The Making of a Surgeon
William A. Nolen wrote a book, The Making of a Surgeon, in 1986. It was his story of becoming a surgeon, and is still a popular book read by many aspiring surgeons to be. This is my brief take on the history of surgery and becoming a surgeon, (and a shameless ad for my book).
Surgery has been practiced by homo sapiens for at least 8,500 years, and maybe even longer as evidence can only be gathered from materials that do not decay, such as bone. Carefully chiseled perfectly round trephination holes have been found in skulls that were buried 6500 BCE in northern France. These skulls belonging to our species survived these “operations” as the edges of the openings showed signs of healing several years after they were drilled. Surgery was practiced in ancient Egypt and India around 1500 BCE with complex procedures such as flap reconstructions of facial injuries, and sophisticated ways to stop hemorrhage and prevent infection. But then the first “Dark Ages” let down their curtains on surgical progress in 1200 BCE, probably related to climate change caused by unprecedented volcanic activity. It was the Greek culture that resurrected medicine and surgery with Hippocrates shortly after 400 BCE. He introduced the idea that illness was not caused by the gods but by our environment, and could be “cured” or at least tamed by environmental manipulations. The Romans copied from the Greeks and added their own wisdom and knowledge through physicians such as Galen and Celsus. Galen, a consummate surgeon, learned from his experience taking care of the gladiators of the Pergamum Coliseum (now in Turkey).
The second “Dark Ages” from the 5th to the 15th century CE brought down the curtains on surgery again. The Middle Ages reverted to superstition and magic to care for the sick. Illness was again seen as God’s punishment for man’s wickedness, and to help those unfortunates was going against God’s will. Ambroise Paré and Andreas Vesalius were the standard-bearers that pushed back the walls of ignorance with observation, trial, and error. Leonardo da Vinci secretly dissected human bodies and made detailed accurate drawings of how we are put together which advanced surgical knowledge dramatically. The first appendectomy for appendicitis, a major killer of humans, was by a French surgeon, Claudius Amyand, in 1735, done in London at St. George’s Hospital.
In the 19th century, surgical science exploded through the genius of people like Theodor Kocher with thyroid surgery, Berhard Langenbeck’s teachings, and Theodor Billroth’s innovations in abdominal surgery. They, in turn, were aided by the basic science contributions of Joseph Lister – with surgical asepsis, and Robert Virchow – with pathology.
It is those individuals, the giants of surgery, on whose shoulders we now stand, to see further into vistas that we could only dream of a hundred years ago. Alexis Carrel gave us the knowledge of repairing and sewing arteries and veins. He and his good friend, Charles Lindberg, of flying fame, teamed up to give us the first artificial heart pump. William Halsted, who went to Europe to glean the secrets of how to teach surgery, then came back to the US and started to produce great surgeons one after the other at Johns Hopkins Hospital. Greats like Harvey Cushing, father of neurosurgery, and Hugh Young, father of urology, founded residency programs that perpetuated “Halstedian principles” for the ages. Many more greats have given us surgery techniques, knowledge, and inspiration to do bigger and better surgical procedures. . Michael DeBakey not only gave us coronary bypass and aortic surgery, but was the inspiration that created the TV series and movie “MASH.” C. Walton Lillehei, the King of Hearts, as his residents fondly called him, invented the repair of congenital heart defects, saving thousands of children that would not be alive today. Then came along Dr. Joseph Murray, with the first kidney transplant, and Dr. Thomas Starzl, with the first liver transplant, and Dr, Christaan Barnard, with the first heart transplant that lived, Human ingenuity and skill are not stoppable!
A surgeon is a doctor first. He or she must understand the anatomy and physiology of the human being before knowing what the scalpel can add to the patient’s wellbeing. Four years of pre-med college give the foundations of chemistry, biology, and the humanities that allow an individual to communicate in a cultured and educated manner. Then comes medical school, the first year the basics: anatomy, physiology, biochemistry, histology. The second-year starts with the study of diseases and how to diagnose them, fondly called P-dog (physical diagnosis) by the sophomoric sophomores. The third-year and fourth-year are the clinical years, medicine, surgery, pediatrics, obstetrics, and gynecology. Graduation comes too quickly, not nearly enough time to learn all there is to know. In fact, learning never stops! Almost everything I learned in medical school has changed. It requires a life-long dedication to keep up, until the day you stop taking care of patients, and even then if you teach you must still keep up, lest you transmit outdated information.
Every state has different requirements for post-graduate clinical experience. The first year used to be called the Internship, but the ACGME (Accreditation Council for Graduate Medical Education) has removed that moniker. It is now called the first year of post-graduate training, the residency. Nevertheless, every state requires anywhere from one to three years clinical experience before you may apply for state licensure that allows you to write prescriptions and exercise independent medical decisions on real patients. Surgical Residency at this time is five years, including the first year of what was once called “the Internship.” Although, because of a new restriction on duty hours of a resident, the person in training has less time to acquire all the necessary skills and knowledge to fulfill their mission. When I finished my residency program in the early 1980s, my average time spent a week was 100 hours, and sometimes 120 hours. The current ACGME rules allow an average of 80 hours maximum a week when spread over 4 weeks, at least 20% less time than the previous generation. If a resident complains to the ACGME about working more than 80 hours, a surgical program could be shut down. This came about through the sad case of Libby Zion. Libby was a college student that died at a Cornell affiliated Hospital in New York, the cause of which was blamed on tired residents making wrong therapeutic decisions. This was actually not the entire or even accurate story, but it nevertheless changed the rules for all of the US from then on. The traditional work hours of the past (don’t quit till the job gets done – quoted from the song by Jason Aldean “The only way I know”) from the old days of Halsted were thrown on the heap of history, despite that it had served us well, producing surgeons that were competent and multi-talented. 80% of residents now take an additional one to three-year fellowship training, usually in a surgical subspecialty, vascular, oncology, pediatric, cardiac, colorectal, minimally invasive, critical care, or transplant surgery. All of which makes the general surgeon more and more obsolete.
If this little vignette piques your interest and you want to know more, read my book: We Stand on the Shoulders of Giants – A Brief History of Surgery, available through Amazon.com.