Scalpel’s Edge

Surgical manners

// June 1st, 2009 // 1 Comment » // Health, Surgery

One of the surgeons I work for has a typical surgeon’s manner. It’s a bit uncommon, now, especially with young fellows. I imagine there used to be a deal made between the surgeon and their society - you revere me and I will allow the hospital and my patients to use up my life. The deal has changed, so the behaviour has, too.

This boss seems to have little empathy for staff. I’m not sure if it is true, as he is really a nice guy, but he certainly gives that impression. You know how some people think that they know how things are meant to work, so get shocked when other people don’t? Like that. I don’t know how he deals with patients, as I never see him outside theatre.

I wanted to share the one thing he has taught me recently. We had a complicated case, and there were a few technical difficulties with the video equipment. Then his favoured instruments weren’t available. Then the staff started to get cranky at him, and the tension started to rise. And this was a complicated case, in a spare theatre, with fill-in staff.

So I learnt that attitude is one of the most important surgical skills. My surgeon expected the best of everyone in difficult circumstances, and got disappointed. Our plan should not be to expect the best and get disappointed. We need to expect the worst and enjoy the relief when people step up.

The other important skill is to plan for hassle-free work. Surgeons are the master of their workplace to some degree, and can manipulate what operations get performed in what situation, especially for elective cases. Especially in the times we expect everyone around us to let us down, we need to keep a margin of safety. Save your regular list, with familiar staff, for tough cases. No one has the right to get miffed if they have planned poorly. Be on time, have a familiar anaesthetist, be honest about the length of the list.

I know this sounds basic, but I have to write it down, because it just keeps bouncing around in my head. A tense workplace with standoffs between staff is unsafe. It’s a long career. Being a donkey at the beginning of a career doesn’t win points.

Image: malia (Flickr)

Motivated to run

// May 11th, 2009 // No Comments » // Health, Surgery

Yesterday was Mother’s day, and for the first time, I ran in the Mother’s Day Classic in Melbourne. This was a part of trying to get fit, and, as I severely hate running, was an exercise in stressing my body (and psyche) despite protests.

Most of the other runners there were also serial fun-runners, or representing various fitness and training clubs. However, there were a big proportion of people running for a cause. The Mother’s Day Classic supports breast cancer research, and many participants wore a tribute placard with the name of their affected relatives and friends. This is pretty typical of charity runs, but I found it particularly moving to see young kids, and obviously unfit adults struggling in memory of “Nanna” or “Mum” or “Auntie Dorrie,” or even “Myself.”

I have not got a strong family history of breast cancer, and I have few friends who have been affected. However, in my few years of training I have done a lot of breast surgery. I have met young women, trying to decide if they will risk getting pregnant again. I have met older women traumatised by an screening interval cancer. I have met elderly women who presented with an advanced cancer after nursing their husband through a long illness.

Breast Cancer is common, so research gets government funding. I believe we have the right to government funded research into common diseases. But I also believe we have the responsibility to contribute to quality healthcare. On the weekend I realised that I believe that extends to medical research. We can expect basic research to continue, but if we care about our medical future, or the treatment of our friends and family, then we should support it.

I was running for selfish reasons yesterday, and happy enough that a portion of my fee was sent to a charity I support. But many people were running and walking because they care, and are taking responsibility. That’s impressive.

Medicine by rote or by consideration?

// May 4th, 2009 // 3 Comments » // Surgery

I had an interesting discussiong with my PhD supervisor. We were doing a laparoscopic cholecystectomy and his philosophy is to not routinely perform a cholangiogram. For those who are not familiar with the topic, this is an xray test performed at laparoscopic cholecystectomy (keyhole gallbladder surgery) which, among other things, proves that you have identified the anatomy correctly. Whether to perform routine cholangiogram (i.e. for every single patient, barring any technical prevention) is an ongoing argument amongst surgeons - one of those decisions where the evidence is not clear and people tend to firmly grasp their choices, and end up really passionate.

I really respect my boss, and he argues that he displays the anatomy well, and therefore there is no reason to routinely cholangiogram. He does show great anatomy, and his point is valid. I am not experienced enough at this procedure to make my own decision, yet. So I said, “The exam answer is to always perform a cholangiogram, right?”

(This is because it is the only way an examiner can guarantee you are going to be safe. They can’t check how well you operate, so this answer proves you are safe surgeon, no matter what your skills.)

My boss, of course, disagreed with my statement. He wants me to have my own opinion and defend it based on the available evidence. This makes sense to me. We should be teaching surgeons to make decisions based on available evidence, and their understanding of their own skills, not based on one-time decisions. And we really shouldn’t be expected to say one thing to examiners where we might be planning to do something entirely different in practice. But my boss is not an examiner. I’ve still got a few years yet to figure out what I will say.

What do you think? Should we favour the safest course, and risk over-investigation, or encourage surgeons to defend their own position, even when they might not agree with the examiner?

Image credit: dcjohn

Junior doctor

// May 1st, 2009 // No Comments » // Family, Surgery

I overhead my three year old daughter on her toy phone this morning. She was “driving” on her bike and had stopped on the side of the road (our front hall) to take a call.

Hello?

Oh, hi. I am on my way. Do you have patients?

[Pause]

I said, do you have patients?

[Pause]

OK. Do you have mobile phones?

[Pause]

Thanks. I’m coming now. I’ll see you soon.

How cool is that? I have never worked in a job where I have to check the presence of patients before I leave in the morning. And don’t get me started on the folly of expecting the public health system to supply your mobile phone. But it warms my heart to see her being a (very) junior doctor.

On second thought, maybe she was ringing up to ask if they have “patience.” She must take after someone else in the family. Because she can’t possibly have overheard me talking to the ED staff in the middle of the night, could she?

Photo credit: tourist_on_earth