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Paul Sutton - Ronald Raven Travelling Fellowship 2013

Report and photos of Paul Sutton's visit to the Mayo and Cleveland Clinics

The Mayo Clinic has been consistently ranked as the leading hospital in the United States, and is home to arguably the most prestigious gastroenterology and GI surgery unit in the world. Having visited the hospital in May of this year it was clear to see why. To be upfront I believe the largest strength of the department, and indeed the institution, is its ruthless commitment to the integration of patient care, research and education. Indeed this was the cornerstone upon which the hospital was founded by Charles and William Mayo in 1889, and is evident in the three overlapping shields on the institutional logo.

But what does this mean for patients? Yes the attending doctors that work at the Clinic are amongst the most committed, dedicated and able I have had the pleasure of working alongside, but the most striking features are of the infrastructure in which they work. Firstly they are surrounded by an incredible team of people. Everybody who works at the Mayo Clinic are selected for being amongst the best at what they do, including a famous restauranteur who now runs the hospital canteen, concierges who have worked in some of the top hotels in the world, and telephonists who undergo a two day selection process for employment. The services that support patient care include a 24 hour interventional radiology service, hot reporting of frozen sections for all(!) surgical specimens in theatre and a very knowledgeable team of nurses, nurse practitioners and physicians' assistants who care for the inpatients in spacious and well appointed single patient rooms. 

Whilst based in Rochester, Minnesota (a corn field in the middle of the mid-west), the reputation of the Clinic continues to attract some of the most challenging oncosurgical cases from around the US and indeed the rest of the world. The buildings themselves are vast, smart and decorated with original works of art complemented by regular musical performances. Patients will travel for days and stay nearby in a hotel; they are allocated their own clinic room and will attend daily for consults and investigations. To highlight this  a young lady with recurrent rectal cancer flew from Louisiana on Sunday, was seen by colorectal surgeons, orthopaedic surgeons, urologists, gynaecologists, oncologists, stomatherapists and many others, had all necessary pre-operative investigations and underwent a pelvic exenteration with intra-operative radiotherapy 4 days later. The patient was discharged from the hospital on day 7, remained locally in a hotel for a further 3 days and was seen again briefly prior to leaving the state. The only disadvantage I saw to this model of care was the difficulties it caused when, for example in the management of benign disease, a period of watchful waiting would have been of benefit. However the care received by patients with advanced malignant disease was quite simply incredible. Another key strength of the surgical department was its trauma and emergency division, which armed with its own fleet of air ambulances deals with an average of 4 trauma calls per day. It was very impressive to see the systems in place for dealing with trauma (a frightening proportion of which was paediatric), including the commitment of the 15 strong trauma team to assessing and stabilising patients within 10 minutes of arrival and facilitating their transit through the department.
Mayo clinic
Whilst the surgical strategies used for the treatment of colorectal and hepatobiliary malignancy were similar to our practice in the UK (albeit with a greater drive for minimal access surgery), what was apparent was a much more aggressive approach to systemic therapy. It was interesting to have discussions with surgeons and oncologists about the role of neoadjuvant therapies, surgery for stage IV disease as well as how their approach to the management of early and screen-detected rectal cancers is changing. I was fortunate enough to observe some complex colonoscopy lists whilst at the Clinic, including the full thickness excision of a T1 rectal tumour. A significant proportion of patients receiving treatment were enrolled into clinical trials, mostly for novel agents. Almost all trials were conceived from the Clinic which also claims one of the most advanced integrated electronic patient record systems in the world. Biobanking of tumour samples is ubiquitous and performed by the pathology team, and laboratory meetings highlighted the very close working of clinicians and scientists who are striving to tease apart the nuances of tumour biology. The hospital also boasts a live animal operating facility for the development of innovative surgical techniques as well as a host of other small animal and in vitro models for translational research.

A strong commitment to education also runs through the ethos of the department. The surgical residents and fellows work extremely hard, with the daily routine commencing at 0600 and ending around 1900. During the week fellows are essentially on call permanently for their service and weekends are divided between them. In return for this they benefit from exceptional training delivered through a mentorship model, access to a purpose built simulation and skills centre and a rigorous programme of almost daily educational conferences. These include grand rounds, case vignettes, morbidity and mortality meetings, didactic sessions covering the syllabus, journal clubs as well as presentations from the residents preparing for their boards. The approach to education however runs much deeper than this, with all healthcare professionals being treated to an equally broad yet focussed educational programme. Finally the emphasis on patient education was also apparent, with a wealth of material provided to enhance the understanding of an already well informed population as well as two dedicated patient education centres within the hospital.

Having completed my visit to the Mayo Clinic I took the short flight to Chicago to join over 30,000 other delegates for the 50th annual meeting of the American Society of Clinical Oncology, the theme for which was 'Science & Society'. Even having visited McCormick Place previously the meeting was vast, although this was well compensated for by the division of sessions into tracts and themes and the ability to review missed sessions online after the event. It was incredibly exciting to hear about recent advances in oncology, one recurrent theme being the incorporation of tumour genotype into study inclusion criteria to ensure best outcomes by focussing on highly specific patient populations. Clearly this allows both the opportunity to trial novel agents whilst simultaneously allowing us to further investigate the biology of the disease.
Cleveland clinic
After the meeting I travelled to another centre of excellence for Digestive Diseases. Founded in 1921 by four renowned physicians, the Cleveland Clinic, Ohio now employs over 40000 people and receives over 80000 hospital admissions per year. At the Cleveland Clinic I had the opportunity to shadow a number of the staff surgeons, including Dr Kalady, who I had made contact with prior to my visit given our overlapping research interests. Dr Kalady is a clinician scientist with an interest in response to neoadjuvant therapy and mismatch repair genes, facilitated by his clinical role in the Centre for Hereditary Colorectal Neoplasia - the largest in the US and second largest in the world. The department's expertise in cancer care is combined with its reputation as a quarternary centre for inflammatory bowel disease as well as housing the Centre for Functional Bowel Disorders.
ASCO symposium
My experience at the Cleveland Clinic hammered home what can be achieved by a department dedicated to patient care, training and both translational and clinical research. Many of the excellent systems and processes I had witnessed at the Mayo Clinic were apparent here. I took the opportunity to explore the decision making surrounding the management of advanced and recurrent rectal cancer, as well as case selection for robotic resections and revision pouch surgery. What was particularly impressive was the organisation of familial screening for those at risk, centred on a one-stop-clinic co-ordinated by a dedicated nursing team. Patients would receive endoscopic examination, uterine ultrasound and dermatological screening as well as clinical review at a frequency determined by both their relative risk and age. Again I visited the endoscopy unit and inpatient wards, and attended numerous grand rounds, conferences, scientific meetings and tumour boards. At all times I was in awe of the commitment and professionalism on display, and what can be achieved, be that clinically, scientifically or educationally, by a dedicated team working in a well-resourced environment.

It has been an absolute privilege to see the work of these two centres of excellence, and I am confident that I have learned a great deal which will shape my own clinical practice. Seeing busy surgeons with 9 operating/clinic sessions a week fully and completely integrate research and training into their practice and simultaneously meet the demands of a complex and demanding patient group was incredibly inspiring, as was their approach to barriers, uncertainty and adversity. I'm grateful to Dr David Nagorney at the Mayo Clinic and Dr Feza Remzi at the Cleveland Clinic for hosting me, as well as Professor Graeme Poston at Aintree University Hospital for his support and mentorship. I'd also like to express my thanks to the British Association of Surgical Oncology for the award of the Ronald Raven Travelling Fellowship, without which this fellowship would not have been possible.

Paul Sutton

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