David Gerber, M.D.

Reflections of a James IV Traveler

Prior to my fellowship numerous former travelers and members of the James IVth Association of Surgeons told me how incredible this experience would be and that the bonds that I would make would last over a lifetime as the fostering of these relationships has been the centerpiece of the fellowship. With that concept as a foundation there were clearly other elements that personally went beyond what I could have imagined. As I had planned to break my fellowship into two travel segments I took the opportunity to bring my family on the first part. At the time of the fellowship my four sons were ages: 7, 9, 12 and 13. I also had the insight to invite my wife’s mother to travel with us; knowing that I would be busy at different times through the trip I felt that it would be a great idea to have another adult to participate in this experience. This was my family’s first international trip and the first time on a plane for my sons in a number of years. Not knowing how our sons would handle the experience, my wife and I tried to prepare for as many situations as we could envision. In summation, the trip was the visit of a lifetime—I had the opportunity to genuinely learn more about healthcare in other countries while cultivating numerous new friendships. At the same time my family was soaking up the culture throughout the cities and countries we were visiting. My wife had coordinated and rented flats in every city which allowed us to integrate into the culture in a way that a hotel experience does not provide. The fact that my sons could travel for a month without fighting with each other or bickering is something that seemed inconceivable prior to leaving. They were like sponges soaking up the environment and truly enjoying each and every experience. In addition, they had their own cameras, etc. and to see the world through their collective “lenses” was exciting and insightful as we reflected on our trip after returning home. In the months after our return, each and every one of them wanted to know when we would be making another trip like that. From a personal standpoint this is a true success. I went through Australia and New Zealand without my family, much to the dismay of my sons and this provided another unique experience. I was able to integrate into the local communities and felt that I had an equally fulfilling time with the surgeons and others whom I interacted with during this part of my fellowship. At times the surreal nature of the fellowship would surface in my consciousness allowing me to appreciate the unique components of this collective travel experience. For future fellows the sage advice shared with me will remain pertinent in 2010 and beyond. It would be difficult to thank everyone that made this such a once-in-a-lifetime event but I would begin by acknowledging Tony Meyer and George Sheldon for nominating me; James Garden for opening up a network that truly has no limit and introducing my sons to Scottish culture; Russell Strong for his insights into travel, transplantation, healthcare and opening his home and lastly my wife for taking on what seemed to be a gargantuan task of mobilizing a family of 7 in the middle of the school year and helping to coordinate a trip that will remain in our collective family memory for years to come.

University of Oxford

After arriving in London early March 6th I helped my wife and sons get situated in a flat that we rented in London for the beginning of my James IVth travels. I subsequently boarded a train and headed out to the University of Oxford and Oxford Radcliffe Hospital. After my arrival and a brief walk around an outstanding college community I situated myself in lodgings at Balliol College and met with Prof Jonathan Meakins (a former James IVth traveler) and his wife, Dr. Jacqueline McClaran for dinner in the college. This was an extraordinary experience as we had the dining facility to ourselves, a level below the main eating area for the students; reminiscent of a scene from Harry Potter. Jonathan is the chair of the department originally from Canada and finishing his time as chair of the department. We enjoyed an inspirational conversation involving topics of healthcare economics, the evolution of surgeons from generalists to specialists and differences in culture at Oxford compared with McGill University. As this was the spring of 2008, and the U.S. presidential primaries were underway we also had a very animated conversation about Hilary Clinton and Barack Obama. This discussion, while it may have been the first, was certainly not the last about U.S. politics. On the morning of the 7th I presented a lecture to the students and faculty in the Nuffield Department of Surgery on Stem Cells and Regenerative Medicine. Following the lecture I had a brief tour of the hospital before meeting with Dr. David Kerr, a medical oncologist involved in the care of patients with hepatic malignancies. We compared the multidisciplinary approaches to treating these patients in the U.S. and U.K. and found many similarities. I also had the pleasure of attending their multidisciplinary conference which was similar to the conferences we have at my institution. During this time I had the pleasure of meeting Peter Friend a transplant surgeon at Oxford. Oxford doesn’t have a liver transplant program which is a bit of frustration at the institution, but the designation of transplant centers in the U.K. is performed at a national level to minimize redundancy and optimize efficiency.

University of Cambridge

After spending the weekend in London with my family and visiting friends, I made a trip to visit with Prof Andrew Bradley and his team at the University of Cambridge and Addenbrooke Hospital. I made ward rounds with the group but more importantly I had the opportunity to sit down with a group of the younger consultants and learn more about academic surgery in the U.K. The transplant program is comprised of 8 consultants and they have an active liver and kidney transplant program. Most of the surgeons had trained elsewhere in the U.K. and then come to Addenbrooke. There is collaboration between them and the program in Edinburgh (my next destination). The consultants helped me understand how certain individuals have academic appointments at the university while others are appointed to the hospital. This is important when studying their model of compensation. The consultants are on fixed salaries and a bonus structure exists based on achieving certain metrics in their professional careers. There are five categories reviewed annually and the consultant accumulates points towards salary and pension. We had time to compare the evolution of trainees in the U.S. and U.K. and everyone acknowledged a decrease in autonomy amongst the trainees. In addition to this, the groups in the U.K. are struggling with developing models for compliance under the EU 46 hour work week. Clearly there was no sympathy for the U.S.–80 hour work week. For a large clinical unit they are an incredibly collegial and close knit community.

Royal Infirmary of Edinburgh and University of Edinburgh

On March 12th, we headed from London to Edinburgh by train; a concept that seemed simple in the planning stages but more challenging in execution. We were unaware of the challenges in the U.K. rail system so when our direct train to Edinburgh stopped in Doncaster due to a power line issue we were a bit caught off guard. Fortunately my entire family maintained a positive outlook despite the weather (rain and cold) and we eventually arrived in Edinburgh about 3-4 hours later than expected. We had rented a 4th floor “walk-up” overlooking the castle. Excellent opportunity for exercise, but the rental agency waited until we hit the fourth floor to let us know that there was a heating problem with the flat and they were working on getting it fixed. Let’s say that centuries old buildings are well insulated and while the heating was never fixed, we were never cold. March 13th I headed to the RIE and began my day by meeting with Prof James Garden. James is a former traveler, current member and officer for the association. An incredibly warm and inviting individual I must begin by saying that James’ web of contacts are one of the most extensive that I have seen. James and I spent part of the morning going over the events of being a traveler while also suggesting things to do in and around Edinburgh. Although this was my first encounter with James I came to rely on him as I planned the second half of my travels. The RIE is the only liver transplant program in Scotland and James has built an incredibly robust clinical unit. There is one other large hospital in Edinburgh but their specialization focuses on neurosurgery and colorectal surgery. This model is a bit of an anathema to those of us in the U.S. but with upcoming healthcare reform and other external factors it is conceivable that we may also move to a similar model. My visit was at the new RIE (less than 5 years old) and from what everyone said, I missed a real opportunity by not being able to visit the old RIE when it was functional. After a tour of the ward I went to the theatre to observe a hepatic metastectomy. The operating room was huge and well lit with indirect lighting. I was immediately aware of an incredible rapport amongst all of the individuals in the operating room. The charge nurse was highly engaged with respect to the cases on the elective and emergency schedule and there was a coordinated fluidness about getting the patient in the operative suite, completing the case and moving the patient out that I don’t routinely see at my own institution. As the hospital is fairly young there is still room for expansion within the physical plant; a blessing for any surgical services department. During the day I met with Damian Mole, a lecturer performing basic research who took me for a tour of the research facility. The building is state of the art with an integrated design so that the researchers can easily interact with one another. It is also outstanding that the physical structure is close to the clinical unit which is conducive to cross-talk between scientists and clinicians while also being helpful to those “clinician- scientists.” In the afternoon, the team was beginning a liver transplant. The group routinely incorporates a temporary porto-systemic shunt within their practice. That evening James and his wife, Mandi, took my wife and I along with Steve Wigmore and his wife Lynn for dinner at Martin Wishart. An additional benefit was that Steve is also a James IVth traveler during this year so it gave us time to compare notes and plans. No surprise to those who know James; the restaurant was an outstanding venue and great dining experience.

The following day involved rounding on the service with James and the house officers. Following this there was coffee with James, Steve and Rowan one of the other consultants. Our discussion revolved around the role that surgeons play in medical education. This is a topic that all of them are very invested in and the breadth of the education model throughout the U.K. makes it a more engaged issue for the surgeons than in the U.S. They also provided more insights for me with respect to the economics of a surgical unit in the NHS. It is a distinctly different model than the U.S. and some surgeons maintain private lists that they manage at other hospitals. This is dependent upon the interest of the surgeon. Steve and I subsequently made a tour through his lab. It is an integrated lab that he shares with several other principal investigators. Even during one visit I could appreciate the high level of collaboration that occurs in their research environment. Very similar to the relationship that I have at UNC. This was a welcome interaction for me as Steve and I are at similar points in our careers and trying to balance basic science efforts with our clinical demands. Same challenges, no new solutions on that side of the Atlantic. The rest of the day was spent in their liver selection conference and multidisciplinary meeting for hepatobiliary patients. A very similar model to what I had seen elsewhere in the U.K. and what we have at UNC. That afternoon I gave a lecture to the surgical department on the management of hepatocellular carcinoma and the role of liver transplantation.

The weekend was upon us and our family had the chance to get a feel for many of the sights in Edinburgh and on Sunday the Gardens had us to their home for supper. Not a small undertaking considering the size of our brood. It was a great opportunity for our sons, Ann and myself; even after our return to the states my sons still talk about “Professor, Doctor Garden.”

After the weekend there was one more day at the RIE and I spent this with the basic science group. I gave a presentation with updates on our lab’s efforts to date and I spent some time with some of the researchers in the group. That afternoon I picked up my youngest son and took him for a tour of the Royal College of Surgeons Museum. What an experience, for both of us; from Burke and Hare through Conan Doyle and Joseph Bell, there was a wealth of history. While the volunteer that checked us in was concerned about the vividness of some of the exhibits, my son was fascinated and educated his 1st grade class about the Surgeon’s Museum.

Hopital Beaujon, Clichy, France

March 18th we flew from Edinburgh to Paris; “The City of Lights.” This was probably our smoothest travel to date and we settled into yet another flat, located in the 6th arrondissement a wonderful location in Paris. The next morning I took the Metro to Hopital Beaujon to meet with Jacques Belghiti, a former traveler, and my host in Paris. Jacques is a very welcoming individual and I had a very enriching experience during my days in Paris. He was able to provide insights about building his program from the ground up. Due to his efforts the hospital has a true surgical focus which has tremendous benefit for the HPB group. The liver unit has its own operating suite space, so the concern of being “bumped” is a non-issue for Jacques’ group. We discussed numerous topics from live donor liver transplantation, the professional development of his junior consultants and the ongoing challenges with EU work restrictions. My sense is that he is very committed to his faculty and trainees but less concerned about the work hours, while the individuals in the UK were more focused on this issue. Jacques coordinated an informal program for my visit; personally I had a great time and his graciousness and time with me was much appreciated. During my days at Hopital Beaujon I had the opportunity to witness a laparoscopic liver resection, redo liver transplant and several pancreatic resections. The surgeons were all highly skilled and receptive to having me as a visitor. During my stay I gave a presentation on hepatocellular carcinoma and treatment options. This allowed me to share our as yet unpublished experience with radiofrequency ablation. After the presentation I had a very stimulating dialogue with Jacques who was interested in our outcomes. He is an academic at heart and very passionate about all facets of healthcare. The time I spent with him was invaluable and helped inspire me to get our data organized and published.

Paris was an outstanding visit for my entire family. We traveled in and around the city catching all of the sights, museums, churches and gardens. We visited Sacre- Coeur, the Eiffel Tower and other typical tourist destinations. As this was my family’ s first experience in a non-English speaking country, it provided for many interesting encounters. From Paris we were heading to Barcelona for the last leg of the European half of my travels. Somewhere in my mind I recalled the joy of traveling Europe by train so we decided to take the TGV as far south as possible in France and then rent a car to drive to Barcelona. Unfortunately when we were in the U.K. we were informed that there was no vehicle available for my family’s size so we decided to train the entire way. As I was making my arrangements in Paris, Jacques’ senior registrar was surprised that I wouldn’t just fly since it was much quicker. Nevertheless we wanted to enjoy the scenery so early the next morning we headed to the train station and took the TGV to Perpignon in the south of France. From there we took the equivalent of a “mule train” to Port Bou. This was a cramped local train and provided yet another experience for the Gerber clan. The train was brought to a stop on the way to the border and the French gendarme boarded, requesting passports and documentation. I had been separated from the rest of the family due to space constraints and I was also separated from my passport. Fortunately I don’t look suspicious and certainly not as menacing as the two individuals sitting next to my son. They were promptly removed from the train for “papers not in order” or at least that was how it was translated to my wife by the individual sitting next to her. We finally made it to Port Bou for our last leg to Barcelona. Not realizing that this was also a local train, we started the ride with lots of space but as we approached Barcelona it became more and more crowded until my sons were sitting on each others’ laps and the elderly couple with the barking dog was crowding their space. My sons’ consensus was that next time they are in Europe they would rather fly from one destination to the next.

Hospital Clinic, Barcelona

On March 25th I headed to the Hospital Clinic in Barcelona. This is one of the largest hepatocellular programs and very highly regarded. There was no James IVth member to host this part of my trip and I couldn’t see that there were any former travelers but I was fortunate that through a connection at UNC I got linked with a liver transplant surgeon, Constantino Fonde. He is a junior consultant in the group and a rising academic star. It was a “great find” for me as he was a great host and prepared an excellent itinerary. During my stay I visited the surgical suites, ICU and wards. I also had a lot of time with the medical students and gave a lecture on Surgical Education in the U.S. This was an exciting topic for their students and their faculty and it initiated a vibrant discussion. I also had time to meet a group of the researchers while I was Barcelona and had a similar presentation opportunity to share our lab’s activities in stem cell biology. The group in Barcelona, and the rest of Spain, are struggling with the EU work force issues and I see where the commitment to surgery has waned amongst their top graduates who are not inspired for an academic career because of the increasing burdens that they see amongst the consultants. While I believe that I was the first traveler that this group has had, I hope that others follow me because it was a great time.

From Barcelona we headed back to Chapel Hill to return to work and begin planning the second half of my travels. I had previously decided after some discussion with former travelers that I wanted to head towards Australia and New Zealand for the remainder of my fellowship. Due to numerous transitions in my home unit and the time of the year, I ended up scheduling my travels to Australia and New Zealand to occur from the end of January 2009 through February 2009.

I headed to Australia in the end of January 2009, no small feat coming out of Chapel Hill as it takes two flights just to get to LAX. Despite the economic downturn, my flight (in the economy section of the plane) was packed, so not a lot of opportunity to stretch out. This was confounded by the fact that my luggage ended up missing the flight and would reunite with me in Australia the next day, not an uncommon experience for fliers on Qantas. The upside is that Qantas provided me with $100AUD for the inconvenience.

Princess Alexandra Hospital Brisbane, Australia

I started this leg of my fellowship in Brisbane, Queensland. My host in Brisbane was Russell Strong (a former traveler) and his wife Jude. I had been connected with Russell through the chair of my department of surgery, Tony Meyer and George Sheldon (previous chair of my department). They had supported my nomination as a fellow and had made acquaintances with Russell years earlier when they were still at UCSF. In my email exchanges with Russell, he had invited me to stay at their home; a wonderful invitation that provided me with a unique perspective on life in Australia. I was going to be in Brisbane from January 27 through February 1; also Russell’s suggestion. After my morning arrival we headed to the hospital (a little sleep-deprived) where I had the chance to meet the individuals that help run Queenslanders Donate, which is the national organization that helps coordinate organ donation and allocation. Russell is the medical director of the organization and it was a unique opportunity to learn about the similarities and differences between the organ allocation process in Australia versus the U.S. Australia and New Zealand have a sharing system and organs are locally allocated to a center first in comparison to the U.S. model which is a patient driven model within the local organ procurement organizations. The politics of organ allocation are very similar the world over and it was comforting that all of us struggle with the same issues. During the afternoon I met David Gwaltney, also a former traveler and some of the members of the hepatobiliary group at PA. During my visit I was able to observe a laparoscopic right hemi-hepatectomy performed by Shinn Yeung. It was one of their first lap liver cases and the patient selection was optimal for the procedure. I also met Steve Lynch, Chairman of the Department of Surgery and a former transplant fellow at the University of Pittsburgh. Since I had been a medical student at Pitt and involved in transplantation during those years, Steve and I realized that we had numerous acquaintances and this provided a tremendous amount of entertainment as we shared many “war stories” from Pitt and the Starzl era. This was supplemented by Russell’s own experiences at Pitt during the mid-80’s. During my visit I was received firsthand insights into their early experiences with adult to pediatric living donor liver transplantation. I also was treated to an incredible experience in the Strong household and on the weekend after spending several days in the hospital we made a day trip along the Sunshine Coast. I finished out my stay in Brisbane with an evening dinner at the Strong’s with the other surgeons from the group. As with other segments of my travels I had an incredible amount of one-on-one time with individual surgeons and groups. The folks in Brisbane are facing the same issues of a changing culture in medicine. Some of these changes are easier to incorporate into the daily practice while others are not. Part of the experience of being a traveler involves the dynamics of the people who you visit. This was very true throughout Australia as I developed an appreciation for how close the hepatobiliary community is throughout the country. The night of our group dinner at the Strong’s it came up that I would be traveling to Adelaide as my next destination. James Garden had given me Rob Padbury’s name as a key individual to visit and someone who would “take care of me” during my visit. Rob has a reputation in many areas, not the least of which is his role as an oenophile with an extraordinary wine cellar. During that last dinner in Brisbane, Steve Lynch (ever the practical jokester) called Rob to tell him that I was impressing the locals with my extensive knowledge of wine. It should be noted that this is not an area of expertise that I can lay claim to, but that wasn’t important to Steve as he “rattled Rob Padbury” prior to my arrival. I have to add an extra acknowledgement related to this part of my trip. In addition to the Strong’s inviting me to stay at their home Jude prepared dinner for us every evening which covered a variety of meals and wines and a Pavlova for dessert on my last evening in town. This experience was unique and the genuineness of the Strongs greatly enhanced my time in Brisbane.

Flinders Hospital, Adelaide

On Sunday, February 1 I flew to Adelaide to spend several days with the group at Flinders. Rob Padbury picked me up at the airport and I will add that we had a funny encounter at the hotel as the clerk made the assumption that we were partners. I should add that Rob also has four children whom I had the chance to meet later that day. After getting settled at the hotel we headed to Rob’s home, just outside of downtown. While it was summer in Australia, I hit a period where it was exceedingly warm, so our day was limited to a tour in the wine region outside of Adelaide and a return to the Padbury’s so we could cool off in their pool. As I was unfortunately not traveling with my family on this leg of the trip, I welcomed the balance that Rob’s four children brought to the day and after being introduced to his wine cellar I had much greater insight into why this part of his reputation is worldwide in the surgical community. I capped the first night by having an outstanding dinner with Rob and Jenny. During the next couple of days I traveled in Flinders’ Medical Center and had the opportunity to participate in the multidisciplinary settings of the liver group and made rounds with the clinical service. I also visited the group at the Royal Adelaide as Rob has expanded the group’s footprint for hepatobiliary. Rob has an interest in continuous quality improvement and we were able to sit and discuss different strategies that are being tried at his medical center compared with approaches that I have been involved with at UNC.

From Adelaide it was off to Melbourne where Ben Thomson was my host. Ben is a former fellow from Edinburgh and James Garden introduced us. Ben is a few years younger than me, originally from Adelaide I believe, but he moved around as a youth due to his father’s medical career and he subsequently did most of his education and training in Melbourne. After his fellowship in Edinburgh he returned to Melbourne and currently has clinical practices at the Royal Melbourne and Peter Mac. Ben really took charge of my schedule (much appreciated) and organized a great several days for me. During my time I rounded with the housestaff and spent a lot of time with them collectively and as individuals. I also had the opportunity to meet some of the other surgeons including his partner, Simon Banting. I also met Bruce Mann, one of the endocrine surgeons at the Royal Melbourne and Bruce was just selected to be a James IVth traveler during the upcoming year. It was a great opportunity for both of us as I was able to share some of my own experiences and thoughts about planning for a James IVth traveler. I was also probably the third traveler in a very short period of time to visit the group in Melbourne. They were great sports for having so many travelers in a short period of time. As with other healthcare models that I was introduced to during my travels, these surgeons have commitments through the national health system and they supplement their academic time with private lists. This is an atypical concept for the U.S. academic surgeon where most of us are typically employed by a medical center and practice at the hospitals affiliated with the medical center. At the end of my time in Melbourne, Ben had arranged a visit with Christopher Christophi at the Austin Hospital in Melbourne. They have the only liver transplant program in town and during the day at the Austin I was able to interact with a number of students, registrars and academic researchers. I will add that our conversations during the day and over dinners involved the changing economic times and recent election of Barack Obama as president of the U.S. There is clearly a close identification for the Australians with the UK, but they are also very closely aligned to the U.S. on many issues and almost everyone spoke to this throughout my visit in Australia. After completing my trip in Melbourne it was time to travel to New Zealand. On the day I left Melbourne, February 7, they had the hottest recorded temps 47°C. While we don’t use Celsius for our ambient temperature in the U.S., it didn’t take me long to figure that this was around 117° F. It was also the day that the bushfires began around Melbourne. Unfortunately I learned after my return home that Ben lost a farm, but thankfully no one was personally injured. Possibly due to the heat, we had a travel snafu with an engine that blew up en route to Auckland so we ended up spending an additional 12 hours on the ground waiting for a replacement plane. I finally arrived in Auckland, NZ early the next morning.

Auckland, New Zealand

Auckland City Hospital, University of Auckland

On February 8 I arrived in Auckland. This would be the last destination of my fellowship. I had never been to New Zealand, but it gave me a chance to see Bill Hecker, a friend and former co-fellow from my time at UPMC. Bill is a kidney transplant surgeon on staff at the Auckland City Hospital. New Zealand is smaller than Australia in population and they have one liver transplant program in the country, located at the Auckland City Hospital. They are part of the bigger organ allocation network with Australia, but I imagine that the logistics of transporting organs is a little more nuanced for these units than in the states due to international issues. My host in Auckland was John Windsor, head of the department of surgery at the University of Auckland. John has a clinical interest in pancreatic surgery and is a very innovative thinker. He has spearheaded a project based on technology innovation where the unit at Auckland is using “Second Life” to create an education module that simulates the clinical activities of their unit. The opportunities provided by this type of unique thinking are limitless as the IT developments continue to improve and provide advances in medical education at all levels. John is from Auckland, but grew up for a number of years in India as his father was a medical missionary. He clearly has a global perspective and I had a number of high quality exchanges with him. I again thank James Garden for the introduction to John.

For those who have never traveled to New Zealand, it is a spectacular country. I spent my time on the North Island, in and around Auckland which the locals said was not nearly as enriching as the rest of the country. I guess that I will have to make another trip in the future. During my first day at Auckland I met with the research fellows and had a great session discussing the roles of surgeon- scientists and differences between academic life in the U.S. versus the local environment. That afternoon I met with Ian Civil, MBBE; director of surgery and trauma at ACH, and rumored to be a candidate for the president of the RCACS. Ian had spent some time in the U.S. during his earlier years, primarily in New Jersey and Indiana. The following day I met with Steve Munn, the head of the abdominal transplant program, and a former fellow at Mayo. Steve’s role involves many of the same features as that of a comprehensive transplant director in the U. S. While in the U.S. we are typically negotiating with the leadership of our individual healthcare system for additional resources, Steve’s negotiations occur at a government level because of the role that national healthcare plays. The incidence of fulminant hepatic failure patients seems higher in NZ than what we see and it is interesting to see that they philosophically use adult living donation as a primary means for OLT in this subset, whereas in the U.S. this has been an area of concern due to issues of informed consent, emotional coercion and having the time to fully understand the risks of living liver donation. The challenge in NZ is the shortage of donor organs that drives this living donor process. I also spent time in the operating room with John Windsor and one of Steve’s partners, John McColl. Ironically both surgeons were performing splenectomies and I could appreciate that there are delays in their system similar to my own when it comes to turnover. I also became aware of an increased burden of documentation for the consultants. This is similar to what we are seeing in the U.S. although there are slight differences with the processes. John had scheduled my days so that I would have the opportunity for travel time, which I spent traveling around Auckland, learning more about the culture. As this is a major port city there were numerous cruises docking with tourists, mostly seniors from the U.S., Canada, the U.K. and Australia. On my third day in Auckland I participated in the daily clinical activities of John’s unit. They have a weekly process that involves the nursing staff, registrars, attending, and other members of the healthcare team. This is very similar to processes that our own hospital has adopted in an effort to provide enhanced communication and more efficiency with respect to a patient’s hospitalization. While length of stay is not as critical an issue in Auckland, communication contributes to an improvement in outcomes everywhere in healthcare. That afternoon I met Rod Dunbar, an outstanding and accomplished young investigator at the University of Auckland. Rod has a medical degree but is primarily a researcher with a focus on cell biology cell-cell interactions and melanoma. He is incredibly successful and partners with clinicians from the academic units. It is an advantage for Rod that he truly understands the role of clinicians and science. Rod and I spent hours that day sharing ideas; a real plus for my visit. On my last day in Auckland I presented a lecture on stem cells and regenerative medicine after which I headed to the airport for my journey back home.

In closing, while this may be a somewhat extensive monologue of my travels; the trip can only be defined as a “once-in-a-lifetime” experience as our world becomes more fast-paced with little time to reflect.