Surgeons learn in a very special way; we learn by watching, then by assisting, then by doing small parts of a procedure under supervision, then small parts unsupervised, then the whole operation supervised, followed by increasingly large parts unsupervised and then independent practice. It is not a linear progression and no two operations are ever the same, one virgin abdomen and a small, flaccid gallbladder makes for a very different laparoscopic cholecystectomy than the patient with a BMI of 38, a previous laparotomy for a perforated ulcer and a five 5 day old acute gallbladder the size of a ferret. Learning will proceed with ups and downs over time and mastery of a particular skill takes repeated attempts, repeated errors and their consequent correction as well as increasing technical skill. Acquisition of the theoretical knowledge takes time as well.
Theoria, from which the word theory is derived, meant more than that in ancient Greek, it is thinking and theory, but also contemplation and the art of being a spectator. Praxis, also from ancient Greek, is the application of that theory in the real world, the process of applying ideas and doing what you have learned, practice. They are two of Aristotle’s basic activities of man, the other being poeisis, (making) which is what with all the theoria and praxis is the end result, you have made a consultant surgeon.
I had no idea what books to buy when I commenced surgical training, to gather all the theory, nobody sat me down and told me how or what to learn. I received a salary and did a job and the implication was that in the course of doing my job I would pick up the skills along the way. The process of postgraduate exams has always ensured that the correct amount of knowledge was acquired by trainees, the ridiculous hours worked meant we picked up the on the job knowledge and technical skills.
Having been trained by someone recently who had an above average interest in what and how I was doing every single thing, I have spent more than my usual amount of time reflecting on my practice. It is a term that medical students on the most part dislike and some struggle with reflecting effectively.
Surgeons in Bighospital are not prone to introspection, at least they are not prone to it in public with us and they don’t teach us to do it. We do something called M&M, morbidity and mortality, where we discuss deaths and complications and ask as a team what we could have done differently. It is very benign, we almost never decide that we have done something wrong, we certainly do not admit to what we could have done better at an individual level. In some hospitals there is a robust and almost aggressive analysis of management of complications but not here. I am always amazed at US medical shows where someone is destroyed at the M&M. It is not like that in the U.K.
The key to reflection in my mind is the question “What could I have done better here?”.
This is the way I approach most of my post operative analysis and is a very simple and unstructured way of assessing performance. Reviewing recorded laparoscopic operations is very helpful and a good way to see where you could have improved operatively. I have spent several hours this evening watching a pile of videos of my recent laparoscopic procedures and reflected on what I could have done better (lots). But it is much more than just how you actually do the procedure, Bighospital is not short of competent and talented technicians who do a great operation but they don’t run their theatre efficiently or have a happy team.
There are several global areas where you must perform. Firstly, your aim is the execution of an operation that proceeds at an appropriate pace with economy of movement and is as skilled a job as possible. This means that you do a good theatre brief, that intraoperatively you ask for things well in advance of needing them (staplers, meshes etc.) so you don’t have any pauses waiting for kit. That you minimise errors, anticipate the anatomy and respond and adapt your technique according to the conditions.
Visualisation of a procedure is very helpful preoperatively, which can be done whilst washing your hands pre surgery or a more detailed preparation outside the theatre if the case or your ability demands is also helpful. You need a plan and a back up plan and a bail out plan.
Then there is the need for good communication with anaesthetic and nursing colleagues, they shouldn’t have to be psychologists to work out from your body language how the operation is progressing. One of my anaesthetic friends teaches her senior trainees how to read the body language of the most personality disordered of us all. How sad that it is necessary to rely on these non-verbal clues when this individual could just say “We are struggling here, its going to take a bit longer”.
When it gets difficult or bloody, or bloody difficult you need to articulate that and communicate to the room. Nurses are not mind readers, and terseness and unpleasantness towards them is unacceptable and is a reflection of your failure to communicate adequately. A bold statement for a surgeon to make but very true.
You want to make sure your assistant is happy, that they eat, visit the toilet and are trained (it is unusual for a surgical Registrar to finish a day in theatre having achieved these four goals). On the day you want to start on time, finish on time and you do not overbook lists giving your team undue pressure.
I have been very quiet on this blog recently, I am counting the days to not being a trainee anymore and the weight of the responsibility of independent work is weighing on my shoulders. Every anastomosis, every closure of a midline wound, every possible readmission, every single damn thing I do is my responsibility and the complications that are going to start coming any minute now as they leave me to do almost everything alone, are weighing on my mind. I’ve waited longer than anyone else for this, all those maternity leaves, all that watching and learning and waiting and thinking and now I’m scared I might be shit at it. I might crumble under the pressure. I might turn into a horrible person. I might get a reputation for laziness, for being slow, for being rubbish in theatre, for calling for help all the time, for not calling for help when I should, for getting the most complaints, the most leaks, the most deaths. I might get an anaesthetist who hates me, I might hate them. There are so many ways to fail.
Reflecting on over twenty years of training and preparing and learning, I have learned a lot, I am a patchwork of other people and like a child I bear the DNA of my surgical “parents”. Hopefully I have taken the best bits of them, because my time is up.