“Medicine is a social science, and politics is nothing else but medicine on a large scale.”
— Rudolf Virchow1
Late last week, I was struck with a familiar sense of helplessness. My patient, Mr. J, a gentleman in his 30s, had a piece of his skull missing, was nonverbal, and scored a three on the Glasgow Coma Scale. He was admitted for injuries sustained after being brutally assaulted while in prison. Having already undergone multiple operations, the prognosis for the return of his neurological function was close to zero.
As surgeons, we are trained to solve the problems in front of us—to work with our minds and hands to “fix” issues. However, we often care for patients like Mr. J for whom we have little to offer, those we cannot help get better using only our surgical skills. The issues that affect the care of these surgical patients are complex and run along society’s fault lines—imperfect health care delivery systems, unequal access to care, gun violence, homelessness, structural racism, and institutionalized sexism. As such, the solutions need to go beyond the traditional definitions of surgical care and straddle the social, economic, and the political.
The evolving role of the surgeon-advocate
The history of surgery illustrates the ever-changing role and scope of the surgeon and what they can do—from the “minimally educated, itinerant barber surgeons” of lore to today’s highly respected surgeon-scientists who practice evidence-based medicine.2
The surgeon-scientist has, over the last century, built an impressive body of work that often exists at the intersection of the social sciences and surgical care. Rigorous scientific inquiry has helped determine the causes of disease processes, while research has helped quantify the effect of socioeconomic determinants on individual and community health.3 However, today’s health care climate and its unique challenges mean that surgeon-leaders are called upon to take on new roles that move beyond well-established clinical and research frameworks.
Whereas health care problems are myriad, there are striking commonalities in the reasons that contribute to their continued prevalence. For example, smoking, a known carcinogen, is staging a comeback among young adults, especially in low- and middle-income countries.4 Obesity, a leading modifiable cause of mortality and morbidity, remains difficult to prevent and treat despite scientific advancements.5 Gun violence, with well-understood links to lax gun control laws, continues unabated in the U.S.6
The disparities in health care outcomes for racial, ethnic, and sexual minorities are documented extensively but have yet to be dismantled.7-9 There is little scientific uncertainty about the efficacy of vaccines or the inevitability of global warming—yet we live in interesting times, where scientific evidence is no longer correlated with public opinion or reflected in policy change. The failure to find workable solutions in health care today has not been due to a dearth of knowledge, but rather to a lack of effective health care policies, consensus among stakeholders, targeted heath education, and political action.
A curious mix of naivety and arrogance has kept surgeons from engaging in policy work and political discourse. There is a tendency to view the study and practice of policy, advocacy, and public health as incompatible with real surgery, and that contributing to policymaking is something we only do when we can no longer perform surgery and engage in hard science. The reality is, health care and health policy experts exert influence over what kind of operations we can perform, the setting in which we perform them, who has access to our services, what our remuneration will be, and ultimately, how well we can do our jobs, and how satisfied we are performing them. As the surgeon-scientists among us well know, political will is linked to priority setting in biomedical research, and influences what kinds of research gets bankrolled, which disease studies are funded, what research methods we use, and which regions of the U.S. and around the world receive allocated resources.
Engagement at all levels
It is clear that for surgeons to continue to provide excellent clinical care, remain relevant in today’s health care environment, and strive for societal well-being as a whole, we have to be prepared to fully engage with health care in its entirety and lend ourselves to being not just clinicians and scientists, but also strident health care advocates. In doing so, we may seek inspiration from those among us who have already mastered working across disciplines and outside of established paradigms. Surgeons such as Atul Gawande, MD, MPH, FACS, a general and endocrine surgeon, Brigham and Women’s Hospital, Boston, MA, and a leader in the discussion of surgical quality improvement, have reached millions through the written word and focused national attention on topics as varied as surgical safety and end-of-life decisions.10 Others like Dorry Segev, MD, PhD, FACS, a transplant surgeon at Johns Hopkins University, Baltimore, MD, and an internationally recognized expert in the area of organ allocation, have taken their research to Capitol Hill and spearheaded the passage of legislation that allows for human immunodeficiency virus-positive organ transplant.11 Other physicians, such as Melina Kibbe, MD, FACS, chair, department of surgery, University of North Carolina at Chapel Hill, have harnessed the power of the media to draw attention to gender disparities in research and the widespread implications it has for efficacy and safety of treatment modalities in the market.12 Along with these high-profile examples of surgeon-advocates in action, there are many others who are quietly collaborating with and leading stakeholders, including patients, patient advocates, policymakers, public health professionals, the media, and others through this turbulent era in health care.
As surgeons, we prize single-minded focus and a certain insularity in our dedication to our craft, but we should vigilantly stand guard against this single-mindedness blinding us to the struggles of the patients we serve. Surgery is responsibility—our careers and our lives are built upon this foundation. But how far does this responsibility go? Does it stop with caring for Mr. J as he is now, or does it extend to preventing this situation from happening to others? Should a surgeon try to address the issues related to mass incarceration, the disproportionate arrests of men of color, and the effects of structural violence on patients and their families? The answer, I realized, captures the essence of what I believe is the role and future of surgeons as leaders.
- JRA. Virchow misquoted, part‐quoted, and the real McCoy. J Epidemiol Community Health. 2006;60(8):671. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC2588080/. Accessed October 13, 2017.
- Evers BM. The evolving role of the surgeon scientist. J Am Coll Surg. 2015;220(4):387-395.
- Marmot M. Social determinants of health inequalities. Lancet. 2005;365(9464):1099-1104.
- World Health Organization. Tobacco fact sheet. May 2017. Available at: www.who.int/mediacentre/factsheets/fs339/en/. Accessed September 13, 2017.
- U.S. Department of Health and Human Services. National Institute of Diabetes and Digestive and Kidney Diseases. Overweight & Obesity Statistics. Available at: www.niddk.nih.gov/health-information/health-statistics/overweight-obesity. Accessed September 13, 2017.
- Center for Gun Policy and Research, Johns Hopkins Bloomberg School of Public Health. Webster DW, Vernick JS (Eds). Reducing gun violence in America: Informing policy with evidence and analysis. The Johns Hopkins University Press. 2013. Available at: https://jhupress.files.wordpress.com/2013/01/1421411113_updf.pdf. Accessed September 13, 2017.
- Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care; Smedley BD, Stith AY, Nelson AR (Eds). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press; 2002.
- Mayer KH, Bradford JB, Makadon HJ, Stall R, Goldhammer H, Landers S. Sexual and gender minority health: What we know and what needs to be done. Am J Public Health. 2008;98(6):989-995.
- Fiscella K, Franks P, Doescher MP, Saver BG. Disparities in health care by race, ethnicity, and language among the insured: Findings from a national sample. Med Care. 2002;40(1):52-59.
- Sandhu S. Atul Gawande: If I haven’t succeeded in making you itchy, disgusted or cry I haven’t done my job. The Guardian. October 11, 2014. Available at: www.theguardian.com/books/2014/oct/11/atul-gawande-surgeon-author-interview. Accessed September 13, 2017.
- Victor D. Johns Hopkins to perform first H.I.V.-positive organ transplants in U.S. New York Times. February 10, 2016. Available at: www.nytimes.com/2016/02/11/health/johns-hopkins-wins-approval-to-perform-hiv-positive-organ-transplants.html?mcubz=3&_r=0. Accessed September 13, 2017.
- CBS News. Sex differences in medical research 2014. Available at: www.cbsnews.com/videos/sex-differences-in-medical-research/. Accessed September 12, 2017.