On Training and Trainers

On Training and Trainers

On Training and Trainers

I just got to 10 years of being an independent surgeon in Cardiothoracic surgery in England. When I look back there are many things I am proud about and quite a few things I wish I had done differently. I thought I must put some thoughts together on the major influences on my training that got me through these ten years.
I feel a need to thank my trainers for giving me the grounding that has helped me be successful over the past 10 years. Over my many years of training, leading up to now, I worked with a few surgeons. I feel four surgeons stand out as the ones I learnt most from, on how to do things. Of course I learnt a lot from some other surgeons on how not to do things and that may also be considered important by some. For the purposes of this reflection I have decided that the greater influence was the surgeons whom I still try to emulate and fail.

The first Cardiothoracic surgeon who inspired me was Colin Hilton. I first met him when I interviewed for the post of a junior doctor at the Freeman hospital, Newcastle. I remember him looking at my CV and pointing out that he had qualified as a doctor the year that I was born! When I worked in his firm I was amazed how he did very complex operations and the majority of patients were going home in a week or so. I had, had an impression that cardiac surgeons were so full of themselves that I had avoided that speciality throughout my training. When I saw Colin at work it really inspired me to try and do what he did. His ward rounds were very informal and he rarely made a fuss with the patients. What I remember was that he was an excellent surgeon. I have often been asked about what makes an excellent surgeon. I think the best description is what I once heard as the definition of Pornography. You can’t exactly define it but when you see it, you know it. Its the same with surgery. When you see a good surgeon, you know it because its a maximum impact with minimum effort. To this day I do things the way I remember him doing them. Even today, I hate having an entourage with me when I see my patients post surgery. The other thing I admired about Colin was that towards the end of his career he decided to take a year off to experience life in Hobart in Southern Australia. When he came back he was doing new operations that he had picked up so late in his career. He never stopped learning. I was so pleased when he became the President of the Society of Cardiothoracic Surgeons of England.

The next surgeon to whom I owe a lot is Simon Kendall. I first met him when I took up my post in Middlesborough as a middle grade trainee. He very quickly gave me a lot of responsibility which made me feel very important. I still remember him asking me to present the evidence behind using a Bypass machine for people who fall into cold water. He then asked me to do the presentation on Microsoft Powerpoint. This was 1996. I had no idea how that worked, so he gave me the book that came with the program and asked me to learn about both topics in the next few days. I somehow struggled through both the topic and the software and he very graciously came up to me and said, “I have no doubt I will have to pay to hear you speak some day”. For a young guy trying to do his best, this was the kind of praise that made me go the extra ten miles for him. He was a master of working you hard and then praising the good things first and being able to give negative feedback just as well. He gave me my first heart operation to do early in 1997. I will never forget the thrill I got from that first case. I think I still get the same thrill even today. Simon did a very serious job but never took himself seriously. He recently won the best surgical trainer in Europe and this was well deserved. I have no doubt that he will be elected a president of the SCTS in the near future.

Professor Peter Goldstraw was an artist who had ended up doing Thoracic surgery. I got my chance to work with him when I interviewed for his assistant at the Royal Brompton hospital in London. He did not give me the job. He was clear that he did not want to teach Thoracic surgery to Cardiac surgeons. When he asked me why I wanted to work with him I said I wanted to see thoracic surgery done properly. He laughed and said I should stay up north. I don’t know what happened, but a few months later they asked if I would still be interested and I jumped at that chance. I spent 18 months in all at the Brompton. Peter only let me work with him for six but it changed my life. He was the most organised man I had come across until then. Watching him operate was like watching a west end play. It was informative, enjoyable, slick and quite predictable. He taught by continuous diffusion of knowledge through exposure of anatomy and description of the reasons he did things. He was very demanding and proud of it. When I worked with him he had at least 7 visiting surgeons from all over the world watching him operate. He was very theatrical in his style. Visiting surgeons loved it and I learned a lot from the questions they asked. I clearly remember him being very difficult with nurses and once when I asked him why, he said that if he was not very demanding he would have the youngest and newest nurses placed with him and that would slow him down. This way most nurses were scared of him and so only the experienced and good nurses would scrub with him. When I finished my time with his firm I got six months with Sir Magdi Yacoub, also based at the Brompton. It was a huge contrast moving from one to the other. Yacoub was not a pretty surgeon to watch. He was fast and made a lot of mistakes but corrected them as quickly as he made them. At the end, everything came together but the process was stormy. With Peter the process was always smooth and the operation predictably boring. It was like watching a golfer hit down the fairway consistently while, with Yacoub, it was like watching someone getting in and out of the rough and bunkers with a mixture of skill and experience. I know I left the Brompton wishing to be more like Peter but hoped that I would be able to get out of trouble like Sir Magdi, if I ever got into it!!

My final mentor was Asif Hasan a paediatric and congenital cardio-thoracic surgeon beyond compare. He hated me when he first met me as a junior trainee and would get me to leave his theatre half way through a case. The job he did was high pressure and with a low margin for error. This made him highly strung and I initially got on the wrong side of him with my casual style. When I got to work with him towards the end of my training I had already acquired the skills along the way that made me a useful individual. I remember one morning getting called about a month old baby having poor oxygen levels. An Xray was done and it showed that the baby needed a drain into its chest. I knew I should call Asif in the early hours but as I was confident about what needed to be done I went ahead and did the procedure. When he came in later that morning he called me over to ask why I did not let him know through the night. I said that I was sure I could do the job. He asked if I noticed that the baby was on a jet ventilator that causes the baby to vibrate a bit? I replied that I was sure that my anxious tremor was in tune with the babies vibration and so it would be absolutely fine. He looked at me, laughed, and said that I should never do that again. He did not think I would be safe and probably rightly so as at that age things can go wrong so easily. Fortunately for me the baby did fine and my career was saved. The best thing I learned from him was how to learn a new procedure without a learning curve. He decided to learn a procedure called a Pulmonary autograft procedure and he published how he went about learning this without a single patient harmed. I have used that a lot through out my career when starting a new program. The toughest challenge is how to learn to do new things once your training period is over in an era where learning curves are not accepted. It can be done and Asif is a testament to it. He has done many procedures that he never trained to do and most importantly then managed to teach other surgeons too. This is an amazing feat that is greatly under recognised.

With every passing year I value increasingly the kindness these trainers showed me during my formative years. They say that if somebody gives you money you can pay it back, if someone shows you kindness you are indebted for life. I hope that the patients that I am able to help in my career is my only way to pay back these acts of kindness. I continue to train junior surgeons on a daily basis and to pass on the wisdom gained and live in hope that some day, I will measure my life by the number of people I have trained up to be safe surgeons and the lives they improve going forward.

Mr Joseph Zacharias is a Consultant Cardio-Thoracic Surgeon who over the past 18 years has introduced many patient centred procedures and reviewed, presented and published his excellent results. He is passionate about teaching and training and continues to help disseminate his learning and skills to doctors at all levels of training. Mr Zacharias has one of the largest experiences in endoscopic heart surgery in the UK and continues to maintain a busy practice in both complex heart and lung surgery.


Consultant Cardiothoracic Surgeon | Joseph Zacharias

Alexandra Hospital Mill Lane, Cheadle, Manchester

0161 5273832