There is an eternal struggle in healthcare, that of the surgeon vs. the medicine man.
This is not obvious from outside the professions, but the evidence is all around us. The surgeon is a much more glamorous specialty; life and death sometimes literally rest in a surgeon’s hands. The surgeon is richly rewarded for sometimes heroic efforts, and is among the highest paid and most respected of any specialist.
The medicine man (internist) spends time in the much less dramatic pursuit of disease prevention and cure through medications. This is a quiet and thoughtful profession, but much like the tortoise and hare, the medicine man is winning.
This struggle was highlighted last week by studies showing that antibiotic treatment is as safe and effective as surgery for acute appendicitis (and a whole lot less miserable for the patient).
That is the exact opposite to the training surgeons received for the last 50 years. We believed that antibiotics never cured an appendicitis, it just made it harder to diagnose, thus delaying surgical treatment until after it burst (peritonitis).
So we will see a lot less appendectomies in the future. Score: Medicine 1,
Surgery 0.
Thinking about life and death surgery, the cardiovascular (heart) surgeon has no equal.
But the triple bypass is steadily losing ground to prevention and alternative treatments. Medications like statins to reduce cholesterol and blood pressure medications are keeping the vast number of patients from even getting coronary artery disease. Even if you get coronary artery disease, the chances are that your treatment will be an angioplasty/stent rather that having your “chest cracked.”
There is a reason they call it chest cracking! That’s 2/0, in the Medicine Man’s favor – if you are keeping score.
Ulcer surgery used to be one of the most commonly performed operations. Then came the invention of Tagamet, a class of acid reducers light years ahead of antacids (acid neutralizers). Then came the proton pump inhibitors (Prilosec), which was the knockout blow that virtually eliminated ulcer surgery.
Cancer has always been first and foremost a surgical disease. What is more appealing than cutting the cancer out? These days, the answer is a lot of things. Prostate cancer was always treated with prostate removal, and a frequent complication was impotence.
Now oral medications like anti-androgens, or alternative treatments like radiation, have dramatically decreased the number of prostates we remove, and the number of people needing Viagra is also reduced.
Breast cancer was first treated with the big operation: radical mastectomy. This evolved into simple mastectomy, now lumpectomy, or even just needle biopsy. Medical treatment for breast cancer does a better and less traumatic job of curing many of these unfortunate problems for women.
In fact, just about pick your cancer, and the treatment has dramatically moved from surgical to medical in the last 30 years.
But never fear, orthopedics can be a safe haven for underemployed surgeons. A pill for a broken bone is still a while away. But I wouldn’t quite classify it with teleportation; we may come up with something.
Having trained in general surgery, and then practiced occupational medicine, and urgent care for the last 30 years, the sweep of change I’ve seen has been dramatic. Every year we find new magic pills that retire another scalpel.
Call me a wimp, but I’ll take my Lipitor and Tenormin; and eat walnuts if I want to hear a cracking sound.
Take care.
Dr. B.