Foreign Body in Rectum (a public service post)

Foreign Body in Rectum (a public service post)

Once again some unfortunate person who lives in Bighospitalburgh has stuck something up their bum and had the misfortune to either through bad luck or excitement, lose their grip on the item (in this case a carrot in a condom) and have it disappear beyond the reach of their frantic fingers.

Once again, this person decided to attempt to retrieve the object and subject themselves to hours of pain, unpleasantness and sphincter stretching damage before accepting that this isn’t something that can be done alone.

Shower heads, carrots, cucumbers, vacuum attachments, bottles, cans, light bulbs, aerosol sprays, handles of brooms…we have seen it all. Inexplicably we have also had a few pens, which seems rather half arsed, if you will pardon the pun.

All of these people have waited a while prior to seeking medical attention and most come to hospital anticipating that we will have some suction device or long tongs that will swiftly and efficiently rid their rectum of the object so they can be once more on their merry way, back home to once again poke about in their posterior.

I haven’t done a retrospective case study on this, but my experience is that these guys are usually married and their wife is unaware of this new interest and it seems to take place when she is away. This was certainly the case last month when my patient turned up via A&E with a carrot in situ. He caused total fucking chaos by using a fake name initially which led to us having massive difficulty in ordering bloods, X-rays and getting notes organised.

By the time we had a real identity and got him assessed and admitted and checked out he was starting to get a bit cross.

I was duty surgeon and had the job of explaining that his retrieval foreign body rectum and examination under anaesthetic was scheduled for the end of the emergency list, which would likely happen at around 2am. Mr Carrot was displeased, he wanted it all dealt with somewhat faster, he felt that as he had accidentally fallen on top of the carrot and had the almost unbelievable misfortune for it to go right up his ass he should be dealt with a bit quicker. The reasons for this urgency, in his estimation, being; the carrot could be causing damage and his wife was due home soon and he didn’t feel the need to worry her about this.

Wives quite often don’t know what their husbands get up to, that’s why deleting browsing histories was invented, and Mrs Carrot was no exception. I reassured him that we would give no information over the phone or to her in person about his admission and that our discretion and confidentiality could be relied on. I suggested that a peri-anal abscess would be a suitable cover story (I know, loads of lies for and to patients recently). He duly phoned his wife and told her he had an abscess and was going to theatre that night.

Of course, Bighospital is a big hospital and at midnight we had an emergency operation to do that took my patient’s slot in emergency theatre. By the time the laparotomy was finished it was 5am so a decision was made to put Mr Carrot off until the morning, which he was very cross about and let me know about when I saw him at 8am.

I took him to theatre a short while later and removed a really quite thick looking carrot from his rectum, which I disposed of, confident that he would not want it back. He then did what almost everyone does in that situation, he absconded from the ward very soon after he was returned from theatre never to be seen or thought of again.

However, this man was so intent to keep up the story about his admission to his wife that he has now had the audacity/madness/balls to write a complaint about his admission and brief stay for his “abscess” due to the delay in getting his procedure. I have had to respond to this, mindful that I don’t breach confidentiality of either his carrot cover story or the life or death laparotomy that took precedence over him in the middle of the night.

So, in an attempt to improve our service to people with this embarrassing and frightening problem here is my guide to what to do in this situation:

1. Don’t keep trying, you won’t get it out.
2. Don’t eat or drink anything from now on, you need to fast as you are going to theatre.
3. A good cover story is that you have peri-anal sepsis. The length of stay and the embarrassment factor that your wife will pick up on can be explained by an infected peri-anal haematoma or skin tag. The operation is also the same “examination under anaesthetic”.
4. We won’t give you a fake or inaccurate discharge letter. You are on your own there to dispose of or alter that accordingly.

We don’t care what you’ve stuck up there, we have seen it all before. We won’t tell anyone in your family, we can’t tell them unless you say. We are a little bit amused, but we won’t seem so to your face and we will protect your dignity and confidentiality. Lots of people do this and we will ask you how it happened and examine you carefully but that is because it is our job to do so.

Don’t delay seeking medical attention; abdominal pain, nausea and vomiting, pain on coughing or laughing necessitate urgent medical attention. It usually just goes in to the top of the rectum but some things can perforate the bowel and cause peritonitis. I have never seen this, even with lightbulbs so don’t be alarmed.

Mr Carrot has had the briefest and blandest of complaint responses from me where I once again have not breached his confidentiality.

He owes me a drink if he ever sees me again.

In general, prevention is better than cure so if you are stumbling across this post whilst contemplating some “back door fun” with something not designed for the purpose (google with flange) my advice is don’t do it.

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Preferably organic

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Rizzo’s Rule

Rizzo’s Rule

What’s the worst thing I could do?

Grease is a marvellous movie, I used to know all the words, and the character I wanted to be most of all was chief Pink Lady, Rizzo. Sandy was not for me; she was a saccharine, simpering twit and although she looks fabulous in those black shiny trousers at the end you just know she is a girl who doesn’t know how to have fun.

Rizzo, however, she was a woman of the world and had the best songs of the movie in my opinion. Even her real name, Stockard Channing was great.
As you may know her “Look at me I’m Sandra Dee” is a sort of homage to anaesthetists, but her other song is surely meant for surgeons. There are worse things I could do, lyrics are here, has the brilliant line “that’s the worst thing I could do”.

Before you start every operation and during each stage of an operation you should ask yourself, much like Rizzo does “what’s the worst thing I could do?”

Let’s take a laparoscopic cholecystectomy:

Port insertion: Rizzo says “you could stick it straight on through, pop the colon, spread some poo”

Calot’s triangle: Rizzo has a lot to say here

“You could fuck the CBD,
take the right hepatic artery.
Stick a grasper in the liver,
make it bleed just like a river,
with no IOC to bail you out,
how your boss will scream and shout,
hepaticojejunostomy…”

Another way of doing the same thing is by naming and preparing for your enemy. Guddling about under the right colon: the enemy is inadvertent damage to the ureter and duodenum. It’s all the same thing that Rizzo says.

Think about it, then don’t do it. Don’t be scared to do an operation but know what you could do wrong and avoid it. Rizzo wasn’t scared of anything either.

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Guest Blog on Women in Surgery

Today I am super excited, I have been asked to be a guest blogger and contribute to the Women in Surgery blog where they publish research on the experience of women in surgery; the website is run by the RCSEng and University of Exeter, thank you to them for the invitation. This is the post below with a link to their website here. My views on this blog are just that, they do not represent all women and are based on my experiences and peculiarities (of which I have many)…

On Role Models (and surgery as a boyfriend)

Much as changed in the near 20 years I have been in and around the medical profession and the progressive feminisation has been wonderful to see and be part of.

There are many women in surgery, far more now than when I was a medical student and I don’t think there is any real problem with being a woman in surgery. Some of the women in surgery I encountered early in my career had children and husbands but very few of them were living a life I aspired to. In fact, if anything they put me off and some made me feel even less welcome than the boys. I don’t know if you’ve ever seen the movie Legally Blonde, imagine that but everyone in white coats; times have changed though and we have a gradual spread of women throughout surgery, not all of whom are doing it like the men did.

I have to acknowledge my parents input, who have an unshakeable belief (which they passed on to me) that I can do anything that I want to do. I was never expected to be slower, weaker or less at anything compared to my brothers and male cousins so not doing general surgery because I was a girl never crossed my mind.

It was on everyone else’s mind though, when I first started popping up in theatre as a super keen student and junior house officer the animosity from some middle grade doctors and the theatre nurses was incredible, I was never expected to actually, really be a surgeon. Also, some well meaning consultants would gently suggest that maybe I would change my mind about general surgery once I had a husband and children and would I really want to work weekends and night shifts forever? Maybe I would think about doing general practice?

We now have hordes of female medical students and junior doctors all wanting to do surgery, most of whom want to come and spend some time hanging about with me. I am aware that as the part time mummy surgeon in great shoes I have a responsibility as a role model to them. When I was a medical student I would have run a mile from the likes of me, but this lot are sent to me by my colleagues to get “the talk”. Three things about this situation bother me, which I no doubt contribute to by seeming approachable.

Firstly, they seem to think that my personal life and circumstances are something that they can ask all about. How do I organise my childcare? Have I encountered any discrimination problems? How do I manage to get up and dressed and organise things and get there for 0745? How much maternity leave did I take? Do I ever feel guilty about leaving my children and not making it home for bedtime? So far nobody has asked me if I had vaginal deliveries but they have gotten close.

I don’t mind this when it is a doctor I actually know, someone who is considering embarking on a career as a surgeon but I do mind having to tell every student that comes through the department about how my kids are looked after and whether or not I have a cleaning lady (I do, twice a week in fact, so I can get to the gym on my days off and not spend the time ironing) or if I do the cooking at home. They also want to know what Mr KBW does and how we make our marriage work with our busy schedules. This seems totally irrelevant to being a surgeon and more to do with being a mummy and a wife, it amazes me that these young girls are thinking about their 35 year old selves, I certainly never did.

The other thing that bothers me is that some are entirely focused on being discriminated against because they are a woman. This has not been my experience at all, there have been very few people (one particularly rude man who is responsible for most of the bile duct injuries within 100 miles of Bighospital) who have openly discriminated against me.

The only real problem I’ve had because I am a woman is getting elbowed in the chest during laparoscopic surgery all the time and trying to accommodate my enormous 38 weeks pregnant abdomen at the table during laparotomies. Not that I think being female has made it easier, even if my colleagues (and so called friends) said my viva exams were dumbed down because I was the pretty girl. Maybe they were, but I knew the answers to the harder stuff as well so bollocks to them.

Finally, not one single boy has ever especially come to me or been sent to me to discuss a career as a surgeon, perhaps they get sent to the men.

So what do I tell these girls in “The Talk”?

I admit there is the endless everyday sexism that all women encounter but I suspect it is not any different for women in law, the police, schools and offices. They see this on the ward round, in clinic, with my bosses and there is no point ignoring it. For example, I won a prize last month and was quite pleased about it “well done” said my boss “a lot of guys on the panel?” as he gave me a “friendly” tug on my pony tail, ho ho. This is everyday sexism, as are the patients who reply “all the better for seeing you sweetheart” when I do my rounds and enquire how they are; it used to flummox me or make me angry or embarrass me.

This isn’t discrimination based on gender, but it is sexist behaviour. It could be demeaning if I let it demean me. So I tell the students that they will experience very little discrimination but occasional sexism but it probably isn’t any worse than in any other job.

I tell them that they have to love surgery because it will take them away from people they love. They have to love it like a crazy obsessed stalker lady. First days at school, Christmas Day, nativity plays, family birthdays, your wedding anniversary…the list of days you won’t and can’t be there is endless. If you don’t love your job you will resent the time you spend there when you feel you should be somewhere else and that makes you a bad doctor. The hours at the computer writing papers, the long trips travelling cheaply to conferences alone, the late nights etc.

Surgery is like a boyfriend who constantly makes you prove how much you love him and plays games with your feelings. The semi mandatory research PhD and MD degrees are like getting a tattoo of his name and just when you think he loves you, and you and he are getting on so well he will punch you in the face with a complication that makes you buckle at the knees.

I also tell them to speak to people about it and urge them to get feedback on their hands and technical skills. Not everyone can do surgery and the sooner you realise that you have hands suited for a career as an occupational health physician the better. I also try and discourage them from being rigidly attached to a specialty very early. Better to want to be a surgeon and consider all the surgical specialties early on than having your heart set on being a head and neck cancer surgeon from the age of 19.

Again, to use the boyfriend analogy, not many people who are determined to find and marry a blonde 6 foot welsh rugby player, 2 years older than them, with no baggage, minimal chest hair, nice feet and works as a vet in the country end up doing so (trust me on this one, I know the woman who wanted this and she is 38, lonely and miserable). So keep your options open and consider all types of surgery.

It also helps to have role models and mentors to guide and influence you. They don’t need to be told that they are your role model, there is no need to formalise the process. Mine have been almost entirely male, there have been about four that have massively influenced my professional and personal life for either a brief period (an amazing plastic surgeon who wrote plays and was an amateur actor) or the few that have been around for most of my adult life (the great leaders).

What most of mine have in common is a rich and varied life out with medicine; all are excellent surgeons and lead their teams well, they are well liked and respected and are exceptionally nice and clever people. These characteristics are not gender specific, as a group they probably are slightly more effusive than other male surgeons but they are all white, British, quintessential Royal College material men. There are of course a few women that have influenced me, one in particular that is about 5 years ahead of me has taught me a lot more than just how to operate and it has been interesting to watch her go from stage to stage and see the few mistakes she has made and the many things she has done right and continues to refine.

Find people you want to be like and ask them how they got there. That might be the workaholic, hugely productive university professor who spends every second at work and publishes endlessly. It might be the guy in the super flash suit whose patients love him and he works tirelessly for them. It might be the forgetful, kind hearted amazing surgeon who can teach almost anyone to do anything.

Above all else, realise that this is a journey where there is no final destination. You will always be learning, always trying to get better, always be teaching others and trying to get better at teaching others.

There is nothing I would rather do than my job, it is the greatest privilege and the most amazing challenge and it is super fun and makes me happy. Not many people can say that about their work, so find a role model that smiles on the way into the hospital and looks happy in theatre because that’s how you should want to feel too.

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One for the urology trainees….

You can’t hide your lying eyes

You can’t hide your lying eyes

The Eagles remind me of long car journeys to France listening to tapes of my parents choosing and being given mental arithmetic challenges to pass the time. “If we are traveling at 75mph and it’s 375 miles to go until we are there, and we are going to stop for an hour, when will we be there?”. What fun! Now children watch DVD’s in the car- though not mine I hasten to add- I have a low opinion of that, regardless of the length of the journey.

I want to talk about lying to patients. Last week I was instructed to tell a patient that she must wait until 5pm to get her biopsy results from the consultant himself, which I happily did. I told her I hadn’t seen the result, which was true I hadn’t seen it, but I knew she had metastases and that the biopsy was positive. It was a small lie, one I was happy to do as at 5pm her husband was coming, the specialist nurse and my bad news bearing boss and crucially it was 4pm when I was lying to her.

My moral judgement was that this little lie was the right thing to do.

On the same ward under a different consultant was another man awaiting bad news, the worst news in fact. He is young, under 50 and has inoperable advanced cancer with weeks to live. He had been told that his treatment plan would be made at the MDM, this is in-spite of his CT being suitable for an undergraduate exam question it being so obviously bad news, but the consultant was postponing the bad news. I was at the MDM, I knew he was for palliative care only and I met the patient in the corridor a few hours later. I told him I hadn’t been at the MDM and hadn’t seen his consultant yet so didn’t know the outcome. (MDM is a multi-disciplinary meeting of surgeons, oncologists, radiologists specialist nurses, etc)

Fast forward to the ward round at 5pm, his consultant still hasn’t been to see him, he is sitting with his ashen faced wife, waiting. I phone him before I start and ask if I can tell him the news, he says no. He says he will come later and do it which of course he fucking doesn’t do. The next morning the patient isn’t in his bed at the 8am round so I have a reprieve, he’s away for a fag.

We are now almost 2 days from the MDM, it is the evening ward round, he is again in bed and again has his wife with him. I phone my boss (who I now really hate) and I have the specialist nurse with me, who is furious too and I ask him if I can just tell the man. Again he says no, he says he will come later.

The man, who I have known a few weeks, says “it’s bad news isn’t it, that’s why he is avoiding me”. I tell him I think he should prepare himself for that possibility, that my boss is too busy just now but he will come soon. Then I tell him that I am very sorry about that, that I have tried to make him tell him sooner, that I would like to give him the information he needs but my boss has said he will come that evening and he wants to speak to him himself. He came the next morning, when his wife was gone, the specialist nurse was gone and he finally told him the bad news and discharged him from hospital.

What is the difference in the two lies? Morally none at all, I lied in both instances but in the case of my palliative man, I felt I was contributing to torturing him and his wife in withholding this information. I nearly went over Mr Avoiding Things head but I was too cowardly to disobey him, even though I thought it was wrong. Ultimately he isn’t my patient, but the specialist nurse was egging me on to do it, the ward nurses were and I couldn’t look the man in the eye and keep lying to him.

It was torture for that man and his wife to wait 3 days to be told he was completely fucked. It was cruel anyway to let him think he had a chance at surgical cure in my opinion but that is this particular boss’s style to string them along until they’ve been MDM’d and then seem all surprised and sorry and that it’s a shame he won’t get to save them.

The GMC (who’s advice I blatantly ignore in having a pseudonym for this blog) say that I should be honest in my dealings with patients but don’t specifically go into the shades of grey that are lies of omission, delays in telling bad news etc.

My own prejudice in this is that the first consultant is a pain at times but generally is one of life’s good guys and he cares about his patients more than anything else. This meant that I was happy to lie for him because I genuinely thought it was in the best interests of the patient. Mr Avoiding things is not a great leader and never will be, he has a nasty habit of losing the plot in theatre and if I met him in a psychiatry clinic I would give him lithium.

I don’t even know what my point is in writing this, I can do nothing about it, I am too cowardly to confront my (frankly unapproachable) mad as a stick boss and morally I have no issue lying to patients when I think in my patronising and paternalistic way that it is “for the best”. I suppose I just want to say sorry to the man and his wife for the part I played in making the worst week of their life even more painful than it had to be.

This man will probably end up back in with us as his illness progresses, hopefully we can get it right then.

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Kneading their mummy

All weekend I have been busy preparing a paper for work, which I had left to the last minute and so I wasn’t available to my children and their constant call of “mummy” 327 times every hour. This lead to me feeling guilty about not playing with them (as if a weekend with Mr KBW at the helm would kill them) and it was horrible to see their little faces peek round the study door and ask me if I wanted to play with them yet or was I still busy.

Central to the weekends calls of “muuuuuuuuummmmmmy” was oldest child’s insistence that they wanted to make bread. I had neither the yeast nor the patience for that sort of activity so told them no. Bad, bad mummy.

I arrived in from the shops (today is a holiday) armed with a bag of bread flour and fresh yeast and I had Paul Hollywood’s recipe on making white bread at the ready.

700g strong white bread flour, 2 tsp sea salt flakes crumbled, warm water and fresh yeast; I was even wearing an apron and was bare foot in the kitchen feeling earth mothery. The water has to be the temperature of blood apparently, handily I am ideally placed to assess blood temperature as I spend a lot of time up to my wrists in it. In fact, I am so good at assessing body temperature I can frequently tell the anaesthetist that the patient is pyrexial or hypothermic before they have checked. There really is nothing worse than operating on a cold person, it is a grim prognostic factor.

None of them wanted to help, nobody wanted to make bread with me. I tried to tempt them in, calling that kneading is great fun, that they can make the bread into a crazy shape and managed to recruit one semi-interested party who buggered off again when she realised bread mix and cake mix taste quite different.

So, I have made bread which is a task I have never done before without the aid of a bread making machine (it lasted about a week and then moved to the garage where it may well still be now I think about it) and not done before with fresh yeast. Interestingly, this looks like the stuff that comes out of your rectum when you have a defunctioning stoma……inspissated is a great and underutilised word, like capacious, which also applies to some rectums.

My house is filled with the amazing smell of fresh baked bread, which brought them all into the kitchen where they are now happily having homemade bread and butter. “Mummy” says the oldest “I really want to make butter”. Kids are funny.

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These are my efforts, handily snapped with my trusty iPhone camera and the floury one is the great Paul Hollywood’s image from How to Bake. The bread looks pretty good though I think, no soggy bottoms round here.

BMJ Breastfeeding

When you are breast feeding you get a little bit crazy, it’s the oxytocin rush and the subsequent addiction and the intense physical contact and the mad love you feel for these tiny people that you have made and are somehow growing bigger with milk from your breasts. It seems a miracle and it is, a wonderful lovely miracle. I slumped into a sort of depression when I gave up breast feeding on my return to work and missed the little hand resting on my breast and the sound of their greedy, snuffling, gulps. Anyway, you get the idea, I am pro-breast feeding. It is also the lazy woman’s first choice; I could never have been bothered with all that sterilising and faffing about, breast is best for everyone.

My Friday ritual is to read the BMJ whilst making dinner, TV being absolutely crap and not wanting to get grubby cooking smears on my iPad, I have found this habit an easy one to adopt. So just now, whilst making the family tea I came across an advert at the back of the BMA News (a supplement that comes each week with the BMJ). It is full of doctors moans and gripes, a trade union weekly round up of issues and news and it is read by most doctors.The back page features this advert, featuring the loveable Harry here.

20140502-204349.jpgIt is an advert for formula milk, albeit a lactose intolerant form, as poor little Harry has a cow’s milk allergy.

Here is the BMJ’s policy on formula feeding advertising:

(iv) Baby milks

All advertisements are to be submitted for editorial approval and have to comply with FMF Code of Practice for the Marketing of Infant Formulae in the UK, which states that “Information provided by manufacturers and distributors to health workers regarding infant formulae should be restricted to scientific and factual matters and such information should not imply or create a belief that bottle-feeding is equivalent or superior to breast feeding.” Such information “should accurately reflect current knowledge and responsible opinion.” All claims must be referenced to full length research papers published in peer reviewed scientific journals. (Abstracts won’t do.)

Because advertising is tightly regulated and because readers know it is different from editorial material, BMJ Group has a liberal policy on advertising. The group’s publications will carry virtually all advertisements that are “legal and decent.”

I disagree with this, they should not be advertising formula. I know they have to make money, I know the makers of formula milk have to advertise but they should not be doing it in the BMJ.

A liberal policy indeed, they don’t seem so liberal about bossing people about smoking, obesity, exercise and global fucking warming; just 4 weeks ago they were telling us that every doctor has a moral obligation to counteract global warming and we must do something as a profession. Sorry BMJ, I think you should reconsider your liberal policy on advertising, if we have a responsibility as a profession to address all the many, many issues you rally us to support, then the journal and the trade union weekly should walk the walk as well as talk the talk.

 

ASGBI: A Spotter’s Guide

This week it is ASGBI, just about everyone who thinks that they are anyone in surgery in the UK is there. KBW is not there, as some of us have to stay at home and do some work……also, I didn’t bother submitting anything as I will have to be there for the next two years kissing surgical ass and presenting pointless audits all to get the job I want.

Here is my guide to some of the types of delegates you get at ASGBI:

The newly appointed consultant
This guy is cock of the walk, he wants to show his colleagues just what a great decision they made appointing him. He will have 3 videos, 2 talks and a few posters. He will ask lots of questions, slag off other people’s work and will be wearing a suit.

The bonkers staff grade
Bonkers staff grade does a nice wee job in a district general hospital and does nothing but hernias, haemorrhoids and gall bladders. Inexplicably they will be at a practical session about trans anal microsurgery and a talk on the new Reboa balloon in major trauma, where they will ask questions like “usually in trauma we do a diagnostic peritoneal lavage”. No, we don’t.

Party boy
Party boy is on a mission, a mission to get trashed like it is 1996 and throw up during the plenary lecture and not recall anything about the presentation he gives because he was still drunk. Woo hoo!!

The post-CCT registrar
This guy will hopefully be a newly appointed consultant next year but right now he is sweating and stressed. He is looking for a job, he has to ditch party boy and bonkers staff grade who are both making him look bad (really bad) and start speaking to people and making a good impression. He has 4 posters (disaster) and the medical student he supervised has been given an oral presentation, the little bastard.
He is getting a lot of love from the reps, not as much as new consultant but enough to make him feel important.

Good Guy Professor
Good guy is loved by everyone, he knows everyone and keeps his team (including party boy, bonkers staff grade and all the registrars) on speed dial and firmly on his radar. He manages to look after everyone and deliver a superb plenary talk. The team would walk over coals for him, they all want to sit beside him in the pub. He buys all the wine and has never tried to shag his trainees.

The Sex Pest
This man is easy to spot, he’s staring at every female (10% female delegates) like he wants to lick her. He has delivered a few talks, but is feeling inadequate because his old SHO has somehow become a Professor and has a hot wife and an A merit award and he is feeling hard done to. It would help if he could have sex with someone, anyone. He sits with his legs open looking at his crotch and licking his lips when a woman is presenting and smiling at her, like a wolf. He will try to grope a ripe young medical student if he gets within feeling distance.

The wanker
Wanker is a junior registrar in a suit. He has his name badge proudly on display and has been up to every important person and introduced himself. He goes to every session from 8am to 6pm and all the lunch sessions too. He makes notes and takes photos of himself with notable professors from around the world that he puts on Facebook. His colleagues hate him, he eats lunch alone because he makes eating noises and talks shop.

It’s truly painful. I have three audits on the go just now that will hopefully lead me to oral presentations at ASGBI next year. I have a military style attitude to this meeting; get in and get out. Arrive late and leave early. Bring a faithful wingman if possible and avoid all of the above apart from Good Guy Professor.