New Zealand

New Zealand

The flight from San Francisco was long, untroubled and only physiologically three hours difference in time, despite a lost day. Auckland was sleepy and warm when we arrived and had a traffic free drive to the Peace and Plenty Inn, a charming bed and breakfast, on the waterside at Devonport. This suburb is just over the harbour from the main city and so travelling in is rather fun and very quick by the Fuller’s ferry which docks a couple of hundred metres from our Auckland abode.

So restful was the place that we settled here for all our Auckland time, now I am sitting in the garden amongst the ferns, alongside the goldfish pond with the cicadas energetically noisy. The breakfasts are a treat, on the sun kissed balcony eating Belgian waffles, syrup and bacon with a cornucopia of fruit: melon, pineapple, blueberry, pomegranate, raspberry, grape, cherry, banana and, of course, kiwi fruit all crowded on to my plate this morning. The coffee, a NZ enthusiasm is locally blended and perfectly delicious.

The modern traveller, equipped with computer and Skype telephone, cannot rest until they are on line, so here sitting in the garden typing away, wirelessly connected to the world this modern traveller is content.

Well what of the country? It is beautiful, crowded around Auckland (one third of the country’s population lives within twenty miles of the city centre) and surrounded by sea, oceans, inlets, bays, peninsulas and islands which are the backdrop to the rolling and sometimes mountainous terrain. We spent the weekend at the Bay of Islands, the site of the initial contact that the west, in the person of Captain Cook and the Endeavour had with the Maoris. This beautiful seascape had an adventurous past and was once the main port of call from all voyages in the south Pacific, for re-victualling and repair. The abundance of Kauri (a large evergreen tree, native to New Zealand that has oval leaves and is valued for its strong timber. Latin name: Agathis australisthis) and flax (for making rope) meant that the 19th century sailing ships could undertake running repairs as well as trade.

In Russell the bed and breakfast we stayed in had matchless views across the bay, much enjoyed when we had a “sun downer” with our host, before setting off to a pleasant meal overlooking the now moonlit bay.

The highlight of our stay was a trip in the R Tucker Thompson, a tall ship, in the historic design of a North West American Halibut Schooner. We sailed , and motored, around the bay and were privileged to have a couple of representatives of the NZ Historic Places Trust, who gave us enthusiastic and detailed accounts of the happenings around the bay in the late 18th and early 19th century.

I have not lost sight of the purpose of this journey, and last week spent a profitable three days in Melbourne, guest of the Royal Australasian College of Surgeons. I was privileged to be admitted to their inner councils and see something of their governance. I was impressed by their ability to be forthright and courteous at the same time. Much of what they are doing in Surgical Education mirrors our efforts and one of the benefits of a journey such as mine is that you can see various solutions, some which might transfer to different cultures.

Meeting colleagues in NZ has been a joy; they are hospitable, relaxed and purposeful. They are conscious of being able to do a great and worthwhile job in a beautiful country, of which they are very proud. The trainees I have met are like all trainees, courteous, loyal and have a different take on the changes that are being carried through. In NZ they are adopting a single entry point to surgical training, so that if someone wants to embark on a surgical career and hey apply and are accepted they should finish, provided they cross the relevant hurdles. The essence of this is humane. It is clearly unfair to recruit two surgical hopefuls to junior posts and only to allow one to progress, however good the one who has to find an alternative career path is. However the transition has delivered some rough justice and the trainees I spoke to ere unhappy that a couple of their colleagues, of whom they thought highly had to seek training in another specialty, despite the time the they had already committed to a surgical career.

Tomorrow it is proper holiday and Port Douglas in Northern Queensland.

More from California

Travelling surgeon

It is a glorious evening in San Francisco. Jane and I have left the Merzenich’s and are waiting to start the next part of our journey, to Auckland.

We really enjoyed revisiting California, where I had been a research fellow twenty three years ago. Much was the same. Some of what was unusual then has become commonplace in English society, we are much more informal than we were quarter of a century ago, we use disposable utensils for our eating away from home, we use the mobile in the street and we say “enjoy”! – or at least some of us do! However on the financial side we did note a difference: when we were here in the early 80’s the dollar was nearly worth a pound, now a dollar is worth just over 50 cents.

I had planned a slightly less intense time in California, so we could spend some time together and could visit my aunt and uncle in Santa Barbara., and with Mike and Diane. All four have been most generous to us, now as then.

My aunt and uncle are in their early eighties, have had their share of maladies (some interesting and challenging) but both approach life with zest and vigour. We arrived at dusk and were immediately whisked downtown to a crowded steak house, so crowded that we left and had a Chinese meal, returning for our steak on the following evening. We spent a couple of hours going through family photos before lunch the next day. These times are invaluable, because they give you a perspective on your lot in life, and in my case make me reflect how fortunate I have been. Then a walk with my uncle, we were all for telling him not to exert himself, but we would have been denied a great walk if we had succeeded. Like most people who know an area well, the walk was perfectly judged, Jane and I would not have done it on our own. We walked around the estate of a rich man, that is we circumnavigated it. I mention this as we did the same the next day, when we visited Hearst castle.

We decided to drive up Highway 1, the wonderfully scenic and sometime precipitate California highway that hugs the coast of the state, and gives a splendid view of the Pacific, as it belies its name and crashes into the seashore. Hearst castle was interesting, it was out of our reach when we were here with the family. You are boarded on a bus and taken up the five miles to the “ranch”, more like a small Italian hilltop town, with several villas (guest houses) and the cathedral or parish church, in this case the main house, complete with two bell towers. The swimming pools are pure fancy, with reconstructed Roman and Greek remains built into a pastiche of the ancient world, which works surprisingly well. The house itself was impressive, and the magpie collection of innumerable valuables in none generation, which then stopped, was fascinating. However without the story, this part was less impressive, we are fortunate in having dozens of stately homes in England, some enormous and internationally known, some only locally known but none the less impressive, with large rooms and the evidence of one or more energetic and acquisitive owner. We watched the film, and were thoroughly immersed in the life of William Randolph Hearst.

Our day was finished in Carmel, the small town just to the south of Monterey that is the home of film stars and the haunt of golfers, Pebble Beach lying just to the north. When we came they had just said goodbye to a great number of people following a golf tournament. We had stayed at a pretty little in 10 years ago and it was still there, with a room and ideal in every way (or almost, breakfast was served in disposable cups and plates).

All the rest of the time we spent with Mike and Diane. Mike is a neuroscientist, who was originally involved in the cochlear implant project but has moved to more central disorders of the brain. He is awash with ideas, energy and goodwill. Part of his current life involves developing the small holding which he and Diane have, about an hour out of San Francisco. They have a very productive kitchen garden and orchard, beehive and a vineyard. We visited this just before we left, and were most impressed, it is in a lovely spot, with uninterrupted views over the Bennet valley (near Sonoma, California wine country) perched on a hillside, with terraces, a small, wood, a creek, a swimming pool and most rewarding of all the signs of active grand-parenting wherever you look!

The remainder of the time we lived in their small guest annex in their San Francisco.
The whole episode was a wonderful demonstration of friendship and generosity.

Arrived Auckland, more sun, more charm and more excitement!

A tale of two centres

Chicago and Toronto are two major North American cities, both with several University teaching hospitals. In Chicago I visited Northwestern and in Toronto the University Hospital Network, the several teaching hospitals in Toronto working together.

What strikes you as you enter them is the considerable local philanthropy which has gone to build them. The buildings are all named after local benefactors, whose name does not necessarily have world wide resonance, Galter in Chicago and Eaton in Toronto are both people of local rather than worldwide renown.

It is also apparent that North America views health care with great seriousness. They are both impressive medical complexes, with space for patients and for teaching. They have both made considerable investments in surgical education, both at under and postgraduate level. Both have well resourced, charismatically led surgical skills centres and both let me have an office for my stay!

In both I met a whole series of committed clinicians, research scientists and teachers, who gave generously of their time and expertise. In both I was fed copiously!

In both the leader is one of the major players in surgical education in North America. In fact there is a foursome, renowned as the main initiators of surgical education, Richard Reznik in Toronto and Debra Da Rosa at Northwestern, as well as Ajit Sachdeva in Chicago at the American College of Surgeons (right next to Northwestern) and Gary Dunnington at Southern Illinois. They have all inspired each other and all worked together on the Surgeons as Educators programme. All were extremely welcoming and all gave me an inspired view of their units.

In Chicago, I spent three hectic days looking at and listening to the scope of the programme. I met the main teachers and the researchers and was allowed to try their simulators, meet their residents and speak to the main players. They have some interesting ideas, they have created an apprenticeship scheme, whereby a trainee is attached to a trainer for a couple of months and does everything with them, this sits alongside the normal programme which fill the rest of the time. I saw a talented trainee at the end of their training being taken through a complex operation (a pancreatectomy), both trainer and trainee filled you with confidence, this was an operation done with tempo and clarity, each step was discussed before execution. The student who was second assistant was expected to know the anatomy and physiology, and did!

I then spent half a day at the American college of surgeons, where they very kindly put on a seminar for me outlining the work that they were doing. They have great energy and address problems with panache.

The University of Toronto had three facilities associated with education, the Wilson Centre primarily concerned with educational research, the Skills lab for surgical skills simulation and the Faculty development unit which was concerned with faculty development. I spent time in all three, and all gave me plenty of ideas of how we might do things. The skills lab was used by first year trainees every week as in SIU and they had a clearly structured programme to follow, with six faculty teaching week by week. The Faculty development unit ran courses for teachers, but in the main had only managed to recruit surgical trainers who were in difficulty. There is a case, as back home, to use development resources for all staff, good and bad. Then I was told about the regular evaluation that went on for the faculty. They were all told how they performed on a regular basis and this was particularly helpful for the struggling trainer. As usual it was not as simple as that, and one of the faculty told me how demotivating it was to receive moderate reviews (you are the 52 most popular trainer!) and we both agreed that feedback needs to be distilled rather than given raw!

Both had rigorous assessment programmes, involving local and national tools. There was several knowledge based tests that all the trainees undertook, there were clinical skills vivas , which were fairly structured. They both used OSCEs (Objective Structured Clinical Examinations) and OSATS (Objective Structured Assessment of Technical Skills).

There was much to admire and plenty to adopt at both places. Thanks to all my hosts for their kindness and concern.

Main points to be considered for use in the Oxford Programme:

Recruit theatre nurses to run surgical skills lab
Recruit nurse educators to help deliver training, for students preparing for surgery and residents.
Have regular surgical skills training, rather than separate courses
Consider part of a trainees training as an apprentice to a particularly good teacher
Develop faculty, encourage sharing of ideas as the best way to teach surgery

Now for Stanford and the University of California San Francisco.