Friday, May 29, 2015

Cardiac Surgeons Were Once Untouchable

About 30 years ago, coronary artery bypass graft surgery (CABG) was the mainstay of treating narrowed coronary arteries that supplied blood to the muscle of the heart.  Such surgery was predominantly, if not all, performed in the public hospital system where there were long waiting lists.  Demand outstripped supply of such service and cardiologists were at the mercy of cardiothoracic surgeons who could determine which of their patients they would accept for treatment and the priority afforded to them.  The CABG was a genuinely life saving type of surgery and the high success of this surgery by highly trained surgeons provided them with unparalleled status in the hospital pecking order.  The cardiac surgeons received the adulation of the press and public for the life saving work that they were performing and sure enough, they came to truly believe that they were the heroes of the medical profession.

The behavior of cardiac surgeons was one of self-entitlement and demand for unquestioned respect and admiration.  Whilst capable of great empathy and care for their patients, they treated members of their surgical team and own profession with disdain and at times unbelievable cruelty. As providers of essential services that were in short supply and high demand, hospital administrators would bow to unreasonable demands. They were effectively untouchables.

Whilst there are too many stories to mention, here a couple that I recall as vividly as if it happened yesterday. 

When I was a junior doctor, I had softly remarked that my nose was itchy under the theatre mask. This was overheard by “sir” who then came up to me and squeezed my nose and twisted and said “this will fix it” and went off laughing.  The pain was excruciating and I quietly slipped away outside the operating room pretending that it did not hurt at all. My nose was bleeding.  Once cleaned up, I returned to the operating room and pretended that nothing had happened.  I did not dare challenge him for this assault and I also knew that nobody in the room would dare to support me for all of us were afraid of him. 

My six months as a surgical registrar to “sir” was a tough gig psychologically, The work itself and at times long hours was never an issue but the constant barrage of abuse was taxing.  I was so ashamed of admitting that it was getting to me that I recall not even discussing it with my girlfriend of the time (who was also a junior doctor) or any friends as I felt that I could not afford to demonstrate to anybody any sign of weakness or potential inadequacy to make it through the rigors of surgical training. “Sir” loved an audience and we would usually have up to twenty people in the operating theatre to observe such as medical students and physiotherapy students.  He just adored the physiotherapy students, particularly the attractive female ones who appeared to get special attention and this was returned with blushing adulation.  Not uncommonly, I would start closing up the wound and he would go out to make a phone call. He would then return and yell to the entire room “Henry, you’re meant to be getting better, not worse” and would then storm out of the theatre.  The operating room would then be so quiet that you could hear a pin drop above the noise of the anaesthetic monitoring devices. I could go on and on, but I made it through.  I survived.

In later years I had transferred training programs and went from being a general surgical registrar to a urology registrar.  At a different hospital, I entered a service lift and the only other occupant was a cardiac surgeon, a different “sir”.  He did not acknowledge me in any way but what did I care.  The next floor, a wardsman entered the lift and tripped over the lip of the elevator floor and bumped into “sir”.  Yes, he committed the greatest possible crime and touched “sir”.  Over the next couple of floors, “sir” proceeded to abuse him “how dare you blah blah blah …..” and refusing to listen to his repeated attempts to apologise.  The wardman was petrified that the surgeon would lodge a complaint and that it would lead to his dismissal.  I was so shocked that I stared in silence and whilst he had little ability to impact on my future career, I was still too frozen in fear to say anything.  Immediately after the event, I felt enormous guilt for having said nothing. For me it will always be one of those moments that you remember where something could have and should have been said.

These stories are pretty tame compared to others I have heard. The fortunes have changed significantly for cardiac surgeons.  Coronary stents are now used where surgery was once necessary. Cardiologists control the flow of work to cardiac surgeons and can make or break the success of their practices.  I have personally seen where a cardiac surgeon at a hospital I worked at was completely starved of work to the extent that he had to take a salaried position interstate.  There was never an issue with his clinical judgment and technical skills but with a totally obnoxious personality from the cardiac surgeon old school, his private practice disappeared in favour of other surgeons who were prepared to be more personable.  Cardiac surgeons can no longer be seen to be self entitled poisonous individuals.  Everybody knows that cardiologists are the masters of cardiac surgeons and what huge fall it has been from the top of the ivory tower.

Having said all that is above, I have great respect for my cardiac surgery colleagues. Their professionalism and care for my own family members who have needed their skills will always be appreciated.  I really believe I have seen the worst and now best that these surgeons can offer.  

At least in this surgical specialty of cardiac surgery, technology and medical advances have had a positive affect on surgeon behavior. 

Wednesday, May 27, 2015

Bullying Culture in Surgery - Has Nothing Changed?

The airing of the Four Corners report on an entrenched culture of bullying of surgical trainees and medical students has for the very first time pushed this matter into the public spotlight.  The obvious reason for the suppression of this ugly behavior is the enormous power imbalance that exists between perpetrators and victims.  Medical students, and particularly surgical trainees, are unwilling to come forward as their career progression is totally at the mercy of those who have significant influence over the results of their progress reports.

I hear the argument from a number of my colleagues who say that everybody is getting too soft and that they dread the ability of these ‘mollycoddled children’ to handle the stress of dealing with catastrophic bleeding at 3 am in the morning. I totally reject this assertion as justification that an intimidating bullying culture has a role to play.  I am not aware of any evidence that a non-confrontational approach to training will impacts upon the ability to perform following the completion of training.  When we look at the commercial airline industry, it is the meticulous training that prepares pilots for a variety of catastrophic events.  Being yelled at, publicly humiliated and often being left wondering what it was that was done wrong (because one could not dare ask what it was that was done wrong as one should know) is not training. 

It is bullying and harassment and nothing more.

I was on the receiving end of bullying during my training, particular at the hands of a cardiac surgeon, well before I started training in urological surgery.  At that time I felt that he had total and absolute control over my career.  However, it was far more often that I observed my junior colleagues being on the receiving end abuse and harassement. What worries me is that many of my colleagues who were bullied and harassed as junior doctors, do not reflect back as this having been the case.  This is how the cycle of bullying continues. Their interpretation of bullying has been reset by their experience to become a norm of surgical training.  They too go on to repeat the behavior experienced during their formative years as surgeons.  The words of Dr Vyom Sharma are chilling but demonstrate great clarity in the problems we face: –

"In one moment I could just see how this all happens. Someone bullied him, he bullied someone else, and now it's my turn."

The stories on Four Corners make me worry and wonder if it really could be a case of where “Nothing has changed”.

Maybe I should provide some context of how things were different when I was training.  I was absolutely everything that was atypical and confrontational to the surgical establishment when I wished to undertake surgery as a career in the late 1980's. 

I was Asian, went to a public high school and at that time, hated rugby. 

I was definitely not “one of the boys”. Tearoom discussions were often lonely as I had no ability or real interest to discuss the results of the last weekends’ private school rugby game or who should play fly half for the upcoming Bledisloe Cup.  Apart from clinical matters, I had very little in common with my surgical seniors.  My colleagues who fitted the perfect surgical role model would regularly get the pat on the back for being a ‘good bloke’ and were rewarded with more opportunities to try their hand at surgery. The diversity of surgical trainees and subsequently trained surgeons has changed enormous since then due to surgical training programs being taken out of the hands of individual hospitals and therefore the hands of a very few powerful individuals.  Centralised selection for surgical training was a very positive step forward although for general surgery it was introduced after my time.  I remember having little support base as none of the surgeons were really my ‘mates’ but I was fortunate to have sufficient numbers of surgeons who saw that I had talent and were prepared to put their reputations on the line to help me achieve my career aim.  I always remember this as a reminder that there was also a lot of good in many of the surgeons who mentored me as a junior doctor and it was not all bad.


(Note for those outside of Sydney - back in the 1980's Rubgy Union was a game that was almost exclusively played in elite private schools. Public schools and non-elite private schools tended to play Rugby League.  Back then, the vast vast majority of surgeons had been educated in the private school system apart from a handful from exclusive selective public schools)