Â Issue No.Â 34 -Â July 2011
by Michael Laurence (WOC Newsletter)
May I address some principles of practice which mirror training programs in general? When a patient consults a doctor â or makes a complaint of his or her state of health, he does so with considerable anxiety. He chooses the doctor with the best reputation gleaned from âpeer reviewâ from friends, family or better still, other doctors. This reputation will be based upon clinical outcome, how his other patients have done, and how they felt. But fundamentally reputations are lost on mishaps and mistakes.
In the operating theatre of a âWesternâ hospital, the surgeon relies upon the theatre to have to hand every item of surgical equipment that might predictably be required. This is not possible in the developing world. For that standard to be reached is prohibitively expensive and in practical terms impossible. It would be tantamount to neglectful if one were to embark upon a surgical procedure without a âplan Bâ, an escape, or salvage plan in mind. The hospitals of the world are filled with the complications of surgery which has failed to achieve its aim. The implication is that surgery is often embarked upon not unwisely, but with more enthusiasm than circumspection. These thoughts lead me to the conclusion that the most vital preparation for training in technical surgery is a thorough grounding in conservative modes of management, which all too often turn out to be required in the face of failure. Under such circumstances non-operative management is infinitely more difficult and less likely to succeed than if surgery had never been attempted in the first place.
My second conclusion is to regret that so much of âWesternâ surgical training is in the hands, not of mature and experienced surgeons, but of the manufacturers of quite excellent surgical equipment. Great surgeons can, through ingenuity, get themselves out of trouble. The greatest do not get into it. But everyone needs the ingenuity to think laterally during an operation, not to blame the instruments, nor the lack of them. In the operating theatre of the developing world, complete sets of tools are rarely found, and never regularly maintained. For all these reasons the experienced surgeon, who has seen it all, and escaped from it, is the best one to teach from his own lessons (often learned the hard way) the young surgeons who, in the developing world, will need that facility more than anyone else.