On the art and science of medicine.

Two friends are leaving for private practice this year. What surprised me was how differently they left.

My classmate first.

He is always learning. And always teaching. There is always another book to read and another technique to refine. He teaches juniors because he can't help it. Not because it is in his job description.

He is going private so he can offer patients what he cannot yet offer in public service. Newer, less invasive procedures that may take years to become standard of care. To learn from the people who do these procedures best, he has gone overseas on fellowships he paid for himself. A bet on his own craft, placed with his own money.

What strikes me is how patiently he intends to build his practice. He is not in a rush to chase revenue. He is looking for partners who believe things can be done better, and he is careful about who he builds his team with.

This is not the playbook of someone optimising for the next couple of years. This is someone who wants to be playing for the next twenty years.

Next: A different game (Part 2 of 3)

My senior next.

He is a good friend, and a big brother figure during my training. He has been in public service for more than fifteen years, and spent the last five years pushing his craft as far as it could go. The sickest patients. The hardest cases. His care didn't end when the patient was extubated. He followed up on his patients until he was satisfied they were well.

I never heard him complain. He went the extra mile so often it stopped looking like an extra mile. When I write about mastery, he is who I have in mind. Much of it, I learnt from him.

So when he told me why he was leaving, I wasn't ready for it. He feels he has achieved what he set out to achieve. He is ready to play a different game.

The game outside still demands good care. His patients will be well looked after. I have no doubt. But it is also a game of revenue. Building an efficient practice. Stacking his cases. Optimising income. It is no longer only about giving each patient the best care possible. He knows this. He knows what he is giving up and what he is walking into. He has chosen it with his eyes open.

And yet.

Part of me believes the best clinicians should stay. When he leaves, the department will feel it. The surgeons will feel it on the bad days, when the case turns ugly and they look up to see that he isn't at the head end. The patients will feel it, though most will never know why. The juniors will feel it most. They lose a senior who shows them the level of care that is actually possible. You cannot learn that from a textbook. You learn it standing next to someone who does it.

I wish him well, and I mean it. He has earned the right to choose his next game.

Next: The infinite game (Part 3 of 3)

My classmate continues playing the long game outside. My senior has finished one game and chosen another. The game I want to play is one that has no finish line.

Simon Sinek calls it the infinite game. A finite game has fixed rules and an end. Someone wins. An infinite game has no end. The aim is to keep playing, and to play well enough that others want to keep playing with you.

Medicine is an infinite game. There is no final case, and nothing to win.

And almost everything I care about in it compounds. Clinical knowledge. Procedural skills. Relationships.

This is the game I want to play. Long-term relationships with long-term people. Surgeons, nurses and patients who trust my work. An environment where I keep creating value, and keep pushing towards a better version of myself. I believe doing good and doing well can coexist. Create real value, and the reward tends to follow.

I feel blessed to do what I do every day. What I want to build in the long run, I don't exactly know yet. Patient care will continue to sit at the centre of it.

Beyond that, I am curious. Curious what it looks like to pay back the seniors who taught me, by paying it forward to the juniors who come after. Curious what the next few years do to my sense of professional satisfaction.

I intend to keep playing to find out.

It's MOPEX changeover season.

I spent the past week narrating everything I do in OT. The same basic things, in the same order, to a different MO each time. Where the monitors go and why. How to operate the syringe pump. What to watch for on the EEG.

My lists run slower. My attention splits three ways instead of one. By the fourth case, I am more tired than if I'd done the list solo.

The emotional tax of teaching someone from zero.

My seniors paid this tax for me years ago without asking for anything back. Patiently. And more than once. I was blissfully unaware of the toll it had on them.

I get to pay it back now, by paying it forward.

For years, I thought my problem was a competency gap. I would replay what went wrong, why I struggled with something which my consultant executed with ease. I assumed that once I was competent enough, I would stop beating myself up. I wanted to be a competent doctor, and competence felt like the destination.

At 6.30am near the end of a night shift recently, I found myself struggling during induction. After putting in more than ten thousand hours and ten thousand iterations. At a point in my career where I thought I was competent enough to manage this case without much trouble.

Fatigue, maybe. But complacency, and the carelessness that accompanied it, probably played a bigger role.

Competence is the proven ability to execute a task effectively. But being able to do something once, in ideal conditions, is not the same as being able to do it consistently. Consistency regardless of physical state or operating environment. At 6.30am. On your tenth case when it is the patient's first.

The antidote is shoshin: beginner's mind. Approaching each case as if it still demands your full attention. Because it does.

Some juniors register for the exams without believing they will pass.

They will not say it that way. They will say they are sitting early to leave a buffer for a second attempt. That this first try is just practice, before doing it properly the following year. The logic sounds prudent. Underneath it is a belief: I don't believe that I will pass.

Limiting beliefs are self-fulfilling. Stop thinking "I only have a 30% chance", "I can't finish studying", "I am not ready". I am not arguing for blind confidence over preparation. You need a high degree of commitment and resilience. Hard work, deliberate practice, attending tutorials are important. But these are downstream. Energy flows where your focus goes. They come in naturally once you believe that you can and will pass.

There is a quieter dividend. Believing that preparing properly for the exams makes you a better clinician, and the preparation stops being punishment. You are not grinding towards a meaningless degree. You are building the doctor you want to become.

Good news: you have 100% control over what you choose to believe. Beliefs shape thoughts. Thoughts shape action. Action shapes outcomes. Make it work for you.

Mohnish Pabrai built a successful fund by copying Warren Buffett. He calls it cloning, and says it without embarrassment. There is no reward for originality in investing. The reward is portfolio return.

The same applies to anaesthesia exam preparation. Juniors spend weeks working out how to prepare, then months executing a plan they built from scratch, only to go back to the drawing board with each unsuccessful attempt.

Originality doesn't have to be the starting point. The answers already exist in the seniors who have passed. First, identify who to copy from. Someone trusted, reliable, and similar enough to you. Find time to ask them. Copy what worked.

Then modify. Work out from first principles whether their strategy holds true for you. Map the differences between you and your seniors (studying style, environment) and adapt your approach to fit your context.

There is no reward for originality in a high-stakes exam. The reward is passing.

I used to worship grit. David Goggins was the epitome. How he pushed his body past what anyone thought possible. I thought that was the template for greatness.

I was wrong.

The athletes I look up to now are the ones still lifting heavy at seventy, still running fifty kilometres a week as grandparents. It can take more discipline not to push. Stick to zone 2 for the bulk of training. No just one more rep. The reps compound only if they don't lead to injury.

Medicine works the same way. Residency does not reward the most diligent workers if they burn out. And the hardest-working, most conscientious trainees are often the ones most at risk. Treating sleep as optional. Not taking sick leave when unwell. Saying yes to every opportunity. The resident who runs herself into the ground to take exams a year early is training through injury.

Longevity isn't about endurance. It's the discipline to protect your capacity to still be doing this well in thirty years.

Two residents go through the same postings, the same lists, the same caseload, in the same hospital. One is noticeably ahead of the other at the end of training. The easy explanation is talent.

Talent can give someone a head start. There are colleagues who grasp concepts faster than everyone else in the room, who never seem to struggle, who look natural at a procedure the first time they do it. Such people exist.

But rate of growth does not have to rely on talent.

What is more important is the ability to aggressively extract lessons from their cases and furiously apply them to the next. Given the same exposure over the same period, the learning machine pulls ahead. Not because they did more cases, but because each case became an iteration of their craft rather than just logging numbers. Malcolm Gladwell popularised 10,000 hours. Naval got it right: it should be 10,000 iterations.

When I look at juniors, I'm less interested in where they are. I want to know how fast they're levelling. The resident struggling now but getting better each week doesn't concern me. The one who is seemingly competent but stagnating does.

Talent tells you where someone starts. Rate of growth tells you where they'll end up.

I took time to walk her through every step of a peripheral nerve block, pausing to explain why. Why the tray is opened that way. Why the draping sequence matters. Why the needle is angled in that direction, and why you watch where the LA spreads before you commit the rest.

For the next patient, she set up unaided. The tray looked similar. The sequence was roughly right. But she had reconstructed the steps from memory, not from principle. She thought she had prepared everything the way she was taught. When the guiding logic wasn't there to check against, small things drifted. Things that matter.

That was when I understood what I hadn't transferred. I can explain every why and still not transfer understanding. Gaps unravel under pressure.

We will do better next time.

A good list ends with the surgeons and patients having forgotten you were there.

That sounds like a complaint. It isn't.

The measure of good anaesthesia, from the surgeon's side of the drape, is the absence of friction. The patient asleep on time. The haemodynamics stable through the bleeding phase. The wake-up clean and fast when the last suture goes in. None of it remarkable. All of it the result of decisions made quietly, well before anything went wrong.

The work that earns that trust is invisible.

Positioning the arm so the plexus doesn't get stretched. Titrating the relaxant so reversal is prompt. Taking care to ensure patient is comfortable for same-day discharge. None of it shows up on the op note.

Juniors sometimes worry they aren't being seen. They are. The best surgeons I know watch out for the things that don't shout: the patient who wakes without retching, the haemodynamics that held steady during dissection, the handover that needed no clarification.

Being noticed for problems is easy. Being trusted for the absence of them takes years.

Overlisting. Double covering. No cover for breaks. The sense that your bosses, colleagues, patients take what you do for granted.

Yet every one of those complaints was once an aspiration.

Getting into medical school. Graduating. Matching into residency. Passing the registrar exams. And finally, earning the privilege to exit as a consultant, in a position to make a meaningful difference to the scariest day of someone's year.

This is not an argument for accepting less than you deserve. Push back where push back is warranted. But make time for gratitude.

Take time to appreciate consultants who carved out evenings for exam prep tutorials. Registrars who guided you through a difficult procedure at 3am when it was easier to just do it themselves. Colleagues who covered for you when you were on study leave. Seniors who believed in your potential.

The shift from expectation to appreciation costs nothing and changes everything. Thank you for showing up. For doing what you do every day.

Two chefs given the same ingredients can cook the same dish and produce very different results. One is memorable. The other is forgettable. The difference goes beyond the recipe.

Anaesthesia is the same. Two anaesthetists with the same patient, the same surgery, the same drug list. One patient wakes calm, comfortable, oriented. The other wakes groggy and nauseated.

What differed was the cooking. The attention paid to each variable: the dose, the timing, the speed of administration. Each alone seems insignificant. Together they compound.

A strong grasp of pharmacokinetics isn't enough. It must be in sync with the surgical phases. Morphine titrated perfectly to address tourniquet pain will leave a patient drowsy and nauseated when the cuff deflates at the end.

Good anaesthesia is prepared in advance, and executed in real time. Adjust the heat when the pan changes. Taste before you serve. When the case ends, evaluate the dish honestly. And let that shape the next list.

The recipe is just the starting point. The chef makes the meal.

There are juniors who get shamed when they ask for the video laryngoscope. Then there are juniors who are only allowed the video laryngoscope with the screen turned away: a direct laryngoscope with a safety net they're not allowed to use.

The updated Difficult Airway Society guidelines are unambiguous: video laryngoscopy is first-line, not rescue. The hesitation comes from an older framing, one that treated direct laryngoscopy as gold standard and everything else as admission of failure.

That frame no longer stands. Let it go.

Using the videolaryngoscope well takes deliberate practice. The screen gives you the view; it doesn't guarantee the intubation. What changes with VL is that mouth opening matters more than you think: the more restricted it is, the less freedom you have to manoeuvre the tube to the laryngeal inlet. Pre-shape the ETT into a tighter curve. Apply external laryngeal pressure early. The tube cannot be forced; it has to follow an arc.

The shame was never about capability. It was about a failure to update.

Landmark technique assumes the artery is straight and runs exactly where you palpated the pulse. This assumption is tested after the first failed pass.

Ultrasound removes this uncertainty. Arteries that are calcified, tortuous, small in calibre, or deep may still be challenging. But they won't come as a nasty surprise. You see the anatomy before you commit to it. The calcified segment, the tortuous path, the artery sitting deeper than expected. Each one changes the approach: a more acute needle angle, a Seldinger technique, a different vessel altogether.

The procedure that follows is smoother and kinder to the patient.

Using the probe takes a minute. The failed cannulation costs the patient a bruised artery, and you a much harder second attempt.

For years, my pre-op counselling was a list.

Awareness: rare but possible. Nerve injury: rare but possible. Death: rare but possible.

I was thorough. I was also not really talking to the patient. I was documenting that I had talked to the patient.

What I've come to understand is that most patients waiting in the pre-op bay aren't waiting to hear the statistics. They already know surgery carries risk. That's why they're frightened. What they want to know is simpler: Will I wake up? Will it hurt? Will everything be fine?

I still go through the list. That's my job. But I lead with assurance now. The other part, which costs nothing and matters more, is letting my patient know I will do my best to take care of them.

My default for LMA cases is to extubate in the operating theatre. Not PACU.

The downstream benefits are real: lower laryngospasm risk during transfer, faster post-op recovery, reduced PACU workload. But that's not why I do it.

The reason is the discipline the choice imposes on everything else.

If I'm committed to extubating in OT, I cannot be laissez-faire about washout or analgesia. Opioids have to be carefully titrated, not given as careless boluses. I have to stay present during the final fifteen minutes instead of mentally moving on to the next case. I have to pay attention to the surgeon.

Where you extubate says something about the standard you set for your practice. It's about raising the bar when your environment tolerates much lower.

The decision between LMA and RSI intubation can be a consequential one for patients in the grey zones: the borderline obese, the long-standing diabetic, the patient with vague reflux symptoms. It's often a judgement call based on experience, and occasionally on guesswork.

That judgement call doesn't have to be blind. A curvilinear probe, some acoustic gel, and fifteen centimetres of scan depth is all you need.

If the antrum is empty on gastric ultrasound, the LMA plan stands. Accompanied by NGT decompression for good measure. If it isn't, the plan changes to RSI intubation. I scan every emergency OGD listed for MAC before proceeding with sedation. It takes no more than a couple of minutes. It replaces a probabilistic argument with a more objective measure.

The barrier to using gastric ultrasound isn't equipment. The curvilinear probe is already in the room. The barrier is the habit of not picking it up, because of lack of confidence, because it feels like extra work, because gastric ultrasound hasn't yet made its way into best practice guidelines.

Let the probe replace the judgement call. Let it decide what's best for your patient.

I get the AU nurse to set the cuff pressure to 22 cmH₂O by default. So that I don't get distracted by a nurse asking if 30 cmH₂O is okay (it isn't) when I'm trying to focus on positioning the patient after intubation.

The same logic runs through the rest of my practice. I have standard set pieces for different surgeries (induction sequence, drug dilution, pump programming, ventilator settings), all optimised in advance, not renegotiated each time. I keep drug ampoules for later use out of the induction tray so I can't pick up the wrong one. I pre-chart the intra-op notes before the case starts so I'm not splitting my attention between the patient and the computer afterwards.

None of these individually changes an outcome. Collectively, they free up a finite resource: our attention. The patient whose pressure is drifting. The surgeon who has gone quiet. The suction bottle filling faster than it should.

The best anaesthetists I know aren't thinking harder than everyone else. They've arranged their practice so they don't have to.

My seniors often stressed that anaesthetists must be patient advocates. This came with a second refrain.

Watch out for the surgeon.

They downplay co-morbidities. They underestimate blood loss. They tell you forty-five minutes and mean two hours. They don't always tell you when something goes wrong on their side of the drape. And when lists overrun, somehow it is our lines that took too long.

The problem is when vigilance hardens into suspicion. When we are primed to be antagonistic. When the default is silent angst instead of communication.

We may be on different sides of the drape, but we are on the same team. The surgeon wants their patient to do well. So do you. That alignment is not nothing. It is the whole substrate of good theatre work.

If you want better outcomes, make the effort to build trust with your surgeons. It is not soft. It is clinical.

To my juniors in OT.

I apologise for not giving you enough to do.

I do most things myself. The junior in my OT watches more than they do. The lines go in first pass because it is my pass. We are almost at the target nerve before I hand the needle over to you.

The anaesthetist next door will hand their MO the laryngoscope, the block needle, the arterial line. Their procedures take a little longer. Their lists end slightly later. Occasionally something goes less smoothly than it might have. That is the price of training the next generation. I know. I was a beneficiary of this system.

I will teach you what I know. Show you how I work. But I know it is not the same.

The apology is not rhetorical. And I will keep trying to get the balance righter.

Anaesthetic drugs are complicated. There is no universal standard dose. Most have to be calculated based on body weight.

As a trainee, I remember working with consultants who didn't seem to calculate anything. Small boluses of propofol, a touch of fentanyl, until the patient fell asleep. Going by feel rather than hard science. I found it almost offensive: the opposite of the meticulous, detail-oriented anaesthetist I aspired to be. Yet somehow their patients always did well.

It took years before I understood what they were doing. They weren't being lazy. They were silently accounting for other variables (age, cardiac function, drug interactions) in their head while titrating with their hands. The reference range is just a guide. The dose that should actually be given is the minimum effective dose: any lower and efficacy suffers, any higher and the patient pays for it unnecessarily.

I was the lazy one. Giving a safe dose that was defensible. Comfortable. Thoughtless.

Tailored anaesthesia is worth the effort. Haemodynamics that stay stable through induction. A patient who wakes oriented rather than drowsy. No vomiting in PACU. The payoff doesn't show up in the notes. You know it when the case ends quietly, without fuss, and there's nothing to rescue.

There is a convention at induction: tell your patients to keep their eyes open and take deep breaths. At emergence: tap shoulders, shout their name, wake up, open your eyes, take deep breaths.

This was how I was taught. And that was my practice for many years before I stopped doing either. Because I don't think the patient should have to experience it.

At induction, the last thing the patient hears should not be someone shouting at them to keep their eyes open. They have spent the morning anxious, fasted, undressed, wheeled into a cold room full of strangers. The kindness we can offer, at the one moment they feel most vulnerable, is to let them drift off to sleep. Quietly. Gently.

At emergence the clinical argument is even stronger. A patient in a light plane, shouted awake and stimulated vigorously, will cough, strain, bite the tube. Premature extubation. Bad wake-up. The way to a smooth extubation is not to demand one loudly. It is to have titrated the anaesthetic and analgesia so the patient surfaces at their own pace.

Let them drift off. Let them surface. Quietly.

Modern ultrasound changed regional anaesthesia more than any drug or needle has. Before it, a landmark block was a probabilistic exercise: feel the pops, crank up the nerve stimulator, and hope your needle ends up near but not piercing the nerve. Now you place the needle tip where you intended, watch LA spread in real time, and give only what is needed.

That precision opened the field in two directions. The older nerve-localisation blocks got safer and more consistent. And an entirely new category of blocks became possible: fascial plane techniques, placed far from any nerve. Performable under GA. Near-zero risk of nerve injury. The repertoire available to a regional anaesthetist today looks nothing like it did ten years ago.

A working block means lower sympathetic stress intraoperatively and a patient who wakes up comfortable rather than in pain that needs chasing. Opioid-sparing, or opioid-free where the anatomy allows. This is what the research keeps pointing towards.

It's also one of the fastest evolving subspecialties in anaesthesia. Reason enough to stay close.

Before you can get better, you need to know what better is. Sounds obvious. Except it isn't.

Many anaesthesia trainees aim to get better through volume. Intubate more. Set more lines. Perform more blocks. Be the hardest worker in the room. But being able to do a procedure and achieving excellence are not the same thing. If you can't tell the difference, you are improving towards nothing in particular.

Taste, in the culinary sense, is the ability to notice. Not the ability to cook. That comes later. First comes the discernment: this sauce is flat, the pasta overcooked, the timing off.

Without taste, you are cooking blind. You can practise a recipe for years and never improve, because you cannot tell the difference between the dish you produced and the dish you intended.

Observe your consultants with this in mind: what they are doing, what feels different. The list that runs without friction. The tubes and lines placed without anyone noticing. The patient who wakes oriented and comfortable without anyone having made a fuss. These are the flavours. Start appreciating them.

This discernment has to be developed deliberately, the same way a chef trains their palate, not simply by cooking more, but by tasting more, and tasting with attention. You have to have great taste.

Once your palate is calibrated, learning has a direction. Until then, you are just accumulating hours.

The first weeks in anaesthesia are disorienting. The room moves faster than you can follow, everyone seems to know something you don't, and the list doesn't wait for you to catch up. The instinct (reasonable, human) is to find something you can do. Contribution as a foothold.

There is nothing wrong with this. But don't let it become your main focus.

The junior who spends the list running errands learns to run errands well. The one who stands close and watches, who notices what the consultant checks when the blood pressure drops, who asks why the airway plan changed, who pays attention to what's happening on the other side of the drape — learns anaesthesia.

The disorientation you feel isn't a problem to be solved. It's the sensation of your brain reorganising itself around something genuinely difficult. Filling it with tasks disrupts the process.

Don't worry about being useful just yet. Pay attention. The usefulness will follow, and it will be built on something.

Most block failures are not anatomical bad luck. They are imprecision measured in millimetres and millilitres: LA deposited not within the nerve sheath, not in the target fascial plane, but in the muscle belly next door.

Intramuscular local anaesthetic does not block anything. It gets absorbed, wasted, and the patient wakes up in pain. You will see it on the ultrasound if you look for it: instead of clean spread along a fascial plane, the LA expands into a rounded mess within muscle. Fail to recognise it in time, and the distorted field makes the block nearly impossible to salvage.

Build the habit of injecting a small test volume first. Watch where it goes before you commit the rest. If it goes wrong, stop, reposition, try again.

Don't waste any more precious drops.

The highest-performing anaesthetists are fast. Not by rushing. Not by cutting corners. Through deliberate practice, until the essentials remain and every movement has a purpose.

Juniors sometimes hold themselves slow on purpose. A kind of performed carefulness. Palpating the same vein or artery twice to confirm it's still there. Pressing the back until the skin indents to reassure themselves of the space. Staring at the ultrasound with ferocious intensity to convince themselves they're not imagining things.

Don't.

Train your hands to be quick. Get into a flow state. Know your equipment and where everything is before you need them. Over time you'll find that speed and safety are found on the same curve, practised from different ends.

In crises where seconds matter, be the anaesthetist who has been training for that exact moment on every ordinary list before it. Speed is a skill which must be trained.

This site existed before anything worth reading does.

It's never been easier to access learning resources for anaesthesia: medical education blogs, dedicated social media accounts, YouTube channels. Everything is there, indexed, freely available.

What's harder to find is a guide on how to reflect. How to look back at a list, and extract something useful from it. How to notice what the majority overlooks.

That's what I want to write. Not another reference. Short notes from someone who is still learning, for anyone who cares about getting that 1% better.

Frequency will be irregular. I'm an anaesthetist first.

Thank you for being here early.