‘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:
Bachelor of Science: AUD$25,000 per annum x3 = $75,000
PGY2&3 BST: $15,000
ASSET, CCrISP, EMST, CLEAR, EMSB: $15,000
BST Exams: $6000 x2 = $12,000
Dunedin Course: $5000
BST Conferences: $6000
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
Temporal Bone courses x3: $8000
FESS Course x2: $5000
H&N Course: $4000
Reg conferences: $5000
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.
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.
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.