I have been fortunate to have lived through a period of revolution in medicine. Indeed, had I been born 50 years earlier I would likely not be bothering you now.
There have been huge changes, but I will focus on an area in which I have participated, the interface between medical doctors (let’s call them “Physicians” as in Britain) and Surgeons.
First a little history. My Dad was a country doctor in England. When I made house calls to farms with him almost 80 years ago, the practice of medicine had changed little in centuries. He held hands, gave advice, delivered babies and signed death certificates. His tools were his brain, his hands, basic x-rays, some vaccines, and a few medicines, many concocted in our house by a live-in pharmacist called Ballard.
Things changed after the war. Penicillin arrived in 1948. We got the first refrigerator in the village to keep it cool. People came from far and wide to marvel at it (the refrigerator). During the 50s, 60s and 70s, Dad’s toolbox swelled with more antibiotics, diuretics, analgesics, cardiac meds and much more.
Diagnoses were made by enquiry, palpation, often leading to a “diagnostic laparoscopy”. The field changed dramatically with the development of scans in the mid 70s. Some of the first abdominal Ultrasound and CT scans were done on my patients at The Middlesex Hospital in London.
As the complexity of medicine and its treatments expanded, so did the number of Physician specialists, such as Cardiologists, Pulmonologists, Nephrologists and many more, not least Gastroenterologists, like me. Throughout this period, all of these remained Medical “Physicians” and were clearly distinct from Surgeons who worked only in hospitals and boldly cut and sewed.
Surgeons started as barbers a very long time ago. I read that they were first employed by Catholic monasteries to keep the tonsures tidy. Some got ambitious and started cutting deeper and were called upon to deal with injuries in warfare. They were not recognized by the established Physicians. A Society of “Barber-Surgeons” was founded in England in1540. The Surgeons split from the Barbers 1745 and founded the Royal College of Surgeons of London in 1800. Surgery became less “barbarous” late in the 19th century with the application of disinfection and anesthesia.
The ancient distinction (and sometimes rivalry) between Physicians and Surgeons lives on in Britain (and some parts of the old British Empire) where Surgeons are not called “Doctor”.
The practice of Physicians changed dramatically and progressively in the 1970s, at least in some specialties, as they became more invasive and infringed on traditional surgical turf.
Gastroenterologists developed flexible endoscopes to explore the digestive tract and its appendages through the mouth and anus. This allowed us to make more precise diagnoses, but also to treat many conditions on an out-patient basis that previously required an “open” operation and at least a week in hospital. Quickly we learned to treat esophageal and intestinal narrowings, remove swallowed foreign bodies, stop bleeding ulcers, extract bile duct stones and remove small growths.
Whilst many surgeons were probably not pleased to lose territory that they had spent years to train for, the advantage of many of these simpler treatments was so obvious that the changes occurred without significant “turf” disputes. After I gave a lecture to the Royal College of Surgeons in London about removing biliary stones through the mouth, the President, a wine connoisseur, said that they could license a few Physicians to do it but would charge “corkage” for each stone.
The science and practice of Surgery also developed substantially during this period, becoming less invasive with laparoscopic techniques (“Keyhole surgery”) and more so with organ transplantation and joint replacements.
Incidentally, the major shift in this Medical-Surgical boundary could have been felt in the pocketbook for those in private practice (like most of those in USA) who are usually paid by procedure. It was said “if you have only a hammer, everything looks like a nail”. Being compensated on a fixed salary reduces any temptation to steer patients towards your own technical expertise.
By the middle of my career, Gastroenterologists like me looked and behaved like Surgeons. Discarding smart suits and ties, and then white coats, we graduated to scrubs, gowns, masks and gloves. We had complex tools in our hands and steered them on TV monitors. Our patients were asleep. We had so much more in common with our Surgeon friends than with the “Medical” colleagues that we had trained with, such as Dermatologists and Psychiatrists.
Whilst Gastroenterologists have taken over the treatment of some digestive conditions, Surgeons remain dominant in others. However, there are also many circumstances in which the choice of treatment is nuanced, and where collaboration between them and indeed other specialists is essential. This is necessary not only to ensure that patients get the most appropriate treatment (and efficiently), but also to pursue the research needed to improve it.
And that is the problem with the system that has been with us since the Middle Ages. Medical schools throughout the world have major departments of “Medicine” and “Surgery.” Students and would-be specialists grow up in separate silos with distinct cultures, and, in most hospitals and private clinics, then practice separately. It seemed to me that this arrangement was no longer relevant and indeed potentially harmful, especially when dealing with complex patient problems. A patient going through the wrong door might not get the best treatment, at least initially. With so many diagnostic and therapeutic approaches to many diseases, not least cancer, it seemed a no-brainer to break the boundaries and develop a multidisciplinary approach.
I wrote an editorial to that effect in 1994 (referred below) and was invited to move from Duke to the Medical University of South Carolina to set up the first multi-disciplinary Digestive Disease Center. This included GI Surgeons and Gastroenterologists (as well as related specialists, such as Oncologists, Pediatricians and Radiologists). It seemed to work well in clinical practice and the concept has been adopted n many institutions, and indeed in other specialties.
Such collaboration is essential in daily practice, but also when new treatments develop and impact the interface, as happened recently. “Bariatric” surgeons have thrived for several decades with various operations for obesity. The most successful was removal of half of the stomach to make patients feel full rather quickly. I was involved with research to develop procedures that could be done instead endoscopically, through the mouth. The best so far is “gastroplasty”, which involves reducing the size of the stomach with a swallowed miniature suturing machine, which was invented by a company called Apollo Endosurgery (of which I was a founder member). Only a few years ago I predicted that doing such “bariatric endoscopy” procedures would become a major role for Gastroenterologists. But, suddenly, and very recently, along came the GLPI-1 antagonists, injections that work very well and are greatly impacting the more invasive, costly and permanent approaches by Surgeons and Gastroenterologists.
It is not difficult to imagine other similar future paradigm shifts. Many Gastroenterologists now spend their days doing colonoscopy to find and remove polyps. Their practice (and income) will be mightily disrupted when someone finds a pill that will prevent or dissolve polyps.
We can only wonder what the Gastroenterologists we are training now will be doing in 10,20- or 30-years’ time. I pass on some wise advice, given to me by a mentor: “Stay flexible, or prepare to get bent out of shape”.