The Orifices -- Where Most of Medicine's Money Is Made


November 02, 2022

Since antiquity, physicians have used their senses to study and try to understand human health and disease. Sight, sound, touch, smell, and taste. For much of history and for most physician-clinicians today, those five senses, when used well, are enough. Listening to the patients' history remains the most important clinical tool. And, as Yogi Berra famously stated, "You can observe a lot by just watching."

But there are obvious limits, and good physicians have inquiring minds.

When I began medical school in 1953, my biochemistry professor, Dr Emmett B. Carmichael, told our entering class that doctors made most of their money at "the orifices." Natural anatomic orifices back then (and now) were the nostrils, the mouth, the ear canals, the urethra, the vagina, and the anus — openings that allowed the physician to take a look, palpate, and obtain a specimen or two in pursuit of a diagnosis. Many natural orifices have been used to mechanically access deeper regions.

Being a biochemist, the esteemed professor can be excused for not recognizing that the largest human organ, the skin, which is primarily subject to direct observation, could also become the largest human orifice.

Professor Carmichael may not have considered the potential of the hollow needle and syringe device (credited to Alexander Wood in Scotland, who invented it around 1850 to deliver medications into the body). As a bidirectional tube, it would become the most common artificial orifice for probing the "mysteries of the deep" — the body almost in toto. Cannulas and catheters likewise serve as artificial orifices to access an almost unimaginable panoply of internal organs and tissues.

Through Wood's hollow needle, blood is drawn and delivered to a clinical chemistry laboratory, like the one I created from scratch at the new Druid City Hospital in Tuscaloosa, Alabama. In 1953, we could perform only the following blood tests:

amylase, creatinine, calcium, chloride, glucose, urea nitrogen, lipase, carbon dioxide, prothrombin, total and free cholesterol, uric acid, inorganic phosphate, alkaline and acid phosphatase, total protein, albumin and globulin, and thymol turbidity. Soon to come (as we introduced flame photometry) were sodium, potassium, and lithium.

Orificial Progress

Today, we use endoscopy via nearly any natural (or artificial) lumen with video, fine-needle biopsy directed to just about any tissue, imaging from almost any direction, and penetration of many cavities with remote control and even robots to perform previously manual manipulations. This is all possible because of the many orifices that permit access plus the imagination and creativity to exploit these opportunities.

Of course, Professor Carmichael was correct. Physicians do make most of their money at the orifices. And if there is no natural orifice, an enterprising interventionist simply creates one.

Anything seems possible. But how much is enough and how much may be too much? If a patient is diagnosed with cancer and undergoes surgery, radiation, chemotherapy, or even targeted therapy or immunotherapy, immediately after treatment the patient asks, "Did you get it all? Am I cancer-free?"

The pathologist describes clear margins and routine, organ-representative blood tests are normal; the radiologist finds no evidence of continuing or recurrent cancer on imaging.

Still, the patient wants to know, Am I cured?

Until now, the honest clinical oncologist has only been able to say, "We find no evidence of residual cancer, but we cannot be certain and will need to monitor you either forever or for some finite period of time, depending on cancer type."

Still to be worked out for sensitivity, specificity, predictive value, guidelines, and, someday, "standards" are the astonishing ramifications of one of the newest applications of orificial medicine, the liquid biopsy. A blood sample can be obtained from the patient with cancer who tests "cancer-free" by all previous means. Molecular testing of circulating tumor cells or cell fragments, or cell-free DNA or RNA, searching for measurable (or minimal or microscopic) residual disease , even cancer-specific. Such testing is rapidly becoming widely available, informing prognosis or indicating the need for additional treatment and monitoring its effects.

All of this in the course of one professional lifetime — mine. Professor Carmichael would be astounded and very proud.

That's my opinion. I'm Dr George Lundberg, at large for Medscape.

George Lundberg, MD, is contributing editor at Cancer Commons, president of the Lundberg Institute, executive advisor at Cureus, and a clinical professor of pathology at Northwestern University. Previously, he served as editor-in-chief of JAMA (including 10 specialty journals), American Medical News, and Medscape.

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