REFLECTIONS ON SURGICAL TOPICS
I have always had the greatest respect for surgeons. The reader may have already read what I believe about their being the finest physicians, and the most valuable ones, being the only ones truly able of curing illness.
If by cure is meant the complete reversal of an organ to its former healthy self, then alas, no medical specialty is yet able to do that, including surgery.
But what the surgeon does is resect an unhealthy organ, or part of it, and hope that the body can heal itself afterward, or be in no need for it. Surgeons utilise the fact that the human body has a great surplus of tissue, and as such, are able to operate on it without much detriment. For instance, when the colorectal surgeon is resecting a segment of cancerous bowel, he is using the fact that the body can spare some of it without much harm. The same applies to the breast surgeon, who can remove an entire breast, or the urologist, who can remove the prostate, or a cancerous testicle or kidney, each of which God has kindly blessed us with two of.
Even when they are operating on something as simple as an appendix, they are using the body’s innate abilities to compensate for this organ, which “contains masses of lymphoid tissue, and as part of MALT, it plays an important role in body immunity”. They do not bring the appendix back to its healthy self, but spare the victim of appendicitis any present or future problem related to it.
Nevertheless, their management is arguably the most beautiful of all medical specialties. Here is one human being, relying entirely on his manual dexterity, being completely devoted to another, without an overdue reliance on drugs, which may take days, if not weeks or months to kick in.
In surgical operations, humanity has its finest hour. Here is one human being, the patient, devoting, and entrusting his entire self, to the skill of another, the surgeon. The patient is deliberately cut, caused to bleed, led into pain, scars and disruption of everyday living, with his or her own informed consent. Is there anything more incredible than that? In this, in inflicting ‘torture’ upon another human being, for the human being’s own good, the surgeon is exhibiting what can be regarded as almost exclusively divine. No human being is allowed to do these things to another, for it would be regarded as manslaughter or even murder. Only God, and a fair judge, has that right of punishment for the sake of mercy and the greater good. Indeed, it may be from this knowledge that most surgeons who I have encountered develop that strain of arrogance and pride; Bertrand Russell once remarked, “Most people wish they were God, few entertain the impossibility”. That quote is probably most suitable for the surgeons – in whose hands life, future suffering in life (with the long term complications of their surgery) and death, lie – via God of course.
Richard Schaus, a contemporary US surgeon put it well, “Surgery is the endeavor where intellect and dexterity meet at the highest level in the creation of a peerless human accomplishment”. It combines manual skill, craftsmanship and artistry, with knowledge of all the basic medical sciences, and most importantly, with wisdom and humanity. I leave the penultimate word with Oliver Wendell Holmes, whose following statement is worth a great deal of contemplation:
“As I sat by the side of this great surgeon (Lawson Tait), a question suggested itself…Which would give the most satisfaction to a thoroughly humane and unselfish human being, of cultivated intelligence and lively sensibilities: to have written all the plays Shakespeare has left as an inheritance for mankind, or to have snatched from the jaws of death more than a hundred fellow-creatures…and restored them to sound and comfortable existence?”
The answer is obvious, unless one regards the existence of humanity negatively.
THE SURGEON AS ARTIST
The manual skill of a surgeon can be likened to that of an artist or sculptor. Perhaps this was best exhibited in the great Theodore Billroth, who we mentioned in the section on ‘Alternative Medicine in the Age of Unreason’. Not only was he one of the greatest surgeons of all time (certainly the finest one of the 19th century). He was a first class artist, a man who devoted himself equally to his beloved surgery and his music. One can even imagine him say, in a manner analogous to the great Russian novelist Anton Chekhov, “Surgery is my lawful wife and art my mistress; when I get tired of one, I spend the night with the other”, for he too was a man of strong passions, who “enjoyed drinking and ate heavily, and it is said that no cigar was too strong for him to smoke”. He was intensely devoted to his art, and despite his surgical brilliance, many of his biographers in feel that, “The dominant passion throughout Billroth's life was his love of music”. One of his colleagues, described him as "an enthusiastic patron of music and a capable musician, who had an unusual knowledge of the master works in music and who was also a good drawer and painter". He exhibited his artistic regularly, conducting works with the great Johannes Brahms, who he told in one of his letters, "It is one of the superficialities of our time to see in science and in art two opposites…Imagination is the mother of both”, and, “I have never met a great physician who was not basically an artist with a rich imagination and unaffected mentality…science and art draw upon the same source”.
In a short biography of the man, ‘Theodore Billroth as Musician’ in the ‘Bulletin of the Medical Library Association’, F. William Sunderman, concluded as follows:
“It is perhaps not unexpected to find among physicians many men of artistic temperament. The noblest conception within the range of Greek mythology places Phoebus-Apollo as the god of both medicine and music. In the life of Billroth art and medicine were merged to a degree which stimulated Welch to remark that here indeed was a man " who warmed both hands before the fire of life ".
Many years afterward, many surgeons have emphasised this artistic side to surgery, Wilfred Batten Lewis Trotter, one of the first surgeons to emphasis the importance of total resection of tumours, and a brilliant ENT and maxillofacial surgeon of the 20th century put it this way:
“It is sometimes asserted that a surgical operation is or should be a work of art…fit to rank with those of the painter or sculptor. That proposition does not admit of discussion. It is a product of the intellectual innocence which I think we surgeons may fairly clam to possess, and which is happily not inconsistent with a quite adequate worldly wisdom.”
Sir Berkeley Moynihan, another famous British surgeon also emphasised the same point:
“As art surgery is incomparable in the beauty of its medium, in the supreme mastery required for its perfect accomplishment, and in the issues of life, suffering, and death which it so powerfully controls.”
Indeed, one cannot imagine a surgeon, the medical professional most intimately attached to the anatomy of the human body, to fail to be moved by its glory, that silent beauty that has moved artists of the greatness of Leonardo da Vinci and Michaelangelo, let alone men of a more rudimentary artistic sense.
Michelangelo for instance, regarded by some as “the greatest Renaissance artist of all time” is said to have shown:
“His greatest love (in) the study of the human body, both in painting and in sculpture. He concentrated on observing the human body and was often allowed into hospitals to study bodies of those who had died. Some say that had Michelangelo been left to himself to sculpt instead of paint, he would have become a sculptor because no other form of art so beautifully expressed the richness of the human body”.
Another biography states that:
“To Michelangelo there was splendorous beauty in the human body…Michelangelo's search for God, whose sublime purpose he saw revealed in the beauty of the human form and his disinterest in any subject save the human form, which he held to be the supreme vehicle of expression, led him to an intense and exhaustive study of the human body. His belief that nothing worth preserving could be done without genius was attended by the conviction that nothing could be done without persevering study. So Michelangelo studied the human form. He studied the ancient sculptors who knew how to represent the beautiful human body in motion, with all its muscles and sinews. However, he was not content with learning the laws of anatomy secondhand. He made his own research into human anatomy, dissected bodies and drew from models until the human figure did not seem to hold any secrets for him. He strove with an incredible singleness of purpose to master this one problem and master it fully until it was rumored that this young artist not only equaled the renowned masters of classical antiquity but actually surpassed them.”
As for Leonardo, everyone is familiar with his anatomical drawings, the most famous of which is the ‘Vitruvian Man’ – a picture of which is worth a thousand words; Leonardo at his brilliant best, as anatomical observer and artist.
THE SURGEON AS A MAN OF KNOWLEDGE
There is a preponderant myth that is widely known among medical students and many doctors, which says:
“Surgeons do everything, but know nothing. Internists know everything, but do nothing.
Psychiatrists do nothing and know nothing. Pathologists know everything and do everything, but too late”.
Nothing could be further from the truth. How could a surgeon practice his art without a precise and detailed knowledge of anatomy for example, which the great William Hunter described as being to the “surgeon what geometry is to the astronomer”. Indeed, how could he practice without awareness of the functions of the different organs, which constitutes physiology? Finally, how could he practise without knowing how far the medical option has been taken? As everyone who has been involved with both specialties (general medicine and surgery) knows, surgeons only get involved in the management of ‘medical problems’ when medicine has exhausted itself; the cardiothoracic surgeon is called upon when the anti-thrombotic agents used start failing, or the PCI stents start blocking, or when the heart or lung completely fails in a patient able to receive a heart or lung transplant. The colorectal surgeon is called upon when the patient’s inflammed bowel, secondary to Crohn’s disease, or ulcerative colitis, is not under control with the steroids and immunosuppressants used therein, or if the latter has become cancerous. The urologist is called upon when the kidneys completely fail, and is asked to insert a new one. The list goes on and on. Thomas Clifford Allbutt put it perfectly, “From the time of Hippocrates, surgery has ever been the salvation of inner medicine.”
The surgeon has to be completely aware of the medical option, before embarking on his incredible journey, and it may be safely concluded that the best surgeon is also a physician. This was noted by John Shepherd, the famous 20th century British surgeon, who remarked, “Every surgeon should be something of a physician”, and much before him, Guido Lanfranchi, the French-born physician stated, “Keep well in mind …nobody can become a good surgeon who knows nothing about medicine.” It is no surprise that nearly all the best surgeons who I have encountered carry both memberships and even fellowships with both royal colleges, of physicians and surgeons. But is it not fascinating to know that in Glasgow, between 2000 and 2005, the very president of both colleges was the same (Professor Andrew Ross Lorimer)!
I conclude this section with an invaluable quote from none other than the late Michael DeBakey, a man whose contributions, as we see in the aortic dissections chapter, extended to both fields:
"It became popular in recent years to divide medicine into cognitive and noncognitive disciplines--a throwback to the schism between medicine and surgery in the Dark Ages, when use of the hands was demeaned and the status of surgery, and indeed of all medicine, declined significantly. But the labeling of surgery as a noncognitive discipline is fallacious and totally unsupported by its history and achievements."
THE WISDOM AND HUMANITY OF SURGERY
The most important question in surgery is arguably when to operate (and mutatis mutandis, when not to operate). Indeed, the first Nobel laureate surgeon Theodor Kocher defined a surgeon simply as, “a doctor who can operate and who knows when not to”. The answer to it requires a great deal of wisdom and courage.
I say wisdom because it entails prediction of the possible impact of extending medical therapy and trying to predict the future prognosis of a patient without operating.
I say bravery because in no other discipline is a doctor directly involved or responsible in curing a patient as in surgery. The physician never cures (with the possible exception of infections, and even that we are becoming less successful with the arousal of resistant strains and new difficult to eradicate bugs), and his treatments are completely indirect; he acts via drugs, which in turn act via receptors, and those act via second messengers and genetic impact. The surgeon however observes directly, resects directly, and stops bleeding directly. Henri de Mondeville, the French surgeon put it well in his ‘Treatise on Surgery’:
“Surgery cures diseases that cannot be cured by any other means, not by themselves, not by nature, nor by medicine. Medicine indeed never cures a disease so evidently that one could say that the cure is due to medicine”.
Surgeons live with the most painful of uncertainties – that of possibly inflicting harm on another, a harm which may extend all the way down to the death of the patient, who he tried to rescue earlier. René Leriche, the famous French professor of surgery put it brilliantly:
“Every surgeon carries about him a little cemetery, in which from time to time he goes to pray, a cemetery of bitterness and regret, of which he seeks the reason for certain of his failures.”
Can anything be more painful, or more striking to the wisdom of man, than this uncertainty, which those brave men live with, confront on a daily basis and burden their consciences with? I think not. But it is testimony to the greatness of the surgeon, who has tried by all means, to help his fellow man.
It is perhaps this daily encounter with debilitating complications, pain and even death, that makes the surgeon a rather serene figure, a man who wishes not to complicate matters too much, tending to look at things directly and concisely.
This is evident in their history taking, which is nearly always to the point, concise and brief. While the physician relies intensely on investigations of various types to support his diagnosis, the vast majority of surgical diagnoses are actually clinical – based on the history and physical examination; this is partly because surgery is older than medicine, developing at an age when CT-scans and MRIs were non-existent. But more importantly, it is because, many surgical conditions cannot be diagnosed except clinically, or cannot await the time taken to prepare and take a patient for investigation. The perfect example of the former is the only too common condition, acute appendicitis, which remains an entirely clinical diagnosis (and we are advised by the Bible of medical students and junior doctors, ‘The Oxford Handbook of Clinical Medicine’, “Don’t rely on tests – may cause fatal delay”). Examples of the latter are testicular torsion and aortic dissection, two conditions over which we are advised, “Take the patient straight to theatre. Do not waste time doing X-rays (or other scans), fatal delay may result”.
Indeed, it is true that surgeons do request investigations, but they are usually very simple ones that are absolutely crucial. They do not screen for everything; and in that sense have remained true to medical tradition, where a doctor takes a history, examines and requests tests based entirely on his clinical acumen. And I say this having done both neurosurgery and neurology, gastroenterology and colorectal surgery. The differences are phenomenal. While the neurologist requires sending the blood sample to France for a test that is only done there, and the gastroenterologist to Birmingham for another, the neurosurgeon and colorectal surgeon merely asks for a white cell count, a CRP, and at most, an amylase or blood gas.
One is also often under the impression that surgeons tend to request scans, when they are more than happy to proceed with an operation, because of the fact that we are living in a litigation culture. Indeed, this is the approach recommended by Colin Bicknell and N. J. W. Cheshire, two vascular surgeons based in St Mary's Hospital in London, who writing in the commonly used postgraduate surgical textbook, ‘Clinical Surgery in General’ say:
“Although you may be certain in your own mind about the diagnosis and appropriate management, you may need to protect yourself against future claims of incompetence against you, or the patient may wish to have objective evidence available in claims against a third party following, most commonly, an accident.”
Patients are not satisfied now, unless they have had some sort of test, and the more complicated it sounds, the more trust they have in it. It gives them a lot of reassurance, which in fact can be false reassurance, considering the inter-observer variability in the interpretation of some of those tests. They ignore the fact that, even in the presence of such sophisticated technology, there will always be limitations to them, as well pointed out by Gray and Toghill (2001):
“You must remember too that the discovery and interpretation of a large number of physical signs cannot be matched by investigations or advanced imaging technology. So far we have yet to produce a machine that tells us that ‘the patient looks ill’, a subtle skill which remains entirely within the province of the experienced clinician. More specifically, the hearing of triple rhythm, the sight of spider naevi, and the smell of hepatic foetor are physical signs that cannot easily be replaced by investigations”.
That, “more mistakes are made from want of a proper examination than for any other reason”, as Russell John Howard put it, and the historical fact of how much our predecessors did with the aid of simply the five senses. The decline of clinical examination, mostly thanks to litigation lawyers, is one of the saddest features of modern medical history.
WHY ARE THEY DISLIKED
The serenity and straightforwardness of surgeons should make them more affable people. Alas, most people, including myself, have not had that experience with most surgeons, although, without a doubt, the nicest doctors I have ever met or worked with was an Egyptian vascular surgeon in Harlow. He was the most trustworthy, faithful, honest, down to earth, hard working and sensible doctor, and much loved by patients and fellow doctors alike. I don’t know if it is controversial to say this, but I get the impression that Muslims tend to prefer surgery to other specialties, perhaps because it’s so down to earth, simple and curative, like Islam. Most Muslims who I have worked with in hospital lean towards surgical specialties. And encountering a Muslim in hospital, he is more likely to be a surgeon than not.
So what is it that makes surgeons rather abhorrent? I think there are 4 answers to this question.
Firstly, in that surgeons are superior to physicians in terms of their ‘healing’ expertise – the only true measure of usefulness of a medical professional. There can be no argument about that fact. A surgeon can be a physician, but a physician cannot be a surgeon. I am yet to encounter a person with MRCS and MRCP who practises hospital medicine; although I am sure they do exist. The surgeon knows of his superiority, but the physician is often in denial, believing that he is the harbinger of all knowledge, forgetting that knowledge without practical action, symbolised ultimately by surgical intervention, is as useless as a fifth wheel. As put by Sidney M. Schwab, one of America’s best known surgeons in his autobiography, ‘Cutting Remarks’, "To a surgeon, an internist is someone who talks all day and gets very little accomplished. We understood medical issues; they were clueless about surgery”. Writing in the journal ‘Surgery’, Thomas Findley states, “An internist has been defined as a man who is totally unable to answer either yes or no to any question”. I don’t agree with this definition myself, but there is an element of truth in it. Physicians tend to be rather indecisive men (and women). The surgeon is all about decision; for him, to operate or not to operate – that is the question, the ultimate decision.
Interestingly, a fascinating study by three Spanish physicians based in the University of Barcelona - Antoni Trilla and Maria J Bertran, both epidemiologists, Marta Aymerich, a haemopathologist, and Antonio M Lacy, a consultant in general and digestive tract surgery, which was published in the BMJ (BMJ 2006;333:1291-1293) concluded that:
“Our study shows that, on average, senior male surgeons are significantly taller and better looking than senior male physicians…Perhaps because of their training, surgeons have a different attitude and approach to the practice of medicine compared with physicians. The surgeon's image is that of competence, trust, expertise, and compassion. Surgeons are the only doctors who practise what has been called "confidence based medicine," which is based on boldness. They are often practical and fast acting, and they exert tight control on their natural turf—the operating theatre. Being taller and better looking has several evolutionary advantages for surgeons. Their extra height makes them more likely to be masters and commanders, and gives them a better view of the operating room, including the patient lying on the table. Also, as the senior male surgeon is normally surrounded by junior surgical staff, training fellows, nurses, anaesthetists, and the like, his height and appearance make him easily identifiable as their leader.”
In addition, the surgeon knows he is the only one capable of a cure of a condition, as I have pointed out many times in this and other essays. He knows that in deciding to operate, he may bring the patient back to life, so to speak or kill him or her. Because of these unique ‘God-like’ qualities, the surgeon can develop a strain of deplorable arrogance. Indeed, in having so much ‘greatness’ and ‘Godliness’, it would be hard not to develop a streak of pride, and become lacking in humility. Indeed, some think they are God. No one emphasised this more than Dr. Jed Hill, the surgeon portrayed by Oscar nominee Alec Baldwin in the 1993 movie, ‘Malice’, when he was accused of having a ‘God Complex’ by his medical board:
"I have an MD from Harvard. I am board certified in cardiothoracic surgery and trauma surgery. I have been awarded citations from seven different medical boards in New England, and I am never, ever sick at sea. So I ask you: When someone goes into that chapel and they fall on their knees and they pray to God that their wife doesn't miscarry, or that their daughter doesn't bleed to death, or that their mother doesn't suffer acute neural trauma from postoperative shock, who do you think they're praying to? Now, go ahead and read your Bible, Dennis! And you go to your church, and, with any luck, you might win the annual raffle, but if you're looking for God, he was in operating room number two on November seventeenth, and he doesn't like to be second guessed. You ask me if I have a God Complex? Let me tell you something - I am God."
And nothing is more abhorrent to God more than arrogance and a lack of humility. It was the reason why Satan was kicked out of the Heaven (“He (God) said, ‘Descend from Heaven. It is not for you to be arrogant in it. So get out! You are one of the abased.’ “(7:13), having said before, “We said to the angels, ‘Prostrate to Adam!’ and they prostrated, with the exception of Diabolis. He refused and was arrogant and was one of the disbelievers” (2:34)). And why God promises a great deal of punishment for those guilty of it:
“As for those who believe and do right actions, He will pay them their wages in full and will give them increase from His favour. As for those who show disdain and grow arrogant, He will punish them with a painful punishment. They will not find any protector or helper for themselves besides Allah” (4:173)
“Who could do greater wrong than someone who invents lies against Allah or denies His Signs, or who says, ‘It has been revealed to me,’ when nothing has been revealed to him, or someone who says, ‘I will send down the same as Allah has sent down’? If you could only see the wrongdoers in the throes of death when the angels are stretching out their hands, saying, ‘Disgorge your own selves! Today you will be repaid with the punishment of humiliation for saying something oher than the truth about Allah, and being arrogant about His Signs.’”(6:93)
The atheist or agnostic surgeon, who may outwardly show innocence and humility, is deep down, an arrogant figure, for he believes everything he does is his, all the knowledge and its application that has been revealed to him is because of his efforts, when in fact it is God who cures, and God who has bestowed a person with that knowledge and skill (and belief in this, the unity of action of God in all good things is the ultimate form of monotheism). This is something so simple, so self evident, that, as I mentioned before, the prophet Abraham mentioned it to his people thousands of years ago (Quran (26:80).
The surgeon is witness to some of the most incredible actions of God. That is why Ambroise Pare, regarded the founder of modern surgery, as one of the greatest surgeons who ever lived, through whose writings, “did more than anybody else to raise the previously poor reputation of surgery "to one of dignity and esteem””, and arguably the “greatest perhaps in his humanity and charity”, was the one to remark, “Je le pansai, Dieu le guérit" ("I dressed him, and God healed him”), and why another great surgeon remarked, “When I am operating, I feel the presence of God so real that I cannot tell where His skill ends and mine begins”. This can serve him immensely, for I believe that the only thing that can hold this arrogance in check is a belief in God, a belief that all cure is in His hands of God, and not in one’s surgical hands. And indeed, that most affable of doctors I have just mentioned was a deeply religious man. In addition, among my close network of friends, I have only two who are established in a surgical training programme (other than gynaecology), one who is outspokenly religious, the other, silently religious, and both most amazing men.
Secondly, there is a perception of the surgeon as a cold, unmovable, emotionless figure. Biographies of great surgeons do not show this to be true; quite the contrary. The source of this conception however may be the following.
First - the need for a surgeon to be stern in the face of adversity. It is a vital leadership quality. And surgeons are born leaders. No weak man can become a surgeon. If the sight of blood, of cutting into a human being, of the possibility of him dying with his or her blood on your hands cannot be entertained, then you cannot be a surgeon. The greatness of military leaders such as Napoleon, Alexander The Great, Omar Ibn Al-Khattab, and even the Prophet Muhammad (PBUH) is that, while they expressed sadness for their many casualties, they remained persistent, never letting their sadness bother them, and thereby achieved their great successes. The brilliant Richard Selzer, a recently retired professor of surgery at Yale University explained this phenomenon brilliantly:
“In the operating room the patient must be anaesthetized in order that he or she feel no pain. The surgeon too must be anaesthetized, insulated against the emotional heat of the event so that he can perform the act of laying open the body of a fellow human being, which, take away the purpose for which it is being done, is no more than an act of assault and battery. A barbaric act. So the surgeon dons a carapace which keeps him from feeling. It is what gives many surgeons the appearance of insensitivity.”
The Roman surgeon Celsus also put it well in his ‘De Medecina’ (Book VII (50 AD)):
“A surgeon should be youthful or at any rate nearer youth than age; with a strong and steady hand that never trembles, and ready to use the left hand as well as the right; with vision sharp and clear, and spirit undaunted; filled with pity, so that he wishes to cure the patient, yet is not moved by his cries, to go too fast, or cut less than is necessary; but he does everything just as if the cries of pain cause him no emotion.”
Secondly, in the fact that many present day surgeons are simply not interested in the psychosocial aspects of their patient’s illness. This, however, is not the fault of surgery, but of bad practice. Great surgeons are always aware of the psychosocial element of disease, and never neglect it. Henry Cushing, one of the greatest of surgeons of all time, and the founder of neurosurgery emphasised this point many times, saying, “A physician is obligated to consider more than a diseased organ, more even than the whole man – he must view the man in his world”, and “Three fifths of the practice of medicine depends on common sense, a knowledge of people and of human reactions”. This point was re-emphasised by another great surgeon, Sir Hugh Cairns, the Australian-born British neurosurgeon and former Professor of Surgery at Oxford University, who said in an article in ‘The Lancet’ in 1949:
“How does one become a good doctor? When one doctor says of another, "He is a good doctor," the words have a particular meaning. You will hear the expression used not only about some general practitioners, but also about some specialists. As I understand it a good doctor is one who is shrewd in diagnosis and wise treatment; but, more than that, he is a person who never spares himself in the interest of his patients; and in addition he is a man who studies the patient not only as a case but also as an individual. . . . . The good doctor, whether general practitioner or specialist, is also a man who studies the patient’s personality as well as his disease” (Lancet, 1949; 2: 665)
The third reason why I think surgeons are not generally well perceived is that they are leaders. One cannot become a surgeon except if he had leadership qualities, and I think, as I will explain in more detail in another essay, that this is one of the reasons for the preponderance of males over females in surgery. The great American cardiothoracic surgeon Edward D. Churchill put it thus, “The difference between a surgeon and an internist, is that the surgeon is captain of the team, while an internist never has a team”.
This of course is an exaggeration if applied to this day and age. It may have been an entirely true statement in the past, but not now, in the presence of ‘multidisciplinary teams’ this notion of the physician as one without a team, is incorrect. However, he remains without that clear cut surgical characteristic – leadership. The surgeon remains captain, the physician would never be. And in that characteristic lies their unparalleled egoism. In addition, it may be true that, because we live in the age of anarchy, a time when we really lack charismatic leaders, when the USA is being led by a man (even that is a controversial designation) as dull and gruesome as George W. Bush, and the rest of the world having no sense of direction, especially so in the rotten Arab world. We are living in the age of “student protest movements, peace movements, squatter movements, and the anti-globalization movement, among others”; people dislike their leaders for legitimate reasons. They then develop a subconscious dislike of leadership in general. And this may be why a subconscious fear and dislike of surgeons may develop.
The fourth and final reason for it I think has to do with tradition. When the surgical trainee enters the surgical world, he inevitably, unless properly equipped to resist negative changes, will develop those abhorrent characteristics we mentioned above. As one medical school dean in USA put it:
“Surgeons are the playground bullies of the medical world. Any compassion and genuineness has been beaten out of them long ago. They’re so used to talking to others through screaming that their encounters with students and residents are rarely pleasant. That’s not to say that all surgeons are like that. Urologists and Ophthalmologists bring civility to the medical community.”
Describing his work in hospital, one medical student’s blog states the following:
“And then there were the surgeons. These were the ones who walked past you with a sense of purpose, with an expression that sent lesser medical personnel scurrying out of their paths in terror, and with eyes whose gaze could physically melt medical students if you weren’t careful. Several walked past us, instantly recognizable, and those who bothered to look at us did so with a disdainful expression, dismissing our existence as being too trivial to bother their exalted minds. They were Lords of their Domain; entire operating theatres were built as shrines to their greatness. Why shouldn’t they walk around as if they owned the place?
I’ve always wondered why surgeons seem to be more affected by the famous God complex that seems so prevalent in the medical profession. Recently, my cousin brother underwent surgery…and the surgeon, who operated on him, whilst perfectly competent, also demonstrated this uppity demeanour. She strode into the OT (fashionably late) without seeing him pre-op, and didn’t even check on him post-op. During the surgery she didn’t bother to reassure him; it was the nurses who did this…. (The egoism of surgeons) is completely unnecessary when it causes them to ignore patients, shout at nurses and look down on doctors from non-surgical specialties. And abuse medical patients. Especially when they abuse medical patients.”
Can this sorry state of affairs ever be amended? Indeed, the question poses itself – should this state of affairs be amended?
I think it should be. Not because, as one paediatrician puts it (as reported on one blog), “The distinction matters because the dichotomy between doctors who perform procedures and those who practice ‘cognitive medicine’ [listening to and talking to the patient] is a major culprit in driving up the cost of American medicine.” But because of something far more fundamental.
The attitude of surgeons ought to change primarily because their current attitude goes against the historical tradition of surgery. I have iterated and re-itereted time and time again in the course of this book how medicine has become a victim of the attitude of many its users and abusers. Surgery, being another medical profession, is equally affected, but it carries the additional burdens that I have just outlined.
There is no need for these burdens. Surgery has ‘suffered’ so to speak, quite a lot in recent years. Interventional cardiologists, for example, have made the need for cardiothoracic surgeons less essential. Of course they will always be needed, not least for heart valve repairs and transplants, but less so for CABGs and similar procedures. As put by Reckless and Dwight in the cardiology chapter of the excellent book, ‘An Insider's Guide to the Medical Specialties’:
“One almost feels sorry for the cardiothoracic surgeon, who having completed one of the most demanding and onerous training programmes around, is now rather less the NHS lynchpin than they may have anticipated…both their NHS and private practices are drying up due to a combination of the herds of interventional cardiologists stepping heavily on their toes and Government waiting list targets. In recent years, it has come to be widely accepted that coronary artery bypass grafting and angioplasty offer similar prognostic and symptomatic benefit in multivessel disease.”
Thus, to help alleviate those burdens, and to stop victimising surgery, the attitude of the vast majority of surgeons ought to change. And this can only take place through three things.
Firstly, the continuous remembrance of God, which we mentioned above. This is not difficult, considering that, no other medical professional has as intense a contact with the glorious human body as the surgeon. He is the master of practical anatomy, and as such studies God’s architecture better than anyone other medical professional. He observes derangements of it, more than anyone else. He is witness to the intelligent design therein. He can announce with Shakespeare’s Hamlet, “What a piece of work is a man, how noble in reason, how infinite in faculties, in form and moving how express and admirable, in action how like an angel, in apprehension how like a god! The beauty of the world, the paragon of animals”, and paraphrase Sir Isaac Newton, who famously remarked that, “In the absence of any other proof, the thumb alone would convince me of God's existence”, for there is more to surgery than orthopaedics – the surgeons deals with every single aspect of human anatomy. He is the possessor of the ‘surgical hand’, which one author listed with, "An artistic snowflake, a beautiful butterfly, a Coleus leaf, a panda bear, the complex vertebrate eye, and the hand of a surgeon” as “all examples of intricate designs found in nature”. God tells us He is nearer to man than his jugular vein (50:16). To the surgeon, His signs ought to be evident everywhere, even on his own hands.
Second, in the continual remembrance of the history of surgery. If I were to devise a curriculum for surgical trainees (not to say medical students) I would certainly make it compulsory to learn about the progress of surgical history, and the great figures of the history of surgery. Who can fail to be moved by the great humanity of Ambroise Pare that we have mentioned before? Or the bravery of Dominique Larrey, regarded by many as “the most outstanding surgeon of the Napoleonic era”, the man who “was the first to take first aid treatment to casualties on the battlefield with the introduction of ambulances and introduced the concept of triage in the evacuation of his patients”, the man described by Hayes Agnew, the American surgeon as follows, “As an operator he was judicious but bold and rapid; calm and self-possessed in every emergency; but full of feeling and tenderness. He stands among the military surgeons where Napoleon stands among the generals, the first and the greatest." A man praised equally by the Duke of Wellington, who “ordered his soldiers not to fire in his direction so as to 'give the brave man time to gather up the wounded' and saluted 'the courage and devotion of an age that is no longer ours'”, as by his Napoleon himself, who remarked, “If the army ever erects a monument to express its gratitude, it should do so in honor of Larrey”. He now has two monuments, erected in 1850 in the court of the Val-de-Grâce military hospital and in the hall of the Academy of Medicine in Paris.
Or the greatness of Henry Cushing, the father of neurosurgery, whose emphasis on a holistic vision of patients we have see before, a man “who possessed to an outstanding degree the attributes of a pioneer. He had determination, self-criticism, obsessional thoroughness, perseverance, extraordinary industry and stamina, an enterprising spirit second to none, and complete devotion to his patients”, who with his patients, “was almost charming, friendly and compassionate, never in a hurry of any kind”.
Or the brilliance of Frederick Banting, who in 1919 he was awarded the Military Cross for heroism under fire, whose research led to the discovery of insulin – and in that saved more lives than most. Or his namesake, Frederick Treves, whose beauty and humanity is known to everyone who watched the Oscar winning movie, ‘The Elephant Man’.
Or the equal philanthropy of Sir David Wilkie, a man who is “widely regarded as the father of British academic surgery, (who) proved to be a generous benefactor of the disadvantaged”, whose “main legacy to surgery was the establishment of a scientific tradition of discipline and criticism in surgical research and clinical practice. His recognition that acute appendicitis required urgent intervention undoubtedly influenced clinical practice”, who, as Sir Charles Illingworth said, showed his greatest contribution “in the influence he exerted amongst his colleagues and assistants. His genius lay in his ability to foster cooperation and inspire enthusiasm”. A man who in a recently published biography of him entitled, ‘Sir David Wilkie (1882–1938): surgeon, scientist and philanthropist’ by Scottish surgeon Iain Macintyre was described as:
“A man of singular charm, with a happy knack of breaking through the barrier of reserve. When introduced to a visitor, he would come forward with a welcoming smile, his eyes glowing warmly, his arms outspread as though for a continental embrace so that the stranger at once felt himself brought within the circle of his intimacy. He adopted the same welcoming smile in his daily encounters with patients and his associates, even down to the most junior houseman. He must have had many causes for irritation like the rest of us, but in the 12 years I knew him I never saw him angry or annoyed or anything but friendly. Like most of the others of my generation – Wilkie’s young men as we were called – my admiration for him was nigh unto idolatry.”
A man whose humanity and big heart is described by Macintyre as follows:
“His profound interest in what was then called social betterment is reflected in his collected papers by the eclectic range of charities to which he gave his time and support, from nursery schools in Edinburgh to missionary work in China, from scouting to opening a children’s garden and to radio appeals for support of some of these”.
Or the equal humanity of Alexis Carrel, who we mentioned before, who, “had certainly, along with Jaboulay, the best surgical hand that I ever witnessed in a career which allowed me to watch most of the great surgeons in the world”, as the great French surgeon René Leriche (1879-1955), put it. A man who wrote volumes about humanity, about its problems and possible solution, a man who made not just his patients, but the whole world, his concern. A legacy that continues to this day, in the charitable works of the late Michael de Bakey and recently retired Sir Majdi Yaqoob, the two most famous names in cardiothoracic surgery in the USA and UK.
Or the philosophical brilliance of men like Sir Michael Baum, Abraham Colles and Allan Whipple, who share with Carrel this reflective characteristic. In remembering all those great figures and others, men whose accomplishments in the operating room as well as in general aspects of human life, “were so brilliant that they forever shine in the history of surgery… the giants on whose shoulders we stand today”, men whose stories, as the great William Osler put it, “(do) much to stimulate our ambition and rouse our sympathies”, would it not be difficult to remain the ‘nasty surgeon with the ego’ so prominent in hospital life today. I think so.
And the third most important counter to the tide of arrogance and unpleasantness that has swept most of surgeons today, is the remembrance of a very important fact – that were it not for other specialties, surgery would have remained at a standstill. All successful surgery requires a pre-operative work up, and none of this is surgical. It is thanks to the radiologists, radiographers, nurses and microbiologists, that we can do X-rays, ECGs, and prescribe prophylactic antibiotics before an operation.
It is equally thanks to the works of hundreds of thousands of anaesthetists, medical scientists and pharmacologists, who devise analgesics, antiseptics, antibiotics and anaesthetic agents, as to the work of the operating surgeon and his assistants that operations succeed. Can a surgeon operate without the assistance of an anaesthetist, I wonder. The answer is obvious.
Even postoperatively, the majority of complications are ‘medical’ in origin – the patient is confused, hypoxic, feverish, vomiting, or dehydrated; most of which can be solved medically. Only rarely does the need arise when a patient needs to be taken again to theatre.
In recalling these three things, in remembering God, humanity, the surgeons of the past, and the surgeons of the present, and all fellow medical professionals (from the health care worker who took the patient’s ‘observations’ (or vital signs) and finds the patient to be in abdominal pain, to the house officer on call who assessed him, to the nurse practitioner who performed the ECG that made sure the patient was not having an MI, to the phlebotomist who took his blood, to the biochemist on call who by checking the patient’s amylase, ensured he did not have acute pancreatitis, to the radiographer on call who kindly took up the X-ray machine to the ward on the 10th floor to provide the surgeon with the X-ray that showed the perforated peptic ulcer, to the anaesthetist who ensured the patient was fit for theatre – all of these wonderful men and women have helped the surgeon in his most noble ideal – the rescue of a human life from the jaws of death), will the surgeon of the future achieve the success he deserves for his most intentions, for which he will get the greatest reward, as stated by God, “If anyone saves a life, it shall be as though he had saved the lives of all mankind” (5:32). Is there any greater incentive to become a surgeon more than that verse I wonder – for who saves lives and cures more than a surgeon?
In like fashion, the physician, in his numerous, often justifiable, but sometimes unjustifiable criticisms of surgeons, ought to remember that were it not for the genius of certain surgeons, their medicine too would have come to a standstill. No one can argue against the fact that infections, hypertension and diabetes cause a great proportion of death around the world. And who was it who discovered penicillin? The great Alexander Fleming, who became (and this will come as a great surprise to most) a “certified surgeon in 1906”.
The measurement of blood pressure was made possible only after the work of Nikolai Sergeievich Korotkov, “a Russian surgeon, a pioneer of 20th century vascular surgery and the inventor of auscultatory technique for blood pressure measurement”. And who was it who discovered (or co-discovered) insulin? An orthopaedic surgeon, by the name of Frederick Grant Banting. Is this not incredible? It is in the realisation of all these facts of history that the physicians are forced in developing a huge respect for surgeons.
Surgery and medicine and their branches, are twin professions. They complement one another, and one will not survive without the other. It is only in developing a mutual respect that they can survive as the magnificent healing arts that have carried mankind forward to this day. There is no doubt in my mind as to who would be king of the Kingdom of Medicine, but there is equally no doubt either as to who would be the queen, the myopic prince, the hyperopic princess with unilateral blindness and a hemianopia in the other, or prime minister – the jack of all trades, and master of none.
Undoubtedly, the surgeon is king – for he deals with everyone and cures, and the physician is queen, who occasionally supports and reverses (in the very acute scenario) but never cures. The myopic prince is the paediatrician, who is the mummy’s boy, closer to his mother than to his father, who only sees the immediate neonate, baby and child, and never deals with anything further. The hyperopic princess with unilateral blindness and a hemianopia in the other eye, is gynaecology and obstetrics, for she ignored half of humanity, deals mostly with post-pubertal women, and looks only at one region of the human body, the abdomen (with the perineum). She is a princess who, even if she tried, can never become king, unless she lends herself to a surgeon who turns her into a transvestite, another case where she is subordinate to he who is king. The prime minister would be the general practitioner, in whose hands lies a great deal of power and money. The soldiers are the radiologists, microbiologists and pathologists, who combine to defend the crown
Only in their integration will we achieve the harmony that the patient, the resident of the Kingdom of Medicine, thoroughly deserves.
 As the Quran says on the tongue of Abraham, "And when I am ill, it is He Who cures me; Who will cause me to die, and then to life (again)" (26:80-1).
 I do understand that referring to the ‘Surgeon’ as a man will raise some eyebrows, especially that there are some female surgeons. But it will make my life easier to refer to surgeons as men – especially in view of the fact that only 6% of surgeons in Britain are female (according to a recent poll by the ‘Royal College of Surgeons’) and in the USA, “76% of women who plan to pursue surgery lose their interest and commit to something else”.
 And since, “The Best Physician Is Also a Philosopher” (as Galen put it) – it may be safely concluded that the best surgeon is also a philosopher. A few examples that support this notion are: Guido Lanfranchi, a famous professor of surgery of the 13th century, who remarked, “It is necessary that a surgeon should have a temperate and moderate disposition . . . He should be well grounded in natural science, and should know not only medicine but every part of philosophy”. Abraham Colles, the famous Irish surgeon and student of George Berkeley, who remarked, “That no man can know his own profession perfectly, who knows nothing else; and that he who aspires to eminence in any particular science must first acquire the habit of philosophising on matters of science in general”. Alexis Carrel, who is one of the fathers of vascular surgery and the first American Nobel laureate (he was originally French), who one recent biography stated, “maintained this resilience through all his existence and his work defines the Carrel as the complex man he was, as the spiritual student he attempted to be, and as the philosopher of the human race he so desired to be in his writings”. Rudolf Matas, who was the true father of vascular surgery according to William Osler, who remarked, “To do all this to be all this, the Master Surgeon must be a man of mind, a man of thought, a man who knows his province, the human body, as a whole and not only one of its parts.” Allen Oldfather Whipple, the father of pancreatic surgery, who was known as the ‘surgical philosopher’, who a recent biography says, “Perhaps his research in the history of medicine is only one example of his dedication to the search for truth. A truth that would have been buried in between the folds of the past if it was not for his diligent work enlightened by his deep affection and life-long interest in the history, culture, and welfare of the people of the region where he was born.” Michael de Bakey, whose philosophical interest led the Academy of Athens, the world’s oldest philosophical institute to, induct him, in 1992, as member of the society. Last, but not least, Michael Baum, one of world’s most renowned breast surgeons, who prides himself in being a student of Karl Popper, and in calling himself a ‘philosophical surgeon’.
 The authors even pose an answer to the question, “How do surgeons become taller and better looking than physicians?” saying, “There are several potential explanations for the phenotypic changes between surgeons and physicians. Firstly, surgeons spend a lot of time in operating rooms, which are cleaner, cooler, and have a higher oxygen content than the average medical ward, where physicians spend most of their time. Furthermore, surgeons protect (but not always properly) their faces with surgical masks, a barrier to facial microtrauma, and perhaps an effective anti-ageing device (which deserves further testing). They often wear clog-type shoes, a confounding factor that adds 2-3 cm to their perceived height. The incidental finding that fewer surgeons are bald might be related to these environmental conditions and to the use of surgical caps. In contrast, senior physicians are surrounded by fewer people in their habitat (the patient's bedside and the office), and they therefore have less need to be easily identified or spotted by families and nurses in the middle of a swarm. Physicians tend to hang heavy stethoscopes around their necks, which bows their heads forward and reduces their perceived height. They also complain of a (clearly abnormal) need to endlessly update their knowledge in accordance with the current evidence based approach to medicine by reading and studying heaps of medical journals; this overload of information further grinds them down. Although a prospective study found that doctor's white coats decrease in weight with increasing seniority, no significant difference was found between the mean weight of physicians' coats and surgeons' coats (1.4 v 1.5 kg).” Fascinating!
 And associating partners with Him.
 I sometime think of what Tariq, one of my best friends, may God bless him and grant Him peace, would have become had he been still with us. A man I can only describe with the words - angel in disguise, with a heart of gold. And I think, in spite of his beautiful personality – the like of which I have never seen – (which makes one initially think he would never be a surgeon), he actually would have become the greatest one. I base this on my afore-mentioned beliefs, and on the fact that his brother Sherif, the closest person to him, has opted for a career in surgery, and his father is an ENT surgeon. I could be mistaken.
 It is interesting, for example, to note that some biographers of Alexis Carrel regarded him as the greatest vascular surgeon, not because of his technical virtuosity or manual dexterity (which he undoubtedly had, as described by Leriche above, but because “of his recognition that a rigid asepsis is absolutely essential for success”.