Friday, March 20, 2015

Poaching staff is not the done thing. Or is it?

It takes a lot of effort to train up a surgical assistant, particularly with complex surgery. Surgeons who have been involved in this process will by virtue of human nature and tradition of self entitlement, feel some sense of ownership for the person that they trained and the expectation of some loyalty.  I am not saying that this is a correct way of thinking but it is human nature.  

Over the past week, two of my surgical assistants were approached by a colleague in my specialty who attempted to entice them away with significantly greater remuneration. The initial reflex response was "How dare he?" and “This is totally non-collegiate”.  Both of them had no interest in changing surgeons but had rightly done their own due diligence to learn more about the surgeon making the offer. They had both come to their own conclusions on the basis of feedback that they would prefer not to work elsewhere in spite of the higher remuneration. 

Initially I felt a little irritated but this was very quickly followed by the rationalisation that we have an open business market in Australia and this type of activity is fair game.  Whilst surgery is associated with a special relationship that the defines the patient-doctor relationship, there is a business side to it that is no different to any other business.  For example, Virgin Australia is free to approach key Qantas staff that it may wish to headhunt for a role in its own organisation.  Even though Qantas may have been invested enormously in training a given individual, they have no ownership of that person’s career destiny.  

Whilst the behaviour of headhunting staff is nothing unusual outside the medical profession, we have to learn to adapt to the fact that we are subject to same market forces and expectations as any other business. The old boys club approach to how we do our business does not cut it anymore.  This is no different to how the medical profession must be expected to deal with issues of sexism and harassment like any other profession with the same transparency and commitment. Time to get to down from the ivory tower.  

Friday, March 13, 2015

It Was All My Fault That a Patient Died.

Back in the late 1980’s, I was working as a junior general surgical registrar. In such a role, I was allowed to perform minor surgery, often unsupervised. Back then, general surgeons were commonly performing carpal tunnel release surgery although nowadays, they are performed predominantly by specialist hand surgeons. I operated on a man who had bilateral Carpal Tunnel Syndrome.  The surgery was performed under a local anaesthetic block which means that his arm was made numb and he was able to be awake for the duration of this short case. I operated on one side.  All went well.  About three months earlier, he had been operated on the other side by one of colleagues (who was at the same level of training as myself).

Totally unbeknown to me was the fact that an intern had ordered pre-operative blood tests, an electrocardiogram and chest X-Ray in the week prior to the surgery.  These tests in an otherwise well man with no co-morbidity and having a procedure under a local anaesthetic block is unnecessary. I was to learn that this was the case about 8 or so months after performing the surgery and by this time, I was working rotation at a secondment hospital.
I was one of two carbon copied doctors on a letter that had been written by a cancer surgeon.  The other cc doctor was a respiratory physician.  

The surgeon described the history that had led to the presentation by this patient with symptoms. He wrote “somebody had operated on this patient and not checked his CXR which at that time showed an obvious coin lesion in the lung”.  It was intimated that the patient could have been cured of cancer if diagnosed at that time had the CXR result had been checked at the time.  It was very obvious that he was apportioning blame on me for not checking the result of a test that I had not even known or should have expected to have been performed. It was interesting that the same unnecessary work up had been performed for the patients first carpal tunnel operation a few months earlier.  I could see exactly how this would have happened on the second occasion where an bewildered intern just followed what was done on the  previous occasion.
I was devastated to receive this letter.  I did not dare communicate with the surgeon to explain my case as I truly believed at that time, any disagreement with the surgeon would be the end of surgical career. Over the next 18 months, I continued to be copied in on correspondence outlining the patient’s demise in spite of curative attempts and ultimate death.  Every time I received these letters, I would fall into depths of depression for several days but I would always develop a mechanism to cope. When the letters arrived, dread would fill my face before opening the envelope as I always knew what lay within.  I would go to a room by myself and read it again and again and again.  I looked at it as being my problem and could not feel I could raise it with anybody, including my partner at the time or my surgeon mentors.  He had amassed incredible power in surgical politics and was not one to be reckoned with.  I was totally and absolutely petrified of him.

Periodically I would think of this case and it was not until some 15 years after the event that I would seek closure. This matter had ruminated in my head like a festering sore.  This process began went I was invited to a 50th birthday party and at dinner happened to be seated next to the respiratory physician who was involved in the case.  I found myself opening up to him about this story that I had kept locked away for so many years.  It was quite liberating to be able to speak about it for the first time.  It was amazing that he seemed to remember the case.  The physician was less than complimentary about this surgeon's general behaviour over many years that had been characterised by bullying, narcism and arrogance.

I had copies of the letters and selected additional clinical information and certainly more than enough evidence for commencement a bullying claim.  I had already briefed a high profile lawyer who was eager to take the case,  Given the particular high profile of the individual and what she considered to be unjust treatment, she was prepared to commence this case without any cost to me. I reflected and asked her to allow me do one last thing before commencing litigation.

I took the step of writing to the surgeon who at this stage was a national figure. He was  big fish to fry if I were to take the matter further. He wrote a meticulously neat hand written letter to me explaining that he regrettably had no recollection of the matter and wished that I had been able to raise the matter with him at the time. The final paragraph was repeated unreserved apology.

Whether the apology was disingenuous or not, I felt that I had got this matter off my chest and he was now aware of what I had experienced as a result of his actions. The act of opening up about this case and to then communicate my story to the perpetrator was extraordinarily liberating to me and to the extent that I had lost energy to commence litigation that was destined to make the press.  

I destroyed the documents.  The matter was over from my perspective.  The chapter was closed.  I did not think about this story again until the recent media coverage of harassment in the medical workplace.  I have my blog and here is my story. Do you have a story to tell?

Click below for:-

Background to my relationship with the surgeon discussed is covered in the short piece that precedes this post.

Feeling Like You Have No Control Over Your Destiny

This very short blog piece serves as some background information for the next piece.

When I was a surgeon in training, there was obvious rivalry between two members of the unit. If one of the pair liked you, your time with the other was going to be challenging if not miserable.  It wasn’t necessarily vice versa because you could always be facing the wrath of both with the result of saying goodbye to your surgical career. You did not have a choice. It was like the sorting hat in Harry Potter that chooses your house.  

The surgeon who did not take a shine to me was often critical and certainly made little effort to engage with me about matters unrelated to surgery. This did not worry me so much for the fact that I was in constant fear of having my career axed if I put a step out of place.  I was not one of the "boys" - I was from an ethnic background, went to a public school and had no interest at that time in rugby union.  I was everything that establishment surgery was not.  My colleague mentioned in my next blog piece was one of the "boys" and went on to socialise with him outside the work setting.

He enjoyed having an audience in his operating room. Typically there would be 12 to 15 people and depending upon the week it might be other doctors, nursing students or physiotherapy students.  On one occasion, he left me to close the wound so he could step out to make some phone calls. When I reached the skin closure, he came back into the room and yelled at me "Gee Henry, you're meant to be getting better, not worse" and stormed out of the room.  For that moment, it felt like there were 100 people in the room.  I was totally and absolutely humiliated.  

This was the most stressful period of surgical training.

Related Blog Piece - click below
It was all my fault that a patient died

Sunday, March 1, 2015

How Cancer Spreads.

Think of London as an overcrowded uncontrolled population of humans. Humans are like the cells that make up a cancer. Think of London as a primary cancer. I think of it as being an aggressive prostate cancer that wishes to progress but it could be any type of cancer. During the 1700’s and 1800’s, boats set sail across the oceans to find new lands to conquer. Initially, the journey provided many hazards to prevent these boats reaching their destination just in the same way that our blood stream and lymphatic channels have defences that destroy cancer cells as they enter into the circulation. Over time, new skills were acquired such as better boats, better sailing practices and the ability to fight journey related diseases such as scurvy. In a similar way, cancer cells entering into the circulation develop new skills to overcome the defence mechanisms in the circulation by mutations and are eventually able to reach their destination afar. 

Once the boats reached their destination, Sydney in Australia being a perfect example, there were local challenges to be overcome in order to survive and grow. These included food and water supply as well as battling a hostile indigenous population. This is a similar situation to when cancer cells attempt to implant at a place distant to their primary location after surviving and travelling throughout the circulation. When prostate cancer arrives in bone, the immediate instinct of bone is to mount an attack against the foreign invaders.  In a similar way to acquiring the skills to survive and travel through the circulation, the cells must now acquire the skills to overcome the local host defence mechanisms.  When this occurs, the cells are able to set up a colony and expand and gradually consume the host organ as they had done to the primary organ. 

When we look at the population of humans under the microscope during the period of British colonisation, the humans in London look the same as in Sydney.  When we look at cancer cells from the primary and compare them to the ones seen in the secondary or metastasis, they likewise look the same. 

To recap the British colonisation model for metastasis, London is the primary cancer, the oceans the circulation, and Sydney a secondary cancer or in other words a metastasis of London.