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. 

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! 

Finding your surgical persona 

Finding your surgical persona 

“Work me” is not the same as “home me”, but both these people are true and genuine people. Many of my colleagues are the same at all times and have the same demeanour and seriousness about wrapping a birthday gift as they do about a laparotomy, but that wouldn’t work for me sadly and much like I have separate clothes for work and home I have had to separate out some of my behaviours. 

Being “fake” is hugely unpopular amongst people nowadays and that you might not be being true to your authentic self is a crime in the eyes of modern magazines for women and widely disparaged in society in general. I disagree, I have to have a professional persona in order to make people feel I am in control. Leadership of the team (despite the anaesthetists thinking they are the leader)  and taking responsibility for difficult decisions is part of my job. The real me, when left alone and unobserved, likes lying on the couch in ill fitting clothes, texting people and swearing. Real me is a dreadful person, with a smutty and childish sense of humour who prevaricates endlessly and can waste hours of time achieving nothing. 

At a friends last weekend I was drinking wine and chatting about nonsense when someone suddenly wanted medical advice. I immediately switched into doctor mode and everyone was amused at the change that came over me when faced with a serious question. I don’t have a problem with this split personality, I have worked out a way of being “me” but being professional. 

I’ve complained before about irritating altricial people who are seemingly born consultants and arrive at medical school with the gravitas and seriousness of  a professor. They don’t want to laugh and giggle and have silly games with their colleagues; they fascinate me in a way because I am so easily distracted and diverted from what I’m meant to do by the slightest bit of nonsense and novelty and find it makes the day more enjoyable. And as a recently personality profile has told me, I need to be amused and constantly stimulated in order to do any work. 

Finding the balance between being yourself and being a professional takes time and trial and error. I have spent lots of time behaving like other people I admire or was in awe of. In this way, mentors are hugely important, but watching people do things you don’t like is just as valuable as those you do wish to emulate. 

You put on clothes to make you look like the professional that you are expected to be and there comes a degree of professionalism when I walk in the door of Bighospital wearing my work clothes. 

Some people erroneously assume that to be treated as a professional you cannot be called by your first name. None of the scrub staff and only a very few, new, junior nurses call me Mrs KBW and they are corrected immediately. I am on first name terms with everyone and it’s only with patients that I will introduce myself with title and surname and I don’t hugely mind if they go on to call me by my first name. 

I’m not a nurse because I didn’t want to be a nurse, I wanted to do this. A nurse is a nurse because they wanted to be a nurse. It doesn’t fit with my philosophy on life to assume that they are nurses because they couldn’t be doctors or that being the surgeon makes me better in any way. I have a leadership role and decision making falls to me but we are a team and we need every member of the team, all are important. The NHS is not the army, or the police, we are a team. We are the public’s servants,  all working to the same goal, I absolutely abhor the idea that one of us in the team thinks that they are better than any other member. 

My surgical persona has not changed with moving from trainee to the boss, I’ve been warned not to develop new consultantitis (seemingly decent registrars lose the plot with their new role and start demanding things and having tantrums) but it really isn’t in me to behave like that. I genuinely have affection and respect for my colleagues, they are mostly brilliant and a pleasure to work with.

We have to move away from thinking that the way (men) of between 55 and 65 conduct themselves is the way to behave as a consultant. They are probably copying how their bosses behaved 40 years ago when they were my age and that is far from where society and teamworking and patients are now. 

I am as professional and credible and competent as any man in a bad suit and college tie combo and I am no longer apologetic for being nothing like that. It has taken a long time to reach this conclusion and have that degree of confidence and I wish I’d realised it sooner. 

Some people think that being professional is about what people call you, it isn’t. It’s how you behave, how you treat other people, how you operate, how you treat your patients, how you speak to colleagues. Respect is earned and not asked for and not wanting to be called by your first name by adult colleagues whose assistance and cooperation your job depends on is totally fucking weird. 

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.

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.


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. 

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?