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Now, thanks very much for doing the interview, 10th of November 211 for interview by Eric Hockaday.

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Neil Mortensen. Now, I guess you came from Bristol, too.

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Yeah, I was a senior lecturer in Bristol and eventually died.

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I remember sitting in my house in Clifton and my Kettlewell rang and said, would you be interested?

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And one thing and another. And in fact, the appointment didn't I didn't think happened.

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Manuell died in February, I think.

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And the appointment didn't actually happened on May, June time and actually started in late 1986, about November time.

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I think, you know, why did you want to move from Houston?

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Why did you decide to move?

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Um, well, I was a senior lecturer, and in those days, people made you quite aware of the idea that a senior lectureship wasn't forever.

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Right. And I'd seen other people kind of become stalled or low flying or a bit disgruntled

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because they didn't get the right spot actually as it happened when I got the job,

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partly because, I mean, I was very interested in obviously the the gastroenterology GI surgery stuff.

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And obviously Sydney had been on the staff and then Derek Jeter and I used to come as a registrar before this was even a kind of twinkle in his eye,

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as it were, to the gastroenterology course. I always liked medical gastroenterology and the whole theory of how GI diseases happens.

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And would you come in? You know, so I didn't come every single day.

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I came quite long. So I quite liked it from that point of view.

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And I, I obviously knew my Kettlewell very good, very well from sort of surgical circles.

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So it was very attractive. And, you know, these these jobs in big teaching hospitals like this don't come up every every day.

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And it's flattering to be asked to anyway.

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So just to digress slightly, Robin Williamson, who is a professor in Bristol, then immediately took the job at the Hammersmith.

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And then I was at sixes and sevens.

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And actually my I was very understanding and I said, well, look, can I just stick around and see if I can have a go at Bristol and make a long

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story short to out to two years went by and they appointed somebody else.

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So I stayed. And that and how big and sort of name was Sydney in those days?

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Oh, he was a sort of towering figure in gastroenterology. He was the person who put the management of colitis on the map.

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He set up the idea of five days.

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And if the patient isn't getting better, think about surgery. So and you, if you like, he was the surgeon and friendly physician in gastroenterology.

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He was the one who said to his colleagues, it's not getting better by now than you.

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You do need a surgeon. And that's very important. I sort of imagine that the steroid treatment would have reduced the amount of surgery.

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Well, it did. But it's interesting, you know, still to this day, we're talking about 2014.

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If you come in with an acute severe attack of ulcer colitis, one third of those patients will end up there and then having their colon removed,

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even with the new iterations of treatment after steroids, which are these biologics.

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And so did you do any general surgery? I mean, you can.

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Oh, yes. I mean, how it's changed. It's unbelievably I mean, obviously, I so just just being back to Bristol.

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So I had a general surgical training, but I emphasise GI disease.

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And in fact, I had done a six month attachments and hospital in London, sort of giving me sort of lower GI credentials.

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And when I arrived, I think two or three things to reflect on.

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No one might well and I really did most of the major luminal gastroenterology surgery.

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So we would take out oesophagus as we would do port cable shunts for portal hypertension.

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We would do the colitis and the Crohn's disease for what was now Derik having succeeded Sydney.

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And obviously there were sort of plenty of colon cancers around and so on.

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And the other thing that struck me was that the surgical firms were arranged for the benefit of the undergraduates completely.

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There was no, if you like, interest in trying to concentrate expertise to make the patients have a better outcome.

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It was all about undergraduate teaching.

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So I was on a service with Joe Smith Urology. And Nick Dudly, who did Paediatrics and adults and yes, students saw fantastic range of stuff,

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but I felt in my bones that the future had to be increasing specialisation and little by little, I wore everybody down.

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I remember there was a meeting at Oriel College. I think Nick Dudly was was a member of the Senior Common Room.

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And we had dinner. And then we sat around and chatted and I sort of flew the flag for specialisation.

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This is about just about four or five years, six years after I arrived.

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And there was tremendous hostility to start with.

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Everybody said, oh, well, you know, what about, you know, teaching at the undergraduates and all that stuff.

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But, you know, the writing was on the wall. Yeah.

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So when you came, did you go to the church because Gervaise of the church?

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Yeah. No, no, no. So we had we had a ward at the John Radcliffe and obviously sort of emergencies went there.

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And I think I had I think I had I tell you what I had and this is typical new boy stuff I had all day Friday at the John Radcliffe.

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And I had Thursday afternoons at the Churchill, all loaded on to the end of the week,

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which when I was travelling backwards and forwards for the year or so, was actually quite tough.

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Yeah, and that's the way it goes. I mean, I sorted it out eventually.

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So we had beds on both sides, really. We did the smaller stuff of the church.

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Yeah. So when did you get the specialisation introduced? Roughly, roughly about sort of 95, 96.

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I think we began to sew my cattle and I would get on on a firm together.

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And there was tacit agreement from the other college colleagues that we were going to subspecialties.

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So Julian, Britain did particularly. Mike still did oesophagus.

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I stopped doing oesophagus because there was plenty of the rest of it to do my Greenall by then, and he was still doing better.

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General surgery was kind of small with breast disease. And so that's the way I went.

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I think Nick Dudley carried on doing some endocrine stuff and the adult general, but I had lots of paediatric stuff to do as well.

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So I think by then people recognise that we had to have specialisation.

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And interestingly, even before that, and this was true of Sydney to the gastroenterologists were very,

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if you like, careful who they ask to do their bad IBD cases because there were some really bad ones.

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I mean, it was a national referral centre. And, you know, even if somebody else was on call, you know, they'd bring Micra up and say, look, you know,

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this patients really we would be grateful if you take a personal interest and do this yourself so that there was

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already specialisation for that aspect of your work in a funny sort of way before it became obviously agreed.

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And do you think it had an effect on undergraduate teaching and clinical student teaching?

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Um. Well, it's interesting.

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Of course, I've just come off being chairman of examiners and I've seen what's happened to the changes in the undergraduate curriculum.

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Now, of course, they spend only as part of their first year in clinical medicine, only two or three weeks with us in GI surgery.

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Um, there's tremendous demand for lots and lots of other subject areas and so on.

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Um, but they do get sort of two or three weeks with us and that's nothing else.

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So they get us sort of concentrated exposure, which I suppose it's ensured that they do.

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But the whole sense of being part of a team, being accepted as part of the team and part of the furniture, if you like,

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an even bigger accepted to a degree socially and an element of pastoral care that went with that from us has now completely disappeared.

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And of course, the pastoral care element is now either provided by their college tutors or by Tim Lancastrian.

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You know, the medical school office to encourage admits to be a Amitav, a Medick attached to one of the colleges.

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Um, well, I mean, obviously there are college tutors who both preclinical and clinical.

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And I think I think the students now see their college in the provision by their college and Tim Lancaster as their kind of their home,

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they kind of just visit us. Whereas in the past they were actually part of our team and we got to know them quite well.

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And then, of course, you were able to say and the bright ones were able to say to us, can I please do one of the hardest jobs here?

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Now, that's all completely disappeared with natural matching schemes and.

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We now we're getting as part of the national scene and we get people who've never,

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ever worked in Oxford ever before and they're passing ships in the night,

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we get them for two months at a time and with their kind of night commitment and shifting and so on,

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you've just about got to know their name before they shove off and go somewhere else.

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And again, the pastoral care element in the sense of being part of a team is much more different.

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I feel very sorry for his, but I also felt that you don't know what they've been taught.

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If somebody comes from Oxford, you may know that they're going to be weak on.

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Yeah, but if they come from somewhere else, you don't know what they could. You know.

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I know. I mean, having said that, although it is does seem to be sort of a throw of the dice or pot luck,

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certainly in the last year we've had some very good, very good people. Good. This must be on a matching scheme.

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Yes. A national party. Yes. If you're choosing good guys and they are choosing.

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Yeah, there's a there's hope because the Americans used to do this and get their knickers in a terrible here.

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Well, I mean, at one time we got incensed because I can remember about five years before I finish as chairman of the Examiners,

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one of the people who won the top PRISE, surgical nurse Medick.

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Right. And this was I mean, we you know, we remember her being examined absolutely outstanding.

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Couldn't couldn't because of the match, you see, and get a house job in Oxford.

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I mean, it was terrible. It's stupid. The physical signs, I suppose, have receded with imaging.

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I mean, how important are the physical signs? I think really, really good doctors.

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Listen, take a very good history and you have to examine the patient.

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And that's still the case. But if you take, for example, the generality of emergency surgical take,

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being able to say without a doubt that patient has acute diverticulitis makes a big difference to the speed with which you're able to manage them,

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discharge them, most importantly these days, with the huge volumes coming through and then decide on strategy,

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there isn't that they come in with non-specific abdominal pain quite so much as there was in the past.

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So I think imaging has made a fantastic difference and partly what I've said about listening and taking good history and so on,

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since so much else of what we do as being industrialised,

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in a sense, I think personally that every person coming in with abdominal pain should have some kind of either a CT scan or in the future,

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maybe some kind of non irradiation based imaging just as part of that walk through the door and then,

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you know exactly what's going on to a degree, and you can set up a proper treatment strategy and so on.

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I think it's it's revolutionised what we do. And I mean, since you've asked about imaging, one of the areas I deal with is rectal cancer and imaging,

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first of all, and the luminal ultrasound, which I was involved in developing in the UK.

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And now MRI scanning has completely revolutionised how we manage rectal cancer.

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We used to feel and the finger was supposed to coming back to physical signs was supposed to tell us how advanced it was by how movable it was.

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Now, with an MRI scan, we can tell exactly how far through the wall the tumours got.

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When the lymph nodes are involved, whether it's out of our dotted line, our normal surgical margin,

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whether we need to give chemo radiotherapy to shrink it down so we don't get a cancer at the margin.

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So it's making a point that we know the support.

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The surgeon, the nursing home. Did the nursing compare with Bristol?

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I thought when I first out of the nursing, it was good. Good.

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I mean, it does it did depend very much on the ward system, which obviously went away for a bit and has come back again.

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And, uh. I know, no, I think they're equivalent, to be quite honest.

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Yeah, and when you came, I mean, did you have the same root system for five years without that already gone?

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No. I mean, then there was some stability,

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but clearly that's now changed and people lost in the job a year or two before either going off into management or changing tack.

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And then the anaesthetists. Did you have one of these is all through.

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Have you changed a bit? I've specialised in Knights of the Realm.

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So when I was in Bristol, I had Cedric Roberts, who is a professor of anaesthesia there.

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And then I came here and on Fridays I had Sir Keith Sykes as my anaesthetist.

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So and they were they were both good colleagues.

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And I was still pretty young. I mean, I became a consultant in Bristol.

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I was 32. And, you know, when I arrived here, I was still I think I was sort of 38, 39 ish and still had lots to learn.

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So, you know, especially with the difficult stuff, you know, was around that to to help with the subject.

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Always changing, isn't it? I mean, that alone, whether you have made it before.

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And then who followed Keith Sykes then?

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I was very, very fortunate. I had a long standing anaesthetic relationship, as they say, with Dr Duncan Young, who became the head of the ETU.

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So it was fantastic.

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So for our really sick patients, we used to have some what we call train wrecks in Crohn's disease, who'd had multiple surgeries elsewhere.

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Their abdomen was a massive fistula. They were unable to maintain their own nutrition, their own long term parenteral nutrition.

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They were kind of intestinal cripples and medically train wrecks.

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And he was absolutely brilliant. And of course, he had access to ICU when we needed it.

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So I I absolutely loved working with him.

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As soon as the medical director, he had done some anal rectal physiology.

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Yeah. What was that on muscle? So one of the things I did in Bristol before I came here,

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I was interested in physiology and I'd done some work on temperature and the way in which temperature might affect sensation and the in guts.

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And it also develops, as I was saying, and the luminal ultrasound in the UK.

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And then when I arrived here, I found Alison Brading, who worked in the Department of Pharmacology.

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She was, of course, interested in smooth muscle function in relation to bladder dysfunction.

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And I said to her, can't we do the same things that you're doing with bladder muscle?

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We've got muscle. And she thought that was a great idea.

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And I had a succession.

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I must have had six or seven fellows who worked with her funded in all kinds of different ways, all of whom did MDs or similar.

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And we, for example, found the first evidence that nitric oxide was a neurotransmitter for the anal sphincter,

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which led to I mean, up until then, if you were trying to change something around the tail end,

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you could put a bit of anaesthetic on, you could have a bit of kind of soothing lotion on,

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but actually to do something pharmacologically to it, you couldn't.

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And after the discovery of nitric oxide as a neurotransmitter, they've now been a whole range of drugs.

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So nitric oxide donor's cholesterol, tri nitrate derived calcium channel blockers and even botulinum toxin,

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all of which we showed experimentally worked in in the in the sort of

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pharmacological water bath experience before it was then applied or used in humans.

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And then the thing to do is I thought it was remarkable. If you stimulated enough, it becomes voluntary, smooth muscle turns into a voluntary.

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Was that quite wrong? But I think I think some of its characteristics change, but it doesn't change completely.

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Right? Yeah. Yeah. And actually, interestingly, as far as, again, the tail end is concerned,

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everybody thought that botulinum toxin only affected striated, but that's right.

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Well, we were able to show that it effects smooth muscle and then into after sound.

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I mean, then you started. Didn't respond. Yeah. Did you do more in Oxford?

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Well, I still had a research fellow going and I did it for a little bit longer.

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And there were basically there were two uses for it.

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One is you could look at the annual stream and look at sphincter tares, which we weren't able to do before.

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All that, so you could look at a woman who'd had a bad obstetric injury and do an ultra

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luminal and enter luminal anal ultrasound scan and show the break in the muscle,

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I mean, that was a revolution.

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And then you could put the thing in the rectum and actually look at the tumour and see how far through the wall it had gone.

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So for about sort of five to 10 years, that became one of the ways of looking at rectal tumours.

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But it's been superseded now by MRI since in and over the years.

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I mean, the results got demonstrated better. I imagine patients do do better.

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Yes. Well, if we look at IBD, for example, I think we've learnt when to operate and we're not operating Crohn's disease.

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Timing is everything. The big development in my professional lifetime for the colitis population has been up until around the mid seventies,

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there was only the Brian Brook inverted spouted ileostomy.

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And then along came a temporary continent ileostomy, which didn't last very long.

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But then the thing that really made the huge difference was an alien opower.

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So all these young people could be joined together and not have a permanent ileostomy.

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We used ileum as a kind of neo rectum.

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And if you look at the results of those patients, you know, certainly over sort of 25 years, we got better and better doing it.

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But interestingly, and this is,

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I think one of our problems at the beginning of sort of 2010 onwards is as the operation gets diffused out into the generality of surgery,

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people do smaller volumes. I mean, there's been a recent British Society of Gastroenterology survey and our Association of of Proctology,

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which, incidentally, is only now sort of 18 years old.

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So the speciality of colorectal surgery in the UK has only had a society for 18 years or so.

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Those operations are done in small hospitals on average three times a year, which is obviously completely unacceptable.

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And one of the things we now see a kind of generational shift.

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So I started doing the brand new patients and we still do lots of those and we've got better and better answers and the complications have gone down.

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But now we're seeing a kind of new business coming our way, which is the redos of the ones done else,

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which haven't quite worked out and need in kind of some tuning or even complete reconstruction.

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The Association of Colorectal Surgeons, due to being secretary president.

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Yeah, I kind of did everything. So I was one of the founding members.

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I started its research foundation and I was the treasurer and and eventually president.

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You said, where would they meet in London? Well, it became quite big.

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So in the end there was only Harrogate and Birmingham and Liverpool with its new

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conference centre with the sort of ones that were big enough and Manchester as well. London was always difficult because it was so expensive.

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So we usually met outside London when I was president, actually, because we we are an association of Great Britain and Ireland.

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We had the meeting at that very nice conference centre in Edinburgh, which was excellent.

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Yes. And with the colon colon cancers, do you think that is important?

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Yes. I mean, all the I mean, in my my lecture, the students, you know,

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there's a good correlation between red meat intake and the incidence of colorectal cancer.

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But I think it's it's interesting looking at that as a whole issue.

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I think people trying to change their diet doesn't seem to have made any difference to the incidences we see it.

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The big difference in our business has been the introduction of a of a national bowel cancer screening programme.

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So at the age of 60, people are invited to do blood tests and if they're positive, they get a colonoscopy.

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So we have this tranche of 60 year olds with very small tumours who have a keyhole operation

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and they're out of hospital in three or four days and they're not there at the weekend.

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It's absolutely amazing how things change,

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whereas in the past we were relying on symptoms and those mid to late 60 year olds would on the whole be not quite so fit.

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And they would have a big tumour, much bigger operation to get through, much more complications and problems and difficulties.

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And you can rely upon the small tumours to be positive.

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And, you know, I mean, obviously some some will escape. The patients are repeatedly tested, so they get another test.

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After two years, they get another kind of chance. Yeah.

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With the research people, you know, the doctorate's where they're doing clinical practise at the same time.

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But they do sort of, you know, have a year's work, a third of their work in clinical, much less than that.

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No, we tried to I mean, I felt very strongly we had to protect them so they would do a clinical week.

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And then they come to our weekly seminar. They don't really give a talk.

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They'd be academically stimulated. But clearly they didn't do cool or they didn't do ordinary work.

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Very good. Very good to achieve that, I think, because it's difficult that it is very difficult.

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So how the junior staff then changed during the year over the years?

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I mean, have you noticed the change of heart? So I think the first thing to say is obviously I got on the staff in Bristol on the academic side,

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and that was fortunate because you could get on at a younger age.

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I was with a cadre of senior registrars who are all in their late thirties or early forties.

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It was a really bad time. And these guys were going around to 30, 40, 50 interviews without getting a job, but on the staff of the hospital.

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And to a degree, as soon as I moved from Bristol to here, there were these guys who are incredibly experienced,

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who are effectively consultants who could do this stuff.

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They could do the operations, they could do the management. They could do that. They could do everything really.

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And then, of course, times changed.

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We didn't have senior registrars anymore.

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The whole thing has been swept away and it's become more consultants delivered and more certainly more consultant led.

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And with European Working Time directive, the amount of time that people on our home grown rotations have before the mast has reduced dramatically.

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I calculated even though I got a job at the age of 32, I had worked in an environment where I was on one in two.

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I did a senior registrar job in Exeter. I can remember at the end of it I was completely sick of surgery, which for me was very, very unusual.

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I calculated I'd done thirty four to thirty five thousand hours in training and the guys coming off the schemes now have six or seven thousand.

246
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Wow. That's a fairly massive difference.

247
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And of course they can narrow their portfolio, become more specialised as a way of coping with having fewer hours.

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But in the craft specialities, I think there's there's still no substitute for experience.

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And it's interesting that we have a development rather like they have in the United States,

250
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where people have a kind of broad ish general surgical training and then they do a fellowship.

251
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And that's exactly the same things happen in the UK now, partly because the kids don't feel they're ready.

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And certainly we see them working with them across the operation table in the clinics.

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They're much less experienced, much less technically composed and capable, much less ready than you kind of like them to be.

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I mean, in the their days, these surgeons have done a lot of woodwork and that sort of stuff.

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Do they still do that? No. But of course, that's been replaced by computer games.

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So the next generation. So all our stuff.

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So in 1973, I set up a charity which became a proper charity in nineteen seventy four nineteen and start again in 2000 and four.

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So Charity 2002, 2003, 2004. And it was called up to us up to Oxford Colon Cancer Trust.

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And one of the things I'd found in Oxford was that you could get help.

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You could get fellows working on things in the lab.

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Walter Bodner and so on, I've worked with and they'd be a great deal of interest in why a cancer cell did one thing or another.

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But we still had this decision that was kind of world class cancer biology and we still had pretty rubbish operating theatres and gear.

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So the idea of this charity was that we would make the leap into keyhole surgery big time.

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And we have really, really done that in a big way so that the new generation of surgeons now will do everything really on a TV screen.

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I mean, some of the big, difficult operations we still have to do open,

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but it's it's much more keyhole than the skills they have from sort of playing computer games, I guess.

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And is the image magnified or is it a normal size?

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The image is magnified a bit. And obviously we have high definition screens.

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An operation I pioneered in the UK, especially for early rectal cancer,

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is an operation where we put a basically a rather large and eye wateringly distressing looking tube up the tail end.

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We put in carbon dioxide, we have gas imports, we have a binocular optic and we look on a TV screen that's five times magnification.

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And so we're able to cut a disk and set it up all from the inside as the beginning of the,

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you know, the what will be the revolution and then the luminal surgery.

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I think because Julian Britten was used to say they had to learn to peel an orange.

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Yeah. Is that what you just did wrong? Not the the things the things moved on.

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And so for the completely new Oz, if you like, some of the students, some of the completely new surgeons,

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now there are virtual training programmes where you can sit in a console or

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sit looking at a screen and you've got sort of virtual things to play with,

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picking things up, putting them down.

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I mean, Julian's idea of the peeling an orange inside a box was absolutely brilliant, but it's also been superseded by other things.

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Yeah. Do you find yourself watching a junior doing an operation?

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I mean, you're just there in case he gets into trouble or to tell him he's doing the wrong thing.

283
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So I'm now at the either the end or the top stage of my career.

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How do you like to put it? And I've done lots and lots of things before.

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So unless it's really very, very complicated or very difficult, I now see my job as helping the surgeons of the future learn how to do it really well.

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So I'm always actually scrubbed in.

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And the thing about the keyhole surgery is that I'm holding the camera so I can effectively switch it off or turn it away or say,

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stop doing that and try and do this. And I can actually stop them saying yes in a way which you can't do in open surgery.

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So that keyhole surgery in our business lends itself to breaking down a big operation into a series of modules.

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And so the guys will learn an operation in stages and then they'll build up the modules until they can do the whole thing.

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And actually, although that sounds rather dull in a funny sort of, I really,

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really enjoy helping them do it well and and love seeing them getting better at it and and and seeing them kind of problem.

293
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So, you know, how do you get around a technical problem? Maybe there's a bit of bleeding, maybe you can't see well enough.

294
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Maybe the tumour is a bit big and getting in the way all that stuff.

295
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I think I think it's it's great to see how they manage. And of course, some of our I was explaining earlier,

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we've had the change in the experience of our home grown trained registrars and their European working time directive problems.

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And we've added in to that. We think some of the best surgical trainees from around Europe who want to come to us.

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So we have some outstanding people from all over Europe now, probably in the best sort of top percent of their countries trainees.

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And they come to us and they, of course, raise the standard of everybody.

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Some of them are technically absolutely brilliant and it's just a joy to help them do the stuff.

301
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Yes. How much time do you find yourself outside Oxford?

302
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I mean, you must have a lot of national international commitments. Yeah.

303
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So I think recently I've decided to do a bit less international travelling.

304
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I think once you've done it, you sort of find that it's not.

305
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It is exciting and so on, as it used to be, I was for a while.

306
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Director of surgery and being away a lot and doing that was very difficult.

307
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I'm just recently on the Council of the College of Surgeons, so that's taking me up to London a bit more.

308
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So I guess maybe I'm away a day, a week or something like that.

309
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Director of surgery. What does that involve?

310
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So that I was actually clinical director of general surgery, vascular surgery, trauma surgery and gastroenterology.

311
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I did it all incredibly badly.

312
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I was completely against great, big, long, boring committee meetings and thought that it should be reduced to the absolute bare minimum.

313
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I guess somebody had to do it. I don't feel any kind of sense of pride about it.

314
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I felt that I had the maximum amount of responsibility and the minimum amount of power, and I didn't have a budget I couldn't hire and fire.

315
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I had to consensus build. If somebody was a problem, if a department was a problem, I had to kind of find a compromise way around it.

316
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And I think the other thing is inevitably you make decisions which colleagues don't agree with and you lose friends.

317
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And I think it's very, very difficult to do it well.

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And I remember my Kettlewell did it for a spell.

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And when he finished, I think he said, you know, I feel really wary and I don't think I've achieved very much at all.

320
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How long do you do it for? I did it for five stroke, six years.

321
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So what about the administrators, the lay administrators? Do they come into this?

322
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Well, again, I think I was talking to one of my medical colleagues on Sunday evening,

323
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and I think that two or three things have happened across my practising lifetime.

324
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Number one, the rise of the managerial class in hospitals. And number two, the politicisation of health care.

325
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And I think those are both made it much more difficult to be a professional.

326
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So probably the surgical team delivering the surgery is now dwarfed by all the people around the edges,

327
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the people who manage the theatres, the people manage the waiting list, the people who manage the bookings for the clinic.

328
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There seem to be lots and lots of them and actually delivering the service.

329
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I think unless we had this tranche of fellows we've attracted from all over the place,

330
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I think it would be very difficult or impossible to to sort of keep saying and do a really good job.

331
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So I don't know whether we will see the trend reversed.

332
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At the moment. I see a kind of unstoppable march towards effectively a kind of industrialisation of health care with

333
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getting the maximum for the least cost and grinding out professionalism and variability and opinion and.

334
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Trying to have everything as uniform as possible. Now politicians will say, well, we don't want centres of excellence, that we don't want elites,

335
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we want the best possible treatment for everybody in Milton Keynes or whether they're in Oxford.

336
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And the way we do that is that we put in the structures and processes which make sure that everybody has exactly the same.

337
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Now, obviously, at the high end of medicine, we find that extremely difficult to agree with, and it's quite painful.

338
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The rise of the administrator. Do you think it happened in my generation, as it were, the ways of the past, or did it happen in your generation?

339
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A hundred years ago, I can I can remember Malcolm Gough in the bar at the John Radcliffe when you were allowed to drink on the premises,

340
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you know, railing against administration. So I think it's always been there.

341
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I think that, you know.

342
00:38:02,670 --> 00:38:06,270
Well, you do. In 1960, I would've said no. I mean I mean, it's interesting.

343
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A huge difference is the chief executive of the hospital, of course, now is actually under the court from the Department of Health.

344
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I mean, one time I'm not quite sure about it right now, but at one time,

345
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the chief executive of the Johnnetta was being phoned every week by the minister of health in that degree of of pressure.

346
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And does it make any difference? Does it make what happens any more?

347
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You know, any better? Is there any more accidents in terms of health care? You know, it's it's difficult to say.

348
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I guess the whole standard has gone up anyway. But why?

349
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What has it been?

350
00:38:46,050 --> 00:38:56,490
Well, there's been investment in health care, which needed to be good for the Labour Party in the last government for that big increase in investment.

351
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But all these other bits around the edges,

352
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I'm not I'm not sure that the rise of the interference from the managerial class has actually made any difference to standards, to be quite honest.

353
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I mean, it's been made a bigger bureaucracy. Things are more difficult to do.

354
00:39:14,940 --> 00:39:21,870
Do you think they as it will keep patients away from you at times?

355
00:39:21,870 --> 00:39:26,340
I think quite the reverse. I mean, we now don't have control over who comes to our clinic.

356
00:39:26,340 --> 00:39:31,860
Somebody knows that they're pushing people in. Yeah, absolutely. We say I can only manage, you know,

357
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twenty in an afternoon and you find there are 40 because they're under pressure for targets and so on and so on and so on.

358
00:39:39,540 --> 00:39:51,330
I mean, it's no I mean, we're now talking about the middle of November 2014 and next year there's going to be a general election.

359
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It is no surprise that from the Department of Health comes a directive.

360
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There must be not one single patient waiting for surgery. More than 18 weeks on the waiting list.

361
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Doesn't matter whether they've got any kind of a clinical priority.

362
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So you guys don't matter. You can't use it. We're going to choose and we're going to choose it on the basis that they've been waiting that long.

363
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And that is an example of gross political interference, which we've never quite had in this way over in the past, I don't think.

364
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And does anybody do anything about that in the sense of resisting it?

365
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I mean, the College of Surgeons say, well, now that's a very, very good question.

366
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The College of Surgeons at the moment is in the good books of the government,

367
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because when there were big discussions about the arrange the relationship between the government and the profession about two and a half,

368
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three years ago, the GPS and a number of other colleges said that they wouldn't co-operate,

369
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but the College of Surgeons decided that they would do what they could to help.

370
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And I personally think we've been a bit compromised, to be quite honest,

371
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although it's been good because we've got the ear of government and they like

372
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us going in and out of the Department of Health in a way in which that never, ever happened before.

373
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There's been a price to pay, which is that I think we've been compromised a bit.

374
00:41:27,390 --> 00:41:34,680
Yeah. Just to go back for a minute, the big operations, really big operation, say five modules.

375
00:41:34,680 --> 00:41:49,110
How long would that take? Um, well, a very low rectal cancer in a male done by Keyhole will take four or five hours.

376
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Some of our Crohn's disease patients with a real abdominal mash up, even done open will be five.

377
00:41:57,820 --> 00:42:04,450
Or six hours. Yeah, yeah, yeah. Um, then I was thinking,

378
00:42:04,450 --> 00:42:11,320
did you think the anaesthetise at any time you were saying that the administrators and the people on the periphery doing the bullying,

379
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did the admin did the anaesthetise ever limit the amount of surgery you could do?

380
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Because there was one time they sort of knocked off at five o'clock?

381
00:42:20,050 --> 00:42:28,570
Well, I mean, there was a very there was also a very fierce theatre system at the John who, you know,

382
00:42:28,570 --> 00:42:37,690
at about two thirty three o'clock would put a head round the door and say, Mort, you've got to be finished in half an hour.

383
00:42:37,690 --> 00:42:47,890
And it was it was it was difficult because you had an obligation to somebody who was very ill, you felt needed to be done.

384
00:42:47,890 --> 00:42:55,660
And where were you going to get it done if you didn't get it done that day? So it was less it was less the anaesthetist, to be quite honest.

385
00:42:55,660 --> 00:43:01,810
I mean, both Keith Sykes and Duncan were very understanding about the complexity of the case.

386
00:43:01,810 --> 00:43:07,610
So they would understand that you couldn't always predict how long it would take and they'd stick around for as long as it did take.

387
00:43:07,610 --> 00:43:16,060
And interestingly, in our new wards and theatres of the Churchill Hospital, where we now do our elective surgery,

388
00:43:16,060 --> 00:43:21,520
having previously been in the John Radcliffe, we now have what we call three specialists.

389
00:43:21,520 --> 00:43:31,660
So previously a day would, you know, maybe go from sort of nine o'clock till five thirty ish.

390
00:43:31,660 --> 00:43:37,460
And you carry on if you if you if you needed to in special circumstances.

391
00:43:37,460 --> 00:43:41,920
Now, listen to this for a change.

392
00:43:41,920 --> 00:43:48,670
I arrive at about seven twenty and I consent the houseman can't do it anymore.

393
00:43:48,670 --> 00:44:00,340
I can send the patients for the list that day. We have to meet at ten past eight for a to check on all the cases we're going to do on the day.

394
00:44:00,340 --> 00:44:09,070
Have we all introduced ourselves what Kit will we need? And then the list starts at eight thirty, usually pretty promptly to be fair.

395
00:44:09,070 --> 00:44:14,380
And we can carry on till seven thirty eight in the evening and we quite frequently do.

396
00:44:14,380 --> 00:44:19,090
And you're tired. You need a good drink. Yeah.

397
00:44:19,090 --> 00:44:24,310
Yeah. And only the post-operative care.

398
00:44:24,310 --> 00:44:30,490
I mean have you been heavily involved in that or through that other people on the firm who tend to do that,

399
00:44:30,490 --> 00:44:39,460
all the electrolytes and drips and whatever. Uh well again two or three things have happened.

400
00:44:39,460 --> 00:44:44,500
The first thing that's happened is, um, there've been specialised anaesthetists.

401
00:44:44,500 --> 00:44:53,470
So rather than having a cab rank principle, there will be anaesthetists, you know, all kinds of patients.

402
00:44:53,470 --> 00:44:57,100
Secondly, there's a better understanding of all kinds of patients recovery.

403
00:44:57,100 --> 00:45:03,640
And in fact, there's been a whole movement in surgery and general surgery, GI surgery called enhance recovery.

404
00:45:03,640 --> 00:45:10,720
So people don't have tubes down their noses anymore. They're give a drink, say, eight o'clock that evening.

405
00:45:10,720 --> 00:45:12,100
They are starting on a diet.

406
00:45:12,100 --> 00:45:22,660
The next morning, they're told to get up and walk up and down and we try and reduce the amount of opiate analgesia as much as possible.

407
00:45:22,660 --> 00:45:27,940
So all those things have sped up post-operative recovery. And it's because the anaesthetics later.

408
00:45:27,940 --> 00:45:30,490
Do you think, as it were later in quotes and. Yes.

409
00:45:30,490 --> 00:45:37,900
And so the use of there was there was big obviously those big epidural, which is slowly going away because of his complications.

410
00:45:37,900 --> 00:45:47,020
And the latest vogue is for either spinal anaesthesia, one shot spinal anaesthesia or so-called tap locks,

411
00:45:47,020 --> 00:45:55,870
which are multiple blocks in the abdominal wall for the for the dermo terms of the area, the operating.

412
00:45:55,870 --> 00:46:00,340
And those things have made a big difference. And I think, obviously, keyhole surgery has made a big difference.

413
00:46:00,340 --> 00:46:03,940
They don't have a cut from his sternum to pubis.

414
00:46:03,940 --> 00:46:08,770
They have a very small incision and a few steps. And that's obviously much easier to get over.

415
00:46:08,770 --> 00:46:14,920
Plus along with, if you like, medical specialisation has some nursing specialisation.

416
00:46:14,920 --> 00:46:22,990
So we now have a colorectal ward. The nurses all know everything there is to know about current patients so they're not jumbling up.

417
00:46:22,990 --> 00:46:28,960
You know, a bit of a had a bit of a knack, a bit of a chest. And I think that makes a fantastic difference to recovery, too.

418
00:46:28,960 --> 00:46:35,980
Yes. Yeah. Um, now you must have written a lot published about.

419
00:46:35,980 --> 00:46:45,940
Oh, um, yes. I've also probably learnt quite a lot of my junior colleagues in terms of getting them to do the work and then.

420
00:46:45,940 --> 00:46:50,560
Right. And then I'm kind of edited is um. And your name would be on the paper.

421
00:46:50,560 --> 00:46:57,100
My name would be on the paper but never first. It was always it was always it was always them.

422
00:46:57,100 --> 00:47:11,340
So. Yeah. I mean, over 300 original articles and I've written or edited about 10 books, lots of chapters, all that stuff.

423
00:47:11,340 --> 00:47:19,500
So when you do that at night, yes, usually.

424
00:47:19,500 --> 00:47:27,390
Or snatches during the day or if I'm on a train or something, you can do stuff that is and I was one of the nicest jobs I've done professionally as

425
00:47:27,390 --> 00:47:32,250
well as all that is I have been chairman of the British Journal of Surgery Society.

426
00:47:32,250 --> 00:47:38,850
So the British Journal of Surgery is the top, if you like, European General Surgery Journal.

427
00:47:38,850 --> 00:47:48,990
And it's actually owned by a society, not a national general surgery society, but something called the General Surgery Society.

428
00:47:48,990 --> 00:47:54,030
So kind of owns itself. And I was the chairman of that.

429
00:47:54,030 --> 00:48:05,430
We had royalties of half a million a year and we were able to put that to good use with student ships, lectures,

430
00:48:05,430 --> 00:48:13,350
training programmes, travel grants, all kinds of stuff for the promotion of surgery around the world.

431
00:48:13,350 --> 00:48:18,300
So it was nice to be involved in something which was obviously the whole business of publishing,

432
00:48:18,300 --> 00:48:26,010
the whole business of the interaction between commercial companies like the publishers and medicine,

433
00:48:26,010 --> 00:48:30,300
and also to be positive rather than, you know, sort of cutting costs all the time.

434
00:48:30,300 --> 00:48:39,780
And in a world where we had money and we were able to be generous and encourage people, which is great and private practise, how did that fit in?

435
00:48:39,780 --> 00:48:50,520
Yeah. So for example, I know that Peter Morris, formerly Nuffield professor of surgery, was very much a Ginnette.

436
00:48:50,520 --> 00:49:01,920
And in the 50s and 60s there were a group of professor of surgery in the UK who largely came from Scottish schools,

437
00:49:01,920 --> 00:49:10,080
either Edinburgh or Glasgow or their iterations, who are also DenTek in private practise.

438
00:49:10,080 --> 00:49:20,010
I have had a much more liberal view and obviously in a place like Oxford, it's not like working in London or any other big city.

439
00:49:20,010 --> 00:49:26,340
So it's it's limited. But I've really enjoyed being able to set the pace myself.

440
00:49:26,340 --> 00:49:31,290
How many people I see, how long I spend. And I've met some really, really interesting people.

441
00:49:31,290 --> 00:49:37,710
Yeah. And one or two of them have been incredibly generous to the hospital and therefore have,

442
00:49:37,710 --> 00:49:43,020
you know, have been to the advantage of of all the patients, not just the private patients.

443
00:49:43,020 --> 00:49:51,840
And you do that in the jar or somewhere. So in terms of consulting, they used to be the Åkerlund Hospital,

444
00:49:51,840 --> 00:49:56,910
which then moved to what was the amount of football ground is now the Nuffield Manor Hospital.

445
00:49:56,910 --> 00:50:07,860
Yes. So consulting there. But all our majors we do actually at the Churchill we have we have bookable private lists and the big case is done there.

446
00:50:07,860 --> 00:50:16,590
And also, again, I help the fellows and the junior guys do those cases and they are often very interesting, very challenging,

447
00:50:16,590 --> 00:50:22,110
intellectually stimulating, because they've come from elsewhere with particular problems and complications and so on.

448
00:50:22,110 --> 00:50:27,430
So I think it adds to the general educational you know, I absolutely yeah.

449
00:50:27,430 --> 00:50:31,200
The administrators do favour that. They're likely to do it.

450
00:50:31,200 --> 00:50:35,070
Well, they're schizophrenic. Yeah. I mean, they like they like the money.

451
00:50:35,070 --> 00:50:41,280
Yes. It brings in it, but they're under the cosh. So there's this funny schizophrenia.

452
00:50:41,280 --> 00:50:46,140
On the one hand they say we think it's fantastic, please bring as many as you can.

453
00:50:46,140 --> 00:50:51,720
But on the other hand, they're constantly under the cosh in terms of getting the NHS cases done.

454
00:50:51,720 --> 00:50:59,550
So the space for the admissions of the private patients is constantly being squeezed and reduced.

455
00:50:59,550 --> 00:51:10,110
So, um, if it's the kind of person who wants the operation done yesterday for either convenience or cosmetic reasons,

456
00:51:10,110 --> 00:51:19,260
we are completely unable to provide a service that if they've got cancer or something serious and they're prepared to kind of go through the process,

457
00:51:19,260 --> 00:51:26,640
then we can provide a service to them. And is the new oncology centre at the Churchill affect you or are you really separate?

458
00:51:26,640 --> 00:51:35,760
Sure. Well, I think the first thing to say is that GI Surgery never wanted to go to the Churchill side,

459
00:51:35,760 --> 00:51:40,560
but wanted to stay at the job to be next to gastroenterology.

460
00:51:40,560 --> 00:51:48,810
I always said in discussions with three chief executives with whom it was discussed ad nauseum,

461
00:51:48,810 --> 00:51:57,740
that it was a bit like putting heart surgery on a different side from cardiology, however.

462
00:51:57,740 --> 00:52:08,000
The practicalities were that in the early 90s, we were cancelling about 80 percent of our patients on the day of surgery,

463
00:52:08,000 --> 00:52:13,070
which was nationally one of the highest and completely unacceptable.

464
00:52:13,070 --> 00:52:20,510
So David Hiken, when he was chief executive, managed to get a new block built at the Churchill Hospital.

465
00:52:20,510 --> 00:52:25,310
And interestingly, this is this is really interesting about the relationship with oncology.

466
00:52:25,310 --> 00:52:30,710
And so clearly the oncology department at the Churchill side needed a rebuild.

467
00:52:30,710 --> 00:52:41,480
It was a disgrace, really. And all that was going to be built was a medical and radiation oncology department.

468
00:52:41,480 --> 00:52:47,690
And they had a visiting surgeon who came to discuss being an oncology centre.

469
00:52:47,690 --> 00:52:55,190
And he said to them, I don't get this. He said, surgery cures 60 percent of patients with solid tumours.

470
00:52:55,190 --> 00:52:58,190
Where are your surgical wards?

471
00:52:58,190 --> 00:53:08,420
And so suddenly, almost as an afterthought, they built some surgical wards and then the pressure was on for everybody to go there.

472
00:53:08,420 --> 00:53:14,750
We work closely with gastroenterology in terms of the management of gut problems

473
00:53:14,750 --> 00:53:20,030
in patients who've had surgery or are about to have surgery for GI problems.

474
00:53:20,030 --> 00:53:30,590
We certainly do discuss at our weekly multidisciplinary team meetings what should happen to the cancer patient with the oncologists.

475
00:53:30,590 --> 00:53:39,470
But we rarely do joint clinics. They rarely come to theatre and in a sense, we don't need to be there.

476
00:53:39,470 --> 00:53:48,800
Really was very interesting, however, is that as the money and the, if you like,

477
00:53:48,800 --> 00:53:58,040
the clinical application of modern oncology to a wider group of patients has rolled out,

478
00:53:58,040 --> 00:54:06,890
we're having patients on the oncology wards who are very sick with GI problems, and we are now the people who are sorting that out.

479
00:54:06,890 --> 00:54:16,220
So we most often, to be frank, go to the oncology ward not to discuss how to manage a new cancer or something like that,

480
00:54:16,220 --> 00:54:19,190
but to help with somebody who's got a neutropenic diarrhoea,

481
00:54:19,190 --> 00:54:27,410
who's got a perforation or who's got an obstruction as part of their ongoing oncology management.

482
00:54:27,410 --> 00:54:35,160
Suppose you have somebody you want to shrink the tumour, you was saying. So you would just sort of send them over to chemotherapy for a bit?

483
00:54:35,160 --> 00:54:36,650
Yes. So we I mean,

484
00:54:36,650 --> 00:54:46,580
one of the things the government did in the late 90s was enshrine effectively in law the need for all patients with the cancer to be discussed,

485
00:54:46,580 --> 00:54:53,600
a multidisciplinary team into very good. So no cancer patient can be treated without that.

486
00:54:53,600 --> 00:54:58,550
And the people who deal with a particular cancer have to have a specialism.

487
00:54:58,550 --> 00:55:00,180
And again, that's driven specialism.

488
00:55:00,180 --> 00:55:07,730
So in the old days of general surgery, somebody could do a gastric cancer, a thyroid cancer and the colon cancer all on the same list.

489
00:55:07,730 --> 00:55:12,620
That's now completely impossible because you'd have to go to all those three meetings.

490
00:55:12,620 --> 00:55:16,550
You'd have to know all the ins and outs of, if you like, the advance treatment and so on.

491
00:55:16,550 --> 00:55:21,620
So there we are on a Monday morning between nine and 10, 30.

492
00:55:21,620 --> 00:55:27,170
We have this enormous list of patients, old and new, some operated, some recurrence and so on.

493
00:55:27,170 --> 00:55:32,330
And the discussion goes, this is a new patient with rectal cancer.

494
00:55:32,330 --> 00:55:37,310
It's biopsy positive. Paing, the radiologist puts the images of the MRI up.

495
00:55:37,310 --> 00:55:42,260
We all sit there and say, yes, that looks as though it's quite near the recession margin.

496
00:55:42,260 --> 00:55:46,250
We think this patient and again, it's agreed by the radiation oncologist,

497
00:55:46,250 --> 00:55:53,360
by the imager and by the surgeons all round the table and quite a large number of specialist nurses.

498
00:55:53,360 --> 00:56:01,610
The patient should have chemo radiotherapy to shrink it down. So it's done as a team, but then they disappear into oncology.

499
00:56:01,610 --> 00:56:06,350
Well, when they have that, yeah. Yeah, this is being great. But what should I have asked you?

500
00:56:06,350 --> 00:56:11,360
What would you like to say that I haven't talked you into?

501
00:56:11,360 --> 00:56:17,930
I've had an absolutely wonderful time. I mean, I think I think Oxford is quite tricky when you come in as a newcomer.

502
00:56:17,930 --> 00:56:22,340
And I think it really grows on you. I think it's kind of got depth of interest.

503
00:56:22,340 --> 00:56:28,250
There's obviously some fantastic, fantastically clever people in town.

504
00:56:28,250 --> 00:56:37,040
And if you're lucky enough to work with some of them to operate on some of them, it's been a fantastic privilege.

505
00:56:37,040 --> 00:56:41,390
You said you'd worked with Burton. Have you talked about. Yes. What was that about?

506
00:56:41,390 --> 00:56:53,870
So Walter needed surgeons to help him both get material and to work on outcomes.

507
00:56:53,870 --> 00:57:05,540
So he's very, very interested in the genetics. If you like, of common cancers are with the established cancer syndrome, so he is,

508
00:57:05,540 --> 00:57:13,700
you know, discovered the gene responsible for familial polyposis colon cancer,

509
00:57:13,700 --> 00:57:19,100
but he's also been interested in a number of other hereditary cancers and also interested

510
00:57:19,100 --> 00:57:23,600
in this kind of grey area in the middle where people have a vague family history.

511
00:57:23,600 --> 00:57:26,780
But it's not terribly strong what it is that might be causing that.

512
00:57:26,780 --> 00:57:37,490
So, again, I've had or shed five or six research fellows with him down through the years, both providing material,

513
00:57:37,490 --> 00:57:46,070
getting cell cultures, going from some of our patients and looking at family trees, looking at outcomes and so on.

514
00:57:46,070 --> 00:57:51,560
Would your your students would they do genetic analysis themselves?

515
00:57:51,560 --> 00:57:55,640
Yes. Again, things have changed a bit.

516
00:57:55,640 --> 00:58:04,840
There's been a turn away perhaps in the last five or six years from the generals here, research fellows doing lab stuff.

517
00:58:04,840 --> 00:58:11,540
And there are some elite guys who are really outstanding who are still doing lab stuff.

518
00:58:11,540 --> 00:58:15,420
But again, the world has become professionalised.

519
00:58:15,420 --> 00:58:27,950
So there are now professional scientists who have a fantastic amount of backup for writing grants, write them very professionally.

520
00:58:27,950 --> 00:58:34,070
And it's extremely difficult for, if you like, casual surgeons to compete in that process.

521
00:58:34,070 --> 00:58:39,620
So they tend to be, you know, helpers in the big game going on team up with them.

522
00:58:39,620 --> 00:58:48,830
Yeah, exactly. Yeah. But the business that every cancer has, about five different genetic sets within every cell is different.

523
00:58:48,830 --> 00:58:55,310
Will that get us anywhere, do you think? Well, the big idea is it's quite interesting.

524
00:58:55,310 --> 00:59:00,140
There are parallels between inflammatory bowel disease management and cancer management.

525
00:59:00,140 --> 00:59:07,490
The big new drugs on the block are what are called the biologics. These are the therapeutic antibodies.

526
00:59:07,490 --> 00:59:22,820
And in IBD, these are two inflammatory mediators and in cancer that to things that help cancer cells make new blood vessels and so on.

527
00:59:22,820 --> 00:59:27,680
In very, very general terms, they are incredibly expensive.

528
00:59:27,680 --> 00:59:33,470
And what we want to know before we start is will this patient be a responder or not?

529
00:59:33,470 --> 00:59:41,240
So it's beginning to help. And the big sort of buzzword is personalised cancer and diabetes, the Americans.

530
00:59:41,240 --> 00:59:46,730
So you don't spend thousands, thousands of pounds on a patient who isn't going to respond.

531
00:59:46,730 --> 00:59:52,880
It's slowly getting there. I think it's it's happening much slower than everybody anticipated.

532
00:59:52,880 --> 00:59:58,220
I think some famous professor of medicine here would have said it, you know, would have happened 10 years ago.

533
00:59:58,220 --> 01:00:03,030
But I think it's still 20 years. It was the same with transplants. It was a bit longer than that.

534
01:00:03,030 --> 01:00:07,760
Yeah. Now, last question and don't just answer yes or no.

535
01:00:07,760 --> 01:00:11,520
Not with a name. You know who your successor is. No. Right.

536
01:00:11,520 --> 01:00:16,757
Okay. Well, thank you very much. It's been terrific.