Guest Speaker at ADAD UK

Good afternoon everyone. I'd like to thank Dan personally for giving me the opportunity to just discuss with you what I've done here and how this can help patients like yourselves in the journey against the aortic dissection, this fight that we all have against it. Now I don't boast of public speaking of Mr Cooper so you have to bear with me as I go along. So what I'm going to try and explain today is why fellowships are important in the delivery of treatment for this disease and relatively other diseases as well. So I'm going to give you a quick overview of the structure of surgical training in the UK and where fellowships fit in and I'm going to talk a bit about the aortic service here at Liverpool Heart and Chest which is where I was lucky enough to receive this training And I'll try to finally make this link between what we have here today and where fellowships and how they both are two faces of the same coin in trying to improve our services. So this is just a bird's eye view of cardiothoracic training in the UK. You finish medical school and the first two years, foundation years one and two, followed by specialty training years one and two, which would be surgery if you want to be a surgeon. These are broadly to cover general surgical aspects. Then you take the membership exam of the Royal College and you choose your specialty of choice. For me it was cardiothoracic. So it's spread over six years, the higher surgical training. First year is a ST stands for specialty training especially training three you're just learning how to walk basically learning small steps trying to understand what is a bypass machine so very basic but you do start doing bits and bobs here and there building on the general surgical training that you've taken before. SD four you're actually doing steps of the operation and maybe achieving some cases but all supervised. SD5 and SD6 are the main bulk of training where you're doing cases, a lot of the cases you're starting to do independently but it's all in the generic aspect of cardiac and thoracic surgery. Towards the end of your training year seven you start developing a subspecialist interest maybe because you worked with a boss who you liked or you've done some more reading on a certain subject that you feel you want to pursue but then the cycle starts again but at a higher level so you're still learning, learning steps of the subspecialty. Come ST8, start knowing a bit, people have faith in you that you can start doing some subspecialty cases and once you start and that's it training's finished, you have to start applying for consulting jobs. As Mr. Cooper alluded to earlier, we're becoming more and more sub-specialized because medicine is progressing at an incredibly fast pace. In order to keep up with all the new operations and techniques, we have to sub-specialised into smaller aspects of the curriculum. Add to that that during those six years you're not 100% in the operating room, you've got service commitments, you've got studying and examinations, you're moving around, changing rotations, you've got unfruitful rotations for any reason and you've got European Working time directive which governs how long you can spend in training. So things can get delayed and I'm saying this because I've spent another fellowship elsewhere in Europe in Brussels and the UK training system is an excellent training system, but still you need the time, you need the years to develop all the expertise to do such operations. So why are fellowships important? Well, they're important because they offer you that extra bit of time. Instead of finishing training in eight years, you'll do it over nine years or ten years, and time counts. During those years, you shape your own training. You're not spending it in other aspects of the specialty that you're not interested in pursuing later on, and also the training is tailored towards the trainees' needs. We're all different what we need. More importantly, it kind of puts you on the path for your professional career to follow, so you start knowing experts in the field, you start making those connections and you start building relations that will help you deliver the service later on in life. And finally, you have more time on your hands to do extracurricular things, you're not just studying and going to the operating room, you've got more time to join forums like this to raise awareness, like I did when I was a fellow with Debbie, we went to the A&E consultants and discussed the autodissections, so you have more time for the small things, the cherry on the top of the cake of your training. So a fellowship year can be a wasted year, so you need to choose very carefully where you go. And there are three aspects that govern my choice. One is the centre. So it has to be a centre which has high volume, which is delivering cutting-edge treatment in aortic surgery, there's training at more than one level with cardiologists, vascular surgeons, interventional radiologists, and surgeons, and there's a healthy fellowship environment. That means that the unit and the surgeons and everyone around are used to having fellows around, they're used to training people from outside. This is the team that trained me, they have a high training ethos from previous fellows, there's a uniformity in training because they all learned it together and they support one another but also support the fellow in what he's doing. And finally the job, I was lucky enough to get my funding through Heart Research UK and therefore it's an external funding so the trust didn't have to pay me anything which is good and therefore you can be supernumerary you can spend the time in quality training procedures and therefore I was focused the training was tailored as I said before and it was flexible and varied, so I got the full aspect of aortic surgery. Needless to say again, we are the highest volume in the UK with a full complement of services and having a dedicated subspecialist team has really tipped the balance for the surgeon activity outcome and that's why we're able to deliver at such high results. So this is my basic week, I had three days operating, I had an aortic clinic which I was in charge of the following patients, monthly aortic MDT where lots of surgeons, interventional radiologists, vascular surgeons discuss complex cases, so you get exposed to these cases that would in other hospitals happen in the corridor between a senior surgeon and a senior cardiologist which you wouldn't be privy to. I was also first on call for aortic emergencies, dissections, and I took the call from the referring hospital, reviewed the images, spoke to my senior colleagues and then got the patient across, was the first operator if the case was permitting, and then followed it through. So I had the view of the whole patient story from admission to discharge, and I was able to do a good number of dissections which I wouldn't have been if I was in my usual training. also able to, because of the extra time on your hand, attend courses and conferences and do a bit of publications on the side which boost up your theoretical aspect of the job. So this is my operative experience and in every forum I show this, people are amazed by the number of cases and the independence level that was offered to me here. that's the final line, more time, so I had more time to help with some of the courses that we ran here, I had more time to support other groups like this one and to raise awareness of the important conditions that we deal with. And that's where our paths meet. I think the ultimate goal, as everyone was saying, so everyone was saying, so we have early diagnosis, early referral and you need a surgeon to operate. This is what fellowships provide. Fellowships provide this final link in the long chain to save an aortic dissection patient, but it's all the other things that happened before that that will only make that happen. So support groups like yourselves, especially in diseases which are relatively rare are very important because together you're all empowered, as Ms Lupo was saying, to enact change and allow laws to be set in and certain operational procedures to be in place. They're also important for fundraising, for charity work and for organising events which do raise awareness, and all of this promotes collaboration between all the stakeholders in the fight against the autistic dissection. So what do we need to do? Well, you need to sign this if you haven't, but we also need to fill the gaps in each part of the chain, so raising awareness of A&E's, the A&E's Diagnose early, make sure that we have, as Debbie explained earlier, that we have something similar to the primary PCI network of emergency services to get patients across. Have more surgeons ready at the door, and finally we'll work together to try and change the legislation so this is set in stone. Thank you very much. Thank you.