Clinical Digest15 Cutting
on Ashtin Doorgakant (Malawi), 26/Nov/2011 19:41, 34 days ago
The blog Not Made in China produced the desired response (largely due to its controversial nature). The controversy was without a doubt about Gaddafi and I deliberately did it and I'm glad I engaged some minds in debate. So I'll start with a little disclaimer to clarify my thoughts on him. I'm no starry eyed fan of no ageing dictator who's held on to power for far too log (even 10 years is too long for me), with an appalling record on human rights. But lets face it there is no leader white, black, yellow or brown worldwide that can claim a clean record. Western leaders often get praises for the good they've achieved (such and such peace deal or economic prowess) instead of being forever damned for their records on arms trade, secrecy, covert human rights abuses, economic subjugation of the world etc. So make no mistake about it (Bushism!), Gaddafi is no angel but he's one guy who has stood up against the unjust global power system. He's literally torn the UN constitution in a statement that's been mocked by those it blamed for maintaining such a fake global democracy. He has pulled Africa together across tribal divisions more than any other living person and formed the albeit flawed African Union. And if even Mandela sees him as a friend (he was a major international driver in the overhaul of apartheid in SA while Western leaders were still pontificating on such and such legal loophole!), lets place credit where it is due. Cause if we can give it to the likes of Thatcher, Bush, Churchill (not exactly famous for his racial ideas), Mitterand and the rest where they're deemed to have been successful without provoking such controversy, then I think we can grant Gaddafi his claim to fame..Cutting!Is it right to come to Africa for cutting? This is an oft-bandied about expression from home, referring to the benefits of doing elective or other work abroad when you’re a trainee surgeon. It usually goes:-“I don’t know what the interview panel will think about the experience I gained abroad, given it’s a different system.”-“Don’t worry about it! You’ll have loads of “cutting” and they’ll be well impressed.”Thus as a trainee surgeon, one embarks on this mission to get cutting as much as possible so that they can go back with an extensive logbook to prove their diligence away from home. Befitting my general cynicism on the over-competitive UK training system, I came here with a much tempered sense of necessity to acquire this cutting experience, unless of course, it formed a natural part of my work.Cutting, especially unsupervised, for the sake of cutting in an environment where adequate safeguards might not be in place is akin to human experimentation. Thus, despite doing some rather cutting edge cutting (involving unfamiliar territory like urology, gynaecology and general surgery in addition to orthopaedics) in my very first weeks of induction in Lilongwe, my logbook numbers dwindled significantly while in Ntcheu. In fact all I was cutting was the numbers! But that was fine then and I got a chance instead to deepen my understanding of other areas of management, which frankly I would have missed out on by coming straight to Queen’s. These include the technical aspects of conservative treatment and above all the insight into wider aspects of organisation such as procurement, maintenance, theatre safety, data management, networking etc.But now I’m at Queen’s, the nature of my job has been radically transformed. There are designated people for all of the above tasks, who need very little input from me and the need for my skills is very much at the service level, the shop floor, the wards and theatres. And let’s not forget the classes,as the academic department staffing required to meet the needs of the ever-growing student population at the adjoining medical college is very much stretched to its very limits. And every visiting doctor automatically gets a timetable of lectures as part of the package. Mine has recently been expanded that little bit more, with the arrival of the TOCOs (Trainee Orthopaedic Clinical Officers), such that the only free half-day slot left in my weekly schedule, that of Friday afternoon has now been filled! But then again, I love teaching. As Martin Luther King Jr. said"the function of education is to teach oneself to think intensively and to think critically"...But let me cut the chase and come to the point again, that is cutting. That’s what I do at least 3 days a week now and on occasion 4 or even all 5. Let me tell you that I’ve never done so much operating (to use the official term for cutting) in my life before, let alone so much new operating. My learning curve is near-vertical now and my brain is quickly replacing oldcells (probably devoted to such past idlings of my mind as French literature or German speaking- sorry continentals, nothing personal!) with new ones packed with pictures of approaches, exposures and metal implants not to mention the long paragraphs that describe them! I’m quickly tackling operations like forearm and ankle platings, intramedullary nailings of femurs and tibias and external fixations, not to mention skin grafting and soft tissue procedures like tendon repairs with greater degrees of independence. To have leapt to that level in such a short time is quite phenomenal and not without its challenges (an all-encompassing term here in Malawi which I’ll tackle bit by bit now). Well the first challenge is really that: is that surgeon competent enough to do all these new cases? Well the simple answer is no! But then there’s challenge number two, how do we provide an essentialservice when there’s not enough hands on the ground to provide it? Should we use people with some but not full training and crash course them into doing the job? To that, considering that’s what I’m undergoing, I’ll have to answer yes, with the proviso that the trainee is responsible enoughto recognise their limitations and do their homework rigorously. That’s what happens naturally back home, and that’s what the stringent UK selection process (when not marred in favouritism and nationality biases) endeavours to achieve. And that’s why no trainee surgeon will be allowed to operate unsupervised until they’re consultant level pretty much. And that introduces the third challenge which is supervision. I’ve already said that every member is stretched almost to the point of having their limbs dismembered here. Hence a surgeon might feel the pressure to do most of the operating themselves, so that they can get all the cases done rather than painstakingly take trainees slowly through the processes. Thankfully that’s not what happens at Queen’s and for that reason alone, it deserves a 5 star grading as a surgical training institution. What’s more, it constantly receives visiting surgeons from various schools of surgical thinking (German, Dutch, English, rest of the world) and each one has a different way of doing things. This, when one doesn’t get confused instead, imparts an overall diversity which absolutely enhances understanding, probably better than having 10 supervisors who all have to follow the same approaches back home. So the issue of unsafe operating is taken care of by the system I think, but the problem remains that there are very few trainees coming through. Lack of competition and the pressure to produce more surgeons to cope with the ever increasing demand makes it very difficult to turn applicants down let alone fail them during training. Yet again, Queen’s has a very impressive academic record, and at least the graduates that have entered into surgical training (as opposed to pen-pushing jobs of DHO for which they are not qualified) are in my opinion, of the right ilk. The question is how do I, and the like of me fit into that system, especially the likes of me with a real hunger for cutting?! Are we depriving the local trainees of adding up their own numbers or are we providing much needed competition so they can up their game. I’m lucky to have come into Queen’s at a time when the number of local trainee is very low, hence there is enough work to keep everyone busy. But this is bound to change with time, at the rate at which the College of Medicine is churning out new graduates, and with all the DHO posts already taken up.So, to cut a long story short, my point is that coming here for cutting is an ethical dilemma the visiting trainee has to address thoroughly in advance, lest they slip into human experimentation and disrupt rather than benefit a system.Just like cutting in surgery, the role of volunteers in all lines of work needs equal consideration before rushing to the conclusion that being a volunteer is, de facto, a good thing that benefits a poor country. There are many challenges in all areas (culture, language, expectations, let alone technical ones specific to the subject) that might make the work of a volunteer ineffective, if not even negative. The standard of personal responsibility and social awareness of many volunteers (especially VSO as we get training in these areas before coming here) works as a natural check that’s often enough to mitigate against such adverse outcomes. But these days, there is a certain romance associated with working abroad (especially in Africa) and people embark upon such missions either for adventure, to meet a challenge or simply get a job/ experience with the job opportunities suffering back home. I warn against volunteering on these grounds. Doing a paid job is another thing. The main motivation in volunteering should be that of bringing positive change to the place and people. Should one feel they’re not achieving that, then they should change what they’re doing or stepaway rather than continuing for the other reasons. Especially relevant in this context are the very short term exchanges that abound in health care where people come here on glamorous (all inclusive) grants for 6-12 weeks and expect to change things in that time. I think these brief visits should be exclusively for observational/ research purposes and the volunteers ought to be briefed in advance that this will be their role (unless undertaken by experts, especially ones with experience in Africa, providing consultation). Their work has to be supervised and they should assist rather than takeover things.That is my 2-ish years’ worth on the subject and I’m certainly still learning the system more than I’m running it. I might have got it wrong in my analysis but these are my thoughts heretofore and that’s pretty much the only place I can record them.Cut!