Anonymous Doctors on Twitter

It’s 2014 (almost). Twitter has been around for ages (about 7 years to be exact). And I can’t believe I’m still asked this question. We’ve gone through this before, but let me clarify my thoughts.

I refer you to an excellent article by Dr Jennifer Gunter on why doctors should be allowed to post anonymously online.

And here are my personal thoughts.

1.     Twitter is a social space, not an office. Twitter is much like the public square or the public train. There are lots of conversations going on at once. You listen to some, and you join in with others. You hop into the train, talk to a few strangers and see if the conversation goes in a likeable direction. You can carry on the conversation, or you can drop off at the next station. Can a doctor enter the train and be anonymous? Sure. You should be allowed the freedom to be a Joe Blow on the train, and on Twitter. Do you believe other train passengers when they tell you that they are rocket surgeons? You shouldn’t, just like you shouldn’t trust anyone one twitter who say that they’re doctors.


2.     Twitter is not a medical conference. Most of us on twitter are here for social contact and communication. When doctors advertise their practice and expertise on Twitter, they abide by rules that govern advertising, not twitter communication. When doctors give professional opinions on medical conditions, then yes, they should reference their name and expertise. However, many doctors are on twitter not for medical or professional reasons. They are there for social reasons. Sure some of them may tell you about their experiences at work, just like when you tell a taxi driver that you’ve just finished an amazing surgery, but that does not mean that a professional information exchange has occurred. Doctors should be allowed the freedom to be a Joe Blow on Twitter.


3.     Why is it that doctors often think that we are an elite group who has to abide by a higher set of rules? Can nurses, lawyers, pharmacists, astronauts, air traffic controllers and politicians tweet anonymously? Sure they can. Why can’t doctors do that? When I go to the local pub, I have the right to tell Happy Jan, that I am Joe Blow, an Olympian, astronaut, and eccentric baker. I also have the right to hide the fact that I am probably a doctor.


4.     I am followed. I do not make others follow me. Whenever there is something not likeable, you are free to unfollow. I do not enforce any opinions on others. Followers are free to listen in to my thoughts, and free to discard me. It so happened that some of my thoughts are medical in nature, but that does not mean that I am doctoring you. Should doctors be allowed to be themselves on twitter, share their lives and not be a doctor? Sure.


5.     Should doctors tweet anonymously? That is the wrong question. The question should be: Can a doctor be anonymous on twitter? Basic human expectation in a public space is respect. Shoulds and shouldn’ts should not be the basis of interaction. When I go to a party I do not have to be forced to reveal my job, my conflicts of interest, my professional affiliations. That’s not a party. When I go to a party I want to be myself. I don’t tell others I’m a doctor. Sometimes I strike a good conversation and people discover that I spend my days in the medical industry. But that does not mean that I am making them my patients. They don’t need to take me seriously. It’s a party. It’s twitter. You should be free to be whoever you want to be, as long as you are not intruding on the lives of others by making inappropriate comments. The general rules of being social and having fun in a party while respecting others should be the same rules that govern twitter communication. You shouldn’t be seeking out a doctor’s professional opinions on Twitter. You should also respect a doctor if he or she chooses not to be identified as a doctor.




Why I love Twitter but need to let it go.

I joined twitter 3 years and 4 months ago. I did it twice. The first time as an observer-explorer, but gave up on it. The second time, with a friend’s encouragement I tried it again. Like any new technology, medium of expression, or tools, there were trials and errors. I didn’t know how to use twitter at first, but well, none of us did. People got into trouble for their tweets, and I did too. There have been doctors out there ready to crucify me and my tweets as it did not fit their brand of professionalism. The legal boundaries formed around tweeting doctors were blurred and there was a period when we doctors were forced to ‘come out’. All these anonymous witch-doctors were being pulled kicking and screaming out into the open.

Why did I join twitter?

1. Enjoyment (Social)

It’s social media after all. Twitter is mostly fun, encouraging and funny. There are a few out there for negative reasons, but it’s a mostly safe social arena. I have met many wonderful, interesting, fascinating people who are now dear friends to me. These are not friends I’d ever meet through ‘traditional’ social methods, frankly because I have no time to socialize in parties or pubs anymore. Remember that for every tweet, there are plenty of personal DMs not seen by the public. Some of those DMs from close twitter friends have pulled me together during difficult times. Hey, I even got Canadian socks from an awesome Twitter friend who I’ve never met before. It’s like pen pals in the past. The sharing of words and lives is an inherently human experience.

2. Education (Learning)

I’m on twitter to learn a bit of medicine, surgery and life skills in general. Some of the studies that have changed the way I practice surgery I first read on twitter. Some life wisdom that has encouraged me to live a better life I first read on twitter. Funny one liners, trivia, awesome pictures, random information, latest news and all sorts of beautiful things that colour my day all gets delivered through twitter. I have learned much through twitter. I’m usually the first on my unit to hear about a breaking news, new ideas, interesting studies, etc.  Twitter adds colour to my days.

3. Engagement (Teaching)

Yes, if you haven’t figured that out already, I’m an ENT surgeon in training. It means that one aspect of my calling as a doctor is to teach others how to live better lives and help them through their ENT problems. I also freely give out life advice that I’ve found helpful. Take it or leave it. More importantly, I want people to laugh or smile when they read my tweet. I want people to enjoy my tweet, not get a PhD in ENT.

What else have I learned through twitter?

1. Twitter is here to stay.

Just like moving from snail mail to e-mail, from phone landlines to mobile phones, from desktop computer to portable personal computing, Twitter is a new medium of communication that is here to stay. When I’m looking up another doctor, I not only look up their addresses, emails or phone numbers up, I also look up their twitter handle. Twitter is a new address, a new email, a new phone number, a new contact point in this increasingly interconnected society we live in. It almost does not matter if we live on different continents, as long as you’ve got twitter, you can contact/DM/interrupt my day any time, as if you’re a colleague working in the next operating theatre.

2. Twitter helps me express my thoughts.

I used to journal my thoughts. I still do. The word is my medium of self-expression. I find that I feel better if I can articulate my convoluted mind using a few well-chosen words. Not that I’m a poet or anything. Twitter is like a toothbrush. It keeps my brains clean and free from thought sediments. My wife knows this and although she hates me for spending too much time on twitter, she also knows that it is my medium of expression. It’s a way of me clearing up my thoughts as I go through my stressful surgical days. That’s why I hope to continue tweeting to keep my mind active.

3. Get a shorter twitter handle next time.

4. 3,500 followers mean nothing if you’ve added nothing into their lives.

There are celebrities with millions of followers. I don’t want to be that. But I do want to be an inspiration to a few. I want to help if I can. Twitter is a unique method of getting into people’s lives. When I’m followed, it means that I’ve been invited to enter into the lives and thoughts of someone, and I need to respect that. I cannot be putting up garbage on their timeline. I want people to laugh, or be inspired, or learn something from my tweets because they have allowed me the privilege of allowing my words to enter into their conscious minds.

5. The timeline is the appetizer.  The DMs is where the public becomes personal.

I’ve seen your hurts on your DMs (Direct Messages). I want to reach out and help. Words, even mere words, can be an incredible powerful agent of change. Tell me your pain, and I will do what I can to share in your struggles. It’s like being in a busy train, sometimes you strike up a good conversation and tell your story to a total stranger who can share your pain even if only briefly.

6. People are inherently interested in other people’s lives.

The common bond amongst us all: life. We have lives to live, stories to tell. I’m interested in your life and thoughts. And I know that many people are interested in what it’s like to be training as a surgeon. I tell you my story. I allow you to see the raw emotions I feel when I’ve been on call non-stop for 10days. I tell you my struggles with family, work, dying patients, etc. And I’m interested in your stories too. It’s like sitting around a campfire, trading stories, enriching lives.

7. Don’t judge a tweep by a single tweet. See the whole timeline.

Lots of bad twitter fights happen because of this error in misinterpreting a single tweet. In life as in twitter, there is no point winning an argument but losing the friendship.

8. Everyone is equal and accessible on Twitter.

I can speak to a professor, an astronaut and a Miss Universe contestant on Twitter. And I get to discover that they are all down to earth people, happy to live out their ordinary lives. It’s inspiring like that. Similarly, I hope people can just tweet me up and I can help them in whatever way I can.

9. There are different uses for twitter.

Some are on twitter for commercial reasons. Some for clinical reasons. Some for political reasons. Others like me, are here for fun. Just like in any social gathering, don’t assume that everyone is here for serious purposes. For example, my lighthearted comments about medicine and surgery have been mistaken for serious criticisms. The funny thing is I never meant for any of my tweets to be a serious opinion. I liken myself some times to the court jester who performs and cracks jokes to provide a lighthearted alternative at looking at this serous business of life and surgery. The Surgical News, which is the monthly magazine of The Royal Australasian College of Surgeons, read by thousands of Aussie and New Zealand surgeons routinely include several articles written by anonymous Prof R U Kidding, Dr BB Gloved and Dr IMA Trainee. They are anonymous articles meant to poke fun at the serious business of surgery. Sometimes being told directly about an issue has a negative effect compared to being told a funny story by an anonymous. The effect is the same though: laughter, enlightenment and behavior change. I hope my tweets do that. If you’re looking for medical information, there are plenty of doctors on twitter who do that better than me.

10. It’s ok to be an anonymous doctor.

I know some would not agree with that. This is how I see it: being a doctor is who I am. I cannot separate who I am in real life and who I am on twitter. But I’m not here on twitter as your doctor, so I’m not going to offer you personal medical advice. Also, I’m not here as a professional entity, although I will remain professional and courteous. I’m not here marketing my surgical practice. I’m here as me, myself and I, who happened to be a doctor and tweet doctorish thoughts. If I can help you in any way, does it matter if you don’t know my full name? I’m not endorsing any special treatment, surgery or thoughts. You don’t really need my name.

Sometimes I share the raw emotions, the confusions,  the frustrations, the anger, the uncertainties, the inexactness of the science and practice of surgery. All those things are real. Real patients and real doctors know that. Medicine is not a sterile, perfect, exacting practice. I don’t think I’m painting a bad picture of medicine and surgery when I share some of those raw experiences. I don’t think I’m being unprofessional when I’m questioning my own and my hospital practice. I don’t think I’m being unprofessional when I’m sharing the human side of medicine and surgery – the blame game, the politics, the money, the administration, the ego clashes. And I don’t think that I’m hiding behind my anonymity when I do that. I’m sharing the real story behind doctoring that does not need to be hidden. One day I will come out. But at the moment I still feel that I am effective being an anonymous. And yes, I am accountable for every tweet I have tweeted. I’m fine with that.

Twitter has become a routine part of my daily life. I’ve had so much fun with it. I’ve learned much, and I love it. It has given me so much needed support during odd hours of my nights. It has been a real enjoyment, education and engagement tool. I hope to have inspired some lives out there during the process.

But I need to let it go.

Why? Because it has taken up so much of my thoughts and my time. I need to focus on something else of immense importance in the next 3 months, and I need to be single-mindedly preparing for this and this alone: FRACS Fellowship Exam. It’s like taking a sabbatical. I need to focus on studying and training myself up to be the best I can be, so that hopefully I can return as a fully trained surgeon and be even more helpful for the people around me and my friends on twitter.

So farewell, my friends. While I fall in love with ENT, will you keep a space for me when I return?

PS. I’m still instagramming, though.

What will greet me this Christmas: ENT Emergencies.

I’ve been told many times, “You’re doing ENT, that’s great. Early Nights and Tennis. Easy life with no emergencies, right?”. I’ve also been asked many times, “Is there such thing as an ENT emergency?”

Well, let me list some of the emergencies I’ve personally been involved with over the last few years. When I’m oncall for 10 days straight over the Christmas & New Year period, these are the emergencies that I will meet at odd hours of the night.

·      Post operative tonsillectomy bleed: a bleed from a branch of the high-pressure external carotid artery into the oral cavity and airway, meaning one can exsanguinate to death in 5 minutes. Picture those horror movies where blood pours out of the nose and mouth. I have had to put my hand in a girl’s mouth and knelt over her body as we got wheeled into the operating room with full on resuscitation.

·      Gunshot wound to the neck. Messy.

·      Gunshot wound to the face. Bloody.

·      Airway obstruction from an invasive thyroid cancer. Emergency awake tracheostomy performed through friable cancer mass. Death stands beside me while the patient in distress stares back at me as I cut her throat awake.

·      Tooth abscess becoming a Ludwig’s angina, compartment syndrome of the floor of mouth. Mouth swollen, can’t be opened.

·      Tongue cancer bleeding into the airway. Cannot intubate through cancer and bleeding tongue the size of cheeseburger in the mouth.

·      Quinsy peritonsillar abscess becoming parapharyngeal abscess and disseminating rapidly inferiorly into the mediastinum. Death.

·      Epiglottitis, cardiac arrest. Emergency specialist and anaesthetist cannot intubate cannot ventilate. Slash tracheostomy in 10 seconds.

·      Massive epistaxis in a haemophilliac, or those on warfarin/Coumadin/aspirin/assasantin/dabegatran, or those with platelet disorders, or arteriovenous malformation.

·      Facial trauma, midface degloving, massive bleeding from ears, noses, eyes, mouth.

·      GCS 5, cerebral abscess and cerebral vein thrombosis from acute otitis media and suppurative mastoiditis.

·      Arteriovenous malformation bleed from an erupted tooth requiring maxillectomy.

·      Airway burns from house fire.

·      10month old child swallowing an opened safety pin, lodged in the larynx next to the carotid arteries.

·      11month old swallowing Christmas ornament, lodged in mid oesophagus.

·      12month old child swallowing a button battery, resulting in perforation of the trachea and oesophagus.

·      Fishbone lodged in the larynx.

·      Lamb bone perforating the oesophagus.

·      Epistaxis from a nasopharyngeal carcinoma, out through the nose, and down into the airway.

·      Lego piece inhaled into the lung.

·      Denture with metal hooks swallowed and lodged between the larynx and oesophagus.

·      GCS7, meningitis due to frontal sinus abscess penetrating into the brain.

·      Eye abscess secondary to bacterial sinusitis. A young lady was blind in 12 hours from a misdiagnosed sinusitis.

·      Acid and alkali ingestion causing airway chemical meltdown.

·      Nasal septal abscess causing bilateral cavernous sinus thrombosis, blindness and death.

·      Carotid artery blowout due to erosion from neck cancer.

·      Relapsing polychondritis and Wagener’s granulomatosis causing cricoid airway obstruction.

·      Kids developing abscesses behind the eye from a bacterial complication of the common cold.

·      Acute mastoiditis from ear infections in young kids, causing facial paralysis and brain abscess.

·      Meningitis and CSF leak from a nasal cancer invading into the brain through the cribiform plate.

·      Retropharyngeal abscess in young kids, causing stiff neck and airway compromise with pus into the airway.

·      Invasive fungal sinusitis/mucormycosis in chemotherapy, transplant and immunosuppressed patients, causing fungal invasion into brain and eyes.

·      Airway obstruction and suffocation in patients with laryngeal cancer.

·      Clothesline injury/hanging injury causing laryngeal fracture and laryngo-tracheal separation.

·      Neonate with airway obstruction from vascular ring, vocal cord paralysis, choanal atresia.

·      Tracheostomy tube eroding into the arch of aorta.

·      Jellybeans, lego, foam in noses that can possibly end up in the lungs.

·      Infected branchial cysts and deep neck space abscess causing airway obstruction.

·      Skullbase fractures, CSF leaks from ears and noses.

·      Sudden deafness and dizziness from brainstem tumour.

·      Airway obstruction from glandular fever.

·      Paradoxical vocal cord movements from whooping cough causing airway obstruction.

·      Neck and airway trauma.

·      And many more.

Season’s greetings!

Wishing you a safe Christmas and praying that none of you would ever need to greet a surgeon this season.

Butchery. What non-surgeons really think of surgeons.

I was asked to see an elderly lady in her nineties with a locally invasive parotid gland malignancy. She had a high grade cancer in the salivary gland. It is never easy to manage cancer, and it is even harder when you consider the context of that cancer in an elderly patient. A senior surgeon reviewed the patient and discussed her case in a multidisciplinary meeting with the expert input of oncologists and radiation oncologists. As a multidisciplinary team, we elected to offer her the option of surgery with curative intent.

What shocked me was what happened after that.

Butchery. The medical team looking after her essentially said, “How could you surgeons butcher a ninety-something year old?” The patient advocate was called in by the medical team, to protect this lady from the butchers’ knives.

As a doctor working with a Head and Neck Cancer unit, I see some truly deforming tumours. Cancer anywhere in the body is bad but to have cancer visibly growing around the Head and Neck is very confronting to the patient and the family. Patients talk about the embarrassment of losing their hair after chemo. Think about what patients feel when they have a fungating tumour growing on their face or neck. Head and neck cancers kill by erosion of the airway (they suffocate and die), erosion of the food pipe (they can’t swallow), erosion of the blood vessels (massive bleed), erosion of soft tissue and bones (horrible facial deformities). Patients and their families are visually reminded of this. The lasting image of their dying parents is that of a face deformed by tumour.

Oftentimes, when head and neck cancer have progressed so badly around the face, patients beg us to cut it out of their face, so they can be rid of the fungating lesion, putrid tumour, and excruciating pain each time they smile, speak or swallow.

The medical teams do not see the horrible effects of a head and neck cancer left alone to run it’s (un)natural course. Doubling time of tumour biology teaches us that a cancer will exponentially grow in size given enough time. Patients will wake up every morning and see with their own eyes the growth of this tumour. Imagine seeing your face being slowly eaten by cancer.

I discussed the options of surgery, radiotherapy and no treatment to the patient and the family. This ninety something year old with a sharp mind smiled and said, “Thank you. I know what I want now.”

The medical team thinks they are being a patient advocate by trying to protect her from the butchers’ knives. The surgeons think that they are being an advocate by offering the patient a surgical option.

The patient advocate asked me this rhetoric question which I absolutely abhor because it is a stupid question, “What would you do if this was your grandmother?”, in essence trying to place guilt upon me for even suggesting the surgical option.

I replied, “I would not change anything because I TREAT EVERY PATIENT AS IF THEY WERE MY FAMILY MEMBERS. I will discuss at MDM, offer them the options and let them chose what is best for them. Don’t you do that?”

Throughout my training I see surgeons agonising over decisions to take patients to theatre. Sometimes, we hate doing it, but it has got to be done, because not operating on them is against the patient wishes and will result in a more horrible outcome. Head and neck operations also carry a different physiological effects on a patient as opposed to an intrathoracic, intracranial or intraabdominal surgeries. One cannot assume that all operations are the same.

There are no 2 patients alike, no 2 diseases alike and no 2 operations alike. To make a decision based on age alone is unfair to the patient. Head and Neck cancer carry a heavier burden of physical appearance, form and function. They affect a patient’s identity: their face, look, smile, voice, speech, swallow, breathing. The patients need to know this too, way ahead of time.

I would never suggest to a medical team when they should chose metoprolol or bisoprolol on their patients. So they should never tell a surgeon when they should or shouldn’t operate. To think that surgeons are butchering their patients is unprofessional and discourteous.

As doctors, we need to serve our patients better by doing what they and their family think is best for them, not what WE THINK is best for them.

The Costs of Surgery

‘Surgery’ comes from the Latin word ‘chirurgia’, or Greek ‘kheirourgia’, meaning ‘working with hands’. A surgeon is one who works with his/her hands. Since I got on to medical school, the field of surgery endeared my heart. I did not think I could ever be a surgeon, but today I cannot think of becoming anything else but a surgeon (I’m not there yet). I’ve always thought that the responsibility of cutting open a person and bringing healing with the knife had to be reserved for the chosen few with the hands, heart and mind set apart from all other mortals. I did not think I was one of them, and certainly did not think I deserved to be one of these elite few. But the road of life has taken me through many turns, and I’ve ended up on this pathway of surgery with much fear and gratitude to the One who has called me to this vocation.

I still believe that surgery is a high calling and I am therefore glad that the training is one that is arduous, long and filled with many challenges. The standards are high, because we have a patient asleep at the other end of our scalpels. The surgical training pushes you to the limits. The training is meant to break you and re-mould you into a surgeon whose mind, heart and hands remain calm under intense pressure. It is for good reasons that many surgical trainees have been broken during the process. It needs to happen.

The last few weeks have been rough for me. It has pushed me to my limits. I have questioned my reasons for doing surgery. I have counted the costs again.  Lots of thoughts have been running in my mind.  Words have always been my therapeutic outlet. Some words have been uttered unwisely, but others would know that those words are out of character with who I really am. Those negative words uttered in desperation are expressions from a surgical trainee pushed to the limits and pleading for a helping hand, instead of hands that would push me over the boundaries.

Here are some of the costs that I have been counting:

Financial costs

Bachelor of Science: AUD$25,000 per annum x3 = $75,000

MBBS: $150,000

PGY2&3 BST: $15,000


BST Exams: $6000 x2 = $12,000

Dunedin Course: $5000

BST Conferences: $6000

PGDipSurgAnat: $15000

Masters of Public Health: $15000

SET1 Gen Surg: $5,000

Gen Surg Conferences/Courses: $3,000

SET1-5 ENT: $30,000

ENT Part 1: $5000

Equipments: $5000

Temporal Bone courses x3: $8000

FESS Course x2: $5000

H&N Course: $4000

Reg conferences: $5000

ASOHNS: $6000

Other ENT courses/conferences: $20000

Fellowship Exams: $8000

That amounts to $412,000. Plus flights & accommodations for all these courses/conferences, and the all-expensive overseas fellowship years x2. During those fellowship years, relocating a family, getting visas, accreditation and other matters in the new country as you can imagine, is quite costly as well. Hence, the actual cost of surgical training start to finish would be well past half a million by the time I finish. Even before becoming a consultant, I have paid over half a million for my training costs.

Physical Costs

As a surgical trainee, my day typically lasts 12 hours long as a minimum, from 7am to 7pm, and then being on call from then on. We are usually oncall 1 in 2.  More often if we are the solo registrar for the hospital, less often if there are other registrars on the unit. Whatever ENT emergencies that occur during the night, we have to go back to the hospital to deal with them.  That might mean sleepless nights. We also tend to get interrupted sleep due to numerous phone calls during the night as ENT problems are very common (ear infections, tonsillitis, sore throat, ingested or inhaled foreign bodies, paediatric tonsillitis, sinusitis, epistaxis, dizziness, hearing loss, airway, facial trauma, teeth and oral infections, etc.). As registrars, we are physically pushed to the limits. There are seasons when things do run smoothly. There are other times when we sleep a mere 4hours nightly for a few nights in a row.

You might ask, is that safe? Well this is a subject where much discussion and opinions abound: the resident/registrar duty hours. I refer you to other sources for the clinical, biopsychosocial, safety and medicolegal discussions regarding this matter.

Key issues: specialist trainees are few in numbers, covering specialist areas (not easy to get locums/cover), Emergency calls are notoriously unpredictable (some days no calls, other days, multiple call backs to hospital), adding shift work covers and duty time limits dilutes the training experience for the specialist trainee and potentially reduces patient safety, each oncall period and emergency surgery is a learning experience, etc, etc. There are lots of other issues involved in this matter. The truth is, every surgeon would have operated and worked when they were sleepless and exhausted. I remember a senior surgeon describing an experience when he was a trainee where he started incising his own fingers because he was too exhausted. Every surgeon, specialty and department has also developed ways to deal with this problem. In fact, I dare say that operating under pressure and in physical exhaustion is a skill that is required as part of training. Not in elective procedures, but in emergency context. No one is ever fully awake at 3am, but a surgeon needs to be able to operate at 3am when the situation demands it.

Key principle: patient safety comes first, and doctor safety comes a close second. Once you abide by the simple rule of patient safety being paramount, you develop methods to ensure that principle is upheld. They are not necessarily in the form of protocols, guidelines, etc. But common sense would help. When I have been on call for too long, I would notify my consultants of the physical state that I am in. Depending on the procedures involved, I would perhaps be allowed to do low risk ones, while my bosses perform high risk ones. I would be allowed to take a nap during the day, between cases or in clinic. I would pass on my phone to my interns so I can get uninterrupted nap. Overnight, if I desperately needed sleep, I would speak to the ED in charge to ensure that they field my calls and to the best of their ability, and leave me with uninterrupted sleep between midnight to 6am. These are not enshrined in protocols, but they are simple problem-solving solutions. There are many other safety maneuvers I do to ensure that no matter how tired I am, my patients will not be placed in any risk of harm.

But the bottom line is this: surgical training is meant to push you physically to the limits. It is a physical specialty. Though I don’t wield the hammer and chisel, I do operate and travel on cranial nerves for up to 6-8 hours at a time. I need a strong physical and mental capacity. Being tired and exhausted and operating out of that is a skill I need to develop during training and even more important than that, knowing my limits is a skill I must attain during training. I have trained myself over the last 8 years to be working on little sleep and little food. My body is accustomed to it. It’s not an overnight thing, but it’s part of training. I certainly do not expect other specialty trainees to be doing what I am doing. This is my specialty and this is my training. I need to train myself up to the demands expected of me. If there is an airway bleed at 3am, I know that I am up to the challenge because I have trained myself physically for it. For the sake of my patients, I will be alert and competent at 3 am to save their lives, because I have trained physically for it.

All these long hours at work and away on conference also mean being physically absent form my loved ones. This, to me is harder than the long hours itself. On top of the long work hours, I have research studies to complete, examinations to sit, talks to present, meetings to prepare for and attend, etc. If I really calculate my average working hours including on calls, research, etc and turn that to shift work, I’d say that I work 6 am to 8 pm 6 days a week.

Emotional costs

Being away from family really hurts me. The physical tiredness can bring my mood down, but the emotional drain of the job often leave me with an empty tank by the time I get home. I deal with many patients with cancer and those who are walking their last mile. I give bad news to patients. I deal with difficult, demanding patients. I see my own complications or personal deficiencies. I work within a health system so under pressure. I work with discourteous, rude, unreasonable staff members. I work with big egos in surgery. I see my ENT patients die horrible deaths. I have cried with patients’ families.

My working day takes its toll on me. When I get home, my wife and 2 sons are asleep. I can’t burden them with the weight of my day. I can’t share too much of my day with them. Already, my wife is practically a single mother with me being away at work most of the time.

With the emotional costs of surgery, I need an outlet. For me it is important to lay my thoughts down in word format to keep me sane. Twitter, blogging, journaling have been my therapeutic outlets. Some of those who have known me on Twitter and blogs know the ups and downs of my emotions. But they also know that I am all for the patient. There have been times when the twitter community has heaped more stress on me, but in general, I have found twitter to be a surprising source of support. Twitter is that virtual conversation that I can have at any odd hours of my day, as compared with me talking with family or other trainees for emotional support.

Surgical training and the surgical life has admittedly hurt many marriages and relationships.  I have seen many ENT registrars lose their marriages and many surgeons lose their families. I know that it is not necessarily the job that killed the relationship, but it would be naïve to say that the job did not contribute to their marital demise. I do not want that to happen to me. I place my family as a priority over my job. However, I also do know that these incredibly long hours are a feature of this season of training where my working hours are beyond my control. If or when I finally become a consultant, I have better control of my own hours. I get to choose if I just wanted to work in 1 hospital or 5. Hence despite my long hours, my wife is gracefully still extremely supportive of me. She understands that until I finish my training, I have no control over my hours.

Counting the Costs

Surgical training is expensive, exhausting, and emotionally draining. It hurts the wallet, the mind, the heart, the body, and the loved ones. But it is only a season. It is right that the journey is arduous, long and lonely, because a surgeon needs to be extremely well trained. It is for good reasons that a surgical trainee is pushed to the limits. As a trainee, I have placed my comfort, my time, my wallet, my sleep, my holidays, my family at the altar of surgical sacrifice.

The big question, therefore, is: Is it worth it?

After being selected for medical school, then passing exams, then being selected for internship, then basic surgical training, then General surgery, and then ENT, is this journey worthwhile? Nationally in Australia about 12 trainees are selected each year from over 100+ applicants. I am lucky enough to have been selected. So when I look back at the training program, despite the long hours, I am extremely grateful for this opportunity to be trained by some of the world’s best in such an amazing specialty area.

Is it worth all the sacrifices, though? Well, I have not reached the finish line yet, so I cannot answer that question. At this stage of the game, I can only be thankful that I have enjoyed the journey thus far. I believe in something beyond, Someone bigger than myself. I am not interested in making a life for myself. I’m not interested in making a name for myself. I want to be a part of something bigger. ENT is only a tool in that plan. If ENT & surgery was taken away from me, I would still carry on and move on, in a different role. At this stage, I believe that ENT is my vocational calling, and I’m happy to leave it at that. I LOVE ENT. I cannot think of doing anything else at this moment. I love this job and I love my family. I need to display excellence in ENT daily, and that’s what I’m going to train for, everyday.

On Hold

I wished I had all the time in the world to pen my thoughts.

I don’t.

I have a hurdle to jump. An Everest to climb.  A Surgical Fellowship Exam to sit. Until then, this blog will be on hold while I pursue the F word. (“FRACS” – Fellow of the Royal Australasian College of Surgeons)

Will miss your company.



ENT Case File no 1: Not just a sore throat

29 year old male referred by ED for sore throat and jaw trismus with a provisional diagnosis of quinsy (para-tonsillar abscess). On the phone, ED doc said, he also has a large right sided neck swelling and the tonsils “don’t look too asymmetrical”.

Could this be quinsy? NO!

On review of the patient, he did have trismus and a large right neck swelling. Also, the patient added, “I have always had rotten teeth and I think this is a bad tooth infection”. The patient is right.

On examination: jaw trismus, large right neck swelling involving the jugulodigastric region (anterior triangle, inferior to angle of mandible) and extending over the submandibular region. Swelling feels hot and tense. Patient is drooling, Tongue is elevated (not swollen). Right inferior molars are rotten. Tonsils look normal and symmetrical. More importantly, the floor of his mouth feels swollen, tense and tight.


Ludwig’s angina secondary to odontogenic infection. This could become an airway emergency.

Paratonsillar abscess (quinsy) is an abscess formation behind the tonsil in the paratonsillar space (between tonsil and superior constrictors). Key findings: inflamed asymmetrical tonsils, uvula deviated to opposite side, bulging of abscess seen superiorly over upper pole of tonsil and soft palate, jaw trismus. Neck swelling is not likely. Neck lumps due to lymphadenopathy is possible.

Ludwig’s angina is cellulitis in the submandibular space. Think of it as compartment syndrome of the floor of mouth. It is often due to teeth infection. It can rapidly lead to an airway compromise as the tight space result in swelling posteriorly and inferiorly. Key findings: rotten teeth! trismus, tongue elevation (not swelling) due to tense swelling on floor of mouth, deep neck space infection and inflammation.

Imagine intubating a patient with trismus, tongue elevation and tight floor of mouth. Hence not a small number of these patients get emergent awake fibreoptic intubation or tracheostomy (up to 20% according to some reports).

Tips for docs: The patient tells you that he has rotten teeth. Believe him. Examine the floor of mouth and teeth when you think that a patient has any intra-oral infections. The clues are hidden there in the history and examination.