Beyond fucked 

Beyond fucked 

Everyone has their own ideas about what constitutes being totally fucked, by which I mean that level of gubbedness that is unsalvageable and not worth even trying. There are various ways of thinking about it,  you can do a P-possum, check their base excess and pH, look at them from the end of the bed, but one thing is sure. There is rarely a return to health from being totally fucked. It can be depressing.

Bighospital is totally fucked just now….

We have 8 nurses off sick on my ward alone; 5 with either flu or vomiting and 3 with stress and this situation is repeated everywhere.

We have no beds for elective operating as we are full of unwell medical patients. We do physically have beds, but we have no staff to open them.

We have an A&E that is full and overflowing with staff at the ends of their tethers. Patients are being told they have inappropriately attended and should have waited 2 hours to speak to NHS 24 and then 6 hours for a GP to come.

We have trainees (entitled and snowflakey in a way I never was) being taken off on call and moved to elective operating lists in case they complain in their GMC survey and we lose them entirely. Newsflash to anyone who thinks like this: this isn’t school, you get a salary, start delivering some value for money.

We have some consultants who won’t do anything that isn’t in their job plan and obstruct and hinder attempts to improve service. “I’m a consultant surgeon, nobody can tell me what to do”…you’re a salaried employee, not a deity.

We have managers who can’t manage. Leaders who can’t lead.

Bullying, misogyny and bitching are endemic.

Patients on the ward are sometimes not washed or fed because nurses are filling in endless paperwork and “magic stickers”* for every problem that must be completed or some nurse manager will explode.

I can’t get the elderly and dependent patients out of Bighospital because there are no carers to look after them in the community. They remain there, pathetic and heartbreakingly vulnerable, not having been home for weeks. These people haven’t seen the sunshine or felt the wind on their face, and they bear it politely and impassively in a way I could not.

We are beyond fucked. It is the same everywhere, I’m not sure it can be fixed and I suspect that our conservative government doesn’t care if it dies.

*magic stickers are Bighospital’s response to all problems. For any target or goal or other utterly unnecessary nonsense that trained nurses and doctors do anyway there is a sticker. For example; a doctor is asked to review a patient with a low blood pressure. The patient is 17 and weighs 50kg and is asleep, her BP is 80/50mmHg. It was similar to this when she was awake. This is normal, but the nurse has to mention it to the doctor. A year ago we could say “that’s fine. Thanks, I’m ok with that” now the junior must complete a fucking sticker and a complete assessment and stick it in the notes.

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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. 

Ward Round Bingo 

Ward Round Bingo 

We have all been there, stuck on a tiresome and boring ward round that feels like it will never end. I have the solution to the ennui induced by listening to someone drone on and on about the amylase, whether or not the TED stockings have been prescribed and the patient is wearing them, and worse; teaching rounds with no obvious point other than to make the teacher look smart. 

I have the solution to this problem right here. Ward Round Bingo, your very own print and use set of Bingo cards. No more texting, no more tweeting, no more surreptitiously trying to make your pager go off and thus escape. There is a heavy general surgery element but you can adapt for orthopaedics (NOF, FOOSH, ORIF), ENT (posterior nasal pack, post tonsillectomy bleed, tracheostomy problem, fish bone), general medicine (ward round exceeds 5 hours, increase statins, dual antiplatelets, Guillan Barré). What fun! 

Teaching is not about me 

Teaching is not about me 

Something has occurred to me recently, something that should have occurred to me years ago, and it’s that the teaching sessions I deliver are not about me. It may sound terribly self absorbed (it’s a flaw of mine) but for the last near 20 years I’ve been worrying about what I was going to say and how I was going to say it. Wrong! God what a vain and stupid cow I am. It’s about what they are going to learn and how they are going to learn it. 

Recently I’ve learnt the basics of how to teach and I can’t stop proselytising away about learning objectives and types of learners. It culminated in a session this afternoon (impromtu) in endoscopy when the nurses said at the end “that was great, what a brilliant teaching session, I’ve learned a lot too and how you did it was so clever”. I could not have been happier. 

I had one student and then an hour later I had two. I had decided the learning objectives for student 1 when he came in and we were making progress through the three objectives and then  when student 2 came I made student 1 teach student 2 what he’d learned; thus consolidating 1’s learning and freeing me up to do the paperwork.  Rather than me getting in a pickle about the pharmacology of buscopan, a distant and vague memory, we focused on just a few things and we did it well and when we finished they had learned something. It’s genius, and of course very obvious to people who know how. I’ve recently been criticised for my affection for the University’s “Teachometer” (not it’s actual name), as time spent teaching is not an measure of quality. I’m now on a one woman mission to make my teaching time quality time. 

Freeing myself from the terrible sense of fear that I might not know enough about the subject and therefore not be worthy of delivering teaching has been a long time coming. We filmed some of  a course we delivered locally and part of it involved me delivering a small group session. I have realised several things; I have a weird teacher voice, much quieter and softer than my usual speaking voice, I am not as fat as I think I am and nobody knew when I got the order wrong. 

In my perfectionist mind I had planned on saying things in a particular order but on the day, I didn’t, and despite my heart rate rising to 180 and feeling distraught at my failure, it was not at all apparent and didn’t seem like it was a disaster at all. This has helped me considerably to relax and enjoy my teaching because nobody but me knows what I am going to say and when. 

The observation that I get a gentler voice is not because teaching is anything like parenting, Mummy Me these days is a harassed and often shouting individual with little patience. I think it’s because I feel nervous and unsure, although fortuitously this is not how I come across and if I can project a bit more and change the tone back to my normal then it will seem more genuine. 

Anyway, now that I know that it isn’t about me I’m much less likely to get myself in a state mid lecture thinking I’ve ruined everything if I cock up my running order. Having the focus on them rather than me, so simple and so obvious, maybe that’s why nobody told me? 

I have lots of teaching to do this week and now that I am combining enthusiasm with some knowledge, theory and skills it might just be good quality. Can’t wait for the feedback/happyforms…but are they the right measure? Probably not but I’m excited nonetheless! 

Taking charge of your training 

Taking charge of your training 

I think there should be a mirror in our registrar room, (this mirror would be handy anyway as a regular mirror for me to check my face in) but it should have a sign above it reading “The person responsible for your training”.

The apprentice/trainer model is dead in most hospitals and training is increasingly squeezed out of the operating theatre due to targets and time constraints. See this recent letter from the RCSEd president which makes this point well.  https://www.rcsed.ac.uk/media/414502/hunt.pdf

Many people, trainees and trainers, sit back and complain and compare today to the training in the good old days. As much fun as this is (I did a one in four, I did 90 hours a week, we operated 72 hours straight with no food…whatever!) it doesn’t help us in the current climate. I’m counting the days until I am done training, but will soon be a trainer. I think I am rather well placed to advise on training in general surgery as I have been training for so very long.

The people who have trained me, were trained in the old system by people who worked 100’s of hours more than I will. They learnt to teach me from how they were taught and most of them are bad at it.

Models of training

1. Apprentice and trainer. This model is the ideal and results in steady progress and a joyful and rewarding relationship over time. This model is dead in most hospitals and is what we all constantly lament the loss of. 

2. We don’t know any other models. 
I don’t really know how to get better at teaching people, I keep trying it and I’ve been reading lots of books on the subject but I cannot quite bring myself to do a certificate or diploma in education because it will cost me some of my hard earned money and probably be boring. 

I know I vehemently dislike most undergraduate teaching; nothing fills me with ennui more than 4 dull faced slack jawed millenials who can’t tell me what a hernia is, what the contents of the inguinal canal are, what bugs cause wound infections and how local anaesthetic works. 

Why should I show these eejits what I am doing and explain what is vas and what is sac when they are patently clueless? Somewhere there are lots of parents going without summer holidays and sirloin steak to put these children through medical school, they are most undeserving of the sacrifice. 
I do like post graduate teaching though, these are motivated learners, panicking about career progression and paying out their own money for exams. 

What I’ve realised over the years of good and bad trainers is that the person responsible for it all is me. Most of the years have been good but I have behaved appallingly at times in the past and let someone not train me, because I was being petulant and it suited me to say that this person doesn’t teach. I stood about huffing and moaning that they don’t let me do anything whilst never asking to do anything. 

ISCP, our internet based reflective continuous assessment website is really good when used regularly and appropriately and sadly it is not used to its full advantage by most trainers and trainees. I have had the benefit of working for one or two amazing trainers, one person in particular who I want to be like and so far I am managing to do what he did when I operate with the juniors. I am desperately trying to use ISCP the way we did but am failing to get my trainers to engage with what my needs are. 

In a relationship if you aren’t having your needs met you have “a talk” with your other half and sit down together and tell them you need more hugs/sex/help with the hoovering. In a training relationship you should do the same but I am struggling to find anyone who wants to listen.

How can we all engage more in training, how do you motivate the people who teach you to train better, how do you get them to change what they are doing without moaning and complaining and offending?  

(Don’t feel sorry for me, this situation is very much all my own fault) 

Surgery and Sports Psychology 

Surgery and Sports Psychology 

The hopes of a nation rest on one man as he prepares to take a kick with 30 seconds left in a game, the pressure is immense. The player does not disappoint and the try is converted. Millions roar with delight and admiration. The pressure on that person in that moment is unimaginable, even watching it you feel the tension. 

What you don’t see is that they have prepared for this eventuality. They have rehearsed this moment and developed coping mechanisms. They have prepared and rehearsed and are ready for the pressure. 

Have you ever watched a bobsleigher mentally prepare for a race? Or a formula one driver? Or any sportsperson at a high level prepare for a big event. They are “in the zone”.  They perform at the highest levels with high stakes and millions of eyes on them and they excel and exceed those expectations. 

Arguably, the pressure on a surgeon or trainee in the operating room are similar. The nurses are talking, the anaesthetist is laughing loudly and the rectum is not coming out easily; a piece of retractor digs painfully into your side when you suddenly get torrential bleeding that wells up obscuring your view just as the medical student on the StMark’s says she’s going to faint.  At that moment we batten down the mental hatches and cope, we do not launch the StMark’s across the room or start swearing, or indeed swearing more than you are already. 

The stakes are high, not just life and death although that is often a consideration; but continence, sexual function, bowel continuity (absence of a stoma) and other equally important outcomes depend on our ability to perform under pressure.

Unlike for example, premier league footballers these coping skills are not formally taught to us, we do not have a team around us helping us mentally prepare for operations but perhaps we should adopt some of the lessons learnt in professional sport to help us become better surgeons and crucially, better trainers and trainees. 

Even in amateur sports many people are obsessed with improving their performance. The proliferation of books on this subject are evidence that even the humblest of sportsmen and women wish to achieve their maximum potential, or at least remove any psychological obstacles. 

Traditionally and stereotypically surgeons are portrayed as being confident and composed in every situation. In theatre we act the part as expected of us and do not hesitate or crack under pressure. 

Squashing Ants is the term used by sports psychologists (ANT’s being automatic negative thoughts) to overcome our doubts and negative thoughts. “I can’t do that operation on my own” or “I can’t get this tumour out” are dismissed with positive rebukes for each negative thought. 

It takes practice, especially if, like me, you are prone to catastrophising and worrying that you can’t do something. For each “ant” you squash it with a good thought; for me this would be  “I know I can do this operation and if I need help I will call for it”. 

Visualisation is another sports technique that should be applied more in surgical training. Running through the operation verbally with a trainer and mentally alone prior to a case is very useful. Imagining intraoperative challenges and how you would respond to these helps build confidence and maximise learning, I think. 

I’m off to squash some ants! 

Dealing with complaints 

Dealing with complaints 

A lovely reader of this blog has asked me to write a post on complaints and I am happy to oblige. Complaints come, no matter how marvellous you are, no matter how pleasant and decent and good you think you are, you will inevitably have to deal with a complaint. 

Complaints are like any feedback, they represent a useful moment to reflect on your practice and how you appear to others. 

This is the policy and advice from the NHS in England on how to make a complaint..http://www.nhs.uk/NHSEngland/complaints-and-feedback/Pages/nhs-complaints.aspx

The people who complain are not the ones that you expect, by which I mean the anastomotic leak that stays in hospital for 3 months and requires two further laparotomies and a month of TPN is usually grateful and appreciative of your expert care that rescued them from the brink of death. You should instead beware the person who stays 48 hours and has no acute surgical problem, these are the complainers. 

The purpose of dealing with a complaint, for me, is to make it go away and not lead to further grievance. It is not the moment to try and justify what you said or did or score points. 

Let’s take the common complaint of “not caring enough and not spending enough time with me”, this was a complaint about me recently in a patient with, by the time she and I met,  a CT proven diagnosis of diverticulitis. I erroneously thought there was no need to take a massive history as the troops had already told me all about her, I had instructed them to do a CT and most unusually we had got one within a few hours and had a diagnosis. Job done, great care! Or so I thought…

She said I was in a rush and didn’t seem to care about her. Now, in all honesty I probably don’t care enough about this 48 hour stayer that wasn’t super sick and I did spend the right amount of time on her in the context of the emergency ward round on a busy Monday where she had a diagnosis and a plan and most of them didn’t. But I went about it all wrong, I quickly prodded her tummy, looked at her CT, growled at the junior who hadn’t commenced antibiotics (happy to discuss benefits of this or not, but in Bighospitalburgh we do) said a few words to her about the natural history of her condition and moved on. 

One hour later I am called back to see her and her daughter to apologise, which cost me 20 minutes. 

The response to a complaint cannot allude to her need being less than that of any of the other patients, nobody likes to hear how they were the least important person on your radar.

This is instead your opportunity to deeply regret how your behaviour made them feel, that you are saddened and ashamed that any person under your care would feel that you didn’t have their wellbeing at the centre of what you are doing. You have reflected on their comments, you have taken them on board (a phrase I never use in real life), and you will do better. 

None of this is being said with my usual jaded sarcasm. I made an elderly, frightened, unwell lady feel bad and genuinely I am ashamed of that. 

One of my much respected senior colleagues, as senior as they come, sits down next to old ladies like this and takes their hand and introduces himself. He appears to the patient to have all the time in the world, he tells them that “his team” has kept him informed of everything that has happened during her admission and that he is pleased with their swift and accurate diagnosis and management. Then he asks them a question like “And how are you? Anything  you want to ask or to tell me?” 

(I know! He’s great and I am still such a total amateur at this, after 20 years of medicine. I hope that having some insight into my failings will lead to being as good as my colleague.) 

I still feel bad about this, if someone made my wee Granny feel frightened and neglected I would be most displeased with them. 

The other complaints I have had experience of have been of two varieties; communication related and people upset that I told them to lose weight, which is also communication related. 

It is apparently “easy for me to say” as a normal BMI individual that people must lose weight. It certainly is not easy to say, and I have a new policy with weight; I only mention it if they do or if I truly feel I cannot operate on them due to their BMI. 

The best advice I can give you when dealing with a complaint is to say “What happened? What should have happened? What is the difference between those two things?” 

This should form the basis of your response, along with the words “I am sorry that you feel”. The medical notes are crucial in your defence of a complaint. “She didn’t care” can be met with a robust response that you saw her twice a day, examined her carefully, sent her home with a sack of painkillers, an outpatient appointment and that she was discharged well aware of the plan. If the notes just say “Home” you have a problem. 

Serious complaints of  medical negligence are a different sort of thing to what I allude to here. Legal advice and defence union input should be sought in the event of such an allegation.