Can a surgeon who is sitting perform abdominal operations

A loyal reader alerted me to news of a lawsuit brought by an obstetrician in South Carolina who is suing a hospital for suspending his privileges. He had performed a cesarean section while sitting on a stool because he had a foot fracture secondary to diabetes. Several witnesses said that the doctor "had been unable to properly view the surgical field, unable to properly handle the baby and unable to address hemorrhaging." The patient later developed a serious infection.

A seated surgeon can operate on the hand and arm. In fact, thats the way everyone does it. The surgeons knees easily fit under the small table holding the outstretched arm. Certain anorectal operations and gynecologic procedures done through the vagina can be done by a surgeon who is sitting, but abdominal and pelvic operations done via laparotomy cant be safely done that way.

The problem is that when a surgeon is sitting, she cant get close enough to the OR table and the patient to see way down into the abdomen and pelvis. If bleeding occurs deep in the wound, controlling it would be challenging to a surgeon who is sitting. Tying a secure knot in the pelvis while sitting might even be impossible.

With the exception of robot-assisted surgery where the surgeon sits a console remote from the operating table, a seated surgeon would have trouble doing both open and laparoscopic procedures. Even with a robotic operation, there can be problems. If the surgeon cant stand, an assistant would have to help insert the robotic ports. What if something went wrong and the abdomen had to be opened?

In a laparoscopic case, the video monitor could be seen by a sitting surgeon, but manipulating the rigid instruments would be difficult because of the angles created by the locations of the ports through which the instruments are passed.

As a retired surgeon, I sympathize with anyone who might be forced to quit operating because of illness or disability, but the safety of the patient comes first.

I hope that the suit is resolved quickly and we learn what the outcome is.

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So you want to be a Radiologist

A student writes, Ive been following some of your posts and noticed some of the comments by others mentioning that radiology residencies/jobs are drying up and even face the possibility of disappearing completely. Could you explain why? I am currently a senior pre-medical student whos taken a recent liking to radiology after following a few radiologists in a hospital, so I would just like to get some input.”

A colleague, Dr. Saurabh Jha, an Assistant Professor of Radiology at the Hospital of the University of Pennsylvania, has graciously agreed to respond. He can be followed on Twitter @RogueRad.

Should I go into radiology?

I used to be a surgical resident in the UK. One day, I was a little dispirited during a brutal call, and my senior resident asked “do you love surgery?”

“I like surgery,” I replied.

“If you don’t love surgery, love it unconditionally I mean – like loving your child – you will be unhappy.” He warned.

I really liked surgery. I like radiology. I’m happy as a radiologist. Radiology fits my temperament. You don’t have to love radiology like one has to love surgery, but you have to like it. It helps if you like it a lot.

The worst reasons to go in to radiology are to make lots of money and to avoid patients. The days of radiologists making $500 K + 12 weeks of vacation after reading 20,000 studies a year are over. Radiologists doing interventional, ultrasound, mammography and fluoroscopy (such as barium enemas) must speak to patients, and speak well.

Radiology is a tech-heavy field. If you’re excited by technology, you will like it. Radiologists are leading healthcare in IT. If you have an interest in health IT, then some programs will integrate informatics with your training.

Residency involves substantial reading. You have to master anatomy, radiological pathology, and physics, as well as have a decent knowledge of clinical medicine. Prepare for 20-30 hours of reading a week. Radiology is now 24/7. Calls are intense – 12 hour shifts are non-stop. But when you are off, you are off.

Believe it or not, international health – if you are into that – increasingly asks for radiologists. Although you won’t be parachuting in to Sierra Leone or quarantined in Fort Hood.

Will there be jobs when I graduate?

Like Yogi Berra I am reluctant to make predictions, particularly about the future. But radiologists have a poor record in making predictions about jobs. During Hillary care, we thought there would be a surplus of radiologists. We were wrong. During the Bush era we thought there would be a shortage of radiologists. We were wrong.

That’s 0/2. That’s worse than a coin toss.

Here is what I can say. American medicine will not do with fewer imaging tests. American population is not getting younger. Healthcare coverage is not shrinking. There are more lawyers who need something to do. Bottom line: demand for medical imaging will not fall suddenly.

There are emerging number of “empowered consumers” who want to pick up disease before symptoms. They will need radiologists, or someone who understands false positives, to keep their normal kidneys from the surgical pathologist’s slides.

Will residency positions be reduced?

They should but won’t be. That means you have the upper hand – because supply of residency spots exceeds demand. Beware though. The demand for good residencies has increased. The current first and second year residents at my institute are the brightest I’ve ever seen. They’re scary good.

Ask the program director how many of their residents had to do two fellowships before getting a job. Demand that information. You have a right to know how their residents fared in this competitive market.

What should I do to before residency to be a better radiologist?

Rule 1: avoid radiologists and radiology rotations. You’ll have a life time of us. And there’s only so much you’ll learn watching us stare at the screen and bark at the mike.

Improve your knowledge of medicine. Spend time on the ICU, in the ED, at the trauma bay, with the surgeons in the OR. Understand clinical decision making. Understand how doctors think. Understand the ill patient. Become a doctor. I don’t mean that in touchy-feely terms. I mean develop clinical acumen.

The radiologist with a sharp eye and no clinical acumen is a generator of differential diagnoses – though not as good as IBM’s Watson will be. The radiologist with common sense (read clinical acumen) and even a mediocre eye will prevail.

Any other advice?

Join radiology’s professional society – ACR – it’s free and has a vibrant section for trainees. Get yourself employment-specific disability insurance, if possible.

Get in to the habit of exercising or playing sports. You will not be walking as much as your clinical colleagues.

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