Surgical Professionalism


acs logo

The logo of the American College of Surgeons


Medical physicians, physiology doctors, evolved from the medieval Catholic Church. Hospitals were nearly universally established by churches and monasteries and convents to care for the sick and the dying. If you were sick and went to the hospital in 1200, you would be cared for by a physician-priest or monk, who would examine you, and attempt to fit your disease in with the common understanding of physiology of the time, the balances of the four humors, bequeathed to the church by Aristotle and Galen. They would then attempt "cure" by rebalancing the humors, well, really by directing others, usually nuns and surgeons, to rebalance the humors through time, attentive care, and, the occasional surgical correction of an anatomic problem. The Fourth Lateran Council in 1215 forbade physicians in holy orders from performing surgery:

"No subdeacon, deacon, or priest shall practice that part of surgery involving burning and cutting." (Canon 18)

Since hospitals in Europe were largely monastic institutions, the overwhelming majority of physicians at that time were in holy orders. The church then made a separation between physicians and surgeons a codified part of canon law. Surgery reverted to Barbers, nuns (exempted from the canon law) became nurses and intermediate practitioners, and priests became physicians. Medical Practice by physician-priests was strictly controlled by the church (including the demands for confession of sins before treatment). The Barbers and surgeons in England had coalesced into the Worshipful Company of Barbers by 1308. The surgeons, with a different focus from the barbers, formed a subsidiary group still under the supervision of the Barber guild. In 1462 the livery company, the Worshipful Company of Barbers, received its first Royal Charter. In 1540 the affilliation between Barbers and Surgeons was formally recognized as the Company became "the Worshipful Company of Barber-Surgeons."

thomas Linacre

Because of their differing roles and perspectives, Surgery and Medicine evolved separately. Physicians, those trained in diagnosis and medical treatment, what we now think of as Internists, evolved from the priesthood and by the Renaissance were the products of a university education. Thomas Linacre, the Oxford trained Humanist philosopher and physician had been the exemplar of English medicine since he had founded the Royal College of Physicians in 1518 with a charter from King Henry VIII.

charter-given-to-the-guild-of-barber-surgeons-by-henry-viii1

Charter given to the Barber-Surgeons by Hans Holbein


ThomasVicary

Linacre's surgical contemporary was Thomas Vicary, the King's surgeon, and who in 1540 became the first Master of the reorganized Barber-Surgeon Company. Significantly, Vicary opened the first human dissection hall in England, and obtained the rights from the Crown to 4 human cadavers a year for the purposes of anatomic study.

The Surgeons and the Barbers did not part ways until the surgeons separated into an independent guild in 1765. The Royal College of Surgeons was chartered in 1800. (Souvenir of the Centenary of the Royal College of Surgeons of England 1800-1900)

At that time, the Royal College of Physicians insisted that, in order to be considered a “college” of professionals, that the surgeons be required to hold University Medical degrees. The 300 founding surgeons agreed, but in retaliation required that all surgeons who are members of the Royal College of Surgeons be addressed as “Mister” instead of as “Doctor.”

This exchange from Sherlock Holmes, written by Sir Arthur Conan Doyle (who was trained as an eye surgeon):

"Come, come, we are not so far wrong after all," said Holmes. "And now, Dr. James Mortimer--"

"Mister, sir, Mister--a humble M.R.C.S."

With the requirements of 1800 that Members of the Royal College of Surgeons attend medical school and obtain a legitimate degree, surgeons had the same undergraduate medical training as their physician colleagues; surgeons had progressed from a lay apprenticeship in cutting and bloodletting, to a professional degree and certification by examination.After 1800 in England the primary difference between a physician and a surgeon was in a chosen path of specialization and in post graduatetraining.


RCS crest

Crest of the Royal College of Surgeons (England)

Medical care in the United States evolved in a very different fashion from their British counterparts. As a much younger and more secular culture, the United States lacked the centuries of codified tradition with regard to medicine and surgery. In addition, the large distances and hardships involved in travel in "the Colonies," necessitated a much more individualistic, or independent mind among the American physicians and surgeons. Which explains why Ephraim McDowell performed the first abdominal surgery in the world on the frontier in Danville, Kentucky in 1809, and why the first use of ether anesthesia was by Crawford Long in rural Georgia.

Medical training in the United States was notorious for its varying quality, and in reality, becoming a surgeon in 19th century rural America could involve only a few months at a degree mill, upon which a degree would be issued, and then the simple declaration, "I am a surgeon." There was no formal examination or qualification needed, and there were no supervising bodies.

Helen Clapseattle described the frontier dilemma very well in her book "the Doctors Mayo," speaking about how carefully William Worrell Mayo, himself a degree mill doctor, went about the process of selecting proper Medical Schools at Universities for his sons, William and Charles, later collectively known as "the Mayo Brothers."

The specialty of surgery began to develop in earnest in the late 1800's, again as anesthesia allowed for more involved and technically demanding operations. A "grand tour" of the Surgical Clinics of Europe, particularly those of Lister in Edinborough, Billroth in Germany, and Kocher in Switzerland, became a de rigeur, part of the rising surgeon's training.

William Halstead expanded the European surgical training model to the United States at Johns Hopkins, in Baltimore, effectively inventing the americal surgical residency training program. Other surgeons around the country began holding clinics, and surgeons, in addition to travelling to Europe for training, began to travel to each others clinics and sharing experiences. Franklin Martin of Chicago expanded this concept, and started an independent journal, Surgery, Gynecology, and Obstetrics, and by 1912, the travelling meeting had attracted over 1000 surgeons from around the world, and thirty of the leaders formed the American College of Surgeons (ACS).

Unlike the Royal College of Surgeons, the ACS did not administer examinations or "qualify" surgeons for practice. Admission as a "fellow" of the College rested on, and still rests on, training, reputation, and the recommendation of other surgeons.

In the 1920's and 1930's there was a push in the US for examination of surgeons. A group of "young Turks," led by Evarts Graham, of St. Louis, pushed for, and then formed the American Board of Surgeons. There was always a rumor of a lasting enmity between Graham and the Mayos over this dispute, that continued institutionally and was relayed to me by the surgeons at my medical school, Washington University in St. Louis, as I applied for residency where I had grown up, the Mayo Clinic.

Despite that, American surgical training has, in my opinion, no equal in the world, in terms of developing a failrly uniform and highly trained product, a new surgeon. The Board examination for surgery is very rigorous, and consists of two examinations, first a written test of knowledge, which, if passed, leades to an invitation to oral examination. The surgical oral examination is a ustly famous, set of three one half hour oral examinations of a candidate by two surgeons for each examination. At the end of the day, the six examining surgeons discuss each candidate and pass or fail based upon performance in each of the three rooms. The candidate is evaluated on knowledge, safety of thought process professionalism, and demeanor. A successful surgical board examinee has really passed a very rigorous interview for an exclusive club. In theory professionalism is assured.

After Board examination, though, the surgeon must then practice for two years, and develop experience and a reputation before becoming a fellow of the American College, which is still dependent upon the recommendations of activefellows in order to be successful.

So, if you are looking for a surgeon, your best bet, apart from already knowing someone, is to find a Fellow of the American College of Surgeons. Click here to go to the ACS "find a fellow" website.