WHY SURGEONS OPERATE
A distinguished Canadian surgeon describes the subtle forces that impel doctors to reach for the scalpel — whether the patient needs it or not
Dr. Benge Atlee
Dr. Atlee is emeritus professor of obstetrics and gynecology, Dalhousie University, and is associated with Victoria General and Grace Maternity hospitals, Halifax. He is an author of short stories and science articles.
IS TOO MUCH SURGERY being done? This question disturbs every thoughtful and conscientious surgeon, not only with regard to the activities of his more itchy-fingered brethren, but concerning his own practice. It should also disturb every patient who enters the operating room. A considerable number of pressures combine subtly yet powerfully to urge every surgeon to do the thing he has been trained to do—to operate. No matter how sensitive his conscience or high his sense of responsibility, he cannot entirely escape this pressure, and probably few, if any, of us have fully and consistently resisted it. What are some of these pressures that constrain the surgeon to overoperate?
The glamor boys of medicine
To all but the most highly civilized medical minds, surgery is a most attractive way of dealing with disease. In an age when miracles no longer seem to happen, surgery allows one to do things to the human body that partake of the miraculous, and in effect is one of the few remaining ways in which man can play God. As a result the surgeon has become the glamor boy of medicine, not only to his colleagues in other specialties but to the public. Here is a patient with a ruptured duodenal ulcer, an intestinal obstruction, acute appendicitis, or obstructed labor, and likely to die but for the operation that is almost certain to cure. This cure is quick and more or less complete. There is no long dieting, no continual taking of pills and mixtures, no necessity of giving up pleasant habits and adopting an austere way of life. No wonder it appeals to the suffering public. No wonder the young medical student is strongly attracted by the field of surgery.
Nor can the surgeon fairly be denied credit for what he has done. In the last 150 years his advances have conferred a tremendous boon on the public. The point has now been reached where every last cavity and part of the body has been explored, including the heart itself, with amazing results. These results, in terms of lifesaving and the relief of suffering and disability, are incalculable.
Yet, the surgeon is essentially a doer rather than a thinker, materialistic rather than imaginative, more apt to take himself seriously than to display a sense of humor, impatient for the quick effect rather than reflective. He lacks as a rule that capacity for contemplation and self-
FHE OVER-EAGER SURGEON
examination by which he might become mature. For instance we surgeons, of all the practitioners of medicine, find it hardest to accept the psychiatrist and his concept of disease, to entertain the idea that there are more things in heaven and earth than are dreamt of in our philosophy. Because of our urge to seek a cause for all ailments in some palpable and obvious derangement of the human cell, we often fail to realize that there may be impalpable derangements of such cells due to the emotions, which can mimic practically any ailment. This factor, I am sure, has tended to increase considerably the number of hasty and ill-considered operations.
I don't think we should blame this obsession entirely on the surgeon. All doctors are so affected, and only the wisest and shrewdest rise above it. A young student entering medicine is immediately set in quest of this human cell and its palpable ailments. In anatomy, physiology and pathology, the earliest subjects in his medical curriculum, his mind is focused on the cell and its physical derangements. When he comes to study the effects of derangements of the psyche on the cell, when it is suggested that a large number of human ailments begin in the psyche rather than the cell, or at least are a combination of the two, he finds it difficult to accept this concept and often closes his mind to it.
They shrug their shoulders and start cutting
Nor can this be wondered at when he encounters among his teachers those who, if they do not actually scoff at psychiatry, appear to hold it in some contempt. As a result, most doctors seek first the tangible deranged cell and only entertain the possibility of the deranged psyche when they have become completely baffled. In the course of reaching such bafflement they may actually have done one or more operations.
One of the real difficulties facing a full acceptance of psychiatry by the other branches of medicine, including the general practitioner, is that modern psychiatry is not only a new field—dating back little further than Freud— but that the psyche is much more elusive than a cell which can be seen under a microscope. As a result psychiatry has made, and will make, many mistakes, will push into blind alleys, and develop erroneous theories. All this causes it to be continually suspect in the eyes of the profession.
What is even worse is that so many of psychiatry’s concepts are expressed in language so complex, so exotic and abstruse that most doctors regard it as gobbledvgook. T his jargon is difficult even for psychiatrists to grasp.
Diagnosticians often find themselves confronted with English words that convey no real meaning and are in effect pure psychiatric jargon; surgeons simply shrug their shoulders and start cutting again. This also, I am convinced, is responsible for a fair amount of unnecessary surgery.
A passing pain often condemns a healthy appendix
In the past, a doctor became a surgeon by process of trial and error. Armed with his medical degree and an extra supply of initiative and courage, he began to operate on his own emergency cases. As his experience and facility increased, he extended his scope to more and more operations and, though still doing a fair amount of general practice, was presently accepted as the surgeon in his community. Only in the larger cities, and when he became a member of a teaching hospital, did he limit his work to surgery alone. He was, apart from an occasional visit to such centres as the Mayo Clinic, and various medical society meetings, entirely self-trained. It became easier and easier for him, when faced with some vague condition in the abdomen, to open it to see what he could find. Lacking sound basic training in the principles of pathology and surgery, he performed many unnecessary operations. This factor is still at work in large areas of Canada.
Until very recently, if a person developed chronic pain in the right side, he was likely to lose an appendix which later was found to be normal. If a child had large tonsils, whether diseased or not, out they came. It is not so long since a noted London surgeon was removing most of the large bowel to cure chronic constipation, and urologists were suspending every movable kidney that came into their purview. By and large this overoperating is due to ignorance or lack of experience. It is disappearing as hospitals become more insistent that doctors who operate undergo proper basic training as interns and residents and pass searching examinations leading to certification as specialists in surgery. It could disappear further.
It may seem incredible to a logical observer but few hospitals or surgeons attempt systematic follow-ups of patients to determine the results being obtained by operations. Occasionally, an individual investigator will do so with regard to a certain operation and write a paper on it for the medical journals, but such efforts are haphazard and incomplete. This research is extremely time-consuming and few individual surgeons can afford either the time or the clerical help necessary to carry it out properly. It should be the business of the hospital; every hospital where surgery is being performed should adopt such a
DOES WOMAN GRAVE HARM
checking procedure, and the results should be presented periodically at meetings of the medical staff. In fact, it should be a routine practice not only in surgical cases but in all cases treated in hospital. The surgeons are not the only ones who don't know what results they are getting. 1 am sure such records would prove most revealing and thought-provoking. I am sure they would show, for instance, that all too many patients who seem to do well in hospital following treatment or operations, find their symptoms returning a few weeks after they go home.
Of course anything but the most comprehensive follow-up, including frequent examinations, might not pick up all the facts. Let me illustrate the pitfalls in the search for truth. Within ten days two women presented themselves in our service who had had their wombs suspended bv operation because the wombs were tipped, or retroverted. One of these had returned after twelve years, having developed recently the very same symptoms for which she had originally been operated on with complete relief. She was sure her womb had become untethered and wished us to rehitch it again. But when we examined her we found the womb was, in fact, being held in excellent position. “But it must have broken loose!" she protested. "I've got exactly the same symptoms — exactly!" This naturally caused us to wonder if the suspension we had done twelve years earlier had been necessary.
The other woman, who was being treated this time for another condition altogether, also had had her tipped womb suspended some years before with complete relief of symptoms. Yet, when we examined her now we found her womb was tipped again, and could only have torn away from its moorings a few days after the operation. In other words, whatever the operation had done, it had not cured the tipping. If she had gone and bathed in the Jordan she would probably have got as good a result.
One way to deflate surgery’s self-esteem
All this shows how difficult it is for doctors, even when they carry out a follow-up, to be sure of the results they are obtaining with surgery, of how these results are obtained. Yet, despite the pitfalls and difficulties of properly interpreting the follow-up, I am convinced that if it were introduced universally in our hospitals we would be wiser doctors and would have a less inflated opinion of the value of our surgical procedures. This deflation would not only result in fewer operations; it would be good for our souls.
Women are particularly vulnerable to the surgeon with the impatient ego and the itchy fingers. For one
thing they seem more prone than men to chronic pelvic pain of indeterminate origin. Consequently, a deplorably large number of women are operated on for chronic appendicitis in whom a normal-looking appendix is found after the abdomen has been opened. The surgeon then reaches into the pelvis, dredges up the ovary and proceeds to remove part o*r all of it on the theory that since the appendix didn't cause the pain it must have been the ovary. If all the normal ovaries removed or tinkered with since surgeons started to open the abdomen were laid end to end they would extend almost as far into space as Yuri Gagarin traveled.
The ovary is rarely painful—but out it comes
I have felt for a long time that providence played a dirty trick on women when it hid their sex organs inside the abdomen, instead of allowing them to be worn outside. We very seldom hear of men having their testicles removed, and I am sure that this is largely because of the location of those organs and not because they are less sensitive to pain than the ovary. Yet even among women it is commonly held that a pain in the side is ovarian, and they will come to us with the categorical statement: "It's my ovaries, doctor." It is my experience that the ovary, like the testicle, is rarely the site of pain—and that any pain, acute or chronic, felt in their location is almost always due to some other condition.
Some years ago 1 was embroiled in a controversy in the correspondence column of one of the medical journals over the matter of the tipped womb, or retroverted uterus. Yly contention was (and is) that the tipped womb, which seems to be present in twenty percent of the female population, very seldom causes the symptoms it is credited with, and that an operation rarely alleviates these symptoms. One of the best-known of the older school of American gynecologists wrote me a chiding personal letter— more in sorrow than in anger—pointing out how unfair I was to withhold from suffering women this operation that he had performed with gratifying results (to him) on more than 2,000 cases. Today the indications for correcting a tipped womb by operation have become much less frequent as more and more gynecologists have had the experience I had with the two cases previously mentioned. If one of us had been bemused enough to perform it 2,000 —or even 200—-times he would certainly not brag about it.
Aside from the surgeons’ ignorance of the results of their own work, there is another less reputable cause of unnecessary surgery—money. The following, an old chestnut among medical men, illustrates how it works. Dr. A.
THE UNWORTHY MOTIVES
says to Dr. B.: ‘T see you operated on Mrs. Brown yesterday. What did she have?”
“A hundred dollars.”
“Yes—but what did you operate for?”
“A hundred dollars.”
Surgeons are human: they, too, like money
A few years ago a woman came to me who had had twelve operations performed on her by the same doctor. The cause of this extraordinary saga of the knife was a chronic pain in her side. She still had the pain (intensified) but in addition she now had several other pains and aches and was, in effect, not only a surgical hut a nervous wreck. Honest curiosity on the part of her doctor might have excused the first two operations, but only God, in 1 lis infinite mercy, could forgive the rest, since it is almost impossible to explain them away on any other basis than that she happened to have a hundred dollars each time.
While we surgeons do not like to admit the monetary factor, we have had to face up to it. Only recently. Dr. Leonard W. Larson, the newly elected president of the American Medical Association, was quoted in the New York Limes as follows: “The percentage of doctors who do not observe the law, or the dictates of their conscience is infinitesimal . . . However, that tiny fragment must be excised from the body of medicine, lest it grow like a cancer and thus pollute and corrupt the entire profession.”
While 1 can't go along with Dr. Larson's understating adjectives “infinitesimal'' and “tiny,” he must be given credit for admitting a situation that always arises in the face of the dollar bill. After all, we surgeons—despite rumors to the contrary—are human beings, subject to the same temptations, and the same yen to yield to them, as the rest of the race, although 1 doubt that we do yield to the extent that those in other fields do. I f you live—as we do— in a society where the size of your income largely determines your place in the sun, and if the size of your income depends on the number of operations you do, even the surgeon with stoutest surgical conscience tends to reach for the knife when confronted with a patient that pills might, but surgery certainly would cure. And since, among surgeons, as among all other human beings, there are those with little if any conscience, the Mrs. Browns arc likely to continue to undergo unnecessary operations. Even one of the disciples betrayed his ideal for thirty pieces of silver; the prevailing fees for major surgery are considerably higher than that.
But we are trying, not only to restrain our personal
weaknesses in this regard, but to set up machinery to limit the likelihood of our succumbing. In our best hospitals there are committees that scrutinize operation records in an attempt to ensure that only necessary operations are done, to look for explanations for any apparently unnecessary operation, and to bring such cases to the attention of the surgeon concerned and the whole medical staff for discussion. In addition, all our hospitals are inspected by experts sent by the Canadian Hospital Association to investigate—among other things—this very matter. However, it will never be possible to eliminate the man who will operate for a hundred dollars. The best we can hope for is that we can set up in our hospitals such safeguards as will make it more and more difficult for him to operate following a purely monetary diagnosis.
This brings us to the kernel of my case. How can we reduce the number of unnecessary surgical operations being performed? What are these safeguards that I believe must be introduced into our hospitals? In the first place, in all our hospitals we should enforce effectively and conscientiously those regulations which only the best hospitals already have adopted. This would help to clean up some of the worst aspects of the situation, even if it is a negative, thou-shalt-not approach to the problem.
One answer: insist on consultation
In the same category would fall a regulation which I feel must sooner or later be adopted : no operation to be performed without prior consultation with at least one other qualified surgeon. This should apply to acute as well as chronic cases, since I have known of many patients rushed to hospital for emergency appendicitis operations which revealed normal appendixes. Granted that, where there is any honest doubt in the case of acute appendicitis, it is better to operate than dally. Nevertheless, I am sure that consultation in such cases would prevent a fair number of unnecessary operations. The argument that there is no time is not valid except in the rare case of bleeding so excessive, internal or external, that any delay would be fatal. All good maternity hospitals insist on consultation before a Caesarean section is done, and the situation for which this procedure is required is often extremely emergent. If it is good practice to insist on consultation here, it should be good practice to insist on it for all emergency procedures.
But where an operation is nonemergent, ample time is available for reflection. I feel sure that eventually we will require that all candidates for this type of surgery
GLAMOR AND COLD CASH
shall first go before a consultative group consisting not only of at least one other surgeon, but also of an internist, a psychiatrist, any other specialist into whose field the patient's condition might fall, and the patient's general practitioner when he is available. Such a body would not only cull out the unnecessary operation; it would also come as close as possible to finding out what procedure other than surgery offered as good a chance (or better) for a cure.
Another answer: deglamorize surgery
Then there is the need to take some of the glamor out of surgery, not only in the eyes of the medical profession but in those of the public. Let us give the surgeon his due credit: his exertions have expanded amazingly the curability of disease. But this credit really belongs to those surgeons who pioneered new and better operations, or for the first time successfully invaded hitherto unexplored parts of the human body. The rest of us—at least ninety percent—who spend our days doing operations that have already been perfected and to which we add nothing but our facility in performance, are in a different class and should be so considered. We may be good technicians but we remain technicians, and our skill—though perhaps on a somewhat sublimated plane—is of the order of plumbing, carpentering, or electronic mechanics. It would be better for all concerned if this were recognized and surgery were placed in its proper perspective against the work of other members of the medical profession. It is a far more difficult undertaking, and requires a far higher type of intelligence and insight, for a psychiatrist to uncover those elusive emotional factors which produce symptoms, than for a surgeon to open the abdomen and take out a gall bladder. Yet the psychiatrist is considered anything but the glamor boy of medicine, and this I am sure indicates a lack of civilized perspective. I am equally sure that if the glamor were taken out of surgery, less surgery would be done.
It might aid this “deglamorization" if the recompense of the surgeon were brought more into line with that of other workers in the medical field. If a man has a vested interest in surgery he will do surgery: if the amount of surgery he does plays no part in determining his income he will tend to try to find some less arduous method of dealing with disease. It might be a good idea to put him on a salary, as is the case with doctors engaged in public health activities. It cannot be held that the work of the surgeon has conferred any greater benefits on humanity
than that of the public health man: the lives saved by surgery are few compared with those spared by inoculation against smallpox, diphtheria, polio, and with the various measures that are wiping out diseases like malaria, typhoid, and yellow fever.
But the real need is for something more positive than policing regulations. We must find other cures than surgery for human ills. We must furthermore find out how to prevent those ills for which surgery now seems the only answer. For instance, some better method of treating cancer must be found. While surgery is often the best we have to offer in the case of malignant tumors, the cure rate is too low to be really satisfying, and the deformities produced are another drawback. What is more, we have gone about as far as we can in perfecting the techniques required in this type of surgery. The hope of the future is the discovery of some nonsurgical treatment for this widespread and lethal condition.
The same is true of bleeding in women that is not due to tumors or pregnancy and now accounts for a considerable amount of the surgery done on women. There can be little question that we are hovering on the discovery of some more effective hormone-like substance than any we have now, which will act as an efficient menstrual regulator and so make unnecessary many pelvic operations.
Until then, the question lingers
Nor is it unlikely that we will, through the discovery of the real cause, find methods of preventing such common conditions as gastric ulcer, gallstones, appendicitis, and so on. We may even learn to prevent the various congenital deformities such as heart conditions, harelip and clubfoot when we pursue further the effects of the various virus diseases as they affect women in the early stages of pregnancy. We know already, for instance, that German measles when contracted in the first two months of pregnancy is apt to cause deformity in the baby.
It is therefore not impossible to foresee that in the end surgery will only be done on any large scale for those traumas that result from accident, and a few other conditions that escape some future day’s non-surgical methods of prevention and cure. And when that day arrives who can deny that we will look back on the present era as essentially barbarous?
In the meantime, the question will continue to lurk in the back of every thoughtful surgeon’s mind: Which is better — to operate for a disease; or to find a simpler and less devastating way to cure it? ★