TIME TO MAKE ANAESTHESIA FIT FOR THE FUTURE - Launching our new campaign to secure a sustainable anaesthetic workforce
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March 2021
The PIG that flies!
Upcoming elections in
Scotland and Wales
Prime time for paediatric
prehabilitation
TIME TO MAKE
ANAESTHESIA
FIT FOR THE
FUTURE
Launching our new
campaign to secure
a sustainable
anaesthetic
workforce
Page 4
rcoa.ac.uk
@RCoANews
Bulletin | Issue 126 | March 2021
RCoA Events COVID-19 Conference Anaesthetic Updates
15–17 June 2021 29–31 June 2021 JULY
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rcoa.ac.uk/events Online RCoA, London
Final Revision Course
events@rcoa.ac.uk Primary FRCA Revision Course Start date: 5 July 2021
Start date: 21 June 2021 Online
@RCoANews
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Online
Airway Workshop
MARCH APRIL 12 May 2021
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Venue to be confirmed
Patient Safety
AaE: Introduction
Ethics and Law
20 April 2021 Ethics and Law
%
11 March 2021
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Online 13 May 2021
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FULLY BOOKED
for Anaesthetists
Online
After the Final
AaE: Simulation Unplugged
21 April 2021
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12 March 2021
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Online Anaesthesia 2021
Online
13 May 2021 | Online
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Cardiac Symposium 2021 18–20 May 2021
Developing World Anaesthesia Online
22–23 April 2021
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15 March 2021 More information is available from
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Online
Online
events@rcoa.ac.uk
Clinical Directors Senior Fellows and Members
Global Anaesthesia
16 April 2021 Club Meeting
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16 March 2021
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Online 25 May 2021
Online
Invitation only Online
Leadership and Management:
Leadership and Management:
Listen to our latest podcast:
AaE: Teaching and Training in
The Essentials
Preparing for CCT and
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the Workplace The Essentials
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17 March 2021
beyond
28–29 April 2021 27 May 2021
Online
Edinburgh Online
Anaesthetic Updates
GASagain (Giving Anaesthesia You can listen to the RCoA podcast in many
23–24 March 2021
JUNE
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Safely Again) places: search for RCoA on the podcatcher
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Online
28 April 2021
of your choice.
Regional Anaesthesia Masterclass London AaE: Teaching and Training in the
24 March 2021 Workplace rcoa.ac.uk/podcasts
%
%
Online
MAY 2–3 June 2021
FULLY BOOKED
Leadership and Management:
Personal Effectiveness AaE: An Introduction Anaesthetic Updates
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26 March 2021 10 May 2021 15 June 2021
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Online Online Bristol
LISTEN
AaE: Anaesthetists’ Non-
NOW >
Technical Skills (ANTS)
%
11 May 2021
Online
Discounts may be available for RCoA-registered Senior Fellows and Members, Anaesthetists in Training, Discounts may be available for RCoA-registered Senior Fellows and Members, Anaesthetists in Training,
Foundation Year Doctors and Medical Students. See our website for details. Foundation Year Doctors and Medical Students. See our website for details.
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Book your place at rcoa.ac.uk/events Book your place at rcoa.ac.uk/events | 1
Bulletin | Issue 126 | March 2021 Bulletin | Issue 126 | March 2021
Contents
The President’s View 4
News in brief 8
Guest Editorial 12
Faculty of Pain Medicine (FPM) 14
From the editor
Faculty of Intensive Care
Medicine (FICM) 15 Dr Helgi Johannsson
SAS and Specialty Doctors 16
Society for Education in
Welcome to the March Bulletin.
Anaesthesia UK (SEAUK) 18
As I look out of the window I see the early evidence of spring – the daffodils in our terrace containers have
Patient perspective 20
started sprouting and are showing just the start of the flower bulb. By the time you read this they will hopefully
Revalidation for anaesthetists 22 have bloomed and I welcome you to spring, and the new edition of the Bulletin.
Perioperative Journal Watch 23
This time last year I would never have believed that we would be in lockdown number three, and dealing with
Anaesthetists as ‘knowledge yet another surge of coronavirus. This time is a little different: we have some treatments, and know our enemy a
translators’ with Cochrane 26 little better, and most of us are pretty confident using Teams and Zoom to manage the various meetings that got
Core trainees: the COVID cancelled in the spring. It is obvious that this isn’t a sprint, and although the vaccine provides a lot of hope we now
Guest editorial career challenge 28 know that education, exams and training have to continue.
Global anaesthesia: always a How ergonomic is
your anaesthesia workplace? 30
Drs Shah and Syed (page 44) demonstrate that this is not only possible but effective for our novice new starter
courses, but Dr Ng (page 28) reminds us that the COVID pandemic has caused major disruption to an entire
good time Supporting progress: the new
anaesthetics curriculum 34
generation of trainees, with further recruitment difficulties and uncertainty to come. The challenge over the next
few months and years will be to accommodate their training needs, and to prevent a recruitment crisis of fully
Dr Wong and Dr Lubis tell us about colleagues who Updating assessments: the
trained anaesthetists. In the next few years the great priority will be to try to catch up, and provide operations
for all the people currently living in pain and disability, while waiting for routine surgery. We will be at the
went abroad at different stages of their careers and new anaesthetics curriculum 36
centre of that drive.
the challenges they faced Upcoming elections in
Scotland and Wales 38 I read with interest the article by Dr Marks (page 30) on ergonomics in the workplace. I know several of my
Page 12
Get involved in CPOC’s colleagues have had cervical intervertebral disc problems in the last few years, with at least two operations. Our
Green Paper 40 ergonomics are so often wrong in the workplace, and the twists and tensions of our day to day job could easily be
improved with some thought into the placement of monitors, and the height of the patient when intubating.
The President’s View Out of our comfort zone Finding new success in novice
training 44 One of my career regrets is that apart from a fantastic elective in rural South Africa as a medical student, I have
Time to make anaesthesia Working with medical students in
Trainee-led virtual never worked abroad, which is why I wanted to highlight the article by Drs Wong and Lubis (page 12) sharing their
fit for the future. Read about a Family Liaison Team during the and others’ experience of anaesthesia in a global setting, demonstrating it really isn’t too late for any of us. We
symposiums: the foolproof guide 46
our new campaign on the COVID-19 pandemic just need to be able to travel!
anaesthetic workforce International accreditation of
Page 32 perioperative neuroscience Over the next few issues you will see some changes to the way the Bulletin is laid out and I want to thank those
Page 4 fellowships 48 of you who took part in our members’ survey and shared with us how you want to read it. As always, I want to
Prime time for paediatric Meet the new Council members 50 encourage you to write articles for us, strictly not over 800 words, but on a variety of subjects. I would particularly
The PIG that flies! prehabilitation welcome personal accounts and experiences not only as doctors, but also those of you who have been patients.
Being an Event Clinical
Read about the work of the RCoA While adult prehabilitation Content Lead 52 I hope you are enjoying the blooming of spring and I really hope that by the time you
Patient Information Group from is becoming more widely As we were... 54 read this there is at least some return to normality.
our patient information lead established, paediatric
New to the College 56
Page 24 prehabilitation trails behind
considerably Letters to the editor 58
Page 42 Notices, adverts and College
events 59
2 | | 3
Bulletin | Issue 126 | March 2021 Bulletin | Issue 126 | March 2021
Professor Ravi Mahajan
President
president@rcoa.ac.uk
I spend a lot of my time as President representing the College at
meetings with external stakeholders and Government officials,
often with my counterparts from other medical royal colleges.
One of the concerns which gets raised continually is workforce
shortages across the whole of the NHS.
The College welcomed the publication of the needs of a growing and ageing population would
People Plan (bit.ly/3ipw6D4). This is the latest require hospital activity to increase by almost 40%
attempt at producing a workforce strategy for the over the next 15 years’.
NHS and is supportive of the many initiatives in this
And yet we know from our 2020 Census
around wellbeing, diversity and leadership. Unlike its
(rcoa.ac.uk/census-2020) that the anaesthetic
counterparts in the devolved nations, which set out a
workforce is not growing fast enough to keep pace
roadmap for comprehensive workforce planning, this
with demand and that increasing pressures are
strategy now needs to be backed up by commitment
placed on anaesthetic departments to deliver more
to tackling workforce pressures across the whole of
with less. Currently 90% of anaesthetic departments
the healthcare system, not for just a few specialties.
have at least one consultant vacancy and the
We must move away from the piecemeal approach
consultant gap has increased steadily over the past
of allocating resources to specialties when the
five years. This is not surprising given that there
need becomes critical. What we need is a joined up
has been a steady decline in the number of newly
workforce strategy that looks at systems as a whole
qualified anaesthetists from 569 in 2013 to 373 in
and that is based on population needs for the future.
2019, a 34% reduction. The Census also reports 243
This is particularly important for anaesthesia. vacant SAS doctor posts across the UK.
The President’s View The Office for National Statistics predicts that Despite these challenges, at the height of the
TIME TO MAKE ANAESTHESIA
there will be an additional 8.2 million people COVID-19 surges, anaesthetists all over the UK
aged 65 and over in the UK by 2068.† At the have stepped up to support the NHS at the time of
same time, advances in medicine, including less greatest need and have demonstrated their value in
FIT FOR THE FUTURE
invasive surgical techniques, and changes in healthcare systems to a wider audience than ever
population health dynamics have led to an increase before. But we also know that this has come at a
in the number of older patients living longer with personal cost for many of our members and that this
complex diseases. The Institute for Fiscal Studies crisis has further increased the impacts of workforce
Launching our new campaign to secure a sustainable
and the Health Foundation‡ predict that ‘meeting the shortages for our specialty.
anaesthetic workforce †
Overview of the UK population. ONS, 2019 (bit.ly/3oXvd7r).
‡
Securing the future: funding health and social care to the 2030s. IFS, 2018 (bit.ly/3o0TsA6).
4 | | 5
For more information on
Bulletin | Issue 126 | March 2021 Bulletin | Issue 126 | March 2021
Anaesthesia – fit for the
future, please go to:
rcoa.ac.uk/anaesthesia-
Bulletin
The Office for National Statistics predicts fit-future of the Royal College of Anaesthetists
that there will be an additional 8.2 million Churchill House, 35 Red Lion Square, London WC1R 4SG
020 7092 1500
people aged 65 and over in the UK by 2068 The College’s ‘Stay in anaesthesia’ campaign will be rcoa.ac.uk/bulletin | bulletin@rcoa.ac.uk
looking to address the retention challenges facing our @RCoANews
specialty by investigating the causes of poor retention /RoyalCollegeofAnaesthetists
for anaesthetists approaching retirement and developing
policy solutions to enable them to stay in work in a way Registered Charity No 1013887
When we do start to emerge from the 2 improving retention of our most programme and this requires a financial that is sustainable for them and beneficial to the specialty. Registered Charity in Scotland No SC037737
pandemic, we need to be more vocal experienced anaesthetists commitment from Governments in VAT Registration No GB 927 2364 18
about the crucial role that anaesthesia 3 supporting the development of SAS the four home nations. Supporting SAS anaesthetists President Dr Emma Stiby
has in the delivery of healthcare, anaesthetists. SAS anaesthetists play a critical role in the delivery of
Anaesthesia – fit for the future will Professor Ravi Mahajan SAS Member
not just in times of crisis, but also in anaesthetic services and have played a huge part in
enabling the NHS to return to normal The choice of these priorities reflects be the College’s flagship campaign. Vice-Presidents Dr Susannah Thoms
supporting departments throughout the pandemic.
levels of healthcare service delivery. the urgency that it was felt was needed It is comprised of a programme of Dr Fiona Donald and Anaesthetists in Training
However, our latest Census reveals that SAS anaesthetists’
to address the workforce shortages for work spanning across the next two or Professor William Harrop- Committee
numbers have changed little over the last five years.
We need to continue to educate the specialty and to find solutions to three years and aims to make the case Griffiths Carol Pellowe
the public and the wider healthcare nurture, retain and develop the existing for the expansion of the anaesthetic Given that SAS anaesthetists account for almost a quarter Editorial Board Lay Committee
community about how anaesthesia talent, so that the safe delivery of workforce across all grades and of the anaesthetic workforce, we need to look at ways to
operates well beyond the realm of the Dr Helgi Johannsson, Editor Gavin Dallas
anaesthetic services can be maintained roles. It will investigate the increase make the role more attractive and to address the inequity
operating theatre, and how it supports a Dr Krish Ramachandran Head of Communications
in the long, medium and short term. in demand for anaesthetic services of treatment that many SAS colleagues still experience.
wide range of healthcare settings, from and forecast workforce requirements Council Member Mandie Kelly
The College’s ‘SAS anaesthetists can’ campaign will aim
maternity units to pain services, from Making the case for more for ‘team anaesthesia’ over the next Professor Jonathan Thompson Website & Publications Officer
perioperative care clinics and enhanced to support the development of SAS anaesthetists. We will
anaesthetists five to ten years across all relevant Council Member Anamika Trivedi
care units to pre-hospital medicine. aim to raise awareness of the importance of professional
healthcare settings. Website & Publications Officer
Anaesthesia plays a critical role in the development opportunities for SAS anaesthetists and Dr Duncan Parkhouse
Advocating for the anaesthetic delivery of secondary healthcare. Many encourage more joined up thinking on how they can Lead Regional Advisor
workforce is now a key priority for the areas of the NHS could simply not
Retaining our most Anaesthesia
make an even greater contribution to the delivery of
RCoA, and I am committed to making function without anaesthetic services, experienced anaesthetists anaesthetic services. Dr Hugo Hunton
the case for why investment in our not just surgery, but also maternity, The latest Census shows that the Lead College Tutor
specialty is so urgently needed. This emergency, and trauma and pain anaesthetic workforce is ageing, with the Get involved
is why in 2021 the RCoA is launching services, to name just a few. As we number of consultants who now work Articles for submission, together with any declaration of interest,
This campaign is for you, our fellows and members.
its Anaesthesia – fit for the future emerge out of the pandemic and the beyond the age of 60 and approaching should be sent to the Editor via email to bulletin@rcoa.ac.uk
Throughout the campaign we want to make sure that we
campaign, an ambitious programme NHS resets itself and begins to restore retirement having increased by 2% over never lose sight of what matters to you. All contributions will receive an acknowledgement and
of work over the next two to three normal levels of service, anaesthetic the past five years; 39% of consultants the Editor reserves the right to edit articles for reasons of
years aiming to: services will be pivotal in tackling the are now over 50 years old – an increase We have set up a fellows and members’ sounding board
space or clarity.
backlog of elective surgery and in from 31% in 2007. at the start of the campaign to help us test our initial
1 change policy to secure a thinking, but we are also keen to continue to engage with The views and opinions expressed in the Bulletin are solely
reducing waiting times.
sustainable anaesthetic workforce While it’s critical that we boost the you as the campaign progresses. those of the individual authors. Adverts imply no form of
2 make a difference to the working The negative growth trend for the pipeline supply of new anaesthetists endorsement and neither do they represent the view of
lives of our members anaesthetic workforce highlighted in the coming through training, more must If you are interested in joining our campaign sounding the Royal College of Anaesthetists.
Census needs to be reversed urgently also be done to retain our most board please email advocacy@rcoa.ac.uk
3 be profile-raising and impactful. © 2021 Bulletin of the Royal College of Anaesthetists
if we are to ensure that the NHS can experienced anaesthetists so that they
Finally, if you have any comments or questions about All Rights Reserved. No part of this publication may be
Following a period of analysis and continue to recover from the pandemic can continue to contribute to service
any of the issues discussed in this President’s View, or reproduced, stored in a retrieval system, or transmitted in
engagement with stakeholders, fellows and that it can deliver the safe and delivery and make the best use of their
would like to express your views on any other subject, any form or by any other means, electronic, mechanical,
and members, we have identified three effective care that patients expect in talent and experience, while at the
I would like to hear from you. Please contact me via photocopying, recording, or otherwise, without prior
areas for the campaign to focus on: the 21st century. The bottom line is same time acknowledging their need
presidentnews@rcoa.ac.uk permission, in writing, of the Royal College of Anaesthetists.
that we need more anaesthetists to to have more flexible job plans as they
1 expansion of the anaesthetic
come through the anaesthetic training approach retirement. ISSN (print): 2040-8846
workforce
ISSN (online): 2040-8854
6 | | 7
Bulletin | Issue 126 | March 2021 Bulletin | Issue 126 | March 2021
NEWS IN BRIEF
News and information from around the College
Anaesthesia 2021 Honours and thank yous
The Lancet goes virtual Have you ever wondered what type of individual might become an honorary fellow of the College? Why not read the criteria
Countdown on We are excited to announce that
for honours, awards and prizes (rcoa.ac.uk/honours-awards-prizes) and see if you can nominate a worthy group or individual.
Health and Anaesthesia 2021, the College’s
flagship conference, will now be
College honours are given in recognition of outstanding achievement, contribution and work done for the College or for
the specialty of anaesthesia, relevant science, critical care medicine or pain medicine. This will have been work done in a
Climate Change held virtually. So why not join us sustained way and for a prolonged period, at national or international level, or for a defined substantial project not otherwise
from wherever you are on the commissioned or rewarded.
The College, alongside the Lancet
18–20 May 2021, for a packed live-
and the Association of Anaesthetists, has published a policy brief for the Sometimes honours are given to non-anaesthetists for work in
streamed programme.
UK (bit.ly/2NibTDJ) presenting data from the 2020 Lancet Countdown on collaboration with us or for otherwise furthering the interests
Health and Climate Change (bit.ly/2Nusch1). The brief focuses on three No matter what stage of your career, of the specialty.
key themes: sustainable and resilient cities, healthcare sector emissions, Anaesthesia 2021 has something
and reaching net zero across sectors. Some awards and some lectureships are funded from donations
for you. From local legends to
which were made in memory of anaesthetists from the past, hence
international icons, the programme
In a leading effort to minimise the contribution of healthcare to climate some of the eponymous awards.
offers the chance to learn, stay
change, the NHS in England has declared its ambition to deliver a ‘net
informed and network with your peers. Most importantly, our honours and awards can only ever be as
zero health service’ by 2040.
inclusive and diverse as the nominations we receive so we would
We are very much
The College is committed to promotion of sustainability through our love to hear from you if you know of an individual or a group who
looking forward to you
Strategic Plan 2018–2021 (rcoa.ac.uk/strategy-vision), our Sustainability you think would be worthy recipients.
joining us online in May;
Strategy 2019–2022 (rcoa.ac.uk/sustainability), and the Joint
don’t forget to book your place
Environmental Policy Statement (bit.ly/362O2P9) with the Association
by midnight on 18 March
of Anaesthetists.
to be eligible foran early bird discount.
More information about our range of work to support the environment
Visit rcoa.ac.uk/anaesthesia to book
Macintosh Professorships
can be found here: rcoa.ac.uk/environment-sustainability
and view the programme or see
further information on pages 64 and
awarded to Dr Tonny Veenith
65 of this issue. and Dr Brendan McGrath
Tell us your COVID-19 story We are keeping our fingers The College is delighted to announce details of two
crossed that we will be able to visit Macintosh Professorships approved by the Nominations
As part of its COVID-19 campaign, the Policy and Public
Manchester for Anaesthesia 2022 in Committee (rcoa.ac.uk/news/macintosh). Dr Tonny
Affairs team is keen to hear from Fellows and Members
May next year. Veenith, Consultant in Neurocritical Care and Critical Care
about their experiences. The stories will be used to
Medicine at Queen Elizabeth Hospital in Birmingham, and Dr Tonny Dr Brendan
highlight the important role anaesthetists are
Dr Brendan McGrath, Consultant in Anaesthesia and Critical Veenith McGrath
playing in responding to the pandemic.
Care at Wythenshawe Hospital in Manchester, have been
To find out more about how to have
awarded for their outstanding contributions to academic
your story published, visit the
anaesthesia and research.
College website:
Find out about this, and other College awards, by visiting our
rcoa.ac.uk/ website at: rcoa.ac.uk/honours-awards-prizes
covid-19-campaign
8 | | 9
Bulletin | Issue 126 | March 2021 Bulletin | Issue 126 | March 2021
NEWS IN BRIEF
News and information from around the College
2020 National Emergency 24,823 patients had emergency
laparotomies in England and Wales
Laparotomy Audit (NELA) report National 30-day mortality
The Sixth Patient Report of the National Emergency Laparotomy rate has fallen to 9.3%
Audit (rcoa.ac.uk/news/nela-2020) outlining the results, conclusions (11.8% in Year 1)
and recommendations from the audit has been published. Annual
research led by the College focused on the care of over 24,800 85%
NHS patients before, during and after emergency bowel surgery, of high-risk patients
has shown that enhanced patient care has successfully reduced the admitted to critical care
30-day mortality rate from 11.8 percent in 2013 to 9.3 percent in 2019. (80% in Year 4)
But problems with other elements of patient care do still remain.
Our Global anaesthesia: towards health equity The RCoA believes that the recommendations in this report must
Improvements in care have reduced patients’
In partnership with the World Anaesthesia Society, the College is holding the Global anaesthesia: towards health equity be shared across the NHS, with hospitals, health Boards and Trusts average hospital stay from 19.2 days in 2013
event on Tuesday 16 March. Discounts are available and doctors living and working in low and middle income countries taking on the need to reassess their care pathways for elderly to 15.4 days in 2019
(LMICs) will be able to attend the event for free. patients, focusing on systematic improvements to ensure improved
consistency of care. We must see organisational change before
19.2 DAYS
The event will explore key topics from a variety of disciplines to highlight and explore how to address health inequalities in a
variety of different contexts. Attendees will come away with a greater understanding of the challenges and ways forward in
further improvements can be realised. 15.4 DAYS
addressing health inequality in different healthcare settings. Topics will include improving access to healthcare for marginalised
communities, social determinants of health and the connectedness of ‘Global’ Health.
For LMICs to claim their free place, email global@rcoa.ac.uk to receive the discount code.
For everyone else wanting to take advantage of the 25 percent discount to attend this event – more details can be found on
the event booking page: rcoa.ac.uk/events/global-anaesthesia
NATIONAL INSTITUTE OF ACADEMIC
ANAESTHESIA
Medical Workforce Census Report Health Services Research Centre
The College has released its Medical Workforce Census Report 2020
(rcoa.ac.uk/census-2020), showing on-going and significant workforce gaps in
Medical Workforce
Census Report 2020
Post of HSRC Director
the service. The RCoA is warning that data gathered from 97 percent of NHS hospital This post is a three-year fixed term
Boards and Trusts shows that more than one million surgical procedures will need appointment to direct, manage, develop and
to be delayed every year unless anaesthetic workforce numbers are increased to deliver the aims and objectives of the NIAA
meet patient demand. Health Services Research Centre in line with
its strategic plan, ethos and policies.
To address this situation, the RCoA is again calling on the government to invest in
anaesthetic training places, packaged within a sustainable, long-term approach to
COVID-19 RESOURCES
For more information (including the job
the funding of medical training places in the UK. The RCoA is currently working to description and person specification) and to
define the number of anaesthetists needed over the next five-year period and calls apply, please visit our website: bit.ly/36A5yui
on the government to work with them and stakeholders to fill these anaesthetic Stay up-to-date with all our latest clinical resources
workforce gaps, so NHS patients can receive the hospital care wherever and Further information about the HSRC is also and guidance for anaesthetists and intensivists:
whenever they need it. available here: niaa-hsrc.org.uk
icmanaesthesiacovid-19.org
For further information or queries on workforce, please contact: workforce@rcoa.ac.uk Closing date for applications is
Friday 26 March 2021
10 | | 11
Bulletin | Issue 126 | March 2021 Bulletin | Issue 126 | March 2021
Dr Jan Man Wong
Dr Nur Lubis
ST3, Whipps Cross University
Locum Consultant
Hospital, Barts Health NHS Trust
Anaesthetist
wongjanman@gmail.com
Guest Editorial
GLOBAL ANAESTHESIA:
ALWAYS A GOOD TIME
The All-Party Parliamentary Group on Global Health highlighted the need
for UK health services to support international volunteering. This is echoed
in the Department of Health’s Engaging in Global Health framework.1,2 The
College has been a keen supporter of these initiatives at both strategic and
educational levels.
After core training, I was confronted charity, via contacts from the course, Anaesthesia Simulation Training (VAST)
with a desire to work in developing and subsequently volunteered. She courses worldwide. She has found her Leone together with a team of GPs,
countries and with uncertainty about conducted educational activities, College Tutors very supportive towards Emergency Department nurses and
the ethical standing of what I could including trauma training and her endeavours. Infectious Diseases specialists in a
offer. I sought advice from different simulated scenarios. Her experience field hospital. This experience came in The retired consultant
individuals, and decided to go made her realise the importance The senior trainees handy during the COVID-19 pandemic, Upon retirement, Dr Ravalia became
own path in global anaesthesia and
ahead with a non-clinical leadership of constructive feedback and providing familiarity with PPE and also involved with the World Federation
Dr Pillai spent six weeks completing the overcome perceived hurdles with
placement in South Africa with Health encouragement when teaching, which developing mental resilience. of Societies of Anaesthesiologists’
RCoA Developing World Anaesthesia good preparation, time management
Education England.3 My initial dilemma she has applied to her NHS work. Palestine Anaesthesia Teaching
module in Sri Lanka in her ST4 year. and determination.
led me to team up with Dr Lubis, a The consultant Mission, and is currently Head of
She was given four weeks for the
veteran in global anaesthesia, to find Dr Saddington spent three months in Having a consultant post at a tertiary Programme. Coming from an era where
module, and used two weeks of annual Acknowledgement
out about the experiences of others. Mandalay, Myanmar, before starting her hospital has not stopped Dr Choyce anaesthesia was less ‘high tech’, he
leave over the summer holidays. She We would like to thank the anaesthetists
We spoke to six colleagues who went ST3 post. She taught 50 anaesthetists from dividing his time between working feels he has a lot to offer. He has no
worked in a district general hospital we interviewed for their time and for
abroad at different stages of their on the MSc programme, spent time in in the NHS and being an anaesthetist intention of ‘properly retiring’.
covering paediatrics and adults, where giving us an inspiring insight into their
careers to find out how they did it, the the ICU, and occasionally helped out with Orbis providing ophthalmic
she experienced different practices involvement in global anaesthesia.
challenges they faced and why it had in theatres. She was initially connected anaesthesia training. Dr Choyce was Conclusion
compared to the UK. She took her
been worth it. These colleagues ranged via one of her consultants, but has initially an Orbis volunteer in 2005 Speaking to like-minded colleagues References
children, husband and mother – proving
from core trainees to practising and since made in-country contacts and is before negotiating a sabbatical to has confirmed our view that this is
that having a family is not a barrier. 1 The UK’s contribution to health globally:
retired consultants. hoping to set up a Myanmar fellowship. spend more time with the charity. a worthwhile and rewarding path to benefiting the country and the world. All-
She has sent another trainee to Yangon Dr Smith was an ST3 when there was a On his return, he was able to agree pursue, and that opportunities are Party Parliamentary Group on Global Health
The core trainees and organised the inaugural Safer national call for medics for the Ebola on a contract which allows him to be present at any career stage. None of 2015 (bit.ly/39w1Ke3).
away for 12–14 weeks a year. He has 2 Engaging in global health – the framework
After deciding to switch to anaesthesia Anaesthesia from Education (SAFE) response. As she was on a non-essential our colleagues mentioned the financial
for voluntary engagement in global health
following her ACCS EM training, Obstetric course in Myanmar. Now unit of training, she spoke to the completed 80 projects with Orbis sacrifice of this, often voluntary, work by the UK health sector. Department of
Dr Green took time off to complete that she is back in training, she uses College tutor and training programme worldwide. and we also do not see this as an Health and Department for International
a combination of study leave, post- director, who released her temporarily obstacle. It is possible to create your Development 2014 (bit.ly/2MTJ5kL).
the Diploma in Tropical Medicine.
nights rest-days, and annual leave to 3 Improving Global Health through Leadership
She found out about Friends of the from training. She worked with the
Development programme. Health Education
Nepal Ambulance Service, a UK enable her to deliver SAFE and Vital International Medical Corps in Sierra England (bit.ly/39ARZva).
12 | | 13
Bulletin | Issue 126 | March 2021 Bulletin | Issue 126 | March 2021
Faculty of Pain Medicine (FPM)
Report from the Chair of the Faculty of Intensive Care Medicine (FICM)
Professional Standards Committee Dean’s update
Dr Paul Wilkinson, Chair FPM Professional Standards Committee Dr Alison Pittard OBE, Dean FICM
contact@fpm.ac.uk contact@ficm.ac.uk
The FPM’s attention over the last six months has been firmly on COVID-19. As spring approaches, we look forward to longer days and warmer weather...
Many projects were, temporarily, put on hold with a focus on producing maybe! Consolidating learning from 2020, we are looking to refresh our
essential COVID-19 guidance. From the outset, I would like to thank all strategy for 2021 and beyond. Although activity continues on a virtual basis,
members of the Professional Standards Committee who have worked tirelessly we have plans for our return to ‘business as usual’, whatever this looks like.
on these efforts. Our new curriculum was approved Another incredible achievement References
in December last year with of Faculty members, and others, 1 FICM10 Essay Prize – Tim Evans Award.
The response to the COVID-19 In addition, we will soon publish a There are a variety of other projects
implementation from August – an in December was the release of a FICM (bit.ly/34BgVBk).
pandemic can be summarised as follows: COVID-19 national survey focused ongoing or on hold which I have not
amazing achievement by everyone, and recorded single, Every breath you take 2 Critical Futures Initiative. FICM
on the far-reaching changes and summarised here, and I apologise to (bit.ly/3aD5sEW).
■ an initial national COVID-19 survey one which will see a reduction in the (we watch over you), building upon our
experiences in pain practice across the those members who are involved in 3 Voices from the Frontline of Critical Care.
to assess the global impact of assessment burden. Having postponed success with the Joint Fatigue Working
United Kingdom. those projects. FICM (bit.ly/34zhSd8).
COVID-19 on pain services our 10th anniversary celebrations last Group and promoting our Voices from
4 Kari Olsen-Porthouse: I help workplaces
guidance on managing the initial For the last 10 months, it has been The need to maintain the high year, we are excited to continue these the Frontline3 in a slightly different
■ create and maintain harmony through group
impact of COVID-19 very difficult to think beyond COVID- standards of pain practice at a time during 2021. The inaugural Timothy way. In collaboration with a freelance singing (libertysinger.com).
19, but we have maintained a number when resources and personnel Evans Essay Prize1 was awarded in choir director,4 more than 100 voices
■ guidance on the use of steroid
of significant projects. The update of are diverted to manage the December, and our collaboration rehearsed the song virtually over two
injections with COVID-19
Core Standards of Practice, which is a consequences of the pandemic with the College of Intensive Care weeks, demonstrating that by working
■ guidance on the safe reopening of large volume providing best standards has been highly challenging for all, Medicine, Australia and New Zealand, together as a team almost anything
practice of multidisciplinary care, will shortly but there is an emerging sense of goes from strength to strength, can be achieved. It was such a boost
■ advice on managing consultations be completed. A further major strand optimism that practices may revert focusing on training and wellbeing. In for morale and wellbeing, and a fitting
and commissioning adjustments in of work relates to the opioid crisis. back to normal for good in the other collaborative news, we recently end to what was undoubtedly a very
COVID-19 This work, undertaken with the Royal coming months. consulted on our #BetterTogether difficult year.
■ managing the impact on College of Surgeons of England and framework with the Royal College of
interdisciplinary care is covered in a Royal College of General Practitioners, Emergency Medicine, on the interplay
... by working together as a
further publication in collaboration is close to completion and will result between intensive care medicine and
with the British Pain Society. in a major publication on opioid emergency care. Our Life After Critical
management perioperatively. There Illness guidance, the latest instalment
These materials are available in the
COVID-19 section of the FPM website
is also further advice planned about
reducing opioids for specialists.
from our Critical Futures initiative,2 will
be published soon, resulting in a more
team almost anything can be
(bit.ly/3nHWGZ4). uniform approach to patients’ needs
following discharge. achieved
14 | | 15
Bulletin | Issue 126 | March 2021 Bulletin | Issue 126 | March 2021
we are asking. Specific examples to
Do’s Do’sDon’tsDon’ts
Dr Kirstin May
Dr Robbie Kerry illustrate your point can be helpful,
Associate Specialist,
Consultant Anaesthetist and and they may come from non-clinical
Oxford University Hospitals contexts. You may be asked clinical
Clinical Lead, Horton Hospital
Foundation Trust questions, but the interview is unlikely
Banbury
sas@rcoa.ac.uk to resemble a clinical exam. The person
specification and job description may ■ Prepare by reading the application ■ Don’t be late.
well give you pointers towards likely pack and your submission Don’t waffle.
SAS and Specialty Doctors
■
questions, as they should emphasise thoroughly.
SHINING AT INTERVIEW
■ Don’t lie, exaggerate or fabricate
what is important to the department If shortlisted, contact the department
■ experience.
and the clinical role you are applying to get more information or to
for. If you have little experience of the ■ Don’t ask questions that are clearly
arrange an informal visit – speak to
interview process, asking someone answered in the application pack or
the clinical lead or a current post
for a practice ‘mock interview’ may be about pay.
Following our recent experiences with repeated recruitment rounds for helpful. The interview is your chance to
holder.
Follow interview booking Good luck!
specialty doctors and clinical fellows, we shared our top tips for getting
■
market yourself, so make the most of
instructions, arrive on time, and
the opportunity. Towards the end of the
shortlisted in the RCoA Bulletin July 2020.† We would now like to shine the allotted time you will usually be given a
look smart.
spotlight on the interview process. chance to ask questions yourself. If you ■ Show yourself as enthusiastic,
are well informed about the job already personable and honest.
An interview is a chance for the vacancy rate across the country The size of the interview panel varies you may not have any questions, and ■ Make good eye contact. Want to know more
department to get to know a candidate (rcoa.ac.uk/census-2020). There is no and is likely to involve more interviewers that is absolutely fine. You will usually ■ Give concise answers – we can about building your
beyond what is possible from paper need to take a scatter-gun approach to for permanent posts. You are likely to
be asked questions by several different
hear the outcome within a few Days. If
unsuccessful ask for feedback.
always ask you to expand if we anaesthetic career?
alone. It is a chance for both sides to job hunting and apply for potentially would like to hear more.
assess how well they may suit each unsuitable posts or jobs in geographical
individuals. As many candidates for
■ Ask for clarification if you don’t
Join us at our After the
other – it is important to remember this areas you would not wish to live in.
specialty-doctor posts come from understand a question. Final Course:
is a two way process. We are looking abroad, the interview is an opportunity
Feel free to ask questions about the
rcoa.ac.uk/events/
■
for a team member above all, so how Over the last few years it has become to assess language and communication
job, the department or the local area.
skills. If candidates have no experience
well a new person would fit in is very common practice to offer remote
of working in the NHS the interview
after-final-frca
important. It is a good idea to make interviews as an option, and since
contact with the department in advance may explore their understanding of the
COVID-19 this has probably become
of interview to ask for more information. NHS organisational structures and how
the norm. It is customary to dress
An informal visit might be possible healthcare is delivered in the UK.
smartly in business attire. Remember
as well as a telephone conversation It is usual practice to ask set questions
first impressions count: double-check
with a current post holder and/or the to make it easier to compare candidates
the instructions, arrive promptly,
clinical lead. Finding out during an and – through standardisation – make
and make sure we can see your
interview that the job is not right for you it as fair as possible. You are likely to
face and hear you if attending by
is a waste of the candidate’s and the be asked to outline your career to date
videoconference. If you are wearing
interview panel’s time and may deprive and your future plans. Other common
scrubs, a theatre-hat and a face mask
another applicant of an opportunity. topics are team working, patient safety
Recruitment is costly for employers the interviewers cannot really see you
and good medical practice principles
and time consuming for clinicians, or even hear your answers clearly. It
(bit.ly/2p8GWq3). We are looking
who are likely to conduct shortlisting is wise to have key contact details in for someone who is a careful listener
and interviews in their own time. The case of technical difficulties. If you and addresses the specific question.
job market is favourable for specialty- have changed your mind about the You may reflect the question back,
doctor candidates, with a significant job, please cancel. to ensure you have understood what
bit.ly/WinShortlisting
†
16 | | 17Bulletin | Issue 126 | March 2021 Bulletin | Issue 126 | March 2021
Despite needing to address issues like
Dr Natasha Santana-Vaz Mayer’s principles Video design cyberbullying, the digital divide and
ST7 Anaesthetic Registrar, 1 Coherence: remove extraneous, recommendations quality-assurance difficulties, the use
University Hospitals Coventry and Warwickshire distracting material. 1 Keep it brief. of applications, courses and social-
nsv@doctors.org.uk 2 Signalling: highlight key points. networking sites can progress remote
2 Complementary audio-visual
teaching and learning experiences. It
3 Redundancy: use narration with elements.
certainly is an exciting and novel time
Society for Education in Anaesthesia UK (SEAUK) graphics, limit text. 3 Signal key concepts.
for medical education, with wonderful
REMOTE LEARNING:
4 Spatial contiguity: keep linked 4 Enthusiastic, conversational style. opportunities to share with and learn
text and visuals physically close. 5 Promote active learning from others all around us.
5 Segmenting: present information with questions or interactive
in segments. elements. References
educational principles
6 Multimedia: combine words and 1 Singh D, Alam F, Matava C. A critical analysis
pictures. Twitter incorporates humanist and of anesthesiology podcasts: identifying
determinants of success. JMIR Med Educ
behaviourist theories. Natural human
for success
2016;2(2):e14 (DOI: 10.2196/mededu.5950).
YouTube educational videos largely eagerness to learn is facilitated through
2 Daniel D, Wolbrink T. Comparison of
encompass practical skills or pre- post comments enabling development healthcare professionals’ motivations for
recorded talks, with visual information over time. Behavioural changes using different online learning materials.
delivery by independent or embedded result from feedback gained through Pediatr Invest 2019;3:96–101.
The current digital age has prompted a significant transformation within mechanisms. During design we comments and retweets, with clinicians 3 Dombrowski T et al. Flipped classroom
frameworks improve efficacy in
should consider cognitive load theory, reporting that relevant research shared
medical education. Remote learning, where student and educator are not balancing the intrinsic, germane and via social media has changed the way
undergraduate practical courses – a
quasi randomized pilot study in
present in a traditional classroom environment, was the exception to the norm. extraneous load elements to favour they do or intend to practise.7 otorhinolaryngology. BMC Med Educ
2018;18:294.
long-term memory.6
Recently though, its popularity has risen, with better resources empowering Conclusions 4 Oakley B, Sejnowski T. What we learned
WhatsApp exemplifies constructivist from creating one of the world’s most
clinicians to balance continuing medical education requirements with educational theory with collaborative
Remote learning within medical popular MOOCs. NPJ Science of Learning
multifocal demands on their time. learner contributions rather than
education is increasingly popular and 2019;4(7):1–7.
5 El-Bialy S, Jalali A. Go where the students
important. Applications, courses and
student–facilitator interactions. Small are: a comparison of the use of social
Remote learning options include media, may have greater longevity.1 could be applied to ultrasound- social-networking sites are powerful
group discussions between learners can networking sites between medical
applications (‘UpToDate’, ‘Medscape’, Unfortunately applications often lack guided regional blockade and central remote learning tools, and considering students and medical educators. JMIR
be self-maintaining and adaptable over
journals, podcasts), courses (modular, interprofessional engagement and venous catheterisation teaching, in relevant educational principles Med Educ 2015;1:7.
time. The non-hierarchical environment
webinars, seminars), and social- knowledge-acquisition assessment. addition to airway skills lab sessions or improves success. 6 Brame C. Effective educational videos:
promotes engagement, with end-to- principles and guidelines for maximizing
networking sites (YouTube, Facebook, resuscitation courses.3 end encryption maintaining privacy. student learning from video content.
WhatsApp, Twitter). All are powerful Courses Nevertheless, teacher monitoring is Life Sci Educ 2016;15:es6 (DOI: 10.1187/
pedagogical tools underpinned by Successful massive open online courses cbe.16-03-0125).
Remote online courses (modular, essential to minimise topic deviation and
educational principles. (MOOCs) recommend using Mayer’s 7 Maloney S et al. Translating evidence into
webinars, seminars) can easily address common misunderstandings.
principles of multimedia learning to practice via social media: a mixed-methods
disseminate the latest specialty-specific study. J Med Internet Res 2015;17(10):242.
enhance efficacy. Equally applicable to
Applications advances. The convenience factor
webinars and seminars, the embedding
Adult learning theories, such as offered by flexible anytime, anywhere
of humour within material is advocated.4
Knowles’ principles of andragogy, learning, coupled with the ability to
inform the use of applications, with study synchronously or asynchronously
Social-networking sites (SNSs)
students identifying research topics. is great. Furthermore, incorporating
Unfortunately not everyone finds the online discussion allows in-depth SNSs dominate learners’ social lives.
didactic delivery styles of UpToDate, concept exploration and encourages Facebook has 2.6 billion monthly active
Medscape and journals appealing. participation from nervous learners.2 users, YouTube and WhatsApp 2 billion
each, and Twitter fewer at 326 million.
Alternatives like podcasts suit auditory Using online learning to complement While educators acknowledge that the
Visual Auditory Kinesthetic model face-to-face sessions, as in the use of social media enhances learning
learners, offering journal article flipped-classroom teaching model, experiences, the majority do not use it
discussions and exam preparation is complementary to courses and within teaching. Those who do mostly
support. Shorter podcasts, including recognised within undergraduate post opinions or share videos via
case summaries and integrating social practical skills teaching. This model Facebook and Twitter.5
18 | | 19Bulletin | Issue 126 | March 2021 Bulletin | Issue 126 | March 2021
We now have a chair-designate in Internally, we continue to contribute I have appreciated the learning
post in the final months of the chair’s to all relevant College business. opportunities afforded by the
term which enables handover and Anaesthesia Clinical Services College. Attending the conferences
encourages a continuous dialogue. I Accreditation (ACSA) demands was particularly useful, and they
am delighted that Pauline Elliott applied considerable time, though members were a good opportunity to network.
and have every confidence in her enjoy the experience of seeing Rewriting the curriculum is a huge
leadership over the next term. I have anaesthetics ‘for real’. I suggested a undertaking, and the Lay Committee
a final year to serve on the committee couple of important changes to how appreciate being involved. Members
and look forward to contributing to its ACSA is organised, and I am delighted find assisting at the OSCEs very
work from the sideline, that they were accepted. Wherever insightful, and they hopefully add a
we contribute to College business, different dimension. Simulation and
Once I took up post, I was shocked to members find that they are treated Equivalence add their own demands
find that half of our membership was as equals and their contributions are but I feel a lay view is useful.
about to retire within six months. Liam, valued. This is tremendously important
as President at the time, allowed me to When I first started in post, I
and a huge encouragement to
retain three members for an additional received secretarial support from
members, as they are often working
6 to 12 months to maintain the the President’s office. Soon after,
on their own. Another area we are
committee’s work. We have now a full responsibility for the committee
beginning to work on is pairing
complement of excellent people who was moved to Kathryn Stillman’s
up members to assist with sharing
work well together. The only aspect Directorate of Communications and
workloads and understanding the
we are lacking in diversity, and this is a External Affairs. None of the work we
whole work of the College.
key focus for this year’s work. Despite have done would have been possible
Carol Pellowe the lack of face-to-face meetings, we Despite working in the NHS and without the guidance and advice from
Chair, RCoA Lay Committee have honed our Zoom skills, though we academia since leaving school, I had El Fabbrani, ably supported by Rasheda
look forward to meeting face-to-face a lot to learn about anaesthetics and Begum. I have never had to worry
laycomm@rcoa.ac.uk
again. We are sharing out responsibility the College. I walk regularly with two about what to do and when, as they
for coordinating replies to consultation (now retired) anaesthetists, but this did have kept me on track and provided
Patient perspective
reports and writing for the Bulletin, not prepare me for the complexities all the necessary paperwork. So, a
which improves cohesion and morale. of College business. At first, I found big thank you to them!
A reflection on the last Despite working in the NHS and academia
three years as Chair of the since leaving school, I had a lot to learn
Lay Committee about anaesthetics and the College
We joined the Lay Committee of the Council meetings overwhelming, but
Academy of Medical Royal Colleges, I have gradually come to appreciate
This will be my final article as Chair of the Lay Committee, as I which has enabled our focus on the areas of its business that I need to
demit the post in March. I am not sure where the time has gone; patient issues regarding COVID-19. In be fully cognisant of. Everyone is very
friendly and keen to assist, which I have
it has certainly flown, but on reflection I hope we have positively particular, we were concerned at the
appreciated and always stress when
delays in seeing a general practitioner
developed aspects of our operation. in some areas of the country and potential lay members ask me about
also at patient fears about attending the bonuses.
hospital appointments. Working with all
the medical colleges’ lay committees
we feel we were able to give an
enhanced voice.
20 | | 21Bulletin | Issue 126 | March 2021 Bulletin | Issue 126 | March 2021
Revalidation for anaesthetists
Some data on usage of
the Lifelong Learning PERIOPERATIVE JOURNAL WATCH
Platform Dr Yohinee Rajendran and Dr Jia Liu Stevens, ST6, North Central London School of Anaesthesia
Perioperative Journal Watch is written by TRIPOM (trainees with an interest in perioperative medicine – tripom.org) and is a brief
distillation of recent important papers and articles on perioperative medicine from across the spectrum of medical publications.
Chris Kennedy, RCoA CPD and Revalidation Co-ordinator
revalidation@rcoa.ac.uk Body habitus and dynamic Brief preoperative Association of frailty with Randomised controlled
surgical conditions screening for frailty and morbidity and mortality in trial of sugammadex or
Usage and performance of the Lifelong Learning Platform is kept under independently impair cognitive impairment emergency general surgery neostigmine for reversal
pulmonary mechanics predicts delirium after spine by procedural risk level of neuromuscular block
regular review by the College team, with a number of key areas reported on during robotic-assisted surgery The effect of frailty on on the incidence of
each month. A more detailed data report is produced at the end of each year laparoscopic surgery: a Postoperative delirium is morbidity and mortality pulmonary complications
cross-sectional study a common complication, after elective surgery has in older adults undergoing
and, given the unique circumstances from 2020, we would like to share some This is a single-centre study which affects 20–80% of been extensively studied. prolonged surgery
of this information with you. of 91 patients. Pulmonary older surgical patients. This is
a single-centre prospective
However, its contribution after
emergency general surgery
Residual neuromuscular
mechanics were measured blockade has been associated
during four separate stages of cohort study of 229 ≥ 70-year- (EGS) is less well established. with postoperative pulmonary
The Logbook, plus the functionality in examined, over 100,000 Logbook there being an understandable drop in
surgery, with BMI stratified into old patients undergoing This is a cross-sectional complications. 200 >70-year-
the Lifelong Learning Platform focusing entries were added in each of the CPD activities being added during April five categories. At baseline, elective spinal surgery. Both study analysing 882,929 old patients were enrolled in an
on anaesthetists in training, was months except for March, April and and May in particular, before a record transpulmonary driving the five-item FRAIL scale and Medicare inpatient profiles open-label, assessor-blinded
launched in August 2018 and, up until May, and July. monthly high of 5,623 activities was pressures (TDP) increased cognition screening were used between Jan 2007 and Dec RCT; patients either received
the end of 2020, a total of 1,116,201 added in November. in each BMI category (1.9 ± preoperatively. The primary 2015. The primary outcome 2 mg/kg sugammadex or
Continuing professional development 0.5 cmH2O; MD ± SD; P < outcome was delirium. 25% measured was overall 30-day 0.07 mg/kg neostigmine.
workplace-based assessments (WPBAs)
(CPD) functionality – a new and The number of CPD accreditation 0.006). Pneumoperitoneum of the patients developed mortality after discharge. There were no significant
had been completed. During 2020 it
enhanced system for recording and applications also dropped during the and Trendelenburg further this. On multivariable analysis, EGS was stratified as low- differences in the primary
was interesting to note that May and frailty (scores 3–5, OR 6.6; and high-risk dependent on
reflecting upon completed activities, months from April to August 2020 elevated TDP (2.8 ± 0.7; 4.7 ± end-point of postoperative
June were the peak months for WPBAs, 1.0 cmH2O, respectively; P < 95% CI, 1.96–21.9; P = surgical magnitude. Frailty pulmonary complications
and for applying for event accreditation before a total of 315 was received
as can be seen from Figure 1. 0.001) and depressed end- 0.002) vs. robust (score 0) on was assessed using a model (33% vs 40%; OR, 0.74;
– was launched in November 2019, from September through to the end the FRAIL scale, lower animal similar to the Rockwood Frailty
expiratory transpulmonary 95%CI, 0.40–1.37; P=0.30).
Between 1 August 2018 and 31 and a milestone was reached in early of the year. This coincided with the pressures (–3.4 ± 1.3;–4.5 ± fluency scores (OR 1.08; 95% Index. Frailty was significantly Sugammadex decreased
December 2020, more than 2,865,000 January 2021 with 40,000 personal introduction of ‘Virtual CPD’ as a new 1.5 cm H2O, respectively; P < CI, 1.01–1.51; P = 0.036), associated with mortality (OR, residual neuromuscular
Logbook entries had been added into activities added. This feature of the category, both for individual activities 0.001) compared with and more invasive surgical 1.64; 95%CI, 1.60–1.68). After block (10% vs 49%; OR, 0.11,
the Lifelong Learning Platform. This Lifelong Learning Platform was more and for events being provided; this type baseline. Optimal PEEP was procedures (OR 2.69; 95% CI, stratification, this remained 95%CI, [0.04-0.25]; PYou can also read
