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ask questions. Hello, Good evening. Good day. Good afternoon, Wherever you are in the world. And welcome to the Black Belt Academy of Surgical Skills. My name is David of Reagan. I'm a cardiac surgeon in Yorkshire in the United Kingdom and the past director of the Faculty of Surgical Trainers for the Royal College of Surgeons of Edinburgh and a visiting professor at Imperial College, London. If you're returning and one of the 3258 followers on Facebook or 492 followers on Instagram, thank you very much indeed. And if this is your first time to the Black Belt Academy of Surgical Skills, welcome our format this evening is somewhat different in so far as that we're not going to look at Modell's in dissection. We're going to look at the decisions before incisions, but along with the same theme of all the other talks we've done so far draw on inspiration from martial arts. And the book that I use in quote from is by me um, you to Musashi, an undefeated samurai warrior of 16 50 three, famed for his swordsmanship and his thinking in the art of martial arts. At the beginning, I quoted his nine rules that I believe pertain to surgery and equally this evening with decision making. Think of what is right and true practice and cultivate the science, Become acquainted with the arts, Know the principles of the crafts, understand the harm in benefit in everything. And that's pertinent to the consent we're going to be talking about. Learn to see everything accurately become aware of what is not obvious. Be careful even in small matters, and do not do anything useless. The Euclidean angle of 90 degrees is a perfect angle because it's fourth part of the circle. And as I've explained with all our models to date with the needle and the scalpel, 90 degrees is very relevant to your alignment and setup, because in operating is not the action of stitching. But it's your alignment and set up that is of critical importance. Those have brought home to me of the weekend as we ran our 22nd power excellence course in the Skill Center and hull, after which we all go for a golf lesson. You cannot hit a golf ball properly unless you hold the club properly, align your feet, shoulders and hips and then let the club do the work and the ball goes in the direction it's supposed to go, and it's all about setup. But part of that is clearing the mind because the harder you try and the more distracted you are, the less likely you are to hit the golf ball correctly. And it's a bit like surgery. But we're going to think of all the process is before that, the decisions you need. The right information, the right reason to operate or not operate the right time. The right mindset for you and the patient. Right consent and on the human factors in surgical error side the right side, the right equipment, the right team, the right position, the right drapes and right landmarks. And I'm sure you can give me many more rights. But why I put this there is very simply this. Once you've made the incision, there's no going back. I'll say that again. Once you've made the incision, there's no going back up until that point, no matter where you are, even in the anesthetic room, even with the tube down, even with the lines in if one of those parameters are not correct. I believe you are justified in saying Stop and I recall doing to emergency operations. After the first one, I was told that there was no more seven of Is it black knowing that my next case was a 78 year old diabetic acute that needed urgent surgery, and I knew on the angiogram they had calcified vessels. I declared to the team that I was not inclined to operate without the right needles. They will agree with me and we cancelled. Lo and behold, one of the senior managers was seen in a few weeks days later, walking around, holding the two sutures, saying, I don't know what planet is on, but that person wasn't doing the operation. And I maintained that I didn't have the right equipment to proceed. When I did, I proceeded with the operation and I went without event. But just imagine if I went ahead without the operation and struggled, whose fault would it be then? So let's go through this process, and I believe history and examination has become a forgotten art. There are a few tablets and stone in medicine, and Saturday in particular, I think you have to look the part. You wouldn't go to a hair dresser that looked like several snap with greasy, oily hair, and you would not go to a dentist who had halitosis about teeth. You have to look at the part, and I recall pointing out to one of the junior doctors one day. Although they were dressed unlocked, presentable, it was more appropriate for an appearance on the stage, that little mix or the Spice Girls rather than on the ward. The other thing is, please suspend your judgment. You're not there to make any judgment on any person by what they look. You don't judge your book by the cover, but patients will judge you buy your cover and therefore you need to look at the part. The other thing is, please do not assume, and I said, What matters to the patient That is appropriate. And my little story here is Martin came through as the registrar to tell me, and we'll say, Mrs Jones. Mrs Jones was, in his own words, being a broad, Yorkshireman said, fit or bad with good concert. And she's a good candidate for surgery and I said, Really, Martin Well, let's go across and see the patient. And perhaps you could present the story to me in front of the patient. Now he did. So I was looking at the patient carefully, having invited them to interrupt if Martin was presenting the wrong story, because I would interrogate Martin and cross examine her on some of the questions. I was watching the way she was sitting and presenting herself and said, What? What really is the problem? And she replied, Doctor, my husband's got dementia. I see. I replied, Yes, doctor, my husband's got dementia and he falls on the floor. And when he falls on the floor, I get chest pain because I can't and I can't pick him up. And she then went on to say, Doctor, I do not want an operation. I want somebody to look after my husband, but we've been married for 55 years. He thinks I'm trying to get rid of him, and he's asking for a divorce. Now this is a lady who went to primary care secondary here presenting to tertiary care. And quite frankly, nobody had listened to actually what you wanted. So the second part of this I would like you to think, and I'll ask you to put comments in the chatter box. You've heard of the phrase service with a smile. We work in the UK in the National Health Service, and I think the operative word there is service. Put some adjectives into the chat box. And what do you think is good service when last did you get good service? And what adjective would you use to describe it? How did it make you feel? Because that is the ultimate is How did that service make you feel? And also then asked to yourself What organization on the planet depends? And the success and continued success depends entirely on how they make you feel. So please drop some comments in the chat box. Any comments at all? Anybody know that organization? Well, it is Disney, because if Disney didn't delight and make you excited, they would never, ever have an audience come back. And what perfect customer relations management should count is the five out of five satisfaction, because the difference between five out of five is the five out of five is the Ah ha had a good experience, and the four out of five is 75%. Walk away, never come back and say, Well, that was good But there you go. So think about it. It is service with a smile and what we are doing and what we're privileged to do is offer a bespoke service to the patient. Now Sherlock Holmes, the character written by Arthur Conan Doyle, was based on Professor Bell, a professor of surgery in Edinburgh. And indeed, there is a room at the Royal College Insurgents. Vanderburgh, because called the Conan Dorm Room and taking in history and examining the patient requires all your senses. And there's no need to point out the ratio of two ears to one mouth and listening. But listening, but also looking and interpreting, or the expression in the body language that goes with it is important. Walking onto the ward, I can smell a urinary tract infection can smell a gangrenous foot Pseudomonas cluster here, all by the smell. In yesteryear, people used to taste the urine. Hence diabetes, myelitis and diabetes insipidus. And of course, there is a field. To get through the door, you have to use the handle and therefore it is always hello my name is, and every patient is entitled to a handle. A consultant surgeon I trained with was really indignant that his name Richard was reduced to Dickie without his consent at all times. Your patient needs to be comfortable. I always ask all my male colleagues to always have a chaperone with them. When examining women patients, however, you could argue that every patient deserves a chaperone. Remember that you're in a position of privilege, and we are very fortunate in our profession to be more trusted than anyone else on the planet. Please don't abuse their trust, but likewise, just because you have a degree, it doesn't make you any better or any worse than the person in front of you. And they power distance standing above patients. Power dressing is not thinking about the patient. On a level, your room must look and feel warm and fresh, not akin to a sterile cold environment but more a warm, welcoming hotel environment. And I do have to laugh about these curtains and recall my grandfather at 94 being hospitalized and everybody draws the curtain around because that is a soundproof barrier gives privacy, but he used to recall all the ailments that everybody else on the ward. I personally don't like kickboxing because people take the boxes, but you don't get the neurons. You don't really understand what is being said. More importantly, you're not looking for listening to what is being said because you're taking the boxes, and that is important because we should be looking for the nonverbals. We've got 54 muscles in the face that actually described 10,000 facial expressions. There's an art in reading those expressions and reading the patient's expression, simply raising eyebrows, looking to the left, looking to the right. The CIA A and other people are really adapt at spotting these, and only a few people on the planet can hide what they're thinking from their facial expression. On one of them is a poker player. The other one is a really well briefed liar. Listen, do not interrupt, and that's interesting, isn't it? I pause there, and you wondered what was going on, but that was only 15 seconds, and you immediately starting to think I need to interrupt. Most patients are interrupted within 20 seconds. Listen, pause and be present. And when somebody is telling you they're presenting complaint. Put your pen down, watch the whole expression of the pain in the hand gestures and the facial movement. But at the same time ask when did it start? How did it progress? How frequently does it happen? Is it's getting worse. What makes it worse than what are the relieving factors? Are you taking tablets for these? And do they work as well? Remember that visceral plane being supplied by the Afrin fiber's going through the parasympathetic system is very vague, their eggs located to the dermatomes relevant to those nerve roots. But the vague pains, however, the pleura and the peritoneum like the skin, are symptomatically supplied, and therefore you can point. It hurts here, doctor. Remember that the pain and the joint could be because of the problems above and below the joint. Very, very few pains bring tears to the eyes. So when somebody is describing, that was enough to bring tears to the eyes. Beware. One of the worst pains is aortic dissection and also renal colic, but on the wall. So beware if a patient is silent, particularly if they're old, and particularly if they're very young and there is a story of the lady in a care home who is very silent and look distressed and just so happened that another doctor was walking around and said, Well, did you see that? Mrs Jones has got a dislocated jaw and he went there, Put a drawback in a position She said, Thank goodness for that doctor. I've been trying to get everybody's attention for a long time. Do not dismiss the persistent, and those people you think are complaining a lot usually have a problem. And I recall my case When I was a Houseman, Lady came in with a painful blue swollen leg and relishing the thought of writing the diagnosis of Phlegmasia Cerullo Dolan's painful, blues swollen leg for a like a vein thrombosis. Symptoms were fleeting over the weekend. She was seen by seven senior registrars and the consultant. Nobody had written anything in the notes. And, of course, by the Monday morning she went off for a venogram and, lo and behold heard a nice big vein thrombosis because nobody had written in the notes. She actually said that very nice Irish doctor made the diagnosis, but nobody listened, and she sued risk factors. Living is a risk. But some of the other risks smoking, alcohol, drugs, even recreational are risks. Family history is important. The profession you work and we know that certain professions carry risks. And I was interested to see the Ted talk recently about lack of sleep inducing cancer and think of our profession. The environment in which we work causes a problem, and the sun is particularly detrimental. Remember to ask about any previous hospitalizations and even ask. Have you had an operation before? Well, I asked this of a young lady of 26 who came in with all the symptoms of signs of appendicitis to Bhambri, and she had right eye fossa puritanism. But gross, really. Gravidarum and abdomen were no obvious scars, and I asked her previously had she had any operations and she said no. I took it to theater and opened up, and it was a pristine abdomen with no fluid, no adhesions. And the amazing thing was, I traced the right heavy colon down to the apex, where the tenure color meat. That's where the appendix is. And there was no appendix, and I thought, Oh, goodness gracious. This must be the first case of the absent appendix closed her up, satisfied? There's nothing else going on. Put her back on the ward and asked her. I explained. I couldn't find the accu panics. I have no explanation until the notes arrived two days later and in the notes only two years previously, before a child, she had an appendectomy, and when I asked her this, she said, Oh, that's what they put me to sleep for. So when you ask, have you had an operation? Do ask. Have you had an anesthetic as well? And did you have any problems of that anesthetic? But do bear in mind in this day and age that small incisions in key hole surgery might not be perceived as operations, particularly if you come to look for scars? If that wasn't difficult enough, I think a good systems inquiry is a sieve now. This is not totally comprehensive, but it needs to be put in plain language and open questions. Listening for the reply. Cardiovascular system, Simple things. How far can you walk? How many pillows do you sleep with and any discomfort in the chest of the legs? What's your breathing? Like any cough, wheeze or noisy breathing. Do you cough up anything? And what color do you have? Any problems eating or swallowing? What is your weight doing? Then you can go in with any nausea, vomiting, difficulty swallowing or indigestion. Any problems with the bowels? We're going to the toilet, then go in with any change. Colors, shapes, blood or mucus. Any problems passing water, passing urine and the flow, Hesitancy, urgency, blood or stinging. And in women as well. Any problems with the periods? Be careful. Don't assume that somebody's postmenopausal or premenopausal. Are you having periods? Any problems or any problems with the foreign passage? Any unusual headaches, dizziness or fits? Any problems with your mobility Pins and needles lost. The sensation aches, muscle weakness twitching. So basically, you've got a sieve there of open questions, followed by close questions. But all the time I'm looking at you and I'm watching your reply and pausing. If you're hesitant in your reply and then your answer, and you can follow that through with further questions pertinent to those specific symptoms, and if they come up with a positive in any of those symptoms, then you go back to the when deterioration progression, relieving factors aggravating factors. What medication are you on? What tablets are you taking? And that includes over the counter tablets and prescription tablets. But if you don't know what they are, look them up and use this as an opportunity to learn the pharmacy. Psychological effects of tablets. I recall a gentleman leaving clinic, and he was 74 it was one of those hands on the door situations that I saw coming. But I didn't anticipate the answer, your question, and he turned to me and said, Doctor, I have one problem. I said Yes. He said yes. I am a coach for two female hockey teams and after successful matches and, uh, the the showers in the bath. What he was worried about was the beta blockers that he was on and therefore being unable to do what the hockey team wanted him to participate in after the games. I will not pursue that any further, but leave that to your thinking. Are you allergic to anything now? I think this is the most important question because yes, I'm allergic, Doctor. What does that actually mean? What was the reaction to often be putting these red bull bracelets? on patients to say that they're allergic to somebody, but nobody's actually described the reaction they had to a drug now. Obviously, if they received penicillin when they're young and being told you must never, ever have that again, that is important. But if they say I'm allergic to penicillin and they say you ask, Well, what exactly happens? They say, Well, I feel a little bit sick, but that's not a type one. Arthur's reaction. I'm not allergic reaction. It's an intolerance, and putting a red bracelet on them could prevent them having a life saving drug. So please describe the allergy. I think that this is the most important part of your history To date. It's a social history and going to customer service. Those who attend hairdressers who have good hair. Dresser's what they actually do after chatting to you and asking questions that you think we're just innocent about what your holiday was like or all your wedding is coming up. They've gone after you left hand, written on a card with your name on it, getting married in June. So when you come back in July, they say, Well, how did the wedding go? What was that like, How are you going to? How does that make you feel as a customer? Or you've been to have to the barber and you're chatting about your holiday, the Maldives, and then returned? They say, How was your holiday in the Maldives? It makes you feel special, so I would also put it, too. There's a pleasure and learning about people because their memories and their stories, their occupation, their lives is important and I think is grossly underestimated element to the history. One gentleman was in the cold stream guards and very pertinent at the present moment in time with the passing of Queen Elizabeth, the second he had met her on several occasions, tripping the color. I'll never forget that man. Likewise, I met somebody who designed the Spitfire, another who designed the turbines for the Rolls Royce engines and in my early days, somebody who was in biplanes throwing bombs by hand over the edge of the plane onto the enemy. Those are stories that you can't even make up, and to me, that is where the delight in the excitement and the pleasure is in meeting so many people in our position and an instant becoming part of their lives and suggest that that is where the joint is and what we do now. There's a very nice talk by the G v e r g h e S e. And he talks about the power of touch and recall another princess many years ago hugging somebody with HIV and everybody gets She hugged somebody with HIV. Unless the person has got open source or very contagious disease. Most we're almost all of what appears on the hands, provided you haven't got open wounds at all can be washed off a simple soap and water. Florence Nightingale knew that, and I see some people put on gloves just to examine a routine patient and personally wonder how I would feel that somebody's putting gloves on to examining me if I didn't have an open wound. I feel very uncomfortable, if not dirty. The patient must feel comfortable, and part of the examination is inspection. Pa patient percussion auscultation and it's important that they're in the correct position, comfortable, not unduly exposed, and you talk them through what you're going to do each time and get their concerned, and you must be confident the trick the handling babies is to handle them with confidence because they very quickly pick up the fact that you might be nervous. It's like riding a horse riding a horse. The horse knows if you a poor rider on how you sit on them. It's a confidence. Not that I'm asking you to sit on patients far from it. But the baby will pick up the same and there must be an air of confidence. But certainly no arrogance. Wash your hands before and wash your stethoscope. Not only hygienic doing in front of the patient is respect. Look asked before you move. Remember palpitation as we have talked before, and holding instruments is with the palps of the fingers. You don't have to need dough. Simply laying your hand on is enough, and palpitation is not pressure the blanching of the fingernails. It is the softness of touch percussion. Percussion is basically clinical ultrasound, as on listening and saying, 99 putting your hands on the chest. I I see people doing this with the hands to try and get them level attacked are focal parameters holding the chest. You take gitana the side of your hands, your feeling tactile vocal affirmative, clinical ultrasound. And when you listen, listen to what is there. But also what is not there, particularly listening to the heart sounds as well. So you're using all of your senses. Some examinations will be personal examinations, but you need to actually describe that to the patient, and I think it's important as well. And certainly when somebody presents for the surgery in cardiac surgery, I am not going to operate on them unless I have given them a full mot. In my honest opinion, anybody turning up in the hospital deserves a full MRI T. And if your practice to doing this, this doesn't take an enormous amount of time by being thorough and diligent in what you do as virgins says instills confidence in the patient and what you're going to discuss with them. So when you're looking at something when you're putting your hands on somebody when you're putting your stethoscope in somebody, I think it's important. As I said by Miyamoto, Musashi is know the principles of the craft and become acquainted with the uh, you need to know your anatomy and surface anatomy is very important, and I'd like to invite you every time you examine the patient. Next time I think of what is under your stethoscope and what is under your hand. If you don't know, go and look it up. You'll be better practiced and more informed less time. Use all your senses and indeed, go to the door of the outpatient room to call the patient end. Watch them get up. FAILTE Index is determined by how well a patient rises from a chair, and I recall one dear lady who was referred for cardiac surgery. I went to call her. She couldn't get up. And when she got up with the help of two nurses, she had sadly, had become incontinent and, uh, required to people to be walked to the door for heart surgery. You see what I'm getting at? The other thing is, I do shake people by the hand, and you might actually think, no, there is a clinical significance to this related to grip strength. The first things to disappear in a cachectic state are the intercostal muscles on the hand and all the arms as well. So frail people do not have a good grip strength, so simply shaking by the hand is not only polite but as part of your clinical process. And I think what is very important is you need to start thinking and when I teach them more rounds of medical students is saying, Is that normal? Abnormal? Do they look well or unwell? And when you're examining somebody, we are symmetrical down the middle so you can always compare right with left. Is it normal or abnormal? And I recall emphasizing this to a student in clinic, and when you feel the pulses, you feel them symmetrically, and the student said, Oh, the left pulse is weaker than the right pulse, I said. Interesting. And indeed, that person, just by pointing out, picked up an undiagnosed cooptation of the order, color and temperature. Very important indicators of perfusion. So in a lower limb, loss of hair, shiny skin guttering, cool to temperature are very important. But one thing you can do, even in a trauma situation by feeling the heart rate, which is going to go up and shock feeling the foot pulses, wrist break your family carotid. I have here the minimum pressure you'll feel at each of those levels so very quickly you can work out what the systolic pressure is of a patient, the little squiggle. There is a brewery and listen to the breweries feel for the aneurysms. Document them because this is an indication of perhaps systemic disease. And certainly chronic disease is a cardiovascular problem affecting all the vessels. I remember doing an Oscar, and the patient was there on on on ski station, and I had forgotten to take my stethoscope because I was running from clinic to the examination home and I looked at this gentleman I thought, Hmm, interesting. There are two blue dots in the front of the chest. As I've shown there, there was a scar on the neck. There's a left hypochondria, um, incision. And there was a scar on the chest as well, but quite marked decreased size of the left chest with constriction of the ribs. And I said to him just by looking at him, you've probably had lymphoma diagnosed from the lymph biopsy in the next 20 years ago, your treatment included a splenectomy that you had mental radiotherapy to the chest, and hence the two dots you've got, because that's odd fashion. Uh, radiotherapy marking this was complicated by Bronchiectases. You had a pneumothorax, had chest drains put in, and you have had repeated chest infections. All that was diagnosed just by looking at the chest. And when I watched the students come in, I saw 20. During the course of the day, nobody commented on the symmetrical tattoos on either side. One actually said there's no evidence of any scars, and only two people out of the 20 said. There was a cemetery of the chest, and I sat there thinking to myself which part of the inspection was not there and thought of Professor Bell and Sherlock Holmes likewise to examine the abdomen. Remember that one third of the abdomen is above the costal margin, and one third of the abdomen is below the pelvic rest. So if the patient is not lying down, then the costal margin will be touching the pelvic rest, and you won't be able to feel the abdomen. But some people can't lie down because they're breathless or got kyphosis. Remember that the diaphragm is a dome, and as you breathe in, it pushes all the viscera down. So to feel abdominal organs, all you need to do is place your hands on the abdomen and the organs will move up and down underneath. And then my fellowship exam was taken on the short station. They said What is wrong with this patient? And they wanted the history of the examination, and I looked at the patient and there's a smooth mess moving up and down in the right hypochondriac. And I said, This man's got a solitary liver cyst, which was correct. That's how did you know that? I said, Well, it's not toxic, It's a regular. It's not tender. It's moving up and down in the right upper condom, and it's therefore a solitary liver cyst. Next, and we moved on. What was interesting? An award. I went to see a patient and the cardiology award, and all they had was this hexagon drawn November like us. And it was a male, and I asked the S H O u haven't looked at the testicles and one of the phrases used in neurology when I first started, and I always smiling. If you can't save lives, you saved testicles. Now the thing about the private said that there are private and people are embarrassed to talk about them. But When is somebody going to check? A case appeared on the table for acute carrots, and as the team scrubbed up, I went to Catheterize the patient and diagnosed cast and over the Penis with lymph nodes in the groin. But nobody had ever looked likewise with breast lumps. It's interesting that another story. Somebody was sent for a chest X ray and everyone he went got metastatic disease. But when somebody went back to examine the breast for lumps in the breasts and again, nobody had examined proper examination and full examination, I believe a mandatory before you make an incision. This is my diagrammatic view of the breast symmetry, discharge, discoloration and lumps, remembering that the axilla and everyone get you sweaty axilla and get my hand in there. They're five parts of the axilla anterior posterior, mediolateral and apical, and you need to feel for the nodes, not just casually slip your hands and go there. You can wash your hands afterwards plates, as I've said, but feel for the nodes because lymph nodes in the axilla might be something sinister is like the lymph nodes around the body. Submental submandibular juggling die gastric prayer curricula post auricular occipital down the internal chain down the external chain subclavicular gentle power patient. Do not prod. Feel with the help of your fingers. Of course, that's external examination, but we do have tools. They enable us to look internally. My son went for a examination for his patty scuba diving, and the only part of that examination that I actually thought was pertinent and relevant or complete was using and or a scope to look in his ears. Because the rest of the examination, I thought was quite cursory is lift the shirt, breathe in, breathe out, put the shirt down. The position of the stethoscope did not actually demonstrate to me that had any knowledge of the lobes of the lung. And for the cardiothoracic registrar would expect that knowledge to extend to the stethoscope. Showing where the bronchopulmonary segments are and for those of you are interested, is at the Apical segment of the lower lobe sits at the level of the spine of the scapula, and that is the segment where the Bronchopulmonary segment is perpendicular to the Broncos. And that is where you aspirated to. Knowing your anatomy is important. Of course, everything has to be written down in that story of the lady with phlegmasia This ruling Dolan's It was important, but likewise young Lad came in with a mild concussion, having had a ball playing football, and he was admitted to the orthopedic ward. And one thing. Orthopedic surgeons don't like their head injuries. Why do I have to bother myself, particularly if this is young lad fitting? Well, he had had a ball. What was peculiar about this young lad? He wasn't quite right. I couldn't put my finger on it, but it was interesting that he had an increase in pyrexia during the night. There are no lateralizing signs, no papillary sides at all. But I was worried, and I called the neurosurgeon and three times during the night and said, Something's not right here. Do you think he's got blood in the brain because his temperature is going up? Yeah. No, no, no. And I documented this all in the notes. Lo and behold, the next morning he was rushed off to theater, and the neurosurgeon, in his own words, drained the biggest frontal subdural hematoma he'd ever seen. I've written it all down on the notes. Time date. Full name Black eligible 24 a sign print status. GMC number on every page and filed. So I hope with your full examination, you now know everything about the patient. And decision to go to surgery or intervene is basically a risk benefit equation. As a surgeon, I'm acutely aware that I can frame the question using Carmen's theory of low, unknown, high unknown Lodrane hydrate. And this is what newspapers did. What we know is with high unknown and hide red. You end up with a fright factor. So I put it to you that infection and bleeding we know about. You know what causes that we know it's part of an operation. People are not worried about that MRSA and organ failure hydrate, which happens as part of the consent process load read higher. Known what we're uncertain about death and what it means, but it's implicit in the cardiac operation. But if I actually paused in my consent and even inflicted the word and of course, there might be a stroke, the fright factor induced in the patient I know I could have changed their mind about an operation. I loved this work up of consent from the patient point of view. It's what it's worth to the patient at what matters to them. That is what's on the X axis. And that's their values, their family, the situation, the beliefs, their interpretation there, uncertainties. But the patient is scared. Lack of access, lack of time, lack of knowledge, lack of control, like of privacy and sometimes alone for the surgeon. We need to know the science, the evidence of doing something, but more importantly, doing nothing Because good surgeons operate better, surgeons are good at operating, and the best surgeons know went on not to operate. You have met my son assisting me, and he fell off his bike two years ago and fractured his clavicle and the distance between the two ends of the clavicle. Was this quite alarming? It was interesting. I presented this slide to orthopedic surgeon and was a 50 50 split. It would appear that most adults, surgeons say plate plate plate operate bring it back together, although the concomitant risks. But I saw a very experienced pediatric orthopedic surgeon and said, Look, he's young bones are still growing properly in the Singh. Keep it supportive and we'll go back to normal. And of course, it did do nothing was a good option because he knew it had the experience not to. And this is the risk factor. And this is Carmen's prospect theory, which I think is very potent to us. Thinking about how we present things to patients on the X axis is the utility or value of that decision, and that is entirely dependent on what the patient wants. It's not for you to tell them what to do, and I sit in MDT meetings and saying, Well, we need to tell the patient to do as I said No, no, no. We'll inform the patient of possible outcomes and perhaps no alcohol at all, But we're not here to tell them what to do is for them to make up their own mind. And if they're hesitant, I say, don't do it or come back to discuss it. Think again. I don't need a decision Now. I want you to understand the potential gains, the potential losses and what it means to you. My job as a surgeon, it's know the probability of outcomes, risk of death, but risk of all the other morbidities more infection stroke. But really, what we should be doing is putting a decision tree together. And if you put a decision, tree together and look at outcomes, particularly in the elderly, some of them live question marks. And you think, Well, what is the prognostic value of operating on somebody at the age of 77 for coronary artery disease? And I had two gentlemen in my feet to admit clinic. We had put the pregnant pause in the process before decisions and incisions to consent in a comfortable, non threatening environment to invite people to challenge me on whether they wanted the operation or not. And these two gentlemen, as they turned up club Thai army tying very proud, have gone through the whole examination process and then sat down with me and said, Doctor, do I really need this operation? And I said, Well, good question. Why do you ask? And they said, Well, you know, I only get chest pain if I go to the pub on the other side of town. But if I go to the pub down the road, I can. So I'm happy to continue going just down to the public down the road so his symptoms were changed by changing lifestyle and the way he approached it. But the age of 76 with three vessel disease and stable angina, I could not argue that I'm doing this for prognostic reasons, because I don't think the evidence is there. But it's not age that counts. It's biological age because indeed, I've seen a 94 year old who's so symptomatic from aortic valve disease, very sprightly, fantastic grip, strength who wanted the operation, understood the risks and was up and walking around the ward four days post up. I had him carrying a sign saying, I'm 94 What's your problem? But what I actually do, particularly with the elderly people and in cardiac 30 I've been inviting or trying to get a geriatrician to be part of this process, decision process and to have or have not an operation because we know over the age of 75 decision theories that if you're at that age, you're more likely to chop and change your mind. But fundamentally, I actually say, Look, you drive a car. Normally say yes if I got into your car in the tank was on empty. I would not know if I had to walk around the corner to get a Jerry can to fill it up. If I could drive it around the corner to fill it up, Or indeed, I might have three days of puttering around in the car before I needed to fill it up. So I asked the patient to look inside and tell me what you feel, what matters to you. Do you have enough fuel in the tank? It's not my decision, but is my responsibility to be honest about what I can do, what I can't do, what science can do, can't do what the operation can do, can't do and actually be really and honest about the outcomes. And I don't think we are often. And sadly, we continue to have this disease convey about. And I have no doubt Mister Jones would have gone through the system, had an operation because she would have actually turned up in the bed the night before surgery put in, PJs got into bed. I felt like a patient doctor stood over, appeared at her, said sign here for the operation, which you would have done, and it might have gone very well. But just think what would have happened if she had a stroke? If the outcome wasn't what she expected, I would never forgive myself. She would never forgive the system because she would have been compelled to have the operation. So please get all your facts straight. Know what you're going to do. Be honest with the patient. And above all, remember that were in the service industry is how you make people feel. I saw a Twitter social media presentation of a picture of a teacher taking a deep breath again before we went into the classroom. It's the same thing. Have fun meeting new people. Enjoy being a doctor. Being a surgeon is a particular privilege, and you don't want to abuse your position or power because we have God power that can be used in the wrong way. Learn, please, What is normal. And as with everything, practice. Enjoy your surgery. I hope I've given you some thinking. As far as history and examination is concerned, I'm still looking here for questions or comments. I'm very happy to take some Thank you very much for your attention. Any questions, please? Any questions from you, sir? not from me, but I'm hoping that somebody will have a question. I There are no questions, no questions at all. I hope that means that I've stimulated your thinking and stimulated your reflection. Remember, I think the most important quality to have is a surgeon is humility, patients and the ability to listen. Thank you. Yeah, and thank you very much for joining us from Malaysia. Very kind indeed. I have to meet you one day. I'm exploring options. Ah, very good, Mr. Should one trust machine readings and s p 02 monitors. I like this question. The answer to that is No. Absolutely no. And why I say that is on two accounts. One simple example is pacemakers. People put a pacemaker on external pacing or pacing and say, Look, we've got a QRs complex, but what they're not doing is feeling the pulse. There's no point saying all we've got a QRs complex. If you haven't got an output, your finger needs to be on the pulse. Likewise, I was called in as a consultant. Uh, surgeon cardiac said to see a patient who is not responding to inner trips. And I said, I'll come in and have a look. From the end of the war, I could see the bed of moving like this as if it was from The Exorcist. There was a possession in the bed, moved Essentially. What was going on is that they had increased the adrenaline further and further and further, and they were in a high output cardiac situation, as evidenced by huge bounding pulses. Erythema patient felt hot and the whole bed was shaking. What this person did not need was adrenaline, but what they needed was nor adrenaline and a vasal constrictor. So you're clinical. Assessment is important. How do you assess things by the bedside? Simply, can they do daily things? Can you complete a sentence? Can you blow out a candle? Shaking urine in in a urine part doesn't froth. If it does, it's probably got protein in it. There are a lot of simple clinical skills that I think are being missed and not taught today because we do rely too much on images. That young man who had a subdural hematoma Yes, he should have had an investigation earlier. You should go on the clinical, and what I'm interested in is in the Oxford hamburger surgery. At the end of it, there are all these syndromes, and all the syndromes are compilation of clinical science. These are the Sherlock Holmes deduced syndromes, and I remember, uh, Doctor Somerville and esteemed cardiologist Brompton and a clinical pathological conference sitting there when somebody was presenting a very rare syndrome. And within the first three sentences, she said, Well, it's this syndrome, Isn't it obvious? And the thing about being a doctor is is it really a polished form of pattern recognition that you can only practice by inspection, palpitation, percussion or close quotation and knowing what's normal and not normal? I suppose that some guy up in Malcolm Gladwell's book Blink, It's the intuitive, but that's not intuitive. That's a result of a volume of competency and pattern recognition. And that's what good clinicians do. An award around. When I was a student, Doctor Bamford, he had huge hands, size nine hands and the size of a plate, and you put them on the abdomen and I wouldn't have to move it, of course, because all the organs move underneath and you go. Hmm, saucy. We used to play cricket and count how many times he used to say sauce in the world, but an outstanding clinician and diagnostician and I think those skills are blunted. And part of the joy of what we do is commissions is not only meeting people but perfecting your own clinical skills, your ability to use them and the most important one is to listen and enjoy patient stories. Thank you very much indeed.