Out of Touch

Out of Touch by Leo A. Gordon, MD. Touching is the culmination and the fortification of the hallowed physician-patient relationship. The act of touching creates a bond unlike any other in clinical medicine. It was this magnificent act of directly touching disease that led me to choose surgery as a career. I was thrilled to be able to cradle human pathology in my hands. I felt innate satisfaction identifying the nature of and removing offending pathology. I reveled in recreating the patient and relieving that patient's problems. There was something magical about using my prehensile limbs, limbs that had evolved over the millennia, to rearrange or to remove diseased parts of a fellow human. As I touched those organs, Their rich evolutionary history was always in my mind.

As I dissected the gallbladder with my hands guiding an instrument, I was at one with Dr. John Bobbs and his patient on a kitchen table in Indiana in 1867. As I grasped the top of the gallbladder, I always looked for a Phrygian cap. Why? Because the history of Phrygia and its cap of freedom has meaning for me and for every American. As I searched for the base of the appendix, I was at one with Houdini and Edward VII.

I was Charles McBurney and Reginald Heber Fitz. I had earned the privilege to establish direct personal contact with these organs. And because of that direct personal contact, I became part of human history and the evolution of surgery. I was one of the chosen vehicles for passing the accrued knowledge of centuries on to the next generation of surgeons. Over the years that sense of touch became refined.

These hands could assess degrees of inflammation and the extent of disease. My hands became finely tuned tensiometers. They had achieved, as the old professor described it, tissue sense. Tissue sense is the ability to assess human tissue with your hands and to gauge the extent of the underlying process. Tissue sense tells you what you can and cannot do to that particular tissue. As the years of practice went by, I was no longer just a surgeon. I was part of a grand arc of historical and embryologic one-on-ones. That sigmoid lesion in my hands conjured up the embryology of the hindgut. How did the haustra get their name?

How did the teniae get their name? Why is it called the sigmoid? The value of asking these critical questions was enhanced with my hands. Then, with my hands, we would join together. The anastomosis became a metaphor not only for making the patient whole, but for making the surgical team whole.

Who was Connell? Who was Lembert? Has anyone ever read Erle Peacock's Treatise on Wound Healing? Does it matter? Of course it matters because I had earned the privilege of touching this diseased organ.

I wanted to communicate what was required to achieve that privilege. Through the touching we achieved the zen of the intestinal anastomosis. The surgical process was a communal touching of the evolution of the mud slug who slithered out of the primordial ooze as its gastrointestinal system evolved. Is not the sense of touch one of the basic senses? Why did the sense of touch evolve embryologically?

All of these questions were magnified, dignified, by holding. Then, in a critical blow to the value and the joy of surgical touching, the laparoscope and grasper replaced my hands. Is the surgical event the same when the pathology is a yard away at the end of a light stick projected onto a video screen? The relativity of the surgical process changed. Einstein explained relativity this way.

Put your hand on a hot stove for a minute, and it seems like an hour. Sit with a pretty girl for an hour, and it seems like a minute. Einstein was, in a sense, describing surgical relativity. Yes, the time is the same. But the relative influence and impact of that time is vastly different.

Progress is never easy. Old habits and prejudices die a slow and sometimes agonizing death. The history of medical progress has always been the history of the past, clashing with a vision of the future. Laparoscopic surgery, for many of my generation, resembled a love affair gone awry. The enchanting and enticing object of our affection began to move away.

That object no longer sits next to us. What was close and intimate is now distant and disinterested. The touching, whether a handshake or an embrace, has disappeared. Laparoscopy, the single greatest advance in general surgery during the course of my career, distanced me from the entity to which I was slavishly devoted. My lover left me for a more attractive mate.

Even as a scorned surgeon, I accepted the rejection. I learned the ways of the laparoscope. My romance with human pathology, once an evolution, became a speed date. Laparoscopic surgery was better for the patient. As time went by, it made remarkable progress.

I now no longer even look directly at the organs I had come to love and appreciate. They have undergone some sort of visual plastic surgery. They are larger and brighter. They appear stunningly absolutely beautiful on the screen. Are there Hollywood makeup artists lurking in the foramen of Winslow?

Are these organs real or are they apparitions? Operating on these organs is now like visiting someone in a maximum security prison. Touching is now separated by a thick glass partition. Our loving hands are separated from the object of our desire. We speak remotely rather than whisper lovingly into a receptive ear.

The clock has been turned back on my prehensile limbs to the Mesozoic era. I can no longer touch my cavemate. Further and further away I moved, but I have adapted. I took solace in the fact that I would never, ever be further away from the object of my surgical affection. I could live and even flourish with this new visual and tactile approach that had transformed my chosen profession.

Then, my distanced lover moved even further away. She left me for a robot, instead of the direct approach to the organ by laparotomy or the once-removed approach via the laparoscope, the robot now placed the operating surgeon even further away from the patient. In some instances, the surgeon was even moved out of the operating room. Everyone's hospital wants a robot. Every patient inquires about the robot.

Who would ever think that he is a robotic surgeon would be a compliment? From Hippocrates to Osler to Halsted to Tobor the Fourth, we are now further away from the patient than we have ever been. I have marveled at the robot's hands performing a 360-degree turn. I have admired the robot's hands as they extend rigid and free of a tremor. I have seen the robot maintain a fixed position for hours.

I have seen the joy and sense of accomplishment by robotic surgeons as they roboticize and romanticize their efforts. But for me, it is not the same. I think this is why internet grocery shopping failed. Everyone wants to squeeze the cantaloupes before they buy them. As I approach the third and final period of my professional life, as a hockey fan I divide my career into three periods, I feel a sense of accomplishment for the patients I have helped. But I also feel a profound sense of loss as the human pathology I was educated to eliminate is retreating further and further away from me. I envision a future conversation in the common room of an assisted living facility. A lovely couple is sitting next to me, Server One, and his wife, Servina. They are retired robots.

We chat for a while. I notice a certain sadness and regret in the conversation. They were at a major medical center several years ago. They fell in love and prospered. But then, facing the inexorable wave of medical progress, they too were distanced from the objects of their professional affections. Their hands were no longer useful. Most of the diseases they treated were now cured with genetically engineered pills or with stem cells. Servina focuses her dark blue triple-chip lens on me and says wistfully, �Can you imagine these beautiful titanium arms, joints, and graspers being replaced by some pill. I was always thrilled to be able to cradle human pathology in my hands.