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Prof Roger Kneebone

Roger Kneebone trained first as a general and trauma surgeon, working both in the UK and in Southern Africa. After finishing his specialist training, he decided to become a general practitioner. In the 1990s he pioneered an innovative national training programme for minor surgery within primary care, based around intensive workshops using simulated tissue models and a computer-based learning programme. In 2003, Roger left his practice to join Imperial College as a Professor of Surgical Education.

Most people don’t get the opportunity to go into the operating theatre and have a go

On becoming interested in science

I think I was always interested in biology at school, like many people, and I kind of fell into medicine without really knowing what it was going to be like – like most people I guess – and to begin with it wasn’t particularly interesting, it was fairly dry, particularly at that time, lots of anatomy, lots of physiology and stuff.  But then when I got onto the clinical path, that really fired my imagination and about then I really decided that I wanted to do surgery because I loved the sort of physical bit, the doing things with your hands.

So that’s what I did in the first phase of my career was to become a surgeon and I must’ve done that for about 10 years or so after I qualified, spent quite a lot of time in Southern Africa, operating largely for people who’d had trauma of various kinds, so lots of people who’d been stabbed and shot and blown up and things in South Africa and then in Namibia, so I got quite a lot of experience in what it is to operate in various ways, particularly doing things that I hadn’t done before, and all the time I was doing that I was also interested in teaching, so I did a lot of teaching how to do these skills that I’d kind of learnt how to do without really knowing how I’d learnt them, I just kind of had at that stage. 

But even then, at that early time, I was always interested in other areas outside medicine, so for instance when I was in Africa I spent quite a while learning to fly a tiny little aeroplane, I was interested in music, there were various things that I liked doing or was interested in and then, difficult to say exactly when, but from fairly early on I started making connections I think between what I was doing as my main area, which at that time was surgery, and making parallels with things outside it.

And then after that, the next phase of my career, I became a GP; after I’d become a consultant in surgery I then changed direction and became a GP and so spent…first off spent a year in Lichfield as a GP trainee, learning the job really, and then joined a practice in Wiltshire where I was for the next 15 or so years.  And that was very interesting because that’s a completely different perspective, because instead of seeing people who come into hospitals with something wrong with them and you’ve never seen them before, you make a diagnosis, you do an operation, they get better, you hope, and they go home and you often don’t see them again, particularly in Africa, as a GP you have a different kind of perspective because you’re seeing people for a lot longer, you know them for years and years and years and you see them with all different kinds of things wrong with them and sometimes you send them to hospital and then they come back.  And you’re not there in the operating theatre doing the operation yourself, but nonetheless you’re building up a picture of them and their family and so on.

On working in trauma surgery

When I was doing this in surgery, thinking about the sequence of events with trauma surgery where I was, which to begin with was in Soweto on the outskirts of Johannesburg where there was a lot of violent crime and you’d be on on a Saturday night and somebody, another person would come in having been stabbed or shot and you’d assess them first of all, you’d see how they were and make a diagnosis but usually if they’d been shot or stabbed and they had guts sticking out or whatever, you knew that you had to take them to the operating theatre, so you would take them along to the operating theatre, the anaesthetist would put them to sleep and you would open them up and see what the problem was.  And one of the interesting things about that was that although you knew in advance that there was a problem of some kind, it wasn’t until you’d started the operation that you knew exactly what was wrong, so you very quickly got a lot of experience in following bullets, for example, wherever they happened to lead and you had to…I had to build on the knowledge of anatomy that I’d developed – I spent a year teaching anatomy before I did all this  – that sort of book learning and anatomy from dissecting cadavers,  from corpses into what it’s really like on a real person when there’s blood everywhere and you often don’t really know what you’re going to find.  And so part of this was, it was sort of learning to deal with being uncertain, to deal with not knowing exactly what was happening and going into parts of the body that you probably wouldn’t have dared to go to if there hadn’t have been a good reason; but of course someone being shot is a very good reason because you just have to deal with it on the spot when it happens.

So it was a bit of a different kind of surgery from the sort where you know you’re going to take out half of somebody’s colon for cancer or something, you know a lot of it’s very similar but there are a lot of very different bits and that…not knowing exactly what you’re going to find ‘til you get there is writ large in trauma surgery then and of course now.

On public engagement in medicine

Yeah, well, the aim of public engagement to me is to…is really to bring about a dialogue between different groups of people.  So, I think traditionally public engagement has often been about scientists or whoever explaining what they’ve already done to people who don’t know and giving them information but I see it very differently really, I see it much more as a sharing of expert perspectives.  So I have an expert perspective of course on what it is to operate on people, say, or what it is to teach other people to operate, that kind of thing, but other people, everybody has a different perspective of what it is to be operated on or have someone in the family who’s had an operation or is going to have an operation or looking after someone who has so this world of surgery, it looks…it affects us all,  or it could do at any time, and so the way I see public engagement is a way of bringing out into view practices that are normally hidden; most people don’t get the opportunity to go into the operating theatre and have a go, see what’s happening, try it out, you can’t do that and for very good reasons.

But the stuff I’ve been developing around public engagement, a lot of it has been using simulation to create very realistic operations, for example, where you have a group of people who normally do that in their day job in the operating theatre, so real surgeons, real anaesthetists, coming and showing what they do with very realistic models and then inviting members of the public to come and put on a gown and gloves and feel what it’s like to be a part of that team and then to have a discussion and which says OK, we’ve shown you what our world is like from our point of view, now you tell us how you see it from your point of view, you tell us things we might not have thought of that you can make us think differently because you’ve got a different perspective, your perspective is a patient’s perspective, a carer’s perspective.

And I think that also applies to science because very often the science that goes on, you don’t hear about it until it’s been written up, it’s in Nature, it’s on television or whatever.  But by that time, in a way, a moment has passed because it’s already been done, and one of the things that excites me particularly and that I’m exploring with my Wellcome Engagement Fellowship is the idea of bringing out science while it’s still happening, showing it to people and saying OK, you tell us things about this that we might not have thought of, you tell us what this is like for you.  So for instance, recently at the Barbican we did a simulation around brain surgery where we got members of the public to come and drill holes in people’s heads with real brain surgery equipment; it sounds a bit grisly but it was very effective, very powerful.  To relieve a blood clot in somebody’s head you drill three holes in their skull and then you join between the holes with a saw and you take out a flap of bone and there’s the blood clot and you remove it; that’s a bit over-simplified but that’s the principle, and neurosurgeons have been doing that for years, making three holes, cutting between, taking out the bit.  When we were there, an engineer in the audience said, why do you make three holes, why these days, why don’t you just make one hole and then cut around where you need to go with a jigsaw, why do you need three holes?  And so I started thinking well, you know, there may well be very good reasons for that or it may be that it’s done like that ‘cause it’s always been done like that.  But it’s a really interesting question to ask; it’s not a question that brain surgeons or people in the medical world usually do ask because they’re used to how things are, they don’t come from the outside and say, couldn’t it be done completely differently, and it’s that process I’m getting at, where if we’re bringing out a piece of biomedical science and we ask an aircraft engineer or a medieval historian or somebody who works in the community, or whatever, whoever it might be, we might get completely different questions which make us frame our research differently.  And if that happens while the research is still going on rather than when it’s finished, I think that’s a really valuable sort of different way of looking at things that we don’t have because we tend to sit in laboratories or operating theatres or whatever that other people can’t get to, and so we tend to think within our own frame, we don’t think radically outside it.

On reactions to simulated surgery

Well, sometimes people say “urgh” to begin with and sometimes they feel sick, sometimes they feel faint, sometimes they do faint, but usually they get over that pretty quickly and most people are very surprised, they’re surprised at what it feels like to be working very closely with a group of people.  Because normally when we’re talking to someone in a cafe or the pub or something we’re, you know, reasonably close together but not absolutely next to each other, but when you’re operating, you’re absolutely squashed up with three or four other people, staring intently at a very bright light at a particular thing or looking on a screen at a view of a keyhole operation, but you’re standing in a way that would never normally happen socially and you can’t understand people, you can’t read people’s faces in the normal way because people are wearing masks or they’re not looking at you, they’re looking at what they’re doing.  And so one of the things that strikes people, I think, is how you’ve got this very sort of tightly knit group of people who are doing very, very delicate, highly synchronised things all together, but yet how it’s possible to bring somebody who’s never been there and get them to take part.  Members of the public come and a surgeon gives them a retractor, a curved bit of metal to pull something out of the way, for instance, puts that in where it needs to go,  hands that over to the person who’s joining and says OK, hold that there, don’t let it move.  And something simple like that gives you a real sense of being part of an operating team but without having to have all that specialised knowledge that allows you to do the difficult extra bits.  And so I think people say afterwards that this is an experience that’s completely different to watching it on television or reading about it or seeing it at the cinema because you’re actually in there, or you’re watching other people coming in there, you’re seeing something that’s evolving in front of your eyes rather than just looking on a screen at something that’s already been filmed.

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