Intended for healthcare professionals

Opinion Dissecting Health

Scarlett McNally: Shared learning and trust are a gift from patients

BMJ 2024; 385 doi: (Published 21 May 2024) Cite this as: BMJ 2024;385:q1116
  1. Scarlett McNally, professor
  1. Eastbourne
  1. scarlettmcnally{at}
    Follow Scarlett on X @scarlettmcnally

Some of my most heartfelt gifts from patients have come with the words, “It’s OK, Doctor, I know you did your best.” Around 12% of operations have a complication,1 many medicines have side effects, and 11% of hospital patients have a prescribing error.2 We know that adverse events in healthcare happen, but listening to and learning from patients can improve outcomes.

Surgeons such as Henry Marsh and Atul Gawande have written eloquently about feeling haunted after adverse events in their patients. René Leriche is quoted as saying “Every surgeon carries within himself [sic] a small cemetery, where from time to time he [sic] goes to pray”3; and Albert Wu describes the surgeon as the “second victim.”4 Only recently has the impact of adverse events on surgeons been analysed, finding significantly worse effects from errors or avoidable complications than from unavoidable complications.5

A few years ago, when I was director of medical education for my trust, I got sent every complaint involving doctors, many of which were harrowing. The main motive for patients and their families in complaining was to provide a learning point to stop something similar happening to someone else. Seen from the outside or with hindsight, a patient’s trajectory can seem inevitable—as though every patient is on a conveyor belt of symptoms, investigations, intervention, and recovery. Initiatives such as “high volume, low complexity” hubs6 can reinforce this picture. But most surgical patients have complexities or multiple comorbidities.

We need a clearer understanding and more transparency with patients. The focus on communication is often on kindness, listening, and empathy. But perhaps we need to be clearer in stating whether an intervention is standardised or complex, while exploring alternative and non-operative options.

Options and alternatives

Two areas need focus. Firstly, we know that we can reduce the risk of complications by around 50% and the length of stay by 1-2 days through seven interventions: smoking cessation, exercise, nutrition, senior or medication review, alcohol reduction, psychological preparation, and practical preparation.7 We need the phrases, systems, interventions, and staff to provide information and to have these conversations with patients at the right time.

Secondly, many patients wouldn’t want to proceed with an operation if they knew what postoperative life or complications were really like. “Shared decision making” has been endorsed by NICE since 2021,8 but do we really do this? Surgeons talk about benefits and risks, but we sit in isolated clinics, with limited time to challenge any inflated expectations of surgery. Patients should be empowered to explain their thoughts and values and to ask about “BRAN”: benefits, risks, alternatives, and non-operative options.9 We need more clinic space and better teamwork so that other staff can have discussions with patients, encourage optimisation, and highlight the practicalities of alternatives—but this should be adjacent to surgeons and within our clinics, to ensure efficiency and clear understanding across professional groups and with each patient.

As a new consultant I was taught about the importance of BRAN. Twenty years ago I explained to an older lady what surgery her elbow needed, and we signed a consent form. She returned a few days later—with a kind gift of a pretty plastic flower that still sits on my desk—to say that she’d given it some thought and decided to take the non-operative option, explaining that she could manage without an operation. It’s a humbling reminder that every encounter with a patient is valuable—an opportunity to share trust, learning, and occasionally a gift.


  • Competing interests: Scarlett McNally is a consultant orthopaedic surgeon, deputy director of the Centre for Perioperative Care, and president of the Medical Women’s Federation.

  • Provenance and peer review: Commissioned; not externally peer reviewed.