President’s Address

 

Mr Arvind Vashisht MA MD FRCOG

President – BSGE

BSGE President Arvind Vashisht presented his inaugural President’s Address to delegates at ASM 2024 in Belfast. 

Before I start my President’s Address, I’d like to acknowledge Shaun and the Local Organising Committee for Belfast 2024 who have really laid on a terrific scientific and social programme. I’m also thankful to many of you, BSGE members, friends and colleagues, who have offered lots of kind words, encouragement and support as I begin my time as President.

The Presidential address has no set agenda, it’s really a blank canvas. I thought that we could talk about some of the things that interest me and some questions about the BSGE including: ‘Where did it all start?’ and ‘Why are we here?’

I want to introduce you to some great thinkers and philosophers of our time. Firstly Sir Francis Bacon, a 16th Century philosopher and the father of empiricism. Empiricism is scientific knowledge that’s based on reasoning and observations. So perhaps particularly pertinent to us as scientists. Also Gabrielle Suchon- a 17th Century French thinker who argued, quite revolutionary, thoughts that women deserved the natural rights of liberty, learning and authority. Thirdly, Galen, who was a Second Century Greek philosopher and great anatomist, physician and surgeon, which again, fits very well for our conference. Finally, Emilie du Chatelet an 18th century French woman who was a philosopher and mathematician who sadly died in childbirth. Rather than perhaps having these as abstract, philosophical contexts and concepts I’ve given it some reference to our Society. I think, pertinently for the Presidential address, I’ll provide some explanation what we’ve chieved so far- and, importantly from me as, the President, deliver some ideas about where I think that we can go and where I’d like to take the Society.

 

Now, I’ll take you on a small trip down memory lane.  BSGE was originally founded in 1989. Of course, the world was very much a different place then: the Union of Soviet Socialist Republics was one country  and there was a, so-called, iron curtain that separated East and West Europe. It was a time of great change, perhaps most famously characterised by the felling of the Berlin Wall. Similarly, this was a time of significant change in surgery.
There was a surgical revolution with the advent of minimal access surgery.

 

In 1989 some of us we may not have been born- but I was finding enlightenment in my gap year in Southeast Asia.

The original founders of the BSGE can be seen in this picture:  Alan Gordon can be seen on the top left ( he was actually born in Belfast) as well as Vic Lewis, Chris Sutton and Adam Magos who was the first BSGE Treasurer. Adam was a surgeon gynaecologist at Royal Free, where our current Treasurer Fevzi Shakir is from. These pioneers wanted to form a society to encourage the development of new minimally invasive surgical techniques. They wanted to provide facilities for training and also monitor and prevent complications, areas that we have developed over the years since the original seeds were sown by our predecessors.

 

Whilst across the world there might be bigger society meetings an,  in mainland Europe, there may be some units that produce data on larger groups of patients I think, as a society, we’ve developed a really collaborative and accessible approach to delivering high-quality care for women. We’ve built in quality assurance and governance and developed training opportunities- and we’ve done this on a national scale. I don’t think that there is another society that’s been able to equal the BSGE’s achievements over that time.

 

You’ll have heard that our membership numbers have been increasing.
If we examine the breakdown of members (thanks to Johnny, my PhD fellow for putting this slide together) you can see that the chief rise in numbers has been through nurse specialist and trainee members. I think that’s a reflection of their interest- and I hear a very clear message from the trainees and the CNS saying: ‘We’re here and we want to learn and we want to train.’

 

I think the increase in numbers is partly a reflection of what the BSGE has laid on to be inclusive and attractive as a society. We have expanded the nurse specialist portfolio, which is now represented in two ways with both endometriosis and hysteroscopy representatives. This map shows the hysteroscopy opportunities up and down the country. The BSGE has also endorsed recommendations to support the endometriosis CNS role in terms of agenda for change, banding and allocating a minimum of ten hours

for the nurse specialist to be engaged in dedicated endometriosis work.  There are key elements to the CNS role which include holding a clinic and being that pivotal member between the patients, the MDT and primary and secondary care. There’s mentoring and there’s educational and professional development- of course including having to attend the ASM every couple of years or so.

 

Our trainees are the clinicians of now and the clinicians of the future. This image shows a laparoscopic map of the UK which details all the regional and local laparoscopic training opportunities available.

 

I’m sure we’ve all heard about the Registrars in Gynaecological Surgery- the so-called RIGS programme. To those of you who don’t know, it’s a centralised, standardised programme in the BSG that’s delivered through a series of webinars and hands-on workshops with different streams from basic, intermediate to advanced which aligns with the core curriculum. Of course, there are also national programs and awards and we have links with our European partners as part of the very successful GESEA programme.

 

An area that’s been very close to my heart has been the development and growth of the BSGE Endometriosis Centres. Following the original inception of the BSGE in 1989, this was, I think, the next big step for our Society. It was borne out of members deciding that they needed to take something to a different level. In this particular instance, it was a recognition that we needed to deliver better surgical treatment for our patients with severe endometriosis. This was going to be done in two ways:  The concept of developing specialist centres and the concept of monitoring and auditing some form of outcome data. 

 

 

I think the Endometriosis Centres project established the concept of the continuum of care. Whilst we had many practitioners who were delivering terrific care and they were generating some form of noise, we moved towards a much more symphonic orchestral piece of music whereby all the important players were all working together to deliver the best possible care with the patient very much at the centre of things.

 

It has been a very successful project with increases in the number of patients that have been put on the database to the extent that we now have 2500 or so. Of course, there was a dip during the national pandemic.However, if we look at the number of Endometriosis Centres that have been established up and down the country, we’re now up to around 75
which is a reflection of the interest and enthusiasm from grassroots teams to develop and produce these high levels of service.


 

From the Endometriosis Centres database, there have been several research outputs, perhaps best exemplified by Dominic Byrne’s paper in BMJ Open which showed the largest world series of data demonstrating the effectiveness and the symptom improvement in women undergoing surgery for the most severe forms of endometriosis.

 

We have built strong links with industry. This is a symbiotic and required relationship and we’re grateful to our industry partners for taking forward so many innovations that were initially the brainchild of clinicians. Industry helps put our ideas into practice. Ultimately we hope that innovations are translating into better and safer outcomes for women in terms of what we can offer in ambulatory care, tissue retrieval techniques and in progress within operating theatres. We couldn’t run a successful ASM without industry’s help and we know their input also trickles all the way down to the local support we get in our hospitals and within our individual services.

 

The Society has also been involved in guidelines, training, commissioning, and general information giving. We work with national bodies and charitable organisations to issue statements. We’ve also been involved with changes to the curriculum and some of the commissioning work initially back in 2013.

In terms of information giving, the BSGE podcast series has been a big success, this is another example of innovation. During the pandemic, we embraced the idea of taking on podcasts- but hey, so did many people. But the BSGE continues to produce some of the highest quality webinars and podcasts together with Instagram, Facebook, Twitter and  other forms of information giving when many other societies or projects have fizzled away. We are still at the top table delivering the highest quality information. The Scope magazine that Jimi and Jane have been instrumental in maintaining from the initial works from Shaheen and the rest of his team.

 

So that is your organisation. But of course, we couldn’t have any discussion about the BSGE without mentioning Atia, who has been the absolute bedrock of everything that has happened within the Society over the years. She’s carefully steered the Presidents, the Council and all of us even when we’ve not had official BSGE roles. We really are exceptionally grateful to Atia for steering and supporting us so well. Atia is now also ably assisted by Charis Ayton – together they form a great team.

 

I think we are all indebted to our Past Presidents for navigating a direction from the early beginnings to where we find ourselves today. I am particularly indebted to my predecessor Andrew Kent, who has set the direction for training and leadership and has been instrumental in recent changes to the College curriculum. He has also helped drive the delivery of many courses and training opportunities including the new senior training course. Hopefully he will continue his involvement in the service specification (which happens slightly outside of the BSGE.)

 

This is a great opportunity to formally thank Andrew for his fantastic and diligent work as a Treasurer and as President- thank- you!

 

So, what’s next? We could relax, have some fine wines and cigars. We could reminisce about the old days and how great the times were before. We could talk about our humble beginnings- of course, there’s nothing that consultants like more than that! This is exemplified in this clip from Monty Python’s ‘Four Yorkshiremen’ in which they discuss the bad old days and how young people don’t properly appreciate what their elders had to go through!

 

That is probably reminiscent of some surgeons’ coffee rooms! But, in the BSGE, I think that we don’t have that option. Indeed, in the President’s document, my role is to have a strategic vision which represents the purpose of the organisation. In the rest of this address, I’d like to share that strategy, what I’d like to propose for the future of our Society and make some key pledges.

 

I’ve based our strategy on being true to the Society’s first principles. If we cast our mind back to why the Society was originally started- it was for: the development of pioneering surgical techniques, to provide facilities for training, and to monitor and prevent complications. 

 

I’d like to add an addendum for 2024, which is: to be inclusive and to listen to our patients.

 

Let’s take those principles in turn:

 

 

When we talk about pioneering surgical techniques, I think the largest innovation and surgical tool has been the advent of robotic technology. I don’t think we can sit back and observe this technology from afar. We have to immerse ourselves in it and embrace it.

 

Although many of us, as surgeons, are well on our way with training and including robotic technology as a tool, as a Society, we haven’t incorporated it as well as we could. We’ve got the infrastructure and we’ve got the membership to do this properly. So my first key pledge is to work with national societies, the College  and industry to evaluate robotic technology and where it is going to fit into the surgical treatment of women with endometriosis and complex benign disease.

 

What does that really mean? It means that we need to get involved in the guidance. We need to get involved with the training, we need to get involved in mentoring, and we need to look at the outcomes.

 

 

I’d also like to look at the concept of what makes a surgeon and what makes a CNS. I think all of us observe our colleagues and mentors, we may see their skills and think that we’d like to be like that person. The thing that often holds us back is a lack of confidence. That lack of confidence can come from fear or from ignorance. The way to resolve both of those issues is through training.

 

As a surgeon, I think one of the most fundamentally important factors is knowledge of anatomy. Surprisingly, as pelvic surgeons, we are sometimes not as aware of anatomy as we should be. And it’s not just pelvic surgeons, in one study from 15 years ago, Abdul Sultan questioned obstetricians and midwives, who routinely performed episiotomy as their most frequent procedure. Despite this experience, less than half of respondents knew which muscles they were cutting during episiotomy, and the vast majority felt that their training in surgical anatomy was lacking.

 

I’d also like to look at the concept of human factors in surgery, which is another subject in which we’re not particularly well trained. We need to consider why we think in certain ways, how we minimise complications, and how we manage ourselves during a complication or a difficult scenario.

 

We saw an excellent example of this during the pre-congress live endometriosis masterclass. I’m not sure what Mikey was told before the operation, but he was all set to perform a hysterectomy and maybe an ovarian cystectomy. Actually, when they started the operation, it was clear that the surgery was much more complicated than it was originally billed. It was really good for me to see the surgical steps, but it was also fascinating to observe Mikey’s thinking process when faced with unfamiliar territory, how his mind moved to asking what steps he should perform before reverting back to basics.

 

This form of thinking can be trained and we need to look at this area more as surgeons. The airline industry understands this training well. I think the reason they minimise risk and train how to manage crises is because if the plane goes down, they go down with it.

We’ve got to develop that kind of mindset as surgeons and as nurse specialists, as well as developing mentoring programs.

 

 

Another pledge is to work with the college to incorporate surgical anatomy and human factors, via perhaps immersion programs and a mentorship program, into training.

 

 

Monitoring and preventing complications speaks very much to what Angus Thompson has discussed in terms of the planned evolution in our Endometriosis Centres project with database and service specification changes. We need to make sure that we marry up the two processes of accreditation and the change in service specification. Let’s get the database to a contemporary level, it was great for 2012, 2013, but now the questionnaire and the surgical classifications are a little dated and it’s rather cumbersome in IT terms.

 

 

We are going to work to produce something that’s more fit for purpose and more suitable for 2024 and the future. We’ll also have to change the way that we think about

how we deliver care for women with endometriosis ( Angus also touched on this in his Endometriosis Centre meeting). We need to look at the concept of much more collaboration and potentially explore network working.

 

 

The addition to the BSGE’s core principles is to be inclusive and to listen to our patients.

What does that mean? Of course, we listen to patients as practitioners- but the all-party parliamentary group report in 2020 made for interesting and harrowing reading. It offered insights into the difficulties and negative impacts that endometriosis has on many sufferers. Many messages came out of the report- but the key theme was the delays in diagnosis. That’s been a running theme for a long period of time which really gives us a target to improve.

 

We have a tool that can help us improve, a tool that is commonplace, cheap and accessible. In my opinion, that tool is ultrasound. The problem we have is that whilst, a selected can scan to a very high level, there is grassroots level of ultrasound delivered. We need to look at how we can shift that level up to improve the diagnosis of women with endometriosis.

 

 

We pledge to try and work with the College to try and implement some form of skeleton or infrastructure to deliver a higher quality of ultrasound scan.

 

 

These are the four key pledges that I plan to put forward, to achieve and to deliver.  But this is not something that I can do alone. I will be ably assisted by the Council members all of whom have portfolios and, I hope, share my wish to deliver the ambitious vision that we have set.

 

 

But there is a fifth pledge- and that is to involve all of you, our members, friends and colleagues. Please make sure that you also engage in the process. When your Officers or Representatives approach the College or industry, we have more impact if we can say that we represent and reflect the voices of 2000 professionals. We will be very grateful for your ideas, your feedback and your input in delivering our pledges. We have always been a very receptive and accessible Society, and we want you to feel that it’s your Society and that you have a voice.

 

I hope you think it’s right and proper that I paid homage to our predecessors- the pioneers who shaped the Society. They had ideas, just like you and I might have ideas. But they were bloody minded and persistent to make changes. We owe a debt of gratitude to them all.

 

I’m now going to be the 18th President, and 18 is an auspicious number. If we regard 1989 as the birth of the BSGE and the development of Endometriosis Centres as the 11 plus. We’re now 18, we’re ready for another big leap! We’re in a dynamic, interesting time where there are new voices and new technologies. It’s time for us to develop a seismic change in what we deliver as a Society.

 

We heard yesterday from our keynote speaker Joe Amaral about the concept of innovation and the surgeon/gynaecologist. Innovation is very much at the heart of what we do in the BSGE. All of these new techniques are available, there’s no way that we can just simply sit back and reflect like those four gentlemen from yesteryear. We have to see innovation as an opportunity rather than a threat. Of course, we’re in a time where many of us struggle in our local hospitals, struggle with beds and with staffing. But this is the kind of paradox that’s always been there for many, many centuries. The challenge is as true today as it was in the time Charles Dickens. I’d like to leave you with the opening line of ‘A Tale of Two Cities.’:

 

 

 

Thank you very much.

 

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