My place

I had the privilege of learning vascular surgery during the time that vascular surgery was first recognized as a surgical specialty. As a “fellow” in a highly competitive emerging specialty I viewed myself among the ‘best and the brightest.’ There are many hierarchies within medicine, based upon the ‘importance’ of what we care for, the brain or the heart, or how much we earn, orthopedics or plastic surgery, or how many papers we write, academic versus community or even who we care for, concierge practices and sport team physicians. All of these help us understand our place. And thinking back to the earliest, TV shows about medicine everything orbited around a single male; Dr. Kildare, an intern, or Dr. Casey a chief resident in neurosurgery, or Dr. Welby, a family practitioner. Vascular surgery has always been the center of my medical universe; it has always held a pre-eminent position in these hierarchies of place.

In 1543, Copernicus moved the earth from the center of the universe, replacing it with the Sun, and the heliocentric theory. Dr. Mario Livio, an astrophysicist working with the Hubble telescope states

“…We then discovered that the Earth is not even at the center of the solar system. We then discovered that the solar system is not at the center of our galaxy, the Milky Way galaxy. We are about two-thirds of the way out. Then … astronomer Edwin Hubble discovered that there are billions of galaxies like ours and, in fact, with the Hubble telescope we have shown that there are about 200 billion galaxies like ours just in the observable universe. … ”

CMS provided a Hubble telescope in the recently published payments for 2013. Here is a graphic:

Vascular surgery cared for 3% of Medicare patients in 2013, a number dwarfed in comparison to primary care, ophthalmology, podiatry, and orthopedic and general surgery. But for our patients, our role in improving life and sustaining functionality is critical.

Livio continues that an inevitable consequence of Hubble’s findings is that “… our physical existence has become more and more miniscule in all of this.” Similarly, vascular surgery, while the center of my universe, is not the center of our universe. So, what is a surgeon suppose to do when the axis shifts so radically?

Dr. Livio offers solace for our shrinking physicality,  “… our minds become more and more important… we will discover more and more things about life.” Our place is more miniscule and at the same time more complex.

Today’s televised reflections of medicine are ensembles, like Gray’s Anatomy, involving an inclusive team; the white male is no longer centric. Patient stories are the narrative glue holding the soap opera together. Does Dr. Kildare provide a possible understanding? “In the series' first episode, Gillespie tells the earnest Kildare, "Our job is to keep people alive, not to tell them how to live." Kildare ignores the advice, which provides the basis for stories … episodes began to focus less on him and his medical colleagues, and more on the stories of individual patients and their families. Perhaps my newly found contentment in doing locums comes from my greater emphasis on patient’s stories than procedures.

 The shifting focus from an event to chronic care, from procedures to population health, from keeping people alive to prevention is no different than that heliocentric shift. While my sense of place has become smaller, it retains the ability to inspire awe for the opportunity it provides.