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go into the heart of Congo, in Central Africa, you will see a different spectrum of disease, when compared with the middle of New York City. The kit changes, the availability of techniques and drugs changes, but actually the diseases don't change that much. The way you approach them and investigate them might be different, but the range of options is the same. When you've got a wide spectrum of surgical experience, then you can deal with it. I told you the story a moment ago about my lifetime Gold Card with British Airways. I go around different parts of the world often enough, to see different things and learn different techniques. I went, for example, a couple of years ago to an unusual place in Southern Africa, where they amputate the foreskin of adolescents when they are teenagers. They do it with a bloody great big dagger and with the patients standing up, without anaesthetic. Then, the patients go and sit down in a corner of the jungle and squeeze their penis for a little while, until it all stops bleeding. That's how they do circumcisions. I don't think I should be adapting my technique to try that particular form of circumcision myself. But it is interesting to see what people tolerate as a matter of routine. Imagine seeing a dozen boys standing there, waiting to have that done to them and watching the ones before them having it done. Oh, my God! I would have run away!
F.N.: If you could change one aspect of modern surgical practices, what would that be and why?
Prof. Anthony Mundy: Just starting out as a consultant surgeon there was Richard Turner-Warwick working in London, doing stricture surgery. He was extremely well known for doing that sort of work. He did some spectacular stuff. He was a very good
talker and a very good technical surgeon. But the range, scope, and scale of what he did was very small compared with what we do these days because he only dealt with “local” patients. My skills haven’t developed because I'm particularly clever or a particularly good surgeon. It's because I have seen and operated on a very large range of problems. As I told you, there used to be 90 consultants and 12 trainees in the entire UK. Now, there are 1000s and of course, those 1000s have done all sorts of other aspects of medical and surgical training and have a completely different experience. The only way that people can make a difference in such circumstances is by teaching themselves, by going to different places around the world and seeing different people doing different things in different ways. There you learn to deal with different problems and not just urethral strictures and post-prostatectomy incontinence. So, the critical question is whether you are going to send trainees from Athens over to the Gaza Strip, to see a bit of trauma surgery there. You can go on down to Congo and learn how to do circumcisions on adolescents standing up in front of you and many other things, like dilating mitral valves. Another example these days is that there are patients who I get sent from colorectal surgeons, with difficult abdominoperineal resections for rectal cancer, because they no longer do it the same way, since robots became available. They used to take out the rectum from inside the pelvis with their bare hands and feel what they were doing, but they're now doing it with a robot in an altogether different way and they are running into problems as a result leading to uro- rectal fistulae. Gynaecologists face the same problem. Also, I remember years ago seeing a youngster, 14- 15 years-old, with Crohn's disease. I had never seen it at the age of 14 or 15 before. The paediatrician who wanted me to see the patient, because he had a urethral stricture, said: "You haven't seen it before at that age, because all of these adolescents used to die". I said: "I beg your pardon?". He said “I have a ward full of patients with Crohn's disease and they continue in the adult gastroenterology as well, because we can treat it now with drugs. Twenty years ago, people used to die when they were children or teenagers, because there was no treatment for Crohn's disease”. Thus, I think that you don't change surgical practice, but surgical practice changes in many different ways by its interaction with various factors. You just adapt to it.
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