Training surgeons –breaking free

As the 21st century dawned, the hospital had achieved many of the goals its citizen founders and staff had dreamed of and fought for.

It was a large acute care public hospital serving the people of the western suburbs with its own clinical school for undergraduate medical students.

Its specialty surgical units were flourishing. But the hospital had a large gap in its post-intern training. Interns who wanted to pursue a career in surgery had to apply elsewhere to be appointed as a registrar, the gateway for entry into specialist training.

Western Health (which operates Footscray Hospital and the other acute care public hospitals of Sunshine Hospital and Williamstown Hospital) - was unable to appoint its own registrars to its hospitals because it lacked a training program for surgery. Instead, other hospitals with training programs for surgeons – the Royal Melbourne Hospital, the Alfred Hospital and Monash Medical Centre – sent their registrars to Footscray and Sunshine to get experience in grassroots, high volume general and specific surgery.

Registrars spent six months in surgical training at Footscray and Sunshine before moving to other hospitals to complete their training course. “Our inability to choose our own registrars was a totally unsatisfactory arrangement and it meant we were subservient to the institutions of the Royal Melbourne, the Alfred and Monash,” according to Associate Professor Trevor Jones, one of Footscray Hospital’s senior surgeons and a former Clinical Services Director.

Exterior of the hospital in 2015.

Western Health archives

In 2005 a young colorectal and general surgeon, Matthew Croxford, was appointed as surgical hospital supervisor. He and Mr Trevor Jones and Dr Arlene Wake, the hospital’s Executive Director of Medical Services, were involved in crafting a strategy to convince the Royal Australasian College of Surgeons (College of Surgeons) that the hospital should become a training hub.

They argued that the hospital was big enough and had enough clinical expertise in its sub-specialties to run its own training program. Rather than taking its registrars from other hospitals, it would select and train its own registrars, rotating them between the hospital’s sub-specialties.

“If we could get recognition as a training hub we could retain some of our excellent junior doctors who wanted a career in surgery but under the current system had to leave and go somewhere else to start their surgical training,” Mr Croxford said.

Luck was on their side. Coincidentally the College of Surgeons decided to expand the size of Australia’s training program in general surgery by increasing the number of training hubs.

General surgery is one of about nine specialty groups within surgery under the auspices of the College of Surgeons. Each specialty has its own training program. Registrars accepted into general surgery spend five years training in that specialty. General surgery is the biggest training program in Victoria, with about 140 trainees statewide.

Mr Croxford and Western Health’s leadership team sent a proposal to the College of Surgeons, suggesting that Western Health should become a training hub for registrars specialising in general surgery. The College approved the plan and Western Health started its surgical training program with two training registrars in 2006.

It is now one of Australia’s largest, most successful training hubs for general surgery, achieving higher pass rates among its trainees sitting the Fellowship exam than many of Australia’s other general surgery training hubs.

Independence at last

“Accreditation from the College of Surgeons was a recognition of the quality and volume of surgery and the work being done at Western,” Mr Jones said. “It liberated us. It established our position among the other hospitals because throughout our history, we had always been subservient to the other large teaching hospitals.

“Our evolution as an independent organisation confirmed what we always knew about the calibre of the staff at Western.”

Dr Wake said the general surgery training program strengthened the surgeons’ relationship with the hospital and their commitment to the registrars under their tutelage. “The surgeons started to appreciate that now these people weren’t just rotating in from the Royal Melbourne or wherever. It was actually their training program to improve and make sure their trainees were getting through their exams.

“There’s a sense of celebration among the surgeons when their trainees get their fellowship. Because the registrars are with us and no one else, you can start to build up audits and databases, research projects and all sorts of things. But when people come to you for just six months, it’s hard to get those things up and running.”

The training hub added an extra layer to the hospital’s growing reputation as a major teaching hospital. It helped solve the hospital’s recruitment problems by making Western Health a more attractive destination for local medical students, interns and registrars. More than 1,000 medical graduates applied for 63 intern positions in 2014, compared with 2005 when the hospital struggled to recruit enough interns to fill positions available.

The combined benefits of the training hub, accreditation from the College of Surgeons for other surgical training programs and Sunshine Hospital’s new facilities have strengthened other surgical specialties apart from general surgery. A growing number of surgical trainees, who spend a year at Western Health as part of their specialty training program in specialities such as orthopaedics, urology and ENT, are choosing to return to Western Health as consultants after they graduate.

Doug Travis, Western Health’s former Director of Surgery and former head of urology, said almost all of the new appointees over the last seven years to the urology unit’s team of about 14 consultants were people who had completed a training rotation at Western Health.

The urology unit is believed to be the biggest and busiest unit in Melbourne. It has about 25 operating lists each week, compared with the Royal Melbourne Hospital’s urology unit, which has about 12 operating lists.

A sea change in the profession’s attitude

Over a 30-year career at the hospital, Mr Travis witnessed a sea change in many consultants’ attitudes towards Footscray and Sunshine. An indifference to a hospital service perceived to be on the wrong side of the Maribyrnong River has started to make way for a growing appreciation of its training and new facilities. Most surgeons no longer see Western Health as a career way-station en route to a more prestigious appointment elsewhere.

Doug Travis, Western Health’s former Director of Surgery and former head of urology. The urology unit is among the biggest and busiest units in Melbourne, with about 25 operating lists each week.

Doug Travis

“A decade ago we struggled to attract people to the specialties,” Mr Travis said. “There are obviously now more doctors graduating but the fact that we’ve become a desirable environment has more to do with the culture of the Western, of looking after people and slowly over time that reputation grows . . . the indifference is starting to dissolve. Western wasn’t on the radar of most surgeons and the facilities were not good.

“Surgeons like to have toys to play with and our intensive care has taken time to develop. We’ve gone from having a tiny four to five bed intensive care unit in 1980 to having dual campus, very high tech intensive care units with up to 20 beds where we can do whatever surgery we wish to do because we have the back up and support to look after sick people, which is not just a matter of having a surgeon to do the job. Looking after sick people is a team effort involving the physicians, the intensive care units and allied health teams.”

Mr Travis said the hospital now had a large coterie of highly trained young surgeons aged in their 30s and 40s who were committed to staying in the west.

“If you walk around the hospital now, there’s a very large number of young people - a generation of surgeons who have a long term commitment to the hospital, who will drive its reputational change for the better. For them it’s not a matter of spending two years here and then going on to the Royal Melbourne, it’s about establishing their career pathway and their credibility at Footscray and Sunshine. It’s a different mindset from the past where surgeons usually had dual appointments and divided their time between hospitals.”

A stronger capacity for training has led to more of Western Health’s own registrars gaining entry into the other specialty training programs overseen by the College of Surgeons.

In the specialty of orthopaedics, hundreds of applicants compete for about 8-10 training positions in Victoria’s orthopaedic training program – a five year specialist course overseen by the College of Surgeons.

Over the last few years, about one quarter of those training positions have been won by registrars trained at Western Health, according to Phong Tran, head of Western Health’s orthopaedic unit. “That’s a huge accomplishment for any hospital and I don’t think any other hospital does that on a year on year basis,” he said. “It’s a symbol of how highly our hospital is regarded and how we’re attracting the best interns and residents to train with us because they know we offer such high calibre training.

“We routinely get our unaccredited registrars to advance to that higher level – two or three of our registrars get accepted into the training program each year out of the eight or so training posts available.”

Role models for the next generation

Mr Tran and many of his peers were mentored by the hospital’s senior surgeons – people such as Trevor Jones, Graeme Thompson and Chris Haw. Standards set by these older surgeons have been passed on to the next generation of unit heads.

“I sit down with all the junior doctors in my unit and plan a career path with them,” Mr Tran said. “It means you have a very loyal team that works really hard for your patients.”

Associate Professor Graeme Thompson and Associate Professor Trevor Jones have played leading roles in training hundreds of medical students and surgeons at Western Health.

Mr Thompson was born in Sunshine and educated at Sunshine High School before completing his medical degree at Melbourne University. He joined the hospital in 1989 as a general surgeon, and for five years juggled that appointment with another post as a general surgeon at the Austin Hospital.

A proposed amalgamation between the Austin and the Heidelberg Repatriation Hospital forced him to make a choice between the Austin and Footscray. At the same time, Professor Bob Thomas, Footscray’s newly arrived chairman of surgery, encouraged Mr Thompson to take up training in ERCP (endoscopic retrograde cholangiopancreatography) and become more involved with teaching the hospital’s medical students.

Mr Thompson accepted the offer. “The Western was developing and it had a great future,” he said.

“I could see that I could make a contribution to the western suburbs.”

He became head of the general surgery unit in 2001 and oversaw the establishment of surgical services at Sunshine Hospital. General surgery, orthopaedic, plastics, paediatric and emergency surgery units operated at Sunshine for about a year until Western Health management chose to move some of the units back to Footscray Hospital.

“The new surgical services at Sunshine were draining funds and work from Footscray and management was not prepared to bite the bullet to advocate to continue that level of service,” Mr Thompson said. “Sunshine became an elective surgery hospital for a number of years. Since then services have gradually been built up and it’s now a very busy general hospital.”

Associate Professor Graeme Thompson, general surgeon and president of Footscray Rotary Club.

Western Health archives

Speaking out

When Mr Thompson turned 65, he stepped down as head of the general surgical unit to focus on the hospital-wide issue of quality and safety in patient care. One of the first issues he was asked to tackle was a problem that occurs in all hospitals – the uncommon incidence of patients who experience severe physical complications or death soon after surgery.

Hospitals categorise these post-operative surgical patient cases as ‘adverse events’ and their numbers are officially recorded each year.

Bleeding, respiratory problems or septicaemia are the most common causes of complications experienced by patients after surgery.

Mr Thompson noticed that one of the biggest contributing factors in these events was the poor communication between junior doctors and their senior medical staff. In some cases, junior doctors failed to alert their senior colleagues when the patient’s condition started to deteriorate. Some medical graduates were reluctant to seek advice from senior clinicians.

“If someone has had an operation and something isn’t quite right, the first port of call is the junior doctor, especially after hours or on weekends when staffing levels are reduced,” Mr Thompson said. “But a significant number of our doctors were reluctant to ring the consultant after hours and perhaps get their heads bitten off – which apparently happened sometimes. Other junior doctors hadn’t recognised that the patient was developing complications.

“There were cultural issues, issues of ignorance and issues about the failure to ask someone for advice – whether it was because of a fear of being wrong or because of hubris among some staff. It’s a set of complex circumstances that influence a person’s decision not to seek advice from a senior colleague.”

To deal with the problem, Mr Thompson introduced an orientation program for all new interns, registrars and junior medical and surgical staff. Senior surgeons deliver the program. They outline the standards expected of new staff, making it clear that junior staff should not hesitate to call a consultant if a patient’s condition deteriorates.

“We’re trying to inculcate a culture and attitude among our staff where it’s far better to speak up and get help. It’s not an admission of failure or of ignorance, it’s good clinical practice.”

Since the orientation program was introduced, the number of severe adverse surgical events investigated by the hospital’s adverse events committee has fallen markedly. Mr Thompson retired from Western Health in 2015.

Surgeons help save stabbed colleague’s life

In February 2014, an unprecedented incident at Footscray Hospital tested the mettle of the surgical workforce and attracted headlines in the media across Australia and internationally.

Mr Michael Wong, a consultant neurosurgeon, was attacked in the Footscray Hospital foyer, by a former patient who knifed Mr Wong in the back before repeatedly stabbing him.

The assailant stabbed and slashed Mr Wong’s face, chest, hands, forearms, torso, stomach and legs about 25-30 times.

Four people - three staff and a patient - managed to drag Mr Wong away from the attacker and rush him to the emergency department.

The man was arrested and the hospital’s medical staff transferred Mr Wong to an operating theatre for life-saving surgery.

Over the next 10 hours, Mr Wong lost his entire supply of blood (between five and six litres were replaced through transfusions) as a large team of Western Health surgeons and other medical staff – battled to save his life.

Mr Wong has since regained full movement in his arms and hands and has returned to work.

A Supreme Court trial in December 2015 found Mr Wong’s assailant not guilty of attempted murder due to mental impairment. The man was remanded in custody for custodial sentencing.