Futility 

Futility 

What do I hope the outgoing FY doctors have learned after their time in surgery? For the surgical futured ones there are practicalities like tying a knot properly and closing the skin and inserting ports, as well as hopefully communicating with them the “hidden curriculum” of hard work, professionalism, kindness and care. The ones destined for general practice or other specialties. Someone much smarter than me wishes that they leave with foresight, insight and hindsight, which I love. 

One of the things I want them to leave with is how to recognise dying and manage it well. There are many phrases about knowing when not to operate being more important than when not to; same with ITU admissions and critical care beds. It is really hard to tell someone that they are dying, you can’t deliver it in the same way you tell them that their CRP is going up or down. It takes time and compassion and usually briefly takes a piece out of you emotionally. 

Do not avoid theses conversations, don’t prolong death with TPN and blood transfusions and pointless antibiotics. Do not shrink from your responsibilities and hide behind interventions and futile treatments. Recognise dying and help your patient and their family face it. It’s important. 

Advertisements
Men: desist from this thing immediately please

Men: desist from this thing immediately please

Imagine the scene, you’re sitting listening to a speaker opine on a topic and when they reach their concluding slide instead of a great slide summing up their message they have a picture of their children. Pause for us all to admire Thomas and Em’s extreme cuteness. Then they make some annoying reference to their progeny being way smarter than they are or some other shitey humble brag. 

A certain subset of men then make reference to their amazing wife (a stay at home mum) who keeps them in clean shirts and feeds everyone. I don’t know how she does it! 

I feel the more kids they have the more likely they are to mention it. 

Why do they do this? Women don’t. Is it to brag about their overall successfulness? “not only have I conducted a randomised controlled trial but I have fathered three children”? It’s vile. If I ever get to the point where I am important enough to be chairing meetings I’ll start telling the offenders that it is pathetic. 

Take the slide of your kids out. Don’t ever make reference to them again in a talk. Nobody cares about your children. 

73 things a surgical trainee should know 

73 things a surgical trainee should know 

1. Be kind to everyone. 

2. Look after your mental health. 

3. Be honest always. 

4. Never put anything in writing you wouldn’t say aloud 

5. Don’t trust everyone you meet. 

6. Nobody cares about you more than you should care. 

7. Keep fit. 

8. Keep a diary of operations and techniques. 

9. Organise yourself. 

10. Drink enough every day and never miss more than one meal. 

11. Remember this is just work. 

12. Forgive yourself your small mistakes and forgive others theirs.  

13. Don’t walk away from the operating table with any regrets or concerns. Deal with them there and then and walk away happy. 

14. People die. 

15. The nurses should like you,  but if they all like you all the time you are probably going wrong. 

16. You don’t have to justify your choices to anyone. If you walk away from this and do something else or if you decide you want to be professor of surgery, both choices are equally valid and worthwhile. 

17. Don’t shit on your doorstep. Take it from me, it never ends well. 

18. Your professional reputation will come from what you do and how you do it, it takes time to build but seconds to destroy it. 

19. When you need help, ask for help. 

20. There is no shame in not knowing something. 

21. Always be truthful in your professional life. 

22. Consent people with plenty of time and due care, preparing for surgery is important and consent should be done just as well and carefully as the operation is performed. 

23. Sometimes your best won’t be good enough. 

24. You won’t like all the patients you meet. 

25. They won’t all like you either, recognise that when it happens and step back. 

26. Be especially kind to yourself, be your own best friend. 

27. Find people you admire and watch how they work. 

28. Same for people you don’t like, pinpoint what you don’t like and avoid doing that. 

29. You can still be you and be a surgeon. 

30. Some patients will touch your heart and stay with you forever, remember them and the lessons they teach you. 

31. Don’t trust the sigmoid for an anastomosis. 

32. Don’t fuck with the pancreas 

33. A cut blood vessel has two ends 

34. The operation can’t be said to have gone well until the patient is discharged home and you have seen the pathology results. 

35. When you feel like crying, have a cry and then wipe the mascara, give yourself a hug and carry on. 

36. You are not as good as the last operation you did, so don’t crumble when something goes wrong. 

37. The natural history of most things is that they get better with time. 

38. Apart from appendicitis, that usually  gets worse. 

39. You are more than just your work, don’t let it define you. 

40. Be kind and nice to juniors, they might overtake you and anyway they will spread your reputation wherever they go. 

41. Don’t dislike pretty female medical students, they are the future and need to feel welcomed. 

42. Have a daily routine for where you keep your watch and rings, it’s unprofessional to flap about at work looking for lost jewellery and wastes time when you should be working. 

42. Always, always have money on your person to buy food and drink. You don’t know how badly wrong your day can go and having change at 10pm can make or break you. 

43. Caffeine. You will need caffeine. 

44. Alcohol, this you don’t really need. Never drink when you are sad, or if you are operating next day. 

45. You will never stop learning or improving, it’s a lifelong process. Enjoy it. 

46. There is always going to be someone better than you. 

47. Very few surgeons think that they are average surgeons, half of them are worse than average. Have insight into where you are. 

48. Wearing makeup and pretty shoes and reading Grazia as well as the BJS are all perfectly acceptable. 

49. Not wearing makeup is also acceptable. Your female surgeon friends should be cherished and respected for who they are. 

50. Rise above the stuff that doesn’t matter. 

51. You will carry with you and become a product of all of the people who train you and mould you. That’s a gift and a joy to be a part of. 

52. Remember that being a trainee is a transitory role, don’t be a dick. 

53. Don’t lose your temper, ever, in a professional setting. 

54. Hospital politics requires years of practice, listen and watch but stay out of it until you are well established. 

55. Organise the rota if you can, it is worth the hassle. 

56. Don’t disrespect LTFT trainees or people on maternity/paternal leave, it might be you one day. 

57. Stand up for what is right. 

58. It should feel good and make you happy at least 50% of the time. 

59. The purpose of a ward round is to make the patients feel cared for and safe, not just to ensure they are cared for and safe. 

60. When you feel you’ve made a mistake or had a complication do a ward round, it makes everything better. 

61. Don’t trust a surgeon who isn’t happy and relaxed in theatre. 

62. Don’t trust an anaesthetist who never questions any of your decisions. 

63. The anaesthetist is your friend. 

64. Lead the team in a way that feels comfortable to you. 

65. Don’t try and be someone else. 

66. Don’t hide your intraoperative problems from the anaesthetist. 

67. Remember that you are lucky to live in this world, in this time, to do this job and be so privileged. 

68. Smile and enjoy it. You have worked hard. 

69. Foster good relations with other specialists, you never know when you might need them. 

70. Don’t do drugs, ever. 

72. Treat your seniors with respect, even if you don’t respect them that much. 

73. Be prepared to be the subject of gossip, you will be talked about; good and bad, accurate and inaccurate. 

Beware the patient you don’t like

trump.jpg

He’s not on my ward, nor is he ( I imagine to our mutual happiness) darkening the door of my clinic. But if he was, I would not look forward to seeing him. 

Generally speaking, I like all of my patients and care deeply for their well being, I also get a lot of satisfaction from looking after them and making them feel cared for. Some of that caring is tied up in my responsibility for their well being, but I genuinely do care for them, 99.9% of them. Sometimes you get a patient that you don’t like. It doesn’t happen often and it usually doesn’t matter as the appointment or the consultation is over rapidly and forgotten quickly. It becomes more of a problem when you have an inpatient that you don’t like.

One of my great leaders (who is in fact married to a nurse) likes to say that if the nurses like you all the time then you aren’t doing a good job;  this is true, my recent frustration with a ward’s inability to record a daily running total of a fistula has meant I have had to “have a word”. I’m not here to be popular and many of my male colleagues are not popular at all or particularly liked, but they are respected and admired. This doesn’t work so well for me, or most women, and whilst I don’t require to be adored by all those I work with and operate on, I struggle to cope with people I dislike or dislike me.

Patients disliking me doesn’t cause me too much bother, I can hide behind extreme frosty professionalism and generally have the upper hand. Pissing off the nurses (rarely) or radiology (weekly) also doesn’t cause me too many problems. Patients that I don’t like cause me problems for many reasons mainly because I don’t want to go and see them, and when I see them I want it to be over quickly. These two things in combination are doubly dangerous and bad and lead to mistakes.

Having insight into this is something that they never teach you at medical school, they don’t even mention it. Beware the patient you don’t like; the man who makes lewd comments when you examine his abdomen, the racist patient who insulted your colleague, the patient who refuses to wash, the lazy one who won’t get out of bed, the angry man who isn’t coping with his diagnosis. They deserve the same service as the rest, maybe even a better service, because they are the ones where you will miss a problem or a complication.

You will fail to detect trouble in the earliest stages that in your pet patient you would have picked up 12 or 24 hours earlier. It might not affect the outcome but it will make you feel terrible and it doesn’t do your patient any good. So if you feel a heaviness in your heart when you see a dreaded name on your clinic or postpone and put off until last on your ward round the one you don’t like, put that feeling aside and go and see them.

The GMC has the following advice:

Establish and maintain partnerships with patients

You must be polite and considerate.

You must treat patients as individuals and respect their dignity and privacy.1

You must treat patients fairly and with respect whatever their life choices and beliefs.

You must treat information about patients as confidential. This includes after a patient has died.10

You must support patients in caring for themselves to empower them to improve and maintain their health. This may, for example, include:

    1. advising patients on the effects of their life choices and lifestyle on their health and well-being
    2. supporting patients to make lifestyle changes where appropriate.

     

    You must work in partnership with patients, sharing with them the information they will need to make decisions about their care,15 including:

     

    1.  their condition, its likely progression and the options for treatment, including associatedrisks and uncertainties
    2. the progress of their care, and your role and responsibilities in the team
    3. who is responsible for each aspect of patient care, and how information is shared within teams and among those who will be providing their care
    4. any other information patients need if they are asked to agree to be involved in teaching or research.9

    You must explain to patients if you have a conscientious objection to a particular procedure. You must tell them about their right to see another doctor and make sure they have enough information to exercise that right. In providing this information you must not imply or express disapproval of the patient’s lifestyle, choices or beliefs. If it is not practical for a patient to arrange to see another doctor, you must make sure that arrangements are made for another suitably qualified colleague to take over your role.17

     

    Show respect for patients

    1. You must not use your professional position to pursue a sexual or improper emotional relationship with a patient or someone close to them.12
    2. You must not express your personal beliefs (including political, religious and moral beliefs) to patients in ways that exploit their vulnerability or are likely to cause them distress.17
    3. You must be open and honest with patients if things go wrong. If a patient under your care has suffered harm or distress, you should:
      1. put matters right (if that is possible)
      2. offer an apology
      3. explain fully and promptly what has happened and the likely short-term and long-term effects.

     

    There are very few problems that don’t seem better after you have done a ward round.

     

    In praise of women

    In praise of women

    Whilst comforting a friend recently, one who feels her husband doesn’t understand, love or support her I was struck by how often I have heard the same thing from so many of my girlfriends. My response to this scenario is always the same “he is doing his best, he can’t show that he loves you the way you do.”

    Men are great, but they aren’t women. Women notice you have lost 5lbs, bought a new scarf, that you are wearing a different eyeshadow. They text you to tell you that you are in their thoughts in good times and bad, they remember birthdays and buy thoughtful and personal gifts.

    We cook and bake for each other, send each other little gifts via Amazon, buy and send funny and cute cards, we tell each other how loved we are and never judge or criticize. I love seeing my friends and will make an effort when we go out, choosing an outfit and making an effort with getting ready. It is exactly the way you behave when you are dating.

    Since I have stopped expecting my husband to behave like a woman, my life has improved significantly. Yesterday I came home having bought an expensive jacket, he was watching tv, the tennis was on. Previously I would have become annoyed that he was not interested in the new jacket, put off the tv and started an argument. This time I asked “is this an important match?” Apparently it was desperately important, so I waited and showed him it later. He doesn’t like the neckline, but otherwise thinks it is fine.

    Four hours previously my friend and I were at the shops, we had spent an hour or more discussing jackets, her holiday wardrobe and the difficult question of “is a white jacket insanity with 3 kids?”. Then we spent an hour looking for a top for her, traipsing round the shops together and chatting and having fun. We went back to the white jacket shop three times in total before I bought it. Afterwards she texted to say how much fun it had been, that she loved her top, and that her husband had said “it’s nice”. Men aren’t women, a top is a top, it has sleeves or not, a collar or not, buttons or not.

    If we stopped expecting men to behave like women (or like men do when they are trying to get in your pants) the world would be a happier place. Be thankful that someone noticed your new lipstick, that someone wrote you a poem for your birthday, that someone sent you a text after they saw you looking tired to say “hope all ok, anything I can do?”, don’t be cross that it wasn’t your husband.
    Anyway, the purpose of this is not to berate men, it is to praise the general fabulousness of women. I am grateful for the women who make my life a better place, they make me feel normal and understood, they do this whilst juggling work, kids, husbands, hobbies, families and homes. 

    Make up that lasts all day

    Make up that lasts all day

    This is a seriously girlie post and I apologise for those who are not interested in make up; you may wish to stop here. I am interested in make up, like most women are and I love pottering through duty free and department stores.

    Surgical make up has specific requirements (as opposed to mummy make up/weekend make up and special occasion makeup which involves significantly more stuff and effort);

    1.It needs to be applied at 6.30am and look exactly the same at 8.30pm without any touch-ups or ever even looking in a mirror during that time.

    2. It has to be hard wearing, we sweat, we wear a mask all day, we get hit in the face sometimes with fluids of varying degrees of horribleness.

    3. Mascara can’t flake, there is nothing worse than catching sight of yourself in the middle of a ward round looking like a panda eyed drug addict.

    4. Lipstick must last all day, must not bleed, must not transfer onto your mask, must not leave stains on coffee cups and must not leave you with that awful look of lip stick round the outside of your lips and nothing in the middle. It should not ever get on your teeth!

    5. Don’t ever get caught doing your make up. This is my own insane rule, because I imagine how the nasty nurses (a tiny minority) would just love to catch me preening in the mirror putting on lipstick. I show no weakness in this regard.

    6. Night shift makeup. Concealer. Vaseline. That is it. Anything else looks insane at 3am when you’ve been woken from sleep with mascara on your cheeks.

    7. Sparkle is a no-no. Surgeons should not shimmer or sparkle at work.

    Handily, due to me being at this game for a very long time now I have whittled my make up bag down to the barest of surgical essentials.

    These are:

    not just for men, for me.

    Not just for men, perfect for me.

    Skin: I avoid foundation for work as I can’t be bothered with it. However I am a fan in the summer of matching my white SPF protected face to the rest of me and if my arms are brown as they usually are, then I like this stuff. It looks like black slime but a little bit of this blended with moisturiser makes you golden brown all day and doesn’t fade until you wash it off. It’s in the Clinique for men range, it is no nonsense stuff. Unscented and sparkle free.

    benetint

    Glow in a jar

    Cheeks: benetint it’s amazing. It gives you a just jumped off your bike glow that lasts all day.

    even in bright, slutty red this stuff lasts all day

    Even in bright, slutty red this stuff lasts all day

    Lips: max factor lipfinity. It really does last until you take it off, which requires a heavy duty remover (Clinique lips and eyes does the job nicely).

    the best mascara ever

    The best mascara ever, fact.

    Mascara: benefit again, “they’re real” mascara. It’s Britain’s best seller for a reason, even on your bottom lashes it lasts all day.

    expensive but worth it. Use it to hide bags, redness, darkness, spots, sunburn, contouring...

    Expensive but worth it. Use it to hide bags, redness, darkness, spots, sunburn, contouring…

    Concealer, for me it will always be Touché Eclat by YSL. There is nothing comes close, shade 2 in pale and interesting winter and shade 3 in the summer. I could not live without it.

    So, Clinique, MaxFactor, Benefit..if you’re thinking of a new advertising campaign featuring a real person putting your stuff through it’s paces…I am available!

    Leave the January Gym Goers Alone

    Leave the January Gym Goers Alone

    I know that lots of people are complaining about the people who clog up gyms in January, but it really is unfair. When we were all down the pub in December, dancing and laughing and drinking alcohol, none of the regulars were mean to us and tutted when they couldn’t get served at the bar. So instead of moaning that spin is full, that your metafit class has been made easy for the new people, that everyone shouts “No” to your lone “Yes” when the instructor asks if you want to do another set of abs, just get over yourself.

    As I tell my children repeatedly, if you have nothing nice to say, say nothing at all.