‘For my part, I travel not to go anywhere, but to go. I travel for travel’s sake. The great affair is to move.’
— Robert Louis Stevenson
Today was a day of transition. We moved from London to Oxford to progress our journey throughout England. Fortunately, the minibus was large enough to carry everything we packed — including all our shoes. After we transitioned to our new accommodations in Oxford at the Linton Lodge Hotel, we unpacked and set out to discover food. Despite a bit dreary weather, the spirits were high and the sense of adventure palpable.
First stop was at a falafel stand, then the tour of the closed market and the downtown area.
The market was lovely and reminded us of many similar markets we have visited elsewhere: bustling, energetic, eclectic, and fun. On the way home, we surveyed many different areas for academic study including the Bear, the Wheatsheaf, the Gardener, the Jericho Inn, and the Linton Lodge. In essence, we saw the spires of Oxford as we were passing by…
Following this we adjourned until Prof Matt Costa joined us to take us to dinner at Cherwell Boathouse for an elegant dinner by the River Cherwell. Dinner was glorious; conversation was elegant.
We were joined by Xavier Griffin and Steve Gwilym to discuss the intricacies of the acetabular fracture reduction and repair, the glories of upper extremity fracture surgery, and the challenges that are similar between the US and UK systems. Dinner entailed detailed discussions of our practices as well as social networking. During dinner and on the way home, Joe revealed to us his quaternary area of expertise in upper extremity robotics.
We adjourned to bed with plans for an early and exciting day of academics tomorrow.
In the morning, Jonathan Miles met us at the hotel and set a frenetic pace throughout the morning. He notified us that we were going to experience the “Holy Trinity:” God, the Queen, and the Royal National Orthopaedic Hospital. He certainly delivered.
We received a private tour through Westminster Abbey, touring the grave sites and markers of many English Kings and Queens. The starting area with scientists including Faraday and Sir Isaac Newton greeted us first. To follow, the royal lineage was discussed and demonstrated elegantly by David Mott, one of the Westminster staff
that Jonathan had arranged for us. We even had a chance to enter the chapel where Edward the Confessor was buried. We were impressed by the English Perpendicular Ceiling in the Henry VII Ladies Chapel.
Poet’s corner was also amazing with monuments and burial markers to famous actors, writers, and musicians. This tradition started with the death of the first Crown Poet, Geoffrey Chaucer, who was remarkably short for a writer who had such an impact on English literature. After that we viewed the Shakespeare monument and the shortest thing ever written that bears the name Charles Dickens.
After a leisurely stroll through London traffic, we alighted at the Tower of London to visit with John Skinner a 2004 alumnus of the ABC Fellowship. This tour included views of the city, London Bridge, and the Thames river, as well as an opportunity to view the Crown Jewels, portions of the royal armory, and Joe’s first exposure to Fish and Chips. He pronounced them good. We were awarded by Colin with Tower of London Hats to fight the drizzle and sleet.
After another opportunity to experience London Traffic, we arrived and were able to expedite our excellent talks.
This was in order to facilitate a wonderful roundtable discussion with Prof Tim Briggs about the utility of big data and registry data in standardizing quality of care and how this could be applied the rising cost of healthcare in North America. After receiving ties with the Non Facimus Mediocriter and the RNOH coat of arms, we headed back to the hotel to freshen for the British Orthopaedic Association gala dinner.
The BOA dinner was held in the famous One Whitehall Place, home of the largest cantilever marble staircase in Europe (yes, it’s larger than that one in Italy). The library where the dinner was held was extraordinary and the guest list was humbling and exciting at the same time. President Ian Winson gave a wonderful speech, and welcomed us to the BOA. Sparkly hats were mentioned for some reason…
Conversation was vibrant and the fellows were pleased to receive their BOA cufflinks. One of the most interesting parts of the evening was meeting famous surgeons from throughout the UK, but the best part may have been the constant ribbing of consultants from one site toward the surgeons at the other sites. Some things don’t change with crossing the pond. Eric gave a gracious toast and we enjoyed the evening.
After the requisite nightcap, the crew adjourned for the night. We know that tomorrow we transition to Oxford, and look forward to the future experiences.
Today started like a surgeon’s day – bright and early and with coffee! When we met Sam Oussedik at 6:55, we were all ready to hit the road. The weather was bright but cold and a brisk wind blew through the London streets. As we walked to the University College London Hospital main campus, it was suprisingly busy. We passed the School of Oriental and African Studies that was quite busy with students milling about for that hour.
Sam had arranged a meeting with Prof Marcel Levi, CEO of UCLH. He is a unique presence in the National Health Service because of two reasons: it is unusual for a physician to serve in this role for a hospital system and it is unusual for a non-British citizen to serve as well. He is recently appointed in this role and spoke to us about his transition from the University of Amsterdam in his native Netherlands three months ago. We discussed quite forthrightly the system of private payers that is developing in the NHS and the fact that there was no ongoing obligation for private party physicians to maintain relationships with their patients. There is also no risk stratification to the private system, so it tends to leave the more complex medical and surgical patients in the NHS. We spoke of the role of education for his consultants that he hopes to increase as well as the role that Brexit may play in staffing difficulties. In his hospital >20% of the staff and nurses are non-British and they come from over 120 countries. In terms of research, most of the funding at this time comes from the EU and the UK is quite good at receiving more research funding per unit pound than that pay to the Euro. In other words, when they provide 1 pound to the EU, they receive approximately 2 pounds back in funding. There is currently a merit-based system that rewards research and healthcare innovation dollars to the most qualified applicants in the system throughout the UK.
We followed this with a frank discussion about the role that physician communication has in the discussions about end-of-life care. This discussion was greatly enhanced by his extensive experience as a hematologist. “The higher the quality of your palliative care,” he said “the easier it is to discuss end of life care with patients.” Additionally, he added, it is easier for patients and their families to accept palliative care if it is discussed early and is of high quality.
Following this, we broke into groups, with observations of Mr. Johan Witt (hip arthroscopy), Prof Fares Haddad (robot-enhanced knee replacement), and Mr. Adam Meir.
My group joined Adam at the National Hospital for Neurology and Neurosurgery at Queen’s Square. This Victorian hospital has a storied history and abuts the Great Ormond Street Hospital for Children that we also toured. It was the site of the first intradural surgery in the world performed by Sir Victor Horsley in 1886. We spent the morning discussing the logistics of running a complex spine practice in the NHS as well as Adam’s experience being the only orthopaeidic surgeon in a group that is otherwise entirely neurosurgeons. It was a wonderful morning.
We met at the Institute of Sport Exercise and Health (http://iseh.co.uk/) that is an incredible byproduct of the 2012 London Olympic Games and attempts to enhance sports performance, recovery, and population health. For our academic session, Mr. Simon Lambert gave a thoughtful description of his varied clinical research interests including the anatomy of the teres major (useful for planning transfers) the subclavius (useful for fracture fixation surgery or Latarjet), implant design for clavicle fractures, and prospective multi-centre collaboration on upper extremity trauma. He also has expertise and interest in Faciocapulohumeral Dystrophy and Sprengel’s deformity. Lastly, he spoke of work using modernization of the Bayley-Walker fixed-fulcrum reverse total shoulder replacement and design updates that may improve stability of the glenoid implants. He monitors this with implanted telemetric assessments of function in shoulder and elbow replacement patients. When speaking of his experience working collaboratively, he echoed the theme of our fellowship nicely “What is great about orthopaedics is that we don’t know boundaries in terms of countries.”
Our first academic section went well (despite some difficulties with audiovisual and staying on time.) All of the talks were well received and a great discussion followed Fares’ discussion of the important strengths and limits of registry data and the correct application of those data to clinical practice. The biggest surprise of the afternoon may have been the fact that Nick Bernthal is a monkey doctor, but not a movie star. (http://ortho.ucla.edu/alumni)
Following an adjournment to freshen for dinner (and complete this blog post), we met for dinner at Morton’s Gentleman’s Dining Club as guests of Sam’s brother James Oussedik at his club. We also enjoyed meeting Jonathan Miles, our host for tomorrow. We wore smart casual attire. Hilarity ensued.
There was the expected return to hotel with the needed nightcap.
Consensus was that it was a fabulous day and we appreciate the late start tomorrow.
After a breakfast entertained by Prof Fares Haddad with tales of his ABC Fellowship travels and the excitement of covering the Tottenham Hotspur “Spurs” Football team, as well as the development of the non-operative sports surgeon profession in the UK, we traveled to Imperial College Labs to visit with Prof Justin Cobb.
The lab was incredibly diverse and the tour started with demonstration of the lab’s ability to transport from the imaging study for a patient to the 3D modeling and planning software to the 3D printer for custom instrumentation. This software also can be used to plan complex surgeries such as revision osteotomies. We had the chance to try single-use acetabular reamers that could reduce shelf storage in the hospital and potentially reduce cost.
We also had a chance to review the role of the gait lab and the evaluation of patients with different pathologies. It turns out that patients with hip resurfacing and
unicompartmental knee patients do well in terms of normalizing the gait and total hip arthroplasty patients do relatively well. The total knee patients do not normalize their gait patterns in terms of force pressure and length of stride analysis. Patients with hip pathology have extreme difficulty with walking uphill. Dr. Joe Hsu did his best imitation of a revision arthroplasty patient with spinal stenosis.
Following this, we had a review of the recently published paper by Dr. Richard Abel in Nature Scientific Letters from the lab demonstrating that different biomechanical and microscopic characteristics can be noted in bone samples from patients who were on bisphosphonates. This was controversial at the time of publication and we reviewed not only the data from the study but the development of it as well. This fascinating work used the particle accelerator to achieve micron-level resolution bone CT imaging.
We then stepped into a room for a review of new Augmented-Reality technology that was shown by their lab to enhance the ability of non-surgeons to reliably place an acetabular component in a simulated hip replacement model. Aside from interesting 3D visualizations, the group agreed that there are excellent opportunities for application in learning as well as using this technology for overlay of clinical or imaging data in the operating room. Dr. Eric Strauss impersonated E.T. to the amusement of all.
Our excellent morning ended with a frank discussion with Dr. Catherine Van Der Straten and her research on meniscal transplantation outcomes.
The lab was an amazing opportunity and the experience of these scientists with the personal impact of publishing scientific data that is controversial and bucks common practice was enlightening.
A glorious lunch with Prof Haddad at the Gerkin followed with a lively discussion where politics (American, Canadian, and British) raised its ugly head for the first time and we spoke of practice efficiency and leadership opportunities on both sides of the pond. The view of the moist London skyline was transcended only by the conversation and the food.
In the afternoon, we enjoyed a trip to the Bone and Joint Journal headquarters. This visit, once more led by Editor-In-Chief Fares Haddad was a background of the history of the BJJ (by Emeritus Editor James Scott) as well as the history of the ABC Fellowship (given during a return visit by Deborah M. Eastwood) were informative. Sir Reginald Watson-Jones was a centerpiece of this history of the BJJ (in addition to so many other aspects of orthopaedics) because of his gift withprose and his numerous anatomic treatises that changed the course of orthopaedic surgery. It was a priviledge to hold a paper copy of one of the seminal journal articles in shoulder anatomy (Inman, 1944) – particularly since it was Watson-Jones’ personal copy that I held in my hands.
The discussion that followed centered on the challenges of navigating the current challenges of academic publication from a journal and from a scientist standpoint. After the requisite photo-op in front of the building it was back to the hotel for a quick freshen before dinner with Prof Haddad et al.
The evening was a delightful dinner at the Orrery with Peter Richardson, Timothy Wilton, Honorary Secretary Deborah Eastwood, and President Ian Winson. After a brisk walk home and the customary nightcap, we retired for tomorrow.
Today was arrival day for the ABC fellows. On the way in from the airport, I noted long lines of French ex-patriots waiting to vote in the French election. We also worked our way through significant traffic furniture as the London Marathon was today as well.
As we arrived in our chartered cars from the airport and gathered in our wonderful accomodations at the Holborn Grange Hotel where the BOA has placed us we were greeted by Ms. Hazel Choules, Director of Events Management for the BOA. Her experience with this process was immediately clear (and appreciated by those of us who are new to the traveling fellowship experience).
We had coffee and biscuits with Deborah M. Eastwood, MB, FRCS, a former traveling fellow who welcomed us and shared stories from her time as a resident entertaining the ABC fellows as well as reminiscing about her time on her own tour.
We broke for the afternoon and then most of us gathered for our first dinner together on British soil. Indian food was to order and the fare was only outdone by the conversation.
After a brief nightcap, we took the chance to adjourn early to start again tomorrow when we will tour the BJJ.
“Travel is fatal to prejudice, bigotry, and narrow-mindedness, and many of our people need it sorely on these accounts. Broad, wholesome, charitable views of men and things cannot be acquired by vegetating in one little corner of the earth all one’s lifetime.” — Mark Twain Innocents Abroad
For those new to the American British and Canadian Traveling Fellowship, it started in 1948 when the first group of British surgeons crossed by steamship to visit North American surgical centers. The idea was generated during World War II as the North American and British surgeons worked together in the European Theatre. The exchange of knowledge made possible by that translocation of surgeons was important to 20th century orthopaedics. Consequently, the American Orthopaedic Association (AOA) and the British Orthopaedic Association (BOA) determined to continue the conversation by sending surgeons on biannual visits. The quote from Twain above mirrors the reasons for the introduction of this Traveling Fellowship. Over time, the ABC came to include the Canadian Orthopaedic Association (COA), the New Zealand Orthopaedic Association, the Australian Orthopaedic Association, and the South African Orthopaedic Association (SAOA). In even number years, North American sites welcome surgeons, and in odd numbered years, North American surgeons travel. This year we will visit the UK (as we do every outbound trip) and South Africa. The South Africa leg alternates with Australia/New Zealand. The process is selective and varies from society to society. The goal of the ABC Traveling Fellowship is to enhance collaboration, foster relationships, and develop future leaders in orthopaedic surgery globally.
I am honored to be traveling with my classmates:
Nicholas M. Bernthal, MD – UCLA; Santa Monica, CA
Jonathan P. Braman, MD – University of Minnesota; Minneapolis, MN
Brett A. Freedman, MD – Mayo School of Graduate Medical Education; Rochester, MN
Joseph R. Hsu, MD – Carolinas Medical Center; Charlotte, NC
Eric J. Strauss, MD – NYU Hospital for Joint Diseases; New York, NY
Wade Gofton, BScH, MEd, MD, FRCS(C) – The Ottawa Hospital; Ottawa, Ontario
David M. Sheps, MD, MSc, MBA, FRCSC – University of Alberta; Edmonton, Alberta
Today, as I reviewed the itineraries for our UK and South African legs, I grew even more excited. It is with some trepidation that I board my plane to London tomorrow, as most of us have not yet met. Furthermore, I have been blessed to have mentors, friends, and partners on the ABC Alumni list. It is a great honor to have our names atop this list. The excitement of representing two countries and two orthopaedic associations (COA and AOA) on this historic fellowship is exhilarating and I know that we all look forward to rising to that challenge.
We will be taking turns blogging on these pages over the coming five weeks. Thank you in advance for all the great logistical work that our AOA support staff has put into this project, as well as the work that the BOA and SAOA have done to make it possible for us to join them. We look forward to the friendships, the learning, and most of all to getting out of our “little corners of the earth!”
As we near the final stretch, we had the most amazing dinner last night, with our friends at Tokai University. It included fresh (I mean still moving) lobster and abalone. It also included the local Ukai steak cooked on a teppanyake grill (what we know as Hibatchi style). Earlier in the day we saw the Odawara castle, where we had the opportunity to dress as ninjas and samurai. Great pics for the family (see below). Today, we were able to observe 4 excellent surgeries, including a marvelous resection of a C2 schwannoma. They made it look easy! One more night and then off to Chiba for final stop on this fellowship. Man what a night!