The Knife’s Edge. Stephen Westaby
after conclusively demonstrating comprehensive knowledge and skills were we allowed to move on and specialise. I failed both the primary and final fellowship on first sitting, an expensive exercise. Most of my associates did too. The whole miserable process was there to sort the wheat from the chaff, and I wasn’t fazed by failure. It was just like rugby, the sport I loved above all others. Some games you won, others you lost.
The surgical world resembles the army. The consultants are the officers and the gentlemen, the trainees line up in tiers through the ranks: senior house officer is equivalent to corporal, registrar acting as sergeant, senior registrar akin to a non-commissioned officer doing all the work and eventually being promoted to the officer’s mess. That final step was the most competitive of all. For the ruthlessly ambitious it had to be a top teaching hospital. Heart surgeons strove for London hospitals like the Royal Brompton, the Hammersmith, Guy’s or St Thomas’. Appointment to one of these, and you had made it big time. In those days Cambridge had a vibrant cardiothoracic centre in Papworth village out of town. Oxford was doing very little.
All this took place during our formative years, our late twenties and early thirties, when normal people cement relationships, settle down in one location and start a family. Trainee surgeons lived like gypsies, moving from city to city – wherever the best posts were advertised. Something about being a surgeon elevated us to a different plane. We were the fighting cocks of the doctors’ mess, the flash Harrys who constantly strove to outdo each other and ruthlessly coveted the top jobs; the guys – and at that time, as now, it was almost exclusively guys – who stayed in the hospital night after night seeking every chance to operate, or, if it was quiet, drifting across to the nurses’ quarters, where other exciting action was easy to find.
I was a backstreet kid from Scunthorpe who had married his childhood sweetheart from the local grammar school. Caught up in this whirlwind of ruthless ambition, things changed and marriage became an unintended casualty. I was ashamed of this, but I knew some surgical teams where every member, from junior houseman to consultant, was having an affair in the hospital. Grim in reality, but the stuff of television soaps that glamorise adultery. So widespread was the problem that the Johns Hopkins Hospital in Baltimore carried out a formal study of divorce as an occupational hazard in medicine. The younger their residents were when they married, the higher their divorce rate. Understandably, divorce was commonplace when the spouse did not work in the medical field. Blame it on the communication gap. They had little to talk about because doctors – and especially surgeons – are engrossed in their hospital life.
The Johns Hopkins study showed that more than half of psychiatrists and one in three surgeons divorced. Cardiac surgery had an impressive divorce rate, which I already knew from my colleagues’ experience. Reasons cited were high testosterone levels, long hours and nights in the hospital, and close working relationships with numerous attractive young women, often in stressful and emotional circumstances. Professional bonds are formed, and these evolve into romance. At one stage the Dean of Duke University Medical School saw fit to warn applicants that the institution was experiencing a greater than 100 per cent divorce rate. Why exceeding the maximum? Because students showed up already married, got divorced, then remarried and divorced a second time. They all lived a life in which work was seen to come first, with everything else a distant second.
Once at a conference in California I picked up a copy of Pacific Standard magazine that contained an article entitled ‘Why are so many surgeons assholes?’. Obviously it was about prevailing personality types. A scrub nurse friend of the journalist described an incident in the operating theatre where she had passed the sharp scalpel to the surgeon and he lacerated his thumb on the blade. Now furious, he shouted at her, ‘What kind of pass was that. What are we, two kids in the playground with Play-Doh? Ridiculous.’ Then to emphasise his point he threw the scalpel back at her. The nurse was horrified, but as she didn’t know how to react she just kept quiet. No one stood up for her, and no one ever reprimanded the surgeon for being aggressive or throwing the sharp instrument. The inference was that this is how a lot of surgeons behaved and they get away with it all the time.
I have known many surgeons who threw instruments around the room, and although I never aimed one at an assistant I did use to toss faulty instruments onto the floor. It meant that I couldn’t be given them a second time. Having said that, most successful surgeons have certain malign traits in common. These have been summarised in the medical literature as the ‘dark triad’ of psychopathy, Machiavellianism – the callous attitude in which the ends are held to justify the means – and narcissism, which manifests as the excessive self-absorption and sense of superiority that goes with egoism and an extreme need for attention from others. This dark triad emanates from placing personal goals and self-interest above the needs of other people.
Just in the last few months psychologists at the University of Copenhagen have shown that if a person manifests just one of these dark personality traits, they probably have them all simmering below the surface, including so-called moral disengagement and entitlement, which enables someone to throw surgical instruments with absolutely no conscience at all. This detailed mapping of the dark triad is comparable to Charles Spearman’s demonstration a hundred years ago that people who score highly in one type of intelligence test are likely to perform equally well in other kinds. Perhaps the daunting road to a surgical career inadvertently selects characters with these negative traits. It certainly appears that way, yet I had a very different side to my personality when it came to my own family. Maritally I fell into the same old traps, but I would go to any lengths to make my children happy or my parents proud.
I was not rostered to be in surgery as it was my daughter Gemma’s birthday and I hoped to be free. The phantom father who had let her down so many times in the past, I planned to drive to Cambridge in the afternoon to surprise her. Then I discovered that three of our five surgeons were out of town. Two were committed to outreach clinics at district hospitals trying to bring in ‘customers’, as the NHS now called them, or better still the odd private patient. The third was away at a conference, one of those academically destitute commercial meetings at a glamorous resort paid for by the sponsor, with business-class flights and all the rest. As a gullible young consultant I had enjoyed these trips, but it eventually wears thin – tedious airports, buckets of alcohol and forced comradery with competitive colleagues who would cheerfully drive their scalpel into your back the minute it was all over.
It was this surgeon’s operating list that lay vacant, and the unit manager had twisted my arm to stand in for him. To let an operating theatre with a full complement of staff lie idle for the day was a criminal waste of resources, so I reluctantly agreed to the request. I had built this unit from nothing to being virtually the largest in the country, not that anyone could give a shit. The management changed so frequently that history was soon forgotten, dispatched to oblivion by the quagmire of financial expediency. So my daughter would have to wait. Again.
When I asked Sue, my secretary, to find two urgent waiting-list patients at short notice, I didn’t mention the birthday. Just two cases should see me on the road by mid-afternoon. I suggested that one should be the infant girl with Down’s syndrome who had been cancelled twice before. She was in danger of becoming inoperable because of excessive blood flow and rising pressure in the artery to the lungs. I bore special affection for these children. When I started out in cardiac surgery, many considered it inappropriate to repair their heart defects. I couldn’t get my head around a policy that discriminated against kids with a particular condition, so ultimately I overcompensated by taking them on as desperately debilitated young adults – trying to turn the clock back, sometimes without success.
The second case needed to be more straightforward. Sue had repeatedly been pestered by a self-styled VIP who held some snooty position in a neighbouring health authority. When I reviewed this lady in the outpatient clinic, she took exception to my suggesting that weight loss would not only improve her breathlessness but reduce the risks during her mitral valve surgery. I was sternly reminded that she had featured in a recent honours list, presumably for services dedicated to getting her onto an honours list, as is frequently the case in healthcare. I wasn’t in the slightest bit impressed – and she could see that. But she kept insisting on an early date and I couldn’t blame Sue for wanting her out of the way. The titled