GUEST EDITORIAL: “GREAT MEN” WITH GREAT IDEAS

It is a privilege to practice medicine. It is even a greater privilege to have other human beings place such high trust and confidence in our abilities that i t is taken for granted that we will make most of the blind see and many of the deaf hear.

Recently, several techniques designed to allow voiceless patients to talk have been developed, modified, and proven reasonably successful. The first few successes have, un- fortunately, been misrepresented by some physicians and then exploited by the media, with sensationalism as the result. Little has been done in responsible medical circles or centers to curb this zealousness. To make matters worse, the many laryngectomized pa- tients who have not been able to communicate-in some cases for a number of years- have had their hopes falsely inflated. When failure results because of aspiration, stenosis, prolapse, recurrence, infection, or pain, a patient becomes further depressed. While vir- tually all of these patients can be enabled by reconstruction to utter usually intelligible sounds, the continuing problems, sometimes arising many months later, may offset the hoped-for advantages. Microvascular surgery and reimplantation of amputated digits and limbs are also excellent examples of surgical techniques which may produce sen- sationalized results. The good results are all too often overshadowed by postoperative morbidity with stiffness, sensation loss, and infection, and the final result may be no bet- ter than a functionless “warm prosthesis.”

This is not to say that we should stop our investigative work to improve our tech- niques, but rather that it must be continued with critical evaluation and sharing of our scientific differences. This has been the history of all advances in medicine. From periods in which many work toward the same goals comes a common denominator which stands the test of time and establishes the investigational technique as an accepted medical technique. In the course of my pioneering experience with mediastinal and craniofacial surgical techniques, I have not encountered many patients who were disappointed with the outcome of surgery, successful or not. This may seem strange, but I attribute this finding to the fact that full disclosure of operative procedures was always made and in- formed consent was always obtained. The media have never forced an issue because these types of operations no longer have sensational appeal. However, restoration of hearing, sight, and voice still do.

Doctors, let us make sure that we level with our patients by giving them the realistic prospects of surgery. During these difficult times, when we are perhaps on the threshold of another major medical breakthrough, let us not condone the self-serving, proselytizing “great men,” no matter how talented. Every scientific discovery may not be equivalent to

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the discovery of atomic energy, but the demands on the scientist to exercise responsibility and particularly temperance are no less. We must remember that the practice of medicine is a privilege granted to us by our patients.

George A. Sisson, MD Northwestern University

Medical School Chicago, ILL

EDITOR’S NOTE

O u r editorial office recently received a letter from which the following is taken:

I wonder if you would consider writing an editorial commenting on the ma- nipulation of the lay press and the speech therapists in this reconstructive laryngectomy operation. I am not only concerned that the peer review pro- cess of critical evaluation of medical progress is being bypassed . . . I am also concerned that patients are being ripped off.

The letter refers to a current flurry of nationwide publicity, as discussed by Dr. Sisson, regarding “miraculous” operations for the restoration of voice following laryngectomy. The truth is that no such operation exists. What, then, is the truth and how has this unfortunate situation occurred?

When a truly total laryngectomy is performed, variations in the concept of the tracheo- esophageal or tracheo-pharyngeal shunt are at present the most satisfactory surgical pro- cedures that provide vocal function. They suffer from the disadvantages of requiring a permanent laryngostome, a fistula which must remain patent but not leak, the need for manual control for air shunting, and the need for an additional surgical maneuver. Many persons consider a skilled esophageal speaker to have vocal capabilities that are virtually equal. When portions of the larynx can be spared, more ingenious procedures can be de- vised which have the potential for maintaining internal functioning air and food pas- sages (Sisson’). Research is under way a t several centers and it is clear that we are just beginning to see some of the exciting possibilities. This kind of scientific ferment also produces the inevitable attempts to exploit potential but as yet undeveloped advances in medicine. This exploitation is a result of the insatiable appetite of the media for new in- formation and of the uncontrollable desire of a few physicians for self-aggrandizement. The result is disastrous for all concerned. What results for the lay public is the creation of unreasonable expectations and then the inevitable disenchantment when the truth be- comes apparent. This is compounded when a few physicians imply that they are uniquely qualified and that exorbitant fees are justified as a consequence. What results for the medical profession is a loss of confidence which can impair the careful experimentation necessary for the development of viable solutions.

Alan M . Nahum, MD Editor

‘Sisson GA, Bytell DE Becker SP et al Total laryngectomy and reconstruction of a pseudoglottis problems and complications Laryngoscope 88 639-650.1978

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