Ian R. Gough

AUSTRALIAN ENDOCRINE SURGEONS GUIDELINES AES06/01. POSTOPERATIVE PARATHYROID HORMONE MEASUREMENT AND EARLY DISCHARGE AFTER TOTAL THYROIDECTOMY: ANALYSIS OF AUSTRALIAN DATA AND MANAGEMENT RECOMMENDATIONS

Background:u2003 The risk of hypocalcaemia after thyroidectomy has traditionally mandated inpatient monitoring for signs and symptoms as well as frequent measurement of serum calcium levels. In recent years there has been much interest in the published work about the use of intact parathyroid hormone (PTH) to better predict hypocalcaemia after thyroidectomy. Although generally accurate, the use of intact parathyroid hormone in Australia has not become widespread. On behalf of the Australian Endocrine Surgeons an analysis of Australian data on the use of PTH levels to predict hypocalcaemia after thyroidectomy was carried out. The data were analysed with a view to making recommendations about the use of this test in clinical practice and the feasibility of achieving safe early discharge for patients.

A new surgical education and training programme

Educating and training tomorrow’s surgeons has evolved to become a sophisticated and expensive exercise involving a wide range of learning methods, opportunities and stakeholders. Several factors influence this process, prompting those who provide such programmes to identify these important considerations and develop and implement appropriate responses. The Royal Australasian College of Surgeons embarked on this course of action in 2005, the outcome of which is the new Surgical Education and Training programme with the first intake to be selected in 2007 and commence training in 2008. The new programme is competency based and shorter than any designed previously. Implicitly, it recognizes in the curriculum and assessment development and processes, the nine roles and their underpinning competencies identified as essential for a surgeon. It is an evolution of the previous programme retaining that which has been found to be satisfactory. There will be one episode of selection directly into the candidate’s specialty of choice and those accepted will progress in an integrated and seamless fashion, provided they meet the clinical and educational requirements of each year. The curriculum and assessment in the basic sciences include both generic and specially aligned components from the commencement of training in each of the nine surgical specialties. Born of necessity and developed through extensive research, discussion and consensus, the implementation of this programme will involve many challenges, particularly during the transition period. Through cooperation, commitment and partnerships, a more efficient and better outcome will be achieved for trainees, their trainers and their patients.

Total thyroidectomy for amiodarone-associated thyrotoxicosis in patients with severe cardiac disease

BackgroundSurgical treatment of amiodarone−associated thyrotoxicosis (AAT) is effective although fewer than 100 cases have been reported world wide.Materials and MethodsWe reviewed 14 patients treated with total thyroidectomy by a single surgeon from 1998 to 2005.ResultsThere were 11 male and 3 female patients who ranged in age from 26 to 82 years (average 50.5). Nine patients refractory to medical management and 5 in whom amiodarone needed to be continued were treated surgically. Ten patients developed thyrotoxicosis while being treated with amiodarone, but 4 became thyrotoxic after ceasing amiodarone 2, 2, 6 and 13 months previously. One patient recently had a cardiac transplant, and 4 were on the active cardiac transplant waiting list. Cardiac ejection fractions ranged from 15% to 50% (average 39%). Four patients had serious complications from medication used to control thyrotoxicosis, including one case of agranulocytosis from carbimazole. Total thyroidectomy was performed under general anaesthesia with no significant intraoperative complications and no deaths. There were no recurrent laryngeal nerve injuries. Two patients required short-term calcium supplementation. All patients had rapid resolution of their symptoms and were euthyroid on thyroxine postoperatively. Two patients had such improvement they were removed from the cardiac transplant list.ConclusionsDespite severe cardiac disease, total thyroidectomy can be performed successfully under general anaesthesia. Surgery should be considered early in the treatment plan. Surgery is particularly appropriate where it is considered necessary to continue amiodarone, when there are complications from the medications used to treat thyrotoxicosis and to facilitate fitness for or defer the need for cardiac transplantation.

Oncoplastic Breast Surgery: A Global Perspective on Practice, Availability, and Training

Oncoplastic surgery is the seamless joining of the extirpative and reconstructive aspects of breast surgery that is performed by a single surgeon. A symposium was held at ISW 2007 in Montreal with a prearranged aim to publish an article on the current and historical record of the developing specialty of oncoplastic breast surgery. The presenters and authors are well-known breast surgeons from Australia, Croatia, India, Sweden, and South Africa.

An academy of surgical educators: sustaining education – enhancing innovation and scholarship

Context:u2002 The aims of surgical education, training and professional development programmes are to ensure surgeons will provide high quality health care throughout their professional lives. Development and delivery of these programmes requires a mixture of surgeons with a different but complimentary range of competencies in medical education, all eager to facilitate learning and support educational scholarship.

Mentoring: historical origins and contemporary value.

There ismuch contemporary interest inmentoring. It has been advocated and has received strong support within the Council of the Royal Australasian College of Surgeons and is under consideration for inclusion a routine part of surgical education and training. The original Mentor was a character in ‘The Odyssey’, the epic poem by Homer. Mentor was a friend of the king Odysseus and was entrusted with the care of the royal family of Ithaca while Odysseus (Ulysses in Latin) was away fighting the Trojan wars. Mentor has been particularly credited with helping Telemachus, the son of Odysseus, to mature from adolescence to adulthood. However, according to Roberts,1 careful study of the Odyssey text shows that the original Mentor was not particularly effective in his role. In the Odyssey story, Athena, the Greek goddess of war and wisdom, took the form of Mentor and Roberts contends that it was really Athena who helped Telemachus the most. The word mentor was first used in the English language in 1750 and is defined in the Oxford English Dictionary as an ‘experienced and trusted advisor’.2 It is thought that the modern meaning of the word mentor arises from a popular seventeenth-century French book ‘Les Aventures de Telemaque’ by Francois Fenelon (illustration, Fig. 1)3. The book is an allegory on the French monarchy and is a form of continuation or sequel to ‘The Odyssey’. The character of Fenelon’s Mentor1 is more like the contemporary conception as a wise and experienced person who advises, counsels, guides, teaches, inspires, motivates, challenges, corrects, nurtures, enables and serves as a role model.4,5 The immediate past President of the American College of Surgeons, Edward Copeland III promoted ‘The role of a mentor in creating a surgical way of life’.6 He referred to the recipient of the mentoring in the relationship as a ‘protégé’ although some others use the term ‘mentee’. He thought that there would usually be a hierarchical relationship between the mentor and protégé but acknowledged that this could also include a partnership. A supervisor–trainee relationship is different to a mentor–protégé relationship. A supervisor educates and trains and is also responsible for exercising the power of objective assessment with potentially positive or negative consequences. A mentor would expect to have a longer-term relationship with a protégé, perhaps lifelong if the relationship is successful. An essential element from the outset is mutual respect. The mentor would be supportive through good times and bad. The relationship could on occasions, although not routinely, develop into a form of friendship if both parties were agreeable. If a mentor was also required to act as supervisor, that role would usually only be short term and the boundaries would need to be clearly defined. An individual may have more than one mentor. Mentors may have shared or overlapping roles or have distinct roles such as one mentor for clinical surgical experience and another for research experience, while both mentors would have a roles as life coaches. The key roles of a mentor, although not a comprehensive list, are shown in Table 1. There is a considerable amount of effort involvedbybothparties in a mentor–protégé relationship, but a great deal of reward and satisfaction as well. Surgeons are encouraged to offer mentorship to surgical trainees and trainees should ensure that they have a mentor.

The impact of reduced working hours on surgical training in Australia and New Zealand

There is a worldwide trend for reduced working hours for doctors, particularly in the developed western countries. This has been led by the introduction of the European Working Time Directive (EWTD) that has had a significant impact on work patterns and training. Australia currently has a more flexible working environment but this is changing. In New Zealand there is a contract for resident doctors defining a maximum 72 h of rostered work per week.

THE COLLEGE–UNIVERSITY CONCEPT

Over recent years there have been discussions on the relationships between the Royal Australasian College of Surgeons (the College) and universities in Australia and New Zealand. Debate intensified during 2006 with the development of a new College Surgical Education and Training programme (SET)1 and a proposal that a consortium of universities might develop an alternative surgical vocational training programme (Consortium of Universities for Professional Health Education, CUPHE).2 SET has progressed through accreditation by the Australian Medical Council and will commence in 2008. The university consortium CUPHE decided to disband in late 2006, but was a catalyst for ongoing discussions. During the past two decades there has been a progressive decline in the numbers and influence of surgical academics in medical schools. Many academic surgeons feel undervalued and undersupported by their institutions. Many departments of surgery, including research staff, have fallen below a viable critical mass and recruitment of new academic staff is extremely difficult. There has been concern for many years about the progressive reduction of basic science education and surgical education in medical schools. Surgeons have noted the lack of knowledge of human anatomy displayed by senior medical students and junior doctors aspiring to be surgeons. The time allocated for surgery in medical school curricula has been reducing over many years. Most surgical specialties, if they are offered at all, are only available as brief elective options. The College has held productive discussions with leaders of many medical schools and there is recognition of the issues and an intention to address them positively. With the introduction of SET, which selects into one of nine surgical specialties during July of postgraduate year 2, there is a need for the College, specialty surgical societies and universities to cooperate to facilitate the experiences and education of potential surgeons so they may make the correct career choice. The idea of surgical ‘streaming’ in the last 2 years of medical school is under consideration. The new College SET programme is specialty specific, shorter than previously, and relies on frequent in-training assessment of achieved competencies before trainees are considered ready to sit for the final Fellowship Examination. There is emphasis on course work and skills laboratory work to ensure competencies are acquired progressively and efficiently. The additional demands on time and facilities will be considerable. Surgeons have traditionally trained the next generation of surgeons pro bono. Although some training is done in hospitals where surgeons are employed, much additional training and assessment is done on a voluntary unpaid basis in the surgeon’s private time. It has recently been questioned whether this pro bono contribution by surgeons to SET is sustainable. Several surgical specialty societies have commenced development of new training modules for specific competencies and are collaborating with higher education providers who have the relevant expertise. These new relationships have complexities involving intellectual property issues and considerable financial costs. A working party involving the College, the Neurosurgical Society of Australasia and Macquarie University’s Australian School of Advanced Medicine is developing a cooperative programme that will produce specialist neurosurgeons with extra education in science and research and a Masters degree in addition to the Fellowship of the Royal Australasian College of Surgeons (FRACS). Other specialties may be included in similar programmes in the future. The possibility that the College might develop its own university has been discussed at several meetings over the last year. There is concern that the College is nearing its capacity to deliver surgical education and training such that further progress will require a different model. College Council, the senior education boards andmeetings with Specialty Society and Association Presidents all agreed to examine the concept further and a working party has been formed to gather further information. Some of the reasons for considering such a reorganization may be inferred from the background issues already mentioned. In 2006 the newly appointed Australian Federal Minister for Education, Science and Training, Julie Bishop, advocated greater diversity in higher education.3 Subsequent amendments to the Higher Education Support Australian Capital Territory 2003 introduced in 20064 make it feasible for an educational institution, such as the College to become an approved higher education provider, specifically a specialist surgical university. Universities are institutions of higher education and must be commercially viable. They charge student fees that are competitive in the marketplace and students of higher education providers are eligible to access student loans. University funding needs to be adequate to cover the costs of delivery of their programmes, including remuneration of staff, and they may budget for a surplus to develop and improve their product. Government funding through the education budget is available and a university associated with the College may be able to access funding from health sources, education sources and other private funding. Adequate funding would make it easier to develop and deliver improved surgical education and training programmes. A specialist surgical university might provide rewarding employment options for academic surgeons as an alternative to employment in a traditional medical school that provides essentially undergraduate rather than specialist vocational education. The wide variety of skills courses, both technical and non-technical, that are required for the development of competencies during SET might be delivered by a college university. A university has authority to develop, conduct and accredit its own courses. The qualifications available must comply with the Australian Qualifications Framework.5 The qualifications of most interest to a possible specialist surgical university would be Masters and Doctoral degrees, although various diplomas could also be made available. There is no university qualification similar to the FRACS. Therefore it would be necessary for the College, through the Court of Examiners, to continue to provide the FRACS as the specialist qualification in surgery for Australia and New Zealand. The assessment for approval as a university is necessarily rigorous. A specialist surgical university could be established in ANZ J. Surg. 2008; 78: 361–362 doi: 10.1111/j.1445-2197.2008.04477.x