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Surgical Training in Retrospect
Surgical Training in Retrospect VERNON C. DAVID, M.D., F.A.C.S. *
IN CONSIDERING surgical training in retrospect, I have been struck with the tremendous changes that have occurred in the lifetime of one man, as experienced by himself and as heard from the lips of his elders. The medical curriculum of today may be contrasted with that of 1869, when my father graduated from Rush Medical College, then a leading medical school of the Middle West. The student of that day enrolled for a six months' course of instruction, which was repeated in the following year, and then "rode" with, or joined an established doctor in practice for another year, at which time he received his M.D. degree. The Professor of Surgery of that day, Moses Gunn, rode to school on horseback, came into the clinical amphitheater and removed his coat and replaced it with a black alpaca one, with the ligatures from the previous days threaded through its buttonhole, and went to work. At a later period, about 1882, I have heard Dr. Lewis Linn McArthur tell of his assisting at the first operation performed under the Lister carbolic spray antiseptic method at the Cook County Hospital.
CONTRIBUTIONS OF THE EARLY MASTERS
At the beginning of this century our leading teachers of surgery, and professors in our medical schools, were trained anatomists and had often come into the field of surgery from the anatomical field. A few in the Middle West, such as Christian Fenger, were trained pathologists. Fenger in particular had great influence in stimulating interest in, and in the development of, surgical pathology. Nicholas Senn, a contemporary of Fenger, had a great part in the stimulation of laboratory experiments in his study of air embolism, gunshot wounds and intestinal anastomosis. John B. Murphy, during the same period, conducted pioneer experiments on end-to-end suture of blood vessels, intestinal suture and anastomosis, and joint surgery. Rudolph Matas at the same time in New Orleans was laying the foundation for the radical surgical cure of aneurysms. All of these men were widely traveled, and received graduate training in European Clinics and laboratories. They were fully informed in the surgical literature of the world.
* Professor Emeritus, University of Illinois College of Medicine (Rush), Chicago. 3
Vernon C. David In Europe, the surgical schools of Billroth in Vienna, and later Eiselsberg, emphasized the importance of surgical pathology in training surgeons, whereas Kocher in Bern, Horsley in England, and Halsted in Baltimore, Crile in Cleveland, and Murphy in Chicago emphasized the physiological and experimental aspects of surgery. These men were general surgeons in the broadest meaning of the term. Their education had been catholic in its breadth, and their assistants and pupils were trained in the fundamentals as they were understood at that time. This training offered a tremendous stimulus to the imagination of the leading teachers of surgery, with the result that the frontiers of surgery were rapidly widened, and special fields were opened. This was particularly true in the development of special skill in the treatment of goiter by Kocher, Crile and Charles Mayo, the surgery of blood vessels by Matas, Murphy and Carrell, the surgery of the breast and hernia by Halsted, neurological surgery by Cushing and Dandy, pupils of Halsted, surgery of the chest by Sauerbruch and Graham, to mention only a few of the pioneering studies that grace the early part of this century. TOWARD A FULLER UNDERSTANDING OF BIOCHEMICAL AND PHYSIOLOGICAL FACTORS IN SURGERY
These outstanding advances in various centers of the world left much to be desired in the understanding of the surgical patient from the standpoint of his biochemical and fluid balance-his respiratory quotient, blood loss and replacement, shock, anesthesia and dietary balance which have become so much better understood with the passage of time. As an instance in the Cook County Hospital in 1908, it was practically routine to administer 2 grains of calomel, followed by an ounce of magnesium sulfate, just before an operation. Blood typing and transfusion of blood by the Crile cannula, which was an artery-to-vein direct and unmeasured transfusion, was rarely used. Fluid replacement was by rectal drip or subcutaneous injection of salt solution. Shock was treated by fluids, external heat and lowering of the patient's head. To mention these few examples of surgical management, and to compare them with present procedures, indicate the progress made. Ernest Miles, the originator of the one stage abdominoperineal operation for cancer of the rectum, stated that with the advent of transfusion of blood his surgical mortality was cut in'half. Throughout this era the importance"of experimental surgery, even as at the present time, was manifest. The fundamental work of Lexer on transplantation of tissue has remained inviolate. The First World War gave great impetus to plastic surgery, when Gillies in England and Blair in St. Louis did outstanding work in developing a fascinating field. Also during the First World War the study of the physiological implications of opening the chest cavity carried out by Graham in his
Surgical Training in Retrospect
5
work on empyema, together with the later advances in anesthesiology, laid the foundation for thoracic surgery as it is practiced today. THE GRADUATE SURGEON 40 YEARS AGO
The young surgeon of 40 years ago saw large numbers of patients afflicted by surgical tuberculosis involving glands, joints, pleura, urinary tract, meninges and peritoneum. These have almost vanished, by reason of tuberculin testing of milk herds. Infections, trauma, hernia, appendicitis, tumors and urinary obstruction led the list. The attending surgeons were general surgeons, and the training of the young men under them was largely unspecialized. There were no residents in the hospitals of the Middle West, although the system had been inaugurated at The Johns Hopkins Hospital by Osler and Halsted. After completing an internship, the young surgeon either went into general practice and built up a surgical practice in that way, or became attached to the faculty of a medical school. Hopefully he became an assistant to one of the established surgeons. His own practice developed slowly, so that he had ample time for teaching and investigative work in the laboratory. His energy and accomplishments in these latter fields had much to do with his advancement, as well as giving him special interests and knowledge in the field in which he was working. Graduate work in Europe, in either pathology or physiology, was anticipated. The year or more spent in the scientific atmosphere of one of the great laboratories brought him home with a broadened viewpoint and intellectual stimulation which fitted him for better work in the clinic as a teacher and investigator. IMPROVEMENTS IN GRADUATE TRAINING
Medical education in the United States was much improved in the early 1900's, by the survey of medical schools carried out by the Committee on Education and Hospitals of the American Medical Association. It resulted in the elimination of a number of weak institutions, as well as strengthening the remaining schools. At the same time the American College of Surgeons began its campaign for improvement of hospital standards and organization, and developed a program for graduate training of surgeons. This was followed by the establishment of the American Board of Surgery by the American Medical Association, and the development of a program of graduate surgical training on the residency level, that led to examination and certification of qualified men at the conclusion of their graduate work. Within the year a committee including the American Hospital Association, the American Medical Association, the American College of Surgeons and the American Board of Surgery had taken on the work of listing the hospitals where graduate training in surgery could be attained because of their suitable organization, equipment and staff,
6
Vernon C. David
All of these steps have had an important bearing on the development of graduate training in surgery-training that allows the participation of young aspirants to a surgical career in an organized plan in accepted hospitals, where the educational atmosphere offers exceptional opportunity in clinical experience, teaching and investigation. As a resident he joins a team in the hospital. Success in the present plan of resident training is largely dependent on the leader of the team: first, because his own education has been sound; second, because he is wholeheartedly interested in training young men; third, because he brings into the team high ideals of practice, high standards of conduct, the very important human relationship that sees behind the patient's lesion, the need for kindness, an appreciation of his emotional balance and his personal problems; and fourth, because he is imaginative and in turn stimulates the imagination and curiosity of those who work with him. Under such leadership the whole team develops, the leader no less than the youngest and least experienced member. Without adequate leadership in resident training, the novitiate merely becomes an assistant in the operative field of surgery. His mental and spiritual growth comes in spite of his job, rather than because of it. In the early days of examin.ation of residents by the American Board of Surgery many interesting defects in our teaching program came to light. These defects included deficiencies in knowledge of regional anatomy, gross and microscopic pathology, fluid balance and blood loss following operations, and the maintainance of proper levels in blood chemistry. It was learned that in some institutions, resident training had been too specialized. The well trained abdominal surgeon might be grossly ignorant of the problems of peripheral vascular disease. Many were the discussions and suggestions as to how the errors could be corrected. It was anomalous that men recently graduated from medical schools were deficient in the application of fundamental science to clinical medicine. It soon became evident that repetition of courses in these subjects was not the answer, but rather that the senior members of the hospital services should themselves be responsible for the everyday application of these facts, so that it became second nature to view the patient from a physiological, biochemical and anatomical angle as well as from a pathological and clinical one. It was also obvious that a resident should have some experience in the special field of surgery as well as the conventional general training. Likewise the principles of surgery must at all times be emphasized, as they are the common denominators of all surgical thinking. Blood loss and replacement, fluid and chemical balance, control of hemorrhage, gentleness in handling tissue, protection from trauma of tissue exposed but outside of the operative field, anesthesia, shock, necrosis, infections, early ambulation, physiology of respiration, thrombosis and embolism must be of great importance to anyone who professes to be a surgeon.
Surgical Training in Retrospect
7
A young surgeon must have training in independent operating. In the beginning this should be carefully supervised, but with increasing experience he should be given greater opportunities to develop independent judgment, resourcefulness and responsibility. In the teaching program everyone on the team should have his objective. The resident supervises and helps teach the interns and clerks, and not too uncommonly, makes suggestions and improvements helpful to the whole team. Ideally, the resident should be assigned to one of the laboratories for at least six to twelve months of his service, where he can devote his whole time under the direction of his chief or the head of the laboratory in working on a problem which is such that he can make some contribution to the subject during this period of his training. Some men have a natural aptitude for research, are keen students of the literature of their subject, and imaginative in their approach to it. These men will probably always be contributors of experimental work. Others have little flair for research, but during their period in the laboratory will become acquainted with scientific methods and controls and will acquire more than average knowledge of one of the fundamental sciences which will be of great value in their future work. For instance, how important it is for a surgeon to have sufficient training in pathology to be able to determine at the operating table whether the cut section of a suspicious breast tumor is malignant or benign! A thorough knowledge of pathology is extremely important for every surgeon, and this is somewhat harder to come by now that the great gross pathologists, largely European trained, are passing from the scene. With the complexity of available knowledge today, it is impossible for a resident to become well trained in all branches of fundamental science, but it is of inestimable value for him to have a major interest in at least one phase which will serve him well as he develops over the years. Such training and a knowledge of the literature of the subject will often serve as a stimulus for further progress both from a clinical and investigative standpoint. Specialization is the order of the day, but it has its pitfalls. Whereas the highly trained specialist may make outstanding contributions to his field, he may be a poor trainer of others if he fails to insist on a broad educational program for his assistants, for one specialist training another soon gets into the apex of the triangle and develops men with a narrow perspective. General interests in medicine and training in the fundamentals are as important today as they were in the period that Billroth, Halsted and Mayo were responsible for developing schools of surgery. THE PROFICIENT SURGEON AND THE SOCIETY IN WHICH HE LIVES
To be proficient in any profession, a knowledge of the literature, both past and present, is essential; this means a reading knowledge of
8
Vernon C. David
at least two foreign languages. My advice to my young associates has always been to keep themselves poor by subscribing to the world's best current literature. If, on coming home at night, a pile of medical magazines on the desk meets the eye, and a knowledge of the cost is ever present, it is obvious that these magazines will be read. The journals in the library which have cost him nothing will sometimes be forgotten in the press of other work. The medical library will be used for special research, or to supplement other reading. For the young surgeon, attendance at the meetings of his local surgical society is important and, as his experience expands, contributions to its proceedings should be an objective. Travel to other clinics is especially desirable, for the stimulus obtained from observing the various interests in them, the humility that is generated in viewing superior accomplishment, and the friendships of fellow workers are important factors in making the life of the young surgeon full and rewarding. Dr. Harvey Cushing once outlined what he considered to be the necessary requirement of a man selected to become head of a department of surgery in a medical school. He listed all the essential attributes of character, a happy family life, outstanding ability as a teacher, investigator and surgeon, an imaginative and stimulating mind, a pleasing personality, an interest in public affairs, etc. He then said no such man existed. It is equally true that the young man in surgery today cannot be all things to all men, and that his activities must not be spread out too thin and essential objectives obscured. An interest in the society in which he lives and functions is, however, important. Our institutions for the care of the poor, our visiting nurse and infant welfare societies and similar activities should attract the interest and support of the young doctor who thereby increases his stature as a good citizen. A disturbing awareness of the long period of training for the young medical man is receiving attention by our leading educators. Our medical curriculum is being examined with the hope that quality may be preserved and quantity somewhat reduced. The junior and senior clerks in the hospital are largely supplanting the duties of the intern. Possibly they may entirely replace him. A better integration of fundamental science, as taught in the first two years of medical school, with clinical medicine is desirable and is being considered. These studies are helpful in the training of the young surgeon of the future. These thoughts are personal opinions, often obvious and in some instances debatable. They reflect the views of one who has enjoyed to the fullest a "surgical life." 1624 Wesley Avenue Evanston, Illinois
IN CONSIDERING surgical training in retrospect, I have been struck with the tremendous changes that have occurred in the lifetime of one man, as experienced by himself and as heard from the lips of his elders. The medical curriculum of today may be contrasted with that of 1869, when my father graduated from Rush Medical College, then a leading medical school of the Middle West. The student of that day enrolled for a six months' course of instruction, which was repeated in the following year, and then "rode" with, or joined an established doctor in practice for another year, at which time he received his M.D. degree. The Professor of Surgery of that day, Moses Gunn, rode to school on horseback, came into the clinical amphitheater and removed his coat and replaced it with a black alpaca one, with the ligatures from the previous days threaded through its buttonhole, and went to work. At a later period, about 1882, I have heard Dr. Lewis Linn McArthur tell of his assisting at the first operation performed under the Lister carbolic spray antiseptic method at the Cook County Hospital.
CONTRIBUTIONS OF THE EARLY MASTERS
At the beginning of this century our leading teachers of surgery, and professors in our medical schools, were trained anatomists and had often come into the field of surgery from the anatomical field. A few in the Middle West, such as Christian Fenger, were trained pathologists. Fenger in particular had great influence in stimulating interest in, and in the development of, surgical pathology. Nicholas Senn, a contemporary of Fenger, had a great part in the stimulation of laboratory experiments in his study of air embolism, gunshot wounds and intestinal anastomosis. John B. Murphy, during the same period, conducted pioneer experiments on end-to-end suture of blood vessels, intestinal suture and anastomosis, and joint surgery. Rudolph Matas at the same time in New Orleans was laying the foundation for the radical surgical cure of aneurysms. All of these men were widely traveled, and received graduate training in European Clinics and laboratories. They were fully informed in the surgical literature of the world.
* Professor Emeritus, University of Illinois College of Medicine (Rush), Chicago. 3
Vernon C. David In Europe, the surgical schools of Billroth in Vienna, and later Eiselsberg, emphasized the importance of surgical pathology in training surgeons, whereas Kocher in Bern, Horsley in England, and Halsted in Baltimore, Crile in Cleveland, and Murphy in Chicago emphasized the physiological and experimental aspects of surgery. These men were general surgeons in the broadest meaning of the term. Their education had been catholic in its breadth, and their assistants and pupils were trained in the fundamentals as they were understood at that time. This training offered a tremendous stimulus to the imagination of the leading teachers of surgery, with the result that the frontiers of surgery were rapidly widened, and special fields were opened. This was particularly true in the development of special skill in the treatment of goiter by Kocher, Crile and Charles Mayo, the surgery of blood vessels by Matas, Murphy and Carrell, the surgery of the breast and hernia by Halsted, neurological surgery by Cushing and Dandy, pupils of Halsted, surgery of the chest by Sauerbruch and Graham, to mention only a few of the pioneering studies that grace the early part of this century. TOWARD A FULLER UNDERSTANDING OF BIOCHEMICAL AND PHYSIOLOGICAL FACTORS IN SURGERY
These outstanding advances in various centers of the world left much to be desired in the understanding of the surgical patient from the standpoint of his biochemical and fluid balance-his respiratory quotient, blood loss and replacement, shock, anesthesia and dietary balance which have become so much better understood with the passage of time. As an instance in the Cook County Hospital in 1908, it was practically routine to administer 2 grains of calomel, followed by an ounce of magnesium sulfate, just before an operation. Blood typing and transfusion of blood by the Crile cannula, which was an artery-to-vein direct and unmeasured transfusion, was rarely used. Fluid replacement was by rectal drip or subcutaneous injection of salt solution. Shock was treated by fluids, external heat and lowering of the patient's head. To mention these few examples of surgical management, and to compare them with present procedures, indicate the progress made. Ernest Miles, the originator of the one stage abdominoperineal operation for cancer of the rectum, stated that with the advent of transfusion of blood his surgical mortality was cut in'half. Throughout this era the importance"of experimental surgery, even as at the present time, was manifest. The fundamental work of Lexer on transplantation of tissue has remained inviolate. The First World War gave great impetus to plastic surgery, when Gillies in England and Blair in St. Louis did outstanding work in developing a fascinating field. Also during the First World War the study of the physiological implications of opening the chest cavity carried out by Graham in his
Surgical Training in Retrospect
5
work on empyema, together with the later advances in anesthesiology, laid the foundation for thoracic surgery as it is practiced today. THE GRADUATE SURGEON 40 YEARS AGO
The young surgeon of 40 years ago saw large numbers of patients afflicted by surgical tuberculosis involving glands, joints, pleura, urinary tract, meninges and peritoneum. These have almost vanished, by reason of tuberculin testing of milk herds. Infections, trauma, hernia, appendicitis, tumors and urinary obstruction led the list. The attending surgeons were general surgeons, and the training of the young men under them was largely unspecialized. There were no residents in the hospitals of the Middle West, although the system had been inaugurated at The Johns Hopkins Hospital by Osler and Halsted. After completing an internship, the young surgeon either went into general practice and built up a surgical practice in that way, or became attached to the faculty of a medical school. Hopefully he became an assistant to one of the established surgeons. His own practice developed slowly, so that he had ample time for teaching and investigative work in the laboratory. His energy and accomplishments in these latter fields had much to do with his advancement, as well as giving him special interests and knowledge in the field in which he was working. Graduate work in Europe, in either pathology or physiology, was anticipated. The year or more spent in the scientific atmosphere of one of the great laboratories brought him home with a broadened viewpoint and intellectual stimulation which fitted him for better work in the clinic as a teacher and investigator. IMPROVEMENTS IN GRADUATE TRAINING
Medical education in the United States was much improved in the early 1900's, by the survey of medical schools carried out by the Committee on Education and Hospitals of the American Medical Association. It resulted in the elimination of a number of weak institutions, as well as strengthening the remaining schools. At the same time the American College of Surgeons began its campaign for improvement of hospital standards and organization, and developed a program for graduate training of surgeons. This was followed by the establishment of the American Board of Surgery by the American Medical Association, and the development of a program of graduate surgical training on the residency level, that led to examination and certification of qualified men at the conclusion of their graduate work. Within the year a committee including the American Hospital Association, the American Medical Association, the American College of Surgeons and the American Board of Surgery had taken on the work of listing the hospitals where graduate training in surgery could be attained because of their suitable organization, equipment and staff,
6
Vernon C. David
All of these steps have had an important bearing on the development of graduate training in surgery-training that allows the participation of young aspirants to a surgical career in an organized plan in accepted hospitals, where the educational atmosphere offers exceptional opportunity in clinical experience, teaching and investigation. As a resident he joins a team in the hospital. Success in the present plan of resident training is largely dependent on the leader of the team: first, because his own education has been sound; second, because he is wholeheartedly interested in training young men; third, because he brings into the team high ideals of practice, high standards of conduct, the very important human relationship that sees behind the patient's lesion, the need for kindness, an appreciation of his emotional balance and his personal problems; and fourth, because he is imaginative and in turn stimulates the imagination and curiosity of those who work with him. Under such leadership the whole team develops, the leader no less than the youngest and least experienced member. Without adequate leadership in resident training, the novitiate merely becomes an assistant in the operative field of surgery. His mental and spiritual growth comes in spite of his job, rather than because of it. In the early days of examin.ation of residents by the American Board of Surgery many interesting defects in our teaching program came to light. These defects included deficiencies in knowledge of regional anatomy, gross and microscopic pathology, fluid balance and blood loss following operations, and the maintainance of proper levels in blood chemistry. It was learned that in some institutions, resident training had been too specialized. The well trained abdominal surgeon might be grossly ignorant of the problems of peripheral vascular disease. Many were the discussions and suggestions as to how the errors could be corrected. It was anomalous that men recently graduated from medical schools were deficient in the application of fundamental science to clinical medicine. It soon became evident that repetition of courses in these subjects was not the answer, but rather that the senior members of the hospital services should themselves be responsible for the everyday application of these facts, so that it became second nature to view the patient from a physiological, biochemical and anatomical angle as well as from a pathological and clinical one. It was also obvious that a resident should have some experience in the special field of surgery as well as the conventional general training. Likewise the principles of surgery must at all times be emphasized, as they are the common denominators of all surgical thinking. Blood loss and replacement, fluid and chemical balance, control of hemorrhage, gentleness in handling tissue, protection from trauma of tissue exposed but outside of the operative field, anesthesia, shock, necrosis, infections, early ambulation, physiology of respiration, thrombosis and embolism must be of great importance to anyone who professes to be a surgeon.
Surgical Training in Retrospect
7
A young surgeon must have training in independent operating. In the beginning this should be carefully supervised, but with increasing experience he should be given greater opportunities to develop independent judgment, resourcefulness and responsibility. In the teaching program everyone on the team should have his objective. The resident supervises and helps teach the interns and clerks, and not too uncommonly, makes suggestions and improvements helpful to the whole team. Ideally, the resident should be assigned to one of the laboratories for at least six to twelve months of his service, where he can devote his whole time under the direction of his chief or the head of the laboratory in working on a problem which is such that he can make some contribution to the subject during this period of his training. Some men have a natural aptitude for research, are keen students of the literature of their subject, and imaginative in their approach to it. These men will probably always be contributors of experimental work. Others have little flair for research, but during their period in the laboratory will become acquainted with scientific methods and controls and will acquire more than average knowledge of one of the fundamental sciences which will be of great value in their future work. For instance, how important it is for a surgeon to have sufficient training in pathology to be able to determine at the operating table whether the cut section of a suspicious breast tumor is malignant or benign! A thorough knowledge of pathology is extremely important for every surgeon, and this is somewhat harder to come by now that the great gross pathologists, largely European trained, are passing from the scene. With the complexity of available knowledge today, it is impossible for a resident to become well trained in all branches of fundamental science, but it is of inestimable value for him to have a major interest in at least one phase which will serve him well as he develops over the years. Such training and a knowledge of the literature of the subject will often serve as a stimulus for further progress both from a clinical and investigative standpoint. Specialization is the order of the day, but it has its pitfalls. Whereas the highly trained specialist may make outstanding contributions to his field, he may be a poor trainer of others if he fails to insist on a broad educational program for his assistants, for one specialist training another soon gets into the apex of the triangle and develops men with a narrow perspective. General interests in medicine and training in the fundamentals are as important today as they were in the period that Billroth, Halsted and Mayo were responsible for developing schools of surgery. THE PROFICIENT SURGEON AND THE SOCIETY IN WHICH HE LIVES
To be proficient in any profession, a knowledge of the literature, both past and present, is essential; this means a reading knowledge of
8
Vernon C. David
at least two foreign languages. My advice to my young associates has always been to keep themselves poor by subscribing to the world's best current literature. If, on coming home at night, a pile of medical magazines on the desk meets the eye, and a knowledge of the cost is ever present, it is obvious that these magazines will be read. The journals in the library which have cost him nothing will sometimes be forgotten in the press of other work. The medical library will be used for special research, or to supplement other reading. For the young surgeon, attendance at the meetings of his local surgical society is important and, as his experience expands, contributions to its proceedings should be an objective. Travel to other clinics is especially desirable, for the stimulus obtained from observing the various interests in them, the humility that is generated in viewing superior accomplishment, and the friendships of fellow workers are important factors in making the life of the young surgeon full and rewarding. Dr. Harvey Cushing once outlined what he considered to be the necessary requirement of a man selected to become head of a department of surgery in a medical school. He listed all the essential attributes of character, a happy family life, outstanding ability as a teacher, investigator and surgeon, an imaginative and stimulating mind, a pleasing personality, an interest in public affairs, etc. He then said no such man existed. It is equally true that the young man in surgery today cannot be all things to all men, and that his activities must not be spread out too thin and essential objectives obscured. An interest in the society in which he lives and functions is, however, important. Our institutions for the care of the poor, our visiting nurse and infant welfare societies and similar activities should attract the interest and support of the young doctor who thereby increases his stature as a good citizen. A disturbing awareness of the long period of training for the young medical man is receiving attention by our leading educators. Our medical curriculum is being examined with the hope that quality may be preserved and quantity somewhat reduced. The junior and senior clerks in the hospital are largely supplanting the duties of the intern. Possibly they may entirely replace him. A better integration of fundamental science, as taught in the first two years of medical school, with clinical medicine is desirable and is being considered. These studies are helpful in the training of the young surgeon of the future. These thoughts are personal opinions, often obvious and in some instances debatable. They reflect the views of one who has enjoyed to the fullest a "surgical life." 1624 Wesley Avenue Evanston, Illinois