A specialist in complex open aortic surgery, Rachel Bell speaks to Vascular News about her career so far. Raised in Yorkshire, UK, she moved to London for medical school before recently making the move back to the north of England to take up the role of clinical lead for vascular surgery at the Freeman Hospital in Newcastle upon Tyne, UK. She advocates for retaining open surgery skills in an increasingly endovascular world and underlines some of the key challenges facing the specialty in the wake of COVID-19 and against the backdrop of a health service under “massive stress”. Aside from her clinical achievements, she was recently named president of the Vascular Society of Great Britain and Ireland (VSGBI)—making her only the second woman to be elected to the position .“I think we are stronger together,” she says, summarising a key belief behind her main aim in the role of encouraging wider, more inclusive participation within the society.
Why did you decide to pursue a career in medicine and why, in particular, did you choose to specialise in vascular surgery?
I think I pursued a career in medicine because my mum was a nurse and I grew up listening to all the stories from her training and it piqued my interest. She also used reverse psychology as she told me when I was 13 that I might not be clever enough to be a doctor, and so, to prove her wrong I decided I was definitely going to become a doctor. I chose to go to medical school in London because I had lived in Yorkshire for almost all of my childhood and, aged 18, I just needed to experience life outside of Yorkshire. I started at Guy’s and St Thomas’ medical school in 1989 and had pretty much determined by the time I had finished that I was more likely to be a surgeon than a medic. I did not like the medical ward rounds that lasted all day—my attention span is not that long. I did my surgical house jobs at Guy’s and I worked for Professor Lord McColl, who was a general surgeon, but linked to our firm was Professor Peter Taylor, who was inspiring, and he is the main reason I did vascular surgery. He was very inclusive of ‘the firm’ as it was in those days of house officers, senior house officers and registrars— we were all part of his team. I can remember him letting me close an aneurysm sac at the end of an open aneurysm repair and, as a house officer, that was it, I was sold. I think a lot of people would say that I am quite a confident individual and I think he fed into that, because he encouraged the trainees to be involved and speak up, and there was something incredibly powerful about that.
What has been the most important development in vascular surgery over the course of your career so far?
There has been a paradigm shift from open surgery to endovascular treatment and it has really broadened the specialty. You have to be multiskilled and that has changed everything. It has changed how we treat our patients, how we work within the hospital, how we train our juniors and it has changed vascular research. From an endovascular point of view there are questions about durability, but we are now able to offer very complex surgery to a much larger population and that has been the biggest and the best change. However, there is still a role for open surgery. I am a complex open aortic surgeon— because I come from a generation that spanned the ‘old’ open surgery world and the beginning of the endovascular revolution. Nowadays, I see younger vascular surgeons with a total passion for the endovascular side who are a little bit scared of open surgery, particularly in the abdomen. Training has changed now to encompass the endovascular requirements, but the need for open surgeons has not gone away.
What are some of the biggest challenges currently facing vascular surgery?
I think UK hospitals are still struggling to recover after the COVID-19 pandemic. Also, I think vascular surgery suffers a bit because we do not have a cancer. My personal feeling is that cardiovascular disease—and particularly things we treat such as aortic aneurysms, symptomatic carotids and critical limb ischaemia—is our cancer. You are potentially going to die far more quickly from a symptomatic carotid, critical limb ischaemia or even a ruptured aneurysm than from cancer, and yet on a day-to-day basis a critical care bed will often be allocated to a cancer patient over my open aneurysm repair patient.
Vascular surgery is an urgent specialty and we need to learn to tell our story slightly differently. True elective surgery only makes up a small proportion of our workload and as we have set tight targets for the treatment of our patients with urgent conditions it has put a lot of pressure on our hospital systems to ensure patients get seen, imaged and treated in a timely manner. I think during COVID-19 we were ‘lucky’ because we had symptomatic patients with carotid disease and critical limb ischaemia that needed treatment immediately and could not wait until the pandemic was over. Hence, we did not come out of the end of the pandemic with massive waiting lists like other specialities. However the NHS is currently under incredible pressure and the combination of trying to get on top of the waiting lists whilst simultaneously coping with the problems of staff retention and burnout, the financial crisis and industrial action puts the NHS in the most perilous position that I have witnessed in the last 30 years.
What are the aims of the Aortic Dissection Toolkit and how are things progressing with the programme?
The Aortic Dissection Toolkit was launched last March to improve the pathway for patients with acute aortic dissection and ensure good regional governance. We have asked regions to get together and discuss how they can organise an aortic dissection pathway for their area that is sympathetic to their geography and skill mix. We would like each region to publish a rota for the aortic dissection service so that it is crystal clear who they need to phone when they get an aortic dissection case. The regional team also have responsibility for ensuring there is a safe way of transferring patients to the right hospital and that their imaging can be efficiently electronically transferred so that the receiving clinicians can managed the patient as quickly and effectively as possible. Another responsibility of the regional team is to ensure that we collect data so that we can track our progress and make sure we are making a positive difference. Unfortunately whilst this is incredibly important work the toolkit has no allocated resource. We are essentially asking several specialties—vascular surgery, cardiac surgery, interventional radiology, critical care and emergency medicine—to get together to sort out this problem countrywide for free and I am very grateful to everyone who is participating in this programme. The trick now is to keep up the momentum to ensure these pathways get embedded into normal clinical practice.
What do you hope to achieve as the president of the VSGBI?
I am only the second woman to be president of the VSGBI, after Professor Averil Mansfield, and I feel honoured and quite humbled to be mentioned in the same sentence as Averil. It never crossed my mind that one day I would follow in the footsteps of some of my vascular surgical heroes and heroine. I would like to make the Vascular Society more inclusive and less elitist. As a society we are aware that many vascular surgeons around the country are not members of the VSGBI and I would like to know why that is and what can be done to change that. I may be a bit biased but the work that the VSGBI Council does behind the scenes is incredible and I would like to encourage others to get involved to shape the society for the future. We are about to send out some engagement questionnaires asking as many non-members that we can contact what things they would like to see that might encourage them to join, because ultimately we are stronger together. We know that there are big problems around pensions and burnout and the society would like to provide some support, or at least be there to listen. I would also like to see younger members on Council and obviously more women, as it would make it more balanced. Alongside all of that I would like to continue the drive to ensure safe national pathways for patients with aortic dissection. That may mean defining specialist centres for complex aortic problems to ensure patients get the best care by the right specialists when they need it.
What are your hobbies and interests outside of medicine?
If I had not been a vascular surgeon, I probably would have been a singer. I sing all the time—to patients, in theatre, and I am a member of a choir—it brings me joy. I have also spent a lifetime following cricket, from county cricket to test match and one day internationals, and I do like a good gin and tonic.