Thoughts on ‘A surgeon’s lifetime – Evolution in General Surgery 1959 to 2001’, by David Watkin

As health care assistants or nurses we work with them every day, but are we really co-workers? The question of ‘what is a doctor’ is an awkward one, and as we can see in the review below, the category of the doctor underwent massive transformations in the last five decades. 

First and foremost, the doctor is a professional wage worker who can use their expert status on the market in order to obtain relatively high wages. In relation to other workers and patients the specialised knowledge of a doctor forms the basis for a dependency, which usually creates a hierarchy. In most cases, in particular in a hospital setting, this ‘knowledge hierarchy’ is formalised into a managerial or supervisory hierarchy. In hospitals, consultants often have not only medical functions, but also shape the work process and financial decisions as managers. 

Beyond the hospital, consultants are often included in a local or regional political sphere, e.g. as advisors to state administrations or politicians. This tends to happen primarily once the doctor collaborates more closely with the science and academic sector.

Finally, in many cases doctors receive incomes beyond their wage. This can happen in various ways: as ‘self-employed’, who work extra-hours in a private setting; as ‘experts’, who are invited to take part in trials or conferences of medical companies; as ‘entrepreneurs’, who, in particular in the surgical field, develop certain techniques or technologies and sell these insights as shareholders or patent holders; finally as employers, who own clinics or surgeries and employ staff for their enterprise. 

Why would it be important to understand the various positions and interests of doctors?

For us as workers it is important to be able to understand the contradictions that doctors find themselves in, once we form bonds with them to struggle together. In the history of working class movements and revolutions, a majority of doctors tended to support the old regime, which appealed to them as experts. A minority became ardent comrades for the cause. Any efforts to create a new society will, at least initially, depend on doctors’ expertise – until medical knowledge can be socialised to a higher common degree. 

In this sense this review is another piece of the jigsaw. So far we have interviewed medical students and resident doctors about their work experiences. We have reviewed books like ‘Can medicine be cured’, which is critical of the modern medical system from a doctor’s point of view, and rightly so, but retreats into a conservative affirmation of professional status. We are working on a longer text on the ‘class history of surgery’, which we can hopefully discuss soon. 

We have structured this review as follows:

1. A Summary of his career
2. The doctor as worker
3. The relation to knowledge and science
4. The relation to management
5. The relation to capital
6. The relation to the political sphere
7. The historical changes
8. Conclusions

*** A Summary of his career

David Watkin started as a medical student in Cambridge in 1953. During the 1950s and 1960s he went through the various medical stages, from junior doctor to senior registrar, and in 1971 he became a consultant. He took on additional ‘private work’ in 1972 and became co-owner of a small clinic in 1978. He became a sub-dean in 1976, which included teaching and managerial tasks, e.g. setting up training courses. In the 1980s he joined the District Management Team of surgeons, while continuing medical work. This got him in touch with the political sphere. In 1987 he became the regional representative for the council of the Association of Surgeons of Great Britain and Ireland and in 2000 the president of the Association of Surgeons.

David Watkin’s career was considerably successful, but it also seemed to have happened ‘organically’, meaning, at each step there were obvious possibilities that opened up due to the nature of the job, the labour market and the administration, rather than due to particular ambition. He didn’t necessarily want to pursue academic, managerial or entrepreneurial progress, but the opportunities arose structurally with the inbuilt cross-roads of the medical profession.   

*** The doctor as worker

He writes a fair bit about the low wages and long working hours during the first years of working as a (student) doctor, e.g. a pre-registration house officer had to sleep in tiny bedrooms in the medical school and received £420 a year for a 90 hours week, after deduction of boarding £240, which was “less than the wage of a bin man” – but this seems to be accepted as the difficult bit to get through. 

There is little mention of cooperation with other workers, apart from the surgical ‘firms’, but a fair bit of detail of the competition that exists when it comes to registrar posts, e.g. he describes the competition between different surgical firms at a trust in Derby where he worked, over which firm will be given a Senior Registrar position. He also describes how connections are helpful for the career path, e.g. that one of the consultants who were deciding about the Senior Registrar vacancy was a “fellow Cambridge graduate”. While he also writes about the motivation of ‘learning’ and ‘taking on responsibility’ that comes with a medical career progression, the monetary outcome is given as much space, e.g. the climb on the property ladder or the holidays that come within financial reach. As a Senior Registrar his annual wage was £2,000 in 1967, while at the time a modern semi-detached house in Sheffield cost £5,750. The competition for consultant jobs in the late 1960s was relatively high, with approximately 40 applicants per post. 

About the patients Watkin mainly writes as medical cases, he provides little insight about their social background and how this might have impacted their health. Despite having worked in working class areas, such as Leicester or Sheffield, the class condition of illness and health is only mentioned once:

“A middle-aged man, of Pakistani origin, was admitted with gross ascites (an accumulation of fluid in the abdominal cavity). The differential diagnoses were tuberculous peritonitis, cirrhosis of liver or disseminated intra-abdominal cancer. […] The patient’s job involved stirring an open vat of chemicals to produce a special adhesive. I wonder whether inhalation of chemicals from this might have caused the occlusion of the veins…”

He mentions an act of collective sabotage in the 1970s, when surgeons and staff were unhappy with the reusable steel ‘guest’ cannulas and red rubber intravenous giving-sets, partly due to the higher risk of infections. Hospital management told staff that these reusable items had to be ‘used up’ first, before disposable plastic ones would be bought – and staff accelerated the wear and tear.

He also talks about a collective dispute in the 1990s. “However, in the 1990s the residential accommodation was disposed of, and the management expected doctors on duty to remain awake through the night even though they might have no work to do. The juniors objected and we managed to reinstate some on-call rooms. Concurrently, junior doctors’ hours of work were being reduced. As a result, fewer doctors were on duty, but their workload increased, so there were less opportunities for sleep. These changes were associated with the demise of the junior doctors’ mess as a social centre.”

*** The relation to knowledge and science

Watkin claims that training has changed a lot over the decades. About his time in the 1950s and early 1960s he writes: “I acquired great clinical and operative experience but by modern standards little training.” 

When it comes to the link between daily medical practice and research he mainly mentions that “publications were necessary for promotion” to Senior Registrar and Consultant posts. His first research results were published in the British Medical Journal in 1964, dealing with the treatment of duodenal ulcers. It was a comparative study of 177 surgeries from within his sphere of experience. It would be good to know whether it is still common to engage in research with such close relation to medical practice or whether things have largely moved into a separate sphere – as described by a friend who works as a research nurse.

After working as a Senior Registrar, he applied for a lecturer job as a sub-dean in 1976, which also entailed medical practice. He describes the situation: “Working in the professorial unit at the Royal Infirmary I had three roles: my two research projects, covering the registrar when on take and providing the surgery course for dental students.”This mix of tasks overstretched the capability of a single person: “After much thought, I concluded that a professor of surgery is required to fill too many roles: clinical surgeon, director of research, teacher and university administrator…”

He gives an example of the use of new stapling devices, which he was not able to learn due to various other tasks. We have a situation where consultants become detached from new procedures because of managerial work: “All this was a challenge for surgeons. I was busy with the work of clinical sub-dean and then in hospital management, so did not have the time to acquire all these new skills.”

*** The relation to management

The professional category of a doctor has supervisory and managerial functions, which are likely to be expanded during the career progression. Watkin describes how senior colleagues suggested to him as a registrar in the 1960s: “They took me with them to clinical meetings at the Royal Society of Medicine and the Royal College of Surgeons and encouraged me to attend a course on health service management at the King’s Fund.” 

He later on describes the relation between consultants and hospital management: “Hospital medical staff committees, comprising the whole body of consultants, could offer advice, but were kept at arm’s length from the management. As an SR I had attended management courses at The King’s Fund and in the Sheffield region, and I realised that consultants had a responsibility to engage with the managers.”

In 1974, he became part of the Project Group responsible for the redevelopment of the Leicester Royal Infirmary. This group consisted of 25 members, managers, architects and two hospital consultants. This Project Group dealt not only with ‘technical issues’, but also promoted a restructuring that affected the wider workforce. “To raise funds, we discussed the closure of pre-convalescent homes and the sale of surplus buildings and land.”

In 1983, Roy Griffiths, a director of the supermarket chain Sainsbury’s, conducted an inquiry into management in the NHS and stated that there was a “need for general management”. Watkin summarises the impact on the hospital level: “Griffiths recommended that all day-to-day decisions should be taken at unit level, with a general manager in charge of each unit. Functional management, with representation of each profession at every level, was abolished and the requirement for consensus was reduced.”

Based on his previous experience in the Project Group, Watkin became a member of the District Management Team, where he worked 10 hours a month, in addition to his medical work.

“Another reward of the office was being invited with our wives to dinner at Quorn House, the historic family home of the chairman of the DHA (District Health Authority).”

As a consultant with management functions he shaped the work process, e.g. in 1990, “theatre staffing shortages were alleviated by amalgamating the roles of nurses and operating department practitioners, so that the latter took on ‘scrubbed’ duties.”

He represented the hospital management vis-a-vis the worker interests of the other doctors and medical staff: “One year, an activist house officer organised his colleagues to record the occasions when they finished work after the planned time and coordinated a group claim for back pay. We had to concede this, but it seriously overstretched the directorate’s budget.”

We can see that despite the ‘managerialisation’ of the NHS after the Griffith Recommendations in 1983, the system still has a need to draw medical professionals into contradictory managerial positions, appealing to their expertise and motivation to ‘run an efficient health service’.

*** The relation to capital 

He mentions that ‘taking on private work’ was seen as a prestige thing, a necessity to gain a certain reputation. In 1972 he started working two half-days a week for a private clinic, depending initially on referrals from GPs. He claimed that in these two half days he earned about 85% of his full-time NHS pay. By 1978 Watkin was one of five partners / co-owners of the clinic. The clinic was sold in 1991 after most surgeons went to the bigger BUPA clinic.

He describes the corrupt practices of doctors who have their feet in both sectors: “Investigations were an awkward issue. The senior pathologist (one of the partners) would take blood samples at De Montfort Street [private clinic], have them processed in the lab at the LRI and charge the patient for the consultation.” That this is not a thing of the past can be seen in the current practice of consultants setting up private agencies that supply workforce to NHS trusts, e.g. to take-over weekend work in surgical theatres. 

In the 1980s, the NHS management facilitated additional private work by changing rules and regulations: “…so that any consultant could have private practice earnings of up to 10 per cent of NHS income, without forfeiting one-eleventh of their NHS pay. As a result, several additional anaesthetists became available for private cases, and I noticed another effect. Some of them had been notorious for deferring patients on NHS operating lists for trivial medical reasons, to the great irritation of their surgeons. Once they were seeking private work this behaviour ceased.”

Watkin himself actively defends the right of consultants and surgeons to engage in private business, using his position as the regional representative for the council of the Association of Surgeons of Great Britain and Ireland (ASGBI): “With the president, I had to represent the Association before the Monopolies and Mergers Commission, which was investigating whether private medical practice was a cartel – they decided it was not.”

As a treasurer of the ASBGI, he is responsible for managing the substantial reserves of the association, which are partly invested on the stock-market.

*** The relation to the political sphere

His position as a regional representative of his profession and a participant in regional management teams got Watkin in touch with state departments and political representatives. The regionalisation and, later on, the splitting up into individual NHS trusts introduces a competition for funds: “In November 1986, the DMT (District Management Team) travelled to the House of Commons to urge our local MPs to press for the district’s per capita funding to be brought up to national average.”

Watkin describes that from a local management point of view the creation of trusts initially appeared as a liberation from the wider bureaucratic apparatus: “In 1989 we attended a meeting in Nottingham at which Kenneth Clarke, then secretary of state for health, outlined plans in the white paper Working for Patients. These included the ‘internal market’ and the proposal for hospitals to become NHS trusts. This would give them new freedoms and offered financial incentives, at least in the short term.” As we will see, he later on admits that the ‘competition’ between local trusts created its own contradictions, extra work and waste of resources.

As a representative of the ASGBI he encourages the development of ‘sub-specialities’:

“I decided to visit each city or town to meet the general surgeons, with two main topics in mind: establishing a separate urology service and reorganising the registrar posts (…) Urology, defined by the skill of endoscopic resection, was emerging as a distinct speciality, supported by a long-established organisation, the British Association of urological Surgeons (BAUS). (…) I encouraged the DGHs to move towards specialised urology. The obstacle was that those consultants with neurological interest were still members of the general surgical emergency rota and so would need to be replaced…” As we will see, he also acknowledges that the creation of sub-divisions undermines general and emergency surgery.

At this point the representative of surgeons has become part of the national elite. In 1991 he was invited to Buckingham Palace Garden Parties and he also became a member of the Specialist Advisory Commitee in General Surgery, which supervises the general surgical training. This committee is a link institution between civil and military health sector: “The membership of the General Surgery SAC comprises five surgeons nominated by the colleges, five nominated by the ASGBI, three form the Association of Professors of Surgery, a representative from the armed forces and a trainee, with a term of office of five years.”

*** The historical changes

The auto-biography does not only contain interesting details about his personal development, but also reflections on the wider changes in surgery and hospital organisation. To sum it up:

“Surgical techniques advanced, particularly after the introduction of video-laparoscopic operating. Gastro-intestinal endoscopy and cross-sectional imaging increased the power of investigation. Lengths of hospital admissions shortened, and many more procedures were carried out as day cases.”

• The workforce

One of the major changes was the questioning of male monopoly in surgery and the wider medical profession. Watkin claims that the national output of medical students trebled between 1970 and 2002, and that many of these new medical students were women. In 1953, Christ’s was a single-sex college and women were not accepted until 1978. In Westminster Hospital Medical School, only 15% of students were female in 1956, now it is 60%. At the Leicester Royal Infirmary, married women could not be ward sisters (lower management) in 1975. Only in 1984, the LRI had its first female consultant and she would remain the only one till the late 1990s.

Working conditions have also changed. In 1959, as a pre-reg house officer, Watkin was expected to be on duty for 6 months, apart from one weekend off. At the same time work was less intense, there were less patients and a lower turn-over. The 90 hour-week for junior or resident doctors only changed in the 1990s. ‘The New Deal’, negotiated by the BMA in December 1994 stipulated a maximum of 72 hours per week. In 1998, this was (formally) reduced to 48 hours due to the European Working Time Directive. We know what happened to that. Overall, a reduction in working times translated into an increase of the numbers of doctors, e.g. at the LRI there were 160 beds for eight consultants in 1979 and 90 beds for 10 consultants in 1999.

• Surgical technology and procedures

Watkin makes interesting observations about the changes, in particular those affecting the duration of the hospital stay post-surgery. For example, in 1956 a hernia repair required a 10 day stay in hospital, with some patients being well enough to “help with tea rounds”. 

There were no joint-replacements yet and no ultra-sound imaging. This meant that patients with suspected intracranial bleeding had to undergo diagnostic burr holes in their skulls. CT scans only became available at Watkin’s hospital in 1973, ultrasound and full-body CT scans only in the early 1980s. This meant, for example, that there were no preoperative diagnostic tests for breast cancer, which had traumatic results for many women, as the decision for a mastectomy was sometimes taken during the diagnostic operation itself.

In 1979, surgical instruments were still sterilised by boiling in the theatres themselves. There was no recovery space for patients, they went straight back to the wards. In 1983 endoscopes were introduced with a small video camera at the tip, which in some cases increased the risk of serious surgical accidents, in particular due to lack of training, but overall reduced recovery time due to key-hole surgery.

In the 1980s, surgeons started to administer prophylactic antibiotics before surgery and low-dose subcutaneous heparin to avoid deep vein thrombosis. By the 1990s they used dissolvable subcuticular sutures and laparoscopic technology. The fatality rate for abdominal aortic aneurysm dropped significantly by being able to check the artery size through ultrasound and to operate early enough through minimally invasive surgery (implanting a graft through the groin). The spread of computer systems facilitated the expansion of evidence-based medicine.

But Watkin is not a technology fetishist, he maintains a critical view on the introduction of new procedures: “Subsequently, the published trials showed only small advantage for laparoscopic hernia repair as measured by modest reduction in pain and a shortened recovery time. These advantages must be set against higher cost for equipment (and disposables) and very infrequent but serious complications, due to damage to intra-abdominal organs during insertion of the laparoscope.”

He also describes how, with the advance of medical science, many conditions that used to need surgery can now be treated medially. “The management of duodenal ulcer (DU) is an example of the profound changes in medicine during my working life.” These ulcers were first described in the 1830s, and saw a massive increase to ‘epidemic proportions’ amongst young men’ in the 1910s. The standard operation until the 1950s was a partial gastrectomy, removing about two-thirds of the stomach, which had major side-effects. The only alternative operation was to divide the vagus nerve supplying the stomach (vagotomy). Only in 1984 they discovered that primarily a bacterium (Helicobacter pylori) was responsible and that the ulcer can be cured with antibiotics. By the 1980s, elective operations on duodenal ulcers had ceased. “Research projects measuring gastric secretion in relation to operations for DUs were a large part of the activity of academic surgeons in the 1970s; it is chastening to realise that all that effort was irrelevant.”

It is surprising to read how late comprehensive audits and systematic studies about the outcome of operations were introduced in the health system – and it is perhaps less surprising that there was considerable resistance from surgeons against this introduction. “In 1980, Clive Quick, our SR (at the LRI), produced a plan for surgical audit, to record the basic details of diagnosis, operation and complications for all inpatients, using a personal computer. (…) Our application was turned down because ‘Members felt that there is yet little evidence that surgeons are amenable to submit their work to audit’.” The main concerns with the publication of individual results was that surgeons might avoid risky operations in order to not ‘have negative results in their data’. The audits were only adjusted by risk in the 2010s.

• Surgical organisation and the problem of sub-specialisation

Another major shift was the deepening of specialisation. In the 1970s “the range of general surgery at LRI was very wide. All five surgeons did urology, gastrointestinal malignancies and breast cancer and three of them did a few arterial operations….” By the end of the 1980s, surgeons would largely do only breast or only gastro surgeries etc.. 

Watkin doesn’t give too many clues concerning the reasons for specialisation. Commonly it is assumed that the acceleration of progress and the difficulty to keep up to date with particular discoveries or technical change requires specialisation. Watkin only mentions the example of not being able to learn new skills, such as the use of skin staplers, due to being overstretched with managerial duties. Instead he hints at other dynamics, for example the dynamics of commercialisation:

“During the 1990s vascular surgery in Leicester began to diverge from general surgery, providing a separate emergency rota from 1995. In due course vascular surgeons took over the treatment of varicose veins, which previously they had eschewed. There were two reasons for this: varicose veins provide suitable operative experience for junior trainees; and there is scope for private work, whereas arterial surgery requires more supporting services than may be available in private hospitals.”

He also mentioned that “subspeciality societies encouraged sub-specialisation”, meaning, once you have an organisational interest to boost your particular speciality, e.g. in order to get more funding, the process of specialisation intensifies. “In 1998, I published an article entitled ‘Can there be too many surgical subspecialities?’. I identified 61 specialities and subspecialities across the whole of surgery, the criteria being the existence of a society and a journal.”

Watkin describes two main problematic outcomes of sub-specialisation, firstly, the lack of surgeons who have general enough a knowledge in order to be able to work on general and emergency rotas, but also to be able to deal with unexpected situations: “When I started as a consultant my operations ranged from thyroidectomy to gallstones and breast and rectal cancer. Subspecialisation narrowed surgeons’ elective work and I became a coloproctologist. The quality of care for defined conditions is enhanced, but perhaps the capacity to handle the unexpected is impaired.” Secondly, specialisation contributed to the dissolution of ‘surgical firms’ and thereby the undermining of bonds and collectivity, in particular for new colleagues. “Increasingly, cross over between surgical specialities added to the pressure of work for the more junior grades – fewer hours but greater intensity. The firm structure was weakened, undermining mentoring for trainees. Gaps in shifts because of study leave or illness are filled by short-term locums.”

“It was a great privilege to have this role in the setting up of a new medical school and it was satisfying to find that the arrangements continued substantially unaltered for about 15 years. By that time changes in hospital practice and the increasing subspecialisation within general medicine and surgery rendered the firms used for teaching in the third and fifths years unsuitable for their original prolonged attachments. Surgical patients were no longer admitted the day before operation, which had allowed time for student clerking and for teaching. As new subspecialities developed, and individual consultants limited the scope of their elective work, six or eight weeks attached to a ‘general’ firm no longer offered a broad experience of medical or surgical conditions. Shorter attachments to multiple units with different interests could solve this problem, but with a loss of the continuity in relationships between students and all grades of the medical staff. Such familiarity provided more than just instruction, adding mentorship and informal advice.”

• Hospital organisation

Watkin talks about various changes, e.g. that in the 1960s there were still floors for private patients in NHS hospitals. The main overall changes he describes happened in the 1990s, with the creation of trusts and the creation of the ‘internal market’. 

With the NHS and Community Care Act 1990, trusts “could set their own management structures, employ their own staff (including consultants), buy and sell assets and borrow capital, subject to limits.”

He talks about the other consequences of Leicester Royal Infirmary getting trust status. “Our general surgeons were now in competition with LGH and Glenfield [other local trusts]. The other specialities in the directorate were monopolies, but we had to plan to maximise our share of the general surgery in the district. The vascular unit was one obvious strength. We envisaged that it would provide the service for the whole district and increasingly attract outside referrals. However, it would need additional consultant staff, by the transfer of posts from LGH.”

The competition between trusts creates extra work and waste when it comes to investments. “Radiotherapy gradually changed its name to oncology as its staff were increasingly involved in chemotherapy. It had occupied the ground floor and basement of the 1771 building [at LRI]. The plan had been for it to move to new accommodation at Glenfield [nearby trust] – an ideal arrangement as it is one of the few specialities that does not need to be represented on the A&E site […] but the oncologists resisted this idea. The LRI Trust, enjoying its independence and competing with the other sites, built a new block beside the pathology departments […] This was just one example of the way the existence of three trusts could prevent proper strategic planning of major developments.” (…) “A fundamental issue affecting Leicester was the arbitrary national policy limiting the size of hospitals, producing three rather than two and resulting in difficulties in junior staff cover as working hours were brought under control.”

A by-product of the model to run trusts like businesses are corporate expenses, e.g.

“In 1994 the LRI trust proposed the engagement of management consultants to advise about improvements and effectiveness of the hospital, at a cost in the order of £1 million.”

*** Conclusions

The conditions and position of doctors in society is changing and we need a collective debate about the implications, both in terms of the immediate working together, but also in terms of political struggle. This aim in mind we will interview young doctors from MedAct in the near future.

Watch this space!