HEART BEAT: Surgical training schemes as such did not exist in the bad old days. You became a surgical registrar working for a group of surgeons in varying disciplines. You provided surgical cover for the hospital at night and dealt with surgical cases from the A&E department.
It was in such a position that I found myself, approximately two years after finishing my intern year. Another exam passed, various locums, hospital and general practice undertaken, a period as Resident Medical Officer (RMO) in a private hospital and now I arrived back in the Mater as a surgical registrar.
The surgical NCHDs (non-consultant hospital doctors) comprised a gaggle of interns, two surgical registrars, and a surgical tutor or senior registrar. The consultants encompassed the main surgical specialties and sub specialties and, in the case of the Mater, cardiac surgery also.
I was assigned to my group of surgeons, three to be exact, and my job was to assist them in theatre and cover their ward beds and casualty admissions. This took all my time and the fact that there were only two registrars meant that every second night and weekend I was on duty.
My chain of command was through the consultant on duty or the consultant whose patient had some problem. I was better paid than as an intern, I think I had reached the dizzy sum of £1,200 a year, with no overtime. The latter word was, as yet, a distant mirage. I was still resident in the hospital but I now had a small room, referred to as The Mezza, off the staircase leading to the residence. I had the luxury of an en suite bathroom and I also had a bedside telephone. That being said it was pretty basic.
What was new and soberly challenging was that I was the surgical registrar on duty. This meant that the assessment and often the treatment of surgical emergencies devolved to me after I had been called. Sometimes it was little trouble, other times it was dangerous and life threatening. I notified my consultant of the problem and sometimes he would come in and take responsibility for the case, sometimes, and particularly as I became more experienced, he would leave the management to me.
This brings me to a pertinent point. Any registrar worth his/her salt in any discipline wished it so. We did not feel exploited and overworked. We wanted to be able to do what was required without the necessity of the consultant coming in and taking over. It was not always possible and it was a measure of yourself and the consultant that problems should not arise through your misplaced over confidence.
Deloitte and Touche in its Value for Money audit of the Irish health system referred to consultant problems being exacerbated by the degree of delegation to NCHDs. I wondered how they would know anything worth knowing about that. I was an NCHD, I was delegated to and I welcomed it. I was not given problems I could not handle. Help was always at hand. I was challenged and that is how I learned my art.
In their recent book, How Ireland Cares, Tussing and Wren carried this nonsense even further. They say had Deloitte and Touche been concerned with the medical consequences of litigation, "they might have mentioned the harmful effects excessive delegation has on quality of care and hence necessarily on medical outcomes, patient health and even mortality".
The Brennan Commission, in a gratuitously insulting and ill-informed comment, recommends that consultants be unambiguously accountable both financially and clinically for their work. They always were.
Over all, the above nonsense is a depressing layer of ignorance. Winston Churchill wrote: "in these days it is necessary for everyone who means to be well informed to have a superficial knowledge of everybody else's business". The superficial knowledge of the above contributions ignores the fact that medicine is far from an exact science; that people die, that wrong diagnoses are entertained and that mistakes are made. It is so in every healthcare system in the world, sadly it will always be so. It is when the "superficial knowledge" is promulgated as established fact that problems arise.
The surgeons who taught me wherever in the world did so conscientiously and to the best of their ability. In my turn, I have endeavoured to do the same for my trainees. This is how doctors have been trained in the western world. It has grown and developed with newer teaching methods and aids but it has served doctors and patients well. From my present situation looking back on life as a surgeon, I can tell the "know alls" referred to above, that delegation, portrayed as an easy and lazy option, is in fact the hardest task in a consultant's life.
My task then was to become a surgeon as competently and quickly as I could while remembering Russel John Howard's admonition, that "the most important person in the operating theatre is the patient".
Paracelsus (1493-1541) defined a good surgeon as having the following qualities:
A clear conscience
Desire to learn and gather experience
A gentle heart and cheerful manner
Moral manner of life and sobriety in all things
He must not be married to a bigot
He should not be a runaway monk
He should not practice self abuse
He must not have a red beard,
There you are now; we haven't changed all that much in 500 years.
Maurice Neligan is a cardiac surgeon.