”Once you have seen the bloom of a decent surgical incision, nothing in nature looks bright by comparison,” says Gabriel Weston, an ear, nose and throat surgeon and mother-of-two. Weston’s first book, Direct Red: A Surgeon’s Story, is currently wowing critics, for between its covers she has exposed the bloody nature of surgery itself, laying herself and her colleagues out so that we can see their profession, fully dissected, in all its terrible beauty.
Direct Red is far too literary to be called an exposé, but if you’ve ever wondered what happens when the hospital trolley rattles off down the corridor and the theatre doors swing shut, after reading Weston’s book you will wish you’d never asked. Operations, played out against cheesy songs belting from radio stations, go wrong regularly. Surgeons lose control of situations — if only for a few seconds. Blood spurts across the room; surgeons get drenched to their underwear; innards are piled onto trolleys and lie in bowls.
Weston (38) has been a member of the Royal College of Surgeons since 2003, a feat she achieved just three years after qualifying as a doctor and shortly after the birth of her first child, Sam, now five. Today she is sitting before me in an immaculate, expansive flat overlooking London’s Battersea Park. Corridors are lined with glass partitions, glitter balls hang from the ceiling. There are clean lines everywhere, as if Weston has applied the same precision to her domestic sphere as she has to her professional realm.
For a woman with such a huge brain she is a slip of a thing, with the tiny, honed limbs of a ballet dancer: ”It’s because I swim so much to relieve the stress,” she says. ”At least a mile every swim, sometimes a few kilometres. It would be a bottle of wine a night otherwise. If somebody said I couldn’t swim, that would be a huge problem for me managing my life,” she pauses, ”and I’m neurotic, so I’m always thin.”
Weston admits to living in a constant state of tension. ”I have learnt to live with a constant level of fear — it’s with me all the time, like that sick anxiety you feel when you walk into an exam. I have been in the middle of operations when the panic threatens to take over, but you have to use your conscious brain to get yourself over it, saying to yourself: ‘Don’t be ridiculous, don’t panic! You can do this.”’
She recalls one such operation in the book, a tonsillectomy, which usually she loves. With a vast lamp-like light strapped to her forehead, the patient’s mouth clamped open with a metal gag, in she goes with her scalpel and forceps. The first tonsil pops out, the second, hardened with pus, won’t budge: ”Blood was pouring out from the tonsil and every time I tried to grab on to the meat of it, bits broke off and the whole thing bled more.”
The patient’s mouth begins to fill with so much blood, the nurse can’t suck it out quick enough.
Flesh comes away in Weston’s forceps as she tugs and pulls within the bloody soup. Panic surges through her until, eventually, she loses it. ”I can’t manage. I need some help. Who is around?” she asks a scrub nurse. She is told that a consultant is nearby and sends for her. She relaxes, pleased she has identified the importance of asking for help: ”My shame was out. My fear was out. I had handed on the baton of responsibility, and my emotions seemed my own again.” Phew, we think. But just when we see a world we recognise again — Weston will be OK, the patient won’t bleed to death — a message comes back from the consultant: ”JFDI!” – Just fucking do it!
Weston gazes down at the bloody mess before her. But, like all fine surgeons (”Never be operated on by anybody who does not practise in the NHS,” she advises me. ”It’s so competitive, they have to be good on the NHS”), she rises to the moment and regains control. Afterwards the consultant says: ”I knew you’d be fine, and next time I think you’ll know too.”
”How could she do that to you?” I ask, thinking mostly of the poor clueless patient lying on the operating table who will never know of this unfolding crisis. ”The consultant was right,” explains Weston, ”a surgeon is never placed in an operation they can’t handle, and there will always be somebody to come in at the last minute if it is really needed. She was always nearby on hand if there had been real danger – the nurse knew that, it’s just I didn’t.”
Direct Red is a work of art, divided into short essays addressing the big questions of practising medicine: death, sex, beauty, hierarchy, emergencies, ambition and so on. There is not a page that disappoints, from the prosaic but riveting day-to-day business of cutting people open, to Weston’s observations about humankind, exposed in all its vulnerability. She recalls the child she sees on call, through a sleep-deprived haze, whom she felt she had shortchanged with her time, only to find out that he later died of a hidden brain tumour; the dignified young woman in for a double mastectomy whose only request is for Weston to save the mole between her breasts (Weston manages to honour the patient’s wish with a closely placed swab as a knife-wielding surgeon threatens to slash straight through it on purpose); the lady who comes in with piles as big as fruits, a candidate for surgery but whom Weston treats herself by pushing them back in with her fingers because she knows her boss will regard her more favourably for promotion for keeping operating lists to a minimum; the erudite professor who hugs his wife, only minutes later to have his guts spilled out on a trolley as the surgeon battles to save his life.
”I’ve never lost anybody on the operating table myself,” she says, ”or been close to it. Fear is with me always, although it’s not like that for other surgeons I know.” She pauses. ”There is the feeling you get if you have done a nice bit of facial surgery and the stitches look neat and it’s not bleeding. But then you are always thinking: I hope it’s OK now, because it could start bleeding or the patient could get sick. Just because you think you’ve done it properly, it’s not a done deal.”
Weston says that she chose surgery because of the drama, the machismo, the fear. All her life she has been super-competitive. Her father is Sir John Weston, former British ambassador to Nato, and her mother was a barrister before she became a Foreign Office wife. Even at Bedales, the UK’s most relaxed boarding school, Weston was pushing herself to achieve — ”I don’t think it’s to do with my father,” she says, ”I think it’s my personality.” In fact, she read English at Edinburgh before realising medicine was her calling. She got herself on a then new and experimental course set up to make doctors of arts graduates: ”I had no science at all, not even O-levels, apart from biology. That first year was very, very tough.”
When she saw the knife go in for the first time, she knew: ”I think surgery self-selects,” she says.
”Some people hate it. I love it.”
Surgery, she says, is full of ”every kind of dishonesty there is”: surgeons passing off operations as their own when, in fact, a junior did it; surgeons giving an overoptimistic view of the removal of a cancerous tumour when, in truth, some of it still remains. ”It’s not that he was lying,” she says of the surgeon she saw doing this. ”It’s just that I could see the operation wasn’t as positive as the view he was taking.”
A world where surgeons are weighing up the impact of an op on their career as much as the impact on the patient’s health? Surgeons too afraid to say the word ”cancer” or ”death”, using euphemisms instead. Can this be true?
Contemplating all this, one begins to feel dizzy with fear. Yet Weston’s honesty makes you realise what is, of course, obvious: that surgeons are not gods, or super-humans, that they exist in a workplace just like the rest of us, where egos battle, where there are tensions and office politics, where the patients are only part of the story. ”As with every profession,” she says, ”the people in it range from fine to the slightly weaker, more confused, and because the subject is more important, you really notice when a surgeon’s judgement is not good — everything is amplified. When you see people being honest and self-critical and then you see somebody not being that, it matters. The really good ones are tough, really tough; they make junior doctors quake, they can be detached and engaged when they need to be — for example, if somebody is dying or very miserable. Incidentally, I think women surgeons are very good at being self-critical because, as women, we are brought up to question everything we do.”
The book spans her years of training in London hospitals through to her becoming a member of the Royal College of Surgeons and gaining the position of registrar in 2003. (She had her first baby while she was sitting these exams.) At the beginning, Weston paints a world populated by swaggering, sexist consultants — ”old dinosaurs”, she calls them: ”I had such a large pool to draw from in the book.” They seem to do their best to belittle women. One, for example, calls her ”Flossie” in the most patronising way when she has already reached a degree of seniority herself.
One, nicknamed the Lion, goads her while she has a gland hanging from its pedicle. She is a beginner, too slow: ”Cut it! What are you — chicken?” he shouts. Under pressure, she cuts, hitting a facial artery and blood sprays a foot across the room. The theatre staff move closer to watch what happens next. The Lion steps forward and saves the day. It’s a show, and there is only one star.
”One threw some forceps at me during an operation,” she tells me. ”I was holding a cavity open and it must have slightly slipped. He’d never get away with that now. They’re a dying breed, although the egos are still there. Maybe it is because I am older I can handle it, I don’t know.”
She says that, contrary to the opinion of other doctors she knows, all the female surgeons she has ever worked with, bar one, have been unbelievably tough but supportive, no doubt identifying in her too the steel, the clear, focused potential needed to get to the top. One of these women is her best friend and mentor, a consultant head and neck surgeon — ”about as macho surgery as you can get”. The one unsupportive woman is painted as a textbook baddie, with scrub top pulled too tight over her chest, heavy black eyeliner, pink-candy blush — ”Are you sure you’re in the right business, darling?” she says to Weston by way of insult, elbowing her away from the operating table. ”You’d make a lovely GP.”
Weston, by her own admission, could handle the machismo — in fact, she thrived on it: ”People ask me about surgery being sexist, but I actually feel grateful to it even now as a place where I can be really competitive and motivated and where these things are considered normal. Part of me misses the old times. There was a grim humour to it all, and you could give it back, too.” She describes herself as an ”alpha” personality and says that she is more at home in a macho environment than a domestic one: ”I find the whole playground thing much more of a challenge.” One of her friends jokes that she is a ”biological male”, and she’s right. There is something quite blokey about Weston’s manner, too. She says ”the guys” a lot, and uses macho phrases such as ”busting my arse”, but the male/female comparison annoys her. ”Doesn’t it show how limited people’s views of women are?” she says. ”I’ve got ovaries, I’ve had children, and I’m as much a woman as anybody else, but I’m just very, very alpha. I’ve got all these traits that people would associate more with men, and yet maybe we are just expecting women to be too soft?”
There is a twist to Weston’s tale of success. Following the birth of her second child at the beginning of 2007, she turns her back on her dream to be a consultant surgeon. She writes about seeing a 10-day-old baby in intensive care and feeling a maternal pang, a pull that she does not feel towards her own baby, at home in its cot, a child she sees asleep for five minutes at the end of each day. In reality, she admits, it wasn’t quite like that, but she uses the image to try to translate the powerful, complex reasons that led her to step off the career ladder and give up her hard-earned registrar’s number (what you need to move up the pecking order). Instead, she takes a part-time job in a smaller hospital, with no teaching obligations, no on-call, no audits, no prospects. It is where she works today.
”One woman told me: ‘Just get a good nanny so you don’t have to worry about it,”’ she recalls. ”I know women surgeons who have made the calculation that it is going to be best for them to work full time, and those women are women I admire who have really nice children. But for me, I was this ludicrous person who was trying to be aggressive at work and then come home and force the children to make fairy cakes so I could feel like I was a good mother.”
What? Can this be the same woman who looked down on the ”softer” kind of doctors who decide to be GPs — who spent 15 driven years pursuing a dream? ”I know, I know,” she says. ”I kept asking myself: ‘Why do I have to make things so difficult for myself all the time?’ But even then I was in the most painful dilemma for about six months, because once I stepped off that ladder there would be no going back.” Her husband, an Australian consultant physician who is older than her, refused to offer an opinion: ”We talked it through, but it was my decision.”
The book’s last chapter, Home, is a powerful evocation of the pull of motherhood. ”Sometimes, when I look back on my dreams of becoming a consultant surgeon, I feel sad about the notional future I have given up,” Weston writes. ”And occasionally I baulk at the essentially female nature of the rearrangements I have made. But for the most part, this is not so. I see myself as I am now, sitting in an operating theatre in the hospital which has become my second home.”
The decision is working for her, although she is not unaware of the irony that, true to her alpha personality, she gave up her hot-shot job only to get a hot-shot book deal and the lure of a new writing career. The book has been sold all over the world, and tours in Canada and the US beckon:
”My ego hasn’t really suffered yet,” she says, laughing. ”The big test will be when the book thing dies down and I’m left with this little job. Whatever happens, I will never, ever leave surgery.” – guardian.co.uk