Heraclitus and the European Working Time Directive

Here's a post from a guest author - a highly regarded NHS stalwart - who is nearer the end of his consultant career than the beginning. A role model, no less, if you aspire to be a great orthopaedic surgeon without losing your humanity and affability. I haven't identified him, intentionally, but he's not me. 


He's responding to a post in the BMA news. There's lots of this stuff out there (1, 2, 3, 4, 5), and I even blogged on it myself.  See what you think. By and large he's right - this is real world medicine from a real world expert.


Front Page of BMA News:     

“One I am terribly sorry to have to say this but we have to train our young doctors to be prepared for life in the real world and not for life in some utopian fantasy land. I agree that the life of a trainee is less satisfactory nowadays than it was in the 1970s and 1980s where although hours of work were much longer and more arduous, and pay for overtime was only 1/3 of the basic rate, and when you could be on call on a 1:2, 138 hours in a week, you were valued, cherished, appreciated, helped by your seniors and by experienced nurses. You would live in the “Mess” with fellow housemen experiencing the same joys and hardships. These times have gone. 

At that time Housemen and Housewomen were expected to take on, and did take on responsibilities that our current young doctors would baulk at, but it prepared them well for the future. I fail to see how “sleep deprivation” can possibly be a problem in a situation where our trainees work shifts and never work more than 48 hours average a week. These are young, generally healthy, men and women.  Why should they be any less able to deal with a bit of hard work than we were? 

We have gone too far in our efforts to adhere to European Working Time Directives especially when those who travel in Europe and elsewhere know that the trainees there (in common with trainees in America, Australia, Canada and New Zealand) work much longer hours without complaint as they realise that it is the only way to become experienced enough to deal with the rigors of a senior appointment. 

I had the unedifying experience of hearing young trainees described as “Babydocs” by someone in our Deanery which I felt was not only demeaning to the mature men and women who had spent 5 years at University and another year as an FY1, but indicative of the lack of insight in our educationalists who do not begin to appreciate that the sooner someone stands up and takes responsibility for their own actions, the better equipped they will be in later life to deal with the difficult decisions that come to all of us. 

Medicine is not an easy job. People who can’t manage to cope with the stresses and strains, with the long hours and challenges may be better to be advised at an earlier stage to consider an alternative career."

The great man has just looked at the New Deal regulations...

You may think it's harsh, the voice of an old fart, perhaps, who doesn't get the groovy new way of doing things. I'm afraid though, that some aspects of medicine don't change. Two of our most effective operations today, for example, were practised by Hippocrates and his pals, in not dissimilar ways to our current techniques - amputation and draining abscesses. 

Note that part of this relates not to service delivery or alleged risks to patients from 'tired doctors', but to the happiness and job satisfaction of the medics themselves. However physically and mentally challenging work has been, there is immense satisfaction from having done it and done it well. A point neatly encapsulated by another experienced medic, Theodore Dalrymple, in a classic Spectator piece:

No one wants to be treated by a dog-tired doctor, but even less does he/she want to be the parcel in the medical game of pass-the-parcel that is now commonplace in our hospitals. The European Working Time Directive has transformed doctors into proletarian production-line workers, much to their dissatisfaction with their work and to the detriment of their training and medical experience. It means that doctors no longer work in proper teams, patients don’t know who their doctors are and doctors don’t know who their patients are. The withdrawal of the directive would improve the situation.

Medicine in general, and surgery in particular, is ruled by Eternal Verities**, whatever the New Deal, the EWTD and the BMA say. 

  **although he didn't invent the term, Greek philosopher and writer, Heraclitus, from about two and a half thousand years ago, was the father of the Eternal Verities. He realised that reason and wisdom are what leads to contentment, with all the moral, metaphysical and religious implications that might flow from that. Somewhat more profound than complaining after not getting a mandatory 30 minutes break following 4 hours of work (or whatever this week's formula is).

Alt.orthopaedics: 10 things I hate about you

Orthopaedic surgeons are well known for being romcom fans, of course, so it seems appropriate to reprise the title of one of the more adventurous examples of the genre - given that it's a straight lift from Shakespeare's Taming of the Shrew - which is 10 Things I Hate About You.

This post derives from a recent conversation with consultant colleagues from various other hospitals, the chat turning to the most annoying habits/traits/actions of trainees. We're not saints ourselves, we know we annoy, frighten and upset our trainees occasionally - no gain without pain etc.

In fact we love our trainees, really, but sometimes you end up meeting situations that are really, really annoying. It's best to know these things, both to amend one's errant behaviour now, if as a trainee you recognise yourself in the list, or just as importantly, to prepare yourself for the weighty responsibilities of being a consultant, and having to yourself nurture the delicate talents of future generations.

Please note, any trainees/residents who read this, I am very happy to publish your Top 10, 9, 8  whatever, things you hate about consultants, attendings etc. Just get in touch or add something in the comments

So, in no particular order:

1. Inappropriate familiarity

I don't think most surgeons are too up themselves. Friendliness and camaraderie are by far the commonest features of the trainer/trainee relationship, in my experience. Most trainees recognise that there is an assumed (and inevitable) hierarchy, and that it's there for a reason. One day they will sit at the top of it. Not all trainees seem to get it though. The famous incident that springs to mind relates to a shoulder surgeon painstakingly dissecting in the axilla in an unusual and complex trauma case. As the axillary vessels came into view, with the theatre atmosphere quiet and a little tense, the trainee exclaimed "...whoah! Easy there, tiger".

Not good.

2. Obsequiousness.

It doesn't hurt the patient, but boy, can it be irritating. My favourite example is the experienced and highly regarded surgeon who'd been pestered by a visiting surgeon in the department to allow him to scrub in, to which he assented, out of courtesy. The visitor's attitude was grovelling from the start, larding praise on unremarkable observations in a particularly annoying way. The nadir came early, when after starting a standard total knee replacement, the visitor lavished praise on the execution of the incision.

Too much. Way too much.

3. Telling the surgeon how other people do it

Actually, all of us gain the odd pearl from our trainees, based on what they've encountered elsewhere. Indeed, it can add to the camaraderie.

But...

Some trainees have a tendency - possibly induced by nervousness - to spend operations telling the boss how someone else they've come across does the procedure. It doesn't matter that you're the world expert with thousands of cases under your belt, they're still going to persecute you with tidbits that frankly you don't want, nor need, to hear. Reps do it too.

My worst ever offender had done 6 months in a bone tumour unit. It's amazing how virtually every procedure has a bone tumour link, if you try hard enough.

4. Tiredness

Actually, I've never had this happen to me, but there have been occasions when during a busy on call the boss asks the trainee if they'd like to do the case and they reply, something on the lines of "not really, I'm pretty tired". It may be true, it may even be 'prudent' (on dubious safety grounds), it may have the virtue of candour.

However, it is highly unlikely to make your boss admire you more.

5. Not taking advice (or instruction, as it's otherwise known)

If I say to the trainee, this ankle fracture would benefit from a stronger plate such as a  DCP on the fibula, and a syndesmosis screw (a real example), it is only in part a fascinating clinical discussion. It is also a not-very-coded instruction to actually do that. When the postop X ray shows a third tubular plate and no syndesmosis screw, it creates mysterious feelings of anger and disappointment. When, on questioning, the trainee says that they did it because an even more junior trainee said "that's all it needs", these feelings well up and may lead to unpleasantness.

If you decide not to follow instructions, then let your boss know at the time. Another interesting discussion will ensue.

5. Economy with the truth

A phrase which reached maturity in the heady days of the Thatcher era. It does not sit well in clinical practice. An example will suffice:

Trainee arrives late for the first theatre case, but seems to be expecting to do the operation...

"Why are you late?"

"I was at the trauma meeting"

"I didn't see you there"

"I was on the ward"

"Oh, what was Mrs Smith's last haemoglobin?"

"...er...12.5"

You know where this is heading. The wretched trainee had not been in the trauma meeting, on the ward, or seen Mrs Smith. There is no need to lie, as it's normally called. But once you do, you will easily be found out, if your boss can be bothered. Your card is marked. You now have a (deserved) reputation. Being late is a far lesser crime than lying.

6. Picking on underlings.

One Saturday night, in the middle of a weekend on call, a Junior House Office (F1 doctor in today's money) knocked on my office door, and was weeping profusely. She stated that she'd had enough, and was quitting medicine. This had two effects on me at the time. One was a genuine sympathy given the real distress that she was feeling. The other was the annoyance at being landed with a problem of this kind at the wrong point in the week. What had happened to her?

Well, as is often the case in acute surgical practice, a patient had become profoundly unwell postoperatively. I forget the details at this point, but she'd struggled with both diagnosis and initial management, and had called the registrar, quite correctly. He quickly sorted things out then had a go at her, concluding with the stinging rebuke "you nearly killed this patient", which wasn't remotely true. He had major self aggrandisement traits, average surgical skills, and a tendency to be jovially matey with the consultants. Wrecking his colleague's week was meat and drink to him. It wasn't the first time.

Another example. The urology registrar wanted the image intensifier for calculus removal, fair enough.  However, the radiographer was just about to start a hip fixation, and the urologist wanted to get home (this was a Saturday morning). His next tactic, with the 'lowly' radiographer? "If my patient suffers because of this delay, I'll make sure that you're sacked!"

I had no idea the lad had so much power. Typically though, when I phoned him to point out his 'behavioural issues', he turned into full grovel mode, and claimed he was just worried for his patient. Of course he was.

As the saying goes: The same people you misuse on the way up, you'll meet up with -  on the way down




7. Not visiting the bedside.

This got a whole post devoted to it. The problem is getting worse. Recent examples include: a patient with back and leg pain, previous disc prolapse and intermittent difficulty in peeing. The neurosurgeon, busy playing the odds, said at the end of the phone "doesn't sound like a cauda equina problem". He didn't come to see the patient. Another: possible necrotising fasciitis (treated mortality ~ 25%, untreated mortality ~ 100%) in an oncology patient (not an 'orthopaedic' problem in our hospital), the plastic surgeon said "it's cellulitis", we're not seeing it. Ho hum.

Read the post.

8. Complacency.

In the UK, if you get an orthopaedic training job in what is called 'run through training' - for which the competition is fierce - then you're set up for 8 years, barring death, emigration, imprisonment, or possibly, these days, a new career in reality TV.

This happy state does have some negative consequences, however. Here's just one example. In the days when you had to reapply for a job after three years you might be trying harder to impress. In my case this would mean that after two years as a registrar I would (reasonably) expect a trainee to know all the common fracture classifications, apply them, and discuss the 'classic' papers (eg femoral nailing: 1, 2), plus the most recent journal stuff of note. That will all come from self learning, which with the internet is easier than ever.  And it does happen, sometimes. Often as not though there'll be blank looks at the trauma meeting. People tend to view this stuff as exam preparation - which it is - as opposed to helpful in practice - which it is as well.

Complacency actually stops people from discovering what a treasure trove the published literature - old and new - actually is. If you don't know the Lauge-Hansen classification after two years of training jobs, you are officially complacent.

9. "Yes, I know how to do this"

Actually quite a nuanced complaint, raised by an esteemed colleague. When a trainee is starting out with a new boss, however experienced the trainee is, there will still be things you can learn (good and bad). Therefore when, at the start of your first lists together, your boss says something like "can you do a knee replacement", an answer along the lines of "yes, no problem" may in fact be counterproductive. Particularly if the boss is fairly expert in the procedure.

Far better to say that yes, you've done quite a few, but there's always stuff you can pick up, and it would be great to assist in the first instance, to see how the boss likes it to be done.

A small distinction, you might say, possibly even pandering to someone's surgical ego, God forbid. But one of the greatest virtues you can take into your burgeoning surgical career is humility. For lots of reasons.

10. Ingratitude.

The state has probably trained you in medicine to the tune of about £250,000 (for UK readers). After that you've been paid well, with years of job security,  and you are possibly on the way to become an actual expert, courtesy of the taxpayer. People have let you practice on their bodies, potentially to their detriment. Unless you royally screw up, the chances are that you'll have guaranteed and well remunerated employment - with a handsome pension, paid sick leave, study leave, maternity/paternity leave, parental leave - for 20-30 years.

Not bad, eh?

So when you reach the consultant pinnacle, it doesn't look that great, when you either:

a. Declare that you don't do procedures X, Y and Z, even if they work and are needed in the population you serve, because you only want to do procedure A. This is often dressed up in a spurious 'safety' argument. It is a common example of entitlement, a harbinger of troubles to come.

b. Disappear into private practice.

Seriously, spend a few years honing your general skills, getting peer credibility and respect, and gradually establishing an authentic subspecialty expertise. It's only fair.

...this is what it was like in the 1980's, kids...

Lessons from the movies - how to be a consultant surgeon

When the more senior trainees approach me, as they frequently do, seeking my advice on how to behave as a consultant, I can offer no greater example than this early training film**:



Of course he's a dinosaur, completely out of touch with the modern world - the labs haven't done the bleeding time for years.

**under no circumstances should you base your practice on this other movie.

PS: thanks to my Greenock colleagues for the recommendation

The midnight hour

Even with the lousy anti-training New Deal foisted on the medical profession by the BMA and their dweebish unclinical negotiators, junior doctors - if the term is still permitted - can still end up doing a true on call, rather than shifts, and can still be called in in the middle of the night.

It seems not to be like it was however, and in many ways that's a good thing.

In the early 90's, before we had consultants in Casualty (which became A&E, now Emergency Medicine, these guys are very into semantics), patients still survived. I do welcome senior Casualty/A&E/Emergency Medicine presence, and I'm sure it's saved a few lives, though there can be a downside in terms of ownership of the case and the early decision making. But I digress.

It was correctly recognised that having a raw untutored SHO trying to resuscitate two polytraumas on his or her own, waiting for the cavalry to arrive, was not ideal. I've been there, it was pretty tough. So in my hospital we instituted the 'Trauma Bleep'. The deal was that there were three pagers held by the senior registrar in orthopaedics (me), the senior registrar in general surgery, and the senior registrar in anaesthetics (the important one, though I hate to admit it). If the bleep went off, you went straight to Casualty, no questions asked. It worked over many miles, so there was no escape. In any event, there were no mobile phones then, if you were out and thought you'd call in to see if you were really needed.

Most of the calls were not that critical, plenty of low grade stabbings that barely made it through the dermis, but there were still quite a lot of people who benefited from rapid resuscitation, airway security and all that. It coincided with the emergence of ATLS in the UK and the whole thing was really a big step forward in quality.

However, it could be bruising. My worst night I went in (a 6 mile round trip, so not too bad) at 11.30pm, got home at 2am, in again at 3am, home at 4.30am, in again at 5.30am, home for a shower at 7.30, staggering in to work for a full day starting at 8.30am. None of the cases was major trauma, but we were there, just in case.

You have to be at the bedside/trolley side to properly assess things, and it's a dying art.

I'm not recommending a return to that, but I still do on call from home, and I still go in. It's easier now as a consultant - much easier in fact, for various reasons - than it was 10 years ago and 20 years ago, when we were always having to go back in.

All this is a long winded preamble to a piece lifted in its entirety from the magnificent GomerBlog, which is mostly written by frontline clinicians. You can always tell....



On-call ophthalmologist heroically manages eye emergency from bed

DES MOINES, IA – Answering his phone in a daze at 2 AM last night, on-call ophthalmologist Reece Barnett reportedly handled a vision threatening eye emergency from the comfort of his nice warm bed.

“It was intense,” says Barnett.  “At first I was propped up on one elbow when I answered the phone. Then the emergency doc told me the patient had severe vision loss.  At that point, I sat straight up in bed with my down comforter only covering my legs.  I started getting a chill, but you gotta take these things seriously.” 

Barnett was able to listen to the patient’s history in between yawns, occasionally having the consulting doctor repeat things while he rubbed the crust from his eyes.  After several seconds of thoughtful consideration, Barnett thought it would be best to see the patient in clinic in the morning.

“This was a tough situation,” reports Barnett.  “By the end of the conversation, my sheet was all bunched up and my pillow was flat in all the wrong places.”  When asked why he elected to see the patient in the morning, Barnett replied, “By the time I get out of bed, get in my car, drive all the way to the hospital and see the patient, it will only be a few hours until morning anyway.  This is the best thing for the patient.”

At press time, Barnett was seen coordinating care for a patient with ocular trauma while wearing his eye mask.

I don't want to just pick on the eye guys, when did the on-call (and paid for it) dermatologist/breast surgeon/nearly all physicians/psychiatrist last come in at 3 in the morning?

It's bad enough trying to get a bedside visit during the day**.

**there are of course many honourable exceptions to this genuine and somewhat alarming trend

Celebrity trauma: Deniz Tek

Deniz with Iggy

In a bland era of X Factor music, you need someone like Deniz Tek. As the great man put it, talking about the onset of punk, following what he calls the 'post-hippie malaise period' of the early 70's (I remember it well):

At last, somebody getting back to basics. You compare it to maybe one or two years before, everybody’s listening to a triple album by Yes called Tales from Topographic Oceans, and if there’s anything more boring in the world, you’d have to tell me about it. That was just the epitome to us of the dreadfulness and horror of what music had become, and it was a breath of fresh air when these New York bands started blowing all that away.

There's a lot out there on this polymath, but put simply, if you like punk, metal, surf music, and the darker edges of those, like fellow Australians (sort of) The Saints playing Nights In Venice, then you'll love Tek and his awesome band, Radio Birdman. Or as this website said, he’s the “axe-wielding rock soldier commanding the legendary Radio Birdman blitzkrieg”, which is about right. Think also Stooges, MC5 (both bands were his buddies), Blue Oyster Cult, early Alice Cooper etc. Halcyon days.

But why am I writing this? Most orthopaedic surgeons these days seem to listen to Ed Sheeran or U2, who make the previously mentioned Yes seem like the Sex Pistols. The above named bands are the antidote.

Well Tek is different. When he was in his band in Australia (he's actually from Michigan) in the 70's he was studying medicine at the University of NSW. He got the textbooks out on tour.

In the 80’s he joined the US Navy, based in Hawaii and ended up as a flight surgeon organising medic evacuations, major trauma protocols and delivering emergency care all over the world, in all climates. His radio call sign actually was Ice Man.

He subsequently went on to run an Emergency Medicine service with a lot of trauma in Montana, and now combines music with painting, writing and doing EM work part time in both the US and Australia. You thought you had a complicated life?

Here he is on the professional medic/rock musician dichotomy:

"usually if it's a busy shift or there's heavy things going down I don't think of anything else until the shift's over. The other thing is you can compartmentalise and whilst I'm taking care of sick people music doesn't intrude. I think that in aviation there's a lot of value in that also. Guys that climb into the cockpit of a jet have to be able to leave their family problems behind. Y'know...the wife's goin' out with someone else or the kid's on drugs. They climb into that cockpit and if they don't do everything exactly right they're gonna die...and may be kill other people too.

One of the requisites for that is to totally compartmentalise your mind.  They screen pilots for that ability in psychological tests. If you're not that sorta person...you're just not right for the job."

Fair point - ever had the stress-inducing bleep about a family matter when you’re  in the middle of a long operation? Compartmentalise!

His website is excellent on many levels, but I particularly commend this tale of being called out to a military plane crash in Arizona. Even the Guardian likes him.

He gives career advice too:

"Any encouraging words to the young kiddies?


Work hard at whatever it is you like to do. Nothing worthwhile comes easy. And stop complaining."

Old farts strike back: surgery and bible edition

...obviously not ALL the old stuff is good

If I may get biblical,  from the Book of Job, 12:12 - With the ancient is wisdom; and in length of days understanding.

With this in mind, although I've nothing against him personally, when I'm urged to read Atul Gawande's books about aspects of surgical practice, particularly outwith the technical skills, I wonder what makes him such an expert.

Here's the evidence:

Qualified in Medicine at Harvard in 1995 aged 30
Master of Public Health degree in 1999, then 6 years of residency training in surgery - ie. junior doctor acquiring experience - till 2003.
He spent quite a bit of time from the late 80's involved in writing magazine articles and working in Democratic politics.

His first book, Complications: A Surgeon's Notes on an Imperfect Science, came out in 2002, when he was still a junior doctor in training, far from the finished product. The next one Better: A Surgeon's Notes on Performance, was released 5 years later. I assume he'd been busy in clinical practice for this time, with possibly some of the previously noted extracurricular activities getting in the way occasionally.

An NHS consultant surgeon, 5 years in, working in a busy hospital is, in my view still very much on the learning curve. 'Surgical maturity', I would say, is at least 10 years in. Some people never get there.

Gawande's Wiki entry implies that from about 2009 onwards he was doing more and more non-surgical things, fair enough, he seems an interested and accomplished fellow, but I feel very strongly that the way you get better in medicine is, I'm afraid, long hours, year in year out, in the wards, the theatres and the clinics. It's a lifelong thing, even if - as I do - one has plenty of other interests.

One of the classic scenarios in the NHS is the consultant who having got to the top - as it was perceived in the old days - realises that he or she wants to get out. Often 'management' and 'governance' are the dubious beneficiaries of their career move, which amazingly usually involves telling working clinicians what to do. Not that I'm accusing Gawande of that, but some individuals closer to home, certainly.

Anyway, this preamble is to praise the benefits of long, hard won clinical experience, especially of the surgical kind. There is a significant difference between prescribing a drug - which could do harm - and opening someone up with a knife, which is intrinsically harmful before it gets better, even if everything goes well.

Is there a plausible alternative to working the hours? I think not. Don't get me started on the world of 'simulated surgery'.

All of which brings me to a fascinating interview with both Stephen Westaby (69), heart surgeon and Henry Marsh (67), neurosurgeon. Both have a public profile, both have performed thousands and thousands of challenging high end operations, for the NHS. With respect to the aforementioned competition, these are the guys that I want to hear from. They've also written books for the general public, as it happens.

There are numerous gems in the interview, here's some tasters:

HM:  We have this very complex relationship with patients. It’s not one of straightforward altruism at all; it’s a very difficult relationship. You have to be both hard and soft at the same time. You certainly don’t want to be empathetic. If empathy means you actually feel what your patients are going through, actually . . . you can’t do it.

...the problem is you could spend the entire national income on healthcare and everybody still dies — there is 100 per cent mortality — so you have to decide somehow where to set your artificial floor on that bottomless pit.

...[When he was PM] David Cameron made this speech about we must have “zero harm” in the NHS, which struck me as the most incredibly stupid thing to say because it suggests that when anything goes wrong, therefore somebody’s to blame. The whole point about medicine is it often goes wrong. The decision whether to operate or not, to recommend an operation or not, is all about probabilities, and these are very subjective, difficult judgments. Everything we do is in the face of uncertainty and a lot of the time patients come to harm. It doesn’t necessarily mean that anybody’s at fault. So I thought that was a very, very naive and rather silly thing to say.

SW:  The job is difficult enough without having the press and everybody else on your back. A British heart surgeon had the idea when he became the medical director of the NHS that surgeons’ death rates should be published and available for the newspapers. Let me ask you: which surgeons would have the highest death rates, the worst ones or the best ones? The best surgeons attract the worst patients like a magnet. So if you want to make your best surgeons defensive, you start counting the bodies and putting it into the public arena. My particular branch of the profession is now risk-averse. Fewer heart surgeons want to come to Britain to do heart surgery and the British especially don’t want to do heart surgery. They’re long operations, you can end up operating all night, every day of the week, and it’s taxing and it’s rotten when people die. It’s totally rotten to have to go out of an operating theatre and tell a couple of young parents that their baby’s just died on the operating table. It’s misery. None of us lose patients because we’re careless or don’t care. So I’ve seen my profession wrecked, I’m afraid.

HM:  Forty years ago, the power structure in hospitals in this country was very simple. There was a senior doctor, a senior nurse and one manager, and basically the hospitals are run more or less by the senior doctors, for better or for worse. Now you have a whole series of competing pyramids. The management, the doctors, the nurses — more or less autonomous now — the other paramedics and physios and people like that, so there’s a real sense of nobody being in charge. I would go to work in the morning and I wouldn’t know what I was going to do that day because it all depends. Is there a bed? Is there an intensive-care unit bed? Is there a bed on the high-dependency unit? You have to negotiate with each of these individual power structures, it’s deeply chaotic

...Another example is that, after the Stafford scandal [over nursing care] and the Francis inquiry [into it], the General Medical Council wrote to all the doctors saying that when a mistake is made you must apologise and then it said that this is usually the duty of the senior clinician; in other words, whoever makes the mistake, muggins here has to go and say sorry. And then thirdly it added that for an apology to be meaningful, it must be genuine. If the GMC can’t see there’s a problem here — if an apology is compulsory, how can you force it to be genuine? Well, the answer is that it is genuine if the senior doctors have a sense of authority, if they feel they’re trusted and then they do feel responsible for what happens in their department.

Just superb, and not calculated or self-serving, simply real world experience of something very important. Westaby's line "The best surgeons attract the worst patients like a magnet" is very very true.

I'm also ending with a bit of biblical advice, Jeremiah 6:16 - put yourself on the ways of long ago and enquire about the ancient paths: which was the good way? Take it then, and you shall find rest

Trainees, your aged consultants will guide you in 'the ways of long ago'. Catch them before they retire.

The earthquake dislocated my hip replacement

When I was training, one of my distinguished bosses, an academic, used to tell me about one of his trainers back in the 70's who used to listen to the occasional patient in the clinic who'd not had a good outcome. He'd acknowledge their unhappiness, and indeed, empathise very effectively. When the frustrated patient eventually left the consulting room, he'd turn and face his registrar (my boss) and say sadly:  "funny fellow that".

The moral of the story - as it was emphasised to me - was never blame the patient.

Own your own mistakes and bad results. Be brave, dig deep. Good advice, I suppose.

Later, as my boss approached retirement, he'd show me an X ray - often of a knee replacement who'd got some residual pain - and say something like "I can't see much wrong with it. He's a strange fellow though. You never succeed with people like that"

For any one case he may have had a point, but he'd forgotten his own advice. Never blame the patient.

So blame can be an issue. Not in the medicolegal sense, more in terms of peer respect and apportioning embarrassment. Maybe that patient fell because your hip replacement dislocated, rather than your assertion that it dislocated because they fell. We're only human after all.

So in the spirit of making excuses for cock ups, I give you a short video of a  handy set of excuses for the next time you have had a hand in a surgical complication.  One of them will apply, I'm sure.

The 654 year old surgeon

The oldies we quote are usually Hippocrates, Galen and folk like that. Here is a new one for me:

Guy de Chauliac makes some good points. It gets a bit tricky towards the end for some surgeons, perhaps. He appears to have been an early proponent of simulated surgery or skills labs, according to Wikipedia:

 "It was seemingly from books that [Chauliac] learned his surgery.... He may have used the knife when embalming the bodies of dead popes, but he was careful to avoid it on living patients".

Dead popes can't be easy to come by.

Bearing in mind the bafflingly poor knowledge of anatomy in UK undergraduates now, he makes another observation:

"A surgeon who does not know his anatomy is like a blind man carving a log"

I've assisted at operations like that.

Probably not peer reviewed. 

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!

Old farts may be correct shocker!!

From a recent BMA News (normally awful), presented without comment, other than to say: good points, well made.

True dat

Our orthopaedic ancestors

Could you think up an operation like this?

There are an awful lot of very good surgeons about these days. And of course we all consider ourselves at least slightly above average - I know, a statistician's nightmare - but how many great surgeons, or surgical pioneers are there?

Answer - not many.

So when you meet these people, or more probably, when you work with one of their previous trainees, you should cherish it and realise that you are indeed the recipient of significant accumulated orthopaedic wisdom. It is a privileged position,

In my own case I worked with Colin Howie, who worked with Robin Ling (Exeter hips for young readers), and I learned a lot. I also worked with David Rowley, who worked with Reg "not quite a genius" Elson, who worked with the ne plus ultra of hip arthroplasty, Sir John Charnley. In addition, David Rowley worked with John Insall on developing the next stage of the enduringly good Insall Burstein knee replacement. These are not negligible figures. I learned hands from John Dent who worked with Harold Kleinert  and  Graham Lister. I worked with Jimmy Innes who'd been a colleague of Marvin Tile and Robert Salter. I learned  a lot of trauma surgery from Jeremy Martindale, who worked with Chris Colton and the whole AO group. My own AO course involved Alan Apley (possibly the most natural teacher I ever heard speak), Maurice Muller, Hans Willenegger, Tom Ruedi and many more. I'm old enough to have met and heard lecture Bernie Morrey, Emile Letournel, Allan Gross, Gus Sarmiento, Charles Rockwood, Reinhold Ganz (a legend), Derek McMinn and quite a few others.

None of this makes me as good as these guys, but they are 'names' for a reason. Of course, I also worked with several outstanding surgeons who may not be quite as storied, but are just as great as surgeons, mentors, colleagues and teachers,

My point is this - treasure such encounters and listen to the details, the 'small print' of their lives and careers. They are potential treasure troves that will benefit you and your practice.

Most recently I met Diego Fernandez, the multilingual Argentine working in Switzerland, now in his seventies, and still working hard. He was charming and friendly - not everyone of these big names is -  and gave a marvellous talk on his life as a surgeon. Clearly brilliant technically, the unspoken messages were: be humble, think laterally, retain an interest in general orthopaedics, commit to a problem case, and have other facets to your life - in his case, incredibly, ocean surfing, still. Also, don't retire if you don't want to.

I mention Dr Fernandez partly because of this recent encounter, but also because of his influence on my practice. Let's face it, most of our reading - BJJ, JBJS, CORR, JArthroplasty, J Trauma etc etc - contains papers of some interest, but only very rarely something that changes one's practice. At the end of this post is Diego Fernandez' outstanding and exceptionally original paper on correcting post-traumatic problems of the distal radius, and doing it properly (ie. anatomically). Simply outstanding, and I use these techniques to this very day.

Graham Lister's comments at Harold Kleinert's death are what we would all like to have said about us, as surgeons and trainers: he had a profound effect on me as a person, on my career, and on how I approach the many problems we deal with in our discipline.

Cherish your orthopaedic lineage!

GO A S Y P

Here's an edited email from another specialty about a patient with an ischial pressure sore. There are no patient or doctor identifiers. The writer of the email had not seen the patient concerned.

Thank you for your email. I have discussed this with the registrar who received a phone call  from a Foundation doctor regarding this patient.

Note the sniffy tone. What was the F1 doctor meant to do? The specialty concerned refuse to carry pagers, and are routinely a hassle to track down. The point of all the specialties being under one roof - which is called 'a hospital' -  is undermined by such difficulties in access.

Advice was given with regards appropriate dressings, ensuring good nutrition (albumin of 21 is not optimised) and appropriate pressure relief with mattress, cushion, turning, etc.

As the ward nurses concerned said to me: "appropriate dressings and nutrition! Brilliant. We'd never thought of that". Furthermore, the patient was verging on being morbidly obese. Malnutrition was not an issue. Isolated albumin results are not the gold standard. This was an obvious 'end of the bed assessment' point.

He also made it clear that we do not routinely operate to close pressure sores, and would certainly not do so in the presence of osteomyelitis.

This was not requested. The specialty concerned are just one part of the appropriate multidisciplinary input the the patient needs (and can reasonably expect). A bedside review would be the obvious first step

I have reviewed the recent MRI scans, which show destruction of the ischial tuberosity and oedema of the surrounding muscles.

'destruction' suggests something dramatic. In reality it was typical superficial osteomyelitis at the base of a sore. The ischium was essentially intact. MRI is very sensitive and needs to be interpreted with care

He should continue with dressings and antibiotics. The pressure sore will never heal unless the osteomyelitis is adequately treated.

The first bit is misleading,  he definitely needs an operation, which is why the second bit is true. Established osteomyelitis is not treated by antibiotics without surgery. If there's pus, let it out (the old ones are the best).

As it turned out, the pressure sore was excised and the osteomyelitis debrided back to healthy bone, there was plenty of soft tissue to allow a tension-free closure, so there were no secondary soft tissue reconstructions needed. This was exactly what could be expected from even a brief visit to see the actual patient. 

Hence the title, GO A S Y P  or 'goasyp' to keep it catchy. Go and see your patient.

This is not picking on any one specialty - we are all capable of making this mistake. I don't, to give a common example, think you can properly assess an acute abdomen without a bedside assessment. In that example and in others more orthopaedic, like possible compartment syndrome, it may easily need several such visits. That's your job.

Once the problem has been referred to you, it becomes to a variable degree your patient. Act accordingly. When was the last time you let Kwikfit sort out your car over the phone?

Being easily available (why do people not want to carry their pagers - mobiles are no substitute?) makes a huge difference and will enhance your reputation.

This is not just  kind and humane - the patient always appreciates a bedside visit - but how the hell can you make a key decision without all the relevant facts? You can't, at least not consistently. Relying on data from your work PC instead is part of what I call Google Medicine (more another time). Anyone can look stuff up. It is not equivalent to taking a history and examining your patient. How could it be?

Not only is this advice good for the patient, it is good for you too. It will protect you when if, one day, there is a clinical mishap because of advice given over the phone or by email, though there had been nothing stopping you from actually doing what every doctor since Hippocrates has been routinely taught.

GO A S Y P !!!

....old school (in every way). Note that the surgeon is at the patient's bedside.

The Germans have a word for it

um....nice screws

There is an orthopaedic 'walk of shame', more literally a walk in the old days before digital X rays, when one had to go to the front of the room in the morning trauma meeting to put up the latest X rays of one of your hip dislocations. Every man/woman and his/her dog will then opine confidently on impossible-to-verify topics such as "your cup is too anteverted on that X ray". Their faces betray no hint of sympathy for your pain, and indeed that of the unfortunate patient. Disappointingly, there may be seen traces of joy. Dislocation, being so blatant on X ray, is probably the best example of this meme.

Thanks guys, I never knew you were all so expert on this.

However, they will regret it.

Many years ago, one of my bosses who was an erudite and witty man, and something of a Germanophile, introduced me to the now ubiquitous subject of schadenfreude. I have seen countless examples since then. If guarded against, it induces the salutary virtue of humility, something all doctors, especially surgeons, should cultivate.

Schadenfreude is a human response, but also a human failing. As Leo Gordon tells us in his vivid example below:

The gods of surgery giveth, and the gods of surgery taketh away.

You have been warned.

Surgery as a zero sum game (Hadden's Law)

This is probably a historical law, rather than one that applies to current orthopaedic elective practice. It fits more with the days when the treatment for hip and knee arthritis was osteotomy and fusion rather than our zinging arthroplasties.

But.....

I have recently been reviewing detailed audit outcomes data from parts of elective orthopaedics outwith our gold standard joint replacements, and it's not such a pretty sight. I won't say exactly what it refers to, but essentially at 6 months and 1 year there's an approximately 30% patient dissatisfaction rate with surgery.

Is that good? Is it better than the natural history of the condition with conservative treatments? The trouble is that we orthopods are very self-critical. Our only rival in the life-changing elective procedure stakes is cataract surgery. A 30% dissatisfaction rate, I would hazard a guess, might be quite a favourable result in some other specialties. Breast implants, anyone?

Anyway, back to Hadden's Law. It is named after one of those rare surgeons who is not only a very fine clinician and operator, but also a mentor, in this case Bill Hadden, now retired, but one of the most humane and likeable surgeons that I have ever met. Neither Bill nor I are sure who invented it but it was he who introduced me to the concept nearly 30 years ago. It's straightforward:

For every operation you do that does good, award +1

For every operation you do that does harm, award -1

For every operation you do that probably makes no difference in the long run, it's zero

If, over the course of a list, a working week, month or whole career you're achieving a slight positive surplus, then you've done alright.

I know, I know, it sounds awful and nihilistic, and if you're knocking in Exeter hips all day you'll be very positive indeed. But look around you: is it completely wrong, even in 2017?

Early neurosurgery. They "all did very well" (thanks to Hieronymus Bosch)

Verify it yourself, get the old notes

How often have you, as a clinician, either been told a dud bit of information - or conveyed one- when discussing a clinical case? We probably all have. It's the equivalent of idle chit chat, which in gossip can cause emotional and other harm, but in clinical care it could kill. Such misinformation has almost certainly lead to doing unnecessary operations, tests etc

I had a patient who kept getting put on theatre lists for 'wound excision and exploration'. He had been labelled as a case of pyoderma gangrenosum for years, by various doctors, including dermatologists. This 'clinical meme' had stuck to him. He quoted it himself. He certainly had intermittent cutaneous sepsis, but PG is a very specific condition, the treatment for which includes immunosuppression, which no-one had quite got round to. It all seemed very unlikely to me. It certainly wasn't a classical presentation.

So I got the old notes - they were pretty thick. The meme had been repeated on many occasions, but never proven. No histology, no test of treatment, yet here he was continually turning up and getting listed for surgery for possible deep infections, with this impressive label stuck to him. The notes told a long and confusing but very helpful story, if you took an hour to read them.

I sent him back to see a new, very thorough dermatologist. No evidence of PG. It turned out to be self-inflicted, AKA dermatitis artefacta. A completely different sort of problem.

Likewise, if you do a lot of revisions (I do), you will encounter plenty of patients who have undergone multiple surgeries - occasionally into double figures - with different implants, approaches, rationales etc. There is no more useful exercise in planning treatment than summarising the relevant old notes and imaging - often going back years - and sending a copy to the GP. Clarity is everything here. It can be extraordinarily revealing. It's one reason why when I first meet a patient with a problem joint replacement one of my first questions is: why was this done, did they ever have painful arthritis in the first place? That may sound daft, but it is incredible how frequently the answer to their dissatisfaction lies in a poor original decision to operate.

So back to our wise surgeon, Leo Gordon. The Four F's are a bit outdated, and there's a mention of something called the World Wide Web, but this is the voice of experience. Get the old notes!

An orthopaedic uncertainty principle

It's not that common for orthopaedic papers to have great titles. There are exceptions though. I always like the sense of existential despair invoked by "The futility of predictive scoring of mangled lower extremities" (a good paper). Likewise, one is inevitably keen to see the X rays in "Late complications of total hip replacement from bone cement within the pelvis. A review of the literature and a case report involving dyspareunia". **

My absolute favourite though is neither peer reviewed nor 'scientific', although it's a genuinely valuable contribution to the specialty: Fergal Monsell's beautifully written "My Journey Into Uncertainty" from BJJ News in 2015, the story of his life in orthopaedics. Possibly the most humble title in any orthopaedic journal, and all surgeons need humility. Not only is it both funny and practical, it contains this gem (he's a paediatric surgeon):

I am also convinced that any operation for Perthes' Disease, DDH and slipped epiphysis is only legitimate if it does not interfere with future replacement of the hip

Terrific advice, if it means avoiding the THR in a 23 year old with a femur deformed by a 'last fling' valgising osteotomy after SUFE.





**In case you're wondering, here's the X ray. Not entirely sure where the dyspareunia came from

*

Surgical teaching and the mating habits of the pheasant

A tenuous analogy, to be honest

As a trainer, Philosophy #1 is tempting, particularly when you're a new consultant.

The trainees in my deanery have pretty full logbooks, and we get trainer feedback that tells us if we're not giving trainee cases. But, there is an unhappy and impractical obsession with some surgical trainees putting operating as a priority far beyond clinical assessment, ward work, outpatient clinics and all the other stuff that doctors - as surgeons, believe it or not are doctors - should be doing.

To be fair the UK ISCP system using work based assessments does make an attempt to deal with this, albeit there's a limit to how much you can bureaucratise clinical work and clinical education.

At the very least Leo Gordon's phrase: awarding surgical responsibility without demanding (such) knowledge sells the resident short. In a greater sense it sells short the discipline of surgery...merits a little bit of contemplation.

And the penultimate paragraph is 100% true.

The same dudes that you misuse on your way up...

Most people would claim to adhere to this, but do you really? I'm not referring to life in general, but in your ward/office/theatre/teaching session.

Apply it to your workplace!

Do you speak to the cleaners? Do you know their names? How about all the nurses, including the students?

Do you ever have a go at the theatre staff? Did it go beyond the necessary correction?

I try to avoid it, but I have done it. Such is the hierarchy of hospitals, and the status and (residual) power of surgical consultants, we should all be aware that a kind word, a personally addressed comment, involving a student nurse in clinical care - there are hundreds of possible examples - may make their day, make them think well of you and might in some way benefit you too.

I know a consultant who asked of an earnest and trembling junior who had approached him, "what grade are you"? The quiverer answered "senior house officer".

"Go away, I don't speak to anyone less than a registrar".

Hmm. Funny in a way, but not good. If you're not nice to patients and their relatives you might end up in trouble. In part it's self-preservation.. It's how you behave with these other people, who can't hurt you, that is the best judgement.

The old claim that "he may be a bastard, but it's worth it because he's a great surgeon" was always rubbish. Great surgeons show greatness of spirit.

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

Revision syndrome

It tends to only be in operations that last more than about 90 minutes. Hand surgeons rarely suffer from it. Acetabular revision and primary joint replacement are usually OK. But be warned, if you're going to start chipping out the femoral cement, do a tumour prosthesis or something a bit challenging/demanding/stressful, then you may well be exposed to this pernicious syndrome.

I understand it. The only person actually having any fun at this point is you, as the main operator. The assistant is in a trance, the anaesthetist has probably 'just popped out', according to the abandoned anaesthetic nurse, but you need, right now, that particular instrument from supplementaries, so you ask for it. The scrub nurse looks shifty and utters the dread words: "you may have to wait a minute, I'm on my own right now".  Many surgeons will be familiar with this. You look around, the circulating nurse has disappeared, the auxiliary is mysteriously absent. Nobody knows where they are.

It was all so different at the start of the operation, the theatre was crowded, a herd of students grazed quietly outside the laminar flow, there was a subtle sense of anticipation at doing 'a big case'. Now, all gone. You're alone. Ten minutes is added to the procedure by the time the instrument has been located and staff have drifted back.

It's revision syndrome. True, it is eventually self-limiting, but boy, is it annoying.

My theatre