When the Surgeon Was an Uneducated Barber
nautil.us
nautil.us
[^1]: https://www.gutenberg.org/files/26038/26038-h/26038-h.htm
[^2]: https://muslimheritage.com/paediatric-urology-1000-years-ago...
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.
Empire of the Scalpel The History of Surgery By Ira Rutkow
Still is, if you ask many doctors (or unhappy groin mesh or hip replacement patients etc)
Also: The doctor who proved hand washing before surgery saves lives (in 1846): https://www.npr.org/sections/health-shots/2015/01/12/3756639...
Recently posted here the guy who made eye surgery to Bach and Handel comes to mind.
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.
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.
With the exception of some plastic surgery I would assume
That's exactly right. Surgeons are used to a backlog of patients who show up with a history, records, paperwork etc.
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.
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.