MEDICINE
To cut or not
JOIIN ROWAN WILSON
Some interesting facts about surgery have just been brought to light by Dr John P. Bunker, an anaesthetist writing in the New England Journal of Medicine. Dr Bunker has collected figures to show that the number of surgeons, and the number of operations per- formed each year, is about twice as great in the us as in this country. While we run to 9,000 surgeons for the 48 million or so people in England and Wales, the us deploys 75,000 for its 197 million population, together with an extra 10,000 physicians who engage in part-time surgical practice. And while we clock up only 1.7 million operations in a year, they manage as many as 14 million.
Obviously these figures can be interpreted in different ways, according to your views about surgeons and about the different systems of medicine operating in Britain and the us. Some people would draw the con- clusion that there are too many surgeons in the us, doing too many operations, because under a system based on private practice surgery is a highly profitable occupation. Alternatively it might be claimed that under the National Health Service patients are not getting the operations they need because the state has not been prepared to pay for suffici- ent surgeons or sufficient hospital beds, and that many people who require operations have been kept hanging about for years on the waiting lists.
There is something in both these argu- ments. While there are few surgeons who will deliberately carry out an operation they believe to be unnecessary, there is a fairly large area in which it is a matter for debate whether surgery is indicated or not. A young man at the beginning of his career, and totally dependent on private practice for his income, may well be tempted to remove a so-called 'grumbling appendix' or excise a pair of tonsils, when the indication is only marginal. The National Health surgeon suffers from a precisely opposite temptation. Some operations are not specially urgent and are very tedious to perform. Examples of this are such conditions as bunions, varicose veins, and haemorrhoids. All these diseases cause considerable discomfort and interfer- ence with normal activity. But because they are not actual killers, they are left on the waiting list for months or years, on the grounds that the surgeon's time is fully occu- pied with more serious matters.
Apart from financial and administrative influences, there are differences in clinical judgment which affect the surgeon's decision to operate. Every now and then, collective obsessions can upset surgery in the same way as they infect education, or economics, or architeture. Cutler Walpole. the surgeon in Shaw's Doctor's Dilemma, who insisted on removing the nuciform sac on all his patients, regardless of what they complained of, was a direct parody of a surgeon alive at that time, who believed that all human ills arose from the absorption of toxins from the lower bowel. While this absurdity was soon abandoned, it was succeeded by similar theories in regard to the tonsils and the appendix. I cannot quote any such aberra- tion existing at the present time, but this does not mean that none exist. It may be that some operations which are generally accepted as valuable now will be proved quite useless by a later generation. There is, for example, some support for the belief that radical amputation of the breast, which has for long been regarded as the correct treat- ment for breast cancer, may confer no more benefit than a strictly limited excision of the tumour.
Differences in practice between one society and another may spring from varia- tions in patient demand. Unquestionably this is one factor in producing the highlriumber of operations in the United States. The search for perfection, physical, mental, and social, is an innate characteristic of North American culture; this is allied to a touching belief in the capacity of modern technology to solve all problems. The American is not happy to possess a joint that creaks or a scar that shows or a fracture that has united slightly askew. He is prepared to pay out large sums of money, and subject himself to a great deal of discomfort, to dispose of physical imper- fections which most of us would take in our stride.
The final factor in the equation, and possibly the most important, is the general practitioner. One of the differences between American medicine and our own is that in this country one can only see a specialist after being referred by a GP. Americans, by contrast, tend to go straight to the specialisk.v following their own judgment as to which ' specialist is indicated in a particular case. A patient who goes straight to a surgeon has obviously an increased chance of receiving a surgical solution to his problem. The GP, for all his faults, at least does not have too much of his emotional capital locked up in a specific method of treatment. It is possible that it is not in what he does, but in what he doesn't do, that he makes his greatest con- tribution to our welfare.
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