A modest proposal: for preventing the trainees of poor surgeons in Britain from being a burden to their consultants or ward
Authors: Oisin J F Keenan
Journal: Journal of the Royal Society of Medicine (2010)

It is a melancholy object to those who walk through this great hospital or travel in the deanery, when they see the corridors, the cubicles and coffee rooms crowded with consultant surgeons of either sex, followed by three, four or six trainees, all in scrubs and importuning every passer-by for an e-learning experience. These consultants, instead of being able to work for their honest livelihood, are forced to employ all their time in reflective appraisal and carrying out workplace-based assessments for their helpless trainees who, as they grow up, either turn general practitioners for want of work, or leave their dear native health service to fight for the competition in Australia, or sell themselves to BUPA.

I think it is agreed by all managers that this prodigious number of trainees at the elbows, or on the backs, or at the heels of their consultants, and frequently of their educational supervisors, is in the present deplorable state of the health service a very great additional grievance; and, therefore, whoever could find out a fair, cheap and easy method of making these trainees sound, useful members of the multidisciplinary team, would deserve so well of the public as to have his statue set up for a preserver of the nation.

But my intention is very far from being confined to provide only for the trainees of flagging surgeons; it is of a much greater extent, and shall take in the whole number of trainees of all medical specialties who are working for consultants in effect as little able to train them as those who demand our charity in the operating theatre.

As to my own part, having turned my thoughts for many years upon this important subject, and maturely weighed the results of the Medical Training Application Service and the European Working Time Directive, I have always found them grossly mistaken in the computation.

There is likewise another great advantage in my scheme, that it will prevent those voluntary resignations from surgical training, and that horrid practice of consultants humiliating their fixed-term trainees, alas! too frequent among us! sacrificing the poor innocent locums more for the power trip than the anatomy lesson, which would move tears and pity in the most savage and inhuman anaesthetist.

The number of souls in all deaneries being usually reckoned 60,000, of these I calculate there may be about 5000 surgical trainees. The question, therefore, is how this number shall be trained and provided for, which, as I have already said, under the present situation of affairs, is utterly impossible by all the methods hitherto proposed.

I shall now, therefore, humbly propose my own version of Modernising Medical Careers, which I hope will not be liable to the least objection.

I have been assured by a very knowing professor of my acquaintance in the Royal College of Surgeons, that a young healthy trainee well-versed in aseptic non-touch technique is at ST1 level a most obliging, competent and skilled hand-washer, whether sleeveless, watchless or tieless; and I make no doubt that they will equally serve as a floor-washer or bed-maker.

I do, therefore, humbly offer it to managerial consideration that of the 5000 doctors already in surgical training, 20 may be reserved for training, which is more than we allow to consultant posts. That the remaining 4980 may, at ST1 level, be offered in the sale to Sodexo; always advising the consultant to let them scrub up plentifully in the last month, so as to render them with the appropriate competencies for evidence-based cleaning.

I think the advantages by the proposal which I have made are obvious and many, as well as of the highest importance.

For first, the surgical trainees will be much suited to the manifold uses of the vacuum cleaner, being well-versed in coupling and decoupling of its parts, and well-practised in holding suckers for long hours in theatre.

Second, continuing professional development is vital in this field: the gifted trainee will progress quickly from cleaning with iodine in a wetlab experience to advanced cleaning simulations with robotics and autoclaves.

Third, their microbiology training will not have been in vain; eminent academic cleaner trainees will emerge with revolutionary developments in decontamination regimens. Of course, industry involvement is very important here.

Finally, the trainees are highly skilled at leaving on time, so that hours-monitoring will never pose another problem, and many other advantages might be enumerated.

A very worthy person, a true lover of the health service, and whose virtues I highly esteem, was lately pleased in discoursing on this matter to offer a refinement upon my scheme. He said that many managers of their trusts, having of late streamlined their workforce, he conceived that the want of porters might be well supplied by the bodies of young surgeons and medics. But with due deference to so excellent a friend and so deserving a patriot, I cannot be altogether in his sentiments; for as to the surgeons, my professor acquaintance assured me, from frequent experience, that their conversation was generally so tough and abrupt, that they were unable to interact with a conscious patient; and to send them on a communication skills course would not answer the charge. Then as to the medics, it would, I think, with humble submission be a loss to the public, because porters would soon become non-medical prescribers themselves; in which case, I confess, no patient would be portered anywhere without an alteration in the dose of his medication.

I have too long digressed and, therefore, shall return to my subject. Some persons of a desponding spirit are in great concern about that vast number of people, who are aged, diseased or maimed; that is to say, in other words, our ageing population. And now that our wards are cleaned and our cubicles tidied by that great swathe of specialist cleaners, who will do the surgery? Again, I submit my modest proposal for the reader's benefit.

I humbly suggest that nurse practitioners should do the operating. Nurses are wonderfully thorough in their attendance to guidelines and protocols, and are universally credited with excellent stitching skills. They demand less remuneration than their medical cousins, and their countenances are often fairer in regard for the waking patient. Some are even much skilled in cherry-picking.

I can think of no one objection that will possibly be raised against this proposal, unless it should be urged that the number of trainees will be thereby much lessened in the deaneries. This I freely own, and 'twas indeed one principal design in offering it to the Royal College.

I profess, in the sincerity of my heart, that I have not the least personal interest in endeavouring to promote this necessary work, having no other motive than the public good of my country, by advancing our trade, providing for patients, relieving the sick, and giving some pleasure to the managers. I have no trainees by which I can propose to get a single CPD point; the youngest being a medical student, and my career past retirement.

The End.