BJJ News | I ssue 7 | J une 2015
Orthopod’s view
T. Morley
Things I wish I’d known when I started Having recently been ‘defrocked’, it seems opportune to look back on the lessons of a long career in orthopaedics. The choice of a surgical career is a mixture of chance and serendipity. As a medical student I never had any doubts that I wanted to be a surgeon, for I had been dissecting worms and frogs from the age of six, but what did concern me was what field of surgery to undertake. Having qualified, I looked at surgeons: at that time cardiac surgeons were the ‘glamour boys’ and I could not resist the temptation to join them. How do you go about becoming a cardiac surgeon? I concluded the way forward was to visit the Mecca, at that time Houston in Texas. On the cardiac unit in Texas there was no shortage of drama: the atmosphere was both challenging and unpredictable and at times depressing. However the cardiac surgeons were different. Does the speciality breed personality or is it the other way about? I sought in vain for humility and insight but this did not seem to exist in the infancy of open-heart surgery. I came home convinced that it was not the speciality for me. When I was training, there always seemed to be time to reflect and make career choices. It took fifteen years to become a consultant, during which time we were exposed to many subspecialties and gained a very broad perspective of surgical opportunities. I decided I would become a neurosurgeon. Six months as a neurosurgical trainee was challenging, unpredictable and often depressing. Sadly, only too few patients seemed to benefit from intervention. The neurosurgical response was to become eternally optimistic, unfailingly confident and with even a touch of the deity. I felt I did not fit, so what next? Having sailed all my life and loving water I considered urology, but found that triangulation is not a natural gift: I spent many frustrating hours finding my way back to pathology, fleetingly glimpsed in the gloom. At this stage I was exposed to orthopaedics, and thus ended my dilemma. Orthopaedic surgeons were different, a happy, outgoing breed, cheerful and unfailingly optimistic despite setbacks. I came to appreciate that nature and growth could easily destroy success but at the same time could turn a sow’s ear into a silk purse. There was an immediate synergy; I had always felt comfortable in the pub after a long frustrating clinic. I had not, however, appreciated how diverse a speciality orthopaedics is; was I going to be a trauma surgeon, a microsurgeon or even an arthroscopist? At just this time, the freedom to plan one’s future career was lost when we were all assigned to training rotations. As a rotating registrar, the worry about unemployment was removed at the expense of the freedom to research and plan your future. Just as a six-month assignment became interesting and you became a valued member of the team you were moved to another unit, which was inevitably never going to fire the enthusiasm. Training rotations are set up with the aim of satisfying service needs, not necessarily a chosen pathway
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designed to train, stimulate and enhance. A trainer’s ability to excite and stimulate interest in a sub-speciality is dependent on a broad knowledge of the subject, a solid research background and an ability to demonstrate technical skills, a combination difficult to achieve and to quantify. Now that nobody swears the Hippocratic oath, the ability and responsibility to pass on knowledge to the next generation is being lost. Orthopaedics has never come to terms with evaluating surgical skills, so much a part of surgery. The manual skills of engineers and airline pilots are regularly assessed but, for some reason, those of surgeons are not. As my registrar passed a needle through my finger whilst operating on a patient known to be HIV and hepatitis E positive, I was able to accept that I was not a very good judge of technical skills either. In the past I have advised a trainee that they lacked the necessary manual skills, and that this would inevitably have an impact on their future. To have raised this during training was justified recently when a past trainee wrote to me on his retirement as a professor of pathology thanking me for diverting him into a speciality that had given him immense pleasure and satisfaction. Before embarking on a medical career I worked as an engineer. The skills learnt at the bench stood me in good stead and laid a foundation of biomechanics and wear properties. Later, I was involved in designing a spinal implant but soon learnt that commercial pressures do not sit comfortably with medicine. Commercial relationships with implant companies need to be strictly monitored; there are too many pressures on clinical time and too many financial temptations to resist. The partner to freedom is the need to respect clinical commitments. When I was exposed to spinal surgery, I realised that I had been lucky enough to find my niche, however that exposure was by pure chance. A balance of challenge, innervation and risk that I found invigorating was combined with a mix of orthopaedics and neurosurgery. When you take on the responsibility of becoming a consultant, it is difficult to appreciate that with it comes worry and uncertainty for surgeons, patients and relatives, as well as the pleasures of success. It is no easy task to train in empathy when you are so intimately involved. A surgical career is both a celebration but also an addiction. There is no doubt that one’s family suffers as patients intrude into your life and it is at times like this when one is grateful for the teamwork and support of colleagues and staff, and, of course, the administration. It is always said that an orthopaedic surgeon is as strong as an ox and twice as intelligent. After a long career I will embrace that view with no regrets. A uthor
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Tim Morley Formerly Consultant Orthopaedic Surgeon, Royal National Orthopaedic Hospital morley@fifehouse.freeserve.com