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.

Speech to the Wannabes

Good evening. Thank you for giving me the opportunity to speak. I remember sitting in those very seats you are in now, back in the days when I was a medical student like yourselves.

I was asked two weeks ago, by your faculty Dean to give a talk to you all, on why I chose to do Surgery.

I thought very hard about it, maybe too hard. I thought of all the clichés I should throw in, like it’s satisfying, it’s challenging, it’s interesting. But what field in Medicine isn’t? Somedays, I catch myself envying my colleagues in their jobs, and somedays I walk away from a problem, glad I didn’t have to deal with it.  There are days I am appreciated by others for what I do, and there are days when I am belittled and teased about what I can’t comprehend as a surgeon.

So I have decided that, today, I will tell you why I chose not to do anything else.

I don’t think I could ever be a radiologist. I am afraid of the dark. In surgery, I am always working in a well-lit room. In fact, people around me will always move the light so that it is directed at me and my work. The operative lights are powerful, and for someone who loves being the centre of attention, I am constantly in the spot light.

I could never be a pathologist. They deal with dead people, or bits of tissue (which are also dead) removed from the body. I like to work with living people and living tissue. I also like the skills I possess to revive them under certain circumstances. I am sure findng the cause of death or disease is satisfying for the pathologists, but I figured that finding the cause and being able to fix it, is even more gratifying.

I would find it hard to be an anaesthestist, because then I would end up spending the majority of my time with people who are asleep. I already do that when I get home late from work, although occasionally I do get a grunt or two when I tell my husband about my day while he is slumbering. I am not very good at crosswords and sudoku either. I think if I had to sit there, listening to the steady beep, beep, beep for hours, staring at the squiggly lines on the screen, I’d find it hard to stay awake. Worse still, if I was an anaesthetist, I will have to stand there and be a spectator while the really exciting gory stuff is happening on the other side of the drapes. That’s just not me. I’d rather be the loud conquering hero, elbow deep in blood, than the quiet achiever behind the scenes.

I might have be tempted to become an Emergency physician. TV dramas always project them as exciting heroes, with challenges where they can save lives.  But when I did my ED term as an intern, I realised that these dramatic moments come rarely (which I guess is actualy a good thing). I spent plenty of my time in ED admitting little old ladies with pneumonia and falls, stitching up aftermath of drunken brawls, and sedating IV drug users whilst trying not to get spat at. Sometimes I think it’s awesome that the emergency doctors do shifts. That when they leave work, they don’t really carry further clnical responsbilities because they have ‘handed-over’ to the next doctor. I also found it frustrating, because I never found out what really happened to that 40 year-old man who came with babushka dolls in his rectum, as seen on his abodminal x-ray (because he fell on them, so he said). I felt like a traffic director because the responsibility ended when the patient has been referred on to the appropriate speciality for further management. So I never knew what was done to treat them, or if I even got the diagnosis right in the first place.

I don’t have the strength to be an Oncologist. It is probably one of the very few specialties where the doctor deliberately harm the patient with poisons, in the hope that it will treat or hold their cancers at bay. For the few that are saved, many benefit from prolonged lives, which sometimes, are accompanied by suffering. I think if I was an oncologist, I will have to be comfortable with the concept of Death. This would be hard, because in many fields of Medicine, death is viewed as a failure of the doctor’s abilities, even when we know there is nothing that can be done. I like successes, and I take failures too personally. I would not last in Oncology.

I love Paediatrics. It’s the parents I can’t deal with. There were days when I did paediatrics that I was tempted to prescribe sedatives for the parents, and gave my little patients vitamin C pills (also known as placebo for children), just so that the parents felt that I was doing something for their child. Dealing with babies, is like vetenary medicine. If the child doesn’t bark (cry), play, eat or poop, one had to figure out what is wrong with it, sometimes with almost no lead to follow. I am not that smart, I like my patients to tell me what’s wrong and what they want. And I need clues like sledgehammers.

I am a planner – my life is planned down to 15-minute blocks. Obstetrics would wreck havoc with my mental stability. Babies never book an appointment to appear. They come when they are ready, or sometimes, even when they are not ready. They also don’t book the length of their appointments, some want only half an hour and the others take their sweet time in getting to the point. Getting up at 2am to extract inconsiderate babies and performing an emergency caesarean to facilitate their wish to exit via the sun-roof, does not sit well with my planning tendencies. No, obstetrics would definitely antagonise the control freak in me.

I think General Practictioners are important. Family doctors are the crux of all communities and health systems, and they are family to many patients. They deal anything from simple cough and colds to complex medical dilemmas. Their knowledge has to be so broad as to include all possibilities in medicine. They also have to think about their patient’s social situations, and almost take on the role of a social worker. I have neither the acumen for broad general knowledge (I am always the weakest link on quiz nights) or the patience for complex social situations (I have serious foot-in-the-mouth syndrome), so I think I would score an epic fail in family medicine.  I know just about everything in my little specialty corner amongst the big wide world of medicine – so I think I will stick to what I know.

I can deal with a lot of gory things, like chopped off fingers, haemorrhage and fungating tumours, but there are a few things that make me gag. Phlegm and Mucous. I guess that ruled out respiratory medicine for me. Collecting and looking at gooey bubbly mucous in collecting pots brought bile to my throat. Subconsciously, whenever I hear a very fruity cough, I hold my breath to push down my gag reflex. I admire those who deliberately seek out rattling mucous in patient’s lungs with their stethoscopes. Ergh.

Physicians are smart. Like Sheldon in Big Bang Theory. Comprehending complex medical problems, working out multiple drug-interactions and ordering the right tests to solve confusing symptoms seem like second nature to them. They can’t fathom why anyone else haven’t worked it out yet and the looks of incredulous disbelief (or disdain) when a question is asked, is part of their usual demeanor. And yet, for all that incredible intellect, they are pathetic mechanics. They don’t seem to be able to grasp the physical aspects of the human body nor the common sense of surgically removing the cause of a problem.  Don’t ever try to quiz a physician on anatomy. They do know a lung, stomach or the brain when they see one, and they do know the rough whereabouts these organs lie, but they’d be hard pressed to know the origin and route of every blood and nerve supplies. Some even turn pale at the sight of blood, and becomes completely useless when anything remotely looking like a surgical instrument is placed in their hands. My mind is not geared like a physicist or mathematician. I cannot think like a physician. I don’t have the patience to wait and see whether a drug I have prescribed is going to work or not. I would much rather do something active about it. Even then, after surgery, I usually can’t wait for the patients to wake up and let me know if they feel better.

By now, you might think if I wasn’t committed to the world of insane, I would make a good psychiatrist. Wrong. I have lots of time for shrinks. In fact, I have spent a lot of time with mine. I remember thinking, as I went on and on about the stresses of my work and how pathetic I feel, painfully dragging it out into a full hour, why anyone would spend day after day listen to people whine about their problems. In fact, what was even more frustrating, was the fact that there was nothing he could do about my situation. He couldn’t make my bullying colleague stay away from me; he couldn’t tell the crazy patient to stop hassling me; he couldn’t give me two months’ worth of salary so I could take a holiday; nor could he try and change my husband into a domestic goddess. He was a sounding board, someone to make me see a different perspective of my life, and occasionally, fiddle with my medication. He has always told me that I would not get better, or cope with life, until I have decided that I can and  I will. I would find being a shrink so frustrating, because I cannot control how my patient feels, change their situations and be able to actively do something to help. For this one, I think I’d rather stick to my role as a patient.

Please don’t think I am bashing other specialities. In fact, I admire all my colleagues, and at times, I envy them. Because I know I can’t do what they do. But if you want a straight answer to why I chose surgery, here it is.

It is because I love it. I can make a difference in people’s lives, I find what I do exciting, and I know I can do it well.

But this is what every doctor will tell you about their specialty.

Don’t just chose surgery when you grow up, chose something that excites you and something that you are passionate about.

And if that happens to be Surgery. Then you have great taste. Like me.