2014 – Geoff Porter

Geoff Porter, Canadian James IV Traveling Fellow

I feel incredibly privileged to have been a Canadian James IV Travelling Fellow. My Fellowship had dual themes, reflective of my current professional interests: (1) clinical surgical oncology, with a focus on advanced GI malignancies; and (2) population-based cancer control strategies. I conducted my travels over 2 legs: (1) New Zealand/Australia in November/December 2014; and (2) Europe in April 2015

AUCKLAND

The host for my visit to New Zealand was Dr. Jonathan Koea. Jonathan is a New Zealand-trained surgeon who did both Surgical Oncology and Hepatobiliary training at Memorial Sloan Kettering. Aside from his clinical practice, where he is clearly very well-regarded, has had a substantial impact on hepatobiliary surgery in his country. He has trained eleven Fellows in hepatobiliary surgery, all of whom are practicing surgeons in New Zealand. Among of all of his accomplishments, of which there are many, he is most proud of this impact.
Shortly after my arrival in Auckland, I had the opportunity to meet several individuals at the North Shore Cancer Program involved in a recently announced New Zealand initiative which aims to ensure patients go from initial concerning symptomatology to first cancer treatment in 62 days. This is a national program, but involves local implementation, and is an excellent example of the importance of context in cancer quality initiatives. I was very impressed with the engagement, enthusiasm, and investment, specifically by the cancer nurse coordinators/navigators. The North Shore Cancer Program has adopted a very wide view to include everything from concerning symptomatology through surveillance; I contrast this to Canada where cancer navigation typically begins after first visit to the cancer centre and ends following the completion of active treatment.
I gave Grand Rounds at the North Shore Hospital entitled “Cancer Control: The Canadian Experience”. This is perhaps the first time I have ever given Rounds to an audience where I knew absolutely no one. They were an extremely gracious, inquiring, and interested group, and I greatly enjoyed several interesting discussions afterwards.
I had a wonderful dinner with Jonathan Koea and Richard Harmon, Head of the Department of General Surgery at North Shore. The discussion was wide ranging including clinical approaches in cancer care in general and some of the similarities and differences between Canada, New Zealand and the United States, where all three of us had spent time in our postgraduate training. Jonathan and Richard spoke of a clear desire to serve patients, which I came to discover is pervasive within the New Zealand surgical community. Specifically, Jonathan struck me as a thoughtful, energetic, and very forward thinking individual who, at the end of the day, places the New Zealand cancer patient first in all that he does.

WELLINGTON

In Wellington, I spent a day at Cancer Care New Zealand, the country’s national cancer control agency. Cancer Care New Zealand is an organization of modest size with an active national program in palliative care, a full country-wide cancer registry, and the previously-mentioned initiative of a 62 day target from concerning symptomatology to first treatment for all cancer patients.
In the morning, I gave a presentation regarding the Canadian experience with synoptic pathology and surgical reporting to the Board of the New Zealand Cancer Registry.   New Zealand is very active with the Australian College of Anatomic Pathologists, as well as in their work with the International Collaboration of Cancer Reporting (ICCR). Dr. Brent Truelove, a pathologist and Chair of the Cancer Registry Board is committed to the implementation of synoptic pathology reporting in New Zealand.
In the afternoon I attended a very interesting workshop where a model examining the impact of antenatal hepatitis B transmission on subsequent development of chronic liver disease and hepatocellular carcinoma was presented.   Although the number of hepatocellular carcinoma cases prevented was modest in the model, the impact on chronic liver disease was quite substantial. During this workshop, it struck me how cancer control challenges in prevention, diagnosis, and treatment amongst First Nation Canadians are in many ways quite similar to that of the Maori people of New Zealand.

CHRISTCHURCH

I was delighted to spend two days visiting Christchurch Hospital/University of Otago at Christchurch.   I attended both the Upper GI/Hepatobiliary Cancer multidisciplinary meeting as well as the Colorectal Cancer multidisciplinary meeting. I was incredibly impressed with the level of engagement, infrastructure support, and efficiency of this clinical working conference. All specialties were represented, and the meeting was exceedingly well-organized with rapid access to all pertinent clinical information as well as efficient pathology and radiology review. It is clear that the Christchurch Hospital has prioritized this type of activity, and the level of engagement from outside sites by teleconference was outstanding. I believe that one of the major reasons it works so well is the rather flat hierarchal structure; this was a theme I noted throughout my visit to Christchurch that was not restricted to multidisciplinary conferences. Although several more “academically prominent” physicians were present, it appeared all felt free to voice opinions and clear management plans emerged.
I was similarly impressed in my conversations with other surgeons, specifically Ross Roberts, Frank Frazzle, Richard Tapper, Greg Robertson, Tim Eglinton and Chris Wakeman. The group hosted me for a very lively and enjoyable dinner, including delicious cow cheeks, and I was struck by the collegiality and respect that seemed to be pervasive throughout the Department of General Surgery. The overall relaxed New Zealand nature indeed reminded me of my current situation in Nova Scotia.
I also had the opportunity to spend some time with surgical trainees, both junior and senior level, as well as Fellows. I was struck that completion of a research project as a mandatory element of surgical training in New Zealand; the lack of a peer-reviewed publication precludes writing final exams. The organization of GI cancer surgery in New Zealand certainly differs from Canada in that all esophageal and gastric surgery is within the domain of the Department of General Surgery whereas the lung cancer surgery is performed predominantly by cardiothoracic surgeons.
I gave two presentations during my visit to Christchurch, one entitled “Cancer Synoptic Reporting in Canada” and the second entitled “Cancer Control: The Canadian Experience”.
The host for my time in Christchurch was Saxon Connor, a Hepatobiliary/Upper G.I. Surgeon. Although I had not met Saxon previously, it was immediately apparent that he is an extremely unique individual with an infectious passion and energy for what he does. How many surgeons would take the time, on a weekly basis, to bring a coffee to a pathologist and review the gross and microscopic findings of the last week’s cases? Although some might call this “old school”, I would submit that Sax simply views such direct relationships as being key to providing excellent care and leading through example.
There is a “just do it” attitude that is pervasive in Christchurch. The cancer society tissue bank is an illustration of such where, with determination, a large and valuable tissue bank has been established from extremely modest resources. Finally, the physical devastation of the two earthquakes in Christchurch which occurred just over three years ago is striking. On reflection, I realize I think about natural disasters predominantly from the perspective of underdeveloped nations; I was amazed by the level of devastation and its continued impact in this very developed nation. In my estimation, only 10% of the downtown core is currently usable; gravel parking lots representing demolished buildings are aplenty. In my meetings with the Chief of Surgery, Greg Robertson recounted with pride the acute disaster management and staff engagement in the time of change since. The building of the new hospital, eagerly awaited, has been a testament to the quiet but efficient determination of those who remain in Christchurch.

MELBOURNE

I had the great pleasure and privilege to be one of 200 invitees to the World Cancer Leader Summit in advance of the UICC World Cancer Congress in Melbourne, Australia. This one-day summit was structured around the theme of economics in cancer prevention and control. There are now more cancers deaths in low and middle income countries than in high income countries (previously, most cancers were in high income countries); the global cancer burden has never been greater. The day was illuminating, not just in the information and data presented, but in discussing the economic case to be made for cancer control interventions. Investments targeting tobacco control, diet and obesity related cancers, and vaccination will have profound positive cancer-specific health and economic effects. Simple structures and processes addressing early cancer detection, basic components of treatment (including surgery), and palliative care will undoubtedly be even more important moving forward.
I also had the opportunity to be faculty for a Master Course within the UICC World Cancer Congress. This course addressed the design of cancer system performance, and my talk covered knowledge translation/exchange activities and the specific benefits of cancer data presentation. I found the course participants were both engaged and remarkably well-informed; I learned a great deal and enjoyed the day thoroughly.
The UICC World Cancer Conference occurs every two years, last taking place in 2012 in Montreal.   I was struck by both the breadth and content of cancer control activities occurring around the world in high, middle and low income countries. Clear progress is being made, and Canada’s contribution is significant. More specifically, Dr. Mary Gospodarowicz, a radiation oncologist from Toronto is the President of the UICC, and Dr. Heather Bryant, Vice-President of the Canadian Partnership Against Cancer has made incredible contributions to UICC and international cancer control. The highlight of this meeting for me was a presentation by Canadian Stephen Lewis, where he used his extensive and successful experience with HIV in the developing world in considering the upcoming WHO non communicable disease (NCD) initiative to start in 2015 (where cancer will be an important element). His speech was a real “call to arms”; rather than presenting platitudes around progress to date, he made the strong case for an aggressive approach by the cancer control community at all fronts.
Following my time at the UICC Meeting, I had the opportunity to spend a day at the Peter MacCallum Cancer Centre in Melbourne, organized and hosted by Professor Sandy Heriot (a dynamic colorectal surgeon and Chief of Surgery at the Peter Mac). The Peter Mac is a remarkable institution; it is the largest free-standing cancer centre in Australia and is one of ten largest such cancer care facilities in the world. I received a wonderful tour of their impressive research facilities and met with several clinical faculty. During my Grand Rounds, I noted that the audience was exceedingly engaged and very interested in the similarities between cancer care in Australia and Canada. I had a very pleasant dinner with the Director of Research, Dr. Wayne Phillips as well as Michael Henderson, clearly a “father” of Surgical Oncology in Melbourne.
The following day I visited the Royal Melbourne Hospital, a large tertiary/quaternary care institution. I had a wonderful session in the morning with the General Surgery trainees and gave a clinical talk entitled “Liver Resection for Metastatic Colorectal Carcinoma”. This time with the house staff was coordinated by Robert Tasevski, who did his surgical oncology training in Toronto several years ago. He has a clinical practice in breast, endocrine and sarcoma surgery and is the equivalent of a Residency Program Director as per the Canadian model. I also met with Dr. Jim Bishop, Director of the Victoria Cancer Care Coalition. He is charged with the immense amalgamation of the “New Peter Mac” with surrounding health care institutions, including the Royal Melbourne Hospital. He is a seasoned administrator but clearly this > $1 billion new build, along with the important partnerships and collaborations that will ensue, is a massive undertaking. Finally, Professor Bruce Mann brought me to the Breast Multi-Disciplinary Rounds where I was once again impressed, as I was throughout my tour of Australia and New Zealand, with the functionality of this meeting. It does strike me that clinical leadership along with infrastructure support are critical success factors which seem to have been established throughout all the institutions I visited.
Bruce Mann (my host in Melbourne), provides a great example of the benefits of focused dedication.   The PROSPECT Trial, which he conceived and funded, aims to potentially reduce the need for radiation therapy based on pre-operative MRI criteria in patients undergoing breast conservation surgery. This trial is an example of how he has been able to bring focus not only from a research perspective but from a clinical perspective, to the Breast Program at the Royal Melbourne. Bruce is a highly accomplished surgeon and researcher, and a true gentleman. It was an absolute delight to spend an evening at his house with his children and wife Julie Miller (a very accomplished Endocrine Surgeon, they share an office!). The Mann/Miller family showed me great hospitality that I only hope one day I can repay.
I spent the following day with Bob Thomas, a surgeon who is now the Special Advisor on Cancer to the Department of Health in Victoria (equivalent to a provincial Ministry of Health in Canada). I gave a very well-attended talk entitled “Canadian Cancer Systems”. Bob Thomas explained some of the very impressive initiatives that are occurring within the state of Victoria specifically around its monitoring of hospital activities and trying to move through critical pathways of care for selected disease sites. As I noted in other areas of my visit of both Australia and New Zealand, the existence of dual public and private systems does present challenges specific to cancer. These challenges include, but are not limited to, data acquisition and monitoring as well as the embedding of standards within both systems.

ADELAIDE

 Upon arriving in Adelaide, Marcus Troschler, a young faculty upper GI/liver surgeon on staff at the Queen Elizabeth Hospital in Adelaide, picked me up from the airport. I was delighted to meet his four-year old son and have a beer with Marcus in the evening. Marcus underwent his residency training in Switzerland and came to Adelaide for fellowship training in upper GI and hepatobiliary surgery under the supervision of Professor Guy Maddern, and has stayed. Marcus strikes me as a young surgeon with abundant energy, intellect, and skill who will likely be important to the future direction of surgery in Adelaide. Despite a clear academic and clinical focus in HPB surgery, his staying in Adelaide required him to sit his Australian exams. This required him to go back to learning vasectomies and carpel tunnel repairs – skills which he continues to use as part of a week-long rotation in a “country hospital” approximately every eight weeks.
I spent a great day at the Royal Adelaide Hospital (RAH), the largest and oldest of Adelaide’s health care institutions where I had the opportunity to observe an upper GI multi-disciplinary tumor board. Again, this meeting was remarkably functional, chaired very capably by Dr. Sarah Harmer, another young faculty in Adelaide who had done her General Surgery training in Calgary, Alberta. I observed Ward Rounds where the entire team including faculty (junior and senior), surgical trainees and medical students round on a daily basis to review all patients. I gave rounds entitled “Overdiagnosis” to a group of GI physicians and surgeons and was again impressed by their great questions and engagement. Peter Debit, the Head of the Upper GI Surgery Program and Chris Worthley, Head of the HPB Unit at the RAH are clearly committed to patient care and are fiercely loyal to the history and clinical activities of the Royal Adelaide Hospital. A highly collegial citywide group of Upper GI and HPB surgeons met that evening for their monthly Journal Club. Over an absolutely wonderful meal I had the opportunity to talk about synoptic reporting in cancer surgery, as well as share many conversations and discussions regarding surgical education and clinical service delivery in Canada and Australia.
The following day was spent at the Queen Elizabeth Hospital and started with a morning “audit” of the clinical care delivered at one of the “country” hospitals in the small community of Whyalla, approximately an eight hour drive from Adelaide. The Adelaide residency program provides trainees, and faculty from the Queen Elizabeth hospital frequently rotate for a week at the institution (e.g. see above Marcus Troschler). The breadth of this audit, entirely put together by the Registrar who had just completed a three- month rotation, included, burns, colon resections, orthopedic cases, cesarean sections, and seemingly everything in between. I was struck with how well this tight affiliation between the QEH and “country hospitals” worked for both groups.
I spent several hours with the research trainees and was quite impressed with their “no nonsense” approach to lab research. I noted that the QEH Department of Surgery places on a significant priority on research training, but also requires research trainees to demonstrate independence and initiative in order to be successful. Lunch and far reaching discussions with the Honourable Andrew McLachlan (is a sitting elected member of the state Legislature in South Australia) as well as a retired surgeon Frank Bridgewater was a real privilege.
I visited ASERNIP-S (Australian safety and Efficacy Register of New investigational Procedures – Surgical), and was treated to several excellent presentations regarding the work of this group as it relates to technology approval, surgical training/simulation and breast cancer system performance. ASERNIP-S, a program of the Royal Australian College of Surgeons, was conceived and built by Professor Maddern, and is an excellent example of how outstanding focused work often brings many new and diverse opportunities.
I flew that evening to Port Lincoln with Jim Young; Jim was a longtime academic surgeon in Adelaide for many years, retiring officially from the Queen Elizabeth over five years ago. He periodically goes to “country” hospitals to provide General Surgery coverage for short periods of time, and was going to Port Lincoln to serve this purpose for the next week. Jim was an absolutely delightful gentleman with abundant experience, a love for the craft of surgery, and a highly entertaining personality – truly refreshing in a time where the day to day clinical and academic demands tend to wear one down. challenges. Upon my return from a Saturday of shark cage diving (an experience I will never forget), dinner with Jim where he talked about the sigmoid resection he had just performed with a family doctor and his training stories from the U.S. in the 1960s made for a memorable evening.
Professor Guy Maddern has had, and continues to have, a massive positive impact on surgery in Adelaide and South Australia. From ASERNIP-S, to surgical research training, to all aspects of clinical care delivery (including “country hospitals”), to the upcoming reorganization of surgical services in the city, to countless other initiatives/programs – Professor Maddern drives it all. He does do with both an energy and optimism that enables his success.

SYDNEY

I visited the Cancer Institute of New South Wales (CINSW) – the equivalent of a provincial cancer agency in Canada.   The CINSW has strong leadership comprised in its CEO, Dr. David Currow, as well as its Director, Sanchia Archivez. Both are highly impressive, and clearly focus on the importance of cancer control activities on improving cancer outcomes for the state. Although the CINSW does not have any direct clinical care mandate, it clearly is the “go to” organization for cancer related issues within the state of New South Wales. It has a strong approach to tobacco and sun tanning legislation, with a view towards activities that have tangible policy impacts.
The Cancer Information Analysis Unit of CINSW shares many of the approaches to cancer system performance measurement to Canada, as well as the challenges of data acquisition. Ainsling Kelly provided a fantastic overview of EviQ, a web-based informatics tool that has become the preferred resource for cancer professionals regarding clinical care. No analogous model exists in Canada, and I believe that there is opportunity for collaboration, perhaps through my role at the Canadian Partnership Against Cancer.
I also had the opportunity to visit the Royal Alexander Hospital, organized by Professor Michael Solomon. The remarkable infrastructure and surgery research engine at the Royal Alexander Hospital is largely attributable to Professor Solomon, who did colorectal fellowship training in Canada under Dr. Robin McLeod. He clearly has remarkable visionary and builder skills. I spent the morning at SOURCE, a surgical outcomes research unit established 10 years ago by Professor Solomon. SOURCE is a great example of clinician/clinical scientist collaboration with a strong focus in colorectal disease. The resultant establishment of an academic institute of surgery, which is essentially a hybrid model incorporating both hospital and university, has the potential to deal with the significant clinical strain of many Departments of Surgery. At SOURCE, I gave a presentation entitled “Cancer System Performance in Canada.” I had a great tour of RAH by Chery Koh, a relatively young faculty colorectal surgeon with a strong clinical and research interest in pelvic exenteration. The Royal Alexander Hospital is a world leader in pelvic exenteration; I don’t think there is anywhere else in the world which actually has a pelvic exenteration-specific multi-disciplinary tumor board!

AMSTERDAM

 I visited the V.U. Medical Centre (VUMC) in Amsterdam, hosted by the current Chairman of the Department of Surgery, Dr. Jaap Bonjer. Jaap was the previous Head of Surgery at Dalhousie University and, unfortunately for Canada, left for the VUMC approximately five years ago.
 The VUMC is an impressive facility. The hospital is run primarily by physicians, with surgeons being front and centre. Interestingly, the Department of Surgery also includes emergency medicine, stemming from a history where surgeons were the physicians that serviced the Emergency Room. The Department of Surgery is organized along divisional lines, most of which are similar to Canada but with some substantive differences. A trauma surgeon in the Netherlands does the full range of fracture care as well as basic neurosurgery and thoracic surgery. In fact, the vast majority of operative fracture care in the Netherlands is provided by such surgeons; orthopedic surgery is a completely separate training stream with a primary focus on arthroplasty.
 Clinical care within the VUMC is incredibly collaborative. On a daily basis all surgeons and trainees attend a 7:45 AM conference where all the nighttime operative cases and admissions are reviewed, and subsequent plans for inpatient care for the day are discussed. Approximately an hour later, a LEAN methodology-inspired approach to clinical care and patient disposition within their Rapid Admission Unit (<48 hour admission) occurs. Several years ago, not dissimilar the situation in many Canadian hospitals, the VUMC experienced long waits for patients who were admitted from the Emergency Rooms getting to an inpatient bed. They created a ward of 25 patients with an objective of a maximum 48 hour stay, after which either patients were discharged or were assigned to an actual hospital bed. To make this work, physician representatives across specialties meet every morning , where the actual plans are reviewed collaboratively. At 5:00 p.m., the Department of Surgery meets once again daily to review the upcoming cases for the evening, potential problem patients, and the planned operative cases for the following day.
 This whole process is quite interesting. Patients undergoing lumbar spine fixation for vertebral fractures are presented alongside cases of elective endovascular aortic aneurysm, non-operative aortic dissections, complex hepatobiliary surgery, and lung cancer resection. Although, as in Canada, VUMC surgeons have clearly defined areas of interest and expertise, it is recognized that all have potential input on patient care, particularly with the need for shared and efficient use of resources. In addition to the collaborative nature of rounds, the departmental members work together in other ways. It is not uncommon for a staff surgeon to be paged to help out in a clinic that was running late, even if it is not completely in their area of expertise. This is very different to how surgical care and surgeon autonomy has evolved in Canada.
I had the opportunity to witness several operative cases during my time at the VUMC. Theseincluded a laparoscopic mesorectal excision for rectal cancer using a three dimensional camera as well as an attempted minimally invasive thoracic esophageal cancer resection. I was struck by the clear commitment to innovation and technology advancement at the VUMC. Essentially no patients with esophageal carcinoma undergo open resection, and open resection for colorectal disease is confined to exceedingly complex and/or re-operative cases.
I also had the opportunity to spend time with Geert Kazemier, Professor of HPB Surgery and Director of the Cancer Centre at the VUMC. It is interesting that in the Netherlands, surgeons must enter their surgical cancer cases into a national registry; this is made mandatory by being linked to hospital reimbursement via the insurance companies. Although not truly population-based cancer registry (cancer patients not undergoing surgery are not included), it is a very interesting model that has worked well in the Netherlands. The cancer centre itself successfully leverages philanthropy for large equipment purchases, including a recent MRI/PET scanner, the first of its type in the Netherlands.
In my time with both the surgical residents and the surgical research trainees, I learned that in the Netherlands, trainees with an interest in a surgical career typically embark on research, usually in the form of a PhD, following a six-year medical school; this seems to be almost a requirement to subsequent admission for surgical training. Within Dr. Bonjer’s Department, there are eight such PhD students at present There are multiple examples at VUMC of such research trainees launching and completing large national or international randomized trials, including the recently published TIME trial of minimally invasive esophagectomy. Significant basic science and other health services research also occur in this setting.
I gave Grand Rounds during my time at the VUMC entitled “Cancer Control in Canada: The Example of System Performance”. I was struck by some of the similarities and important differences with the Netherlands pertinent to this topic. We had a very good discussion regarding the benefits and risks of public reporting of cancer outcomes.
Finally, I remain amazed by Jaap Bonjer. Although I knew him reasonably well from his time in Halifax, I remain amazed at his enthusiasm and determination in his administrative work. To his credit, he as clearly moved this department forward from an academic perspective while maintaining clinical excellence and significant innovation. Like several other surgical leaders I met through my travels, Jaap has his hand in just about everything from meeting on a bi-weekly basis with all research trainees (not just those he supervises), to a clear understanding of the clinical and academic work of all surgeons within his department, to the organization of diverse services within the hospital. He believes strongly in effective surgical management and is an outstanding communicator.

DUBLIN

The Royal College of Surgeons of Ireland (RCSI) is one of six medical schools in Ireland and is co-located with the Beaumont Hospital in Dublin, Ireland. I had the opportunity of presenting at their Grand Rounds with my presentation entitled “Overdiagnosis In Cancer: What the Surgeon Needs to Know”. Interestingly, as part of weekly Grand Rounds, verbal highlights of the current week’s New England Journal of Medicine were provided as was a brief presentation representing the journal article of the week and a brief interesting case presentation was also made. These hour long rounds, chaired very dynamically by Professor Arnold Hill (my host in Dublin) were dynamic, varied, and fast moving. The concept of integrating more than a single hour long presentation into an academic Grand Rounds was very engaging and effective.
I had the opportunity to witness research presentations by three separate trainees within the Department of Surgery. These included an examination of a large prospectively maintained breast imaging clinical database, as well as two other presentations representing several years of fundamental science experiments of endocrine resistant and aromatase inhibitor resistant breast cancer.   I was impressed not only with the quality of the presentations, but also with the clear thinking, focus and logical sequence of work they represented.   On my subsequent tour of the RCSI research areas, it was clear to me that programmatic focus in research is a true strength of the RCSI. Professor Hill’s vision, and a true strength of the research at the RCSI, is that research (particularly at a basic science level) cannot be all-encompassing; success will be best obtained with a more programmatic focused approach.
I greatly enjoyed an excellent dinner with Professor Hill as well as Professor Austin Leahy (a vascular surgeon) and Dr. Ann Hopkins (a primary scientist within the Department of Surgery).   We had a very wide ranging discussion including models of care and surgeon organization all the way through the trials and tribulations of child rearing in the setting of an active clinical practice.
Overall, there exists a clear commitment at RCSI to undergraduate medical education, specifically within the Department of Surgery. Professors Hill and Leahy, as well as Dr. Hopkins, spoke in great detail about the content of the undergraduate curriculum as well as the extensive reach of RCSI outside of Dublin (e.g. Malaysia and Bahrain). For example, the final oral examination for senior medical students, consisting of two major cases, was upcoming with the details clearly important to many of the faculty. I would be surprised if many academic Canadian surgeons knew the timing or content of medical school exams, and such exams would not be major events within typical Canadian Departments of Surgery. I left reflecting upon the mechanisms to reprioritize undergraduate medical education in what I do on a daily basis.
Finally, I was impressed with Professor Arnold Hill. Arnie is clearly a dynamic leader with an incredibly “large engine”. He has an active clinical practice in breast and endocrine surgery and has been the Professor & Head in the Department of Surgery at RCSI for almost ten years. Two years ago, he was appointed the Head of the School of Medicine at RCSI, the equivalent of a medical school Dean in Canada. He also maintains and supervises a very active lab research program. At a time where the aspiration of being a “triple threat” in surgery is often felt to be unrealistic, Professor Hill still clearly reaches and exceeds this bar.

LONDON

 I had the great privilege of visiting the Department of Biosurgery and Surgical Technology at St. Mary’s Hospital in London, part of the Imperial College of London (ICL), hosted by Professor Ara Darzi. Professor Darzi, a Lord and member of the Queen’s Privy Council, is an unbelievable visionary, surgeon and researcher. Dr. Karen Kerr, the Director of Research, facilitated my visit.
There are over 40 clinical research fellows at any one point in time across the five major research priority areas within the ICL Department of Surgery. I received a snapshot of some of this work, which included:

• Use of virtual reality technology as a training technique
• Simulation – a wide spectrum including surgical/procedure oriented, as well as situational (including OR camp). The simulation equipment at the Imperial College of London both within the Department of Biosurgery and Surgical Technology, and at the adjacent Patterson Building, certainly exceeds that of any other institution I have ever seen.
• Metabonomics of suctioned air through a cautery/smoke evacuation system to guide cancer surgery
• Anatomage anatomy lab – this looks remarkably like a shuffle board table, but provides remarkable anatomy demonstration in all planes.
• A functioning neurogenomics laboratory which examines surgeon neuroactivity in real time as they are performing a variety of operative tasks
• HELIX – an incredibly novel facility charged with creating new intelligent simple designs within health care.

The number of research projects, their organization, funding and productivity is truly incredible within the Imperial College of London. All research programs are multi-disciplinary and incorporate non-surgical personnel as required. Emphasis is placed on establishing proof of concept and clear progress. I had the opportunity to give rounds entitled “Canadian Cancer Control & System Performance” to a combination of academic consultant surgeons and clinical research fellows.
The following day, I had an extremely refreshing and insightful tour of The Royal Marsden Hospital by Shahnawaz Rasheed (Shanu). Shanu is a colorectal surgeon at the Marsden with a significant interest in rectal cancer and great experience in robotic approaches. Notwithstanding the impressive technology in the operating rooms (including the newest version of the DaVinci robot) of this very old facility ( > 150 years old!), I was most impressed with culture of the Marsden itself. Shanu appeared to know everybody who worked in the institution, and was on friendly terms with all from senior consultants to janitorial staff. Care of the cancer patient comes first and foremost at the Marsden, and its reputation as a top tiered cancer hospital seems is well-founded. “Just getting it done very well” seemed to be the mantra of the institution.
I then met with several individuals from the Centre For Health Policy, which has a clear affiliation with The World Innovation Summit For Health. Both are Chaired by Professor Darzi, and both have had significant impact. The World Innovation Summit of Health, a co-initiative of the Imperial College of London and the Qatar Foundation, has had two very successful Congresses, targeting high level health policy decision makers from around the world.   I was most interested by the work addressing value in cancer care, diffusion of healthcare innovation, and the delivery of universal health coverage. The model involves a very strong team of committed individuals who are able to leverage relationships with carefully selected Chairs for the individual content initiatives upon which they embark. The ICL’s Centre for Health Policy, and Department of Surgery, also have a big data unit directed by Ryan Callaghan. They have used UK discharge abstract data (HES) to examine complications and morbidity of surgery at a population level.
I met with the Chief of the Division of Surgery, Professor George Hanna, a noted upper GI surgeon, who also has significant expertise in quality assurance for surgical procedures. In addition to building a very strong Division, he also has an extremely active research program. Professor Hanna spoke eloquently about the different phenotypes that make up an academic surgery department, and made the case that almost all provide value. In my brief visit with him, Professor Hanna struck me as a very thoughtful and intelligent leader both from a clinical and research perspective.
I then had the opportunity to visit the Hunterian Museum, at the suggestion of Dr. Garth Warnock. For any surgeon who is visiting London, even as a tourist, 60 – 90 minutes at the Hunterian Museum is time well spent. Not only do you walk out of the museum gaining an appreciation of important surgical historical events, the layout of the museum was such that it made me consider the future of surgery. The depiction of vanguard practices “of the time”, both those subsequently well-accepted and those abandoned, makes one think about the eventual place of the vanguard procedures of today.
Overall, I expected that The James IV Fellowship would be a once in a lifetime professional opportunity; indeed it was. The benefits of observing other institutions’ approaches to clinical and academic surgery, combined with the exposure to a variety of cancer control systems, will have a lasting impact when I consider what I do, and how I do it.  I was left with a renewed enthusiasm for both the craft of surgery and the act of inquiry. Although there are marked differences in our environments, institutions and structures, it is clear to me that it is the people that are most responsible for an institution’s/organization’s success. At a time when we tend to focus in the things – operating room time, next generation laboratory molecular sequencing, the newest operating room technology – it is clear that smart, dynamic, passionate and visionary people are our greatest asset.