Person or system – What leads to surgical advances?

Individualism

With the advent of anaesthesia, antiseptics and radiology at the end of the 19th century opportunities for surgical treatment changed radically making it possible for surgeons to operate with relative safety on structures they had not considered treating in the past.

William Arbuthnot Lane (1856–1943) was a surgeon who in 1892 promoted a new method of treating closed fractures of limbs, which caused great controversy at that time. ¹ However, Lane pursued his surgical ideas as an individual and not as someone who acted collectively. He promoted the idea that in order to achieve alignment of bones and to prevent non-union, internal fixation was required. Lister had attempted this, with limited success, by internally fixing a patella fracture with wire. ² However, the very idea of opening a closed fracture and exposing the bone to the risk of infection by internal fixation was hugely contentious at that time. The President of the Royal College of Surgeons of England (RCS) stated: ‘A man who converted a simple into a compound fracture was guilty of malpractice and should be brought before the GMC (General Medical Council)’. ³ Despite this antagonism towards his methods, Lane continued to fix closed fractures internally, although he was cautious of using internal fixation for open fractures since these may already be contaminated. ⁴

Furthermore, although Lane’s method was abhorred by many in Britain, it was taken up by surgeons in Germany and the United States of America. Consequently, he became a frequent visitor to these countries. ⁵ Lane did not see active service but he wrote authoritatively about fractures in First World War (WWI) and laid down 14 principles of their management. ⁶ He continued to practise his new methods in the face of fierce animosity from his peers and was often seen as a dangerous maverick although he was given some support, albeit grudgingly, from later surgeons, most notably Robert Jones who wrote:

We owe to Arbuthnot Lane recognition of the good he effected by his operative campaign. He at least drew attention to the deplorable condition of the results of the treatment of fractures in this country. ⁷

In reality, Lane did far more than just draw attention to internal fixation – he revolutionised the management of fractures. ⁸ He readily adapted the new sciences and technologies that were available to him to make a significant contribution to the practice of orthopaedic surgery both in internal fixation and also by following Listerian Principles ⁹ and reducing the risk of infection by advocating the Non-Touch Technique.^10,11 It is easy to dismiss him as an individual only interested in his craft at the expense of a wider vision, but the question remains as to whether without people such as Lane can real progress ever occur?

Scientific management and standardisation

In the early part of the 20th century, the treatment of fractures was an undervalued part of surgery, lagging behind general surgery in teaching, research and specialisation. ¹² During this time a surgeon, Robert Jones (1857–1933), emerged who understood the new and interesting concepts of scientific management that had been developed in industry.

In the early 20th century, scientific management was popularised as a means of improving industrial output. It was conceived by Frederick Winslow Taylor (1856–1915), an engineer working for the Midvale Steel Company in the USA. In 1911, Taylor argued that the workforce should no longer be made up of individuals working on their own but should become a combined labour force functioning in harmony under management who, in turn, would know the best way to produce the end product. To do this, Taylor stated that the labour force needed to be trained, taught and developed, leading to ‘An almost equal division of responsibility between management and the workman’. ¹³ Taylor also discussed the training of surgeons and reasoned that this was almost identical to that of a workman under the principles of scientific management. Taylor explained that a surgeon throughout his early years of training was under close supervision by more experienced men. The experienced men provided the trainee with the implements to do the work, each implement being developed solely for the purpose. Taylor posits that this method of teaching in no way narrows the outlook of the surgeon, arguing that, on the contrary, the surgeon is provided with the latest knowledge and implements from his predecessors. ¹⁴ There is a problem with this vision as it supposes that, once trained, the surgeon is the complete product and is then able to show qualities of both ingenuity and originality founded entirely on his training. It is also the case that this utopian concept of scientific management is based firmly on cooperation between the worker and management and, as such, is in sharp contrast to the individualism shown by Arbuthnot Lane.

Not everyone though was in agreement with Taylor’s ideals, in 1912, Frank Bunker Gilbreth (1868–1924), an expert on industrial efficiency, ¹⁵ published his polemic on scientific management, ¹⁶ in which he challenged Taylor, stating: ‘It is the aim of scientific management to induce men to act as nearly like machines as possible’. Gilbreth argued that scientific management keeps the worker from being an all-round mechanic and instead turns him into a narrowly trained specialist, which he suggests would be for the better. Gilbreth also argued that specialisation improved the standing and increased the earning power of the specialists. Gilbreth’s view of specialisation was that a man should have ‘A great deal of knowledge about his speciality and life work, rather than a little knowledge about many kinds of work’. ¹⁷ When Gilbreth explores the question of experience as being the best teacher, he discards it as being meaningless. Instead, he concludes that when the best experience has been found and measured it should become the standard. ¹⁸

Examining the value of standardisation, Gilbreth agreed with Taylor and dismissed the view that standardisation precluded innovation and improvement. He reasoned that standards should be few in number but that they should be first class and were preferable to having many ill-conceived standards. Bowker and Star however point out that standards have an inbuilt inertia, so that once they have been accepted they can be difficult and expensive to change. ¹⁹ Taylor’s views gradually unravelled in the 1910s because the idealistic views of a benevolent management, producing perfect mechanical control, was considered unrealisable. ²⁰

Robert Jones drew on the principles of scientific management and applied them to the treatment of the injured during the construction of the Manchester Ship Canal (MSC). ²¹ In 1888, he was appointed surgeon to the MSC with a staff of 14 surgeons. Jones constructed hospitals all along the canal and assigned a matron, a surgeon and two nurses to each hospital consisting of 26 beds and two small wards. The surgical staff in these hospitals were trained specifically in the management of fractures with non-medical staff trained for plaster application and wound dressing and, over a five-year period, 3000 serious accident victims were treated in these hospitals. ²²

In March 1916, Robert Jones was appointed Director-General of Military Orthopaedics with the rank of Major-General. His role was to inspect and organise the orthopaedic treatment of war injuries and he was invited to develop military hospitals in the same way as he had managed injuries from the MSC. ²³ Before the outbreak of WWI, 7000 beds were available to the military in the UK of which about 2000 were occupied, but by the time of the Armistice in 1918, there were 364,133 beds for other ranks and 18,378 for officers. ²⁴ The number of injured soldiers increased dramatically as the war progressed, reaching a peak in 1917 when more than one million men occupied hospitals beds in Great Britain (Figure 1). OPEN IN VIEWER

One such flagship was the military hospital at Shepherds Bush, London, now known as the Hammersmith Hospital. This hospital consisted of 30 beds for officers and 1070 beds for other ranks. ²⁵ Jones directed that the hospitals should be staffed by surgeons with minds that were ‘Sufficiently flexible to grasp new ideas’. ²⁶ His view that the surgeons should be able to grasp new ideas is pertinent as it reflects Jones’ continued concerns about entrenched opinions in the light of new developments such as standardisation and specialisation.

Using his experience from organising the treatment of the wounded along the MSC, Jones developed the hospitals along super-specialist lines. Thus fractured femurs were treated altogether in one ward and fractured ankles in another. ²⁷ There the surgeon and other staff did exactly the same procedures without variation. It is evident that Jones’ organisational skills were far reaching and his overall approach was one of collectivism at the expense of individualism. Nevertheless, he was not fettered by dogmatism, which allowed him to compromise when the occasion demanded, in contrast to the individualist Arbuthnot Lane. An example of Jones’ pragmatism was seen in July 1918 when the Council of the RCS decried the development of specialisation and particularly of orthopaedic surgery. ²⁸ Initially, Jones tried to influence the government and the military to support his views on specialisation but, perhaps realising that he was unlikely to win his case given his opponent’s entrenched views, withdrew his position when on 11 April 1918, the RCS awarded him with the Fellowship. Jones went on to describe the award as ‘The greatest honour I have ever received’. ²⁹

However, the problem with specialisation would not go away. In 1925, Sir Henry Makins (1853–1933), President of the RCS, wrote:

We find a specialist for the treatment of fractured jaws; another for fractures of the thigh; and strange inconsistency we meet with a third department, that of orthopaedics. ³⁰

Scientific surgery

The principles of scientific surgery were applied during WWI by Dr Alexis Carrel (1873–1944), a Nobel Prize-winning French surgeon who had been assigned by his Government to develop a method for preventing infection in soldiers following war injuries.

In the early part of the 20th century, the concept of experimentalism ³² was embedded in medicine and was based upon the pioneering work of Claude Bernard (1813–1878). Working with a team of scientists near to the front line during this war, Carrel used experimentalism and introduced the principles of scientific surgery to manage these injuries. When defining the term science, Karl Popper says, ‘one may be tempted to say that science is nothing but enlightened and responsible common sense, broadened by imaginative critical thinking’. ³³ When this view is then combined with the principles of standardisation and specialisation and taken in conjunction with Claude Bernard’s experimentation and then applied to surgery, the concept of scientific surgery can be explained.

As a young surgeon, Carrel had been hugely critical of the medical establishment in France, which he found to be profoundly antiscientific. ³⁴ The resulting fall out saw Carrel leave France to join the staff of the newly formed Rockefeller Institute of Medical Research in New York, United States of America. When WWI broke out in 1914, Carrel returned to France and in 1915 he was invited by the French Minister of War to establish a military hospital, which was to be part funded by the Rockefeller Institute. The hospital was opened on the edge of the Foret de Compiègne, about 12 km from the front line, with 51 beds and twice as many staff. ³⁵ Carrel approved of the principles of Listerian antisepsis for treating wounds and from the outset realised that he needed a chemist to assist him in developing a suitable antiseptic solution. In 1915, Dr Henry Dakin joined Carrel at the hospital in France, ³⁶ and after a short while, Dakin developed the hypochlorite solution that was an antiseptic that was bactericidal, diffusible and caused little irritation to the surrounding tissues. The solution was cheap to produce but unfortunately was relatively unstable and needed preparing at regular intervals. By 1916, Carrel had developed his method for delivering Dakin’s hypochlorite solution. ³⁷ At the same time, Carrel acquired the services of a French mathematician, Pierre Lecomte du Nouy (1883–1947). du Nouy then developed the planimeter for measuring the wound surface area, and he also created the formula which measured the curve of healing of the wound. ³⁸

Carrel established precisely the procedure for treating wounds, ³⁹ which comprised of thorough debridement of all dead tissue, with 2 mm margins of skin being removed; all foreign bodies including any dead bone were excised and careful haemostasis achieved. The wound was then washed out by continuous or intermittent irrigation using the Dakin solution via a multi-outlet device fed by a reservoir on a drip stand. Regular bacteriological examination was taken from the wound and if the bacterial count was reduced to no more than one microbe per field, on consecutive days, the wound would then start to be closed. ³⁹

Whitfield records that Carrel was influenced by Gilbreth’s writings to ensure that accurate measurement became an essential part of surgical treatment. ⁴⁰ The Carrel-Dakin method is an example of the principle of scientific surgery. There was enlightened and imaginative critical thinking to produce the correct solution to the problem along with the system of delivery designed by Carrell. Standardisation was used in that each medical person involved did the same thing for every patient. Specialisation took place as each member of the team was an expert in their allotted task. Measurement of wound healing was carried out by the planimeter and the du Nouy formula. Experimentation was involved as Carrel treated the patient as a scientific object where only the wound was of concern to the team. ⁴¹ Carrell had definite views about the competence of the surgeon in the field at that time – ‘A surgical method is practical only when it can succeed at the hands of unskilled and ignorant doctors’. ⁴² This was something Arbuthnot Lane, who knew Carrel, would probably have agreed with. Later when Carrel’s method had been put into clinical practice Carrel celebrated its success by stating:

The French surgeons cannot realise that Dakin and myself, two laboratory workers, have found what they failed to find, a solution to the problem of infected and suppurating wounds. ⁴³

However, although very appealing, this scientific method was ultimately impractical for use both in war time and peace. There was strong resistance to using Carrel’s method ⁴⁴ largely because most surgeons on the front line at war found it difficult to continue the meticulous technique that was proposed with its detailed monitoring and recording of the process of wound healing. The haphazard nature of war meant that the front line frequently moved and so did the surgical teams, making measuring and sampling the wound virtually impossible. ⁴⁵

Discussion

In clinical practice, there exists a tension between the notion that individuality and collectivism are incompatible. It has been argued that it is possible only to have one or the other the evidence presented here suggests that they need each other to flourish.

Arbuthnot Lane, who understood the importance of asepsis in surgery and was proficient in anatomy, introduced new methods for treating fractures. Lane acted as an individual attracting great controversy from his surgical colleagues in London, but he persevered which is important for innovation to succeed. Part of Lane’s problem however was that he acted autocratically expecting others to follow him. ¹⁰ In Lane’s time, it was necessary to question the conservative methods of treating fractures to prevent deformity and non-union of the bone, but the surgical establishment’s response to him was understandable because of the fear of introducing infection into a clean area. Lane lived in a time of significant scientific advancement. He developed an idea that was important and, although the introduction internal fixation was hampered by WWI, fundamentally it was an original concept. He did, however, contribute to the tension between the individual and collectivism by persisting with his ideas without deviation, even in the face of fierce opposition. Despite the issues that arose from this, the underlying contention is that Lane’s individualism was vital for surgical progress and that the world needs people like him, even today.

Popper (1902–1994) suggested that individualism is either in opposition to collectivism or to altruism. Popper defined the opposite of altruism as egoism, and concluded that individualism can be identified with egoism, with the converse, altruism, being identified with collectivism. ⁴⁶ Bernard Shaw characterises this individualism in ‘Man and Superman’ when he remarks

The reasonable man adapts himself to the world: the unreasonable one persists in trying to adapt the world to himself. Therefore all progress depends on the unreasonable man. ⁴⁷

But the individual actions of a surgeon do need to be questioned and subjected to analysis. One way to do this is for networks to be established, which were not available to Lane. Successful surgical networks have been developed by the AO (Arbeitsgemeinschaft fur Osteosynthesefragen) School of Osteosynthesis in the 1960s. The AO School established a system that consisted of scientists to study primary bone healing and fixation of the fracture, with new improved materials for plates, screws and instruments, and they successfully organised courses for surgeons to be taught their technique. ⁴⁸ Furthermore, they developed a database of patients for evaluating the results, as did Carrel for his wounds. Indeed, this confirms Codman’s original concept which invoked the term ‘End Results’ where patients’ outcomes are readily available for all to see and evaluate. ⁴⁹

In contrast to Lane, Robert Jones, used methods developed from industry to apply to surgical practice to treat large numbers of injured, both in peace time and in war. His organisational skill and pragmatic approach to difficulties allowed for effective treatment and rehabilitation of the injured. However, it is arguable that Jones was more of a collectivist who made long lasting achievements through standardisation. In one sense, Carrel can also be seen as a collectivist notably in his approach to managing war wound infections. He created his method by employing a world class chemist and biophysicist along with a team of experts to produce a defined method of treatment more or less in laboratory conditions. Yet he could also be considered an egoist who believed in his science-based work above all others. In this he had some justification, his scientific background was impeccable for in 1912, he was only the second surgeon to be awarded a Nobel Prize. ⁵⁰ Alexis Carrel produced an expensive highly scientific technique and results were produced, but it required a team of specialists for the technique to be delivered, and it was not reproducible. Variations of the Carrel-Dakin principles are used today in the form of wound washout and debridement along with sampling for pathogens, ⁵¹ but Carrel the scientist was too rigid in his beliefs, like Lane but unlike Jones.

Standardisation has enormous benefits especially when dealing with large numbers of patients and notably in an organisation such as the NHS. Standardisation can be applied by means of Integrated Care Pathways, so that everyone knows exactly what to do when a patient arrives in hospital. The problems with formulaic instructions though are what happens when there are any deviations in the patient’s presentation. Guidelines, another form of ensuring standardisation, are provided by NICE for treating patients, but Bishop et al. ⁵² in a study of NICE guidelines for low back pain found that the overwhelming majority of 53 clinical staff surveyed reported that the guidelines had little influence on their individual clinical decision making. It is also worth considering whether those who design guidelines have a vested interest or indeed have the necessary knowledge. Also as was noted by Bowker and Star, once guidelines have been accepted it is difficult to remove or change them. ⁵³

This all suggests that formulaic instructions either prevent initiative or are simply ignored, reinforcing the concept of conflict between individualism and collectivism. Carrell applied standardisation to his model, his aim being to ensure the correct application of the technique, not so much the expectations of the individual patient. This would reflect the clinical thinking of the time in which the patients experience did not carry the weight that it does today. ⁵⁴

It would appear therefore that the factors which influence innovation are not binary or indeed even mysterious but are many and variable. The problem however is that having a defined training followed by specialisation and super specialisation, the surgeon of today still needs to have the ability to think independently, both for the sake of innovation and for the patient. If the system’s structure becomes too rigid because of pathways and guidelines, then it could be argued that the opportunity for individual thought or action in developing any new treatment would be lost. If all surgeons are reduced to well-trained technicians, who then will be the Lane or perhaps the Carrel of the future?

In conclusion, advances in treatment in orthopaedic surgery are dependent on the individual who needs a degree of freedom within the system for his innovations to flourish. Yet it is also the case that the distinction between innovation and standardisation is in reality blurred and that the two practices are not in conflict. Popper argued that individualism and collectivism are opposed to each other. ⁵⁵ The truth though is more complicated and the factors that are claimed to inhibit innovation, such as overwhelming standardisation and super specialisation, which are thought to result in a technician who is unable to think for himself, are in fact not what they appear to be. These views do not hold up any more than Gilbreth’s view that Scientific Management would induce men to act like machines. ⁵⁶

Exploring of the views of these three surgeons, it is apparent that innovation can occur within the confines of collectivism provided the individual is given the opportunity to think independently.

In the end, though it is still essential to have the ability to imagine and to develop new ideas for, as William Blake (1757–1827) wrote, ‘What is now proved was once only imagined’. ⁵⁷ In other words, even though an innovation has now become a standard, it must be imagined first. Therefore, in order to ensure that innovation prospers, the ideal position is that individualism and standardisation work in harmony, while leaving room for the individual to develop his ideas, particularly in the best interests of patients.