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Id Entity

21 January 2022

Id Entity 

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

It was 1983 and we had just moved into our student house for our third year of medical school. The house should have been a condemned property! It was however convenient, as it was situated next Southampton General Hospital. It was unashamedly called The Victory - over what, to this day, I do not know. Summing up the appeal of our new residence was eloquently done by my housemate’s girlfriend on her first visit when she brazenly asked me ‘Oi.. Dave! Where’s the BOG?!’. I find that being called ‘Dave’ is reserved for perhaps only three people in my life and prefer that the ‘id’ is included in David-it otherwise, personally, it feels… funny?

Sigmund Freud introduced the psychoanalytical describing the three agencies of human personality: super ego, ego, and id. The superego in theory is the moral compass and provides standards by which the ego operates. The ego develops from the id and ensures that the impulses from the ‘id’ are expressed in a socially acceptable manner; this is the element that is responsible for dealing with reality. The superego and ego are supposed to keep the ‘id’ in check but not infrequently in our profession we witness that that self-regulation is lost or abused. The competitive environment in which we as surgeons are trained perhaps upsets his homeo-psychological-balance as a ‘dog eats dog’ still prevails and ‘one-up-man-ship’ is tolerated. A career Cardiothoracic surgery sometimes felt like swimming in a pond of great white sharks (aka. Carcharadon Cardiothoracus) when the only time you would see the white of their underbelly (figuratively their ‘id’) was when they were rolling over to take a bite. Fortunately, it is changing but the primeval instinct is still there when there is a smell of blood in the water. It is a sad reflection on our profession, and it is particularly distressing to see this continue today. We are failing ourselves because our inability to respect the ‘id’ in others –‘id’iocy! Our leadership at society and college levels knows this is going on (even in our own back yards) and yet, it appears to be tolerated? Personally, I do not believe one deserves being in a society or fellowship of surgeons if you indulge in ‘one-up-man-ship’ and ‘blue-on-blue fire’ in particular. We are letting ourselves down, notwithstanding, enabling a divide and rule at the micro, meso and macro levels. As a profession we could and should be dictating how we deliver a patient-centric service, but we cannot even agree to adhere to standard operating protocols defined by best evidence. It is not infrequently taken as an afront to the ‘id’ – I know better. Some even believe that their way is better. A perversion of ego and superego often undermines the ability of teams to function as one and fails to drive quality through adherence to rapid PDSA cycles. I was advising trainees applying for consultant jobs and recommended, above everything else, they must be certain they are working with the right people. I am delighted that both have got their dream jobs and I have no doubt that they will succeed, and their units and hospitals will be better off with them in their employment.

According to Freud the ‘id’ is the source of all psychic energy and the primary component of our personality. Furthermore, he suggests that is there from birth. The ‘id’ strives for the immediate gratification of all needs – as in the lyrics of the song sung by Freddie Mercury of Queen ‘I want it now and I want it all’. This would be disruptive and socially unacceptable if not controlled. I think back and recognise this as an anthem of the 1990s. We even sung about it in Christmas shows adapting the song from the Jungle Book sung by that big ape, King Louie – ‘I am the King Consultant, The hospital VIP’. No, they were ‘id’s out of control.

Miyamoto Musashi was a renowned undefeated Samurai warrior who lived in the 1600’s. He wrote’ there is nothing outside of yourself that can ever enable you to get better, stronger, richer, quicker, or smarter. Everything is within. Everything exists. Seek nothing outside yourself. He was referring to the ‘id’ and your mental bearing. The first principle in karate is self-control and the second is to have an indomitable spirit and the third is to persevere. All three can be aptly applied to a career in surgery.

It is described that the most interesting of human studies is yourself and we are urged to complete our allotted task while it is still day. Morihei Ueshiba said that ‘true victory is victory of oneself’. Old martial art masters knew this – they understood that warriorhood meant more than the ability to fight, the warrior had to be able and willing to help people live a better life, spiritually, mentally, and physically. A warrior is one who sacrifices themselves for the good of others. People get hung up in the term warrior as someone who is trained in warfare and fighting. Ginchin Funakoshi said that the ‘ultimate goal of Karate is the perfection of one’s character; – a harmony of the Freudian trilogy. The appropriateness of this ethos to surgery is self-evident. Indeed, in Japan today, Sensei will only accept candidates with good character (id) into their ‘dojos’ and I understand that there are many surgeons in Japan today who have a Samurai lineage. We need to build self-control and development into the way we teach surgery – we do not want to encourage or cultivate the ‘id’ n isolation.

Budo – is the Japanese word for the martial arts way – the objective is to use martial arts to focus your energies on working towards goals in every part of your life to become the best person you can be. To deliver the best you must be at your best. It is sad to read that the basic needs of our trainees are not being met – hydration, nutrition, and appropriate rest. It is further distressing to read on social media that junior surgeons are leaving the profession, after having enough and feeling burnt out. What a waste and sad inditement on the system highlighting a lack of support and a ‘warrior’ code of ethics. Perhaps we could learn from martial arts by cultivating health spiritual, mental and physical attitudes to training. The ‘id’ needs support.

The closing chapter of Michael West’s book on Compassionate Leadership is about Self Compassion. This is not self-esteem or narcissism but the ability to recognise we are human and we do make errors. Failing and experiencing difficulties are inevitable especially in surgery. We need to be kind to ourselves and each other. There is absolutely no place for one-up-man-ship. We need to be able to see ourselves and each other without fear or condemnation or point scoring. We need to be able to accept our ‘id’ and restore the balance and to be able to regulate them. This is necessary for use to grow as individuals and to be able to accept change. The means that we need to recognise our ‘id’ and respect it in others. Perhaps the lessons of Zen and Taoist philosophy could be embedded in our teaching programs and in our surgical ‘dojos’.

I think back to 1983, my medical school days and career in surgery and feel that not enough time was given to ‘id’ nor was this element on any curriculum. I do not see it today. Perhaps it is time we should – the word identity is a unification of ‘id’ and entity. Being or existence, self, team and profession, id-ego-superego: One for all and one for all. Now that is what I would call The Victory.

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