Reflections of a newly appointed consultant.
Abstract: I had no idea what kind of medicine I wanted to practise when I left medical school. What I did know was that I didn't want to do psychiatry, and I didn't want to do obstetrics and gynaecology. My father is a GP, and I thought I'd follow in his footsteps, but general practice struck me as a tough specialty. In my opinion the hardest job in the NHS to do well, but one of the easiest to do badly. I was jealous of my peers at medical school who loudly declared their love of a particular specialty, and trauma and orthopaedics was particularly popular. I ended up in Colchester, Essex where I met two people who changed my life forever.

KEYWORDS Consultant / Hip surgery / Trauma and orthopaedics
Subject: Consultants
Author: Ingham, Christopher
Pub Date: 09/01/2012
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: Sept, 2012 Source Volume: 22 Source Issue: 9
Accession Number: 309315281
Full Text: Shiv Shanker was a London trained orthopaedic surgeon, and his mantra was 'Do everything to your own satisfaction'. I was an SHO at the time and I wasn't sure what he was talking about. I regard him as the model professional - systematic but not dogmatic, demanding high standards but also easy to work for. Now I am the consultant, I can at last manage patients my way, 'to my own satisfaction'. During my training, I've seen the same operations performed in various ways. Now I can do them the way I want to. I've combined the bits I like from some trainers, and discarded the bits I don't like from others. I recognise that my practise will evolve as I develop as a surgeon and I look forward to honing my skills. Sadly the subject matter we hone our skills on is a patient and we should never forget that. They have placed enormous faith in us when they go under the knife and now that I'm in charge I'm reminded of the privilege and responsibility involved when people come to you for help.

When you are junior you often don't know any better so you go along with what your seniors tell you. An unquestioning respect of authority exists in medicine, and I've heard several colleagues defend their actions by explaining that they were only following orders. 'Why on earth did you do it like that?' 'Mr X said that's what he wanted.' Not quite Nuremberg trial standard, but this defence doesn't stand up in court. Virtually every decision I make is influenced by the spectre of medico-legal action, even more so now the buck stops with me.

The diagnosis is usually pretty obvious in trauma and orthopaedics. The challenge is deciding on a management plan, and then executing said plan to the best of your abilities. There are several ways of skinning the proverbial orthopaedic cat and, as I gained experience and knowledge, I found my way would often differ from the consultant's way. Now I call the shots and it feels good to put my training into practice. The flip side is that I take the flak if and when things go wrong.

Relationship with staff

I loved being a senior trainee. I worked in friendly hospitals, received excellent training and loved going to work. I was competent enough to fly solo, but with the parachute of having someone higher up the food chain to bail me out if things went wrong. Fortunately, I work in a supportive unit where even as a consultant I feel able to call for help when swimming out of my depth. Not every newly appointed consultant is as lucky.

I have lost count of the times theatre staff have commented on how people change once they are appointed. 'But he was so lovely when he was a registrar'. Being a consultant is stressful and I don't think theatre staff appreciate the other pressures we are under outside of theatre. Waiting list targets, overbooked clinics, complaints from patients, aggressive relatives, endless referrals from primary care. So there is this extra stress that you don't have as a registrar.

It's boringly obvious but treating everyone with respect, making reasonable demands and communicating your wishes clearly and in a timely fashion make for a pleasant working environment.

Having an experienced theatre scrub nurse makes a huge difference. I often hear juniors whingeing about inexperienced scrub teams, but frankly, you shouldn't be operating if you don't know the kit. It's up to the senior staff to educate them, not let them experiment on patients.

I'm also fortunate to work with a team of experienced scrub practitioners, many of whom have assisted at more hip and knee operations than I've had hot suppers. I'm not too proud to ask their opinion, and they've dug me out of several holes. It's also good to hear stories about cases the senior surgeons have struggled with: 'Oh yeah, Mr Y did that when he started out as well'. Always makes you feel better.

Training

Surgical training is essentially an apprenticeship. I have been taught by fifty different surgeons during my training, and I have adopted and adapted techniques as I progressed.

The other surgeon I met in Colchester was an SpR called Matt Costa. He, alongside Shiv Shanker, set the benchmark for training and I strive to meet it in my practice. That is easier said than done. Letting someone else perform the surgery which you probably (but not always) do better is difficult; and leaving them to operate unsupervised is a leap of faith. Because when it goes wrong, I'm accountable.

I think a skill gap exists between the current and previous generations of surgeons. Cases which SHOs would do ten years ago without batting an eyelid now challenge even experienced SpRs. If we don't let them operate independently, this skill gap will widen further. However, they must be supervised so our patients do not come to harm. This is another important role the scrub practitioners fill. Once I'm happy to allow a trainee to operate solo, I'll sit un-scrubbed in theatre. All it takes is one look (usually raised eyebrows or exaggerated eye-rolling) and I'll scrub up to see what's going on. Trauma surgery is easier to monitor - you can tell if the surgery's going well by watching the fluoroscopy monitor. Elective surgery is not so easy. If that femoral component has been cemented in backwards you have a late finish on the cards. Prevention is better than cure, and that means an appropriate level of supervision.

A lot of my peers point blank refuse to let their trainees operate on elective cases. I like to think I strike a happy medium. You have to gauge the abilities of your trainee, the complexity of the case, the experience of the scrub team and behave accordingly. It can be painful to watch trainees struggle, but we all went through it. I don't think you need extraordinary dexterity to be a surgeon - plating a fibula is hardly painting the Sistine chapel. Saying that, there are trainees who just don't have the spatial awareness and skills necessary to execute surgery safely. This seems to be more of a problem with the post Modernising Medical Careers generation; fantastic CVs, with publications and presentations all over the world, but unable to cut their way out of a paper bag.

Home

Unless you already live in the area where you're appointed, there is going to be some upheaval. My better half has given up a job which she loved and excelled at to follow me to Norwich. She says she knew this kind of change was on the cards, but I still feel bad for dragging her away from people she's worked with for over ten years.

The hassle of moving to a different area should not be underestimated. I am lucky enough to have landed a job in the region I trained in, so the disruption could be worse. House hunting started out as fun. Now it's developed into a chore. The kids are still young, but their future weighs on my mind. Are they going to get a place in nursery? What are the primary and secondary schools like? For every person who gives me one bit of advice, the next will say exactly the opposite.

At least I have these things to worry about. Jobs in trauma and orthopaedics are few and far between, and some of my friends are emigrating in order to find work. So I count myself lucky to have a job, in a great unit, in a beautiful part of the world.

* Christopher Ingham

Trauma and Orthopaedic Surgeon, with a special interest in hip and revision hip surgery, Norfolk and Norwich University Hospital

Thoughts and reflections on issues of interest to perioperative practitioners

Provenance and Peer review: Commissioned; Not peer reviewed; Accepted for publication June 2012.
Gale Copyright: Copyright 2012 Gale, Cengage Learning. All rights reserved.