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The surgical working environment has changed considerably since the World Health Organisation (WHO) declared the coronavirus outbreak, COVID-19 (SARS-CoV-2), a pandemic on 11 March 2020. Measures remain in place to reduce the risk of spread from patients to surgeons, nosocomial infection and amongst healthcare workers. However, despite these protective measures, healthcare staff are at risk with the number of health workforce deaths increasing worldwide. This article sets out to explore the roles and responsibilities of the surgeon during these extraordinary times and discuss how we can improve our practice to reduce the risk of harm to patients, surgical staff and ourselves.

There is growing evidence to suggest that the success of a team relies not just on its leader, but also on team members or followers. Effective leadership is a two-way relationship between a leader and their followers with problems on either side leading to potential safety issues as well as effects on morale and wellbeing. Assertive, or courageous, followership has been identified as a means to make a team safer. In this article we review the role of followers, and discuss how assertive followership can make for a safer and more effective team.

Deep head and neck space lesions can present a number of diagnostic challenges due to their deep anatomical position and difficult access for diagnostic tissue sampling. We describe a series of percutaneous ‘transfacial’ buccal space computed tomography (CT)-guided core biopsies of these lesions and subsequent histological findings. Six patients underwent CT-guided core biopsy of deep parotid, parapharyngeal, or masticator space lesions over a 30-month period. We describe our biopsy technique and correlate our histological findings with subsequent surgical resection where performed. Five of six of CT-guided biopsies obtained sufficient tissue for histological interpretation with varying findings, including salivary gland tumours and squamous cell carcinoma confirmed on subsequent resection. One patient was treated palliatively following core biopsy. No biopsy-related complications were observed. In our small series, percutaneous CT-guided transfacial biopsy via the buccal space has proved an excellent option for the minimally invasive tissue acquisition of deep head and neck space lesions.

The COVID-19 crisis has caused many issues across healthcare. In surgery, many operations have been cancelled with some surgeons losing their regular operating lists. During this time, technical expertise and decision making can deteriorate. In aviation after a prolonged period of absence from flying, this deficit in keeping skills and thinking up to date is known as being "out of currency" or "not current". Although aviation and healthcare cannot be compared, numerous human factors concepts are applicable to both. In this article, we explore the likely impact of potentially prolonged absences in operating on surgical skills and psyche, and introduce the concept of a Surgical Skills Currency Barometer. We also discuss a "task-o-meter" thought experiment, and suggest practices which could be adopted to help protect surgeon workload from exceeding surgical capability when returning to operating following a period of prolonged absence.

High Reliability Organisations (HRO), including healthcare and aviation, have a common focus on risk management. The human element is a ‘weak link’ which may result in accidents or adverse events taking place. Surgeons and other healthcare professionals can learn from aviation's rigorous approach to the role of human factors (HF) in such events, and how we can minimise them. Air Accident Investigation Branch (AAIB) reports show that fatal accidents are frequently caused by pilots flying outside their own personal limits, those of the aircraft or environment. Similarly, patient morbidity or mortality may occur if surgeons work outside personal their capability, with poor procedure selection and patient optimisation, or with a team or theatre environment not suited to the procedure. We introduce the personal limitations checklist – a tool adapted from aviation that allows surgeons to define their limits in advance of any decision to operate, and develop critical self-reflection. It also allows management of patient expectations, shared decision making, and flattening of team hierarchy. The minimum skills, patient characteristics, team and theatre resources for any given procedure to proceed are defined. If the surgeon is ‘out of limits’, redressing these factors, seeking additional assistance, or thorough patient consenting may be required for the safe conduct of the procedure. We explore external pressures that could cause a surgeon to exceed both personal and organisational limits.

While healthcare should not be compared to aviation or indeed other high reliability organisations (HROs), many lessons, attitudes, and transferable practices can be applied and, more importantly, adapted from them to improve patient safety and team morale. The team brief before any interventional list is one such process that can have a significant effect on the delivery and safety of patient care and effective team working. Due to NHS pressures and the perception by some in healthcare that the time taken to conduct a full team briefing has little importance, it can sometimes be rushed or regarded as a 'tick box' process that delays a list. However, when used appropriately, the briefing is a chance to lower authority gradients and thereby improve patient safety. It also reduces the likelihood of medical errors, builds and improves situational awareness by considering various 'what-if' scenarios and how they will be dealt with, and considers wider issues including potential distractions. An important outcome is its effect on team morale through empowerment, and it is an opportunity for learning. In this article, which has been written following a unique opportunity to observe a full team brief on an Airbus A380 flight deck, we consider how, through the thorough use of checklists, briefings can be used to best advantage for interventional teams. We raise the question 'would you engage differently with the briefing if your own life or procedure depended on it?'

The COVID-19 pandemic resulted in an unprecedented reduction in the delivery of surgical services worldwide, especially in non-urgent, non-cancer procedures. A prolonged period without operating (or 'layoff period') can result in surgeons experiencing skill fade (both technical and non-technical) and a loss of confidence. While senior surgeons in the UK may be General Medical Council (GMC) validated and capable of performing a procedure, a loss of 'currency' may increase the risk of error and intraoperative patient harm, particularly if unexpected or adverse events are encountered. Dual surgeon operating may mitigate risks to patient safety as surgeons regain currency while returning to non-urgent operating and may also be beneficial after the greatly reduced activity observed during the COVID-19 pandemic for low-volume complex operations. In addition, it could be a useful tool for annual appraisal, sharing updated surgical techniques and helping team cohesion. This paper explores lessons from aviation, a leading industry in human factors principles, for regaining surgical skills currency. We discuss real and perceived barriers to dual surgeon operating including finance, training, substantial patient waiting lists, and intraoperative power dynamics.

As a result of COVID-19, there has been an exponential increase in the use of remote technology for many local, regional and national meetings that would previously have been held on a face-to-face basis. Remote meetings have ensured that essential clinical, educational and strategic work can continue but it is not ‘business as usual’, although colleagues accept this form of communication as the new norm. In medical education and assessment, the Annual Review of Competence Progression (ARCP) meetings and other formative educational meetings are being conducted remotely. This form of communication has some advantages but may also present possible barriers for feedback and development particularly for ‘trainees in difficulty’ when there are concerns about progression, and when an unsatisfactory outcome has been awarded. It is also worth remembering that there may be generational differences with the ease of use of virtual meeting platforms. We present some of the important factors for optimising the panel of virtual ARCPs and discuss methods to improve feedback given remotely for trainees.

OMFS training is perceived as a long and expensive pathway although papers have shown it compares favourably with other surgical specialties. Every OMFS clinician has a vested interest and duty continually to improve the quality of training and minimise costs, especially to trainees at junior levels. Any serious proposal to fundamentally change the format of training, must be given due consideration by all stakeholders. In 2016, a British Medical Journal article whose authors included the BAOMS President of that year and OMFS Specialty Advisory Committee (SAC) Chair, posed the question - should the future of OMFS training revert to single dental degree, change to single medical degree - or continue as a dual degree specialty? The BMJ publication was discussed at the British Association of Oral and Maxillofacial Surgeons (BAOMS) Council in March 2016 and all present unanimously supported the dual degree pathway. Later that year a formal proposal was made by the BAOMS immediate past President that training in the UK change to single medical degree ‘Maxillofacial Surgery’ similar to the training in Spain, France or Italy. Evidence around the risks and benefits of making this change to OMFS training was assembled and reviewed by BAOMS Council in March 2017. BAOMS Council once again unanimously supported continuing OMFS as a dual degree specialty with the observation that the quality of patient care which this training provided was the specialty’s Unique Selling Point or USP. The requirement for both degrees to provide care for OMFS patients had been confirmed by external scrutiny on two separate occasions by the responsible regulators. In this paper, we outline the key steps to be considered when making major changes in the OMFS training pathways using this event as an example and the suggestion that those proposing changes should assemble and present evidence to support their proposal using the template provided.

Introduction The specialty of OMFS in the UK is a dual degree specialty which was recognised in Europe within Annex V of Directive 2005/36/EU. Currently UK law matches that of the EU. Brexit may change this. Directive 2005/36/EU Defines two specialties within European nations, Dental, Oro-Maxillo-Facial Training DOMFS (Basic dental & medical training) and Maxillofacial Surgery (basic medical training). The UK sat within DOMFS and so specialists from DOMFS nations could travel and work in the UK. Specialists from all other nations were required to use the Certificate of Eligibility for Specialist Registration (CESR) route. Directive 2013/55/EU This directive updated 2005/36/EU regarding Mutually Recognised Professional Qualifications (MRPQ) including creating an international alert system for doctors in difficult Entry onto the UK OMFS Specialist List by CESR Route CESR application is a large and complex portfolio of evidence to demonstrate knowledge, skills and experience are equivalent to a Certificate of Completion of Training (CCT) holder. To date, no EU applicants have successfully completed a CESR application. Union of European Medical Specialists (UEMS) Even after Brexit, the UK will remain a full member of UEMS. The OMFS Section of UEMS is a source of information and support for specialists wishing to work in other nations and for nations wishing to develop an OMFS specialty in their nation. Access to UK OMFS training for non-UK trainees Applicants meeting the person specifications for approved OMFS specialty training (ST) posts in the UK are welcome to apply to the national selection process for OMFS specialty training in the UK. Many have done so successfully. Fixed term appointments and Fellowships are advertised and represent a useful route to gain support for application for training or through the CESR Route. Conclusions The UK remains part of the diverse OMFS community in Europe. There is support from within the UK and from UEMS for trainees and specialists interested in coming to the UK to train or to work.

The United Kingdom left the European Union (EU) in January 2020. As it is unclear how many of the rights of OMFS surgeons to travel and work will remain after the transition period, we have reviewed how these rights have been used in the past. The OMFS specialist list from the GMC was compared with a database of current OMFS colleagues. Data were analysed using WinStat® (R. Fitch Software). Of 494 active surgeons on the OMFS specialist list, 23 (5%) completed their OMFS training outside the UK. Of these, 22 were specialists from Europe of whom 12 were substantive NHS consultants with others working as Fellows or visiting the UK occasionally. Two per cent of UK OMFS consultants are -specialists from Europe, the majority from Greece. Of the OMFS specialists who completed training in the UK since 1995, 24 are currently working outside the UK, and of them, 16 left the UK to return to their nation of origin (all 11 of those working in the European Economic Area [EEA] were born there). Of the seven UK-born specialists working overseas, none was working in the EEA. Twenty per cent of UK trainees whose primary degree was known (n = 117) received their primary qualification outside the UK, 38 in from the EU, and 79 from further afield. The majority of these UK trained specialists with non-UK first degrees (n = 101) stayed in the UK to work after training. The most significant impact of Brexit on OMFS could be a restriction on the opportunity for non-UK doctors and dentists to come to the UK to train and stay to work.

It is increasingly being recognised that human factors can contribute to error in complex safety systems. Healthcare, however, has a long way to go before the promotion of training in, and awareness of, human factors will catch up with other high-risk organisations. A critical component that is deemed essential both for improving clinical performance and reducing medical error is situational awareness (SA). This is dynamic and can reduce quickly or be lost entirely, particularly when the workload is heavy. Tunnel vision, in which healthcare professionals concentrate on a single aspect of a patient's care, is just one example of reduced awareness that can be detrimental to safety. As in aviation and other high-risk organisations, a reduction in SA, if not recognised by individuals or the wider team, can lead to serious or potentially fatal outcomes. We therefore give an overview of SA and show how it can easily be reduced. We also suggest some simple but effective ways to improve it and in turn improve patient safety. We emphasise the importance of clinical teams looking out for each other, particularly in the operating theatre.

It is increasingly common in OMFS to treat patients who are taking therapeutic doses of anticoagulant or antiplatelet drugs, or both. These patients have a high risk of postoperative bleeding ranging from minor oozing that can be managed using local measures, to a major haemorrhage necessitating transfusion. The risk of bleeding associated with tyrosine kinase inhibitors (TKI) taken orally is not well-known in the specialty. We report a case series of two patients treated with them and discuss this group of drugs.

Aim Successful completion of the MRCS examination is mandatory for progression into higher surgical (registrar) training in the UK. National selection for training programmes is a highly competitive process. Despite this, the ranking of applicants does not currently include MRCS performance scores. This offers a unique opportunity to compare two independent assessments of surgical trainees to establish whether MRCS performance can predict future surgical career outcomes and competitiveness in training. Method All UK candidates who attempted MRCS between 2007-2020 were matched to career outcome data using the GMC list of registered medical practitioners and anonymised (n = 2910). Chi-squared tests determined associations with first attempt MRCS pass/fail outcomes. Multinomial regression models were developed to establish the predictive power of success at MRCS in determining surgical specialty and training deanery choices. Results There was statistically significant variability in MRCS Part A pass rates, ranging from 55.1%-76.7% between surgical specialties (P=0.001) but no significant variability in Part B pass rates (P=0.655). There was significant variability in Part A and Part B pass rates between training deaneries (P=0.010 and P=0.036 respectively). Pass rates ranged from 59.9%-77.7% for Part A and 70.1%-85.0% for Part B between training deaneries. Those in more competitive specialties and training deaneries performed better in MRCS in terms of first attempt pass rate, scores and number of attempts taken to pass. Conclusions MRCS performance is an early predictor of surgical career choice and competitiveness. Trainees who perform well at MRCS are more likely to enter competitive surgical specialties and training deaneries.

Aim The number of clinicians with disabilities is increasing, however there is no data on the performance of doctors with registered disabilities in the postgraduate environment. If we are to ensure diversity and equality within the workforce, we must first identify whether attainment differences exist in markers of performance. To address this, we assessed the impact of disabilities on performance in the MRCS. Method All UK medical graduates who had attempted MRCS Part A (n = 9,597) and Part B (n = 4,562) between 2007-2017 with linked disability data in the UK Medical Education Database (https://www.ukmed.ac.uk) were included. Univariate analysis identified associations with MRCS performance and logistic regression models identified independent predictors of success. Results Candidates with registered disabilities (n = 635) had lower MRCS Part A pass rates (46.3% vs 59.8% (p 0.05). Pass rates were similar for candidates with specific learning difficulties and those with other registered disabilities (p>0.05). Conclusions This is the first study to assess the impact of disability status and type on performance at a postgraduate medical examination. It appears that candidates with registered disabilities performed less well in formal, written examinations generally. Although our data indicate that current MRCS testing accommodations are fair, enabling performance unrestricted by disability.

The understanding of why air accidents occur and all the factors involved with them has been a strong and constantly evolving driver for improving flight safety. While they are diverse professions, there are many similarities between flying commercial aircraft and surgery, particularly in relation to minimising risk and managing potentially fatal or catastrophic complications. Safety developments in the operating theatre seem to have lagged behind other High Risk Organisations (HROs). A 2018 Quality Care Commission report stated that never events are wholly preventable and expressed the need to learn from other industries. In this article we discuss various transferable lessons and procedures advocated from aviation that could be applied to OMFS in an attempt to improve team culture and safety for our patients.

Background Selection into UK medical school typically involves a combination of three measures: prior academic attainment, selection tests (e.g., the University Clinical Aptitude Test (UCAT), Biomedical Admissions Test (BMAT), Graduate Medical School Admissions Test (GAMSAT)), and an interview. We investigated whether prior attainment and selection test scores can predict MRCS success. Method We used the UKMED database to analyse selection data for all UK graduates who attempted MRCS Part A (n = 9729) and Part B (n = 4644) between 2007-2017. Univariate analysis and Pearson correlation coefficients were used to examine the relationship between selection scores and first attempt MRCS success. Results Successful MRCS Part A candidates had better A-Levels and higher scores in UCAT, BMAT and GAMSAT examinations (p Conclusions A-level results and medical school selection tests predict success in the knowledge-based (Part A) MRCS examination.

Background UK medical schools vary in terms of factors such as mission, specific curricula and pedagogy. As relatively little is understood about the impact of these differences at a post-graduate level, we examined the relationship between medical school and MRCS success. Method Using the UKMED database we analysed data on UK medical graduates who attempted MRCS Part A (n = 9729) and MRCS Part B (n = 4644) between 2007-2017. Univariate analysis characterised the relationship between medical school and first attempt MRCS success. Logistic regression modelling identified independent predictors of MRCS success. Results MRCS pass rates differed significantly between medical schools (P Conclusions Medical programme and medical school are associated with MRCS success. Further research is needed to tease out the relationship between individual factors, medical school and MRCS performance.

Background Identifying factors that predict success in the Membership of the Royal College of Surgeons (MRCS) examination can aid trainees’ exam preparation and help deaneries identify candidates likely to require additional support. We assessed whether performance at Medical School and UK Foundation Programme selection (Educational Performance Measurement (EPM) and Situational Judgement Test (SJT)) predicted MRCS success. Method We analysed data from the UKMED Database for UK graduates who had attempted MRCS Part A (n = 1,975) and Part B (n = 630) between 2013-2017. Univariate analysis examined the relationship between performance and the likelihood of passing MRCS at first attempt. Logistic regression identified independent predictors of MRCS success. Results Each additional EPM decile increased the chances of passing MRCS by 52% for Part A (odds ratio 1.52 [95% confidence interval 1.46-1.60]) and 27% for Part B (1.27 [1.18-1.38]). Each EPM point awarded for degrees increased the likelihood of passing Part A by 29% (1.29 [1.12-1.48]). SJT score was not a statistically significant independent predictor of MRCS success (P>0.05). Conclusions This is the first study to investigate the relationship between UK medical school performance and postgraduate surgical exam success. Higher ranked students are more likely to succeed in the MRCS compared to their lower ranked peers.

The UK COVID vaccination programme has progressed at an astonishing rate since the first patients received their doses in December 2020. It is well known that other vaccines including influenza and human papilloma virus (HPV) can result in reactive lymphadenopathy in the axilla and/or neck. Patients are now presenting via the two week wait neck lump clinic with supraclavicular fossa and low neck lymphadenopathy related to COVID vaccination, and to similar one stop breast clinics with axillary lymph nodes. In an audit of 80 patients seen over a period of one month, we found COVID vaccine-related low neck lymphadenopathy in four cases (5%), with an additional rectal cancer patient thought to have metastatic disease who presented with a Virchow type node. COVID vaccine-related lymphadenopathy should be considered in the differential diagnosis of low-neck nodes if they occurred shortly after vaccination, but it is important to exclude sinister disease using ultrasound and other investigations as necessary.

The first COVID-19 vaccination was given in December 2020 and there is an effort to vaccinate the international population on a massive scale. Common side effects from the vaccine include headache and tiredness. Regional lymphadenopathy has been described in relation to other vaccines. We describe two cases of supraclavicular reactive lymphadenopathy presenting in patients who had the COVID vaccination in the ipsilateral arm. Awareness of this diagnosis is important for patients presenting to the neck lump clinic.

Never events that are relevant to OMFS include wrong-site procedures (including tooth extraction), and retained instruments and swabs. In February 2021, the list of never events was updated to exclude wrong tooth extraction, as the systemic barriers to prevent these incidents were not considered 'strong enough.' We discuss the matter, and provide some recommendations to minimise the risk of wrong tooth extraction, which to date has been the commonest never event in the NHS.

The COVID-19 pandemic has catalysed the computerisation and online delivery of postgraduate examinations. Social distancing regulations and lockdown measures resulted in many written and clinical examinations being cancelled during the initial surge of the virus. In an effort to reinstate the assessment of trainees and enable career progression, the UK medical regulator, the General Medical Council (GMC) has approved unprecedented changes to clinical examinations, including virtual assessment. We outline the changes made and the advantages and disadvantages of these new examination formats. We discuss ways for candidates and examiners to optimise their virtual environment and develop skills that can improve performance.

Background Fitness to practice (FtP) investigations by the General Medical Council (GMC) safeguard patients and maintain the integrity of the medical profession. The likelihood of FtP sanctions is influenced by specialty and socio-demographic factors and can be predicted by performance at postgraduate examinations. This is the first study to characterise the prevalence of FtP sanctions in early-career surgeons and to examine the association with performance at the Membership of the Royal College of Surgeons (MRCS) examination. Methods All UK graduates who attempted MRCS between September 2007–January 2020 were matched to the GMC list of registered medical practitioners. Clinicians who had active FtP sanctions between 28th August 2018 and 28th August 2020 were identified. Data were anonymised by RCS England prior to analysis. Results Of 11,660 candidates who attempted MRCS within the study period, only 31 (0.3%) had FtP sanctions between 2018 and 2020. Of these, 12 had active conditions on registration, seven had undertakings and 14 had warnings. There was no statistically significant difference in MRCS performance in either Parts A or B of the examination for those with and those free from FtP sanctions (P > 0.05). Conclusions In this, the largest study of MRCS candidates to date, the prevalence of active FtP sanctions in early-career surgeons was 0.3%, significantly lower than the prevalence of sanctions across more experienced UK surgeons (0.9%). These data highlight early-career surgeons as a low-risk group for disciplinary action and should reassure patients and medical professionals of the rarity of FtP sanctions.

The COVID-19 pandemic has brought unprecedented changes in healthcare and surgical training, with elective operating reduced or stopped, conferences rearranged and examinations cancelled. Trainees and trainers have adapted, creating innovative and resourceful ways to continue learning, enabling progression through surgical training. With rising COVID-19 cases across the world and further waves of infections likely, we reflect on recent changes to surgical training and discuss how best to support the next generation of surgeons during this period of uncertainty.

We previously published a study on the provision of emergency maxillofacial services during the first UK COVID-19 pandemic national lockdown. We have repeated the study during the second lockdown, and present our findings highlighting the main differences and learning issues as the services have evolved during the pandemic.

High-risk organisations (HRO), including aviation, undergo formal communication training, with emphasis on safety-critical moments. Such training is not widespread or mandatory in healthcare, and while there are many differences both share the ‘human element’ with circumstances leading to an increased risk of harm. A typical operating theatre consists of an operating surgeon, and an assisting surgeon, roles that may change throughout the course of a procedure. Similarly, a training aircraft or multi-crew cockpit (flight deck) has a pilot in control, or ‘pilot flying’, and a ‘pilot not flying’. Both interact with wider teams, for example the scrub team and air traffic controllers, respectively. Surgical error is the second most prevalent cause of preventable harm to patients after drug errors. Every year in the UK National Health Service (NHS), there are typically 500 never events, 21,000 serious incidents, and many more episodes of physical or psychological harm. Ineffective communication (46%) is the most common behavioural factor leading to a never event. In this review, we examine the concept of ‘sterile cockpit’, use of unambiguous terminology, callsigns, important information readback, sharing of mental models, and the mini-brief, and how these may be used to reduce patient harm during safety-critical moments.

OMFS is the surgical specialty which bridges dentistry and medicine. As the specialty of OMFS emerged from the dental specialty of Oral Surgery during the 1980s the Dentists Act 1984, whose purpose included preventing medical practitioners providing unregulated general dental care, was published. In 2008 the Postgraduate Medical Education and Training Board (PMETB) review of training in OMFS concluded that dual qualification was essential and recommended that OMFS specialists should only be required to register with one regulator, the General Medical Council. For OMFS to continue to provide high quality patient care, and to help the GDC and GMC in their roles regulating our specialty, BAOMS has identified 5 areas for regulatory change: (1) All OMFS specialists should be able to practice the full curriculum of OMFS with only GMC registration if they wish to - this was recommendation 4 of the PMTEB Review of OMFS in 2008. (2) If an OMFS specialist or trainee is registered with both the GMC and GDC. (3) A Memorandum of Understanding between the GMC and GDC should prevent any fitness to practice concerns being processed by both regulators. (4) Dually registered OMFS specialists should be able to indicate that they have had "appraisal of the full scope of practice" to comply with GDC Continuing Professional Development (CPD) regulations. (5) Oral Surgery specialist list should retain Route 11 for OMFS specialists as the Oral Surgery Curriculum is entirely within the OMFS curriculum. Legislative changes may be the best route to deliver these recommendations. Until these changes happen, the GMC, GDC and BAOMS should work together in the best interests of patients.

Our professional and private lives changed on March 11 2020 when the coronavirus disease 2019 (COVID-19) was declared a pandemic by the WHO. By March 16, surgical training was suspended, MRCS and FRCS examinations cancelled and all courses postponed. In theory, essential cancer surgery, emergency and trauma operating will continue. All elective, non-essential cases are currently cancelled. While we adapt to our new ways of working, we remind ourselves that surgeons are flexible, resilient and, ultimately, we are doctors in the first instance. We present a short article on operating during the COVID-19 pandemic.

The COVID-19 pandemic has thrust not only a novel virus onto the world, but new challenges resulting in novel approaches. Governments have reduced regulation in order to facilitate timely advances to combat the disease. Antibody testing has rapidly been deployed but it is creating challenges for staff and patients. Mask use has come to the forefront and human factor (HF) strategies must be examined to reduce risk associated with lack of engagement from both healthcare staff and patients. In this we explore these issues and suggest some solutions.

On 30 January 2020, the WHO declared the coronavirus disease 2019 (COVID-19) a public health emergency of international concern. By 11 March 2020, it was designated a pandemic owing to its rapid worldwide spread. In this short article we provide some information that might be useful and help equip colleagues to reduce medical error during a pandemic. We advocate a systems-based approach, rather than an individual's sole responsibility, and, look at ways to provide safer healthcare.

The global pandemic of Coronavirus disease (COVID-19) represents one of the greatest challenges to healthcare systems, and has forced medical specialties to rapidly adapt their approaches to patient care. Oral and Maxillofacial Surgery is considered particularly at risk of disease transmission due to aerosol generation during surgical interventions, patient proximity and operating environment. On day 2 (26th March, 2020) of when severe restrictions in population movement were instigated in the United Kingdom, we began a study to prospectively monitor the presentation and management of maxillofacial emergencies at five hospital trusts. Data was collected onto an online live database fed through a smartphone application. Of the total 529 patients over six weeks, 395 attended for face-to-face consultations and 134 patients received remote consultations via telephone or video link. There were 255 trauma related cases, 221 infection and 48 cases of postoperative complications. Most trauma cases were minor soft tissue injury related to slip, trip or fall at home. There were 44 cases of facial fractures with a tendency for conservative treatment. 19 cases were related to domestic violence or self-harm. Of the 216 dental related emergencies, 68% could have been managed in the primary care setting. A quarter of all emergency patients were satisfactorily managed by remote consultations. There was a significant change in the provision of emergency maxillofacial service during the pandemic lockdown. We discuss the study findings as well as the potential implications in relation to planning for possible further COVID- 19 spikes and future pandemics.

During the current coronavirus pandemic, social distancing and restrictions on travel have resulted in a dramatic rise in the use of technology (including video conferencing) for remote meetings. From local multidisciplinary team (MDT) meetings to national and international committees, this form of communication has been vital to ensure patient-related and other business can continue, albeit in a sometimes unfamiliar environment. In this article we consider some of the human factors elements of remote meetings and provide suggestions to enhance the experience of team and committee members during this unsettling time. It is possible that this form of communication will continue to flourish after the pandemic is over.

Workplace-related illness is common in the UK, and in healthcare more than five million working days over 10years have been lost as a result. Occupational stress is well known and can affect clinicians at any stage, yet many healthcare professionals continue to work with this or other psychological problems (including anxiety, chronic fatigue, and burnout) as they do not wish to let their colleagues down. Mental health issues might be dismissed, particularly in surgery, because there is a misconception that surgeons can cope better with stress than those working in other specialties, and are better protected from clinical burnout. The benefit of exercise on physical health is clear, but its role in the maintenance of good mental health and well-being should not be underestimated. As society adopts an increasingly sedentary lifestyle, exercise for many has a lower priority than other activities. In this article we give an overview of the mental health issues that might affect doctors and surgeons, and explore how exercise can benefit our well-being and clinical performance.

Streptococcus constellatus is part of the Str milleri subgroup. It is a commensal organism that is often present in the oral flora, and has been implicated in pyogenic infections of the central nervous system, abdomen, and deep neck spaces. We present three patients within our unit who developed bony destruction in the facial bones and base of the skull after odontogenic infections. Str constellatus, a known oral and gut commensal that may cause atypical presentations in odontogenic abscesses, was cultured in all cases.

As clinicians we sometimes fail to look after ourselves at work. We often do not drink enough during the day or miss lunch breaks while caring for patients, and this can be particularly evident during an all-day operating list when procedures are long and complex. Some operating theatre staff do not even eat breakfast regularly. Inadequate intake of fluids or nutrition can impair performance, lead to tiredness and headaches, and may compromise both our own health and the care we provide to patients. Other high-risk organisations, including aviation, have recognised that employees must look after themselves if they are to optimise their performance. In this review, we discuss the importance of adequate hydration and nutrition at work to raise awareness that this is essential if we are to provide the best care for our patients.

While a neck lump is a common presentation that can raise suspicion of a potentially serious underlying disease, a hard lump, though less common, may be even more concerning for the patient, and prompt urgent investigation. Metastatic squamous cell carcinoma is the commonest underlying diagnosis that must be excluded, but other diseases or even normal anatomy of the neck can be associated with lumps that are hard or bony. Many of these presentations are relatively rare and may not be familiar to oral and maxillofacial surgeons (OMFS) (particularly more junior clinicians) as a differential diagnosis of a hard neck mass. We have reviewed these lesions to raise awareness of possible unusual causes, particularly when patients are not initially examined in a specialist neck lump clinic where ultrasound is readily available.

Intensity-modulated radiation therapy (IMRT), a relatively new method of delivering radiotherapy, can precisely target a point within a specific tumour and reduce the dose to nearby anatomical structures. This is particularly important in the head and neck where radiotherapy can easily and irreparably damage the salivary glands, spinal cord, and eyes, and where, with increasingly better outcomes and survival, late complications of conventional radiotherapy (including osteoradionecrosis of the cervical spine) can be difficult to manage. IMRT has the potential advantage of reducing side effects including xerostomia and myelopathy of the cervical spinal cord. Several clinical trials have recently been published, and in this update we give an overview of IMRT for oral and maxillofacial surgeons, and discuss what the future may hold for radiotherapy.

The British Association of Oral and Maxillofacial Surgeons (BAOMS) has been at the centre of the transition of our specialty in the UK from a branch of dentistry to one of the 10 UK surgical specialties. In this role it has, at different times, pushed boundaries against resistance from other specialties, and redirected the ambitions of the deputy chair of the Postgraduate Medical Education and Training Board (PMETB) review to produce recommendations that were exactly what OMFS needed. The editorial Our specialty. The future. Is the writing on the wall? is just the most recent iteration of half a century of internal debate. Whilst there are some issues with how the authors have presented recruitment data (their figures omit ST1 run-through and do not recognise that the same single, unfilled post may be present for two or more national selection rounds) their first paragraph A debate that we feel is long overdue presents the greatest concern. In this short communication, we illustrate that in the last 20 years the specialty has not been short of debate. In the absence of new and specific evidence that any other route forward would be supported by our national training committee (OMFS SAC), our regulator (GMC), the breadth of our specialty (including our current specialists and our current and future trainees) and, most importantly, would actually address our problems, we should avoid putting energy into an empty debate. Our focus should be on delivering the PMETB recommendations and inspiring our future trainees.

The reporting of the outcomes of flap reconstruction is often based on numerical success rates. Whilst this remains a useful variable with which to measure success, it is limited in its ability to reflect the complex processes involved. The lack of consistency in the categorisation of outcomes of flap reconstruction in the head and neck could potentially lead us to lose the opportunity to fully capture the implications of its success or failure, or both. We propose a classification that moves away from primarily reporting the results of its binary nature, and focuses more on the process of reconstruction, particularly in the head and neck.

Human error is as old as humanity itself and occurs on a daily basis, whatever we are doing. Recognising our fallibility is the first step to understanding error and ways to reduce it. The term "never event" is, therefore, a misnomer as these serious adverse incidents can never be eliminated completely. Up to 1 in 20 hospital admissions includes some form of error, and while many have little detrimental effect on patients' care (such as forgetting to write a discharge summary), 6% are serious. Many medical errors could have been prevented through the understanding and application of human factors (HF) including (but not exclusively) better team working, situational awareness, and the lowering of authority gradients. In this article we provide an overview of error and introduce the concept of threat and error management (TEM) which is used in other, high-reliability organisations, and provides three layers of defence to reduce the effect or severity of any error. We discuss how to try and avoid medical error in the first place (the first line of defence), trap errors when they occur, and mitigate the consequences of any error to help further safeguard our patients.

We report on an additional innervation to the sternothyroid that, to our knowledge, has not been previously described. During a cadaveric neck dissection, we found an aberrant nerve to the sternothyroid in addition to the normal innervation. The classical innervation to the sternothyroid is through the ansa cervicalis (C1-C3), and the sternothyroid muscle is important for depression of the thyroid cartilage that is involved with swallowing and speech. The cervical plexus is difficult and time consuming to elucidate in fixed cadavers, which limits knowledge of variations from this source. Branches of the plexus are delicate and can be damaged during operations on the neck. Awareness of variations in innervation during operation reduces the chance of damage to nerves and prevents functional changes postoperatively.

Leadership is uncommonly taught formally at any level in surgical training, and is not often evaluated formally either within assessment programmes or during appraisal. Good leadership skills in oral and maxillofacial surgery (OMFS) include professionalism, technical competence, motivation, innovation, ability to communicate, resilience, and effective teaching. They also include the recognition of when and how to "follow" when appropriate. Such skills can be developed through experience, observation, and education using a framework that can include mentoring, coaching, and feedback. This review provides some guidance in how to improve leadership skills in OMFS, which we hope will to improve the quality of training and care of patients.