Surgical Training: Could you make the cut?

 

Like lots of you I recently read the article this week that outlined a female surgeon’s harrowing journey in the hospital system in New South Wales. Dr Yukimo Kudota discussed her health issues that arose as a result of work conditions; the continuous on-call shifts, hundreds of hours of overtime and lack of support in the hospital system – despite seeking assistance, she did not receive it.

 

As I read the article my heart broke – I am a GP who honestly, did not enjoy my time in the hospital system. Whilst I have never aspired to be a surgeon I did dabble in physician training for 18 months, I had toyed with becoming a geriatrician or rheumatologist but the hospital system, the hours, the culture, the “don’t speak out because it will most definitely ruin your career” did not sit well with me, and so I left and I have never looked back.

 

What scared me most when I read the article was that Dr Kudota’s story was not unfamiliar. I am married to a training plastic surgeon – he is in the final 6 months of his training program and honestly, if there were more time left I don’t think his mental health (and mine) or our marriage could take it. The truth, that I suspect many in the community don’t fathom, is that unrealistic and untenable work hours are the norm for aspiring surgeons.

 

I’ve seen many terms used in the media this week without much background being given for those who don’t live and breathe medicine. Dr Kadota was an unaccredited registrar – this means she was not in the training program yet – she was working the hours, doing the surgeries aspiring to get a place on the plastic and reconstructive surgery training program. There is no guarantee, none, that despite doing years and years of harrowing hours/surgeries/on calls you will get onto the program. I’ve seen people try for 5 years or more; their families, partners, children waiting with baited breath every year as they sit the interview hoping that this time they “get on” so that they can start the actual 5 years of training in will take for them to be qualified. Once on the program, if you are ever accepted, you are deemed an accredited registrar – you do all the same hours, with more obligations to training (exams, tutorials, course requirements) but your time is ticking – you know there is a light at the end of the tunnel and that one day you will be qualified.

 

This week the medical world has been buzzing with this story – I’ve spoken to my GP colleagues (many of whom considered surgery seriously earlier in their career) and surgeons (my husband being one of them) and the consensus is – this is normal. Every doctor I have spoken with is surprised to see the attention it has received in the media and those in medicine know that there is a lot of work, far more than is possible in the next 5 years, to change the story of training surgeons like Dr Kadota.

 

This story has shone the light on not only surgical training but the plight female surgeons, of which there are very few compared to their male counterparts. Recent research has revealed at only 10% of surgeons in Australia and the UK are female – whilst some could argue that less females consider surgery as a career option given the hours and barriers family life and motherhood as a result – there is also the issue of entrenched gender imbalance and the fact that a female surgeon does, without a doubt, have a harder road in surgery when compared to a male trainee. Whilst we like to think a lot has changed – surgery is still very much a male dominant field and the term “boys club” would not be an inaccurate descriptive term. If a female surgeon speaks about gender imbalance/unsustainable work hours/lack of support then she is easily branded “hysterical” or “emotional” – surgery and medicine are not the only field to do this, but the problem still deeply exists. And not just from colleagues by the way – most patients will assume a female looking after them in a hospital is a nurse, and female doctors and surgeons have to correct them (or just go along with it). A female surgeon I spoke with recently told me her struggles with how she is perceived – she wanted to be taken seriously, be firm and knowledgeable but she did not want to lose her femininity and so she felt she had to roam the wards in high heels and high waisted skirts to preserve her femininity. I’ve seen my husband in at 5AM most mornings either throw on shorts and a tshirt because he knows he will be in scrubs all day or wear a very similar chino and shirt combination because he will be on the wards – the same issues do not plague a male surgical trainee and thankfully my husband will readily admit that.

 

My husband is not a whinger, if I was doing his job (and thankfully I am not) I would be emotionally and physically broken. It is not unusual for my daughter and I to not see him for 4 nights in a row because he is stuck in the hospital. He leaves the house at 5AM returning at midnight – it’s not uncommon for my 2 year old to ask me if Daddy is on holiday or sick when these spells of absence occur. When not on call he is finishing late surgeries, checking in on patients post operatively and seeing patients for the next day. The 100 hours of overtime in a month that Dr Kadota mentioned in her story sadly, is the norm for lots of surgical trainees, I know that’s what our household lives through on a frequent basis. When my husband is on call the phone rings often consistently through the night – amputated fingers/machete wounds/skin infections/ dog bites are run by him at 2AM in the morning. When his alarm goes off at 430AM you can be rest assured that he hasn’t properly slept but he will be operating through the day. This is the norm for a large proportion of both unaccredited and accredited surgeons in Australia – his story is again, not unique.

 

The notion that a surgeon can be sleep deprived and exhausted and be deemed “safe” to perform surgery has baffled me for a long time. When I raise it with my husband the response is “it’s just the way it is.” In surgery, like a lot of training programs in medicine, the unspoken word is to never ever question the system, never appear disgruntled with the gruelling hours/lack of support or supervision because your career will likely take a hit. If you’re deemed someone who rocks the boat or who doesn’t fly under the radar then it’s likely your journey through training will be more difficult, if you ever get onto the surgical training program that is.

 

Despite medicine being an industry where we help our patients with physical and mental wellbeing- honestly, we’re just not that good at it when it comes to ourselves as a profession. Doctors supporting their colleagues, fighting bullying, sexual harassment and gender biases is not done as well as it could be. There are attempts being made, but we are still a long way off from an acceptable standard.

 

My husband and I have spent some time discussing the issues raised in this article, before the article was in fact published. The truth is that these issues are deep seated in the medical and surgical world – and just because the gruelling hours, on calls, unsupervised surgical time is the norm does not mean it is acceptable. Dr Kadota’s story is not a surprise to most of us in the system and that’s the most frightening part. I’ve said to my husband plenty of times that change needs to come from within the system – it needs to come from the majority within the profession who need to dispel the notion that just because they did it tough the next generation should too. Perhaps think about it this way – if your child or mother was being wheeled into surgery to have their appendix removed would you be content knowing that the training surgeon about to do the operation has slept a total of 8 hours in the last 3 nights, is emotionally and physically exhausted and dealing with some baseline anxiety that is perpetuated by sleep deprivation and fear of failure? The answer most often is no, and so something needs to change.