Is there any chance of you coming back to labour ward?

No, I have always said I would stop clinical work at 60. It is physically and mentally so demanding and although one’s brain and decision making are likely to remain good for a while longer, physically I get more tired. My back is not as healthy as it used to be and I have injured both my shoulders on a number of occasions operating on large ladies. Also we know that surgical performance does go down with age: we know that from many studies, and while decision making in the clinical setting counteracts that for a while but the tipping point tends to be at around 60 and I’m not prepared to get into the situation where I feel I should have retired yesterday.

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What made you go into Obs and Gynae in the first place?

I was going to be a GP because I saw the medicine and lifestyle of my father who was a GP in the Scottish Border Hills. He had his own maternity hospital and cottage hospital and did deliveries, minor ops etc, as well as home visits and consulting in the surgery. In those days they were  truly multidisciplinary family physicians. I loved that. As children we used to go out with him to some of his visits and I thought I’d love to do that sort of medicine. When I saw what general practice was in London and in fairness in the modern day city, it no longer appealed to me. I would have been be a terrible GP - I don’t think I would have enjoyed the demands of screening through many minor ailments to find the ones that needed escalating. I much prefer treating patients with more serious pathology. As a student I loved theatre and I loved children so I then thought I would be a paediatric surgeon to combine those two loves, but when I did paediatrics I found I didn’t enjoy dealing with sick children I preferred children who could be played with. My next attachment was O&G which I was not looking forward to but I absolutely loved it from day one. It’s got the theatre, it’s got the emergencies, it’s got the well kids that come in with the pregnant mums. I got all my surgery from the gynae side of it and it just ticked all the boxes, I absolutely loved it

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You said to me yesterday that you have the FRCS – when and why?

In those days we could train ourselves, there was no run through training. As soon as you started one job (each was for 6 months) you started applying for the next one. Whilst this was unsettling and demanding it did mean that you could build your own expertise up. It was great - you weren’t taking anyone else’s number so you could take the time you needed to develop your own skills. I loved theatre and I thought actually I would probably end up as a gynae oncologist and therefore wanted to get detailed surgical training. So I did Obs and Gynae for a year to demonstrate that I wanted to do it and then went off and did anatomy demonstrating, A&E, ortho & trauma and general surgical training all of which I loved. After I got my fellowship I came back into O+G as planned, and I have found this surgical training hugely valuable throughout my career. The depth of knowledge you have to know for anatomy for primary fellowship exams was phenomenal and was very helpful when operating in a difficult pelvis. Knowledge of the physiology was really good, and generally being comfortable doing laparotomies for patients with acute abdomens was really useful. It is such a shame that run through training has stopped all that because people can’t do each other’s professions. And if you do do it, it’s at such a junior level you don’t really get appropriate experience and understanding. The surgery I did included GI surgery, colonic resections with colostomies etc and I was also on the renal transplant team and usually had the job of mobilising the ureters etc so really good experience for gynae.

 

Who influenced your career the most?

A number of people over the years: I worked for a surgical tyrant called Bert Thompson who we were all terrified of as houseman, but he taught us attention to detail. He made us phone him up every night to talk through his patients which was an education in itself, being critical in reviewing patients, and he always asked the Why question, and he checked we understood what we were doing and was so obsessive about it, it was such good training. He once asked me with a renal transplant patient what the patient’s weight was after I had done my evening round -  I had no idea and  said so but added that the weight chart  looked like the North Face of the Eiger going down ( we looked at their weight to see when they started peeing as an indication the transplanted kidney was starting to work) I was expecting to be blown through the roof because I didn’t know the number but what mattered was that I understood why weight was important and that the relevant fact was that it was going down and therefore he said no that’s fine you understand the principle behind it and that is most important. So he was good at teaching why things matter and as such he was very influential in the sense of the detail with which he expected us to know our patients and our understanding of the why.

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Then in O+G at St Thomas’s I worked with Cathy James who later went into the MDU and she was a really good diagnostician, and I always said I would want her to decide which operation I needed and then I’d want Tony Kenny to do the operation – he was great with his hands.

But I suppose my pinnacle would be David Morris who is now dead:  a Welshman who was a consultant at Charlottes, and a wiser man I have not met. I used to find myself thinking when I was on my own going solo after my junior years: what would David Morris do in this situation and his reasoning would come to me and I would manage things.  He was thoughtful and careful and a really good technician too – a truly holistic doctor.

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Do you think that the people that have influenced you, have influenced the way that you teach the trainees now?

Yes I’m sure of that. The first one who instilled such terror in us all was a good example of how not to do it- but his principles were excellent – just the way he did it was so intimidating. The teaching and emphasis on why we do things I did appreciate though, and no-one ever doubted his commitment to his patients who adored him.  I have therefore not avoided expecting high standards, but I hope I have required them with a constructive supportive approach.

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What has been the high of your career?

Gosh, in terms of job progression I think probably getting the senior registrar job at Charlottes because it was earlier than I (or anyone else) expected me to get a Senior Reg job. I guess they recognised I might be useful to them at a stage when I wasn’t really sure I would be. The job highs have mostly been to do with a job well done, be it a complex operation or delivery (how funny that with these the patients so often take  it for granted things went well and you think hang on I’ve done a really good job there but they haven’t recognised it because you’ve been very calm about it) or at other times  just doing  straightforward things well and often these are followed by the patient / relatives being so grateful!

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I have also loved the teaching too and watching trainees learning, improving, and especially coming back at more senior levels well equipped and competent.   I got a text not so long ago, a couple of years perhaps, to say ‘thank you, you’ve just saved a life’ –an old  trainee of mine who was now a consultant had done something really skilful and obviously had thought about what I had taught him and contacted me to say I had saved a life even though I was hundreds of miles away -  that was a really nice feeling.

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What about the lowest point in your career?

Worst point – I walked into a room at the old Charlottes as a senior registrar and there were two SHOs trying to get a fetal blood sample – it was so difficult because the head had drifted out of the pelvis because the uterus had ruptured. The baby died and I was very upset about it – I had taken over a labour ward that was manic and heaving and I had prioritised three patients that all needed to go to theatre, one of whom was this woman and she had been 3rd in the queue and I’d done two CS and come back to find this lady decompensating -  I don’t know to this day if I had done them in another order, whether one of the other babies would had died instead but I couldn’t do all three at once. That was really tough because I knew she needed delivering but I couldn’t physically do them at the same time – that was terrible, a bad moment.

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In those days how did you debrief, did you have anyone to talk to about it?

The consultant came in the next day, and I told him what had happened, and he noticed I was about to drive up to Scotland and he said you can’t drive up because A) you are upset and B) you’ve been up all night. I went anyway and I sat in a coffee bar by the motorway and everyone was going home with their Christmas presents and I was sitting there with tears running down my face and they were all looking at me thinking what is happening with that poor woman. There was not really debriefing in the way that there is now.

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What advice would you give the trainees now, moving on from junior to senior or senior to consultant?

Well the most basic principle of clinical safety is to make sure you never miss something that should be obvious to you if you take the time to think about it. The safest question you should be asking yourself is Why? – if someone comes in with a transverse lie, or in preterm labour- why is that the case? -  it sounds obvious but it is often not done. Often at the end of a clinical assessment people don’t make a decision on what it might be, they just think well it is abdo pain and we’ll do some tests, but I think they need to come off the fence and make a decision / differential diagnoses: think  what is most likely and also what must you not miss – working from first principles using  basic knowledge and common sense helps with this process.

The other thing in terms of progressing up the chain of command is to think – when I am at the next level would I want to know what is going on now – if so then for goodness sake tell them. A phone call is easy, and informing upwards is always a good thing – not only does voicing your summary inform them it often informs you as you collect your thoughts.

 

What are the common mistakes that you think registrars make?

Not thinking – doing things too quickly, not being critical. The other advice at each level of senior jumping, particularly at senior levels – along the same lines as above recognise when you are getting  into difficulties and tell your consultant sooner rather than later. Because part of the problem when you become a consultant is you are called to see things that would never have happened if you’d been dealing with it yourself. One of the things is recognising and avoiding getting into difficulty, not just being able to bail yourself out of it.

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Why do you think some trainees are afraid of you?

I am very sad if they are. I can see that I am particular about attention to detail, and as such I’m a hard taskmaster, but that should not engender fear. I would understand apprehension and hopefully a striving to get things right and be thorough. I hope they’re not actually frightened as this can inhibit learning. If it puts people on their toes that’s a good thing I suppose, but if I genuinely frighten people then I have failed!

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What makes you happy?

My family is top of the list, then doing a good job, seeing a good job done, and especially seeing other people whom I have taught doing a good job