Common questions in Quora are about medical specialties that are hardest to get trained in, are the most difficult to practise, and who among the specialists makes the most money? The last question we will leave to income-tax and IRS officers to answer. No specialty is more difficult than the other to either specialise or to practise though each one poses problems that are unique to it. The layman would rank a cardiac surgeon or a brain surgeon high on the list but to a patient with eczema his dermatologist is king.
Coronary bypass operation, though losing its lustre of late in the public eye, is a great surgical achievement. But it is not a one-man procedure. An astonishing array of specialists take part in the operation. The cardiologist who made the initial diagnosis, radiologist who after a coronary angiogram maps out the narrowed coronary vessels, the anaesthesiologist who oversees the patient during the critical phases of the operation , the team that operates the heart-lung machine, the surgeon who harvests the graft vein from the lower limb, the surgeon who lays open the heart by splitting the breast bone, and finally the cardiac surgeon who does the intricate operation of stitching the bypass graft. The goal scorer accepts the kudos on behalf of the team.
The brain surgeon has other problems. Unlike the cardiac surgeon he has an imperfect knowledge of the organ he is repairing. The heart can be understood in simple mechanical terms. It is a pump with chambers and tubes leading in and out of the chambers with valves at the connections, and a thick muscle to power it. In heart attack the power is at fault and the bypass or the stent restores power. In valvular disease the valves are replaced and if the tubes (blood vessels) are weakened and are stretching (aneurysm) they can be removed and synthetic tubes stitched in their place. The brain surgeon has no such resources.
For all the marvellous functions that the brain performs it is just a lump of tissue with no moving parts. But it must be doing a lot judged by the large amounts of energy it consumes. An ounce of brain tissue uses 20 times the amount of oxygen that an ounce of resting muscle needs. What is the brain doing with all that energy? There is no answer yet. The brain’s need for energy is so great that if oxygen supply is cut off for just 4 minutes the brain is irrecoverably damaged. What makes it so fragile is again an unanswered question.
Much is known about the function of the brain though. Advances in tumour surgery and surgery for Parkinson’s disease are many but if brain surgery is to take off a breakthrough is necessary in our understanding of the physiology of the brain.
Nothing comes easy in any specialty. Groin hernia may be the commonest operation performed worldwide but one takes it for granted at one’s peril as a senior and very skillful surgeon in the district hospital in Trichy, India found to his cost. This event happened in 1960. The patient, a brother of the hospital nurse, had come from two hundred miles away to get his hernia repaired by this surgeon. The operation went off without a hitch but in the postoperative ward the patient started passing blood in the urine. The urinary bladder can get injured in groin hernia operation. Surgeons are aware of this and take care to identify the bladder and keep it safe. At same point in the repair apparently the surgeon had taken a stitch that had caught a bit of the bladder wall. Such a mistake had never happened in the hundreds of hernias he had repaired but this time it had. A urologist with a cystoscope could have helped but was not available in Trichy 60 years ago. Other methods were not effective and by the second day the patient had to be transfused 3 bottles of blood. Then suddenly the bleeding stopped on its own. When I met him, he was sunken eyed and worn out by the ordeal—not the patient, the surgeon. Contrary to what the public assumes, death or near death of a patient suffering from a non-life-threatening illness owing to misdiagnosis or surgical accident leaves doctors and their staff in misery.
General medicine and general surgery are popular specialties. In themselves they are good but in addition they are takeoff points of cardiology, cardiac surgery, neurology, neurosurgery, nephrology, urology etc. Paediatrics is very popular in the developing world but not so in the developed world. Anaesthesiology is popular. It needs skill and these specialists earn good money, but they must spend long hours waiting for the surgeon to finish and in the end though they are key members of the surgical team they work in total anonymity.
At one time radiologists sat in front of the x-ray lobby and reported on x-rays. Now they do more. Interventional radiologists have simplified many surgical feats. One example. By guiding a thin tube through a neck vein into the liver the radiologist can insert a stent to connect the hepatic vein branch to a portal vein branch and stop bleeding in oesophageal varices. This procedure called TIPS has removed a major surgical operation called portocaval shunt from the surgeon’s list.
Some years ago, cancer cases were the responsibility of the specialty the cancerous organ belonged to. Thus, general surgeons or gastroenterological surgeons will take on cancer stomach cases, and gynaecologists cancer uterus and so on. With advances in cancer chemotherapy and radiotherapy cancer cases are now the combined responsibility of medical oncologists, radiotherapists and surgical oncologists.
Urology is a specialty that has travelled far from the days general surgeons were doing that work. Removal of a kidney stone would leave the patient with a 6-inch scar on his side but now the urologist with his endoscopes and ultrasound would remove the stone leaving no scar. Removal of the prostate used to be a major ordeal for the patient, but now thanks to the endoscopes and the trans-urethral approach it is no more than a short nap for the patient.
How doctors choose their specialty is instructive. Sometime during their general training, they develop a liking for a specialty. That is about all. It is their personal fancy. No other calculation like time it will take to get trained or money to be made goes into making that decision. One would assume that leprology will be very low in demand, but it is not so. One of my classmates in MBBS, Ganapathy, who was expected to become a consultant physician chose leprology. He won many awards for his pioneering work among the leprosy patients of Mumbai. He passed away a few years ago. He said that he was once posted to the leprosy department where he was so impressed by his senior’s work there that he fell for it. Leprosy hospital is full of doctors so stricken. Leprosy patient suffer from may disabilities health wise and in society but lack of doctors and nurses to attend on them is not one of those.
