The Myth of being Plastic Fantastic

Some days I am a little sick of the stereotyping inflicted on me as a Plastic Surgeon, so I am here to put all the urban legends  to rest. There are plenty of myths about plastic surgery from both public ignorance and misconceptions established by shows such as ‘Nip Tuck’.
Myth #1 We use plastic.

Once I had a young tradesman whose face was smashed up by the windscreen in a truck rollover. Just before he was put to sleep (and this is after I have spent an hour explaining to him how I was going to put his face back together), he asked me, ‘So doc, where do you put the plastic?’

*Insert eyeroll*

I have lost count the number of times I have been asked that question. Plastic surgery doesn’t mean we play with plastic or put plastic in people. In fact, if we were to use any form of prosthetic device, it is usually silicone. The ‘plastic’ in plastic surgery is derived from the Greek word plastikos. It means to change shape, or to mould. The aim of plastic surgery is to change the shape of any part of your body, for cosmetic or functional reasons.

So, sorry folks, we don’t shove blocks of plastic into people.

Myth #2 We can perform surgery without leaving a scar or we can remove scars

Here’s a couple of frustrating conversations I have regularly with patients every week.

Scenario one:

Me: We have to make a cut around the skin cancer on your face to remove it. Once we stitch it up, it will leave a straight line scar.

Patient 1 (outraged) : A scar? But you are a plastic surgeon; I have come to you to have this done so there will be no scars.

Scenario two:

Me: I hope you have recovered from your fall last month. Your cut lip has healed really well since the stitches came out, it looks great.

Patient 2: I hate it. I can’t believe you put a scar on my lip; I want you to remove it.

Ok people, I know plastic surgeons are incredibly good, but we can’t perform miracles. Where there is a cut, there will be a scar. We can’t remove scars either. If you want scarless surgery, you should have had your surgery done when you were a foetus – that is the only way to perform surgery without leaving a scar. And if you want us to stitch up your injuries, it was not me who had created those scars; it was your stupidity in falling into a window whilst you were pissed.

So what makes us better than others in scarring? We stitch differently to other surgeons, we use finer sutures, we know how to hide and minimise scars. We have techniques which can camouflage or improve scars. We have the knowledge and means to treat bad scars.

So, apart from making people look hot, we can make your scar look sensational too. But unlike God, we cannot remove history which has been carved onto your body.

Myth #3 All we do are boob jobs, facelifts and buttock enhancements

‘I don’t understand why I have to come to see a plastic surgeon to have my skin cancer cut out, it’s not like I want a facelift or something,’ said the man sitting in front of me with a fungating growth coming out of his nostril. Unfortunately, I was the one who had to break the bad news to him, that the cancer in his nose was so big that we would have to amputate his nose. Any surgeon would be able to remove his cancer, but he would be left with a hole in the middle of his face. The reason he needed a plastic surgeon was because we can remove the cancer and reconstruct his nose.

The acronym for our specialty is actually PRS – it stands for Plastic and Reconstructive Surgery. There are two components to our work:

Reconstructive surgery: which is surgery to improve and restore function, to minimize disfigurement and reconstruct structure which was lost due to trauma, disease, cancer or birth defect. Basically, our job is to fill up a hole anywhere on the body. Sometimes we excise tumours ourselves, but often we work in tandem with other oncological surgeons such as orthopaedic surgeons who resect bone and soft tissue tumours, ear nose and throat surgeons who resects tongue, nose, throat cancers, as well as breast surgeons who perform breast cancer surgery. The way I see it is that my oncology colleagues are the ‘destructive’ surgeons and I am the ‘constructive’ surgeon. I remember when I first started training I was hesitant as to how much margin to take around a tumour. My supervising surgeon took me aside and said, ‘Just remember, Tiff, the reason you are going to be a plastic surgeon is because you are not afraid to make a big hole. Unlike other surgeons, you can fix holes.’

Aesthetic or cosmetic surgery: which is surgery to enhance, or to rejuvenate a specific body part, it is designed to improve a person’s appearance by reshaping facial or bodily features. So yes, we get a chance to make people beautiful. We make boobs bigger, smaller, perkier or firmer. We lift up butts, thighs, arms and faces (not specifically in that order). We inject, insert, eliminate and suck to enhance contours. There has not been a single part of the human body that a plastic surgeon has not attempted to alter, although I gladly admit that I have had no training or experience in anal bleaching – nor am I interested in expanding my field into that area.

Myth #4 Our work is frivolous and we perform non-essential surgery.

As my husband (who is a heart and lung surgeon) sums it up succinctly, ‘Honey, I save lives, you just make the world beautiful.’

Even though spoken in jest, unfortunately it is a view held by many, including hospital administrators, insurance companies and sadly, our colleagues in other specialties. I have had medical students who did not attend their plastic surgery sessions with me at the clinic because they feel that it is not something they need to learn about. I was once told by a second year student that plastic surgeons are not real surgeons who practice ‘true medicine’.

People seem to forget that plastic surgery is not just about cosmetic surgery, but that the most important aspect of our role is to improve a person’s self esteem. No matter how much the self-help books may claim about not placing too much importance on one’s appearance, and to stop using your looks to determine your self-worth, the reality of life is simply – people do judge you by the way you look. And that includes yourself.

It is amazing the difference we sometimes see in our patients. Like the 12-year-old boy who was constantly teased at school for his bat ears – he got it fixed before he started high school. He became a completely different person; he happily went to the barber to have him shaggy long hair removed, started going out with his friends and strutted into my office at 8 weeks postop as if he owned the world like a typical 12-year-old boy. My favourite last month was a 30-year-old mother who had a nasty burn scar over her neck and chest from a childhood hot-water scald. The scars stopped her breasts from developing properly and distorted whatever little breast tissue that did develop. After surgery to correct the deformity and implants to provide shape, she swapped her oversized jumpers for tailored dresses, and started becoming more involved in mother’s groups. She wore a pink singlet with a pearl pendant dangling in her new cleavage when she came to her appointment, despite the visible old burn scars which covered her neck.

Surprising it may be, we do perform surgery that saves lives and limbs. We are often called upon to join small blood vessels under the microscope for organ transplantation in children. We reconstruct the neck after throat cancer, so that the patient can still eat, drink and breathe. We put fingers back on after they have been accidentally severed, and we transplant soft tissues into smashed up legs that otherwise would have had to be amputated.

Unfortunately our work often goes unrecognised, as throughout history, we have had to repeatedly fight for our patients’ right to access plastic surgery. When hospitals have budget cuts, our operating lists are often the first to be cut. Breast reconstruction after cancer was the last one they slashed from our hospital, because once the cancer has been removed, it is no longer considered life-saving surgery. Health insurance companies which exclude plastic surgery cover leave their members with a policy which pays for the cancer removed, but not the plastic surgical procedure to reconstruct or repair the hole.

Admittedly I sound like I am trying to justify our existence, but I truly believe that even though we are not saving lives every day, our work makes a siginificant difference in people’s lives.

Myth #5 We date our patients

There seems to be a misconception that we fall in love with our creations. I explored this particular issue with my male colleagues. The answer was a categorical no, although they have had plenty of invitations from patients to cross that line. Not only is it ethically wrong and fraught with medicolegal implications, it is also rather disturbing that someone would fall in love with an image they have created, which may have nothing to do with the actual person underneath.

Myth #6 We make lots of money because we charge ridiculous amount of money

I am not blind to the fact that as a plastic surgeon, I am often the target of many sarcastic jokes about money. This not only comes from patients, the general public, but sometimes our own colleagues in the medical fraternity. When I was sitting my specialist board exam, one of the candidates for general surgery taunted me, ‘I think your essay question would be on whether a Maserati is better than a Lamborghini.’ I was not shy to show him the finger as I sweetly replied, ‘well, I do hope you know the answer to your essay questions, which hole to put your finger up.’

Once I was leaving work, and one of my patients walked past me as I was putting my bag into the boot of the car. He took one look at my ten year old Toyota Corolla and shook his head. ‘Oh, doc, you need to get a new car, people would think you are not very good if they see you driving that car.’ I just shrugged and said, ‘Don’t worry Mr B, I leave my Ferrari in the garage for weekends.’ At his stunned look, I had to tell him I was joking.

It is not uncommon sometimes for our patients to comment on the cost of surgery, especially if it involves cancer surgery. For some reason people seem to think that we should do their surgery out of the goodness of our hearts if they have cancer….. but that’s another story altogether. One of the reasons that plastic surgery costs a lot more money than most other surgery is the rebate from health funds are low (because our procedures are not deemed to be a necessity), but also our practice has a lot of overheads, especially with wound care, garments, implants and dressings. We also employ a greater number of staff than other specialties, because there is a lot more patient contact time pre and post operatively. Plastic surgery patients and procedures are more complex to organise, and often requires various number of phone calls and coordination. Not to mention, our patients are usually high maintenance and requires constant reassurance.

Yes, some of us drive Aston Martins, stay at 6 star hotels, wear Gucci and walk in Louis Vuitton, but we work hard for it, and our responsibilities may not be life and death, but there is still a lot of stress involved in our surgery because we know the end result will have a life-long impact on our patients’ life.

Myth #7 We drive fast cars, hang out with celebrities, party like animals, snort cocaine and have the most glamorous life of any doctors

This is simple. We drive fast cars, because we have very busy lives and have places to get to. That’s my excuse and I am sticking to it. And trust me, my Corolla is pretty fast.

The only celebrities we hang out with are those that come for treatment. As I don’t perform a lot of cosmetic procedure, most of the celebrities I have contact with are those who have injured themselves or need reconstruction for cancers. They don’t usually act anything like celebrities when they are in my office and the last thing they need is for me to ask them for a selfie.

We try to party like animals, but often our job stops us. We are notorious for pulling out of social commitments at the last minute. One of the worst thing about being a reconstructive surgeon, is that our colleagues take all day to remove the cancers, and we have to sit around waiting for them to finish (or we may have to watch them so they don’t destroy our reconstructive options whilst cutting out the cancer). Once they are done, they piss off to enjoy their evening, while we start our work, usually at the unsociable hour of 4-5pm, working well into the night to patch up the ‘mess’ they have left behind.

What glamorous night life?

As for cocaine, yeah, I know colleagues who do it at parties, but honestly, it usually doesn’t take long for the Board to find them. It is rare that a plastic surgeon is stupid enough to risk their career and reputation to develop such an expensive habit.

Myth #8 We all have had some ‘work’ done on us

I would not deny that some plastic surgeons have had work done, but not all. Although I can’t say the same for the wives or staff! Personally, I don’t trust anyone enough to have plastic surgery done on myself and it is a little difficult perform a facelift on yourself when you should really be asleep throughout the procedure. I know colleagues who inject themselves in the mirror, but I have this unusual need to close my eyes when I see needles coming towards my face, so the results would be rather questionable if I went down that path.

Most of my staff have injections, not because I force them, but it is something I offer them if they want it. And who could say no to free Botox? Because I am very conservative in my treatments, my staff are actually free advertisements of my work. When one of my staff admits to having treatment, the patients are reassured that they won’t look like Jocelyn Wildenstein when they leave my practice.

But, truthfully, the greatest benefit in giving my staff Botox is its efficiency in stopping my practice manager frowning at me and my receptionist frowning at my patients.

Myth #9 Our practice staff are picked for their looks

So, supposedly, this means that our staff should be beautiful young girls with faces full of injectables and look-at-me enhanced breasts. I mean, it is free advertising after all, and who would’t want to be surrounded by luscious females?

Truth number 1 – Most surgeon’s practices are run by their wives. So, which wife would be stupid enough to surround her husband with gorgeous young things?

Truth number 2 – Young girls who are obsessed with their looks don’t usually have the right personality nor the prioritisation skills to run a business well.

Truth number 3 – Experience comes with age. So unless you want to be surrounded by rookies who have no idea what they are doing, you would pick more ‘mature’ staff members to make your own life easier.

Truth number 4 – Patients and clients sometimes find perfection intimidating. They are more comfortable talking about their inadequacies to someone who has flaws as they feel that someone would understand what it is like to be ‘ugly’.

Myth #10 We can make Queen Latifah look like Heidi Klum and vice versa

This is the ultimate myth. I always know it is going to be a difficult consultation when a 5’3, 200+lb person walks in and slaps a picture of Gisele Bundchen on my desk.

So here’s my spill:

  1. I cannot make you taller – go see an orthopaedic surgeon or stick to your heels
  2. I cannot make you a natural blonde – you need a hairdresser or a beautician
  3. Neither can I change the colour of your skin – that’s a disease called vitiligo
  4. Lipsouction is not a form of weight loss – get a personal trainer and stop eating junk
  5. A tummy tuck will not give you six-pack if you haven’t got one to start with
  6. I cannot turn back time to make you look 40 years younger, maybe 10, without the pimples
  7. I cannot make your woo-hoo look perfect nor make you a virgin again (yep, this is a genuine request, apparently Dr Google says it is a great anniversary present for your husband, or wedding present if you are marrying a younger man.)
  8. I cannot reverse gravity with a cream, it is called surgery
  9. And of course, I cannot perform scarless surgery
  10. Oh, and I cannot execute plastic surgery which will make your husband stop sleeping with his 20-year-old secretary, unless you want me to ask my Urology colleague to do a quick operation on your husband.

So, we may be Plastic Fantastic, but we are really just like any other regular surgeons. We cannot perform miracles, and we cannot change who you are. You need to speak to either God or a Shrink about that one.

 

 

Not a Saint Hospital

One morning I found a note on my desk from my secretary. It said:

The Medical Director at St X would like an appointment with you to check that everything is going well for you at St X.

It wasn’t unusual to get a ‘summon’ from the Medical Director of these private hospitals. Usually, it is a low-key chat to make sure that the private surgeons working there are not having issues with the operating theatre equipment or staff, and that they have no complaints about ward care of their patients. It was just over 2 years since I have started bringing patients into St X for my surgical lists so I was expecting an invitation from the MD sooner or later.

I asked my secretary to shorten my next St X operating list, and arrange an appointment with the MD afterwards around 5pm for me.

This was the conversation:

MD: Hi Dr T, thanks for taking the time to see us. So, how’s everything going?

Me: Great. I have had no problems, the theatres are great, the nurses on the ward are helpful, my patients have had no complaints. They are liking the private rooms and….

MD: (Nodding vigorously and leaning forward to cut me off). Well, I want to talk to you about Mrs Y.

Me: Oh? Is she causing problems with the staff?

Mrs Y was a patient of mine on the surgical ward whom I had just admitted two weeks ago. She was a teacher in her late 50’s who sustained severe spinal injuries when she was a teenager and is now wheelchair bound. Mrs Y was also a long term insulin dependent diabetic who unfortunately had severe ketoacidosis last year and ended up in ICU, ventilated for 2 months. During her illness, they didn’t look after her pressure areas so she ended up with severe grade IV pressure sores over both the ischium and sacrum by the time she was transferred out of ICU. She was then discharged from hospital with this problem as no one wanted to deal with it whilst she was an inpatient. Mrs Y went back to teaching, and spent hours every day in her chair. When her blood sugars started to deteriorate and her family doctor noticed an unpleasant smell during one of her visits, it led to the discovery of her persistent pressure sores. By the time she came into my office, she was hyperglycaemic, septic with infection as both pressure sores were wide and deep enough for me to put two fists in each. I could see her ischial bone at the base of one, and the rectum at the base of the other, and because she was incontinent from her spinal injury, the wounds were severely contaminated with faeces as she sat in the wheelchair in her soiled diapers. Understandably, both her and her husband were by now, agitated and frustrated with unhelpful medical staff and hospitals.

I admitted her into St X, because it was a large tertiary private hospital with all specialties on hand. She required an urgent endocrinology review, infectious disease input, a general surgical procedure to divert her faecal output via a temporary colostomy, dressings and pressure care. Needless to say, she started to improve within 7 days. She required intensive nursing care with four times a day dressing change (to prevent accumulation of pus that was continually exudating from the wound) and two hourly turns to prevent development of new pressure sores while she was bed bound.

Mrs Y, at the beginning of the week, cranky from feeling ill and hating being bed bound, was not the best compliant patient. She was a teacher after all and did not like being told what to do. She was also a little distrustful of the nursing staff as it was poor nursing care in ICU which resulted in her current problems. However, after seeing herself improve over a week, she became the most pleasant and grateful patient on the ward. She helped the staff by setting an alarm clock and turning herself so that all the nurses had to do was to pop their heads into her room and check that she was in a different position. She also changed her own colostomy bags so that the staff didn’t have to deal with this particularly unpleasant job. The nurses told me that they enjoyed looking after Mrs Y.

I was rather surprised that the MD had brought her up in our meeting.

MD: No no, nothing like that at all. (He cleared his throat awkwardly). Patients like Mrs Y, well, we find it hard to accommodate them in this hospital.

Me: I know, I know, spinal patients should really be in dedicated spinal units, but there are no private spinal facilities for these patients. Mrs Y has been paying her private health insurance for over 30 years, so she didn’t want to go to a public hospital; she wanted to be looked after in a private hospital.

MD: We understand that, but private health funds in general don’t pay us very much for looking after patients like her. She requires intensive nursing care so we actually don’t get any profit for such a heavy nursing load.

Me: (Speechless for a second) So, let me get this right. You don’t want patients like Mrs Y because her admission doesn’t generate enough profit for the hospital?

MD: I just wanted to make you aware of this, so that you will remember in the future not to bring patients like her into our hospital. We would prefer day surgery patients, but if you feel strongly about keeping them overnight, we are more than happy to accommodate that. As for Mrs Y, I believe you are planning to keep her in hospital for a while?

Me: Yes. At least 3 months.

Both Mrs Y and I had a long discussion about this. She had agreed to take a whole semester out of teaching and come into hospital to have her sores treated properly. This meant bed rest with appropriate pressure care, no sitting in her wheelchair and regular dressings. I had explained to her in depth that if we could make her overall health better, these sores may heal without intervention. If not, they may need an operation. However, even with an operation, she will need to be off the surgical wounds for 6 weeks before she could sit on them. She knew she was in for the long haul, because she didn’t just bring her suitcase when she checked into the hospital, she also brought her Nespresso machine. According to Mrs Y, 3 months was a long time to go without good coffee.

I watched the MD’s face cringe.

Me: I can’t rush the healing process, and I have to wait for the infection to settle.

MD: Maybe you can find a little operation for her so that we can get a little more money out of her health fund during her stay?

Me: But she doesn’t need an operation. She just needs dressings.

MD: We are probably going to lose money if she stays that long.

Me: Would you like me to transfer her to the public hospital? (The MD looked up at me with surprise and a glint of hope in his eyes). I could just say to Mrs Y that St X doesn’t want you here because they are unable to make a profit out of your stay. They think you should really be in a public hospital despite the fact you have paid your private health premiums for the last 30 years…..

MD: No, no. (He started to clear his throat again). There is no need for that. I suppose since we are a hospital affiliated with the church, we can show charity by letting her stay her for a while.

Me: Righto. Is that all? (I started to get up to leave).

MD: But, (he stopped me turning towards the door), if you do a few more of your cosmetic cases here at St X’s, it may compensate for her stay.

He stood up and reached out to shake my hand.

Me: Well, I cancelled two breast augmentations this afternoon because of this meeting. I have transferred them to my lists at another hospital tomorrow.

I ignored his hand, turned to open the door, and walked out of his office without a backward glance.

Mrs Y stayed for the full 3 months and went back to teaching full time, sitting in her wheelchair with a beautifully healed bottom.

 

Old Shakey

Doogie Howser2

People write passionately about discrimination in Medicine: sexism, racism and even fattism (yes, there is such a word, I checked). Today, I want to talk about Ageism.

Ageism = Prejudice or discrimination on the grounds of a person’s age. (Oxford Dictionary)

Like all forms of discrimination, it goes both ways. There is ageism from the doctors to the patient, and then there is ageism from the patient to the doctors. The latter is the cause of my ongoing angst.

When am I going to see the real doctor?

This is actually something I get on a regular basis, usually after spending 45 minutes with them, taking a history, examining, diagnosing and explaining their treatment options. I suppose I should really consider it as a compliment. I do know I look young for my age. I know I don’t look like I am about to turn 40 (*sigh*). This can be attributed to both my ethnic background, but also to the fact that I don’t smoker nor spend much time in the sun (I do, however, sport a very unattractive sallow chronic ‘fluorescent tan’.) Yes, I do look after myself, but despite being a plastic surgeon, I have yet found a colleague trusty-worthy enough to stick needles or scalpels in me, and I am definitely too chicken to do it to myself in front of the mirror (unlike some of my colleagues – *winkwink nudgenudge*). So, no, my youthful appearance is not chemically or surgically enhanced, all I can blame it on is my genes.

So, why, you ask, am I complaining about looking young? Well, here’s a list of reasons why my age-inappropriate appearance doesn’t exactly make my job easier.

I don’t mind having someone young for the cough and colds, but can I please have someone older for the serious stuff?

I am not having someone fresh out of medical school operating on me.

You are too young to understand my problems

I need someone who are older and know what they are doing.

You look younger than my granddaughter, how old are you?

I am not being judgemental, but you are too young, I want someone who’s competent.

I have a very complex problem, I need someone with a little bit more experience.

The standards for the young graduates nowadays are not like the good old days, I want an older doctor who has been through the real training.

I want a doctor who is at least my age.

Now, what in the world makes you think you have the right to ask for my age? You are saying it isn’t being judgemental. But it is. You are judging my capabilities as a doctor by my age.

These patients feel that because of my age, I lack experience and should only treat the ‘easy’ stuff. There are two incorrect assumptions here. Firstly, the inferred ‘lack of experience’ by my age. Most people don’t realise that to become surgeon, one has to finish medical school, gain basic medical experience working as a junior doctor before being selected via a rigorous process to become a trainee in surgery. The surgical training program can range from 3 to 7 years, depending on the actual specialty, any sub-specialisation training within that specialty, and any additional overseas training to gain a wider perspective. At the end of which, one has to go through a series of very stringent assessments before a specialist qualification can be granted. I was at least 10 years out of medical school before I became a fully-qualified specialist surgeon. All I can say is, if 10 years of working and training (and not forgetting the 6 years of medical school before that) doesn’t constitute ‘enough experience’, and my qualification ain’t worth shit to you, then go ahead and set your own definition of ‘experience’.

Secondly, the patient’s assumption what ailments are ‘easy’ to treat and what aren’t, may not exactly correlate to true clinical relevance. A cough and cold may be easy to treat, but it may also be a manifestation of something more sinister. I would never presume a cough and cold as exactly that – I am a plastic surgeon after all – I always refer the patient back to their Family Doctor, as that is something those doctors would have more knowledge of. Patients who infer that they know what is ‘easy’ and what is not, show not only a total lack of awareness for the complexity of medicine, but also their disrespect for their doctor’s judgement. What may appear to be ‘easy’ may just be a harbinger for an underlying problem which is very difficult to treat, or it may just be the tip of the iceberg where surgical complexity is concerned. One of the most critical aspect during our training is to be able to recognise when we are out of our depth. If your doctor admits to needing a second opinion or assistance of another specialist, you should be grateful that you have found someone who will not take risks with your health.

People think that lack of ‘life-experience’ due to age is a deterrent to being a good doctor who could understand the issues of the ‘older’ population. This myth is easily busted when I look around at my colleagues. Which one of us isn’t jaded by what we have seen during our careers? We have seen it all. Birth, Life, Death, Disability, Misfortune, Pain, Suffering, Drug Use, Crimes, Abuse, Deviants, Perverts, the Insane, Murderers, Liars, Malingerers, Sadness, Grief, Anger, the list goes on. Some of the things we see and the frequency in which we see them, gives us multiple life-times of the so-called ‘life-experiences’. Sure, we may not have experienced any of these ourselves personally, but sometimes watching somebody we care for going through it and feeling utterly helpless can be just as real to us as the person who is experiencing it. Many of us view some of our patient’s misfortune as personal failures, and they take their toll on our own mentality.

Each specialty also has their demographic of patients; to assume that we have no inkling to a patient’s particular age-related issues is really quite ignorant. Most of my patients with skin cancers are elderly; I understand they may have issues getting to and from hospitals, care at home and simple matters such as attending appointments for dressings. We organise nursing home-visits for their dressings, and sometimes, arrange suitable surgery dates so that their family can take time off work to care for them. Most of my breast cancer patients have young children. We fit their appointments around school pick-ups and their surgeries out of school holidays so they can spend as much with their children as possible. Doctors are not unaware of our patient’s personal situations; we are not blind to possible social issues surrounding health problems. We, ourselves, have elderly parents, young nieces and nephews, friends outside of medicine and older/younger siblings. Often when we meet new patients, if they are not of similar age or demographics as ourselves, we can still relate them as one of our own relatives or friends.

So you think we don’t have enough ‘life-experiences’? Well, tell me, have you ever had to listen to a mother’s heart-breaking sobs in the middle of the night while she is sitting next to her dying 3-year-old baby? Have you ever had to spend two hours stitching up a battered wife’s mangled face and then watch her leave with her husband because she refused to report him despite your best efforts in counselling her? Have you ever stood in a room, watching a whole family saying goodbye to a man dying, while you are busily pumping him full of morphine because you know there’s nothing else you could do for him? Have you carefully removed a brain tumour from a patient who only hours before, had a psychotic episode and scratched, punched and spat at you? I could go on, but did you just say you were abused as a child? I have lost count of the number of child-abuse victims I have seen, but I understand everyone’s story is different. A different variation of the same……

Education has changed dramatically over the years, and this has definitely influenced Medical Schools. Standards are different, and they are different for a reason. The emphasis in medical training has changed, from purely scientific rote-learning to a more holistic clinical approach. Yes, I may have bitched and moaned about some of these changes as a teacher, but I can see why these changes needed to happen. To be honest, I don’t envy the students and trainees nowadays, an explosion in medical knowledge and technology over the last two decades has added a phenomenal amount into their core curriculum. Some of which I have yet to catch up with because it bears no relevance to my current sub-specialty. When I attended medical school, notes were written on paper, lab results were given over dial phones (yep, I am that ancient), X-rays were on films and put up on light-boxes, blood pressures were taken manually, pulses were counted with a pocket watch, surgical drills and saws were hand driven (not powered by electricity or gas). Back then, the list of diseases I needed to exclude for any presentation could be written on half a page, the number of tests I needed to do could be counted one hand and the number of ways I could treat it could barely fill a chapter in a textbook. Things are so different now, possibilities in Medicine are endless. Medical education nowadays place importance on basic core knowledge so that a graduate is not expected to know everything, but rather, to be able to pick out and apply relevant components of their knowledge to clinical situations. Most importantly, they need to know how to approach the problems and where to source the information they require. The point of today’s schooling is to generate a doctor that thinks, rather than one that relies on a checklist. So give your young doctor a chance, you might be surprised, he/she may think of another approach to your chronic problem. Something that is different to the same old thing which hasn’t been working for you.

We all know that we are getting old when we think everyone else is looking younger, especially when we see our pilots boarding the same plane we are travelling on. Commercial pilots start their careers in their late 20’s and to a lot of us think they are just kids, really. They are responsible for hundreds of lives for hours, but their age does not reflect their capabilities in getting all of us to the correct destination, safely. Why? Because of their qualifications. No airline would put a pilot at the helm of a plane unless he/she has passed all the requirements and assessments, whether they are young or old. In fact, once the pilots have reached a certain age, they have to be re-assessed for their ‘fitness’ to fly.

Some patients actually admitted to coming to me because their previous surgeon was getting old and I looked young (if only they knew!). Some do so in the hope that I have more up-to-date knowledge on new techniques, new technology or new approaches to their chronic problem. Some change surgeons because they have become concerned as their previous surgeons are deemed to be ‘too old’ to still be operating (ageism in the opposite spectrum), whilst some disliked the more paternalistic approach and ‘old-school’ attitude of their previous older surgeons.

Some older surgeons nearing their retirement have insight into their decreasing capabilities. Their eyes aren’t as sharp anymore, their hands have started to tremor, or they are now on several heart medications and struggle to cope with long cases. They cut down on the number of cases they take on as well as limit the type of operations they do. Many become surgical assistants to their younger counterparts. When I first started, I had one of the retiring Professors of Surgery as my regular assistant. It took a long time for me to adjust to giving him orders and correcting him when he is not doing something right. The nursing staff used to giggle when I would say, ‘Would you mind sewing that drain in for me, Sir?’ But it was a very happy arrangement. Prof could still get his hands dirty without the stresses and responsibilities of a surgeon, at the same time, I had instant access to any advice I needed. Not to mention the stories he used to tell as we were operating, those were gems to learn from. He would always tell me that he was not there to judge my competence, but to be my assistant for procedures I was more than capable of doing on my own.

So next time you meet a young doctor, don’t ask them how old they are, ask them what their qualifications are. And if they are just learning, give them the benefit of the doubt, because you could contribute so much to their education and experience by sharing yours with them. You never know, when your doctor retires, and when you are much older, they will be the ones in their prime, in charge of your health.

So you still want a doctor who is at least your age? Ok then, why don’t you go down the corridor and see Old Shakey next door?
Doogie Howser

* Disclaimer: Please do not take this blog as a disrespectful post to generations of surgeons before myself; I fully acknowledge the fact that their expertise could not be surpassed by myself. I am deeply appreciative of their willingness to share with me all that they know, as well as their unfailing support to me as a fellow surgeon, despite my age.

 

 

The Expert Opinion of Medical Students

med student

Ok. I am an old and cranky surgeon. And this post is going to make me sound positively ancient. It starts off with

When I was a medical student……

Is it just me, or are the medical students these days getting more brazen, opinionated and full of self-importance?

I used to love clinical teaching. Our students used to turn up early on consultant ward rounds, some with prepared case studies of patients on the ward, and helped out our residents and interns with preparations of the round. In the operating room, they used to stand quietly at the head of the patient, peering over the anaesthetic drape and asked intelligent questions. Questions that showed they had checked what was on the list and read about it the night before. They stayed until the case was finished, whether it would be 6pm or 1am. They were eager to scrub in if they were offered the chance and absorbed information like sponges.

Nowadays, they turn up on the ward round at the same time as me, with no idea of the patients on the ward, nor their names and procedures, let alone their histories. The interns and residents struggle with charts, dressings and memorising lab results for each patient, whilst the students look on with vacant smiles, hands firmly tucked into their pockets.

When I was a medical student, I used to arrive an hour before my consultant, print out a patient list, and write out all lab results next to their names for the intern. I would then put all the charts onto a trolley, opened to the latest page, and stamp in the date, ready for the round. While the round is happening, I would carry a box of gloves so that the senior doctors can open the dressings, and be the official scribe in the notes while decisions are made and patient discussed. I would hand the latest lab results to my intern and make sure he/she was aware of any abnormalities. I never spoke unless spoken to. My role was to be helpful to the junior staff and be a thirsty sponge to absorb all the information bantered around my head.

Over the last few years, something changed in our medical students. I don’t know why these young minds are being poisoned, but I sure would like to correct whatever delusions some idealistic non-clinical academic lecturer are feeding them. Whatever fibs they are being told – may work great in theory and on campus, but disastrous if they really want to gain the most out of their clinical attachments. The attitude these beliefs breed in our medical students, alienates them from the real doctors in the ‘real’ world.

1. You are an important member of the clinical team.

Then they get fed this bullshit story about how once there was a patient nobody knew why he was dying and some medical student came alone, discovered the diagnosis and saved the patient. It is an Urban Legend, people. Don’t come onto my team thinking you are going to discover some astonishing fact, talk to us as if everything you have to say is of utmost importance, and please don’t look at us expectantly for a thank-you for your effort. Oh, I don’t dispute that sometimes the medical student finds something that no one else on the team knew, but it is often either of small significance, or most commonly something that would not have changed the big picture.

Nope. You kids are not important. You earn your importance. If you put in the work and help out with the team, then maybe, just maybe, you are useful. Students are actually economic burdens. Teaching takes time, time cuts into efficiency, and decreased efficiency means less thorough-put. Less thorough-put means I don’t meet my KPI (key performance indicators), and failure to meet my KPI means I don’t get my bonus. Oh, and did I mention that I don’t get any extra pay for being a teacher or having students on my team? So to cut a long story short – teaching you kids cost me my bonus. For those who put in the work, I consider it worthwhile, I’d be happy to give you my bonus just so you can stay on the team longer and learn more, because sometimes listening to my students talk intelligently makes me puff up with pride.

You are also not so important that you can call me ‘Tiff’. My intern, residents and registrars call me Dr Tiffany, and that’s forgivable because I have a unpronouncable surname (thanks to my Eastern European husband). So, at the very least, you could do me the same courtesy. Yelling down the corridor, ‘Hey, wait up Tiff’ is just not acceptable behaviour for a student on my team. Why the hell would I wait for you when you are late to the ward round anyway?!?!

2. As a medical student, you have ‘rights’

Hahahahahahaha. Sorry, I had to laugh at the absurdity of this concept. What ‘rights’ would you be referring to?

Last month, we were doing a six-hour operation which started at three pm. The student was scrubbed in to help with some retraction. As a ‘reward’ for his efforts, the senior registrar showed great patience and took her time teaching him how to stitch. When it turned six o’clock, the student wanted to be excused. The registrar made a comment that if he stayed, he could practice more suturing and close one of the wounds. His reply was, ‘I am not paid to be here. I am only here to learn. As a student, I have the right to leave when I have done my allocated hours.’

The registrar looked at me and said, ‘Great. Dr Tiffany, why don’t we all just leave the patient on the table and go home? I think I am  on the 40th hour over my allocated hours for this month. The anaesthetist here is on his 37th hour, How about you?’

Another example of the so-called ‘rights’ was demonstrated to me by a student who stood at the head of the table observing an operation last week. It was a difficult case – I was digging through scar tissue to access some very fine blood vessels without clobbering any of them and causing a blood bath. There was concentrated silence in the theatre for 2 hours. During which time, I was trying not to get too annoyed with his continuous fidgeting, coughing and sighing. When we finally negotiated through the difficult part of the operation, and I was able to relax (i.e. multi-task), I asked the student if he saw what we were trying to do. He shrugged and said that he didn’t really understand because I didn’t talk to him. I held onto my patience and pointed out all the blood vessels I have dissected out and asked him if he recognised them.

‘No, I have never seen them before. I wouldn’t know what they are. You are supposed to teach me today, but i haven’t learnt anything. I have just stood here for two hours. I don’t think we learn very much watching operations, when are you giving us a tutorial? We have a right to proper teaching.’

Time paused. I could see myself pointing to the door, and yelling ‘Get the F%$#& out of my theatre and don’t ever let me see your #$@% face ever again!’

Instead, I said, ‘If you go home and read about the anatomy of this area, you can give me a tutorial tomorrow on it, and I will tell you whether I could have done that dissection better.’

3. Your opinions are important

Trust me when I say, No, Your opinions are best kept to yourself. In regards to opinions, I have two rules I live by: One, your opinions are only worth mentioning if you are either as old as the person you are giving the opinion to, or you have at least half the experience of the subject as the person you are talking to. Two, some opinions are best left unsaid even if it is a good one.

So if you have had no experience in surgery, you need to shut up, watch and learn. I asked a medical student on her first day once, about what she think Plastic Surgery was about. She said that she knew it was all about reconstruction after removal of cancer and injuries, but ‘in my opinion, it is not really essential, so I think they should cut it out of the public health budget.’

Hmm. Let’s imagine the scenario of Miss Smartass getting run over by a car, then carted into my theatre with crushed legs. There I was, standing over her, waving my amputation saw, as she is drifting off to sleep under anaesthetic,  ‘so who think plastic surgery is not essential now?! Mwahahahaha.’

My pet hate is the student who watches me do an operation and tries to tell me how they would do it and why. Ah huh, and sorry if I sound rude, but how many of these have you done? I had to laugh once when a student actually replied, ‘Oh, I haven’t done any, but I have seen quite a few.’ My dear boy, this is not a football game, everyone is an expert because they have watched the game for years. Trust me, if you put any one of those loud, opinionated, beer-drinking, fat bastards who are always yelling obscenities from the couch, onto the football field to play, do you think they can score?! You think they’d win the game? Why don’t you just finish off this operation while I go for my tea break.

4. Medicine can be mastered with ‘Problem Based Learning’ (PBL)

I don’t think I have ever hated a mnemonic more than PBL. Don’t get me wrong, I understand the basis behind PBL, but I think PBL should be taught at the level of training registrars and residents. Teaching PBL to medical students, is like teaching a 17-year-old how to drive without him/her having passed the traffic rule-book written test. You cannot solve the problem, without rote-learning the basics. Yep. Rote-learning, reading, studying and memorising. No shortcuts or ‘I will be able to work it out.’ If you don’t have the knowledge, you won’t be able to ‘wing-it’. And trust me, when someone is bleeding to death on the operating table, they wouldn’t want you to ‘wing-it’ either. Medical school is all about garnering the basic knowledge required to make decisions, and clinical experience during internship and residency is about using that knowledge to perfect the art of clinical judgement. I am still doing problem based learning every single day I am at work. It is something I believe I will continue to do until the day I retire.

Back in the days when I was a medical student (here she goes again *eye-rolls*), we had structured learning of all sciences. It was boring, it was tough, and the amount we had to know seemed irrelevant and insurmountable. But man, was it all so useful when I started surgical training. I am a firm believer that my role as a clinical teacher is to demonstrate to my students the importance and relevance of the basic sciences. I am not trying to teach them how to do an operation, diagnose a disease or to predict prognosis. That is something I teach my surgical trainees. For the medical students, all I am trying to do, is to show them that if they know their sciences well, there will be a whole new world for them to explore with the knowledge they have.

5. There is no such thing as a Stupid Question

WRONG. There is such a thing as a stupid question. Like, ‘What sort of surgery do you do?’ Ok, let me get this right. You have been assigned to my team for 6 weeks and you have no idea what specialty we are in?

If you are thinking of asking a stupid questions, it is better that you say nothing at all. There is nothing more annoying than silly questions from medical students which reflect their complete lack of preparation. Not to mention the polite but pathetic inane questions that accentuate their complete disinterest, absence of comprehension and desire to be somewhere else. Just give me the goddamn attendance form, I will sign it so that you can get your irritating bored ass out of my theatre.

I do like questions when I operate. I like intelligent questions from my students. When a student asks me a question which showed that they have actually done some background reading, I am in seventh heaven. I would take them on a tour of every detail, every aspect and every possible outcome of the surgery we are doing. It is almost orgasmic when my diatribe generates more intelligent questions, showing that they understood what I have been trying to show them, and their interest in what I do. To me, that is like the ultimate ego-stroke.

Sometimes the students are very quiet in my theatre. I suspect it is because they don’t want me to know that they have NFI (No F%$#&ing Idea).

6. Participate in ‘Active Learning’ – speak up and question your clinical teacher

This is like a fast train wreck combining both number 3 and 5.  This is an example of ‘active learning’ from a 3rd year medical student I had last year.

Expert Medical Student: Why are you removing the rib like that?

Me: Because it is a safe way of doing it and it is how I normally do it.

EMS: I don’t think you are doing it right.

Me: Why do you say that?

EMS: I have seen Dr X and Dr Y do this operation last week and that’s not how they did it.

Me: There is usually more than one way of doing an operation, we all have our own preferences.

EMS: But I think their way is better.

Me: Because?

EMS: They are older and much more experienced, so I think you should do it like them.

I wondered if I would get reported if I picked up my sharps dish and bitch-slapped his face with it.

Me: Why don’t you just watch the way I do it and see if it achieves the same result.

EMS: I wasn’t trying to be rude or anything, it’s just that we are told to question everything so that we can learn why you do what you do.

Me: Ask me why then.

EMS: Why what?

Deep breath.

Me: Forget it.

I love my students. Really. I do. I am just very selective whom I show my love to. I love them by teaching them, and I only teach the ones that put in the effort, show respect for their teachers, don’t take our time for granted and don’t make unnecessary noises. I am too old to waste my time and effort on the others.

I sound like an old, arrogant and cranky surgeon. In actual fact, I am afraid to say that my rant reminds me of the Professor of Surgery I had when I was a medical student. Oh God, I really am ancient. I will know I am archaic when I find my portrait next to his in the hallway of the department of surgery.

 

Just a R&R on Allergies

allergies

Humour me – I need to do a R&R (Rant and Rave) on patient’s allergies.

I am sick of people with ridiculous allergies.

My anaesthetist once told me, that if a person put down more than three drug allergies, then he/she is most likely crazy. I have had patients who ran out of space on their pre-consultation questionnaire for their allergies that they started to list them on the back of the form. I understand that there may genuinely be people who have multiple allergies, but these people are extremely rare. Their allergies are often proven with forma allergy-testing.

I have had patients who have listed every class of antibiotics under their allergies, so I have had to tell them that I couldn’t operate on them, because if they got an infection, I won’t be able to treat it.

Then there are the patients who put down ‘allergic to general anaesthetics’ when they check into hospital for their operation. Really? Would you prefer a sledgehammer instead? You can’t be allergic to general anaesthetics – to put someone to sleep it requires a finely-balanced cocktail of different intravenous drugs and inhalable gases. Sure, there are known idiopathic reactions to specific anaesthetic drugs, but these are rare – often the specific agent can be identified and the patients are informed in detail. The generalisation of being allergic to general anaesthetics just shows patient’s complete ignorance to their true allergies. Nausea and vomiting or a mild rash after a GA is common – it doesn’t mean you are allergic to it.

Patients who are allergic to multiple pain killers are a complete headache to surgeons. When patients put down that they are allergic to all narcotics except Pethidine, they shouldn’t be surprised that medical and nursing staff treats them like Pethidine addicts. Pethidine is a narcotic, it’s hard to fathom that someone could be allergic to all narcotics but not Pethidine. Most often, people who get a high on Pethidine prefer Pethidine injections to any other narcotic as their pain relief. There are also patient who claim they are allergic to simple analgesia like paracetamol/acetaminophen, or anti-inflammatories, but can only take narcotics. That to me, also sounds pretty suss.

Then there are patients who think they are hilarious. When I ask them what they are allergic to, the response is, ‘doctors’, or ‘pain’, or ‘hospitals’. If only I had a penny for each time I get the funny patient, I’d be a millionaire by now. What about patients who write ‘hay fever’ or ‘eczema’ in the box next to ‘Drug Allergies’. Really?! Do they know of any doctors who prescribe ‘hay fever’?

Food allergies, however, are important to disclose, as some people who are allergic to seafood or crustaceans can also be allergic to iodine. One of the intravenous anaesthetic (propofol) also has egg protein in it, so can cause severe allergic reactions in those who are allergic to egg. As for being allergic to cat? Well, we don’t normally prescribe cat, and the well known cat-gut sutures are actually made out of sheep gut.

People need to understand the difference between side effects and allergy. Nausea, indigestion or even itch sometimes, is not an allergy; it is just a common side effect. These side effects can be avoided if advice or treatment is sought. Being sensitive to something is not an allergy. Patients love telling me they are allergic to all tapes.  When tested, they are usually not allergic to any, because the ‘red rash’ they describe are just irritation from the sweat which has accumulated under the tape on their sensitive skin. Some people are also quite ‘sensitive’ to medications, and although understandable, is still not a true allergy. All that is needed is a dose or timing adjustment or even treatment to prevent these sensitivities.

Sometimes I have to admit, it can be the doctor’s fault that patients think they are allergic to numerous things. When a patient reports a side effect, the doctor is often quick to blame the drug and put it down in the allergies column, instead of explaining to the patient that it is not a true allergy, and find out if the drugs were taken correctly.

Why is it so annoying to a doctor when patients put down allergies which are not true allergies? Because once you have written it down as an allergy, medicolegally, we find it very hard to give that particular drug to you, even if you need it desperately. So if you put down that you are allergic to an antibiotic when all you get is a bit of nausea, we have to give you a second-line antibiotic choice to treat your infection because we don’t want to be sued for drug reactions. If, instead of putting it down as an allergy, you tell us that you get a bit of nausea with the antibiotic, we will dose it so that you can take it with food and maybe some antacids to treat the side effect, but you will now get the best antibiotic for your infection.

So next time you write down your allergies, think twice before you start listing them.

What about the patient who told me that she was allergic to light?

I told her that it was ok. I can operate in the dark.

 

‘Doctor’ is my Job. Not who I am.

I hate travelling alone. Somehow or rather, I always end up having a conversation with whoever sits next to me. I don’t mind the conversation, but sooner or later, the ‘oh-so-casually-asked’ question comes up: ‘So, what do you do for a living?’

I always hesitate. I always consider lying about what I do. I just don’t want to say I am a doctor.

It took me a while figure out why. Apart from the fact that once people find out they are talking to a doctor, they lose all interest in talking about anything else. Anything else but every medical condition or surgery they have ever had. Then they move onto each of their family members and friends. In between, they give you their five cents’ worth of why they knew better than the doctor, and how Dr Google was so helpful. By the end of the flight, they would be asking for a free in-flight consultation as to what my opinion was in regards to dear old departed Grandpa’s gouty big toe.

I get that. I really do. I find myself doing the same when I talk to people in certain jobs. When I first met my friend who is an airline pilot, I told him about all my terrible flying experiences. I could literally see his eyes roll to the back of his head as I carried on. But he has no qualms in telling people he is a pilot. In fact, he loves it, because he says it is a great drawcard for chicks.

I don’t think it is a drawcard for me. You could see the interest dimmer in men’s eyes when I tell them I am a doctor, or the body language wthdraws when I mention that I cut people up for a living. Well, not exactly in those words. It is often hard to tell whether it is because they are intimidated or they are just not interested in female doctors. Of course, once they get over that fact – and they haven’t moved onto someone else with a greater one-night-stand potential – I get the low-down about their latest health problems over a beer. No Siree, there’s no flirting for the female doctor at the bar, It’s all serious talk about their latest health problems. When boys fantasize about playing doctors and nurses, I guess they just never really imagined playing the nurse.

People judge people by what they do. Assumptions are made- some are true, but majority of the time, it can be quite far off the mark. These are often based on stereotypes. So, when I tell people I am a surgeon, people usually presume that I am a smart, rich, arrogant, bossy, ball-breaking feminist. Some even assume that I am single. Interestingly, some people talk differently to me once they realised what I do for a living. It is almost insulting when people make comments like ‘You know, you are not like a typical surgeon. You are so normal and down to earth.’  Yep. I eat, drink, wee and poo like any other normal person.

But most of all, I hate telling people that I am doctor, simply because it is not who I am.

I am a surgeon, and yes it consumes my life, but it is still just a job for me. I would still be me if I was a teacher, waitress or cleaner. I would still have the same work ethic, the same standards and the same approach to my work. I don’t identify myself with what I do for a living, but rather, what I do in life.

I think it is a good thing.

It allows me to separate my personal life and work life better. In the time continuum, they do overlap. For instance, when I am out shopping for groceries, I get a phone call from work. But I don’t think of myself as a surgeon doing groceries, I identify myself with everyone else around me doing groceries, the only difference is I am getting a call about work when it’s a Sunday afternoon. When I have issues at work, I don’t bring it home to my personal life.  When I have problems at home, I deal with it like a concerned wife, not like a surgeon.

It is also good for protecting myself. When I get abused by patients, or complaints from colleagues, I find it easier to see it as a criticism of my work, and less an assault of me as a person. They don’t know me, not really, they are just angry at the doctor. This allows me to look at my work more objectively and find out what I may be able to change or improve, rather than get all upset because I feel incompetent, hurt and lose my self-confidence.

My husband likes it. He thinks that I keep the non-doctor part of myself only to those closest to me. He often chuckles when he hears me speaking on the phone to my colleagues at home. ‘You talk like you have balls.’ Not the most eloquent compliment he could bestow on his wife, but he loves the fact that as soon as I put the phone down, I revert back to the quirky chick he married. The one that snuggles up to him on the sofa and lets hm believe that she worships the ground he walks on, whilst taking a piss out of him all at the same time.

Most of all, separating my job and my identity allows me to have a life outside work. I have other interests, many of which are not exactly congruous with what I do for a living. I suppose most people think doctors play golf, sail, travel during their spare time. Me? I enjoy bashing up my Sensei and his gigantic sons during my karate training sessions (free medical care offered if I win).  Other weekends I go to the gun range and work on my not-so-perfect trap-shooting technique, in between cheese tasting with the large Italian community at my local gun club. I seriously think that I would be more comfortable calling myself a mediocre amateur trap shooter (who loves her chilli cheese), than I would a surgeon.

Discovering my identity outside my work gives me the opportunity to find out who I am, and confirms that I am not my work.  It gives me a purpose in life even if someone strips me of  my job and all the associated status it represents. It determines how I do my job.  How many times have I heard of senior colleagues continually postponing their retirement? It is because they are too afraid of retiring – they have nothing besides their work and they are at risk of losing their identity once they stop being a doctor.

I would hate to think my view is a reflection that I am not committed to my work or that I don’t love my work. In fact, I really believe that I make a better surgeon if I am also a regular human being. I hope that people don’t just see me as a ‘doctor’, but rather a kind, thoughtful, considerate, empathetic, intelligent, decisive and trust-worthy person. A person that they feel confident in as their doctor. Because that’s who I strive to be.

Back to the plane.

‘So, what do you do for a living?’

‘Oh,’ I would shrug, ‘not much. I am a lady of leisure.’ I wave my hands around elegantly like a practiced socialite. ‘but I am fairly busy,’ a sweet innocent smile thrown in here, ‘I go to lunches with my girl friends, I love a bit of shopping; I organise charity functions and I always attend my husband’s work-do’s, you know.’

Usually I get an indulgent smile. ‘Well, you lucky girl.’

I would give a very girlish giggle. ‘I know, my husband spoils me.’

The conversation takes a brief break as the air hostess wheels the coffee cart up to us. She bends over to me.

‘Dr Tiffany, can I offer you a coffee?’

Damn. Sprung.

May be there is a doctorate in home-decorating?

Diagnosis: I Don’t Give a S#@% about myself

One of the most frustrating things I encounter at work is trying to help people who doesn’t want to help themselves.

Here are the 10 top clinical signs (for the novice):

1. The beautifully tanned patient who is sunburnt all over, (looking like he/she has just spent their weekend on the beach), and is about to go into the operating theatre to have a melanoma excised.

2. An obsession with blenders. The lap band is tight to maximise weight loss, the patient is supposed to be on a portioned healthy vitamised liquid diet. Instead, he lives on a  ‘vitamised diet’ of Big Mac and French Fries, liquified via a blender. ‘I just don’t understand why I am not losing weight…

3. The dangerous oxygen tank. The patient who just had 1/2 of his right lung removed for cancer – so now he is dependent on oxygen – lighting up a cigarette in the hospital courtyard. Taking a drag on their cigarette in between inhaling a whiff of oxygen from their mask. Honestly – if you want to kill yourself, that’s ok, but to blow up the hospital???

4. An X-ray that shows a new fresh hand fracture through plates and screws over an old fracture. Excuse: ‘Well, punching my fridge is better than punch my Dad in the face, rght?’

5. The MIA patient. The patient was called for the operating room, but he couldn’t be found anywhere. Because he was outside for his ‘last smoke’ before having half f his lip removed for  lip cancer. ‘You only told me that I couldn’t eat or drink before my anaesthetic, you didn’t say I couldn’t smoke.’

6. Patients with bags of ‘unfilled’ medication scripts. One is really unsure as whether these patient don’t take their prescribed medications (for their heart disease, cholesterol, diabetes, infections etc), because they can’t be bothered, they don’t want to or they just ‘don’t believe in taking medications.’

7. DNA’s (did not attend). Patients who have appointments for their cancers to be assessed and removed do not turn up to their appointments despite multiple phone calls, or simply, they have important work-commitments or holidays and need to move their appointment to 6 months later when things are quiet (and the cancer will be inoperable.)

8. The broken plaster on a broken arm. Sometimes, the non-existent plaster on a broken arm. ‘I know my arm is broken, but it got so itchy I had to take the plaster off’.

9. The gigantic fungating cancers. It takes time for cancers to grow. When I see a very very large cancer, I wonder why patients don’t come in when it was the size of a coin. Once I had a patient with a skin cancer on his chest. It was the size of a dinner plate, and it had already eaten into his breast bone. I asked him why he left it until now to come, he said that he only came in because it was growing into his neck and he couldn’t hide it behind his business shirt and tie at work anymore. Did he know it was a cancer? Yes, but he was too busy at work to take time off for an operation.

10. The smoker with a cigarette dangling out of his neck. The throat cancer patient who had his throat removed now has to breathe out of his tracheostomy. He was found lighting up with a cigarette taped to his tracheostomy. A short-cut highway of delivering poisons directly into his lungs. Well, I guess he won’t get oral cancers from smoking this way.

The Differential Diagnoses:
1. I have a severe case of NFI (No F&%$* Idea)
2. I am so f$%#@ scared that I’d rather bury my head in the sand
3. My health is my doctor’s responsibility because that’s their job to fix it

But sometimes we just have to face the harsh diagnosis of: I don’t Give a Shit about Myself.

 

Teaching by humiliation

This is not a blog about bullying. Just about teaching.

Last week, I witnessed a scene in an operating theatre.

Two doctors were operating on a patient. One was the senior consultant and the other, the junior resident. The tension in the room was palpable, and even the humming of the ventilator sounded like a jumbo jet. The operation was not going well. There was constant welling of blood in the body cavity they were concentrating on, and the sucker tubing gurgled continuously with bright red fluid. Stress was evident as expletives started to escape from behind the older doctor’s mask., directed at the younger man.  The junior resident was trying his best to help, but he was obviously straining under the other man’s diatribe, apparent in his worsening tremor and the inability to stop the blood from flooding the operating field.

Then, miraculously, the senior surgeon managed to control the situation, and it was as if everyone in the room released their long-held breath in unison. The older surgeon gave an arrogant laugh, ‘It would really ruin my numbers if that one got out of control.’ He daftly tied the loops around the bleeding arterial branch. The operation continued, but as it progressed, it was clear that the resident was starting to annoying the older surgeon with his scrutinised clumsiness. At times when the younger man got in the way, his hands were swatted away like a bothersome fly, accompanied by over-dramatic exasperated sighs from the senior surgeon.  When the resident missed a suture with his scissor, it was snatched out of his hand with an expletive, as the older man made a deliberate show of cutting his own sutures, to demontrate the younger doctor’s incompetence.

The tremor in the young man’s hands deterioated. By the time it came for him to close the wound, one could almost hear the instruments vibrating against the patient’s skin. Criticisms started with a few grunts, escalating into abrupt barks of ‘Don’t’ and ‘Stop’. Finally, the needleholder was grabbed from his hand roughly by the senior surgeon. The older man started to close the wound himself in angry jerky movements, at the same time, a barrage of insults descended on the young doctor.

‘Pathetic aplitude for surgery….’

‘You will never make a surgeon…..’

‘What were you thinking taking on this job…..’

‘I don’t know how you could have made it this far as a doctor…….’

‘you are useless…. It wouldn’t have taken me this long if it wasn’t for you……’

‘Why is it that I always get the most pitiable incompetent junior doctors….. ‘

It was as if the avalanche was unstoppable, hammering down at the young man whose head was bowed over his scissors, staring at the wound in concentration as if it was his lifeline. As the last stitch was cut, the older man threw down his instruments on the table and tore his mask off.

‘Put the dressing on and get out of my operating room, before you sabotage anymore of my operations, you worthless excuse.’ He marched out angrily.

The room was quiet. No one said a thing in the last two hours. Including myself. Why? You may ask. Because we were all too afraid, that if the attention was drawn away from the junior doctor, the torrent of abuse would only continue, just at a different target. We knew this from experience. Dr M* was well-known for his vicious disposition. Anger management classes and suspensions did not apply to him, as everyone knew that he was about to become the next Director of Surgical Services. Over the last few years, complaints about him mysteriously got lost, and disgruntled staff members seemed subdued when questioned.

But, it wasn’t the unfairness, or the endless onslaught of malice that shocked me, but the silent tears that were now running into the mask of my younger colleague as he carefully applied the bandages on the wound.

In front of me, was a grown man, reduced to tears.

I knew Peter* well. He was an eager young medical student when I was a first year training resident in surgery. It was an interesting time, with me trying to find my feet as a newbie in surgery while he took everything I did as gospel. Peter was like a curious sponge, everything I taught him, he investigated and researched until he fully understood all there was to know behind each surgical fact.

But that was more than 10 years ago. The man in front of us now was a final year trainee, about to step into the world as a fully qualified surgeon within 3 months. He was a husband to a fellow doctor and a father to 8 year-old twins. What would the children think, if they ever saw their father, standing with his shoulder slumped, his hands shaking, and tears pooling in his mask? It broke my heart. This was a grown man, broken, momentarily, by the maliciousness of another.

Awkardly, I walked over to him. I took the bandages from his limp hands, and I rested my hand on his back.

‘Three months, Peter. Three months. Just hang in there.’

He stared at the floor.

I gave him a gentle shove. ‘Go and write up your operation notes. Grab a coffee. You have another case to go.’

He seemed to gather himself. He took his mask off and swiped at his eyes. He nodded, then looked up. Like all surgical trainees – hard veterans of regular abuse – he reached deep inside himself, found his ultra-thick ‘surgical hide’, and threw it over himself in a protective shroud. Like a magical cape, the despair was suddently erased from Peter’s eyes as if the last 3 hours did not exist. Red rims and puffy eyelids were the only evidence that something may have been amiss. A lop-sided smile broke through. ‘I need something stronger than coffee.’ A self-depreciating laugh followed as he strolled out of the room, looking for all as if he had just accomplished a simple case without a hitch.

It is true that bullying is rife in the field of surgery. It may sound as if I am making excuses, but the stress and pressure can often result in unintended explosions of emotion – which majority of the time, is usually let lose at the most junior person in the room – and never in a positive way. The inferno is often directed at the person least powerful to fight back – which is our trainees or students. They are dependent on their senior surgeons for their assessments and recommendations. Not to mention references for future positions. Surgery is a small world, and a close one.  Reputations have a way of establishing itself as early as one’s training years.

It is such a cliché when I say that it was the way I was ‘brought up’ in the world of surgery, and I honestly believe, it made me tougher. A surgeon need to be able to withstand unforeseen stresses, make snap decisions in dire situations and be able to get on with the next operation even when the previous one has failed. I remember being completely accepting of the fact that when I signed up for surgical training, I was going to get abused, yelled at, bullied, hassled and most likely reduced to tears at the most inconvenient times. I remember the incredulous looks from my non-surgical colleagues when I said (tongue-in-cheek), ‘but there is no such thing as bullying in surgery. It is called teaching.’

I remembere being pulled aside by my mentor in my early years, who tried to warn me about a particular senior surgeon’s bad temper, and his love for torturing trainees with spiteful intimidation. I just shrugged, to her amazement, I was not concerned, ‘Well, the way I see it, is that he doesn’t have to teach me at all, but if he is willing to teach me, even if it’s by humiliation, I am willing to learn.’

Sure. I know I am tough. But I had to be. When I was training in surgery, I was one of the very few females in my specialty. I was determined not to give anyone an excuse to call me a girl – because I was a grown woman, and I was gong to be as good as any grown man around me. Some were harsher with me because they thought I belonged in the kitchen, some were easier on me because they were susceptible to a pretty smile, heels and pencil skirts. Constructive criticisms were given, some verging on bullying, whilst others just needed to be accepted with a stiff upper lip.

Now, don’t get me wrong. I don’t think it is right to teach by abuse, but everyone knows how hard it is for an abused child not to repeat the same life-cycle as his/her parent. I cringe everytime I hear myself say, ‘back in my days…..’

Because back in my days, if a trainee has not looked up an operation the night before the operating list, he would have been sent to the library for the remainder of the list until he knew how to recite the all the procedures back to front. Then, maybe, he may be allowed to hold a scissors and cut the sutures for the senior surgeon.

Despite the long-history of the harsh realities in surgical training, generation change has definitely brought new approaches to teaching. A trainee is like a trade apprentice. Except teaching only knowledge and skill is not enough. The importance of cultivating empathy, integrity, responsbility and collegiality all need to be incorported into the rearing of a good surgeon. And if we start with abusing them, none of these quality will get an opportunity to flourish. Not if their everyday aim was to survive the day without being reduced to tears, or feeling as small as an ant that is just about to be crushed under a surgical boot.

I remember vividly the first advice ever given to me.

You will become a good surgeon if you are a good person, but you aren’t necessarily a good person just because you are a good surgeon. When surgery fails, your integrity is the only thing that will lead you to make the right decisions.

Peter is a good man. He will one day make a great surgeon.

*All names have been changed to ensure confidentiality and protect personal identities.

The Frustrations of Caring

Sometimes I wish I didn’t care.

I remember when I was an intern, the professor of surgery once said to me, ‘the trick of lasting in this gig, kiddo, is to stop caring so much.’

I thought at the time that he was referring to caring about what other people think.Then I realised he meant caring about patients. I was outraged; absoluately convinced that he was just a cynic.

Now, I think he is actually just a realist. A very experienced one at that.

Caring about patients need to have limits. I have learnt the hard way, that if not, the patient will start pushing boundaries with their expectations, my whole existence becomes one big worry-farm, and then my personal life deterioates.

When I meet my patients for the frst time in a consultation, I take the time and effort to explain everything to them. I care about how much they understood and whether they feel reassured. During surgery, I do my best to be efficient, methodical and meticulous, because I care about the success of their surgery. While my patients are recuperating, I make sure they have all the information and instructions to follow and a contact number to call if they are concerned, because I care about decreasing their distress and anxieties while they are recovering. And at their final followup, I care, in particular, whether they are happy with the result.

This translates to worry. I worry if they have had enough time to digest the information and ask me questons. I worry if I have done my best with their procedure. I worry if they are going to develop a complication after surgery. I worry if they are having problems at home after surgery. I worry if they are dissatisfied with their result and if there is anything further I could do for them.

I worry. And it’s tiresome. But after many years, this constant caring and worrying becomes part of normal living – a bit like the constant background hum one hears in an airconditioned room. Some days the humming is louder, like when I am working over 100 hours a week and I have lost count of the number of patients I have seen. Other days, it’s like a sledgehammer, when I am dealing with problematic patients and complex surgery. Rarely does it becomes silent, even when I am asleep (yes, I do dream of operations and patients), or when I am on holidays (I still receive emails of lab results, letters etc).

Sometimes I resent it. Like when I receive a text message from a patient at 1am with a selfie of their wound or surgical site. I feel like yelling in frustration. But I constantly have to remind myself that it’s not the patient’s fault my life is like this. They are only doing the right thing – contacting me when they feel something is not right. It’s my fault. My fault because I care. I care enough to ring them back and listen to why they can’t sleep, talk about their concerns, and address their anxieties. Then I lie awake worrying. By the time my caring has finished, it is time for me to get up to start my 12-hour day again.

Sometimes my husband resents it. ‘Why do you have to go in to work on Sunday?’ Because I worry that my inpatients may have deterioated overnight, or need an increase in their painkiller prescription. I worry that they are sitting in hospital on a Sunday, feeling abandoned by their doctor (who feels too guilty to have a day off). ‘Why can’t you switch your phone off for dinner?’ Because I worry that my patients may need me and I won’t be there for them. ‘You are thinking about work again and not listening to me.’ I was worrying about what I could have done better in surgery, instead of giving the one most important person in my life the attention he deserves. I worry because I care.

Believe me. I tried. I tried to stop worrying, and erect a wall against caring. I tried to emulate some of my colleagues who has Not-Caring down to an art. But my conscience kept me awake, and my attempt lasted for all of 10 seconds. I know I don’t have to care, I just have to provide a service to my patients. I have seen very capable and successful surgeons who don’t seem to care and still have excellent results. They shrug off complications, they don’t take their patient’s problems home, and they brush off complaints at the office door. They live by the ‘Shit-Happens’ Rule. They don’t ever look worried. Either it is because they aren’t, or they have lived with it for so long, it is unrecognisable.

The problems with caring, is it’s closely associated with feelings and emotions. More and more, I have had to find the strength to put it aside. I have seen that too much caring can cloud one’s judgement, especially if I worry too much about how they might feel. Sometimes, cold clinical judgement to do the right thing, which may not be what the patient want, is the only way to make sure they have the best outcome. The hardest part is stepping away from their expectations, so that the bigger picture can be see in perspective. Thus lies the basis for not
treating our own relatives.

And now I understand that the advice was given to me to prevent ‘Burn-out’. I have learnt that sometimes I am unable to solve all my patient’s problems, and that I am not responsible for all their woes. I have also realised that just because I can’t help them, it doesn’t mean I don’t care. It is often enough for people to know that someone cares.

I have discovered that I need to reserve some ‘caring’- for myself and people who love me. I need to care about my health, that I shouldn’t live on chocolates and coffee. I need to care about my husband, what problems he’s having at work and why he’s wearing a shirt with missing buttons. I need to care about my mother, who still refuses to have her home security installed. I need to care about my 90-year-old neighbour, who still push my bin out every week for the rubbish truck but can barely manage to climb up the stairs of his porch. I need to care about my ever-loyal staff, who stays behind in the office and keeps their family waiting in the evening because I have two extra patients to see.

But how does one measure ‘caring’? And how do you dish it out in equal portions? What is enough and what is too much?

Caring is frustrating. It brings with it tiresome worries, sleepless nights and at times, total helplessness.

If I could talk to Prof now, I would ask him, ‘But, how do you NOT care?’