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.