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Julie Cornish's Ronald Raven Fellowship-Travelling Report 2014

Report and photos of Raven Fellow Julie Cornish's visit to Strong Memorial Hospital, Rochester, New York State

Julie Cornish is currently a Senior Colorectal Fellow (pelvic floor) in Oxford University Hospital Trust. She has a strong academic interest, particularly in functional outcomes following surgery. She went to medical school in Cardiff, University Hospital of Wales, going onto general surgical training and gained an MD from Imperial College, London in 2011, under the supervision of Professor Paris Tekkis.  Her MD Thesis on "Inflammatory bowel disease and female reproductive health" focused on the impact of IBD on functional outcomes and quality of life in women following restorative proctocolectomy.  She set up the Welsh Barbers Research Group in 2009 as the surgical trainee collaborative in Wales (www.welshbarbers.org.uk). As part of the WBRG, she also established the HART trial development group. HART (Hughes Abdominal Repair Trial) is a multicentre NIHR funded RCT designed to assess the incidence of incisional hernias in patients with a midline incision for colorectal cancer surgery in two different arms; mass closure and the Hughes repair (a modified mattress suture).

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I was awarded the Ronald Raven Travelling Fellowship in 2014 and was fortunate to be able to use this towards funding a two week observership at University of Rochester Medical Center Complex (URMC), in Strong Memorial Hospital's Colorectal Department with Professor John Monson. Strong Memorial Hospital is a large modern medical facility with 830 beds.

Professor Monson was originally appointed as a colorectal consultant in Hull and came to URMC as a visiting professor. He then stayed on to become Chief of URMC's Division of Colorectal Surgery and Vice Chair of its Department of Surgery in 2008.  His experience of both the U.K and the U.S. healthcare system has allowed him to see the merits and flaws in both systems, which has led to an interest in outcomes in surgical care. He is also a leader in the field of low rectal cancer and part of the OSTRiCh Consortium (Optimizing the Surgical Treatment of Rectal Cancer) to improve the quality of care for rectal cancer in the U.S.

Day one in the department of surgery started with a 7am Quality Improvement meeting, which was attended by a large number of surgeons and trainees. Very different to the attendance of a typical UK 8am departmental meeting!  I was struck by the genuine interest by all staff in the QI programs that had been initiated and how they had impacted not only on cost but also on patient care. Even the most junior of trainees understood the requirement to produce high level care with service efficiency and cost effectiveness.

Julie Cornish

During the two weeks I attended theatres regularly, watching robotic and advanced laparoscopic cases. I saw a relatively new insufflation device (AirSeal) for the transanal total mesorectal excision. In combination with the Gelport the approach seemed to reduce many of the issues that have been reported with transanal TME, with minimal billowing and good views. There were more than 30 theatres and several robots in use, mostly by gynaecologists and urologists.

The majority of the cases were anaesthetised by a nurse anaesthetist. This requires a 4 year nurse training degree, followed by at least one year in ITU, then a very competitive entry onto a 24 month course which costs them around $50K to do. The nurse anaesthetists do most lists independently except obstetrics, cardiac, vascular and transplant.  Interestingly the general feeling from the surgeons was they preferred this to the doctor anaesthetists! I asked the anaesthetic trainees how they felt about it and they were not unhappy with it as the nurse anaesthetists acted to provide gaps in the service rota not covered by trainees.

During one of the outpatient clinics I met a patient who had had driven for more than 8 hours to be treated at Strong Memorial.  She explained that her local surgeon had kept cancelling appointments and didn't talk to her. The surgeon at Rochester had taken the time to explain the procedure to her and didn't mind answering any questions she had. As her husband put it "Its simple really, it's about people skills. If you don't treat people as people they aren't going to trust you, even if you are the best technical surgeon in the world."

That's one thing I did notice about the culture in the hospital; from the posters on the wall to the smiling faces of the receptionists, the hospital gave off an atmosphere of approachability and being patient focused.

During outpatient clinics I attended there was a significant difference to the UK, with more discussion about mood, family and outcomes since discharge. This is probably due to the longer time slots, with clinician consultations lasting between 40-60 minutes per patient.  One aspect that I really liked was the lounge area for patients and relatives, which was located close to theatre. Relatives were encouraged to attend with patients. There was airport lounge style board updating on patients location and progress through the process and clinicians would go and speak to the relatives immediately following surgery to speak to their family and reassure or update them on their condition.

All of the departments had their own weekly grand round and the surgical update was on the use of medical marihuana, entitled "Drugs, sex and rock and roll". This 7am morning lecture was attended by nearly 60 juniors and consultants. Professor Gary Morrow gave an interesting lecture, although it's not something I intend on trying to instigate back home. Additional talks from the pharmacy and physiotherapy departments gave useful insights into local policies and opportunities for collaboration between departments.

The department of surgery also has the SHORE research facility linked on site.  SHORE (Surgical Health Outcomes & Research Enterprise) aims to identify the most effective ways to organize, manage, finance, and deliver high quality care as well as reduce medical errors, control costs, and improve patient safety.  SHORE is an excellent unit that has several surgical research fellows, as well as researchers from public health, IT and biostatistics who work in collaboration.  Professor Monson and Dr Fergal Fleming act as clinical leaders for SHORE with Dr Katia Noyes acting as the scientific director of the unit. I was impressed with the training programs for the surgeons and enjoyed seeing the benefits of the collaboration to look at projects from a variety of viewpoints. I have instigated some joint research projects with the unit which I hope will lead to future collaboration. I would like to thank Professor Monson and the team in URMC for their kindness in making me feel welcome, showing me around and giving advice on where to go.

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Special thanks to Carmella Re, Professor Monson's secretary, for organizing my schedule and finding me when I got lost and to Dr Fergal Fleming and his wife Natasha who were especially generous with their time and hospitality.I would also like to thank the British Association of Oncology for their generosity, without whom I would not have visited this amazing hospital and seen the "other side of the mirror" for healthcare.

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