2016 Chris O’Brien Traveling Fellowship Recipient, Lessons from the US

Chris O’Brien Travelling Fellowship
Update from Dr. Martin Batstone, 2016 Award Recipient

From the 24th of June to the 20th of July 2016 I was privileged to undertake the Chris O’Brien Travelling fellowship to the United States culminating in the AHNS 9th International meeting in Seattle, Washington.

The logistics of a month away from work are daunting to say the least but I was fortunate to be recently joined at the Royal Brisbane Hospital in our department by another full time Head and Neck Surgeon (Dr Scott Borgna) which allowed me to at least travel knowing that operations were still happening, new patients were being seen and old patients reviewed.

My day to day work focusses on oral cavity cancer, salivary gland, some oropharyngeal cancer and both primary and secondary reconstructive surgery so it was with these interests in mind that I chose the three American hospitals to visit.  Contact was made over 12 months from the visit and timing and communication of course is key to make sure the individuals you wish to interact with are not away from work themselves.

My first stop was the MD Anderson Hospital in Houston Texas.  The chair, Dr. Randal Weber was instrumental in setting up the Chris O’Brien travelling fellowship and one of the attendings (Dr Michael Kupferman) was the 2014 Travelling Fellow to Australia. Houston itself was flat, hot and far greener than expected.  Frequent thunderstorms and humidity reminded me of Brisbane in summer!

I had chosen the MD Anderson because I thought a visit to a very large American cancer centre with a strong research focus would be eye opening for an Australian where the population is less than 10% of the USA. In that respect I was certainly not disappointed.  The MD Anderson Cancer centre is a large hospital in itself, but resides within a complex of other large hospitals which seem to cover several square kilometers making up the “Texas Medical Centre”.  Apparently 21 hospitals in total!

The MD Anderson is a cancer specific hospital and the Head and Neck Department occupies a whole floor.  There were 16 attending surgeons in the surgical department but clinics were held concurrently with Radiation Oncology and Medical Oncology in the outpatients department.  Reconstructive surgery was undertaken by the Plastic Surgery department.  New cases of Head and Neck and Thyroid were around the three thousand mark per year which is approximately triple the throughput of the Royal Brisbane and Womens Hospital.  Needless to say with such an extensive case load all sub specialities were covered and each of the attendings had specific interests but the cross over was greater than expected in such a large department.  Some of the surgical staff appointments were part time research with protected time for lab work or other activities.

The Head and Neck MDT was attended by all Surgeons, Radiation oncology and Medical oncology.  Although the throughput was rapid I was impressed by the attempt to recruit all attending patients in a clinical trial with that discussion often taking some time.  I was pleased to see that although the volume of patients was much greater, with the exception of a Proton Therapy Machine, the facilities in our public system in Queensland at least were equivalent to those on offer in the best of US Hospitals.  What is not as evident at home though was the research focus and the willingness of a hospital or health system to employ clinicians specifically to undertake research.  The integration between Universities, research institutes and clinicians in Australia leaves much to be desired despite steps in the right direction.

Next stop was Head and Neck Surgical associates (led by Dr Eric Dierks and Dr Brian Bell) in Portland Oregon.  This is a group of Oral and Maxillofacial Surgeons and Otorhinolaryngologists who have had a number of Australian fellows over the years and practice in one of the nicest parts of the US I have visited.  I had decided to come here to get a better understanding of Virtual Surgical Planning which is in use for every composite reconstructive case (and a number of deformity cases as well).  Although it has been used in our unit and others in Australia its cost makes its integration prohibitive currently.   Dicom CT data is used to fabricate models and a web based planning session is undertaken for each patient which leads to the generation of 3D printed models and customized plating with cutting guides etc.  It is certainly a streamlined system in the Providence group of hospitals with enviable results.  The challenge for Australians is to bypass some of the more costly aspects of the process which is no doubt the way of the future.  Since returning to Australia I was pleased to discover our hospital had appointed a 3D modeler (a person!) with a high quality printer and he already has 3 job orders from our department.  The other strength of Portland is as a hub for immunotherapy with one of the most integrated research institutes I have ever seen.  I attended their lab meeting on Friday morning where there were multiple clinicians (surgeons, medical oncologists, radiation oncologists) in attendance with lab scientists.  As a weekly occurrence it seemed quite unique to me.

Portland is famous for its microbreweries which are certainly spectacular and I gave a lecture at one on the “Use of Radiotherapy in Intermediate Oral Cavity SCC” to the HNSA group and other head and neck specialists from the Oregon Health and Science University.   Not too many IPA’s were consumed as another lecture was delivered the next morning on “Alternative composite free flaps” to the reconstructively minded trainees and consultants.

The final hospital on my fellowship was the University of Washington Medical Centre in Seattle Washington.  It is headed up by Dr Neal Futran but I also had the opportunity to join his colleagues Dr Jeffery Holton and Dr Eduardo Mendez.  Dr Futran is well know from his publications and international teaching on the AOCMF program.  It was useful to ‘pick his brains’ about difficult cases and tap into what is clearly a vast experience.  Dr Mendez is flying the flag for transoral robotic surgery and his lecture on Friday of the week was very informative with regards to setting up a robotic service.  The University of Washington team put on a pre conference workshop on the Friday prior to the AHNS meeting with a focus on reconstructive surgery.  I felt very lucky to attend and hear international experts such as Dr Mark Urken (Paediatric free flap surgery) and Dr Ralph Gilbert (Midface recon).  Probably the most eye opening talk was by a speech pathologist arguing for esophageal speech as a method of voice restoration.  The argument was particularly powerful as she had had a laryngectomy!

The 9th International AHNS meeting was held at the Washington Convention centre and the educational program was of its usual high standard.  It was also great to catch up with colleagues from Australia, Europe and the USA.  The conference rounded off my trip to the USA and after one month of living out of a suitcase I was ready to head home.

I am incredibly grateful to the ANZHNCS and AHNS for bestowing the Chris O’Brien travelling fellowship on me.  I feel that it came at the right time of my career and has left me with several things.  Firstly some new friends on the other side of the Pacific, new ideas for research, an understanding of a different health system, and a list of improvements that can be made within our own service at home.  Finally, I am grateful to the American clinicians who hosted me and patients who allowed me to attend their clinics and operations.  I am sure that my constant questioning was occasionally annoying but they had the good grace to pretend it wasn’t.