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. 

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. 

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? 

Keeping it in the family

I wouldn't let her take out my spleen

I wouldn’t let her take out my spleen

The test of whether or not you rate a colleague as any good is whether or not you would let them operate on a member of your family. This test is seldom (thankfully) applied but patients in your care sometimes ask if the surgeon who will operate on them is any good and seek your assurance, as a doctor that they know and trust, that this stranger is up to the task. This question is easily answered when it someone you do rate highly as a surgeon and is fraught with problems and stress when it is someone you would not let near your neighbour’s cat. Again, this occurs rarely as most people are good enough at most things that they do. It is good fun in fact to recommend a former boss who you think is great. The pain comes when it’s the opposite. To avoid answering this question directly one could use a generic reply “all the surgeons here are good, I’ve not heard anything to the contrary about Mr Handslikeshovels and I am sure it will go fine” If anyone recommends a colleague this half heartedly they are trying to tell you that they do not hold this person in high esteem.

A similar thing can occur with certain new and novel treatments and certain operations. A friend of mine used to regularly talk patients out of their Whipple’s the night before surgery much to his consultant’s fury. He was firmly in the “get pancreatic cancer and spend your last few months in hedonistic glory” camp, not for him months in hospital with comorbidity and misery. He is a pessimistic kind of guy and I disagree about Whipple’s as it happens and would take my chances with surgery.

The test of a new operation is would you want your family member to have it done the new and novel way if required. Quite frequently the answer is that you wouldn’t. Old ways were of course once new ways but any new technique should be applied with caution and continual audit of personal and unit results. When offered a new operation or a new procedure be sure to obtain the surgeons own results, find out their own experience and what complications they have had. You wouldn’t let just anyone do your garden or your decorating, apply the same prudence in letting someone take a knife to you.

To finish on a happy note a patient I had admitted and looked after was handed over to my colleague, the Prof, for his operation. “Is he any good this chap?” asked my patient. “I’ve known him more than 13 years. He’s the best there is” I said “He is as good as we have got and a really nice guy too”. The patient was out of his bed day 1 walking all around the hospital and was ready for home day 2. He believed the top man had done the operation, and so he had an exceptionally good experience and fast post operative recovery whilst most patients who have this operation stay 3 to 4 days.