James IV Travelers Report –2014
Matthew M. Hutter, MD, MPH, FACS
Massachusetts General Hospital. Boston, MA.
Division of General and GI Surgery
Director, Codman Center for Clinical Effectiveness in Surgery
Director, MGH Weight Center
I am most thankful for the opportunity to have been the James IV Surgical Association Traveling Fellow from the United States for 2014-15.
I traveled in Europe for the month of July 2014 — to Amsterdam, London, Scotland and Paris. The second leg of my travelling fellowship was to Hong Kong, China and Australia in February 2015. This allowed me not only to align the trips with my kids’ school calendars, and to split up my time away over two fiscal year, but serendipitously I was able to enjoy an Australian summer during a record setting snow fall in Boston!
My goal was to see how surgeons from different countries, with different health systems and different cultural and political challenges, are able to assess the quality of surgical care, and to promote and incentivize high quality care. My other goal was to learn how they can safely introduce novel techniques and technologies. What I learned was so much more. I learned from such varied experiences as meeting one on one with both the recent CEO of healthcare for all of England, as well as hiking with a private practice surgeon and her dog in an Australian park. The opportunity to share this experience with my family, who accompanied me for the majority of the trip, was an experience that we will never forget.
It would be impossible to describe all the remarkable people I met, and things I experienced in 18 hospitals in seven countries over six weeks where I met 16 James IV travelers, but I would like to briefly relate some highlights.
Europe – July 2014.
My first trip was to Amsterdam where Professor Jaap Bonjer was my host. Jaap is the Head of the Department of Surgery and Chairman at VU Medical Center. He leads a department with unbounded energy and enthusiasm and he has created a stellar esprit de corps.
Over the days that I spent at VUMC whether in the OR or meeting with research fellows and staff, I became enamored of the Dutch people and system, as well as the city of Amsterdam. First of all, their culture of safety was unparalleled. When I think of the challenges I had encountered instituting checklists, SCIP compliance, or other QI projects, it was a pleasure to see a system where all genuinely seem to have bought into it. The responses to my probing questions made me realize that they truly believed in it too. A great example was their initiative to decrease infections by minimizing OR traffic. All the doors in the ORs were pocket doors, and slid into the wall so that they would not swing particulate matter and infection about the room. The amount of times these doors were opened during a case were tracked electronically, and every effort was made to minimize the number and duration of door openings. Nurses would talk on cell phones, separated by the glass of the door, rather than open them up to have a discussion. When I wandered out a door, the anesthetist hustled through with me – he had been waiting for a bathroom break but was not going to leave until someone else could share the door opening with him. This is very different from what our ORs where the OR door swings practically onto the Mayo stand in some of our operating rooms, and where the OR at times seems more like a thoroughfare than a sterile sanctuary.
I was also amazed how well the Dutch work together to perform nationwide clinical trials. With a very limited budget similar to what we in the U.S. would get to do pilot studies, they are able to pull off world class nationwide clinical trials like the COLOR trial (Colon Cancer Laparoscopic of Open Resection). Surgeons across the country feel it is their duty and pleasure to be involved, and to hire study staff and enroll patients on their own dime and time, in order to advance surgical knowledge. It is part of their social fabric of their surgeons, and reengages surgeons across the country who had worked or trained together in years past. Amazing.
With charismatic leadership and the cultivation of a culture where all are working towards a common goal, it is amazing what the Dutch have accomplished with regards to quality and safety or academic output like clinical trials.
London was our next stop and Professor the Lord Ara Darzi was my host at Imperial College. He is the Chair of Surgery at Imperial College and has created a world class surgical research department, the breadth and depth of which I have not seen. He has also been able to navigate the political and policy fields as demonstrated by his accomplishments of being knighted in 2002, raised to the peerage in the House of Lords in 2007 and appointed the Parliament Under-Secretary of State in the Department of Public Health, and the Global Ambassador of Health in the UK. Truly an impressive man.
I met one on one with Sir David Nicholson who was the Chief Executive of the National Health Services in England from 2006 to 2014, having retired from that post 3 months prior to my visit. He spoke freely and thoughtfully of the lessons learned in the NHS over those years, and provided deep insight into those experiences as well as the challenges facing the US in the coming years. I also had the privilege to have an extended one on one lunch with Sir Liam Donaldson, who had held a 12 year post as the Chief Medical Officer of England – the US equivalent is the Surgeon General. The discussions about his experiences and lessons learned at the helm of UK healthcare were remarkable, as were discussions about his current focus on incident reporting and the status of data in the NHS England. I toured all the different surgical research programs that Ara Darzi has spawn and spent two days in the “theatre” at the Queen Mary Hospital and Royal Marsden Hospital.
Ara Darzi was gracious enough to invite me and my family to High Tea at Parliament, reserved solely for the members of the House of Lords and their guests. He personally led us on a tour of Parliament, and showed us the inner chambers that are otherwise inaccessible. This experience was a highlight of our travels.
I next traveled to Edinburgh Scotland, where James Garden was my host. Professor O. James Garden is an HPB surgeon and the Chair of the Royal Infirmary of Edinburgh. He had just returned from his meeting with the Royal medical staff, as he is the “Surgeon to the Queen in Scotland”. He was a tremendous host and crafted a visit that included Edinburgh, Dundee and Glasgow. In Edinburgh, I met with surgeons and residents at the Royal Infirmary, and spent time in their theatres.
I traveled to Ninewells hospital in Dundee where Bob Steele, a James IV member, was my host. I met with their surgical researchers, and the Sir Alfred Cuschieri Skill Center, as well as the Medical Science and Technology Institute where clinicians work with industrial engineers to create prototype surgical instrumentation and equipment right at the hospital.
I went to Glasgow where I met with the Head of Health Protection Scotland, which is the Scottish version of our CDC. I spoke with their quality improvement teams and epidemiologists about similarities and differences of our healthcare systems for measuring and improving the quality of care, and especially the challenges of implementing change. I also met with their Health Services Research group, who analyze the outcomes of surgical care.
After learning much about the National Health Services in England, it was fascinating to juxtapose it to the NHS Scotland and to see the differences that seemingly small differences in how the systems run can have such large impacts.
Professor Brice Guyet was my host in Paris. Brice is an HPB surgeon and laparoscopic innovator who works at L’Institut Mutualiste Montsouris, a private non-profit hospital that participates in the public hospital service. It was fascinating to see how he has developed novel techniques of laparoscopic liver resections using new technologies. Perched on a stool, with sock feet on the Bovie foot pedal he would use the “French Touch” with bipolar cautery to stop bleeders right on the IVC. 3D imaging and an Aesop driving the laparoscope further helped him execute with precision. With passion and conviction he has been an innovator and pioneer in his field. We were in Paris for their Bastille Day celebration, saw the Tour de France come through town, and saw all the sites that the kids had studied in school.
Asia and Australia – February 2015.
The second leg of our journey was in February 2015 when I visited Hong Kong, Shenzhen, China as well as Sydney, Cairns and Melbourne in Australia.
Professors John Wong and C.M. Lau, the past and current chairs of surgery, were my hosts at Queen Mary Hospital in Hong Kong. Hong Kong has two systems – private and public – and the economics drive many accomplished academic surgeons to the private side eventually. I found Hong Kong and its culture to be fascinating, as well as its hospitals and their leaders. I spent time on the wards and in theatre, had meetings with their research and quality teams, and had brunches, lunches and dinners which they had arranged for me to meet with members of the department from junior trainees to emeritus professors. Professor John Wong had been their chair for 20 years, and he shared his reflections and thoughts about mentoring, career development and building a modern surgical department with the financial challenges of competing public/academic and private models.
I traveled to Shenzhen on Mainland China, to the brand new 2,000 bed Shenzhen Medical Center with 10,000 outpatient visits a day. China is building out its medical expertise, not only with state of the art medical centers, but they are working with partners from overseas to import a modern management style that includes staff and leadership. I was fascinated to learn of their challenges with merging cultures, and the adoption of new models for patient care, leadership and management.
I traveled to Sydney Australia where Michael Solomon was my host at the University of Sydney where I visited Queen Victoria Hospital and the Prince Alfred Hospital. I met with his team at SOuRCe (Surgical Outcomes Resource Centre) and discussed measuring quality in Australia, and in the US. I also met with Cliff Hughes a surgeon who runs the Clinical Excellence Commission which is their governmental to lead quality and safety in New South Wales. I also met with the Minister of Health from New South Wales at his request, so he could learn about EHRs and their challenges with regards to implementation and quality and safety in the US. I met with the surgical leaders of the Agency Clinical Innovation on behalf of the American College of Surgeons, as they had just implemented the NSQIP at 5 hospitals. We discussed lesson learned in the US with leveraging the NSQIP to drive quality improvement, and I learned of the carrots and sticks they use in Sydney to drive Quality Improvement.
My family joined my in Sydney where we saw the sites, climbed the Sydney Bridge, watched the Australian Open of surfing, did some surfing ourselves, and met with plenty of kangaroos and koalas. We then headed to Cairns and snorkeled on the Great Barrier Reef. After my family headed home, I continued to Melbourne.
In Melbourne, Bruce Mann and Julie Miller were my hosts, and they were kind enough to put me up in their home. They are both surgeons, and have three charming children, and I felt like I really got a true taste of life at home and work for an Australian surgeon. I visited the Royal Melbourne Hospital, the Royal Women’s Hospital, the Peter MacCallum Cancer Center and the Alfred Hospital. I met with their Surgical Outcomes group — the Melbourne EpiCentre. I spoke at the Melbourne Bariatric Surgery Society Meeting. I met with Paul O’Brien who has written the landmark studies on outcomes of the laparoscopic adjustable band, and those discussions were so interesting that he invited me to his house where we figured it all out over a bottle of champagne. I met with the leaders of the academic medical centers, and discussed the fiscal and political challenges of building an academic medical center.
One common theme from all these visits is that “All politics is local” and indeed in all these countries with government involvement I would add “All healthcare is political”. We in the United States seem to be further venturing into this realm with the Affordable Care Act. Whether in Amsterdam, Scotland, Hong Kong or Australia, politics has a significant role in how health care is delivered. We as surgeons in the United States need to continue to do what is right in the face of political challenges and changes in healthcare, and advocate for our patients to fight the surgical diseases that afflict them.
I would like to thank my wife, Amy, and kids Max, Will and Anna (ages 12, 10 and 8) who made this trip so special. Amy organized everything – a truly stupendous feat. Max, Will and Anna each carried their own weight – with a carry on suitcase and back pack — across miles of underground Tube, Metro and train stations, and quaint cobblestones roads to our flats. My daughter still asks for malt vinegar for her French Fries. While I was in the hospitals, they would be out seeing the sites and tell me all they had done over dinner. I could share with them the highlights of the day as I was processing them. Of course, there were weekends and days where were able to see the sites and explore the cities together.
I want to thank the James IV Association of Surgeons for what has certainly been one of the highlights of my surgical career to date. I would like to thank my host surgeons from all these countries who created amazing itineraries at each hospital, and rolled out the red carpet for us. They dined and entertained, and put us up either in housing or their homes, and even pretended to be interested in the talks I gave. I would like to thank Keith Lillemoe for sponsoring me, David Rattner and my colleagues in General and GI Surgery for allowing me the time away, and especially partners who cared for my patients during my extended absences.
My mind and my world have been opened up and enriched by meeting so many fascinating and kind people, and experiencing how surgery is performed in many different countries. My family will cherish this experience as well. Thank you for this remarkable opportunity.
The Lord Ara Darzi, Chair of Surgery at Imperial College in London, shows the Hutter family the inner chambers of Parliament after High Tea with members of the House of Lords.
With Professor James Garden (center) and former James IV traveler Rowan Parks (right) in Edinburgh Scotland.
With Professor John Wong at Queen Mary Hospital at the University of Hong Kong.
Note, the James IV traveler is expected to wear the traveler’s tie, which as you can see from the pictures, I dutifully did.
Shenzhen Hospital in China and their state of the art operating rooms.