The surgical hierarchy

If human suffering can’t be measured, should doctors be differentiating between patients with minor illnesses and those with serious conditions

What is the prestige of hierarchy in medicine?” a bald friend of mine asked, when I referred him to a general surgeon to remove an annoying sebaceous cyst on his sparkling scalp. “Brain surgeons don’t deal with such paltry problems,” I said with jolly arrogance, dismissing the puffiness on his head. “I’ve had it removed twice before and it keeps coming back, which is why I want you to do it,” he said, massaging my ego.

“Neurosurgeons are on top of the medical totem pole,” I said to answer his question. “We do the most sophisticated and precise work. Also, our job has the maximum potential to harm and hence, the stakes are very high—because the brain and spinal cord control everything,” I explained. Just then, quite coincidentally, my cardiac surgery colleague peeked his head into my office to see if I was free to discuss a case. “Cardiac surgeons come a close second, but their job is essentially plumbing, knowing how to bypass faulty pipes!” I said, to humour him. “But we do the plumbing when the tap is running or while the toilet is being flushed,” he interjected, justifying his position at second, “Everyone else languishes at the other end of the spectrum!” My poor friend now looked quite baffled by our banter. “The general surgeons, urologists, and gynaecologists are quite literally furthest away from the top,” we explained.

A physician, overhearing our open-door conversation, levelled the playing field. “Do you know that in some countries like the United Kingdom, surgeons are not even called doctors? They lose their title of ‘doctor’ when they branch out to do surgery; they are simply called ‘mister’ then. In the olden days, they were considered unskilled, like barber surgeons. It’s us who are the thinkers and planners, telling the surgeon what to do,” he finished and quickly exited, leaving no room for debate. 

A couple of days later, I got rid of the cyst that got us started talking about this. When my friend complained of unbearable pain, I rebuked him gently, saying, “Do you know what some of the people who come to us are going through?” 

That made me think about what someone posed to me recently: “Does suffering have a hierarchy? Does a person who is disabled by injuries and pain deserve more sympathy than one whose life has been crippled by grief brought on by failed or lost love?”

Until recently, I used to placate patients for their so-called minor issues by comparing their ailments with the dreaded ‘C’: “At least you don’t have cancer.” But I now believe that this is the incorrect way to empathise with someone. Who are we to judge if someone’s depression, an unseen illness, is less grave than something we can see, like a tumour biding its time inside someone? How can you justify the loss of a parent being less intense than the loss of a child, even though the anguish of the latter seems to be almost universally greater? Why is heartbreak always looked upon as something that someone will get over in due course of time? 

Just because some people seem okay while they are going through whatever they are, doesn’t mean they feel it any less. They have either found a way to channel their hardship into something transformative or make peace with it, accepting what is. According to me, there are two ways to live: one, as if everything is a matter of life and death; the second, as if nothing is.

Each person’s suffering is their own and does not exist in relation to anyone else’s, even though it is human nature to compare suffering: theirs with ours, theirs with someone else’s. Being in the profession, I have come to see with my own eyes that most people live with much more suffering than what is visible to the most sensitive and proximate onlooker. “I’ve had this pain for the past two years, but I informed my family only a week ago, when it became unbearable” or “I haven’t been able to see clearly for six months, but I told my husband just a few days ago, when I started bumping into objects,” is something I commonly hear, and unfortunately, it often is an indication of a patient coming to us a little too late in the course of a disease. 

Sometime ago, I was operating on a brain tumour through the nose with my ENT colleague, biting away all the nasal debris with hubris. “Be a little gentle with the nose,” she nudged me, as I was showing scant respect for it. “There’s nothing really important in here!” I said, marching on. She responded, “The next time your nose gets blocked, you’ll realise its value.” The sentence clung to me like food that’s stuck in the molars: even after you’ve removed it, it feels like it’s still there; exactly how an unblocked nose still feels blocked. 

Even COVID has its own chain of command. Two years ago, the virus was treated with a fearful distance that was more than just social, as we were apprehensive of those who had it; now, we are suspicious of those who don’t. Sometime ago, a fever was a phobia; now, it’s freedom—to take a week off. “It’s just a cold!” is no longer the ubiquitous expression that the higher order allows us to use.

Human needs have a hierarchy, as proposed by Maslow, which range from the basic physiological ones of food, water, and shelter, to safety, love and belonging, esteem, and finally self-actualisation—the desire to become the most one can be. Humour also has a hierarchy, with dumb jokes and puns forming the base of the pyramid, practical jokes and irony somewhere in the middle, and self-deprecation and paradox at its apex. Art has its own hierarchy (though it can easily find its place in the hierarchy of humour—especially modern art), as does architecture and science. There is a hierarchy to the functioning of the universe, so why not in medicine.

A recent study published by the British Medical Journal found (not to my surprise at all) that neurosurgeons are no smarter than the general population. Maybe it is time to ditch the phrase, “It’s not exactly brain surgery!” and give another specialty a chance to be on that pedestal. Any takers? 

P.S.: Dermatologists, you are not allowed to apply. 

The writer is practicing neurosurgeon at Wockhardt Hospitals and Honorary Assistant Professor of Neurosurgery at Grant Medical College and Sir JJ Group of Hospitals.

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