My goals for the Traveling Fellowship included exchanging with ANZ surgeons ideas and solutions for patients with vascular disease. Specifically, I wanted to accomplish the following:
- Share my expertise in vascular surgery, endovascular therapies, and vascular biology with surgeons in Australia and New Zealand
- Discuss and directly observe complex surgical and endovascular techniques
- Understand new training paradigms for the next generation of vascular specialists
I believe I achieved all of these goals and much more.
First stop, Malaysia
One of the requirements of the Traveling Fellowship is to address the Royal Australasian College of Surgeons (RACS) Scientific Congress. For the first time in many years, this meeting was not held in Australia or New Zealand, but in Kuala Lumpur, Malaysia, which proved to be a fantastic choice of venues.
Traveling to Malaysia and then to Australia and New Zealand did create some time and cost challenges for one trip, so I actually made two trips. I want to thank Stephen Deane, MD, MB, BS, FACS, FRACS, FRCS(C), Chair of the ACS International Relations Committee, for helping to orchestrate the trips.
I went to Kuala Lumpur in May 2012, where I interacted with multiple ANZ and Malaysian surgeons (see photo, this page). Ian Civil, MB, ChB, FACS, PRACS, a general and trauma surgeon at Auckland City Hospital, NZ, introduced me to several ANZ vascular surgeons. Despite his multiple time pressures as President of the RACS, Dr. Civil graciously attended my lectures and discussed my research regarding endothelial dysfunction. Of note, he had trained at the Cleveland Clinic where I spent eight years of my professional career, and we traded many stories. His partner at Auckland City Hospital, Andrew Hill, MB, ChB, FACS, FRACS, is a widely recognized endovascular surgeon. Dr. Hill and Andrew Holden, MB, ChB, FRANZCR, have written extensively on cutting-edge endovascular therapies that are being incorporated into surgical practice worldwide. We exchanged ideas and debated visceral and mesenteric endovascular strategies. Ravi Huilgol, MB, BS, FRACS, from Sydney coordinated the vascular sessions and organized an outstanding program.
During my week in Malaysia, I participated in multiple forums regarding the current state of vascular surgery and intervention. An added benefit was hearing Malaysian surgeons’ approaches to vascular care.
Back to Australia
I returned to Australia in October 2012 and traveled to Melbourne and Sydney. During my visit to Melbourne, I attended the ANZ Society for Vascular Surgery meeting. Prof. Robert Fitridge, MB, BS, MS, FRACS, from Adelaide invited me to give multiple presentations. He and his colleague, Peter Subramaniam, MB, BS, FRACS (Surgery), FRACS (Vascular Surgery) run a highly reputed limb salvage program. Similar to the worldwide epidemic, diabetes is rampant in ANZ, especially in the Aborigine community. Geoff Cox, MB, BS, FRACS, has a large aortic practice in Melbourne. He was a gracious host and took some American visitors on a boat ride down the Yarra River (see photo).
Domenic Robinson, MB, BS, PGDipSurgAnat, a vascular trainee at the Austin Hospital, asked me to present Reflections at Mid-Career to ANZ residents, trainees, and students during a dinner meeting in Melbourne. In Melbourne, I visited the Alfred Hospital and the Baker IDI Heart and Diabetes Institute. At the Alfred, I observed a thoracic endovascular repair for thoracic aortic pathologies, among other operations.
In Sydney, I visited Dr. Huilgol; Prof. James May, AC; and their colleagues at St. Vincent’s Hospital, a prominent private institution. We spent time on the wards and reviewing cases. Raffi Qasabian, MB, BS, BSc, FRACS, allowed me to scrub in on some endovascular cases (see photo). He performed endovascular therapy for patients with critical limb ischemia. Despite the recent evolution of this therapy, the actual techniques are remarkably similar to those approaches that we use in the U.S.
Lessons learned
I learned a great deal as the ANZ Traveling Fellow. Vascular surgeons in that region have been at the forefront of open surgical and endovascular procedures for many years. The opportunity to visit surgeons at their institutions, to engage in personal interchanges, and to directly observe procedures was invaluable. Examples of the lessons I learned are as follows:
- Endovascular therapies are used routinely throughout Australia and New Zealand. ANZ surgeons have high-level endovascular skills, and variance of endovascular capability may be less than in other regions, possibly due to a smaller pool of vascular surgeons and training programs. There is rapid dissemination of new endovascular techniques throughout the ANZ vascular surgery community. However, like many U.S. surgeons, vascular surgeons in ANZ are debating the indications and long-term benefits of endovascular procedures.
- In ANZ, practices often are defined by whether the surgeon works at a public versus a private hospital, although many surgeons have appointments at both types of institutions. Public hospitals largely provide care to patients with government-sponsored medical insurance and house most of the training programs. Private hospitals treat patients with supplemental private insurance who may seek care without the delays inherent in the public system. Despite the patients’ impression that private hospitals may provide higher-quality care, most surgeons confide that sometimes their most challenging cases are done in the public hospital, given the intraoperative assistance and postoperative vigilance trainees can provide.
- Vascular surgery training in ANZ is undergoing marked change similar to what we are experiencing in the U.S. Many vascular training programs in the U.S. are adopting “0–5” programs in which medical students go directly into vascular training for five years after medical school. This system is in contradistinction to the traditional “5–2” program in which one finishes a five-year general surgery residency before starting a two-year vascular fellowship. Similarly, vascular surgery training is being streamlined in ANZ. The RACS plays a large role in training paradigms in ANZ, and fellowship status in RACS is a milestone for ANZ surgeons.
- Given ANZ’s relatively small population, staff positions are also limited and highly competitive. Many trainees seek additional “super fellowships” to make themselves more attractive for top spots. Travel throughout ANZ and abroad is common. Interest in vascular disease and the highly competitive vascular surgical field appears to be high among medical students and junior trainees.
- Many vascular surgeons are on the cutting edge of vascular innovation in ANZ. Stent-grafts for complex aneurysm pathology, advanced endovascular techniques for occlusive disease, treatment of arterio-venous malformations, and minimally invasive techniques for venous disease are advanced by many ANZ surgeons.
- Like other surgeons around the world, ANZ vascular surgeons are critically examining their results with audits in which most surgeons participate.
Friendships formed
The Traveling Fellowship led to multiple social interactions. In Melbourne, John Michael Quinn, MB, BS, FACS, FRACS, executive director for surgical affairs at the RACS, hosted a fabulous dinner at the Melbourne Club. The history of Australia appeared on the walls with multiple murals of famous explorers and settlers of the continent. John (Jack) Harris, MB, BS, FACS, FRACS, head of the department of surgery at the University of Sydney, hosted another memorable meal at the opulent Australia Club.
During my multiple visits Down Under over the last two decades, I have found that the culture in ANZ is open, friendly, and welcoming, which spills over to the surgical community. The collegiality among surgeons, often at competing hospitals, is striking. The discourse at both the medical meetings and hospital rounds is educational with a typically jovial tone—an attitude that we all likely could benefit from adopting.
During my travel to ANZ, I also enjoyed meeting many American vascular surgeons as well. Jon Matsumura, MD, FACS, chief of vascular surgery at the University of Wisconsin, Madison; Melina Kibbe, MD, FACS, Edward G. Elcock Professor of surgical research, Northwestern University Feinberg School of Medicine, Chicago, IL; Manju Kalra, MB, BS, FRCS(Ed), of the Mayo Clinic, Rochester, MN; Scott Lemaire, MD, FACS, professor of surgery, Baylor College of Medicine, Houston, TX; James Valentine, MD, FACS, Alvin Baldwin Jr. Chair in Surgery, University of Texas, Southwestern Medical School, Dallas; and many other surgeons were traveling to meetings in the area as well. Meetings with ANZ and American surgeons led to interchanges regarding novel therapies to enhance patient care. Comparing and contrasting care delivery with surgeons from different settings was illuminating.
On a personal note, my wife, Sangeeta R. Kashyap, MD, an academic endocrinologist, joined me for some of the travel. Our ANZ hosts treated us like royalty, and we had a chance to visit some vineyards in the Mornington Peninsula near Melbourne, and the sights in Sydney (see photo).
It was a privilege for me to participate in a very exciting dialogue with our Australian and New Zealand colleagues as the Traveling Fellow. This was truly a tremendous opportunity to learn and share ideas and techniques that may profoundly affect patient care. This experience has helped me grow as a surgeon and will have a lasting impact on my surgical career. I cherish the professional and personal connections that I made. This Fellowship has been the highlight of my career. I thank my ANZ hosts and I humbly thank the American College of Surgeons for this singular honor.
