operations that no one would ever perform. Did I miss surgery? Not at all, surprisingly enough. Forty years had been plenty. But it remained a great mystery to me how I had achieved so much from my humble beginnings in the backstreets of a northern steel town. Perhaps it was that battle to escape obscurity that provided the momentum. I wanted to be different, and I had the ruthless ambition to take on the system and overcome my past.
Although I spent my whole career writing textbooks and scientific papers for the profession, I reflected for many years on whether it was appropriate to discuss my battles in a public forum. Ironically it was my own patients who urged me to do so, even the loved ones of some who died. So many were eager for their stories to be told. From my own perspective, I always found the history of modern heart surgery to be among the most compelling stories ever told. As a trainee in London and the US I actually knew a number of the pioneers personally, and they had shared their own trials and tribulations with me face to face, encouraging me to make a difference, not to sit in the shadows avoiding conflict. And I certainly attracted trouble right from the start.
The government’s policy of releasing named-surgeon death rates to the press was another factor that edged me towards writing a tome for consumption by the general public. What is life really like on the other side of the fence? Is it different from being a statistician, politician or a journalist? The barrister and medical ethicist Daniel Sokol wrote in the British Medical Journal, ‘The public has an appetite for glimpses of the private lives and thoughts of doctors. They demystify a profession that was once deemed blessed with magical powers.’ Perhaps some of us still do have mystical powers. There are few things more intriguing than delivering electricity into a patient’s head through a metal plug screwed into their skull like Dr Frankenstein’s monster or reinventing human circulation with continuous blood flow without a pulse. These innovations may be construed as witchcraft, but they were my own practical solutions to the terrible illness that is heart failure. Sokol went on to say that doctors are in the habit of revealing ‘not the chiselled frame of Apollo … but the wart covered body of Mr Burns, the Simpsons character’. But Burns was the rich factory owner. I’m more of a sensitive intellectual, like Bart Simpson’s father Homer.
As is often the case, the French have a phrase for it: ‘se mettre à nu’, to get naked. So that is what I decided to do, although this was a much more interesting spectacle in my younger years than now. My own insight tells me that the public are happier to learn that their surgeon, even a heart or brain surgeon, is human and subject to the same core emotions as anyone else. But because of a freak sporting accident, some qualities possessed by the vast majority of people were lost to me for a while, which proved an unexpected but substantial boost to a career at the sharp end – life perpetually on the ‘knife’s edge’.
1
When I searched the internet for a contemporary description of the surgical personality, I found this:
Testosterone-infused swagger, confident, brash, charismatic, commanding. Arrogant, volatile, even bullying and abusive. Aggressive. Cuts first, asks questions later, because to cut is to cure and the best cure is cold steel. Sometimes wrong but never in doubt. Good with his hands but no time to explain. Compassion and communication are for sissies.
The psychologist author argued that the highly stressful, adrenaline-fuelled environment in which surgeons work attracts a certain personality type. And so it does. Cutting into people, then wallowing in blood, bile, shit, pus or bone dust is such an alien pastime for normal folk that the mere process of operating immediately sets us apart. Those with introspection and self-doubt select themselves out from my specialty.
It is hard to describe how agonisingly difficult it was to gain access to a cardiac surgery training programme in the 1970s, when open heart surgery with the heart–lung machine was only in its second decade. The surgeons of that era were an unashamedly elitist group with the guts, skill and sheer daring to expose a sick heart and attempt to repair it. Methods to protect the muscle when it was starved of blood were frequently inadequate, and prolonged interaction between blood and the foreign surfaces of the bypass machine triggered a damaging inflammatory reaction known as the ‘post-perfusion syndrome’. Heart surgeons therefore needed above all to work against the clock – deaths were a daily occurrence, yet most patients were so sick that this wasn’t considered a catastrophe. While survival and symptomatic relief were gratifying, death put an end to suffering. Consequently, most families were grateful that their loved ones had at least a chance of their condition improving through surgical intervention.
We all had to go through general surgery training first to show that we had what it takes. First, good hands – and you have to be born that way. Most organs just sit there while you cut and sew them, but the heart is a moving target, a bag of blood under pressure that bleeds torrentially if you bugger it up. Just touching it clumsily can provoke disorganised rhythm and sudden cardiac arrest. Second, the right temperament – the ability to explain death to grieving relatives and to bounce back from a bollocking in the operating theatre. Then courage – the bravery to take over from the boss when he’s had enough, the guts to take responsibility for the post-operative care of tiny babies or to address a catastrophe in the trauma room when the nearest consultant is an hour away. Then patience and resilience – being able to stand there as first assistant for six hours without losing concentration, sometimes with a hangover, or to face five days continuously on call in the hospital, day and night without respite. That was surgical training in those days.
A series of infernal exams to become a fellow of the Royal College of Surgeons was an additional burden over and above the clinical work. These covered every aspect of surgery and only a third of the candidates passed each time. It didn’t matter that I wanted to operate in the chest. For the ‘primary’ fellowship we were required to know the anatomy of a human being in minute detail, brain to asshole, teeth to tits – every nerve, artery and vein in the whole body, where they went, what they did, what happened if we damaged them. We had to learn the physiological processes of every organ and the biochemistry of every cell. After some basic operative experience, the ‘final’ fellowship examined us on the pathology of every surgical condition in the book, then the diagnostic and surgical techniques for each specialty. Only after conclusively demonstrating comprehensive knowledge and skills were we allowed to move on and specialise. I failed both the primary and final fellowship on first sitting, an expensive exercise. Most of my associates did too. The whole miserable process was there to sort the wheat from the chaff, and I wasn’t fazed by failure. It was just like rugby, the sport I loved above all others. Some games you won, others you lost.
The surgical world resembles the army. The consultants are the officers and the gentlemen, the trainees line up in tiers through the ranks: senior house officer is equivalent to corporal, registrar acting as sergeant, senior registrar akin to a non-commissioned officer doing all the work and eventually being promoted to the officer’s mess. That final step was the most competitive of all. For the ruthlessly ambitious it had to be a top teaching hospital. Heart surgeons strove for London hospitals like the Royal Brompton, the Hammersmith, Guy’s or St Thomas’. Appointment to one of these, and you had made it big time. In those days Cambridge had a vibrant cardiothoracic centre in Papworth village out of town. Oxford was doing very little.
All this took place during our formative years, our late twenties and early thirties, when normal people cement relationships, settle down in one location and start a family. Trainee surgeons lived like gypsies, moving from city to city – wherever the best posts were advertised. Something about being a surgeon elevated us to a different plane. We were the fighting cocks of the doctors’ mess, the flash Harrys who constantly strove to outdo each other and ruthlessly coveted the top jobs; the guys – and at that time, as now, it was almost exclusively guys – who stayed in the hospital night after night seeking every chance to operate, or, if it was quiet, drifting across to the nurses’ quarters, where other exciting action
