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Abstract The practice of surgery and education of surgeons in the United States progressed as scientific knowledge and technological discovery advanced. As scientific discovery in medicine advanced, medical education for surgeons improved significantly. In this paper, we will cover the progression of surgical practice and education from the pre-industrial era to the postindustrial era. We will then examine current trends in surgical practice and education and look at possible future directions for surgery in the United States.

Introduction In the last 300 years, the practice of medicine in the United States progressed from a crude trade requiring little skill or knowledge, to a state-of-the-art profession grounded in science, technology and research. At the heart of the medical profession, are the physicians who dedicate their lives toward promoting health and disease management. Surgeons are especially important because they are called upon to help with the most serious and urgent health problems. Because surgery is one of the most challenging specializations in the medical field, surgeons are required to obtain the most rigorous medical education. Education for surgeons evolved with the advancement of medical science and technology. In the preindustrial era, most medical practitioners had few proven tools at their disposal: therefore surgery was primitive and often lead to death. During the 19th century, the medical school system began to take shape in the US, and medical education gained more support and prestige. Because of the huge leaps in scientific discovery that occurred during the 20th century, surgery also advanced at a propitious rate. Today, surgeons can perform many life saving procedures, but are required to sacrifice a lot of time toward intensive education and

training. As scientific discovery is constantly progressing, surgery is also moving toward a more technological dimension, and surgeons will be able to perform many more life-saving procedures in the near future. Surgery in the Pre-Industrial Era During most of the 1700s and the early 1800s, surgery in the United States was a crude art, based little upon science and performed without instruments of precision (Leitman, 1991). Until 1751, when the Pennsylvania Hospital opened in Philadelphia, there were no operating hospitals in Colonial America. Most surgeons did not have formal education; some were apprentices with other physicians while others were entirely self-taught (Grillo, 1999). The most common procedures at the New York Hospital in1798 were bleedings and amputations of fingers, arms or legs (Leitman, 1991). There were no formal education requirements to become a physician. Some medical colleges began establishing more stringent admission requirements in the late 1700s. To graduate with a Bachelor of Medicine from the Medical College of Philadelphia, a student was required to have had an apprenticeship for 3 years with a reputable physician as well as a broad knowledge of liberal arts, history, Latin and French (Burns, 1975). However, these requirements were not enforced nationwide and most physicians during that time were self-taught tradesmen with little formal medical education. Several factors lead to reforms in surgical education and practice in the pre-industrial era. The Massachusetts General Hospital opened in 1821 with a dual purpose of treating patients and educating physicians. In 1846, ether anesthesia was introduced into surgical practice, which made surgery a more popular medical treatment. And in 1847, the American Medical

Association formed with the purpose of reforming medical education in the US and professionalizing the medical profession (Grillo, 1999). The American Civil War (1861-1865) allowed for the development of trauma surgery in the US. War surgeons developed an inhaler to administer anesthesia to wounded soldiers. Confederate physicians developed the first mobile army surgical hospital (MASH). And unlike images that portrayed amputations as grizzly scenes with soldiers screaming while their limbs were hacked off, actual amputations were done under full anesthesia, with patients being put completely to sleep (Belferman, 1996). In the latter half of the 19th century, science was finding its way into medicine and surgery (Grillo, 1999). American medical schools began modeling their curriculum and structure after medical schools in Austria and Germany, which were at the forefront of medical education. Johns Hopkins University in Baltimore, MD was the first American university where the university, hospital and medical school were closely integrated. The medical school admitted students with a Bachelors degree and provided a 4 year, full-time curriculum that was centered on science, research and patient care. William Stewart Halsted was credited with being the catalyst for reforming surgical education and practice in the late 1800s. Halsted began the Johns Hopkins School of Surgery in 1888. He modeled it after the German system and created a hierarchy of interns, residents, and chief residents. His best students became surgery professors in other medical school around the country. He was also credited with pioneering new surgery techniques, including performing the first radical mastectomy, which revolutionized the treatment of breast cancer (Tan & Uyehara, 2010).

Surgery in the Post-Industrial Era As the United States shifted into the post-industrial period, there was a huge shift in technology and lifestyle. During the post-industrial period, the United States moved away from industrial economy, and shifted towards knowledge based society. As the country started to develop into knowledge based society, technology advanced very rapidly, as the 20th century had the most technological advancements then any of the previous centuries. In the late pre-industrial period, medical schools were being built all over the United States. In order to create regulation of these schools, the Federation of State Medical Board (FSMB) was created in February 1912, when the National Confederation of State Medical Examining and Licensing Boards and The American Confederation of Reciprocating Examining and Licensing Boards merged. The FSMB today is the overseer in promoting excellence in medical practice, licensure, and regulation of all state medical licensure. One man that contributed vastly in the medical education system in the United States was Abraham Flexner who helped raise the standards for medical students to become doctors. In 1912, Abraham Flexner wrote a report claiming that American medical schools should enact higher admissions and graduation standards. He also wrote in his report that there were too many medical schools in the U.S., and there would be negative consequences in producing too many medical doctors. Due to the Flexner report, more than half of all American medical schools merged or closed down between 1910 and 1935. As technology advanced during the post-industrial era, surgery also became more refined and advanced. Three seemingly insuperable obstacles beset the surgeon in the years before the mid-19th century: pain, infection, and shock. (Britannica para 1). With the advances in medical technology these three types of problems were prevented.

When a person loses a large amount of blood, they can go into circulatory shock, which is a life-threatening medical condition. The understanding of blood clotting in the 20th century greatly reduced the risk of shock during surgery. One person that helped reduce the risk of this potential life threatening medical condition was Karl Landsteiner with his discovery of blood grouping. Understanding blood grouping lead to the development of blood transfusions, a procedure that was first performed in 1901. With the greater advancements in medical and technological knowledge, the number of outpatient surgeries have increased. By 1995, more than 56% of all surgical procedures in the United States were done on an outpatient basis, without an overnight stay in hospitals. ((Encyclopedia Brittanica, vol. 6). With surgical advances in the 20th century hundreds of thousands of lives have been saved.

Current Trends in Surgical Education and Practice Surgery is one of the most exciting and dynamic fields in medicine today. Surgeons care for a range of health problems, from the simplest invasive surgery to a complex heart procedure. Because surgery can carry some degree of risk to the patients life, rigorous medical education for surgeons is required. The process to becoming a surgeon today is long and challenging. According to the United States of Department of Labor (2009), formal education and training requirements for surgeons include: 4 years of undergraduate school, 4 years of medical school and three to eight years of internship and residency. They also need to pass the United States Medical Licensing Examination (USMLE) or the Comprehensive Osteopathic Medical Licensing Examination

(COMLEX.) To be eligible for these examinations, physicians must graduate from an accredited medical school. Currently, a major problem in medical education is that medical residents are starting their careers with hundreds of hours less training than they did before. According to Senior Attorney John Kasprak (2004), surgical residents are being accountable for 80 hours of training per week instead of 100 hours per week, including in-house call. Some specific rules and guidelines have been given to in-training physicians to follow. The guidelines are: medical residents must have one free day from all clinical and educational responsibilities, duties cannot last for more than 24 hours, and residents must be given 10 hours for rest and personal activities between work duties. Decreasing their experience and exposure can be detrimental to the doctors training because it will produce less confidence and ability to operate or assist in complex operations. However, if any accredited hospitals fails to comply with any of these standards they are subjected to lose their medical residency accreditation programs. One overshadowing goal of the healthcare system is to improve health outcomes while minimizing medical errors. Several techniques have been developed to minimize bleeding during surgery. According to Leonila Ybardolaza Manalang, RN (personal communication, November 5, 2011), some techniques to increase blood count prior to surgery are to run laboratory blood tests such as compute blood count, electrolytes and prothrombin time-partial thromboplastin time. The functions of these tests are to know the hemoglobin, hematocrit, platelet count and electrolytes prior to surgery, so the surgeon can restore the balance of fluid volume if necessary. The better educated and prepared the surgeon is the faster the procedure will be to limiting the duration of bleeding. In addition, surgeons use surgical sponges to absorb liquids and to control bleeding.

However, medical errors do occur during surgery. According to Rasim Gencosmanoglu (2003), gossypiboma is when surgical tools such as gauze or surgical sponges are left inside a patients abdomen after surgery. According to VP Medical Consultant, LLC (2010), 1,500 people a year sue surgeons for sewing surgical sponges and gauzes in their body accidentally. As a result hospital administrators have implemented a reform for surgeons to implement a surgery checklist designed for safety, reducing surgical complications and deaths (Life Clinic, 2009).

Future Trends in Surgery The future of surgery and education of future surgeon brings forth new opportunities and challenges. The progress from open to minimally invasive surgery (MIS) has improved patient recovery and outcomes due to the reduction of incisions from very large to extremely small. MIS reduces trauma to the patient, decreases the need for pain medication, shortens recovery times and hospital stays, while improving cosmetic results (An Online Resource & Directory for Minimally and Less Invasive Procedures, 2009). With the use of virtual reality and simulations, training in the future will be based less around time and more around effectiveness and efficiency. Before actually providing medical diagnosis or treatment on a person, students will continue to train on simulators. This will decrease operating time and errors. (http://www.medscape.com/viewarticle/723240_3, 2010) With new discoveries in robotics and computer technology, surgeons will be able to perform more precise movements with a better range of motion. One example of refining the current MIS techniques is increasing haptic feedback. Because robot assisted MIS lacks haptic feedback, engineers are developing a pneumatic balloon-based feedback system that provides the

surgeon with accurate physical feeling of what the robot is doing (From Open Surgery to Robotic Surgery and Beyond, 2009). Most new and future discoveries in healthcare come from the Department of Defense (DoD). The US military has a project called Virtual Soldier, where a total body and organ scan of a soldier is made. By carrying this scan on an electronic dog tag, if the soldier is wounded, the medic or surgeon will have an image of the soldiers body scan. By importing the scan of the patient the surgeon can pre-plan the operation and even do a surgical rehearsal of the procedure, safely making mistakes virtually rather than on the patient (The Future of Neurosurgical Education, 2011). Through new techniques in telesurgery and the use of robotics, surgeons will be able to perform many procedures remotely from their computer. Telesurgery was first developed by the US DoD to allow surgeons to operate on wounded soldiers in the battlefield. Telesurgery could allow surgeries to be performed by expert surgeons in places where expertise and facilities cannot be found. Future technology will also open the doors to microscopic surgery. There is a new Femto-second lasers make it possible to create a hole in a membrane without damaging it. With access in the cell, surgeons will be able to manipulate the cell structure. Future surgeons may use this technology to change the biology of the cell to manipulate genetic material or operate on genes. ( http://www.cns.org/publications/cnsq/pdf/CNSQ_11summer.pdf, 2011) Conclusion Throughout US history, surgery has progressed from a crude art, based little upon science and performed without instruments of precision, to one based entirely on rigorous education and use of the most advanced technology. Development and formalization and of the

medical field has created the need for formal education. Technology is advancing so quickly that even as new procedures like minimally invasive surgery are being rapidly replaced. New technology produces new opportunities, especially with the emerging non-surgical technologies. Some of these technologies will increase the ability to perform surgery while others will replace the need for surgery entirely. The practice of surgery is changing faster than it ever has in the past. What is pure fantasy today could become undisputed fact tomorrow. References Belferman, M. (1996, June 13). On surgery's cutting edge in civil war. Washington Post. Burns, C. R. (1975). History in medical education: The development of current trends in the United States. Bulletin of the New York Academy of Medicine, 51(7), 851-869. Grillo, H. C. (1999). To impart this art: The development of graduate surgical education in the United States. Surgery, 125(1), 1-14. Leitman, I. M. (1991). The evolution of surgery at the New York hospital. Bulletin of the New York Academy of Medicine, 67(5), 475-500. Tan, S. Y., & Uyehara, P. (2010). William Stewart Halsted (1852-1922): Father of American surgery. Singapore Medical Journal, 51(7), 530-531.

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Medical boards history

http://www.britannica.com/EBchecked/topic/372460/history-ofmedicine/35690/Surgery-in-the-20th-century http://www.infoplease.com/ce6/sci/A0861371.html

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http://www.racgp.org.au/afp/200812/29327

http://www.infoplease.com/ce6/sci/A0861371.html

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