Let us assume that surgeons and patients agree on the objectives of high quality, precise, knowledgeable, safe and skillful care in a supportive, well-managed environment that shares these objectives, in a rational financial system and government that shares these objectives.
The condensed viewpoint might be “optimum surgical care balanced between high quality for reasonable cost.” Many dialectic factors affect these objectives.
These layers do not integrate as easily as an onionskin, but still can make everyone cry.
Vectors are forces with direction, originating at one point, presently at another point in the present and continuing on a line forward. That is history in social sciences as well as Physics.
Do these forces still share common direction for medical care?
Are they convergent for common purpose, divergent or parallel?
The Era of Modern surgery began in Europe in the late 19th century in Europe in response to scientific ambition, the microscope, curiosity, war, disease, infection and actual and accelerated definition of human anatomy. With challenges and the little new knowledge, “expert” (for that time) surgeons taught unproven procedures in clinics and poorly maintained charity hospitals within an apprentice system within a severe hierarchy and extreme work demands. ”Expertise” is a relative term.
The beginning of the era of Modern Surgery stove to perfect successful techniques, developed scientific principles, intuitively and inductively devised diagnostic methods and accumulated data (frequently of questionable validity) on results. The few empowered surgeons negotiated coordinated support systems with sympathetic and responsive institutional leadership, standardized professional team work along with safe anesthesia, antisepsis, sterile and Halstedian technique. Surgeons devised and directed new systems, incorporated academia, scientific method as best possible, peer review and technical education.
Use of the Scientific method and the organized Residency program created at Johns Hopkins by William Halsted in 1889 rapidly spread throughout North America. These programs multiplied as the newly trained and enthusiastic surgeons cloned the system assuring more standardized education in antisepsis, technique, diagnosis, perioperative care, analysis of results, application of science and innovation originating in the laboratory carefully transitioned with oversight to clinical use.
The Spanish American War, World War I, World War II catalyzed skills. Korea and Vietnam resulted in thousands of experienced surgeons essentially sharing Halstedian principles and cooperating with skilled, well-trained, experienced and dedicated nurses as a mutually respectful and coordinated team sharing the same coordinated objectives and continuously improving results.
In the mid 1960's advancement of cardiac catheterization, Cardiopulmonary bypass, endoscopy for many body parts, monitoring, ventilators, interventional radiology, safe blood transfusion, new orthopedic and other sub-specialty technology grew quickly. The new skills were installed carefully with controls by enthusiastic surgeons in leadership positions and enabled a growing number of new sub specialists. These changes resulted in continued elevation of realistic technical ambitions and the accomplishment of new exciting procedures for previously unapproachable problems.
Adding new technology like CT scans Ultrasonography, later MR and many laboratory tests assisted in accurate pre-operative diagnosis. Less traumatic treatment could replace extremely traumatic interventions.
In the last century, surgeons’ experience produced greater prospective diagnostic precision, strategic and tactical planning and improved results. Surgeons were stimulated and enthusiastic. They felt ethically obliged to train the next generation who were, in turn appreciative and respectful of mentors for the transfer of knowledge. Their dedicated lifestyle involved extraordinarily long hours in study and patient care, living within the hospital and delaying family and independent endeavors. A limited number of hospital managers supported physicians and surgeons who significantly controlled the clinical systems within financial boundaries. Hospital Trustees were involved, monitored and assured financial solvency and vested support and guidance. The community was involved and those who were able added endowments. The hospitals involved in training surgeons were not–for-profit, and made no profit.
Anesthesia advanced remarkably with control of newly understood physiology, better anesthetic gases, pharmacology, and dependable safe systems with dependable monitoring. This encouraged bolder surgical technique and technology and created new specialties.
The convergent factors encouraging and facilitating the growth of surgical training, experience and creativity resulted in formalization of many procedures and options that were communicated and taught during training, postgraduate education, peer review periodicals, in hospital formal and informal discussion.
The fact that knowledge of variations of surgical technique, variations in anatomy, different type and extents of pathology and the course of different diseases was appreciated as a requirement for mastery of surgery.
An attempt to apply the same operation to different problems resulted in failure. In other words, it was common sense that a “square peg cannot be put in a round hole” and “one solutions does not fit all similar problems.”
The environment changed and the response was Darwinistic.