January - September 1999
Having spent two years in full-time research in lung transplantation, specifically in the field of lung preservation and reperfusion injury, I decided that it was time to experience the clinical reality. Coupled with my desire to spend some time abroad with my family prior to accreditation, I approached the famous Toronto Lung Transplant Group with a view to securing a clinical fellowship. The contribution of Toronto to the specialty of thoracic surgery and lung transplantation needs no introduction. They perform around 40 transplant procedures per year, making it one the most active programs in the world. An encouraging response form the Division Chief, Professor Tom Todd, led to a visit to Toronto in May of 1998. This was a sound investment of time and money.
Fortunately, the College of Physicians and Surgeons of Ontario recognise British postgraduate qualifications. Obtaining a licence was a lengthy procedure, but there were no obstacles. Medical defence subscriptions are reasonable. Family health insurance was significant, though after three months, I was covered by the Ontario government health insurance scheme. All that remained for me to do on my arrival in January was to present myself in person to the College with my original certificates.
Within 24 hours of arrival I had my licence, and within another 24 hours was retrieving my first set of donor organs. Previous experience in the lab in Manchester came to fruition immediately, and soon I was entrusted with the entire donor process. The director of the Lung Transplant Program is Dr Shaf Keshavjee. Both Professor Todd and Dr Keshavjee were excellent trainers. Usually after a retrieval, I would also do the implant. Organs are retrieved from all over Canada, because the only other major lung transplant program is in Montreal, which we visited fairly frequently. One of the memories I will hold for considerable time is flying to Kelowna, British Columbia, and descending steeply through the sunlit Okanagan Valley in our chartered, very plush Citation jet. Thankfully the double lungs worked well after an ischaemic time of ten hours. Equally important was the experience of working within the highly energetic multidisciplinary lung transplant group. I worked closely with the chest physicians, and learnt much of the complex (and sometimes disappointing) medical aspects of lung transplantation.
The current philosophy is to perform bilateral transplants as often as possible. However, the shortage of donor organs is challenging this philosophy, and more single lungs might be performed over the next few years. Ontario has a poor donation rate similar to the United Kingdom of around 14 per million population per year. There is a paediatric program, and I therefore spent considerable time at the famous Hospital for Sick Children. A 120-bed ICU is a sight to behold. We also performed two heart-lungs during my time. Dr Keshavjee runs a very active thoracic surgery laboratory, which has flourished previously under the direction of Drs Joel Cooper and Alec Patterson. Current research projects involve organ preservation, reperfusion injury, gene therapy and investigation of agents for the prevention/amelioration of bronchiolitis obliterans. Top-class Fellows from around the world contribute to the diversity and productivity of the research department. I was thus able to work alongside some extremely motivated fellows, and was able to introduce some concepts derived from my own MD work into their organ preservation studies. The possession of my FRCS and MD also enabled me to examine medical stuents of the University of Toronto - this I did on a frequent basis.
In addition, I was able to undertake some thoracic surgery when the other residents were away. I was also proud to introduce a little of British practice into the department in the form of the Bradford extrapleural block (Sabanathan et al.) The anaesthetists were astonished by its effectiveness. Thankfully the first few worked well! I was pleased to meet Dr F G Pearson, who retired this year. I was honoured to be asked to write a chapter for the next edition of his Thoracic Surgery textbook.
In retrospect, arriving the first week in January with a young family to a downtown dwelling, amidst temperatures of minus 30 and snow storms was not the greatest thing we have ever arranged. Although Downtown Toronto is a spectacular and vibrant city in summer, it is inhospitable and unpleasant in winter. The population literally hibernates for the first four months of the year. However, prior to our return home at the end of September, we were able to spend some time touring the Maritimes and Quebec, and we departed Toronto in good spirits. Ontario and Eastern Canadian provinces really are beautiful between the months of April and October.
Without the generous financial support of the Society, this venture would have been impossible. Unfortunately, the Government of Ontario does not salary overseas fellows. Presumably they rely on the world class reputation of Toronto (in many specialties) to attract fellows from around the globe. A modest(?) stipend was offered to me from what appeared to be a transplant slush fund. Our bank manager has been extremely understanding, and we hope to have cleared our debts within the next five years or so. However we believe that our investment has already paid handsome dividends in many ways.
Would I recommend this kind of venture? Yes. The clinical and academic experience was phenomenal. As a family, we have benefited enormously. However, as many members of the Society will testify, this is no easy ride for even the most supportive family. Certainly, instant immersion into clinical practice in a new country is a challenging experience. A research post might offer a more graduated introduction to life overseas. For any trainee who is considering a clinical fellowship abroad, the following points should be considered: