Scalpel's Edge

A surgeon's notes



My husband has a passion for finding ignored projects that can make a big difference.  Since moving to Nepal, he has worked on some maintenance projects that had been neglected long enough that they became renovation projects.  He has installed smoke detectors and arranged fire extinguishers.  He has now been working on a project to build a oxygen generator on the hospital compound (we currently truck in our oxygen along a landslide-prone road).

My kids are passionate about their friends and school.  Zoe is passionate about school and meeting new people.  Jacob and Angus are both passionate about minecraft (a construction based computer game), but Jacob also loves parkour and climbing.  Angus is obsessed with lego.

Since I started surgical training, I have been passionate about education.  I love talking to patients and helping them to understand their condition, empowering them in their treatment.  But I am even more committed to teaching medical students and residents.  I never understood as a student how exciting, interesting and challenging surgery can be.  I left medical school thinking that smart, thinking doctors would get bored as surgeons.  I think that we tend to teach surgery by stripping it down to mechanics, simplifying to make it easier to explain. By removing complexity, however, we make ourselves sound simple.  Surgical education needs to convey the excitement, the thrill of a successful outcome, and even the fact that the simple mechanical solutions don’t always work.  

The body is an amazing creation, and we have the opportunity to watch it move, and heal and adapt.  Furthermore, we can learn to work alongside those adaptions to create good function.  We can break the body to help heal it.  We take advantage of healing to remove non-functional or diseased tissue.  We work in teamwork with the body to achieve an outcome that both we and the patient desire.  This job is not boring, or simple, but a chance to work in the presence of God.  Even readers who don’t agree with my religious perspective have to accept that the body is a miracle, with unrivalled complexity, and that surgeons daily work in partnership with the physiological processes of the body itself.  What an honour.

Despite this background, I didn’t realise that surgical education would be a focus of my work here in Nepal.  Surgeons are desperate for education in Nepal, where  typically knowledge is gained through experience.

Most of my surgical experience was developed in a formal, apprentice-like training program in Australia.  After medical school, I spent nine years working in hospitals before I was fully qualified as a surgeon. I also spent a further three and a half years on a PhD, which was extra, but the nine years is pretty typical for surgical training.  Some surgical specialties take even longer (cardiothoracics, for example).  A lot of general surgeons go on to have further training in a subspecialty area, like hepatobiliary, or breast surgery, taking one or two or more years focussing on that area of the body.  

In Nepal, surgical training is less available.  Within the country, there are limited positions, which are difficult to access, and expensive.  Many people leave Nepal and pay for training in another country.  We have recently had a lot of surgeons come from training in China.  Typically, these guys (have not met many Nepali surgical females yet) are taught in english (which is at least their second language) and learn mandarin/cantonese to speak to patients.  They are often assigned to a single clinical unit and work not as a primary surgeon, but as an assistant.  They learn surgery by observation.  I know some surgeons who have managed to change their clinical unit to get a broader experience, but they have to be motivated to do that.

Once they return from overseas, they sit an exam (written) and are formally registered as a surgeon, able to work independently.  At our hospital, we employ these doctors as senior surgical residents and teach them the operations and clinical decision making that they weren’t exposed to during their training.  This can take two or three or more years, as some have had very little practical experience.  At any stage they can leave for a more lucrative job in a private hospital and learn the remainder “on the job”, from other doctors, from textbooks and from making mistakes.  If they stay longer with us, they can learn enough general surgery that they are (in our opinion) safe to work independently.

There’s a temptation to think that my surgical skills are what I donate when I volunteer here.  I work on call and operate in the middle of the night.   I do my shifts in outpatients and operating theatre.  Certainly, if I didn’t operate, my spot in the roster would be difficult to fill. But with an adequate salary, a Nepali surgeon could be found to do all that work.  I think the real role for mission surgeons is to operate as little as possible, like I did when working with trainees in Melbourne.   I need to donate the training that I received from friends, mentors and supervisors over many years.  I work to find opportunities to train and teach and transfer what I have learnt to residents, and GPs and staff.  I am grateful that I was taught some adult education skills, however briefly, and I recognise that my previous passion is probably more important here, than it was at home.

Ironically, Nepali doctors understand the importance of surgery, more than I did in medical school.  Availability of surgery in the developing world is key indicator of health outcomes. The operations we do save lives regularly and visibly, and no one has to be convinced.  Mission hospitals play a key role in education, as only hospitals that care about good health outcomes will dedicate resources to education. For at least the short term future, I donate my training and my passion to this place, in the hope that we can create a cadre of well-trained surgeons who can, in turn, mentor the surgeons of the future.

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