A good surgeon is simply a good physician, like any good internist, cardiologist, nephrologist, psychiatrist and so on........The core character traits are the same regardless of the discipline one chooses to practice. Stating the obvious, each discipline will have their own respective manual skills demanded by their respective discipline. In my law practice surgeons or "cutting doctors" have the highest number of malpractice cases, which will beg the question "is it the different character traits" that brings about the increase number? To be candid about, as an internist I continue to be awed by  good surgeons.

Some surgeons think the're held to a different, more rigorous standard. That's because their work is not simply invasive but that a failed surgery may have disastrous consequences beyond those of a normal GP. When some specialities fail, or fall short of the mark, they can be tasked with questionable judgement. But a botched surgery (for instance, removing the wrong breast in a maestectomy or leaving a bad suture in a bowel resection leading to bleeding or rupture) is life threatening. If you're late with a flu shot or give a dubious but understandable diagnosis ... blame is harder to assess. That said, surgery requires a type of attention that is somewhat distinct from that of the general physician; the neurosurgeon and the neurologist may have different points of view, different relations to the patient

But a good surgeon is or should be first, a good physician--one whose principal concern is the patient's well-being. Hope that helps.

But the way the history here is somewhat complex, the modern divisions more strict than in history, especially pre-anaesthetic.

Thanks. Though it is clear that surgeons must be good physicians first and indeed, be excellent diagnosticians, I was after more specifics. I.e., it is clear from above that even other medical colleagues define surgeons by the unavoidable complications that occur after surgery. Yet, I know of no surgeon who would knowingly perform a mastectomy on the wrong breast or leave an anastomosis in-situ, if it was doomed to leak. 

To phrase this a different way, I would ask surgeons with more than 10 years experience to look back to when they decided they wished to be surgeons - be it pre-medical, during or following their medical degree. When they looked at their batch mates or at peers, what qualities do they believed they possessed such that they thought they would succeed as surgeons? To my senior physician colleagues I would ask what were the reasons they did not choose a career in surgery? I do not know of too many professions where, despite training longer, with more intensity, to more rigorous and objective standards, one is held accountable to the extent surgeons are. From high profile cases, it would appear that surgeons are held guilty - even by other medical colleagues - till proven innocent, and even if proven to be innocent, as the doubt remains, surgeons' reputations and thus careers are forever ruined. Is it that medical students and junior doctors are unaware of these facts, or are there some personality characteristics one should look for when advising juniors on their speciality choices in the health care profession?

Thanks Kamal for a fascinating topic. You are absolutely right, surgeons are and have to be different. We are physicians who operate and more... To be able to see a patient, assess them and make a decision which has a profound visible impact on a patient by your own hands, requires a great deal of courage and self-belief. 

The primacy of a diagnosis is extremely important, but not the sine qua non - often recognising the direction needed to be taken based on the patients physiology and the “big picture" is key but it all depends on context: seeing a cancer patient and teeing them up for an anterior resection requires extreme diagnostic precision and logic, but dealing with an acute abdomen requires quick but focused and practical thinking and directed action.

When seeing patients in clinic, I often give them an analogy that I think helps summarise the philosophical difference between surgeons and other healthcare providers: "The difference between a pharmacist and a doctor, is that a pharmacist (with all due respect) just treats symptoms, without quite knowing why they are there - you have diarrhoea, you take some loperamide, but the pharmacist doesn't quite know why you have diarrhoea (is it infective, ischaemic, inflammatory etc). As doctors, we treat the underlying cause - we make a diagnosis first and treat that. Now as surgeons we are, dare I say, wise enough to know that often we cannot know everything! We therefore settle for what is NOT the cause for our patient’s symptoms, rather than what is the cause. So long as our patient’s symptoms are not due to cancer, or anything sinister, they are by definition benign. Then to complete the analogy you can go and see a pharmacist to help with symptoms..." Quite helpful when you are dealing with patients who require reassurance after normal investigations for functional symptoms (rather than subjecting them to invasive tests which won’t change management – if they want them of course they can be done/referred for them).

As surgeons we audit our work more thoroughly, I see a patient, take their history, examine them, look at their CT images, laparoscope them and then look at the histology. I am therefore performing constantly auditing myself and performing "quality assurance" every step of the way, thus bettering myself as a diagnostician and a clinician. My medical colleagues (especially the acute medics) often don't have the luxury of following patients through their journey as they are shipped around from ward to ward. In case anyone forgets complications, there are regular "Mortality and Morbidity" meetings to remind us and educate us of our shortcomings.

It struck me some years ago as a Registrar in Surgery, seeing a young patient in Casualty and making a clinical diagnosis of acute appendicitis and booking him for theatre, what influence we have as surgeons. I sat in theatre with the House Officer who was to assist me and I said to him, how incredible it is: from me saying "you need an operation" a whole chain of events unfolded (seen by anaesthetist, moved to theatre etc etc) - culminating in an asleep patient in front of me, with me yielding a scalpel.

There is a great deal of power we have as surgeons, with people’s lives literally in our hands - but with that, a great responsibility and a occasionally a heaviness of heart. One needs enough doubt to be humble, but not too much to cause paralysis and fear of decision making.  Not long ago I gave a presentation saying that as surgeons we all have the "Sword of Damocles" hanging over our heads. We all need to develop healthy ways of managing this – and this is what makes the difference between surgeons and physicians - the personal responsibility of your decision making and treatment.

There will always be personal targets to surgeons over other specialties: as Brendan Moran has wisely noticed when people discuss problems related to treatments: "Oncologists have side effects, surgeons have complications": neutropaenic sepsis from chemo is a "side effect" but anastomotic leak is a "complication" - implicitly blame is placed on the surgeon due to the choice of words. “It’s not the drugs you prescribed that didn’t work, it’s your anastomosis that leaked…”. To manage that needs a combination of a thick skin, ability to reflect and supportive colleagues and family.

Nonetheless we are in an extremely privileged position in that it is our decisions and treatment that can make such a great impact on patient's lives, often for the better. This is particularly the case in rectal cancer surgery where it is the quality of the resected specimen that governs local recurrence and cure.

Thanks again.

BW,

John.

Hi John. As my legal friends have taught me - in cross examination, never ask a question you don't already know the answer to, so thanks for your response! I would say you're nearly there. I would add a couple of things, that Brendan would probably have said to you on occasion:

1. K.I.S.S.: we need our physicians to be well-read and up-to-date, to come to the fancy diagnosis and remind us about the natural history of said-diagnosis; this is EBM. Once they present us with all this information, we then make crucial but very simple decision: To operate or not. I.e. Which act - that of omission or commission will result in the least harm. You are right to talk about pharmacology versus surgery, because even with the best intentions, non-interventionalists do not know if the indirect agent will result in the predicted consequences. For us, however, it is the quality of each minute decision we take that counts.i.e. If the ultra-low anastomosis looks dodgy then the patient has already been consented for an ultra-low Hartmann's as well. Evidence-based surgery on the other hand is what surgeons, from experience - either their own or that of peers - do with first-class information e.g. We do not change what we do just because a RCT tells us to; we retain the information, and think about applying it, if we believe the situation calls for it. 

2. You mention power, so I ask you how powerful you feel as a consultant in today's NHS? Surgeons by nature are problem-solvers and need to be team leaders when caring for their patients. Irrespective of the current restraints, the power is essential, but, the power, like any other, is a multiple, not additive, for it is the power of the surgeon patient relationship. We are team-leaders not for ourselves, but on behalf of our patients; ensuring we do not our, but whatever they believe to be their best. We advice and educate our patients and support them such that whatever decision they make is the right decision for them.

3. In cancer particularly, we do not operate because that is what the patient wishes, but help them to understand and hence agree that in the case of carcinomatosis, resection is not in their best interests, though we will fight with whoever stands in the way if there is an appropriate alternative pharmacological option. 

4. It boils down to respect. We respect our patients' choices, taken from their own individual contexts once we have explained ours and in return we can expect to be respected for the job we do. You are absolutely right - we explain the limits to what we can do for them rather than brag about what procedures we are individually capable of performing. The respect is of the autonomy to make clear decisions for our patients, teams and services in general.  You would agree in the absence of fluoroscopic imaging only another colorectal surgeon would be able to judge if you should have left the ULAR as such or taken it down and made that permanent colostomy. You might not like him, you might not even trust his intentions, but as long as you agree with his arguments, you have to respect him if his decision in a M&M differs to yours.

In case you're wondering why I asked the question, it is because currently, I am having to defend to ethicists in Australia what we as surgeons believe our duty is. They insist at best I could describe this in terms of what I personally wish surgeons should be like from an ethical standpoint; I argue that they are wrong in presuming there is a difference between what we should be and what we are! Onwards!

Respect to both yourself and Brendan!

Kamal

Thanks Kamal,

Really fascinating topic - thank you so much for bringing it up.

I'm a firm believer in thinking critically and philosophically about what we do - so often people quote papers at me, missing the fundemental point of non-translation to the individual patient in front of you, your hands doing the operating etc (let alone the epistemological foibles of epidemiological research!). 

Well done for your work and I look forward to hearing the outcome.

Best wishes from the UK,

John.

PS We've no power in the NHS! I was referring to actioning decisions of care (but I know you knew that!). TC - J.

In fact, you could help me - do let me know if you ever meet or hear of a surgeon whose sole intentions were to harm a patient - if you hadn't made sure he/she was buried already... 

...And don't ever get me started on the male versus female surgeon debate, for then you would see my physical power, for I would not waste an iota of EEG on this one

I can't believe I'm about to use a quote from a Cliff Richards' song: Power to all our friends, to the music that never ends!

Would wish you the best from Antipodes, but it's too hot here just now!

Cheers

Kamal