Monday, November 21, 2011

“I could teach a monkey how to operate”

“I could teach a monkey how to operate” or so some people think. This cliché has been around for years. Recently, I saw it on a Sermo [MD gripe site] post and someone said it in a comment on one of my blogs. The other day I used it in a tweet trying to entice people to read my blog on the pitfalls of dictating. And then I thought about it.

I will admit that many procedures we do are simple. I have taught physician assistants to perform such tasks as closing a wound, excising small skin lesions, draining abscesses and the like. PAs who work in cardiac surgery can harvest veins and perform other more advanced procedures. When I was teaching residents, I taught them just about all types of operations, from the most basic to the most complex.

But a Medline search has failed to produce even one paper showing that a monkey has successfully been taught to operate on even another monkey. Even if a monkey could be taught to operate, would she know when and on whom to operate?

Let me give you an example. Thanks to the ever increasing use of CT scans, I have been asked to see a number of patients who have gallstones and abdominal pain. This may surprise you, but many of these patients do not need surgery because their pain is not due to the stones. A recent study with an almost 30-year follow-up confirms this.

Sometimes we get the question, “Is that tumor resectable?” In other words, Can you take it out?” My answer is usually, “Anything is resectable [see hemicorporectomy], but will the patient survive?” That is the real question.

I don’t think a monkey is who you want making that decision.

11 comments:

Dr Nikola said...

That's the point. As medicine is shifting towards rewarding specialist who can perform perfectly one and only one procedure it also shifts away from forming experienced doctors ready to make decisions and be responsible for them. Probably we can teach a monkey to operate but we hardly can teach a doctor during his residency to decide properly what is right for patient

Skeptical Scalpel said...

Dr Nikola

Thanks for commenting. I disagree that we can't teach residents to make good decisions. It's not easy with all the regulations about supervision, but maybe it can be done.

drbculp said...

I agree and disagree with Dr. Nikola. That's the whole point of the saying "We can teach a monkey to operate". ANYONE can do the manual maneuvers of operating with practice/teaching. However, residency SHOULD be the time when we teach a doctor how to decide what is right, what to do and when. Anyone CAN do the operation, but SHOULD they? This is a VERY old saying in the surgical world, and it is often used in the context to describe the situation in which someone can have plenty of manual dexterity, but have very little in the way of good decision making skills. A surgeon is far beyond a monkey and far more than just the worth of their hands.

Skeptical Scalpel said...

drbculp

Thanks for the comment. Obviously we are in agreement.

EmD28 said...

I'm not sure if I agree with this "anyone can operate" thing. Surgery is about perfection and dexterity. It's not just about cutting through skin and taking something out or putting something in. So although we need to teach the residents how to make decisions, we also need to let them operate to gain experience. How am I supposed to reach perfection if I'm not allowed to stay as long as I want in the hospital and see as many cases as possible. Long story, I don't have the energy to bring this up again and I have been making myself to believe the exact opposite for the sake of my residency interviews.

Norman Briffa said...

A good surgeon knows when to operate and a wise surgeon knows when NOT to operate.

Skeptical Scalpel said...

EmD28: Thanks for the comments. You sound like the type of person I would have accepted into my training program. I'll tell you a secret. I really don't think anyone could teach a monkey to operate.

Norman: Thanks for commenting. I agree. It's just as important to know when not to.

EmD28 said...

Skeptical Scalpel: Thank you sir, it means a lot to me.

ffolliet said...

In my experience we teach many monkeys to operate. The sadness is that is often the extent of it. What we need is that evolution, if you will, from simple tool user to sentient, insightful, reflexive, caring and intelligent being. That requires desire from the "monkey" and a supportive, insightful educator. And time. Sadly our whole systems mitigate against such.

Anonymous said...

The question here, I think, is replacing experience and education with a lower cost provider. Patient's are tricky people. The ordinary and routine can change in an instant to require skill, knowledge, and experience. I'll pass on the monkey.

Skeptical Scalpel said...

ff and Anon, thanks for commenting. I'll am placing you both in the "Agree" group.

Post a Comment