A Strawberry Peppercorn. A Massala Chai. A Stohlen Moment. One filter coffee.
I was sat in Newcastle’s Quilliam Brothers’ Tea House with my sister, Holly Speed, and her fellow medical student, Dua Hashmi. But the star of our Sunday morning meeting was Miss Tani Fasih; Dua’s mother and medical craftswoman.
I say ‘miss’ because once a doctor qualifies in a surgical specialty; they adopt the title of ‘Mr’ or ‘Mrs/Miss’. This is an indication to the history of medicine my sister pointed out. “Barbers were often trained as surgeons because of their steady hands. That is why the symbol for the barbers is symbolic of a blood stained cloth around a white pole”. However, today surgeons must complete the same formal medical training as doctors, despite the fact that their titles are not the same.
Tani completed her training in Barnsley near Sheffield, where she also began her rotation as a registrar. After her husband, who is an orthopaedic surgeon, was offered a training post in the North East she moved- 17 years ago- to Newcastle. Following the birth of her two daughters she continued and then completed her rotation as a registrar in the North of England. Although Tani is qualified as a general surgeon, her specialty is breast surgery. Tani wished to pursue a specialism in colorectal surgery as a second specialty, but due to the demanding nature of the field, it meant she was only able to pursue one.
Considering the amount she has had to learn, in order to become a surgeon, Tani actively agrees to be an on-call surgeon. This is not usual behaviour I am told, as on-call surgeons are those that respond to accidents and emergencies, and are therefore often working in high-pressure situations. However her reason for doing this she explained to me is to counterbalance the emotional strain that she experiences through her work as a breast surgeon.
As a breast surgeon, Tani works with many patients that are battling cancer. Her youngest patient, she told me, was a twenty-three year old. Young women are at a lower risk of disease and are therefore not screened as regularly but are more likely to present with aggressive disease. Tani recounted the painful story of losing a patient aged just twenty-nine, after she had displayed symptoms of mastitis. Within one year of diagnosis her patient had died.
The way Tani responded to my question, ‘How do you find working in a male-dominated field?’ surprised me, as she replied with, ‘The whole world is male-dominated, so it makes no difference’. She went on to explain the beneficial insight that female breast surgeons have, which I must admit, makes complete sense. As a woman, Tani is able to offer her patients a better understanding of how they might be feeling. For example, following a mastectomy, she has found that what the majority of women want is a good quality of life; this often does not come through a full reconstruction of their breasts, but simply through having a cleavage. These women are able to maintain their femininity without the need for masses of cosmetic surgery or a prosthetic nipple. It might also be that some women wish to remove both breasts, regardless of how early the stage of cancer has been detected, as this eliminates the chance of the cancer returning in the future, which is highly likely to reawaken old memories and stresses. Having the insight as a woman, and a mother, Tani is able to relate to these women on a closer level than perhaps her male colleagues. What is interesting to acknowledge is how breast surgery and gynaecology, although considered sensitive subject matters or slightly taboo, they are still male-dominated fields. How can this be? Surely the more women that enter into these fields of work, the better it would be for patient wellbeing?
Tani’s experiences of a gendered world come from her upbringing in Karachi, Pakistan. She explained how she has come from a culture where men are valued more, where women are often described as being ‘not settled’ if they are unmarried. She recounted how a family might have six daughters before they have a son, which she refers to as a ‘full stop’. She shared a shocking story of a friend losing their 3 babies through childbirth, and someone saying ‘at least you lost a daughter and not a son’, which demonstrates to what extent the ideology that men are of more value is ingrained into the culture.
Having come from a family of doctors, it is no surprise that Dua, Tani’s oldest daughter is now studying medicine at Newcastle. Having come from an educated background, Tani was fortunate to have a father who believed, “you have to be the voice for the people who don’t have a voice”; a view that she shares, as she believes everything that exists is in this world, so we must therefore make it count.
After getting married, Tani kept her family’s name, which she admits was not related to any ‘feminist’ thinking as, it was simply her belief that she did not need to change her identity for anyone else. “Now I know my rights”, she said. “Women have to do what they think is right”.
There are many ways that craft has influenced Tani’s approach as a surgeon. The most illustrative one being the way she introduced a new method in the hospital where she works when carrying out a mastectomy. A procedure called ‘quilting’, which literally involves creating a series of stitches to create a quilt-like texture under the skin, which reduces the likelihood of fluid building up on the chest, and therefore risk of infection, as the need for the fluid to be drained or for further surgery is reduced. It is not a standard procedure and offered to patients only at the surgeons’ discretion.
[Tani’s diagram of the ‘Quilting’ process that she introduced at the Queen Elizabeth Hospital.]
The importance of neat stitching is something greatly valued by patients, as it is this area of the surgeons work that is so easily scrutinised. Any internal work is far harder to be appreciated! As part of her job, Tani teaches final year medical students as part of the surgical rotation that she has introduced, which presents them with a theatre-like scenario. The stages of this rotation are: scrubbing, knot tying, suturing (using the surgical instruments for operations), drainage of abscesses, and excision of skin lesions (removal of tissue).
I enquired as to what suturing was and what was the need to learn hand stitching if there are medical instruments to assist you. The answer I received was that basic skills must still be learned, because in various surgical scenarios there might be an occasion where hand stitching is required. In order to understand this concept fully, I offered a comparison with furniture. “So it is like learning to use a hand plane to square a piece of timber, even though I could use a planer and thicknesser machine?”
Tani’s training is drastically different to the experiences of many medical students currently studying. In Pakistan death happens a lot more openly, so the sight of a dead body, as medical students are introduced to cadavers, was not as much of an issue. During her education, observational drawing from specimen jars and (very) still life models was in fact part of the exam. Aspects that Tani very much enjoyed, and would even help her colleagues by doing some of their drawings for them. The involvement of art during her medical training was invaluable; not only was it enjoyable, but it taught the students to observe more closely the anatomical structures that they were to work so closely with.
This use of drawing has extended into Tani’s medical practise, as she uses drawing as a means of communicating procedures to her patients. She proceeded to draw some examples for me (see images). How is a patient, with no medical training, to understand the significance of removing the gall bladder to treat pancreatitis? However with a verbal explanation, along with the visual aid of a hand drawn diagram, this understanding can be made clear. Even the use of a spoon and slice of cake was able to help convey the concept of keyhole surgery to me, as Dua explained the difference between Laparoscopic (keyhole) and open surgery.
[Top: Tani’s diagram of why the gallbladder should be removed if a patient presents with pancreatitis. Bottom: Tani’s diagram explaining the different forms of breast cancer.]
[Tani’s diagram of key hole surgery.]
[Demonstrating keyhole surgery using a spoon and cake.]
The role of a craftsperson is to manipulate materials with skill, so therefore in surgery, the human body: bone, tissue and sinew; are just other materials to be used. This idea is demonstrated further, as Tani described her fascination with the way the butchers in Pakistan cut the meat by hand; the skilful way they crafted each cut, working the knife through the joint. This early memory is perhaps what sparked her curiosity in human anatomy.
Our time with Miss Tani Fasih was coming to an end, and to close our conversation we considered the importance of the human hand in surgery, considering the continuing development and use of robotics. Dua explained to me the first example of remote surgery in 2001, where a surgeon in the US performed surgery on a patient in France (https://news.nationalgeographic.com/news/2001/09/0919_robotsurgery.html). Once again, I was shocked at the similarities between our two fields. Will surgeons become as redundant as furniture makers if the robots take over? Our agreeing opinion is that these smart machines are just another tool. Surgeons and other craftspeople will always be relevant due to their haptic abilities, just so long as they remain informed of current technologies. However, I still believe that the human hand is of such vital importance in human development and learning, and our exploration of the world through tactile experiences can offer us such pleasure. Smart machines definitely have their place, but as Tani explained, a lot of her favourite foods are eaten with her hands.
[Miss Tani Fasih and her daughter, Dua, presenting an example of their craft work.]
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