HCA International Foundation Travelling Scholarship Report

Candidate: Mr Sidhartha Sinha

Canadian Fellowship (July 2018 – December 2018)

Background

I commenced an Advanced Clinical Training Fellowship in Vascular Surgery at the Vascular Surgery Division of the University of Toronto on the 1st July 2018. This was planned to be a 12 month long clinical fellowship rotating through three hospitals at four monthly intervals in the following order –
St Michael’s Hospital [SMH] (July – October 2018), Toronto General Hospital [TGH] (October 2018 – January 2019) and Sunnybrook Health Sciences Centre (SHSC) (January 2019 – June 2019).

Expectations

Having met Vascular Staff Surgeons from each of the hospitals in October 2016 when I attended forface-to-face interview and spoken with previous Fellows, I was advised that I could expect a fellowship experience commensurate with my status as a post-CCT surgeon from the UK. Central to
the expectation was exposure to a high operative case load and training in endovascular and interventional techniques such as endovascular aneurysm repair (EVAR) and lower limb angioplasty.

Firm Structure

Firm structure comprised Vascular Staff Surgeons, Vascular Fellows (all of whom were International Medical Graduates from either the UK or from Saudi Arabia), Vascular Residents (ranging in seniority from PgY1 to PgY5), “Off-service” Residents (either from General Surgery or Cardiac Surgery) and Vascular Nurse Specialists.

The specific numbers of staff at each of the units I rotated to are listed in Table 1 and Table 2.

Whilst the UK Fellow was posted to each unit for a four month period, it was important to note that clinical schedules for all Residents was organised by four-weekly “blocks” such that they could be assigned anywhere from one or more consecutive or non-consecutive blocks at each unit. Consequently there was a high turnover of junior staff through each unit over a given four month period. This was a consequence of the Canadian Vascular Surgery training programme which required exposure to several specialities and sub-specialities during a relatively short training period (5 years).

However, the result of this was that there were frequent periods where firm structure at ward level and on-call level was only dual-tiered (i.e. comprising the Vascular Staff Surgeon and either the Vascular Fellow or a senior Vascular Resident [i.e. PgY 3 – PgY 5]).

Typical Weekly Schedule

Clinical activity at each unit was comprised of morning ward rounds, ward (also known as “floor”) duties, elective operating lists, outpatient clinics, on-call duties / emergency operative cases and academic activities (such as journal clubs). Sample weekly schedules for St Michael’s Hospital and Toronto General Hospital are presented in Tables 3 and Table 4

Table 3: Sample weekly schedule at St Michael’s Hospital.

Table 4: Sample weekly schedule at Toronto General Hospital.

The average number of 1st on-call, 2nd on-call, ward cover, outpatient clinic and operating theatre sessions per month are listed in Table 5 (where a session denotes approximately one day’s worth of clinical activity; 8 hours for elective activity such as clinics and 24 hours for on-call). Approximately 65-70% of time was spent on non-operative clinical duties and academic work.

Table 5: Collated sessional activity for Canadian Fellowship averaged out over 6 months (across 2 sites SMH and TGH).

On-call frequency varied from 1-in-2 to 1-in-4 on-call from block to block. In total, 78% (38/49) of on-call sessions were performed as the 1st on-call doctor which included first point-of-contact from ward nurses for standard ward administrative tasks throughout the night (such as the prescription of anxiolytics, laxatives, intravenous fluids or analgesia). Ward cover duty days involved the completion of patient discharge summaries, liaising with ancillary specialities regarding patient plans and managing patient flow through the vascular ward whilst elective activities such as outpatient clinics and operating lists were running. Phlebotomy and cannulation were generally well covered by a hospital-wide Phlebotomy Service whilst the Vascular Clinical Nurse Specialists also provided support in terms of completion of clinical administrative tasks (such as completion of discharge summaries).

There was no access to the Interventional Suite at SMH until this was specifically requested of the International Fellowship Director (IFP). It became apparent that such access had never previously been provided for Fellows. It was with some difficulty that the IFP was able to arrange a half-day session per week at SMH – this amounted to a total of 3 sessions for the four month long block (as the sessions commenced halfway through the block). At each of these sessions, the Interventional Radiology Department insisted that an Interventional Radiology Fellow scrub for all cases as the 1st operator. There was no scheduled access to the Interventional Suite at TGH.

Case Volumes

A total of 125 cases were performed (either in the capacity of assistant, first operator with Staff Surgeon scrubbed or first operator with Staff Surgeon unscrubbed but present in theatre) during the 6 month period across both sites (SMH and TGH). This equated to 20.8 cases / month. The breakdown of cases by type is listed in Table 9 and Figure 2 to allow comparison with the Australian Fellowship experience.

Academic Outputs from Fellowship

One peer-reviewed paper was accepted for publication in the Journal of Vascular Surgery –

Systematic review of contemporary outcomes of endovascular and open thoracoabdominal aortic aneurysm repair. Rocha RV, Lindsay TF, Friedrich JO, Shan S, Sinha S, Yanagawa B, Al-Omran M, Forbes TL, Ouzounian M; Journal of Vascular Surgery [accepted for publication June 2019].

In addition to the above, academic departmental presentations were made in July 2018 at SMH (on NICE draft guidelines regarding abdominal aortic aneurysm repair) and in November 2018 at TGH (on treatment of organ mal-perfusion in type A aortic dissection and revascularisation strategies for chronic mesenteric ischaemia).

Positive Aspects of Fellowship

Particular aspects of the Fellowship experience which deserve to be highlighted included –

1) Exposure to supra-clavicular 1st rib resection for treatment of thoracic outlet syndrome at SMH. Staff Surgeon and Chief of Department Dr Mohammed Al-Omran has a particular interest in this procedure with one of the largest personal case series in the world and regularly performs 1-2 procedures per week. He provides structured teaching in the procedure such that Fellows are scheduled to operate with him for 2 consecutive blocks (i.e. 8 consecutive weeks) with a graduated increase in the proportion of the case performed by the trainee under his direct supervision.

2) Exposure to pre-operative planning for endovascular aneurysm repair at both SMH and TGH. Staff Surgeons Dr Mark Wheatcroft, Dr Thomas Lindsay and Dr Thomas Forbes have large aortic practices and there is ample opportunity for case discussion in multi-disciplinary meetings (known as “EVAR rounds”) as well as pre-operative stent-graft size planning (through good links with industry representatives such as from Cook Medical).

3) Vascular Staff Surgeon attitudes to teaching and training in both the outpatient clinic and operating theatre was positive with time taken to explain questions regarding management or operative technique.

4) Inter-personal relationships between Staff Surgeons, ancillary specialities (such as Cardiac Surgery, Nephrology and Intensive Care) and Allied Health Professionals (nurses, nurse specialists, physiotherapists etc) were cohesive and friendly which made it a pleasant working environment.

Negative Aspects of Fellowship

Unfortunately, there were a number of aspects with the Fellowship which failed to meet expectations –

1) Scheduling conflicts with Residents –

a) It was evident that the cohort of University of Toronto surgical trainees had an expectation that they would be prioritised for access to operative cases. This expectation was supported by Departmental policy as outlined in the contract of employment (Figure 1).

Figure 1: Excerpt from employment contract regarding training of University of Toronto surgical residents.

b) Particular difficulties arose when discussing scheduling for “routine” cases such as standard endovascular abdominal aortic aneurysm repair (EVAR), open abdominal aortic aneurysm surgery, infra-inguinal bypass, vascular access and open venous surgery. Whilst the viewpoint of Residents (that Fellows were “fully trained” and so did not require access to such cases) was understandable to a degree, it meant that Fellows were rostered to proportionally more outpatient clinic duties.

c) Scheduling responsibility was delegated to a nominated “Chief” Vascular Resident at each site which further accentuated the difficulties listed above.

2) Falling case volumes –

a) The number of hospitals providing Vascular Surgery services in the Greater Toronto Area has expanded over the preceding 5 years such that outlying smaller hospitals (such as Humber River Hospital, Scarborough Hospital and Trillium Hospital) would take on standard cases which – previously – would have been transferred to one of the 3 major centres (SMH, TGH and SHSC).

b) Vascular Residents were eligible to be posted to these outlying units where they were able to accumulate significant case volumes. Fellows were not eligible to be posted to these units.

3) Increased numbers of Vascular Residents and Fellows –

a) The relatively recent emergence of Vascular Surgery as a standalone speciality from General Surgery meant that each unit was obliged to provide speciality-specific operative exposure for Vascular Surgery Residents when – previously – Vascular Fellows would have been prioritised over General Surgery Residents.

b) Through a relatively recent collaboration with the Kingdom of Saudi Arabia, several Vascular Fellows from Saudi Arabia were enrolled along with post-CCT Fellows from the UK. This meant that – in some units – there would be more than one Fellow requiring access to operative cases.

c) There would frequently be 2 or 3 Vascular trainees or Fellows at open surgical cases and, additionally, at least 1 Interventional Radiology Fellow for endovascular aortic cases. This required the attending Staff Surgeon to compartmentalise each procedure (where possible) such that it was not infrequent to only be involved in a small part of a given procedure (e.g. gate cannulation during EVAR).

4) Lack of dedicated sessions in the Interventional suite –

a) Unfortunately this aspect of the Fellowship proved to be the most disappointing. As described above, there was no preceding mandate for provision of this aspect of training. Whilst a half-session per week was eventually specifically negotiated at SMH, this was only allowed by the Radiology Department with the proviso that an Interventional Radiology Fellow would also scrub for every case.

b) There was no provision made at TGH with the Fellow reduced to spending spare time observing cases in the Interventional suite. Conversely, dedicated training blocks in Vascular Interventional Radiology were provided to Vascular Residents at TGH. seemed to perpetuate the ethos described in point 1 above.

5) Lack of a dual-tiered deployment of juniors / trainees / Fellows –

a) As described previously, firm structure was essentially two-tiered (i.e. comprising the Staff Surgeon and a Vascular Fellow or Senior Resident) at on-call and ward level. This resulted in Fellows (i.e. experienced

surgeons at post-CCT level) spending fairly significant amounts of time on administrative clinical activity such as completing discharge summaries, optimising EPR ("electronic patient record") entries and directly managing patient flow; this was of particular concern when it prevented access to operative cases.

b) A particular problem arose with the management of routine ward duties out-of-hours. Thus, although on-call duties were nominally “non-resident”, the lack of a ward-based junior doctor for the Vascular unit would mean frequent telephone calls from ward nurses for medications, intravenous fluid prescription and clinical advice throughout each night on-call.

Conclusion

It became apparent to me during the Fellowship that it would not provide the training experience I was seeking. My enquiries included extending specific questions to the other UK Fellow who had been concurrently appointed with me for the year and who started his rotation at SHSC. Unfortunately, the answers provided did not reassure me sufficiently that persisting with the Fellowship until I rotated to SHSC would obviate the limitations which I had identified. I therefore made the decision to resign from the Fellowship in December 2018.

On reflection, I would say that the Vascular Fellowship offered by the University of Toronto is unsuitable for most post-CCT surgeons from the UK (in particular those seeking high volume exposure to endovascular and vascular interventional cases). It is likely that more junior vascular trainees (for example from ST5-ST8) may benefit more from the large proportion of non-operative workload (such as ward-level inpatient management, outpatient clinics and academic activities).

Australian Fellowship (February 2019 – November 2019; data only presented for the 6 month period from February 2019 – July 2019)

Background

I commenced a Vascular Surgical Fellowship at St George Hospital in Kogarah, Sydney, Australia in February 2019. The hospital forms part of the South Eastern Sydney Local Health District (SESLHS) and is a 600-bedded tertiary and designated trauma centre. It includes specialised services such as cardiac and neurosurgery whilst the Vascular Unit is staffed by four Consultant Vascular surgeons. The Fellowship was planned as a 9 month long Fellowship. In order to allow comparison with the Canadian experience, only data for the first 6 months of the Fellowship is presented (i.e. from February 2019 to July 2019).

Expectations

I was appointed to the Fellowship after open application and through a competitive (telephonic) interview. Given the issues described during my Fellowship in Canada, I was careful to ask specific questions of both the Consultant Vascular surgeons and also the outgoing Vascular Fellow regarding case volumes, access to endovascular cases (such as EVAR, lower limb angioplasty and arteriovenous fistula salvage) and firm structure. I was able to satisfy myself that the Fellowship would provide the training experience which I was seeking.

Firm Structure

Firm structure comprised Vascular Consultant surgeons, Vascular Fellows, accredited Vascular trainees, non-accredited Vascular trainees and Vascular Interns.

The specific numbers of staff at the unit are listed in Table 6.

Typical Weekly Schedule

Clinical activity at each unit was comprised of morning ward rounds, ward (also known as “floor”) duties, elective operating lists, outpatient clinics, on-call duties / emergency operative cases and academic activities (such as journal clubs). Sample weekly schedules for St Michael’s Hospital and Toronto General Hospital are presented in Tables 3 and Table 4 below.

Firm activity was hierarchical such that Fellows were prioritised for endovascular and complex operative cases. The accredited Vascular Resident (a SET1 i.e. equivalent to a 1st year Registrar) was provided with exposure to components of basic vascular operative procedures (e.g. vessel anastomosis in arteriovenous fistula creation or vessel dissection in open varicose vein surgery). Ward-based management was led and supervised by the Fellows although performance of routine clinical tasks (such as venepuncture, cannulation, completion of discharge summaries and liaison with ancillary specialities) was performed by the Vascular Residents and the Vascular Intern. There was an expectation that the primary goal of the Vascular Fellows was to operate and to teach the Vascular Residents.

On-call duties were “non-resident” at a frequency of 1-in-3 (shared with the second Vascular Fellow and the accredited Vascular Resident). Importantly, the accredited Vascular trainee and the unaccredited Vascular Resident served as the 1st on-call during working hours (i.e. until 1530) on weekdays (Monday to Friday) such that the Vascular Fellows were generally free to operate during the day (i.e. were 2nd on-call). For night on-call duty periods, all wards had on-site medical cover by Interns or Residents and therefore even 1st on-call duty was restricted to the assessment and admission of new patients with vascular pathology. In total, 62% (36/58) of on-call duties were as 1st on but with the important distinction that resident ward cover during these periods was provided by more junior staff.

The average number of 1st on-call, 2nd on-call, ward cover, outpatient clinic and operating theatre sessions per month are listed in Table 8 (where a session denotes approximately one day’s worth of clinical activity; 8 hours for elective activity such as clinics and 24 hours for on-call). Approximately 35% of time was spent on non-operative clinical and academic work.

Case Volumes

A total of 333 cases were performed (either in the capacity of assistant, first operator with Staff Surgeon scrubbed or first operator with Staff Surgeon unscrubbed but present in theatre) during the 6 month period. This equated to 55.5 cases / month. The breakdown of cases by type is listed in Table 9 and Figure 2 to allow comparison with the Canadian Fellowship experience.

Academic Outputs from Fellowship

One poster presentation was accepted at an international meeting in October 2019 (the Asian Society for Vascular Surgery’s 20th Annual Congress) –

Endovascular repair of ruptured, infected infrarenal aorta – a case report and discussion. Cheng C, Ying A, Sinha S, Amin T, Quayle C, Iliopoulos J; ASVS [October 2019].

In addition to the above, an academic departmental presentation was made at hospital-wide surgical grand rounds in May 2019 on venous disease.

Positive Aspects of Fellowship

The main advantages of the Fellowship were –

1) Exposure to a very high case volume of vascular interventional procedures (particularly lower limb angioplasty, arteriovenous fistuloplasty as well as endovascular abdominal aortic aneurysm repair [EVAR]). These procedures were performed with the Vascular Consultants in a modern hybrid operating theatre. The occurrence of near-daily operating lists meant that it was possible to fully immerse oneself in endovascular practice and consequently learn a huge amount within a relatively short period of time.

2) A departmental ethos and firm hierarchy which supported the idea that the primary role of the Fellows was to gain operative competence with a view towards independent practice. Important ancillary roles of the Fellows were to supervise junior members of the team during operative cases (commensurate with the seniority of the trainee) and in managing inpatients.

3) A multi-tiered deployment of junior staff which allowed maximal exposure to operative cases for the Fellow.

4) A very friendly and collegiate group of Vascular Consultants who went to considerable lengths to teach endovascular principles and techniques.

Negative Aspects of Fellowship

For my own personal situation, I am unable to name any negative aspects of the Fellowship. It should be noted, however, that outpatient clinics were relatively infrequent (one half-day clinic per week) and that the main source of patients for surgery were from the Consultant’s private rooms. Additionally, there was an expectation that the Fellows should either possess the FRCS or the FRACS and consequently be in a position to be able to supervise junior Vascular Residents and Interns. Finally, it should be noted that endovenous procedures are not readily available in the SESLHD hence the Fellowship did not provide significant training in these techniques – only isolated cases were performed where special funding was obtained for patients on a named basis. It should also be noted that endovenous techniques were entirely unavailable in the Canadian public healthcare system.

Conclusion

I found the Australian Fellowship experience to be immensely fulfilling. It provided me with exposure to a high volume of endovascular and interventional cases which will provide an excellent basis to commence independent Consultant practice.

The Fellowship is most suited towards post-CCT surgeons who specifically wish to maximise their exposure to operative endovascular cases rather than to more junior trainees also seeking training in non-operative aspects of vascular practice such as inpatient ward management or outpatient clinic assessment.

Case Log Comparison between Canada and Australia

Comparative case numbers are listed in Table 9 below and displayed graphically in Figure 2.

As all lower limb endovascular reconstruction (i.e. lower limb angioplasty and stenting) and arteriovenous fistula salvage (i.e. fistuloplasty and stenting) were performed by the Vascular Consultants in the hybrid operating room, there was a significantly greater exposure to these techniques in Australia compared to Canada (where such cases were performed by Interventional Radiology). The firm structure and working conditions described above also meant that the Fellow was able to attend every operating list during the Fellowship without exception. Consequently, in addition to endovascular cases, the Fellow was involved in more open surgical cases (i.e. infra-inguinal bypass, open vascular access creation and open varicose vein surgery) in Australia.

By virtue of such extensive exposure to endovascular cases, I was able to gain familiarity with the full spectrum of equipment and techniques required to start my endovascular practice (e.g. wire, sheath, catheter and stent systems, percutaneous clot aspiration and thrombolysis, percutaneous closure devices, ultrasound and fluoroscopic-guided vessel puncture). This experience will be crucial for my future Vascular practice.

The Canadian Fellowship offered excellent training in supra-clavicular 1st rib resection for thoracic outlet syndrome and a greater exposure to open abdominal aortic surgery.

Figure 2: Comparative case volumes between Canada and Australia.

Closing Statement

I was forced to change my Fellowship plans midway through the year in order to seek out an experience which was more concordant with my expectations. Although moving from Canada to Australia proved to be an extremely arduous and costly logistical affair, I am glad that I persevered. My experience in Australia proved to be excellent and I will come to rely on it greatly when I start my Consultant post.

Acknowledgements

I am grateful to the HCA International Foundation for its support which allowed me to undertake this fellowship experience.