Edward E. Whang, M.D.

INTRODUCTION

My James IV Traveling Fellowship allowed me to visit academic Departments of Surgery in the Republic of Ireland, the United Kingdom (Scotland and England), Germany, South Africa, China (Hong Kong and Beijing), South Korea, and Japan.

I approached this experience as a once-in-a-lifetime opportunity to gain a global perspective on surgery. As a result, my travels exceeded the usual scope of this fellowship, both in duration and in number of countries visited. I was rewarded with the opportunity to meet a remarkable group of surgeons who, while facing unique challenges, are each profoundly committed to their patients and to our profession. I will be forever grateful to these individuals (who included both James IV members and those unaffiliated with this association) for their openness and hospitality.

In this report, I begin with a narrative of my visits. Then I summarize key observations. Finally, I acknowledge those who made this extraordinary experience possible.

REPUBLIC OF IRELAND

I began my travels by spending the first week of July 2007 in Dublin. My host Professor Arnie Hill, Chairman of Surgery at the Royal College of Surgeons in Ireland (RCSI) and a former James IV Traveler, had arranged an itinerary for me that included not only his own institution, but also two of the other major teaching hospitals in Dublin. I had met Arnie earlier in the year, when I attended the Society of Research and Academic Surgery meeting in Cambridge, UK, to deliver the annual British Journal of Surgery lecture. Arnie’s enthusiastic invitation for me to learn about surgery in Dublin was an offer I couldn’t refuse.

My first visit took place at Mater Misericordiae University Hospital (also known as Mater Hospital). Professor Tom Gorey, a distinguished surgeon who had completed a portion of his training at Johns Hopkins Hospital, was my guide. I toured the hospital, made rounds with the hepato-pancreato-biliary (HPB) service, attended breast multi-disciplinary conference, and observed operations.

Three observations struck me during my visit at Mater Hospital. First, private and public patients are geographically segregated. Private surgical patients undergo surgery and receive inpatient care in a separate, but adjacent, building from that which houses the public patients. Surgical registrars’ duties are limited to the care of public patients. What this means is that consultant surgeons (who take responsibility for both private and public patients) perform their private operations and provide much of the associated postoperative care for these patients without the help of trainees. For complex private cases, trainees can be invited to assist, but they are considered “moonlighters” and must be compensated accordingly. Second, the distribution of surgical responsibilities among the consultants differs from that to which I am accustomed. For example, I met “oncoplastic” surgeons: surgical oncology-plastic surgery hybrids who perform their own post-mastectomy reconstructions. These same surgeons who specialize in elective breast surgery also provide a considerable portion of emergency and trauma surgery care (I also saw this pattern at the other Dublin hospitals I visited). Third, there was a remarkable emphasis on multi-disciplinary teams and conferences (more on this topic later).

I then visited St. Vincent’s Hospital, where Enda McDermott, a breast surgeon who had completed fellowship training at Memorial Sloan-Kettering Cancer Center, was my guide. Just before my Grand Rounds lecture on pancreatic cancer, one of the registrars presented the case of a patient with a metastatic carotid body tumor. I was asked to give an impromptu scholarly discussion on this topic to the Department. There must be an art to giving commentary on subjects about which one knows absolutely nothing. Unfortunately, as I learned, I had yet to master this art.

After Grand Rounds, I attended “Dry Rounds” during which consultants, trainees, and nurses met in a conference room to discuss the inpatients, ward-by-ward. I was surprised to hear of patients who were in their 10th postoperative day following mastectomy, with the stated reason for their prolonged in-hospital stay being that they still had a surgical drain in place. Clearly, “drive-through mastectomies” do not occur at St. Vincent’s. I was also surprised to learn of an evolving approach to the management of perforated sigmoid diverticulitis: laparosocopy with wash-out and antibiotic administration (without colonic resection or diversion). I look forward to seeing the data that validates this approach.

We also visited the breast clinics, where I saw how peculiarities of governmental funding mechanisms can distort surgical care. In the Republic of Ireland, screening for breast cancer is a national mandate, and accordingly is funded generously. A public patient whose minute breast cancer is detected through screening is seen in the elegant “screening clinic” and undergoes expeditious surgery. In contrast, a patient with large cancer found on self- examination is seen in the comparatively dilapidated “symptomatic clinic” and typically undergoes surgery only after a prolonged wait, much later than the first patient.

The last hospital I was to visit in Dublin was Beaumont Hospital, the main teaching hospital of the RCSI. I attended a research meeting with Arnie, who directs a laboratory-based research program on breast cancer biology, and gave Grand Rounds. I also participated in “Dry Rounds,” during which all of the surgical patients were presented by 1st-year medical students. I found the depth of their clinical knowledge and the degree to which Arnie held them accountable for the care of their patients extraordinary. I thought I was listening to interns presenting, before I was told they were 1st-year medical students. I was observing an innovation at RCSI, in which medical students undergo “intensive clinical immersion” very early in their curriculum, even before exposure to the basic sciences. I completed my visit by touring the historic buildings of the academic campus of the RCSI, after which I heard presentations from the surgical research fellows and basic scientists.

Of all surgical chairmen I’ve met, Arnie is, without a doubt, the most focused on medical student education. He is exceptionally devoted to his students, and they to him. He is the perfect fit for his role as chair of surgery at the RCSI, for that institution as a whole seems to have medical student education as its core mission. It has invested in innovations that may change the nature and duration of medical school education in Ireland. Furthermore, the RCSI is taking its program global; it has opened medical school campuses in Malaysia, Bahrain, and Malta. I think this institution bears watching.

To complete my Irish experience, Arnie and his colleagues treated me to a genuine Irish pub and some fine Irish food (including my first and last taste of rhubarb). In addition, I saw the spectacular Cliffs of Moher on the Western coast of Ireland, Trim castle (for which Arnie recruited Enda Kelly, his top student, to serve as my tour guide), and, of course, the Guinness brewery, which is the dominant feature of the Dublin skyline.

SCOTLAND

After my wonderful week in Dublin, I flew to Edinburgh, where Professor OJ Garden was my host. Although this would be my third visit to Edinburgh, I still looked forward to returning to this beautiful city with great anticipation.

I began my Scottish week in the operating theatres of the Royal Edinburgh Infirmary. I found the new facilities of this institution to be magnificent. Anyone planning to design a new hospital would do well to visit Edinburgh. Being in the hospital evoked a sense of beauty, space, and tranquility. And it is surgeon-friendly. For example, each of the spacious operating rooms has an adjacent smaller room in which anesthesia is induced. While a team of surgeons is completing an operation (perhaps closing a laparotomy wound), the patient scheduled to undergo the next operation is already being anesthetized in the adjacent induction room. You can imagine how efficient operating room turnovers are (I later would see similar OR anatomy and efficiency in Heidelberg).

The operations I observed included liver and pancreatic resections. The procedures consisted of precise anatomical dissection, with minimal blood loss, even with the trainees doing the majority of the cases. The operating room environment was among the best and most stress-free I’ve seen. Even during the most difficult moments of the cases I observed, there occurred non-stop teaching and witty exchanges among the consultants, trainees and theatre sisters (scrub nurses). Lest you think I’m being too generous with my praise, I will note that (Prof) James had selected only thin (pediatric-like) patients for the cases to which I was assigned.

I gave a Grand Rounds lecture and, in turn, had the opportunity to hear research presentations from many members of the surgical faculty. One concept of which I had not previously heard is “ERAS” (Early Recovery after Surgery). ERAS, as explained to me by Professor Kenneth Fearon, is a comprehensive approach to promoting rapid recovery after major operations that has been receiving increasing attention in Europe. It includes components that would be familiar in the United States, such as elimination of nasogastric tubes and early ambulation, as well as some seemingly unusual items, such as perioperative “laxation” and preoperative carbohydrate-loading. Incidentally, Prof Fearon was himself a James IV Traveler, who during his travels spent much time in the laboratory of Douglas Wilmore at the Brigham & Women’s Hospital (in the same physical space where my laboratory is located today). When I learned Prof Fearon had been a James IV traveler, I felt what I continue to feel when I encounter a former traveler: an instantaneous bond that transcends time and place.

This Boston-Edinburgh connection may continue, for Mark Duxbury has joined the Surgical Department in Edinburgh as a clinical lecturer. Mark is a UK-trained surgeon who spent two years with me in Boston as a research fellow. He is superstar of whom I’m sure you will be hearing much in years to come. Among the highlights of my visit to Edinburgh was the opportunity to spend time together with Mark and James discussing surgery and research. Another highlight was wining and dining with various faculty (including the eternal Sir David Carter), operating theatre personnel, and trainees at the best restaurants in Edinburgh. Being someone who usually skips dessert, I will forever remember having a soufflé on each of three successive nights in Scotland.

I also spent two days during this week at the Royal Glasgow Infirmary, where my host was Ross Carter. Glasgow isn’t immediately visually appealing in the way Edinburgh is, but a drive with Ross revealed glorious countryside and Loch Lomond just minutes outside the city center. I had arrived shortly after the Glasgow airport terrorism incident – the one masterminded, to a large extent, by foreign physicians working in the UK. One of the perpetrators of the incident (who later was to die of burn injury) was hospitalized in the ICU of the Royal Glasgow Infirmary during my visit. Heightened security was visible but didn’t interfere with my visit.

Ross is a member of a remarkable team that provides the highest level of care for pancreatic diseases. Clem Imrie, a giant in pancreatology, is the father figure of this team; he recently has retired but can’t seem to stay away from the hospital. The current team includes Colin McKay and Euan Dickson. The Glasgow pancreatic unit is a model for team- and disease-based care. They share patients, work together, and learn from (rather than compete against) each other. They also have mastery of the full spectrum of tools necessary for care of patients with pancreatic disorders. For example, the same individuals perform aggressive resections for pancreatic cancer, complex ERCP-based procedures for chronic pancreatitis, and innovative minimally-invasive debridements for necrotizing pancreatitis. Neither time nor energy need be wasted on intra-team or inter-specialty- related turf battles. Patients benefit from this arrangement. Those fortunate enough to be treated by this team get access to not just a single surgeon, they get access to the entire team’s skills and experience.

One observation that struck me was the absence of white coats at Glasgow Royal Infirmary. The housestaff appeared to be wearing street clothes (in some cases jeans and t-shirts). In fact, such attire is not unusual in the UK. As of January 2008, a new NHS policy underwent implementation in England that bans physicians from wearing white coats, long-sleeved shirts, ties, and wristwatches during patient encounters. These items, because they are rarely, if ever, washed, are believed to promote transmission of infectious organisms from patient-to-patient. It is ironic that the physician’s white coat (which is associated with cleanliness in the United States) is now believed to be a vector of infectious disease in the UK. It is also ironic that I first became aware of this belief at the very hospital where Joseph Lister introduced the concepts of surgical asepsis.

I suggest U.S. readers of this report ask their housestaff how often they change or launder their white coats. I was shocked at some of the answers I received when I returned to Boston. One resident (one of our best) admitted to having worn the same white coat without a single wash for his entire internship year!

ENGLAND

I spent the third week of my fellowship in England, divided evenly between Liverpool and Oxford. My visit to the Royal Liverpool University Hospital started inauspiciously. Immediately in front of the hospital, I was attacked by a particularly aggressive albatross. Covered in albatross droppings, I then was required to undergo a formal medical examination and provide documentation of immunizations before I could continue my visit.

I had come to meet Professor John Neoptolemos, Department Chairman and leader of the highly successful, important, and controversial (at least in the United States) ESPAC trials in pancreatic cancer. He was a charming and enthusiastic host with some colorful traits I can’t but help relating in this report. First, he is a contrarian. I observed him disciplining one of his interns for not wearing a white coat (I was surprised, given the new NHS policies that forbid physicians from wearing white coats). Second, he has a passion for ballroom dancing that manifests itself at unexpected moments. For example, our rounds on patients with acute pancreatitis were interrupted several times by his spontaneous and unprovoked demonstrations of dance steps (each lasting at least 10 seconds in duration). Third, he stands on his tip-toes whenever he is in a group photograph. Thus, in the photograph his secretary took of the two of us, he appears taller than me (in reality, he is several inches shorter than me). Prior to my taking a photograph of him with his senior registrar (James Gardner-Thorpe, another superstar UK surgeon who had completed a research fellowship with me in Boston and is quite tall), he stood on his tip-toes and directed James to bend his knees so that in the photo, he again appears to be the taller. Finally, I was surprised by the degree to which this surgical Chairman is committed to basic research. His office is immediately surrounded by cell and molecular biology laboratories, in which 30 of his Department’s scientists study the biology of pancreatic cancer. For my Grand Rounds lecture, he told me to discuss only basic science; he advised me that the audience would walk out on me if I discussed anything related to surgery. I found this request intriguing but unique among my travels. This request also required me to stay up at night formatting a new lecture on my laptop at the last minute, as I had left my basic science slides in Boston.

My only regret was missing the opportunity to observe (Prof) John performing a Whipple procedure (I’m sure that experience would have yielded important lessons and fascinating anecdotes). I had been scheduled to join him in the operating theater the final day of my visit. However, the night before, he had diagnosed an incarcerated femoral hernia in his wife. He came for my morning Grand Rounds lecture, but then cancelled his operation so that he could attend to his wife. I took the opportunity to visit the Liverpool Cancer Research Centre, from which John chairs the ESPAC trials. Sometimes you can sense quality in the air – I got just such a sense as soon as I walked into the Cancer Research Centre. The facilities and people I met there were superb, and I found myself wondering my no centers in the United States participate in the ESPAC trials.

After a much needed overnight respite in Bath, during which I sampled the healing waters, I arrived in Oxford. As long as I can remember, I had wanted to visit this center of learning and scholarship. And now, not only would I be visiting, I would also be giving a Grand Rounds lecture at John Radcliffe Hospital, at the oldest university in the English-speaking world! Jonathan Meakins, the Department Chairman, was my host and had made arrangements for me to stay at Balliol College. Founded in 1263, Balliol is one of three oldest constituent colleges comprising Oxford University. My room was located directly over a magnificent dining hall that appeared to be straight out of a Harry Potter movie.

Highlights of my visit included in participating in morbidity and mortality conference and a Department administrative conference, both of which were virtually identical to their counterparts at my hospital. During these conferences, I noticed someone who looked vaguely familiar. Then I recognized her to be Linda Hands (perfectly named for a surgeon). Linda was the vascular surgery fellow at the University of Chicago when I was a senior student rotating on her service. She was a great teacher then, so I wasn’t surprised to learn that she is now a successful academic vascular surgeon at Oxford. I was pleasantly surprised, however, to learn that she herself recently had been a James IV Traveler and that she had included Brigham & Women’s Hospital in her fellowship travels.

It was at Oxford where I realized the value of the UK emphasis on multi-disciplinary teams. I learned that in the UK, as a matter of national policy, prior to any patient undergoing major cancer surgery, his or her case must be presented and discussed in a multi-disciplinary conference. These conferences are more than mere formalities; I observed care plans being completely reversed. These types of conferences do exist to some extent in the United States, particularly in specialty centers, but even at my hospital, only a minority of cancer cases is discussed in such a format. I will have more to say on this issue later.

I also enjoyed discussions with (Prof) Jonathan, his wife, and colleagues at their gentrified home and at their neighborhood gastropub on the future of academic surgery. Jonathan believes basic science will play a diminishing role in the academic Department of Surgery of the future, and he encouraged me to add to my own research portfolio new lines of investigation that are immediately relevant to clinical practice. His hint that surgical decision- making is an area ripe for surgical scholarship is one I will remember.

In the final morning of my English week, the rains began. The rains were heavy enough to cause severe flooding in Oxfordshire and the surrounding region. Heathrow airport was in pandemonium, with virtually every outbound flight (including mine to Germany) having been cancelled. Even the London tube system was in chaos. Fortunately, the Eurostar was still operational, and I was able to reach the continent with only minor delay.

GERMANY

Following an unscheduled overnight layover in Brussels (a Eurostar terminus), I was able to reach Heidelberg by train. Heidelberg is a beautiful city straddling the Neckar river. Similar to Edinburgh, it has a magnificent castle that dominates the skyline. It was easy to imagine myself a modern-day Mark Twain, as I ambled around the castle and on the Philosphenweg. The University of Heidelberg, founded in 1386, rivals the University of Oxford in being among the oldest institutions of higher learning in Europe.

I had added Heidelberg to my itinerary because it, as far as I can tell, has the highest- volume pancreatic cancer surgery program in the world. They also have 50 scientists and an entire building devoted to pancreatic cancer research. Markus Buechler, my host, and his Department perform over 500 pancreatectomies annually. Each day of my half-week visit, I observed at least 5 pancreatic resections daily. The opportunity to scrub in and assist (Prof) Marcus was among the highpoints of my fellowship.

Several observations remain foremost in my mind. First, I encountered the Visceral Surgeon. I observed this specialist performing major pancreatic and liver resections, colorectal surgery for cancer and for inflammatory bowel disease, minimally-invasive bariatric procedures (laparoscopic sleeve gastrectomy, which has supplanted the lap band as the bariatric procedure of choice in Heidelberg and likely will do so in the U.S. in the near future), thoracotomies for parathyroid disease, and solid-organ transplantation. I observed not only advanced technical expertise but also unexpectedly profound understanding of disease processes and management options for the very large body of conditions this specialist treats.

Second, I observed a training paradigm very different from ours. The residents, even in their final year of training, do nothing more in the operating room than retract. They place not even one stitch. Only after they finish residency (which is not of fixed duration but ends only when Marcus deems them ready), do they actually begin to operate (by this time their hunger to operate must be prodigious). On the other hand, formal training continues (and perhaps begins) at the attending level. Each attending receives intensive intraoperative mentoring from his seniors that stops only when (if) he becomes the Department chair. I observed Marcus to check in on and make key decisions for each operation. Decisions such as “colostomy versus primary anastomosis” or “proceed with resection versus perform palliative bypass” required the chairman’s approval. Jan Schmidt, the Vice-Chairman, acted almost like a literal “chief operating officer,” shuttling from room-to-room, scrubbing in whenever a difficulty was encountered by the more junior attendings. What I observed could be interpreted as being consistent with the rigid hierarchical structure normally thought to be a defining feature of German surgery. On the other hand, I can’t but help think this system effectively promotes quality control. Obviously, this sort of system also allows the Chairman to exert tremendous influence, at many levels. I observed extremely aggressive surgery for pancreatic cancer; I heard the phrase, “nothing is unresectable” repeatedly. Amazingly, the presence of up to three liver metastases found intraoperatively is no contraindication to pancreaticoduodenectomy in Heidelberg.

Third, I observed a remarkable degree of transparency. For example, intraoperative photographs documenting key stages of each procedure are taken, and copies of these photographs, together with specimen photographs and dictated reports, are mailed to referring physicians. Referring physicians are also allowed to join their patients in the operating room. During my visit, a Russian VIP’s personal surgeon scrubbed in, to get a better view of Marcus’s technique during his patient’s exploration for locally-advanced pancreatic cancer. The Heidelberg surgeons were also completely open in discussing the challenges they face, including the strike in which they had recently participated. They felt justified in their actions and had the support of the Marcus (who did not participate), for they were striking for the sake of their profession, not for personal gain.

Just before leaving Heidelberg, I spent some time with Marcus in his office. The previous night, we had shared the two vices in which he admits indulging. One is cigar smoking. The other is riding in his custom-made Mercedes. I received some wise and practical career advice, and he encouraged me to participate in scientific and surgical collaborations. He has several pictures prominently displayed in his office, one of which is of his mentor Hans Beger. Another is a photograph depicting an operation by the Nobel laureate Theodor Kocher. Also shown in this photograph is a young William Stewart Halsted, who visited Theodor Kocher’s Department during one of his early travels to Europe. I got the impression that Marcus views himself a modern-day Kocher; in fact, he previously held the same chair Kocher once had held in Bern. For the briefest moment of reverie, I fantasized being a modern-day Halsted visiting this modern-day Kocher………and I had a photograph of us taken for posterity.

INTERLUDE

After a brief detour for a hike in the Bernese Oberland region of Switzerland (to which I am repeatedly drawn), I returned to my duties in Boston. Between the two legs of my fellowship, I had much catching up to do. However, I did take a break by attending a surgical meeting in Ecuador, in the Galapagos Islands, with two of my research fellows. Wandering among the diverse fauna in its natural setting, I began to wonder what observations Charles Darwin (I had visited the building where he lodged while he was a medical student at the University of Edinburgh) would make were he to undertake a James IV Traveling fellowship today. Do unique local selective pressures allow certain surgical practices to flourish and cause others to become extinct? Can one understand the laws of surgical evolution and use them to make predictions and direct policies?

During this meeting I got to know Nestor Gomez, who is a dynamic Ecuadorian surgeon (he had trained in Germany and is now a governor of the American College of Surgeons). We had a fascinating discussion on malpractice in Ecuador. There, surgeons accused of malpractice are jailed first; questions are asked later. They are guilty until proven innocent. Given the indescribable things that happen in South American jails and the slow pace of legal deliberation, Ecuadorian surgeons, when faced with even the hint of an accusation of malpractice, must flee (out of the country for those with means, and into the jungle for those without). I wondered how surgery would evolve under such harsh selective pressure, or would it undergo extinction?

In October, I attended the Clinical Congress of the American College of Surgeons in New Orleans, during I enjoyed the James IV banquet and presented a report on the first half of my travels to the members of the James IV Association. The day after giving my report, I began the second leg of my fellowship.

SOUTH AFRICA

With an around-the-world airplane ticket in hand, I felt like less like Twain, Halsted, or even Darwin and more like Phileas Fogg, as I set out on my circumnavigation of the globe.

Following a layover in Munich, I arrived at my destination. Having read much of the worsening violence in Johannesburg, I went straight to the Protea Wanderers Club, a gated site where the South African HPB Meeting was being held, and didn’t leave during the entire duration of the meeting. My concerns were validated when I learned that a speaker in the session following one of my lectures would be absent. This speaker (a distinguished academic pathologist) was unable to attend because several days earlier, he and his family had suffered a violent attack in their home of a nature too terrible to describe. As one would imagine, a somber tone prevailed throughout this meeting.

A brief break in the gloom occurred during an evening braai (South African version of barbeque) when we watched the Rugby World Cup semi-finals match between England and France. England, the winner, would go on to play South Africa in the finals. I would later see the World Champion South African team in person at the airport, as they were returning from the World Cup matches the same day I was leaving South Africa. Other highlights of the meeting included meeting the South African HPB surgeons, many of whom I would see again later during my South African stay, and running into Ross Carter again, who had flown in from Glasgow to speak about pancreatitis.

In contrast to the disturbing initial impression I had of Johannesburg, I found Cape Town to be impossibly beautiful. As I toured the coastline, Table Mountain, and wineries with my host Professor Phillipus (Phil) Bornman, I became convinced Cape Town is one of the most spectacular spots in the world. Fittingly, Cape Town University and its Groote Schuur Hospital are stunningly sited, with inspirational views of mountains, the ocean, and even herds of large African antelope. I delivered my Grand Rounds lecture just steps from where Christiaan Barnard performed the first successful heart transplant. I spent much time with (Prof) Phil and Jej Krige, another leading HPB surgeon. We spent hours in rounds and conferences, and I held tutorials for the medical students. It was clear that the highest level of surgical care exists at Groote Schuur Hospital. I was also able to understand why every South African-education physician and surgeon I had encountered in the United States was so well trained.

The highest possible level of surgical care also exists at the Chris Hani Baragwanath Hospital, but in completely different form. I returned to Johannesburg to visit this remarkable hospital, where Professor Martin Smith was my host. With over 3200 beds, Baragwanath has been reputed to be the world’s largest hospital. It provides 20% of hospital care in South Africa, and is a particularly important resource for the residents of Soweto township, to where, during the Apartheid era, the black population of Johannesburg literally had been herded.

Trauma and HIV-related conditions seemed to dominate surgical care (40% of patients on the surgical services are HIV-positive) at Baragwanath, but there was also a sizeable HPB service. During teaching rounds, I encountered a series of patients (housed 30 to a room) that had been managed in ways that contradict textbook approaches. Standard algorithms seemingly had been ignored. For example, a patient with suspected pancreatic head cancer had been subjected to ERCP prior to undergoing CT scanning. Another patient with a pancreatic head mass and what appeared to be a liver metastasis had been scheduled to undergo laparoscopy rather than percutaneous biopsy. Given these were teaching rounds, I proceeded to “teach” the students and residents the “correct” way to manage pancreatic cancer. It was only when I rounded on these same patients with Martin and the other HPB attendings, that I learned the error of my assumptions. These patients, in fact, had been managed “correctly” within the context of resources available at this hospital. A diagnostic CT can take weeks to obtain, and CT-based interventions are almost non-existent. In contrast, the HPB surgeons perform their own ERCPs and have control of their operating room schedules. These surgeons had evolved diagnostic and therapeutic algorithms to best serve their patients, given the selective pressures imposed by their environment.

Overall, South Africa seemed to me a land of contradictions, with an uncertain future. It contains the first and third worlds in close juxtaposition. Increasing violence continues to drive many to leave this land of overwhelming beauty. Yet, those who remain are a proud and resilient group. I came to see these South African surgeons as heroes, doing their best for the sake of their patients, and succeeding, in a challenging environment. Their work provides universal lessons.

I ended my South African tour by visiting the very worthwhile Apartheid Museum and seeing all of the big five on safari before leaving for my next destination.

CHINA

The air in Hong Kong was noticeably hazier than what I remembered having experienced during my previous visit to attend the 2002 ISDS meeting. I was told that pollution from factories in Southern China is responsible for this smog (which often makes it impossible to enjoy the stunning harbor views one normally associates with Hong Kong). I was also told that the mainland Chinese respond to this accusation with the reminder that these same factories are owned by Hong Kong industrialists, not the mainland Chinese.

Despite the haze, my week in Hong Kong was thoroughly productive and enjoyable. I began by tending to administrative matters (e.g., getting a VISA for my subsequent visit to mainland China) and shopping (I had three suits tailor-made). Then I visited Queen Mary Hospital of the University of Hong Kong. Located on the face of a mountain facing the South China Sea, Queen Mary was one of two most spectacularly sited hospitals (together with Groote Schuur) I encountered during my travels. My host was the venerable Professor John Wong. I was treated like royalty, with even a chauffeured limousine at my beck-and-call.

The Department of Surgery at Queen Mary Hospital has had disproportionately large impact on clinical surgery. So much of what we do in daily surgical practice has its basis in work done at and reported from this institution. And this productivity has been sustained over decades. Even today, high-quality presentations from this Department are highlights of our major annual academic surgical conferences. What is their secret?

I wasn’t able to uncover a simple answer, but I can think of several possibilities. First, their patient volume for certain conditions is prodigious. In their clinics and operating rooms, I saw an endless stream of patients with cirrhosis and hepatomas. Second, their talent pool is remarkably deep. In their HPB Surgery unit, ST Fan (whom I had met during the James IV banquet in New Orleans but was away during my visit in Hong Kong) is the senior surgeon, but CM Lo and Ronnie Poon are each world-renowned leaders in their own rights. There is also a cadre of emerging junior surgeons, each of whom is outstanding. Third, they feel no hesitation in disagreeing with each other. There is no “group-think” that dampens individual contributions. For example, their HPB unit had recently presented (at the American Surgical Association) and published (in Annals of Surgery) results of their RCT that suggests stenting of pancreaticojejunal anastomoses decreases leak rates. However, I observed CM refusing to stent his Whipple patients; he unflinchingly disagrees with the findings of their own study. Even more instructive, CM Lo’s dissent was viewed with interest and respect, rather than with scorn, by his colleagues. Finally, I observed an utter lack of complacency. There was never any reminiscence over past accomplishments, only anticipation of the future.

And what does the future hold for this Department? Greater interaction with counterparts in mainland China seems inevitable. For the most part, I sensed optimism over this increasing interaction. Educational exchanges are already taking place. I observed a HIFU (high- intensity focused ultrasound) unit donated to them by a mainland Chinese manufacturer. But this optimism is not without caveats. I learned that this Department is seeing an increasing number of patients (Hong Kong residents) who travel to mainland China to get organ transplants (in many cases involving purchased organs harvested from executed prisoners) and then return to Hong Kong for management of their post-transplant complications.

To get some sense of the future of China, I made brief visits to Beijing and Shanghai. I recall contrasts. I observed fruits of civilization (e.g., the great wall, the forbidden city, and the clean and wide boulevards of Beijing). I stayed in the world’s highest hotel and rode on the world’s fastest commercial train. I also observed absence of civility (e.g., the lack of respect for queues among the general population).

With the assistance of Dr. Hong Cai, who had spent many years as a scientist at Dana Farber Cancer Institute in Boston, I visited the Peking University Health Sciences Center. Peking University is the top-ranked university in China, and its medical school is considered the best. I met with medical school’s Executive Vice President, Dr. Ke Yang, who had spend many years at the NIH in the U.S. earlier in her academic career. She has a thoroughly modern view of medical education and the need for education reform in China. One of her main missions is to establish exchanges with medical institutions in the west. I’ve since learned that such an exchange between her medical school and Harvard Medical School will occur this year (three senior Harvard medical students will go to Beijing for two months, and three of their medical students will come to Boston for two months).

I also visited the HPB unit at Peking University’s cancer hospital. The brand-new hospital was strikingly similar in appearance to the main building at Dana Farber. Dr. Xing, a staff HPB surgeon, showed me around the hospital and took me on rounds. He was kind and spoke excellent English. In the United States, he would be considered one of the highest volume HPB surgeons. Yet what I observed was just the tip of the iceberg. Within China, there is a staggering burden of surgical disease, particularly of HPB and upper GI cancers. As China modernizes, we, no doubt, will hear a great deal more of Chinese surgery. In exactly which direction will Chinese surgery evolve? Only time will tell, but I hope the Queen Mary surgeons will continue to provide leadership.

SOUTH KOREA

My half-week visit to Seoul, South Korea was orchestrated by Dr. Ed Mun, a surgical colleague of mine from Brigham & Women’s Hospital who has many medical contacts in Korea. A specialist in laparoscopic and bariatric surgery, he had arranged his schedule so that he would be in Seoul during my visit, so that he could serve as my guide.

We visited two academic hospitals (Seoul National University Hospital and Yonsei University Medical Center) and two corporation-run hospitals (Asan Medical Center and Samsung Medical Center). Seoul National is a public institution that is the most prestigious university in South Korea, whereas Yonsei is the most prestigious private university. Asan Medical Center is affiliated with Hyundai (a group of companies that includes Hyundai Motor Company). Similarly, Samsung Medical Center is affiliated with the Samsung Group (which includes Samsung electronics). These two corporate hospitals employ their medical and support personnel and provide care largely for employees of their constituent companies (the general public can also receive care at these hospitals; however, they face higher fees and longer waits for services).

Seoul National University Hospital is not unlike academic institutions in the West. However, the three other hospitals were striking in several respects. First, these hospitals were gigantic (each exceeding 2000 inpatient beds by a considerable margin). Second, complex care is regionalized at these hospitals to an extent I had not previously encountered. As a result, they have ultra-high volume surgeons. For example, I met Dr. Noh of Yonsei, who has done over 10,000 D2 gastrectomies and is currently doing over 600 of these procedures annually. Such concentration of complex procedures among individual surgeons is something I saw repeatedly during my visit. Third, advanced technology is aggressively embraced. For example, robotics is all the rage, with surgeons in all specialties fighting for access. When patients check-in for their 10-minute clinic appointments (yes, a patient with a new diagnosis of gastric cancer is allowed only 10 minutes with his surgeon, without exception), they do so using an automated kiosk (reminiscent of an airport check-in kiosk), into which the copay is inserted, rather than with a human receptionist. Medical records are completely electronic; vital signs and other data are automatically uploaded directly from monitoring devices. In this respect, Korea, with its efficient 24-character phonetic alphabet, has an advantage over China and Japan, in which electronic record- keeping is hindered by complex indigenous writing systems. In several hospitals, I observed not only video-recording of each operation, but also video-recording of each operating room in its entirety. As I sat in the OR control room, I felt like a James Bond villain as I spyed on the events unfolding in each operating room on my multi-paneled screen. Furthermore, the video-records are stored electronically, presumably for quality-control purposes. This experience gave me an idea, which I will describe in the summary section.

Striking as I found what I saw, the surgeons I met were frank about the challenges they face. These individuals had no hesitation in describing the problems in their work-lives. After all, these surgeons, like their counterparts in Germany, had previously gone on strike for the sake of their profession. My sense is that the overarching emphasis on achieving high surgical volumes, while facilitating technical excellence in those working under this system, is somehow destroying the art and joy of surgery. The younger generation has sensed discontent and is voting with its feet. Medical students simply are no longer entering surgical careers, and even the most prestigious hospitals can’t fill their surgical residency positions. At Seoul National University, I was scheduled by Professor Sun Whe Kim, the Department Chairman, to spend an hour with the medical students and surgical residents during which we discussed careers in surgery. Interestingly, this session was videotaped by reporters from KBS (Korean Broadcasting Company, the major television network in South Korea), who were preparing a documentary with the title “A Crisis In Surgery.” This documentary focuses on the predicted extinction of surgeons as an endemic species. To those in the United States, these issues will be familiar, although in less acute form. At least temporarily, we’ve successfully reversed declines in medical student interest in surgical careers. But that doesn’t mean we should stop working to improve the work-lives of our surgeons.

Mid-week, I left for Japan, while my guide Ed Mun stayed in Seoul to lecture on the benefits of bariatric surgery. As you might imagine, bariatric surgery is virtually non-existent in Korea, as there are few patients who would qualify for these procedures were traditional weight criteria applied. However, Ed predicts huge growth potential for bariatric surgery in Asia, as he hypothesizes that a BMI of 25 – 30 in an Asian patient has the same implications with respect to obesity-induced co-morbidities (particularly diabetes) as does a BMI of 40 in a Caucasian patient. Stay tuned.

JAPAN

I spent the final half-week of my travels with the gastric cancer surgery service at the National Cancer Center (NCC) Hospital in Tokyo. My host was to have been Mitsuru Sasako. Dr. Sasako is widely acclaimed for his contributions to gastric cancer surgery and was a highly effective ambassador for the Japanese approach to this disease. Disappointingly, shortly before my arrival in Japan, Dr. Sasako suddenly resigned from his position at the NCC for reasons that still elude my understanding. Fortunately, Hitoshi Katai, the current chief of gastric cancer surgery at NCC filled in and was a gracious host.

The gastric cancer service at NCC consists of four attending surgeons and five trainees and performs approximately 600 D2 gastrectomies annually. This volume is impressive but not as great as I had encountered in Seoul, where some individual surgeons perform the same volume of gastric cancer surgery. I realize the sample size of my observations is limited, but the gastrectomies I observed in Tokyo were a fascinating contrast to those I observed in Seoul.

Each Japanese surgeon did at most two major operations per day during my visit, in contrast to the five or more per day for the Korean surgeons. As a result, the procedures in Tokyo progressed at a more leisurely pace. Classical music filled the operating room. The operations were accompanied by a great deal of discussion, teaching, and ceremony. For example, the operation began with the operating team doing some sort of team huddle with a cheer for surgical success shouted in unison (reminiscent of what a U.S. football team does before each play). At decisive moments during the operation, such as gastric division using a surgical stapler, the team would yell ritualistic and sometimes frightening sounds (these surgeons were reminiscent of samurai in a Kurosawa film). I observed fine anatomical dissection with zero blood loss. I was able to follow the operations despite the language barrier, whereas the speed of surgery in Korea had made it difficult for me understand what was happening. Between cases, I looked over one of the patient’s charts. It contained a 4-page consent form, completely hand-written and hand-illustrated with beautiful diagrams drawn by the attending surgeon. This was no product of a 10-minute clinic appointment.

The roles of the surgical trainees also were fascinating to watch. One of the residents was scrubbed and performing the majority of the dissection. Another resident was scrubbed to assist. The three other residents on the service were in the operating room during the entirety of every operation. Each of them displayed unwavering concentration as they studied every step of each operation – and they took notes! The concept of watching operations is foreign to residents in my hospital; unless they are scheduled to do an operation, they do not come near the operating room. In Japan, it seems, the focal point for surgical resident education occurs in the operating room. In fact, residents are forbidden from participating in outpatient clinics, as they are thought to be of little educational value. Instead, the surgical residents’ priority is to learn how to operate! In the U.S., it is in vogue for us to tell our residents to spend less time in the operating room, to spend more time in outpatient clinics or with surgical simulators. I can’t help but think the approach I saw in Tokyo makes more sense.

I found what I saw in Tokyo enormously appealing. Here, the emphasis was on quality rather than quantity. Here, I saw the art of surgery, the drive to achieve perfection. And I found myself yearning to perform a single perfect operation…

Thus ended my fellowship. What did I do the last night of my journey? My last night in Tokyo? I decided to take a risk. I went to a renowned restaurant in the Ginza district for a meal of fugu. Fugu, or puffer fish, is claimed by its aficionados to be the most sublime tasting of all fish. However, it contains tetrodotoxin, and if not prepared with better-than- surgical precision, can be deadly. Approximately 20 diners in Japan reportedly die each year from eating inexpertly prepared fugu. After my meal of fugu prepared in three different ways, the head chef, when he learned I was a surgeon from Boston, gave me a tutorial on preparing this deadly delicacy followed by a hands-on skills session using his personal knife and real fugu flesh. We then spent an hour discussing the Boston Red Sox (who had recently won the World Series with the help of its Japanese pitcher and are scheduled to play an exhibition game in Tokyo this year), surgery (he recounted prominent Japanese surgeons, some of whom I actually recognized, for whom he had prepared fugu), and his profession. Several years of intensive training are required before candidate fugu chefs can sit for the standardized certification examination (which includes skills evaluation). The exam is so rigorous that only 30% of examinees pass. If a fugu chef ever loses a customer (by serving fugu containing too much toxin), professional norms dictate that he is honor- bound to take his own life. As our discussion evolved, whatever maladaptive thoughts I may have had about my chosen profession underwent extinction. I guess the fugu worked.

SUMMARY OF OBSERVATIONS

My fellowship gave me enough experiences to last a lifetime of thought and study. Here I list some observations that are currently foremost in my mind.

A team-based approach to surgery. In the United States, surgeons become individual practitioners that day after they graduate from formal training programs. Post- residency/fellowship training is limited to weekend courses and the like. Even in academic centers, individual surgeons tend to compete against (rather than work with or learn from) their peers. I observed the team-based approaches I saw at Glasgow and Heidelberg, for example, fostering high-quality care of patients and ongoing training of attending surgeons. I believe this type of approach will become even more important as the rate at which technical innovations (and the need to master them) are introduced into surgery accelerates.

A multi-disciplinary approach to medical decision-making. As I indicated, multi-disciplinary conferences do exist in the United States. I have seen their application to be particularly effective in breast cancer units. However, presentation of all cancer cases is in no way required, as it is in the UK. And why limit this requirement to cancer? Why not expand this concept to include all complex medical decisions for which multi-disciplinary input would provide added value? Doing so would require small investments of time, but it would add automatic second and third opinions for patients and a valuable educational resource for surgeons and physicians and their trainees.

A video-based operation report. The Op Notes we dictate convey no more information than would have been possible in Mesopotamia in the year 3000 B.C. The intraoperative photo- documentation I observed in Heidelberg coupled with the James Bond-like video-recording I observed in Seoul has led me to conclude that all operation reports should contain unedited videos in addition to a dictated narrative. The technology is available; all’s that’s required is a desire for transparency. These videos should become a permanent part of the medical record and should be made available to patients (perhaps in the form of a CD) should they so desire. Skeptics might fear increased litigation based on these videos, but what do we have to hide? The surgeons I observed during my fellowship certainly have nothing to fear. If we are operating appropriately, these videos should serve in our defense in the event of litigation. And think of this: if you were a patient, would you rather have your operation performed by a surgeon who offers you a CD of your procedure or one who refuses you access to this information? These videos also would be an enormously valuable educational resource (imagine how much more sophisticated and instructive morbidity and mortality conferences would be were videos depicting the instant at which a complication was initiated available).

International exchange. I was struck that nearly every surgeon I encountered during my travels had completed a portion of their training abroad. Every Irish surgeon I met had conducted research in the United States. OJ Garden and David Carter had spent time at UCLA in Los Angeles (where I trained). Ross Carter and his colleagues had honed their skills around the world. John Neoptolemos did research at UCSD in San Diego. Jonathan Meakins, of course, is an explant from Canada. Each of Murcus Buechler’s senior visceral surgeons had done research or clinical fellowships in the United States. Phil Bornman trained in Edinburgh. And so on. Even in Korea, every surgeon I met had spent time training in the United States.

Having completed my entire education and professional career in the United States, it is easy to be complacent, to believe that all that is good in surgery emanates from my country. This fellowship reminded me that most of what we, in the United States, would consider “American surgery” is, in fact, derived from the contributions of our overseas surgical ancestors. Today, our colleagues around the world continue in this tradition. These surgeons and their practices face selective pressures unique to their environments. In response, these dedicated individuals are developing unique and innovative solutions that are worthy of study and, in many cases, emulation. I am convinced that we, in the United States, have more to learn from our international colleagues than we could possibly teach them.

ACKNOWLEDGEMENTS

I am grateful to Mike Zinner, my Department Chairman, for nominating me for this fellowship and Mike Sarr for seconding my nomination. I am privileged to be associated with these two individuals, each of whom is an outstanding role model who represents the best our profession has to offer.

I am forever indebted to my principal hosts and guides Arnie Hill, OJ Garden, Ross Carter, John Neoptolemos, Jonathan Meakins, Marcus Buechler, Phillipus Bornman, Martin Smith, John Wong, Ed Mun, and Hitoshi Katai. Each devoted prodigious amounts of time and effort to ensure I had a rewarding experience. Of course, space limitations have forced me to omit the names of their associates, each of whom welcomed me into their operating rooms, their clinics, and their lives. I very much look forwarding to working with these new colleagues, almost legion in number, in the years to come in our shrinking world.

I also thank my colleagues and trainees at the Brigham & Women’s Hospital for covering my clinical, educational, and administrative duties during my absences. Even my research fellows’ progress continued unabated (perhaps too exuberantly, as their expenses ran astronomically over-budget during the second leg of my fellowship).

Finally, I thank the James IV Association of Surgeons and its entire membership for your wonderful gift. I hope you will continue your important mission, and I hope to one day be able to contribute something commensurate with your generosity. Godspeed.