Inside the operating theatre
“Whereof one cannot speak, thereof one must be silent” – Ludwig Wittgenstein
Ludwig Wittgenstein, arguably the most revolutionary voice in 20th century philosophy, spent his days and nights locked in an intellectual battle between our world and our language.
He highlighted throughout his career the (for him) unmistakable disconnect between philosophical questions and the spoken word; for him, such questions were meaningless, tautologies based on a misunderstanding of the way our language works. And in reading his work, consuming his complicated rhetoric and dense aphorisms, I have gathered a similar discord with the world within medicine that we dissect and inhabit every day of our student lives.
The main portal from Wittgenstein to the medical world, excluding his brief tenure as a porter in Guy’s Hospital in London during World War Two, is an ability to see beyond the conditions that make a medical workforce sufficient in its practice, and instead to look towards shaping what is necessary to the health of the establishment.
My orthopaedic surgical rotation in my third year of university consisted of a team of talented yet perhaps ideologically narrow individuals, focused on a particular joint, or a particular technique, a certain type of prosthesis or even a favourite operating room.
Advice at the end of the rotation was equally reductive; many of the surgical specialities are really sub-specialties, designed to create the most efficient form of medical labour. Ten years of strict study and focus awaits Buddhists monks and trainee surgeons, with one visiting doctor saying he sacrificed a year of his relationship with his wife to achieve the prestige of being an orthopaedic surgeon.
The heady aroma at the orthopaedic clinic wafts upstairs to the physicians who managed the patients pre- and post-operatively, preventing and treating recurrent DVTs, pneumonia and bed sores on the wards.
Downstairs in the operating theatre, the hip surgeon asks, unabashedly, whether the patient he is operating on is male or female. For him, it has become a cut and paste job. Combined with often exorbitant fees and the rock star status of surgeons, it’s no wonder the surgical community has fallen foul of a sizeable portion of the general public.
Why does this culture exist in the first place?
Poor female representation and allegations of systemic bullying are the core tenets of the surgical critique, yet for 20 years females have outnumbered males in medical schools.
It was Christine Lagarde, Managing Director of the International Monetary Fund, who said that increasing female participation improves a business’s bottom line. Yet societal pressure, such as parenthood and caring for aging relatives, often hamstrings women. It’s not sufficient for women to firstly become mothers, which is hard enough labour as it is. It is expected then, as a peer of mine recently pointed out, to become good mothers. Typcially there is no such expectation thrust upon men, despite their intentions to be or not to be good fathers. It’s even a bonus, an attribute worthy of praise, when we see a father being a ‘good’ dad, as if that shouldn’t be the minimum expectation to begin with.
These points are all valid into democratising some of the more arcane parts of medical specialties, in particular surgical specialties. Yet the response by the College of Surgeons is to create a more hostile and competitive application process that favours long hours and expensive postgraduate degrees in order to delineate between the best candidates.
Again, this is reductive thinking not dissimilar to the orthopaedic clinic I described earlier, more of a Wal-Mart than an outpatient service. Worse still, it immediately crowds women out of the surgical market by monopolising a commodity of which they are in short supply: time.
And at risk of sounding contradictory, allow me a moment of reductionism to add to Christine Lagarde’s fact: improve the working conditions of trainee surgeons, and you will have greater representation of female surgeons, and you will improve the bottom line.
The message is clear. As a new generation of medical students graduate and their broader ambitions within the medical world take shape, there will be a changing of the guard.
The system must reboot; specialties such as surgery must change for the better.
What’s more, it is imperative that the medical establishment is continually reminded of the need to change. Silence allows the norm to flourish, unimpeded and unflinching. If change flows, the health of the establishment will follow.
The views and opinions expressed in this article are those of the author and do not necessarily represent those of the Doctus Project.