28 June 2013

ACPGBI Travelling Fellow Report on a two week visit to the Cleveland Clinic and Cleveland Clinic Florida. Oliver Warren MD FRCS (Gen.Surg)

Background

I am currently an RSO at St. Mark’s Hospital, Harrow and this year was awarded one of the two inaugural ACPGBI Travelling Fellowships for 2013. These new fellowships, which are awarded through a competitive process, give significant funding (£2500) towards an educational two-week trip to a unit of your choice, anywhere in the world.

Where did I go and what did I see?

I chose to try and visit two units, both within the same USA provider organization and thus in March 2013 I spent two very interesting and exciting weeks at the internationally renowned Cleveland Clinic. The main campus of the Cleveland Clinic consists of 41 buildings on more than 140 acres in Cleveland, Ohio. The Clinic operates 14 family health and ambulatory surgery centers in surrounding communities, a multispecialty hospital and family health center in Weston, Florida and an outpatient clinic in Ontario. My fellowship started in Cleveland itself, at the main campus, one of the most famous hospitals in the world. This gargantuan hospital was established less than 100 years ago but has grown at a spectacular rate; it employs 45,000 staff and in 2011 treated 4.6 million patients!! There are over 90 operating theatres and separate ITU’s for cardiac, neurosciences and respiratory medicine to name a few. It really has to be seen to be believed in terms of the sheer scale of the operation. The Heart and Vascular medicine building, one of the modern centre pieces of the facility is alone bigger than many hospitals I’ve worked in. Professor Feza Remzi chairs the Department of Colorectal surgery, part of the Digestive Diseases Institute. The department is sizeable, they run 5 full time specialist colorectal theatres every day, employing 22 consultants. Professor Remzi was my host for the week, and he was incredibly welcoming and supportive of my trip, but I was equally supported by a significant number of the Attendings, Residents and Fellows. I spent most of my time in the operating theatres; I was encouraged to move from theatre to theatre to see as many different cases as possible. Sadly, being the USA, I was observing and was unable to so much as touch a patient, a consideration for any colleague planning such a trip again. However, I saw some excellent cases including repairs of entero-cutaneous fistulae, restorative proctocolectomies (RPCs), re-do RPCs, laparoscopic cancer resections, a pull-through for pouch-vaginal fistulae, and episioproctotomy for obstetric injury. Whilst many of these I have seen or been involved with in the UK, the sheer volume of cases was astonishing; they have a 75 bed unit plus some outliers and in one week I probably saw the equivalent of a few months work for many UK centres. Beyond the operating theatres, I attended a number of educational opportunities, including the weekly teaching for fellows and residents and the colorectal cancer MDT. I also went to clinic on one occasion to see if things were particularly different (which they weren’t!). I set up very interesting meetings with Dr. Jamie Stoller, the Director of the Institute of Education and Dr. James Merlino, a colorectal surgeon who is also Chief Experience Officer at the clinic, to see what they are doing in training, human development and patient experience, areas of personal interest to me. I toured their multi-million dollar simulation facility with Dr. Stoller, which was breathtaking in its size and innovation. After a week in Cleveland, Ohio (with snow and in temperatures of around -40C!) I flew down to Miami, Florida to a much more palatable 280C and an equally warm welcome from Professor Steven Wexner (see photo) and his team at the Cleveland Clinic, Florida. Located in Weston, about 45 minutes drive north of Miami, the CCF is a much smaller affair (by comparison, but still around the same size of many of our hospitals!). There, 7 attending colorectal surgeons provide an equally comprehensive range of colorectal services, with all of them having a super-specialisation. They still run two or three full theatre lists a day and I saw TEMS, laparoscopic colostomy formation, pouch excision for multiple fistulae, laparoscopic ventral hernia repair, laparoscopic hartmann’s reversal, reversal of ileostomy, a laparoscopic ileo-rectal anastomosis for colonic inertia, and lots of proctology including stapled haemorrhoidectomy. I observed their monthly Morbidity and Mortality meeting, which was superbly attended and quite thorough, and their anorectal physiology meeting, along with morning rounds every day at 0630. Finally I went to three outpatient clinics with Professor Wexner, which was very educational, and set up perfectly so that he (and I) could see all the cases referred to him. Oliver Warren and Dr Steve Wexner What did I learn from my fellowship? Whilst I saw lots of very interesting cases, I think my main learning points were more around the organization and the system. The Cleveland Clinic’s motto is ‘Patients First’ and they live up to this statement. The care is of an incredibly high quality, and is patient focused. There appears a huge slick machinery around each patient, designed to streamline their entire pathway from admission to discharge. They emphasise that ALL staff are ‘caregivers’ and are proud of the role of their receptionists, porters, guides and administrators in ensuring that the patient feels constantly looked after. This ethos is something everyone appears to buy in to and the staff and the patients are proud of the Cleveland Clinic ‘Brand’. Whatismore, their systems and processes are ahead of the majority of organisations here; theatre time is far less wasted, there are clearer emergency and elective splits, and they utilise Physician Assistants, Nurse Anaesthetists and Nurse specialists to free up the interns, residents and fellows, ensuring they receive the education and training they require to progress to become attendings in much less time than we do. Having said that, I also saw quite a few patients who had been sent to both the units for ‘salvage’, and was shocked at some of the very poor quality care they had received elsewhere in the US. It really does appear that there are large variations in care within even the same city and that whilst rightly proud of some of the centres of excellence that it has, the USA needs to think carefully about how it might improve the overall level of quality of care colorectal patients receive. They have far less with regard to voluntary national reporting, databases and standards of care, and it made me proud of a lot of the things we have established in the UK along these lines. This is something the senior attendings and departmental leads at the Cleveland Clinic are aware of, and they along with others at other centres of excellence are trying to change. In conclusion, this was a fantastic two weeks, giving me a chance to visit one of the greatest healthcare organisations in the world, meet some incredibly impressive surgeons, see the strengths and weaknesses of a different healthcare system and just as importantly make some new friends! I am incredibly grateful to the ACPGBI educational committee for bestowing the fellowship to me, to Professors Remzi and Wexner and Dr. Dietz for hosting me, and to Professor Tekkis, my mentor in the UK who helped me set up the fellowship. I would thoroughly recommend it to anyone within a year or two of their CCT.

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