This is the second article of a three–part series. In this, the author explores the importance of knowing one's ability and capacity. Part 1 examines the difficulties of a complex surgery and patient care (https://bit.ly/30cZPq4), and the next part explores the importance of adopting innovation and technology, and developing collegiality within the profession.
The truth about knowing yourself
Having been a consultant surgeon for more than seven years, the trials and tribulations I have experienced are hard to condense in just a few pages – I am sure every consultant has their own war stories to share. Almost ten years ago, Dr Alfred Kow and I wrote a personal Opinion piece listing the challenges a surgical trainee would face (https://bit.ly/2SWWiJ5). They included having limited clinical cases to operate on, balancing the need for research and education, as well as finding a specialty and place in a department that he/she would fit in. This has not changed much with time. But the jump to becoming a consultant was quite a leap across a treacherous chasm.
Firstly, knowing yourself begins the moment the specialty examinations finish (successfully!). My own opinion is that even after completing the exit examination, a surgical associate consultant (AC) must view him- or herself as a mere advanced trainee. Although the learning curve of every specialty is vastly different, I am quite certain that there requires a certain volume of operations performed independently, albeit with mentorship and supervision, before a minimum proficiency is achieved. While having the Specialist Accreditation Board certificate denotes independence, I think it is quite clear that the residency training does not equip anyone sufficiently to call him- or herself a specialist surgeon in the field of choice (eg, breast, hepato–pancreato–biliary, colorectal). The mentorship and coaching an AC receives will ensure a good start in his/her clinical career, and is paramount and vital for long lasting competency and safety.
Ability and capacity
As the surgeon grows and matures, one must thus be aware of his or her ability and limitations. This does not mean solely being proficient with the technical know–how, but also ensuring maintenance of currency in knowledge, trends and research developments. Like it or not, one must also keep up with public and political knowledge of the various policy changes that affect how we consult with patients on their care options (eg, Community Health Assist Scheme and Medishield Life). Additionally, one should constantly audit results and be cognisant of his/her outcomes. As one grows in seniority, he/she will start to perform more complex procedures on more difficult patients. It is thus important to understand one's physical (technical) and mental (knowledge) ability to determine how best to help the patient, or to refer to another surgeon if the expertise is lacking.
Besides the physical and mental ability, physical and mental capacity also has to be nurtured. As we age, it is quite easy to see our waistlines bloat and fitness levels drop. For some, it may simply be a lack of self-discipline, while for others it may be due to ageing – I spent almost an hour in my optician's chair trying to figure out the best lens degree for me when I started developing farsightedness on top of my myopia and astigmatism. When asked what job I did, I replied that I needed to look at something say at arm's length (open surgery) and also perhaps almost two metres away (laparoscopic surgery screen). Exasperated, my young lady optician said "Uncle, your eyesight very difficult leh…" Sigh.
Staying fit
In addition, being able to operate through the night, standing for prolonged hours and basically just being able to tahan (slang for endure) a 90- to 100-hour work week isn't a simple task anymore once you cross the big 4-0. Unlike protected working hours and fixed weekend days off for the junior staff, the seniors are expected to toil without complaint. I constantly encourage my surgeons to keep fit and exercise. Like all athletes, we have to be at the top of our game every time we are doing a procedure. Being fit ensures concentration. Having stamina ensures good decision making. More importantly, recovery processes are also faster. With the constraints of time, I have started running on some mornings before work, but the distance is limited since I have to ensure that I still have enough in the tank for the day ahead. I have, however, found that the exercise definitely helps. One must be able to function at the same high intensity for a full operating theatre (OT) list from 8.30 am to 5.30 pm, and be able to recover and function again if called back at 2 am. Keeping physical capacity strong therefore is important for sustainability of a surgical career.
Mental capacity is basically resilience and stress management, and this is linked to and affected by physical capacity. When one is tired, the stress threshold is breached easily and may lead to a compromise in decision making. Anger becomes a surrogate manifestation and when the surgeon becomes surly, rude and insulting, or belligerent with shouting and temper tantrums, the entire OT team and environment is affected with possible detriment in outcomes. The opposite may be worse; where there is paralysis and the surgeon becomes indecisive when faced with stress. Delays or unmeasured thinking can often lead to adverse outcomes.
Burnout is the corollary many juniors complain of and the simple fact of the matter is that they just do not have control of their schedules and lives but are dependent on "orders" from the bosses. My perception of burnout is not so much being overworked, but rather the lack of finding meaning and being valued at work. It is thus important, as a surgeon, to figure out his/her capacity and to have internal warning flags when certain thresholds are reached. Recovery has to happen intra–day and inter–days. Deep breathing, meditation, exercising or just a simple five to ten–minute solitude away from the hustle and bustle can often do the trick. Adequate nutrition with small frequent meals, techniques in "mindfulness" while performing simple things like walking, or a short smart phone or device/email break also helps. But when the warning symptoms of frequent anger and stress are displayed, it is better to attend professional courses to learn and reinforce techniques. This helps to build a sustainable career for the future. More importantly, surgeons act as a role model for the future generation, keep the junior teams engaged and happy, and have a very huge ripple effect on morale for a multitude of hospital staff and patients, when he/she is cheerful and engaged. Having a broad and resilient mental capacity does prolong and enhance one's physical capacity and vice versa. What is also true is that when one is confident about their ability, their capacity increases as well. These are all linked!