To Be Or Not To Be...

An article by Mr David J O'Regan, Director of the Faculty of Surgical Trainers (FST)

My archetypal Victorian-like grandmother, barely five-foot with significant dropsy, could confirm that I always wanted to be surgeon, ever since I was six years of age. I cannot identify the source of that conviction, as there was no family history for an anchor or role model.

Medical school gave me an insight into surgery that affirmed my convictions. There were many colourful characters like Mr Brice – a neurosurgeon, who delivered amazing lectures and in a flamboyant manner by mimicking tabetic gaits, with such vigour that he hit his head when failing to stop at the wall! The first hurdle was the primary FRCS examination – I failed first time and was asked to come back ‘when the leaves were green’. These are not mythical stores but real. Months of a monastic existence and reading rituals meant that I was invited into the library for the celebratory glass of sherry. The exam was demanding and in a somewhat dispassionate, if not brutal manner, sorted ‘the sheep to the left (exit) and goats to the right (library)’. It was literally a ‘rite of passage’ that was later was crowned with passing the part two examination. An examiner left temporarily to his own devices delighted when if proffered a cosmetic incision for exposure if the jugular vein triumphantly stated that I clearly had never done any neck surgery. He did not appreciate the rebuke and detailed and nuanced description of a partial thyroidectomy – I did six operations as an SHO and knew the pitfalls. I failed. I passed the second attempt at the Royal College of Surgeons of Edinburgh and delighted in the metamorphosis from ‘Dr’ to a ‘Mr.’

Entry and acceptance to the club was iterative. The ‘basic skills’ included learning to talk, walk and look like a surgeon. We had to talk like a surgeon – the most memorable course was delivered by an imposing surgeon who explained why surgeons need to talk without hesitation, deviation, or reservation. He explained the use of language instilled confidence in the team and the patient.  One surgeon instructed me that surgeons ‘walk down the middle of the corridor because the walls were for physicians.’ He did tell me that he only approved of silk ties – I was pleased to answer I only bought silk ties and observed, with wry amusement, his frustration and indignation that Alistair, the senior registrar insisted on a wool tie that was embroidered with an antelope that looked like the Rudolf the Red Nosed Reindeer. Mr Southwood, a very congenial man, epitomised by a radiant smile on a big round moon face atop a morning suit with gold watch pocket, whose written word would be they envy of any calligrapher, asked one day if I had a jacket. I replied in the affirmative and he said ‘excellent – lunch at the club.’ I had made it – ‘The Club’.

Of course, there is the ‘doing’ of surgery. My first list was ‘you obviously know your anatomy, there is a knife. Off you go!’ Learning was literally by doing – I recall a colleague taking two hours to do a circumcision, he realised that this was not for him and left the rotation.  As a Junior Surgeon, I continued to look up – the most immediate ‘anchors’ were the registrars and the, more aloof, the senior registrars.  The registrars appeared to have cultivated that ‘Chelsea look’ – brown brogues, beige flannels, blue blazers, and club ties. Some even indulged in pipes and the quintessential British made sports cars – the Morgan. Certainly, flash cars were popular – GTI’s and the Ford Cosworth reflected the image of life in the ‘fast lane’.  The doctors’ mess partied and celebrated when a Senior Registrar declared that they had successfully done a rupture abdominal aortic aneurysm. That was the pinnacle, the surgeon really can save lives. I do recall when I was a fifth year student in Portsmouth, the consultancy entering the affray of a salvage abdominal aneurysm congratulating the Senior Registrar but picking up pieces of entrails and saying ‘ you clearly had difficulty identifying the anatomy!’ It was however a success, and everyone celebrated as the ‘consultant-in-the-making ie Senior Registrar’ had done it; they had seized their wings!

I relate these quixotic stories as they coloured my image of what it was to be a surgeon. They haunt and distort my recollections - were we brave or were we at best naive or just stupid? The landscape has changed – the age of enlightenment is upon us and the call of duty far clearer. The title on a surgical periodical ‘knife before wife’ explained the high divorce rate - I am a casualty - and the ‘club’ was full of men. 

Work life balance is extolled, but I do question if it is enacted. My cardiothoracic training in the then regarded ‘Parthenon of Excellence’ demanded unequivocal subservience and compliance with a one in one on call rota. We lived and breathed surgery; at the expense of everything else – a second casualty.

I am relieved that the new millennium has heralded ‘glasnost’. I think it should be called a ‘gladnost’ because I do not believe ethos of surgical training in my day was winning hearts and minds. It was not unlike navy seals training and survival of the fittest. 

I am delighted that value diversity and welcome inclusion. I am pleased to look at many surgical forums today and not be able to identify a ‘standard surgeon’. That is because the attributes of a surgeon go far beyond the alluded simplistic action man. Pockets of this Neolithic thinking still exist and receive appropriate scorn for our community when they surface in poorly conceived letters to editors.

There is much more to being a surgeon. The ‘doing’ element is evolving at an exponential pace – I marvel at the skills and the reach of laparoscopic surgery.  I see nano technology emerging and my thinking is literally ‘warped’ by Dr McCoy – what will the future look like and what will we as surgeons be doing? I wrestle with the theoretical, yet probable scenario, that a laparoscopic surgeon may run into trouble and not know how to do an open operation. The ability of the surgeons’ hands to ‘caress tissue and not merely be a hewer of flesh – Lord Berkeley Moynihan’ may be at risk – I do not know but concern is visceral. No matter what the future, I believe healing hands will still be needed if only in the meet and greet of patient and the need for the universally recognised empathetic touch that cannot be surpassed by artificial intelligence. There is a lot more to be human and being a surgeon.

We have peppered the trainee programs with ‘doings’- competencies, lots and lots of them, but are they enough. There are many other dimensions in listening, reasoning, deduction, communication, situational awareness, human factors, and crew resource management. The action of ‘doing’ something to someone else does require knowledge and skill but it also demands courage and conviction. This needs to be balanced with empathy, humility, fallibility, and insight. These attributes cannot necessarily be quantified but most surgeons will recognise the dangerous juxtaposition of lack of insight and ability. How do we address and measure this? The list of recognisable non-technical skills is increasing. They are important. These are the humanistic elements of being a surgeon that beg the question how we teach and instil the elements of being a surgeon. It cannot be done with ‘trial by sherry’ nor will we see the reincarnation of the apprenticeship training. We must think differently because our trainees and the context in which we are training is appropriately different.

So, this begs the question, how do we teach people to be surgeons? The trainee requires role models and anchors that will resonate and guide their own values and beliefs. Our purpose is to serve the patient – since we are all customers every day, the delivery and experience of an excellent service should be visceral. This value is shared although not cognisant or explicit – we are all here to serve.  Good service and good training go hand in hand. Trainees need good role models and must afforded legitimate participation in all clinical environments. As Gill Hardman (RCSEd Trainee's Committee) poignantly stated in our recent webinar, ‘we are all human beings – we all crave to be valued’. Trainees are experts as well – we need to learn from them, and they must be included.

I would be guilty of my own observations if I had answers. I would therefore to like to generate a conversation; I would like to invite thoughts and ideas from you, the reader – what is it to be a surgeon, and how do we teach it? It is clear to me that there is a lot more involved, and therefore we need to identify, nurture and support and recognise the good trainer. Do we need to redefine what is needed to be a good teacher?

Let us know, email fst@rcsed.ac.uk with your thoughts.