CHAPTER 18

An accidental fraud

A few years ago I was consulted by a man in his late eighties. More than two decades previously he had received a coronary artery bypass grafting operation in another hospital. The bypass grafts were working fine, but over the years he had, as so many older people do, developed a tightly narrowed aortic valve and his coronary artery disease had progressed somewhat, so that another coronary artery, which was not touched at the first operation, was now blocked. He was keen to explore the possibility of a second operation and had asked his general practitioner to refer him back to the hospital where the first operation was carried out. He was turned down for surgery there because it was not felt that the benefits could justify the risk at his advanced age. He tried two other hospitals with the same disappointing result and finally presented himself at Papworth.

When I saw him, he was a slim, sprightly and energetic old man who still had all his wits about him. I listened to his complaint of breathlessness and explained to him that the risk of a second-time, double-procedure operation would be substantial and that, at his age, it would be unlikely that such an operation could actually prolong his life. In fact, an operation could actually bring his life to a most abrupt end, so that I wouldn’t dream of considering it as an option for him unless his symptoms were very severe, producing a substantial limitation on the quality of his life.

I then questioned him in detail about the nature and severity of his symptoms and he declared again that his only problem was that he became short of breath when he exerted himself. I asked him how much he could do before breathlessness stopped him and he said that if he tried to walk more than a couple of miles at a fast pace or uphill he became breathless. I then told him that there were many folk in their eighties who would be more than happy to be able to walk fast for two miles and that I did not consider this to be severely limiting, and he replied, ‘You don’t understand: I’m a hillwalker. I live for hillwalking. If I can’t climb hills, I don’t really want to live. I don’t care tuppence about the risk. Now are you going to fix me or not?’

Of course, after that, he got his operation. He spent a few days longer in hospital, because of his age and the complexity of the procedure, and went home in good shape. A few weeks later I received a postcard from him. It featured a photograph of him standing at the top of a hill in Derbyshire with a brief note expressing his gratitude. That postcard made my day and is precisely the sort of thing that makes it all worthwhile.

I sometimes give career guidance to Cambridge medical students as part of a surgical specialty ‘fair’. In this sort of event, representatives of the various strands of surgery lay out their wares and give short talks to the students in the hope of attracting and recruiting the brightest and the best to their branch of the profession. When it is my turn to talk about heart surgery, I do my best to tell it like it is. I explode a few myths, such as heart surgery is ridiculously competitive and impossible to get into, because it’s not. It is probably more competitive than some specialties, but it is accessible and achievable for any aspiring doctor prepared to put in the work and the hours. I also debunk the myth that it is a dying specialty because, allegedly, soon the cardiologists will be able to do with a catheter and an X-ray machine everything we surgeons do with a scalpel and an operating theatre: they will not. The cardiologists may have already creamed off some of the easier procedures, but in the end it is often only an open heart operation that will fix the big breakages in the heart. I still recall that the first time I heard a cardiologist declare heart surgery to be a ‘dying specialty’ was over 20 years ago. During that time, heart surgery has continually expanded in volume and in the range of treatments that it offers, so that, to paraphrase Mark Twain, the reports of its death have been greatly exaggerated. I also put paid to the notion that you must have phenomenal manual dexterity to succeed as a heart surgeon: you do not. Anyone who is not all thumbs can be taught the required skills. I am sometimes asked if I have had my hands insured. Of course I have not, but if I were to buy an insurance policy for any body part essential to my career, it would be for my brain rather than for my hands.

After this somewhat encouraging busting of myths, I tell them some discouraging stuff that they should also hear in the interests of balance: heart surgeons are not rich. They are not exactly poor either and will not be struggling to feed their families, but their earnings are nowhere near what some other surgical and medical professionals can achieve. It may be a glamorous profession to declare on meeting a stranger in a pub, but real money in surgery flows in specialties where several short and easy operations can be performed in one sitting. By comparison, a heart surgeon’s standard working day of two four-hour-or-longer operations is not likely to turn into a money-spinner. I also tell them about the endless commitment that heart surgeons feel for their patients, and the heartache that complications bring, together with the huge disruption of social and family life when these complications happen after hours. In heart surgery, the responsibility for a patient does not end when the surgeon gets home, regardless of whether that surgeon is on call or not. We are always on call when it is one of our own patients.

Another essential feature of heart surgery is one that does not often spring to mind: it is rarely, if ever, ‘ablative’. Many surgical specialties deal with a problem by removing the bit of the body where the problem lies. In fact, a well-known maxim of general surgery is ‘If in doubt, cut it out!’ This is more prevalent than you think, and goes way beyond the obvious example of amputation for gangrene. Think about the appendix, the gall bladder and varicose veins, which are the fodder of a huge number of operations in which the offending part is simply removed. Add to that all of the operations on toenails and lumps and bumps, plus almost every operation done for cancer. In fact, when I was in training, the standard operation for a benign stomach ulcer was to cut out part of the stomach. If the ulcer was in the duodenum, the surgeons, on finding that the duodenum could not be easily cut out, went ahead and cut out part of the stomach anyway! (This was ostensibly to reduce the acid production that was blamed for the ulcer, but now we know things are a lot more complicated than that and we have medicines that can treat ulcers better than any surgery achieved in the past.) General surgery, neurosurgery and large chunks of other surgical specialties are still substantially ablative, whereas heart surgery simply cannot be: you can’t cut out the heart (unless it is to replace it with something), so you simply have to find ways of fixing it by bypassing blockages, repairing or replacing faulty valves and so forth. This reconstructive nature of the specialty is one that I (and many others) find so appealing.

Where heart surgery truly excels is in two vital areas. The first is that there is not a single specialty in medicine that does more good. The overwhelming majority of our patients find that they feel hugely better after an operation. The symptom that took them to the doctor in the first place will have gone. Angina disappears completely in over 90 per cent of patients who have a heart operation. Breathing improves measurably in a similarly large proportion. Patients regain a normal quality of life and their sick hearts no longer restrict them or their activities, but that is not all. If heart surgery is effective when it comes to helping people feel better, it is even more so when it comes to helping people live longer. The majority of heart conditions that we treat are not just awful to live with, they also shorten life. A successful heart operation will result in substantially longer life for many, whereas an unsuccessful one will result in an abruptly shortened life for the few. The net result is a huge number of net life-years gained, so it is a field which yields generously both in quality of life and quantity of life, and, in this context, there is no medical field that comes close. Because of this, I don’t think that I have ever gone home after a long day’s operating thinking, ‘Well, that was a waste of time.’

The second area is that both the rewards and punishments that this specialty dishes out to its practitioners are immediate and they are directly related to how well the operations went. By and large, barring a few exceptions and bolts from the blue, and assuming a good level of decision-making in selecting an operation for a particular patient, the connection between how technically good an operation is and how well the patient responds and recovers is a very tight one. The aphorism ‘Cut well, sew well, get well’ is largely true in this specialty.

All of this means that heart surgery is a job where the rewards, even if not financially lavish, are rich and plentiful in so many other ways. What’s not to like? My now retired colleague John Wallwork was fond of repeating the mantra that we heart surgeons are so very fortunate in that our job is one of the very rare professions where we are actually ‘paid to have fun’. I am not sure that I fully agree with him that ‘having fun’ is the best way of describing what we do, but I do not for a minute doubt that there is a huge enjoyment factor and that the satisfaction of doing a lot of good for a lot of people is hard to beat.

During my career, the number of surgical trainees whom I have encountered on our training programme over the decades must be in the hundreds. Some were born to do heart surgery and some had it thrust upon them. Others have rationally and systematically explored all the medical and surgical specialties before making an informed decision that heart surgery was, in fact, their career of choice. These trainees, and the medical students whom I teach regularly, have often asked me when and how and why I decided to be a heart surgeon. Others have wondered about the sequence of events that led a Palestinian boy who was raised in Beirut to end up as a heart surgeon in Cambridge. I was most certainly not born with that calling, nor did I ever make an informed decision based on facts. In reality, I became a heart surgeon through a series of serendipitous accidents and stupid decisions made in absolute ignorance.

Most of my family had studied literature, education and philosophy and there was not a single doctor among them. As I was growing up in Beirut, I was reasonably good at science in secondary school, but had no idea what to study at university other than something vaguely related to science, such as engineering. I was about to go to an A-level college in Loughborough to study physics, mathematics and applied mathematics, since that seemed to offer a decent grounding for such a career aspiration, vague as it was, when I was struck with an unusual pneumonia. After I had suffered a few nights of high fever and hallucinations, my parents and our family doctor were getting worried and had me admitted to hospital.

The hospital in question was the American University Hospital in Beirut, a gleaming, modern building enviably located next to the university campus and overlooking the Mediterranean. I was admitted to a private room on the ninth floor with a fantastic sea view through the floor-to-ceiling glass window. Within a couple of hours of arriving my fever had taken its course and I felt much better, but the attending physician kept me in hospital for four more days while the lung changes on my chest X-ray improved, and so, I spent four healthy days feeling quite well and observing the hospital environment.

The nurse who attended me was beautiful, bubbly and blonde. Groups of medical students came to visit me and to listen to my chest and they were charming, attractive and very happy people. I must have been the only patient of their generation on the floor as they seemed to choose to take their coffee and lunch breaks in my room. We talked a lot and almost became friends and I could not help thinking that here was a group of young people who seemed massively to enjoy what they were doing and in whose company I felt very comfortable. I also thought that they looked super cool in their white coats and, on top of all that, I’m ashamed to say, I really enjoyed playing with the buttons which moved, reclined and adjusted the elaborate and hi-tech electrically powered hospital bed. That, and the very large colour television set with a remote control (a novelty in those days) clinched it for me. Forget engineering: I decided to become a doctor, and the decision was entirely based on one pretty nurse, some cool-looking medical students, an electrically operated bed with a sea view and a television set.

I arrived in Loughborough and immediately switched from applied mathematics to chemistry, so as to fulfil medical school requirements. I shared a tiny room in ‘digs’ with another A level student at the college. He was from Hong Kong and spent most of his time in London playing the stock market, so that he rarely turned up either for classes or in our digs, which was a relief as the room was barely big enough for one.

More importantly, there was nowhere to store food and no cooking facilities. Eating out rapidly became economically untenable, as a simple calculation showed that I would fritter away my monthly allowance in a week if I relied solely on fish and chips, and even more quickly if I varied the diet. I had to think of a way to eat cheaply at home and decided that some bread and olive oil, the poor Arab’s staple food, would have to do. I went to several shops and supermarkets to try to find some olive oil and was met by blank stares from all the shop assistants. Finally, one of them pointed out a large store across the street and said, ‘I think they may have some in there.’ I crossed the street and walked into said shop, which immediately struck me as an extremely unlikely place to stock any olive oil. I nevertheless asked if they had any and was directed to a particular aisle. Sure enough, there it was: an exorbitantly priced tiny bottle, containing a small amount of pallid olive oil that would be barely enough for drizzling on a single salad, with instructions on the label on how to deliver the oil up one’s bottom. The shop was Boots. Nowadays, supermarket shelves in the UK groan under the weight of dozens of beautiful and characterful olive oils from all over the world, and seeing the range, quality and variety of what’s on offer always reminds me of that visit to Boots all those years ago.

In college, my fellow classmates were a motley crew. Some had transferred from mediocre schools in the hope of achieving better A level results in Loughborough College, which focused on sixth-form studies among a few other things. Others were repeating previously unsatisfactory A level attempts, or, like me, had come from abroad with the specific aim of acquiring the A levels that would allow them to attempt entry into a British university.

At that time, medical school entry was highly exclusive and unquestionably traditional. The typical successful applicant to medical school was an upper-class white male, educated at a reputable public school and preferably the son of a doctor who qualified at the very medical school the applicant was hoping to join. I do not exaggerate: these were the features that often decided who succeeded and who did not. However, I knew nothing of all this and had naively assumed that medical school entry would be purely meritocratic.

One morning, the headmaster came into our class, just one of dozens of A level classes in the college.

‘Who here wants to study medicine at university?’ he asked.

More than half the class put up their hands.

‘I have something important to tell you,’ he said. ‘This college would be considered very lucky — no: extremely lucky — if one, just one, of our many A level students in the entire year group made it as far as being interviewed for a single medical student place this year. In other words, the chances of any of you getting an interview are smaller than 1 per cent. Think again, and please choose something other than medicine.’

Having dropped that bombshell, he walked out.

I duly filled in the application form for university entrance, placed four universities as my top choices for medicine and added a bottom back-up choice for engineering, as instructed by the head teacher. That year, the college was indeed ‘lucky’: as I was that one student who was granted an interview for medical school. I turned up at Southampton University, utterly ignorant of the system, its traditions and requirements. I wore a wholly inappropriate snazzy brown spiv suit with a ridiculously wide psychedelic tie. I had shoulder-length hair and looked more like an applicant for a job as a nightclub disc jockey than a serious and conservative future doctor. My interviewers asked many questions about why I wanted to be a doctor and tried to find out if I knew what a medical education was about. It was immediately apparent that I knew little about medicine, even less about medical education and absolutely nothing about the NHS. Needless to say, I was not offered a place at Southampton. I returned to Beirut and entered the American University there, the very institution whose shiny, gleaming hospital had converted me towards a medical career when I was briefly an in-patient there three years previously.

In Beirut the university followed the American system and medicine was a postgraduate course. Aspiring medical students had to do a bachelor’s degree with a core ‘pre-med’ curriculum, and then compete for medical school entry based on their performance in this undergraduate work. On top of that, the university had a unique feature: all undergraduate students, including us ‘pre-meds’, were required to take four semesters of Cultural Studies, and this mysterious course began with a lecture on a Tuesday. Since the entire freshman year was there, hundreds of us filled the largest lecture theatre on campus and waited for the lecture to begin, somewhat unsure what Cultural Studies meant.

A Swiss professor named Heinrich Ryffel walked onto the podium. He wore a very crumpled linen suit and was smoking a pungent pipe. He held up a book called The Epic of Gilgamesh and lectured us about it. It was the first literary work ever, written more than 4,000 years ago. He spoke about its provenance in Mesopotamia, highlighted its importance and tried to convey the essential messages that the book carried. Then he instructed us to read it immediately. On Thursday we had a discussion seminar about it. On Monday we were told to write an essay about it. Then on Tuesday we all trooped in to the same massive lecture theatre for the next instalment: the pre-Socratic philosophers. Again: read, discuss, write the essay. Then Socrates the following week. Then Plato. Then Aristotle. Then the Old Testament, the New Testament, the Qur’an, St Augustine, the Renaissance works, Kant, Hegel, Hobbes, Mill, Rousseau, Descartes, and all the way through every single important landmark of human culture until we reached the end of the course and the very last tome, which was the Little Red Book entitled The Thoughts of Chairman Mao. By the end of the two-year course, I had not only secured a place at medical school, I had received a true education.

I started medicine the following year, and the Lebanese Civil War broke out. The country split along several sectarian and political divides, which were fluid and unpredictable, so that at one point or another every sect had aligned itself with almost every other sect in fighting every other sect. What this meant was violence and murder on a grand scale, roadblocks which sprang up out of nowhere and at which innocent civilians were summarily shot if they were perceived to be ‘the enemy’ at that particular point in the war. The city of Beirut was divided along sectarian lines and the battle was raging only a few blocks from the medical school. There were food and fuel shortages, power cuts and interruptions to the water supply. There were snipers who took potshots seemingly at random, and my car had two bullet holes to prove it.

Throughout this mayhem, my overriding thought was not fear of the civil war itself – it is remarkable how quickly one can adapt to new circumstances and somehow manage to live with them. My main concern was a simpler one: it had taken me three years of hard graft and stiff competition to secure a medical school place, and now it looked like my medical school was being threatened with disruption and likely closure due to the war. I started to apply for a transfer elsewhere. I applied to hundreds of universities, in any country where I could speak the language. I was rewarded with hundreds of rejection letters which I used to wallpaper my bedroom. Finally, two universities said yes: Montpelier in France and Bristol in England. Montpelier wanted me to start at zero, whereas Bristol recognised my first year in Beirut and accepted me into year two. Bristol it was. And the American University of Beirut? Well, despite the raging, bloody war on its doorstep, it never did close its doors. My year-group friends made it, and most of them became very successful doctors.

I arrived in Bristol in the beautifully hot summer of 1976 and joined the second year of the preclinical course. After completing that year of lectures, laboratory work and microscopes, we started year three in which we would finally be allowed to see real, live patients. I was with the group of medical students assigned to Ward 20 of the Bristol Royal Infirmary. At long last, the time had come to play doctor properly.

Feeling very cool in a crisply starched white coat, I entered the ward. It was a traditional NHS Nightingale ward: a huge and grey dormitory with two long rows of beds. The few windows let in the grey light of the rainy September day outside. There was no gleaming white room overlooking the Mediterranean, no electrically powered beds and no colour televisions. The patients were anything but glamorous. The nurses looked harassed. The place smelt of stale urine. My hastily made and ill-conceived decision to study medicine suddenly seemed like the biggest mistake ever. Was this ghastly environment now going to be the backdrop to my life? What had I done?

The second accident was in deciding to become a surgeon and this was for even stupider reasons. I was in London as a surgical ‘houseman’ or house officer, the lowest rank of the hospital medical team. Among my many, chiefly administrative chores was to ask physicians for advice about surgical patients with complex medical problems. Since I then wanted to be a physician, I resented having to ask outsiders to help with medical problems that I thought we could handle ourselves, but my surgeon bosses were not interested in these problems: they just wanted to operate and leave the finer points of drugs and potions to the experts. What was worse, however, was that whenever we asked a medical team to review a surgical patient, it was my duty as a houseman to accompany them on their visit, answer questions about the patient and implement their recommended treatment.

The problem was that, as I saw it, these medical teams seemed to have a lot of time on their hands. They would descend en masse on our surgical ward: professors, lecturers, consultants, trainees, fellows, visitors, house officers and medical students. The entire mob would surround the hapless patient (and the even more hapless surgical houseman) and ask many questions. Then they would begin to discuss the most recent research, vying with each other to quote the latest hot-off-the-press offering in this or the other journal. As a busy surgical houseman, I had very little spare time on my hands and the last thing I needed was to waste any of it listening to their irrelevant and lengthy verbosity, when there were dozens of clinical jobs clamouring to be urgently done on the hectic surgical wards.

It seemed that the hottest topic for physicianly debate back then was whether potassium supplements should be given to patients receiving diuretic drugs, as such drugs are known to cause loss of potassium. From my point of view, the debate appeared Byzantine. Who cares? Give potassium routinely, or don’t give it, or give it only if the potassium level drops: they all seemed valid options and hardly the sort of stuff to get excited about, but for a few weeks, every time I asked for a physician’s opinion the horde descended and started to argue about this mindlessly tedious topic. I began to dislike physicians intently.

One day I was asked by my surgical bosses to request a review of one of our patients with Parkinson’s disease. As I did so, I told myself that if they mentioned potassium just one more time I no longer wanted a career as a physician. The mob came and assembled around the bed. To the best of my ability I pointedly kept the discussion focused on Parkinson’s disease, and they were just teetering on the brink of telling us how to manage it when one of them, a lecturer, picked up the drug chart.

‘I see the patient is taking a diuretic,’ he said.

‘Ah!’ said the professor, ‘how interesting! Is he receiving potassium supplements? Because this morning’s Lancet has a paper which shows that … ’

I had already stopped listening and resolved to become a surgeon.

I had no idea what surgical specialty to go for, other than a vague inclination to avoid any career choice which would entail a lifetime of peering down, through and up orifices. This excluded ear, nose and throat surgery, urology, gynaecology and proctology. I kept an open mind for other specialties until a couple of years later when I was doing my basic surgical training in Exeter and I worked for Mike Pagliero, a charming thoracic surgeon who specialised in lung and gullet surgery. He allowed me to do a fair bit of operating, despite my relative inexperience. I thought I had decided to become a thoracic surgeon because I liked the specialty, whereas, in truth, I just liked Mike Pagliero. I told him my decision and he was very supportive, but he informed me that in the UK there is no such thing as a dedicated thoracic surgery training programme: thoracic surgery was part of cardiothoracic surgery and I would have to train in heart surgery as well, and then ditch the heart bit to concentrate on lungs and gullets much later. Fine, I said. How hard could the heart be?

Deciding to go for surgery as a career meant that I had to become a Fellow of the Royal College of Surgeons (FRCS). In those days, the Fellowship was obtained by taking an examination in two parts. The primary part began with a multiple-choice paper in only three theoretical subjects: anatomy, physiology and pathology, and those candidates who achieved a reasonably good score went on to a viva examination, where they were asked more questions about the same three subjects, using dissected cadavers and dusty and archaic pathology specimen jars. Patients and surgical topics formed no part of the primary examination: it was all basic (and, for an aspiring surgeon, bloody boring) science.

I was working on a (now illegal) rota, which precluded any form of serious study: on call one-in-two. This meant non-stop work (with occasional snatched short naps) from Monday morning to Tuesday evening, Wednesday morning to Thursday evening, Friday morning to the following Monday evening, Tuesday morning to Wednesday evening and Thursday morning to Friday evening. After this arduous stretch, there finally comes one brief weekend off duty every fortnight. Had my colleagues and I been sensible, we would have ideally devoted this valuable weekend to studying for the Fellowship exam and to catching up on the lost sleep from the previous two weeks. We were not sensible and did neither of these things. Instead, for most of us junior hospital doctors, that priceless weekend after two weeks of working hard was instead dedicated to partying hard, which meant that we started the next gruelling fortnight as tired and sleep-deprived as we finished the last one.

I had done virtually no studying when I took the primary Fellowship exam and, of course, failed it. Twice. I did not even manage to get past the multiple-choice section either time. The third time I scraped through (just) and went on to the viva. I struggled with the questions, but did the best I could with my limited knowledge, trying hard to convey an impression that I was, actually, somewhat familiar with the anatomy of the human body. My examiner then took me to a dissected cadaver and pointed to a nerve that coursed between the lung and the heart on its way to the diaphragm. He asked me what nerve it was. It was a relatively easy question and I replied correctly that it was the phrenic nerve. He then asked me if I knew what the word meant. My father had studied classics and had tried to teach me some philosophy and ancient Greek, in which phrenos referred to the mind, so I again replied correctly. He asked why the phrenic nerve should be thus called, when it controlled the breathing muscle that is the diaphragm. I replied by wondering out loud if the Greeks felt this was the nerve by which the mind controlled the guts, and manoeuvred the conversation towards Plato’s divisions of the personality and of society. My examiner was visibly impressed. We had a brief but animated conversation about Greek philosophy and for the rest of the exam he asked me ridiculously easy anatomy questions along the lines of ‘What’s that?’ ‘The liver, sir’, ‘Jolly good. Have you actually read Plato’s Republic?’ ‘Yes, sir’, and, from that point onwards, I could simply do no wrong. I passed the examination, not by having expert knowledge of the subject matter, but by having a little grounding in the Classics (thank you for that, Dad, and my Beirut university) and by being lucky enough to meet an examiner who appreciated this utterly irrelevant erudition.

In those days what mattered far, far more than knowledge was whether ‘your face fits’. Tall, handsome, public-school educated rugby players from the Home Counties tended to pass the exam with inadequate preparation, whereas short, unsporting, comprehensive school products with a background from the Indian subcontinent could fail, despite having all the requisite knowledge. Women especially had a hard time entering this far-from-meritocratic profession. Things have changed, and today’s examinations are conducted in a much fairer and well-governed manner, with integral processes designed to prevent unfair discrimination in the profession. Back then, however, whether your face fit played an important role and, for some strange reason, mine luckily did.

My knowledge of anatomy was appalling when I passed the primary Fellowship and is still, in fact, embarrassingly patchy to this day. In my first year in Beirut we had covered the anatomy of the arm, the thorax and the abdomen. When I transferred to Bristol straight into the second year, my fellow students had covered the arm, the leg and the thorax in their first year. This meant that I went through the anatomy course across two medical schools, but without ever looking at the anatomy of the leg. A few times during the medical course I idly mused that I really must, someday, at least take a glance at the anatomy of the leg and try to learn the basics, but other, far more pressing demands on my time always took precedence. These included clinical studies as well as parties, beer, crosswords and the rock band in which I played guitar (badly).

A few years later I was a casualty officer in a London teaching hospital when a woman presented with a sore ankle, having twisted it badly on the edge of a pavement. I examined her and she had all the classic hallmarks of a fracture: swelling, bruising, exquisite tenderness and a visible angle where there should definitely not be one. I requested an X-ray, which showed the fracture very clearly, so I immediately bleeped the orthopaedic surgeon on call for the day, very chuffed with myself for having made the correct diagnosis.

‘Hello, it’s the casualty officer here and I’ve got a lady with a fracture,’ I said, triumphantly.

‘Where?’ he asked.

‘In the Casualty Department, of course.’

‘No, I meant where is the fracture?’

‘In the left leg.’

‘Where in the leg?’

‘In the ankle.’

‘You don’t get it, do you? Now listen carefully to what I am about to ask: WHICH – BONE – IS — BROKEN?’

The orthopaedic surgeon was shouting now, and, just then, it suddenly dawned on me that I had absolutely no idea which bone it was, having never studied the anatomy of the leg. A few seconds of awkward silence ensued.

‘Erm, you know how there are two long ones? Well, it’s the thinner one of the two that’s broken.’

I cannot fully remember the terminology he employed next, but it most certainly included some juicy expletives. Whatever the exact words were, their subtext was definitely along the lines of ‘What kind of utter incompetent idiots are we now appointing to the Casualty Department at this hopeless hospital?’ — or something to that effect.

About a year after my primary examination I took the final Fellowship examination, again from a one-in-two rota and again with nowhere near the required knowledge to be a surgeon. The 100-or-so candidates who took the final viva exam that day were numbered 200 to 299, and we all gathered around the statue of John Hunter in the august and imposing atrium of the Royal College of Surgeons in London. We were all waiting for the verdict. After a seemingly interminable wait, the college porter finally shuffled out and stood underneath the great statue. We all fell silent. He produced a scrap of paper from his pocket and started reading out the numbers of the successful candidates.

‘Two hundred and twenty-seven,’ he proclaimed as 26 faces dropped, and 26 despondent figures dragged their sorry legs out of the college. He continued, and with every successful candidate number, a bunch of others exited the college, defeated. He read my number. I had again scraped through, probably because ‘my face fits’. Finally, there were only about a dozen of us successful candidates left standing in the college atrium. He instructed us to wait there and walked out. Some 15 minutes later, the members of the College Council appeared in their full regalia. They wore long black ceremonial robes embellished with red and gold and marched slowly and with gravitas past us in a single file procession towards one of the meeting halls. The porter reappeared and motioned to us successful candidates to follow them. We all trooped into the hall and the doors were closed. We were each served a thimbleful of cheap sherry. After some 15 minutes exchanging bland pleasantries, the council members majestically walked out again. I was now a proper surgeon, with an FRCS, and ran out with all the other new proper surgeons with an FRCS to the pub for a proper drink.

And so I became a surgeon through a series of stupid and misguided decisions based on the most spurious motivations and arising from inconsequential and barely relevant events; and after five more years of training in cardiothoracic surgery, I similarly became a heart surgeon after even more ill-advised decisions and seemingly random events, but I am glad to say that I have never regretted that career choice.

Perhaps as a result of the profound ignorance I have had of what I was letting myself in for, every step of the way I felt like a fraud. From becoming a medical student, to a qualified doctor, to a surgeon-in-training, to a heart surgical specialist trainee and all the way to senior consultant surgeon, I always felt, deep down, that I had no right to be there.

This feeling is a well-recognised feature of ‘the impostor syndrome’ a term coined in 1978 by two American clinical psychologists, Pauline Clance and Suzanne Imes. The syndrome describes the inability of some high-achieving individuals to accept and enjoy their accomplishments, and one of its features is a persistent fear of being exposed as a fraud. I had it, big time. I was constantly in awe of my supremely confident peers, who invariably seemed to know everything and relished sharing that knowledge. They always knew what they wanted in their professional life, had made a firm career plan and behaved as though they were made for the job. In contrast, I was always full of self-doubt, unsure I was worthy of being let loose on innocent patients and certain that I was most definitely not made for the job. I always had the nagging feeling that I was, to some extent, a fraud, but, over the years, that feeling became less and less troublesome. It would be nice to say that this happened because I gained more knowledge and confidence. It did not. What gradually dawned on me over the years was that, after all, those supremely self-confident individuals did not know and never had known everything. They too were, to some extent, frauds, but they were far more adept at hiding it. We doctors never know everything but, fortunately, most of us recognise our limitations, are capable of seeking knowledge when ours is lacking and do not hesitate to marshal the expertise of others when it can help us and our patients, and, as long as we have the humility to accept this fact, we muddle along just fine.

Let us now move on to a different kind of impostor.

If you can dream — and not make dreams your master;

If you can think — and not make thoughts your aim;

If you can meet with Triumph and Disaster

And treat those two impostors just the same

. . . .

If you can fill the unforgiving minute

With sixty seconds’ worth of distance run,

Yours is the Earth and everything that’s in it,

And — which is more — you’ll be a Man, my son!

So wrote the great poet Rudyard Kipling in his poem with the laconic title ‘If—’, reportedly the British nation’s favourite poetical work. In this poem, Kipling advocates the development of elaborate indifference to ‘those two impostors’ triumph and disaster. He seems to say that we should adopt a stoical, or almost Buddhist, approach when it comes to reacting to triumph and disaster, and that we should learn to ignore them in order to become fully mature and enlightened.

I beg to differ.

Triumph and disaster are precisely the very factors that motivate us, inspire us and drive us forward. We learn from them, we celebrate one and mourn the other, and our professional life, to a large degree, consists of striving endlessly to achieve triumphs, while dodging disasters. In short, they are the stuff that life is made of. Heart surgery teems with both of them with an abundance that no other vocation can match. The elation from a surgical triumph knows no bounds, whereas the misery of a disaster can reach an abysmal profundity.

As my career progressed through the years, the triumphs have continued to accumulate and, since we now operate on older and sicker patients and perform ever more complex and dangerous procedures, both the number and the magnitude of these triumphs have steadily increased with time. What has not increased, however, is the elation that should come with them: on the contrary, such elation is slowly but perceptibly diminishing in intensity. Perhaps this is as a result of the familiarity that builds up with the passage of time and the rising level of expectation; perhaps it is a natural by-product of simply getting on in years, but I no longer get quite the same ‘kick’ out of a triumph from a hugely complex and dangerous operation. Paradoxically, the misery from the occasional disaster remains unchanged in both magnitude and impact. I imagine that one day, if present trends continue, I may find that triumph elation no longer compensates for disaster misery and then, perhaps for purely selfish reasons, I’ll put the scalpel away for good.

But not yet.