What is a junior doctor?

At the moment, our counterparts in the UK are under attack from the government regarding their contracts. In case you have missed it, the government is forcing a new contract on 'junior doctors' which will lead to:

  • Reduction in pay of around 30%, in part due to normal working hours including evenings and weekends
  • Financial penalties if time is taken off for say, having children or performing research
  • Loss of protection from unsafe working hours

Although half a world away, the battle hits very close to home for all doctors. The health minister, Jeremy Hunt, has been bending statistics and scaring the public to make them think junior doctors are lazy and money hungry. It would appear that it is the other way around, as while the NHS is figuratively starving to death, the MP's have still received a 10% pay rise.

Australia has a better but still very imperfect system. You would be hard pushed to find a doctor in Australia who hasn't had a problem with pay or working conditions. We have been unpaid, refused overtime pay or rostered for unsafe hours. However, at the moment, we're not in the terrible predicament the NHS docs are. Half of the problem, I feel, comes from calling it a 'junior doctor' problem. Referring to any doctor as 'junior' is a misnomer and belies the countless financial, personal, professional and educational contributions made not only by the doctors, but their families too.

A junior doctor refers to anyone who is a fully qualified doctor but is still in the process of attaining a qualification in a specialty. It covers wide ages ranges from doctors in their mid 20's to well, the sky's the limit. It covers doctors one year from medical school or doctors ten or twenty years from medical school. It covers doctors who have attained their specialist qualification and are fully registered with medical boards, specialty colleges or Medicare as specialists but haven't got a permanent consultant job yet, either because we have a bottleneck for positions or because they are continuing to gain experience in super sub-specialised areas.

If you come to hospital with a heart attack in the middle of a night, the first person you might see is a 'junior doctor'. If your heart stops beating, it will be 'junior doctors' who will start it again. It may be a 'junior doctor' who takes you to the cardiac catheter lab and starts performing the lifesaving procedure to restore blood flow to your heart, while the consultant makes her way to the hospital. They are helped by another 'junior doctor' who gives an anaesthetic and keeps your body in optimal condition. It is the 'junior doctor' in intensive care who will be monitoring your heart rate and blood pressure, talking to your family and reassuring them and informing them.

It takes at least ten years to train as a specialist but during that time, a 'junior doctor' is no less valuable to society, to patients and hospitals. They are still accumulating expert knowledge and spend many, many unpaid, unrecognized and unforgiving hours honing their craft, performing teaching or administration all to one basic end. We all got into this because primarily, we like helping people. We love technical and intellectual challenges too, but we really just want to take a disease and kick its butt.

I think the term 'junior doctor' is a serious understatement of how important 'junior doctors' are. I would prefer something like pre-specialist. Or specialist in training. Or down right legends. Because that is what junior doctors are. They deserve respect and protection like any other occupation or person in society. They deserve to be able to pay their mortgages and their training fees. We seem to have lost our way as a society with where our respect goes. Put out a sex tape and become 'Instafamous'? Money and fans and respect are yours. Study for over ten years, work like a dog and sacrifice? The bureaucrats will ensure that your are undervalued and underpaid.

Superstar doctors of the NHS - we are with you 100% of the way. Good luck!

The standard we're all walking by

The Royal Australasian College of Surgeons recently released report by the External Advisory Group (EAG) was a damning look into the culture of bullying and harassment in surgery. In an unprecedented move, Professor David Watters, in his role as President of RACS, issued a public apology to those who have been bullied by surgeons. At the moment, we are awaiting the final EAG report where recommendations will be made into where to from here to stamp out bullying and harassment. I am impressed that RACS took this step in the first place. Surgery has a terrible reputation and the EAG report has unfortunately, upheld that. But where is the rest of the healthcare system? Where are the other specialty colleges, allied health, nursing, medical administration? RACS, if they continue on this pathway of addressing harassment, have an opportunity to be leaders. But it cannot be done alone.

Hospitals are a melting pot of different beliefs, ages, genders, races, backgrounds and experiences. It is natural that there would be interpersonal conflict. And there is. Whilst surgeons may well have learnt themselves a pretty bad rap, on a day to day basis, people from all walks of life are making someone else miserable. Since the report has been released, I have very rarely heard anyone else say that their specialty or profession or hospital are prone to bullying and harassment. I haven't seen (at least not well publicised) another speciality college saying that they will follow the lead of RACS and investigate bullying and harassment in their own specialty too. The hospitals have just carried on, business as usual.

Bullying happens everywhere in hospitals. I don't know what it is. The list of episodes of bullying and harassment is extraordinary. From the pay office who 'forget' to pay junior doctors to the senior nurse who likes to push around the interns. There was the time a senior physician commented about how women shouldn't be allowed to do surgery. There was the surgeon who liked to treat his theatre nurses so poorly, they had such a rapid turn over. A senior nurse was suspended for bullying her juniors, only to return to work. Some of these things, I've seen happen. Some have been stories from other colleagues at various times and at various hospitals. And quite often, the solution is to do nothing. Even those with some power do nothing; problems with staff members, especially if not your own, go in the too hard basket. And quite often, young doctors are told not to make a fuss, not to stand up for what is right because 'it may affect their career'. Even senior staff members within hospitals will freely admit that there is a problem, with an individual, a group or a culture then follow up by saying 'it's not worth the trouble'.

I agree, standing up for what is right may have negative consequences on the career  prospects of an individual. You are thought of as a trouble maker. And very often, as was identified with the RACS EAG report, a power differential exists. People have great ways of making your life miserable within the hospital environment. Despite this, one thing I am truly sure of. That is that the current standard of behaviour that we are accepting in our hospitals is definitely harming our staff members.

Again, I am going to refer back to doctors, but I would be quietly confident that this happens everywhere. Why would anyone subject themselves to constant stress? Good people leave. They leave that hospital, they leave the public health system, some leave healthcare all together. What's crazy about this is that the perpetrators, the system sees that as a win. But I can tell you it is an enormous loss. The people who care enough to say when something stinks can be our greatest assets, trying to change the status quo.

I worked with a colleague several years ago who was an extraordinary doctor. They came up against some difficulties with their training body and was not at all supported. This brilliant young doctor left the hospital system altogether. The people who made life difficult were pleased to have a problem out of their hair. The public should mourn this loss for we have lost a brilliant physician who was just beaten down by the constant fight just do a job.

So, now that the EAG report is out and RACS has been held responsible, I would like to see every area of healthcare take this lead. They may not need to commission an independent report, but I would like to see some of the recommendations made carry over to every other specialty college and healthcare profession. Surgery may have learnt it's stripes but let me assure you, that is not the bounds of the problem. It's time to stop walking by an unacceptable standard or pretending that your s*** doesn't stink. It's time for a multi-pronged approach to bullying and harassment in our hospitals. I hope that I can say in the future, that I am proud that RACS, my college, led the way on this and that we all rose to the occasion.

Toxic hospitals: when workplace culture has a bad attitude

I have been asked on a few occasions why I chose to do cardiac surgery. Aside from the subject matter, the technical challenge, the real difference you can make to someone, it was the team work. At the hospital where I started my training, I was lucky enough to work with a wonderful team. It made me appreciate how each of us, as cogs in the larger machine, came together for a common end. I hope my colleagues felt the same, but to me, it was collaborative, collegiate, sometimes fun but above all, healthy. We didn't always get along, nor did we always agree. But it was a kind of functional chaos that I have not really seen replicated. With the release of the Royal Australasian College of Surgeon's EAG report on bullying and harassment in surgery, the focus on what is a good workplace is at the forefront of our minds. Even just in day to day life, there seems to be a shift in how people perceive others' behaviours in the hospital work environment. Could it be that we are becoming emotionally intelligent about what makes a workplace healthy and what makes a workplace toxic.

A toxic workplace is a workplace that negatively impacts on the welfare, productivity and wellbeing of employees. In the healthcare sector, there is an added and vitally important group at risk - the patient. If we are too busy bullying, bitching and being obstructive to one another, aside form our own health, we are risking that of the very person we are there to save.

Toxic hospitals are horrific places to work in. Every day is a constant battle to get what you want or what you need from your workplace. What you want or need might be to be treated fairly. Or it might be appropriate instruments. It might even be teaching or support or holidays or rostering support. People go home every day exhausted, emotionally and physically. And they leave to greener pastures. But a toxic workplace or coworker doesn't see this as a loss. They prefer maintenance of the status quo - people who don't challenge the culture.

Toxic workplaces are often deeply engrained with practices of bullying and harassment, fuelled by toxic co-workers. These individuals and consequently organisations don't always see their practices or behaviours as problematic. You probably recognise these workplaces by their battle cry - 'we've always done it like this' or 'nobody else has had a problem before'. As a consequence, enforcing change is so difficult. Look at surgeons for example. It took a very public exposure of these practices in surgery to begin a paradigm shift.

I want to make one thing very clear. Surgeons have as I said, been exposed and held to account for its past practices. And they should. The rest of the health care system needs to follow suit. Toxic coworkers should not be tolerated. The sooner hospitals who have toxic work environments admit they have a problem and take steps to rectify them, the better. And the more people who stand up to toxic coworkers and toxic workplaces, the better for us, the employees and of course our patients.

As a final note, if you are interested in reading more about toxic work environments, I would highly recommend reading 'Toxic Coworkers' by Alan Cavaiola or 'No Asshole Rule' - all excellent places to start with to build a healthier workplace.

It's a man's world, baby.

I attended a function recently with some of the best and brightest female minds in medicine. After we discussed the medical topic at hand, conversation turned, as it often does, to gender issues in medicine. In a room of around twenty bright women, there was not a single dissenting voice to say that they had not found gender to  be an issue during their careers. As you may realise from reading this blog, I am a bit of a feminist. I believe that gender roles still very strongly define the lives of Australian women. I recently re-read Sheryl Sandberg's fantastic book, 'Lean In'. Actually, I listened to the audiobook because that's how I read these days, it uses my travel time very well. I found myself nodding enthusiastically at the impostor syndrome, the tiara syndrome, the fact that men are chosen on potential, whilst women are chosen on past achievements. I realised the importance of how women act or perceive ourselves (and each other). Sheryl Sandberg is a COO for Facebook and a graduate of Harvard Business School but even in the humble auspices of medicine, without a 'corporate ladder', it still a man's world out there.

The Impostor Syndrome is alive an well

I really think sometimes that I am here truly by accident. I wasn't actually meant to get into medical school because I'm rubbish at maths. And well finishing medical school, I just pulled the wool over someone's eyes. As for my specialty training, I am waiting for them to call me up and ask for it back, a mistake had been made. Turns out, impostor syndrome is everywhere in medicine. A quick chat to my female colleagues revealed an incredible amount of unfounded insecurity about their achievements. This is from a group of wonderful women who are bright and caring and ambitious. Truly, we have no reason to believe that we don't deserve it, yet we are constantly acting like we don't.

Sexism sells (us all short)

Just two days ago, a male physician approached me and said something along the lines of 'Are they letting girls do cardiothoracic surgery now?'. He seemed to think this was hilarious and followed up by saying 'That's not sexist is it?'. A few years ago, I might have laughed off the comment or made a joke but not that day. That day, this man got schooled as to my qualification and the sexist tone of his remarks. His response? 'Well good for you.' Good for me? It's bloody brilliant for me, actually. It's bloody brilliant for anyone who has made any achievement, especially with short sighted remarks like that. While it may seem amusing or cheeky to say things like that all the time, it's really neither. All that comes from that kind of remark is us both looking like idiots. Me for doing a 'man's job' and you for your short-sightedness.

Double standards

One thing Sandberg references in her book is that women don't ask for promotions or needs to be met. Partly because we think we will be denied, or don't deserve it or worse yet, judged for it. If you do need to ask for something, there is a right way to do it if you are a woman. Be humble, be community-minded. My female colleagues experiences seem to echo this. Rather than asking for a day off when heavily pregnant, one colleague pushed on through until the late stages of pregnancy. When she finally asked for a day off or some leniency for the on-call roster, she was told 'oh no, please don't get upset!' A male colleague who had a physical illness (not pregnancy) was given leniency on the on-call roster, days off, you name it.

Women are our own worst enemies

Everyone knows that if you put a whole bunch of women together, there's too much oestrogen and things get catty. I don't watch it, but I understand that is the premise for the Bachelor? Although they fight tooth and nail through hardship of being a female in a male dominated profession, not all women mentor their young female counterparts through the same positions. Women will make it father when we stop competing and comparing, whether it be the workplace or socially. Lift as you climb, ladies.

I think that we are all susceptible to subtle and sometimes unconscious expressions of gender bias. I am also saddened that in a room of professional and successful women, so many of us have experienced this. Nobody has the right to make us feel inferior for who we are, including ourselves. I can't way for the day when we have equity and strong female role models are not such an endangered species. The #ILookLikeASurgeon and #ThisIsWhatWeLookLike campaigns are already making so much ground in shattering stereotypes and providing inspiration the world over.

Medicine is a man's world baby. And it's a about time we changed that.

Women's troubles: why women still come second in heart disease

I love a bit of Barbra Streisand. The woman spells her name without an 'a' just to be different. One of Barbra's finest films is Yentl, based on a short play about a young Jewish woman who upon her father's death, pretends to be a man to be allowed to study at a Jewish religious school. Barbra won the Best Director Golden Globe for this film, the first woman to do so. So why are we talking about early 1980's films? Well, Yentl syndrome was first described by Dr Bernadine Healy to describe a phenomenon where women are more likely to be underdiagnosed, under-treated and die from the heart disease from their male counterparts. Women who present with typical or atypical symptoms of coronary disease are much less likely to undergo diagnostic coronary angiography (where dye looks at the blood vessels of the heart to see where they are narrowed) or be started on medications we would normally deem necessary for a patient with heart disease. Now this is not a gender-based discrimination problem, but rather a problem in biology. Men who have coronary artery disease tend to present with fairly typical symptoms like central chest pain, have big or obvious blockages of big coronary arteries and then therefore go on to get the appropriate treatment. Women, on the other hand, have atypical symptoms like tiredness, atypical chest pain or shortness of breath that may not trigger an angiogram. If they do have one, it is more likely to demonstrate what we term 'microvascular disease' where tiny blood vessels are blocked and may fall outside of the abilities of diagnostic tests or treatment.

Currently, the Annals of Thoracic Surgery has an article in press entitled 'Comparison of 3-Year Outcomes for Coronary Artery Bypass Graft Surgery and Drug-Eluting Stents: Does Sex Matter?'. This study, by Hannan et al seems to show that we do have a gender difference that is a little concerning.

The study looked at a group of men and women who had had either coronary artery bypass surgery or a stent for their coronary disease. As with most studies, there was more than double the number of male patients in the study. But each gender was then divided into two equal groups; those who had surgery and those who had a stent. The group then looked at how many people survived, had another heart attack, a stroke or another procedure to unblock the coronary arteries. The idea was to see whether men or women did better with heart surgery versus stents.

There is a noticeable difference between the men and women patients. For patients undergoing heart surgery, the mortality rate for women was 11.8% and 8.0% for women. A similar trend was seen in those getting stents. The women who had stents had a 13.7% rate of death, the men 9.1%. Similar trends were seen for strokes, heart attacks and needing another procedure.

While this study was not set up soley to look at how women performed to men in treatment, there is quite a noticeable gender difference. This is supported by a growing body of evidence that suggests all of the things I mentioned earlier. Women present later, get diagnosed less, get undertreated and do poorly when the have heart disease. For a condition that is killing women more frequently than cancer or any other disease, we seemed to have underperformed in both studying why and translating this to better care for women. Again, this not a discrimination thing, this is a biology thing. But one thing is abundantly clear, we desperately need more work and much more attention into women's heart disease.


Hannan et al. Comparison of 3-Year Outcomes for Coronary Artery Bypass Graft Surgery and Drug-Eluting Stents: Does Sex Matter? Annals of Thoracic Surgery 2015. Article in Press

, , , , , , . Factors influencing underutilization of evidence-based therapies in women. European Heart Journal. http://dx.doi.org/10.1093/eurheartj/ehr027

Update: #ILookLikeASurgeon going viral

A very quick post: The Huffington Post has put out an article about the 'I Look Like A Surgeon' campaign and I am very appreciative that mainstream media has picked up on it. The Daily Mail quickly followed it up with a very large article solely on me and pulled pictures from my blog to fill it up. As thrilled as I am that DM picked this up, the article is put together from quotes pulled from the Huffington Post and social media, not from any of my direct comments to them, nor give explicit permission for use of any images, quotes or the like.

I am very flattered that the social media campaign has reached such wide audiences. This is not a campaign about, for want of a better term, fame and fortune. It's about role models, solidarity, collegiality and inspiration. In the last couple of weeks, I've chatted with surgeons from around the globe and met some lovely people! I hope people who read what is quite a sensational headline on the Daily Mail website, read the story and the stories of many women who have contributed to the I Look Like A Surgeon campaign.

As trite as it may sound, I became a doctor to help people. And I chose my specialty for it's technical ability, the subject matter is fascinating and for the wonderful people I work with. It was not only the surgeons I worked with that mentored me and inspired me, it's the nurses from my early days as a resident and junior registrar who taught me how to manage wounds or put a bag of fluids up. The anaesthetists who showed me how to read an echocardiogram, the perfusionists who taught me more about physiology than I thought possible. I loved the early morning or late night chats I had with ward clerks, cleaners, secretaries and patients. Because without all of us working together to help me learn and do my job to the best of my ability, I wouldn't be doing my job to the best of my ability. When I finished my training, I know I said to some of those people how thankful I was for their help and teaching, but now I want to say it again.

I do truly want to inspire men and women to do my job. I hope that by all of these wonderful surgeons jumping on this campaign we attract the best and brightest to our profession. And if you want to do this, check out the #ILookLikeASurgeon hashtag on twitter or Facebook - you will find no shortage of wonderful men and women to mentor you.

Holding on for the ride!



Why women in surgery need other women in surgery - #thisiswhatwelooklike and #ilooklikeasurgeon

I recently spoke at another university 'Women in Medicine' night. I find these events both enjoyable and educational. It's a great opportunity to meet colleagues and other young women who are studying to become doctors and try and inspire and instruct some students (both male and female) into what I hope will be fulfilling and productive careers.

But every time I get ready for one of these talks, two things go through my head. The first being that I have no idea what they really want to hear. I had some very good advice that they just want to see that we women surgeons are real and that it can be done. (Turns out that is true) The other thought I have is how relevant is this anymore? After all, over half of medical students in a number of universities now are female. And then...

Whilst waiting to talk to a patient on the phone "Hang on, the nurse is here to see me" (after seeing them every day for a week and doing the surgery)

From a male physician "Women should just work harder to make up the pay gap. And because they have time off for children."

From a colleague involved in conflict resolution, man (and recent) cases of women in distress due to discrimination in the workplace, resulting in illness or leaving the profession.

Let's be honest. In my country, I won't be injured or killed for walking down the street with a man who is not my husband. I can drive, I can vote, I can be educated and I can be gainfully employed. When you look at things that way, I am very fortunate. However, this does not mean that we don't have some problems with the way our society views and sometimes treats professional women. Whether it be medicine, corporations, politics, law, trades or engineering, women are by and large, a minority group. Which means that for younger women wanting to join the ranks of the patriarchy, finding someone to identify with is pretty difficult. And we know that gender plays an important role in mentoring in medicine.

As a junior doctor, my mentors were male doctors. They were and still are, excellent mentors and I am very appreciative of their guidance. In fact, on several occasions, they were insightful and sensitive enough to make sure that I was aware that some unique challenges may face me in my career and made sure that I was equipped to think them through as part of my career and life planning. Sometimes though, I really wanted to know how that actually played out for someone like me. I was very resolved to the fact that I was to some extent going to have to carve out my own path in life. And I have been okay with that.

There is some research around that by and large supports the availability of women mentors for young women doctors and medical students. Gender matching can have a very positive influence on a mentor-mentee relationship with the 'mentee' being more comfortable to seek out advice from a mentor of the same gender without worrying that gender will colour the perception of the question or the advice itself. What it may boil down to is as simple as my talks for women in medicine nights. We just want to see that it can be done and learn from a mentor's journey.

Finding a female mentor, in surgery especially, can be tricky. Finding any mentor can be tricky. It is a relationship like any other, where both party needs to be satisfied with in order to work. When we have a lack of women on a a sheer numbers basis, finding a gender equal you identify with can be really hard!

Social media has been awash in the last few months with campaigns and hashtags such as #thisiswhatwelook like, a campaign created by an anaethetist and a philosopher to challenge societal and professional ideals of what professional people look like. It's extended to virtually every profession and skill you can think of; CEO, drummer, programmer, lawyer and surgeons. I got on board pretty early with my 'This is what a surgeon looks like' t-shirt and it's been great fun to be a part of. Recently, engineers joined in with a hashtag #ilooklikeanengineer when a young woman apparently was not considered to be what we would consider 'looking like an engineer' and has crossed professional lines to surgeons with #ilooklikeasurgeon now trending. And I love it. Being a part of this feel inclusive, inspiring and just fun. In the last few months, I've chatted with women surgeons around the world about surgery and not about surgery. But by and large, it's been about positive change and positive role models. It's about changing perceptions and expectations and encouraging young women into a profession that we all love.

   Every time I talk about being a woman in surgery, I want to achieve a few things. Firstly, I want to show people that I have a cool job and inspire others to maybe try it out. I love when a junior doctor (male or female) tells me they've loved cardiac surgery and now they want to do it. Secondly, I want to share that you absolutely do not have to be a certain race, gender, personality, sports fan or other group to be a surgeon. In fact, diversifying our specialty to involve women, for example, is a fantastic thing. Every different person has something unique to bring to the table and we should encourage that enrichment. And finally, I want to show the world that I don't have to be a stereotype to be a surgeon. Because I am a surgeon and this is what I look like.


Mentors can certainly mentor across gender and racial boundaries. But let's be real, in a world where people can still discriminate or belittle or neglect you like my two short (and very recent) examples, a ground swell against stereotypes can only be a good thing. If I encourage one young woman to be a surgeon just by being one myself, that's wonderful. If together, we can all make positive changes in a society and a system that is imperfect, then that is amazing and is truly an achievement to behold.




P plate surgeons - teaching, learning and ethics

The New England Journal of Medicine has published a fantastic article on trainee participation in surgery. The story is told by an ophthalmology resident (registrar equivalent) with a patient, none the wiser that a training surgeon, fully supervised, has just performed successful cataract surgery. The author talks about striking the right balance between teaching and training and what the patient would wish to have happen. Hospitals, especially teaching hospitals, are home to doctors of vastly different experiences. There is the professor, with thirty years of experience on one side of the table. On the other side of the table, there may be a doctor with weeks, months or only a few years experience. It is through this vast experience that an exchange of knowledge and learning of skills takes place. And at the centre of this is the patient.

I have always found that patients, by and large, do not have an understanding of the medical hierarchy. Which is understandable. There are so many words, terms, faces. Interns, residents, registrars, fellows, consultants. Age, or rather a perception of the doctor's age, is one thing I think patients use to try and work out who is in charge or experienced. They may perceive the person they have had the most contact with as the leader or the person who spoke to them for the longest. While I'm sure the patients appreciate that a hierarchy exists, I'm not sure that they always appreciate that there can be a chasm of experience, skill and knowledge between two people.

But whether they appreciate that difference or not, the patient has a most vital and important role in closing that knowledge gap. It is through their illness that junior doctors learn. I actually loathe to use the word practice. To me, that sounds akin to shooting hoops from the free throw line, over and over, hoping you get one in. Refinement. Advancement. Training. That is what it is actually like. A process rather than a crack at the goal. And with an experienced person standing there. I'm not sure during training that we say often enough that we are thankful for the trust our patients place in us. Without them, we simply could not learn.

But we don't say it. Very often, we don't specifically inform a patient that a surgeon in training may perform some or all of their surgery. A number of consent forms have a standard provision that reads something along the lines of 'a doctor other than the admitting doctor may perform the procedure'. As the New England article mentions, the patient may well not consent to a trainee performing their procedure. Which leaves us in somewhat of a pickle. Like so many situations, we have an obligation to more than one person. We have a very important responsibility to protect our patients and their health and well being. And we also have an obligation to train surgeons, for without them future generations would not benefit from medical care.

A number of things are leading to concerns with training young surgeons. Sicker patients requiring true expert intervention, changes to surgical training program execution, excessive working hour restrictions and oversubscription of doctors at certain levels of training. The use of simulation in both high and low fidelity models has been used to teach, develop and refine skills prior to getting to the operating theatre. I had the opportunity to practice on some fantastic models during my training. Paul Ramphal, an American surgeon who works in the Bahamas, has a fantastic simulator that uses a pig heart in a model chest cavity and has engineered in a way that it 'beats'. I had the opportunity to practice coronary bypass grafting on this model several years ago. And it was great fun. There is nothing quite like the real deal, but I think we will move towards simulation more and more as a way of teaching and training. Aviation and sport have made use of such technology for years and medicine is now catching up.

But what about for the now? Well, for starters, in cardiothoracic surgery, the literature seems to support that a patient's operation will not be compromised by having it performed by a junior surgeon. For coronary artery bypass grafting and valve surgery, there have been a number of publications that suggest that the outcomes are similar between a training surgeon and an experienced operator. In my field therefore, I can tell a patient that having a trainee operate should not adversely impact on their outcome. Their grafts will still flow and their valves will still open and close.

But we do need to be more open. And we need to do it such a way that the patient is not only reassured but also happy to be part of a very important process. The New England article makes mention of another ophthalmology publication whereby the authors got 95% of patients to consent to trainee participation by honest and open discussion in the informed consent process. And honesty and openness is so important to not only the consent process but the respect for the patient's autonomy and as a fellow human.

Personally, I think that moving towards transparency is the correct move. I think if I can reassure a patient that their outcome is unlikely to be unchanged, that they will participate in a very important process and of course, that trainee surgeons have appropriate supervision, then that is a process that it is ethically sound. However, I would be lying if I thought that a proportion of patients would decline a trainee surgeon or that all of their anxieties would be put to rest by any open and honest discussion. Going for surgery is scary at the best of times, adding another possibly worry into the mix may not be helpful for some people.

During my training, a small proportion of patients have asked who will actually be doing the surgery. Most of the time, I answered that it will be the consultant they were admitted under. If I knew that I was going to be do that patient's operation, I told them that too. I am very, very grateful for the patients who taught me. Who taught me simple things like placing an IV cannula. To the ones who showed me where their good veins were for taking blood. I am grateful for donor families who trusted me to use their loved one's organs for transplant and to the patient on whom I learnt how to perform joins in arteries with a suture the thickness of your hair. I am grateful for the learning because my future patient's will reap those rewards. But most of all I am grateful that you trusted us, all of us, to look after you when we were still learning the nitty gritty of just how to do that.

Why I'm quitting 'I Quit Sugar' - a response to Sarah Wilson's views on helmets

This is a slightly tongue in cheek yet factual response to claims made that helmet use will not prevent injury. If you are offended by (very ordinary) humour, my apologies but drawing attention to a serious issue is vitally important. Dear Sarah Wilson,

I have, in the past, enjoyed your cookbooks and some of the sentiment in your program I Quit Sugar. Western societies consume a lot of things, including sugar in excess. I have made a few recipes from your cookbooks and found them to be quite tasty. But you have overstepped the mark I am afraid with your comments on bicycle helmets lacking evidence and not preventing head injuries. I understand that when you ride your fixie bike with trendy basket full of fresh vegetables (not fruit, fruit apparently contains too much sugar), a helmet can ruin your perfectly coiffed hair. We all feel your pain on that matter. But let me put it to you plain and simple: helmets have been shown to reduce the risk of head injury. Fact.

Your 2010 blog post on why it's okay to not wear a bicycle helmet has recently resurfaced after an instagram post suggested that people don't ride bicycles anymore because we legislate that people wear helmets.

Sarah, I am a real, certified, trained, educated doctor. And I have seen many, many head injuries during my career. And a number of those patients that I have seen have been at organ retrievals when I go and bring home the beautiful gift of donor organs from a person who has had a bicycle accident and sustained a serious head injury. But as I am a doctor who is trained to look for (real) evidence and not just sprout my opinion, here is some evidence for you.

Head injuries account for 75% of deaths in cyclists. The Cochrane review is a collaborative database that reviews the scientific evidence of many topics. The Cochrane review in to bicycle helmets looked at all of the best available evidence into the use of helmets in cyclists and discovered a reduction in head injury of 63-88%. Helmets also reduce the incidence of injuries to upper and mid face region by 65%. Facial injuries don't just disfigure you, you can indeed bleed to death from severe facial injuries, lose your sight, have difficulty speaking and swallowing. Same goes for offering protection from serious scalp injuries - helmets can help prevent you exsanguinating from your scalp. Yes it can happen - the scalp is one of the most well vascularised regions in the body. Not wearing a helmet leaves you five times more likely to have a serious head injury. That's data from Sydney by the way.

Sarah, you are absolutely correct that we have never done a randomised control trial into helmets. And here's why. A randomised control trial involves taking two groups of people. You give one group the treatment (in this case, a helmet) and the other group nothing (in this case, no helmet) and then you would have to subject them to serious trauma and see who does better. As you can see, we could never do that. I'm quite certain even you would not volunteer for this experiment and not wear a helmet. In instances like these, we clever doctor types put together all of the information available and come up with what is still a scientifically sound answer. And thanks to people like yourself who do not wear helmets, we have plenty to compare with.

I understand Sarah that you consider yourself somewhat of a guru, navigating through science and picking out what the people really ought to know. You even throw in scientific jargon every now and again. Except that your jargon isn't scientific at all. Linear speeding and angular acceleration are made up, just like the Easter Bunny. Neither are terms that would be used in a hospital to describe how an injury happened. Real doctors use terms like direct blow, contrecoup injury, axial loading, hyperflexion or hyperextension to describe how an injury happens. But I'd hate to correct a wellness blogger like yourself. What would we know?

Helmets may not prevent every injury every time. If you are unfortunate enough to go head first at speed into a bus or a truck, then a helmet may reach it's limits of helpfulness. But for serious accidents, even when you do hit a car on your push bike, there is evidence to say that wearing a helmet just might save your life. I'm quite sure people who have been involved in accidents where they were wearing a helmet are pretty grateful that they were.

Sarah, everyone is entitled to have a thirst for knowledge and even share that knowledge. But what is insufferable and inexcusable is sprouting dangerous, unsupported rubbish that may affect some of our most vulnerable and precious people like children. I am terribly sad that the medical profession is not as appealing to the general public as you seem to be (for the moment). I feel like we sometimes fall short of protecting the general public from anti-helmet crusaders like yourself. Perhaps we need to harness the power of social media a bit more? Maybe we need an Instagram page dedicated to an intensive care unit or a rehab ward? Would our message get across then?

I hope that when you go on an unsupported, selfish, incorrect and vile rant next time, you will spare a thought for the people's who lives have been transformed by a traumatic brain injury. Aside from dying from these injuries, sufferers of traumatic brain injuries are forced to endure a lifetime of conditions like seizures, severe personality change, loss of independence (that means someone else may have to wipe your bottom for you Sarah), speech difficulties and memory loss. Imagine forgetting who you are, who your spouse is, or having to be fed through a tube for ever. Traumatic brain injury is a terrible, terrible waste of many people's lives and should not be trivialised by a 'wellness guru'.

I have always thought that I could take on board bits and pieces from your books and websites and integrate it into my own solid, scientific background. However, as I write this, I am putting your book into the trash where it belongs. I hope many, many others will follow suit. And I also hope that if you continue to ride your bike with no helmet, trendy glasses and golden locks flowing, that you never have an accident where you or your family wishes you were wearing your helmet.

Sincerely, wearing a bright green Stackhat,


The 'B' Word

Bitches get stuff done. - Tina Fey My team had developed a little habit of being late to work. I hate being late, it's just something I really try to avoid doing. For the first four months, I let it slide. But then, I told them all that they need to be on time. I did not name call or swear or shout. But I saw it all on their faces, the raised eyebrows, the downcast gaze. And then, as predictable as death and taxes came the 'B' word. Bitch. How original.

I have been called a bitch for as long as I can remember. And some of the time, it really makes me mad. That ambition, assertiveness, requesting a standard, standing of myself or taking no rubbish from people equates aggressiveness, dominance or is in some other way threatening is the way female behaviour is often skewed. The rest of the time, I wonder what fool would call a woman a bitch if he really thinks she is aggressive, domineering and won't take his BS? Talk about poking a bear!

It's not so much the choice of the word bitch that annoys me, it's what it implies. If a male boss asked his juniors to perform to a certain standard, he may be called firm but fair. If he wanted to advance his career and expressed desire to lead or win or achieve, he would be called ambitious. A woman in those same positions gets called a nasty bitch or a bossy bitch. Why should a woman boss not demand a certain standard? Why should a woman not express ambition to rise through the corporate ranks? What is that is so wrong with this? Why do women get name-called for it?

I'm a bitch, I'm a lover, I'm a child, I'm a mother. - Meredith Brooks 'Bitch'

When you call me a bitch, you turn me into a one dimensional nasty, scheming, domineering and unstable woman. I could be a sweet as pie, laughing and joking, even inspiring for 95% of the time. The 5% of the time I get cross or demand a standard or assert myself and get called a name colours everything else I do. Nobody will seem to remember that 95% of the time. Nobody will ever remember that their actions necessitated repercussions. My team for example, very swiftly forgot that they had mostly been 5-10 minutes late the entire year and that asking for everyone to be on time is courteous to everyone who is.

Once you are called a bitch once, that is all you are. Everyone is waiting through the fun times and laughter to see what I will next identify as unfavourable and 'turn into a bitch' about. A woman who is a bitch is incapable of expressing a range of emotions, of which anger or frustration are normal human emotions. She can only be that one thing from there on out. She has been painted with the bitch brush and that is hard to erase.

Bitch, like a number of other derogatory feminine nouns, is thrown around so commonly these days. It's no surprise that even as children, we use the word bitch and pretty indiscriminately too. Rap songs have been infamous for their use of words such as bitch, hoe or slut. Snoop Dogg, a pretty masculine kind of guy, recently came out and said that with his daughter and mother in mind, he would never refer to women as 'bitches' again. He would be horrified for someone to use those terms to describe his daughter so he should lead by example. And how true is that? We call each other names that if they were used for the women in our life that we care for, we would be furious. But with terms like bitch firmly engrained in our vernacular, is it any wonder that we so freely use the term in a derogatory fashion?

She didn't care that people called her a bitch. 'It's just another word for feminist,' she told me with pride.

By all accounts, Steve Jobs was a hard task master. He demanded excellence from his employees and from himself. When he sadly died from cancer, the world mourned the loss of this brilliant mind and business man. People called him a visionary and a genius. Will we do the same if the world were to lose a bitch? Probably not.

If being a bitch means voicing an opinion or demanding a high standard, then I am a bitch. If it means that you don't take someone's BS and will fight back when insulted, then I'm guilty on those counts too. If you think that I am confident and not afraid to challenge the status quo, then again, I am sorry to say that I am a bitch. And you'd better watch out. Because the bitches of the world are coming. Beyonce, Sheryl Sandberg, Michelle Obama, Hilary Clinton, Oprah Winfrey, Julia Gillard, Julie Bishop, Taylor Swift and Melissa Mayer. The woman executive at the bank, the lawyers, the doctors, the politicians. The small business owner and the athletes. If you are threatened by the bitches of the world, you had better get over that quick smart.

I am not going to say that I am 'proud to be a bitch'. I do my best to be a good leader and although I am not perfect and have plenty of learning to do, I actually think I do an okay job of it most of the time. I am proud to be opinionated and dedicated. I am proud to believe in high standards and I will never apologise for wanting to be good at my job, for wanting the best for my patients from myself and from those around me. I will not let go of my ambition because I am proud of my drive and dedication. I will not admit to being consistently even tempered or sugar, spice and all things nice. I am human and I express anger, sadness, happiness, despair, jealousy, fear and hope, all normal and healthy human emotions. If you want to call me a bitch, that's fine. I won't stop you. But don't be surprised when I use all of my 'bitchy' qualities to succeed while you call the next ambitious woman names behind her back.

As much as I say that sometimes being called a bitch upsets me, I know who I am and I am proud of who I am. If those qualities that I am proud of also get me called a bitch, then so be it. I have broad, bitchy shoulders that should have no trouble bearing the load. I can't wait to be in a workplace with more 'bitchy' women. We're going to do a great job!

Being a doctor is nothing like Grey's Anatomy


Do you want this guy as your doctor?

I never really watched medical shows, even before and during medical school. I watched maybe one season of ER, a couple of seasons of Grey's Anatomy and House MD and maybe one episode each of Private Practice, Chicago Hope, Emily Owens MD and other random medical shows. The only medical show I made an exception for was Scrubs, because it was funny and poignant and the closest to replicating what life is actually like in a hospital (but still a long shot I'm afraid!). Oh and I want to be able to whistle like Dr Cox. I'm sure like every profession, seeing your own profession on the big or little screen is generally frustrating because of the gross misrepresentation of your profession, daily life or working environment. Hollywood likes to play fast and loose with facts and science. Entertainment is great and all but that doesn't stop me from yelling at the television 'That's not real!'. So I thought I would compile a list of some of my favourite fictional faux pas.

House MD: You just cannot be addicted to painkillers and still employed. I feel pretty confident to say that if a patient upsets you and you insult them, even humorously and with a razor-sharp wit, you would be in a lot of trouble! Same goes for your colleagues. The medical profession takes substance abuse pretty seriously and Gregory House would have been parked in rehabilitation and his services declined with his opiate addiction. Brilliant as he may be, anyone with such a serious problem would be directed to the appropriate services. And by the way House, it's not lupus. It's never lupus.

House MD (again): Doctors don't do every single kind of procedure themselves, or even at all! Oh wow, this one grinds my gears. After breaking into a patient's house to confirm that they have been lying to you, you take the samples of mould found in the air conditioning vent to the lab where you run a host of tests to tell you all you need to know and save the day. I should mention that this was a follow-up procedure to you individually performing a patient's gastroscopy, brain biopsy and MRI. Does not work like that. We specialise. We outsource to experts. You just cannot be abreast of all of these procedures. It would be like me performing heart surgery and then popping to theatre next door to deliver a baby or administer an anaesthetic.

Every medical show or movie ever: Everyone who has a cardiac arrest gets a minute of (sub-par) CPR and a shock and then coughs and wakes up.  This one upsets me the most because when it really happens, it's not a happy ending. It's really sad explaining to families that we did CPR but things didn't work out. Or that not everyone's heart can be restarted (or should be) with a shock called a defibrillation. The survival for an out of hospital cardiac arrest is around 10%. However, I hope that seeing CPR on TV or at the movies encourages people to learn CPR. It may very well save a life. I'm also thrilled to see so many places now having automated defibrillators. It may give a few people a real chance of making it.

Grey's Anatomy: Interns do not do surgery alone. Even if they are getting it on with McDreamy. Interns are doctors in their first year out of medical school. I remember my intern year so well - it was scary and exciting and so fascinating. I learnt so much and got to do so much. I learnt to put in chest drains, arterial lines, do lumbar punctures and ascitic taps (read: nerdy surgical intern). However, the consultant neurosurgeon or cardiothoracic surgeon is not going to give you the suture or scalpel and say 'go for it!'. Nor are you ever likely to be put in that situation in the first place. Medicine is a skill to be learned over a period of time and we all have to take it one step at a time. Maybe it wasn't Meredith and McDreamy hooking up that promoted her, he probably just couldn't stand her pouting if he said no?

Every medical show or movie ever: There is no McDreamy (or equivalent) True story - when I graduated medical school, my grandmother, ever the feminist, said "well now you can meet a nice doctor and get married and have kids!". I am a nice doctor! Besides, going to medical school is a very extreme form of husband hunting! I hate to say it too, but doctors are a great big bunch of nerds. We don't swan in with our designer stubble and perfect hair or make-up. My make-up is generally found on the inside of my surgical mask so at the end of the day, I'm more McYuck than McSteamy. Doctors may scrub up all right but by and large, work is work and scrubs look good on nobody. Sorry. On the upside, the constant time indoors means we have lovely skin. Winning!

Grey's Anatomy: Cutting your LVAD patient's drive line will not bump him up the transplant list Just won't. It will get you deregistered and probably kill the patient a lot faster than you will ever find a heart. Sorry Izzie. Transplant is a highly regulated and very sacred process and we are not about to screw it up like that. Actually, that kind of thing would probably get you arrested, not fast asleep in your prom gown with your friends looking after you.

Every medical show or TV show ever: Random old school x-rays  These days, we mostly use computers to look at x-rays or CT scans. But why is there, always some random, usually chest x-ray, which bears no relation to the 'patient' hanging up in the background? You don't just leave x-rays lying around a hospital, they'll vanish never to be seen again. And by the way, Betty from Mad Men. Your chest x-ray was pretty darn good for someone with terminal lung cancer.

Pulp Fiction: Stabbing someone with adrenaline in the heart will not cure their OD. I feel like I'm telling a whole bunch of kids that Santa is well, you know. And if John Travolta stabbing Uma Thurman in the heart isn't one of the best damn scenes ever, well I don't know what is. But let me reassure you, that will not work. Now, in cardiac surgery, I have given intracardiac adrenaline before, but that is with and open chest, where I can directly see the heart and when things are not going very well at all. But that is pretty uncommonly used really. Plus, a needle into someone's heart can make the heart bleed, and the bleeding squashes the heart causing a condition called cardiac tamponade. So in reality, about an hour or two later, Uma's heart would have stopped and Marcellus Wallace would have been seriously unimpressed.

Every movie or TV show ever: If you are in a coma, you need a breathing tube, not a little bit of oxygen up your nose. This really grates me. If you are in a coma, you generally cannot breath for yourself. So we put a tube down your throat and breathe for you. Nasal prongs are so seriously pointless and downright negligent. I get it though, the marvellously attractive actor would not look so nice with a piece of plastic down their mouth.

Every movie or TV show ever: 'Flatlining' is not called flatlining, it is called asystole. And it cannot be fixed with a shock. Flatlining is one of those funny lay terms that if you hear being shouted in a hospital, you should turn the TV down. A flat line on a monitor means the monitor is disconnected or the patient has asystole where the heart has no electrical or mechanical activity at all. Unfortunately, this cannot be fixed by a defibrillator shock.

Rant over.

I'm going to start watching legal shows.

Can you have it all?

A few years ago, I spoke at a women in medicine day for a university surgical society. The theme of the day was how to have it all. I felt more than a little nervous. I don't know that we can. But I had decided in fairness to both sides of the debate to try and tell these young women how I try and 'have it all'. What was ironic was the morning of the presentation, I had been called in at 4am for an aortic dissection. What was more ironic was that 5am was when I was supposed to be finishing my talk because I hadn't had time to finish it before then. But I did my best. My opinion was that you can have it all as long as you work out what 'it all' means to you as an individual, family or couple and that it may not all happen at once. A fellow speaker who was a rural GP/surgeon stood up at the end of my talk and wanted to know if I ever 'take me batteries out'. I don't know what she meant by that but she may not have listened to the bit where I said do what is right for you. A friend of mine is applying for surgical training and I fully support her and I think she will be wonderful. We had a bit of a talk last night about one thing that is really worrying her about embarking on a surgical career. That is, meeting someone and having a family. How do you do both? Can you have both? Or do you have to choose?

Women, regardless of professional standing, are more likely to spend more time with household chores and child rearing tasks. If they are married to another professional, for example two doctors, the woman is more likely to forego or change her career to a different specialty that is more conducive to family-related tasks. Even if her specialty is perceived as 'more prestigious'. Women physicians are more likely to be married to another physician while male doctors are not. And when we look at a doctors' formative years, women doctors are a lot less likely to have children than their male counterparts. But it's not doom and gloom, we're not a lonely barren lot. Women doctors are married and procreating at rates comparable to the general population. No need to break out the cat lady starter kit just yet.

I am going to go back to the statement that I made at the university function. Everybody is different. I don't think you necessarily have to pick one thing over the other. It is surgery or it is a family. It is work or it is a marriage. It is operating or exercising. The scalpel or drinks with friends. It is balancing these in a mixture that makes you happy that I think you really need to work out. At the same time, I also don't think that if you for example see family as your number one in life, the thing you will be most whole with and that you're worried how surgery will impact on that, well that's cool. Nobody wants to spend their life in a career that they resent away from something or someone that they love.

I think what I want to say is that I think it's possible to tick all of the things in life that you want. I'm reluctant to say 'have it all' because really, I think that saying in itself is rubbish. But you need to work out what the important things in life are to you. Then it's just a matter of timing.

Sisters are doin' it for themselves: a girl's guide to heart disease

Welcome to June sisterhood! June is the month the Australian Heart Foundation uses as it's Go Red for Women month. A time to raise awareness and funds for women's heart disease. Yesterday was Go Red for Women day and it was lovely seeing social media awash with red as we all remember how scary heart disease in women. A lot of people would be forgiven for thinking that breast cancer is the leading cause of death in Aussie women. But unfortunately, that is not the case. Heart disease is the leading cause of death for Australian women. It's so important that we recognise that and understand that it is not just a bloke's disease. It can affect any of us and unfortunately, if it does, the consequences can be terrifying. Women with heart disease don't fair as well as the blokes. Even in younger women, ladies with heart disease die of the disease more often and have poorer quality of life. Think of quality of life as being able to do the things you need or want to do. Dancing, swimming, walking, shopping, stairs or going to the toilet yourself.

So in honour of Go Red for Women, here is my brief guide to heart disease in women.

Coronary artery disease in women

Coronary artery disease refers to blockages in the coronary arteries. These are the arteries that supply blood to the heart muscle. When these get blocked, you have what is commonly referred to as a heart attack. A bit of the heart muscle dies - this can be a big bit or a little bit. Coronary artery disease kills nearly 10,000 women a year in Australia (compare this with breast cancer which is about 3,500).

The risk factors for coronary artery disease in women are being overweight or obese, high blood pressure, high cholesterol, diabetes, genetics and smoking. See what is interesting about that list? They're virtually all changeable risk factors.

After a heart attack, a number of things can happen. Some people who have a heart attack can die immediately from the heart attack due to an abnormal heart rhythm, a rupture of part of the heart muscle or the pumping mechanism of the heart being so badly damaged. Other people may recover to a point, but some of these people have longer term problems. These can include heart failure which can stop you doing even simple things like getting dressed or angina which are like multiple 'near heart attacks' and can seriously limit how you live your life.

Ladies with coronary artery disease don't do as well as the blokes

I hate to say it but this is one area the men have us covered. Women with heart disease tend to see the doctor later, have it detected later and do badly after a heart attack. This is partly because the symptoms of a heart problem tend to be a little different to the men. Women tend to present with vaguer symptoms like being tired doing physical things or short of breath. The typical chest pain in the middle of the chest may be a slightly more vague discomfort, not even in the chest but in the jaw or arm. As such, the symptoms are not usual and it can be easy for patients and health care professionals to miss.

The way women block their coronary arteries is different to the men. Women have very small blood vessels blocked which makes the symptoms different and the diagnosis and treatment harder. It means that if you are a woman with risk factors for heart disease, you should be vigilant for changes in your ability to do physical tasks, funny niggles in the chest region or getting super short of breath doing things like climbing stairs.

The later diagnosis and later or different treatment mean that women who get coronary artery disease don't do as well. Even younger women with heart attacks fair badly. They unfortunately die from their disease more often and don't recover particularly well.

Modern medicine is pretty cool but not always able to save the day

Prevention is better than cure. It's a bit of a modern way of thinking that if we get sick, we can have a tablet or an operation and everything will be okay. I'm afraid that is simply not always the case. We see patients regularly who have heart disease who cannot have an operation to fix their blockages in the coronary arteries. These patients have to be treated with medicines that don't fix the problem. They're more like putting band-aids on a gun shot wound.

The best defence we have against heart disease is to not get it in the first place. And with modern life catching up with a lot of us leading to inactivity, weight gain, high cholesterol, smoking rates alarmingly high in young women, we need to put the brakes on immediately. Today is as good a day as any to stop smoking, get active and lose weight. It's not easy or fun. Well sometimes it's fun. But I can guarantee you, recovering from heart surgery or worse yet, dying from heart disease is even less fun.

Don't forget about other forms of heart disease

Coronary artery disease is the main offender but not everything. We see a number of women with other nasty heart conditions like heart failure, rheumatic heart disease or congenital heart disease. The number of women with these conditions are growing and doctors and researchers are working tirelessly to manage these growing problems.

Worried? Get checked up.

Like that ad for the national terrorism hotline a few years back, we should be alert, not alarmed. (Who would have thought that phrase would have stuck so much?) If you are worried that you are at risk of heart troubles or have a heart problem, see your GP and get everything checked.

For more information: visit the Heart Foundation Australia website here

And importantly to donate to Go Red for Women: click here

And lastly - watch this fabulous video by C. Noel Bairey Merz about women's heart disease

And - #WeWillBeRed


'We don't do that at home' 

I am away at the moment in Fiji with Open Heart International. The organization has been traveling overseas to many countries providing services including cardiac surgery, burns and women's health. This is my first trip with the team and it has been a really incredible time. One of the things I've found myself saying a lot is 'we don't do that at home!'. We don't have mice and geckos on the ward, we don't reuse items that are meant to be disposable (like oxygen masks and nasal prongs and plastic gowns). Our parents sleep on a rollout bed with linen next to their kids in hospital at home. Here, they sleep on a hard wooden bench about 4ft long. There's been a lot of things that we do not do nor do we see at home.

And that is just the tip of the iceberg.

The local villagers did an ask around and came to visit the children and their families I the ward after their open heart surgery. They gave each family $250 (Fijian) to help while their child is sick. We don't do that at home.

The local blood bank has a bus that is run by an ex-pat volunteer. When the locals donate blood, they test them for a wide range of things including kidney function and HIV for free. People here can't afford the blood tests so they get it for free for donating blood. We don't do that at home.

 When doctors train here, they earn a very low wage. Partly because they have to pay back the government for their studies. But when they have finally paid that back, the doctors send the bulk of their earnings back to their whole villages. Most of us don't do that.

We operated on a six year old girl today and her mother left the anesthetic room in tears, worried for her little girl. But her operation went smoothly and she was awake in ICU not long after. Her mother, with tears in her eyes, hugged me so tight. It was all I could do not to cry myself! Some people say thank you at home but that soulful, deep and genuine gratitude. We barely acknowledge each other sometimes. Little or big, thankfulness is something we struggle with at home.

This trip was about changing lives. Operating on men, women and children who will now hopefully go on to lead productive lives in their community, who will grow up big and strong, or who will see their own kids grow up. But really, they change us too. They make us feel the warmth of the local welcoming and gratitude and we will take that back home. Maybe it will be some small thing that we will show gratitude to somebody else for, like the guy who makes your morning coffee. Or maybe something big like your surgeon. But no doubt about it, there's a lot of things I've seen in this little country that we don't do at home. But boy do I wish we did.

At Their Mercy - Doctors behaving badly

The last few months have seen surgeons in particular gain notoriety as tyrannical teachers at best and destroyers of dreams and souls at worst. The 4Corners episode last night entitled 'At Their Mercy' set out to expose some of the terrible behaviour that goes on in hospitals. I only managed to watch it, piecemeal, this evening. The show told the story of Dr Caroline Tan, Melbourne neurosurgeon and Dr Gabrielle McMullin, whose throw away comments (now known as blow-job-gate) at a book launch launched not a book, but a ground swell of support from doctors around the country. The momentum with which the masses have moved to get bullying, harassment and doctor wellbeing on the table and in the minds of people everywhere has been extraordinary. What has been particularly positive is the Royal Australasian College of Surgeon's response. For something that has allegedly in the past been swept under the rug, they have mounted a credible response on this occasion. It may well be in response to media pressure but nonetheless, it is a step in the right direction. When Dr McMullin's comments first came to light, there was a number of people both within the medical community and outside who dismissed her claims as preposterous. This was followed by a very swift and growing counter response from young doctors everywhere who have seen or been bullied, harassed or generally down trodden. It has become very hard for anybody to deny that we have a serious problem here.

The bulk of reporting, including 4Corners, has focussed heavily on surgeons. I suppose it is with good cause. Surgeons have the worst reputation amongst other doctors for being 'difficult'. But let us not forget that bullying and harassment happens not only in all walks of life but within a hospital, from many different groups within health care. Nurses, all kinds of doctors, allied health, medical administration all bully within their craft groups and to others. Junior doctors can be especially vulnerable to insults from all sides. What really needs to come from this process is for any positive changes in surgeons to overflow into the whole of hospital life.

Hospitals are actually the employers of young surgeons, not the Royal Australasian College of Surgeons. As such, they are beholden to provide workplaces that are safe from problems like bullying and harassment. 4Corners touched on some of the alleged problems with the hospital response to complaints, such as those made my Dr Imogen Iblett. The response of the hospital concerned with regards to her complaint was described as manifestly inadequate. The Royal Australasian College of Surgeons has borne the brunt of the media attention but I would definitely like to see a shift to the hospitals, the employers. They too have a role to play. It is not unusual when a doctor is badly behaved for it to be acknowledged that the hospital knew about it and apparently did nothing, aside from a slap on the wrist.

With the now growing acknowledgement that we are in a very messy situation here, I've noticed amongst friends and colleagues a change in how we all look at our own behaviour. Some of us will of course be more insightful than others, but a degree of introspection is occurring. Questions like 'Am I a bully?' seemed to be asked. I would possibly say that if you have enough insight to ask the question, your behaviour is probably okay! But again, a lovely side effect of the media attention is to make all of us aware that the little off the cuff remarks or hard-line teaching may actually be very hurtful to someone. It should make us assess our teaching methods. Hell, it should potentially make us want to learn some teaching methods! A mentor of mine once told me that insight is one of the most important characteristics for a surgeon to have.

Bullying is a little hard to define for some people. Particularly for some of our senior colleagues where there was not just teaching by humiliation but by annihilation. There were racial slurs, name calling, denial of training opportunities. And they were for the most part, shaken off. It was just the way things were. The denial of those kinds of behaviours as inappropriate will only lead to their perpetuation. The philosophy and pattern of 'It was done to me, I'll do it to someone else' rests largely on the premise that I survived it, therefore, it couldn't have been that bad. Today's trainees just need to toughen up. That is entirely the wrong approach. This is not about mental or physical toughness. Yes, there is a degree of tenacity and thick skin that I think you truly do need in surgery. But nobody should have to endure character assassination and racial, gender or other slurs. They are not okay. How would you feel if it was your daughter who had been groped at her workplace? Had listened to sexual innuendo? It would be, I suspect poorly tolerated. Educating our doctors on what is okay behaviour and what is not will go a long way to creating the generational change we so desperately need.

The Expert Advisory Group from the Royal Australasian College of Surgeons has released a survey yesterday to trainees, fellows and international medical graduates (IMG) to truly gauge the magnitude of the problems of bullying. I would implore everyone, whether they have been bullied or not, to complete the survey. I feel very strongly that we need to stand with the College on this matter, whether you trust them, believe them, have been hurt by them or wholly disagree with the existence of widespread bullying or not. They are a group who have a very real chance to make a difference. Whilst it remains to be seen if real tangible change will happen in workplaces, the movement is here. It's in our College, it's in our doctors. Keep the momentum going and let's make our noble profession proud.

Are you okay doctor?

This post contains some strong language. Apologies if you are offended but sometimes, you just need to use something a little stronger.

I hate depression. Depression is a real asshole. It sucks your life force and can destroy you. It is indiscriminate and destructive. The pain depression brings to those who suffer it and those around them is horrendous. I would do anything to reach inside and take that pain away.

I have wanted to write about depression in doctors for a while now. My life and the life of some lovely people I care very much about has been touched by this bitch of an illness. Sometimes with devastating consequences. Beyondblue released a report into the mental health of doctors last year which reported a distressing trend of psychological distress, depression, anxiety and suicidal ideation at levels higher than the whole Australian population. Very few of us were surprised. Take a group of type A personalities and a very high stress work environment and attach some pretty significant stigma regarding mental health and it is a disaster. We all have seen people around as at work who are quite clearly struggling. Some of us are struggling ourselves.

I want to touch a little on my own experience but I hope you will understand that I don't want to divulge everything. My own experiences make me still quite sad and I hate to say it, but ashamed.

A few years ago, I got very sick. A bad job and social isolation in a new town precipitated a change in me so that I didn't even recognize who I was anymore. Gone was a healthy, resilient and outgoing me, replaced by a crappy imitation shell who struggled with some pretty basic tasks like getting out bed, sweeping the floor or doing my washing. I gained 10kg and stopped exercising. Unfortunately, my personality, my genes and my situation collided into a big messy train wreck of a woman. And what is crazy, I knew what was wrong with me long before I actually sought help. I am eager to jump to help my patients or a friend but I couldn't quite make that leap for myself. Which is stupid. But I did and I got better with some help from professionals and friends alike. 

What was messed up was why I let things get a little out of control before asking for help. It was because I thought I was stronger than that. More resilient. That as a care giver, it shouldn't happen to me. I should be better than that. 

Doctors are often reluctant to seek help. There is a fear and a stigma still attached to mental illness in the medical profession that is a significant barrier to getting treatment. Dismissive remarks about how it is weak and that an individual is simply not coping. A friend of mine said recently about someone who was struggling a little that they were having a 'bit of a moment'. A moment? That's an understatement. I cannot for the life of me understand why such stigma exists from people who let's be honest, should know a little better. I suppose like the rest of the world, health care professionals are subject to societal norms and expectations like anyone else. We are after all human.

I really don't understand why stigma around mental health exists amongst health professionals. We are trained to look out for it and treat it. We know that it's a real disease just like coronary artery disease. I would love to see us lead by example. The death of three psychiatry trainees in Victoria should serve as reminder that mental illness is as deadly as any other disease we treat. We as a profession should take this threat seriously and attack it with the same fervor we would attack pneumonia or gall stones. The Royal Australasian College of Surgeons recently partnered with an independent service to provide support to surgeons and trainers and that is a very good step in the right direction.

Doctors need to stamp out stigma attached to mental illness. I really believe that we have a duty to our colleagues to be much more compassionate than we currently are. Depression is not weakness nor is it an inability to the job. It's a nasty bitch who can strike down anyone. We give our patients the support they need so please let's do the same for our selves and each other.

For help in a crisis, please call Lifeline on 13 11 14 or visit BeyondBlue at beyondblue.org.au

Update - a few people have asked me if I'm okay which is so touching. I am fully recovered nowadays and have put the black dog in a kennel where he belongs. I am in charge of my life, not anything else. Thanks for reading.

So you want to be a woman surgeon?

I am lucky enough, from time to time, to be invited to speak to young women who want to be surgeons when they 'grow up'. I always have a hard time striking a balance between what I should share that is positive and inspirational and what I should share that is a little harsh and uncomfortable. Once, I turned to my friends and colleagues on Facebook on what they thought about my topic for a women in surgery talk which was on how to have it all. One of my more opinionated friends summed it up pretty well - "I'd like to find the bitch who has 'it all' and slap her!" I love going to these events, I really do. I want to inspire students and junior doctors, whether they be male or female, to a career in surgery. But I also want to leave them with a positive yet realistic message about what this game is about. To follow on from my 'So you want to be a surgeon?' post, here is my advice to the lovely ladies who want to heal with steel.

Starting with - 1. Stop thinking you can have it all!

Or at least redefine what 'it all' is to you and to the significant people in your life. I still don't know some of the things I want in my life. Women in careers are still the child bearers and still account for more responsibility with regards to household chores and raising children. Women are more likely to change specialties in order to account for these 'extra-curricular' activities, even if they have the more prestigious career. (Read The Changing Face of Medicine for more) My mother worked very little when I was growing up, she picked my brother and I up from school and was there during holidays. I know that if I have kids, that will not be their reality.

I have had to think about what all of the professional and personal goals will look like. I have worked out what is super important, what is less so and what I will go to the pearly gates being comfortable with. Work out what your needs are and adjust accordingly.

2. Don't be a bitch but be prepared to be called one

As I've made clear in my previous posts, I don't much rate bullying and being a pratt for the fun of it. But medicine and surgery is serious business and you need to be doing your best. It's okay to be firm but fair, especially when someone's safety is on the line. Unfortunately, in the process, you will be probably be called a whole bunch of less than ideal names like a bitch, bossy, domineering, and so on. I am proud to get the best from people and I am conscious to be the best human I can to do that. Doesn't make me a bitch. That being said, try not to be one. Everyone loves to tear down the nasty, grumpy woman. Don't give them a reason to. Create a workplace you want to work in, you're proud to be a part of and gives the best to the patients.

3. Be a girly girl, be a tomboy, just be yourself 

I think I'm a weird hybrid and that my folks got a son and half. When I was little, I used to ride BMX bikes (after seeing Nicole Kidman in BMX bandits) in kitten heels and a twin set. And I could beat up the boys, no dramas. I think I still am a hybrid! Most importantly, I am what I am. I am not going to give up heels and makeup to be a surgeon, I certainly won't stop reading Vogue! It's what makes me, me. I know that there is a stereotype that women surgeons need to be more masculine than the blokes but that is just not a great way of thinking. Be who you are, it's more interesting and much easier. You'll have enough on your plate already!

4. Get a mentor and no, it doesn't have to be a woman

My mentors have been all men. They've taught me about surgery, life and rugby. I am learning about rugby begrudgingly though. The important thing is not their gender but their ability to support you and guide you. Trumps chromosomes any day of the week.

5. Get some hobbies and friends who aren't doctors

I think this is so important for women in surgery. Surgery can be all consuming and it's so important to be able to talk about something else. This has the dual benefits of keeping your sanity and helping you be a well rounded person. Work life balance is so important to us all and surgery-free time means your surgery time is so much more rewarding and successful.

6. Think about how you are going to introduce yourself to patients 

I am not a middle aged man and therefore, I am often confused for something other than a doctor - physio, nurse, device rep come up quite commonly! I am finding now that the best way around this is to say 'Hello, I'm Dr Nikki Stamp'. But once I've got that sorted, I'm happier to be called by my first name. Don't want to be too formal!

7. There is no good time for small people

I feel a bit of an impostor dishing out advice on this one, as I don't have kids. But, there is not a universally accepted good time. Before, during or after training will not be easy. My friends and colleagues (and their families) have survived by just doing it and being in a supportive environment with help as they need it.

8. Choose your battles 

Yes sexism. It's there in varying degrees. My philosophy has always been to choose what you're going to jump up and down about. I am not going to advocate accepting outright discrimination but I've sometimes thought that if I get aggro at every off joke told in theatre, I'd be too busy being outraged to do any work. Bullying and harassment is at the forefront of our minds right now (as it should be) and if you do experience something seriously upsetting, there are processes in place. Hopefully, as we speak, these processes are going to be improved and refined to serve those who need them best.

9. Wear compression tights or stockings in theatre 

Practical tip. We ladies seem to be more prone to broken veins from the constant standing. Not only that, but if I forget my tights, I can't fit into my heels at the end of the day. Thanks to the scrub nurses for drumming this one into me! I wear 2XU tights and there are loads of small businesses selling super funky compression socks!

10. Your physical fitness is super important so don't neglect it!

I am not perfect in this arena. I would dearly love to run more than I do. Surgery is a physical job and being strong and fit makes it so much easier. It's not cool to run to a cardiac arrest and look like you need a resuscitation team of your own. I find my back and legs hurt so much less when I'm fitter. Exercise is also good for your mental health and surgery can be very good at testing that. Do something that makes you feel good. I can highly recommend running, weight training for strength on your feet and yoga for the strength, stretching your tired body and some serious zen.

Bonus tip number 11. Go for it girls!

Good luck superwomen!

Hey shorty! Height and heart - how does that work?

I'm what you'd call average height for a woman - about 5'7" in the old terms. Whilst I had always longed for a few extra inches, I'm actually pretty happy with my height considering the genes I got. You see my mum is tiny - just 4'11" - we were the same height when I was 12 or 13. 

One of my favoured and regularly read journals New England Journal of Medicine published an article yesterday online about height and the risk of coronary disease. Unfortunately, those with a little less height will be short changed in the coronary risk department. (Yes, it was a pun. I'm only a little sorry)

The study looked at some fairly complex genetic markers and so I thought I might try and unravel what they've said. 

So here's the guts of it. The investigators looked at the genes of 200,000 people of European descent, specifically the genes that influence a person's height. The people who had genes that meant they were pre-programmed to be a little shorter were also more likely to have coronary artery disease. But why is that? It's probably related to the increased likelihood that these people were more likely to have risk factors for coronary disease, specifically raised levels of LDL cholesterol and triglycerides in the blood. Both of these we know are risks for development of coronary disease. 

Genes are pretty complex. As is height. Being born with genes that make you tall doesn't mean that you are exempt from having a heart attack. Even if you are born to be tall or slim or any number of traits, how you interact with your environment has a big impact on what actually happens to you. So if you're leggy but smoke and live off burgers, your tall genes won't save the day.

So what does this mean for your average Joe? At present, probably nothing major. If anything, the study demonstrates how complex genetics are when related to some diseases. It probably won't mean that we will investigate shorter patients more aggressively. I think what we should take away from this is that you do not know what genes you have been gifted with. Your genes may protect you against disease or quite the opposite. Since we don't know what we've got, taking care of ourselves should be paramount. Not looking after your body is a little like Russian roulette - having a heart attack is a pretty rubbish way to find out you got the dud coronary genes!


Nelson et al. Genetically determined height and coronary artery disease. New England Journal of Medicine. ePub Apr 8 2015.

Body image and healthy weight: how do they go together?

Taryn Brumfit burst into the news a year or so ago. This is a woman who is a mother, was a body builder and is now a champion for positive body image with her movement and documentary 'Embrace'. I love the idea she's promoting. Being proud and happy who you are. Redefining what it means to be beautiful. Being a woman with wobbly bits who still gets her kit off if she wants to. I think it is absolutely wonderful to have a strong woman like Taryn shouting from the rooftops that it's okay to be who you are. Not everyone can have rock hard abs. Not everyone wants them. Positive body image is so important. I feel like as a society, we're pretty hard on women (but also men) who don't conform to what is sexy, what is beautiful. We fat shame people who deviate from this ideal, even a little. A woman who is otherwise slim (and probably healthy) but has a little bit of a belly that pokes out of her jeans may be met with a sort of disgust. Like she should 'put it away'. Poor body image sets women in particular up for psychological harm. They're less likely to take part in physical activity which is so important for health. Feeling bad about what we see in the media has even been offered up as a reason for eating disorders. I love that we are learning to be kind to ourselves and to one another.

There is a but coming. Obesity is probably the biggest, global health issue facing humans. Obesity is responsible for a huge amount of sickness the world over. Obesity is a problem that is running away from us and is very hard to reign in. So, the question is, how do we integrate a message of positive body image with a message of maintaining a healthy weight, a message that really drives home that obesity is just not good for you?

It is possible that you can be fit and overweight, but only if you also meet a certain few criteria. That is not being 'centrally obese' - also known as a beer belly. This is usually a marker of carrying too much pudding around your vital organs like liver, heart and gut. This kind of cushioning for your internal organs is really, really bad for your health. Aside from that, you also need to be free from diabetes, high blood pressure and high cholesterol. That's not forgetting some other diseases like osteoarthritis which can then go on to limit your ability to be fit because your knees just aren't up to the task. I have seen plenty of people running in races, even half and full marathons who are beating me and quite a bit bigger too! For some people, you can be fit and healthy and also be overweight.

I've noticed an increase in people who are overweight or even obese having big social media followings. They are huge champions of the messages to change standards of beauty, promoting that stick thin people are not the only attractive people. I'm not going to make some sweeping statement that any of these people are unhealthy because I do not know what they do and if they are healthy or not. If they make a generation of young people feel a little more comfortable in their own skin, that is a positive. However, at what point do we say that positive body image must also take into account a person's health and well being? And who says that? Someone, anyone, flicking through the pictures of a beautiful woman who is several sizes bigger than the average bikini model? A health expert? A doctor? I don't think we do have the right as random people to call out any of these people on social media for their weight when in actual fact we know nothing about them.

So what we have here is a pretty one sided mathematical equation. Overweight is bad. Negative body image is bad. What do those two add up to? Do they go together? And if so,how? Honestly, I have no idea. But I do strongly believe in maintenance of a healthy body weight. Evidence shows us that a healthy weight is most conducive to health and well being. I strongly advocate physical activity. But I also strongly advocate positive body image. I just don't know how to reconcile the two. And that's why I'm writing this collection of thoughts on the topic - I just do not know how to approach it!

A person's outward appearance (particularly one on social media) is not a reliable indicator of anything much. You cannot tell how healthy they are, what they eat, if they exercise or if they have disease. It will not tell you if they're a nice person with a kind heart, if they're mean or if they're smart. It doesn't tell you if they're lazy or busy or relaxed or worried. I think that obesity is a major health problem that needs to be addressed. People need to move more and eat better, healthy foods. But stigmatising people as 'fat' and all the negative connotations that come with that (lazy, unintelligent, unmotivated) is not only just downright mean, it's so counter-productive. Why would someone you just called fat and lazy want to go to a gym, or walk along the beach when they've just been told they're not good enough to do it? Why would they choose vegetables over a burger when you just sneer at them - they might as well have the darn burger.

Positive body image should lead to one thing only - health. Physical and emotional. If we can have people of all shapes and sizes feeling good about themselves, enough to love themselves to be fit and healthy, then so be it. It is not the right of anyone to name-call. Positive body image should encourage us to be kinder to ourselves, each other and our health and wellbeing.

So you want to be a surgeon?

My interns started the term with mixed career aspirations. One wanted to do interventional radiology, the other - 'not sure'. (They may actually be reading this while they're trawling through discharge summaries on the ward. Hi guys!) Now, in their last few weeks of our term, they're thinking about a surgical career. Which I think is great. I've been lucky enough to have had some great advice over the years and I've nutted a few things out myself along the way. All through medical school, I wanted to be a surgeon. I'm pretty sure my fellow students found me obnoxiously set in my ways. Some of my clinical mentors (GPs, surgeons, physicians) would often refer to me as 'the girl who wants to be a surgeon'. I lapped up my surgical terms. It seems I was blessed with small hands with long fingers, a knack for anatomy and the ability to stand up for hours on end. I stayed in theatre whenever I could. I could not be gotten rid of. Even back then, I loved it. I loved doing things with my hands, I loved the ability to make a real tangible difference to people's lives. It was surgery and me; two peas in a pod.

I spent a lot of time trying out every surgical specialty. General surgery, orthopaedics, plastic surgery. I used to want to be a hand surgeon when I was at university which meant doing plastic surgery or orthopaedic surgery. When I was in my second year out of med school, I was trying desperately to get a term in orthopaedics. As a trade off, I got cardiothoracic surgery. To which I was seriously unimpressed. It just did not tickle my fancy at all. But I did it. And I never left.

So what have I learnt along the way?

1. Be enthusiastic but not obnoxious

If you really want to be a surgeon, come to theatre. Follow your registrar when they're on call and see patients in the emergency department. Ask to scrub. Learn to suture, learn to hand tie. But be respectful. This is people's workplace and that is a real patient. Be polite and learn to take no as an answer. Not all the time, persistence matters too. I guess it's a pretty fine balance. I had a medical student once ask me if he could take the vein from the leg for a coronary bypass operation. the answer was of course no, but I had to have a giggle at his guts for asking! By being enthusiastic and keen, you get known by bosses and other people who will then be more likely to support you. Plus you will learn so much! Most importantly, you will learn how surgery and you go together.

2. Surgery is seriously hard work

The days are long, you can go a whole day without eating or going to the bathroom. Emergencies happen in the middle of the night. Your patience will be tested by any number of people or processes. The process of skill acquisition can be hard and frustrating. The stakes are very high. Even if you have a 'gentle' job without inhumane hours and have a great team, it's still pretty hard. I never really appreciated how hard this job could be until I was in the thick of it. Sometimes I have been so tired, I just want to cry. Or quit. I think I could probably get a job as a crew trainer at Maccas. I have no idea where it comes from, but there is something fanning the flames at this point that helps you keep going. Sometimes it's the patients. Sometimes, it's the fact that you know you love the job. Sometimes it's just sheer tenacity. Whatever it is, it sustains you from time to time.

I get through the hard times by trying to maintain some work-life balance. I only do this now because I saw what happens when you let everything get out of balance. Decompensation is not pretty. Even the strongest can fall. Holidays, sleeping in, seeing friends and exercise keep you sane and healthy. Self-care means you are physically and mentally able to give the best to your patients. We don't train for the easy ones, doc.

3. Not wanting to do it is also okay

If you change your mind, it's cool. We work for 30-odd years in our chosen careers. Do you want to be unhappy for 30 years? Probably not. Do something you really want to do and that suits you in all facets. Suits your lifestyle, your skills, your passion.

4. Publish, publish, publish

Surgical training is highly competitive and is becoming more so. More and more medical graduates are coming through and are competing for similar numbers of training spots. You need to stand out. Get great references (see point 1) and great experience. Increasingly though, I'm seeing people publish a lot of material. It can be case reports or full blown research. Ask consultants and registrars you work with if they have anything you can write up and publish.

5. Have a locker and have some stuff in it

My locker contains: lots of funny scrub hats, toothbrush and toothpaste, change of underwear (for long nights), shampoo, mascara, lip balm, make-up remover and emergency food (brown rice and soups). It helps me look like a human rather than the girl from The Ring after pulling an all nighter. I hope it makes me smell a little less like I've been up all night.

6. Get a mentor

I have several mentors. Some have been there at different stages of my career, some have stuck with me. Some aren't even doctors! I'm sure I'll collect a few more along the way. These people have been sounding boards, advocates, advisors, teachers, drinking partners and friends. You don't have to have some awkward conversation like you do when you first start dating someone. (Will you be my boyfriend? Or in this case, my mentor) Most of the time, it's just a natural progression. However, a lot of societies and Colleges now have a mentor matching scheme. You can even chat to someone overseas.

People who aren't your mentors also have things to teach you - what to do, even what not to do. Listen to lots of advice and opinion and formulate your own take based on all of your information.

7. Be yourself

I'm not your usual cardiac surgeon. I read Vogue* and wear high heels. I giggle and I'm pretty cheeky. But I think that probably helped me stand out a little amongst the crowd. And I wasn't about to compromise who I was at heart. But most importantly, don't think because you don't fit a mould - whether it be gender, race, height, choice of extra-curricular reading materials - that you can't do this. Diversity is important. Different people bring different skills sets and interests and create tolerance and understanding in workplaces. (*By Vogue, I mean NW Magazine. Oh the shame!)

8. Learn about management, leadership and teamwork

A big part of being a doctor is to be a leader or part of a team. Not everyone is naturally gifted at this. But being rotten at it can seriously limit your career aspirations. Hospitals and surgery in particular, are basically big teams. We're working towards the same goal in different but cohesive ways. When the team does not work, it's not great for the outcome we're trying to achieve. I would highly recommend reading Harvard Business Review's articles on management and leadership, a book called 'The Charisma Myth' by Olivia Fox-Cabane and the No Asshole Rule by Robert Sutton. Look up to people who manage well and fairly. Learn from them. Trust me, it will set you apart and lead to a great workplace and great outcomes for your patients.

9. The rules of surgery are finite.

I was told these by a paediatric surgeon when I was a medical student. Eat when you can, go home when you can and don't **** with the pancreas. So true. Especially the bit about the pancreas. This advice keeps you alive and upright.

10. Learn mindfulness

This is by no way compulsory but a seriously useful tool. Mindfulness is a form of meditation that does not always involve you sitting down and chanting. Mindfulness is a technique of keeping focus on one thing at a time. Such as watching Keeping up with the Kardashians and not checking Facebook at the same time. I took up mindfulness as a way of managing anxiety and also improving my ability to concentrate on one task at a time. It made me so much more relaxed but has had added benefits in the operating theatre, keeping my focus laser-like. I would suggest reading anything by Jon Kabbat Zinn or using an app on your smartphone such as Buddhify, Headspace or Smiling Mind.

These rules are by no means exhaustive and nor are they compulsory. These are some of the slightly random or seriously helpful things I've picked up during my career. I'm sure if you ask one hundred surgeons for their ten tips, you will get a huge variation in what is actually important. I hope these help you in some way. And just for the record, I never watch Keeping up with the Kardashians. I am moderately addicted to Mad Men though.

Good luck!P1000071