Frugal Physician Prescribes
Common Sense and Enthusiasm
Cut to Cure
drugs form the right arm of modern medicine, surgery makes up the left.
The left is surely not as busy as the right arm or half as muscular,
but not for the lack of trying. Modern surgeons evolved from the
barber-dentist-bonesetters of the past and thus have taken second place
to their drug-dealing brother medics. But, they stand proud of their
abilities. Surgeons often come to the rescue to bail out their
“pill-pushing” fellows in many emergencies.
Surgeons have an
aura about them, generally macho and aggressive, in a hurry, no
nonsense. Even they have changed with the litigious bent of modern
society. Overall, surgeons have had to slow their pace, follow more
protocols and bow to more paperwork. To be sure that all tests are
ordered and Is dotted and Ts crossed.
Early on in medical
training, students become aware of the differences between medical
specialists: Internists (internal medicine) are the thinkers in
medicine, thrive on testing and detective work. Pediatricians are
internists in miniature. Obstetrics (and gynecology) is a branch of
surgery (more or less), but its practitioners who work constantly with
women seem more mellow and compassionate. Psychiatrists, pathologists,
and radiologists stand on the fringe of medicine and, it seems, at an
even greater distance from people. Most of them rarely get close to
patients - other physicians don’t get much closer. Radiologists study
Xrays, pathologists read tissue slides, psychiatrists study behaviors.
All are generally aloof from real patient involvement.
is in a class of its own. Emergencies are very rare and business is
always booming because everyone gets zits and doesn’t want his face to
fall off in front of the boss. So, the skin doctor has a place of
relative honor, uses lots of potions and lotions as well as pills, and
rarely gets his hands bloody.
The long white medical frock
which is almost synonymous with medicine and physician-hood has come to
symbolize separation: separate knowledge and power as well the
separation between physician and patient. These days, physicians are
clean and sterile (interesting word - sterile), as if patients are
unclean and infectious.
Within medicine as a whole, an aphorism
circulates which may put some perspective on the various disciplines.
It has a number of variations, but this one is a good approximation:
“Family physicians know nothing and do nothing. Internists know
everything and do nothing. Surgeons know nothing and do everything.”
adage does justice to none of the specialties, yet it gives valuable
hints about how they are perceived. It also tends to empower surgeons.
Not that they need more.
During most of the surgical rotation of
my internship, I spent much of my time following, assisting, and
listening to Dr. Elwood Owens. Owens was a large man and looked bigger
when he briskly toured the wards in his white, flowing coat. He had
dark hair, a round face, and wore spectacles.
weren’t Army issue. Owens had no intention of looking or acting
military any more than required. Elwood was a brusque, talkative, proud
Southerner. He really was a “good ol’ boy,” an enthusiastic operator
with eyes on advanced training in cardio-thoracic surgery at Emory
University in Atlanta.
He couldn’t tell me often enough in his
Georgian accent about his plans: “I’m gettin’ outa here as soon as I
can. I’m gonna do hots (meaning hearts).” Arrogant and obnoxious though
he could be, it was hard not to like Owens and get a chuckle from his
stories - or at least his telling of them.
One of his favorite
ditties went like this: “When the Army drafted me, they made me a Major
doing General Surgery. I told them, “I would much rather you make me a
General doing Major Surgery.’”
Although Dr. Owens tried to
maintain an aura of superiority, his impression of himself was not
universally shared. Many people thought him sadly laughable. Prior to
my arrival at Martin Army Hospital, the staff had included another
surgeon named Haywood Owens, Elwood’s brother. I gathered that Haywood
was more productive and less verbal than his younger brother. Tall,
red-haired, and good-looking, Haywood favorably impressed many hospital
workers. From time to time, the two surgeon-brothers would be seen
walking the hospital hallways. A common refrain heard at the time was,
“There they go: Redwood and Deadwood.”
Elwood was convinced that
surgeons were not only the real elite of the medical profession but
also God’s greatest gifts to humanity. To become a cardiac surgeon
would place him in the highest exalted state. Elwood didn’t think much
of internists or most other non-surgeons. Speaking with his round,
pompous drawl he used to say, “They just play with their tests and
pills. Especially those neurologists. Tests and pills. When they get
stuck, they have to call on us. We can do anything an internist can do
and cut besides. You know that surgery is the only permanent way to
cure. We surgeons cut to cure. Yes, we do. Cut to cure.”
is warranted in many situations, especially in event of trauma. But
like the prescription of medication, surgical procedures are much
overdone. “My feeling is that somewhere around ninety percent of
surgery is a waste of time, energy, money and life.” (Robert Mendelsohn)
it doesn’t take long for a keen observer to discover that cutting does
not make for a sure cure even when indications seem clear. In fact,
surgery can do more harm than good, especially when entered into
“CUT TO CURE,” Owens believed. There are a number of ways to address that idea. Let’s see what surfaces.
• First off, we might want to consider the difference between curing and healing. There is a difference, you know.
is about fixing and repairing. Curing is more superficial, to my way of
thinking, than healing. Some ailments can be cured, yet a healing does
not take place.
In recent years, different US government
administrations have been working at “fixing” the medical system.
Something like a cure. But, it will take more than “fixes” to put
Humpty Dumpty back together again.
People are the same. The superficial patching up of patients never guarantees that the effort will be a whole success.
• There may be something to the idea a friend once told me, “You can cure hams, but can’t cure people.”
sentiment points to the requirement for the patient - at some level -
to be actively involved in the process. Just cutting - even technically
perfect, may only take care of one layer of a problem. Human problems
almost always have several layers deep. The physical body alone
certainly has many layers, but how many others are there yet for modern
scientists and physicians to uncover?
• Another friend, Benjamin
Franklin is noted for saying, “God cures and the doctor takes the fee.”
This idea, which undoubtedly predates Franklin, draws in those layers.
It also hints that the physician’s role, although sometimes necessary, is often secondary or even merely window dressing.
Have you ever noticed that “curing” one problem brings another to the
surface. That seems to be a common event in home repair. Before you get
the original job done, you have created more to deal with than you
I have noticed the same in writing books. Editing can
be very tough. (You might call it part of “curing” a book.) It
seems almost impossible - especially editing one’s own work - to clear
errors without making further ones. I have never been able to come up
with a perfect copy, even on a relatively brief essay. Only God is
perfect, and I wonder about that some times.
Just think how much more complicated a human being is compared to a book or a home improvement project.
Simple incision into the human body is more involved than Regular
Surgeons know or will lead their patients to believe. It is not like
cutting a cooked ham or turkey which may be a chore in itself.
into tissue is like entering a temple. Full preparations and obeisance
to holy rites should be followed. That would go far beyond surgical
scrubs and draping. Playing rock and roll in the operating theater is
probably not compatible with treating the body as the holy temple which
The surgeon’s work is most certainly a technical skill.
Yet, humans are not just biological machines and surgeons should
develop skills which go far beyond cutting and debriding, extracting
My mind now carries me back to the Surgery Service
at the Hermann Hospital, Houston, Texas. The first surgical patient I
met was an elderly black man named Abraham Johnson. He had been in the
Surgical Intensive Care Unit for some days and was being readied for
skin grafting. Abraham had suffered severe burns to large areas of both
of his legs as the result of a freak accident.
Abraham was sitting peacefully in his easy chair watching a favorite
television program when the TV exploded before his eyes. Unfortunately,
Mr. Johnson had some neurological deficit which prevented him from
responding rapidly to this emergency. What should have been a minor
mishap became a major physical trauma.
On that same day, the
newbies were introduced to the real oddity of the whole surgical wing,
Jeremy Jones. Jeremy was a twenty-five year old man who had been
injured in a motor vehicle accident several years previously which left
him with all extremities paralyzed (quadriplegic). Jeremy reacted not
atypically to his grievous injury by acting out his anger against
everyone who came into his aura. He eventually landed in a nursing
home. His condition and care deteriorated over time as the aides and
nurses “burnt out” trying to deal with both his devastated body and his
Jeremy had been admitted to the University
Hospital because of huge gaping, oozing, stinking bed sores over both
hips. He had been treated with the gamut of surgical debridement,
continuous dressing changes, and a host of antibiotics with no lasting
benefit. The surgical staff was at that time making the decision to do
a radical operative procedure to “fix” his problem.
repairs or even routine operations were never (at least in this
lifetime) high on my list of favorite medical interests. Oh, there is a
genuine mystique about the Operating Room, but not one powerful enough
to hold my attention long. At the present point in my life, I halfway
imagine that much of my distaste for surgery comes from myself being a
surgeon under horrid conditions during the American Civil War.
tried watching surgeries from the operating theater gallery, looking
over the shoulders of physicians, nurses, and students in the OR suite,
and even peering into the operative field while holding retractors.
But, I never obtained much of a view through the surgical incisions or
developed more than a passing curiosity regarding the surgeons’
I was occasionally called upon to hold retractors and
considered that task engrossingly boring. (another oxymoron) It was
exhausting to stand utterly immobile for what seemed like hours on end
doing the job of a very dumb machine - holding a hooked metal bar or
two ever so steadily and with the right amount of tension. All too
often the surgeon decided that, “You're not holding the retractor
firmly enough” or “Damn it, loosen up. You'll tear the guy’s flesh.” It
didn’t take long for my feet, back, and eyes to begin to ache. I would
selfishly, but unashamedly pray that the surgeon would work rapidly and
efficiently. Fortunately, I was never delegated the job of retracting
for one of their marathon procedures. In fact, my retracting days were
relatively few as a student as well as an intern. Thank God for small
favors. As far as I was concerned, they could take those darn
retractors and ....
Some days along the way, Mr. Johnson was
taken to the OR. His legs were grafted with split thicknesses of pig
skin in hopes of stimulating recovery from his burns. He was then
returned to the SICU for observation. At about the same time, Jeremy’s
festering wounds had received maximum medical management and his op day
also arrived. When the procedure began, there were more techs,
students, nurses, and interns in the OR than I could count.
was wheeled into the suite on a stretcher and moved to the operating
table. The crew not so dexterously propped him on his left side,
anesthesized, surgically scrubbed, and draped him. His wounds were
still so wet and pussy that the antiseptic scrub didn’t seem likely to
have had much effect. The surgeons and helpers proceeded to flay his
right leg, disarticulate the femur at the hip joint, and create a large
pad over the hip with a generous portion of thigh tissue. Bluntly put,
they cut his damn leg off!!
I managed to watch the spectacle for
a half hour or so, but could take only so much. The operation was so
revolting to me and my sensibilities. I was equally disturbed by the
surgeons simplistic assumption that cutting his leg off would be a
quick and effective way to get rid of his infected bed sore. Even
before he went into surgery, they were making plans to eventually
amputate the other limb.
Despite his terrible physical
disability, his emaciated frame, and depressed mental state, Jeremy
must have had some powerful will to live. For, he was soon out of
intensive care and on a surgical floor. We made regular rounds to dress
his surgical wound and other bed sore. I always joined in on rounds,
but from that surgery on, I made myself as scarce as possible in the
OR. Apparently, I was not greatly missed. No one ever questioned my
Mr. Johnson didn’t fare quite so well as Jeremy.
Actually, his life was soon in danger for the second time. Mere hours
after his grafting, he was spiking a fever, his blood pressure was
drifting south, and he was in deep trouble. Johnson was in a state of
shock, source undetermined. The surgeons started doing blood cultures,
pumping shotgun antibiotics, and pouring in IV meds to prop up his
Yet, they scratched their heads in wonderment
about the cause of the episode. It took several hours of fighting a
battle with septic shock before the chief resident had the sense to
take a look at the obvious source of the problem -- the recent porcine
skin grafts. A grisly, oozing mess appeared when Abraham’s dressings
were removed. The tissue combination had become a culture medium and
the graft was rejected - or was it the other way around?
the removal of the dressings and grafts, the cleansing of the slimy
debris, and the administration of lots of IV fluids, Abraham came
around rapidly. But, the dangers to his recovery were not yet dismissed.
few days further along, Jeremy was making an amazing recovery. His
surgical wound was closing and drainage decreasing. While he still had
the gaping sore on the opposite hip, improvement on the surgical side
was easily recognizable. He perked up psychologically as well,
communicated and cooperated with medics and nurses. Surely, positive
hopeful attention had effect.
The surgeons seemed to take the
effects of Jeremy’s surgery as some sort of universal sign. One
morning, we rounded the SICU and passed beyond Mr. Johnson's bed. The
staff talked about their success with Jones and lack thereof with Mr.
Johnson. The chief resident was so thrilled wtih Jeremy's speedy
recovery that he couldn’t resist, “Maybe we could do Johnson a favor
and cure him too by cutting his legs off.”
comment may have “just come out” and was never seriously considered. At
least as far as I know. I soon passed on to another rotation and have
no knowledge of eventual outcomes for Misters Jones and Johnson.
some surgeons have this simplistic “cut-to-cure” perspective. They
sincerely believe they are specially trained and ordained to do
“miracles.” And, the public clearly buys into their spiel, beliefs, and
implied promises. Even though, they never make guarantees.
Physicians and Prudent Patients realize that there is much more to life
than the bodies in which we navigate the planet. That even in the 21st
century, much is left to be learned about even the material form, which
is just the tip of the iceberg of our being. That life and death,
coming into and departing the body is always more involved than a
medical operation or decision. And, that real cures - healings - cannot
be done to a patient. Such events arise from the inside out. If a
physician or surgeon is involved, s/he is just one part of the picture.
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