Dr. Nelson Soucasaux, Brazilian gynecologist
After having published three articles on this site about the problematic traditional tie between gynecology and obstetrics (see list below), now it is time for a more detailed approach of the equally problematic traditional tie between gynecology and surgery. Gynecology was regrettably born, in the history of medicine, from surgery and obstetrics, and this double-origin "congenital malformation" resists everything, even the evolution of medical science. The fact is that, sadly, even today gynecology remains considered mostly as a "surgical speciality", despite the enormous development of the clinical part of the speciality along the last 50 years. As a consequence, the great majority of the gynecologists are fundamentally surgeons who also practice the clinical part of gynecology. This fact has serious implications in the way the speciality is usually practiced.
This view of gynecology mostly as a surgical speciality is another serious conceptual distortion coming from the past and totally devoid of scientific and medical basis. This old concept became totally obsolete in the last decades, since the clinical part of the speciality by far has surpassed, in extension, the operatory one. The great majority of the gynecological consultations are situated in the area of clinical gynecology, of clinical assistance. Gynecology should be an essentially clinical speciality, the surgical part of it remaining as another speciality whose practice should be in charge of surgeons specialized in female pelvic surgery and breast surgery. (As to breast surgery, it becomes more and more a domain of mastology, a subspeciality of gynecology that is acquiring a highly debatable "status" of autonomy in relation to the latter.)
Gynecologic surgery is, in practice, inseparable from female pelvic surgery and, in a way, also part of the latter. This is due to the very close anatomic relations between the female genitals, the woman's urinary system and several other pelvic organs and structures. Therefore, gynecologic surgeons cannot restrict their operatory ability and skill to the female genitals, and usually they are quite aware of that.
Because of the present-day enormous and truly fantastic development of endoscopic surgery, traditional surgeons are being obliged to learn these totally new operatory techniques in which instruments completely different from the traditional ones are used. This means almost the same as learning to operate again. In gynecologic surgery, the development of these new endoscopic techniques - both the laparoscopic and the hysteroscopic ones -, has been quite amazing in the last years. (As to hysteroscopy, see Note 1 below).
All of this confirms the need for an almost exclusive commitment and dedication to surgery on the part of those who practice this kind of medical activity. Therefore, I think it is not difficult to conclude that it is almost impossible for the same physician to practice clinical and surgical medicine with the necessary competence and expertise, and that obviously this is entirely applicable to gynecology. Considering the human limitations in face of the present state of medical knowledge, the same physician cannot simultaneously practice the clinical and the surgical parts of gynecology as, regrettably, most of the gynecologists still insist on doing.
Moreover, we must remember that clinical and surgical medicine have been, since their very beginning, two entirely different kinds of medical practice. It is well known that, in medicine, the cognitive, perceptive and psychomotor attributes required for the practice of clinical and surgical activities are very different and that the same is true for the required kinds of temperament and psychological type. This is so true that, in many of the medical specialities, their respective clinical and operatory parts are not only practiced by different professionals but also defined and conceptualized as diverse areas of expertise.
Here are a few examples: cardiology, for instance, was always practiced as a clinical speciality, the surgical part of it being defined and practiced as another speciality, cardiovascular or heart surgery. The same happens with gastroenterology, which was always separated from the surgery of the digestive apparatus. In the same way we can mention specialities as pneumology and thoracic surgery, pediatrics and pediatric surgery, neurology and neurosurgery, etc. - all of them deeply related areas of medicine but in which their respective clinical and operatory parts are in charge of different professionals (Note 2 below).
Nevertheless, in gynecology, regrettably, it was officially "established" that the physicians who practice the speciality must be surgeons practicing simultaneously its clinical part. This mistaken idea has been dogmatically (and irrationally) constantly repeated in almost all medical schools and exerts an unimaginable influence. This deplorable point of view causes serious problems to the practice of clinical gynecology, and this is mostly due to the fact that, in all medicine, the practice of surgical activities demands specific traits of temperament and kinds of attitude that differ very much from those required for the practice of the clinical activities. It must be emphasized that clinical medicine is totally different from the surgical one, and that the adequate practice of each one of them requires physicians possessing very specific and different psychological features. For that reason, good surgeons very often are not good clinicians and vice-versa (though obviously there are some exceptions).
In this way, once again I repeat what many years ago I wrote in my book "Novas Perspectivas em Ginecologia" ("New Perspectives in Gynecology") : "... just as what happens in many other areas of medicine, would it not be much more reasonable for gynecology to be an essentially clinical speciality, the surgical part of it remaining as another speciality, female pelvic surgery and breast surgery?"
Note 1: Hysteroscopy is an endoscopic procedure in which an optical device connected to a video screen is introduced into the uterine cavity through the vagina, allowing not only a detailed examination of the interior of the uterus but also the performance of several intra-uterine surgeries.
Note 2: Some new surgical specialities have had an amazing development in the last years, though being all of them completely different from traditional surgery. In cardiology, for instance, we have the so-called "invasive cardiology," comprising widely known procedures like catheterization, angioplasty, etc. In gastroenterology we have the enormous expansion of digestive endoscopy. The present-day great development of endoscopic procedures is invading many specialities. And, as all of these procedures are, by definition, "invasive," all of them must obviously be considered as surgical ones despite their great difference from traditional surgery. Thus, all of the observations I made in this article regarding surgery are equally applicable to them.
Articles about the traditional tie between gynecology and obstetrics available on this site:
1) "The gyneco-obstetric-surgical stubbornness and the perpetuation of one of the greatest mistakes of women's medicine"
2) "Gyneco-Obstetrics: What lies behind"
3) "Gyneco-Obstetrics: One more unanimously accepted great mistake"
For information on my aforementioned book "Novas Perspectivas em Ginecologia" ("New Perspectives in Gynecology"), published by Imago Editora, Rio de Janeiro, 1990, see page http://www.nelsonginecologia.med.br/novas.htm at my Web site www.nelsonginecologia.med.br .
Copyright Nelson Soucasaux 2004
Nelson Soucasaux is a gynecologist dedicated to clinical, preventive and psychosomatic gynecology. Graduated in 1974 by Faculdade de Medicina da Universidade Federal do Rio de Janeiro, Brazil, he is the author of several articles published in medical journals and of the books "Novas Perspectivas em Ginecologia" ("New Perspectives in Gynecology") and "Os Órgãos Sexuais Femininos: Forma, Função, Símbolo e Arquétipo" ("The Female Sexual Organs: Shape, Function, Symbol and Archetype"), published by Imago Editora, Rio de Janeiro, 1990, 1993. He has been working in his private clinic since 1975.
Web site (Portuguese-English): www.nelsonginecologia.med.br