Editor’s note: The following comments were received regarding recent articles published in the Bulletin.
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Surgery for the developing world
In his letter “Back to basics” (Bull Am Coll Surg. April 2013;98:69-70), Edward Walworth, MD, FACS succinctly describes his joy at contributing to surgical care in the Ivory Coast and Haiti. He commends the American Board of Surgery for allowing certain trainees to engage in an elective in the developing world and bemoans the trend toward reliance on surgical technology, which may leave some trainees unable to perform open laparotomy with needle and thread.
Although aptly put, the threat that surgeons will no longer be capable of performing such traditional procedures goes beyond a decline in dexterity, and extends to the whole art of clinical diagnosis. Those surgeons who have a few or more grey hairs will undoubtedly recall the masters of old who, with great panache, could diagnose dextrocardia or malingering from the foot of the bed! They were the experts, the “Sherlock Holmes,” who spotted the tell-tale signs that others had missed and put the whole picture together in a shattering display of clinical acumen.
Such clinical mastery is now frowned upon in preference of the apparent surety of the computed tomography or magnetic resonance imaging scan, despite numerous descriptions of their limitations. Alas, the false confidence now given to technological aids has not only engulfed our trainees, but also the public and worse, the lawyers. Furthermore, perfectly appropriate techniques, such as closed treatment of fractures or symphysiotomy for obstructed labor, have been consigned to the dustbin of the past, and those surgeons who use these approaches (often with aplomb and excellent results) are at risk of legal action unless they gain categorical assent from their patients.
All this means that the surgical trainee of today is ill-equipped to deal with the surgical problems of the developing world. Dr. Walworth, in contrast, could rely on his training and experience of the 1970s, and his efforts were met with very acceptable results, despite the absence of nearly all laboratory equipment.
His story demonstrates eloquently that good practice in a resource-poor setting may yield positive results. In the quest for perfection, we in the resource-rich world have forgotten that this reliance on technology comes with a price—not just financial, but social and practical. No wonder the poor benefit only from approximately 3.5 percent of all surgical procedures done worldwide.* Millions of people have no access to surgical care and die from conditions that could be treated fairly easily.
It is time that surgery was recognized as an adjunct to primary care. It has been shown to be hugely cost-effective—far more so than most medical interventions—and successful surgical care in the developing world setting gives all other medical care credibility.
The International Collaboration for Essential Surgery has drawn up a definition of 15 procedures that would address approximately 85 percent of the surgical needs of people in the developing world who currently have no access to surgical care whatsoever.
It is our humanitarian duty to train health care personnel, not necessarily physicians, to perform these procedures so that the unmet burden of surgical disease does not haunt the profession for generations to come.
Michael Cotton, MA (Oxon), FACS, FRCS(Eng), FCS(ECSA), FMH (Switzerland)
*Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, Gawande AA. An estimation of the global volume of surgery: A modelling strategy based on available data. Lancet. 2008;372:139-44.
Dr. Jordan inspires
Having recently published a short autobiographical work titled Lifetime and Fortune: A 20th Century Neurosurgeon’s Journey, I read with interest the column titled “Is medicine still a good profession? Reflections of a retired surgeon” by Paul H. Jordan, MD, FACS, in the January Bulletin (Bull Am Coll Surg, 2013;98:58-60). Although negative aspects of neurosurgical training are discussed in my book, my enthusiasm for the profession has persisted for nearly 40 years.
However, I was both surprised and appalled to read that “90 percent of 5,000 physicians who participated in a study by The Doctors Company were unwilling to recommend medicine as a profession.” In my book, I reflect on the satisfaction of providing lifesaving interventions to patients. Almost weekly during my years of practice I was encouraged by the knowledge that an individual incapacitated due to severe pain/weakness could promptly be returned to productivity and relative enjoyment of life by a “simple” operation.
Since childhood, I have been a recipient of medical/surgical interventions that have allowed me to enjoy excellent health at the age of 76. The negative attitude toward medicine described by Dr. Jordan suggests to me that its origins lie in the energy, time, and cost required in reaching the goal of being a reliable health care professional rather than the lack of satisfaction derived from practice. I would be most interested to hear/read further comments on the topic.
Edward R. Lang, MD, FACS
The article in the January 2013 issue of the Bulletin by Paul H. Jordan, MD, FACS, is the nicest and most inspiring piece I have read in some time, and he should be complimented by all of us sharing his pride in the practice of general surgery. Thank you for this first article in the Bulletin’s new and very welcome column, From Residency to Retirement.
I first met this unassuming but impressive and friendly man when I was a freshman at the University of Chicago, IL, and he was a medical student. He has been a role model and a warm friend since that time. Dr. Jordan has been a truly major contributor to both the science and the practice of surgery over the course of an unusually long and distinguished career at Baylor College of Medicine, Houston, TX, but he retains the spirit of his youth as demonstrated by this essay. His message is powerful, and I am now copying his presentation for my medical student tutorials at my own university. He has an important message, and he tells it well. Our students need to hear him!
Walter Lawrence, Jr., MD, FACS