical
and family history of the patient. However,
this needs to be communicated to the patient
at the initial consultation so that the expectations of the patient are consistent with yours.
The legislation places a high premium
on the right of an individual to gain access to
personal information held by a medical practitioner.
Accordingly, you will need to think carefully about the way in which you intend to
give effect to this right and have in place a
policy for dealing with access requests, and
any applicable fees.
You will also need to review methods
of storage and ensure that patient records are
retained for the prescribed period.
Above all you will need to take a proactive approach to the privacy laws and demonstrate to patients that you take the new
regime seriously. You should introduce a
privacy statement and place this prominently
in places such as waiting rooms.
Make privacy compliance a priority and
ensure that it becomes an important part of
the professional service already offered to
patients.
What to do:
Steps that doctors and particularly hospitals
and health bodies should consider are:
Cleft & Cranio-Maxillofacial
Anomalies
Keynote speakers include:
Associate Professor Philip Kuo-Ting Chen,
Professor Lim Cheung
Associate Professor Michael Cunningham
Dr Jeffrey C. Posnick
Dr Eric Arnaud
Prof Mary Hardin-Jones
Prof David L. Jones
For registration and information visit www.cleft2007.com.au or call 03 9417 0888
The AMA has issued kits to assist doctors.
Faculty of Pain Medicine Inaugural Spring Meeting
“Waves of Change
in Pain and Suffering”
20–23 SEPTEMBER 2007, ROYAL CHILDREN’S HOSPITAL, MELBOURNE
This four- day conference is a combined meeting of the Australasian Cleft Lip and Palate
Association and the Biennial Paediatric Plastic & Maxillofacial Surgery meeting of the
Royal Children’s Hospital of Melbourne
The conference will present the “state of the art” treatment of cleft and craniofacial patients,
and all of the clinicians involved in this area will be represented to comprehensively cover
care from diagnosis to the completion of treatment.
• Undertake a comprehensive audit of current procedures dealing with the colletion, storage and maintenance of personal
information.
• When collecting personal information
from now on, seek consent from individ
ual concerned to use and disclose the
information in the manner required.
• Consider seeking similar consent from
individuals in respect of the personal
information already held.
• Develop a Privacy Statement and appoint
a privacy officer.
• Review contracts to ensure they do not
breach the Act.
• Where transferring personal information
to third parties, obtain written undertakings from them to ensure they comply
with the legislation.
A well drafted Privacy Statement and
patient consent form will address most issues
for doctors under this legislation.
T
he Faculty of Pain Medicine will hold its
Inaugural Spring Meeting in association
with the Medico-Legal Society of
Queensland at the Sheraton Mirage Resort
and Spa on 12-14 October 2007.
This meeting will provide a forum for
discussion to improve efficacy and efficiency
of management through communication of
the core issues for medical practitioners and
lawyers.
Keynote speakers include Professor Dan
Carr, Saltonstall Professor of Pain Research
in the Departments of Anaesthesia and
Medicine at New England Medical Centre
in Boston, Massachussetts; The Hon Cecil
William Pincus, QC, Adjunct Professor of
Law, University of Queensland; Alastair
Lynch, Former Captain, Brisbane Lions; and
Nikki Hudson, Olympic Gold Medallist and
Captain, Hockeyroos as well as a number
of outstanding speakers from a range of
specialities.
A full program and registration information
can be found on the Faculty’s website:
http://www.fpm.anzca.edu.au/2007spring-meeting. Alternatively, contact the
Conference Secretariat, Christine Gill
[email protected]
SURGICAL NEWS P20 / Vol:8 No:8 September 2007
P18-23 SEPT SN.indd 4
7/09/2007 10:55:08 AM
PROFESSIONAL
STANDARDS
Ensuring Correct Patient,
Side and Site Surgery
Rob Atkinson,
Chair, Correct Patient,
Correct Side and
Correct Site Surgery
Working Party
THE COLLEGE COUNCIL approved revised
Implementation Guidelines for Ensuring
Correct Patient, Correct Side and Correct
Site Surgery in October 2006, in response
to concern raised regarding the existence of
multiple guidelines with varying processes
for ‘final verification’ or ‘time out’.
The Correct Patient, Correct Side
and Correct Site Surgery Working Party
continues to promote the guidelines as
an important tool for the maintenance of
standards and ensuring quality and safety
in healthcare.
The guidelines encourage Fellows to
adopt protocols utilising multiple, complementary strategies and promote flexibility
between surgeons, specialties and hospitals.
To assist with promotion of the Implementation Guidelines, they are featured as
a poster lift out in this edition of Surgical
News. Fellows are encouraged to display
the poster prominently in operating theatres and hospitals.
The Implementation Guidelines will
be reviewed again in September 2008 after
consultation with the Specialty Societies,
Regional Committees, relevant Medical
Colleges and a range of medical defence
organisations. The working party welcomes all feedback on the guidelines.
OF COURSE YOU INVEST IN YOUR HEALTH…
REPORT
STRAP
–
LAW
But, is everything covered?
When it comes to maintaining your health, you know how to optimize it.
But, will you be prepared when you need healthcare?
Are you prepared?
You think twice when you’re paying ‘just in case’ something happens. However, life is
full of random events which can impose unfortunate outcomes. With high healthcare
costs even a happy event like childbirth or a common procedure like a shoulder
arthroscopy will cost more than $6,000.
What you can do
To deal with those unexpected healthcare episodes The Doctors’ Health Fund can
help you choose cover to fit your healthcare and financial expectations. With the
Federal government’s initiatives you can reduce your health insurance costs and
taxation, even with our lowest level of hospital cover your reduction will be
more than $640.
Plus get your cover in place before you turn 31 and save 2% per year
The Doctors’ Health Fund – here for you
We’re your not-for-profit private health insurance fund, offering you a choice of high
quality health cover. From very economical to our ‘Top Cover’ with the greatest
medical benefits in Australia, which are based on AMA List fees.
For all the information you need and to
join visit www.doctorshealthfund.com.au
or contact us at 1800 226 126 or
[email protected].
P18-23 SEPT SN.indd 5
7/09/2007 10:55:13 AM
P18-23 SEPT SN.indd 6
7/09/2007 10:55:18 AM
include the side and site. This includes patient notes, hospital forms and operating theatre lists.
The site and side of the operation must be recorded in full (i.e. RIGHT or LEFT) and not abbreviated to R or L, whenever the side is recorded. All documentation must
• Patient’s full name • Name of procedure • Site of procedure • Side of procedure
The consent form must include and the patient or representative must verify:-
Patient consent must be obtained.
Appropriate legal requirements in this matter must be attended to.
Verification of the patient must be made with the patient or the patient’s designated representative (if the patient is legally a child or unable to answer for him or herself).
Consent and Documentation
surgery for a particular procedure.
There should be no criticism of persons raising concerns even if their concerns prove to be unfounded. Surgeons should be aware of the level of risk for wrong site or side
immediately voice their concerns.
aware that the correct patient, side and site are operated on. If any member of the team believes the incorrect patient, side or site is being prepared for surgery, they should
Adopting a “team approach” in the theatre will reduce risk but the operating surgeon is ultimately responsible. Every member of the operating theatre team has a duty to be
process.
multiple, complementary strategies. To the extent possible, the patient or their designated representative should be involved in the
The College recognises the paramount importance of patient safety and expects hospitals and surgeons to adopt protocols utilising
CORRECT PATIENT, CORRECT SIDE AND CORRECT SITE SURGERY
IMPLEMENTATION GUIDELINES FOR ENSURING
ROYAL AUSTRALASIAN COLLEGE OF SURGEONS
P18-23 SEPT SN.indd 7
7/09/2007 10:55:20 AM
should be postponed or cancelled.
Review date: September 2008
form should be completed. If the surgeon remains uncertain of the side/site of surgery or the side/site differs from that previously discussed with the patient, the procedure
The surgeon should satisfy him/herself of the appropriate side/site of surgery and record this in the patient’s medical notes before proceeding with surgery. An incident
incorrect documentation should be changed and signed, and an explanation of the inconsistency recorded in the patient’s medical history and signed by the surgeon.
At all stages of this process, there should be consistency of documentation of side/site. If any inconsistency arises, progress towards operation should be suspended, the
In emergency (life or limb threatening situations) some of these steps may be omitted.
Emergencies
confirmed. A “time out” or “final check” should be part of this procedure. This should preferably occur before induction of anaesthesia.
The surgeon, anaesthetist and nursing team must confer and concur to ensure the correct patient, procedure, site and side. Marking of the operative site must be
Final Verification
The surgeon and his/her team must confer that the appropriate images are available, and confirm the site and side of the proposed surgery.
Imaging
The surgeon and the operating nurse must check the presence of the appropriate implants in the operating theatre before the anaesthetic commences.
Implants
• The surgeon visibly checks the pen mark prior to commencing surgery and ensures this is in accord with his or her intended operation before induction of anaesthesia.
• The pen mark is checked by the scout nurse prior to the patient entering the operating theatre. This mark must then be verified by the scrub nurse.
• The pen mark is checked by the nurse as the patient leaves the ward or holding area for the operating theatre.
operative field and should be initialled by the person making the mark. Multiple operation sites must be individually marked.
and medical record. The patient (who should not have been sedated) is informed that the pen mark indicates the site of the operation. The mark should be within the
• An indelible pen is used to unambiguously mark the side/site of the procedure. This is done or checked by the surgeon in consultation with the patient (where possible)
• The surgeon should be satisfied on which side and site the procedure is to be performed. This should occur in consultation with the patient.
Marking the Site of the Procedure
INTERNATIONAL
MEDAL
Outstanding service
Two remarkable men have been awarded the RACS International
Medal, one of the College’s highest honours
TWO MEN WHO have made a career-long
commitment to the wellbeing of people in
developing nations have been awarded the
RACS International Medal.
Cardiothoracic surgeon Associate Professor
Alan Gale, who helped established cardiothoracic units in 11 Pacific and South East Asian
countries, and Dr John Hargrave, who helped
control the spread of leprosy in East Timor
and parts of Indonesia, were unanimously chosen by the selection committee to receive the
medal – one of the highest honours bestowed
by the College.
The RACS International Medal, established
in 1998, is awarded in recognition of outstanding international service to surgery, education
and special contributions.
Unlike some other awards, it is not given
out annually, and is only awarded when
appropriate candidates are recommended and
approved by the committee. Since the award’s
inception there have been only three recipients.
Associate Professor Gale will receive his
award next year at the ASC in Hong Kong,
while Dr Hargrave will receive his at a ceremony near his home in Hobart.
Associate Professor Gale has spent decades
building cardiothoracic units from Tonga and
Vanuatu, to Mongolia and Nepal through the
charity Operation Open Heart, which was
established in 1986. He has undertaken more
than 50 international trips.
He said the program had two strands, one
designed around service delivery, where large
teams with the necessary equipment flew
into various countries to operate, and another
designed to establish cardiothoracic units and
upgrade the skills of local surgeons.
Associate Professor Gale is the Director
of Advanced Surgical Training at the Prince
Charles Hospital in Brisbane and Associate
Professor of Surgery in the School of Medicine
at the University of Queensland.
SURGICAL NEWS P24
P24-29 SEPT SN.indd 2
Patients arriving at Hill Station East Timor during the Indonesian occupation period
He said that while he was honoured to
have been selected for the award, the work
itself had been the most rewarding.
“As this program was being rolled out, we
had to decide which countries could establish
their own units with a bit of help, and (which)
were too isolated or economically deprived, in
which case we would fly in and treat as many
cases as we could,” he explained.
“For the most part we were treating congenital abnormalities and the ravages of rheumatic fever, but there is an increasing need
for cardiothoracic surgery, particularly in Asia,
because of the prevalence of cigarette smoking.
“In most of the Pacific countries we offered
that service commitment, but in most Asian
countries we helped upgrade the systems that
existed though the surgeons were severely limited
in terms of money and access to education.
“We provided skills transfer through every
member of each team, from surgeons to anaesthetists to nurses.
“At times it was difficult work, sometimes
having to stay up all night in places like Nepal,
deciding on whom to operate because 300
people needed cardiothoracic surgery while we
only had the capacity to treat 15.
“Those moments were gut-wrenching, but
the rewards have been huge.
“The enthusiasm for education in emerging nations is phenomenal, the learning capacity of medical staff is phenomenal and some of
the finest skills I have ever seen, have belonged
to surgeons working in under-resourced hospitals in under-resourced countries.
“It has been enormously satisfying to run
courses and lectures in various cities, then come
back one year later and see the development of
skills in our absence.”
Associate Professor Gale said Operation Open
Heart was now funded through AusAID with
support from the College and significant financial
contributions from Rotary International.
It is co-ordinated through the Sydney
Adventist Hospital Foundation.
Plastic and Craniofacial Surgeon Mr Mark
Moore travelled with Dr Hargrave towards the
end of his career while he treated those with
/ Vol:8 No:8 September 2007
7/09/2007 10:59:10 AM
John Hargrave examining
a patient in East Timor
John Hargrave treating a leprosy patient
in the Northern Territory
Alan Gale listening
to a monk’s heartbeat
leprosy in the poorest parts of Indonesia and
the politically troubled region of East Timor.
In his citation to the International Committee, Mr Moore said Dr Hargrave’s work showed
the value of aid programs that were developed
at a grassroots level, rather than controlled by
the health ministry.
“John Hargrave’s record in managing and
effectively eliminating leprosy from the Aboriginal populations in the Northern Territory
is well known – his MD thesis on this work
is not only a testament to his clinical expertise but also to a rigorous and detailed clinical audit process well ahead of (its) time,” the
citation reads.
“Not content with this John saw the need for
a similar reconstructive surgical service to those
with leprosy and a range of other physical disabilities and deformities in our nearest neighbours.
“Beginning in 1990/1991, he sought to
connect and build networks with institutions
and individuals in (Nusa Tenggara Timur), one
of the poorest and most disadvantaged Indonesian provinces, and East Timor, with all its
political issues.
“Having led volunteer surgical missions to
this region in John’s wake, I am continually
reminded of the value and esteem in which
he is held by old patients, nursing staff, physiotherapists and doctors.
“The model of healthcare delivery from
the ‘bottom-up’, which John championed,
Alan Gale operating in China
with many keen observers
remains that which I and others working in this
region seek to utilise and develop.
“(His work) over not only the period of
his active involvement, but also in the years
since, demonstrates … professionalism, integrity, respect and compassion, commitment and
diligence, collaboration and teamwork.”
Mr Moore said one of the most significant
aspects of Dr Hargrave’s work had been his
capacity to build trust where none existed.
“John used to go to East Timor and Flores
in the early 1990s when it was under Indonesian rule at a time of political unrest and strife,”
he said.
“He used to go out there by himself or
with a nurse for weeks at a time and in certain
places at certain times became the one person
that local people felt they could trust.
“And that trust played a central role in
managing and containing the disease, because
people who suffered from it felt confident they
could come forward for treatment and not be
judged or disregarded.
“His work showed great courage and
commitment, particularly given his willingness to go into regions where few others
would go, and he designed a programme that
we still follow.”
The RACS International Committee
agreed with Mr Moore, given that the stated
values behind the International Medal include
service and professionalism, integrity, respect
and compassion.
Committee member Professor David
Scott said both recipients had clearly made a
significant and lasting contribution to the care
of people in underprivileged countries.
“This award is given to those who are
approaching the end of their careers who have
shown a long-lasting dedication to international aid,” he said.
“We have quite consciously determined
that this medal is not bestowed each year but
only when worthy candidates are put forward
for consideration, so that we do not diminish
its value and meaning.
“It is given in recognition of a generosity
of spirit and a willingness to make a particular
commitment to a particular area of need that
has great meaning and offers a lasting contribution to those in need.
“We have chosen specifically to honour
those at the end of their career rather than midcareer, so the merit of their contribution can be
more easily assessed.
“Everyone on the selection committee
agreed that Associate Professor Gale and Dr
John Hargrave easily met the criteria and were
worthy recipients.”
The International Medal can be awarded to
an Australian or New Zealand Fellow. Nominations are called for annually.
SURGICAL NEWS P25 / Vol:8 No:8 September 2007
P24-29 SEPT SN.indd 3
7/09/2007 10:59:19 AM
RESOURCES
College properties
What do you own and does the College maximise these investments?
Keith Mutimer,
Honorary Treasurer
Melbourne – College Building
Overview
THE COLLEGE HAS activities in every Australian state and territory as well as in New
Zealand. It owns property in Adelaide, Brisbane, Melbourne, Sydney and Wellington
and leases premises in Canberra, Hobart and
Perth. The overall cost of College properties
is in excess of $23 million, with a combined
market value of about $30 to $32 million. The
value of the Victorian property is estimated to
be more than $24 million.
How tight is the budget?
The operating budget for the College aims for
a balanced result each year. In 2006, expenditure on College properties totalled $1,032,000
and is estimated to be $995,000 in 2007.
The returns from the College Investment
Portfolio are retained in the Foundation for
Surgery and are matched against committed
assets. Surplus funds are held for future development projects and are not generally available
to fund property development and acquisitions.
College funding for property development
is limited and any future developments will
be funded from external sources and secured
against a charge over the College properties.
Issues regarding repairs
and maintenance
All properties in Australia have a facilities maintenance program to ensure they are maintained in a
professional and safe manner. The New Zealand
property is being assessed for a similar program.
Because of the heritage value of Collegeowned properties, repairs have been a significant issue in 2007. In 2006, the South Australian building was assessed as requiring over
$$220,000 in heritage repairs, in addition to
routine maintenance costs. The New South
Wales property has had repairs in recent times
and the heritage stables are currently being
renovated at a cost of about $350,000.
Meanwhile, in New Zealand, the Wellington property is subject to earthquake-proofing
regulations and must be strengthened within
the next ten years. This, along with ongoing
maintenance issues, will continue to be a drain
on College resources.
The Queensland building is being assessed
for a complete redevelopment program.
The original building in Melbourne,
which is now the south wing, is heritage
listed and requires significant maintenance to
its exterior. The estimated cost of these repairs
is $350,000-$500,000. The west wing is also
nearing the end of its life and will require
substantial repair or rebuilding to meet future
College needs.
College property investments
Adelaide: 51-54 Palmer Place,
North Adelaide 5006
This two-storey house was built in 1901 for
William Honeywill, an Adelaide draper, and
named “Keynedon Brougham”. In 1910, the
Honeywill family returned to England, and
the house was sold to Frederick Bullock, a
former Lord Mayor of Adelaide. The prop-
SURGICAL NEWS P26 / Vol:8 No:8 September 2007
P24-29 SEPT SN.indd 4
7/09/2007 10:59:31 AM
Queensland College buliding
New South Wales College building
South Australian College building
erty, which overlooks the Adelaide CBD, is
in the city’s historic medical precinct. It was
acquired by the College in 1997, through the
efforts of the then South Australian Chairman
Glen Benveniste, with the support of President Colin McRae, and was heritage listed
in 2006. This enables the College to apply
for funding to assist with the restoration and
maintenance of the building. The College
occupies the upper floor of the house. Downstairs is occupied by a number of associations
affliated with the College
Brisbane: 50 Water Street,
Spring Hill 4004
The Brisbane office of the College is housed
in a two-storey commercial brick building
constructed in the 1960s. This was the first
property to be owned outright by the College,
which acquired it in 1988. The building has
since been jointly occupied by the College, the
RACP and RANZCOG. It is showing signs
of age, and will require substantial maintenance
and renovation if it is to be retained. The site
is being assessed to determine how it can best
meet the needs of Queensland surgeons.
Melbourne: College of Surgeons Gardens,
Spring Street, Melbourne 3000
The College building in College of Surgeons Gardens, Spring Street was designed by
Leighton Irwin and built in 1934 for about
£15,000. It stands on the site of the Old
Model School, built 1852-54. The original
section, the south wing, is in an interwar geometric style known as “stripped classical”, and
was the winner of the RVIA Street Architecture Medal in 1937.
The site was acquired by the College in
1932 and the old building was demolished.
Extensions to the 1934 building were made
in 1964-65, which included a science block
on the west side, and the Great Hall on the
east side. The west wing has since been converted into office accommodation, and the
Great Hall has been replaced by the east wing,
which includes a Skills Centre.
In 1932, the College negotiated a 50-year
lease on a peppercorn rental with an option
to renew, and responsibility for maintaining
the grounds was handed to the City of Melbourne. The lease expired in 1982. On 17
June 1992, after 10 years of negotiations with
the government, the College bought the site
and building by Crown Grant for $4.2 million, and leased the grounds to the City of
Melbourne for 99 years.
Sydney: 177A Albion Street,
Surry Hills 2010
The Sydney office occupies an historic threestorey terrace house built by John Turner, for
his own residence, circa 1880. Its ornate Italiante style is rare in Sydney. The area is one of
the oldest in Sydney, formed when the street
grid was laid out by Major Mitchell in 1831.
The property has had many uses over the
years, including periods as a boarding house
(1903) and a brothel (1930s). At the right is
a carriageway to the stables at the rear. The
sandstone stable block was a horse cab depot,
built by Daniel Bryan circa 1863. It was converted to a boarding house in 1886 and has
had several other uses, including as the headquarters of the Urological Society of Australasia. The College purchased this property
in 1991, enabling it to move out of shared
accommodation with the physicians in Macquarie Street.
Wellington, New Zealand: 43 Kent Terrace, Wellington South
The College’s New Zealand base, “Elliott
House”, is an historic house, built in 1913 as
home and consulting rooms for James Elliott,
then a young practitioner. It was designed by
Elliott’s friend Gray Young, a promising architect. The house was on Kent Terrace next to
the Presbyterian Church (now gone) where
James’ father Dr Kennedy Elliott was minister.
Sir James Elliott (1880-1959) became one
of New Zealand’s great medical figures and
played a prominent role in the formation of
the College. His three sons, Kennedy, Robert
New Zealand College building
and Randal, became Fellows of the College.
Sir James lived in the house until age forced
him to sell it, and the College, which had been
looking for a home for more than a decade,
acquired it in 1990. The building was named
“Elliott House” and remains largely intact. It
was registered by the New Zealand Historic
Places Trust on 20 July 1989 and is a South
Wellington landmark.
What is the way forward?
The ongoing issue for the College is the level
of investment and maintenance required for
all College properties. As mentioned previously, the combined market value of College
properties is $30 to $32 million. It needs to be
discussed whether the investment required to
maintain the properties as professional assets is
an effective use of College resources.
The privilege (onus) of owning heritage
properties comes with significant responsibilities. The question is: should the College own
heritage properties, which are very expensive
to maintain and renovate, or should the College rent its offices, allowing it to maximise
the returns on the capital released from the
sale of College properties?
The latter option would free up funds to
allow the College to pursue further and new
initiatives for the advancement of surgery in
Australia and New Zealand.
Obviously, this is an ongoing issue which
will generate wide-ranging discussion. I welcome responses from all Fellows.
SURGICAL NEWS P27
P24-29 SEPT SN.indd 5
/ Vol:8 No:8 September 2007
7/09/2007 11:00:13 AM
NEW TO
COUNCIL
Election of office bearers
Allow me to tell you a secret. I think that I may know who is going to be the
RACS President in the near future. It’s Ian.
IMA Newfellow
THE ELECTION OF office-bearers is quite
an odd procedure in Council. Apparently
no-one nominates, no-one lobbies, noone announces their platform and there are
no ballot papers. In this sea of nothingness
I would not be surprised if no-one voted.
I believe that there is a vote however. Mr.
Experienced Councillor tells me that there is
the opportunity for persons who do not want
a particular position to “opt out”. A series
of blank coloured papers are handed around
and Councillors write the name of the person
that they want for each position. The lowest scoring person is then eliminated and it is
all repeated. I would have thought that with
25 Councillors there could easily be 25 different Presidential votes. But no. Amazingly
often the office bearers are elected on the first
ballot. Surely that implies that there is a God
and he is a surgeon. (In view of our Adelaide
President another explanation, that does not
bear countenance, is that there is a God and
he lives in the City of Churches).
It would be tough being the President. As
well as dozens of meetings and speeches there
is a lot of travel, especially of you don’t live in
Melbourne. Mr. Experienced Councillor tells
me that although he has been on Council for
seven years he has not served under a Melbourne President. He also said that the four
Presidents that he has known have all basically
given up their normal work for the two years
of their Presidency.
Andrew Sutherland gets off lightly as he only
serves one year; his 10 year tenure on Council
expires in 2008. Our President must have his
head around so many complex issues that my
mind trembles; however it would be a challenge.
On the other hand there would be positives.
Think of those meetings with important people
like the Minister of Health, other College Presidents, journalists out to lambast you, disgruntled
fellows and trainees, politicians who hate all you
represent. Don’t forget the overseas trips - three
countries and four meetings and eight speeches in
10 days. All Business Class of course.
The other senior positions are also hard
work; Ian Gough, Vice President; Ian Civil,
Censor-in Chief; Ian Dickinson, Chair of
CPD and Standards and Keith Mutimer,
Treasurer. Keith is the only non-Ian amongst
this group and also the only one who could
possibly manage all the finances of the College. He is used to large sums of money as he
is a Plastic Surgeon.
Now the other person of real power is the
CEO, Dr. David Hillis. I will tell you more
about him next month but for now I must
let you know that he is really the Censor-inChief. Ian Civil thinks that he is but these articles are looked at by David Hillis and he sure
censors them and censures me. He warned me
of the dire consequences of influencing the
Council’s vote and independence by saying
who was likely to be President one day. But
he misunderstood me. He does not know my
ambitious nature and also overlooked my first
initial - it is “I” for Ian.
applied ultrasound for surgeons
A practical workshop
23 November 2007
This one-day seminar and workshop is designed to enable surgeons to gain an understanding of the role of ultrasound in various
surgical spheres and to assist in the development of skills to incorporate ultrasound into their daily practice. This course will cover all
areas of interest to General Surgeons relating to surgeon-performed ultrasound.
Convener:
A/Professor Ian Bennett
Speakers:
A/Professor Daryl Wall
Dr Michael Schuetz
Mr Brian Starkoff
Dr Melanie Bond
Dr Shinn Yeung
Dr Brian Meade
Dr David Schache
Venue:
Princess Alexandra Hospital
Brian Emmerson Seminar Room
Registration:
$200 excl.GST
Please register early as
number will be limited.
Trainee registrars welcome
For registration please contact
Ms Brandi Thompson/Desley Thompson
Surgical Specialities, 4th Floor
Princess Alexandra Hospital
Ipswich Road
Woolloongabba QLD 4102
Phone: +61 7 3240 2767/+61 7 3240 7029
Fax:
+61 7 3240 7011
E-mail: [email protected]
Princess Alexandra Hospital
SURGICAL NEWS P28
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/ Vol:8 No:8 September 2007
7/09/2007 11:00:38 AM
DEEPLY
MISSED
Raymond Arthur Chapman
College Secretary 1962 - 1989
4 March 1928 – 9 August 2007
Written by D G
(Scotty) Macleish
JUDY (RAY’S WIDOW) has asked me to speak
about Ray’s career as Secretary of the College. It
is a privilege to do so on behalf of a host of surgeons whom Ray has helped and befriended in
his role as chief executive of the College.
Ray came to the College as a Certified Practising Accountant and an Administrative Cadet
from CSIRO. In mid 1961 the position to which
he was first appointed was Assistant Secretary.
The President in 1962 was Julian Ormond
Smith – a swash-buckling, warm-blooded surgeon of the older school, who is credited with
having filled every position on College committees, not all at the same time. Viewed in retrospect, perhaps his master-stroke in 1962 was to
appoint as Secretary Raymond Arthur Chapman
who was at the ripe age of 34 years.
I think Julian Smith recognised his intelligence and initiative and that is what he wanted in
his lieutenant and adjutant. Little did he bargain
for the versatility, sound judgement and affable
personality which Ray brought to the job.
For many, first contact with the College was
made through Ray Chapman. Moreover, entry
to Fellowship of the College is preceded by a
stiff but fair Part II exam. Ray organised those
examinations like clockwork. After each, there
would be those who were happy, and those who
were sad. Ray, who knew his scriptures, was able
to comply with the exhortations of St Paul the
Apostle to the Romans to “Rejoice with them
that do rejoice, and weep with them that weep”.
So began a bond with new Fellows of the
College, some of whom enter at their first attempt,
some at their second – and others take longer.
Ray maintained contact with Fellows, and
was a personal friend of many of them throughout Australia and New Zealand. Many were surprised when they telephoned the College, that he
could recognise the voice before they had introduced themselves. He was very much the face of
the College to all.
To my knowledge, there was only one occasion on which he was paraded before higher
authority – to explain his actions, and for repri-
Raymond Chapman
mand. I know because I was paraded with him.
It came about this way.
In preparation for the Golden Jubilee General Scientific Meeting in 1977, the command
was issued by the Vice-President, impending
President, and former naval officer D’Arcy Sutherland that the College Headquarters were to be
cleaned up. Much had accumulated in the vaults
at Spring Street, and had been put there during
the war when the building had been occupied
by the Red Cross and National Authorities. The
task was given to Chapman and Macleish, who
had just been appointed to the House Committee. Our solution was to put everything from
the vaults in a removal van and take the lot to
Heidelberg Repatriation Hospital. We spent a
weekend in boiler suits sorting. Unused toilet
rolls, out-dated stationery, etc were thrown out
and anything bearing a hint of archival significance was put in the van and brought back to
the College.
Thereafter, it was found that certain records
were missing, including the colourful Grant of
Arms issued by the College of Heralds in London. We were summoned to face the Archives
Committee. The dressing down was merciless.
All we could do was to maintain that we had
sifted wheat from chaff. It carried little weight.
A substitute Grant of Arms had to be obtained
from the College of Heralds – through the good
offices of Wyn Beasley.
Fortunately, shortly afterwards, an official of
the ANZ Bank called Mr Chapman to state that
in the vaults of the bank there had been found a
red box labelled ’Surgeons’, and “was he inter-
ested?”. He was. It contained the missing original
Grant of Arms. Chapman and Macleish received
no formal apology, but were not dismissed.
In 1984, Ray was awarded the RACS Medal
“For singularly valuable and dedicated contributions to the College”. He had contributed to the
well-being of all aspects of College activity. It is
not my role or intention to make odious comparison. I know that times change and the College has
grown. But the simple mathematical fact is that all
the portfolios that Ray Chapman carried are now
carried by seven different individual people.
In 1987, after 25 years as Secretary, he was
elected to Fellowship of the College – a most
unusual honour for someone who has not studied
anatomy. As a rule, the anaesthetist commences
manoeuvres before the surgeon, but in this case,
two years later he was elected to Fellowship of
the Faculty of Anaesthetists, in recognition of all
the work he had done for the Faculty in its earlier days. He thus became both a surgeon and an
anaesthetist, but being the good administrator that
he was, he did not enter into competition with
his clinical colleagues.
The College Office was a happy place, and
his supportive secretarial staff were fond of him.
The nature of his approach was reflected in their
enthusiastic work for the betterment of the College. In the age of acronyms, RACS became
interchangeable for R A Chapman Secretary and
Royal Australasian College of Surgeons.
When he retired from the College in 1989
after 28 years service, he left “with friends and
admirers aplenty, and without an enemy of consequence”. His Headmaster’s report card would
have read: “Could not have done better”.
Though it is difficult to be certain of more
than a few predictions, I think the College will
not see his like again.
May I close by paraphrasing Kipling but slightly:
“Wherefore praise we famous men –
Men of little showing,
For their work continueth
Broad and deep continueth,
Great beyond their knowing.”
SURGICAL NEWS P29 / Vol:8 No:8 September 2007
P24-29 SEPT SN.indd 7
7/09/2007 11:00:43 AM
ACCOUNTABILITY
Privilege and Responsibility
in Plastic Surgery
Acceptance speech of the Prince Henry’s Medal (continued)
Donald Marshall
I BECAME PARTICULARLY interested in
breast reconstruction and whereas cosmetic
surgery had never featured high on my
agenda, I responded to the increasing demand
and found the gratitude of well managed
patients surpassed that of all other areas of
plastic surgery
Plastic surgery practice was very stable
during this time, although there were a few
who pushed the boundaries. With strong
ethical guidelines, which were enforced by a
powerful Medical Board, and the absence of
advertising, this had little impact on everyday
practice.
Payment of fees prior to an operation was
unheard of, but one of our more entrepreneurial colleagues, convinced his patients to
prepay for their operations at this time by telling them he found that if they paid their fee
before the operation, their mind was at rest
and they healed more quickly, with a lower
rate of complications. Noblesse oblige was
weakening!
Two of our Residents from the VPSU,
John Anstee and Murray Stapleton joined us
in practice and with the imminent retirement
of Benny, John, Murray and I established our
Junction House partnership in Kew, where
we had a number of productive and entertaining years. John became Head of plastic
surgery at the Alfred Hospital and Murray,
Head at the Queen Victoria Hospital, which
enabled us to establish the Monash University
Plastic Surgery Fellowship, which was funded
from private practice and allowed the Fellows
to be exposed to both public and private hospital practice; not as a service provider, but
purely for training. We had some great Fellows, including the current President of our
Society.
This was an expression of the principle of
noblesse oblige where training was seen as a
privilege – not a job!
SURGICAL NEWS P30
P30-35 SEPT SN.indd 2
The surgeons of my generation were
largely educated at public expense and it is not
surprising that with this privilege, most felt
there was a responsibility to the Community,
which they were happy to accept and repay in
various ways, including pro bono work.
The X & Y generations, who have grown
up in a post modern world, have been forced to
pay for their education as a result of the market
economy and are likely to be less inclined to
accept this responsibility, or to enjoy the same
privileges afforded to surgeons in the past.
Noblesse oblige has little appeal for them.
Many privileges have disappeared and
have been replaced by the fundamental privilege of the market economy and that is to
make money. Our responsibilities have not
diminished, they have, if anything, increased.
There is certainly a greater duty of care
than in the past, regarding the information
which should be provided to patients. With
an emergency procedure, the information
required is less than for an elective operation,
but for a discretionary, cosmetic procedure, a
full explanation of the benefits and risks of the
operation is obligatory.
Advertising has had a major impact on the
practice of plastic surgery. It generates unrealistic expectations in many patients and it is not
surprising that premiums for Medical Indemnity Insurance have soared. It is my personal
view that we have no need for advertising,
but some plastic surgeons feel they must compete in the cosmetic surgery market place.
This issue has divided the plastic surgery community and is a dilemma which is driving a
wedge between plastic surgeons who practice
mainly reconstructive surgery and those who
practice cosmetic surgery.
Patients seeking cosmetic surgery, who
come by work of mouth, already place trust
in the surgeon, but patients who respond to
advertisements have no such trust – why anyone would wish to treat them, is difficult for
me to understand! I once attended a cosmetic
surgery meeting, at which there was a session
on business management, during which it
was suggested by one speaker that one could
increase the amount of cosmetic surgery in
one’s practice, by teaching the receptionist to
deliberately misread referrals and to tell the
patient for instance, who had been referred
for a nose operation, how much the surgeon
could do to improve her eyelids. In this way,
the patient would end up with two operations,
rather than one. Sadly, one of our colleagues
thought this was a great idea! Noblesse oblige
was on its knees!
This breakdown of ethics is not confined
to cosmetic surgery. There are also ethical
problems in reconstructive surgery, where the
cost is often born by a third party and some
complex surgery is performed without indication and without benefit, other than financial
gain.
These are extreme examples of a failure
of professionalism by surgeons. These entrepreneurial business and advertising strategies
exploit vulnerable patients and give over optimistic predictions. There is a parallel failure
of professionalism by patients, with an increase
in malingering and litigation for the purpose
of financial gain. Patients and surgeons both
have professional and ethical responsibilities,
which requires surgeons to provide more
accurate information and patients to better
educate themselves.
If we, as plastic surgeons, wish to play
our part in this shared responsibility, we must
ensure we produce well trained, all round
plastic surgeons, who will accept the practical and ethical responsibilities of undertaking
all aspects of plastic surgery. This can best
be achieved through the Royal Australasian
College of Surgeons and I am saddened at
the decision to hold the main plastic surgery
meeting next year separate from the Annual
Scientific Meeting of the College.
/ Vol:8 No:8 September 2007
7/09/2007 11:03:09 AM
We need to maintain a strong and
coherent College and the interchange with
colleagues from other specialities is vital to
the well being of plastic surgery and to the
survival of our specialty.
Fragmentation is a major danger for plastic
surgery and the Aesthetic Society is evidence
of this division, which has its roots in the
history of plastic surgery in Australia. There
appears to be no reason for a separate group
and in my view, until this schism is corrected,
plastic surgery cannot regain the position of
respect and strength it previously enjoyed.
After all, plastic surgery is a very small part of
overall surgery, which itself, is under threat
and to divide our influence further, weakens
our position unnecessarily.
In the post modern era, it appears the
concept of noblesse oblige is no longer valid,
but there is one area in which it is alive and
well. Some 25 years ago, Interplast Australia
was founded by Rotarians, with the co-operation of Fellows of this College. This organisation, now called Interplast Australia & New
Zealand, arranges for voluntary teams of surgeons, anaesthetists and nurses to travel to our
neighbouring countries where plastic surgery
services are not so readily available to help in
the delivery of plastic surgery and the training
of plastic surgeons. Every surgeon who goes
on such a programme gives freely of time
and expertise to practice the fundamentals of
plastic surgery and returns refreshed and
invigorated with a well earned sense of
achievement. There is no financial reward,
but there is great personal satisfaction. More
than 50 per cent of all the plastic surgeons in
Australia and New Zealand have contributed
to such programmes and the organisation
continues to grow and prosper.
Interplast Australia & New Zealand and
the other surgical overseas aid programmes of
the Royal Australasian College of Surgeons
have the potential to make a major contri-
bution to the development of surgery in our
region.
This College has a vital role to play in the
future of plastic surgery, as it is involved in
the selection and training of plastic surgeons,
their examination and continuing education
and for the maintenance of adequate standards
of practice in all areas of plastic surgery, both
reconstructive and cosmetic.
We should not confuse cosmetic surgery
“We must ensure we
produce well trained, all
round plastic surgeons, who
will accept the practical and
ethical responsibilities of
undertaking all aspects
of plastic surgery.”
with the ill advised, excessive and inappropriate surgery which fills magazines and so-called
reality TV programmes.
All plastic surgery should be practised in a
responsible and ethical manner.
1. It should not be promoted.
2. Only the minimum surgery required
to satisfy the needs of the patient
should be undertaken.
3. We should perform the operation
for a fee commensurate with other
surgical procedures.
4. We should only undertake procedures
where the benefits clearly outweigh
the risks.
5.We would be happy for the
opertion to be undertaken on a member of our family.
These principles are the basis of our position of professional privilege. Our responsibility is to uphold them. This requires a commitment of service to patients, based on a body
of knowledge and skills, where the service is
not regulated primarily by the capacity of the
patient to pay and if we wish to maintain our
practical and ethical standards by self regulation, we must be prepared to exclude those
who do not meet these high standards.
To be a Fellow of this College remains
a great privilege and with it comes the
responsibility to maintain the highest
standard of surgery. At the moment, this
College is seen to have a monopoly situation in regards to surgery, which will be
increasingly difficult to maintain, unless
we adhere to these principles.
During the modern era, when
noblesse oblige reigned supreme, surgeons were able to set the agenda and
practice surgery with a “top down”
model, which was then appropriate
– it is not now! The post modern era
in which we now live has moved to a
new paradigm, in which we are required
to educate the public, particularly in matters
of discretionary surgery, with a “bottom up”
approach. Our pedestal has long since gone
and unless we grasp this fundamental change
and react appropriately, we are in danger of
becoming irrelevant.
Despite the demise of noblesse oblige,
we are still in a privileged position, but our
responsibilities are different. We need to
embrace the changes and share our knowledge and decisions with our patients as much
as possible. We should avoid the commercial
pressure to engage in advertising and concentrate on setting our own house in order, particular in regard to ethical standards. We will
not go far wrong if we remember our legitimate interest remains, as always, the business
of surgery and NOT surgery as a business!!!
SURGICAL NEWS P31
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/ Vol:8 No:8 September 2007
7/09/2007 11:03:23 AM
FELLOWS IN
SECTION
STRAP
THE
NEWS
Trauma team saves lives
The treatment of Paul de Waard is just one example of
fulfilment of the original plan for tertiary trauma centres
THE INTENSE PUBLIC and media interest in
the saving of Good Samaritan gun shot victim
Paul de Waard should be seen less as homage
to the skills of the surgeons involved and more
that the decision to establish tertiary trauma
centres was a good one and does work.
All the surgeons who spoke to Surgical
News said that while the incident was horrific, there was at least serendipity in where de
Waard was shot (only minutes from the Royal
Melbourne Hospital) and when he was shot
(just after 8am Monday when the hospital was
fully staffed but with theatres still available).
They said it was the ability of the trauma
team – from the paramedics to the perfusionists - to swing into rapid action that stopped de
Waard from dying from massive blood loss.
De Waard was wounded on Monday,
Russell Gruen
SURGICAL NEWS P32
P30-35 SEPT SN.indd 4
June 18, in a now notorious incident in the
Melbourne CBD when he tried to assist a
woman being assaulted outside a nightclub.
That woman, Kara Douglas, was also shot
and she too was taken to the Royal Melbourne Hospital. Sadly, another man who
tried to help, Brendan Keiler, died from gunshot wounds at the scene.
Shot twice, de Waard arrived at the
Royal Melbourne Hospital just after 8.30am,
with three wounds to his chest and abdomen, following a phone call from paramedics to alert the trauma team to his imminent
arrival. Bleeding profusely, he was assessed in
emergency then rushed to theatre where he
was treated by cardio-thoracic surgeons Dr
Victoria Atkinson and Professor Alistair
Royse, trauma surgeon and Associate Professor of Surgery Russell Gruen and vascular
surgeon Mr Noel Atkinson.
Dr Victoria Atkinson said she received the
call to assist while her first patient scheduled
for the day was asleep on the table.
“He was 15 minutes in emergency where
they intubated him and put in chest tubes and
then rushed him to theatre because we had to
stop the bleeding,” she said. “We didn’t know
how many times he had been shot because
he had three wounds, two in the chest which
were entry and exit wounds. He was in shock
and hypotensive so we had to work extremely
fast to stem the bleeding.
“Calls then went out around the hospital and everyone arrived. We had empty
theatres, we had anaesthetists and scrub
nurses ready.
“Any later and we would all have been
working on other patients which would
have meant having to make a choice and
that is very difficult.”
By this time de Waard was losing litres
of blood and had no recordable blood
pressure. Fortunately, he was quickly
delivered to a theatre ready to go, com-
plete with a cell-saver to recover, concentrate
and pump the blood back into his system and
a perfusionist, Dr Peter Angelopoulos, with
decades of experience.
At one stage up to six surgeons were working on the Dutch backpacker. Dr Atkinson
opened the pericardial sac to check for bullet
wounds to the heart then followed the trajectory through the lung. She described what
she then found as looking as if “a blender had
gone through the lung”.
She stapled and resected the damaged lung
and ligated an artery close to the sternum that
had been split by the bullet.
While she was working on the chest
cavity, general surgeon Russell Gruen had
opened de Waard’s abdomen to deal with
massive intra-abdominal bleeding.
With the rostered vascular surgeon already
in theatre with the other victim, Dr Atkinson
knew her husband, vascular surgeon Noel
Atkinson was in his consulting suites adjacent
to the hospital. Together he and Associate
Professor Gruen stemmed the bleeding caused
by the damage done to de Waard’s illiac vessels and stapled off his perforated bowel.
By then de Waard had lost more than
twice his blood volume, his oxygen saturation
was flagging, his temperature had dipped to
32C and his blood was not clotting.
“While I had closed his chest, it was
decided at this stage to pack his abdomen
off and give the blood factors time to work
with time also to try and warm him,” Dr
Atkinson said.
“You can plug the hole but when the insult
is so severe and his physiology so deranged it
sometimes is not enough.
“It was a testament to the anaesthetist and
perfusionist that he was even still alive.
“When we took him down to Intensive
Care he was still losing one litre of blood an
hour from his abdomen and there were many
times we thought he would not make it.”
/ Vol:8 No:8 September 2007
7/09/2007 11:03:24 AM
By then, de Waard had lost about 20 per
cent of his right lung with two holes in his
bowel temporarily stapled off with the bullet
still in place deep within his pelvis. Associate
Professor Russell Gruen attempted to retrieve
the bullet for police when de Waard was taken
back to surgery two days later but decided it
was too risky.
“Paul was shot once in the chest and once
in the right hip through the sacrum, through
the illiac veins and through the sigmoid
colon,” he said.
“The bullet was lodged deep in the muscles of his pelvis behind major vessels that supply the lower limbs and we would have had to
cut and search to find it which would involve
further risk. Now instead he will be like the
thousands of war veterans walking around
with shrapnel in their bodies.”
Associate Professor Gruen said he and
Mr Atkinson took de Waard back into theatre at 7pm that night to check for any further bleeding from his sacrum but he had
pretty much stopped bleeding by then.
He was vacuumed closed rather than
stitched to allow for further surgery over
the next 36 hours.
“Paul de Waard came as close as anyone
can go to bleeding to death but in a strange
way he was lucky in that he went into a cardiac
theatre where there was access to a perfusionist and the cell saver. As a team we were in the
right place at the right time and there were
dozens if not hundreds of people involved in
his care within that first 24 hours,” Associate
Professor Gruen said.
“Without the great work done by the anaesthetists, perfusionists lab staff and many other people there is not much that surgeons can do.
“And it should be noted that there were
two victims in the hospital, both at risk of
bleeding to death at the same time so we
needed two of everything.
“That means six surgeons, several anaes-
thetists, two theatres
and many theatre
nurses.
“It placed an
enormous stress on
the system but the
system coped.
“I think what
it means is that the
people of Victoria should feel very
much reassured that
in their moment of
need we have such
a trauma service that
can cope despite
what you throw at
it.
“While this was
an
extraordinary
incident, we are a
very busy trauma
hospital, dealing with
over 700 severely
injured patients each
year. This is what we
are trained for.”
Vascular surgeon Mr Noel Atkinson particular praised the work of the anaesthetic team in
keeping up de Waard’s blood pressure and the
perfusionist in maintaining blood volume.
“This was a major logistical exercise in terms
of marshalling all the help available with supplies
of blood brought in, supplies of blood agents and
the personnel needed to cope with his disordered
physiology,” he said. “All this was done too in a
situation of controlled chaos.
“This young man was unfortunate to have
been shot but fortunate to have been taken to
a place with the resources and people ready to
act. Many, many things fell into place and if
he had been wounded in such a way at a different place and at a different time he may not
have survived.
Paul deWaard and Russell Gruen face the press
Noel & Victoria Atkinson.
“This shows that the Royal Melbourne Hospital, because it was established
some years ago as a trauma centre, has the
experience and expertise and the systems in
place to minimize delay and get people working swiftly in their allocated roles.
“The treatment of Paul de Waard is just
one example of the fulfilment of the original plan for tertiary trauma centres. It does
however place heavy demand on resources
and at times the hospital staff and facilities are
stretched to near breaking point.
“But it is fortunate that everything fell
into place for this young man.”
Mr de Waard has now returned home to
Holland and will undergo further bowel surgery in coming months.
SURGICAL NEWS P33 / Vol:8 No:8 September 2007
P30-35 SEPT SN.indd 5
7/09/2007 11:03:32 AM
SKULL BASE
SURGERY
Gator Tails
Neurosurgery in the Florida swamp
US-BASED COLLEGE Fellow, Dr Stephen B
Lewis MBBS FRACS, returns to his hometown
this October to offer a rare opportunity for Australian neurosurgeons and residents to gain handson experience in anatomical approaches to
skull base surgery.
Dr Lewis, who got his international start
with a College Travelling Fellowship in 2000,
works alongside world-renowned expert Professor Albert L Rhoton, Jnr., MD at the University
of Florida. Along with local convenor Professor
Neville Knuckey, the pair will run a Skull Base
Dissection Master Class at the Clinical Training
and Education Centre (CTEC) in Perth for the
first time since 2003. Dr Lewis shares his thoughts
on coming home, working in the USA and the
Master Class at CTEC:
“I completed Medicine at the University
of Western Australia in 1985 and my internship and junior residency rotations at Sir
Charles Gairdner Hospital before heading to
Adelaide for a job in neurotrauma research.
After commencing my neurosurgery training
in Adelaide, I returned to Perth to complete
the final two years.
“Neurosurgery is a field of endeavour that
offers great variety and complexity in medicine. Neuroscience remains a frontier scientific effort with much to learn and understand
about the brain. After qualifying as a neurosurgeon, I worked for six months in Perth
then ventured overseas.
“I am proud of the training I received in
Australia. It equipped me to work with the
best in the world and I believe we are a leading country in neurosurgical training. During
my training I was fortunate to benefit from
some of the first courses at CTEC organized
by Professor Alan Crockard, who I eventually ended up working for at the National
Hospital for Neurology and Neurosurgery
in London.
“After six months in London I moved
to Gainevsille, Florida. My original intent was
SURGICAL NEWS P34
P30-35 SEPT SN.indd 6
for one year but at the end of that year, an
opportunity arose with resignation and retirement for me to stay on at the University of
Florida. It was a case of in the right place at
the right time. I inherited one of the highest
profile and busiest cerebrovascular and skull
base practices in the US.
“From a patient care perspective I specialise in adult blood vessel disorders of the brain
as well as brain tumours. Last year my ceebrovascular service treated over 350 aneurysms
and 40 arterio-venous malformations as well
as multiple carotid endarterectomies / stents,
“I am proud of the training
I received in Australia. It
equipped me to work with the
best in the world and I believe
we are a leading country in
neurosurgical training.”
intracranial-extracranial bypasses procedures
and surgery for skull base tumours. The large
population in Florida allows me the opportunity to treat a much larger number of cases
in my subspecialty area of cerebrovascular and
skull base neurosurgery.
“We run two Senior Neurosurgery
Trainee Skull Base Dissection courses per
year in Florida. We get 30 residents per
course who come from around the country.
Professor Rhoton also directs a brain anatomy
course in February for a whole week. I am
fortunate to work at the University of Florida
alongside Professor Rhoton, one of the most
recognized names in world neurosurgery.
“Our Skull Base Dissection courses in the
US are always oversubscribed and our participants unanimous in their positive feedback
because they get so much hands-on experi-
ence. They get a chance to venture around
areas of the brain and skull they wouldn’t normally have access to through this experience
and, from this, learn the limits of where they
can and cannot go in real life situations.
“Participants in the CTEC course will
perform approaches to skull base surgery via the
anterior and middle cranial fossa and the lateral
posterior fossa. Some of these areas are traditionally hard to get to but we’re teaching them the
finesse to do so.
“A highlight of the course is Professor Rhoton’s anatomy slides which are in 3D. We all
wear the 3D glasses for his presentation. The
slides are terrific and give a unique perspective on
the anatomy of the brain and skull.
“Using cadavers is still one of the best ways to
learn these techniques before putting them into
practice. Skull Base Dissection courses take a lot
to coordinate and are expensive to run. We did
one at CTEC in 2003, which was great and well
attended by the neurosurgery trainees in Australia.
“The facilities at CTEC are fantastic and I
know them well. Perth is also my hometown
and I love showing it off to my colleagues
from overseas.
“Gator tails – Neurosurgery in the Florida
Swamp is the title of a free seminar I’ll be giving
about my work at the University of Florida. The
Gator is our university mascot and the swamp is
the nickname of our football field.”
While in Australia, Dr Lewis will be teaching surgery trainees and attending grand rounds at
Sir Charles Gairdner Hospital. His free one-hour
seminar, “Gator Tails – neurosurgery in the Florida Swamp”, takes place at CTEC from 6pm on
10 October and is open to all members of RACS
(RSVP only). Dr Lewis will talk about what his
experience within the US medical system and life at
a busy university academic neurosurgery practice.
To register for the Skull Base Dissection Master Class or to RSVP for “Gator Tails – neurosurgery in the Florida Swamp” contact CTEC on
+61 8 6488 8044 or [email protected]
/ Vol:8 No:8 September 2007
7/09/2007 11:03:39 AM
ASERNIP-S
ASERNIP-S Update
Six new reviews have been published
Guy Maddern,
Chair, Research
Audit, External Affairs
ASERNIP-S has published the
following Reviews Systematic
literature reviews
• Centralisation of selected surgical procedures: implications for Australia ASERNIP-S Report no. 57
• Scalpel safety in the operative setting
ASERNIP-S Report no. 59*
• Surgical simulation for training: skills
transfer to the operating room
ASERNIP-S Report no. 61*
• Natural orifice translumenal endoscopic surgery (NOTES) ™ for intraabdominal surgery
ASERNIP-S Report no. 62*
Other reviews
• A review of policies and processes for
the introduction of new interventional
procedures ASERNIP-S Report no. 58
• Rapid versus full systematic reviews: an
inventory of current methods and practice
in Health Technology Assessment
ASERNIP-S Report no. 60
You can access the above reviews and plain
English summaries for reviews marked with
an asterisk * on the publications page of the
ASERNIP-S website at http://www.surgeons.
org/asernip-s. The summaries will be published
in this and subsequent editions of Surgical News
in 2007. The findings of the centralisation systematic review and other reviews are briefly
described below.
Centralisation
The aim of this was to assess the efficacy of
centralisation for the following surgical procedures in the Australian setting: abdominal aortic
aneurysms, knee arthroplasty, liver resection,
oesophagectomy and prostatectomy. Efficacy
was assessed by comparing the outcomes in
patient morbidity, mortality and length of stay
according to either the volume of procedures
performed at a range of hospitals or the volume
of cases performed by each surgeon.
The studies were mainly from North America, with some from Europe and a few from
Asia. Unfortunately, no Australian studies met
the inclusion criteria. The systematic review
provides an overview of the outcomes for each
procedure performed at different volume hospitals, or by different volume surgeons; however,
due to the breadth and complexity of this field,
the reported results must be read in the context
of the full review.
In addition, further studies incorporating the
unique attributes of the Australian healthcare
environment must be conducted before any
definitive conclusions can be made.
A review of policies and
processes for the introduction of
new interventional procedures
The aim was to identify and review both
Australian and international policies and
processes for the introduction of new interventional procedures into clinical practice,
and to determine:
• how decisions on the adoption of new interventional procedures are made. These decisions depend largely on clinical outcomes
(e.g. clinical need; and burden of disease;
safety, efficacy and effectiveness of the procedure) and organisational outcomes (e.g.
cost considerations; training requirements
of the procedure). Few organisations have
reported their experience with such policies
and processes and there is a paucity of information on the outcomes and organisational
impact of these initiatives.
• the extent to which evidence-based information, particularly health technology
assessments (HTAs), is used in the decision-making process. While it is clear that
such information, is frequently used in
decision-making regarding the adoption
of new interventional procedures, a lack
of access to relevant and timely HTAs is
an important barrier. Therefore, greater
effort needs to be put into establishing
information infrastructure in order to
make evidence more readily available to
decision makers.
Rapid versus full systematic
reviews: an inventory of current
methods and practice in Health
Technology Assessment
This review examined the status of rapid
reviews in the HTA arena, utilising three concurrent methodologies.
A survey tool to assess current practice in
the preparation of rapid reviews was developed
and distributed to members of the International
Network of Agencies for Health Technology
Assessment (INAHTA) and other prominent
HTA organisations. The survey identified axiomatic trends, but little cohesion between
organisations regarding the content, methods
and definition of a rapid review.
A systematic literature search was conducted
on the current evidence base for methodology of rapid reviews. Studies identified did not
specifically address the methodology underpinning rapid review, but many highlighted the
complexity of the area. Authors suggested
restricted research questions and truncated
search strategies could limit the time taken to
complete a review.
Comparisons were carried out between 11
products on four topics to determine if there were
differences in the essential conclusions of rapid
and full reviews on the same topic. Obvious differences were identified; however, there were no
instances in which the essential conclusions of the
different reviews were opposed. The full reviews
consistently provided more detailed information
and recommendations pertaining to the implementation of each particular health technology.
SURGICAL NEWS P35
P30-35 SEPT SN.indd 7
/ Vol:8 No:8 September 2007
7/09/2007 11:03:42 AM
ASERNIP-S
Surgery in the abdominal
cavity through natural openings
Guy Maddern,
Chair, Research
Audit, External Affairs
THE AUSTRALIAN SAFETY and Efficacy
Register of New Interventional Procedures
- Surgical (ASERNIP-S) looked at the safety
and effectiveness of Natural Orifice Translumenal Endoscopic Surgery™ (NOTES™) in
intra-abdominal surgery, compared with traditional abdominal surgery. This new procedure is performed through natural openings
in the body, rather than via a cut in the skin;
hence the nicknames “incisionless”, “no scar”
or “seamless” surgery.
The following summary has been prepared by a team of surgeons, consumers and
researchers to inform patients making decisions with their doctors on their treatments.
Main messages
As the use of NOTES in intra-abdominal surgery was at a very early stage of development,
the available evidence was limited and only
involved animal studies. Hence it was not
possible to compare the safety and effectiveness of NOTES with traditional techniques.
However, ASERNIP-S noted that:
• At this early stage it appeared that NOTES
was less safe and effective for intraabdominal surgery than traditional techniques (laparoscopy and laparotomy).
• The technique was evolving rapidly and
it was likely that more evidence would
become available.
• Well-managed human studies were
needed to compare the safety and effectiveness of NOTES for intra-abdominal
surgery with traditional techniques. Studies could begin with hybrid NOTES/
laparoscopic procedures and move to
NOTES trials.
Conventional abdominal surgery
Traditionally surgeons have operated on
organs of the abdomen through a large cut in
the abdominal wall. However, this can lead
SURGICAL NEWS P36
P36-39 SEPT SN.indd 2
to complications such as infection, scarring
and pain. Over the last 20 years, minimally
invasive surgery has become popular. With
this approach the surgeon accesses the organs
through small cuts in the skin (laparoscopy).
This reduces the complications which are
associated with large cuts. Laparoscopy, however, has its own risks, such as organ puncture,
abscesses and adhesions. In addition, surgeons
need to learn to use the new technology and
expensive instruments are needed.
Abdominal surgery through
natural openings in the body
A technique is being developed so that surgeons can pass an endoscope through a natural opening in the body into the stomach,
colon, bladder or vagina, cut a small hole in
the wall of this organ and thread the endoscope through into the abdominal cavity.
This new procedure, called NOTES, allows a
surgeon to operate on abdominal organs like
the gall bladder without cutting the patient’s
skin; hence the nickname “no scar” surgery.
The advantages of this procedure are: no skin
wound complications; less anaesthesia; better
access to abdominal cancers in overweight
patients; and its potential use in children to
avoid long-term skin wound complications.
The disadvantages are: it has many of the complications of laparoscopy; longer tubes reduce
the surgeon’s view and movement; and the
need for more specialised equipment.
The aim of the ASERNIP-S review was
to assess the safety and effectiveness of surgery in the abdominal cavity through natural openings before the technique becomes
widely used in the community.
What is the evidence?
The evidence available was very limited at this
early stage of development of the procedure and
all studies were conducted in animals. It was not
possible to compare the safety and effectiveness of
NOTES with traditional procedures. However,
the Review Group noted that:
• At this early stage it appeared
that NOTES was less safe and effective
for intra-abdominal surgery compared to
existing techniques.
• In animal studies, complications included
failure to close the small cut in the wall of
the stomach, colon, bladder or vagina that
could result in peritoneal infection.
• It was not possible to determine the best
entry point into the body (mouth, anus,
vagina, urethra).
• NOTES was developing rapidly and the
evidence base would likely increase.
• Although NOTES could be suitable for
use in some intra-abdominal surgery in
humans, it was too early to state if the
potential advantages outweighed the disadvantages. (Review published in June
2007)
What is ASERNIP-S?
ASERNIP-S is a program of the Royal Australasian College of Surgeons. ASERNIP-S conducts
literature reviews on the safety and effectiveness
of new surgical techniques before they are widely
used. Each review collects all relevant information, or evidence, on new and standard techniques
used to treat a medical condition. The quality of
evidence is assessed. ASERNIP-S then makes
recommendations on the safety and effectiveness
of the procedures, that are endorsed by the College, sent to hospitals and surgeons in Australia
and overseas, and published on the website with
summaries for consumers.
Glossary
Abdominal cavity: the space between the thorax
and the pelvis in which the abdominal organs lie
Endoscope: a tube with a viewing mechanism at
the end, used to see inside hollow organs in the
body and to perform various surgical procedures
Laparoscope: a tube with a video camera
attached to the end, which is passed through a
/ Vol:8 No:8 September 2007
7/09/2007 11:07:22 AM
“Traditionally surgeons
have operated on organs
of the abdomen through a
large cut in the abdominal
wall. However, this can lead
to complications such as
infection, scarring and pain.”
small cut in the abdominal wall and used to see
inside the abdomen and to perform various surgical procedures
Laparotomy: a cut through the abdominal wall
Literature review: ASERNIP-S conducts literature reviews on the safety and effectiveness of
new surgical techniques before they are widely
accepted into the health care system. Each review
collects all relevant information, or evidence, on
new and standard techniques used to treat a medical condition. The quality of evidence is assessed.
ASERNIP-S then makes recommendations on
the safety and effectiveness of the procedures that
are then endorsed by the College.
Minimally-invasive treatment: operation accessing the site using a telescope through an opening
in the body or small cuts
NOTES: natural orifice transluminal endoscopic surgery, also known as incisionless or
“no scar” surgery
For further information on surgery in the
abdominal cavity through natural openings, please
see the full systematic review on the ASERNIP-S
website: http://www.surgeons.org/asernip-s
For more information on ASERNIP-S,
please contact: Professor Guy Maddern,
ASERNIP-S Surgical Director,
PO Box 553 Stepney,
South Australia 5069 AUSTRALIA
Phone: 61 8 8363 7513
Fax: 61 8 8362 2077
Email: [email protected]
General Surgeon
Acute and Chronic Care Services, Ref 1918
We have a unique opportunity for a part time (20 hours per week)
permanent Consultant General Surgeon with a subspecialty
interest to join our team of five general surgeons and seven junior
staff. There are options close by for additional private work or in
adjacent District Health Boards. Applicants must be eligible for
vocational registration with the Medical Council of New Zealand.
You will be responsible for participating in an on-call roster,
attendance at appropriate meetings and supervision and teaching of
junior medical staff.
Hutt Hospital is located in Lower Hutt City, 20 minutes by road
from Wellington, the capital of New Zealand. There is opportunity
for most recreational pursuits, sporting and cultural activities.
There are also excellent educational facilities available.
Hutt Valley District Health Board operates Hutt Hospital. It is a busy
285-bed district general hospital serving a population of 138,000.
We offer secondary general surgical services including upper GI,
lower GI, breast (with the Regional Breast Screening Unit) and
endocrine surgery.
For further information contact: Mr Hugh Cooke, Clinical Head
of General Surgery, phone +64 4 566 6999, fax +64 4 570 9254, or
email [email protected]
Applications close Sunday 30 September 2007.
For further information, job descriptions and application forms,
please visit our website.
www.healthyjobs.co.nz
SURGICAL NEWS P37
P36-39 SEPT SN.indd 3
/ Vol:8 No:8 September 2007
7/09/2007 11:07:31 AM
MEMBER
BENEFITS
RACS Member Advantage Services
Ph: 1300 853 324
Web: www.member-advantage.com/racs
Looking for a Credit Card that will take you on holidays?
The Lounge:
The new oasis for business travellers
Member Advantage has partnered with Virgin Blue The Lounge to offer you an exclusive one year membership
rate of $269 and a $99 joining fee. But if you join before 30 September 2007 the joining fee will be waived.
Exclusive membership to the Lounge entitles you to a host of very special services and facilities including
wireless broadband internet, premium food and beverages, Foxtel and more.
Simply join online via www.member-advantage.com/racs. Don’t forget to enter “Member
Advantage” in the company field on the online application form to ensure you get these special rates.
Alternatively, call Member Advantage on 1300 853 324 for friendly assistance.
New Car Savings
Purchase new cars at fleet prices with the Member Advantage Car Buying Service:
• Available throughout Australia in both metropolitan and country areas
• Access to every make and model, including BMW, Audi, Volvo, Land Rover, Peugot, Lexus, Jaguar, Saab
and many others
Interested?
Visit www.membership-advantage.com/racs or call 1300 853 324.
The Member Advantage Car Buying Service is provided through Automotive Fleet Management Pty Ltd
P36-39 SEPT SN.indd 4
7/09/2007 11:07:34 AM
HERITAGE
REPORT
Snuff Boxes
The College has an impressive collection of silverware
these boxes were donated by distinguished Fellows
Keith Mutimer,
Honorary Treasurer
TWO SMALL BUT significant objects in the
College’s collections are two fine snuff boxes,
one English, the other Italian.
The English snuff box was originally presented to Dr Edward Blackmore, physician
at the Plymouth Public Dispensary, for his
work during a severe outbreak of cholera at
Plymouth in 1832, which claimed over 1000
lives. There is a long inscription on the lid
which reads:
“To Edward Blackmore MD in testimony
of the gratitude and esteem of his fellow townsmen for his humane and unceasing attention to
the poor during the awful visitation of malignant
cholera at Plymouth AD 1832”
The box is made of sterling silver with
a gilt interior. It is hallmarked, bearing the
marks of the anchor (Birmingham assay),
Gothic letter J (year 1832), and the maker’s
mark NM (Nathaniel Mills).
Testimonial boxes were frequently used
in this era to express gratitude and appreciation to individuals for exceptional or devoted
service. They usually carried an engraved
dedicatory inscription on the lid. This box is
an excellent example of its type.
Nathaniel Mills (1811-1873) is recognized
as one of the greatest makers of small silver
boxes. He belonged to one of the four leading
silversmith families of Birmingham, the centre
of British silver manufacture at this time. He
brought new techniques to the industry in the
1830s, including stamping, casting and engine
turning. He made a fortune from the production of snuff boxes and vinaigrettes (perfume
boxes), and when he died in 1873, his estate
was valued at £30,000.
This box has a further inscription on the
front edge, near the clasp. It reads “W. Hall
fecit”, indicating that Hall worked for Mills,
and was of sufficient stature to be allowed to
engrave his own name on the work.
This very fine piece was presented by Gustave
Heuze Hogg in 1949. Dr Hogg (1869-1950)
P36-39 SEPT SN.indd 5
was a distinguished ophthalmic surgeon in Launceston, and a Foundation Fellow of the College.
Snuff box of Ray Last
The Italian snuff box is rectangular with
scalloped edges and made of silver. The lid is
engraved with a scene depicting the Rialto Bridge
in Venice. It is undated, but was probably made
in the late 19th or early 20th century.
The box belonged to Raymond Jack Last.
It was given to him by the Professor of Anatomy at Rome University in the 1950s. He, in
turn, gave it to A.B.N. Rao, a former student
of his in 1985 as a token of friendship.
Ray Last was one of the great teachers of
anatomy of the 20th century. He was born
in Adelaide in 1903. Born into a poor
family, he won a bursary which enabled him to enter the University of
Adelaide in 1918, and in 1919
he began medical studies.
The greatest influence on
him was the Professor of
Anatomy, Frederic Wood
Jones. Shortly before the
outbreak of World War
II he went to England to
further his studies. In 1940
he attempted to return to Australia, but his ship, the Napier Star,
was torpedoed off Iceland, and after
being rescued, he and his wife Margret
returned to England to stay.
In 1941 he participated in the liberation
of Abyssinia, and was personal physician to
Emperor Haile Selassi from 1941 to 1945.
After the War he returned to England and
became Professor of Applied Anatomy at the
Royal College of Surgeons in 1950, in succession to his old friend and mentor Wood
Jones. He held the position until his retirement in 1970, and in this rôle he taught and
inspired generations of surgical students from
all over the world.
Using Malta as a base after retirement,
he toured and lectured widely, visiting many
countries, and held the post of Visiting Professor of Anatomy at UCLA. He died in a
nursing home in the Maltese town of Sliema
after a short illness, on New Year’s Day
1993.
One of Ray Last’s idiosyncrasies was the
taking of snuff. He took up the habit in an
attempt to wean himself away from cigarettes.
Over the years he built up an impressive collection of snuff boxes, of which this is one.
This fine snuff box was presented to the College by
Narayan Rao OAM FRACS in April 2007.
Written by Geoff Down.
Snuff box of
Edward Blackmore
7/09/2007 11:07:44 AM
TRAINING
The SAT SET Course
Why you should do it!
Bruce Waxman,
Chair, SAT SET
Course Committee
IMPLICIT TO THE introduction of the Surgical Education and Training (SET) program,
is training surgeons in the methods of assessing competence and in the management of
underperforming Trainees. The educational
experience for Supervisors And Trainers in
assessing and managing Trainees in SET is the
SAT SET course.
A Trainee’s progression through SET
will be dependent on successfully completing
formative, in-training assessments in the College core competencies. Those who under
perform need to be identified early. Once
a Trainee’s under performance is identified,
objective goals need to be established, monitored regularly and achieved to avoid dismissal
from the program.
The SAT SET course gives you the opportunity to understand the process of assessment
in SET.
The course is relevant whether you are
a supervisor of training in your hospital or
region or a trainer (a surgeon who oversees
a Trainee during a regular operating list or
outpatient clinic). In SET, all supervisors and
trainers will be involved to some extent in the
assessment and management of Trainees.
How do you determine when someone
is competent? Over the past two decades
there has been increasing interest in the use
of competency-based workplace assessment to
answer this question.
Competency-based,
workplace assessment
has four key principles:
1. Validity: Assessments cover the range
of knowledge and skills needed to demonstrate competency and integrate these
with their practical application.
2. Reliability: There is consistency in the
interpretation of evidence from one
SURGICAL NEWS P40
P40-44 SEPT SN.indd 2
assessment to the next.
3. Flexibility: Assessment procedures should
provide for the recognition of competencies in a range of situations and contexts.
4.Fairness: Assessment procedures and
practices must be clear and not disadvantage any Trainee. Provision must also be
made for reassessment.
Why the change? Competency-based
assessment is evidence-based so it enables a
training program to be transparent, as the performance of a Trainee can be judged against
publicised and endorsed industry benchmarks.
Secondly, the Trainee or the assessor can
ask for an assessment within a time frame,
which allows assessment to be learner-driven.
Thirdly, the assessment tools also clearly identify the areas of unsatisfactory performance so
that support, supervision, additional training
and career advice can be provided.
Competency-based assessment tools are
being introduced into medical training to
provide more robust formative assessment, by
most colleges, here and internationally. These
tools include the Mini Clinical Examination
(mini CEX), Directly Observed Procedural
Skills (DOPS), 360-Degree Survey (MINIPAT) and Case-Based Discussion (CBD).
Some specialties have already introduced
competency-based assessment as part of their
training programs. All nine specialties support
the introduction of the SAT SET course and
encourage surgeons in their specialty to complete a course
The Provider SAT SET course is three
hours in duration. It focuses on the assessment
tools being introduced by the College; the
surgical DOPS and mini CEX. Participants are
able to practice using these tools and compare
scores. They also have an opportunity to discuss the purpose of the rotation/run Trainee
meetings, which will be integral to SET, at
the start, in the middle and at the end of each
term and explore effective feedback strategies.
The course outlines approaches to managing
underperformance and participants are introduced to a template that is used to prepare
a Trainee management plan. Supervisors and
Trainers are also able to clarify their roles in
the assessment process, and better understand
legal implications and the College policies relevant to the dismissal and appeals processes.
Surgeons who are interested in instructing
(facilitating) on SAT SET provider courses
will need to attend an all-day facilitators’ SAT
SET workshop.
There has been considerable interest
shown in this course already. In April 2007,
17 Fellows trained as course facilitators at the
inaugural SAT SET Facilitators Workshop,
and the first SAT SET Provider Course was
successfully launched this year at the ASC in
Christchurch, with forty five Fellows attending
Supervisors and Trainers play a pivotal
role in training surgeons, so it is vital that you
stay up to date with the latest developments.
SAT SET courses are being rolled out across
all states of Australia and New Zealand and all
nice specialites, over the next 12 months and
I urge you to attend a SAT SET course in the
near future, in your region and/or specialty.
The SAT SET course is managed by the
SAT SET committee which is responsible to
the Surgeons as Educators Committee and via
PDSB to the College Council. The SAT SET
committee is liaising closely with the Specialty
Societies and Boards and regions when planning and conducting Courses.
To learn more, simply Google® SAT SET or visit
the College website at www.surgeons.org then click
on Free Supervisor Training Course on the home
page in the Examinations section.
Alternatively contact Merrilyn Smith on
+613 9276 7441 or [email protected]
/ Vol:8 No:8 September 2007
7/09/2007 11:09:40 AM
PROFESSIONAL DEVELOPMENT OPPORTUNITIES
The College’s calendar of professional development opportunities continues to offer a diverse and exciting range of courses, supporting
surgeons in all aspects of their professional life. There are still places available on some courses in 2007, so come along to one of these
valuable courses available in October and November;
Beating Burnout:
SAT SET Course: Supervisor & Trainer Course
Date: 27 October, Melbourne
Cost: $200.00 CPD: 3
Dates:
The stress and demands of clinical life appear to be ever increasing
and sometimes unavoidable. Not surprisingly, clinicians are at a
higher risk of suicide, depression and substance abuse. Recognising
the competing priorities surgeons face and the challenge of the
patient and society’s view that surgeons should always be ‘on call’,
this half day workshop offers advice and practical strategies to
work towards achieving better work/ life balance.
Practice Management for Practice Managers
Date: 27 October, Melbourne
Cost: $265.00
Need to improve your time management skills? Would you
like to boost motivation and team work in your practice? Want
strategies and tips to deal with the challenges of running a
busy surgical practice? Learn all this and more at this exciting
workshop designed for surgeons and managers of surgical
practices. Participants share the challenges and solutions to
running a successful surgical practice while developing a network
of professional colleagues. Fellows are encouraged to attend with
their practice managers.
Winding Down from Surgical Practice
Date: 20 October, Melbourne
Cost: $165.00 CPD: 6
Thinking about retiring from surgical practice? Want to get a
head start on planning your future? This whole day workshop
will explore issues relevant to those retired, semi-retired or
contemplating retirement in an interactive discussion format.
Topics will include the psychosocial implications of changing
roles, implementing lifestyle change, post-operative career
options and the legal and financial issues associated with closing
a surgical practice, to name a few.
P40-44 SEPT SN.indd 3
24 November, Melbourne
3 November, Hunter Valley NSW
3 November, Brisbane
Cost: Free CPD: 3
The new SAT SET course for supervisors and trainers will provide
practical training in the effective use of workplace assessment
tools; mini CEX and surgical DOPS. Participants will also have an
opportunity to compare scores, discuss assessment feedback
and management strategies for Trainees. College policies and
processes in relation to training, particularly the appeals process,
will be addressed.
Further Information
Contact The Department of Professional Development on +61 3
9249 1106 or by email [email protected]. Or why not
visit the website at www.surgeons.org select the Fellowship and
Standards menu and then click on Professional Development.
Easy online registration is now available for all workshops.
OCTOBER
20
Winding Down from Surgical Practice
27
Practice Management for Practice Managers
27
Beating Burnout
VIC
VIC (ASM)
VIC
NOVEMBER
3
SAT SET Course
NSW (Hunter Valley)
3
SAT SET Course
QLD
17
SAT SET Course
NSW
17
Communication Skills for Cancer Clinicians
VIC
24
SAT SET Course
VIC
DECEMBER
1
SAT SET Course
WA
7/09/2007 11:09:58 AM
SUCCESSFUL
SCHOLARS
John Lowenthal Research Fellowship
Gene technology could provide a cure for epilepsy
NEUROLOGY TRAINEE DR Yi Yuen Wang,
has used the funding provided to explore the
changes of gene expression in the ictal hippocampus that may cause temporal lobe epilepsy.
Dr Wang said that while there were drug
and surgical treatments to control the condition,
there was no cure, and gene technology could
provide one. His research project is part of a Doctor of Medicine degree and has been conducted
through the Centre for Clinical Neuroscience
and Neurological Research at St Vincent’s Hospital in Melbourne.
“Epilepsy is a debilitating condition that can
cause death at its worst through asphyxiation during a seizure, but also there is considerable social
stigma attached to the condition because of those
seizures. We know the part of the brain that is
affected to cause temporal lobe epilepsy, but now
we are looking at the alteration in specific genes
that may cause it,” he said
“We believe that by identifying the genes
involved, we could find a way to target them to alter
their expression and ultimately cure the condition.”
Dr Wang said the research team, working
under the supervision of surgical director Professor Michael Murphy and medical director Professor Mark Cook, had discovered several groups of
genes that were altered when the condition was
present.
Dr Wang said mouse studies formed the
basis of his research. “We used a kindling
model of mouse temporal lobe epilepsy specifically developed from our laboratory and found
several statistically significant differentially
expressed genes. These were annotated to specifically identify groups of differentially expressed
genes and further confirmed with proteomic
studies on mice brains,” he said.
Dr Wang has researched with the support of
Professor Seong-Seng Tan at the Howard Florey
Institute. He was now in the process of finalising
his thesis and had gone back to his clinical studies in
neurosurgery. “The main purpose of my research
was to identify those genes that require further
research into their relevance to mesial temporal lobe
epilepsy.”
PROFESSIONAL STANDARDS
Surgical Competence and Performance
THE DEVELOPMENT OF BETTER processes
for assessing competence and performance
and identifying underperformance are key
College strategic imperatives. As a result,
the Surgical Competence and Performance
Working Party has been established. The
intent is to identify and remediate, rather
than adopt a punitive role when addressing
competence issues.
The Working Party consists of Fellows
from a range of specialties with an interest in
performance assessment and support mechanisms for Fellows.
The Medical Indemnity Industry Association of Australia have funded the appointment of a Project Manager to support to the
SURGICAL NEWS P42
P40-44 SEPT SN.indd 4
working party to develop the protocol. Dr
Ian Graham (general practitioner/ health
management consultant) was appointed as the
Project Manager in June 2007.
Specifically, the Surgical Competence and
Performance Working Party will address:
• Processes and tools for assessing technical and non-technical competencies
• Pathways to assist, advise, and when
necessary re-skill surgeons, including
mechanisms for addressing outliers identified by surgical audit.
• Pathways to assist surgeons who
require support for health and other
personal problems.
“So, in other words, we are just starting
the process of true experimentation. That
means that while a cure may be some time
away, at least we are now starting to know
where to look to find one.”
He said the research had already been presented at national and international conferences,
and he hoped to have his findings published in
epilepsy and basic science journals.
“I was very grateful for the opportunity provided through the scholarship to devote myself
to pure science, particularly given that I have
a family. The research has given me an understanding of the workings and processes involved
in biochemical experiments, which allows me
to further understand the pathological investigations often used in the field of neurosurgery,” Dr
Wang said.
The John Loewenthal Research Fellowship was established in honour of Sir John Loewenthal, who served as President of the College
from 1971 to 1974. It is intended to promote
surgical research.
Ian Dickinson,
Chair Competence &
Performance Working Party
• A course of action to deal with complaints or concerns raised from hospitals/ other parties and referrals from the
Medical Boards or Medical Council of
New Zealand
The Competence and Performance Protocol will be developed in consultation with
the Specialty Societies. The protocol developed will apply to other areas of the medical
profession and medical colleges, and will be
made available to the Committee of Presidents of Medical Colleges for this purpose.
I look forward to providing further details
about the competence and performance protocol, which is expected to be finalised in
March 2008.
/ Vol:8 No:8 September 2007
7/09/2007 11:10:06 AM
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P40-44 SEPT SN.indd 5
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7/09/2007 11:10:10 AM
For beautiful looking hands.
Be Ansell sure.
Moisturising surgical gloves – skincare at work
Surgical scrubbing can be harsh on your hands – causing
dryness and abrasion. Waiting until the end of the day
to care for your skin, can be uncomfortable. Now, Ansell’s
unique HydraSoft formulation moisturises your skin
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Ansell and Gammex® PF HydraSoft® are trademarks owned by Ansell Limited, or one of its affiliates.
© 2007 All Rights Reserved.
P40-44 SEPT SN.indd 6
7/09/2007 11:10:11 AM