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When the Surgeon Was an Uneducated Barber (nautil.us)
47 points by samizdis on Aug 2, 2022 | hide | past | favorite | 27 comments

This piece is a pretty good (though a bit all over the place) survey of the history of surgery. My main nitpick is that it's a bit Western-centric in terms of its narrative. William Harvey was predated by ~400 years by Ibn al-Nafis (though I think Harvey's discovery was based on independent work, though I may be wrong since I haven't checked any primary sources on this), who also discovered Galen's mistake. Al-Zahrawi also had an early (10th century) treatise of surgery and surgical instruments [^1]. And the famous al-Razi (Rhazes) also had a treatise on urological procedures (as well depicting the devices for performing some of them)[^2]. It's not as if they were unknown in Europe either, Vesalius published a translation of Rhazes.

[^1]: https://www.gutenberg.org/files/26038/26038-h/26038-h.htm

[^2]: https://muslimheritage.com/paediatric-urology-1000-years-ago...

and no mention of suśruta https://en.wikipedia.org/wiki/Sushruta whose works were copied extensively by Arabs.

Looks like there was a translation of Susrutas book into Arabic. Not sure what citations show "extensive copying".

Surgeons and barber-surgeons have an interesting history in France, although I don't know how well it correlates to what was happening in the rest of Europe.

There was an official brotherhood of surgeons founded in the 13th c. in Paris, made of highly educated members molded in the scholastic tradition. Newcomers had to go through a commission of peers to be inducted as masters.

In parallel, there remained a much more numerous flock of barber-surgeons who weren't well regulated and were for the most part only allowed to do small work.

Because the surgeons were both in regular conflict with the medical doctors (who had higher standing) and the barber-surgeons, the medical faculties ended up opening surgical degrees to barber-surgeons in the early 18th c. which led to their disappearance and the consolidation of surgery as a singular discipline.

Should've mentioned the mandatory tonsure instead of the beard ban as the cause why there were so many barbers around monasteries. Of course it's a minor nitpick but an article that mentions the book Empire of the Scalpel should've pointed out the scalp shaving tradition of the catholic monasteries rather than some boring beard ban. Would've made a better story! I've also heard the church forbid monks from dealing with blood so they taught their barbers who were already familiar with sharp instruments to do the surgeries instead.

It’s fair to wonder: (1) How barbaric today’s techniques will be considered in the future (2) Whether innovation is speeding up when it comes to medicine (3) What the state of the art will be in 40 years in the future

This is, I believe, why British surgeons are properly addressed as Mr/Mrs/Miss/Ms LastName, rather than Dr LastName: originally a way of keeping them in their place (because only physicians were "real" doctors), it has since been adopted as a badge of pride.

It’s funny because they change too. They’re Dr when they first qualify and do general training for a couple of years, then they become Mr/Ms/etc. and then if they do a PhD they will often choose Dr in the academic setting like a conference but continue to use Mr/Ms at work. And then if they’re a professor they might use that both clinically and in academia!

It occurs to me that many here may have never seen this 1978 SNL skit:


There is an excellent book on this that methodically walks the reader through the subject.

Empire of the Scalpel The History of Surgery By Ira Rutkow

>When the surgeon was an uneducated barber

Still is, if you ask many doctors (or unhappy groin mesh or hip replacement patients etc)

Totally off topic but the site has some sort of bug where it triggers a reload infinitely. When I loaded the site up it just endlessly refreshed the page by itself. Seems to be a conflict with some of my extensions because it was able to load fine in an Incognito window.

It is unlikely it was a truly uneducated person. Only a total sociopath would cut up people without any idea how to help them, and they would not stay in business (nor in town) long. There are plenty of valuable things you can learn on the job, and not from books. Surgery was apparently one of them. (Shudder.)

Also: The doctor who proved hand washing before surgery saves lives (in 1846): https://www.npr.org/sections/health-shots/2015/01/12/3756639...

Through the system of surgical residencies, surgery is still something one mostly learns on the job rather than out of books.

Not really. It’s a mixture of theoretical and practical learning which reinforce one another. Simulation is also being brought in although it’s limited by unrealistic models.

> Only a total sociopath would cut up people without any idea how to help them

I dont think its hard to imagine that all it takes is the _belief_ that you know how to help them. Throw in an anecdotal case of it actually "working" one time and I'm sure you get all sorts of "well-meaning" quackery.

>Only a total sociopath would cut up people without any idea how to help them, and they would not stay in business (nor in town) long

Recently posted here the guy who made eye surgery to Bach and Handel comes to mind.

> Only a total sociopath would cut up people without any idea how to help them, and they would not stay in business (nor in town) long

Surgeons needing to perform number of procedures for their medical specialty, insurance related quotas, etc.? They'll cut you without talking to you in person. Good luck proving that and your complain and opinion will be powerless.

That is a pretty wild claim there. Care to elaborate?

When you're holding a hammer, everything is a nail.

Surgeons will often have this bias, because they're seeking cases which fit their area of research. They're also often collecting data for the research. This helps advance their careers, makes them eligible for higher pay, advances them in the hierarchy, gives them many perks etc. Oh and obviously - successful research improves overall medical knowledge.

Many surgeons will cut you without talking to you because they don't see the point. In fact, some surgeons believe staying focused on the bio-mechanical aspects of the work and not getting emotionally involved helps improve their outcomes. Others, of course think and do the exact opposite - but this also depends on the local culture. My own personal view is that for the patient talking to the surgeon is like talking to the chef of a restaurant - it doesn't change anything about what happens in the kitchen, and there is a whole team of people working in the kitchen anyways.

As far as insurance and quotas - there are definitely others watching when you work anywhere as a surgeon. There might be pressure to use particular equipment that was purchased (DaVinci robots and disposable instruments are good examples). Or there might be pressure to do a procedure a particular way (to reduce insurance risk, even if surgeon would prefer to do it differently). In poorer countries there might be limitations around available equipment, or lower familiarity of the team with a procedure.

All in all, I don't think any of this is something to get worked up about. Sure, there are inefficiencies and imperfections in every system, but surgery really was macabre until very recent times and it's amazing what these people can do.

I know all this because I'm a PM in a company that makes surgical training devices and materials - I regularly talk to surgeons from around the world, I've visited OR's, conferences etc.

Atul Gawande in his Checklist Manifesto compares the future of surgery to changes in construction. We used to have master builders who would deliver entire buildings start to finish. Now we have specialized contractors who hand off their work between each other. This is where surgery is going.

Aren't most surgeries recommended after consult with a specialist physician? I don't think I've ever heard of someone just going to see a surgeon and getting surgery without that sort of due process

With the exception of some plastic surgery I would assume

It's absolutely a case and the reason is money and desperation. Imagine there is no public healthcare (USA) or the public healthcare is completely dysfunctional (Poland, Romania). Then you pay for every encounter with every medical specialist, who is mostly interested in charging and dismissing the patient, resulting with the patient turning increasingly desperate and impatient.

Well, some physicians are more likely to cut than others. Surgeons are more likely to do so, sure. The difference is prevalent when it comes to ortheopadics, knees and things. Surgeons in that field tend to prefer surgery, non-surgeons tend to be more conservative. As usual, neither is wrong. And neither is that kind of surgery done without consultation with the patient or due to "insurance quotas"...

Oh yeah that one didn't even come across my mind.

That's exactly right. Surgeons are used to a backlog of patients who show up with a history, records, paperwork etc.

Insurance related quota?

So your profile is right - eg. gender, age, reported pains. The hospital has still 10 guaranteed procedures from the insurer for this year. The pieces fit together. Why bother investigating further, simply do the procedure and write-off the patient. eg. tonsillectomy, many other -ctomies.

That's not how health insurance works - at least the US.

Insurance companies reimburse either on a fee-for-service model, in which the hospital is paid for every procedure they do (with no cap); or bundle style model (capitation or diagnosis-related group), where the hospital is paid a flat fee, regardless of what procedures they might do.

So while there are maximum quotas in the bundle style model, you actually make if you do fewer procedures, not if you do more.

> Why bother investigating further, simply do the procedure and write-off the patient. eg. tonsillectomy, many other -ctomies.

Because the insurance company will audit the medical chart and deny payment for the surgery if they deem the surgery to have been inappropriate. There is a huge incentive for them to do this - $500 dollars of audit time on their end could save them $10,000 or more if they end up denying payment.

It actually much more profitable for the hospital to exactly the opposite of what you suggest - only do a surgery if they are 99% sure that the insurer will pay for it in full.

This is one of the biggest sources of health care inequality in the US. Poor people are more likely to have cheap insurance that has a high rate of denying payment. Profitable hospitals don't want to risk nonpayment, so they will decline to do expensive surgeries on these patients and instead refer them to county hospitals or safety-net hospitals that operate at a loss and generally have poorer quality facilities and longer wait times.

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