Respectful Insolence

You want to know how to make a surgeon angry?

i-e7a12c3d2598161273c9ed31d61fe694-ClassicInsolence.jpgVacation time! While Orac is off in London recharging his circuits and contemplating the linguistic tricks of limericks and jokes or the glory of black holes, he’s rerunning some old stuff from his original Blogspot blog. This particular post first appeared on June 3, 2005. Enjoy!

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.

madmarv

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.

Comments

  1. #1 Tomas
    September 1, 2007

    Ok, let me see if I can piss you off again. I am of the opinion that most surgeons, most engineers and other non-research doctors are not scientist. The defining function of the scientist is to systematically add to our common knowledge about the world through the use of scientific methods. There is a difference between knowing science and doing science. People who know science are in science based profesion, people who do science are scientist.

    That is not to say that engineers or doctors cant be scientist, but that depends on whether they do science or not.

  2. #2 Tomas
    September 1, 2007

    Woops, im not really disagreeing with you…hmm, then I guess im just trolling :(

    Need to upgrade my reading skills.

  3. #3 rlbates
    September 1, 2007

    Maybe some of us surgeons aren’t scientists, but Dr Joseph Murray was both prior to retiring. http://rlbatesmd.blogspot.com/2007/09/dr-joseph-murray-plastic-surgeon.html

  4. #4 blf
    September 1, 2007

    Thanks, Thomas, for the correction to the initial comment. I am a software engineer by profession,† educated as a mathematician (and also as an engineer), and tend to blow up much as Orac does whenever I see engineers and engineering so casually dismissed. I was about to explode (again), pointing out that Orac more-or-less squarely hit the target, and with the change of some details, his post could be re-written (re-read?) as using “engineer” instead of “surgeon” without any significant change to the message.

    † At the moment, however, I am unemployed; please see my résumé if you are looking for a software engineer.

  5. #5 Toaster
    September 1, 2007

    Well, it could also be argued that a lot of what scientists do isn’t exactly science, but instead a lot of technical procedures. I mean, sure, we’re scientists when we’re analyzing gathered data and planning experiments, but when we’re just doing DNA isolations to genotype a mouse so we can decide whether or not to breed it into the colony, then we’re just technicians, as least until we have to analyze the gel bands.
    In fact, there’s currently a push in my lab to compile a big book of SOPs so that we can have a reference.

  6. #6 A Bohemian Road Nurse...
    September 1, 2007

    I think you might be a little thin-skinned, no insult intended.

    For example, for decades many of us nurses have been dismissed as “doctors’ handmaidens”, “pooper-scoopers”, and sometimes the whipping posts for grouchy doctors in general (especially mercurial surgeons, heh heh). But our profession has never allowed that to hinder us in our endeavor of the pursuit of scientific knowledge of The Patient and the illnesses which beset him/her.

    For proof simply view the development of the nursing profession: whereby we began as task-oriented (“technicians”) versus today’s very sharp-minded, creative, and knowledge-hungry nurses who can create individualized patient care plans, interpret lab/chemistry reports, memorize zillions of medication facts and their effects on The Patient, interpret EKG’s, and pick up subtle clues in a patient’s condition—all while managing increasingly complicated computerized machinery and gadgets. The scientific progress of our profession is amazing if you really think about it.

    Therefore, I think that if somebody calls any medical professional a “technician” versus a “scientist”…..

    Well then, in that case, I think one must simply shrug their shoulders and and go on—ignoring those silly fools who have no clue about what they’re speaking….

  7. #7 Michele
    September 2, 2007

    I don’t think you’re over-reacting at all. I react the same way whenever a nurse who doesn’t have a clue what goes on in the O.R. tells me “I could never work in the O.R. you don’t do anything but sit there”.

  8. #8 Deborah
    September 2, 2007

    Medical Technologists are also under-appreciated. “The Lab” is to most people, even doctors and nurses, a black box where all you do is “push a button” and lab results come out. Most people only see the phlebotomists and have no idea how the test results are produced. The worst insult was when the owner of a lab that I worked at asked if I could train the janitor to do some of the work when we were short staffed. And he was an MD!

    The education is similar to a pre-med plus a clinical internship. We work as clinical microbiologists, hematologists, chemists, blood bankers and more. Continuing education is a must to keep up with new technology and tests. While Med Techs are not research scientists, a good understanding of science is needed to ensure quality results for the patients and physicians. Pre-analytic, analytic and post analytic issues need to be addressed for each sample. You have to know the principles of the tests and how to interpret them.

    It can also be a high pressure job when the floors are screaming for results and your assay is not working or there are complications, poor specimens, or interfering substances. Or when a surgeon orders a crossmatch in the middle of surgery, there is an unidentified antibody, you can’t find compatible blood, and they are calling every 5 minutes to see if the blood is ready yet because the patient is bleeding out.

    There is a technician aspect to the job, when things go well, but you have to know what to do when things aren’t working right. Oh and we make less than nurses and have nearly zero recognition.

  9. #9 Kassiane
    September 2, 2007

    Best way to piss off a surgical PATIENT:

    Don’t tell her anything, including that you have never done this delicate operation before, much less the risks, and treat her as though she has no brain but just a (insert injured/ill body part here). Then get inordinately angry when she requests, oh, actual information.

    I suspect this happens more with some kinds of surgery than others?

  10. #10 Michele
    September 3, 2007

    Kassiane,
    Just with some individual surgeons more than others. If you find yourself in that situation run, do not walk to a different surgeon. In these days of informed consent you should have a very good idea of what is supposed to happen when you walk out of that office. If you don’t, find someone who will give you the information you need.

  11. #11 Kassiane
    September 3, 2007

    Michele,

    NOW I know to run. This is the first medical thing I didnt research to the HILT (didn’t have time. Fractures are fast like that)…and it may require ANOTHER surgery and is requiring total lifestyle change. No more 20 mile hikes. No more back flips on balance beam. Running on a fractured talus would have been colorful but I would have found a way, if I had it to do over.

    That is one doctor i dont regret pissing off, but that was way post op.

  12. #12 Bongi
    September 4, 2007

    i really think someone who says a surgeon is just a technician has no idea at all. someone who throws a comment out without the slightest concept of what he is talking about does not base his opinion on empirical fact and therefore is not scientific either and can’t be taken seriously.

    i don’t think you over reacted at all. however i wouldn’t get angry with the ignorant. they know not what they do.

  13. #13 Shygetz
    September 4, 2007

    Wow, let me oil up my World’s Smallest Violin for the surgeon. I am a Ph.D. analytical chemist and biochemist; do you know how often I hear that I’m not a real doctor? It was the worst when I was working as a student doing research in a hospital. Ph.D. scientists were not recognized by title, while they were expected to address MDs as “doctor”. So, I think the meat mechanics of the world need to develop a hide and get over the idea that they are not scientists :-)