Allowed to Decide

Some words stay with you.

Not the ones from a formal lecture, or a carefully rehearsed presentation. Sometimes it's a sentence someone says almost in passing — you hear it, the conversation moves on, and years later you find you are still turning it over.

One of the best trainers I ever worked under said something to me once that I have never quite put down.

"I'm fine when I'm allowed to make my own decisions."

At the time it sounded almost throwaway. The longer I have practised, the more I have understood exactly what she meant.

It wasn't arrogance. It was responsibility, and the two are not the same thing. Arrogance says I don't need anybody else. Responsibility says I am prepared to listen to everybody, but ultimately I need to make the decision I believe is right. The second requires considerably more maturity than the first, and it took me years of training to understand why.

Surgery can develop a strange pack mentality. A problem arrives, and everyone gathers around it — everyone has a view, everyone wants to contribute, and there is something reassuring about consensus. If five people agree, surely the decision is better than if one person makes it alone. Not necessarily. Sometimes five people thinking superficially add up to less than one person thinking deeply.

Expertise isn't democratic. That doesn't mean experts are always right — they aren't — but it does mean that opinions aren't automatically equal simply because everyone is entitled to hold one. A surgeon who has spent twenty years with a particular problem has usually considered possibilities that someone meeting it for the first time hasn't yet had the chance to. That isn't elitism. It's experience.

I have watched a senior surgeon reach a considered conclusion, only for someone else to offer a different view — sometimes reasonable, sometimes worth discussing, sometimes simply another opinion that happens to have been spoken aloud and so becomes part of the decision as though it carried equal weight. It doesn't.

This is one of the hardest things to learn as a trainee. You're encouraged to ask questions, and rightly so — you should challenge, you should consider the alternatives, you shouldn't blindly follow the most senior voice in the room. But there is a separate skill that only comes with time: knowing which opinions actually add value, and which simply add noise.

The operating theatre isn't a parliament. Nobody needs to vote on the right approach. Sometimes a decision needs many voices in the room. Sometimes it needs one experienced person to listen to all of them and then say, this is what we're going to do — and take the responsibility that comes with saying it.

That last part is the one people forget. When the operation goes well, everybody is happy to have been part of it. When it doesn't, something shifts. The question stops being what did the group decide and becomes, quite suddenly, what did you do.

That is the reality of holding the knife. At the end of it, the responsibility comes back to you, and no version of the registrar suggested it, or that's how the last consultant did it, or everyone in theatre agreed, or the MDT recommended it, changes the patient's outcome. None of it removes what's yours to carry.

I have heard some version of but everyone told me to throughout my training. It's understandable. It might even be legally relevant in certain circumstances, and it can help explain how a decision was reached. But it isn't a sentence I would ever want to say to a patient sitting across from me. I'm sorry this happened, but everyone told me to do it — what is anyone supposed to do with that? It doesn't ease their pain, restore their function, or reverse what's been done. It doesn't give them back the confidence they had when they walked into the hospital.