Surgeon-anatomist to robotic technician? The evolving role of the surgeon over three centuries

Introduction

Since the 18th century, advances in our understanding of disease and innovations in science and technology have together expanded the range of conditions amenable to surgical treatment. As surgery has advanced, so the role of the surgeon has changed and continues to change.

In this article, we have selected examples to demonstrate the evolving role of the surgeon from the latter half of the 18th century through to the 21st century and speculate how this might further develop in the future.

18th century

Surgeon anatomists

For much of the 18th century, British surgery was largely based on only one science; the study of anatomy, mainly inspired by the first Edinburgh professor of anatomy Alexander Monro primus (1697–1767) and by the brother surgeon-anatomists William (1718–1783) and John Hunter (1728–1793), who established a celebrated anatomy school in London. Anatomy was at the heart of surgical education and training, and surgical knowledge and technique advanced through an increasing understanding of anatomical structure and function. In London, William Hunter studied midwifery under William Smellie (1697–1763) and published on the gravid uterus. His collection – including his art, books and curiosities – is now housed at the University of Glasgow. John Hunter, often described as the father of scientific surgery, was an experimentalist who would employ the results of his experiments in making clinical decisions. ¹ John’s prestige did much to change surgery from a manual craft to a scientific discipline. Among the many influenced by the Hunter brothers was John Bell (1763–1820), an Edinburgh-based surgeon and anatomist who emphasised that the practice of surgery must be based on the study of surgical anatomy. Bell stressed the teaching of anatomy related to surgery and his many books on the topic were influential, due to his acclaimed anatomical illustrations. A talented artist, with an interest in classical artworks, John Bell also wrote Observations on Italy, in which he described the relationship between anatomical correctness and art. He intended that his anatomical plates should combine the aesthetic with the functional, hoping that they would be judged as ‘excelling in what is beautiful; yet, not wanting in what is useful’ ² (Figure 1).

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Figure 1.

Second dissection of the belly. Drawn by John Bell and engraved by John Beugo from John Bell, Engravings explaining the anatomy of the bones, muscles and joints, Edinburgh, 1794.

The study of anatomy was evolving in the late 18th century with increasing emphasis on morbid anatomy, the analysis of the structure of diseased organs. In the last decade of the 18th century, Mathew Baillie (1761–1823), a nephew of William and John Hunter who inherited their anatomy school, published The Morbid Anatomy of some of the most Important Parts of the Human Body (1793), ³ in which he portrayed morbid anatomy as an independent science, describing correlations between clinical features of disease and pathological change.

19th century

20th century

Asepsis developed in the 1890s and in the early 20th century and it was further advanced by the surgeon William Arbuthnot Lane (1856–1943) who was effectively the first to routinely perform internal fixation for fractures of the lower limb. ¹¹ Lane also advanced aseptic surgery with his ‘no-touch’ technique. Surgeons’ hands were not allowed into the wound, his instruments were long handled to keep hands away from the tissues. Possible contamination was further reduced by these being given to the surgeon using other instruments and not by hand. ¹² Yet Lane was severely criticised and despite his success many surgeons still felt it was not justifiable to open a fracture and to risk introducing the possibility of infection. In a way, Tait and Lane exemplify the fearless surgeon described by the American surgeon Frederic Shepard Dennis (1850–1934) who wrote in 1905, ‘There is no science that calls for greater fearlessness, courage and nerve than that of surgery’. ¹³ These surgeons embodied the attributes of fearlessness and courage but mainstream surgical opinion, conservative by nature, disapproved of what they perceived as reckless and risky innovation. Both men were certainly innovators and individualists whose contributions were to improve surgical outcomes.

At the beginning of the 20th century another influential change occurred, diminishing the role of such individualists, the introduction of ‘Scientific Management’ from industry. The concept of scientific management was created by the American engineer Frederick Winslow Taylor (1856–1915), who wrote ‘the aim of scientific management is to reduce men to act as nearly like machines as possible so that the workforce is no longer to be made up of individuals’. ¹⁴ Taylor’s work was complemented by that of another American engineer, Frank Gilbreth, (1868–1924) who published A Primer in Scientific Management, in which he described an ideal factory in which ‘every operation was performed according to predetermined schedules and definite instructions. By this means errors are prevented instead of being corrected’. ¹⁵ Gilbreth encouraged specialisation, suggesting that a factory worker ‘needs a great deal of knowledge about his speciality, rather than a little knowledge about many kinds of work’. ¹⁵

The orthopaedic surgeon Robert Jones (1857–1933) applied scientific management principles to the care of his patients at the Royal Southern Hospital in Liverpool. Charles Macalister (1860–1943), a physician at the hospital at that time, wrote

[Jones] got through an immensity of work. He had around him a number of helpers, some of them medically trained … others nursing staff trained in the application of splints and plaster of Paris … others kept an eye on the home conditions of the patients with reference to their feeding and regular attendance for massage, or other special treatment. ¹⁶

By the middle of the 20th century, surgery had evolved dramatically because of the improvement in anaesthesia, asepsis, blood transfusion, antibiotics, imaging and more. But further change was to come with the influence of technology on surgical practice. Nevertheless, during this period the pioneers of surgery were still in many respects in the mould of the pioneers of the turn of the century. They were individualists who, driven by the desire to improve outcomes, pioneered new treatments for their patients.

One example was John Charnley (1911–1982), who pioneered the modern era of total hip arthroplasty. ¹⁸ In his own workshop, Charnley designed and made his own instruments and implants (Figure 2), assisted by a skilled technician, Harry Craven (1928–2007). Charnley also worked with industry, particularly with Charles Thackray and Co., to develop the implants, and with Howorth Airtech to develop clean-air systems which ensured a significantly reduced risk of bacterial contamination.

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Figure 2.

John Charnley at his lathe in his workshop where he made implants and instruments (courtesy of the Thackray Museum of Medicine).

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Figure 3.

Robotic surgery of the abdomen. The surgeon is seated extreme right at a console remote from the patient. Oil painting by Inês-Hermione Mulford, 2021 (courtesy of Surgeons’ Hall Museums).

Further technological advances in the 20th century included improved endoscopic lighting and optics, which, together with chip-camera systems, facilitated the onset of minimally invasive surgery. In the last decade of the century, ‘key-hole surgery’ rapidly came to replace open surgery for many common procedures.

21st century

The continuing drive to improve surgical safety and outcomes saw the widespread introduction of the surgical safety check list in the early 21st century. The Institute of Medicine published To Err Is Human in 2000 and showed that some 98,000 deaths in healthcare in the USA were preventable. ¹⁹ The report recognised that larger surgical teams interacting around increasingly high technology inevitably raised the risk of complications. The widespread use of a Safe Surgery checklist introduced by the World Health Organization exemplified the increasing safety culture in surgical practice. ²⁰ The importance of human factors in the operating theatre was increasingly recognised as relevant to improving surgical outcomes, as were non-technical skills, for example situation awareness, decision making, teamwork and communication. ²¹ As Scientific Management influenced practice at the start of the 20th century, models such as Systems Engineering Initiative for Patient Safety are becoming influential at the start of the 21st. ²²

Surgical technology at the beginning of the 21st century saw the introduction of robotic surgery, which requires further specialist training by the surgeon. It also requires a different mindset, as the surgeon is usually seated at a console visualising the procedure via a screen some distance from the patient (Figure 3).

While applicable at present to a minority of procedures, its use is increasing. The Future of Surgery, a report commissioned by the Royal College of Surgeons of England (RCSEng), predicted that robot-assisted surgery will involve the use of ever smaller and smarter surgical robots, ‘micro-robots that are swallowed or otherwise implanted can navigate the body to fix medical issues and are then expelled’. ²³

The urologist John Wickham (1927–2017) predicted that ‘surgeons appear almost destined to become pure technologists despite the hope that they will remain the all-encompassing physician who operates’. ²⁴ In 1994, Wickham envisaged a surgical team that would be led by a Director of Interventional Therapy and would include: endoscopists; interventional radiologists; anaesthetists; bioengineers; nurse practitioners; and the surgeon. ²⁴ The Future of Surgery drew similar conclusions predicting that surgeons will need to become ‘multi-linguists, understanding the language of medicine, genetics, surgery, radiotherapy, and bioengineering’. ²³ Interwoven with these concepts of specialised technical skills of the surgeon is Technoscience, the interrelationship between the state, academia and industry. ²⁵ This includes availability of resources, the training and specialisation of the surgeon, and the standardisation of approach, as surgical activity is increasingly governed by regulators. All of these factors are apparent throughout the world in current healthcare programmes. However, as Geoffrey Bowker and Susan Starr pointed out in Sorting Things Out, ‘Standards have significant inertia and can be very difficult and expensive to change’. ²⁶ James C Scott, the American political scientist and anthropologist, wrote in Two Cheers for Anarchism, ‘The gospel of efficiency, is that technical training and engineering solutions implies a world directed by a trained rational professional elite’. He concludes that ‘Human nature seems to shun a narrow uniformity in favour of variety and diversity’. ²⁷ Scott’s view debunks the concept of a professional elite dictating universally applicable solutions suggesting that individualism is a fundamental human trait.

All this begs the question: are advances in surgery made by inspired chance by individuals – as by Charnley and the application of polyethylene in total hip arthroplasty – or by adhering to evidence-based scientific surgery as set out, for example, in NICE guidelines? The predictions of Wickham and the Future of Surgery are right in that surgeons are now team members. They are also in part technicians who must be familiar with sciences such as bioengineering and molecular biology but remain essentially team players, a far cry from the surgeons of the past where the views of the individual surgeon were paramount.

This also, to some extent, rejects Charles Bell’s position of the artistic ideal of surgery and raises the question of whether surgery can have any lingering pretentions to be an art form. The Future of Surgery talks of the changing relationship between the patient and the surgical team. ²³ How will this affect the patient’s perception of the surgeon, the individual perceived by patients as the one in whom they have to trust, in some cases with their lives?

The relationship between the patient and the surgeon can become complicated. The historian John Pickstone (1944–2014) argued ‘Doctor does not have the experience of dealing with a particular illness day in and day out, but the patient does and therefore patient groups are better informed’. ²⁵ There is now increasing emphasis on personalised care leading to greater patient involvement in decision making, a concept promoted by NHS England in Shared Decision Making, ²⁸ by The Academy of Medical Royal Colleges in Choosing Wisely ²⁹ and, of course, by patient support groups. The view of the patient about the management of their condition is ever more important. The landmark UK Supreme Court ruling in the Montgomery case in 2014 effectively gave patients the right to make their own informed decisions about their treatment, having been told the risks and benefits by the surgeon. ³⁰ So reason, and now the law, demands the use of evidence-based medicine when deciding which (if any) surgical procedure to recommend to a patient. Pressured by such patient involvement and increasingly constrained by guidelines, protocols and regulators, can there be any role for the surgeon to show the creativity, individualism and imagination needed if surgery is to progress?

In other words, will tomorrow’s surgeons have the freedom to develop and create innovative procedures and new techniques and technologies? In the drive to uniformity promoted by Taylor and Gilbreth, can there still be a place for the pioneers, the innovators, the Taits, Lanes and Charnleys? Taylor studied surgeons in training and argued that with scientific management the trainee surgeon would have ‘the best up to date knowledge, instead of reinventing things and would be able to use his own originality and ingenuity to make real additions to world knowledge’. ¹⁴ On the other hand, the RCSEng report Introduction of New Technology or Techniques in Surgery stated that ‘there is no place for the maverick surgeon who proceeds without appropriate peer review or training’. It goes on, ‘Surgeons have a duty to consider carefully whether or not the innovation has a real patient benefit, at an affordable cost, both in terms of morbidity and mortality and of cost effectiveness compared with established procedures’. ³¹

Surgery has changed out of recognition since the latter part of the 18th century. Major advances in anaesthesia, imaging, transplantation and surgical technology, to name but a few, have long since displaced anatomy as the scientific basis of surgery.