Orthopaedic heroes: the sage of Oswestry

Back in the day, about the time when the FRCSOrth examination changed from being voluntary, with a less structured format, to compulsory (though even then it was still a moderately agreeable experience), there were relatively few examination preparation courses. This was the mid 90's, and the main course, I would say, was the one run in Oswestry, overseen by a relatively small group of surgeons, one of whom was David Jaffray.

He was an eye opener to many of the attendees, for quite a few reasons. He had an unreconstructed North East Scottish accent, an unusually informal approach to meeting strangers ("is NAME REDACTED still ******** NAME REDACTED?" he immediately enquired when learning which hospital we'd been working in), a very caring attitude to trainees and patients, and he was an awesomely good teacher. Quite superb, and very funny.

An example might illustrate some of this,  I think I remember it accurately.  He'd been up for a job in the university department of orthopaedics at my hospital, quite a few years before, as Senior Registrar/Lecturer. He came up the day before, to have the standard look round, and try to meet people (still essential, by the way). In the course of this, he began to feel that he didn't particularly want the job. He probably hadn't met the cream of the department, to be honest, but I knew exactly what he meant. The trouble was, he was manifestly the best candidate, and was almost certain to get it offered to him. Backing out at this point was considered very bad form, and difficult to explain. As he put it "I realised that I had no choice. I had to sabotage my own interview". The next day dawned, and the interview panel was the usual mix of university, management, potential NHS colleagues, an external and so on. The questions began, and it came to the turn of the extremely famous and acerbic professor of general surgery, representing 'undergraduate education'. "Mr Jaffray, tell me, what would you suggest to improve our undergraduate course in orthopaedics ?"

I will pass you over to DJ's words, which I still recall: "This was my opportunity, I had to act fast. I looked at him and said firmly 'abandon it!' " This apparently did not go down too well.  "It did the trick. After that I had no chance".

Perfect. And there are lots of other similar anecdotes .

I can't say I knew him really, but we had the odd contact about trainees. He was unfailingly helpful and completely up to speed on all aspects of training, as well as being very frank. Ask around, the man is a bit of a legend.

All of which leads me to the short memoir he put into BJJ News, which is a pure and perfect gem.

If you read this blog, you'll see that one of its themes is the value of listening to the wise older surgeons, many of whom are both highly rated as surgeon/clinicians but also funny, smart and charismatic figures. There are lots of fine surgeons about. There are probably fewer really gifted  trainers. There are even fewer who combine the two at a very high level.

The paragraph on the right is a tad pessimistic , and I can vouch from my own experience that being ...er...candid  (as opposed to confrontational) is often welcomed by senior management who may be as sick of the daft aspects of bureaucracy as you are. Meeting colleagues face to face is nearly always the best way of dealing with issues. Beyond that, the whole article is laden with  reflections, wisdom, humour and practical tips, culminating in a profound final bit of maternal advice.

Read and learn!

A cost rather than an opportunity

Another oldie from Nigel Hawkes, but a good one. Depending on in which part of the NHS you work, I doubt that much has changed.

Years ago I saw a statistic that the city of Cincinatti (population about 300,000) had more MRI scanners than the NHS (UK population about 64 million). I'm sure that the ratio has improved since, but bearing in mind that the innovations behind the clinical use of MRI were primarily British, it makes a good point. In fact, Hawkes makes a very similar point here, in this case about Japan.

Medics are not particularly slow to innovate, but their plans may well be derailed by management, who, as Hawkes says, generally are slow to innovate - they're usually firefighting. And that's because of the pressure from the government behemoth above them, as much as anything, combined with poor spending decisions, often as not.

You don't have to be Albert Einstein to recognise that "if you always do what you always did, you will always get what you always got", but funnily enough, it was him who said it.

Have you paid your college fees?

Back in 2007, when Modernising Medical careers was fresh and found to be pretty flawed, the reliably insightful Nigel Hawkes wrote a piece in the BMJ wondering:

a. Why did we make this change (see my other post here)?

b. What are the colleges actually for?

He had a point. He still does. A colleague and friend of mine who has spent years labouring for a distinguished college - and attaining high office - recently told me he wasn't sure, other than postgraduate examinations, what his college was for any more. There was a lot of business class overseas travel, and fine wining and dining, but...

Most surgical postgraduate education doesn't need college input, and ultimately one could envisage examinations being dealt with effectively by other bodies, too. The historical precedents set by the colleges are not set in stone. My own experience, and observations from wider practice, are that they are not great at advising government either.

Hawkes' piece is probably more relevant than ever, particularly with the ongoing success of specialty bodies like the British Orthopaedic Association, imperfect though it is. He absolutely gets the mindset:

 The purpose of MMC, it seems to me, was to wrest control of higher training from the colleges, and shape it in ways designed to suit the employers. The colleges were placated (a cynic might say bought off) by allowing their exams and their income flow to continue, at the price of having little further influence. Many of those who take the exams hail from overseas. The colleges did not want this source of income to dry up either, but nor did they want foreign graduates to take up too many of the training opportunities.

A pretty cynical state of affairs indeed. Read the paper - it doesn't take long

Deferring death v stupid politicians, AKA what is the NHS for?

I don't want to get party political, as this pretty much applies to all political leaders who make crazy promises about healthcare. It's a global problem, as Obama has found out. This one though is written by Iona Heath, a remarkably insightful President of the Royal College of General Practitioners (2009-2012), and a voice of reason in discussing what she calls 'too much medicine', AKA the overdiagnosis and medicalisation of life. It's not just unaffordable, it actually can cause harm.

This open letter to Gordon Brown, who happened to be the PM at the time, and even by NHS standards was ridiculously spendthrift on things that perhaps were not that useful, is exceptionally good. It's all still applicable. Osteoporosis spending springs to mind, considering Heath's phrase: the extent to which contemporary preventive medicine has got itself trapped on a treadmill of risk factors.

One of the issues I have, as a highly paid NHS staff member, is the constant refrain for more money for the NHS. I'm also a taxpayer and the NHS has buckets of money. It might need more, but before that it needs a review of what it's going on already. So much of the budget is spent on low value interventions and pet projects, spurred on by mysterious 'health planners' in the civil service, various Public Health types, and vested interests.

Picking on my own specialty, in a nutshell, if I do a hip replacement I'm usually providing lasting value.....hip arthroscopy? Not so much.

A little politics: MMC and dumbing down

It's that time of year again, when doctors just over one year out of medical school are being nudged into a straitjacket of specialty training before they've even experienced a small percentage of their possible career options. Yes, it's the annual expression of MMC (Modernising Medical Careers, from 2005).

Very many of us felt it was an unnecessarily doctrinaire and remarkably bureaucratic approach to careers, particularly when you're dealing with some very high achieving individuals who would not gain from stifling their career options, and nor would the taxpayer who paid for their education. In addition, Ken Calman's late 90's superb postgraduate training reform programme had only just bedded in, and it was a fantastic improvement from what had gone before. It was abandoned prematurely by the self-appointed 'great and the good' of UK medicine. Their mantra was 'something must be done for the SHO's'. In fact many SHO jobs were deservedly popular for lots of reasons, and it's a pretty odd motive for reorganising the whole training structure (again).

So why did we bother with MMC? Apart from glory hunting by ageing clinicians eager to reduce their clinical commitments, consultant oncologist (and top irritant of governments) Clive Peedell  thought it was fairly obvious: to save money. He might be right.

I take the view that this was the then government's plan to undermine all those professions which retained the public's affection/respect despite their faults: teaching, the clergy, medicine and others. I still think that. Everyone has to be similar/dumbed down, everyone has to become primarily an employee, as opposed to a vocationally minded self-motivating highly expert clinician. It went in tandem with the disastrous and extraordinarily cynical changes to the GP contract - which has wrecked much of out of hours care - and the awful New Deal/EWTD that has badly damaged essential apprenticeship-style training. Simulated surgery is not the answer (I might return to that in another post).

The GMC did their bit by - in conjunction with the government - radiating an aura that doctors probably were not to be trusted after all, and the "presumption of innocence" rule in complaints and Fitness to Practice investigations virtually disappeared.  Read the heartfelt comments at the end of this piece on the GMC's own website.

Anyway, back to Clive. This 9 year old piece still resonates.