Goldwyn’s Laws of Plastic Surgery

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.


Another thoughtful essay from Dr. Robert Goldwyn’s book “The Operative Note: Collected Editorials” (published in August 1992).  I left out the section between the third paragraph and the “plastic surgery laws”  as they were general day to day ones.

Laws of Plastic Surgery

We pitiful human beings, born not of our will, are thrust into this world, which throughout our lives we try to comprehend.  To make sense of our existence, we seek the verities; we try to formulate laws of earthly happenstance and human behavior – basic tenets akin to the laws of gravity and energy.  Take, for example, Benjamin Franklin’s fundamental:  “…in this world nothing is certain but death and taxes.”  And closer to our time is the observation of Professor Parkinson:  “Work expands so as to fill the time available for its completion.  Thus, an elderly lady of leisure can spend the entire day in writing and dispatching a postcard, another in hunting for spectacles, half an hour in search for the address….”

As valid as the law seems, it is not always true.  There are, I am sure, older retired women who would never devote more than a half hour to writing to their relatives.  So we have another law:  “Every rule has an exception (even this one).”  Whether the exception proves the rule, or the rule, the exception, I leave to that genre of professional deep thinkers, known as logicians.

The laws concerning how our world functions or malfunctions contain much wisdom in few words.  While we might add a qualifying “usually” to the statement, its soundness and acumen remain incontrovertible.  That the law does not hold for every circumstance should not disconcert us.  The impression of precision – "’a la Heisenberg – is a preoccupation of today’s mathematics and physics…….

Permit me a few “laws” of plastic surgery:

The preoperative photos that are lost are always of the patient with the best result.

The last stitch in a blepharoplasty always starts bleeding.

No insurance company ever makes a mistake in your favor.

No medical organization to which you belong ever reduces its dues.

The patient whose operation you do for visiting surgeons will have the hematoma.

VIPs are magnets for complications.

The patient with the best initial result never returns for follow-up.

The dissatisfied patient never moves away.

The older the surgeon, the less he or she perceives the need to retire.

The older plastic surgeon never thinks there is room for a younger one in town.

The initial sponge count is never correct when you are behind schedule.

The rhinoplasty patient with only a fair result is your most enthusiastic supporter.

The lengthy operative note (discharge summary) is the one that gets lost.

No surgeon ever has enough operating time.

No hospital ever has enough operating rooms or personnel.

Plastic surgeons resent a colleague in direct proportion to the aesthetic content of his appearance in the media.  Corollary:  The expert on hypospadias is never maligned.

Most surgeons lack the enzyme allowing them to praise the results of a colleague.

Most surgeons feel a twinge of pleasure at another’s complication.

Our readers doubtless have better rules of their own – and that, perhaps, is another law.

Knowledge: What Kind and How Much?

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.


Here is a second essay from Dr. Robert Goldwyn’s book “The Operative Note:  Collected Editorials” (published in August 1992).  

Knowledge:  What Kind and How Much?

A few years ago, when my daughter was a high school sophomore, she asked me to help her prepare for a biology quiz.  She was astounded that this paterfamilias, a certified physician, was ignorant of the precise base sequence of DNA-RNA.  In self-defense, I said that most of my colleagues would probably fail her test but were good doctors nevertheless.

“but how can they take care of patients properly if they don’t know all about these important nucleic acids?” she asked.

“Surprisingly,” I replied, “they do very well.”

This incident, aside from revealing my daughter’s knowledge and my lack of it, is relevant to the greater considerations of learning – What kind and how much?  Publilius Syrus, known for his maxims in the first centery B.C., said:  “Better be ignorant of a matter than half know it.”  Many centuries later, Alexander Pope expressed the same thought in his famous “a little learning is a dangerous thing.”  Huxley’s retort was “Where is the man who has so much as to be out of danger?”  In truth, most of us are in various stages of ignorance.

A medical student asked me, “How much basic science do I have to know to be a good doctor?”  The question, which may be unanswerable, is nevertheless perennial.  Because knowledge and wisdom are not synonymous, the central query is how much of each is necessary.  Any answer must take into account the individual’s needs at a particular time.  Students regularly complain about the irrelevance of the material they must digest, and teachers constantly chide them for their lack of perspective in not realizing that what may seem useless today may be helpful tomorrow.  What to teach and what to learn have stimulated curriculum committees to produce ponderous reports that rehash everything and resolve nothing.  Rare is the year without another “definitive” statement on the aims and strategies of education.

The human being functions astonishingly well knowing comparatively little.  Global enlightenment is unnecessary.  For most people, making a living in our complex society demands narrowness not breadth.  We are job-specific.  Major league pitchers would fail a high school physics test on mass, velocity, friction, and wind currents, yet they could easily strike out every professor at the Massachusetts Institute of Technology.  So also can a doctor do considerable good for a patient with more know-how than knowledge.  Deplorable, perhaps, but true.

Let us take the example of reconstructing the breast in a 45-year-old woman who has had a mastectomy.  How many plastic surgeons could discourse on the hormones at menopause?  Could we pass a thorough examination on the  various ways of treating breast cancer:  radiation, chemotherapy, surgery?  Are we well read in the history of each of these therapies?  Do we have a picture in our minds of the histology of the most common kinds of breast cancer?  Do we know the chemical structure of silicone and how the implant is made?  During the procedure are we familiar with the anesthetic agents and their pharmacology and physiologic effects?  Do we understand the manufacturing process of the surgical blade and suture material?  And what about wound healing, not only the names of the classic stages but the biochemical and biomechanical aspects?  Certainly, it would be better if we had this knowledge.  However, even if we possessed it, we still would have to know when to operate, on whom, and how.  And what about the not-so-small matter of being a compassionate physician with psychological understanding of this unfortunate person and a feeling of permanent responsibility toward her?

This editorial is not a plea or an apologia for ignorance, not is it a eulogy to it.  It is an attempt to recognize things as they are.  Often we are hypocritical in being hypercritical.  We usually demand more knowledge from others than from ourselves.  Furthermore, within the medical sphere, if we are honest, we would admit that many errors arise not from lack of knowledge but from absence of what moralist one called “character.”  In this situation, what motivates the doctor may imperial the patient to the detriment of both.

Unfortunately, I cannot offer a solution to the problem that prompted this editorial:  Knowledge: What Kind and How Much?  What is certain, however, is that knowledge without wisdom is like a ship without a rudder.  Correct timing and the proper application of  information hopefully come with experience.  Yet, as someone observed, there is a difference between a person who has 20 years of experience and someone with 20 years of 1 year’s experience.  Let us hope, at least, for the former.

Dr. Goldwyn’s “Surgeon”

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

After learning about Dr. Robert Goldwyn’s death, I pulled out his book “The Operative Note:  Collected Editorials” to reread (published in August 1992).  I’d like to share a few with you over the next weeks/months.

The first is entitled “Surgeon”

On a recent trip to Hawaii, I learned that in the Polynesian dialect spoken there, the word for surgeon is kauka oki:  doctor (kauka) who cuts (oki).  While some of us surgeons might resent such a graphic, “cut and dry” definition, we cannot deny its verity.  No matter how we may slice it, a surgeon is a doctor who makes incisions.  In fact, the origin of the word surgery is Greek, from cheir, meaning “hand,” and ergon, meaning “work.”  That surgeons work with their hands did not always bring honor.  Centuries ago, one recalls that those who cut on others, with their permission, generally held a lower status than those who eschewed the knife.

At the bottom were the barbers, and slightly above them, the surgeons.  In England in 1462, the Guild of Barbers became the Company of Barbers, and under Henry VIII, the Barber Company was united with the smaller Guild of Surgeons to form the United Barber-Surgeon Company.  In commenting on Henry VIII’s role in this episode, Garrison cites the painting by the younger Holbein, the court painter:  “Henry VIII—huge, bluff, and disdainful—in the act of handing the statute to Vicary [Thomas Vicary, First Master of the United Barber-Surgeon Company], in company with fourteen other surgeons on their knees before the monarch, who does not condescend even to look at them.”1  Perhaps Henry was irate at having to leave his dinner table and his newest wife.

The metamorphosis from the lowly barber to the glamorized surgeon has been long.  I am sure that Henry VIII did not envision the consequences of his royal decree.  The seesaw of history is marvelous as long as you are on the upswing.  The rise of the surgeon did not erase the schism (in fact, it may have intensified it) between the so-called thinkers and the doers.  This enmity, although lamentable, is centuries old.  some, however, such as Lanfranchi of Milan (the first to describe concussion of the brain and to distinguish between cancer and hypertrophy of the female breast), did rise above the petty, professional fray.  In his Chirurgia Magna, completed in 1296, he wrote:

• Why, in God’s name, in our days, is there such a great difference between the physician and the surgeon?  The physicians have abandoned operative procedures to the laity, either, as some say, because they disdain to operate with their hands, or rather, as I think, because they do not know how to perform operations.  Indeed, this abuse is so inveterate that the common people look upon it as impossible for the same person to understand both surgery and medicine.  It ought, however, to be understood that no one can be a good physician who has no idea of surgical operations and that a surgeon is nothing if ignorant of medicine.  In a word, one must be familiar with both departments of Medicine. 2

We do accept the fact today that the best surgeon is one who knows not only how to operate, but when not to.  Harvey Cushing, about the time that he became the first Surgeon-In-Chief of the Peter Bent Brigham Hospital, Boston, said in his letter to his counterpart in medicine, Henry Christian:  “I would like to see the day when somebody would be appointed surgeon somewhere who had no hands, for the operative part is the least part of the work.” 3

Cushing, of course, did have hands, good ones, and more important, a superior brain, which he used prodigiously.  His remark was a hyperbole that reflected his correct view of surgery; it must grow from research and basic sciences and from its application to clinical problems.  Surgery, despite the awe it now has (for those who doubt this, see the afternoon “soaps”), represents a failure of nonoperative medicine.  Who would not want to take a pill rather than undergo an operation for cholecystitis, breast cancer, or benign prostatic hypertrophy if the results were the same?  Would not genetic engineering by medication to prevent facial clefts be preferable to repairing them, no matter how meticulous and innovative the surgeon?  The thought that a capsule could safely enlarge or reduce breasts or salve could eliminate Dupuytren’s contracture or a prominent dorsal hump may seem too fanciful even for the most imaginative, yet landing a man on the moon and retrieving him without mishap has long been a fait accompli.  However, since medical Shangri-La is many years hence, we heirs of Pare will be continuing our manual ministrations, our barbers’ burden.

References

1.  Garrison, F.H.  An Introduction into the History of Medicine with Medical Chronology.  Suggestions for Study and Bibliographic Data, 4th Ed.  Philadelphia: Saunders, 1929; reprinted in 1960. Pp. 238-240.

2.  Lanfranchi of Milan.  In M.B. Strauss (Ed.), Familiar Medical Quotations.  Boston: Little, Brown, 1968. P. 583.

3.  Fulton, J.F.  Harvey Cushing:  A Biography.  Springfield, Ill.:  Charles C. Thomas, 1946.  P. 352.