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Feedback Loops

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I swear by Apollo the Healer, by Asclepius, by Hygieia, by Panacea, and by all the gods and goddesses, making them my witnesses, that I will carry out, according to my ability and judgment, this oath and this indenture.

To hold my teacher in this art equal to my own parents; [--]; to consider his family as my own brothers, and to teach them this art, if they want to learn it, without fee or indenture; to impart precept, oral instruction, and all other instruction to my own sons, the sons of my teacher, and to indentured pupils who have taken the physician’s oath.


— The Hippocratic Oath

 

 

Feedback Loops — Chapter 1: Roll Call

 

"Staff exit at five?" John asks, pocketing the car keys as they begin the walk from the staff garage to the hospital.

He receives a frown and then a nod from Sherlock. "I should have the DBS stimulator removal done by then unless the infection has disintegrated the whole thing to pieces. Thank god I won't have to operate with the patient awake, could be quite a mess in there."

Two neurosurgeons at King's College implant deep brain stimulators to treat various neurological issues and treatment-resistant OCD. Sherlock is not one of them; the procedure is not complex enough to have tickled his fancy, and at the meeting where the unit's DBS program was being planned, everyone had laughed at the idea of him doing awake craniotomies. To adjust the stimulator, the patient is awakened during the operation and the surgeon communicates with them as they operate to make sure no other areas than the target spots are being affected; brain tissue does not feel pain, but understandably being aware of what is going on can be a distressing idea for the patient and requires outstanding interpersonal skills from the whole team. Even though Sherlock wasn't interested in learning the DBS installation procedure, it still stings that he had been cast aside because of who he is.

His tumour operations sometimes do call for an awake craniotomy approach, and to his annoyance, Lestrade has told him that for those cases, he needs to pair-up with another surgeon, or have John do the anaesthetics. Since Sherlock would loathe discussing such an imperative with a colleague, finding a space in John's busy admin calendar for those cases is his only option.

'You'll never be a neurosurgeon, Holmes; the very idea of you doing any kind of clinical work that would involve discussing difficult topics with patients is preposterous,' Cambridge's professor of neurosurgery had told him within earshot of a bunch of other trainees, who had snickered and given him snide looks as he headed out of the ATC4 lecture hall at Addenbrooke's Hospital.

Who the hell has the right to tell someone else what they can, or can't do? Isn't the very purpose of training someone to teach them to overcome their particular challenges? Do teaching staff not understand the fragility of the confidence of their students? Shouldn’t they take more responsibility for the consequences of such throw-away comments?

Idiots.

Thankfully, Sherlock had been able to obtain a recommendation letter from one of the other professors in Cambridge's renowned neuroscience centre—one who happened to have studied at Oxford with Mycroft in the same college. Sherlock would have preferred to get accepted into training with his own merits—he's against nepotism on principle because the result of it often is that the most competent candidates get side-lined—it was just that he didn't see many other options of getting where he wanted to be.

Once within the walls of the National, Sherlock watches John heading out of the main entrance hall and towards the Bessemer Wing. Just as John is about to grab a door handle, a young woman with a stroller practically crashes into both him and the door. She drops a bag and nearly the baby she holds in her arms. Her hair is a mess, she's laden with various other bags, and the infant in the stroller is now wailing and wide-eyed; the stroller is turned just so that Sherlock can see the tears and snot running down the face of the dark-haired child.

"Can I give you a hand?" he hears John interrupt the woman's florid apologies.

The mother drops what looks like a backpack on the floor and looks like she wants to hug John. "Thanks. It's been a bloody nightmare of a morning."

"Heading to the paediatrics unit?" John asks, then looks startled as it is the baby the woman shoves into his arms and not a bag.

The toddler in the stroller is still wailing, and Sherlock has to supress an instinct to leave, or to shut the noise out of his head by pressing his palms to his ears. 

"Yeah, Monet's got a check-up with our diabetes doctor, don't you?" she learns over the stroller and plants a wet kiss on the toddler's forehead before attempting to rearrange her things. This at least turns the screaming into a sorrowful snuffling.

Monet? Christ, Sherlock thinks, knowing full well the burden of being saddled with a strange first name. Well, he'd been called by the first of his three first names—William—for most of his youth, but it had never felt like him. He must have been destined to be a Sherlock, despite his parents' efforts to make him sound like everyone else. He isn't like everyone else, so a strange name doesn't add much to the trials he has to go through which normal people can just sidestep.

He should be going since he is on ward round duty this morning—boring!—which he needs to be done with by lunchtime because he's got a summons to go see Greg at noon, but he finds himself highly distracted by the sight of John holding the baby. John is saying something to it—Sherlock can't hear what exactly, but it looks vowel-heavy, possibly a nursery rhyme. He has grabbed the baby's chubby little hand and is swinging it back and forth. Sooner rather than later, he manages to coax a giggle out of the child who starts frantically kicking against his stomach. John pretends to get winded by this and the woman gives him an appreciative glance.

"Ooh, this one'll be a Beckham yet!" John exclaims.

Sherlock doesn't know what a Beckham is. Presumably some brain-rotting children's TV series?

The mother holds out her arms and receives her child back from John. "Thanks, you're a star."

John then helps her arrange the rest of her bags on the stroller and on her shoulder.

She glances at the wall clock behind them in the main hall. "Shit, we gotta run. Have a good one!"

John holds open the door for them, and walks down the corridor after the troupe, soon disappearing from view.

Sherlock, however, is frozen in place, because an epiphany has hit him like a freight train. Why has it never occurred to him to ask this question before? He had always assumed it was something to be dealt with in the future, but John is approaching the age of forty. Surely, he has considered the topic by now. Had he discussed it with Molly, his therapist? Why hasn't he raised the subject with Sherlock? He wants to kick himself for failing—yet again—to realise such an obvious, important issue needs to be addressed. Because it has to do with relationships, despite John's assurances that he does fine in the one they are in, Sherlock knows that this is his weakness, his deficit that he cannot make sense of such matters without someone explaining them to him.

And, now he's gotten lost in self-loathing instead of addressing the actual question. Which is—obviously—this: does John want children?

 

-o-0-o-0-o-0-o-0-o-0-o-0-o-

 

John is just about to grab his jacket and head down to the cafeteria for a working lunch with the head of the acquisitions committee. The purpose of their rendezvous is to see about getting new anaesthesia workstations in the trauma ORs. He's just about to push open his office door, when his mobile rings.

"Hey Greg. I was just about to get some food."

"Never mind that. I'm going to need your glare in five minutes."

"Excuse me?"

"I need that glare of yours, you know, the one that always keeps him from throwing a hissy fit."

John sighs. It's becoming rarer for people to request that he do a bit of Sherlock-whispering, and he really shouldn't reinforce the idea that such a thing is even needed, but if Greg Lestrade, the head of neurosurgery, requests his help then shit must be truly about to hit the fan. "What's up?"

"You know that this year's Match results have come through, don’t you?"

"Of course."

"Due to that one weirdo last year who kicked up a fuss when we showed him the door, we're facing an inspection this year from the GMC over training conditions. To show them that we're a fully functioning training unit we need everybody on board with a maximum number of registrars and SHOs under their wing—and I do mean everyone."

John grips the phone tighter. "Greg, no."

"That would be Greg yes, I'm afraid." His colleague sighs. "Even Sherlock."

-o-0-o-0-o-0-o-0-o-0-o-


"We had an agreement!" Sherlock snarls, slamming his palms on Lestrade's desk. "My time is too valuable to be wasted with fumbling idiots. The deal we made was that, as long as I agree to run the ward on two days a week, I will not be obligated to put up with––"

"––interns and junior doctors. I remember. But, proper neurosurgery registrars and fellows are a different matter, and I need all hands on deck," Greg argues while John watches the proceedings from the doorway, arms crossed.

The occasional medical student teaching round at the ward is bearable, as long as Sherlock doesn't have to get to know any of the students beyond glancing at their name tags. When he's in a good enough mood, he might even whip up a mini-lecture on whatever his brain has latched onto recently, and it's nice to bask in the limelight for a moment. A medical student is in sufficient awe of any proper doctor, that they are positively star-struck by him, which helps them ignore his faults. On the other hand, FY1s and FY2s—meaning relatively newly graduated doctors—are not a good fit to be taught by someone who has no patience and no understanding for those inferior in intelligence and skill, never mind that everyone has been a beginner sometime. Trainees shouldn't be allowed near him; he doesn't want to inadvertently say something that will feel as crushing as the things he had been told early into his career. Someone with more finesse and skill in being tactful and supportive needs to handle such matters. Not him.

It irks him that Lestrade has summoned an audience. Everyone always assumes that John's presence is like a tranquiliser dart for him, making him malleable. "Registrars and fellows can be perfectly well trained by the average neurosurgeon the peak of whose career involves bread-and-butter cases. You don't need me to show these people the ropes, unless you want me to inadvertently hang them. It's a waste of everybody's time."

"I don't have a choice. The Board has to deal with the upcoming Royal College inspection, and the notion of a consultant deemed unfit to teach might undermine our education funding."

Unfit. For once, Sherlock agrees with his boss.

He crosses his arms, a frown twisting his forehead into a furious landscape of dismay. "Then make it temporary. Hire some locum you can parade in front of the Royal College brass and kick them out after the inspection is done."

John sits down at the edge of Lestrade's desk, presumably to form a unified front. "They do inspect the trainee paperwork. They'd spot that little dodge very easily."

Sherlock wants to protest some more, but that would lead to question starting with the word 'why', and he isn't willing to talk about why it's just a knee-jerk response for him to refuse.

Maybe the only way out of this is to sacrifice one trainee to demonstrate what a disaster Lestrade and John by extension are insisting on cooking up. Let them see.Let them all see what happens, when someone's career is put in the hands on a single person, and that single person happens to be him. He doesn’t want the burden of having to monitor everything he says. There are no scripts to handle the situations training someone would land him in, which is why he has always avoided it until now. If they are stupid enough to disregard his warning, then they get what they deserve.

So, he huffs and squares his shoulders. "Then, at least give me someone adequate."

Greg digs out a pile of applications carefully organised into a fan shape.

John is frowning at Sherlock, probably surprised at how quickly he had yielded. This will reinforce John's thinking that his presence can keep Sherlock from blowing a gasket.

Maybe it does.

"You get first dibs in picking one," Greg placates.

Sherlock shoves the papers around until he finds the thickest manila folder. He leafs through it and then shoves it into John's hands. "This one, then. Perfect Match score, thrice the number of recommendation letters compared to the other applicants, two research papers published in reputable journals. Can't be entirely incompetent." This trainee looks like someone who just might be able to walk away unscathed once this stupid arrangement implodes in everyone's face.

Greg spreads his arms. "Fine. I'll also need you to pop into the morning assembly on the first day of the induction week," he says with a strained expression, probably preparing for another argument with his moody star consultant.

"What on earth for?"

"It's a show of solidarity, a welcoming gesture of us all being there to meet with our new trainees."

"You have blackmailed me into dealing with one trainee; I see no reason to waste time the others. And, as you and I already know my colleagues are never exactly happy to see me."

"Think about how you would have liked to be treated during your first day as a neurosurgical trainee. If the person you were assigned to never showed up, you’d have felt embarrassed. "

"I didn't need mollycoddling, welcoming gestures or an induction week. They should be proving their worth to us, not the other way around," Sherlock argues, arms crossed and eyes narrowed in his usual posture of high-calibre scepticism.

"Monday the fifteenth August at 7:45 at the smaller basement lecture hall. That's an order."

Sherlock huffs, and marches out.

 

-o-0-o-0-o-0-o-0-o-

 

"That went well," Greg comments bitterly to John while shaking his head. "Should we give this future reg of his The List?"

John shakes his head. "I don't even really approve that they give it to the new nurses."

The List, also known as the Holmes Codex, is a collection of pointers for those previously unfamiliar with Sherlock's preferences and demands. The collection of lore includes clinical pointers, a schedule of Sherlock's usual weekday routines, his tea and coffee and instrument and glove preferences, a list of acceptable and unacceptable music choices, and random notes on preventing getting shouted at in the OR or chewed out on the ward rounds. The last piece of advice on the list says: 'When all else fails, call Clinical Director of Operative Services John Watson'.

In John's opinion, it shouldn't be acceptable in this day and age that nursing staff would be exposed to the shenanigans of a moody surgeon, but even the hospital Trust Board has been willing to make certain concessions to keep their neurosurgical star happy. One of them has been that he is allowed to shirk the duty of having a Specialist Trainee on his service.

What irks John the most is that he has heard corridor rumours that he had been the one to condone the existence of The List, since he's Sherlock's partner. Some people even think he wrote the damned thing. It doesn't exactly help that Sherlock is not above using his name as leverage when he wants to crunch a decision through the slow wheels of hospital bureaucracy. John has been trying to encourage him to sort out his own issues—to finally take full responsibility over even his most problematic patient interactions. They’ve been through a lot over the past year, what with his injury in Afghanistan and then Sherlock’s incarceration in the halo when he’d broken his neck; they have both had to learn a lot and adapt, so he knows Sherlock is perfectly capable of picking up new interpersonal skills. Their relationship now feels stronger than ever, and Sherlock seems to be more willing recognise his need to adapt to changing circumstances. Maybe this registrar training thing could be the an important step on that road? Stepping into an educator role might teach Sherlock quite a few things about human interactions.

The new House Officers and Specialty Registrars start their training years on 15th August, but their first week will be spent in the inductionGreg had mentioned, which means introducing them to the Trust they will be working in and making sure they have the requisite knowledge and skills to make it through their rotation. That's still a month away; there's plenty of time for Greg to try to hammer into Sherlock's brain that since someone had gone through the considerable trouble of training him, he should pay that debt back in the spirit of collegiality by training someone himself.

John is torn. He knows that Sherlock doesn’t give a toss about educational philosophy or tradition. He never hides his deeply negative ideas about the current training paradigms, and sometimes John wonders what lies beneath all the venom that oozes out of his diatribes on the subject. His arguments are often vague, and he tends to clam up when John asks why he has such a personal beef with the system. Pushing him into this could help him come to terms with those issues—or might just make them even worse?

John peruses the folder which Sherlock had shoved into his arms. Within a minute, he whistles: "Plenty of glowing reviews. Outstanding exam and application scores. And, this poor girl has even specially requested to be assigned to Sherlock for some reason."

Greg leans closer to have a look at the application form John is holding. "Sherlock's right—she's clearly the best of the bunch. We'll just have to hope it's enough to survive him."