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

!!!!!!???????

This may be a dying problem, particularly if the admonitions of GO ASYP are not heeded.

Have you ever been irritated by a differential diagnosis in the notes, for a basically simple clinical  presentation, such as chest pain:

?angina
??MI
??? PE
???? reflux
?????Boerhaave's
?????? Tietze's syndrome

I could keep adding. It tends to be less of an issue in orthopaedics, rather than acute medicine and general surgery, if only because it's hard to look past a broken femur.

That said, Leo Gordon provides some rich examples, noting the history of punctuation, and the philosophy underpinning this nonsense. More usefully, he suggests punishments for this terrible crime. If I may add a few musculoskeletal essay titles to make offenders think before they do it again:

Discuss the public health debate regarding osteoporosis

Discuss the suggested 'treatments' for osteoporosis, and the evidence for their use

Discuss the similarities between osteoporosis and wrinkles

Discuss Camilla Parker Bowles' public statements on osteoporosis

I could probably find some more. Unlike Leo Gordon, I have fewer problems with exclamation marks, they rarely seem to be used in orthopaedics and trauma. We are a phlegmatic, calm bunch, ordinarily speaking.

However, if electronic records really catch on, I expect to see emojis all over them.  Perfect for that dislocated hip replacement.

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 metaphysics of nursing (part 1)

I am very specific in my clinical instructions. I frequently write them in by hand on the ward round, always in theatre, the drug kardex etc. I speak to the relevant staff. I don't rely on people reading my mind, or following "that's what he always does". There are always important exceptions cropping up: if they already take aspirin I don't want them on rivaroxaban and aspirin; if I very occasionally want 'none weight bearing' I make it clear.

But...

....after a complete, documented and thorough ward round I will frequently get bleeped 10 minutes later to be asked if a patient can mobilise. I will find patients being sent home on subcutaneous heparin injections - which I never do. The wrong consultant's name will remain above the bed despite daily requests to change it. There are many, many examples.

This is one of Leo's funniest matrix lessons, he really gets going in the second half. It touches on metaphysics and welding. It is also entirely true.

Avicenna did not have a phone

It's for you, doctor..

This is one of the great Leo Gordon's finest matrix lessons, which is saying something. It is also a near daily decision that I have to make at the hospital, on the wards and in theatre. You just want to be helpful and after all, what harm can it do to answer a phone? The matrix lesson references Dorothy Parker, and the quotation is not dissimilar to Ogden Nash's line: Middle age is when you're sitting at home on a Saturday when the telephone rings and you hope it isn't for you. Which is, rather pathetically, where I'm at - home and work - most of the time. 

 The list of awful possibilities is a long one. Leo provides some classics, I would emphasise my own pet hates: staff wanting to discuss their off duty; relatives wanting an update on someone who is not your patient; the labs raising a potentially important test result about someone whom you have never met or been involved in their care.

Part of the problem these days in the UK is that in many hospitals bleeps  have virtually been abandoned and random phone calls (and email) have filled that void. Bleeps are good, and it was my fellow consultants who began the trend to leave them in a drawer with the airily offered alternative of "just try my mobile", which doesn't get answered, usually. A good doctor makes themselves available if at all possible.

Which is not the same as answering an unattended telephone.

Sitting Bull

Master the use of this 

When I was a general surgical trainee, learning the ropes, one of the most technically accomplished consultants was a urologist. He'd actually trained as a thoracic surgeon, and unlike a lot - not all I should add - of the current general surgeons, he was completely unfazed cracking open a chest, say for trauma, even if he'd not done it for 5 years.

He gave me two excellent pieces of advice. Firstly, avoid cutting with scissors, use them sparingly, the best surgeons use a knife as much as they can. I still recommend this, although I occasionally permit myself a bit of blunt dissection with scissors - isolating the sciatic nerve for example. I saw him do a nephrectomy very quickly and deftly, without using the scissors once, as far as I can recall. The second piece of wisdom is probably the reason why he switched to urology: always sit down, "as you never know when you'll next get the chance". When he asked me what I wanted to do, and I said probably orthopaedics, he advised me to subspecialise in hand surgery, as "they seem to sit down a lot". He had a point.

We brings me back to Leon Wiltse, who also advised sitting down - primarily to be better at humanising the inevitably hierarchical doctor/patient relationship. A hero of this blog, Leo Gordon, said something very similar, in his usual way, "the most basic of surgical actions":

The wards are not crap

We were happy back then

If you want to get plenty of complaints, or possibly sued, as a consultant, then neglect the wards. If you want to be disliked by the nurses and have ungrateful patients, then neglect the wards. If you want to become the cliche of the 'technical surgeon' obsessed with operating, then neglect the wards. On that last point, the best surgeons also tend to be the most assiduous at ward work and knowing their patients. There are no surgeons who are so good at the cutting stuff that we should ignore their failures in care elsewhere.

If you want to go home content and banish that lingering unease in the back of your mind, then do a ward round.

Here is a very perceptive piece by, God forbid, an anaesthetist on this very topic, one to which I will return.  And note this also:  the best trainees are those who are on top of their inpatient duties