Under the Knife

ANY OPTIMIST TRYING to imagine what kinds of weird and wonderful things surgeons might be capable of in the future actually pinpoints the shortcomings of surgeons today. Science fiction has been in existence as a literary genre for more than two hundred years and, in that time, writers have often tried to imagine what a doctor or surgeon would be able to do in a time of unlimited possibilities. Sometimes their portrayals have displayed surprising insight, at others they have been ridiculously naive. Below is a top 10 of surgeons from the classics of science fiction.

10. Victor Frankenstein

Frankenstein was the ultimate do-it-yourself surgeon with an insane ambition. In Mary Shelley’s 1818 novel, the mad doctor cobbles together a new being from pieces of dead bodies and uses science to bring it to life. To his great alarm, his patient proves to be an intelligent being with its own opinions. Victor becomes a slave to the monster’s will, which costs him his health, his marriage and ultimately his life.

The surgeon–patient relationship has changed a lot in the past fifty years, but fortunately not with the negative consequences that Victor Frankenstein faced. Communication between patient and surgeon has increased in both directions. In the twentieth century, patients still tended to allow themselves to be led to the operating room like docile sheep, without a clear explanation of what was wrong with them or what the surgeon was going to do. If they were suffering from cancer, that was often not said in as many words, and if there were several options for treating their illness, it was frequently left to the specialist to decide which course of action would be taken, without any discussion.

Fortunately, patients became more vocal, organised themselves into support groups, and demanded more insight into the results of surgery. A modern patient will inundate the surgeon with questions before agreeing to an operation. And quite rightly. Of course that can sometimes be difficult for the surgeon but, even though a patient’s opinions or demands may at times push a doctor’s self-control to the limit, they will never be so bad that they cost him his health, his marriage or his life. On the other hand, surgeons also cover their backs much more these days by explaining as much as possible about the illness and the treatment. That may of course be daunting for the patient, who is not always pleased to be presented with a whole list of possible risks, complications and side effects, but it has become a fixed feature of the modern doctor–patient relationship. The downside of this improved communication is that modern patients no longer trust their doctors as in the past. They seek a second opinion more frequently, which leads to ‘medical shopping’ and overconsumption of health services.

9. Miles Bennell

Dr Miles Bennell was a man who told the truth but was not taken seriously. In Jack Finney’s The Body Snatchers (1954), Bennell’s patients turn, one at a time, into extraterrestrial vegetables, but no one believes him – except, eventually, his psychiatrist.

Today, surgeons are obliged to report abnormal cases and other calamities to the health inspectorate. An inquiry has to be set up to analyse what the normal circumstances would be and how it was possible that they no longer applied in the abnormal situation. This is followed by a plan of action, with a number of points for improvement, which must be assessed after a specified period. Patients unhappy about their medical treatment or how they have been dealt with by their medical carers can lodge a complaint with the complaints official or department at the hospital. Everyone is taken seriously these days – doctors and patients – no matter how strange their complaints may seem.

8. Dr Blair

In The Thing, the 1982 film directed by John Carpenter, a surgeon is infected while doing his work and becomes a monster himself. An extraterrestrial being arrives at a scientific research station in the Antarctic and starts taking the place of the researchers. After each killing, Blair has to perform an autopsy on the deformed body and finally becomes infected himself (he wasn’t wearing a surgical mask). He withdraws from the group and changes into The Thing.

Surgeons work with knives, needles and other sharp instruments all the time, with which they can injure themselves. The patient’s bodily fluids can also splash into the surgeon’s eyes or find their way into small wounds. Surgeons are therefore very concerned about avoiding infection. They wear gloves when touching anything, they have all been vaccinated against hepatitis B, and they wear surgical masks, glasses and a cap to protect themselves while operating. Despite all these precautions, diseases can be transmitted to the surgeon, perhaps through a small hole in the thin rubber gloves caused by a needle or the point of a scalpel, or a stray drop of fluid that manages to get into the eye. The patient then has to be asked for permission to be tested for HIV and hepatitis C. If the HIV test is positive, the surgeon has to take antiretroviral drugs for a month to minimise the risk of infection and only engage in safe sex to prevent further contamination. Infection with HIV and other viruses is an occupational hazard in surgery.

7. Helena Russell

Helena Russell was a doctor in the not too distant future, from the perspective of the 1970s. She was a character in the BBC series Space: 1999, which was aired from 1975–7. As the title suggests, the series is set in 1999. The Moon has been knocked out of its orbit around the Earth. The future looks very unpredictable for the lunar colonists of Moonbase Alpha. And their surgeon is a woman – a very futuristic choice in the 1970s.

There is nothing at all about surgery that makes it unsuitable for women. Women can deal with the physical load, the responsibility, the pace of the work and the night shifts just as well as men. And they can possess just as much technical insight. Women are not by nature less technically minded than men, and they can sometimes be much better than men in social terms. And yet, female surgeons are still very much in the minority. But, with the proportion of women surgeons increasing rapidly, that may indeed change in the not too distant future. Back in 1999, however, female surgeons were still relatively rare – no more than one in eight in the Netherlands, and in England only 3% of consultant surgeons were women.

6. Men in white suits

In Steven Spielberg’s 1982 film E.T. the Extra-Terrestrial, anonymous doctors from a secret government organisation perform their work ruthlessly on cuddly extraterrestrial E.T. Without asking, they take over the house where the young Elliott lives and transform the living room into an operating theatre. Because they do not take the time to first listen to the patient and to Elliott and his family, they don’t understand that E.T.’s only problem is that he is homesick, and they make everything a lot worse than it already was.

The frontiers of surgery are being pushed back further and further. That often raises the question whether all this progress is necessary. Mottos like ‘aiming not only to achieve the most humanly possible but also the most humanly desirable’, or ‘not only adding years to life, but also life to years’ are heard more and more in recent decades. Making a good decision whether to perform an operation or not means striking a good balance between benefits for the patient – in terms of both length and quality of life – and the risks of the procedure. Both patients and surgeons can have a say in this decision. Patients are given a treatment code based on their own wishes and the nature and prognosis of their illness. Choosing full treatment without restrictions means that everything will be done to cure the patient and save his or her life. Specific treatment limits can be agreed upon, for example, that everything should be done except resuscitation, if that should prove necessary. Opting for a complete limitation of treatment means that nothing more is done to save the patient’s life, and only those steps are taken that make the end of life as comfortable as possible.

Women

Although it is almost taken for granted today that surgery is practised by both men and women, the profession has been so male-dominated in the past 200 years that it seems as if women wielding surgical knives are something new. Yet there have always been respected female surgeons. Around the year 1000, (male) surgeon Abu al-Qasim Khalaf ibn al-Abbas Al-Zahrawi, better known as Albucasis of Córdoba, wrote that women who suffered from bladder stones could best be treated by a female surgeon. Descriptions of the skills of female surgeons are also to be found in twelfth century French literature. In Italy, women were trained to be surgeons as early as the thirteenth century and in France the widow of a surgeon was even allowed to take over her late husband’s practice. The more than 3,000 surgeons who graduated in Salerno in the fourteenth century included eighteen women. In the same century, the surgeon at the court of the King of England was also a woman. After the Middle Ages, however, two remarkable changes of attitude led to the almost complete disappearance of women from surgery: the witch-hunts of the sixteenth century and the prudery of the nineteenth century, which prevailed until at least 1968. In the Netherlands, the proportion of women among newly registered surgeons between 1945 and 1990 was around 3 per cent. That increased to 12 per cent between 1990 and 2000. In 2010, 25 per cent of surgeons in the country and 33 per cent of those in training were women. By 2016, 11.1% of consultant surgeons in England were female.

5. Three sleeping doctors in cryogenic hibernation

In Stanley Kubrick’s 1968 film 2001: A Space Odyssey, three doctors spend their voyage on the spacecraft Discovery One fast asleep. They were put into cryogenic hibernation at the start of the mission and are due to be woken up when Discovery One reaches its destination, Jupiter. However, while they sleep soundly, suspecting nothing, the on-board HAL 9000 computer hijacks the ship. The ‘IT department’ completely takes over the tasks of the three doctors and ends their lives.

Somewhere in the period of the Internet bubble, in the mid-1990s, a definite start was made on computerising health-care. Surgeons, too, had to go with the flow and accept these developments. Anyone who chose not to fell hopelessly behind. Handwritten medical records, prescriptions and referral letters are becoming things of the past. Every modern hospital has electronic patient records and all treatments, admissions, results and complications are registered digitally. The number of medical secretaries has consequently decreased, with the result that surgeons now find themselves with much more work to do. It all sounds wonderful, the electronic letters and files, but there is no output without input. Computerisation has not been able to prevent a sharp increase in the volume of administration that surgeons and other medical specialists are expected to contend with. There is (unfortunately) as yet no question of computers completely taking over the tasks of human doctors.

4. Leonard McCoy

Leonard McCoy was the quiet ship’s doctor on the USS Enterprise in Gene Roddenberry’s original series of Star Trek, which was aired from 1966 to 1969. For a man of the twenty-third century, McCoy is quite old-fashioned. He wants nothing to do with the technology and ice-cold logic of his sparring partner Mr Spock. No evidence-based surgery nonsense for him, just good old rest, routine and cleanliness. His patients lie in the neat and tidy four-person sick bay, fast asleep. Under McCoy, there is no fast-track when it comes to post-operative care on the Enterprise.

In our minds, bed-rest is inextricably bound up with post-operative care. Who could ever have thought in the 1960s that lying in bed actually does more harm than good in the important phase of recovering after an operation? McCoy did have a small device, about the size of a smartphone, with which he could obtain a detailed diagnosis simply by moving it back and forth over the patient. His treatments, too, were futuristic, even if only because he could get every crew member who had been attacked by an alien back on his or her feet in no time, leaving no handicaps or scars. But there was nothing futuristic about his policy after administering this high-tech treatment: just as in the great hospitals of the seventeenth century, he would simply put his patients in bed and wait for them to recover.

3. The Robot Surgeon

In George Lucas’s 1980 epic Star Wars: The Empire Strikes Back, an anonymous robot fits Luke Skywalker with a mechanical arm after the young hero loses his right hand in the war between good (The Force) and evil (The Dark Force). At the same time, Luke realises that the evil Darth Vader, who had hacked off his hand with a laser sword, is actually his father. Such a half-baked fairy tale always has to have a happy ending. As a kind of deus ex machina, the robot replaces the lost limb with a bionic hand. Although in this future, Luke Skywalker is a satisfied patient, surgeons seem to have become completely superfluous.

Breathtaking technical developments have been made in surgery in the past thirty or forty years. Increasingly complex operations have become possible, with smaller and smaller incisions. Remarkably enough, robotics have not played a particularly important role in that rapid progress. Certain abdominal operations can be performed using a robot, but the robot cannot be pre-programmed; a surgeon always has to control it in real time. Moreover, robotic surgery offers no new options: the same procedures can be performed without robots. Other technologies, however, such as those relating to navigation and virtual reality, are more interesting in terms of improving operating procedures. In that respect, films like The Matrix (Andy and Larry Wachowski, 1999) and Total Recall (Paul Verhoeven, 1990) present a more realistic picture of the future of surgery than Star Wars.

2. Dr Ash

Ash is the doctor on board the space freighter Nostromo in Ridley Scott’s 1979 film Alien. When a nightmarish alien appears on board by bursting out of the chest of one of the crew members, Dr Ash thwarts the efforts of the rest of the crew to destroy it. The crew kill him and discover that he was not human, but a mechanical android that blindly followed its pre-programmed instructions. The company operating the spaceship had given the android secret orders to search for alien life. Ash was thus a doctor who follows the instructions of his board of directors to the letter, even at the expense of his own colleagues.

Medical specialists determine the quality of their care themselves. Together with the patient, they decide what is to be done and the best way to do it. This is in the hospital’s interests, but hospital boards have other interests, too. They have to pay salaries, purchase medical supplies and manage the hospital building, all without spending too much money, of course. Although the same quantity of care can sometimes be provided with less money, less well-trained staff, cheaper materials and fewer facilities can naturally have a negative impact on quality. Of all the specialists in a hospital, surgeons are perhaps most dependent on well-trained staff, good quality materials and up-to-date facilities. That also makes them the most dependent on the policy of the hospital board. They should therefore be able to keep a finger on the pulse of how that policy is made. Unfortunately, surgeons have the least time of all medical specialists to do this. Generally speaking, policy-making in health care – nationally and in individual hospitals – is in the hands of managers and non-surgical doctors, while surgeons look on from the sidelines.

1. Peter Duval

Peter Duval is the handsome surgeon on board the submarine Proteus in Richard Fleischer’s 1966 film Fantastic Voyage. A prominent scientist from the Eastern bloc defects to the West, bangs his head and suffers a brain haemorrhage. Only a minimally invasive operation can remove the blood clot in his brain. And that is taken very literally in this science fiction film. Using futuristic technology, a nuclear submarine, crew and all, is reduced to the size of a red blood cell and injected into the man’s neck. The sub loses its way and has to take a much more exciting route to the brain, via the heart and the inner ear. To make things worse, it proves to have been a serious error to take an internist along on the voyage. As the story evolves, it becomes clear that the internist, Dr Michaels, is a spy and is sabotaging the team’s well-intentioned plans. But Michaels receives his just deserts when he is devoured by a white blood cell. Surgeon Peter Duval can then put on his tough-guy diving suit and, with the beautiful Raquel Welch at his side, start zapping the blood clot with a large laser cannon.

Only a surgeon could have written such a scenario! Unfortunately, even now, blood clots are not treated by surgeons in miniature submarines, but by medicines administered by non-surgical medical specialists. Just as minimally invasive, but not as much fun.

Minimally invasive treatment is the key concept in the surgery of the near future. Operations are becoming smaller and smaller and take much less time, so that the patient experiences less discomfort and inconvenience. Moreover, fewer operations are necessary because some illnesses can just as easily be treated with drugs or non-surgical procedures. Yet surgeons will never disappear completely, or be replaced by robots or computer technology. There will always be a need for a man or a woman with a knife to save people’s lives, repair damage, remove cancer and alleviate suffering.