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. 

ASGBI Guide to who is who

ASGBI Guide to who is who

This post was published in 2014 and I have updated it for ASGBI 2017. 

This week it is ASGBI and just about everyone who thinks that they are anyone in general surgery in the UK is there.

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

The reps
The reps have a secret agenda, the chances are that you aren’t it, nonetheless they have to be polite and humour your enquiries and idiotic questioning undertaken to fulfil your agenda; trying to see down her low cut top and check out her impressive tits. 
I have an ASGBI shopping list, pens, a novelty USB drive, mints, a rucksack and something childishly smutty, like anal dilators.

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, well at least none of the current ones. 

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 second 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.

The Specialist Surgeon 

Fuck knows why he has come to Glasgow. All he talks about is how he has three presentations at his specialty meeting. He asks stupid questions that begin “this is more of an observation..”. He hates general surgery and only knows about polyps of the anterior rectum that are more than 2cm and less than 4cm. He doesn’t do other operations or any scopes or any general surgery like hernias and gallbags (please, I’m special) or on call (yuck!) because he is so special. 

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.

Serious inequalities in the provision of elective versus emergency care

Serious inequalities in the provision of elective versus emergency care

If you have rectal cancer, the ideal scenario is that it is picked up on screening (biannual FOB tests from 50 years of age followed by colonoscopy if positive), you then enter into a smooth and well oiled machine of investigation and treatment. Within 14 days of that colonoscopy and biopsy you will have had a CT scan of your chest, abdomen and pelvis, an MRI scan of your rectum and your case will have been discussed at a multi-disciplinary meeting of surgeons, oncologists, pathologists, radiologists and other interested and relevant parties.

You will be given a plan for your treatment and a specialist colorectal cancer nurse who is on speed dial for you with your questions and concerns. You will then begin either long course chemo radiotherapy followed by surgery or proceed immediately to surgery.

Wham, bam, we’ll whip your rectum out before you can say “pain in the ass”. It is as smooth and controlled and informed a ride as it can be, and you can be reassured that at every stage you will be looked after by the right person, who has been trained accordingly and is audited and checked up on.

If, however, you are unlucky and on the days of the FOB testing your rectal cancer isn’t in the mood to bleed, if you ignore the weight loss and the rectal bleeding and you present as an emergency with an obstruction, then your outcome is far from guaranteed. Your survival depends on where you decide to present to, which is terrifying and appalling.

If you were me, or a relative of mine, you would drive to somewhere like Bighospital and bend over one of their beds to present your obstructed rectum to one of my colleagues. The reason you would do this is because a hospital where there are more HDU beds, more ICU beds, that do more CT scans per bed per annum, that have more operating theatres per bed are significantly more likely to get you out of hospital alive than a hospital where that does not happen. (Symons et al 2013. British Journal of Surgery 100:1318-1325). And an early CT is associated with a decreased risk of death (Ng et al. 2002. BMJ:3251387

You wouldn’t be taken to one of these local hospitals with a knife in your chest or following a road accident, no way. Trauma goes to a Level 1 trauma centre because we know that these people die in District General Hospital Land.

You are much more likely to get rectal cancer than have a knife in your chest; and yet off you will be referred in the dead of night, vomiting shit out of your mouth to a tiny little dump that does no CT scanning out of hours and cannot stent your cancer anyway because they don’t have interventional radiologists and has no middle grade resident cover overnight.

This figure shown below is of a funnel chart, the line in the middle is the average mortality for emergency admissions, the dark dots are the badly performing institutions, the empty ones are the exceptional units. Age, social deprivation, comorbidities and female sex all correspond with poor outcomes but there still remains a worrying variety in mortality outcomes across the country. Without being a stats bore, everybody should be inside the funnel, that means you are within the average, some better some worse. It is the outliers outside of the funnel that are concerning or superbly impressive.

IMG_0929.PNG

If someone published the same data on breast cancer survival, or as happened many years ago on trauma survival, there would be an uproar. We urgently need to reshape and rethink how we organise emergency generally surgical provision and centralise services. We need more acute surgical beds, improved access to out of hours radiology (yes radiology I mean you, get out of your beds) and more HDU and ICU beds for emergency admissions. What we need most urgently, is for surgeons involved in the provision of this care (which makes up half of our workload) to start caring as much about the standard of emergency care as we do about elective care. One ass hole I work with said “what a great year, not a single elective death”, he couldn’t understand why I thought that was not worth bragging about.

The other people who need to listen to us are the politicians who do not allow us to ring fence resources and budgets towards emergency care. They have been beating us with the twin sticks of waiting times in A&E and waiting times for operations for years and it is time that we told them to shut up and show the public that the real problems are in emergency unscheduled admissions. The ASGBI issued a consensus statement to this effect which I would urge interested parties to read, but it failed to ignite a political and media debate on this issue.

This is an exciting time to be involved in general surgery as perhaps emergency care is slowly getting the attention it deserves. The government has to listen to us, we and they have to explain to voters that going to your local hospital might be nice, it might be handy for you to visit Granny, but it means that you have an increased risk of dying that a 30 minute drive can reduce by over half. We managed it with trauma care and we have managed it with cancer care we just have to do the same with provision of emergency surgery.

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.