If you know anything about me, you know that it takes a lot to offend me and that I don't get angry easily. If you don't know anything about me, then you also know this because I just told you. I realised long ago that getting angry at someone or something doesn't help anything, it just makes me do stupid things like bash my hand against a solid wood door (yes, I did this) or throw a glass against the wall so it discharges hundreds of shards of glass around the room including into a pot of simmering soup (yes, I did this too). In other words, offending and angering me is difficult.
That said, I'm both offended and angry. Really fucking offended and really fucking angry.
I was perusing the internet yesterday when I came across an article on Aeon.co entitled "There is no place for the surgeon myth in modern medicine." Based on the title I assumed it was written by a surgeon-in-training who had encountered a prototypical "Asshole Surgeon" and was railing against his bad behaviour in the operating theatre. Instead, I was chagrined to discover that the author, Alexis Sobel Fitts, is a freelance journalist who writes about science and medicine after studying science journalism for one year at Columbia University (and English at Yale) but seemingly has no actual science or medical training whatsoever (according to her website).
That bothered me a little bit. How could this woman know anything about surgery? I thought. Then I started reading the article, and by the second paragraph I wanted to reach through the computer and slap the living shit out of her.
I rarely give the punchline before the joke, but fuck it, here it is anyway: she claims that surgeons are essentially nothing more than thoughtless, crude barbarians with scalpels who descended from butchers and barbers and merely do, rather than think.
After reading that last paragraph back, I feel the anger rising again.
I'm going to take the liberty of quoting liberally from Ms. Fitts' heaping pile of bullshit, er, article. No, sorry I was right the first time. Heaping pile of bullshit.
She starts by describing a scene from The Knick, a show on Cinemax (that I've never seen) which focuses on a surgeon at the Knickerbock Hospital in New York in 1900. Yes, 1900. Dr. Thackery is about to perform a life-saving surgery in the era before antibiotics and anaesthesia, and he looks like "the perfect hero", according to Ms. Fitts. But then she descends into the first bit of bullshit when she relates a joke her sister (who is in medical school) told her: "'An internist can figure out what’s wrong with you, but he can’t fix it,’ it goes. ‘A surgeon has no idea what’s wrong with you, but he’s happy to fix it.'"
Fucking hilarious, right? Because surgeons don't ever think, and we have glorious cold hard steel to do the thinking for us! Ha fucking ha! It gets worse. Much worse.
She then describes a cadre of medical students who appear to have self-selected as future surgeons as "the frat boys of medical school". According to Alexis' sister these students are "the first to volunteer for dissection, and the last to answer basic science questions during drills," and that there was a difference "between surgeons, whose ability to solve problems was lauded by the public, and the rest of the medical establishment, whose ability to analyse data and diagnose was valued within."
If you aren't detecting Alexis' pattern of the surgeon being an unthinking idiot with a 10 blade, then you aren't paying attention. First of all, many medical students don't decide on surgery until they are years into medical school. I was in the middle of my third year (up until that point it had been a tossup between psychiatry and paediatrics), so this whole idea of a pack of surgical frat boys is ridiculous. Second, the only people I knew in medical school who didn't want to dissect their cadaver intended on going into neurology or psychiatry. Everyone else was more than eager to dissect. Third, some of the biggest gunners (those students who raise their hands first and always seem to study most) were future surgeons, because they had to be (since surgical training is very competitive). Fourth, since fucking when do surgeons not analyse data (more on that later)?
It became clear to me at this point that Ms. Fitts had not spent one goddamned second with an actual surgeon and was basing her entire ludicrous hit piece on fictional early-20th century television surgeons and whatever lies her sister told her. It became even more obvious that she had done exactly ZERO research (other than a 0.253-second search on YouTube) when she made several glaring errors in her next paragraph about an internal carotid endarterectomy:
On YouTube, anyone can watch a vascular surgeon remove a growth from the carotid artery, the passageway that transports blood to your face and brain. It is stunning: the skull, splayed open, revealing the thrumming sinewy flesh beneath. The procedure is as uncomfortably intimate as it is delicate. Any missteps might incite devastating consequences, as the surgeon navigates around the vagus nerve, which dictates facial response, and the hypoglossal nerve, which controls the tongue.Good fucking grief. Where do I even begin.
- It's not a growth, it's called a plaque.
- The internal carotid artery (which is being operated upon) doesn't supply blood to the face, the external carotid does.
- The carotid artery is accessed via an incision on the side of the neck, not by "splaying open" the skull.
- "Thrumming sinewy flesh"? Seriously?
- The vagus nerve does not innervate the face, that would be the facial nerve.
Anyway, Alexis continues her relentless assault on surgery:
But remove the glamour of labouring beneath the skin, and surgery can seem much duller. After all, fixing problems is corporeal, often removed from the more intellectually nimble task of diagnosis. It’s physical work, at its crudest achieved with simple steel tools and at at its most advanced using tiny, specialized cameras and computerized guides.Later she adds this little gem:
Surgeons are valued for their ability to execute, not analyse.Remove the glamour of . . . wait, what?!? Of course it's duller if you remove the surgery from surgery! Wouldn't cardiology be less glamorous if you remove the heart? And surgery is never "removed" from diagnosis! Does she honestly believe that surgeons simply walk into a room and fix something without knowing what they're fixing or why? When I see a patient with a bowel obstruction, for example, I first must determine if there is an obstruction. I do this by 1) interviewing the patient, 2) examining the patient, 3) reviewing labwork to see if there is any evidence of systemic illness (elevated white blood cell count, hyperglycemia, hyponatremia/hypochloremia, lactic acidosis, hypotension, etc), and 4) reviewing the X-rays and/or CT scans. Once I've determined that an obstruction exists, I then have to determine the best course of action - a trial of non-operative management (since many obstructions will resolve on their own) versus surgery, and if the patient needs surgery, when. If there is systemic sickness (ie sepsis or impending sepsis), the patient needs immediate surgery. AND THEN I have to operate and actually fix the problem with my simple steel tools or my tiny, specialised camera (ie a laparoscope).
Does that sound like I'm removed from the more intellectually nimble task of diagnosis? I have to do this for every single patient I see. Granted with many patients it is easier and simpler. But at no time am I ever not thinking.
Are we done yet? Not remotely.
While medicine sprung from the academy, surgery originates with tradesmen. In the Middle Ages, ‘barber-surgeons’, who had knives and razors at the ready, performed bare-bones amputations and tooth extraction alongside haircuts. Becoming a doctor called for university training, but surgery – requiring less skill – was passed down by apprenticeship. Even women, barred from becoming physicians until the 20th century, could train as surgeons. Low rank is implicit even in the title, surgeon, which is derived from the combination of the Greek words for ‘hand’ and ‘work’. Surgery's place at the bottom of the medical hierarchy can be attributed to the crude cruelty of early surgical procedures.Wh . . . wha. . . what the fuck was she smoking? Yes, barbers used to perform surgery, but that was ages ago. What the fuck does it matter now? Why even bring that up except to make surgeons look bad? Surgeons attend the exact same schools, in the exact same classrooms, take the exact same tests . . . god damn it, you get the fucking point. And "less skill" and "low rank"? Bottom of the medical hierarchy? According to whom, YOU? Don't misunderstand me, I'm not saying that surgeons are at the top of the medical totem pole, because there is no top or bottom. Every specialty is necessary and important. But surgeons spend the most time after medical school of any specialty, often 8 years or more, learning their craft. Less skill? Are you fucking kidding me?
Next, Ms. Fitts laments the lack of women in surgery, stating that "surgical specialties remain segregated":
An operation is performed within a distinctly macho context: a showdown between disease and individual doctor, leading a team through authoritative decision-making.How is that macho? What does that even mean? Do women not solve problems in Alexis' universe? Regardless of that bit of inanity, it took me all of about 13 seconds (admittedly a bit longer than usual) to find out that while the number of women in surgery is still relatively low, the trend is the exact opposite:
|Percentage of women in surgical specialties
I thought enough must be enough. Her attack on surgeons has to be over, right? HA! No. Somehow in her mind there is something wrong with the fact that only 10% of articles in the prestigious New England Journal of Medicine have to do with surgical innovation:
As evidence-based medicine has become increasingly the standard of discovery, surgeons have not risen to the top of scientific enquiry. Since the 1950s, laboratory science has increasingly been the origin of medical innovation. Which is why, over the past four decades, merely a 10th of the articles published in The New England Journal of Medicine have covered surgical innovation.Apparently Alexis didn't get the memo that we surgeons have our own journals. Hundreds of them. And guess what percentage of their articles are about surgery and surgical innovation? ONE HUNDRED FUCKING PERCENT.
But Ms. Fitts still isn't finished with her all-out assault on surgeons, now claiming that we don't know how to play nicely in the sandbox with the other kids:
And the future of medicine is forcing surgeons to adapt. While surgical achievement fixates on the craft of the individual, advances in medicine are forcing physicians to adapt a team-based approach. Increasingly, a surgical procedure is only a part of an overall treatment plan – forcing surgeons to work alongside their peers in internal medicine. This is coupled with a technological revolution that is creating intelligent tools, requiring the contemporary surgeon to guide their actions by data, rather than instinct.All this does is demonstrate that Ms. Fitts has no fucking clue how medicine works. As technology has improved, surgeons have had access to more and more data. Thus we haven't had to act "by instinct" for decades. Plus, I consult my internal medicine colleagues regularly to assist in management of medical problems. For those patients of mine with kidney disease, do I do my own dialysis? Of course not, I call a nephrologist. I don't read 2-D echocardiograms, I let my cardiology experts do their job. I'm not "forced" to work alongside these people, rather my colleagues and I know how the cogs in the medical system all turn. Ms. Fitts obviously does not.
But she wasn't done yet. I could almost hear the "plop" as Alexis dumped her concluding steaming pile of excrement:
Atul Gawande, a surgeon and staff writer for The New Yorker implored his peers to place increasing emphasis on diagnostics rather than skill, in a lecture delivered to the Association for Surgical Education in 2001. ‘We are doctors, not technicians,’ urged Gawande, even though for the rest of the world, being a technician might be glamorous enough.Not that it matters much, but Dr. Gawande was still in his residency when this speech was given, which is surprising considering he was asked to talk about how to improve surgical training when he had not finished his own. Irrespective of that, Ms. Fitts completely misinterpreted the point of Dr. Gawande's excellent speech. He wasn't talking about surgeons becoming mere thoughtless automatons, but rather about expanding surgeons' training on surgical diseases and improving communication between 1) surgeons and patients, and 2) surgeons and the rest of the surgical team.
And with that last heave of excreta, Alexis was finally finished. I counted 17 new dents in my desk where I bashed my head while reading her
I would apologise for the number of "fucks" and the ridiculous length of this post, but I don't think I have any more fucks to give.