01 October 2018

The Association of Coloproctology of Great Britain and Ireland (ACPGBI) invited colorectal trainees and consultants within 5 years of qualification to apply for the position of British Travelling Fellow to the USA. This is an ACPGBI and ASCRCS funded observership in the USA which entails the recipient to visit 1-2 units in the USA and attend the ASCRCS international conference (held in Nashville Tennessee for 2018). I was the fortunate recipient for this award for 2018.

It was indeed a thrilling and memorable way for me to end the year 2017, having received the news of being selected for this award just before Christmas. As a pelvic floor surgeon, I was keen to visit Cleveland Clinic Florida and Cleveland Clinic Ohio as well as attending the ASCRCS conference in Nashville. Preparations for this got underway within a few weeks. I would have floundered in my attempts to coordinate this had it not been for the expert help and guidance of the excellent ASCRCS team who were there to help me every step of the way- thank you!!. I gratefully acknowledge my surgical colleagues in Northern General Hospital Sheffield who had no hesitation in letting me take the time off work for this travel. The ASCRCS Team -Elaina McCalmont, Lisa Aguado and Kristi Conley It was with trepidation and excitement that I took off from Manchester airport on the 9th of May 2018. After checking in at a hotel close to Cleveland clinic Florida I went for a scouting look at the hospital where I was to spend the next 1 week. If first impressions were to go by I would say I was awestruck. It was with trepidation and excitement that I took off from Manchester airport on the 9th of May 2018. After checking in at a hotel close to Cleveland clinic Florida I went for a scouting look at the hospital where I was to spend the next 1 week. If first impressions were to go by I would say I was awestruck. Cleveland Clinic, Florida Dr Steven Wexner and Anil George After a pleasant and quick Monday morning Medical Personnel induction, I was taken to surgical outpatients where I officially started my observership - mainly with Dr Steve Wexner. The next few days were a whole new experience - waking up at 4:30 am to reach the hospital for a 5:30 am ward round and a subsequent starting of OT by 8 am was not a routine I was by any means used to!!. Using the time between 7 am (after completing the early morning ward rounds) and 8 am (Start of OT) for educational meetings and MDT proved a clever and compact way to best utilize the morning time. The surgical exposure that I had at Cleveland Clinic Florida was a singular experience with a wide variety of cases seen across the outpatient clinic as well as in the operating theatre. The significantly rapid turnover of patients that occurred in order to facilitate the smooth running of the theatres was impressive, given that it was only a 150 bedded hospital. The insightful experience allowed me to compare and contrast two different health systems (the UK NHS system and the US system). I realised that bed shortage issues were a common problem on both sides of the Atlantic! I am grateful to the junior members of the surgical team – as my main interactions were with them. I acknowledge the vast amounts of clinical work that the junior members put in and realise that the 48-hour working week we in the UK enjoy is but a dream in the USA. That first week in Florida went by in a blur, however, every day brought me exposure to completely different sets of patients and operations- all of which broadened my awareness of surgical repertoire. Socially I made new friends and met a lot of new people- from USA, UK and India- friends who invited me to their homes for dinners with their family, making the time and effort to show me around their hometown. I gratefully remember the unconditional affection, care and warmth that was extended to me by strangers, making my stay in Florida truly memorable. With Dr Guy R. Orangio (ASCRCS President) & Mrs Orangio I left for the ASCRCS International conference in Nashville on Saturday 19th May. A short flight early in the morning brought me to the land of country music. The Omni hotel- where I was booked into by the ACRCS team- provided a memorable stay, in terms of excellent ambience coupled with the opportunity to meet and network with the conference committee members. Special thanks to Dr William Cirocco (ASCRCS Council Member) and Dr Guy R. Orangio (ASCRCS President) for the warm welcome extended to me during my time there. The ASCRCS Conference gave me an insight into the medical technological advancements that was at the forefront in the U.S.A. Robotic surgery is a subspecialty that the U.S excels in and it was enlightening to see the advances and developments in robotic surgery presented at various sessions at the conference. The variety of colorectal cancer and pelvic floor symposiums and sessions were interesting, providing a great opportunity to ‘top up’ on developments as well as to compare and contrast with what is practised in the United Kingdom. As the British Travelling Fellow, I was invited to attend the Young Surgeons Committee meeting at the ASCRCS. This represents the trainee body in the USA and is much like the Dukes' Club in the United Kingdom. It was a privilege to be at a national forum where training and examinations and mock exams were very much the debate. It was reassuring to know that the worries and concerns for trainees on either side of the Atlantic were very similar. Concerns about endoscopy and training were discussed and I was able to give brief outlines about what trainees in the United Kingdom face and how we were overcoming them. The research was very much on the forefront and the idea of research collaborative was being discussed and how this could take off in the United States. I contributed by sharing advances in research collaboratives in the United Kingdom and their excellent research output. With the Members of the Young Surgeons Committee The social events at the conference were truly unique and gave me the opportunity to meet and talk to senior and junior surgeons as well as trainees. ‘Riding the Bull’ was an amazing charity experience and perhaps something we could do for conferences in the UK as well. Meeting up with many friends and surgical colleagues from the USA and the UK (who were attending the conference) was great company and late nights were spent either talking or walking and seeing the spectacular sights of Nashville. Crossing the Cumberland River and being on the John Seigenthaler Bridge at night (one of the longest pedestrian bridges in the world) was a breath-taking experience. The 5 days of the conference finished in a whirlwind of attending sessions and talks as well as informal get-togethers and before I knew it I was ready to fly to Ohio for the third and final leg of my travelling fellowship in Cleveland Clinic Ohio. Front view of Cleveland Clinic Ohio I reached Ohio on 23rd May to a bright warm and lovely Ohio weather. I had arranged my accommodation in a guest house about 10 minutes away from the Cleveland Clinic. If Cleveland Clinic Florida was amazing then I would say that Cleveland Clinic, Ohio was even more impressive. Cleveland Clinic Ohio has its own police department!! The following morning was spent in induction and getting ID badges. Over the next week, I met several of the top colorectal surgeons in Cleveland Clinic- Dr Tracy Hull, Dr James Church and Dr Scott Steele. The colorectal center in Cleveland Clinic Ohio was a pioneering center for excellence under the mentorship of the late legendary Dr Victor Fazio and this continues even today. I had an excellent exposure to complex cases in the outpatient department- from cancer cases to benign proctology and tertiary referral pelvic floor cases. Robotic ventral mesh rectopexy procedures were a delight to watch- through the techniques and meshes used differed from our practice. Academia forms a significant part of activities at the Cleveland Clinic and I was able to join a monthly morning research meeting where the research fellows updated on the ongoing research work at Cleveland Clinic – it was good to have an understanding of the large amount of academic work that went on behind the scenes at Cleveland Clinic. Attending a colorectal MDT at Cleveland clinic was interesting and was a different experience to our own UK Colorectal cancer MDT format. Cases were presented by the junior fellows and discussions were held with extensive quoting of literature. MDT meetings were usually accompanied by a full-on breakfast as well! I spoke to several research fellows and junior doctors during my time at Cleveland Clinic. Training in the USA is modelled on a different system from back in the United Kingdom. Research fellows, who enter the country aspiring to get onto a residency programme, spend a year or two working doing audits and small projects in each hospital. There were several of such research fellows at Cleveland Clinic –who I met and spoke to. It was an interesting experience to sit in on a research meeting where the research fellows present the fruits of their labour to the supervising attending consultant. I realised that the issues we face with data collection, analysis and statistics exist just as strongly on American soil as well. A Research Update Meeting underway The research fellows are expected to present and publish regularly to enable their attempts to get onto the training residency ladder – which I could see was no easy feat. Getting onto the residency scheme does not guarantee completion of their training and much like our Annual Review of Competency Progression (ARCP), the residency fellows have yearly reviews which are not an easy hurdle to overcome. Once residency is completed then begins the term of being an associate, who works for a year or two in a subspecialty of his or her choice and gets exposed to more complex, difficult procedures and cases. They then progress to become independent consultants or attendings. This varies from the training system in the United Kingdom – though the expertise and calibre of the trainees at the end of the training is by all means comparable. Post-surgical training fellows from the United Kingdom go over to Cleveland clinic for a year of specialised overseas colorectal training. I, therefore, was able to meet up with one of my colleagues – Mr Jim Tiernan –who was doing his 1-year overseas fellowship. After having left Cleveland Clinic (Florida and Ohio) after a week each of observership, I felt that I have become a more complete surgeon. The number, spectrum and management of cases that I have seen have widened my surgical perspective and experience. There are several areas where I feel that surgeons in the UK perform and manage patients differently. I have discussed this with the consultants in Cleveland clinics and perhaps it could be that there are different routes to attaining the same good quality patient care and no single method is the only best way. Discussion of colorectal cancer cases at multidisciplinary meetings (MDT) is a concept that is slowly picking up in the USA -though, at present, this remains confined to the main tertiary referral centers. Discussion of complex pelvic floor patients at Pelvic floor MDTs is a concept that is yet to gather momentum in the USA. The very recent mesh controversy that is looming over the UK pelvic floor surgery horizon is a concern that seems to be only on this side of the Atlantic. Stenting of ureters prior to right and left-sided cancer surgery is a routine procedure carried out in both US centers that I visited- this procedure is only very sparingly used in UK colorectal cancer approaches. Research and academia are also interestingly completely different on either side of the Atlantic. Multicenter trials and multi-institution studies are uncommon in the USA though there is a deep desire for this to happen. The role of trainee led research collaboratives is in its infancy in the USA while its rollout in the UK has been both rapid and rewarding – both in term of research data as well as participation. The phrase ‘publish or perish’ rings true for research work carried out by the many research fellows that I met in the USA – if they do not publish their study or their data then they stand little chance of being recognised and getting onto the surgical training ladder. I wistfully remember the many audits and small research projects that I undertook which though painstakingly done and completed never reached fruition in the pages of a published journal. The honour and privilege that I had to cross the Atlantic and visit the United States of America as the British Travelling Fellow have been a once in a lifetime opportunity. As my plane taxis and takes off from Ohio international airport to take me back to my loved ones, family and alma mater and the twinkling lights of the ‘Land of the Free and Home of the Brave’ recede behind me, I look back in respect and gratitude, awe and acknowledgement, thanks and fond memory. Respect and gratitude for the many American people and families who after having met me for the first time as a stranger from a foreign land treated me as their own and opened their hearts and homes to me unreservedly. Awe and acknowledgement for the great and expansive American land and the vast medical network which in spite of its failings and shortcomings does a brilliant job of keeping the ‘star spangled banner’ healthy and flying full mast. Thanks, fond memory and a grateful farewell to the many senior attendings, associates, residents, junior doctors and research fellows who took time to show me their skills, techniques and routines which is what has kept America truly on the forefront of medical science and technology.

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