Surgeons never want surgery themselves. We know far too much about what can go wrong even in straightforward operations. During my urology training, prostatectomy carried two major complications – incontinence following relief of the obstruction, then impotence through damage to the nerves that regulate blood flow to the expandable parts I had valued for so long. This sobering memory from my years in training lingered with me over forty years later. On the other hand, how many prostate glands had I buggered up while trying to relieve the agony of urinary retention? For some, the alternative to the conventional but agonising catheter route was to stab a suprapubic tube directly into the bladder through the abdominal wall. Patients didn’t object to that since it provided sweet relief from misery, which was all that mattered. So precarious was my situation that I still carried the catheter and anaesthetic gel everywhere I went. And for years I took a drug euphemistically named Flowmax. This enabled me to dribble marginally more effectively as I leaned precipitously forward against the bog wall.
Every year I took the prostate specific antigen blood test to exclude cancer. This remained persistently in the ‘low risk’ range, so I avoided going back to Professor Cranston. Then in 2017 two close cardiology friends who did not have urinary symptoms were diagnosed with prostate cancer. They could still piss with impunity, so what should I do when the antigen test was continuously rubbished as unreliable?
During the hot summer of 2018 I flew to Greece to review a series of patients whom, with my old trainees, I had injected with stem cells during coronary bypass surgery. Now a company doctor rather than a famous heart surgeon, I was obliged to travel in economy class. Predicting the inevitable, I purposefully dehydrated myself for the early morning flight. Nevertheless the urgency came on just as the drinks trolley blocked access to the lavatories at the back of the plane, leaving me with little choice but to seek relief forwards in the lightly subscribed business-class cabin. Sneaking through the blue curtain separating us plebs from the privileged few proved simple enough. But with my objective in clear sight I encountered a stroppy cabin services director helping herself to breakfast in the galley. Despite more than twenty years with frequent-flyer ‘Gold Card’ status, my path was blocked with grim determination.
‘Economy passengers are not allowed in these toilets, sir,’ she said. ‘Your facilities are in the back of the aircraft.’
With that stern rebuke I leaked like a naughty schoolboy and the urgency passed. You can image the social media coverage – ‘Heart surgeon pisses his pants in panic’. Happy days. Eventually I made it to the queue at the rear of the aisle, resolving never to fly British Airways again. That resolution escalated to not flying at all until I’d had my miserable prostate bored out.
Any deliberation over the matter was now gone. Severe bladder outflow obstruction together with dehydration precipitated the crisis we call obstructive uropathy, an immediate threat to the kidneys. So after an uncomfortable return journey I called David Cranston that evening. Next day I met him in his clinic for another Dyno-Rod experience, followed by ultrasound scans of my prostate and bladder. These showed that my bladder simply didn’t empty. I would waste minutes trying to piss but only pass one-third of the contents, like a rain barrel overflowing from time to time. Into the bargain it hurt, so I thought I had a urinary tract infection.
David was waiting for me to make my own mind up about surgery. In the interim I researched less radical alternatives. There is a new method of embolising the prostate’s blood supply via a leg artery so that some of it dies and shrinks. Then there is the injection of pressurised steam to vaporise the obstructing tissue, but I visualised my penis blowing off like a factory whistle and didn’t really fancy that. We drew the conclusion that it was not the time to piss around, in the colloquial sense. David’s advice was to have the ‘gold standard’ transurethral resection, which is much safer than when I had a bash at it as a trainee. Back then it was done by peering up the narrow channel of a rigid metal instrument and burning away chunks of tissue with a hot wire. The residual gland would bleed profusely and fill the bladder with blood clots. Not surprisingly, I didn’t much fancy that either in its earlier form.
Things were different now. My insides would be displayed with magnification on a television screen, the cutting could be carefully controlled, and the bleeding vessels seen and cauterised with a lower risk of complications: impotence 1 per cent, incontinence 1 per cent, I was told. For maximum enjoyment I could opt for a spinal anaesthetic and watch the televised proceedings myself. Not by any stretch of the imagination did I want to do that, nor have a needle probing around my spinal cord. Compared with my wife, then my daughter having their respective caesarean sections with regional anaesthesia, I was a complete coward.
Now down to the practicalities. Something had to be done soon to relieve the back pressure on my kidneys. I naively expected the surgery to be done in the NHS urology department, and as usual I wanted it to be done tomorrow. Then came sobering news. The best I could expect from the Churchill was an indwelling catheter to relieve the obstruction, then a place at the end of the waiting list. Why should that be after more than forty years of NHS service? Already there were 120 patients with benign prostatic hypertrophy on the waiting list, and many had indwelling catheters already. They were not being operated on. Why? Because the surgeons were treading water to keep up with cancer patients who had to be treated within the government’s prescribed time frame. Regrettably I was not prepared to endure a year with a pipe stuck up my penis and a bag of piss strapped to my leg without guarantees at the end of that time, nor did I want to progress to advanced kidney failure. So it was off to the private hospital the following Saturday morning to get it all over with.
It takes a conscious effort to switch from surgeon to patient. Thanks to the miracle of modern anaesthesia and surgical skill, the filleting and restoration of my claw hand had been achieved as a day case. Now I was facing ‘a few days’ in hospital, where I would have to adopt a passive approach and do what I was told. As I agonised about whom the anaesthetist should be, Sarah started fussing around practical issues, such as ‘I didn’t own a dressing gown or slippers.’ The only pyjamas I possessed were a gift from a kind patient with her own lingerie company – bright blue pure silk, not quite the thing for a hospital stay. So off Sarah went to Marks & Spencer. My only contribution was to give my liver a rest for a couple of nights.
I was expected at the crack of dawn for the first operating slot. With the gleeful prospect of having my naughty bits on display for nurses I had worked with, I was up at 5.30 am and into the shower. I grabbed a couple of medical journals that had dropped through the letter box the previous day, then Sarah drove me to town. After years of putting this off, I experienced a mix of trepidation and relief as I stood in line at the reception desk, waiting to hand over my credit card. Then the ward itself was familiar to me. When we operated in the building on NHS waiting list initiative patients, they were housed here because it was next to the intensive care unit. From the consultants’ names on the doors it now appeared to be a gynaecology ward. I knew my room well enough too. The only NHS ventricular assist device patient I had operated on in this hospital died here the night after leaving intensive care. The young woman had a huge cerebral bleed from an aneurysm in the brain. She was celebrating the relief from breathlessness and being able to lie flat again, to the delight of her husband and children who were there to visit her. It was pure serendipity that her surgeon was allocated that same haunted room ten years later.
Nurse Grace from Botswana came in to weigh me and record my vital signs. First the sphygmomanometer used to measure blood pressure didn’t work. I just told her what my blood pressure normally was and suggested she added an increment for the anxiety I ought to be experiencing before surgery. Except that I felt no stress – I was more concerned before a haircut. Next Grace and I wandered out to a weighing machine in the corridor beside the nurses’ station. That didn
’t seem to work either, so the poor girl became frantic with embarrassment. I told her it didn’t matter, no one would ever look at my weight. With that I sat in the corner of the fateful room and flicked through the pages of the British Medical Journal. I always start at the back in the ‘Jobs’ section. I was still tempted by advertisements for a heart surgeon in Africa or the Middle East, where I could operate on children again. Indeed anywhere that valued technical skills and experience over fabricating appraisal forms or using that word ‘reflection’.
Surprise, surprise. My eyes were immediately drawn to an article outlining the General Medical Council’s new guidelines for ‘reflection’. This kicked off with a statement: ‘There is a strong public interest in doctors being able to reflect in an open and honest way.’ Really? But so far, so good, because that’s exactly what I’ve done in this book. They went on to say, ‘Time should be made available for self-reflection and to reflect in groups.’ Like group sex, I thought mischievously. By this point I was thinking about all the time I had wasted operating when I could have more profitably been reflecting. Perhaps Professor Cranston and I should enjoy a period of reflection together before my prostatectomy. We could reflect on all the operations the NHS couldn’t do, such as my own, because surgeons were overwhelmed by bureaucratic crap.
What induces the General Medical Council to conclude that today’s doctors are so thick that they need to be told how to think? Take this for a reflection. Virtually every heart surgery unit in the country has suffered a public scandal through working in highly pressured, inadequately staffed and poorly equipped facilities. Some of my post-operative deaths occurred because we didn’t have consistent surgical or nursing teams – so-called ‘failure to rescue’ deaths, where the patients could have been saved by more effort and expertise. Few people can afford Oxford property, so we were inundated with temporary staff at enormous cost. When the General Medical Council claim that ‘teams and groups improve patient care and service delivery when they are given opportunities to reflect together,’ I say, ‘Show me the bloody team and we’ll find something to reflect upon.’ Something other than ‘You just fucking killed my patient.’
It was at this point that a monosyllabic Romanian doctor came in to take blood. ‘I need to take some blood,’ was all he said, but he did it skilfully by finding the vein first jab. And he knew to remove the tourniquet before extracting the needle so I didn’t bruise or bleed. He then produced the consent form and told me to sign it, which I was happy to do. I was spared the dismal recital of potential complications that normally makes any sane patient run a mile.
As the efficient young man turned to leave, I said, ‘Please tell Professor Cranston that I don’t want any blood transfusion.’ Then, tempting fate, I added, ‘If I suffer a fatal stroke during surgery I’m happy to be an organ donor.’ Altruistic to the end, but he didn’t hear me so the gesture was wasted. With the introduction of ‘presumed’ consent in contrast to voluntary donation, I’ve since reconsidered that. It’s a throwback to the body-snatching era.
I was still reading in my white theatre gown when Oliver Dyar the anaesthetist walked in. I had known Oliver for twenty years or more as one of the intensive care consultants who looked after my patients.
In his uncompromising manner he said, ‘Steve, you could have a spinal anaesthetic and stay awake but frankly we don’t want the interference. Nor will it get you out of here any quicker. So I’m putting you to sleep and will prescribe some pain medicine for afterwards. See you in a few minutes.’
That brief encounter was just what I wanted from the person responsible for keeping me both asleep and alive. I had no appetite for sycophantic compassion, empathy or any other emotional crap that had no bearing on the outcome of my operation. I had a bit of a phobia about waking up during the proceedings but was not going to insult him by mentioning it. Minutes later I wandered off to the operating theatre in my Marks & Spencer slippers and dressing gown. I jumped onto the trolley and stared at the ceiling, then, with a sharp needle prick in the back of my hand, I lapsed into unconsciousness. Anaesthetic in, lights out.
The squeeze of a functioning blood pressure cuff on my right arm roused me an hour or so later, and I emerged as if from fog in an unfamiliar place. I was staring across the recovery room that I used to look into from the operating theatre corridor, but it took me a while to work that out. There were conversations going on in the distance, then a question close by that seemed to be directed at me.
‘How are you feeling?’
This was my recovery nurse in her purple dress. By reflex I groped down under the blanket at the stiff pipe emerging from my bladder. In doing so I yanked on the drip tubing, displacing the cannula in the back of my left hand and making it sting. This dragged me to my senses, shifting focus away from the nurse’s legs. Fluid was pouring into my bladder from a gigantic plastic container, then it flushed out again to the drainage bag – crystal clear in, bright pink out. I felt that there couldn’t be much bleeding, otherwise it would have been darker. Also there was no empty blood bag on the drip stand, so I assumed the operation had gone well. A deep sense of euphoria now suffused me. After ten years of misery I had finally summoned up the courage to sort myself out. And so far, it was less disagreeable than I’d expected.
By 2 pm I had talked with my family to confirm my survival and was back in the haunted room. Bored already, I began sifting through the journals again. I found another article in the British Medical Journal in its regular ‘The Big Picture’ section. The piece was entitled ‘After a near decade’s wait, a patient appeals for a donor heart’ – his second, apparently – which could only have been written about the NHS. Allegedly, this man had been on a heart transplant waiting list at home for all that time. Now consider that the only patients proven to derive survival benefit after a heart transplant are those already in hospital on powerful drugs or circulatory support devices. So the title should have been ‘Man celebrates 10 years of survival by avoiding a heart transplant’. But don’t let’s worry about facts or evidence. This was simply an emotional appeal for more organ donors when a rational argument to introduce ventricular assist devices would have been more appropriate. Take one from the shelf, stitch it into the failing heart and switch on the controller. Symptoms gone, life extended, no dead person required.
I tossed the journal away and turned to the Bulletin of the Royal College of Surgeons. Oh shit! There was a paper entitled ‘Surgeons’ personalities and surgical outcomes’, which explored the relationship between heart surgeons’ personality types and their mortality rates. The punch line was that heart surgeons differ from the general population by being more extrovert, but that introverts have lower death rates than extroverts. Bloody obvious, I’d have said. Extroverts don’t agonise about which patients to operate on or cherry pick to protect their results and reputations. What’s more, introversion and a high level of conscientiousness were recognised as a recipe for stress and burnout. It transpired that the authors sent a questionnaire described as ‘the most parsimonious and comprehensive model of normal adult personality’ to all 261 consultant heart surgeons in the UK, then endeavoured to match these with their so-called ‘risk-adjusted mortality rates’ collected by the Society for Cardiothoracic Surgeons. The five characteristics examined were conscientiousness and openness, which I hope all doctors have; agreeableness and extroversion, which surgeons usually have; and lastly neuroticism, a feature of introverts from the outset.
Just ninety-six diligent individuals replied, and mortality statistics were available for only fifty-three of them. In reality, the authors of the paper had analysed information from a conscientious, self-selected one-fifth of the population, then derived the conclusion that those with the highest personality scores for openness killed more patients. On the basis of these curious findings, they concluded that the selection process for surgeons should admit more introverts. Yet we all know that extroverts made heart surgery possible in t
he first place when the introverts and neurotics were too stressed to continue. By now I was losing the will to live. In the two years since I stopped operating, 40 per cent of newly qualified heart surgeons had allegedly been suspended from practice – it was easy to see why.
The Bulletin’s next article – ‘Surgery and emotional health’ – didn’t exactly inspire me with confidence either. It covered a series of Royal College of Surgeons workshops on ‘stress, burnout and bullying’, then ‘anxiety, doubt and grief’, followed by ‘compassion and sympathy’. These touchy-feely events were undoubtedly attended by the introverts, while their extrovert colleagues stayed in the operating theatre boosting the body count. In a ‘breakout discussion’ focusing on ‘recommendations for change’, delegates to the event stressed that ‘hospitals needed to make surgeons and their teams feel valued and appreciated, and help their staff develop supportive working relationships’. Poor paranoid, introverted surgeons. How things have changed in this business. I didn’t belong anymore.
I mention these articles only because they provide a barometer on the prevailing attitudes among the surgical profession today. Fewer operations, more talking about it. For me this was Women’s Institute coffee-morning stuff, just the ticket for the mandatory ‘professional development’ folder that we were all meant to compile for the General Medical Council. It came as something of a relief that it was now time for Cranston to visit and tell me how he empathised with my prostate gland as chunks of it were tossed into the bin.
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