WA News Feature Articles The Cutting Edge
The Cutting Edge
Written by Jan Hallam
Monday, 28 November 2016

201612-Fletcher-David-Prof Nov16Prof David Fletcher, a self-confessed rugby tragic at the Test between The Wallabies and the All Blacks at Eden Park

 

It’s no lofty tower where the Head of General Surgery at Fiona Stanley Hospital Prof David Fletcher clocks in for service each day. His office is just another rather spartan square in the rubric cube that is this enormous hospital. Yet it suits this plain-speaking, no-frills clinician who fixes you with his sharp eyes and greets you with his steady handshake – both pretty important attributes for a surgeon.

But deeper into the conversation, it is evident David has worked in some interesting places. Take the time in his early days of medicine when he took a short-term job as a ship’s surgeon and found himself operating on a Greek seaman who had suffered a cerebral haemorrhage with a drill bit the ship’s engineer had fashioned for him.

That was only after David played an integral part in the mid-sea patient transfer in big swell the likes of which Bear Grylls would be proud.

“The chance of his survival was only 15-20% but we got him to Singapore and put him in an ambulance. I asked them to let me know how he got on – I’d spent a week of my life with the bugger, my wife Chrissy helped nurse him, and we never heard a thing. I was a bit pissed off to be honest,” he said.

This knack to call a spade a shovel has at times put him at odds with system types who prefer to be agreed with. But, as David puts it: “I guess it is how I was raised.”

Social conscience from the cradle

“I was born in WA and we moved to Fremantle when I was three. My father was a fitter and turner at the local power station, my mother was a district nurse. She went on to be hospital almoner and then became the first social worker at Fremantle Hospital. The Old Man became the local MP and Chair of the Fremantle Hospital Board.”

The ‘Old Man’ was die-hard Labor man Harry Fletcher who held the seat of Fremantle for 18 years and his mother was Esme Fletcher who negotiated the establishment of a low-fee day nursery for children of distressed families so mothers could work. It became known as the Esme Fletcher Day Care Centre. She was to go on to become deputy mayor of the City of Fremantle.

So not surprisingly David and his older brother, John, grew up handing out how-to-vote cards and understanding there were many people in their community who needed a fair go.

“It was a family tradition to use whatever talents we had for the benefit of those around us. If we believed there was a problem, it was our duty to fix it,” David said.

He put that creed into action as a junior hospital staff president in the early 1970s when he saw an injustice being done to a colleague.

The cost of speaking up

“I got fired but they did me a favour in the end.”

The ‘favour’ was the push he needed to decide to head to the UK  after Fellowship for advanced surgical training.

“For the first three years of medical school I concentrated on rugby and mischief. By the time I got to fourth year I started to pay attention and it was then I saw [Perth surgeon] Nazir Ahmed at work and it inspired me. Everything he did had a logic and was done with textbook precision so I set my sights on surgery.”

David and Medical Scientist Chrissy, who married in 1970 in David’s intern year, established themselves in Fremantle where both worked. They welcomed their son in 1974, on the eve of their move to the UK once surgical training was completed.

“I knew I wasn’t ready and needed further experience, so I went to practise on the Poms. I landed a job at the Hammersmith in London where I was  Resident Surgical Officer responsible for the junior staff. It meant I sat on the executive at a time when the hospital was going through transition (1977-8) with the arrival of Prof Les Blumgart and as a result I actually got some management training.”

“The new boss was hard as nails but he went about the policy-making process democratically. However, once a decision was made you did it, or else. There was no arguing. He stood up and supported his staff and I learnt a big lesson from that. You need to be a democrat and listen to people and try to get them to share your vision.”

Research opens doors

As a kid, David was inspired by Howard Florey and had thoughts of being a researcher until healing with his hands took over. But at the Hammersmith he fell into research.

“There was a research boffin in every cupboard at Hammersmith and it was an exhilarating experience. I became involved in endocrinology research for my MD (PhD) but when we were ready to return to Australia, I wasn’t invited back to Perth because I had trodden on toes. I had two job offers in Melbourne so that’s where we went.”

“It was hard leaving the Old Man behind – he was on his own by then; Mum had died from a heart attack in 1977 – but a job at the Austin and research opportunities at Melbourne University were too good to pass up. My interest after the Hammersmith experience was upper gastro-intestinal surgery and in 1987 when the department was planning its first liver transplant, I became part of the team (1988 to 1994) – it was an innovative place.”

“The boss went to France and happened to witness one of the first laparoscopic cholecystectomies. We thought he was nuts but when he showed us the video, we change our minds and trained ourselves up. In February 1990, we performed the first laparoscopic cholecystectomy in the country. It began the biggest surgical revolution of the modern era.”

Leading from the front

201612-Fletcher-David-Prof-Fishing Nov16Prof David Fletcher with a big catch“It was a wild ride. The College had this revolution on its hands and the dilemma of training 2000 surgeons across Australia and NZ in a technique that they had not seen done before. The College got us to produce the guidelines and we ran workshops town to town using pigs as models. When I left the department in 1994, they gave me a toy pig as a farewell gift.”

The episode stirred a new passion in David – training – and he’s good at it, a fact acknowledged by his students and peers alike. This year he received the College’s Supervisor/Clinical Assessor of the Year Award for WA.

He has worked doggedly and tirelessly to support his students in their endeavours to become competent and skilful surgeons and that sometimes has meant butting heads with the system.

“The world has moved on so much that the ability to do everything has gone. The laparoscopic revolution made that very clear. We used to say in private those who wanted to be surgeons needed to operate on anything they could get their hands on … and that is now the problem.”

“Younger surgeons are being forced into the private sector because there’s no work in the public sector to support them. That’s a real problem. You need full-time people in a hospital like this one but you also need part-timers too because it keeps everyone honest.”

Inefficiencies killing the system

“The current method of sorting this out is utter bullshit. They are trying to squeeze more out of the hospitals. We are overloaded and being squeezed because of inefficiencies in the system. My surgeons are saying they want to operate on the never ending flow of elective and emergency cases coming through the door..”

Another valuable innovation, which David said was improving both patient safety and enhancing training was the development of the Acute Surgical Unit (ASU) in 2008.

“It gives trainees broad exposure and they are well supported because it is Fellow and Consultant led 24 hours a day with a Consultant in the Hospital every day and one on call after hours.. There is a growing problem of getting the training balance right. There is so much technical expertise to develop and you can’t know it all or do it all. The ASU provides that additional training.”

While David will put it on the line for trainees, he said he wouldn’t hesitate to fail someone during training if they weren’t up to scratch.

“Good supervisors, who train and assess pro bono, know early on if a trainee is going to be a constant performer.”

Legal challenges cause headaches

“The profession needs to be tightly regulated in terms of assessment; we actually have trainees challenging decisions in court. It’s a sad reality that the college, when it sought insurance it put tenders to 16 companies only four applied. We now have a $100,000 excess. Unless we document the appraisal extremely carefully and are able to justify everything, they can go to a lawyer.”201612-Fletcher-David-Prof-with-grandson-Callan Nov16Prof David Fletcher with grandson Callan

“We have had a couple of cases in WA where that’s happened but they got nowhere because we had been thorough. There is a lot of pressure on trainees but there is no room for poor performance and we’re not talking just technical expertise.”

“That said, there are some outstanding trainees and it’s our responsibility to pick the ones who are going to be good. I recently witnessed a procedure being done by one of my former Fellows. I was both amazed and proud of what he was capable of.

Bullying and harassment in surgery have been in the headlines and RACS was rapid in its response to the controversy with new guidelines, standards, education programs and a complaints hotline the result.

“This behaviour is not acceptable. Surgery is demanding and stressful and when you’re up to your neck in ’nure, you’ve just got to go on and you have to be confident you will survive the challenges.”

“But it’s not about ‘if I can do it, you can do it’; or, ‘if you don’t do it like me you won’t succeed’. That attitude is part of the problem and now becoming the past. I want my students to challenge and question the system. I don’t want to appoint a clone, I want to employ someone who asks questions and thinks ‘how can we do it better?’.”

System change necessary

“Improving the quality of an individual patient’s life is extremely satisfying, it’s the joy of surgery; impacting on many is even more satisfying. Those with knowledge of the system need to be involved in pursuing improvement. You can achieve a lot by changing the system.”

But politics has a habit of getting in the way.

“Fiona Stanley Hospital is a spectacular place and what’s in it, staff and equipment, are spectacularly good, but there are problems – political problems.”

And those problems stretch back to the deviation from government planning which would have seen two tertiary medical hubs, FSH in the south and SCGH in the North, delivering complex care and secondary hospitals delivering care closer to where people live. It would have produced better outcomes and less waste.

“And it would have worked but we are now back where we started from in 2002 and it’s a tragedy that came about because of politics, votes and self-interest. We don’t build hospitals for those who work in them but for those we serve. I don’t think some people understand that,” he said.

“My job now is to continue to strive for system change and to protect the staff so they can do the job. It is also to create opportunities for those who deserve it and we have some really great staff.”