Poker face 

Poker face 

I watch a great many of my colleagues operate, some junior and some senior and some around the same as me. One of my great leaders tells me that my biggest problem in life is my inability to control my face. I can keep my mouth shut but the contents of my head are visible in my expression. Handily I wear a mask in theatre but it’s in the eyes and eyebrows apparently. Somehow people can see “oh my god that is horrible” and “seriously, you’ve made another enterotomy” just from the eyes. 

Why this is my problem I don’t know, it has served me well in my personal life and on the odd occasions when it has led to be being caught out telling a lie, that was for the best in the end too. 

One of my bosses just now encourages me  not to talk at all when I am operating, we do mostly laparoscopic surgery together. This person wants me to not utter a word other than to the scrub nurse or to my assistant to pull harder or clean the camera. This is very difficult, my constant chatter and explaining to everyone what is happening  is a longstanding habit. 

This person thinks that I/we should know that it is now time to move to the next part of the operation, by careful following of the case. This gets on my nerves immensely and when I used to assist, rather than operate under the supervision of this individual, I would frequently fall asleep holding the camera as it was so very quiet, boring and  hot beside the Bair Hugger. 

In terms of surgical philosophy this person and I are at opposite ends of the spectrum, the annoying thing for me is that I have to pretend I agree with all they say and do as that is what a registrar does. 

I’m a fake, everybody else in theatre knows I’m a fake and that this silent operating is not me. When I am alone there is talking, music, teaching, communicating. I’m not even quiet when I’m sleeping and frequently wake myself up talking loudly. If it gets hard or I can’t concentrate I am a big enough girl to establish silence in theatre. 

This boss insists I persevere with this odd, almost religious silence, we have music on very briefly sometimes but it has to be quiet and goes off at the first sign of difficulty. 

I wonder what the scrub nurses make of it all. In a few weeks I will be free to sing along to the music and enjoy my job the way I want to, all the time, not just when I have my own lists or am being left alone. I am so tired of doing everything somebody  else’s way and nodding like an idiot with things I completely disagree with when everyone can see I am a fake.

“Yes I totally agree”.

Theoria and Praxis

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. 

 

 

 

Make sushi not rice 

It takes 7 years of cooking rice before a sushi chef gets his hands on the fish. 

Replace rice with “appendixes, abscesses, hernias, manual evacuations” and fish with “major cancer resection” and you have the model of surgical training we are all labouring through. 

My kids can make half decent sushi, but they can’t make rice. It’s about the training! 

Make sushi, not rice. It’s my new training motto. 

Spot on John Humphrys; that’s how I feel too

Spot on John Humphrys; that’s how I feel too

The lovely, clever and doggedly determined John Humphrys is the man who wakes me up in the morning. I was sad to read in yesterday’s Sunday Times that he is contemplating retiring soon, although the rest of the Today programme presenters are also first class and I enjoy listening to them all. I like to imagine that if I met them in the pub I would get to hang out with them and join in their clever and amusing chat; they would probably not want to hang out with me though, when they discovered I couldn’t define Keynesian economics and sometimes get muddled between gross and net pay.

Anyway, John Humphrys is quoted as saying;

“Sometimes the programme they present you with at 4am is just absolutely brilliant and you think, ‘Wow’. But mostly it’s not. So you have a moan and a whinge and then after half an hour you think, ‘Actually, I am bloody lucky doing this’. Most mornings at some point I think ‘God this is fun’. Don’t tell them but I would do it for nothing.”

And that is what my job is like, that is what other people don’t get when they say to me “I don’t know why anyone would be a doctor nowadays”. Good, I am glad you don’t, it is because it is often the most marvellous fun.

today-programme-presenter-005

Some of the Today show presenters, which I think my work colleagues are a bit like, but we know about surgery… as opposed to knowing about everything. 

 

Reading between the lines 

Reading between the lines 

We do not always mean what we say…

To the anaesthetic team 

“I think they moved/coughed” 

They most definitely did move or cough. 

“Are they relaxed?”

They are not relaxed 

“We still have to close, are they relaxed?”

Right, I’ve been at this for 4 hours and now, in the final five minutes, you have let the paralysis wear off. You’ve had your lunch and several coffees and you’ve spent all day texting and emailing someone (fucking theatre bloody wifi) so you WILL paralyse them so I can finish and I don’t care that you will then be stuck here for 20 minutes until you can wake them up again. 

“Is it possible that they aren’t fully relaxed yet”

I saw you pretend to paralyse them, that wasn’t sux, that was saline.

“This is a bit more difficult than we thought”

This has the potential to turn into a total disaster and some lack of foresight on my part is now quite clear to me, which is doubly disappointing. 

“We have got rather a lot of bleeding here at our end”

There is a massive black pool of blood that is sucking at our sleeves and seems unstoppable. You should prepare yourself for some drama. 

“Would you please be so kind as to fill in the frozen section request path form/intraoperative cholangiogram request”

My registrar should have done this and she hasn’t. She knows this is a terrible and shameful error. I won’t look at her, you look at her for me and then sigh. She will then know that she is a disgrace and we are aware of her incompetence. 

“We will be done in 40 minutes”

An hour and a half. 

“We are nearly done”

We have reached half way. 

“It’s absolutely imperative that we get into emergency theatre next” 

I want to go home before midnight, fuck the urologists and their stents. 

“The anastomosis was perfect, they leaked because they had a low blood pressure”

From your completely unnecessary epidural. 

“Yes, I think we have a sample, certainly  they should have been grouped and saved”

I have no idea if they have been or not but we both know they should have been, in 3 minutes I’ll be scrubbed and sterile, so I’m not going to check. You can do it. 

“As far as I am aware of, no, I don’t think that they are on anticoagulants”

I have no idea if they are or not and I don’t massively care because they need an operation right now for their dead/perforated guts. 

“It will only take me an hour”

It will take an hour to do the bit I consider  most difficult. Total operating time is about 2 hours. 

To the scrub nurse

“The usual stitch I use here”

I don’t remember what I use here, give me what someone else uses here.  

“I did give you back the swab from inside”

Not sure. I want to carry on closing. 

“Yes I will need more wash”

Don’t roll your eyes at me, go and get the wash

“These needle holders are unusable”

I am stressed and want something nice to hold 

“This is broken, send it back”

I have broken this. 

“This wash is too cold”

For fuck sake, can’t you give me warm saline 

“Can I have a bit of quiet please in theatre just now”

Shut up, this is hard. 

To your assistant 

“Can you pull a bit harder please?”

You puny little shit. I held onto a Lloyd Davies for 7 hours once. 7 hours!!!

“Whoa! Watch the spleen. Your hands are a bit too rough”

They are like shovels, you useless lump. You should be a bricklayer. 

“Did you tie that properly. That is the IMA, are you sure you tied it right?”

I’ll kill you if they bleed post op. I will exsanguinate you, slowly

“are you ok to close?”

I’ve had enough. 

“Show me that properly and nicely”

You have no idea what I am doing here. 

“What’s that big vein there?”

If you answer this correctly you can take over. If you don’t know then you will only be closing the skin. 

Management miss the point (again)

Management miss the point (again)

I was saddened recently to hear of the death of Kate Grainger, a doctor in palliative care who was also a blogger and campaigner for improved communication in hospital. She left a wonderful legacy in the form of her “Hello my name is” campaign. This involves all medical, nursing and support staff trying harder to always introduce themselves to patients. Bighospital, like other hospitals have been quick to adopt this brilliant idea and have issued everyone with badges that instead of saying just “Mrs KBW” they say “Hello my name is Mrs KBW”.

Which is quite clearly NOT THE POINT!!!

I have by some miracle avoided this badge and continue to introduce myself and my boss and my team, no matter how fucked off they all get with me doing it 30 times on a ward round

.

Training diary for trainers 

Training diary for trainers 

There is an interesting document I have come across recently, it is from those rather clever and switched on people in the West Midlands (wherever that is) who seem to come up with lots of good ideas. The link is here

They propose a really quite revolutionary idea that trainees should feedback to trainers what they think of them via a handover diary that they pass on the next fellow in a fellowship post, I think it was plastic surgeons but the lessons are transferrable to us in general surgery too.

The endless and one way process that goes on between trainer and trainee is good when it works well, obviously  I have to say it works well as I am a ticking clock heading towards independent practice. 

They tell us how to do things, they tell us what they like and don’t like. Some train like they were born to teach, these are the only ones who get feedback as they are rewarded by us telling them they are amazing, nominating them for silver scalpels (lots and lots of male winners, just the one female so far I think…), fighting amongst ourselves to go theatre with these golden gods of training. 

Everybody else (99%) is either ok or shit. They have highs and lows and good days and bad days but they receive no feedback on how they are as a trainer. Do they erroneously assume that they are good at it? How do they improve? How will I be the trainer I want to be?

West Midlands plastic surgeons possibly have the answer in the form of this diary.

All of us should keep a book of how to do operations and what individual bosses teach you. I know as many different set ups for how to do an anterior resection as I do things to do with my hair.

 Informally I have done the oral version of this trainer diary in the form of a chat with the incoming registrar to the job I was leaving. “He hates it when you use cutting diathermy, or the heel of the hook, he “doesn’t believe” in drains, he likes antibiotics to be iv for all things, he doesn’t like lateral sphincterotomies/ he loves lateral sphincterotomies, he hates Prof Bigshot/he is Prof Bigshots biggest fan”. The difference is we don’t tell them any of this. Only one person I have ever worked for has asked me what I think of him as a trainer and wanted feedback, it’s no coincidence that he is also the best trainer I have ever had. And I’ve been at this surgery malarkey for 15 years. 

How brave a trainer would you have to be to ask your trainers for honest and frank feedback about you as a trainer in written form to hand on to your next trainee? You would have to be thick skinned and able to cope with criticism, be willing to change your way of teaching to suit different individuals learning modes and needs (which almost none of them are able to do), willing to try new things and change and evolve. These are not easy tasks and are not very typical skills of consultant surgeons. 

Bighospital has been shaken recently by a lack of trainees and people talking about not everyone getting registrars if they don’t train. So far this is just chat and noise and there are no real plans to make it the case. It is conceivable though in the future that only those who can teach get the privilege of training the ever dwindling number of trainees, chances are we will have to be good at it. 

Will I be a brave enough brand new consultant to purchase a little notebook and ask my registrars for feedback? Yes. Will I cry under my desk when they write “KBW is a terrible trainer and has a short temper and a foul mouth”? Probably. 

Can you imagine how good they’d be at teaching if they thought we would write a report that was personal rather than the anonymous and vague GMC Survey?