Time to retire the labels “Medicine” and “Surgery” after 400 years

Time to retire the labels “Medicine” and “Surgery” after 400 years

When I was a young doctor, a long time ago, it was not difficult to distinguish medical physicians from surgeons. Physicians, at least in England, wore smart pin-striped suits and carried stethoscopes. They managed patients with sympathy and medicines. Surgeons wore pyjamas and gloves, and looked for things to connect, drain or remove.

The distinctions are even older than me. From my friend Wikipedia: From the middle of the sixteenth century…. Physicians advised and prescribed medications, apothecaries compounded and dispensed those remedies, and surgeons performed all physical intervention from bloodletting to amputation. These rights and duties originated with Henry VIII, who established the Royal College of Physicians in London in 1518, and in 1540 approved the merger of the Company of Barbers and the Guild of Surgeons. For more details, click

http://www.midlandshistoricalreview.com/physician-apothecary-or-surgeon-the-medieval-roots-of-professional-boundaries-in-later-medical-practice/

Royal physicians looked down on the uppity Barbers who started cutting more than hair. Emblematic of this rivalry is the fact that surgeons in UK are still called “Mr.” not “Dr.”.

A quick diversion to reduce transatlantic confusion over the word “physician”.  In USA it is the same as “doctor”, but in UK (for my US friends, UK stands for the United Kingdom, not the University of Kentucky) the word “physician” means someone who has undergone extra post-graduate training to become a specialist, like a gastroenterologist or cardiologist. I will stick with the UK usage.

So, what changed big time quite recently? Very simple. Mere physicians started to do “surgery”. I will explain.

In the early 1970s, some gastroenterologists like me were lucky enough to be carried along on the tidal wave of endoscopic innovation. The development of flexible fiberoptic instruments allowed us to shine bright lights into human tunnels. Gastroscopy and colonoscopy greatly enhanced our ability to make diagnoses in the esophagus, stomach, duodenum and colon, with pathological conformation by taking tissue samples.

That phase was exciting and impressive enough but was quickly followed by an even greater revolution, as pioneers developed tools which allowed us “endoscopists” to treat many of the common digestive diseases. Thus, we began to use cautery and injections to stop bleeding from ulcers and varices, balloon catheters to relieve strictures, snare loops to resect small polyps and tumors, and sphincterotomes and baskets to remove stones from the bile duct.

For hundreds of years the defining hallmark of surgeons was their training and license to cut and to sew. Suddenly that distinction disappeared. Gastroenterologists cut with hot wires and lasers, and were even able to sew with small gismos attached to their endoscopes (the first one of which was commercialized by the Apollo company which I helped to found).

The overstitch endoscopic sewing machine. Yes, you swallow it

Other specialties experienced similar dramatic expansions of their portfolios. Cardiologists learned to pass catheters through big veins to reach the heart and use balloons to reopen the coronary arteries. Interventional radiologists explored the whole vascular system and managed many of its disorders.

It is important to realize that most of these conditions had previously been managed by surgeons, often requiring prolonged hospitalization, incisional pain and substantial costs. Clearly the new era of “less-invasive” treatments brought many advantages, but, you may wonder how our surgical colleagues reacted to the fact that mere physicians were stealing much of the turf which they had nurtured and were accustomed to dominate? A few surgeons of the old school, whose worth was measured by the size of their incisions, were dismissive. Most surgeons had plenty to keep them busy and (fortunately for people like me) failed to embrace the new flexible instruments themselves. So, the paradigm of “interventional gastroenterology” blossomed progressively, with new training schemes, special tools and appropriate facilities. Patients certainly benefited from the less invasive procedures.

Abdominal surgeons eventually recognized the value of ”keyhole surgery” in the early 1990s when they rediscovered the laparoscope, which gynecologists had been using for years. They started by removing gall bladders laparoscopically (a paradigm shift from open surgery that was powered by patient demand rather than academic leaders) and moved on to almost any organ in the abdomen. Other specialists had similar lightbulb moments:  orthopedic surgeons used arthroscopes, and urologists used ureteroscopes.

So, by the mid 1990s, it was difficult to distinguish the traditional disciplines at work. Most surgeons, gastroenterologists, interventional radiologists (and cardiologists, pulmonologists etc) were all wearing scrubs and gloves, handling long instruments looking at TV monitors.

Why might that be a problem? I will explain. The bountiful smorgasbord of treatments being offered by different specialists was (and is) confusing to patients, and indeed often to the primary care/general practitioners who try to steer them to appropriate specialists.

For instance, a patient with gall stones may learn that they could be treated by a surgeon (gall bladder removal), a gastroenterologist (pills to dissolve stones), an interventional radiologist (catheter drainage or solvent) or even a kidney doctor (shock wave lithotripsy to shatter stones), not forgetting the general physician/internist who might question the need to intervene at all, and advise a wait and see approach.

Similarly, there were now many different ways to investigate and treat a patient with obstructive jaundice, resulting in a maze for patients to navigate.

Such mazes resulted from the fact that the involved specialists spent years training in separate and powerful Departments of Medicine and Surgery, as rooted in the middle ages.  Their cultures were different with limited appreciation of the potential of their “competitors”. Equally important, they were usually to be found in different buildings. The patient entering the wrong door might not receive the most appropriate treatment. As you know “to those who have only a hammer, everything looks like a nail”. And the situation is potentially more problematic in “fee for service” medical systems (like USA), where recommendations may not always be devoid of financial bias.

When leaving UK for USA, one of my then surgical colleagues warned me about the potential for American surgeons to resist or resent my invasion of their territory and livelihood. He said that I would find that their office walls are full of diplomas extolling their qualifications. So, he gave me one to display……

Another key aspect of this fragmentation and the inevitable resulting competetion is its impact on clinical research. Studies initiated in one discipline tended to produce results favorable to it, when compared with others. Head to head unbiassed evaluations were difficult to set up, and consequently rather rare.

The recognition that inter-disciplinary collaboration was essential started slowly. In academic centers, specialist physicians and their surgical counterparts began to meet to discuss “interesting cases” with input from pathologists and radiologists. Initially these were past cases in which the outcome was known. These meetings did at least help specialists better understand what their “competitors” could do. The next step was to discuss active cases, to attempt consensus on the best methods for diagnosis and treatment. These meetings flowered particularly (and still do) in the cancer field, where many treatment options exist and where the knowledge of the very latest research is often crucially important.

So far good, but to me not enough. The specialists and their clinics were still separated. I wrote an editorial when leaving Duke University 25 years ago, emphasizing the perceived problem and proposed a restructuring to facilitate collaboration, at least in my digestive world. I did not note any enthusiastic reception.

Cotton PB. Interventional gastroenterology (endoscopy) at the crossroads: a plea for restructuring in digestive diseases. Gastroenterology. 1994 Jul;107(1):294-9. doi: 10.1016/0016-5085(94)90087-6. PMID: 8020673.

I moved to the Medical University of South Carolina (MUSC) in Charleston in 1994 because I was invited to explore the idea and develop a multi-disciplinary Digestive Disease Center (DDC).

Chairs of Medicine, Surgery and Radiology were supportive, along with the Dean and Hospital. I was not asked to take control of the specialists, but charged with providing the infrastructure and resources needed to facilitate their collaboration.

Our mission statement was: To provide courteous and cost-effective multi-disciplinary care for patients with digestive disorders, and to provide a springboard for the research and education necessary to enhance it.

Key elements included bringing people physically closer together wherever possible and appointing “coordinators” (senior nurses or physician assistants) to help patients through the maze of modern medical practice. Indeed, these people are often called “navigators”.

The DDC seemed successful, and MUSC soon applied the same logic to other disciplines, initiating so-called “service lines” for organ systems, thus Cardiovascular (cardiologists and cardiac surgeons), Bone and Joint (orthpods and rheumatologists), Neuroscience (neurologists and neurosurgeons) and others. The name was later changed to Integrated Centers of Clinical Excellence (ICCE) for some reason.

Many other major medical centers have made the same structural changes. Multi-disciplinary systems of care are popular with hospital administrators who see the efficiencies of clinical practice, but are less so with the chairs of the Department of Medicine and Surgery who lose some of their authority as a result. They continue to train their specialists separately and employ them with different salary structures and promotion paths. It also seems potentially wasteful that they may both have basic research labs working on parallel problems in different buildings.

So, maybe another step on this journey? If patients are best treated in multi-disciplinary facilities, should not the doctors be trained in the same way. I am suggesting that we break loose from the shackles of the middle ages and restructure our academic world, replacing the all-powerful traditional Departments of “Medicine” and “Surgery” with Departments of Digestive Science, Pulmonology Science, Neuroscience, Renal Science etc.

Within each there would be a spectrum of skills with increasing “aggressiveness’. Thus, in my Digestive world, after basic training, I see gastroenterologists choosing between 5 main streams of future practice: consultation (like hepatologists) or general GI with lots of endoscopy, or advanced endoscopy, or minimally invasive surgery, or major surgery (transplantation).

Whoa, I hear concern that this increasing fragmentation and super-specialization is taking us away from the need to focus on a holistic approach to our patients. As my friend Solly Marks said “Peter, pay attention to the whole patient, not just the hole in the patient”. I don’t see a problem if that need is emphasized in early basic medical training, and we will still have “general” and “primary care physicians”, indeed their roles may well need to expand.

In removing the ancient bastions of “Medicine” and “Surgery”, am I simply imposing a different set of silos that could make it difficult to collaborate between the new demarcations?

Is there another step on this journey? Maybe. Many of the professional Societies/Associations/Colleges around the world are still focused separately on Medicine or on Surgery. Britain has separate and powerful Royal Colleges of Medicine and Surgery, both in London and in Edinburgh.

I cannot resist revealing the response when I first demonstrated endoscopic removal of bile duct stones at the Royal College of Surgeons of London. The President, a wine connoisseur, said that the College should charge a “corkage fee” for each stone. Later they kindly elected me to fellowship (FRCS)

The fragmentation extends to the specialty level. The digestive world in USA has a plethora of large and rich national societies with different primary foci, from science (AGA), clinical practice (ACG), endoscopy (ASGE), surgical endoscopy (SAGES), liver disease (AASLD), surgery (SSAT, ASCRS and HPB), interventional radiology (SIR), Nutrition (ISN), neurogastroenterology and motility (MSNS) and GI nursing (SGNA). I have argued previously, when recalling the abolition of the British Society of Digestive Endoscopy, (https://drpetercotton.com/what-happened-to-the-british-endoscopy-society-40-years-ago/) that such fragmentation of effort must reduce the power of the voice when dealing with payers, whether government or insurers, and indeed when informing the broad public. The various societies do collaborate on specific topics. One good example was when the Endoscopy and Surgery Societies together formed the NOSCAR (sic) organization to explore and manage the amazing concept of NOTES (Natural Orifice Transluminal Endoscopic Surgery) proposing that the gall bladder and appendix could be removed through the mouth. Honest

I dream of an overarching American Society for Digestive Health pulling all these parts together in harmony.

Just a dream, or was it a nightmare?

All part of life’s rich tapestry