Decisions Before Incisions

“Walpole has no intellect. A mere surgeon. A wonderful operator but, after all, what is operating? . . . . Manual labour.”
― George Bernard Shaw, The Doctor's Dilemma

I am prompted to write this blog following the Faculty of Surgical Trainers webinar on 19^th January 2021 – ‘What makes a good trainer? – the trainee view’. We were exploring the trainees’ perspectives on training. They offer valuable insights into how we can improve the system and how we can improve as trainers.

I was struck by one element. Several of the panel said that the first time they were asked about their clinical decision-making and how they exercise judgment was during an exam. I am in fact aghast that this is the case, and I am left wondering why? What are we missing?

It is said that a surgeon is one who cuts, a good surgeon knows when to cut and an excellent surgeon knows when not to cut.

“My father, for whose skills as a surgeon I have the deepest respect, says, "The operation with the best outcome is the one you decide not to do." Knowing when not to operate…” ― Abraham Verghese, Cutting for Stone

Decision-making and exercising judgement is fundamental to our everyday practice. It is not necessarily the emergency that presents the problem. We can all fall back on our TCUP (Thinking Critically Under Pressure) training, and apply the A, B, C of resuscitation and the principles taught in an excellent course such as ATLS, but even then, this can be challenged by the context. A few ATLS trained doctors took the resuscitation bay at St Mary’s Hospital on the day of the Paddington rail crash. I recall rehearsing in my mind the type of injuries that we could expect from a moderate velocity by high momentum collision (Momentum = Mass (train) x velocity (entering station 35 km/hour). The management of crush injuries and large bone fractures dominated my thinking, but it all went out the window when the first victim was brought in. He was a conscious male in his forties and was burnt black from his head and arms to his waist, front and back – the rules of nines multiply exponentially. Airway monitoring, saturations were immediate, and IV access was not possible in the antecubital fossa. I put long lines in the groin – the first hit the artery but we needed blood gas and the second hit the vein. The exudate and water on the dressings soaked the floor and made it slippery so I called for rolls of cling film from the kitchen. I had read that this was a clean and safe dressing to apply temporarily to a limb. In situations like this we do not step up to the mark, but rather we fall back on our training and experience. This echoes the training of the Navy SEALs.

The most difficult decision-making is when you are faced with something that is not acute. More often than not this is in outpatients, the walk-in side of accident and emergency or seeing the follow-up patients in clinic. The training doctor is often relegated to seeing follow-up patients, particularly if the consultant is absent. I previously surveyed over twenty training doctors and asked them what they would do if a follow-up patient had a problem, and they did not know how to manage it – their answer was that they would bring the patient back in three months. Why three months? – Well, they would have moved on. This still happens. It is a waste of the learning opportunity, a total waste of time for the patient and waste of resources. I do not believe an outpatient clinic should be held if the consultant is not present.

I further believe that the new patient should be seen by trainees of every grade. Staffing of outpatients is always given lowest priority when we are short of staff. Theatres and hands-on opportunities are seized upon first by trainer and trainee and ITU cover in cardiac surgery comes in second. We ignore the fact that outpatient clinics offer unique one-to-one protected time for teaching in the hurly-burly of clinical practice. The trainer can, and should, observe the trainee taking a history and examining (inspection, palpation, percussion and auscultation) the patient. Indeed, I ask the trainee to demonstrate knowledge of the surface anatomy of the lung by watching the placement of the stethoscope. Once I am satisfied that the basic skills are there, I can leave them to see the patient and they are welcome to take as long as they like. The trainee then calls me to either watch them examine or to deliver the history to me IN FRONT of the patient. I always get a better history as I am watching the patient as I listen to the history and can explore non-verbal cues and avenues not explored by the trainee. It is then possible to ask the trainee what they would do and cite the evidence whilst involving the patient in the discussion and ascertaining what matters to them. This is one of the rare opportunities in daily practice to explore decision-making and judgment.

From my experience, it has become a more effective use of my time in clinic as I pop in and out of training rooms. The patient is delighted as they get to see two doctors and the service is optimised as it is front-loaded with the expert. I am delighted to report an over 90% 5/5 patient satisfaction for new and old patients. Good service and good training go hand in hand.

The system must change. This starts with our thinking. I was reprimanded by colleagues for allowing medical students to dictate the outpatient letter – what they did not understand is that the medical student’s dictation was typed up verbatim, and my secretary and I edited the letter. The medical student received both copies for learning and we discussed the letter. I had to remind my colleagues that the name of the hospital included the word Teaching and that the end paragraph stated that the history, examination, and discussion included the patient, and I was present. We also need to recognise the value of outpatients as a teaching setting and give it more priority in staffing. The sign of a failing service is a full waiting room. Patients often give up a whole day, travel far and have the inconvenience of parking to see a doctor but staffing is often undermined by other pressures leaving one doctor and a full waiting room.

Good history and examination followed by an evidence-based discussion, with regular practice in outpatients, is the basis of learning clinical decision-making and honing judgment. We can, and again should, apply the same principles to the bedside, pre-admission clinics with consent, and a pre -briefing discussion to plan training opportunities in theatre. Clinical decision-making and judgement need to be practiced and rehearsed.

If you have any questions or comments regarding this blog post or any previous posts please email fst@rcsed.ac.uk

About the author:

David O'Regan is the Director of the Faculty of Surgical Trainers. He has been a Consultant adult Cardiac Surgeon in Leeds since 2001.