Friday, June 03, 2005

You want to know how to make a surgeon angry?

madmarv
Grrr.

I was browsing one of my favorite science blogs, Pharyngula, enjoying PZ's evisceration of a clueless creationist foolish enough to resurrect once again that long-debunked hoary old creationist canard that evolution is somehow not consistent with the Second Law of Thermodynamics, when I saw this in the comments section:
Surgeons and other medical staff are the equivalent of technicians, engineers, plumbers or carpenters. They are not scientists. They are not studying the details of the relevant science. They don't have to understand it - just carry out procedures by rote. Though the ones who do have a clue will be a lot better at adapting to new circumstances because they'll make more correct guesses based on their understanding than the clueless ones will.
I'm sure that my fellow surgeon-bloggers Dr. Bard Parker and Aggravated DocSurg will back me up on this if they see this post, but there are few things you can say that will royally piss off a surgeon faster than a statement like this, which, whether the commenter realizes it or not, relegates surgeons to the realm of not being doctors, but rather to the realm of skilled tradesmen. Don't get me wrong. I have nothing against plumbers or carpenters, both of which represent skilled trades that I can't do. I certainly don't have anything against engineers (a slightly more apt analogy, given that engineering is applied science) either--and indeed one commenter was not happy with engineers being lumped into the group. However, there is so much more to being a surgeon other than doing procedures "by rote" that I had to point out to this person that he clearly had no clue what it took to become a surgeon or what surgeons do. It is true that some of what we do is purely technical. When an oncologist asks me to put a Port-a-Cath (and here) in a patient, I don't need to engage in any heavy thinking or differential diagnoses. I just have to make sure there are no contraindications and schedule the surgery. In addition, although it is true that most surgeons are not scientists, it is also most definitely true that they do need a strong understanding of the relevant science and an understanding of the scientific method in order to evaluate the medical literature and distinguish good studies from the not-so-good. Yes, a lot of what we do is procedure-oriented, but to understand how to do those procedures and, more importantly, whom to do them on and whom not to do them on requires a pretty strong understanding of physiology. We have scrub techs and surgical assistants who can "carry out procedures by rote." Sometimes, they're even technically better than the surgeons with whom they operate, but they cannot take care of the whole patient. That is the role of a surgeon.

We have a saying in surgery: "You can teach a monkey to operate; you just can't teach a monkey when to operate or who needs what operation--or what to do if things are not what expected." To understand that requires a thorough understanding of human physiology, anatomy, and, yes, sometimes even molecular biology. I would also add that you can't teach a monkey how to take care of the patient before and after the operation. People don't seem to realize that surprisingly little of most surgeons' time is spent actually in the operating room doing procedures, usually no more than two days a week. (One of the biggest surprises awaiting residents when they become attendings is how much less they get to operate; when they are residents they operate almost every day.) Only exceedingly busy surgeons spend more time than that in the operating room. Indeed, we have another saying, at least about general surgeons, that "a surgeon is an internist who can operate." I'm not sure I'd go that far, but it's definitely true that surgeons have to understand far more medicine than internists have to understand surgery. Those of us who deal with critically ill patients (as I routinely did until around 6 years ago) need a very strong understanding of physiology and critical care medicine far beyond what most internists ever achieve without undertaking a critical care fellowship.

Perhaps you might think I over-reacted. I rather suspect that the person making the comment had no idea how annoying it would be (although perhaps he should have guessed, as he managed to irritate an engineer as well). However, his further comments tended to make me think that perhaps I didn't over-react as much as I thought I did. His dismissive "not a scientist" attitude towards surgeons in particular (he pointedly didn't mention internists or other doctors in his "not a scientist" category, just "technicians" and "medical professionals") revealed an attitude that is all too prevalent, however, and that was what rankled. On the other hand, he seemed to use the term "technician" as a catch-all insult for any profesionally, scientist or medical who possessed pseudoscientific beliefs. In the way of context, I will point out that the comment happened to have come up in the context of a discussion about evolution, and it's probably true that most physicians don't have as strong an understanding of evolution as they should. Indeed, many of them embrace intelligent design (and here), and fewer than I would like to admit recognize ID as the pseudoscience that it is. The implications of this and why evolution is important for a good understanding of medicine these days will probably be fodder for another post sometime next week, but those are the numbers. I couldn't resist pointing out, though, that there were quite a few Ph.D.'s who have been seduced by pseudoscience, whether it's Michael Behe and intelligent design, Boyd Haley and anti-vaccination pseudoscience, or even the Nobel Laureate Linus Pauling, who, later in life, became enamored of vitamin C quackery. Even a Ph.D. in a scientific discipline is no guarantee that one will never stray from the path of science. Of course, the problem is, those with a Ph.D. who do stray are often the most intransigent pseudoscientists of all.

But I make no apologies for being annoyed. Perhaps I have a thin skin, given the dismissive "just an M.D." attitude I encounter sometimes among basic scientists. Being a surgeon, I get to experience the dismissive "just a technician" (translation: "not a Real Doctor") attitude that some internists have towards surgeons too. Maybe keeping the underdog attitude is good for me. If I'm lucky, it might keep me from developing a swelled head.

32 example(s) of insolence returned:


At 6/03/2005 8:34 AM, Anonymous Otterdoc said...

You've got every right to be rankled by that kind of post. I get just as angry when my clients ask, "Why didn't you become a real doctor?"

-Otterdoc

 

At 6/03/2005 8:36 AM, Blogger james gaulte said...

Well, maybe not "an internist who knows how to operate" but my med school chief of surgery said a surgeon was "a physician who knew how to operate" and he made sure that his residents knew how to read a ekg (not just call it a "four liner".)And by "physician" he did not mean just someone with an MD degree.When I was in practice as an internist and pulm. doc,There was much interaction with chest surgeons and while I could not really tell how well he did in the OR, I could see his post op care and I choose among surgeons-all of whom seemed to have good operative results-those to see my patients who provided the best post op care and saw the patients every day even though I am sure I lost some referrals by not spending the surgery around to more surgeons.

 

At 6/03/2005 8:42 AM, Blogger Internal Medicine Doctor said...

I'm sure the commentor really has absolutely no true understanding of surgery or any other field he belittled for that matter.

Maybe he learned his surgery by watching Grey's Anatomy.

 

At 6/03/2005 9:10 AM, Anonymous Paul said...

Oh! Oh! Oh! That's the kind of person that makes you wish you could reach out and slap them through the ether. I understand why you are upset. I know that if my Engineer buddy ever sees that comment, I wanna make sure I'm not in the same room at the time, 'cause I can see furniture being thrown...

 

At 6/03/2005 9:18 AM, Anonymous Joseph Paduda said...

As one on the "payer" side, I recognize that the insult, intended or not, adds to the divide between payers and providers. It is quite clear that solutions to the big and small problems inherent in US health care are only going to be found if we work together. Pejorative statements and demeaning references set us back.

 

At 6/03/2005 11:24 AM, Blogger Kelly said...

Nurse Kelly worships neurosurgeons (the only type of surgeons I know anything about). I've never once heard a surgeon referred to as a technician or something of that sort. Everyone I know recognizes surgery as a rare specialty reserved for the best-of-the-best.

I hope most of us here wouldn't let a surgical tech use stealth technology to resect a tumor imbedded in your brain.

 

At 6/03/2005 12:32 PM, Anonymous Nicolas said...

This is totally up my alley here.

Believe it or not, I was a surgeon for over 18 years when I discovered (after a serious problem arose at my home)Plumbers make about as much sometimes more money that I do, with less headache and grief!

Surgery years ago was an elite group, nowdays surgeons and interns are turned out at such an incredable rate that they only know half of what they should, or what we were required to know before we opened someone up.

Todays surgeons have become the surgical mechanics of the human body, gone is the bedside manner and treating patients as real people, nowdays patients have become a procedure with underlying pathology rather than a person. Misdiagnosis is at an incredable level, as witnessed by unecessary surgical procedures performed.

So guess what I do now? That's right I'm a Plumber! Have been for over 10 years now and it sure beats being closed inside all day fielding telephone calls, paying malpractice insurance, office staff and dealing with patients that don't follow directions, or incompetent OR nursing staff that want to test your patience and time schedule.

Good God if I only knew the crap I would put up with as a Surgeon I would have started as a Plumber years ago!

Funny thing though, I met alot of surgeons who would have been better off as auto mechanics than surgeons right from the start, and I know some Plumbers that would make dam good surgeons now thats a scary thought eh?

I've also met some dam good surgical techs that were actually better than some surgeons I knew and some of them I would let operate also !

 

At 6/03/2005 12:48 PM, Blogger Orac said...

But would you let a surgical tech decide which operation to do on you, how to deal with intraoperative surprises, or how to take care of you before and after the surgery? (I did point out in my post that some surgical techs are technically better than the surgeons they assist.) I know I wouldn't. They don't have the knowledge base or the understanding to do that. If they did, it wouldn't take so much less time to train a surgical tech compared to a surgeon.

As for surgeons being turned out at "an incredible rate," I think you're wrong there. In fact, we're probably not turning them out at the rate that's going to be needed over the next 20-30 years, as the Baby Boomers age and need more medical and surgical services. Fewer medical students want to go into surgery, mainly because of lifestyle issues.

Finally, I have nothing against plumbers or carpenters. They're highly skilled trades that I probably wouldn't be particularly good at.

 

At 6/03/2005 2:46 PM, Anonymous Anonymous said...

Yes... if you try to tell the R&D engineers at my facility, most of whom have patents on the wall, that they are JUST technicians... Whoo boy.

What you said about knowing what to do when and how applies double for these guys, who are trying to invent new technologies to get more oil out of the ground cheaper and safer. Not know the science? With degrees in physics, geology, metallurgy, and chemistry? How could they do their work if they didn't know the science?

 

At 6/03/2005 3:14 PM, Blogger Judy said...

Nicholas apparently hasn't met any of the surgeons I've come across lately. They're mostly pediatric surgeons, but I've met a couple as a result of family and personal health problems too. I've been impressed with all of them.


The only person I've ever heard tell a surgeon to his face that he was "a technician" was a ticked-off anesthesiologist. Actually, it was a surgical resident, and he had started the procedure before the patient was under -- twice. I expect that somebody "educated" him a little more thoroughly once the procedure was over.

 

At 6/03/2005 4:03 PM, Anonymous chaperonin60 said...

Orac - since your blood is boiling let me add some gasoline to the fire and post about what phyisicians know and don't know.

Written by Robert J. Cihak, M.D. (IDiot Institute Fellow)

"My fellow physicians and I were taught that evolution is how we came to be, starting from those first mysterious single-celled living organisms. Alternative theories are not usually presented to medical students or even to biologists studying for doctoral degrees, since such theories are quickly branded as "creationism," mocked, and dismissed.

So how is it that 65 percent of the doctors surveyed by the poll, even though they obviously received the full dose of evolution-as-the-only-answer indoctrination in medical school, responded that they thought intelligent design should be allowed or required to be taught in schools along with Darwinian evolution?"


http://jewishworldreview.com/0605/medicine.men060305.php3

Listed feedback email
schmooze@jewishworldreview.com

 

At 6/03/2005 5:11 PM, Blogger Orac said...

Gee thanks. I had a really annoying day yesterday (can you tell?), and now you show me this...;-)

 

At 6/03/2005 6:16 PM, Anonymous Anonymous said...

hey orac,

I saw that silly comment on Pharyngula couple of days ago, but didn't say anything. It's very typical of some science PhDs (although I'm not sure the person who said it is even that). I have both doctorates, so I can appreciate the perspectives of both doctors and scientists. I agree with most of what you say above.

However, in defending surgeons against the mindless bashing of the ignorant, there is no need for you to indulge in a little mindless bashing of your own.

There are a few spots in your diatribe where you said something like the following, but I'll comment just on the most egregious:

Those of us who deal with critically ill patients (as I routinely did until around 6 years ago) need a very strong understanding of physiology and critical care medicine far beyond what most internists ever achieve without undertaking a critical care fellowship.

This is a bit absurd. You are comparing "surgeons who treat critically ill patients" with "internists and medical specialists who don't treat critical patients", and saying that one knows more intensive care medicine than the other.

Well duh. You are better than this, Orac.

I am not going to get into a turf squibble here, but I hope you concede that's a ridiculously meaningless comparison. Would a general surgeon who did lots of trauma surgery know more critical care medicine than a dermatologist? Of course. He'd be expected to. Would a plastic surgeon who does mostly rhinos know more crit care medicine than, say, even a regular cardiologist, or even a general internist staffing acute wards? We'll not even think about comparing dr.rhino to an actual instensivist.

In my experience, generally, more medical specialists (as in people who did an IM residency - we seriously need a word for them, the Brits have the right idea with physicians vs surgeons) really understand physiology better than more surgeons, with the exception of surgeons who regularly care for their own patients in the ICU. And I'd argue that even here what the surgeon's understand really well is a subset of human physiology that's specifically important for acutely ill patients, eg fluid management, etc.

This does not make one group of specialists "better" than another. We all do different jobs, some overlap, some don't. The important thing is for us to be very good at what we're supposed to know best. It wouldn't matter to me if my orthopod didn't have a clue about the simplest bits of critical care physiology - but I'd care like hell that he knows how to fix my knee.

 

At 6/03/2005 6:39 PM, Anonymous Eliza said...

Wow. If anything, I would have thought the general public opinion went the other way, with surgeons' being seen as "higher" than docs in non-surgical specialities (not that that's cool either, natch).

But, yes, I can certainly see being offended by that comment. (As a teacher, I got the "But you're too SMART to be a teacher" bit a lot. Like we should only have the STUPID people teach children. The response that I get to my teaching graduate students is quite different, which just cracks me up, because, imho, teaching at the university level is a lot less work than teaching middle school (or, at least, than teaching it *well*). And, I think my neurosurgeons are pretty impressive scientists. [Some of the others who are no longer my docs, maybe not so much].

Wow, guess it's time to start asking potential docs if they believe believe in ID. Because, dang, if they DO, they do NOT need to be messing with my not-so-intelligently-designed body.

 

At 6/03/2005 6:57 PM, Anonymous Nicolas said...

Orac

You said: They don't have the knowledge base or the understanding to do that

That may be true for some, but I have known in my medical career some dam fine techs, most of them were ex-military trained technicians, and the best appeared to be the Navy trained techs.

Doing some research I discovered the Navy Techs undergo some very rigorous and intensive training in physiology, biology, microbiology, Pharmacology, Wound Care, etc etc.

Putting them on atleaast a level equal or higher to some P.A.'s. The Navy training is equal to or greater than an surgical residency & internship undoubtedly.

Some of the best Dr's, nurses and technicians come from the armed forces where they practice surgical trauma on a daily basis, there is no question of thier competency in all related medical fields, and many a soldier and sailor has had surgery in the field and aboard ship, and recieved better care than some community hospitals I practiced in for years I am sure.

I think sometimes as surgeons we have the tendency to over inflate our ego's by believing only we as surgeons are capable of delivering the care necessary, when in fact that simply isn't the case.

It could be that your looking at technicians right from school or from the trade schools that have blossomed lately that do not provide intensive training, I don't know.

Do some research and tone down the ego, your only human.

Surgeons, Plumbers, Carpenters & Engineers all put thier pants on the same way. Just don't ask me to engineer something !

 

At 6/04/2005 9:43 AM, Blogger Orac said...

Nicholas: You're raising a strawman here. I'm not criticizing military doctors or technicians. Also, we're talking about civilian life here. Military medical techs and corpsmen are a distinct minority of the technicians out there, trained for a distinct situation. Outside of my rotations at VA Hospitals, I've encountered very few surgical technicians who were military-trained. Would you concede that the vast majority of surgical technicians in the U.S. don't have anywhere near that level of training?

Anonymous: Perhaps I expressed myself poorly. My point was mainly that some of those internists who look down on surgeons as "just technicians" don't understand complex physiology as well as the surgeons they denigrate, which makes their looking down on surgeons even more galling.

 

At 6/04/2005 2:44 PM, Anonymous Anonymous said...

I understand completely. I am a Paramedic with ten years experience and 5 years of college. Now you have a taste of what I go through every single time someone looks at me and utters the words "Ambulance Driver".

 

At 6/04/2005 3:02 PM, Blogger Orac said...

Hey, I have nothing but respect for paramedics. I used to moonlight as a helicopter flight physician. I did it for nearly three years, and during that time I came to develop a great deal of respect for the paramedics at the scene when we landed.

 

At 6/05/2005 10:39 AM, Anonymous PaulP said...

Orac quoted a poster: "Surgeons and other medical staff are the equivalent of technicians, engineers, plumbers or carpenters. They are not scientists"

I am not sure the poster was discriminating between types of medics.
I've written comments like this a few times and have included pharmacists (I think you might call them druggists) as targets.
I was thinking about homeopathy, and pharmacists and doctors who peddle this particular quackery and justify their behaviour by citing quantum mechanics. To which nonsense I must rejoin that they are as qualified to speak as authorities on QM as your local auto mechanic is qualified to lecture on Newtonian mechanics simply because he is adept at using the law of the lever.


I think the poster is on to somethingm but went wrong by using the concept of "rote" learning. For example a lot of us use numbers quite intellignetly but I ain't going to debate them with a mathematician.

 

At 6/06/2005 6:12 PM, Blogger MD said...

Yeah, but what is even the point of a making a comment like the one Orac is highlighting? What is the commenter trying to say? That surgery and basic science (bench work) are different? Well, duh. I should hope so. Both involve - no, require - critical thinking and that *is* one of the key components to do both, right?

Or was the commenter trying to say that surgeons are not *real* scientists and therefore not as smart? Or as important? Or as pivotal? Or as critical? I mean, is it just ego talking?

Whatever.

I get a different sort of comment directed at me as a pathologist - the implication is that we are lazy, don't work as hard, have easy hours, do this for lifestyle reasons, etc, etc, etc.

No comments from the peanut gallery, ok, surgeons :)

 

At 6/07/2005 7:30 AM, Anonymous PaulP said...

"Yeah, but what is even the point of a making a comment like the one Orac is highlighting?"

That expertise in one area does not make one an expert in the areas to which belong the tools one uses.

 

At 6/07/2005 9:36 AM, Blogger Doctor Disgruntled said...

First of all, surgeons are technicians - just technicians with more training than most other kinds. And training that includes pre- and post-operative care, ethics, and a tremendous amount of physiology, basic science, etc. A surgical tech is *just* a technician - absolutely right that he/she might be able to clamp cut and tie, but maybe not so confident telling a patient, "You need surgery NOW. Here are the risks, benefits, and alternatives. If anything goes wrong in there, I'm fully responsible," and I'll continue to take care of you to the best of my ability...forever.

Second, the best surgical techs I've even met were *invariably* military trained. Period.

Doctor Disgruntled.

 

At 6/07/2005 10:49 PM, Anonymous Anonymous said...

Well, the "reality" I see (as a non-surgeon) is much like the characterization of a former senior partner of mine: there are two aspects of surgery -- the decision-making part and the technical operating part. You can be good, bad, or mediocre at each independently. And our sense of these features determine who we send patients to for surgery.
As far as the the "real" doctor issue -- the thing us nonsurgeons hear is that we just diagnose, we don't actually "do" anything like a surgeon.

 

At 6/09/2005 12:25 PM, Blogger Aggravated DocSurg said...

Oh, this just pisses me off -- right after I come back from some needed R&R on the beach, and this gets my blood pressure back up!

I'm not sure I can add much that Orac has not already stated more eloquently than I can. I am a physician. My partners are physicians. The pulmonologists down the hall are physicians. What we do on a day to day basis is take care of patients. There are technical and non-technical components to what we do, and a lot of "thinking" that occurs on the part of all of us. I suspect that whoever made these comments simply does not understand one single thing about the delivery of quality health care; that is a reflection upon him, and his education, and not upon physicians, nurses, or even plumbers.

 

At 6/15/2005 9:01 PM, Anonymous Anonymous said...

Ok but can any of you install
a Zoeller 650 pump 6ft deep in concrete slab and maintain 4000
ft of stainless processing piping?

Can you install & repipe an entire 3 bath home in 2 days and run A 3" C.I. Venting System in the same day?

Can you give me the mathematical equation to the terminal velocity of a water column in 4" pipe from a head pump of 400 gpm?

What is the level of "fall" for drainage pipe in your home?

Technician ha !

Lemme see one DR. in here pass the Plumbing contractors Exam !!!!

 

At 6/15/2005 9:32 PM, Blogger Orac said...

Of course, they can't pass that exam, but that's an unfair challenge. I'm sure most doctors could pass the plumbing contractor's exam if they undertook all the the training necessary to become a plumbing contractor.

 

At 7/08/2005 10:34 AM, Anonymous Anonymous said...

give me a break! i think the distinction drawn is between scientists and surgeons, not physicians and surgeons etc.

and the distinction is accurate in general. while surgery is medicine (not plumbing), it is a technical craft, not science. the goals of surgery per se are not to advance understanding, create knowledge, and develop scholarship. they are to cure disease by cutting. it's quite simple. surgeons are just surgeons. don't be ashamed.

 

At 7/23/2005 7:16 PM, Blogger Jodie said...

Heh. "Just a doc"???

That's an eye-opener.

It's a pet peeve of many nurses to hear "just a nurse" from some MD (and I am not implying that you would ever do this, BTW). It has certainly never occurred to me that MDs might hear this too.

 

At 9/15/2005 11:14 PM, Blogger Junaid said...

while on vacation from my surgical residency i visited my aunt's house. my cousin had a cold and my aunt suggested she come to me for help. i guess she was tired of the whining. my cousin's answer sums up what a lot of people think about our profession: "He can't help me. He's not a doctor, he's a surgeon."

 

At 9/27/2005 9:28 PM, Anonymous veronica said...

I'm stunned, this mentation is not my experience and I've been an RN for many years.

My surgeon is a brilliant physicians. I pulse with my breast oncologist who suggested bilateral MRM's and intuitively took muscle on the right which showed tumor present. As a bc pt I can say it is a huge adjustment to be turned over to an onc. I consider my bc surgeon to be the 'one' in charge of my treatment protocol. Til death do us part.

Interesting I arrived here searching for another er/pr+ pt with an oncotype score of 30. I'm stunned as my tumor was grade 1. blah blah blah

 

At 10/08/2005 10:16 PM, Blogger Bogdana said...

I think that commentor pays too much attention to Tom Cruise. You know, Im surprised you have any time to blog, being a doctor and all.

 

At 12/05/2005 5:24 PM, Anonymous BronzeDog said...

This particular post is fairly old, but I feel obligated to comment:

I'm not a doctor or anything (just a humble skeptic trying to help you turn back the tide of quackery), but I really appreciate what all you doctors, surgeons, nurses, and so forth do, as well as what you went through to get the requisite skills. Especially the one (probably not here) who kept me walking erect like a modern human being, rather than hunched over like a Creationist.

You all have sexy, wrinkly brains.

 

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