Domhnall MacAuley: The surgeons who are not doctors

Domhnall MacauleyThe surgeons who are not doctors.

Reading this headline, I expected a story on training healthcare workers as surgical technicians in some under doctored developing country. But no, it was in the UK. I was intrigued.

Medicine is introspective, protective, and doctor centric; self regulating and self directing. Places at medical school are highly prized, access is increasingly competitive and based on academic achievement. We have created a professional fiefdom. But, could others do the job better?

Watching skilled craftsmen is a pleasure. I marvel at cabinet makers, boatbuilders, plasterers, tilers, and plumbers. A job well done looks easy and, if I need a hip placement or knee surgery, I hope that my surgeon has the skills and finesse of the master craftsmen. But, where will my surgeon have learned these skills and were they always “good with their hands?” Unlikely. Being bright at school, they were probably diverted down an academic stream at school—the bookworms and academic nerds separated from those more vocationally skilled. Surgeons will have spent their most formative years with their heads in a book leaving little time left to develop fine movement skills, hand eye coordination and train a plastic brain in neuromuscular coordination. At school and university they had to read, write and recite and progressed by examination rather than apprenticeship. Where was the skills training at a time when skills are learned best?

Working backwards—if you could identify the skills needed for surgery and choose those teenagers with most talent for technical skills, you wouldn’t choose the academics. You would train those with the best manual dexterity; the skilled mechanics, woodworkers, electricians and metal workers. These are the craftsmen (and women) I would like to do my operation.

Domhnall MacAuley is primary care editor, BMJ.

  • To be surgeon, undoubtedly skills are important but skills is not the only thing you need to be surgeon, leave apart being a good surgeon.

  • AHowell

    Stating that the most important skill set for a surgeon is manual dexterity is akin to saying that the best qualifier for a GP is to be an effective communicator. These skills are important, but to disregard the other abilities which universities prize, or to suggest that for surgeons a high IQ is unnecessary is an oversimplification and underestimates the profession.

  • After watching one plastic surgeon I know at work and commenting on the fineness of his touch he replied, “the practical aspect of surgery is not the difficult part. Even a monkey could do it if it repeated the movements enough times.” I figured he was exagerating for dramatic effect but his point became clear when he went on to say, “the surgoens that impress me are the ones who know when not to operate.” His point was a good one. As important as technical skills are, one almost inevtitably acquires these but judgement is really what makes the difference. That judgement is acquired by having a wide knowledge base, allowing the surgeon to appreciate all eventualities and options. Im in no doubt the more academic minded are probably better at this. I suspect its easier for the academic minded to acquire technical movements than it is for the technical to acquire a surgical knowledgebase.

  • dev srivastava

    It is sad to note your mechanistic and reductionist thinking about surgeons.This provides further ammunition to the managers.

    As astronomy is not about being able to count the maximum number of stars but an ability to understand patterns and infer meaning, so is surgery not solely about mechanical ability.

    There is a dictum which says that a surgeon spends a decade learning ‘how to do it’, then a decade learning ‘when to do it’ and finally another decade learning ‘when not to do it’.

    So in summary surgical skills are not just plain carpentry – you must have consummate skills as a ‘doctor’ before you will succeed in surgery or in any intervention based speciality in medicine.

    Dev Srivastava

  • Anna Slavinska

    Mr. MacAuley,
    Would you be telling me that the seven years of grueling 80-hour weeks of practice that my son is going through in a minimum of seven years for a surgery residence AFTER receiving his very needed M.D. for the surgery are in vain?
    What country do you live in?

  • William Taylor

    It has to be said that getting into medical school in the UK requires more than passing exams. Extra-curricular activities such as music and sports are essential if you want a place-so these budding surgeons are spending their formative years practising hand-eye co-ordination. Also never forget the ubiquity of computer games among teenagers.