In George Bernard Shaw’s play The Doctor’s Dilemma, written early last century, the knife-happy surgeon invents a nut-shaped abdominal organ, the ‘nuciform sac’. It is situated near the appendix, ‘full of decaying matter’, and requires removal, assuming the patient can afford the fee. The surgeon, Cutler Walpole, has the line: ‘The operation ought to be compulsory.’
Bernard Shaw labours the point that removal of the nuciform sac equals 500 guineas, and not removing it equals nought guineas. He then suggests, wickedly, that we want our surgeons to be mortal, ‘quite as honest as most of us’, not God-like. Which of us, he asks, would not be influenced by the financial equation, if it is impossible to prove that this organ might be better left in situ? Add in the need to pay for a Harley Street consulting room, school fees, and a wife with expensive tastes and the choice is self-evident. Every nuciform sac must come out. No one dares challenge the wisdom of the great man, though the operation is of course pointless.
It might surprise a reader to know that there are real ‘nuciform sac’ operations being performed every day in private medicine by surgeons just as eminent as Walpole. The organs being cut out really do exist — but the operations are often as unnecessary, and always expensive. A few decades ago tonsils and adenoids were the nuciform sacs of their day. It was deemed important to excise them for any child with recurrent throat trouble. An accomplished private surgeon always had an explanation for why the lucrative operation was needed, although there was very little actual evidence that removing them made much difference.
It was the same for the removal of varicose veins. No more justification was needed than the patient’s request. Both these operations are now performed less frequently but each era has its own nuciform sac, and the fashion has moved on to endless ’oscopies and keyhole procedures. Any symptoms in the relevant area may lead to one of these, such as arthroscopy, cystoscopy, GI endoscopy, colonoscopy, laparoscopy and many more. The reason given by your private doctor is always that serious pathology such as cancer is best diagnosed early, and these modern ‘look-see’ operations are relatively small and safe compared with the old days, when a ‘look inside’ was itself a major procedure.
Of course the reason is often valid, and indeed therapeutic, such as knee arthroscopy for a torn cartilage, where the diagnosis is confirmed, and curative treatment carried out at the same time through a minute incision. However the arthroscopy epidemic has spread to many smaller joints, where the view is tiny, and the chance of finding serious or treatable disease equally tiny. In other situations, the search for early cancer is often genuine, such as any patient who has seen blood in urine or faeces or vomit or phlegm. But patients with nebulous symptoms should beware.
How could a caring surgeon, with a clear conscience, put a patient through the risks of an anaesthetic and a procedure that it would be difficult to describe as necessary? What you have to remember is the complication rates of unnecessary surgery are very low. Wounds heal better if unhindered by the presence of disease. The full benefits of the placebo effect add on to the likelihood of success. Patients like being told they need an operation. It’s a simple solution. The patient has already had the satisfaction of knowing ‘it was bad enough to require an operation’. Even the passing of money increases the desire for success. No one — patient or surgeon — wishes to think the fee was wasted.
Do I sound cynical? Yes, but a healthy cynicism is no bad thing in all aspects of life, including medicine. Having an awareness of the pitfalls is all I am advocating. Time and again, in recent years, living in wealthy non-medical communities, I have listened to tales of remunerative procedures on friends and acquaintances that just don’t ‘stack up’ in terms of vital need. My own operating days are long past, but I remember my father, an Essex GP, pushing The Doctor’s Dilemma across the breakfast table to me when I was a pre-medical student. I was suitably appalled, but put the matter on one side for a decade. I then found myself drawn to a career in surgery, with no time for anything except the long, tough vocational training.
Fast-forward another few years and I was in my first year as a consultant general surgeon in High Wycombe. I felt I had arrived in paradise. The work was entirely NHS, and there was soon more than I could easily handle. No patient needed to worry about the cost of their operation, however great. I had to focus on the cases that required my so-called skills, and exercise some degree of appropriate delegation.
I have the lists of operations I performed in four busy weeks spread over those early years. The average was ten major, six intermediate and five minor procedures each week. The word ‘major’ indicates any abdominal operation, mainly bowel surgery or gallstones, or, outside the abdomen, removal of the breast, prostate or thyroid gland. ‘Intermediate’ indicates operations such as hernia, varicose veins or piles, and ‘minor’ indicates removal of cysts or skin lesions or vasectomy. The ’oscopies were rare in those days, but were classified as ‘intermediate’.
After the first few months something unexpected happened. GPs started asking me to see occasional private cases. How was I to overcome the doctor’s dilemma? How would I know my motives for suggesting some expensive op were not self-interested?
My answer was to apply what I think of as the NHS test: would you still operate if there were no financial gain? My NHS income was adequate. I consulted in my own home with my wife as my secretary, and thus had no overheads. The NHS test meant that I would sometimes veer away from intervention, perhaps wrongly, but always in the best interest of patients. My NHS thinking cost me further referrals from at least one GP: ‘I asked you to operate on her varicose veins, not tell her she could wear a support stocking and keep them.’
Over time, the level of private medical insurance increased. South Bucks was an affluent area, and the amount of private work also went up. For a short spell I rented a room in Harley Street one half-day a month, at minimal cost. This enabled local GPs to tell their patients that they did not need to travel to London to see a ‘Harley Street surgeon’ if that was their wish.
The challenge then became one of time allocation, never short-changing NHS commitments for private practice. I also had a personal fetish about never having an NHS waiting list. No patient had to ‘go private’ to get the operation done. At times the workload was almost overwhelming, but that in itself made for safety. A busier surgeon is a better surgeon for reasons I’ll explain.
The only way to try to establish that your operation, whatever its nature, is truly necessary is to apply an NHS test too — to go through the diagnosing and referring process. Once the decision is made then you may wish to declare your private insurance, and ask for the great man’s private phone number. You’ll then have the choice of time, place and creature comforts in hospital. Your surgeon is contracted to do the operation himself, a promise that must not be made in an NHS setting, although it may be implied — ‘none of my juniors know how to do this operation’, for example. You will be reducing the pressure on the NHS, where you may or may not get speedy and excellent service.
The bigger your operation, the more quickly you are likely to be dealt with on the NHS. Long waits are probable for procedures for hernia, piles and varicose veins, but your turn will come, and your operation will be competently done.
There is one more word of caution. Make sure that your surgeon is very busy in his NHS practice, and not looking for cases to fill his operating lists. It is safer for patients if the surgeon has too much work. He will then choose to operate only on the patients who will benefit most, and those on the borderland of necessity will not have an operation.