wellingtongoose (wellingtongoose) wrote,

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Semantics of Healthcare Part 3 - Guide to Making John a Real Army Surgeon

I've had many wonderful discussions with readers in the past few days! Thank you all very much. 

Many people have expressed a desire to make John an Army Surgeon. I understand why John the army surgeon is such an appealing idea and adds wonderful depth to his back story. 

Part 3 is a short guide to how John the Army Surgeon can be made compatible with reality. It's just an interesting meta on what John went through to become an army surgeon and what he would actually do on the frontlines. I also explore why he's Dr Watson and not Mr Watson, where John actually got his medical degree from, and how John can have an MD in the modern age of medicine. 

Like a Surgeon...

ACD!Watson vs BBCSherlock!John: a brief history of British Medicine

In ACD's canon John Watson is an army surgeon. It’s hard to reconcile this with the GP version of John we have in the modern adaptation. However at in the nineteenth every doctor in the army had surgical training and could be considered a surgeon.

An army surgeon at that time was a multipurpose professional. Remember this is over a hundred years ago when doctors did not specialise in a particular field of medicine. You could do both medicine and surgery (any and all types of surgery). In the modern era this is simply not possible. Orthopaedic surgeons only operate on bones; plastic surgeons only patch up skin and soft tissue. Thus one wounded soldier would need many different doctors to attend him in the present day, whereas in ACD's time one doctor would do everything for the patient including his follow up care. 

In order to update John Watson - we have had to give him a speciality and the only speciality he can possible have if he managed to get a locum GP job in London is General Practice. This is still in keeping with his ACD canon counterpart as a GP has the broadest workload of any doctor. He would be able to treat anything from a broken finger to malaria. John would never have performed major surgery but GPs in the army can do small surgical procedures that don’t involve general anaesthetics such as stitching up wounds and removing sutures. 

Guide to making a John a Realistic Army Surgeon

I have had many comments from people who really want John to be an army surgeon because that’s what ACD!Watson did and it also opens up some awesome potential in terms of fanfiction. Who am I to deny people their ArmySurgeon!John? So here is a handy (not-too-serious) guide to making John the Surgeon as realistic as possible:

John’s GP Training – When John graduated from medical school GP training was much more loosely organised and less formal. It may be that he spent 2 to 3 years after finishing his hospital House Officer Jobs working as trainee GP. During the time John was practicing it was much easier to change from one speciality to another so he could have changed his mind and decided to become a surgeon instead after qualifying as a GP. 

(My headcanon – John started training as a civilian GP trainee and then decided he wanted to do surgery instead. However surgery training posts are always hard to get in NHS hospitals so John might have joined the army surgery training program instead, which is still competitive but the army always needs more surgeons. Doctors can join the army in this way but you miss out on army sponsorship during your medical school. On the other hand, you do not have to sign a minimum contract to work for the army for 7 years.)

John’s Surgical Specialty - The army has a restricted range of surgical specialities – demand is very high for trauma specialists. In civilian NHS hospitals the orthopaedic surgeons operate on nearly all of the trauma cases with the help of the plastic surgeons who repair skin and soft tissue. However they mostly deal with road traffic accidents and violent crime. Gunshot wounds are very rare in UK hospitals because possession of guns is still quite rare even amongst the criminal classes. Most violent crime involving weapons are committed with knives.

However in the army the major causes of trauma are gunshot wounds, shrapnel and explosions. Therefore the army requires a large number of trauma specialists. If you want John to be a surgeon – the most likely surgical speciality he would be a  specialist "trauma surgeon" (not an orthopaedic surgeon). Trauma specialists aim to stabilize soldiers who have sustained massive trauma as that they can be moved out of the country to receive more specialist intensive care treatment and follow up in the UK. 

There are other types of surgeons in the army and they are deployed to the front lines but they would not be responsible for operating on the soldiers who are heavily wounded. They are the second line of treatment once the trauma specialists have done their job. It is also the trauma specialists who fly out to pick up wound soldiers on the battlefield.

I have said in Part 1 that retrieving wounded soldiers may be how John was routinely sent into full combat. He would on these missions be given full body armour and stand issue weapons to defend himself. He would in some cases have had to fire back at the enemy but that would not have been his priority.

(Side Note - The army does actually employ civilian doctors in large military hospitals away from the frontline in Afghanistan. I assume that these doctors are better trained to provide the long term care that wounded soldiers need.)

Thus most of the doctors that ever enter the combat zone would be trauma specialists and we all know John would want to be as near to the fighting as possible.

John’s surgical training – Trauma specialists cannot be easily trained in military hospitals in the UK. They really need to be in regions with active combat in order to learn the skills they need. Therefore it is likely as soon as John gained a place on the trauma training program he would have been sent out to whatever active war zone was available.

Although the war in Afghanistan only started in 2001 and Iraq in 2002, the British Army has been deployed as part of NATO and UN peacekeeping forces to some of the most war torn areas of the globe. Therefore John really has seen “enough [trouble] for a lifetime”. He probably was only a few years out of medical school before he was introduced to the adrenaline inducing, horrific world of real battlefield medicine.

 All surgical training programs are split into Core training and Speciality training. In Core training you learn general surgical techniques that can be applied to nearly all operations. In speciality training you learn to do all the operations that your speciality routinely performs: for orthopaedic surgeons it would be joint replacements, for eye surgeons it would cataract surgery. However trauma specialists do not perform elective surgery (i.e. all their operations are emergencies) and they have to deal with a wide range of problems. Therefore their specialist training would be much like a continuation of Core training as they need to acquire a very flexible set of surgical skills. 

Addition: Surgical training officially takes between 5 to 9 years but because Consultant posts are highly competitive and require a great deal of experience, in reality it takes 8 - 15 years of training to become a Consultant. Some of these years would be used to get extra qualifications such as an MD or a PhD (yes John would then be Dr. Dr. Watson) and doing fellowships abroad in different parts of the world. John probably never took time out to do a fellowship abroad as the Afghan war broke out early in his training. 

In the field of trauma, experience is very important because of the emergency nature of their work and the many different types of cases they must contend with. Therefore senior doctors need many years of experience behind them in order to be competent enough to make good clinical decisions. I believe that when John got invalided out of the army he would be getting to the tail end of his training but he wouldn't be a Consultant surgeon yet. 


(For those who want to draw John's military uniform correctly!)

John the Army Captain – In Part 1 (Exploring Dr Watson's Army Career) and Part 2 (BAMF!John and Reality), I have pointed out that after 10 – 15 years of graduating from the medical school, John should have advanced further up the career ladder than Captain. As an army doctor you are automatically promoted to next military rank when you advance up the medical career ladder. Your promotion has nothing to do with your efficacy or experience as a military officer.

John still being a Captain can simply be a sign that he is still undergoing his trauma specialist training when he was invalided out of the army. Promotions in rank are given in accordance to time spent in the Army and pay. Captain is a relatively junior rank for a qualified doctor in the RAMC. 

Side Note: Enlistment - John did not enlist in the army because the rank of Captain is a commissioned officer. If you enlist in the army you can only be promoted to non-commissioned officer ranks, the highest of which is Staff Sergeant. A commissioned officer was traditionally any officer with a "royal commission" i.e. a directive from the Queen. Commissioned officers are not promoted along the same system as enlisted soldiers and their commission was used to distinguish them from the ordinary non-commissioned officers. 

In the modern day all commissioned officers in the army must go through a course at Royal Military Academy Sandhurst. Professionally trained officer candidates like John would go through a shorter course as he does not actually need to lead troops into battle. However he does need to acquire some leadership skills because he is going to be a commissioned officer. 

John’s actual job - As a surgical trainee John would get to do a lot of the straight forward operations on his own. He would definitely be able to extract bullets and sow up gunshot wounds without supervision as long as the bullets haven’t nicked something vital. He would probably not be doing amputations – this is the job of the orthopaedic surgeons. Instead he would be working with anaesthetists who have training in intensive care to physically stabilize wounded soldiers i.e. stop internal bleeding, extract shrapnel, sow up wounds, bandage wounds as best as possible. However in complex patients John would be the assistant surgeon to the Consultant during the operation. He would also not be in the position to make final decisions on treatment and he must defer to his superiors.

John, as a more junior member of the surgical team, would participate in retrieval missions more than the Consultant surgeons. This is because Consultants are very valuable and trainees less so. It makes more sense to send junior doctors into the combat zone because they are more expenable. Thus John would probably be pretty handy with a weapon if he has to routinely fly into combat areas, much more so than any of his bosses. 

The Mystery of Mr Watson - It has been pointed out to me that John can’t be a surgeon because he would be referred to as Mr Watson and not Dr Watson. This is both true and not true (confusing right?). A surgeon only gains the right be referred to as Mr/Mrs/Miss once they pass the all important Membership of the Royal College of Surgeons (MRCS) exam, which aspiring surgeon taken towards the end of their core training program. This exam needs to be completed before you advance to a specialist training program. Unlike in GP, all trainee surgeons do Core training and then Specialist training, which is why it takes much longer to train as a surgeon than as a physician.

If your heart tells you John is definitely a surgeon not a GP: John could still be Dr Watson if he started a Core surgical training program but never finished it before being invalided out of the army.

Alternatively he may just like being called Doctor and he legally has the right to carry that title. It’s more a point of pride amongst surgeons that they drop their doctor title and not a legal requirement. Unless they have spent time under the surgeon’s knife, other people who meet John may not know the age old tradition of referring to a surgeon as "Mister". It gets quite difficult for surgeons, particularly in their private lives, to explain to people why they don’t carry the title of doctor. It usually confuses people and makes them question whether you are “a real doctor”.

Also if John spent most of his time working at the Camp Bastion Field Hospital, which is the major military hospital in Afghanistan, he would have worked closely with American colleagues. American surgeons definitely go by the title of Doctor and perhaps John got into the habit of referring to himself as Dr Watson. 

(Side note – for anyone who is interested, the reason why surgeons are referred to as Mr/Mrs/Miss is because in the eighteenth century all surgeons were “barber surgeons”. They had no formal training and where not considered part of the medical profession. The Royal College of Physicians snootily refused them the title of Doctor. However once surgery really took off in the nineteenth century the surgeons decided they rather like being distinguished from their physician colleagues and started the practice of dropping the Dr. title from their  name once they became members of the Royal College of Surgeons)

This does raise the very interesting question of just what does Miss Molly Hooper do – because she’s not a pathologist. If you’re confused by this I’ve written a nice little meta about her as well.

John's Orthopaedics Job - several people have pointed out that John’s CV (on screen caps during TBB) shows that he trained in trauma and orthopaedics. I think it says: PRHO at University College Hospital London, SHO at Broomfield Hospital Chelmsford, which is listed as "Trauma and Orthopaedics".

I understand this was drawn up by producers who probably know nothing about medicine but I have to say in this case they actually got it right. 

This is a typicaltypical junior doctor rotation. PRHO is his House Officer job, the first job he got straight out of medical school and SHO is his second year job. As a junior doctor you rotate through many different hospitals and specialities, moving every few months. This does not mean John specialised in orthopaedics – if he did he would have spend 7-9 years doing it instead of a few months as it says on his CV.

He might have been interested in orthopaedics but it is more likely that this was just the rotation he ended being allocated to by the hospital or Medical Deanery (the body responsible for the medical education of junior doctors within each group of hospitals). In this rotation he would have done only civilian trauma not battlefield trauma.

*Pictures in this section courtesy of the army.mod.uk. These images are actually of real army doctors in the RAMC, a good reference point for anyone wanting to draw John in uniform.

Give John back his MD!

John’s MD – Amendment: Doctor of Medicine is a higher qualification that requires a two year original research project, similar to that of a PhD. MD are more popular with surgical trainees, whereas medical trainees tend to favour PhDs. I believe this is because PhDs take 3-4 years of full time research. This is a long time to take out from surgical training and your surgical skills inevitably become rusty if you are not practising full time. This is often less of a problem in medicine there are less practical procedures that require muscle memory. 

Higher research qualifications give specialist trainees essential research experience. Consultants, especially medical Consultants, in teaching hospitals are usually required to participate in medical research as part of their contract. Therefore having an MD or a PhD would give any specialist trainee a good foundation for their Consultant post and it is a something that most employers will look for. 

However in order to do most research projects you need access to a well equipped laboratory. If John Watson was an army surgical trainee on the front line he would not have the facilities to do an MD. If John Watson is a GP trainee, he would have no need for an MD because there would be no expectation for him to conduct medical research once he has finished his training. 

If anyone would like John to have an MD because it makes him sound awesome, there are some realistic ways you can do this:

  1. If your headcanon says John is a surgeon then at some point in his training he would have got an MD. I think John would have probably investigated the best way to extract bullets from deep tissue (this is actually the title of someone’s PhD thesis) or new techniques for wound closure. These projects could potentially be acceptable and not need access to a research laboratory. 

  1. If you believe that John has to be GP in order for it to fit canon – John may still have an MD, though most GPs don’t go in for that sort of thing. Their top jobs are not as competitive. However a research project might have caught his eye – it would be more along the lines of biochemistry/pharmacology he’s a medical doctor not a surgeon. There might be a plot bunny in there when Sherlock stumbles upon John’s ago old dissertation and realises just how clever John really is.

John’s Medical Degree

(Kings College London)

King’s College not Barts – I have been informed by the eagle eyed trishkafibble that John’s CV says he got his MBBS from King’s College London but in the show it Sherlock says he trained at Barts!

Most likely the producers made a mistake. However I love to look for in-universe explanations for the unexplainable so here we go:

John did spend time in St. Barts Hospital but as part of his House Officer Jobs after he graduated. We can only see two jobs listed on the CV at University College Hospital and Broomfield; in reality you have at least 6 different jobs in the first two years of being a doctor. Each job would be in a different speciality and possibly in a different hospital. So it’s plausible that John worked at Bart’s with Stamford during his junior doctor days. Barts Hospital is very busy and requires a huge number of junior doctors to staff; it is also highly regarded as a teaching hospital for trainee doctors (and medical students).

Today St. Barts Hospital is used predominantly for Barts and the London medical school to train their medical students. However a small number of Kings College and University College London students end up in Barts Hospital for one or two placements. It’s all rather bizarrely organised. Don’t worry if you’re confused, the medical students are even more confused.

In ACD canon John got his medical degree from the University of London not Kings College. This squares well with his modern counterpart because John technically did get his degree from the University of London whether he went to Barts or King's College. All universities in London up until very recently issued their graduands with certificates from the University of London. It does fit quite nicely with canon, no? 

Part 1 - Exploring Dr Watson's Army Career

Part 2 - How can an Army GP be fighting on the front lines? John's Dual Career

Feedback is very welcome - I love to discuss things with readers!
Tags: meta: john watson

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