How to work in general surgery
As well as technical expertise, one of the most valuable assets a surgeon can have is knowing when not to operate, says Dr Theshni Govender
There is an unconscious instinct that propels some doctors towards a career in surgery. It is not perceived as a rational or practical choice by doctors who pursue specialties where training posts are more easily available and the minimum time required to complete training is less than five years.
The present requirements are a reflection of the competition for training posts in surgery. Experience beyond community service in a formal surgical service, completion of ATLS, a basic surgical skills course, and the primary examination of the College of Surgeons, together with a keen interest in research have all become necessary.
Surgery epitomises decision science in medicine and community service is the starting line for developing surgical insight and instincts. Working in remote areas with resource and staff constraints exposes methods that are innovative and ingenious and conditions that are frustrating and potentially hazardous in some instances. Finding time to study, write the primary examination and attend the required courses in these environments is challenging at best.
Surgery epitomises decision science in medicine and community service is the starting line for developing surgical insight and instincts
Spending time in an established surgical service at a level two or three hospital as a medical officer, post community service, is perceived as an opportunity to ‘learn to cut’. This is a great time to start chronicling your development in a logbook. Aside from being an attachment to your CV, habitual and meticulous recording will save you time and effort spent on retrieving this information retrospectively during your formal training. Operative skills learnt in these environments have less to do with technical knowledge and more to do with decision science and carefully honing the most valuable asset a surgeon can have – knowing when NOT to operate.
Academic surgery is ever-inspiring and challenging. The technical prowess displayed by the finest surgeons at the peaks of their careers is a veritable wonder to behold. Discussions with these intellectual giants are stimulating and fascinating. It becomes clear that a surgeon is an excellent physician who has exemplary technical skill with his hands. Imbuing this mindset into the very fibre of your medical mind is crucial to success in surgery. A good surgical trainee is well read and never stops thinking, planning ahead and considering possibilities.
The general perception of a surgeon is that of a doctor operating on a patient. Although this is the most anticipated and treasured facet of the job, it is only a small proportion of the work that surgeons actually do.
Days in surgery are far longer than the sun shines. Ward rounds define where days begin and end: between rounds are clinics, operating lists in theatre, teaching sessions with students and learning sessions with seniors. In an academic setting, weekly meetings include radiology consults, multidisciplinary team discussions (with pathology and oncology) and the morbidity and mortality review.
Surgical on call is mentally and physically demanding and routinely extends beyond the following afternoon until all cases admitted during the call are completely managed. On call in the trauma unit is a component of general surgical training – these calls in a busy centre provide invaluable opportunities for developing technical and decision-making skills. Calls also challenge your ability to lead and be part of a team.
This career is an academic apprenticeship gleaned from many mentors. The learning environment is often incredibly stressful. Teaching, particularly during technically demanding surgical procedures, can be interpreted as highly critical and harsh. It is crucial to understand these situations in context, extract the teaching point and continue with the task at hand with proficiency and professionalism. Highpressured situations are synonymous with this career – they need to be handled with diplomacy and tact, none more important than when patients and their families are present.
Surgery as a field of research is evolving: new developments make surgery less invasive. We are fortunate to be exposed to traditional and modern techniques. Learning has to be constant and a willingness to change and adapt is necessary. The emphasis on research is evidenced by the introduction of the MMed (Surgery) as a compulsory component of the Fellowship.
Knowledge of research methodology, statistics and scientific writing is beneficial in executing this project timeously. Instead of a task, this project can be viewed as an opportunity to spend some time on a subject that is your passion or field of interest. At present, not all centres have equal support systems or a dedicated amount of time allocated for research.
A surgeon is only as good as his or her team: remembering and acknowledging the value and contribution of every member of the team is the key to success
The bigger picture
Surgery is very much a team sport. Apart from learning, teaching and doing research, the surgeon must be the conductor of the orchestra involved in the care of his patient. Well before reaching the ‘red-line’ in front of the operating theatre, the efficient surgeon has co-ordinated the physician, anaesthetist, radiologist, oncologist and intensivist who are all critical in the medical care of the patient.
At the red-line, he or she conducts the nursing staff, porters and the family with a last word of reassurance before entering the operating room. Under the lights, the focus must be on the procedure being performed without losing sight of the patient’s physiology and the theatre staff. After the surgery, the surgeon must ensure that his or her patient is stable and that all the required postoperative instructions have been followed.
Outside the operating theatre, another host of hospital employees facilitate our work. The clerks in the clinics and the wards, radiographers, physiotherapists, dietitians, cleaners and porters all deserve recognition as members of a successful surgical team. A surgeon is only as good as his or her team: remembering and acknowledging the value and contribution of every member of the team is the key to success.
As a surgical trainee, self-awareness is a prized virtue. Knowing the limits of your capabilities and recognising when you need assistance during a surgical procedure places the value of your patient’s well-being above your own ego. As with everything in life, mistakes will happen. Accepting and learning from them will allow you to progress and excel.
At the end of five years of training, an MMed thesis, and an impressive logbook, the general surgeon faces his or her next challenge: choosing a subspecialty, working in the private sector, pursuing research, or working in a peripheral hospital. Only at this point do you make any real choices. Up until now, you have been chosen, for as much as each of us thinks we chose to be surgeons, it is surgery that has chosen us.
Only a surgeon can have the privilege to hold a beating heart in their hand and mend the tear
It’s one thing to know the anatomy of a heart from a textbook or a dissection lab; know the physiology of the muscle cells and conduction pathways; be able to interpret the most complicated ECG; visualise the coronary arteries on a screen and stent them percutaneously; replace a valve through the femoral artery – all are medical marvels and technical triumphs. A bleeding heart, torn at the ventricle, threatening its vulnerable body with only minutes to live, is another entity in itself.
Only a surgeon can have the privilege to hold a beating heart in their hand and mend the tear. It is privilege earned by sacrifice and, to my mind, worthwhile beyond all description!
Dr Theshni Govender is the President of the South African Society of Surgeons in Training, and is currently a senior registrar at the University of the Witwatersrand
Support in Training
The South African Society of Surgeons in Training (SASSiT) is a not-for-profit society for trainees, run by trainees.
SASSiT aims to make life easier for surgical trainees, for example they provide fast-tracking for the ATLS course, facilitate exam preparation courses, and represent trainees at national forums. More information can be found at: www.sassit.co.za Facebook (search training surgeon) Twitter (@tweetsassit)