BJS Bookshelf: Mastery
10 March 2023
17 January 2022
I retired from clinical surgery in 2015. My main area of interest was surgery of the upper GI tract. I was Professor of Surgery at the Universities of Bristol then Birmingham for 18 years, President of the Royal College of Surgeons of England from 2017 to 2020 and have been associated with BJS for over 25 years, becoming joint chief editor of BJS in 2010 and founding chief editor of BJS Open in 2017.
At the end of my third year as a medical student in Newcastle, I had a 3 month elective. I had enjoyed my first surgical attachment, so I asked the Professor of Surgery where I might go to see if surgery was the specialty for me. He recommended and helped me get a place at the University of Chicago. At the end of that summer, I had made up my mind.
Just about every surgeon I came into contact with during my training, had some influence. Sadly, there were some whose attitudes and clinical skills left much to be desired, but if nothing else, they made me think ‘I will never do that’. Two individuals stand out though in my development.
George Block was the surgeon in Chicago who turned me into an aspiring surgeon in the summer of 1974. I could write a separate article on his methods of inspiration. Although he would undoubtedly have struggled with 21st century attitudes, his basic beliefs still hold true today. Reading widely around your subject, formulating your own views about the quality of evidence and being willing to challenge all that was weak was fundamental. The welfare of the patient was paramount. It overrode all social activities and most family ones. I never had the courage to ask what the latter involved. Striving for clinical excellence was the only way to deliver high quality surgery. He emphasised the importance of judgement based on risks versus benefits for each patient and there was no excuse for technical ineptitude either due to lack of practice or deficient knowledge of pathological anatomy.
I had known John Farndon since starting medical school and who was a surgical registrar when I completed my final year attachment in surgery on the Professorial unit. Our careers were to remain intertwined for the next 27 years. He was Professor of Surgery in Bristol and Chief Editor of BJS at the time of his sudden death in 2002. His devotion to clinical and academic endeavour was inspirational but he also made me realise the importance of the trust that the patient places in the surgeon along with the privilege that accompanies that sentiment. Humility is a characteristic rarely attributed to the surgeon, but certainty and misplaced over-confidence remain traits that are too frequently exhibited by surgeons. Twenty years after his death, I still miss his friendship.
The most enjoyable period of my training was probably 1980, the year I acquired FRCS when I was a general surgical registrar at Newcastle General Hospital. As is the case now, performance reflected the abilities of the junior members to function as a team. I was fortunate enough to share responsibilities with Malcolm Clague, who understood the bond between surgeon and patient better than most, and Mike Griffin, later to become President of RCS Edinburgh, who questioned everything. The balance between patient care as a team and the individual taking responsibility for actions was never an issue for us.
Every operation that goes well is a triumph, but I suppose we remember those where the outcome is better than expected. A radical pancreaticoduodenectomy for metastatic sarcoma in a 35 year old should not result in a congratulations card when I became College president 20 years later. Unexpected triumphs are great, as long as you keep them in perspective.
A vital characteristic of the surgeon is a willingness to examine events in detail when a patient develops a serious complication or dies. It is important to learn from these events, but not to set out looking for blame. Surgical disasters come in two varieties. There is the type where despite your best efforts something beyond your control results in an adverse outcome. A technically straightforward repair of a ruptured aortic aneurysm complicated by a fatal myocardial infarct merits careful audit, but is unlikely to stop you from doing this operation again. Contrast that with a leak from an oesophageal anastomosis – highly likely to reflect errors in patient selection and preparation for surgery, intra-operative judgement, technical failure or combinations of these factors, that need to be identified and corrected
I have gained most pleasure from witnessing the success of colleagues whose careers I have influenced, especially those who have gone on to lead surgical teams both in the UK and other countries. I am particularly proud of the successes achieved by the women who trained with me in Bristol and Birmingham. It would be wrong not to mention being elected as President of RCS England, but pride in that achievement was always tempered by the sense of responsibility that went with the post.
Fell-walking is my main hobby, allied to local history of the area where I am walking. I am an enthusiastic gardener and chef.
Evolution of a surgical career is important. Although clinical skills are fundamental, it is important not to neglect teaching, research and managerial responsibilities. Each will play an important part at some time in your career
I really have no idea. In medicine, I think probably a pathologist, but I have never thought seriously about a career outside medicine.
None whatsoever, beyond getting older and realising the need to slow down.
Part of the charitable activity of the Society, BJS Academy is an online educational resource for current and future surgeons.
The Academy is comprised of five distinct sections: Continuing surgical education, Young BJS, Cutting edge, Scientific surgery and Surgical news. Although the majority of this is open access, additional content is available to BJS subscribers and strategic partners.