In the not so distant past a surgeon was defined as a doctor who was skilled with the knife. At the time I attended medical school and trained in general surgery from 1949 to 1960, students learned general medicine as a basis for general practice or a specialty. First, there was a thorough grounding in the basic sciences, especially anatomy and pathology. We learned to appreciate disease by seeing, touching and smelling cancers or syphilitic aneurisms and learned to evaluate laboratory work by doing our own blood counts and bacteriologic stains. The finding of acid fast bacillus in a patient’s sputum brought together the patient’s cough and the rales in his lung with our laboratory finding.
A course in physical diagnosis, based on that greatest of all medical textbooks, “Physical Diagnosis” by Richard C. Cabot and F. Dennette Adams, two gifted Boston physicians, preceded clinical clerkships. The stethoscope, used to detect rales, intestinal activity and cardiac murmurs was an important diagnostic tool, not just an ornament to hang around at technician’s neck.
In two years of in-hospital study, we rotated from medicine to pediatrics to surgery and obstetrics along with shorter periods on specialties and outpatient clinics. We learned to look in ears, examine the eye grounds and to do a pelvic examination. We followed the residents and attending’s on rounds to pick up ‘pearls’ and spent long hours holding retractors in the operating room. It was often tedious, but at the end of four years’ students in my class could care for common problems in pediatrics or medicine, deliver a baby, cast a fracture, suture a laceration, do a spinal tap and diagnose appendicitis.
The now out of fashion rotating internship added to our understanding of the human condition and shaped students into ‘complete doctors’. This further exposure to a variety of specialties allowed young doctors to better select their life’s work. More than one intern who originally thought he would become an internist became bored with dispensing pills and chose surgery or obstetrics. We have all seen the tragedy of a clumsy resident who chose surgery during medical school but should have been in a different specialty.
My general training was an excellent preparation for my tour of duty as a medical officer on an aircraft carrier in the navy. I treated the full spectrum of diseases, ingrown toenails, venereal disease, common aches and pains, allergies, fungus infections of the skin, pneumothorax and emotionally disturbances. I did my first appendectomies, with a spinal anesthetic at sea. There were also fractures, shoulder dislocations and a multiply injured pilot who required a tracheotomy.
The surgical residency at the Cook County Hospital in Chicago included six months on pathology, divided between the morgue and surgical pathology. The daily autopsy was an opportunity to learn surgical anatomy and the study of microscopic sections allowed us residents to correlate the patient’s clinical picture with his cellular pathology. The mastery of surgical anatomy is essential for surgeons to find the a vascular planes of dissection that make every operation bloodless and ‘easy’. At the end of my career, I volunteered to ‘cover’ for the pediatric surgeon at the Cook County. I knew something was very wrong with the training system when we were scrubbing for a left upper lobectomy. I asked the resident if he had dissected the blood supply of the lung at autopsy. He said, “I have never seen an autopsy.
The surgical residency at the Cook County Hospital during the late 1950’s included rotation through fractures, neurosurgery, thoracic surgery and pediatric surgery. Several of my fellow residents who practiced in smaller communities managed head trauma and fractures along with the full gamut of general surgery, including the emergency resection of abdominal aneurysms.
I spent two additional years in thoracic/cardiac surgery and then practiced pediatric surgery, which included a full spectrum of disease, including tumors and malformations of the neck, tumors of the urinary system, thorax and congenital malformations of the gastrointestinal tract and lungs. Pediatric surgery was, indeed general surgery of the infant and child. At one time or another, all my training was useful. I once explained to an orthopedic resident how to reduce and cast a Montegia fracture, [fracture of the ulna with dislocation of the radius].
As medical education tended toward early specialization, my residents in pediatric surgery-who had completed general surgery no longer knew how to examine an ear or recognize the significance of the odor of ketones in a child with diabetes.
When I developed a small skin lesion, that any surgical intern could have removed in a half an hour, I went to a local clinic and consulted a ‘primary care physician’ to remove the lesion. He said he couldn’t do it and referred me to a dermatologist. Since I didn’t have insurance, the office person asked for my credit card number. The first dermatologist did the biopsy then another dermatologist excised the lesion and a plastic surgeon closed the wound, all for $5000.
A few years later, I had some abdominal pain and low blood pressure. The E.R. and ICU doctors did not do a history or a physical examination, but with a battery of tests and scans they found a gangrenous gallbladder. The surgeon who said he was going to operate did not bother with an examination and admitted he had not seen my medical record. I told him to get lost. The next surgeon did a laparoscopic cholecystectomy, but left the post-operative care to ‘hospitalists’, including a wound care doctor.
Politicians quibble over the delivery of medical care, but the real problem lies in medical education. The leaders of our medical schools must decide if their graduates will have sufficient education in general medicine to deserve the M.D. [medical doctor] of if they are going to train specialists and sub-specialists. If some plans to restrict his practice to knee replacements, there is no point in spending four years in medical school. A degree in mechanical engineering or robotics plus a couple of weeks’ study of the leg from mid-thigh to mid-tibia followed by a few months’ apprenticeship to someone who does knee implants would be sufficient training. That person would not be an M.D. but could be termed a K.T. or knee technician.
While the subspecialists carve patients into ever smaller bits and pieces, general care will be left to nurse practioners working in drug stores or home care medical kits.