Category Archives: surgeons

Sex only at the end of an elaborate pas de deux, if even then

Dalrymple observes that the world depicted by Alan Thomas in The Surgeon (1964)

would be almost as remote to a young person today as that of, say, the court of Frederick the Great.

The surgeon

is called to the hospital because a minor Conservative politician, Sir Humphry Halland, Bart., has had a car crash and fractured his lumbar vertebrae, on which the surgeon operates. In those days, if the novel is to be believed, titles still inspired awe; when Halland’s young wife asks to be called Gloria instead of my lady it is a sign of her broadminded and democratising informality.

The surgeon and Lady Halland

fall in love while Halland is flat on his back in hospital. They do so very chastely, I must say, despite Lady Halland being 20 years younger than her husband. He is referred to throughout the book as if he were an old man, though he is only 53.

The novel, Dalrymple observes, is

Lady Chatterley in reverse.

The world that Thomas portrays is one in which

  • hospital consultants are gods
  • nurses are ministering angels
  • divorce is an utter scandal
  • porters and butlers are deferential
  • Daimlers are chauffeur-driven
  • sex occurs only at the end of an elaborate pas de deux, if even then
  • the rich smoke as a matter of course

Dalrymple wonders if such a world ever existed.

The NHS belief system

screen-shot-2017-01-14-at-09-27-00National religion

One of the most curious political phenomena of the Western world, writes Dalrymple, is

the indestructible affection in which the British hold their National Health Service. No argument, no criticism, no evidence can diminish, let alone destroy, it. The only permissible criticism of it is that the government does not spend enough on it, a ‘meanness’ (with other people’s money) to which all the service’s shortcomings are attributable. In effect, the NHS is the national religion.

Sacred cow

Very quickly after its inception, the NHS

established itself as a sacred cow in the mind of the British population. A certain historiography of healthcare became an unassailable orthodoxy: that before the service was established, proper healthcare was not available for the majority of the population which, if it was treated at all, was maltreated.

Egalitarianism

The NHS was founded, Dalrymple explains,

in the great egalitarian aftermath of the Second World War, when a brave new equal world would arise from the ashes of the old. If healthcare were provided to everyone irrespective of his ability to pay, on a foundation of a highly progressive tax system, how could the system fail to be egalitarian? It was its egalitarianism that appealed so strongly to the population. Perhaps there was also the hope that one would get more out of it than one had put into it, that it was a kind of lottery with a much higher chance of a winning ticket than in a normal lottery.

Ideological hallelujahs

Unnoticed by the population or by the NHS’s ideological praise-singers, Dalrymple points out,

the NHS had no egalitarian effect, rather the opposite. The difference between the health of the top economic decile of the population and that of the bottom decile, which had been more or less steady for decades, began to widen immediately. The difference in the standard mortality rate of the richest and poorest is now almost double what it was when the NHS began.

Mythology

But the myth that it is egalitarian

lives on, perhaps because it appears to spread its inconveniences over the entire population equally (but only appears to do so – the reality is very different).

Another myth that persists among the British, Dalrymple notes,

is that foreigners somehow envy them their health service, which might just be true in Nigeria but is certainly not true of any European anyone has ever met. On the contrary, the NHS has a dismal reputation among all Western Europeans and its hospitals are to be avoided like night-time excursions in Dracula country.

The operation was a success but the patient died

Very occasionally, support for the mythology comes from elsewhere in the world and is given wide publicity. For example, in 2014 the Commonwealth Fund published a report comparing 11 Western health care systems. According to the report, the British NHS

was best on all measures except one, in which it was the worst apart from the US system. The measure on which it was next to worst was the number of deaths preventable by healthcare. On every other measure it was simply splendid. This rather reminded me of the 19th-century surgeon’s refrain, ‘The operation was a success but the patient died.’ No doubt it is naïve of me, but the prevention of preventable deaths seems to me the whole, or at least the most important, purpose of a health care system. If it fails in that, it fails in everything.

The fact that thousands of people die every year in Britain who would have been saved in any other country in Europe

simply does not register, any more than that repeated scandals in the NHS destroy the national affection for it.

The right day for your operation

Screen Shot 2016-04-09 at 12.04.19Dalrymple draws attention to a UK statistical study that examined 30-day death rates after non-emergency operations in 2008-11 (except day cases) according to the day on which the procedure was performed. There were 27,582 deaths after 4,133,345 operations, a raw rate of 6.7 per 1,000.

  • Those who underwent an operation on Friday had a death rate 44% higher than those who underwent an operation on Monday
  • Those who underwent an operation at the weekend had a death rate 82% higher

Screen Shot 2016-04-09 at 12.10.15The death rate

increased steadily as the week progressed.

Perhaps, says Dalrymple,

hospital staff, especially surgeons and nurses, grow steadily more tired or careless as the week progresses.

Not everyone who needs surgery can have it done on Monday. Therefore,

so long as the information is not known by everyone, the wise patient would be well-advised to keep it to himself. A small number of patients, but not many, can ask for their operations on Monday and have their wishes respected.

May my surgeon be human-hearted

Screen Shot 2016-04-04 at 08.49.19Dalrymple points out that the media’s attitude towards medicine

swings between lauding a miracle cure and excoriating the murderous incompetence of doctors, leading to a dialectic between unfounded hopes and hostile suspicion.

Yet very occasionally it perhaps ought to be acknowledged that medicine,

for all its deficiencies and the carping of its critics, is a noble enterprise.

Doctors must act

in the absence of definitive knowledge. Sometimes this leads to tragedy, sometimes to triumph.

Screen Shot 2016-04-04 at 08.20.47A paradox

Everyone who comes under the knife

wants his surgeon to be as highly trained and as experienced as possible: but how is the surgeon to come by that training and experience unless he practises on people while he is untrained and inexperienced? Someone has to be operated on by tyros, even if they are under the supervision of more experienced surgeons. In practice, for compelling practical reasons, that supervision may be light: senior surgeons cannot be everywhere at once. What is true of surgery is true of other specialities: decisions of vital importance to individuals are taken by people who are still learning.

In the old days,

Thomas Rowlandson, 1793

Thomas Rowlandson, 1793

perhaps explanations of treatment options were less elaborate or full than they are today, but they were still given and consent to such treatments was still sought.

Patient autonomy as the single most important guiding principle of medical ethics has drawbacks.

Patients who are very ill are often in great pain, or severely weakened. Their concentration is poor, they may be irritable or in a state of panic. This is not generally the best moment to ask them for a reasoned assessment between two or more alternatives, each with its own advantages, side-effects and chances of failure. The insistence that they do so is often a form of disguised cruelty.

Dalrymple says that when he has been seriously ill or injured,

I have wanted my doctors just to get on with it as best they could, without any interference from me. So far, at any rate, my confidence in them has not been misplaced; and the paradox in the doctrine of autonomy is that the person may — in fact, often does — wish to abrogate it.

Surgeons

need human as well as technical understanding, and kindness is at least as important as respect for patient autonomy.

How a surgeon of experience and integrity acts

Screen Shot 2016-04-02 at 17.58.19Dalrymple has an example in his family history

of a surgeon who acted in a way that would now be deemed ethically reprehensible, and perhaps actionable, but which seems to me to have been in the very highest tradition of his profession.

His name was Cox,

and I don’t know whether he is still alive: by now he would be very old. I thanked him insufficiently at the time.

Dalrymple was in Africa when he telephoned his mother.

She was about to go to America on a visit, but she told me that she had been bleeding intestinally. I told her she must abandon her visit and see a surgeon at once, which she did.

It was cancer.

She underwent an operation within the week. I returned home before the operation.

Dalrymple mère

said that she wanted nothing hidden from her; she wanted to be told everything, and made me promise that I would hide nothing.

Dalrymple mère exuded

pride in her own rationality.

After the operation, the surgeon Cox

spoke to me. Whether he was franker with me than he would have been with a son who was not a doctor I do not know; but he told me that, while he had excised all the cancerous tissue that he could see macroscopically, histology demonstrated that my mother’s prognosis was very bad. There was an 80% chance of recurrence within a year.

Dalrymple said that Dalrymple mère had made him promise that he would tell her everything.

The surgeon said that, on his estimate of my mother’s character and personality, this would not be a good idea. He advised me against this course of action; and since he was clearly a man of experience and integrity, I took his advice.

Dalrymple mère asked Dalrymple, when she had recovered sufficiently from the operation, what the surgeon had said.

I told her that, as far as he could see, he had cut out all the cancerous tissue. This was the truth, but of course not the whole truth, and I rather dreaded further questions, to which I might have to reply with outright lies: and I might not prove to be a very convincing liar. My mother was perfectly well aware that removing all cancerous tissue to the naked eye was not the whole of the matter, but to my surprise – and relief – she enquired no further. Despite her protestations beforehand, she did not want to know everything.

In the event, Dalrymple mère

lived another 19 years without recurrence and relatively free of anxiety about her cancer because the surgeon had ‘cut it all out’.

Dalrymple was impressed by the surgeon Cox.

It seemed to me then, and seems to me still, that he had acted as the model of a fine medical practitioner. He was technically accomplished, it goes without saying; the operation went smoothly, with no avoidable complications. But more than that, he had given consideration to my mother as a person, as a human being; and on the basis of limited acquaintance with her – at most, a few examinations in the clinic – he had come to a shrewd and, I believe, accurate assessment of what was best for her, better indeed than my assessment.

Surgeons

are often accused of being brash, mere technicians without human subtlety, but this was certainly not the case with him.

The surgeon Cox

is a hero to me.

His

understanding of the requirements for decency was much more sophisticated than that of modern medical ethics. He understood that people generally live in a social situation, not as isolated beings, and that it is sometimes right for relatives to know more about an illness than the ill person him or herself.

Dalrymple is sure that the surgeon Cox

knew that truthfulness can descend into indifference to suffering or even to sadism. To try to force people to know what they do not want to know can be cruel, and ineffective into the bargain.

Screen Shot 2016-04-02 at 17.36.46

David Rijckaert III, The Surgeon, 1638. Musée des beaux-arts de Valenciennes

Economics of sham operations

Dalrymple comes across a paper in the New England Journal of Medicine comparing physical therapy with surgery for meniscal tears in the knees of people with osteoarthritis.

There was no difference in outcome, an important finding since 465,000 people undergo operations for this situation every year in the USA alone.

Actually, says Dalrymple,

the uselessness of operation had been established before — uselessness from the patients’ point of view, that is. Two previous trials had compared real with sham operations, and with no operations at all, and found no difference in the outcome two years later. One might suppose that, in the light of these findings, the 465,000 operations still performed annually constituted something of a scandal.

Dalrymple considers the economic aspect of unnecessary operations. Granted that

unnecessary operations are more expensive than intensive physical therapy, do these operations increase or decrease gross national product? At first sight they do. As everyone knows, operations are not cheap. Without them, the GDP would fall. So would the incomes of those who perform them – orthopædic surgeons, for example, and their hangers-on such as operating room nurses. Presumably their incomes have a multiplier effect, for example on the legal profession. On the other hand, there are opportunity costs of employing money in this rather futile, indeed counterproductive, manner. But would the money in fact be better employed elsewhere? Would not something just as unproductive be done with it?

Screen Shot 2016-03-31 at 16.14.18

In the operating theatre

Screen Shot 2016-03-18 at 18.47.37Writing of his Bulawayo days as a house officer at Mpilo Hospital (‘a large building of red brick in the parsimonious British municipal style of the 50s, with metal-framed windows and no embellishments’), Dalrymple says he learnt little in the operating theatre because

I wished to learn little. Assisting at operations was, for me, a kind of slow torture. It is one thing to take infinite pains yourself, quite another to watch someone else doing it.

It is a law of surgery that

Mpilo hospital opened in 1958

Mpilo hospital: it was opened in 1958

the assistant can never satisfy the surgeon. He either pulls the retractor too hard or not hard enough, but never just right. There is an old joke about a medical student who asks the famous professor of surgery: ‘And how would you like your stitches cut today, professor? Too long or too short?’

The layman may think

of the operating theatre as a place of drama,

Screen Shot 2016-03-18 at 18.41.33and it is true, says Dalrymple, that

there are moments of drama, or rather of crisis, but for the most part there is only tedium exacerbated by the desultory conversation between the anæsthetist (if he is not wholly absorbed in his crossword) and the surgeon concerning their sailing dinghies, dogs or vegetable gardens.

Screen Shot 2016-03-18 at 18.42.27Dalrymple admires the surgeon’s

capacity for prolonged concentration, up to ten hours at a time; the concern for the welfare of patients that such an effort implies; and the coolness with which crises, when they arise, are handled.

Screen Shot 2016-03-18 at 18.41.45He remembers a surgeon accidentally cutting an artery,

and the strong instantaneous jet of crimson blood spattering his face and soaking his mask. It was enough to make even a brave man flee, but in one swift and sure movement of his finger he staunched the jet, and the crisis was over before it had properly begun.

Screen Shot 2016-03-18 at 18.45.53This

was not work I could enjoy, and I never left the theatre without feeling great relief.

Screen Shot 2016-03-18 at 18.42.01Screen Shot 2016-03-18 at 18.40.33

A chilling epigraph

Screen Shot 2015-12-25 at 07.58.21It is contained, Dalrymple writes, in Jürgen Thorwald’s The Dismissal: The Last Days of Ferdinand Sauerbruch (1960). It is by Josef Naas, director of the Akademie der Wissenschaften der DDR, and reads:

In the coming struggle of the proletariat, in the clash between socialism and capitalism, millions will lose their lives. In the face of this fact it is a trivial matter whether Sauerbruch kills a few dozen people on his operating table. We need the name of Sauerbruch.

Sauerbruch, Dalrymple explains, was

a brilliant but arrogant surgeon who began to dement and did not realise his powers were declining. He persisted in operating, though he started to kill patients. He did this with the complaisance of the authorities because, after the war, the East Germans were pleased, for reasons of propaganda, that he continued to work in Berlin.

A nasty drunk inclined to bullying and violence

Screen Shot 2015-04-08 at 22.29.58Also a snob and a social climber.

One critic said that no one who knew him ever liked him, although others have denied this. It is rare for anyone to be disliked by everyone.

Dalrymple on John O’Hara, who was

the son of a surgeon, Patrick O’Hara. The father wanted the son to follow in the profession, but he would have none of it, even rejecting his father’s offer of $10,000 if he would do so. O’Hara junior said that he wanted to be a writer; his father said that no good would come of it.

Screen Shot 2015-04-08 at 22.23.15 Screen Shot 2015-04-08 at 22.21.30 Screen Shot 2015-04-08 at 22.24.26

Why you should want to be operated upon by a three-parts-drunk imbecile of a surgeon

Screen Shot 2015-03-14 at 21.12.04You may die as a result of the procedure, indeed you may die painfully, but you will have the consolation of knowing that you are part of a society that is appalled by the discrimination suffered daily by surgeon-cretins and other downtrodden groups, such as Islamists, a society prepared to act to correct these injustices. Dalrymple puts it this way:

Social justice is social justice, and not good surgery. The achievement of such justice requires that we all be prepared to make sacrifices for it: a botched operation is a small price to pay for the satisfaction of knowing that surgeons are demographically representative of the population as a whole.